BACKGROUND INFORMATION

Date of Report: January 27, 2018 & February 2, 2018

Client’s name: B. D.
Date of Referral: January 17, 2018
Age: 53
Primary Intervention Diagnosis/Concern: 2 years post- TBI. Client sustained TBI when he fell
down the stairs, hitting rock fireplace with anterior aspect of his skull, resulting in frontal lobe
damage.
Secondary Diagnosis/Concern: history of alcohol abuse, high blood pressure, hospitalized for a
seizure in December 2017
Precautions/Contraindications: seizure precautions
Reason for Referral to OT: Client is seeking services to increase independence and address
concerns resulting from his TBI.
Therapist: Jessica Smith, OTS (with co-therapist Jenna Euteneier, OTS)

SUBJECTIVE (S): The client stated that his memory is almost back to how it was before the

injury. Client’s sister stated that client is prone to suggestion and easily influenced when asked

to make decisions; therefore, asked OTS to be aware that what he says is not necessarily

representative of what he feels. Client’s family expressed concern about how his “microwave

diet” is negatively effecting his nutritional health.

OBSERVATION (O):

Client was seen on 1/26/18 and on 2/2/18 in the simulation apartment for his initial interview

and Comprehensive evaluations with Occupational Therapy Students (OTS) d/t concerns related

to a Traumatic Brain Injury (TBI) he received 2 years ago. Client was driven to both appointment

by his sister Terri and his mother Ruth. A modified Canadian Occupational Performance

Measure (COPM), and an observation of occupational performance were administered on

1/26/18, and the Contextual Memory Test (CMT), the Motor-Free Visual Perceptual Test

(MVPT-V), and a portion of the Mini-Mental State Examination (MMSE) were administered on

2/2/18.
Occupational Profile:

Client is seeking services to increase independence and address concerns resulting from

his TBI. Client moved into his parent’s home in Millcreek a few years before his accident to help

care for his ill father; when his father passed, he remained in the home with his now 93-year-

old mother (Ruth) and their cat. Client is currently independent in all activities of daily living

(ADLs), and is successful in some instrumental activities of daily living (IADLs) including, making

coffee, retrieving the mail and newspaper daily, caring for their cat, and taking out the garbage

on Fridays. His mother manages most household, cooking, and medication management tasks,

while the client manages most outdoor home maintenance tasks, such as mowing the lawn and

salting the driveway. Client’s family reports that client is able to make simple meals in the

microwave, such as mac and cheese and quesadillas, but that he rarely uses the stovetop for

cooking due to memory problems and confusion resulting from TBI. Client values his family,

friendships, and the outdoors where he enjoyed hunting, fishing, skiing and hiking with his dog

before his accident. Since the accident, client has lost the ability to drive and expressed that this

has been a barrier to him participating in the outdoor activities he enjoys. Client values his

independence and hopes to get out into his community more. Prior to his TBI, client worked

full-time as a tile-layer. Client is not currently working, but expressed interest in working again

in the future. Client currently spends most days at home, reading, watching TV, or occasionally

socializing with friends and family. Some supports to client’s occupational engagement include

his family, the central location and easy accessibility of his home, his belief in improving his

independence, and his opportunity and desire to continue seeking rehabilitative services. Some
barriers to client’s occupational engagement include his loss of close friendships, his driving, his

decreased eyesight and his family’s perception of what may be possible for client to achieve.

Client identified priorities for therapy in the following areas: increase participation in

medication management routine, improve ability to independently use public transportation to

access his community, and time permitting, improving cooking skills.

ASSESSMENTS PERFORMED:

Canadian Occupational Performance Measure (COPM) – 1/26/18

The COPM is a semi-structured interview tool used to help recognize client’s goals, concerns,

supports, barriers, and priorities for therapy. A modified version of the COPM was administered

with client to accommodate for client’s cognitive deficits and decreased insight.

Client’s priorities identified during the COPM include:

- Using the bus/ public transportation to access his community

- Medication management

- Improving cooking/grilling skills and independence

- possibly improve basic work-related skills

Informal Performance Observation – 1/26/18

Client was asked to prepare a simple meal (stove-top Macaroni and Cheese) in the simulated

apartment. OTS placed ingredients (milk & butter) in the fridge, and had cooking supplies (pot,

utensils, stirring spoon, measuring cup, and dishes) placed in various cupboards around the
simulated kitchen, with the box of Macaroni and Cheese placed on the counter. Instructions

were enlarged and pasted on the back of the box. D/t client’s decreased eyesight and him not

having brought his reading glasses, instructions were still too small, requiring OTS to read

instructions step-by-step to client throughout task.

Observation of this performance was meant to help OTS gain a more comprehensive

picture of client’s current abilities, and to compare those abilities with client’s perceived

abilities noted in the COPM. This observation was also meant to identify challenges/barriers

and strengths of the client while performing an unfamiliar task in a novel environment.

Results:

- client required Mod VCs and gesturing to locate cooking supplies

- client requiring Min VCs to accurately word-find for names of common items (i.e.

butter, knife)

- client required Min A to measure water and butter

- Client requires glasses for reading. Client presents with deficits in the following

areas: decreased insight, short-term memory, word-finding, scanning, problem

solving, possible decreased attention to right arm, and possible figure ground

discrimination deficits. Client also presented with an inconsistent hand tremor.

- The task lasted 40 minutes, 20 minutes over session time, d/t client requiring

consistent cuing and assistance. This additional time demand will be considered

when planning future sessions.

 Mini-Mental State Examination (MMSE) – 2/2/18

The MMSE is a cognitive screen meant to help identify deficits in: orientation, memory,

attention, calculation, recall and language. The screen is a structured assessment where client

is asked to answer questions, recall information, and perform basic tasks to evaluate their

reading and comprehension skills.

When the client was prompted to orient self to time (year, season, month, day and

date), he could not name the specific words (February, Monday, Winter, etc.), but he could

accurately describe the timeframe (i.e. 2 months from now would be April, his birth month).

Client stated frustration about not being able give the precise time/words. D/t client’s

expressive language challenges d/t anomia (poor word-finding), Supervising Therapist

(Jeanette) suggested that this assessment be discontinued at this time.

Contextual Memory Test (CMT) – 2/2/18

The CMT is standardized assessment designed to evaluate awareness of memory capacity,

strategy use, and recall in adults with memory dysfunction (such as TBI). This assessment

includes a list of pre- and post- questions related to self-perception of memory and abilities.

This test also requires client to study a stimulus picture of 20 items for 90 seconds, and then

recall or recognize the items later in the assessment.

Results – Part 1: Morning (context) & Recognition Sections:

Client was able to immediately recall 6 items, scoring in the severe deficit range.

He predicted that he would remember ~15 /20 items shown. After the assessment client

thought that he named off 17 of the 20 items, when he only named off 6.
 Motor-Free Visual Perception Test (MVPT-V) – 2/2/18

The MVPT-V is a visual perceptual assessment to evaluate visual discrimination, visual figure

ground, visual memory, visual closure, and spatial relationships without requiring a motor

component. This assessment includes 36 items with multiple choice picture answers for client

to respond to.

Results –

Individuals w/o Head Injuries  Client ranked in 5th percentile group overall

Individuals w/ Head Injuries  Client ranked in 58th percentile group overall

Items Categories Client’s Score

1–3 Shape Recognition 2/3

4 – 8, & 10 Visual Figure Ground 5/5

9 – 13 Form Constancy 3/5

14 – 21 Visual Memory 5/8

22 – 32 Visual Closure 8/11

33 – 36 Visual Discrimination 4/4

ANALYSIS (A):

Analysis of Assessments:

Informal Performance Observation – 1/26/18 – stovetop Mac & Cheese

Client’s perception of functional abilities expressed during the COPM, and his

performance during the informal cooking task suggest that client is experiencing decreased

insight as a result of his TBI. This supports the family’s concerns about client’s self-awareness.

His performance in the cooking task suggests short-term memory deficits, word finding deficits,

problem-solving difficulties, and possible decreased attention to his right arm. He also

displayed visual perceptual difficulties when trying to locate items in cluttered cupboards or

drawers, specifically in regards to scanning and figure ground discrimination.

Mini-Mental State Examination (MMSE) – 2/2/18

Client’s performance on the MMSE could not be measured as test was not completed

and data was not collected. However, facilitation of the beginning of this assessment resulted

in client responding with self-directed frustration; this may suggest a higher level of insight than

previously considered.

Contextual Memory Test (CMT) – 2/2/18

Client’s performance on the CMT suggests that awareness (insight), strategy use,

and recall are severely impaired. The assessment results also suggest that client has STM
deficits. His poor recall but good recognition skills, suggest that his performance was likely

influenced by his difficulty with word-finding.

Motor-Free Visual Perception Test (MVPT-V) – 2/2/18

Client’s performance on MVPT-V suggest that his visual perceptual skills are typical for

an individual with a head injury (in the 58th percentile), and suggests that his difficulty with

visual memory and visual closure may impact skills needed to safely navigate a public

transportation bus.

OCCUPATIONAL ANALYSIS:

Areas of Occupation: Client identified the following as areas of occupation that he

would like to work on while in therapy: Driving or using public transportation (buses) to access

his community, improve his health management and maintenance by improving his

independence with his medication management routine, improving his ability to cook (meal

preparation) meals for himself and his mother, improve his leisure participation and social

participation by going hunting/fishing with friends, and possibly improving work-related skills so

that he can return to work in the future. Identification of these interests required direct and

indirect verbal cues by the OTS d/t client’s decreased insight.

Performance Skills: searches, locates, initiates, notices/responds, accommodates, and

benefits

Performance Patterns: relatively consistent morning and daily routines.

 Client Factors: higher-level cognition (judgement, executive functions, cognitive

flexibility, insight and concept formation), attention, short-term memory, thought, experience

of self and time, temperament and personality (lacks confidence, and some impulse control);

involuntary movement (hand tremors), visual functions (needs glasses for reading), and speech

production (anomia – word finding difficulty), visual perceptual.

Supports for the client include: his family and their willingness to both provide care,

and to provide transportation and ensure basic life needs are met, another strength is that the

client wants to increase his independence and get back to what he use to enjoy doing. His goals

are sound and important to his life situation.

Barriers for the client include: that the client will have to overcome is figuring out how

to become more independent in a safe and responsible way, as well as how to navigate a public

transportation system while having decreased memory and insight.

Research Evidence:

In preparation for our future treatment sessions with this client, an article written by

Gover, Johnston, Toglia, and Deluca (2007) helped to create a basis for how we will try to

improve client’s self-awareness (insight) to help improve occupational performance in his

above-mentioned priorities. This article used a protocol for increasing self-awareness in

patients; we will not be using the protocol, but have adapted the idea of the protocol to

implement in a two-parts that will be administered before and after each intervention/activity

with our client. It is a type of pre-post self-rating assessment that will have client rate how he

believes he will perform during the activity, and then will again have him rate how he feels he
performed after the end of the activity. Additionally, the OTS will provide objective feedback of

client’s actual performance during the activity. This will help client to increase some insight,

but will also potentially help his procedural and anticipatory memory.

Prioritization of Need Areas:

Based on my professional reasoning and research evidence, I will be using Model of

Human Occupation (MOHO) as my organizing model, and the Dynamic Interactional Model

(DIM). MOHO will remind us that when “therapists are mindful of their client’s volition,

habituation, performance capacity and environmental conditions, they can monitor how these

aspects are responding in the therapy process and make adjustments” (Kielhofner, 2009). This is

an example of, if in therapy our client becomes overwhelmed or frustrated, we can help him by

changing the demands, responding in the moment and adjust the situation to better fit his

needs – providing that just-right challenge. Additionally, DIM will help guide intervention in

similar ways; “performance is improved by changing the demands of the activity and the

environment” (Toglia, 2011).

While MOHO is more focused on how to respond to the client’s change in volition,

performance capacity, etc., DIM is helping to also address the activity demands and

environmental demands. This will be especially important to keep in mind during bus route

planning interventions.

PLAN (P):
Client was part of a discussion on 2/2/18 to determine goal priorities for therapy. He had

initially (1/27) identified being able to ride the bus as the most important goal, but on 2/2

(possibly as a result of external influences – a pill bottle sitting on the table next to him), client

identified priorities for therapy as follows: increasing independence in managing his

medication, ride the bus to access community, and increasing cooking skills/safety as a

potential 3rd goal to add in the future. Together, the following goals were written:

LTG 1: In 6 weeks, client will be able to organize medications using visual reminders.

STG 1: In 4 weeks, client will independently organize one day’s worth of medications using a

visual reminder.

STG 2: In 2 weeks, client will independently follow instructions for sorting one medication using

a visual reminder.

LTG 2: In 6 weeks, client will be able to independently ride 2 chosen bus routes using

compensatory strategies with Min A from bus driver.

STG 1: In 4 weeks, client will draw on a map a bus route to and from his house using visual

reminders.

STG 2: In 2 weeks, client will plan out a schedule for using a bus route, including stop times and

destination business hours, with fewer than 3 verbal prompts.

 By addressing these goals, we will be able to our client’s Quality of Life (community

access), role competence (adult male), and improve his participation (medication management)

in his health management and maintenance.

Expected Frequency, duration and intensity: Client will be receiving skilled occupational

therapy services for a 60-minute session, 1 time per week, for 6 weeks to address goals.

Location of Intervention: Sessions will be held in the Health Sciences Education Building on the

1st floor, in the simulated apartment.

Jessica Smith, OTS 2/3/18

______________________________________________________________________________

Signature Date
References:

Gover, Y., Johnston, M. V., Toglia, J. & Deluca, J. (2007). Treatment to improve self-awareness in
persons with acquired brain injury. Brain Injury 21(9), 913-923. doi:
10.1080/0269905070155320

Kielhofner, G. (2009). Conceptual Foundations of Occupational Therapy Practice (4th Ed., Pp.
147-174). Philadelphia: F. A. Davis Company (Kielhofner, 2009)

Toglia, J. (2011). The dynamical interactional model of cognition in cognitive rehabilitation. In N.

Katz (Ed.), Cognition, occupation, and participation across the lifespan: neuroscience,
neurorehabilitation, and models of intervention in occupational therapy (pp. 161-195).
AOTA Press.