Date of Assessment: 2/18/2021

Name: MH
Diagnosis: Right hand disarticulation of MCP joint for digits 2-5, thumb amputation with
residual limb proximal to DIP joint on R hand, L wrist disarticulation. 50% of total body surface
area is grafted from burns.
Occupational Therapy Initial Evaluation
S: “I can do most things that I want to, but I would really like to work on cars with friends
again.”
O: Client was seen on February 18th for a comprehensive occupational therapy evaluation,
including the Canadian Occupational Performance Measure (COPM), and an occupational
observation of preparing a to-go lunch.
Occupational Profile:
Client is in his 60’s and seeking services to increase occupational performance in leisure
activities. He was referred by an OT professor at the University of Utah. Due to a motor vehicle
accident, client sustained a R hand disarticulation of MCP joint for digits 2-5, thumb amputation
with residual limb proximal to the DIP joint, a L wrist disarticulation and 50% of TBSA burns
that were later grafted. Prior to injury, he was right hand dominant, but later switched to being
dominant with his L prosthetic. He received his second prosthetic for his RUE a few months ago
and reports he is getting accustomed to it. He now wears a bilateral pulley hook prosthesis for the
majority of the day. He puts his L prosthetic on in the morning, and his right one when he needs
to, or switches it out with other terminal devices. He received OT services in the hospital
immediately following his injury, as well as through home health.
Client lives in a home with his two teenage sons, five cats, and two foster cats. His ex-
wife comes by the house regularly to visit with his sons. He reports that his sons are helpful
when needed but allow him space to do things independently when he wants to. Client wakes up
at various times before he has to be at work at noon. He dons a shirt and then his L prosthetic,
prepares himself a bowl of cereal, and cleans up after himself. He reports as being independent
with adaptive equipment in all of these occupations as well as full body dressing, grooming,
toileting, feeding, bathing and showering. He is also independent in I-ADLS including, meal
prep and clean up, grocery shopping, transportation/driving, and home maintenance such as
vacuuming and laundry. He reports interest in improving skills such as scissors use and ziploc
bags.
Prior to his injury, client worked as a carpenter, making cabinets. Currently, he has
expressed no interest in returning to that work and sought out a job that required less time on his
feet, given he is only comfortable standing and walking for a couple hours a day. Currently, he
works for a pharmaceutical company and makes deliveries via driving a pick-up truck. He
operates automatic and manual vehicles, with the exception of a push button gear shift vehicle.
He volunteers at the hospital as a peer mentor for burn victims and amputees. Prior to his injury,
he spent a significant amount of time fixing up old cars, and has begun to do this more often
again. He reports this as his hobby for socialization with his friends, as well as for relaxation. He
reports that he often needs to operate a wrench or a ratchet wrench for car repairs, but can have
difficulty using them. According to the client, returning to this occupation of auto repair is a top
priority for him. He states that he highly values spending this time with friends.

Occupational Performance Assessment: (OTPF S17) (consider all of domain OTPF S4; P-E-O).
Client began session wearing both his left and right pulley hook prosthesis. He completed
prosthesis hygiene by opening a container of disinfectant wipes and wiping both hooks down
thoroughly.
When instructed to retrieve materials to prepare a sandwich, client opened refrigerator
and retrieved a loaf of bread from the bottom shelf, a jar of jelly from the side shelf, and an apple
from the drawer. All movements were done smoothly and efficiently. He then retrieved a
ceramic plate by opening an overhead cabinet with a secondary locking mechanism, and
reaching with his L UE, grasping the ceramic plate and transporting it to the countertop. He
similarly retrieved a jar of peanut butter (PB) in from an overhead shelf. Next, he opened waist
level drawers with L hook and retrieved a butter knife, and later spoon, and chopping knife.
Utilizing both prosthetic limbs, he opened the bread bag, poured out bread, and explained
how he had to be very careful not to squish the bread with his hooks when transporting it to the
plate. He then opened the PB jar by grasping the jar to stabilize it with one hook, and applying
pressure and spinning the cap off with the other palm. After a few unsuccessful attempts to
retrieve PB with a butter knife, he modified his approach and switched to using a spoon. For the
jelly jar, his original approach did not work so he modified and removed his R prosthetic for a
grippy glove that exposes his thumb. With the addition of a shelf grip liner, he opened the jelly
jar and subsequently spread the jelly with the spoon as well. He continued to use his grippy glove
for the rest of the session.
Next, he cut an apple into 4 slices by grasping a cutting knife with his L hook and
applying pressure to the top of the knife with his grippy glove. When asked to put items into two
ziplock bags, client was able to open both bags on the second or third attempt. He loaded items
in the bag smoothly and closed them by applying pressure to the tops of them. He then placed
items into a zip lock lunch box (zipper pull of about 1/4 inch long) and closed it with a few
attempts but still under 30 seconds.
Client also participated an a COPM interview and yielded the following occupational
performance priorities;

OCCUPATIONAL Impt PERFORMANCE SATISFACTION

PERFORMANCE “How would you rate “How satisfied are you
 PRIORITIES the way you do the with the way you do this
activity now” activity now?”
Using auto tools 10 4 1
Scissors use 7/8 1 6/7
Ziplock bag 8 2/3 2/3
TOTAL 25.5 7.5 10
Average Scores 8.5 2.5 3.3

A: Interpretation:
Supports to his occupational performance include his attitude and motivation to try new
strategies, skills he has already gained in previous ADLs and I-ADLs, high cognitive level to
problem solve, and his two teenage sons. Barriers include lack of fine motor ability due to
amputations and disarticulation of L & R hands, his prosthetic use that has increased his ability
to grasp objects, yet still has limited ROM and dexterity, and his pain in feet from standing and
walking activities lasting more than an hour. His environment allows him access to successfully
perform ADL’s and has the tools he needs to perform I-ADL’s, however he is lacking the
adaptive equipment to connect his skills with the occupations he desires to engage in.

P: MH will be treated for 60 minute sessions 1/week for 8 weeks to address grasp and
manipulation deficits in tool use that interfere with occupational performance in household tasks
and leisure. Skilled OT services are required for identifying/creating relevant adaptive equipment
and appropriate grading of activities that will allow him to utilize desired tools. MH’s complex
condition of being a bilateral upper extremity amputee as well as history of skin grafting from
burns requires advanced clinical judgement to adjust the presentation of activities that will
properly challenge him while also teach him to generalize strategies beyond the treatment
session. Awesome!
Goals
LTG1: By d/c, client will independently complete simple car repair with tools utilizing adaptive
strategies.
STG1: In three weeks, client will identify and utilize an efficient grasp with car repair
tools in a seated position using adaptive strategies and ModA.
STG2: In five weeks, client will utilize tools to screw/unscrew bolts from various
positions or angles, using adaptive strategies with minA.
LTG2: By d/c, client will cut coupons out of paper independently.
 STG1: By week six, client will independently open and close scissors five times without
dropping them.
STG2: By week seven, client will utilize scissors to cut snips from a paper independently.

GAS charts

**HINTs: each column should have 3-5 bulleted measures.

***It’s easier if you fill out the “0” column (Goal measures – LTG/Measurement Criteria – STO) first, then the “-2” column (Baseline
performance) and then fill in the rest of the columns in between.

Distal Outcome (LTG):By d/c, -2 -1 0 +1 +2

client will independently (Baseline) (Goal)
complete simple car repair
with tools utilizing adaptive
strategies. Much Less Less Expected Level Better Much Better

(Occupation/Target Behavior) Utilizing tools Utilizing tools - By d/c, client will

with unable to independently
assistance, generalize skill complete simple car
unable to to car repair. repair with tools
generalize to utilizing adaptive
car repair. strategies.

Proximal Outcomes (STGs) Measurement Criteria Baseline

In three weeks, client will
identify and utilize an
efficient grasp with car
repair tools in a seated
position using adaptive
strategies and ModA.
-Efficiently holds tool for a full -Client has not yet identified efficient grasp.
minute while making movements
-pronation
-supination
-radial deviation
-ulnar deviation

In five weeks, client will
utilize tools to
screw/unscrew bolts from
various positions or
angles, using adaptive
strategies with minA.
- Able to screw bolt from sitting, - Client cannot yet utilize tools from a variety of
leaning to the left w/ support, positions. Will need to complete STG1 prior to this.
leaning to the right w/ support,
leaning forward w/ support,
reaching to the front, reaching to the
left, reaching to the right (across
midline).
**HINTs: each column should have 3-5 bulleted measures.
***It’s easier if you fill out the “0” column (Goal measures – LTG/Measurement Criteria – STO) first, then the “-2” column (Baseline
performance) and then fill in the rest of the columns in between.

Distal Outcome (LTG): By -2 -1 0 +1 +2

d/c, client will cut (Baseline) (Goal)
coupons out of paper Much Less Less Expected Level Better Much Better
independently.
(Occupation/Target Client could cut Client will utilize By d/c, client
Behavior) coupons with a cutting will cut
MinA. (may need instrument to cut coupons out of
to be adjusted vertical strips paper
after down a paper
independently.
observation) independently.

Proximal Outcomes (STGs) Measurement Criteria Baseline

By week six, client
will independently
open and close
scissors five times
without dropping
them.
-Client will scissors with or without -Client has not yet been observed utilizing scissors.
propping them depending on (To be updated)
identified strategy.
-Client will open scissors with one
extremity.
-Client will close scissors with one
extremity.
-Client will open and close scissors
without needing to pause and
readjust grasp.

By week seven, client
will utilize scissors to cut
snips from a paper
independently.
-Client can hold scissors -Client currently reports he cannot hold scissors or
(or identify a way of utilizing that has not identified scissors that have worked for him.
does not involve holding)
-Client can open scissors without
dropping them.
-Client can close scissors on paper
without dropping them.
-client can stabilize paper that is
being cut, either while holding it or
seuring it to the table, depending on
cutting technique.
-client can make 5 1’ snips.

MH is an excellent candidate for progress with OT services. Thank you for the opportunity to
assist him in returning to independence in his occupations.

Research Evidence and choice of practice models to support your intervention for your
community client. Attach evidence or provide access to the article/s. Research evidence is
accurately described to justify the intervention. Justification of practice models including
postulates for change
PEO: By addressing the transaction between MH as a person, the occupation he would like to
engage in and the environment around him, we can improve his occupational performance. Often
times for MH the environment can assist him by providing space to prop his elbow on, lean
against different surfaces, or stabilize objects using the surrounding environment. The
occupations are dynamic and can be adapted by altering the way he completes them. MH himself
is also a dynamic individual, and he can continue to learn new strategies or utilize equipment to
help complete tasks. One postulate that guides this theory is that “the person is a dynamic,
motivated, and ever-developing being; attributes are amenable to change, although some are
more responsive to intervention than others”. MH has demonstrated his ability to utilize new
techniques and be adaptive to change in the three years post this injury, so this postulate is
especially relevant to him. Another postulate is that “Occupations meet intrinsic needs for
maintenance & expression and fulfillment within the context of personal roles and environment.”
This also is especially evident given the way MH expressed how meaningful it would be for him
to participate in his passion of fixing up old cars. He reported this as something that provides a
sense of identity, relaxation, and socialization with others. Lastly, “interventions that address the
transaction of PEO, PE, PO, EO can enhance congruence and optimize occupational
performance.” This last one would be the foundational reason why we are addressing PEO to
improve MH’s occupational performance.
Rehabilitative FOR - This frame of reference considers rehabilitation the process of facilitating
patients in fulfilling daily activities and social roles with competence. Given that MH’s
underlying impairments are going to be permanent, we must focus on the remaining abilities to
attain the highest level of function possible. This model postulates that by using compensatory or
functional methods and making use of adaptive equipment or environmental modifications, the
client can restore function. This will be especially applicable, as MH already has several pieces
of adaptive equipment to complete other occupations, so we know he is willing to try adaptive
strategies and capable of making adjustments. MH has great potential and motivation to learn -
and we can continue to understand his preferred learning method, making the rehabilitative FOR
a great choice.
Articles that could guide intervention:
Friedmann L. (1965). Special equipment and aids for the young bilateral upper-extremity
amputee. Artificial limbs, 9(2), 26–33.

-Hidden within this article, I found that to aid school children in using scissors, the embedded
one end into a wooden block to hold it down, and then used a hook to move the scissors up and
down.

Development, W. (2017, August 01). Bilateral upper-limb-loss rehabilitation. Retrieved

February 20, 2021, from https://www.amputee-coalition.org/resources/bilateral-
upper-limb/
-This article highlight how rare upper limb loss, and goes into how OT can be helpful in
regaining independence. The key point in working with individuals with upper limb loss
include the following;

• Most individuals are motivated and inventive/creative in how they adapt.

• Having a strong support system is a vital part of being successful.
• It is essential to have a backup set of arms in the event of repairs and maintenance on
prosthesis
• Having multiple terminal devices gives the px the ability to complete a variety of daily tasks,
much like a box of tools a handyman would have.

Melanie Canna, OTS