BACKGROUND INFORMATION

Date of report: 2/3/17 Clients name or initials: XXX

Age: 27 Date of referral: 1/23/17
Primary Diagnosis: L CVA
Secondary diagnosis/concern: R hemiparesis, expressive aphasia
Precautions: Fall risk
Reason for referral to OT: learned non-use in the RUE which is negatively impacting
participation
Therapist: Rachel Swan, OTS

S: The client expressed his desire to get back to his previous occupations and abilities

saying normal and pointing to his RUE when asked about his goals for therapy.

FINDINGS (O):

Occupational Profile:

XXX is a 27-year-old male that had a L CVA in September of 2016. He was living in

Pennsylvania at the time, attending the University of Pennsylvania to obtain his PhD in

engineering. His girlfriend lives in Salt Lake City, and is getting her PhD in Chemistry. Due

to her being a primary caregiver for him, XXX moved to SLC after his stroke and now lives

with his girlfriend. After the stroke, his mother also traveled from China and is now living

with them as well. XXX cannot currently drive, and his mother takes him to all of his

therapy appointments, which include speech therapy and physical therapy. He is not

working or attending classes right now, in order to focus on rehabilitation. He participates

in leisure activities such as reading and writing in the evenings, and enjoys going on

mountain drives with his mom and girlfriend. He also mentioned that he spends a lot of

time on his computer, using his LUE to type and control the mouse. He is currently writing

with his LUE, which is a new skill he has learned since his stroke since he is right hand

dominant. He is experiencing difficulty with feeding, dressing, and writing while utilizing his

RUE. Although he has increased functionality in his LUE, he wants to be able to write with
his right hand again and incorporate it into daily activities. The client demonstrates high

potential for succeeding in occupational therapy services. He seems to value

independence and is working hard to get as much back as he can. His family is also a

strength for him, since they seem very involved in the therapy process and eager to help

XXX progress.

OCCUPATIONAL ANALYSIS (O):

The client was seen at the Life Skills Clinic on 1/27 and 2/3 to complete a

comprehensive occupational therapy evaluation. He was accompanied by his mother and

girlfriend during the first session, and just his mother during the second. Speaking was

difficult for him, and most verbal communication was between the therapists and the

clients girlfriend. His mother does not speak English. The COPM was administered to

identify goal areas that are to be addressed in therapy. The COPM is an individualized

measure designed to detect change in clients self perception of change over time. It is a

semi-structured interview. Top OT Problems are identified, and then performance and

satisfaction of each item are rated on a scale from 1-10, with 1 meaning not able to do it at

all/not satisfied at all and 10 meaning able to do it extremely well/extremely satisfied. The

top priorities identified with this evaluation were writing with the R hand, self-feeding, and

tying shoes when dressing. Results of the COPM are as follows:

OT Problems Performance Satisfaction

Writing with R hand 1 4

Feeding with R hand 3 4

Tying Shoelaces 1 1
Total 5 9

When observed putting on a zip-up jacket, the client required max assistance with RUE to

hook the zipper and pull it up. The client independently donned a pull-over shirt as well as

a button-up shirt with only the use of his L hand. He was able to rinse a glass by passively

holding it with his RUE and supporting it with his LUE, and running it under water. He

washed a bowl by placing a sponge in his R hand and holding the bowl in his L hand,

using that L hand to run the bowl along the sponge. He dropped the sponge one time.

After placing a cup in his R hand with his L hand, he was able to bring an empty cup from

the table to his mouth. The use of a smaller cup made this task more manageable for him.

He was able to bring a spoon with a built handle up to his mouth with his RUE, without the

use of his L hand. During a writing task, he was unable to write a letter with his R hand

using an Expo marker, but was able to write the phrase Good Morning with his L hand.

During all activities, the client required moderate verbal cueing to use his RUE.

During the second evaluation session, the Fugl-Meyer was administered to

obtain baseline information about XXXs current UE function. The Fugl-Meyer is a stroke-

specific, performance based index. It is designed to assess motor functioning, balance,

sensation, and joint functioning in patients with post-stroke hemiplegia/paresis. The rating

scale for this assessment is as follows:

ROM: 0- only a few degrees 1-decreased PROM 2-normal PROM

Pain: 0-marked pain at end range or pain throughout 1-some pain 2-no pain

Light touch: 0-Anesthesia 1-Hyperesthesia/dysesthesia 2- Normal

Proprioception: 0- no sensation 1-75% correct 2- all answered correct

Sterognosis: % accuracy

Motor Function: 0-cannot be performed 1-performed partly 2-faultless

The client scored 35/66 on the motor function section, 0% accuracy on the stereognosis

section for his RUE, 10/12 for light touch and proprioception, and 24/24 on the joint motion

and pain section. After the completion of this assessment, he was observed tying his

shoes, and was was able to pull his laces using both of his hands, demonstrating a

pincher grasp with his RUE, with moderate hand over hand physical assistance.

INTERPRETATION (A):

The client required moderate verbal and moderate physical assistance for

activities due to right-sided hemiparesis secondary to a L CVA. He presented with

expressive aphasia, making verbal communication moderately more difficult. However, he

followed cues well, indicating that his receptive language centers are functioning. Difficulty

performing open-chained activities was observed when the client was asked to reach and

grab an item off a shelf, which he could not do. Due to learned non-use, he required

moderate verbal cueing to integrate his RUE during activities. Overall, he has poor grasp

and AROM in his RUE, and his movements are not controlled or functional. He also

demonstrated compensatory trunk and shoulder movements when trying to use his distal

RUE during fine motor tasks such as writing and tying shoelaces. His LUE is very

functional, which has reinforced the learned non-use of his RUE. The results of the Fugl-

Meyer test reinforce the information that was collected through observation, and gave the

therapists a good baseline for intervention. As the results show, the client has poor

stereognosis and light touch sensation in his RUE, as well as low motor functions scores,

which can be a barrier to function. He has good PROM and proprioception in his RUE,

which is promising for his ability to see progress in occupational therapy sessions. Overall,

XXX has a good support system in his mother and girlfriend. They are able to drive him to

all of his therapy sessions, shop, and maintain the apartment. His apartment has an
elevator that he can use, and he did not express any barriers in his environment. So far,

he has worked hard to complete tasks in therapy, and is hopeful that about his recovery.

Prioritization of Need Areas: Writing, feeding, and dressing (tying shoes, using fasteners)

PLAN (P):

Goals:

LTG: Within 6 visits, client will independently grip and manipulate a pencil to write a

sentence, to his satisfaction, with his RUE

STG 1: Within 2 visits, client will be able to stabilize a pencil in his hand using a functional

tripod grasp with minimal physical assistance and AE as needed

STG 2: Within 4 visits, client will be able to handle a pencil using a functional tripod grasp

to write his first and last name with minimal physical assistance

LTG: Within 6 visits, client will complete a meal while independently incorporating the use

of his RUE to bring food from a plate to his mouth

STG 1: Within 2 visits, client will pierce food with RUE using a built up handle to complete

a meal with moderate physical assistance

STG 2: Within 4 visits, client will scoop food on a plate with his RUE using a plate guard to

complete a meal with minimal physical assistance

The client will participate skilled occupational therapy sessions for one hour for six more

visits to address learned non-use and improve motor control and function of the RUE. In

order to improve these performance skills, the PEO model will be implemented to address

this client's strengths, barriers, and environment so that he is treated as in a holistic way.

He values education and participating in practical activities, so this is something that I will
want to consider when planning his treatments. I want to make activities meaningful to him

so that he is encouraged to continue working hard in sessions. Most of the changes with

XXX will occur on the person and occupation levels, since these two areas are currently

incongruent for him. He seems to have a supportive environment, so that will not be the

focus of therapy.

Motor control will be used to help teach the client problem-solving strategies so that he

will be able to more readily find solutions to challenges the he encounters outside of the

treatment setting. This model postulates that repetition is key to motor learning, therefore,

this will be utilized during intervention. Finally, the rehabilitation model will be incorporated

into therapy to address compensatory strategies and the use of adaptive equipment.

Research indicates that interventions, including repetitive task practice, help improve

UE function, activity, and participation. Training of the impaired arm using individualized

tasks that are goal-oriented and promote frequent repetition have been shown to improve

functionality of the affected UE after stroke (Nilsen, et al., 2015). By obtaining an

occupational profile and collaborating with the client to create his goals, we will be able to

choose occupations for specific task training that will help him improve the mobility in his

RUE in a meaningful way.

Source:

Nilsen, D.M., Gillen, G., Geller, D., Hreha, K., Osei, E., & Saleem, G.T. (2015).

Effectiveness of interventions to improve occupational performance of people with motor

impairments after stroke: An evidence-based review. The American Journal of

Occupational Therapy 69(1).

Therapist Signature:

Next Session: 2/10/2017