Student

Name: Jessica Smith Case: #3 - Ursula Date: 2/5/18

1. Diagnosis, Referral, Setting, Reimbursement, LOS

Ursula is a hair stylist diagnosed with bilateral Carpal Tunnel Syndrome (CTS). She began
experiencing tingling, loss of sensation and painful sensations in her right hand 1 month ago while at
work. She is 1 week post-CTS nerve compression release surgery on her right hand. Her left hand is
also presenting with early symptoms of CTS. She was referred by her Hand Specialist to receive
Outpatient Occupational Therapy (OT)/Hand Therapy twice weekly for 4 weeks.
- Private insurance will be paying for her treatment w/ referral stating: OT to evaluate and treat
2x/week for 4 weeks.
- Client/Hand Specialist are hoping to treat the symptoms in her left hand more conservatively (not
a nerve compression release surgery at this time)
- Client works as a hairstylist 6 days/week
- Hand Specialist had prescribed her anti-inflammatory medication, rest and a pre-fab wrist splint
purchased at her local pharmacy.
- History of smoking

2. Pragmatic Factors to Consider

- Client wants to go back to work as soon as possible – she may lose her position at her hair salon
if she cannot pay the rent on the chair/return to work.
- What goals can be addressed/accomplished during this many visits (8).
- Client’s schedule; spouse/children’s schedules; any other Dr. appointments/check-ups planned
- Out of work currently.
- Post-surgery precautions
- Client & husband’s bowling schedule (only in winter months)

3. Context: Occupational Profile & Current Occupations

Cultural: - Client is an African American woman hairstylist - African American culture often
has very intensive hair care/styling demands – stylists/barbers may be doing more
than just cutting, brushing, drying, washing, and styling hair; and appointments
may be very lengthy (i.e. styling with braids, corn-rows, of weaving the client’s
hair can be very intensive, detailed, time consuming, and repetitive work).
- Client is deeply religious and attends/volunteers at church on Sundays.
-
Physical: - Client needs to maintain her ability to work to justify paying rent on her chair at
the salon; if she cannot work, the salon owner will rent chair out to someone else
and she risks losing clientele base.
- Afro-Ethnic hairstyles tend to be intensive, time consuming to complete, and
physically demanding on the hands of the stylist (tight braids, corn rows, weave,
twists, calming treatments, etc.)
- Salon where she works, Church, home
- Pre-fabricated wrist splint
Social: - Enjoys bowling with her husband one night/week in the winter months
- Volunteers at church on Sundays
- Has family (spouse and 4 children aged 8 to 16), friends, and clients
- You must be a very social person to be a hair stylist – they always keep the
conversation flowing.

Page 1 of 18 Revised 1/9/17

Personal: - 44-year-old, African American woman, working as a hair stylist; volunteers at
church, mother of 4 children, spouse.
- Her role as a mother caring for the household has lessened as her symptoms have
worsened.
Temporal: - Client is a deeply religious woman who volunteers at her church on Sundays; she
has to work the other 6 days of the week to make enough money to pay rent on her
chair at the salon.
- She makes her own schedule and tells the receptionist for scheduling.
- If cannot return to work soon, client risks the loss of her chair in the salon, her
clientele base, and her income.
- Bowling 1 night/week with husband (during winter months)
- Time of day may impact CTS symptoms (nighttime symptoms vs. daytime
symptoms)
Virtual: - Learning salon’s new electronic appointment and billing system – she can make
her own hours
- Sending messages to friends, or typing on the computer may be difficult/painful for
client d/t symptoms of CTS
Prior Occupations:
- Full-time hair stylist at a local salon – working 6 days/week to justify renting chair
- Goes bowling 1 night/week with her husband (in the winter)
- Goes to church and volunteers at church on Sundays
- Prior to injury/surgery, client was active in performing household maintenance duties; since the
injury/surgery, her family has been pitching in, but her role within the household has lessened as
her symptoms have strengthened.
- Mother & Wife– child rearing, household maintenance and meal prep (IADLs), self-care (ADLs)
– increasing difficulty washing and drying own hair d/t pain!
-
Current Occupations:
- Recovering from Nerve Compression Release surgery on her R hand (1 week post-surgery)
- Participating in therapy to address CTS symptoms of her L hand (early onset)
- Wanting to get back to work (hairstylist) as soon as possible
- Mother – child rearing, household maintenance, self-care (ADLs) – increasing difficulty washing
and drying own hair d/t pain!

4: Top Three Client/Family Goals and Priorities

1. Return to work as a hair stylist

2. Independently perform self-care (i.e. washing/blow-drying/styling hair) tasks that are currently
designated as “severely difficult” on the DASH evaluation.
3. Increase Household IADL participation/performance/role competence

5. Diagnosis and 6. Scientific Reasoning & Evidence

Expected Course List the barriers to performance typical of this diagnosis:

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Bilateral Carpal Tunnel Barriers to performance typical for this diagnosis:
Syndrome (CTS) – type - Functional limitations & impairments (lack of muscle
of repetitive use injury strength/innervation/sensation) d/t inflammation/compression of the
Median Nerve in the carpal tunnel space of the wrist. This may likely
R – 1-week post Nerve cause decreased mobility, decreased endurance, decreased grip strength,
Compression Release decreased intrinsic hand muscles and muscle movements – may drop
Surgery things
- Do not perform heavy lifting, grasping or gripping until at least 3 weeks
L – beginning to post-surgery
experience symptoms of - Decreased sensation, decreased ROM, possible wasting of thenar
CTS – early stages muscles, decreased strength, post-surgical precautions
____________________ - Wound healing.
CTS – commonly
caused by repetitive/
over-use injuries Expected Recovery milestones for Carpal Tunnel Release Surgery:
- 1 week post-surgery – bandages and stitches removed, therapy to
Post-Surgery Conditions improve stiffness and restore ROM
- Open or endoscopic - 2-4 weeks post-surgery – pts gradually resume activity in affected hand,
surgeries – have return to work (for sedentary jobs that require no. heavy lifting or hard
different recoveries labor), pts can expect gradually decreasing pain in the palm and
- Wound care at soreness to touch. – massaging scar w/ lotion may help decrease
suture site, discomfort and soften area. – driving, self-care activities, typing and
decreased use based light lifting/gripping are permitted around this time. – splint may be
on protocol used occasionally to reduce pressure in wrist and pain
- Pain/swelling/ - 4 weeks post-surgery – pts should regain full mobility of digits by this
stiffness time
- 6-8 weeks post-surgery – pts should be back to nearly full daily life and
Early Onset Conditions sporting activities – still feel some soreness in palm to deep pressure or
CTS is caused by touch. Nighttime symptoms improve, but numbness in fingers may
compression/irritation of remain
the Median Nerve in the - 1 year post-surgery – most pts will have all function of CTS release
carpal space on the volar surgery. Pts w/severe/chronic Median N damage, pinched nerves in
side of the hand. neck, or wasting of muscles prior to surgery may continue to have limits
in hand function and strength post-surgery.
Typically affects thenar
muscles and intrinsic This is a rehabilitation protocol (slightly different than the one listed above)
muscles of digits 1-3 for one clinic’s post-surgery protocol for CTS release surgeries:
with sensory distribution https://med.virginia.edu/orthopaedic-surgery/wp-
across volar surface of content/uploads/sites/242/2015/11/copy_of_CTROPENProtocolandHEP.pdf
digits 1-3 and half of the
palm. The American Academy of Orthopedic Surgeons – Carpal Tunnel
Syndrome:
Generally, more https://orthoinfo.aaos.org/en/diseases--conditions/carpal-tunnel-syndrome/
common in women – d/t
narrow carpal tunnel.

Begin treatment as early

as possible.

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- NSAIDs –
medication to
address
inflammation caused
by CTS
- Wrist splinting
- Hand Therapy
- Surgical Release of
compressed Nerve
- Nerve gliding
exercises
- Yoga – for strength,
stretching & balance
of UE – reduces pain

Possible complications
from CTS:
- Neuroma
- Nerve damage
-

7. Practice Models Guiding Assessment and Rationale

Treatment
1. PEO PEO is a relevant model to use with Ursula due
to how her recent Carpal Tunnel Syndrome
(CTS) symptoms may have effected the
congruence between the Person - (Ursula), the
Environment - (her returning to work after her
carpal tunnel release and therapy), and then with
the Occupations, (such as independence in ADL,
IADL and work skill tasks – hairstyling).
PEO can help to guide assessment and treatment
by being aware that sometimes, it is easier (and
more appropriate) to make changes to the E, or
the O, rather than to the P. For example. PEO
can help therapist to understand that adapting the
task or environment by suggesting an
environmental modification (such as splinting
wrist or using a self-standing hair-dryer AE) is
likey a better starting point than attempting to
jump straight into changing the person
(repeating use in the exact same way the hand
was used prior to surgery/therapy itnervention),
while also making it occuaptiona based by
focusing on houshold IADLs, self-hair care, and
returning to work as a hair stylist.

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2. Rehabilitation The use of the Rehabilitation Model with Ursula
is to address her motor difficulties, pain,
stiffness, weakness and tingliness and numbness
(if found to be present). This is relevant to
Ursula because it is important for her to begin to
utilize adaptive techniques/compensatory
strategies and adaptations to the environment or
occupation in order to improve independence
and functional abilities, while her hands/wrists
are healing (i.e. functional hand splint during the
day, resting hand splint for nighttime use); once
this acute phase of rehab is complete, client
should be working to eliminate the number of
AE they are still using. It is important to help
Ursula begin to utilize various techniques,
compensatory strategies, and environmental
modifications in her home in order to increase
her independence and maximize performance
and participation in occupations.
3. Biomechanical The use of the Biomechanical Frame of
Reference is important to use with Ursula due to
her carpal tunnel syndrome symtpoms (pain,
weakness, tingling senstion and stiffness). It
would be important to enhance occupational
performance through increasing strength (in both
UEs - it is unknown which is her dominant hand,
but it is important to build up strength in both to
allow for better bilateral function), assessing and
possibly increasing ROM (AROM & PROM)
(keeping precautions in mind) in order to keep
nerve gliding appropriate, and the limb as
functional as possible. Each of these things is
also important for Ursula as she begins to heal in
preparation for possibly being fitted with and
trained to use various splints (which is another
reason for using biomechanical - to reduce
pain/weakness and prevent deformities (such as
wasting thenar muscles and decreased ROM).

8. Specific Areas of Occupation

What do you know? What do you need to know?

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*Many of the ADL and IADL difficulties are
based off of scores on the DASH*
ADLs
Bathing/Showering – has “severe difficulty”
washing and drying hair – almost “unable” to do
(according to DASH scores)
Dressing – has mild difficulty donning pull-over
shirt
Functional Mobility – no difficulty getting
around; mild
Personal Hygiene and Grooming – increasingly
difficult to style/wash hair d/t symptoms; safety
concerns as a result of decreased sensation (if
using heat iron/curling products, possibility of
burns to hands)
Sexual Activity –is not influenced by CTS
symptoms
IADLs
Care of Others/Child Rearing – caring for
family/children. Household chores, helping
children with their ADLs and IADLs as needed
depending on age.
Care of Pets
Communication Management
Driving/Community Mobility –
Client is able to manage his transportation needs
Financial Management – difficulty managing
finances as a result of not being able to currently
work
Health Management and Maintenance – self-
care difficulty. Management of pain/tingling/
weakness/stiffness;
Home Establishment/Management –
- turning a key, pushing open heavy door, ,
gardening/yard work, and making her bed are
all mild difficult for her now – as a result of
CTS in hands.
- placing objects on shelf above head, doing
heavy household chores (washing
walls/floors), carrying a heavy object
(10+lbs), replacing overhead lightbulb, and
opening tight jars/containers are moderately
difficult for her now – as a result of CTS in
hands.
Meal Prep/Clean-up –
- experiencing moderate difficulty opening
jars/containers d/t CTS pain; mild difficulty
preparing a meal; moderate difficulty place
Page 6 of 18
*Little is yet known about client’s current ADL
and IADL participation and functional abilities*
ADLs –
Bathing/Showering – what strategies is she
currently using to wash hair/dry hair/style hair? –
Is she doing simpler hair care routines, showering
less frequently, or
Toileting – how is her pain, stiffness, tingling,
weakness affecting her toileting routine?
Dressing - has her pain impacted what she is
wearing, are zippers or buttons more difficult for
her?
Personal Hygiene and Grooming – what does it
look like when she is doing task? How is she
holding items, does she flip her head over so she
doesn’t have to reach and extend so far? Is it the
vibrating from the dryer that is difficult? The
weight? Is it her ergonomics? What specific part
of the task is most difficult for her?
IADLs
Communication Management – does she find
texting, holding the phone or using her computer
to contact anyone more difficult d/t symtpoms?
Can she do these things in her pre-fab brace?
Driving/Community Mobility-
–does the pain/stiffness cause difficulty when
driving? Does she drive an automatic or a manual
vehicle?
Financial Management – does she find it
difficult to count out money or change / handle
money d/t symptoms? How is she compensating?
Health Management and Maintenance – how is
client currently managing pain /tingling/
weakness/stiffness
Home Establishment/Management - are some
tasks more difficult than others? What makes
tasks difficult for her? Is it the way her hand
holds on to something? Or the weight?
Meal Prep/Clean-up - is she able to clean up
after meals and meal prepping is just difficult?
Are some meals easier based on time of day?
Religious/Spiritual Activities & Expression -
does her religion influened at all by her pain?
Shopping
- Is she using cart or other people to carry her
objects? What happens when she is alone and
needs to get something heavy?
Revised 1/9/17
 object on shelf above head (cooking
item/supplies); moderate difficulty carrying a - how is she compensating for her decreased
sack of groceries, mild difficulty using knife
to cut food; safety concerns as a result of
decreased sensation
Religious/Spiritual Activities & Expression –
client is a deeply religious woman; volunteers at
her church on Sundays
Safety and Emergency Maintenance –
- using a knife to cut food, and performing
tasks that are painful/flare up symptoms
Shopping –
Cannot carry heavy items or grocery sacks
REST & SLEEP
- Client is beginning to have trouble sleeping as
a result of her worsening symptoms (pain is
mild to moderately affecting her sleep)
EDUCATION
- Client is not currently in school, but all of her
children are school aged, and thus, likely need LEISURE
help with their homework.
WORK
- Client works as a hair stylist – has been out of
work for at least 1 week d/t recovery from –
CTS condition is causing her to be unable to
work for the time being.
- CTS release surgery on R hand; L hand is also
experiencing
- While at work prior to surgery, client felt that
doing her usual work and spending her usual
amount of time doing her work is moderately
difficult d/t CTS condition. She also found
that using her usual technique for her work,
and doing her work as well as she would like
was severely difficult for her as a result of
pain/condition.
REST & SLEEP
rest/sleep right now? Is she managing with
pain medications or PAMS before bed? Does
positioning help? Has she worn her splint at
bedtime?
EDUCATION
- does she have to help her children with their
homework? Is she able to do this
successfully?
WORK
- how long is her job willing to let her be out of
work for? What is her specialty at work?
(cuts, colors, relaxation treatments, weaves,
braids, twists, etc.) – how intensive does she
need to get back to immediately. How many
clients does she see daily? How many hours
daily? Can she go back part time and share
chair rental with another woman? Can she cut
from home with clientele for now?
- other than bowling, is there anything else she
would like to get back to that she isnt’ able to
do right now d/t symptoms?
SOCIAL PARTICIPATION
- how has this impacted her social
participation?

LEISURE &SOCIAL PARTICIPATION

- Bowling – client enjoys bowling with
husband 1 night/week – with her hands in
their current condition, she will be unable to
bowl; likely for months (which will then be
spring /summer (only bowls that often in
winter
- Recreational activities with some impact or
force through arm, shoulder or hand (golf,
hammering, tennis, etc.) is moderately
difficult

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- Recreational activities where you move arm
freely (Frisbee, badminton, etc) are no
difficulty for client
- Social participation slightly impeded d/t
arm/shoulder/hand problems

Page 8 of 18 Revised 1/9/17

 9. Performance Skills
What do you know?
MOTOR SKILLS
Stabilizes, grips, manipulates, positions, reaches,
lifts,
- she dropped things before surgery, couldn’t
hold onto hair dryer and scissors while
wearing pre-fab splint, cannot lift heavy
things
SOCIAL INTERACTION SKILLS
Social interaction skills intact.
What do you need to know?
MOTOR SKILLS
- how is her endurance? Is she able to calibrate,
is gripping and manipulating easier and
harder depending on shape and weight of
object? How is she compensating for these
things right now?
PROCESS SKILLS
- how does she pace activity/her day/work
schedule?
- How is she choosing and using tools? Is it
appropriate and safe? Can her organization be
improved for ergonomics? Does she make
adjustments to decrease pain?

10. Performance Patterns-Habits, Routines, Rituals, Roles

What do you know?
- Client works 6 days/ week
- Attends church on Sundays
- Role – mother, spouse, full-time employee,
hair stylist (often have strong relationships
with clientele), friend, renter (salon chair),
and woman of faith
- Bowling 1 night/week during the winter
- Pay rent (monthly?) on her chair at the salon
- Takes lunch break and short cigarette break in
the morning and afternoon each day
- Has been off work for 1 week
What do you need to know?
- How many hours is she working everyday
that she works – how many clients is she
having on those days? – are all days as
intensive? – does she tend to try to group
certain types of hair style appointments on the
same days/separate days?
- How long is she at church on Sunday? – how
many hours is she volunteering?
- What are her typical self-care routines? – does
she shower daily? (some Afro-Ethnic
hairstyles require washing to occur only
1x/week or possibly even further between
washes)
- What are her children/family’s typical
routines?
- How long are her lunch/ cigarette breaks
- How often/much is she smoking (routine)

11. Activity Demands for the Client Goals and Priorities (CHOOSE 1)
What do you know? What do you need to know?

Page 9 of 18 Revised 1/9/17

Blow-drying hair
Relevance & Importance to Client –
- It is important to client on a personal and a
professional level.
Objects Used & Properties –
- It is known that a hairdryer is used, but it is
not sure what kind or if there are any
additional products or tools she also uses.
Space Demands –
- Open space with enough room to move arms
around without hitting anything
Social Demands –
- None for self-dryinghair; if drying someone
else’s hair, you may be expected to sustain a
conversation with them before and after you
dry their hair.
Sequencing and Timing –
- She likely continues drying until all of hair is
dry; length of time likely exacerbates
symptoms
Required Actions & Performance Skills –
- Grip, manipulate,
Required Body Functions –
- Available ROM in UE, strength and grip
strength strong enough to hold onto dryer
without dropping it
Required Body Structures –
- Hands, wrists, arm, joints,
Relevance & Importance to Client –
Objects Used & Properties –
- Are there are any additional products or tools
she also uses.
Space Demands –
- Not sure where she is performing task right
now (for self, at least)
Social Demands –
- Is it easy/difficult for her to maintain social
demands during tasks?
Sequencing and Timing –
- How long does it take her to dry her own
hair? Someone else’s hair? Does she take
breaks during? Does she pause to brush
through it? Does she hold drying in same
hand then entire time? Is dryer heavy? Does
she turn head upside downto dry hair?
Required Actions & Performance Skills –
Required Body Functions –
Required Body Structures –

12. Client Factors- Values, Beliefs, Spirituality

What do you know? What do you need to know?
- Client is a deeply religious person, attends - What are her beliefs about recovery time post-
church and volunteers at church every Sunday surgery
- Client values her family, values her job
- Client believes she will lose her chair in the
salon if she doesn’t return to work soon
- Client believes she is losing her role in her
family d/t not being able to contribute as
much to household chores
-

13. Client Factors- Body Functions & Structures

What do you know? What do you need to know?

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BODY FUNCTIONS BODY FUNCTIONS
- Client’s cognitive functioning appears to be Sensory Functions
fully intact - Decrased sensation may lead to skin
Sensory Functions breakdown, sores, or potential for safety
- Decreased sensation on both hands (median N concerns
distribution, possibly more if nerve damage Neuromusculoskeletal & Movement-Related
occurred to other nerves during surgery) - What is current ROM, Muscle strength? How
- Pain, tingling sensation up arm and in hands is thenar muscle formation? –wasting?
Neuromusculoskeletal & Movement-Related BODY STRUCTURES
- Decreased ROM in affected joints Skin integrity, wound care, suture site, how is she
Muscle Functions managing these?
- Decreased strength d/t possible muscle Muscled wasting?
wasting, and nerve impairments Was surgery a success?
- Decreased endurance Any complications?
Movement Functions Any radiating nerve pain?
OTHER

BODY STRUCTURES
Received surgery to release nerve compression

Page 11 of 18 Revised 1/9/17

 14. Evaluation: What Assessment tools and other means of assessment will you use?
Top Down Assessment: Prioritize one Occupation to observe the client perform
Observed Occupation
I would like to observe Ursula performing some
type of self-care task – preferably something to
do with her hair (brushing, hair-drying, etc.)
Method/Tool
1. Sensation Testing on the Hands
(Median N distribution)
Sensation on B UE
(Light Touch - monofillaments,
Temperature and Pain)
Page 12 of 18
Rationale/How will you use this information
I would like to observe Ursula performing a
typical self-care task (as well as she can while
still maintaining surgical precautions for her
right hand – such as keeping surgical site clean
and clear, and not using right hand very much.).
Preferably I would like to see a small example of
what is the most difficult for her to do (i.e. hair
drying or putting product in her hair). As she is
performing task, I would ask her clarifying
questions to have her explain what exactly is
painful about the way she is currently doing task
(angle of holding the dryer, using both hands,
reaching up by flexing shoulder/extending
elbows and wrists, gripping hard on the handle,
managing the blowback from the dryer, etc.) By
seeing these things, I would have a better idea of
what is possible to do/modify to make this task
more achievable – i.e. would ergonomics alone
be helpful? Would a splint that allowed
for/accommodated for supporting tools used
during hair-drying be beneficial, or even
possible? Is there any additional AE that could
be utilized? (self-standing hair drying stand) is
time the largest culprit for
pain/tingling/discomfort, etc.
Rationale/What is being Assessed
It is important to assess her level of sensation on
her UEs and trunk to help determine where her
sensation is intact, where it may be absent, and
where he may have partial sensation (Median
Nerve distribution). Sensation is also important
to assess if there is a safety concern for tasks
(i.e. being able to sense temperature on thumb,
index and middle fingers – to prevent burns
while styling hair, prevent cuts, and prevent
injuries during cooking and household tasks, will
help client (and therapist) be aware and problem
solve when this will be important to use
functionally.
Revised 1/9/17
2. Provocative Tests (Tinel’s Sign & Phalan Test) It would be important to re-evaluate L UE with
(on L UE) these tests to double check that Median N
compression at the carpal tunnel is actually what
is the concern for the L hand before treatment
begins.
3. BUE MMT – especially Thenar muscles Performing BUE MMT will help determine
baseline, will help to assess where strength and
weaknesses are, as well as (likely) pain is
impeding muscle strength, as well as functional
possibilities. This can be performed on L hand
at initial session, but double check post-surgery
precautions on R hand before administering any
strength testing to prevent injury or prevent
opening of suture site. MMT will help
determine which muscle groups may benefit the
most from strength exercises. This is also
important to evaluate if there is any wasting of
the Thenar Muscles.
4. Jebsen Hand Function This assessment will help determine baseline
level of function for Ursula on both UE (post-
surgical precautions permitting). A section of
this test requires client to pick up heavy and light
items, which is one of the main reasons I would
want to perform this assessment (or at least
perform pieces of the assessment). I would like
to see if and how client picks up these different
items to help determine what about the items
may be challenging.
5. Bilateral AROM & PROM through the hand It would be important to assess AROM and
(and possibly UE) PROM on both hands (surgical precautions
permitting for R hand). It is important to assess
what client can do actively in each hand/joint;
this will help to know what is possible
functionally and can thus help to know what
strategies would be the most beneficial to use. It
is also important keep those joints moving in the
hand to promote functional use and to keep joint
capsules from tightening up. Teaching ROM
and Nerve Gliding will be important steps in the
rehabilitation process to regain as much hand
function is possible.
6. Grip Strength Use dynamometer to assess strength on B hands.
Do not perform grip strength on R hand until at
least 3 weeks post op – d/t precautions.

15. CPT Evaluation Code: Justification

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Low Complexity (97165) Based on no complex Occupational Profile/previous medical history, no
need for time consuming and intensive clinical reasoning – plan of care,
and his Assessment is fairly low as well!

Therefore, Low Complexity

16. Projected Outcomes: Type of Outcome

Improved occupational performance in job related skills/tasks (hair Occupational Performance
styling, drying, washing, cutting – scissor manipulation/control,
combing, etc.)

Prevention of Thenar Muscle wasting as a result of CTS. Prevention

Increased Participation in job – hair stylist Participation

Improved occupational performance in ADLs & IADLs – to also Role Competence &
improve Role Competence. Occupational Performance

17. Resources and Team Members

- Mayo Clinic – Carpal Tunnel Syndrome Information: https://www.mayoclinic.org/diseases-
conditions/carpal-tunnel-syndrome/symptoms-causes/syc-20355603
- The American Academy of Orthopedic Surgeons – Carpal Tunnel Syndrome:
https://orthoinfo.aaos.org/en/diseases--conditions/carpal-tunnel-syndrome/
- Hand Specialist (physician)
- Client is the most important team member; Client’s spouse and family (kids) are also important
members of her team
- Salon owner?

18. Intervention Plan

Barriers Supports

Page 14 of 18 Revised 1/9/17

- Inability to return to work until healed – has a job that is - Motivation to get back to work
highly intensive work for hands - Private insurance to pay for
- Possible lack of strength, endurance or ROM may therapy
contribute to requiring assistance with more complex - Carpal Release Nerve
tasks. Compression surgery –
- Ursula’s motivation to be completely independent in life- hopefully pain/complications
she was dependent on her family/children for household have subsided.
tasks since surgery- it is unclear if she is motivated to be - Cognition appears to be intact
completely independent in life, or if she would prefer to - Support from husband, children
have assistance for some things (i.e. cleaning/maintaining and other family members
her home/living environment)- she has shown motivation - Seeking additional services with
in some tasks though, so motivation could also be a OT/CHT
strength! - Husband’s schedule, husband’s
- Surgical precautions on R hand, decreased function on L job
hand - Kids can help out around the
- Pain, stiffness, weakness and decreased sensation house
- Not wanting to spend time recovering, but wanting to - She can still drive
return to work immediately.
- Difficulty holding tools when wearing pre-fab splint

Goals Practice Model for each goal

1. LTG:
Within 4 weeks, client will improve independence with ADL Biomechanical and PEO
tasks performance, while maintaining safety.

1a.STG:
Within 2 weeks, client will increase AAROM in B Biomechanical and PEO
hands/wrists with Mod A from therapist, to improve
performance in ADL tasks.
1b.STG:
Within 2 weeks, client will independently demonstrate safe Biomechanical and PEO
nerve-gliding technique to perform daily at home.

2. LTG:
Within 4 weeks, client will independently perform IADL Rehabilitation and PEO
tasks while utilizing compensatory strategies and AE for
maintaining safety.
2a. STG:

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Within 2 weeks, client will demonstrate use of functional Rehabilitation and PEO
splint while performing AIDL tasks, with min VPs, and while
maintaining precautions.
2b. STG:
Within 2 weeks, client will perform IADL tasks with Min A Rehabilitation and PEO
while utilizing compensatory strategies and while maintaining
precautions.
3. LTG:
Within 4 weeks, client will independently perform basic hair Rehabilitation and PEO
styling techniques while using AE, compensatory strategies
and maintaining safety precautions.
3a.STG:
Within 3 weeks, client will be able to independently use hair Rehabilitation and PEO
styling tools while wearing a wrist splint for support on L UE
and maintaining precautions.
3b. STG:
Within 1 weeks, client will independently demonstrate Biomechanical and PEO
awareness of post-surgical hand/wrist precautions for RUE
while performing work related tasks.

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19. Treatment Sessions: Plan for first two 45 minute treatment sessions:
1. What will you do? Identify Approaches Based on which
goal(s)?
AROM/PROM/AAROM & NERVE GLIDING Establish/Restore & 1a, & 1b
Prevent
I will use this initial intervention meeting to teach
client how to perform ROM and Nerve Gliding
exercises safely on their hands (or with the
assistance of a family member/caregiver).

I would start by reviewing the surgical precautions

that they are on for their R hand, and depending on
physician’s precautions, will instruct client when
they can begin doing these exercises more
intensively with the R hand. The majority of the
time will be spent today working with her L hand.

After she has a thorough understanding of her

precautions (and we will continue implementing
and talking about these throughout the session),
then I will begin with ROM.

I would like to begin by having her try to mimic the

movements I do with my hand (AROM), when I see
how far she is able to go on her own, I passively
help her continue through her full available range. I
would also like to try AAROM with her, depending
on how her strength and pain is.
(if her pain is too bad, I may implement some type
of PAMS with her prior to manipulating joints).

I would teach her a beginner’s self-ROM or

caregiver assist – ROM to have her practice at
home.

With time, endurance and pain permitting, I would

next like to teach her nerve gliding techniques that
she can perform multiple times of the day to assist
with recovery and improve functional use without
pain for symptoms of CTS. Depending on how she
performed, I would likely send home a print out of
nerve gliding techniques she can practice until our
next meeting, at which point we may add on and do
a more thorough arm ROM and full arm nerve
gliding/stretching.

It is important to remind her not to perform past

pain!

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2. What will you do? Establish/Restore, Based on which
Modify goal(s)?
At the next treatment session, or possibly during the 2, & 2a
second week of treatment sessions (depending on
progress up to that point), I would like to spend a
little time fabricating 2 splints for Ursula. (both of
these splints would be for her Left hand at this
point.)

The first splint would be a splint to support her

hand while not using her hand, such as while she is
sleeping. This splint would be important to
decrease pain to allow for better rest at night.

The next splint I would want to make, is another

wrist support, but I would attempt to form the splint
with holding tools in mind. This splint would be
meant to help with ADL and IADL participation
and performance, but the main goal of this splint
will be to have a functional support to lessen pain
once client does go back to work in few weeks.

I would ask client to bring items/tools that she will

be commonly using with her left hand (both work
related items and home related items). I would then
form the splint to her hand, and periodically re-
warm up splint, while maintaining structural
integrity, in order to also account for being able to
functionally grasp and manipulate objects in a safe
way. I may also add a type of material to the palm
of the splint to provide more grip or some traction
to promote holding items. It would be important to
problem-solve and collaborate with client in the
process to make this splint a success. With time
permitting, I would then have client
perform/practice some of the basic skills she will
need to be able to do.. such as brushing hair.

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