The Integration of Occupation-based Treatment into Hand Therapy

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Author's Note: The case study presented in this article is provided to the reader as an example of a treatment planning approach. The activities selected by the therapist in the case scenario should not be interpreted as a treatment protocol for wrist fractures. Treating therapists should always consult with the referring physician when upgrading the activity level of a hand therapy patient.

Definitions:

Occupations-Activities of everyday life, named, organized and given value and meaning by individuals and a culture. Occupation is everything people do to occupy themselves, including looking after themselves, enjoying life and contributing to the social and economic fabric of their communities

Activities-A term used to describe a class of human actions that are goal directed.

1. Creating an Occupation-centered Treatment Plan

Introduction

Occupation-based occupational therapy is certainly not a new concept. As a matter of fact, OT was founded on the basic principle that individuals will be healthier, happier and more functional when they are engaged in doing things that are meaningful to them. What has changed in OT since the initial founding of our profession is the way occupations are used and how they are perceived.

In 1921, Dr. Adoph Meyer defined occupations as being those things that were work, yet pleasurable, and that helped the individual to define time and to have a sense that something was accomplished with the use of time. Individuals occupied their time with tasks that had a purposeful outcome that inherently held meaning for them.

Today the terms "occupation" and "activities" have become synonymous and are used interchangeably. Unfortunately, using the word activities in place of occupations has changed the way that OT is practiced in the clinic. OTs now use "activities" and "tasks" in the place of occupations. Of course, activities can be very helpful indeed, but often they miss the depth of meaning that true occupations can hold for an individual. Activities by definition do not need to have a purposeful outcome or hold special significance for the individual. They do pass time, but there may not be anything to show for it that the person can be proud of.

Mary Beth Early in her book Physical Dysfunction Practice Skills for the OTA, provides a clear definition and differentiation of four levels of activities and occupations:

  • adjunctive methods. These are techniques used by the therapist to prepare the patient for eventual engagement in occupations. These methods include such things as physical agent modalities and therapeutic exercises. Adjunctive methods are done to the patient, not by him.
  • enabling activities. These tasks, such as cone-stacking and therapy putty exercises, specifically address components of function yet do not have inherent meaning or meaningful outcome.
  • purposeful activities. These are the first level of occupation-based activities, such as dressing, bathing, cooking and job and leisure related activities that have specific meaning for clients. Purposeful activities can be either broken down bits of occupational role functions or can be other meaningful tasks that address components. Crafts, for example, are meaningful to some people and can be created to address physical and psychosocial components that may be needed in an occupational role and to relieve depression.
  • occupations. Occupational roles are the multifaceted functions comprised of purposeful activities that humans do on a daily basis. Occupations are things like self-care, care of others, working and engaging in leisure pursuits. An OT who pays a home visit to ensure that a hemiplegic mother can complete the ADL needed to care for her herself and her young child, and can make adaptations if necessary to care for her home and perhaps engage in her avocational role as an artist is doing this. Even though the specific tasks that go into these roles are important and can be simulated through purposeful activity, the roles need to be addressed in the real-life and time context in which they occur in order for the patient to feel successful.

By this definition, enabling activities (which are now widespread in hand therapy practice) do not inherently hold meaning for the individual. Although they can be fun and act as a diversion, they do not touch him at the psychosocial level needed to engage his entire being. And that is what constitutes real occupational therapy-the ability to engage the mind and the heart in order to create health and promote healing.

I have an example from my own life. My father is currently undergoing chemotherapy for CLL. Despite the belief of all within the medical community that he should retire from his job as an operating engineer in heavy construction, he has pushed and pushed until he received an OK from his doctor to work. Even his well-intentioned OT (his daughter) was busy suggesting puzzles and assorted household odd jobs that he could do in order to keep himself active and engaged. Nothing, however, meant more to him than to return to work. I spoke to my father on Father's Day and asked how work was going. His reply was, "The chair is not as comfortable as my recliner at home, but the time goes by much faster." Well said, Dad.

Hand therapists "came to be" through the combined efforts of OTs and PTs who were working very closely with hand surgeons who needed specialists to work with their very delicate post-op hand patients. The blend was terrific. The delicate nature of the surgery combined with the splinting and fine-motor focus of the OT and the knowledge of PAMs and joint mobilization techniques of the PT to create a well sought after mix of expertise and professionalism. Hand therapy progressed into a quasi-separate profession with it's own credentialing process. This process, however, still necessitates that the therapist first be trained and work as a generalist OT or PT. The question now turns to how does the OT hand therapist interested in redefining hand practice go about doing that? I believe the answer is quite simple. It takes only a motivated and creative OT to create a treatment plan that reflects and preserves a tried-and-true discipline.

Setting the Stage with Assessment

The ADVANCE Hand Therapy Practice Survey, returned by more than 500 hand specialists, showed evidence that respondents did not understand references to "top-down" and "bottom-up" approaches to evaluation. Many left the questions blank or put question marks behind them.

These are assessment styles analyzed by Slagle lecturer Ann Fisher in 1999. They refer to a therapist's approach to observing a patient. Hand therapists are experts in the "bottom-up" approach to patient assessment. In other words, they evaluate patients on their ability to complete arcs of motion or squeeze a dynamometer and on how swollen a hand is according to a tape measure or volumeter. The "bottom-up" approach assumes that when components of function are missing, terminal functions (occupations) must be missing as a result. The hand therapist will determine where the deficits lie in components and build a treatment plan to correct these defective components. Once corrected, it is assumed that the patient will resume a fully functional life style. If not fully corrected, the hand therapist will offer suggestions for modifications and adaptations.

By using such an approach, a therapist can make erroneous prognoses about current and future occupational performance. Occupational performance is actually independent of such components. It may be compromised, of course, and this is where an OT will help an individual accommodate for missing abilities. A hand therapist who chooses an occupation-centered approach will first determine which occupations have been disturbed by the current pathology and build a treatment plan to correct the problems that are leading to the functional limitation. This is known as the "top-down" approach, and while the areas addressed are ultimately the same, the changed focus can lead to an amazingly different treatment plan and a very different level of engagement for the patient.

Perhaps the easiest way to complete a top-down approach to assessment is with the Canadian Occupational Performance Measure (COPM). This tool was devised by Mary Law et al. and is applicable to all OT settings, including hands.

The format of the assessment is a questionnaire that can be completed in 30-45 minutes. During the question-and-answer period, the patient is asked to reflect upon those areas of function that are currently troublesome and then to rate those areas on levels of difficulty and level of priority that that function has. Through this method, the hand therapist will immediately learn what is important to that patient and can begin to create a plan to address those specific areas of function. No need to waste time waiting to fix assorted components of function; the work toward getting that patient back to what makes him or her happy and whole can begin immediately. COPM measurement forms are not necessary for this course, but if you are interested in purchasing any parts of the COPM packet, you can do so by going to www.slackbooks.com or calling Slack Inc. publishers, Thorofare, NJ, 1-800-257-8290. The cost is between $11 and $45.

Hand therapists still can and should also use the tools that measure components; there are still component areas to be addressed. Part of the beauty of the COPM is that is can be used in conjunction with all other assessment tools. What changes through using the COPM is that the patient immediately sees what he is working toward, and activities become linked to the desire to return to life occupations. The focus of treatment is not simply to strengthen fingers or move a wrist, but to become a father, a worker or a student once again. The task of the OT also becomes easier because occupation-based activities will appear to create themselves; they do not simply work on components, but involve the mind, body and spirit of the patient.

Creating an Occupation-based Treatment Plan

Creating the treatment approach starts once the assessment is complete. This is probably the most challenging step for the hand therapist who wants to ensure an occupation- and performance-based plan that simultaneously reflects patients goals and is realistically centered around current pathology.

To simplify this task, I recommend a worksheet-type format. Within this format, the client's goals can be written, ranked and placed next to the reasons for the limitations. Precautions specifically related to the diagnosis can be written to serve as a reminder when choosing purposeful activities. The therapist can devise purposeful activities that can be realistically accomplished and that relate specifically to the desired occupational roles. Lastly, enabling activities and adjunctive techniques can be added to the plan as needed in order to focus attention on resilient dysfunctional components.

Always remember, however, that patients need to know exactly why they are completing enabling activities and why adjunctive methods are being applied so that they can "buy into" the activity. That is, the activity will take on meaning in the context of  reaching the long-term goal.

The following is an example of the chart:

Hand Therapy - Occupation-based Treatment Worksheet
Name: Diagnosis:
Patient's desired occupations/long term goals

1.

2.

3.

 

Components of occupations impacted by diagnosis

1. a.

b.

c.

2. a.

b.

c.

Realistic limitations due to diagnosis

1.

2.

3.

Patient component leading to occupational dysfunction

1a.

 b.

 c.

2a.

 b.

 c.

3 a.

  b

  c

Components to be addressed through occupation-based activity selection

1.

2.

3.

Purposeful activity selection based upon patient's desired role performance/occupation/long-term goals

1.

2.

3.

Additional adjunctive methods and enabling activities

1.

2.

3.

This initial chart will be updated on a weekly or bi-weekly schedule based upon changes in the status of the hand/UE condition or the reaching of initially established occupational goals.

The following case study exemplifies the use of the COPM, the selection of appropriate goals and the use of purposeful (occupation-based) activities.

Case Study

Jack is a 27-year-old roofer who runs his own small roofing company. Jack fell off a ladder and sustained a distal radius fracture to his dominant right wrist. He was initially splinted and had been casted for one and a half weeks as of the date of his OT evaluation. Jack was referred to OT/hand therapy by his orthopedist to address some concerns with decreased ROM of all digits and swelling of his right hand. Jack was expected to be in his cast for four more weeks and to then wear a thermoplastic splint for up to three more weeks.

Before beginning any evaluation of ROM or edema, the OT asked questions in the format of the Canadian Occupational Performance Measure and learned that Jack was extremely concerned with the welfare of his small company. He typically does most of the work himself and hires helpers when needed. 

He reported that he has had several sleepless nights worrying if the people that he scheduled for new roofs would cancel and leave him with no work when he was able to return. He reported that this was the most important thing that he needed to return to, and that he was currently unable to do it.

Jack also reported that he was having difficulties with self-care ADL. He is a single man who owns his own home and is independently responsible for all household tasks and self-care activities. He was embarrassed to say so, but was having a difficult time with toilet hygiene since his fall and could not pull zippers or button tight buttons. Although not as important to him as keeping his business afloat, these self-care issues were very important to Jack. He felt that he was accomplishing these tasks at a 6 on a 10-point scale. Jack reported that he had not been able to engage in desired leisure activities since his fall. Fishing is what he enjoys, but he did not think he could handle a fishing pole or attach a lure at this time. "Anyway," he stated, "My whole life is leisure now."

Following baseline measurements of UE ROM (all joints), a pain scale assessment and circumferential edema measurements, the OT began to fabricate a preliminary treatment plan on the spot with assistance from Jack.

The following is the initial treatment plan as it looks on the worksheet.

Hand Therapy - Occupation-based Treatment Worksheet

Name : Jack

Diagnosis:  Right Wrist Fracture

Patient's desired occupations/long term goals

1. Return to work as a roofer

2. Return to I in ADL's

3. Return to leisure activity of fishing

 

Components of occupations impacted by diagnosis

1 a. Unable to climb ladder

   b. Unable to maintain quadruped while on roof

   c. Unable to carry supplies onto roof

   d. Unable to hammer shingles

2 a. Poor coordination with Left hand

   b. Cannot carry laundry basket

   c. Cannot zip or button

3 a. cannot tie lures onto line

   b. Cannot carry supplies out to lake

   c. Cannot cast line

Realistic limitations due to diagnosis

1. Casting 4 more weeks

2. Unable to move wrist for weight bearing in quadruped secondary to cast

3. Pain as a result of fracture

Patient component leading to occupational dysfunction

1a. Patient unsure of grip strength with cast in place and swollen digits

  b. Cannot hyperextend wrist

  c. Cannot firmly hold hammer as a result of cast and swollen fingers

2 a. No experience with left hand in dominant role

  b. Cannot carry large laundry basket  with one hand and grip is limiting 2 handed carrying

  c. Swollen digits and poor FMC of left hand

3 a. Swollen and stiff fingers

   b. Unable to carry weight with fractured arm

   c. Impaired forearm ROM and dif. With grasp because of swollen and stiff fingers.

Components to be addressed through occupation-based activity selection

1. Swelling of fingers

2. ROM of shoulder, elbow and digits

3. Psycho-social issues such as stress and boredom

4. Pain

Purposeful activity selection based upon patient's desired role performance/occupation/long-term goals

1. Provision of adapted equipment, and technique for self-care independence (within first 1-2 days of therapy)

2. Fly tying activity for FMC, Bimanual dexterity and to decrease edema of involved hand

3. Patient to bring in roofing supplies for graded roofing simulations. Will work on FMC, decrease edema and improve psychological outlook as well as reduce pain

4. Discuss business goals for next four weeks including marketing, contacts with clients, supervising on the job site. To improve psychological outlook, keep patient from becoming isolated and depressed and maintain integrity of business.

Additional adjunctive methods and enabling activities

  • Isotoner glove
  • Retrograde massage
  • Hand helper
  • AROM exercises
  • Ice and elevation

It should be noted through the example activity plan that hand therapy will not change. The knowledge of the hand therapist in working with acutely injured patients in a medical model setting does not need to change. What does change is the focus of the sessions and the selection of the main treatment activities.

The entire process now revolves around the patient returning to the occupational roles that are important to him. The clever OT has modified specific activities within those roles that more accurately address the components. Treatment is no longer a session of range of motion, but is a session spent getting the patient back to occupational roles. In this way, hand therapy has once again become occupational therapy.


The Integration of Occupation-based Treatment into Hand Therapy:
Creating an Occupation-centered Treatment Plan
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