1. Brief description of the client ------ Just to give you a brief description.

My client is a 22 year old female, named Francesca Fine – currently living with her parents and
younger sister in the Greater Macarthur region.

She is a third generation Italian immigrant. Her family lives in a one story home, which they own. As
a family they enjoy sit down meal times and travelling in the family van to quite natural locations.

Francesca has Spastic Diplegic Cerebral Palsy, which primarily impacts her lower limbs, she is non-
ambulatory. The CP itself is not expected to progress further but there is some concerns of muscle or
joint overuse in the upper limbs over time (ref).

She acquired her current chair when she was a teenager and has reported some slight changes in her
size since then, as well as general wear and tear and reduced support in some regions.

Francesca has decided to start studying part-time at a local college later this year and has expressed
that she would like to independently travel to and from the college by train.

2. Description of the condition and its impact on occupational performance within their
environment ---- To give you some more detail about Fran’s specific condition and the
performance problems she faces.

Fran’s diagnosis has resulted in spasticity and contractures in her hamstrings, ankles and feet. She
presents with adduction in her thighs and feet. She is also slouching/sliding forward in her current
chair, indicating the possibility of posterior pelvic tilt. Additionally, Fran appears to have a single
curve scoliosis causing her to lean to the right.

The condition of her spine and pelvis in her current sitting situation has resulted in Fran experiencing
pain and fatigue after sitting for longer periods at a time. This has impacted her ability to be in the
community for longer periods, meaning she sometimes misses out on family visits to nature
locations, longer social outings with friends and it would be likely to impact on her occupation as a
prospective student. Impacting on her overall wellbeing, quality of life and sense of identity as a
young adult.

It has also meant that she has had to pick and choose which occupations to engage in during the
day, in the sense that (for example) if she went shopping for a few hours in the middle of the day, it
is unlikely that she will have the sitting tolerance/energy to attend a sit down meal with her family in
the afternoon. Which again limits her ability to engage in meaningful occupations.
Fran is able to lie sideways on her couch when her sitting tolerance is low – However, upright sitting
- is important for engagement in her occupations of studying, eating and for general social
interaction.

Fran’s self-care is also affected by her condition and current seating situation. While Francesca
usually transfers onto the toilet independently with the use of a slide board; she reports that her
current foot pedals get in the way as they do not fully swingout. Additionally, if Fran is experiencing
a lot of pain or is fatigued she occasionally will require her mother’s assistance for this transfer.
Which impacts her self-esteem.

For showering, Fran uses a mobile shower commode – which she also transfers onto with a sliding
board. (her shower has no hob). She reports no problems with this method, besides the footplate
issue and her sitting tolerance issues brought on by her current sitting situation.

Her current wheelchair is a manual, which means she is required to self-propel – which Fran has
reported isn’t a problem within the home – However, in the community this is sometimes
problematic. Also there are some concerns about long term wear and tear of the shoulders and
upper limbs.

She currently has a Jay cushion for pressure care, this is her preferred cushion (she has tried others
in the past) and would like to continue using this type of cushion.

3. Assessment
Ø COPM – One assessment measure I would like to use for my client is the Canadian
Occupational Performance Measure (COPM). This is so that not only we gauge a better idea
about Fran’s seating related performance and satisfaction but also so that we can evaluate
the effectiveness of our future interventions. The objectives/goals that will be focused on in
this measure include: (ref).
Performance Satisfaction
Toilet and commode 6 4(can technically perform
transfers. these transfers it’s not done
optimally for the client’s
liking/needs.
community locomotion 4 4
Sitting tolerance 4 3
Ø Next I would like to conduct a full postural assessment (with some assistance from another
college to improve accuracy of findings). This will include an assessment on the client in a
supine position, in unsupported sitting and in current sitting. This is so that we can confirm
and gauge a better understanding of any postural problems – so these factors are
considered in our intervention/final prescription. (Ref). major finding were:
What was found (bony land What does this Flexible/fixed/li
marks) indicate (postural mited
problem)
The supine sitting we found Indicating Posterior Flexible back to
that, pelvic tilt nutral without
PSIS lower that the ASIS. (likely the cause of her issues
Overall palpitation showed the sliding in chair)
pelvis tilting back in relation to
the rest of the trunk.
In both unsupported and Indicating high right Flexible
current sitting it could be Pelvic obliquity
observed that
the R ASIS was higher than the
L.
During unsupported sitting Indicating C curve Flexible
(sticker method). - confirmed scoliosis- convex left
Lateral C curve in the thoracic side so leaning R.
region. – convex left (May have come
about as
compensation for
pelvic obliquity).
Thigh adducted (both sides) Limited
movement back
to neutral.

Foot inversion Flexible

Ø The Lack of support of her back and pelvic structures is likely what has been causing her to
experience pain and fatigue easily when sitting.
Pressure injury risk is something that is of great consideration for our client, because she does spend
the majority of her time in her chair. Gauging how susceptible the client is to acquiring a pressure
injury is important as it will inform the pressure care interventions taken. For this reason I have
opted to use the Braden scale for predicting pressure sore risk. It is comprehensive, appropriate for
her age. – Score of 14 – moderate risk category. (Risk factors: chair fast, limited mobility in lower
limbs, friction/shearing as she slides in chair).

4. Occupational therapy goals

I have a long term goal and a short term goal for my client.

In the short-term (i.e before our new chair comes in) we are going to counteract the issue of sliding
forward in her chair during meal times. To do this I will be prescribing Francesca a seat wedge for her
chair so that the anterior of her current chair is at a higher inclination, preventing forward sliding
(this will go under her current pressure care cushion – jay cushion).

In the longer term, we aim to significantly increase Fran’s sitting tolerance so that she can travel to
and attend her college classes. We’re going to do this by ensuring her new seating system supports
her pelvis and spine in as neutral of a position as possible. – to reduce pain and fatiguing

5. Occupational Therapy Intervention strategies (including application of evidence based

practice)

Evidence – going to have 4 sessions.

Session 1 (1.5hr)– Goal: To trial interim solutions and take measurements for the prospective seating
system.

Trial a variety of wedge heights and types, placed in varying manners to counteract posterior pelvic tilt
and pelvic obliquity. (May need >1 simultaneously). (From loan pool). Take anthropometric measurements
correlating to the depth, width and height of the new seating system (measuring tape). Also COPM.

Session 2 (1.5 hr) –. To provide pressure care education. As well as precautionary manual handling
education for her mother. Just in case they do come across…….

Advise the client on skin monitoring and pressure care considerations (adequate cushion already in situ
<2 years old). Provide mother with manual handling education in case the client is too fatigued to do own
transfers (interim solution, this does not occur too often, have mentioned some situations – just incase).

Session 3 (2hr)– Set up, trial and provide education on the new seating system.

Chair details:

- Power wheelchair – reason we have opted for this is because many of Fran’s current and desired
occupations involve significant amounts of community locomotion, avoid over usage of her upper
limbs and avoid fatigue from self-propelling for great distances (nature, travel).
- PO -The chair will be customised to have a seat cushion that is 7cm higher on the left to counteract
the client’s R side high pelvic obliquity (flexible) {7cm because in trial of wedges this was the height
needed to bring the pelvis back to neutral}.
- Scoliosis - It will also have lateral supports to counteract her scoliosis curve. One on the left in the
region of the apex of the curve and one on the right slightly higher, as well as another one on the R at
the pelvis. The higher ones will flip completely out of the way for transfers. Costigan & Light, (2011).
 - Adduction of thighs – very thin flip down pommel.
- PPT - 4 point pelvic strap (45˚ and 90˚ attachment) and Sacral pad in backrest.
- The footplates on this chair will completely swing out of the way, unlike the last chair, to make
transfers safer.
- FOOT INVERSION – foot plate angled laterally and ankle straps with a line of pull towards the medial
side of each footplate.
- Hanger angle: 90 (not to worsen PPT and accommodate hamstring tightness) seat to floor height:
45 cm – so that she can still sit comfortably at a desk or dining table and also so the chair will fit into
the family van (premeasured).
- Wheels suitable for outdoor terrain. All of the measurements took into consideration the addition of
her jay cushion.

We’ll be testing out all of these features during this session.

Session 4 (1hr) - Review seating system after 2 months of use. Review the seating system and receive
feedback from the client. Receive feedback about community usage.

- Review transfers. Reassess COPM.

6. Outcome measurement

1. After Fran has had some time with the new seating system, one of the outcome measures
used will be the re-administration of the COPM. This measure is valuable for assessing the
client’s perceived satisfaction and performance (donelly) - considering the cost factors and
the fact that a seating system is used every day, evaluating whether the client perceives
improvement or not is very important.
Performance Satisfaction New P New S
Toilet and 6 4 8 7
commode
transfers.
community 4 4 7 8
locomotion
Sitting 4 3 8 8
tolerance

2. Verbal feedback from the client will also be used to evaluate the intervention. This will be
taken both on the first day with the new seating system and again 2 months later, after the
client has had more use with it. – We specifically want to gauge if there are any concerns
and if it’s improving occupational performance rather than hindering it. Which can be done
by asking specifically to describe its use in particular occupations.
- Importantly I also asked about pressure injuries and whether they have checked their skin
entirely to ensure that the seating system is not resulting in any PI.
From verbal feedback:
 o The client reported that she could be seated for the majority of the day without pain
or overly fatiguing.
o Reported no issues mobilising in the community – and that she can now do so for
much longer periods than before.
o Reported that hasn’t developed any pressure injuries or noticed excess pressure in
any regions.
o On initial attainment of the seating system the client reported to be comfortable in
the chair. (first tried out the chair) – This was reconfirmed in the follow up visit.

3. Observing the seating system in use will also be used as an evaluation measure. Specifically,
as with the old system there was a safety concern about transfers, observing transfers in the
new system was a high priority. Additionally observation of the client’s fit within the seating
system and their use of it for mobility was also conducted during initial attainment of the
power chair and in the follow up visit a few months later.

o During this we observed that no parts of the chair obstructed slide board transfers
(toilet and mobile commode).
o Client had good control of the chair when mobilising.
o She was able to adequately sit at the table and at her desk.
o Didn’t appear to be any sliding and posture appeared to be much improved (no
more leaning).