Learning by doing

There is only so much that lectures, labs and role play situations can teach an occupational therapy student. Peggy Barco, OTD, OTR/L, SCDCM, instructor for the Interventions Supporting Recovery and Participation in Individuals with Cognitive and Learning Challenges course, knew from her own experiences as a clinician that cognition wasn’t something that could be learned exclusively in the classroom.

“Each client has their own unique personality and goals. Clients with cognitive issues often do not have just one set of issues; they may have several impairments that present simultaneously such as comprehension, expression, performance perception and memory/attention,” Barco explains.

“Being able to observe these impairments during a session and use clinical reasoning to help develop the strategies to manage them through the everyday challenges that they experience is the essence of occupational therapy intervention.”

When Barco first began teaching the course eight years ago, she sought opportunities that would allow students to work directly with clients by reaching out to facilities with which she had existing relationships in her role as a clinician. “We cannot offer this experience to our students without the help of our community partners. We are sensitive to the clinical demand at each facility, and we work with and around the clinicians’ time. The Program provides the supervision for the students, and the assessments and interventions are approved so that we know they are appropriate and safe,” Barco says.

Barco has partnered with various local organizations including SSM Health Care’s outpatient therapy centers (in DePaul and Florissant), Ranken Jordan Pediatric Bridge Hospital, Alternative Opportunities, the Center for Head Injury Services and The Rehabilitation Institute of St. Louis. Students work in small groups and see clients with cognitive impairments who have recently transitioned into outpatient therapy or been discharged to their home. These clients can have a variety of diagnoses including stroke, traumatic brain injury (TBI), Parkinson’s disease, dementia and/or developmental disabilities.

“The students meet with their client three times over the course of a month. They are able to do an hour-long interview, a functional cognitive assessment and a  cognitive intervention,” Barco says. “This experience takes the student from learning about frameworks/models of cognitive intervention to choosing which intervention models are appropriate to the clients, and how to apply the intervention techniques to the unique functional needs of clients.”

Alison Kwalwaser, OTD/S ’17, and her group experienced those unique functional needs first-hand while working with a 35-year-old female who sustained a work-related TBI in 2011. “The client presented with specific cognitive impairments including aphasia, difficulty ‘finding’ the right word and ‘sensory overload.’ In addition, she expressed concern with her inability to plan ahead, divide her attention among multiple tasks simultaneously, and follow written or verbal instructions,” Kwalwaser recalls.

While their client was able to return to work and live independently after her TBI, she was still having struggles with common activities of daily living such as grocery shopping and cooking independently. Kwalwaser and her group chose a cognitive assessment to identify her cognitive impairments and determine how such impairments impact function. 

“We selected the Complex Task Performance Assessment (CTPA), which assesses executive function through scoring the client’s inefficiencies, rule breaks, interpretation failures and task failures while completing cognitively demanding clerical work. After scoring the client’s performance on the CTPA, we identified that she demonstrated inefficient cognitive/work strategies, decreased planning, decreased ability to multi-task and problem solve, incorrect math calculations and perseverative thinking,” Kwalwaser shares. “We were able to use that assessment to work on her goals of independently implementing a grocery list, navigating the store, following a recipe and making healthy smoothies for breakfast. We used the Dynamic Interactional Model when we worked with our client to develop and use strategies to help her accomplish those goals.”

Focusing on client-centered goals is an integral part of occupational therapy, but some goals aren’t always straightforward – or even realistic – when dealing with cognitive challenges.

“Students learn through this course that they can’t always jump to the end goal with every client; sometimes, they have to assess what the client needs to do first to get there,” Barco says. “They also learn how to identify problems when multiple cognitive, language and perceptual impairments are present. They may have to problem-solve a solution on the spot in midst of a therapy session. These types of situations can’t be replicated without a real client.”

The students find working with clients with cognitive impairments to be unique, challenging and rewarding. Following the sessions, Barco has each group share their experiences with their peers during class discussions and presentations. and she emphasizes that no two clients with cognitive impairments are alike. Kwalwaser felt that prior classroom work and role play assignments had prepared her to work with clients, but the actual interactions were much more intense.

“I felt more pressure trying to follow the correct protocol and instructions when administering assessments while trying to ease the anxiety of the client. When I was administering the CTPA to a real client, the errors the client made and the concerns she expressed were real and unique to her specific impairments from her TBI,” Kwalwaser says. “This valuable experience will influence my future practice. As an occupational therapist interested in the area of neurorehabilitation, I will be working with clients who have various cognitive impairments and are all functioning at different levels. This course has shown me first-hand the importance of identifying the specific domains of cognition when assessing a client, and developing an appropriate and beneficial intervention plan to help them progress through their recovery.”

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