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The self organizing human open (or dynamic) system

Occupational Performance

OT Models

Several different options for Occupational Therapy Models

used to provide an integrative approach and guide occupation-based practice, clinical reasoning and OT-roles within chronic pain (and psychosocial) assessment and treatment.

An Occupational Therapy Case study

Some relevant examples

MOHO within Chronic Pain

Jaap Rigtering - NZROT

Questions?

- Gary Kielhofner 2008

Volition

Habituation

Performance

Performing / doing

Case study - Journey

Lived alone

Working as Call-Center operator for internet provider - Achieving well within her job

At time of referral

Unable to work due to problems with mobility and sitting

Moved in with her mother

Spends a lot of time resting

Minimal social contact

Significant financial worry and fearful about her limitations increasing in the future

Anxiety regarding origin of pain; i.e. cancer or other unknown cause for her pain

Significant anxiety and distress about family communication; Increasing difficulty communicating with brothers

Struggling with fact her identical twin sister is doing well and of a lower BMI

continued

Case study - Client Profile

December 2009

Referred by obstetrician & Gynaecologist to:

Anaesthesia National Women’s Health - Pain clinic

Physiotherapy and Psychology input to help with function and coping strategies

July 2011

Gradual return to work and managing a four hour day (three times a week). Seemed to be coping better h/w no difference in pain.

Unable to increase hours (cause for further emotional distress & fear of loosing job). Trial with TENS during Physio (unsuccessful).

November 2011

Reviewed quite extensively by Gynaecologist:

- no real evidence of macroscopic organic disease on MRI

- no requirement for surgical input

January/ February 2012

Attended a six hour group education programme for women with pelvic pain

Inability to sit for more than approximately five minutes (on normal chair) at work: stress between her and her supervisors

Referral to TARPS completed => CPA done in November 2012

March 2013

Attended PMP at TARPS. Referred to OT in April at one month follow-up. (ACC approval received late June 2013)

Case study - Client Profile

November 2009

43 year old woman

Excision of small benign granular cell tumour left vulva

Left with ongoing vulvodynia

- Increase of pain (4-10/10) with any activity; walking, clothing rubbing is irritating

- Symptoms worsen as day goes on

- Relieved by resting in her lazy boy chair

Normal periods, bladder / bowel habits

Weight gain

Other history:

- Dysmenorrhoea

- Injury in her 30s where she fell hard on to a step leaving her with a bruised, tearing feeling through the left abdominal area and left buttock)

Case study continued

process in which; 'the clients motivation for occupation, habits and performance interact with facilitators and barriers in the environment'

Increase use of skills:

- Assertive communication

- Pacing and use relaxation within work day

- Regular exercise (for maintenance)

- Graded building; sitting tolerance

Performance

-Unsure on how to adapt her routine

-Back in old roles/ habits: doing unpaid

overtime

-Difficulty with implementing pain

management and coping strategies

- Physically fitter after PMP (however

reducing as not exercising)

- Many new skills after PMP on

communication, relaxation, pacing and

regular exercise (however minimal use)

Habituation

Performance

OT Treatment Focus

- Elicit confidence and a sense of competence

and control

- Ax meaning and values of activities and roles

Referral options

Access to OT Input

Volition

- Pacing and using relaxation during work

- Assertive communication

- Making time for her own health

- Relaxation/ reduction of anxiety

- Psychological strategies

- Lack on confidence (in own 'new' skills)

- Fear of ‘busting' or getting set-back

- Anxiety regarding communication with boss

- Anxiety regarding expectations and 'stress'

from family

Volition

- Break old routines, develop new habits

which includes coping skills

- Ax roles and patterns (work, family)

Habituation

Using strategies within own environment

OT Assessment

OT outcome

Outcome

- Pacing and using relaxation during work; able to find ways to do relaxation breaths in

between phone calls and during lunch time. Working twenty hours.

Employer now moving towards ending contract.

- Assertive communication; able to communicate own needs towards her boss and

her mother - h/w not towards brothers yet.

- Making time for her own health; able to plan four regular exercises per week.

Now going to the gym twice and going swimming twice per week. Also freed up time

for herself in the weekend.

- Relaxation; reducing anxiety with regular formal breathing/ relaxation exercises,

planned within her week. Regular informal breathing and taking things 'as they come'

- Thought management; using psychological strategies on a daily basis to 'check in' with

herself, stay positive and challenge own negative thoughts

Four sessions on consolidating learned skills and eliciting confidence to use these, maintain and monitor own performance and adapt to what best suits own health and own needs WITHIN OWN ENVIRONMENT!

OT Outcome - Detailed

Canadian Model of Occupational Performance and Engagement

Intentional Relationship Model - R. Taylor 2008

Intake

Taking in info of interest or relevance

Output

Interaction through occupation ("doing")

Environment

Temporal, Physical, Sociocultural

Feedback

Change over time by

thoughts/ feelings

created through doing

Understanding how 'occupation is motivated, organized, performed in and influenced by the context of environment'.

MOHO

Model Of Human Occupation

Environment

Constant interaction

change in any area can lead to whole shift of system over time (healthy or unhealthy change )

Task/ Occupation

Person

Habituation

Pattern

Organized and structured behavior through

doing, habits, routines and roles of daily life.

-Consistent behavior = a habit

-Collection of habits = a trait

-Trait = learned behavior based on previous success and motivation.

-Cluster of traits = a role

-Traits and roles explain a persons motives and lead to Intentional functioning.

-Intentional Functioning is goal driven which leads to change

Volition

Motivation

Values, Interest, Personal Causation

-Competence = attempt to become competent through experience

-Effectance = desire to cause effect through doing/ actions/ occupations

Performance

Skills; motor, processing & communication skills

available for "doing" activities

Lumbar flexion: 60º flexion and 25º extension (normal values = 60/25º)

Neck range of motion: 50º flexion and 50º extension (normal values = 45/50º)

Trunk strength and endurance: Able to hold Biering Sorenson’s test for 44 seconds (normal value = 60 seconds)

Sit ups: Able to do 4 (normal value = 20-23)

Push ups: Able to do 5 (normal value =13-19)

Grip strength: (combined) 36kg (normal values 61-65kg)

Dynamic box lift test: Able to repeat four repetitions of 10 kg (normal value = 4 x 12kg)

Physio Pre-programme PCE assessment

Details on medication

June 2011

50mg Amitriptyline nocte

20mg Xylocaine, no improvement

10mg Kenacomb injection (march 2011). Some increase in pain on steroid injection

1000mg Paracetamol x3pd

100mg Gabapentin x3pd introduced with plan for further slow increase

Pregabalin advised however not approved by ACC

Primolut and Ponstan (for menstual problems)

September 2011

All of the above with an increase in Gabapentin to 100mg-200mg-300/400mg

October 2011

10 mg Clomipramine nocte (instead of her Amitriptyline)

February 2012

1000mg paracetamol x4pd

300mg Gabapentin x3pd: short term memory loss and concentration difficulties

March 2012

75mg Pregabalin x2pd (trail): working well

1000mg paracetamol x3pd

100-200-300mg Gabapentin

25mg clomipramine nocte

May - June 2012

10-20mg Noratriptoline x1 nocte

2% Lignocaine hydrochloride x1 pd

Difficulty with ongoing funding ACC funding: Pregabalin stopped

July – November 2012

1000mg paracetamol x3pd

300mg x3pd Gabapentin: ongoing memory difficulties

25 mg clomipramine x1nocte

25mg Noratriptoline x1 nocte

20 mg Fluoxetine

2mg Diazepam for acute anxiety

300mcg/24hr Clonodine patch

November 2012

ACC funding restarted: re-application for Pregablin

January 2013

75mg Pregabalin x1 am, x2 nocte

June 2013 (post PMP)

1600mg Brufen SR x1 daily

2mg diazapam (increased frequency of use)

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