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 nonstandardized 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.
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3) Performance Context Evaluation
a) Cultural barriers.
b) Architectural barriers.
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
o
client’s Identification of problems in performance in areas of occupation:

Client’s rate importance of self-care

Productivity

Leisure skills
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
2
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:
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
3
-
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
-
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
4
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

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
5
-

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
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APPENDICES
Appendix A – Multidimensional Fatigue Inventory
7
Appendix B – Amyotrophic Lateral Sclerosis (ALS) Rating Scale
ALS Functional Rating Scale
1. Speech
Normal speech processes
Detectable speech disturbance
Intelligible with repeating
Speech combined with nonvocal communication
Loss of useful speech
2. Salivation
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
8
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
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
9
12. Respiratory insufficiency
None
Intermittent use of BiPAP
Continuous use of BiPAP
Continuous use of BiPAP during the night and day
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
13
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
14