John Sartoris is a 23-year old (right handed) man with no previous medical history of neurologic disease or other major health impairment. He has recently been released from an acute care setting, where he remained for 6 weeks subsequent to a motor vehicle accident which
resulted in a broken right femur, and extensive soft tissue injury to his right wrist. In addition, he suffered brain trauma from the impact of the accident. The left side of his head hit the driver’s side door post, before he was thrown across and out of the car. He remained in a coma for three days following the accident, but emerged from the coma responsive and continues to improve.

Prior to the accident, John was living independently and working as a computer software trainer and trouble shooter for the local university. He enjoyed spending his free time pursuing his hobby, video gaming. His family lives in the area and is anxious to provide anything John needs.
He has expressed his desire to resume life as he knew it.

ID of likely language limitations: The patient has experienced a TBI. It is possible that the injury is of the coup-contra coup type. His content problems may include: word-finding; difficulty with abstract meanings, idioms, or proverbs; confabulation; and, use of nonspecific references. Impaired auditory comprehension, paraphasias (if he also experiences aphasia), dysarthria and/or apraxia, and voice problems may be issues that he would experience in relation to form. However, the bulk of the difficulties he may experience will be with the use of language to communicate. Difficulties with prosody could be flat affect, slowed initiation of speech and overall rate, and difficulty interpreting emotional prosody. Emotionally and nonverbally, he may experience reduced ability to comprehend or express emotional information, inappropriate nonverbals, or laughter. His speech acts may include an inability to be concise, poor topic maintenance, stereotyped responses, decreased comprehension, limited use of clarification strategies, and an inability to judge context.

Caren Hamrick

ID of likely speech limitations: Review of the patient's accident suggests that the patient has suffered from TBI and possible coup-contra coup type injury. This type of head injury could produce widespread damage to the brain resulting in bilateral damage to the pyramidal and extrapyramidal systems as a result of the brain being violently shifted within the cranium. In such a case, the patient may exhibit spastic dysarthria, or a mixed dysarthria such as flaccid-spastic or spastic-ataxic. Speech characteristics might include imprecise consonants, slow movement of the speech structures, monopitch, reduced stress, harsh voice quality, monoloudness, low pitch, slow rate hypernasality, strained-strangled voice quality, short phrases, distorted vowels, pitch breaks, breathy voice (continuous), and/or excess and equal stress. Some other characteristics may include uncontrollable crying or laughing as a result of damage to upper motor neurons of the brainstem (area of the brain responsible for inhibiting emotions) and drooling.

Kristine Foxworth and Natasha Smith

ID of likely swallowing limitations: Based on the historical information provided, identify the swallowing difficulties the patient is most likely to exhibit.

ID of likely limitations in basic ADL's: Mr. Sartoris will have difficulty performing most all of his basic ADLS. His difficulty with dressing both upper and lower extremities, grooming, bathing, and feeding would be secondary to his injured wrist. Any activity that requires him to use dynamic standing balance would be affected secondary to his broken femur i.e. toileting and dressing. Also, safety would be a concern when performing ADLs because of the patients impulsivity, which is characteristic of a TBI patient.

Holly Creeger

ID of likely limitations in complex ADL's: The patient has experienced a TBI. Due to the historical information given in the case provided the patient's family lives in the same area. This will help the patient out a lot due to some of the limitations that he will experience in his complex ADL's. For instance he will have trouble with driving due to the insight and executive function deficits he may experience. He may also have trouble with meal preparation due to executive functioning deficits. Balancing a checkbook, money management, shopping, household maintenance, and caring for himself. The case did not indicate if the patient lives alone but if he does he may need adaptations and compensations for I-ADLS.

Molly Houk

ID of likely limitations in cognition: John has suffered from traumatic brain injury. ASHA labels traumatic brain injuries as cognitive-communicative disorders. There are four key aspects to consider when determining possible cognitive deficits: attention and information processing, memory, reasoning and problem solving skills, and executive function and metacognition.

First, John may exhibit attention difficulties. Solhberg and Mateer (1989) identified a hierarchical clinical model of attention, where each level is viewed as more complex then the previous one. The model begins with focused attention (the ability to respond to specific visual, auditory, or tactile stimuli), then moves to sustained attention (the ability to maintain attention consistently over a certain duration), next is selective attention (the ability to attend to specific stimuli while simultaneously minimizing or excluding others),alternating attention (the ability to shift attention from one stimulus to another), and finally divided attention (the ability to attend to more than one stimulus simultaneously).

Secondly,it is likely that John’s memory will be impaired. The different types of memory are: sensory, short term, working, and long term. TBI patients are also susceptible to pretraumatic and posttraumatic amnesia. Pretraumatic amnesia is the loss of memory for events occurring before the trauma and posttraumatic amnesia refers to the loss of memory for events occurring after the trauma.

Thirdly, John may exhibit deficits in executive function, which includes goal setting,awareness of self, initiation of goal-directed behavior, sequencing, planning,organizing, and problem solving.

The fact that John is responsive and continues to improve is helpful in considering his prognosis. The clinician can also utilize his hobby, video gaming and his worl with computers when targeting some of the cognitive areas such as problem solving and executive function.

Kristin Cerati

Assessment of swallowing: Identify the swallowing assessment tools that would be most effective in assessing the impairments. Describe specific findings the given tool(s) would provide.

Assessment of language: Language problems acquired with TBI are primarily related to the cognitive and social demands of communication. When assessing in general, it is first important to collect information through a case history. By doing this, you are able to talk with the patient and the family about the situation and also take into consideration any ethnocultural considerations prior to assessment. When assessing
language in a TBI patient, I would obtain an informal language sample through conversations with the patient. This would help in identifying
the patient?s current language functions and whether the patient is experiencing problems with content, such as in word-finding difficulties; with form, such as in impaired auditory comprehension and paraphasias; and with use, such as in poor topic maintenance or inability to judge context. I would take note of any of these occurrences during the language sample and evaluate further if needed. If aphasic-like symptoms are noted during the language sample, then I would administer a standardized test, such as the Examining for Aphasia by J. Eisenson, which would assess receptive and expressive language skills and the Amsterdam-Nijemegen Everyday Language Test by L. Blomert et al. This test would assess pragmatic language skills, since pragmatics tends to be the most affected skill in a patient with TBI. It is important to remember that TBI patients initially have confused language and aphasic-like symptoms in the initial stages. But, the aphasic-like symptoms tend to clear up. However, it may still be necessary to administer some aphasia batteries. Another test to consider while assessing language, would be the Communicative Abilities in Daily Living by A. L. Holland. This test assesses functional communication skills. When administering such tests, it is important to give frequent breaks since a TBI patient is likely to get tired more often during the assessment. Typically, when assessing language in a patient with TBI, you would discover that the patient is able to talk a lot, but communicate very little.

Hegde, M.N. (1996). Pocketguide to assessment in speech-language pathology. San Diego: Singular Publishing Group, Inc.

Kristen Jacobs

Assessment of speech:

Based on the likelihood of TBI, in my opinion a battery of tests would be useful in assessing is overall speech function. To assess overall function in relation to language, and therefore speech, I would first give subtests from the Boston Diagnostic Aphasia Exam by Goodglass and Kaplan or the Brief Test of Head Injury by Nancy Helm-Estabrooks, making sure to take note of speech characteristics throughout the tests. These tests would be practical in assessing the likely etiology of damage to the perisylvian area of the left hemisphere. After language has been assessed, I would then move to assess speech.

Here it would be useful to compare the sequential motion rate to the alternating motion rate. A conversational speech sample would be valuable. An analysis would provide information about phonemic errors. This comparison to automatic speech would also provide added information concerning AOS. Increasing word length imitation would also provide valuable information to the clinician. Caution should be taken to provide visual models if aphasia is present. A thorough oral mechanism exam should also be included to assess articulatory function, and therefore impairment to speech.

Jill Hammer

Assessment of basic ADL's: Mr. Sartoris has suffered from multiple complications as a result of his MVA. In order to have an accurate assessment he should be observed in each setting identified earlier.(dressing, grooming, feeding, toileting...) Since he sustained a TBI the setting in which he is being observed in should remain concrete and distraction free. During the observation the therapist should note his routines, so when he is ready to learn remedial or compensatory strategies the therapist will not try to teach a completely new strategy. ie- dressing, pull-over or arm through.

Shelley

Assessment of complex ADL's: There are several assessments that are appropriate to use with Mr. Sartoris. First I would determine his Rancho Los Amigos Scale score to determine how cognizant he is of his surroundings and able to receive information or instruction. Formal evaluations that might be conducted include the Allen Cognitive Level Test, the Rivermead Behavioural Memory Test, and the Cognitive Assessment of Minnesota. The Allen Cognitive Level test would be useful to help predict specific needs in areas such as cues, attention, activity, speed, visual-spatial, and verbal propositional. The results of this test would be useful to determine what types of IADLs he may be likely to accomplish and which would create the most difficulty.20 The Rivermead Behavioural Memory Test is an evaluation of everyday memory functioning. The results would provide information about how well Mr. Sartoris can remember first and second name, belonging, appointment, pictures, story (immediate), story (delayed), faces, route (immediate), route (delayed), message, orientation, and date. The Cognitive Assessment of Minnesota contains 17 subtests. They include, attention, memory, orientation, neglect, following directions, money and math skills, planning, abstract reasoning, and problem solving. This test would be very beneficial to determine Mr. Sartoris' IADL abilities since it specifically tests
executive functioning and high level reasoning skills. In addition to standardized testing, it would be important to observe John completing
complex ADLs first hand to assess what difficulties he has. In order to discover which might be the most important to see, Mr. Sartoris and the
therapist need to collaborate to determine which are the most functional in his life. By watching John complete IADLs directly it will give the OT direct information about what he is having trouble with for specific activities. It would also be important to test his safety skills in various activities such as cooking since patient's with TBI have a tendency to be impulsive. A driving evaluation would also be appropriate to determine whether or not he would be safe to begin driving following instruction. Assessments such as active and passive ROM, manual muscle testing, gross and fine motor testing may be needed to determine what physical deficits he has in his right hand and arm. Since use of fine motor skills is important for typing this information would be useful to find out if he will need adaptive equipment for his computer or other complex ADLs to regain maximal function.

Emily Cobble

Assessment of cognition: Assessment of cognition In looking at cognition you want to look at memory, attention, reasoning/problem solving, and executive functioning of the client. This is important to observe to see where the client is and how alert they are in order to provide therapy for the client. This also effects what you would do in therapy for the client. When entering the client's room ask them "Who are you?, "I like your hotel room they have it set up nice for you" (so it is in a conversational manner instead of question by question), Do you know what today is?. You could see how there memory is "what did you have for breakfast this morning" or "what did you do for a living". Have a conversation with Mr. Sartoris to see how cognitive and aware he is. To use a formal test I would use the RIPA (Ross Information Processing Assessment) I would also use this because Mr. Sartoris has had a brain injury and it will assess his memory, spatial orientation, environmental orientation, recall of
information, problem solving/reasoning, organization, and auditory processing. To assess Mr. Sartoris' cognition further I would use the Rivermead Behavioral Memory Test since he suffered from brain trauma on the left his head. It is likely that deficits will be present in cognition especially concerning his orientation, recall of information, short-term memory, and reasoning. Since Mr. Sartoris is making improvements it is likely that he will have a good prognosis in good time. He is young and has no previous neurological deficits. With good family involvement and if the client shows motivation, recovery should be good. Another plus is that Mr. Sartoris wasn't in a coma for a very long time.

Amanda Fowler

Prognosis: After an extended acute care stay, John is most likely to go to an inpatient rehab service facility for 3 weeks. There he will undergo intensive therapy in occupational therapy, physical therapy, and speech. This recommendation is based on John’s motivation to improve and resume premorbid activities of daily living. After inpatient rehabilitation, John will attend outpatient therapies pending progress/remaining deficit (speech 2 times/week). The family and patient should given materials/therapy resources to be used at home. The patient has a favorable prognosis noting recovery already evidenced, internal motivation, and quality external resources.

Kara Warner

Swallowing targets and activities: Swallowing Targets & Activities:

Goals:
1. Will use compensatory strategies such as postural changes and enhanced sensory input.
2. Improve the speed of triggering of pharyngeal swallow.
3. Improve the extent of movement of tongue, including elevation and lateralization to improve oral transit.

Activities:
Postural Changes- To redirect food flow and change pharyngeal dimensions in systematic ways.
1. Sit upright while eating.
2. Chin- Tuck posture- Gets tongue base to pharyngeal wall & narrows airway.

Increase Sensory Input-
1. Increasing downward pressure of the spoon against the tongue as the bolus is delivered into the mouth.
2. Introducing bolus with increased sensory characteristics; cold bolus, textured bolus, or bolus with strong flavor.
3. Bolus requiring chewing- mastication provides preliminary oral stimulation.
4. Thermal tactile stimulation- improves speed of pharyngeal swallow. To perform the clinician places a cold laryngeal mirror at the base of anterior faucial arch. Complete contact is maintained while rubbing up and down vertically five times. Repeat on opposite side. Upon completion of stimulation, immediately give a small amount of iced liquid barium and told to swallow.

Range of Motion Exercises-
1. a.)Open mouth as wide as possible and elevate the tongue as high as possible in the front, hold for 1 second.
b.)Elevate the back of the tongue as far as possible, hold for 1 second.
c.)Stretch tongue to each side as far as possible & extend tongue straight out as far as possible, and pulling it back as far as possible, for 1 second in each direction.
* Should be repeated 5 to 10 times in 1 session, 5 to 10 times in a day.

Resistance Exercises-
1. Push tongue up against the tongue blade, to the side against the vertically positioned tongue blade, or thrust forward against it with tongue blade pushing back against the tongue tip.
* Patient should hold pressure for 1 second.

Erica Raiti

Basic ADL targets and activities: List at least two functional goals and list those treatment activities (including compensatory strategies and therapeutic techniques) which would be utilized.

Complex ADL targets and activities: Discharge placement was not mentioned in the case study, but because of his supportive family it is likely that he was discharged under family supervision and assistance. Thus not living independently as he was prior to the MVA. Because the impact of the injury occurred on the L side of the brain the likely hood of L side brain dysfunction is great along with possible R side dysfunction secondary to the coup-contra-coup as previously mentioned. Therefore the extent of Mr. Sartoris's injuries affect both his cognitive and physical abilities.

STG: 1- Patient will perform simple meal prep with Min. A.
LTG: 1- Patient will perform simple (cold) meal prep with Mod. I.
Treatment Activities
Using R arm as an assist
Learning Simple kitchen compensation tech, such as sliding items vs. carrying, sitting while preparing etc.
Energy conservation tech to limit stress on R. arm, and on R leg.

STG: 2- Patient will verbally identify 5 safety hazards with Min cueing.
LTG: 2- Patient will verbally identify 5 safety hazards Independently.
Treatment Activities
Set up a safety problem scenario in ADL kitchen during the first part of meal prep.
Use flash cards to identify the scenes with every day home dangers,
Ex. Hairdryer plugged in lying next to the sink filled with water. Etc.

STG: 3-Patient will use medication organizer to organize medications with Min. A
LTG: 3- Patient will use medication organizer to organize medications with Mod. I.
Treatment Activities
Organize playing cards in various patterns
Actual hands on with medication organizer and different fake medication bottles with
Beans inside, with different times.

STG: 4-Patient will balance checkbook with Min. A.
LTG: 4-Patient will organize and balance monthly budget with Mod. I.
Treatment Activities
Using the R dominant hand for writhing might be difficult because of the injury
Therefor a built up writing device might be used.
Simple math equations would be a basic starting point
Organizing a typical house hold expenditure

LTG: 5- Patient will participate in leisure activity of playing computer games with Mod. I.
Treatment Activities
Adjusting the computer set up so that the client could play with the keys on the keyboard
Vs. the complex joystick.
Adjusting the computer's sensitivity as to allow for less force / energy /or ROM required
To participate in the game.

One of the biggest issues for this client, beyond simple ADL's is the ability to return back to work. Nevertheless I feel that for specific arrangements in that area he should be referred to vocational rehab. I also feel it to be necessary to refer this client to get a drivers evaluation and rehab, if necessary.

Holly Wagstaff

Language targets and activities:Long Term Goal: Mr. Sartoris will increase his pragmatic skills with 90% accuracy.

Short Term Goals:
1. Mr. Sartoris will concentrate on emotional and nonverbal communication during speech with 90% accuracy.
2. Mr. Sartoris will increase his communication in context with 90% accuracy.

Nonverbal skills that will be target in therapy are paralinguistic features, facial expressions, posture, and eye gaze. TBI patients usually have problems with these nonverbal skills, and usually they will affect their social communication. During therapy, Mr. Sartoris will be presented with stories, pictures, tapes, etc. that will involve the use of nonverbal behaviors. The clinician will then ask Mr. Sartoris how he felt about what he saw or read, and ask for an emotion. The clinician will provide him with the appropriate nonverbal behavior for what he read or saw. To increase his communication in context, the clinician will work on topic initiation and maintenance, turn taking skills, and awareness of social context. The first short term goal can be combined with this one as well. Most of the therapy will focus on conversation between the clinician and Mr. Sartoris. The clinician will monitor maintenance of the topic and turn taking skills, by correcting or redirecting the patient during the conversation.

Long Term Goal: Mr. Sartoris will increase his expressive language abilities with 90% accuracy.

Short Term Goals:
1.Mr. Sartoris will increase word retrieval to 90%.
2.Mr. Sartoris will increase his use of abstracts meanings during speech with 90% accuracy.

The clinician will use confrontation naming and function tasks to increase Mr. Sartoris’s word retrieval abilities. The clinician will present a familiar object or picture to Mr. Sartoris and ask him "What's this?" or “What do you do with this?” For example, the clinician may show him a picture of a hairbrush, and ask him, “What do you do with this.” The clinician will allow plenty of response time for Mr. Sartoris. Mr. Sartoris’s use of abstract meanings will be addressed by presenting him sentences and asking him to finish them or add more using the features he is lacking. Cueing and probing may be used.

Jamie McKeon

Speech targets and activities: Assuming that the patient presents with imprecise consonants, slow movement of the speech structures, monopitch, reduced stress, monoloudness, low pitch, slow rate, hypernasality, short phrases, distorted vowels, pitch breaks, breathy voice (continuous), and/or excess and equal stress, we would implement the following functional goals and related activities:

Functional Goal: John will maintain intelligibility with family, co-workers, and clients for a minimum of 30 minutes in conversation.
Short Term Goals/Activities:
1.) Change pitch/inflection a minimum of 5 times during a paragraph reading to encourage normal prosody.
2.) Use resistance from C-PAP to increase velopharyngeal strength and promote velopharyngeal closure to decrease hypernasality.
3.) Participate in laryngeal adduction exercises (i.e. pushing & pulling/effortful closure techniques, hard glottal attack, etc.) to decrease breathy voice quality.
4.) Use compensatory articulation strategies such as overarticulation to increase intelligibility during the production of functional phrases.
5.) Use self-monitoring skills throughout each therapy session to promote generalization of compensatory strategies outside of therapy.

Abby Pfeiler
Sarah Rice

Cognitive targets and activities: Since John may exhibit some attention, memory, and executive functioning difficulties, his career as a computer software trainer will be affected. These goals may be met through individual therapy and/or group therapy activities and compensatory strategies.

1. Studies show that attention has improved after treatment involving auditory and/or visual modules (Ben-Yishay, Piasetsky, & Rattock, 1987)
and verbal repetition (Malec, 1984). John may be able to increase attention with computer-assisted attention retraining (hierarchy of
computer tasks for focused, sustained, selective, alternating, and divided attention). Since he has been exposed to computers in the past, this type of retraining might be beneficial.

2. The use of a memory book might be a compensatory strategy when addressing reduced memory. If John learns to use this book independently, he will be able to return to work and live in an apartment with minimal assistance despite his deficits in memory and
new learning.

3. In addressing John's executive functioning deficits (forming goals, planning how to achieve them and carrying out plans effectively), John
could improve using self-monitoring procedures and visual feedback (videotape). Executive functioning generalization training would give
John practice in the planning and analysis of task demands, selecting a strategy, monitoring the strategy, and carrying out the strategy with
success. John should apply this type of training to real-life problems.

Corinne Kelsey

Review and question:

From an OT standpoint there are many suggestions, patient education,and materials or resources that John could use at home. Are there any
specific suggestions relating to his diagnosis that you would make be important to let him and his family know about? Thanks,
Emily Cobble

This is in response to Kimberly Elkins question about the CADL test by A.L. Holland. While searching the internet, I came across a website, www.neuropsychologycentral.com which gave a description of the test. This is what it listed: "The CADL examines how the patient might handle life activities by engaging him/her in role-playing in a series of simulated situations such as "the doctor's office" or "the grocery store." In keeping with the goal of making the examination as naturalistic as possible, the examiner is encouraged to carry out a dual role as examiner/play-acting participant with such props as a toy stethoscope or boxes of packaged soup. Responses are scored on a three-point scale according to their communicative effectiveness, regardless of the modality used (i.e. spoken, written, or gestural responses are all acceptable). The 68 CADL items sample teen categories of behavior, such as "speech acts," "utilizing context," "social convention," and capacity to participate in role-playing. A series of evaluations of CADL performances of 130 aphasic patients demonstrated that this test was sensitive to aphasia, age, and institutionalization, but not sex or social background. The manual provides category patterns for differentiating aphasia types and cut-off scores for identifying aphasics within predominantly nonaphasic populations. Self-training procedures for examiners are provided on scoring standardization."

This might give an idea of the CADL. Also, refer to Holland, A. (1980). Communicative abilities in daily living: a test of functional communication for aphasic adults. Baltimore: University Park Press.

Also, I would like to make a correction in my "Assessment of Language for Case 3". I wrote that Examining for Aphasia by J. Eisenson was a standardized test, but while looking at the same web site mentioned above, it said that it is not a standardized test. This is what it stated: "The author states: "Aphasic patients are characteristically too inconsistent in their responses to permit formal scoring standards to be developed meaningfully." Meaningful interpretation of a patient's performance thus requires considerable clinical judgment with respect to degree of impairment."

Kristen Jacobs

Everyone did a good job with their responses. The deficits discussed were very likely to have occurred as a result of Mr. Satoris’ traumatic brain injury.

Likely limitations: All limitations were strong responses and well thought out. It was noted that there was a possibility of a coup-contra coup type injury resulting in injury to both sides of the brain. Language limitations were accurate portrayals language deficit’s as a result of traumatic brain injury. Speech limitation were also accurate based on the place of injury. However, paraxial of speech was also a possibility. Limitations in ADLs also seemed accurate. It was mentioned that he may have difficulty with driving due to the insight and executive functions he may experience, but he also may have problems with driving due to his injury to his leg and wrist.

Assessment:

All areas of assessment were very well thought out and useful in helping us determine the Mr. Sartoris‘ abilities. Thanks to Kristen for the website information regarding tests she included in the language assessment. It was noted that it is important to observe Mr. Sartoris both informally and using formal assessments.

Treatment/activities:

Goals and activities seem to be appropriate for the above deficits. Swallowing goals/treatment could have been more personalized to Mr. Sartoris by the use of a MBS. Complex ADL targets were very appropriate and activities were well planned. Language activities were also appropriate and well planned, although the long term goals could have been written so that they were more functional. Speech targets were also appropriate. I would caution using strengthening exercises (i.e. CPAP) in the absence of weakness which is not a characteristic of spastic or ataxic dysarthria. Cognitive goals were also very helpful and on target.

Question/Comments:

I agree that driving should be assessed/targeted due to impulsivity associated with TBI, but this assessment should be delayed until the femur and wrist have healed.

Would planning for activities for swallowing intervention have been different if MBS results were discussed?

How would speech activities have changed if apraxia of speech were also present?

GOOD JOB EVERYONE!

Mandi Stutsy

Summarize: Provide a brief summary of the case, highlighting the most pertinent issues for speech, language, swallowing, cognition, and ADL's