Barrett (2.5 y/o)
Barrett (2.5 y/o)
Diagnosis & Diagnostic Hx: Quadreplegic CP
1 week old - Hypoxic-ischemic encephalopathy (HIE)
2.5 y/o botox injections to hip adductors and flexors; received B hip abduction brace
2.3 y/o increased gabapentin to decrease tone in aims to help sleep
1.5 y/o given p! meds to address sleeping problems
2 y/o Diagnosis of quadriplegic CP w dystonia and recommends increasing gabapentin to inhibit hypertonia in extremities
1 y/o diagnosed with cortical visual impairment (CVI)
True knot and emergency C section @ 11 months old
Assessment findings from administering MBSS in a hospital setting
Reflection of clinical presentation: Barrett was coughing, choking, aspirating, and experienced reflux during the MBSS. Dysphagia was present.
Relevant Feeding Hx: Puree foods with nectar consistency is current diet and nutrition status
Method of feeding: Providing different consistencies and textures of liquids/foods to assess swallowing mechanism and to observe outcome
Caregiver priority: To continue to learn how to provide safe eating for their son.
Rationale: What is impeding Barrett from consuming thin liquids? Choking concerns? Metabolic disorder? Food allergies? Dysphagia? Head and neck related problems?
Assessment Results: Nasopharyngeal reflux, choking, coughing, aspiration present when consumed solid foods and thin liquids.
Intervention strategies to improve self-feeding
Implement more self-feeding to impact oral motor skills during small meals such as snack time (HOH) to address hypertonia in UE
Provide low-tech AT (utensils with shorter handles to promote more independent feeding, U-shaped cup) also to assist in more control in the mouth and pharynx during swallowing
Positioning adaptations to facilitate more grasp patterns and hand to mouth movements in UE
Adaptive positioning: a chair that provides good postural support and allows access for a tray for a more UE stability
Caregiver Education; communication with caregivers, give educational information about diagnosis and things to expect, resources, strategies to promote self-feeding.
Occupation Based Problem List
Functional ambulation is affected by hypertonic extremities and hypotonic trunk. Wheelchair mobility affected by poor ability to maintain palmar grasp, impaired intentional release, impaired bimanual skills in UE.
Eats purees and soft foods with nectar thick liquids
Unable to hold or maintain position of sippy cup, poor bimanual skills and palmar grasp, impaired intentional release for self-feeding aspects
Requires total assist, but more independent with straw, requires HOH to scoop food
Will maintain grasp of spoon during feeding with assist to manipulate orientation of spoon to mouth
Unstable in truncal flexion and posture control --> impacts positioning during feeding
Rest / Sleep participation
Gabapentin used to decrease neurologic pain and decrease hypertonic extremities, having difficulty sleeping with hypertonic limbs
Play exploration / participation
Problems with joint mobility, muscle power, muscle tone, muscle endurance, motor reflexes, involuntary movement reactions, gait. Play exploration and participation is limited.
Impaired intensional release
Impaired bimanual skills
Gross palmar grasp with poor ability to maintain position of object
Intervention strategies to improve play exploration / participation
Create flexibility in environment and schedule for play opportunities
Adaptation of toys (incorporate augmentative devices)
Parent Education; working with the parents to ensure play opportunities and collaborate together to find "just right" and safe play activities for Barrett
Engage Barrett in cooperative play in order to engage with other children his age and facilitate interaction
unable to maintain unsupported sitting
poor head/neck control
Retained ATNR & STNR
Absent protecting reactions
Hypotonia in core w hypertonia in extremities
Cognitively appears intact
Intervention strategies to improve functional mobility
Adjust lateral head and neck supports to support poor posture and control to encourage easy chin-tuck position
Stretching to decrease hypertonia in extremities, provide regular massage to reduce tone and increase relaxation before feeding
Strengthen and promote fine motor skills for increased HOH stability and precision
Raised tray to support hypotonia in trunk; work on weight shifting reactions to promote balance in hypotonic trunk; engage Barrett in normal extensor and flexor patterns of the trunk
Intervention strategies to improve rest/sleep participation and preperation
Educate parents on relaxation techniques, nightly massage for hypertonicity, and stretching for relaxation purposes
Use a transitional object, pictures, video modeling to promote bedtime
Address possible environmental adaptations such as bed positioning, equipment used to ensure better sleep for Barrett
Address contextual modifications (establish bedtime and wake-up routine)
Rationale: Addresses the physical deficits, assists as a bottom-up approach; has the outcome of increased participation in meaningful activities; acts to decrease and delay aspects of fatigue, and increase energy conservation; overall increasing functional activity
LTG: Within eight weeks, Barrett will independently maintain position of sippy cup with HOH assistance in order to improve fine motor skills and muscular endurance in UE to facilitate self-feeding.
STG: Within one week, Barrett will demonstrate the use of B UE manipulation when picking up and putting down sippy cup with moderate assist from therapist twice a week in order to facilitate B manipulation and intentional release skills for self-feeding.
Graded intervention strategy for supportive positioning and functional mobility
Rationale: To support hypotonic trunk, help stabilize use of UE, and facilitate safe oral motor and swallowing skills as well as grasp patterns and facilitate hand to mouth movements during feeding.
Example: Provide a supportive and elevated chair with an elevated tray table during mealtime to compensate for dysphagia. Record the number of times Barrett needs to be repositioned throughout the day without the supports, and observe if the number decreases with the supportive/adaptive positioning.
How to make this easier? Add additional lateral supports
How to make this more challenging? Decrease number of supports in order to facilitate balance, posture, and control of trunk
Graded intervention strategy for play participation / exploration
Example: Engage Barrett in cooperative play with peers his age
How to make this easier? Engage in parallel or associative play
How to make this more challenging? To engage in cooperative play
Rationale: To promote interaction with kids his age, and to engage in play to increase self-confidence, learning, and self-expression.
Graded intervention strategy for feeding with low-tech AT
Example: Provide low-tech AT utensils with shorter handles and U-shaped cup
How to make this easier? Assist Barrett with utensils, and use an adapted handle with a strap to ease tone and manipulation
How to make this more challenging? Use regular utensils for self-feeding and low assist
Rationale: To promote more independent feeding and to assist in more control in the mouth and pharynx during swallowing
Graded intervention strategy for seep participation / preparation: establishing a sleep routine
Example: Establish a sleep routine with a regular bedtime and calming sleep behaviors; track how many times Barrett is able to stick to the routine. This routine would include (putting on PJs, brush teeth, reading book with caregiver.)
How to make this easier? Give Barrett more verbal cues and include more strategies to promote a good nights sleep (e.g. pillows, adapting environment to include light, sound, temp.)
How to make this more challenging? Decrease verbal cues, and have Barrett list what is next on the sleep routine.
Rationale: To improve sleep with a non-pharmacological intervention strategy for Barrett