Case STUDY: POKER HANDS

Emily Matthews, OTS

Client initially sustained multiple

fractures to both of his small fingers in
an accident during tennis tournament in
Michigan.
He did not seek medical care and he
drove 36 hours back to Vegas.
Upon arriving to Vegas, he checked
himself into a hospital for medical
attention.

Poker Hands

To his surprise, he received surgery on

both of his small fingers and got pins
placed in both fingers to help secure the
fracture.

Retrieved from www.handpinlab.com

Retrieved from www.slidshare.net

Mr. Gs fracture on his right small finger was the

first to get the pins out which were placed in for a
total of 2 weeks. He started therapy on his right
hand while he remained in a cast on his left hand
for 3 additional weeks.

Hand therapy clinic

40-45 patients a day
One hand therapist OTR/L, CHT
One occupational therapy tech
Shared space with Physical therapy department
Hand clinic area could service 8 patients at a time
Average treatment time was ~1 hour

Setting

PEOP

Biomechanical FOR

Subjective
Occupational Profile
Interview
Functional
COPM
MOHO assessments
Activity card sort

Objective
Self Report Measures (DASH)
Goniometry (AROM & PROM)
Manual muscle test (MMT)
Dynamometry (grip and strength
testing)
Circumferential measures (edema)
Wound care
Sensation (Semmes Weinstein
Microfilament)
Pain scales
(Gillen, 2014)

Evaluation

PEOP

Biomechanical

Top down approach- Holistic

Functional tasks and activities that
are meaningful
Uses the interactions of a persons
intrinsic factors and extrinsic or
environmental factors
Clients perceptions of
occupational performance issues
become the cornerstones for
clinical intervention. The clients
view of the problem becomes the
top priority for intervention.

Bottom up approach
Restore or establish client-level
factors, performance skills,
performance patterns.
The clients impairment can be
remediated or restored

(Rybski, 2011)
(Cole & Tufano, 2008)

Intervention

Occupational Profile
Mr G:
56 years old
Poker Dealer
Lives alone
Family in Michigan
Independent
Has a small dog
Enjoys scenic driving and
traveling
Very competitive
Prior level of function - Independent in
ADLS, IADLS, full duty/seasonal worker
as a poker dealer

Retrieved from www.pokerplace.com

 The Person Environment Occupation

Performance (PEOP) model describes the
combined nature of the person, occupation,
environment, and performance as they
influence the human being (OBrien,
2012).

PEOP
Retrieved from www.wellsearch.com

Retrieved from www.cb3e.slackbooks.com

PEOP MODEL

Physiological- Client is very active, works out everyday, enjoys taking his dog for
2 mile walk at Sunset park. Has not been able to lift weights due to his recent
injuries. He has limited ROM and decreased strength in his both of his small
fingers.
Cognitive- Clients memory intact, rational with reasoning, adequate attention
span, executive functioning in working order. No injury was made to his head
during accident. However sometimes his pain medication may influence his mood.
Spiritual- Client believes that he will get better and attends church every Sunday.
He believes in staying positive will produce positive outcomes in life.
Neurobehavioral- All sensory and motor systems are intact. Mr. G experienced
numbness and tingling around his PIP joint in both small fingers as well as pain.
Psychological-Very optimistic person, happy, he believes he can do anything he
puts his mind to, he is anxious to get better to start working again.
(Cole & Tufano, 2008)

Person

Father- Has two adult children

Boyfriend- Has a girlfriend that he dates on the weekend
Works at the Venetian As a poker dealer
Walker- Enjoys talking walks everyday at the park his dog
Poker Player- His main hobby is to travel to different casinos
and try is luck playing poker
Friend- Has a group of friends he travels with to play poker
and to do scenic driving
Cook- One of his favorite pastimes is to cook healthy meals
(Cole & Tufano, 2008)

Occupation

 ADLs Bathing, Dressing, grooming, toilet hygiene; took longer than

expected and got fatigued easily
Exercising- Does not go to gym anymore due to restrictions and
limitations
Poker dealing- Pitching and stacking, not efficient, dropping cards and
coins
Splint- Prevented him from performing certain fine motor activities
Pain medication- Moody, limited driving abilities
Meal preparation- Reduced to eating microwave or take out meals
since cooking and cleaning became difficult
(Cole
& Tufano,
Leisure participation- Declined significantly, no longer
hangs
out with2008)
friends or plays poker

Occupation Performance
and Participation

 Due to the severity of Mr. G injuries, his performance in

many of his client factors were comprised. Also,
depending on if he took pain medication, his mental
functions were comprised as well. Side effects of the
medication included sedation, impaired concentration,
fatigue, and sleepiness.

Performance

Retrieved from www.blogtsu.edu

 Social Support- Girlfriend, local friends and neighbors to help

him when he needed
Social and Economic Systems- Social economic status (SES):
Lower middle class. Culinary insurance, 20 visits a year/20
dollars a visit. Frequency therapy 3X a week. Within a month
and a half all visits were used and patient had to pay out of
pocket at $70 visit before the new year. Luckily he won some
money to help pay for his out of pocket expenses before the new
year started. This allowed him to continually get therapy care
without interruption.

(Cole & Tufano, 2008)

Environment- Quality of Life

 Culture and Values- American citizen born and raised in Michigan.

Moved to Vegas to become a poker dealer. Believes in hard work.
Helps his children financially monthly.
Built environment and Technology-Hand therapy clinic with
therapeutic modalities to help to increase function and overall
comfort. Splints to help protect Mr. G from dangers in the
environment that can cause further injury.
Natural Environment- Lives in Vegas, average temp 65 degrees,
therapeutic surroundings of the Mountains to promote healing.
(Cole & Tufano, 2008)

Environment (Cont.)

 Abilities- grooming, light cleaning around the house, shuffling

cards, light meal preparation (squeezing condiments, holding
utensils)- promoting flexion and ROM
Actions- Slow to complete task and used compensatory methods
(especially when pins were in hands)
Tasks- Pitching a deck of cards into a hat starting at 3X a day with
increase accuracy, stacking chips at different heights, using both
hands to drive.
Occupations- Dealing poker with a group of small friends to
increase confidence, performing desired ADLs and IADLs
Occupations are the activities and tasks done in managing a persons
daily life; set of tasks grouped together in some meaningful way so that
the person can perform life roles.

PEOP- Interventions

(Cole & Tufano, 2008)

 Occupational performance improvement -Mr. G is

actively more engage in occupations he gave up due to his
injury
Quality of Life- Improved due to satisfaction towards
progress of goals. His hope to return to work increased,
happy about able to perform more activities and tasks with
shorter time and greater accuracy.
More functional in everyday activities and tasks
(AOTA, 2014)

PEOP Outcomes

 The biomechanical frame of reference addresses peripheral

nerves, integumentary system, cardiopulmonary system
and musculoskeletal capabilities.
Bottom up approach, only looks at the area(s) that are
causing dysfunction (not holistic).
Biomechanical approach is good for remediating and
restoring client level factors, performance patterns and
performance skill (ROM, strength, endurance).
Mr. Gs impairment can be restored or remediated through
strengthening and endurance activities.
(Rybski, 2011)

Biomechanical FOR

 Grip Strength- Not tested initially due to restrictions.

Swelling- girth around PIP joint for right small finger 6.7
cm, girth around left small finger 6.6 cm.
Sensation- Hypersensitivity and numbness at tips of the
small fingers

Evaluation

Extension
Left

Right

MP

-5 (0)

PIP

-55 (0)

-55 (0)

IP

-10 (0)

-5 (0)

Flexion
Left

Right

MP

30 (90)

20 (90)

PIP

55(100-105)

55(100-105)

IP

35 (80)

35 (80)

Evaluation -ROM

 Moist heat- 15 minutes Pre-Treatment

Ultrasound- 5 minutes at 1 MHZ
Splinting- Ulnar gutter splint used for the first few weeks,
then progressed to Buddy straps. Dyna splints at night for
flexion and extension
Joint Mobilization- Passive, Active, Active Assist
Strength training/endurance training- rice, flex bar, digit
flex, putty
Vibration 5 minutes
Paraffin- 10 minutes in moist heat

Intervention

Retrieved from www. Ncmedical.com

Retrieved from www.galleryhip.com

An ulnar gutter splint was made for the left

hand and buddy straps and digit sleeves
were used for the right hand.

Intervention

Interventions

Interventions

 Occupational Performance
Prevention

Increased ROM
Increased Strength
Increased Endurance
More functional!!

(AOTA, 2014)

Outcomes

PEOP model and biomechanical frame of

reference were used in concert to provide the
best intervention plan and goal setting to give
the client the best possible service delivery.

Questions?

AOTA. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of
Occupational Therapy, 68(Suppl. 1), S1-S48. http://dx .doi .org/10 .5014/ajot .2014 .682006
Cole, M.B., & Tufano, R. (2008). The Person-Environment-Occupation-Performance Model. In Applied theories in
occupational therapy: A practical approach. (pp. 127-133). Thorofare, NJ: Slack Inc.
Gillen, G. (2014) Motor function and occupational performance. In B.A.B. Schell, G. Gillen, & M.E Scaffa (Eds). Willard
and Spackmans occupational therapy (12th ed., 750-778). Philadelphia: Lippincott Williams &Wilkins.
OBrein, J., & Hussey, S. (2012). Introduction to Occupational Therapy (4th ed.). St. Louis, MO: Mosby.
Rybski, M. (2011). Kinesiology for occupational therapy. Thorofare, NJ: Slack Incorporated.

References