ROLE OF OCCUPATIONAL THERAPIST

OT gathers information about patient’s HPI and medical background such as previous interventions received by the

patient, when and how the disease occurred, as well as medications taken before and during the evaluation period.

OT facilitates the making of patient’s Occupational Profile.

Based on the information gathered in patient’s history and profile, OT identifies what appropriate evaluation tools and

methods to use for the patient’s medical condition.

OT must also take note of the precautionary measures to be done while performing assessment procedures in

patients.

OT documents all the information gathered (via interview, direct observation or through standardized and non-

standardized tests) in the evaluation process.

AREAS OF EVALUATION

1) Evaluation of Client Factors and Performance Skills

a) Determine the sensory and motor dysfunction and strengths.

i) Extent of paralysis/weakness.

ii) Severity and distribution of spasticity.

iii) Gross and fine motor coordination loss.

iv) Evaluation of sensory modalities: light touch, pain pressure, proprioception, kinaesthesia, temperature,

gustatory, olfactory, auditory.

v) Postural control evaluation.

vi) Range of motion testing.

vii) Manual muscle testing.

viii) Skin integrity.

b) Determine cognitive/perceptual dysfunction and strengths.

i) Evaluation of foundation visual skills: acuity. Visual fields, ocular range of motion, accommodation, pursuits,

saccades.

ii) Evaluation of pervasive impairments: decreased arousal, decreased alertness, los of selective/sustained

attention, concrete thinking, decreased insight, impaired judgement, confusion, disorientation, language

dysfunction, impaired motivation and impaired initiative.

iii) Evaluation of the impact of specific deficits on basic and instrumental activities of daily living and mobility

including: apraxia, spatial neglect, body neglect, perseveration, spatial relations dysfunction, various agnosias,

organization and sequencing dysfunction, and memory loss.

c) Determine psychosocial dysfunction and strengths.

i) Evaluation of emotional/affective disturbances: lability, euphoria,apathy, depression, aggression, irritability,

frustration tolerance.

ii) Coping mechanisms.

iii) Adaptation to change in occupational functioning or to difficulty in assuming occupational roles.

2) Occupational Performance Evaluation

a) Basic activities of daily living.

b) Instrumental activities of daily living.

c) Durable medical equipment evaluation.

d) School/work and return to school/work issues.

e) Play/leisure interests.

f) Mobility needs.

g) Social participation interests.

3) Performance Context Evaluation

a) Cultural barriers.

b) Architectural barriers.

1

c) Societal limitations.

i) Financial barriers

ii) Stigma

d) Home evaluation.

e) School/work site evaluations.

4) Bibliography: Flemming-Castaldy, Rita P., PHD, OTL, FAOTA, National Occupational Therapy Certification Exam Review

and Study Guide, 5th edition, TherapyEd, Evanston, Ilinois, USA

EVALUATION TOOLS

1. Canadian Occupational Performance Measurement

Client-centered assessment tool based on:

o client’s Identification of problems in performance in areas of occupation:

Client’s rate importance of self-care

Productivity

Leisure skills

o Perception of performance and satisfaction with performance

Used as an outcome measure and as client satisfaction survey.

2. Allen’s Cognitive Rating Scale

is part of a body of assessment tools and references that comprise the Allen Battery. The screening tools are

designed to provide an initial estimate of cognitive function. The score from the screen must be validated by

further observations of performance.

3. Beck Depression Inventory

21 items self-rating scale with attitudinal, somatic, and behavioural components

4. Occupational Self-Assessment (OSA)

Clients' perceptions of their own occupational competence on their occupational adaptation. Clients are provided

with a list of everyday occupations, and assess their level of ability when participating in the occupation and their

value for that occupation.

5. Multidimensional Fatigue Inventory

Is a 20-item self-report instrument designed to measure fatigue. It covers the following dimensions: General

Fatigue, Physical Fatigue, Mental Fatigue, Reduced Motivation and Reduced Activity.

6. Purdue Pegboard

This device has been used extensively to aid in the selection of employees for jobs that require fine and gross

motor dexterity and coordination. It measures gross movements of hands, fingers and arms, and fingertip

dexterity as necessary in assembly tasks.Measures two types of activities: gross movements of hands, fingers

and arms, and "fingertip" dexterity in an assembly task. Involves sequential insertion of pegs and assembly of

pegs, collars and washers.

7. Minnesota Rate of Manipulation Test

Is a series of tests of eye hand coordination and motor abilities.It measures the speed of gross arm and hand

movements during rapid eye-hand coordination tasks.

8. Seven Point Global Deterioration Scale

Is a global rating scale which is used to summarize whether an individual has cognitive impairments consistent

with dementia (including Alzheimer's disease). Individuals are rated according to a seven-point scale, as outlined

below; a score of 4 or higher is usually considered to be indicative of dementia. A score of 3 on the GDS is

considered consistent with mild cognitive impairment (MCI).

OT EVALUATION PROCEDURES AND TECHNIQUES

1. Evaluation begins with interview gathering information on:

2

o Client’s history of the disease

o Valued roles and occupations

o Screens for specific concerns or problems

2. Interview should bring up topics on different problem areas:

o Fatigue

o Depression

o Sexual function

o Cognitive concerns

3. Select tools or measures that may give detailed information on areas of concern.

CASE STUDIES AND EVALUATION PROCEDURES

1. Amyotrophic Lateral Sclerosis (ALS)

Anna, a 50-year-old client, has an unusual gait which may be associated with calf stiffness. She developed right foot drop

after some months of progressive weakness. She expresses her difficulty in writing, right arm and hand weakness and

diffuse muscle twitching accompanied by painful muscle cramps within one year and 3 months. Assessment showed

weakness in all her limbs, more prominent in her right side, together with muscle atrophy. She had hyperactive reflexes

and fasciculations were noted in the right leg. Anna was severely disabled within 2 years due to generalized weakness.

She had no sensory problems, intellectual deterioration or skin breakdown despite her degree of immobility. She uses

gastromy tube secondary to dysphagia.

OT EVALUATION

- Levels of function as well as individual’s needs and priorities are the bases for assessment

- Determine functional ability:

- Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) assessment

- Purdue Pegboard, Minnesota Rate of Manipulation Test (MRMT), other timed Upper Extremity

(UE) function test, Range of Motion (ROM), Manual Muscle Testing (MMT)

- Multidimensional Fatigue Inventory (Sample form refer to Appendix A)

- ALS Rating Scale (Sample form refer to Appendix B)

2. Alzheimer’s Disease

This is the case of Jim Mann, 58 years old.Jim is working at an airline industry, and his job requires him to navigate the

airport frequently on a regular basis. During one day at work, he suddenly finds himself riding the escalator up and down

repeatedly, and feels a sense of bewilderment. In the following days, he gets lost while driving his car, and even while

walking the dog. After sensing he has problems, he visits the doctor, who remarks that it is not a serious problem.

OT EVALUATION

- Occupational Performance, Functional Abilities, Skills

- Functional Behavior Profile

- Activity profile

- Caregiver's Strain Questionnaire

- Katz Activities of Daily Living Scale

- Instrumental Activities of Daily Living Scale

- Mental Status Exam

- Kitchen Task Assessment

- Executive Function Test

- Allen Cognitive Level Test

- Assessment of Motor and Process Skills (Sample form refer to Appendix C)

- Disability Assessment for Dementia

3

- Independent Living Scales

3. Huntington’s Disease

Carl is a 34-year-old male Caucasian. He was lively and talkative during his childhood and was able to complete high

school with grades like A and B. He continued with 4 years of college but had poor grades. At 24, he worked as a cook

and dishwasher but had noticed incoordination. When he was 27, he had dysphagia, dysarthria, slow ataxic gait stiffness

and dementia. He had no history of Schizophrenia nor depression. He had negative results in the neurological review of

systems. His parents were both in their 70s and were in good health with negative signs of dementia. There was no family

history of any neurodegenerative disease. He had 3 sisters within the age range of 35 to 39 and they were in good

health.Physical Exam score of the patient was 20/26 on the MMSE. Remarkable decrease in upgaze, saccadic

extraocular eye movement, dysarthria and hyperactive gag reflex were noted in the Cranial Nerve Exam. Increase in tone

in all extremities with normal strength and wide-based and ataxic gait were noted.

OT EVALUATION

- Evaluation for Functional Ability

- Environmental Evaluation

- Evaluations for Psychological Issues

- Canadian Occupational Performance Measurement

- Beck Depression Inventory

- Occupational Self-Assessment(Sample form refer to Appendix D)

- Unified Huntington's Disease Rating Scale (UHDRS)

4. Multiple Sclerosis

Mrs. M., a 32-year-old woman diagnosed with relapsing-remitting multiple sclerosis 2 years prior to her first visit to

occupational therapy, had recently submitted her resignation to her employer of 15 years. She was sad because she was

to quit her administrative job, she reported the following problems: (1) severe fatigue, which increase in the past year

which inhibits her to do her normal house hold tasks, perform her ADL, and work without becoming exhausted; (2) a

marked increase in lower extremity weakness, with decreased ability to perform tasks requiring prolonged walking or

standing; (3) a feeling of heaviness and stiffness in upper and lower extremities; (4) decreased manual extremity; (5)she

would frequently fall; (6) she reported she would likely to have daily headaches; (7) feel dizziness; (8) bladder problems;

(9) vision problems; (10) disturbed sleeping; and (11) increased attention and memory problems. Her adaptive equipment

at that time of her initial therapy visit included a manual wheelchair and a quad cane. She had quit driving. Her husband

was very supportive and had recently stopped adoption proceedings because of her MS changes. Medication included a

bladder medication and MS disease-modifying drug.

OT EVALUATION

Specific assessments to be used:

- Modified Fatigue Impact Scale

- Modified Ashworth Scale

- Functional Independence Measure

Evaluation Tools:

MS Functional Composite (MFSC) measure

- Includes timed 25-ft walk

Nine-Hole Peg Test

Paced Auditory Serial Addition Test (PASAT)

Modified Fatigue Impact Scale

6-minute Walk Test

- To assess endurance and fatigue

Sleep History, questionnaire, or diary

4

Minimal Assessment of Cognitive Function in Multiple Sclerosis (MACFIMS)

Vision evaluation

Beck Depression Inventory

Functional Independence Measure (FIM)

ADL, IADL, and dysphagia assessments

Purdue Pegboard

Semmes-Weinstein Monofilaments

Modified Ashworth Scale

Tremor and Ataxia assessments

Vestibular evaluation

Trigger point evaluation for head, neck, and shoulder muscles

5. Parkinson’s Disease

Anton, a 65-year-old college professor was diagnosed with Parkinson’s Disease when he was 55 years old. He lives with

his wife in a small one-story house while his 3 adult children live in another state. According to Carl, he is interested in

travelling, reading, painting and watching concerts. Recently, Anton has had an increase in tremors in both hands which

makes it difficult for him to correct papers. This made him consider early retirement. He has problems with endurance due

to stiffness. He reports that he cannot paint because of the hand tremors. He is unsure if he wants to continue driving

because of these tremors even if he does not state that he is depressed, his wife noticed features of depression like a

decrease in interest in watching concerts and making summer vacation plans to visit the children and grandchildren. His

wife noted that Anton appears depressed about the possibility of early retirement and status loss as a professor in

college. Anton can independently complete most of his personal Activities of Daily Living but has a hard time getting into

and out of his bath tub and shower. His wife expresses her fear that he will fall and states that she often helps him get into

and out of the shower. Anton has a hard time tying his neck tie and buttoning his shirt. Tremors are noted in both hands

and there is slight rigidity during PROM. On uneven surfaces and stairs, his dynamic balance is compromised. Anton has

been taking Sinemet (levodopa and carbidopa medications) for 3 years now to reduce the rigidity and tremors. He does

not have any reported dyskinesia. When Anton was asked about his personal goals, he answered “I have more time now

to read.”

OT EVALUATION

Evaluation tools used:

- Brief history

- Identification of occupational performance problems related to:

Reduced mobility

Safety issues

Fine motor incoordination

Stiffness

Depressed affect

- Environmental assessment

Assessment tools include:

- Occupational Self-Assessment

- Beck Depression Inventory(Sample form refer to Appendix E)

- Canadian Occupational Performance Measure

- UPDRM

- PDQ-39

5

APPENDICES

Appendix A – Multidimensional Fatigue Inventory

6

Appendix B – Amyotrophic Lateral Sclerosis (ALS) Rating Scale

ALS Functional Rating Scale1. Speech

Normal speech processes

Detectable speech disturbance

Intelligible with repeating

Speech combined with nonvocal communication

Loss of useful speech

2. Salivation7

Normal

Slight but definite excess of saliva in mouth; may have nighttime

drooling

Moderately excessive saliva; may have minimal drooling

Marked excess of saliva with some drooling

Marked drooling; requires constant tissue or handkerchief

3. Swallowing

Normal eating habits

Early eating problems-occasional choking

Dietary consistency changes

Needs supplemental tube feeding

NPO (exclusively parenteral or enteral feeding)

4. Handwriting

Normal

Slow or sloppy; all words are legible

Not all words are legible

Able to grip pen but unable to write

Unable to grip pen

5. Cutting food  with gastrostomy

Normal

Somewhat slow and clumsy, but no help needed

Can cut most foods, although clumsy and slow; some help needed

Food must be cut by someone, but can still feed slowly

Needs to be fed

6. Dressing and hygiene

Normal function

Independent and complete self-care with effort or decreased

efficiency

Intermittent assistance or substitute methods

Needs attendant for self-care

Total dependence

7. Turning in bed

Normal

Somewhat slow and clumsy, but no help needed

8

Can turn alone or adjust sheets, but with great difficulty

Can initiate, but not turn or adjust sheets alone

Helpless

8. Walking

Normal

Early ambulation difficulties

Walks with assistance

Non-ambulatory functional movement only

No purposeful leg movement

9. Climbing stairs

Normal

Slow

Mild unsteadiness or fatigue

Needs assistance

Cannot do

10. Dyspnea

None

Occurs when walking

Occurs with one or more of the following: eating, bathing, dressing

(ADL)

Occurs at rest, difficulty breathing when either sitting or lying

Significant difficulty, considering using mechanical respiratory

support

11. Orthopnea

None

Some difficulty sleeping at night due to shortness of breath. Does

not routinely use more than two pillows

Needs extra pillow in order to sleep (more than two)

Can only sleep sitting up

Unable to sleep

12. Respiratory insufficiency

None

Intermittent use of BiPAP

Continuous use of BiPAP

Continuous use of BiPAP during the night and day

9

Invasive mechanical ventilation by intubation or tracheostomy

13. How many years since onset of symptoms?

 years

(source: http://www.outcomes-umassmed.org/als/alsscale.aspx)

Appendix C – Assessment of Motor and Process Skills (AMPS) Score Form

10

11

Appendix D – Occupational Self-Assessment

12

Appendix E – Beck Depression Inventory

BIBLIOGRAPHY

1. Occupational Therapy for Physical Dysfunction Fourth Edition by Catherine A. Trombly Wiliam and Wilkins,

Copyright 1995

2. Chapter 40 Occupational Therapy for Physical Dysfunction Sixth Edition, Mary Vining Radomski, Catherine

A. Trombly Latham, C&E Publishing Copyright 2008

3. Chapter 35 Pedretti's Occupational Therapy Practice skills for Physical Dysfunction 7th Edition, Heidi

McHugh Pendleton, Winifred Schultz-Krohn, Elsevier Mosby, Copyright 2013

4. http://www.outcomes-umassmed.org/als/alsscale.aspx

5. Chapter 35 Heidi McHugh Pendleton, PhD OTR/L, FAOTA and Winifred Schultz-Krohn, PhD, OTR/L, BCP,

SWC, FAOTA, Pedretti’s Occupational Therapy Practice Skills for Physical Dysfunction Sixth Edition,

Philadelphia USA, Copyright 2006

6. Flemming-Castaldy, Rita P., PHD, OTL, FAOTA, National Occupational Therapy Certification Exam Review

and Study Guide, 5th edition, TherapyEd, Evanston, Illinois, USA

13