Student

Name: Tambra Rasmussen Case: Date:

1. Diagnosis, Referral, Setting, Reimbursement, LOS

Diagnosis-A left broken wrist due to a fall that occurred in the client's home. The fall was possibly
due to an increase in Parkinson's symptoms which include right-side tremors. He also has bi-lateral
cataracts.
Past Medical History-History of Parkinson's disease and cataracts. Nothing else of note was
mentioned
Referral-Charlie's physician
Setting- Transitional Rehab
Reimbursement-10 days of OT services paid for by Medicare. In this setting, the client will be
expected to tolerate 3 hours of therapy per day, which will be divided between OT, PT and SLP.

2. Pragmatic Factors to Consider

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-How will Charlie's cast affect how he complete's ADL's? Will he need to learn to do them a
different way until the cast is removed? According to the COPM, he is sponging off in the sink for
bathing which is likely not getting him clean enough. What can be done in order for him to take a
shower independently or with modified independence once he is discharged?
-Is Charlie experiencing pain that may impact therapy?
-Is pain a factor in self-care?
-How do Charlie's cataracts affect his ability to complete ADL's and IADL's?
-Who will help Charlie with transfers, covering his cast, and lower body dresssing/washing when he
gets home if he does not become modified independent in these areas at rehab?
-Has a home evaluation been completed? Is there anything that can be done to/in his home to
prevent future falls?
-Aside from the housekeeper and daughter, who does he have to help him? Are his friends available
to help?
-What are the levels of assist for? Is Mod A for lower body dresing while standing for balance or
something else? Would he not need assistance for lower body dressing if he completed it seated, or
in bed?
-Are his hands not working right due to tremors or something else like arthritis or both?
-Based on his daughter's concerns, the time he forgot to pay bills, and the incomplete COPM, does
he have some cognitive problems?
-Does he care for Boyd independently?
-Is he able to complete his projects at home safely?
-What are his daughter's motives? Is she legitimately concerned about her dad? Does she truly think
he should live in a nursing home, and wants to sell his assets to pay for it? Or, does she want to get
him out of the way because he's an inconvenience? Does she want to sell his things and pocket the
money? Can she be counted on to help in any way? Does she see him frequently enough to really
understand what he is capable/incapable of doing?
-Is Charlie taking medication to manage his PD, specifically a dopamine agonist? If so, therapy may
need to be scheduled when Charlie is at his best after taking medication. Additionally, he may need
to be taught to do important tasks when he is on his medication and most functional.
-The ten day length of stay at transitional rehab does not give Charlie a lot of time to become
safe/independent at home.
-Charlie's age may be a factor in his recovery
-How much of his left arm is casted? Does the cast extend past his wrist?
-Does Charlie have vison problems aside from cataracts that are often associated with either age or
PD?

3. Context: Occupational Profile & Current Occupations

Cultural: SKIP

Physical:

Social:

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Personal:

Temporal:

Virtual:

Prior Occupations:

Current Occupations:

4: Top Three Client/Family Goals and Priorities

1. SKIP

2.

3.

5. Diagnosis and 6. Scientific Reasoning & Evidence

Expected Course List the barriers to performance typical of this diagnosis:
Parkinson's Disease -Akinesia-difficulty in initiating movement makes functional tasks difficult. For
(PD) is a example, when driving, if initiation of a movement takes too long, an accident may
degenerative occur. Other activities that will be affected by akinesia include tasks like dressing
neurologic disorder and eating. Walking is also commonly affected by akinesia. People with PD often
with three classic take a long time to initiate walking. Pedretti page 941
symptoms,
bradykinesia, -Bradykinesia-slowness in maintaining movement. Slowness in movement makes
tremor, and rigidity. completing functional tasks difficult and may be the most disabling symptom of
It typically affects PD. Not only does it affect movements like walking, it also impacts speech.
individuals who are Pedretti page 941 and https://www.ncbi.nlm.nih.gov/pubmed/16340393
older than 55 and
more males than -Rigidity-muscle stiffness impedes smooth movement. This occurs in each plane
females. PD affects of motion in a specific joint. Rigidity may be painful and contribute to decreased
the substantia nigra AROM and PROM. Pedretti page 941 and
nuclei which https://parkinsonsdisease.net/symptoms/rigidity/
deteriorate as the

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disease progresses. -Resting tremor which is a disturbance in involuntary movement. Tremor often
Due to the diminishes with activity, but in some people, it persists during activities. If tremor
degeneration of the persists during activity, it will impact the quality and precision of movement. For
substantia nigra, less example, self-feeding would be extremely difficult with a tremor in the hand. It
dopamine is would affect the ability to scoop food onto a spoon or fork, and bring it to the
produced which mouth, and get the food into the mouth. Pedretti 941 and
causes a reduction https://translationalneurodegeneration.biomedcentral.com/articles/10.1186/s40035-
in spontaneous 017-0086-4
movement.
Additionally, there -Gait-throughout the course of the disease, gait changes. Initially it may be
is formation of normal, but as it progresses, changes occur in stride length, speed, trunk rotation,
Lewy bodies in the and arm swing. PD is in part characterized by a shuffling gait due to those
brain which lead to changes in movement. Additonally, "freezing" or ceasing movement may occur
problems with when the person attempts to change directions, or approaches a narrow hallway or
movement, stairs. Freezing may also occur with functional tasks, or when changing trajectory
behavior, mood, and while walking. Pedretti 941
cognition. PD
progresses slowly -Postural changes may include stooped posture with the head positioned forward.
and people may live Additionally, people with PD tend to stand with hips and knees flexed. This
up to 30 years with posture may cause pain in the back/neck/spine. Pedretti 941 and
this disorder. It is https://nwpf.org/stay-informed/blog/2014/03/parkinsons-posture/
not considered a
fatal disease, but -Righting and equilibrium reactions are reduced with may cause frequent falls.
many people die due Pedretti 941
to complications of
the disease. PD -Masked face- people with PD have decreased facial expressions. Even when
consists of a feeling strong emotions, a person's expression may appear impassive. This may
progressive loss of affect interactions with other people (including medical professionals) who often
motor function. rely on facial expressions to determine how a person is feeling. People may also
Dysfunction affects isolate themselves because they are embarrased by their decreased facial
both voluntary and expressions as well as other disorders in movment. Pedretti 941
involuntary
movements. -Emotional disturbances-depression and anxiety may be caused by Parkinson's
Akinesia, related changes in the brain. About half of people with PD will be diagnosed or
bradykinesia and exhibit symptoms of depression. Additionally, apathy is frequently seen in patients
rigidity all impede with PD as well as impulse control disorders. All of these affect the general health
movement. and well-being of the person experiencing them. They made lead to problems
Additionally, such as social isolation, suicidal ideation, lack of desire to participate in
emotional meaningful occupations, and a change in the way PD patients interact with the
disturbances people around them. Pedretti 941,
including depression https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181807/, and
and psychosis are https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3177157/
prevelent. Gait
deterorates as the -Hallucinations and delusions-psychosis is a common complication of PD. These
disease progresses. disturbance impact cognitive abilites and may limit functional skills.Visual
Initally gait may be hallucinations are relatively prominent. Overal, psychosis has been shown to
close to normal, but create a disturbance in daily life and lead to poor outcomes. Pedretti 941 and
as the disease https://www.ncbi.nlm.nih.gov/pubmed/18665659
progresses, stride

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length and speed -Visuospatial perception is freqently impacted due to structural abnormalities in
change to create the the fronto-parietal areas and subcortical regions. These abnormalities cause a
"shuffling" gait reduction in efficiency and compensatory mechanisms regarding visuospatial
characteristic of this relationships. This can affect things such as walking, driving, and completing
disorder. Arm ADL's/IADL's. Pedretti 941
swing and trunk
rotation also -Cognitive activities such shifting attention, processing simultaneous information,
decrease with time. and completing sequential tasks may be impacted. Tasks that involve doing more
Postural changes than one thing at once become very difficult. Driving is a task that could be
include the severly impacted because it involves attending to a variety of stimuli at once.
development of a Additionally, tasks that involve a specific sequence such as self care activities like
flexed, stooped dressing and brushing teeth are impacted. About a third of people over the age of
posture with the 70 with PD develop dementia. Pedretti 941
head positioned
forward. Balance is -Dysphagia-frequently occurs in the later stages of PD and puts the patient at risk
also compromised. for choking and aspiration pneumonia. Pedretti 942
Approximately half
of patients with PD -Autonomic dysfunction-There may be bowel and bladder problems, which may
expereince include reduced intestinal motility and increased frequency and urgency of
depression due a urination. Additionally, orthostatic hypotension is common as well as bouts of
decrease in the sweating and abnormal tolerance of heat and cold. Pedretti 942
production of
seratonin. In early -Dysarthria- speech may become difficult to understand, quiet, and monotone.
stages, mental status People with PD may appear to be whispering due to changes in speech volume.
is quite normal, but Pedretti 942
visual spatial
perception is -Micrographia-in early stages of PD, handwriting may be altered to produce small,
compromised. cramped letters. Muscle cramping may occur with long periods of writing. These
Other common changes in handwriting may affect the ability to do some tasks in the workplace
deficits include well. Pedretti 942
autonomic
dysfunction,
dysphagia and
dysarthria, and
bowel and bladder
dysfunction.
Frequently the first
symptom to be
diagnosed is a
unilateral resting
tremor in the hand.
Clients in stage one
of PD exhibit
unilateral
involvement but no
impairment in
functional abilities.
Other symptoms of
stage one include

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micrographia,
fatigue, and poor
endurance for
previous
occupations. Stage
two typically starts
about two years
after initial
diagnosis and is
characterized by
bilateral motor
disturbances, mild
rigidity, difficulties
with simultaneous
tasks, and deficits in
executive function.
At this point, the
client is still able to
do ADL's but some
IADL's may need
modifications
because of motor
difficulties/cognitive
dysfuction. Posture
becomes stooped
with flexion at the
knees and hips. In
stage two, people
are still able to
ambulate
independently and
relatively safely.
Stage 3 PD
manifests with
delayed righting and
equilibrium
reactions. Balance
is impaired and
standing tasks are
difficult. Walking
may become less
safe due to balance
problems. In stage
3, skilled sequential
tasks become
difficult. People in
stage four of PD
have significant
difficulties

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completing ADL's
and though still
ambulatory, they
have severely
compromised
balance. Stage four
shows a decrease in
fine motor function
and oral motor
deficits. Stage five
is the final stage of
PD and the client is
likely dependent on
others for all self
care.
-Pain/stiffness- pain may prevent the use of the hand distal to the affected wrist
Wrist Fractures- which may lead to problems such as tendon adherence and lost ROM. Pedretti
when a fracture of 1049
the wrist occurs, the
doctor will attempt -Edema- Swelling is often present with a fracture and needs to be monitored. This
to achieve good problem may continue after the cast has been removed. Pedretti 1049
anatomical position
and immobolize the -Trauma to nerves and tendons- frequently, when a fracture occurs, there is also
wrist in extention trauma to adjacent structures. Pedretti 1049
with MP joint
flexion, and with -Adherence of the tendons- if mobilization does not occur early enough the
extension of distal tendons may adhere which may cause pain and loss of mobility and range of
joints if the specific motion. Pedretti 1049
injury allows that
position. A cast is -Abnormal joint changes may occur due to immobilization. Pedretti 1049
typically worn for 4-
10 weeks. In -Limitations-depending on where the fracture occurs, there may be limitations in
Charlie's case, he is flexion, extension, supination, and/or pronation, additionally, there will likely be
wearing it for six weight bearing restrictions due to the fracture. Pedretti 1076
weeks. Sometimes,
dynamic splints are
necessary to achieve
full ROM or prevent
abnormal joint
changes at 6-8
weeks after a
fracture occurs.

Cataracts are the

clouding of the lens -lighting- good lighting will improve the ablity for people with cataracts to see
of the eye. They well enough to do functional tasks. Pedretti 1230
may be due to
aging, other eye -Visual contrast-cataracts affect the ability to see contrast. Pedretti 1230
conditions, long

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term use of steroids, -Falls can be decreased by completing a home evaluation that looks at the layout
or genetics. of the home. Potential hazards can be mitigated. Pedretti 1230-1231
Typically, they form
slowly over time,
and eyesight is not
impacted initially.
Signs and symptoms
include cloudy
vision, increasing
difficulty with night
vision, sensitivity to
light and glare, a
need for brighter
lights for activities
like reading, seeing
halos, changes in
eyeglass
prescription, double
vision in a single
eye. Cataracts can
be surgically
removed, but many
people do well with
glasses and other
vision aids.

7. Practice Models Guiding Assessment and Rationale

Treatment
1. PEO PEO will be used with Charlie because
addressing his environment will be helpful in
making occupations easier for him as he
recovers and will also be used to improve the
safety of his home environment. Adapting the
way occupations are completed will allow
Charlie to continue to participate in the
occupations he enjoys such as tinkering with
small appliances and restoring his car. PEO also
addresses the client's satisfaction with their
transaction between themselves, the
environment, and their occupations. This model
will be used to better determine where Charlie is
dissatisified and help improve performance by
either changing him, the environment, or the
way occupations are completed. PEO provides a
holistic approach were changes can be made in
multiple dimensions.

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2. Rehab The Rehab model will be used to provide
Charlie with compensatory strategies as well as
adaptive equipment that will help him become
engaged or re-engaged in meaningful
occupations that have been distrupted by PD as
well as his recently broken arm.
3. Motor Control/Learning This model works to improve movement and
motor control deficits while also addressing the
role of the environment in accomplishing
occupational performance. The following
change postulates from this model will be
utilized to help Charlie improve movement and
movement patterns.
1.Motor control is learned through a process in
which the person seeks optimal solutions for
accomplishing an occupation. Hence, learning is
dependent on the characteristics of the
performer, the context, and the task being
performed.
2. Heterarchical control explains that movement
is the result of several factors interacting
together. Movement is understood as a result
from the interaction of: personal factors (CNS
and musculoskeletal systems), the nature of the
task being performed, and conditions in the
environment.
3. Unlike the hierarchical theory, the
heterarchical theory believes that the CNS does
not act as the central executor but instead the
control of movements depends on the interaction
of person, task, and environment through the
communication of higher and lower centers
within the musculoskeletal system. Therefore,
explaining both normal and abnormal movement
patterns.
4. The contemporary motor control approach
stresses learning the entire task not a single
factor. Instead each factor contributes to the
dynamic whole in which motor behavior
emerges.

Diane W. Tse & Sandi J. Spaulding (2009)

Review of Motor Control and Motor Learning,
Physical & Occupational Therapy In Geriatrics,
15:3, 19-38, DOI: 10.1080/J148v15n03_02

8. Specific Areas of Occupation

What do you know? What do you need to know?

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SKIP

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 9. Performance Skills
What do you know? What do you need to know?
SKIP

10. Performance Patterns-Habits, Routines, Rituals, Roles

What do you know? What do you need to know?
SKIP

11. Activity Demands for the Client Goals and Priorities

What do you know? What do you need to know?
SKIP

12. Client Factors- Values, Beliefs, Spirituality

What do you know? What do you need to know?
SKIP

13. Client Factors- Body Functions & Structures

What do you know? What do you need to know?
SKIP

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 14. Evaluation: What Assessment tools and other means of assessment will you use?
Top Down Assessment: Prioritize one Occupation to observe the client perform

Observed Occupation Rationale/How will you use this information

I would like to see Charlie choose his clothing
from his closet and get dressed for the day.
Method/Tool
1. Home Evaluation
By watching Charlie ambulate to his closet, I
will get an idea of how well he moves, and how
much PD is affecting his ability to initate
movement. I will see if tremors/rigidity are
impacting his ability to get around and
manipulate items such as doors, drawers,
hangers, and clothing. I will also be able to see
if eyesight appears to be an issue for him as far
as finding items and getting dressed go. By
watching him get dressed, I will be able to see if
he has implemented strategies on his own to do
this safely and as efficiently with his broken
wrist and if he is using any adaptive equipment.
Depending on what symptoms he displays such
as bradykinisea or akinisa, I will get an idea of
how far into the disease process he is which will
give me a better idea of what he can and cannot
do on his own. Getting dressed is typically done
in a sequence. If this is difficult for him, I will
be able to see that his cognition may be
impacted. I will get an idea of what his balance
is like as well as if he has the functional range of
motion necessary to get dressed which will give
me an idea of what his AROM is for other
functional tasks. I will also see how he is
managing these tasks with a broken wrist. Is he
able to complete dressing with the cast on his
left arm?
Rationale/What is being Assessed
A home evaluation could be useful to determine
if anything in Charlie's home environment can
be changed or modified to prevent future falls
and if anything can be done to enhance his
ability to continue to engage in meaningful
occupations such as restoring his car.

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2. Parkinson's Disease Quality of Life
Questionnaire
3. Pain Scale-before and after treatment sessions
4. Upper body ROM and MMT screen including
AROM and PROM
5. Parkinson Neuropsychometric Dementia
Assessment (PANDA)
Page 13 of 20
Assuming that Charlie is able to self-reflect well
enough to complete this questionnaire, it will be
useful to address the psycho-social aspects of his
life. It appears that there may be some family
stress based on the way his daughter talks about
him, and the fact that his wife is not longer with
him. This combined with the recently broken
arm, and the fact that depression which is
common in people with PD, it may be good to
look at how he perceives his quality of life. This
will help us see if there are specific areas of the
disease process that are affecting him
psychologically. This questionnaire also
addresses some physical symptoms that he may
be expereincing that he may notice, but that may
not be apparent in a quick medical exam.
If Charlie is experiencing pain due to his broken
wrist, it may affect his ability to participate in
therapy, and if pain persists upon discharge, it
may affect his ability to take care of himself.
This will help determine if Charlie has decreased
strength or range of motion that would impact
his ability to complete important occupations. It
will give me a better idea of what's possible for
him, and if this is something that needs to be
addressed in therapy. His left arm will be
assessed gently so that his injury is not
aggravated, especially if that arm has any weight
bearing precautions.
This assessment looks specifically at cognitive
deficits that are frequently observed in people
with PD which makes it more applicable to
Charlie than other cognitive assessments
because it is written for people with PD where
some of the other cognitive assessments are
written more for dementia. It looks at delayed
recall, alternating verbal fluency, visual spatial
dysfunction, working memory/attention, and
mood.
Revised 1/9/17
6. Eye Screening It would be useful to see how much Charlie's
cataracts are affecting his ability to complete
ADL's/IADL's. We know that he is having
difficulty restoring his car due to vision and that
his vision may be part of the reason he has a
hard time paying bills/writing checks. Is he
experiencing any vision deficits that are
common with PD such as visual spatial deficits.
Are his vision deficits something that can be
remedied by the use of adaptive equipment and
better lighting? If not, does he need to be
referred to an eye doctor?

15. CPT Evaluation Code: Justification

97166 Moderate complexity- Charlie's evaluation will include an expanded
review of his medical history along with assessment of his current injury
and how it is affecting his ability to complete/participate in occupations.
Comorbidities are present and he needed some task
modifications/assistance with assessment in order to complete the
evaluation.

16. Projected Outcomes: Type of Outcome

SKIP

17. Resources and Team Members

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-Occupational therapist
-Physical therapist
-Speech therapist
-His doctor who showed concern and care for Charlie by suggesting he spend some time in
transitional rehab.
-Nurses
-CNA's
-Other staff at the transitional rehab center (dining room/receptionist/cleaning)
-His daughter
-Other family and friends
-Possibly a psychologist if depression is found to be a problem for Charlie
-Social worker if Charlie's family is not looking out for his best interests
-Spiritual leaders if important to Charlie

18. Intervention Plan

Barriers Supports
-His daughter's attitude that Charlie's assets should be sold -His daughter if her motives and
and that he should be put in a nursing home attitude are from legitimate concern
-Charlie lives alone which may be problematic if he is unable about her father
to complete his ADL's and IADL's safely and independently -House cleaner who helps Charlie
-Charlie's eyesight appears to be a barrier in his ability to maintain his independence by taking
complete the occupations he needs/wants to do care of chores that may be difficult
-His broken arm will make already difficult activities even for him
more difficult -Charlie appears to have a circle of
-He currently needs assistance for lower body close friends who may be able to
dressing/bathing/some transfers/and to cover his cast. Who provide physical as well as
will provide assistance at home? emotional support
-Medicare is only paying for 10 days in transitional rehab. -Being better to take care of Boyd
Will it be enough time? and spend time with him may
-Charlie may have cognitive deficits that he is unaware are motivate Charlie
affecting his performance. For example, he appeared to have -Charlie appears to have a middle
a hard time with self-reflection when completing the COPM, class lifestyle that may allow him
and if there is truth to his daughter's statements about how he the resources to purchase AE
spends his time, he may be unaware of what his reality is
versus what he thinks it is.
-His home environment may not be set up in a way that will
help Charlie be as safe and efficient as possible when
completing occupations

Goals Practice Model for each goal

1. LTG:
PEO/Rehab/Motor Control
Within 10 days, the client will shower with Mod I.

1a.STG:

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Within five days, with no more than three verbal cues, the PEO/Rehab/Motor Control
client will transfer to a shower bench.

1b.STG:
Within one week, the client will appropriately cover his cast PEO/Rehab/Motor Control
prior to showering with Min A.

2. LTG:
Within ten days, the client will self-feed with Mod I with no PEO/Rehab/Motor Control
more than three spills per meal.

2a. STG:
Within five days, the client will retain food on his fork two PEO/Rehab/Motor Control
out of three attempts with Mod I.

2b. STG:
Within one week, with Min A, the client will initiate PEO/Rehab/Motor Control
movement within ten seconds per bite to self-feed using
compenstory strategies.
3. LTG:
Within ten days, the client will pay all bills due within the PEO/Rehab/Motor Control
duration of his stay with no errors with Mod I.

3a.STG:
Within one week, with Min A, the client will fill out a check PEO/Rehab/Motor Control
using Mod I.

3b. STG:
Within five days, the client will track bills due for the month PEO/Rehab/Motor Control
using compensatory memory strategies with no more than
three verbal cues.

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19. Treatment Sessions: Plan for first two 45 minute treatment sessions:
1. What will you do? Identify Approaches Based on which
goal(s)?

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Improving Charlie's manual dexterity will improve Establish/restore and #1, #2, and #3
his ability to successfully complete ADL's and Prevent
IADL's. In this session, I will spend time teaching
Charlie an in-room program that has been shown
through an RCT to improve dexterity in patients
with PD. This is a program that he can continue to
implement upon discharge and that has been shown
to translate to improvement in ADL's as well as
improved performance on manual dexterity tests.
This program includes some occupation based
activities that will apply directly to Charlie. There
is a section where the client uses a pencil to cross
out specific shapes on a grid. This will give him an
opportunity to practice the skills necessary to
improve legibility/precision for check writing.
Additonally, there are exercises that use washers as
well as nuts and bolts. These are materials that
Charlie will likely need to use when tinkering in his
garage and working on his car. The booklet of the
activities recommended for Charlie will be included
at the end of this Case Map. The HOMEDEXT
program targets control of force,
selective/independent finger movements, finger
coordination, and motor sequence performance.
When teaching these activities to Charlie, I will
make sure that he understands how to perform each
exercise correctly, and what each exercise is
targeting. Charlie will be encouraged to perform
these activities in his room for 30 minutes every
day. I will encourage Charlie to focus on making
each movement as deliberate and as smooth as
possible and in teaching these movments, offer
assistance to initiate/complete movement with a
functional movement pattern. I will also teach him
strategies such as supporting his elbows on the table
to give him more distal control of his hands.
Though in a cast, he will be encouraged to complete
each activity bi-laterally. Some may be difficult
with his impaired wrist movment due to the cast, but
these activities will keep his left hand moving so
that he will not lose finger function/ROM/dexterity.
It is important to prevent a decline in function in the
left hand due to casting because it will be difficult
for Charlie to regain any lost function. While
teaching this program to Charlie, I will also be
getting a better idea of what activities are hard for
him, and how his vision may be impeding his ability
to perform functional tasks. If vision appears to be
a problem, I will take it as an opportunity to educate

Page 18 of 20 Revised 1/9/17

Charlie on ways to set up his environment with
better lighting and AE such as maginifying tools.
Charlie will also be introduced to AE such as
weighted pens that will hopefully help make writing
tasks easier. Charlie will also be educated on how
good posture may allow him to write better as well
as minimizing the demands of tasks by focusing on
one activity at a time.

RCT about dexterity training. http://www.prd-

journal.com/article/S1353-8020(17)30187-6/fulltext

Here's a link to the booklet of HOMEDEXT

dexterity exercises. https://ars-els-cdn-
com.ezproxy.lib.utah.edu/content/image/1-s2.0-
S1353802017301876-mmc1.pdf

2. What will you do? Identify Approaches Based on which

goal(s)?
In this session, Charlie will work on self-feeding. Establish/Restore #2
The session will start by introducing Charlie to Prevent
adaptive equipment that he is unfamiliar with that
may help him self-feed more successfully.
Together, we will explore whether weighted
utensils with large handles, universal cuffs, or self-
stabilizing silverware will be most affective for him
as well as what is cost effective. We will also look
at the use of scoop plates (which help with low
vision as well as manual dexterity deficits) and
different solutions for drinking such as nosey cups,
or cups with lids and straws. Once Charlie has
identified what types of AE he is open to using,
Charlie will eat a meal with the equipment he has
chosen. He will be given assistance to initiate
movement if hypokinesia is observed. He will
practice scooping and stabbing food and bringing it
to his mouth. If needed, assistance will be provided
to encourage a functional movement pattern. If
chaining all of the steps required for self-feeding is
difficult for Charlie, the activity will be broken
down into smaller, more manageable steps that
Charlie will be cued for individually until he can
isolate, and manage these steps on his own.
Additionally, he will be encouraged to use strategies
such as supporting his elbow on the table to to give
himself more stability. Charlie will be educated on
possibly timing his bigger meals for when his

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medication is on and his tremors are best controlled.
Charlie typically experiences right sided tremors, so
together, we may explore using his left hand to self-
feed if it appears steadier. Self-feeding with the left
hand may be more functional for him, and may also
serve as a way to prevent decline of functional
movement in the left hand while the left wrist is
casted. If low vision is found to be a problem for
Charlie regarding self-feeding, he will be educated
on ways to improve lighting in his dining areas as
well as the potential for using dishes that are a color
that contrasts with his dining room table so that he
is able to better see where his plate is. Charlie will
also be cued to be aware of his drooling so that he
can wipe it with a napkin before it becomes
noticeable to other people he may be dining with.

Page 20 of 20 Revised 1/9/17