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OCCT 657A:

Case Study
Sotheavy Moeung
Touro University Nevada

Who is Papi

He is a 26 years old
From close-knit
Mexican family
Nuclear family
includes:
7 siblings and a mother
and father

From Nevada but


travels for work
Takes contract positions in
California
Prioritizes work

Lives in California with


2 roommates in an
apartment

Retrieved from http://twc2.org.sg/2012/10/20/three-cranioplasties/

Practice Setting
Sub-acute/ LTAC/ SNF
for adults
Dx: Multiple trauma,
orthopedic,
tracheostomy, wound
care, amputee care,
SCI, and TBI
Services offered:
1:4 staff to patient
ratio
1:1 therapy
24/7 care

Interdisciplinary Treatment Team includes:


Physicians, nurses, case managers, social workers,
neuropsychological specialists, activities directors,
dieticians, and physical, occupational, speech, and
respiratory therapists

FRONT OF
BUILDING

COMMUNITY AREA

REHAB GYM

PATIENT ROOM

Papis Medical History


MVA
TBI
Craniectomy
Bone flap stored in
the abdominal pocket
Persistent Vegetative
State (PVS)
Tracheostomy
PEG Tube

Retrieved from http://www.dailymail.co.uk/news/article2727092/Liam-Knight-questions-attackers-eight-yearsentence.html

Papis Milestones
Wee Milestones
k
1 Blinking and some eye movement, flaccid tone
2 Involuntary reflex movements, spasticity, cries/moans
3 Increased eye tracking, recognizes immediate family
members, reach and grasp
4 Answers simple questions such as family members names,
Increased voluntary movements such as release
5 Increased sensation of physiological needs (void; drinking
water), increased ROM
6 Answers in 3-5 word sentences such as I want to go home,
increased normalization of tone and ROM WFL
7 Bone flap placed back on, increased cognitive function such as
attention to task
8 Tracheostomy tube removed, assist in ADL skills, increased
motor planning

Model of Practice I: PEOP

Retrieved from http://handtherapycanbefun.weebly.com/peopmodel.html

Retrieved from
http://etc.usf.edu/presentations/extras/letters/varsity_letters/54/28/i
ndex.html

PEOP Construct I- PERSON


INTRINSIC FACTORS
Neurobehavioral

Flat affect
Impulsivity
Excessive drowsiness
Disorientation

Physiological

Flaccidity upon arrival


Weakness
Fatigue
Decreased ROM
Involuntary reflex and
movement patterns
Spasticity
Decreased endurance
Decreased movement,
balance, and coordination
Decreased static and dynamic
sitting
Dysphagia
Dyspraxia
Decreased motor
planning

PEOP Construct I- PERSON


INTRINSIC FACTORS
Psychological

Poor judgment and inhibition


Impulsivity
Apathy
Lack of initiative

Spiritual

Family values
Family involvement with
treatment
Hands-on

PEOP Construct I- PERSON


INTRINSIC FACTORS
Cognitive

Reduced attention
Decreased attention span
Difficulty with selective
attention
Impaired sustained
attention for task
completion
Deficits in attention
shifting between tasks
Decreased executive
functioning
Difficulty with initiation of
tasks
Decreased planning and
organization
Decreased problem

Decreased memory
Greater impairment with
STM than LTM
Impaired metacognition
Anosognosia
Poor self-regulation
Impaired spatial cognition
Ambulation and self-care
skills
Disorientation
To self, situation, location,
time
Impulsivity
Decreased safety awareness

Retrieved from
http://etc.usf.edu/presentations/extras/letters/varsity_letters/16/17/i
ndex.html

PEOP Construct IIENVIRONMENT


EXTRINSIC FACTORS
Culture & Values

Strong Mexican culture


Family involvement with
therapy process
Elder brother took on
responsibility full time

Built Environment &


Technology
3 months residency at Care
Meridian
Restraint bed until
cognition and safety
awareness increases
Return to dynamic
environment
Possible DME & A/E
required:
Wheelchair
Shower bench
Slide board
3:1 commode

PEOP Construct IIENVIRONMENT


EXTRINSIC FACTORS

Natural Environment

Care Meridian
Outside
Mostly flat terrain
Limited areas to practice
ambulation
Consistent warm weather
Inside
Patient room
Bed mobility
Toilet transfer
Shower transfer
Therapy Gym
8 step staircase
Peer modeling
Community Area
Opportunities for
social interaction

Societal

Strong interpersonal
relationship with family and
community

PEOP Construct IIENVIRONMENT


EXTRINSIC FACTORS
Social Interaction

Family involvement 24/7


Strong community ties

Social & Economic


Systems

Medicare Part B
10 hours of direct therapy per
week
Currently 5 hours PT & 5
hours OT
In need of speech therapy
since cognition has
improved
Limited hours impact
growth

Retrieved from
http://etc.usf.edu/presentations/extras/letters/varsity_letters/54/27/
index.html

PEOP Construct III- OCCUPATION


Abilities

Agreeable nature
Good shape prior to incident
Hard working attitude
Inquisitive mind

Social &
Occupational Roles

Sibling
Son
Friend
Uncle
Labor contract employee

Actions

Immediate voluntary
grasp/release skills with RUE
Eye contact with max verbal
prompts
LTM more in tact
Knows family members
and close friends
Asks and reaches for mom
and brother often
Motivation to get out of bed
Desire to functionally
ambulate
Desire to use toilet
Desire to return to work

PEOP Construct III- OCCUPATION


TASKS

OCCUPATIONS

Assisting to pull
up socks

ADL: Dressing

Assisting in
pushing w/c

ADL: Functional
Mobility

Assist in sponge
bathing UE

ADL: Bathing &


Showering

Assist in applying
lotion
Reaching for ball/cone &
crossing over in various
planes and heights

ADL: Personal
Hygiene & Grooming

ADL: Toileting

Retrieved from
http://etc.usf.edu/presentations/extras/letters/varsity_letters/39/28/in
dex.html

PEOP Construct IV: OCCUPATIONAL


PERFORMANCE
Strengths
Familys active involvement
& encouragement
social interaction
Interdisciplinary team
collaboration
Rate of improvement

Weaknesses

Limited treatment times


Limited facility equipment
cognition
Family involvement longterm

PEOP Construct IV: OCCUPATIONAL


PERFORMANCE

What does Papi want to


accomplish?

Goals are established based in collaboration


between family and interdisciplinary
team
STG:
LTG:
spasticity & involuntary
reflexes
Check for skin integrity
UE ROM
bed mobility
visual tracking
object
reach/grasp/release
Follow 1-2 steps
commands

(I) dressing
w/c mobility
(I) functional
transfers
safety
awareness
static sitting
motor planning

Model of Practice II: NDT Frame


of Reference

Retrieved from http://www.ndta.org/

Neurodevelopmental
Treatment (NDT)
Background
Founders:
Berta Bobath (physiotherapist)
Dr. Karel Bobath (psychiatrist/
neurophysiologist
Implemented in 1940s focusing
on patients with stroke & CP
(NDTA, 2011)

Definition
Neuro: brain & nerves
Developmental: normal
movement patterns
needed for functional
motor skills (Australian
Neurodevelopmental Therapy
Association, 2014)

Assumptions
1. Normalization of tone
2. Normalization of
movement patterns
3. Emphasis on symmetry
and integration of both
sides of the body
4. Inhibition/avoidance of
abnormal movements
5. Hierarchical model of
motor control (Pendleton
&
Schultz-Krohn, 2013)

Relevance of NDT
Setting
Can be used in settings that work with the
following dx:

Traditional: CP, hemiplegia


Modern: TBI, Down Syndrome, Spina Bifida,
Developmental Delays (Pendleton & Schultz-Krohn,
2013)

Most commonly used in:

Stroke and TBI rehabilitation


Preparatory interventions

Most effective when:

IDT use similar approaches with client

Relevance of NDT
Papis Case
Advanced hands-on tx. for patients with
disturbances in function, movement, and postural
control due to CNS injury
NDT look for atypical movement patterns and
facilitate more typical movement patterns to
increase functional skills
Family members receive education to increase
the quality of movements and generalization of
functional skills into a range of environments
(Australian Neurodevelopmental Therapy
Association, 2014)

EVALUATION

Application of NDT:
Evaluation
EVALUATION:
Observe client and formulate hypothesis of
current functional skills
Interplay between tone & movement quality
Influence of postural control on coordination
of movements
No formal assessment related to NDT used
with adults*
Motor, cognitive, perceptual, & psychosocial
needs/deficits
Discuss with family STG/LTGs to facilitate
patients needs/wants/ desires (Howle, 2002)

INTERVENTION

Application of NDT:
Intervention

INHIBITORY
TECHNIQUES
abnormal
muscle tone
lengthen spastic
muscles
unwanted
movement
patterns and
reactions
abnormal
posture

HANDLI
NG
Produce
changes
in tone
&
posture

FACILITORY
TECHNIQUES
normal
movement
patterns &
sensations
stimulate
muscles directly
to contract
practice wanted
movements
utilize more
involved side
during activities
(Martin, 2014)

OUTCOMES

Application of NDT: Outcomes


Family
Accomplish STG & LTG
Independence in ADLs
Cognition

Safety awareness

Bring Papi home

Patient
I want to go home
I want to go to work

IDT

Maximal independence reached with allotted time


DME & A/E required
Home evaluation
Recommend further resources (Spanish)
https://www.uab.edu/medicine/tbi/informacion-en-espanol

P
E
O
P

&

N
D
T

Evaluation using PEOP & NDT


Occupational Profile through observation of client & interview
family

Intrinsic & extrinsic factors


Environments
Meaningful occupations: means to ends
Strengths vs. weaknesses

Hands-on evaluation

ROM
Tone
Strength
Patterns of movements
Posture
Symmetry
Motor control

Evaluation: ASSESSMENT TOOLS*


INITIAL
EVALUATION

FIM/FAM
FAM includes cognitive, behavioral, communication and community
functioning measures (Wright, 2000)
JFK Coma Recovery Scale-Revised (CRS-R)
measure small clinical changes in patients with severe brain
injuries who function at very low levels characteristic of nearvegetative and vegetative states (Giacino & Kalmar, 2006)
Introduction to the Level of Cognitive Functioning Scale
assess cognitive functioning in post-coma patients (Bushnik, 2000)

MIDPOINT
Introduction to Independent Living Scale (ILS)
assesses three main areas: ADLs, behavior, & initiation (Persel, 2012)

DISCHARGE
Introduction to the Supervision Rating Scale
measures the level of supervision that a patient/subject
receives from caregivers (Brooke, 2001)
FIM/FAM

Intervention using PEOP & NDT


Physiological
Flaccidity upon
arrival
Decreased ROM
Involuntary reflex &
movement patterns
Spasticity
Decreased static
and dynamic sitting
Decreased motor
planning

Cognition
Reduced attention
Difficulty with
initiation of tasks

Task

Tim
e
(mi
n)

Inhibit abnormal tone & lengthen


spastic muscle & ROM on RUE

Inhibit abnormal tone & lengthen


spastic muscle & ROM on LUE

10

attention to task, visual


attention, and motor planning
with cone stacking

15

sitting tolerance at EOB with


Mod A & don socks

20

Caregiver education &


documentation

10
Total: 60

Outcome using PEOP & NDT


Improved occupational
performance
Meeting STG/LTG
Increasing functional
movements

Improved health and


wellness
Becoming more
independent in
occupations

Improved quality of life


Less family support in
self-care skills
Return to home & work
Previous roles

References

Australian Neurodevelopmental Therapy Association. (2014). Neurodevelopmental therapy. Retrieved from


http://www.abndta.asn.au/view/about-bobath/what-is-bobath
Boake, C. (2001). The supervision rating scale. The Center for Outcome
Measurement in Brain Injury. Retrieved from http://www.tbims.org/
combi/srs
Bushnik, T. (2000). The level of cognitive functioning scale.The Center
for
Outcome Measurement in Brain Injury. Retrieved from
http://www.tbims.org/combi/lcfs
Cole, M. & Tufano, R. (2008). The person-environment-occupationperformance model. In Applied theories in occupational therapy: A
practical approach. (pp. 127-133). Thorofare, NJ: Slack Inc.
Giacino, J. & Kalmar, K. (2006). Coma recovery scale-revised.The Center
for Outcome Measurement in Brain Injury. Retrieved from
http://www.tbims.org/combi/crs
Howle, J. M. (2002). Neuro-developmental treatment approach:
theoretical foundations and principles of clinical practice.
NeuroDevelopmental Treatment.
NDTA. (2011). What is NDT? Retrieved from
http://www.ndta.org/whatisndt.php

References Cont.
Martin, S. (2014). Stroke intervention strategies: Bobath/NDT.
(PowerPoint Slides). Retrieved from https://bbtun.touro.edu/webapps/portal/frameset.jsp?tab_group=courses& url=
%2Fwebapps%2Fblackboard%2Fexecute%2Fcontent%2Ffile %3Fcmd
%3Dview%26content_id%3D_2117848_1%26course_id
%3D_3476862_1%26framesetWrapped%3Dtrue
Pendleton, H. M., & Schultz-Krohn, W. (2013). Pedretti's occupational
therapy: practice skills for physical dysfunction. Elsevier Health
Sciences.
Persel, C. (2012). The independent living scale. The Center for Outcome
Measurement in Brain Injury. Retrieved from http://www.tbims.org/
combi/ils
Wright, J. (2000). The functional assessment measure.The Center for
Outcome Measurement in Brain Injury. Retrieved from
http://www.tbims.org/combi/FAM
UAB School of Medicine. (2014). Traumatic brain injury model system
information network. Retrieved from
https://www.uab.edu/medicine/tbi/informacion-en-espanol