I want to provide another case study as a follow up yesterday's case.
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HISTORY:
68 y/o male with unremarkable medical hx except for a recent CVA
with left side hemiplegia.
EVALUATION:
Left UE has little active movement and no functional use.
Patient c/o of increased pain during shoulder passive range of
motion. Decreased active ROM and strength in left lower
extremity, more proximal than distal. Wearing AFO secondary to
foot drop.
Sit to stand from chair with min - mod assist. Ambulates with
CGA using quad cane. Shower transfers with mod assit. Requires
mod - max assist for dressing, showering and toileting.
GOALS:
Patient desires to decrease the amount of assistance his wife
provides for him to stand up.
TREATMENT:
Initial OT treatment involved therapeutic activity focusing on
sit to stand procedures to reduce dependency on wife. Patient
was educated and practiced proper techniques to improve use of
his affected extremity during sit/stand from various surfaces.
Patient quickly responded with decreased dependence on wife.
During tub transfers, patient's lack of active hip flexion
resulted in necessary assistance to clear affected extremity
over tub edge. Treatment was provided to increase active hip
flexion including: up/down steps, mobility training with and
without cane with verbal prompts from therapist to "pick up
hip". After several weeks, patient was able to clear tub with
his affected extremity, reducing the amount of assistance
required from his wife.
After meeting these goals, there was a brief focus of treatment
on the patient learning to ride a 3-wheel bicycle. But,
secondary to financial restrictions, the patient was unable to
purchase a bike.
Unfortunately, the patient was unable to identify and additional
occupational goals. Despite the fact that he still requires
assistance for dressing, bathing and toilet hygiene, he elected
to NOT address these disabilities. He stated that his only goal
was "walking like a man". As such, the patient was discharged
from OT.
SUMMARY:
This is sort of a perplexing case. If PT was not involved in
this patient's care, I would not discharge him. I think "walking
like a man" is well within OT's scope of practice but with PT
being involved, it's a duplication of service. On the flip side,
it's always a struggle for me knowing the distinction between
gait training and functional mobility.
Obviously, teaching a person to walk to the bathroom involves
gait training components, but is it truly gait training? I guess
for me, the bottom line comes down to goals. If the goal is
walking, that's PT. If the goal is walking to the bathroom,
kitchen, bedroom, car, etc, then it's OT. If the goal is
improving the way one walks, it's PT. If the goal is enabling a
person to engage in occupation, it's OT.
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Anyway, these are two very interesting cases where improved occupation
was the goal of the patient. In both of the cases, PT continues seeing
the patient.
Thanks,
Ron
--
Ron Carson MHS, OT
www.OTnow.com
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