Subjective

Client was polite and seemed interested in participating in therapy. His mother
accompanied him and was very willing to participate in the Canadian Occupational Performance
Measure (COPM). They seemed to understand what occupational therapy encompassed and were
prepared with their wants and needs. They were very helpful and knowledgeable in explaining
Michaels condition and were pleased to answer our questions. Michael has a good sense of
humor and was joking with us throughout both sessions. He stated that his adaptive device for
speech was detrimental to his conversational abilities.

Objective
Michael is 33 years old. He was seen at the Life Skills clinic on 1/26/17 and 2/2/17. He
was diagnosed with Myotonic Dystrophy was he was 14. He was referred to occupational
therapy so he could learn to balance his daily routine with his medical condition and become
more functionally independent. He recently had some surgeries regarding a fistula and had a
pace maker put in December 2016. He has no precautions following his surgeries. He has poor
muscle tone, problems with balance and walking, excessive fatigue, difficulties with speech and
swallowing, and some problem solving and reasoning issues. Michael has a computer he utilizes
as an adaptive device. He can type in a sentence, and it will read it aloud for him. He only used it
three times during the first visit and did not use it during the second visit. He was frequently
asked to repeat himself and never repeated himself without prompting. His dysphagia led to the
insertion of a feeding tube that is used daily for hydration purposes. He occasionally experiences
anxiety. He takes medication for his diagnosis which include stimulants to keep him alert. He
lives with his brother, Chad, in a government funded apartment. His mother is his guardian and
primary care giver. They speak on the phone daily. She is writing a book in conjunction with an
author regarding her and her familys experience with myotonic dystrophy. She sent us a copy of
the rough draft. He has a caregiver that visits in the morning and the evening. The caregiver
performs the laundry, dishes, cooking, and cleaning. They only have one grab bar in their home
outside of their shower. He says he tries to go for a walk everyday but often forgets. He also has
a hard time remembering some of his other self-care activities like putting on face cream, using
his cough assist, and sleeping with his BiPap at night.
Michael values both his family and his education. His family is very close. His three
siblings and father have myotonic dystrophy. They are a great support system for Michael and
can empathize with any of his experiences. Michael graduated from college last year with a
Bachelors degree in communication from the University of Utah. He worked for Hillcrest high
school grading AP papers up until March of last year. Michael values his education and would
like to use it to become a writer in the future. He enjoys playing video games, chatting to people
on the computer, and reading. Staying social and finding a girlfriend are also important aspects
of Michaels life. He was raised LDS but is no longer a member of the church.

Assessments Administered
Michaels evaluation consisted of the COPM, the shopping, dressing, and medication
management sections of the PASS, and the observation of functional tasks. These included:
cooking, laundry, putting away groceries, filling out a job application, and a shower transfer.

Functional Observations. Michael only required nondirected verbal cueing during the
laundry task to identify which machine was the washer and which was the dryer. He struggled to
open both the washing machine and the dryer. He required minimal assistance to complete the
cooking task. He misread the instructions during the task and required a direct verbal cue and
gesture to remedy his mistake. He could not open the salt container independently and held it
upside down while pouring it. Michael was able to independently put away grocery items in the
clinic kitchen and fill out a mock job application by hand. Michael was able to remember in
which drawer to store the measuring cups a week after learning the location. Michael had good
posture and stabilization of the paper with the nondominant hand while writing; however, his
writing was slow, he used inconsistent letter formation, and used a static thumb wrap grip during
the task. His range of motion in his functional activities was within functional limits in all
directions. He experienced a loss of balance while loading and unloading the washing machine,
putting away groceries, and getting into the tub/shower combination at the clinic. He did not
attempt to use the grab bars when stepping over the side of the tub.

COPM. The client was administered the COPM on the first visit. He and his mother were
able to give a holistic view of his daily life as well as his occupational history. The five areas that
Michael singled out as being important to address during therapy were the daily application of
cream to his face, twice daily use of his cough assist, participating in daily walks outside,
deciding what type of job he wanted to pursue, and increasing his social interaction. The
following chart illustrates his scores for each of these subjects in the categories of importance to
address in therapy, current occupational performance, and satisfaction with current occupational
performance on a 10-point Likert scale in which one is unimportant/poor
performance/unsatisfied and 10 is very important/good performance/satisfied.

Applying Using cough Daily walk Choosing a Socialization

face cream assist job
Importance 4 7 7 4 8
Performance 7 5 2 5 3
Satisfaction 8 3 4 7 3

The following chart represents the averages for the previous performance and satisfaction
categories:
Total Performance 22
Average 4.4
Performance
Total Satisfaction 25
Average Satisfaction 5

PASS. During the shopping task he used the calculator to sum up the amount of money
he needed for his purchases instead of looking at the total on the bottom of the receipt he was
given. He had a hard time opening the wallet during this task as well. He stood while donning
and doffing his pants and experienced a loss of balance during both activities. He was able to
independently don and doff the provided cardigan but was slow at fastening the buttons. He
completed the medication management task proficiently except for following the directions
regarding in which days of the week to place the pills. The following chart represents the clients
average adequacy, safety, and independence scores for each task on a three-point Likert scale in
which three is independent/safe/adequate and zero is dependent/unsafe/inadequate.
 Adequacy Score Safety Score Independence Score
Dressing Task 2 2 3
Shopping Task 2 n/a 3
Medication Task 2 3 2.83

Assessment
Michael relies on his mother for many of his needs. She is his primary care giver and
assists him with activities ranging from taking him to appointments to calling him to get out of
bed in the morning. He also relies very heavily on his brother, Chad, to translate his speech to
other people. Michael and Chad are very close and are often each others main source of social
interaction. His apartment is government funded and will not allow many modification to the
home. He has only been allowed to place one grab bar outside of the shower. Michael did not
seem interested in participating in any home maintenance tasks such as laundry. He stated that he
was fine with his daily caregiver managing these tasks as a form of energy conservation and that
he knew how to complete them if necessary. His lack of skill during the cooking task illustrated
that he may not be as self-sufficient as he thinks and his self-awareness may be lacking. He may
be dependent on his caregiver completing these daily activities for energy conservation as well as
a lack of knowledge in that area.
Michaels cognitive problems and lack of insight were apparent during his evaluation.
During the task of putting away groceries Michael did not attempt to find the correct place for
any of the objects. Instead he decided to put the objects in similar drawers as he did at home.
While interacting with the stacked washer and dryer in the clinic Michael immediately started
loading the top machine first and needed to be verbally cued to check that he was loading the
washing machine. He stated that his washing machine at home was on top, illustrating the fact
that he did not realize that the situation elsewhere could be different. He struggled to open the
washing machine and dryer doors for the same reason. When getting into the shower at the clinic
Michael did not use the grab bar. This could be attributed to the fact that either it is in a different
location than the one he has at home and he didnt think to use it or because he does not utilize
the grab bar in his own home. His trouble with the salt during the cooking task could be due to a
problem-solving issue. It could also be attributed to a lack of skill in that area. Michael is not
aware that he has any deficits in the area of cooking which points to a lack of insight. Michael
struggled to open a wallet during the PASS exam and kept repeating the same action while trying
to open it. While talking about goals he decided he wanted to volunteer somewhere like an
animal shelter; however, he wanted the location to be within a block of his house. He was able to
name all of the businesses within that range but did not seem to realize that there was not a
location at which he could volunteer. Michael does not recognize when others do not understand
his speech and does not pick up on nonverbal cues. He may not realize how impacted his speech
is by his condition which is why he does not expect people to have a hard time understanding his
speech.
Michael experienced some fine motor defects while writing and buttoning his shirt. These
are most likely a result of deteriorating muscle strength caused by his myotonic dystrophy. This
disease often affects distal muscles first. He experienced a loss of balance while performing
activities that required him to stand on one foot or lift an object. This may be the result of poor
muscle tone in his lower extremities caused by his condition.
 Research and practice models
PEO
I want to view my client in as holistic a way as possible. The PEO model allows me to
analyze his occupational performance in as many combinations of occupation and environment
as I want. His performance of an occupation will be affected by his attitude and functional ability
as well as the environment in which it takes place. This information is very important when
taking into consideration the generalization of strategies and skills. My client will be learning
most of these new skills in the Life Skills Clinic which is not his natural environment. We will
only have one session in which to implement these strategies in a more natural place. Teaching
my client shower safety in the clinic may not have the same effect as being able to teach him the
same skills in his own home. Occupation is also an important factor to consider. There are some
activities that may be inaccessible to my client due some of the cognitive impairments caused by
his condition. For example, my client wants to volunteer somewhere on a regular basis.
Changing buses may not be something he is able to do. Taking one bus or walking to a location
is a modification of the activity that is more within his functional abilities. The goal of therapy is
to give my client the necessary strategies and tools he needs to perform his desired occupations. I
will be teaching him how to enhance his cognitive abilities to expand his functional
independence.

CO-OP
The cognitive orientation to occupational performance model was originally designed for
children with developmental coordination disorder. It has since been adapted to be used by adult
populations with executive function impairments. This model will work well with my client
since he displays some aspects of executive dysfunction common to his diagnosis of myotonic
dystrophy. A study by Dawson et al. (2009) worked with adults who had received a TBI that
resulted in executive dysfunction. The intervention centered around teaching these participants to
independently implement the global strategy of Goal-Plan-Do-Check to self-monitor their
occupational performance during client-selected daily tasks. These participants showed
improvement after the intervention. CO-OP also places a large emphasis on making sure the
goals are client-centered. My client has chosen a few daily self-care activities that he would like
to become more proficient in performing regularly. I will implement similar strategies to
promote his functional independence in his daily tasks.

DIM
The dynamic interaction model is used to promote change within a persons processing
strategies. This allows people who have executive dysfunction to adapt to occupations that may
have previously been outside of their occupational performance abilities. People with myotonic
dystrophy often have symptoms of impaired executive function (Meola et al., 2003).
Occupational performance improvement can be achieved through allowing them to become more
aware of their deficits so that they will be able to compensate for them using strategies.
Intervention can be based around structured activities in which the client may not succeed but
will be able to evaluate their own performance. I will be able to help my client improve his
occupational performance by providing him with a just right challenge during therapy.

Plan
 Michael would benefit from skilled occupational therapy services. Treatment will occur
at the Life Skills Clinic with the exception of one visit to his apartment. Michael identified some
goals he wants to work on during therapy. He would like to become more adept at following his
daily self-care schedule, including putting on his face cream and using his cough assist more
regularly. He would also like to be able to socialize more often. He agreed that volunteering or
joining a club that met regularly would be the best course of action. Gagnon, Mathieu, & Noreau
(2007) suggested that people with myotonic dystrophy would benefit from volunteer
opportunities. These would allow them to interact with others while participating in a meaningful
occupation without the stringent rules and demands of an actual job.
Intervention will be based around establishing both a daily routine and a regular social
interaction. Intervention will focus on increasing awareness, insight, and the implementation and
generalization of cognitive strategies. Using these strategies, treatment will work toward
increasing the clients social repertoire and functional independence. It will also focus on
creating a client-chosen daily routine to which he can adhere by utilizing the previously learned
strategies. He will be seen for one hour once a week for six more weeks.

LTG: After six visits, client will follow daily routine with minimum assistance from caregiver.
STG: After four visits, with minimum assistance to use strategies client will apply his face cream
during his morning routine.
STG: After two visits, with moderate assistance client will use strategies to identify if he has
missed any activities in his daily schedule.

LTG: After six visits, client will independently volunteer at a chosen location weekly.
STG: Within four visits, client will use transportation with minimum assistance to reach location
of volunteer opportunity.
STG: Within three visits, with moderate assistance client will have selected a suitable location at
which to volunteer.

Therapist: Rebecca Hahnlein

Date: 2/4/17