I am using the blog to release case studies in the musculoskeletal evaluation and intervention course that I teach in the occupational therapy program at CSU.
Sam is a 60 year old man who arrives at an outpatient clinic with a prescription from his doctor for OT services. He is having extreme pain in his right arm following an incident at work where a heavy door fell on him. AROM for elbow flexion is less than 45 degrees, he has trace movement in forearm pronation and supination, and AROM in wrist flexion is less than 10 degrees. He has no active wrist extension. The OTR is unable to complete PROM due to the pain. Left upper extremity is WFLs. Sam is worried about returning to work because he is the sole breadwinner in his family. He also has an adult son with a developmental disability who lives with his wife and him. His son requires 24 hour support for all ADLs. His wife provides that support during the days, but he helps in the evenings and on weekends. Sam does not have a lot of leisure time, but when he does, he likes to play golf and watch sports on TV or at the local bar with friends. Sam is having difficulty concentrating and sequencing due to his pain and he is getting frustrated as evidenced by decreased motivation with therapy – he thinks it is taking too long to get better. He has impaired sleep because “he can’t turn off his mind”.
Frank is a 35 year old man who was in a motorcycle accident 3 months ago. He was driving home from a family reunion in North Carolina when he had to maneuver around a deer that got in his way. Luckily, he was only traveling at 35mph and was wearing all his safety gear. He walked away from the accident with a broken left collarbone which needed to be pinned. All his upper extremity ROM is WFLs. His right upper extremity strength is 5/5 throughout with grip strength via dynamometer at 75 kg. His left shoulder strength in flexion is 3+/5, shoulder abduction is 3+/5, shoulder internal rotation is 5/5, and shoulder elevation is 4/5. His left elbow flexors are 5/5 while his elbow extensors are 4/5. His grip strength is 45 kg. He continues to have some difficulty with work tasks. He is a construction worker, mainly doing home remodeling projects – tearing out bathrooms, replacing tubs, sinks, and toilets, tiling, etc. When he is not working, he likes to stay active: mountain biking, kayaking, rock climbing, etc. He is getting frustrated because all of his activity is impacted by the collarbone injury. Frank has poor frustration tolerance and it is impacting his ability to participate in therapy. He has been yelling at the therapist while she is trying to complete passive range of motion exercises with him – “This doesn’t help!!”.
Kim is a 19 year old university student. Four weeks ago, she was walking to class and tripped going up the steps to the student center. She sustained a left radial head fracture. She is unable to actively move her left wrist or pronate or supinate her right forearm at this point in time. She has 75% AROM in her left hand fingers. She is unable to oppose her thumb to her fingers and she has limited thumb MCP and CMC motion (<50%). Thumb IP motion is approximately 45 degrees of AROM. The OTR assumes PROM to be WNLs at this point, but she is unable to get accurate measurements, due to Kim’s complaints of pain during all assessment procedures. Kim is also having difficulty with left elbow flexion – AROM into flexion from 25/100. She has difficulty with left AROM in shoulder flexion 0/75 and shoulder abduction 0/80. Right side AROM is all WNLs and right upper extremity strength is 5/5. Prior to her fall, Kim was volunteering with a student group to serve food at a homeless shelter on the weekends. She was also going to run for office on student government. Outside of school, she helps take care of her grandmother, who lives with her family. Her grandmother needs help with all ADLs – dressing, bathing, toileting, etc. In high school, she was very active and exercised daily by doing yoga and running with her friends. Kim wants to return to her previous level of activity but it has been challenging for her – she feels tired all the time and is having difficulty at school because she has decreased memory and attention. She has good motivation and realized that this is just “a bump in the road”.
Ginny is 95 years old and was admitted to the hospital with pneumonia. She has 5 children and her husband has been deceased for 20 years. Ginny grew up on a farm and she is a retired hospital volunteer. She is proud to tell the OTR that she is a great-grandmother to 15 grandchildren ranging in age from 1-8. She is active at her church where she helps recent immigrants find work. Ginny has difficulty with both her shoulders – AROM and PROM approximately 90 degrees of shoulder flexion. She has noticeable arthritic changes throughout her upper extremity, limiting her strength. Bilaterally in upper extremity joints, she is 3+/5. She wants to return home with her granddaughter and her granddaughter’s family who have been taking care of her for a few years. She uses a straight cane to walk. She is able to walk community distances, but needs to have someone walk with her. It tires her out, so she has to be careful about what she plans to avoid becoming overly fatigued. Ginny has good attention, memory, and thought. However, she has become labile due to the new disability that she is facing. She continues to have good motivation for therapy but the OT notices that she complains of decreased sleep and asks “Will I ever get back to where I was at before? I want to play with my grandchildren again!”.
Wanda is a 57 year old female who is a long term resident of a nursing home. She was in a car accident when she was 24 which left her cognitively impaired. Her parents were taking care of her until they had to stop, due to health problems. None of her siblings were able to provide the type of care that she needed. While walking back from BINGO activities at the nursing home, Wanda tripped over her untied shoe, fell and broke her right humerus. It has been 6 weeks and her arm is healing well. She continues to have decreased AROM in right shoulder flexion to 100 degrees, shoulder abduction to 90 degrees, and internal rotation to 25 degrees. She has full PROM in all these planes of motion and her left upper extremity is WFLs for PROM and AROM. Left upper extremity strength is 4/5. Prior to the car accident, Wanda was in university for architecture. She really likes to draw and participate in creative tasks, according to the activities director. She also loves to take care of the community parakeets that live on her unit, per nursing staff. Wanda has impaired memory and attention due to the remote motor vehicle accident. She is oriented to herself and place only (not time). She needs 24 hour supervision because she is unable to manage safety concerns in her environment and has difficulty sequencing simple ADL tasks. She is motivated by the parakeets and social activities within the nursing home.