Physical Therapy is the Best Treatment Option for Chronic Low Back Pain, Grace Walker, DPT, Walker Physical Therapy, Orange, Orange County, CA

Low back pain is the second most common reason for visits to the doctor’s office other than the cold and flu. Four out of ten American suffer from pain. According to Dr. Grace Walker, physical therapist and director of Walker Physical Therapy & Pain Center in Orange, CA, “The key to effectively treating chronic low back pain is avoiding too much medicine.” The American Pain Society states that for people suffering from chronic low back pain, physical therapy supported by evidence should be tried before surgery, invasive diagnostics, epidurals, and other interventional therapies.

The American Heart Association issued a statement on February 26, 2007 that recommends that doctors change the way they prescribe pain relievers for patients with pain. The American Heart Association advises that doctors start with non-pharmacologic treatments such as physical therapy before they prescribe pain relievers for patients with heart disease or for those who are at risk for heart disease. Many pain relievers that are currently prescribed for patients suffering from low back pain and joint pain have been associated with gastrointestinal complications and have indicated an increased risk of cardiovascular disease. According to Grace Walker, DPT, OTD, “The best option and the first option that should be used for patients suffering from low back pain is physical therapy.”

Many things can cause low back pain, however the most common causes are:
1.Early Arthritis - As we age, the daily forces from lifting, bending, and twisting can slowly wear on our backs.
2.Disc Problems – In our society we tend to sit a lot and the excessive sitting really takes a toll on the discs of our spine which leaves us vulnerable to injury. Most disc problems do not heal on their own.
3.Sprains/Strains – Even minor sprains and strains can take their toll on our backs and leave us more susceptible to more pain and more severe injuries.
4.Car Accident/Trauma – Some injuries can remain with you for many years so it is important to take them seriously and get thorough and complete treatment in order to prevent future problems.

The physical therapists at Walker Physical Therapy & Pain Center in Orange treat low-back pain gently and conservatively without medication, side effects, or invasive procedures. We use a combination of hands on care and an active exercise approach to provide effective results. The experts at Walker Physical Therapy & Pain Center focus on getting to the root of the problem and not merely treating the symptoms so that your pain stays away once your problem is resolved. Our solutions actually speed the healing process and make your body less vulnerable to re-injury and the return of pain.

Physical therapy is also one of the most cost effective choices for the treatment of low-back pain. Physical therapy costs less than expensive tests, surgeries, and endless prescriptions of pain medication. Our goal at Walker Physical Therapy & Pain Center is to provide patients with effective care that is long lasting and affordable. We are the experts when it comes to obtaining fast and effective relief of low-back pain.

For more information about your low pain problem, please call 714.997.5518 or visit our website at www.walkerpt.com.

Physical Therapy relieves Baby Boomers Back Pain by Grace Walker Doctor of Physical Therapy, Walker Physical Therapy, Orange, Orange County, Calif.

Because of increasingly demanding jobs, hectic daily schedules, participating in recreational activities, and caring for children, grandchildren, and elderly parents, back pain is becoming a common thread among baby boomers. However, this generation is less resigned to simply accept the changes brought about by aging, says Grace Walker, DPT OTD.Director of Walker Physical Therapy.

Baby boomers, those born between 1946 and 1964 and who now make up one fourth of the U.S. population, are leading more active lifestyles than previous generations. "Baby boomers are as active as they were when they were younger, but now they're living with chronic low back pain or osteoarthritis," says Grace. "These conditions as well as others can benefit greatly from physical therapy intervention."

and is not a substitute for a visit to a physical therapist or other health care professional.

"Frequently, patients may unknowingly exacerbate their pain by exercising improperly or by having poor posture," Walker says. Physical therapists can help to identify and correct those behaviors. Physical therapists work on increasing muscle strength and cardiovascular endurance, restoring and improving range of motion in joints, and decreasing muscle and joint pain. Secrets of back pain relief can be found at http.//walkerpt.com.

Physical therapy interventions may include therapeutic exercise, manual therapy, and functional training, as well as exercises for strength, flexibility, and range of motion, and devices designed to rest or support the joint, such as lumbar supports or pillows. "The goal of a physical therapist is to get you back to doing what you enjoy on a daily basis with as little discomfort as possible."

For those patients who either are just starting an exercise regime, or for injured weekend warriors just getting back in the game, Walker recommends starting off slowly and not doing too much too fast. She notes that physical therapists devise step-wise plans in order for patients to gain strength and mobility.

Walker also suggests investing in an ergonomically correct chair for work, taking frequent breaks from computers, and participating in stress-relieving activities, such as yoga or meditation, to offset back pain.

Physical therapists (PTs) are health care professionals who diagnose and treat individuals of all ages, from newborns to the elderly, who have medical problems or other health-related conditions that limit their abilities to move and perform functional activities in their daily lives. PTs examine each individual and develop a plan of care using treatment techniques to promote the ability to move, reduce pain, restore function, and prevent disability.

Post-Operative Treatment at Walker Physical Therapy by Grace Walker Physical Therapist, Walker Physical Therapy, Orange, California 92868

Post-Operative Treatment at Walker Physical Therapy
Physical Therapy is a key aspect of recovery after surgery.
“By increasing the muscle function and range of motion of patients that have undergone recent surgery procedures, we can promote a healthier recovery and minimize potential problems down the road. When we treat a body part it is important that we assess and evaluate the surrounding body parts to ensure maximum function and recovery.” –Doctor of Physical Therapy Grace Walker
Walker Most Common Post-Op PT Treatments
■ Spine Surgery
■ Elbow Surgery
■ Wrist/CT Surgery
■ TMJ/Jaw Surgery
■ TKR &THR
■ Foot and Ankle Surgery
■ Shoulder/RC Surgery
■ Knee Ligament Repair
Post-Operative Program Consists of:
1. Core Strengthening which targets deep trunk muscles to aid in stability.
2. Resistance exercise to increase functional movement.
3. Cardiovascular training to rebuilds stamina which has been shown to reduce pain incidence.
4. Mobility and Flexibility to overcome tension with gentle stretching and soft tissue mobilization.
Success Story: “On September 19, 2006 I had lumbar fusion surgery. I was having trouble walking and a bad balance problem. I needed to return to work the week of Thanksgiving (kind of hard to work when you have difficulty walking). I came in and the team had me walking on my own within a week. I was able to go back to work. With exercises and stretching I feel about 90% better, post surgery. I can’t thank all of you enough for all you’ve done for me. This is a great place. Everyone was helpful and understood my situation. All of you have been the best, and I would recommend Walker Physical Therapy to everyone.”
- D. Drehsen

WHEN IT COMES TO BACK PAIN “LESS IS MORE” by Grace Walker Physical Therapist, Walker Physical Therapy, Orange, California 92868

Orange, California, June 18, 2008 – When it comes to chronic back pain management patients should know that “less is more.” The American Pain Society at their annual meeting unveiled a current review on invasive procedures for the treatment of chronic low back. The scientific review concluded that most invasive interventions, including spinal joint injections, radiofrequency denervation, intradiscal electrothermal therapy demonstrated no evidence of effectiveness. Furthermore, surgical procedures for chronic low back pain demonstrated only small improvement in pain and disability but were accompanied by considerable risk.
"The expert panel reaffirms its previous recommendation that all low-back pain patients stay active and talk honestly with their physicians about self care and other interventions. "In general, non-invasive therapies supported by evidence showing benefits should be tried before considering interventional therapies or surgery," said Chou."
“The American Pain Society panel has acknowledged the central role of an active physical therapy program in managing low back pain patients,” noted Grace L. Walker, DPT, OTD and President of Walker Physical Therapy. “The key in chronic low back pain is avoiding too much medicine. There is no magic bullet but a combination of hands on care and an active exercise approach is the best solution.”

Carpal Tunnel Syndrome and Occupational Therapy... A case report, Grace Walker, Doctor of Physical Therapy and Doctor of Occupational Therapy

Clinical Case
Janice was referred to occupational therapy (OT)/hand therapy by her physician with a diagnosis of carpal tunnel syndrome (CTS) (ICD9 Code 354.0) on her right wrist, which happens to be her dominant limb, in order to address her lack of ability to sustain work, household and leisure activities. Janice is a 45-year-old female who owns her own computer-based financial advising business. Janice is also a single mother of two young children (a 10 year old girl and a 13 year old boy). Janice’s typical weekday includes working 8-10 hours per day, five days a week at her home-based computer workstation, meal preparation, and taking care of her children. On the weekends, she enjoys scrapbooking with her friends.
Before beginning any evaluation of physical structure and function, I administered the Canadian Occupational Performance Measure (COPM), which is used to identify and detect changes in a client’s self-perception of occupational performance over a period of time (Law, Baptiste, Carswell, McColl, Polatajko, & Pollack, 1999). From the COPM, I learned that Janice was extremely concerned about the welfare of her small company. She is unable to type for more than five consecutive minutes without symptoms of pain and paresthesia. Additionally, Janice stated that she has not been able to successfully modify the set-up of her monitor, keyboard, phone and calculator in order to decrease her symptoms. Janice also reported that she was having difficulties with certain instrumental activities of daily living (IADL). In particular, she has had difficulty with several aspects of meal preparation which includes: opening jars, cutting food, picking up heavy containers and preparing meals without increased symptoms. Although Janice’s primary concern was keeping her business afloat in order to support her family, these IADL concerns were also important to her since she has always prided herself in preparing and providing nutritious meals for her family.
In addition to her work and IADL concerns, Janice reported that she has not been able to engage in her desired leisure activity of “scrapbooking” since it increases her symptoms. She is having the most difficulty with performing certain scrapbooking tasks including: cutting photos with scissors into intricate shapes, using a “corner rounder” tool, cutting paper with a “trimmer” and manipulating the “tape runner” tool since these all three of these tools require a dynamic radial-digital grasp (Moffett-Boyd, Garbarini, D’Angelo & O’Sullivan, 2004). In addition, the “tape runner” tool also requires wrist flexion and extension. Finally, Janice reported having a difficult time sleeping at night. She believes that this is due to wrist pain at night and the stress related to not being able to perform her necessary work and cooking responsibilities.

Occupational Therapy Practice Framework
Domain
A domain in occupational therapy serves as the foundation for occupational therapy practice. It is based upon the provision of assistance to others in the experience of engaging in occupations. Such occupations have unique meaning in a person’s life. The domains in the Occupational Therapy Practice Framework (Framework) identify the various aspects that occupational therapists and occupational therapy assistants attend to during the process of providing services (American Occupational Therapy Association, 2002). These aspects include performance in areas of occupation; performance skills and performance patterns used to describe the observed performance when engaging in occupation; context, activity demands, and client factors known to potentially influence both performance skills and patterns.
In this clinical case, each relevant aspect of the domains is addressed in Table 1.



Table 1. Domain of occupational therapy applied to clinical case
DOMAIN
CLINICAL CASE
Performance in Areas of Occupation
When working with Janice, it was important to take into account all of the occupations in which she engages that may be impacted by her clinical condition. For Janice these included:
IADL: meal preparation
Work: completing work tasks such as typing (Job Performance)
Leisure: participating in scrapbooking activity (Leisure Participation)

Performance Skills
Motor Skills: Janice is uncertain of proper wrist positioning when performing various tasks, including using her computer keyboard, calculator and phone (Posture). She also has a difficult time manipulating pieces of paper when working on her scrapbook projects (Coordination). Janice also has a difficult time opening jars and cutting food in preparation for meals (Strength and Effort).

Performance Patterns
Habit: Janice continually demonstrates wrist positioning habits that interfere with functional performance in areas of occupation.
Role: Janice is a mother of two and works full-time to sustain her business and family. Symptoms from carpal tunnel syndrome have affected this because she is has had to take time off from work and has been unable to cook regular evening meals due to pain.
Routine: Janice’s routine has been affected in that she is forced to take numerous breaks from work throughout the day and has hired a helper to prepare evening meals during the work week.

Context
Social: Janice’s extended family does not live in the area and she reports having very few friends, since most of her time is spent working to sustain her family. Her closest friends are fellow scrapbookers.
Personal: Janice is a single mother with a single income. She has a business degree from a prestigious university and owns her own computer-based financial advising business.
Temporal: Janice’s typical day, prior to her injury, followed a strict schedule. She had allotted certain hours for work and certain hours to maintain her household and family. In addition, Janice’s business is in its busiest time of year (this consists of the last two months of the year when her clients are preparing their financial year-end strategies).
Table 1 (continued). Domain of occupation therapy applied to clinical case


DOMAIN

Activity Demands

CLINICAL CASE

Objects and their properties: Scrapbooking requires the use of scissors, a corner rounder, trimmer and tape runner (tools), and her work requires the use of a computer keyboard, monitor, mouse, phone and calculator (equipment), and meal preparation requires the use a knife, and the manipulation of objects such as jars and containers.
Required actions: Janice’s meal preparation requires lifting and moving cookware. Work requires Janice to sit and type for long periods of time. Scrapbooking requires Janice to engage in numerous hours of dynamic wrist movement.

Client Factors
Mental function: Janice has experienced nocturnal paresthesia, which has caused her to complain of generalized fatigue during the day due to lack of sleep, and has interfered with her daily occupations.
Sensory functions and pain: Janice experienced wrist pain and paresthesia while performing work, household, and leisure activities.
Neuromuscular and movement-related functions: Janice has experienced decreased wrist stability, mobility, and grip weakness (Body Function).

OT Process
The process of OT relates to service delivery, and includes evaluating, intervening and targeting outcomes (Brayman, 2004). The process is dynamic and interactive in nature. In addition, it is client-centered, which in this clinical case involved collaborating with Janice throughout each aspect of service delivery. An understanding of her concerns, problems and risks was the cornerstone of the process. It was important for Janice to understand that her whole being, not just the injury, was going to be addressed in therapy. In order to set the stage for this, I used the COPM, which offers clients the ability to discuss their injury in the context of their daily lives and relate their current perceived satisfaction (Law et al., 1999). Therefore, during the evaluation, I developed an occupational profile of Janice; analyzed her ability to carry out everyday life activities; and determined her occupational needs, problems and priorities for intervention. Throughout this process, I recognized that all interventions must be focused on Janice’s priorities in order to incorporate the value of client-centered approach.
Following the completion of the COPM and the development of the occupational profile, I performed an analysis of occupational performance for three of the needs/problems identified by Janice as priorities. These consisted of the following: difficulty in performing routine work duties, difficulty in preparing meals, and difficulty in performing scrapbooking activities. Janice reported that the primary reason for her difficulties in performing all three tasks was pain. During the analysis of occupational performance I gathered more specific information about her actual performance and the factors that support or hinder performance for each of her priorities (Tables 2-4). My initial hypothesis was that Janice’s decreased ability to perform tasks of daily life was due to poor wrist positioning, resulting in pain.

Table 2. Analysis of occupation performance for work
ANALYSIS STEPS*

Identify categories of occupation and specific contexts

CLINICAL CASE

Work (Job Performance)
Select occupational therapy theories or frames of reference

Rehabilitation Theoretical Concepts: This model focuses on the patient’s ability to perform ADLs with a goal of achieving maximum independence (Jacobs & Jacobs, 2004).

Model of Human Occupation Theoretical Concepts (MOHO): This model focuses on order and balance within the human system and the promotion of better health, rather than pathology (Jacobs & Jacobs, 2004).

Biomechanical Theoretical Concepts: This model focuses on mechanics of human movement (Jacobs & Jacobs, 2004).

Table 2 (continued). Analysis of occupation performance for work


ANALYZE STEPS

Observe performance


CLINICAL CASE

Janice was observed at a computer workstation in our practice which was set up to simulate her personal computer workstation.


Identify performance patterns
Janice demonstrated wrist positioning habits that interfered with work performance. For example, when typing she would position her wrists in extension by resting the proximal region of her palmar surface on the desktop. In addition, her mouse and mouse pad were placed 14 inches lateral to her monitor and keyboard which resulted in poor postural mechanics.

Analyze activity demands
Objects and their properties: Use of workstation (keyboard, monitor, mouse, phone, calculator)
Required body functions: Mobility of wrist joints

Select specific assessments
The following assessments were used:
· Goniometry - To assess range of motion (Horger, 1990).
· Dynamometer - To assess grip strength (Bellace, Healy, Besser, Byron, & Hohman, 2002).
· Visual Analog Scale (VAS) - Used before and after work related tasks as a self-perceived measure of pain (Bijur, Silver, & Gallagher, 2001). A score of “0” would be no pain at all and a score of “10” would be the worst pain possible.

Interpret data
Janice is experiencing difficulty in performing her computer workstation duties due to pain, paresthesia and impoverished habits.

Refine hypotheses
My initial hypothesis was that Janice’s decreased ability to perform tasks of daily life was due to poor wrist positioning resulting in pain. Therefore, Janice’s performance in daily occupations was affected. However, after completing specific assessments, I also found that Janice’s work station was set up in a way that did not promote proper upper body (trunk and cervical) positioning which may contribute to her overall discomfort when performing work related tasks. In addition, I discovered that Janice was experiencing stress, anxiety and frustration as a result of her decreased ability to complete her work responsibilities and support her family.




Table 2 (continued). Analysis of occupation performance for work


ANALYSIS STEPS

Revisit frames of reference





CLINICAL CASE

Based on my current understanding of the occupational performance problems, issues and factors that are affecting performance, I will continue to use the frames of reference that I initially selected (Rehabilitative, MOHO and Biomechanical
Theoretical Concepts) to guide my thinking about intervention (Kielhofner, 1997).

In addition, Janice’s psychosocial issues (increased stress and anxiety) will be addressed using the MOHO frame of reference from a psychosocial approach (Bruce & Borg, 2002).

Collaborate with the client
I collaborated with Janice to target reasonable outcome measures and to create goals to address these outcomes.

Select outcomes
Long term goal:
1. Janice will be able to independently perform work activities safely for an 8-hour day by her 8th treatment session.

Short term goals:
1. Janice will demonstrate the set up at her home based work station with moderate assistance and will adhere to ergonomic instruction in order to tolerate working a 3-hour work day by her 3rd treatment.

2. After skilled ergonomic instruction, patient will demonstrate the ability to safely sustain a 5-hour work day using adaptive equipment by her 5th treatment.

Delineate intervention approaches
· Modification approach
· Establish/restore approach
· Create/Promote approach
· Prevention approach
· Maintain approach
(*American Occupational Therapy Association, 2004)






Table 3. Analysis of occupation performance for meal preparation
ANALYSIS STEPS*

Identify categories of occupation and specific contexts

CLINICAL CASE

Instrumental activities of daily living (meal preparation).
Select occupational therapy theories or frames of reference

Model of Human Occupation Theoretical Concepts: This model focuses on order and balance within the human system and the promotion of better health, rather than pathology (Jacobs & Jacobs, 2004).

Observe performance
Janice was observed in doing a simulated cooking task in our practice (i.e. making a peanut butter and jelly sandwich).

Identify performance skills.
Janice demonstrated poor wrist positioning when performing cutting and jar opening tasks.

Identify performance patterns
Janice demonstrated wrist positioning habits that interfered with performance. For example, she placed her right wrist in extreme extension when cutting with a knife and when opening the lid of the peanut butter jar and jelly jar. In addition, she had difficulty manipulating the jar lids due to decreased grip strength. Furthermore, she complained of pain while spreading peanut butter on the bread.

Analyze activity demands
Objects and their properties: Use of knife and food objects such as peanut butter jar, jelly jar and loaf of bread.
Required body functions: Mobility of wrist joints and grip strength.

Select specific assessments

The following assessments were used:
· Goniometry - To assess range of motion (Horger, 1990).
· Dynamometer - To assess grip strength (Bellace et al, 2002).
· VAS - Used before and after cooking tasks as a self-perceived measure of pain (Bijur et al., 2001).

Interpret data
Janice is experiencing difficulty in performing meal preparation duties due to pain, paresthesia and impoverished wrist positioning habits.

Refine hypotheses
My initial hypothesis remains the same.


Table 3 (continued). Analysis of occupation performance for meal preparation




ANALYSIS STEPS

Revisit frames of reference.



CLINICAL CASE

Based on my current understanding of the occupational performance problems, issues and factors that are affecting performance, I will continue to use the Model of Human Occupation Theoretical Concepts to guide my thinking about intervention.

Collaborate with the client.
I collaborated with Janice to target reasonable outcome measures and to create goals to address these outcomes.

Select outcomes.
Long term goal:
1. Janice will cook a meal for herself with minimal assistance from her two children for their family dinner by her 8th treatment session.

Short term goals:
1. Janice will tolerate at least 15 minutes of bilateral fine motor activities with a reported VAS of less than 5/10 by her 3rd treatment session.

2. Janice will complete a 3-5 step cooking task with a reported VAS of less than 3/10 by her 5th treatment session.

Delineate intervention approaches.
· Modification approach
· Prevention approach
· Maintain approach
(*American Occupational Therapy Association, 2004)








Table 4. Analysis of occupation performance for scrapbooking
ANALYSIS STEPS*

Identify categories of occupation and specific contexts

CLINICAL CASE

Leisure (leisure participation)
Select occupational therapy theories or
frames of reference.

Model of Human Occupation Theoretical Concepts: This model focuses on order and balance within the human system
and the promotion of better health, rather than pathology (Jacobs & Jacobs, 2004).

Observe performance
Janice was observed in our practice doing simulated scrapbooking tasks.

Identify performance skills.
Janice demonstrated poor wrist positioning when performing scrapbooking tasks.

Identify performance patterns.
Janice demonstrated wrist positioning habits that interfered with performance. For example, she placed her wrist in extreme extension and radial deviation when cutting paper shapes and trimming pictures. In addition, she frequently rested the proximal region of her palmar surface on the table surface that she was working on.

Analyze activity demands.
Objects and their properties: Use of scissors and activity specific tools such as the corner rounder, trimmer, and tape runner.
Required body functions: Mobility of wrist joints and grip strength.

Select specific assessments.
The following assessments were used:
· Goniometry - To assess range of motion (Horger, 1990).
· Dynamometry - To assess grip strength (Bellace et al., 2002).
· VAS - Used before and after scrapbooking tasks as a self-perceived measure of pain (Bijur et al., 2001).

Interpret data.
Janice is experiencing difficulty in performing scrapbooking activities due to pain, paresthesia and impoverished habits.

Refine hypotheses.
My initial hypothesis remains the same.




Table 4 (continued). Analysis of occupation performance for scrapbooking



ANALYSIS STEPS

Revisit frames of reference.





CLINICAL CASE

Based on my current understanding of the occupational performance problems, issues and factors that are affecting performance, I will continue to use the Model of Human Occupation Theoretical Concepts to guide my thinking about intervention.

Collaborate with the client.
I collaborated with Janice to target reasonable outcome measures and to create goals to address these outcomes.

Select outcomes.
Long term goal:
1. Janice will independently complete 5 pages out of her 20 page scrapbook for her fathers 70th birthday by her 8th treatment.

Short term goals:
1. Janice will tolerate greater than 5 minutes using the necessary scrapbooking tools with a reported pain level of less than 3/10 by her 4th treatment session.

2. In order to complete her scrapbooking tasks independently, Janice will tolerate greater than10 minutes of activity with no more than one rest period by her 6th treatment session.

Delineate intervention approaches.
· Modification approach
· Prevention approach
· Maintain approach
(*American Occupational Therapy Association, 2004)


In general, my evaluation and intervention addressed several of the domains that influence occupational performance and recognized that these domains continually interact with one another. Because of this dynamic interaction, these factors, or domains, were frequently evaluated simultaneously throughout the process as their influence on performance was observed.
In working with Janice, I quickly recognized that she portrayed how clients often view themselves in relation to their occupational abilities and roles (Amini, 2004; Law, 2002). Janice’s limitations related to her CTS were interfering with her life roles, habits, time use, activity patterns, and occupational experiences, and these were creating in her a sense of dysfunction and yearning for normalcy. Therefore, I incorporated occupational activities to provide meaningful experiences. I chose this approach based on the Framework’s emphasis of “engagement in occupation to support participation.” For example, I paid attention to details of day-to-day functioning (ADL, IADL, work, play, and leisure), and included activities such as computer workstation simulation, meal preparation and scrapbooking activities. In addition, I collaborated with Janice and created short and long-term goals that related specifically to the areas of performance to which she wished to return. Furthermore, I provided the opportunity for Janice to work on activities that were true-to-life functions, allowing her to hope and believe that normalcy would probably return.
While the process of OT relates to service delivery, I found it important to keep in mind that context is an overarching, underlying and embedded influence on the process of service delivery (American Occupational Therapy Association, 2002). In working with Janice, I recognized that her external context could provide resources that potentially support or hinder her performance, as well as delivery of occupational therapy services. For example, during the beginning of the OT process, Janice did not have any support in the home. Instead, she was a single mother working full-time, raising a family and taking care of the household. This affected her ability to the gain full benefit of initial treatment sessions. Therefore, since her external context did not consist of available resources (i.e. family members or housekeeper) to contribute to daily tasks such as cooking, Janice was not supported by her external context. This aspect of her context was addressed throughout the OT process, which resulted in Janice learning new cooking strategies and techniques to promote proper wrist positioning and prevent pain. In addition, Janice started giving her children daily kitchen chores related to meal preparation.
Overall, based on my understanding of the Framework, I emphasized “engagement in occupation to support participation” throughout the dynamic process in this clinical case. Throughout the delivery of service to Janice, I recognized that all interventions must be focused on her priorities in order to have the greatest influence on her future actions (Law, 2002).

OT Intervention Approach
Intervention approaches are specific strategies that are selected to direct the process of intervention based on the client’s desired outcome, evaluation data and evidence (American Occupational Therapy Association, 2002). In order to address Janice’s specific desired outcomes, five approaches were implemented. A create approach (American Occupational Therapy Association, 2002) was used to provide Janice with an enriched activity experience that would enhance performance. Specifically, I created a series of scrapbooking sessions that included Janice’s closest friends. During these sessions, I was able to promote Janice’s participation by encouraging her friends to help out with tasks such as corner rounding and photo trimming. These scrapbooking sessions were beneficial to Janice, since she needed extra help in completing her father’s album in time for his birthday. During these sessions, proper postural positioning was promoted by having the participants in a large room with adequate table space and ergonomically-correct chairs.
The establish and restore approach (American Occupational Therapy Association, 2002) was also used with Janice since she needed to establish new work, meal preparation and scrapbooking routines in order to sustain work, household and leisure activities. In addition, this approach addressed the coping skills necessary to handle workplace demands, particularly those increasing stress and anxiety levels. Furthermore, this approach was used to restore Janice’s ability to complete her work, leisure and IADL activities with decreased pain and paresthesia.
A maintain approach (American Occupational Therapy Association, 2002) was used in order to retain and preserve all of her newly acquired habits. This approach focused on maintaining the capabilities that Janice had regained in order to continue to meet the daily demands of her work, meal preparation and scrapbooking activities. Through this approach, Janice was required to maintain appropriate breaks in her daily repetitive activities by using a timer to delineate breaks. In addition, Janice was required to maintain the ergonomic set up of her work station in order to promote continued safety of joints and positioning. The primary aim of this approach is to allow Janice to turn these newly acquired habits into life habits.
A modification approach (American Occupational Therapy Association, 2002) was used in order to revise Janice’s current context and activity demands in order to support performance. Specifically, the aim of the OT intervention was to modify her performance patterns, modify her computer and scrapbooking workstation, and modify her daily routines. With regard to her performance patterns, the intervention was directed at modifying wrist position during activities related to work, cooking and scrapbooking. In modifying her computer and scrapbook workstation, the positioning of equipment was altered to become more ergonomically correct, and certain equipment was added to support performance. For example, Janice purchased a new keyboard to promote proper wrist position during computer use. She also purchased an ergonomic “corner rounder,” which is used with a neutral wrist position and incorporates shoulder action rather than wrist action. With regard to modifying her daily routines, Janice delegated certain tasks related to meal preparation to her children. For example, she had her kids start taking out the garbage, setting the table, cleaning up dishes, and wiping the counters. In addition, I also promoted the modification of Janice’s routine by teaching her alternative approaches to cooking. For example, I suggested she use recipes with fewer ingredients, use the crock-pot, and use frozen chopped vegetables.
A prevention approach (American Occupational Therapy Association, 2002) was also used in order to address client-body structures. In particular, Janice was instructed to wear a wrist splint at night in order to prevent pressure on the median nerve which was producing pain and paresthesia (Li, Lili, Masako, & Warren, 1999).

Types of OT Intervention
Intervention is the process of putting the plan into action. The first step of intervention implementation is to determine and carry out the type of occupational therapy interventions to be used. In this clinical case, I used four interventions consisting of the therapeutic use of self, therapeutic use of occupations or activities, consultation process, and education process (American Occupational Therapy Association, 2002).
Therapeutic Use of Self Intervention
For my intervention (addressing all occupations), I planned to use my insights, perceptions and judgments as part of the therapeutic process. In particular, my goal was to base my insights, perceptions and judgments on my exposure and understanding of evidence-based research (American Occupational Therapy Association, 2002).
Therapeutic Use of Occupations and Activities
For my intervention (addressing all occupations), I also planned to prepare Janice for purposeful and occupational-based activities (therapeutic use of occupations and activities: preparatory methods). The preparatory methods included wrist splinting, nerve tendon gliding exercises (Appendix A), manual therapy, and home exercise program (Akalin et al., 2002; Gerritson, DeVet, Scholton, Bertlsmann, De Krom, & Bouter, 2002; Li et al., 1999; Tal-Akabi & Rushton, 2000; Totten & Hunter, 1991).
My intervention also included purposeful activities that allowed Janice to engage in goal-directed behaviors and activities within a therapeutically designed context in order to lead to occupations (therapeutic use of occupations and activities: purposeful activity) (American Occupational Therapy Association, 2002; Pedretti & Early, 2001). Different purposeful activities were included based on their relevance to the three primary occupations designated (working, cooking and scrapbooking). Purposeful activities related to working included educating and simulating proper workstation ergonomics, such as wrist position with keyboard and mouse, monitor position in relation to body, feet position and placement of the telephone (Keir, Bach, & Rempel, 1999; Rempel, Tittiranonda, Burastero, Hudes, & So, 1999; Seradge, Jia, & Owens, 1995; Silverstein, Fine, & Armstrong, 1987; Szabo & Chidgey, 1989). The intervention included practicing, simulating, and role-playing these activities.
Purposeful activities related to cooking included practicing unscrewing lids and opening jars, using dycem, using adaptive equipment to slice vegetables, using rocker knives, and using an electric can opener. Additional purposeful activities related to cooking included partially opening packages with scissors prior to using hands, practicing using two hands when lifting and carrying items, and practicing using proper wrist positions when manipulating cooking objects and making peanut butter sandwiches. Purposeful activities related to scrapbooking included education and simulation of posture and wrist positioning similar to that given when addressing work station ergonomics, and practicing several scrapbooking activities while focusing on proper wrist positions. These activities included corner rounding, photo trimming, and using the tape runner.
My intervention also allowed Janice to engage in actual occupations that were part of her own (therapeutic use of occupations and activities: occupation-based activity) (American Occupational Therapy Association, 2002). In relation to work, Janice implemented ergonomic strategies and techniques at her home workstation over an 8-hour workday. In addition, she practiced relaxation techniques in her own environment (Astin, 2004). Janice also made a home-cooked meal for her family (cooking), and was able to complete her dad’s photo album for his 70th birthday (scrapbooking).
Consultation Process
My intervention consisted of an ongoing collaborative process in which I worked with Janice in identifying the problem, creating different solutions to promote the most functional way of doing things, trying out the solutions, and making necessary modifications as indicated (American Occupational Therapy Association, 2002).
Education Process
My intervention consisted of a process in which knowledge regarding occupation and activity was conveyed to Janice in both verbal and written formats. In reference to all occupations (working, cooking and scrapbooking), I gave Janice the AOTA Carpal Tunnel Syndrome Pamphlet (Appendix B) and a 3-part cumulative trauma prevention videotape series (Comprehensive Loss Management Educational Opportunities, 1990). with regard to each of the three occupations, I gave her occupation-specific handouts which described ergonomically correct workstation concepts, proper wrist positioning during occupation specific activities, and tips on how to modify your workstation (e.g. placing your mouse pad closer to your keyboard, using a step stool in the kitchen, making sure your seating is positioned at the proper height) (Appendix C). In addition, Janice was given a handout illustrating scrapbooking ergonomic principles (Appendix D). Each of these occupation-specific handouts included pictures to provide Janice with a visual examples.
Outcomes
Outcomes Related to Assessments
Before beginning any assessment of physical structure and function, I administered the COPM, which is used to identify and detect changes in a client’s self-perception of occupational performance over a period of time (Law et al., 1999). The COPM is comprised of three scales which are importance, performance and satisfaction. Upon completion of the initial COPM evaluation, it was determined that the three activities of work, meal preparation, and scrapbooking were of greatest importance to Janice (importance scores of 10/10, 9/10 and 9/10, consecutively). The performance and satisfaction scales were completed at Janice’s initial evaluation and at her discharge. A score of “1” on the performance scale would reflect “not able to do it” whereas a score of “10” would be reflect “able to do it extremely well.” A score of “1” on the satisfaction scale would reflect “not satisfied at all” whereas a score of “10” would reflect “extremely satisfied.” The COPM has been proven to be reliable, valid and responsive (Baptiste, Law, Pollack, Polatajko, McColl, & Creswell, 1993; Law, Baptiste, McColl, Opzoomer, Polatajko, & Pollack, 1990).

Table 5. COPM Findings
PROBLEM

IMPORTANCE

1st
TREATMENT
PERFORM.
SATISFACTION
8th
TREATMENT
PERFORM.
SATISFACTION
Work

10
2
1
8
9
Meal
Preparation
9
3
1
8
9
Scrap-
booking
9
2
1
7
9

Pain intensity was quantified using the Visual Analog Scale (VAS). With this scale, a score of “0” is no pain at all and a score of “10” is the worst pain possible. VAS which has been proven to be reliable and valid (Bijur et al., 2001). Janice’s VAS was recorded at her 1st treatment as an 8/10 and at her 8th treatment as a 1/10. I also found this to be an effective tool in measuring Janice’s level of pain before and after activities related to work, meal preparation and scrapbooking.
Bilateral wrist and radioulnar ROM were taken to compare Janice’s affected right (R) wrist with her unaffected left (L) wrist. A goniometer was used to measure wrist flexion, extension, ulnar deviation, radial deviation and radioulnar pronation and supination (see Table 6). These goniometric measurements have been proven to be reliable and valid (Horger, 1990).
Table 6. ROM of bilateral wrists at 1st treatment and right wrist at 8th treatment
WRIST AND RADIOULNAR
1st TREATMENT
8th TREATMENT
ROM
RIGHT
LEFT
RIGHT
Flexion
38°
75°
65°
Extension
52°
70°
60°
Radial Deviation
12°
15°
15°
Ulnar Deviation
28°
30°
30°
Pronation
70°
80°
80°
Supination
70°
80°
80°

Janice’s grip strength was measured using a JAMAR Deluxe Hand Dynamometer, using the second grip handle. The average of three successive readings was taken for each hand in a supported sitting position with the elbow flexed to 90 degrees in mid pronation and supination and the elbow resting on the table. The JAMAR adjustable hand dynamometer has been proven to be a reliable measure of force production (Bellace et al., 2002). Janice’s grip strength was measured at her 1st treatment and 8th treatment (see Table 7).

Table 7. Grip strength in kilograms of force of bilateral wrists at 1st treatment and right wrist at 8th treatment

GRIP STRENGTH

1st TREATMENT

8th TREATMENT

RIGHT
LEFT
RIGHT
Trial 1
32
40
36
Trial 2
35
43
39
Trial 3
36
39
38
TRIAL AVERAGE
35
40
37.7


Outcomes Related to Framework

Table 8. Outcomes related to Framework
OUTCOME

Occupational performance

CLINICAL CASE

Janice’s occupational performance improved, resulting in increased independence and function with work (work) scrapbooking (leisure), and meal preparation (IADL).

Client satisfaction

Janice attained a high level of satisfaction as measured by the COPM.

Role competence
Janice is now able to meet the demands of her work and meal preparation responsibilities. In addition, she is able to enjoy her desired leisure activity with significantly decreased pain.

OUTCOME CLINICAL CASE
Table 8 (continued). Outcomes related to Framework



Adaptation




Janice demonstrated the necessary strategies to handle pain and paresthesia, as well as work-related stress.

Health and wellness
Janice’s interventions were designed to achieve health and wellness. She appears to be enjoying and appreciating the fact that her symptoms have decreased and she can take pleasure in a balance of work, family and leisure activities.

Prevention
Janice followed the advice of the OT team and by lifestyle redesign was able to meet her highest level of functional
performance. It is expected that this lifestyle redesign will enable Janice to continue performing at the necessary level and prevent the return of symptoms (Clark, Carlson, Jackson, & Mandel, 2004).

Quality of life
Overall, Janice’s quality of life improved through interventions, which resulted in participation in her most important occupations. This participation positively affected her socioeconomic status (she was able to sustain her business), self concept (she was satisfied that she could accomplish her necessary daily tasks), and functioning (she was able to demonstrate competence both at home, work, and in her leisure activities).


REFLECTION
Through the process of understanding the Framework, I have come to realize that a fundamental aspect is the top-down approach to evaluation. When initially exposed to this concept, I was apprehensive and uncertain about how it could be utilized when working with clients with CTS. However, upon completion of this project, I have a strong understanding of the importance of beginning my evaluation of clients with CTS with an examination of their occupation performance in order for that examination to be grounded in a client-centered/top-down approach. More specifically, I have developed new strategies to incorporate and emphasize the importance of client satisfaction with the level of functional performance, engagement in desired occupations, and objective determination of safety in the goals of therapy.
By going through the process of this project, it became clear to me that using this approach in directing the focus of an evaluation determines the goals and outcomes of treatment. An illustration, presented in one of my readings, of the application of these new concepts to clients with CTS solidified these concepts for me (Bonzani, 2003). The primary premise of the illustration was that often occupational therapists focus their attention on the compressed median nerve when working with clients with CTS. However, the reality may be that an occupational therapist can do very little for the compressed nerve, but a great deal for the person that is attached to the compressed nerve. I have come to realize that as an occupational therapist I need to integrate my advanced technical skills (such as biomechanical assessment) with the core concepts of the client-centered approach. Within my arena of practice, the common notion has been that knowledge of protocols and the particulars of tissue healing physiology are what make hand therapy practitioners experts. However, it has become clear to me that this focus on the discrete physical impairment can detract from the client-centered, holistic focus which is encouraged through the Framework. I feel that this realization has allowed me to go beyond “function” in my practice and return to the roots of occupational therapy. With regard to hand therapy, I now believe that there is a need redefine “traditional” hand therapy practice within the context of the Framework (Amini, 2004).
With regard to my practice, we have developed a plan to re-integrate the basic tenets of OT by adopting the principles of the Framework. This process will begin with presenting a series of inservices on the Framework to my therapists and staff. As a side note, I should mention that I have been informally sharing concepts of the Framework over the past few months with several of the occupational therapists within my practice. These therapists have had minimal exposure to the Framework; however, they are very familiar with the Uniform Terminology for Occupational Therapy-Third Edition (UT-III). Therefore, these inservices will include a section focused on the similarities between the Framework and the UT-III. In addition to the monthly inservices, we will begin to present a client case scenario that has incorporated the Framework once a month. The integration of the Framework into our clinic will include the development of new evaluation and documentation forms which integrate the Framework’s principles and language.
While my initial exposure to the Framework has been predominately positive, some weaknesses have been evident. In my opinion, the primary weakness of the Framework is that it is lengthy and slightly obscure, particularly for a therapist that has not had any prior exposure to it. As a practical matter, these characteristics do not lend to therapists casually “picking it up” or learning the concepts on their own time. Rather, it necessitates formal instruction and education in its principles and application. In my view, the Framework could be stronger if it were more concise and practical with less jargon for third-party payers and other members of the team who may view the document. Specific improvements would include examples expanded under outcome measures and explanation of roles.
The process of applying the Framework to my clinical case was fairly easy when done in a step-by-step methodical manner. In this particular clinical case, I found that applying the principles of the Framework allowed me to effectively use the COPM, which set the stage for the client-centered approach. In my experience, the strengths of the Framework included its layout and format, comprehensive approach, link to UT-III, and outcomes accountability. Overall, I found that the Framework truly spelled out the scope of our practice broadly from evaluation to treatment. In summary, I believe I have developed a solid understanding of the Framework, which has enhanced my personal vision of occupational therapy.





















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