Amanda Barr – OCCT 657A

Demographics  42 year old wife and mother  Part time work in Law office  Lives in 2 story home with husband and teen son  5 foot 1 inches tall and roughly 104 lbs.  Health conscious  Unremarkable medical history  Active in snow sports, competes in triathlons, loves to travel

Hospitalization  Suffered a fall from a 2 nd story bay window, landed in the bushes of her front yard.  Complete SCI at the level of L3-L4  L1 –S1 Complex spine surgery  2 wks Post op transferred from General Hospital to Acute Rehabilitation hospital  Pt fitted for TLSO – Thoracolumbosacral Orthosis  Doctors orders to wear when patient is upright

Evaluation Methods  Prior level of function  Establish length of stay; rehabilitation potential  Discuss Home environment  Entry, Bathroom, number of steps,  FIM scores: 8 areas  Self care: Eating, Grooming, Bathing, shower t/f, Dressing UE & Dressing LE  Functional transfers: Shower and toilet  Manual Muscle Testing for UE  Determine strength, endurance and tone  Testing LE Sensation  Track presence or absence (compare with Acute hospital)

Person – Intrinsic factors  Physiological  Sensori-motor deficits - flaccidity and minor spasticity  Sensory system – tactile and proproception  LE muscle atrophy  Bowel and Bladder control  Neurobehavioral  No behaviors found based on neurological condition  Cognitive  Actively engaged & memory intact  Able to perform multi-sequence tasks  No limitations noted that impair performance

Person – Intrinsic factors  Psychological  Depression*  Decreased sense of self worth and purpose  Emotional conflict - desire to be self sufficient but feels hopeless  Spiritual  Stated she is spiritual but is not affiliated to a church  No specific beliefs that would interfere with standard medical practice.

Environment – Extrinsic Factors  Social support  Son and 2 close friends visit daily  Husband attends therapy sessions in afternoon  Social and Economic systems  Lives in small community, close to neighbors  Middle class family – Husband works 6 months of out year as civil engineer  Using savings for home modifications  Culture and Values  Core values in relationships with family and friends  Culture of an athlete: father was a professional skier – hardworking nature and dedication to goals

Environment - Continued  Built Environment and Technology  Home is a 2 story, 16 steps into entry, planning to use garage as entry; 1 st floor bathroom with tube  Pt utilizes her IPhone to communicate with family and friends  Pt stated she is well versed in computer from her job  Natural Environment  Positive feelings and emotions when outdoors; especially vivid stories about her training routine for triathlons  Pt asked for a window bed in her room to view the snow falling and the sun in the morning

Occupations  Basic ADLs  Pt stated more important focus on transfers, bathing and toileting  Work  Possible return to Paralegal for Real Estate, Water Law & Environmental Law office  Play/Leisure  Physical Activity – dedicated daily routine  Reading  Social Participation  Nurture relationships with son, husband and close friends  Education  Newly acquired tasks, compensatory strategies and health related training

Performance  Patient able to maneuver wheelchair in hallways and into bathroom at slower speed.  Reduced strength and endurance with transfers - use of upper body  Motivated for physical activity – requested therapy target cardiovascular exercise and strength training of UE  Minimal social interaction with residents and staff; noticeable change in demeanor after therapy

Goals Initial:  To transfer ModA from Bed ↔ w/c using slideboard  Perform UE and LE dressing ModA supine in bed  Bathing and shower t/f ModA using AE Progressed:  Perform laundry task with ModI  Prepare a stovetop meal with supervision  Independently return to w/c from ground level

Occupational performance & participation  Personal care  Motivated to overcome limitation from injury and handle the environmental barriers for her own expectations  Productive activities  Initial environmental constrict regarding w/c use and accessibility  Emphasis on developing skills for patient to engage in meaningful activities in hospital setting  Home maintenance  Home modifications to alter environment to allow patient to enter home, work at in kitchen and get in and out of 1 st floor bathroom  Simulated tasks during therapy

Occupational Performance & Participation  Recreation  Balance of personal factors and environment regarding outdoor leisure for meaningful activity; spoke with Disabled Sports of America  Leisure  Continued leisure activities through physical activity in therapy and reading in her room. Patient has healthy balance of her

Interventions  Development of patient–therapist relationship through basic skill development in self care  Supine dressing in bed using AE  Daily routine of shower and dressing (Hall, 1999)  Improve UE strength and endurance for through patient directed activity  Upper Extremity bike with moderate resistance  Environmental obstacles and weighted item retrieval (Hammell, 2009)

Interventions  Enhance new identity by overcoming insecurities and apprehension that limits social interaction.  Core training on mat in therapy gym  Group therapy for UE exercises (Isaksson, 2007)  Focus on the rewarding activities that enhance the patient’s perspective of their abilities.  Functional transfer in transitional living room (bed and bath)  Home management tasks; stovetop cooking and laundry (Donnelly, 2004)

Transition to Home  Family training  Car transfers  At home consultation  OT and Physical Therapist visit  Fall training  Patient and therapist create best fit technique for patient to return to wheelchair from ground

References American Occupational Therapy Association. (2008). Occupational therapy practice framework: Domains & process (2 nd ed.). The American Journal of Occupational Therapy, 62, \ Cole, M.B. & Tufano, R. (2008). Applied theories in occupational therapy: a practical approach. Thorofare, NJ: SLACK Incorporated. Donnelly, C., Eng, J. J., Hall, J., Alford, L., Giachino, R., Norton, K. & Kerr, D. S. (2004). Client-centred assessment and the identification of meaningful treatment goals for individuals with a spinal cord injury. Spinal Cord, 42, 302–307. Hall, K.M., Cohen, M.E., Wright, J., Call, M. & Werner, P. (1999). Characteristics of the functional independence measure in traumatic spinal cord injury. Archives of Physical Medicine and Rehabilitation, 80, 11, Hammell, K.W., Miller, W.C., Forwell, S.J., Forman, B.E. & Jacobsen, B.A. (2009). Managing fatigue following spinal cord injury: A qualitative exploration. Disability and Rehabilitation, 31, 17, 1437–1445. Isaksson, G., Josephsson, S., Lexell, J. & Ska, L. (2007). To regain participation in occupations through human encounters – narratives from women with spinal cord injury. Disability and Rehabilitation, 29, 22, 1679–1688.