Student

Name: Jessica Smith Case: #2 - Chart Date: 1.25.2018

1. Diagnosis, Referral, Setting, Reimbursement, LOS

Chart was in a serious car accident, 1 year and 1 week ago. During the accident, Chart was pinned
on ground under the car, resulting in an ASIA A (complete) Spinal Cord Injury (SCI) at C6-C7 level
with an additional fracture at T1.
- Chart was referred by his Physician to NeuroWorks to receive Occupational Therapy (OT) services
in his home environment for 2 visits/week for 10 weeks; NeuroWorks is paid by Chart's private
insurance as an outpatient clinic, and is thus, not technically a homehealth organization.
- Although not currently receiving services, Chart raised money through a fundraiser to pay for
Physical Therapy (PT), and will soon return to PT services to address w/c mobility, transfers and
strengthening.
- Client was inpatient for 90 days at the University of Utah Hospital, and received an additional 4
months of outpatient services.
- Client lives in a renovated, w/c accessible basement in his family's home; he shares the home with
his parents and his two teenage sisters. His mother works from home, and is often available to assist
Chart during the day. Client enjoys reading (on Kindle), gaming, and watching movies with friends.
- Client requires Mod A and AE for LE dressing, can independently dona pullover shirt, but is
dependent for donning socks and shoes, and for any type of fasteners.
- Client requires Max A with bowel and bladder care.
- Client is able to bathe I with AE and set-up A, however, he does not currently like his shower chair
d/t inability to I propel. - Client also requires set-up assist to perform grooming/hygiene (i.e. mostly
opening containers and accessing needed items).
- Client can make a simple cold snack and warm up simple meals in the microwave, but is unable to
prepare meals.

2. Pragmatic Factors to Consider

- Physical Therapy - will address w/c mobility, transfers, and strengthening
- What goals and priorities can be addressed and paid for through private insurance through an
outpatient clinic (NeuroWorks), but in the home setting (meaning, possible community-based
treatment too)
- What goals can be addressed/accomplished during this many visits (20).
- Caregiver's Schedule (Mother's/Parent's), PT schedule (once starts up again); school schedule
(once starts up again); any other Dr. appointments/check-ups planned (schedule)
- Homebound (and basement-bound) - unless family/friends can provide transportation (to leave
home), or can carry client to other floors of home
- Level of SCI (and any sensation/motor gains made over time - although likeliness decreases as
time post-injury increases)
- Possible shoulder pain/injury - as a result of compensatory movements and impact from transfering
- Endurance (physical and respiratory), & decreased Vital Capacity
- Possiblility of Autonomic Dysreflexia, Orthostatic Hypotension, Spasticity and Heterotopic
Ossification limitations/complications during treatment.
- Bowel & Bladder management and scheduling
- Trunk stability/control - dynamic sitting difficulty d/t level of injury

These limitations will impact length and level of difficulty during treatment and evaluation sessions,
and will also impact scheduling of sessions as well as breakdown of appointments.

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 3. Context: Occupational Profile & Current Occupations
Cultural: - Prior to the injury, Chart was a 21-year-old student, attending a junior college. -
- Client also enjoyed playing sports with friends (especially basketball)
- Additional information is needed as little else is know about Chart's cultural context
- It may be appropriate to ask client if they are any religious or spiritual gatherings
that he attends, or if there are any cultural customs that are significant in his life??
- Prior to -SCI - although specific cultural beliefs are unknown, His being 21-years-
old (when accident happened), still living at home with his parents, having a job (didn't
mention), only studying generals at SLCC, and his allowing (or expectaing?) his
mother to fully clean up after him, may be very common in his culuture, and may
suggest a learned helplesssness - especially for past IADLs.
Physical: - Basement Bound & Homebound
- uses a manual w/c for mobility (uphill is difficult, but flat surfaces aren't bad)
- has a sleep number bed (helps with bed mobility)
- uses transfer board for transfers (i.e. into car from w/c)
- currently using shower chair - but unable to propel I
- Renovated basement apartment (with help of Assist) to help with w/c accessibility
needs (kitchen - accessible sink, lower microwave, bathroom, (ramp to back yard,
bedroom, living room, etc.)
- No access to rest of house (staircases separating floors)
- No ramp accessibility to main level of home
- Renovated bathroom has a lip on the floor around the shower - this limits Chart's I
with maneuvering/propelling shower w/c - (another therapsit brought shower bench,
but client has not yet tried this AE)
- Yard - have to access his basement through a backdoor into backyard
Social: Chart values his relationships with both friends and family members; he also relies on
these relationships to assist with transportation, transferring, ADL and IADL needs.
- he has friends that he watches movies with, hangs out with, and goes places with
(community access & mobility)
- has 2 teenage sisters and his parents (family social) whom he socially interacts with.
- Although unknown, he likely has a social community through his online gaming.
- He enjoyed playing sports (basketball) and would play with friends.
- Friends and family got together to raise funds for Chart to receive PT out of pocket
- Social interactiosn during appointments (physicians, PT, OT, Voc. Rehab, etc.)
- participation in programs for individuals with disabilities to stay active (i.e. Trails
group went Hand Cycling at park)
Personal: Chart is a 22-year-old male client with a C6-C7, ASIA A SCI, 1 and 1 week year post
accident. He lives with his family in an renovated apartment (made to be more w/c
accessible), in the basement of his parent's home. Prior to the accident, Chart with I
with all ADLs, and able to perform many IADLs, but was still reliant on parent's
(especially mother) for tasks such as cooking and cleaning the household)
- Client is unemployed, but is working with Vocational Rehab to develop work skills
and get back into school and/or get a job.
- all aspects of client's life (all morning) - he required assistance to do everything in…

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Temporal: - Chart is at the stage of his life - Early adulthood - where he should have been
developing independence in all ADL and IADL tasks prior to injury; it is unclear if this
is simply a cultural preference, or if it shows lack of direction and motivation in life.
college age, beginning jobs/careers).. He is also at the stage where life is typically the
most active and busy, but he has many limitations for access to the environment,
mobility and currenlt independence that are impeding his ability to be very active and
busy!
- Season of the year will greatly impact Chart's schedule with his morning routine and
with dressing - especially LE dressing (as dressing LE in shorts, no socks and likely
slip on sandals is (in theory) much easier, much quicker, and requires less energy to
perform - as opposed to dressing in the winter when long pants, socks, warmer shoes,
etc. are more appropriate for season & weather. Additionally, colder months may call
for client to wear gloves, which may impede his ability to use his tenodesis (if
developed) as effectively.
- in post-acute phase of his injury (over 1 year post-injury), but still may be potential
for functional gains.
- Schedule for cathing - every 4 hours (day time), and ever 6 hours (night time)
- ADLs and IADLs are also influenced by and dictated by caregiver's schedules.
Virtual: - Chart spends a lot of time online - specifically he enjoys oline gaming, and likely
uses outlets such as social media/email on computer.. It may be beneficial to help
client locate online chat rooms or support groups for people in a similar situation to
him.
- if Chart wanted to send a message to his friends, it may be time consuming (to type
onto keyboard with limited hand motor precision), or it may be frustrating (if trying to
type from speech, but the program isn't working efficiently).
Prior Occupations:
- Prior to the accident resulting in SCI, client was a college student attending Salt Lake Community
College (SLCC), completing his general studies credits, and considering career paths - possibly
computer science.
- Client was I in all ADLs (dressing, bathing, toileting, etc.), but was limited in IADLs (cooking and
home management) - likely d/t lack of motivation, cultural beliefs (mother wants to/ or is expected
to cook and maintain household? - not necessarily d/t lack of ability.
- Prior to accident, client was living at home, played sports with his friends (basketball especially),
and was very active.
- I with transportation - unclear if able to drive/have access to a car - but ability was there.
- was able to prepare simple meals in microwave (top ramen & macaroni and cheese)
Current Occupations:

Page 3 of 25 Revised 1/9/17

- Hanging out with friends, watching movies, being on the computer, online gaming, reading (on
Kindle), etc.
- Trying to stay active through handcycling through the Trails Program at Fairview Park.
- Vocational Rehab - unclear how often, but is working on basic working skills, getting some funding
for schooling, and possibly assistance w/ enrolling in school for the coming semester.
- Preparing to go back to college classes (SLCC) next semester! - online, as transportation situation
is unknown for now.
- Attending Therapy and doctor's appointments (OT, PT - beginning again soon, and Voc Rehab
(little is known about this)
- Self-Care (brushing teeth, hair, showering, dressing, toileting - bowel & bladder management w/
cathing, bowel care unknown, etc.)
- Dressing specifically - UE is good, LE is tough and requires A - socks are very difficult, D for
socks - can get on slip on shoes
- cooking - wants to learn new skill to cook better, be more independent and improve his nutrition (if
someone else isn't making it for him, then he is eating easy foods that aren't always very healthy.
- IADLs - is able to prepare simple cold meals
- Functional Mobility - w/c accessibility and ability to propel/maneuver (uphill is challenging, flat
surfaces are okay), shower w/c (unable to self-propell over lip in shower - so not I in bathing), unable
to access other floors in home. Transfering to and from surfaces (uses transfer board). Also has sleep
number bed to assist w/ bed mobility.
- A lot of Leisure tasks now being homeboud & basement bound (reading, computer, hanging out
with friends, watching tv/movies, etc.)
- Trunk Control/Dynamic sitting - he has poor trunk stability and control d/t lack of ability to fire
abdominal muscluature. - uses arms to balance and prevent self from flopping frontwards or
sideways in chair..Need more information from observation.
- Hand cycling activity - w/Trails program at Fairview park - trying to stay active.
- able to use mouse and keyboard to control computer.

4: Top Three Client/Family Goals and Priorities

1. Be able to independently dress LE

2. Learning new cooking skills - more complex cooking tasks

3. Being able to independently bathe and manage bowel and bladder (i.e. self-catheterization of
bladder) - so doesn't have to rely on mother doing these tasks.

4. Client would also like to get back to driving, working, going back to school, and ability to live I in
future if he chooses to move out of his parent's house eventually. - these are not goals I will be
addressing with him at this time however.

5. Diagnosis and 6. Scientific Reasoning & Evidence

Expected Course List the barriers to performance typical of this diagnosis:

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ASIA A (complete)
Spinal Cord Injury (SCI) Movement Possible: - from Pedretti Ch 36 (pg. 969- 977)
at C6-C7 level with an C6
additional fracture at T1 - Scapular protractor – some horizontal adduction, forearm supination,
radial wrist extension (absense of wrist flexion, elbow extension, hand
Expected Course - movement; - total paralysis of trunk and lower extremities
Prognosis for recovery: - Respiratory – low endurance and vital capacity – paralysis of
- severity of original intercostals – may require assist to clear secretions
injury will determine - Bowel – some total A – equipment – padded tub bench w/commode
whether recovery will cutout – other AE as needed - Bladder - Some total assist w/ equipment –
occur (no severity test may be I w/ leg bag emptying – AE as indecated
avaliable) - Bed mobility – some A – full electric hospital bed w/ side rails
- incomplete injuries are - Bed to w/c transfers – some A to I (level surface), some to total A
associated w/ better (uneven surface) – transfer board or mechanical lift
chance of further - w/c propulsion – power chair I, manual – I indoors, some to total A
recovery than complete outdoors
injuries - but neigher has - Pressure release/positioning – I w/ equipment and/or adapted techniques
guarantee for full - Standing/ Ambulation - Stading: total A – ambulation: not indicated –
recovery. hydraulic standing frame
- most recovery that will - Eating – I w/ or w/o equipment; except cutting – total A; (AE – U-cuff,
occur will start within the tenodesis splint, adapted utensils, plate guard)
first few weeks - each - Grooming – some A to I w/ equipment; AE as indicated
day w/0 any return of - Dressing – I UE; some A to Total A for LE – (AE – button-hook, loops
function means liklihood on zippers, pants; socks, velcro on shoes)
of recovery is reduced - Bathing – Upper body – I; Lower body – some to total A (AE – padded
- no amount of hard work tub/transfer bench or shower/commode chair – handheld shower – AE as
will cause nerve function needed)
to return - Communication - I w/ or w/o equipment – (AE as indicated – tenodesis
- rehabilitationwill not splint; writing splint for keyboard use, buttonpushing, page turning, object
affect the degree of manipulation)
recovery (rehabilitation is - Transportation - I driving from w/c – mod van w/ lift – sensitized hand
to prevent further controls – tie-downs for w/c
medical complications - Homemaking - Some A w/ light meal preparation – Total A for all other
through ecucation, homemaking - AE as indicated
maintain and improve - Assistance Required - Personal Care: 6 hours/day – Home care: 4
strength and skills hours/day
present, maximize
function and facilitate C7 –C8
mobility to optimize - Elbow extension; ulnar/wrist extension; wrist flexion; finger flexions
lifestyle options for client and extensions; thumb flexion/extension/abduction - Paralysis of trunk
and family and lower extremities; limited grast and dexterity secondary to partial
intrinsic mm of hand (c8)
Acute care: - Respiratory – low endurance and vital capacity – paralysis of
- possible surgery intercostals – may require assist to clear secretions
immediately after surgery - Bowel – some to total A – equipment – padded tub bench w/commode
to decompress and re- cutout – other AE as needed - Bladder – I to some A– AE as indecated
align spine, stabilization - Bed mobility – I to some A – full electric hospital bed or full to king
of zpine, anti standard bed
inflammatory and

Page 5 of 25 Revised 1/9/17

steroidal drugs to - Bed to w/c transfers –I (level surface), I to some A (uneven surface) – w/
minimize swelling or w/o transfer board
- Neurological exam - w/c propulsion –manual – I indoors and level outdoor – some A for
performed (regularly in uneaven outdoor
the beginning), to assess - Pressure release/positioning – I w/ equipment
level of injury - Standing/ Ambulation - Stading: I to some A – ambulation: not indicated
calssification - scanning – hydraulic or standard standing frame
and imaging for further - Eating – I – AE as indicated
evaluation. - Grooming – I – AE as indicated
- Dressing – I UE; I to some A for LE – AE as indicated
Complications from SCI - Bathing – Upper body – I; Lower body – some A to I (AE – padded
to remain aware of: tub/transfer bench or shower/commode chair – handheld shower – AE as
- skin breakdown, needed)
pressure sores, decreased - Communication - I (AE as indicated)
vital capacity, - Transportation - I in car if I w/ transfer and w/c loading/unlocaing ; I in
Osteoporosis, Orthostatic driving modified van from capitain’s seat - Modified vehicle – transfer
Hypotension, board
AUTONOMIC - Homemaking - I w/ light meal preparation and homemaking – some A in
DYSREFLEXIA, complex meal prep and heaving housecleaning - AE as indicated
Spasticity, Heterotopic - Assistance Required - Personal Care: 6 hours/day – Home care: 2
Ossification. hours/day

Barriers to performance typical for this diagnosis -

- functional limitations & impairments (lack of muscle
innervation/strength), decreased mobility and independence with
functional tasks. Decreased grip strength, no intrinsic hand muscles
movements, uneven distribution between BUE (for C6-C7 injury - one
side is commonly more effected than the other). Decreased endurance.

Articles -
This article supports the use of the SCIM as a functional measurement in
post-acute rehab program for people with SCI.
https://www.nature.com/articles/sc2009140

This is a reaserch platform from AJOT about the Longitudinal change in

ADLs for persons with SCI. It supported the importance of
"understanding functional patterns of SCI across time… is an essential
step to predict, monitor and improve long-term recovery for individuals
with SCI".
https://ajot.aota.org/article.aspx?articleid=2636566&resultClick=3

7. Practice Models Guiding Assessment and Rationale

Treatment

Page 6 of 25 Revised 1/9/17

1. PEO PEO is a relevant model to use with Chart due to
how his ASIA A Spinal Cord Injury (SCI) at C6
– C7 may have effected the congruence between
the Person - (Chart), the Environment - (his
adapted apartment in his parent’s basement, that
was built to fit his needs post SCI), and then
with the Occupations, (such as independence in
ADL, IADL and leisure tasks).
PEO can help to guide assessment and treatment
by being aware that sometimes, it is easier (and
more appropriate) to make changes to the E, or
the O, rather than to the P. For example. PEO
can help therapist to understand that adapting the
task or environment by suggesting an
environmental modification (getting a more
mobile shower chair that can be wheeled in and
out of the shower with ease to increase Chart’s
independence) is likely a better starting point
than attempting to jump straight into changing
the person (which, other than through allowing
contractures resulting in tenodesis, this is almost
impossible), while also making it occuaptiona
based by focusing on LE dressing, self-care, and
cooking goals.
2. Rehabilitation The use of the Rehabilitation Model with Chart
is to address his neuromotor limitations and
challenges, as well as to begin to assess any
cognitive or psychosocial deficits he may be
experiencing (if any are found to be present).
This is relevant to Chart because it is important
for him to begin to utilize adaptive
techniques/compensatory strategies and
adaptations to the environment or occupation in
order to improve independence and functional
abilities during LE dressing, cooking, and other
ADL and IADLs (such as adding a shower
bench/chair to her bathroom to promote a safer
and more independent bathing environment), (or
such as utilizing AE such as a tenodesis splint,
dycem or adaptive cooking supplies -possibly a
suction-cup mixing bowl). It is important to
help Chart begin to utilize various techniques,
compensatory strategies in his home in order to
increase his independence and maximize
performance and participation in occupations.

Page 7 of 25 Revised 1/9/17

3. Biomechanical The use of the Biomechanical Frame of
Reference is important to use with Chart due to
his SCI. It would be important to enhance
occupational performance through increasing
strength (in both UE - it is unknown which is his
dominant hand and which side is C6 vs c7 inury,
but it is important to build up strength in both to
allow for better bilateral function), assessing and
possibly increasing proximal ROM (to keep the
UE as functional as possible - while also NOT
stretching out the contractures on the C6 side
that can be used functionally for tenodesis), and
also to improve endurance.

8. Specific Areas of Occupation

What do you know? What do you need to know?

Page 8 of 25 Revised 1/9/17

ADLs:
-BATHING/SHOWERING – I, but needs
assistance to propel shower w/c over lip on
shower floor – also likely needs supervision or
CGA for safety while transfering
-TOILETING - Needs to Cath every 4 hours
(during day), and every 6 hours (at night)
- DRESSING – I w/ Upper Body dressing, needs
A for Lower body dressing
-FUNCTIONAL MOBILITY - uses w/c for
mobility, has ramp to access his apartment, but no
access to other floors in house. Has sleep number
bed. Transfers w/ transfer board - uneven surfaces
are more difficult. uphill is more difficult in w/c.
IADLs:
- COMMUNICATION MANAGEMENT -he is
on his computer a lot.
- DRIVING/COMMUNITY MOBILITY - he is
unable to drive right now, gets rides from friends
or from mom/family. he hopes to drive again in
the future.
-FINANCIAL MANAGEMENT - he recieves
funding for OT through Private insurance
-HOUSEHOLD MANAGEMENT - prior to
accident, it seems that his mother did most, if not
all, of the houseohld work.
-MEAL PREP/CLEANUP – could make mac and
cheese and top ramen in the microwave
-EDUCATION – He was attending SLCC
working on general studies. He is working with
Vocational Rehab to get set up to re-start classes
next semester – he is thinking he may want to
study computer science. Waiting to return to
campus until transportation can be arranged.
- WORK - He is interested in working in the
future.
- LEISURE – He enjoys hanging out and
watching movies with his friends, reads a lot, is
on the computer a lot, he is a gamer, he likes to
stay active (enjoyed playing basketball prior to
accident), and occassionally will go do activities
with Trails (i.e. handcycling at the Park). He
does not seem to get out of his apartment very
much, but he has a lot of free time for leisure
activities.
- SOCIAL PARTICIPATION
Community- Trails participation
Page 9 of 25
NEED TO KNOW:
ADLs:
-BATHING/SHOWERING - level of assist
(LOA)needed during transfer from w/c to shower
w/c.
- TOILETING/HYGIENE - need to know Assist
level required for transfer to toilet from w/c
(when going to w/c); What type of Cath/Cath
system is client currently using? does this system
change if client is in the community? how is
client managing challenges they may be having
(ie. balance while wiping; LOA and type of A w/
Bowel stimulation, supository, Catheterization,
etc.); how are they managing toileting while out
in the community. In general, bowel and bladder
routine (does he have one? How is it working?)
- Current Bowel & Bladder management plans,
techniques, schedule, level of assistance needed,
time requirement for voiding/bowel movement.
- Daytime VS. Night Bowel & Bladder routines
- Classification of Neurogenic Bladder and
Bowel (reflexes intact? , sensation? … etc.)
- Use of commode, transfer to toilet, or external
toilet commode frame?
- DRESSING - LOA needed for LE dressing,
what parts of dressing is challenging? Is he using
any AE for dressing? Does his mom retrieve his
clothes for him? Does he get dressed early each
morning, or will he spend a lot of his time in the
clothes that he slept in? Is he choosing which
clothes he wants to wear? What types of clothing
does he prefer to wear/learn how to self-dress
with? How long does this routine typically take?
How much is Chart helping right now? How
much is mom just doing? Is he getting dressed
while in his bed, or while in his w/c, or
somewhere else? How is the clothing storrage
accessibility in his room?
-FUNCTIONAL MOBILITY - Is he able to get in
and out of house independently (up/down ramp
into his apartment). How is his bed mobility?
How does he transport items?
IADLs -
COMMUNICATION MANAGEMENT - does he
have a phone/cell? can he/how does he
communicate with others (text, calls, social
media, just on the computer, etc.)?
Revised 1/9/17
Family – he is a son, he has 2 teenage sisters, and
a mother and father – all who appear to support
him. His mother is his main caregiver and helper
throughout the day, as she works at home.
Peer/Friend – He at least has a few friends that
come visit him, go to the movies with him, and
take him for drives.
Page 10 of 25
- DRIVING/COMMUNITY MOBILITY - has he
ever used public transportation or would he want
to? is he satisfied with relying on others for
mobility? are there some cars he cannot transfer
into? does he use a lift? (likely just a transfer
board)
- FINANCIAL MANAGEMENT - does he have
any other form of income/assistance? Is he able to
buy the things he wants and needs?
- HOUSE MANAGEMENT - does he want to
help out around the house more? does his mom
want him to ?
- MEAL PREP/CLEANUP - is he planning out
meals? does he ever help prepare meals or set the
table? does his mom cook all of his meals for
him? is he eating alone, or does his family come
to his apartment to eat with him? does he help
clean up after meals? (putting things away,
washing dishes, etc.)
- WORKING - unclear if he has worked before
- SOCIAL PARTICIPATION - unknown how
much/often he is engaging with his family, and
what they do together -mentioned friends a lot,
but not really family much. He mentioned Trails,
but didn't say how often he is participating.
Revised 1/9/17
 9. Performance Skills
What do you know?
MOTOR SKILLS -
- aligns - he was proping himself up on back of
couch during interview.
- he is able to move his w/c around his apartment
PROCESS SKILLS -
- organizes - his apartment was organized
(meaning, his computer area was set up for
optimal use, he had space to move around, etc.
SOCIAL INTERACTION SKILLS -
As Chart does not have known cognitive deficits,
I would expect that all of these skills are intact.
- he socializes with friends, therapists and his
family.
10. Performance Patterns-Habits, Routines, Rituals, Roles
What do you know?
Page 11 of 25
What do you need to know?
MOTOR SKILLS -
- stabilizes - how is his balance? can he sit
straight without needing to stabilize?
- reaches - how is he reaching for items? does he
use AE? does he loose balance?
- bends - can he sit himself back up if he bends
too far forward?
- grips - does he utilize tenodesis? how is he
gripping items functionally? does he use AE?
-manipulates, movies, lifts, transports, endures -
need to observethese skills in general
PROCESS SKILLS -
- most of these process skills still need to be
observed. Most important to observe are the
following :
accommodates - is he able to prevent ineffective
task performance; Restores - does he put away/is
he able to put away tools and matierials in
appropriate places (mom is currently doing this);
Paces - is he able to pace activities to optimize his
endurance?; is he able to Choose, Use and Handle
tools (AE) appropriately and functionally?; is he
able to Gather and Locate items, tools or
materials for a task?
SOCIAL INTERACTION SKILLS -
- Expresses emotions - is he able to effectively
express his emotions when frustrated, needing
help, or wanting to do something for himself?
What do you need to know?
Revised 1/9/17
 - Needs to Cath every 4 hours (during day), and
every 6 hours (at night)
- Mom helps him get dressed in the morning
- has scheduled therapy sessions and Dr.
appointments that he attends.
- He is a son, a friend, a big brother and (if he
considers this a role) a student/person with a
physical disability/limitation.
11. Activity Demands for the Client Goals and Priorities
What do you know?
Page 12 of 25
Need to know more specifics about hygiene
routines (time of day/how often showering - does
the time of day impact his energy levels an
influence his safety during showering?), more
specific information about his Bowel and Bladder
management routines!
When does he game? - is there a specific time of
day/week that he meets up with friends online to
play games?
What does his morning routine look like? Does it
happen around the same time everyday? What
about his day routine? Evening and Night
routines? Is there any specific weekend vs.
weekday routines he and his family do?
Need to know other habits, roles, routines and
rituals.
Could ask him about specific routines and habits
that he has, or use to have, that he thinks he will
now have difficulty doing because of his current
condition and mobility challenges.
What do you need to know?
Revised 1/9/17
Catheterization:
-need to cath every 4 hours (during day), and
every 6 hours (at night)
Relevance & Importance to client -
- he wants to be I so that his mom doesn't have to
help him cath forever.
Objects used -
- he uses some type of catheter
Space Demands -
- would need a large enough space to either
transfer onto toilet to empty, or get w/c close
enough to toilet to empty collection bag attached
to catheter.
Social Demands -
- is currently relying on others (mom?) to cath
him
Sequencing and Timing -
- must insert cath once bladder is full, but either
be on toilet to catch drainage, or have cath
attached to collection bag. be prepared, or it can
make a mess.
Required actions/performance skills -
- grip/manipulation needed to open package,
position and insert cath, and remove cath - as well Required Body functions -
as stabilize penis during cathing. - also being able - is he able to grip? can he use tenodesis to
to feel the sensation of needing to urinate is
helpful.
Catheterization:
Objects used -
- what type of catheter(s) does he use? does he
use the same during the day and in the evening?
does his insurance pay for them? is he able to do
any of the task on his own? has he tried using
anytype of AE?
Space Demands -
- is he currently transfering onto toilet? or
draining while sitting in w/c?
Social Demands -
- what does he do if mom is not avaliable?
does/can he talk someone else throug it? is mom
doing it everytime?
Sequencing and Timing -
-need to know specific type of cath/cath setup
used to determine appropriate sequencing and
timing.
Required actions/performance skills -
- need to observe to determine what
grip/manipulation is needed to open package,
position and insert cath, and remove cath - as well
as stabilize penis during cathing.
cath/use AE?

Required Body functions -

- must be able to move hands into appropriate
place to perform cathing, must be cognitively
aware of steps needed to safely perform and how
to maintain clean technique

Required Body structures -

- need hands, penis, and a bladder that will
support the use of an intermittent cath - or
possibly do indwelling

12. Client Factors- Values, Beliefs, Spirituality

What do you know? What do you need to know?

Page 13 of 25 Revised 1/9/17

He values his friends and family. He values - Do not know if he has a specified spirituality or
therapy and progressing forward with what he is religious affiliation.
able to do. He values his computer and gaming, - Do not know his beliefs on what is possible for
watching movies with friends, reading and him to do/achieve in his life, despite limitations
staying active. He believes that he will possibly from SCI.
be able to drive someday. He values his
education and is working towards returning to
school next semester. He values increasing his
independence in self-care tasks (dressing,
cooking, self-cathing, etc.).

13. Client Factors- Body Functions & Structures

What do you know? What do you need to know?

Page 14 of 25 Revised 1/9/17

BODY FUNCTIONS -
- higher level cognition, attention, memory,
thought, and mental functions of sequencing
complex movement all appear to be intact.
GLOBAL MENTAL FUNCTIONS -
- seems to be conscious and aware, as well as
oriented.
- he is motivated and seems agreeable
(temperament and personality)
- he seems motivated w/school and with
increasing independence in some areas.
SENSORY FUNCTIONS -
- appears to have intact visual, hearing taste, and
smell functions
- Needs to Cath every 4 hours (during day), and
every 6 hours (at night)
Neuromusculoskelletal and Movement-Related
Functions -
- Possible shoulder pain/injury (common with
higher level SCI - d/t high impact and reliance
(compensation) at the shoulder girdle
- at risk for Autonomic Dysreflexia d/t injury
level
- at risk for skin breakdown d/t decreased
sensation - needs to do adjustments often to
prevent skin breakdown/pressure sores.
- SCI ASIA A C6-C7
- likely has respiration deficits - common with
this level of injury.
Page 15 of 25
BODY FUNCTIONS -
- need to know his Experience of Self and Time -
has his awareness of identity changed since the
injury? if so, how?
- Emotional - is he able to regulate and express
his emotions appropriately since his injury? when
he gets frustrated, how does he react/respond?
GLOBAL MENTAL FUNCTIONS -
- unclear how his temperament and personality
has changed/been influence since accident - does
he maintain self control? does he have
confidence?
- how is his energy level? does it change
throughout the day? is his motivation poor in
some areas?
- sleep - how are his sleep patters/routine? does
he feel restless?
SENSORY FUNCTIONS -
- these need to be determined - specifically touch,
pain, proprioception vestibular and thermal
awareness. - important to know his level of
awareness for these for safety and functional
purposes.
Neuromusculoskelletal and Movement-Related
Functions -
- need to assess AROM in UE (for functional use,
reaching, etc.), and possibly LE (for flexilibity in
LE dressing - i.e. moving foot to opposite knee to
don socks)
- joint stability is also unknown - shoulder girdle
may be compromised d/t impact from transfering.
MUSCLE FUNCTIONS -
- muscle strength, endurance (muscle and
respiration endurance) and tone (is spasticity
present? )
MOVEMENT FUNCTIONS -
- how is his invoulntary movement reactions? -
can he do body adjustment reactions or postural
reactions?
OTHER FUNCTIONS:
- How is his blood pressure? Does he know how
to recognize and respond to Autonomic
Dysreflexia?
Revised 1/9/17
 - Current Bowel & Bladder management plans,
techniques, schedule, level of assistance needed,
time requirement for voiding/bowel movement.
- Daytime VS. Night Bowel & Bladder routines
- Classification of Neurogenic Bladder and
Bowel (reflexes intact? , sensation? … etc.)
- Use of commode, transfer to toilet, or external
toilet commode frame?
- Client likely has respiration deficits/limitations
(common w/ his level of injury)
- hand dominance
- Which side R vs L UE has which level of injury
(C6 or C7)
- is client currently using tenodesis? How are his
contractures? (tight enough for function?)

Page 16 of 25 Revised 1/9/17

 14. Evaluation: What Assessment tools and other means of assessment will you use?
Top Down Assessment: Prioritize one Occupation to observe the client perform
Observed Occupation
Observe Chart doing part of his typical morning
routine - specifically - LE dressing
Method/Tool
Page 17 of 25
Rationale/How will you use this information
I would use this opportunity to observe and
evaluate many of the above mentioned motor
and processing skills that need to be further
assessed. By having him perform his morning
dressing routine (LE only), I can observe his
functional mobility around his room (to gather
his clothing - unless his mother is doing this for
him), I can observe how/if he is transporting or
carying things from one location to another, and
how he is manuvering w/c around space (is he
pushing or pulling, or using hand holds on the
wheels, is he using both arms equally, etc.)
This task will also allow me to evaluate his
pacing of the activity, and begin to determine
level of assist he may need. I would like to
observe him first doing the task with his
mother's assistance (how they typically do it),
and then I would like to observe him attempting
the task (pants, shoes and socks - I would skip
underware in this initial meeting if he were
feeling uncomfortable) on his own, to determine
a baseline. During this observation, I can also
strike up a conversation with him (if he is able to
effectively multitask) to gain more background
information about his interests, concerns, life
history (basic), and begin to build a therapeutic
relationship with her, as well as begin to get her
"buy in" to the therapy sessions. Later on during
the observation, I would also (if appropriate)
begin to provide feedback, guidance and cuing
to see how/if he responds. I would also try to
introduce some simple strategies for him to try
as the activity comes to an end.
Rationale/What is being Assessed
Revised 1/9/17
1. Sensation on B UE and upper trunk It is important to assess his level of sensation on
(Light Touch - monofillaments, Proprioception, his UE and trunk to help determine where his
Temperature and Pain) sensation is intact, where it may be absent, and
where he may have partial sensation. It is also
important to determine which arm has which
level of sensation - it is a safety concern for
tasks (i.e. being able to sense temperature on R
forearm, but not on L forearm, will help client
(and therapist) be aware and problem solve when
this will be important to use functionally - such
as when testing the shower water with the R
forearm prior to getting completely in the water
to prevent burns.
2. MMT BUE it is important to test MMT on both UE to
determine where strengths currently are,
determine if there are any weak innervations that
could be strengthened and used functionally.
Also, It would help me to assess which side (R
or L) is classified as C6 and C7. Being aware of
which extremity has which function will help
therapist determine more effective and efficient
set-up for tasks (i.e. if they have C7 function on
their R side, you would likely have them hold
items on lap with L arm while they use R arm to
reach for items) and the best techniques and
strategies to implement.
3. AROM BUE I would have him perform AROM on both UEs
to create a baseline of avaiable range, and to see
where (if any) limitations or challenges exist.
Additionally, understanding what client is able
to actively do in each extremity, will help
determine what may be possible functionally,
and thus would help determine which strategies
and techniques would be the most beneficial
with client.
4. ADLs - SCIM This ADL assessment is a specialized version of
the FIM scores, but specific to SCIs. Although
likely meant for inpatient use, the sections in this
assessment were more relevant to Chart than any
other assessment I could find. While all sections
were relevant, I especially would like to see the
results of the Respiration and Sphincter
managemnet section - I would likely use this as
a semi-structured way to ask Chart (and his
mother) about specifics with bowel and bladder
care and respiration.

Page 18 of 25 Revised 1/9/17

5. Jebsen Hand Function This assessment will help determine baseline
level of function for Chart on both UE. A
section of this test requires client to pick up
heavy and light items, which is one of the main
reasons I would want to perform this assessment
(or at least perform pieces of the assessment). I
would like to see if and how client picks up
these different items to help determine what
about the items may be challenging.
6. Mental Health Screen SCIs often cause mental health concerns (such
as depression, loss of positive body-image,
fellings of grief, etc.), so I would do a very brief
mental health screen to determine if any
concerns are present. If concerns came to light, I
may then refer him to additional treatment or
counceling to address these concerns.

15. CPT Evaluation Code: Justification

High Complexity Chart should be considered a High Complexity CPT Code based on the
(97167) following items:

Occupational Profile/Medical and Therapy History -

- Chart has a high complexity Profile and History d/t extensive inpatient
and outpatient therapy post-SCI for over 1 year (barely). His history is
specific to one condition (ASIA A SCI at C6-C7), but this condition is
extensive and has had a HUGE impact on every aspect of Chart's life
and previous occupations/levels of functioning. Additionally, Chart was
involved in many occupations prior to injury (college, sports teams with
friends, independent with all ADLs, independent with many IADLs,
going out with friends, lived with parents, drove, etc.), and is still
motivated to be involved (participating in Trails activity programs,
doing therapy (OT, PT soon, and Vocational), hanging out with friends,
wanting to get back to driving, possibly working, possibly moving out
in future, and getting back into college classes (online) next semester).

Assessment of Occupational Performance & Identification of Deficits -

- Chart will require pretty extensive assessment in order to identify and
pin-point deficit areas. SCIs cause extensive performance - skill and
pattern - deficits (more than 5 physical, based on the high complexity
classification) that result in activity limitationsn and/or participation
restrictions.

Clinical Decision Making -

- Chart will have high complexity classification d/t comprehensive
assessments needed (MMT, AROM, Sensation, observation of
occuaptional performance, etc.), consideration of multiple treatment
options (tenodesis, AE, dynamic splinting (although not likely), address
spasticity (if applicable) w/ modalities, and occupation-based
intervention, etc.), severe modifications (depending on deficit

Page 19 of 25 Revised 1/9/17

 addressed) - and high analytic complexity (understanding on neuro
anatomy and physiology of SCI, assessment and interpretation methods,
ruling out possibilities and pin-pointing abilities and functional
areas/levels). However, Chart does not at this time have a Comorbidity
(that I am aware of)

The classification code is based on the lowest level in the three above
listed sections; all 3 sections are justified for High Complexity,
therefore, the code should also be High Complexity (97167).

16. Projected Outcomes: Type of Outcome

Improved independence with ADL and IADL tasks around the home Occupational
- increased independence in LE dressing, bathing routines Improvement
- increasing safety, independence and attention with cooking/baking
- increasing independence with bowel/bladder care (cathing) Quality of Life

17. Resources and Team Members

- Physician (general health & Neuro specialist)
- Chart (patient) is the most important member of his care team.
- Chart's parents (and possibly sisters).
- Local home health supply company - as a resource for family to purchase safe/more accessible
shower w/c (or bench - & depending on how trial of bench previous OT brought for Chart to try out).
- possible referral to psychologist to address any mental health concerns (depression)
- Physical Therapy
- Trails Program (and other outdoor active involvement groups for SCI or disabilities)
- The National Spinal Cord Injury Association webpage - https://www.unitedspinal.org/resource-
center/askus/index.php?pg=kb.page&id=401

18. Intervention Plan

Barriers Supports

Page 20 of 25 Revised 1/9/17

 - Possible household barriers (i.e. not having a shower chair - Adaptive Apartment in basement
that can be easily and I manuvered - get over bump on floor), of parent's home
lack of w/c accessibility to enter/exit home on other levels of - Health Insurance - for OT
home, or from the front door) may limit outcomes. (seeking continued services)
- Possible lack of strength, endurance or ROM may - Fundraising (and people who care
contribute to requiring assistance with more complex tasks. enough to set up and facilitate
- possibly Chart's motivation to be completely independent in fundraising) - for PT
life- he was dependent on his mother for household tasks prior - Chart is motivated to keep
to injury - it is unclear if he is motivated to be completely moving forward in life (going back
independent in life, or if he would prefer to have assistance to school, getting a career, learning
for some things (i.e. cleaning/maintaining a home/living to drive, being independent,
environment)- he has shown motivation in some tasks though, continuing to learn and be active
so motivation could also be a strength! within his new ability set.
- Has social support through friends
and family
- Has friends and family willing to
provide transportation to
appointments, to outings, etc.
Goals Practice Model for each goal
1. LTG:
Within 10 weeks. client will I perform self-cath routine using PEO, Biomechanical & Rehab
AE while maintaining clean technique, within a 20 minute
time frame.
1a.STG:
Within 6 weeks, client will I insert catheter using AE Rehabilitation
(tenodesis catheter inserter), while maintaining clean
technique.
1b.STG:
Within 2 weeks, client will I open catheter while maintaining Biomechanical
clean technique within a 2 minutes time frame.

2. LTG:
Within 10 weeks, client will I dress LE by utilizing AE and PEO, Biomechanical & Rehab
compensatory strategies and maintaining safety, within a 40
minute timeframe.
2a. STG:
Within 7 weeks, client will dress LE with Mod A while Biomechanical & Rehab
utilizing AE and maintaining safety, within a 35 minute
timeframe.
2b. STG:
Within 4 weeks, client will increase UE strength needed to Biomechanical & Rehab
bring foot up to opposite knee utilizing AE and maintaining
safety.

Page 21 of 25 Revised 1/9/17

3. LTG:
Within 8 weeks, client will independently prepare a simple PEO, Rehabilitation
stovetop meal using compensatory strategies while
maintaining safety.
3a.STG:
Within 6 weeks, client will prepare ingredients with Min A Biomechanical, Rehab
for a simple stovetop meal, using compensatory strategies and
while maintaining safety.
3b. STG:
Within 2 weeks, client will I retrieve and transport cooking PEO, Rehabilitation
supplies to workstation, while maintaining safety.

Page 22 of 25 Revised 1/9/17

19. Treatment Sessions: Plan for first two 45 minute treatment sessions:
1. What will you do? Identify Approaches Based on which
goal(s)?
- (20 Minutes): Observe Chart's typical morning Establish/Restore , 2, & 2a
lower body dressing routine w/ assistance from his Modify
mother. Have Chart (and mom, as needed) both
Don and Doff LE clothing - pants, shoes, socks, and
underware (if Chart feels comfortable doing this on
day 1).
- Things I will be looking for: (does his mom
retrieve his clothes for him? does he get dressed
early each morning, or will he spend a lot of his
time in the clothes that he slept in? Is he choosing
which clothes he wants to wear? What types of
clothing does he prefer to wear/learn how to self-
dress with? How long does this routine typically
take? How much is Chart helping right now? How
much is mom just doing? Is he getting dressed
while in his bed, or while in his w/c, or somewhere
else? How is the clothing storrage accessibility in
his room?)
- (5-10 minutes): After this initial run through, I
would spend 5-10 minutes providing feedback and
instruction to client and/or mother to help them
challenge Chart's level of independence. At this
point, I may suggest strageties or the use of AE
(which I will have brought - a few options at least)
he can try during these tasks.
- (20-25 minutes): Next, I would want to observe
Chart donning the LE clothing as independently as
possible. I will be close by to provide assistance
and direction as necessary, but will want Chart to
utilize strategies and/or AE as independently as
possible. (if mom is willing to stay, it may be
helpful for her to learn helpful levels of A to give)
- (5-10 minutes): Next, the same steps will be taken
but while doffing LE clothing.
- Based on how the strategies and AE are helping or
hindering Chart's performance and independence,
and depending on the amount of time left in the
session, I would possibly run through the whole
routine again. Most likely, I would choose one
component (i.e. putting on socks) to spend more
time on for the remainder of the session.
- I do not expect that Chart will be I with LE
dressing (or even any component of it) after this
one session, but this will provide me with a good
idea of what specific areas would be good to focus
on in later sessions.

Page 23 of 25 Revised 1/9/17

2. What will you do? Identify Approaches Based on which
goal(s)?
- Observe client make a simple cold meal (making a Establish/Restore, 3, 3a, & 3b
sandwhich). The purpose of this activity is to Modify
observe Chart's functional mobility around the
kitchen and observe how he is currently retrieving
and transporting food items and cooking items from
around his kitchen space, as well as observe how he
is opening containers and using cooking utencils.

- Provide Chart with a simple recipe and

instructions for making a sandwhich (2 slices of
bread, sliced ham, pre-sliced cheese, pickle slices,
mayonase and mustard; and plate, knife for
spreading, fork to retrieve pickles from jar,
papertowel, etc.).

- (15-20 minutes): Have Chart locate all items,

retrieve them, and transport them back to work
station (this will give me a better idea of how his
functional mobility is, how is he reaching for items,
what is the most difficult part of retrieving items,
are different types of items more difficult for Chart
to retrieve and/or transport, etc.)

- (30-35 minutes): Have Chart follow instructions

for making a sandwhich; for example:
1. put 2 slices of bread flat on plate
2. Open mayo bottle; use butter knife to get mayo
out of bottle and spread mayo on one side of each
slice of bread. Repeat step 2 with mustard.
3.Open package of sliced deli meat, put desired
number of slices of meat onto one piece of bread.
4.Open package of sliced cheese, put desired
number of slices of cheese onto other piece of bread
5. Open pickle jar, use fork to retrieve pickle slices
from inside of jar; put desired number of pickle
slices on top of meat on bread.
6. Put slices bread together to form into a
sandwhich.
7. Close pickle jar, meat package, cheese package,
mayo and mustard, and loaf of bread. Return all
items to where they came from. Put dirty fork and
knife in sink for later clean up.

- While Chart attempts to make a sandwhich, he

will likely run into difficulty opening and
manipulating items - I will provide assistance as
needed (especially this being an initial tx session),

Page 24 of 25 Revised 1/9/17

will help him brainstorm possible solutions through
use of gesturing and indirect VCs, and will provide
AE for him to use (tenodesis splint - pre-fab, dycem
to hold jars in place while twisting off and on tops
and for putting under plate while using knife to
spread mayo and mustard, and universal cuffs (or
similar) to assist w/ holding utensils.

Throughout activity - offering opportunities to

work on reaching/increasing ROM, practice
transporting items and performing purposeful task
that is hopefully meaninful and important to client.

If mom is willing and with her schedule permitting,

client could also make her a sandwhich, or have her
provide min to mod A (w/my guidance) throughout
the cooking task - this would provide mom with an
opportunity to learn what she can work on with
Chart between therapy sessions.

Page 25 of 25 Revised 1/9/17