1

school systems and outpatient rehabilitation facilities as a tool to

address social participation, communication, motor planning, fine
motor coordination, and sensory perception (Hoesterey & Chap-
pelle, 2012; Waite, 2012).
The use of the iPad and various software applications, or apps
to assist patients during physical and cognitive rehabilitation has
become more common over the past few years (Waite, 2012). The
iPad is a handheld tablet device that is roughly the size of a sheet
of paper, weighs approximately 1.5 pounds, and has a touch screen
display. The iPad was originally designed for consumers who
wanted a mobile device that was bigger than a smartphone but
smaller than a laptop, and it has evolved into a tool that can be very
useful for communicating, engaging, and interacting with patients
in a variety of practice settings. The iPad provides a more high-tech
option for communication than commonly used paper-and-pen
communication boards, or dry-erase boards. Over the last several
years, iPad apps have been developed and used by therapists (e.g.,
Dexteria, Aphasia, MyMedList) to target specific rehabilitation
therapy goals in both inpatient and outpatient clinic settings. There
is therapeutic value for patients who use iPad devices during their
occupational therapy sessions, which is evident across populations
and settings, because the device allows the user to interact with the
environment in a versatile, unique way (Hoesterey & Chappelle,
2012). There are apps that support patients with varying diagno-
ses to participate in tasks requiring fine motor skills, figure-ground
perception, spatial memory and planning, and communication.
Incorporating iPads Into Occupational Therapy
Sessions in the ICU
The use of the iPad in the ICU setting has been under researched,
although it has potential to significantly benefit patients in this
practice area. The ICU can be a stressful environment for patients
with critical illness, which is exacerbated by a patients inability to
communicate or engage in routine self-care activities. The imbal-
ance of stimulation that is typical in this environment often results
in either overstimulation or understimulation. Introducing a piece
of assistive technology such as the iPad can improve communica-
tion, provide access to the environment, and increase a sense of
control, decreasing the stress and frustration often experienced by
patients in this setting.
September 2014, Volume 37, Number 3
SPECIAL INTEREST SECTION QUARTERLY
Published by The American Occupational Therapy Association, Inc.
Sponsored in part by National Association of Home Builders
Physical Disabilities
Use of iPads by Occupational
Therapists in a Medical
Intensive Care Unit
Angela M. Regensburg, MS, OTR/L
As the number of patients admitted to the intensive care unit (ICU)
each year continues to increase, so does the incidence of mechani-
cal ventilation (Carson, Cox, Holmes, Howard, & Carey, 2006). Sur-
vivors of critical illness are at increased risk for long-term impair-
ments in their physical, mental, and cognitive status (Parker,
Sricharoenchai, & Needham, 2013). More specifically, patients who
experience lengthy ICU admissions are at risk for ICU-acquired
weakness due to prolonged periods of immobility and impaired
physical functioning (e.g., inability to perform activities of daily
living [ADLs]) and cognitive impairments (e.g., deficits in execu-
tive function, memory, attention, and mental processing speed).
Patients surviving critical illness who demonstrate these long-term
impairments are given the diagnosis of post-intensive care syn-
drome (PICS; Needham et al., 2012; Parker et al., 2013; Robinson,
2013).
Individuals with PICS can experience a variety of limitations
and impairments that are not always easily recognized. Limita-
tions can be apparent, such as neuromuscular dysfunction, or less
evident, such as mild cognitive impairments (Robinson, 2013).
Patients who present with these new or worsening impairments
often see them persist beyond their acute care hospitalization, and
they can last for several months or years after hospital discharge
(Parker et al., 2013). In a cohort of survivors of acute respiratory
distress syndrome, only 34% returned to the workforce 2 years fol-
lowing their ICU admission. This group of survivors demonstrated
physical deficits such as fatigue and impaired endurance, and well
as cognitive deficits in memory, executive function, and attention
that limited their ability to return to work (Hopkins & Jackson,
2006).
As early mobility and rehabilitation in the ICU setting become
more commonplace, the potential role of occupational therapy
in the ICU is also emerging. Evidence supporting the benefits of
early occupational therapy and physical therapy in the ICU has
evolved, demonstrating that early rehabilitation in the ICU is both
safe and beneficial (Needham et al., 2010; Schweickert et al., 2009).
However, providing early intervention by engaging in activities
geared toward the patients current physical and cognitive con-
dition may be a difficult task in the ICU, as patients may require
life support, including mechanical ventilation and/or dialysis, and
have a multitude of lines, tubes, and drains. Occupational therapy
practitioners are turning to advanced technology and alternate
devices such as the iPad to assist with successfully completing
therapeutic activities in the ICU setting (Needham, Truong, & Fan,
2009). The iPad is already being used for therapeutic purposes in
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2
Quiz, are then trialed based on patients physical capabilities, abil-
ity to comprehend the information being presented, and occupa-
tional therapy goals. Apps are also available to assist with patient
and family education on various medical topics, including the ICU.
Examples of patient-caregiver education apps include Patient Com-
municator and iOrtho+, which are designed to assist both patients
and family members in understanding their medical stay, as well
as help them to express concerns or issues related to their pain,
their level of comfort, and overall hospital stay. Features of these
two apps include translations into a variety of languages, diagrams,
and definitions of commonly used phrases. Family members are
also provided with guidance on how to assist the patient with using
apps that are introduced by the occupational therapist.
In addition to the iPad being a therapeutic tool, it also has
many supplementary functions including visual or audio record-
ing, word processing, and even augmentative communication. Set-
tings can be adjusted to accommodate each patients specific needs.
Adjustable settings include a voiceover function for patients with
impaired vision, automatic dictation of voice to text formation
(speak-to-text function), size of text, high contrast backgrounds,
volume controls, and accessibility options such as custom gestures
or finger movements to control the screen and apps (Hoesterey &
Chappelle, 2012).
The iPad can also be used as an augmentative communication
device for patients who are orally intubated or otherwise unable
to communicate, allowing patient participation in more meaning-
ful activities, such as communicating with others through written
conversation, and expressing feelings or emotions through words
or pictures.
The majority of patients in the MICU who are using the iPad are
supine with the head of the bed elevated to at least 30. Adaptations
may be necessary to promote optimal use of the iPad, including
positioning it close to the patients arms and hands and providing
physical assistance. A foam wedge, available for patient position-
ing, can be used to mimic a desk on a patients lap and is avail-
able on the unit for all staff members to provide to patients who
are using an iPad. The iPad is placed on this wedge so the patient
can see it better. Standard pillows are often used underneath the
patients elbows for proximal support when attempting to reach
or make contact with the device. The occupational therapist can
then grade the amount of physical assistance that is needed for
the patient to perform various tasks on the iPad. The occupational
therapists role continues to include adjusting the position of the
patient and/or the device for optimum use, adapting the type and
difficulty of tasks within the apps to progress the patient toward
individualized therapeutic goals, and educating staff and family
members on how to facilitate increased use of the iPad throughout
the day. Nursing and other staff members who assist with the daily
care of the patient are educated on the adaptations provided by the
occupational therapist, and how to maintain these adaptations to
increase the patients participation with the iPad to achieve goals.
Case Example
Laura is a patient who initially presented to the Neurosciences Crit-
ical Care Unit at Johns Hopkins Hospital for seizure activity. How-
ever, she was subsequently transferred to the MICU due to severe
In a cohort of patients with acute respiratory distress syndrome
who were receiving occupational therapy services in the ICU, the
most common interventions by occupational therapists included
upper-extremity exercise, range of motion, ADL training, and func-
tional mobility (Dinglas et al., 2013). These standard methods of
practice adequately address a patients basic occupational needs in
the ICU. However, by incorporating iPad-based activities into ther-
apy sessions, patients are given the opportunity to challenge their
cognitive abilities as well as their physical function, and to interact
with technology in a physically limiting environment. The iPad has
the potential to facilitate cause and effect skills, upper-extremity
coordination, fine motor skills, communication, visual-perceptual
skills, and sequencing in a manner that is unique to each patient
and provides the just-right challenge.
Patients can be assessed for their appropriateness and ability to
use the iPad device during their initial occupational therapy evalu-
ation. Considerations include their current method of communica-
tion, ability to perform fine motor coordination tasks, and cognitive
status (ability to comprehend and follow simple/complex direc-
tions). When screening patients for appropriateness with using the
iPad, patients should demonstrate some active range of motion in
their fingers or wrists of at least one upper extremity in order to
activate the controls and iPad screen, and demonstrate the ability
to touch the iPad screen when prompted at a basic level. The moti-
vating aspect of the iPad, paired with the versatility of the device
(which is portable and can be kept at the patients bedside), enables
patients to continue to use it for further therapeutic value after the
therapist has provided a daily therapy session and left the room.
Patients can be provided with specific apps to use after their occu-
pational therapy treatment session is completed in order to con-
tinue to work toward therapy goals. Examples of these apps include
Matrix Game 2 for visual perception, Little Finder for figure-ground
perception, and Dexteria for fine motor coordination.
iPads in the Medical Intensive Care
Unit (MICU)
The 24-bed medical intensive care unit (MICU) at Johns Hopkins
Hospital in Baltimore uses four iPad devices in conjunction with
occupational therapy treatment sessions for patients who are criti-
cally ill. The patients admitted to the MICU have a variety of medi-
cal diagnoses, including acute respiratory failure and sepsis. These
patients are often receiving mechanical ventilation, but are fre-
quently awake and alert. Muscle weakness and fatigue often make
using a pen and paper to communicate difficult; the same is true
for completing basic self-care tasks. Many of these patients develop
delirium as a result of their diagnosis, their need for mechanical
ventilation, and organ failure. Delirium is characterized by impair-
ments with attention, orientation, and memory.
Upon the patients initial occupational therapy evaluation in
the MICU, the patient is screened for use of the iPad. Patients who
would be considered for iPad-based therapy include those who are
alert, are able to follow simple step commands, and have the use
of their hand(s) to make contact with the iPad screen. When the
iPad is introduced to patients in the MICU, they are oriented to how
the device is controlled through a series of finger-activated selec-
tions made on the iPad screen. Apps, such as Little Finder and Letter
Physical Disabilities Special Interest Section Quarterly
ISSN: 1093-7234
Chairperson: Lauro Muoz Editor: Claudine Campbell Production Editor: Cynthia Johansson
Published quarterly by The American Occupational Therapy Association, Inc., 4720 Montgomery Lane, Bethesda, MD 20814-3449; subscriptions@aota.org (email). Periodicals postage paid at Bethesda,
MD. POSTMASTER: Send address changes to Mental Health Special Interest Section Quarterly, AOTA, 4720 Montgomery Lane, Suite #200, Bethesda, MD 20814-3449. Copyright 2014 by The American
Occupational Therapy Association, Inc. Annual membership dues are $225 for OTs, $131 for OTAs, and $75 for students. All SIS Quarterly newsletters are available to members at www.aota.org. The
opinions and positions stated by the contributors are those of the authors and not necessarily those of the editor or AOTA. Sponsorship is accepted on the basis of conformity with AOTA standards.
Acceptance of sponsorship does not imply endorsement, official attitude, or position of the editor or AOTA.
3
acute respiratory distress syndrome. Laura was orally intubated
upon transition to the MICU and mechanically ventilated.
Laura was evaluated by an occupational therapist on her
second day in the MICU, while she was still receiving mechanical
ventilation. She presented with substantial global weakness that
prevented functional use of her arms and legs in daily activities.
Her occupational therapy sessions were geared toward improv-
ing physical strength in both gross and fine motor functions,
engaging in ADL tasks, and increasing functional mobility while
mechanically ventilated. Assisting Laura to engage in functional
activity and mobility early on, even while receiving mechanical
ventilation, was crucial for improvements in her physical function
upon hospital discharge (Schweickert et al., 2009).
Laura and her family expressed that she enjoyed technology
and would be eager to utilize the iPad during her occupational
therapy sessions. Laura was still unable to communicate with staff
members using pen and paper, unable to activate or control her
nursing call-bell, and unable to assist with basic ADLs due to ICU-
acquired weakness and an overall deconditioned state. The iPad
was used during occupational therapy sessions to improve finger
strength to perform fine motor coordination tasks, to increase fin-
ger isolation movements to activate her call-bell, and to increase
functional communication with staff members.
The most frequently used communication app during Lauras
therapy sessions were Talk Tablet US and Speak Aid HD. The Speak
Aid HD app allowed Laura to select thoughts, feelings, or basic
expressions on picture boards. She simply had to make contact
with a picture corresponding to her thoughts or feelings, and the
iPad would state her selection aloud. Once Laura was able to form
isolated finger movements and had the upper extremity strength
to move her hand across the screen, she began using the Talk Tablet
US app. This app had pre-made picture boards for communication,
but also allowed her to use her finger as a stylus to manually write
out what she wanted to say on the screen.
The apps used to assist Laura with fine motor coordination
included Bubble Snap, Letter Quiz, and Little Finder. She initially
participated in gravity-eliminated upper extremity exercises using
the Bubble Snap App, which required her to make contact with
all of the targets on the screen with her fingers. This app can be
graded in difficulty by changing the size of the targets. As Laura
gained strength in her fingers and hands, the occupational thera-
pist introduced letter formation apps, such as Letter Quiz. Laura
was required to use proper finger positioning to trace letters on the
screen. The Little Finder App was also used for Laura to increase
her upper extremity endurance while isolating finger movements
to locate objects on the screen. Laura would locate this object on
the screen and use her finger to select it without making contact
with other objects located on the same board.
The apps used during Lauras occupational therapy sessions
were graded daily in order to adapt to her improvements in anti-
gravity movements, finger strength, and overall endurance. Laura
initially required significant hand-over-hand assist for correct
hand and finger positions during activities, adaptations to the
position of the iPad to better see it during use, and increased rest
breaks to accommodate her fatigue. Laura continued to make
progress during each session with the iPad and was able to write
basic comments and feelings using the apps that were previously
described. Laura and her family were provided with a list of apps
used in her occupational therapy sessions during her ICU stay and
they were encouraged to continue to use the iPad as a therapeu-
tic tool in the inpatient rehabilitation setting and at home when
discharged.
Conclusion
The use of the iPad during occupational therapy interventions
is increasing in a variety of practice settings. The iPad has thera-
peutic value in the hands of a skilled occupational therapist when
equipped with a diverse selection of applications geared to address
a multitude of impairments and injuries. The iPad plays a particu-
larly important role when working with patients who are receiving
mechanical ventilation and present with communication, cogni-
tive, or physical deficits in the ICU. Occupational therapists work-
ing in this unique practice setting can utilize the iPad to improve
communication between the patient and staff or family members,
while simultaneously improving a patients cognition, physical
abilities, and quality of life by increasing the patients successful
interaction with the environment.
Resources
Dexteriawww.dexteria.net
Matrix Game 2www.myfirstapp.com
Patient Communicatorwww.sccm.org
Bubble Snapwww.shinyfoil.com
Letter Quizwww.tantrumapps.com
Little Finderwww.alligatorapps.com
Talk Tablet USwww.talktablet.com
Speak Aid HDwww.dementidapps.blogspot.com
iOrtho+www.therapeuticarticulations.com
References
Carson, S. S., Cox, C. E., Holmes, G. M., Howard, A., & Carey, T. S. (2006). The
changing epidemiology of mechanical ventilation: A population-based
study. Journal of Intensive Care Medicine, 21, 173182.
Dinglas, V. D., Colantuoni, E., Ciesla, N., Mendez-Tellez, P. A., Shanholtz, C., &
Needham, D. M. (2013). Brief reportOccupational therapy for patients
with acute lung injury: Factors associated with time to first intervention
in the intensive care unit. American Journal of Occupational Therapy, 67,
355362. doi:10.5014/ajot.2013.007807
Hoesterey, C., & Chappelle, C. (2012). Touch the future: Using iPads as a thera-
peutic tool. OT Practice, 17(13), 79.
Hopkins, R. O., & Jackson, J. C. (2006). Long-term neurocognitive function after
critical illness. Chest, 130, 869878.
Needham, D. M., Davidson, J., Cohen, H., Hopkins, R. O., Weinert, C., Wunsch,
H., . . . Harvey, M. A. (2012). Improving long-term outcomes after dis-
charge from intensive care unit: Report from a stakeholders conference.
Critical Care Medicine, 40, 502509.
Needham, D. M., Korupolu, R., Zanni, J. M., Pradhan, P., Colantuoni, E., Palmer,
J. B., . . . Fan, E. (2010). Early physical medicine and rehabilitation for
patients with acute respiratory failure: A quality improvement project.
Archives of Physical Medicine and Rehabilitation, 19, 536542.
Needham, D. M., Truong, A. D., & Fan, E. (2009). Technology to enhance physical
rehabilitation of critically ill patients. Critical Care Medicine, 37, S436S441.
Parker, A. M., Sricharoenchai, T., & Needham, D. M. (2013). Early rehabilitation
in the intensive care unit: Preventing impairment of physical and mental
health. Current Physical Medicine and Rehabilitation Reports, 1, 307314.
Robinson, M. R. (2013). Postintensive care syndrome: The important implica-
tions for occupational therapy practitioners. OT Practice, 18(13), 79.
Schweickert, W. D., Pohlman, M. C., Pohlman, A. S., Nigos, C., Pawlik, A. J.,
Esbrook, C. L., . . . Kress, J. P. (2009). Early physical and occupational
therapy in mechanically ventilated, critically ill patients: A randomized
controlled trial. The Lancet, 373, 18741882.
Waite, A. (2012). Apptitude: Smart gadget applications showing their worth in
practice. OT Practice, 17(12), 912.
Angela M. Regensburg, MS, OTR/L, is an Occupational Therapist II at Johns
Hopkins Hospital, Meyer 2-109, 1800 Orleans Street, Baltimore, MD
21287; afreela5@jhmi.edu. She currently serves as the lead occupational
therapist in the medical intensive care unit and has a special interest in
working in critical care.
Regensburg, A. M. (2014, September). Use of iPads by occupational therapists
in a medical intensive care unit. Physical Disabilities Special Interest Section
Quarterly, 37(3), 13.
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P E R I O D I C A L S
P O S T A G E
P A I D A T
B E T H E S D A
M D
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T h e A m e r i c a n O c c u p a t i o n a l
T h e r a p y A s s o c i a t i o n , I n c .
4 7 2 0 M o n t g o m e r y L a n e , S u i t e # 2 0 0
B e t h e s d a , M D 2 0 8 1 4 - 3 4 4 9
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