Acute Occupational Therapy Case Studies

Julia is a 43 year old female initially referred to acute occupational therapy due to a recent onset of symmetrical numbness, tingling, and weakness in her hands and feet. Julia reported having an upper respiratory infection two months prior and reports showing symptoms shortly after. Julia lives with her husband in Washington State and has two adult children who are out of the house and reside in different states. Julia initially only had numbness and tingling in the feet but over the past eight weeks has been progressing to her hand. Julia was fully independent two months ago and now requiring moderate to maximum assistance with activities of daily living (ADL’s) and is dependent for instrumental activities of daily living (IADL’s). Julia

had a job that required writing skills but was unable to fulfill the job requirements and has been let go. Julia’s husband works full time and has needed to recruit help to assist and check in with his wife during the work week.
Julia’s insurance will only cover thirty days in any rehab setting per year since the recent diagnosis of Guillain Barre Syndrome (GBS). GBS affects about one to two individuals per 100,000, GBS is a disorder in which the body’s immune system attacks part of the peripheral nervous system with the initial symptoms varying degrees of weakness or tingling sensations in the legs and hands (Sawant & Ferzandi, 2015). Julia is a highly motivated, positive, and energetic individual who currently has two great supportive individuals willing to take on this unknown disease with her. This case with examine and discuss the use of the dynamometer, the benefit of fine motor interventions for treatment for individuals with GBS, addressing the psychological aspect of individual’s, and how the functional independent measure plays apart in the rehab setting.
Case Study
Initially Julia was evaluated by an occupational therapist in the acute care setting during her two week stay in the hospital but soon she was moved to inpatient rehab (IPR) where she stayed for eight days. In this particular setting she would receive three hours of occupational and physical therapy a day. In the setting Julia would receive the therapy she needed to be on the road to recovery. According to Brooks (2011), approximately 15-20% of individuals with GBS endure persistent debility and about 70% make a full recovery or have minimal remaining deficits.
Once Julia was moved to IPR she was reevaluated by Shannon, the occupational therapist and Sarah, the occupational therapy student. Upon entering the room Julia was very pleasant, welcoming and eager to work. Sarah began the interview process by asking questions about Julia’s home setup specifically the layout, bathroom, and equipment she had. Since Julia and her husband had been dealing with this unknown disease for about two months simple modifications to the bathroom had already been completed.
Once this section was discussed and address the process was next geared towards Julia’s current physical state.

Julia had no visual, cognitive, or verbal deficits that were discovered during the initial or reevaluation. Her primary deficits were as follows; limited sensation in hands and feet, primary weakness in the hands, trunk instability, limited trunk control, inability to stand, decreased activity tolerance, poor overall strength and little to no fine motor capabilities of the hands. Julia’s personal goals were focused on hand strengthening, independence in ADL’s and IADL’s, handwriting, and increase overall strength.
Due to Julia’s generalized hand weakness and personal goals it was determined to test her grip strength with the hand held dynamometer. According to Kolber and Cleland’s (2015), study the hand held dynamometer is a reliable and valid method to assess grip strength as long as the following guidelines are carried out 1) the tester as well as the device is stabilized; 2) the testing protocols are being carried out; 3) the device is perpendicular to the testing limb; 4) repeated measures are conducted with same device; and 5) appropriate trials are completed for accuracy. Julia’s grip strength was as follows:
Table

1
Initial Test Retest
Hand Right Left Right Left
Average Grip Strength in Pounds 11 13 25 25
Once these formal assessments were completed Shannon and Sarah wanted to see more of Julia’s functional abilities. Through the informal assessments it was found and observed that Julia was able to donn and doff her sock on the left lower extremity with minimum assistance and needed maximum assistance for the right lower extremity. She was unable to button or zip zippers for shirts or pants. Julia could not complete a transfer safely from her hospital bed to wheelchair without maximum assistance. Julia could not stand without maximum assistance. When asked to simulate donning and doffing a shirt while standing Julia could stand to complete with minimum to moderate assistance but when simulating to doff pants Julia required maximum assistance. Although this was not an actual assessment this simulation gave Sarah and Shannon a better idea of her current function, what her needs were and what areas she was struggling to complete independently. This also gave insight to Sarah and Shannon for goal formation.
During the evaluation Julia became emotional especially when she was told her grip strength compared to the norms. Sarah educated Julia on how this was just a number to show progress and although it might not be where it should be they would work on it in therapy. When collaborative goals were being made for therapy Julia broke down and shared that there was a lot of uncertainly with GBS and that no one has or can give her answers. Once she was able to express her concerns Shannon stepped in and provided an informational booklet about GBS. Brooks (2014), states “Some patients may benefit from being referred to a pastor; however most patients call for support and opportunities to share concerns, fears, and aspirations.” Sarah then provided Julia information about online support groups for individuals with GBS. Julia was very thankful for this information and later expressed how she was able to connect with others who have this rare disease. Brooks (2014), also mentions that occupational therapists should not underestimate the importance and impact their role can play on providing information to patients and family. When providing educational opportunities to patients and family they will be more prepared to make healthcare decisions (Brooks, 2014).
After the evaluation the IPR doctor and healthcare team meet to discuss the approximate duration of each patient’s stay. The doctor in IPR decided that for Julia’s case fourteen days would be enough for her recovery process. Julia’s insurance would cover thirty days in any rehabilitation facility. This would allow that if Julia would become sick again she would still have therapy days covered by insurance. The typical time frame for the recovery process for individuals with GBS is six to eighteen months (Tomita, 2016). Additional education on this rare disease as well as patient education and advocacy may have benefitted Julia.
The model that assisted with making client centered goals was the Person-Environment-Occupation (PEO) Model. This model helped identify Julia’s roles, meaningful activities, and the context where she wanted to carry the activities out. This model uses the expertise of the therapist and collaboration of the individual to find effective strategies to complete activities. What is unique about this model is that it is the patients responsibility to achieve outcomes and the outcomes depend heavily on the clients willingness and determination (Tomita, 2016); which in this case was a great fit due to the patient’s determination, motivation to recover, and duration of IPR stay.
In inpatient rehab each patients first treatment session is a shower, this establishes the client base line for rehab which are then graded through the functional independence measure (FIM). According to Hobart et al. (2001) the FIM is an effective tool for measuring ADL progress, has excellent test-retest reliability, and is an evidence based assessment to measure outcomes for neurological diseases. Julia’s total FIM scores upon admission were as follows:
Table 2
Tasks Initial Score Final Score
Eating 3 5
Grooming 2 5
Bathing 2 6
Upper Body Dressing 2 6
Lower Body Dressing 2 6
Bed to chair transfer 2 5
Toilet transfer 2 5
Shower transfer 2 5

Julia’s treatment interventions focused on adaptive equipment to help assist in ADL’s and IADL’s, fine motor activities to increase hand function, upper extremity strengthening, energy conservation and work simplification techniques, patient/family/caregiver education, and psychological support. Each of these interventions were important to Julia’s recover, through collaboration and client centered care Julia and the inpatient rehab therapists helped her achieve her goals.
Adaptive equipment was introduced to Julia to assist with lower body dressing. She was taught how to use the reacher, sock aid, long handled shoe horn, dressing stick, and button hook. Julia was a fast learner and once she was introduced to these items she was able to complete dressing within a few days modified independently. Fine motor tasks such as graded peg board activities, nuts and bolts activities, clothes pins, and putty exercises were addressed each day in therapy. Julia was given an upper extremity thera-band exercise regimen to complete twice a day and to continue as a home exercise program. Energy conservation and work simplification techniques were taught to Julia to decrease her fatigue level and increase her independence while completing ADL’s and IADL’s. Fatigue was important to address due to its residual and disabling affect it can have on quality of life for individuals with GBS according to Sawant & Ferzandi (2015). Patient, family, and caregiver education and training is a key part of inpatient rehab. Julia, her husband, and her close friend went through two days of training with the physical and occupational therapist. This was to ensure Julia, family, and caregivers were educated and trained on safe transfers.
Julia made tremendous progress from day one to day eight that she was in inpatient rehab. Her grip strength increased to twenty-five pounds (see table 1) in both hands which she was overjoyed. Julia’s total FIM scores at discharge can be found in table 2. Julia made tremendous gains in eight days but the ethical issue behind this case is being aware of the recovery process and realizing that Julia could have made greater gains. Why would we stop therapy when Julia was modified independent when her base line was a fully functional independent woman?
One of the biggest gains that Julia made was with her hand writing. On day one of rehab she was unable to even grasp a pen. By the end Julia could sign her name on the discharge paper work. Another one of her biggest gains was that she was modified independent with use of a wheelchair by day eight. Although Julia may have benefited from further skilled therapy she did make tremendous gains in her short stay. Another interesting aspect of this case is that Julia was initially supposed to stay for fourteen days in IPR but Julia and the doctor allowed her to discharge on day eight. Further education could have benefited Julia on her decision for discharge. Patient advocacy is important as well as educating the client and family on discharge planning and diagnosis. Because GBS has a rehabilitation window from a six to eighteen month period more information and home programming could have been put into place to aid Julia to a full recovery versus modified independent in a wheelchair.