Background Information
Date of report: 2/9/18 Clients name: Ms. L
Age: 51 Date of referral: 1/17/18
Primary diagnosis: Multiple Sclerosis
Precautions/contraindications: High endurance or high energy activities.
Reason for referral to OT: concerns with energy conservation, fine motor control, and stability
Therapist: Derek Jones
S:
Client states that she is excited to see what occupational therapy can help her with in her daily
life. She seems like she is very dedicated to improving her condition and managing her
symptoms.
O:
Client was seen for comprehensive evaluation involving a series of assessments and observation
of occupational performance.
9-hole peg test
Client was administered the 9 Hole peg test which is a test designed to upper extremity function
and finger dexterity. Both hands were tested and results are as follows:
Left hand: 58 sec
Right hand: 31 sec
Average 9 hole peg test scores for female subjects of the same age are 22.5 for the left hand,
and 20.5 for the right.
Reaction time test
Client performed a standardized reaction time test using a click test on the computer. A series of
red and green lights were shown and client was asked to click the mouse as fast as she could
when the light turned green to measure her reaction time. Each hand was tested five times and
results were as follows:
Trial Left Hand Right Hand
(ms) (ms)
1 1519 704
2 1216 666
3 860 773
4 1571 500
5 1048 635
Ave. 1243 656
Normative data shows that average scores for both hands range from 200 -250ms.
COPM
Client completed the Canadian Occupational Performance Measure (COPM), which is an
assessment that identifies top priorities for goals and outcomes as well as the perception of the
current performance, and performance over time in each specified area. The following
items were indicated as highest areas of concern (in order of most important to least
important.)
OCCUPATIONAL PERFORMANCE IMPORTANCE PERFORMANCE SATISFACTION
PRIORITIES (On a scale of 1-10; (On a scale of 1-
1=not performing, 10; 1=not
10=performing satisfied,
independently) 10=highly
satisfied)
Driving 10 8 9
Handwriting 8 6.5 3.5
Keyboarding 8 3 2
Cooking 7.5 3 2
Dressing with fasteners 7 6.5 4
TOTAL 27/5= 5.4 20.5/5=4.1
Dressing observation
Client was observed donning a long sleeve button up shirt. Client independently situated shirt
around shoulders and pulled arms through sleeves. She required min A to align buttons. Client
took 5 minutes to independently button one button while sitting in chair. After completing one
button, client buttoned two more buttons with min A using button hook.
Meal preparation observation
Client was observed making a partial meal that consisted of mixing pasta sauce and spices in a
bowl. Client stood next to counter without cane while performing meal prep activities. Client
independently opened pasta jar and poured a small portion in the bowl using her right hand
while bracing herself with the left hand on the counter. Client independently opened can of
tomato sauce using a hand crank can opener with right hand and independently opened a small
spice jar and box of pasta which she added to the mixture. When asked to add salt with a salt
grinder, client grasped salt grinder with both hands and turned salt grinder but did not add
much salt to the mixture. Client stood for 5 minutes while completing meal prep activities
without breaks and bracing against countertop for support.
Occupational profile
Reason the client is seeking service and concerns related to engagement in occupations
Client is a 51 year old female diagnosed with multiple sclerosis currently living in Midvale Utah.
Client is seeking occupational services due to concerns with energy conservation, fine motor
control, and stability that are impacting her participation in daily occupations. She reports that
she is having difficulty with donning button up shirts and that she doesn’t wear them very often
due to the amount of time that it takes her to button them up. She reports that dexterity in left
hand is worse than in right. Client also reports difficulty with cooking full meals because of the
energy it takes to cook the food and clean up afterwards. Client just got approved to retain
license for 5 more years but is concerned about her driving ability on the freeway and does not
want to see her ability to drive regress. Client has difficulty with performing household tasks
that involve prolonged standing. She reports a standing tolerance of about 5 minutes.
Occupations in which the client is successful
Client is successful in both her ability to get around her house and the community. She attends
regular MS exercise and educational courses at the held at the University of Utah and other
various locations throughout the community. Client is Independent in all ADL’s and IADL’s but
wishes to be more efficient in these areas
Personal interests and values
Client enjoys being outside and participating in outdoor activities like hiking and snowshoeing.
She enjoys dancing and the performing arts. Client also values her religious beliefs and the
social opportunities that are presented through her participation in church activities. She values
friendship and spending time with those she is close with.
Occupational history
Before being diagnosed with MS, client regularly participated in activities such as biking, skiing,
dancing, softball, aerobics, and snowshoeing. Client was diagnosed with MS at age 34. She has
worked with a physical therapist at the University of Utah in the past and had a brief experience
with an OT involving only a few sessions at an outpatient clinic in sugarhouse. She worked full
time before she was diagnosed but since has reduced her hours to part time at an attorney’s
office that allows her to be flexible with her hours.
Performance patterns (routines, roles, habits, & rituals) (p. S8)
Client reports disturbances with her nightly sleep routine saying she has a difficulty going to
sleep at night and not feeling rested. She has been prescribed a C-Pap machine but has not used
it because of how cumbersome it is at night. Client has changed showering routine from the
morning to the night because the heat exacerbates her MS symptoms which are easier to deal
with at night when she is getting ready for bed and doesn’t have as many performance
demands. She typically attends educational or exercise classes for her MS symptoms in the
morning which leaves her without much energy left for activities the rest of the day.
Supports and barriers to occupational engagement
Client lives with two other single women who are very supportive and accommodating of her.
She also has a good social support system through her activity in her church group. She lives in a
house that is accessible to her and owns a car which enables her to get around the community
when she needs to.
Desired outcomes
Client understands the progression of her disease and hopes to be able to maintain her current
functionality. She hopes that through occupational therapy she can learn ways to restructure
activities and learn how to use adaptive equipment along with light strengthening to increase
her ability to dress using button shirts, drive safely, improve her ability to cook meals, and
increase her standing endurance.
A:
Clients performance in both the 9 hole peg test and the observation of dressing reflect her
inability to control fine motor movements with her hands and fingers. Her left hand is much
more impaired than the right and displays a slight tremor when doing fine motor tasks. Her
struggles in fine motor tasks are also affected by her lack of sensation in her hands and fingers
which makes manipulating objects more difficult. Clients below average reaction time test
results represent a common issue among those with MS and can likely be attributed to the
diseases effect on neuronal pathways slowing conduction of nerve impulses. Client displayed
the ability to stand for 5 minutes while doing meal preparation tasks without taking a break and
without losing balance however near the end of the task she began to look more fatigued and
used the countertop more to brace herself with. Client lacks the dynamic standing balance to
move about easily without her cane which makes her dependent on bracing herself against
nearby objects. She shows a lack of muscle endurance when it comes to doing tasks that require
a degree of physical effort especially while standing. She possesses the grip strength, bimanual
coordination, and dexterity to complete the simple meal prep activities we observed like
opening a can with a hand crank can opener and opening jars and small spice containers. It
appears that her biggest barrier however is the amount of energy that each of these tasks take
for her to complete. The compounding of multiple tasks leaves her fatigued and her
performance decreases as time doing a physical task increases.
Practice Models
PEO. The PEO model states that the person, environment, and occupation transact continually
over time and their congruence or “fit” can influence occupational participation (Law, Cooper,
Strong, Stewart, Rigby, & Letts 1996). It is important to consider client factors/performance skills
as well as the environment and the occupational task demands and how they contribute to the
clients overall occupational performance. Relevant postulates of change from this model
include: 1. A change in one of the components of this model will affect the other components as
well. 2. The environment is dynamic and can have enabling or constraining effect on
occupational performance. These postulates will help guide our intervention with the client in
helping us assess the different components of her occupational performance and making
changes in those aspects in order to increase congruence between these components.
OA. The OA model aims to maximize the client’s effectiveness in using his or her own ability to
be adaptive. Given the nature of MS and the typical progression of the disease, it’s important
that we focus on teaching the client how to approach things from an adaptive mindset. Relevant
postulates from this model include: 1. The greater the level of dysfunction, the greater is the
demand for changes in the person’s adaptive processes. 2. Success in occupational performance
is a direct result of the person’s ability to adapt with sufficient mastery to satisfy the self and
others. This model will help guide us in Increasing the clients adaptiveness, relative mastery,
self-evaluation and internal adaptation process.
P:
Goals
Goals were desired outcomes were discussed with client. Client communicated that she
understood the reality of not expecting to make large gains in function but instead wanted to
focus on maintenance and adaptations. The following goals were developed by client and
therapist.
LTG: Within 2 months client will independently cook stove-top meal using energy conservation
techniques
STG: In 1-month client will independently use energy conservation techniques while dressing
per client report
STG: in 2 weeks client will utilize button hook to don button up shirt
LTG: Within 2 months client will independently don button up shirt using energy conservation
techniques
STG: in 2 weeks client will utilize button to don button up shirt
STG: in 1 month client will independently use energy conservation techniques while dressing
per client report
Prioritization of need areas:
Client is determined to do what is necessary to manage her symptoms and work hard to
improve her functioning. She is invested in the therapy process and has supportive family and
friends nearby. She also works at a place that allows her to be flexible with hours which allows
her to structure her day the way she wants to. Her biggest barriers come in the form of task or
environmental demands that require a lot of strength and high endurance.
Plan:
Client will continue to be seen for 5 more 60 minute sessions to address concerns in fine motor
control for dressing, utilizing energy conservation techniques, and increasing dynamic standing
balance and endurance. Research has shown that energy conservation programs can
significantly reduce fatigue impact and help increase self-efficacy for individuals with MS
(Mathiowetz, Finlayson, Matuska, Chen, & Luo, 2005). This will be a large part of our treatment
approach. Research also backs the use of balance rehabilitation training in treatment in order to
improve dynamic balance for functional tasks (Cattaneo, Jonsdottir, Zocchi & Regola, 2007).
While the main focus of our treatment will be teaching techniques and adapting task demands
to improve functional performance, improving balance and increasing strength will also be play
a role in treatment. Evidence for increasing strength in MS is varied and is largely dependent on
the case itself however there is some evidence that suggests that strength gains can be made
through resistance training for individuals with MS (White, Mccoy, Castellano, Gutierrez,
Stevens, Walter & Vandenborne, 2004). A combination of approaches and techniques based off
of these studies as well as other evidence from the literature will be employed in order to
provide the best care for the client.
Quick links to articles
Mathiowetz: http://journals.sagepub.com/doi/abs/10.1191/1352458505ms1198oa
Cattaneo: http://journals.sagepub.com/doi/abs/10.1177/0269215507077602
White: http://journals.sagepub.com/doi/abs/10.1191/1352458504ms1088oa
References
Cattaneo, D., Jonsdottir, J., Zocchi, M., & Regola, A. (2007). Effects of balance exercises on
people with multiple sclerosis: a pilot study. Clinical Rehabilitation, 21(9), 771-781.
doi:10.1177/0269215507077602
Law, M., Cooper, B., Strong, S., Stewart, D., Rigby, P., & Letts, L. (1996). The person
environment-occupation model: A transactive approach to occupational performance.
Canadian Journal of Occupational Therapy, 63, 9-23.
Mathiowetz, V. G., Finlayson, M. L., Matuska, K. M., Chen, H. Y., & Luo, P. (2005). Randomized
controlled trial of an energy conservation course for persons with multiple sclerosis.
Multiple Sclerosis Journal, 11(5), 592-601. doi:10.1191/1352458505ms1198oa
White, L. J., Mccoy, S. C., Castellano, V., Gutierrez, G., Stevens, J. E., Walter, G. A., &
Vandenborne, K. (2004). Resistance training improves strength and functional capacity in
persons with multiple sclerosis. Multiple Sclerosis Journal, 10(6), 668-674.
doi:10.1191/1352458504ms1088oa
