Occupational Therapy on Limbs Limitations Report

Introduction

The changes that are currently being experienced within the healthcare industry have made it mandatory for occupational therapist to focus on the long-term needs of their clients (Kaplan, 2009). In the process of developing healthy behaviours, occupational therapists not only need to put measures that will improve the health status of their clients but also need to come up with measures and practices that will reduce their overall medical costs in the long run. In this respect, it is the role of occupational therapists to mobilise the community and involve them in a range of services and activities that aim at improving, promoting, and protecting the overall health status of the community (Crawford, 2007). This will ensure that a given community comprise of healthy individuals who play an active role in the development of their society (Trombly, 2005).

This paper therefore represents an occupational therapy plan of Mrs. Kubinski, an 83 year old woman. As a result of Polio, Mrs. Kubinski has minor limitations on her upper and lower limbs. Consequently, she has been diagnosed with osteoporosis as well as chronic obstructive pulmonary disorders that are considered to be the likely cause of the fall that she experienced. The fall had a negative impact on her confidence since she is always in a constant fear of having another fall again. Based on her age, health status, and the fall, Mrs. Kubinski has become socially disadvantaged since her movements have been limited by the fact that she can only drive within the local area. As a result, Mrs. Kubinski has been less involved in her charity work, an activity that she valued and gave her a great level of joy and satisfaction. Despite all this and the fact that she has a son, Mrs. Kubinski lives alone and wishes to continue living at her home for as long as possible. To realise this goal, Mrs. Kubinski needs to undergo through an occupational performance therapy as a means of ensuring that she is actively engaged in her daily life activities. This occupational therapy plan therefore presents the proposed assessment approaches that will be used in this case, the goals that are to be achieved in the process of implementing this plan, and the possible occupational therapy interventions that will be applied to realise the proposed goals.

Proposed Assessment Approach

From clinical literature, it is evident that the occupational functional model (OFM) is the most effective method that is used to evaluate and treat individuals who are suffering from any form of physically impairment (Fisher, 1999). The main purpose of this model is to enhance the competency of an individual with regards to occupational performance. By critically analysing Mrs. Kubinski situation, OFM is thus the most effective model to base the assessment approach of her occupational therapy plan. This is because the approaches and applications of this model are based on research and practice that originate from clinical practice. Due to this fact, they are evidence based (Watts, 2007). Through the application of this model, occupational therapists aim at rejuvenating the level of self-efficacy, self-esteem, and self-satisfaction that clients lose due to their reduced levels of occupational performance as a result of their physical inability (Blue, 2005).

In accordance of OFM, the occupational performance of an individual is based on a hierarchy of abilities and capabilities (Kielhofner, 2007). Therefore, to critically understand and capture the needs of patients, assessments should follow a top-down approach (Levett-Jones, 2012). Following this approach, occupational therapists need to determine the roles and tasks that their patients were engaged in before becoming physically dysfunctional as a result of a medical condition or an accident. In our case, some of the activities that Mrs. Kubinski was involved before her fall (which worsened her occupation performance) include:

1. Conducting normal household chores (since she lives alone)
2. Charity work
3. Driving as a basic means of transportation (she is not fond of public transport).

However, it is critical for occupational therapists to consider the activities that their patients value the most. In the case of Mrs. Kubinski, the assessments below can be used to achieve this goal:

1. The role checklist assessment
2. Client oriented role evaluation (CORE)

Based on the role theory, these types of assessment are based on the relationship that exists between the roles of individuals, their occupation, as well as their identity (Allen, 2005). According to the role theory, the fulfilment of a role is determined by the expectation that an individual has, the expectations that other individuals have, and most importantly, the level of satisfaction that of the individual gets from an activity (Allen, 2005). From a societal point of view, the roles that individuals are engaged in play a significant role in determining their identity as well as their lifestyles since they establish norms, patterns, and behaviours (Micheals, 2004).

In our case, the role checklist method will not be effective in determining the most valued roles of Mrs. Kubinski. This is because it will be difficult for her to reflect on her role components based on her age. Consequently Peters (2005) discouraged this method because it does not measure the relative importance of the selected roles with regards to the patient in question. However, the CORE approach is an effective method with regards to the case of Mrs. Kubinski. This method will enable her to determine the impacts of her roles. Here, Mrs. Kubinski will be expected to define specific roles before and after she became socially disadvantaged. The main purpose of this step is to determine the effect that these roles have to the self-identity of a patient (Damschroder, 2009). Consequently, this approach is effective in determining the level of satisfaction the patient received from the roles that he/she was engaged in. This is usually achieved through the role appraisal process where a patient is asked to rate the level of satisfaction she is receiving. Unlike in the previous step where the patient rated her experience before and after being socially disadvantaged, here, the patient is expected only to report about her post disadvantaged status with regards to the level of satisfaction that she enjoys from her roles. In the study that was conducted by Fairman (2011), patients measured their post injury level of satisfaction on specific roles based on a scale of 1-10 (1 being least satisfactory and 10 being fully satisfied). This similar approach will be used to rate Mrs. Kubinski level of satisfaction. The role that will have the highest score will be considered as the most valued while the one with the lowest score will be considered as the least valued. Consequently, this approach will be used to measure the level of self-efficacy that the patient has especially with regards to functional activities. As Jefferson (2003) asserted, it is critical for occupational to understand the level of confidence that their patients have especially with regards to undertaking functional occupational roles. In the case of Mrs. Kubinski, this assessment will reveal the level of confidence that she has while performing functional roles such as cooking, cleaning, personal grooming, and driving. Toal-Sullivan and Hernderson (2004) conducted a study that provides level 3 evidence on the current plan. However, the results of this study are valid since they can be easily generalised to reflect trends in the target population.

Finally, it is critical to consider the impact that the environment has on the occupational performance of a patient. The environment can either enhance or hinder the occupational performance of an individual based on the social disabilities of a patient (Schildkrout, 2011). While different home assessment techniques are present, the most effective method for the case of Mrs. Kubinski is the home occupation-environment assessment method (HOEA). According to Ehart (2002), it is essential for occupational therapist to assess the physical and social environments that an individual lives in. This is because occupational therapists need to have a clear understanding about the level of performance of a patient under these conditions (Pollard, 2005). Studies have revealed that individuals tend to have the best performance their activities of daily living (ADLs) in an environment that they are familiar with and comfortable in (Salamy, 2013). Thus, it is the duty of an occupational therapist to ensure that this environment is safe. At the same time, an occupational therapist is expected to determine whether this environment can promote the independence of patients as well as enhancing their quality of life.

In accordance to the HOEA method, environmental cues are used to determine the patient’s level of function. This is an essential consideration as it determines the level of function of a patient with regards to ADLs as well as the level of support that he/she might require to perform various activities (Schoonhoven, 2008). Mrs. Kubinski seemed to have been living a comfortable life. However, after her fall, she lost her level of self-efficacy and self-confidence. In this respect, she might find it difficult to undertake her daily chores as she used to before the fall. As an occupational therapist, it is critical to determine her level of function based on specific goals of the therapy. While focusing on the kitchen, for instance, it is essential to determine whether Mrs. Kubinski can prepare her own food. At this point, it will be of essence to determine whether she can purchase food at ease or whether she has food in the house. As Llorens (2006) asserted, an occupational therapists need to conduct a thorough physical assessment of the patient’s home while focusing on the following three areas:

1. The entrance way – Here, an occupational therapist needs to determine whether the patient can identify the main entrance. Does the house have stars and railings? Is the patient capable of locking and unlocking doors? Can the patient move around the house at ease?
2. The kitchen – Is the patient comfortable with the current table heights? Can he/she open the refrigerator/kitchen cabinets?
3. Bathrooms – Is the patient capable of moving from a wheelchair to the bathroom/toilet? Are there safety bars?

Finally, it is essential to determine whether a patient can respond effectively in an event of an emergency. A systematic review with randomized controls that was conducted by Haastregt et al. (1999) provided level 1 evidence on the Oxford 2011 levels of evidence based on the application of HOEA approach in this occupational therapy plan. Furthermore, the evidence of this study was valid since it could be easily generalised to represent trends within the intended target population.

Goals

Like Mrs. Kubinski, many patients who undergo rehabilitation through occupational therapy suffer from complex problems that require different assessment approaches and interventions. Mrs. Kubinski suffers from polio that has brought about limitations to her upper and lower limbs. At the same time, she is suffering from osteoporosis and chronic obstructive pulmonary disease that has a negative effect on her skeletal structure. From the research that has been conducted, it has emerged that osteoporosis might cause falls (Schell, 2013). This revelation can thus be used to explain the fall that Mrs. Kubinski experienced. Finally, Mrs. Kubinski movement has been hindered since she can only drive to areas that are within her locality. Due to this fact, she cannot actively engage in her charity work. Based on this profile, the following SMART goals are appropriate for the rehabilitation process of this client:

1. To enhance her physical activity. Here, Mrs. Kubinski should be engaged in morning walks 5 days per week. During the first two weeks, the distance that Mrs. Kubinski is expected to cover is three 3000 meters. After every week, she is expected to add 500 meters. Mrs. Kubinski should keep up with this exercise for the rest of her life.
2. To enhance her driving skills. Mrs. Kubinski needs to engage in routine driving exercise. However, she needs to undergo physical medical check-ups to determine her overall well-being especially with regards to her eyesight after every six months. At the same time, she needs to get encouragement from her son as well as her friends to boost her self-efficacy and her self-esteem.
3. To enhance her oxygen uptake. Mrs Kubinski needs to undergo oxygen therapy as well as well as pulmonary rehabilitation. This will increase her oxygen uptake if she is exposed to an environment with high concentration of oxygen for 15 hours per day. As a result, the rates of survival as well as the quality of life of Mrs. Kubinski will be greatly enhanced.

These goals are appropriate since they are specific in nature. The first goal of this plan aims at assisting Mrs. Kubinski to overcome the limitations on her upper and lower limbs as a result of her polio condition. Therefore, the overall aim of this goal is to enhance her mobility. By critically analysing this goal, it is evident that the progress made by the patient can easily be measured. Consequently, the activities of this goal are attainable since they are not intense (the age of the patient has been taken into consideration). Finally, the duration in which this goal should be applicable has been stated. Given her fragile age, Mrs. Kubinski should keep up with this exercises to ensure that her body is physically fit hence enabling her to attend to her ADLs at ease. The other two goals also take a similar approach.

Occupational Therapy Intervention

From the studies that have been conducted, it has emerged that occupational therapists can use various approaches to realise their overall goals (Ma, 2004). However, the enhancement of occupation performance has always been considered as the integral objective of occupational therapists (American Occupational Therapy Association, 2008). Through this objective, occupational therapists aim at ensuring that their clients are actively engaged in their daily life activities. According to Mountain (2005), the client-centred approach is the most effective and efficient way that occupational therapists can use to realise this goal. Through the client-centred approach, occupational therapists need to team up with their clients as well as the individuals who are within their immediate environment in the process of helping them to develop skills as well as make modifications in their lives as a means of enhancing their occupation performance. This is an essential strategy as it assists clients and their caregivers to overcome the barriers that make them to be socially disadvantaged (Ayers, 2001).

The main aim of occupation therapy is to ensure that the physical and mental needs of patients are met. Based on the goals that have been set it in this plan, two different interventions can be put in place to ensure that they are realised. The first intervention focuses on provision of critical information to Mrs. Kubinski with regards to her medical condition and need for therapy. Information has always been considered as an integral aspect of a therapy process (Kielhofner, 2005). It is from the received information that a patient learns how to put his/her medical condition under control. For this intervention, the target audience is the patient (Mrs. Kubinski) and her caregiver (her son). The action of this intervention should be taken by the occupational therapist. Therefore, as the occupational therapist, I will:

1. Provide practical solutions to the problems faced by the patient and her caregiver.
2. Involve the patient in the process of developing strategies to enhance her quality of life.
3. Increase her knowledge and awareness with regards to the medical conditions that she is suffering from and possible means of putting them under control.
4. Encourage feedback from the patient and her caregiver. This information will be used to determine the level of progress as well as the level of engagement and motivation from the client.

After conducting a systematic review of 143 studies to determine the role played by information in enhancing patient-cantered care, Jayadevappa and Chhatre (2011) provided level 2 evidence. These results were valid since the results can be easily generalised to the elderly population suffering from physical dysfunction and the methods used to collect, analyse, interpret, and present the information are effective and efficient.

The second intervention will focus on the physical wellbeing Mrs. Kubinski. This intervention will pay particular emphasis on the walking exercise as well the exercise that the patient will be involved in. Like the previous intervention, the target audience of this activity is the patient and her caregiver. This activity should thus be undertaken by the individual who will be taking care of Mrs. Kubinski. The caregiver is thus expected to be involved in the following roles:

1. Offer the patient walking schemes. These walking schemes should be of a moderate intensity based on the age of the patient.
2. Encourage the patient to participate regularly in this activity.

In this activity, the caregiver needs to ensure that:

1. He/she is the one who organized and leads the walking exercise.
2. Conducts a brief before the exercise explaining the course and expected duration of the activity to the patient.
3. Set up the days in which the activity should take place.
4. Monitor the progress that the patient is making over time.
5. Get feedback from the patient regarding her overall attitude towards the activity.
6. Encourage the patient to suggest changes/modifications to the activity.

Studies that have been conducted on rehabilitation have pointed out physical therapy as being one of the most important intervention methods of enhancing the overall physical wellness of patients irrespective of their age and medical condition (Dusdal et al., 2011). As Dusdal et al. (2011) asserted, it is essential for individuals to maintain constant physical activities especially during the later years of life. This is because regular exercise is beneficial especially in enhancing the health levels of individuals, as well as their mobility and independence. Through this intervention therefore, Mrs. Kubinski is expected to enhance her mobility and independence hence realising the first and second goals of this occupational therapy plan. Through physical activity, Mrs. Kubinski is also expected to enjoy additional such as reduction levels and anxiety. Physical exercise is also expected to boost her levels of self-efficacy and self-esteem hence ensuring that she effectively attends to her ADLs. A systematic review conducted by Dusdal et al. (2011) on the effects of therapeutic exercise on elderly individuals suffering from osteoporosis asserted that therapeutic exercise is essential enhancing the overall physical wellness of patients. Using the Oxford 2011 levels of evidence, I can rate the evidence presented in this paper at level 1. Consequently, the results of this study are valid since random sampling technique was used hence they can be easily generalised to represent trends within a larger population.

References

Allen, C. (2005). Occupational Therapy for Psychiatric Diseases: Measurement and Management of Cognitive Disabilities. Boston: Little Brown,

American Occupational Therapy Association (2008). ‘Occupational therapy practice framework: Domain and processes.’ American Journal of Occupational Therapy, 62 (1), 625-683.

Ayers, A.J. (2001). Sensory Integration and Praxis Test. Los Angeles: Western Psychological Services.

Blue, T. (2005). Understanding cognitive performance modes. Florida: Ormond Beach.

Crawford, C. (2007). Occupational Performance History Interview. Oklahoma: Clearinghouse.

Damschroder, L. (2009). ‘Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science.’ Implementation Science, 4: 50-64.

Dusdal,K., Grundmanis, J., Luttin, K., Ritchie, P., Rompre, C., Sidhu, R., Harris, S. (2011). ‘Effects of therapeutic exercise for persons with osteoporotic vertebral fractures: a systematic review.’ Osteoporosis International, 22(3), 755-69.

Earhart, C. (2002). Occupational Therapy Treatment Goals for the Physically and Cognitively Disabled. Chicago: Rockville, MD.

Fairman, J. A. (2011). ‘Broadening the Scope of Nursing Practice.’ The New England Journal of Medicine, 364 (3), 193-214.

Fisher, G. (1999). Assessment of Motor and Process Skills. Colorado: Three Star Press.

Haastregt, J., Diederiks, J., Rossum, E., and Witte, L. (2000). ‘Effects of preventive home visits to elderly people living in the community: systematic review.’ BMJ, 320(1), 754-80.

Jayadevappa R. and Chhatre, S (2011). ‘ Patient Centred Care: A Conceptual Model and Review of State of the Art.’ The Open Health Services and Policy Journal,4(1), 15-25.

Jefferson, A. (2003). ‘Position paper: Purposeful activity.’ American Journal of Occupational Therapy, 47 (1), 1081-1088.

Kalplan, K. (2009). The Occupational Case Analysis and Interview and Rating Scale. New Jersey: Slack.

Katz, N. (2009). Routine Task Inventory. Journal of Occupational Therapy, 54(2), 1174-1189.

Kielhofner, G. (2005). A Model of Human Occupation: Theory and Application. Baltimore: Lippincott Williams & Wilkins.

Kielhofner, G. (2007). A Model of Human Occupation: Theory and Application. Baltimore: Lippincott Williams & Wilkins.

Levett-Jones, T. (2012). Clinical reasoning: Learning to think like a nurse. Frenchs Forest, N.S.W.: Pearson Australia.

Llorens, L. (2006). Application of a Developmental Theory for Health and Rehabilitation. New York: Rockville, MD.

Ma, H. (2004). ‘Effects of task complexity on reaction time and movement kinematics in elderly people.’ American Journal of Occupational Therapy, 58(2), 150-158.

Micheals, F. (2004). ‘Uniform terminology for occupational therapy.’ American Journal of Occupational Therapy, 48 (3), 1047-1058.

Mountain, G. (2005). Occupational Therapy with Older People. Hoboken, NJ: Wiley

Peters, A. (2005). ‘The philosophical base of occupational therapy.’ American Journal of Occupational Therapy, 49 (2), 1026-1040

Pollard, D. (2005). Cognitive levels: Meeting the challenges of client-focused services. London: Sage

Reilly, M. (2012). ‘Occupational therapy can be one of the great ideas of 20th century medicine.’ American Journal of Occupational Therapy, 56(2), 1-9.

Salamy, M. (2013). The Assessment of Communication and Interaction Skills. Chicago: Wiley and Sons

Schell, B. (2013). ‘Clinical reasoning in occupational therapy: an integrative review.’ J Occup Ther, 47(1), pp. 605-610.

Schildkrout, B. (2011). Unmasking psychological symptoms: How therapists can learn to recognize the psychological presentation of medical disorders. Hoboken, N.J.: John Wiley & Sons.

Schoonhoven, L., (2008). ‘Nursing implementation science: How evidence-based nursing requires evidence-based implementation.’ Journal of Nursing Scholarship, 40(4), 302-310.

Toal-Sullivan, D., & Henderson, P. R. (2004). ‘Client-Oriented Role Evaluation (CORE): The development of a clinical reha-bilitation instrument to assess role change associated with disability.’ American Journal of Occupational Therapy, 58(1), 211–220.

Trombly, C. (2005). ‘Occupation: Purposefulness and meaningfulness as therapeutic mechanisms.’ American Journal of Occupational Therapy, 49(10), 960-972.

Watts, J. (2007). Assessments in Occupational Therapy in Mental Health. New Jersey: Slack.