Abstract
The investment of time and self to develop therapeutic relationships with clients appears incongruent with today’s time-constrained health care system, yet bridging the gap of these incongruencies is the challenge therapists face to provide high-quality, client-centered, occupation-based treatment. This case report illustrates a shift in approach from biomechanical to occupational adaptation (OA) in an orthopedic outpatient clinic. The progress of a client with lupus-related arthritis who was 6 days postsurgery is documented. The intervention initially used a biomechanical frame of reference, but when little progress had been made at 10 weeks after surgery, a shift was made to the more client-centered OA approach. The Canadian Occupational Performance Measure was administered, and an OA approach was initiated. On reassessment, clinically important improvements were documented in all functional tasks addressed. An OA approach provides the bridge between the application of clinical expertise, client-centered, occupation-based therapy and the time constraints placed by payer sources.
Peloquin (1990) noted that mechanical expertise and skill were the primary focus of occupational therapy curricula and observed that through the sixth edition of Willard and Spackman’s Occupational Therapy, no chapter discussed the therapeutic relationship or made reference to the terms rapport, relationship, empathy, or trust. Over the past 20 years, there has been an awareness of the need for a shift in focus back to our “caring” roots to include a more holistic, client-centered approach that could supplement the strong manual skills of more biomechanical approaches (Chan & Spencer, 2004; Dale et al., 2002; Peloquin, 1993). For therapists to truly demonstrate care, therapeutic relationships must be formed. This investment of time and self appears incongruent with today’s health care system, in which productivity is paramount and treatment time is curtailed, yet accountability to both patient and payer sources is essential. In this era of managed care, hand therapy is increasingly perceived as a practice area in which mechanical skill must often overshadow client-centered approaches to meet health insurer demands. Bridging these incongruencies to provide skilled, holistic, client-centered care is the challenge that every practicing therapist faces. Individualized, occupation-based treatment in a hand therapy setting has been linked to enhanced patient outcomes (Chan & Spencer, 2004); however, concrete examples documenting how therapists can shift from a mechanistic to a client-centered and occupation-based approach have not been published. This case report provides a novel illustration of how the shift from a strictly biomechanical to a client-centered, occupation-based approach in hand therapy practice can be made to enhance patient outcomes.
The occupational adaptation (OA) framework (Schkade & Schultz, 1992; Schultz & Schkade, 1992) provides a basis for patient care regardless of setting and addresses the need for a more client-centered, holistic approach by fostering a client–therapist relationship that facilitates the patient’s adaptation and ownership of treatment goals and progress. These concepts are embedded in the Occupational Adaptation Guides to Practice (Schultz & Schkade, 1992) from the data-gathering stage, when the patient’s evaluation is viewed holistically, and includes obtaining information on the patient’s performance, ability to adapt, environments, roles, and occupations. Data gathering is also client centered, seeking patient and significant others’ input on concerns, goals, level of desired occupational performance (efficiency, effectiveness, and satisfaction), and approach to adaptation.
By comparing the OA model to the typical biomechanical–rehabilitation model applied to patients recovering from hip fracture, Jackson and Schkade (2001) demonstrated that patients benefit when the OA framework is used. Application of the OA framework improved patient outcome efficiency and generated higher patient satisfaction ratings when compared with performance and ratings using the biomechanical model. Providing occupational therapy services under the OA framework can be both an art and a skill executed with method and precision, while providing the collaborative care demanded by this generation of consumers (Schultz & Schkade, 1992).
The purpose of this case report was to illustrate that a shift in frames of reference from a biomechanical to an OA approach in an orthopedic outpatient clinic can facilitate adaptation, improve patient motivation, and provide documentation of clinically significant functional progress. This case report presents a complicated, orthopedic, postsurgical patient who presented with severely deformed bilateral distal extremities after multiple surgical interventions. The conduct of this case report was approved by the Texas Woman’s University Institutional Review Board; the patient provided informed consent to be part of this study.
Client History
To protect confidentiality, the pseudonym Susan was used. Susan was diagnosed with lupus at age 16; lupus-related arthritis resulted in significant joint deformities to both hands (see Figures 1 and 2) and feet. Although the physical limitations resulting from these deformities did not prevent Susan from participating in daily activities, she reported having a great deal of difficulty growing up with the diagnosis. She identified her positive attitude and sheer determination as two of her greatest assets. Susan was a 51-year-old, divorced mother of two children. She and her children shared a single-level, three-bedroom home in a rural northwestern community. She provided financially for her family through disability benefits and state funds, and received 143 hr per month of personal caregiver assistance.
Volar view of (B) hands.
Dorsal view of (B) hands.
Initial Evaluation
On initial evaluation, Susan presented with a bulky dressing on her left distal forearm and hand. Only 6 days prior, she had undergone simultaneous left thumb interphalangeal joint hardware removal and arthrodesis revision, left open carpal tunnel release and synovectomy, left radius scapholunate fusion, and a left index finger flexor digitorum superficialis to flexor digitorum profundus (FDP) tendon transfer. Susan also identified a history of emphysema but denied further medical complications or other diagnoses.
After the patient interview, her bulky dressing was cut away to reveal healing, blood-crusted suture lines with no abnormal erythema or drainage noted. Typical measurements were taken of the incisions; all sites presented moderately tender to pressure. Susan’s left hand rested in a dependent flexed posture with her wrist in neutral. Goniometric measurements were taken on her left index finger metacarpal joint; in active range of motion (AROM), she demonstrated a 20° extension lag and 50° of flexion. A straight fist measured 4 cm from fingertips to proximal palmar crease. No other ROM measurements were taken at this time because she was less than 1 week postoperative. The figure-8 edema measurement was taken of the left hand and noted as 36 cm; 32 cm was noted on the right for comparison. Susan was initially placed in a forearm-based volar resting splint with her left thumb and digits positioned for comfort to support, protect, and immobilize the joints during the healing process.
Problems identified on the initial occupational therapy evaluation included pitting hand edema, decreased ROM in all digits, increased pain, and decreased function. Susan was scheduled for occupational therapy services twice per week for 6 weeks, for modalities, manual therapies, and therapeutic exercise to address treatment plan goals. The patient’s verbalized goals noted at the time of the initial evaluation included the desire to be able to resume playing Frisbee with improved grip and the ability to resume normal activities of daily living (ADLs) that she had been able to complete before surgery. The following short-term goals were established: Patient will (1) be independent in home exercise program within 4 weeks, (2) demonstrate 2-cm decrease in edema using figure-8 measurement within 4 weeks, (3) demonstrate well-healed incisions with maturing flat scar tissue free of tethering within 4 weeks, and (5) demonstrate straight fist 1.5 cm from proximal palmar crease within 4 weeks. Long-term goals were established as follows: Patient (1) will have the ability to grip pants to pull them up independently in 8 weeks, (2) will have the ability to manipulate and open pill jars in 8 weeks, (3) would like to have the ability to resume playing Frisbee with improved grip, and (4) would like the ability to resume normal ADLs that she was able to complete before surgery.
Treatment
Occupational therapy services were initially provided under the biomechanical frame of reference with a heavy emphasis on protecting the surgical interventions; gaining and maintaining both AROM and passive ROM (PROM); and reducing present edema, promoting wound healing, and providing scar management (see Table 1). Treatments consistently included modalities, retrograde massage, and manual scar mobilizations as well as therapeutic exercises. Dressing changes and debridement of wounds were performed as necessary. Splint modifications were performed as edema subsided, and pressure areas were noted. Susan was seen in the clinic seven of eight scheduled visits; only one appointment absence occurred within the first 5 weeks of care.
Schedule of Intervention Activities and Treatment Focus
Five weeks after surgery, a follow-up occupational therapy assessment was performed because of poor glide of the transferred index finger FDP tendon. Susan reported intermittent pain with increased frequency and length of duration associated with swelling of the left index finger after her home exercise program. She was able to demonstrate independence with her home exercise program and verbalized precautions independently. The therapist’s objective findings included healing scar tissue with limited mobility at the dorsal and volar wrist incision sites and slow healing at the thumb interphalangeal joint. Of the established short-term goals, Susan met two by independently performing her home exercise program and by presenting with a 2-cm decrease in hand edema. However, tethering scar tissue and an inability to make a straight fist prevented her from meeting the other two goals. The therapist’s assessment identified minimal FDP firing but noted that the index finger’s distal interphalangeal joint was firm with contraction. This condition was attributed to heavy scarring at the incision sites. It was also noted that Susan was compensating with the lumbricals at the metacarpalphalangeal joint. Her treatment was changed to include the use of continuous ultrasound followed by continued aggressive scar massage to reduce adhesions. Functional electronic stimulation, which simultaneously blocked the lumbricals’ function, was added after scar massage to aid in tendon pull through. An AROM, active-assisted ROM, and PROM home exercise program and splinting for protection were continued as appropriate until Susan was discharged from occupational therapy (see Table 1).
Susan attended an additional seven of eight scheduled appointments with one absence over the next 5 weeks. She verbalized compliance with all instructed tasks but reported discouragement in the poor progress she felt she had made regarding her scar mobility and ROM. Nine weeks after the operation, buddy tape was issued to address an ulnar drift of Susan’s left index finger over her long finger during composite flexion. One week later, at the 10th week postoperative progress report, we found that minimal improvements could be documented. Objective findings identified poor tissue mobility at all incision sites. We assessed the patient’s functional grasps through her ability to pick up small objects, such as buttons; however, she was unable to hold them in the palm of her hand. She was unable to hold a knife to cut food and unable to grip a mug with her left hand. The therapist encouraged Susan to continue her home exercise program, aggressive scar massage, and buddy tape as a stable post for her index finger to push against during task performance. The long-term goal initially established to address improved Frisbee throwing skill was discontinued at this time. Other established functional goals remained in place.
After the 10th week, Susan again expressed discouragement with the small objective gains documented. She shared her thoughts that although only small gains were seen in the documentation, the same small gains often resulted in major shifts in her occupational performance. She was disappointed that her occupational performance gains were not reflected in the biomechanical goals or biomechanical measures. We decided that a shift in frames of reference to a more client-centered approach was needed. Research supports that when the client is engaged in meaningful occupation and is invested in his or her recovery process, better outcomes are achieved (Dolecheck & Schkade, 1999). We selected the OA model because it would incorporate the needed client engagement and occupation-based approach and facilitate generalization of skills to novel activities and self-initiated adaptations. The Canadian Occupational Performance Measure (COPM; Law et al., 1999) was selected to (1) identify Susan’s primary occupational roles and important occupational performances and (2) obtain client-rated objective measurements of her current levels of performance, specifically noting perceived levels of efficiency, effectiveness, and satisfaction.
Shifting to a Client-Centered Approach
The OA framework states that OA is a normal process that every person experiences. When a person is faced with a life transition, such as a surgical intervention, compounding disabilities that may already be present, the OA process is at risk for dysfunction. It is through the use of the holistic approach of OA that clients may be facilitated to become their own agent of change. The model has been successfully used in a variety of settings and compared with other models (Gibson & Schkade, 1997; Jackson & Schkade, 2001; Johnson & Schkade, 2001).
The COPM is a semistructured interview in which the patient reports performances of concern in the areas of self-care, productivity, and leisure. Once problems are specified, the patient is then asked to rate his or her perceived ability of performance and satisfaction with performance. The tool may be used to aid in treatment planning and reassessment and has been found to be a valid and reliable measurement tool in a variety of settings (Carswell et al., 2004; Watterson, Lowrie, Vockins, Ewer-Smith, & Cooper, 2004).
Implementing the OA Approach
The COPM was administered to Susan to initiate the shift from a biomechanical approach to the more holistic, client-centered OA approach. Because Susan was exceedingly limited in her abilities to perform any tasks, the COPM was used as a baseline to gain her input on which occupational tasks were of most concern to her. Susan identified the desire to be able to supinate, specifically “to turn door knobs or get change from my purse.” She also identified the desire for functional pinch, “so I can get my own toothpaste out or squeeze a ketchup packet.” She voiced the desire to hold a book and cup as well as safely manipulate her car window controls. On a Likert scale ranging from 1 to 10, she was asked to rate her current level of performance and her own satisfaction with that performance (see Table 2). Susan’s averaged scores were calculated by adding the number of performance or satisfaction scores and dividing by 5, which represented the number of problems identified. For example, Susan’s average performance score was 16 (16/5 = 3.2). As seen by these ratings, all <5 (midrange), Susan’s perceptions of her level of performance (3.2) and satisfaction with her performance (2.2) were very low.
Susan’s Initial and Reassessment Scores on the Canadian Occupational Performance Measure
Susan attended six of eight additional scheduled treatment sessions; each session addressed the activities that she had identified as important to her on the COPM. The treatment approach focused on performance of functional activities and included compensatory techniques and adaptive equipment for alternative solutions (see Table 1). Through collaboration and problem solving, each issue was addressed functionally and in the context of performance. For example, two activities that Susan verbalized the desire to accomplish were to open doors independently and to receive her loose change from store clerks in her hand. She was unhappy having to ask store clerks to “toss the change in my purse because I can’t hold it in my hand.” From a biomechanical perspective, this was a lack of supination and hand closure. Using the OA approach and deeper investigation into the client’s occupational performance and mastery of her activities, this desire was found to stem from the need to master her environment, to experience efficiency and effectiveness in her performances, and to perform satisfactorily for herself and in the eyes of others. Use of dycem and external rotation at the shoulder provided successful adaptation to manipulate door knobs. The use of her debit card eliminated the majority of situations where she received loose change. She was able to maintain grasp on standard pens and provide a signature without difficulty. Her car window controls were adapted with thermoplastic material to provide a lever she could manipulate with increased ease and safety per demonstration.
Although the same biomechanical concepts were followed to address the underlying ROM deficits, the emphasis shifted to facilitating Susan’s experience of improvement in her own occupational performance. She verbalized in these treatments her excitement over the functional solutions catalog filled with the options for adaptive techniques. Although she still verbalized disappointment over the mobility lost at her wrist and poor recovery of her index finger, she stated that she was attempting more occupational tasks than she had before.
On reassessment, the COPM demonstrated that the OA-facilitated intervention made performance-based changes that resulted in improvements on the COPM (see Table 2). Susan rated her satisfaction with her performance and her ability to perform functional activities such as manipulating door knobs, holding a book, manipulating car window controls, and grasping a cup. Her overall perception of these five functional tasks increased from a 3.2 to a 5 of 10, and her satisfaction level of her own performance increased from a 2.2 to a 4.8 of 10. Although these numbers still appear relatively low, Carswell et al. (2004) identified that, on the COPM, a changed score of ≥2 points, when comparing baseline and reassessment, is clinically significant.
In complicated surgical cases such as Susan’s, the biomechanical model and intervention tools are valuable. However, combining the biomechanical approach with client-centered, holistic treatment is difficult, especially for hand therapists working within the current conditions of managed care and cost containment (Dale et al., 2002). This sentiment could be expressed by practitioners in many practice settings. However, it is easier to identify the presence of this ever-pressing challenge than it is to address it. Documenting progress through biomechanical goals, in this case report, noted minimal gains, discouraged the client, and failed to demonstrate functional gains important to the client. A shift to a client-centered, occupation-based approach facilitated the client’s adaptation, improved her motivation and outlook, and provided documentation of the clinically significant functional progress attained.
Discussion
This case report of a patient who received hand therapy in an orthopedic outpatient clinic after surgery to correct joint deformities secondary to lupus-related arthritis illustrates that a shift in frames of reference from a biomechanical approach to an OA approach facilitated adaptation, improved motivation, and provided documentation of clinically significant functional progress. Initial evaluation and treatment were based on the biomechanical approach. The patient became discouraged, and her motivation decreased with continued documentation of only minimal gains on traditional biomechanical measures. She stated that her occupational performance gains were much more significant than what the biomechanical measures showed. We shifted to a more client-centered approach—the OA model—and used the COPM to document the patient’s primary occupational roles and important occupational performances and obtain client-rated objective measurements of her current levels of performance.
With the shift in treatment approach, the focus turned toward performance of functional activities that the patient identified as important to her on the COPM and included compensatory techniques and adaptive equipment for alternative solutions to increase independent performance of occupational activities. Through collaborative problem solving, each issue was addressed functionally and in the context of performance. On reassessment, the COPM demonstrated that the OA-facilitated intervention made performance-based changes that resulted in improvements on the COPM. In complicated hand therapy surgical cases such as Susan’s, the biomechanical model and intervention tools are valuable; however, combining the biomechanical approach with OA allowed a more client-centered, holistic approach that facilitated the client’s adaptation, improved her motivation and outlook, and provided documentation of the clinically significant functional progress attained.
Therapists in other hand therapy settings may find that inclusion of the OA framework (Schkade & Schultz, 1992; Schultz & Schkade, 1992) provides a basis for patient care that addresses the need for a more client-centered, holistic, occupation-based approach. Patient ownership of treatment goals and progress is increased through collaborative goal setting and development of a positive client–therapist relationship that facilitates the patient’s adaptation. The Occupational Adaptation Guides to Practice (Schultz & Schkade, 1992) provide guidance to therapists who want to incorporate OA into their treatment approach. The guides describe the therapeutic approach from the data gathering (initial assessment) stage through treatment and reassessment. Providing occupational therapy services under the OA framework can be both an art and a skill executed with method and precision while providing the collaborative care demanded by this generation of consumers (Schultz & Schkade, 1992).
The mechanical expertise and skill of occupational therapists practicing in a hand therapy setting is vital for skilled patient care; however, improved patient outcomes may be facilitated by supplementing biomechanical expertise with a more holistic, client-centered, occupation-based approach. Although the investment of time and self appears incongruent with today’s health care system, bridging this incongruence is a challenge that therapists may need to assume to best meet patient needs. Yet examples of how to accomplish this shift in treatment perspectives have yet to be published. This case report provides a novel example of how to incorporate the OA framework to shift from a mechanistic, strictly biomechanical hand therapy approach to a client-centered, occupation-based, holistic approach.