occupational therapy case study presentation

OT Case Study

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• 1. The Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital and Richard J. Solove Research Institute OT Case Study Rachel Walton OTR/L April 6, 2016
• 2.  The role of occupational therapy in oncology is “to facilitate and enable an individual patient to achieve maximum functional performance, both physically and psychologically, in everyday living skills regardless of his or her life expectancy” (p. 75). 2 OT Roles in Cancer Rehabilitation • ADL/IADL training • Cancer-Related Fatigue • Caner-Related Cognitive Dysfunction • Chemo-Induced Peripheral Neuropathy • Cancer-Related Pain
• 3.  National Comprehensive Cancer Network (NCCN):  “Cancer-related fatigue is a distressing, persistent subjective sense of tiredness or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and interferes with usual functioning.” 3 Cancer-Related Fatigue Cancer-Related Cognitive Dysfunction  Cancer-related cognitive dysfunction or CRCD, describes memory or thinking problems that occur as a side effect from chemotherapy treatments. It can affect a person’s ability to carry out daily tasks
• 4.  70 year old female  Medical History  Diagnosed with breast cancer in 2006  Underwent right mastectomy and right axillary sentinel lymph node biopsy  Received post-op systemic chemotherapy  Patient developed lymphedema in her right arm in 2012  History of mild cerebral palsy affecting her right arm and seizure disorder  Social History:  Living in an assisted living apartment  Involved in church  Supportive family in a different state 4 Case Study: Jillian
• 5. 5  Increased Fatigue with daily activities  Mental Fatigue with social interactions  Difficulty remembering to perform important tasks and attend appointments/events  Difficulty multi-tasking and staying focused on a task  Increased anxiety and stress Global Complaints
• 6.  Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL)  Difficulty with upper body dressing and morning routine due to increased fatigue and limited use of RUE  Increased fatigue after cleaning apartment  Increased fatigue with cooking due to only using LUE  Forgetting to pay bills on time  Difficulty with carrying out grocery shopping  Leisure  Forgetting to attend volunteering events at church and increased fatigue with attending Sunday morning church service  Increased mental fatigue with social gatherings at assisted living apartment 6 Impact of Jillian's Functional Ability
• 7.  Canadian Occupational Performance Model (COPM): looks at self-reported occupational performance problems 7 OT Assessments Performance Problems Satisfaction Performance Morning Routine 5 5 Cleaning house 2 3 Grocery Shopping 5 4 Money Management 4 6 Performance: 1= not able to do at all ----------------- 10 = able to it extremely well Satisfaction: 1= not satisfied at all ----------------- 10 = extremely satisfied
• 8.  Multidimensional Assessment of Fatigue Scale: 40.1 (50 = severe fatigue)  Highest self-rated fatigue scores were with household chores, bathing/dressing, shopping/errands  FACT-COG (2008): assesses perceived cognitive dysfunction quality of life measure  Perceived Cognitive Impairments  Perceived Cognitive Abilities  Comments from Others  Impact on Quality of Life 8 OT Assessments
• 9. 9 OT Intervention Patient will verbalize at least 5 different fatigue management and energy conservation strategies utilized with morning routine. • One handed dressing techniques for UB/LB dressing • Adaptive equipment education • Adapt patient’s home and bathroom environment in order to ensure optimal performance with morning routine. • Organization • Energy conservation strategies
• 10. 10 OT Intervention Patient will be able to complete weekly routine chores, without experiencing an increase in symptoms, utilizing compensatory strategies. • Activity modification • Developed a weekly schedule • Schedule in rest breaks • Energy conservation strategies
• 11. 11 Activity Modification Examples
• 12. 12 • Education on external memory aides (calendar's, making a list, task reminders on smart phone, written instructions on refrigerator, memory book) • Organize a routine schedule for paying bills each month • Develop a checklist of bills that need to be paid and review it last week of the month Patient will be educated on and demonstrate independent use of 2-3 compensatory strategies to improve functional memory skills in order to increase independence with money-management tasks. OT Intervention
• 13. 13 Develop an action plan • Break down task and decide what makes the task difficult • Develop strategies/alternative ways of performing task • Trail new strategies • Modify as needed based on patient success Patient will independently utilize cognitive strategies to initiate, plan, and organize functional tasks in therapy to promote independence with grocery shopping. OT Intervention
• 14. 14 Develop An Action Plan • Break down task and decide what makes the task difficult • Scheduling transportation • collecting all needed items • making sure your within budget • getting back to bus on time • Develop strategies/alternative ways of performing task • Write bus schedule in calendar/memory book/post on refrigerator • Choose the same time to catch bus each week • Make a grocery list, start at one end of store and work your way down • Decide budget before leaving, plan meals for the week • Set phone alarm 15 minutes before bus arrives, as well as when bus arrives • Trail new strategies • Modify as needed based on patient success Problem solving steps repeated for maintaining budget.
• 15. 15 OT Problem Solving Worksheet Example
• 16. 16 Conclusion Global Fatigue Score went from 40 to 27. Patient demonstrated a 8 point increase on FACT-Cog – demonstrating minimal detectable change Patient reported feelings of being more equipped to take on the challenges of fatigue and cognitive dysfunction. COPM Initial Assessment Re-Assessment Performance Problems Satisfaction Performance Satisfaction Performance Morning Routine 5 5 7 7 Cleaning house 2 3 5 5 Grocery Shopping 5 4 7 6 Money Management 4 6 7 7
• 17. 17 Questions
• 18. Thank You 18 For more information on OT’s role in cancer rehabilitation please contact: Rachel Walton OTR/L Stephanie Spielman Oncology Rehabilitation [email protected]

Case Study Presentation

Feb 06, 2014

540 likes | 1.51k Views

Case Study Presentation. Aged Care and Rehabilitation Service October 2012. Aged Care and Rehabilitation Service (ACRS). Aged Care and Rehabilitation Service: Multidisciplinary team Geriatric clients 28 beds Short and medium inpatient care . Frameworks .

• hip replacement
• occupational profile
• mary health care ltd
• occupational therapy practice process
• less nursing assistance

Presentation Transcript

Case Study Presentation Aged Care and Rehabilitation Service October 2012

Aged Care and Rehabilitation Service (ACRS) • Aged Care and Rehabilitation Service: • Multidisciplinary team • Geriatric clients • 28 beds • Short and medium inpatient care

Frameworks • Person-Environment-Occupational Performance (PEOP): • Highlights complexity of person-occupation-environment relationships • Occupational performance as outcome • Client central to care plan • Client-Centred Frame of Reference (FOR): • Client needs direct planning and intervention (Christiansen, Baum, & Bass, 2011; Parker, 2012; Cole, & Tufano 2007; Parker, 2011)

Communication and Rapport • Fosters therapeutic relationship • Honesty • Confidentiality • Respect • Clarity • Client-centred

Pseudonym: Ms Pamela Watson • Member of aged demographic • Fractured pre-existing hip replacement • Left hemi-arthroplasty • Deconditioned • Bilateral Odema • Urinary precautions • Higher risk of nursing home placement • Extended Aged Care at Home Package (EACH) (ABS, 2011; Spealstra, Given, You, & Given, 2012; McCallum, Simons, Simons, & Friedlander, 2005; Koval, Skovron, Aharonoff, & Zuckerman, 1998, Australian Associated of Occupational Therapists, 2001; Altizer, 2005; Australian Department of Health and Ageing, 2009)

Function • Pre-morbid: • Independent with all Activities of Daily Living (ADLs) • Assistance with showering • Admission: • Maximum assistance with ADLs • Current: • Minimal assistance with ADLs (Bynon, Wilding, & Eyres, 2007; Van Huet, Parnell, Mitsch, & Mcleod-Boyle, 2011)

Framing • Automatic referral • Responded to in timely manner • Comprehensive client evaluation • Occupational Therapy Code of Ethics • Little Company of Mary (Little Company of Mary Health Care Ltd, 2007; Australian Association of Occupational Therapists, 2001; Roberts, & Evenson, 2009)

Focussing • Acquired client 3.5 weeks into Occupational Therapy Practice process (OT Process) • Handover provided • Gather current function and further deficits • Minimum standards for information gathering • Maintained confidentiality (Occupational Therapy Australia, 2010; Australian Association of Occupational Therapists, 2001)

Informing • Integral to Occupational Therapy Practice Process • Determine effect of intrinsic and extrinsic factors on occupational performance • PEOP and client centred FOR guided assessment process (Hocking, 2010; Roberts & Evenson, 2009; Welch & Lowes, 2005; Liu et al, 2005; Christiansen, Baum, & Bass, 2011; Parker, 20122; Cole, & Tufano 2007; Parker, 2011)

Assessments • Functional Independence Measure (FIM) • Assess physical and cognitive function level of assistance required for care • Measures patient progress and rehabilitation outcomes • Responsive to change • Initial: • Develop occupational profile • Fosters therapeutic relationship (Glenny, Stolee, Husted, Thomspon, & Berg, 2010; Henry & Kramer, 2009; Haidet & Paterniti, 2003; Rogers, 2009; Rogers, & Holm, 2009)

Assessments • Rowland Universal Dementia Assessment Scale (RUDAS): • Valid screening tool for cognitive impairment • Culturally diverse • Applicable to range of settings and diagnoses • ADL assessments: • Bed mobility • Shower • Toileting • Meal preparation (Unsworth, 2011; Rowland et al, 2006 Measurement scales used in elderly care, N.d; Liu et al, 2005)

Assessments (Welch & Lowes, 2005; Wancata et al, 2006) • Home Access Visit: • Identifies barriers to home discharge • Integral aspect of discharge planning • Geriatric Depression Scale (GDS): • Assess presence of depression • Clinically valid and reliable in rehabilitation setting

Identifying

Occupational Issues • Unable to transfer in/out of bed independently • Unable to maintain stamina to perform light meal tasks • Unable to dress lower limb independently • Unable to perform self-care tasks with minimal assistance

SMART Goals • By the end of 6 weeks, Ms Watson will be able to independently transfer in and out of bed within the ACRS setting utilising her own physical strength and endurance. Ms Watson will practice transfers daily and a weekly follow up discussion will be utilised to identify progress. • By the end of 6 weeks, Ms Watson will be able to independently make a cup of tea in the ADL kitchen utilising the toaster, tap and condiments. Ms Watson will practice making tea weekly and weekly functional observation will be utilised to measure progress (Occupational Therapy Australia, 2010)

SMART Goals • By the end of 6 weeks, Ms Watson will be able to independently dress the lower limb within the rehab setting utilising her own physical strength and flexibility. Ms Watson will practice daily, reducing the nursing assistance provided. Functional observation and review will be utilised to measure progress • By the end of 6 weeks, Ms Watson will be able to independently transfer on and off the toilet using an over toilet frame in her rehab room. Ms Watson will receive less nursing assistance daily and functional observation and review will be utilised to measure progress (Occupational Therapy Australia, 2010)

Intervention • Client-centred • Compensatory: • Equipment provision • Recommendations • Remedial: • Retraining • Practice (Christiansen et al, 2011)

Intervention (Pierce, 2008; Hagsten, Svensson & Gardulf, 2006; Kortebein, Bopp, Granger, & Sullivan, 2008) • Functional task retraining: • Increases physical functioning and independence • Maximises functional recovery following hospital related debility • Group Participation: • Re-learn adaptive skills • Maintain occupational performance • Facilitate socialisation

Intervention • Equipment provision in hospital: • Adjustable shower chair • Over toilet frame • Long handled reacher • Case Conference: • Weekly • Presented current care plan and goals (Koval & Cooley, 2005)

Intervention • Family Meeting: • Multidisciplinary • Discharge destination • Future improvements required • Recommendations post-home visit: • Client function, intrinsic factors • Environmental modifications, extrinsic factors

Intervention • Unable to achieve SMART goals • Discharged from occupational therapy • Awaiting Nursing Home Placement: • Unsafe for discharge home

Service Evaluation • Integral to professional reflection and development • Functional review • Observation • FIM (Duncan, 2011; Glenny, Stolee, Husted, Thomspon, & Berg, 2010 ; Australian Association of Occupational Therapists, 2001)

Service Evaluation • Challenging result • Improvements not always achieved • Duty of care • Client safety central to care (Australian Association of Occupational Therapists, 2001)

Altizer, L. (2005). Hip Fractures. Orthopaedic Nursing, 24, 283-292 Australian Association of Occupational Therapists. (2001). OT Code of Ethics Australian Bureau of Statistics. (2011). Population by Age and Sex, Regions of Australia (No. 3201.0). Retrieved from http://www.abs.gov.au/ausstats/abs@. nsf/mf/3235.0 Australian Department of Health and Ageing.(2009). Extended Aged Care at Home (EACH) Packages: Information Sheet no. 4. Canberra: Author Bynon, S., Wilding, C., & Eyres, L. (2007). An innovative occupation-focussed service to minimise deconditioning in hospital: Challenges and solutions. Australian Occupational Therapy Journal, 54, 225- 227 Christiansen, C., Baum, C.M., & Bass, J.( 2011). The Person-Environment- Occupational Performance Model. In E.A.S. Duncan (Eds.) Foundations for practice in occupational therapy (5th edition pp 93-104). London: Elsevier Cole, M, & Tufano, R. (2007). Applied Theories in occupational therapy: A practical approach. Thorofare,N.J: Slack Eyres, L., & Unsworth, C.A. (2005). Occupational therapy in acute hospitals: The effectiveness of a pilot program to maintain occupational performance in older clients. Australian Occupational Therapy Journal, 52, 218- 224. Reference List

Reference List Glenny, C., Stolee, P., Husted, J.,Thompson, M., & Berg, K. Comparison of the responsiveness of the FIM and interRAI Post Acute Care Assessment Instrument in Rehabilitation of older adults. Archives of Physical Medicine and Rehabilitation, 91, 1038-1043 Hagsten, B., Svensson, O., & Gardulf, A. (2006). Health-related quality of life and self-reported ability concerning ADL and IADL after hip fracture. Acta Orthopaedica, 77(1), 114-119 Haidet, P., & Paterniti, D.A. (2003). “Building” a history rather than “taking” one. Archives of Internal Medicine, 163, 1134-1140 Henry, A.D., & Kramer, J.M. (2009). The interview process in occupational therapy. In E.B. Crepeau, E.S. Cohen, & B.A. Boyt Schell (Eds.), Willard & Spackman’s Occupational therapy (11th edition pp. 342-358). Baltimore, MD: Lippincott William & Wilkins. Hocking, M. (2010). Process of assessment and evaluation. In M. Curtin, M. Molineux & J. Supyk-Mellson (Eds.) Occupational Therapy and Physical Dysfunction (6th edition pp 81-93). London: Elsevier Kortebein, P., Bopp, M.M., Granger, C.V., & Sullivan, D.H. (2008). Outcomes of inpatient Rehabilitation for older adults with debility. American Journal of Physical Medicine and Rehabilitation,87, 118–125 Koval, K.J., & Cooley, M.R. (2005). Clinical pathway after hip fracture. Disability and Rehabilitation, 27(18-19), 1053- 1060

Koval, K.J., Skovron, M.L., Aharonoff, G.B., & Zuckerman, J.D. (1998). Predictors of functional recovery after hip fracture in the elderly. Clinical Orthopaedics and Related Research, 348, 22-28 Little Company of Mary Health Care Ltd. (2007). Philosophy: the philosophy of the health, community and aged care service which is a ministry of the Sisters of the Little Company of Mary Liu, S., Kuo, J., Wei, H., & Banks, R. (2005). Clinical Value of ADL Assessments for Inpatients post-Total Hip Replacement Surgery. (Unpublished Student Research Project). University of Queensland and Mater Adults Hospital, Queensland. McCallum, J., Simons, L.A., Simons, J., & Friedlander, Y. (2005). Patterns and predictors of nursing home placement over 14 years: Dubbo study of elderly Australians. Australian Journal on Ageing, 24(3) pp 169-173 Measurement scales used in elderly care. Retrieved Oct 4, 2012 from http://www.dementia- assessment.com.au/symptoms/FIM_m anual.pdf Occupational Therapy Australia [OTA]. (2010). Australian Minimum Competency Standards for New Graduate Occupational Therapists. Parker, D.M. (2011). The client-centred frame of reference. In E.A.S. Duncan (Eds.),Foundations for practice in occupational therapy (5th edition pp 140-152). London: Elsevier Reference List

Pierce, S.L. (2008). Restoring Mobility. In M.Vining Radomski & C.A.Trombly Latham (Eds.) Occupational therapy for physical dysfunction (6th edition pp 817-853). Baltimore: Lippincott Williams and Wilkins Roberts, P., & Evenson, M. (2009). Settings Porividng Medical and Psychiatric Services. In E.S.Crepeau, E.S.Cohn, & B.A. Boyt Schell (Eds). Willard & spackman’s occupational therapy (11th edition pp 1074-1079). Philadelphia: Lippincott Williams & Wilkins Rogers J.C., & Holm, M.C. (2009). The Occupational Therapy Process. In E.S.Crepeau, E.S.Cohn, & B.A. Boyt Schell (Eds). Willard & spackman’s occupational therapy (11th edition pp 478-518). Philadelphia: Lippincott Williams & Wilkins Rogers, J.C. (2010). Occupational reasoning. In M. Curtin, M. Molineux, & J. Supyk- Mellson (Eds.) Occupational Therapy and Physical Dysfunction: Enabling Occupation (6th edition pp 57-65). London: Elsevier Rowland, J., Conforti, D., Basic, D., Vrantsidis, F., Hill, K., LoGiudice, D., Russell, M., Haralambous, B., Prowse, R., Harry, J., &Lucero K. (2006). A study to evaluate the Rowland Universal Dementia Assessment Scale (RUDAS) in two populations outside of the Sydney South West Area Health Service. Retrieved Oct 4, 2012 from http://www.fightdementia.org.au/comm on/files/NAT/20110303-Nat-CALD- RUDASvalidation2007.pdf Reference List

Spealstra, S.L., Given, B., You, M., & Given, C.W. (2012). The Contribution Falls Have to Increasing Risk of Nursing Home Placement in Community- Dwelling Older Adults. Clinical Nursing Research 21(1) pp 24-42 Van Huet, H., Parnell, T., Mitsch, V., & Mcleod- Boyle, A. (2010). Enabling engagement in self-care occupations. In M. Curtin, M. Molineux & J. Supyk-Mellson (Eds.) Occupational Therapy and Physical Dysfunction (6th edition pp 341-355). London: Elsevier Wancata, J., Alexandrowicz, R., Marquart, B., Weiss, M. & Friedrich, F. (2006). The criterion validity of the Geriatric Depression Scale: a systematic review. Acta Psychiatrica Scandinavica , 114 (6), 398-410 retrieved from http://onlinelibrary.wiley.com/doi/10.111 1/j.1532-5415.2005.53461.x/full Welch, S., & Lowes, J. (2005). Home assessment visits within the acute setting: A discussion and literature review. British Journal of Occupational Therapy, 68(4), 158-164 Reference List

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Occupational Therapy, Case Study Example

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Occupational Therapy: A Client Centered Analysis and Project Planning

Client Demographic and Medical Information

The client is a female who lives alone in her own apartment. She has had a post open reduction internal fixation on the right femur fracture and from it has developed respiratory abnormalities along the way. The said health status has been a result of a past accident while the client was on vacation. After the accident, the client had an operation on her right leg and was then transferred to another hospital later on due to the swelling of the operated leg. From there the swelling has imposed another form of problem which resulted to her respiratory function abnormalities.

Target Point of Development: Goal of Therapy (Daily Activities)

The client basically wants to function normally again especially when it comes to moving the legs freely and specifically breathing normally with no specific hindrances to the function of the respiratory system. Considerably, the process by which the therapy entails to respond to these problems is through imposing regular slow-walking activities that would gradually increase in time-length as the client begins to adapt to the therapy’s everyday nature. Along with that comes the daily breathing exercise that shall be imposed so as to make sure that the client’s breathing process would be further defined for improvement. Like the first type of development, the client’s breathing exercise shall first pick up from slow and short span of therapies towards longer spans hence increasing the capability of the client to perform long term breathing exercises.

Other Goals

Short Term Goals:

Activity: Assistance  to patient when it comes to dressing herself up [this shall include a 20 to 30 minute dressing up so as to make a considerable approach in helping the patient train to do the task]

Rationale: Patient expresses her desire to dress on her own without assistance later on but accepts the fact that as of now she needs to practice regularly to be able to attain the said state.

Activity: Assistance to patient when walking to and from her own kitchen and dining room. [the distance is pretty close and the activity is expected to be held at least three times per day with at least 10 minute session each practice]

Rationale: The client asks that she be assisted to walk around the house freely after the therapy

Long Term Goals:

Activity: Walking outside the house within the neighborhood for at least 10 minutes each day

Rationale: The patient wants to be able to walk around the neighborhood freely as she follows the pattern of recovery that the therapy intends to impose on her current health status.

Activity: The therapy shall involve a more defined way of allowing the patient gain full control of herself especially when it comes to standing up. The activity shall involve points of development in a gradual manner that includes standing freely for three minutes and later on shall adjust up to five-ten minute practices.

Rationale: Patient asks for assistance in standing up for long minutes without the need to feel extensive pain.

Occupational Therapy Interventions

Preparatory Method

The client should be specifically prepared in three different aspects of development specifically considering physical, mental and emotional factors of individuality. This will help the client inhibit a positive outlook of the situation that she is supposed to undergo during the entire therapy session. With the assumption of mental preparedness, the OT attendant could provide a summation of the goals that are to be achieved in the course hence giving the client an overview of what she would expect to happen after the application of the process of development being imposed through the therapy. This ideal assumption of development could be further imposed in the aspect of emotional and physical preparedness.

Purposeful Activity

In the process of preparation, it is important to have a correlative talk with the client which shall further help her redefine her being alongside the developments that she is supposed to incur through the time frame being completed for the therapy. The purpose of this approach is to make sure that the client knows what she is supposed to expect and further help her make a list of goals she herself would like to accomplish during and after the therapy sessions.

Treatment Session

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Occupational Therapy �Case Study: Rotator Cuff Injury Rehabilitation

Christine Ruhe

Basic Patient Information

• Middle-aged male
• In this report, patient will be referred to as Joe
• Injured his shoulder while working in delivery services on September 21, 2012
• Underwent rotator cuff surgery on right shoulder on March 6, 2013

Patient History

• Joe’s symptoms started in his right shoulder on September 21, 2012 when he was at work. Joe primarily works in delivery but is currently working in an office while in therapy. On September 21 st , while performing a delivery task, he pulled his right shoulder while pulling cases of beverages up a step. He describes it as feeling like it was pulled out of the joint and reports that there was extreme pain. Joe’s work involves the lifting of trays of beverages that are around twenty pounds each, totaling around 160 pounds being pulled when walking up steps. After participating in therapy with limited success, Joe was referred to a Hand Specialist at Excel Rehab & Sports. Rotator cuff repair surgery on his right shoulder was recommended and performed on March 6, 2013.

Rotator Cuff Repair

• The rotator cuff is a group of 4 muscles that stabilize the shoulder joint and allow a person to raise and rotate his/her arm
• Made up of the: supraspinatus muscle, infraspinatus muscle, subscapularis muscle, and the teres minor muscle
• A rotator cuff repair is when part of the muscle belly or tendon is torn
• Surgery may be used to treat a rotator cuff injury when damage is severe and/or if nonsurgical treatment has failed to improve shoulder movement and strength

Rotator Cuff Surgery

• “Surgery to repair a torn rotator cuff tendon usually involves:
• Removing loose fragments of tendon, bursa, and other debris from the space in the shoulder where the rotator cuff moves
• Making more room for the rotator cuff tendon so it is not pinched or irritated. This may include shaving bone or removing bone spurs from the shoulder blade
• Sewing the torn edges of the supraspinatus tendon together and to the top of the humerus”
• Source: http://www.webmd.com/a-to-z-guides/rotator-cuff-repair

Subjective Post-Surgery Evaluation

• Joe reported that pain at time of evaluation was 0/10
• Joe reported that his max pain level over the past week was 9/10
• Pain is reported on a 0-10 scale where 0 is no pain and 10 is maximum pain possible
• Prior level of functioning:
• Joe reported that he was independent with all ADLs (activities of daily life) and IADLs (instrumental activities of daily life)
• "I want to be able to just do daily activities and not have pain”

Objective Post-Surgery Evaluation

• Range of Motion
• SPROM (spontaneous premature rupture of membranes)
• Flexion: 70 degrees
• Abduction: 60 degrees
• External rotation: 10 degrees
• Internal rotation: 40 degrees
• Manuel muscle testing right shoulder and left shoulder, flexion, abduction, external rotation, internal rotation
• Not tested as per protocol
• Neurological
• Within normal limits
• Observation
• Scar lines healing well
• Apprehension to movement
• Scapular winging on right compared to left
• upper trap tightness
• Noted by Doug Lauber, OTR/L, CHT

Post-Surgery Evaluation Assessment

• Joe reported that he was having difficulty with all activities of daily life and of having poor endurance and strength

Post-Surgery Evaluation Summary

• Joe’s signs and symptoms are consistent with stated diagnosis
• Joe would benefit from therapy at this time to address:
• Decreased strength resulting in functional limitations with over head lifting
• Decreased active range of motion resulting in functional limitations with over head lifting
• Pain with activities of daily living, resulting in decreased function with bathing and dressing
• Functional issues present with safety issues in kitchen

Plan of Care Treatment

• Manual therapy
• Therapeutic exercises
• Neuromuscular reeducation
• Home exercise program
• Therapeutic activities
• *see protocol for specifics

Type 3 Rotator Cuff Repair �Arthroscopic Assisted – Mini-Open Repair�Large to Massive Tears (Greater than 4cm)� Protocol�

• Phase I – Immediate Post-Surgical Phase (Day 1-10)
• Maintain Integrity of the Repair
• Gradually Increase Passive Range of Motion
• Diminish Pain and Inflammation
• Prevent Muscular Inhibition

Phase I – Immediate Post-Surgical Phase� Protocol

• Sling or Slight Abduction Brace **Physician Decision
• Pendulum Exercises 4-8x daily (flexion, circles)
• Active Assisted ROM Exercise (L-Bar)
• ER/IR in Scapular Plane
• Passive ROM
• Flexion to tolerance
• ER/IR in Scapular Plane (Gentle ROM)
• Elbow/Hand Gripping & ROM Exercises
• Submaximal Gentle Isometrics
• External Rotation
• Internal Rotation
• Elbow Flexors
• Cryotherapy for Pain and Inflammation
• Ice 15-20min every hour
• Sleep in sling or brace
• Continue use of brace or sling
• Continue Pendulum Exercises
• Progress passive ROM to tolerance
• Flexion to at least 90 degrees
• ER in scapular plane to 35 degrees
• IR in scapular plane to 35 degrees
• Continue elbow/nad ROM and gripping exercises
• Continue submaximal isometrics
• Flexion with bent elbow
• Extension with bent elbow
• Abduction with bend elbow
• ER/IR with arm in scapular plane
• Elbow flexion
• Continue use of ice for pain control
• Use ice at least 6-7 times daily
• Continue sleeping in brace until physician instructs
• PRECAUTIONS
• Maintain arm in brace, remove only for exercise
• No lifting of objects
• No excessive shoulder extension
• No excessive or aggressive stretching or sudden movements
• No supporting of body weight by hands
• Keep incision clean & dry

Type 3 Rotator Cuff Repair �Arthroscopic Assisted – Mini-Open Repair�Large to Massive Tears (Greater than 4cm)

• Phase II – Protection Phase (Day 11 – Week 6)
• Allow healing of soft tissue
• Do not overstress healing tissue
• Gradually restore full passive ROM (week 4-5)
• Re-establish dynamic shoulder stability

Phase II – Protection Phase� Protocol

• Continue use of brace
• Passive range of motion to tolerance
• Flexion 0 – approx 125 degrees
• ER at 90 degrees abduction to at least 45 degrees
• IR at 90 degrees abduction to at least 45 degrees
• Active assisted ROM in tolerance
• ER/IR in scapular plane
• ER/IR at 90 degrees abduction
• Dynamic stabilization data
• Rhythmic stabilization drills
• Flexion/Extension at 100 degeres Flexion
• Continue all isometric concentrations
• Continue use of cryotherapy as needed
• Continue all precautions
• Initiate AAROM Flexion in supine (therapist supports arm during motion)
• Continue all exercises listed above
• Initiate ER/IR strengthening using exercise tubule at 0 degrees of abduction
• Progress Passive ROM till approx. Full ROM at Week 4-5
• Initiate prone rowing to neutral arm position
• Initiate isotonic elbow flexion
• Continue use of ice as needed
• May use heat prior to ROM exercises
• May use pool for light ROM exercises
• Continue use of brace during sleeping until end of week 4
• Discontinue use of brace at end of week 4
• May use heat prior to exercises
• Continue AAROM and stretching exercises
• Initiate active ROM exercises
• Shoulder flexion scapular plane
• Shoulder abduction
• Progress Isotonic Strengthening Exercise Program
• Sidelying ER
• Prone rowing
• Prone horizontal abduction
• Biceps curls
• PRECAUTIONS:
• No excessive behind the back movements
• No supporting of body weight by hands & arms
• No sudden jerking motions

Type 3 Rotator Cuff Repair �Arthroscopic Assisted – Mini-Open Repair�Large to Massive Tears (Greater than 4cm )

• Phase III – Intermediate Phase (Weeks 7-14)
• Full active ROM (weeks 10-12)
• Maintain full passive ROM
• Dynamic shoulder stability
• Gradual restoration of shoulder strength and power
• Gradual return to functional activities

Phase III – Intermediate Phase� Protocol

• Continue stretching & PROM (as needed to maintain full ROM)
• Continue dynamic stabilization drills
• Progress strengthening program
• ER/IR Tubing
• ER sidelying
• Lateral raises* (active ROM only)
• Full can in scapular plane* (active ROM only)
• Elbow extension
• *patient must be able to elevate arm without shoulder or scapular hiking before initiating isotonics; if unable, continue glenohumeral dynamic
• Continue all exercise listed above
• Progress to isotonic lateral raises & full can
• If physician permits, may initiate light functinal activities
• Progress to Independent Home Exercise Program (fundamental shoulder exercises)
• Phase IV – Advanced Strengthening Phase (Weeks 15-22)
• Maintain full non-painful ROM
• Enhance functional use of UE
• Improve muscular strengthen & power

Phase IV – Advanced Strengthening Phase� Protocol

• Continue ROM & stretching to maintain full ROM
• Self capsular stretches
• Progress shoulder strengthening exercise
• Fundamental shoulder exercises
• Continue to perform ROM stretching, if motion is not complete
• Phase V – Return to Activity Phase (Weeks 23-30)
• Gradual return to strenuous work activities
• Gradual return to recreational sport activities

Phase V – Return to Activity Phase� Protocol

• Continue fundamental shoulder exercise program (at least 4 times weekly)
• Continue stretching, if motion is tight
• May initiate interval sport program (i.e., golf, etc)
• **Protocol information obtained by the Advanced Continuing Education Institute, LLC
• www.advancedceu.com

Joe’s Therapy

• At Excel Rehabilitation and Sports Enhancement, Joe participates in Occupational Therapy. The Occupational Therapists and the Occupational Therapy Assistant assist Joe in his rehabilitation journey. After his initial evaluation after his surgery, Joe began therapy and has performed the exercises listed on the protocol for a rotator cuff repair.
• Joe is currently 6 weeks post-surgery; therefore, he is completing Phase II of the protocol (listed previously in this study)
• At Excel, he has the options of e-stem, IFC, and heat pads for his heat treatment prior to his exercises. Joe is usually put on the SciFit or NuStep machine (photo of both machines) for six minutes after his heat treatment. Typically, the pulleys (bottom photo) are next, followed by basic ROM exercises.
• With the continuation and eventual completion of therapy, Joe should achieve normal range of motion in his right shoulder in order to complete normal daily activities and achieve his therapy goal.