Thursday, June 12, 2014

KKI Discharge Evaluation

We got the final discharge paperwork from KKI constraint therapy program in the mail yesterday.  Here are some of the highlights.

She picked up two new grasp patterns.

At admission, Allie could do the following three grasp patterns with her right hand:

  • Raking: extending arm toward a desired object but does not yet have the ability to purposefully grasp it in the hand, may place fingers over top of object but unable to squeeze to grasp it.
  • Gross (or Palmer) Grasp: fingers flex simultaneously around the object in the midsection of the pal. The thumb is adducted and not assisting with grasp.
  • Cylindrical Grasp: the fingers and thumb close and flex around a cylindrical object such as a tube or pencil, which is stabilized against the palm of the hand.

At discharge, she could do the following two new grasp patterns:

  • Lateral Pincer: object being secured between the adducted thumb and radial side of the flexed index finger. The thumb is not opposed, but slides over in a pattern of adduction to trap an object against the side of the index finger. Web space is closed.
  • Inferior Pincer: thumb adduction and emerging opposition to secure the object against the extended index finger.  The object is held proximal to the pad of the finger.

Here are the grasp patterns that we're still working on:

  • Hook Grasp: transverse metacarpal arch is flat, fingers are adducted with flexion at the IP joints, flexion or extension at MCO joints.
  • Disc Grasp: finger abduction graded according to the size of the object held, hyperextension of the MCP joints and flexion of IP joints.  For larger objects pad of fingers may be all that is in contact with objet. Example: grasped used on the lid of a jar to open it.
  • Spherical Grasp:  the fingers and thumb close and flex around a round object such as a tennis ball, which is stabilized against the palm of the hand.

  • Tripod Pincer:  thumb opposition to the digits 2 and 3.  The object is held proximal to the pads of the fingers with space visible between the object and the palm.  The ring and little finger are flexed. 

  • Superior Pincer:  this grasp is characterized by thumb opposition to the index and middle fingers.  The object is held at the pads of the index and middle fingers, as well as the pad of the thumb.  The OP joints of the index and middle fingers range from extended to slightly flexed, with flexion of the MCP joints. 

She improved her bilateral hand skills.

The Assisting Hand Assessment (AHA) measures how effectively children with unilateral upper limb impairment use their affected hand/arm (assisting hand) in play requiring bimanual performance.

Initial score: 48 (39% of the possible score)

OT's initial assessment comments: "There is a slight delay in initiating use of her RUE (Right Upper Extremity) during play.  Her LUE (Left Upper Extremity) often touches the objects first, grasps it and then she brings her right hand to the toy.  Allison primarily uses her RUE as a stabilizer or to support/hold objects.  She stabilizes objects with some difficulty and effort.  Stabilization is not always reliable for all objects, especially those that are larger in diameter or heavier.  She seldom uses varied positions of the upper arm/shoulder but when she does she has a large ROM (range of motion).  She moves her R fingers with some difficulty and does not always abduct her thumb.  She has some difficulty coordinating movements between her right and left hands.  Tasks are performed with reduced precision, slowly or with external stabilization on her trunk or table top surface.  She reaches for objects on the table primarily with her LUE and has limited reaching range of motion with her RUE.  She does not release objects in her right hand directly to the table but rather pulls them out of it with her left hand of opens her hand with delay or effort.  To reach for objects on her right side, she crosses midline with her LUE.  She uses the same gross grasp for all tasks; she does not have a variety of grasp patterns in her RUE."

Discharge score: 61 (59% of the possible score)

OT's final assessment comments: "At discharge Allison is not reaching to her right side with her right hand more often.  She releases toys and objects to her right side more often and with verbal cues.  She picks up some items from the table spontaneously such as paper, wood, and metal cymbals.  She is also releasing these items directly to the table with a fully open hand.  For other items she released them from her right hand to her left hand quickly and without delay.  Release is now active with full opening of her hand with improved efficiency instead of pulling them from her right hand.  When reaching for objects she has a completely open hand and actively abducts her thumb during reach and grasp.  She is using right gross grasp but on a variety of objets but can grasp a greater variety of items with  that grasp pattern.  She stabilizes objects both on the table top with her whole body weight and with grip.  She has overall improved coordinating when manipulating objects with 2 hands.  She supinates to midway actively."

She improved her overall right arm use.

The Quality of Upper Extremity Skills Test is used to evaluate quality of upper extremity function in the following four domains:

  • Dissociated Movement
    • Admission score: 71.88
    • Discharge score: 75
  • Grasps
    • Admission score: 44.44
    • Discharge score: 85.18
  • Protective Extension
    • Admission score: 50
    • Discharge score: 41.66
    • Comments: At initial testing Allison was more cooperative with protective extension testing.  At discharge a number of items were not tested due to decreased cooperation despite multiple attempts. 
  • Weight bearing
    • Admission score: 74
    • Discharge score: 98 

She met most of the OT goals set for the program.

Here are the 6 goals that we set at the beginning of the program.
  1. Allie will open age appropriate containers of various sizes 75% of the time with no more than 2 verbal cues for strategy.
    • Admission status: total assistance required 
    • Discharge status: ongoing/emerging, 90% met.  She can open Ziploc bags with verbal cues but has difficulty with larger containers such as PlayDoh containers and needs assistance to open markers.
  2. With supervision Allie will doff her pants from hips to ankles using both hands.
    • Admission status: with increased time, doffs pants with dominant hand only.
    • Discharge status: met.
  3. Allie will doff a t-shirt with moderate assistance.
    • Admission status: total assistance required.
    • Discharge status: met.
  4. Allie will don a t-shirt with maximum assistance.
    • Admission status: total assistance required.
    • Discharge status: met.
  5. Allie will advance her pants from knees to ankles with 2 hands and supervision. 
    • Admission status: total assistance required.
    • Discharge status: met.
  6. When grasping toys at eye level or below, Allie will reach grasp with thumb abducted 75% of trials.
    • Admission status: reaches with thumb adducted 90% of trials; self-initiates strategy of stretching thumb prior to trying to grasp.
    • Discharge status: met.

Summary of Skills

Allie has has mastered or greatly improved the following skills:
  • Supinating to midline 
  • Active thumb abduction 
  • Pushing pants down with 2 hands
  • Wrist extension
  • Releasing items in her right hand directly to the table instead of passing them to her left hand
  • Carrying items with her thumb in abduction 
  • Carrying items like a tray with forearm supinated 
  • Carrying item in right hand, while using left hand to open drawer/cabinet
  • Squatting to floor to retrieve things
  • Opening eye level drawers/cabinets with thumb abducted/in cylindrical grasp 
  • Carrying a large ball/bin with two hands 
  • Carry up to 1 lb object in right hand
  • Weight bearing through right hand while playing using her left hand 
  • Going up the stairs with an alternating pattern 
  • Peddling a tricycle

Emerging skills:
  • Pulling pants up with 2 hands 
  • Taking off and putting on a shirt 
  • Carrying items with 2 hands and maintaining proper item orientation 
  • Right forearm supination in combination with almost full elbow extension 
  • Jumping with both feet evenly 
  • Catching a ball
  • Going down the stairs with an alternating foot pattern 
  • Steering a tricycle 

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