Occupational Therapy in Community-Based Practice Settings 2nd Edition by Marjorie Scaffa, Maggie Reitz

تمرين 2

Sandy
Sandy, a 35-year-old woman, was diagnosed with CTS in her right, dominant hand. For the 10 years prior to this diagnosis she had worked in a variety of clerical positions, using a computer for the majority of the workday. Approximately one year before her diagnosis, she received a promotion that she reported increased her workload considerably, making it essential for her to take work home to complete the work her employer expected her to perform.
Sandy described her workstation and reported that she would like her work situation to be evaluated because she was sure it was not set up correctly for her small stature. At work she used a laptop/notebook computer in a docking station, which she stated is set up like a regular computer workstation. She reported that her computer workstation has a nice chair, but the chair seems not to fit her well. She also indicated that nobody has instructed her in how to adjust the chair correctly. At home she uses the laptop/notebook computer placed on a dining room table.
Sandy reported that she had seen a hand surgeon, who remarked that if her current symptoms worsen, it would be necessary to carry out a surgical release of the flexor retinaculum to remove pressure from the median nerve, which is causing considerable pain on the palmer surface of her right hand. The client stated that she told the doctor she did not want surgery unless it was absolutely essential. Her hand surgeon gave her a cortisone injection and referred her to occupational therapy. He also referred her for nerve conduction studies. The occupational therapy referral requested an evaluation of her symptoms; wrist cock-up splinting; a computer workstation evaluation, specific to CTS; therapeutic exercises; and precautionary and preventative education.
Sandy completed the COPM with her occupational therapist. She reported that the pain was worst at night and at work; she also reported having difficulty sleeping, feeling overwhelmed at work, and feeling inadequate to perform her current job. She had missed work on three separate occasions due to her symptoms in the recent past, had been absent from work for the last two days, and was in the process of submitting a claim for workers' compensation. Her COPM importance scores were all high, and her performance and satisfaction scores were all relatively low. During the completion of the COPM, she reported her major problems to be difficulty sleeping and completing work tasks; she noted that she was bothered by feelings of inadequacy at work and difficulties carrying out routine ADLs due to pain in her right wrist. Cognitively, she reported she could not cope with the complexity of her work since her promotion and believed she was less than competent at her job. She could not see a way of overcoming her work performance deficits.
In addition to the COPM, her physical function was assessed, and education and a splint were provided. Active range of motion was within normal limits in the right hand, wrist, and elbow. Tinel's test and Phalen's test were both positive. Her sensation testing had positive finding in the right median nerve distribution, and she had stereognosis deficits. Her grip and pinch strengths were slightly lower in the right hand than the left. A right wrist splint was fabricated and fitted; a schedule for splint wearing and positioning information to enable her to sleep more comfortably were also provided. In addition, Sandy was instructed in tendon gliding and median nerve gliding exercises.
A computer work assessment was carried out at her work location, and her chair and other workstation devices were adjusted to fit well. In addition, the following items were requested to ensure a good fit at her workstation:
• Foot rest
• Back support filler (Obus-Forme cushion)
• Document holder
• Phone headset
The computer wrist pad in front of her keyboard was removed because she was pressing down on it very firmly. She was educated about the importance of positioning the whole upper extremity to gain as good a position as possible without placing excess pressure on the palmer surface of her hand in the region of the flexor retinaculum.
Education was provided with handouts to reinforce the importance of proper positioning at work and home. Educational materials were also provided regarding easy adaptations to make at home to correct the screen height of her laptop/notebook computer and on the use of a separate keyboard and mouse. A consultation with her work supervisor occurred, and he reported that he was not aware of the client's concerns. He noted that he would provide instruction to the client and intended to send her to two training courses to enable her to feel more competent in her new role. He reported that she was a good worker and capable of carrying out the work in her new job role. The occupational therapist discussed with Sandy the difficulties with routine ADLs by reviewing the tasks she reported to be difficult or those that caused pain. The tasks reported as most difficult were opening cans with a manual can opener and lifting heavy pots and pans. Ways to avoid aggravating her injury were discussed, and it was suggested she use an electric can opener and avoid lifting heavy pans when cooking.
After 3 weeks of intervention, the client was reassessed and her COPM findings were much improved, so intervention was discontinued. She had returned to work one week prior to discharge and was managing much better at work using her modified workstation location. She reported that she was pleased that she was scheduled to complete training courses at work. She had tried using her laptop at home on a box with a separate keyboard and mouse and had found this much better than using the laptop/notebook alone. After doing her exercises at home, she had completed some of her routine ADLs and was now managing all routine ADL and IADL tasks without difficulty when using the suggested modified methods and electronic equipment.
How do the overall framework, constructs, and principles of a theoretical model match the interventions provided?