Student

Name: Jon Bateman Case: 3 Date: 2/5/2020

1. Diagnosis, Referral, Setting, Reimbursement, LOS

Dx: Bilateral Carpal Tunnel Syndrome, 2 weeks post- endoscopic surgery on R UE, beginning stages on L UE
Referral: Hand Surgeon
Setting: Outpatient hand clinic
Reimbursement: Workman’s Compensation Insurance
LOS: 4 weeks, 2x a week

2. Pragmatic Factors to Consider

Workman’s comp demands.
Financially tight and needs to work to provide money for family.
Job demands are provoking the symptoms
If she doesn’t pay rent for her chair salon owner will rent it out to someone else and she will lose her client
base. If not functionally well and able to return to work within 4 weeks, does she have private insurance to
take over or can workman’s comp extend services?

3. Context: Occupational Profile & Current Occupations

Cultural: Caretaker, values hard work, helps provide for her family, African American

Physical: Salon, house, church, bowling alley

Social: Husband, 4 children, client base, church group, salon owner,

Personal: 44 year old African American female hairdresser

Temporal: 4 weeks of treatment, 2x a week,.44 years old, Onset of bilateral carpel tunnel syndrome one
month ago, 2 weeks post-surgery, works 6 days a week, goes to church every Sunday, 6-8
weeks to resume to work with modified schedule
Virtual: Computer, keyboard, mouse, telephone

Prior Occupations:
Hair dresser, religious woman/church volunteer, bowling, living independently with ADLs and IADLs

Current Occupations:
ADLs and most IADLs IND, Household management duties have lessened, church/volunteer, using mouse
and keyboard in workplace to learn new system.

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 4: Top Three Client/Family Goals and Priorities
1. She wants to return to work as soon as possible as a hairdresser.
2. Wants to return to household duties.
3. Wants to be able to cook again for family.
5. Diagnosis and Expected Course
Post surgery can remove bandage after two days
Need to keep incision dry until next doctors visit
Two days after sutures are removed and skin is
completely closed scar management through
massage may begin.
Common to have post operative pain. Generally use
ice and elevation for pain, if there is increased pain
an anti inflammatory may be used.
You can use your hand to dress yourself, comb your
hair, and do self-care activities immediately
after surgery, as tolerated. You can do light work
such as typing and using the telephone the
day following surgery. It will take 4 to 6 weeks
before you can perform strenuous work.
(https://www.orthoillinois.com/hand-wrist-
elbow/carpal-tunnel-syndrome/)
After a week of surgery bandages and stitches will
be removed. 1-2 weeks bandages should be
removed. Generally provided exercise to help avoid
stiffness.
Can gradually resume to daily activities after 2-4
weeks of surgery depending on the type of work.
Light lifting and gripping are permitted in this time
frame.
Within 4 weeks you can potentially regain mobility
of digits.
During the period of 6-8 weeks after surgery you
can potentially expect to return to work. Deep
pressure and touch may still cause soreness.
Depending on the extent of the damage prior to
surgery to the median nerve may alter the outcomes.
Potential for symptoms to return whereas surgery is
not always successful
(https://www.hopkinsmedicine.org/health/treatment
-tests-and-therapies/carpal-tunnel-release)
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6. Scientific Reasoning & Evidence
List the barriers to performance typical of this diagnosis:
Can have decreased muscle strength, potentially reduced
thumb flexion, palmar abduction and opposition,
thenar eminence appears flat. Sensory loss. Orthoses
that position thumb in palmar abduction and slight
opposition increase function use of the hand.
Avoided use of hand due to lack of sensation rather
than muscle paralysis, nevertheless the weakened or
paralyzed muscles should be protected.
The syndrome is associated with increased pressure in
the carpal canal because of trauma, edema, or
retention of fluids as a result of pregnancy, flexor
tenosynovitis, repetitive wrist motions, or static
loading of the wrist. The symptoms are night pain
severe enough to waken the client; tingling in the
thumb and index and middle fingers; and, if the
condition is advanced, wasting of the thenar
musculature caused by pressure on the motor branch
of the nerve (Pedretti Ch. 39)
Left UE pain, numbness, or tingling in the palm, thumb,
index, middle, and radial aspect of the ring finger.
(Andrew Bracken)
R UE may experience pain post-surgery anywhere from
a few weeks to a few months.
Need to be aware if any of the signs are present post
surgery, redness swelling, bleeding, drainage, increased
pain around incision.
https://www.hopkinsmedicine.org/health/treatment-
tests-and-therapies/carpal-tunnel-release
Scar management
Decreased endurance in distal UE
Using a splint gets in the way performing functional
activities
Revised 1/9/17
  Driving (a couple of days after surgery)
 Writing (after a week, but expect 4-6 weeks
before it feels easier.)
 Pulling, gripping, and pinching (6-8 weeks
out, but only lightly. Expect 10-12 weeks
before your full strength returns, or up to a
year in more severe cases.)
https://www.webmd.com/pain-
management/carpal-tunnel/do-i-need-
carpal-tunnel-surgery#3

7. Practice Models Guiding Assessment and Rationale

Treatment
1. PEO Addressing the situation taking into perspective how
the person, environment, and occupation interact will
help frame and make apparent deficits and strengths.
Ursula’s recent experience with bilateral carpal
tunnel syndrome is limiting her personal ability to
engage in occupations. Her occupations of hair
dressing household management have been impeded
due to pain, numbness, and tingling. Can
environmental factors be altered to enable
occupational performance? Can components of hair
dressing be altered to enable occupational
performance? Will a splint provide the support
needed to help enable occupational performance?
2. Biomechanical ROM, strength, and endurance have all been
negatively affected by the pain stemming from
bilateral carpal tunnel. She is unable to hold objects
or keep up with the demands of her work.

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3. Rehab
8. Specific Areas of Occupation
What do you know?
Works as a hair dresser. Prepares meals for her family.
Performs household duties and the whole family
helps. Attends church. Enjoys bowling. Navigates and
uses electronic billing system.
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This model can be used to address the need of
adaptive equipment and compensatory strategies.
The use of customized splints for Ursula will be
beneficial to provide support and help keep in hand a
in neutral position. Are there compensatory
strategies or modifications which can be made to
help reduce the strains of the activity demands to
perform her job? Reduce the force required to cut
hair. Sharpen her scissors. Take more rest breaks
while cutting hair, build a gap between clients in her
schedule.
What do you need to know?
What position does she sleep in at night? When can
she go back to work and not compromise her health?
Are any other ADLs or IADLs being impacted by her
condition? Are there different tools or AE that would
help make her work more ergonomically sound? Any
precautions limited by hand surgeon limiting
occupations? Is she currently bowling once a week?
Were symptoms aggravated when using the mouse
and keyboard at work while learning the new system?
Are there scissors which require less force to perform
her job? Are there ways to decrease repetitions needed
to complete her job? What type of hair dressing does
she typically do? Does she do men’s haircuts, braids,
coloring, trims, perms, extensions?
Revised 1/9/17
 9. Performance Skills
What do you know?
Decreased pinch and grasp strength due to pain. Wrist
support provided by doctor decreased agility to grasp
hair dryer and scissors. Unable to perform household
chores due to symptoms. Upbeat outlook on life,
concerned about ability to return to work quickly.
Assume she has intact cognition due to ability to learn
new work system and manage clientele. Decreased
endurance.
What do you need to know?
What do her social interaction skills look like? How
does she interact with her boss? How has surgery
impacted her motor skills? Does her left hand need to
be treated the same way as the right hand? Is she able
to grip, manipulate, and endure repetitious movements
with weighted objects throughout the day? Hand
dominance? Current level of hand coordination and
strength? If she changes her form, takes frequent
breaks, improves posture, changes equipment, would
aversive symptoms decrease?

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

What do you know?
Routines: Works 6 days a week. Attends church every
Sunday. Takes a lunch break and a quick smoke break
in the morning and afternoon each day. Bowls one
night a week in winter months.
Roles: Spouse, mother, employee, hair dresser,
religious woman
What do you need to know?
Does she make dinner every night? What time of year
is it, is she currently bowling once a week? What is
her husband’s schedule? How much do the kids and
husband help out at home? Is the salon chair really
worth it if the rent for the chair is forcing her to work
six days a week? Could she get a job at a different
salon and get her clientele to follow? Is she still taking
any medications? What other potential factors are not
mentioned within her daily routines which can be
provoking the injury? Are there potential adjustments
which can be made to help reduce aggravation of the
median nerve? Can her work schedule be altered? Can
rest periods be built in between clients? Can she
change the way she is doing certain repetitive
movements?

11. Activity Demands for the Client Goals and Priorities

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

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Hair Dressing:
Motor skills needed to use hair dressing supplies,
electronics, and tools.
Bilateral coordination to manipulate hair while using
scissors, hair products, or hair dryer.
Social interaction skills
Strength to grip and manipulate tools to cut and dry
hair, also needed to open small containers.
Cognition to follow a process while cutting hair
Observe safe practices while using scissors, especially
near client’s hair.
Endurance to sustain repetitive movements over a
period of time.
Endurance also needed to maintain position of hair
dryer.
12. Client Factors- Values, Beliefs, Spirituality
What do you know?
Values hard work
Deeply religious woman.
Wants to provide for her family
13. Client Factors- Body Functions & Structures
What do you know?
Bilateral carpel tunnel syndrome, Endoscopic surgery Has the wound healed properly? What are her current
to relieve nerve compression.
Experiencing pain and decreased strength. Impaired
sensation. Compressed median nerve and tendons.
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What does it look like when the client attempts these
activity demands? What is the extent of her deficits?
Which of these are limiting her ability to return to
work? When is an appropriate time for the client to
return to work?
Is she able to use her hands without provoking them?
Can she do her job effectively with a splint?
Are there ways to reduce the force required of
scissors? Can you get adaptive scissors which utilize a
different grip?
What can be done to decrease the demands of
repetitive movements?
What style of hair dressing does she do? Does she
intricately braid hair, do extensions, apply weaves,
color hair, do simple men’s haircuts, add beads into
hair, ect…?
What do you need to know?
What is her relationship like with her husband,
family? What is her relationship like with her boss? Is
her ability to participate in spiritual functions
hindered?
What do you need to know?
symptoms in R UE and L UE? Any other body
functions or structures impacted which were not
mentioned? Any precautions provided by hand
surgeon? Hand dominance? Tightness in intrinsic or
extrinsic muscles? ROM in wrist, hand, and finger?
Muscle endurance while performing tasks with distal
UE? How is she holding up mentally with the
pressures to provide for her family and going through
injury? Stiffness? Poor posture or positioning causing
problems?
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
Facilitated hair dressing using yarn or thread
mimicking hair. I want to see how she is cutting and
drying hair.
This allows me to see how the client interacts
(position, grips, manipulate) with her tools (scissors,
hair dryer) and gives me the opportunity to suggest
changes in form or technique.
I want to ensure she is not using repetitive movements
involving flexion or extension in her wrist.
Throughout the process I can educate on the need to
take breaks, maintain proper body mechanics (such as
keeping that median nerve in a neutral position as
much as possible)
Method/Tool
1. AROM/PROM in wrist, hand, fingers
2. Grip and Pinch Test using a dynamometer and a
pinch gauge, MMT in wrist, hand, and fingers
3. Pain Scale w/ faces handout
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Rationale/How will you use this information
Ursula’s primary goal is to be able to return to work
and sustain the daily demands of her job day in and
day out. I want to ensure that she is set up for
success. I want to see what she will be doing every
day and look for ways to decrease the risk of having
the CTS return and impede her performance. I want
to look for ways to position the tools in her hands to
decrease the pressure applied to median nerve. I want
to look for adaptations which can be potentially
made to her equipment to make them easier to hold
and manipulate. I would provide a semiflexible or
neoprene orthosis, rather than a completely rigid one,
which may be used to provide support while
allowing a small amount of flexion and extension for
greater functional use.
Rationale/What is being Assessed
Has nonuse or pain limited the clients ROM? Want
to ensure she can move fingers freely without
limitations.
I would want to establish a baseline. Also it is
important to note if client is experiencing pain
limiting ability to exert full force while performing
tests. I want to know what kind of strength she has.
I want to ensure there is not any debilitating pain
which is present impacting function. What level of
pain does she have and is what I am doing
throughout the therapy process helping to decreasing
the pain levels.
Revised 1/9/17
4. Specific Vocational Evaluation (Valpar It is an occupation functional assessment. This would
International) help identify her readiness and ability to return to
working as a hairdresser. Where she has bilateral
carpal tunnel syndrome, I would want to see her
current abilities to manipulate scissors, a hair dryer,
and computer. What length of time is she able to
sustain use of tools before it becomes a problem? I
also want to see what positions she utilizes while she
is working.

5. Mohberg Pick Up Test Due to her injury incorporating the median nerve this
assessment is appropriate. This test involves picking
up, manipulating, and identifying small objects. It
also assesses the client’s ability in regards to
perceive constant touch, precision grip, and
cutaneous feedback. The demands for hair dressing
match well with what this test assesses.
6. Edema Over a period multiple treatment sessions, I want to
measure to see if she has edema present. If so, are my
treatments helping reduce it?

15. CPT Evaluation Code: Justification

Low Complexity Brief medical history and documentation to review. There are no comorbidities
listed. Does not demand a high level of experience to resolve.

16. Projected Outcomes: Type of Outcome

Client will return to work and resume normal functions. Quality of life, role
competence, well-being,
Pain, numbness and tingling will more than likely disperse over time. Normal participation
sensation will improve if not fully recover.

Client will be able to resume normal household management activities,

ADL’s and IADLS.

Inflammation will decrease.

17. Resources and Team Members

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Workman’s comp, family, employer, hand surgeon, primary care physician, OT, PT, mental health
professional, financial advisor (balance income and demands to rent chair at salon) amazon.com to buy better
quality or adapted equipment (scissors with a spring, larger handle blow dryer)

Home exercise program

https://orthoinfo.aaos.org/en/recovery/carpal-tunnel-syndrome-therapeutic-exercise-program/

18. Intervention Plan

Barriers Supports
Decreased muscle strength Workmans Comp
Decreased ROM
Potential Pain Family to help assist
Potential Edema
Potential lack of sensation. Will have a customized splint which
Desire to return to work ASAP enables function through proper
High demand to work many hours to afford chair at salon and positioning and support.
worried about losing clientele.
Can customize her own schedule.

Upbeat outlook on life.

Religious woman

Goals Approach and deficit(s) for each goal

1. LTG:
By discharge, client will work 3 days a week with mod. IND Quality of life, participation, role
competency, well-being: Strength,
AROM

1a.STG: Quality of life, participation, role

competency, well-being
Within 2 weeks client will increase wrist flexion by 10 percent to
brush hair. AROM

1b.STG: Quality of life, participation, role

competency, well-being

Within 3 weeks client will increases grip strength by 5 percent to Muscle strength
use scissors.

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2. LTG: Quality of life, participation, role
competency, well-being

By discharge, client will IND use proper body mechanics to reduce Pain management, positioning
pain.

2a. STG: Quality of life, participation, role

competency, well-being

Within 1-week client will IND complete CTS home exercise Pain management, strength
program daily to increase strength to support hair dressing tools.

2b. STG: Quality of life, participation, role

competency, well-being

Within 2 weeks client will IND complete stretching routine AROM, Pain management
between each set of clients.

3. LTG: Quality of life, participation, role

competency, well-being
By discharge, client will IND implement pain management skills.

3a.STG: Quality of life, participation, role

competency, well-being
Within 1 week, client will IND implement the use of a nighttime
orthosis and self-report impact on quality of sleep Pain management, quality of sleep

3b. STG: Quality of life, participation, role

Within 2 weeks client IND will implement a work schedule which competency, well-being
has a minimum 30-minute break between clients, with no more than
4 clients per day.

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19. Treatment Sessions: Plan for first two 45 minute treatment sessions:
1. What will you do? Identify Practice Based on which goal(s)?
This first session will be heavily focused on client Model
education and providing resources which she can 1, 1a,1b
implement manage pain, improve ROM, increase PEO 2, 2a, 2b,
strength, and avoid future injury. I would start the Biomechanical 3, 3a
session by examining her wound. Then icing her wrists Rehab
to help reduce inflammation with the goal of enabling
greater ROM throughout the session. I would then begin
to stretch each wrist using small amounts of flexion and
extension. I would provide a handout including stretches
and have her go through them daily. We would run
through the stretches together to ensure she is doing
them properly. After her wrist is loosened up I would
have her demonstrate how she grips scissors and a hair
dryer. After seeing the positions she holds her tools in I
would make recommendations to help decrease pressure
on the median nerve. I would recommend investing in
more ergonomic equipment (larger handle for a blow
dryer or spring-loaded scissors). I also would
recommend sharpening her scissors often to reduce the
force needed to cut. I would have a little craft activity
prepared which involves using scissors. (cutting out the
shapes of a persons face and adding fake hair to it) In
order to grade the activity, I would have various textured
paper. I also would have various sizes of yarn and thread
incorporated to grade the activity. I would encourage her
to keep her wrists as close to a neutral position as
possible. I would tell her not to place her wrists in
positions which apply pressure to them such as resting
them on the table when navigating the work computer or
sleeping with her arm under her head. I also would
instruct her to limit the amount of times she flexes or
extends her wrists reducing the amount of pressure
which is repetitively applied to her wrist. I would
customize a set of orthosis which she can use while
sleeping. I would instruct her to wear it every night as
she sleeps. I would also provide her a neoprene orthosis
she can wear when performing functional tasks
throughout the day.

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2. What will you do? Identify Practice Based on which goal(s)?
Model
1, 1a,1b
The second treatment session would start with PEO 2, 2a, 2b,
preparatory methods like the first one. I would start Biomechanical 3, 3a
using ice and light stretching. While doing this I would Rehab
talk to the client and follow up on her adherence to what
we talked about in the first session. I would want to
know if there were any roadblocks or difficulties. I want
to ensure she is taking breaks often while performing
activities, stretching, using her splints, and icing her
wrists. I would question her about proper body
mechanics and positioning. Ask if there were any
obstacles which came up since our prior visit? I would
collect information on her pain levels, ROM, and grip
strength. This session I would implement light resistive
exercises to start working on her grip strength. I would
go through a handout with her and make for sure she
doesn’t have any questions. The home exercise program
involves theraputty and elastics, so I would try various
resistances with her and find an appropriate resistance. I
would have her bring a couple items she uses to get
ready in the morning and go through her morning hair
dressing routine. We would work on identifying barriers
in her process and overcome it. Maybe she braids her
hair and needs a clip to hold something in place, maybe
she needs a different style brush which can move
through her hair easier with less resistance, maybe she
needs to change her style of hair for the time being?
This could go a million different directions but in the
end, we would look for resolves to improve body
mechanics, include rest breaks, reduce repetitive
movements, and decrease resistance or force needed to
complete activities.

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