April 2001

Implementing Ingenuity

By Heather J. Haug, MA, OTR

Implementing Ingenuity

Casa Colina’s Vocational Readiness Program uses technology, creativity, and tenacity to help quadriplegic clients return to work.

A spinal cord injury (SCI) that results in quadriplegia can be devastating to individuals and their families. Rehabilitation services for SCI traditionally follow the progression of acute hospitalization, inpatient rehabilitation, discharge to home, and outpatient therapy. Occupational and physical therapies return clients to greater independence with self-care and mobility activities. But once outpatient therapy ends, what happens next?

The SCI Vocational Readiness Program at Casa Colina Centers for Rehabilitation, Pomona, Calif, is based on a combination of work hardening, assistive technology, and the Model of Human Occupation Theories of Occupational Therapy.1 The clinical objectives of the program are threefold: find tools and assistive technology that will allow the client to complete job tasks (increasing sense of volition); increase endurance and strength; and develop new habits and routines (regaining habituation).

The program starts with early intervention during inpatient rehabilitation and continues after discharge with 20 days (4 consecutive weeks for 3 hours per day) in the Assistive Technology Center. Although the goal of the program is to get people with quadriplegia back to work or school, the benefits greatly influence their families, physical health, and psychological well-being.

While still inpatients, clients are brought to the Assistive Technology Center and shown how physical tasks can be accomplished with the use of adaptive tools and equipment. Community resources are provided, including contact information for local departments of rehabilitation (DRs). Through this first stage of intervention, the idea is instilled that returning to a productive life is not only a possibility but an achievable reality.

When inpatients are discharged and begin outpatient therapy, they are encouraged to begin contacting their DRs. The DR or other referring source will send clients to the 4-week Vocational Readiness Program when they decide that clients are ready to redevelop daily structure and a productive life. Clients of the program do not need to have a job that they are returning to, and they can have an injury to any cervical level of the spinal cord. The 4 weeks in the program are spent finding the tools and accommodations that bridge clients’ skills to their employment goals, while requiring that they use the tools and new skills to gain strength and endurance.

The following case example describes a typical intervention.

Innovative Intervention

John is a 39-year-old male who fell and sustained a C-5 incomplete SCI. While he was an inpatient, he was given information on the tools available to help him begin his journey back to work. He had worked in the food service industry as a food broker for most of his life. His DR counselor believed that John had the ambition to return to work, but not the physical ability or stamina. She sent him to Casa Colina’s SCI Vocational Readiness Program.

Week 1: Evaluation and establishment of goals. On the first day of the 20-day program, John was interviewed and assessed for functional abilities, range of motion, and strength. John reported poor sleeping patterns, with poor habit structure. He was taking large amounts of medication to relieve pain in his shoulders and neck. His hair and beard were long, and he dressed in casual clothing. In the first week he complained of fatigue, had difficulty staying awake through the morning, and missed 1 day due to illness.

John and the occupational therapist developed goals. John’s main goal was to return to his previous place of employment and continue work as a food broker. His employer was consulted. He said he was eager to have John back, and would have no problem restructuring his job if needed. John’s job had three main tasks: sell food, keep records, and do marketing. Each task had performance components. John was not able to complete any of these requirements independently due to either limited upper extremity function or poor endurance. Task requirements became the focus of the next week’s objectives: to find what would enable him to complete each task.

Week 2: Building the bridge. The physical environment is often the first limiting factor. The occupational therapist visited John’s work site and found that the building and office were wheelchair accessible but the desk was not. The standard desks were not high enough to allow John to pull his electric wheelchair up to it, and his manual chair was too wide. In the Assistive Technology Center, John had the opportunity to try desks that varied in height and width, and had special accommodations (eg, cutouts for drive controls, swivel desktops to assist with limited reach). John found that a desk with a motorized lift allowed him to raise and lower the desktop height, giving him access whether he was in his power chair, reclined, or in a manual chair. This allowed for the greatest independence with turning on the computer and manipulation of paper materials.

Now that an accessible workspace was set up in the Assistive Technology Center, specific job tasks were addressed. The most important was answering and making phone calls. John tried a variety of phones until he found a solution—a speakerphone with large buttons and a headset for more private conversations. To push the buttons, John used a pen in his flexor hinge splint that he acquired in the second week of the program. Placing orders and taking notes were two tasks that had many of the same performance components, thus requiring the same solutions. Due to lack of finger movement, John was unable to write or type out orders or take notes while on the phone with his customers. The solution was a voice recognition program on a computer at his desk. This program would type out everything that John would say.

When answering a phone call, he could turn on the microphone and repeat everything the person on the phone was ordering. As a backup, his employer purchased a tape recorder that could be connected to the phone line (although John found he had difficulty pushing the buttons on the machine).

John also needed a way to write by hand, for times when he needed to sign paperwork or write when not in front of his computer system. He also had task components he could not complete, such as picking up paper out of the printer. It was decided that a flexor hinge splint with extension assist and writing attachments would not only allow him to write, but also pick up paper and small objects.

The evaluation process does not end after the first 2 weeks. Clients’ strength and endurance increase every day they attend the program. Frequently, the accommodations they need at the beginning of the program may not be what they need at the end, due to changes in functional abilities.

Week 2-3: Training and strengthening. The first 2 weeks were the most difficult for John. He was fatigued, and redevelopment of consistent habits is often difficult. He was in pain at the end of each day because he was using his arms and moving more than he had since his accident. He was frustrated by his lack of endurance and the interruptions in his work schedule that were necessary so he could attend to his health needs like pressure relief and catheterization.

This stage of the program is a time for relearning work habits. Getting up at the last minute and running out the door was no longer an option for John. He needed to plan his work day ahead of time, reserving special transportation provided by a local van transport company. In the second and third week of the program, clients are required to begin training to use the tools and accommodations needed to complete job tasks, as well as learn adaptive methods for doing things.

Progress Made

By the third week, John was a changed man. He got a haircut and shaved off his beard and mustache. There was a noticeable increase in his upper extremity strength, as well as his endurance. He was not as tired by the end of the day, and looked forward to coming back in the morning. John was using skills he had learned in the program at home. He was using his flexor hinge splint to play “army men” with his son, and had gained the confidence to start doing things independently.

Week 4: Job attainment skills training. The final week is spent with clients reevaluating goals and refining skills and knowledge. John’s initial plan was to begin working from the home, and eventually move back to his office. By the end of the program, John decided that he was ready to return to the office for a 6-week trial period, after which he would decide how much time he could commit to working each day. John was taught about the resources available to him. If John had not had an employer holding a job for him, this final week would have been spent preparing him for obtaining a job. Clients may be referred to the Career Development Center at Casa Colina, where they receive assistance writing their resumes, learn how to deal with interviews and awkward questions, and may be connected directly with prospective employers. Recommendation and discharge. On John’s last day, a discharge evaluation was performed, and the previous 4 weeks were reviewed. When asked what he got out of this program, John gave a long list of changes that he witnessed in himself, “Now I have the know-how to function again.” He reported that he had stopped taking all narcotic pain medication, and was experiencing less pain. He believed that his home life was more stable as well.

The SCI Vocational Readiness Program is unique in that it offers time, opportunity, and encouragement to reconstruct habits and routines while building endurance and strength. An Assistive Technology Center can provide the accommodations to create an environment where clients can learn what tools will allow them to be independent in work tasks, and then put them to use while working in the program.

Heather J. Haug, MA, OTR, is director of the Assistive Technology Center at Casa Colina Hospital for Rehabilitative Medicine in Pomona, Calif. She can be reached at (909) 596-7733 ext 3041, or via email: techcenter@casacolina.org.

Reference

1. Kielhofner G, Burke JA. Model of human occupation, part one, conceptual

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