Scenario 1 - 2nd SBL Instructions

 Report back to your SBL group about the learning issues you identified in the
previous tutorial. Share new insights gained from your study and resource
sessions and explore them together.

 Identify sources from which information was gained. Critique their value for
finding out about the identified learning issues.

 Discussion of STUDENT TASK: As a group, collate your knowledge about:

(i) further assessments and action that should be taken with Huda

(ii) The occupational performance limitations you would now expect Huda to
experience, justifying each on her clinical condition as well as known
performance restrictions.

(iii) Discuss the areas you believe would benefit from occupational analysis

(iv) Discuss relevance of the WRI and WEIS to assessing Huda’s situation.

 What concepts still require further understanding / knowledge?

Final Impressions

You accompany your supervisor Kate on two home visits to Huda during the
assessment phase.

At the first visit as Huda leads you through to the lounge room you notice that
although she walks quite quickly with her single point stick, she is inclined to
shuffle. You also notice that her hands are visibly deformed. Kate proceeds to
conduct an initial interview with Huda to clarify and expand on the information in
the referral. At the second visit Kate conducts a COPM with Huda. The results
of the assessment process are as follows:

Performance rating Satisfaction rating

Occupational Priorities: (1=low, 10=high) (1=low, 10=high)
1 Self Care,
a. dressing, 6 7
b. housework 3 3

2 Leisure
a. playing cards 7 7
b. socialising 7 6
2 2
3 Productivity
a. looking after Sarah 5 4
b. working 1 1

Huda is independent in personal and domestic ADLs. She wears clothing that
does not require much buttoning because it is too difficult to do up buttons. She
tends to wear clothing with Velcro fastenings or elastic waistbands. She was
shown how to do up her bra at the front and purchased a bra that was easier to
fasten. She wears slip on shoes wherever possible. Kate suggested that she use
an electric toothbrush.

She gets home help once per fortnight to help her with heavier household tasks
such as washing and vacuuming. For cooking on the stove, Kate recommended
that she use special grippers to manage the handles of pots and pans. She has
assistive equipment including a jar opener, electric can opener, shower stool and
lever taps. She eats at least two fish meals a week to increase her Omega 3
intake that may help to reduce some of the inflammation in her joints. She takes
her evening medications with her dinner.
She has been having difficulty getting herself and Sarah into and out of the car,
and opening locks. Kate suggests a special key enlarger attachment for Huda’s
house keys which makes it easier to turn the key. Her car transfers will need to
be monitored. She has only one step at each entrance to her home. Huda
states she has decided she needs to focus her energy on activities that are
significant to her.

 Huda’s goals in order of priority were:

o Huda wanted to talk with her daughter about her current issues with
looking after Sarah. She wants to continue to care for her
granddaughter, Sarah but only for one day per week and only one
night.
o Huda wanted to return to work on a part-time basis.
o To improve ease of management of tasks involving pinch and grip
o To reduce progression of deformity and improve the aesthetic look
of her hands
o To manage fatigue

Clinical situation
 Huda’s RA is largely quiescent. Morning stiffness lasts only as long as it
takes to have a hot shower and is likely more related to osteoarthritis than
RA. She feels generally well, except for being tired a lot of the time. She
has no current signs of vasculitis and no extra-articular nodules. However,
Sjogren’s symptoms persist. Huda uses liquid tears for her dry eyes,
artificial saliva drops and has regular dental check-ups.
 Huda states the only pain she currently experiences relates to her left
knee. She states she is on the waiting list for a left total knee joint
replacement, but is not keen on further surgery. However, on examination
Huda also has wrist and MCP discomfort at end range and on palpation.
She dismisses this as “nothing” in comparison with the pain of the past.
 Following ROM assessment and an occupational analysis of performance
issues raised by Huda, her major joint limitations are as follows:
o Inability to fully extend left knee
o Reduced forearm supination
o Wrist radial deviation deformity
o Thumb CMC subluxation into adduction, right thumb MP
hyperextension and IP flexion (- left dominant thumb MP fusion six
months ago)
o Mild index and middle MCP synovitis of both hands. Ulnar drift of
all fingers. When Huda attempts to actively correct the drift she can
bring her fingers back to neutral position with effort, but cannot
radially deviate. Swan neck deformities of index fingers – unable to
actively flex PIPs.
Recommendations
Kate sourced information about caring for infants for people with arthritis and
visited at times when Huda was caring for Sarah. Huda was resourceful herself
based on her previous experience of caring for her daughter when she was
newly diagnosed with RA. The major issue was pulling the adhesive tabs on the
disposable nappies, managing snap fasteners on Sarah’s clothing and lifting
Sarah. These issues were resolved with a change in brand of nappy and Huda’s
daughter dressing Sarah in clothing that Huda finds easier to manage.

Neoprene wrist wraps were made to support Huda’s wrists and she was taught to
encourage Sarah to climb up onto her lap when she is seated to avoid the need
to lift her. Huda spoke with her daughter about having Sarah for only one night.
At first her daughter was a little annoyed, however she agreed that she had been
relying too heavily on her mother and would need to find alternative child
minding.

Kate also provided education regarding the impact of long term synovitis on joint
structure and function, and discussed the fact that often when swelling subsides
ligamentous laxity and hence deformity become more pronounced. Kate
provided joint protection education and a home exercise program, designed to
maintain or improve existing function and reduce progression of deformity. She
also provided splints to position index finger PIPs in slight flexion to improve
pinch. Night resting splints were not supplied due to potential falls risk. These
measures and the neoprene wrist wraps resulted in improved pinch and grip
strength and increased ease with daily tasks. Although Huda continues to be
concerned about the appearance of her hands she is not interested in surgery at
present, as her function has improved.

Kate asked Huda to complete a time use diary including when she feels tired and
when she experiences most joint pain. When reviewing this dairy, Huda admitted
that she is often out later than she is used to, visiting her friends in the evenings.
She had not considered that caring for Sarah twice per week had commenced at
the time of her disease coming under control, and this lifestyle change may be
contributing to her tiredness. Kate encouraged her to take a nap when Sarah has
her afternoon sleep and to make a habit of this on other days. She also
reinforced energy conservation and work simplification principles that Huda had
allowed to slip in the last 12 months. Huda says when she puts these measures
in place she is far less tired. When she is tired she now reflects on lifestyle
causes and is not constantly fearful that it is a sign of a flare of her RA.

After negotiation with the food services manager, it was agreed Huda will return
to work for three days per week (10am - 2pm). Given the new strategies that she
has learnt in energy conservation, grading and adapting activities, she will be
managing making and organising the cold food section and so avoid having to
handle heavier (hot) cooking pots.
Kate also referred Huda to the Community Health Service physiotherapist to
assess and advise with regard to her mobility issues. As a result of this Huda
now attends a local exercise group, which has increased her energy and
endurance for activity. She also has started a hydrotherapy class with the physio
at the local pool. This has helped her to meet some new people.

Kate developed a good rapport with Huda over the four weeks of intensive
involvement and two follow-ups at one month intervals after that. At discharge
Kate was aware that not all issues were resolved and other issues are likely to
arise in the future. She has encouraged Huda to contact her when she requires
future input.
Working in a Group

 Comment on how the dynamics of the group influenced learning this week
(focus on the group – consider communication, organisation, decision
making, task completion, cohesion, conflict / issues, membership issues –
punctuality, roles, attendance). Did everyone contribute to the discussion? If
not why not?
 Has the learning / information been pitched at the “right level” for the group
members? To what extent have group members understood the material?
How could this be improved for next time?
 Has there been sufficient time for everyone to contribute?
 Has too much / too little time been spent on some topics?
 Chair, Scribe and time keeper: Provide a brief self-evaluation – how did it feel
to take this role? What would you like to happen next time in this role?

Learning Objectives

At the completion of this scenario it is expected that students are able to:

 Describe synovial joints, including different shapes, movements, structures,

and contributors to stability
 Explain the clinical features of Rheumatoid Arthritis (RA) with reference to
joint changes in the lower and upper limbs in the early presentation and in a
chronic/later presentation of RA
 Describe the soft tissue features of RA
 Outline the anatomy of the hand, including bones, joints, muscles, tendons,
and nerves
 Describe what is meant by “the systemic nature” of RA, the areas of the body
that may be involved and the outcome for the client
 Describe the range of medications (prescription, non-prescription and
alternative) available for someone with joint disease and the potential side
effects of each
 Describe and apply at least one preferred functional assessment that has
been designed specifically for clients with rheumatological disease
 Identify assessments that provide detailed occupational performance issues
for a person with RA (e.g. pain diary, ADL assessment)
 Identify issues that may be of concern to a client, that are related to RA and
often arise as part of the ongoing ‘therapeutic relationship’
o Work (function at work, psychosocial issues, EEO, Discrimination,
OHS)
o Domestic situation (mother role, instrumental ADL)
o Personal factors (altered body image, personal ADL)
o Social/recreational interactions and opportunities (decreased
independence)

Page 6 of 7
OCC312 Scenario 1: Huda (Student Copy)
 Describe the application of a biomechanical model in assessment and
intervention for someone with physical limitations
 Critique the strengths and limitations of using a biomechanical approach for a
person with RA over other approaches (e.g. MOHO including Volition,
Habituation, and performance capacity and the lived body. Outline a process
for analysing occupations using a biomechanical approach.
 List the principles of energy conservation and apply these to analysis of
occupations
 Demonstrate the process of carrying out a muscle strength assessment,
applying the Oxford scale of classifying muscle strength
 Demonstrate the process of measuring and recording joint range of motion

Page 7 of 7
OCC312 Scenario 1: Huda (Student Copy)