Running head: INTERVENTION PLAN

Occupational Profile and Intervention Plan for Client Status Post Cerebrovascular Accident
Marissa Stendel
Touro University Nevada

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Introduction
During my four week level one fieldwork experience at Healthsouth I was able to
conduct an interview and view treatment for a client by the name of Rhys Williams. Over the
course of a few weeks I was able to observe Rhys several times during his treatment sessions and
learned much about his life through our interactions and from his wife, Angie. Rhys journey to
recovery following his cerebrovascular accident (CVA) last winter has been a long but
continually moving journey as he progresses through his deficits and into fully functional
capacities. Rhys has many goals for himself and his future ahead and has been thoroughly
optimistic about his recovery. Learning about the variations in stroke presentation has helped me
to understand what might be most important to each individual on their path to recovery in
regaining function in a variety of aspects within their lives.
Occupational Profile
Rhys Williams is a 58 year old male who has sustained a right CVA with left hemiparesis.
Rhys is a husband, father and professor at a local university in computer networking at a local
university. The client is seeking outpatient occupational therapy services to restore function in
his left upper extremity (LUE) in order to begin teaching again. When the stroke occurred, Rhys
was away at a family reunion and in a hotel room alone. As an EMT in the past, he knew
immediately what was happening when he was unable to move his left side. The client displays
left hemiparesis due to right CVA, a decrease in activity tolerance, decrease in sensation,
neuropathic pain, minor subluxation in the left shoulder, decrease in coordination and strength,
and a decrease in balance. The client is seeking occupational therapy services for upper extremity
function and physical therapy services for lower extremity function as he is in a power chair at
this time.
The client feels successful in general mobility in the household and around the
community but only with the help of his wife. The client is able to sustain ADL function by using

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the right arm however, is limited in most ADLs that require both hands and IADLs because of
his inability to functionally move his LUE due to decreased strength and limited sensation. The
client views his wife, Angie, as a key element in his daily life because she is his primary
caregiver and primary source of social interaction. Rhys also views his home and power chair as
key components of his everyday environment. Without the use of a power chair Rhys is unable to
walk more than 80 feet. Rhys would like to return to work as soon as possible and has even
successfully given one lecture status post CVA within the last month.
Rhys grew up participating in drama and plays as a child and young adult. He enjoys
theatre and helping in the local theatre companies in his spare time. Rhys worked as an EMT
prior to his career as a professor of computer networking for over 30 years, and he would like to
continue down this path until an appropriate retirement age. The clients ability to maintain a
position at his current place of employment is of highest value to him. The client also has a
notably large extended family that he plans reunions for every few years. Generally Rhys values
time with his wife, and family, and enjoys planning and participating in local theatre productions.
On a daily basis, prior to his accident, Rhys enjoyed being active in his community, cooking
dinner for him and his wife, and tending to a vegetable garden that they began last year.
Rhys would like to improve his occupational performance in most every aspect of his
daily routine. However, the occupational therapist, client and caregiver would most like to see
improvement in his overall fine motor skills in order to participate more in IADLs such as work
in order for him to be successful in typing which is a large component of his work life.
Secondary to work, Rhys has expressed his discomfort in his wife appealing to his every need
and wishes he could prepare dinner time meals for the two of them at least a few times a week.
Later on, the client would also like to be able to drive again with or without the use of adaptive
equipment after further recovery has been attained. Additionally, other priorities that are more

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medically related are prevention of a second stroke by reducing risk factors associated with that
incidence and increasing Rhys safety awareness because of a slight decline in cognition post
CVA.
Rhys has worked very hard in the past six months to recover being moved from inpatient,
to outpatient and finally discharged only to come back to outpatient therapy on his own to regain
further independence. Overall, the client would like to increase independence in ADLs and
mobility, increase LUE motor function and sensation, decrease the pain in his affected side and
increase his overall quality of life by participating in his desired IADL occupations.
Occupational Analysis
Context/ Setting of Services
The client is being treated in an outpatient rehabilitation hospital where primary treatment
occurs in the rehabilitation gym. Therapy typically occurs at the table where the client can
complete activities and work on range of motion (ROM) in the upper extremities. The contexts
of this specific clinic include a wide variety of populations that are staying within the facility for
inpatient or outpatient rehabilitation services. Other components of this setting include the
physical and social environments. The rehabilitation gym has an extensive selection of exercise
equipment, mat tables, weights, an aquatic therapy pool, and even a vehicle. There is generally a
variation of patients in the gym working through various deficits along with their occupational
and physical therapists at any given time during the time that Rhys is receiving treatment with
his occupational therapist.
Activity Observed
The very first client I was able to work with was Rhys. I realized he had sustained a CVA
and had left hemiparesis with flaccidity in his upper left extremity and spasticity in his lower left
extremity just by observing him and knowing what diagnosis those symptoms typically stem
from. His cognition levels were relatively high and I was able to speak with him about his life
before and after to the accident which occurred about 6 months ago. Rhys was able to use his left

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side in small push and pull motions when completing ROM exercises with the therapist and was
able to grasp small items on the table with hand over hand and extra time. Other deficits that I
observed included an overall decrease in ROM and mobility in the LUE. Flexion and extension
of the shoulder girdle, elbow and wrist is impaired, along with supination and pronation of the
forearm and flexion and extension of the digits in the LUE. The client typically experiences high
levels of pain and takes tramadol and codeine as necessary.
Key Observations
During the performance of the activities described above, key observations were made in
the clients ability to perform, his motivation, and his desire to engage in the treatment session.
The client had a notably low tolerance for pain or exemplified pain to a high degree because of
his injury to his shoulder. That being said, the occupational therapist was also carrying out her
interventions through assisted active range of motion (AAROM), passive range of motion
(PROM), and improve his ability to complete active range of motion (AROM) in the LUE as
much as possible through movement in space. After viewing this activity through a client
centered occupation based approach, I believe it might be better to have the client partake in
activities that are more meaningful and that take away the constant neuropathic pain that is
present when movement is made. On that note, while the client was participating in PROM with
the occupational therapist and speaking with his wife and myself simultaneously, I noticed his
mind was elsewhere because he did not experience or express as much pain. Through social
interaction Rhys was able to complete the activity with ease.
Domains
Domains of OTPF most significant to the clients ability to engage focus on the
transactional relationship and the significance of meaningful occupations for the basis for both
occupation as a means and the ends for interventions (American Occupational Therapy

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Association [AOTA], 2014). By identifying all aspects of the domain that are most impacted by a
deficit or diagnosis, an occupational therapist can consider the client holistically.
For Rhys, the domains most impacted that include occupations are ADLs, IADLs, work,
and leisure. The client has difficulty completing ADLs such as bathing and showering
independently, dressing, and personal device care. IADLs most effected by his diagnosis include
communication management, driving and community mobility, home management, meal
preparation, and most importantly safety. The last occupation that is most effected and most
valued by this client is his work. Rhys primary goal for himself is to return to work at an
appropriate level where he can work at his most functional and optimal levels of job
performance.
Client factors that can be identified to which the client may need restoration include body
functions that effect high level cognitive pursuits, attention, memory, emotional regulation, and
pain. Other client factors that are affected include those related to neuromusculoskeletal
movement primarily in joint mobility and stability, muscle power, tone and endurance. These
deficits vary considerably in this patient where his mental functions are at a higher level than
those classified under neuromusculoskeletal related function. Rhys has considerably high
cognitive function but can have a low attention span and be forgetful. He also has a low tolerance
for pain and therefore has limitations in participation of daily life activities that in turn effect his
joint mobility and stability as he progresses toward an increase in strength and endurance.
Performance skills that are affected include motor and social interaction skills. Most of
the motor skill impairments are exemplified within and throughout Rhys left side of his body.
Rhys has some degree of difficulty participating in activities that include his LUE and specific
skills that include manipulating, gripping, coordinating and moving objects. Lower extremity
motor skill impairments mainly affect walking. Social interaction skills that are affected for this

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client include speaking fluently, and emotional expression. These skills are displayed overtly
through slowed speech and some outbursts when severe pain occurs.
Rhys also has difficulty completing routines that he once had the ability to complete with
effortlessness. Status post stroke, Rhys daily morning, afternoon and evening routines have
changed drastically. Prior to the stroke, the client typically went to work every day and spent
time at home on the weekends whereas now he spends most every day at home with his wife as
his caretaker or in therapy. Completing ADLs has become difficult for Rhys. However, with the
help of his wife he is able to complete a modified bathing and grooming routine. The client also
has trouble with IADLs such as meal preparation, gardening, participating in theatre production,
and planning of activities for him and his family. These familiar routines provide structure to
Rhys life and enable him to find meaning in daily occupations.
Lastly, the clients contexts and environments are affected by this injury. Rhys primary
contexts effected are his virtual, physical, and social environments. Computer networking is a
primary work occupation for Rhys and falls under the virtual contexts for this client because his
primary way of communication includes computers. While virtual contexts have changed
drastically for Rhys, so have his physical and social environments. Rhys typically spends his
days within his home or running errands that are within his activity tolerance levels with his
wife. Having had a large change in these contexts and environments can affect Rhys will to
recover and work toward his goals.
5 Functional Problem Statements and Justifications
1. Client is unable to perform computer work as a professor secondary to right CVA and
LUE paresis and pain.
a. The clients treatment based in an outpatient setting helps to determine what goals
the client is seeking to reach. When addressing this functional problem statement,
the client would like to see overall increase in participation and role competence

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as an outcome. The clients overall primary goal for himself is to return to work as
a computer networking professor. This functional problem statement can be
addressed in the context provided by compensatory and high repetition upper
extremity task specific training exercise interventions.
2. Client is unable to complete meal preparation independently due to decreased strength
and safety awareness.
a. Rhys demonstrates decreased strength and safety awareness and therefore is
unable to complete IADLs independently or without supervision. Although Rhys
main priority is to regain the ability to return to work, safety awareness must be
addressed during treatment especially when completing an occupation that he
enjoys and wants to regain independent function. In order to enforce safety
awareness and work on upper extremity strength, within the outpatient setting we
will utilize education and virtual systems to increase performance in IADLs such
as meal preparation. The outcome within this context will be to increase
occupational performance specifically through occupational improvement.
3. Client is unable to grasp and manipulate small utensils and tools with left hand due to
poor sensation and a decrease in fine motor skills.
a. The targeted outcome for this particular functional problem statement is
occupational improvement. Through interventions in the outpatient setting, Rhys
will increase his occupational performance specifically in increasing motor skills.
Utilizing NMES and functional activity Rhys will relearn how to grasp and
manipulate small objects. This problem statement is third because in order for
Rhys to regain functional mobility in his left upper extremity, left hand fine motor
skills must be intact.
4. Client is unable to complete gardening independently due to poor bilateral upper
extremity coordination.

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a. In order to increase involvement in leisure activities such as gardening at the

outpatient facility, the client can participate in gardening at the facilitys outdoor
garden and other activities that simulate this important leisure occupation that he
completes with his wife. The desired occupation under this problem statement is
gardening and therefore is defined as participation and role competence under
desired outcomes.
5. Client requires minimal assistance for bathing secondary to poor balance and lack of
adaptive equipment.
a. This functional problem statements desired outcome falls under occupational
enhancement. This client will be able to work on transfers with adaptive
equipment in the simulated context of the facility and transfer those techniques to
the home.
Intervention Plan and Outcomes
Long Term Goal #1
Client will perform basic computer skills utilizing compensatory techniques adaptive
equipment Mod (I) in order to return to work within 2 months.
Short Term Goal #1
Client will use an adaptive mouse on the affected side to sign into computer and browse
internet for 15 minutes Mod (I) within 1 month.
Intervention
In order to regain function within the LUE, the client can achieve high levels of
independence through the use of compensatory techniques within the unaffected limb and
adaptive equipment for the affected side. According to Wolf and Birkenmeier (2011), therapists
should include the affected extremity in therapy as much as possible and only use the unaffected
side when the client is unable to complete the task. By asking Rhys to use his LUE to control an
adapted mouse, one fit to the needs of Rhys hand function and finger dexterity, Rhys will be
able to eventually utilize features any computer software includes. If Rhys has a difficult time

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achieving the benchmark time for 15 minutes without using his unaffected side, compensatory
strategies such as adjusting or using controls on the computer screen or keyboard can be made to
help him complete the task.
In order to regain the ability to return to work Rhys must be able to operate a computer
and its controls with adaptations. Utilizing compensatory strategies such as motor techniques and
contextual training will help Rhys achieve this goal. Contextual training involves practicing a
task until it becomes learned and therefore increases independence (Wolf and Birkenmeier,
2011). This activity will begin at a low level and slowly work its way up to an activity tolerance
level of about 15 minutes. Breaking up the tasks associated with the short term goal will allow a
gradual increase in progression towards meeting the short term goal and eventually long term
goal.
The approach of this intervention falls under the category modify. In order for Rhys to
return to his place of employment, it is important to find ways to revise the current context or
activity to meet those specific occupational needs (AOTA, 2014). To meet this short term goal,
the client will be using compensatory techniques such as simplifying tasks and making
adjustments or adaptations to the routine of the activity. The outcome we hope to achieve
through this intervention is participation. This occupation that is considered desirable by the
client can be modified to meet the demands of his role as a professor but also of the general
expectations of this culture (AOTA, 2014).
Short Term Goal #2
Client will type a 250 word email describing a course assignment Mod (I) within 6
weeks.
Intervention
In a study presented by Waddell, Birkenmeier, Moore, Hornby, and Lang (2014),
feasibility of delivering an individualized, progressive, high repetition upper extremity task
specific training protocol for people with stroke was assessed. It has been demonstrated that

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upper extremity training in an outpatient setting can be feasible if completed in one hour therapy
sessions (Waddell, Birkenmeier, Moore, Hornby, & Lang, 2014). The study further discussed the
findings of this data which concluded that it is feasible to deliver substantially higher number of
repetitions of individually tailored, progressive, task-specific training in an inpatient setting
(Waddell et al, 2014). That being stated, implementing such a program with Rhys could be
beneficial in regaining the ability to type and ultimately return to work. For this intervention
specifically, Rhys would practice typing on his laptop or the facilities laptop with the use of
adaptive equipment if needed using his LUE to complete the task until he reaches his goal of 250
words. The article did not mention constraint induced movement therapy as a means of allowing
high repetitions. Therefore, it can be indicated that using the unaffected side is acceptable in
completing the task and even assisting with the simulated movements the left side should be
making.
The approach to intervention for this goal is the establish/ restore approach. In
completing this intervention, we would like to restore the skill of typing towards completing the
occupation associated with Rhys work contexts. This outcome is similar to that of short term
goal one in that this intervention is being applied to the same occupation. The outcome for this
intervention is participation and or role competence. Both of these outcomes can be viewed as
either essential or desired outcomes for the client.
This activity can be graded up or graded down easily to support the needs of the client.
By increasing the word count or placing a time frame on the completion of the activity the
activity will be graded up. By decreasing the number of words in the email or using an assistive
device such as an intelligent personal assistant where the client can talk and the text will be
written for him on the computer, the activity will be graded down.
Long Term Goal #2

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Client will prepare a box of macaroni and cheese fewer than 2 VC for correct
sequencing and safety in the rehabilitation kitchen within 2 months.
Short Term Goal #1
Client will be able to grasp and manipulate 10 objects needed for cooking activity
utilizing a virtual context Wii game while adhering to safety precautions within 1 month.
Intervention
According to Ellington, Adams, White, and Diamond (2015), the use of virtual reality
systems such as Xbox Kinect, Nintendo, Wii, Sony and more are growing within rehabilitation
and show a potential to positively influence outcomes for patients. Recent studies have found
that virtual kitchen task predicted actual task performance and that movements learned in virtual
contexts can often be transferred to real life scenarios (Ellington, Adams, White, & Diamond,
2015). Utilizing such equipment can be motivating and enjoyable for the client and help to make
a task more meaningful to the client as a means to an end. For Rhys intervention, playing a
game that involves grasping and manipulating objects associated with the upper extremity can be
enjoyable, increase the use of the affected side, and can reflect real life occupations such as
retrieving items to prepare a meal.
The intervention approach used is the establish/restore approach where the client will be
working towards restoring functional usage of the affected upper extremity. Through the use of
virtual context, the client can play games that involve picking up and putting down items which
implement fine motor skills, and play games that involve bilateral coordination and balance. The
expected outcome for this intervention is occupational improvement by using virtual reality as an
occupation as a means to an end (AOTA, 2014). Eventually Rhys will need to fulfill his long
term goal of completing a cooking activity, something that he finds to be important in
maintaining his home. By restoring fine motor skills, Rhys will be able to participate in a number
of activities outside of cooking that will achieve his other occupations in life.
Short Term Goal #2

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Client will recall and describe implementation of education on safety awareness

techniques by preparing a five step hot meal Mod (I) within 1 month.
Intervention
In order to implement education on safety awareness the occupational therapist must
appeal to the clients educational needs and apply those needs in an occupation based way. By
providing handouts and verbal cues as to how to be more aware of safety, the therapist can help
the client to be safer within their home and in the community. Later, Rhys will rehearse and
implement safety techniques and precautions he has learned while preparing a simple meal. In
the research provided by Latham, Jette, Coster, Richards, Smout, James, Gassaway, and Horn
(2006), occupational therapy activities and intervention techniques for clients with a stroke in six
rehabilitation hospitals were assessed to find what interventions were used most frequently.
Research demonstrated that neuromuscular treatments and education were amongst the highest
used intervention components for activities (Latham, Jette, Coster, Richards, Smout, James,
Gassaway, and Horn, 2006). With this intervention, caregiver education can also be given to help
the client and caregiver better understand the diagnosis and occupations that may need extra
safety concern.
The last approach to this intervention is prevent. Using this approach to intervention aids
the client in preventing further injury to them self. The outcome for this intervention is also
prevention in order to reduce the chance of further injury or secondary conditions.
Precautions and Contraindications
Intervention considerations including caregiver training, precautions, and
contraindications should be put into place while working with the client and post discharge.
Specific precautions that pertain to stroke patient commonly include secondary diagnoses such as
hypertension, coronary heart disease, and congestive heart failure (Wolf and Birkenmeier, 2011).
The clients physicians may have other precautions that the occupational therapist may want to

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take into consideration such as heart rate, oxygen saturation levels, and blood pressure. Also, in
order to avoid cardiac stress on a patient that has sustained a CVA, activities that involve
isometric, resistive and overhead reaching are typically contraindicated (Wolf and Birkenmeier,
2011). It is important to note too, specifically in Rhys case, that proper alignment of all joints
are maintained in order to increase functional range of motion, decrease chance of decubitus
ulcers, decrease edema, and avoid impingement and damage to soft tissues. This precaution can
be executed by placing the affected arm in its correct functional position during tasks (Wolf and
Birkenmeier, 2011).
Duration of Intervention Plan
For the duration of treatment for this client in this specific setting approximately two
months is the appropriate time frame. The client has been undergoing outpatient therapy for one
month at this facility and attends occupational therapy treatment four times a week for 45
minutes. An additional two months time should be feasible to make functional gains in the
problem areas described above. However, if the client does not feel that he has made enough
progress or that he has met his goals he can continue or discontinue treatment at any time
because he is paying out of pocket for these services.
Framework for Intervention
The overarching framework for this intervention plan stems from the task oriented
approach (TOA). This approach was designed under models of motor control and biomechanical
sciences, and organizing intervention around a task/ activity in order to complete or fulfill a role.
Reorganization of the model from an occupational therapy standpoint was formed from
Tromblys proposition that to engage in a life role, a person must be able to complete tasks that
make up that particular rolethis is unique to occupational therapy. Additionally, roles
associated with occupations that clients need to do and want to do can be done through
purposeful and meaningful tasks. This also helps the occupational therapist to choose

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interventions that are occupation based and client centered using the natural environment (or in
this case an outpatient rehabilitation setting) in order to adjust the task to meet the desired role of
the client. Lastly, this model asserts that there are five main areas to assess when using the TOA:
the role performance, occupational performance tasks, task selection and analysis, the person,
and the environment. With these five areas to assess within the TOA an occupational therapist
can view the clients needs holistically during rehabilitation.
This model revolves around the more broad aspects of a client such as their personal self,
their environment and the roles they take, a persons occupations, client factors, performance
skills, performance patterns, and contexts which are all important when influenced by the TOA.
To explain further, Rhys life roles are defined by the occupations they take on or see fit to that
particular role. Some of these roles for Rhys include his work as a professor, a husband, and
secondary roles that revolve around leisure occupations like cooking and planning family events.
Client and Caregiver Education
Client and caregiver education will be addressed during intervention sessions. The client
and caregiver, or his wife, will be provided with handouts addressing several topics such as home
modifications, compensatory strategies, and energy conservation techniques in order to enable
the client to become more functionally independent. Home modifications can be made to allow
entrance into the home and transferring surfaces as well as safety concerns that may impinge the
client to put him in danger. Compensatory strategies for reaching and adapting the environment
can be made to assist the client in everyday tasks. The client will also be given education on
energy conservation techniques to conserve energy for activities that he has to do or needs to do
such as therapy in order to achieve the most out of his entire energy expenditure.
Other forms of education can be provided to the caregiver and client such as verbal
communication. Verbal education could be used to address superficial needs or general questions

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that the client or his caregiver might have to address daily needs that might not be covered within
the general handouts. Many questions were answered verbally during the observation time that I
spent with Rhys and my fieldwork educator. Since the stroke occurred, Rhys has already made
gains in improving his physical environment within his home and vehicle to better accommodate
his condition at this time as prescribed by the occupational therapist.
Progress towards Goals
Progression towards goals and monitoring of the clients responses to the interventions
will be assessed through skilled observation and reassessment. During treatment, the
occupational therapist will observe and note all gains toward expected outcomes in order to track
the progress of the client. Daily notes or soap notes can be made along with other documentation
which can be done within the facilities standards. If the client does not appear to be making
progress or display disinterest in the intervention itself, the occupational therapist can edit the
intervention plan to meet the needs of the client.
Other ways of monitoring the clients responses and gains throughout the intervention
process can be done through reassessment and finding objective measures to track progress.
When Rhys began treatment, his occupational therapist performed the FUGL-Meyer Assessment
on Rhys to assess his functional capacities within the upper extremities. Performing an
assessment is an objective and more concrete measure of assessing the functional outcomes of a
clients progress throughout treatment. Advancement towards goals and responses to treatment
interventions are of utmost importance to the interdisciplinary team and to the client themselves.
Skilled observation and proper recording of documentation can demonstrate how effective
occupational therapy can be not only for clients on an individual basis but for the growth and
future evidenced based development for the field of occupational therapy.

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References

American Occupational Therapy Association. (2014). Occupational therapy practice framework:

Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1),
S1S48. http://dx.doi.org/10.5014/ajot.2014.682006
Ellington, A., Adams, R., White, M., & Diamond, P. (2015). Behavioral intention to use a virtual
instrumental activities of daily living system among people with stroke. American Journal
of Occupational Therapy, 69, 6903290030. http://dx.doi.org/10.5014/ajot.2015.014373
Latham, N. K., Jette, D. U., Coster, W., Richards, L., Smout, R. J., James, R. A., Gassaway, J., &
Horn, S. D. (2006). Occupational therapy activities and intervention techniques for
clients with stroke in six rehabilitation hospitals. American Journal of Occupational
Therapy, 60, 369378. http://dx.doi.org/10.5014/ajot.60.4.369
Waddell, K. J., Birkenmeier, R. L., Moore, J. L., Hornby, T. G., & Lang, C. E. (2014). Feasibility
of high-repetition, task-specific training for individuals with upper-extremity paresis.
American Journal of Occupational Therapy, 68, 444453.
http://dx.doi.org/10.5014/ajot.2014.011619
Wolf, T.J., & Birkenmeier, R. (2011). Intervention to increase performance and participation
following stroke. In In C. H. Christiansen & K. M. Matuska (Eds.), Ways of living:
Intervention strategies to enable participation (4th ed., pp.282-294). Bethesda, MD:
American Occupational Therapy Association.