Case Study
Sotheavy Moeung
Touro University Nevada
Who is Papi
He is a 26 years old
From close-knit
Mexican family
Nuclear family
includes:
7 siblings and a mother
and father
Practice Setting
Sub-acute/ LTAC/ SNF
for adults
Dx: Multiple trauma,
orthopedic,
tracheostomy, wound
care, amputee care,
SCI, and TBI
Services offered:
1:4 staff to patient
ratio
1:1 therapy
24/7 care
FRONT OF
BUILDING
COMMUNITY AREA
REHAB GYM
PATIENT ROOM
Papis Milestones
Wee Milestones
k
1 Blinking and some eye movement, flaccid tone
2 Involuntary reflex movements, spasticity, cries/moans
3 Increased eye tracking, recognizes immediate family
members, reach and grasp
4 Answers simple questions such as family members names,
Increased voluntary movements such as release
5 Increased sensation of physiological needs (void; drinking
water), increased ROM
6 Answers in 3-5 word sentences such as I want to go home,
increased normalization of tone and ROM WFL
7 Bone flap placed back on, increased cognitive function such as
attention to task
8 Tracheostomy tube removed, assist in ADL skills, increased
motor planning
Retrieved from
http://etc.usf.edu/presentations/extras/letters/varsity_letters/54/28/i
ndex.html
Flat affect
Impulsivity
Excessive drowsiness
Disorientation
Physiological
Spiritual
Family values
Family involvement with
treatment
Hands-on
Reduced attention
Decreased attention span
Difficulty with selective
attention
Impaired sustained
attention for task
completion
Deficits in attention
shifting between tasks
Decreased executive
functioning
Difficulty with initiation of
tasks
Decreased planning and
organization
Decreased problem
Decreased memory
Greater impairment with
STM than LTM
Impaired metacognition
Anosognosia
Poor self-regulation
Impaired spatial cognition
Ambulation and self-care
skills
Disorientation
To self, situation, location,
time
Impulsivity
Decreased safety awareness
Retrieved from
http://etc.usf.edu/presentations/extras/letters/varsity_letters/16/17/i
ndex.html
Natural Environment
Care Meridian
Outside
Mostly flat terrain
Limited areas to practice
ambulation
Consistent warm weather
Inside
Patient room
Bed mobility
Toilet transfer
Shower transfer
Therapy Gym
8 step staircase
Peer modeling
Community Area
Opportunities for
social interaction
Societal
Strong interpersonal
relationship with family and
community
Medicare Part B
10 hours of direct therapy per
week
Currently 5 hours PT & 5
hours OT
In need of speech therapy
since cognition has
improved
Limited hours impact
growth
Retrieved from
http://etc.usf.edu/presentations/extras/letters/varsity_letters/54/27/
index.html
Agreeable nature
Good shape prior to incident
Hard working attitude
Inquisitive mind
Social &
Occupational Roles
Sibling
Son
Friend
Uncle
Labor contract employee
Actions
Immediate voluntary
grasp/release skills with RUE
Eye contact with max verbal
prompts
LTM more in tact
Knows family members
and close friends
Asks and reaches for mom
and brother often
Motivation to get out of bed
Desire to functionally
ambulate
Desire to use toilet
Desire to return to work
OCCUPATIONS
Assisting to pull
up socks
ADL: Dressing
Assisting in
pushing w/c
ADL: Functional
Mobility
Assist in sponge
bathing UE
Assist in applying
lotion
Reaching for ball/cone &
crossing over in various
planes and heights
ADL: Personal
Hygiene & Grooming
ADL: Toileting
Retrieved from
http://etc.usf.edu/presentations/extras/letters/varsity_letters/39/28/in
dex.html
Weaknesses
(I) dressing
w/c mobility
(I) functional
transfers
safety
awareness
static sitting
motor planning
Neurodevelopmental
Treatment (NDT)
Background
Founders:
Berta Bobath (physiotherapist)
Dr. Karel Bobath (psychiatrist/
neurophysiologist
Implemented in 1940s focusing
on patients with stroke & CP
(NDTA, 2011)
Definition
Neuro: brain & nerves
Developmental: normal
movement patterns
needed for functional
motor skills (Australian
Neurodevelopmental Therapy
Association, 2014)
Assumptions
1. Normalization of tone
2. Normalization of
movement patterns
3. Emphasis on symmetry
and integration of both
sides of the body
4. Inhibition/avoidance of
abnormal movements
5. Hierarchical model of
motor control (Pendleton
&
Schultz-Krohn, 2013)
Relevance of NDT
Setting
Can be used in settings that work with the
following dx:
Relevance of NDT
Papis Case
Advanced hands-on tx. for patients with
disturbances in function, movement, and postural
control due to CNS injury
NDT look for atypical movement patterns and
facilitate more typical movement patterns to
increase functional skills
Family members receive education to increase
the quality of movements and generalization of
functional skills into a range of environments
(Australian Neurodevelopmental Therapy
Association, 2014)
EVALUATION
Application of NDT:
Evaluation
EVALUATION:
Observe client and formulate hypothesis of
current functional skills
Interplay between tone & movement quality
Influence of postural control on coordination
of movements
No formal assessment related to NDT used
with adults*
Motor, cognitive, perceptual, & psychosocial
needs/deficits
Discuss with family STG/LTGs to facilitate
patients needs/wants/ desires (Howle, 2002)
INTERVENTION
Application of NDT:
Intervention
INHIBITORY
TECHNIQUES
abnormal
muscle tone
lengthen spastic
muscles
unwanted
movement
patterns and
reactions
abnormal
posture
HANDLI
NG
Produce
changes
in tone
&
posture
FACILITORY
TECHNIQUES
normal
movement
patterns &
sensations
stimulate
muscles directly
to contract
practice wanted
movements
utilize more
involved side
during activities
(Martin, 2014)
OUTCOMES
Safety awareness
Patient
I want to go home
I want to go to work
IDT
P
E
O
P
&
N
D
T
Hands-on evaluation
ROM
Tone
Strength
Patterns of movements
Posture
Symmetry
Motor control
FIM/FAM
FAM includes cognitive, behavioral, communication and community
functioning measures (Wright, 2000)
JFK Coma Recovery Scale-Revised (CRS-R)
measure small clinical changes in patients with severe brain
injuries who function at very low levels characteristic of nearvegetative and vegetative states (Giacino & Kalmar, 2006)
Introduction to the Level of Cognitive Functioning Scale
assess cognitive functioning in post-coma patients (Bushnik, 2000)
MIDPOINT
Introduction to Independent Living Scale (ILS)
assesses three main areas: ADLs, behavior, & initiation (Persel, 2012)
DISCHARGE
Introduction to the Supervision Rating Scale
measures the level of supervision that a patient/subject
receives from caregivers (Brooke, 2001)
FIM/FAM
Cognition
Reduced attention
Difficulty with
initiation of tasks
Task
Tim
e
(mi
n)
10
15
20
10
Total: 60
References
References Cont.
Martin, S. (2014). Stroke intervention strategies: Bobath/NDT.
(PowerPoint Slides). Retrieved from https://bbtun.touro.edu/webapps/portal/frameset.jsp?tab_group=courses& url=
%2Fwebapps%2Fblackboard%2Fexecute%2Fcontent%2Ffile %3Fcmd
%3Dview%26content_id%3D_2117848_1%26course_id
%3D_3476862_1%26framesetWrapped%3Dtrue
Pendleton, H. M., & Schultz-Krohn, W. (2013). Pedretti's occupational
therapy: practice skills for physical dysfunction. Elsevier Health
Sciences.
Persel, C. (2012). The independent living scale. The Center for Outcome
Measurement in Brain Injury. Retrieved from http://www.tbims.org/
combi/ils
Wright, J. (2000). The functional assessment measure.The Center for
Outcome Measurement in Brain Injury. Retrieved from
http://www.tbims.org/combi/FAM
UAB School of Medicine. (2014). Traumatic brain injury model system
information network. Retrieved from
https://www.uab.edu/medicine/tbi/informacion-en-espanol