Occupational Therapy Case Presentation (Neurology)

Prepared by: Teoh Jou Yin (A 118729)Occupational Therapy ProgrammeFaculty of Allied Health SciencesNational University of Malaysia

Occupational Therapy: Helping people live lives THEIR way.

~ British Association of Occupational Therapy

Demographic Data

Name: N

Age: 60

Marital Status: Married

Race: Malay

Religion: Muslim

Diagnosis: Lt Posterior Communicating Artery Aneurysm

Date of Referral: March 2010

Date Seen: 23 Sept 2010

What is Occupational Therapy’s role?

To FACILITATE / ENABLE / EMPOWER clients to engage and participate in life processes and activities that are important and of value to them, i.e. to do the things in life that they want to do and need to do.

(Teoh et al. 2010)

How to do that?

CONCEPTUAL MODEL

OF PRACTICE

Conceptual models of practice describe phenomena of interest like “occupation” or “occupational performance”, guide treatment approaches by easily allowing therapists to focus on the right problem areas, and help to predict outcomes in clinical interventions.

(Iwama 2010)

The Kawa Model

The essence of the Kawa Model (Iwama 2006) is basically to enable occupational therapists everywhere to “just ask the client how they want to live their lives so that it is more meaningful to them, and look together with them at what we can do to achieve that.”

The Kawa Model can be used as a conceptual model of practice, frame of reference, assessment tool and modality. (Iwama 2010)

It can be used with any population since it is based on the client's own perceptions of what is important to them, and the only possible contraindication is an occupational therapist unskilled in the therapeutic use of self.

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FRAMES OF REFERENCE

FORs can be defined as the principles behind practice specific to a client population.

FORs include a statement of the population to be served, guidelines for determining adequate function or dysfunction, and principles for remediation.

(Bruce & Borg 1987)

Neuro Developmental Frame of Reference (Pendleton & Schultz-Krohn 2006)

Neuro: brain function

Developmental: Components of movement required to develop.

Core principles:

1. Individualize functional outcomes – provide interventions specfic to client’s context.

2. Emphasise motor control – quality of movement

3. Increase active use of the involved side – manual cues and progressive challenge

4. Provide Practice to improve motor performance leading to motor learning.

5. 24 Hour management to increase retention and turnover.

6. Interdisciplinary approach.

OCCUPATIONAL THERAPY

PERFORMANCE FRAMEWORK

A summary of interrelated constructs that represent and guide occupational therapy practice and articulate occupational therapy’s

contribution to promoting health and participation through engagement in occupation.

(AOTA 2008)

Areas of Occupation-Activities of daily living (ADL)- Instrumental activities of daily living (IADL)- Rest and sleep- Education- Work- Play- Leisure- Social participation

Client Factors-Values, beliefs and spirituality- Body functions- Body Structures

Context & Environment-Cultural- Personal- Physical- Social- Temporal- Virtual

Performance Skills-Sensory perceptual skills- Motor and praxis skills- Emotional regulation skills- Cognitive skills- Communication & social skills

Performance Patterns-Habits- Routines- Roles- Rituals

Activity Demands-Objects used and time properties- Space demands- Social demands- Sequencing and timing- Required actions- Required body functions- Required body structures

EVALUATION

SUBJECTIVE EVALUATION

STEP 1: FIND OUT WHAT THE CLIENTS WANT AND NEED.

Kawa Interview (23/9/2010, 30/9/2010)

Blue - river - life flow and overall occupationsRed - river walls and floor - environments, social & physicalLilac - rocks - circumstances that block the river flow and cause dysfunction/disabilityYellow - driftwood - personal resources that can be assets or liabilities.

Life Flow / Overall OccupationsSignificant events and activities that the client regards as important, meaningful

and of value.

Past -Client used to work as clerk.- Now retired.- Attended religious classes for adults in UIA Gombak (10 mins drive from home)- Enjoys socialising and going for drives- Does household chores, i.e. cooking and cleaning.

Present -Spends time at home in room while waiting for husband to come home from work.- Reads religious books, watches television- Husband does cooking, community management.- House chores being managed by hired helper once a week.- No longer visits friends, friends come instead

Future - Client hopes to be able to drive again- Cilent wants to be able to “be as normal again as possible”.

EnvironmentsThe variety of interrelated conditions surrounding the client in which the client’s

daily life activities occur. (AOTA 2008)Social Environment Family history:

-Husband age 62- 4 sons, ages 31, 30, 25, 24.- 2nd and youngest son are still staying at home.- children do not help with housework, all working.

Friends mainly from religious class.- Friends go to her house to visit her regularly.

Physical Environment -Single storey house- Sitting toilet at home- Client only stays in house, does not go out to garden.- Client has restricted herself to certain areas of home only, i.e. bedroom and living room.- Client says that hardly thought of going to other areas of home after incident.

Obstructions to Life FlowOccupational performance difficulties

- Nominal aphasia (difficulty finding words.)-Gait problems during ambulation.- Client c/o toileting and bathing.

Fears and concerns -Fear of falls.- Feeling bored staying at home- Low self esteem “I feel stupid” (because of nominal aphasia)

Inconvenient circumstances

- No transport when husband is not around.- Public transport inconvenient.

Impairments / Medical Conditions

- Right side hemiplegia.- Learned non-use in affected limb.- Limited ROM in right upper limb, gross motor movements.- Muscle tone in distal right upper limb, flexor synergy.

Observation & Interview

- Client does not perform home programmes (c/o cannot remember to do them regularly.)- Client is disengaged from therapeutic process.- Client is experiencing occupational self-deprivation: does not attempt to even try activities that she used to do, i.e. going to areas of the house like balcony.

Personal Assets & Liabilities(Client & Family)

Personality Traits - Client used to be active outgoing person.- Client becomes easily anxious during therapy sessions.- Client is someone who is concerned about self image.- Client thinks a lot.- Client demonstrates high passivity after incident, i.e. does not dare to go to other areas of own house, etc.

Family Resources - Client’s husband very accomodating, patient person.-Financially ok as husband is still bringing in source of income.- Children all grown up, not much financial burden.

EVALUATION

OBJECTIVE EVALUATION

STEP 2: VERIFYING THE DETAILS.

AREAS OF OCCUPATION

Categories articulating “the many types of occupations in which clients might engage” (AOTA 2008)

Activities of daily living (ADL), Instrumental activities of daily living (IADL), Rest and sleep, Education, Work, Play, Leisure, Social participation

Areas of Occupation

1. Activities of Daily Living (MBI) – 23.9.2010

Activity Score Description

Personal Hygiene 5/5 Fully independent.

Bathing 3/5 Help required in some areas. (Moderate)

Feeding 10/10 Fully independent.

Toileting 5/10 Help required for washing. (Moderate)

Stair Climbing 8/10 Minimal help required.

Dressing 8/10 Minimal help required.

Bowel Control 10/10 Fully independent.

Bladder Control 10/10 Fully independent.

Chair/Bed Transfer 15/15 Fully independent.

Ambulation 15/15 Fully independent. (at home only)

Total 89/100 Mild dependency

CLIENT FACTORS

Specific abilities, characteristics or beliefs that reside within the client and may affect performance in occupation. (AOTA 2008)

Values, beliefs & spirituality; body functions; body structures

Client Factors: Body FunctionsNeuromuscular skeletal and movement related functions

Dominant hand: Rt Affected hand: Rt

Joint Range of Motion: (23 / 9 / 10)

Lt UL AROM: full

Rt UL ROM:

1. Shoulder external rotation: AAROM 90, AROM 502. Shoulder abd/add: AAROM 80, AROM 603. Shoulder Extension: AROM 20,4. Shoulder Flexion: AAROM 120, AROM 20 (will produce compensatory movements)5. Elbow: AAROM 70-160, AROM 70-1106. Forearm: No movement, remains in supine postition7. Wrist: No movement.

Muscle Tone (Modified Ashworth Scale)

Right arm and forearm: 0 / 5Right wrist and fingers: 3 / 5Left upper limb: 0 / 5

Activity Demands

Specific features of an activity that influence the type and amount of effort required to perform the activity. (AOTA 2008)

Activity Demands (Activity Analysis) – 30 / 9 / 10

#1 Ambulation- pt walks with abnormal gait- rt knee straightened- rt hip in abduction- rt ankle shows eversion when lowering foot

#2 Toileting- pt's toilet and bathroom layout was evaluated and drawn out- pt's tap and hose is on rt side of toilet bowl, towards the back end close to the wall.- pt has difficulty reaching for hose with left hand.- pt does not use toilet paper at home- pt can wash self using hose only, but not clean enough as unable to douche with other hand- pt is able to wipe self and put on garments including panties.

Contexts & Environments

The variety of interrelated conditions surrounding the client in which the client’s daily life activities occur. (AOTA 2008)

Home (Bathroom Assessment) – 30 / 9 / 10

Problems:- Client unable to reach

for pipe to wash after toileting.

- Client might have safety concerns getting up from toilet bowl

- Client at risk of falls (instable gait + potentially slippery floor due to shower area being right in front of toilet bowl).

INTERPRETATION

Identifying and prioritising AIMS.

STEP 3: IDENTIFYING AND PRIORITISING AIMS.

Prioritised Problem List Short Term Goals

Client has safety concerns: fear of falls. To address safety concerns during functional ambulation

Client is experiencing disengagement from therapeutic process.

To involve client in more participatory role in therapeutic process.

Client has difficulty with emotional regulation (easily anxious) to extent of affecting performance.

To develop emotional regulation strategies for anxiety.

Client wants to regain hand function in affected hand.

To regain hand function in affected hand.

Client neglects to use affected hand in daily activities and to perform therapeutic exercises as prescribed.

To correct learned non-use of affected hand.

Long Term Goals

To regain participation and engagement and participate in life processes and activities that are important and of value to client.

INTERVENTION

STEP 4: OCCUPATIONAL THERAPY TREATMENT PLANNING

Problem: Client has safety concerns: fear of falls. (30/9/10)

Aim: To address safety concerns during functional ambulation.

Intervention: Gait training (Pendleton & Schultz-Krohn 2006)

Method:- Pt was given prompts to raise knee while walking, hip will naturally align

into proper position.- Pt was also given prompts to invert ankles when lowering foot.- Duration for practice was also provided: 10 mins.- Therapist uses modelling, walking alongside patient at a diagonal angle in

order for patient to mimic movements. - Carer was also educated to observe patient movements during ambulation

in order to provide cues when appropriate.

Problem: Client is experiencing disengagement from therapeutic process. (Noted since 23/9/10)Aim: To involve client in more participatory role in therapeutic process.Intervention: Collaborative Goal Setting Activity between therapist and client. (30/9/10)

Method:- Pt was asked to evaluate and express feelings about progress in therapy

from referral and first visit to present.- Pt was then educated on why she has to take responsibility and initiative to

perform home programme- i.e. that once a week therapy was insufficient, that she cannot depend on

therapist entirely to take responsibility for her recovery. - Pt was encouraged to set timeline for herself to evaluate progress with

goals- Metaphor of running a race and training for race so can reach finish line

was used.

It is not what the therapist “does” to the patient, but how the client takes on board the info presented and uses it himself. (Cotton 2005)

Problem: Client has difficulty with emotional regulation (easily anxious) to extent of affecting performance.

Aim: To develop emotional regulation strategies for anxiety.

Intervention: Relaxation techniques are incorporated into home programme i.e. deep breathing and imagery. (30/ 9/ 10)

Method:- Pt is taught to exhale when performing movements that are more strenous (i.e.

require high muscle tension) and inhale for less strenous movements.- Pt is also taught to close eyes and take deep breaths when aware that she is

beginning to feel anxious.- While closing eyes, client is taught to think of calming soothing images i.e.

beachside scenery, etc.- Outcomes: Pt is now able to perform movements smoothly and easily with

minimal fatigue.

Source: Conscious Relaxation (Cotton 2005)

Problem: Client wants to regain hand function in affected hand.Aim: To regain hand function in affected hand.Intervention: Bilateral isokinematic training (Cotton 2005) - 23 / 9 / 10

Method:

- Air splint was first applied to affected hand to address flexor synergy.- Visual imagery was used, together with deep breathing.- Pt was asked to relax, close eyes, and visualise both hands opening

and closing in slow, controlled movements. (Fine motor movements.)- Gross motor movements were addressed by means of shoulder

extension exercises (both hands clasped together.)- Pt was also educated about purpose of activity and how to perform it at

home.- Pt was also encouraged to involve affected side in typical everyday

movements i.e. wiping, raising hand to switch, etc.

Problem: Client neglects to use affected hand in daily activities and to perform therapeutic exercises as prescribed.

Aim: To correct learned non-use of affected hand.

Intervention: To develop home programme that is appropriate to client’s condition and life schedule. (23 / 9 / 2010)

Method:- Client’s daily life schedule was evaluated via interview.- Pt is taught to make use of television viewing times as home programme

exercise times. - Pt watches tv at 11am, 6pm and 10pm.- Pt was told to perform programme throughout the entire duration of the show

(typically 1 hour.)- Exercises as taught in bilateral isokinematic training are applied into home programme (gross and fine motor movements.)

Rationale: According to Bobath principle to provide interventions specfic to client’s context. (Pendleton & Schultz-Krohn 2006)

Reevaluation (30/9/2010)

Activity Analysis - Execution of home programme (Upper extremity gross motor movements, bilateral shoulder raises.)

Aim: To identify possible reasons why pt is not compliant to home programme.

Method: Pt is asked to demonstrate how she performs exercises at home.

Findings: Pt is easily agitated when trying to perform movements, will tense muscles and hold breath, causing easy fatigue.

To address: Pt was taught to utilise proper body movements and alignment and incorporate with emotional regulation exercises. Rhythmic breathing was also taught. (Cotton 2005)

Prognosis

Good.

Client has good environmental supports, however much depends on client’s internal locus of control and ability to engage as active part of therapeutic process. Further therapy recommended to address psychosocial issues especially by means of therapeutic use of self.

Future Plans

Continue occupational exploration.Home visit.Reevaluate interventions.Further assessment of hand disabilities.Community mobility.Driving assessment.

"We simply come into (our clients‘) lives as a visitor/tourist - short period.“

~ Dalai Lama

Further Questions or Discussion?

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Dr Michael Iwama will be happy to hear from you.

(As well as 1500+ OTs from 6 continents all around the world.)