Definition/Introduction

The dressing is considered an essential daily living activity, together with eating, bathing, or toileting; we can find a definition in the International Classification of Functioning, Disability, and Health (ICF) published by the World Health Organization (WHO), which allows the description and classification of functioning from a general point of view. The dressing is defined as the correct and coordinated development of putting on and taking off clothes and footwear in an appropriate way, according to the climatic and social conditions. On the other hand, disability is a term that has developed during the history until turning into a multidimensional concept nowadays; disability involves damaging in body structures or functions, capacity limitations, environment, and participation.[1]

Issues of Concern

According to the WHO, around 15% of the global population lives with some type of disability. The rising of life expectancy in most of the countries around the world causes aged populations and an increment of chronic health conditions. This epidemiological change involves an increase in the prevalence of disability, especially the one related to the essential daily living activities, such as dressing. Dressing disability is more evident during the last 24 to 36 months before death.[2][3] Moreover, disability has related to acute medical illness, as one of the after-effects during the first six months after hospitalization, especially in cases of trauma, neurological, and other severe conditions. The prevalence of people living with a disability is expected to double by 2050.[4][5]

Clinical Significance

Aging is one of the main factors directly associated with disability. Moreover, aging is a determining factor related to worse nutritional status and frailty, which are other indirect conditions that predict the onset of disability, morbidity, and mortality.[6][7][8] Not only aging is within the significant causes of disability, but it could also relate to many different diseases, such as muscular diseases (muscular dystrophy), traumatic conditions (spinal cord injuries or hip fracture), and especially, neurological impairment, such as, for example:

Dementia:  it is a neurological disorder, with many subtypes of which Alzheimer's is the most common. Dementia is characterized by a decline of one or more cognitive functions of the brain (language, memory, perceptual-motor) that is severe enough to interact with the daily activities and the independence of a person.

Parkinson disease: it is a neurodegenerative disease whose cardinal symptoms are related to the motor system (tremor, bradykinesia, rigidity, and postural instability). It is also common to find other manifestations, especially neuropsychiatric, which make Parkinson disease a condition with a significant impact on the quality of life of these patients.

Stroke: it is cerebrovascular disease, with two main subtypes: ischemic or hemorrhagic. Ischemic is the most common, usually with an atherothrombotic etiology and risk factors (hypertension, diabetes mellitus, dyslipidemia, smoking, and aging); it makes the blood perfusion of specific brain areas to fail, causing different neurological manifestations. If the vascular event is severe enough, infarction and permanent neuronal loss can happen. Depending on the affected area, the symptoms and signs may vary; it is frequent seeing hemiparesis or hemiplegia (weakness or paralysis in half of the body), sensory loss, dysphagia, speech impairment, or body schema disorder, among others. Stroke is the first cause of disability in industrialized countries. Therefore, timely interventions and rehabilitation play an important role in the prevention and treatment of these patients.[9]

Dressing disability is assessable using different scales and indexes. These methods provide us with an idea of the requirements, demands, and vulnerabilities of people. There are different types of indexes for evaluation of the essential daily living activities (DLA), such as the Katz Index, the Functional Independent Measure, and the Barthel Index for Activities of Daily Living.[10]

The Katz ADL and The Barthel Index are probably the most commonly used. They assess functional independence in different areas, such as feeding, bathing, grooming, dressing, bowel and bladder control, toilet use, transfer, and mobility in different circumstances. Each section has a scale and punctuation to assign; the dressing scale includes +1 for the independent, and +0 for those who are unable in the Katz ADL, and +10 for the independent, +5 for those needing help, and +0 for those who are unable in the Barthel Index.[11]

Nursing, Allied Health, and Interprofessional Team Interventions

Disability changes dramatically the life of those who suffer any disabling condition, but also for the patient's relatives and persons close to them. Management of dressing disability should be global, including medical, psychological, social, political, and economical. The measures to approach the problems derived from disability vary from simple measures to very complex and global strategies that must be taken by the governments. They should include disease prevention, doctors and allied professional training, rehabilitation, occupational therapists interventions, caring strategies, and sociopolitical initiatives.

Regarding dressing disability, above all, it is important to highlight the importance of a multidisciplinary approach, especially rehabilitation and occupational therapy interventions. Firstly, rehabilitation primarily focuses on maintaining and improve the physical condition, which enhances the quality of life, socialization, and can have positive effects on certain diseases, delaying its development.[12] On the other hand, occupational therapy focuses on assisting people and caregivers; it is a discipline whose main goal is helping the patient through educational advice, compensatory strategies, activity modifications, and environmental accommodations to achieve the highest level of independence and optimum level of function.[13]

Some interventions try to help to adapt to the new life of the disabled people and their careers. As more global, for instance, modifying clothes and shoes (open back shirts; slip-on shoes; snaps, magnets or velcro instead of buttons;  zippers, etc.), furthermore, some assistive devices like shoe horns or button hooks, which are very useful for people with damaged fine mobility or decreased range of movements.

In patients with hemiplegia/hemiparesis and other conditions causing weakness and dressing disability, it is of major importance to teach and advise the patients and careers about how to get dressed. It is useful to sit down to gain the support and stability of the body.

Specific instructions should be given depending on the garment. In the case of a shirt, it should be unbuttoned, the damaged or weaker arm should go first into the sleeve, using the stronger arm to help; then, the shirt should be adjusted from the back again with the stronger arm to place it into the other sleeve, the better hand should fasten the garment. In the case of a pullover and similar garments that go over the head, the method is similar, with the damaged arm being placed firstly into the sleeve, and then use the better arm to place the neck opening over the head, and finish placing the better arm into the other sleeve. For trousers, the weaker leg should be placed over the stronger one so as to put it into the trouser leg, after that, it is easier to put the better leg into the other trouser leg, the stronger or both arms are of great help to make these maneuvres; then, depending on the balance, we can advise the patient to stand up or lie down in the bed to finish pulling the trousers up over the hips. Finally, In the case of socks, it may be useful placing the foot on a stool or crossing one leg over the other, then, using the better hand, the sock can be placed into the weaker foot first. To undress requires the reverse of the steps mentioned above.

From a more concrete point of view, occupational therapy makes a specific work though differents interventions in the more disabling diseases. All these strategies become essential to achieve and maintain optimal functioning.[14] Some of these interventions are:

• Optimizing the day structure and routine, to handle in a better way the time and energy, improving cognition and feelings.
• Education and coaching can motivate the patients to participate in adapting and to apply self-management with an active role. This point is especially important in the OT interventions for children with disabilities, with the purpose of driving them to improve developing their personal independence, and participation in their daily life roles. In this sense, this intervention can be named the backward chaining, an effective intervention to teach complex behavior involving multiple steps in a sequence giving up the assistance gradually from the last step to the first.[15][16]
• The patient needs strategies for motor complex sequences, such as manual activities, like dressing or doing handworks. These strategies are carried out in the following steps: the therapist observes the patient during the activity to analyze which components are limited. After that, the therapist helps the patient recognizing the activity and selecting the most optimal movement components. The sequence of components has to be summarized in key phrases, preferably supported by visuals (auditory cues can also help). Then the patient is guided in the performance the steps aloud (motor imagery has a positive influence) to integrate it.[17]

Psychological care should always be a consideration in this group of people. Disability results in a condition where an individual has fewer opportunities for favorable contact with their social environment. This isolation has a negative influence on mental health and well-being and should also be managed accordingly in multidisciplinary teams, with patients, families, psychologists, and doctors.[18]