Occupational Therapy Evaluation Report and Initial Intervention Plan

Background Information:
Client’s name: Client (AM)
Date of referral: 1/25/18
Date of Report: 2/4/2018
Date of Birth: 7/6/1956
Primary Intervention diagnosis/ concern: Huntington Disease, TBI, CVA, Dementia
Secondary diagnosis/ concern: Expressive Aphasia, Ideomotor Apraxia, right-sided weakness
Precautions/contraindications: Walnut allergy
Reason for referral to OT: Difficulties with eating with utensils, inability to transfer in and out of car and
bed
Therapists: Gabby Skoczylas, Kenzie Smith

S:

Client’s wife reported that he will be accompanied by an aide for the next session. Client did not like

using the swivel spoon and the spoon with the larger handle during the feeding session.

O:

Assessments performed:

Client was seen on 1/25 and 2/1 for an initial occupational therapy evaluation. A modified version of

the Canadian Occupational Performance Measure (COPM), which is a semi-structured interview, was

administered to determine client goals, priorities, strengths and weaknesses. Client’s wife was present

during both sessions and assisted Client in answering questions during the interview. Client’s numbered

ratings of the COPM were not recorded due to cognitive limitations. A modified version of the Mini-

Mental State Examination (MMSE) was also administered in order to determine the Client’s cognitive

impairment. Observations of Client’s ability to manipulate utensils and self-feed, as well as transfer into

and out of bed, were completed.

Assessment results:

COPM: A modified version of the COPM (numbered ratings not recorded due to cognitive limitations)

found that Client is dependent on majority of ADLs and IADLs. Priorities that were determined by Client
and his wife include improving the overall motor control of his right upper extremity, improving his

ability to self-feed with utensils, and improving his skills of transferring to and from the bed and car.

MMSE: Client received a score of 25/29 on the modified version of the MMSE. This indicates that his

degree of impairment is “questionably significant.” He may have clinically significant but mild deficits

that usually impact only demanding activities. Client demonstrated good short term memory but lacked

awareness in regards to the date and the day.

Observations of occupational performance: Observations of Client’s performance found that he can self-

feed independently with his right hand but has an atypical grasp when manipulating utensils. As he

brought the utensil closer to his mouth, he would speed up and insert the utensil quickly. He was able

to scoop food onto a spoon. When given a fork, he proceeded to scoop the food, and pierced the food

only when cued. He required one cue to pierce the food. He required minimal cueing to stabilize the

bowl with his left hand. Client continuously spilled on himself while eating. Before the feeding task,

Client demonstrated how he takes his medication. Client independently manipulated the vitamin C and

proceeded to chew without any difficulty or occurrence of choking.

Observation of the bed transfer found that Client requires an explanation and demonstration of verbs

and directions such as “put your knee up” and “go back.” He required min verbal cueing and min assist

to transfer onto the bed. Due to the size of the bed, the wife was unable to demonstrate the full

transfer. Client then required min cueing and min assist to stand back and sit down in his wheelchair.

During this observation, it was found that Client had urinated in his pants due to missing the urinal, prior

to the accident. His wife stated it was an accident and does not typically happen. She requested not to

document it in his “chart.”

Occupational Profile:
Client is a 61 year old male who has a diagnosis of Huntington disease, traumatic brain injury (TBI),

stroke and dementia. He has ideomotor apraxia, expressive aphasia and right sided weakness. He also

has a severe allergy to walnuts. Client and his wife are seeking services for him because he has

difficulties with manipulating utensils, using his right upper extremity and transferring to and from the

bed and car. He is dependent on his aids and wife for dressing, showering, grooming, toileting, mobility

and all IADLs. Occupations in which Client is successful in include reading the paper, watching the

Rachel Maddow show, and attending all of his therapy appointments. Client has a very positive outlook

on life and a wide variety of interests that keep him busy such as going to dinner with his wife and

friends, playing videogames and backgammon, listening to jazz music and swimming in the Trails

program. Supports to Client’s occupational engagement include his wife and his optimistic beliefs.

Barriers that are affecting his performance include his diagnoses and related medical concerns

mentioned previously. A physical barrier that is impacting Client is his high bed, because he is unable to

transfer onto it without assistance. He requires max assist to put his knee up on the bed at the

beginning of the transfer. Client’s daily morning routine includes waking up in the morning, showering,

getting dressed, having breakfast and coffee, taking his medications and reading the newspaper. He

then attends physical, neurological, occupational, speech and music therapy. He typically has fast food

for lunch and has meals delivered from Meals on Wheels during the day. Client usually comes home

around 5:00 p.m., has dinner and watches the news. Before bedtime, he watches more television and

has a snack consisting of cookies, ice cream or tapioca pudding. His roles include being a husband,

friend, father to a son with schizophrenia, and client for various therapy services. His priorities and

desired targeted outcomes include gaining more control in his upper extremity so that he can gain more

independence.

Occupational Analysis:
Areas of occupation: Client is independent in self-feeding and wife reported that he has been able to

doff a loose t-shirt, however, he typically is dependent on his wife and two aides for all ADLs and IADLs.

Client does not work or attend school. His leisure activities include reading, watching television, and

playing backgammon. In regards to social participation, he and his wife go out to dinner with friends.

He also has interaction with his aids, therapists, and other medical personnel.

Performance skills: Motor performance skills in which he shows deficits include stabilizing, reaching,

gripping, manipulating, coordinating, moving, lifting, calibrating, flowing and enduring. These deficits

interfere with his ability to properly and safely transfer and self-feed. Client did not demonstrate any

significant deficits in process and social skills.

Performance patterns: Client’s daily routine includes waking up in the morning, showering and getting

dressed (with the help of his aids or wife), eating breakfast, drinking coffee, taking his medication and

reading the newspaper. He then attends therapy sessions all day, receives meals from Meals on

Wheels, has dinner at home, watches more television and has a snack before he goes to bed. His roles

include husband, friend, father, and therapy client.

Client factors: Client values his relationship with his wife, his friendships and his independence. He has

an optimistic outlook on life and believes that he can still participate in the things he enjoys. He has a

variety of interests and hobbies, so if he cannot participate in one hobby, he still has more to choose

from. Client’s body structures are intact, however, he has deficits in several body functions. His

experience of self and time has been negatively impacted due to his dementia; this was evident during

the MMSE since he did not know the date and day, even with the assistance of a printed calendar. His

vestibular functions have also been impacted, as demonstrated by requiring contact guard assist to

maintain safe balance while standing. His Huntington disease and stroke have weakened the muscle

control in his right upper and lower extremities. He also demonstrates a lack of control of his voluntary
movements, caused by Huntington disease. This lack of control was evident in the feeding session;

Client speedily and unsteadily brought the utensil into his mouth.

Activity demands for self-feeding: The ADL of self-feeding is relevant and important to Client because it

is necessary for him to get the proper amount of nutrition, especially since he needs to maintain his

weight. His wife would also like him to eat without making a mess; this would make eating in public

more enjoyable and allow Client to keep his dignity. Objects used for self-feeding include utensils, and

any necessary dishware. Space demands required include an appropriate amount of space on the table

and a chair that he can sit on. He is allowed to make a mess in his home environment, however, that is

not acceptable in a restaurant. Social demands relevant to this activity include eating with his wife at

home, or going out to eat with friends in public. In regards to sequencing and timing, Client is able to

perform the steps of feeding in the proper order (pierce/scoop food and bring to mouth). The necessary

performance skills for self-feeding that Client is demonstrating deficits in include positioning, reaching,

gripping, manipulating, coordinating, calibrating and flowing. Required body functions include

attention, visual functions, touch functions, proprioceptive functions, joint mobility/stability, muscle

tone and control of voluntary motor movement. Required body structures include all those listed in the

OTPF.

Context: See Occupational Profile for information on context.

A:

Interpretation

Strengths and areas in need of intervention:

Client’s strengths include his cognition, his positive outlook on life and motivation to participate in

various types of therapy. Areas in needs of intervention include his ability to properly use utensils

during self-feeding, and safely transferring to and from his bed and car.

Supports and Hindrances to Occupational Performance:

A social support to Client’s occupational performance includes his wife, who is more than willing to help

Client out whenever she can. She wants him to keep his dignity and be as independent as possible. She

also encourages him to participate in therapy and various social and recreational activities. The group of

friends whom he goes out to dinner with are also a social support. A cultural support includes Client’s

optimism and belief that he can still do the things that he enjoys. Eating Chinese food with his wife is

also a cultural support and a routine that he can look forward to. A physical barrier that is interfering

with Client’s performance includes the height of his bed, as the bed is very high and it makes

transferring difficult.

Analysis summary:

The difficulties he is experiencing during self-feeding such as grasping the utensil, piercing the food, and

calibrating the movement of the utensil from plate to mouth are due to his HD, ideomotor apraxia and

his right sided weaknesses, caused by stroke. His lack of understanding of instructions during

transferring (such as “put your knee up) is due to his dementia, stroke and TBI. The physical difficulties

he is experiencing during transferring (such as not being able to lift his right limb) are also due to the

weakness and apraxia. The lack of awareness in regards to the date and the day is due to his dementia,

stroke and TBI. It is also possible that he knew the answer, however, was not able to verbalize due to

his aphasia. He has good short term memory, as demonstrated by recalling information on the MMSE.

Client has a very positive attitude in regards to his diagnoses and deficits, and is motivated to improve.

Prioritization of Need Areas:

Prioritization of need areas for therapy include self-feeding with utensils, and transferring to and from

the bed and car.

P:

Recommended intervention methods and approaches:

1. Functional rehabilitation of upper limb apraxia in post-stroke patients: study protocol for a

randomized controlled trial.

This study focused on evaluating upper extremity apraxia in stroke patients that had suffered from

either left or right cerebrovascular accidents. The therapeutic approaches that were used to address

the apraxia included a restorative and compensatory approach. The groups in this study were separated

into a traditional health education group, a functional rehab group and an experimental group. The

experimental group was treated for their apraxia with both restorative and compensatory approaches

that lasted 3 days a week for 30 minutes sessions, for 8 weeks. Results of this study showed that

teaching clients new techniques that allow them to adapt to activities enabled them to increase their

independence in ADLs. The importance of restoring function (if possible) was also stressed in this study.

This evidence is relevant to our client, because it provides us with an evidence based way to treat his

deficits and improve his performance. We will plan on teaching Client safe and adaptive ways of feeding

and transferring into his car and bed. Since Client has right sided weakness, we will also plan on

strengthening the neuromotor pathway, in order to help him gain motor control. Restoring his motor

control and providing him with adaptive techniques that he can utilize during his ADLs will allow him to

improve his independence and quality of those occupations.

2. Development of a person-centered lifestyle intervention for older adults following a stroke or transient

ischemic attack.
This article focused on analyzing how a person-centered lifestyle intervention can be effective in older,

post stroke individuals. The COPM was administered and utilized to help create a person-centered

intervention for each client. The results of this study proved that individuals post stroke benefit the

most from interventions that are client centered, instead of just biomechanical. These person-centered

approaches enabled a better quality of life for these participants, and it also improved treatment

outcomes. This evidence is relevant to our client because we want him to be able to participate in the

activities that are the most meaningful to him. Although he has deficits with motor control, we plan on

implementing interventions that he would enjoy and are relevant to his life, rather than having him

participate in purely motor treatments.

Models:

The models that will be used during therapy sessions include PEO, Rehabilitation and Biomechanical

models.

PEO will enable me to gain a better understanding of the relationship between Client (person), his home

(environment) and his various occupations (feeding, transferring, etc). Through this model I will be able

to determine what exactly is causing the lack of congruence, and what can be done to fix that. The PEO

model will guide me in understanding Client’s priorities and perspectives, enabling me to choose client-

centered treatments that will improve his occupational performance.

The Rehabilitation model will guide me in selecting the appropriate compensatory strategies and

adaptive equipment that Client may need in order to be successful in his occupations of self-feeding and

transferring. It will help me to determine how his current abilities can be used to help him increase his

occupational performance. It will also guide me in figuring out how to modify the way Client performs

every day activities.

The Motor Control model will be implemented when addressing Client’s weakened muscle control

during feeding and transfers. It will be used to determine the best way to improve his neuromotor

pathways, such as by practicing the specified tasks as a whole or by using errorless learning. This model

will enable him to increase the control of his motor movements, such as appropriately bringing the

utensil to his mouth. The motor control model will enable Client to figure out the optimal solutions for

performing his occupations.

Goals:

LTG #1: Within 6 weeks, Client will independently self-feed with less than 3 spills.

STG #1a: Within 4 weeks, Client will calibrate utensil to mouth movement with min verbal cueing.

STG #1b: Within 4 weeks, Client will improve right handed grip when independently self-feeding without

dropping utensils.

LTG #2: To be determined after observing car transfer during session 3.

STG #2a: To be determined after observing car transfer during session 3.

STG #2b: To be determined after observing car transfer during session 3.

Expected frequency, duration and intensity: Client will be seen once a week for one hour, for a total of

6 weeks.

Next session: 2/8/2018

Location of intervention: HPEB apartment clinic

Anticipated D/C environment: Home