Therapeutic Intervention for a Posterolateral Hip Arthroplasty

It is critical in occupational therapy practice to use the appropriate models or frames of references to guide intervention for clients. For Hilary Henderson’s case, it would be most beneficial to apply three theories: The Model of Human Occupation (MOHO), the Biomechanical and Rehabilitative Frame of Reference (FOR), and the Occupational Adaptation (OA) Model. The profession of occupational therapy is highly client-centered, putting the needs and wants of the client at the forefront of intervention. Given the circumstances of Hilary’s personal life, it may be hard to find the motivation to participate in the necessary therapeutic interventions to enhance her recovery. In this case, the MOHO would be used to tap into her inner volition to complete therapy. This may include her will to get back to gardening, caring for her cat, participating in social gatherings at the senior center, or returning to independent driving and shopping. The Biomechanical and Rehabilitative FOR is essential for clients who receive any type of orthopedic surgery, as Hilary did, to focus on the recovery of body functions, including strength, range of motion (ROM), and endurance (Cole & Tufano, 2008). This model will help guide Hilary’s intervention to best fit her needs for recovering these body functions to complete her goals of being modified-independent using assistive devices in all activities of daily living (ADLs) and enjoyed leisure and social activities. Lastly, applying the OA model will help focus the intervention around “the interactive process between a person and his or her occupational environment” (Cole & Tufano, 2008, p. 107). In other words, using adaptive methods to modify Hilary’s environment to best suit her deficits to allow her to participate in all the activities she desires.

For example, the occupational therapist will provide Hilary with dressing aides, such as a sock aide and a shoe horn, to allow her to dress without breaking any hip precautions. These models, along with many others, “provide explanations for the interaction of the person with his environment through occupations: providing practitioners with a framework for decision-making around occupation-based intervention” (Vermaak & Nel, 2016, p. 35).

As a practitioner, it is essential to know the abilities of all patients to provide the best quality care specific to each patient. Therefore, assessments are used to provide the practitioners with significant information regarding this area. According to Hilary’s medical record, prior to her fall and surgery, she was extremely active within the social community, including participation in senior center activities and volunteering her time at the hospital. However, she is now limited in this area due to deficits in functional mobility. According to Chisholm, Toto, Raina, Holm, & Rogers (2014), the Performance Assessment of Self-care Skills (PASS) helps occupational therapy practitioners “determine clients’ capacity for community living” by using “measures that capture the person-task-environment transaction and compare clients’ task performance to a performance standard” (p. 59). Using this assessment for Hilary will be necessary for her intervention plan as it will make clear the adaptations she needs to be able to participate in her desired social activities. For example, it will address her current level of functional mobility, safety, and independence in activities requiring community mobility and provide a better understanding of what she needs to compensate for them. To supplement that assessment, the Goal Attainment Scale (GAS) would be used to determine if and how completely Hilary’s goals regarding social participation were met (Ryan, 2014). However, this is not the only goal that could be measured with this assessment, as every goal achievement level can be assessed. Additionally, there is a pain management aspect of the GAS which would be used to determine the extent to which pain limits her functional performance. This gives the occupational therapist vital information to consider when planning Hilary’s intervention plan.

“Approaches to intervention are specific strategies selected to direct the process of evaluation and intervention planning, selection, and implementation on the basis of the client’s desired outcomes, evaluation data, and evidence” (American Occupational Therapy Association, 2014, p. S33). The three most important approaches to intervention to use for Hilary’s treatment include modify, prevent, and restore. First, concerning the OA model for Hilary’s treatment, modifying her environment will enhance her ability to complete her ADLs at home. In her medical record, it states that she lives alone in a two-story home. This environment will be a great hindrance to Hilary’s ability to complete the daily activities she wants and needs to complete. Given that she requires maximum assistance to complete housework, providing her with a modification to her stairs is necessary for future independence. Secondly, prevention of future injury for Hilary is going to be a key factor in her independence due to her age and current functionality. The modification to the stairs will also contribute to this approach as it will provide a safer way for her to reach the top floor of her home. Also, one of the most important aspects is educating Hilary on her hip precautions so that she can prevent further injury to the surgical site, and possible future surgery. Lastly, relative to the Biomechanical and Rehabilitation FOR, restoring strength, range of motion, and endurance in her lower extremities is critical to her recovery. Restoring these body functions will allow her to complete meaningful activities independently and provide an aspect of safety to her mobility.

Given the approaches of intervention taken for Hilary, there are three types of occupational therapy interventions that will be used: occupations and activities, preparatory methods and tasks, and education and training. The recovery of a posterolateral hip arthroplasty involves a few hip precautions, including avoiding adduction of the leg past midline of the body, avoiding bending at the waist past ninety degrees of flexion, and externally rotating the hip. Educating and training Hilary on these precautions and how to avoid breaking them will be essential to preventing future injury, as well as the possibility of a future surgery. With those hip precautions in mind, it is necessary to take the next step in establishing appropriate occupations and activities and preparatory methods and tasks for Hilary. Occupations that will be used include morning dressing, bathing, and gardening with adaptive devices. Each of these occupations can be supplemented with activities that support the development of independence. Some activities that will be used include allowing Hilary to choose her clothing, practicing safe transfers into and out of the shower area, and choosing which type of flower she wants to plant that day. Each activity adds a bit more meaning and relevance to the occupation in which it relates to. Lastly, using preparatory methods and tasks will help prepare Hilary for the highest level of occupational performance possible. As mentioned, she will use adaptive devices to complete her occupations. Items such as a sock aid, shoe horn, grabber, longer handles for gardening tools, and a walker will be issued to her to ensure she can complete her desired occupations without breaking hip precautions.

The result of Hilary’s intervention plan should include at least three aspects: participation, prevention, and quality of life. As mentioned, Hilary is extremely proud of her garden, volunteer participation at the hospital, and loves going to the senior center for social activities. Completion of the intervention program specific to her and her needs will allow her to participate in these activities safely and independently. Additionally, it will increase engagement in ADLs. Also, because of the prevention tools put into place for Hilary, including education and adaptive devices, she will be at a reduced risk for reinjury or any new injuries that could occur. These, along with many others, will greatly contribute to the quality of life that Hilary achieves. According to the American Occupational Therapy Association (2014), quality of life can be defined as the “dynamic appraisal of the client’s life satisfaction, hope, self-concept, health, and functioning, and socioeconomic factors” (p. S35). The outcome of her intervention plan will ultimately enhance her quality of life. (American Occupational Therapy Association, 2014)

The intervention strategy of using occupations and activities has specific demands: “relevance and importance of the client, objects used and their properties, space demands, social demands, sequencing and timing, required actions and performance skills, and required underlying body functions and body structures” (American Occupational Therapy Association, 2014, p. S32). This section will discuss the demands associated with the leisurely occupation of gardening as they pertain to Hilary. To hone in on a particular aspect of gardening, planting a bundle of flowers will be of focus. According to Hilary’s medical record, she values the independence in planting flowers outside of her home because she finds it enlightening how just flowers can light up the whole house. It brings her joy each time she looks out the window or passes by in her car. The objects needed to complete this occupation are a bundle of flowers, a long shovel sharp enough to break ground, watering pot with water, soil, and a space large enough for the flowers to grow in front of her home. After choosing the bundle of flowers at the store that she desires, she chooses the best space for them to be planted and digs a hole large enough for the roots of the flowers to be placed. Next, she covers the roots with the soil that she previously made the hole with and waters the newly planted flowers with the water in the watering pot. From there, she continues to water them daily, or as needed. Although she typically completes this activity alone, she considers her neighbor’s garden when choosing where and which flowers to plant, giving gardening a social demand for herself, even though there is no true social interaction. Along with choosing the appropriate objects and tools needed for planting a bundle of flowers, Hilary must also be able to appropriately locate, gather, use and handle them (American Occupational Therapy Association, 2014). Inquiring about the best way to care for the flowers after planting is also a huge part of this activity. Initiating, continuing, following the correct sequence, terminating, and adjusting to this activity’s demands will be necessary to complete it as Hilary desires. Lastly, a new aspect to this activity that Hilary will have to be aware of currently is how she is going to navigate around the area she is going to plant. Her hip precautions will force her to change her way of approaching the area as she is normally on her hands and knees close to the ground. For example, she would use a hand shovel before her surgery; however, a long-handled shovel will be necessary for engagement after her surgery.

There are several ways to take the occupation of gardening and make it more difficult for Hilary, as well as there are several ways to make it less difficult. For example, increasing the number of bundles she plants and increasing the rigidity of the soil/ground will significantly enhance the difficulty of the activity. Contrarily, downgrading the activity could include providing her with assistance from a caregiver/ therapist or allowing her to plant a seed versus an entire bundle of flowers.

Utilizing therapeutic use of self in practice as an occupational therapist is using one’s personality to interact with and serve the clients on a personal level. After evaluating myself and my personality, I found that the four therapeutic modes that I used the most with Hilary during her intervention are advocating, collaborating, problem-solving, and encouraging. I first utilized the collaborating mode of my personality to converse with Hilary on what she desires and any barriers she felt that she had so that I could include the necessary methods to accommodate to those factors into her intervention plan. An example of this would be the implementation of the occupation of gardening and use it as a means so that it was meaningful to her and provided her with an applicable therapeutic technique. Next, I used problem-solving skills to reflect logic onto what Hilary needed and the reason she would benefit from the intervention I planned for her. After determining that she could benefit from adaptive devices to participate in her ADLs, leisure and social activities, and other necessary occupations, I advocated by providing her with these, along with modifications to her stairwell. Lastly, the most prominent mode of my personality is encouraging. Throughout the entire course of Hilary’s treatment, I have and will continue to encourage her by complimenting, applauding, and instilling hope in her heart that she will have the ability to fully recover and be able to participate in all the activities that she enjoyed prior to her fall.

Given that Hilary underwent an orthopedic surgery, it would be extremely beneficial for the occupational therapist on her case to collaborate with the orthopedic surgeon who performed the surgery. He/she would be aware of any complications that arose before, during, or after the surgery that the therapist would need to keep an eye on. Also, the surgeon is the professional who provides the patient and therapist with a list of precautions to abide by so that the risk of reinjury is lessened. Having contact with Hilary’s nurse is vital in her health and safety during occupational therapy. For example, Hilary is on a list of medications, provided in her medical record, that can cause side effects that may hinder her ability to participate in therapy. If the therapist did not know what was going on that day, it could cause Hilary serious complications with her health status. Lastly, it is almost always the case that when a patient is being seen for occupational therapy, they are also being seen by a physical therapist. The collaboration of the occupational therapist and the physical therapist is necessary for providing the best quality of care for Hilary. Each therapist needs to know what the other one is doing in treatment so that they can reinforce and build on each other’s interventions.