Occupation-Based Hand Therapy!

The PEOP Model

Image taken from the following: Christiansen, C. H. & Baum, C. M. (2005). Occupational Therapy: Performance, Participation, and Well-Being.  Thorofare, NJ: Slack Incorporated.
A defining characteristic of this model is that it emphasizes occupations (consisting of valued roles, tasks, and activities that are personal to the individual) and performance – thus requiring a top-down approach.  A top-down approach emphasizes looking at all the components that make up an individual, studying how they relate and interact with one another, and regarding each of them during treatment.  This model uses the interactions of a person’s intrinsic factors (such as psychological, physiological, cognitive, spiritual, and neurobehavioral factors) and environmental factors (aka. Extrinsic factors such as social supports, economic systems, culture, built environment and technology, and the natural environment) that either support or restrict the performance of activities, tasks, and roles of that person to treat them holistically.

An Occupational History might first be collected.  An OH helps the practitioner to learn about the roles of the client, the impact of their culture on their life, leisure activities, social interests, responsibilities of work, self-care, home management, and participation in community.

* Roles: Jim is a 25-year old 2nd year medical student / Prosector / Teammate / Friend

* Culture: Claims to be spiritual, not religious.  Medical student culture.  Young single male culture.  Caucasian from upper-class home where both parents are doctors.

* Leisure: Enjoys fixing things like motorcycle.  Plays basketball on a team.  Plays golf for fun.  Lifts weights at the local gym.

* Social: Goes to bars on weekends when time allots it.

* Work Responsibilities: Prosects bodies for about 8 hours every week.

* Self-care: Social smoker but otherwise healthy and independent

* Home management: Lives with 3 friends in a 2-story house.  Duties include keeping living areas and his bedroom neat.

* Community participation: Has a car he uses to get around.  Grocery shops 1 day per week.  Occasional visits to the post office, bank, car mechanic, etc.

An Occupational Profile can then be performed to ascertain past, current, and future roles of the client.  It should include a description of lifestyle issues and routines that are carried out on a daily – weekly basis.  The Role Checklist might be recommended for use here.

Upon waking, how does Jim’s day go?  Make sure to get a complete list including small things that might slip his mind such as brushing his teeth and whether he cooks breakfast or simply microwaves something.  Are there things he does a few days a week such as hobbies / sporting activities / certain chores / things for class / etc.

            What are the client’s Short and Long Term Goals?  It is important to have some sort of background on the client before broaching this in order to help them formulate goals that are not only achievable but also meaningful.  The Canadian Occupational Performance Measure might be a good tool to use here.  If there is excessive discord between the client’s goals and the therapist’s knowledge of treatment – so much so that referral to another professional / set of resources might be more useful – then this should be addressed here.

Remember a good long term goal should never simply be “Reduce pain from an X to an X”.  The pain is a symptom of performing some sort of occupation, therefore the performance of the occupation needs to be dealt with instead of just the pain rating.  If there is too much pain being experienced, referral to a medical doctor for a shot of cortisone is an additional step that can be taken before surgical intervention in Jim’s case.

            If the goals are appropriate, then the client’s Person Factors (intrinsic) should be explored here.  You can see them detailed in the pictorial representation of the PEOP model within the P Factors circle.  The Environmental Factors (extrinsic) should also be investigated as well.  These are depicted within the E Factors of the circle.  The Occupation Factors involve the roles of the client and can be further explored in order to decipher what tasks may be required of each to perform well in that role.  These should be located within the O Factors sphere.  Combined, these will help the therapist to understand the client’s capabilities and the barriers that are currently limiting their performance in activities, tasks, and the roles that make up their occupations.

* Possible P Factors: young male, feels frustrated, experiences pain/tingling/numbness when doing certain things

* Possible E Factors: 2-story apartment, school environment, dissection suite environment, gym, his friends, his roommates, his family, the culture of medical school, the work he does on his bike

* Possible O Factors: medical student, prosector, roommate, friend, teammate

Once these factors have been accounted for, a client-centered plan of care is constructed.  It is the responsibility of the therapist to help the client understand what is possible as well as the issues involved in helping the client to meet their goals.  If requested, the therapist should also be able to show the client evidence that the proposed intervention will help them achieve their goals.

The intervention should be applied using several different forms to address the multiple areas that may be affected by the primary injury.  Some are directed at restoring function, remediation, promoting health, preventing secondary problems, educating the client about their condition, and helping them self-manage the issue. 

* Jim may be given a personally-fitted splint. 

* He and his therapist may come up with a way for Jim to remember to put on the splint such as an alarm that goes off at a set time (since he is prone to falling asleep studying).

* The therapist can instruct Jim about alternate methods of performing tasks such as opening jars, doors, etc. and provide certain AT such as built-up handles for his dissection instruments or car keys or car tools or steering wheel.  The therapist can also instruct Jim where to purchase such items.

* The therapist may have Jim perform tasks he loves and analyze the biomechnical positions of not only his hand but the rest of his body in relation to what he is doing.  The therapist can then alter his positions so that they result in less stress on his joints.

Outcomes should be measured to ensure the ability to track the progression of the interventions, evaluate its effectiveness, and for purposes of payment and/or referral.  It can also serve as proof of treatment that may help to change social and monetary policies on a large-scale.

The main goal of occupational therapy intervention is to foster occupational performance and participation and help the client achieve a level of functionality that meets their roles, responsibilities, and interests.

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