Creative Occupations Case Study
Client Information Pertinent to Treatment Plan
Sally is a 72-year-old Hispanic female. Eight weeks ago she experienced a left CVA which resulted in right hemiparesis and expressive aphasia. She spent the first two weeks in a community hospital and then an additional six weeks in a rehabilitation hospital. She has now been discharged to go home. Prior to this incident she had a history of transient ischemic attacks and hypertension.
Sally has two sons who are grown and live nearby. They are busy with their own families and are used to only seeing Sally once every other week. Sally is retired from her career as a legal assistant. She lives on her own in a studio apartment. Prior to her stroke, Sally was independent in self care activities and socially very active.
Sally voiced that she was embarrassed about her expressive aphasia. She has been declining visits and phone calls from all of her friends. Another fear that she shared is that she will not be able to take care of herself and may end up in a nursing home.
Sally was referred to the Visiting Nurse Association (VNA) for occupational therapy. During the initial occupational therapy evaluation Sally became frustrated at her inability to adequately express herself and stopped trying to communicate. Her cognitive level was not able to be formally assessed due to her limitations in communication. She did, however, demonstrate a difficulty in new learning and preferred to do things as she always has in the past. Sally transfers and ambulates independently with use of a quad cane. She uses a shower seat and is able to independently bath herself with a sponge. She needs assistance with all her home management tasks. She is also dependent on her sons for instrumental activities of daily living such as shopping, laundry, and bill management. In addition to occupational therapy services, she has been referred to the VNA for physical therapy, speech, and a bath aide.
Creative Occupation for Sally
In occupational therapy, it is important to be client-centered. When therapy is client-centered the client will be motivated to participate and excel in therapy since it centers on what he/she personally wants to be able to accomplish. From reviewing Sally’s case, one of the main areas of concern for her is that she is embarrassed about her expressive aphasia and is avoiding her friends because of it. This problem may turn into a deeper issue and lead to signs of depression. Since this is weighing heavy on Sally’s mind and social interaction used to be such an important part of her daily life, it is crucial to address her inability to speak and interact with friends in therapy.
A creative occupation that would be beneficial to implement with Sally would be drawing or painting. Using the creative occupation has the potential to allow an alternative means of communication for Sally, increase her social involvement, and increase her fine motor coordination. This art may include painting, pencil sketches, or whatever Sally is most comfortable with. Through learning to use art to communicate, Sally may become less frustrated at her inability to clearly articulate what she is thinking. People who have expressive aphasia are able to have thoughts and create sentences in their minds but are unable to speak what they are thinking (Skinner & Lyon, 1996). Participating in art may also lead to Sally being a part of a new social activity. She could meet new friends at painting or sketching classes or her current friends could join an art group with her.
Sally could use her left or right arm to paint or draw. If her right side is used, she may need an assistive device such as a universal cuff or an arm sling in order to participate. The use of her right upper extremity during art will also have therapeutic value for Sally. Art can be a great way to get her arm and hand moving and gaining strength. It could be used for fine motor control skills training. The fine motor skills learned while participating in art could also benefit other fine motor activities she engages in throughout the day.
Evidence-Based Practice Supporting Chosen Creative Occupation
Drawing as a means of communication. It is not a new concept to use art as a means of communication. Everyday artists use their work to express themselves in symbols and pictures. Art can also be used to communicate in a very practical manner for those who have impaired speech. According to Lyon (1987) those adults who have expressively restricted aphasia may use drawing as a viable alternative to communication. This form of communication results in a permanent record that may be expanded on by the client or the person with whom he/she is communicating with (Rumble & Whurr, 1998).
A study done by Sacchett, Byng, Marshall and Pound (1999) supports the use of drawing as a means of communication in adults with aphasia. The adults used in this study all had moderate to severe aphasia. They participated in a twelve-week drawing therapy program. After the twelve weeks, all participants made improvements in their drawings. The drawings were easier to recognize and received a higher rating on accuracy. The improvement in drawing made non-verbal communication through art a more viable option for these individuals. One individual in this study was previously only able to verbalize a word for “yes” and his attempts at drawing were unrecognizable. At the end of the twelve weeks of therapy, his wife reported that he was able to draw and communicate the message that he was given the wrong pills and that they were different than the ones he had been taking. He was able to communicate choices, life events, and ask questions through the use of drawing (Sacchett, Byng, Marshall, & Pound, 1999).
Skills necessary to communicate through art. Lyon mentions several skills that must be intact to use art as purposeful communication. These skills include: visuosemantic symbols of the items to be expressed, mental ability to access these symbols, motor ability to depict symbols, and the ability to expand upon these symbols to use in interactive speech. Since cognitive testing has not been completed secondary to Sally’s expressive aphasia, these abilities can only be assumed until proven otherwise. In a study done by Trupe in 1986, it was found that the people with expressive aphasia (or Broca’s aphasia) were able to demonstrate more complex and interactive thoughts than those with global and Wernicke’s aphasia (Lyon, 1987). This information is encouraging for Sally’s case since she has expressive aphasia.
Related case study. Skinner and Nagel (1996) describe the rehabilitation story of a man who has the same diagnosis as Sally. He was a former artist who experienced a left CVA and has resulting right hemiparesis and expressive aphasia. He became depressed due to social isolation from the embarrassment of attempting speech with his peers. His rehabilitation process included drawing a mural on the wall. Through this process of participating in art he was able to exercise his upper extremities, improve standing balance, and increase activity tolerance. People who heard about the mural came to visit him and admire his work. This part of the experience helped boost his self-esteem and increased his social interaction (Skinner & Nagel, 1996). Sally could have similar benefits of increased activity tolerance and social interaction with the use of art in therapy.
Fine motor training after stroke. In a study by Byl et al. (2003), there is evidence supporting the use of fine motor and sensory rehabilitation post-stroke. Two groups were examined in this study. One group received four weeks of sensory training followed by four weeks of fine motor training and the second group received the reverse. Both groups made greater than 20% gains in upper extremity function, which included fine motor coordination. The fine motor training they received largely revolved around using the involved arm to practice fine motor tasks. These tasks included writing, drawing, eating, using tools, and moving objects. The positive results from this study were accredited to the principles of neuroplasticity (Byl et al., 2003). This article supports the use of drawing in therapy to help increase Sally’s fine motor coordination.
Treatment Plan for Sally
In order to follow through with a treatment plan consisting of using art as a means of communication, I would first do some preliminary testing on Sally. I would explain the idea to Sally and make sure that she was motivated to attempt this new idea as a possible means of self-expression and social interaction. I would then see if Sally was able to use a pencil or other writing utensil to draw pictures. I would equip Sally with any necessary assistive devices in order to complete drawing tasks. Depending on how Sally performs these tasks, I would have a good idea of where to start in therapy.
A treatment plan for Sally would include fine motor coordination training through the use of drawing. This would first take place at her home therapy sessions early on in her therapy process. Since Sally has already demonstrated difficulty in new learning, she would be first asked to copy simple pictures from index cards. She would be given tips and advice on how to draw so that her art may be recognizable by others.
If this task was too difficult, she might be asked to copy items as simple as a vertical line to begin with. Another idea to grade the task to an easier level would be for Sally to receive hand-over-hand guidance and verbal cues to copy the simple pictures. If Sally chose to draw her art with her affected side, a gradation could also be moving from a regular size pencil to a built up pencil or large crayon.
The activity can also be graded to a more difficult level. Sally could be asked to draw simple objects, such as a tree or a dog. To do this she would have to be able to visualize these objects and display them through her drawings. The next progression in grading may be to have Sally draw answers to simple questions given by the therapist. She would have to implement problem solving skills to draw a picture that would answer the questions. Hopefully, Sally would progress through these gradations and be able to display thoughts and answers to questions through her drawings.
Sally’s recent lack of social interaction can also be addressed through the use of her learned drawing skills. To start off, one or two friends could attend a home therapy session. Sally could attempt verbal communication with her friends and use her drawings to fill in the gaps when she cannot say what she is thinking. Once Sally gets more comfortable talking to peers with use of her drawings, she could start attending a community art group and practice her skills. Ideally, Sally would become comfortable and confident in social interactions and using drawing to complement her impaired speech. A treatment plan for Sally could include these goals:
--Sally will increase fine motor coordination with use of any necessary assistive devices by copying simple pictures from note cards with the picture correctly identified by the therapist 6 out of 10 times within two weeks of therapy.
--Sally will increase ability to exchange information by drawing responses to the therapist’s simple questions that are correctly interpreted by the therapist 8 out of 10 times within six weeks of therapy.
--Sally will increase social participation and communication by having two friends attend a therapy session and successfully use drawing as a means of communication as necessary at least 3 times with minimum assistance by the 6th week of therapy.
--Sally will increase social participation by attending a community art group/class and express a question or thought through drawing to three different people within 8 weeks of therapy.
Creative Occupations and Traditional Practice
Some therapists may be apprehensive of implementing creative occupations into treatment plans. No matter what setting a therapist practices in, there are always concerns over reimbursement. Creative occupations can be interwoven into traditional treatment plans and help work toward the same goals. Various kinds of art may be implemented to work toward increased fine motor coordination, motor planning, increased activity tolerance, and range of motion. Motivation is also an important aspect to consider. A patient may not be interested or motivated in participating in a traditional occupational therapy treatment session but may be very excited about learning a new creative art skill to work on various impairments. For example, instead of completing Theraband exercises, a patient may work on upper extremity strengthening through painting a picture mounted on the wall with use of attached arm weights. Creative occupations can be a vital part of occupational therapy practice if the therapist takes the time to implement meaningful, creative, client-centered treatments.
In Sally’s case, her treatment plan stemmed from the rehabilitation model. Sally is unable to communicate as well as she would like. The intervention will ideally allow her to compensate for this inability to speak by using art as a means of communication. Compensation is part of the rehabilitation frame of reference. The biomechanical frame of reference is also being used in Sally’s treatment plan. This frame of reference has to do with analyzing the movements needed to accomplish a certain task and addressing the impairments in treatment. Using art to work on fine motor coordination follows this method (Pendleton & Schultz-Krohn, 2006).
Reflection from the Author
This case study stressed the importance of evidence-based practice. There should always be literature supporting treatment in occupational therapy. As I experienced from this assignment, sometimes finding literature takes time and effort, but it is worth the hunt. Searching literature can give evidence to back up the treatment selected or bring new ideas for interventions to mind. It is important for the validity of the profession to use evidence-based practice.
This case study just begins to scratch the surface of what can be done with creative occupations in therapy. I was encouraged to know there is literature available that provides evidence for creative occupation interventions. It is important to select interventions that are meaningful to clients in order for them to be motivated to participate in therapy. Sometimes incorporating creative arts into a treatment plan may give a client the motivation he/she needs to engage in therapy.
References
.Byl, N., Roderick, J., Mohamed, O., Hanny, M., Kotler, J., Smith, A., Tang, M., & Abrams, G. (2003). Effectiveness of sensory and motor rehabilitation of the upper limb following theprinciples of neuroplasticity: Patients stable postroke. Neurorehabilitation and Neural Repair, 17, 176-191.
Lyon, J. G. (1987). Drawing: Its communicative significance for expressively restricted aphasic adults. Topics in Language Disorders, 8(1), 61-71.
Pendleton, H. M. & Schultz-Krohn, W. (2006). Occupational therapy practice skills for physical dysfunction. St. Louis, MO: Mosby Elsevier.
Rumble, E. & Whurr, R. (1998). An investigation into the drawing skills of aphasic adults. International Journal of Language and Communication Disorders, 33, 218-223.
Sacchett, C., Byng, S., Marshall, J., & Pound, C. (1999). Drawing together: Evaluation of a therapy programme for severe aphasia. International Journal of Language andCommunication Disorders, 34, 265-289.
Skinner, M. K. & Nagel, P. J. (1996). Painting a mural and writing an article: Creativerehabilitation strategies. Rehabilitation Nursing, 21(2), 63-66.