Functional Intervention Occupational Therapy Kit Description

Occupation/ Impairment that Kit Meal Preparation – Apraxia

Addresses

Itemized list of contents in kit 1. Plate

2. Spoon
3. Knife
4. Fork
5. Cup
6. Shallow ladle
7. Deep ladle
8. Small bowl
9. Large bowl
10. Granola bag
11. Bag clip (x2)
12. Plastic Tupperware container
13. Peanut butter jar
14. Cinnamon shaker
15. 1/3 measuring cup
16. 1 TBSP
17. Clear glass gems
18. Beads

Pictures of all components of kit

Instructions for use of kit
Examples of intervention
activities
How kit can be graded for low
and high level patients
This kit includes activities to target both ideational and ideomotor
apraxia through the use of strategy training. Because of the nature
of apraxia, the activities are intended to be as functional as possible
by simulating participation in activities surrounding meal
preparation. Furthermore, each activity can be modified in many
ways, graded up or down in order to tailor it to the patient’s
cognitive and motor strengths and/or limitations. Each activity is
also intended to involve as many repetitions as is beneficial and as
time may allow, given that patients with apraxia benefit from both
repetition and adequate time to process requests. According to
Heugten, the OT can use different techniques to facilitate optimal
patient performance, depending on the nature of the patient’s
difficulty during activity performance. A brief explanation is
provided below in the section regarding activity grading, but please
see Appendix A for a detailed explanation taken directly from
Heugten et al. (1998).
1) Creating a basic table setting
a) Have patient create a basic table setting using a plate,
spoon, fork, knife, and cup
2) Ladling soup
a) Have patient practice using ladle to scoop and transport
“soup” from large to small bowl
3) Pouring a bowl of cereal
a) Have patient open granola bag (fastened with either
Ziploc or bag clip) and pour themselves a bowl of cereal
4) Following a recipe
a) Have patient follow recipe card for peanut butter
oatmeal, combining ingredients in bowl
i) 2/3 cup oatmeal (beads)
ii) 1 TBSP peanut butter (beads)
iii) Dash of cinnamon
According to the strategy training approach, the cognitive and
physical demands of activities may be graded through the OT’s
implementation of either instruction, assistance, or feedback.
Grading for lower level patients
 General grading for lower level patients may involve
intentional setup of materials (i.e. items placed within
reach, in direct line of sight, at waist level, etc.), presenting
items one at a time, providing step-by-step instructions
regarding use of each item, using the shallow ladle to
minimize pronation/supination demands during scooping
activity, and/or using the clothes pin to close the bag of
granola (requires less pincher force to manipulate).
For patients experiencing difficulty with task initiation:
 OT may provide step-by-step instructions, verbal
instructions, pictures demonstrating the activity, and/or
written instructions
  OT may demonstrate performing the activity or may place
objects close to the patient and/or in the proper sequence
 OT may provide patient with a single item at a time
For patients experiencing difficulty with task execution:
 OT may provide verbal assistance to name each step of the
activity, to name each item, to direct patient’s attention
back to the task at hand
 OT may use gestures to demonstrate movement patterns
 OT may physically assist the patient in performing each step
For patients experiencing difficulty with task controlling/correcting:
 OT may provide verbal feedback after activity performance
(identifying correct performance and errors observed)
 OT may provide verbal feedback throughout activity
performance to facilitate real-time error identification
 OT may have patient perform activity in front of a mirror or
may show patient video-recording of their performance

Grading for high level patients

 OT may challenge patients to perform entire activity
without additional instructions, assistance, or feedback
 OT may provide all materials at once and/or may increase
the challenge in item retrieval by placing out of arms reach,
increasing height of item placement, and/or by dispersing
items throughout therapy room (as possible)
 OT may have patient use deeper ladle to increase challenge
for wrist ROM and forearm pronation/supination
 OT may seal the granola bag using the Ziploc mechanism to
challenge grasp and FMC
 OT may present the oatmeal container, peanut butter jar,
and/or cinnamon shaker with the lids on
 OT may ask patient to use an object symbolically for
performing a task unrelated to the item, such as strumming
a ladle as a guitar

*Please see Appendix A for more detailed explanation from Van

Heugten about how the OT’s can increase/decrease the demands of
the activity.
**Please see
 Appendix B for lower level patient instructions
 Appendix C for higher level patient instructions
Appendix A– Interventions Implemented by the OT Throughout Activity

Taken directly from:

Van Heugten, C.M., Dekker, J., Deelman, B.G., Dijk, A..J. van, Stehmann-Saris, J.C., & Kinebanian, A.
(1998). Outcome of strategy training in stroke patients with apraxia: A phaseII study. Clinical
Rehabilitation, 12, 294–303.

The specific interventions are built up in a hierarchical order, depending upon the level of functioning
of the patient. The therapist can use instructions, assistance, and feedback.
Instructions
The occupational therapist can give the following instructions:
 Start with a verbal instruction.
 Shift to a relevant environment for the task at hand.
 Alert the patient:
o by touching,
o using the patient’s name,
o asking questions about the instruction.
 Use gestures, point to the objects.
 Demonstrate (part of) the task.
 Show pictures of the activity.
 Write down the instruction.
 Place the objects near the patient, point to the objects, put the objects in the proper sequence.
 Hand the objects one at a time to the patient.
 Start the activity together with patient one or more times.
 Adjust the task to make it easier for the patient.
 Finally, take over the task because all efforts did not lead to the desired result.
Assistance
The following forms of assistance can be given by the therapist:
 There is no need to assist the patient during the execution of the activity.
 Verbal assistance is needed:
o by offering rhythm and not interrupting performance,
o to stimulate verbalization of the steps in the activity,
o to name the steps in the activity or name the objects,
o to direct the attention to the task at hand.
 Use gestures, mimics, and vary intonation in your speech.
 Show pictures of the proper sequence of steps in the activity.
 Physical assistance is needed:
o by guiding the limbs,
o in positioning the limbs,
o to use the neurodevelopmental treatment method (NDT),
o to use aids to support the activity,
o to taking over until the patient starts performing,
o to provoke movements.
 Finally, take over the task.
Feedback
Feedback can be offered in the following ways:
 No feedback is necessary because the result is adequate.
 Verbal feedback is needed in terms of the result (knowledge of results).
 Verbal feedback by telling the patient to consciously use the senses to evaluate the result (tell
the patient see, hear, feel, smell or taste).
 Physical feedback is needed in terms of the result (knowledge of results):
o to evaluate the posture of the patient,
o to evaluate the position of the limbs,
o to support the limbs.
 Physical feedback is given by pointing or handing the objects to the patient.
 Verbal feedback is needed in terms of performance (knowledge of performance).
 Physical feedback is needed in terms of performance (knowledge of performance).
 Place the patient in front of a mirror.
 Make video recordings of the patient’s performance and show the recordings.
 Take over the control over the task and correct possible errors.
Appendix B – Instructions for Patient

Scenario 1:

Your family is sitting at the table for dinner, but they forgot to set you a
place at the table. Create a place setting like the image below:

1. Place your plate directly in front of you.

2. Place your knife to the right of your plate.
3. Place your spoon to the right of your knife.
4. Place your fork to the left of your plate.
5. Place your cup to the right of your plate, beyond the knife and
spoon.

Scenario 2:

Your family just sat down at the table for dinner. They begin passing
around a large bowl of soup.

1. Pick up the ladle.

2. Use the ladle to scoop soup out of the large bowl.
3. Dump soup into your bowl.
Scenario 3:

It’s morning and you’re in the mood for a bowl of granola.

1. Remove clothes pin from bag of granola.

2. Pick up bag of granola.
3. Pour Granola into your bowl.
4. Set bag of granola on table.
5. Replace clothes pin on bag of granola.
Appendix C – Instructions for Patient

Scenario 1:

 Your family is sitting at the table for dinner, but they forgot to set
you a place at the table. Select any items out of the bin that you
may need and set them up on the table in front of you as you
might to create a typical table setting.

Scenario 2:

 Your family is sitting at the table for dinner and they just passed
you a large bowl of soup. Select from the bin an appropriate bowl
and utensil to serve yourself a bowl of soup.

Scenario 3:

 It’s morning and you’re in the mood for a bowl of granola. Pour
yourself a bowl of granola. Don’t forget to close the bag when
you’re done.

Scenario 4:

 Your friend told you about this great recipe for homemade peanut
butter oatmeal. Combine the following ingredients in your bowl
as preparation for your bowl of oatmeal:
 2/3 cup oatmeal
 2 TBSP peanut butter
 Dash of cinnamon