Salasiah Ismail 2009776589 CLIENT DATA COLLECTION The clients name is pseudonyms.

This case scenario is get from clinical setting at Malacca Hospital. Marina is 245 year-old Malay woman. She was diagnosed as closed fracture left radius with Distal Radius Ulna Joint (DRUJ) disruption. She was hospitalized after sudden accident and inward for 13 days. An operation has done for Dynamic Compression Plate (DCP) at left radius. She has a restaurant and works as a chef at her restaurant. After she was discharged from ward, Marina was then referred to occupational therapy department for further treatment in splint and hand therapy. At this present condition, Marina had dry wound and scar noted on volar forearm, ulnar styloid displacement noted, complain of pain, limited Range of Motion (ROM) at left hand, able to do all fingers opposition, and able to do all hand prehension (hook, cylindrical, and spherical grasp).

ETIOLOGY OF THE CLINICAL CONDITION She had closed fracture left radius with DRUJ disruption. In a close fracture the skin is either intact, or if there are any wounds these are superficial or unrelated to the fracture. So long as the skin is intact, there is no risk of infection from outside. Any haemorrhage is internal (Duckworth, 1995). Dislocation of distal radioulnar joint (DRUJ) may be seen in association with Galeazzis # or distal radius/ulna fractures. May be an isolated injury without fracture. Mechanism of injury is fall on an outstretched hand with hyperpronation (dorsal dislocation of the ulna) or hypersupination (volar dislocation of the ulna); or hand caught in rotating machinery (forced pro/supination). Forcible rotation of the wrist causes triangular fibrocartilage complex disruption which is the major stabilizer of the DRUJ (may also result in avulsion of ulnar styloid). Hx: sudden onset of snapping sensation in wrist with swelling, pain, limited ROM Tenderness over the ulnar aspect of the wrist with

Salasiah Ismail 2009776589 palpable crepitus on supination/pronation. Dorsal dislocation of ulna: ulnar styloid will be more prominent and limitation of supination. Volar dislocation of ulna: loss of normal ulnar styloid prominence with limitation of pronation.

OT MODEL OF PRACTICE Model of practice that has been used in this case study is based on Model of Human Occupation (MOHO). This model emphasizes the circumstances which are both within the person and in the environment. It contributes to the persons motivation, patterns of behavior and occupational performance (Kielhofner, 2002). This models aims are to understand peoples occupational nature and lives, guide interventions towards enabling occupational performance and offer a range of practical tools and strategies for occupational therapy intervention. Individuals are conceptualized as being made up of three interrelated components (volition, habituation and performance capacity) that occur within the broader (physical, social, cultural) environment. This model offers a sophisticated theoretical and holistic approach to understanding occupational performance and the nature of occupational identity. The practice model is based on the concept of occupational dysfunction, to respond when personal behavior results in loss of meaning, hope, habits, and/or roles. Assessment involves examining the strengths and limitations of the persons system organization, environmental influences on occupational behavior, and the persons system dynamics when engaged in occupation within the individuals environment. Interventions include increasing the strengths of the persons system organization, using occupational form to promote change and using context and environment to organize occupations (Reed & Sanderson, 1999).

Salasiah Ismail 2009776589 OT ASSESSMENT The writer evaluated Marina using both standardized and non standardized assessment. Subjective assessment will provide by interview and also observation. Objective assessment will provide by standardized and non-standardized

assessment. Before started any assessment with the client, the writer do explain to the client about procedures of assessment and outcome from the assessment being done. Assessment is very important to develop rapport between the writer and client, as client might be afraid from the information gain through the assessment might have negative effect on them (Kielhofner 2004). From the subjective assessment, the writer noted that Marina has dry wound and scar noted on volar forearm, ulnar styloid displacement noted, limited ROM at left hand, able to do all fingers opposition, able to do all hand prehension (hook, cylindrical, and spherical grasp). She had complained of pain up to level 6/10 on the visual analogue scale (VAS). She also had complained of difficult to continue her job as a chef at her restaurant and shopping for her restaurants groceries. For objective assessments, the writer uses standardized and nonstandardized assessments. Assessments that used in this case study for occupational performance areas (OPA) are Modified Barthel Index (MBI), and Instrumental Activities of Daily Living Form. In investigated about occupational performance components (OPC), the writer uses Assessment of Joint Range Measurements, and hand and pinch strength. In order to find optimal ADLs for Marina, the writer will carry out MBI. MBI is one of the tools to assess the patients activity of daily living. According to Formiga (2005), the Barthel Index was known as best instrument in terms of its sensitivity, simplicity, communicability, scalability and ease of scoring. Mahoney (1965) and Leung (2007), shows that MBI consist of 10 items that will assess on Marinas ADL.

Salasiah Ismail 2009776589 Once the patient get injured to the brain or limited function of the extremities, it may involve problems in ADL. Evaluation and training in the performance of these important life tasks have long been important aspects of OT programs. Loss of ability to care of personal needs may result on decrease in self esteem (Pedretti & Farly, 2001). According to MBI result, Marinas got score 86 that presented mild dependency level and required 13.0 hours of help per week. From the MBI, the problem that Marinas most problems problem in personal hygiene, bathing, toileting, and dressing. For detailed result of this assessment please refer appendix 1. The IADL form is valuable to assess the level of disease and to determine the patient's ability to care for him- or herself. At a higher level of functioning are the instrumental activities of daily living (IADLs). Performance of IADLs requires mental as well as physical capacity. IADLs are scored based on what an individual can do rather than what he/she is doing. IADLs should be scored based on how an individual usually performs a task (Lawton & Brody, 1969). Marina have problem in food preparation, housekeeping, and laundry. For detailed result of this assessment please refer appendix 2. The writer decided to assess further in neuromusculoskeletal area using Assessment of Joint Range Measurements. According to Pedretti and Farly (2001), joint measurement is an assessment tool often used for physical disabilities that cause limited joint motion. Specific purpose for measuring ROM are to determine limitations that interfere with function or may produce deformity, determine additional range needed to increase functional capacity or reduce deformity, determine the splints and assistive devices, measure progress objectively, and record progression or regression. For her condition, she can move safely within 45 to 65 degree of wrist flexion and extension, within the first 2 to 4 weeks postoperatively (Burke, Higgins, McClinton, Saunders, & Valdata, 2006). From the assessment, the writer had found out the client do have limitation at the forearm, wrist and fingers joint. For detailed

Salasiah Ismail 2009776589 result of this assessment please refer appendix 3.The writer evaluates the client ROM and helps the client to determine treatment goals and thus, select an appropriate treatment modalities and proper positioning technique to overcome to reduce the client limitations (Pedretti, 1996). The client was assessed on her strength. The writer took the client hand and pinch strength to determine the client strength and capabilities. The writer used dynamometer and pinch gauche to measure the reading. However, strength assessment only done for unaffected hand due to strengthening may begin at 4 to 6 weeks, as tolerated by patient because power grasp and excessive lifting and carrying should be avoided until 8 to 12 weeks postoperatively (Burke, Higgins, McClinton, Saunders, & Valdata, 2006). From the assessment, the writer had found out the client do have decrease in grip and pinch strength. For detailed result of this assessment please refer appendix 4. The client priorities that can be identified by the writer are according to her hand function, based on client priority in ADL and IADL function, and also return to her previous work.

OT INTERVENTION From the assessment, the writer may formulate aims of treatment. The aims will divide into short term aims and long term aims. For the short term aims, the writer identified 4 aims: 1. To protect surgical procedure, to promote healing process, and to promote proper positioning. 2. To reduce pain.

Salasiah Ismail 2009776589 3. To increase AROM at affected joints (forearm, wrist, and fingers). 4. To increase grip and pinch strength of left hand. For long term aims, the writer identified 2 aims: 1. To improve ADL and IADL function. 2. Return to work.

In order to protect surgical procedure, to promote healing process, and to promote proper positioning, the writer provide volar cock-up splint for Marina. Splinting is a commonly used therapeutic procedure in the management of hand injuries. Splints can provide the essential therapeutic means of maintaining a position and holding it both statically and dynamically. It provides optimal support to the carpal bones, recommended for joint inflammation or instability; the volar surface of the hand is naturally well padded and tolerates the palmar base well (McKee & Morgan, 1998). The authors of a study on rehabilitation of distal radius fractures using volar plate fixation, found that wrist extension was sometimes difficult to achieve post-operatively. Therefore, their protocol increased the wrist extension of the protective thermoplastic splint to 30 degrees of extension (Smith et al, 2004). Ruch, Slutsky, and Adams (2010) moderately recommend the rigid immobilization in preference to removable splints when using non-operative treatment for the management of displaced distal radius fractures and weak recommendation for the use of removable splints is an option when treating minimally displaced distal radius fractures. This splint should be wearing for 2 to 4 weeks and may extend to 9 to 12 weeks. However, discontinued splint if the patient relatively pain free after 4 weeks (Burke, Higgins, McClinton, Saunders & Valdata, 2006).

Salasiah Ismail 2009776589 In a clinical setting heat is used to increase motion, decrease joint stiffness, relieve muscle spasms, increase blood flow, decrease pain, and aids in reabsorption of exudates and edema in a chronic condition (Pendleton & Krohn, 2006). Hotpack is used to reduce pain at affected hand. Therapeutic heat is used for a number of reasons including decreasing stiffness and pain, and reducing muscle guarding (Michlovitz, 2002). Heating connective tissues prior to exercise can decrease the risk of tissue damage (Stanley, 1992). Whilst the application of heat can increase blood flow locally, it can also cause changes in the collagen molecule. At temperatures between 41 and 45 degrees centigrade, collagen bonds denature and allows tissues to elongate. A study that combined the techniques of heat together with stretch, demonstrated an effect greater than heat or stretch used in isolation (Hardy and Woodall, 1998). For ROM treatment, the writer use PROM, AROM, and continuous passive motion (CPM). Passive movements are used to influence joint and soft tissue mobility and can be used preferentially over active movements in the early stages of healing, to influence collagen formation without causing pain (Stanley, 1992). For passive exercise, from shoulder to wrist (proximal to distal) but fingers (distal to proximal) able to stimulate joints, prevent joints stiffness, realign soft tissue and to increase muscle properties for example muscle flexibility (Hall,1998). Without normal movement across joint surfaces, tissues undergo structural changes and become stiff. Stiffness from the joint capsule contributes 47% and muscle 41% of all tissue changes across a joint. A study that combined the techniques of heat together with stretch, demonstrated an effect greater than heat or stretch used in isolation (Hardy and Woodall, 1998). Active exercises of the wrist should begin after the inflammatory phase of healing - and the benefits include: the maintenance of length in capsular structures, gliding of tendon and other tissue interfaces, assistance in bone and cartilage repair and soft

Salasiah Ismail 2009776589 tissue rehabilitation is able to begin (LaStayo et al, 2003; Meads and Prosser, 2003). In primary healing, without a callus to convert to bone, cyclical loading provided by AROM exercises provide a stimulus to the early bone formation which promotes tensile strength (LaStayo et al, 2003). Therapeutic early, controlled motion improves collagen orientation and decreases cross link formation, thus assisting in connective tissue mobility. This will be especially beneficial in the proliferative/fibroblastic phase of healing. Active as opposed to passive exercises, also maintains muscular contractility, reduces oedema, and is a stimulus for bone integrity (Stanley, 1992). Furthermore, AROM exercises stimulate nutrient diffusion to articular cartilage, which assists in healing (Stewart Pettengill, 2002). These joints need individual attention through joint mobilisation techniques, to regain full movement (Salter and Cheshire, 2000). Joint mobilisations are glides that attempt to restore the accessory movements of a joint. These movements stretch the joint capsule at the end of its range, and are used in a oscillating manner in order to improve ROM (Kaltenborn, 1989). Debate abounds in the literature regarding the effectiveness of joint mobilisations. A follow-up study of distal radius fractures which received joint mobilisations compared to those that didn"t, demonstrated no significant difference long term (Meads and Prosser, 2003). However, a systematic review found two well conducted studies which supported the use of joint mobilisation in patients after distal radius fracture, in increasing joint range of motion in the short term (Michlovitz et al, 2004) Development and subsequent research regarding CPM was driven primarily by the theory that joint motion would promote the healing and regeneration of articular cartilage. Although cartilage healing and regeneration continues to be an active area of research, the major clinical use of CPM today is to avoid arthrofibrosis following trauma or surgery on joints that are prone to stiffness, such as the knee, elbow, and joints of the hand. CPM is indicated to prevent stiffness and to maintain motion

Salasiah Ismail 2009776589 obtained at the time of surgery, particularly following joint replacement, synovectomy, contracture release, excision of heterotopic ossification, and fixation of intra-articular fractures. This is particularly true for joints that were stiff preoperatively. It is relatively contraindicated if the soft tissue constraints (ligaments) are insufficient, if the joint is unstable, or if rigid fixation of fractures has not been attained. By following these guidelines and adhering strictly to the principles of CPM use, one will increase the chances of obtaining maximum range of joint motion following trauma or surgery. (Giori & ODriscoll, 2000) Following injury, muscle atrophy occurs due to a cellular response and inactivity, pain, inflammation and immobility (Brukner & Khan, 1998). Many functional tasks are limited due to decreased strength following a distal radius fracture, such as the grip and lift required in filling a kettle. It is reported that light activities of daily living require 5-10 pounds (2.3-4.5 kg) of grip strength (Orbay, 2005). The requirement for strengthening is that the healing bones are able to withstand the high muscle forces placed upon them, and therefore typically this is delayed until eight weeks postop/post injury. At eight weeks, the remodeling phase of healing has started, and bone is able to gain strength through calcification, dependent upon stress and load (LaStayo et al, 2003). Hypertrophy of muscle is obtained by contracting at 60-80% of the maximum that one repetition can produce, after some weeks/months of training. This hypertrophy is due to an increase in protein synthesis that is stimulated by the tension within a muscle for a sufficient duration (Hakkinen, 1994). Treatments for strengthening are digiflex and hand helper. Digiflex develops isolated finger strength , flexibilty and coordination as it build hand and forearm strentgh (Copley J, 1999). Increase the time of building your muscles and finger tolerance (Pedretti, 1996). Finger measurement of initial strength as well as patient progress. According to Burke E.R. progressive resistance in different level of compression allow each exercise to be graded to the patient and

Salasiah Ismail 2009776589 show a clear measure of progress. Versatile hand helper hand exercisers provide an effective way to incraese strength and range of motion of the finger. Varying the number and /or color of rubber bands increases or decreases resistance , making eaach band exerciser ideal for progressing through the early stages of rehabilitation. Routines contemplating the exercising of fingers by flexing the fingers against the resistance of springs are frequently used to strengthen the fingers or hand. Devices that provide resistance against extension of the fingers (as opposed to flexure of the fingers) have also been used for exercising the fingers and/or hand (Silagi, 2007). Versatile hand helper hand exercisers provide an effective way to incraese strength and range of motion of the finger. Varying the number and /or color of rubber bands increases or decreases resistance , making eaach band exerciser ideal for progressing through the early stages of rehabilitation. There are 18 muscles that work together to flex the hand and fingers. The two largest ones , each with four tendons (one for each finger) , are the Flexor Profundus , which goes to the end of each finger and the Flexor Sublimus, which attaches at the middle joint. The sixteen other small muscles assisst in the flexing and other intricate motions that make the hand so useful (Pedretti, 1996).

REASSESSMENT AND FUTURE PLAN The writer had plan to do reassessment and future plan for Marina. The writer plans to do reassessment for every 3 cycle of seeing the client. This is to monitor the client performance, improvement, or any discomfort feeling about her condition. The client did complaint about having pain when performing task, the writer plan to do relaxation technique and biofeedback. According to Taylor (1995), the two major programs for the client able to generate relaxation response to the client in order to help to client overcome or manage pain. ADL intervention follows two major

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Salasiah Ismail 2009776589 approaches, restoration of impaired skill through skill retraining and adaptation of disability through environmental modification or adaptive aids (Thrombly, 1993). Remediation, adaptive methods, and adaptive equipment techniques that may be used to enable task performance are suggested based on the impairment that limits function. Remediation technique should be used only if the condition is likely to improve based on knowledge of the diagnosis and the patients case history. Remediation technique are based on impairment rather than being specific to a particular task. Remediation techniques also can be used during ADL adaptive technique training and should be incorporated in all aspects of treatment (Hopkins & Smith, 1993). For IADL, adaptive equipment and technique were given based on the compensation approach focuses on the use of remaining abilities to achieve the highest level of functioning possible in the area of home and family management. If the patient cannot perform these tasks in the usual manner, then adapted techniques or equipment are used to maximize patient abilities. This strategy can be used when a patients condition is temporary (Hopkins & Smith, 1993). For return to work, achieve improvement in OPC are required and adaptive equipment and technique given same as IADL because her job as a chef. In conclusion, the writer wanted the client to get maximum functional capabilities in future.

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