Running head: OCCUPATIONAL PROFILE AND ANALYSIS

Occupational Profile and Analysis William Unger OCCT 651 Touro University, Nevada

OCCUPATIONAL PROFILE AND ANALYSIS

Occupational Profile The Client Tim is a 35 year old man living in Las Vegas who has been diagnosed with severe bilateral cubital tunnel syndrome. While his cubital tunnel syndrome is the primary reason Tim is seeking OT services from a certified hand therapist, he also has a longstanding diagnosis of bipolar disorder. Tim is currently unemployed and lives with his wife and two grade school aged children. Tim was previously employed in finance, working as part of a firm responsible for managing investments in the stock market. Why the Client is Seeking Services / The Clients Current Concerns Tim first started experiencing symptoms of cubital tunnel syndrome in his right upper extremity one year ago, and in his left upper extremity seven months ago. What initially started as tingling and occasional numbness eventually progressed into a significant loss of muscle control and frequent pain and numbness the ulnar side of his hands. Tim described this pain to feel like, shards of glass, and reported a tremendous amount of interference into his daily occupations. At the time of treatment, the muscles innervated by Tims ulnar nerves had atrophied to the point that he could barely flex his fourth and fifth digits, and Tim had significantly reduced lateral pinch strength of his first digits. A few months prior, he had undergone a cubital tunnel release surgery to attempt to improve his functioning and halt the progression of his condition. However, for whatever reason, the surgery failed to successfully remediate Tims symptoms, and after some sporadic progress followed by a period of stagnation, he began to again decline in functioning.

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Tims primary concern is that the severity of his symptoms prevents him from being able to return to working. Tim had previously been the breadwinner of his family while his wife was earning her undergraduate degree, and his primary treatment goal is to be able to regain enough functioning and pain relief to be able to re-enter the work force. Areas of Occupation ADLs. Deficits in grip strength prevent Tim from easily dressing and performing grooming ADLs. While he is still able to do these occupations independently, he reports experiencing high amounts of pain throughout the required motions. Tims physical appearance was fairly unkempt, with unwashed and messy hair, an unshaved face, and uncut and dirty nails. This was likely due to his hesitance to engage in self-care activities which might illicit pain. IADLs. Tim and his wife both acted as caregivers for their two children, but as his wife was about to start graduate school, he was concerned that he would have a difficult time fulfilling many of the duties she typically performed. This included meal preparation and household chores, both of which he found very difficult given his impaired grip strength and frequent pain. Tim reported that his inability to perform these tasks made him, feel useless. Rest and sleep. Tim reported that his pain frequently prevented him from getting restful sleep, as he would often wake in the middle of the night in response to it. Additionally, Tim reported that he would find himself sleeping on his stomach with his forearms pronated and elbows flexed placing his hands under his pillow. This position put considerable strain on his already irritated cubital tunnels, and was likely a large contributor to his slowed recovery. Tims therapist had previously made the recommendation to use supportive devices which would pad the elbows during sleep, but Tim had not followed her recommendation to obtain a pair.

OCCUPATIONAL PROFILE AND ANALYSIS Work. Tim was no longer employed, and stated that he didnt think he would be able to work given his debility. His previous job required him to use the computer for long lengths of time, of which a large portion was spent typing. As effectively typing was very difficult for Tim to accomplish given his debility, returning to work within that same field would necessitate significant recovery. Tim is still very financially oriented and made frequent comments over the stress he felt from not being able to provide a source of income for his family. Leisure. Tim did not speak very much about how he spent his leisure time, but it could be assumed that the time he spent on the computer (unfortunately in a contraindicated posture)

was a form of leisure participation. Developing a method in which Tim can continue to engage in his preferred leisure activities without aggravating his cubital tunnel syndrome should be a focus of future interventions. Social participation. Tim appears to be a fairly introverted person, and didnt speak about any relationships other than those he has with his family. Symptoms from his bipolar disorder could potentially limit his ability to engage in social activities with peers. Furthermore, increased reliance on his wife for transportation as a result of his functional limitations from cubital tunnel syndrome limits his ability to independently go on community outings. Contexts and Environments Personal. Tims personal context is that of a 35 year old husband who is a father of two. The current role expectations of a father, husband, and income earner demands a level of functioning which Tim currently does not feel he can fully perform. Virtual. Tim enjoys working with computers, and has mentioned on several occasions spending time reading on his home PC. Tim has the potential to work from home via his computer, but would first need to regain functionality in his upper extremities.

OCCUPATIONAL PROFILE AND ANALYSIS Physical. Tims significant impairment in grip strength may potentially present issues in independence in his home environment, particularly with regards to opening or closing drawers, cabinets, locks, or doors. Social. Tim frequently spoke about his family, suggesting that he has regular social interaction with his wife and children. They appear to be a major source of happiness in his life, an important fact given his otherwise pessimistic demeanor. Occupational History As stated earlier in this paper, Tim is currently unemployed due to a combination of factors, primarily as a consequence of his bipolar disorder and his cubital tunnel syndrome related debility. Previously, Tim had worked a broker for a financial investment firm. Tim demonstrates a remarkable intellect and extensive knowledge of economics. His previous work had earned his family a very comfortable salary in the past, but he chose to leave the workforce for some time after entering a particularly challenging depressive cycle. Tim reported that this overlapped with the onset of his cubital tunnel syndrome. Despite medication, surgery, and rehabilitative treatment, the combination of his symptoms makes functioning in the manner his previous career necessitates practically impossible. Priorities and Desired Outcomes Tim wishes to become more independent to relieve the burden he feels he is placing on his wife. He wants to become a better caregiver for his kids and wishes to eventually return to work. Fortunately, Tim sees a high amount of value in his hand therapy, and praises the interventions of his therapist. His adherence to her recommendations at home, however, has proved to be inconsistent in the past. Working to develop a home intervention that Tim sees value in would be an important part of his future treatment goals.

OCCUPATIONAL PROFILE AND ANALYSIS Occupational Analysis Due to the context of services in which I observed Tim, I did not have the opportunity to directly observe him engaging in any occupation based activities. However, based on his

description of his prior career environment and current preferred leisure activities, it has become clear that the ability to safely and successfully operate a computer with close to normal performance would be of great benefit to improving Tims quality of life. This being the case, I have chosen to analyze what Tims current performance would likely be in this activity.

Deficits in Body Function Categories Mental. Tims bipolar disorder presents many psychological challenges. This can vary depending on what kind of cycle he is experiencing. Furthermore, Tim regularly takes medication to even out his mood and disposition. These can also have an effect on his mental state. Intellectually, however, Tim is incredibly capable. This presents him with the opportunity to engage in complicated activities, particularly those which involve mathematics and economics. Sensory and pain. Tim experiences high amounts of pain and diminished tactile sensation in his affected ulnar sides of his hands and wrists. The sensation of tingling frequently accompanies and often precedes these symptoms. Neuromuscular-Skeletal and movement related. Bilateral damage to Tims ulnar nerves has resulted in muscular atrophy of many of the innervated structures. This has caused Tim to have limited muscle strength and range of motion, particularly in lateral pinch with the first digits and flexion of the fourth and fifth digits.

OCCUPATIONAL PROFILE AND ANALYSIS Activity Demands Object needs. Working from home requires either a laptop or desktop computer. Along with the computer itself, additional required components would be a monitor, keyboard, mouse, and mouse pad. For safe engagement in this activity, Tim would require padded surfaces to cushion his vulnerable structures during work. Tim would additionally require a sturdy chair which supports an anterior pelvic tilt, along with adequate lumbar support and adjustable height to properly position his arms and hands on the desk. Space demands. Working on the computer requires a well-lit indoor area, free from as

many distractions as possible. This would preferably be a dedicated room to be used as an office, but can also be a quiet area of the house with adequate space for a desk. Social demands. Working at home from a computer would include expectations to be able to regularly complete work on time and meet all work quotas, along with the expectation of regularly checking email and voicemail to receive and respond to any messages from peers or superiors. Sequence and timing. Sequencing and timing are variable, but computer work would generally begin by interfacing with the keyboard and mouse, then viewing resulting work on the computers monitor. Tim must be able to plan and organize his tasks around upcoming deadlines. Required actions or skills. Tim must be able to grasp and manipulate his computer mouse around the mouse pad with sufficient degrees of motion to navigate computer operations. Tim must also be able to type intermittently for periods of up to an hour before taking a break. Short periods of rest during this hour can be accommodated for if his pain interferes with his ability to be productive.

OCCUPATIONAL PROFILE AND ANALYSIS Performance Patterns Habits. Tim has a dominating habit which significantly interferes with the recovery of his cubital tunnel syndrome. Whenever Tim is working on the computer, specifically when he is reading and not using both hands, he rests his head on his hands with his elbows flexed and

pressing on the table top surface. This puts a significant amount of pressure on the cubital tunnel for what are often extended periods of time. Despite his awareness of the harmful effects of this position, Tim remarked that he would fail to notice himself doing this until pain was elicited. By this point, irritation of his sensitive cubital tunnels had already occurred. Addressing this habit, either through behavior modification or compensatory strategies, will be one of the primary goals of an intervention to address Tims recovery. Routines. Tims routine when working on the computer typically begins with checking his email and opening the necessary programs required to do his job. His subsequent tasks then depend on whatever his workload prescribes for the day. Roles. Tims primary role is that of an employee, but this role contains several subroles which must also be considered. As an employee of his particular profession, Tim often finds himself in the role of an advisor, a negotiator, and a salesperson. Additionally, while not directly related to the work he is performing on the computer, Tims role of a provider for his family serves as a constant motivator for his work performance. The inability to remain employed and provide a source of income for his family was cited as a primary factor of his depression. Performance Skills Motor and praxis skills. Fine motor control and praxis are incredibly important parts of operating the computer efficiently. To use the computer optimally, Tim should have full range of motion in each digit, and sufficient strength to press a key or click a mouse button. Additionally,

OCCUPATIONAL PROFILE AND ANALYSIS Tim needs to be able to have the motor coordination and praxis skills to plan, sequence, and execute hand and finger movements very rapidly. Additionally, some internal and external rotation of the forearm along with flexion and extension of the shoulder and elbow are required to move the mouse around the mouse pad. Sensory perceptual skills. With respect to typing, the primary sensory skill required is that of mechanoreceptors in the fingertips. These receptors will determine whether or not sufficient pressure has been applied to the key in order to produce a keystroke, as well as determine if the finger is properly positioned on the center of the key, or is stretched across multiple keys. Proprioceptive sensation in the joints of the upper extremity is also required to provide feedback regarding the quality and distance of movement. As mentioned earlier, a primary reason for which Tim has found himself unable to work on his computer is due to significant pain caused by his cubital tunnel syndrome. This results in abnormal pain sensations when performing tasks which should otherwise be painless. In this way, decreasing, compensating, or ignoring the presence of pain has become an additional sensory requirement for Tim.

Emotional regulation skills. Working in finance, Tims job is almost certainly subject to emotional turmoil. A combination of high expectations for performance and the fear of making costly decisions create a stressful work environment. While he had been well compensated for his work in the past, his inability to work effectively coupled with his diagnoses of bipolar disorder made emotional regulation incredibly difficult. In order to perform his job optimally, Tim must be able to handle the stress, and this could largely be accomplished through an increase in confidence of his ability to perform up to the standards of his profession.

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Cognition. The day to day operations of his profession require a high degree of cognitive capacity, including the ability to rapidly calculate mathematic operations and make judgment calls on risk versus reward scenarios. Tim is well educated and comes across as very intelligent in conversation. His medication for his bipolar disorder, however, appears to have an inhibitory effect on his processing speed. The degree to which this interferes with his cognitive capacity is unclear, but his medication schedule is definitely something which should be considered when evaluating his ability to be productive during his work. Communication and interaction skills. Despite working out of the home, Tims job requires regular communication with his clients, peers, and superiors. This typically involves communication via email or an electronic instant messaging service, but could also entail communication over the phone. Tim must be able to articulate his ideas clearly and effectively, and must be able to comprehend information provided to him during these communications. Additionally, Tim must be able to operate these devices, including all typing and mouse movements. Use of a traditional telephone is not required; Tim can instead choose to use a hands-free phone. Body Functions and Structures Influenced by Task Mental functions. Higher level cognitive function is paramount to working in the field of finance. Tims job requires him to use short-term, long-term, and working memory on a regular basis. Multitasking of different activities requires Tim to have sustained, selective, and divided attention. Sensory functions and pain. Tims job requires him to have a functioning visual perceptual system, and the ability to discriminate between applications on his computer using figure ground perception. Communication with co-workers and clients require Tim to have a

OCCUPATIONAL PROFILE AND ANALYSIS functioning auditory system. Vestibular systems are required to maintain sitting balance, and proprioceptive systems are required to judge and grade movements. Neuromusculoskeletal and movement-related. Operating the computer requires functional use of two upper extremities, including full range of motion in the digits and wrist,

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and at least 90 degrees of elbow flexion. Internal and external rotation of the humerus is required to move hands from the keyboard to the mouse, and shoulder flexion and extension are required to push the mouse about the mouse pad. Cardiovascular, hematological, immunological, and respiratory system function. Due to the low MET requirement of computer work, cardiopulmonary requirements are very low. Operating the computer at a desk requires tolerance of sitting upright for extended periods of time, and individuals with severe bradycardia could potentially have issues maintaining such a posture. Fortunately, this is not the case for Tim. Voice and Speech. Communicating with co-workers and clients requires functioning vocal cords and neural speech and language centers. The ability to accurately convey detailed information is incredibly important for this type of profession. Skin. Use of the computer requires cutaneous sensation to accurately manipulate keys, and any pathological thickening of the skin could decrease an individuals capacity to navigate a keyboard with ease. Skin should be resilient enough to endure very light friction with keys and mouse buttons. Contexts and Environments Related to Performance Cultural. The culture of the financial industry is very competitive and performance driven. Individuals are expected to bring financial gain to their employers and clients, and being ineffective at ones job or making risky decisions without a resulting benefit are looked down

OCCUPATIONAL PROFILE AND ANALYSIS upon. Individuals who do not meet these expectations can be ostracized or prevented from

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advancement within their place of employment, and the somewhat cutthroat nature of this culture can cause employees to feel high amounts of stress from their work. Physical. Working from a computer at home creates an interesting dynamic for the environment of employment. The individual finds themselves engaged in their career oriented occupations, but are physically present in the same environment they live in with their families. This has the potential to create an odd dichotomous relationship with ones home, become an environment in which family and work roles interact in ways they might not in a traditional work setting. Social. The social environment is closely related to the cultural environment with respect to a career in the field of finance. Social relationships within the work environment can often be viewed as a part of an individuals productivity and contribution to the company. Individuals who are seen as successful are likely to garner greater attention from their peers, while those who are seen as unsuccessful may find themselves more isolated. Additionally, working from home has the social implication of having to create a barrier between family members and the worker during work hours, despite being present in the same house. This requires all family members to be aware of situational boundaries in order to maintain a harmonious balance between work life and home life for the employee. Virtual. The virtual context is a large component of working from home. The large majority of work related actions and interactions occur in a virtual environment. Restriction to such an environment has some inherent benefits and limitations. Benefits include the opportunity for instant and constant communication between involved parties, while limitations include a lack of face to face communication.

OCCUPATIONAL PROFILE AND ANALYSIS Problem Statements 1. Client is unable to successfully operate a computer due to limited bilateral UE ROM and strength secondary to impaired ulnar nerve function.

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2. Client is unable to sleep through the night due to pain elicited by bilateral ulnar nerve damage. 3. Client is unable to perform self-care ADLs without pain in bilateral UE secondary to ulnar nerve damage. 4. Client is unable to prepare meals for his children without pain in bilateral UE secondary to ulnar nerve damage. 5. Client is unable to drive due to bilateral decreased grip strength secondary by ulnar nerve damage. My reasoning for prioritizing the list in this way was based on my impression of the clients priorities for treatment outcomes. Tim seemed to primarily be preoccupied by his inability to earn an income, and I felt that due to the computer based context on his previous job, helping him to regain functioning in this occupation would be of primary importance. Second, I chose to address Tims disturbed sleep patterns. Lack of restful sleep can have a cascading effect on engagement in practically every other occupation, and there are some simple compensatory interventions which could be taken to improve Tims sleep quality. Next, I chose to prioritize Tims ability to comfortably engage in self-care ADLs. I felt this choice made the most sense due to his outward physical appearance. While he stated he could still complete the activities, I believe that the pain he endures in doing so decreases his motivation to complete them regularly. The final two goals are certainly important to allow Tim to fulfill the needs of his roles and promote community mobility; however his wife is able to fulfill the requirements of these goals without any significant disruption in their familys quality of life.

OCCUPATIONAL PROFILE AND ANALYSIS References

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American Occupational Therapy Association. (2008).Occupational therapy practice framework: Domain and process (2nd ed.). American Journal of Occupational Therapy, 62,625683.