Running head: OCCUPATIONAL PROFILE & ANALYSIS

Occupational Profile & Analysis: Pauls Story Victoria L. Pringels Touro University Nevada

OCCUPATIONAL PROFILE & ANALYSIS Pauls Occupational Profile Paul is a 34 year old male currently living with his 72 year old mother with mild dementia. His husband, Charles, also resides in the same home along with their two pit bulls. They live in central Las Vegas in a three-bedroom apartment on the second floor. Paul was involved in a car accident, where he was side-swiped by another driver, injuring his back in 2010. Consequently, he has been experiencing significant low back pain ever since the incident. Paul has tried conservative methods of treating the pain such as one year of physical therapy,

several cortisol injections, and rest; however nothing seems to permanently relieve the pain. Paul was diagnoses with a lumbar disc herniation and is two weeks away from receiving a L5-S1 spinal fusion. Paul is a young, active man who loves the outdoors. In his leisure time he enjoys hiking and biking around the greater Las Vegas area. He has a 10 minute commute to his workplace where he manages a Del Taco restaurant. He is usually on his feet for the majority of his eight hour shifts, five days per week. The nature of the restaurant industry often requires that he work late night and weekend shifts. Paul tries not to let his low back pain hinder the meaningful occupations in his life; however he is looking forward to living pain-free after his spinal fusion. He has high hopes of joining his husband as a participant in a local cycling club following his recovery. Clients Current Concerns Paul experiences numbness, tingling, shooting, and burning pain in his back, legs, and feet throughout the day. His main concern is his inability to complete an eight hour shift at work without severe pain, often reporting pain as high as nine out of ten on a traditional subjective pain scale. This affects his ability to sit or stand for long periods of time and bend throughout his

OCCUPATIONAL PROFILE & ANALYSIS shift. Aside from the negative impact this pain is having on his work ability, it is also impacting his home-life. Once home, he is exhausted and has difficulty maintaining the household chores. He is currently on Loratab and Morphine to control his pain; however he is unable to sleep peacefully at night and often experiences night-sweats due to the medications. Successful Occupations and Areas of Concern Within the Occupational Therapy Practice Framework (OTPF), the areas of occupation Paul struggles with the most relate to instrumental activities of daily living (IADLs), rest and sleep, work, and leisure (American Occupational Therapy Association [AOTA], 2008). Activities of daily living (ADLs), in contrast, have proven to be successful areas of occupation for Paul. He is satisfied with his ability to dress, shower, manage bowl, bladder and toileting needs, eat, feed, and take care of his personal devices. In terms of IADLs, Paul has difficulty taking care of his mother who often needs assistance with her own IADLS such as remembering to take her medications, meal preparation, and general housework. He also has difficulty caring for his two pit bills. Paul is often required

to bend and lift objects when he is feeding, bathing, or walking the dogs. General housework can also be taxing on Pauls back depending on the task. These IADLs are being impaired due to pain, fatigue, and limited lifting and bending capabilities. Paul also experiences insomnia attributed to the medications he is taking to control the pain. The medications make getting a restful night sleep difficult, often causing night sweats, awakenings throughout the night, and nightmares. Furthermore, his impairment is significantly hindering his ability to work successfully. He has exceeded his paid sick days and often has to call out of work. His boss has initiated several meetings with him regarding this issue, and Paul feels he is on the verge of losing his job. Lastly, he is unable to participate in many of the leisure activities he enjoys,

OCCUPATIONAL PROFILE & ANALYSIS including biking and hiking. This adversely impacts his social participation, because those activities provide a great avenue for socialization. Supporting and Inhibiting Context and Environments From the six context and environments derived from the OTPF, Paul finds support in his cultural, virtual, temporal, and social contexts (AOTA, 2008). Pauls Asian culture has shaped a unique family dynamic that is compassionate and helpful during times of need. As part of this

culture, Paul and his husband are happy to care for his elderly mother. They believe she provides a wealth of wisdom, despite her fading memory. He also has many close family members that are always willing to provide food and support whenever necessary. Additionally, Paul is an active participant in the virtual blogging world, where he uses the internet to connect with many of his friends. This social support positively influences his well-being and attitude towards his future by providing laughter and diversion from his otherwise stressful life. Pauls temporal context is also beneficial to his recovery as he is still at a young stage in life. This aids in his physical recovery as he is healthy and expected to rebound quickly from his surgery. Pauls physical and personal contexts have the potential to inhibit his participation in meaningful occupations. Physically, Paul lives on the second floor of an apartment building, which provides an additional obstacle for remaining active after his surgery. It is important for Pauls physical and mental well-being that he does not let this environmental obstacle keep him home-bound during the recovery process. Pauls personal context, specifically his socioeconomic status, is a possible barrier to successful occupations as well. He is not happy at his current job, but does not have the education or financial means to quit and look for something that would be a more suitable for his medical needs.

OCCUPATIONAL PROFILE & ANALYSIS Clients Occupational History Nearly 15 years ago Paul was hit by a car while walking on the Las Vegas Strip. This incident changed the course of his life. He was on track to attend an out-of-state university with the hopes of becoming an engineer. While he only suffered a few broken bones to his lower extremity, the injuries forced him to postpone college. He has continued to have minor residual back pain from this injury, but never as severe as the pain he is currently experiencing after his most recent car accident in 2010. Paul still aspires to obtain a higher education degree, but

cannot foresee that commitment happening in the near future. He wishes he had a college degree so he could leave the restaurant industry for a more prestigious and financially supportive career. He dreams of traveling the world, especially through Asia to learn more about his heritage. Clients Priorities and Desired Outcomes With the help of therapy, Paul hopes first and foremost to return back to work pain free. This includes being able to sit or stand for long periods of time, as well as bend or lift objects throughout the restaurant. Next, he would like to contribute to more of the household chores so he is not a burden on his husband and elderly mother. He would also like to be able to walk up and down the stairs into his apartment with ease. Lastly, he intends to start training on his bike so he can join the cycling club with his husband. Analysis of Occupational Performance The orthotic and prosthetic clinic that Paul received his initial back brace evaluation does not perform treatment interventions other than consultations and client education. As on occupational therapy student, I observed Pauls evaluation for a custom fit lumbar-sacral orthosis (LSO) to wear after surgery. The evaluation consisted of obtaining an occupational profile, gathering measurements, and educating the client on the recovery process. The occupation based

OCCUPATIONAL PROFILE & ANALYSIS activity I observed was Paul donning the LSO in a seated position. Initially, Paul will need assistance donning the brace and will do so lying in bed. However, for this activity he demonstrated his ability to correctly don the brace according to the occupational therapists instructions in the seated position, without assistance. Paul will be required to wear the brace throughout the entire day, doffing it only for bathing purposes. This activity helps give Paul confidence to don the brace independently once cleared by the physician. The following is an analysis based on the domains identified in the OTPF, along with the necessary components of

donning a LSO that may be impacted by Pauls current pain and future back precautions (AOTA, 2008). Affected Body Functions Mental functions. The pain medications Paul is currently taking, along with the medications he will be receiving post-surgery, may interfere with his judgment, concept formation, awareness, and attention. They have a tendency to cause depression, delirium, agitation, anxiety, and dysphoria. This could negatively impact his ability to remember how to properly don his LSO. Understanding which side of the brace goes in the front of the body, and which side is the top or bottom, can be difficult for someone whose mental functions are slightly off. Currently he only reports decreased awareness and judgment, but he should be monitored closely for the other possible mental side-effects from the medications after the surgery. Sensory functions and pain. Paul is able to use the majority of his senses as normal, though he experiences extreme pain in his lower back, legs, and feet. He rates the pain as a nine out of ten on the traditional subjective pain scale. When donning the brace for the first time, he reported feelings of numbness in his toes, tingling in his feet, shooting pain in his posterior legs, and burning and aching pain in his lower back. This report of pain is typical of the pain he

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experiences on an everyday basis during routine tasks. When donning the LSO, he will also need to be careful of decreased sensation due to the pain medications he will be taking. This is very important to ensure the LSO is not too tight, which has the potential to cause pressure and breakdown of the skin. Neuromusculoskeletal and movement-related functions. Paul has limited trunk range of motion (ROM). He is unable to extend or rotate his trunk without extreme pain. While he is able to flex his trunk with only moderate pain, he tries to avoid this movement whenever possible. His upper extremity, on the other hand, is functioning normally which will aid in his ability to don the LSO properly. Cardiovascular, hematological, immunological and respiratory system functions. Pauls cardiovascular, hematological, immunological and respiratory functions are all intact and have not been affected by his lumbar disc herniation. His stamina and endurance to complete tasks that involve bending, lifting, or remaining stationary for long periods of time has decreased, but his aerobic capacity, blood pressure, and heart rate all remain normal. Voice and speech functions. Pauls voice and speech are functioning normally and were not impaired due to his lumbar disc herniation. Digestive, metabolic, and endocrine system function. Pauls metabolic and endocrine systems are functioning normally and were not impaired due to his lumbar disc herniation. However, he reports digestive issues, specifically constipation and occasional nausea, due to the pain medication he is currently taking. Genitourinary and reproductive functions. Pauls genitourinary and reproductive systems are functioning normally and were not impaired due to his lumbar disc herniation.

OCCUPATIONAL PROFILE & ANALYSIS Skin and related-structure functions. Pauls skin, hair, and nails are not impaired due to his lumbar disc herniation. However, post-surgery Paul will need to be especially careful of the skin around the incision site. Proper care of the scar and close monitoring of the skin that comes in contact with the LSO is important to reduce incidence of skin breakdown. Affected Body Structures Pauls lumbar disc herniation, which caused the need for his surgery, has resulted in the need for occupational therapy services to aid in his recovery process. The surgical spinal fusion of L5-S1 will affect his ability to bend, lift objects, and twist his trunk for six to 12 weeks after

surgery. Directly following surgery, Paul will be required to wear the LSO to limit motion in the spine which will help to strengthen the bone fusion. Motion of the lumbar spine can delay healing of the post-operative fusion. The spine will be especially vulnerable to further injury as it begins to heal. Activity Demands Objects and their properties. When Paul dons his LSO the only tool that is necessary is the custom-fit LSO. Pauls custom-fit LSO consists of a bi-valve feature, meaning it opens on both sides of the trunk, posterior over anterior closure, and is made out of polyethylene plastic that is 3/16 of an inch thick with an aly plast liner. He chose the tornado style transfer which is a brightly colored swirl design. The straps are made of Velcro for ease of use. Paul will complete this activity sitting down or lying in bed, so a chair or bed is also needed. If no chair or bed is available, once cleared by the physician, this activity could be completed standing as well. Space demands. This activity requires a space large enough to accommodate either a chair or bed so that Paul can comfortably move his upper extremities in all planes while donning

OCCUPATIONAL PROFILE & ANALYSIS the LSO. Paul completed this activity in the patient consultation room where it is quiet, well lit with typical florescent lighting, and well ventilated. Social demands. The patient room is typical of a doctors office where socialization is limited to the occupational therapist and an assistant, if available. This activity is an ADL task which generally is completed alone, without any type of socialization. In Pauls natural

environment, however, he will likely have his husband or home-care nurse assist him in this task which may allow for brief conversations. Sequence and timing. For this activity, it is essential to start donning the LSO in the proper position as indicated by the physician. Determining the front, back, top, and bottom is extremely important before initiating the task. The next step is to secure the LSO in the proper location of the trunk. Lastly the LSO should be further secured with the velco straps. In the beginning this activity could take 15-30 minutes to complete. However, once it has been performed enough times, Paul should be able to successfully don the LSO within a few minutes. Required actions and performance skills. Donning the LSO requires coordination of both hands to position the LSO on the trunk with one hand, while the other hand secures the straps. It is also necessary to use a firm grip when adjusting the straps to ensure they are attached tightly. The starting position is seated with feet firmly on the floor. This activity should be completed without any bending or twisting of the trunk or spine. Performance Skills Motor and praxis skills. Paul is able to maintain a solid grip on the straps after coordinating both of his hands to position the LSO properly. Both his motor and praxis skills during the task are satisfactory, as he safely secures the LSO to his body without bending or twisting.

OCCUPATIONAL PROFILE & ANALYSIS Sensory-perceptual skills. Paul visually determines the top, bottom, back, and front of

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the LSO. He then positions his body properly before starting the activity. Through proprioceptive and tactile feedback, he is able to secure the LSO without bending or twisting. Emotional regulations skills. Paul displays appropriate emotions throughout the task. He shows signs of pain through facial grimacing, which is a typical reaction for clients donning a LSO for the first time. He also responds appropriately to verbal prompts from the therapist. Cognitive skills. After determining the front, back, top, and bottom of the LSO, Paul sequences the task accurately. He understands where to align the LSO and how it should feel once attached properly. He also demonstrates knowledge of the proper wear schedule and cleaning instructions for the LSO. Communication and social skills. Paul is very approachable and friendly. He initiates conversations with the occupational therapist and responds to questions from myself and the other students. He maintains proper eye contact and follows social norms and expectations. Performance Patterns Habits. After surgery, Paul will get into the habit of donning and doffing his brace before and after bathing. Also, he will likely adjust the straps in the same manner and to the same location each time. Routines. After surgery, Paul will perform routine skin checks to ensure the LSO is not causing any skin breakdown. He will also routinely clean the LSO and follow the proper wear and care instructions. Roles. Paul is a young adult recovering from a spinal fusion. He also acts as partner to his husband and a caretaker for his elderly mother and two dogs.

OCCUPATIONAL PROFILE & ANALYSIS Rituals. A ritual related to this activity is that Paul finds guidance for his recovery process through meditation. He believes by meditating, he will calm his body and heal quickly without any further problems. Body Functions and Structures Related to Donning a LSO

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There are several body functions and structures influenced by the task of donning a LSO. Areas of mental function include higher-level cognition, attention, perception, sequencing movement, consciousness, orientation, temperament, and energy and drive. Sensory functions include visual, tactile, and proprioception. Neuromusculoskeletal and movement related functions include bilateral joint mobility in the upper extremity, stability within the muscles of the back and core, muscle power and endurance in the upper extremities to secure the LSO straps, and control of voluntary movements. Respiratory and cardiovascular functioning could potentially be included within this activity depending on Pauls levels of endurance, stamina, and tolerance to complete the task. This activity also influences Pauls skin functions as his skin integrity will be weak near the surgical site on his lower back. The body structures that are influenced during this task include: eyes, skin, cardiovascular system, respiratory system, and structures related to movement in his upper extremity, trunk, and back. Context and Environments Cultural. Treating chronic pain with surgery is not common to all cultures. It reflects the use of the modern medical advances that not all cultures value as much as Western cultures. Paul is electing to have this surgery, although it is not vital to his health. Instead, this surgery is a way to enhance his quality of life. Personal. Paul is a 34 year old manager of a Del Taco restaurant. He is a caretaker and the proud owner of two dogs.

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Temporal. Pauls rehabilitation comes at a time in his life where he is still searching for meaning within his life roles. He is unhappy with his current career choice, but is unsure how to provide for his family while making a career transition. Given his life circumstances, he is looking forward to regaining a sense of normalcy without pain. Virtual. Paul uses technology, specifically the internet and his cell phone, as a means to stay connected with his social support systems including his family, friends, and virtual blogging community. Physical. Pauls physical environment, particularly his housing situation, influences his motivation to attend therapy. He is excited to be able to walk up and down the flight of stairs that leads to his apartment without pain. The physical requirements of his work also influence his need to recover in order to continue to contribute financially to his family. Social. Paul has a very supportive network of close friends, family, and co-workers. He has the social support necessary to be successful in therapy and pursue his future endeavors. Problem List 1) Client unable to perform work duties 2 post-surgical back precautions. 2) Client requires mod bathing 2 post-surgical back precautions. 3) Client requires mod to don & doff LSO 2 post-surgical back precautions. 4) fatigue and endurance results in need for caregiver assistance to complete general housework. 5) Client unable to participate in cycling club 2 fatigue & endurance. Prioritization and Justification The problem list has been prioritized according to Pauls areas of concern and the activities that are most important to him. Above all, Paul would like to return to work as a restaurant manager. His financial contributions are essential to providing the necessary food and

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shelter for his family. Therefor returning to work as quickly as possible is extremely important to Paul. After surgery, Paul is concerned that he will be unable to bathe, don, and doff his LSO without assistance due to the post-surgical back precautions. This is concerning because he will need to don and doff the LSO frequently throughout the next six to 12 weeks and does not want to rely on assistance each time. Similarly, bathing reflects another area of concern as he does not feel comfortable requiring assistance to complete this private task. Instead, he would like to learn strategies to be as independent as possible in both of these tasks. Additionally, Paul would like to regain his ability to complete general household maintenance to decrease the burden placed on his husband and elderly mother. Many of his other difficulties, such as cycling and other leisure pursuits, are also related to lumbar pain, decreased ROM, decreased endurance, and increased fatigue. It will be beneficial to focus additional attention on improving those skills in Pauls intervention plan. The surgery should reduce his pain and discomfort but he will need therapy to increase ROM, improve his endurance, and decrease his fatigue.

OCCUPATIONAL PROFILE & ANALYSIS References

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American Occupational Therapy Association. (2008). Occupational therapy practice framework: Domain and process (2nd ed.). Baltimore, MD: AOTA Press.