Evaluation Report

Client: Client
DOB: 03/31/1951
Primary Diagnosis: multiple CVAs
Referral: referred by student speech clinic for an evaluation
Dates of Evaluation: 1/28 & 2/4/16
Therapist: Melanie Francis, OTS
Background
Client is a 64 y/o female 3 years post L and R CVAs. Approximately one year after her CVAs she
had a fasciotomy to relieve compartment syndrome in her R forearm. She lives in the Salt Lake
area with her husband, adult son, and cat in a multi-story home. Her husband quit his job to take
care of her shortly after her CVAs and has not worked since. She presents with R UE
hemiparesis, high tone, and slight wrist contracture, R subluxed shoulder, and general weakness.
She was referred by the student speech clinic. She continues to see speech and physical therapy.
S: Client and caregiver stated they were glad to be here and appreciate the help.
O: Client is seeking OT services due to decreased occupational performance, participation, and
satisfaction. Prior to her CVAs, Client was performing all occupations independently. She was a
house cleaner by trade and an avid cook. She took great pride in her homemaking tasks and
values her family.
Client currently feels successful in managing her medicine, brushing her teeth, washing her face,
and applying makeup. Her husband is home to assist her as required so most occupations are
completed with his assistance. He readily stated that he helps more than he should and expresses
he feels somewhat responsible for where she is functionally 3 years post CVAs.
An unstructured interview was conducted. Clients fatigue kept her from participating fully so
most responses came from her husband. In the second session, Client completed the ADL-IADL
Addendum to the Occupational Self-Assessment, which measures the clients competence and
importance of ADL and IADL occupations, with minimal input from her husband. The
assessment identified bathing, dressing, house cleaning, and laundry as her top priorities for this
therapy episode of care.
ADL-IADL Addendum to the Occupational Self-Assessment
Performance
Bathing
Lot of problem
Dressing
Some difficulty
Grooming
Well
Meal preparation
Lot of problem
Toileting
Extremely well
Driving
Lot of problem
House cleaning
Lot of problem
Laundry
Lot of problem

Importance
Most important
Most important
Most important
Not so important
Most important
Most important
Most important
More important

Grocery shopping

Lot of problem

Not so important

Client reported her typical day begins with her waking up. Her husband makes her breakfast.
She takes her mediations. She gets ready for the day. She (I) brushes her hair, brushes her teeth,
washes her face, and applies make up. She says she spends about 70% of her day in her
bedroom. Her husband prepares all meals. Depending on the meal she may assist with a side
dish. She has all of her meals with her husband; on occasion her son will be home and have
dinner with them. At the end of the day she gets ready and goes to bed; her husband will try to
stretch out her RUE before sleeping. She has therapy or doctor appointments weekly and may go
out on errands with her husband but prefers not to because he goes to multiple stores per trip.
Clients PROM was assessed. Her LUE is WFL but her RUE is significantly decreased. After
joint mobilization, her RUE PROM was improved.
Observation of Occupational Performance: Client was observed donning and doffing a
sweater and making a peanut butter and jelly sandwich. She doffed sweater while seated with 2
verbal cues from her husband for difficulty removing from her RUE. She donned her sweater
while seated with modA from her husband. Client made the sandwich with setup and maxA for
stabilization. She opened, removed, and placed bread on the plate (I). She required maxA to
stabilize the jars and plate while spreading the peanut butter and jelly on the bread. She also
required modA to close the bread bag and jars. She sustained her attention throughout each
observed task. She was also observed transferring from walker to bed. She used a bed rail and
required modA with verbal cues to position feet.
Environmental Assessment: Client is a 64 y/o wife and mother. She is a retired house cleaner
due to disability as a result of the CVAs. Her home is multi story with her bedroom and
bathroom being upstairs from the kitchen and other living spaces. Her sons room and the
laundry room are downstairs from the main living space. While at home she uses a standard w/c
but is confined to her room and bathroom because of the stairs. It is also hard for her to selfpropel because the flooring is predominantly carpet. Her bathroom is accessible with grab bars
installed and a walk-in shower. She has a shower chair to which her husband helps her transfer
and the shower taps are within her reach. She has a bedside commode over the toilet to aide her.
She is dependent on her family, primarily husband, to get to the other spaces in their home. Once
in the kitchen her w/c is too wide to move around because of an island so she stays in one area.
When leaving her home, she uses a FWW for the convenience of transporting it. She uses it as a
w/c though with her husband pushing her while she sits.
A: Client required a verbal cue for initiation and attention to doff her sweater because of her
cognitive deficits and energy level post CVA. Her difficulty removing RUE from sweater is due
the her subluxed R shoulder and high tone in her RUE; she also has a slight contracture
inhibiting movement. She may have required less assistance but her husband stepped in before
she had any real issues. Therapist set items required for the sandwich on the table within arms
length. Due to her RUE weakness and limited motor control, she required assistance to stabilize
objects for the sandwich preparation. Her RUE PROM was significantly decreased by high tone
and a slight contracture. The joint mobilization reduced her tone to improve RUE A/PROM.

P: Client will be seen for 6 sessions over 3 months with a d/c date of 4/21/16. Client and her
caregiver will be taught PROM and joint mobilization techniques to decrease tone in her affected
arm. Client will be educated on strategies to utilize her affected arm as a stabilizer to increase
independence in functional tasks.
Goals were created to support Clients desires. In order to improve her performance in bathing,
dressing, house cleaning, and laundry, she needs to find a functional use for her RUE. Her RUE
will best serve her as a stabilizer. Part of her issues with these occupations is her safety. Goals for
her care are:
LTG 1: By d/c, CLIENT will use her affected arm as a stabilizer during meal preparation
with no more than 3 verbal cues.

STG 1: In 3 weeks, CLIENT will use her affected arm to prevent items from falling off
tabletop with no more than 2 physical cues.

STG 2: In 6 weeks, CLIENT will (I) initiate use of her affected arm during meal
preparation.

LTG 2: By d/c, CLIENT will safely transfer to/from w/c with minA for ADL participation.

STG 1: In 4 weeks, CLIENT will correctly position feet for transfer with no more than 3
verbal cues for ADL participation.

STG 2: In 6 weeks, CLIENT will safely transfer to/from shower chair with modA.
Melanie Francis
2/6/16
Setting Goals
Goals were prioritized with Client and her husband in order to optimize her occupational
participation and performance. By setting goals based on her desires we get her buy in and
desire to participate in therapy.

Practice Models
MOHO

Clients characteristics and the external environment are linked together in

a dynamic whole which is why we will do a home eval and assess her environment

Occupation reflects the influence of both the persons characteristics and

the environment

A persons inner characteristics (i.e. capacities, motives, and patterns of

performance) are maintained and changed through engaging in occupations our goal is
to change her patterns of performance by encouraging her to use her affected arm instead
of ignoring it as well as to encourage her husband to do less for her promoting
independence.
Biomechanical/Rehabilitation
Activities may be progressively modied to intensify or reduce task demands to either
increase musculoskeletal capacity or match limitations the tasks in our interventions will be
tailored to provide her RUE an increasing role from week to week
Increased strength, ROM, and endurance can potentially help the client function in everyday
occupations we will be doing joint mobilizations to increase her ROM and task which will
increase her strength and challenge her endurance
AE promotes independence not dependence any equipment we identify for her will
promote her independence
DIM

just right challenge will push her to use her affected arm
Cueing will encourage her to use her affected arm and eventually (I) acknowledge and
use it.
Activity analysis will help her and the therapist to understand the demands and how to
implement energy conservation strategies to promote success.

Intervention outlines
#1 Objective: use RUE as stabilizer during meal prep task
LTG 1: STG 1

joint mobilizations (10 mins)

educate client/caregiver joint mobilizations, duration, frequency
corn bread
spread butter & honey
joint mobilizations (10 mins)

#2 Objective: use RUE as stabilizer during household management task

LTG 1: STG1

joint mobilizations (10 mins)

educate client/caregiver joint mobilizations, duration, frequency, importance of using
RUE
folding/hanging laundry
joint mobilizations (10 mins)

#3 Objective: use RUE as stabilizer during household management task

LTG 1: STG1 & STG2
joint mobilizations (10 mins)
educate client/caregiver verify correct joint mobilization
cleaning counters/dishes
joint mobilizations (10 mins)
#4 Objective: identify supports and barriers in home, teach transfer techniques in natural
environment, suggest modifications to routines & organization of the home
LTG 2: STG1 & STG2
joint mobilizations (10 mins)
Home Eval
educate client/caregiver modifications to routine or organization of home, transfer
techniques
transfers
joint mobilizations (10 mins)
#5 Objective: use RUE as stabilizer during dressing task
LTG 1: STG1 & STG2, LTG 2: STG1
joint mobilizations (10 mins)
educate client/caregiver
dressing
transfers
joint mobilizations (10 mins)
#6 Objective: use RUE as stabilizer during bathing task to increase awareness and functionality
LTG 2: STG1 & STG2
joint mobilizations (10 mins)
educate client/caregiver home program to continue after d/c
bathing/transfers

joint mobilizations (10 mins)

Research
Nilsen, D. M., Gillen, G., Geller, D., Hreha, K., Osei, E., & Saleem, G. T. (2014) Effectiveness
of interventions to improve occupational performance of people with motor impairments

after stroke: an evidence-based review. American Journal of Occupational Therapy, 69,

6901180030p1-6901180030p9. doi:10.5014/ajot.2015.011965
This study highlights repetitive task practice, strengthening and exercise, mental practice,
action observation can improve upper-extremity function, balance and mobility, and/or activity
and participation. The effective interventions used goal-directed and individualized tasks.
http://ajot.aota.org/article.aspx?articleid=2087148&resultCliclient=3
Ada, L., Dorsch, S., & Canning, C. G. (2006). Strengthening interventions increase strength and
improve activity after stroke: a systematic review. Australian Journal of Physiotherapy,
52(4), 241-248. doi:10.1016/S0004-9514(06)70003-4
This study found that strength training post stroke increases strength without increasing
spasticity.
Harris, J. E., & Eng, J. J. (2010). Strength training improves upper-limb function in individuals
with stroke a meta-analysis. Stroke, 41, 136-140. doi: 10.1161/STROKEAHA.109.56743
This study found that strength training post stroke increases strength without increasing
tone or pain. http://stroke.ahajournals.org/content/41/1/136.full
Kawahira, K., Shimodozono, M., Etoh, S., Kamada, K., Noma, T., & Tanaka, N. (2010). Effects
of intensive repetition of a new facilitation technique on motor functional recovery of the
hemiplegic upper limb and hand. Brain Injury, 24(10), 1202-1213.
doi:10.3109/02699052.2010.506855
Repetitive facilitation of the affected limb by multiple sensory stimulations is more
effective than conventional therapy.
http://www.tandfonline.com/doi/full/10.3109/02699052.2010.506855
Liu, K. P., Chan, C. C., Lee, T. M., & Hui-Chan, C. W. (2004). Mental imagery for promoting
relearning for people after stroke: A randomized controlled trial. Archives of Physical
Medicine and Rehabilitation, 85(9), 1403-1408.
Mental imagery can improve the planning and execution of functional tasks with the
affected arm. Mental imagery appears to help patients relearn functions and generalize them
better. http://www.archives-pmr.org/article/S0003-9993(04)00270-9/fulltext
Yeh, C. Y., Chen, J. J. J., & Tsai, K. H. (2007). Quantifying the effectiveness of the sustained
muscle stretching treatments in stroke patients with ankle hypertonia. Journal of
Electromyography and Kinesiology,17(4), 453-461.
This study shows PROM increases ROM and decreases spasticity as measured by the
Modified Ashworth Scale.