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Several different options for Occupational Therapy Models
used to provide an integrative approach and guide occupation-based practice, clinical reasoning and OT-roles within chronic pain (and psychosocial) assessment and treatment.
Lived alone
Working as Call-Center operator for internet provider - Achieving well within her job
At time of referral
Unable to work due to problems with mobility and sitting
Moved in with her mother
Spends a lot of time resting
Minimal social contact
Significant financial worry and fearful about her limitations increasing in the future
Anxiety regarding origin of pain; i.e. cancer or other unknown cause for her pain
Significant anxiety and distress about family communication; Increasing difficulty communicating with brothers
Struggling with fact her identical twin sister is doing well and of a lower BMI
December 2009
Referred by obstetrician & Gynaecologist to:
Anaesthesia National Women’s Health - Pain clinic
Physiotherapy and Psychology input to help with function and coping strategies
July 2011
Gradual return to work and managing a four hour day (three times a week). Seemed to be coping better h/w no difference in pain.
Unable to increase hours (cause for further emotional distress & fear of loosing job). Trial with TENS during Physio (unsuccessful).
November 2011
Reviewed quite extensively by Gynaecologist:
- no real evidence of macroscopic organic disease on MRI
- no requirement for surgical input
January/ February 2012
Attended a six hour group education programme for women with pelvic pain
Inability to sit for more than approximately five minutes (on normal chair) at work: stress between her and her supervisors
Referral to TARPS completed => CPA done in November 2012
March 2013
Attended PMP at TARPS. Referred to OT in April at one month follow-up. (ACC approval received late June 2013)
November 2009
43 year old woman
Excision of small benign granular cell tumour left vulva
Left with ongoing vulvodynia
- Increase of pain (4-10/10) with any activity; walking, clothing rubbing is irritating
- Symptoms worsen as day goes on
- Relieved by resting in her lazy boy chair
Normal periods, bladder / bowel habits
Weight gain
Other history:
- Dysmenorrhoea
- Injury in her 30s where she fell hard on to a step leaving her with a bruised, tearing feeling through the left abdominal area and left buttock)
process in which; 'the clients motivation for occupation, habits and performance interact with facilitators and barriers in the environment'
Increase use of skills:
- Assertive communication
- Pacing and use relaxation within work day
- Regular exercise (for maintenance)
- Graded building; sitting tolerance
-Unsure on how to adapt her routine
-Back in old roles/ habits: doing unpaid
overtime
-Difficulty with implementing pain
management and coping strategies
- Physically fitter after PMP (however
reducing as not exercising)
- Many new skills after PMP on
communication, relaxation, pacing and
regular exercise (however minimal use)
- Elicit confidence and a sense of competence
and control
- Ax meaning and values of activities and roles
- Pacing and using relaxation during work
- Assertive communication
- Making time for her own health
- Relaxation/ reduction of anxiety
- Psychological strategies
- Lack on confidence (in own 'new' skills)
- Fear of ‘busting' or getting set-back
- Anxiety regarding communication with boss
- Anxiety regarding expectations and 'stress'
from family
- Break old routines, develop new habits
which includes coping skills
- Ax roles and patterns (work, family)
Outcome
- Pacing and using relaxation during work; able to find ways to do relaxation breaths in
between phone calls and during lunch time. Working twenty hours.
Employer now moving towards ending contract.
- Assertive communication; able to communicate own needs towards her boss and
her mother - h/w not towards brothers yet.
- Making time for her own health; able to plan four regular exercises per week.
Now going to the gym twice and going swimming twice per week. Also freed up time
for herself in the weekend.
- Relaxation; reducing anxiety with regular formal breathing/ relaxation exercises,
planned within her week. Regular informal breathing and taking things 'as they come'
- Thought management; using psychological strategies on a daily basis to 'check in' with
herself, stay positive and challenge own negative thoughts
Four sessions on consolidating learned skills and eliciting confidence to use these, maintain and monitor own performance and adapt to what best suits own health and own needs WITHIN OWN ENVIRONMENT!
Canadian Model of Occupational Performance and Engagement
Intentional Relationship Model - R. Taylor 2008
Taking in info of interest or relevance
Interaction through occupation ("doing")
Temporal, Physical, Sociocultural
Change over time by
thoughts/ feelings
created through doing
Understanding how 'occupation is motivated, organized, performed in and influenced by the context of environment'.
change in any area can lead to whole shift of system over time (healthy or unhealthy change )
Organized and structured behavior through
doing, habits, routines and roles of daily life.
-Consistent behavior = a habit
-Collection of habits = a trait
-Trait = learned behavior based on previous success and motivation.
-Cluster of traits = a role
-Traits and roles explain a persons motives and lead to Intentional functioning.
-Intentional Functioning is goal driven which leads to change
Values, Interest, Personal Causation
-Competence = attempt to become competent through experience
-Effectance = desire to cause effect through doing/ actions/ occupations
Skills; motor, processing & communication skills
available for "doing" activities
Lumbar flexion: 60º flexion and 25º extension (normal values = 60/25º)
Neck range of motion: 50º flexion and 50º extension (normal values = 45/50º)
Trunk strength and endurance: Able to hold Biering Sorenson’s test for 44 seconds (normal value = 60 seconds)
Sit ups: Able to do 4 (normal value = 20-23)
Push ups: Able to do 5 (normal value =13-19)
Grip strength: (combined) 36kg (normal values 61-65kg)
Dynamic box lift test: Able to repeat four repetitions of 10 kg (normal value = 4 x 12kg)
June 2011
50mg Amitriptyline nocte
20mg Xylocaine, no improvement
10mg Kenacomb injection (march 2011). Some increase in pain on steroid injection
1000mg Paracetamol x3pd
100mg Gabapentin x3pd introduced with plan for further slow increase
Pregabalin advised however not approved by ACC
Primolut and Ponstan (for menstual problems)
September 2011
All of the above with an increase in Gabapentin to 100mg-200mg-300/400mg
October 2011
10 mg Clomipramine nocte (instead of her Amitriptyline)
February 2012
1000mg paracetamol x4pd
300mg Gabapentin x3pd: short term memory loss and concentration difficulties
March 2012
75mg Pregabalin x2pd (trail): working well
1000mg paracetamol x3pd
100-200-300mg Gabapentin
25mg clomipramine nocte
May - June 2012
10-20mg Noratriptoline x1 nocte
2% Lignocaine hydrochloride x1 pd
Difficulty with ongoing funding ACC funding: Pregabalin stopped
July – November 2012
1000mg paracetamol x3pd
300mg x3pd Gabapentin: ongoing memory difficulties
25 mg clomipramine x1nocte
25mg Noratriptoline x1 nocte
20 mg Fluoxetine
2mg Diazepam for acute anxiety
300mcg/24hr Clonodine patch
November 2012
ACC funding restarted: re-application for Pregablin
January 2013
75mg Pregabalin x1 am, x2 nocte
June 2013 (post PMP)
1600mg Brufen SR x1 daily
2mg diazapam (increased frequency of use)