Neuro Rehabilitation Reports | Occupational Therapy Reports
Speech-Language Pathology Assessment Report | Social Work Initial Assessment
OCCUPATIONAL THERAPY INITIAL ASSESSMENT
Dated January 31, 2007
"ASSESSMENT FINDINGS
Physical Function Post-accident Performance
Observed:
- Balance: Swayed while standing with eyes closed for 30 seconds."
Post-accident Performance
Observed:
- The TVPS was administered. This non-verbal assessment examines visual perceptual abilities in the areas of visual discrimination, visual memory, visual spatial relationships, visual form constancy, visual sequential memory, visual figure ground and visual constancy.
- [Christa] scored poorly on all subtests."
"Communication Skills
Post-accident Performance
Reported: [Christa] reported that her thought process is scattered. She mixes up words. She has difficulty recalling words.
Observed: [Christa] had word finding difficulties during the interview and mixed up words…"
"Behaviour/Psycho-social Skills
Post-accident Performance
Observed: [Christa] was cooperative and pleasant during all sessions with this therapist…"
Pre-accident Performance
Post-accident Performance
Reported: She tried to take a project following her first accident and took a very long time to complete the written work." "…her performance was below what she would have done pre-injury both in terms of quality and quantity. She has not been able to return to work since. She reported practicing her writing skills in her free time but has a hard time formulating ideas and thinking creatively."
"SUMMARY AND ANALYSIS
[Christa] is a 38-year-old married woman who was involved in two motor vehicle accidents, the first on September 16, 2005 and second on February 10, 2006. She appears to have suffered physical and cognitive sequelae possibly as a result of both accidents. She is working very hard to manage her own, her babies’ and family care. Her husband does all the homemaking tasks and some baby care tasks, as she is no longer able to complete them. She requires further functional assessments in her home to determine the extent of her deficits.
Strengths
- Pleasant and cooperative
- Pre-injury history of being independent and self-sufficient…"
- "Supportive husband
- Socially appropriate; good interpersonal skills observed by this therapist
Impairments from an Occupational Therapy Perspective:
- Headaches.
- Right hip pain, right shoulder pain, low back pain, TMJ [Joint].
- Impaired balance and dizziness.
- Decreased physical tolerances.
- Numbness in the hands and feet.
- Cognitive changes, including memory deficits and decreased attention span.
- Decreased activity tolerance and endurance.
Disabilities (Functional Implications) Resulting From the Above Impairments:
LONG TERM GOALS AND PLAN
To make "positive adjustments to life after brain injury."
"RECOMMENDATIONS
- Occupational Therapy as per above goals and plans.
- Referral to an ENT specialist re: dizziness.
- A referral has been made to St Michael’s Hospital, Head Injury Clinic for a comprehensive evaluation…
- Referral to a Speech Language Pathologist…
- Social work referral.
- Attendant care and homemaking allowance for [Christa] to hire help to assist her with her self-care and household activities."
OCCUPATIONAL THERAPY PROGRESS REPORT
Dated: August 22, 2007
"CLIENT’S PROGRESS SINCE LAST REPORT
An Occupational Therapy (OT) Initial Assessment was completed on January 31, 2007 and a treatment plan for weekly occupational therapy was submitted along with the report. However, funding for OT treatment was denied by the insurer. [Christa’s] OT treatment plan was subsequently approved in May 2007 by her lawyer…"
"[Christa] is currently awaiting social work counseling and speech language therapy to be approved by the insurer. …She reported being very stressed with having to wait for all of her rehab treatment programs to begin. She is having a lot of difficulties coping with all the changes that have occurred since the accident and reported losing patience with her family."
"[Christa’s] home was in disarray with piles of undone laundry on the couch and in the living room. The main level of her room was full of clutter and [Christa] reported having difficulty managing the housekeeping duties due to her decreased energy level, limited physical tolerance, pain and dizziness. A Rehab Coach is recommended to work with her twice a week to set specific time-oriented goals around managing her housekeeping duties and setting up a routine. [Christa] responds well to structure and routine, however since she is consumed by external appointments, managing her family life and has poor coping strategies, she is unable to follow through independently with the strategies that have been taught to her."
"Summary[Christa] has been receiving occupational therapy once a week for the past 3 months. Her progress has been slow due to a number of factors: limited involvement of other rehab professionals due to funding issues, which has resulted in a breakdown in multidisciplinary therapy, numerous external independent medical examinations she had to attend to, poor psychological adjustment to her injuries, family obligations and pain. [Christa] has difficulty applying the strategies that have been taught to her in occupational therapy due to her physical, cognitive and psychological difficulties. She expressed frustration with the delay in her rehab program and is concerned that she is deteriorating physically, cognitively and psychologically. She requires speech language therapy, physiotherapy and social work counseling urgently. She also requires a Rehab Coach to work with her twice a week to ensure that she is carrying through with the goals and strategies that are being taught to her. The Rehab Coach will work under the supervision of the Occupational Therapist and ensure that [Christa] is completing the goals successfully and will monitor her performance more closely."
"RECOMMENDATIONS
- Rehab coaching twice a week, Occupational Therapy once every 2 weeks…"
- "Approval for social work counseling, speech language pathology and physiotherapy."
SPEECH-LANGUAGE PATHOLOGY ASSESSMENT REPORT
Dated: September 20, 2007
By: A Speech-Language Pathologist: "Practicing for 17 years including 12 years in assessment and treatment of children and adults with traumatic brain injury."
"The purpose of the assessment was to identify cognitive-communication deficits and make appropriate recommendations."
"HISTORY AND BACKGROUND INFORMATION"
"Pre-Injury Educational & Avocational History"
"The scope of her work included doing research and writing grant proposals for research funding, manuscripts for scientific journals, interactive websites and CD ROMs for healthcare professionals and pharmaceutical representatives, and assessing findings in clinical trials and communicating this information to physicians to help them understand the benefits of pharmaceutical products."
"Family and Social Support System
Pre-Injury, she was actively involved in assisting her parents care for her adult autistic brother and they were dependent on her due to their limited command of English and also due to their own poor health."
Attention & Concentration
- [Christa] described her attention and concentration deficits as "devastating" and that they compromised her information processing.
- Her job required a high level of attention and concentration to complete."
"FUNCTIONAL IMPLICATIONS: Reduced attention and concentration will have a negative affect on sustained attention required for all cognitive-communication tasks, including her previous work tasks."
"Orientation & Memory
- [Christa] indicated that she got disoriented at times when driving… She would call her husband at work several times a day for directions and he received a "warning" at work due to the number of phone calls she was making.
- She described significant difficulties with memory. She gave the following examples: forgetting to drop off her kids at daycare when she was on her way to a physiotherapy appointment (she had to drive back from the PT clinic to the daycare to drop them off); going to the wrong appointment on the wrong day."
"FUNCTIONAL IMPLICATIONS: Like attention and concentration, memory is the basis of all cognitive-communication skills, was necessary for her job, and recall of information in her daily life. Memory deficits will affect auditory processing and memory, word finding, expressive language, reading comprehension, pragmatics, and organization skills."
"Oral-Motor/Speech (Articulation)/ Swallowing
…TMJ pain made chewing difficult and [Christa] needed to eat softer foods as a result."
"Articulation:
Vocal loudness was adequate but inflection was flat and there was reduced range of motion of the jaw while talking (ie. reduced jaw excursion).
FUNCTIONAL IMPLICATIONS: TMJ pain affects chewing and quality of the eating experience. It also contributes to reduced jaw movement while speaking and flat vocal inflection."
"Auditory Comprehension & Information Processing
- [Christa] reported that she missed details of TV shows. She felt information was too fast for her to process adequately.
- Results of the "Oral Directions" subtest…:
- Standard Score (SS) = 3, Percentile Rank (PR) = 1, representing significant difficulties following increasingly longer and more complex directions. The longer the direction, the harder it was to recall, complex directions were "lost" half way through and she wasn’t able to retain the information.
Results of the DCT [formal testing]:
"These results indicated significant difficulties listening for and identifying the details of short paragraphs, especially details that were implied and that required inferencing (reasoning skills).
FUNCTIONAL IMPLICATIONS: Speed, complexity, length, and volume of information affect [Christa’s] comprehension of information presented orally. She demonstrates significant difficulties with auditory processing and comprehension, including following oral directions and listening for details in orally presented paragraphs. Results of formal testing are consistent with her reports of frequently missing details of TV shows."
"Word Finding
Results of the BNT:
Score = 54, just under the mean (average) score for ages 18 – 39 (ie. 55.8)"
"Discourse
FUNCTIONAL IMPLICATIONS: Mild word finding deficits and moderate expressive language difficulties affect [Christa’s] communication effectiveness in conversations.
Pragmatics/Social Behavioural Observations
- [Christa] indicated that, in her job, she was required to speak with various types of people and to change how she spoke depending on her audience."
- …"Affect was flat and vocal inflection was also flat.
- Excessive speaking (verbosity) was clearly apparent during face-to-face conversations and on the phone.
FUNCTIONAL IMPLICATIONS: [Christa’s] pragmatic language skills were mostly preserved, with the exception of flat inflection and affect and excessive speaking. These behaviours may appear "odd" to business colleagues and may interfere with effective social interactions."
"Reading Comprehension
…Her job had required a very high level understanding of technical terms and information, including technical scientific manuals and journal articles."
Christa’s "…results indicated difficulties reading for and identifying the main idea (when implied) and details of short paragraphs, especially details that were implied and required inferencing (reasoning skills)."
"FUNCTIONAL IMPLICATIONS: Results of formal testing may underestimate [Christa’s] difficulties with reading comprehension. Although the estimated TORC-3 results are within average range, it is possible that her pre-accident skills were far superior to average, given the reading expectations of her job."
"Written Expressive Skills
- [Christa’s] job involved writing highly complex and technical scientific and medical material. The material was required to be concise and error-free, since it was information that would be passed on to patients taking medications and doctors prescribing them (ie. drug monographs and advertising material).
- Samples of her pre-accident work-related writing were reviewed. The samples contained graphs, researched information on subjects such as the circulatory system, statistical information, and technical terms.
- Following the first accident (September 2005), she accepted a new contract position in November 2005. The job had a one month deadline, however, due to her difficulties understanding the technical terminology and recalling it, she was not able to deliver the job on time, despite putting in extra hours.
- She reported having difficulties summarizing in point form in a coherent way using technical language and significant difficulties processing the information. She had difficulty "putting her thoughts together" and "pinpointing where she was having problems", indicating difficulties with expressive writing and reasoning skills.
- She later noticed that she was writing too much to explain a concept and that she had been able to be more concise prior to the accident.
- The company, that contracted her, asked her to revise her work and she needed extensive revisions compared with only one or two prior to the accident."
"FUNCTIONAL IMPLICATIONS: Results of testing indicated…It is likely that her present writing skills would not be adequate to meet deadlines and to comply with the complexity of the material she would be expected to write."
"Thinking, Reasoning, and Problem Solving Skills
- [Christa] described her job as "deciphering the data and translating it into more palatable, bite-size information" depending on her target audience. She was required to research and study the material.
- She indicated that she now became confused about the interpretation of the material."
"FUNCTIONAL IMPLICATIONS: Results suggest significant difficulties with higher level language skills and flexible thinking required to understand the nuances (ambiguities) of language. Her job would require significant reliance on higher level language skills and the poor results are consistent with her reports of difficulties with the demands and expectations of her job. These deficits would also have a negative effect on her various social interactions with family and friends."
"Executive Functions (Goal setting, planning, initiation, self-monitoring, evaluation)
- [Christa] showed good insight into her difficulties and was able to describe them in detail.
- She would like to return to her former occupation but realized that her skills were not adequate enough at this time.
- She appeared to have difficulty monitoring her responses for length, usually providing too much detail and information."
"ANALYSIS…
Impairments:
- Reduced attention, concentration, memory…"
- "Significant difficulties following increasingly longer and more complex directions.
- Difficulties listening for and identifying details of orally presented paragraphs.
- Mild word finding deficits
- Expressive language formulation deficits, including excessive talking and details.
- Difficulties with reading comprehension, including reading for implied main ideas and details.
- Difficulties with higher language skills such as inferencing and understanding multiple meaning words."
"Disabilities:
Cognitive-communication deficits will have negative effects on [Christa’s] return to her former occupation as well as her social interactions."
RECOMMENDATIONS
SOCIAL WORK INITIAL ASSESSMENT REPORT
Dated: August 3, 2007
"Pre-Accident Individual Functioning
Prior to her injury, Christa was independent in all areas of activities of daily life. …She worked as a very successful independent consultant who was a pharmaceutical/scientific medical writer. The work was highly technical in nature but she reported she loved the challenge and having to write to suit her audience. She found real meaning in her work and loved the fact her work helped people. Much of Christa’s self esteem and self worth came from the work she did and she describes her work as ‘a passion in her life; not just a job’."
"By all accounts, Christa enjoyed a productive lifestyle busy with two small children, a husband, an extended family and a job that she loved."
"CURRENT FINDINGS
Post-Accident Individual Functioning
As a result of the accident, Christa has experienced significant cognitive, physical and emotional changes that have impacted her functioning and performance in all aspects of her life.
From a cognitive perspective, Christa has difficulty remembering things and has to use memory aids to help her organize herself. She gets off track easily during her day and reports having difficulty focusing on something for long periods of time. She reports that she can no longer write or read at the high level she did before the accidents. This change causes her a great deal of stress and anxiety as she desperately wants to return to her job.
From a physical perspective, Christa is struggling with back pain and often has to wear a back brace to deal with it. She also has to cope with pain in her right hip and shoulder. She suffers constant fatigue and has difficulty at times dealing with the demands of her young family because of it. Christa also reports that her balance is off and she is experiencing dizziness.
Christa has experienced problems with her jaw and is suffering from TMJ pain. She had surgery on her jaw last year, and will have to have surgery again this year. This problem with her jaw has caused her difficulty with chewing and she reports she is on a soft diet and often drinks supplement meal drinks in order to ensure she is getting her daily calorie intake.
From a psychological and emotional perspective, the accidents have had a dramatic effect on Christa’s life. She reports that she is very depressed and worried about what will happen to her and her family. She is not sure what the future holds for her. She reports she is having difficulty sleeping and often wakes up due to the nightmares of the accidents and the tooth she has lost. She is feeling overwhelmed much of the time.
The fact that Christa is not able to return to work has been extremely hard on her. She states that going back to work is her top priority and without her work ‘she feels like she is dead inside’."
"Changes in Significant Relationships
Christa reports that there have been major changes in many of her significant relationships. She reports that her relationship with her young sons has been drastically affected by all the changes. She is unable to parent the way she did before and struggles to play an active role in their lives. She is unsure of what to say to her children about what has happened to her. She also states that she was not there for her children during their critical years and this belief makes her extremely sad.
The marital relationship has changed a great deal between [Christa and her husband]. Christa’s husband has had to take on much of the parenting role and chores within the house. Christa worries how much her husband has to do and cope with, and she feels a lot of guilt about this.
Christa has also had to take a step back from helping her family of origin as she is having enough difficulty just meeting the demands of her daily life. This has caused some tension between Christa and her parents as they were very dependent on her for support and advice and do not really understand what has happened to their daughter. Christa feels a great deal of guilt about having to pull back from her parents and struggles setting this boundary."
"Therapist’s Behavioral Observations
This therapist noticed that Christa easily lost track of the topic she was talking about, and at times struggled to find the correct words she wanted to use. With respect to her mood, Christa demonstrated a great deal of sadness and sense of loss, particularly when discussing the changes in her life and her family’s life that have resulted from the accidents."
"SUMMARY AND ANALYSIS OF PSYCHO-SOCIAL IMPACT
In summary, Christa has experienced significant and dramatic changes in her life due to her injuries resulting from the accidents. These changes have resulted in significant role changes in her relationships within her immediate family and within her extended family. She has had to become reliant on her husband to complete much of the household and caregiver responsibilities for their children. She has also had to cope with being unable to return to her job, which she loved and got much of her identity from. Social Work intervention is necessary to begin to address her emotional functioning, adjustment issues and to begin to provide education and support to the family system."