Running head: OCCUPATIONAL PROFILE AND INTERVENTION PLAN

Occupational Profile and Intervention Plan

Kristen D. Kincaid
Touro University Nevada

OCCUPATIONAL PROFILE AND INTERVENTION PLAN

Occupational Profile
The client is a 65-year-old man living in Las Vegas, Nevada, with his wife in a two story
home. The client has many conditions that affect his overall health and wellbeing. Ten years ago,
at the age of 55, the client was diagnosed with rheumatoid arthritis (RA). The client was in a
serious car accident in 2006 that injured his right ankle and left hand; both were operated on.
While being treated for these injuries, a new physician diagnosed the client with RA. Prior to the
diagnosis the client had multiple back injuries. One of which occurred when he was 32 when he
lifted a 650 pound generator that fell on a co-worker. The injury led to a five-level, anterior and
posterior fusion, from L1-L5. After the surgery, the client was in a body cast and had to relearn to
walk. In 2004, the client when to the Mayo Clinic and learned he had a herniated cervical disc
and several cracked cervical vertebrae. The attending physician recommended fusion of these
vertebrae, but the client declined. The client also declined fusion of T6-T10 when he injured his
back in 2010 while doing yard work.
Following the RA diagnosis, the client was started on NSAIDs to treat the pain and
inflammation. These were the primary course of treatment for the first 1-2 years. Next, the client
was started on DMARDs. The first of these was Enbrel, which the client injected once a week for
two years. The medication caused severe headaches. The client reports that his headaches have
been debilitating for the past 12-14 years. However, due to Reiki treatments, the client hasnt
reported a headache in the past 3-4 months. After Enbrel, the client received an infusion of
Humira once a month for two years. The treatment took 4-5 hours. The client didnt feel well
after, but reported no serious side effects. For the past five years the client has been receiving
Rituxan every six months. The treatments leave him feeling ill, like he has the flu, for 3-14 days.
In 2012 the client was diagnosed with diabetes. He takes two medications to help keep
the diabetes under control. After diagnosis the client made attempts to alter his diet and states
that he reduced his overall consumption of meat and drinks less alcohol. He has lost 50 pounds in

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the past year. The client has numerous medications that he must take: Soma, Opana, Rituxan,
Lyrica, Glipizide and Metformin, Nexium, Lisinopril, Lunesta, and Polyethylene Clycol. In
addition to his regular medication, the client receives a cocktail of 8-32 injections when he has
to drive long distances. The shots include, but are not limited to, corticosteroids, pain medication,
muscle relaxers, vitamin B, and Novocain.
The client has smoked since he was 16 and currently smokes three packs of cigarettes a
day. He has successfully quit twice before, for a total of eight years, but started again because
he finds it enjoyable. He is aware that the smoking can worsen his RA and impact his blood
circulation to his feet. He states that he has chronic foot fungus and has large cracks in his feet
that dont seem to heal. The cracks contribute to his pain when walking.
The client moved out of his parents house when he was 16 and opened a construction
business when he was 18. Over the years, he has stayed in construction. He currently works full
time for a construction firm that bids for, and builds, new franchise locations. He has worked his
way up in the field and is now responsible for bidding new jobs, overseeing construction, and
managing his crew. He has been married to his second wife for the past 18 years. He had three
children with his first wife; they are all adults with children living in Utah.
The client is seeking services to increase his endurance, strength and ROM, which have
decreased due to generalized deconditioning secondary to treatment for his Rheumatoid arthritis
(RA). The client went in for his bi-yearly treatment of Rituxan. He felt ill afterward, but he
reported this as a typical side of the treatment. However, the client began to feel substantially
worst and stopped engaging in many ADLs and IADLs, confining himself to his recliner
downstairs. He decided he needed more rest to recuperate and stopped going into work. He
managed his crew from his phone while his wife brought him food. The client became
deconditioned quickly and experienced great difficulty when walking to the bathroom. Two
weeks post treatment; the client was unable to walk upstairs to take a shower and relied on his

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wife to assist him while walking to the bathroom. When he reached the bathroom, his wife
helped him sponge bath, brush his teeth and shave while he sat on the toilet.
Getting to the doctor was difficult for the client, and he relied on assistance from his wife.
The clients physician noted that the client was deconditioned due to decreased engagement in
activities. The physician recommended the client be admitted to an acute inpatient rehabilitation
facility. The client agreed and is highly motivated to return to his prior level of functioning. He is
concerned that if he doesnt feel better and increase his strength and endurance, he will be
dependent on his wife. He wants to be able to care for himself for as long as possible and wants
to return to being independent in his ADLs and IADLs. In addition, he is concerned that if he
continues to have to work from home, he will lose his position at the construction company.
Regaining independence is his primary reason for seeking OT services.
The client reports that he no longer feels successful in any occupation. Prior to admission
to HealthSouth, he states that he was independent in all areas of occupation, but notes that he
was not happy with his performance. He reports that chronic pain, sleep deprivation, medication
side-effects, muscle atrophy and changes in ROM have limited his success. The client sites pain
as a constant factor limiting his success in occupations. The pain stops him from engaging in
occupations, limits the time spent performing them, and mediates the enjoyment he can garner
from them. On a day to day basis, the client rates his chronic pain at a 7. The pain level will
increase during periods of high activity or RA exacerbation. The client reports being chronically
sleep deprived which makes it difficult to get through the day. In addition, the client is on
numerous medications, all of which have side-effects. Some of these are headache, nausea,
constipation and brain fog. In addition, as his RA progresses the client says that his is losing
muscle mass and has limited joint movement.
The client has a very supportive home environment. He lives with his wife of 18 years in
a 2-story home in Las Vegas, Nevada. The client has adapted his home living environment to his

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specifications and enjoys being at home. However, there are no bedrooms on the first floor of the
house and prior to admission; it was becoming increasingly difficult for the client to go up and
down the stairs. In addition, due to pain from his back injuries and RA, the client states that he
cant sleep in a normal bed and instead sleeps in a recliner in the living room. He only goes to the
second floor to shower and dress, the rest of the time he is on the first floor. The client states that
his wife is very supportive and always accommodates his energy and pain levels. She is the
primary cook of the house and prepares simple casseroles or sandwiches. The client states that he
is responsible for barbecuing. The client has hired a pool and yard service to care for his
property, and has the means to hire a cleaning service if necessary.
The client works as a foreman for a construction company and manages the job site and
crew. The position allows for flexibility in regards to hours worked. The client reports that when
he has trouble sleeping, he will frequently go into work at 2 a.m. to prepare bids for future
projects. In addition, the flexible schedule allows him to work from home when his pain is too
intense, he feels ill, or has scheduled doctor appointments or treatments. However, his job is also
incredibly stressful with budgets, work crew, and delivery dates to manage. The client states that
he vomits most mornings. His wife attributes this to the stress of the job, but the client denies
this, stating that he vomits on the weekend too. In addition to increasing his stress level, his
position requires him to travel to oversee job sites. At the moment, the client must travel by car
for 8 hours to reach the site. The trip is incredibly taxing on the client and causes him much pain.
Prior to the trip, the client will visit his pain management doctor for a cocktail mentioned
previously. Regardless, his career allows him flexibility, but also demands high output that can
be difficult during periods when the client does not feel well. An additional benefit of his career
is that it pays well, and when combined with his wifes income, the couple is considered uppermiddle class with a household income of over 150,000. The client reports that his income allows

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him to hire people to perform maintenance on his property, to eat out and enjoy entertainment, to
pay for medical expenses, and to buy items to support his hobbies. The client states that he
continues to work because he is accustom to the income. The client knows that he is old enough
to retire, but is not ready to completely give up the benefit of his income and the purpose and
meaning to his life that his career provides.
The client states that he has lived in Utah for a significant portion of his life, but prefers
living in Las Vegas. The client states that he enjoys the weather because other climates are too
cold in the winter and hurt his joints. In addition, he states that he enjoys the freedoms offered by
Las Vegas. He enjoys spending his free time in casinos at the slot machines or going out to
dinner with his wife. Furthermore, he notes that his house would be substantially more expensive
in another area and that property taxes are ridiculously low when compared to other areas of
the country. He also states that he enjoys living away from his adult children because they can be
draining, and he likes that people tend to keep to themselves in Las Vegas.
The client states that he has had a full life. He says he left home, began a business,
married and had children younger than most people. He states that he has always worked and
would feel lost if he didnt at least work part-time. He states that he stayed married until his
children finished school and then filed for divorce. He was content being single for many years
until he met his current wife. After the client remarried, they purchased their current home in Las
Vegas. He states that his wife is always trying to get him to take better care of himself. She has
asked him to quick smoking again, and has told him the cracks in his feet could get infected,
requiring amputation. He says that she had been pestering his to try Reiki for years to help with
his headaches, but he resisted calling it Voodoo crap. However, the client began receiving
Reiki once a month for the past 3-4 months and reports an absence of the headaches that used to

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plague him daily. He has been able to stop injecting himself with his headache medication and is
more willing to try complementary therapy.
The client has sustained multiple injuries to his back, neck, leg and hands. These injuries
were outlined previously. They have left the client with considerable residual pain and limited
ROM. The client has been advised to have additional cervical and lumbar vertebrae fused, but
refuses because he believes it will severely limit his ability to move and function. In addition, his
doctor has advised a bilateral knee replacement, but the client is wary of any additional surgery.
The client values his independence and doesnt want anyone taking care of him. He is
thankful that his doctor has kept him out of a wheelchair. He values the freedom that his salary
offers. It allows his to seek medical treatment, live comfortably and pursue hobbies. The client
also values solitary time.
The client has numerous interests but has had to cut back severely on the occupations he
engages in due to generalized pain and his RA. The client enjoyed a multitude of outdoor
activities in the past. He liked to go on long bike rides on his Harley Davidson, but had to sell it
five years ago because he was unable to ride it any longer due to the vibrations causing too much
pain. Furthermore, he can no longer horseback ride due pain from the impact as the horse gallops
and needing to grasp the reins. The client used to enjoy golf, but the twisting motion and grasp
required to play are too difficult to perform without an unacceptable pain level. Recently the
client has stopped working on household repairs and other crafts due to the limited ability to
grasp tools, fatigue and pain. This has been a particularly difficult transition for the client
because he loves to build and repair items. His garage is outfitted as a shop and it used to be a
hobby he enjoyed immensely. When he has made attempts to reengage in this occupation, he
states he is quickly frustrated with his diminished capacity and feels like a cripple. The client
now spends his free time during the warmer weather on his boat on Lake Mead. He recently
purchased a larger boat because the impact from the waves would jolt his smaller boat and cause

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too much pain. As the pain from the previous injuries and the RA increased, the client limited his
hobbies to boating, slot play, sitting by the pool, eating out and watching TV. The client states
that he cant maintain one position for very long, so he has to be free to get up, sit down, or walk
around. Prior to the recent deconditioning, the client walked his dogs around the block during
cooler weather and treads water in his pool during the summer. He states that being in the water
takes away a significant amount of pain. He explains that he can only do this activity in the
summer because he likes to use his pool and wont visit a public pool in the winter.
The clients sleeping has been dramatically altered in the past ten years. The client reports
that he is unable to sleep through the night and is only able to sleep intermittently for 3-4 hours
at a time. He has not been able to sleep on a mattress for the past five years; instead he sleeps in
his reclining chair in the living room. He takes medication to help fall asleep and to ease his pain,
but it is not enough to keep him asleep throughout the night. He states that the lack of sleep
makes everything harder. He is always tired and fatigued. The client states that he copes with the
lack of sleep, but that it impacts his quality of life.
In addition, over the years the client has outsourced many tasks that he used to perform
himself. He states that taking care of his yard, trimming the bushes, and planting flowers in the
spring used to be very enjoyable, but he has had to hire a yard service to take over these duties.
In addition, the client states that he needs to repair the fascia long his roof, but that he can do it
himself anymore. He states that he enjoyed doing these home repairs, especially painting, and is
annoyed that he has to hire other people to perform work he knows how to do himself. Finally,
the client always used to be out and about, but now finds himself home much more often. When
at home, the client is typically watching TV or sitting by the pool.
The client has numerous roles. Although his wife works full time, he has the role of
primary income generator for the couple. He states that if they lost his income, they would have
to alter their lifestyle. The client is also a father. However, this is not a role he actively engages in

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any longer and prefers his family to live in another state. Next, he has the role of husband to his
wife. He believes it is his job to protect his wife and help support her. The client also takes his
role as a homeowner seriously. He wants the yard and house kept in good repair. He gets
frustrated when he cant make the improvements to the property that he believes it needs. The
client also identifies with the role of worker and supervisor. Another role that the client
frequently has is that of a patient. Every day the client is required to take a multitude of
medications to treat his ailments. Prior to the clients recent state, his doctor had been performing
tests to try and find the underlying cause for his frequent illness.
A typical day for the client prior to the deconditioning for which he is seeking services,
begins at 5:30 a.m. After waking, the client may vomit if not feeling well. Then he takes his
morning medication and heads to his local Circle K for coffee. From there he heads to work
where he will grab a burrito for his diabetes. The client states that around 9-10 a.m. his nausea
will subside, and he will start to feel better. The client would then work till 4-5 in the evening.
He does acknowledge that lately he has been returning home early, usually anytime afternoon,
because he is not feeling well. In the evening, he will eat dinner with his wife, visit a local
casino, or watch TV.
The clients main priority is to return to independence in all aspects of his life. He states
that it is very important for him to be able to care for himself and not rely on his wife for
anything. He wants to be able to return to work on a more consistent basis and have enough
energy on the weekends to go boating. He desires to return to his prior functioning level. The
client states that a decrease in his constant pain would greatly improve his quality of life.
Furthermore, he states the Reiki has stopped his headaches, and he is now open to ideas that
would help his nausea and overall sense of malaise. Other outcomes he would like to achieve
through occupational therapy include more strength and endurance. The client reports that the

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fatigue limits his engagement in many occupations. In addition, the client states that more sleep
would improve every aspect of his life. However, he does note that he doesnt think anything can
be done to improve it. The client states that he would like to remain functional for as long as
possible and wants to stay mobile without an assistive device. In addition, he wants to slow down
the progression of his RA. The client states that he doesnt expect to be able to return to all his
previous occupations, but that he would appreciate being able to fix small things around the
house with relative ease.
Occupational Analysis
The client was admitted on 8/18/2014 to HealthSouth Rehabilitation Hospital in Las
Vegas, NV where he received occupational therapy services. This is an inpatient, acute
rehabilitation facility that provides nursing and physician care while the patient receives OT, PT,
and SP when appropriate. The patient must be able to participate in 3 hours of therapy daily, split
evenly between OT and PT. The client is being seen for generalized deconditioning.
The activities observed at HealthSouth included the client transferring from supine in bed
to the edge of the bed, functionally ambulating to the bathroom with a front wheel walker
(FWW) and performing grooming while at the sink. The client had difficulty getting to the edge
of the bed. The OT provided minimum assistance (Min A) to aid the client with sitting and
regaining his balance. Then the OT provided Min A to the client while he transferred from the
bed to the FWW. Min A was provided as the client functionally ambulated to the bathroom. The
client stopped once to rest. The client exhibited kyphosis and took small steps when walking.
Once in the bathroom the client stated that he was tired and needed to sit. A wheelchair was
placed behind the client so he could rest. The OT then asked the client to perform tasks
associated with grooming. The client was asked to open a new toothbrush and toothpaste and
brush his teeth. The client had significant difficulty with the fine motor skills required to open

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the packaging. Therefore the OT provided Min A with the task. Once the packaging was open,
the client possessed the cognitive skills necessary to sequence brushing his teeth. In addition, the
client was able to brush his hair, but his limited shoulder flexion interfered with task
performance. The client compensated by lowering his head to reach his hand. Finally, the client
was instructed to shave. He was able to perform the task with Mod A. The client required four
breaks to complete the task in its entirety.
Key observations made from observing the client perform the activity are that the client
has limited strength, endurance, and ROM. In addition, the client has intact cognitive skills and
is aware of his surroundings. The difficulty experienced by the client when trying to rise out of
bed indicate that he has limited upper extremity strength and endurance. Similarly, when
ambulating to the bathroom the client needed a rest break and a FWW which signifies his
decreased lower extremity strength, endurance and balance. The client also often grimaced while
rising from bed and walking. The small steps the client took while ambulating indicate that he
may fear falling and has a decreased sense of balance. Furthermore, the numerous breaks
indicate that the clients cardiopulmonary endurance and his upper extremity strength and
endurance is low. The client has fine motor impairment and limited shoulder flexion as observed
while grooming. Observations of the client also indicate kyphosis, muscle atrophy, limited
shoulder flexion, ulnar deviation, and issues with skin integrity.
Through observation of the activity and the client, there are many domains significantly
impacting the clients ability to successfully engage in occupations. From the clients grimaces
while performing the activity, an onlooker can see that the pain is a domain that affects the
clients ability to engage in occupations. By his admission, pain significantly impacts his life.
The client says he experiences constant generalized pain, throbbing, burning and tingling in
different parts of his body. From observations a therapist can conclude that the clients

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neuromusculoskeletal and movement-related functions are diminished and greatly impact his
occupational engagement, these include: joint mobility, joint stability, muscle power, muscle
tone, muscle endurance, and gait patterns. In addition, the domains of cardiovascular, respiratory
and skin functions can limit the clients engagement in occupations. Furthermore, the cients
motor and praxis skills are impacted by his injuries and RA, and limit his ability to perform
certain occupations. For instance, the client had difficulty manipulating the toothbrush and
toothpaste in his hands (AOTA, 2014).
Problem List
1. Client requires Min A while using a FFW for functional ambulation 2 strength,
2.
3.
4.
5.

cardiopulmonary endurance, muscle endurance & balance.

Client required Min A FFW SC 2 balance and strength.
Client requires Min A to perform grooming at sink 2 UE ROM & muscle endurance.
Client requires Min A c fine motor tasks required for dressing 2 stiffness & pain 2 non-use.
Client is unable to stairs in his house 2 cardiovascular endurance, strength & stiffness
in LE 2 non-use.
Listing the clients functional ambulation as a primary concern is justified because the
client wishes to walk independently to the bathroom and around his house. This is also important
to address because if the client cant ambulate well, he may continue to remain sedentary,
resulting in further deconditioning. Furthermore, the second problem statement addresses the
clients desire to shower safely without the help of his wife. This is listed below functional
ambulation because it solely addresses showering while the other can be applied to multiple
ADLs and IADLs. The next problem was listed third because, although the client wants to be
independent in this activity as well, he values independent toileting and showering above
independent grooming. Dressing was listed as forth because the client has compensated by
wearing elastic shorts and sweats with pull over shirts. However, he would like to be able to
dress himself in more formal wear when going out or attending a meeting at work. Finally, the

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client would like to be able to go upstairs to his bedroom independently, but values this less than
the other problems listed because he sleeps in his recliner downstairs, and his wife will bring him
a change of clothes from the closet.
Intervention Plan & Outcomes
1. Client will be able to join his wife while walking their dogs I for 15 min c one rest break by
09/01/2014.
a. Client will build and paint a craft birdhouse I while standing for 45 min c three 5 min
breaks by 08/28/2014
b. Client will ambulate to outside recreation area to visit his wife c Mod I by 08/31/2014.
2. Client will be able to transfer to SC & shower using energy conservation techniques by
09/01/2014.
a. Client will demonstrate understanding of energy conservation techniques I by explaining
how to apply the concepts to 2 activities performed at home by 08/27/14.
b. Client will SC Mod I 2 to safety concerns in a walk in shower by 08/28/2014
To address goal 1a, the intervention plan will focus on remediating the clients standing
tolerance and upper extremity ROM, strength and endurance through the use of play. The method
used will be restoration, while the outcome desired is role competence. The client will receive a
moist heat pack on his shoulder and hand joints, assuming the joints are not acutely inflamed.
The heat should provide pain relief, increased blood flow and increased tissue elasticity for the
client (Deshaies, 2013). Meanwhile, the OT will provide education on various adaptive
equipment (A/E) to assist in dressing to promote independence until ROM and strength are
restored. Then, the client will play Texas hold'em while standing at a raised table in the therapy
gym. Studies have indicated that standing tolerance is greater when play is used compared to
other purposeful activities like folding towels or reading a book (Hoppes, 1997). Texas hold'em
was chosen because the client enjoys playing it in the casino. The table will be positioned in
front for support, and a wheelchair positioned behind the client if he fatigues and needs to sit. In

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order to grade this intervention up, the client can be offered fewer breaks that would require
greater standing tolerance. In addition, the client can flex the shoulder to 90 degrees while
holding the cards. This will provide an opportunity for isometric strengthening. To grade the
intervention down, the client could incorporate more breaks, requiring less standing tolerance. In
addition, a card holder can be utilized to decrease the stress on the hand joints and the strength
required to hold the cards.
To address goal 1b, the intervention plan will focus on improving the clients ability to
functionally ambulate through the use of ADLs. The intervention will tax the clients ability to
move within his environment, his cardiopulmonary and respiratory systems, and provide
opportunities for strengthening and stretching the upper extremities. The approach used is
remediation and the outcome desired is participation in desired occupations. The intervention
will incorporate a full shower while sitting, grooming at sink while standing and gathering of
clothes in various locations in the room (Early, 2012). First, the intervention will focus on the
preparatory activities of isometric exercises and stretching. In clients with RA, isometric
exercises usually result in less pain and are just as, if not more effective. Each movement should
be held for 6-12 seconds (Deshaies, 2013). Afterward the client will be instructed to collect the
clothes items needed for dressing after the shower. The items will have been spread out in the
clients room to encourage more functional ambulation (Early, 2012). An assistive device may be
used if necessary. Then the client will put the clothes in the bathroom and then transfer to the
shower chair to shower. While showering, the client will be required to reach for toiletries, and
engage in isometric strengthening while holding the shower head and washing his hair. After
drying and dressing, if time allows, the client will perform grooming activities standing at the

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sink. If the client is fatigued, a wheelchair can be provided for completion of activity. Client will
then return to bed or a chair at the conclusion of therapy.
To address goal 2a, the intervention plan will focus on client education and application of
techniques learned. In addition, the clients standing endurance will be taxed while performing
grooming tasks. The main intervention approach utilized is to prevent further losses and the
outcome type is role competence. Moist heat will be applied while the OT educates and
demonstrates to the client how to perform a ROM exercise plan. Then education on the benefits
of incorporating the plan into daily life will be addressed. Such benefits include the fact that
joints that are less stiff and have balanced strength will be less susceptible to further injury. In
addition, when a joint has limited ROM available, it transmits force to another joint that may
have to compensate by performing an exaggerated movement, increasing the likelihood of injury
(Deshaies, 2013). Next, the client will demonstrate learning of the ROM exercises by performing
the complete series with the aid of a handout. The client will then be instructed to perform the
exercises at least once a day. After the ROM exercises, the OT will educate the client on the
principles of joint protection and fatigue management. There is strong evidence that instruction
on joint protection leads to an improvement in functional mobility (Steultjens et al., 2004).
Finally, the client will demonstrate learning and generalization of joint protection and fatigue
management by incorporating the techniques into grooming performed while standing at the
sink. Real-life application and reinforcement of techniques learned is central to client education
(Deshaies, 2013).
To address goal 2b, the client will prepare a meal in the HealthSouth rehabilitation
kitchen outfitted with the Biodex Freestep SAS. The invention approach is remediation with the
outcome goal being prevention of falls. First, the client will receive moist heat on his shoulder
and hand joints. The client will prepare a barbeque chicken with a grill pan and a side vegetable.

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The activity is chosen because barbecuing is a meaningful occupation to the client, provides an
opportunity to discuss healthy eating options, and allows the client to challenge dynamic
standing balance within a safe environment. While receiving moist heat, the client will select the
seasoning and vegetable he wishes to use in the meal prep. The Biodex Freestep SAS will be
utilized during this activity because it will allow the client a safe environment to learn how to
respond correctly in order to recover from a balance perturbation. The ability to respond with
effective movements to balance perturbation determines whether or not an individual will fall.
Balance perturbations can result from slips, trips, or a consequence of volitional movement
(Mansfield, Peters, Liu, & Maki, 2007) The Biodex Freestep SAS will assist in helping to relieve
the clients free of falling and allow motor retraining to occur. Materials and tools are located
throughout the kitchen environment, providing an opportunity for dynamic movements. In
addition, the client will be reminded to incorporate joint protection and fatigue management into
the activity. Time will be allotted for the client to return to his room and discussion of success
and failed attempts to regain balance will be addressed.
While in the acute rehab setting the client will receive 90 minutes of OT, six days a week,
for two weeks. While providing treatment to this client, there are numerous precautions to
consider. The first of which is to respect pain. The client should be instructed to alert their
therapist if any activity causes pain that does not diminish within 1-2 hours after completion of
therapy. In addition, while performing MMT, the OT should apply resistance at the end range of
pain-free motion, not at the true end of ROM. The other precautions are as follows: avoid
fatigue, avoid placing stress on inflamed or unstable joints, use resistive exercise with caution, be
aware of sensory impairments, be cautious with fragile skin that may result from systemic
disease or pharmacologic side effects, and work within the clients comfortable ROM.
Contraindications for this client include: the use of resistance when client is in the acute phase,

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heat on acutely inflamed joints, grip strengthening exercises, or active or passive stretch during
the acute phase (Deshaies, 2013).
The biomechanical frame of reference (FOR) is utilized as the primary framework
guiding the interventions with this client. This is due to the belief that many of the clients
functional difficulties arise from a recent decrease in strength, endurance and ROM. The belief is
that remediation of these areas is possible. Therefore, the interventions focus is on restoring the
clients musculoskeletal system through purposeful activities to return the client to his previous
level of functioning (Rybski, 2004). Research supports the use of the biomechanical frame of
reference to reach the goals of increasing body strength and endurance by using repetitive
exercises and providing a gradual increase in resistance (OBrien & Hussey, 2012). The FOR
guided the goal setting for this client because the long term goals (LTG) require an increase in
the clients endurance, strength, and ROM. To help the client meet these LTG, short-term goals
(STG) that gradually tax the impaired musculoskeletal systems were created. The STG require
the client to perform activities for a longer duration and with less assistance in order to provide a
just right challenge for the client. The biomechanical FOR also includes teaching the client new
skills, behaviors, or habits to reduce dysfunction and to enhance performance (Rybski, 2004).
This is incorporated into the inventions when educating the client on energy conservation
techniques, avoiding positions of deformity, and utilizing durable medical equipment (DME) like
the shower chair.
In order to address client education, one intervention will specifically focus on joint
protection and fatigue management. In addition, the OT will incorporate education on the RA
disease progress, symptom management, and community resources. Teachable moments during
therapy will be used to help educate the client on proper positioning and address other client
concerns (Deshaies, 2013).

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The clients response to interventions will be monitored by comparing scores after the
completion of all interventions to baseline scores taken when the client was first seen for his
evaluation. The OT will evaluate ROM, MMT and activity tolerance. The OT will also document
the clients pain level (0-10) and FIM scores. If the client increases his ROM, strength, and
endurance and then applies the increases to a functional task, like bathing, we will assume that
the interventions were beneficial and would expect a higher FIM score. Furthermore, if the client
can generalize the energy conservation techniques to his daily occupations, we would expect an
increase in performance satisfaction. In addition, the client should be administered the COPM
prior to intervention to document his satisfaction with his current occupational performance.
Then, prior to discharge, the COPM should be administered again to see if the clients
satisfaction with his occupational performance increased. As stated before, pain should be
assessed throughout all interventions with the goal of decreasing pain and increasing the clients
quality of life. In addition, an open dialog will be established with the client to make sure the
interventions are taxing the clients systems by providing a just right challenge.
References
AOTA. (2014). Occupational therapy practice framework: Domain and process (3rd ed.).
American Journal of Occupational Therapy, 68, S1-S48.
Deshaies, L. (2013). Arthritis. In H. M. Pendleton, & W. Schult-Krohn (Eds.), Pedrettis
occupational therapy practice skills for dysfunction (7th ed., pp. 1003-1036). St. Louis,
MO: Elsevier Mosby.
Early, M. B. (2012). Physical dysfunction practice skills for the occupational therapy assistant.
(3rd ed.) St. Louis, MO: Elsevier Mosby.
Hoppes, S. (1997). Can play increase standing tolerance?: A pilot-study. Physical and
Occupational Therapy in Geriatrics, 15(1), 65-73. doi:10.1080/J148v15n01_05

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Mansfield, A., Peters, A. L., Liu, B. A., & Maki, B. E. (2007). A perturbation-based balance
training program for older adults: study protocol for a randomised controlled trial. BMC
Geriatrics, 7(1), 12.
OBrien, J., & Hussey, S. (2012). Models of practice and frames of reference. In K. Falk & J.
Gower (Eds.), Introduction to occupational therapy (4th ed., pp. 135-143). St.
Louis, MO: Elsevier Mosby.
Rybski, M. (2004). Kinesiology for occupational therapy. Thorofare, NJ: Slack Incorporated.
Steultjens, E. M., Dekker, J., Bouter, L. M., van Schaardenburg, D., van Kuyk, M. A., & van den
Ende, C. H. (2004). Occupational therapy for rheumatoid arthritis. Cochrane Database of
Systematic Reviews (1), CD003114. doi: 10.1002/14651858.CD003114.pub2