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Copy of Occupational Therapy Case Study: Neurology

For presentation at Hospital Tengku Ampuan Rahimah (HTAR), Klang as requirement for Bach. OT - sem 1, 2013/14.

laura hartley

on 28 November 2014

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Transcript of Copy of Occupational Therapy Case Study: Neurology

Background photo by t.shigesa
Introduction & Evaluation
Outcomes & Prognosis
Neurology Case Study:
Traumatic Brain Injury (TBI) with Left Hemiparesis

Preliminary Information
53 y/o, forklift driver
50 y/o, housewife
15 y/o, high school student
19 y/o, college student
Ruban S.
I / 22 y/o / Hindu
Education/Work History
completed SPM
employed - despatch worker - until MVA
on MC until 13 Nov. 2013, extended to 15 Mar. 2014
Medical History
o- smoking, o- alcohol
Medications: for post-surgery recovery, unknown side-effects
Case History
2nd Aug. 2013
HTAR - HSB until 23rd Aug. 2013
suffered traumatic injury to the brain
TBI with Lt- hemiparesis
Signs & Symptoms
location- & severity-specific
Physical functioning
Cognitive functioning
Behavioral control
Perceptual skills
Sensory functioning
Rt hemisphere/side of brain structure
focal/multi-focal/diffuse BI
Type of impact/extent of damage
Physical Fx
muscle weakness b/s U/LE
reduced functional endurance
pain w AROM of all extremities
Cognitive Fx
mpaired memory
impaired processing skills
Speech & Communication
speaks in lowered volume
difficulty initiating speech
answers in single words
Reason for Referral:
ADL training, cognitive training

6 . 11 . 13
15 . 11. 13
25 . 11 . 13
2 . 12 . 13
Male Young Adult
Financial independence, contribute to family household, have a circle of friends to spend time with, have an anticipated plan for career or personal advancement in life.
Eldest Son/Brother
contribute financial/social support to parents: emergency-support, run errands, participate in gatherings, maintain relationship with younger sisters.
Despatch Worker
delivering goods via MB - travel to multiple locations daily. Works irregular hours. Drives MB to/from work.
Participate in religious observances daily, and in occasional rituals at home/temple.
Personal Context
young unmarried adult - supported & living with family - earning own pocket money.
spends most of day at work or with friends - when at home, was not involved in specific activity.
was not involved in sports/music.
Temporal Context
Pt. had no definite plans for his future career - intended to "find a girl and settle down when the time is right" - F
Physical Context
Pt.'s occupational performance occurred mostly at home, workplace and occasionally in public places - restaurants, futsal courts, shopping malls.
Cultural Context
Pt. is expected to have personal independence in occupational performance and financial needs d/t his age, background & abilities.
This requires having adeq. motor & cognitive functions.
Client Priorities:
Occupational Task
Canadian Occupational Performance Measure (COPM) assessment date: 25 . 11 . 13
Barriers to Occupational Performance
Motor & cognitive impairments - pt. unable to perform any task from areas of
B/IADL, and social participation
without max. assist. from care-givers.
Motor & cognitive impairments - pt. unable to return to
roles and perform desired
Edema: nil.
Subluxation: nil.
Scars: 2-3cm scars on dorsal hand, x2-3 on each hand. No skin breach
Body Functions
Mental Functions
: MMSE done
6 . 11 . 13
15 . 11 . 13
2 . 12 . 13
Impaired memory
impaired orientation of time, place, person
impaired working memory
impaired procedural memory
impaired episodic memory
Impaired higher mental functions
Reading, spelling
Abstract thinking
Attention, concentration: able to sustain concentration throughout ax, except when pain is felt.
Sensory function & Pain:
Neuromusculoskeletal and Movement-related Function:
Muscle Strength
Voice & Speech Function:
Light Touch (cotton): nil. at Lt hand - elbow
Pain (pinwheel): normal
Monofil.: not done d/t impaired processing skills
Vision: normal
Hearing: normal
ltd AROM d/t pain
Grip Strength
Lateral Pinch
2-point Pinch
3-jaw Chuck
R: 2 L: 0
R: 2 L: 0
R: 4 L: 0
R: 2 L: 0
1.5, 0.5
0.5, 0
0, 0
1.5, 0.5
0.5, 0
0.5, 0.5
1, 0
0, 0
0.5, 0.5
1.5, 0.5
0.5, 0.5
1.0, 0
Pt. speaks in low volume, single-word responses.
3-5 sec. to answer.
Was not shy/did not have difficulty speaking.
Body Structures
Body Functions
Performance Skills
Motor & Praxis Skills
Gross Motor Skills:
Postural control: no issues
Physical endurance: <5 min.
uses quadrupod
slow gait
Berg's Balance Scale (BBS)= 20/56 - high risk of falls
Fine Motor Skills:
Pt. able to perform all prehension patterns - w marked weakness.
Communication & Social Skills
Unable to initiate communication w gestures/facial expressions/verbalization - difficult
Able to respond w single-words, nods/shakes
Emotional Regulation Skills
Pt. able to control behaviour appropriately.
Pt. unable to express emotions.
Pt. has difficulty smiling, able.
Areas of Occupation
Modified Barthel Index (MBI):
MBI Score
Lawton IADL Scale
items expected to score:
ability to use telephone
arranging transportation
responsibility for own medications
ability to handle finances
Carers - return to employment.
Pt. unable to go out with friends.

Ruban's Fit: "Person" vs. "Occupation" vs. "Environment" fit
What needs fitting? - Prioritized Problems List
Acute stage of rehab. - intensive adjunctive training.
Prioritized Problems List
Short-term Goals
Long-term Goals
Inability to initiate communication d/t dysphasia.
Severe memory deficits.
Reduced joint ROM of shoulders d/t pain.
Reduced muscle strength and endurance.

Pt. to achieve full independence in BADL.
Pt. to be able to participate in tasks of IADL.
Pt. to be able to find a suitable employment opportunity.
Pt. to return to desired leisure occupation/social participation (family, friends & society).
To improve communication skills.
To improve memory functions.
To reduce pain in both UL.
To improve AROM in both UL.
To improve strength in both U/LL.




STG #1: To improve communication Skills.
Intervention #1: Providing opportunities for communication.
Intervention #2: Writing practice (home program).
STG #2: Improve Memory Functions.
STG #3: To Reduce Pain in both Upper Limbs.
STG #4: To Improve AROM.
STG #5: To Improve Strength and Endurance in both Upper Limbs and Lower Limbs.
Frame of Ref:
Client-centered FOR
Workbooks/worksheets: Practice writing words/names of every-day objects (with pictures) - copying, repetitive practice.
Functional writing: Encourage Pt. to write what he intends to express - however Pt. unable to perform.
Repetitive writing and naming activities improve this ability with people with aphasia. "Message therapy" uses intrinsic motivation, pt.s are able to generalize into daily functional communication. (Robson et al. 2010).
Frame of Ref:
Client-centered FOR
Apply principles in social approach to aphasia (Simmons-Mackie 2000):
Emphasize authentic, relevant and natural contexts.
Assume that communication is designed to meet the dual goal of social interaction and transaction of messages.
Allow time for pt. to answer
Provide assist. = multiple-choice answers, modify question to closed-type, provide meaning to options of answers, use short and comprehensively worded questions.
Let pt. know that he is allowed to speak/gesture at any time during therapy.
The social approach emphasizes goals that enhance social participation to the extent that the pt. desires. (Simmons-Mackie 2000)
Intervention #1: Memory Training.
Intervention #2: Reality Orientation Therapy.
Frame of Ref.:
#1 Orientation Drills
Presentation and repetition of orientation information throughout therapy at regular intervals (every 30 minutes).
#2 Task-Specific Activity - Orientation-related
ADL training according to sequence in daily routines.
Pt. is re-oriented to time-of-day practiced.
Reality Orientation is associated with significant improvements in both cognition and behaviour. (Spector et al. 2000)
It creates continuity and awareness from constant stimuli presentation, allwoing neural reconnections.
Frame of Ref.:
#1 Memory Drills
Use image cards. Introduce to Pt. the images (registration, encoding, storage). Explain to Pt. if needed.
Revise with Pt. about each image. Ask Pt. questions about image - e.g.: "What is this?", "What is it for?", "How is it used?" (retrieval).
#2 Task-Specific Training: ADL Simulation
Cued ADL sequences: practice of ADL tasks (dressing and toileting).
Therapist provides cues for the next step in sequence if Pt. does not perform/incorrectly performs within approx. 5 seconds of completion of previous step.
Apply consistent practice & cue fading principles.

Higher frequency of cortical activation results in adaptation in neural connections thus enhancing performance. (Hempel et al. 2004)
Practice in actual setting promotes better function due to direct application of skills in desired situations. There is paucity in evidence of generalizability of skills learned. (Singer & Cauraugh, 1985)
Intervention #1: Therapeutic Modalities.
Frame of Ref.:
Biomechanical FOR
1 Physical Agent Modality
Superficial heat: paraffin wax, fluidotherapy.
#2 Transcutaneous Electrical Nerve Stimulation (TENS)
Battery-powered generator that sends mild electrical currents through electrodes.
Placed on the skin at or near pain site.
Heat increases local metabolism and circulation. Vasoconstriction occurs initially, followed by vasodilation causing muscle relaxation. (Engel 2013)
Stimulation of A fibers block pain signals to the brain. (Engel 2013)
Ischemia—e.g., arterial insufficiency
Metabolic requirement of the limbs is increased with the use of heat. (Note: for every 10° increase in skin temperature, there is a 100% increase in metabolic demand.)
Bleeding disorders (e.g., hemophilia), Hemorrhage—there is an increased arterial and capillary blood flow with heat
Impaired sensation—e.g., spinal cord injury (SCI) may predispose to burns
Inability to communicate or respond to pain—e.g., dementia
Malignancy—May increase tumor growth
Acute trauma or inflammation—Diffusion across membranes is increased
Scar tissue—Elevation of temperature increases the metabolic demand of the tissue. Scar tissue has inadequate vascular supply, and is not able to provide an adequate vascular response when heated, which can lead to ischemic necrosis.
Edema—Diffusion across membranes is increased
Atrophic skin
Poor thermal regulation
Pregnant women
Placement at lumbar spine or abdomen
Pt.s with installed pace-makers.
Frame of Ref.:
Biomechanical FOR
Activity levels are increased on a gradual basis, as opposed to pain before rest period.
Rest periods are scheduled within task performance.
Pt. not allowed to initiate rest period at onset or exacerbation of pain to avoid reinforcing pain behaviours (Huddleston 1961)
A gradual increasein activity lessens exacerbation of pain. (Huddleston 1961)
Intervention #2: Activity Tolerance
STG #2: To Improve Memory Functions.
Intervention #1: Goal-Management Therapy
Intervention #2: Compensatory Strategies Training
STG 4 & 5: Improve AROM, Strength & Endurance of Upper & Lower Limbs
Intervention #1: Progressive-Resistive Exercises (PRE)
Intervention #1: ROM Exercises.
Intervention #2: Stretching Techniques.
Frame of Ref.:

Method #1: Manual Therapy
Joints are moved by therapist/caregiver.
Limbs should be well supported with stable positioning to prevent joint trauma.
Movements should be slow and rhythmic and within Pt.'s tolerance.
Method #2: Therapeutic Exercise
Joints are moved entirely by Pt. or max. 50% by therapist/caregiver.
Therapeutic Activities
Bilateral Ring Tree
Arm Skateboard
*apply Physical Agent Modality to muscles prior to exercise to improve extensibility and elasticity of muscles (Lentell et al. 1992).
Therapeutic Exercises improve blood circulation, decrease muscle atrophy, and improves motor function.
ROM exercises prevent joint adhesion/contractures, and instead maintains joint mobility.
Intervention #2: Endurance Training.
Frame of Ref.:
Biomechanical FOR
Apply static stretching - muscle is elongated to tolerance at low speed and held for 20-30 seconds at end position.
Maintaining the position at maximal end range results in firing of Golgi tendon organs, resulting inhibition of the muscles being stretched through mechanisms of autogenic inhibition.
Static stretching improves muscle elongation and poses less danger for soft tissue tearing.
Frame of Ref.:
Biomechanical FOR
Using free weights - graded according to Pt.'s tolerance.
Functional activity: ADL simulation - resistance is provided by gravity and body weight is applied simultaneously to multiple moving segments.
e.g.: Dressing - moving UL against gravity to reach the end of shirt over back.
e.g.: Toileting - squatting puts resistance on b/s hip, knee and trunk flexors.
Combining strength training protocols with task-specific training is an effective strategy to maximize transfer gains of functional skills.
Strengthening protocols use the overload priniciple - to incur more force to muscle than normally applied (Enoka, 2002).
Frame of Ref:
Biomechanical FOR
Graded increase of length of time of repeated movements.
Applied in Therapeutic Exercise and Task-Specific Activity.
Avoid exertion over RPE scale value 4.
A proper endurance training program avoids over-exertion, overwork weakness and risk of injury (Aitkens et al. 1993).
Frame of Ref.:
Cognitive Behavioral FOR

Goal Management Training (GMT) (Robertson 1996) is a theoretically derived protocol that addresses that subset of executive functions serving maintenance of intentions in the self-regulation of behavior. Disruption of these functions cause neglect, or failure to execute intentions, which in turn can result in everyday dysfunction.
Frame of Ref.:
Cognitive Behavioral FOR
Memory Notebook - Pt. to practice noting down important items to remember for functioning.
Retrieval Practice - Pt. is presented with information-to-be-learned, Pt. is quizzed repeatedly, or given a variation of quizzing. This strategy will be used to retain semantic memory. - Time of retrieval attempts will be recorded and aimed to improve.
Memory notebook is effective in improving ADL scores and sense of memory self-efficacy in persons with cognitive impairments (Greenaway et al. 2013).
Retrieval Practice - effective in TBI survivors (Sumowski et al. 2013).
Increased retrieval effort or difficulty, and demonstrate the importance of retrieval success for retrieval-based learning activities (Smith & Karpicke 2013).
Intervention: ADL Training

Frame of Ref.:
Client-centered FOR
Task-specific Activity: select next prioritized task to be practiced.
Repeat practice and feedback - provide gradation.
Modified gradation for Dressing: undergarments, tight clothing, small buttons, jeans, back-zippers, two-piece suit.
Modified gradation for Toileting: practice proper sequence and actions with less assist., improved timing.
Gradation provides ability to develop underlying skills and to be practiced directly into functional task.
Grip Strength/Pinch Strength
once MMSE improved, progress to further cognitive assessments - LOTCA & COTNAB
Discharge Planning
Pt. scores >95% in MBI
Pt. able to participate in IADL tasks
Pt. able to manage employment opportunities
Pt. able to participate in leisure occupations/social participation.
Pt. will benefit from intensive HEPs. Treatment at home will be followed closely through schedule reports prepared by caregivers.
Medical: good - Pt. is young and is in good health condition. Neural plasticity is active and well-nourished.
Rehabilitation: fair - Pt. has potential to regain functioning d/t support from family, however extent of damage and client motivation may be a limiting factor.
as assessed in Roles and Contexts.
By Fatimah Az-Zahraa, A131153
For NK4035 (Penempatan Klinikal Neurologi)

A case from Occt. Ther. Unit, Hospital Tengku Ampuan Rahimah (HTAR), Klang
Personal Hygiene = 0
Bathing = 3
Toileting = 2, 5
Dressing =5, 8
Minimal assist.
Chair/bed transfers
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