OCCUPATIONAL THERAPY PRACTICE FRAMEWORK Case Study Maggie is a 24 year-old woman who sustained a spinal cord injury (SCI) during a motor vehicle accident while on her honeymoon. Her husband was thrown from the vehicle but received only minor injuries. Maggie was transported by EMS to the local emergency department. She was diagnosed with a C5-6 vertebral subluxation and a C6 crush injury, resulting in a complete C6 spinal cord injury. She also sustained a left clavicular fracture. She received nasal O2 for respiratory support. Once stabilized, she was transferred to the specialized trauma center near her home. A halo vest was applied which stabilized her cervical spine. No operative procedures were indicated at that time. After 22 days, her endurance improved so that she could tolerate sitting upright in a chair for up to 1 hour. She was transferred to the nearby rehabilitation facility’s SCI unit. During her 12 week stay, she will only wear the halo brace for the first 3 to 4 weeks and her left shoulder flexion and abduction will also be limited (<90°) for the first several weeks until the clavicle fracture heals. Her only complications were two episodes of autonomic dysreflexia (apparently secondary to hard stool in the lower rectum) and a mild UTI. Before her injury, Maggie was a college student in a liberal arts curriculum. She and her new husband had recently signed a 1-year lease on a second-floor apartment close to the university. She had been totally independent in all of her ADL and home-management activities. Her leisure pursuits included recreational team sports (particularly softball) and more sedentary activities like reading and gourmet cooking. She was also involved with her family, particularly two sisters and her parents, all of whom live close by. You are assigned to be her primary OT and her expected stay in the rehabilitation setting is 12 weeks. Currently Maggie is dependent for transfers, contact guard for sitting balance in the wheelchair and dependent for all BADLS of feeding, dressing, bathing and toileting. 1. What are the areas of Maggie’s occupation that have been affected due to her injury? The following areas of Maggie’s occupation have been affected by her injury: ADLs: bathing/showering, bowel and bladder management, dressing, eating, feeding, functional mobility, personal hygiene and grooming, and toilet hygiene. Other areas that may be affected but are not specifically noted in the report include: personal device care and sexual activity. Some of her IADLs should be investigated further to see if her injury has affected them (since she was so independent before the accident). Some of these may include: care of others, care for pets (if she has any), communication management, community mobility, financial management, home establishment and management, meal preparation and clean up, religious observance (if applicable), safety and emergency maintenance, and shopping. It could be inferred that many of these areas (especially community mobility and meal preparation and clean up) would be affected based on the BADLs that she is dependent on others to complete. Additionally, all areas under the “rest and sleep” category should be further investigated to discover if these areas have been affected by her injury. The area of education, specifically formal education participation will probably be affected not only because she is taking time off of school due to her injury, but she will have major changes once she returns to school. This report does not state whether or not Maggie is currently employed or not; this area should also be investigated further; not only for her current work situation but also considering her future work setting. Because Maggie is an adult, the area of leisure instead of play should be looked at. Areas such as leisure exploration and leisure participation will most likely be affected by her injury. Additionally, the areas such as social participation, community, family, and peer/friend can also be affected. 2. What aspects of Maggie’s performance skills are affected due to the injury? Multiple aspects of Maggie’s performance skills are affected by the injury: motor and praxis skills as well as sensory-perceptual skills. 3. What were the occupational roles Maggie had assumed prior to the injury? If Maggie decided to complete her college degree, how would you assist in establishing her habits and routines so she can fulfill her multiple occupational roles with ease? Prior to the accident, Maggie had assumed the roles of wife, friend, daughter, sister, student, and softball player. To fulfill all of these roles, she could set routines for herself that balance all of the roles. For example, she can set aside time each day for studying, housework and time with her husband. On a weekly basis she may schedule time for her family and leisure activities (which may have been adapted). She may also have other routines that help her fulfill these roles, such as having a routine for making meals (helping fulfill her role of wife) as well as having routines for carrying out how she performs housework. 4. Describe different aspects of Maggie’s context and environment: Cultural, Personal, Physical, Social, Temporal and Virtual. Maggie’s cultural context needs further investigation because not much is provided in the report. It may be helpful to know her ethnicity and some occupations related to her culture that she deems important. She has close family ties and married when she was 24, which gives some cultural context. She is going to college as well. Personally, Maggie is a 24-year-old married female college student. Her socioeconomic and employment statuses are unknown. She is involved in team sports, but the level or organization is unknown. Temporally, Maggie recently experienced the injury and may still be adapting to the ways in which is affects her life. This injury is viewed as permanent. She is in her mid-20s and seemed to be a fairly active woman. Because virtual aspects of the environment are becoming more and more prevalent in today’s society, much of Maggie’s context probably has a virtual component. It would be helpful to know how often she uses a cell phone, land line phone, television, internet, video games, and other technology. Maggie’s physical environment is composed of a second story apartment (which may pose a problem for wheelchair access) and the physical buildings that compose the university. Wheelchair accessibility should be investigated at her university and apartment. It would be helpful to know the weather conditions of her current place of residence as well. Maggie’s social context is composed primarily of her relationship with her husband, sisters, and parents. However, she also has relationships with her peers/classmates and the people she plays sports with. 5. Which of the following OT intervention approaches will you consider when planning Maggie’s treatment? Please describe. Create or promote Establish or restore Maintain Modify Prevent I would use the “establish and restore” approach in Maggie’s treatment plan to tackle her goals of being able to independently perform ADLs and many IALs. Some of this requires building more strength and learning how to re-use certain body parts that have been weakened due to the injury. Also, I would modify many of her activities and environments to allow her to become more independent. For example, it may be beneficial to modify her living environment so that countertops are lower, the bathroom is larger, and the apartment is on the first floor (unless there’s access to an elevator) in order to accommodate her wheelchair. Also, modifying her ways of transportation by use of the wheelchair could be integrated into treatment. I would also want to prevent Maggie from experiencing depression and/or other emotional declines as a by-product of how her injury affected her; which could occur after such a life altering experience. 6. Describe the possible occupation-based activities, purposeful activities, and preparatory methods that you may adopt to help enhance Maggie's level of participation in all areas of occupation. These three categories of intervention can be used for all of Maggie’s goals in all occupational areas. For example, for an ALD goal of feeding herself (occupation-based activity), Maggie can practice grasping eating utensils as well as practicing bringing the utensil to her mouth (purposeful activities). She can also do hand exercises and upper extremity range of motion exercises (preparatory methods). Other occupation-based activities may include: performing housework, preparing meals, dressing oneself and maintaining personal hygiene, using transportation to school/family member’s houses/shopping/etc., playing softball, and reading a book. Some purposeful activities may be: practicing how to button/tie/snap articles of clothing, practicing movements involved in brushing one’s teeth, practicing using the wheelchair on the ground and with handicap vans/buses, practicing transfers, practice using adaptive techniques for softball and holding a book. Some preparatory methods may include: building endurance, building strength in specific areas of the body, learning what the technology and devices available to Maggie are and how to use them, and learning new sequences of events to use to complete a task. 7. Which of the following outcome measures would you consider important during Maggie’s rehabilitation process? Why? Occupational Performance: Improvement. Because Maggie has gone from being completely independent in many of her occupations to completely dependent. It is very important to consider improvement in occupational performance in order to determine if she is regaining her independence in regards to ADLs and other occupational areas. Adaptation: Maggie will need to adapt her behavior and ways of carrying out occupations due to her new injury. It is important to measure her adaptation to track her progress in adaptation. We (Maggie and I) may need to focus our attention on certain areas that may be more difficult to adapt to than others or try multiple strategies for adaptation. Health and Wellness: This is important to measure because Maggie was very active and completed many occupations independently prior to the accident. Therapy should help Maggie regain the skills necessary to become active, healthy, and well psychologically, physically, and emotionally. The importance of her social relationships with her husband and family may be a focus area here as well as softball and other leisure activities. Participation: Similarly, this should be tracked and goals should be set that help Maggie reenter the occupations that were so important to her before, such as softball, gourmet cooking, and reading. Being able to go back to school would also be focused on in this realm. All of these occupations help mold Maggie’s self; therefore therapy should focus on returning her to these occupations or adopting new ones that also prove meaningful. Prevention: This area may be important in monitoring Maggie’s mental and emotional state throughout therapy and after. I would want to prevent Maggie from experiencing depression or other related issues due to the dramatic change she experienced. Quality of Life: Quality of life is very important in life; Maggie’s life is no different. It would be important to measure Maggie’s view of her quality of life currently/throughout treatment compared to before the injury. As a therapist, I need to work with Maggie to develop ways to improve her quality of life if she is not satisfied with its current status. Role Competence: Maggie fulfills many roles in life, as noted previously. This type of outcome should also be measured because we want Maggie to be able to continue to fulfill all of her roles even after the injury. Self-advocacy: This may be important for Maggie to know and/or be able to learn her rights as a person with a disability. She may need to request special transportation, a note taker in class, or some other type of aid to help her function to her highest ability. Occupational justice: This is an important outcome type because Maggie is very involved in occupations and may have trouble adjusting to the changes in her life. She should be able to continue to be involved in occupations such as school and soft ball. Occupational justice should be measured to determine if Maggie is/is not receiving adequate access to occupations she wishes to participate in and action should be taken accordingly.