Case Study: Neurological rehabilitation
by Joanna Bresi-Ando
Lucas was a 49 year old male, who ran his own business as an IT consultant. He lived with his wife and 2 adult children in their own home. Lucas was previously fully independent with all his daily activities and had no significant past medical history.
Lucas fell down the stairs at work and sustained a sub arachnoid haemorrhage, a fractured skull, facial lacerations and 2 fractured ribs. He was admitted to the nearest hospital with a trauma centre, where he underwent surgery to debride and evacuate the depressed skull fracture and debride and repair the lacerations.
As a result of the brain injury, Lucas was left with the following impairments;
- Left sided lower limb weakness
- Reduced balance
- Cognitive difficulties - particularly working memory, reduced attention and executive function skills
- Expressive and receptive language difficulties
- Low mood
- Increased fatigue.
Following his acute admission, Lucas was transferred to a rehab unit, however his low mood deteriorated and he was increasingly agitated. Lucas made very little progress on the unit, so it was decided in his best interests for his rehab to be continued at home.
NHS community services in his borough did not provide neuro specific rehab and Lucas’ Case Manager began the search for a neuro Occupational therapist.
Reason for referral
Lucas was referred to occupational therapy for an assessment of his physical and cognitive needs, to allow him to reach his optimal level of function.
Lucas was independently mobile indoors and short distances outdoors using a walking stick with supervision.
He was independent with personal care and able to prepare simple meals such as breakfast and a hot drink, however he struggled with complex meal prep tasks. He previously enjoyed cooking and this had been the main household task he would participate in prior to his accident. Lucas’ goal was be able to independently cook a complex meal for his family.
Lucas required support to manage his daily routine; he required supervision to access the community and was dependent for financial management. He fatigued easily and struggled to join in with group conversations, so was increasingly socially isolated.
Recommendations for occupational therapy intervention were to
- Develop meaningful roles and a routine focusing on productivity and structure.
- Develop fatigue management, pacing and energy conservation techniques.
- Use relaxation techniques to help manage his fatigue.
- Develop memory aid strategies, such as using his phone as a reminder and a notebook to write down prompts and lists.
- Explore vocational pursuits
Other recommendations were;
- To continue with physiotherapy treatment
- To be assessed by a speech and Language therapist for continuing communication issues.
- To be assessed by a neuropsychologist for further assessment of his cognitive function and work collaboratively with the occupational therapist in the areas of vocational rehab and mood management.
Lucas was able to come up with an overall cooking goal with support from the occupational therapist; he wished to prepare spaghetti bolognese safely and independently without getting distracted from the task.
The occupational therapist then worked with Lucas and his family on the following short term goals:
- To be able to produce a shopping list with minimal assistance,
- To be able to access his local shops with distant supervision and
- To shop for the ingredients with distant supervision.
The short term goals were incorporated into a structured weekly timetable for Lucas to follow.
Assessment and treatment was completed simultaneously, through the use of functional tasks and repetitive practice of that task.
Although Lucas had an overall cooking goal, in order to achieve it, meant that he was required to work on other functional skills at the same time, such as searching for and locating items in his kitchen in order to work out what was missing and would need to go on a shopping list, safely accessing the community to get to the local shops and making his way around a supermarket, as well as paying for shopping and transporting it home.
Occupational therapists are very aware of how frustrating it can be for clients to achieve what seems to them to be the simplest of tasks and how this frustration can turn into a negative mind set and demoralise the client. In order to avoid this and empower the client to gain a sense of achievement, a graded approach to activities is often used.
In Lucas’ case he was initially given one step of the overall task to complete, i.e. cooking the mince independently and then would be assisted with the other steps. Over time he was encouraged to complete more of the steps on his own. Discussion with Lucas before starting a task and getting him to rate himself on how well he thought he would perform and then reflecting back at the end of the session on his actual performance also served as a method of encouraging self-monitoring and helped him to realise he could manage better than he thought.
Lucas was taught a strategy of using simple worded checklists for each step of the task and checking them off, before moving on to the next step.
The OT would intervene each time he deviated from the task and bring him back to the checklist.
To address attentional difficulties, the OT began to introduce distractions into the environment, i.e. radio on in the background or talking to Lucas when he was completing a task.
By the end of 12 weeks of rehab Lucas was able to make Spaghetti Bolognese with distant supervision.
Lucas had taken on board the strategies of using checklists to help him through the task, but was unable to recognise when he had deviated from a task and always required a prompt to return to his checklist. Lucas’ safety awareness during meal prep improved and family were happy for him to make them a meal with minimal support from themselves.
As Lucas had been required to regularly walk to his local shops, his confidence with community access improved along with confidence to speak with strangers and articulate his needs.
Lucas has not yet been able to return to work and is unsure of whether he wishes to do so, but he is interested in volunteering with a local charity as a means of further occupying his time and increasing his social interactions.
He continues to work with the occupational therapist on managing his fatigue.
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