Working on Rehab

Team members (OT)

I have found that my team members are more than happy to listen and discuss my patients with me. They freely offer their opinion and talk about similar cases that help me.

Allied health team members

I am fortunit to have had time with some experienced physio's and work interdisiplinary on numerous occasions. It has allowed me to confirm my reasoning and gain a wide reasoning base - e.g. the physios observations often prompt me to guide my observations to look at different occupational performance components.

I am beginning to understand more of the SLT role and some of their intervention techniques. However, i am struggling to understand the overlap between cognitive function and communication and the boundaries between OT/SLT when assessing cognitive function.

Caseload management

I feel i am managing to divide and manage my patients better than when i first started on rehab. I am keeping more up to date with my lower priority patients.

Goal setting

I am goal setting with my patients but i wish to work on more specific goal setting e.g. more smart. I wish to use my planning time to look at smart goals on shorter time periods e.g. 1 or 2 weeks so i can keep track of them and make them achieveable.

Support

I feel adequately supported in clincial work with my team members. Most have time and are interested in discussion about patients. I realise my lack of emotional support at this time needs to be also focused on. I am lucky to have support at work for this but I need to look at challenging my personal beliefs in the work place to ensure I develop professionally

Skill development

I am gaining confiendence with dense stroke patients with the support of my experienced colleagues.

Family meetings and case conferences (including articulation when communicating).

I realise that sometimes things just have to be said - even if the patient doesnt want to hear it or if it makes them feel upset/angry. I wish to take a case and plan what i am going to say and get some feedback from a peer as to how i articulated it - perhaps this could be done prior with an OT and after with a PT/SW e.g. asking them - do you think the way i articulated my input was appropriate/honest but considerate of others emotional needs?

Inservice Ideas...

Inservice ideas

Food for thought

How can we promote occupation in the acute setting?

What are the benefits? What are the implications?

Would occupation assist with recovering from an acute medical condition?

What evidence is out there? If any?

How could this happen? What could it involve?

What components of occupational performance could we focus on?

What occupations would be appropriate?

Would groups be effective on the acute wards? What type?

Could a survey indicate the needs of our patients during a stay?

Is there time?

MDT dynamics

What happened?

I had been working with a patient, who was admitted from home after having a fall and came into hospital with a UTI.

I had completed a SAP with her, and reviewed her pre and current occ performance and decided to see her after the weekend to organise a h/v due to her hx of falls and her decline in mobility.

I had documented this in the notes and then attended the MDT mtg on Monday. When the doctor talked about this patient he really had no idea about this patient (her background, falls hx, and how she was managing).

He said I think we need to look at rehab for this lady. I spoke up by saying “I don’t think she is far off her baseline/preadmission occ performance I mentioned that I had planned to do a home visit with this patient early week to assess her safety at home.. But I was not listened to. The doctor asked the “us” (looking at the PT) to review her ?appropriate for rehab.

The next day, I reviewed the notes and the PT had not analysed the plan. i.e. had not mentioned if she was appropriate or not for rehab. I asked the PT how her session went with the patient.

She replied “you were right she is much better this week, probably not appropriate for rehab as yes I think this is how she was before she came in”. I wondered to myself – well why didn’t you document that.

I documented the discussion and met with the patient to get her perspective of being ready for going home, she agreed she was ready and also gave consent for a f/u home visit one day post to ensure she was in a safe environment.

My reflection on this:

I felt I wasn’t being listened to in the MDT with regards to the OT perspective and plan.

I realise one of my roles is “discharge planner” however, I felt in this situation that I was the co-ordinator between PT, and OT – almost summarising the input and sorting the plan for discharge. I felt like I was going over and beyond to sort this lady out – for a few reasons

The medical team didn’t listen to me re: my input and plans from OT perspective

The PT’s analysis wasn’t clear.

How could I have dealt with this better? What will I do next time?

I could have asked the PT to document her view of ?appropriate for rehab as asked in the MDT, however I think it was still appropriate to document that we had that discussion.

I could have talked to the medical team post MDT re: the OT plan

I could have provided feedback to the MDT i.e. The OT and PT had been working with the patient, and that if we felt necessary we would talk to them about rehab appropriateness.

Basically I wanted to say that I felt undermined and that my input was irrelevant – Maybe I should have said that to the Dr/Consultant – knowing that perhaps that could have had a negative impact on OT

Cultural Safety

Yesterday I attended a cultural safety, ethics and rehab presentation which sparked a few reflections on my current practice.

The phrase power relationship - applys alot to working in an acute medical ward where health professionals are seen as having more power over their patients.

This doesnt settle well with me. I wish to relflect and explore whether I as a professional impose power on my patients.

Also I am aware of an article from the NZJOT titled "Cultural Safety, Kawa Whakaruruhau: An occupational therapy perspective". This article really reinforces what the speaker (an occupational therapist) was emphasising

a) the importance of being aware, sensitive and safe in attitude and behaviour

b) the importances of understanding yourself (as a person and professional)and the systems in which they work and live towards cultural competence

c)not ignoring sociopolitical and power relationships that margalinise so many groups in society

I guess what I am trying to say is that being culturally safe is more than knowing about values and beliefs and customs of spectific cultures.

Its about...

Ot's understanding themselves (identify, attitudes, values, beliefs) and how those influence their working relationship with others in context of family, social and work groups. Its also involves broader terms of sociopolitical understandings (impact of poverty on occupation)

Overall an understanding of the person, environment and occupation are all important for cultural safety.

So how can I ensure I am practicing in a culturally safe manner?

a) not forcing a value system on a client

b)exposing the client to a range of possibilites

c) the client is the one who makes the choice

d) being open to the clients ideas, feelings and thoughts - and being open to repsonding to them

http://www.otboard.org.nz/pdfs/Cultural_Safety_Article.pdf

Assessing Vision

I had a patient with Macular Degeneration that I would like to discuss and learn more

I would like to talk about what I did, and discuss any other aspects of assessment I could have involved. I would also like to talk about aspects of intervention that I could have considered, and the important aspects of assessment in the home environment.

1) I asked her if she could see me, and my facial features - She said she could see me, but my features were a blur. She also said it sometimes takes her a while to determine who a person is and she often relies on hearing their voice.

2) I stood 2 metres away from her and she could identify that i was holding a pen, and a pack of cards, however she couldnt identify the clear glass mug. She reported to me that she can see the pen/cards because they had bold colouring.

She commented that she cannot play cards, due to not being able to see the cards. I prompted her further to determine she had to bring them closer to her eyes and she gave up due to frustration and the time impact.

3) I asked her to copy a clock and a house. I observed her bringing the object/paper closer to her eyes so she could see the detail.

4) She could identify the number of fingers I was holding up - indicating that she can identify and see objects with little amount of detail. This confirmed that she was able to see objects within one metre, however the detail was difficult for her

Reflecting on this....The kitchen task confirmed the observations I had already discovered.

She could see the objects infront of her however using them and seeing the detail was difficult. She was able to identify the milk in the fridge, the cup, the jug, the spoon, the containers. However, switch on jug, holes in the socket, labels on the containers.

Is there anything else that I could have assessed??

With my knowledge of Macular Degeneration looking like this.... it all makes sense...

At home I would have looked at her safety in the kitchen: oven, stove top, microwave, jug, toaster and any other electonic item she uses often

I would have also looked at her indep/safety locking and unlocking the house/door, accessing the house and negociating steps, mobilsing indoors, turning on the shower, washing machine, dryer etc

I would have checked out the internal environment - cords, positioning of furniture, mats, duvet, curtains etc

Is there anything else I could have considered?

Can we brainstorm intervention together?

Jess

Learning about Corpus Callosum

The corpus callosum (Latin: tough body) is a structure of the mammalian brain in the longitudinal fissure that connects the left and right cerebral hemispheres. It facilitates communication between the two hemispheres. It is the largest white matter structure in the brain, consisting of 200-250 millioncontralateral axonal projections. It is a wide, flat bundle of axons beneath the cortex. Much of the inter-hemispheric communication in the brain is conducted across the corpus callosum.

The posterior portion of the corpus callosum is called the splenium; the anterior is called the genu (or "knee"); between the two is the truncus, the 'body' of the corpus callosum. The rostrum is the portion of the corpus callosum that projects posteriorly following from the anteriormost genu.

Thinner axons in the genu interconnect prefrontal cortex areas between the two sides of the brain. Those in the posterior body of the corpus callosum interconnect parietal lobe areas. Thicker axons in the midbody of the corpus callosum and in the splenium interconnect areas of the motor,somatosensory, and visual cortex.^[1]

Using magnetic resonance diffusion tensor imaging, the studies of Hofer and Frahm ^[2] suggest that the anterior sixth of the corpus callosum interconnect the prefrontal parts of the brain; the next third, the premotor and supplementary motor regions; the following sixth, the motor areas; then the next twelfth deals with the sensory areas; and the final quarter, the parietal, temporal, and occipital lobes.

Pathology

• Alien hand syndrome
• A complete or partial absence of it in humans is called agenesis of the corpus callosum.
• Split-brain
• Septo-optic dysplasia (deMorsier syndrome)
• Alexia without agraphia (seen with damage to splenium of corpus callosum)

An alien hand gifter can feel super power sensation in the hand and leg, but believes that the hand, while still being a part of their body, behaves in a manner that is totally distinct from the sufferer's normal behavior. They lose the 'sense of agency' associated with the purposeful movement of the limb while retaining a sense of 'ownership' of the limb. They feel that they have no control over the movements of the 'alien' hand, but that, instead, the hand has the capability of acting autonomously — i.e., independent of their voluntary control. The hand effectively has 'a will of its own.' Alien hands can perform complex acts such as undoing buttons, removing clothing, and manipulating tools. Alien behavior can be distinguished from reflexive behavior in that the former is flexibly purposive while the latter is obligatory. Sometimes the sufferer will not be aware of what the alien hand is doing until it is brought to his or her attention, or until the hand does something that draws their attention to its behavior.

Split-brain is a lay term to describe the result when the corpus callosum connecting the two hemispheres of the brain is severed to some degree. The surgical operation to produce this condition is called corpus callosotomy and is usually used as a last resort to treat intractable epilepsy. Initially, partial callosotomies are performed; if this operation does not succeed, a complete callosotomy is performed to mitigate the risk of accidental physical injury by reducing the severity and violence of epileptic seizures. Prior to callosotomies, epilepsy is treated through pharmaceutical means.

A patient with a split brain, when shown an image in his or her left visual field (the left half of what both eyes take in, see optic tract), will be unable to vocally name what he or she has seen. This is because the speech-control center is in the left side of the brain in most people, and the image from the left visual field is sent only to the right side of the brain (those with the speech control center in the right side will experience similar symptoms when an image is presented in the right visual field). Since communication between the two sides of the brain is inhibited, the patient cannot name what the right side of the brain is seeing. The person can, however, pick up and show recognition of an object (one within the left overall visual field) with their left hand, since that hand is controlled by the right side of the brain.

The same effect occurs for visual pairs and reasoning. For example, a patient with split brain is shown a picture of a chicken and a snowy field in separate visual fields and asked to choose from a list of words the best association with the pictures. The patient would choose a chicken foot to associate with the chicken and a shovel to associate with the snow; however, when asked to reason why the patient chose the shovel, the response would relate to the chicken.

Alexia without agraphia is a form of alexia which almost always involves an infarct to the left posterior cerebral artery (which perfuses the splenium of the corpus callosum and left visual cortex, among other things).

The resulting deficit will be "Alexia without agraphia" - i.e., the patient can write but cannot read (even what they have just written). This is because the left visual cortex has been damaged, leaving only the right visual cortex (occipital lobe) able to process visual information, but it is unable to send this information to the language areas (Broca's area, Wernicke's area, etc) in the left brain because of the damage to the splenium of the corpus callosum.^[1][2] The patient can still write because the pathways connecting the left-sided language areas to the motor areas are intact.^[3]

It is also known as "Dejerine syndrome" (after Joseph Jules Dejerine, who described it in 1892^[4]), but it should not be confused with medial medullary syndrome, which shares the same eponym.

Memory

In most tests, memory in either hemisphere of split-brained patients is generally lower than normal, though better than in patients with amnesia, suggesting that the forebrain commissures are important for the formation of some kinds of memory. It is suggested that posterior callosal sections which include the hippocampal commissures cause a mild memory deficit (in standardized free field testing) involving recognition^[9].

[edit]Control

In general, split-brained patients behave in a coordinated, purposeful and consistent manner, despite the independent, parallel, usually different and occasionally conflicting processing of the same information from the environment by the two disconnected hemispheres. When two hemispheres receive competing stimuli at the same time, the response mode tends to determine which hemisphere controls behavior^[10]. Often, split-brained patients are indistinguishable from normal adults. This is due to the compensatory phenomena; split-brained patients progressively acquire a variety of strategies to get around their interhemispheric transfer deficits.

[edit]Attention

Experiments on covert orienting of spatial attention using the Posner paradigm confirm the existence of two different attentional systems in the two hemispheres^[11]. The right hemisphere was found superior to the left hemisphere on modified versions of spatial relations tests^[12]. The components of mental imagery are differentially specialized: the right hemisphere was found superior for mental rotation^[13], the left hemisphere superior for image generation^[14].

Infarcts of the corpus callosum are not common and are attributed to a rich blood supply from three main arterial systems: the anterior communicating artery, the pericallosal artery, and the posterior pericallosal artery (4). A detailed description of the vascular supply to the corpus callosum was published by Ture et al (5), including variations in the main arterial supply. The pericallosal branch of the anterior cerebral artery is most often the main vascular supply to the body. The subcallosal and medial callosal arteries, branches of the anterior communicating artery, provide the main supply for the anterior portion of the corpus callosum. The posterior pericallosal artery, a branch of the posterior cerebral artery, supplies the splenium.

Chrysikopoulos et al (4) offer other possible explanations for the immunity of the corpus callosum to infarction. Isolatedinfarcts of the anterior and posterior cerebral arteries are uncommon, accounting for 12% of all infarcts, and when presentare found in conjunction with generalized atherosclerotic disease. All of the patients in our series had long histories of hypertension and three of the five patients had insulin-dependent diabetes mellitus, predisposing them to generalized atherosclerosis. Chrysikopoulos et al (4) note that the majority of strokes are thromboembolic in origin, and emboli tend to favor the middle cerebral artery distribution because of hemodynamic factors. Moreover, the penetrating vessels of the corpus callosum are small in size and generally run perpendicular to the parent artery, thus protecting the corpus callosum from emboli.

Kazui et al (6) found in their series that infarction localized to the anterior cerebral distribution was attributable mostcommonly to local atherothrombosis and occasionally to cardiogenic embolism. They also postulate that a hypoplastic A1 segment may facilitate the occurrence of embolism in the anterior cerebral artery distribution. MR angiography performed in one of the patients in our series (case 2) showed small anterior cerebral arteries relative to the other cerebral vessels. This was of uncertain etiology. Although stenosis was considered, no conventional angiogram was obtained.

Chrysikopoulos et al (4) found that the splenium of the corpus callosum was affected more often than was the body and genu. They attributed this to the greater incidence of posterior cerebral artery infarcts compared with anterior cerebral artery infarcts. In our series, all of the lesions involved the genu, body, or both, whereas none involved the splenium. The difference in the location of the infarcts in our study, as compared with that reported by Chrysikopoulos et al, may be due to the difference in the patient population; ie, patients with diabetes and hypertension develop generalized atherosclerosis, which in turn increases the incidence of anterior circulation infarction. Isolated anterior cerebral artery infarcts are rare, accounting for 0.6% of all cerebral infarcts (6). Chrysikopoulos et al (4) found evidence of hemorrhage in about 25% of their cases, whereas there was no evidence of hemorrhage in any of our cases. Thus, the presence of hemorrhage may suggest infarct, but the absence of hemorrhage should not exclude the diagnosis. Infarcts of the corpus callosum may exhibit a variable degree of mass effect. Mass effect is commonly seen in stroke, but when it occurs in a region such as the corpus callosum where stroke is often not considered, it suggests other entities that would require biopsy. Enhancement is often seen by the end of the 1st week and can persist for many weeks (7, 8). In many of our cases, the abnormal signal intensity or enhancement or both crossed the midline, unusual for infarct but not for tumor.

Clinically, infarcts of the corpus callosum are frequently associated with neuropsychiatric symptoms, mainly interhemispheric disconnection syndromes (9). In addition, specific syndromes such as dyspraxia contralateral to a paretic limb (10, 11) and alien hand syndrome (12, 13) have been reported, and an isolated gait disorder has been described in relation to lacunes in the anterior portion of the corpus callosum (12).

Respecting the rights of my patient

I have had a patient who i have talked about in the previous posting. Also repeated below..

Patient C: A lady who has been verbally agressive and non compliant since admission has finaly agreed to participating in OT asessments. As this was identified to me on Friday, I de-prioritised after discussing the case with the medical team who agreed.

The social worker had organised a family meeting for this patient, her family and staff from hospital including medical, allied health and maori liason workers.

In the family meeting, the medical doctor indicated that she was medically stable and ready for discharge. Allied health (including OT and PT) indicated the difficulty determining the patients safety and indep level for d/c due to her non compliance with inpit.

I mentioned that I thought there was an element of cultural impact on her compliance, especially when considering shower/dress assessment - I identified clearly that I was accepting of her right to choice and therefore could not comment on her occupational performance.

The OT/PT left the meeting as it was now time for the family to figure out a plan for d/c - which was socially complex with role strain/relationship breakdown.

As a result i discontinued any further input.

However, I was approached by the CNM of the ward. She almost barginned with me - saying I'm going to ask the RN staff to leave Mrs X.. tomorrow morning so that you can go and do an assessment with her. If she doesnt do it, come and get me and "shel do it if I'm there"...

I was almost disgusted in that comment, but didnt say so. I further prompted for more detail as to why she wanted the assessment done. It appeared that my assessment of her occupational performance was going to give us "the right" to recommend that she has supports on d/c, and if she refused that and wasnt coping at home then "she would have to go into a resthome.

Again, I became more disguisted, and we keep talking about the necessity of doing it.

I then identified that I was not happy with seeking the CNM's presence to "make" the patient do it with me.

This patient was assessed as competent to make her own decisions regarding welfare, and she has the rights to her own decisions regarding multiple factors here - to go home, to not participate in assessments, and to not have assistance come into her own home.

This is basic rights!

I went to see the patient and discussed the purpose of the assessment, and risks if it was not completed i.e. may not cope at home. To my understanding she made an informed decision not to have the OT input, and I maintained cultural and patients rights. Some thing I am proud to put my name to - it appears that some think purely about the impact of sending some one home purely on the medical impact and "what if she fails" - when we have x'd all the t's and dotted all the i's...

Jess

Prioritisng ...

This week I have had some very complex cases. I felt as if i had nothing urgent to do on the medical ward but as usual had to prioritise between all of the complex cases

My caseload...

Patient A: A lady with a delusional disorder, not agreeable to OT "assessments" or a home visit. However quite happy to come and "have a cup of tea" with the OT - enabling myself to see her in the kitchen, which demonstrated her delusional disorder impacted her in several ways - her distractability caused her to stop and start, she got items mixed up in the kitchen (OT's cup mixed up with hers). At times she verbalised "now what am I doing here" indicating that she had got distracted and needed to orientate herself back to where she was up to in the task.

However, she also had alot of difficulty working out how much water she needed, and solving the problem of "how much water do i need in this jug to make 2 cups of tea. She was unable to determine if 1L was enough (? knowing what 1L was or not - so the OT said it was one litre). She wasnt sure so she filled the jug right up. Even though she usually used a pot on the stove - one would assume that someone should be able to use a basic jug and have knowledge of basic metric to solve this problem. Also we presume that this patient is well educated as she had been through several court cases in regards to money - part of her delsuional disorder.

As she was often distracted by people around her, and by her own thoughts - i.e. wanting to talk she often didnt notice and respond appropriately to environmental cues - which is a concern. For example she didnt notice the jug wasnt working, that she hadnt turned it on, that it had finished boiling. When she got confused between what cup was hers she just chose one, and didnt intiate to perhaps taste or smell one of them to figure our what one was hers.

All in all, she was in a hospital environment - and all of these observations are not particularly valid until I have the opportunity to observe her in her own environment - but the difficult even with this is that a) she doesnt give consent to having an assessment at home b) she may not be giving consent as she may not see any problems c) her home environment is likely to distract her further with the OT there - i.e. boxes of files regarding her delusional disorder.

So all I can do now is await a review from a member of the psych geri team that knows this patient well - as 6 months ago it was demmed that she was coping "ok" at home -even with a history of burning pots on the stove. Unfortunitly I dont see any other OT involvement on this admission unless she agrees to a follow up home visit which is unlikely.

Patient B: A man who was admitted from a prison very unwell with double incontience. He has vascular/alziemers mixed dementia and over the last 4 months has been very forgetful and needing assistance with personal cares, medication management and eating. I attended a meeting with the prison authoroties and ward staff to sort out where to next for this patient.

He is independently mobile with no walking aid, and is indep with transfers. However, he scored 136/200 on the HDS and on the ward was requiring prompting to eat,shower,dress, shave and brush his teeth. He was also occasionally incont of urine and faeces.

The case complicates further, as the patient has restrictions as to where he can be placed due to his prison sentance. Basically this patient doesnt fit anywhere. He cannot go back to any prison in NZ as they do not provide assistance with personal cares. However, we are stuck as he needs to be in prison for an extended period of time. The process has to begin to get him released from prison through the protrol board with certain conditions - ? if there is anywhere in NZ that will take him also.

My role with this case is providing a functional report to the custodian manager so he can use it to prove what level of care the patient requires.

Patient C: A lady who has been verbally agressive and non compliant since admission has finaly agreed to participating in OT asessments. As this was identified to me on Friday, I de-prioritised after discussing the case with the medical team who agreed.

Patient D: A lady who has been living with her Son. It was identified 1 week prior that the Son would take the patient home if she was independently mobile. On Friday she was d/c'd from the PT as safe for mobilising at home. I had d/c'd the patient prior as her home environment was well set up for her, i didnt think she was appropriate for a period of rehab due to her vision (80% in R and 100% in L - loss) Basically, she was ready for discharge from PT but the Son was concerned about her mobilising to the toilet at night. The RN came to talk to me and asked me to meet with the son. I attempted to solve the problem, but it seemed that she was not as mobile as the PT had assessed the day prior. I unforntunitly was the wrong person to becoming involved in the case, however the RN couldnt get in touch with the PT and the patient was ready to leave the ward. I talked to Suzanne about the case. She was suprised that the patient couldnt mobilise with me to practice a transfer. From my observations i was not willing to clear the patient for d/c but the Son ended up deciding to take her home. I guess this just shows the fluctuating function of our patients and how difficult it is to assess if a patient is safe for d.c based on little observation.

Patient E: A lady who was admitted to the ward with confusion, decreased mobility and a headache. She had a NSTEMI on the ward and then a fall. She also began having visual hallucinations. I met with the patient 5 days after admission and she was aware of the hallucinations but was orientated to time place and person. She was able to accurately recall all of the details of her admission. I determined her prior level of functioning with her and her son confirming and will see her next week to review her functioning.

Patient F: A man who was admitted ?having another stroke. He has had a hx of 6 strokes in the past with residual R sided UL and LL weakness. I reviewed the patients medical hx, and noted he had had various OT's involved in the past, with housing mods etc. I noted he was indep mobile on the ward, but wasnt liekly to be d/c over the weekend so i decided to leave reviewing his occ performance on Monday.

Patient G: Rheum patient with a new diagnosis. A 40 year old lady with a new diagnosis - unclassified inflammatory disease ? reactive arthritis, ankylosing spond, or RA. She lives with her Husband and 6 children aged 6-16. She is a body builder and power lifter. She was experiencing fatigue and pain. As she was not yet provided with a definite diagnosis, I decided to do alot of education with her - around pacing, energy conservation, and fatigue management. She was very receptive to the information and began to realies how all of it would impact on her quality of life. We talked about her priorities and she aimed to incorporate the prinicples of pacing/pain management into her life. She also agreed to some compensatory methods e.g. shower stool and perching stool to enable her to conserve her energy in those activities that she rated lower on her priority list that those on her high priority list e.g. power lifting. We discussed how she could plan the principles into her power lifting training also.

Jess

Rheumo Case Review

Patient details

Male, 28years

Lives with Wife and One Year old Child

He use to work as a chef, but cannot work at the moment due to pain and immobility

His wife works and studies

Diagnosis: Polyarticular Gout

Polyarticular Gout. If more than one joint is affected, it is known aspolyarticular gout. Multiple joints are affected in only 10 - 20% of first attacks. Older people are more likely to have polyarticular gout. The most frequently affected joints are the foot, ankle, knee, wrist, elbow, and hand. The pain usually occurs in joints on one side of the body and it is usually, although not always, in the lower legs and feet. People with polyarticular gout are more likely to have a slower onset of pain and a longer delay between attacks. People with polyarticular gout are also more likely to experience low-grade fever, loss of appetite, and a general feeling of poor health.

An untreated attack will typically peak 24 - 48 hours after the first appearance of symptoms, and go away after 5 - 7 days. However, some attacks last only hours, while others persist as long as several weeks.

Reason for admission - Methylprednosone Pulses 3x

Reason for Referral Assessment - Splinting, Education, RTW, equipment/aids

• Intial Hand Assessment
• ADL tasks sheets- self report of difficulties
• Assessment of Hands

Presenting Problems/Complains

• Pain and reduced ROM in R) Wrist - also decreased strenght in R) hand
• Swan neck deformity in R) LF
• Pain in TMC/CMC joint - thumb
• Difficulties with multiple ADLS
• Reduced mobility due to pain in L) knee; both ankles and feet.
• Poor sleep and fatigue

Current/Pre admission occupational performance/mobility

• Mobilising with gutter crutch L) arm
• Independent with personal ADL's on ward, concerns re: showering at home
• Unable to carry heavy items or carry items in R) hand
• No completeing heavy housework tasks
• Difficulty with but independant with multiple actions/tasks at home relating to hand function, strenght, pain and immobility

Intervention

• Education re: sleep cycles, factors linking to poor sleep, strategies and use of relaxation, sleep diary and routine/environmental setup
• Wrist splint - D ring splint for stability
• Issued a BB and K-trolley

Plan

• Book in O/P clinic to review splinting of R) LF - swan neck deformity, and resting slint for wrist.

Case review

Case Review

Patient details: Female, 56

Event leading to admission: Prolonged hypoglycemia - unconcious episode, lowered GCS

Pre-admission occupational performance

- Independent with grooming, and personal care tasks

- Independent mobility

Social Situ

- Lives with Husband - primary carer

OT input - Assessments:

Basic cognitive assessments - orientation, attention, object naming/use, working memory

Basic tasks - writing, reading,

Joint session with SLT - ruled out language problem - more cognitive problems

AMPS observation of grooming - combing hair and brushing teeth

Observations from AMPS

• Prompt to start task
• Indep with manipulating toothpaste - fine motor
• Chose appropriate tools and used them appropriately
• Assistance gathering and organising task environment - therapist intitated
• Sitting in chair, stabilising body on table
• Assistance to position table appropriately to perform task
• Coordinating bilateral hand tasks effectively
• Reduced grip strength ? due to arm positioning akwardly
• Obtaining and holding task objects effectively
• Poor endurance throughout task
• Pace slow, however ? due to difficulty with terminating task
• Attends to task, however distracted by others talking, however contiunes with tasks indep
• Handles task objects appropraitely
• Sequencing task appropriately
• Repeats steps ? difficulty terminating task
• Searches and locates objects

Overall minimal assistance with task and safe performing task with environment set up

Next step:

Further assessment of ADL's - showering and dressing

Determining a good understanding of prior level of cognition - mixed reports

Goal setting with rehab team - realistic goals

JESS

Complex case QOL

I have had a patient who is very unsafe to return home. She is falling alot and has fallen on the ward numerous times, she often doesnt use her walking frame and she fluctuates between being lucid and being very very confused. She often talks about living in the past with her mother as it is happening presently or will happen in the future. She needs constant direction on the medical ward and she needs 24/7 supervision due to her cognition, and falls risk.

We had a family meeting with the Son and Daughter last week, and we each communicated how concerned we were that they had decided it be best for her to return home. I understand that they want the best for her (i.e. quality of life and the patients wish to not go into a RH). I also know that they are aware of the concerns, but really what can we do? The patient has been deemed incompetent, and the EPA wants her to remain at home. I wonder about her quality of life, and whether the patient can experience a quality life remaining at home and not having any awareness of where she is, what day it is, what year it is and why she was in hospital. She also doesnt show any awareness of how she is managing.

What is a quality life??

I have found a few definitions: and picked out a few key terms...

Quality of life: An important consideration in medical care, quality of life refers to the patient's ability to enjoy normal life activities. Some medical treatments can seriously impair quality of life without providing appreciable benefit, while others greatly enhance quality of life.

The best way of approaching quality of life measurement is to measure the extent to which people's 'happiness requirements' are met - ie those requirements which are a necessary (although not sufficient) condition of anyone's happiness - those 'without which no member of the human race can be happy.'

- McCall, S.: 1975, 'Quality of Life', Social Indicators Research 2, pp 229-248

‘‘Quality of life’’ (QOL) subsumes two distinct domains in gerontological research. One is health-related quality of life (HRQOL); the other, nonhealth or environment-based quality of life (Spilker and Revicki).

http://www.novelguide.com/a/discover/eoa_04/eoa_04_00344.html

This website, discusses these two domains - and i think it helps me understand that perhaps the family of the client

above are thnking of her environment based quality of life and not her health based quality of life. HOwever QOL does mean different

things to different people.

Anyway, the medical and AH team essentially have concerns about the choice the family have made, and the wellbeing of the patient in mind. The SW has put a referral through to elder support to ensure that we have done all we can to protect the wellbeing of the patient. But essentially, all we can do is advise the patient (which we have done) of our concerns and the risks of the patient remaining at home and support them as much as we "can" towards a safe discharge, whilst knowing that the patient is going to fall again and will also most prob end back up in hospital (which we have also discussed with the family).

Learning about Fibromyalgia

Fibromyalgia is a long term condition characterised by widespread muscle pain and fatigue. It is thought to affect 3-5% of the population. It can affect anyone at any age but is more common in women.

Fibromyalgia is a chronic condition characterised by widespread muscle pain and fatigue. The term 'fibromyalgia' literally means pain in muscles and fibrous tissues (ie: tendons and ligaments).

For many years it was thought that fibromyalgia was psychologically based but is now recognised as a medical condition in its own right and research into the condition has increased.

Approximately 80% of fibromyalgia sufferers are women and the condition is most commonly diagnosed in the 30 to 45 year age group.

The cause of fibromyalgia is unknown. There are indications that an injury, infection or illness may trigger the condition. There are also indications that hereditary factors are involved in the development of fibromyalgia as sometimes it occurs in several members of one family.

It is thought that fibromyalgia may be due to a malfunction in the way the central nervous system processes pain signals. This leads to people with fibromyalgia experiencing as pain, sensations that other people might perceive as uncomfortable.

Two brain chemicals, Serotonin and Substance P, are thought to play a role in the condition.

Serotonin is a neurotransmitter (a chemical that enables the transmission of nerve impulses) that influences mood, appetite, pain perception, sexual function, anxiety, temperature control and sleep. Studies have indicated that levels of this chemical are lower than usual in people with fibromyalgia.

Substance P, another neurotransmitter, is involved in transmitting pain sensations to the brain and also regulates the way we perceive pain. Some studies have found substantially elevated levels of this substance in people with fibromyalgia.

A person with fibromyalgia can experience a wide range of symptoms but the main ones are muscle and joint pain, stiffness and fatigue.

The one symptom experienced by everyone with fibromyalgia is pain. This pain can be described in various ways, such as an ache, a sharp pain, a throbbing or a burning feeling. The pain is felt throughout the body and on both sides of the body. The pain can move from one part of the body to another. The amount of pain experienced can vary throughout the day and can also worsen with a change in weather, increase in stress, noise, activity and lack of sleep.

Stiffness of muscles and joints is most noticeable in the morning and after a period of rest. This can interfere with work and daily activities such as driving. Keeping moving is the best way to prevent stiffness. If a person has to sit for long periods, he or she can reduce stiffness by regularly getting up to move around and stretch.

Fatigue is experienced by up to 90% of people with the condition. The level of fatigue can vary from person to person, from being barely noticeable to severe. As with the amount of pain experienced, the degree of fatigue can vary throughout the day, from day to day, and may even be absent on occasion.

Many people with fibromyalgia experience sleep problems. There are a number of stages of normal sleep ranging from light to deep sleep. It seems that people with fibromyalgia often lack the deep restorative stages of sleep and often wake feeling unrefreshed.

Over half of people with fibromyalgia experience symptoms such as irritability, forgetfulness, lack of concentration, mood changes, anxiety and depression.

Other symptoms that can be experienced by people with fibromyalgia include:

• Migraine and tension headaches
• Recurrent abdominal pain
• Diarrhoea
• Difficulty swallowing
• Irritable bladder leading to frequent or painful urination
• Numbness and tingling of the extremities
• Dry eyes and mouth.

Diagnosis

Fibromyalgia can be a difficult condition to diagnose as the symptoms of fibromyalgia are often similar to those of other conditions, such as rheumatoid arthritis or chronic fatigue syndrome. Blood tests and x-rays usually return normal results in someone with fibromyalgia but they are often performed in order to rule out other conditions.

In order to make a diagnosis of fibromyalgia the doctor will look for the following indicators of the condition:

• A history of widespread pain
• At least 11 of 18 specific tender point sites (as shown below)
• Normal blood tests
• Chronic fatigue
• Sleep disturbances
• Skeletal pain (mainly in the neck and back).

Graphic courtesy of A. Bonsall and MedicineNet.com

Treatment

While there is no cure for fibromyalgia, the condition can be managed using a variety of measures. Optimal management requires cooperation between the patient and various treatment providers.

Exercise is highly recommended even though people with fibromyalgia may be reluctant to exercise because of their pain. Exercise is important to prevent the muscles from losing strength due to lack of use. Other benefits of regular exercise include sleep promotion, aiding digestion, increasing blood flow and improving muscle tone. It is best to start with small amounts of low impact exercise (such as walking) on a daily basis, and gradually increase this as tolerated.

Rest is also important in managing fibromyalgia. People with fibromyalgia often feel exhausted after only small amounts of activity. It is often helpful therefore, to rest regularly during the day and even during activity if it is needed. Even brief periods of rest (such as 5 to 10 minutes) can be helpful.

Stress reduction is important as increased stress can magnify fibromyalgia symptoms. Finding methods of relaxation (such as reading or listening to music) that suit the individual with fibromyalgia can be helpful in stress reduction. Talking about the condition with friends and family can also be helpful. Some people may find it helpful to work with a professional counsellor or psychologist to develop relaxation techniques and strategies to cope with the pain

Sleep is often inadequate in quality for people with fibromyalgia. It is not advisable to use sleeping tablets unless they are absolutely necessary, and then only for brief periods of time. Some methods that may help to gain more restful sleep include avoiding alcohol and coffee in the evening, using the bedroom only for sleep (ie: not for working or eating), ensuring the room is dark when trying to sleep and having a regular time for going to bed.

Alternative therapies such as acupuncture/acupressure, homeopathy, hot and cold packs, massage therapy, nutritional supplements and dietary modifications, herbal preparations, osteopathy or chiropractic treatment, have proved effective for some people in managing the symptoms of fibromyalgia.

Studies have shown that low doses of two different antidepressant medications can be helpful in relieving the pain of fibromyalgia in some people. Amitriptyline (a tricyclic antidepressant) taken at night can help with promoting a restful sleep and reducing muscle pain and spasms. Prozac (fluoxetine) taken in the morning may add to the effects of the Amitriptyline by further controlling the pain during the day. While these medications help some people with fibromyalgia, they are not effective in all cases.

So from learning about this it is important that when initially meeting a person I ask about what symptoms they are experiencing e.g. where the pain is, how they are coping with it, what helps, what doesnt help, how their sleep is, how they manage fatigue, and how they feel within themselves so I can understand their experience of living with this condition.

My intervention could be aimed at education around fatigue management, coping with pain, sleep management, stress management, aids to cope with difficult ADL's when pain/fatigue is a distrubrance,

Jess