Case Scenario

Janet S. Jedlicka, PhD, OTR/L, Anne M. Haskins, PhD, OTR/L and Jan E. Stube, PhD, OTR/L

Ryan, a 25-year-old construction worker, fell from a 2-story scaffolding structure onto the construction site. He suffered a left upper extremity brachial plexus injury with left shoulder dislocation and a tibia-fibula fracture of the left lower extremity. He was medically stabilized and had reasonable control of his pain with IV ketorolac. Now he is concerned that he might not regain the full functions of his limbs and runs the risk of losing his livelihood.

How could you help Ryan?

Early intervention and liaison between the treating physician and the occupational therapist can help in restoration of functional ability of the patient and also play a significant role in controlling pain.

During an initial evaluation, on day 3, conducted by the occupational therapist (OT), a medical record review and an occupational profile interview established that the client had been previously healthy and living independently. He is single, living with two male roommates, and interests include frequenting nightclubs, skiing, and all terrain vehicle racing. His physical and cognitive/psychosocial skills by OT evaluation concludes the following. Ryan's left upper extremity (UE) has minimal passive range of motion (PROM) at the shoulder, all planes, with pain self-rated at 8 on a scale of 0-10. Distally, Ryan has full active range of motion (AROM) and functional strength from the elbow distally, including the hand. He has some mild loss of tactile pain discrimination and touch awareness sensation at the left shoulder region only; otherwise, he has intact sensation of his left UE. He self-limits use of his left UE presently due to pain and expresses frustration that he "can't do anything" using only one hand. He wears a shoulder stabilization soft brace, which limits passive and active motion at the shoulder only. The OT notes that Ryan is visually sensitive to sunlight in his hospital room and loses his concentration easily. The OT plans and discusses intervention with Ryan, then documents the findings and agreed-upon goals.

Enumerate the possible occupational therapy interventions?

OT interventions fall broadly into three major types: physical management, psychosocial management, and environment/contextual adaptations. All these can be used in the case of Ryan. After OT consultation with the attending orthopedic surgeon's physician assistant, safe parameters have been set regarding OT intervention (1) for left UE range of motion, actively and passively, to within pain tolerance and (2) to promote use of the UE in activity, as client tolerates. The soft shoulder brace may be removed for bathing and left UE activity.

By day 5, the occupational therapist has been seeing Ryan once daily for UE passive to active-assisted exercise, teaching Ryan to perform specified exercises on his own once to twice daily. Breathing techniques, visual imagery, and goal-focused strategies have been used to assist Ryan in making gains in motion at his left shoulder. Ryan's occupational therapy has also included transfers to his bedside chair. In sitting, Ryan has been engaged in practice and problem-solving OT sessions to promote use of his left arm and hand as an "assist" for two-handed activities of daily living (ADLs) such as cutting meat, spreading jam on toast, holding paper as he writes, fastening his clothing. Further, Ryan has been encouraged by practice with his OT to assertively ask for controlling the lighting in his room, to request rest breaks, and to communicate his other needs to his health-care providers, family members, and friends.

By day 7, Ryan has been prepared by his occupational therapist, other health-care professionals, and discharge-planning professional for return to his family's home. From an OT perspective, Ryan will require minimal assistance for bathing at home (provided by his family), will be independent with adaptive strategies for dressing, and will require maximal assistance for heavy home management tasks over the next month. Driving and return-to-sedentary work have been postponed for 4 weeks. Outpatient occupational therapy has been ordered by the orthopedic surgeon for fortnightly sessions over the upcoming month for continuation of left UE ROM and strength improvements, increasing ADL independence, and evaluation for safe return to driving and work.

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