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An occupational therapist works systematically with a client through a sequence of actions called the occupational therapy process. There are several versions of this process as described by numerous scholars. All practice frameworks include the components of evaluation (or assessment), intervention, and outcomes. This process provides a framework through which occupational therapists assist and contribute to promoting health and ensures structure and consistency among therapists.The Occupational Therapy Practice Framework (OTPF) is the core competency of occupational therapy in the United States. The OTPF framework is divided into two sections: domain and process. The domain includes environment, client factors, such as the individual's motivation, health status, and status of performing occupational tasks. The domain looks at the contextual picture to help the occupational therapist understand how to diagnose and treat the patient. The process is the actions taken by the therapist to implement a plan and strategy to treat the patient.Occupational therapists work with infants, toddlers, children, youth, and their families in a variety of settings, including schools, clinics, homes, hospitals, and the community.Assessment of a person's ability to engage in daily, meaningful occupations is the initial step of occupational therapy (OT) intervention and involves evaluating a young person's occupational performance in areas of feeding, playing, and socializing daily living skills, or attending school.Occupational therapists take into consideration the strengths and weaknesses of a child's underlying skills which may be physical, cognitive, or emotional in nature, as well as the context and environmental demands at play. In planning treatment, occupational therapists work in collaboration with parents, caregivers, teachers, or the children and teens themselves in order to develop functional goals within a variety of occupations meaningful to the young client. Early intervention is an extremely important aspect of the daily functioning of a child between the ages of birth-3 years old. This area of practice sets the tone or standard for therapy in the school setting. OT's who practice in early intervention develop a family's ability to care for their child with special needs and promote his or her function and participation in the most natural environment as possible. Each child is required to have an Individualized Family Service Plan (IFSP) that focuses on the family's goals for the child. It's possible for an OT to serve as the family's service coordinator and facilitate the team process for creating an IFSP for each eligible child.Objectives that an occupational therapist addresses with children and youth may take a variety of forms.For example:Providing splinting and caregiver education in a hospital burn unit.Facilitating handwriting development by providing intervention to develop fine motor and writing readiness skills in school-aged children.Providing individualized treatment for sensory processing.Teaching coping skills to a child with Generalized Anxiety Disorder.Consulting with teachers, counselors, social workers, parents/ caregivers, or any person that works with children regarding modifications, accommodations, and supports in a variety of areas, such as sensory processing, motor planning, visual processing sequencing, transitions between schools, etc.Instructing caregivers in regard to mealtime intervention for children with autism who have feeding difficulties.In the United States, pediatric occupational therapists work in the school setting as a "related service" for children with an Individual Education Plan (IEP).Every student who receives special education and related services in the public school system is required by law to have an IEP, which is a very individualized plan designed for each specific student (U.S. Department of Education, 2007).Related services are “developmental, corrective, and other supportive services as are required to assist a child with a disability to benefit from special education,” and include a variety of professions such as speech-language pathology and audiology services, interpreting services, psychological services, and physical and occupational therapy.As a related service, occupational therapists work with children with varying disabilities to address those skills needed to access the special education program and support academic achievement and social participation throughout the school day (AOTA, n.d.-b). In doing so, occupational therapists help children fulfill their role as students and prepare them to transition to post-secondary education, career, and community integration (AOTA, n.d.-b).Occupational therapists have specific knowledge to increase participation in school routines throughout the day, including:Modification of the school environment to allow physical access for children with disabilitiesProvide assistive technology to support student successHelping to plan instructional activities for implementation in the classroomSupport the needs of students with significant challenges such as helping to determine methods for alternate assessment of learningHelping students develop the skills necessary to transition to post-high school employment, independent living or further education (AOTA).Other settings, such as homes, hospitals, and the community are important environments where occupational therapists work with children and teens to promote their independence in meaningful, daily activities.Outpatient clinics offer a growing OT intervention referred to as “Sensory Integration Treatment”. This therapy, provided by experienced and knowledgeable pediatric occupational therapists, was originally developed by A. Jean Ayres, an occupational therapist.Sensory integration therapy is an evidence-based practice that enables children to better process and integrate sensory input from the child's body and from the environment, thus improving his or her emotional regulation, ability to learn, behavior, and functional participation in meaningful daily activities.Recognition of occupational therapy programs and services for children and youth is increasing worldwide.Occupational therapy for both children and adults is now recognized by the United Nations as a human right which is linked to the social determinants of health. As of 2018, there are over 500,000 occupational therapists working worldwide (many of whom work with children) and 778 academic institutions providing occupational therapy instruction.Health and wellnessAccording to the American Occupational Therapy Association's (AOTA) Occupational Therapy Practice Framework, 3rd Edition, the domain of occupational therapy is described as "Achieving health, well-being, and participation in life through engagement in occupation".Occupational therapy practitioners have a distinct value in their ability to utilize daily occupations to achieve optimal health and well-being. By examining an individual's roles, routines, environment, and occupations, occupational therapists can identify the barriers in achieving overall health, well-being, and participation.Occupational therapy practitioners can intervene at primary, secondary, and tertiary levels of intervention to promote health and wellness. It can be addressed in all practice settings to prevent disease and injuries, and adopt healthy lifestyle practices for those with chronic diseases.Two of the occupational therapy programs that have emerged targeting health and wellness are the Lifestyle Redesign Progra and the REAL Diabetes Program.Occupational therapy interventions for health and wellness vary in each setting:SchoolOccupational therapy practitioners target school-wide advocacy for health and wellness including bullying prevention, backpack awareness, recess promotion, school lunches, and PE inclusion. They also heavily work with students with learning disabilities such as those on the autism spectrum.A study conducted in Switzerland showed that a large majority of occupational therapists collaborate with schools, half of them providing direct services within mainstream school settings. The results also show that services were mainly provided to children with medical diagnoses, focusing on the school environment rather than the child's disability.OutpatientOccupational therapy practitioners conduct 1:1 treatment sessions and group interventions to address: leisure, health literacy, and education, modified physical activity, stress/anger management, healthy meal preparation, and medication management.Acute careOccupational therapy practitioners conduct 1:1 treatment sessions, group interventions, and promote hospital-wide programs targeting: leisure, stress management, pain management techniques, physical activity, healthy food recommendations, and medication management.Community-basedOccupational therapy practitioners develop and implement community-wide programs to assist in the prevention of diseases and encourage healthy lifestyles by: conducting education classes for prevention, facilitating gardening, offering ergonomic assessments, and offering pleasurable leisure and physical activity programs.Mental healthThe occupational therapy profession believes that the health of an individual is fostered through active engagement in one's occupations (AOTA, 2014). When a person is experiencing any mental health need, his or her ability to actively participate in occupations may be hindered. For example, if a person has depression or anxiety, he or she may experience interruptions in sleep, difficulty completing self-care tasks, decreased motivation to participate in leisure activities, decreased concentration for school or job-related work, and avoidance of social interactions.Occupational therapy practitioners possess the educational knowledge base in mental health and can contribute to the efforts in mental health promotion, prevention, and intervention. Occupational therapy practitioners can provide services that focus on social-emotional well-being, prevention of negative behaviors, early detection through screenings, and intensive intervention (Bazyk & Downing, 2017).Occupational therapy practitioners can work directly with clients, provide professional development for staff, and work in collaboration with other team members and families. For instance, occupational therapists are specifically skilled at understanding the relationship between the demands of a task and the person's abilities.With this knowledge, practitioners are able to devise an intervention plan to facilitate successful participation in meaningful occupations. Occupational therapy services can focus on engagement in occupation to support participation in areas related to school, education, work, play, leisure, ADLs, and instrumental ADLs (Bazyk & Downing, 2017).Occupational therapy utilizes the public health approach to mental health (WHO, 2001) which emphasizes the promotion of mental health as well as the prevention of, and intervention for, mental illness. This model highlights the distinct value of occupational therapists in mental health promotion, prevention, and intensive interventions across the lifespan (Miles et al., 2010).Below are the three major levels of service:Tier 3: intensive interventionsIntensive interventions are provided for individuals with identified mental, emotional, or behavioral disorders that limit daily functioning, interpersonal relationships, feelings of emotional well-being, and the ability to cope with challenges in daily life. Occupational therapy practitioners are committed to the recovery model which focuses on enabling persons with mental health challenges through a client-centered process to live a meaningful life in the community and reach their potential (Champagne & Gray, 2011).The focus of intensive interventions (direct–individual or group, consultation) is engagement in occupation to foster recovery or “reclaiming mental health” resulting in optimal levels of community participation, daily functioning, and quality of life; functional assessment and intervention (skills training, accommodations, compensatory strategies) (Brown, 2012); identification and implementation of healthy habits, rituals, and routines to support wellness.Tier 2: targeted servicesTargeted services are designed to prevent mental health problems in persons who are at risk of developing mental health challenges, such as those who have emotional experiences (e.g., trauma, abuse), situational stressors (e.g., physical disability, bullying, social isolation, obesity) or genetic factors (e.g., family history of mental illness). Occupational therapy practitioners are committed to early identification of and intervention for mental health challenges in all settings.The focus of targeted services (small groups, consultation, accommodations, education) is engagement in occupations to promote mental health and diminish early symptoms; small, therapeutic groups (Olson, 2011); environmental modifications to enhance participation (e.g., create sensory-friendly classrooms, home, or work environments)Tier 1: universal servicesUniversal services are provided to all individuals with or without mental health or behavioral problems, including those with disabilities and illnesses (Barry & Jenkins, 2007).Occupational therapy services focus on mental health promotion and prevention for all:encouraging participation in health-promoting occupations (e.g., enjoyable activities, healthy eating, exercise, adequate sleep);fostering self-regulation and coping strategies (e.g., mindfulness, yoga);promoting mental health literacy (e.g., knowing how to take care of one's mental health and what to do when experiencing symptoms associated with ill mental health).Occupational therapy practitioners develop universal programs and embed strategies to promote mental health and well-being in a variety of settings, from schools to the workplace.The focus of universal services (individual, group, school-wide, employee/organizational level) is universal programs to help all individuals successfully participate in occupations that promote positive mental health (Bazyk, 2011);educational and coaching strategies with a wide range of relevant stakeholders focusing on mental health promotion and prevention; the development of coping strategies and resilience; environmental modifications and supports to foster participation in health-promoting occupations.Productive agingOccupational therapists work with older adults to maintain independence, participate in meaningful activities, and live fulfilling lives. Some examples of areas that occupational therapists address with older adults are driving, aging in place, low vision, and dementia or Alzheimer’s Disease (AD).When addressing driving, driver evaluations are administered to determine if drivers are safe behind the wheel. To enable the independence of older adults at home, occupational therapists perform fall risk assessments, assess clients functioning in their homes, and recommend specific home modifications. When addressing low vision, occupational therapists modify tasks and the environment.While working with individuals with AD, occupational therapists focus on maintaining the quality of life, ensuring safety, and promoting independence.Geriatrics/productive agingOccupational therapists address all aspects of aging from health promotion to the treatment of various disease processes. The goal of occupational therapy for older adults is to ensure that older adults can maintain independence and reduce health care costs associated with hospitalization and institutionalization.In the community, occupational therapists can assess older adults' ability to drive and if they are safe to do so. If it is found that an individual is not safe to drive the occupational therapist can assist with finding alternate transit options.Occupational therapists also work with older adults in their homes as part of home care. In the home, an occupational therapist can work on such things as fall prevention, maximizing independence with activities of daily living, ensuring safety, and being able to stay in the home for as long as the person wants. An occupational therapist can also recommend home modifications to ensure safety in the home.Many older adults suffer from chronic conditions such as diabetes, arthritis, and cardiopulmonary conditions. Occupational therapists can help manage these conditions by offering education on energy conservation strategies or coping strategies. Not only do occupational therapists work with older adults in their homes, but they also work with older adults in hospitals, nursing homes, and post-acute rehabilitation. In nursing homes, the role of the occupational therapist is to work with clients and caregivers on education for safe care, modifying the environment, positioning needs, and enhancing IADL skills to name a few.In post-acute rehabilitation, occupational therapists work with clients to get them back home and to their prior level of function after a hospitalization for an illness or accident. Occupational therapists also play a unique role in those with dementia. The therapist may assist with modifying the environment to ensure safety as the disease progresses along with caregiver education to prevent burnout.Occupational therapists also play a role in palliative and hospice care. The goal at this stage of life is to ensure that the roles and occupations that the individual finds meaningful continue to be meaningful. If the person is no longer able to perform these activities, the occupational therapist can offer new ways to complete these tasks while taking into consideration the environment along with physical, psychosocial, and physical needs. Not only do occupational therapists work with older adults in traditional settings they also work in senior centers and ALFs.Visual impairmentVisual impairment is one of the top 10 disabilities among American adults.Occupational therapists work with other professions, such as optometrists, ophthalmologists, and certified low vision therapists, to maximize the independence of persons with a visual impairment by using their remaining vision as efficiently as possible.AOTA's promotional goal of “Living Life to Its Fullest” speaks to who people are and learning about what they want to do, particularly when promoting the participation in meaningful activities, regardless of visual impairment.Populations that may benefit from occupational therapy include older adults, persons with traumatic brain injury, adults with the potential to return to driving, and children with visual impairments. Visual impairments addressed by occupational therapists may be characterized into 2 types including low vision or neurological visual impairment. An example of neurological impairment is a cortical visual impairment (CVI) which is defined as “...abnormal or inefficient vision resulting from a problem or disorder affecting the parts of the brain that provide sight”.The following section will discuss the role of occupational therapy when working with the visually impaired.Occupational therapy for older adults with low vision includes task analysis, environmental evaluation, and modification of tasks or the environment as needed. Many occupational therapy practitioners work closely with optometrists and ophthalmologists to address visual deficits in acuity, visual field, and eye movement in people with traumatic brain injury, including providing education on compensatory strategies to complete daily tasks safely and efficiently. Adults with a stable visual impairment may benefit from occupational therapy for the provision of a driving assessment and an evaluation of the potential to return to driving. Lastly, occupational therapy practitioners enable children with visual impairments to complete self-care tasks and participate in classroom activities using compensatory strategies.Adult rehabilitationOccupational therapists address the need for rehabilitation following an injury or impairment. When planning treatment, occupational therapists address the physical, cognitive, psychosocial, and environmental needs involved in adult populations across a variety of settings.Occupational therapy in adult rehabilitation may take a variety of forms:Working with adults with autism at day rehabilitation programs to promote successful relationships and community participation through instruction on social skills.Increasing the quality of life for an individual with cancer by engaging them in occupations that are meaningful, providing anxiety and stress reduction methods, and suggesting fatigue management strategiesCoaching individuals with hand amputations how to put on and take off a myoelectrically controlled limb as well as training for functional use of the limbAs for paraplegics, there are such things as sitting cushion and pressure sore prevention. Prescription of these aids is a common job for paraplegics.Using and implementing new technology such as speech to text software and Nintendo Wii video gamesCommunicating via tele-health methods as a service delivery model for clients who live in rural areasWorking with adults who have had a stroke to regain their activities of daily livingAssistive technologyOccupational therapy practitioners or OTs are uniquely poised to educate, recommend, and promote the use of assistive technology to improve the quality of life for their clients. OTs are able to understand the unique needs of the individual in regard to occupational performance and have a strong background in activity analysis to focus on helping clients achieve goals. Thus, the use of varied and diverse assistive technology is strongly supported within occupational therapy practice models.Travel occupational therapyBecause of the rising need for occupational therapy practitioners in the U.S., many facilities are opting for travel occupational therapy practitioners—who are willing to travel, often out of state, to work temporarily in a facility. Assignments can range from 8 weeks to 9 months, but typically last 13–26 weeks in length.Travel therapists work in many different settings, but the highest need for therapists is in home health and skilled nursing facility settings.There are no further educational requirements needed to be a travel occupational therapy practitioner; however, there may be different state licensure guidelines and practice acts that must be followed.According to Zip Recruiter, as of July 2019, the national average salary for a full-time travel therapist is $86,475 with a range between $62,500 to $100,000 across the United States.Most commonly (43%), travel occupational therapists enter the industry between the ages of 21–30.Occupational justiceThe practice area of occupational justice relates to the “benefits, privileges, and harms associated with participation in occupations” and the effects related to access or denial of opportunities to participate in occupations. This theory brings attention to the relationship between occupations, health, well-being, and quality of life.Occupational justice can be approached individually and collectively. The individual path includes disease, disability, and functional restrictions. The collective way consists of public health, gender, and sexual identity, social inclusion, migration, and the environment.The skills of occupational therapy practitioners enable them to serve as advocates for systemic change, impacting institutions, policy, individuals, communities, and entire populations.Examples of populations that experience occupational injustice include refugees, prisoners, homeless persons, survivors of natural disasters, individuals at the end of their life, people with disabilities, elderly living in residential homes, individuals experiencing poverty, children, immigrants, and LGBTQI+ individuals.For example, the role of an occupational therapist working to promote occupational justice may include:Analyzing tasks, modifying activities, and environments to minimize barriers to participation in meaningful activities of daily living.Addressing physical and mental aspects that may hinder a person's functional ability.Provide intervention that is relevant to the client, family, and social context.Contribute to global health by advocating for individuals with disabilities to participate in meaningful activities on a global level. Occupation therapists are involved with the World Health Organization (WHO), non-governmental organizations and community groups, and policymaking to influence the health and well-being of individuals with disabilities worldwideOccupational therapy practitioners’ role in occupational justice is not only to align with perceptions of procedural and social justice but to advocate for the inherent need of meaningful occupation and how it promotes a just society, well-being, and quality of life among people relevant to their context. It is recommended to the clinicians to consider occupational justice in their everyday practice to promote the intention of helping people participate in tasks that they want and need to do.Occupational injusticeIn contrast, occupational injustice relates to conditions wherein people are deprived, excluded, or denied opportunities that are meaningful to them.Types of occupational injustices and examples within the OT practice include:Occupational deprivation: The exclusion from meaningful occupations due to external factors that are beyond the person's control. As an example, a person who has difficulties with functional mobility may find it challenging to reintegrate into the community due to transportation barriers.Occupational apartheid: The exclusion of a person in chosen occupations due to personal characteristics such as age, gender, race, nationality, or socioeconomic status. An example can be seen in children with developmental disabilities from low socioeconomic backgrounds whose families would opt-out from therapy due to financial constraints.Occupational marginalization: Relates to how implicit norms of behavior or societal expectations prevents a person from engaging in a chosen occupation. As an example, a child with physical impairments may only be offered table-top leisure activities instead of sports as an extracurricular activity due to the functional limitations caused by his physical impairments.Occupational imbalance: The limited participation in a meaningful occupation brought about by another role in a different occupation. This can be seen in the situation of a caregiver of a person with a disability who also has to fulfill other roles such as being a parent to other children, a student, or a worker.Occupational alienation: The imposition of an occupation that does not hold meaning for that person. In the OT profession, this manifests in the provision of rote activities which does not really relate to the goals or the interest of the client.Within occupational therapy practice, injustice may ensue in situations wherein professional dominance, standardized treatments, laws, and political conditions create a negative impact on the occupational engagement of our clients.Awareness of these injustices will enable the therapist to reflect on his own practice and think of ways in approaching their client's problems while promoting occupational justice.Community-based therapyAs occupational therapy (OT) has grown and developed, the community-based practice has blossomed from an emerging area of practice to a fundamental part of occupational therapy practice (Scaffa & Reitz, 2013).Community-based practice allows for OTs to work with clients and other stakeholders such as families, schools, employers, agencies, service providers, stores, day treatment and daycare, and others who may influence the degree of success the client will have in participating. It also allows the therapist to see what is actually happening in the context and design interventions relevant to what might support the client in participating and what is impeding her or him from participating.Community-based practice crosses all of the categories within which OTs practice from physical to cognitive, mental health to spiritual, all types of clients may be seen in community-based settings. The role of the OT also may vary, from advocate to consultant, direct care provider to program designer, adjunctive services to the therapeutic leader.EducationWorldwide, there is a range of qualifications required to practice as an occupational therapist or occupational therapy assistant. Depending on the country and expected level of practice, degree options include associate degree, Bachelor's degree, entry-level master's degree, post-professional master's degree, entry-level Doctorate (OTD), post-professional Doctorate (OTD), Doctor of Clinical Science in OT (CScD), Doctor of Philosophy in Occupational Therapy (PhD), and combined OTD/PhD degrees.Both occupational therapist and occupational therapy assistant roles exist internationally. Currently, in the United States, dual points of entry exist for both OT and OTA programs. For OT, that is an entry-level Masters or entry-level Doctorate. For OTA, that is an associate degree or bachelor's degree.The World Federation of Occupational Therapists (WFOT) has minimum standards for the education of OTs, which was revised in 2016. All of the educational programs around the world need to meet these minimum standards. These standards are subsumed by and can be supplemented with academic standards set by a country's national accreditation organization.As part of the minimum standards, all programs must have a curriculum that includes practice placements (fieldwork). Examples of fieldwork settings include acute care, inpatient hospital, outpatient hospital, skilled nursing facilities, schools, group homes, early intervention, home health, and community settings.The profession of occupational therapy is based on a wide theoretical and evidence-based background. The OT curriculum focuses on the theoretical basis of occupation through multiple facets of science, including occupational science, anatomy, physiology, biomechanics, and neurology. In addition, this scientific foundation is integrated with knowledge from psychology, sociology, and more.In the United States, Canada, and other countries around the world, there is a licensure requirement. In order to obtain an OT or OTA license, one must graduate from an accredited program, complete fieldwork requirements, and pass a national certification examination.Theoretical frameworksA distinguishing facet of occupational therapy is that therapists often espouse the use of theoretical frameworks to frame their practice. Nonetheless, many have also argued that the use of theory complicates everyday clinical care and is not necessary to provide patient-driven care.Note that terminology differs between scholars. An incomplete list of theoretical bases for framing a human and their occupations include the following:Generic modelsGeneric models are the overarching title given to a collation of compatible knowledge, research, and theories that form conceptual practice.More generally they are defined as "those aspects which influence our perceptions, decisions, and practice".Person-Environment Occupation Performance ModelThe Person Environment Occupation Performance model (PEOP) was originally published in 1991 (Charles Christiansen & M. Carolyn Baum] and describes an individual's performance based on four elements including environment, person, performance, and occupation. The model focuses on the interplay of these components and how this interaction works to inhibit or promote successful engagement in occupation.Occupation-Focused Practice ModelsOccupational Therapy Intervention Process Model (OTIPM) (Anne Fisher and others)Occupational Performance Process Model (OPPM)Model of Human Occupation (MOHO) (Gary Kielhofner and others) MOHO was first published in 1980. It explains how people select, organize, and undertake occupations within their environment. The model is supported by evidence generated over thirty years and has been successfully applied throughout the world.Canadian Model of Occupational Performance and Engagement (CMOP-E)Occupational Performances Model – Australia (OPM-A) (Chris Chapparo & Judy Ranka)The OPM(A) was conceptualized in 1986 with its current form launched in 2006. The OPM(A) illustrates the complexity of occupational performance, the scope of occupational therapy practice, and provides a framework for occupational therapy education.Kawa (River) Model (Michael Iwama)The Biopsychosocial ModelThe biopsychosocial model takes into account how disease and illness can be impacted by social, environmental, psychological, and body functions. The biopsychosocial model is unique in that it takes the client's subjective experience and the client-provider relationship as factors to wellness. This model also factors in cultural diversity as many countries have different societal norms and beliefs. This is a multifactorial and multi-dimensional model to understand not only the cause of disease but also a person-centered approach that the provider has more of a participatory and reflective role.Frames of referenceFrames of reference are an additional knowledge base for the occupational therapist to develop their treatment or assessment of a patient or client group. Though there are conceptual models (listed above) that allow the therapist to conceptualize the occupational roles of the patient, it is often important to use a further reference to embed clinical reasoning. Therefore, many occupational therapists will use additional frames of reference to both assess and then develop therapy goals for their patients or service users.As with the conceptual models discussed above, these frames of reference are used infrequently in routine clinical practice, and often obfuscate clinical decision-making. ,Biomechanical frame of reference. The biomechanical frame of reference is primarily concerned with motion during occupation. It is used with individuals who experience limitations in movement, inadequate muscle strength, or loss of endurance in occupations. The frame of reference was not originally compiled by occupational therapists, and therapists should translate it to the occupational therapy perspective, to avoid the risk of movement or exercise becoming the main focus.Rehabilitative (compensatory)Neurofunctional (Gordon Muir Giles and Clark-Wilson)Dynamic systems theoryThe client-centered frame of reference this frame of reference is developed from the work of Carl Rogers. It views the client as the center of all therapeutic activity, and the client's needs and goals direct the delivery of the occupational therapy process.Cognitive-behavioural frame of referenceEcology of the human performance modelThe recovery modelThe sensory integration framework is commonly implemented in clinical, community, and school-based occupational therapy practice. It is most frequently used with children with developmental delays and developmental disabilities such as autism spectrum disorder and dyspraxia.Core features of sensory integration in treatment include providing opportunities for the client to experience and integrate feedback using multiple sensory systems, providing therapeutic challenges to the client's skills, integrating the client's interests into therapy, organizing of the environment to support the client's engagement, facilitating a physically safe and emotionally supportive environment, modifying activities to support the client's strengths and weaknesses, and creating sensory opportunities within the context of play to develop intrinsic motivation. While sensory integration is traditionally implemented in pediatric practice, there is emerging evidence for the benefits of sensory integration strategies for adults.ICFThe International Classification of Hearing, Functioning, Disability, and Health (ICF) is a framework to measure health and ability by illustrating how these components impact one's function. This relates very closely to the Occupational Therapy Practice Framework, as it is stated that "the profession's core beliefs are in the positive relationship between occupation and health and its view of people as occupational beings".The ICF is built into the 2nd edition of the practice framework. Activities and participation examples from the ICF overlap Areas of Occupation, Performance Skills, and Performance Patterns in the framework.The ICF also includes contextual factors (environmental and personal factors) that relate to the framework's context. In addition, body functions and structures classified within the ICF help describe the client factors described in the Occupational Therapy Practice Framework.Further exploration of the relationship between occupational therapy and the components of the ICIDH-2 (revision of the original International Classification of Impairments, Disabilities, and Handicaps (ICIDH), which later became the ICF) was conducted by McLaughlin Gray.It is noted in the literature that occupational therapists should use specific occupational therapy vocabulary along with the ICF in order to ensure correct communication about specific concepts.The ICF might lack certain categories to describe what occupational therapists need to communicate to clients and colleagues. It also may not be possible to exactly match the connotations of the ICF categories to occupational therapy terms. The ICF is not an assessment and specialized occupational therapy terminology should not be replaced with ICF terminology.The ICF is an overarching framework for current therapy practices.Global occupational therapyOccupational therapy is practiced around the world and can be translated in practice to many different cultures and environments. The construct of occupation is shared throughout the profession regardless of country, culture, and context. Occupation and the active participation in occupation are now seen as a human right and is asserted as a strong influence in health and well-being.As the profession grows there is a lot of people who are traveling across countries to work as occupational therapists for better work or opportunities. Under this context, every occupational therapist is required to adapt to a new culture, foreign to their own.Understanding cultures and their communities are crucial to occupational therapy ethos. Effective occupational therapy practice includes acknowledging the values and social perspectives of each client and their families. Harnessing culture and understanding what is important to the client is truly a faster way towards independence.The World Federation of Occupational Therapists is an international voice of the profession and is a membership network of occupational therapists worldwide. WFOT supports the international practice of occupational therapy through collaboration across countries. WFOT currently includes over 100 member country organizations, 550,000 occupational therapy practitioners, and 900 approved educational programs.The profession celebrates World Occupational Therapy Day on the 27th of October annually to increase visibility and awareness of the profession, promoting the profession's development work at a local, national, and international platform.WFOT has been in close collaboration with the World Health Organization (WHO) since 1959, working together in programs that aim to improve world health.WFOT supports the vision for healthy people, in alignment with the United Nations 17 Sustainable Development Goals, which focuses on "ending poverty, fighting inequality and injustice, tackling climate change and promoting health".Occupational therapy is a major player in enabling individuals and communities to engage in "chosen and necessary occupations" and "the creation of more meaningful lives".

Please explain what and when the procedure was performed. Has the patient been seen since surgery by the physician? What was the reason provided for not seeing the patient?There is a patient abandonment issue. The person doing the surgery should do follow up for any complication related to the procedure he/she performed. Is it because of noncompliance, schedule conflict, non-payment etc?[Edit: Per additional history provided in the Comments section. The article below addresses medical management after bariatric surgery. The physician has tried to work up surgical complications. This is the section regarding nausea and vomiting. The authors mention antiemetic unless there are other issues. I hesitate to second guess what the surgeon’s train of thought is. I do think there should be response to the patient’s communications. I understand the frustration and the cost of repeat emergency room visits. Someone here has suggested contacting the chief of surgery. Post bariatric surgery recuperation can be problematic and I hope the symptoms resolve in time.Nausea and vomitingNausea and vomiting can often be helped by antiemetic or prokinetic drugs, however, some patients have chronic functional nausea and/or vomiting that does not fit the pattern of cyclic vomiting syndrome or other gastrointestinal disorders, hence particular attention should be directed to potential psychosocial factors post bariatric surgery. Therefore, low dose antidepressant medications and psychotherapy should be addressed. On demand CT scan and Gastroscopy could be the gold standard investigations in chronic situations[39,40].]World J Gastrointest Surg. 2014 Nov 27; 6(11): 220–228.Published online 2014 Nov 27. doi: 10.4240/wjgs.v6.i11.220PMCID: PMC4241489Medical management of patients after bariatric surgery: Principles and guidelinesAbd Elrazek Mohammad Ali Abd Elrazek, Abduh Elsayed Mohamed Elbanna, and Shymaa E BilasyAuthor information ► Article notes ► Copyright and License information ►This article has been cited by other articles in PMC.Go to:AbstractObesity is a major and growing health care concern. Large epidemiologic studies that evaluated the relationship between obesity and mortality, observed that a higher body-mass index (BMI) is associated with increased rate of death from several causes, among them cardiovascular disease; which is particularly true for those with morbid obesity. Being overweight was also associated with decreased survival in several studies. Unfortunately, obese subjects are often exposed to public disapproval because of their fatness which significantly affects their psychosocial behavior. All obese patients (BMI ≥ 30 kg/m) should receive counseling on diet, lifestyle, exercise and goals for weight management. Individuals with BMI ≥ 40 kg/m and those with BMI > 35 kg/m with obesity-related comorbidities; who failed diet, exercise, and drug therapy, should be considered for bariatric surgery. In current review article, we will shed light on important medical principles that each surgeon/gastroenterologist needs to know about bariatric surgical procedure, with special concern to the early post operative period. Additionally, we will explain the common complications that usually follow bariatric surgery and elucidate medical guidelines in their management. For the first 24 h after the bariatric surgery, the postoperative priorities include pain management, leakage, nausea and vomiting, intravenous fluid management, pulmonary hygiene, and ambulation. Patients maintain a low calorie liquid diet for the first few postoperative days that is gradually changed to soft solid food diet within two or three weeks following the bariatric surgery. Later, patients should be monitored for postoperative complications. Hypertension, diabetes, dumping syndrome, gastrointestinal and psychosomatic disorders are among the most important medical conditions discussed in this review.Keywords: Obesity, Bariatric surgery, Postoperative care, Body-mass index, El bannaCore tip: Obesity is a growing health concern worldwide that impacts the life of individuals both physically and psychologically. There are several well-established health hazards associated with obesity. Additionally, obese subjects are often exposed to public disapproval because of their fatness which significantly affects their psychosocial behavior. Bariatric surgery is one of the definite solutions for obesity. In this review, we will briefly discuss the general guidelines that should be considered before bariatric surgery. Also, we discuss the protocols of patients’ postoperative care and the management of medical disorders that must be considered after bariatric surgery.Go to:INTRODUCTIONObesity is a chronic disease that impairs health-related quality of life in adolescents and children. In 2010, overweight and obesity were estimated to cause 3.4 million deaths, 3.9% of years of life loss, and 3.8% of disability-adjusted life-years worldwide. Obesity is increasing in prevalence, currently, the proportion of adults with a body-mass index (BMI) of 25 kg/m or greater is 36.9% in men and 38.0% in women worldwide[1]. Attempts to explain the large increase in obesity in the past 30 years focused on several potential contributors including increase in caloric intake, changes in the composition of diet, decrease in the levels of physical activity and changes in the gut microbiome. More than 50% of the obese individuals in the world are located in ten countries (listed in order of number of obese individuals): United States, China, India, Russia, Brazil, Mexico, Egypt, Germany, Pakistan and Indonesia. Although age-standardized rates were lower in developing than in developed countries overall, 62% of the world’s obese individuals live in developing countries. Recently, United States accounted for 13% of obese people worldwide, the prevalence of obesity was 31.7% and 33.9% among adult men and women, respectively. In Canada 21.9% of men and 20.5% of women are obese. Reported prevalence rates of obesity include: 27.5% of men and 29.8% of women in Australia, 24.5% of men and 25.4% of women in the United Kingdom, in Germany 21.9% of men and 22.5% of women, in Mexico 20.6% of men and 32.7% of women, in South Africa 13.5% of men and 42% of women, in Egypt 26.4% of men and 48.4% of women, in Saudi Arabia 30% of men and 44.4% of women and in Kuwait 43.4% of men and 58.6% of women Figure ​Figure11)[2].There are several well-established health hazards associated with obesity, e.g., nonalcoholic steatohepatitis (NASH), type 2 diabetes, heart disease, chronic kidney disease, gastroesophageal reflux disease, gastrointestinal motility disorders, sexual disorders, cerebrovascular stroke, certain cancers, osteoarthritis, depression and others[3-10]. The risk of development of such complications rises with the increase of adiposity, while weight loss can reduce the risk. Bariatric surgery could be the definitive clue in many situations[11-15]. Bariatric surgery is one of the fastest growing operative procedures performed worldwide, with an estimated > 340000 operations performed in 2011. While the absolute growth rate of bariatric surgery in Asia was 44.9% between 2005 and 2009, the numbers of procedures performed in the United States plateaued at approximately 200000 operations per year[16,17]. Starting in 2006, the Center for Medicare and Medicaid Services, United States, restricted the coverage of bariatric surgery to hospitals designated as “Centers of Excellence” by two major professional organizations[18]. Medical management and follow up of patients who have undergone bariatric surgery is a challenge due to post operative complications.GENERAL GUIDELINES FOR SURGEONS/GASTROENTEROLOGISTSA well skilled physician or a surgeon has to consider the followings:(1) as the prevalence of obesity increases so does the prevalence of the comorbidities associated with obesity. Losing weight means overcoming illness at the present, complications in future and alleviating the economic burden in the present and future;(2) Overweight; BMI between 25 and 30, technically refers to excessive body weight, whereas “obesity” BMI ≥ 30 kg/m refers excessive body fat, “Severe obesity”, BMI ≥ 35 kg/m, or “morbid obesity” refers to individuals with obesity-related comorbidities. Furthermore, severe obesity and morbid obesity groups who failed dietary and medical regimens are candidates for bariatric surgery;(3) Children obesity; refers to children with BMI > 95th percentile for their age and sex and “overweight” refers to children with BMI between the 85th and 95th percentile for their age and sex;(4) Patients undergoing a bariatric operation should have a nutritional assessment for deficiencies in macro and micronutrients, also with no contraindication for such a major operation;(5) Most of bariatric procedures are performed in women (> 80%) and approximately half of these (> 40% of all bariatric procedures) are performed in reproductive aged women, accordingly, pregnancy planning and contraception options should be discussed in details with women who will undergo bariatric procedures. Fertility improves soon after bariatric surgery, particularly in middle-aged women, who were anovulatory. Additionally, oral contraceptives may be less effective in women who have undergone malabsorptive bariatric procedure. Therefore, it is better to delay pregnancy for 6-12 mo following bariatric surgery. Risk of preeclampsia, gestational diabetes, and macrosomia significantly decrease post bariatric surgery, but the risk of intrauterine growth restriction/small infants for their gestational age may increase. Body contouring surgery is in high demand following bariatric surgery;(6) All bariatric operations are accompanied with restrictive and/or malabsorption maneuvers; less food intake and malabsorption concepts;(7) The most common types of bariatric surgeries performed worldwide are Sleeve gastrectomy (SG): This procedure involves the longitudinal excision of the stomach and thus shaping the remaining part of the stomach into a tube or a “sleeve” like structure. SG removes almost 85% of the stomach (Figure ​(Figure2);2); Roux-en-Y gastric bypass (RYGB): It reduces the size of the stomach to the size of a small pouch that is directly surgically attached to the lower part of the small intestine. In this procedure, most of the stomach and the duodenum are surgically stapled and therefore, bypassed (Figure ​(Figure3);3); The laparoscopic adjustable gastric band (AGB): This is one of the least invasive procedures, where the surgeon inserts an adjustable band around a portion of the stomach and therefore, patients feel fuller after eating smaller food portions (Figure ​(Figure4).4). Bariatric surgical procedures, particularly RYGB, plus medical therapy, are effective interventions for treating type 2 diabetes. Improvement in metabolic control is often evident within days to weeks following RYGB; and(8) Complications reported following bariatric surgery vary based upon the procedure performed. Cholilithiasis, renal stone formation and incisional hernia could be the delayed phase complications; on the other hand, bleeding, leaking, infection and pulmonary embolism could be the early phase complications following the bariatric procedure. The overall 30-d mortality for bariatric surgical procedures worldwide is less than 1%.Roux-in Y Gastrectomy, sleeve gastrectomy. and adjustable gastric band.POST OPERATIVE CARE AND FOLLOW UPEarly post operative period; (1-3) d post bariatric surgeryPatients undergoing a bariatric operation are admitted to the post-anesthesia care unit (PACU) immediately at the conclusion of the operation. Usually, on postoperative day (POD) one, we begin oral therapy in tablet or crushed-tablet and liquid form if there is a naso-gastric tube after the gastrografin leak test. A basic metabolic profile (e.g., complete blood count, electrolytes, renal function, liver function, prothrombin time and partial thromboplastin time) should be obtained every 12 h for the successive two PODs, then every 24 h for another 3 d. Oxygen is administered by nasal cannula and weaned thereafter. The likelihood that, early specific complication, will arise for a given patient is determined by the nature of the procedure, the anesthetic techniques used, and the patient’s preoperative diseases. Respiratory problems are common complication in the early postoperative period following bariatric surgery. Patients with significant comorbidities, particularly neuromuscular, pulmonary, or cardiac problems are at a higher risk for respiratory compromise, but any patient can develop hypoxemia following bariatric surgery. For prophylaxis against Deep Venous Thrombosis (DVT) following bariatric surgeries, ultrasound evaluation is recommended for all patients, D-dimer test should be applied for suspected patients with DVT, especially after long operative time, repeat ultrasound or venography may be required for those with suspected calf vein DVT and a negative initial ultrasound investigation[19,20].Late post operative monitoringAfter the PACU period, most patients are transferred to the inpatient surgical postoperative unit. For the next 24-72 h, the postoperative priorities include ruling out an anastomotic leak following laparoscopic RYGB or laparoscopic SG. If no leak is observed, patients are allowed to start a clear liquid diet and soft drinks. The postoperative care team cares for the following: control of pain, care of the wound, continuous monitoring of blood pressure, intravenous fluid management, pulmonary hygiene, and ambulation. Post-bariatric nausea and vomiting is directly correlated with the length of the surgery; it also increases in females, non-smokers, and those patients with prior history of vomiting or motion sickness. Prophylaxis with pharmacologic treatment before the development of post operative nausea and vomiting significantly reduces its incidence after surgery[21-23].After hospital dischargeDiet: Usually patients are discharged 4-6 d after surgery. Most patients are typically discharged from the hospital on a full liquid diet, patients should be taught to keep monitoring their hydration and urine output. Approximately two-three weeks after surgery, the diet is gradually changed to soft, solid foods. The average caloric intake ranges from (400) to (800) kcal/d for the first month, and thus the daily glycemic load is greatly reduced. We encourage patients to consume a diet consisting of salads, fruits, vegetables and soft protein daily.To control the epigastric pain and vomiting, patients should be taught to eat slowly, to stop eating as soon as they reach satiety and not to consume food and beverages at the same time. For most patients suffering chronic vomiting, prokinetic therapy and proton-pump inhibitors (PPIs) should be considered. Patients, who underwent SG, LAGB or RYGB, benefit from a well-planned dietary advancement. Patients should understand that the surgery has changed their body but not the environment, they have to choose healthy foods, do not skip meals and to visit the dietitian regularly in the first 12 mo after surgery. However, if food intolerance develops, patients may choose a more vegetarian-based diet. Nevertheless, fresh fruits and vegetables are usually tolerated without a problem. The daily protein intake should be between 1.0 to 1.5 g/kg ideal body weight per day[24]. The biliopancreatic diversion/duodenal switch (BPD/DS) is a malabsorptive procedure for both macro- and micronutrients. Hence, we encourage higher protein intake of 1.5 g to 2.0 g of protein/kg ideal body weight per day, making the average protein requirement per day approximately 90 g/d[25,26]. Alcohol is better prevented in the first 6-12 mo after surgery[27].Monitoring: Patients should generally have their weight and blood pressure measured weekly until the rapid weight loss phase diminishes, usually within 4-6 mo, then again at 8, 10 and 12 mo, and annually thereafter. Patients with diabetes are encouraged to check their blood glucose daily. Glycemic control typically improves rapidly following bariatric surgery. Patients maintained on antihypertensive or diabetic medications at discharge should be monitored closely for hypotension and hypoglycemia, respectively, and medications should be adjusted accordingly. We recommend that the following laboratory tests be performed at three, six, nine months and annually thereafter: (1) Complete Blood Count; (2) Electrolytes; (3) Glucose and Glucose Tolerance test; (4) Complete iron studies; (5) Vitamin B12; (6) Aminotransferases, alkaline phosphatase, bilirubin, GGT; (7) Total protein and Albumin; (8) Complete lipid profile; (9) 25-hydroxyvitamin D, parathyroid hormone; (10)Thiamine; (11) Folate; (12) Zinc; and (13) Copper.Complications following the surgical treatment of severe obesity vary based upon the procedure performed. Secondary hyperparathyroidism, Hypocalcemia, Gastric remnant distension, Stomal stenosis/Obstruction, Marginal ulcerations, Cholilithiasis, Ventral incisional hernia, Internal hernia, Hiatus Hernia, Short bowel syndrome, Renal failure, Gastric prolapse, infection, Esophagitis, Reflux, Vomiting, Hepatic abnormalities and dumping syndrome are common late-phase complications after bariatric surgery. However, the clinician should aware of complications specific for every bariatric procedure[28,29]. Before therapy, the clinician should understand that the impact of various bariatric surgeries on drug absorption and metabolism are scarce. On the other hand, RYGB and other malabsorptive procedures that significantly exclude the proximal part of the small intestine, decrease the surface area where most drug absorption occurs and may result in a reduction in systemic bioavailability[30-32].Go to:COMMON MEDICAL CONDITIONS FOLLOWING BARIATRIC SURGERYHypertensionHypertension is not always related to obesity, and dietary interventions do not assure the normalization of blood pressure. However weight loss, whether by an intensive lifestyle medical modification program or by a bariatric operation, improves obesity-linked hypertension. Patients should be monitored weekly until the blood pressure has stabilized, and patients may need to resume antihypertensive medications, but often at adjusted doses[33].DiabetesPatients with diabetes should have frequent monitoring of blood glucose in the early postoperative period and should be managed with sliding scale insulin. Many diabetic patients have a decreased need for insulin and oral hypoglycemic agents after bariatric surgery. Oral sulfonylureas and meglitinides should be discontinued postoperatively as these medications can lead to hypoglycemia after bariatric surgery. Metformin is the safest oral drug in the postoperative period, since it is not associated with dramatic fluctuations in blood glucose. RYGB is associated with durable remission of type 2 diabetes in many, but not all, severely obese diabetic adults. However those who underwent LAGB generally exhibit a slower improvement in glucose metabolism and diabetes as they lose weight in a gradual fashion[34,35].RefluxMedications for gastroesophageal reflux disease (GERD) may be discontinued after RYGB and Laparoscopic AGB, however, SG has been associated with an increased incidence of GERD in some procedures. Recurrent GERD symptoms after RYGB, particularly when accompanied by weight regain, should raise the possibility of a gastrogastric fistula between the gastric pouch and remnant, and should be investigated by an upper GI contrast study or CT scan and referred to the bariatric surgeon. Upper endoscopy is the best investigation to exclude other esophagogastroduodenal disorders. GERD may be associated with esophageal complications including esophagitis, peptic stricture, Barrett’s metaplasia, esophageal cancer and other pulmonary complications. Failure of the PPI treatment to resolve GERD-related symptoms has become one of the most common complications of GERD after bariatric surgery. Most patients who fail PPI treatment have Non Erosive Reflux Disease and without pathological reflux on pH testing. In patients with persistent heartburn despite of medical therapy, it is reasonable to recommend avoidance of specific lifestyle activities that have been identified by patients or physicians to trigger GERD-related symptoms[36-38].Nausea and vomitingNausea and vomiting can often be helped by antiemetic or prokinetic drugs, however, some patients have chronic functional nausea and/or vomiting that does not fit the pattern of cyclic vomiting syndrome or other gastrointestinal disorders, hence particular attention should be directed to potential psychosocial factors post bariatric surgery. Therefore, low dose antidepressant medications and psychotherapy should be addressed. On demand CT scan and Gastroscopy could be the gold standard investigations in chronic situations[39,40].Marginal ulcerationDue to increased risk of ulcer formation from nonsteroidal anti-inflammatory drugs (NSAIDs), these medications should be discontinued postoperatively, especially after RYGB. NSAID use is associated with an increased risk of bleeding. If analgesic or anti-inflammatory treatment is needed, the use of acetaminophen is preferred in a dose of 1-2 g/daily[41-45]. Other factors associated with increased risk of ulcer formation are smoking, alcohol, spicy food, gastrogastric fistulas, ischemia at the site of surgical anastomosis, poor tissue perfusion due to tension, presence of foreign material, such as staples and/or Helicobacter pylori infection. Diagnosis is established by upper endoscopy. According to our strategy, all patients should undergo diagnostic upper endoscopy to exclude congenital or GI diseases prior to bariatric procedures. Medical management is usually successful and surgical intervention is rarely needed[46-48].Go to:DUMPING SYNDROMEDumping syndrome or rapid gastric emptying is a group of symptoms that most likely occur following bariatric bypass. It occurs when the undigested contents of the stomach move too rapidly into the small intestine. Many patients who underwent bariatric bypass experienced postprandial hypoglycemia. However, the dumping syndrome usually occurs early (within one hour) after eating and is not associated with hypoglycemia. It is presumed to be caused by contraction of the plasma volume due to fluid shifts into the gastrointestinal tract. Dumping syndrome may result in tachycardia, abdominal pain, diaphoresis, nausea, vomiting, diarrhea, and sometimes, hypoglycemia. The late dumping syndrome is a result of the hyperglycemia and the subsequent insulin response leading to hypoglycemia that occurs around 2-3 h after a meal. Dumping syndrome is a common problem that occurs in patients who have undergone RYGB and when high levels of simple carbohydrates are ingested. Accordingly, patients who have experienced postgastric bypass bariatric surgery should avoid foods that are high in simple sugar content and replace them with a diet consisting of high fiber and protein rich food. Eating vegetables and salad is encouraged; beverages and alcohol consumption are better avoided[49].Go to:PSYCHOSOMATIC DISORDERS/DEPRESSIONMany patients usually experience enhanced self esteem and improved situational depression following weight loss. Depression often requires continued treatment, specially that, many patients with severe obesity often use food for emotional reasons. Therefore, when those patients experience a small gastric pouch postoperatively they may grieve the loss of food. Many studies documented the relationship between eating disorder and anxiety disorder, depression or schizophrenia[50,51]. Displaced emotions can result in somatization with symptoms of depression and psychosomatic disorders. It is important that clinicians recognize the psychological aspect of food loss after bariatric surgery, and reassure patients that the symptoms are related to the small gastric pouch size. Antidepressants often help to decrease the anxiety related to grieving associated with food loss, although the use of antidepressants needs to be approached with an empathetic style. Behavioral and emotive therapies are reported to be very helpful[52,53].Go to:OUTCOMEBariatric surgery remains the only effective sustained weight loss option for morbidly obese patients. The American Society for Metabolic and Bariatric Surgery estimated that in 2008 alone, about 220000 patients in the United States underwent a weight loss operation. The optimal choice for type of bariatric procedure, i.e., RYGB, SG, AGB or the selected surgical approach, i.e., open versus laparoscopic depends upon each individualized goals, i.e., weight loss, glycemic control, surgical skills, center experience, patient preferences, personalized risk assessment and other medical facilities. Laparoscopic sleeve gastrectomy is the most common bariatric procedure. However weight re-gain after long-term follow-up was reported[54-58]. Prospective studies and reviews report a general tendency for patients with metabolic disorders to improve or normalize after bariatric surgery. However weight loss is highly variable following each procedure. Recent studies have evaluated the potential impact of obesity on outcomes in organ-transplant recipients, for example bariatric surgery may be an important bridge to transplantation for morbidly obese patients with severe heart failure[59-63].Go to:RECENT ADVANCES IN BARIATRIC SURGERYA modified intestinal bypass bariatric procedure (Elbanna operation), reported a novel surgical technique designed to maintain good digestion, better satiety, and selective absorption with less medical and surgical complications (Figure ​(Figure5).5). This procedure preserves the proximal duodenum and the terminal ileum and thus preserving the anatomical biliary drainage and enterohepatic circulation[64,65].Figure 5Novel ElBanna surgical procedure.Recently, a novel bariatric technique dedicated; Modified Elbanna technique in childhood bariatric, showed promising success in pediatric surgeries (non published data).Go to:CONCLUSIONThe rising prevalence of overweight and obesity in several countries has been described as a global pandemic. Obesity can be considered like the driving force towards the pre-mature deaths. It increases the like hood for the development of diabetes, hypertension and NASH. The American Heart Association identified obesity as an independent risk factor for the development of coronary heart disease. In order to minimize post-surgical cardiovascular risk, surgical weight loss may become a more frequently utilized option to address obesity. Currently, bariatric surgery passes through a plateau phase, hence medical management and follow up of patients who have undergone bariatric surgery is a challenge.Go to:FUTURE RECOMMENDATIONSChildren obesity has become one of the most important public health problems in many industrial countries. In the United States alone, 5% of children have severe obesity. It is imperative that health care providers should identify overweight and obese children so as to start early counseling and therapy. To establish a therapeutic relationship and enhance effectiveness, the communication and interventions should be supported by the entire family, society, school, public media and primary health care. Bariatric surgery could be considered in complicated cases that failed all other options.Go to:FootnotesP- Reviewer: Amiya E, Firstenberg MS, Narciso-Schiavon JL S- Editor: Tian YL L- Editor: A E- Editor: Lu YJGo to:References1. 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