Occupational Therapy Case Presentation (Medical setting)
Prepared by: Teoh Jou Yin (A 118729)Occupational Therapy ProgrammeFaculty of Allied Health SciencesNational University of Malaysia
Occupational Therapy: Helping people live lives THEIR way.
~ British Association of Occupational Therapy
Demographic Data
Name: N
Age: 45
Marital Status: Married
Race: Malay
Religion: Muslim
Diagnosis: Inclusion Body Myositis
Date of Referral: 5 June 2010
Date Seen: 27 July 2010
Diagnosis: Inclusion Body Myositis (IBM)
Inclusion body myositis (IBM) is an inflammatory muscle disease characterised by slowly progressive weakness and wasting of both distal and proximal muscles, most apparent in the muscles of the arms and legs. There are two types – sporadic inclusion body myositis (sIBM) and hereditary inclusion body myopathy (hIBM)
The common type is sIBM and it strikes individuals apparently at random. The disease in itself is not fatal, but the sequelae (loss of function and mobility, causing a high risk for falls and dysphagia) can be dangerous.
(Source: Wikipedia)
CONCEPTUAL MODEL
OF PRACTICE
Conceptual models of practice describe phenomena of interest like “occupation” or “occupational performance”, guide treatment approaches by easily allowing therapists to focus on the right problem areas, and help to predict outcomes in clinical interventions.
(Iwama 2010)
The Kawa Model
The essence of the Kawa Model (Iwama 2006) is basically to enable occupational therapists everywhere to move beyond the construct of "occupation" and its implications in various cultural contexts, yet still be able to adhere their practice as closely to the mandate of occupational therapy as is possible - which is to “support health and participation in life through engagement in occupation.” (AOTA 2008)
Occupations: Activities that one participates in a day-to-day basis which are important and of value to us. (AOTA 2008)
Let’s just ask the client how they want to live their lives so that it is more meaningful to them, and let’s look together with them at what we can do to achieve that. ~ stuck on Dr Michael Iwama’s monitor bezel.
FRAMES OF REFERENCE
FORs can be defined as the principles behind practice specific to a client population.
FORs include a statement of the population to be served, guidelines for determining adequate function or dysfunction, and principles for remediation.
(Bruce & Borg 1987)
Biomechanical Frame of Reference
Based on kinesiology. Combines neuromuscular physiology, musculoskeletal anatomy and biomechanics.
Involves graded programmes of exercise for restoring neuromusculoskeletal and movement-related functions to normal or optimum, i.e. joint ROM, strength and endurance.
Techniques involved include resistance, repetition, duration, range, speed, etc.
(Hagedorn 1997)
Occupational Adaptation Frame of Reference
Focuses on enabling and engaging in occupations - “life activities that are purposeful and meaningful” (AOTA 2008) rather than functional activities and treating performance components.
A functional life devoid of meaning is merely existence, not living. Robots perform tasks, people engage in life activities to create and derive meaning ~ Charles Christiansen (2010)
Emphasises on “the creation of a therapeutic climate, the use of occupational activity, and the importance of relative mastery.” (Schultz & Schkade 1992)
Utilises occupation-based intervention: A type of occupational therapy intervention in which the occupational therapy practitioner and client collaboratively select and design activities that have specific relevance or meaning to the client and support the client’s interests, need, health, and participation in daily life. (AOTA 2008)
OCCUPATIONAL THERAPY
PERFORMANCE FRAMEWORK
A summary of interrelated constructs that represent and guide occupational therapy practice and articulate occupational therapy’s
contribution to promoting health and participation through engagement in occupation.
(AOTA 2008)
Areas of Occupation-Activities of daily living (ADL)- Instrumental activities of daily living (IADL)- Rest and sleep- Education- Work- Play- Leisure- Social participation
Client Factors-Values, beliefs and spirituality- Body functions- Body Structures
Context & Environment-Cultural- Personal- Physical- Social- Temporal- Virtual
Performance Skills-Sensory perceptual skills- Motor and praxis skills- Emotional regulation skills- Cognitive skills- Communication & social skills
Performance Patterns-Habits- Routines- Roles- Rituals
Activity Demands-Objects used and time properties- Space demands- Social demands- Sequencing and timing- Required actions- Required body functions- Required body structures
EVALUATION
SUBJECTIVE EVALUATION
Kawa Interview (27/7/2010, 9/8/2010)
Blue - river - life flow and overall occupationsRed - river walls and floor - environments, social & physicalLilac - rocks - circumstances that block the river flow and cause dysfunction/disabilityYellow - driftwood - personal resources that can be assets or liabilities.
Life Flow / Overall OccupationsSignificant events and activities that the client regards as important,
meaningful and of value.
Past(Premorbid Hx)
Client was first aware of condition in 1998.“My legs were always weak and I started falling down a lot at my workplace toilet.”Client was working as clerk in government service, took optional retirement in 1/4/2010 on medical reasons.Client’s husband was working as environmental health officer, took optional retirement on 1/6/2010.Client used to enjoy dancing traditional Malay dances, aerobics, and meeting friends at social functions.
Life Flow / Overall OccupationsSignificant events and activities that the client regards as important,
meaningful and of value.
Present Client and husband are enjoying retirement and do not intend to return to work.Client spends most of her time at home reading newspapers and books.Client and her husband enjoy cooking and gardening together.Gardening is also a source of side income for husband.Husband enjoys DIY and planting exotic fruit (grapes, kiwi, apples)Client and husband are very proud of garden. Garden has been featured in local newspapers and magazines, and husband runs a blog about gardening.Client and husband enjoy organising gatherings and pot lucks.
Future Client would like to be able to travel together with husband.Client would like to learn Mandarin and improve her English.Client would like to be able to have internet access on her home computer so that she can explore the world from home.
EnvironmentsThe variety of interrelated conditions surrounding the client in which
the client’s daily life activities occur. (AOTA 2008)
Social Client and husband have no kids.A very loving couple who share the same interests and values.Relatives stay in Gombak.Both staying together in house. Nobody else.Client and husband often have visitors to their house.
Physical Stays in single storey house in Rawang, with garden.No home assessment done.Sitting toilet.Client reports that toilet and bathroom are equipped with non-slip mats.No grab bars.
Personal Assets & Liabilities
Personality Traits Active, outgoing, extroverted.Optimistic, cheerful, fun-loving.Does not like difficulties, will complain and needs much encouragement before she will attempt something she perceives as difficult for the second time.Friendly, chatty, loves to talk.
Special Skills and Abilities
Open-minded and willing to learn.Sociable and good with people.Allows herself to be helped.Happy to depend on husband.
Beliefs, values and principles
Still feels that she is young and there is much to be had out of life.Believes that relationships are important.Believes that life is to be enjoyed no matter what.Husband is a source of emotional security to her.
Obstructions to Life Flow
Occupational performance difficulties
Pt c/o – easily fatigued during occupations, low endurance in tasks.Pt c/o mobility issues in toileting, difficulties with transfer (w/c to chair), sliding buttock on bed.
Fears and concerns Pt c/o safety concerns, used to fall often in workplace.Pt c/o inability to stand affecting her social participation, feels self conscious and “not normal.”Pt c/o lacking confidence to attempt independent mobility. Feels that holding onto husband is more secure.
Inconvenient circumstances
Pt c/o community accessibility issues, lack of w/c-friendly facilities, doesn’t feel confident going out in w/c.
Impairments / Medical Conditions
Pt is concerned about high cholesterol and other health concerns which can be aggravated by her condition, i.e. HBP and DM originating from obesity, osteoperosis, hip fractures from increased risk of falls.
Pt reports discomfort when waking up in morning due to pins and needles in left foot.
EVALUATION
OBJECTIVE EVALUATION
AREAS OF OCCUPATION
Categories articulating “the many types of occupations in which clients might engage” (AOTA 2008)
Activities of daily living (ADL), Instrumental activities of daily living (IADL), Rest and sleep, Education, Work, Play, Leisure, Social participation
Areas of Occupation
1. Activities of Daily Living (MBI) – 8.9.2010
Activity Score Description
Personal Hygiene 5/5 Fully independent
Bathing 5/5 Fully independent
Feeding 10/10 Fully independent
Toileting 5/10 Assistance required for transferring.
Stair Climbing 0 Unable to climb stairs.
Dressing 8/10 Minimal assistance required – shoes
Bowel Control 10/10 Fully independent
Bladder Control 10/10 Fully independent
Chair/Bed Transfer 8/15 Requires assistance of one person. Asst may be required in any aspect of transfer.
Ambulation 3/15 Constant presence is required during ambulation
Total 64/100 Moderate dependency
CLIENT FACTORS
“specific abilities, characteristics or beliefs that reside within the client and may affect areas of occupation” (AOTA 2008)
Client Factors
Body Structures (observation and examination on 9/8/2010)
Client is obese at body weight of 75kg with high concentration of fat at the abdomen.
Client shows eversion of feet and hip abduction. This results in her being unable to bear weight on the soles of her feet.
Hip flexion is obstructed by abdominal fat.
Body Function
Neuromusculoskeletal Functions
MMT for Knee flexion and extension (27/7/2010): 2 (left), (2 right)MMT for Knee flexion and extension (9/8/2010): 2 (left), 2 (right)
MMT for hip flexion (8/9/2010): 2 (left), (2 right)
Sensory Functions and Pain
Semmes Weistein Monofilament Test
(9/8/2010 – Left side) – sensations are normal (2.83)
ACTIVITY DEMANDS
“the specific features of an activity that influence the type and amount of effort required to perform the activity.” (AOTA 2008)
Activity Demands
1. Functional Transfers (Sit-to-stand) – Task analysis
Client reports that the process of sitting to standing during transfering often causes her a lot of difficulty. A task analysis has been carried out on 9/8/2010 to determine the causes of her difficulty.
The results of the task analysis are as follows:
2. Client has involuntary bilateral hip abduction which causes ankle eversion.3. While trying to stand from a sitting position, client’s knee is slightly
extended with feet placed in front of knees.\4. Heels are not parallel with knees.5. Client does not scoot buttock to edge of seat while attempting to stand.6. Client maintains trunk in extension while trying to stand, with body weight
backwards. Posterior pelvic tilt.
INTERPRETATION OF DATA
Aims
Prioritised Problem List
1. Safety concerns in transferring
1(a). Risk of falls because of incorrect biomechanics in sit-to-stand task1(b). Discomfort from pins and needle sensation in left foot in mornings.1(c). Foot eversion on both lower limbs.
2. Difficulties in functional ambulation
2(a). Weakness in lower limbs2(b). Inability to participate in physical exercise causing obesity
3. Difficulty in performing life activities (occupational performance) due to fatigue.
4. Health concerns as part of aging process, aggravated by current condition, which can affect occupational performance.
Short Term Goals
1. Prevention of falls during transfer
1(a). Educate client in proper body mechanics during sit-to-stand task.1(b). Educate client on how to prevent or reduce pins and needle sensation before getting out of bed in mornings1(c). Educate client on proper footwear to address foot eversion.
2. Facilitate functional ambulation
2(a). Compensate for weakness in lower limbs with walker.2(b). Graded, aerobic exercise programme with resistance focusing on upper limbs and trunk.
3. Improve performance in life activities (occupational performance) by applying fatigue management principles.
4. Prevent and reduce possible difficulties in future occupational performance by health complications which can occur with aging and degenerative condition.
Long Term Goals
1. Facilitate aging in place.2. Enabling participation in activities involving community
INTERVENTION
Problem: Safety concerns in transferringAim: Prevention of falls during transfer
Cause:Risk of falls because of incorrect biomechanics in sit-to-stand task
Solution:Educate client in proper body mechanics during sit-to-stand task for transferring(Pendleton & Schultz-Krohn 2005)
A graded training programme in proper biomechanics should be practised and a gait belt used during training. Example: Sit-to-stand.
• Patient has to first shift her buttock to the edge of her seat, with as small a contact area as is possible without falling down.• Patient should then grasp the walking frame firmly in front of her, with both hands.• Both her feet are pressed firmly on the ground and her toes parallel to her knees.• She then has to bend her trunk forwards, lifting up her buttocks, using her hands as support to push her body upwards.• Assistance is required: support from the back and also to keep feet blocked.
Problem: Safety concerns in transferringAim: Prevention of falls during transfer
Cause:Discomfort from pins and needle sensation in left foot in mornings.
SolutionEducate client on how to prevent or reduce pins and needle sensation before getting out of bed in mornings
Client is advised to facilitate circulation in feet before moving it and attempting to get off bed, i.e. rubbing, slow movements.
Cause:Foot eversion on both lower limbs.
ProblemEducate client on proper footwear to address foot eversion (Pendleton & Schultz-Krohn 2005)
Client has both feet in eversion during rest and also when walking. An AFO has been prescribed and client is advised to always wear proper footwear during ambulation and not go barefoot.
Problem: Difficulties in functional ambulationAims: Facilitate functional ambulation
Cause:Weakness in lower limbs
Solution:Compensate for weakness in lower limbs with walker.(Pendleton & Schultz-Krohn 2005)
Functional ambulation: “Walking within one’s immediate environment with other activities chosen by the individual.” Functional ambulation may be conducted with aids, i.e. walkers and crutches.
In this case, a walking frame has been tested and found to be comfortable for patient. Suggestion has been made to obtain one with gov funding (letter from doctor.)
Rationale: - supports part of body weight through arms, provides sensory cues for balance and enhance stability by increasing size of base of support.
Walking activities should be incorporated with ADL and IADL for relevance.
Problem: Difficulties in functional ambulationAims: Facilitate functional ambulation
Cause:Inability to participate in physical exercise causing obesity
Solution:Graded, aerobic exercise programme with resistance focusing on upper limbs and trunk.
Client is put on a graded upper body aerobic exercise programme using dumbells with light weight resistance of 1kg. Exercise time is designed to gradually increase to at least 30 minutes for optimal fat burning activity.
Programme has a predominant focus on core muscles of all sides of the trunk, with some upper limb movement.
Exercises are performed both sitting down and lying down.
Rationale: Abdominal fat on client is currently obstructing trunk movement during sit-to-stand and stand-to-sit tasks and also causing difficulty in walking.
Problem: Difficulty in performing life activities (occupational performance)Aim: Improve performance in life activities (occupational performance)Cause: Fatigue
Solution: Fatigue Management Principles(Pendleton & Schultz-Krohn 2005)
•Alternate muscle movements on a regular basis rather than use one particular muscle group for a prolonged period of time.
• Prioritse: activities that cannot be stopped when becoming too stressful, or which cannot broken up into smaller chunks should be avoided.
• Rest and activity should be balanced – the key to increasing functional endurance is to rest before becoming over fatigued, then gradually increase the activity duration or decrease the resting time in between.
• Reduce force and effort.
Problem: Health concerns affecting future occupational performance.Aim: Prevent and reduce health complications to promote optimum occupational performance.
Causes:High cholesterol, obesity causing risk of high blood pressure and diabetes, risk of osteoperosis, high risk of hip fracture due to tendency of falls.
Solution:Client education & family discussion
Client and family should be made aware of all these possibilities and begin taking precautions, i.e. weight resistance exercises to increase bone density, aerobic exercises to lose excess fat, proper diet control, environmental modification to facilitate aging in place.
Prognosis
Good. Client has good social environment supports and many personal traits and resources that she is able to use to her advantage in coping with her degenerative condition.
Awareness and education is most important and future considerations must be taken into account, especially as her current degenerative condition and obesity will amplify the complications that come with aging.
Future Plans
Regular reassessments.Maintain body functions.Home assessment.Environmental modification to facilitate aging in place.Community mobility assessment.Fall management programme (i.e. teaching how to get up from the ground)
