The Therapeutic Process in Occupational Therapy (OT)
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The therapeutic process in occupational therapy (OT) is intricate, bringing together the art and science of healing through a holistic approach. As presented in the case study, the patient, Hillary Henderson is 77 years old and was admitted into the hospital for a right hip fracture. She underwent surgery to repair the fracture with an endoprothesis as recommended by her doctor. The surgery was successful and her physician referred her to OT for post-operative rehabilitation. This paper will be discussing various models and frames of references that can be applied to this case, in addition to interventions, outcomes, activity demands, therapeutic use of self and the role other professionals play in the rehabilitation of this patient.
Models & Frames of Reference
There are numerous models and frames of references which occupational therapy practitioners can choose from as a basis for their interventions when working with patients. Each model provides a client centered approach that is applied in the evaluation and throughout the intervention process. In the case of Hillary, an OT could apply the Model of Human Occupation (MOHO), Ecology of Human Performance (EHP) and Biomechanical & Occupational Adaptation.
Model of Human Occupation
Occupational behavior and general systems theory are the basis of the model of human occupation (Cole & Tufano, 2008). This model offers a holistic approach to the patient and addresses all phases of the lifespan. MOHO looks at three key factors, volition, habituation and performance (Cole & Tufano, 2008). This model “provides a structure to understand each person’s problems and strengths and how these are related to a unique patterning of motivation, habits, performance capacity, skills, and/or the environment” (Maciver et al., 2015, p.146). When applying this model to Hillary it would be important to find out what motivates her. It is noted in her evaluation that she owns a cat, enjoys gardening and socializing in her local community center; one or all of these factors could be used in her intervention to keep her motivated.
Ecology of Human Performance
EHP examines the details of context and its impact on human performance (Cole & Tufano, 2008). The exchange between a person and their environment is referred to as ecology. The primary focus of this model would be the relationship between Hillary and her environment, they are dependent on one another and jointly impact her performance. There are four main components of EHP: person, task, context and personal-context-task transaction (Cole & Tufano, 2008). The OT could look at where Hillary is following her operation, as well as her prior level of function. The therapist would analyze Hillary’s personality and behaviors to see if she is excited and driven to achieve her goal. Also, it would be important to consider Hillary’s home environment. Seeing that she does not recall how she fell, it would be good to look around her home for potential fall hazards.
Biomechanical & Rehabilitative Frames
Biomechanical & Rehabilitative frames address a specific area of disability and evaluate the barrier, which leads to less or no occupational performance (Cole & Tufano, 2008). This unique frame works well in Hillary’s case as it is a combined approach to therapy. The goal of this frame is to restore skills as well as modify certain tasks or the environment so the individual can have optimal occupational performance. The evaluation process of this frame is comprised of three parts, range of motion (ROM), strength, endurance, and pain. Hillary’s ROM, strength and endurance were affected after her surgery. Since she lives alone she needs to regain her strength in order to complete her daily routines and continue participating in activities which are meaningful to her.
Comparison of Models and Frames
The above mentioned models and frames were most applicable to Hillary’s case compared to others because it took into account her motivation, environment, and factual evidence on progress made in her ROM. MOHO and EHP both address patients of all ages throughout the lifespan and have a similar view on function and motivation. MOHO views functioning individuals as those who choose and engage in occupations which have meaning to them. EHP also views a functioning individual as someone who has passions and interests which drive their participation in different occupations. In addition, both EHP and MOHO address motivation in that they state an individual is more likely to engage in a task if it has meaning to them. The individual will feel empowered to make decisions which will lead to positive changes in their life. The biomechanical frame adds an essential layer to the models in that it can quantify the progress made in therapy by taking measurements early on and seeing how its improved throughout time. The motivation addressed in the models go hand in hand with how driven the patient feels to make progress in their measurements and strength. However, there are some differences such as MOHO and EHP addressing dysfunction differently. MOHO identifies dysfunction as a disorder whereas EHP states that disability is when the relationship between the individual and their ecology is unbalanced. It is important to note that EHP really addresses the environment of the individual and MOHO closely looks at the person. In regards to the biomechanical frame, all frames of references really address a specific area of disability which is unlike the above mentioned models.
There are numerous assessments available to practitioners to use when working with their patients, which cover a wide variety of conditions. Two assessments that would be valuable in Hillary’s case are, The Barthel Index and Assessment of Motor and Process Skills (AMPS). The Barthel Index is an assessment which examines the ability of an individual to care for themselves who have a neuromuscular or musculoskeletal condition (Shirley Ryan AbilityLab, 2018). This assessment looks at gait, functional mobility as well as ADLs. Seeing that Hillary recently fell and had surgery and her musculoskeletal system is a concern, the Barthel Index is a great fit for this case. There are ten sections which address mobility and ADLs, that will gather what Hillary is able to do on her own. Observing Hillary’s functional mobility is an important component to take into consideration when creating her intervention plan.
The AMPS is an assessment in which the therapist can observe and evaluate the motor and process skills of their patient as well as how it affects their ability to perform activities of daily living (ADL) or instrumental activities of daily living (IADL) (Fioravanti, Bordignon, Pettit, Woodhouse, & Ansley, 2012). There is a total of 36 items this assessment addresses, 16 are motor based and 20 are process based (Canadian Partnership for Stroke Recovery, 2018). The motor skills look at the actions someone takes when they perform an activity such as reaching, grasping, walking or positioning their body. On the other hand, process skills observe the ability of the person to sequence actions of the task in a logical manner. This assessment would be valuable for Hillary in that it takes a top down approach and will bring to light the things Hillary can do on her own. This assessment will also allow the OT to find out more about her occupational concerns and what is important to Hillary.
Approaches to Intervention
The first type of OT intervention approach a therapist could apply in Hillary’s case is restore. With a focus on restoring her lower extremity movement to enable transfers, gait and mobility. This intervention will allow her to get back to the activities she loves such as gardening and taking care of her cat. The next type of intervention approach applicable to this case is promote. The OT would provide safety education and training on how to use adaptive equipment. Ensuring that Hillary is aware of her hip precautions as it is impertinent to her recovery. The therapist should have her repeat the precautions back to them to make sure she understands. Lastly, modify would be a great intervention approach. The OT would modify Hillary’s dressing routine and how she get’s out of bed to ensure she is not breaking hip precautions. They could introduce assistive devices such as a sock aid and a walker. The walker will provide support and stability she may feel she is lacking after surgery and it will allow her to move freely in her environment.
Types of OT Interventions
The first intervention type applicable to this case is occupation. This refers to the use of real life occupations and activities to provide therapy and addressing the needs of the patient (American Occupational Therapy Association [AOTA], 2014). According to the patient’s chart, Hillary lives alone and owns a cat. Applying the IADL occupation of caring for pets as an intervention would be great for this case. This could be addressed by raising the feeding area for the cat, as it will prevent Hillary from breaking her hip precautions. The second type of intervention is preparatory methods. This refers to the use of devices, modalities or techniques to assist the patient in occupational performance (AOTA, 2014). In Hillary’s case getting her fitted for a walker will allow her to maneuver around her environment and improve her mobility. The third intervention type is education and training. This refers to conveying information about health and participation in occupations to the patient which fosters good behaviors and habits and training is learning skills which can be applied to daily life (AOTA, 2014). The OT would provide her with information on her hip precautions. Then, once she is discharged and back home the therapist could ensure she is informed about home and activity modifications so she can safely carry out occupations in her home.
The first outcome which is expected with Hillary is, occupational performance improvement. After working with her on her ROM, stability and mobility with a walker the OT should be able to see Hillary participate in activities that are meaningful to her, independence and increased neuromusculoskeletal and muscle functions. According to research, the use of adaptive devices and strengthening techniques in OT on independence and functional outcomes were positive and effective on patients receiving a total hip replacement (Jame Bozorgi, Ghamkhar, Kahlaee, & Sabouri, 2016). The second outcome expected to see with Hillary is, quality of life. “Adaptive device usage can lead to less reliance on others during personal ADL and optimize physical function maybe by enhancing self esteem and controlling fear of movement without threatening the replaced joint” (Jame Bozorgi, Ghamkhar, Kahlaee, & Sabouri, 2016, p.150). Hillary’s self esteem and her fear of falling can greatly impact her quality of life, therefore the use of assistive devices as well as education and training can help her with her movement functions such as her gait patterns. The last outcome expected to see with Hillary is, participation. According to her evaluation she is very social and enjoys attending senior center activities and volunteering at the hospital. The aim is to see her participating in those activities again as it brings purpose and joy to her life. Hoorntje et al., found that most people with hip replacements return back to work after nine weeks (2018). Therefore, an outcome for Hillary to participate in activities she enjoys is reasonable as many of the mental functions (affective, cognitive and perceptual) required to function at work is also needed to engage and interact with her friends at the senior center.
Activity and Occupational Demands
The IADL of caring for her cat is both relevant and important to Hillary. Pets can be a companion to patients and taking good care of her cat is important to Hillary. Therefore, using that occupation as a means to intervention is valuable. The objects used and their properties for this occupation are cat food in the form of a pull tab can, counter-top, a bowl, a table (hip height), and her walker. The space demands would be a large open space, no trip hazards like a rug or electrical cord such as a phone charger. The social demand would be her duty to feed her cat. If people come over to visit her home and see her cat is malnourished that would be socially unacceptable. The sequencing and timing required for this occupation is to first grab her supplies, the bowl and cat food. Then, Hillary needs to open the cat food by pulling on the tab. Next, she will need to empty the cat food into the bowl. Then, she needs to throw away the empty tin. Lastly, Hillary needs to place the bowl on the raised table so her cat can eat. The required actions and performance skills are choosing the objects needed, gripping the can of food, and using the right amount of force to open the can. The required body functions are Hillary being conscious and aware of the occupation she is carrying out as well as her body movements being fluid throughout the occupation. The required body structures are all of her limbs, olfaction to ensure the cat food has not gone bad and sight for safety and to see throughout the occupation.
Grade and Adapt Interventions
One way an OT could adapt the activity of feeding is by finding a raised table which has enough room for Hillary’s cat to fit on and comfortably eat. They could place the table in a large open area so Hillary has plenty of space to access it. This will ensure that she doesn’t break her hip precautions and is still able to feed her cat. This intervention could be graded down by using dry food that is prepackaged and does not require her to use a lot of upper extremity strength to open versus the pull tab cans. This intervention could be graded up by removing the raised table and have the cat food placed on the kitchen floor where it normally is placed. Another way of grading this intervention up is by adding a water bowl that needs to be filled. This would add another component to the IADL of feeding her cat.
Therapeutic Use of Self
Establishing a therapeutic relationship with your clients is a valuable tool in using your personality, perception and insights throughout therapy. Four modes which could be applied in this case would be collaborating, empathizing, instructing and encouraging (Taylor, 2008). Collaborating with your patients is a fundamental pillar in occupational therapy. Ensuring that Hillary’s voice is heard and that she has to opportunity to make decisions with the therapist is important to her motivation in therapy. Next, the OT could empathize by putting themselves in Hillary’s shoes to see what she is going through and struggling with. This is important because getting a different prospective can potentially change the direction you take as a therapist. Then, the OT could instruct Hillary on her hip precautions and how to use assistive devices. Lastly, the therapist could encourage Hillary and remind her that she is on the road to recovery and the goal is to get her back to doing the things she loves. One thing I would change about myself when instructing Hillary would be not to be too direct and technical as that can overwhelming to the patient.
There are several professionals outside the field of occupational therapy who could provide helpful insight into this case. First and foremost, the physician Dr. Martinez. Hillary’s doctor initially saw her when she had the femoral neck fracture and discussed with her the treatment choice of getting an endoprothesis. The doctor is also familiar with her past medical history and can be a great resource. Another professional the OT could work with in executing the best intervention plan for Hillary would be a physical therapist (PT). The PT would look at Hillary’s actual impairment and try to improve it by aligning her bones and joints to increase her mobility and provide exercises or massages to lessen her pain. Lastly, the OT could collaborate with Hillary’s nurse, who carries out numerous roles some being administering medication and monitoring her condition. The line of communication is crucial with her nurse if for example there is some adverse side effect from medication Hillary is taking or the OT notices a dramatic change in her vital signs.
In conclusion, the process of occupational therapy can be very rewarding to the therapist and provide a sense of accomplishment to the patient regardless of the degree of the injury. With a fundamental understanding of the frames and models used in occupational therapy a therapist can cater each intervention specifically to their patient. Using the patient’s occupations and hobbies they enjoy as a source of motivation can yield life changing results, ultimately allowing them to live a meaningful life.