Client’s name or initials: TP

Date of referral: 1/25/18

Date of Report: 2/1/18

Date of Birth/ age: 5/27/1965

Primary Intervention diagnosis/concern: RCVA, Left Sided Hemiparesis

Secondary diagnosis/concern: Depression, possible Early-Onset Alzheimer’s Disease

Precautions/contraindications: N/A

Reason for referral to OT: RCVA and improving occupational performance with left-sided

weakness

Therapist(s): Jessica Brauzer, OTS and Meghan Berry, OTS

S: “Holy crap that’s the fastest I’ve ever done that”-Client making a statement in reference to her

performance on the 9 Hole Peg Test while using her affected left hand.

O: Assessments performed:

Client was seen on 1/25/18 and 2/1/18 for a comprehensive occupational therapy

evaluation. The following assessments were administered: Modified Canadian Occupational

Performance Measure (COPM), passive range of motion (PROM), Stroke Impact Scale (SIS), 9

Hole Peg Test, grip strength and the Performance Assessment of Self-Care Skills (PASS). The

COPM is a semi-structured interview which measures the client’s occupational priorities for

intervention. The COPM looks at 3 areas: self-care, productivity, and leisure and how one rates

their current performance and satisfaction in 5 priority areas. Since the COPM was modified, we

did not receive any number ratings. Her PROM was assessed on BUE’s to evaluate any

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functional limitations in how far her joints move. The second session began with our client self-

reporting on the SIS. This assessment was designed to assess multidimensional stroke outcomes,

strength, hand function, ADLs, IADLs, mobility, communication, emotion, memory and

thinking, and participation. The next assessment administered was the 9 Hole Peg Test, designed

to measure manual dexterity where the individual works quickly to place 9 pegs into holes on a 5

inch square board. Client performed this assessment with her unaffected or right hand first, and

then performed with her affected left hand. Grip strength was measured by having client grip a

dynamometer as hard as she could with R hand first, for a total of three times. The process was

repeated with her affected left hand. The last assessment administered was the Performance

Assessment of Self-Care Skills or (PASS). This 26- task related assessment provides information

about a client’s skills in completing daily living tasks and to assess if any assistance is required

of the individual, and the occupation that was chosen to assess was dressing.

O: Findings from assessments:

After administering a modified COPM, both client and therapist(s) decided that focusing

on balance, grip strength and motor control as it relates to her participation in daily ADL and

IADL occupations are the priorities for therapy. Relating to IADLs, client has a desire to obtain

disability, which may be an area that is addressed in the near future. Overall, the information

gathered from the COPM show that grip strength is a main priority as it relates to daily

occupations such as: upper and lower body dressing, especially fastening; folding laundry, and

the desire to be stronger with holding plates when putting dishes away. Results from PROM

showed within normal limits (WNL) on right UE, and below functional limits (BFL) on her left

UE. High muscle tone (spasticity) was observed while her range of motion was being assessed.

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 After reviewing the SIS, the priority areas that may need to be addressed in therapy

include: 1: LUE (specifically arm and hand); 2: The ability to solve everyday problems involving

memory and thinking; 3: Controlling emotions; 4: ADL functions such as cutting food with knife

and fork; 5: Mobility such as climbing stairs; 6: Grip strength as it relates to opening jars and

tying shoes; 7: Meaningful participation in activities such as active recreation; and 8: Overall

giving a rating on how much she has recovered from her stroke with a self-report score of

65/100% (with 100 being full recovery). Results from the 9 Hole Peg Test show that client is

quicker when manipulating pegs with her R hand over her L as her time with the R hand clocked

in at 25.72 seconds, and L hand time (with 3 pegs) in 4 min. Although she did not place all 9

pegs in the hole, she did make an improvement with the three, before frustrations overcame her

ability to complete the test.

Results from the grip strength assessment show that client is stronger in manual dexterity

with her R hand over her L as her results with her R hand were respectively 35,40,40 lbs

(average 38.3 lb.) and L hand results were 5,2,2 lbs. (average 3 lbs.). The PASS was the last

assessment and client was able to complete dressing independently. However she has adapted a

compensatory strategy over time that has allowed her to complete this activity in a modified

manner, especially using dominant R hand to don and doff garments and fasten clothing. Results

from this assessment showed an independence mean score of 2.7, safety mean score of 3, and

adequacy mean score of 2.

O: Occupational Profile:

Client is a 52 year old female who is seeking Occupational Therapy services to improve

functional occupational performance in her LUE. Client suffered a RCVA in June of 2016 while

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traveling which resulted in left-sided hemiparesis. Client currently lives in Kearns, Utah in a one

level mobile home with her 7 cats and 23 year old son who works at a Big 5 Sporting Goods

store. Her mother lives nearby and often helps her with completing her daily occupations. Client

has been a smoker for the majority of her life. She works part –time for a painting company as an

office manager where she has a pretty flexible schedule, working 4 hours per day, 2 days a week,

and 2 hours per day the remaining three days of the week. Client is able to drive herself to work

and around the community. One year ago client received occupational therapy with 2

occupational therapy students at the Life Skills Clinic to address the limited mobility in her LUE.

She has also received PT to address her gait and lower body strength. The medications our client

is currently taking are two antidepressants: Citalopram and Trazodone to treat depression, in

addition to Gabapentin used to treat nerve pain, epilepsy, and nausea. She is currently seeing a

gastroenterologist, and a doctor for her back.

In December 2016, our client underwent surgery to repair a PFO in her heart, which was

found during hospitalization for her stroke. In December 2017, she saw a physical therapist to

address hip pain, which her doctor stated had been caused by pulled muscles in her groin. During

the interview, client stated that she has been in two car accidents in the past year. The first

accident resulted in a fender bender, and the second accident resulted in her hitting a pedestrian

where her insurance dropped her. She was able to find new insurance after the second accident

which is still pending in court.

Client has some friends in the area, but most are San Francisco, California, who she

enjoys visiting with when the opportunity arises. Prior to her stroke, client was independent in all

ADL and IADL occupations. Client has stated that post-stroke she has learned to utilize

compensatory strategies with her RUE (she is right hand dominant) to perform everyday

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occupations, allowing her to be independent. She needs assistance with fasteners (zippers and

buttons) with UE dressing. The occupations that she currently feels successful in include: ADLS

such as toileting, eating, and dressing (as long as it mainly involves her RUE and no fasteners are

involved). The IADL’s that she feels successful in include: taking care of her cats, medication

management, driving (although we may have some concern in this area), sleeping on her couch

(feels better and more restricting which she prefers, however would like to move to her bed in

the future), making her bed, taking out the garbage, and simple meal prep (as our client prefers to

eat frozen foods the majority of the time). The occupations that are a barrier to her performance

include: showering (maintaining balance), dressing (especially fasteners), feeding (such as set up

and cutting food with BUEs), functional mobility (mainly going up stairs), personal device care

(cleaning her dentures), financial management, health management, home management

(particularly laundry, dishes and yard work), shopping (carrying heavy grocery bags), and

complex meal preparation.

Our client values independence, her job, being in control of her emotions, and time spent

with family (especially her son and mom). Her interests include spending time with her cats,

traveling (whether it’s around Utah or out of state), and visiting with friends in CA. Client’s roles

include mother, daughter, sister, employee and friend. A typical routine includes waking up,

eating breakfast, working 4 hours per day at the painting company, enjoying down time at home

and going to bed. Client’s habits include depending on RUE to complete daily occupations and

not using affected L side as much, and smoking.

A: Occupational Analysis:

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 Due to the impact of her right sided stroke, client presents with deficits in the following

performance skill areas: 1) motor skills: aligns, due to left sided hemiparesis client has difficulty

with maintaining proper alignment when standing or seated, stabilizes, clients presents with poor

balance especially in a standing position for longer period of time, reaches, client’s LUE range of

motion does not allow her to put away dishes or reach for soap in the shower, grips, client is

unable to open a container or turn a circular doorknob with LUE, manipulates, client has

difficulty manipulating objects and dexterous finger movements with LUE as evident with her

trouble manipulating the peg in the 9 Hole Peg Test, coordinates, client presents with challenges

in coordinating a movement such as upper body dressing with BUEs, lifts: client is unable to

hold a heavy object in her LUE, walks, client drags left foot when walking, endures, client tends

to fatigue more often in the afternoon as opposed to the morning, and 2) process skills: initiates,

client presents with minor deficit in initiating a task.

Client presents with deficits in the following client factors: 1) beliefs: positive self-talk or

thinking, 2) mental functions: emotional, client states that she takes two anti-depressants to help

control emotions, energy and drive: client often feels more lethargic in the afternoon 3) sensory

functions: vestibular function, client’s balance is affected post-stroke, 4) neuromusculoskeletal

and movement-related functions: client’s joint ROM and stability is more limited on left side, 5)

muscle functions: client presents with low muscle tone on left side, 6) movement functions:

client presents with a deficit in bimanual coordination and fine motor control due to left-sided

hemiparesis, 7) cardiovascular system: limited stamina and endurance due to years of smoking,

post-stroke effects, and sedentary lifestyle and 8) reproductive function: client reports stress

incontinence.

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A: Interpretation:

After a comprehensive evaluation was done with our client, it has been concluded that

she demonstrates both strengths and areas for improvement in therapy. Regarding her strengths:

client appears motivated and has desire to improve the functionality of her LUE, she knows how

to strategize and has already implemented compensatory strategies when completing daily

occupations, and she is aware of her limitations. Regarding the areas for improvement: 1)

client’s grip strength, ROM and overall functional use with her LUE will be of high priority in

intervention, 2) addressing our client’s mental health and 3) increasing social interactions.

The activity demands for our client in therapy include: relevance and importance to

client, our client has the motivation and desire to improve the functional use of her LUE and

regain independence in everyday functioning; objects used and their properties, our client will

use the equipment in the HPEB apartment clinic and may learn to use some compensatory

strategies and A/E that we teach her; and sequencing and timing, during therapy we may teach

our client specific strategies as to how to sequence a particular task if the task is quite

challenging to complete.

Supportive contexts and environments include: 1) Client lives in a one level home which

allows her to move around the interior of her home much easier; 2) Supportive work

environment as she has a great boss and flexible schedule which allows her to attend therapy

sessions; 3) Supportive family (son and mother); and 4) Client has a cell phone and computer

allowing for good communication access. Inhibitory contexts and environments include: 1) Her

mobile home has 4 stairs and railing on one side leading up to front entranceway which makes it

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challenging for mobility and balance; and 2) Client appears to be of lower SES, smoking history,

52 years old and sedentary lifestyle.

A: Prioritization of need areas:

Client and therapist’s priorities for therapy include: 1) improving balance, grip and UE

strength, and ROM to improve occupational performance in ADL and IADL tasks, and 2)

improving mental health as it relates to improving quality of life and well-being.

P: Plan:

 LTG1: By discharge, client will fasten an upper body garment with minimal assistance

and using compensatory strategies.

 STG1: By 4th visit, client will functionally incorporate LUE when manipulating

fasteners in dressing routine with no more than 2 verbal cues.

 STG2: By 5th visit, client will demonstrate improved grip strength to increase

independence with bilateral coordination in dressing routine.

 LTG2: By discharge, client will complete home management tasks with minimal

assistance.

 STG1: By 4th visit, client will functionally incorporate LUE when drying and putting

dishes away into cupboard with minimal assistance.

 STG2: By 5th visit, client will fold 4 pieces of laundry utilizing functional use of LUE

and compensatory strategies with no more than 2 verbal cues.

P: Recommended intervention methods and approaches:

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 The recommended approaches to interventions will include establish/restore as it relates

to her restoring functional use in her LUE in her ADL and IADLs. The other approach will be

modify as this will help address the areas where adaptations may need to be made to simply her

performance in everyday functional tasks. The types of interventions that may go in our client

therapy sessions include: preparatory methods such as theraputty to prepare her hand muscles for

movement, and occupation and activity interventions such as: 1) task-related/specific practice

such as folding laundry, getting dressed, and putting dishes away, 2) Constraint Induced

Movement Therapy (CIMT) and 3) Mirror Therapy, all to improve functional outcomes. Lim,

Lee, Yoo, Yun & Hwang (2016) conducted a study which looked at patients attempting to move

the hemiplegic upper limb in a manner identical to the unaffected limb, reflected in a mirror

under direction of a therapist. This article supports the use of Mirror Therapy containing

functional task as an effective intervention in improving UE function and ADLs in patients post-

stroke.

P: Models and Evidentiary Support:

The practice models that will be referenced for our client include: Model of Human

Occupation (MOHO) which is our organizing model, and Motor Control and The Rehabilitation

Model, which are our two complementary models. MOHO’s postulates of change state that 1)

occupation reflects the influence of both a person’s characteristics and the environment, 2) a

person’s inner characteristics (motives, volition, performance patterns) are maintained and

changed throughout engaging in occupations. With our client, using her motivation to help

restore her functional LUE in her occupational performance will be imperative and a high

priority for intervention. Our client’s motivating factors to reach her goals in therapy include:

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improving her physical state to perform better in her occupations and improving her overall

quality of life and well-being.

The Motor Control model looks at strengthening one’s neuromotor connection in order to

improve occupational performance. The motor control model looks at the interactions among

cognitive, perceptual, and motor systems within a person and how that person interacts with

tasks and the environment (Gilmore & Spaulding, 2001). This model involves the CNS pathway

so that individual muscles and joints coordinate with one another, and sensory information from

the environment allows the body to control movement, and accomplish whichever goal is in

mind. The postulates of change include: 1) accomplishing necessary and desired tasks in the

most efficient way, given the client’s characteristics; 2) maximizing personal and environmental

characteristics that enhance performance; and 3) enhancing problem solving abilities of clients so

that they more readily find solutions to challenges that are encountered in new environments

(beyond treatment). With our client we will be providing opportunities to improve functional use

in LUE through skill acquisition.

The Rehabilitation Model postulates of change include: 1) activities may be progressively

modified to intensify or reduce task demands to either increase musculoskeletal capacity or

match limitations; and 2) Rehabilitation requires a teaching-learning process, in which the person

needs sufficient cognitive skills to learn and apply compensatory strategies. With our client, it

will be important to address the compensatory strategies she has already made along with any

new additional strategies that we can identify together in order to allow for optimal occupational

performance.

Krakauer (2006) concludes that a combination of motor learning and rehabilitation allows

one to improve functional outcomes and general skills to other areas in life. Shinohara, K;

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Yamada, T; Kobayashi, N; & Forsyth, K (2012) conducted an RCT which looked at a MOHO

based intervention compared to Biomechanical and NDT interventions for patients with stroke.

They found that the MOHO intervention was more effective in capturing the patient’s

perspective in improving the patient’s ADL and QOL in everyday life as compared to the non-

MOHO based interventions. This provides support for using our client’s motivation and

therapeutic strategies to guide our therapy sessions.

Expected frequency, duration and intensity: Client will be seen for 1 hour/1/x/week for 6

weeks.

Location of intervention: HPEB Apartment Clinic

Anticipated D/C environment: Home setting

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 References

Gilmore, P., & Spaulding, S. (2001). Motor control and motor learning: implications for

treatment of individuals post stroke. Physical & Occupational Therapy In

Geriatrics, 20(1), 1-15. doi:10.1300/j148v20n01_01

Krakauer, J. W. (2006). Motor learning: its relevance to stroke recovery and neurorehabilitation.

Current Opinion in Neurology, 19(1), 84-90. doi:10.1097/01.wco.0000200544.29915.cc

Lim, K., Lee, H., Yoo, J., Yun, H., & Hwang, H. (2016). Efficacy of mirror therapy containing

functional tasks in poststroke patients. Annals of Rehabilitation Medicine, 40(4), 629.

doi:10.5535/arm.2016.40.4.629

Shinohara, K., Yamada, T., Kobayashi, N., & Forsyth, K. (2012). The model of human

occupation-based intervention for patients with stroke: a randomised trial. Hong Kong

Journal of Occupational Therapy,22(2), 60-69. doi:10.1016/j.hkjot.2012.09.001

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