Week 2: 10-13 March...
Activity is both the medium and endpoint of Occupational Therapy treatment. The key is choosing an activity that hits all the performance skills that need to be improved, but is at the same time enjoyable and relevant to the client.
When it came to my first activity session, I had it all planned out in my head: I would put a clay pot on an elevated surface, and would assist the client to reach up with her oedematous arm to stick pebbles onto the pot. By doing this, I hoped to maintain AROM of the unaffected shoulder and finger joints and reduce oedema.
However, two problems arose:
1. My client found it painful to flex her shoulder beyond 45 degrees. due to the weight of her cast, and due to the pain of her forearm. Hence, she refused to lift her affected arm up onto the elevated surface, or allow me to lift it for her.
2. Due to the oedema and tight bandaging, the client was not able to close her affected hand without severe pain, therefore she could not pick up the pebbles, even with hand-over-hand assistance.
We reached a compromise by which she would keep her arm as elevated as possible, and use it to hold the clay pot in place, while the other arm would be used to stick the pebbles onto the pot. This way, part of the aim would be achieved in that some shoulder flexion and elevation was maintained.
From this session, I grasped the importance of doing a thorough analysis of what the client can and cannot do so that correct structuring can be put into place. Even though the client should not have had problems with her shoulder and finger movements given that her diagnosis was a distal radial and ulna fracture, the other complications of sepsis, oedema and muscle atrophy due to prolonged hospitalisation must be taken into consideration as well.
For my next session with this client, I decided to use slings and a universal cuff to combat the problems I had experienced in the first session. The aim was to stick a large paper 'canvas' to the wall of the client's hospital room and engage the client in a painting activity through use of the slings to elevate the client's arm, and a universal cuff to hold the paintbrush.
I entered the client's hospital room early the morning of the session, as I'd noticed she is significantly more active and cheerful earlier in the day. However, she had just had the dressings removed on her affected arm and was waiting for them to be reapplied. For infection control reasons, it was necessary to wait until the dressings had been replaced before applying the slings and commencing the treatment. I decided to complete my interview in this time, and demonstrated a one-handed knitting technique using a knitting frame to see whether she would be interested in doing a knitting activity in the next session.
2 hours later, the nurse arrived to redress the arm.
By this time, I had left the client to rest for a bit while I visited my new client, an ankle debridement client who was being prepared for discharge. After determining that she was independent in all ADL's with the use of crutches, was due to make a full recovery after a few weeks of bed rest, and had already been taught elevation techniques by her doctor to relieve oedema, I thanked her and returned to my first client.
Now just after 11am, my client was already starting to tire and was not interested in doing an activity. I decided to set up anyway in the hope of arousing her curiosity. A few minutes later, she walked over to see what I had laid out and decided to participate. As she was slightly tired, we decided to downgrade by using a chair sit and paint instead of standing.
The slings, attached to a metal stand used to hold drips, worked perfectly. Using the slings, the client was able to maintain her arm in an elevated position for around 45 minutes with ease. However, the new bandage had been applied very thickly around the client's hand. As a result, the universal cuff holding the paintbrush could not fit over the client's hand. The client suggested using her other hand to paint, while leaving the affected hand in elevation.
This achieved the aim of elevation to decrease oedema, as well the aim of promoting shoulder flexion to maintain ROM of the shoulder joint. However, the aim of promoting mobilisation of the affected limb to maintain shoulder ROM and decrease oedema was not entirely met, because although the client moved her affected arm slightly to hold the paper as she painted, the horizontal ab- and adduction movements I'd been hoping for were not achieved.
Reflecting back on the structuring, it would have been possible to slide the paintbrush into one of the outer layers of the bandage to hold it in place, which would have allowed the client to paint using the affected hand, and thereby achieve the required mobilisation. However, dipping the paintbrush into the paint and water at this angle would have to be facilitated by me, or would require very specific structuring, e.g. sticking the watercolour palette in a vertical position on the wall next to the canvas.
The client thoroughly enjoyed the activity, and was reluctant to conclude painting once 12 o'clock arrived. I found that being engaged in an activity took her mind away from the pain of her arm, as she did not complain about the pain throughout the session, even though lifting her arm into the same position without an activity caused her to grimace with pain.
Not every client required as much careful planning and structuring. On Tuesday, it was refreshing to receive a finger debridement client, with whom I could conduct the full standard hand assessment, identify clear problems and immediately give him strengthening exercises which he could do on his return home that afternoon.
With more complex clients, such as my CVA client, there are still fairly standard assessment and treatment schedules to follow, with some variations for each client. For me, determining the schedule of treatment still needs some work, as I go about improving performance components in a slightly haphazard manner, for example, mixing fine and gross motor co-ordination activities instead of working from fine motor to gross motor. My structuring of therapy sessions also requires more thought, as there are many NDT principles, such as weight-bearing, crossing the midline and elongation of the affected limb that I can use to influence tone and activate muscle groups. How much physical handling I provide in the form of hand-over-hand facilitation must be modified depending on the activity and the client's progress.
I have also realised that when working in an acute hospital, where patients are discharged before therapy is complete, or even started, it is important to keep a file of home programmes or handouts of each of the common conditions or performance component deficits I am likely to experience, so that the clients can continue their treatment at home.
With 2 weeks complete, I find I'm staring to get a clearer idea of what OT in an acute setting entails, as well as where I as a student fall short. The level of thought that must go into each session to ensure it is entirely therapeutic feels immense to me, but through practice will become a natural second nature (I hope!)
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