Date of Assessment: 2/25/2021

Name: XXX
Diagnosis: R CVA, L Homonymous Hemianopsia

Occupational Therapy Initial Evaluation

S: Wife stated, “I try and help him too much.”

O: (Evaluation overview): XXX was seen 2/11/21 and 2/25/21 for comprehensive occupational
therapy evaluation, including an occupational profile interview, an observation of occupational
performance, and any specific assessments.

Occupational Profile

XXX is a 62 year old male who suffered a R CVA two years ago. He has L hemiplegia and L
homonymous hemianopsia. He was recently diagnosed with prostate cancer and will undergo
surgery on April 16 . XXX had a Baclofen pump surgery on January 21, 2021. He is a retired
th

heavy equipment operator and lives with his wife in a basement apartment. They have three
dogs, two cats, and a bird. He has one son that lives in Washington. During the day he enjoys
watching football and completing jigsaw puzzles. He and his wife drive and pick up their meals
each day from the local senior center.

Before the stroke, XXX was L handed but now uses his R hand for all daily tasks. XXX reports
that he has no use of his L hand and that he has significant spasticity in his L UE, particularly in
the mornings, but the Baclofen pump has helped. He has pain in his back and neck, as well as
on the R side of his body due to overcompensation. He also reports pain in his L hand and
shoulder when using the brace. XXX reports poor vision due to left field cut but mentions that he
is able to compensate. His wife reports that he does not always recognize that people are
standing on his L side.

XXX uses an electric wheelchair in his home and reports that he is able to walk the distance
required from his wheelchair to the toilet. He is also able to walk down the 13 steps, with
handrails, to enter his apartment. Outside in the community, he uses a manual wheelchair that
his wife propels. To walk, he uses a wide based cane and an AFO on his L foot. He has a brace
for his L hand, that he wears 3 hours a day, to hold his fingers and thumb in extension. He does
not currently drive.

At home, XXX reports that he can independently transfer onto his shower bench and with set-up
can complete bathing independently. XXX does require assistance from his wife to dry off
completely after the shower. For dressing, he reports that he is independent in dressing at EOB.
He does not wear clothes with fasteners, buttons, or zippers due to the need for assistance. His
wife reports that he does not always pull up the L side of his pants when dressing. He is
independent in toileting, reporting no difficulties in managing his clothes. XXX is independent in
feeding, reporting the use of his L hand to stabilize if necessary and the use of a rocker knife for
cutting. He stabilizes food containers with his L hand and uses his teeth and R hand to open
bags.

Supports to occupational equipment includes his adaptive equipment and his wife. His wife is
also a barrier in assisting too much in his daily tasks.

XXX identified areas of priority are to use his L hand more functionally in order to hold a mug,
open food containers, and hold a remote in his L hand.

(OTPF S 17) Should not contain any information that does not come from the client or
family.

Observation of Occupational Performance

XXX was asked to sit at a table to complete a meal prep activity. He used his cane and walked
to the table, requiring stand-by assist for safety, but required no cues or physical assistance to
navigate around the treadmill or the edge of the mat table. His L hand remains flexed at the
MCP joints. He was unable to read the written recipe, requiring verbal instruction. XXX identified
all ingredients and supplies placed to the L side. He used his R hand to lift his L arm to the table
to stabilize food, pressing the food into the space between the MCP and PIP on this L hand,
while cutting with his R, requiring no assistance. He independently stabilized food and
containers by placing the item between his legs, and used his R hand to manipulate the objects
to open them. Once the cutting portion was completed, his L arm returned and hung to his L
side. The client was unable to open a milk carton and a can of oranges and did not stabilize with
his L arm. XXX stood to remove sugar, requiring one verbal cue to identify the number of cups
required. He only poured the milk into a measuring cup ¾ full. He stood for 4 minutes of the
activity. He required a visual cue of touching the spatula to initiate stirring. XXX did not use his L
arm to stabilize the bowl.

Occupational Performance Assessment: (OTPF S17) (consider all of domain OTPF S4; P-E-O).
Fugl-Meyer Assessment for Upper Extremity

The Fugl-Meyer Assessment for Upper Extremity (FMA-UE) was completed. XXX’s unaffected
extremity was assessed first, followed by his affected L UE. The following results are in relation
to his L affected UE. XXX sat at the edge of the mat table, unsupported while completing the
assessment. XXX’s reflex activity can be elicited in both biceps and triceps. For the UE, each
movement is scored individually as either a zero, cannot be performed at all, a one, performed
partly, and a 2, performed faultlessly. These individual scores are totaled for an individual
subtest score.

XXX scored an 8/18 in the volitional movement within synergies subtest. XXX could only partly
complete shoulder retraction, elevation, abduction, external and internal rotation and elbow
flexion. XXX was unable to supinate his forearm, and extend his elbow. He performed faultlessly
in forearm pronation. He scored a 1/6 on volitional movement mixing synergies, being unable to
bring his hand to his lumbar spine and to pronate and supinate his forearm when his elbow is at
90 degrees. He was able to partially flex his shoulder below 90 degrees, but he abducted and
flexed his elbow within that movement. XXX scored a 0/6 in volitional movement with little or no
synergy, being unable to abduct his shoulder to 90 degrees, unable to maintain starting position
in shoulder flexion above 90 degrees and unable to pronate and supinate with elbow extended.
In total, for the UE, XXX scored 13/36 points.

The next two sections of the assessment are focused on wrist and hand. For hand, XXX scored
a 0/10 and for wrist scored a 0/10. The wrist assessment was stopped after the first two
subtests, due to the inability to move his wrist. For the hand, the assessment was stopped after
the first two subtests. The cylinder grasp was attempted. The cylinder was placed in XXX hand,
but he was unable to maintain grip once assistance was released.

No coordination tested due to inability to move L distal affected limb.

XXX scored 9/12 in sensation. Light touch was intact in his L arm and forearm, but he had no
sensation in the palm of his hand. XXX had proprioception in his shoulder and elbow but had no
proprioception in his thumb.

Passive ROM was assessed last with a score of 13/24. XXX had normal PROM in shoulder
internal rotation, forearm pronation and wrist flexion. His joint pain scored a 21/24, he had no
pain in all joints except shoulder flexion and abduction, and elbow flexion.

Upper Extremity Subtotal

Reflexes activity 4/4

Volitional movement with synergies 8/18

Volitional movement with mixed synergies 1/6

Volitional movement with little or no 0/6

synergy

Normal reflex activity 0/3

  TOTAL: 13/36
 
   TOTALS

Wrist 0/10

Hand 0/14

Coordination 0/6

Sensation 9/12

Joint Pain 21/24

Passive range of 13/24

motion
 

PROM

After the Fugl-Meyer, XXX PROM was assessed again in side-lying. XXX shoulder was
elevated into the correct position and his scapula stabilized, increasing his PROM of shoulder
flexion to 90 degrees. He had full PROM in elbow extension, pronation, wrist and finger flexion
and extension, and shoulder internal and external rotation. In gravity eliminated with the scapula
elevated and stabilized, he was able to straighten his arm and bring it back to his side. He
reported pain at the front of his shoulder and on the medial border of his scapula but noted a
decrease in pain when the scapula was moved into the correct position.

Clock-Drawing Test

XXX completed the clock-drawing test to assess for spatial neglect. On the first attempt, XXX
filled in the clock using both R and L sides. He missed writing the number 12, recognized his
mistake without prompts, and re-drew the numbers accurately.

Informal Assessments

XXX was asked to identify the items on the table and he was able to identify all items on the L
and R.

For vision, XXX was asked if he had glasses. He put them on and read the lines of a cleaning
bottle, indicating that with glasses, he will be able to read recipes and/or instructions.

When completing the Fugl-Meyer, XXX sat at the EOM with shoulders slumped.

A: Interpretation:

Pain is a barrier to XXX’s occupational performance, particularly in his L shoulder and around
his scapula. Along with pain, XXX only has active movement in his L shoulder along with limited
PROM in flexion and abduction, significantly reducing his ability to use the UE to participate in
occupations. Due to pain and the L UE’s functional limitations, XXX does not consistently bring
and/or use his arm in activities. As noted in the occupational observation, XXX arm hung to his
side even when stabilization was warranted. With his dense L hemiplegia and not positioning
the limb in his daily activities, XXX scapula is not in the correct position, creating consistent
pain. This is evidenced by XXX’s increased PROM and his gravity eliminated movements when
the scapula was elevated and his marked decrease in pain. Positioning his L UE in daily tasks is
important to provide stability for his scapula and shoulder joint. When moving his L UE, XXX
demonstrates a flexor synergy pattern. With gravity, he is unable to complete shoulder flexion
without elbow flexion and shoulder abduction. XXX has little to no volitional movement with
mixed synergies, and no volitional movement with little to no synergies. This greatly impacts his
participation in occupation as he cannot extend his arm or hand to interact with task objects.
XXX demonstrates good problem-solving skills when using his R arm and using compensatory
strategies to stabilize and/or open containers. However, as mentioned above with pain, XXX
does not use his L UE as often as he could to assist in stabilization as the use in his arm is
limited and painful. XXX also has poor overall posture when sitting, increasing the pain in his
back and neck. Left-neglect was addressed due to his wife’s report that XXX forgets to pull up
the L side of his pants and does not always notice or respond to people on his L side. This
inattention was assessed during evaluations, but produced normal results and was not
presented in the clinic. XXX required cues during the occupational observation. Supports to
XXX’s occupational engagement include his one-handed techniques and compensatory
strategies, and accessible home environment. Barriers to occupational engagement include his
pain as it limits the amount of time he uses his L UE in current occupations and how he
positions his arm. His wife may also be a barrier as she admits to doing too much for XXX which
impacts his active participation in occupations. XXX’s priorities are to use his hand more
functionally in tasks which requires proper positioning of his shoulder for stabilization. He also
wants to hold a mug that will be modified through the use of adaptive equipment and
compensatory strategies using his flexor synergy and his R hand.

P:  XXX will be treated for 45 minute sessions 1 once a week for 7 weeks to address pain, and
limited ROM in his L UE that interferes with occupational performance in both feeding and meal
preparation. Skilled OT services are required for appropriate grading of activities that will
address pain, ROM, compensatory, and adaptive strategies. XXX’s complex condition requires
advanced clinical judgement to adjust the presentation of activities that will properly challenge
him while also teaching him to generalize strategies beyond the treatment session. The
following goals were established and collaborated with the client:

Goals

LTG1: By discharge, the client will hold a mug using AE and bring it to his mouth for a drink with
compensatory strategies and Min A during feeding.

STG1: In 6 weeks, the client will bring his L arm up to his mouth for a drink using compensatory
strategies and Mod A.

STG2: In 4 weeks, the client will open his L hand using his R hand and place inside AE around
the mug with Mod A.

LTG2: By discharge, the client will actively position his L UE to stabilize items in meal prep with
no more than 3 indirect v/c’s, using compensatory strategies.

STG1: In 6 weeks, the client will remember to  bring his L arm to table to stabilize items with no
more than 2 direct v/c’s.

STG2: In 4 weeks, the client will improve trunk posture when sitting in a wheelchair with no
more than 2 direct v/c’s.
 
GAS charts

 
The 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.
 
For XXX, there is a lack of congruence between the person, the environment and his
occupations. Pain is a barrier to his occupational participation, as is his wife providing too much
external support contributing to the non-use of his L UE. The PEO model will be used to
address the transaction between XXX and his environment, as well as XXX and his
occupations. The environment will be modified using adaptive strategies so that he will be able
to hold a mug, assisted by his R hand and his flexor synergy pattern. His personal factor of pain
due to his limited PROM will also be addressed to increase participation in his occupations.
The Biomechanical Model addresses ROM and pain. For XXX, pain is a huge barrier to
occupational performance as well as ROM in his L shoulder. The interventions with XXX will
address both areas of function through preparatory methods, positioning, and PROM of his L
UE. This will be done through the use of therapeutic activities. Addressing ROM will also aid in
using his shoulder to lift the mug with adaptive strategies. Lastly, we will use the Rehabilitation
Model as XXX is in a chronic condition now that he is 2 years post stroke. In conjunction with
biomechanical, we are using interventions focused on compensatory strategies to use his L UE
more in daily occupations to stabilize as well as use adaptive strategies to drink from a mug.
 
Research
 
Gilmore, P. E., Spaulding, S. J., & Vandervoort, A. A. (2004). Hemiplegic shoulder pain:
Implications for occupational therapy treatment. Canadian journal of occupational
therapy. Revue canadienne d'ergotherapie, 71(1), 36–46.
https://doi.org/10.1177/000841740407100108

Due to XXX’s shoulder pain in his L UE, intervention will work on actively positioning his limb
and incorporating it into tasks. This means that when XXX is doing a one-handed activity, his
arm is brought to table top and positioned for shoulder support, or if XXX is at the counter, he
remembers to bring his arm up and to place it on the counter. We will also educate XXX on
positioning for his arm when resting and when in his w/c to help decrease the pain from his
scapular instability. Along with this positioning his arm, intervention will focus on incorporating
his L arm into daily tasks, using compensatory strategies for stabilization. This article examined
occupational therapy interventions used in hemiplegic shoulder pain. The article identified that
for shoulder stability, the hemiplegic arm should be placed in positions that allow scapular
protraction, shoulder flexion, and an aligned spine (Gilmore et al., 2004). It also identified that
when bringing the hemiplegic arm into functional tasks, it is important to maintain scapula-
humeral rhythm, which can be achieved by bringing the arm into tasks when they are set up at
around the waistline (Gilmore et al., 2004). Intervention will also work on taping of his L UE to
provide support to his scapula and teaching his wife how to tape. Lastly, XXX has limited PROM
in his shoulder, impacting his ability to bring his arm into functional tasks. PROM stretches will
also be incorporated into treatment. This article also identified that external supports and PROM
are important aspects of treatment when managing shoulder pain, and that pain was low when
the client had a therapist perform PROM (Gilmore et al., 2004). Addressing these areas will also
aid the client in using a mug with compensatory strategies by improving the pain and ROM in
his L shoulder.

Narayan Arya, K., Verma, R., Garg, R. K., Sharma, V. P., Agarwal, M., & Aggarwal, G. G.
(2012). Meaningful task-specific training (mtst) for stroke rehabilitation: A randomized
controlled trial. Topics in Stroke Rehabilitation, 19(3), 193–211.
https://doi.org/10.1310/tsr1903-193
This article found meaningful task-specific training improved functional use as well time spent of
the individual in using the UE to perform the tasks (Arya et al., 2012). It also increased bimanual
coordination which is imperative after stroke and participation in ADLs (Arya et al., 2012). It also
found that using meaningful tasks improved the amount of time the affected UE was used (Arya
et al., 2012). Although we are not focusing on motor control with XXX, this is important for our
intervention of using the mug to drink. As he currently is not using his arm in occupations which
creates shoulder instability, this will provide a meaningful task for XXX to use his L UE and
increase his activity tolerance.

Signature: Kaitlin Brown, OTS