Application Of Biomechanical Approach To Improve Functioning Of Mr JozefJurik: A Case Study

Background of Mr JozefJurik

To analyse and justify the application of a chosen approach to a case study, and to consider the appropriateness of a second approach.

On successful completion of the module, you will be able to:

• Appraise a range of theoretical approaches applicable to occupational therapy.
• Apply a range of theoretical approaches to occupational therapy practice

Using the case study below, from the perspective of an Occupational Therapist, select an approach which you feel would be appropriate when working with this client, and write a written assignment focusing on the application of the chosen approach, along with your justificationof it.

The following client has been referred to you as the community occupational therapist.

Mr JozefJurik is 51 years old, he moved to England 25 years ago from Slovakia as he had met his English partner Teresa, now his wife of 24 years, at language school.  Jozef is proud of his Slovakian heritage, and Roman Catholic faith, but has always missed his parents and brother, and kept in regular contact with them.  

Jozef is a mechanic by trade and has enjoyed employment at a large Derby based engineering company throughout the time he has been based in England. Jozef has enjoyed updating his skills to use digital technology and enjoys teaching apprentices, junior staff and inducting new team members. His boss has always regarded him as one of the most reliable and hardworking members of company, of which Jozef has been proud.

Jozef and Teresa have two sons, who left home about two years ago; Jozef and Teresa saw this as an opportunity to move to a small quiet village on the outskirts of Derby to enjoy the countryside, have a larger garden with a vegetable plot and spend more time outdoors; their sons remain living in Derby. Unfortunately Teresa’s mother in Devon in the last 6 months has become unwell; hence when Teresa finishes her part time teaching job on Thursday lunchtime, she drives straight to Devon to care for her mother, often only returning on a Sunday night before going to work on Monday morning. Jozef misses Teresa during this time, he feels very guilty as he feels family values are of upmost importance, so he agrees she should be looking after her mother, however due to a flare up of symptoms in his rheumatoid arthritis he has not been able to drive to join her in Devon when he finishes work on a Friday evening. Also there is limited public transport in the village, and no Catholic Church, hence Jozef cannot get into Derby to see his sons, or to attend church, and he finds this upsetting.

Currently Jozef is off long term sick from work, and has been for the last two months.  This is in part due to his rheumatoid arthritis, including early morning stiffness and joint pain within his wrist and ankle joints, and fatigue. Jozef has also been seen by his GP who has prescribed him sertraline to manage the symptoms of depression. Jozef is worried about letting his company down; due to problems with his wrists he feels he would struggle to operate the technology and complete heavy manual tasks at work, he has early morning stiffness, and is concerned that he may struggle to stand due to ankle joint pain.  Jozef is also finding that he has reduced stamina and energy in undertaking day to day tasks, both at home and prior to being off from work, within his work setting. He is concerned he is letting Teresa down, as he is doing little round the house when she is away at her mothers, and he is extremely worried that he might be labelled as a bad employee. He dwells on these negative thoughts and seems to think of little else.

Jozef is normally very particular about his appearance, but Teresa has commented to him that he seems not to be taking as much care of himself and his appearance. Teresa is very concerned about Jozef, she identifies that previously she would have described him as chatty, and always doing something, but in the last few weeks he is very quiet, does very little and at times becomes tearful, seeming very unmotivated, assuming everything will go wrong.

Currently Jozef has few leisure pursuits, but had previously been a keen Derby County football supporter, both attending home games and meeting friends at the pub to watch away matches, neither of which he is currently doing. Previously Jozef had also been a keen gardener, and enjoyed driving, but his recent loss of confidence has impacted on his ability to engage in these occupations.

Jozef’s family in Slovakia  have contacted Teresa to express concern that Jozef has stopped making much contact with them by phone, skype or e mail and that when he does all he talks about is how much of a failure he is as both a husband and employee.

Background of Mr JozefJurik

Occupational therapists provide special assistance so that people lead a productive, independent and satisfying life due to developmental, physical, emotional or social problems (Schell et al. 2013). In a similar way, in the given case study, Mr JozefJurik because of his rheumatoid arthritis is unable to complete his daily activities due to morning stiffness and joint pain.  As a result, he is dwelling in negative thoughts considering him incompetent to take care of his family and complete manual tasks at work. In such cases, biomechanical approach and behavioural approach are required for him so that he can lead quality life and overcome his depressive episodes. Therefore, the following discussion deals with the occupational approach techniques required for Mr JozefJurik so that he gain confidence and enhance his ability to be engaged in occupations of his daily living.

In the given case study of Mr Jozef, it is evident that he is suffering from long-term sickness due to his rheumatoid arthritis that causes joint pain in ankle and wrist joints, morning sickness and fatigue. As he is unable to perform his activities and cannot drive to his wife in Derby, he is feeling lonely and depressed. He is dwelling in negative thoughts, as he is incapable to help his wife and complete manual tasks, operate technology at work. These situations are taking a heavy toll on his life and health affecting his quality of life and ability to do occupations. Keeping this in mind, biomechanical approach is the main occupational approach that can be employed for Jozef to make him engaging in occupations and lead a good quality life (Roussouly and Pinheiro-Franco 2011) 

Biomechanical approach is the best occupational approach for Jozef as its designing can provide him structural stability, movement and posture so that he can accomplish activities of daily living (ADL) (Fern'ndez-Baena, Susín and Lligadas 2012). The rationale for choosing this approach is that it would assist Jozef to get engaged in tasks of daily life like heavy manual tasks at work, operate digital technology induct new team members and junior staffs and teach apprentices. Biomechanical occupational therapists employ different principles of movement like strength, range of motion (ROM), ergonomics, endurance that reduces the arthritic pain and assist in client movement (Iacoangeli et al. 2013). Employing biomechanical approach would assist movement so that he could drive to his wife Teresa in Devon and spend time with his family, as he values family and agreed that his wife should look after her mother.

Biomechanical approach refers to the remediation and improvement in strength and endurance where occupational functioning model (OFM) to make clients get engaged satisfactorily to perform their life role and accomplish task which in their opinion is the making up of the role (Hennessy, Woodburn and Steultjens 2012). The traditional approach addressed the physical disabilities, however according to the new concept, occupational therapists recognized both mental and physical features in the occupational performance. Biomechanical therapy is a holistic approach that combines both psychosocial and physical aspects in an individual’s life (Jones et al. 2013). In the given case scenario, it is illustrated that Jozef was unable to perform his daily tasks and drive to his family in Devon, he was gradually feeling low and depressed. He was advised to take sertraline for depression. He loves gardening, however, due to his arthritic pain he was unable to enjoy gardening and gradually lost confidence influencing his engagement in his meaningful occupations. Jozef is having wrist pain that is most complex and pronounced in rheumatoid arthritis (RA). There is high contact pressure created in the wrist joint as compared to non-RA. Biomechanical approach aims at improving the ADL by the patient, adaptation to modified lifestyle changes, functional limitations prevention and improvement or maintenance of psychosocial health (Bajuri et al. 2013).

Employment and Leisure Situation

RA motivates multiplicity of involvements and singularity in daily activity presentation, the first step towards the biomechanical approach is the appropriate assessment and evaluation of the disease. RA assessment in occupational therapy is important to gather relevant information regarding the state and impact of RA on Jozef’s ADLs. Although, this evaluation of RA is an ongoing process, it enables to develop interventions and monitor treatment and making modifications during exacerbation and periods of remission. As the case study depicts, he has painful wrist and ankle joints that has restricted his occupational performance and affected his mental and social state. The assessment methods for RA depend on the complaints and its relevance to RA’s clinical presentation. The OT evaluates it and choice of instrument depends on the information obtained from the patient.  Jozef complains of wrist and ankle joint pain, and OT should design standardized instruments that assess the functional ability of arm, shoulder, hand and ankles. It is also important to assess his depression or anxiety level, as he is depressed and limited social inclusion.

In the given case study, Jozef has characteristic joint impairment due to RA and decreased ability due to painful conditions and associated motor constraints. This is the main reason that is restricting his areas of performance, self-care, home maintenance and heavy tasks at work like operating digital technology. The physical and participation constraints that are experienced by Jozef can be resolved by biomechanical approach where the OT would engage him in productive activities to maintain his physical and psychosocial health. OT is an integral part of the biomechanical multidisciplinary team that is concerned with improvement in ADL performance and inclusion of the client in meaningful activities in his or her life. Previously, he has been a keen gardener and enjoyed driving, however, due to his RA pain; he has few leisure pursuits and loss in confidence affecting his engagement in daily life activities.  

The main concern of biomechanical approach is physical health and musculoskeletal system improvement. When a person is able to perform the ADL, it provides them a basic level of endurance, strength and range of motion by addressing the impairments and improving occupational performance (Baan et al. 2012). Despite of the pharmacological advancements made in RA, biomechanical or rehabilitation therapy is important that is aimed at maximizing the occupational performance, reduction of disability diminishing the impact of RA symptoms on the functional ability of patient (Matcham et al. 2014). In the similar manner, this approach would help Jozef to improve his activity performance so that he can undertake day-to-day tasks at home and within the work settings. He also struggles to stand due to his ankle joint pain and reduced energy and stamina at performing ADL. This approach emphasizes on the designing of body and accomplishment of motion where it restores the abilities of motion of Jozef. Therefore, this approach would assist him with his limitations, mobility and provide adequate strength with sustainability. The subsequent section of the essay in part A will deal with the assessment in biomechanical approach that can be helpful for Jozef.   

Occupational Approach Techniques for Mr JozefJurik

Firstly, the assessment of pain at the wrist and ankle joint is important as the systemic inflammation target the synovial joints. Moreover, Jozef suffer from joint stiffness and pain along with difficulty in standing. Therefore, it is crucial to assess pain by painDETECT tool for the multimodal pain features established in RA patients. It comprises of questionnaire that contains multimodal pain perception and features existing in RA including sensitization and neuropathic elements involved in pain (Ahmed et al. 2014). After the pain detection in Jozef on a scale of 1 to 10, treatments like cold and hot therapy, moist heating pad or electric blanket can relief pain along with pain medications. Exercises that strengthen knee can also be helpful in relieving pain. 

In the biomechanical approach, performance is considered in maintaining and improving the range of motion (ROM), strength and endurance. As Jozef has limited ROM and strength, biomechanical frame of reference is based on ROM. The assessment can be done by using the geniometer, dynamometer, volumeter and measurement of oedema of the hand. In the physical therapy, geniometer measures the ROM joint angles of the body.

The first assessment instrument is Disabilities of Arm, Shoulder and Hand (DASH) because it would help to measure the functional impact level resulting from upper limb impairment. Jozef is unable to perform his ADL related to mobility, self-care, recreation and home maintenance. In addition, this instrument has optional modules to assess the specific work activities impairment like gardening and driving that he used to perform before RA pain. The data collection method for this assessment is self-administered and structured questionnaires ranging from score 0 to 100 that indicate increase in disability due to upper limb involvement (Bilberg, Bremell and Mannerkorpi 2012).

Sequential Occupational Dexterity Assessment (SODA) is another assessment instrument that assesses the performance of an individual based on twelve tasks. The tasks include handling of objects, writing, hand hygiene and pieces of clothing. This instrument would help to assess Jozef’s performance on the daily tasks that are performed bilaterally and unilaterally. This assessment is necessary for Jozef as he unable to perform his daily activities and take care of himself (Holtslag et al. 2013).

Health Assessment Questionnaire (HAQ) is also helpful to assess the functionality of Jozef by measuring the level of difficulty in performing activities in eight areas like self-care, reaching, object holding and mobility. The data collected in this assessment comprises of standardized questionnaire containing 20 questions scoring from zero to three that indicates increasing disability. This assessment is important as it encompasses every aspect of daily functioning from self-care to mobility that is important, as he cannot stand due to reduced stamina and energy (Anderson et al. 2012). This assessment procedure helps to know about the Jozef’s functionality in performing daily activities and develop exercises and interventions based on his disability level measured on the scale.   

Handgrip dynamometry aids in the assessment of handgrip strength through the measurement of maximum force exerted by client when pressing hydraulic dynamometer. It is important to measure the strength of grip of Jozef as he suffers from wrist pain that make it difficult to perform activities involving hand movement. It is considered a standardized test that requites grip and posture standardisation forms that are utilized during the process of evaluation. It is an appropriate assessment instrument for Jozef as grip and posture is associated with wrist and ankle joint pain (Cima et al. 2013). Motor skills in Jozef can be improved by using adaptive and assistive equipments like long-handled reachers, built-up handles that compensate deficits in self-care. Upper extremity orthotics, thera-putty exercises can also help to protect and stabilize weak or painful joints for the holding facilitation and in using utensils.  

Biomechanical Approach

Geniometer is a clinical tool the help to measure the accurate track progress of a patient. It measures the angle and helps to allow the object to be rotated at the angular position. This is used for the measurement of total amount of motion at the specified point. It is used to measure the passive and active ROM.

Dynamometer is used to measure the arm, grip leg or back strength for the evaluation of physical performance, task demands and status. It is used for determining the power and torque for the operation of driven machine like pump. It is designed in such a way called passive or absorption dynamometer. It measures the torque, measuring force or power.

Theraband endurance measurement is a non-standardized procedure to test the strength and endurance of Jozef. The assessment tool is used to measure the muscle resistance and to work on the ROM. It also assesses the general conditioning of the muscles and improvement in the muscle group cooperation. 

Although, these assessments help to assess the ROM and endurance of Jozef, it is unable to assess the psychological aspects of his condition. The cause of his depression or mental health status cannot be assessed by the biomechanical assessments and this is the major limitation of these approaches. 

For the given case study on Jozef, occupational therapy interventions are vital that involves principles of energy conservation and joint protection. Modification of activities and work environment along with patient education and guidance are important occupational therapy interventions suitable for Jozef.  The above discussion explains the assessment in biomechanical therapy, however, it has certain limitations.

Although, biomechanical approach has strengths, it has certain limitations. It focuses on strength, ROM, endurance of the patient with RA; however, it does not address the psychological aspect of Jozef. It looks at the physical health of the patient and does not address his depression due to which he is losing his contact with the outside world. The main limitations of biomechanical approach are the compliance, stigma, safety, failure experience. There might be reduced choice of patient to participate in the program, environmental issues that need to be fixed like over-prescribing of the equipment. The approach only addresses the physical problems and ignores the psychological aspects of the patient with RA. As he is suffering from depression, he may feel unmotivated to participate in the occupational program as he is suffering from depression. 

Compensatory approach encompasses assistive technologies, Upper Extremity Orthotics and Modification of activities and environment. It includes devices that aim to enhance, maintain or facilitate self-care, educational, instrumental, social activities or employment performance. Neoprene or elastic strips favour handling, writing, and hygiene materials like hair comb or toothbrushes. Orthoses or splints are helpful for Jozef as it would help provide support to joint, optimize functionality and reduction of pain. Traction forces can also be helpful for Jozef to treat morning stiffness, joint motion improvement and functionality (Põlluste et al. 2012).

Modification of activities and environment is also a vital intervention for performing self-care, work and mobility activities. Changing of shifts, fair division of work, ergonomic modifications like change in furniture, joint positioning during work and replacement of fixtures by lighter weight objects for better handgrip. These interventions are useful for Jozef to assist him in ADL and activity performance (Ahlstrand et al. 2012).

Rationale Behind Choosing Biomechanical Approach

Upper extremity orthotics also compensate for the strength of upper limb like the one mobile arm support attached to flexor hinge splints and wheelchairs. This intervention compensates the activities of grooming, feeding and writing. 

As it is evident from the above discussion that biomechanical, approach failed to address the psychosocial problems and only focused on the pain and physical mobility of Jozef. Therefore, the second section of the essay deals with the behavioural approach that addresses the psychosocial problems of Jozef.

Different approach that is suitable for Jozef is behavioural approach. This approach is not only related to pain management but also reconceptualise individual to live despite of ongoing pain. This also reinforces acknowledgement of achievements and reinforce progress. In this, a person acquires skills to cope with their physical and mental health conditions as well as make changes for better understanding of pain, strategies and re-engage themselves in activities (Dures et al. 2012).

In the similar way, the behavioural approach would help Jozef to understand and accept that chronic pain (RA) would not change itself; however, he can consider himself well and lead a normal life (Hofmann et al. 2012). Self-acceptance is important for him, as he is depressed because of his inability to perform tasks and engage in leisure activities like driving and gardening. The reason for choosing this approach is that apart from pharmacotherapy, patient education, psychological coping with RA is important as a part of comprehensive disease management. Behavioural approach helps in improving resilience among RA patients based on principles of therapeutic concepts and mindfulness. It encompasses stress reduction that manages pain and enhances quality of life along with sustenance of resilience imparting overall well-being of patient (Dures and Hewlett 2012).Also treating depression can improve quality of life, and maybe even ease joint pain and inflammation associated with RA. This approach would be helpful in treating depression in Jozef as his mood is directly related to his thought pattern.  When his thinking becomes positive and functional, it would help to restore his behaviour, sense of self, physical state like joint pain and stiffness (Davis et al. 2015).

Behavioural approach is a structured, semi-sensitive and client oriented that is directed to solve symptoms of anxiety and depression associated with disease and teach skills that modifies the dysfunctional behaviour and thinking (Davis and Matteson 2012). RA brings about depression in people as the sense of living with pain poses potential disability making the patient feels hopeless and helpless (Matcham et al. 2013). Pain in RA is associated with psychological symptoms like depression and feeling of helplessness. In the given case study, Jozef is highly depressed as he unable to perform his daily activities and spend time in gardening. His wife stays in Devon to look after his mother and due to flare up RA symptoms; he is unable to drive to join her in Devon after he finishes work on Friday evening. He finds this upsetting and there is limited public transport and no Catholic Church that makes him feel depressed. Because of RA, he is off from work from last two months making him feel lonely, depressed and fatigued. He cannot carry out his hobbies, as he is incapable of performing them due to grappling RA pain. This clearly shows that individuals who experience depression have a limited quality of life and diminished level of occupational performance as suggested in literature (Lim, Jin and Ng 2012).

Principles of Biomechanical Approach

Behavioural approach in occupational therapy helps individuals to get through the everyday activities and improve quality of life. The intervention that is important for Jozef is psycho-education that is a part of behavioural approach in occupational therapy. It would be helpful for him to make better choices and lead a normal life despite of the illness (Hewlett et al. 2011). This can be achieved when he knows about his clinical condition and treatment. The autonomy of patient is valued and respected throughout the treatment where the client and therapist are active partners and responsible for the conduct of behavioural therapeutic approach. This is an appropriate intervention for Jozef experiencing health problems and issues associated with medical treatments. Psychosocial interventions are important for him as he is experiencing depressive mood due to functional disability, joint pain, fatigue and feeling of helplessness as he is away from his family and work. There is sufficient evidence in literature that behavioural therapy is an effective and adjunctive treatment for RA that help in improving the psychopathology, disability, levels of pain, joint function and biological indicators associated with RA (Manning et al. 2014).

The assessment of depression in RA is important for Jozef that evaluate the level of depression and its impact on his daily functioning and occupational performance. Health assessment questionnaire (HAQ) is helpful in the assessment of depression in patients with RA and so, it is helpful in addressing the depression and its root causes. In addition, Hospital Anxiety and Depression Scale (HADS) also helps to evaluate the occurrence of depressive symptoms in Jozef. It consists of standardized questionnaire that would be helpful in suggesting the level of depression in Jozef based on score ranging from zero to three. As mentioned above, RA also causes depression in patients, so HADS scale assessment would be helpful in knowing his thought pattern, and depression level and interventions would be developed accordingly. 

Pharmacological interventions work better with psychological approach in the proper treatment and management of disease. Jozef feel hopeless as he cannot help his wife and extremely worried that he is being marked as a bad employee. He is dwelling on negative thoughts and pre-occupied with it. He is very particular about his appearance and lack of self-care made him quiet and tearful gradually making him unmotivated and feeling of hopelessness about his future. The aim of this intervention is to help him learn coping mechanisms and to live with RA. He needs to be motivated so that he can perform his daily activities and develop an adaptive attitude towards the disease.

The strategies include illness education, relaxation training, attention diversion training, and assertiveness, cognitive restructuring that foster positive attitudes towards the illness (Benka et al. 2014). It would also be helpful for Jozef to manage flare-up RA symptoms and life-risking situations and reduce levels of depression.

From the above discussion, it can be concluded that biomechanical and behavioural approach are the two best approaches that would be helpful for Jozef. He suffers from excruciating pain due to flare-up symptoms of RA that is restricting his ability to perform daily tasks and be socially engaged.  He lost his occupational performance and ability to carry out activities of self-care, home management and perform heavy tasks at office. His wrist and ankle joints are painful and lost stamina to even stand and walk. As a result, he is having negative thoughts considering him an irresponsible husband and incapable employee. Therefore, as an occupational therapist, the employment of these two approaches can be helpful in the treatment and management of RA in Jozef. However, there are certain limitations of the approaches that fail to meet the needs of Jozef so that he leads a quality life.

Holistic and Psychosocial Approach of Biomechanical Therapy

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