BACKGROUND INFORMATION

Date of report: 2/2/18

Client’s name or initials: XXXXX
Date of birth/or age: 77 years old
Date of referral: 1/26/18
Primary intervention diagnosis/concern: Hemorrhagic CVA in 2015, ischemic stroke in August
Secondary diagnosis/concern: Expressive aphasia, ideomotor apraxia and right sided hemiparesis
Precautions/contraindications: N/A
Reason for referral to OT: Desire to improve performance and participation with ADLs and use
hemiplegic arm more functionally
Therapist: Lexi Sybrowsky, OTS

S: Client arrived at the second therapy session ready to engage in therapy. Client seemed happy and

appeared to be in a good mood when participating in a variety of tasks.

O: Assessments performed: Client was seen on 1/26/18 and 2/2/18 for a comprehensive occupational

therapy evaluation. During the initial evaluation meeting, a modified version of the Canadian

Occupational Performance Measure (COPM) was administered as well as observation of ADLs and

IADLs like dressing, functional mobility, personal hygiene and grooming and household management

were performed. Additionally, the Motor-Free Visual Perception Test (MVPT-V) was administered to

assess various aspects of her visual perception. A modified Stroke Impact Scale (SIS) was also used to

evaluate how her stroke has impacted her health and everyday life.

Occupational Profile:

Client is a 77-year-old woman seeking occupational therapy services to address a decline in

performance during basic ADLs and IADLs due to apraxia and hemiparesis in her right arm. Client

suffered a hemorrhagic CVA in 2015 as well as an ischemic stroke in August, which is inhibiting her

performance and participation in daily occupations.

Current strengths include her upbeat personality and willingness to participate in therapy. She is

very motivated to get better and comes to therapy ready to learn each week. Another strength for the

client is her adaptability. Though she currently isn’t using her right arm (affected arm) during many tasks,

she has adapted and modified tasks to be done using just her left arm and hand. This adaptability will be

useful in therapy and shows that she is willing to modify tasks she is doing in order to complete them.
Another strength for her is that she is very social and enjoys participating in social gatherings. She reports

that she has many friends that visit her and help her get around in the community. She also attends a

monthly book club where she has the opportunity to interact with men and women, which is something

she looks forward to. Current barriers affecting her success include her hemiparesis, aphasia and apraxia.

Though she is still able to participate in daily ADLs, they can take longer than expected and cause

feelings of frustration.

Some supports within client’s environment include the fact that she is currently living in an

assisted living facility, Sunrise at Holladay Senior Living. Though the assisted living facility is providing

her with the care she needs, she doesn’t like living there and expressed a desire to return to her home.

Though she expressed frustration about living at the facility, it is an appropriate setting for her to be living

in due to the level of assistance and supervision she requires for certain tasks. Client’s room at the

assisted living facility has a living room, bedroom and bathroom, which means that she doesn’t have to

maintain a large space on her own. Client also reported that she is able to access all areas of her apartment

without trouble. Another support within her home environment is her stand up shower with a shower

bench, as she is able to complete showering safely.

Current contextual and environmental barriers include the fact that the majority of her family

lives out of state. Though she has some family members (cousins) and friends that visit, all of her

immediate family lives in Atlanta. Another barrier in her home environment is that she is responsible for

maintaining her own living space at the assisted living facility. Though she reported that she is able to

independently perform these necessary home maintenance tasks, certain aspects of these tasks may be

challenging for her and require assistance completing all of these responsibilities.

Client is the mother of three children and seven grandchildren. She worked as a travel agent and

reported that travelling is something she loved to do. Client’s interests include skiing, reading and

participating in exercise classes. She attends a book club once a month where she is able to socialize and

interact with other people her age. Client is currently attending therapy (OT, PT, SLP and exercise
classes) 5x/week at her assisted living facility as well as at the Skaggs Wellness Center. Client also

attended stroke camp with the occupational therapy department at the University of Utah 2 years ago.

Prior to her strokes, client was able to participate and perform ADLs and IADLs without

assistance. Since having both of her strokes, she has been unable to complete these occupations with the

same amount of ease. Due to her hemiparesis, occupations like dressing, grooming and showering have

become challenging for her. Though her hemiparesis has impacted her ability to use her right arm during

these tasks, she has adapted and modified the task to be able to complete it using only her left arm.

Client’s current desires and goals for therapy include being able to drive again, take a bath and

live independently. Though these are her priorities for therapy, we are unable to work on them at this time

because they aren’t safe for her. Additional goals and priorities were discussed with client which include

being able to use her right arm more in functional tasks, being able to wash and style her hair and getting

dressed with more independence.

OCCUPATIONAL ANALYSIS

Client was observed completing several ADLs and IADLs, including dressing, functional

mobility, personal hygiene and grooming and home management. Client was able to complete UE

dressing independently, but it took her a long time to complete. When donning a pullover shirt, she

required 2 attempts to correctly orient the shirt, thread both arms through and get it over her head and

pulled down. When donning pants, she threaded both legs into the pant legs and pull them up

independently, with her left hand completing 95% of the task. She was also able to don both socks and

shoes, again using her left hand for the majority of the task. Overall, dressing took approximately 15

minutes to complete. Client required the assistance of her left hand to incorporate and position her right

hand into the dressing activity. Client was unable to use proper grip, manipulation and coordination of

objects using both hands, but particularly in her right hand. When asked to use her right hand during fine

motor tasks like zipping or buttoning, she lacked the dexterity and fine motor manipulation to complete

any part of the task solely using her right hand. Client expressed frustration (heavy sighing, grunting)

throughout the dressing tasks due to the amount of time it was taking to complete. Additionally, client
lacked the ability to notice/respond to problems that arose during certain tasks like dressing (bunched up

shirt when dressing).

When completing personal hygiene and grooming tasks (brushing teeth and combing hair), she

required moderate assistance and verbal cueing with brushing all sides of her hair and to remove

toothpaste cap. Client demonstrated awareness and insight by responding appropriately to the hot

temperature of the water. Client also required minimal assistance to complete household management

tasks like making the bed and vacuuming. Client’s ability to produce and speak fluently throughout these

observations was also impacted due to her expressive aphasia. Additionally, it was apparent that she has

formed a habit of using her left arm to complete most of her ADL tasks, with the client agreeing that it

was easier to do things with her left arm that it was to try and use her right arm.

A: INTERPRETATION

A modified version of the COPM was completed due to client’s expressive aphasia. She was able

to provide a moderate amount of information about her typical day, self-care, productivity and leisure

participation. During the COPM interview, client reported that she was independent in all areas of

personal care including dressing, bathing and showering, personal hygiene and home management.

However, after observation, it was apparent that she required some level of assistance for all of the above-

mentioned occupations. The SIS was also administered during her evaluation. Based on her response and

performance during this assessment, final results were not collected as she demonstrated awareness and

knowledge of her deficits. Finally, the MVPT-V was also administered. Again, based on her performance,

final results were not calculated because of the high accuracy of her answers throughout the assessment.

Though she performed well with this particular visual perception assessment, observation of other tasks

hinted that a visual perceptual deficit may be present (possible inattention or neglect) that needs to be

further assessed. Observation of basic ADLs like dressing, personal hygiene and grooming provided the

most information about her current performance. Client ability to participate in many of these tasks was

hindered due to her hemiplegia and apraxia in her right arm. Observation of UE dressing also suggested

possible problems with perception or sensation due to her inability to sense her bunched up shirt. Further
assessment and/or observation will be completed to specify exactly which aspect is hindering her

performance.

Practice Models and Research

Because the focus of the client’s therapy will be on incorporating her right arm into her daily

occupations, using the Person-Environment Occupation (PEO) model would be appropriate. The PEO

model focuses on enabling occupational performance by addressing ways to improve the congruence

between the person (client), the environment (the assisted living facility where she lives) and her

occupations (dressing, showering, grooming, etc.). This model will help guide the client’s intervention

process as it will allow us to assess aspects within her environment that may be changed that will enable

her occupational performance. Focusing on incorporating the client’s right arm into her daily occupations

may require us to adapt or change the environment or introduce adaptive equipment that will allow her to

more fully participate. This model also emphasizes that the person is a dynamic, motivated and ever-

developing being. Client is very motivated to participate in therapy and desperately wants to be able to

use her right arm again. This motivation will be an essential tool that we can use throughout the therapy

intervention process.

The Motor Control/Motor Learning model is a complimentary model that would be appropriate to

use with this client. This model focuses on enabling an individual to complete tasks in an efficient way

through addressing the cortical control of the motor responses from the brain. Due to the apraxia that the

client is experiencing after her strokes, the motor output and movement to her right arm has been

inhibited, so this model will allow us to address that deficit. This model also sees movement as a result of

multiple interactions between the person (CNS and musculoskeletal system), the task being performed (an

ADL) and the conditions of the environment. Motor control also stresses the importance of learning the

entire task and not just a single part of it. Throughout the intervention process with our client, we plan to

address the entire task and not just a small part of it. This is especially important because she does many

of her ADLs independently and will need to be able to complete the entire occupation.
 The Rehabilitation model is also a support to intervention with this client, as we will be teaching

adaptive strategies that can be used to compensate for her current level of ability. Using this model also

allows us to potentially introduce necessary adaptive equipment that can be used to help the client carry

out everyday occupations and tasks.

A study done by Bayona, Bitensky, Salter and Teasell (2005) looked at task-oriented therapy and

how using meaningful tasks produced more function improvements. The authors found that their research

showed that rehabilitation will be more successful if the task is important to the person and that these

functional tasks will produce greater changes in the brain. Furthermore, this study noted the importance of

the intensity of the training in order to produce changes. The authors found that their stroke patients that

received 3-week, 45-minute task specific training showed improvements in motor function and dexterity

in their more affected upper limb. Overall, this study concluded that although repetition plays a major role

in eliciting changes in the brain, if the task has no meaning for the patient, it is unlikely to induce

significant cortical changes. With our client, we have chosen to do task-oriented or task-specific training

with her using the occupations she wants and needs to do every day. By choosing these occupations, the

task training will have meaning for her and hopefully induce the cortical changes necessary to improve

her motor function. Though her apraxia is something that we can’t fix, we hope to be able to repair some

of those cortical connections and improve her overall occupational performance and participation.

Another study done by Wolf, Winstein and Miller (2006) compared the effects of a 2-week

constrain induced movement therapy (CIMT) vs. usual care to improve upper extremity function in

patients 3 to 9 months post stroke. Participants in this study were assigned to either the CIMT group that

participated in repetitive tasks with affected hand or usual and customary care which ranged from formal

rehab to pharmacological or physiotherapy interventions. The group that received the CIMT showed

greater improvements in functional use of their affected hand as well as showed consistent improvement

in the number of tasks they were able to complete. Overall, CIMT produced significant improvements in

arm motor function that persisted for at least one year after intervention was complete. This study can also

be used to help guide our intervention with this client. Though we are not able to do complete CIMT, we
plan to do a modified version and have her complete many of her daily occupations using her affected

right arm. This type of intervention, coupled with the task-specific training mentioned above, will provide

us with the basis of our treatment and intervention sessions with the client over the next six weeks.

P: PLAN

LTG #1: Within 6 weeks, client will complete washing and styling of hair using both hands with min

verbal cues and any necessary AE.

STG #1: Within 3 weeks, client will use right hand to brush hair with moderate assistance/verbal cues

and any necessary AE.

STG #2: Within 2 weeks, client will use right hand to wash hair at least 50% of the time with moderate

verbal cues and any necessary AE.

LTG #2: Within 6 weeks, client will use right arm to independently dress UE.

STG #1: Within 3 weeks, client will use right hand to manipulate fasteners with min assistance and the

use of necessary AE.

STG #2: Within 3 weeks, client will thread right arm through shirt sleeve w/o assistance from left hand

with minimal assistance.

Recommended intervention methods and approaches: Establish/restore, Modify

Expected frequency, duration and intensity: Skilled occupational therapy service is recommended for

1 hour, 1x/week for 6 weeks to address improvement in performance and participation in ADLs and

IADLs as well as increasing the use of her right arm during desired and daily occupations.

Location of intervention: Health Professionals Education Building at The University of Utah

Anticipated D/C environment: Assisted Living Facility, Sunrise at Holladay Senior Living

Lexi Sybrowsky, OTS Date: 2/3/18

 References for Research Articles

Bayona, N. A., Bitensky, J., Salter, K., & Teasell, R. (2005). The Role of Task-Specific Training in

Rehabilitation Therapies. Topics in Stroke Rehabilitation, 12(3), 58-65. doi:10.1310/bqm5-6ygb-

mvj5-wvcr

Link: http://web.b.ebscohost.com.ezproxy.lib.utah.edu/ehost/pdfviewer/pdfviewer?vid=1&sid=1a870b05-
4cdb-48cf-804f-852befb33960%40sessionmgr104

Wolf, S. L., Winstein, C. J., & Miller, J. P. (2006). Effect of Constraint-Induced Movement Therapy on

Upper Extremity Function 3 to 9 Months After Stroke The EXCITE Randomized Clinical

Trial. The Journal of the American Medical Association, 296(17). doi:10.1001/jama.296.17.209

Link: https://jamanetwork.com/journals/jama/fullarticle/203876