Written Output Muscular Dystrophy

VELEZ COLLEGE INC.
College of Occupational Therapy and Physical Therapy

Department of Occupational Therapy
A Case Conference on Seminar I

Muscular Dystrophy
A.Y. 2022-2023
Submitted by:
Bacaro, Sydney Marie
Fabillar, Rinia Ela Justinne
Mabelin, Melanie Andrea
Paculaba, Beverly Angeli
Pizarras, Jaznielle
Vidal, Robin Ayn
Villones, Fatima Therese
December 21, 2022

TABLE OF CONTENTS
I. BACKGROUND INFORMATION
A. Introduction 2
B. Medical Literature
Definition 3
Epidemiology 4
Etiology 4
Pathophysiology 4
Clinical Features 4
Diagnosis 5
Course and Prognosis 5
Medical Management 6
C. Models, FORs, & Approaches Used 7
D. Evaluation and Treatment Guidelines 10
II. EVALUATION
A. Occupational Profile and Performance 12

B. Classical Versus Clinical Picture
C. Strengths and Limitations
III. INTERVENTION PLANNING 20
A. Problem List Prioritization

B. Targeted Outcomes
C. Goals/Objectives and Management
D. Recommendations
IV. TREATMENT SESSIONS 30
V. PROGNOSIS OF TREATMENT 37
VI. REFERENCES 38
VII. APPENDICES 39
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I. BACKGROUND INFORMATION
A. INTRODUCTION
This is the Case of J.J a 53 year old Female from

Zone 1 #14 Deiparine Street, San Isidro, Talisay
City Cebu presenting difficulties in ADLs
specifically in bathing, dressing, and personal
hygiene and grooming due to problems with joint
mobility, muscle power, pain, body structures, and
muscle endurance as evidenced by problems in
reaching for items placed overhead, reaching
distal parts of her body during bathing, reaching
her head when combing, raising her arms to
retrieve items from the cabinet and lifting them to
insert her arms through the holes of her clothes
during donning/doffing.
Client also has difficulty in work specifically job

performance and maintenance due to problems
with joint mobility, muscle power, pain, body
structures, and muscle endurance as evidenced
by difficulty reaching for tools and equipment that
are situated at hip and eye level, and difficulty
enduring more than 10 minutes of work as
observed when her dental assistant would support
her forearms during dental operations.
All of which are caused by Scapulohumeral

Muscular Dystrophy.
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B. MEDICAL LITERATURE
Definition
Muscular Dystrophy is a group of genetic diseases in which muscle fibers are unusually
susceptible to damage. These damaged muscles become progressively weaker. However,
despite the progressive degeneration of muscle fibers, the neuronal innervation to muscle and
sensation still remains intact.
The major types of muscular dystrophy (MD) include:

● Duchenne Muscular Dystrophy
● Becker Muscular Dystrophy
● Facioscapulohumeral Muscular Dystrophy
● Myotonic Muscular Dystrophy
● Limb Girdle Muscular Dystrophy
TYPE DESCRIPTION AGE of ONSET and

PROGRESSION
Duchenne Affects boys only because it is Onset age: 3-5 years - begins in
inherited as an X-linked recessive trait muscles of pelvic girdle and legs
Results from gene mutation that By 12 years, unable to walk;

regulates the protein involved in uses wheelchair
maintenance of muscle integrity
Weakness spreads upward to
shoulder girdle and trunk
By 20 most need respirator to

breathe, with death usually
occurring by age 30
Becker Similar to Duchenne, with milder Onset age: 2-16 years

symptoms. Slower progression of weakness
X-linked recessive, affects boys Survival into middle age
Facioscapulohu Affects both genders Onset age: Adolescence

meral Autosomal dominant Slow progression of weakness
Affects primarily the muscles of the resulting in a near normal
face and shoulder girdle lifespan
Myotonic Affects both genders Onset age: Varies, often adult

Causes weakness but also Involves cranial muscle and
myotonia—prolonged muscle spasm or distal limb weakness rather than
delayed muscle relaxation after proximal
vigorous contraction—especially in May be mild or severe
fingers and face; floppy, high-stepping Associated symptoms progress
gait; appearance of long face and to involve cardiac abnormalities,
drooping eyelids endocrine disturbances,
cataracts, and, in men, testicular
atrophy and baldness
Limb Girdle Affects both genders Onset age: teens to early

Progressive weakness affecting pelvic adulthood
girdle and shoulder girdle first Weakness leads to loss of ability
to walk within 20 years
Relatively slow progression
Death in mid to late adulthood
Table taken from Pedretti
While there is no cure for muscular dystrophy, medications and therapy can slow the course of
the disease.
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Facioscapulohumeral Muscular Dystrophy
Facioscapulohumeral MD is a disorder characterized by muscle weakness and wasting

(atrophy). This condition gets its name from the muscles that are affected most often:
● those of the face (facio-)
● around the shoulder blades (scapulo-)
● in the upper arms (humeral)
The signs and symptoms of facioscapulohumeral muscular dystrophy usually appear in
adolescence. However, the onset and severity of the condition varies widely.
Epidemiology
Facioscapulohumeral muscular dystrophy (FSHD) is a dominantly inherited dystrophy, with a
prevalence of 1:20,000, and is the third most common dystrophy after dystrophinopathies and
myotonic dystrophy.
Etiology
● Genetics
Facioscapulohumeral muscular dystrophy (FSHD) is a dominantly inherited dystrophy.
Having a parent with FSHD gives a 50% chance of inheriting the genetic defect.
Pathophysiology
Facioscapulohumeral muscular dystrophy is caused by genetic changes involving the long (q)
arm of chromosome 4. Both types of the disease result from changes in a region of DNA near
the end of the chromosome known as D4Z4.
● In FSHD1, hypomethylation occurs because the D4Z4 region is abnormally shortened
(contracted), containing between 1 and 10 repeats instead of the usual 11 to 100
repeats.
● In FSHD2, hypomethylation most often results from mutations in a gene called
SMCHD1, which provides instructions for making a protein that normally
hypermethylates the D4Z4 region.
Clinical Features
Weakness involving the facial muscles or
shoulders is usually the first symptom of this
condition.
● Facial muscle weakness often makes it
difficult to drink from a straw, whistle, or turn up
the corners of the mouth when smiling.
● Weakness in muscles around the
eyes can prevent the eyes from closing fully
while a person is asleep, which can lead to dry
eyes and other eye problems. For reasons that
are unclear, weakness may be more severe in
one side of the face than the other.
● Weak shoulder muscles tend to make
the shoulder blades (scapulae) protrude from
the back, a common sign known as scapular
winging. Weakness in muscles of the shoulders
and upper arms can make it difficult to raise the
arms over the head or throw a ball. The muscle weakness associated with
facioscapulohumeral muscular dystrophy worsens slowly over decades and may spread
to other parts of the body.
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● Weakness in muscles of the lower legs can lead to a condition called foot drop, which
affects walking and increases the risk of falls. Muscular weakness in the hips and pelvis
can make it difficult to climb stairs or walk long distances.
● Additionally, affected individuals may have an exaggerated curvature of the lower back
(lordosis) due to weak abdominal muscles. About 20 percent of affected individuals
eventually require the use of a wheelchair.
● Additional signs and symptoms
○ mild high-tone hearing loss
○ abnormalities involving the light-sensitive tissue at the back of the eye (the
retina).
Diagnosis
Given the specific pattern of muscle involvement in the context of an autosomal dominant family
history, the clinical diagnosis of FSHD may be made with a high level of certainty in the majority
of patients. The diagnosis is confirmed with molecular diagnosis, bypassing the need for
muscle biopsy. Standard molecular testing for FSHD demonstrates the presence of a
contraction of the D4Z4 repeats in one copy of 4q35. The standard testing procedure performed
by most laboratories is highly sensitive (95%) and specific (95%).
In cases where no family history are suspected, less expensive and less specific tests may be
done first. These tests include:
● Creatine kinase level - this test measures the amount of creatine kinase in the blood.
When muscles break down, as they do in muscular dystrophies, the CK level is elevated
up to 5 times the upper limit of normal in symptomatic FSHD patients.
● Electromyogram (EMG) - this test measures the electrical activity in the muscles.
Patients with FSHD typically display alterations in EMG waves.
Course and Prognosis

FSHD is a progressive condition with short periods of rapid muscle deterioration. It has no
known cure but supportive care and treatment in rehabilitation can provide a better quality of life
for individuals with FSHD. Generally, the progression of the disease is fairly slow, but both the
age of onset and the degree of severity of the condition can vary greatly among patients, with
symptoms potentially beginning as early as infancy or as late as adulthood. In infantile form
onset, the disorder can be associated with mild hearing impairments or blood vessel problems
of the retina which may also lead to visual impairment. Associated weakness and atrophy of
muscles may result in disability such as difficulty in speaking, gait, and impaired ability to
perform ADLs. In most people with FSHD, it can take as long as 30 years for the disease to
become seriously disabling. Approximately 20% affected by FSHD progress to a more severe
course which may require wheelchair or other mobility equipment for ambulation. However, the
overall lifespan of persons diagnosed with FSHD is not affected.
The rate and extent of progression of the disease is variable; how it begins and how it proceeds
follows a rather uniform path with a very recognizable core pattern.
A patient usually recognizes the disease in his teens but an extreme variation in onset is
reported ranging from early infancy to late fifties, even within a family with all affected members
carrying the same genetic lesion. When the disease progresses to the lower limbs again the
rate of progression is quite variable. Occasionally long periods of standstill have been reported.
Facial weakness is rarely an early complaint and is only occasionally recognized by the patient
as onset of the disease. More than 80% of all patients notice shoulder girdle weakness as the
first symptom of the disease; approximately 5% report facial weakness, 10% foot extensor
weakness and 5% pelvic girdle weakness as the presenting complaint. The next stage in the
disease involves foot-extensor weakness in 80%, or pelvic girdle weakness in 20% of
patients. Pelvic girdle and upper leg muscles reflect the last region of involvement in most
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patients who progress beyond upper extremity involvement. The time to progress from
foot-extensor to pelvic girdle weakness may vary extremely, from 1 to more than 25 years. In
more advanced stages of the disease, the wrist extensors become weak and wrist flexors are
used to aid in elbow flexion resulting in an awkward and weak grip-strength.
A substantial number of patients—experience approximately 30% of all familial cases—never

progress beyond shoulder weakness. Some authors claim that each pattern is restricted to
certain families and therefore might be determined genetically.
Approximately 10% of all FSHD patients and 20% of all patients older than 50 years will become
wheelchair-dependent outdoors.
A mild gender effect has been noted by several authors; women tend to be more often
asymptomatic, have a slightly later onset and a somewhat milder course of the disease. The
clinical severity is wide ranging, from asymptomatic individuals to individuals who are
wheelchair-dependent.
The prognosis in an individual patient is subject to the overall broad inverse correlation between
severity and residual D4Z4 repeat number. Males tend to have slightly earlier onset than
females and also tend to have a greater severity of involvement, at least up to age 50–60 years.
For those patients with the smallest number of residual repeats (1–3 repeats), the likelihood of
loss of ambulation is high, and this has first occurred by age 8 years up to age 25 years. At the
upper end of residual repeat numbers (9–12 repeats), the risk is likely to be very small.
Conversely, if there is no proximal lower limb involvement by the early 20s, the likelihood of
eventual requirement for a wheelchair by age 50–60 years is small.
Medical Management
● Use of Assistive Devices
Custom molded ankle–foot orthoses (AFO) are helpful in the management of foot
drop in patients with FSHD. in patients who have foot drop combined with knee extensor
weakness, use of floor-reaction ankle–foot orthoses (FRAFO) provides extension
force to the knee upon floor contact, preventing buckling of the knee while also
preventing foot drop by keeping the ankle in a neutral angle. Other alternatives include
knee–ankle–foot orthosis (KAFO).
Bracing to reduce scapular winging and to improve shoulder range of motion is typically
futile. Figure-eight braces can reduce visible scapular winging, but cannot apply enough
force to fix the scapulae enough to improve shoulder range of motion.Use of such braces
for short periods may have a role in reducing discomfort in patients with intractable
shoulder pain due to laxity of the shoulder joint.
● Pain
Pain is a frequent complaint among many patients with FSHD. The pain is
musculoskeletal in character and commonly involves joints where the surrounding
muscles are weak. This would include the shoulders and upper back, the knees, and the
lumbosacral region because of the hyperlordosis typical of these patients. The use of
nonsteroidal anti-inflammatory drugs and, if the pain is chronic, antidepressants is
warranted in these patients.
● Exercise
Small, short-term studies of exercise in FSHD demonstrate benefit. Several studies have
shown at least a short-term beneficial effect of both strength training and aerobic
exercise in FSHD.
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Depending on individual disease severity, certain types of exercises will put patients at
risk of falls, in the presence of ankle or knee weakness, or overuse and stretch injuries,
in the presence of shoulder and periscapular weakness. The intensity of allowable
exercise is tailored to the individual patient’s overall strength with the general goal of
emphasizing aerobic conditioning and toning over muscle-building exercises.
Surgical Interventions
● Scapular Fixation
One of the major early functional limitations in FSHD is the inability to raise the arms to
or above shoulder level. Surgical scapular fixation was shown to significantly enhance
arm mobility. Potential complications include a break in the wire, with consequent loss
of the functional gain and, rarely, brachial plexus injuries. Surgery should be considered
only in patients with stable or slowly progressive disease and in those with reasonably
preserved upper-arm strength.
● Other Surgical Interventions

Severe weakness of the orbicularis oculi muscle results in an inability to fully close the
eye, which can lead to exposure keratitis. One potential solution is the use of gold
weights implanted into the upper eyelids to correct lagophthalmos.
Tendon transfer to fix a foot drop has been performed on patients with FSHD. The
patient’s gait improved, and the benefit was sustained for many years. FSHD patients
with the typical combination of weakness of the anterior leg compartment and foot drop,
but with preserved calf muscles and a slowly progressive disease, could benefit from
such an intervention.
Severe orbicularis oris muscle weakness can result in a markedly everted lower lip,
which can, apart from its cosmetic aspects, impair speech and cause drooling of saliva.
One such patient underwent corrective plastic surgery, which resulted in improved
appearance and improved speech, as well as control of drooling.
Pharmacologic Interventions
A number of pharmacological strategies have been tested in FSHD, aimed at slowing or halting
progression.
● Corticosteroids
Inflammation is a common finding in FSHD muscle, at times mimicking inflammatory
myopathies. Corticosteroids have been tried in a number of cases, but with inconsistent
results.
● Creatine monohydrate
There is evidence that phosphocreatine stores are depleted in some dystrophic muscle
and that creatine may have cellular protective characteristics. A randomized
double-blind, crossover trial, in a mixed population of dystrophies (12 of which were
FSHD) demonstrated slight improvement in overall strength following short-term
(8-week) supplementation with creatine monohydrate.
● Myostatin Inhibition
There is currently intense interest in therapeutic interventions that block the effects of
myostatin, a negative regulator of muscle growth.
C. Models, FORs, & Approaches Used
Model of Human Occupation

This model is occupation-focused, client-centered, and evidence-based. It is concerned
with the client’s motivation for engaging in occupations, the pattern and organization of
occupations, the ability to perform occupations, and the influence of the environment on
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occupations. It being occupation-focused helps in understanding the extent at which
individuals with muscular dystrophy can fully participate, how it is organized on a daily
basis, and whether the environment is supportive or interfering with engagement.
Evaluation: By understanding the client’s roles, habits and routines, we are able to use this
information to create an understanding of the patient’s situation. Initial interview shows that
the client is a dentist of 20 years. During evaluation, the client was asked to simulate ADLs
such as feeding, bathing and dressing, in order to determine performance skills that the
client has difficulty with while performing said occupations. The client was also asked to
simulate work tasks including the use of tools during dentist check-ups and surgeries.
Intervention: Using this model guarantees a top-down and functional approach in

generating therapy goals, and helps maintain an occupation-focused approach. An
intervention plan was made, following the goal prioritization of ADLs, specifically bathing,
dressing and personal hygiene and grooming, and job performance. The model can be
used in adjunct with other FORs and models, in order to provide the most appropriate and
measurable goal for the client’s occupation, whether remediative, compensatory or
environmental.
Biomechanical Frame of Reference

The biomechanical frame of reference works to address structural stability, range of motion,
muscle strength, endurance, and edema. This FOR is primarily concerned with an
individual's motion during occupations and to address the quality of movement. It posits
that occupational performance can be regained by addressing the underlying impairments
that limit the performance of daily activities. Considering the course of the condition, this
FOR may be helpful to clients with muscle dystrophy to prevent further deterioration and
maintain existing movement needed for occupational engagement.
Evaluation: The client was evaluated through functional observations of her concerned
occupations, specifically during feeding, bathing, dressing, and work duties as a dentist.
Standardized tests were also administered such as the range of motion and manual muscle
strength testing.
Intervention: Taking into consideration the progression of the condition, the client was given
different exercises to help target her range of motion, muscle strength, and endurance.
Specifically, ROM exercises were facilitated on her upper extremities to increase/maintain
the mobility of the affected areas; resistive exercises to maintain muscle strength;
endurance training to target her diminished muscle endurance; and joint protection
techniques to aid in pain reduction and preserve joint integrity. Education and training on
proper body mechanics and workplace ergonomics were also done to prevent other injuries
from developing.
Rehabilitative Frame of Reference

The rehabilitative frame of reference focuses on enabling clients to return to their fullest
possible functioning and to competently participate in their meaningful occupations and
roles when their impairments are considered to be permanent or is less likely to be
remediated, or when they lack the motivation to participate in remediation. Through this
frame of reference, clients are encouraged to focus on their remaining abilities and achieve
their highest possible level of functioning. This frame of reference is especially helpful to
clients with muscular dystrophy as the nature of the condition is progressive thus requiring
the use of compensatory strategies in order for clients to successfully engage in their
desired occupations.
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Evaluation: For evaluation, skilled observation was used to determine the client’s
performance in selected activities, specifically feeding, bathing, and dressing. In addition to
this, an interview was done to gather information about the client’s daily living priorities.
Intervention: Intervention under this frame of reference includes the use of compensatory
strategies. In the client’s case, since her condition is progressive, intervention included the
use of compensatory strategies, ECTs, adaptive and assistive technology, and
environmental modifications.
Occupational Adaptation
This frame of reference believes that success in occupational performance is a direct result
of an individual’s ability to adapt with sufficient mastery to satisfy the self and others. It
combines the use of a person’s adaptive response to overcome an occupational challenge
with a self-perceived meaningful activity. The FOR comprises three fundamental
components: the individual, the occupational environment, and the interaction between the
two. Each of the elements is influenced by a constant which includes the desire for mastery
in occupational situations (the individual), the demand for mastery from the individual in
these occupational situations (environment), and the interaction of these two constants
results in the constant for the interaction element, a press for mastery. For clients with
muscular dystrophy, this frame of reference can be used in response to the decline in
health status and occupational performance of the client due to the condition.
Evaluation: Under this framework, evaluation was done through interviews to acquire
information about the client, her occupational environment, and her occupational
challenges. Information about these elements guided the intervention to help increase the
client’s adaptive response.
Intervention: Intervention is focused on helping the client adapt to a new lifestyle in order to
help support her engagement in her chosen occupations and overcome the difficulties
brought about by her condition. The client is guided to select an occupational role that she
wants to prioritize. Adaptive methods such as the use of assistive devices and other
specific techniques were given and taught to promote the client’s engagement. Progression
to occupational activities were subsequently done to facilitate the client’s adaptive
response.
Ecology of Human Performance

This frame of reference focuses on how a person interacted with the environment and how
that affects human performance. Furthermore, it looks at the role that the environment
plays with the performance of task demands. The model focuses on the relationship
between several constructs which include the person, context, task, performance, and
therapeutic intervention. Congruence between the aforementioned constructs would thus
lead to successful human performance and a larger performance range.
Evaluation: An interview was done to gather information about the client’s wants and
needs. Furthermore, it was also done to learn more about the client’s context and
environment. Task analysis and observation were also done during feeding, bathing, and
dressing to ascertain the task demands of the selected activities and to assess the person’s
client factors.
Intervention: Therapeutic interventions under this model include ‘establish/restore’, ‘alter’,

‘adapt’, ‘prevent’, and ‘create’, each of which may intervene the person, context, and/ or the
task. For the client’s case, the approach ‘adapt’ was used to modify the task and the client’s
environment to facilitate increased performance in her desired occupations. Additionally,
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‘prevent’ was also used to prevent the occurrence of barriers to her occupational
performance as well as to prevent the fast decline of her function.
D. Evaluation and Treatment Guidelines
Range of Motion Testing

Range of motion testing involves measuring the degree of movement of a joint. This is done
to determine the cause and severity of the client’s limitations in joint motion which impedes
occupational performance. In the client’s case, range of motion testing was done in which it
was observed that the client had limitations of motion in her shoulder due to pain and
muscle weakness.
Manual Muscle Testing

Manual muscle testing is a method of evaluating the extent and degree of muscle
weakness that results from disease, injury, or misuse. It provides the therapists with
information on the baseline functioning of the client which would thereby guide the planning
of the appropriate interventions for such. Muscle weakness is one of the primary symptoms
of muscular dystrophy. As such, manual muscle testing was done on the client and it was
found that the client has muscle weakness in her shoulder muscles as evidenced by the
client’s difficulty in performing activities requiring shoulder flexion, and abduction especially
those above 90 degrees.
Fatigue Numerical Rating Scale

The NRS evaluates patient’s fatigue level at a 0-to-10 scale. The chosen number signifies
the severity of subject’s fatigue, with 0 indicating no fatigue and 10 indicating the worst
possible fatigue. For the case of the client, fatigue is one of the major symptoms that affects
her occupational performance. The NRS is used for the client to rate how tiring or how
much fatigue (on a scale of 1-10) the client finds some of her occupations.
Fatigue Severity Scale

This is a method of evaluating the impact of fatigue on the individual; it is a short
questionnaire that requires the client to rate their level of fatigue. It contains nine
statements that rate the severity of fatigue symptoms. A total score of less than 36
suggests that you may not be suffering from fatigue. A total score of more than 36 indicates
that the individual is suffering from fatigue and may need further evaluation by a physician.
The client has a score of 58, indicating that she experiences fatigue.
PQRST Pain Evaluation tool

The PQRST method of assessing pain is a valuable tool to accurately describe, assess and
document a patient’s pain.
● Provocation/ Palliation
○ What were you doing when the pain started? What caused it? What makes it
better or worse? What seems to trigger it?
○ P - Upon rest and shoulder movement
● Quality/ Quantity
○ What does it feel like?
○ sharp, dull, stabbing, burning, crushing, throbbing, nauseating, shooting, twisting
or stretching.
○ Q - Throbbing
● Region/ Radiation
○ Where is the pain located? Does the pain radiate? Where? Does it feel like it
travels/moves around? Did it start elsewhere and is now localized to one spot?
○ R - Deltoids area
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● Severity Scale
○ How severe is the pain on a scale of 0 to 10, with zero being no pain and 10
being the worst pain ever? Does it interfere with activities? How bad is it at its
worst? Does it force you to sit down, lie down, slow down? How long does an
episode last?
○ S - 5/10 at rest, 7-8/10 upon movement
● Timing
○ When/at what time did the pain start? How long did it last? How often does it
occur: hourly? daily? weekly? monthly? Is it sudden or gradual? What were you
doing when you first experienced it? When do you usually experience it
○ T - Persistent
Short Form (SF)-36

The SF-36 is a generic patient-reported outcome measure that quantifies health status and
measures health-related quality of life. It has 8 subscales namely: physical functioning, role
limitation d/t physical problems, general health perceptions, vitality, social functioning, role
limitation d/t emotional problems, general mental health, and health transition. This is used
to assess the client’s quality of life and her ADLs.
The client garnered the following scores:
Physical functioning: 75 %
Role limitations due to physical health: 25 %
Role limitations due to emotional problems: 66.7 %
Energy/fatigue: 65 %
Emotional well-being: 76 %
Social functioning: 87.5 %
Pain: 32.5 %
General health: 35 %
Health change: 25 %
Pertinent findings:
● Fair general health; Somewhat worse health than one year ago;
● Bathing or dressing limited a lot;
● Has accomplished less than would like due to physical health;
● Was limited in work due to physical health; Difficulty performing work due to
physical health; Difference in carefulness of work due to emotional problems;
Quite a bit of interference of pain with work;
● "I am as healthy as anybody I know" -- mostly false; "I expect my health to get
worse" -- mostly true; "My health is excellent" -- mostly false
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VIII. EVALUATION
A. Occupational Profile and Performance
VELEZ COLLEGE
F. Ramos St. Cebu City
College of Occupational Therapy and Physical Therapy
Department of Occupational Therapy
OCCUPATIONAL THERAPY ADULT INITIAL EVALUATION
DEMOGRAPHIC DATA
Name: J.J. Diagnosis: Scapulohumeral Muscular Dystrophy
Age/Sex: 53 years old, Female Referring Physician: Dr. Jeremy O. Flordelis
Date of Birth: April 25, 1969 Date of Initial Evaluation: December 2, 2022
Occupation: Dentist OT Clinical Supervisor:
Address: Zone 1 #14 Deiparine Street, San Isidro, OT Intern:

Talisay City Cebu Bacaro, Sydney Marie T.
Fabillar, Rinia Ela Justinne B.
Mabelin, Melanie Andrea F.
Pizarras, Jaznielle C.
Vidal, Robin Ayn
Informant: Client Contact Number: 09545543678
OCCUPATIONAL PROFILE
Chief Complaint:
According to the client: “Maglisod ko Ma’am inig shampoo sa akoang buhok kay sakit man gd inig raise sa akoang
shoulders. Asta pud inig lather and rinse sa soap sa akoang lawas. Mao na madugay jud ko ug human ug ligo ma’am
kalasan ko sa oras.”
The client also mentioned her difficulties during grooming. “Before ko mag trabaho kay need man jud na nako hiposon
akoang buhok. Inig sudlay nako kay dili nako makaareach sa top sako buhok kay tungods kasakit. Mao na murag mag
lukot lukot sha nya dugay kayko mahuman para ma hapsay siya. Usahay magpa tabang sad ko sa ako helper sa pag
panudlay.”
When asked about other ADLs, the client mentioned problems in UE dressing. “Maglisod kog isa sa akong bukton kay mu
sakit jud, so naa juy times nga magpatabang ko sa akong helper kay para makailis ko dayun for work. Makaya raman
nako nga ako ra isa most especially if kanang pangbalay ra akong isuot kay medjo lu-ag man ang sanina. Inig kuha pud
sa mga sinina maam kay need baya nako iraise akong kamot inig kuha nako sa cabinet mao na usahay tawgon pa nako
ako helper para kuhaon niya para nako”
Lastly, the client expressed her worries about the condition affecting her work as a dentist. “Sauna kay makatrabaho man
kog straight 2 hours pero karon kay tig 10 minutes nalang jud ko maam nya dali kayko makafeel ug kapoy labi na sa
akoang shoulders dapit. Usahay maam kay pagguniton nako akoang assistant sa akoang arm if makafeel nako ug laylay.
Maka feel sad ko ug sakit kung akoa pugson jud ug trabaho more than 10 minutes. Mag lisod sad kog kab-ot sa akoang
equipment kay naa man koy mga gamit sa cabinets mao na manginahanglan kog tabang sa akoang dental assistants.”
Goals:
According to the client“Ganahan ko na mapangitaan ug paagi maam na maka shampoo ug panabon ko na dili makabati
pud ug sakit ug kapoy aron dali ko mahuman and para di ko malate sa clinic.”
“Gusto ko na makasudlay kos akoang buhok na ako2 ra nya di nako mangailangan ug tabang sa lain tao.”
“Ganahan ko na makasuot kos akoang sinina na dili na mangitag tabang sa akoang helper. Kana lang guro makab-ot nako
ang sleeves asta mga sinina sa cabinet na dili ko makabati ug sakit sa akoang shoulders.”
“Gusto nako na maka trabaho ko for more than 10 minutes and kana dili nako permi makabati gihapon ug kasakit or
kakapoy kay ma affected man gd ako performance if naa ni sila. Basin makasala na nuon kos akoa pasyente if pugson
nako ako kaugalingon. Also ma’am, kana sad jud ako pag reach sa akoang mga gamit na naa sa ibabaw na shelves kay if
ako-ako ra di jud nako makaya na makuha siya.”
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History of Present Illness:
2015 - In late October of 2015, the client noticed that her shoulder blades were more protruded than usual but chose to
blame it on weight loss and did not think anything of it afterwards.
2017 - In early February of 2017, the client found that she was having difficulty maintaining overhead motions when she
had to help her maid fix the kitchen light. She also felt that the protrusion of her shoulder blades were unnatural and
decided to have it checked with an orthopedic doctor. Upon electromyography (EMG), nerve conduction was normal,
however motor unit analysis and MacroEMG showed myopathic changes that correlate with clinical parameters of patients
with FSHD. Upon further assessment via DNA test, the client showed abnormally shortened repeats in the D4Z4 region.
The client was diagnosed with FSHD. During this time, the client opted not to go to therapy due to her full schedule at
work and the client was able to research about the disease, which can take more than 30 years to become disabling.
2018 - The client frequently gets headaches after work and takes over-the-counter medications such as paracetamol with
a dosage of 500mg. This lasted a week, including feeling dizzy after an hour of attending to her patients. She made the
decision to check her blood pressure and it read 140/89. She was diagnosed with Stage 1 Hypertension by Dr. and was
prescribed Losartan 50 mg once a day.
2020 - The client has noticed that she is no longer able to reach the highest shelf in her wardrobe, which contains spare
blankets and pillows. The client also needs assistance in taking the supplies to the top shelf in her clinic. The client
contemplated consulting with her orthopedic doctor, but had difficulty due to the multiple lockdowns and the start of the
pandemic.
2022 - The client started having difficulty in performing ADLs and her performance in work was being increasingly
affected. The client consulted with her orthopedic doctor, after which she was referred to OT for endurance training,
strengthening of UE, and ADL training (dressing, personal hygiene and grooming, bathing).
Referral Information:
The client was referred by an orthopedic doctor on November 30, 2022 for endurance training, strengthening of UE,
and ADL training (dressing, personal hygiene and grooming, bathing).
Other Pertinent Medical History: Safety Awareness & Precautions:
● Client must be reminded not to attempt valsalva
Client was diagnosed with hypertension in 2018 which maneuver during exercises to avoid the risks associated
she has been taking medications for since its onset. with it.
The client also has a family medical history of ● Make sure to monitor the client’s blood pressure before
hypertension, specifically on the maternal side. and after the session since she presents hypertension.
● Client presents a hypermobile scapula; hence, this must
be taken into consideration during exercises as it may
increase the risk for injuries, such as dislocation and
sprains.
Current Medications: Rehab Potential:
● Losartan - 50 mg/ once a day Client has a guarded rehab potential. Despite showing good
● Prednisone - 50 mg/ once a day response and compliance to therapy, the progressive nature of
● Acetaminophen - PRN the condition must still be taken into consideration. In the
● Vitamin C - 500mg/ once a day client’s case, winging of the scapula and muscle atrophy in the
● Vitamin B Complex - 600 mcg/ once a day bilateral shoulder muscles are present, and this has had a
significant impact on her ability to perform her occupations.
Although there is no specific cure for the condition, the client’s
current skills may be preserved with the help of regular therapy.
Performance Patterns: Context & Environment:
Roles Personal
Client is a dentist and owns her own clinic. She is also The client is a 53-year-old female who is single and lives alone in
an employer and employs her own secretary and her 2 storey-house in San Isidro, Talisay. She owns her own
dentist assistant. The client is also a friend to her dental clinic where she practices. The client enjoys watching TV
friends and meets with them occasionally. shows, reading books, and joining social gatherings with her
group of friends during weekends. Additionally, she also enjoys
Routines going on annual trips outside the country with her family and
5:30 am - Client wakes up at 5:30 every Monday to friends. The client does not smoke, does not take illegal drugs,
Friday to get ready for her work. Client usually take and drinks occasionally.
only 1 hour to get ready which includes showering
and dressing. Virtual
The client owns a phone, ipad, and laptop which she uses for
6:30-7:00 - Client eats her breakfast which is work tasks and for communicating with her friends and family.
prepared by her helper/maid. She only seldom eats The client also has a TV which she uses to watch shows and to
rice for breakfast and would usually eat overnight get updates on the current news.
oats, with fruits, yogurt, and quinoa. She usually
takes 30 minutes, and she also spends this time Physical
reading her emails and reviewing her client schedule The client lives in a 2-storey house in San Isidro, Talisay. The
for the day. first floor of the house contains her kitchen, pantry, dining room,
living room, and the maid’s quarters. While the second floor has
her bedroom, guest room, and lounge area. In her bedroom, she
13
7:00-8:30 - Client’s clinic is located just 1 kilometer has a walk-in closet which has floor to ceiling cabinets that
away from her house and would usually be a 5-minute contain her clothes, shoes, and bags. She also has a vanity table
drive. She usually gets driven by her driver as well. which has her accessories and make up, and has a clothing rack
When she gets there, she will open her clinic along which contains other clothes. The client usually wears blouses,
with her secretary and assistant. They would prepare slacks, sandals and accessories. During work, she wears a
the clinic for their upcoming clients for the day, this disposable gown over her clothes. Aside from this, she also has a
includes preparing the tools to be used, arranging bathroom that has a shower, bath tub, toilet bowl, and sink. The
things and the schedules. During this time, the client client’s bath products are located in an overhead organizer shelf.
would also read journals and review methods to When bathing, she usually uses her shower that is attached to
prepare for the day and also keep her knowledge the wall.
sharp and updated
In her dental clinic, there is a waiting area, reception desk, and
8:30 am - 12:00 pm - According to the client she the treatment area. The treatment area has 3 dental chairs
usually accepts and schedules 3 - 4 patients in the where she as well as 2 other dentists work. Her area is situated
morning, with each session running for between 40 near the entrance and near the cabinets which contain the
minutes to 2 hours. dental supplies. The cabinets are situated above eye level which
she often finds hard to reach.
12:00 noon - 12:30/1:00 pm - According to the
client, because of how busy her clinic is, there are Social
times wherein her lunch break only runs for 30 The client is single and lives with her 2 helpers. Her mother
minutes before her next patient arrives. passed 7 years prior due to myocardial infarction and her father
lives with her older brother. Moreover, she reports having a good
12:30 pm / 1:00 pm - 5:00 pm - According to the relationship with her family. Additionally, she has a group of
client, she would accept patients until 5:00 pm and friends who she regularly communicates with and who she
would usually have 4 patients scheduled in the regularly meets during weekends.
afternoon.
At work, the client also has an assistant as well as a secretary
5:00-6:00 pm - Client would stay in her clinic for an that helps her do her work and tasks in the clinic. Client also has
hour after her last patient as she organizes her a driver that does the driving for her as the client is unable to do
patient’s charts and documents while her secretary so due to her condition.
helps/ assists her and her assistant keeps/cleans the
tools they used.
6:00 pm - 6:40 pm - Client would go home and eat

dinner, which is usually vegetable salads and
sandwiches. Client would take this time to rest her
mind and body and would sit in her living room and
take a break while doing nothing.
6:40 pm -7:40 pm – Client would take another

bath/shower after her long day at work. Client would
take an hour and sometimes more because of her
muscle weakness in her arms, fatigue, along with pain
due to her long day of working.
7:40 pm – 8:00 pm – Client uses this time to do her

skin care routine prior to sleeping. She also takes
vitamins every night.
Saturdays: Usually the client would attend onsite or

online seminars related to her profession as a dentist.
These seminars usually run for approximately 3-4
hours.
Habits:
The client has a habit of holding and rotating her
shoulders when she feels pain or fatigue.
Rituals:
The client always travels out of the country every
Christmas and New Year season as a form of vacation
for herself and her friends/colleagues. Additionally,
the client joins social gatherings with her group of
friends twice a month.
BP: HR: Temperature: Pain:
130/80 mmHg 84 bpm 36.8 C P - Upon rest and shoulder
movement
Q - Throbbing
R - Deltoids area
S - 5/10 at rest,
7-8/10 upon movement
T - Persistent
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ANALYSIS OF OCCUPATIONAL PERFORMANCE
Occupation Level of Performance Skills Client Factors Affected
Independence
Bathing Minimal Client is able to rinse off soap Client has:
dependence suds and shampoo since she ● LOM of all shoulder movements
uses a shower. However, she ● Grade 2+ muscle strength on
has difficulties in reaching for bilateral shoulder muscle groups
bathing products, specifically ● Presence of pain
her shampoo, conditioner, and ● Presence of scapular winging
soap that are located in an ● Poor muscle endurance
overhead shelf below her
shower. She also has
problems with reaching distal
parts of her body, specifically
her arms, legs, and head
when applying shampoo and
soap; and would get easily
fatigued.
Personal Hygiene and Minimal Client is able to gather Client has:
Grooming dependence materials for grooming from ● LOM of all shoulder movements
her vanity table but has ● Grade 2+ muscle strength on
difficulty in reaching the top of bilateral shoulder muscle groups
her head during combing. ● Presence of pain
Moreover, the client has ● Presence of scapular winging
problems in continuing as she ● Poor muscle endurance
would get easily fatigued
during combing. She reported
that she would have her
housekeeper help her comb
her hair foe during most days.
Dressing Minimal Client exhibits the ability to Client has:
dependence manipulate and grip the ● LOM of all shoulder movements
garments during donning and ● Grade 2+ muscle strength on
doffing. She is able to wear bilateral shoulder muscle groups
loose clothes independently, ● Presence of pain
but has difficulty lifting both ● Presence of scapular winging
her arms when wearing and ● Poor muscle endurance
undressing tight clothes, such
as those for work, due to pain
and muscle fatigue. Client has
difficulty with enduring
dressing tasks, specifically
when doing overhead actions
and inserting her arms
through the holes, thus
requiring help from her
housekeeper to continue
dressing. Client also has
difficulty with reaching for
clothes from the cabinet since
it demands her to raise her
arms up high; she had to call
her housekeeper to retrieve
the clothes for her.
Job Participation Minimal Client can manipulate her Client has:
dependence dental tools when attending to ● LOM of all shoulder movements
her patients independently. ● Grade 2+ muscle strength on
However, she has problems bilateral shoulder muscle groups
reaching for tools and ● Presence of pain
equipment that are situated at ● Presence of scapular winging
hip and eye level. She also ● Poor muscle endurance
has problems with enduring
more than 10 minutes of work
as observed when her dental
assistant would support her
forearms during dental
operations.
Laterality ROM MMT
AROM PROM Cause of Muscle group Laterality Grading
LOM SH flexors Left Grade 2+
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Left SH 0-40 0-120 d/t pain and
flexor muscle
weakness
Right SH 0-45 0-100 d/t pain and Right Grade 2+
flexor muscle
weakness
Left SH 0-70 0-100 d/t pain and SH abductors Left Grade 2+
abductor muscle
weakness
Right SH 0-60 0-90 d/t pain and Right Grade 2+
abductor muscle
weakness
Left 0-40 0-70 d/t pain, Internal Left Grade 2+
Internal muscle Rotators
Rotators weakness,
and scapular
instability
Right 0-35 0-80 d/t pain, Right Grade 2+
Internal muscle
Rotators weakness,
and scapular
instability
Left 0-35 0-70 d/t pain, External Left Grade 2+
External muscle Rotators
Rotators weakness,
and scapular
instability
Right 0-30 0-60 d/t pain, Right Grade 2+
External muscle
Rotators weakness,
and scapular
instability
Muscle Tone: No pertinent findings. Sensory Analysis
Sensory (+/-) Justification
Activity Tolerance: Modality
Currently, the client asks her housekeeper to comb her Tactile + Client was able to correctly
hair for her because she could not raise her arms above identify touch and location
45 degrees without feeling pain as well as due to muscle in 10/10 trials in both UE
weakness. According to the client, she is only able to
Proprioceptive + Client was able to identify
tolerate a maximum of 5 minutes, when doing activities
direction of movement of
that require repeated movement of her arms and raising
her limbs that were moved
them (through available range). During the therapy
by the therapist in 10/10
session, the client is noted to feel muscle fatigue in her
trials in both UE
arms after 5 repetitions. SOB is often noted because the
client would use trunk muscles to compensate for the Vestibular + Client was able to sustain
weakness in her arms and scapular muscles and the an upright position during
client would often hold her breath. sitting and standing, and
was able to readjust her
According to the client, when she performs her dentistry body during position
work, she feels fatigued 10 minutes into the session but changes.
she chooses not to rest or take rest breaks because she Visual + Client does not have
feels like it is her responsibility to ensure that she finishes prescription glasses and is
the activity and gets it done properly. When she was able to clearly read and see
asked to perform simulations, fatigue in arms was noted the things around her.
after 10 minutes, activities only involved raising her Olfactory + The client did not report
shoulder in pain free range. any problems with smell
and was able to identify
Client was asked to rate her fatigue level from 1-10 and the smell of the
according to her, the following are her scoring: disinfectants recently used
● Dressing: 6/10 in the clinic.
● Bathing: 7/10 Pain + Client was able to identify
● Work participation: 8-9/10 sharp and dull in 10/10
trials in both UE
Grip & Pinch Strength: Client was able to hold the Thermal + Client was able to identify
dinnerware and maintain her grip on the utensils upon hot and cold sensation in
doing the feeding simulation. In terms of her pinch 10/10 trials in both UE
strength, she was able to manipulate the buttons on her Pressure + Client was able to identify
lab coat, but had difficulty with movements that involved deep pressure in 10/10
her shoulder, such as when inserting her arms into the trials in both UE
holes of the sleeves.
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Motor Reflexes: No pertinent findings. Auditory + Client was able to clearly
hear the therapist and
Involuntary Movement Reactions: Client had intact respond appropriately.
involuntary movement reactions as she was able to stand Communication Analysis
and walk upright. She was also able to sit without (+) Expressive language: Client was able to coherently
evidence of propping. express herself in response to the therapist’s questions.
(+) Receptive language: Client was able to hear and respond
Control of Voluntary Movement: appropriately to the questions asked by the therapist.
(+) Eye-hand Coordination: Client was able to reach for
the dental equipment in front of her and rearranged them
in containers without overshooting or undershooting
them.
(+) Crossing the Midline: Client was able to reach for the
comb placed on the right side with her left hand and vice
versa.
(+) Bilateral Integration: Client was able to use her right
hand to untangle the shirt and her left hand to hold it up
by its collar.
(+) In-hand Manipulation: Client was able to perform
simple rotation to properly use the comb with her R hand
and was also able to do finger-to-palm and
palm-to-finger manipulation in picking up and transferring
dental equipment.
(+) Dexterity: Client was able to use a pad-to-pad pinch
in picking up dental equipment and a three-jaw chuck in
unfolding her shirt.
Gait: No pertinent findings.

Cognitive Analysis Perception Analysis
Cognitive (+/-) Justification (-) Visual-perceptual disorders: No pertinent findings.
Skill (-) Visual-spatial disorders: No pertinent findings.
Orientation + Client was able to state her full (-) Right-left discrimination dysfunction: No pertinent
name and was also able to findings.
provide the dates and locations (-) Tactile perception disorders: No pertinent findings.
from when the onset of her (-) Motor perception disorders: No pertinent findings.
condition was and where she (-) Constructional disorder: No pertinent findings.
received help.
Memory + Client was able to recall the
necessary information regarding
the history of her condition.
Sequencing + Client was able to verbalize and
simulate the steps of cleaning
dental equipment independently.
Problem-solvi + Client was able to untangle and
ng turn her shirt inside and out prior
to donning.
Following instructions
Spoken + Client was able to do the
motions during AAROMs given
verbal instructions from the
therapist.
Demonstrated + Client was able to follow the
movements that the therapist
demonstrated during the
exercises.
Written + Not assessed.
Concentration + Client was able to sustain her
and attention concentration and attention on
required the activities performed in the
entire therapy session.
Other Pertinent Findings:
(-) Dysphagia (-) Facial asymmetry (-) Assistive device
(-) Aphasia (-) Nasogastric tube (-) Adaptive device
(-) Dysarthria (-) Nasogastric tube (+) Others: Atrophy on B deltoids, ; B Scapular
Instability
PLAN OF CARE
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OT Diagnosis
Client has difficulty in ADLs specifically in bathing, grooming, and dressing due to problems with joint mobility, muscle
power, pain, body structures, and muscle endurance, as evidenced by problems in reaching for items placed overhead,
reaching distal parts of her body during bathing, reaching her head when combing, raising her arms to retrieve items
from the cabinet and lifting them to insert her arms through the holes of her clothes during donning/doffing.
Client also has difficulty in work specifically in job performance and maintenance due to problems with joint mobility,
muscle power, pain, body structures, and muscle endurance, as evidenced by difficulty reaching for tools and equipment
that are situated at hip and eye level, and difficulty enduring more than 10 minutes of work as observed when her dental
assistant would support her forearms during dental operations.
All of which are caused by Scapulohumeral Muscular Dystrophy.

OT Clinical Supervisor’s Name & Signature
OT Intern’s Name & Signature
Bacaro, Sydney Marie T.

Pizarras, Jaznielle
Vidal, Robin Ayn
B. Classical Versus Clinical Picture
Classical Clinical
Etiology
● Genetics ● The client has no known family
Facioscapulohumeral Muscular Dystrophy history of Facioscapulohumeral
(FSHD) is a dominantly inherited Muscular Dystrophy or any
dystrophinopathies; thus, the
dystrophy. Having a parent with FSHD
exact cause of her condition is
gives a 50% chance of inheriting the unknown.
genetic defect.
Clinical Features
● Facial muscle weakness ● No other extremities were affected
● Weakness in muscles around the eyes other than the client’s bilateral
● Weak shoulder muscles shoulder muscle groups.
Muscle weakness was presented,
○ scapular winging.
as well as scapular winging as
● Weakness in muscles of the lower legs evidenced by the protrusion of the
○ foot drop, medial and lateral borders of the
● Weakness in muscles of the hips and scapula from the back.
pelvis
● Lumbar lordosis
● Additional signs and symptoms
○ mild high-tone hearing loss
○ abnormalities involving the
light-sensitive tissue at the back of
the eye (the retina).
C. Strengths and Limitations
Strengths Limitations
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Context and Environment Performance Patterns:
● Client’s clinic is just a 5- minute drive ● Routine
away from her house
● Social: Client has 2 housekeeper/helper Context and Environment
that helps her around the house and a ● Client’s physical environment
driver that drives her car for her requires a lot of overhead
reaching activities (e.g.
Movement Functions: overhead organizer shelf,
● Involuntary Movement Reactions: clothing rack)
(+) Supporting reactions
● Control of Voluntary Movements: Analysis of Occupational
(+) Eye-hand coordination Performance
(+) Crossing the midline ● Minimal Dependence in Bathing
(+) Bilateral integration ● Minimal Dependence in
(+) Voluntary RGCR pattern Personal Hygiene and Grooming
Grip and Pinch Strength: ● Minimal Dependence in
● good Dressing
Sensory Analysis: ● Minimal Dependence in Job
(+) Tactile Participation
(+) Proprioceptive Range of Motion
(+) Visual ● Shoulder flexors: LOM due to
(+) Pain pain and muscle weakness
(+) Thermal ● Shoulder Abductor: LOM due to
(+) Pressure pain and muscle weakness
(+) Auditory ● Shoulder Internal and External
(+) Olfactory Rotations: LOM due to pain,
muscle weakness, and scapular
Communication Analysis: instability
(+) Receptive Language Muscle Power
(+) Expressive Language ● Shoulder Flexors: MMT Grade
2+
Cognitive Analysis: ● Shoulder Abductors: MMT
(+) Orientation Grade 2+
(+) Memory ● Shoulder Internal and External
(+) Sequencing Rotations: MMT Grade 2+
(+) Problem-solving Muscle Endurance (according to
(+) Following instructions NRS)
● Dressing: 6/10
Perception Analysis: ● Bathing: 7/10
(-) Visual-perceptual disorders ● Work participation: 8-9/10
(-) Visual-spatial disorders Other Pertinent Findings:
(-) Right-left discrimination dysfunction ● Atrophy on Both Deltoids
(-) Tactile perception disorders ● Scapular Instability
(-) Motor perception disorders
(-) Constructional disorders
IX. INTERVENTION PLANNING
A. Problem List Prioritization

1. The client requires minimal assistance in bathing due to limited ROM, muscle
weakness, presence of pain, presence of scapular winging on her bilateral UE, and poor
muscle endurance.
2. The client requires minimal assistance in personal hygiene and grooming due to limited
ROM, muscle weakness, presence of pain, presence of scapular winging on her bilateral
UE, and poor muscle endurance.
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3. The client requires minimal assistance in dressing due to limited ROM, muscle
muscle endurance.
4. The client requires minimal assistance in job participation due to limited ROM, muscle
muscle endurance.
B. Targeted Outcomes
Occupational Performance
● To improve occupational performance through maintaining joint mobility and muscle
strength on the bilateral UE, increasing muscle endurance, and reducing pain,
which are all necessary for performing ADLS, specifically feeding, bathing, and
dressing; and job participation.
Prevention
● To delay the progression of the symptoms brought about by the client’s condition
which hinder her in completing her ADLs and job tasks.
Quality of Life
● To promote the client’s quality of life by addressing the symptoms caused by her
condition and increasing her participation in her chosen occupations.
Participation
● To help the client successfully participate in her meaningful occupations despite the
progressive nature of the condition; to provide opportunities to maintain her
engagement in her occupations.
Role Competence
● To help the client fulfill her role of being a dentist which can be achieved through
effective participation in her job tasks.
Well-Being
● yTo promote the client’s well-being through enabling participation in her meaningful
occupations and providing opportunities for role fulfillment
C. Goals/Objectives and Management

LTG1. Client will be able to perform ADLs, specifically bathing, grooming and dressing, with
modified independence given compensatory strategies and environmental modifications within
10 OT sessions.
Short term goal Intervention Type of Intervention

STG1. Client will be able to 1. UTZ (10 mins, B UE) 1. Interventions to Support
retrieve bathing products middle and anterior Occupations
given environmental deltoids
modifications within 1 OT 2. Electrical Stimulation - 10 2. Interventions to Support
session. minutes, anterior and Occupations
posterior deltoid
3. AAROMEs on both 3. Interventions to Support
shoulder - all planes, 10 Occupations
repetitions
a. shoulder flexion
b. shoulder
horizontal
abduction and
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adduction
c. shoulder
abduction
4. AROM on both UE 4. Interventions to Support
(except shoulder) Occupations
a. Elbow flexion and
extension
b. Forearm
pronation and
supination
c. wrist flexion and
extension
d. finger flexion and
extension
5. Active Prolonged 5. Interventions to Support
Stretching - 15-30 Occupations
seconds
a. Pectoralis
b. Biceps
c. Triceps
d. Anterior and
Posterior deltoids
e. Upper Trapezius
6. Incorporating PNF 6. Interventions to Support
patterns during cone Occupations
stacking, 10 repetitions
a. gravity - assisted,
performed while
standing
7. Strengthening Activities 7. Interventions to Support
using Theraband - 10 Occupations
repetitions or as tolerated
a. chest pull
b. shoulder flexion
c. shoulder
diagonals
d. elbow flexion and
extension
8. Ergobike, 10 minutes 8. Interventions to Support
Occupations
9. Placing items at waist 9. Environmental
level to decrease the modifications
demands of raising her
arms to reach for items.
10. Placing items nearer or 10. Environmental
within arm’s reach of the modifications
client.
11. Retrieving bathing 11. Occupation and Activity
products (e.g. shampoo,
soap, conditioner)
12. Simulated bathing; 12. Occupation and Activity
including the gathering
and transferring of bath
items.
STG2. Client will be able to 1. UTZ (10 mins, B UE) 1. Interventions to Support
lather and rinse hair and middle and anterior Occupations
body with minimal signs of deltoids
pain and fatigue given 2. Electrical Stimulation - 10 2. Interventions to Support
adaptive devices, work minutes, anterior and Occupations
simplification and energy posterior deltoid
conservation techniques 3. AAROMEs on both 3. Interventions to Support
within 2 OT sessions. shoulder - all planes, 10 Occupations
21
repetitions
d. shoulder flexion
e. shoulder
horizontal
abduction and
adduction
f. shoulder
abduction
extension
b. Forearm
pronation and
supination
extension
extension
seconds
a. Pectoralis
b. Biceps
c. Triceps
d. Anterior and
Posterior deltoids
e. Upper Trapezius
performed while
standing
a. chest pull
b. shoulder flexion
c. shoulder
diagonals
extension
Occupations
9. Educating and training 9. Education and Training
the client on energy
conservation techniques
a. Taking rest breaks
in between
the client on work
simplification techniques
a. Sitting on the
bathtub when
bathing
b. Placing elbows on
the sides of the
tub for support
11. Provision of adaptive 11. Assistive Technology
devices:
a. Long handled
22
scalp massager
12. Simulated and actual 12. Occupation and Activity
bathing
STG 3: Client will be able to 1. UTZ (10 mins, B UE) 1. Interventions to Support
comb her hair showing middle and anterior Occupations
minimal to no signs of pain deltoids
and fatigue given adaptive 2. Electrical Stimulation - 10 2. Interventions to Support
devices and energy minutes, anterior and Occupations
conservation techniques posterior deltoid
within 2 OT sessions. 3. AAROMEs on both 3. Interventions to Support
repetitions
a. shoulder flexion
b. shoulder
horizontal
abduction and
adduction
c. shoulder
abduction
extension
b. Forearm
pronation and
supination
extension
extension
seconds
a. Pectoralis
b. Biceps
c. Triceps
d. Anterior and
Posterior deltoids
e. Upper Trapezius
performed while
standing
a. chest pull
b. shoulder flexion
c. shoulder
diagonals
extension
Occupations
9. Provision of a long 9. Assistive Technology
handled brush
10. Training the client to use 10. Training
a long handled brush
when combing her hair
23
● Taking rest breaks
in between
the client on work
● Placing her
elbows on a table
for support
13. Combing her hair 13. Occupation and Activity
14. Styling her hair 14. Occupation and Activity
STG 4: The client will be 1. UTZ (10 mins, B UE) 1. Interventions to Support
able to gather clothes from middle and anterior Occupations
her cabinet given assistive deltoids
devices and work 2. Electrical Stimulation - 10 2. Interventions to Support
simplification techniques minutes, anterior and Occupations
within 2 OT sessions. posterior deltoid
repetitions
a. shoulder flexion
b. shoulder
horizontal
abduction and
adduction
c. shoulder
abduction
extension
b. Forearm
pronation and
supination
extension
extension
seconds
a. Pectoralis
b. Biceps
c. Triceps
d. Anterior and
Posterior deltoids
e. Upper Trapezius
performed while
standing
a. chest pull
b. shoulder flexion
c. shoulder
diagonals
24
extension
Occupations
9. Use of reacher in 9. Assistive Devices
reaching items in the
hanger.
10. Work Simplification 10. Education and Training
Techniques
a. gathering of all
clothing in one
place first before
donning
b. Place frequently
used clothing in
hip level or
bottom shelf
11. Simulated gathering of 11. Occupation and Activity
clothes
STG 5: Client will be able to 1. UTZ (10 mins, B UE) 1. Interventions to Support
don and doff shirt showing middle and anterior Occupations
minimal to no signs of fatigue deltoids
given compensatory 2. Electrical Stimulation - 10 2. Interventions to Support
strategies given 3 OT minutes, anterior and Occupations
sessions. posterior deltoid
repetitions
a. shoulder flexion
b. shoulder
horizontal
abduction and
adduction
c. shoulder
abduction
extension
b. Forearm
pronation and
supination
extension
extension
seconds
a. Pectoralis
b. Biceps
c. Triceps
d. Anterior and
Posterior deltoids
e. Upper Trapezius
performed while
standing
25
a. chest pull
b. shoulder flexion
c. shoulder
diagonals
extension
Occupations
9. Use of dressing stick 9. Assistive Devices
when inserting T-shirt
above her head
10. Training the client to use 10. Education and Training
a dressing stick when
wearing a T-shirt
11. Training the client to lie 11. Education and Training
on her side when
donning or doffing her
shirt to promote
anti-gravity positions
12. Letting the client wear 12. Environmental
loose tops Modification
13. Recommending 13. Environmental
button-up shirts to Modification
minimize overhead
motions
14. Wearing a T-Shirt with 14. Occupation and Activity
the suggested
modifications
15. Doffing a T-shirt with 15. Occupation and Activity
suggested modifications
LTG2. Client will be able to perform work tasks with modified independence given
compensatory strategies and environmental modifications within 12 OT sessions.
Short term goal Intervention Type of Intervention
STG1. The client will be able 1. UTZ (10 mins, B UE) 1. Interventions to Support
to retrieve dental tools or middle and anterior Occupations
equipment given deltoids
environmental modifications 2. Electrical Stimulation - 10 2. Interventions to Support
within 2 OT sessions. minutes, anterior and Occupations
posterior deltoid
repetitions
d. shoulder flexion
e. shoulder
horizontal
abduction and
adduction
f. shoulder
abduction
extension
b. Forearm
pronation and
supination
extension
extension
26
seconds
a. Pectoralis
b. Biceps
c. Triceps
d. Anterior and
Posterior deltoids
e. Upper Trapezius
performed while
standing
a. chest pull
b. shoulder flexion
c. shoulder
diagonals
extension
Occupations
9. Education and training 9. Education and Training
on energy conservation
techniques during work
a. Having rest
breaks in
between
treatment
activities
b. Suggest having
lesser patients for
the day rather
than having one
per hour to allow
for greater rest
time in between
10. Education and training 10. Education and Training
on work simplification
techniques during work
a. Placing frequently
used items within
easy reach
11. Education on the
condition’s progression 11. Education and Training
and the importance of
adhering to the exercises
and modifications to slow
its progression
12. Arranging dental 12. Education and Training
tools/equipment at the
client’s waist or hip level
13. Lowering the patient’s 13. Environmental
bed and the table with Modifications
equipment to avoid
overhead reaching
14. Retrieving and 14. Environmental
transferring dental Modifications
27
equipment to proper
containers
15. Client will use dental 15. Occupation and Activity
tools or equipment as
needed during treatment
of a patient with the
suggested modifications
STG2. The client will be able 1. UTZ (10 mins, B UE) 1. Interventions to Support
to endure 1 session of dental middle and anterior Occupations
treatment given deltoids
environmental modifications, 2. Electrical Stimulation - 10 2. Interventions to Support
energy conservation minutes, anterior and Occupations
techniques, and work posterior deltoid
simplification techniques 3. Intervention for Pain 3. Interventions to Support
within 10 OT sessions. Management Occupations
a. hot moist pack
i. 10
minutes
over
affected
area
b. TENs
i. 10
minutes
over
affected
area
c. Cold Pack
i. 10 minutes
over affected
area; may be
used after
exercises to
address
muscle
soreness
repetitions
g. shoulder flexion
h. shoulder
horizontal
abduction and
adduction
i. shoulder
abduction
extension
b. Forearm
pronation and
supination
extension
extension
seconds
a. Pectoralis
b. Biceps
28
c. Triceps
d. Anterior and
Posterior deltoids
e. Upper Trapezius
performed while
standing
a. chest pull
b. shoulder flexion
c. shoulder
diagonals
extension 9. Interventions to Support
9. Ergobike, 10 minutes Occupations

● Taking rest
breaks in
between
● Accepting a
certain number of
clients per day to
lessen the
workload
the client on work
● Doing dental
tasks sitting down
● Gathering tools in
one place
12. Placing dental tools and 12. Environmental
equipment at reachable Modifications
levels.
13. Using an modified 13. Environmental
armrest to support Modifications
forearms during
operations
14. Activity log to document 14. Occupation and Activity
which activities cause
fatigue the most, and
what symptoms are felt.
it should contain the
following columns: Time
for the day, type of
activity, and symptoms
noticed
15. Incorporating ECTs and 15. Occupation and Activity
WSTs during dental
duties to help the client
endure and complete an
entire treatment session.
16. Simulated dental
29
examinations and 16. Occupation and Activity
operations
D. Recommendations
The client's caregiver should be instructed on how to perform PNF patterns and AROMs at
home.This is to target the affected muscle groups so as to prevent symptoms from getting
worse. To increase compliance and motivation, the client and caregiver should be informed
about the significance of these exercises as well as their benefits for the client's condition. It
is highly recommended to incorporate the said exercises to her daily routine to give a sense
of structure while at the same time, delaying the progression of her condition. It is also
advised that the client take her maintenance medication as directed on a regular basis at
home. Other than these exercises, Aerobic exercises such as fast walking, dancing,
swimming and cycling can be beneficial for the client as these are low-impact exercises and
can help address issues such as endurance and fatigue.
To address the client's scapular winging as well as to prevent subluxation, it is recommended

to use bilateral shoulder braces in order to improve shoulder function as well as reduce pain
and fatigue. Thus, an orthotist or a specialist in orthotics should be consulted. In addition,
preventive strategies for foot drop should also be taken into consideration.
The client is also recommended to an OT who specializes in workplace ergonomics in order

to have a thorough evaluation of the client’s workplace and have more individualized
workplace modifications. Lastly, the client is encouraged to join FSHD communities to
become more informed about potential progression of the disease, and to know more
compensatory strategies that other patients use that may be beneficial for the patient.
X. TREATMENT SESSIONS
DATE OBJECTIVE DATA ANALYSIS OF TREATMENT

DONE
Session 1 Interventions provided The client presented LOM during

(December 2, ● UTZ on (B) shoulders (10 mins, shoulder motions due to pain
2022) deltoids region) during AROM and PROM:
● AAROM exercises on (B) UE (10 Shoulder flexion
mins) with ES on anterior and L AROM: 0-40
middle deltoids R AROM: 0-45
● Shoulder wand exercises (10 reps) L PROM: 0-120
● PNF patterns using cone R PROM: 0-100
Scapular exercises (Shoulder Shoulder abduction
shrugs) L AROM: 0-70
● Ergobike (6 mins) R AROM: 0-60
● ADL simulation (UE and LE L PROM: 0-100
dressing) R PROM: 0-90
Internal rotation
Observations: L AROM: 0-40
Joint Mobility R AROM: 0-35
● The client was not able to reach L PROM: 0-70
full shoulder motions for flexion R PROM: 0-80
and abduction. External rotation
● Towards reaching maximal AROM L AROM: 0-35
for the aforementioned motions, R AROM: 0-30
the client was observed to bend L PROM: 0-70
30
backwards (trunk extensor R PROM: 0-60
compensation). Elbow, wrist, and fingers: WNL
● During the AAROM exercises, full
motions were made, however, The client has problems with
client reported feeling pain at the muscle power as evidenced by
end range. being unable to reach full ROM
against gravity for SH motions:
Sensory Functions ● Shoulder flexion: 2+/5
● Client noted pain during ● Shoulder aB: 2+/5
AAROMEs, specifically in B deltoid ● Shoulder IR: 2+/5
regions. ● Shoulder ER: 2+/5
● Elbow flexion/extension:
Muscle Strength 2+/5
● Client showed difficulty in actively The client also has problems with
raising B shoulders to full range muscle endurances as she is only
against gravity, specifically during able to tolerate up to 10 minutes
SH flexion and abduction. of physical activity.
Muscle Endurance Dull pain is usually noted on the ff:

● Client noted to start getting tired (a) constant pain of 6/10 on R
after more than 5 repetitions of anterior deltoids, (b) pain of 7/10
overhead motions, especially seen with AAROM in full range of
durings AAROMEs. The client also shoulder flexion/abduction, and (c)
requested to rest after 5 minutes pain of 7/10 with AROM of
of continuous overhead motions shoulder internal rotation. Atrophy
during the ADL simulation on (B) deltoids was present upon
(dressing). observation.
ADL Simulation Client was noted to require

● During dressing simulation, the minimal assistance in ADLS,
client was observed to put both specifically bathing, grooming, and
arms inside the armholes first but dressing, as well as minimal
had difficulty in raising B UE to put assistance in job participation.
head through the collar. Despite
multiple tries, she was unable to
lift both hands due to pain. The
therapist had to physically help her
put her head through the hole and
the client was able to
independently adjust her clothing.
● With doffing, the client is able to
grab her hemline opposite to her
UEs, crossing her arms. She is
able to gather the cloth to the level
of her ribs but is unable to raise
her arms to pull her head through
the headhole. The therapist had to
assist her while she flexes her
trunk and she was able to remove
her arms from the armholes
independently.
Work Simulation
31
● Client was able to manipulate
dental equipment and rearranged
them properly into containers
independently, however showed
difficulty when the task required
overhead motions such as
reaching or adjusting the light of
the dental machine.
● Client noted to show signs of
fatigue after 10 minutes of
continuous work, and also noted
that she’d have her assistance
support her arms during
operations.
Session 2 Interventions provided The client presented with LOM

(December 5, ● UTZ on B shoulders (10 mins, during AROM and PROM of
2022) deltoids region) shoulder flexion and abduction on
● AAROM exercises on (B) UE (10 B UE due to pain, muscle
mins) with ES on anterior and weakness and scapular winging.
middle deltoids Shoulder flexion
● Gentle Active Stretches L AROM: 0-40
● Cup Gliding R AROM: 0-45
● Ergobike (6 mins) L PROM: 0-120
● Client education on the condition R PROM: 0-100
○ Progression, what to
Shoulder abduction
expect L AROM: 0-70
● Educating client on environmental R AROM: 0-60
modifications, energy conservation L PROM: 0-100
strategies, work simplification R PROM: 0-90
techniques and adaptive devices Internal rotation
used in bathing L AROM: 0-40
● Bathing simulation using R AROM: 0-35
long-handled scalp massager L PROM: 0-70
R PROM: 0-80
Observations: External rotation
Joint Mobility L AROM: 0-35
● The client was not able to R AROM: 0-30
independently raise B UE beyond L PROM: 0-70
0-45 degrees against gravity, R PROM: 0-60
however she was able to maintain
B UE in 0-60 to 70 degrees Sh The client presented with
flexion when her arms are placed problems in muscle strength as
on top of a table, as seen during seen through the difficulty of
the cup sliding activity. raising B shoulders in flexion and
abduction against gravity to full
Pain range:
● Upon arrival, client reported ● Shoulder flexion: 2+/5
having 5/10 pain on SH area. After ● Shoulder aB: 2+/5
the UTZ, client reported that her ● Shoulder IR: 2+/5
pain decreased to 4/10. ● Elbow flexion/extension:
● The client also reported 7/10 pain 4/5
in B deltoids while performing
32
AAROME. Client’s SH pain at rest decreased
after being given therapeutic
Muscle Strength ultrasound.
● The client showed difficulty in
actively raising B shoulders to full The client also presents with 7/10
range in flexion and abduction pain in the deltoids region during
against gravity. shoulder movement, exacerbated
by scapular winging. Client also
Body Structures has poor muscle endurance.
● The client’s B deltoids were noted
to be dropped, while her lower The client is able to retrieve
trapezius were raised. bathing items on hip level and
below but continues to show
Muscle Endurance minimal to moderate signs of
● Client complained of fatigue and fatigue and pain while bathing with
showed increased respiration rate long-handled scalp massager
after 6 minutes of ergobike.
LTG1. STG1: Client will be able to
Bathing Simulation retrieve bathing products given
● Client was able to retrieve environmental modifications within
simulated bathing materials on hip 1 OT session. - ACHIEVED
level while seated.
● Client was able to reach and
massage her scalp by flexing her
neck and using the long-handled
scalp massager. Client used
mostly elbow movement when
massaging hair. Client was also
able to reach her upper back
without having to flex and abduct
her SH for >50 degrees. Client
was able to complete the
simulation after 5 minutes. Client
showed minimal to moderate
increase of respiration rate and
reported a 5/10 pain after the
simulation.
Session 3 Interventions provided Client presents LOM due to pain

(December 9, ● UTZ on B shoulders (10 mins, and muscle weakness in bilateral
2022) deltoids region) UE. Left UE is WNL upon
AAROME and there is LOM in R
● AAROM exercises on (B) UE (10
UE due to pain and muscle
mins) with ES on anterior and weakness in shoulder
middle deltoids
● Gentle Active Stretches 6/10 Pain in deltoid region was
● Scapular Mobilization noted when client initiates
● Cup Gliding shoulder movement beyond 45
● Ergobike (10 mins) degrees
● Client education on the condition
Muscle Strength
○ Progression, what to ● Shoulder flexors - grade 2+
expect ● Shoulder abductors - grade
● Educating client on environmental 2+
modifications, energy conservation
Client has a hypermobile scapula
33
strategies, work simplification due to muscle weakness
techniques and adaptive devices
used in grooming
Using a long handled brush, the
● Grooming simulation using a
client was able to comb her hair.
long-handled brush Minimal pain, fatigue as well as
fair endurance were noted during
Observations: the activity.
Joint Mobility
● The client showed difficulty in LTG 1. STG 5: Client will be able
raising her arms beyond 0-45 to comb her hair showing minimal
to no signs of pain and fatigue
degrees during AROM and PROM
given adaptive devices and energy
exercises. conservation techniques within 2
Sensory Functions OT sessions. - ACHIEVED
● The client presented with pain on
B deltoids region during shoulder
movement.
Muscle Strength
actively bringing B arms back to
horizontal abduction and
adduction during the cup gliding
activity.
● The client was noted to use her
trunk extensors to compensate for
her UE weakness.
Body Structures
● The client was noted to have
scapular winging, more evidently
on her right.
● The client's R scapula was moving
a lot during exercises.
Muscle Endurance
● The client was only able to endure
no more than 5 reps of
Grooming Simulation
The client is able to brush the left side of
her hair with her right hand and vice
versa, using a long handled brush. With
this, the client only utilized elbow motions
when combing her own hair instead of her
shoulders. No compensatory movements
were noted
Session 4 Interventions provided:

(December ● UTZ on B shoulders (10 mins, Client presented problems with
12, 2022) deltoids region) joint mobility, LOM is due to pain
● ES, 10 mins (anterior and middle and muscle weakness in both UE.
deltoid) with AAROMES on Both Left UE are WNL upon AAROME.
UE LOM in Right UE due to pain and
● Ergobike (5 mins) muscle weakness in her shoulder.
● Theraband Exercises (shoulder
and elbow flexion, scapular Pain was noted on the deltoid
region of client when muscle
34
retraction, shoulder shrugs) contracts whenever client initiates
● Cup sliding with 3 lbs weights (on shoulder movement beyond 45
each cups) degrees.
● Educating the client on
environmental modifications, and The client’s shoulder flexors and
energy conservation and work abductors are graded 2+ as she is
simplification techniques which unable to complete shoulder
can be used for job participation. motions against gravity.
● Job simulation; dental/oral
examination The client has a hypermobile
scapula due to muscle weakness.
Observations:
The client continues to exhibit
Joint Mobility
problems with muscle endurance
● During AROME, client unable to
as evidenced by the need for
perform shoulder flexion and
moderate rest breaks during
abduction beyond 45 degrees
exercises.
● Upon PROM, client reports
tolerable pain on Right shoulder The client was able to complete a
during shoulder abduction total of 8 minutes of job simulation.
● Complete ROM upon AAROME on Moderate rest breaks were given
left UE due to the presence of pain,
● Right UE incomplete Shoulder muscle fatigue, and weakness on
flexion and abduction due to pain the client’s B shoulder muscles.
in shoulders (6/10 on the pain
scale) LTG 2. STG2: The client will be
Sensory Functions able to endure 1 session of dental
● Pain in both shoulders when treatment given environmental
patient tries to actively raise UE modifications, energy conservation
beyond 45 degrees techniques, and work simplification
Muscle Strength techniques within 12 OT sessions.
● According to the client, UE feels - NOT ACHIEVED
weak, when asked to perform
activity, trunk extensors noted to
compensate to help achieve
shoulder motions during the
activities (e.x. cup sliding,
theraband exercises)
● Tolerate very minimal resistance
during shoulder extension and
adduction Body Structures
● Upon palpation, scapula noted to
be out of position, scapular
mobilization applied to bring
scapula back to position
● Scapular winging noted during the
session (Right)
Muscle Endurance
● Client was able to complete 5
minutes of ergobike on B UE,
given moderate rest breaks since
she was observed to present
fatigue and shortness of breath
midway during the exercise.
35
Job Simulation
● Client was able to manipulate the
dental mirror and explorer during
oral examination simulation, but
was observed to rest both her
elbows on the table since she
complained of muscle fatigue on
her B shoulder muscles after 5
minutes of activity. She was able
to raise her forearms back up, but
was only able to sustain around 3
minutes due to problems with
weakness, fatigue, and pain on the
same affected regions.
Session 5 Interventions Provided:

(December ● Ultrasound Both Shoulders, 10 The client has limitations in motion
16, 2022) minutes during shoulder flexion and
● ES 10 minutes on deltoids abduction in both UE due to
(anterior and middle) muscle weakness, specifically in
● AAROMEs on both UE her deltoids.
● Active Stretches
● Cone Stacking using PNF patterns Additionally, the client reported
● Ergobike, 6 minutes pain in deltoids upon movement
● Bathing simulation following work which was exacerbated by fatigue
simplification techniques, energy and lessened by rest.
conservation, use of long-handled
Client has poor muscle endurance.
scalp massager, and work
simplification techniques Client is able to bathe herself with
minimal to no signs of pain and
Observations: fatigue given use of long-handled
Joint Mobility scalp massager, energy
● Client was able to raise both UE to conservation techniques, and work
45 degrees actively. simplification techniques.
● Client was able to maintain both
UE in 60-70 degrees shoulder LTG 1. STG2: Client will be able to
flexion when arms were placed on lather and rinse hair and body with
top of the table during the cup minimal signs of pain and fatigue
sliding activity given adaptive devices, work
Sensory Functions simplification and energy
● Client reported 7/10 pain in both conservation techniques within 2
deltoids upon AAROME OT sessions. - ACHIEVED
● At rest, client’s pain remained at
5/10
Body Structures
● The client’s deltoids in both UE
were observed to drop while her
lower trapezius rose
Muscle Strength
actively raising B shoulders to full
range in flexion and abduction
against gravity.
36
Muscle Endurance
● Client complained of fatigue and
showed increased respiration rate
after 6 minutes of ergobike.
Bathing simulation
● Client was able to complete the
bathing simulation after 7 minutes
due to increase of rest breaks.
Client was able to make simple
linear strokes when massaging
head and back. Client reported
that her pain did not increase
when performing the simulation.
Client also showed minimal to no
signs of increased fatigue after the
simulation.
Session 6 Interventions Provided:

(December ● Ultrasound on both deltoids The client was able to perform
19, 2022) ● ES on deltoids, both UE increased ROM during gravity
● Gentle Stretches eliminated or minimized UE
● AAROME on Both UE movements.
● Scapular Mobilization
● Cup sliding with weights Horizontal abduction and
● Cone stacking adduction on B UE have an MMT
● Client education and HIPs Grade of 2-.
○ JPT, ECTS, and PBM
Scapular winging was still
observed caused by muscle
Observations:
weakness of muscles holding the
Joint Mobility
scapula together.
● The client has difficulty in raising B
UE beyond 50 deg actively due to The client had decreased
pain felt on her shoulders (deltoids endurance on activities due to
region). it was observed that the muscle weakness on B UE.
client extends her trunks to
compensate for UE weakness.
● During cup sliding activity, client
has difficulty bringing both arms
back to horizontal abduction from
horizontal adduction and vice
versa
Body Structures
● Scapular winging was observed. It
was noted that the R scapula was
more mobile during exercises.
Muscle Endurance
● SOB and fatigue was noted during
the session because the client
holds her breath and contracts
trunk extensors to compensate for
both UE weakness.
XI. PROGNOSIS OF TREATMENT
37
The client has a guarded potential in improving performance in her occupations, specifically
in bathing, dressing, grooming, and job participation. Despite showing good response and
high adherence to therapy, the progressive course of the condition must be taken into
account. Progression of the client’s condition makes it difficult to remediate SH strength and
range of motion, and the client’s limited endurance and pain also hinder occupations. Most
interventions are focused on compensating to achieve modified independence. Aside from
this, women with FSHD tend to have a less severe case than that of men. The fact that the
client does not present with symptoms below the upper body after the age of 50 gives a very
low chance that the disorder will progress to further stages and will likely remain on the
upper body only. The condition has no specific cure, however, with continued therapy, it may
help preserve the skills that the client currently has.
XII. REFERENCES
Centers for Disease Control and Prevention. (2021, June 16). Health-related quality of life
(Hrqol). Centers for Disease Control and Prevention. Retrieved December 19, 2022,
from https://www.cdc.gov/hrqol/index.htm
Tawil, R. (2008). Facioscapulohumeral muscular dystrophy. Neurotherapeutics, 5(4),

601–606. 10.1016/j.nurt.2008.07.005
van der Maarel, S., Frants, R., Padberg, G., (2007). Facioscapulohumeral muscular
dystrophy, Biochimica et Biophysica Acta (BBA) - Molecular Basis of Disease,
1772(2), 186-194. Facioscapulohumeral muscular dystrophy - ScienceDirect
Padberg, G. W. (2004). Facioscapulohumeral muscular dystrophy: a clinician’s experience.

Facioscapulohumeral muscular dystrophy, 41, 54. Facioscapulohumeral Muscular
Dystrophy (FSHD): Clinical Medicine and Molecular Cell Biology (ethernet.edu.et)
38
XIII. APPENDICES
Appendix A: Fatigue Severity Scale (FSS)
39
Appendix B: SF 36 Questionnaire
40
41
42
Appendix C: (how the client looks like at present)
43
Prepared by: Noted by:
Bacaro, Sydney Marie T.

Pizarras, Jaznielle
Vidal, Robin Ayn
OT – Intern OT Clinical Supervisor
44

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VELEZ COLLEGE INC.

College of Occupational Therapy and Physical Therapy

A Case Conference on Seminar I

December 21, 2022

A. Occupational Profile and Performance 12

III. INTERVENTION PLANNING 20

A. Problem List Prioritization

IV. TREATMENT SESSIONS 30

This is the Case of J.J a 53 year old Female from

Client also has difficulty in work specifically job

All of which are caused by Scapulohumeral

The major types of muscular dystrophy (MD) include:

TYPE DESCRIPTION AGE of ONSET and

Results from gene mutation that By 12 years, unable to walk;

By 20 most need respirator to

Becker Similar to Duchenne, with milder Onset age: 2-16 years

Facioscapulohu Affects both genders Onset age: Adolescence

Myotonic Affects both genders Onset age: Varies, often adult

Limb Girdle Affects both genders Onset age: teens to early

Facioscapulohumeral MD is a disorder characterized by muscle weakness and wasting

Course and Prognosis

A substantial number of patients—experience approximately 30% of all familial cases—never

● Other Surgical Interventions

C. Models, FORs, & Approaches Used

Model of Human Occupation

Intervention: Using this model guarantees a top-down and functional approach in

Biomechanical Frame of Reference

Rehabilitative Frame of Reference

Ecology of Human Performance

Intervention: Therapeutic interventions under this model include ‘establish/restore’, ‘alter’,

D. Evaluation and Treatment Guidelines

Range of Motion Testing

Manual Muscle Testing

Fatigue Numerical Rating Scale

Fatigue Severity Scale

PQRST Pain Evaluation tool

Short Form (SF)-36

A. Occupational Profile and Performance

Age/Sex: 53 years old, Female Referring Physician: Dr. Jeremy O. Flordelis

Occupation: Dentist OT Clinical Supervisor:

Address: Zone 1 #14 Deiparine Street, San Isidro, OT Intern:

6:00 pm - 6:40 pm - Client would go home and eat

6:40 pm -7:40 pm – Client would take another

7:40 pm – 8:00 pm – Client uses this time to do her

Saturdays: Usually the client would attend onsite or

Gait: No pertinent findings.

All of which are caused by Scapulohumeral Muscular Dystrophy.

OT Intern’s Name & Signature

Bacaro, Sydney Marie T.

B. Classical Versus Clinical Picture

C. Strengths and Limitations

IX. INTERVENTION PLANNING

A. Problem List Prioritization

C. Goals/Objectives and Management

Short term goal Intervention Type of Intervention

10. Educating and training 10. Education and Training

To address the client's scapular winging as well as to prevent subluxation, it is recommended

The client is also recommended to an OT who specializes in workplace ergonomics in order

DATE OBJECTIVE DATA ANALYSIS OF TREATMENT

Session 1 Interventions provided The client presented LOM during

Muscle Endurance Dull pain is usually noted on the ff:

ADL Simulation Client was noted to require

Session 2 Interventions provided The client presented with LOM