History: Sharice is a 15 year old girl who was a passenger in the middle car of a 3 car pile-up on the interstate.  She was in a coma for 2 weeks and has been gradually awakening.  Additional injuries include fracture of right (dominant) wrist and knee.  Sharice was admitted to inpatient rehab yesterday and classified as Rancho Level V.  It appears that she has a left
visual field cut.  Also...Sharice is deaf.

ID of likely communication limitations: Young Sharice may be facing a number of communication limitations.  The appearance of left hemispatial neglect indicates that she has right parietal lobe damage.  The classification of Rancho Level V indicates that Sharice has difficulty maintaining attention, which could negatively affect communication with increased difficulty determining the overall meaning of situations and events, separating important from unimportant information, identifying relationships among individual elements of information, and maintaining appropriate interaction patterns.  Sharice may exhibit excessive, confabulatory, and inappropriate connected sign language.  She may have difficulty comprehending narratives and conversations, due to an insensitivity to relationships among events, failure to judge the appropriateness of events or situations, and making premature assumptions based on incomplete analysis of events and situations.  Sharice may
experience pragmatic impairments, such as reduced eye contact, turn taking, topic maintenance, and social communication conventions.  She may also have difficulty appreciating prosodic indicators of emotions, such as facial expression.  Since Sharice is deaf and sign language involves a great deal of facial expression, this could be problematic for effective communication.  The presence of left hemispatial neglect could influence the comprehension of sign language due to an incomplete recognition of the signing. Finally, Sharice has a fractured wrist which will inhibit her ability to sign as effectively as she did before the accident.

Submitted by: Eve Brosowsky

ID of likely swallowing limitations:

ID of likely limitations in simple ADL's: Sharice will require supervision level or greater for all her basic ADL's at Ranchos Los Amigos level V because she will be highly distractible and in need of constant redirection to attend to tasks.  Since Sharice is deaf the OT will need to use sign language or body language to provide this redirection. Sharice also lacks initiation of functional tasks and may show inappropriate use of objects without external direction.  For instance, Sharice may not be able to begin the task of brushing her teeth because she does not know how to get the toothpaste on the toothbrush to start the activity.  Sharice will have the greatest difficulty in having to learn new ways to achieve ADL tasks because of her right wrist and knee fx. and her left visual field cut.  At level V, Sharice will have most success in performing previously learned tasks and may be unable to learn new modified skills to achieve her ADL's.  Helping Sharice learn new ways
to dress such as how to put her right arm in the sleeve first and then her left, or turning her head more to the right when brushing her hair so that she can see her whole head given the visual field cut, may be unachievable at this level without a lot of hand over hand guiding by the therapist. Safety while doing ADL's will  be of major concern because Sharice is
confused and inappropriate at this level.  There must be structure in her environment and Sharice will need to be watched carefully in all activities that she performs.

April Perryman

ID of likely limitations in complex ADL's:   As this pt. is at Rancho level V she would have much difficulty responding to the more complex demands associated with performance of these tasks. She could respond fairly well to simple commands, but would have memory problems and would lack initiation of any task not associated directly with her own comfort. She also has left visual field deficits, fracture of her right, dominant wrist and knee and deafness. These activities would encompass in a broad sense the areas of home management, community living skills, health management, safety management, and control/manipulation of the environment.
1. Driving-This would be impaired due to both physical and cognitive deficits, she would be unable to use either her dominant hand or leg, and she has a left visual field cut. Her cognitive impairments would provide the greatest degree of impairment as she would be unable follow complex directions of navigation, understand and use street signs, the laws of
the road, and would not fully understand the impact her actions may have on others. This problem is further complicated by her hearing loss as she will need to first learn a means of communication before learning/relearning any task.
2. Meal prep- She would have difficulty following or sequencing the steps of preparing even the simplest of meals and not only would she need to learn how to perform this task but she would have to relearn with a serious cognitive and physical deficits. There would also be serious safety issues as she has vision loss and would be able to maintain only gross attention to the environment, and would be easily distracted.
3. Checkbook balancing- This would also be impaired due to her inability to follow the very complex directions required for balancing a checkbook, I cant do it myself, and because she would not have the cognitive means of sequencing, processing and making sense of symbols, and may have trouble seeing it due visual loss or perceptual problems and she would not
remember simple math skills.

 I have focused only on these three areas, but other areas of IADL function probably impacted include her ability to handle a medication routine, her ability to maintain her own safety, and her ability to maintain a comfortable safe environment. Although these areas are severely impacted it is reasonable to assume she would continue to make improvements and
recovery of a great deal of these skills.

Andy Powers

Assessment of swallowing:

Assessment of communication: This patient presents several challenges in terms of communication assessment. The best approach would be to use a communication board with pictures presented in the right visual field. The assessment would
probably have to be conducted during several short periods of time considering her attention span. Important factors to address are orientation, memory, and receptive and expressive language. She may be able to finger spell using her left hand, or point to a communication board if presented in the right visual field. Simple yes/no questions would be appropriate considering attention span. It would be helpful to provide her with choices so answering will be easier. Eventually after she
is feeling better and more alert, problem solving, reasoning skills, comprehension of written material could be assessed informally again using communication boards with pictures. Formal tests could be adapted if necessary and instructions and test stimuli could be presented through sign if her comprehension is good. However, considering her current impairments it would be more beneficial to establish some means of communication for the present time.

Elizabeth Jackson

Elizabeth,

You've addressed how she might respond (finger spelling and communication board) but how are you going to elicit her responses? Do you know of any materials developed specifically for use with deaf individuals?

I guess responses would have to be elicited via sign. I don't know of any materials developed for use with deaf clients, but if anyone does I'd love to know. ELJ

Assessment of basic ADL's:     Upon assessing a pt's basic ADL's you must first look at the pt's physical abilities.  This is accomplished by testing the pt's strength via manual muscle testing, their gross and fine motor coordination, and their
sensation.  From the info. gathered through these tests you can determine if the pt. is physically capable of performing the ADL tasks.
    Then you would instruct the pt. to perform the BADL tasks in order to observe their ability to perform these tasks.  From the observations of the pt. performing these tasks you can determine the level of assistance the pt. will need in order to complete the BADL tasks.  Then you will assign FIM levels to each BADL task depending on the level of assistance the pt. needs to perform that task.
    The FIM levels are as follows:  7- completely Independent, 6- requires assistive devices to perform the task, 5- requires cueing or supervision, 4- requires minimal assistance( pt. completed 75% 0f the task), 3- requires moderate assistance( pt. completed 50-74% of the task), 2- requires maximal assistance (pt.completed 25-49% of the task), 1- dependent ( pt. can't do the task or completed <25% of the task).
    By assessing a pt's. BADL's you can also assess their cognitive functioning (by looking at how they sequence the task, follow directions, or by how they plan ahead to complete the task).  However, with this pt. functioning at Rancho level 5 the pt. may perform BADL's at a higher level because the tasks are familiar to her and with structure she can do well with these tasks.  So with this pt. further cognitive assessment will be required in order to get a true picture of her cognitive abilities.

Travis Prevette

Travis -
With this patient being deaf and having a visual field cut and fractured of dominant hand, how will you assess HER ADL's?

Given the fact that she has full AROM of her non-dominant hand then she can use the dominate hand to provide gross assist to performing the ADL tasks.  As far as the deafness issue you can show her a picture or written instructions for the ADL task. You would also have to position the objects involved in the task into her visual field to compensate for the area of lost vision.

Assessment of complex ADL's:        When assessing Sharice's complex ADL's, I would start off by having her do AROM and PROM on her left and right upper extremities by using a goniometer.  This would include measuring her shoulders and elbows.  On her left side, I would also measure her wrist and fingers to give a baseline of what her right side would be like.
        Manual muscle testing would be done on her left side to see if she would be able to tolerate the resistance and/or carry items.  This is very important because she  is going to have to do all her activities and relearn ways to achieve all of the complex ADL's with her left upper extremity because her right dominant wrist is fractured.
       I would also give the Jebson Taylor Test of Hand Function to see just how much that left hand will be able to do functionally and safely. This would specifically test manipulation of small objects, simulated eating, and movement of heavy cans.  These would all help assess whether or not Sharice would be able to manipulate keys to open her front door or
pick up a can of soda from the ground.
       Since she fractured her knee, I would do a Home Assessment and Recommendation Evaluation.  This would cover areas like the entrance to the house, doors, hallways, hazards, and  rooms.  I would do this since she is most probably in a wheelchair and accommodations should be done now before she goes home.
      And finally, I would address the possibility that she has a left visual field cut.  For this, I would do the Kinetic Two Person Confrontation Test.  Here you test her field of vision from four different angles.  This would help determine if there is a visual deficit and how bad it is.

Jackie Selwyn

Jackie,
Do you think these are going to be efficient methods considering her head injury and her deafness?

Hello again guys!!!  Here's a little addition to the assessment of complex ADL's.  When doing all of the assessments that I told you previously (MMT, Jebson Taylor Test of Hand Function, Confrontation, etc) she would need to be in an quiet, relatively still area where she will not be distracted (due to her head injury).  Her head injury will also play a factor in the therapist keeping  the evaluations VERY structured and simple.   This should hopefully limit her chances of being confused since she will be participating in tasks that will be unfamiliar to her.  Also since she is deaf, she should be shown either pictures that she can point to or body gestures (such as raising her hand when she sees the pen during the confrontation test). The therapist can write open ended sentences out and Sharice can nod yes or no to them.  I would say have Sharice communicate by writing things out too, but she fractured her right dominant wrist.

Prognosis: Prognosis for Sharice's complete recovery is poor.  However, prognosis for her reaching functionality is fair.  A primary factor that must be taken into consideration is the two week duration that Sharice spent in the coma.  Longer durations of coma are associated with poorer eventual recovery.  According to the Handbook of Neurorehabilitation, 2-week duration yields moderate-severe disabilities.
Additionally, right parietal lobe damage resulted in a left visual field and limited cognitive abilities.  These limitations will negatively impact performance in her daily routines.  Sharice's young age will be one positive influence on her overall recovery.  Also the wrist and knee fractures should heal completely barring any unforeseen complications and Sharice will gain use of these extremities.

Shannon Lane

Swallowing targets and activities:

Basic ADL targets and activities: It is important to have Sharice perform basic ADLs at the appropriate time
and place.  This will be less confusing for her. Sharice will have difficulty with ADLs due to her left visual neglect and her fractured right wrist and knee.  Sharice should be able to use her right hand even though it is in a cast.  Of course it may still be painful so this should be done with caution.  Due to the fracture of her right knee, she may need to sit during her self care activities.

Since Sharice is deaf, cues need to be visual.  Perhaps written down instructions for her to read would be easier.  She may need a sign language interpreter if she can not read or lip read.  Throughout Sharice's treatment, we should all work on her visual field cut by having her work on compensation of the visual cut by cueing her to attend to objects in the left visual space.  This may be done by placing a red tape or other object on the left of the task, (pen and paper task or ADL task). Cues will need to be given to remind her to look all the way to the red tape or other object.

Visual cues such as signs should be placed in her room to help with memory, sequencing, and safety during ADL task.   ADL tasks should be familiar to her and hopefully somewhat automatic.

1.  Pt. will don shirt with min. assistance.
Tx. Activity: Practice dressing upper body during morning ADLs.  She will need tactile and visual cues to perform the task.  A button up shirt would be challenging but it would help her to use both hands together to do the task.  Other treatment that would help with shirt donning would be any bilateral tasks, sequencing task, cognitive task or body scheme awareness
activities.

2. Pt. will brush hair with supervision.
TX. Activity: Sharice will practice grooming tasks during morning ADL's. She should be able to brush her hair with the visual cues of a mirror and visual cues given to her by her therapist.  A long piece of red tape should be placed on her mirror on the left edge.  This will help to cue her to look at her reflection all the way to the red tape.  Of course this means
that she need to be sitting directly in front of the mirror. (so her image is in the middle).  She should be able to use her right hand for brushing her hair, but it would be good for her to practice using both hands or just her left hand.

3. Pt will feed self with min. assistance.
Tx. Activity:  Sharice will practice this during meal time. She will need to eat in a room with few people or in her own room to decrease distractions. Visual and tactile cues may be needed in order for Sharice to see all of the food on her plate.  She will need cues to keep visual attention to her left hand if she is using it to eat.  But because she is right handed she will probably be using her right hand.  Her right hand should still be functional even though it is in a cast.  A red piece of tape or other object should be placed on the left side of her plate.  This will help cue her to look all the way to her left.

Tammy Tankersley

Complex ADL targets and activities: Hi, I hope I am responding to the right case (#3) and to the requested areas (IADL's).  But before I go any further I would like to state my personal opinion about the "reality" of this young lady's life...given
that so many have responded to this case.  Additionally I recognize I may offend people with what I see as the cold reality but this is truly not my intentions.  I merely say the following based on my experience opening a group home for TBI survivors.  Sadly, life as Sharice knew it no longer exists.  This is a given.  However, equally tragic is that her primary support group at this age is her friends which to will no longer exist.  The truth is that at 15 years of age her friends will most likely view her as an object of pity who at best will hopefully tolerate her existence.  15 year old girls (as well as boys I guess) can be mean.
They will be embarrassed by her and therefore lack any reason to maintain a friendship with her.  At 15 (we have all been there) you don't have a license but begin to understand the freedom that accompanies one, learn about parties but have curfews that limit your participation, and I will not even get into the drugs, sex and rock & roll that shadows this period (and yes I realize some of the things mentioned shadow life periods beyond high school years).  All these "things" Sharice was about to embark on (if not already) have now been altered and possibly permanently.  So onto the matter at hand.

Two key points to consider:
1.  She can only follow 1 step commands at this time
2.  No retention and therefore dependent on material cues and compensatory techniques for learning at this time.

IADL's that I would address would be using a telephone and e-mail via computer.
Telephone-I would use a computer screen to display the person with whom she was speaking.  Since she is deaf she would need a decoder (either one like a TDD that the person on the other end could type there message or one that translates spoken language into readable text).  At 15 years of age, talking on the phone is a huge leisure activity.  Granted the only people who probably will be calling is family but she will be able to communicate with them.  And though this may sound expensive, with aggressive funding searches, grants and Medicaid (CAP-MR/DD) which she will qualify for now, she should be able to secure this.  Furthermore she will be able to use her verbal communication skills with a headset/microphone as well as overlays on a key board with symbols to communicate.  With the overlays she would be able to use her non-dominant hand to activate messages.

E-mail-I would teach the use of e-mail in order for her to subscribe to a teen TBI survivor support group whom she could correspond.  With all the technology on different types of "mouse" systems as well as head sets for pointers and cameras that detect eye choices, she would be able to independently manipulate this system.  Also, a digital camera (computer-mount that projects her picture on the screen of others) accessory would allow her to respond to communication received with
simple head nods.

Additionally, she will be able to use the computer for school/academics.  The benefits and possibilities of using the computer
are endless for her.

Adaptations needed include adding a contrast to the computer screen, mouse, mouse pad and keyboard/overlays to ensure she is looking and seeing all of the screen such as a red piece of tape down the side of the screen, overlays for the computer screen to "hide" icons that she would not need at present to decrease the stimulation, chance of errors in execution and hopefully confusion.  Also visual cue cards (with a "check off" component) that sequence steps necessary for executing
programs/task.

I recognize this is not an exhaustive list of compensatory techniques but this is all for now.

Janice Whitley
LRC Occupational Therapy Program

Communication targets and activities: Functional Goal 1--Sharice will utilize a communication board to express
her wants and needs to her caregivers. The communication board will be made up of simple pictures.  Sharice will finger-point to the desired objects.

Functional Goal 2--Sharice will respond appropriately by nodding/shaking her head to indicate 'yes'/'no' answers to questions presented to her by sign. The clinician will ask (by sign) Sharice simple questions (e.g. Are
you a girl) to determine the accuracy of her responses.

Submitted by, Shannon Graves & Holly Hanley

Review & Question: When looking at this case it is apparent that Sharice in not going to be an easy case to have.  With the
fact that she is deaf and possible head injuries she is going to present with a number of challenges for any therapist.  Looking at her with a holistic approach I would want to know:

What are the chances of her learning a new communication technique and how efficient is it going to be?  I see that sign language is recommended but if she has a short attention span and visual field deficits I wonder if this is the correct form of
communication to start off with and if it will ever be complex or will it just be a means of simple communication.

What are some of the time frames that it would be feasible for her to have gains in both communication and function?

Would you talk to this girl who is 15 about her sexuality concerns and her expression of it, the ability for her to be married and have children, so on and so forth?

I know that seeing this case on paper and seeing it in the real world would be two different things and I know that seeing her would answer some of the questions that we all have of what is her real potential?  Is she going to have a fighting chance?
and I wonder what I can really do for her and can I do it right?  These questions would be more understood in
person than on paper.

Frank Younce, OTS

I think sign language will give her the best shot at more complex communication.  Since sign language is a separate & distinct language from English, using another type of communication would require her to learn to communicate in a second language (english) & to learn a new method of communication --right now she's not in a position to be learning complex new things.  If
an alternate communication system is necessary, perhaps something simple such as pointing to pictures (as mentioned by someone).  Maybe pictures and signs would work well together.

I am still wondering how the visual field cut will affect her ability to see signs ...if the signer stands to her right, can she see & interpret the signs in whole --or is this more cognitive in nature, in which she blocks out the left side of each "thing"/entity in her sight? I'm not sure if I'm explaining my question too clearly.

My other question regards the wrist fracture.  As an SLP student, I'm thinking ...broken bone/no problem/it'll heal in six weeks or so.  Is this right?  It seems like OT's have a different perspective on this.  Mention was made of her having to re-learn activities using her left hand due to the fracture.  Is a wrist fracture much worse than any broken bone?  How much worse is it?

One more thing... The last questions you posed sound so sad and hopeless.  I think the answer to these questions in "real life" would be that your focus will be different.  Right now we are thinking of a 15 year old child who had her life ahead of her, but now she does not.  Actually that's not correct ...she still has her life ahead of her, it will just be a different life. In a real life situation, I think we would focus on the here and now.  Yes, it is important to consider long term goals, but at such an acute stage, you will be looking at daily challenges & struggles, and daily successes.

Kathy

I just want everyone to know that I was not trying to be depressive or uncaring in any form.  When I treat a person or evaluate a person I have to take them for who they are, try to assess what is important to them on a personal level and even start to care for them before I can come to a good conclusion of what to do for her.  I was just throwing out some questions.  We
as OTs try to look at the whole picture and then find the small piece that will fit it all back together.When dealing with a 15 year old girl, from the OT perspective you have to deal with all areas of life.  The long term goals are things that we try to
look at from the beginning.  Now we do the easy more successful things right up front and try to help her build self esteem and self confidence and work on all of the other areas of her life that are functional and important to her.  How she looks and presents herself are things that are important to a 15 year old, and as she gets older it may play a bigger part of her life.
So giving her the information up front is just a way of letting her know what her options are and that she can still be "normal" in many areas of her life.

Someone asked a question concerning the OT perspective on the fractures and why we seemed to be paying close attention to them.  Well yes pending complications the fractures will heal but to be independent in the areas of grooming and self care she is going to have to learn new ways of  doing the activities for the time being and then after the healing is complete the arm
and leg will be weak and therapy will be needed to increase strength, ROM, and endurance.  Frank
 

The patient is a 15 year old female patient who received injuries in a three car motor vehicle accident.  Her injuries include a fractured right wrist and knee and damage to the right parietal lobe resulting in a left visual field cut.  The patient had been in a coma for 2 weeks and has gradually come into consciousness. The patient is also deaf.  Possible impairments would be reduced attention/high distractibility, reduced ability to: decipher the meaning of overall situations and events, separate important from unimportant facts, maintain appropriate interaction patterns, maintain eye contact, turn-taking, maintain topic, and follow social communication conventions.  She might also have difficulty understanding the meaning behind facial expressions used in sign language as well as have difficulty understanding sign language as a result of left neglect.

The patient would most likely require supervision level or greater for all ADL's due to reduced attention span and high distractibility.  Assistance would also be required due to the patient's lack of initiation of functional tasks and inappropriate use of objects.  The patient could respond well to simple tasks, however, more complex tasks such as driving, preparing meals, and balancing a checkbook may be more difficult because of the complex nature of these tasks and the left visual field neglect exhibited by the patient.  ADL assessment would include manual muscle testing for strength, observation of patient performing BADL's to determine assistance level and assignment of FIM levels for each task.

Communication assessment would focus on orientation, memory, and receptive and expressive language abilities.  The patient would need a communication board with pictures presented in the right visual field.  Yes/no questions and questions with choices would be most appropriate.  At a later date, assessment of problem solving, reasoning, and comprehension of written materials would be administered.

Basic ADL's should be attempted in the appropriate time and place so that confusion for the patient is kept to a minimum.  Cues will need to be visual due to the patient's hearing impairment and possible written due to the patient's left visual field neglect.  Cues to prompt the patient to attend to the left visual field should be used as well as visual cues for aiding in memory, sequencing, and safety during all ADL tasks.  ADL tasks should be familiar and automatic in nature such as  dressing herself, brushing hair, and feeding herself.

Communication goals will be functional in nature and include utilizing a communication board to express wants and needs and responding appropriately by nodding or shaking her head to indicate yes or no.

The prognosis for complete recovery is poor due to extent of injuries and the duration of her coma.  However, a fair prognosis is indicated for functionality.  Her reduced cognitive abilities and left visual field neglect will have a negative effect on her overall recovery.

submitted by:  Kim Register