Running head: CASE STUDY: SARAH

Case Study: Sarah Kelly Garcia, Yuvkiran Kaur, Shanna Leavitt, Enrique Rivera, and Corinne Trenholm Touro University Nevada

CASE STUDY: SARAH Case Study: Sarah Occupational Areas Sarahs participation in daily life has been affected by her hemiparesis in upper right

extremities and limited sensory awareness at the same time. She has a left parietal lobe lesion, which is associated with mild disorientation with directions and spatial relations .Sarah is left hand dominant. Activities of Daily Living Sarah is able to take a shower but experiences difficulty washing her hair as it requires bilateral use of her upper right extremities (UREs) to shampoo, condition and rinse her hair. Transferring to and from bathing positions is a challenge for her since she neglects her right side. This is a definite safety concern as she is at risk for injury secondary to falling. She has a hard time wrapping towel around her body as she would need to have coordination and awareness of both her upper extremities (UEs). Dressing is another area of challenge for Sarah right now. She is able to dress and undress with SBA however she experiences difficulty putting on clothes that require bilateral mid line use of her UEs. She also requires verbal prompts to use of her RUE while dressing. This is very frustrating for Sarah because dressing, fashion, and looking trendy is part of who she is and is an important aspect of her social culture. While Sarah has no problems with eating and swallowing her food, it takes her longer than her peers. She also has difficulty opening jars that require her to use both UEs, and with stabilizing dishes while scooping food using a utensil. The thought of eating food at the same pace as her peers makes Sarah anxious because she does not want to stand out. Therefore eating lunch with her friends will be problematic for her.

CASE STUDY: SARAH Sarah requires minimal assistance for her self- grooming tasks however, has trouble

brushing and flossing her teeth, and manicuring her nails. Sarah also has trouble applying makeup and styling her hair. These grooming tasks are very important to her because looking good is necessary to be socially accepted as a teenager. Instrumental Activities of Daily Living Sarah has functional mobility wherein she is able to walk on different surfaces and is able to navigate up and down stairs. She walks with a slight limp and has difficulty when she has to walk carrying her lunch tray with both hands or while walking down the hallway holding her books. Sarah is slower than peers in typing on her laptop due to neglect of her right side and her lack of sensory awareness in her RUE. She only uses her unaffected arm and hand unless prompted to use her RUE. It is hard for her to text her friends and browse the web. Internet and phone are extremely important source of social interaction for teenagers and not being able to use these services proficiently can lead to frustration and isolation from her peers. Also computers are important tools needed to complete academic coursework. Sarah is not able to drive currently and her parents are responsible for bringing her to and from school. With weakness in her RUEs, right side neglect, and disorientation in spatial relations, it is not appropriate for Sarah to be driving on the road at this time. Sarah is slower than her peers in determining the amount of money needed to make a purchase and in the actual purchasing process. Her overall activity level is lower than normal due to her lengthy hospital stay. It takes her more time than before to prepare meals and do the clean-up afterward. She has trouble transporting items home after shopping which limits

CASE STUDY: SARAH her independence in this activity. All these activities such as eating out and shopping are important part of a teenagers life because it gives them the opportunity to interact with each other. Sarah wants to regain the ability to participate in all these instrumental activities independently. Rest and Sleep Sarah is able to rest and sleep without any difficulties but preparation before sleeping such as dressing, brushing teeth, flossing etc. is a little hard for her because a lot of it requires her to use both of her UEs. Education Due to motor and cognitive impairments Sarahs participation in academic, non academic and vocational activities has been effected. She experiences difficulty in math, reading, and using the computer to complete her academic coursework. This is due to weakness in her RUE, right side neglect, lack of sensory awareness. Sarah is a high school student and most of her activities that revolve around school have been significantly impacted due to her accident. Play Sarah enjoys playing video games and all sorts of board games. Due to weakness in her UEs she is slower than her peers in doing these play related activities Leisure

CASE STUDY: SARAH Sarahs participation in color guard and spirit club has been impacted by her motor and cognitive deficits. Sarah wants to get back to participating in these activities which are very important part to her and they also allow her to spend time with her friends. Social Participation Sarahs community involvement has been affected significantly because of her injuries. She is not able to drive anymore and cannot participate in school related activities which has

diminished her feelings of self-esteem and contributed to social isolation. She has not been able to spend time with her friends doing the activities she use to do before her accident. She expresses a desire to participate in these activities again and is motivated to engage in occupational therapy. Description of: Movement, Postural reactions, and Reflexes Movement There are various components to movement that must be present and functional in order for a person to independently complete daily tasks. Movement can be broken down into the following components: flexibility, coordination and timing, power, endurance, and muscle movement. All of these contribute to what is considered to be functional movement patterns. If one or more components are not functioning properly other components may be affected and compensation strategies such as adapting or modifying the environment might be necessary. Flexibility is a major contributing factor to overall movement ability. Lack of flexibility may result in decreased ability to participate in ADLs, IADLs due to decreased ROM. Sarahs lack of flexibility may affect her in the following areas: grooming, color guard, and school

CASE STUDY: SARAH activities within the classroom. Interventions that increase flexibility are likely to be effective due to her young age and is a primary concern for her and her family. The coordination and timing of muscles is also needed to produce movement and is necessary in order for Sarah to complete school work and participate in extracurricular activities, like color guard in which she expressed a desire to return to (Cronin & Mandich, 2005).

Due Sarahs right side neglect and RUE hemiparesis, her coordination and timing are not within functional limits which consequently affect her bilateral hand coordination. This can lead to deficits in balance that may affect her ability to walk symmetrically. However this can be circumvented with therapeutic interventions that target strength and ROM. Finally, Sarah must have the power and endurance necessary to develop tension and produce force in the muscles of her RUE so that she may complete the tasks required of her at home and in school. By developing strength and increasing her ROM, Sarah will be able to participate in daily activities more independently. Postural Reactions In Sarahs case, anticipatory reactions are needed to help her preset her body before movements in order to complete an activity. Presetting her body will allow Sarah to use protective reactions to keep herself from serious injury secondary to falls. Equilibrium reactions are needed to help her return her body to a vertical position after displacement. Due to her recent injury, she will have difficulties in all of these areas. Working on postural reactions will help Sarahs stability and equilibrium thus enhancing her overall occupational performance (Case-Smith & OBrien, 2009, p.255). Reflexes

CASE STUDY: SARAH When curling her hair or preparing and cooking meals, Sarah runs the risk for injury

because she lacks the feedback mechanisms for tactile discrimination and pain sensation sue to her injury. These reflexes are particularly important to address with Sarah due to her age, and our concern for her safety and well-being. Sensory integration As mentioned previously, Sarah has loss of sensation to her URE. Sensory loss to her right side puts her at an increased risk for injury. This loss of sensation also affects her movement patterns, and makes it difficult for Sarah to use her right side, in particular her upper extremity in all daily tasks. For example, in the school and home environment she will have difficulty feeling the keys on a computer keyboard causing her to slow down on school assignments as well as message her friends on Facebook which are important aspects of her social life. Grooming activities such as brushing her hair and applying her make-up will take longer because she will be relying primarily on her visual system instead of her tactile system. According to Case-Smith (2010), having proper integration of sensory stimuli is important for functioning at normal levels. This then translates to autonomy and the ability to formulate an adaptive response to feedback from the sensory system. All of the aforementioned information is important to consider when developing interventions for Sarah. Assessments Appropriate for Client In order to evaluate Sarahs cognition we used the Pediatric Test of Brain Injury (PTBI). This test is designed for kids recovering from brain injury between the ages of 6-16 yrs. It is a criterion referenced standardized test that assesses the skills children need to return to school and function in general education curriculum. The PTBI helps providers determine

CASE STUDY: SARAH neurocognitive, language, and literacy abilities. It can then be used to identify personal strengths and weaknesses, and implement effective interventions.

The PTBI may be used to monitor functional changes, track recovery patterns over time, and guide decision-making related to school reintegration. This tool focuses on critical areas for success in school such as listening, speaking, reading, writing, gesturing, working memory, and problem solving. This test was appropriate to use with Sarah since she is 16 years old, recovering from a brain injury, and is in the process of transitioning back into the school system (Paul H. Brookes Publishing Co., n.d.). To gather the necessary information about Sarahs actual motor skills, the BruinicksOseretsky Test of Motor Proficiency-Second Edition (BOT-2) was utilized to provide a detailed and comprehensive picture of her current skill level. It also helped to identify the motor areas for which she is weak. Sarahs performance results showed her scoring below average in balance, bilateral coordination, upper-limb coordination, and fine motor precision. In using this assessment tool, a tailored program was developed to fit her needs. In addition to the BOT-2, the Functional Independence Measure (FIM) assessment tool was used to measure and predict how much assistance Sarah needed to complete her ADLs. Sarah was given this assessment when she initially arrived at the rehabilitation hospital. This assessment was critical in identifying her current level of independence in self-care, mobility, locomotion, communication, and social cognition (Case-Smith & OBrien, 2009, p.480). She scored particularly low in the following areas: grooming, upper body dressing and lower body dressing.

CASE STUDY: SARAH Functional Problem Statements The following five items are the functional problem statements regarding Sarah's case: 1. Due to decreased endurance, strength and ROM in her RUE, the client is unable to play videogames. 2. The client is unable chat with her friends online due to decreased endurance, strength, and sensory loss in her right upper extremity.

3. Client requires min assistance in grooming due to limitations and sensory loss in her right upper extremity. 4. Due to right-sided neglect, the client requires verbal prompts to complete all occupational activities that require the use of both arms and hands. 5. Client is unable to participate in social activities due to limitations in her right upper extremity, decreased endurance, sensory loss, and mild cognitive impairments. Family/Caregiver/Client's Goals The following five items are the goals Sarah specified. Sarah would like to get back to attending school again, driving, participating in extracurricular activities, spending time with her friends, and have the ability to use her right arm and hand better because she wants to "look normal" again and not like a freak. Occupational Therapy Goals The following three items are the goals that were developed by Sarah, her family, and the occupational therapist. 1. Taking no longer than one hour, client will independently complete her morning grooming routine before going to school within 6 weeks.

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2. Client will increase her active ROM, endurance, and strength to be within functional limits in her right upper extremity in order to complete IADLs and leisure activities within 16 weeks. 3. Within 8 weeks, client will independently engage in a Facebook chat conversation with a friend, responding a minimum of ten comments, utilizing assistive technology as needed. Short Term Goals and Activities to Help Reach First Long Term Goal Goal/Objective 1 Client will put her hair back in a ponytail with minimal assistance in front of a mirror in her bathroom within 2 weeks. Activity 1 Client will fully brush her hair using her right upper extremity during constraint induced therapy (Ploughman, Shears, Hutchings, & Osmond, 2007). Activity 2 Client will help her mother put her hair in a ponytail by utilizing bilateral upper extremities to wrap a large scrunchy around her hair once. Goal/Objective 2 Client will apply mascara, blush, and lip gloss with minimal assistance using a personalized make up kit with mirror within 3 weeks. Activity 1 Client will practice applying makeup, starting with her right side, utilizing built up handles on mascara, blush, and lip gloss provided by therapist.

CASE STUDY: SARAH Activity 2 Client will practice applying makeup on her mom and friends utilizing personalized makeup holders created by the OT. Short Term Goals and Activities to Help Reach Second Long Term Goal Goal/Objective 1 Client will complete a five minute known color guard routine with minimal visual cues within 8 weeks. Activity 1 Client will practice a known routine with the use of a video model provided by her coach and family which will increase in difficulty as she progresses. This will be accomplished in the following ways: A. Client will use video modeling to practice without any equipment.

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B. Client will use video modeling to practice with a lighter representation of a flag pole. C. Client will use flag pole to practice routine with minimal visual cues. Activity 2 Client will utilize the familys Wii system playing a variety of games such as tennis, sword play, and bowling, to help with color guard participation by increasing right upper extremity ROM and endurance. Goal/Objective 2 Client will independently make her lunch in 30 minutes or less by using bilateral upper extremity within 4 weeks.

CASE STUDY: SARAH Activity 1

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Client will make a peanut butter and jelly sandwich with all materials provided at her familys kitchen counter with minimal verbal cues. Activity 2 Client will retrieve all needed materials to make a peanut butter and jelly sandwich and add three additional items to pack her lunch utilizing a picture schedule as needed. Short Term Goals and Activities to Help Reach Third Long Term Goal Goal/Objective 1 Client will increase her RUE sensory awareness in order to use her right hand to push the keyboard buttons with minimal cues in 2 weeks. Activity 1 The client will participate in the following sensory home-program, created and modeled by the OT, to build sensory awareness in her RUE focusing on proprioceptive and tactile activities (Wiskind, 2008; Yavuzer et al., 2008). A. Using the clients Wii board and fitness game, the client will engage in the weight-bearing activities that the OT and client have saved to the clients personalized fitness menu. The client will utilize the programs tracking menu to report progress and daily participation. B. With her mom or dad facilitating, client will engage in mirror therapy while listening to music on her IPod.

CASE STUDY: SARAH Activity 2

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The client will make and wear weighted bracelets on her right wrist to increase her tactile sensory awareness while making and wearing the bracelets. Goal/Objective 2 Client will be able to log on to Facebook and navigate her account with minimal assistance in 4 weeks. Activity 1 Client will navigate Facebook using a textured keyboard and color coded keys. Activity 2 Client will log into Facebook and navigate the pages using a picture schedule. Treatment Plan Environmental Setting Taking into consideration the goals and interventions created with the client and family, the current treatment session will take place in Sarahs home. Sarah will engage in a leisure activity in her living room and an IADL activity in the kitchen. Her home provides adequate room for large motor activities as well as proper lighting, ventilation, and equipment. The family has made environmental modifications to their home which provides a safe setting for Sarah to complete these activities. This environment is particularly important as it allows Sarah to engage in therapy in her natural setting. This setting not only helps Sarah generalize the skills she learns into her everyday routines but also allows Sarahs parents to participate in therapy and learn how to support her throughout the week.

CASE STUDY: SARAH Treatment Soap Note

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S: Client expressed excitement to participate in todays tx. session. Mother reports client has required less prompting to use her right arm during daily activities around the home, since last tx. session. O: Client participated in 60 minute OT session at her home focusing on improving cognitive skills, R UE ROM, endurance, and BUE coordination for increased success in IADLs and leisure activities. Client demonstrates limited ROM in humeral flexion, extension, and abduction of R UE while playing Wii. Min verbal cues needed to prompt client to move RUE to hit the targets. During games, client required 2 breaks, lasting 5 and 7 minutes, to rest RUE. Client then participated in a simple meal preparation activity to increase BUE coordination for success in IADLs. Client was able to set up and gather appropriate materials to make peanut butter and jelly sandwich with min assist using a picture schedule. Client required min verbal cues to use BUE during meal preparation process. A: Poor endurance, limited ROM of RUE, and difficulty using BUE limits clients ability to I complete age appropriate IADLs and leisure activities. Despite cognitive difficulties with problem solving and sequencing, clients ability to set up materials for meal prep activity with min assistance from picture schedule demonstrates good progress toward reaching STG of I preparing lunch for school. Client also demonstrates progress by successfully completing tx. activities with min verbal prompting. Potential to improve areas of concern is demonstrated by clients motivation, participation, and progress of BUE use during tx. session. Client will benefit from continued OT skilled instruction to increase BUE coordination, RUE endurance, and ROM necessary for improved occupational performance in ADLs, IADLs, and leisure activities.

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P: Continue to treat client 60-minutes 2x/wk for 14 weeks to address RUE weakness and ROM necessary for increased performance in age appropriate occupational areas. Plan to address BUE coordination with meal preparation and color guard activities. Plan to address cognitive difficulties with continued use of picture schedules. Post-Discharge Environment & Recommendations After receiving outpatient therapy, Sarah would continue services in her high-school setting. A school-based occupational therapist would focus on Sarahs edu cational and transition needs. Recommendations for the family and school-based therapist would include continued focus on sensory loss, neglect, and limited ROM and endurance in her right upper extremity. The family should continue to provide sensory activities and encourage the use of constraint-induced and mirror therapy in the home setting (Ploughman et al., 2007; Yavuzer et al., 2008). Community resources, such as peer and family support groups, can also be given to help Sarah and her family connect with other individuals going through similar distress and to help them build friendships. If needed proper assistive technology and environmental modifications should be provided and modeled prior to discharge.

CASE STUDY: SARAH References Case-Smith, J., & OBrien, J. C. (2010). Occupational therapy for children (6th ed.). Maryland Heights, MO: Mosby Elsevier.

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Cronin, A., & Mandich, M. (2005). Human development & performance: Throughout the lifespan (1st ed.). Clifton Park, NY: Thomson Delmar Learning. Paul H. Brookes Publishing Co. (n.d.). Assess academic skills and help children return to the classroom after brain injury. Retrieved from http://www.brookespublishing.com/store/books/hotz-ptbi/index.htm Ploughman, M., Shears, J., Hutchings, L., & Osmond, M. (2007). Constraint-induced movement therapy for severe upper-extremity impairment after stroke in an outpatient rehabilitation setting: A case report. Physiotherapy Canada, 60(2), 161-170. doi: 10.3138/physio.60.2.161 Wiskind, J. (2008). The intricacies of the parietal lobe. Advance for Occupational Therapy Practitioners, 24(20), 40. Retrieved from occupational-therapy.advanceweb.com Yavuzer, G., Selles, R., Sezer, N., Sutbeyaz, S., Bussmann, J. B., Koseoglu, F.,...Stam, H. J. (2008, March). Mirror therapy improves hand function in subacute stroke: A randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 89, 393-398. doi: 10.1016/j.apmr.2007.08.162