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Running head: OCCUPATIONAL PROFILE & INTERVENTION PLAN 1
Occupational Profile & Intervention Plan
Breanna Dickson Touro University Nevada OCCUPATIONAL PROFILE & INTERVENTION PLAN 2
Occupational Profile The client is a 67 year old African-American woman. She is single and lives in single- story home in North Las Vegas with her 19 year old granddaughter. The client does not drive and relies on her granddaughter to take her to appointments and shopping. Her friends visit her on a weekly basis and she enjoys playing card games with them. The client is in a long-term acute care hospital due to complications from a right-sided ischemic CVA she incurred three months prior. According to the American Stroke Association, paralysis on the left side of the body, vision problems, inquisitive behavioral style, and memory loss can all be effects of a right-sided stroke (Effects of Stroke, 2012). The client has been in the hospital for two weeks and has not been able to get out of bed due to fatigue and weakness. Currently, she relies on nursing staff to complete her activities of daily living (ADLs) due to her left-sided weakness, known as hemiparesis, and decreased endurance. She wants to be able to complete her ADLs independently but is afraid she has lost her endurance for out of bed activities. During her initial occupational therapy evaluation in her hospital room, the client was awake, oriented, and not in pain. She demonstrated good fine motor coordination with her right dominant hand but had poor fine motor coordination with her left hand. She was able to sit at the edge of the bed from the supine position with Mod A and could tolerate sitting upright. The client said she is too fearful to attempt a shower and needs assistance transferring to the commode due to her postural insecurity. She also needs assistance for dressing and feeding. The client also stated that it takes her longer to do things than it did prior to her stroke which is frustrating. OCCUPATIONAL PROFILE & INTERVENTION PLAN 3
It is important to examine which contexts are most supportive and inhibitory for the client. The cultural and personal contexts are supportive of the clients participation and engagement in occupations because she considers herself to be a strong, independent woman and wants to maintain that perspective. It is unknown for how long she has been single, but it is clear that she takes pride in her ability to take care of herself without the help from a spouse. On the other hand, the clients temporal context is proving to be inhibitory of her ability to engage in participation since she has not been out of bed since arriving at the hospital two weeks ago. In terms of physical environments, the hospital setting is supportive of the clients participation and engagement in occupations due to the accessibility of the nursing staff, therapists, durable medical equipment (DME), and assistive devices. At this stage, the clients home setting is both supportive and inhibitory. The clients home is supportive since she lives in a single-story home without any stairs but her home is also inhibitory since the clients granddaughter is gone for most of the day and they do not have any DME or assistive devices in the home. Although the client did not have visitors during her therapy sessions, she has close friends that visit her at home often so it is safe to assume that a social environment would be supportive. The client is a retired licensed practical nurse. She enjoys talking on the phone and playing cards with friends. The client loves to get dressed up for bridge tournaments at the local community center with her friends. When she is not with her friends, she enjoys watching television. The client lives with her granddaughter and is responsible for tidying up the house while she is at school. She relies on her granddaughter to take her to the grocery store and her doctors appointments since she does not drive. OCCUPATIONAL PROFILE & INTERVENTION PLAN 4
The client stated her goal for therapy is to increase her endurance and be independent in taking care of herself. She stated she wants to make sure she will be as independent as she was prior to being admitted to the hospital so as not burden her granddaughter any further. The client wants to be able to get dressed, have her friends come over, and play cards again without assistance. Although the client prides herself on being autonomous, she is not opposed to using DME and assistive devices. Occupational Analysis The client participated in a 30 minute occupational therapy session to address ADLs in her hospital room at the long-term acute care facility where she was staying. When asked to don a shirt, the client needed assistance to pull her affected extremity through the sleeve of her shirt and down over her trunk. When asked to don her pants, she needed assistance throughout due to her poor dynamic sitting balance. The client was unable to don socks due to poor trunk control. The clients left-side hemiparesis also affected her ability to transfer to and from the wheelchair independently. The client was able to comb her hair independently with her right hand but needed assistance setting up her toothbrush since she was not using her left hand secondary to neglect. Due to the nature of the setting, only participation in ADL activities was observed. The client demonstrated impairments in the areas of dressing, functional mobility, and personal hygiene. In terms of client factors, the clients impaired joint mobility, muscle endurance, and muscle power of her left side impacted her ability to participate in ADL activities. For performance skills, the client appeared to demonstrate intact process skills and social interaction skills but had obvious difficulty with motor skills. Specifically, the client demonstrated problems OCCUPATIONAL PROFILE & INTERVENTION PLAN 5
stabilizing, reaching, bending, coordinating, and enduring. In terms of performance patterns, the clients postural insecurity and fear of falling was likely leading to unsafe habits in the form of maladaptive movement patterns. However, the clients role as friend to others was supportive of her engagement in ADL activities since she was eager to socialize with her friends once again. Problem List 1. Client requires Max A for LE dressing due to poor dynamic sitting balance and left-side hemiparesis. 2. Client requires Max A in UE dressing secondary to left-side neglect. 3. Client requires Mod A for wheelchair transfers secondary to left-side hemiparesis. 4. Client requires Mod A in bed mobility due to decreased left-side UE and LE strength. 5. Client required Min A for personal hygiene tasks due to left-side hemiparesis. The clients list of problem statements was prioritized by the amount of assistance needed. The client needs to be as independent as possible for her to return home, so the areas where she needs most assistance need to be addressed early on. The majority of her problems stem from her left-side hemiparesis. If the occupational therapist is able to address this early on, it is likely smaller problem areas, such as endurance, will correct themselves without having to be explicitly addressed. Intervention Plan & Outcomes Long-Term Goal (LTG) 1. Client will complete LE dressing Mod I due to longer time in 4 weeks. 2. Client will complete UE dressing Mod I due to longer time in 4 weeks. OCCUPATIONAL PROFILE & INTERVENTION PLAN 6
Short-Term Goals (STG) 1. Client will don and doff socks with Mod I using a sock aid in 2 weeks. 2. Client will don and doff pants with Min A at edge of bed in 2 weeks. 3. Client will don and doff brassiere using hemi-dressing techniques with Mod I in 2 weeks. 4. Client will don and doff shirt with Min A at edge of bed in 2 weeks. Interventions First STG. To address the first STG, it would be appropriate to teach the client proper use of adaptive equipment for lower-body dressing. Although dynamic balance will hopefully be remediated through therapy, it is still important to respect the clients autonomy and empower her to complete LE dressing through the use of adaptive equipment as independently as possible until her deficits are restored. The occupational therapist can begin by bringing different types of adaptive equipment for LE dressing for the client to try. For the purposes of this intervention, donning and doffing socks has proven to be the most challenging for the client so it should be addressed first. The occupational therapist can then introduce the client to the sock-aid and explain the ideology behind it. Then the therapist should visually demonstrate how to use the sock-aid and how to adapt the sock-aid so it can be used with one hand. Finally, the therapist should have the client demonstrate while resolving any problems or concerns by the client. Once the client is competent in use of the sock-aid, the therapist may choose to introduce other adaptive equipment. Justification. Foti and Koketsu (2013) discuss the role of the occupational therapist in ADLs. The authors mention that sometimes the occupational therapist has to explore a variety of assistive devices to reach a solution for specific ADL problems. For ADL deficits related to limited range of motion (ROM) or strength, the authors identify compensating for the lack of OCCUPATIONAL PROFILE & INTERVENTION PLAN 7
joint excursion and reach through use of adaptive equipment as a solution. Specifically, long- handled dressing sticks, extended handle reachers, and sock aids are identified as adaptive equipment that can be used for LE dressing. The authors also conclude that if the client has potential for improvement of specific deficits, remediation and restoration treatments should also be considered. Precautions. Before providing the client with adaptive equipment, it is important to assess for sensory, perceptual, and cognitive deficits to establish appropriate teaching methods to facilitate learning (Foti & Kokestsu, 2013). Once the occupational therapist determines the client is eligible for adaptive equipment, there are little precautions with adaptive equipment as long the client is competent in use. It may also be good idea to provide the client with a hand-out on how to use the adaptive equipment since memory loss can be affected by right-sided stroke as mentioned previously. Second STG. To address the second STG, it would be appropriate to use functional balance activities to increase dynamic balance, decrease postural insecurity, and increase confidence. The purpose of the activities should be to facilitate weight-shifting while reaching. For example, the client can play a card game while sitting at the edge of bed where she will have to reach laterally and across midline to pick-up cards from a deck. While the client is reaching with the less-affected UE, it is important to have her weight bear on her affected UE. Moreover, to address the clients postural insecurity, the client can stand on the affected LE in front of the sink while holding on to the back of a chair for support. From there, the client can complete grooming activities in this position and practice alternating the standing leg throughout. Finally, the client can sit in a chair and lean forward and laterally to pick up items from the floor, such as clothing prior to dressing. OCCUPATIONAL PROFILE & INTERVENTION PLAN 8
Justification. The purpose of the descriptive correlational study by Kim and Park (2013) was to determine a causal relationship among balance self-efficacy, balance, and activities of daily living (ADLs) in individuals with stroke. The authors hypothesized that balance self- efficacy and balance variables would influence ADLs and that ADLs would mediate balance through balance self-efficacy in community residents with stroke. They found balance self- efficacy has a significant direct effect on balance and a significant indirect effect on ADL through balance. To conclude, the authors propose implications for rehabilitation; occupational therapists should assess balance efficacy as well as balance ability and choose interventions that use a combination of balance training and balance self-efficacy enhancement to improve ADL performance in individuals with stroke. Precautions. Before any functional balance activities are initiated, it is important that the occupational therapist educate the client on establishing a neutral starting alignment. For example, the client should have non-slip socks on, feet firmly on the ground, equal weight bearing through both ischial tuberosities, an erect spine, and neutral to anterior pelvic tilt (Gillen, 2013). The occupational therapist should encourage the client to challenge themselves while listening to their body and stopping when they need to. Finally, the client should always be supervised when performing functional balance activities due to the risk of fall. Third STG. To address the third STG, it would be important to teach the client how to don a brassiere using hemi-dressing techniques. These include fastening the brassiere in the front, using the strong arm to thread the weak arm through the brassiere strap, and pulling the strap on the affected side over the shoulder with the stronger arm (Foti & Kokestsu, 2013). Since this would most likely be learned quickly, it would also be appropriate to incorporate functional activities to increase bilateral coordination. To start, the client can play a card game where she OCCUPATIONAL PROFILE & INTERVENTION PLAN 9
holds cards in one hand while drawing from the deck with the other hand. In addition, the client can make and knead bread dough with both hands for her granddaughter to take home to bake. Finally the client can use both hands to braid her granddaughters hair when she comes to visit. In all of these activities, the therapist or client can provided hand-over-hand assistance to the affected UE if needed. Justification. The purpose of the meta-analysis by Cauraugh, Lodha, Naik, and Summers (2010) was to determine the cumulative effect of bilateral arm training on motor capabilities post stroke. The authors included 25 studies across all three stages of stroke recovery for intervention studies that used bilateral arm movements as a training treatment. For bilateral training techniques, six studies used pure bilateral, seven studies used bilateral arm training with rhythmic auditory cueing, seven studies used coupled bilateral and EMG-triggered neuromuscular stimulation, and five studies used active and/or passive movements, including robotics. The authors found strong evidence supporting bilateral arm training with the mention that two coupled protocols, rhythmic alternating movements and active stimulation, are most effective. Precautions. Fortunately, there are not many precautions when addressing bilateral coordination. If the client has sensory deficits in the impaired UE, it is important to monitor the skin for signs of tissue damage. The occupational therapist should also provide encouragement to ensure the client is engaging the affect side throughout the activities. Fourth STG. To address the fourth STG, it would be appropriate to use constraint- induced movement therapy (CIMT) while completing functional activities to improve motor recovery and increase left UE use. Current literature suggests wearing a mitt on the less-affected extremity while performing repetitive, functional tasks several hours a day for ten to fifteen days OCCUPATIONAL PROFILE & INTERVENTION PLAN 10
(Behrens, 2011). Since therapy sessions in the long-term acute care setting typically only last thirty-minutes at a time, the nursing staff would have to be on board with this plan. For example, the occupational therapist can place the mitt on the client, explain the tasks they want the client to engage in, and then come back or alert the nursing staff to remove the mitt after three hours have passed. Examples of repetitive, functional tasks include completing jigsaw puzzles, playing solitaire, feeding, and typing on a computer. Justification. The purpose of the single-blind, randomized control trial by Wolf et al. (2006) was to compare the effects of a two week program of constraint induced movement therapy (CIMT) to customary care on improvement in upper-extremity function among patients who had a first stroke within the previous 3 to 9 months. The authors recruited 222 individuals with ischemic stroke; 106 in the CIMT group and 116 in the control group. The CIMT group wore a restraining mitt on the less-affected hand 90% of their waking time while engaging in shaping and repetitive tasks involving functional activities performed continuously for 15-20 minutes. The control group received anywhere from no treatment after concluding formal rehabilitation to pharmacologic or physiotherapeutic interventions. The authors used the Wolf Motor Function Test (WMFT) and Motor Activity Log (MAL) to measure outcomes. The CIMT group showed greater improvements on both the MAL and WMFT than the control group. Precautions. The occupational therapist should document that the client has 10 degrees of wrist extension, 10 degrees of finger extension in any two fingers, and 10 degrees of thumb abduction since that is part of the inclusion criteria to be eligible for CIMT (Gillen, 2013). Based on informal observations of the impaired UE, the client is believed to meet these criteria and would eligible. It is important that the occupational therapist monitor for signs of fatigue. Although the mitt should be properly fitted for the less-affected UE, it is important to look for OCCUPATIONAL PROFILE & INTERVENTION PLAN 11
redness, pain, or swelling as they may be indications of pressure sores. Finally, the therapist should explain the benefits of CIMT and encourage the client to maintain the regimen. Approach When choosing an intervention approach, the establish/ restore approach seemed most appropriate. It is likely the client had good dynamic balance and no left-sided neglect prior to the left-side hemiparesis caused by her stroke. The goal of this intervention plan is to restore the clients dynamic balance and bilateral coordination so that she can complete ADL activities, such as dressing, safely and independently. Additionally, the modify approach was included in this intervention plan. The client is unable to complete LE dressing independently so teaching the client how to use adaptive equipment will help her to attain independence. Although the clients underlying problems will likely be remediated, the client mentioned that she is frustrated with having to rely on others to dress her, so by using adaptive equipment, the client can enjoy a present level of modified independence. Outcomes The desired outcomes for this intervention plan include improvement in occupational performance, prevention, quality of life, and participation. By teaching the client proper use of adaptive equipment, increasing her dynamic balance, encouraging bilateral coordination, and reducing left-sided neglect, the clients independence will increase and her occupational performance will be improved. Likewise, the clients balance deficits and left-sided neglect put her at risk for falls, so by addressing these deficits, this intervention targets fall prevention. Quality of life and participation are intertwined because the more the client is able to participate in her ADL activities, the better quality of life she perceives. The client is a strong, independent OCCUPATIONAL PROFILE & INTERVENTION PLAN 12
woman, so it is not only important that she is able to maintain that perspective for others, but for her own psychological prosperity as well. Frequency The frequency and duration of occupational therapy treatment sessions in the long-term acute care setting are typically 30 minutes a day, four to five times a week. Due to the nature of the interventions, many of them can be combined in one treatment session. For example, the therapist may take the first half of the session teaching the client proper use of adaptive equipment and hemi-dressing techniques and use the other half for functional balance techniques. In addition, the client may learn how to use adaptive equipment quickly so that intervention should be addressed early-on and stopped once competency is reached to allow more time for other interventions. Since bilateral coordination and CIMT are being addressed together, it is important that the occupational therapist plan those sessions accordingly. For example, the occupational therapist should implement CIMT at the end of a session and begin the next days session with bilateral coordination exercises. The CIMT will help with the motor recovery of the clients left UE but being able to use both hands together is the ultimate goal. The therapist should use their clinical judgment and input from the client to decide what intervention, or combination of interventions, they want to address that day. Grading The intervention of increasing dynamic balance can be easily graded up and down. For example, playing cards and feeding while seated can be utilized first, followed by wiping countertops and reaching to the floor for shoes which require more weight-shifting. Additionally, OCCUPATIONAL PROFILE & INTERVENTION PLAN 13
the seated position can be graded as well. The client can begin sitting in a high-back chair, followed by sitting at the edge of bed, and possibly progressing to sitting on a large therapy ball. In addition, the standing balance activities can also be graded. The client can begin standing with both feet on the floor, slowly adding in graded weight-shifts until she is completely weight- bearing on the affected LE. Additionally, the client can start with both hands holding on to the back of a chair for support and then progress to only using one hand. Finally, the occupational therapist can extend how far the client will have to reach for items to complete functional activities if the client requires more challenge (Gillen, 2013). Framework The primary framework that was chosen for this intervention plan is the task-oriented approach. This framework was chosen because according to Kovic and Schultz-Krohn (2013), current research indicates that a beneficial way to achieve a successful client-centered outcome is to include interventions that address how the client interacts with the environment and the task. This approach is supported by applied neuroscience concepts that imply that skilled interaction associated with a clients environment and task performance may direct cortical changes and facilitate neuromuscular recovery. In the task-oriented approach, the occupational therapist may apply motor learning concepts, adapt, or otherwise facilitate successful completion of an occupation-based goal. In applying the task-oriented approach, the occupational therapist is incorporating understanding of neuroscience concepts while simultaneously addressing performance skill deficits (Kovic & Schultz-Krohn, 2013). Goal planning was accomplished by addressing the clients performance skill deficits to increase her occupational performance. Kovic and Schultz-Krohn (2013) say that skilled learning OCCUPATIONAL PROFILE & INTERVENTION PLAN 14
occurs through the use of adaptations and strategies that facilitate an adaptive response and this response has been shown to occur with the use of the task-oriented approach. Although some motor learning concepts were applied, the interventions focused mainly on using strategies to facilitate an adaptive response during functional tasks. The performance skills that were most inhibitory of the clients ability to participate in occupations were stabilizing, reaching, bending, coordinating, and enduring. Each intervention tried to address these in some way while incorporating compensatory techniques and adaptations. Client and Caregiver Education Client education needs to be addressed for each of the four interventions. As mentioned previously, handouts can be given to client explaining how to use the adaptive equipment. In addition, handouts can also be provided demonstrating dynamic balance and bilateral coordination exercises. However, if handouts are utilized, it would be important to clearly indicate which exercises the client can perform alone and which ones she needs to have supervision for. Furthermore, when addressing CIMT it is important to explain the benefits and reasoning to the client and nursing staff. It may also be useful to educate the client and nursing staff on the CIMT wear schedule by posting a copy of the schedule in the clients room. As important as it is to educate the client during the intervention process, it is just as important to educate the clients 19 year old granddaughter since she is her primary caregiver. Since the client does not drive, it would be useful to provide the granddaughter with a list of stores along with approximate costs for adaptive equipment in case the client would still benefit from adaptive equipment upon discharge. In addition, along with the balance and bilateral coordination exercise handout, it would be important to provide education to the granddaughter OCCUPATIONAL PROFILE & INTERVENTION PLAN 15
on how to properly do these exercises so that she can correct the client if she notices any improper body mechanics. Finally, it would be wise to provided literature to the granddaughter on the use of CIMT and encourage her to ask questions if any arise throughout the intervention process. Response to Intervention The clients response to intervention will be monitored throughout the intervention process through use of formal and informal assessments and observations. Gillen (2013) recommends a top-down approach to assessment which begins with inquiry into role competency, tasks that define a person, and problems that interfere with occupational performance. The Arnadottir Occupational Therapy Neurobheavioral Evaluation (A-ONE) is an assessment tool that objectively documents how dysfunction of client factors affect ADL and mobility tasks by evaluating neglect syndromes, sequencing dysfunctions, agnosias, and apraxias (Gillen, 2013). Although the initial evaluation had already occurred at the time of intervention planning, the A-ONE would have been ideal to use as part of the initial evaluation for planning client-centered goals. The response to interventions will be measured through the use of the Functional Independence Measure (FIM) prior to beginning interventions and again after two weeks for reevaluation. The FIM is a measure of disability in performing ADLs that evaluates performance for motor and cognitive functioning (Gillen, 2013). Although the FIM assesses many of the ADL areas that the interventions are trying to remediate, it would also be helpful to use specific assessments for certain interventions to ensure the interventions are working as planned. OCCUPATIONAL PROFILE & INTERVENTION PLAN 16
To measure the response to the second intervention of increasing functional balance, it would be appropriate to utilize the Berg Balance Scale. The Berg Balance Scale is composed of 14 items that involve static, dynamic, sitting, and standing balance activities. Performance on items are scored on a zero to four point ordinal scale with four being the highest functioning and zero being the lowest (Gillen, 2013). Furthermore, the Test valuant les Membres suprieurs des Personnes ges (TEMPA) assessment would be appropriate for measuring response to the third intervention of increasing bilateral coordination. The TEMPA measures bilateral and unilateral UE performance through nine standardized tasks (Gillen, 2013). Finally, the Arm Motor Ability Test (AMAT) has been identified by Gillen (2013) as a tool that has been used to document outcomes of CIMT. The AMAT evaluates arm functional mobility and quality of movement during performance of 28 tasks (Gillen, 2013). All of the previously mentioned assessments should be utilized prior to beginning the interventions and again during reevaluation.
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References Behrens, B. (2011). Constrain-induce movement therapy. Retrieved from Mercer County Community College: http://www.mccc.edu/~behrensb/documents/Constrain- InduceMovementTherapyCIMTorCI.pdf Cauraugh, J. H., Lodha, N., Naik, S. K., & Summers, J. J. (2010). Bilateral movement training and stroke motor recovery progress: a structured review and meta-analysis. Human movement science, 29(5), 853-870. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2889142/ Effects of Stroke. (2012). Retrieved from American Stroke Association: http://www.strokeassociation.org/STROKEORG/AboutStroke/EffectsofStroke/Effects- of-Stroke_UCM_308534_SubHomePage.jsp Foti, D., & Kokestsu, J. (2013). Activities of daily living. In H. Penleton, & W. Schultz-Krohn, Pedretti's occupational therapy:Practice skills for physical dysfunction (pp. 157-230). St. Louis: Elsevier. Gillen, G. (2013). Cerebrovascular accident/stroke. In H. Pendleton, & W. Schultz-Krohn, Pedretti's Occupational Therapy:Practice skills for physical dysfunction (pp. 845-877). St. Louis: Elsevier. Kim, J. H., & Park, E. Y. (2013). Balance self-efficacy in relation to balance and activities of daily living in community residents with stroke. Disability & Rehabilitation, 1-5. Retrieved from http://web.b.ebscohost.com/ehost/detail?sid=bd0e71c1-326d-47c2-becb- 24cf4111c838%40sessionmgr113&vid=6&hid=124 OCCUPATIONAL PROFILE & INTERVENTION PLAN 18
Kovic, M., & Schultz-Krohn, W. (2013). Performance skills: Definitions and evaluation in the context of the occupational therapy framework. In H. Pendleton, & W. Schultz-Krohn, Pedretti's occupational therapy: Practice skills for physical dysfunction (pp. 451-459). St. Louis: Elsevier. Wolf, S. L., Winstein, C. J., Miller, J. P., Taub, E., Uswatte, G., Morris, D., ... & EXCITE investigators. (2006). Effect of constraint-induced movement therapy on upper extremity function 3 to 9 months after stroke: the EXCITE randomized clinical trial. Jama, 296(17), 2095-2104. Retrieved from http://www.uni.edu/gabriele/page4/files/constraint-induced- movement-therapy.pdf