• Model-Who Disablement Model
  • Disease:
    • Legionellosis refers to several illnesses caused by bacterium Legionella pneumophilia (LDB), which is an infection of the lungs and is a form of pneumonia.
      • Legionnaires’ Disease is an opportunistic disease and the most severe form of Legionellosis.
      • Pontiac Fever is a more mild form of Legionnaires’ Disease, but is a non-pneumonia disease with a short incubation period of 1-3 days with full recovery usually occurring 2-5 days after onset without medical intervention needed.
    • Relevance/ Prevalence
      • Occurs in 5% of people who are exposed, and is influenced by level of contamination, susceptibility of the person exposed, the intensity of exposure, and duration of exposure.
      • One of the top three causes of non-epidemic, commonly-acquired pneumonia.
      • 25,000 cases are report per year with 4,000 deaths.
      • Many cases go unreported due to level of difficulty with distinguishing the disease from other forms of pneumonia.
    • Symptoms:
      • Early symptoms: slight fever, headache, muscle aches, lack of energy, tiredness, and loss appetite
      • Later symptoms: High fever, cough, difficulty breathing/ shortness of breath, chills, chest pain, nausea, vomiting, diarrhea, and abdominal pain
    • Transmission:
      • Domestic: Warm water systems that disseminates water particularly aerosols, sprays, and mists. Plumbing systems, cooling towers, hot tubs, whirlpools, swimming pools, hot water tanks, and air conditioners.
      • Natural Environment: LDB is commonly present at low levels in lakes, streams, rivers, freshwater ponds, soil, and mud, but LDB levels are typically so low in these locations that it is unlikely someone will contract the disease from these sources.
      • Via: inhalation and/ or aspiration
        • There is no evidence to show that the disease is transmitted from one person to another.
      • Risk Factors:
        • Old age
        • Smoking
        • Immunosuppressive Therapy
        • Chronic conditions, such as COPD, emphysema, Diabetes Mellitus, Kidney Diease, or Cancer
        • Organ Transplant Patients
        • People taking Corticosteroid Therapy
        • People who have a job maintaining the cooling towers in hospitals and nursing homes

• Impairment: a disease caused by bacterium Legionella pneumophilia that mostly affects the lungs and may lead to respiratory failure, septic shock, and/or acute kidney failure. People who are affected by this disease are faced with the psychological factors that accompany acute, severe illness, and may be affected by the 5 Stages of Grief: denial, anger, bargaining, depression, and acceptance.

• Disability: People affected by Legionnaires’ Disease often experience acute onset decreased activity tolerance/ endurance, decreased strength, shortness of breath, and flu-like symptoms.

• Handicap: See “Disability”. Depending on patient’s level of function and length of time from onset, the individual may range from dependent assist to supervision on the Functional Independence Measure. Supervision is recommended due to level of fatigue in the recovery stages of this disease. Often times, these individuals may be wheelchair bound due to decreased level of endurance/ activity tolerance.

• Evaluation
  • Diagnosis: Legionellosis; R lower lobe atelectasis, Acute Renal Failure, Systemic Inflammatory Response Syndrome, Multiple Organ System Failure, Atrial Fibrillation, Shock, Community-Acquired Pneumonia, and Septicemia
  • History of Present Illness & Occupational Profile: He worked at a food service company where he unloaded freight truck deliveries Monday-Friday. He was working and going to football games within the community on Friday nights prior to onset of Legionnaires’ Disease. He had also been doing work outdoors around his home, such as cutting and chopping wood. His hobbies involve outdoor activities, such as camping and hunting.
  • Past Medical History: hypertension and high cholesterol, and, of the known risk factors for Legionnaires’ Disease, he is older and is frequently around cooling systems for his job.
  • Psychosocial Factors & Occupational Profile: He has been married for 46 years, and they have a son who has two children. He has a supportive family and community where he is an involved member of a local church. He appears to be coping well with his diagnoses when he said “I’m doing ok. I just do everything I can to get better.” He stated that his religion and spirituality are his biggest coping mechanisms along with the support from his wife and family.
  • Patient’s Chief Complaint: generalized weakness affects his participation the most within the therapy setting. He struggled the most with the shortness of breath, muscle aches, fever, diarrhea, and chills, which occurred prior to his arrival at WRC.
  • Patient’s Goals:
    • Patient’s Goal: “I want to get back to walking like I was before.”
    • STG: (in 1 week) pt will be (1) Mod I with RLE sock donning with sock aid prn (2) Mod I for donning brief with LH reacher prn (3) Mod I for SPT w/c><toilet with AD/DME prn.
      • Pt met 3/3 STGs.
    • LTG: (by d/c) pt will be Mod I with BADLs, functional transfers, home management skills, and leisure participation with AE/AD/DME prn.
      • Pt met 3/3 LTGs.
    • Objective Information from Evaluation (see p.4 for summary of patient’s evaluation status as compared to discharge status):
      • FIM Scores:
        • Arrival:
          • Feeding: Modified Independence (6)
          • Grooming: Supervision (5)
          • Bathing: Supervision (5)
          • UB Dressing: Supervision (5)
          • LB Dressing: Moderate Assistance (3)
          • Toileting: Supervision (5)
          • Transfers: Minimal Assistance (4)
          • Showering: NT (0)
        • MMT Scores:
          • Arrival:
            • RUE (R hand dominant)
              • 3+/5 with Scapular Elevation, Scapular Depression, Scapular Protraction, Scapular Retraction, Shoulder Flexion, Shoulder Extension, Should Abduction, Shoulder Adduction, External Rotation, Internal Rotation, Elbow Flexion, Elbow Extension, Supination, Pronation, Wrist Flexion, Wrist Extension, Digit Flexion, Digit Extension, Grip

• LUE
  • 4-/5 with Scapular Elevation, Scapular Depression, Scapular Protraction, Scapular Retraction, Shoulder Flexion, Shoulder Extension, Should Abduction, Shoulder Adduction, External Rotation, Internal Rotation, Elbow Flexion, Elbow Extension, Supination, Pronation, Wrist Flexion, Wrist Extension, Digit Flexion, Digit Extension, Grip
• Standing Tolerance:
  • Arrival: 1 minute 5 seconds consecutively
• Design:
  • Treatment Plan:
    • Breathing Exercises/ Re-training
      • See Home Exercise Program & Treatment Plan Attached
    • Optimal Posture/ Positioning
      • See Home Exercise Program & Treatment Plan Attached
    • Strengthening & Endurance
      • See Home Exercise Program & Treatment Plan Attached
    • Compensatory Strategies/ DME:
      • See Home Exercise Program & Treatment Plan Attached
    • Explanation of Treatment:
      • See “rationale” and “activities” in the Treatment Plan for a detailed explanation of treatment methods.
      • Theories/ FOR
        • The same theories/ frames of reference were used throughout the treatment plan to provide consistency of purpose and goals throughout plan of care at WRC and upon d/c home.
      • All Methods/ Activities were client-centered and occupation-based as determined by a discussion with the patient.
      • The HEP is a continuation of plan of care at WRC, but it is a more concise version of the therapeutic activities/ exercises that were facilitated at WRC to promote follow-through once the patient is discharged.
      • Based on the OTPF 2ed., this specific plan of care and HEP were intended to address the following:
        • To promote meaningful and functional involvement with BADLs, IADLs, work, leisure, and social participation.
        • The body functions and structures that were affected by Legionnaires’ Disease, which led to generalized weakness, decreased endurance, dyspnea, and a decline in functional independence.
        • To encourage communication and understanding of the effects of Legionnaires’ Disease.
        • To incorporate the patient’s habits, routines, roles, and rituals into the plan of care at WRC.
        • To consider the cultural, personal, physical, social, and temporal contexts/ environments that would promote or inhibit the patient’s recovery while at WRC and once he returns home after discharge.
      • Clinical Reasoning:
        • See “rationale” in Treatment Plan
      • Scientific Basis
        • Shea, J. & Donty, V. (2009). Pulmonary Rehabilitation. Pulmonary- Critical Care Associates of East Texas. Retrieved on December 1, 2012 from http://www.pcca.net/PulmonaryRehabilitation.html.
          • Exercise Reconditioningà by varying mode, frequency, intensity, & duration of exercise, pt may see an increase in maximum exercise capacity and endurance, and it is an opportunity to learn about their capacity for physical work and to practice breathing techniques.
          • -Respiratory Trainingà does not lead to improvements in overall inspiratory muscle strength and endurance, nor does it lead to an increase in diaphragm strength, but it does help to train/ strengthen the rib cage and accessory muscles.
          • -Breathing Strategies (i.e. Diaphragmatic Breathing, Pursed Lip Breathing)à reduce dyspnea
        • Reed Group’s Medical Advisory Board. (2012). Pneumonia. Medical Disability Adivsor. Retrieved on December 1, 2012 from http://www.mdguidelines.com/pneumonia
          • Suggested Course of Txà breathing exercises and postural drainage techniques to mobilize lung secretions
          • By building endurance, the individual increases resistance to fatigue and the ability to work as endurance increases without shortness of breath, the individual begins active upper and lower extremity exercises using very light resistance.
        • Influencing Factors:
          • Generalized weakness
          • Decreased endurance
          • SOB
          • Decreased oxygen sats
          • Family Support
          • Successful Coping Strategies
        • The treatment plan attached to this document is intended to (1) increase the patient’s accessory muscles for respiration, (2) facilitate optimal posture for breathing, (3) upper body strengthening & endurance, and (4) compensatory techniques/ strategies to promote functional independence upon returning home with wife. These four areas addressed in the treatment plan were areas that the patient and the OTS determined to be most affected/ influential to his progress with recovery from Legionnaires’ Disease. These were the areas that would most likely lead to a full recovery for the patient, based on the patients’ perceptions, the OTS’s perceptions, and research regarding physical rehabilitation for Legionnaires’ Disease/ pneumonia-like illnesses.
        • Expected Outcome:
          • It is expected that the pt will make a full recovery and he plans to return to work within the next 6 months to a year.
        • Conclusion:
          • Assessment of Treatment & Efficacy:
            • Subjective Information from the Patient:
              • “I appreciate everything that you’ve done to help me. I can tell a big difference in what I could do when I came here and what I can do now. I feel ready to get back to my life.”

References:

American Occupational Therapy Association. (2008). Occupational Therapy Practice Framework: Domain & Process 2ed. American Journal of Occupational Therapy, 62(6).

Center for Disease Control. (2011). Patient Facts: Learn More about Legionnaires’ Disease. Legionellosis Resource Site (Legionnaires’ Disease and Pontiac Fever). Retrieved on November 25, 2012 from http://www.cdc.gov/legionella/patient_facts.htm

Mayo Clinic Staff. (2010). Legionnaires’ Disease. Diseases and Conditions. Retrieved on November 25, 2012 from http://www.mayoclinic.com/health/legionnaires-disease/DS00853

Occupational Safety & Health Administration. (2003). Legionnaires’ Disease. OSHA eTools. Retrieved on November 25, 2012 from http://www.osha.gov/dts/osta/otm/legionnaires/index.html

Special Pathogens Laboratory. (2011). General Information about Legionnaires’ Disease. Retrieved on November 25, 2012 from http://www.legionella.org/general_info.htm