Leah Rosler

Occupational Therapy Evaluation Report and Initial Intervention Plan

BACKGROUND INFORMATION:
Clients name or initials: Paul M.

Date of report: Autumn 2014

Date of birth and/or age: 17y.o

Primary intervention diagnosis/concern: fracture dislocation of C7; ASIA C; Tetraplegia

Secondary diagnosis/concern: cervical fusion, laminectomy, multiple lacerations of both hands

Precautions/contraindications: Miami J cervical collar when upright

Reason for referral to OT: Pt suffered a fracture dislocation of C7 (Asia C) as a result of an MVA and was
diagnosed with tetraplegia. The pt is a senior in high school and would like to attend college next year for
computer programming. Pt is also seeing OT for social participation, school participation and being able to care
for himself. OT will also address poor memory, coordination and concentration.

ASSESSMENTS PERFORMED:

Sensation assessment
ROM
MMT
MMPI
ADL (observation)
COPM

FINDINGS:
Occupational Profile:

Paul is a 17 year old male who was in a MVA and suffered a fracture dislocation of C7 (ASIA C) and therefore
has been diagnosed with tetraplegia. He has no PMH but a cervical fusion and laminectomy were performed
on the day of the accident. He has multiple lacerations of both hands and has a precaution of wearing a Miami
J cervical collar when upright. Pt currently lives with his parents, who are immigrants from South Korea, in their
2 story home. His immediate plan is to continue to live with his parents, however he has 2 sisters. One sister
lives nearby and one still lives in South Korea. His parents would like him to live temporarily with his sister who
lives nearby in her assessable home. Pt speaks fluent English and Korean and parents still very much value
traditional Korean culture and values. Paul would like to attend college next year to get a degree in Computer
Programming. Parents are concerned about pts use of alcohol and marijuana. Pt has been neglecting
responsibilities at home and school. Prior to the MVA pt was active in basketball, gold, playing video games,
playing his bass guitar, being with friends and camping. Pt would like to resume these interests, attend college
next year, and care for himself.
Occupational Analysis:
Areas of occupation:

Pt is a 17 year old male who is a senior in high school. In order to return to school pt needs
to be able to toilet, dress, and feed with minimal assistance from others (parents, aide etc).
Pt would like to care for himself and return to playing sports, video games, bass guitar and
social activities. Pt also would like to return to school and attend college next year for
Computer Planning. Based on FIM assessment, patient requires max assist in some ADL
areas and is fully dependent in several other ADL areas. However, FIM showed that
communication and social cognition is fairly intact.

FIM Admission

score
Supervision
Self-Care Eating 2

Grooming 3

Bathing 2

Dressing-Upper 2
body

Dressing-Lower 1
body

Toileting 1

Sphincter Bladder 1
Control management

Bowel 1
management

Mobility: Bed, chair, 1

Transfer wheelchair

Toilet 1

Tub, shower 1
Locomotion
Walk/wheelchair

stairs 1

Communication Comprehension 7

expression 6

Social Cognition Social interaction 7

Problem solving 7

Memory 7
Performance skills:

Pt has impaired sensation (sometimes absent) in UE. Pt has absent BLE sensation for all
sensory modalities. UE muscle strength is decreased and AROM is WNL in innervated
muscles. Both PROM for UE and BLE are WNL. Pt has slight movement in right toe and no
motion in left LE.

Performance patterns:

Although communication and social cognition are intact, pt requires max assist- dependent
assist for all ADLs, except for grooming which is moderate assist. Pts parents stated that pt
regularly neglects responsibilities at home and school.
Client factors:

Pt has multiple lacerations on both hands, but was R hand dominant prior to MVA. Elbow
extensors are weak as well as most hand and finger strength. Pts proximal U.E. strength is
generally stronger with left than right. MMT scores can be found in table below. There are
few isolated muscles are trace in LE, no motion in the left LE and sensory loss in both LE.
Based on interview and observation pt does have impaired coping skills, STM, judgement,
attention span, and safety awareness. Pt is max assist with both dynamic and static sitting
balance and is therefore dependent in all bed mobility activities.

Right Left

4+/5 Shoulder flexors 4+/5

4+/5 shoulder extensors 4+/5

4+/5 shoulder abduction 4/5

4+/5 Shoulder adduction 4+/5

4/5 shoulder IR 4/5

4-/5 shoulder ER 4/5

3/5 elbow flexors 4/5

1/5 elbow extensors 3/5

0/5 Forearm supination 2/5

0/5 Forearm pronation 3/5

1/5 wrist flexors 3/5

2-/5 wrist extensors 4/5

 1/5 MCP flexors 1/5

1/5 MCP extensors 2/5

0/5 DIP flexors/extensors 2-/5

0/5 PIP flexors/extensors 2-/5

0/5 thumb MCP flexors/extensors 2-/5

0/5 PIP flexors/extensors 2-/5

0/5 Thumb opposition 2-/5

Activity demands:

The pt has a goal of becoming more independent in self-care and ADLs. In order to do so,
time will be dedicated to education on how to use varying assistive devices. Some of the
devices that will be useful to Paul will include a universal cuff with wrist support (for eating)
and a reacher and sock aide (for LE dressing (please see goals below). Pt will need to
spend time learning compensatory strategies as well as maintaining ROM and increasing
strength.

Contexts:

Pt would like to learn to care for himself, however is currently max assist-dependent in all
ADLs except for grooming which he is mod assist. Pt is unaware of the implications of a SCI
and expects to walk out of the hospital. He would like to finish school, go to college next
year, return to sports and social activities, but his parents report that he regularly neglects
responsibilities at home and school. MMPI reports that client was confused and has current
internal conflicts. His primary distress is about his physical symptoms and body functions.
Although Paul is friendly and able to maintain relationships, he has been withdrawn,
sensitive, and lacking conversational skills around others. Pt can be expected to be in a
wheelchair and utilize other adaptive equipment for compensation. We will also want to
consider traditional South Korean culture and values due to Pauls family dynamic and his
parents. In the hospital most activities will be done in bed or wheelchair. In inpatient rehab
the environment will closely replicate Pauls situation at home.

INTERPRETATION

Strengths:

Pts proximal UE strength is generally stronger with left. His AROM are WNL in innervated
muscles and his sensation of proximal UE is normal. Pt has goals of returning to caring for
himself and returning to activities he enjoys. He has maintained the goal of going to college
and has a supportive family. Pt fluently speaks English and Korean. He is normally active,
social, and friendly who enjoys the company of others.
Areas in need of intervention:

Paul will require intervention for all of his ADLs. He is currently very dependent on others to
care for himself and the following areas should be addressed:
o Self-care (eating, grooming, UE and LE dressing, toileting)
o Sphincter Control ( bowel and bladder management)
o Mobility with Transfers (bed, chair, wheelchair, toilet, tub, shower)
o Locomotion (walk/ wheelchair, stairs)
Supports:

Paul lives with his parents who are immigrants from South Korea. Pts parents still value
traditional South Korean values and culture. Parents were devastated by event. Pt also has 2
sisters, one who is married and lives nearby with an assessable home.

Hindrances to occupational performance:

Paul does have hindrances to his occupational performance and several of them are listed
below:
o Unable to use legs
o Decreased strength
o Understanding of SCI
o Withdrawn
o Regularly neglects responsibilities
o Confused
o Poor memory
o Difficulty concentrating
o Decreased coordination
 All Patient Priority Long Term Short Term Goals Intervention Rationale/Principle
Problem Areas Occupations Goals Two STGs for each LTG Strategy/Method Link occupation, impairment,
to Address (2 LTG) (total of 4). (Adaptive Techniques, intervention method, and
During CIMT, Energy Conservation, FOR/theory. Use at least two
Intervention Assistive Devices, etc) approaches to intervention
(Ex: compensation, prevention,
health promotion, etc.).
Eating Pt will self-feed Intervention Activities: Due to Pauls current FIM
Self-care (eating, with modified Pt will complete 4/5 Pt will use utility score of a 2 in eating, it is vital
grooming, UE and LE independence bites of soft food (ex: cuff to eat at to dedicate time to intervening
dressing, toileting) by discharge pudding, yogurt, meals within this ADL. Paul currently
from inpatient cottage cheese, Pt will pick up has decreased distal UE
rehab to applesauce etc) with eating utensils strength which will make
Sphincter Control ( bowel increase min assist using a grasping or controlling any
and bladder independence universal cuff with eating utensil difficult. He has
management) in eating. wrist support within 4 Method: Providing Paul the goals of taking care of
weeks to increase with a universal cuff with himself again as well as
Mobility with Transfers independence in wrist supports, and training participating in social activities
(bed, chair, wheelchair, eating. him on how to use this that he did prior to his injury.
piece of adaptive Eating is a vital part of
toilet, tub, shower)
equipment, will assist him independence but eating is
in eating more also often a social activity.
Locomotion (walk/ independently. Paul Using a universal cuff with
wheelchair, stairs) currently has a FIM score wrist supports will allow Paul
of a 2 in eating. This to start self-feeding. By using
assistive device will serve the PEO model to address
as a tool to Paul eventually what is affecting Pauls
self-feeding independently occupation of eating, we
making him less reliant on would be able to work
his family and more together with him to capitalize
confident in participating in on this compensatory strategy
social outings. working toward his
independence in eating. The
compensatory frame of
reference will used to allow
Paul to complete eating as
someone with tetraplegia.
 Intervention Activities:
Pt will eat a piece of
pizza (or some other Patient will
larger finger food like squeeze sponge in
toast etc) with min increase grip
assist within 4 weeks strength
to increase Patient will
independence in perform bicep
eating. curls against
gravity 10 reps X 3
sets 3-5 times a
day
Method: Training Paul to
eat a piece pizza (or similar
food) will require practice
of adaptive techniques to
be independent in doing
so.
LE
Dressing Pt will complete Intervention Activities:
LE dressing with While seated EOB, pt Pt will practice
modified will doff pants with dynamic sitting/
independence min assist within 4 reaching activities
by discharge weeks to increase at EOB
from inpatient independence in LE Pt will practice
rehab to dressing. grasping pants
increase with hands
independence
in LE dressing.
Method: Training Paul to
complete doffing his pants
while seated, having to
engage his trunk strength,
and utilizing dynamic
sitting balance will have to
be a skill he practices. He
will have to learn adaptive
techniques to slide his
pants over his hips and off
Paul has been diagnosed with
tetraplegia. Because he is now
learning to live in a completely
new way, we will be using the
rehabilitation frame of
reference to address any
difficulty he may have with
eating large finger foods such
as pizza. Using the PEO model
and looking at what is
important to Paul, we can
determine that feeding himself
and returning to social
activities (some of which may
include food) it is important to
work to retrain his working
muscles to regain strength in
this plane of motion to
increase independence in
eating. His decreased strength
in his UE is something that we
can work to rehab in order to
increase his ability to eat
independently.
Although Paul will have to doff
his pants a little differently
than he may be used to, the
rehabilitation frame of
reference will be used to work
toward regaining trunk control
and maintaining dynamic
sitting balance to be able to
move his pants over his hips to
take them off. Paul wants to
be able to start taking care of
himself and one step toward
regaining independence would
certainly include dressing his
LEs. His decreased strength in
his UE is something that we
can work to rehab in order to
increase his ability to complete
LE dressing.
 of his legs

Intervention Activities: Pauls evaluation indicates that

While sitting EOB, pt Pt will practice he wants to start taking care of
will use a reacher to picking up pants
complete donning with reacher
pants with min assist Pt will practice
within 4 weeks to
opening and
increase independence closing the
in LE dressing. reacher
Method: Assistive Devices
and training with tools
such as a reacher will be
used to assist Paul in
completing LE dressing.
himself again. Part of taking
care of oneself would include
dressing yourself. His current
limitation in strength and, as
well as no LE motion, is
preventing completing LE
dressing. Using adaptive
devices such as a reacher,, long
handled shoe horn, and elastic
shoe will assist will work to
compensate for his loss of
strength and motion and
promote is independence. The
compensatory frame of
reference will used to allow
Paul to complete LE dressing as
someone with tetraplegia. We
will be working from the PEO
model so we are sure to
consider Pauls home set up
and needs while completing
the occupation of LE dressing.

DISCHARGE RECOMMEDATIONS /REFERRALS

Discharge Recommendations
I recommend that when the pt leaves the Inpatient Rehab facility I would recommend seeing outpatient OT for 3-5 times a week for 60-90 minutes for 1-2 months initially.
Re-evaluation will take place following that time period. Pt will be provided with wheelchair education, energy conservation reminders, and home exercise plan prior to
returning home. Pt should continue home exercise plan to strengthen his UE and PROM his LE to prevent contractures or pressure sores. Family will be provided with
education on moving to prevent pressure sores, catheter education, caretaking, ADL completion etc to best prepare them for life at home. Power wheelchair, slideboard,
sock aide, reacher, utility cuff, dysom, and other assistive devices are recommended for pt to have in order to make living more independently as feasible as possible.
 Family discharge meeting will discuss family comfort level with discharging home and will be used as a time to re-train or answer any questions about pts care. At this
meeting caretaking responsibilities can be roughly decided to best support pts discharge home. Recommendations for grab bars in shower and by toilet will be made, as
well as raised toilet seat and shower chair to ensure pt safety. Ramp to enter house and having access to an assessable vehicle are also recommended.

Referrals
OP Occupational Therapy: To continue seeing OT to work on ADLs, social participation, coping skills, school participation, transitions etc.
Physical Therapy: To continue working on balance and mobility.
Speech Therapy: To consult for cognitive deficits and being withdrawn.
Recreation Therapy: To address sports and extracurricular activities.
Psychology: For counseling and emotional navigation.
CAP #1

Methodology Checklist 1: Systematic Reviews and Meta-analyses

SIGN gratefully acknowledges the permission received from the authors of the AMSTAR tool to base this checklist on their work: Shea
SIGN BJ, Grimshaw JM, Wells GA, Boers M, Andersson N, Hamel C,. et al. Development of AMSTAR: a measurement tool to assess the
methodological quality of systematic reviews. BMC Medical Research Methodology 2007, 7:10 doi:10.1186/1471-2288-7-10. Available
from http://www.biomedcentral.com/1471-2288/7/10 [cited 10 Sep 2012]

Study identification (Include author, title, year of publication, journal title, pages)

Hubbard, I. J., Parsons, M. W., Neilson, C., & Carey, L. M. (2009). Task-specific training: evidence for and translation to
clinical practice. Occupational Therapy International, 16(3-4), 175-189. doi:10.1002/oti.275

Guideline topic: Task Specific Training Key Question No:

Before completing this checklist, consider:

Is the paper relevant to key question? Analyse using PICO (Patient or Population Intervention Comparison Outcome). IF
NO reject. IF YES complete the checklist.

Checklist completed by:

Section 1: Internal validity

In a well conducted systematic review: Does this study do it?

1.1 The research question is clearly defined and the Yes No

inclusion/ exclusion criteria must be listed in the
paper. If no reject

1.2 A comprehensive literature search is carried out. Yes No

Not applicable

If no reject

1.3 At least two people should have selected studies. Yes No

Cant say

1.4 At least two people should have extracted data. Yes No

Cant say

1.5 The status of publication was not used as an Yes No

 inclusion criterion.

1.6 The excluded studies are listed. Yes No

1.7 The relevant characteristics of the included studies Yes No

are provided.

1.8 The scientific quality of the included studies was Yes No

assessed and reported.

1.9 Was the scientific quality of the included studies Yes No

used appropriately?

1.10 Appropriate methods are used to combine the Yes No

individual study findings.
Cant say Not applicable

1.11 The likelihood of publication bias was assessed Yes No

appropriately.
Not applicable

1.12 Conflicts of interest are declared. Yes *there No

are no COI

SECTION 2: OVERALL ASSESSMENT OF THE STUDY

2.1 What is your overall assessment of the High quality (++)

methodological quality of this review?
Acceptable (+)

Low quality (-)

Unacceptable reject 0
2.2 Are the results of this study directly applicable to the Yes No
patient group targeted by this guideline?
CAP #2

Methodology Checklist 3: Cohort studies

SIGN

Study identification (Include author, title, year of publication, journal title, pages)

Casadio, M., Pressman, A., Fishbach, A., Danziger, Z., Acosta, S., Chen, D., . . . Mussa-Ivaldi, F. A. (2010). Functional
reorganization of upper-body movement after spinal cord injury. Experimental Brain Research, 207(3-4), 233-247.
doi:10.1007/s00221-010-2427-8

Guideline topic: functional reorganization of upper-body movement after Key Question No: Reviewer:
SCI
Leah Rosler

Before completing this checklist, consider:

1. Is the paper really a cohort study? If in doubt, check the study design algorithm available from SIGN and make
sure you have the correct checklist.
2. Is the paper relevant to key question? Analyse using PICO (Patient or Population Intervention Comparison
Outcome). IF NO REJECT (give reason below). IF YES complete the checklist..

Reason for rejection: 1. Paper not relevant to key question 2. Other reason (please specify):
Please note that a retrospective study (ie a database or chart study) cannot be rated higher than +.

Section 1: Internal validity

In a well conducted cohort study: Does this study do it?
1.1 The study addresses an appropriate and clearly focused question. i Yes No
Cant say

SELECTION OF SUBJECTS

1.2 The two groups being studied are selected from source populations that are Yes No
comparable in all respects other than the factor under investigation. ii
Cant say Does not
apply

1.3 The study indicates how many of the people asked to take part did so, in each of Yes No
the groups being studied.iii
Does not
apply

1.4 The likelihood that some eligible subjects might have the outcome at the time of Yes No
enrolment is assessed and taken into account in the analysis. iv
Cant say Does not
apply

1.5 What percentage of individuals or clusters recruited into each arm of the study None
dropped out before the study was completed.v
1.6 Comparison is made between full participants and those lost to follow up, by Yes No
exposure status.vi
Cant say Does not
apply

ASSESSMENT

1.7 The outcomes are clearly defined.vii Yes No

Cant say

1.8 The assessment of outcome is made blind to exposure status. If the study is Yes No
retrospective this may not be applicable.viii
Cant say Does not
apply

1.9 Where blinding was not possible, there is some recognition that knowledge of Yes No
exposure status could have influenced the assessment of outcome.ix
Cant say

1.10 The method of assessment of exposure is reliable.x Yes No

Cant say

1.11 Evidence from other sources is used to demonstrate that the method of outcome Yes No
assessment is valid and reliable.xi
Cant say Does not
apply

1.12 Exposure level or prognostic factor is assessed more than once. xii Yes No
Cant say Does not
apply

CONFOUNDING

1.13 The main potential confounders are identified and taken into account in the design Yes No
and analysis.xiii
Cant say

STATISTICAL ANALYSIS
1.14 Have confidence intervals been provided?xiv Yes No

SECTION 2: OVERALL ASSESSMENT OF THE STUDY

2.1 How well was the study done to minimise the risk of bias or confounding?xv High quality (++)
Acceptable (+)
Unacceptable reject 0

2.2 Taking into account clinical considerations, your evaluation of the methodology
Yes No
used, and the statistical power of the study, do you think there is clear evidence of
an association between exposure and outcome?
 Cant say

2.3 Are the results of this study directly applicable to the patient group targeted in this Yes No
guideline?

2.4 Notes. Summarise the authors conclusions. Add any comments on your own assessment of the study, and the
 INSERT CITATIONS APPROPRIATE CAP FORM HERE!!!!

CHOOSE MOST APPROPRIATE CAP FOR THE ARTICLES CHOSEN

EX: QUALITITATIVE, QUANTITATIVE, SYTEMATIC REVIEW

Grading rubric for Group Case Study and Intervention Plan

Criteria Ratings Points

Assessments: Assessments Excellent Good Fair Poor Incomplete __/

chosen for patient are 5.0
5.0 pts 4.0 pts 3.0 pts 2.0 pts 1.0 pts
appropriate for condition and points
patient presentation Met All Met most Met some Met A Few Met No
Criteria criteria criteria Criteria Criteria

Findings: Occupational Excellent Good Fair Poor Incomplete __/ 5.0

Profile: Concise and points
appropriate description of 5.0 pts 4.0 pts 3.0 pts 2.0 pts 1.0 pts
Occupational Profile of
Met All Met most Met some Met A Few Met No
patient
Criteria criteria criteria Criteria Criteria

Findings: Occupational Excellent Good Fair Poor Incomplete __/ 5.0

Analysis: Concise and points
5.0 pts 4.0 pts 3.0 pts 2.0 pts 1.0 pts
appropriate description of
Areas of occupation, Met All Met most Met some Met A Few Met No
Performance skills, Criteria criteria criteria Criteria Criteria
Performance patterns, Client
factors, Activity demands,
and Contexts

Interpretation: Concise and Excellent Good Fair Poor Incomplete __/ 5.0
appropriate description of points
5.0 pts 4.0 pts 3.0 pts 2.0 pts 1.0 pts
Strengths, Areas in need of
intervention, Supports, and Met All Met most Met some Met A Few Met No
Hindrances to occupational Criteria criteria criteria Criteria Criteria
performance
Problem Areas and Priorities: Excellent Good Fair Poor Incomplete __/ 5.0
Appropriate and thorough list points
5.0 pts 4.0 pts 3.0 pts 2.0 pts 1.0 pts
of problem areas for patient,
and appropriate priorities Met All Met most Met some Met A Few Met No
areas to address in Criteria criteria criteria Criteria Criteria
intervention

LTG: Provide two appropriate Excellent Good Fair Poor Incomplete __/ 5.0
occupation centered long points
5.0 pts 4.0 pts 3.0 pts 2.0 pts 1.0 pts
term goal in ABCD format
Met All Met most Met some Met A Few Met No
Criteria criteria criteria Criteria Criteria

STG: Provide 2 appropriate Excellent Good Fair Poor Incomplete __/ 5.0
occupation centered short points
5.0 pts 4.0 pts 3.0 pts 2.0 pts 1.0 pts
term goals for each LTG in
ABCD format Met All Met most Met some Met A Few Met No
Criteria criteria criteria Criteria Criteria

Intervention Strategy and Excellent Good Fair Poor Incomplete __/ 5.0
Rationale: Provide 2 points
5.0 pts 4.0 pts 3.0 pts 2.0 pts 1.0 pts
appropriate intervention
strategies and 2 appropriate Met All Met most Met some Met A Few Met No
rationales for each LTG that Criteria criteria criteria Criteria Criteria
links occupation, impairment,
and intervention strategy
Discharge Plan and Referrals: Excellent Good Fair Poor Incomplete __/ 5.0
Provides appropriate points
5.0 pts 4.0 pts 3.0 pts 2.0 pts 1.0 pts
discharge plan and referral
for patient Met All Met most Met some Met A Few Met No
Criteria criteria criteria Criteria Criteria

CAP: Completes all Excellent Good Fair Poor Incomplete __/ 5.0
information for study points
5.0 pts 4.0 pts 3.0 pts 2.0 pts 1.0 pts
purpose, design, and
conclusion/ result. Met All Met most Met some Met A Few Met No
Criteria criteria criteria Criteria Criteria
Article Appropriately supports
activities in intervention plan.

Total Points:__________