1st LEVEL 1 FIELD WORK:
I observed and assisted for 40 hours over 5 weeks in the occupational therapy department at Boropark Center for rehab. Mentored and supervised by Certified OTA Verlyn Babb. Interacted with patients, PTs, PTAs, and COTAs and OTRs.
LEVEL II FIELDWORK:
320 hours to be work at Ahava Medical Rehabilitation Starting June 17, 2013
Please read the case study for this 8 week placement below:
Alison Berkowitz Case Study
The patient in this case study is a 56-year-old female that will be referred to as SR. She is a white female who is married and belongs to the orthodox Jewish community in Midwood, Brooklyn. SR grew up in Israel and attended two years of college there. She has conservative and traditional values. Women in this vibrant community take pride in observing all the religious customs, holidays and raising a large family. She covers her hair with a scarf and always wears a skirt that falls below her knees. She has six children and ten grandchildren. She does not work outside the home at this time. SR lives at home with her husband and has a full-time home health aide. She has been participating in occupational, physical and speech therapy as an outpatient since April 2013.
SR’s diagnoses are as follows: Parkinson’s, kypho-scoliosis, mild hemiparesis, right-sided muscle weakness, osteoarthritis, r/o herniated disc in C-spine, ORIF of right hip, speech disorder and wheelchair. Her diagnosis of Parkinson’s can be limited to DSM’s axis III since SR does not show signs of dementia. Currently no definitive scan or biochemical test is available to confirm the presence of Parkinson’s. Diagnosis is therefore made on the basis of clinical evaluation achieved through a combination of careful history taking and physical examination. Parkinson’s is a highly complex, idiosyncratic, paradoxical and diverse condition. The main motor symptoms are:
Typical Signs and Symptoms
Presence in Patient
Poor sitting, standing and dynamic balance
SR also has symptoms that include decreased swallowing and sleep disturbance. She doesn’t have a rest tremor. She has a intentional tremor. This means her hands only shake when she is moving them. When I asked her describe what it feels like, she cited a common feeling of people with this disease. That is, she knows that she is trying to send the signal to make a movement, but her body is not following her command. If she has depression related to her loss of function, it is not mentioned in the chart or from the patient herself. However, she sometimes seems tired. Twenty percent of the time, she expressed frustration while trying to walk or to do a transfer.
Most individuals diagnosed with PD are prescribed medications. The most typical are dopamine boosters (Levadopa) are usually used but they are not listed in the chart. Some medications can cause involuntary movements called dyskinesia or liver failure. SR often needs water since the medications are a diuretic and may make her dehydrated. This is compounded the weather in summer. Hence, she may be tired from not drinking enough water. Many people with this issue may avoid drinking water since it is difficult to use the bathroom. When SR calls her aide to use the bathroom, she is gone for at least 20 minutes. SR speaks very low and can only speak in monotone because PD makes it difficult to move the lips and vocal cords. She also gets treatment from the physical therapists and speech language pathologists. There is a doctor or nurse on staff on site. However, SR may have a regular doctor at another facility. The PT, OT and SLP are the main focus of treatment at Ahava Rehab. They work together informally to track SR’s progress. PT and OT treat in the same gym and the SLP calls or walks into the gym to escort patients to their speech therapy session.
Assessments and Evaluation: Moryam conducted this evaluation in April. She interviewed an observed SR to find out what she wanted to work on. The summary of the interview and assessment are attached. SR needed at the time moderate assistance in most BADLs and has pain in her left shoulder. Her goals are to increase independence and improve muscle strength. During the interview, it was also noted that SR has her aide push her wheelchair and has problems transferring from her chair to a bed or to the toilet. Most tasks and movements take and increasing long time to complete. This evaluation brought to light the problems related decreased range of motion, rigidity, pain and weakness. All of these deficiencies interfere with SR’s ability to complete her BADLs.
SR was prescribed four 30-minute sessions of OT and 30- minute sessions of PT per week for 14 weeks. Upon this evaluation, three main general goals for occupational therapy can be identified from the OTPF. First, is to improve active range of motion so that SR can do BADLs with less assistance. A second goal is to increase muscle strength in order to improve static and dynamic balance. This goal is important so that when SR is standing or transferring, there will be a reduced risk of her falling. The third goal is improve fine motor skills that so that SR can perform dressing, feeding and bathing with less assistance. From the three general areas, one can identify and analyze three specific goals. They are being able to manage feeding independently, UE dressing with standby assistance and improving static standing balance. All three require specific activity analysis and interventions. The progress of these interventions was evaluated after 4 weeks
SR had already made some progress in AROM and PROM in BUE from her initial evaluation in April of 2013. However, the goals mentioned here had not been worked on yet when I began working with her at Ahava in June. The main progress in the first two months of her treatment was a decrease of pain in the left shoulder from a 6 out of 10 to a 1 out of ten. The plan for her treatment included stretching, massage, using weights and practicing transfers. These modalities help SR with her gross motor functions. Practicing with pegboard and cones were activity related to maintaining her fine motor skills. Finally, it must be noted that for PD, the ultimate goal of OT is to prevent the progressive loss of function. Hence, even if SR does not achieve deliberate goals as outlined, if her condition does not become more severe, the therapy may be considered valued and time well spent. Indeed, when persons with PD don’t get OT, their condition worsens at a faster pace. Hence, they depend more on caregivers much sooner
Performance in each area of occupation is as followed:
Activities of Daily Living
- Bathing, Showering/ Personal hygiene and grooming: The patient needs moderate assistance with bathing and showering.
- Bowel and bladder management: The patient is not incontinent but has to use the bathroom frequently. Transferring to the toilet is difficult because of problems with ROM .
- Dressing: SR requires moderate assistance (50-75%) of one person with dressing herself, both lower and upper extremities.
- Eating and feeding: SR is able to eat with 50% assistance.
- Functional mobility: Pt. is in w/c and ambulates. As of July. AROM is BUE at shoulder is 0 to 80 degrees and PROM is 0 to 110 degrees, also at shoulder flexion.
- Personal device care: Wheelchair
- Sexual activity: The patient did not raise this as a concern
- Toilet hygiene: the patient is able to perform her toilet hygiene with 75% assistance from aide or husband
Instrumental Activities of Daily Living (IADL)
- Care of others: the patient’s children are already grown and live independently.
- Care of pets: The husband can take care of their dog and cat
- Communication management: the patient has difficulty vocalizing since her muscles controlling her face, larynx and vocal cords
- Community mobility: the patient goes out in the community with the assistance of a skilled home health aid or husband
- Health management and maintenance: SR can manage her medications. The HHA and husband also her make sure her prescriptions are filled. They coordinate her doctors’ visits since some medication require liver tests every 3 months.
- Meal preparation and cleanup: SR’s HHA and husband prepare her meals
- Religious observance: SR attends schul with family regularly. Their temple and religious community help provide routine and social support.
- Safety and emergency maintenance: SR needs supervision all of the time since she does not move quick enough or talk loud enough to make an emergency call.
- Shopping: the patient goes shopping with her aid and husband in the area.
- Rest and sleep: the patient has difficulty with sleeping at night 40% of time since she may have to use the toilet during the night. After doing this, she has trouble going back to sleep.
- Education: the patient is not in school
- Work: SR was a homemaker but her children are grown so she is not working.
- Leisure: Being in a wheelchair makes it hard to do most activities, but SR enjoys spending time with her husband and family. She wears glasses to read, enjoys music, and weekly spiritual events at their local synagogue. At the rehab center, she enjoys being in the aquatherapy pool.
Occupational performance intervention area: Feeding
Goal: SR will be able to use a built-up spoon in two weeks, and will be able to finish eating a bowl of soup while it is still warm. In the long term, SR will be able to use a built up fork and knife.
Method: Each session and at home, SR practices shoulder flexion by stacking therapy cones from one pile to another. This assists in improving range of motion. Therapy may also start by a two-minute massage and manual stretch of the hands arms and shoulder. Fine motor skills are practiced in the OT gym with a peg board and a clip rack. The clip rack is difficult because when SP goes to reach to put a clip at the top of the pole, she experiences an intentional tremor. Precise movements are the most important to practice since this is most similar to using utensils to eat. Her pinching fingers tend to easily slip toward the end of the exercise. SR seems to have accuracy at first, but the tremor and weakness impede completion after doing the activity for 7-10 minutes.
Outcome: Patient reported she is indeed able to use a normal spoon, but has less stamina at the end of the day. During the first four week working with her, her should flexion in AROM in BUE increase from 65 to 85 degrees.
Occupational performance intervention area: Upper Extremity Dressing
STG Goal: After three weeks, patient will be able to don her head scarf with minimum assistant.
Long-term Goal: After 8 weeks, patient will be able to don her t-shirts and blouses independently.
Method: SR practices AROM using a pulley with a 10 lb weight four times a week for 15-20 minutes each session. We used a weight machine that allows her to do a seated row and an overhead pull down. For each exercise, SR does five sets of twenty five repetitions. The weight is not heavy, but each set takes nearly two minutes due to the rigidity and trembling in the hand and forearm while pulling the bar. A therapist is supervising to make sure her hands stay gripped on the bar.
Outcome: SR’s AROM increased enough for her to don her headscarf and a blouse independently. Her ROM does not allow her to don a heavy jacket or tight clothes.
Occupational performance intervention area:
Long-Term goal: Improve both static sitting and standing balance from fair + to good.
Method: In order to improve SR’s mobility during transfers, she needs to have a stronger core and better static balance, even while sitting. The method for working on trunk is to perform sit to stand exercises for 10 minutes three times per week. Also, every two weeks, physical therapy and occupational therapy work as a team to give SR two one hour sessions of aquatherapy. Walking in the water and using Styrofoam weights to practice ROM are an efficient intervention. When SR is in the water, she feels lighter and is not afraid of falling. The warmth of the water help loosen up the stiffness in her arms as well. The therapist both stand near by to reassure her of her safety. They guide her through manual therapy and active exercises that target all the arm, shoulder, back. When she is ready to get out of the pool, her posture looks better and SR appears more relaxed.
Outcome: After two months of this treatment, her sitting and standing balance are good when SR is not moving (static). When sitting and standing are dynamic, they are rated only a fair plus. SR’s intentional tremor impedes her balance and coordination when moving. When she is doing ambulation exercises with her walker, she is worried about fall about 70% of the time. Her confidence in her balance is also impeded by hip replacement and excess body mass in her trunk. She becomes fatigued half of the time in sit to stand exercises because her trunk, buttocks and legs are not conditioned well. For this, the PTs have been working with her on a leg press in addition to the pool. Therapists have seen better muscle in the areas needed for good balance in the past 4 weeks. However, it is hard to know for certain if more muscle will aid SR in sitting and standing, since PD makes the muscles more rigid. Half the time in the 5th repetition of sit to stand, SR will say that she is tell her body to lift, but her body seems not be getting the signal.
Summary and Related Research: In summary, the outcomes in this case were good. Many factors contribute to SR’s progress. Her desire to do well and continue to live at home, even with an aide are the forefront. She is always at therapy when the aide can take her, has a good attitude, and practices at home with her husband. He also, in fact, makes her climb the stairs every night to go to the bedroom and sleep on the second floor. Furthermore, at Ahava, her therapist has had at least three OT or OTA students to assist and supervisor her treatment. Having students interested in supervising her exercises has made her time at therapy more effective. For instance, students help the PT in transferring her to the leg-press machine or into the swimming pool.
Research articles in this area indicate that occupational therapy has a moderate to small effect on the progression of Parkinson’s disease. However, the article that had this meta-analysis was published 12 years ago. It is possible that treatments have become more effective. Another article demonstrated that working with PD patients on UE reach was more effective when using physical moving targets. This study showed that one-one therapy cannot be substituted by computer simulation. Another article which studied preventing falls in patients with PD concluded that dynamic standing balance is important for preventing falls.
One of the most integral parts in managing movements in both reaching for objects with arms and dynamic balance is external and internal cues. In the clinic, I was able to use this advice to tell SR to remind herself of the physical motions she was doing by visualizing the end result or giving her a verbal cue. She also said that reminding herself of the motions in dressing, using a spoon and standing with proper posture helped. Being mindful of her movements made her more confident in walking with her walker, and less afraid of falling. The article on fall prevention cites that confidence in the patient’s posture and not being afraid of falling are the most important factors in decreasing the patient’s risk of falling. This also impacted therapy by reminding SR that she should be proud of her progress and we reminded her to be positive in ability to stand and walk with her walker.
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