April Challenge: make a new handout

How old are your patient/parent handouts? Were they written on a typewriter? Are they mimeographs? Do they have big black splotches from the year of the bad copier? It's time to upgrade!

Today's challenge is to make a new patient/parent handout. It's possible that nothing has changed in the whole world and all the information on your handout is still relevant. But you've probably been to courses and gotten new insights into things, your surgeons have been upgrading their techniques, adaptive equipment has changed in price and new research has changed the treatment protocol. So pick one handout and try to give it a makeover.

Your "makeover" might include printing on letterhead, adding graphics or pictures, or checking to make sure that the reading level is one that will be accessible to your clients. A 6th grade reading level was recommended when I was in school, MS Word has a tool for this and there are online scripts to check as well. Another update you might perform could be making copies of your handouts in Spanish (this will probably need to be run by an office in the facility to check for accuracy).

There are great Fact Sheets on OT provided free by AOTA which cover a multitude of settings and case populations. I liked to give these out in the clinic when people came in for an evaluation so that they would have a good idea of what to expect. Super Duper Publications also has a great number of handouts for those that work in pediatrics.

If you create a great handout, consider sharing it through an OT forum or online through Google Docs. Here's a link to my Homemade Adaptive Equipment handout with computer translated Spanish, and a link to my Heavy Work handout. Leave a comment if you have something to share!

Jobsite Analysis

So I did complete my jobsite analysis long ago, and it was actually simpler than I expected. I was evaluating a worker in the microbiology lab with a diagnosis of writer's cramp. I am finally getting this written up for the blog carnival on clinical reasoning, so make sure that you check that out. If you're new to this blog, perhaps forwarded from the carnival, please be patient since I tend to write long entries :)

OK, background information, since this happened so long ago. As a hospital OT, I was asked as a courtesy to perform a worksite evaluation of a woman ("Wilma") who was having difficulty at work due to a diagnosis of writer's cramp. Before I was asked to do this, I had no experience in work hardening outside of school classes, virtually no experience in hand therapy, or any idea what life was like in the microbiology lab. I was a little bored and willing to take on a challenge, so that's how the eval fell to me. Please note- there is a significant difference between the clinical reasoning used by novice, intermediate, and experienced practitioners; that was all fleshed out in a recent OT Practice CE article. I am not claiming to have an experienced level of reasoning, I just did my best.

My first thought was shock that "writer's cramp" was an actual neurological diagnosis. I mean, I have played Operation, and have had significant pain after essay tests in college filling up Blue Books, but I had no idea that this was real. So I looked online for information on the diagnosis from reliable sites, which included eMedicine, Merck Manual Medical Library, and Medpedia. I learned that this was a focal dystonia and a repetitive strain injury (RSI) that would likely cause increased pain and decreased grip force on small objects.

Next, I went back to my OT bookshelf. I still have many of my texts, but especially those for topics that I found interesting or complex. (I have found it unfortunate how much I have already forgotten from school in topics that have been outside my realm of practice) From my book, I was able to review environmental factors that exacerbate RSIs and go through case studies involving worksite evaluations for desk workers. My book was nice in that it also came with some ready-made forms to record measurements of various workstation pieces (example- depth of chair pan, height of chair from floor). I also asked my coworker if I could review a writeup that he had done for a different person, so I could get an idea of what was expected.

I was feeling more prepared, but still didn't know what to expect in Wilma's office. What does a person in a microbiology lab do? Where to find out? My favorite source for torturing my Girl Scouts when they're doing a career badge- The O*Net. If you haven't used the O*Net before, it's a great resource that has cataloged thousands of jobs, the skills required for each, the expected salary and job outlook for each. So I was able to pull up "Biological Technician," which gave me a few brief ideas aobut what to expect.

After gathering all this information, I spent some time trying to brainstorm possible problems that Wilma might be having. Writing, obviously, but I also thought that she might have some difficulty with manipulating other small-diameter tools, keyboarding, opening or stirring containers.

The morning of the evaluation, I got my tools together- a notebook, copies of the measurement forms from my book, digital camera, tape measure, and a goniometer.

I met with Wilma at the beginning of the day since that is when the bulk of her work was done. I asked her to describe the problem, describe the pain she was having, what made it better or worse and what she had already tried to do to fix the problem. I also asked about what she had done medically- neurologist visit, MRI, EMG, etc. Then I let Wilma go ahead and start her workday, trying to see as many of her essential job functions as possible, and asking her to report anything that caused discomfort or decreased grip. I observed the tools that she interacted with, and any time I saw something that was on my list of possible pain causers or looked like it would aggravate the RSI, I asked specifically aobut that. That included vibration, twisting, squeezing, of various tools including pipettes and cotton swabs. I also took some measurements (not a full spectrum of them) related to the position of Wilma's UE to the work surfaces.

My client was quite reticent throughout the eval, and had relatively few issues. She really only complained of difficulty writing, not with any of the other tools. I knew from my education on RSIs, phyical disabilities and assistive technology that to decrease problems from a tight grip on a small object, that the person would need to change the shape of the grip or the amount of force taken to maintain the grip. I tried to include a variety of high and low tech solutions in my suggestions, and also address other issues that I felt could potentially be a problem to Wilma.

I have the summary writeup in a google document (as always, please be respectful and do not plagiarize my work). All the photos are from Sammons/Preston to give the reader a better idea of the different tools. If it had been me, I would have pushed for a label maker, because I think that would be best for efficiency sake (that and I love labelmakers anyway). I also found a $0.49 pen shaped similar to the PenAgain in a drugstore months later, so there are other options out there in the mainstream. I didn't get any follow up from this client, so I don't know what she chose to do, but I did leave the door open so that if she had any questions or problems later she could contact the department.

So that's the thought process that carried me, an inexperienced practitioner, through my first worksite eval. If anything, I think it was worth it just to get the experience and learn that I do have the foundation for a different type of practice.

Merry File Sharing Day!

So I finally took my memory key to work and got my files off of there. Browse as you wish, I only ask that you do not plagiarize or submit works as your own, but feel free to print for patients. Burst ahead for file-sharing goodness!

OK... so apparently, you cannot upload text files or pdfs to OT Connections. Therefore, it cannot be the prime sharing source. Please let me know if the google documents do not show up correctly and I will email the item to you.

Homemade Adaptive Equipment- instructions for making sock aid, dressing stick, and long sponge in English and Spanish. I ran it through a translator, please don't blame me for the grammar. Speaking of long handled sponges & shoehorns, I always send people to the drugstore or dollar store for these items.

Potential Friends Worksheet- I made up this simple sheet for a child w/ Asperger's who was really upset about not being able to make friends. He liked to plan things out, so we tried breaking down introductory conversations step by step, and then practiced one of these with a PT on break.

Heavy Work Handout- Here's a handout on different heavy work activities, it's mostly for parents but does have a few ideas for classrooms. I did borrow and compile from different sensory resources, the main 2 are referenced.

Yoga Exercises for your Back- I copied and pasted out selected yoga exercises that work on back muscles, unfortunately, I cannot remember the source site.

Tips to Decrease Back Pain (for children)- Here are some child-specific strategies to reduce back pain.

UE AROM handout- goes through basic arm stretches in layman's terms.

I have a hip precautions handout, but only in pdf... I'll have to copy it into word format before sharing.

As an extra bonus for those of you who have read so far down the page, I will tell you that I found ALL of my files from school on this magical memory key, and will share them as quickly as I can, but it will be difficult as I am probably busier this time of year more than any other. There's some great stuff, and one early post will have to be on old-school homemade AE. For other great pediatric handouts, try Super Duper Publications and of course AOTA has great consumer tip sheets.

Case Example with Goals

A review of "recent keyword activity" leading to the blog indicates that there's a lot of people out there looking for example goals and treatments for different diagnoses. I'll try to do some posts in this direction, please don't plagiarize them for your school assignments.

Here's a walkthrough case to see the clinical reasoning behind the goals that are written, and a few example goals.


CASE: Mr. X is a 65 y.o. s/p THR on the acute orthopedic floor. He lives alone, has a tub/shower, and was previously independent with all I/ADLs. He would like to return to full independence.

SETTING BACKGROUND: Heads up- in an acute hospital, your basic joint replacement patients w/o significant comorbidities or post-op complications will leave the floor in 3-5 days. Case management will look to therapy to determine where this person will go (home, SNF, acute rehab). The lack of time for intervention means that your treatments need to cut to the point, so you can give an accurate expectation of how the client will perform in the continuing days, and whether they must have continuing care.

IMPORTANCE: Goals at this level of care have to reflect the quick pt. turnover. What are the most important things for Mr. X to learn and demonstrate before he discharges to maximize his safety and independence?

My ranking: hip precautions; basic mobility; LE dressing; advanced mobility (tub transfer, standing tolerance); home safety. Your clinical reasoning may place importance in a different order, here is my reasoning. He must know hip precautions before moving, to prevent dislocation and repeat surgery. He must be able to stand and take at least 1-2 steps so that at the very least he can get from w/c to BSC, and to facilitate dressing. We have no evidence from our brief case that this man would have any difficulty w/ UE dressing, but he cannot be independent unless ADL retraining is performed for LE dressing. He needs to be able to put on pants and shoes, or he is not going to have anything resembling independence upon discharge. At the point that he can stand up long enough to put pants on, he is probably ready to progress to advanced mobility, and I consider tub transfers to be especially important. It's better to review this in a controlled environment before the pt. goes home and decides to do it anyway. And home safety is always a good thing to work on with your patient, to try to prevent falls and maximize independence. If you, like me, do not get to leave the hospital to investigate the home, you will have to get creative with this.

GOALS
In 3-5 visits, pt. will...
1. verbalize and demo 3/3 hip precautions (we are assuming he doesn't have the extra 'no active abduction' precaution)
2. transfer to BSC w/ CGA and assistive device
3. don socks w/ sock aid independently
4. don pants w/ AE prn and CGA (I almost always use the "AE prn" phrasing since different devices work better for different people, and I have actually seen a person don pants independently w/o any device while observing hip precautions)
5. perform safe tub transfer to extended TTB w/ CGAx1
6. verbalize/demo 3-5 home safety techniques



The best way to get better at writing goals and treatment plans is to practice and get feedback from a trusted advisor- professor, supervisor, etc. The best exercise I know for this is detailed in this simple document. I have not completed an example there as this was an assignment from one of my teachers, and surely others are using it as well.