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Case Study: Training

by Louise Martinez

Rob, is a 55 year old gentleman who sustained significant crush injuries to his pelvic area in a work place accident. The polytrauma included; a fractured pelvis, haematoma, left lower limb numbness and left side lower back pain. Subsequently, Rob underwent external fixation to his pelvis along with a colostomy procedure.

Rob was discharged home mobilising with two elbow crutches following physiotherapy input. He did not receive an occupational therapy assessment in hospital, nor did he receive any follow up once he returned home. He was required to have a downstairs living arrangement as he was unable to manage the stairs. He was reliant upon his wife for assistance with strip washing downstairs as he was unable to access the bathing facilities on the first floor. Following discharge from hospital, and struggling with toilet transfers, the district nurse arranged delivery of a commode and a free standing toilet frame for the downstairs toilet.

Consequently, his case manager referred him to The OT Practice for an assessment to address the resulting difficulties in the home environment and to identify suitable equipment, adaptations or therapeutic interventions to enable Rob to be more independent around his home.

Following the OT assessment, it was established that Rob was unable to negotiate the stairs to access the bathroom and bedroom on the first floor, and these became his primary goals.

He was highly motivated to progress his mobility in using the stairs and without crutches. However, he had been told in hospital he may have had a thrombosis in his left leg. Although this was never confirmed, Rob became anxious about weight bearing on his left leg for fear of causing damage, or triggering thrombosis. The outpatient physiotherapist was reportedly reluctant to exert Rob as a result, and his physiotherapy intervention focused mainly on exercises rather than functional mobility before discharging him without progression from his crutches. This was very frustrating for Rob, who prior to the accident had been a highly active, independent individual, unused to being dependant on others.

His frustration at single room living in their dining room led to Rob attempting to mobilise further distances than injuries allowed in the first few months. Without proper guidance this resulted in several falls around the home. This was distressing for both Rob and his wife, who had given up work in order to care for her husband. She had become frightened to leave him at home for fear of him experiencing a fall. It became apparent through assessment that the client’s desire to progress and return to "normal" as quickly as possible was causing him to push himself beyond his boundaries. Rob was experiencing a typical ‘boom and bust’ pattern of fatigue whereby he was pushing himself as hard as possible to get around the house and return to walking. This left him exhausted and in the afternoons/evenings, he would fall asleep and be unable to complete any other tasks.

Rob and his wife were taught how to pace his daily activities, plan ahead and allow himself regular rest breaks. As he began to utilise pacing more effectively, it allowed him to conserve energy for other tasks during the day such as making himself a snack, or having a visit from a friend. Rob began to understand how his previous approach had been counterproductive. The OT established that Rob responded well to goal orientated treatment so larger goals were broken down into smaller tasks. This provided a sense of achievement for Rob and mastery of the tasks thereby alleviating some of his frustration. For example, Rob was desperate to complete the stairs on his own. We graded this task into him practicing a single step at the bottom of the stairs using both rails on a daily basis. Eventually he built up sufficient endurance and muscle memory to return to completing more stairs in a single go.

Once he had been trained how to pace himself, and his wife understood how to support him, he made safe and steady progress, and was no longer falling. Once he had been taught how to complete activities himself, such as washing, dressing, making a snack, his wife was able to return to work, confident that he would be safe.

A functional assessment of transfers and mobility was completed, during which it was ascertained that Rob was unable to bend, reach, or squat as a result of his orthopaedic injuries, nerve damage and oedema in his left leg causing reduced strength, and development of a significant abdominal hernia as a result of the pelvic injuries sustained. Although the injuries had healed well physically, Rob had developed a reduced confidence in his left leg, for fear of damaging it, or causing a thrombosis. He became reliant upon his wife for putting on his shoes and socks, and washing his lower half in the shower. Small assistive devices were provided such as a sock aid to enable him to don/doff his socks and shoes and a long handled sponge to attend to washing his lower half in the shower which enabled him to regain independence.

Further assessment of gait, balance and functional mobility in ongoing sessions identified that Rob had regained the ability to weight bear through his injured leg for short periods, sufficiently to enable him to begin to progress off the crutches. Having identified this strength, the OT designed a programme of exercises in his own home to be completed under supervision by his wife. Within 6 sessions Rob was able to mobilise indoors without any aids, and outdoors with a single elbow crutch. This dramatically increased his confidence and he felt more in control. This allowed Rob to safely practice his mobility in his own home, whilst reducing the risk of falls. The level of goal setting and tasks had been gradually increased and the pace of training increased as did Rob’s mobility.

Rehabilitation has been a prolonged and frustrating process for Rob, punctuated with the need for further surgical procedures and difficulty adjusting to his new circumstances. However, a difference in Rob’s ability to cope and adjust with his circumstances was noted during his final sessions. He reflected that being trained in the ability to pace himself with tasks had dramatically reduced his fatigue and pain levels and enabled him to achieve more during the day. In addition, he reported that training in how to use small aids such as a simple sock aid, had dramatically increased his independence and allowed him to reduce his reliance upon his wife.

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