Running head: CASE STUDY

Lewis: Case Study

Michelle Ashley, Kristina Harvey, Jordan Jamieson,
Charmaine Loja, Cynthia Rodriguez & Josee Lundquist
Touro University Nevada

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Introduction
Lewis is a 13 year old student, brother, grandson and avid Miami Dolphins fan. His sister
is his primary caregiver and she receives assistance from their grandmother. Lewis is diagnosed
with spastic quadriplegia cerebral palsy (CP). He explores his world through strong athetoid
movement patterns accompanied with dystonia. His increased tone in all extremities and
decreased trunk tone propose many physical limitations. Lewis is mostly non-verbal but utilizes
facial expressions, head nods, and a PRC device to communicate. Fortunately, he shows
cognitive understandings as he responds to instructions with volitional head movements.
Although Lewis diagnosis produces daily challenges for him, his self-motivation, caregivers,
occupational therapist, and educator provide a supportive environment.
Description of Occupational Performance
Activities of Daily Living
Lewis is dependent for the majority of his activities of daily living (ADLs), which
include: bathing, dressing, eating, functional mobility, and personal hygiene. Lewis is able to use
gestures with his family indicating needs such as toileting; however, these gestures do not carry
over into his school environment because there is not a staff member available to help Lewis use
the restroom. Due to his incontinence, Lewis wears diapers when attending school. Lewis also
exhibits poor oral motor skills with decreased strength and coordination in his jaw, tongue, lips
and cheeks, but no apparent signs of aspiration have been shown. He is open to eating various
types of food when given small bites, preferably softer foods that do not require excessive
chewing. He also has the ability to take his food off a spoon and lateralize contents for chewing.
Lewis mostly uses a munching motion with little rotary movement as he chews. He shows the
capability of drinking from a small diameter straw when using short sips, but requires assistance
to stabilize the straw.
In terms of functional mobility, Lewis requires maximal assistance when using his
manual wheelchair. He is currently being evaluated to receive his own power wheelchair and

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receiving training on proper operation. The power wheelchair is equipped with a head array, but
Lewis head control is decreasing. Lewis is practicing using a universal joystick cuff to move his
wheelchair forward, backward, right and left. Lewis is minimally independent in regards to his
locomotion skills and is entirely dependent for bed mobility, transfers, ambulation, and standing.
Lewis also employs additional help by using a support walker.
Instrumental Activities of Daily Living
Lewis requires assistance from his older sister and grandmother when completing his
instrumental activities of daily living (IADLs). He needs maximum assistance when completing
activities that include: community mobility, upkeep of his communication device, managing his
health, preparing his meals, and ensuring his safety.
Rest and Sleep
Lewis family has established a sleep schedule for him to adhere to. The involuntary
movements caused by athetosis often disappear during sleep, so he is able to get an adequate
amount of sleep.
Play/Leisure
Lewis enjoys watching sporting events with his family, especially to cheer on the Miami
Dolphins. Lewis would like to begin participating in wheelchair football with the assistance of
his caregivers. Lewis enjoys attending sporting events and going to his cousins baseball games
with his family. Lewis also enjoys reading, but currently needs his caregiver to prop the book up
as well as turn the pages.
Education
Lewis athetoid and dystonic movements affect his fine motor skills and prevent in-hand
manipulations, ultimately affecting school performance. Additionally, he struggles with releasing
objects and consistently overshoots targets when grasping and pointing with his index finger.
These issues cause difficulty when Lewis attempts to participate in class activities and complete
homework assignments in a timely manner.
As Lewis demonstrates cognitive understanding, appropriate assistive technology would
further his classroom participation. Although no intellectual impairments have been discovered,

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Lewis would still qualify for an Individualized Education Plan (IEP). Special education is
needed to address his lack of communication skills. This deficit would specifically fall under
other health impairment in qualification for an IEP (Lau, 2012). Lewis has potential for
academic progress, but requires an IEP for extra assistance and modifications.
Social Participation
Lewis is mostly non-verbal so he communicates with the help of a PRC communication
device. He also has the ability to answer yes and no questions with a head nod and uses facial
expressions to interact with others. He enjoys spending time with his sister at home and out in
the community.
Description of: Movement, Postural reactions, and/or Reflexes
Lewis has spastic quadriplegia and exhibits strong athetoid movement patterns with
dystonia, which affects his posture. The dystonia and athetoid movement patterns fluctuate
greatly depending on the day. This causes Lewis body to go into full flexion or extension,
causing difficulty for his sister and grandmother to position him in his wheelchair. Lewis upper
extremity posture also varies as a result of his thoracic scoliosis, which measures 30 degrees
concave to the right. Due to his condition, Lewis also has decreased shoulder flexion and
decreased knee extension that limit his ability to carry out daily activities. He exhibits increased
muscle tone in all extremities from the dystonia, and decreased trunk tone from athetosis. This
has affected his ability to maintain proper posture when sitting, causing him to have a posterior
pelvic tilt. In addition, asymmetry is present in his lower extremities with his left hip rotating
out, therefore, contributing to trunk rotation and a lateral head tilt, which is consistently
progressing.
Sensory integration or self-regulation
Lewis issues stem from a lack of postural control and erratic muscle spasms. He does not
exhibit issues with sensory integration or self-regulation at this time.
Assessments appropriate for this client

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To assess Lewis overall function in the school setting, three separate assessments can be
utilized, the Pediatric Evaluation of Disability Inventory (PEDI), Childrens Assessment of
Participation and Enjoyment, and Preferences for Activities of Children (CAPE/PAC), as well as,
the School Setting Interview.
The PEDI is an assessment for children six months to seven years old, or older children
who are functioning lower than a seven year old without a disability. This assessment would
evaluate his mobility, social function, and self-care (Haley, Coster, Ludlow, Haltiwanger, &
Andrellos, 1992).
The CAPE/PAC is an assessment appropriate for individuals between the ages of 6 and
21 with or without a disability. This assessment is utilized to measure different aspects of
participation or engagement outside the school setting (Pearson, 2012). The assessment would be
beneficial to evaluate what Lewis activity preferences and interests are.
The School Setting Interview is a collaborative interview which allows the child to
express how his/her environment affects his/her social, educational, and mobility function within
all school settings including classroom, cafeteria, and gymnasium. This assessment is appropriate
for adolescents from nine years old through high school (Henry & Kramer, 2009). This
assessment will allow Lewis teachers and occupational therapist to make accommodations and
problem solve barriers that Lewis identifies.
It is important to be familiar with the spasticity of a child with CP to assure the
individuals occupations are being addressed properly, and the therapist can effectively grade the
occupations for mastery. The Modified Ashworth Scale of Spasticity can be used to quantify the
spasticity of muscle using numerical values zero through four (Giuffrida & Rice, 2009).
5 Functional Problem Statements
1) Client requires maximum assistance to complete transfers due to decreased locomotion skills.
2) Client is unable to perform controlled release of objects due to decreased manipulation skills.
3) Client requires moderate assistance to sit on bench due to increased tone in all extremities and
decreased tone in trunk.
4) Client has minimal fine motor and in hand manipulation skills.

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5) Client is dependent for all ADLs, including using the bathroom, requiring use of diapers.
5 Family/Caregiver/Child goals
1) Lewis will be able to independently manipulate school textbooks.
2) Lewis will be able to sit upright with minimal assistance.
3) Lewis will be able to participate in a consistent form of communication with family and peers
at school and within the home.
4) Lewis will be able to independently operate a power wheelchair throughout school.
5) Lewis will start to participate in feeding, by holding lightweight utensils.
Goals, Objectives, and Activities
Goal #1: Lewis will independently use an iPad (with Sono Flex Lite application) as a
communication device to promote educational and social participation, with 80% accuracy, by
June 21, 2013.
Objectives:
1. Lewis will independently identify simple greetings, with 100% accuracy, using Sono Flex
Lite application by March 1, 2013.
a. Activity #1: Lewis and Occupational Therapist will play with iSpy books to
facilitate appropriate physical and mental identification of images. The OT will
verbally communicate images Lewis is responsible to identify per page. Lewis
will use right UE to identify hidden image to OT.
b. Activity #2: Lewis and OT will role play appropriate greetings. For example, the
OT may say teacher and Lewis will choose the appropriate greeting on his Sono
Flex Lite application (i.e. Hello, Mrs. Smith rather than whats up).
2. Lewis will independently answer three class questions per day, with 90% accuracy with
use of Sono Flex Lite application, by May 1, 2013.
a. Activity #1: Lewis and OT (or peer) will play iPad Battleship game. Lewis will
use Sono Flex Lite application to communicate desired coordinates.
b. Activity #2: Lewis will use his Sono Flex Lite application to tell his class the day
of the week and date.
Goal #2: Lewis will independently navigate his power wheelchair through school hallways, with
his right hand and 90% accuracy, by June 21, 2013.
Objectives:
1. Lewis will independently master front/back and left/right movements of his wheelchair
with 100% accuracy by March 1, 2013.
a. Activity #1: During computer class, Lewis will use a modified joystick to
complete computer activities to increase joystick control for wheelchair.
b. Activity #2: Playing Simon says with OT to master direction with joystick (i.e.
Simon says move backwards).
2. Lewis will independently maneuver his power wheelchair through the empty school
hallways, with 100% accuracy, by April 15, 2013.
a. Activity #1: Lewis will transport (in his power wheelchair) his class attendance
roster to the office every morning.
b. Activity #2: OT will set up an obstacle course in the gymnasium for Lewis to
maneuver his wheelchair through.

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Goal #3: Lewis will independently turn pages of a classroom textbook, using a pencil eraser as a
page turner, with 100% accuracy by June 21, 2013.
Objectives:
1. Lewis will independently place universal cuff adaptation on right hand, with 100%
accuracy, by April 15, 2013.
a. Activity #1: Rolling play dough to facilitate finger extension and thumb abduction
b. Activity #2: Playing Velcro darts will facilitate UE ROM. Darts are not actually
used, but rather a ping pong sized ball wrapped in Velcro. The important aspect
of this activity is having Lewis pull the ball off the board after the ball is thrown.
This will introduce the strength needed for Velcro resistance (as the universal cuff
has).
2. Lewis will turn a page, with adaptive device, in a textbook with minimal assistance 4 out
of 5 trials by May 1, 2013.
a. Activity #1: Lewis can participate in art class as he paints on an easel. Practitioner
will emphasize painting horizontal lines to facilitate crossing midline.
b. Activity #2: Playing table top golf will facilitate forearm supination and pronation
as Lewis hits the ball with the miniature club. Foam tubing adaptation can be
placed on the club if needed.
Environmental setting
Collaboration between the occupational therapist and teacher is of great importance to
assure Lewis has an optimal classroom environment. The occupational therapist may utilize a
bench for Lewis to practice bench sitting during class time as well as in the lunchroom. Utilizing
this activity in the lunchroom will promote interaction with Lewis peers.
Lewis classroom environment should have the proper adaptive equipment for him to be
able to participate in the classroom as well as communicate with his teacher and peers. Utilizing
a communication device such as an iPad, will be important for Lewiss educational and social
participation. The iPad is portable and can be used for a variety of functions including education
and communication.
One of Lewis goals is to independently use a power wheelchair. It will be important for
the occupational therapist to introduce and utilize a modified joystick to increase strength for
future use of his wheelchair. This could be done during computer class or during class time by
utilizing a computer in the classroom. Lewis will need to learn how to operate his wheelchair

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independently, therefore, utilizing the hallways and gym will be useful areas to practice in the
school.
Occupational Therapy Soap Note
Name: Lewis
Date: 2/19/2013

Age: 13
Time: 11:30 AM

Primary Dx: Cerebral Palsy

S: Lewis was compliant to participate in the OT tx session as he nodded yes when asked if
ready to play. Lewis showed excitement to work on power w/c mobility by displaying a slight
grin and additional head nods.
O: Lewis participated in a 30-minute OT tx session in the school hallways to work on improving
maneuvering his power w/c in order to success in Lewis ability to participate in functional
mobility. The session began in the classroom as Lewis attempted to maneuver w/c out of the
classroom and into the empty hallway. He required min (A) in placing hand through universal
cuff controller of w/c and minimal verbal cues to place w/c in appropriate position to go out the
classroom door. Lewis able to respond to verbal instructions and questions using his PRC device
90 % of the tx time. Lewis observed to be frustrated and took a 2 minute break ~ he maneuvered
his w/c out of the classroom and into the hallway. Lewis maneuvered his w/c down the hall, 15
feet/min, taking 1-2 minute breaks as needed. Lewis demonstrated inability to efficiently use fine
motor control of his right hand to manipulate the w/c joystick while maneuvering down the hall.
Lewis successfully manipulated the universal cuff controller with hand (I) 75% of the session
and was able to problem solve (I) about repositioning his w/c 80% of session.
A: Deficits in UE control and hand currently limit (I) w/c mobility. Lewis increased success
to direct the w/c with the universal cuff controller with hand 75% of the time demonstrates
progress from less than 50% control during the previous visit and indicates potential to progress
to independence in w/c mobility. Lewis would benefit from further activities that increase UE
control of hand to improve (I) w/c mobility.
P: Lewis will be seen 1x/wk. for 1 month to address w/c mobility. Focus will be on improving
independent and efficient manipulation of the universal cuff controller.
Post-discharge environment/Transition Plan
In order for Lewis to successfully transition into high school, his family, therapists, and
educators must collaborate in his transition plan utilizing a nonspecific interview between all
parties. Lewis and his caregivers should discuss his strengths in and out of school, topics that are

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challenging for him, and his current and future goals. His therapist and educators should also
consider his strengths, interests, and learning gaps that may prevent reaching long-term goals and
accommodations to make challenges easier for him (Lane & Bundy, 2012). This transition plan
will re-evaluate Lewis goals and serve as a general discussion to acknowledge Lewis and his
caregivers desires considering his limitations.
Specific Recommendations
Collaboration between the occupational therapist, educator, and caregivers is a necessity
to optimize Lewis treatment sessions. With cognitive abilities intact, recommendations were
made for the teachers to encourage Lewis to participate in class. During class, the teacher can ask
Lewis questions about the readings or assignments to facilitate a response from Lewis with his
communication device. This can facilitate practice with fine motor skills as well as social skills
through the use of the communication program on his iPad. The teacher should also incorporate
the entire class with Lewis treatment. For example, when Lewis is learning to use a power
wheelchair, the teacher should have all of his classmates play the same computer program, as he
practices his joystick maneuvering. This can facilitate socialization and assist in forming positive
peer relationships. By encouraging Lewis teacher to take an active role, the treatment can have a
greater impact on Lewis overall performance and function in a positive way.
An important recommendation for Lewis older sister is to provide opportunities at home
that will allow him to practice all of his activities. Lewis older sister can assist with increasing
upper extremity movement by doing passive and active range of motion exercises. An example
of a range of motion exercise is having Lewis older sister passively flex and extend Lewis
shoulders and arms. Over time, Lewis will gain sufficient movement to allow him to use the
joystick on his wheelchair, use the communication iPad application, and use other adaptive
devices to facilitate independence. Lewis older sister and grandmother can also have him
practice maneuvering his power wheelchair around the house to further master his skills. His

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family can facilitate conversations with Lewis to encourage him to use his iPad application to
communicate. To practice using the page eraser as a page turner, Lewis older sister or
grandmother can help him study and promote use of the page eraser when reading his textbooks.
Although Lewis goals are school-based, incorporating the activities at home will provide more
time for practice and improve his skills, thus increasing the effectiveness of the treatment.
Justification of Treatment Plan
Lewis is part of a special education classroom in his local middle school. After 8th grade,
he will be transitioning into a larger high school. His high school will consist of more students
and an intricate campus layout that may propose ambulation difficulty. Due to the change in
Lewis educational and social environment, it is important for Lewis treatment plan to prepare
him for his transition into high school.
Lewis is currently being evaluated to receive a power wheelchair. To facilitate the use of
a power wheelchair, the occupational therapist will introduce a computer game during computer
class that contains different mazes. These mazes range from easy to challenging. Lewis will then
have to manipulate a joystick in order to maneuver through and complete the maze. The joystick
will be modified to be similar to the universal cuff that he will be using for his powered
wheelchair. Not only will practicing the joystick in a virtual environment be safer for Lewis due
to the lack of actual physical barriers, but it has also been shown that using a computer simulator
program to prepare individuals for powered mobility can enhance performance when operating
an actual power wheelchair (Hasdai, Jessel, & Weiss, 1998).
Lewis limited range of motion in his upper extremity and poor in-hand manipulation
skills create difficulty in turning pages in his textbook. This can then affect his ability to
complete his assignments and be attentive during the lesson, which would then affect his overall
school performance. An adaptive device will be essential to allow Lewis to efficiently turn pages
of his textbook. Assistive technology plays an important role in occupational therapy by

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providing individuals with a disability a modified way complete their daily activities, such as
dressing, bathing, and class participation (Schoonover, Grove, & Swinth, 2010). It has been
shown that incorporating the use of an assistive device into the clients environment, including
the educational environment, can enhance independence by adapting to the clients needs and aid
in particular activities (Dickey & Shealey, 1987). One type of assistive technology is the page
turner. By incorporating a pencil with an eraser, as a page turner in Lewis treatment plan, Lewis
will be able to be more engaged in his studying and participate in his classroom during lecture.
Finally, Lewis will be using a communication application on the iPad that will facilitate
communication and promote socialization amongst his family, peers, and educators. From
students perspective, it has been shown that students most important consideration when
choosing to use an assistive device in school is whether or not it impacts their relationships with
their peers (Hemmingsson, Lidstrm, & Nygrd, 2009). Being that Lewis is an adolescent
moving onto high school, socialization with his peers is an important aspect of his life. The iPad
has been a very popular device amongst adolescents to increase socialization and promote peer
acceptance. Although there has been limited research as to the effectiveness of the iPad as a
communication device, it has been shown that using assistive technology to communicate can
improve students performance and aid in reaching IEP goals and objectives (Watson, Ito, Smith,
& Andersen, 2010).
Conclusion
In conclusion, Lewis is at an age where independence and peer relationships are
becoming increasingly important. It is imperative for Lewis to not only have an optimal learning
environment, but to also be as functional and independent as he can in his environment. Without
cognitive limitations, Lewis is capable of skills similar to his peers, but his physical limitations
hinder his abilities. An effective treatment plan and appropriate modifications to help Lewis
become more independent, and communicate his thoughts and feelings, will help build self-

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efficacy. Assisting Lewis to become more functional and facilitating interaction with peers are
essential occupations every child his age deserves, and occupational therapy can assist him in
achieving such goals.

References
Dickey, R., & Shealey, S. H. (1987). Using technology to control the environment. American
Journal of Occupational Therapy, 41, 717-721. doi: 10.5014/ajot.41.11.717
Giuffrida, C.G., Rice, M.S. (2009). Motor skills and occupational performance: assessments and
interventions. In E.B. Crepeau, E.S. Cohn, & B.A.B. Schell (Eds.), Willard and
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Haley, S. M., Coster, W. J., Ludlow, L. H., Haltiwanger, J. T., Andrellos, P. J. (1992). Pediatric
Evaluation of Disability Inventory (PEDI). Boston: PEDI Research Group.

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Hasdai, A., Jessel, A. S., & Weiss, P. L. (1998). Use of a computer simulator for training children
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.com/HAIWEB /Cultures/en-us/Productdetail.htm?Pid=076-1606432&Mode=summary
Russell, D. J., Rosenbaum, P. L., Avery, L. M., & Lane, M. (2002). Gross motor function
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