Running head: GROUP CASE STUDY ANALYSIS 1

Group Case Study Analysis

Breanna N. Dickson, Alicia A. Ellingson, Susan C. Kaiser
Megan J. Lawrence, Julia R. Lytton, Jessica A. Scott
Touro University Nevada














GROUP CASE STUDY ANALYSIS 2

Description of Areas of Occupation
Liam is a 15-year-old boy who suffered from a brain bleed secondary to an arteriovenous
malformation (AVM). He is diagnosed with global aphasia and verbal apraxia; affecting his
participation in the eight occupational areas as listed in the Occupational Therapy Practice
Framework.
Activities of Daily Living (ADLs)
The OTPF defines Activities of Daily Living as activities that are oriented toward taking
care of ones own body (OTPF, 2008). Liam requires Min during bathing and grooming
activities, such as obtaining and using supplies, drying body parts, maintaining position, and
transferring to and from the bathing position (OTPF, 2008). Verbal apraxia interferes with
feeding and dressing since he is unable to effectively communicate his needs, requiring Mod .
Finally, the ADL of personal device care requires that he learn how to manipulate the DynaVox
communication device for his daily routines.
Instrumental Activities of Daily Living (IADLs)
Instrumental Activities of Daily Living (IADLs) are activities to support daily life
within the home and community that often require more complex interactions than self-care used
in ADL (OTPF, 2008). The subcategories of care of pets, meal preparation and cleanup, and
shopping require Max.
Rest and Sleep
Rest and sleep include activities related to obtaining restorative rest and sleep that
support healthy active engagement in other areas of occupation (OTPF, 2008). Liams mother
has stated that he sleeps well during the night and has a good sleep schedule.
Education
GROUP CASE STUDY ANALYSIS 3

The OTPF (2008) defines education as activities needed for learning and participating in
the environment. Prior to the AVM, Liam was academically performing at his grade level.
Currently, he has difficulty operating a calculator and a using a computer keyboard. Participating
in academics will now require Liam to learn how to use a specialized communication system
(DynaVox).
Work
N/A
Play
Play is defined as any spontaneous or organized activity that provides enjoyment,
entertainment, amusement, or diversion (Parham & Fazio, 2008). In his free time, Liam enjoys
playing computer puzzle games, Candy Crush, drawing, and painting.
Leisure
N/A
Social Participation
The OTPF defines social participation as organized patterns of behavior that are
characteristic and expected of an individual or given a position within a social system (OTPF,
2008). Liam engages in social participation at home with his family. This is considered a social
deficit due to the fact that at fifteen years of age, his primary social interactions should be with
other peers.
Description of: Movement, Postural Reactions, and/or Reflexes
Liams movements, postural reactions, and reflexes have various functional ranges
depending on position. In a sitting position, Liam has good dynamic and static balance.
GROUP CASE STUDY ANALYSIS 4

However, ambulation is complicated by balance issues. Liams RUE remains contracted at the
elbow, hindering the swing motion of the arms during ambulation, causing balance issues.
For children to carry out skillful, coordinated, and effective movements, whether they are fine
motor or gross motor actions, they must have an adequate foundation of balance and postural
control (OBrien & Williams, 2010). As a result, Liam requires Min when walking. This is
a potential safety concern as his RUE is contracted, impairing his protective and equilibrium
reflexes during ambulation. These reflexes help children protect the body from injury during
loss of balance; if some instability occurs that could lead to a fall, the child extends the
appropriate set of limbs to protect the body (OBrien & Williams, 2010).
In addition, Liam exhibits motor planning and coordination impairments when operating
devices such as a computer keyboard or calculator. Motor planning and coordination skills are
essential components needed to complete ADLs and IADLs. Another factor influencing Liams
movement and reflexes is his moderately impaired vision. Liam has difficulty tracking,
decreased awareness of his visual fields, reduced depth perception, and is unable to perform
convergent eye movements. These factors reduce his ability to be aware of his surroundings and
respond accordingly. Children use information from the visual system, including visual
structures and visual perception to understand the nature of the environment so they can respond
to what they perceive and act on it (OBrien & Williams, 2010).
Sensory Integration or Self-Regulation
Post AVM, Liam has developed problems with sensory integration. Jean Ayres (2005)
defines sensory integration as the organization of sensory input for use. The use may be a
perception of the body or the world, an adaptive response, a learning process, or the development
of some neural function. Through sensory integration, the many parts of the nervous system
GROUP CASE STUDY ANALYSIS 5

work together so that a person can interact with the environment effectively and experience
appropriate satisfaction. Liam is noted as having sensory integration issues associated with the
tactile, the proprioceptive, and the visual senses. Specifically in his right upper extremity, the
client has impaired sensations relating to light touch, deep pressure, and sharp/dull pain. Touch
orients the body to its surroundings. For example, discriminating between warm, hot, and
burning begin with touch sensation. Similarly, registering the difference between clothing
fabrics, lotions, water, and most everything that comes in contact with your skin relies on ones
sense of touch.
The client has also acquired moderate vision impairments. He has difficulty with visual
perception, including pursuits, convergent/divergent eye movements, decreased visual field
awareness, and depth perception. Visual tracking is especially important for reading and
handwriting. Tracking is the ability to maintain control and speed when following a sentence,
stopping on a word, or jumping to another paragraph (The Vision and Learning Forum, 2014).
Tracking is also necessary for other occupations such as play and social interactions. Difficulty
tracking reduces the clients ability to engage in the educational environment.
Safety concerns are prominent when addressing decreased awareness of visual fields and
depth perception. According to Windsor (2014) patients often run into objects, lose their place
in reading and are startled by people or objects moving at them suddenly from the lost field.
Running into objects can be potentially dangerous if the client falls, especially if the RUE is
involved and he has less sensory awareness. Finally, decreased depth perception is both a safety
and functional concern. Depth perception allows humans to identify colors, outlines, shadows,
objects in motion, distance, etc. In order to adequately judge hazards, nuances, and objects in
your environment; depth perception is necessary.
GROUP CASE STUDY ANALYSIS 6

There is no notation in Liams chart that he is experiencing problems with self-regulation.
However, given the extent of his impairments, it is reasonable to assume that the client is
exhibiting greater levels of frustration.
Apply the PEOP Model to the Client
The Person Environment Occupational Performance (PEOP) model was developed in
1985 by Christiansen and Baum to highlight the complexity of environment, occupation, and
personal relationships (OBrien & Hussey, 2007). The PEOP is a client centered model. Using a
top-down approach, the PEOP focuses on the clients perception of their occupational
performance issues. The PEOP model can be applied to the client, environment, and
occupational performance in order to guide intervention planning. This will help the therapist
gain a better understanding of the interaction between Liams intrinsic factors and extrinsic
factors, and how they affect his occupational performance.
The person portion of the PEOP model is Liam, a 15-year-old boy who suffered a stroke
last year. For the environmental aspects, he continues to live at home with his mother, father and
sister. For Liam, his home now feels like a new environment, because he has to learn to navigate
his home all over again. Previously, he attended high school, but now spends his days in a
neurorehabilitation treatment program, which is also a new environment he has had to adapt to.
Since his stroke, Liam has experienced global aphasia, verbal apraxia, impaired
sensation, and visual deficits which affect his occupational performance. Liam can answer yes
or no questions 50% of the time. He is in the process of acquiring a DynaVox to aid in his
communication. Liams LUE muscle strength is fair and he has range of motion within
functional limits. Most of the damage Liam sustained post AVM is in his upper right extremity.
His RUE remains contracted at the elbow. This interferes with Liams balance, especially during
GROUP CASE STUDY ANALYSIS 7

ambulation, as he lacks the natural arm swing necessary to maintain balance. Liams difficulty
tracking, inability to perform convergent eye movements, decreased awareness of his visual
fields, and reduced depth perception decreases his ability to perceive his surroundings,
negatively impacting many areas of ADLs.
Since sustaining an AVM, Liam has had to face new challenges that impede his
occupational performance. The interactions of his intrinsic and extrinsic factors require Liam to
relearn how to engage in his occupations of daily life. Through the utilization of the PEOP
model, the therapist can further facilitate Liams recovery.
Most Appropriate Theories and/or Practice Models
Three frames of reference (FOR) that are most appropriate for Liam include:
compensatory/adaptation, psychosocial, and dynamic systems theory. A
compensatory/adaptation model encourages the use of equipment or procedures to save energy
and simplify difficult tasks. Due to global aphasia, Liam is only able to respond to questions with
a yes or no answer. This limits his communication abilities significantly. The use of a
DynaVox would provide him with a way to express his needs and wants. The DynaVox is an
assembly of pictures that can be pressed to make sentences or identify objects, giving Liam a
better way to communicate.
Liam would also benefit from the implementation of the psychosocial frame of reference.
The psychosocial frame of reference would take into account the traumatic, life-changing
experience affecting Liam and his family. Specifically, it takes into account the intrapersonal,
interpersonal, and social aspects that affect a client's situation and actions (Ramsey, 2004). The
intrapersonal component of this FOR is vital because Liam will have to adjust to his new life,
with many new challenges to face. He may become angry and frustrated, necessitating the
GROUP CASE STUDY ANALYSIS 8

importance of a clinician to form a positive and secure relationship with him. In turn, other
people may affect Liams intervention outcomes and influence his functional performance
(Ramsey, 2004). The interpersonal and social aspects affect his relationships with family, old
friends, and new people that come into Liams life.
The dynamic systems theory would also be beneficial to Liam. It identifies how
movement is affected by context and an assortment of sources within those contexts. Sources
such as socio-emotional, neuromuscular, cognitive and environmental all have a direct impact on
Liams intervention outcomes (OBrien, 2010). Liams physical movement has been impacted
by his acquired brain injury; therefore, it is important to consider all of the influences
surrounding Liam in order to provide an intervention that is tailored to his needs. This FOR is
also relevant for Liams caretakers, as the physical exertion of caring for a fifteen-year-old male
is demanding. The more independence and safety Liam can acquire in his movements, the less
physical strain his family will endure.
Assessments Appropriate for this Client
The Childrens Assessment of Participation and Enjoyment (CAPE) and the Preferences
for Activities of Children (PAC) will be used to guide future intervention plans for Liam. The
PAC and CAPE, designed for 6- to 21-year-olds, with or without a disability, assess levels of
participation in a variety of non-school activities. With each of these self-report assessments, the
child is asked to point to the facial expression that accurately reflects how they feel about
participating in a particular activity. The non-verbal characteristic of this assessment is well-
suited for Liam, due to his aphasia. The CAPE portion of this assessment will be used to evaluate
the activities that Liam currently participates in, with whom and where he does those activities,
and how much he enjoys doing them. A wide assortment of activities are listed within the
GROUP CASE STUDY ANALYSIS 9

categories of Hobbies, Crafts, and Games, Social Activities, Quiet Recreation, Organized
Sports, Other Skill-Based Activities, Clubs, Groups, and Organizations, Active Physical
Recreation, Entertainment and Education, and Jobs, Chores, and Employment (King et al.,
2004).
At 15 years old, social participation will be an important aspect of Liams treatment plan,
and knowing with whom he performs activities (alone, with family, or with others), is beneficial
when planning interventions that will help to increase his social participation (King et al., 2007).
The PAC portion of this assessment was designed to be used along with the CAPE, but can also
be administered on its own. The PAC is unique in that it doesnt just look at what a child is
participating in, but what they most enjoy doing and would most like to do if they were able or
given the opportunity. Categories within the PAC include Recreational Activities, Physical
Activities, Social Activities, Skill-Based Activities, and Self-Improvement Activities
(King et al., 2004). Identifying Liams preferences for activities will be an important aspect of
determining future motivating treatment goals.
The Pediatric Evaluation of Disability Inventory-Computer Adaptive Test Mobility
Domain (PEDI-CAT) is another assessment that will be used with Liam. This evaluation tool,
which assesses the domains of Daily Activities, Mobility, Social/Cognitive, and Responsibility,
is appropriate for children from birth through age 20 and all clinical diagnoses. The PEDI-CAT
is intended to enable clinicians to construct a description of a childs current functional status or
progress in acquiring functional skills that are part of everyday life (Dumas & Fragala-Pinkham,
2012). A summary of scaled scores is provided for each of the domains assessed. According to
pedicat.com, Scaled scores are especially helpful in documenting improvements in functional
skills for children not expected to exhibit or regain normative levels of functioning. Since there
GROUP CASE STUDY ANALYSIS 10

is no limit as to how often this assessment can be given, Liams progress can be well-monitored.
Additionally, each of the domains within the assessment is self-contained, allowing them to be
used individually or in conjunction with each other. The PEDI-CAT can be administered by
anyone familiar with the child, including the childs parent, caregiver, or therapist, and requires
no special activities, equipment, or environment, adding to its ease of use. Items under the
domain of Daily Activities include Getting Dressed, Keeping Clean, Home Tasks, and
Eating & Mealtime (pedicat.com). These are all IADLs that are important for a teenage boy to
be able to perform as independently as possible. Mobility assesses Basic Movement &
Transfers, Standing & Walking, Steps & Inclines, Running & Playing, and Wheelchair
(pedicat.com). Because Liam struggles with some of his IADLs, due to restricted mobility, it will
be important to monitor his progress in these areas. The domain of Social/Cognitive includes
Interaction, Communication, Everyday Cognition, and Self Management (pedicat.com);
again, all things extremely important to a 15-year-old boy. Responsibility assesses the categories
of Organization & Planning, Taking Care of Daily Needs, Health Management, and
Staying Safe (pedicat.com). Although the family currently does not want to leave Liam alone
out of fear that something could again happen to him, as he gets older, this will probably not
always be the case. His ability to care for himself and follow safety precautions will hopefully
help the family with this transition. Within the four domains of the PEDI-CAT are 276 activities
and measures of functions. The number of items tested is flexible and can be determined by the
childs abilities. How a client responds to the item in the middle range of responsibility or range
within a particular domain, dictates the next item to be assessed, which will either be easier or
more difficult. (Dumas & Fragala-Pinkham, 2012). A study by Helene Dumas and Maria A.
Fragala-Pinkham (2012) found the PEDI-CAT to be valid and reliable.
GROUP CASE STUDY ANALYSIS 11

Functional Problem Statements.
1. Client requires Max in operating a calculator or computer due to coordination and
motor planning impairments.
2. Client requires Mod in eating due to limited ROM of right fingers and inability to
perform opposition movements.
3. Client requires Mod in dressing and Max A in fastening/buttoning clothes due to
limited RUE shoulder flexion, limited ROM of right fingers, and RUE impaired sensations.
4. Client requires Max in taking care of his dog and shopping due to vision and balance
impairments.
5. Client requires Max in meal prep and laundry due to balance, coordination and motor
planning impairments.
Family/Caregiver/Child Goals
1. Family would like Liam to increase skills required to operate a keyboard and his
assistive technology (DynaVox) with minimal assistance.
2. Family would like Liam to be able feed himself.
3. Family would like Liam to be able to dress himself, including buttoning his shirts.
4. Family would like Liam to be able to care for his dog.
5. Family would like Liam to be able to prepare a simple snack/meal on his own.
Occupational Therapy Goals
Goal: Liam will be independent in meal prep for one meal a day by 12/10/14.
Liam will perform a two-step cooking process with Min while standing by 5/10/14.
Liam will work on coordination and motor planning skills by independently retrieving
five ingredients on a recipe card from the kitchen times by 8/10/2014.
GROUP CASE STUDY ANALYSIS 12

Goal: Liam will be independent in dressing by 12/10/14
Liam will don his pants independently while standing 75% of the time by 5/10/14.
Liam will button his clothing with Min 100% of the time by 8/10/2014.
Goal: Liam will be able to care for his dog independently 75% of the time by 12/10/14.
Liam will leash and unleash dog independently by clasping/unclasping a carabiner 2/4
times by 5/10/14.
Liam will walk his dog with supervision for at least fifteen minutes by 8/10/14.
Objectives for Each Occupational Therapy Goal
Objective: Liam will perform a two-step cooking process with Min while standing by
4/1/2014.
Activity - Liam will practice spreading peanut butter and jelly with a butter knife on
two slices of bread to form a sandwich. During this activity, Liam will utilize fine
motor skills by manipulating the knife to retrieve and spread peanut butter and jelly.
He will use a disc grasp to uncap these items.
Activity - Liam will practice pouring water into microwavable macaroni and cheese
cup (e.g. KRAFT Easy Mac) and placing cup in microwave. During the pouring of the
water, Liam will need to use proper motor planning and judgment to fill the cup to the
proper level. He may need supervision after microwaving to prevent burns.
Objective: Liam will work on coordination and motor planning skills by independently
retrieving five ingredients listed on a recipe card from the kitchen times by 4/1/2014.
Activity - Using a Velcro storyboard, Liam will choose items from a recipe list and
place the picture of the item onto the storyboard. To grade this activity up, verbal
GROUP CASE STUDY ANALYSIS 13

cueing will be limited. The use of a visual storyboard will help Liam organize his
planning within the kitchen.
Activity - Liam will perform a kitchen scavenger hunt to find five ingredients listed on
a recipe card. Directional clues will be provided. Sequencing can be used to grade the
activity up.
Objective: Liam will don his pants independently while standing 75% of the time by
5/10/14.
Activity - In high kneeling, Liam will practice throwing and catching a soft, padded
ball with family members to increase balance. This activity was adapted to provide
Liam more stability. This activity could be graded up by increasing the distance
between him and the family member that he is throwing with.
Activity - While sitting on a therapy ball, Liam will play his Wii video game to
increase balance and upper extremity strength. It is important that the therapist is
within arms reach to ensure Liams safety. The games that should be utilized during
this activity include Wii Mario Kart and Wii Sports.
Objective: Liam will button his clothing with Min 100% of the time by 8/10/2014.
Activity - Liam will play an extraction game with tweezers (e.g. Operation) with his
family to increase pincer strength. This game provides auditory feedback and tactile
input. It also allows social interaction among Liams family.
Activity- Liam will make necklaces for his family members by stringing various size
beads onto a string to increase coordination. During this activity, Liam will use his
right hand to hold the string, while his left strings the beads. Larger beads will be
utilized during initial treatment and will decrease in size as time progresses.
GROUP CASE STUDY ANALYSIS 14

Objective: Liam will leash and unleash his dog by clasping/unclasping a carabiner
independently 2/4 times by 4/1/14.
Activity - Liam will increase L hand grip strength by squeezing paint bottles onto a
palate. This activity stimulates Liams proprioceptive awareness by requiring him to
regulate how forcefully the paint bottle is squeezed. This is a preferred activity of
Liams.
Activity - While playing fetch with his dog, Liam will squeeze the dog ball with his
left hand until he hears the squeak sound, then throw the ball to his dog. Liams
cognitive processes will be needed to have proper sequencing to play effectively with
his dog. Squeezing the dog toy also provides an opportunity to strengthen Liams
hand.
Objective: Liam will be able to walk his dog with supervision for at least fifteen minutes
by 4/1/14.
Activity - Liam will stand with supervision and play Wii Skiing for 10 to 15 minutes.
This will help to improve balance and motor planning. This also helps Liam with
spatial awareness.
Activity - Liam will independently carry his clothes in a basket from the laundry room
to his bedroom. This will help his balance by changing his center of gravity. The
activity can be graded up or down with how much weight is placed in the basket.
Treatment plan
Treatment session with an occupational therapist will take place within the home
environment.
Objectives:
GROUP CASE STUDY ANALYSIS 15

Increase independence in meal prep
Facilitate motor planning and coordination
Increase balance through functional activity
Materials needed:
Bread
Peanut butter
Jelly
Butter knife
Images of 5 food ingredients
Marker
11:00-11:20: Therapist will guide Liam through making a peanut butter and jelly sandwich.
To facilitate the making of a peanut butter and jelly sandwich, the therapist will have an
ingredient list consisting of bread, peanut butter, and jelly. The activity will be explained to Liam
and the ingredient list will be placed on the table for referral. Liam will first be instructed to
gather all of the ingredients. Functional ambulation and motor planning will be monitored.
Once ingredients are placed on the kitchen counter, Liam will remove a butter knife from
the utensil drawer. First he will remove the lids from both jars using a disc grasp. Second, he will
spread the peanut butter and jelly onto the bread. Additional cueing will be provided as needed.
To find Liams just-right level, this activity will be graded up or down by providing physical
assistance while gathering ingredients, having Liam either stand or sit while preparing his
sandwich, and/or by providing verbal cuing as necessary.
11:20-11:40: Return food items to proper storage space.
GROUP CASE STUDY ANALYSIS 16

If desired, Liam will eat his sandwich. The therapist will instruct him to return the bread,
peanut butter, and jelly to the cabinets, allowing the therapist to examine Liams cognitive skills,
in addition to his balance and motor planning.
11:40-12:00: Kitchen scavenger hunt.
Liam will be given a paper with the images of five ingredients that are located within his
kitchen. Using the paper as his guide, he will be instructed by the therapist to gather each item,
one at a time, and place them on the kitchen counter. After each ingredient is placed on the
counter, Liam will use a marker to cross the item off the list. This activity encourages Liams
participation in the kitchen by increasing his knowledge as to where ingredients are located. It
also facilitates Liams balance as he ambulates while carrying items and promotes motor
planning and coordination as he gathers items.
Post-discharge Environment
Liam will require further support at the conclusion of therapy. At the time of discharge,
he will continue to reside at his family home with his mother, father, and sister. They will play a
vital role in helping Liam be as independent as possible, and maintain a positive attitude during
times of struggle. Home adaptations are not needed, but continued supervision in the kitchen and
while walking his dog outside are important to ensure Liams safety. In order for Liam to
continue to make improvements, the family is encouraged to provide support for Liam, so that he
can continue performing activities that were done with the occupational therapist.
It is recommended that Liam continue to play the video games he enjoys, with the
introduction of new, more challenging games, as available or practical for the family. Additional
activities that could further benefit Liam with his fine motor skills include craft and small
building set projects, such as model cars or airplanes. Liam should be encouraged to socialize
GROUP CASE STUDY ANALYSIS 17

with kids his own age, as well as communicate his needs and wants by using the DynaVox as
often as possible throughout the day. Liam will continue working toward the goal of returning to
school with the support of an aid.
SOAP Note
Name: Liam Age: 15 y.o.
Date: 2/13/14 Time: 11:00 AM
S: Liam came into the therapy session with a positive attitude. Mom reports he had a good
nights sleep.
O: Liam participated in a 60-minute OT session at home to focus on improving
independence in meal prep, facilitating motor planning and coordination, and increasing
balance with functional activities. Liam required verbal cueing times to retrieve and
return ingredients for sandwich making activity. Liam used a L lateral pinch to grasp
butter knife and required Min A to stabilize the bread while spreading. Liam required
Min A for functional ambulation due to balance and required verbal cueing to find and
retrieve items during a kitchen scavenger hunt activity.
A: Liams inability to use topographic organization to retrieve items in his kitchen w/o
verbal cueing interferes with his ability to be independent in meal prep. Liam
demonstrates progress by transitioning from L radial palmar grasp to L lateral pinch.
Potential to improve IADLS is demonstrated through clients increased motor planning
during meal prep. Liam will benefit from skilled OT services to increase motor planning,
coordination, and balance with functional activities.
GROUP CASE STUDY ANALYSIS 18

P: Liam will receive skilled in-home OT services for 60-minute tx sessions 2X/wk for 6
months to improve independence in meal prep and facilitate motor planning and
coordination.
Justification
The decision to use a Wii gaming device as an activity to increase muscle strength was
conceived from a study by Lee (2013). This study examined the effectiveness of using video
games (the Xbox in this case) to improve the muscle strength, muscle tone, and the ability to
perform ADLs of patients who had experienced a stroke. Subjects of this study were randomly
assigned to either a control or an experimental group. Both groups participated in 30 minutes of
occupational therapy 3 days a week for six weeks; the experimental groups OT sessions
included an additional 30 minutes of playing Xbox Kinect.
Participants were allowed to engage in a variety of Xbox games they found enjoyable.
They ...receive feedback immediately...because users can see their posture and movements in
the virtual environment in real time (Lee, 2013). Pre- and post-tests showed all participants had
increased upper extremity strength, with the exception of the wrist. Although no significant
difference between the two groups in this study was found, Song et al. (as cited in Lee, 2013)
reported that stroke patients saw a significant increase in upper extremity muscle strength after
training with Wii video games. Additionally, Lee (2013) noted that for functional recovery, the
Xbox Kinect, as an intervention, may be suitable.
The Xbox, as well as similar gaming systems, provide activities that can be used in the
home, with other participants, and without the supervision of an occupational therapist. Different
speeds and muscle activations provide grading of the activities. According to data gathered by
the authors of this case study, this is an age-appropriate device for Liam. The Xbox will also
GROUP CASE STUDY ANALYSIS 19

provide him with an activity that others his age, as well as his family members, can participate in
with him.
One of Liams IADL goals is to participate in a two-step meal preparation process. Poole,
Sadek, & Haaland (2011) compared meal preparation abilities in patients with right or left
hemisphere damage to a healthy control group. The participants were observed during a meal
preparation task which included (1) preparing a simple meal of hot beverage and toast, (2)
eating the meal, and (3) cleaning up (Poole, Sadek, & Haaland, 2011). Significant difference
were observed in participants with right and left hemisphere damage. In comparison to the
healthy control group, individuals with right hemisphere damage (RHD) performed the task
more slowly and made more location and planning errors. On the other hand, the group with left
hemisphere damage (LHD) made greater errors in confusing objects. The author of this study
does not elaborate on the term independence; however, based on their discussion with the two
stoke groups, they each exhibited different problems with functional independence. The RHD
group, exhibited problems with spatial deficits while the LHD group exhibited problems with
aphasia. The authors concluded that increasing the amount of time devoted to mealtime
preparation does not result in functional performance. This information is critical to helping
Liam become independent in meal preparation. Liam, like the participants in the study with
LHD, has aphasia. Therefore, helping Liam to succeed in a two-step meal preparation task will
require visual, tactile, and kinesthetic activities.
An ADL that Liam seeks to achieve is dressing independently. Walker, Sunderland,
Sharma & Walker (2004) studied the difficulties of upper body dressing following a stroke. The
researchers used several assessment tools to analyze upper body dressing, along with the novel
approach of using a video analysis of short dressing. Participants were visually cued, with no
GROUP CASE STUDY ANALYSIS 20

verbal or physical assistance, to put on a shirt. They were given three minutes to complete this
timed task and were rated based on whether an error was repairable or non-repairable.
Participants with left hemisphere damage showed errors which included disorganized
strategy...and failing to push the sleeve high enough over the paretic elbow (Walker, Sunderland,
Sharma & Walker, 2004). The errors expressed with patients with left hemisphere damage
suggest apraxia. Based on video analysis, the authors concluded that the best intervention
strategy for dressing the upper extremities is through a compensatory frame of reference. This
information is extremely applicable to Liam. Currently, he is Mod for dressing without
buttons and Max A for buttoning shirts. Introducing compensatory strategies during treatment
sessions could greatly enhance Liams independence in dressing his upper body.

GROUP CASE STUDY ANALYSIS 21

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