Hand Rehabilitation: A Client-Centered and Occupation-Based Approach Debbie

Hand Rehabilitation: A Client-Centered and Occupation-Based Approach Debbie

Hand Rehabilitation: A Client-Centered and Occupation-Based Approach Debbie Amini, MEd, OTR/L, CHT Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 1 Learning Objectives At the conclusion of this session, participants will be able to Identify the principles and theories grounding the client-centered and occupation-based approach to intervention, Identify techniques and strategies for creating a client-centered and occupation-based milieu within the hand rehabilitation setting, Identify the process for documenting the intervention plan and

intervention when using an occupation-based approach to intervention in the hand rehabilitation setting, and Recognize how the concepts of client-centered and occupationbased intervention are used in the hand rehabilitation setting. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 2 Lessons From Our History Robert K. Bing 1981 Eleanor Clark Slagle Lecturer (see Bing, 2005) We must refuse to accept any alternative to the belief in the wholeness of the humanthat the mind and body are inextricably conjoined. Illness, treatment, and the return to a healthful state simultaneously affect the physiological and emotional processes. Should these processes ever become separated, then occupational therapy would be of no value. The patient has died!

Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 3 Lessons From Our History (cont.) No amount of neurophysiology, psychology, sociology, or child development alone can determine the differential diagnosis, treatment, or prognosis of the patient undergoing occupational therapy. The current trend toward specialization, with its varying emphases upon one or another science, to the neglect of other human sciences, and indeed to the neglect of other nonscientific aspects of occupational therapy, borders on superstition and mythology. It is the continuous acquisition and scientific synthesis of the ingredients of the human organism and its surround that

guarantees authentic occupational therapy. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 4 Differentiation of Occupational Therapy Any definition, any description, any differentiation between ourselves and other health providers must have as its major theme occupation and leisure. Without it, we become a blurred copy, a xerography of a host of others. Without the dynamics of human motion inherent in purposeful activity, we become quasiphysical therapists. Without the interaction between human objects and the objects of work and leisure, we become quasisocial workers, psychologists, or nurses. The more we intermingle our fundamental philosophy and our

treatment techniques with others, the more likely we will become enfeebled, the more likely we will degenerate, the more likely we will eventually disappear. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 5 Roots of Hand Rehabilitation In the United States, Sterling Bunnell was designated to oversee the development of hand services being created at nine army hospitals during the Second World War. These programs focused on a team approach to treating those with upper extremity injuries and included the assistance of existing physical and occupational therapy departments (Hunter, 2002). Hand therapy is considered a practice area requiring training beyond traditional occupational therapy and physical therapy training programs.

Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 6 Roots of Hand Rehabilitation (cont.) Paul Brand (19142003) was a pioneer in the treatment of Hansens disease and used physical therapy to support his orthopedic care. As can be seen in many of his writings, Brand was a highly spiritual man who believed strongly in the mindbody connection and the importance of addressing both in care of the client. His early years were spent in India; he came to the United States in 1966. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 7

Roots of Hand Rehabilitation (cont.) In San Francisco at the 1975 American Society for Surgery of the Hand (ASSH) meeting, a small group of two physical therapists and four occupational therapistsrepresenting various work settings (doctor based, hospital based, and private)met and laid the groundwork for what would become the American Society of Hand Therapists (Hand Therapy Certification Commission [HTCC], 2008). In 1991, the HTCC, which was created by ASHT, administered the first Hand Therapy Certification Examination (HTCC, 2008). Today, 85% of practitioners holding the Certified Hand Therapist (CHT) credential are occupational therapists and 15% are physical therapists (HTCC, 2008). Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 8

Occupation-Based Treatment and the Occupational Therapy Practice Framework (Framework II) The Framework document was first introduced in 2002 (American Occupational Therapy Association [AOTA], 2002). The 2nd edition was published in 2008 (AOTA, 2008). The profession of occupational therapy is concerned with supporting health and participation in life through engagement in occupation (AOTA, 2008, p. 626). Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 9 Thoughts From the Framework II Engagement in occupation [is] the focus of occupational therapy

intervention [and] involves addressing both subjective and objective aspects of performance. Occupational therapy practitioners understand engagement from this dual perspective and address all aspects of performance when providing interventions. (AOTA, 2008, p. 628) Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 10 Thoughts From the Framework II (cont.) According to Wilcock and Townsend, [occupational therapy] practitioners recognize that health is supported and maintained when clients are able to engage in occupations and activities that allow desired or needed participation in home, school, workplace and community life. Thus [occupational therapists] are concerned . . . with the complexity of factors that empower and make possible clients

engagement and participation in positive health promoting occupations. (AOTA, 2008, p. 629) Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 11 Thoughts From the Framework II (cont.) [O]nly occupational therapy practitioners focus . . . toward the endgoal of supporting health and participation in life through engagement in occupations. [Occupational therapists] also use occupations as a method of intervention implementation by engaging clients throughout the process in occupations that are therapeutically selected. The professions use of occupation as both means and end is a unique application of the process. (AOTA, 2008, p. 646) Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American

Occupational Therapy Association at www.copyright.com 12 Domain of Occupational Therapy Areas of occupation Activities of daily living (ADLs) Instrumental ADLs Leisure Work Play Education Rest and sleep Social participation Performance Skills Sensory and perceptual

skills Motor and praxis skills Emotional regulation skills Cognitive skills Communication and social skills Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 13 Domain of Occupational Therapy (cont.) Performance Patterns Habits Routines Roles

Rituals Client Factors Values, beliefs, and spirituality Body functions Body structures Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 14 Domain of Occupational Therapy (cont.) Context and Environment Cultural Personal Physical

Social Temporal Virtual Activity Demands Objects used and their properties Space demands Social demands Sequencing and timing Required actions Required body functions Required body structures Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 15

Process of Occupational Therapy Occupational therapy is a process comprising the following: Evaluation: Occupational profile, analysis of occupational performance Intervention: Intervention plan, implementation, review Outcomes: Determination of success in reaching desired targeted outcomes. Outcome assessment information is used to plan future actions with the client and to evaluate the service program. Occupational therapy is client-centered; the client is an active participant in the treatment process. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 16

Occupational Therapy Interventions Therapeutic Use of Self Occupations and Activities Preparatory methods: Activities that are done to a client, such as splinting, physical agent modalities (PAMs), and passive range of motion (PROM). Purposeful activity: The client engages in specifically selected activities that allow him or her to develop skills that enhance occupational engagement. Occupation-based intervention: The client engages in clientdirected occupations that match identified goals. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 17 Occupation-Based Treatment What it IS:

An approach to treatment that serves to facilitate engagement or participation in a recognizable life endeavor (Christiansen & Townsend, 2004) A departure from a medical model approach to incorporate the clients meaningful and relevant occupations into the occupational therapy intervention plan (Baum & Baptiste, 2005). Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 18 Occupation-Based Treatment (cont.) What it is NOT: A treatment approach that accomplishes therapist-designed goals through provision of isolated and possibly irrelevant activities.

An approach whereby activities (which are sometimes embedded within occupations) are valued more than the occupation itself. A treatment approach that ignores client factors (spirituality, body functions, and structures) as contributing to the occupational well-being of the client. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 19 Occupation-Based Treatment (cont.) Why it is important: People derive satisfaction from successfully accomplishing tasks that they find meaningful in their lives. Predictors of well-being include a sense of efficacy and minimized stress which can result from involvement in desired activities. This phenomenon is important to occupational

therapists, whose roles are instrumental to assisting people to overcome functional limitations and enable them to engage in and complete valued occupations (Christiansen, Backman, Little, & Nguyen, 1999). Studies show significant relationships between the characteristics of persons' goal-related daily occupations and their dysfunctional states, whether physical or psychological. This speaks to the importance of considering the person, his or her occupations, and the contexts in which occupations are conducted (Christiansen, Backman, & Little, 1998). Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 20 Occupational Deprivation Wilcock (1998) described occupational deprivation as a state wherein clients are unable to engage in chosen meaningful life occupations because of factors outside their control. Disability,

incarceration, and geographic isolation are examples of circumstances that create occupational deprivation. Occupational deprivation can lead to depression, isolation, difficulty with social interaction, inactivity, boredom, and a diminished sense of self. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 21 Occupational Deprivation (cont.) The effects of tissue healing sometimes must take precedence over the ability of the client to engage in component activities. However, occupational dysfunction and potential deprivation must be minimized as soon as possible and as thoroughly as possible (McKee & Rivard, 2004). A study published in the March 2002 issue of the Journal of

Occupational and Organizational Psychology found that among people who are unemployed, involvement in meaningful leisure activities (not simply busywork activities) decreased the sense of deprivation (Walters & Moore, 2002). Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 22 Occupation-Based Approach The article How Routine Facilitates Wellbeing in Older Women in Occupational Therapy International described how consistency and routine help maintain the ability to meet obligations, activity level, health, control and balance of ADLs, self-esteem, and motivation for activities (Ludwig, 1997). A 2007 article in the Journal of Hand Surgery supported the premise that providing ADL-based activities early in the hand rehabilitation process expedites the return of function in young

(i.e., third-decade) hand-therapy clients (Guzelkucuk, Duman, Taskaynatan, & Dincer, 2007). Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 23 Occupation-Based Approach (cont.) Palmadottir (2003) completed a qualitative study that explored the clients perspective on the occupational therapy experience. The study concluded that clients experienced positive outcomes of therapy when treatment was client centered and held purpose and meaning for them. Supporting health and participation in life through engagement in occupation (AOTA, 2008) forms the backbone of the Framework and is a defining feature of the profession of occupational therapy. To practice occupation-based treatment is to return to

authentic occupational therapy practice. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 24 Traditional Hand Rehabilitation Model Functional Person Injury Pain Stiffness Edema Scar

Weakness Functional impairment Hand Therapy Method and Modality Decreased pain stiffness edema scar weakness Functional

Client Improved function Figure 1. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 25 Model of Occupation-Based Hand Rehabilitation ADLs, IADLs, Work, Leisure, Social Participation,

Education, Play, Rest and sleep Functional Person Injury Context and Desires of Client Adaptation, Compensation Education, Psychosocial support Resolved

dysfunction Dysfunction OccupationBased Activity Decreased ROM, strength, endurance, pain, scar Traditional hand therapy and preparatory techniques

Functional Client Resolution of injury Figure 2. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 26 Characteristics of Occupation-Based Hand Rehabilitation Focuses on long-range goals that promote return to function in all performance areas (occupations). Links deficits in performance to the underlying pathology versus

attempting to link pathology to performance deficits (top down approach). Links activities to occupational performance to encourage a more holistic view of the client and his or her context. Intervention methods are selected on the basis of their merit for simulating or reproducing real-life occupations. Gives immediate attention to dysfunction. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 27 Characteristics of Occupation-Based Hand Rehabilitation (cont.) Gives immediate attention to eight areas of occupation to avoid occupational deprivation. Uses adaptive equipment and compensatory techniques to

maximize participation while waiting for tissue healing. A treatment approach that recognizes and balances the biomechanical, rehabilitative and client centered frames of reference. Is not the consistent use of contrived activities to simulate ADLs or work tasks. (These are adjuncts and do not define occupationbased treatment.) Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 28 Areas of Hand Rehabilitation Not Changed by Occupation-Based Practice Does not substitute for the need to follow medically sound treatment protocols Will not completely replace the biomechanical frame of reference Does not negate the positive effects of such preparatory techniques as PAMs and splinting

Will not negatively affect productivity or increase cost within the hand therapy clinic. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 29 Rationale for Considering Occupation in Hand Rehabilitation To support the profession of occupational therapy AOTAs Centennial Vision (AOTA, 2007; in 2017, occupational therapy will be 100!) [O]ccupational therapys new vision must be strongly expressed by stakeholders in education, practice, and research. It must be acknowledged by individuals, associations agencies, and higher education institutions. [T]he profession must adopt a unified focus, thereby

creating . . . a profession committed to creating healthier, satisfying lifestyles for the benefits of those we serve. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 30 Rationale for Considering Occupation in Hand Rehabilitation (cont.) Occupation-based treatment provides quality client outcomes Avoids occupational deprivation Is grounded in: Occupational science Published qualitative research Anecdotal examples and case studies. Centers for Medicare and Medicaid Services (CMS; 2006) guidelines Client-centered treatment is encouraged by all fields of medicine in this era of health care. This concept is not exclusive to occupational

therapy. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 31 Assessments Supporting OccupationBased Hand Rehabilitation (OBHR) The Canadian Occupational Performance Measure, 4th edition (COPM; Law et al., 2005) is an interview-based assessment tool created for use in a client-centered approach to occupational therapy. The COPM assists the therapist in identifying problems in performance areas. Additionally, client perceptions of their ability to perform in the identified problem areas and their satisfaction with this ability are determined with the COPM. Figure 3. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com

32 Assessments Supporting OBHR (cont.) Figure 4. The COPM (Law et al., 2005). Image copyright 2005 by Mary Law. Used with permission. The COPM is available through AOTA. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 33 Assessments Supporting OBHR (cont.) The Disabilities of the Arm, Shoulder, and Hand assessment (DASH; Institute for Work and Health, 2006) is a conditionspecific assessment tool that measures the clients perception of

how current upper-extremity disability has affected function. Unlike the COPM, the DASH comprises 30 predetermined questions about function within performance areas. The client is asked to rate his or her recent ability to complete skills such as opening a jar or turning a key on a scale of 1 to 5 (1 = no difficulty, 5 = unable). Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 34 Assessments Supporting OBHR (cont.) As with the COPM, the DASH assists with the development of the occupational profile through valid and reliable measure of clients functional abilities. The client-centered merit of this tool is that the information obtained is about the client and his or her functional abilities. The focus is not on body structures or on the signs and

symptoms of a particular diagnosis. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 35 Assessments Supporting OBHR (cont.) Figure 5. The DASH assessment (Institute for Work and Health, 2006). Image Copyright 2006 by the Institute for Work and Health. All rights reserved. Used with permission. The DASH is available free from www.dash.iwh.on.ca Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com

36 Assessments Supporting OBHR (cont.) The Patient-Rated Wrist/Hand Evaluation (PRWHE; MacDermid & Tottenham, 2004) is also a condition-specific tool through which the client rates pain and functional abilities in 15 pre-selected areas. As with the COPM and the DASH, the PRWHE assists with the development of the occupational profile through valid and reliable measure of the clients functional abilities. The functional areas identified in the PRWHE are generally much broader than those in the DASH but are not open categories, as in the COPM. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 37

Assessments Supporting OBHR (cont.) The Activity Card Sort (ACS) is primarily a tool for older adults. According to the authors, The ACS is a flexible and useful measure of occupation. The ACS allows the practitioner to help clients describe their instrumental, leisure, and social activities. . . . The information obtained by administering the ACS will provide the therapist with an occupational history and the information to help the client build routines of activities that are meaningful and healthful. (Baum & Edwards, 2008, p. 5) Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 38 Assessments Supporting OBHR (cont.)

Figure 6. The ACS (Baum & Edwards, 2008). The ACS is available through AOTA. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 39 Assessments Supporting OBHR (cont.) The Perceived Efficacy and Goal Setting System (PEGS; Missiuna, Pollock, & Law, 2004) is a pediatric assessment tool that enables the child, parent, and teacher to participate in reporting the childs performance on daily tasks and identifying goals for intervention. It

can be administered to children with a variety of functional impairments. It provides children with the opportunity to share their perceptions of their current performance with daily living activities. Figure 7. The PEGS assessment (Missiuna et al., 2004). Copyright 2004 by NCS Pearson, Inc. Reproduced with permission. All rights reserved. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 40 Traditional Hand Rehabilitation Assessment vs.

Occupational Profile Method Goniometers, dynamometers, and monofilaments Are used to measure client factors; Provide limited knowledge about clients and their contextual life issues; Encourage client factors to become the focus of intervention, and improving client factors becomes the goal of treatment (addressing client factors does not always treat the functional deficit); and Must remain as adjuncts to treatment, because physical functioning is an adjunct to occupational engagement. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 41 Writing Occupation-Based Goals Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American

Occupational Therapy Association at www.copyright.com 42 Importance of Occupation-Based Goals Documentation should and must support the profession of occupational therapy. Occupational therapy works toward functional outcomes with the client as the active participant. We must continually talk the talk to reinforce the efficacy and importance of occupational therapy services. We must support and identify the scope of practice to all outside agencies and consumers. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 43

Importance of Occupation-Based Goals (cont.) Consistent documentation of our scope of practice may influence trends in reimbursement. For purposes of reimbursement, appropriate and effective clinical practice is objectively determined by how we assess and treat our patients. This can only be communicated through appropriate documentation. Good documentation is extremely important for reimbursement. Medicare has expanded utilization review to ensure accurate reimbursement for services. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 44

Importance of Occupation-Based Goals (cont.) The focus of the problems, goals, and interventions must be on the client with whom we are working. The client should be at the center of all documentation. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 45 Creating Occupation-Based Goals Begin with client centered evaluation, including occupational profile and occupational analysis. Create a client-centered and evidence-based intervention plan. Ensure appropriate documentation of the relationships among assessment tool outcomes, factor deficits, and occupational deficits.

Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 46 Treatment Problem Statements Problem statements are based on results of assessments. They must be relevant to diagnosis. They must reflect areas of occupation that the client wishes to address. They must reflect areas of occupation traditionally addressed by occupational therapy (i.e., do not list the medical diagnosis as the problem; list it as a limitation or describe it in text of report). Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com

47 Treatment Problem Statements (cont.) Problem statements are based on areas of occupation, not client factors. Client factors and performance skills are components of function; they do not represent the function. Problem statements must reflect only one (possibly two) areas of occupation. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 48 Do Not Include Client Factors in Problem Statements. It is not necessary to add the reason for the functional problem in

the problem statement. This information should be included in the outcome statements within the text of the evaluation. Including client factors is unnecessarily limiting and confuses the focus of intervention. Example: Client is unable to don LE clothing because of limited shoulder ROM. This statement creates the impression that no other issues exist. What if shoulder movement becomes normalized and the client continues to be unable to don pants? It will require reworking problems and goals. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 49 Areas of Occupation (Framework II) ADLs: Self-care activities IADLs: Care for others and home

Social participation: Ability to interact with others Education: Planning for and attending learning events Rest and sleep: Activities related to restorative sleep Work: Vocational and avocational pursuits* Play: Spontaneous enjoyable activity* Leisure: Planned time away from work and ADLs.* *Medicare does not consider this a medically necessary area of function. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 50 Selected Client Factors Problems can be linked to deficits in these areas, but deficits do not define problems. Body functions Muscle functions

Movement functions Joint and bone functions. Body structures Structures of the nervous system Structures of the skin Structures of the musculoskeletal system. Values, beliefs, and spirituality Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 51 Performance Skills Deficits can create problems, but they do not define problems. Motor and praxis skills Motor: Move or physically interact Praxis: Sequential motor activities

Sensory perceptual skills Locate, identify, and respond Emotional regulation skills Identify, manage, and express feelings Cognitive skills Plan and manage activity Communication and social skills Interact with others Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 52 Types of Goal Statements: Long-Term Goals Goal statements identify either long-term or short-term goals. Long-term goals Are also known as treatment goals

Are the goals recognized primarily by most third-party carriers Should be written to reflect either that the functional problem being described will have been completely resolved or that the problems impact on living will have been reduced when the goal is reached. Must be measurable, function based, timed, and client focused. Must specifically address problems. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 53 Types of Goal Statements: Long-Term Goals (cont.) Examples: Client is unable to engage in work activities. Client will engage in regular duty work activities at premorbid

place of employment by 7-30-08. Client is unable to participate in senior citizen volunteer outings with peer group.. Client will fully participate in all senior volunteer activities with peer group within 2 months. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 54 Types of Goal Statements: Short-Term Goals Short-term goals Are subcomponents of long-term goals May be described as behavioral objectives When completed, should indicate that the long-term goal has been reached.

Should be function based, measurable, timed, client focused, and relate specifically to the long-term goal. Each long-term goal should have a minimum of two short-term goals. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 55 Examples: Types of Goal Statements: Short-Term Goals (cont.) Client is unable to engage in work activities. Client will engage in regular duty work activities at premorbid place of employment by 7-30-08.

Client will successfully engage in modified work duties 8 hours per day by 5-30-08. Client will successfully rotate into full-duty work for 4 hours per day by 6-30-08. Client will demonstrate the ability to identify potential signs and symptoms of overuse of extremity while at work and take appropriate action to avoid worsening of condition by 7-3008. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 56 Types of Goal Statements: Short-Term Goals (cont.) Client is unable to participate in senior citizen volunteer outings with peer group. Client will fully participate in all senior volunteer activities with peer group within 2 months.

Client will independently complete morning ADL routine to prepare for outing within 2 weeks. Client will secure desired transportation to and from volunteer site within 2 weeks. Client will safely and effectively operate own motor vehicle within 6 weeks. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 57 Treatment Activities Interventions can easily be created when short-term goals reflect the problems and the long-term goals. Interventions can address function itself or address components that specifically address function. Choose interventions on the basis of evidence, your frame of reference, and type of approach (Framework II) that fits the

situation best. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 58 Third-Level Behavioral Objectives (Optional) May help therapists who feel a strong need to make the connection to body functions and structures explicit within goals Use as daily or weekly subunits of short-term goals Not looked at by third-party payers, but can serve as guides for therapists who need to see the relationship between factors and function. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com

59 Examples of Behavioral Objectives Client will fully participate in all senior volunteer activities with peer group within 2 months. Client will independently complete morning ADL routine to prepare for outing within 2 weeks. Client will actively flex shoulder to 135 within 1 month. Client will demonstrate Good+ strength of shoulder flexor muscle group within 6 weeks. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 60 Test of Occupation-Based

Goals and Problems Ask yourself: Does the goal relate to more than one or two of the eight performance areas? ADLs IADLs Social participation Work Play Leisure Education Rest and sleep

Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 61 Test of Occupation-Based Goals and Problems (cont.) If a goal does relate to more than one or two areas of occupation, it is likely not function based. The statement, as written, will be a component of functionthe client factor or performance skill that is needed for success within many areas of occupation. Example: Client will actively flex shoulder to 160 in 3 out of 4 attempts by 5/1/07. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com

62 Test of Occupation-Based Goals and Problems (cont.) If a goal statement clearly relates to only one (possibly two) areas of occupation, then it is most likely written as a function- or occupation-based goal. Example: Client will demonstrate the ability to independently prepare a light lunch on a daily basis by 5/12/08. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 63 oals Short-Term G

oals Long-Term G ******** Successful Treatment Problems Telescoping of Problems, Long-Term Goals, and Short-Term Goals Figure 8. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 64

Charge Codes Embrace those time-based codes that best represent occupational therapy, such as those for ADL training, Therapeutic exercise, and Therapeutic activities. Use modality codes as needed, but do not create an entire session of modality codes. Work with facility coders or your fiscal intermediary/insurers to determine the best codes to use for your practice to avoid denials. Rogers, S. (2007). Occupation-based intervention in medical-based settings. OT Practice, 2(12), 1016. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American

Occupational Therapy Association at www.copyright.com 65 Occupation-Based Splinting Occupation-based splinting, which can also be described as contextbased splinting, is a means of approaching or reframing splint selection and design; it is traditional splinting looked at from a client-centered perspective. Occupation-based splinting can be defined as specific attention to the occupational desires and needs of the individual, paired with the specific knowledge of the effect (or potential effect) of chronic or acute conditions of the hand/UE, managed or remediated through client-centered splint design and provision. (Amini, 2005, p. 11)

Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 66 Splinting as Occupational Therapy Figure 9. Body components constitute only a part of the occupational makeup of the client. Despite the importance of assisting the healing or mobility of the body component, the therapist must concurrently tend to needs of the client that transcend movement and strength of the body. Figure 10. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com

67 Splinting as Occupational Therapy (cont.) Occupation- or context-based splinting is a treatment approach that supports the goals of a treatment plan that has been created to ensure the ability of the client to engage in meaningful, relevant, and recognizable endeavors within the context of his or her life. Figure 13. Figure 11. Figure 12. Figure 14. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com

68 Splinting as Occupational Therapy (cont.) Unlike a more traditional model of splinting, which may initially focus on body structures and processes, occupation-based splinting incorporates client occupational needs and desires, time of life, culture, cognitive abilities, mental health, and motivation. Figure 15. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 69 Occupation- and Context-Based Splinting Checklist Splint meets requirements of protocol for specific pathology;

ensures attention to bodily functions and structures. Splint allows client to engage in all desired occupation-based tasks through support of activity demand. Splint supports client habits, roles, and routines. Splint design fits clients cultural needs. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 70 Occupation- and Context-Based Splinting Checklist (cont.) Splint fits with temporal needs, including time of year, age of client, and duration of use. Splint design supports clients social pursuits Splint design addresses clients personal needs. Client is able to engage in virtual world, including mobile phone

and computer use. Splint can be used within clients physical environment. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 71 Occupation- and Context-Based Splinting Checklist (cont.) Splint is comfortable and easy to apply. Client has verbalized understanding of splint use, care, precautions, and rationale for use. Client has demonstrated the ability to don and doff splint. Adaptations to physical environment have been made to ensure function in desired occupations. Client has indicated satisfaction with splint design and functionality within splint.

Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 72 Case Study 1: Mrs. P Mrs. P sustained a fracture and underwent open reduction, internal fixation (ORIF) to her dominant, right elbow as a result of a fall approximately 3 weeks ago. The half cast provided by the physician was effective in immobilizing and protecting the joint, yet Mrs. P reported to the therapist the following difficulties: Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 73

Case Study 1: Mrs. P (cont.) Dependent in application of splint (Ace wrap) Limited wrist mobility Bulkiness, creating difficulty with dressing Heaviness, leading to shoulder soreness Generally dependent for all self-care and transportation Inability to swim (an important part of her daily routine). Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 74 Case Study 1: Mrs. P (cont.) Half cast Dependent with Ace wrap application

Wrist immobilized Figure 16. Bulky Heavy Extends high into upper arm Figure 17. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 75 Case Study 1: Mrs. P (cont.) A custom thermoplastic splint was suggested; Mrs. P immediately embraced the idea.

The following outcomes were realized as a result of this splinting alternative: Lighter weight, for less pressure on shoulder Slimmer fit; not bulky under clothing Independence in donning and doffing Fully mobile wrist for improved ability to complete meaningful activities Waterproof for swimming; second set of straps provided to replace wet straps following activity. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 76 Case Study 1: Mrs. P (cont.) Thermoplastic splint Easily applied by client with four hook-and-loop straps

Wrist free Figure 18. Lightweight Lower profile Less noticeable under clothing Functional Figure 19. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com

77 Case Study 2: Mrs. B The case of Mrs. B supports the premise that older adults must maintain consistency and routine. Mrs. B is a 68-year-old widow who experienced a significant loss of function of her nondominant, left arm following a near amputation as a result of a motor vehicle crash. She was having extreme difficulty maintaining her home, enjoying the leisure activity of gardening, and independently driving herself to desired locations. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 78 Case Study 2: Mrs. B (cont.)

Mrs. B was becoming increasingly depressed. Despite the use of the doctor-issued sling to protect her flail left arm, she could not complete the activities that brought her pleasure and made her feel complete. Designing and fabricating a custom-made dynamic elbow-flexion splint enabled her to resume gardening, feel more comfortable in public, cook, and engage in homemaking activities. The active movement allowed within the splint has facilitated brachioradialis and triceps activity. In addition, her hand is positioned for function and adhesive capsulitis of shoulder (determined to be a secondary effect of immobilization) is being resolved. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 79

Case Study 2: Mrs. B (cont.) Figure 20. Gardening without dependent edema or flail and intrusive extremity. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 80 Case Study 2: Mrs. B (cont.) Figure 21. Enjoying the azaleas. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com

81 Occupation-Based Treatment Outcomes Occupational performance Improvement Enhancement Role competence Adaptation. Health and wellness Prevention Quality of life Self-advocacy Occupational justice (AOTA, 2008).

( Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 82 Guidelines for the Integration of Occupation-Based Practice Into Hand Rehabilitation Do not discard the use of preparatory techniques; simply link them more effectively to occupations in both explanation and follow-up treatment. Choose purposeful activities carefully, always opting for components of terminal occupations when feasible. At the very least, explain the connection between preparatory techniques, purposeful activities and terminal occupations. Assist client with adaptations early in the process to facilitate

expedient return to function. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 83 Guidelines for the Integration of Occupation-Based Practice Into Hand Rehabilitation (cont.) Be able to articulate the difference between techniques, activities and occupations. From the inception of treatment, address the use of occupations and abilities to engage in occupations. Occupations may or may not include tasks that deal with the injury itself, and they should be adapted to meet the immediate needs of the client. Use occupations to help clients return to psychosocial and vocational well-being while they await tissue healing.

Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 84 Guidelines for the Integration of Occupation-Based Practice Into Hand Rehabilitation (cont.) Occupations need notand ideally should notbe completed in the clinic setting. Consulting with the client about what he or she can and should not do outside the clinic and giving homework assignments can address occupational goals that exceed clinic staff and budgetary constraints. Use the Framework II to frame treatment choices. Use occupation-based treatment as a model for treatment; it is another tool in the hand therapy toolbox.

Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 85 Creating an Occupation-Based Hand Rehabilitation Clinic Create an occupation-based milieu that includes a social atmosphere of warmth, acceptance, and personal growth. Posters on the wall should describe the philosophy of the clinic. Provide information slots with handouts that offer suggestions for ADL modification and compensation, information on dealing with stress, etc. The intake questionnaire should ask questions similar to those on the COPM to expedite initial evaluation. Display handouts with suggestions of functional activities. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com

86 Creating an Occupation-Based Hand Rehabilitation Clinic (cont.) Examples of posters that promote occupational therapy Figure 24. Figure 22. Figure 23. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com

87 Creating an Occupation-Based Hand Rehabilitation Clinic (cont.) Provide handouts with return-to-work suggestions. Copies of the book One-Handed in a Two-Handed World by (Mayer, 2000) and Tips for Good Living With Arthritis (Arthritis Foundation, 2006) should be visible in the treatment area. A welcome letter to new clients should explain the functionbased focus of services and instruct clients to bring all concerns and deficits to the attention of the therapist. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 88 Creating an OccupationBased Hand

Rehabilitation Clinic (cont.) Orthopedics Occupational/Hand Therapy Service The occupational therapy staff of ABC Orthopedics would like to introduce you to the unique rehabilitative service that you are about to receive. Hand therapy is a subspecialty of the profession of occupational therapy. Occupational therapy is an allied health profession that is concerned with the ability of the individual to engage in all desired tasks within the areas of self-care, leisure/play, education, work, social participation and rest and sleep. While working to enable your arm/hand to function as fully as possible as soon as possible, your therapist will help you maintain participation in all desired life tasks. Occupational therapists believe that arm/hand function improves with activity; we also believe that people should not lose their abilities to do things that they enjoyeven for a short time.

To enhance your recovery, your occupational therapy professional may ask you to bring activities from home that you enjoy, but find difficult, so that we can help you with modifications. We may also ask you to complete function-based homework or have you bring in crafts or other tasks from home to work on in the clinic Please let us know right away if you are having difficulties completing activities that you would like to do. Examples include all self-care and home care tasks, work activities, crafts, gardening, and sports activities. If you are having problems, we will help you to modify the activity or suggest adaptations to enable you to continue to live and enjoy life to the fullest. Figure 25. Sample letter to new clients. Your occupational therapy staff thanks you for letting us help you on the road to full functional recovery.

Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 89 Creating an OccupationBased Hand Rehabilitation Clinic (cont.) Figure 26. Sample intake questionnaire. Occupational/Hand Therapy Screening/Confidential Medical History Patients Name: __________________________________ Age:______ Date: __________ Please complete the following questions to the best of your ability. This will help us to develop a treatment with you that meet your individual needs. 1. Reason for this visit?___________________________________________________________

2. Date of injury or when problem last caused you to seek medical attention:________________ 3. How did your current problem begin? __ lifting __ falling __ motor vehicle accident __ unknown __ Disease related___other: ___________________________________ 4. Were you hospitalized for this problem? ___ yes ___ no If yes, give dates:___________ 5. Are you currently being seen by any of the following? __dentist __chiropractor __osteopath __ physical therapist __ occupational therapist __psychiatrist/psychologist If you are seeing any of the above, please describe the reason: _________________________ ____________________________________________________________________________ 6. Please list functional activities with which you are currently experiencing difficulties under the appropriate heading. In the first column to the right, please rate your level of ability with the task on a 110 scale (10 being perfectly able and 1 being unable). In the column to the right of ability, please indicate your satisfaction with your ability to complete that task (10 = very satisfied with current ability; 1 = completely dissatisfied with current ability). Self-care (dressing, bathing, hygiene, toileting) _______________________________________ _______________________________________ _______________________________________

_______________________________________ Ability (110) Satisfaction (110) ______ _______ ______ _______ ______ _______ ______ _______ Care of home and others (driving, housework, childcare) _______________________________________ _______________________________________ _______________________________________ ______

______ ______ _______ _______ _______ Work (Volunteer and job related) _______________________________________ _______________________________________ _______________________________________ _______ _______ _______ _______ _______

_______ Play/Leisure _______________________________________ _______________________________________ _______________________________________ _______ _______ _______ _______ _______ _______ Social Participation (relationships with friends, family) _______________________________________ _______________________________________

_______ _______ _______ _______ Education (student/school related tasks) _____________________________________ _____________________________________ _______ _______ _______ _______ Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American

Occupational Therapy Association at www.copyright.com 90 Creating an Occupation-Based Hand Rehabilitation Clinic (cont.) Figure 27. Keep ADL equipment in the clinic for purposeful activity and teaching adaptations. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 91 Creating an Occupation-Based Hand

Rehabilitation Clinic (cont.) First question to returning clients: What new things have you accomplished since our last visit? Have purposeful activities visible and ready for use in the clinic. Examples include tabletop weaving looms, macram plant hangers, plants for pruning, and a woodworking corner with tools. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 92 Case Study: Corrine 34 years old, married, mother of two young children Right dominant elbow fracture; status post ORIF Pain and stiffness with inability to complete desired ADLs, IADLs, rest/sleep, and leisure activities

Frustration over dependence on spouse for basic self-care and inability to sleep in own bed Unable to effectively perform roles of wife and mother Patient reports that she is feeling depressed and at times becomes weepy. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 93 Case Study: Corrine (cont.) Initial focus of treatment was to ease stress associated with sudden change in physical abilities. The occupational therapist Provided instruction, techniques, equipment to facilitate engagement in desired house, self-care, and leisure pursuits; Assisted client in creating priority list; Assisted client in determining how many tasks to realistically

accomplish within one day; Instructed client in techniques to try to minimize potential for pain and enhance functional abilities; and Made suggestions for working and playing with children. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 94 Case Study: Corrine (cont.) Additional treatment consisted of the following: Elbow extension splint fabricated at onset of treatment to replace heavy bivalve cast Edema control Pain control Ultrasound Active and active-assisted ROM exercise with progression to

passive exercise. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 95 Case Study: Corrine (cont.) Provided client with in-clinic weaving activity to work on elbow ROM, endurance, and early strengthening. Reviewed laundry skills using affected extremity; provided trial use of adaptive equipment as an option for enhancing function during home IADLs. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 96

Case Study: Corrine (cont.) Weaving activity to enhance motion, strength, and endurance Figure 28. Activity primarily used within clinic; client worked on a placematweaving loom at home. Figure 29. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 97 Case Study: Corrine (cont.)

Instructed client in use of adaptive equipment for laundry. Figure 32. Figure 30. Figure 31. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 98 Conclusion Using client-centered and occupationbased treatment is a winwin approach to treatment. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American

Occupational Therapy Association at www.copyright.com 99 References American Occupational Therapy Association. (2002). Occupational therapy practice framework: Domain and process. American Journal of Occupational Therapy, 56, 609639. American Occupational Therapy Association. (2007). AOTAs Centennial Vision and executive summary. American Journal of Occupational Therapy, 61, 613614. American Occupational Therapy Association. (2008). Occupational therapy practice framework: Domain and process (2nd ed.). American Journal of Occupational Therapy, 62, 625683. Amini, D. (2005). The occupational basis for splinting. Advance for Occupational Therapy Practitioners, 21, 11. Arthritis Foundation. (2006). Tips for good living with arthritis. Atlanta, GA: Arthritis Foundation. Baum, C. M., & Baptiste, S. (2005). Using information to influence policy. In M. Law, C.

Baum, & W. Dunn (Eds.), Measuring occupational performance (2nd ed., pp. 367 374). Thorofare, NJ: Slack. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 100 References (cont.) Baum, C., & Edwards, D. (2008). Activity Card Sort (2nd ed.). Bethesda, MD: AOTA Press. Bing, R. K. (2005). Occupational therapy revisited: A paraphrastic journey. In R. Padilla (Ed.), A professional legacy: The Eleanor Clarke Slagle Lectures in occupational therapy: 19552004 (2nd ed., pp. 305334). Bethesda, MD: AOTA Press. Centers for Medicare and Medicaid Services. (2006). Medicare benefit policy manual (Chapter 15). (Pub. No. 10002). Retrieved from www.cms.hhs.gov/manuals/IOM/list.asp Christiansen, C., Backman, C., & Little, B. (1998). Personal projects: A useful approach to the study of occupation. American Journal of Occupational Therapy, 52(6), 439446.

Christiansen, C., Backman, C., Little, B., & Nguyen, A. (1999). Occupations and subjective well-being: A study of personal projects. American Journal of Occupational Therapy, 53(1), 91100. Christiansen, C., & Townsend, E. (2004). Introduction to occupation: The art and science of living. Upper Saddle River, NJ: Pearson Education. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 101 References (cont.) Guzelkucuk, U., Duman, I., Taskaynatan, M., & Dincer, K. (2007) Comparison of therapeutic activities with therapeutic exercises in the rehabilitation of young adult patients with hand injuries. Journal of Hand Surgery, 32, 14291435. Hand Therapy Certification Commission. (n.d.). Who is a Certified Hand Therapist? Retrieved December 14, 2008, from www.htcc.org/about/index.cfm Hunter, J. (2002). Foreword. In E. J. Mackin, A. D. Callahan, A. L. Osterman, T. M. Skirven, & L. Schneider (Eds.), Rehabilitation of the hand and upper extremity (5th

ed., pp. xixxxi). St. Louis, MO: Mosby. Institute for Work and Health. (2006). DASH Outcome Measure. Toronto, ON: Author. Retrieved December 8, 2008, from www.dash.iwh.on.ca Law, M., Baptiste, S., Carswell, A., McColl, M. A., Polatajko, H., & Pollock, N. (2005). The Canadian Occupational Performance Measure (4th ed.). Ottawa, ON: CAOT Publications. Ludwig, F. (1997). How routine facilitates wellbeing in older women. Occupational Therapy International, 4(3), 213228. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 102 References (cont.) MacDermid, J., & Tottenham, V. (2004). Responsiveness of the Disability of the Arm, Shoulder and Hand (DASH) and Patient-Rated Wrist/Hand Evaluation (PRWHE) in evaluating change after hand therapy. Journal of Hand Therapy, 17, 1823.

Mayer, T. (2000). One-handed in a two-handed world (2nd ed.). Boston: Prince-Gallison Press. McKee, P., & Rivard, A. (2004). Orthoses as enablers of occupation: client-centered splinting for better outcomes. Canadian Journal of Occupational Therapy, 71(5), 306314. Missiuna, C., Pollock, N., & Law, M. (2004). The Perceived Efficacy and Goal Setting System. San Antonio, TX: PsychCorp. Palmadottir, G. (2003). Client perspectives on occupational therapy in rehabilitation services. Scandinavian Journal of Occupational Therapy, 10, 157166. Walters, L., & Moore, K. (2002). Reducing latent deprivation during unemployment: The role of meaningful leisure activity. Journal of Occupational and Organizational Psychology, 75, 1518. Wilcock, A. (1998). An occupational perspective of health. Thorofare, NJ: Slack. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 103

Figure Credits Figure 3: Two women completing the COPM. Photo courtesy of author. Figure 9: A young couple standing with arms around each other. Photo courtesy of author. Figure 10: A splinted hand grasping a paint brush and painting a picture of a butterfly. Photo courtesy of author. Figure 11: An older man sitting with a dog on his lap. Photo courtesy of author. Figure 12: A male high school student playing saxophone in a marching band. Photo courtesy of author. Figure 13: Young woman standing and cheering her team at a college football game. Photo courtesy of author. Figure 14: Image of four young adults sitting at a table at a restaurant. Photo courtesy of author. Figure 15: Splint fabrication. Photo courtesy of author. Figures 16 and 17: Mrs. Ps elbow cast. Photos courtesy of author. Figures 18 and 19: Mrs. P watering plants. Photos courtesy of author. Figures 20 and 21: Mrs. B using a dynamic elbow splint while gardening. Photo courtesy of author. Figures 2224: Examples of posters that promote occupational therapy. Photos courtesy of author. Figure 27: Photograph of a woman wearing a wrist splint on her left hand while using a whisk broom and dust pan. Photo courtesy of author. Figures 28 and 29: Corrine and therapist engaging in weaving activity. Photo courtesy of author. Figure 30: Corrine engaging in laundry activity. Photo courtesy of author.

Figure 31: Corrine using economy reacher. Photo courtesy of author. Figure 32: Corrine engaging in laundry activity. Photo courtesy of author. Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com THE END Copyright 2009 by the American Occupational Therapy Association. Material may be reproduced and adapted for personal use by the purchaser. All other uses must be approved by applying to the American Occupational Therapy Association at www.copyright.com 105

Recently Viewed Presentations

  • Bcl11b Transcription Factor Dephosphorylation by PP6 in ...

    Bcl11b Transcription Factor Dephosphorylation by PP6 in ...

    Why did you try HEK? What I'm not showing you is that Bcl11b follows a phospho cycle in HEK cells, but repression/expression actually requires concurrent sumo/de-sumo, which HEK cells don't do very well.
  • Diapositive 1

    Diapositive 1

    « Lorsque nous regardons les tableaux de Renoir, c'est facile d'oublier que c'était pour lui un problème à cause de son arthrite. La peinture était presque une nécessité physique et parfois un remède, comme si vous souhaitiez créer des choses...
  • Trends in Antifungal Susceptibility of Candida spp. Isolated

    Trends in Antifungal Susceptibility of Candida spp. Isolated

    Notably, 24.4% of C. glabrata isolates and 47.6% of C. krusei isolates appeared resistant with MICs 2 g/ml when tested by the NCCLS method. As reported previously, the agreement between Etest and broth microdilution results was excellent, 98.7% within ±...
  • Student Engagement in Combined Honours

    Student Engagement in Combined Honours

    Student Engagement and partnership inCombined Honours. ... Student expectations and perceptions - match to the 'personal project' and interest in subject . Sufficient challenge and appropriate workload. Degrees of choice, autonomy, risk, and opportunities for growth and enjoyment.
  • Maxillo-Mandibular Relationships

    Maxillo-Mandibular Relationships

    Record bases should not contact. If other contacts, mounting will be incorrect. Mounting Mandibular Cast. Stabilize wax rims together with . sticky wax and sticks . sticky wax directly - 4 spots. Critical for accurate mount. Mounting Mandibular Cast.
  • CH 104: DETERMINATION OF A SOLUBILITY PRODUCT CONSTANT

    CH 104: DETERMINATION OF A SOLUBILITY PRODUCT CONSTANT

    The equilibrium concentrations of Ca2+(aq) and F-(aq) are given algebraic variables based on the stoichiometric coefficients from the balance reaction. Write these equilibrium concentrations of Ca2+(aq) and F-(aq). [Ca2+] = x [F-] = 2x CALCULATING SOLUBILITY FROM Ksp Step #3:...
  • Ethics Cases of the Year: 2017-18 Created by

    Ethics Cases of the Year: 2017-18 Created by

    Although these scenarios—and any associated questions-and-answers—are an important part of understanding aspects of the ethics code, please note that only the Ethics Committee is authorized to give a "formal advisory opinion" on the propriety of a planner's proposed conduct (Section...
  • Native Dynamic SQL Exposed - Amazon S3

    Native Dynamic SQL Exposed - Amazon S3

    SQL> SELECT column_value AS "Three Stooges"2 FROM TABLE(sql_varray('Moe','Larry','Curly')); Casts the SQL varray into a SQL consumable result set. ... Update the nested ADT collection by finding and replacing the 'Shemp' value with 'Curly'. Type of Oracle ObjectsLists or TABLE data...