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Barrett (Client Factors (Impaired strength (Cannot maintain unsupported…
Barrett
Client Factors
Impaired strength
Cannot maintain unsupported sitting
Poor head/neck control
Cognitively intact
Absent protecting reactions
Retained ATNR
Retained STNR
Hypotonia in core
Hypertonia in extremities
Occupation Based Problem List
Feeding
Problems
HOH for food scooping
Assistance for orientation of utensil to mouth
Total assist for holding sippy cup
Support needed for sitting
Strengths
Maintains grasp of utensil
Ind with straw cup
Functional Mobility
Problems
Absent protective reactions
Poor postural alignment & stability
Issues with sit to stand
Hypotonic trunk & hypertonic extremities
Uses arms to stabilize trunk & loses ability to use them for functional tasks
Body awareness
Strengths
Arms used when trunk is supported
Dressing
Strengths
Problems
Eating/Swallowing
Problems
Only nectar thick liquids
Only pureed and soft foods
Strengths
Balanced diet w/ no objection
Acknowledgement/interest in harder foods
Biomechanical Frame of Reference
Maintaining strength & ROM for age & physical characteristics
Prevent additional stress
Activity adaptation
Ergonomics
Posture
Upright
Head supported & neutral
Arms level with table/surface
Interventions
Feeding
Postural alignment
Trunk and pelvis supported in chair w/ use of AT
As tolerated with AT: cervical spine elongated w/ capital flexion
Crescent shaped pillow under head
Slant board & foot support to help with posture during mealtime
Stability
Seated & supported on small therapy ball w/ back straight & pelvis neutral. Bounce ball up and down to stimulate contraction of muscles that stimulate muscles for posture.
Progress to moving up, forward, right, & left. Move slowly & watch for weight shifting in direction of ball movement
Use activities that simulate normal flexor & extensor patterns of the trunk. Work for balance between flexion & extension that provides postural stability of the trunk
Sensory: Face & Mouth
Include physical activities that reduce shoulder girdle retraction & elevation & make it possible for child to bring hands to mouth independently
Provide good postural support of child's body as foundation for bringing hands to mouth & mouthing with easy oral movements
Utensil to Mouth
Ensure the level of the plate is a good distance from the child's plate to his mouth
Consider backwards chaining, move spoon with hand only the last few inches, then from plate to mouth, then incorporates the process of scooping then to mouth
Scooping
Select spoon with deeper bowl for successful scoops of food onto spoon when they are attempted
Present food where it is visible to child & at a level where scooping can be completed with less effort
Ensure the child has a spoon that facilitates a good grip (light weight handle or palm strap if needed)
Incorporate games that require scooping of materials
Use a nonskid place mat or dish that will not move around when he is attempting to scoop
Eating/Swallowing
Increase Sensory Awareness
Present foods that alert the child to different sounds during chewing
Extra auditory information to tell the child where food is in the mouth
(chips, crackers, hard fruits)
Present foods varied in texture for mouth activation of chewing and bolus formation
Introduce cooked fruits & vegetables for bolus formation
Move to raw fruits and vegtables
Introduce foods requiring biting for more active motor involvement
Biting through different textures: Bread (soft then toasted), soft fruit (bananas), hard fruits (apples), crackers, bagels.
Add texture to smooth foods
Graham cracker, wafers, butter cookies, dried cereal to smooth foods to be alerted to different textures
Sensory Awareness
Play games with vibrating toys around face & mouth
Brush teeth with vibrating toothbrush (always permission in any oral activity from child for placement in mouth)
Use therapy ball to roll child onto working vibrator. Encourage mouth on ball for feeling of vibration all over face.
When comfortable with massager, use to introduce to new foods and textures
Sleeping
Develop nighttime routine
Limit arousal during sleep
Use a fan as consistent noise for child during sleep
Functional Mobility
Activities to increase postural alignment & stability
Each of these activities for functional mobility will also help with other occupations and parent's priority of feeding
Moving limbs through full range of motion - decrease hypertonia
Maximize body awareness
Weight bearing activities
Mirror games with position cards within the child's capacity
Improve bimanual skills
Games like Mr. Potato Head
Games like stickers on body & remove them from different areas
References
American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.).
American Journal of Occupational Therapy, 68
(Suppl. 1), S1–S48.
http://dx.doi.org/10.5014/ajot.2014.682006
Cole, M.B. & Tufano, R. (2008). Chapter 14: Biomechanical and rehabilitative frames.
Applied theories in occupational therapy: A practical approach
(pp.165-172). Thorofare, NJ: Slack Incorporated.
Coker-Bolt, P.C., Garcia, T., & Naber, E. (2015). Neuromotor: Cerebral palsy. In Case-Smith, J. & O'Brian, J.C. (Eds.),
Occupational therapy for children and adolescents
(pp. 793-811). St. Louis, MS: Elsevier.
Korth, K. & Rendell, L. (2015). Feeding intervention. In Case-Smith, J. & O'Brian, J.C. (Eds.),
Occupational therapy for children and adolescents
(pp. 389-415). St. Louis, MS: Elsevier.
Client Profile
2.5 y.o.
Male
Enjoys: cars, Daniel Tiger, mom's singing
Performance Skills
Gross palmar grasp
Poor ability to maintain position of object
Impaired intentional release
Impaired bimanual skills
Dx
Quadriplegic CP w/ dystonia
dystonia = involuntary muscle contraction = repetitive twisting motions
CP from true know in umbilical cord
Cortical Visual Impairment (CVI)
Neurologic issue = decreased visual response
Parent Priorities
That Barrett will be able to feed himself is very important. Mom feels this would make him feel confident and inspire him to do other things.
Both parents really want Barrett to start eating solid foods. They are afraid he will never eat solid foods and that people will look at Barrett in a negative way for only eating mushy food.
Mom understands Barrett might always need supports for his posture and stability, but it "breaks her heart" to see him slumped over when he is sitting down unsupported. She really wants to work on his core strength.
Assessments
BDI2
Age Range: Birth to 7 yrs 11 mo
Client Results:
Adaptive
Below
Personal/Social
At age level
Cognitive
At age level
Motor
Below
Communication
At age level
SP2 (Toddler)
Age Range: 7 mo to 35 mo
Client Results
Sensory avoiding more than others
Responds to visual processing more than others
Responds to auditory processing just as much as others
Responds to touch more than others
Responds to movement more than others
More behavioral responses than others
Goals
LTG
In 9 wks, Barrett will self-feed with utensil with min A from caregiver, for 3/5 opportunities, during each meal time for one week, per caregiver report.
STG
In 3 wks, Barret will show improved postural control to engage in feeding while sitting at table with mod A, for 10 min, during 1 meal time, for 3 consecutive days, per parent report.
Ashley Abrego
OCT5355