Case Study: TBI, severe deficits in memory, hemorrhage, mild cognitive slowing

Name of Organization: Therapy Solutions, Wolverine, MI

Associates Name & Discipline: Amy Dubey, OTR/L, CBIS, iLsP, CIMP, SIPT

Age / gender of the client: 24 year old female

Date: November 1, 2016

Background Information:

Sarah has a history of 2 motor vehicle accidents; first in December 11, 2009 (16 years old) and second on October 30, 2015 (23 years old). After her first accident she continued to demonstrate severe deficits in memory and confrontation naming, as well as mild cognitive slowing. There were also concerns about poor judgment and reasoning. The second accident, she hit a telephone pole at a high rate of speed and was unconscious at the scene with a Glascow Coma Scale score of 3 (Severe Disability (3-8): Coma: unconscious state.  No meaningful response, no voluntary activities). Initial CT scan of the head showed a 6 mm right subdural hemorrhage. MRI of the brain showed bilateral subdural hemorrhage with small shift to the left. Follow-up CT scan on October 31, 2015 revealed stable right subdural hemorrhage with slight increase in right to left midline shift and a new subdural hemorrhage on the left superimposed on a chronic subdural hemorrhage.

Sarah lives at home with her mother, step-father, and maternal grandmother (part of the year). She has 2 siblings that live outside the home. In 2012 she graduated from High School; she received special education services following her 2009 brain injury. Prior to the recent brain injury she was working part- time at a restaurant (busing tables, washing dishes) where her mother also worked.

Presenting Problems:

Sarah and her mother reported in August 2016 the following: pain in lower back, pain in right shoulder, loss of balance resulting in occasional falls, sensitivity to light and sound, occasional dizziness, and decreased sensation on the entire left side of her body. Her memory continues to be severely impaired. She can recall information immediately after it was presented and forgets after a short delay. She has trouble keeping up pace with conversations and television. Sarah often thinks everyone is talking about her and insistent to know what they are talking about when she enters a room. Her tone of voice and facial expressions are flat.

Therapeutic Goals:

The following are Sarah’s occupational therapy goals:

1.) Auditory Figure Ground – to be able to participate and recall information, such as social occasions, Dr. appointments, phone calls, television, radio and the like.

2.) Auditory Divided Attention

3.) Rhythm/Timing and Coordination for Safe Mobility

4.) Attention/Focus – to attend while performing activities of daily living (grooming, cooking, and the like)

5.) Motor Coordination – for motor control (left UE) and performance with activities of daily living.

Parent Goals:

1.) increase memory skills

2.) decrease pain

3.) increase sleep

4.) increase ability to perform basic daily living skills on own

5.) follow conversations

iLs Program used: SSP was used 5consecutive days in one week.

She listened 3 days at the clinic and 2 days at home. Days 1, 3, and 5 were completed in the clinic.

Other Interventions Used:

Occupational Therapy – 3 times a week for 1 ½ to 2-hour durations

Speech Language Therapy – 3 times a week for 1-hour durations

Summary of Changes:

The following are changes the mother noted post SSP program:

• better mood
• when her niece scared her, she had a brighter smile and her voice seemed to match the situation
• smile seems bigger and more genuine
• very happy while wearing head phones – almost acts like she wants to laugh
• 4th day of headphones she had excitement while wearing. She wanted to sing and dance with music.

Her mother completed the Caregiver Questionnaire post the SSP. The following are her responses:

Any thoughts or observations regarding specific changes in your child’s behavior following the intervention?

* “Really no change in behavior. But, a change in facial expressions. When happy, she looks a little happier, when angry she has the dirty look face mastered. Voice slightly fluctuating. But still mostly monotone.”

Therapist noted that during the 3 therapy sessions in the clinic that Sarah listened to the entire music session without frustration or wanting to stop. During the 3 rd and 5 th session she was observed smiling and enjoying the music to the point that she was stopping herself from singing and dancing in her chair while listening. Her mother reported that it was nice to see her daughter enjoy the music.

Conclusions and Recommendations:

Upon observation, the music appeared to have a positive effect on the clients emotional state. She was observed dancing in chair slightly and having a smile on her face while listening. She also expressed that she liked the music and enjoyed it. This therapist recommends trying to listen to this again in three months to see if there are additional benefits and/or the same effect on the client.