P eloquin(1990)notedthatmechanicalexpertiseandskillweretheprimaryfocus

Transcription

1 Documenting Progress: Hand Therapy Treatment Shift From Biomechanical to Occupational Adaptation Jada Jack, Rebecca I. Estes KEY WORDS arthritis exercise therapy hand human activities patient-centered care postoperative care The investment of time and self to develop therapeutic relationships with clients appears incongruent with today s time-constrained health care system, yet bridging the gap of these incongruencies is the challenge therapists face to provide high-quality, client-centered, occupation-based treatment. This case report illustrates a shift in approach from biomechanical to occupational adaptation (OA) in an orthopedic outpatient clinic. The progress of a client with lupus-related arthritis who was 6 days postsurgery is documented. The intervention initially used a biomechanical frame of reference, but when little progress had been made at 10 weeks after surgery, a shift was made to the more client-centered OA approach. The Canadian Occupational Performance Measure was administered, and an OA approach was initiated. On reassessment, clinically important improvements were documented in all functional tasks addressed. An OA approach provides the bridge between the application of clinical expertise, client-centered, occupation-based therapy and the time constraints placed by payer sources. Jack, J., & Estes, R. I. (2010). Documenting progress: Hand therapy treatment shift from biomechanical to occupational adaptation. American Journal of Occupational Therapy, 64, Jada Jack, OTR/L, is Private Contract Occupational Therapist, Sequim School District, 503 North Sequim Avenue, Sequim, WA 98382; jadajack@gmail.com Rebecca I. Estes, PhD, OTR/L, ATP, is Department Chair and Associate Professor, Department of Occupational Therapy, University of South Alabama, HAHN #2027, 307 North University Boulevard, Mobile, AL P eloquin(1990)notedthatmechanicalexpertiseandskillweretheprimaryfocus ofoccupationaltherapycurriculaandobservedthatthroughthesixthedition ofwillard and Spackman s Occupational Therapy,nochapterdiscussedthetherapeuticrelationshipormadereferencetothetermsrapport,relationship,empathy,or trust.overthepast20years,therehasbeenanawarenessoftheneedforashiftin focusbacktoour caring rootstoincludeamoreholistic,client-centeredapproach thatcouldsupplementthestrongmanualskillsofmorebiomechanicalapproaches (Chan&Spencer,2004;Daleetal.,2002;Peloquin,1993).Fortherapiststotruly demonstratecare,therapeuticrelationshipsmustbeformed.thisinvestmentof timeandselfappearsincongruentwithtoday shealthcaresystem,inwhichproductivityisparamountandtreatmenttimeiscurtailed,yetaccountabilitytoboth patientandpayersourcesisessential.inthiseraofmanagedcare,handtherapyis increasinglyperceivedasapracticeareainwhichmechanicalskillmustoftenovershadowclient-centeredapproachestomeethealthinsurerdemands.bridgingthese incongruenciestoprovideskilled,holistic,client-centeredcareisthechallengethat everypracticingtherapistfaces.individualized,occupation-basedtreatmentina hand therapy setting has been linked to enhanced patient outcomes(chan& Spencer,2004);however,concreteexamplesdocumentinghowtherapistscanshift fromamechanistictoaclient-centeredandoccupation-basedapproachhavenot beenpublished.thiscasereportprovidesanovelillustrationofhowtheshiftfrom astrictlybiomechanicaltoaclient-centered,occupation-basedapproachinhand therapypracticecanbemadetoenhancepatientoutcomes. The occupational adaptation(oa) framework(schkade& Schultz, 1992; Schultz&Schkade,1992)providesabasisforpatientcareregardlessofsettingand addresses the need for a more client-centered, holistic approach by fostering a 82 January/February 2010, Volume 64, Number 1

2 client therapist relationship that facilitates the patient s adaptationandownershipoftreatmentgoalsandprogress. TheseconceptsareembeddedintheOccupational Adaptation Guides to Practice(Schultz&Schkade,1992)fromthedatagatheringstage,whenthepatient sevaluationisviewedholistically,andincludesobtaininginformationonthepatient s performance,abilitytoadapt,environments,roles,andoccupations.datagatheringisalsoclientcentered,seekingpatient and significant others input on concerns, goals, level of desiredoccupationalperformance(efficiency,effectiveness, andsatisfaction),andapproachtoadaptation. BycomparingtheOAmodeltothetypicalbiomechanical rehabilitationmodelappliedtopatientsrecoveringfrom hipfracture,jacksonandschkade(2001)demonstratedthat patientsbenefitwhentheoaframeworkisused.application oftheoaframeworkimprovedpatientoutcomeefficiency andgeneratedhigherpatientsatisfactionratingswhencomparedwithperformanceandratingsusingthebiomechanical model.providingoccupationaltherapyservicesunderthe OAframeworkcanbebothanartandaskillexecutedwith methodandprecision,whileprovidingthecollaborativecare demanded by this generation of consumers (Schultz & Schkade,1992). Thepurposeofthiscasereportwastoillustratethata shiftinframesofreferencefromabiomechanicaltoanoa approach in an orthopedic outpatient clinic can facilitate adaptation,improvepatientmotivation,andprovidedocumentationofclinicallysignificantfunctionalprogress.this casereportpresentsacomplicated,orthopedic,postsurgical patientwhopresentedwithseverelydeformedbilateraldistal extremitiesaftermultiplesurgicalinterventions.theconductofthiscasereportwasapprovedbythetexaswoman s UniversityInstitutionalReviewBoard;thepatientprovided informedconsenttobepartofthisstudy. Client History Toprotectconfidentiality,thepseudonymSusanwasused. Susan was diagnosed with lupus at age 16; lupus-related arthritis resulted in significant joint deformities to both hands(seefigures1and2)andfeet.althoughthephysical limitationsresultingfromthesedeformitiesdidnotprevent Susan from participating in daily activities, she reported havingagreatdealofdifficultygrowingupwiththediagnosis.sheidentifiedherpositiveattitudeandsheerdeterminationastwoofhergreatestassets.susanwasa51-year-old, divorced mother of two children. She and her children sharedasingle-level,three-bedroomhomeinaruralnorthwesterncommunity.sheprovidedfinanciallyforherfamily throughdisabilitybenefitsandstatefunds,andreceived143 hrpermonthofpersonalcaregiverassistance. Figure 1. Volar view of (B) hands. Figure 2. Dorsal view of (B) hands. Initial Evaluation Oninitialevaluation,Susanpresentedwithabulkydressing onherleftdistalforearmandhand.only6daysprior,she had undergone simultaneous left thumb interphalangeal jointhardwareremovalandarthrodesisrevision,leftopen carpaltunnelreleaseandsynovectomy,leftradiusscapholunatefusion,andaleftindexfingerflexordigitorumsuperficialistoflexordigitorumprofundus(fdp)tendontransfer. Susan also identified a history of emphysema but denied furthermedicalcomplicationsorotherdiagnoses. Afterthepatientinterview,herbulkydressingwascut away to reveal healing, blood-crusted suture lines with no abnormalerythemaordrainagenoted.typicalmeasurements were taken of the incisions; all sites presented moderately tendertopressure.susan slefthandrestedinadependent flexedposturewithherwristinneutral.goniometricmeasurements were taken on her left index finger metacarpal joint;inactiverangeofmotion(arom),shedemonstrated a20 extensionlagand50 offlexion.astraightfistmeasured 4cmfromfingertipstoproximalpalmarcrease.Noother The American Journal of Occupational Therapy 83

3 ROMmeasurementsweretakenatthistimebecauseshewas lessthan1weekpostoperative.thefigure-8edemameasurementwastakenofthelefthandandnotedas36cm;32cm wasnotedontherightforcomparison.susanwasinitially placedinaforearm-basedvolarrestingsplintwithherleft thumbanddigitspositionedforcomforttosupport,protect, andimmobilizethejointsduringthehealingprocess. Problemsidentifiedontheinitialoccupationaltherapy evaluationincludedpittinghandedema,decreasedromin alldigits,increasedpain,anddecreasedfunction.susanwas scheduledforoccupationaltherapyservicestwiceperweek for6weeks,formodalities,manualtherapies,andtherapeutic exercise to address treatment plan goals. The patient s verbalizedgoalsnotedatthetimeoftheinitialevaluation includedthedesiretobeabletoresumeplayingfrisbeewith improvedgripandtheabilitytoresumenormalactivitiesof dailyliving(adls)thatshehadbeenabletocompletebefore surgery. The following short-term goals were established: Patientwill(1)beindependentinhomeexerciseprogram within4weeks,(2)demonstrate2-cmdecreaseinedema usingfigure-8measurementwithin4weeks,(3)demonstrate well-healedincisionswithmaturingflatscartissuefreeof tetheringwithin4weeks,and(5)demonstratestraightfist 1.5cmfromproximalpalmarcreasewithin4weeks.Longtermgoalswereestablishedasfollows:Patient(1)willhave theabilitytogrippantstopullthemupindependentlyin8 weeks,(2)willhavetheabilitytomanipulateandopenpill jarsin8weeks,(3)wouldliketohavetheabilitytoresume playingfrisbeewithimprovedgrip,and(4)wouldlikethe abilitytoresumenormaladlsthatshewasabletocomplete beforesurgery. Treatment Occupationaltherapyserviceswereinitiallyprovidedunder thebiomechanicalframeofreferencewithaheavyemphasis onprotectingthesurgicalinterventions;gainingandmaintainingbotharomandpassiverom(prom);andreducingpresentedema,promotingwoundhealing,andproviding scar management (see Table 1). Treatments consistently included modalities, retrograde massage, and manual scar mobilizations as well as therapeutic exercises. Dressing changesanddebridementofwoundswereperformedasnecessary.splintmodificationswereperformedasedemasubsided,andpressureareaswerenoted.susanwasseeninthe clinicsevenofeightscheduledvisits;onlyoneappointment absenceoccurredwithinthefirst5weeksofcare. Fiveweeksaftersurgery,afollow-upoccupationaltherapyassessmentwasperformedbecauseofpoorglideofthe transferredindexfingerfdptendon.susanreportedintermittentpainwithincreasedfrequencyandlengthofduration associatedwithswellingoftheleftindexfingerafterherhome Table 1. Schedule of Intervention Activities and Treatment Focus Biomechanical Focus Shift of Focus Occupational Adaptation Focus Postoperative Week Evaluation/reevaluation Canadian Occupational Performance Measure Modalities Hot pack Ultrasound in water Functional electrical stimulation Manual therapies Retrograde massage Scar mobilization Range of motion of digits Passive Active assisted Active Range of motion of wrist Active assisted Dressing changes Debridement Splint fabrication modification Buddy tape Occupation-based tasks Functional activity performance Compensatory techniques Adaptive equipment training 84 January/February 2010, Volume 64, Number 1

4 exerciseprogram.shewasabletodemonstrateindependence withherhomeexerciseprogramandverbalizedprecautions independently.thetherapist sobjectivefindingsincluded healingscartissuewithlimitedmobilityatthedorsaland volarwristincisionsitesandslowhealingatthethumbinterphalangealjoint.oftheestablishedshort-termgoals,susan met two by independently performing her home exercise programandbypresentingwitha2-cmdecreaseinhand edema. However, tethering scar tissue and an inability to makeastraightfistpreventedherfrommeetingtheother two goals. The therapist s assessment identified minimal FDPfiringbutnotedthattheindexfinger sdistalinterphalangealjointwasfirmwithcontraction.thisconditionwas attributedtoheavyscarringattheincisionsites.itwasalso notedthatsusanwascompensatingwiththelumbricalsat themetacarpalphalangealjoint.hertreatmentwaschanged to include the use of continuous ultrasound followed by continued aggressive scar massage to reduce adhesions. Functional electronic stimulation, which simultaneously blockedthelumbricals function,wasaddedafterscarmassagetoaidintendonpullthrough.anarom,active-assisted ROM,andPROMhomeexerciseprogramandsplintingfor protectionwerecontinuedasappropriateuntilsusanwas dischargedfromoccupationaltherapy(seetable1). Susanattendedanadditionalsevenofeightscheduled appointmentswithoneabsenceoverthenext5weeks.she verbalizedcompliancewithallinstructedtasksbutreported discouragementinthepoorprogressshefeltshehadmade regardingherscarmobilityandrom.nineweeksafterthe operation,buddytapewasissuedtoaddressanulnardriftof Susan sleftindexfingeroverherlongfingerduringcompositeflexion.oneweeklater,atthe10thweekpostoperative progressreport,wefoundthatminimalimprovementscould be documented. Objective findings identified poor tissue mobilityatallincisionsites.weassessedthepatient sfunctionalgraspsthroughherabilitytopickupsmallobjects, suchasbuttons;however,shewasunabletoholdthemin thepalmofherhand.shewasunabletoholdaknifetocut foodandunabletogripamugwithherlefthand.thetherapistencouragedsusantocontinueherhomeexerciseprogram,aggressivescarmassage,andbuddytapeasastablepost forherindexfingertopushagainstduringtaskperformance. Thelong-termgoalinitiallyestablishedtoaddressimproved Frisbeethrowingskillwasdiscontinuedatthistime.Other establishedfunctionalgoalsremainedinplace. Afterthe10thweek,Susanagainexpresseddiscouragementwiththesmallobjectivegainsdocumented.Sheshared herthoughtsthatalthoughonlysmallgainswereseeninthe documentation,thesamesmallgainsoftenresultedinmajor shiftsinheroccupationalperformance.shewasdisappointed thatheroccupationalperformancegainswerenotreflected inthebiomechanicalgoalsorbiomechanicalmeasures.we decidedthatashiftinframesofreferencetoamoreclientcenteredapproachwasneeded.researchsupportsthatwhen theclientisengagedinmeaningfuloccupationandisinvested inhisorherrecoveryprocess,betteroutcomesareachieved (Dolecheck&Schkade,1999).WeselectedtheOAmodel becauseitwouldincorporatetheneededclientengagement andoccupation-basedapproachandfacilitategeneralization ofskillstonovelactivitiesandself-initiatedadaptations.the Canadian Occupational Performance Measure (COPM; Lawetal.,1999)wasselectedto(1)identifySusan sprimary occupationalrolesandimportantoccupationalperformances and(2)obtainclient-ratedobjectivemeasurementsofher currentlevelsofperformance,specificallynotingperceived levelsofefficiency,effectiveness,andsatisfaction. Shifting to a Client-Centered Approach TheOAframeworkstatesthatOAisanormalprocessthat everypersonexperiences.whenapersonisfacedwithalife transition, such as a surgical intervention, compounding disabilitiesthatmayalreadybepresent,theoaprocessisat risk for dysfunction. It is through the use of the holistic approachofoathatclientsmaybefacilitatedtobecome theirownagentofchange.themodelhasbeensuccessfully usedinavarietyofsettingsandcomparedwithothermodels (Gibson & Schkade, 1997; Jackson & Schkade, 2001; Johnson&Schkade,2001). TheCOPMisasemistructuredinterviewinwhichthe patientreportsperformancesofconcernintheareasofself-care, productivity, and leisure. Once problems are specified, the patientisthenaskedtoratehisorherperceivedabilityofperformanceandsatisfactionwithperformance.thetoolmaybe usedtoaidintreatmentplanningandreassessmentandhas beenfoundtobeavalidandreliablemeasurementtoolina varietyofsettings(carswelletal.,2004;watterson,lowrie, Vockins,Ewer-Smith,&Cooper,2004). Implementing the OA Approach TheCOPMwasadministeredtoSusantoinitiatetheshift fromabiomechanicalapproachtothemoreholistic,clientcenteredoaapproach.becausesusanwasexceedinglylimitedinherabilitiestoperformanytasks,thecopmwas usedasabaselinetogainherinputonwhichoccupational taskswereofmostconcerntoher.susanidentifiedthedesire tobeabletosupinate,specifically toturndoorknobsorget changefrommypurse. Shealsoidentifiedthedesirefor functionalpinch, soicangetmyowntoothpasteoutor squeezeaketchuppacket. Shevoicedthedesiretoholda bookandcupaswellassafelymanipulatehercarwindow controls.onalikertscalerangingfrom1to10,shewas askedtoratehercurrentlevelofperformanceandherown The American Journal of Occupational Therapy 85

5 satisfaction with that performance(see Table 2). Susan s averaged scores were calculated by adding the number of performanceorsatisfactionscoresanddividingby5,which representedthenumberofproblemsidentified.forexample, Susan saverageperformancescorewas16(16/5=3.2).as seenbytheseratings,all<5(midrange),susan sperceptions ofherlevelofperformance(3.2)andsatisfactionwithher performance(2.2)wereverylow. Susanattendedsixofeightadditionalscheduledtreatmentsessions;eachsessionaddressedtheactivitiesthatshe hadidentifiedasimportanttoheronthecopm.thetreatmentapproachfocusedonperformanceoffunctionalactivities and included compensatory techniques and adaptive equipmentforalternativesolutions(seetable1).through collaborationandproblemsolving,eachissuewasaddressed functionallyandinthecontextofperformance.forexample, twoactivitiesthatsusanverbalizedthedesiretoaccomplish weretoopendoorsindependentlyandtoreceiveherloose changefromstoreclerksinherhand.shewasunhappyhavingtoaskstoreclerksto tossthechangeinmypursebecause Ican tholditinmyhand. Fromabiomechanicalperspective,thiswasalackofsupinationandhandclosure.Usingthe OAapproachanddeeperinvestigationintotheclient soccupationalperformanceandmasteryofheractivities,thisdesire wasfoundtostemfromtheneedtomasterherenvironment, toexperienceefficiencyandeffectivenessinherperformances, andtoperformsatisfactorilyforherselfandintheeyesof others.useofdycemandexternalrotationattheshoulder provided successful adaptation to manipulate door knobs. Theuseofherdebitcardeliminatedthemajorityofsituations whereshereceivedloosechange.shewasabletomaintain grasponstandardpensandprovideasignaturewithoutdifficulty.hercarwindowcontrolswereadaptedwiththermoplasticmaterialtoprovidealevershecouldmanipulatewith increasedeaseandsafetyperdemonstration. Althoughthesamebiomechanicalconceptswerefollowed toaddresstheunderlyingromdeficits,theemphasisshifted tofacilitatingsusan sexperienceofimprovementinherown occupationalperformance.sheverbalizedinthesetreatments herexcitementoverthefunctionalsolutionscatalogfilledwith theoptionsforadaptivetechniques.althoughshestillverbalizeddisappointmentoverthemobilitylostatherwristand poor recovery of her index finger, she stated that she was attemptingmoreoccupationaltasksthanshehadbefore. On reassessment, the COPM demonstrated that the OA-facilitatedinterventionmadeperformance-basedchanges thatresultedinimprovementsonthecopm(seetable2). Susanratedhersatisfactionwithherperformanceandher abilitytoperformfunctionalactivitiessuchasmanipulating doorknobs,holdingabook,manipulatingcarwindowcontrols,andgraspingacup.heroverallperceptionofthesefive functionaltasksincreasedfroma3.2toa5of10,andher satisfactionlevelofherownperformanceincreasedfroma 2.2toa4.8of10.Althoughthesenumbersstillappearrelatively low, Carswell et al.(2004) identified that, on the COPM, a changed score of 2 points, when comparing baselineandreassessment,isclinicallysignificant. IncomplicatedsurgicalcasessuchasSusan s,thebiomechanical model and intervention tools are valuable. However, combining the biomechanical approach with client-centered,holistictreatmentisdifficult,especiallyfor hand therapists working within the current conditions of managedcareandcostcontainment(daleetal.,2002).this sentimentcouldbeexpressedbypractitionersinmanypracticesettings.however,itiseasiertoidentifythepresenceof this ever-pressing challenge than it is to address it. Documentingprogressthroughbiomechanicalgoals,inthis casereport,notedminimalgains,discouragedtheclient,and failedtodemonstratefunctionalgainsimportanttotheclient.ashifttoaclient-centered,occupation-basedapproach facilitatedtheclient sadaptation,improvedhermotivation andoutlook,andprovideddocumentationoftheclinically significantfunctionalprogressattained. Discussion Thiscasereportofapatientwhoreceivedhandtherapyinan orthopedicoutpatientclinicaftersurgerytocorrectjointdeformitiessecondarytolupus-relatedarthritisillustratesthatashift inframesofreferencefromabiomechanicalapproachtoan Table 2. Susan s Initial and Reassessment Scores on the Canadian Occupational Performance Measure Identified Task Initial Performance Initial Satisfaction Reassessed Performance Reassessed Satisfaction Supination Functional pinch Holding a book Manipulating window controls Static grasp of cup Total score 3.2/10 2.2/10 5/10 4.8/10 86 January/February 2010, Volume 64, Number 1

6 OAapproachfacilitatedadaptation,improvedmotivation,and provided documentation of clinically significant functional progress.initialevaluationandtreatmentwerebasedonthe biomechanical approach. The patient became discouraged, andhermotivationdecreasedwithcontinueddocumentation ofonlyminimalgainsontraditionalbiomechanicalmeasures. Shestatedthatheroccupationalperformancegainsweremuch more significant than what the biomechanical measures showed.weshiftedtoamoreclient-centeredapproach the OAmodel andusedthecopmtodocumentthepatient s primaryoccupationalrolesandimportantoccupationalperformancesandobtainclient-ratedobjectivemeasurementsof hercurrentlevelsofperformance. Withtheshiftintreatmentapproach,thefocusturned towardperformanceoffunctionalactivitiesthatthepatient identifiedasimportanttoheronthecopmandincluded compensatorytechniquesandadaptiveequipmentforalternative solutions to increase independent performance of occupationalactivities.throughcollaborativeproblemsolving,eachissuewasaddressedfunctionallyandinthecontext ofperformance.onreassessment,thecopmdemonstrated that the OA-facilitated intervention made performancebasedchangesthatresultedinimprovementsonthecopm. IncomplicatedhandtherapysurgicalcasessuchasSusan s, thebiomechanicalmodelandinterventiontoolsarevaluable; however,combiningthebiomechanicalapproachwithoa allowedamoreclient-centered,holisticapproachthatfacilitatedtheclient sadaptation,improvedhermotivationand outlook,andprovideddocumentationoftheclinicallysignificantfunctionalprogressattained. Therapistsinotherhandtherapysettingsmayfindthat inclusionoftheoaframework(schkade&schultz,1992; Schultz&Schkade,1992)providesabasisforpatientcare thataddressestheneedforamoreclient-centered,holistic, occupation-basedapproach.patientownershipoftreatment goals and progress is increased through collaborative goal settinganddevelopmentofapositiveclient therapistrelationship that facilitates the patient s adaptation. The Occupational Adaptation Guides to Practice (Schultz & Schkade,1992)provideguidancetotherapistswhowantto incorporateoaintotheirtreatmentapproach.theguides describethetherapeuticapproachfromthedatagathering (initial assessment) stage through treatment and reassessment.providingoccupationaltherapyservicesundertheoa framework can be both an art and a skill executed with methodandprecisionwhileprovidingthecollaborativecare demanded by this generation of consumers (Schultz & Schkade,1992). Themechanicalexpertiseandskillofoccupationaltherapistspracticinginahandtherapysettingisvitalforskilled patientcare;however,improvedpatientoutcomesmaybe facilitatedbysupplementingbiomechanicalexpertisewitha moreholistic,client-centered,occupation-basedapproach. Althoughtheinvestmentoftimeandselfappearsincongruentwithtoday shealthcaresystem,bridgingthisincongruenceisachallengethattherapistsmayneedtoassumetobest meetpatientneeds.yetexamplesofhowtoaccomplishthis shiftintreatmentperspectiveshaveyettobepublished.this casereportprovidesanovelexampleofhowtoincorporate theoaframeworktoshiftfromamechanistic,strictlybiomechanical hand therapy approach to a client-centered, occupation-based,holisticapproach. s References Carswell,A.,McColl,M.,Baptiste,S.,Law,M.,Polatajko,H.,& Pollock,N.(2004).TheCanadianOccupationalPerformance Measure:Aresearchandclinicalliteraturereview.Canadian Journal of Occupational Therapy,71, Chan,J.,&Spencer,J.(2004).Adaptationtohandinjury:An evolvingexperience.american Journal of Occupational Therapy, 58, Dale,L.,Fabrizio,A.,Adhlakha,P.,Mahon,M.,McGraw,E., Neyenhaus,R.,etal.(2002).Occupationaltherapistsworking inhandtherapy:thepracticeofholisminacostcontainment environment.work, 19, Dolecheck,J.,&Schkade,J.(1999).Theextentdynamicstanding enduranceiseffectedwhencvasubjectsperformedpersonallymeaningfulactivitiesratherthannonmeaningfultasks. OTJR: Occupation, Participation and Health, 19, Gibson,J.,&Schkade,J.(1997).Occupationaladaptationinterventionwithpatientswithcerebrovascularaccident:Aclinicalstudy. American Journal of Occupational Therapy, 51, Jackson,J.,&Schkade,J.(2001).Occupationaladaptationmodel versus biomechanical-rehabilitation model in treatment of patientswithhipfractures.american Journal of Occupational Therapy, 55, Johnson,J.,&Schkade,J.(2001).Effectsofanoccupation-based interventiononmobilityproblemsfollowingacerebralvascularaccident.journal of Applied Gerontology,20, Law,M.,Baptiste,S.,Carswell,A.,McColl,M.A.,Polatajko,H., &Pollock,N.(1999).Canadian Occupational Performance Measure.Ontario,Canada:CAOTPublications. Peloquin,S.(1990).Thepatient therapistrelationshipinoccupationaltherapy:understandingvisionsandimages. American Journal of Occupational Therapy, 44, Peloquin, S.(1993). The patient therapist relationship: Beliefs thatshapecare.american Journal of Occupational Therapy, 47, Schkade, J., & Schultz, S. (1992). Occupational adaptation: Towardaholisticapproachforcontemporarypractice,part I.American Journal of Occupational Therapy, 46, Schultz, S., & Schkade, J. (1992). Occupational adaptation: Towardaholisticapproachforcontemporarypractice,part II.American Journal of Occupational Therapy, 46, Watterson,J.,Lowrie,D.,Vockins,H.,Ewer-Smith,C.,&Cooper,J.(2004).Rehabilitationgoalsidentifiedbyinpatients withcancerusingthecopm.international Journal of Therapy and Rehabilitation,11, The American Journal of Occupational Therapy 87