*K: A CASE STUDY
The two week journey of a seven-year-old in an intense Constraint-Induced
Movement Therapy (CIMT) program.
Presented By: Elizabeth Osborne
“K”: THE CLIENT
• K is a seven year old female
• K lives at home with her mom , dad and five-year-old brother
• K lives in Midland, MI
• K will be in the third grade in the 2014 school year, and attends the local public
elementary school
• K has been diagnosed with Cerebral Palsy, ADHD, and right-sided-weakness, due to
a stroke in utero
• K’s most predominant symptoms include right-sided weakness, including foot drop.
THE DIAGNOSIS BEING TREATED:
CVA/RIGHT SIDED WEAKNESS
• Etiology
• caused by either a blockage or a hemorrhage, termed ischemic or hemorrhagic stroke, respectively.
• Impairments seen after a stroke include, but are not limited to: motor dysfunction, sensory dysfunction, visual
dysfunction, cognitive dysfunction, psychological dysfunction and speech/language dysfunction
• Clinical Course
• The clinical course varies greatly depending on the person, the type of stroke, etc.
• In some cases it is possible to regain all prior functioning, and in some cases it is very unlikely that some
function will ever return.
• Timing: again, depending on the situation, an individual may see gains within a few months after the stroke,
up until several years after a stroke.
• The key to regaining function is early intervention and hard work.
Orchanian, D. P., & Jamison, P. W. (2012). Cerebrovascular accident. In B. A. Atchison & D. K. Dirette (Eds.), Conditions in occupational
therapy: effect on occupational performance (pp. 127-152). Baltimore, MD: Lippincott Williams and Wilkins.
SENSORY AND MOTOR DYSFUNCTION
AFTER A CVA
• Sensory Deficits
• Motor Deficits
• Tactile
• Paralyzation of one side of the body
• Kinesthetic
• Uncoordinated posture
• Proprioceptive
• Shoulder subluxation
• Ideational or Ideomotor
• A disturbance in reflexes
• Stereognosis
• One-sided weakness
• Body Scheme
• Contractures
• Sensory Integration
Orchanian, D. P., & Jamison, P. W. (2012). Cerebrovascular accident. In B. A. Atchison & D. K. Dirette (Eds.), Conditions in
occupational therapy: effect on occupational performance (pp. 127-152). Baltimore, MD: Lippincott Williams and Wilkins.
VISUAL AND COGNITIVE DYSFUNCTION
AFTER A CVA
• Visual Deficits
• Cognitive Deficits
• Hemianopsias,
• Problem solving
• Visual scanning
• Initiation of tasks
• Visual search
• Attention
• Visual sequencing
• Recognition
• Visual agnosia
• Visuospatial agnosia
Orchanian, D. P., & Jamison, P. W. (2012). Cerebrovascular accident. In B. A. Atchison & D. K. Dirette (Eds.), Conditions in
occupational therapy: effect on occupational performance (pp. 127-152). Baltimore, MD: Lippincott Williams and Wilkins.
PSYCHOLOGICAL AND SPEECH/LANGUAGE
DYSFUNCTION AFTER A CVA
• Psychological Deficits
• Speech and Language Deficits
• Denial
• Dysarthrias
• Depression
• Wernicke’s aphasia (speech processing)
• Emotional lability
• Broca’s aphasia (speech production)
• Lack of volition
• Perseveration
• Impulsiveness
Orchanian, D. P., & Jamison, P. W. (2012). Cerebrovascular accident. In B. A. Atchison & D. K. Dirette (Eds.), Conditions
in occupational therapy: effect on occupational performance (pp. 127-152). Baltimore, MD: Lippincott Williams and
Wilkins.
CLIENT PARALLELS WITH THE DIAGNOSIS
• The client has displayed:
• Lack of tactile awareness
• One-sided weakness
• Slight contractures
• Shoulder winging
• Low attention span (Also diagnosed with
ADHD)
• Perseveration
• Impulsiveness
• Some of these “deficits” are a result of the
stroke in utero experienced by the client,
while some of these may possibly be just an
ordinary behavior/trait of a seven year old
child (for example, impulsiveness).
MEDICATIONS
The only medication
the client takes is
Quillivant XR
Side Effects:
*Decreased appetite
*Mood swings
Weight loss
Agitation
Nausea
•
Quillivant (methylphenidate HCI)
is:
*Stomach pain
Dry mouth
*Irritability
Dizziness
Shaking
• FDA approved
Vomiting
• Once-a-day medication
Trouble sleeping
Blurred vision\increase in blood pressure
• Improves attention
Anxiety
Increase in heart rate
• Dosed on an individual basis
Nervousness
Sweating or fever
• Offered in several flavors.
Restlessness
The *starred effects were represented in the client’s daily life/beh
Pfizer. (n.d.) What is Quillivant XR? Retrieved from http://www.quillivantxr.com/quillivant-xr
EFFECTS OF MEDICATION ON
OCCUPATIONAL PERFORMANCE
• As previously discussed, some of the common side effects of Quillivant were
demonstrated by the client during therapy.
• The client complained of stomach pain, which hindered therapy because she wanted to
perform more sedentary activities lying down or at a table top, when we had planned
more active therapy sessions. I imagine the stomach pain affects her daily life outside of
therapy as well, e.g. in school.
• The client had an extremely diminished appetite and would eat approximately 3 bites of
food during the entire 7 hour therapy session. She was a smaller child, and the medication
might not be the healthiest option for her growth and body development.
• Also, the client had mild, to sometimes major, mood swings throughout the day and would
become very irritable with the therapists at times.
FRAME OF REFERENCE
• MOHO (Model of Human Occupation)
• Volition: the motivation for occupation
• Habituation: patterns and routines of occupation
• Performance capacity: physical and mental abilities behind occupational performance
• This model is appropriate for K because motivation to use her affected extremity is sometimes
something she struggles with, so finding meaningful activities is essential to her success in
therapy. Most of the therapy sessions focused on establishing patterns and routines of righthand use in everyday activities. Finally, combining K’s performance capacities with meaningful
activities for volition, and new patterns of movement, will enable her to increase her daily
function, independence and happiness.
Bruce, M., & Borg, B. (2002). Psychosocial frames of reference: Core for occupation-based practice (3rd ed.). Thorofare, NJ: Slack.
OTPF-III: THE PROCESS
• Evaluation
• ROM in the upper extremities
• Grip strength
• Tone
• The Motor Activity Log
• Directed Play assessment
• Observation
• Interview with the client’s mother
• Intervention
• To include play as an occupation to
attain therapy goals set up by the client,
the client’s mother, and the therapist.
DOMAIN: ADLS
• Bathing/showering: Client performs shower tasks mostly one-handed, and uses
affected extremity for support purposes (holds things at the elbow).
• Dressing: The client’s mother reported that K only needs help with fasteners and
shoe tying, although she does dress using only her one hand, and no hand use for
putting on shoes.
• Feeding: The client has some difficulty with using both hands equally to feed herself,
e.g. stabilizing food with fork, while she cuts with knife. If no cutting is required, the
client feeds herself using her dominant (unaffected) hand to hold utensils and cups.
DOMAIN: ADLS
• Functional mobility: The client experiences some foot-drop on the RLE, but she is
able to run, walk and play without falling down. Her mother reported that she
stumbles sometimes at home.
• Personal device care: The client is a seven-year-old, so she is slightly careless when
it comes to device care. For example, the resting hand splint made for her was
forgotten at day care.
• Personal hygiene and grooming: The client does not appear to be unable to
perform these tasks, however they are done with some difficulty, as she performs all
tasks at home one-handed.
DOMAIN: IADLS
• Care of pets: The client reported that she is in charge of feeding the family dog
“every once in a while”. She also pets him and plays with him. These tasks are done
one-handed.
• Meal prep and cleanup: The client has some difficulty with this as she does not use
both hands equally when carrying items. She also lacks grip strength and ROM in her
affected hand, which affects her ability to stabilize items with it.
EDUCATION, PLAY AND SOCIAL
PARTICIPATION
• The client’s mother reported that K receives OT in school, to help with writing and
reading.
• Education, play and social participation are affected because K is unable to partake
in some classroom and schoolyard activities that require dual grip strength, range of
motion, etc.
• Play at home is affected because the client is unable to participate in some activities
that she would like to, for example, the client really wants to make rubber band
bracelets, like her peers, but she is unable to use her affected fingers the way she
needs to to create the bracelets.
CLIENT FACTORS
• Values:
• Her family (Mom, Dad, Brother and Dog)
• Her teachers
• Her therapists
• Beliefs:
• Believes in her ability to adapt her environment to be functional
• Does not believe that it is important for her to use her affected hand for tasks
BODY FUNCTIONS
• Attention:
• Short attention span, even on the medication Quillavent
• Requires continually changing activities
• Perception:
• Sometimes the client is unable to tell whether or not she is holding an item without looking at it.
• She is unable to decipher what hidden objects are, which may also be a product of lack of
manipulation skills.
• Emotional:
• Lacking in regulation skills
• Becomes upset easily, especially when unable to do an activity the correct way. Could be the
result of medication-Quillavent
BODY FUNCTIONS
• Joint mobility
• Limited AROM in the RUE and the RLE
• Muscle power
• Limited in the RUE, especially the hand
• Slight muscle tone/contracture in the RUE and RLE, especially the elbow and knee
• Limited muscle endurance in the RUE, cannot maintain grip on an item for longer than 15
seconds
• Gait pattern:
• Slight foot-drop present in the RLE, especially when tired
PERFORMANCE PATTERNS
• Habits:
• Uses unaffected extremity for all activities, rarely helping with the affected extremity (per mother’s
interview)
• Routines:
• Morning routine established for the school year
• Roles
• Daughter
• Sister
• Friend
• Client
• Student
CONTEXT/ENVIRONMENT
• Personal:
• Lives in Midland, MI
• Big sister
• 7 years old, female
• Student at the local elementary school
• Virtual:
• Loves electronics- iPad, computer, Wii, keyboards
CONTEXT/ENVIRONMENT
• Physical and Social:
• Lives in a house with both of her parents and her brother
• Attends school with her peers and teachers
• Therapeutic relationships with her Physical and Occupational therapists
TYPES OF INTERVENTION
• Occupational
• Activities
• Dressing
• Utensil grasp
• Nail-painting
• Carrying items with whole hand
• Shoe tying
• Pinching small items
• Ball games
• Hopscotch
• Cooking/meal prep
• Coloring/crafts
• Feeding
TYPES OF INTERVENTION
• Preparatory methods:
• Soft cast created for the left arm to cover
all digits except the thumb and extend to
proximal of the elbow
• Resting hand splint created for the left
hand to promote use of the right hand
• Education:
•
•
•
•
Don/doff cast
Don/doff splint
Splint wearing protocol
Home exercise program
• Preparatory Tasks:
• Placing large wooden beads on sticks to
promote pinch strength and wrist ROM
• Weightbearing by wheeling on scooters,
propelling with the hands flat on the floor
• Playing with playdough-pinching, rolling,
twisting, finding items to improve fine
motor coordination and pinch strength
ACTIVITY DEMANDS: CRAFTING
• Importance:
• This activity is very important to the client. She likes to color, cut, staple, glue, etc. She
likes to give the crafts to members of her family as a gift.
• Objects used:
Scissors
Tape
Glue
Colored papers
Glitter glue
Paint
Brushes
Marshmallows
Colored pencils
Markers
Crayons
Jewelry box
ACTIVITY DEMANDS: CRAFTING
• Space demands
•
•
• Social demands
Enough space is needed for the client to have elbow
space while working and reaching for objects.
There should be a crafting space and an area where
cleaning supplies can be stored.
•
The sequence and timing of the activity is determined
by the client
•
•
Small sequencing tasks:
•
Recap the glue, marker
•
Stabilize the craft with one hand and work with the other
hand
•
Dip the paintbrush in the water to clean between colors
•
Put things back as they are taken out
•
Clean the area after the craft
Timing: the activity should not last longer than 50 minutes
•
Peers
•
Therapists
•
The client enjoys giving and receiving ideas for her
craft with other people
•
The client enjoys giving the product away to a member
of her family, or one of her friends or therapists.
• Sequencing and Timing
•
The client especially enjoys crafting with other people
ACTIVITY DEMANDS: CRAFTING
• Required actions
• Required body functions:
• Pinching objects
• Upper extremity ROM and strength
• Gripping objects
• Pinch prehension
• Transferring objects
• Palmar squeezing (glue)
• Intrinsic/extrinsic strength (stapler)
• Stabilizing the paper/object with the
non-dominant hand
• Use both hands in rhythm with each
other to perform tasks.
• Required body structures
• Both hands
APPROACHES TO INTERVENTION
• Establish:
• The client was born with symptoms of a stroke
• We aim to establish movement patterns that the client has not yet been able to experience
• Modify:
• The client has been provided a modified kit for nail painting
• The client has been educated on ways to modify items from home (toothbrush, buttons,
etc)
TYPES OF OUTCOMES
• Improvement in occupational performance
• Client improved in:
• Elbow extension (reaching out toward items, postural/gait appearance)
• Grip strength and endurance (3# to 6# and in amount of time she could walk and hold a
bucket)
• Initiating activities (like opening a door) with her affected hand
• Carrying and pinching items during craft time
• Finger dexterity- was able to apply stickers by the end of therapy, could not at the
beginning
TYPES OF OUTCOMES
• Participation
• In classroom activities
• In schoolyard activities
• In therapy
• In peer events (birthday parties, etc)
• Quality of life
• School
• Home
• Play
STRENGTHS AND WEAKNESSES
• Energetic
• Low expectations for therapy
• Good attitude
• Non-motivated to use the affected hand
for tasks
• Lots of ideas for therapy
• Contractures are very minimal
• Emotional regulation-mood swings
• Low level of muscle atrophy
• Weakness in grip and pinch strength
• ROM in shoulder is almost typical
• Low AROM in the affected hand
GOALS
• 1. The client will improve her ability to tie her own shoes using both of her hands,
independently, within 5 treatment sessions. (LTG established by the client and her
mother)
• The client will complete the steps of shoe-tying using both hands, assisted by a visual aid with
step by step directions and pictures, within 2 treatment sessions. (STG)
• 2. The client will increase her grip strength from 3 pounds to 9 pounds in order to be able
to carry her toys using her right hand while her left hand performs activities like opening
doors, independently, within 12 treatment sessions (LTG)
• The client will increase her grip strength from 3 pounds to 5 pounds so that she can bilaterally
carry items and perform activities, independently, within 6 treatment sessions. (STG)
INTERVENTIONS PROVIDED
• Occupation-based treatments
• Dressing
• Nail-painting
• Shoe tying-on a cardboard sheet with
regular laces
• Ball games
• Hopscotch
• Cooking/meal prep
• Coloring/crafts
• Feeding
• Preparatory methods/treatments
•
•
•
•
•
•
•
•
•
•
Resting hand splint
Utensil grasp
Carrying items with whole hand
Pinching small items
Education
Splint protocol
Activities to do at home (HEP)
Velcro board
Ring arch
Transferring blocks
RECOMMENDED TREATMENTS
• Tying shoes
• Show video of steps for use of media
• Come up with a song to remember the steps
• Grade the activity down by using large laces, to assist with grip and pinch problems
• Make it fun by practicing with alfredo-sized cooked noodles
• Create cue cards for steps
• Use adaptive equipment if necessary
Copley, J. A., Rodger, S. A., Hannay, V. A., & Graham, F. P. (2010). Occupational therapy students' experiences in learning
occupation-centered approaches to working with children. The Canadian Journal of Occupational Therapy, 77(1), 48-56.
Retrieved from http://0-search.proquest.com.library.svsu.edu/docview/212919448?accountid=960
RECOMMENDED TREATMENTS
• Grip strength
• Preparatory activities
• Stress ball/squish ball squeeze
• Squeeze water from baster
• Carry a bucket with increasing amounts of weight
• Occupation-based activities
• Honk horn on bicycle
• Open and close round/lever door handles
• Throw water balloons at target/person
Kreider, C. M., Bendixen, R. M., Huang, Y. Y., & Lim, Y. (2014). Review of occupational therapy intervention research in the practice area of
children and youth 2009-2013. The American Journal of Occupational Therapy, 68(2), e61-73. Retrieved from http://0search.proquest.com.library.svsu.edu/docview/1509022611?accountid=960
SERVICES RECOMMENDED
• Continue physical therapy- to work on gait pattern and core strength, also shoulder
winging
• Continue occupational therapy in school and as an outpatient- to continue to improve
writing skills, other educational skills, peer interaction, ADLs, IADLs, and play
activities
• Support groups for individuals/families with the same condition
• http://www.chasa.org/category/local-groups/
ADDITIONAL PSYCHOLOGICAL FACTORS
• Little brother: the client’s younger brother (5 yrs) is sometimes insensitive to the fact
that his sister cannot perform certain activities. He expects her to be able to do
everything that he can, as fast as he can.
• Peers: the client’s peers are sometimes unable to handle the mood swings that are
caused by her medication. Her mother reported that sometimes she has a hard time
keeping up with her peers, depending on the activity.
DISCHARGE PLAN
• Provide a home exercise plan to include activities and exercises the client can do to
maintain the gains made in therapy
• Recommend continued OT and PT in school and outpatient therapy
• Recommend a support group that the family can attend to get ideas, help others and
connect with other families
• Because the client has been in therapies since birth, other therapies or services do
not seem necessary
REFERENCES
•
American Occupational Therapy Association.(2014).Occupational therapy practice framework: Domain and process (3rd ed.).American Journal
of Occupational Therapy, 68(Suppl.1), S1–S48.http://dx.doi.org/10.5014/ajot.2014.682006
•
Bruce, M., & Borg, B. (2002). Psychosocial frames of reference: Core for occupation-based practice (3rd ed.). Thorofare, NJ: Slack.
•
Copley, J. A., Rodger, S. A., Hannay, V. A., & Graham, F. P. (2010). Occupational therapy students' experiences in learning occupation-centered
approaches to working with children. The Canadian Journal of Occupational Therapy, 77(1), 48-56. Retrieved from http://0search.proquest.com.library.svsu.edu/docview/212919448?accountid=960
•
Kreider, C. M., Bendixen, R. M., Huang, Y. Y., & Lim, Y. (2014). Review of occupational therapy intervention research in the practice area of
children and youth 2009-2013. The American Journal of Occupational Therapy, 68(2), e61-73. Retrieved from http://0search.proquest.com.library.svsu.edu/docview/1509022611?accountid=960
•
Orchanian, D. P., & Jamison, P. W. (2012). Cerebrovascular accident. In B. A. Atchison & D. K. Dirette (Eds.), Conditions in occupational therapy:
effect on occupational performance (pp. 127-152). Baltimore, MD: Lippincott Williams and Wilkins.
•
Pfizer. (n.d.) What is Quillivant XR? Retrieved from http://www.quillivantxr.com/quillivant-xr