Date of Assessment: 2/18/2021

Name: Client

Diagnosis: Hemiplegia secondary to multiple strokes

Occupational Therapy Initial Evaluation

S: “Everything mental is intact”.

O: Client was seen on 2/11/2021 and 2/18/2021 for a comprehensive occupational therapy evaluation,
including an occupational profile interview, an observation of occupational performance during the task
of washing/drying dishes and opening/closing containers, and completion of the Action Research Arm
Test (ARAT).

Occupational Profile: Client is a 24-year-old single male who presents to the clinic with difficulty
completing ADLs due to weakness, lack of strength and ROM due to 4 strokes he acquired on September
7, 2020. Client is R handed. He has little motor control and limited ROM in his R UE. He has minimal
functional use of his R index finger and thumb. He can slightly extend his fingers if he rests his arm by his
side and lets his fingers relax. His left hand is shaky and has some fine motor deficits. He has no
movement in his right ankle but can move his right hip. He does not have any loss of sensation. He
wears an AFO during the day and wears a hand brace 3-4x/week. He is dysarthric, but understandable.
He has no dysphagia. Client states that everything is intact mentally.

Client lives in a trailer home with his mother, who is disabled, his friend, along with his brother
and his brother’s husband. His home has narrow hallways allowing him to walk throughout without the
use of his crutch; he stabilizes himself by holding onto the walls. Client uses a w/c in the community and
a forearm crutch for shorter distances. He is a risk for falling. During the afternoon, client goes with his
friends to the gym. He uses a wheelchair to enter the gym and then walks independently between
machines. He exercises his upper body and has someone there to spot him. Prior to his strokes, client
worked as a janitor at the VA and also as a mechanic. Client does not currently work or attend school. He
enjoys heavy metal music and previously enjoyed singing and played several musical instruments such
as the drums, keyboard, and bass guitar in a thrash band. Playing music is something that motivates him.
He previously started a graphic design program of study online and enjoyed drawing and painting with
acrylic paints. He currently enjoys watching TV shows and going to the gym or park with friends. Client
has a smartphone and uses Facebook.

Client does not always eat breakfast but when he does, he eats around 10:00am. He usually has
eggs or breakfast burritos. His mother cooks his meals. He enjoys most foods, especially steak and hot
wings but he dislikes seafood. He can feed himself independently with his L hand. Client sleeps in the
living room on a bed and says he tends to sleep as much as possible. He can independently get himself
out of bed, walk to the bathroom, and manage clothing during toileting. He can manage most of his
clothing independently but requires A with doffing jeans. He requires assistance getting undressed for
bathing and needs handheld assist for transferring in/out of the tub. Along with the tub he has a walk-in
shower with a shower chair that he can get in and out of independently. He can wash himself
independently. He is also able to take medication independently.

Client is attending rehab services at the sugarhouse clinic. His mother attends all therapy
services with him. Client would like to become more independent in ADLs such as dressing, bathing, and
grooming. He would like to resume working along with engaging in valued occupations such as playing
music, drawing, painting, along with doing graphic design.

Occupational Performance Assessment: Client completed the task of washing/drying dishes along with
opening/closing containers. He was able to stand at the sink that was raised to just above waist level
with CGA. Client used his L hand to place the dish brush in his R hand and then used his L hand to pour
soap onto the brush. He used his L hand to turn the water on and check the temperature. He held the
dish with his L hand and scrubbed with his R. He had difficulty moving his R UE to wash the dish. He
required direct cueing to switch hands and use his R hand to stabilize the dish in the bottom corner of
the sink and use his L hand to scrub. He was able to transfer the dish with his L hand but had slight
difficulty turning his wrist to place the dish in the dishrack. He was able to cross midline to place a dish in
the dishrack with his R hand but had difficulty holding onto the dish and manipulating his R UE to place it
into the dishrack. At times, client would only use his L hand to wash the dishes and refrained from using
his R if he could. After about 10 minutes of standing to complete the task, he started to have some
fatigue and spasticity throughout his legs and needed to sit down. He walked to his chair using his
forearm crutch with CGA.

AROM/PROM testing along with brief MMT were completed on client’s R UE. He was able to
actively flex his shoulder approximately 90 degrees. He can passively extend his elbow with the use of
his L hand. He has minimal movement in his thumb and index finger. He can actively flex his wrist
approximately 45 degrees but does not have any pronation, supination, or extension. During manual
muscle testing, client scored approximately a ⅘ on shoulder flexion, wrist pronation and wrist
supination, MCP flexion, along with thumb adduction.

While sitting, client practiced opening and closing various sized containers. He used his L UE to
wedge the container between his body and R UE and used his L hand to open the container. He was able
to pop open a small lid, and twist open a large and small lid with his L hand. He was able to open a small,
lidded container with his R hand by wedging the lid between his index finger and thumb and then
twisting the container open with his L hand.

Client demonstrated excellent performance with his L UE on the Action Research Arm Test
(ARAT) however, demonstrated poor performance with his R UE which is his affected limb. Client was
unable to pinch or grasp small objects with his R hand. He scored 5/12 on the grip subtest and 7/9 on
the gross movement subtest with his R UE. He was able to complete the gross movement subtest within
functional limits with his R UE but had large deficits in all other subtests. He scored an overall 56/57
points with his L UE and 13/57 overall with his R UE. (See last page for ARAT scoring sheet).

A: Interpretation: Client is a funny, reserved young man who is aware of how his deficits impact his
occupational performance and participation. Client seems to be unmotivated to become more
independent and engage in occupations to take care of himself. His R hemiparesis affects his ability to
engage in ADLs and IADLs. He demonstrates learned non-use in his R UE which is evident in how he does
not initiate movement in his R UE unless cued by the therapist. His scores on the ARAT along with
difficulties during the task of washing dishes and opening/closing containers demonstrates his poor
ROM and fine motor skills of his R side. Client’s mother is a support in that she cares for him although
she may also be a barrier in that client seems to rely on her for his cares. Client’s environment may also
be a barrier for him in that it is an enclosed area that could possibly pose obstacles or cause safety
hazards. Client uses some AE such as a shower chair as a support. Client has friends to support him and
enable him to engage in occupations such as going to the gym. Client is an excellent candidate for
functional rehabilitation as it relates to being more independent and engaging in occupations to take
care of himself.

P: Client will be treated for 60-minute sessions 1/week for 8 weeks to address deficits in ROM, strength,
fine motor coordination, gross motor coordination, along with motivation levels. These deficits interfere
with occupational performance during ADLs such as dressing, grooming and hygiene tasks. Skilled
Occupational Therapy services are required for appropriate grading of activities that will address fine
and gross motor performance deficits. Client’s complex condition requires advanced clinical judgement
to adjust the presentation of activities that will properly challenge him while also teach him to
generalize strategies beyond the treatment session. All goals were determined by the therapist along
with the client and his mother.

Intervention:

Interventions will be client-centered and occupation-based in order to address his deficits to help him
reach his goals. These may include, completing ADLs while using adaptive strategies and equipment,
completing activities that require repetitive motor movements, completing activities that are interesting
 to the client to help increase motivation, along with training on compensatory strategies to improve
occupational participation and performance.

Goals

LTG1: By d/c, client will independently complete total body dressing with AE as needed.
STG1: In 4 weeks, client will independently don/doff leg brace.
STG2: In 6 weeks, client will independently don shoes and tie shoelaces.
LTG2: By d/c, client will independently complete grooming and hygiene as part of a morning routine.
STG1: In 6 weeks, client will independently complete nail care with AE.
STG2: In 4 weeks, client will independently complete facial hair removal.

GAS charts

**HINTs: each column should have 3-5 bulleted measures.

***It’s easier if you fill out the “0” column (Goal measures – LTG/Measurement Criteria – STO) first, then the “-2” column (Baseline
performance) and then fill in the rest of the columns in between.

Distal Outcome -2 -1 0 +1 +2
(LTG):
(Baseline) (Goal)
By d/c, client will
Much Less Less Expected Level Better Much Better
independently
complete total
body dressing
with AE as
needed.

(Occupation/Target Requires max A to Able to Able to Able to Able to

Behavior) don leg brace, independently don independently don independently don independently don
shoes, cannot do slip on shoes and pullover shirt, loose jacket with zipper. jeans and button-
fine motor don leg brace with pants, shoes with down shirt.
manipulation for min A. laces, socks, and
laces and fasteners. leg brace.

Proximal Outcomes (STGs) Measurement Criteria Baseline

1) In 4 weeks, client In order for the client to do this Requires max A to don/doff leg brace.
will independently independently, he must be able to position
don/doff leg brace. the leg brace properly, slide his leg into the
leg brace, along with undo and fasten the
 Velcro strap.

2. In 6 weeks, client In order for the client to do this Requires max A to don/doff shoes and tie shoelaces.
will independently independently, he must be able to position
don shoes and tie his shoe properly and slide his foot into the
shoe, adjust the back/tongue of the shoe
shoelaces.
as needed, and complete tying the
shoelaces (may use AE or compensatory
strategies).

**HINTs: each column should have 3-5 bulleted measures.

***It’s easier if you fill out the “0” column (Goal measures – LTG/Measurement Criteria – STO) first, then the “-2” column (Baseline
performance) and then fill in the rest of the columns in between.

Distal Outcome -2 -1 0 +1 +2
(LTG): By d/c,
(Baseline) (Goal)
client will
independently Much Less Less Expected Level Better Much Better
complete
grooming and
hygiene as part
of a morning
routine.

(Occupation/Target Able to shave face Able to shave face Able to Able to cut toenails Able to
Behavior) with mod assist, with min assist, able independently with min A. independently cut
bites fingernails, cut fingernails with shave face, cut toenails.
able to apply mod A, and apply fingernails, and
deodorant with min deodorant apply deodorant.
A. independently.

Proximal Outcomes (STGs) Measurement Criteria Baseline

1. In 6 weeks, In order for the client to do this Client is dependent for toenail care and currently
client will independently, he must be able to have bites fingernails.
independently fine motor control and grip strength in
order to safely hold clippers to cut
complete nail
fingernails.
care with AE.

2. In 4 weeks, In order for the client to do this Requires mod assist to complete facial hair removal.
client will independently, he must be able to apply
independently shaving cream to whole face, use safe and
steady motions while applying the razor to
 complete facial face, ensure facial hair is removed on all
hair removal. aspects of face, and remove any excess
shaving cream once finished.

Client is an excellent candidate for progress with OT services. Thank you for the opportunity to assist
him in returning to independence in his occupations.

Practice Models:

PEO: The PEO model will guide interventions for this client by addressing the congruence between the
client, desired occupations, along with the environment. Assessing client’s desires and interests,
analyzing the demands of desired occupations, along with assessing barriers in his environment will
allow for the optimal dynamic between these factors to be discovered which will ultimately affect his
occupational performance and participation.

Motor control model: The motor control model will be appropriate for this client. Repetitive
movements will help the client to rebuild neural pathways which will help the client to regain ROM to
promote function.

● Postulates for change to be used with client

o Accomplishing necessary and desired tasks in the most efficient way, given the client’s
characteristics.
o Allowing the person to practice desired occupations in varying and natural contexts so
the learned motor behaviors are more stable.
o Maximizing personal and environmental characteristics that enhance performance.
o Enhancing problem-solving abilities of clients so they will more readily find solutions to
challenges encountered in new environments beyond the treatment setting.
Research

Rehabilitation of arm function after stroke. Literature review

● This article discusses how repetitive training that is task-oriented is a method to ensure a
positive functional outcome in individuals recovering from stroke. This supports my
interventions of using repetitive motor movements during therapy along with the activities
being task oriented.

Oujamaa L, Relave I, Froger J, Mottet D, Pelissier JY. Rehabilitation of arm function after stroke.
Literature review. Ann Phys Rehabil Med. 2009 Apr;52(3):269-93. English, French. doi:
10.1016/j.rehab.2008.10.003. Epub 2009 Apr 9. PMID: 19398398.
Mobile Game-based Virtual Reality Program for Upper Extremity Stroke Rehabilitation
● This article discusses how goal-oriented tasks that use repetitive movements can be an engaging
and motivating tool to use in therapy. This supports my interventions of using repetitive motor
movements that are task oriented to use in therapy. This intervention may also help to increase
the client’s motivation levels and improve overall progress in therapy.

Choi YH, Paik NJ. Mobile Game-based Virtual Reality Program for Upper Extremity Stroke
Rehabilitation. J Vis Exp. 2018 Mar 8;(133):56241. doi: 10.3791/56241. PMID: 29578520;
PMCID: PMC5931529.

Tayler Stokes, OTS 2/18/2021