Neuro Rehabilitation Reports | Occupational Therapy Reports
MEDICAL (PSYCHOLOGICAL) REPORT
By: A Psychologist specializing in the assessment and treatment of psychological sequelae of trauma. (With 40 years of experience in clinical, occupational, and rehabilitation Psychology).
Date of Assessment: February 21 and March 22, 2006
"Objective Findings
[Christa] presented as a reserved but cooperative lady appearing of tall height and medium build. Her hygienic state was clean, clothing casual but neat, posture and muscle movements were guarded and rigid and facial expressions anxious, tense, worried and sad. She was visibly upset about her situation, frustrated with her inability to be such a good writer as before, and seemed genuinely concerned about her cognitive difficulties. Pain behaviour included shifting in seating position, but otherwise remained stoic.
On mental status examination, her attention span seemed adequate and memory preserved. Her attitude was alert, eye contact good and there were no mannerisms in her behaviour noted. No significant signs of physiological distress were observed. Her demeanour was worried and mood contained components of depression and anxiety, uncertainty regarding her future and frustration and discontent with the overall situation. Her speech was rather slow, a bit pressured in energy, verbose in quantity and somewhat over-inclusive in quality." "Her vocabulary appeared sophisticated as far as description of her symptoms was concerned. Thought content indicated the presence of somatic preoccupations and concerns over her bodily functions and dysfunctions and their affects on her cognitive functioning and possible negative impact on her professional work. There were no delusions, hallucinations, allusions, obsessions, and suicidal nor homicidal ideations presented. Her sensorium was clear, she was oriented for time, person and place. She seemed to be motivated for treatment and her insight into psychological difficulties appeared very good. She was a good historian in terms of her reporting and I had no doubts about validity of reported difficulties. Due to the clinical nature of this assessment gearing to assess her recurrent affective functioning, no in-depth neuropsychological assessment of her cognitive functioning was undertaken. However, in the course of this assessment, it was clear that this should be a case."
"On administration of psychological tests, she endorsed statements indicating that she has been suffering flashbacks of the accident, nightmares, bad dreams, anxious and depressive moods, nervousness, irritability, agitation and inner tensions. Her responses would indicate troubles in remembering, concentrating, making decisions, and having the idea that something is wrong with her cognition.
The profile she has obtained on testing was elevated on scales addressing somatic preoccupations, compulsive tendencies in attending her duties and responsibilities typical for high achievers, depression and anxiety. The indexes addressing the severity of personal distress were elevated. Her test-taking attitude was adequate as far as being valid for interpretation of clinical entities. Her profile is similar to patients described as anxious, depressed, unhappy, and uncomfortable with their present situation. They tend to be organized, meticulous in attending their tasks and known for well organized approach to tasks and striving for the best. Once they experience a loss of control, they tend to be frustrated and upset. They experience unpleasant thoughts that won’t leave their minds easily. They worry about sloppiness and carelessness and they have a tendency to check and double-check whatever they do in order to ensure correctness. They may experience a vegetative sign of depressive moods such as insomnia, weakness in parts of their bodies, lack of energy, reduction or increase in their appetites. Similarly, they tend to experience a physiological arousal such as nervousness inside, feelings of inner tensions while exposed to stress and anxious situations."
"Summary:
This psychological/clinical evaluation would indicate that [Christa] has been suffering components of post-traumatic stress anxiety and depression accompanied with irritability, nervousness, vegetative signs of depression as well as physical signs of anxiety, warranting a diagnosis of Post-Traumatic Stress Disorder. Reported cognitive difficulties would suggest a possibility of unresolved post-concussive syndrome of mixed etiology."
"Recommendations:
A consideration should be given to a further assessment of her cognitive difficulties. You may wish to refer her to a neuropsychologist for an in-depth neuropsychological assessment. If there would be difficulties in finding one, I can be instrumental in such a referral. As far as her affective functioning is concerned, her current level of personal distress, insight into psychological difficulties, motivation to relieve them, her age, social, educational and vocational background, would indicate that she is a good candidate for psychotherapy. This should be of a rather short-term nature consisting of 20 sessions of supportive and cognitive psychotherapy, eye movement desensitization and reprocessing, as well as directive counselling. The latter one should be aiming at informing the claimant about self-help techniques which could be used in stress and pain management as well as teaching her relaxation techniques to control her depression and anxiety. Prognostically, she would benefit from the psychotherapy. In my estimation, she would be able to reduce her psychological symptoms as described above, improve her pain management, attendance to her usual daily activities, as well as improve the quality of her lifestyle following psychotherapy." "If cognitive difficulties would persist, however, a cognitive rehabilitation program may be needed in the future to seal advances obtained in psychotherapy. It is hoped that a neuropsychological assessment would yield specific recommendations regarding her cognitive difficulties..."
"It should be mentioned that compulsive features of her personality may complicate the psychotherapeutic process to a certain extent in order to obtain complete relief."
NEUROPSYCHOLOGICAL ASSESSMENT REPORT
Dated: October 11, 2006
"Education and Work History
[Christa] reported that following the first motor vehicle accident she attempted to return to work. She completed a few projects but she found it to be extremely difficult to complete the project. She reported that she was not very efficient and she performed the work very slowly.
[Christa] reported that the work involved analyzing clinical studies. She described the work to be extremely technological in nature. She reported that she now finds the work to be extremely difficult and she is slow to get the work completed. She has had to redo much of her work due to the poor quality of the work which also required multiple revisions. She eventually lost multiple contracts.
[Christa] reported that she would like to return to work but she requires help due to the magnitude of her cognitive difficulties. She noted that she would benefit from acquiring strategies to cope with her difficulties. She noted that she is quite stressed by her inability to adequately perform her work."
"CLINICAL FORMULATION
[Christa] is a 38-year-old, right handed woman who was involved in two motor vehicle accidents in a short period of time; on September 16th, 2005 and February 10th, 2006."
"According to [Christa] and information obtained from her file, in the course of the first motor vehicle accident she struck her head against the steering wheel and she lost consciousness for a brief period of time. She sustained a bump on the front of her head. She has since been diagnosed with a post-concussion syndrome. In the course of the second motor vehicle accident, [Christa] did not lose consciousness although she noted that she did strike her head. She noted that the difficulties which commenced following the initial accident were exacerbated following the second motor vehicle accident.
Since the time of the motor vehicle accident, [Christa] has been diagnosed by [a Psychologist, Dr. X] with Post-Traumatic Stress Disorder accompanied with anxious and depressive moods and possible post-concussive syndrome. Difficulties with attention, concentration, and memory have been consistently reported by [Christa] since the time of the first motor vehicle accident. [A Psychiatrist, Dr. X] diagnosed Post-Traumatic Stress Disorder as well as a relapse of her Depression and Generalized Anxiety.
Since the time of the accident, [Christa] has consistently described experiencing difficulties with her cognitive and emotional functions. [Christa] continues to suffer from significant sequella which she attributed to injuries sustained in the motor vehicle accidents. Physically [Christa] reported that she experiences bodily pain (hip, right leg up to her knee, right shoulder, and lower back) which worsens with activity. She also described pain in her face and jaw which affects her sleep and which affects her ability to speak. [Christa] also experiences frequent headaches which are located to the back and top of her head. With respect to her sensory functions, [Christa] reported that her hearing is reduced, she must frequently ask people to repeat the information, and she has difficulty distinguishing between various sounds. She experiences frequent episodes of dizziness and she now walks with the assistance of a cane due to poor balance, dizziness, and vertigo. [Christa] reported that her sleep is extremely poor, she naps every day, and she experiences frequent nightmares of the accident. With respect to her emotional functions, [Christa] noted that she feels depressed, she experiences frequent mood swings, and she has problems with anger control (ie. she is irritable, she angers quickly, and she yells at other people). Her interests and motivation are limited. With respect to her cognitive functions, [Christa] reported that her attention and concentration are poor, her speed of thinking is slow, she has difficulty dividing her attention and with multitasking. She is also forgetful and distractible, and her memory is poor. She reported that she has some difficulty with her ability to plan ahead, word finding difficulties are a frequent problem for her, her spelling abilities are poor, and she finds it difficult to make decisions, and she will often say things that differ from what she has been thinking.
[Christa] was seen for a comprehensive neuropsychological examination. [Christa] is a woman of Low Average to Average intelligence [based on neuropsychological testing results] who displayed a statistically significant and clinically relevant difference between her Average performance on tests of acquired knowledge, verbal reasoning, and comprehension of verbal information and her Borderline performance on tests of nonverbal reasoning abilities. [Christa’s] performance was notable for variability in performance both within and between domains assessed. [Christa’s] performance on tests of speed of information processing varied between Extremely Low and Average. Working memory was largely intact. Her performance on one test of sustained attention suggested difficulties with vigilance, that is her performance declines (ie. becomes slower and less consistent) over time. Her performance on a test of sustained and divided attention also suggested difficulties with vigilance (ie. her accuracy decreased for the latter half of the task). Her performance on tests of memory fell within average limits overall. [Christa’s] performance on tests of visual spatial and constructional abilities were variable with scores ranging from Borderline to Average. Her performance on tests of language functions were unremarkable. Her performance on a test of executive functions was somewhat lower than would have been expected. Her performance on tests of sensory perceptual and sensory motor abilities was suggestive of right hemispheric lateralization.
[Christa’s] responses to a series of self-report measures of current mood were negative for heightened levels of depression, anxiety, or feelings of hopelessness about her future.Her responses to one detailed measure of personality suggests that she portrays herself as being relatively free of common shortcomings to which most individuals will admit. This reflects a significant tendency to under-report symptoms and to minimize difficulties.
Overall, on a comprehensive battery of neurocognitive measures [Christa] displayed difficulties with attentional functions as well as a profile that is suggestive of right hemispheric findings. Based on the history of the accidents, it appears as if she sustained a mild head injury in the course of the initial accident. The second accident appears to have exacerbated her symptoms and have contributed to her current difficulties with her neurocognitive functions. It is well known that multiple head injuries, especially when close in time can result in sequella that are much higher than would be expected from any one injury alone. Furthermore the recovery from these injuries would likely take longer than one would be seen from a single head injury.
Recommendations
Psychiatric Neurological [Christa] should be referred to a neuropsychiatrist that specializes in treating individuals with the neuropsychiatric/cognitive sequella of a motor vehicle accident would be appropriate. Research has demonstrated that for some people a [medication X] trial is beneficial in terms of helping with variable attention, alertness, and speed of thinking. She might also benefit from a cognitive enhancer medication…" "…it has recently been shown to be beneficial with other cognitive disorders with neuropsychological dysfunction such as the type of sequella that occur following a head injury. Whether these recommendations are appropriate will need to be determined by her treating physician or by a neuropsychiatrist.
Psychological Interventions / Cognitive Remediation [Christa] should continue to receive treatment with her psychologist to help her with her accident-related difficulties. [Christa] would also benefit from cognitive rehabilitation which would be helpful in order to help her to optimize her areas of strength and to use these strengths to compensate for areas of weakness. This should be performed by a neuropsychologist or with a registered psychologist experienced in this area of treatment. [Christa] would benefit from cognitive therapy that focused on methods to improve her attention and concentration. With respect to neurocognitive difficulties, cognitive-behavioural techniques are often employed by psychologists for post concussive syndrome include graded resumption of activity, cognitive restructuring, relaxation training, and rest. Strategies could also include the use of a memory book, to-do lists, and attention training. She should also be educated regarding the injuries that she sustained…" "In my opinion, an additional treatment plan for 24-30 weekly sessions would be appropriate with additional treatment plans being prepared as necessary.
Occupational Therapy [Christa] should have an occupation therapy assessment with an Occupational Therapist experienced with the effects of brain injury.
"Other Investigations Given the findings obtained during the current assessment, [Christa] should have an MRI of her brain."
Date of Report: April 3, 2007
By: Neurologist
"The purpose of the assessment is to determine if there is an MVA related neurological impairment affecting a return to gainful employment, housekeeping and home maintenance. In addition, the assessment will address if further treatment is required."
Identifying Information
"Prior to the accident of September 16, 2005 she worked as a pharmaceutical marketing field."
"Prior to the accident of September 16, 2005, she was independent in personal care activities. She shared all household and housekeeping activities including meal preparation, vacuuming, bathroom cleaning, garbage removal, laundry, dusting, and mopping with her husband."
"Course Since Accident
She began therapy and participated in active and passive treatments following the first accident. She continues to attend therapy regularly. She has had multiple assessments and is being followed by her physician, oral surgeon, and psychiatrist.
Current Symptoms
Headache
[Christa] continues to experience headaches, which are occipital in location and travel to the vertex of the head. They occur daily, and are described as a sharp pain. They are associated with dizziness and vertigo."
"Neck pain
[Christa] continues to experience neck pain that is axial and paracervical in location. It is tight in nature. She rates the pain as 10/10. Overall, there has been no improvement of her neck pain in terms of frequency and severity since the onset after the second accident.
Back pain
[Christa] continues to experience lower back pain daily. Lifting, bending, sitting, standing and walking aggravate the pain. The pain is associated with right-sided posterior radicular pain that extends to the knee. There is bilateral toe numbness. She rates the pain as 10/10. Overall there has been 20% increase of her back pain in terms of severity and frequency since the onset after the second accident."
"Mood, cognitive, and vegetative function
[Christa] continues to experience difficulties in concentration and frequent forgetfulness.
Functional Inquiry
[Christa] is not independent in personal care activities. She is unable to perform heavy pre-accident housekeeping and care-giving activities."
"Physical Exam
[Christa] was awake, alert, oriented, cooperative, and put forth a good effort."
"Summary
[Christa] is a 38 year old female whose current symptoms of headache, neck pain, back pain and pain in the right shoulder are a direct result of the motor vehicle accidents of September 16, 2005 and February 10, 2006.
[Christa] did lose consciousness after the first accident and was dazed and confused. Thus she did sustain a closed head injury. In terms of her headache, she suffers from chronic post-traumatic headaches. These headaches are multifactorial in origin. Firstly, she has the signs of post- concussive headaches. Secondly, she has cervicogenic headaches. This results from damage to the C1-3 facet joints periosteum, and ligaments or trauma to the greater occipital nerves."
"In terms of her neck and back pain, she sustained a moderate myofascial injury of the cervical and lumbar muscles. …She continues to experience symptoms suggestive of a cervical and lumbar radiculopathy."
"Since her headaches, neck pain, and back pain are quite frequent, I recommend a trial of [a prescription medication]."
"Overall, [Christa] continues to suffer from multiple impairments from the accident. These impairments have affected her personal and social life. She has not returned to any of her pre-accident recreational activities. At this point, [Christa] has not reached maximal medical improvement relative to the injuries sustained in the September 16, 2005 and February 10, 2006 accidents."