Date of Assessment: 1/23/2020

Name: V. T.

Diagnosis: TBI

Occupational Therapy Initial Evaluation

S: “I feel a little queasy, it happens with any big head movement.”

O: (Evaluation overview): Client was seen January 16 and 23, 2020 for a comprehensive occupational
therapy evaluation. This included an occupational profile interview, and observation of occupational
performance, and completion of the Canadian Occupational Performance Measure (COPM), Weekly
Calendar Planning Activity (WCPA), vestibular testing, and the Dynamic Gait Index.

COPM: Client completed the COPM, a semi-structured interview designed to define client priorities and
self-reported occupational performance and satisfaction. Client identified five areas of concern.

WCPA: Client completed WCPA in 11:57. He followed the directions during the task, correctly noting the
given time and ignoring questions. Client began entering first appointment immediately, not reading all
the way through the task list. He utilized five strategies: used his finger to track reading appointments
and to keep his place on the calendar, checked off entered tasks, paused and reread, self-checked his
work, and entered fixed appointments first. He reported awareness of entering fixed appointments first
and checking tasks off. Client self-corrected one error, and reported awareness of more possible errors
but did not fix these. He made two errors in location and time of appointments in the task. During self-
report client was accurate in estimating his time and errors during the task, and reported feeling
overwhelmed.
Vestibular testing: Client had normal eye movements during VOR reflex, smooth pursuits, saccades, and
convergence. Tightness in his neck and resistance was felt during VOR testing. After testing, client
reported feeling unsteady, uneasy, and as if his body was disconnected.

Dynamic Gait Index: Client showed typical gait and balance within designated area during testing, with
some stiffness noted during slow walking. Limited neck ROM was seen when client walked while moving
his head vertically. Client reported feeling queasy during testing due to head movement. Client scored
within typical range for balance testing.

Occupational Profile: Client is a 39-year-old male who sustained a TBI four years ago. He had a whiplash
injury at the time of the TBI which causes intermittent chronic neck pain. He takes medications as
needed for neck and back pain and has NKA besides some antibiotics. He is insured through Select
Health and began Vocational Rehab about 2 weeks ago to work on driving and exploring different career
options. Client lives with his mother and stepfather in Payson, Utah. His mother is currently undergoing
chemotherapy. He does not report having much of a daily routine, but says he usually wakes up, makes
breakfast for him and his mother, and begins working as he states he is more productive in the morning.
He performs independent contract work editing scientific articles from his home computer. He is not
satisfied with the current company he is working with, and would like to be more productive while he is
working. He reports mental fatigue and needing several rest breaks during work, and is not satisfied with
his ability to plan a schedule. Client does most of the meal prep at home. His family was planning to do
the cleaning in exchange for his cooking, but as he is home more often this has become his
responsibility. He reports difficulty in cleaning on a consistent schedule. After client makes lunch, he
usually naps in the afternoon as he currently gets only 4-5 hours of sleep nightly. Before his injury he
routinely slept for 7-8 hours per night. He is often tired before bed but does not fall asleep easily, and is
not in the habit of wearing his CPAP machine for his sleep apnea, a symptom of his TBI. His current
activity before sleep is scrolling through his phone. He is also sometimes kept awake by vestibular
symptoms of feeling dizzy and disorientated with laying down. Symptoms also cause him to cancel
appointments, increase his anxiety, and limit his participation in necessary daily tasks. About three
nights per week, client performs with other musicians at a steakhouse in town, playing the banjo.

Client is seeking services to improve his ability to plan/schedule, develop a bedtime routine, and
decrease vestibular symptoms affecting his occupational performance. Besides music, client is interested
in and enjoys cooking, hiking, and watching TV. He currently feels successful utilizing the strategy of
writing things down to remember information, and knows to put important events in his phone calendar
with an alarm right away. He is successful in all ADLs and many IADLs. He is proficient at meal prep,
cooking, and playing banjo. Client feels his lack of routine before bed and vestibular symptoms impact
his ability to function at a satisfactory level. His routine access to technology before bed impedes his
sleep, as well as his dislike of wearing his CPAP. His current mode of transportation is driving himself,
but vocational rehab is requiring him to perform a driving evaluation before his license can be official.
Vocational rehab provides him with bus tokens and he is aware that he should use public transit, but has
difficulty planning and executing travel routes and schedules. Client has strong social support through
his family at home, a sister in the next town over, and another sister who visits on and off. He is also
supported by his friends in town, most of whom he knows through music. Client’s priorities are to
improve his planning, develop a bedtime routine to improve sleep, and decrease his vestibular
symptoms of unease and disconnect to increase his ability to perform daily tasks that he wants and
needs to do.

Occupational Performance Assessment: Client was asked to plan a route on his phone from his home to
the therapy building using public transit. Client took two attempts to find correct UTA website, and was
unaware of the therapy building address. He was able to use a separate application to check the building
address, and entered this address and his home address accurately. Client was able to independently
find transit routes but required a direct cue to select a specific route for further details. He was
instructed in how to use Google Maps for public transit routes, requiring direct cues to enter a starting
address and select a route for further details. Client reported he would like to practice using Google
Maps for public transit routes, and that he learns well through repetition.

A: Interpretation:

Client has clear goals and is aware of his strengths and areas for improvement as noted by the COPM.
His performance on the WCPA also demonstrates his self-awareness as he was accurate in estimating his
errors. He was able to recognize some, but not all of his errors. His errors in time and location on the
WCPA illustrate his difficulty in attending to multiple pieces of information at once. His symptoms
following the vestibular and balance assessments, along with his self-report, indicate vestibular
dysfunction due to his TBI. His limited neck ROM could be attributed to his neck pain as well as his fear
of large head movements that might stimulate his symptoms. When planning a bus route, client was
able to access information but required cueing to find necessary details for successful planning and
execution of using public transit.

Client is aware of his current and ideal level of function, has strong social supports at home and in his
community, and has healthy interests in music and hiking. The level of complexity with planning public
transit online, his access to technology, and current lack of a bed time routine are barriers to his
occupational performance. He is also impeded by his vestibular symptoms and the anxiety caused by
these.

P: Client will be treated for 60-minute sessions 1x/week for 6 weeks to address planning and scheduling
of daily and weekly routines and improve vestibular symptoms that interfere with occupational
performance in daily activities. Skilled OT services are required for appropriate grading of activities that
will address client’s planning, routine making, and vestibular performance deficits. Client’s complex
condition requires advanced clinical judgement to adjust the presentation of activities that will properly
challenge him while also teach him to generalize strategies beyond the treatment session.

Goals

LTG: Within 6 weeks, client will independently use cognitive strategies to plan and execute a weekly
schedule.
STG: In 2 weeks, client will independently use public transit to access desired areas in the
community 4x/week.
 STG: In 4 weeks, client will independently prepare for sleep by 11pm utilizing a bedtime routine
and proper sleep hygiene.
LTG: Within 6 weeks, client will independently report missing 1 or less scheduled daily tasks as a result
of improved vestibular symptoms.
STG: In 2 weeks, client will independently perform vestibular home exercises 1x/day in order to
decrease interruptions in occupational performance.
STG: In 4 weeks, client will independently complete dynamic cleaning tasks with 1 or less
reported vestibular symptoms.

Client is a good candidate for progress with OT services. Thank you for the opportunity to assist him in
returning to independence in his occupations.

Research evidence: Successful cognitive interventions to improve memory focus on the use of external
memory aids and compensatory strategies, such as visual imagery, notes, and technology tools, as in
phone or computer calendars. These interventions are more effective than remediation strategies, such
as drills without purpose. Errorless learning is also recommended for training specific knowledge or
procedures. To enhance executive function, metacognitive strategy training, which intends to improve
self-monitoring and self-regulation, has been shown to be more successful. Examples of these strategies
include breaking down complex tasks and using problem-solving techniques. The importance of sleep
hygiene has been frequently noted in the literature. It is encouraged to develop a consistent bedtime
schedule, avoid time spent awake in bed, and limit time in bed to time spent asleep. Areas for
assessment include the amount of light and noise in the sleep environment, and the temperature of the
room. Vestibular exercises have been shown to decrease sensations of dizziness and sensitivity to
movement, and improve balance and quality of life in individuals with a TBI. To connect these exercises
with occupations, activities can be set up to simulate movements that produce vertigo, which, when
performed in a graded and repeated fashion, can decrease vestibular symptoms. The use of preferred
activities maintains interest and motivation. Clients with neck pain should perform vestibular exercises
in a modified routine to move within a pain-free AROM.

Practice models: I plan to use MOHO as my organizing practice model, as we are working on the client’s
habits to foster his performance in his occupations. As MOHO supports a client’s engagement in
occupations through doing, we will be utilizing his desired occupations within treatment to maintain
motivation and practice strategies in real-world situations. We will also be looking at the client as a
whole to apply strategies that will improve multiple areas of his life, as in assigning vestibular exercises
to improve overall well-being. The supporting model I will use is the Dynamic Interactional Model (DIM),
which will aid in increasing the client’s awareness and successful use of the strategies he has already
integrated into his life, and new strategies that can be used. We will help him generalize the strategies
he learns so they can be utilized in multiple contexts. In doing so, we can help him feel more in control
of his symptoms and his occupational performance. The DIM will be used in treatment to assess the
context in which strategies are used and occupations are performed, and to grade treatment activities
as needed by analyzing activity demands.
Signature: Corinne Buffo, OTS

Attached articles:

- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4904751/
- https://www.archives-pmr.org/article/S0003-9993(07)01556-0/fulltext#sec1.6
- https://academic.oup.com/ptj/article/96/6/839/2686396

Intervention Plan:

- Teach cognitive strategies and practice their use when planning schedules,
appointments, or trips using public transit
- Teach vestibular exercises to decrease vestibular symptoms, challenge vestibular system
with necessary IADLs (cleaning, cooking)
- Educate client on sleep hygiene, develop bedtime routine, track progress of sleep
quality and quantity