Danielle Oberg

OC TH 6520

Occupation in Adult Neuro Rehab

Division of Occupational Therapy
University of Utah
INITIAL EVALUATION
Client Name: A.R.
Date: 10/08/2014
Diagnosis: CVA Age: 49 Gender: Female Date of Onset: January 2010
Pertinent Medical History: Client was diagnosed with brain tumor and underwent
surgery to remove in January of 2010; stroke occurred post surgery. History of
seizures (currently controlled by medications).
Precautions/Contraindications: None indicated
Prior Functional Status: Independent with ADLs and IADLs
Language: (aphasic, English not first language?) Portuguese is first language;
English is second language. Client has slurred speech.
Clients view of current issues requiring therapy/desired outcome: Client would
like to see more functional movement and use of her LUE. Client has increased
flexor tone in LUE that limits AROM in shoulder, elbow, wrist, and hand. Clients
high tone hand has little active movement and she would like to be able to use it
more functionally.
Other therapies or physical activities currently participating in: Client is currently
receiving Physical Therapy at the Wellness Clinic three times a week.
Participation: How has the injury/medical event affected participation in life
activities? Client states that everything has been affected since the stroke.
Everything is much more difficult to complete, especially walking.
ADLs:
Describe any difficulty with dressing, grooming, mealtime, bathing:
Client states that she has home care aides that come every morning to assist
with ADLs. Client completes dressing with min assist from aides. Client reports
completing shower by self with use of a shower bench. Client reports that home
care aides help with preparing meals, although she does often prepare herself
simple snacks. Client has difficulty with her hair.
Describe any difficulty with IADLs (home management, childcare.):
Client reports that home care aides do most of the household cleaning; Client
says she is able to do her own laundry. Client does not drive, but is able to take
public transport or has aides or friends drive her around the community. Client
sometimes needs assistance with shopping for lifting or pushing heavy objects.

Danielle Oberg
OC TH 6520

Mobility:
Describe any problems with ambulation, stairs, bed mobility, transfers..:
Client does have abnormal gait and at slower pace due to LLE weakness. Client
no longer uses an assistive walking device. Client reports increased time to use
stairs. Client reports no problems with bed mobility or transfers.
Upper Extremity ROM:
General description of problems with the upper extremity:
Client presents with increased flexor tone in LUE. Client compensates to
complete many movements (ex. Abducts shoulder to assist with elbow extension;
elevates shoulder to assist in shoulder flexion). Left hand has high tone and little
to no active movement.
Prior hand dominance: Right

Shoulder: Flexion
Extension
Abduction
ER

AROM - R
WNL
WNL
WNL
WNL

AROM - L
80
45
80
Need
measurement
Need
measurement

PROM - R
WNL
WNL
WNL
WNL

Need
measurement
Need
measurement

IR

WNL

Flexion
Extension

WNL
WNL

140

Forearm: Supination
Pronation
Wrist:
Flexion

WNL
WNL
WNL

NT*
NT*

Extension

WNL

NT*

WNL

Fingers: Flexion
Extension
Thumb: Flexion

WNL
WNL
WNL

NT*
NT*
NT*

WNL
WNL
WNL

90
0

NT*

WNL

Elbow:

Need
measurement

Need
measurement

Extension
WNL
*Not tested due to no active movement

WNL

PROM - L
110
50
90

WNL
WNL

140
15

WNL
WNL
WNL

WNL
WNL
Need
measurement
Need
measurement

Need
measurement

Scapula placement and mobility: Scapula seemed to be moving normally, able to

mobilize and moved with UE movements.
UE Tone: Increased flexor tone throughout LUE. Approximately a 2 on the
Ashworth scale. High flexor tone in left hand.
UE Coordination/FM Control: RUE is normal, no concerns. Client has little to no
active movement in left hand. FM control could not be tested for LUE.

Danielle Oberg
OC TH 6520

UE Proprioception/Sensation: Client states she has no major concerns with

sensation for LUE. Sensation in LUE is decreased compared to RUE. Client has
increased sensitivity on tips of fingers and thumb of left hand.
Trunk Control: Client demonstrated good trunk control and was able to maintain
balance during dynamic reaching exercise while sitting on edge of mat. Client
states she has no concerns.
Sit to Stand: Client was able to complete sit to stand with no support; Client
requires a little more time to stand and steady self.
UE Use in Functional Transitions: Client used RUE to assist in transition, there
was little to no use of the LUE.
Cognition: No problems were noted with cognition. Client was alert and oriented,
able to follow directions and problem solve. Therapist will continue to assess
throughout sessions.
Vision/Perception: Client uses glasses for reading, was previously diagnosed
with astigmatism. Client reports no other concerns or no changes since stroke.
(note if any areas need more extensive assessment)
Client Goals for 10 week session: Client would like to increase active movement
of LUE. Client would like to work on opening her left hand and decreasing tone.
Client would like to develop and implement a HEP for improving AROM in LUE.
Client would like to practice completing bilateral tasks, such as doing her hair.
ASSESSMENT:
Impairments:
Functional Limitations: Increased tone, decreased ROM in LUE, weakness in
LUE and LLE
Strengths: Client has intact cognition and is very compliant. Client does have
active movement throughout most of her LUE. Client is able to walk and perform
transfers well. Client has good sensation. Client has good trunk control and
balance.
Problem areas: Client has difficulties in all aspects of her life due to decreased
function of LUE. Client requires help with many ADLs and IADLs.
Statement of General Level of Function (p. 193): Clients general level of function
is fairly good. Client requires min assist with ADLs as well as receives home care
aides to assist with meals and home management. Client relies on others for
community mobility and community tasks.
Family and Environmental Characteristics (p. 193): Client lives alone in an
apartment in downtown Salt Lake City. Client does not have any family that lives
nearby, but she has friends who act as her support.

Danielle Oberg
OC TH 6520

Goal Area No. 1

Functional Long Term Goal (10 weeks):
In 10 weeks, client will independently adhere to HEP 5 out of 7 days in 1 week
Related Short Term Goal (two weeks):
In 2 weeks, client will demonstrate at least one exercise and report performing at
least 3 days in 1 week.
Baseline:
Currently no HEP in place
Goal Area No. 2
Functional Long Term Goal (10 weeks):
In 10 weeks, client will incorporate LUE with min A to perform hair task.
Related Short Term Goal (two weeks):
In 2 weeks, client will increase AROM of shoulder flexion by at least 5 degrees
Baseline:
AROM of left shoulder is approximately 80 degrees

Goal Area No. 3

Functional Long Term Goal (10 weeks):
In 10 weeks, client will actively use LUE to assist in transitions and transfers with
no verbal cues.
Related Short Term Goal (two weeks):
In two weeks, client will actively use LUE to assist in transition with mod assist
min verbal cues
Baseline:
Client as little elbow extension and difficulty opening high tone hand. Does not
use LUE in transitions.

Plan for Next Treatment Session:

Activity
1. AAROM/PROM on
LUE

Set up/Equipment
Mat, self

Rationale
I would want to promote
stretch and mobilization
of the joints and muscles
in order to increase the

Danielle Oberg
OC TH 6520

ROM of her LUE

2. Weight bearing
through LUE

Mat, self, possible

objects to reach for

Weight bearing will give

feedback to the muscles
and may help to
normalize the tone in the
LUE

3. Opening and
maintaining an open left
hand

Mat, self, clients splint,

phone book

The client is concerned

about her hands
function. By helping it to
be open and having it
bear weight on the mat,
we can help to stretch
and normalize tone.

4. Putting away dishes

Dishes, cupboards

5. HEP education

Pictures of exercises

The client will be using

her LUE to support self at
the counter as well as
incorporate it into putting
away the dishes for
bilateral use
The client requested
some exercises to do at
home that will help her to
practice what we work on
during sessions. This will
help maintain and
improve LUE function.

Danielle Oberg, OTS

10/08/14

Occupational Therapy Student Signature

Date