Student

Name: Melissa Weddington

Case: Lai Chi

Date: 2/14/2013

1. Diagnosis, Referral, Setting, Reimbursement, LOS

Diagnosis: R partial rotator cuff tear, L bicep tendonitis
Referral: Nursing at the assisted living facility
Setting: home health
Reimbursement: Medicare
LOS: 3x a week for 30 days

2. Pragmatic Factors to Consider

Short LOS so self management and making the effects of therapy last as long as possible is
important.
Lives at ALF so staff should be involved to educate and train

4: Top Three Client/Family Goals and Priorities

Taking care of herself
physically doing what she needs to do
getting where she needs to go
getting done what she needs to
doing activities she likes
working towards goals
effectively using her abilities

5. Diagnosis and Expected Course

6. Scientific Reasoning & Evidence

List the barriers to performance typical of this
diagnosis:
Evidence:
Pedretti chapter 36
The shoulder positions the hand and
elbow so a person can participate in
everyday activities.

R partial rotator cuff tear:

Diagnosis: A tear in a rotator cuff muscle
(infraspinatus, supraspinatus, teres minor or
subscapularis) that causes the tendon to no longer
connect with head of the head of the humerus or to
connect partially.
Muscle atrophy of the scapular area may be seen. doi:10.5014/ajot.2011.09184American Journal
Significant substitution of the scapula can be seen of Occupational TherapyJanuary/February
when shoulder elevation is attempted.
2011vol. 65 no. 1 16-23
Testing can include a positive arm drop test or less
Not enough evidence to support or
than 3/5 abduction.
refute current interventions for rotator
Causes:
cuff tear including various modalities
Acute tear: caused by a fall on an outstretched arm
and exercises.
or carrying something too heavy.
Current practices include the use of
Degenerative: repetitive stress, reduced blood
modalities, increasing ROM and
supply, bone spurs
strength and using occupation based
Partial Tear. This type of tear damages the soft
activities to facilitate healing.
tissue, but does not completely sever it.
Full-Thickness Tear. This type of tear is a
Barriers:
complete tear that splits the tissue into two pieces.
Pain
In many cases, tendons tear off where they attach
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to the head of the humerus. With a full-thickness

tear, there is basically a hole in the tendon.
Symptoms:
-Pain when resting or at night
- pain when lifting or lowering your arm
-weakness when lifting or lowering arm
- Crepitus or cracking with shoulder movements

Expected course:
Some rotator cuff tears can heal on their own.
Icing, ROM, pain medication and strength
exercises can assist in the healing process. More
severe tears may require surgery.
Healing time varies greatly due to the type and
extent of the tear ranging from 3-12 weeks.
http://orthoinfo.aaos.org/topic.cfm?topic=a00064
http://beta.webmd.com/fitnessexercise/guide/rotator-cuff-tear#2

Reduced shoulder ROM

Reduced ROM in elbow flexion and
supination.
Possible inflammation
Problems sleeping which can affect
healing
Fatigue caused by shoulder weakness and
pain

L Biceps tendonitis:
Diagnosis: Inflammation of the bicep tendon.
The long head of the bicep attaches to the top of
the glenoid. The short head attaches to the
corocoid process.
Often comorbid with other shoulder conditions
including shoulder arthritis, impingement, and
shoulder muscle tears.
Caused by overuse, repetitive overhead motions,
poor lifting techniques, rotator cuff pathology,
poor posture, lack of flexibility, osteoarthritis and
spurring.
Expected course:
Tendon can be red and swollen and tendon sheath
can thicken.
Icing, pain medication, and avoiding heavy lifting
can help aid in the recovery process.
Surgery may be indicated if the tendonitis is
severe.
Healing time varies greatly depending on extent of
injury, how long you have had the injury and your
age.
http://www.summitmedicalgroup.com/library/adult
_health/sma_biceps_tendonitis/
7. Practice Models Guiding Assessment and
Treatment

Rationale

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1. PEO

2. Biomechanical/Rehabilitation model

This is a good model for Lia Chi because this

model focuses on promoting optimal congruence
and satisfaction between person, occupation and
environment. This model gives flexibility in
working with Lia Chi because many things can
be altered to promote occupational performance.
This model can be used with Lia Chi to increase
her ability to participate in desired occupations
including strength, range of motion etc. It can be
used with Lia Chi to modify the occupations she
participates in by changing the materials needed
such as a long handled loofa for showering or
adapting the way she performs the activity such
as dressing her weaker shoulder first. The
environment can be adapted to prevent further
injury by placing heavier items such as pans
where they can be accessed without reaching
overhead. In addition tasks or body positions can
be modified to prevent repetitive injury.
This model is a good fit for Lia Chi because her
injuries of partial rotator cuff tear and biceps
tendonitis can result in decreased range of
motion, strength and endurance of her shoulder
and arm during functional activities. This model
will be used with Lia Chi to help strengthen her
rotator cuff muscles, and increase her shoulder
range of motion. In addition this model can be
used to adapt activities to reduce biomechanical
requirements especially for her bicep tendonitis
that can be caused by poor body mechanics
during tasks and from over use. This model
allows for the use of adaptive equipment as
needed. This may be a good first step for Lai Chi
so she can shower independently or with minimal
assistance using a long handled loofah or other
AE until her shoulder and tendonitis are less
painful and have the ROM and strength needed
to perform the task without AE. This model
would support continued use of AE if Lia Chi
was not able to regain strength and ROM in her
shoulder.

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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
ADL routine including dressing and showering
(or simulated showering see below). This
activity would take place in her home with her
demonstrating how she is currently performing
the tasks. If possible her nursing staff that assists
her would be present and assisting her to get
dressed and shower as she normally would.

Rationale/How will you use this information

This task will provide the following information
A look at how she is performing her
occupations.
See what the documented max assist
looks like
What is nursing helping with?
Could Lai Chi do more?
What is her home environment set up
Simulated showering: This is the first meeting
like?
with Lai Chi and it is important to build good
How does she interact with her
rapport with her and make her feel comfortable. It
environment (shower head, positioning
is not necessary for her to fully shower for me to
of clothing, or products she uses
see what I need to about her current injuries. I am
regularly)
mainly looking for her movements, compensation
Information regarding her personality
and how she does this in her current environment.
and feelings about her current injury
Quick look to see if there are any
Dressing: Special attention to how she is currently
cognitive concerns
getting dressed with help and what is limiting her
What her ballpark ROM is in each of the
independence (strength, ROM, endurance).
shoulders and arms
Shower will be similar with her showing me how
Her level of pain performing the task
she washes her hair and body and nursing
through self-report or facial expression
showing what they usually do.
while doing the task
The process she usually follows and
strategies she is currently employing.
Look for compensatory movements of
the trunk, wrist, elbow or hand
Method/Tool
Rationale/What is being Assessed
1. Palpation and gliding of scapula with special
Before performing activities and ROM
attention to the RUE because of the rotator cuff
involving the shoulder it is important to make
injury, but should look at the LUE as well because sure the scapula is moving properly to prevent
shoulder injuries can cause bicep tendonitis.
further injury to the joint and cause any
(feeling the head of the humerus and scapula and
impingement or pain. Palpation of the
looking and touching to see the alignment and
musculature and boney landmarks will give
musculature)
information about current amount of muscle
surrounding the joint and any unusual feel to the
boney landmarks. Gentle gliding of the scapula
and humerus into elevation, depression,
protraction and retraction gives feedback on the
health of the scapula and the position of the
head of the humerus in the shoulder complex.
This is important information because 60
degrees of movement in the shoulder complex is
due to movement in the scapula.

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2. AROM and PROM

RUE and LUE Shoulder: flexion, extension,
abduction, adduction, and scaption
Elbow: extension, flexion, supination

3. MMT
L UE:
shoulder: flexion, extension, abduction,
adduction, and scaption
Elbow: flexion, extension, supination

4. Simple shoulder test

5. Western Ontario Rotator Cuff Injuries

AROM will be evaluated first to see what the

current range is in each joint with special
attention to pain. It is important not to damage
the rotator cuff injury any further on the right
side. PROM will be done after AROM.
Discrepancies in AROM and PROM may
indicate weakened shoulder musculature.
Reduced ROM may also indicate problems with
scapular movements. During this assessment
compensatory strategies will be observed, as
well as the end feel of the joints and the
presence of creptitus. Look for compensatory
movements of other joints in the UE and of the
trunk.
MMT will be done on the left UE because the
referral indicates that she is having difficulties
with performing everyday activities due to
shoulder weakness. With a tendonitis injury
there are possible shoulder complications. MMT
will provide information on the strength of the
various muscle actions and will indicate which
areas need additional strengthening to help
improve occupational performance.
This test will provide information about how
well Lai Chi feels she is able to perform the
functional tasks such as carry a grocery bag or
tuck in a shirt. This information can be used to
gather information quickly about how well she
is performing a variety of areas. The areas
identified as being problematic can be discusses
with Lia Chi to see where her priorities are and
identify areas that may be useful to address in
therapy. If the therapist wants to gain additional
information the therapist can have her quickly
demonstrate some of the tasks mentioned in the
questionnaire so that occupational performance
can be observed.
This questionnaire asks about a variety of
occupations that may be affected by rotator cuff
injury. It is different from the simple shoulder
test because it includes questions on pain,
psychological affects of the injury,
compensation, and fitness. It is important to
understand the clients outlook on the injury and
this questionnaire can provide the basis for a
conservation about what Lai Chi was able to do
prior to her injury. I would give this assessment
in a more dynamic way asking follow-up
questions and using the template mainly as a
way to spark the conversations.

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17. Intervention Plan

Barriers
Supports
Pain while sleeping and doing overhead
Lives at an assisted living center so
activities.
nursing staff can carryover therapy
Facility that she lives at requires her to be min
Lai Chi is social
assist or less
Enjoys a variety of activities including
quilting and group outings
Currently max assist for ADLS including
dressing and showering
She ahs been approved for
occupational therapy services 3x per
Physical demands of her occupations are
greater than her current level of strength and
week for 30 days.
ROM in her shoulder
Social supports of a daughter who
comes to visit several times a year.
She reports difficulty getting where she needs
to go.
She reports that she is doing well with
Shortage of staff to assist her with mobility on
cognitive tasks including
an outing
concentration, expressing herself,
problem solving, handling her
Perhaps poor endurance or easily fatigue
responsibilities, and making decisions
(because she borrowed a wheelchair to go on
based on what is important
a day outing)
Goals
Practice Model for each goal
1. LTG:
Before discharge, client will perform UE dressing
with min assistance.

PEO

STG:
By session 9, client will have sufficient bilateral UE
strength to don a shirt with mod assistance.

Biomechanical/Rehabilitation

STG:
By session 7, client will have sufficient bilateral UE
ROM to don and doff shirt with mod assistance.

Biomechanical/Rehabilitation

2. LTG:
Before discharge client will shower with minimum assist.

PEO

STG:
By session 5, client will wash upper back with minimal
assistance and adaptive equipment as necessary.

PEO
Biomechanical

STG:
By session 10, client will wash hair overhead using bilateral
UE with minimal assistance.

PEO
Biomechanical

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3. LTG: Before discharge client, will report pain of 3 or less

when performing ADL activities.
PEO

STG:
Within 3 sessions, client will I implement activity modification Biomechanical
techniques during ADL and IADL tasks to reduce stress on her
shoulders.
STG:
Within 8 sessions client will report no sleep disturbances from
pain of her R shoulder for one week through the use of body
positioning.

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PEO
Biomechanical

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18. Treatment Sessions: Plan for first two 45 minute treatment sessions:
1. What will you do?

Identify
Approaches
HEP: Begin the session with teaching of a short home exercise program Establish/restore
and ROM exercises for B UE. Since this is the first session it is important Modify
to do little to no resistance and focus on slow quality movements and not Prevent
to cause further pain.

Based on
which goal(s)?
LTG: 1
STG 1.1-1.2
LTG: 3
STG 3.2

Example exercises include

-Wall walks for shoulder flexion and abduction: client stands with fingers
outstretched towards a wall close enough that the fingers can touch the
wall and slowly walks the fingers up the wall to stretch the joint and
strengthen it. Before pain is reached or when AROM is exhausted client
will slowly bring hands back down. (done side ways for abduction)
-Slow AROM against gravity: It is pertinent that the client does this with
hand in neutral position (thumb up) to avoid further bicep tendonitis and
impingement.
Exercises will take between 5-10 min.
Handouts will be given to remind her of proper positioning during the
gentle exercises.
Occupation-based activity: 15-25 min
Client will work on UE dressing with nursing staff if possible (if not
possible handout or documentation should be given to nursing so they
can better assist her with getting dressed in the future).
Before performing the task the therapist will quickly go over movement
patterns that will cause further damage to the shoulder and stress on the
bicep tendon and talk to Lai Chi about adapting tasks to reduce the
demands they place on the UE.
The client will be instructed to get a shirt from her closet and put it on.
Therapist will provide feedback and assistance with the task and offer
some ideas for compensatory strategies until more strength and ROM are
achieved.
Examples of suggestions and feedback may include
-Selecting a shirt that is oversized to prevent too much bending or pulling
on the joint.
-Dressing her weaker shoulder first so that it does not have to be
stretched as far
-Storing her clothing in a place that does not require her to reach
overhead
-Correcting compensatory strategies that cause further damage.
Additional time would be spent

2. What will you do?

Identify
Approaches
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Based on
which goal(s)?
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Begin with 5 min of warm-up through bilateral AROM and PROM

including shoulder: abduction, adduction, flexion, extension, and elbow
supination, flexion and extension.
Occupation based activity #1 showering
Therapist will provide client with feedback from the initial evaluation
regarding her performance on showering. This may include information
about body position, environmental factors such as shower head or
shampoo bottle placement and compensatory strategies she is using.
Therapist will then have client demonstrate simulated showering (nursing
may be there also or be given documentation as mentioned above). The
will problem solve ways with the client to reduce pain, and strain on the
R rotator cuff and L bicep tendon. The therapist will also problem solve
with the client equipment that may help her increase independence until
her shoulder ROM and strength increase (this may help her continue to
use the joint, but not put undo stress on it)
Examples of problem solving strategies include: placement of shampoo
bottles and soap, ways in which the nursing staff can encourage her to
use her shoulders to do a bit more without causing her pain (allowing her
to wash everything she can do without pain)
Examples of adaptive equipment: a long handled loofah to reach her
upper and lower back without having to flex or abduct her shoulder too
far, long handled hair scrubbers to wash her hair without stressing the
shoulder but would still encourage some shoulder movement.

Establish/restore
Modify
prevent

LTG: 2
STG 2.1-2.2
LTG:3
STG 3.1-3.2

Occupation based activity #2 wheelchair positioning and use for outings

Lai Chis rotator cuff injury and bicep tendonitis occurred after using a
wheelchair for an extended amount of time on an outing. She has
indicated that outings are one of her favorite activities at the ALF
For this portion of the session it would be important to not only educate
the client on this but also to educate the staff at the ALF
-Begin by talking to Lai Chi about her wheelchair use wheelchair
(demands of the most outings: curbs, ramps, long distances). Then have
her demonstrate her wheelchair use by practicing in facility hallway. The
therapist will then provide Lai Chi with suggestions regarding functional
mobility on outings including
-Design and size of wheelchair: Lai Chi is 411 so the basic wheelchair at
the facility may not be a good fit (or may be too heavy) for her. This may
have contributed to the injury in the first place. Instruct her that if
possible she should borrow a wheelchair that is better fit for her size.
-In addition teach Lai Chi body positing and wheelchair techniques for
manual propulsion that will help prevent future injury
-A referral for a PT may be needed to see if a W/C is the best option for
her mobility or if a walker may be a better fit for her needs during
outings (would need to talk to PT about her current injuries in addition)
(want to prevent further injury and facilitate her participation in
meaningful activities)

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