Today is a guest post by Jason Lomond an occupational therapist from Bridgewater, Nova Scotia, Canada. I thought this would be a great opportunity to get to hear what is occupational therapy from an OT himself. Occupation refers to everything that people do during the course of everyday life. So an Occupational Therapist is a regulated health professional that helps you do the activities that you want to do.
I managed to find out about Jason from another Canadian chiropractor who personally recommended Jason. I know a little about the profession of Occupational Therapy so I have been looking forward to hearing more about how OT’s help patients and get involved in the rehabilitation process to better performance.
Occupational Therapy Assessment of Pain and Movement Dysfunction
By Jason Lomond, Occupational Therapist
Traditionally thought of as employment, occupation extends beyond work to include everything that individuals do to occupy themselves, including leisure, productive roles and self-care.¹ An individual’s performance and ability to engage in these three areas of occupation is the domain of occupational therapy.
Simply put, occupational therapy helps to resolve the problems that interfere with the ability to do the things that are important to each individual. It can also avert a problem or minimize its effects. Consequently occupational therapists have a broad scope of practice to assist individuals to achieve their goals, particularly as it relates to the topic of this article: pain and movement dysfunction.
As in all areas of occupational therapy practice, the emphasis in the treatment of pain and movement dysfunction is less on the impairments of bodily function or structure and instead directed more towards improving functional outcomes. In particular the client’s goals related to function. Therefore occupational therapy assessment always begins with the step of identifying the client’s goals. In clinical practice this could be solution focused questions like:
- “What activity would you like to do that you’re not doing?”
- How would that activity be performed differently?
- How do you know when you have achieved that goal?
- What would it look like?”
The questions above are just examples as opposed to being set in stone. Rather the points of the questions are to identify a functional outcome, develop a qualitative measurement of the client’s current performance and elicit the client’s participation in the rehabilitation process. Following identification of client centered goals the occupational therapy process seeks to clarify the three constructs of occupational performance; the person, environment and occupation.
Similar to the bio-psycho-social model, which is currently seen as best practice in the treatment of pain and movement dysfunction, the Canadian Model of Occupational Performance and Engagement (CMOP-E) has a comparable theoretical framework (Figure 1). It depicts occupational performance and engagement as the dynamic interaction between the person, environment and their chosen occupation. These three constructs are made up of several performance components.
The person is composed of physical, affective and cognitive components with spirituality viewed as the essence of the person. Each individual lives within a unique physical, social, cultural and institutional environment. And finally, as mentioned previously, occupation is viewed as having three functions: productivity, self-care and leisure. This interactive, dynamic framework informs the clinician of apparently unrelated performance components that may contribute to, or be associated with the client’s occupational goals.
* Figure 1 reproduced from Enabling Occupation: Advancing Occupational Therapy Vision for Health, Well-Being and Justice Through Human Occupation, 2007, with permission of CAOT Publications ACE 1
As the emphasis is continually on functional outcomes an effective clinical method to assess performance components is to first deconstruct the actual occupation using the Taxonomic Code of Occupational Performance (TCOP).
As shown in Figure 2 the TCOP proposes a hierarchy with each level having greater complexity than the level below. At the top of the TCOP is occupation and at the bottom are voluntary movements or mental processes.
* Figure 2 reproduced from Enabling Occupation: Advancing Occupational Therapy Vision for Health, Well-Being and Justice Through Human Occupation, 2007, with permission of CAOT Publications ACE1
Thus occupations are systematically divided into activities, tasks, actions and voluntary movements or mental processes. This systematic assessment ensures the greatest carryover from the client’s goal to relevant performance components. This also sets the groundwork for further assessment of the person components.
The assessment of physical components of the person is common across several professions. The goal is to identify contributors to the ongoing dysfunction and identify opportunities to improve adaptive potential. The Exstore approach is a novel approach that achieves this aim ². Exstore focuses on the foundations of the musculoskeletal system (pelvic girdle, spine and shoulder girdle) and assesses the stability and range of motion of the skull and extremities in relation to those foundations. Affective and cognitive components of the person may be assessed through questionnaires, the interview process and standardized assessments.
Finally, environment factors are considered in relation to the client’s goals. Because occupation occurs within the context of the environment it may facilitate or impede occupational performance.¹ The environment includes not only the client’s immediate environment but also the larger community and the treatment area. To put this in context, consider an individual that has ongoing pain that increases with stress. That individual’s home and work environment can facilitate or hinder the client in achieving his or her goals depending on whether each environment is more or less stressful.
To illustrate the concepts presented in this article consider an athlete that wishes to perform at her best in the upcoming Summer Olympics in London.
The athlete is competing in the marathon (occupation). She complains of ongoing right knee pain for the past several months. She feels that her performance in the event is a 5/10 at the moment with 10 being the best performance possible. Her goal is to reach 10/10 in 2 months time at the Olympics. During the interview she reports no acute event, pain worse with running or use and that the pain continues to increase in intensity, which worries her. She has been taking NSAIDs, which provided more relief initially but again she is worried about continued use of the medication. She currently trains by herself and works part-time as she cannot afford to train full-time. She notes that her parents have been both emotionally and financially supportive of her goal but she worries that they do not have the money to financially support her. Based on the client’s worry about her performance further questioning is completed related to central factors such as sleep and anxiety. She notes infrequent bowel movements, followed by periods of diarrhea. She states that her energy has decreased lately and she cannot maintain her target heart rate zones during the runs.
Following the interview the athlete is observed performing her occupation of running during her regular training period. A shorter stride is noted on the right side and therefore the TCOP is warranted, which identifies an inefficient pattern in standing, forward trunk flexion. The Exstore assessment is used for the physical assessment, which identifies limitations in right passive internal hip rotation and restriction in the right proximal tibiofibular joint. The right gluteus medius, gluteus minimus, trunk rotation and hip flexion bilaterally all test 3/5 in manual muscle testing. Trophic tissue changes are noted throughout the lower extremity.
This case demonstrates a top-down assessment approach based on the client’s goal of improving her running performance. Within a clinical context it may be easy to overlook contributors to the ongoing dysfunction outside of the physical assessment without a dynamic and comprehensive assessment approach. It highlights several performance components relevant to the client’s goal.
As this article covered assessment in part 2, I will review an integrated occupational therapy approach to the treatment of pain and movement dysfunction. I will also discuss the value of integrative dry needling and neurofunctional acupuncture within this approach for the treatment pain and movement dysfunction.
I always welcome constructive feedback and please feel free to comment with your views as to what you see as relevant performance components in the case example above.
- Townsend, E., Polatajko H. Enabling Occupation: Advancing Occupational Therapy Vision for Health, Well-Being and Justice Through Human Occupation. Ottawa, Ontario. CAOT Publications ACE, 2007.
- Lombardi, A. EXSTORE: Simplified Assessment of Musculoskeletal Injuries, unpublished manuscript. 2011.
Jason Lomond is Registered Occupational Therapist, certified in Contemporary Medical Acupuncture from McMaster University. Occupational Therapist specializing in the treatment of pain and movement dysfunction. Connect with Jason on Twitter or call 902-521-4467
The Bottom Line
Thanks Jason for teaching us today more about what is occupational therapy and how an OT gets involved even in the pain stage of a condition to help improve motion and occupation. I look forward to part 2 of your installment.