Date of Assessment: 2/11/2021 and 2/18/2021

Name: MR

Diagnosis: L CVA with R Hemiplegia and mild aphasia

Occupational Therapy Initial Evaluation

S: “I just got to get this thing working.” The Client gestured to his right hemiplegic arm.

O: The client was seen February 11 and 18, 2021, for a comprehensive occupational therapy evaluation,
including the COPM, an observation of occupational performance of a simple meal preparation, the
meal preparation clean-up activity of the PASS, active and passive ROM, and the Modified Ashworth
Scale.

Occupational Profile:

The client is an African American male who suffered a stroke seven years ago, resulting in right
hemiplegia and mild aphasia. He is originally from Texas but came to Utah to pursue two degrees,
sociology, and law, at Brigham Young University. He lives in Utah County with his wife Lynette, who is a
teacher. He has five kids who have moved from the home, stating one daughter still visits often. Before
his stroke, he was a network marketer at an international business. He used to travel frequently and
even lived in Singapore with his family for a year. Now he works two days a week for four hours at an
LDS seminary for individuals with disabilities. The client is independent in dressing, showering,
grooming, and household management. He states he is able to clean the bedroom, bathroom, and living
area. He is also independent in functional mobility, including driving. He can prepare meals, both
cooking, and baking but reports it is difficult since he is unable to incorporate his right arm. He uses
adaptive equipment while cooking, such as a rocker knife, dycem, and a special can opener. He currently
receives both occupational and physical therapy services. He reports he does not use his right arm and
his right leg is weak. He is right-handed but has had to learn to use his left hand. He also stated his
memory and thinking have not been affected since his stroke except for his ability to speak. He enjoys
playing golf, racquetball, basketball, Pass the Pigs, Backgammon, Monopoly, running. He also enjoys
skiing and biking with the National Abilities Center. The client’s priorities for occupational therapy are
using his right arm during meal preparation and becoming more fluent on the computer with typing.

Occupational Performance Assessment :

The client was observed completing a simple meal preparation of making a ham and cheese sandwich.
He was given the recipe with the appropriate steps, and then the recipe was removed for him to
complete the task from memory. He was able to continue with the task even with distractions in the
environment and independently completed all the steps of the recipe from memory. He accomplished
the task successfully, exclusively using his L extremity and only using his R extremity when prompted. He
was observed using some adaptive strategies to open packaging, such as placing the mayo bottle
between his legs to stabilize it while he opened it with his L hand. During the step with the mustard, He
was prompted to incorporate his R extremity. He placed mustard in his R hand, paused, then took it out
and used the mustard with his L hand. It was noted he had a tight grip on the bottle with his R hand. He
had difficulty opening the ham package. When given a verbal prompt to use his R extremity, he hiked his
R shoulder to place his R hand on the ham package to stabilize it but was still unable to open it. The
client used his teeth instead. Increased tone with effort was noted during the task. His aphasia was
evident during conversation, but he used strategies such as an alphabet board to help him come up with
the words.

Administered Assessments:

Canadian Occupational Performance Measure (COPM): A semi-structured interview used to gather

information about who the client is, their priorities for therapy, as well as performance and satisfaction
scores. The client’s results are listed below.

Occupational Priorities and Performance (1 poor performance- Satisfaction (1 not satisfied-

concerns 10 very good performance 10 very satisfied)

1. Using R U.E. in cooking 4 3

2. Typing on the computer 5 4

Total Scores 9 7

Average score 4.5 3.5

Performance Assessment of Self-Care Skills (PASS) Task C6 Clean-up After Meal Preparation: An
occupation-based assessment used to look at the cognitive and physical skills of an individual in
completing daily activities in the home or clinic. The client’s results are listed below. Attached at the end
of the eval is a comprehensive report of what the scores are and their meaning. Note: The client
completed the activity with his left arm only, which is his unaffected side.

Independence score: 3 out of 3 points possible – no prompts given

Safety Score: 3 out of 3 points possible – safety practices were observed
Adequacy score: subtasks generally performed with precision and economy of effort, with some lack
of efficiency
Process: 2.8 out of 3 points possible
Quality: 2.8 out of 3 points possible

Active and Passive Range of Motion: This assessment was completed to look at the active and passive
motion available in the client’s hemiplegic right upper extremity.

Self-ROM was completed before active, and passive were assessed. The client had more active
movement proximally than distally, and moderate active movement was seen in his shoulder
and elbow. When flexing his shoulder and extending his elbow during AROM, He displayed
substitutional movements such as trunk rotation and scapular elevation. It was noted that he
had little to no active movement in supination, wrist flexion and extension, finger flexion and
extension, and all thumb movements. The client’s passive movement was WNL for all
movements except elbow, wrist, and finger extension, which had limited movement due to
tone.
Modified Ashworth Scale: This assessment measures spasticity and tone in individuals with a CNS lesion
by testing quick muscle movements. The client’s results are listed below. His right upper extremity was
evaluated.

Bicep: 3 – considerable increase in tone, passive movement difficult

Shoulder flexors: 0 – no increase in tone
Tricep: 0 – no increase in tone
Wrist Flexors: 3 – considerable increase in tone, passive movement difficult
Wrist Extensors: 0 – no increase in tone
Finger flexors: 4- affected parts rigid in flexion

A: Interpretation:

The client is a pleasant man who demonstrated good cognition and awareness of his deficits and the
impact they have on his daily life and occupations. He seems motivated and eager to make progress
during therapy. He displays significant motor weakness in his R UE with some active movement in his
shoulder and elbow and little to no active movement in his wrist and hand. He has significant learned
non-use in his R UE which he recognizes but is unaware of strategies to incorporate the extremity in
daily tasks. This affects his ability to engage in meal preparation and computer use in the way he would
like. He has tone in his R UE that increases with effort, making it difficult for him to open his hand and
utilize his wrist and fingers to complete tasks. His aphasia is evident during conversation, and while it
slows down conversation occasionally, it does not impact his ability to interact with others and complete
desired occupations. The client is a good candidate for rehabilitation to increase his performance in
meal preparation and computer use.

P: The client will be treated for 60-minute sessions 1x/week for 8 weeks to address motor and tone
deficits that interfere will occupational performance in meal preparation and computer use. Skilled O.T.
services are required to provide adaptive strategies to incorporate his R UE and treatments to support
occupation that will reduce his tone and promote more active motion in his R UE. Skilled OT services will
also provide him with professional home programming to increase his performance and improvement.
The client’s complex condition requires advanced clinical reasoning to provide appropriate, graded
activities that will address his performance deficits. The following goals were made in collaboration with
the client.

Goals

LTG1: By discharge, client will I incorporate his RUE while preparing an oven meal.

STG1a: Within 4 weeks, client will incorporate his RUE to gather materials for simple meal prep
with no more than 1 V.C.

STG1b: By 4 weeks, client will implement tone reduction strategies appropriately during a
simple meal prep PRN with no more than 2 VP

LTG2: Within 8 weeks, client will independently incorporate his RUE when using the computer utilizing
compensatory strategies.

STG2a: Within 4 weeks, client will type a social media post within 60 seconds utilizing
compensatory strategies.
GAS Charts

Distal Outcome (LTG): -2 -1 0

(Baseline) (Goal)
By discharge, client will Much Less Less Expected Level
I incorporate his RUE
while preparing an
oven meal

(Occupation/Target - Requires more than 2 - requires 2 prompts - incorporates R UE

Behavior) prompts to incorporate to incorporate his R without a prompt
R UE UE - Uses a strategy that is
- Uses no effective - Uses at least one effective
strategies ineffective strategy - Uses his R UE at least 3x
- Uses his R UE only - Only uses his R UE during the task
once during the task 2x during the task

Proximal Outcomes (STGs)

1) Within 4 weeks, client will incorporate his RUE to gather materials for simple meal prep with
no more than 1 V.C.

2) By 4 weeks, client will implement tone reduction strategies appropriately during a simple meal
prep PRN with no more than 2 V.P.

Distal Outcome (LTG): -2 -1 0

Within 8 weeks, client (Baseline) (Goal)
will independently Much Less Less Expected Level
incorporate his RUE
when using the
computer using
compensatory strategies

(Occupation/Target - Uses computer with -requires more than -incorporates R UE

Behavior) L UE and does not 1 prompt to without a prompt
incorporate R incorporate RUE - uses an effective
- does not use - uses a strategy that strategy that limits #of
compensatory causes multiple mistakes
strategies mistakes

Proximal Outcomes (STGs) Measurement Criteria

1) Within 4 weeks, client will 60 seconds

type a social media post
within 60 seconds
 utilizing compensatory
strategies

Practice Models: The following practice models will be used to guide treatment.
1. PEO: This model promotes change to increase congruence between the person, their
occupation, and their environment by recognizing that the person is a dynamic and changing
individual, but some things are more responsive to change than others. It also acknowledges
that the environment can have an enabling or constraining effect on the individual and their
occupational performance (Strong et al., 1999). Using this model with the client, will help
facilitate the process to look at his environment and how it is inhibiting his occupation and
adapting it so it can have a more positive effect on the fit of his P-E-O and help increase
performance although his function may not change drastically due to the time given for therapy.

2. Motor control: With this model, change occurs through repetition, maximizing personal and
environmental characteristics, generalizing strategies, and enhancing an individual’s ability to
problem solve during a task (Kielhofner, 2009). This model will guide therapy with M, as planned
interventions will promote repetition of efficient strategies to incorporate his R U.E. into his
occupations and encouragement to practice them at home, so they are generalized in more
contexts. It will also guide intervention to include opportunities for him to think through a
problem and come up with a strategy to better complete a task with involvement from his RUE
for himself. This model will promote change in the client as it addresses his tone issues through
repetitive interventions to support occupation.
Intervention Plan:
Strategies to effectively use the client’s R UE will be taught and implemented throughout treatment, so
he is able to incorporate his R UE, even if it is passively. Tone reduction activities will be taught and
applied during occupation to help him decrease the effect tone has on his performance. Throughout the
treatment activities, if the client or the student therapist recognizes his tone increases, the treatment
activity will be paused, and he will complete a tone reduction activity before he resumes the previous
activity. Weight-bearing activities will be incorporated throughout treatment as well to help improve
functional performance. Glen Gillen, 2016 in his book Stroke Rehabilitation a Function Based Approach,
teaches that based on research, weight-bearing exercises can help incorporate the affected extremity
and can reduce tissue shortening in flexors (Gillen, 2016).
Home programming will be created for the client to complete at home to carry over treatment and
increase his progress. It will take a lot of work for him to use his R UE more functionally, so home
programming will allow him to continue to make gains outside of therapy. Home programming will
include self-ROM, weight-bearing exercises, and tone reduction activities. In a survey of occupational
therapists, 94% of respondents used HEP’s for individuals with neurological conditions. The therapists
believed HEP’s allowed the client to be more active in the therapy process and that it helped generalize
skills into the individuals’ natural environment (Proffitt, 2016). The article also discusses different
methods, dosages, and types of activities involved in the HEPs, which will be a good place to start.
The client has good rehab potential with OT services. Thank you for the opportunity to assist him in
returning to independence in his occupations.
Megan Wilson OTS
 References

Gillen, G. (2016). Upper extremity function and management. In Stroke rehabilitation a function-based
approach. (pp. 424-487). Elsevier Inc.

Kielhofner, G. (2009). Practice-motor control model. In Conceptual foundations of occupational therapy.

(pp. 175-200); F. A. Davis Company.

Proffitt, R. (2016). Home exercise program for adults with neurological injuries: A survey. American
Journal of Occupational Therapy, 70(3), 1-8. https://doi.org/10.5014/ajot.2016.019729

Strong, S., Rigby, P., Stewart, D., Law, M., Letts, L., & Cooper, B. (1999). Application of the person-
environment-occupation model: A practical tool. Canadian Journal of Occupational
Therapy, 66(3), 122–133. https://doi.org/10.1177/000841749906600304