Running head: OCCUPATIONAL ANALYSIS AND INTERVENTION PLAN 1

Occupational Analysis and Intervention Plan

Emily E. Matthews
Touro University Nevada










OCCUPATIONAL ANALYSIS AND INTERVENTION PLAN 2

Occupational Profile
The Client
The client is a 36 year old married woman who fell at the bottom of her stairs and
fractured her distal radius by landing on her dominant right hand. She recently underwent
surgical repair to address this issue. Since her accident, the client has difficulties with activities
of daily living (ADL) and instrumental activities of daily living (IADL). She expressed that it
took her three times as long to perform activities such as bathing, dressing and personal hygiene.
With this information in mind, the client is considered to be modified independent in these areas
secondary to time. She is the only female in the house and is responsible for cooking, cleaning,
washing, and managing the lives of her two younger children, Jayce and Calvin, ages six and
nine. She works as a regional retail manager in the Las Vegas area for an upscale fashion retailer.
Her job responsibilities include managing all of the operations within her territory, and ensuring
that the stores she oversees meets or exceeds annual revenue goals. She expressed that her job is
very demanding and appearances are very important in the industry she works. She takes pride in
looking her best by having well groomed hair and makeup and wearing the most fashionable
clothes. She works over 40 hours a week and half of her time at work consists of using
electronic devices for communication. These devices comprise of the computer, phone, or I-pad.
The client has been living in Las Vegas for the past fifteen years and has built a support
system based on local friends and her husbands side of the family. She is originally from
Tennessee, and moved to Las Vegas for work purposes. Her husbands side of the family lives
in the Summerlin area and visits her home every weekend to enjoy her southern cooking. She
usually cooks a big feast that feeds around 10-15 people. After her injury, she can longer prepare
the large family meals without assistance. She expressed that she enjoyed scrapbooking, cooking
OCCUPATIONAL ANALYSIS AND INTERVENTION PLAN 3

and walking her two dogs for exercise. Both of her children are very active into sports, and she
attends their weekend soccer and basketball games with her husband. She is often responsible for
taking her children to school and to soccer and basketball practice. She wants to implement yoga
into her daily exercise regimen, but currently her injury is preventing her from achieving this
goal. Her husband works in the construction business and usually works long hours seven days a
week. She exclaimed that she loves her family and wants to get back to her roles and routines she
once did before her injury.
The client is seeking services to address her post-operative surgical repair of her distal
radius secondary to a fall on January 9, 2014. Decreased range of motion (ROM), weakness and
pain in her right hand and wrist have been causing major problems in performing meaningful
activities. The client is concerned with getting back to normal functioning so she can continue
working at her job pain free and being an active mom again. She is concerned with performing
ADLs such as grooming and dressing. She wants to decrease her time it takes to perform
activities such as bathing, dressing, grooming, communication management, home establishment
and maintenance and meal preparation and clean up.
Her husband has been helping her out with dressing tasks by helping her don and doff her
pants and shirts and buttoning and zipping her clothes. Since her husband has a hectic schedule,
he is not always available to help out with dressing. When he is not around, she has to wear yoga
pants to work because of their ease of donning and doffing. He even attempted to apply her
makeup and style her hair, but he was unsuccessful in making her look presentable for work. She
expressed that her husband is not the best makeup artist and hair stylist and wanted to get back
into feeling beautiful again to increase her confidence. Her husband has taken over some of her
responsibilities of the home such as cooking some meals, going grocery shopping, and doing the
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laundry since her injury. Being the perfectionist that she is, she wants to alleviate her husband
from these tasks because she feels as though she can do a much better job. The client is excited
to be in therapy and has a positive outlook on her progression towards normal functioning. She
said once her injury heals and her wrist and hands get stronger, she will be able to resume the
roles and responsibilities she once obtained.
Areas of Successful Occupations
The client is successful ADLs such as bathing, eating, functional mobility and toilet
hygiene however she would like to decrease her time to participate in such activities. For IADLs,
the client is successful in religious and spiritual activities and expression, communication
management, driving and community mobility, financial management, health management and
maintenance, child rearing and taking care of pets. Other areas the client is successful are
activities that involve mental functions because her affective, cognitive, and perceptual abilities
were not impaired in the accident.
Areas of Occupation that are Problematic
Areas of occupation that are causing problems are grooming, dressing, home
establishment and management, meal preparation and clean up, and shopping. She has difficulty
primarily with fine motor activities that involve grasping, pinching, opposition, coordination,
joint stability and mobility and power of her right wrist and hand. Also, activities that cause her
to do a lot of lifting and heavy work are problematic as well.
Contexts and Environmental Supports in Desired Occupation
Contexts and environments that support participation and engagement in desired
occupations are physical supports such as her wrist brace and social supports such as her
husband and other family members.
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Context and Environmental Inhibition in Desired Occupations
Contexts and environments that inhibit participation and engagement in desired
occupations are performing tasks that require two hands because of her inability to use her
dominant right hand and wrist. Currently, she is having the most trouble applying makeup,
styling her hair, buttoning and zipping clothing, taking pots out of the oven and turning the key
in the ignition of her vehicle.
Clients Occupational History
The client enjoys spending time with family and being a wonderful wife and mother. She
is the only female in her household and she values her alone time for pampering. She loves to
feel beautiful by styling her hair and applying makeup. She enjoys wearing the latest fashion
styles and looking her best at all times. She enjoys cooking fresh meals for her family and having
her family eat together at the dinner table. She values her independence and has a hard time
asking for help from other members in the household or friends. She considers herself a hard
worker and tries to be the best can be to inspire her children.
Clients Priorities and Desired Outcomes
The client wants to improve her functional abilities, decrease her pain and swelling, and
increase her strength in her right wrist and hand. One of her main priorities is that she wants to
become independent in grooming and dressing tasks. She also wants to be able to cook
independently by lifting pots out of the oven and the turn her key in her ignition of her car
without pain.
Occupational Analysis
Context/Setting of Occupational Therapy Services
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The client received one hour and fifteen minutes of outpatient hand therapy at Matt Smith
Physical Therapy in Las Vegas, Nevada at the Charleston/Rancho location. The clients session
started with an application of a moist hot pack around her right wrist and hand for 15 minutes.
After the moist heat pack application, the client was given a timer and a set of activities to
complete independently for five minutes at a time. Each activity was performed for the purpose
of dynamic skills training to increase the clients range of motion, improve her function, increase
her strength, decrease her pain and to improve her dexterity and coordination.
Clothespins. The first activity she performed was a clothespin activity with resistance up
to four pounds. This activity helped the client with strength and fine motor abilities. In this
activity, the client used her right hand to perform a tip pinch and three jaw chuck pinch to
remove clothes pins from the bottom of the board to the top. The client experienced some
shaking when she got to the more resistant clothespins. Some grimacing of her face occurred but
she completed the entire activity within five minutes.
Dexterciser. The next activity the client performed was the use of the dexterciser. A
dexterciser is a device that exercises and mobilizes the upper extremity or it can be used to
isolate certain joints when exercising. Made out of aluminum and wood, the aluminum of the
dexterciser was twisted in a way that the client had to manipulate a ball from one end of the
dexterciser to the other end. The client was instructed to hold her elbow at 90 degree flexion and
to rotate her wrist without moving her shoulder or arm. The goal of this activity was to exercise
the wrist through isolation to help with functional motion. This exercise helped in achieving
normal purposeful movement in the wrist. The client did a good job with this exercise. She took
her time with manipulating the ball back and forth on the device and using a cylindrical grip
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pattern. The therapist had to interject a couple of times to remind the client not to move her
shoulder.
Rotation Bar. Next, the client proceeded to use a rotation bar for five minutes. The
rotation bar is a device that has a rotating component to help the user with twisting of the fingers.
This device helped with coordination and dexterity of the fingers. The client performed the
activity with some difficulties especially when she tried to use her 4
th
and 5
th
digits.
Wrist Roller. The client then proceeded to use the wrist roller for five minutes. The
wrist roller is a device intended for strengthening the forearm and wrist muscles in a rolling and
pulling motion. It comprises of a bar with a rope attached, which the user rolls and unrolls. The
client had a challenging time rolling and unrolling the device. Throughout the entire five
minutes, she only rolled and unrolled the device eight times.
Theraputty. The client was also given theraputty for a grip activity. The client used the
theraputty for five minutes and made different shapes with the putty including a ball, cylinder,
and a pancake. The theraputty seemed to be very therapeutic for the client. She expressed that the
putty exercises were her favorite because she could do them anywhere, and she could make
different shapes and still work on her grip at the same time.
Power Web. Next, the client used a power web to work on wrist extension and flexion.
The power web is a large web like device that is made out of high quality rubber for strength and
durability. The power web is used for strengthening, dexterity and range of motion.
Passive Range of Motion. The last intervention used was a manual intervention
performed by the therapist. The therapist did passive range of motion (PROM) on the clients
right hand, wrist and forearm for ten minutes. The therapist manipulated the clients wrist in four
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different ways. I observed the client grimacing, sighing, and making unpleasant faces for the
entire ten minutes.
JAS Wrist System. The therapist ended the session by giving the client a joint active
system (JAS) wrist system to implement in her home exercise program (HEP). The JAS Wrist
system helps clients to achieve restoration of joint ROM in 30 minute sessions three times a day.
It is a client controlled device that passively stretches the wrist in flexion or extension in a set
amount of degrees. The therapist educated the client on the proper ways to wear and use the
device at home.
Key Observations from the Performance of the Activities
Overall, the client worked hard by performing all of the activities during her therapy
session. She experienced weakness and pain that caused her to moan, grimace, and sigh
frequently during the performance of various activities. Even though some activities were
difficult for her to complete, she successfully completed all activities in the recommended
amount of time.
Domains of the OTPF are Most Significantly Impacted
The client is seeking services to become functional in ADLs and IADLs. Based on the
observations of the client, domains of the OTPF that are significantly impacting the clients
ability successfully to engage in occupations are personal hygiene and grooming, dressing,
personal device care, home establishment and management, meal prep and clean up, shopping,
and leisure participation. Client factors that are significantly impacted are body functions under
sensory for pain, neuromusculoskeletal, movement related functions and muscle functions. For
performance skills under motor skills, the clients right hand and wrist have difficulty with
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coordination, flow, lifting, stabilization, movement, calibration, reaching, manipulating and
gripping.
Problem List
Problems Relevant to the Client
The client is experiencing many problems from her fracture on her right distal radius. Based
on the clients occupational profile, she wants to be able to apply makeup and style her hair since
her husband is not proficient at those tasks. She does not want to wear yoga pants to work and
wants to be able to wear more stylish pants that she can button. The client also expressed that she
wants to be able to cook again without the assistance of others. Lastly, the client said she wanted
to be able to scrapbook again. The five different problem statements are identified in order of
prioritization based on the clients occupational profile.
1.) Client requires Max (A) in styling hair secondary to decreased AROM in right wrist.
2.) Client requires Max (A) in applying makeup secondary to decreased AROM in right
wrist.
3.) Client requires Min (A) in dressing activities secondary to poor manipulation in right
wrist.
4.) Client requires Mod (A) in cooking with right upper extremity secondary to 6 out of 10
right wrist pain.
5.) Client requires Mod (A) in scrapbooking secondary to decreased strength in right wrist.
Reasoning for Prioritization of Problem List
Problem statement list is prioritized based on clients level of importance. Since
occupational therapy is a holistic client centered profession, it is important to service the clients
needs if it is within the occupational therapys scope of practice. Appearance was very
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significant for the client; therefore hair styling, applying makeup, and dressing are on the top of
the list. Cooking and scraping booking were not as significant, but the client did express that
those occupations should improve once she regains her strength and range of motion back in her
right wrist.
Intervention Plan & Outcomes
Long-Term Goal 1
Client will demonstrate the ability to style her hair suitable for work with Mod (I) using
appropriate styling tools by the 8
th
treatment session.
Short term goal 1. Client will style hair in a way that is appropriate for community
outings with Min (A) using adaptive styling tools within 4 treatment sessions.
I ntervention 1. Client will practice performing hand movements using mirror visual
feedback therapy for 5 minutes. Then client will style hair for 10 minutes in front of a mirror.
I ntervention approach. The most appropriate intervention approach for intervention #1 is
restore. Restoring a clients right wrist movement will enable her to style her hair in a way that is
appropriate for work.
Literature review. According to McCabe (2011), mirror visual feedback therapy (MVT),
is a well-established tool to help clients understand movement and posture. MVT provides real
time visual feedback to assist in the retraining of muscles and enhances motor planning. MVT
has been demonstrated to have an analgesic benefit and improvement in function. In MVT, the
mirror is used as a device to trick the brain into altering a distortion by providing the deception
of a normal body part. Before MVF occurs, the client is told to rehearse imagined movements to
give insight into the function of motor planning pathways. He/she is told to imagine moving the
contralateral unaffected limb first, then to imagine moving the affected side. For this therapy,
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clients position their limbs on either side of a mirror so that the affected limb is hidden from
view on the non-reflective side and the reflected image of the unaffected body part is in the
perceived position of the affected one. This causes the client to believe that he/she does not have
an impairment. This rehab approach allows the client to become less anxious about moving their
affected body part; therefore the clients movement increases, behavior changes and
rehabilitation progresses (McCabe, 2011). This treatment should be done multiple times a day
for no more than 5 minutes at a time. Having the client use mirror therapy prior to styling her
hair will increase the clients occupational performance and self-efficacy.
Outcome. For intervention #1, occupational performance is the outcome to be achieved.
The client expressed she wanted to be able to style her hair in a way that is appropriate for work.
She currently is unable to style her hair due to pain and decreased range of motion. Since there
is a performance limitation present, intervention #1 increases the clients ability to style hair by
using MVT. Clients increased performance is gained through retraining of lost muscle function
and practice. In Yavuzer et al. (2008) research study found that mirror therapy should be used in
addition to conventional rehabilitation program. This was shown to be beneficial in terms of
hand functioning and motor recovery than a similar treatment without mirroring (Yavuzer et al.,
2008).
Short term goal 2. Client will style hair to achieve hairstyle appropriate for work with
supervision requiring less than three verbal cues to accomplish a neat and professional look.
I ntervention 2. Client will use a paraffin bath to warm up muscles for 15 minutes. She
will then style hair wearing a wrist splint for support. She will use a brush, comb, and a low heat
curling iron to style hair. She will add eight curls around circumference her head and apply eight
bobby pins to the base of each curl.
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I ntervention approach. The most appropriate intervention approach for intervention #2 is
modify. To modify the clients ability to curl her hair using a wrist splint will increase
stabilization of the wrist and reduce pain when styling hair.
Literature review. According to Kjeken (2011), hot paraffin baths before a client started
his/her exercise resulted in more significant improvements in grip and ROM than hand exercises
alone. Hand exercises should also include a ROM exercise with flexion of digits 2-5, starting
with flexion of the PIP and DIP joints (like making a small fist). Fingers then should be extended
before making a small fist again (Kjeken, 2011). This motion is very similar to the same pattern
used to curl hair. Kjeken expressed that an occupational therapist should design therapy to
encourage clients to use their hands in daily activities and to help clients maintain important and
cherished activities. Kjeken expressed that using the hands in daily activities is a natural way to
maintain or even improve hand function (Kjeken, 2011). Performing an everyday activity such as
styling ones hair, will help the client not only improve hand function but also increases the
clients efficaciousness and self-esteem which is therapeutic in itself.
Outcome. For intervention #2, participation is the outcome to be achieved. Client will be
engaging in a desired occupation of styling and curling her hair. The client is expected to look a
certain way at work and, therefore, participating in such activity is congruent with expectations
within her professional career. Also participating in a beauty regimen is self-satisfying and
enables the client to feel beautiful, which is one of her main priorities.
Long Term Goal 2
Client will demonstrate the ability to apply makeup on her face with Mod (I) using
adapted makeup brushes by the 8
th
treatment session.
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Short term goal 3. Client will apply makeup suitable for community outings with Min
(A) using adaptive makeup brushes within 4 treatment sessions
I ntervention 3. Client will practice contouring, circling, shading and blending makeup
for 15 minutes to improve functional hand movements using different size gripped makeup
brushes and different mediums. The different mediums include practicing makeup techniques on
paper and on clients face.
I ntervention approach. The most appropriate intervention for intervention # 3 is modify.
The clients ability to use adaptive brushes for better gripping will increase clients ability to
become successful in makeup application.
Literature review. According to studies reviewed by Colaianni (2011), occupation based
interventions can be the therapeutic mechanism through which function is restored. Occupation
based interventions or purposeful activities increased tolerance, active range of motion,
decreased pain, improved function and decreased length of stay (Colaiammi, 2011). Overall
enhanced outcomes transpired when using occupation based interventions or purposeful
activities by increasing repetitions performed, increasing motor learning, improving quality of
movement and decreasing errors (Colaiammi, 2011). Clients also experienced benefits of
increased enjoyment of the occupational based activities which in turn increased self-
determination and competence (Colaiammi, 2011).
Outcome. For intervention #3, participation is the outcome to be achieved. The client will
be engaging in a desired occupation of applying makeup by using adaptive makeup brushes to
address her decrease in strength, range of motion and grasp. The client wants to feel beautiful
around her husband and friends, and she also enjoys applying makeup for therapeutic reasons.
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Applying makeup is motivating for the client and this increased motivation will encourage her to
participate in other ADLs and IADLs.
Short term goal 4. Client will apply foundation, blush, eyeshadow and lipstick with
supervision requiring no more than 3 verbal cues with appropriate makeup tools within 4
treatment sessions.
I ntervention 4. Client will set up makeup products out of cosmetic bag and apply
makeup to entire face with a neuromuscular electric stimulation (NMES) applied to right wrist to
increase range of motion and activity tolerance for fifteen minutes.
Outcome. The most appropriate intervention for intervention #4 is participation. The
clients ability to participate in applying makeup on her face using a NMES will help the client
complete a finished makeup look and help with functional hand mobility by increasing range of
motion and increasing strength.
Literature review. For intervention #4, Beines (2013) proposed that neuromuscular
stimulation (NMES) can be used during a functional activity to increase range of motion,
strengthen muscles and facilitate muscle contraction. Muscles are then retrained in the purpose
of its contraction. NMES is an electrical stimulation that provides a continuous interrupted
current. Electrodes are applied to the motor area of the innervated muscle that delivers a muscle
contraction (Beines, 2013). Therefore, using NMES will increase the clients range of motion
when applying makeup and help her achieve a desired makeup look. Using the NMES when
performing makeup artistry will increase the clients strength of her right wrist which will allow
for more accuracy and precision of makeup application.
Outcome. For intervention #4, participation is the outcome to be achieved. The client will
be engaging in a desired occupation of applying makeup to her face using the NMES. The device
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will allow her to perform a more precise artistry to her face due to the increased range of motion
and muscle strength.
Precautions and contraindications
For intervention #1, since MVT is being used, contraindications for the client include
increased pain, exacerbation of injury, motor extinction or inability to believe the illusion.
Treatment should be discontinued if no benefit is gained within a reasonable time period or if
any of the contraindications discussed occurs (McCabe, 2011).
For intervention #2, since a paraffin bath is being used, contraindications include
tumors/cancer in the location of the paraffin dip, impaired sensation, acute inflammation,
advanced cardiac disease, deep vein thrombosis (DVT), infection, semi-comatose, impaired
mental status, bleeding tendencies, and rheumatoid arthritis (RA) exacerbation (McCoy, 2014) .
For interventions 1-4, contraindications and precautions are increased pain, loss of
sensation, swelling, tingling, poor circulation and over exercising the joints. The client should
know her limits and the therapist should implement the just right challenge so she does not
overuse injured joints and cause further injury. These contraindications and precautions are
applied to all interventions used due to its applicability.
For intervention #4, since a NMES unit is being used, contraindications are undiagnosed
pain, muscle fatiguing, peripheral vascular disease, cardiac conditions, pacemaker, malignancy,
decreased sensation, cancer, infection, active hemorrhage, obese patients with heavy adipose
tissue, clients who cannot give clear feedback, placement over metal plates or pins, skin
conditions, epilepsy, and trunk of pregnant women (McCoy, 2014).
Frequency and duration of intervention plan
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The client should receive skilled OT rehabilitative therapy two visits a week with an
expected duration of 4 weeks based on physicians orders. Interventions during this course of
treatment will be directed toward addressing the problems and achieving goals previously
outlined to enhance performance. Client will continue home exercise program (HEP) and
suggested therapy until re-evaluation.
Grading Up and Grading Down Activity
For intervention #4, examples of grading up the activity would be to increase the number
of makeup products applied, to add more precise strokes to the makeup application, to add
eyelashes, to decrease the amount of time to complete makeup look, and using tools that are
harder to grasp and manipulate. Examples of grading down are increasing the amount of time to
complete makeup look, to decrease the amount of precise strokes to the makeup application,
using less products, and using tools that are easier to grasp and manipulate.
Primary Framework
The primary framework that was used to guide intervention planning and goal setting for
the client was the Model of Human Occupation (MOHO). The MOHO model is the most widely
used model in occupational therapy and its philosophy is based on four underlining ideas. The
motivation the client has for the occupation (volition), the repetitive patterning of occupation
(habituation), the nature of trained performance and the impact of environment on occupation
(Forsyth et al., 2014). Even though the client has many problems related to her injury, she
stressed the importance of styling her hair and applying makeup as priority. Therefore the top
priority intervention plans discussed in this paper addresses those needs. All interventions
suggested for the client were meaningful and functional.
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In the MOHO model, change is driven by the clients occupational engagement and
motivation is driven by the therapy process. Having the client participate in therapy that is
meaningful enables her to reshape occupational identities and abilities; therefore she will be
more adaptive (Rybski, 2004). Intervention guidelines were based on therapeutic reasoning.
Validating the clients experience and identifying procedural and environmental factors that
could facilitate occupational performance were used to come up with intervention and goals.
The secondary framework that was used to guide intervention planning and goal setting
was the biomechanical frame of reference. It is imperative for hand therapy clinics use a bottom
up approach for remediating and restoring client level factors, performance patterns and
performance skills (Rybski, 2004). The biomechanical frame of reference includes teaching and
training of new performance skills and performance patterns. The biomechanical frame of
reference addresses peripheral nerves, integumentary system, cardiopulmonary system and
musculoskeletal capabilities. Under the biomechanical frame of reference, clients impairment
can be restored or remediated through strengthening and endurance activities (Rybski, 2004).
The biomechanical frame of reference is not a holistic approach and only looks at the area(s) that
are causing dysfunction. That is why the MOHO model and biomechanical frame of reference
were used in concert to provide the best intervention plan and goal setting to give the client the
best possible service delivery.
Client Training and Education
Client will be educated on proper ways to exercise wrist and hand muscles to prevent
further injury. Client will be educated on proper ways to use the NMES to prevent over
fatiguing. Client will be taught ways to modify functional hand movement to become successful
in meaningful and purposeful activities such as hair styling and makeup artistry. Client will be
OCCUPATIONAL ANALYSIS AND INTERVENTION PLAN 18

instructed on the proper use of the JAS wrist system for HEP. Client will be taught home
exercises to implement every day which includes the use of thera-putty and active range of
motion exercises. Client must understand the value of therapeutic activity and instructions given
during rehab session.
Monitoring of Interventions Towards Goals
Clients response to interventions will be monitored and assessed towards the progress of
goals at every therapy session through the observation of functional activities and movements.
Visual observation will include watching the client perform activities, looking at muscle
contours, skin integrity, skin creases and to see if the client is using compensatory movements.
During passive range of motion, joints will be monitored for tone, end feel and crepitation. Also
subjective, objective, assessment, and treatment information will be recorded at each session.
Measurements of ROM will be taken to check for progress and observed closely. Re- evaluation
is warranted at the end of 4 weeks of therapy.








OCCUPATIONAL ANALYSIS AND INTERVENTION PLAN 19

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