● Exploration of alternative methods for creating scarves, including crocheting while wearing orthoses; Mrs. Hernandez reported that she might take a break from crocheting and make machine-sewn blankets for a local homeless shelter. ● Instruction in the use of ice following activities that bring on pain or inflammation. ● Provision of a catalog of adapted equipment and instruction on how to select an adapted aid to decrease repetitive motion, pinching, and rotation forces on thumb; Mrs. Hernandez reported that she would immediately purchase an electric jar opener, since opening jars had become nearly impossible. Mrs. Hernandez was scheduled for a follow-up appointment in three weeks and was instructed to call in the meantime with questions or concerns. During her follow-up appointment, Mrs.
Hernandez reported feeling much better. She had been wearing her orthosis during all activities, removing it for sleep and when at rest. She continued to crotchet but was using an adapted handle for the hook and taking frequent breaks. Mrs. Hernandez reported that work is much easier and less pain-producing because she is writing on a tablet computer rather than using pen and paper. The MAM-20 was re-administered. Scores were 68/80 for functional abilities and 3 for pain. Gross grasp strength had not changed, nor had AROM. Pinch strengths increased by 2 lb for each pinch. Mrs. Hernandez was encouraged to continue to use the orthosis and reduce its use as pain diminished. She was encouraged to use it when engaging in heavy activity. She would continue to follow joint protection techniques and seek adaptations as needed.
CASE STUDY 2: SURGICAL
Mr. Chen, age 54, was seen by the therapist at an outpatient rehabilitation department one week after a right nondominant total wrist fusion. Fusion had been performed in response to a full carpal collapse due to OA from a crush injury that Mr. Chen sustained approximately 24 years ago. During the initial visit, the therapist interviewed Mr. Chen to learn about his presurgical activities, including work, ADL, and leisure. The therapist learned that Mr. Chen is attending classes at a local community college to be trained as a radiology technician. He was unable to continue work as an auto mechanic because of the pain and diminishing strength in his right hand. Mr. Chen reported that this is the best move he could have made, stating, “I don’t really want to work in a garage my whole life.” Mr. Chen scored a 73/80 on the MAM-20, with a pain score of 3. He is having no significant impairments in daily activities but states that he has a lot to get used to because of the new immobility of his wrist. Strength measurements were not taken due to recent surgery. AROM of fingers and thumb were as follows: Right Hand (ext/flex) MCP PIP DIP TAM* Index 0/60 0/90 0/60 210 Long 0/55 0/85 0/60 200 Ring 0/55 0/90 0/55 200 Small 0/54 0/90 0/55 199 Thumb –10/30 0/30 — — (n = 260) *TAM = total active motion Mr. Chen was instructed in AROM exercise of the digits and thumb to prevent extensor tendon adhesions from forming, thus limiting movement of the digits and ultimately functional abilities. He was instructed to complete 10 repetitions of flexion and extension of MCPs, PIPs, and DIPs alone and 10 repetitions of all joints in a composite manner every waking hour. He was also instructed to maintain his hand in an elevated position when walking or resting to limit accumulation of edema. Since he lives alone, Mr. Chen was provided with a booklet of one- handed ADL techniques to assist him with ADL that are difficult due to immobility of his wrist and forearm. However, he was encouraged to use his hand whenever he could for light activities Conclusion Hand and wrist OA are especially debilitating forms of arthritis, secondary to their impact on fine motor coordination and the ability to grip, pinch, carry, and use objects. It is essential to assist a client with preserving occupational identity through adaptation and modification of the environment; protecting
that do not cause pain or discomfort. Mr. Chen was scheduled to return to therapy in two weeks. On his return to therapy at three weeks postsurgery, an increase in TAM of all digits between 20 and 30 degrees was noted. Gross grasping abilities had improved, and extensor lag was not noted. His home program had increased by 10 repetitions of each exercise. Mr. Chen is scheduled to return to therapy in another three weeks, following his doctor’s visit. He was instructed to contact the therapist with concerns or questions. On return at six weeks postsurgery, Mr. Chen was fitted with a bivalve thermoplastic orthosis to provide continued protection for his healing bones. The orthosis can be removed for hygiene, scar massage, and therapy. Treatment included gentle PROM to digits, which were now limited by only 10 degrees of total active motion and did not show signs of extensor lag. The client was instructed in a PROM home program in addition to scar massage. Treatment continued one time per week and included active and passive ROM exercises and scar massage following 15 minutes with a hot pack. He engaged in functional tasks of his choosing that provided additional movement and slight resistance to his digits. At week eight postsurgery, progressive strengthening of Mr. Chen’s hand was initiated, and a home program of therapy putty and a light gripper was provided. The dorsal component of the bivalve orthosis was discontinued. Mr. Chen was instructed in AROM exercises to address supination and pronation; the initial measurements of active motion indicated a limitation of approximately 50%. He was able to supinate to 45 degrees and pronate to 54 degrees (n = 90 and 85, respectively). Mr. Chen was encouraged to engage in moderately resistive daily activities such as vacuuming, laundering clothes (e.g., picking up garments one or two at a time), washing dishes, and preparing simple meals while using a wrist orthosis. Weekly therapy visits continued with provision of heat, followed by active and passive ROM exercise of fingers and forearm. He also worked on various functional tasks to address compensation techniques and increase ROM and strength in a natural context. At 12 weeks postsurgery, the surgeon was satisfied that bone consolidation was complete. Mr. Chen was advised to reduce orthosis wear slowly to be completely without an orthosis at 14 weeks. His current abilities were assessed, and he scored 77/80 on the MAM-20, with a pain score of 1 on a 0 to 10 scale. AROM of all joints, including fingers and forearm, was within normal limits. He reported that he is having no difficulties using his hand for schoolwork, driving, or desired leisure activities (e.g., yard work and fishing). He was discharged at 12 weeks. small joints of the hand and wrist; and gently exercising to maintain flexibility, mobility, and strength. Occupational therapy is a profession based on the understanding that humans are occupational beings who experience satisfaction in life through their ability to participate in engagements they find meaningful.
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Book Code: PTOH1324
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