Week 11 Lab Assignment

Treatment Plan – Stroke

Background

Background

This assignment will be based on a patient case using the ‘Outpatient Assessment, Part 4: Upper
Extremity Motor Control’ video in the ICE Video Library. The occupational profile, ADL/IADL assessment
results, and long-term goals are provided below for this patient. Review these sections prior to
completing the 3-part assignment. Part I of this assignment requires you to analyze the movement
observed in the video, Part II requires you to write short-term goals to work toward the provided long-
term goals, and Part III you will develop interventions to work toward the short-term goals.

The following optional videos may be helpful as a review prior to watching the patient case video to
refresh your memory and understanding of scapulohumeral rhythm and muscle agonists/antagonists. I
have also provided some reflection questions to consider as you watch to begin thinking about his
movement and how to address impairments.

• Video on scapulohumeral rhythm: https://www.youtube.com/watch?v=kkNnc6ssbPI

• Video on Scapular Movement + Scapular Muscles:
https://www.youtube.com/watch?v=PPKlGlwxr5s
• Review of Muscle Agonist/Antagonist (Watch from 0-2:44, elbow flexion/extension):
https://www.youtube.com/watch?v=ljOVGuK1jKY

• What compensatory movement does this patient exhibit when he tries to lift his arm?
• What does his scapula do at rest and with attempted movement?
• Which scapular mobilizations would be most appropriate for this patient? What position should
the patient be in?

Patient Case: ‘Sam Patterson’

Occupational Profile

Sam is a 58-year-old male referred to outpatient OT due to L MCA CVA 3 weeks ago with resultant R UE
hemiparesis limiting his independence with ADL/IADL routine. Pt lives in a 1-story home with his wife.
Prior to his stroke, Sam was working full-time as a construction worker which required both heavy lifting
and fine motor coordination (e.g., to hold a nail while using a drill). Pt reports independence with
dressing and grooming using one-handed dressing techniques but continues to require assistance with
bathing, home management, and meal preparation. Pt does not plan to return to work but does express
interest in completing simple woodworking tasks as a leisure activity as this was his primary hobby prior
to his stroke.

ADL/IADL Assessment Results

• ADL Assessment: Pt scores a 90/100 on the Barthel Index; impairments noted in feeding and
bathing, as described below.
o Feeding: Pt requires assistance with cutting food and opening packages.
Week 11 Lab Assignment
Treatment Plan – Stroke

o Bathing: Pt requires assistance with washing his hair and washing the right side of his
body.
• IADL Assessment: Pt requires assistance with home management and meal preparation IADLs,
as described below.
o Home Management: Pt unable to do laundry or washing dishes, which were his home
responsibilities prior to his stroke.
o Meal Preparation: Pt unable to cut food or do kitchen tasks that require bilateral upper
extremity (e.g., stabilizing bowl while mixing).

Long-Term Goals

1. Pt will be independent with all bathing activities within 12 weeks.

2. Pt will be modified independent with laundry IADLs, using his LUE as a ‘helper hand,’ within 12
weeks.
3. Pt will independently wash dishes using his LUE as a helper hand/to stabilize dishes within 12
weeks.

ASSIGNMENT
Assignment Part I: Movement Analysis

Video: ‘Outpatient Assessment, Part 4: Upper Extremity Motor Control’ video

Observe the following movements and make note of approximate AROM, compensatory patterns
observed, pain, fluidity/coordination of movement, etc. Consider the following for each movement and
make note of this, when applicable:

• What compensatory movement does this patient exhibit when he tries to lift his arm?
o Leans backward, downward chin tilt, watches hand/arm
• What does his scapula do at rest and with attempted movement?
o Left scapula is retracted and elevated – highly noticeable at rest; in movement it seems
to protract, externally rotate some but not as fully as the right, and elevates (motion
was shoulder Adduction?)
o L scapula seems to sit more towards the glenohumeral joint rather than the spine

I have done shoulder flexion for you as an example of what I am looking for here.

• Shoulder flexion
o AROM: ~45°
o Compensatory Patterns (if any): L scapular elevation
o Other Comments (e.g., coordination, pain, etc.): Slow, uncoordinated movement
throughout AROM with abnormal muscle synergies limiting movement. Pt demonstrates
weakness with scapular upward rotation limiting normal scapulohumeral rhythm. (note:
At 1:15 in the video he is asked to flex his shoulder – observe what his triceps does as he
gets closer to end range. Why do you think this is happening?)
• Shoulder abduction
o AROM: 0°, not tested but PROM about 25°
Week 11 Lab Assignment
Treatment Plan – Stroke

o Compensatory Patterns (if any): RUE used to lift LUE into shoulder abduction
o Other Comments (e.g., coordination, pain, scapular mobility, etc.): Pt unable to perform
shoulder abduction due to pain and weakness of shoulder muscles. Pt demonstrates
uncoordinated scapulohumeral rhythm due to the weakness.
• Shoulder extension
o AROM: ~20°
o Compensatory Patterns (if any): trunk rotation to L side, dropping of R shoulder
o Other Comments (e.g., coordination, pain, scapular mobility, etc.): Slow, but
coordinated movement throughout AROM with pain limitations. Pain noted by grimace
and audible gasp. Appeared to be a quick stretch reflex at end AROM.
• Shoulder external rotation
o AROM: ~0°
o Compensatory Patterns (if any): unable to assess
o Other Comments (e.g., coordination, pain, scapular mobility, etc.): Pt unable to
complete shoulder external rotation due to pain.
• Shoulder internal rotation
o AROM: Pt back to camera but PROM assumed to be at midline
o Compensatory Patterns (if any): Pt back to camera but L hand held at midline and LUE
ultimately “pulled” through ROM by the RUE.
o Other Comments (e.g., coordination, pain, scapular mobility, etc.): Uncoordinated
movement of L scapula compared to R. L scapula notably more protracted and elevated
during movement than R.

Assignment Part II: Short-Term Goals

For each long-term goal listed above, write one STG (within 4 weeks) to progress toward the LTG.
Consider the movement analysis completed above and what specific movements you will want to
address to work towards the LTG (example: ‘Pt will increase AROM L shoulder flexion to xx degrees in
preparation for [insert ADL/IADL]). Writing short-term goals helps you to break down the movement
components and task requirements to work towards long-term goals. In thinking about short-term goals
for each LTG, it will make it easier to write intervention plans.

1. Pt will be independent with all bathing activities within 12 weeks.

a. STG 1: Pt will increase AROM L shoulder internal rotation to 90° in preparation for
independence in washing the right side of his body during bathing ADLs within 4 weeks.
2. Pt will be independent with laundry IADLs, using his LUE as a ‘helper hand,’ within 12 weeks.
a. STG 2: Pt will increase AROM L shoulder Abduction to 90° in preparation for using the
LUE as a helper hand to hold the clothing item while putting it on the hanger with the
RUE to increase independence during laundry IADLs within 4 weeks.
3. Pt will independently wash dishes using his LUE as a helper hand/to stabilize dishes within 12
weeks.
a. STG 3: Pt will increase AROM L shoulder flexion to 45° in preparation to stabilize the
dishes with LUE while washing them with RUE to increase dish washing IADL
independence within 4 weeks.
Week 11 Lab Assignment
Treatment Plan – Stroke

Assignment Part III: Intervention Planning

For each short-term goal you wrote, you will develop a treatment plan (in enough detail for another
person to duplicate the activity) to carry out the activity and work toward the goal. The treatment plan
should be for a 45-minute OT session – for simplicity, we can break that into 15-minute increments. For
each 15-minute block of time, describe the following:

• What treatment activity will the patient complete? (describe in enough detail for someone to
duplicate the activity based on your description)
o How will the therapist provide therapeutic use of self (e.g., handling techniques, cues,
etc.) to maximize performance?
o How could the treatment activity be graded up?
o How could the treatment activity be graded down?
• What is the purpose of this activity (e.g., what skill or deficit is this activity working on)?
• What CPT code would you bill for this 15-minute increment?

Treatment Session # 1 (45-minute session to work toward LTG/STG #1)

• LTG 1: Pt will be independent with all bathing activities within 12 weeks.

Activity #1 (15 minutes)

Detailed Description of activity (include therapeutic use of self and how task will be graded)

Preparatory activity: Set a small cup of about 6, 2” nails on Sam’s L side while seated at a table. Give
Sam a small hammer to use with his R hand. Place a block of (soft) wood on the table at Sam’s midline,
and a bolster or rolled towel between Sam’s LUE and L trunk to achieve about 30° of shoulder
abduction. Instruct Sam to pick up one nail at time with his L hand and stabilize it on the block of wood
that is centered in front of him and hammer it down with his R hand just until it stands alone. Instruct
Sam to keep the towel/bolster between his LUE and trunk the entire time. To ensure safety, and employ
TUOS, instruct Sam to only hit the nail until it stands without support in the wood, not until it is all the
way through it.

To grade the task up, add more nails or move the wooden block more towards the R side of Sam’s body.
To grade the task down, use fewer nails, or change the nails to a small pellet like item, take away the
hammer, and have Sam move the pellets from one cup on his L side to another that is slightly past his
midline towards the R with the same set up.

Purpose of Activity (e.g., what skill or deficit is this addressing)

This activity takes a client-centered approach by incorporating a woodworking component, promoting

rapport as well before moving onto more strenuous activities that may not be as appealing. This activity
promotes shoulder internal rotation by bringing the nail to midline/the right side of the body while the
RUE is occupied and therefore unable to assist. Increased AROM of shoulder internal rotation will be
used wash the right side of the body in order to foster bathing independence.
Week 11 Lab Assignment
Treatment Plan – Stroke

CPT Code (refer to CPT resource from lecture on reimbursement and coding)

• 97110

Activity #2 (15 minutes)

Detailed Description of activity (include therapeutic use of self and how task will be graded)

Skill-based activity: Sam will hold a resistance band in his L hand while in a seated position. The other
end of the resistance band should be tied to a door-knob or stable object that is level with the lateral
elbow when it is at about 30° of shoulder Abduction and 30° shoulder extension with a 90° elbow
flexion. Place a rolled towel or bolster between Sam’s trunk and inner LUE to achieve the starting LUE
position as described. Instruct Sam to pull the resistance band across his trunk to the R side as far as he
can without changing the position of his shoulder/elbow. Stabilize the shoulder and elbow to maintain
this position as necessary. Complete for 8-10 reps. TUOS used in instruction and checking in with Sam
to see if resistance needs increased or decreased to promote a “just-right” challenge.

To grade this activity up you can use a stronger resistance band with fewer repetitions, or a lighter one
and encourage Sam to reach beyond his RUE with his LUE. To grade this activity down, decrease
resistance altogether (or lessen the resistance) and/or complete fewer reps.

Purpose of Activity (e.g., what skill or deficit is this addressing)

This activity works to remediate/restore AROM of L shoulder internal rotation by strengthening the
muscles involved. Functional strength and AROM of LUE are necessary in washing the R side of the body
independently. Strengthening the muscles here will also encourage a more coordinated set of
movements/synergies.

CPT Code (refer to CPT resource from lecture on reimbursement and coding)

• 97110

Activity #3 (15 minutes)

Detailed Description of activity (include therapeutic use of self and how task will be graded)

Occupation Based Activity: Sam will wear swimming trunks that are able to get wet or paint on them.
After explaining the activity and ensuring no allergies or sensitivities will interfere, the therapist will put
a quarter sized drop of bright, washable paint at various locations on Sam’s right side. Locations should
include the R shoulder near the acromion process, the R lateral elbow, R lateral trunk near bottom rib,
and R lateral hip. Allow the paint to dry so that minimal scrubbing is required. Sam will prep a
washcloth with soap and water with his R hand and transfer it to his L with instructions to “wash the
paint off using [his] left hand”. Seating optional based on standing endurance. TUOS incorporation may
include identifying spots where paint is still left.

To grade the activity up, locations may be increased and extend from the R side of the head to the R
foot. To grade the activity down, stick to the RUE and the midpoint of the trunk, or do not allow the
paint to become fully dry before starting the activity (no scrubbing required).
Week 11 Lab Assignment
Treatment Plan – Stroke

Purpose of Activity (e.g., what skill or deficit is this addressing)

This task-oriented activity practices washing of the R side of the body with focus on increasing the
shoulder internal rotation of the LUE. LUE internal rotation accomplished by scrubbing/wiping the paint
off the R side of the body. Ability to wash the R side of the body will foster independence in bathing
ADLs.

CPT Code (refer to CPT resource from lecture on reimbursement and coding)

• 97535

Treatment Session # 2 (45-minute session to work toward LTG 2)

• LTG 2: Pt will be independent with laundry, using his LUE as a ‘helper hand,’ within 12 weeks.

Activity #1 (15 minutes)

Detailed Description of activity (include therapeutic use of self and how task will be graded)

Preparatory activity: Using TUOS, instruct Sam about the benefits and purpose of NMES and with his
permission, apply electrodes to the motor points of the upper trap, inferior fibers of serratus anterior,
and the middle deltoid. Set the parameters as follows: frequency 40 Hz, amplitude and duty cycle
according to patient and task preferences/requirements, and treatment duration ~ 13 min. (assuming it
will take about 2 minutes to explain e-stim and the relative benefits). Instruct Sam to abduct his arm as
best he can, trying to go further each time but not so far as to produce pain. While E-stim is applied,
during the contraction phase, ensure proper scapular mobility and passively move the arm through the
full range of motion. TUOS should be constantly employed by asking Sam about the sensations he feels
during the activity.

To grade the task up, decrease the amplitude so Sam has to work more voluntarily/decrease the
assistance provided by the stimulation. To grade the task down, increase the amplitude to increase the
assistance in contraction.

Purpose of Activity (e.g., what skill or deficit is this addressing)

NMES can be used for facilitation or reeducation of nerves/muscles in order to achieve appropriate
contraction (time, speed, force, and range). This should also provide a pain-relieving sensation
throughout the motion that may translate into the additional activities as the shoulder muscles are
being taken through the ROM. This is considered a “warm-up” for the stability (skill-based) activity that
will follow.

CPT Code (refer to CPT resource from lecture on reimbursement and coding)

• 97014
• 97140

Activity #2 (15 minutes)

Detailed Description of activity (include therapeutic use of self and how task will be graded)
Week 11 Lab Assignment
Treatment Plan – Stroke

Skill-based activity: Provide Sam with a wheelbarrow (avg. weight when empty about 55 lbs). Set an
object or brightly colored piece of tape on the floor about 9 feet away from where Sam is standing.
Instruct him to move/carry the wheelbarrow to the “target”, turn if able, and then come back to the
starting position. Allow Sam to set the wheelbarrow down if he feels fatigued or experiences pain at any
point (check in with him verbally and watch physical cues using TUOS). Instruct Sam to do this 5 times
total (down and back). Watch and provide tactile cues/guidance if necessary to ensure both scapula
move in a coordinated/even manner.

To grade this activity up, add weight to the wheelbarrow (start with 5 lbs and then add based on Sam’s
confidence/ability). To grade this activity down, have Sam stand still and just lift the wheelbarrow, hold
for a count of 3, then set it back down.

Purpose of Activity (e.g., what skill or deficit is this addressing)

This skill-based activity addresses the stability and strength of the muscles involved in shoulder
abduction since stability proceeds mobility (to be addressed in activity 3). When the wheelbarrow is
picked up, shoulder abduction occurs. This also may appeal to Sam’s interests and build rapport since
wheelbarrows are often used to collect items for woodworking, or in general house management.
Increasing the stability of LUE shoulder abduction should prepare for the mobility necessary to be more
independent in laundry IADLs.

CPT Code (refer to CPT resource from lecture on reimbursement and coding)

• 97110

Activity #3 (15 minutes)

Detailed Description of activity (include therapeutic use of self and how task will be graded)

Occupation-based activity: Sam will stand near a closet – or simulated closet with a bar to hang clothes
on that is about shoulder level. Sam will be given a basket of 10 shirts that should sit on a table that is
about hip height and sitting in front of him (centered), with a stack of 10 hangers in the same location.
Instruct Sam to pick up a shirt with his left hand, and a hanger with his right. Instruct Sam to abduct his
left arm (demonstrate this as you describe the activity) to hold the shirt up while putting the hanger in
with his right. He may then hang the shirt on the bar with his right hand. Repeat this task for all 10
shirts. TUOS should be used to ensure Sam has proper standing balance, is performing shoulder
abduction correctly (use demonstration and guidance with hand placement on elbow/wrist/or shoulder
as needed) and checking in on any pain or fatigue.

To grade this activity up, add more shirts, or move the bar of the “closet” up higher to incorporate
shoulder flexion as well. To grade this activity down, decrease the amount of shirts or have Sam be
seated for the activity to conserve energy.

Purpose of Activity (e.g., what skill or deficit is this addressing)

This occupation-based activity works to build shoulder abduction of the LUE by requiring it to be a
“helper hand” while hanging the clothes – a portion of the laundry IADL. This task-specific approach
takes on a compensatory frame in order to increase independence of laundry/home management IADLs
and shoulder abduction that can be transferred to other tasks.
Week 11 Lab Assignment
Treatment Plan – Stroke

CPT Code (refer to CPT resource from lecture on reimbursement and coding)

• 97535

Treatment Session # 3 (45-minute session to work toward LTG 2)

• LTG 3: Pt will independently wash dishes using his LUE as a helper hand/to stabilize dishes
within 12 weeks.

Activity #1 (15 minutes)

Detailed Description of activity (include therapeutic use of self and how task will be graded)

Preparatory activity: Have Sam seated in a chair without arm rests, and a pulley system with two handle
loops up above him. Strap the LUE in the loop to ensure it will not slip out – supported at the base of
the wrist, with fingers wrapped around the handle. Instruct Sam to reach up and grab the other handle
with his RUE. At this point the LUE should be in a relaxed position, and the RUE in full shoulder flexion.
Stand behind or in front of Sam to ensure proper posture – hand positioned on shoulders or base of
back. Instruct Sam to slowly pull down with his right hand, engaging the pulley system to pull his LUE
into shoulder flexion. Ensure that the movement of the scapula is smooth by aiding in mobility as
necessary, and that Sam does not pull the LUE to a point of pain. If approaching a painful position, stop
just before and hold for a count of 3 before relaxing. A “just-right” stretch should be achieved and held
for a minimum count of 3 at least 3 times.

To grade the task up, place a weight or resistance on the pulley. To grade the task down, walk Sam
through the motion of shoulder flexion with his LUE in a prone position.

Purpose of Activity (e.g., what skill or deficit is this addressing)

This preparatory activity passively walks through ROM of shoulder flexion, allowing the client to work at
his own pace. This activity is used to wake up the muscles and release any tight antagonist muscles that
are limiting the flexion and proper movement of the scapula. This mobility and “release” is necessary
for use during dish stabilization and transfer during dish washing IADLs.

CPT Code (refer to CPT resource from lecture on reimbursement and coding)

• 97110

Activity #2 (15 minutes)

Detailed Description of activity (include therapeutic use of self and how task will be graded)

Skill-based activity: Retrieve a medium sized exercise ball that is able to support Sam’s weight and has a
contact area slightly smaller than his trunk. Instruct/help if necessary Sam down to his knees on a foam
mat. Instruct and demonstrate if necessary how to perform a wheelbarrow walk. Hands should be
shoulder width apart and flat on the mat, demonstrating shoulder flexion, co-contraction, and full elbow
flexion. The trunk should be positioned on the exercise ball, up towards the armpit to begin. Instruct
Sam to use his hands to walk forward on the ball, moving it down to his hip, then walk backward with his
hands to move it back to his armpits. He should be bearing weight through both upper extremities. Use
Week 11 Lab Assignment
Treatment Plan – Stroke

tactile cues to properly maneuver the scapula if uncoordinated movement or rhythm is identified in LUE.
Repeat the “walk” about 10 times or for 15 minutes, whichever comes first.

To grade the activity up, remove the ball so that it becomes a plank walk, asking Sam to weight-bear
more. To grade the activity down, have Sam stay in the wheelbarrow position on the ball, with the ball
about mid-trunk to promote further shoulder flexion and hold for 3 seconds before returning to his
knees – repeat 10 times.

Purpose of Activity (e.g., what skill or deficit is this addressing)

This skill-based activity works on shoulder stability in terms of shoulder flexion while incorporating
mobility aspects during the walk. Stability and activation of appropriate synergies for shoulder flexion is
necessary for use in washing dishes (home management IADL) as the LUE will be stabilizing the dish for
the RUE.

CPT Code (refer to CPT resource from lecture on reimbursement and coding)

• 97110

Activity #3 (15 minutes)

Detailed Description of activity (include therapeutic use of self and how task will be graded)

Occupation-based activity: Sam will stand at a sink to wash dishes using his RUE to wash, and his LUE to
stabilize the dish. The number of basins at the sink should match Sam’s home set up (i.e. if he has one
basin at home use one, if two use two). Sam should pick up a dish – varying bowls and plates of
different weights and sizes – using his R hand and place it on an edge of the sink (or center support if he
has a double basin sink) and flex his L shoulder so his LUE can stabilize the dish. Sam will wash and rinse
the dish with his RUE and transfer it over to a drying rack or towel on his left side using his LUE. TUOS
should be used prior to the activity to ensure the set-up and dish types match those that Sam will see in
his home. Begin with 10 dishes.

To grade this activity up, add in pots and pans that are of less balanced shapes and weights. To grade
this activity down, allow Sam to be seated and use well balanced, lighter items.

Purpose of Activity (e.g., what skill or deficit is this addressing)

This task-specific activity practices L shoulder flexion both in stabilization of the dish and in passing it
over to the drying rack (incorporating horizontal abduction of the shoulder as well). Both actions are
necessary in order to promote independence in washing dishes, a house management IADL.

CPT Code (refer to CPT resource from lecture on reimbursement and coding)

• 97535