Date of Assessment: 02/19/2021

Name: BB
Diagnosis: R CVA
Occupational Therapy Initial Evaluation

S: Pt states that she is competitive that she wants to utilize as much therapy as possible to improve the
use of her left arm

O: (Evaluation overview)

Occupational Profile:

Pt was seen 02/19/2021 for comprehensive occupational therapy evaluation, including an occupational
profile interview, an observation of occupational performance, and any specific assessments

Pt was self-referred to see Occupational Therapy services at the University of Utah in the Life Skills Clinic
with the desire to regain function of her affected left arm and to utilize as much therapy as she can. She
is an older adult who had a R CVA in April of 2017. She receives OT services with L. Blevins, PT services
weekly, and an OT student comes to her home once a week to work on stretches. She does swim therapy
with L. Blevins every other week. Pt has had 2 neurectomies and a nerve transplant to decrease muscle
tone & improve movement in her L UE & L LE. She reports no changes in thinking and memory.

Pt lives in a single level home with a basement and with her husband, Kelly, who works for Intermountain
Healthcare in Cybersecurity. They were recently married last year in June 2020. Their bathroom is being
remodeled and so she is currently using the shower in the basement. She reports high tone in her L UE,
that she has some movement and some recovery in her shoulder, and that she moves her hand and arm
the slowest. There is no movement in fingers, or they are limited, and has more movement in her L UE
when tone is managed. She reports it can be difficult to carry items up and down the stairs but does not
have trouble with stairs. She has some difficulty getting up off the floor from supine to standing. She can
navigate her home, walks slowly and independently without aids.

Pt’s daily routine depends on the day. On Mondays, Wednesdays, & Thursdays she usually gets out of bed,
showers, gets dressed, and arrives to work at 9:30AM. She is an attorney and owns her own practice in
Ogden working in criminal justice and family practice. She usually works from 9:30AM-5:30PM but is
sometimes works later depending on the day. On Tuesdays & Fridays she is scheduled for therapy with
OT or PT, or she does volunteer work for RAMP as a peer mentor at Intermountain Healthcare for
individuals in rehabilitation. She states that things have changed since COVID-19, but she has received
both doses of the vaccine and his hopeful.
Pt uses one handed technique to complete ADLs independently. She can shower independently but enjoys
the occasional bath. There is a grab bar in the shower she uses for support. She stated that after her stroke
she was able to get on all fours and out of the bathtub independently, but suddenly her wrist became
tight and now she requires assistance from her husband to get out of the bathtub. She can total body
dress independently using her unaffected hand but reports that removing t-shirts or tops is difficult, has
difficulty clasping bras, and generally has her husband assist with dressing tasks that require more than
one hand such as tying straps. She owns over 200 shoes but is now getting rid of many of them as well as
other clothing since she can no longer wear them. She cannot wear earrings with backs on them. She does
her own make up and brushes her teeth.

At work, Pt uses software called Dragon Speak since she cannot type on a regular keyboard with one hand.
It works with speaking into a microphone and the software types. She states it is clunky, she does not like
it, and expressed interest in learning how to use a one-handed keyboard. She drives independently and
uses a spinner knob to control the steering wheel and closes her door with her right unaffected hand.

At home, her husband does most of the cooking. She expressed that cooking is a frustrating task for her
to perform and can be exhausting. Prior to her stroke she used to host parties, and enjoy preparing meals,
but does not host parties as often anymore since her stroke. It brings her anxiety, she is unmotivated to
do it, and does not have much interest in them anymore. She can prepare meals independently but may
need assistance depending on how complex the task or meal is (Example: using a can opener). A Jar or
container opener was installed under her cabinets so she can twist the lids off containers with one hand.
She uses her left arm pit to stabilize items as needed, but generally never uses her left arm. She uses the
corner of the inside of the sink to stabilize dishes to wash and dry them with one hand. She never had to
take medications prior to her stroke, but now she takes medications regularly. She no longer takes
medication for spasticity because it made her “foggy” which was not good for her job as an attorney. She
can do cleaning tasks that she can complete one-handed. She is Catholic, used to go to Mass weekly, but
since the COVID-19 pandemic they attend Mass at home online through YouTube. She had depression
after her stroke and saw a therapist regularly but is now no longer seeing a therapist as she feels like she
has reached the stage of acceptance and that her condition is her new reality.

Pt enjoys boxing and used to box and host parties prior to stroke. She currently enjoys yoga, going on
walks with her husband, and any activity that gets her moving. Since the pandemic she spends most of
her time with her husband, and occasionally sees her Mom and sister who live in the Salt Lake area.

Pt’s social strengths of support are her husband, friends, family, and her therapy team. Other strengths
are her ability to be independent using one-handed techniques as well as other internal strengths such as
motivation, determination, and competitive spirit to accomplish tasks and reach goals. Barriers to
performance are rooted in her L UE deficits and spasticity in her L UE & L LE. This causes her to walk slower,
increases the duration it takes to complete her ADLs, and require occasional assistance to perform tasks
that may require two hands to complete. She desires to be able to get down on all fours, to be able to pull
her car door shut with her left arm, get out of her bathtub, learn one-handed typing techniques, and
improve overall LUE function.
Pt will be receiving occupational therapy services once a week for 8 weeks at the University of Utah Life
Skills Clinic to work on improving LUE functioning, compensatory strategies, and increase her
independence and performance in daily occupations.

Occupational Performance Assessment/Observation of Occupational Performance:

Pt engaged in a baking task making a pan of muffins. She stood up from her chair and walked slowly to
the countertop. Her body leans to the left slightly, her knees are close together, and her feet are placed
in a slightly wider stance as she walks to the edge of the countertop. Her left arm hangs by her side with
her elbow, wrist, and fingers maintained in a flexed position. The box of muffins & equipment them are
set up on the counter. She picks up the box of muffins with her right hand and reads the ingredients and
questions us where the blue berries are. She walks to the oven and preheats it to 400 degrees F and
returns to the ingredients. With her right hand she turns on the sink, walks a few steps to the right to
obtain the measuring cup, returns to the sink and fills it up, walks to the mixing bowl and pours it in, then
returns to the sink to turn it off. Using her right hand, she opens the box using her fingers and pulls out its
contents one item at a time. The box contains a can of blueberries & a bag of muffin mix. She holds
requests scissors or something sharp to open the bag. Scissors are provided and she cuts the bag open
with her right hand and dumps it into the mixing bowl shaking it multiple times to get the mix out. She
grasps the plastic container of vegetable oil and wedges under her left arm pit and twists the lid off with
her right hand. She manages the vegetable oil and measuring cup one item at a time and pours the correct
amount into the mixing bowl. With her right hand she opens the box of eggs and cracks open 2 eggs on
the edge of the mixing bowl and drops them in. Although provided a can opener, she stated that her
husband would have to open the can and that she was unable to it on her own. She does not put blue
berries in the mix. She stabilizes the mixing bowl against her body, obtains the wire whisk, and mixes the
ingredients. Using a measuring cup, she scoops up the batter, and pours it into the muffin pan to make 6
muffins. Her left arm remained at her side during the entire task except for when opening the container
of vegetable oil. She is asked to put on her coat, and she manipulates it using her right hand, placing her
left arm through the arm sleeve first, although not completely, then she puts her right arm through the
right sleeve. She then uses her right hand to push her left hand the rest of the way out of the sleeve so
that it is visible. She removes the coat following the same steps in reverse. She is offered a pan to clean
in the sink. She wedges it in the far-left corner of the sink, soaks it, puts soap on it, then uses the brush to
clean it while it remains stabilized at the corner of the sink. After rinsing the pot, she grabs a dry washcloth
and dries the inner part of pan, then sets it upside down, and then dries the underside. She places the pan
in the dish rack.
Standardized Assessments:

Ashworth Scale
Upper Extremity Score
Shoulder Flexion 1+
Shoulder Extension 1+
Elbow Flexion 2
Elbow Extension 2
Wrist Flexion 0
Wrist Extension 2
Finger Flexion 0
Finger Extension 2

Fugl-Meyer Assessment of the Upper Extremity

A. Upper Extremity, sitting position
1. Reflex Activity Score
Flexors (biceps) 2
Extensors (triceps) 2
2. Volitional Movement within Synergies,
Without gravitational help
Flexor Synergy Score
Shoulder Retraction 2
Shoulder Elevation 2
Shoulder Abduction 90 2
Shoulder External Rotation 0
Elbow Flexion 0
Forearm Supination 0
Extensor Synergy Score
Shoulder adduction/internal rotation 1
Elbow Extension 1
Forearm Pronation 0
3. Volitional Movement with mixing Score
synergies
Hand to Lumbar Spine 0
Shoulder Flexion 0 – 90 1
Pronation- Supination 0
4. Volitional Movement with little or no Score
synergy
Shoulder abduction 0 – 90 1
Shoulder flexion 90 - 180 0
Pronation/Supination 0
TOTAL A 14
B. Wrist
Wrist Score
Stability at 15 dorsiflexion 0
Repeated Dorsiflexion/volar flexion 0
Stability at 15 dorsiflexion 0
Repeated dorsiflexion/volar flexion 0
Circumduction 0
TOTAL B 0
C. Hand
Hand Score
Mass flexion 1
Mass Extension 1
Hook grasp 1
Thumb adduction 1
Pincer Grasp, opposition 1
Cylinder grasp 2
Spherical Grasp 1
TOTAL C 8
D. Coordination/Speed
Items Score
Tremor 2
Dysmetria 2
Time 0
TOTAL D 4
H. Sensation
Sensation Score
Light Touch: Upper arm, forearm 2
Light Touch: Palmary surface of the hand 2
Position (proprioception) Score
Shoulder 2
Elbow 2
Wrist 2
Thumb (IP-Joint) 2
TOTAL H 12

I. Passive Joint J. Joint Pain

Upper Extremity
Shoulder Flexion 0 – 180
Shoulder Abduction 0 – 90
External Rotation
Internal Rotation
Elbow Flexion
Elbow Extension
Forearm pronation
Forearm Supination
Wrist Flexion
Wrist Extension
Motion
Score Score
1 2
1 2
1 2
1 2
1 2
1 2
0 2
0 2
2 2
0 2
 Finger Flexion 2 2
Finger Extension 1 2
TOTAL 11 24

Totals for the Fugl-Meyer Assessment of the Upper Extremity

A. Upper Extremity 14/36
B. Wrist 0/10
C. Hand 8/14
D. Coordination/Speed 4/6
TOTAL A – D (motor function) 26
H. Sensation 12/12
I. Passive Joint Motion 11/24
J. Joint Pain 24/24
TOTAL H – J 47

A: Interpretation:

The occupational profile and occupational analysis indicate that Pt has fully intact cognitive function. This
was observed through her ability to follow directions accurately to make the muffins, request kitchen
tools, her insight on her limitations and strengths to perform tasks, and her ability to problem-solve to
bring the task to completion. Her slight valgus and slow gait are due to the presence of muscle tone & lack
of muscle strength in her L LE, specifically abductor muscles of the leg. This causes her to walk slowly and
with more caution to stabilize her body, maintain balance, and to remain in an upright position. Pt has
limited movement of her L UE due to high tone but has no contractures or sensation deficits. She has
more movement in her shoulder. The amount of movement decreases distally to the hand due to the
location of the R CVA. Her independence in performing ADLs is indicated from learned use of skills to
perform one-handed techniques with her unaffected arm. She requires assistance performing tasks that
need both hands. She does not use her left arm to perform tasks but does use her left armpit as a place
to stabilize and carry objects as seen to open the vegetable oil. Left sided trunk weakness affects her
ability to come from a supine to seated position and high tone in her wrist & fingers cause difficulty with
extension. This affects her functional mobility to come from a lying to a standing position without
assistance. Muscle function is available, although weak and affected due to spasticity. There may be
potential to increase her left arm function through repeated use when performing occupational tasks and
activities. If she does not use her left arm, it will decrease in function and promote learned non-use which
can be prevented.

The Ashworth Scale & Fugl-Meyer Assessment of the Upper Extremity were used to assess for tone and
UE function of the left arm. The Ashworth Scale, which tests for muscle tonicity/spasticity, indicated a
slight increase in muscle tone in the shoulder flexors & extensors, a more marked increase of muscle tone
in most of the ROM in the elbow flexors & extensors as well as wrist and finger extensors. No increase in
muscle tone indicated in wrist and finger flexion. The Fugl-Meyer Assessment of the Upper Extremity
assessed reflex activity, volitional movements, coordination/speed, sensation, & PROM in the shoulders,
elbows, wrists, and fingers. Reflex activity in the L UE in the shoulder and elbow are normal. She indicates
more muscle AROM proximally at the shoulder and AROM decreases in the more distal extremities in the
elbow, hand, and fingers. Her upper extremity score indicates full volitional movement in the shoulder,
but with none to little volitional movement performing external rotation & in the elbows. AROM
movement is limited to none in performing supination and pronation, shoulder extension, and internal
rotation. There is little to no muscle function in the wrist and partial muscle function in the hands and
fingers. She can grasp and pinch objects, she cannot extend her thumb. No tremors or dysmetria was
indicated and touch and proprioception is intact and normal. She had decreased PROM at the shoulder,
elbow, wrist, and fingers, but no PROM in forearm pronation/supination and wrist extension. These tests
indicate that she has partial hemiparesis in her L UE but has normal sensation. There is more muscle
weakness distally in the wrist and hands than in the elbow and shoulders. Her shoulder contains the most
muscle function. Her ability to move the arm is decreased due to muscle weaknesses and is further
impeded due to muscle tonicity or spasticity.

P: Pt will be treated for 1-hour sessions once a week for 8 weeks to address L UE deficits in reaching,
grasping, bending, stabilizing, trunk stability, and muscle strength that interfere with occupational
performance in functional mobility, bathing, and driving. Skilled OT services are required for appropriate
grading of activities that will address L UE motor function and performance deficits. Pt’s complex condition
requires advanced clinical judgment to adjust the presentation of activities that will properly challenge
her while also teach her to generalize strategies beyond the treatment session.

Goals:

LTG1: In 8 weeks, Pt will independently close her car door while in the driver seat with her L UE with hand
using compensatory strategies or A/E
STG1: In 4 weeks, client will independently reach and grab her steering wheel in the bottom left
quadrant with her L UE
STG2: In 6 weeks, client will independently reach to touch her partially open door with her L UE
using A/E
LTG2: In 8 weeks, Pt will be able to get out of a bathtub from supine to standing with supervision
STG1: In 4 weeks, Pt will be able to come from supine to a seated position with Min A & with use
of A/E
STG2: In 4 weeks, Pt will be able to come from a seated position to standing with Min A & with
use of A/E

Pt is an excellent candidate for progress with OT services. Thank you for the opportunity to assist her in
returning to independence in his occupations.
 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 (LTG): -2 -1 0 +1 +2
(Baseline) (Goal)
Much Less Less Expected Level Better Much Better
(Occupation/Target In eight weeks, client In eight weeks, client In eight weeks, client
Behavior) will shut her car door will independently will independently
with her L UE with min. shut her car door with shut her car door with
Driving/reaching and assist and the use of her L UE and the use her L UE.
grasping car door to shut adaptive equipment. of adaptive
, muscle power, muscle equipment.
endurance, trunk
stability

Proximal Outcomes (STGs) Measurement Baseline

Criteria
1) In four weeks, client will independently reach and grab Independent
her steering wheel in the bottom left quadrant with her
L UE. In four weeks, client will reach to touch her steering
wheel with min. assist
2) In six weeks, client will independently reach to touch her Independent
partially open car door with her L UEusing adaptive In six weeks, client will reach to touch her car door
equipment. with her L UE using adaptive equipment with min.
assist.
**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 (LTG): -2 -1 0 +1 +2
(Baseline) (Goal)
Much Less Less Expected Level Better Much
Better
(Occupation/Target Client requires Min A Client will be able to Client will be able to
Behavior) to get out of the get out of the bathtub get out of the bathtub
bathtub from supine to independently
Functional mobility and safety standing with
in a Bathing task: Reaching, supervision
grasping, trunk stability, UE,
LE, and core strength

Proximal Outcomes (STGs) Measurement Criteria Baseline

3) In 4 weeks, Pt will be able to come from
supine to a seated position with Min A & with
use of A/E
4) In 4 weeks, Pt will be able to come from a
seated position to standing with Min A & with
use of A/E
Level of Assistance Client will be able to come from supine to sitting
with Mod A with the use of A/E
Level of Assistance Client will be able to come from a seated position
to standing with Mod A with use of A/E

Research Evidence:

Article 1: Inter-rater reliability of the Modified Modified Ashworth Scale as a clinical tool in
measurements of post-stroke elbow flexor spasticity

The intent of this research study was to test the inter-rater reliability of the Modified Modified Ashworth
Scale (MMAS) when assessing spasticity in adults with post-stroke hemiplegia. This study involved the
participation of 21 adult patients whose affected elbow was assessed with the MMAS. Each participant
was a stroke survivor with upper extremity hemiplegia, had no previous pathology that has affected their
upper limb, and that they had adequate cognition to follow instructions. The results from the study
indicated that the MMAS had very good inter-rater reliability. This article provides evidence and supports
its use with Pt during the assessment phase of the therapy session. Scores gathered from the MMAS to
test her spasticity in her affected shoulder, elbow, wrist, and fingers are reliable findings that provide
useful information for goal and intervention planning.

Ansari NN, Naghdi S, Hasson S, Mousakhani A, Nouriyan A, & Omidvar Z. (2009). Inter-rater reliability of
the Modified Modified Ashworth Scale as a clinical tool in measurements of post-stroke elbow
flexor spasticity. NeuroRehabilitation, 24(3), 225–229. https://doi.org/10.3233/NRE-2009-0472

Article 2: Translating measurement findings into rehabilitation practice: An example using Fugl-Meyer
Assessment-Upper Extremity with patients following stroke

This research study by Velozo and Woodbury tested the Fugl-Meyer Assessment (FMA-UE) of the Upper
Extremity with the use of an evaluation key form. It resulted that the FMA-UE is a well-developed
assessment and that its key form produced reliable information about what the patient can do, can
partially do, and cannot do. It indicates that the FMA-UE keyform can be used as an evidence-based
assessment tool to gather information about a client’s limitations and abilities that will further assist
therapists in the intervention and treatment planning process and the setting of realistic goals.

Velozo, C. A., & Woodbury, M. L. (2011). Translating measurement findings into rehabilitation practice:
An example using Fugl-Meyer Assessment-Upper Extremity with patients following stroke. Journal
of Rehabilitation Research & Development, 48(10), 1211–1221.
https://doi.org/10.1682/JRRD.2010.10.0203

Practice Models:

• PEO: The PEO model is applicable to Pt in a variety of ways. This model focuses on the person,
their environment, and the occupation they are performing. Improving her occupational
performance will follow the theory of finding harmony with their ability to perform the task,
modifying the environment to increase independence, and in occupation itself. Pt’s L UE & L LE
have been affected by her R CVA in 2017 and implementing the PEO model by teaching her
compensatory strategies, modifying her home, or providing adaptive equipment, will improve her
ability to perform tasks more independently and improve her occupational performance and life
satisfaction. Postulates of change that apply to future treatment are that the person,
environment, and occupational transact continually over time and space in ways that increase or
decrease their congruence. The environment is dynamic and can have enabling or constraining
effects on occupational performance affecting congruence between the person, occupation, and
environment. The environment may be easier to change than the person.
• Motor Control Model: The Motor Control Model is tailored for individuals who have a acquired a
form of brain injury or Central Nervous System (CNS) deficit such as a traumatic brain injury
cerebral palsy, stroke, multiple sclerosis, Parkinson’s disease, and those who have difficulty
executing voluntary motor movements. New motor patterns are learned during movement and
this model focuses on neuroplasticity and the ability to learn new motor skills. Postulates for
change incorporate the need for the client to problem-solve so that they can readily find solutions
to challenges encountered in new environments, tasks can be broken down or done to master
them, and that repetition is key to motor learning. Pt has muscle function and through dedicated
practice, repetition, and use of the L UE in occupation-based activities, she will gradually gain
more function as new motor pathways develop.

Signature,

John Barker (OTS)