Case: #3
Date: 2/10/14
Cultural:
Physical:
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Social:
Personal:
Temporal:
Virtual:
One of Marlenes job duties includes meeting one on one with planners and
administrators in her company.
One of her job duties includes answering questions for people at a reception area.
She is not married currently.
Marlene is a 32-year-old woman.
She is reference consultant for a scientific research company
She enjoys cooking, reading, watching TV, going to plays and concerts, and listening
to classical music.
She is left hand dominant.
She was diagnosed with Rhematoid Arthritis 10 months ago.
Her RA cam on very suddenly.
It is wintertime.
She has spent the past 5-6 weeks on a special project that has required more time on the
computer.
She has approximately 2 months of occupational therapy services.
First seen for worsening of symptoms two weeks ago.
She uses a computer for most of her work (about 20-30 hours per week).
She uses a phone for work communication on a regular basis and likely has a personal
cell phone.
She enjoys watching TV.
Prior Occupations:
Worked full time as a research consultant where she works on a computer at a desk, answers phones, meets
with company administrators, handles books, and answers questions at a reception area.
Recently, she had been working as a special project and spending more time on the computer.
She cooked, watched TV, attended plays and concerts, and listened to classical music
Current Occupations:
Lighter work duties as her job: answering questions at the reception desk, answering phones, receiving
requests, and processing paperwork.
Similar hobbies as above, but with increased difficulty due to pain, numbness, and decreased strength.
4: Top Three Client/Family Goals and Priorities
1. Return to completing meaningful activities at work, which include locating research and presenting the
information that she finds to company planner and administrators.
2. Have less pain and discomfort so that she can participate more fully in her hobbies.
3. Complete everyday routines with less discomfort (personal care, household management, and sleeping).
The clients priorities for therapy were not provided in the documentation; therefore, the clients goals above are
inferred based on available information.
5. Diagnosis and Expected Course
Diagnosis:
Carpal Tunnel Syndrome
Trigger Thumb
Rheumatoid Arthritis (previously diagnosed)
Expected Course:
Carpal Tunnel Syndrome:
The prognosis of this repetitive use injury depends
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Rationale
Marlenes participation in work, household
management, sleep, and personal care will increase
if modifications are made to the activities
themselves, he environment they are performed in
and the way that Marlene engages in them. Below
are some examples of how PEO can be applied to
her hobby of cooking:
The cooking activity itself can be change to
decrease repetitive use of the wrist flexors.
Marlene can choose a recipe that does not
require a lot of cutting or chopping.
The environment that Marlene cooks in can
be modified: she can use appliances to
complete work instead of her hands. A
microwave can be used to warm up soup
rather than stirring it in a pot on the stove.
The way that Marlene engages in the
cooking activity can be modified: Marlene
can use larger joints/muscle groups to move
items. Instead of gripping a pan with her
fingertips, she can place both hands on the
bottom of the pan so that her biceps are
doing the work instead of the muscles that
pass through her wrist joints.
With changes to these three areas, (person,
environment and occupation), cooking will be
easier to complete. Similar modifications can be
made to other activities.
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2.
Biomechanical/Rehabilitation Model:
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3.
Lifestyle Balance
Functional mobility:
Marlene stands at a reception area to answer
questions.
Dressing:
Does Marlene have any difficulty getting dressed in the
morning due to wrist pain or morning stiffness?
What aspect of undressing is difficult for Marlene? Fasteners?
Fatigue or pain at the end of the day?
Eating/Feeding:
Does Marlene have any difficulties holding eating utensils?
Pain? Dropping items?
Functional mobility:
Does standing at this area cause any fatigue? How long does
she need to stand for?
Eating/Feeding:
None
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Sexual Activity:
She reported N/A in this category on the DASH
Toilet Hygiene:
None
Communication Management:
Marlene regularly makes phone calls for work.
Community Mobility:
Marlene drives a car.
She has difficulty turning keys.
Financial Management:
Marlenes occupational therapy visits are paid
for by insurance and workers comp.
Health Management and Maintenance:
Marlenes employer allows her complete light
duty tasks due to her RA.
She is reluctant to have CTR surgery because
she does not know how she will manage on her
own during recovery.
She is currently on medications for pain and
joint swelling.
Home management and Maintenance:
Marlene lives alone and likely completes most of
her home management activities.
She indicates that she has moderate difficulty
with household chores and documentation
indicates that she has 70% function in this
category.
Meal Preparation and Cleanup:
Marlene enjoys cooking.
Marlene indicated that she had moderate
difficulty with meal preparation.
Religious Observance:
None
Shopping:
She has moderate difficulty holding a shopping
bag.
Has she been wearing these braces? How does she plan on
washing them if she needs to?
Personal hygiene and grooming:
What personal care activities are going well/not so well?
Does she have any morning stiffness or UE pain during
grooming activities?
Is she able to hold onto smaller items (toothbrush, makeup
applicators, comb, finger nail clippers, etc).
Does she have difficulty gripping her hair dryer and brush? Or,
does she have difficulty holding her arm up for an extended
period of time?
Sexual Activity:
None
Toilet Hygiene:
Does she have any difficulties with clothing management
during toileting?
Communication Management:
Does Marlene have any difficulty pushing buttons to dial a
phone number?
How does she communicate with friends/family? Does she text?
Does Marlene need to send a lot of emails for work?
Community mobility:
Is it difficult to grip the steering wheel of her car?
Does her car unlock with a button or does she need to turn a key
to open it?
Financial Management:
Does Marlene have the financial means to hire any help with
home management activities?
Health management and Maintenance:
What stage of RA is Marlene in? (Likely 1 or 2)
Do her medications have any negative side effects?
When is she wearing her braces?
Is she currently using any strategies to manage her diagnoses?
(Stretching, tendon gliding exercises, using larger joints
whenever possible, avoiding repetitive wrist flexion, etc).
Home management and Maintenance:
Does Marlene need to turn a key to get inside her home?
What aspects of home management or specific chores are
difficult?
Does Marlene currently have anyone who is available to assist
her with home management activities?
Meal Preparation and Cleanup:
How often does Marlene prepare a meal? How complex is it?
What steps are involved?
Religious Observance:
Does Marlene identify with a particular religion?
Shopping:
How does Marlene get her groceries or other purchases to her
car? In a cart? Carry them?
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Rest/Sleep:
She has moderate difficulty sleeping because of
pain in her UE.
Education:
Given her career field, Marlene has likely
graduated high school and gone to college.
Work:
Marlene works as a reference consultant for a
scientific research company.
Prior to her onset of symptoms:
-She spent about 5 hours per day (but more as of
lately) using a computer to search for reference
data and internet sites.
-She spent about 3 hours per day standing and
answering questions at a reception area.
-She spent about 10 hours per week on the phone
and meeting with planners and administrators.
Since her health condition worsened, her
insurance requires her to remain on the job in
light duty roles:
-Time at reception desk responding to questions
-Answering phone
-Receiving requests
-Processing paperwork
She considers these activities less meaningful.
Since the onset of her symptoms she has also
needed to make a more conscious effort about
what to do and how.
Overall, she reports that her diagnoses and
associated symptoms have a slight impact on her
daily schedule.
Volunteering:
None
Leisure Participation:
Marlenes hobbies include:
-Cooking
-Reading
-Watching TV
-Going to plays
-Going to concerts
-Listening to classical music
Social participation:
Marlene lives alone.
Marlene answers questions for people in a
reception area
Marlene meets regularly one on one with
coworkers to discuss her research.
Volunteering:
Does Marlene volunteer anywhere and if so, how is that going?
Leisure participation:
How has Marlenes leisure participation changed since her
change in health status on Nov 1?
On the DASH, what does Marlene mean when she says that she
has some difficulty with holiday things in the recreation
category?
Social participation:
Does Marlene have any social supports in her local community?
Is she spending time with any family/friends for the upcoming
holidays? Would they be willing to assist her if she decided to
get the CTR surgery?
Is Marlene missing out on any social activities because of her
pain level?
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Other:
How does Marlene spend her time on a good day versus a bad
day?
How has Marlenes typical day changed since her symptoms
worsened at the beginning of November?
What is Marlenes classification of function according to the
American College of Rheumatology?
What are her goals for therapy?
9. Performance Skills
What do you know?
Motor and Praxis Skills:
Marlene reports weakness in digits 2-4 on her right
hand.
Marlene has bilateral grip weakness (below average
range in both hands).
She has decreased pinch strength
-Lateral pinch: Well below average bilaterally
-3 point pinch: Well below average bilaterally
-Tip pinch: Well below average in right hand,
normal range in left.
She has decreased wrist ROM:
-Bilateral wrist flexion: loss of 20 degrees on the
right and 30 degrees on the left.
-Left wrist extension (mild): loss of 7 degrees.
Decreased Thumb flexion and extension (secondary to
RA and Trigger thumb)
-Thumb MP (on the left): loss of 8 degrees
-Thumb IP (bilateral): loss of 18 degrees on the
right and 12 degrees on the left.
Bilateral index fingers have full ROM, however, they
require very concentrated effort to get to full range.
Scoring on the DASH indicates a high level of
dysfunction in the upper extremity. Her score was a 90.
A score of zero indicates no dysfunction and a score of
100 indicates severe dysfunction.
The deficits listed above impact Marlenes participation
in everyday activities, particularly those that involve her
upper extremities (turning a key, operating/typing on a
computer).
Sensory Perceptual Skills:
Marlene has decreased light touch sensation on her left
distal volar phalanx. However, her protective sensation
is still intact.
She has normal sensation in her right hand.
She reports numbness in digits 2-4 (secondary to median
nerve compression).
Emotional Regulation Skills:
None
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Cognitive skills:
None
Routines:
Marlene will attend therapy each week for 2 months.
Marlene goes to work 40 hours per week.
Marlenes availability for therapy is dependent on her
busy schedule.
Rituals:
None
Roles:
Marlene is an employee.
Marlene is user of technology.
Marlene is a client of OT services.
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Body Structure:
Marlenes bilateral median nerves are compressed in the
carpal canal, which caused muscle atrophy.
Marlene has nodules in her left thumb that prevent the
flexor tendon from going smoothly through the tendon
sheath.
Body Structure:
Does Marlene have any joint deformities secondary to
RA?
Does Marlene have any nodules or crepitus secondary to
RA?
How much inflammation does Marlene have in her wrist
joints? Is this inflammation impacting her median nerve
or tendon sheaths?
Skin:
Has Marlene experienced any skin changes recently?
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14. Evaluation: What Assessment tools and other means of assessment will you use?
Top Down Assessment: Prioritize one Occupation to observe the client perform
Observed Occupation
Prepare a meal (a typical meal that she would make for
herself).
Method/Tool
1. Interview Marlene about:
-When she experiences the most pain and what
activities she is typically doing then
-What her life looks like outside of work
-How she is feeling about the CTR release
surgery (as her decision affects therapy
approach)
-What social supports she has
-How supportive her employer is
-What activities are the most frustrating for her
-What are goals are for therapy. Confirm if the
current priorities are an accurate picture of how
she would like to spend her therapy time.
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2. Cognitive screening
3. Psychosocial Screening
4. A Home Evaluation
5. MMT on bilateral UE
6. AMPS
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Type of Outcome
Occupational Performance
Prevention
Adaptation
Health and wellness
Participation
Quality of life
Role competency
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Community resources:
Techrepublic.com or www.geeks.com/techtips: These websites provide information about ergonomic
technology options for people with CTS including keyboards, mouses, notepads, etc.
Web MD: This website provides a list of carpal tunnel stretches and trigger thumb exercises.
You tube videos: There are a lot of demonstrations of and trigger thumb exercises and CTS stretches.
The Arthritis Foundation: This organization provides a wide variety of services including how to manage RA
during a variety of activities (gardening, work), community exercise and recreation programs, and self-help
programs. Individuals who have gone through the self-help program have reported a decrease in pain of 20%.
Rheumatoid arthritis support group: Meeting with people in the local community who also have RA could be
very beneficial for Marlene. Other individuals who have co-occurring conditions of CTS or trigger finger may
be able to give Marlene advice or identify with her symptoms.
RA monthly e-newsletters: These have info about the latest research in RA and new treatment options.
Team members:
Marlenes employer should be contacted to discuss how to provide her meaningful work opportunities.
Her physician and hand surgeon can provide info about the recovery process from CTR surgery and pain
management options, which will impact how therapy time is spent.
If Marlene has social supports in her community, they may be able to assist her with some home management
17. Intervention Plan
Barriers
Marlene enjoys researching on the computer but repetitive
motions like typing on the computer exacerbate her CTS and
trigger thumb.
Marlene has difficulty with home management activities but
she lives alone and therefore has full responsibility for them.
Marlenes main work duties (20-30 hours/week) require
typing, dialing numbers, lifting books and other activities that
require good hand function.
Marlene would benefit from CTR surgery but does not feel
that she has sufficient social supports assist her in the
recovery process.
If workers comp is paying for some OT services, they may
specify that therapy address work related functions only.
Goals
Supports
Marlene is receiving OT services
early on after her symptoms
worsened.
Marlene has a wide variety of
interests that can be used in
therapy.
Marlenes insurance covers enough
OT visits to work on a variety of
activities.
In addition, outpatient setting
allows for the opportunity to
address a variety of occupational
areas.
Practice Model for each goal
LTG:
By D/C, client will problem solve one work simplification technique
during a work related activity with min verbal cues.
STG:
By session 3, client will independently use a joint protection
technique while handling an office related item that weighs more
than 5 lbs.
STG:
By session 6, client will independently implement a one-minute rest
break every 30 minutes while typing on a computer.
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Lifestyle Balance
Biomechanical
PEO
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2. LTG:
By D/C, client will receive 7 hours or more of sleep per night for at
least 5 consecutive days as recorded in a sleep chart.
Lifestyle Balance
STG:
By session 2, client will wear braces at least 5 nights per week to
maintain extended wrist position.
PEO
STG:
By session 6, client will report an overall score of 3 or less on the
pain intensity scale upon waking for the previous week.
Biomechanical
3. LTG:
By D/C, client will independently implement rest breaks prn during
home management activities involving the UE.
STG:
By session 7, client will problem solve an activity modification
during meal preparation to decrease wrist flexion with min verbal
cues.
STG:
By session 3, client will utilize joint protection techniques during
household cleaning activities independently.
Lifestyle Balance
PEO
Biomechanical
18. Treatment Sessions: Plan for first two 45 minute treatment sessions:
1. What will you do?
Identify Approaches
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Identify Approaches
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