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Running Head: OSTEOGENESIS IMPERFECTA: A CASE STUDY

Osteogenesis Imperfecta: A Case Study


Orah Kabhai, OTS, Annie Guiliano, OTS, Faith Wilkins, OTS,
Gifty Frimpong, OTS, Nick Druzinski, OTS, and Brianna Pupp, OTS
Touro University Nevada

OSTEOGENESIS IMPERFECTA: A CASE STUDY

Osteogenesis Imperfecta (OI), otherwise known as brittle bone disease, is a genetic


disorder characterized by decreased bone composition due to the inability to form type I collagen
(Case-Smith & OBrien, 2010). While one of the most commonly inherited bone disorders, this
particular disorder has a low prevalence of 1:20,000 live births. It affects males and females
equally, and occurs in all racial and ethnic groups. This rare disorder caused by mutations in the
genes affects both the quality and quantity of bone mass, with a clinical feature of bone fragility
(Balkefors, 2012), leading to recurrent fractures, hyperlaxity of ligaments, short stature and
muscular weakness. Other signs and symptoms associated with OI include; blue or gray sclera,
thin or smooth skin, easy bruising, spinal curvature, bowing of long bones, excessive sweating
and heat intolerance (Hartman & Clements, 2003).
The Sillence classification system uses four OI types to define how severely a person
diagnosed with OI is affected. Our client Jenna originally presented with Type III OI. This form
can be identified using x-rays which reveals healed fractures that occurred before birth. People
with Type III OI may incur anywhere from several dozen to several hundred fractures in a
lifetime (Hartman & Clements, 2003). At birth, Jenna presented with five fractures despite
delivery via cesarean section. However, a skin biopsy exhibited cellular and collagen
characteristics more consistent with Type IV OI, a more moderate form that can range in severity
from characteristics similar to Type I OI to Type III OI. People with this type of OI may be
somewhat shorter than others in their family, have frequent fractures that decrease after puberty,
and have mild to moderate bone deformity (Hartman & Clements, 2003, p. 3). Individuals with
this type of OI have an average life expectancy.
One should note, when working with individuals that have OI, he or she may not express
all characteristics of the type he or she has been diagnosed with. In fact, many people do not

OSTEOGENESIS IMPERFECTA: A CASE STUDY

clearly fit into any of the four types (Hartman & Clements, 2003). That being said, when
working with individuals with OI such as Jenna, it is most effective to focus on the clients
particular abilities, strengths, and weaknesses, rather than his or her OI type. In the following
sections Jennas current status will be specified, along with her long and short term treatment
goals, intended plan of treatment, and various elements of her treatment within the school
system.
Occupational Performance
Jenna is a fifth grader at Mildred Academy in Southern Nevada. She has three older
sisters and both parents are active supporters in her life. Her father is a lawyer and her mother is
a wedding planner. Jennas favorite things to do include swimming, board games, art, and
following the latest fashion trends. At Jennas yearly Individualized Education Program meeting
concerns were addressed regarding Jennas current school performance. The main concerns
addressed were as follows: her decreasing classroom grades despite having no cognitive deficits,
lack of social participation, her limited muscle strength, and lack of independence completing
daily care activities.
Activities of Daily Living (ADLs)
Jenna requires moderate to maximum assistance when transporting herself from her
wheelchair to perform her daily routines. While Jennas functional mobility is limited because
she has difficulty with transfers, Jenna is capable of navigating her wheelchair through her home
and school environment with moderate assistance. Another ADL that Jenna participates in is
personal device care. Jenna maintains her wheelchair by using it throughout the day and cleaning
it once a week. This is important because her wheelchair provides her independence in
mobilization. Finally, since Jenna has difficulty with transfers from her wheelchair to the toilet,

OSTEOGENESIS IMPERFECTA: A CASE STUDY

Jenna has deficits in toileting and toilet hygiene. Once she is successfully transferred to the toilet,
Jenna can independently go to the bathroom.
Instrumental Activities of Daily Living (IADLs)
Two areas Jenna has deficits are health management/maintenance and safety and
emergency maintenance. In school-based therapy, one main focus is Jennas health management.
She is working on strengthening her upper body in order to perform more functional occupations
such as toileting. And, by working on her upper body strength, it will build up her endurance and
increase her ability to participate in physical education classes or other recreational activities.
However, another obstacle Jenna faces when participating in her physical education class is the
threat to her physical safety. Due to the potential for injury, finding a different way for Jenna to
socially participate is recommended.
At home, Jenna and her family focus on activities that support a more independent
lifestyle. Jenna parents have agreed she should take on more responsibility by helping around the
house. Expectations include: keeping her room clean, using a reacher to pick objects up off the
floor or to place them on high shelves, and cleaning up after meals by taking her dishes to the
kitchen sink independently. She earns a small allowance for completing these household chores
and was recently introduced to online banking. Jennas mother wants her to learn basic money
management skills.
Rest and Sleep
In the evening, Jenna performs a sleeping routine which includes: saying goodnight to her
family, brushing her teeth, setting her alarm, and changing into pajamas. She sleeps an average
of eight hours a night with an occasional hour nap after school. When transferring from her
wheelchair to her bed, she needs maximum assistance. Jennas bed is positioned against the wall

OSTEOGENESIS IMPERFECTA: A CASE STUDY

to prevent her from falling off and pillows are used as a barrier to separate the hard wall from her
body at night.
Education
Jenna attends elementary school as a fifth grader. Her mother served as a classroom
helper when she was younger, but currently Jenna now has an instructional aide that assists her
during school. Jenna often compares herself to her peers and sometimes feels very isolated due to
her condition. Jenna is has difficulty with her auditory abilities. She has difficulty hearing
teacher instructions due to the size of the classroom and the number of students. Jenna also has
difficulty with writing due to her hypermobile finger joints, her lack of wrist strength, and
endurance. These problems contribute to her poor performance at school.
Her parents expressed concern about her grades slipping this year and are worried she
may fall even further behind next year when she transitions to the more demanding curriculum of
middle school. Her parents have considered enrolling her in an extended school year program
hoping to decrease the gap that is growing between Jenna and her peers. Due to particular
struggles in math, Jennas parents have signed her up for tutoring on Wednesdays, hoping to ease
her move into sixth grade.
Apart from her academic performance, Jennas participation in physical education (P.E.)
class is limited due to the high demand of physical activity. She is not currently enrolled in an
adaptive P.E. class which significantly decreases her engagement physically and socially. She has
expressed that P.E. is her least favorite class.
Work
Jennas family has noticed she loves animals and started volunteering at the local animal
shelter once a month. She has voiced the enjoy she feels when feeding the animals and walking

OSTEOGENESIS IMPERFECTA: A CASE STUDY

the dogs with employee assistance. Due to Jennas young age and health status, her work
occupations revolve around her role as a student.
Play and Leisure
Jenna loves to go shopping and throw impromptu fashion shows with her older sisters.
On the weekends, they look through magazines together and cut out the latest fashions. Jennas
only participation in sports currently involves observing her sisters while they cheerlead at
different sporting events. Recently, she began asking her mom when she can try out for the cheer
team because she feels left out. Not only can she not join her sisters on the sidelines for fear of
injury, but she is does not participate in any fun extracurricular activities.
Social Participation
Jenna enjoys spending time with her siblings and parents at home and in the community.
At home she plays various games on a Wii game console, and goes grocery shopping with her
father in the community. Jenna also gets manicures with her mother once a month. Unfortunately,
Jennas social participation at school is declining. When she is in the classroom, she has limited
conversation with peers and while in the lunchroom, she sits amongst peers but does not engage
those surrounding her. While in third grade, Jenna attended multiple play dates; however, since
then, peers have started to pull away and she has not be invited to any of their houses. Jennas
mother suspects her peers do not understand Jennas condition and when they question Jenna,
she does not know how to respond.
Movement, Postural Reaction, and Reflexes
At birth Jenna presented with five bone fractures. Due to her diagnosis of Osteogenesis
Imperfecta and the inability to independently weight bear on her lower extremities (LE), Jenna
did not progress typically through the developmental milestones from pull to stand, cruising,

OSTEOGENESIS IMPERFECTA: A CASE STUDY

supported walking, standing, and walking. Postural control requires achieving normal
developmental milestones and includes the maturing of postural reactions (righting, protective
and equilibrium reactions), the integration of primitive as well as normal muscle tone, normal
postural tone and intentional voluntary movement (Wandel, 2000).
Jenna has been unable to benefit from the strengthening of postural control that standing
and walking naturally provide. Beginning in early intervention, Jenna has worked with therapists
trying to develop trunk strength and postural muscles. Jenna progressed from sitting to sit-tostand with an ankle-foot orthoses (AFOs) and a walker. A walker with a bench allows Jenna to
walk while taking necessary breaks with minimal assistance.
While Jenna recovers from broken LE bones, she refrains from weight bearing and using
her walker. During recovery, Jenna is able to scoot on the floor and use her power wheelchair for
mobility. Jennas protective reactions are present but because her bones are so fragile they often
harm her in others ways, such as a broken upper extremity bone. Jenna utilizes an aquatic
therapy program to allow movement with little risk of fracture. Her aquatic therapy program
focuses on trunk strengthening in preparation for a land based walking program.
For greater independence in self-care and transfers during school, Jenna uses a power
wheelchair with a seat elevator. The seat elevator enables Jenna greater access to her
environment. She is able to reach books off the shelf in the library, view the food the cafeteria is
offering, and look classmates in the eye.
Jenna has hypermobile finger joints that impede functional movement. Her fingers are
able to bend backwards to ninety degrees. This flexibility makes her hands less stable. Her hand
muscles have to work harder when trying to grip, lift, and manipulate objects. Jennas school

OSTEOGENESIS IMPERFECTA: A CASE STUDY

performance has been negatively impacted. Lack of strength and endurance is apparent in her
poor handwriting.
Sensory integration and Self-regulation
Due to Jennas specific disorder, Jennas main focuses for therapy include increasing
trunk strength and preventing future injuries. Jenna has no sensory integration deficits. Jenna
demonstrates communication and social skill deficits as well as delays in academic achievement.
In order to improve these deficits, Jenna will participate in interventions which include role
playing and increasing handwriting performance. Due to her fragile musculoskeletal system and
many possible risks, Jenna would not benefit from participating in therapy in an SI clinic.
PEOP Model
The PEOP model has four components which include the person, environment,
occupation and performance. The main focus of the model is on an individuals occupational
performance and participation which is based on the idea of goodness of fit (Brown, 2012,
p.495). An individual achieves occupational performance when tasks and activities that comprise
the occupation are performed as efficiently as possible. Occupational therapists formulate an
appropriate treatment plan for the client using two factors, the person and environment.
The model takes a top-down approach and views the person holistically, by recognizing
the mind, body and spirit. By looking at all the components that make up an individual, studying
how they relate and interact with one another, and regarding each of them during the treatment
plan, the practitioner can foster occupational performance and participation and help the client
achieve a level of functionality that meets his or her roles, responsibilities and interests.
When applying this model to Jenna, the occupational therapist will analyze the
environment as it applies to her as an individual and take the proper steps to ensure the

OSTEOGENESIS IMPERFECTA: A CASE STUDY

enhancement of Jennas everyday performance and participation in school and related activities.
The OT will first look at the person component, the elements that shape Jennas skills, abilities,
values, interests, and life experiences. Jenna is an 11 year old female who is currently a student
in the fifth grade and uses a power wheelchair to allow for more independence. Recently, she has
expressed interest in trying out for the school cheer team (regardless of her brittle bones). While
she has been fracture free for six months, in the past overconfidence in her mobility caused her to
take risks which resulted in higher incidences of fractures. Jennas grades have gone down this
year, partly due to difficulty with writing and hearing. Her main occupations at this stage in life
include being a student, a daughter, and a sibling. As a school-based occupational therapist, the
environment that Jenna is being observed in is the school and classroom.
After Jenna is evaluated holistically, the OT should address the fine motor
skills/performance skills that have declined and are affecting her handwriting. The practitioner
should recommend pencil grasps that will enable her to write more proficiently and consult with
the teacher regarding classroom accommodations. Now in the fifth grade, the OT can assume
that Jenna will have a better understanding of her condition. The practitioner should educate
Jenna to use extra caution in her movements, particularly when engaging in toilet transfers. To
help her avoid overstretching and injury, the OT should teach Jenna to use her strongest muscle
groups to accomplish tasks. While handwriting is a concern of Jennas parents, safetyprecautions take high priority in Jennas intervention. Jenna has expressed interest in joining the
cheerleading team. Because cheerleading is a high impact sport that includes rather vigorous
movements, it is not conducive to Jennas diagnosis. The OT should explore alternative extracurricular activities with Jenna and select one that Jenna will enjoy and can participate in safely.

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It would be conducive to Jennas treatment plan to implement an activity that will help with UE
strengthening as well.
Theories, Practice Models, and Frames of Reference
Abraham Maslow outlined a hierarchy of basic human needs that are believed to follow a
longitudinal sequence where basic needs are prerequisite for the more complex. At the base of
Maslows hierarchy are physiological needs such as sustenance, water, sleep, and shelter. The
next level encompasses the need for safety including physical and physiologic security (CaseSmith & OBrien, 2010). Need for love and belongingness, need for a sense of self-esteem, and
the need for self-actualization complete the hierarchy. Each level must be reached before an
individual is motivated to pursue other life goals (Case-Smith & OBrien, 2010).
Jenna has her physiologic needs met. Hunger, sleep, and shelter are non-issues. Jenna has
been fracture free for six months. While her family and caregivers are well educated about her
condition including all necessary precautions. Jenna has demonstrated a need for increased
awareness in respect to her own safety. Jennas desire to become a cheerleader like her older
sisters indicates a skewed safety understanding but also a yearning to belong. Focusing on
Jennas need for love, especially belonging, is essential for Jennas growth as an individual.
Jennas classroom performance is hindering her academic progression as a student. In the
classroom, Jenna has been falling behind due to impaired hearing and writing difficulties. It is
important to intervene to ensure Jennas success. Further separation from the group could
increase Jennas feeling of isolation. Adaptive physical education activities could promote
inclusion in Jennas physical education classes as well as increase Jennas trunk and upper
extremity strength. Jenna must feel included, respected, and loved to meet her need of belonging.
Her self-esteem will develop once she regards herself as competent and a value to her

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community (Case-Smith & OBrien, 2010). Addressing Jennas needs will assist her in achieving
her highest level of potential, becoming a self-actualized adult.
The compensatory/adaptation approach best allows Jenna to increase independence in
ADLs. Throughout Jennas life, the compensatory/adaptation approach has helped modify tasks
and environments to accommodate participation. Jennas participation is essential to promote her
sense of belonging. In a compensatory approach, Jennas classroom environment and
instructional methods will be modified to accommodate for her limitation in hearing, writing,
and socialization. By establishing compensatory strategies, skill building may then be enhanced
(Case-Smith & OBrien, 2010).
Utilizing a biomechanical frame of reference will assist Jenna in establishing the strength
and endurance necessary to perform occupations, such as participating in physical education
class and engaging in handwriting for prolonged periods. Increasing Jennas UE strength, range
of motion, and endurance will increase inclusivity, promoting opportunities for social
interactions which will support her position on Maslows hierarchy of needs. Strengthening
Jennas trunk will assist her postural muscles in preparation for her land based walking program.
Building Jennas proximal muscles of trunk and neck will support the development of her distal
muscles needed for engaging in her desired occupations. Postural control is necessary for
placement of hand in space and support of the hand during the execution of fine motor skills
such as handwriting and self-care tasks (Case-Smith & OBrien, 2010).
Appropriate Assessments
According to IDEA, Part B, children with disabilities are entitled to educational services
in the least restrictive environment possible (Case-Smith & OBrien, 2010). The School Function
Assessment (SFA) was created to facilitate program planning in elementary education for

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students with a variety of disabilities. This assessment encompasses three domains, including
participation, task supports, and activity performance. It focuses on both the education and
socialization of a student with disabilities within an integrated program. As Jenna spends her
school day in a typical classroom, the SFA will focus on her performance within the typical
classroom. Jenna will benefit from the utilization of this assessment because it will indicate
specific areas of improvement that interventions could address such as handwriting, positive
interactions and safety. Additionally, the questionnaires provide criterion referenced scores to
determine if Jenna is below typical development for her grade level and a baseline for her current
abilities which then offers justification for further services. Thus, the assessment best suited for
Jenna is the School Function Assessment (SFA).
The OT may also use the ETCH assessment to evaluate Jennas legibility and speed of
handwriting. This assessment is typically utilized in schools for children in first through sixth
grade who are experiencing difficulty with written communication (Stewart, 2010). The ETCH is
a criterion-referenced test, therefore, it is helpful in evaluating Jennas functional skills and
determining appropriate activities to target therapy goals during implementation of interventions.
Functional Problem Statements
1.

Client is unable to independently perform toileting activities due to difficulties

with transfers and decreased trunk strength.


2.
Client is unable to initiate social interactions with peers due to a lack of selfconfidence.
3.
Client is unable to engage in writing tasks due to hypermobile finger joints and
lack of endurance.
4.
Client is unable to actively participate in physical education class due to lack of
safety precautions.

OSTEOGENESIS IMPERFECTA: A CASE STUDY


5.

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Client is unable to keep up with her schoolwork due to poor written work

production and hearing difficulties.


Five Family and Child Goals
1.
2.

Jenna wants to safely engage in bathroom activities with limited assistance.


Jennas family will expose Jenna to five new leisure activities to increase her

awareness of opportunities within her community.


3.
Jennas family wants her to increase her social participation by joining a support
group or after school club.
4.
Jennas family wants her to increase her writing performance when completing
written assignments.
5.
Jennas family would like Jenna to independently state a summary of her
diagnosis in order to educate her peers at school.
Occupational Therapy Goals
When forming Jennas treatment plan multiple sources were researched. In particular, the
Osteoporosis and Related Bone Diseases National Resource Center branch of the National
Institute of Health (NIH) was influential in establishing Jennas goal. The NIH (2012) stated the
most important considerations for children with OI in regard to long term goals is good health
and independence in all areas of function (social, educational, self-care, locomotion and
recreation), using adaptive devices as needed. After considering the research and Jennas unique
occupational profile, a decision was made to focus on her social participation, functional
mobility, and her classroom performance.
Long Term Goal: Jenna will develop enough strength to independently and safely complete a
toilet transfer in one year.
Objective 1: Jenna will demonstrate an increased safety awareness by stating the effects of a
variety of unsafe situations four out of five opportunities to do so in three months.

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Activity 1 The OT will present Jenna with various cause and effect situations ranging from
carrying a load of laundry to her room from the laundry room to playing a game of tag with the
kids in her neighborhood. Together the OT and Jenna will work on assessing and identifying
potentially unsafe situations, risks, support networks, and potential outcomes.
Activity 2 Using the board game What Should You Do?, the OT will help Jenna implement
strategy with each question posed. With each card Jenna must: identify the problem, brainstorm
alternative solutions to the problem, consider consequences of all answers options and select a
course of action. The OT then will prompt Jenna to reflect on her decision and determine if she
must move forward or backward in the game.
Objective 2: Jenna will enter and exit the graded aquatic pool using the handrails two times a
week to increase her strength for functional mobility in six months.
Activity 1 Red Light Green Light into and out of the Pool. In previous aquatic therapy
sessions, Jenna used her walker to enter the pool. Therapy now will address Jenna transitioning
by using only the rails on the ramp into and out of the pool. Her entrance and exit will be paired
with the activity Red Light Green Light with the other individuals in the pool. This will increase
her independence and functional mobility.
Activity 2 Row a raft, playing basketball while standing, or standing in the shallow end and
using a row paddle to bring an object closer.
Jenna also has a goal in regard to her social participation that focuses on increasing her
social interaction through a variety of ways. Her social participation goal is below.
Long Term Goal: Jennas social participation will increase so that she can become an active
member on an extracurricular team in one year.

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Objective 1: Jenna will initiate and sustain a minimum 3 minute conversation with peers at the
lunch table three out of five days during the week without being prompted within three months.
Activity 1 Jenna and the OT will act out various roles to improve her social skills. The roles
will focus on initiating and sustaining conversation while simultaneously seeking to improve
Jennas self-confidence. Roles and scenarios may include: lunch room etiquette with peers, help
finding items in a clothing store, and asking a school sponsor how to join a school club.
Activity 2 Jenna and a peer from her classroom will design a clothing line. A classroom peer
who also has OT and a need for increased socialization enjoys drawing, and with Jennas
interests in fashion, together they will collaborate to form a clothing line. This activity not only
has Jenna participating in one her favorite occupations, it also promotes social interactions and
increased self-efficacy.
Objective 2: Jenna will orient at least six students or parents to the school as the school greeter
within the next six months with supervision as needed.
Activity 1 The OT will collaborate with the teacher to assign Jenna the role of morning leader
and she will lead the pledge of allegiance and explain the agenda to her classmates for two
weeks. This will not only serve to improve Jennas speaking skills but also promote positive
interactions with her peers.
Activity 2 In one of Jennas session the OT will push-in and assist Jenna reading an article
from the Daily Life-Science Magazine. This will allow the OT to observe Jenna speaking to
her class which will be a good indicator as to her readiness to meet, greet and show new people
around the school and her classroom.
Jennas last goal focuses on her classroom performance. She has been having difficulty
hearing the teacher at the front of the room when she teaches lessons and gives directions. Jenna

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has been referred to an otolaryngologist with pediatric experience for a hearing assessment. If
hearing loss is discovered, she will be recommended to a certified audiologist who will complete
a formal audiologic assessment yearly (Osteogenesis Imperfecta Foundation, 2005). The OT will
recommend to the teacher that Jenna have preferential seating up front in the classroom along
with having a FM device installed to promote Jennas classroom participation and learning
(Osteogenesis Imperfecta Foundation, 2005). Jennas goal to increase her classroom performance
follows:
Long Term Goal: Jenna will increase communication and written production during classroom
activities as indicated by passing all of her core classes with minimal supervision at the end of
fifth grade.
Objective 1: Jenna will actively engage in the math lessons using eye contact and head nodding
as evidenced by hand raising followed with a comment or question at least one time per math
lesson four out of five times a week in three months.
Activity 1 Jenna will complete a self-advocacy handbook and profile with support from the
OT. She will identify her strengths, learning preferences, as well as her needs. After the
identification phase, the OT will discuss with Jenna how to effectively, assertively and
respectfully communicate her needs. Jenna may also learn through this activity the importance of
self-efficacy and how she may take ownership in her education.
Activity 2 Jenna will participate in an interview activity to increase her active listening skills.
With another peer, Jenna will engage in a conversation about getting to know one another. Both
will have a worksheet to fill out as evidence of their listening skills and to serve as baseline. As
Jennas skills increase, she will be asked to find out new and different information about her
partner.

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Objective 2: Jenna will increase her handwriting performance in the next six months as
evidenced by a 30% improvement in speed and legibility.
Activity 1 Jenna will use an easel to create artwork and practice writing her spelling words.
The vertical surface of an easel requires Jenna to write upright using different arm and shoulder
movements as well as different positions of her wrist and thumb. To encourage Jennas use of the
easel, she will be able to utilize different methods and a variety tools when being creative or
practicing her writing. Some ideas to encourage the use of the easel include: large and small
chalk or markers for drawing, Q-Tips, different shaped ice cubes, and even food items such as
baby carrots for painting, crayons, colored pencils, adapted pencils and grips.
Activity 2 To help Jenna increase her speed and legibility of writing, she will participate in a
pen pal program. This will encourage consistent practice in handwriting in a fun and novel way.
Jenna will be able to write and receive letters from another child within the school district that is
also receiving occupational therapy services for handwriting. Jenna will write her response and
send it via United States Postal Service within one week of receiving her pen pal's response. She
will continue with this program through the end of fifth grade.
Treatment
Jenna receives OT two times a week. The first weekly session is conducted either in the
therapy room or classroom, and the second weekly session takes place in the aquatic center at the
school. During the first session Jenna and the OT focus on various activities to improve safety
awareness, self-advocacy and upper extremity strength by playing the following activities: role
playing, board games based on consequences, active listening program, painting on an easel, and
writing letters to a pen pal. The second weekly session focuses on improved land to water

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transitions, postural strength, and functional mobility. The OT and Jenna improve these skills by
exiting the pool via a ramp, playing a water rafting game and basketball in the pool.
Collaboration
Decision making and increasing independence are key to feelings of competence and
establishing Jennas sense of control. Empowering Jenna with self-determination will increase
her self-esteem. To accomplish this, Jenna will be included in all intervention planning and
decisions. Jennas intervention will utilize a family-centered approach. A relationship between
the therapist and Jennas family based on open communication, shared decision making, and
mutual respect will be fostered (Case-Smith & OBrien, 2010). Jennas family, including her
three older siblings, will be vital team members. Their education and involvement is essential in
Jennas success. Inclusion in all home activities will assist Jenna in gaining the confidence she
needs to be successful in her school environment. Jennas classroom and physical education
teachers will be consulted to ensure they are in agreement with providing Jenna the
environmental modifications necessary for her inclusion in class activities. Effective consultation
will be established to support Jennas teachers in promoting her school-related performance and
adapting activities to enable her participation. The teachers and familys feedback and data are
important in monitoring the progress and effectiveness of the intervention. Modification to the
intervention will be established if necessary.
SOAP Note
Subjective: Parent reports that Jenna has difficulties with core strength, endurance, and fine
motor skills.
Objective: Jenna participated in a one hour therapy session at Mildred Academy to improve her
core strength and writing ability. Jenna demonstrated that she could not independently

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manipulate a paint brush in her right hand. To improve her core strength, Jenna worked on
transferring herself sit to stand from her wheelchair with Min A from the therapist. To improve
her fine motor skills and endurance, Jenna imitated a mature functional grasp with Min A from
the therapist while standing at an easel.
Assessment: Because Jenna showed difficulty with sit to stand from her wheelchair and properly
placing her hand around the paintbrush in a functional grasp, it showed that Jenna has deficits in
fine motor skills and strength. Limited strength, endurance, and fine motor ability limits Jenna in
everyday occupations. Jennas increased exposure to manipulating a paintbrush has allowed her
to generalize this skill and explore potentially new types of developmental and transitional
grasps. Ability to follow directions will allow Jenna to participate in more functional and social
activities as she progresses in therapy. Jenna would benefit from continued OT services to
enhance her fine motor skills, core strength, and endurance.
Plan: Jenna will continue to participate in developmentally appropriate activities to improve her
fine motor skills, endurance, and strength 2x weekly for the remainder of the school year with
the therapist, and daily with her parents. By the end of this year, Jenna will be able to safely
transfer out of her wheelchair independently with less than two tactile cues.
Specific Recommendations and Post Discharge Environment
Before discontinuation of services, Jenna should be knowledgeable about safety
precautions within her environment, be able to self-advocate at school, and actively engage in
social situations with peers. Jennas home and classroom environment should be safe for her to
move around easily without the risk of injury. While assisting Jenna in ADLs, caregivers should
adapt activities in order to make them easier for her to participate in. Exercise is crucial
throughout Jennas life as it promotes muscle and bone strength, which can help prevent

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fractures from occurring. By the time of discharge Jenna should be familiar with the use of
durable medical equipment to improve functional mobility when fatigued.
Justification of Treatment
Children with disabilities are less physically active than children without and are less
likely to participate in sports or other activities (Law, King G., King S., Kertoy, Hurley,
Rosenbaum, and Hanna, 2006). As Jennas first long term goal is focused on increasing her
strength to improve her independence while completing toilet transfers, aquatic therapy offers a
fun and motivating environment while promoting vigorous physical activity. Not only will the
water offer resistance while Jenna is working out, but it will also benefit her cardiorespiratory
endurance, coordination, balance, and her awareness of water safety (Fragala-Pinkham, ONeil,
and Haley, 2010).
The use of role play is a great way to use improvisational and unstructured social skills
that will encourage Jenna to become comfortable interacting with her peers (Gutman, RaphaelGreenfield, and Salvant, 2012). This strategy will also address Jennas long term goal of
increasing her social participation so she may join and be a part of an extracurricular group.
Role-playing will allow her the opportunity to practice her current social skills in a set situation
so she may increase her ability and confidence when conversing with others.
Jennas third long term goal is to increase and improve her written production within the
classroom. Research has shown consistent practice with assistive devices on varying surfaces
helps the child and therapist to determine the most effective writing strategy (Hemmingsson,
Lidstrom, & Nygard, 2009). The use of assistive devices will allow her to find a comfortable and
functional grasp, build up her endurance, and increase her speed. The use of a slant board or
easel, different pencil grips, and varied writing utensils such as an adapted pencil or large

OSTEOGENESIS IMPERFECTA: A CASE STUDY


handled paintbrush can aid Jenna in improving her writing skills. By participating in different
activities that promote the use of these low tech assistive devices, Jenna may voice her opinion
about which technique best suits her needs thereby improving her written communication with
contributing to her self-advocacy.

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OSTEOGENESIS IMPERFECTA: A CASE STUDY

22

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