Occupational Therapy Functional Capacity Assessment

Client Details

• Name: Arthur James Pendelton
• Date of initial assessment: 14/05/2024
• Date of birth: 22/08/1966
• Address: 42 Banksia Street, Joondalup WA 6027
• Phone number: 0412 345 678
• Email address: a.pendelton66@email.com.au
• Next of Kin name and number: Margaret Pendelton (Wife) - 0412 876 543
• Persons present during Ax: Arthur Pendelton, Margaret Pendelton
• Funding body: NDIS (Plan-managed)
• Medical and health history: Secondary Progressive Multiple Sclerosis (SPMS) dx 2012, HTN, neurogenic bladder, chronic neuropathic pain, mild depression.
• Medications: baclofen 10 mg PO TID, pregabalin (Lyrica®) 75 mg PO BID, perindopril 5 mg PO daily, escitalopram 10 mg PO daily, oxybutynin 5 mg PO BID.
• GP details: Dr Sarah Jenkins, Joondalup Medical Centre, (08) 9300 1122
• Living Situation: Lives in a privately owned single-storey brick home with his wife, Margaret.
• Current community services / social supports and/or allied health input: Support worker (SW) 10 hrs/wk for domestic assistance and community access; Physiotherapy fortnightly for hydrotherapy and maintenance exercise.
• Referrer and reason: Chloe Evans (Support Coordinator) for NDIS plan reassessment and Functional Capacity Assessment (FCA), plus trial/prescription of a Powered Mobility Device (PMD) due to progressive lower limb weakness and severe fatigue.

For FCA's

• Level of schooling: Completed Year 12 and Certificate III in Carpentry.
• Employment history: Worked as a commercial carpenter for 25 yrs; medically retired in 2018 due to MS progression.
• Social story, family: Married to Margaret for 32 yrs. Two adult children living locally in Perth who visit weekly.
• Supports that aren't official: Wife provides daily assistance with meal prep, heavy domestic tasks, transport, and standby/minimal assistance for evening ADLs when fatigued.
• NDIS paid for supports: 10 hrs/wk Core Supports (assistance with daily life and community participation); Capacity Building funds for OT and Physiotherapy.

NDIS Information

• NDIS number: 430 892 104
• Plan manager contact details: MyIntegra Plan Management - (08) 9468 7300, enquiries@myintegra.com.au
• Support Coordinator details: Chloe Evans, West Coast Coordination - 0433 221 987, chloe@wccoord.com.au
• Plan dates: 15/06/2023 to 14/06/2024

Other Relevant Information

• Perceived strengths: Resilient, good problem-solver, mechanically minded, strong family support.
• Things wanting to work on: Energy conservation, safe outdoor mobility, maintaining upper limb strength for transfers.
• Fine and gross motor skills: Gross motor impaired by bilateral lower limb spasticity and ataxia. Fine motor impacted by mild intention tremor and bilateral palmar paraesthesia (R > L), reducing dexterity for buttons/zips.
• Sensory needs: Heat intolerance (Uhthoff's phenomenon) exacerbates fatigue and weakness; requires reverse-cycle AC during summer. Decreased sensation in bilateral feet.
• What's something really important to you that you are wanting to do: Independently access the local park and shops without relying on wife to push a manual wheelchair.
• Sleep: Interrupted 2-3x/night due to nocturia and lower limb spasms. Uses a profiling bed to assist with repositioning.
• Social skills/ friends: Socially appropriate and engaging. Attends local Men's Shed fortnightly when fatigue allows; catches up with former workmates monthly.
• Mobility: Ambulates indoors using a 4-wheeled walker (4WW) with a slow, wide-based, ataxic gait. Relies on an attendant-propelled manual wheelchair for community distances > 50 m.
• Assistive Technology Used: 4WW, attendant-propelled manual wheelchair, over-toilet frame (OTF), stationary shower chair, grab rails (bathroom/toilet), electric profiling bed, long-handled shoehorn, pick-up reacher.

Client/Participant - Reports

• Height (Self/carer reported): 178 cm
• Weight (Self/carer reported): 84 kg
• Hand dominance: Right
• Sitting tolerance/balance (Observed): Good static and dynamic sitting balance; tolerates 60 mins in supportive armchair before requiring posture shift for pain/spasticity relief.
• Standing tolerance & static balance (Observed): Fair static balance; requires UL support on 4WW. Max standing tolerance 2-3 mins before lower limb clonus and fatigue occur.
• Walking tolerance & dynamic balance (Observed): Poor dynamic balance; high falls risk when turning. Max walking distance 30 m indoors with 4WW before requiring seated rest. Foot drop evident on R side.
• Sit to stand transfers / other transfers (Observed): Independent with 4WW using UL push-off from firm surfaces; requires 1-2 attempts from low/soft surfaces.
• Car transfer: Independent with standby assistance from wife; uses swivel cushion and door frame for leverage. Wife stows 4WW/wheelchair in boot.
• Current Assistive technology in use (Self/carer reported + observed): 4WW, manual wheelchair, OTF, shower chair, grab rails, profiling bed, swivel car cushion.
• Number of falls in last 6 months (Self/carer reported): 2 falls indoors (tripped on rug edge due to R foot drop; lost balance turning in kitchen when fatigued). No fractures sustained.
• Vision (Self/carer reported): Wears multifocal glasses; history of resolved optic neuritis (L eye), nil current diplopia.
• Hearing (Self/carer reported): NAD.
• Cognitive capacity (Self/carer reported + observed + Ax): Alert and oriented x3. Mild slowed information processing speed and word-finding difficulties when fatigued, consistent with MS. Intact safety awareness and judgement.
• Pressure injury or ulcer history (Self/carer reported): Nil history of pressure injuries. Skin intact.
• Oedema issues (Self/carer reported + observed): Mild bilateral pedal oedema by late afternoon; managed with leg elevation on profiling bed.
• Recent hospitalisations in last month: Nil.
• Upper limb function (Observed): WFL AROM bilaterally. Strength 4/5 bilaterally. Mild intention tremor R UL on finger-to-nose testing. Reduced pinch grip strength.
• Sensory issues or concerns (Self/carer reported): Pins and needles in fingertips bilaterally; reduced proprioception and light touch in feet bilaterally; heat sensitivity.
• Communication issues (Self/carer reported + observed): Mild dysarthria when fatigued; functional verbal and written communication.
• Behavioural issues (Self/carer reported + observed): Nil behavioural issues. Occasional frustration related to loss of independence.
• Leisure activities/previous occupation: Former carpenter. Enjoys woodworking (modified tasks at Men's Shed), watching AFL, listening to audiobooks, spending time with grandchildren.
• Informal supports (Self/carer reported): Wife (co-resident) provides daily care; adult children assist with heavy yard maintenance as needed.
• Community access (Self/carer reported): Restricted; requires wife or SW for transport and wheelchair propulsion. Avoids outings in hot weather.
• Received previous OT input/assessment?: Yes, initial FCA and minor home modifications (grab rails) completed in 2022.

Home

• Type of home: Detached 4-bedroom, 2-bathroom single-storey brick and tile house.
• Main entry when entering/leaving home: Front door has a 120 mm step with a portable rubber threshold ramp currently in place; alternative flat access available via shoppers' entry in garage.
• Topography of block: Level block with paved driveway and flat rear patio.
• Presentation of property: Well-maintained, clean, uncluttered, wide hallways suitable for mobility aid circulation.
• Living situation: Resides with wife, Margaret.
• Time at current property: 18 yrs.
• Ownership of home: Privately owned (mortgaged paid off).
• Landlord details: N/A (Owner-occupied).

Pre-trial Powered Mobility Device (PMD) Questionnaire

• Are PMD users considered motorists or pedestrians?: "Pedestrian"
• At what speed should a PMD be driven?: "Maximum speed 10km p/hr"
• Where should a PMD be used or driven?: "Use the device on the footpath; travel on the road is allowed only when an appropriate footpath cannot be used"
• What position on the footpath should a PMD maintain?: "Keep to the left and yield to other pedestrians."
• If you have to travel on the road, should you be facing the traffic, or should it be behind you?: "When there is no footpath or nature strip, travel while facing approaching traffic."
• When approaching a road, what are three things you will need to consider before crossing?: Check for oncoming traffic in both directions, locate a safe kerb ramp/cut-out, and judge if there is adequate time to cross safely.
• In what position should the PMD be, prior to crossing kerb?: "Straight on/facing curb"
• Can you identify three potential problems or obstacles you may face on a footpath?: Overhanging tree branches, uneven paving/tree roots, and reversing cars from residential driveways.
• How can you make yourself visible to other pedestrians and drivers?: "Use a flag, bright clothing, and lights"

Self-care Activities

• Undressing/dressing: Self-reported: Minimum Assistance. Independent with upper body in seated position (avoids buttons); requires wife's assistance for socks and shoes due to reduced trunk flexion and fatigue.
• Showering/drying: Self-reported: Minimum Assistance. Showers seated on stationary shower chair using hand-held hose; requires wife's assistance to wash and dry lower legs and feet.
• Grooming: Self-reported: Independent. Completes teeth brushing, shaving (electric razor), and hair combing seated at vanity.
• Feeding: Self-reported: Independent. Uses lightweight cutlery; occasional spillage with liquids if tremor increases.
• Toileting: Self-reported: Independent. Uses OTF and bilateral grab rails for transfers; manages clothing and hygiene independently during the day (uses urinal bottle overnight).

Daily Living Skills

• Meal prep & cooking: Carer-reported: Shares task with others or some assistance required. Client can prepare simple cold meals (sandwiches) seated at kitchen bench; wife completes all hot cooking and heavy lifting due to safety risks (heat, balance, tremor).
• Making cup of coffee/tea: Self-reported: Independent. Uses a kettle tipper and insulated mug to safely prepare hot drinks.
• Dish washing: Carer-reported: Shares task with others or some assistance required. Client can rinse light items; wife loads and unloads the lower rack of the dishwasher.
• Cleaning: Carer-reported: Dependent. Completed by SW and wife due to standing/walking tolerance limits and fatigue.
• Grocery shopping: Carer-reported: Shares task with others or some assistance required. Client accompanies wife/SW in manual wheelchair; unable to push trolley or reach high/low shelves independently.
• Making/stripping bed: Carer-reported: Dependent. Completed by wife and SW.
• Laundry: Carer-reported: Dependent. Wife and SW manage washing machine and hanging clothes due to carrying and standing requirements.
• Ironing: Carer-reported: Dependent. Completed by wife; unsafe for client due to tremor and balance deficits.
• Financial management: Self-reported: Independent. Manages online banking and bill payments via tablet.
• Medication management: Self-reported: Shares task with others or some assistance required. Uses pharmacy-packed Webster-pak; wife assists with popping foils when hand paraesthesia/weakness flares.
• Letterbox and mail management: Self-reported: Shares task with others or some assistance required. Wife collects mail due to sloping verge near street; client opens and sorts mail.
• Wheelie bins and rubbish management: Carer-reported: Dependent. Wife takes wheelie bins to kerb.
• Pet care: Self-reported: Shares task with others or some assistance required. Client brushes pet dog while seated; wife manages feeding and walking.
• Lawn and garden maintenance: Carer-reported: Dependent. Managed by funded gardening service and adult children.
• Managing needs of children: Self-reported: Independent. Children are independent adults.
• Phone use / appt making: Self-reported: Independent. Uses smartphone with voice-to-text function to make calls and schedule appointments.
• Driving / Public transport: Self-reported: Dependent. Surrendered driver's licence in 2021; unable to access public bus stop independently due to distance (600 m) and fatigue. Relies on wife or SW for transport.

Client Goals

• To safely and independently access the local community (shops, park, Men's Shed) using a powered mobility device within 6 months.
• To maintain current level of independence in personal care transfers and indoor mobility, preventing falls over the next 12 months.
• To reduce carer burden on my wife by having consistent formal support for domestic tasks and community access.

Progress Notes

• Completed home visit and initial FCA interview with Arthur and Margaret.
• Assessed indoor mobility, transfers, and home environment; identified need for a custom permanent threshold ramp at the front door to replace temporary rubber ramp ahead of PMD trial.
• Completed Pre-trial PMD Questionnaire; Arthur demonstrated sound cognitive awareness of road rules and safety considerations.
• Next step: Arrange joint equipment trial with AT supplier for mid-wheel drive power wheelchair vs. 4-wheel mobility scooter, and compile NDIS FCA report.