Meaningful occupation is key for individuals to feel a sense of purpose in his or her life. Purposeful activities can include tasks such as work, daily grooming, cooking, cleaning, leisure, amongst many others. When the ability to perform these activities is compromised, individuals look to rehabilitation services and assistive devices to go about their everyday lives as independently as possible. There is a tremendous variety of assistive devices that can be designed or adapted to assist a person in performing daily tasks. To illustrate the importance of meaningful daily occupations and the use of assistive devices to perform these activities, a case study was analyzed. Shane’s impairments and meaningful activities were assessed. After analysis of the case, assistive technology recommendations were made to make Shane as independent as possible with his daily activities.
While analyzing Shane’s case, the Human, Activity, Assistive Technology Model of Practice, which is also referred to as the HAAT Model, was used. The HAAT Model consists of four components: the human, the activity, the assistive technology, and the context. All four of these components make up the Assistive Tech System. This system is designed by assessing the individuals needs, goals, and skills. The human is one of the most complex aspects of the model. It refers to the person with an impairment that is being assessed. Within this component, the basic capabilities of the individual are evaluated. Motor outputs, sensory input, and cognitive processing are all considered during this phase of the model. The activity defines the overall goal to be achieved while using the assistive technology. It is the process of doing specific tasks of daily living, work, or leisure and it represents the functional outcome of human performance. The assistive technology pertains to the devices used to increase human performance. And finally, The context refers to the environment in which the activity takes place and under what conditions. The HAAT model of practice was chosen because it’s goal is to provide assistive technology that meets the needs of our client, while staying consistent with his skills to maximize human performance with independent daily tasks.
Shane was a 52 year old male who worked in the cooperate office of a major regional sporting goods store chain. He organized and provided training for sales associates, as well as opportunities to use the products that they sell. His wife worked as an educational aide at a local elementary school, while his two young adult children had just recently started their careers in a nearby community.
Shane recently sustained a gunshot wound to the head as a result of a hunting accident. The bullet entered in the left frontal and temporal lobes. Although improvements had been made while in the hospital, Shane continued to have difficulties with Broca’s aphasia, right sided hypertonicity of both the arm and leg, and cognition deficits. Visual limitations were noted in the upper quadrants of his visual field; however, he had started to compensate for this when verbal reminders were given. The high tone in his right upper extremity was limiting his functional use of that side of the body, which has causing many problems considering he was right hand dominant. He did have a gross grasp with limited range of motion, yet found that his movements were slow with poor fine motor control. He was currently ambulating at the time of the assessment using a hemiwalker with minimal assist.
Shane and his wife lived together in a Ranch style home. There were three steps to the enter the home and the fireplace and hot tub were accessible through a walkout door in the basement. In the morning, the couple enjoyed drinking their morning coffee at a large eat-in bar area located in the kitchen while reading the daily newspaper. Some days, however, they preferred sitting at the computer workstation in the kitchen to catch up on bills, email, and current events. Shane thoroughly enjoyed sports, especially biking, kayaking, pheasant hunting, hot-tubing, and relaxing by the camp fire. He also expressed amusement in following both professional baseball and football.
Shane was about to be discharged from the hospital to move back home with his wife where he would continue outpatient therapy. His wife was optimal that Shane would be able to perform his daily self-care routine independently with any assistive technology that may be needed. She also wanted to see him return back to work performing light work duties on a part time basis. Communication at home and for return to work activities was also an important occupation for Shane to continue to improve, including independent telephone access. In addition to the listed goals, Shane expressed that he would also like to be able to continue to participate in his favorite sporting and outdoor activities as his function improved.
A major task affected by Shane’s injury is his ability to preform ADLs by himself. Tasks like bathing, getting dressed, and grooming which were once second nature to Shane are now of great difficulty. His ability to preform these ADLs are impaired by his limited range of motion, poor fine motor control, high tone in his dominant upper extremity, and cognitive impairments following his TBI. Shane’s limited range of motion and high tone in his dominant upper extremity make it difficult to do such things such as comb his hair, wash his body, etc. His lack of fine motor control makes it difficult for Shane to hold self care items such as a toothbrush, razor, and combs. And most importantly, Shane’s cognitive impairments make it difficult for him to remember the sequence of getting ready and all of the proper steps to take in order to complete his self care routine.
Another one of Shane’s activities which was affected by his TBI is his ability to complete the daily tasks at work which he once was able to. Shane worked in the corporate office of a sporting goods store and was responsible for organizing and training staff. His ability to complete these tasks are most affected by his Broca’s aphasia and impaired cognition. His aphasia makes it difficult for Shane to communicate to his employees like he once was able to. He now struggles to make complete fluid sentences. Shane’s aphasia also makes it difficult for him to make phone calls to perspective employees in order to set up training sessions. His impaired cognition also makes it difficult for him to do his job. Shane has trouble with memory and problem solving which will hinder his ability to instruct new employees.
Shane’s social participation has also been reduced by his recent TBI. His slowed movements along with the use of his hemi-walker makes it difficult for him to ambulate throughout the community. His impaired cognition and limited vision has also reduced his ability to drive, so he is dependent on community transportation or friends and family to get around. Shane’s impaired cognition and aphasia also makes it difficult to communicate with others while he is out in the community.
Shane’s ability to participate in his favorite leisure activities was also compromised by his TBI. His ability to bike, kayak, hunt, etc. are affected by his limited Range of Motion along with the slowness of his movements, impaired vision and cognition, and poor fine motor control. His limited ROM makes it difficult for him to paddle a kayak due to the reach and strength involved while using an oar. Shane’s slow movements make it difficult for him to to again paddle a kayak, pedal a bike, and hunt. These activities require swift fast movements. His impaired vision and cognition also make it difficult for Shane to partake in these activities. In order to be safe, one must be able to see where they are while they are biking, kayaking, and hunting along with also remember what to do if a problem arises. Poor fine motor control may also hinder his ability to be a precise hunter. Following major league baseball and football may be harder for Shane due to his impaired cognition. He may not remember from week to week who has won and who has not.
Due to Shane’s TBI, he struggles to complete his ADLs by himself. His wife’s biggest request is that he will be able to return to completing his ADLs by himself. The goal to address this is Shane will be able to complete his self care routine, including getting dressed, brushing teeth, washing hair and body, shaving, and grooming, within 6 weeks. In order to complete this goal, we have recommended a few aides to assist him in his routine. The first is Using a universal cuff to assist with brushing his teeth. This would be helpful to eliminate the need for him to hold the toothbrush with his palm and fingers. The universal cuff may also be used to hold other self care items such as combs and brushes. A universal cuff can be purchased at Ableware for $12.23 Second, A button hook/zipper aid would be useful to assist Shane in buttoning and zipping shirts, because it eliminates the need of fine motor skills in the fingers and hands. A button hook can be purchased at Active Living Now for $15.99 If Shane is unable to manipulate a button hook, we will recommend using velcro in his button shirts to keep them closed while still giving the illusion of buttons. Built up handles on the combs and shaver, The use of pumps on shampoo, soap and conditioner bottles would also be useful, due to the loss of him fine motor skills. Pump bottles can be found at most retail stores for $1-$5 Third we recommend The use of an electric shaver to increase safety and reduce the need for fine motor skills. An electric shaver can be purchased at any department store for a wide variety of prices. Also to increase safety in the bathroom, re recommend placing a Non slip pad on the bottom of the bathtub to prevent slipping and decrease the likelihood of falls. Bath matts may also be purchased at most department stores with prices ranging from $10-$20 A visual poster consisting of symbols which describe the different tasks Shane must do during his bathing and grooming routine can be hung in the bathroom. This is a way of assuring that Shane is doing all of the appropriate steps, while getting ready. The symbols will make it easy for him to understand what is involved in the task, and difficult tasks can be broken down into steps which could be represented by additional symbols and limited words.
Shane’s aphasia and impaired cognition makes it difficult for him to communicate with others around him. Shane has set the goal of being able to successfully express his wants and needs via a communication device within 3 months after receiving the device. We have recommended the use of Proloquo2go on the IPAD along with other simple communication boards to help facilitate this goal. We have recommended that Shane uses the IPAD communication software as much as possible, but when not feasible the use of premade communication boards will be used. The communication board consists of simple pictures and symbols of Shane’s favorite foods, activities, and occupations. Shane will simply point to a symbol in order to communicate his feelings. Numerous symbol boards can be positioned around his house, so they are available during the different tasks and activities he does throughout the day. The different picture boards can be created through boardmaker or other software already owned by the OT department.
To assist with Shane’s mobility we think that a catrike would be beneficial. Shane and his family have expressed to us that he enjoys riding bike, so we thought that this piece of equipment would incorporate his love for biking and provide an answer for how Shane is going to travel to places he desires to go. This catrike was the appropriate choice for Shane because it is both affordable and user friendly. The recumbent design makes it easy for Shane to sit safely in the wide seat. It also makes it possible for Shane to travel substantial distances with less effort than that of which would be required with a traditional bicycle. The recumbent design makes it possible for Shane to ride a bike, without the feel of falling, due to losing his balance. The adjustable seat back, rear view mirror, and self centering capabilities make it the safe and appropriate bike for Shane. This bike will also allow him to spend time with his family doing something that he loves. This specific Catrike is made by BigCat, and sells for $1800-$2000, depending on the specific model and desired accessories. We believe that the catrike will be both enjoyable and beneficial for Shane.
Since a large amount of Shane’s work tasks are related to computing, we are recommending the Logitech Wireless Trackball Mouse to assist him with mousing tasks. Shane’s limited fine motor skills have proved to be problematic when working with a regular sized mouse. The logitech mouse pictured here would be useful to Shane, because it provides large buttons and a large trackerball. The trackerball built into this mouse is larger than a traditional tracker ball, making scrolling through pages and selecting items on the computer screen easier for Shane. The large buttons on this mouse make the task of selecting items on the computer screen easier for Shane to accomplish, than would regularly be experienced with a traditional sized mouse with smaller buttons. This mouse also glides with ease, assuring that Shane would have to put forth minimal effort to move the mouse to the location he so desires. This specific model of mouse sells for around 69.95 and can be found at any major office supply store or electronic sales store. We are confident that Shane will be successful in using this mouse, and that his lack of fine motor skills will be less problematic while doing mousing and computer tasks.
Typing tasks are problematic for Shane, due to the loss of his fine motor skills and cognitive impairment. An enlarged keyboard would make typing easier for Shane, until cognitive gains are made and fine motor skills are improved. The keyboard pictured here is the Big Key Plus Keyboard made by Fentek industries. The color coded keys would assist Shane in recognizing the appropriate keys. This keyboard can easily connect to any PC or Mac. Since a great deal of Shane’s daily work tasks involve the use of a computer, this would be a beneficial device for him. His work task of typing schedules for employees would be made simpler through the use of this enlarged, color coded keyboard. This keyboard can also successfully be connected to Shane’s iPad, which we have requested funding for, to further provide assistantance for Shane. We are confident that this keyboard will provide necessary assistance for Shane to gain independence with typing tasks.
Through meeting with Shane and his family several times we have learned that Shane enjoys using the hot tub, in their backyard, very much. This struck us as a very important occupation to address, since it is not only something that Shane enjoys, but also something that his family enjoys doing with him. Since his family is such an influential factor in the success Shane will have in therapy, we found it necessary to collaborate and come up with a way to make hottubbing both safe and enjoyable for Shane and his family. Through a home assessment, we found that higher steps would be beneficial, in order to, make climbing in and out of the hot tub safe for Shane. We found 4’ steps that would adequately reach the top of the hot tub. These steps are beneficial for Shane because they are wide and have adequate depth for foot placement. Shane can further benefit from applying not slip tred to the steps, which would further increase safety upon entering and exiting the hot tub. This model of stairs is made by rhtubs and can be bought for around 200-250 dollars.
Another important leisure activity that we have found out that Shane enjoys is hunting. Through interviews with his family, we have learned that Shane has numerous family and friends who are willing to assist him during hunting outings. This information assured us that Shane would be in a safe environment while hunting and using firearms, so we are confident in suggesting a trigger adapter for Shane. The trigger adapter shown here sells for under $10, and can be bought through rjbowers distributers. The trigger adapter attaches to the trigger and eliminates the need for shane to squeeze the trigger with his finger. Instead, Shane can simply use his palm to pull the trigger. Adaptation devices that address leisure activities Shane enjoys are important for us in order to allow Shane to participate in all of his meaningful occupations, and provide motivation for him to continue in therapy and rehabilitation services.
Say something about calling BCBS and asking about the process and that they said to write a justification letter. Look up code for AT in book. Through requesting funding for assistive technology, a justification letter was sent in to the source we were requesting funding from. There are various sources which may fund assistive technology so it important to choose a source that is supportive of your request. Funding sources include public agencies such as Medicaid, Medicare, the office of Vocational Rehabilitation, private agencies, and commercial insurance companies such as State Farm and Blue Cross/Blue Shield, service organizations such as Knights of Columbus, “Make-A-Wish”, and churches, and contributions from businesses or private individuals
Within the justification letter, specific components were addressed in order to successfully rationalize the necessity of the equipment. Some of these included the client’s current capabilities, a thorough description of the device, and how it will benefit the user’s condition.
For the purpose of this case, a request was made to Blue Cross/BlueSheild to fund an Apple iPad for our client, Shane. The introduction of the letter included a brief yet concise description of Shane, his recent injury, and the current impairments he has from the injury. Next, we introduced the interdisciplinary team who was involved with Shane’s evaluation and the decision to request an iPad for assistive technology. The iPad we requested was the Apple iPad 2 32 GB with Wi-Fi capability from apple.com for $599.00. The team came to the conclusion that this would be a primary assistive device for him because it could play the role of a communication device, daily schedule reminder, and email access for future work related tasks. More specifically, it was chosen for its wide range of applications and ability to be easily transported.
Used to set daily reminders and program bus schedule Some of the applications that we as occupational therapists are especially interested in working with Shane to communicate effectively are the Proloquo2Go, which is a cost-effective solution that brings text to speech, the iWorks, including KeyNote (which is similar to the more popular powerpoint), Pages (which is similar to the more popular Microsoft word), and Numbers (which is comparable to the well known excel spreadsheet), all of which will enable the user to create word documents, presentations, and spreadsheets.
Additionally, the iPad will be an effective therapeutic tool for Shane because it will incorporate occupation based games he enjoys like hunting, football, baseball, and biking when the actual activity is unable to be done. These virtual games will serve as an opportunity for Shane to not only do something he enjoys, but to incorporate his family into these leisure activities. There are additional built-in features of the iPad that will assist with Shane’s functional abilities. One feature is Speak Auto-Text, which will help him by suggesting words while typing and then speak it out loud to make sure it accurately expresses what he wants to communicate. There are both audible and visual alerts for incoming and outgoing mail and calendar events.
Due to Shane’s visual impairments, another beneficial feature is the zoom option, which allows the user to zoom in and out on specific areas or magnify the entire screen. The Intelligent Onscreen Keyboard with Predictive Text Entry makes it easier to type and avoid misspellings by incorporating advanced technologies such as autocapitalization and autocorrection. Some general features which will aid Shane with everyday life include street or geographic maps, a notepad to jot down ideas, a calendar organizer, and contact lists to remember people’s names, numbers, or emails.
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