On 10/12/08, Laurie Bauch, COTA, MS, OT says:
LB> Some suggestions might be: Show how you are able to set goals that
LB> focus on occupation and are measurable. Using a few case studies
LB> to demonstrate the difference between a more biomechanical model
LB> and an occupationally based one may be one way to go---in fact,
LB> maybe this list would like to see it too since it seems to be a
LB> common thread throughout the discussions.
I just so happens that I posted just such an example on AOTA's Phy-Dys
list serve. My reason for posting to their list was because some
members believe mobility training is not within OT's domain. None the
less, I think it's a good example of occupation-based treatment, so
I'll post it here as well. There is a follow up to the treatment that
I'll post later. By the way, this is an active patient that I see 3x
week.
===========================================
Recently, it's been suggested that mobility training is not within our
realm, that it should be left to PT or to be considered OT, mobility
training must INCLUDE occupation. I want to provide a case example
which to suggests that none of the above are correct.
This is a patient that I currently see on HH. She is 95 y/o and has
had a slow physical decline secondary to multiple factors.
I evaluated this patient on 8/30/08 and at that time, we established 3
goals. These are her goals, right out of the chart:
By d/c, patient will:
1. Donn/doff underwear safely and independently
2. Amb to/from bathroom with a RW
3. Independently and safely bathe self using AE and tub
transfer bench
(In retrospect, I should have included using the
toilet as part of goal #2. It's implied but not
stated)
The patient was using a BSC and had great difficulty transferring. Up
until three months ago, she was ambulating in her home with a RW but
required assistance for bathing. There is no real diagnosis for her
decline. The patient is very afraid of falling.
So, starting from day 1, the patient and I began working on standing
from bedside. On 9/1/08, I documented that the patient was able to
stand with a RW for 13 secs and 32 secs. On 9/3/08, she stood for 25
secs. On 9/5/08, 35 secs, 38 secs and after much prompting, she stood
for over 2 minutes.
The patient c/o of RLE pain which she claims she injured while trying
to get off the toilet about three months earlier, which coincides with
the start of her decline. However, all medical tests are negative for
injury. None the less, I talked with PT about pain management. PT
thought there was knee joint laxity, so they requested an orhto appt.
The ortho MD provided a steroid injection to the knee. During this
entire time, the patient never c/o of knee pain to me. None the less,
we continued on towards her goals.
On 9/15/08, the patient took two steps inside her RW. On 9/19/08, the
patient took 4 steps inside her walker. (Basically, taking 1 step
forward with both legs, then 1 step back with both legs and repeating)
On 9/22/08, the patient took 5-7 steps advancing walker with mod
assist. On 9/24/08, the patient ambulated 25 feet and min A. to
advance walker.
On 9/29/08, patient reported that she independently doffed her
underwear(see goal #1). On this same day, the patient ambulated across
her bathroom w/o a walker and USED THE TOILET. This is the 1st time in
3 months that the patient has used an actual toilet.
There is still work to do regarding the patient getting to/from the
bathroom with her RW. There are environmental issues to consider and
be worked out. But this patient and her daughter are so VERY happy. As
you can imagine there was lots of smiles and hand clapping when "mom"
went pee on the toilet!
While there is obviously more to this case than what I've typed, I
think it clearly points to the fact that "functional mobility" SHOULD
be within our realm, that the outcomes are EXTREMELY important to our
patients, and that occupational therapy is the BEST profession to
address mobility, especially in the home environment.
This particular patient has required lots of encouragement, time, and
and ever so subtle "pushing". In fact, on 9/29/08's appt, I initially
asked the patient if she wanted to try ambulating to the toilet.
Initially, she was adamant that she couldn't do it. So, we settled on
walking down the hallway with her RW (which is great hands-on learning
for her and an outstanding endurance and strength activity). After she
was successful at ambulating the hallway, I again suggested that we
try the bathroom. She initially refused but after I suggested that we
take her wheelchair to the bathroom door and just look at the
situation, she agreed. After we were there for a few minutes, the
patient VOLUNTARILY got up from her chair and ambulated to the
toilet. It wasn't pretty or safe, but it was a MILESTONE for all of
us!
So, while at times the patient and I were walking were no occupation
was in sight, clearly, occupation is the goal for this patient and
therapist.
Ron
P.S. As usual, forgive grammatical errors. I typed this off the cuff.
============== END ================
Ron
--
Ron Carson MHS, OT
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