Client Evaluation:

Clients initials: AM

Date of referral: 1/25/2018

Date of Report: 2/4/2018

Date of Birth: 07/06/56

Primary Intervention diagnosis/ concern: Huntington Disease (HD), Traumatic Brain Injury

(TBI), Left Cerebrovascular Accident (LCVA)

Secondary diagnosis/ concern: Expressive Aphasia, Ideomotor Apraxia, right-sided weakness

Precautions/ Contraindications: Severe allergy to walnuts

Reason for referral to OT: Difficulties with eating with utensils, inability to transfer in and out

of car and bed

Therapists: Kenzie Smith, Gabby Skocylas

S: Client’s wife stated that she will not be with Client in his sessions for the next two weeks due

to a vacation. During his feeding session, client also stated that he did not enjoy using the swivel

spoon.

O:

Assessments performed: Client was seen on 1/25 and 2/1 for a comprehensive occupational

therapy evaluation. A modified COPM was used as a semi-formal interview with Client and his

wife who was able to assist him with answering questions when needed. Due to cognitive
limitations, the COPM was not assessed using numbered ratings. Observation was done to assess

Client’s abilities to eat with utensils, as well as assessing his abilities to transfer in and out of a

high-raised bed. A Mini Mental test was also given to assess Client’s cognitive abilities. Client

was taking a rest in his wheelchair at the start of the session. During feeding observation, client

was able to

Results/ Findings:

The COPM is a semi-structured interview that determines aspects of the client’s life that they

find successful, and what aspects may need adapting or enhanced. This interview helps to

determine the client’s goals and priorities for treatment. Based on the COPM, the client’s

priorities included being able to eat with utensils, control of his right upper extremity, and being

able to transfer in and out of his bed and car.

The Mini Mental Test is a test used to measure cognitive impairment. This test was modified to

match Client’s capabilities by giving him a printed calendar to refer to when telling us the

month, day, year, writing the instruction of “close your eyes” in larger print on the back of the

assessment, and modifying the image that he was to replicate. We also removed the question

asking him to write a sentence about anything. During the feeding observation, client ate his

salad with a regular fork, but demonstrated the lack of ability to pierce his food. Instead, he

would scoop the salad with his fork. His fork was dropped two times while eating his salad.

When Client ate his chowder, he attempted using a regular spoon, a thick handled spoon, a

curved spoon, and a swivel spoon. Client demonstrated a decreased ability to modulate the speed

at which he brought the spoon to his mouth, resulting in several spills. He was unable to

successfully eat with the swivel spoon as it moved too much to steady, and he did not enjoy the

curved spoon although it resulted in no spills while he used it to eat his soup. There was a
moderate amount of difficulty for Client’s wife to assist with him getting back off the bed, as

demonstrated by not being able to cue him to properly position himself to assist her, and not

knowing how to position him so that she would not be using her back to lift him. With physical

assistance with positioning, the use of a gait belt, and Min A from student therapists and

supervisor, client was seated in his wheelchair.

Occupational Profile:

Client is a 61-year-old man who has diagnoses of Huntington Disease, LCVA, TBI, right

sided weakness, expressive aphasia, and ideomotor apraxia. Other than these diagnoses, Client

has a severe allergy to walnuts. Client currently lives in a home with his wife. Client is seeking

occupational therapy services to address his difficulties eating with utensils, gaining more

control in his right upper extremity, and to work on his transfers in and out of a car and his bed.

Client is currently involved outpatient occupational therapy services, physical therapy, speech

therapy, neuro therapy, and music therapy. Client’s typical day consists of waking up and getting

into the bathroom for a shower where he has aids to assist him. He then eats breakfast that Meals

on Wheels delivers, and drinks his coffee while he reads the newspaper and takes his

medications. He then spends the majority of his day at engaging in his various therapies (speech,

physical, neuro, and music). Lunch during the day usually consists of a fast food meal. Client

gets home around 5 pm where he then eats dinner that his wife prepares and watches the news.

Before bed, Client watches Rachel Maddow and has a “treat” that consists of cookies, ice cream,

or tapioca pudding.
 Aspects of Client’s life in which he feels successful include his positive outlook on his

life and his condition. He has a wide array of interests, so he feels “lucky” that if he is not able to

perform one of his thousand loved occupations, he stills have 999 to fall back on. Client can also

assist with washing his body in certain areas during showering. Current barriers impacting his

occupational engagement include his extensive need for assistance that his wife cannot always

do on her own that requires additional help from aids. Medicaid is their insurance provider, and it

is a barrier to Client as they are not able to get him the equipment he needs when he needs it, like

a functional wheelchair that fits him properly.

Client’s values and interests include his love for music, especially the guitar. He also

loves listening to blues and jazz music and has an extensive collection. He enjoys spending time

with friends and going out to dinner with them and loves food of all kinds. Client also loves

playing video games and playing Backgammon. Client is also a part of the TRAILS program

where he enjoys swimming.

Occupational Analysis:

- Performance skills: For Client’s specific areas of occupational performance (transfers and

self-feeding), the performances skills most relevant to him include that of calibrating the

force at which he is bringing his utensils to his mouth, gripping his utensils in a way that

will not allow them to drop, coordinating movements from his plate or bowl to his mouth,

and pacing through his meal to avoid spills. Performance skills that pertain to his

transfers include stabilizing when standing, enduring the task without fatigue, and

sequencing through the task with the proper steps.

- Performance patterns: Explained in Occupational Profile!

- Client factors: For Client’s body structures, he has all parts intact needed for engagement

in his desired occupations. He does, however, experience deficits in his whole body due

to his Huntington Disease that causes motor abnormalities, as well as weakness on his

right side caused by his LCVA. Body functions that are exceedingly challenging for

Client include that of his memory due to his dementia, his experience of self and time as

demonstrated through his lack of full awareness to his disabilities, and his vestibular

functions that impact his balance and positioning. Muscle power is another body function

that has been impacted by both his HD and his stroke.

- Activity demands:

o Self feeding:

 Relevance and importance: It is crucial for Client and his wife that he is

able to eat without making a mess so that they can eat in public and with

friends and he can keep his dignity.

 Objects used: Feeding utensils- spoon, fork, and knife.

 Space demands: Home environment where messes can be made, vs

restaurants where they are wanting to avoid a mess

 Social demands: When Client and his wife go out with friends to eat at

restaurants

 Sequencing and timing: Client experiences minimal difficulties being able

to carry out the steps of scooping or piercing his utensil and bringing it to

his mouth die to his apraxia

 Actions and performance skills: See above in performance skills

 Body functions and structures: See above in occupational profile

 o Transfers:

 Relevance and importance: Client and his wife would like for him to be

able to assist as much as possible with transfers in and out of bed and their

car. Client’s wife also has to hire additional help as she cannot transfer

him on her own without back pain.

 Objects used: wheelchair, gait belt

 Space demands: Client’s bedroom where they have a very high bed

 Sequencing and timing: Client experiences difficulties being able to

sequence through the correct step (and order of steps) when transferring

(putting feet in first)

 Required actions: See above in performance skills

 Body functions and structures: See above in performance skills

- Contexts: See occupational profile

A: Interpretation:

- Strengths and areas in need of intervention:

o Strengths for Client include his engagement and desire to enhance his

performance. He always has a positive outlook and is willing to try what is asked

of him in his sessions. He is also able to respond and maintain a minimal amount

of reciprocal conversation, which assists with information gathering and making

his opinions on his session known.

o Areas in need of intervention include functional mobility for transfers in and out

of his bed and the car and being able to eat with utensils.

- Supports and hinderances to occupational performance:

 o A social support to his occupational engagement include his wife who is making

efforts to ensure that he is getting the assistance he needs, and who also

encourages his involvement in social and recreational activities whenever

possible. He also has a group of friends that he is able to spend time with who

support him, this is very beneficial for his quality of life and well-being. A

cultural support to his engagement is that of routine Chinese dinners with him and

his wife. While this is a simple tradition, his wife makes an effort to make it a

constant norm for Client, and with his dementia this is something he can look

forward to each week. A physical barrier to his engagement includes that of his

bed setup that is too high for him to get in and out of properly. His car setup is

also a barrier as he experiences issues with transfers.

Analysis Summary: Results from the Mini Mental Test show that Client scored a 24/29 (scores

was not 30 due to removal of one question). The Mini Mental assessment showed that he was

able recall information in a short amount of time, and that he had a moderate amount of

awareness of the time of day, year, season, and month, and was able to tell us about the location

we were at. Interpretation from the Mini Mental Places clients degree of impairment as

questionably significant. Results from Client’s feeding session determined that he experiences

weakness due to his LCVA, and motor planning issues due to his ideomotor apraxia. He also

experiences inability to modulate flow and calibration when bringing food to his mouth due to

his HD. Observation from Client’s transfers show that he is able to assist his wife and aids with

some aspects of the transfer including standing at the edge of the bed and putting his knee up to

assist them. The issues that were faced with the client’s wife with being able to transfer him out
of the bed may have also been due the bed being unfamiliar and more narrow than their bed at

home.

Prioritization of need areas: Based on the two observation and assessment sessions that were

completed with Client, his priorities will focus on his self-feeding with utensils, and transferring

in and out of his bed and car.

P:

- LTG and STG’s 1:

o In 6 weeks, client will independently self-feed with less than 3 spills.

o In 4 weeks, client will calibrate utensil to mouth movement with Min verbal

cueing.

o In 4 weeks, client will improve right handed grip strength as demonstrated by

independently self-feeding without dropping utensils.

- LTG and STG’s 2: REMINDER, YOU ARE HELPING WITH THIS SET

o In 6 weeks, client will

o In 3 weeks, client will

o In 3 weeks, client will

- Intervention methods and approaches: Approaches used with my client will include

creating and promoting, as well as establishing and restoring/ modifying, and preventing.

Our sessions will focus on restorative methods that will strengthen neural pathways that

have been inhibited dur to his LCVA. We will also be focusing on creating new and

adaptive ways of engaging in his desired occupations. This will include introducing

adaptive feeding utensils that will enhance independence in self-feeding and making his
 self-feeding more functional. Prevention will also be addressed with our client as we will

work to prevent loss of independence in self-feeding.

Model articles:

o Functional rehabilitation of upper limb apraxia in post-stroke patients: study

protocol for a randomized controlled trial. This study evaluated upper-limb

apraxia in stroke patients (a common symptom), focusing on a combination

approach of restorative and compensatory approach. The method included

patients with either a L or RCVA, that were broken up into groups of a functional

rehab group, traditional health education group, or an experimental group that

included both restorative and compensatory techniques for upper limb apraxia

three days a week in 30-minute intervention sessions. Results of this session

showed an improved independence in ADL performance due to the focus on

establishing new techniques for the client to adapt to activities they are used to, as

well as working on restoring function in the client where restoration is possible.

This approach will be valuable for us to bring into our sessions, so we will be able

to work on finding adaptive approaches to feeding and transfers, as well as

potentially restoring strength in the effected UE.

o Development of a person-centered lifestyle intervention for older adults

following a stroke or transient ischemic attack. This article focused on the

process of developing a person-centered lifestyle intervention for older adults that

are post stroke. The COPM was given to all participants, and results were used to

create a person-centered intervention and to facilitate the participants’ awareness

of the occupational chclientges in their lives after stroke. Results from this study
 showed that this person-centered approach was much more beneficial than strictly

biomechanical approaches in establishing a successful intervention and creating

stronger outcomes and enhanced quality of life. Being that our client is not only

post stroke but has several other diagnoses and related symptoms, this approach is

extremely beneficial to implement as it helps to focus on intervention that is both

useful AND meaningful to the client. With several relatively severe diagnoses,

our client’s life is somewhat closed in and routine, so this approach will help

focus on what is most important to him, and how we can enhance is opportunities

for a greater quality of life.

- Models used:

o PEO: The PEO model will be beneficial to use with Client as it focusses on him

and his diagnoses and specific needs (person), his natural envirionment where he

lives and spends the majority of his time (environment), and the occupations that

he needs adapting and greater assistance with (feeding, transfers). By using this

model we will be able to focus on creating an optimal congruence between these

factors to make his interventions as successful and meaningful as possible. This

model will be focussing on Client’s and his personal values, interests and abilities,

it will address his home environment to assess adaptations that need to be made to

better enable his desired occupations and increase his independence in self-care

tasks, and it will emphasize the occupations that are meaningful to him. Changes

in the P, E, or O will help to improve Client’s occupational performance.

o Rehabilitation: The rehabilitation model would be useful for Client as it focusses

on compensation for injuries and defecits that cannot be remediated (Huntington

 Disease). Compensatory strategies and envioronmental modifications will be

helpful for Client to assist him becoming even more successful in daily ADL’s

like functional mobility and feeding. Another aspect of this model is that of

motivation. Client is already a motivated and positive individual and this can be

used to guide him into creating new ways of engaging in his typical and desired

occupations, along with caretaker education of the adaptations.

o Motor Control, Motor Learning: The MC/ML model will be utilized with my

client to help accomplish necessary and desired tasks in the most efficient way

given his characteristics. This model will help to maximize personal and

environmental characterisitcs that will help to enhance independence and

occupaitonal performance. This will help to address enhancing the ability to

produce purposeful movements of the extremities in response to activity and

enviornmental demands.

- Expected frequency, duration, and intensity: Client will be seen for1 hour/1x/week for

6 weeks.

- Location of intervention: HPEB apartment clinic at the University of Utah

- Anticipated D/C environment: Home

 References:

Lund, A., Michelet, M., Kjeken, I., Wyller, T. B., & Sveen, U. (2011). Development of a person-
centred lifestyle intervention for older adults following a stroke or transient ischaemic attack.
Scandinavian Journal of Occupational Therapy, 19(2), 140-149.
doi:10.3109/11038128.2011.603353

Thielman, G. T. (2015). Rehabilitation of the Upper Limb Post Stroke: MRI Results of a
Randomized Controlled Pilot Study. Archives of Physical Medicine and Rehabilitation, 96(10).
doi:10.1016/j.apmr.2015.08.329