Occupation-Based Functional Motion Assessment
After studying this chapter, the student or practitioner will be able to do the following:
1 Define occupation-based functional motion assessment.
2 Describe why it is desirable to assess motor function through observation of engagement in occupation and performance of activities.
3 State two circumstances in which assessment of performance skills is indicated.
4 Define individual activity analysis, or “dynamic performance analysis.”
5 Describe why it is not possible to perform an accurate objective activity analysis.
6 List at least three questions that can guide the clinical observation and clinical reasoning of the occupational therapy practitioner when conducting an occupation-based functional motion assessment.
7 List factors other than range of motion, strength, and motor control that can affect motor performance.
8 Discuss how information gained from the occupation-based functional motion assessment differs from that gained during assessment of specific client factors.
9 State the minimum level of strength required throughout the lower extremity for normal stance and positioning.
10 Compare levels of muscle strength and associated endurance in the upper extremities.
11 List areas of occupation that can be used to assess functional motion in the upper extremities and in the lower extremities.
Threaded Case Study
Raymond, Part 1
Raymond is a 60-year-old foreman of several lineman crews of the telephone company. He has been with the company for more than 40 years; although he could have moved into a more administrative position over the years, he has always enjoyed working in the field, being a mentor to the younger workers, and dealing with emergencies. He is known throughout his neighborhood as the person to call when help is needed with home repair tasks, whether it be carpentry, plumbing, or electrical work. He is a member of a championship senior softball team and plays most weekends during the season, sometimes traveling out of town to participate in tournaments. He does quite a bit of volunteering through the outreach program at his church and participates in such activities as collecting, preparing, and delivering food to home-bound elderly and driving new immigrants to various appointments. He shares household duties with his wife and enjoys cooking for her.
Rheumatoid arthritis was first diagnosed in Raymond 10 years earlier when he began experiencing pain and stiffness in his shoulders, hips, and knees. His symptoms were managed with medications, and except for occasional exacerbations, he was able to fully engage in occupations that were meaningful to him. In the last 6 months he has experienced an exacerbation of his symptoms. The pain in his shoulders, hips, and knees has increased, and he also began experiencing pain in his wrists and hands. His wife began to notice Raymond’s change in mood as he became increasingly reluctant to engage in occupations in which he always took the lead, such as helping his neighbors with home projects, preparing food in his church outreach program, and participating in softball games.
Since he could not do things the way he used to, he did not want to do them at all. He stated that he did not want people seeing him fumbling as he attempted to hold tools or cooking utensils because his grip was so weak, nor did he want to let his teammates down because of the decreased power in his batting swing and decreased speed in running the bases. At work he found himself giving more verbal instructions to his crew rather than demonstrating techniques as he had always done before; at times he spoke in a gruff, impatient tone, which was surprising to his fellow workers. His frustration with the increased amount of time that it was taking him to complete activities of daily living such as shaving, buttoning his shirt, and putting on the boots that he was required to wear at work was making him irritable. The fatigue he was experiencing at the end of the day “just from trying to move my body around” was also adding to the depression of this client. This previously outgoing person was withdrawing and becoming more and more socially isolated.
The occupational therapy practitioner to whom he was referred began anticipating the needs of this client based on the profile she developed. Evaluating this client as he engaged in occupations in specific contexts would provide the best information for determining intervention strategies that would be most helpful, such as adaptive equipment and joint protection techniques. Obtaining information underlying the client factors (muscle strength, range of motion) contributing to his decrease in function was critical. Arrangements were made to assess the client in his home and to make a job site visit. By observing the client perform occupation-based tasks and motions at work and home, important information concerning his range of motion, strength and endurance, and motor control could be assessed.
1. What is the advantage of administering an occupation-based functional motion assessment versus more specific assessments, such as joint measurement and manual muscle testing?
2. What information about the client’s muscle strength and joint range of motion can be determined through an occupation-based functional motion assessment? What cannot be determined?
3. What is the value of administering an occupation-based functional motion assessment in different environmental contexts?
Many physical disabilities cause limitations in performance skills and client factors, including joint range of motion (ROM), muscle strength, and motor control. These physical impairments in body functions and motor skills result in limitations in movement that can cause slight to substantial deficits in performance of areas of occupation and prevent pursuit of self-care, work, leisure, and educational and social activities. An occupation-based functional motion assessment is a way of assessing the ROM, strength, and motor control available for completion of tasks by observing the client during performance of functional occupations (activities of daily living [ADLs], instrumental activities of daily living [IADLs], work, or leisure activities) in varied contexts and environments.1
Since the primary responsibility of the occupational therapist is to assess occupational performance, identify problems in performance, and plan intervention strategies that will improve the client’s ability to fully engage in occupations, the sensorimotor limitations should first be assessed through observation of functional activities. When improvement of performance skills is a goal of the intervention program, assessment of performance skills, occupation demands, and client factors in a variety of environmental contexts such as home, workplace, or school may be indicated to make an objective assessment of the physical limitations and gains (see Chapters 19, 21, and 22 for additional information).
Mental functions, including cognitive and perceptual abilities, such as motivation or the ability to sequence complex movement patterns, interpret incoming stimuli, or make use of coping skills and regulation of behavior, can also affect motor function. These client factors must be considered in any performance evaluation (see Chapters 25 and 26 ). However, this chapter is limited to consideration of motor function (i.e., ROM, strength, and motor control) during occupation-based functional motion assessment.
OT Practice Note
Except for a few diagnoses, specific assessments of ROM, muscle strength,4 and motor control are seldom necessary. For example, performing a full ROM assessment or manual muscle test is time-consuming, can be tiring to the client, and may duplicate other services, whereas assessing these factors while the client is engaging in occupation yields the most comprehensive picture of the client’s actual abilities and limitations.
Clinical Observation
It is possible to make a gross assessment of joint mobility and muscle strength by having the client perform the motions associated with functional tasks (i.e., a functional motion assessment). The occupational therapy practitioner could observe as the client reaches overhead, as would occur when putting dishes away in an overhead cupboard, or taking a step to the side, as when stepping into a bathtub.7 This will give the practitioner some basic, though nonspecific information about factors that affect function.
In occupation-based practice, muscle strength, ROM, and motor control can be observed during the performance of ordinary ADLs,3 IADLs, work, and leisure tasks. For example, while assessing ADLs, the therapist can observe for difficulties in performance and movement patterns that may signal limited ROM, muscle weakness, muscle imbalance, poor endurance, limited motor control, and compensatory motions used for function. An occupation-based functional motion assessment has an advantage over functional motion assessment in that although the client will perform motions as just described, there is the added resistance on body structures that will occur as a result of using equipment such as a sliding door, manipulating objects such as cards, or resisting fatigue and having endurance during repetitive activities such as bouncing a ball. In addition, because the client is performing these tasks in environments and contexts that are meaningful, the client’s full participation and engagement in the task may be heightened.
Essentially, when observing a client perform selected tasks, the occupational therapist is performing an individual activity analysis, or “dynamic performance analysis,”7 to diagnose the occupational performance problems of that client. Since people perform the same task in a variety of ways and because there are so many variables in performance of a task, it is not possible to do an objective activity analysis, one that can be applied universally, and describe the sensorimotor requirements for the myriad of ADLs. The purpose of observation is to understand the client’s occupational performance problems in the context of the interaction between the person, the task, and the environment.3 This type of screening will serve the occupational therapy practitioner well in deciding a course of intervention for Raymond, who because of the currently exacerbated status of his disease is not a candidate for more specific assessment of muscle strength (see Chapter 22).
While observing Raymond in his home as he performs the functional tasks described later in this chapter, the therapist will not only be able to assess his available ROM but also make some determination of his muscle strength.
The therapist’s scientific knowledge of the particular dysfunction and an analysis of the ways in which activities are generally performed (activity demands) influence the assessment of performance problems and aid in the development of plans to remediate these problems.3
The following are questions to guide the clinical observation and clinical reasoning processes:
1. Does the client have adequate ROM to perform the task?
a. Where are the joint limitations?
b. What are some possible causes of the limitations?
c. Are there true ROM limitations or are the apparent limitations actually caused by decreased muscle strength?
2. Does the client have enough strength to perform the task?
a. In which muscle groups is there apparent weakness?
b. If strength appears inadequate to perform a task because the client cannot complete the ROM, is there truly muscle weakness or is there actually limited ROM?
3. Does the client have enough motor control to perform the task?
The observing occupational therapy practitioner must also consider the client’s understanding of the instructions and perception of importance of the task, as well as the possibility of sensory, perceptual, and cognitive deficits. Analysis of the results of the occupation-based functional motion assessment may indicate that formal assessment of performance skills or body functions is needed. For example, such an assessment may be needed to differentiate muscle weakness from limited ROM or to quantify (with a muscle grade) muscle weakness in specific muscle groups.
Assessing ROM, strength, and motor control by observing the client perform functional activities can aid in selecting meaningful intervention goals relative to improving occupational performance. The therapist can ask the client about his or her ability to perform the tasks of daily living but should also observe the client performing such activities as dressing, walking, standing, and sitting to make an accurate assessment.2 Having the client perform ADLs in addition to other tasks associated with his or her habits and routines while interacting in varied environmental contexts can also add to the depth of information concerning the client’s ROM and muscle strength. The practitioner delivering occupational therapy services to Raymond has determined that making both a home visit and a job site visit will enhance her understanding of the demands on this client. Observation of Raymond interacting with materials, equipment, tools, and products in these environments will provide information about the critical motions and complex motor patterns required for him to fully engage in the occupations most meaningful to him. Completion of the tasks by Raymond in the timely manner required in these contexts will also give information about the client’s endurance and thus provide more information about his muscle strength.
Joint ROM quantification, manual muscle testing, and assessment of motor control (see Chapters 19, 21, and 22) will give the therapist specific information about the function of the musculoskeletal, neurophysiologic, and sensorimotor systems. Although the tests require minimum to maximum active output by the client, the therapist will not be able to determine the client’s ability to integrate these systems to perform specific goal-directed tasks based on the results of these assessments. Rather, the therapist will acquire information about movements of a specific limb or a combination of limbs. Under carefully controlled conditions, the therapist will determine the flexibility of the components of the joint and the strength of muscles to create movements such as flexion, abduction, and external rotation. However, the client’s motor performance capabilities are not measured by these assessments. For example, the manual muscle test cannot measure muscle endurance (number of times that the muscle can contract at its maximum level and resist fatigue), motor control (smooth rhythmic interaction of muscle function), or the client’s ability to use the muscles for functional activities.2
OT Practice Note
While observing a client performing functional activities, it would be most helpful if a therapist could also estimate the client’s existing ROM, muscle strength, and motor control.
At his job site Raymond had difficulty stepping up into his truck (the cab of which was somewhat elevated as a result of oversize tires) since he did not have enough hip and knee flexion ROM. The occupational therapist also observed that if the truck was parked near a curb or he could first step onto a box and then onto the step of the truck, thus requiring less flexion ROM, he had less difficulty. However, in both instances he lacked sufficient strength in hip and knee extension to launch himself into the truck without compensating with his upper extremities.
Occupation-Based Functional Motion Assessment
The activities listed in the following sections for an occupation-based functional motion assessment are suggested as a general starting place for the student or beginning practitioner. Only upper and lower extremity activities are included. Movements of the face, mouth, neck, and spine are beyond the scope of this chapter. Many more motions and tasks could be suggested in each category. The reader is referred to Joint Motion and Function Assessment: A Research Based Practical Guide, 2nd revised edition by Clarkson,2 for a comprehensive and detailed discussion of musculoskeletal assessment and its functional application.
Lower Extremity
Because of the somewhat stereotypic movements of the lower extremity, the arrangement of the large muscle groups, and the nature of the overall functions of weight bearing and ambulation, assumptions can be made about muscle strength during functional activities. For example, to assume a normal stance pattern, ambulate without any compensatory gait patterns, or position the lower extremities (without the assistance of the upper extremities) during dressing, a minimum of fair plus (F+) muscle strength is required in the musculature of the hips, knees, ankles, and feet. If muscle strength in the lower extremities is only F throughout the lower extremity, ambulation without aids will not be possible.5 Good to normal muscle strength is required for the endurance to perform the small postural adjustments needed for maintenance of standing, the repetitive movement patterns inherent in walking, and the lifting, maneuvering, and balancing on the lower limbs that usually occur during dressing.
Hip Complex
The hip joints support the weight of the body. Each joint acts as a fulcrum when a person is standing on one leg. Hip movement makes it possible to move the body closer to or farther from the ground, bring the foot closer to the trunk, and position the lower limb in space.2
During functional activities, lumbar-pelvic movements accompany hip movement, which extends the functional capabilities of the hip joint. The hip is capable of flexion, extension, adduction, abduction, and internal and external rotation.2
Flexion and Extension: Full flexion and extension are required for many ADLs and IADLs. Standing requires full hip extension. Squatting, bending to tie a shoelace with the foot on the ground, and toenail care done with the foot on the edge of a chair all require full or nearly full hip flexion. Other activities that require moderate to full flexion and extension are donning panty hose or socks, bathing the feet in a bathtub, ascending and descending stairs or a step stool, sitting and rising in a standard chair, and riding a stationary bicycle.2
Abduction and Adduction: Most ordinary ADLs and IADLs do not require full ranges of abduction and adduction. The main function of the hip abductors is to keep the pelvis level when one foot is off the ground. For ADLs, hip abduction may be used when stepping sideways into a shower or bathtub, donning trousers when sitting, squatting to pick up an object, sitting with the foot across the opposite thigh, getting on a bicycle, or as in the case of Raymond, shifting weight from one foot to the other as he strides when swinging the bat.2,6
Hip adduction brings the foot across the front of the body. An individual uses this motion when kicking a ball, moving an object on the floor with the foot, or crossing one thigh over the other for donning or removing shoes and socks.2
Internal and External Rotation: Internal rotation occurs when a person is pivoting medially on one foot. When a person is sitting, there is internal rotation when the person reaches to the lateral side of the foot for washing or donning socks. Internal rotators are active in walking.2
External rotation with hip flexion and abduction brings the foot across the opposite thigh for donning shoes or socks or for examining the sole of the foot.2,6
Knee
The knee joint supports the weight of the body. With the foot fixed on the ground, knee flexion lowers the body toward the ground and knee extension raises the body. If the foot is off the ground, as in sitting, the knee and hip are used to orient the foot in space.2
ADLs that require moderate to full range of knee flexion and extension are standing and walking, squatting to lift an object from the floor, crossing the ankle of one foot over the thigh of the opposite leg, sitting down and rising from a chair, and dressing the feet.
Ankle and Foot
The foot is a flexible base of support when a person is on rough terrain. It functions as a rigid lever during terminal stance in the walking pattern. It absorbs shock when transmitting forces between the ground and the leg. The foot and ankle function to elevate the body from the ground when the foot is fixed. Dorsiflexion and plantar flexion occur at the ankle joint. Foot inversion and eversion occur at the subtalar joint.2
Plantar Flexion: Full plantar flexion is used when a person is rising on the toes to reach upward to a high shelf. Some plantar flexion is used to depress the accelerator on an automobile or the control pedal on a sewing machine and when donning socks or shoes.
Dorsiflexion: Full range of dorsiflexion is needed to descend stairs. Dorsiflexion is used in such activities as positioning the foot to cut the toenails or tying shoelaces.2
Inversion and Eversion: Inversion and eversion function to provide flexibility when an individual is walking on uneven ground. Inversion is used when the foot is crossed over the opposite thigh to inspect the sole.2
Threaded Case Study
Raymond, Part 2
When administering an occupation-based functional motion assessment at Raymond’s home, the occupational therapy practitioner was able to observe that in his attempt to don his shoes and socks, Raymond was unable to abduct and externally rotate his hip sufficiently in combination with full flexion of the knee to place the ankle of one foot over the opposite thigh.
Upper Extremity
By simply observing a client engaging in functional activities, the therapist cannot make general assumptions as easily about muscle strength in the upper extremities as in the lower extremities. There are three reasons why this is the case: (1) the variety of ways in which the upper extremity can be positioned to complete any given task (i.e., there is no one right way to do the task), (2) the complexity of motor patterns possible requiring gross motor and fine motor skill, and (3) the dependency of the distal joints and musculature on the more proximal joints for positioning.
If several people are observed donning shirts, it will be apparent that different techniques are used by each. One person may lift the arm out to the side and increase shoulder abduction as the shirt is drawn onto the arm. Another person might prefer to dress with the arm more in front of the body, thus positioning the humerus in flexion. A third person might hyperextend the humerus as the shirt is pulled on. The difficulty, of course, is determining exactly how much ROM and muscle strength are minimally required at all of the joints involved when so many options are available to perform one task.
In the first two examples of donning a shirt, the musculature of the shoulder complex would certainly have to create more tension than if the humerus were in the adducted position. It would be inappropriate for the therapist to instruct the client on how to don the shirt if the therapist’s goal was to attain some information regarding the client’s level of independence in dressing and secondarily to make assumptions about ROM and muscle strength.
While observing a client perform occupation-based tasks and motions with the upper extremities, it is important to remember that even when it is not obvious or readily apparent, the muscles of the shoulder complex are contracting with varying degrees of tension. They may have to contract with enough force to position the hand in space and maintain it there, such as when a person is combing hair. At other times the humerus must be held close to the body to provide a stable base from which the forearm, wrist, and hand can maneuver, such as when striking the keys on a keyboard, cutting food with a knife, or writing. It would be an inaccurate assumption that the extremity is just hanging passively at the side when in fact the static contractions around the proximal joints make it possible for the musculature of the distal end of the extremity to work effectively. Conversely, the shoulder complex may have to be a moving unit as opposed to a positioning one, such as when moving groceries from a countertop to shelves in a kitchen cabinet.
General guidelines exist when assessing strength for function in the upper extremities. With good to normal endurance, a client with good (G) to normal (N) muscle strength throughout the upper extremity will be able to perform all ordinary ADLs and IADLs, work, play, and enjoy leisure and social participation occupations without undue fatigue.5 A client with fair plus (F+) muscle strength will usually have low endurance and will fatigue more easily than a client with G to N strength. The client will be able to perform many basic ADLs and IADLs independently but may need frequent rest periods. Work, play, and some social participation occupations may prove to be too strenuous, as in the case of Raymond attempting to hit a ball with force.
A client with muscle grades of fair (F) will be able to move parts against gravity and perform light tasks that require little or no resistance.3,5 Low endurance is a significant problem and will limit the amount of activity that can be done. A client with low endurance will probably be able to eat finger foods and perform light hygiene if given the time and rest periods needed to reach the goals.5 Poor (P) strength is considered below functional range, but a client with poor strength will be able to perform some ADLs with mechanical assistance and can maintain ROM independently5 (see Chapter 30, Section 2, Mobile Arm Supports). Clients with muscle grades of trace (T) and zero (0) will be completely dependent and unable to perform ADLs without externally powered devices. Some activities will be possible with special controls on equipment. Examples include power wheelchairs and electronic communication devices such as voice recognition computers or environmental control systems.5
Individuals use a variety of motor patterns when performing a functional task, and no one way is the right way to perform the task. These facts make it impossible for the therapist to predetermine the level of muscle strength, amount of ROM, and degree of motor control needed in the upper extremity to perform any given task. Individual styles of moving, numerous possibilities for compensatory movements when faced with loss of joint flexibility, poor endurance, lack of motor control, impaired sensation, and pain are all factors that may affect the client’s ability to generate tension in a muscle or muscle group and sustain muscle activity. The pain that Raymond experiences in his hands may be the primary cause of his inability to manipulate objects such as the buttons on his shirt.
Shoulder Complex
The shoulder complex is the most mobile joint complex in the body. Its function is to move the arm in space and position the hand for function. The shoulder complex is composed of the acromioclavicular, sternoclavicular, scapulothoracic, and glenohumeral joints and the muscles, ligaments, and other structures that move and support these joints. In the performance of functional activities, scapular, clavicular, and trunk motions normally accompany glenohumeral motion. These associated movements increase the range of glenohumeral motion for function. The shoulder complex functions in a coordinated manner that is accomplished through scapulothoracic and glenohumeral movement. This coordinated function is called scapulohumeral rhythm. Thus, movements at the shoulder are actually combinations of several joint motions and are dependent on scapulohumeral rhythm for the performance of any given activity.2 Activities such as placing an object (e.g., book, box, or cup) on an overhead shelf or reaching overhead to pull on a light cord require these movements.2
Shoulder Flexion and Abduction with Scapula Upward Rotation (Overhead Movements): Activities such as placing an object (e.g., book, box, or cup) on an overhead shelf or reaching overhead to pull on a light cord require these movements.
Shoulder Extension and Adduction with Scapula Downward Rotation: Activities such as reaching back for toilet hygiene, Raymond swinging his arm backward when preparing to pitch the softball, reaching backward to put an arm through the sleeve of a coat, and pulling a refrigerator door open require these movements.2
Horizontal Adduction and Abduction: These movements allow the arm to be moved around the body. Reaching the opposite axilla or opposite ear for hygiene activities, opening and closing a sliding door, combing the opposite side of the hair, and reaching the upper part of the back while bathing are some activities that use horizontal adduction and abduction.2
Internal and External Rotation: Some degree of either internal or external rotation accompanies every glenohumeral motion. ROM varies with different positions of the arm. Full range of external rotation is required for reaching the back of the head for combing or washing hair. External rotation is often associated with supination when the elbow is extended, as when rotating a doorknob in a clockwise direction.2
Internal rotation is used when buttoning a shirt, eating, and drinking from a cup. Full range of internal rotation with scapulothoracic motion is used to reach into a back pocket, fasten a bra, put a belt through the belt loops on trousers, or do toilet hygiene. Internal rotation is often associated with forearm pronation, as when placing a pillow behind the lower part of the back, turning a screwdriver to unfasten a screw, rotating a doorknob in a counterclockwise direction, and pouring water from a vessel.2
Extension and Adduction: Extension and adduction are used to return the arm to the side of the body from shoulder flexion and abduction, as after reaching overhead. These motions are also used when quick movement or force is required, as when an individual is closing a vertically oriented window, walking with crutches, or pushing off to rise from an armchair, or when stabilizing the humerus to the lateral aspect of the trunk, as when carrying a basket of laundry.2
Elbow and Forearm
Elbow and forearm movements serve to place the hand for function. Elbow flexion moves the hand toward the body, and elbow extension moves the hand away from the body. Forearm pronation or supination usually accompanies elbow flexion and extension. Pronation and supination position the hand precisely for the requirements of the given activity. The elbow and forearm support the skilled and forceful movements of the hand that are used during performance of ADLs and work activities.2
Full or nearly full range of elbow flexion, usually with some humeral flexion and forearm supination, is used to bring food to the mouth, shave the face or underarms, hold a telephone receiver, place an earring on the ear, and reach the neck level of a back zipper.
Full range of elbow extension, usually with pronation, is used when an individual is reaching to the feet to tie shoes, throwing a ball overhand, and using the arms to push off from a chair. Many other ADLs and IADLs require less than full range of these movements.2
Wrist and Hand
The wrist controls the length-tension relationships of the extrinsic muscles of the hand. It positions the hand relative to the forearm for touch, grasp, or manipulation of objects. Wrist extension and ulnar deviation are most important in performance of ADLs.2 It is possible to perform some ADLs when there is loss of wrist ROM by using compensatory movements of the proximal joints.
The primary functions of the hand are to grasp and manipulate objects and to discriminate sensory information about objects in the environment. The arches of the hand make it possible to adapt the hand to the shape of the object being manipulated.
Power grip and precision grip are the bases of all hand activities. Power grip is used when force is required for grasping, such as holding a hammer handle, a full glass, or the handle of a purse or suitcase. Precision grip is used when an object is pinched and when it is being manipulated between the thumb and one or more fingers. Precision grip is used for holding a pencil, moving checkers or chess pieces, turning a key, threading a needle, and opening the cap of a medicine bottle.
The occupational therapy practitioner observed Raymond in his home as he was preparing to make homemade soup. She noted that Raymond easily accessed ingredients that were on the first two shelves of above-counter cabinets but displayed quite a bit of facial grimacing and two attempts at reaching overhead to the top shelf. He was observed to be able to fully open his fingers but not able to make a tight fist. When chopping vegetables, he was able to manage the less resistive ones such as tomatoes and celery but could not exert enough force to cut through carrots. Although he could carry an empty pot to the sink without difficulty, he was not able to stabilize his wrists to carry a full pot of water to the stove. At his job site, the occupational therapy practitioner again noted that Raymond had difficulty holding some of the heavier tools in position and exerting appropriate force, such as with the large wire cutters.
Threaded Case Study
Raymond, Part 3
Because of the difficulty that Raymond experienced when donning his socks and shoes, getting in and out of his truck, reaching overhead, and manipulating and applying the force needed to use kitchen and work tools, the occupational therapist has determined that ROM and muscle testing assessments should be performed for some of this client’s specific joints and muscles.
After the occupation-based functional motion assessment, the next step in the occupational therapy process would be for the therapist to plan the intervention. The reader should refer to Chapter 38 on arthritis for some ideas for interventions that could be implemented to return Raymond to participation in his customary rounds of occupation. The reader should also refer back to the beginning of this chapter and reflect on the three probative questions posed at the end of Raymond’s case study and be able to describe the advantages of using an occupation-based functional motion assessment, the amount and type of information on Raymond that was gleaned from this assessment, and the value to the occupational therapist of conducting this assessment in both the home and work contexts and environments.
Summary
Many physical disabilities cause deficits in ROM, strength, and motor control that limit occupational performance. The occupational therapy practitioner is primarily responsible for assessing occupational performance, identifying problems in performance, and planning interventions that will improve the client’s occupational performance.
Because people perform the same activity in a variety of ways, the level of ROM, strength, or motor control needed to do a task is variable. Physical limitations can be assessed through observation of a client’s performance while engaged in a variety of occupations. Therefore, as in the case of Raymond, the therapist must observe the client performing selected tasks in the person-task-environment interaction.3
While assessing the client’s ability to perform ADLs, IADLs, work, or leisure occupations, the therapist should observe for sensorimotor problems. Analysis of the results of observation may indicate that an assessment of specific body factors or performance skills is needed.
Questions to guide clinical observation and clinical reasoning and suggested activities to assess function of the upper and lower extremities are outlined in this chapter.
1. Compare and contrast functional motion assessment versus occupation-based task and motion assessment.
2. In occupation-based practice, how are sensorimotor functions first assessed?
3. What is meant by individual activity analysis?
4. Why is it not possible to perform an objective activity analysis?
5. List three major questions that can guide the clinical observation and clinical reasoning of the occupational therapy practitioner when making an occupation-based functional motion assessment.
6. Which factors, other than strength, ROM, and motor control, can affect functional task-motion assessment?
7. How is the information gained from assessment of specific body factors different from that gained in an occupation-based functional motion assessment?
8. What is the minimum level of strength required throughout the lower extremity for normal stance and positioning?
9. List some activities or occupations that can be used to assess general function in the lower extremities: hip, knee, ankle, and foot.
10. Compare levels of muscle strength with endurance in the upper extremities.
11. List some activities that can be used to assess general function in the upper extremities: shoulder complex, elbow and forearm, and wrist and hand.
References
1. American Occupational Therapy Association. Occupational therapy practice framework. Domain and process (2nd ed.). Am J Occup Ther. 2008;62:625–683.
2. Clarkson, HM. Joint motion and function assessment: a research-based practical guide, ed 2 revised. Philadelphia, Pa: Lippincott Williams & Wilkins; 2005.
3. Crepeau, EB, Schell, BA. Analyzing occupations and activity. In Crepeau EB, Cohn ES, Schell BA, eds.: Willard and Spackman’s occupational therapy, ed 11, Philadelphia, Pa: Lippincott Williams & Wilkins, 2009.
4. Hislop, HJ, Montgomery, J. Daniels’ and Worthingham’s muscle testing: techniques of manual examination, ed 8. Philadelphia, Pa: Saunders; 2007.
5. Killingsworth, A. Basic physical disability procedures. San Jose, Calif: Maple Press; 1987.
6. Latella, D, Meriano, C. Occupational therapy manual for evaluation of range of motion and muscle strength. Clifton, NY: Delmar Thomson Learning; 2003.
7. Polatajko, HJ, Mandich, A, Martini, R. Dynamic performance analysis: a framework for understanding occupational performance. Am J Occup Ther. 2000;54(2):65.