Occupational Therapy Evaluation Report and Initial Intervention Plan

Background Information

Client’s name or initials: P.B.

Date of referral: 1/17/2019
Date of report: 1/24/2019
Date of birth &/or age: 69 years old
Primary intervention diagnosis/concern: Right Thalamic Hemorrhagic Stroke
Secondary concerns/diagnosis: At this time, client presents with no secondary
concerns.
Precautions/contraindications: Client is at risk of falling while ambulating due to
hemiplegia on left side of body and lack of sensation
Medications: Baclofen
Reason for referral to OT: Self-referral to address decreased left upper
extremity function
Therapist: Alexandria Marshall OTS
Medical History: Received occupational and physical therapy at the
University of Utah’s Inpatient Medical Rehabilitation
for one month. Currently, he receives 6 hours of
occupational therapy, physical therapy, and personal
training every week to work on improving function on
hemiplegic side.

_____________________________________________________________________________________

Subjective: Upon arrival (1/24/2019), client greeted my partner and I and said he spent the past week

thinking about what he would like to work on. He stated, “My top priority is to be able to put my shoe

on.”

Objective:

Client was seen 1/17/2019 and 1/24/2019 for a comprehensive occupational therapy evaluation at the

Life Skills Apartment.

 Occupational profile:

Client is a 69-year-old Wyoming native, who has resided in Salt Lake City for the past 30 years. In

September 2017, he was on a trip visiting his son in New York City and had a thalamic stroke, which

resulted in left hemiplegia. He lives with his wife in a single-family three-story home and occasionally

resides in his condo which is close to work. He works full-time Monday through Friday, and returned to

work in January 2018. He is the president of a large corporation and also serves on the business advisory

board of four different universities. He expressed that he takes great pride in his “intellectual” work and

loves staying busy. He also employs two full-time aides to assist him with various physical and work-

related tasks. He follows a structured daily routine which consists of his aide waking him up every

morning at 6 a.m. to perform his home exercise program and help him get showered and dressed for

the day. After work, he eats dinner prepared by his wife or chef, watches tv, and arranges for bed. Prior

to his stroke, he was an avid skier and loved going on hikes in the Wasatch Mountains. Since his stroke,

he stated that he no longer participates in either activity because of the extreme spasticity on the left

side of his body. He said that he would love to get back out on the slopes one day.

Regarding occupational success, client stated that currently he is able to perform the majority of

his daily living activities on his own and wakes up everyday feeling well-rested. However, he relies on his

aide or wife to help him reach his right armpit while showering, tie his tie, button his right arm cuff, and

put on his left shoe. He stated the only shoes he can get on independently are his shower shoes, and

while showering he has difficulty holding the shower head and leans on the door frame for support.

Also, he completed a driving rehabilitation program and stated that he can drive, but prefers to be

driven around. While at work, client reported he spends most of his time meeting with clients, but has

difficulty typing short emails that involve “technical” phrases and sorting through files. Additionally, he
uses a dictation app for longer emails. He said he has trouble remembering appointments and times and

finds that “bothersome.” He walks using a four point cane and wears an ankle-foot-orthosis.

He enjoys going to Jazz games and cheering on the Denver Broncos and has a genuine interest in

learning about ways to improve his functional independence. During the Canadian Occupational

Performance Measure (COPM), client stated that his main priorities are to dress more independently,

improve his typing abilities, reach his right armpit while showering, manage files at work, and improve

his scheduling management.

Administered Assessments:

The following assessments were administered:

 COPM: A semi-structured interview that identifies the client’s top occupational concerns and helps

establish goals and outcomes for therapy. In addition, the assessment looks at the client’s level of

satisfaction and performance in each specified area. The test was administered in a relatively quiet

room in the Life Skills Apartment.

o See results from the modified COPM in the table below.

Occupational Concerns/Priorities Performance Satisfaction

T1 T1
1. Dressing- buttoning right cuff, tying tie, & putting on left 1 2
shoe
2. Typing on computer at work
3 2
3. Showering- reaching all body parts 4 5
4. Paper management- filing 4 6
5. Scheduling- remembering appointments 7 5

TOTAL 19 20
Average Scores 3.8 4

 Action Research Arm Test (ARAT): A 19-item evaluative measure designed for people post-stroke

with hemiplegia. It assesses a person’s ability to manipulate objects of different shape, weight, and
size and detects specific changes in limb function. The assessment contains the following sub scales:

grasp, grip, pinch, and gross movement.

o Client engaged in the ARAT for approximately 15 minutes on 1/24/19. He was seated in

an armless chair and instructed to keep his feet on the ground and remain in an upright

position. He was given 60 seconds to complete each task using only his left hand.

Throughout the grasp subscale, client’s trunk and upper body leaned to the right, and his

left shoulder was hiked while attempting to grasp objects and place them on top of a raised

shelf. His shoulder did not go past about 110 degrees of forward flexion. He grasped the 10

cm block, but was not able to place it on top of the shelf. However, he was able to place the

remaining 5/6 items on the shelf, but performed “abnormally.” When grasping the

sharpening stone, the client dropped the stone from his hands one time before successfully

placing it on the shelf.

During the grip subscale, client had difficulty using his left arm to pour water from one

cup to another cup without using his right hand to stabilize, and he attempted the task two

times. On the second try he self-corrected his grip. He attempted to get the alloy tube on a

peg three times, but continuously overshot or undershot the target. He performed all 5 grip

tasks “abnormally”.

In the pinch subscale, client attempted to pinch the ball bearing in his 3rd finger and

thumb, but was not able to pick up the ball. He also attempted to pick up a marble with his

2nd finger and thumb, but was unable to do so without dropping the marble from his

fingertips.

During the gross movement subscale, client was unable to get past about 80 degrees of

shoulder abduction when attempting to touch his hand behind his head. When touching his
 hand on top of his head, he slumped down and flexed his neck, but was not able to reach his

head. Lastly, client successfully put his hand to his mouth.

o See results from the ARAT in the table below.

Scores range from 0-57. The higher the score, the better the performance.
Affected UE= LEFT
Grasp Subscale Total: 11
Grip Subscale Total: 8
Gross Movement Subscale 5
Total
TOTAL 24

Observations:

Client was observed completing the following tasks: typing, lower extremity dressing, and filing.

Client was observed performing a two-sentence typing task while seated in a chair with armrests

at a table. Client mainly typed with his right hand and primarily used his middle finger to touch the keys,

while his left hand rested flat on the table. Client was unaware of spelling errors until he had typed at

least two other words. In total, it took him two minutes to type eight words. Client stated that he relies

on his left hand to press the shift key and the letters “A” and “S”. No verbal cues were given throughout

observation to establish a baseline of how long it took for him to notice his errors.

Client was observed putting on his left sock and shoe while seated in a chair with no armrests.

Client attempted to put sock on his left foot for about one minute while bent over in his chair, but was

only able to get the sock over his big toe. When asked what sort of strategies he had used in the past to

put on his socks, he said he had tried sock aides, but felt they lacked efficiency. He then rested his left

leg on top of his right knee and required max assist to hold left leg on top of right knee. In this position

he attempted to thread his sock 6+ times using his right arm until succeeding. Once his sock was on, he
independently put his foot drop brace on using his right hand, and pushed his foot into his left shoe

while the shoe was stabilized by a fellow occupational therapy student. He required max assist to tie his

shoes. Throughout the observation, client stated that he had little to no sensation in his left limbs. When

his lower leg was lightly touched, he said he was barely able to feel it and only noticed that he was being

touched due to being aware of the tactile stimuli beforehand.

Client performed a filing task while seated in a chair with no armrest. He was asked to find the

file that said “office supplies” and to put the papers from the office file into the “banking statements”

file. Client performed the task with moderate speed and required no assistance to complete the task. He

used his right hand to open the office drawer and remove files and his left hand to stabilize the papers.

Client stated that if he was challenged to sort through multiple papers, that would be challenging for

him.

Assessment:

The Action Research Arm Test results, occupational observations, and the client’s priorities from

the COPM demonstrate that the client has deficits in sensory functions, muscle functions, and

movement functions. Collectively, the client’s high tone, spasticity, and lack of neural feedback on the

left side of his body interfere with his ability to perform motor skills, such as gripping, manipulating, and

reaching various task objects. These deficits affect the client’s ability to be efficient at work,

independent in his self-care tasks, and participate in meaningful leisure activities.

Client demonstrated decreased fine motor skills while performing the Action Research Arm Test.

He had trouble effectively grasping, gripping, or pinching the various objects. When he attempted to

make intended movements while aiming for the pegs, his lack of voluntary motor control hindered his

performance, causing him to miss the target on his first attempt. In addition, decreased motor control in

his upper extremity and fingers contributed to difficulties lifting heavier objects throughout the
assessment. In terms of gross motor movement and reaching overhead, the client’s high tone and

decreased motor control impacted his ability to achieve full range of motion while attempting to touch

his hand to the back and top of his head. The client’s lack of sensation in his hands also contributes to

difficulties manipulating small objects.

During the typing, filing, and dressing tasks, client displayed similar deficits. While typing, the

client’s lack of sensation and proprioceptive input on his left hand caused him to hit keys unintentionally

on the keyboard. Client demonstrated poor finger isolation while attempting to type, as noted by his

ability to use only three keys with his left hand. While dressing, client was unable to cross his left leg on

his right knee independently to thread socks due to lack of motor control in his left leg and high tone.

His lack of hand dexterity in his left hand also makes it difficult to manipulate socks with both hands and

hold onto his left shoe. Overall, the client’s lack of sensory input, decreased motor control, range of

motion, and difficulties incorporating bilateral movements affect his ability to participate in meaningful

occupations within his daily life.

The client’s greatest strength is his self-determination to regain function on the left side of his

body. The client has many supports to help him improve his occupational performance. He also has the

financial means to access a plethora of resources and receive advanced medical procedures. For

example, he stated that he is receiving a spinal cord stimulator on January 28th and has already had a

neurectomy performed in his left upper extremity. He identifies his spouse, trainer of 15 years, aides,

and therapists as being a major support. In terms of environmental supports, 85% of his home is

accessible on the main-floor. However, his home is currently on the market, so he can not make

structural changes to the house. While his aides are a great help, at times they hinder his ability to be

self-sufficient. He often relies on them to perform tasks that he is capable of doing, but chooses not to

because it is easier if they do it. Nonetheless, they offer him companionship and help him complete

activities at home and work.

Plan:

Practice Models: the following practice models will be used to guide treatment

 PEO: The Person-Environment-Occupation Model operates from a holistic viewpoint. The model

defines occupational performance as the result of the dynamic interaction between the person,

environment, and occupation (Law, 1996). When the person, environment, and occupation do

not have a dynamic transaction, dysfunction results (Law, 1996). Thus, PEO aims to achieve a

harmonious balance amongst the person, environment, and occupation by providing the “just

right” challenge. Currently, the client is no longer participating in work, leisure, and ADLs, such

as bathing and dressing at his prior level of function. The task demands of the activities exceed

his current physical abilities. Thus, PEO would find ways to adapt and modify his environment

(cultural, physical, social etc.) to match his current skills. In addition, PEO will also examine the

client’s social-emotional context. This is important because the client is likely still learning how

to cope with the loss of function on his left side. These modifications will improve the client’s

performance satisfaction and increase feelings of self-efficacy.

 Motor Control Model: The Motor Control Model aims to seek optimal solutions in improving

movement and motor control deficits considering the demands of the environment and the task

(Kielhofner, 2009). Being that this model is intended for people who have experienced central

nervous system deficits that result in a disruption of neural circuitry between the body and

brain, this is the perfect model for our client. Performing his desired occupations in the most

efficient way align with the model’s postulates of change. In addition, this model focuses on

specificity and repetition in order to promote transference of functional movements. By

establishing the client’s optimal movement patterns, occupational engagement will improve.
  Rehabilitative Model: This model incorporates assistive technology and adaptive equipment.

This model also focuses on ensuring that the client will return to the fullest possible physical,

social, mental, vocational, and economic functioning possible (Gillen, 2014). Being that we are

only seeing our client for a limited amount of time, it is likely that adaptive equipment will help

the client reach his goals in a sufficient manner.

 I chose to use the above practice models because they align with my client’s goals of improving

functional independence. People who have had a stroke typically present with motor control

deficits. The goal of therapy is to ensure that the client rebuilds and strengthens neural

pathways to enable occupation. However, the demands of the client’s desired goals exceed his

current physical abilities. Thus, the rehabilitation model will be used as a means of incorporating

adaptive devices and compensatory strategies to reach the client’s goals in the allotted

timeframe. Nonetheless, the client will be encouraged to practice the principles of motor

control and rely on their adaptive equipment only when necessary. Lastly, P-E-O ensures that I

always provide the “just right challenge”.

______________________________________________________________________________

It is recommended that the client receive skilled occupational therapy services at the University

of Utah’s Life Skills Apartment are recommended 1x/week for 60 minutes for 6 sessions to improve

upper extremity function. Self-care training, occupational activities, and therapeutic activities will be

used throughout therapy in an effort to improve movement functions, sensory functions, and motor

functions. Goals were established based on the client’s desires and interests expressed during the

COPM. Thus, goals are client-centered and were formulated in collaboration with the client. In addition,

the anticipated discharge environment was taken into consideration.

Intervention Goals:

 LTG1: By discharge, client will complete lower body dressing with modified independence.
 o STG1a: With modified independence, client will don crew socks within 3 weeks.

o STG2b: With modified independence, client will don tennis shoes within 4 weeks.

 LTG2: By discharge, client will demonstrate improved job performance by typing 5 words

correctly in succession.

o STG2a: Within 4 weeks, client will increase the number of keys used by the left hand

from 3 to 5.

o STG2b: Within 4 weeks, client will type 4 words without error using less than 1 verbal

prompt for attention.

We will address the client’s limited upper extremity function by working on repetitive

movements that are task specific in hopes of improving performance in self-care skills and typing skills.

This will involve incorporating movement of both upper extremities to increase use of his left extremity

during all activities. Occupation-based interventions will be used to improve ADL function, in addition to

repetitive task training.

We will establish what the most effective body positioning is for the client to get his shoe and

sock on. This will be done on a trial and error basis because trial and error learning has been found to

have better retention when used for learning how to don a sock with patients post-stroke (Mount et al.,

2007). The emphasis will be on arm and hand function for engagement in occupations. The client’s

interest will also drive the selection of the task used for repetitive training. Meaningful Task Specific

Training (MTST) has shown positive improvements at the post and follow-up assessments in comparison

to people who were trained using the Brunnstrom stage and Bobath neurodevelopmental technique

(Narayan et al., 2012). Meaningful Task Specific Training produced statistically significant improvements

in upper extremity motor recovery for patients post-stroke (Narayan et al., 2012). The goal will be to

maximize repetitions for reaching, grasping, pinching, and transporting meaningful items. The just right
challenge will be provided by grading activities up and down by altering the predictability of the

environment and changing the size, shape, and weight of items.

By providing the client with compensatory strategies, adaptive techniques, and Meaningful Task

Specific Training, the client will gain more functional independence throughout his everyday life. Client

will continue alternating between his home and condo. He will continue having full-time aides and his

wife at home to assist him. He will also continue receiving 6 hours of therapy a week outside of the

clinic. The skills learned in therapy will result in improved feelings of self-efficacy and life satisfaction.

Therapist Signature: Alexandria Marshall OTS Date __2/15/2019_

 References

Gillen, G. (2014). Occupational therapy interventions for individuals. In B. A. B. Schell, G. Gillen, M. E.

Scaffa, & E. S. Cohn (Eds.), Willard and Spackman's occupational therapy (12th ed., pp. 322-341). Formatted: Font: Italic

Philadelphia: Lippincott Williams & Wilkins.

Kielhofner G (2009) Conceptual foundations of occupational therapy practice. 4th ed. Philadelphia, PA: Formatted: Font: Italic

FA Davis.

Law, M., Cooper, B., Strong, S., Stewart, D., Rigby, P., & Letts, L. (1996). The person-environment-

occupation model: A transactive approach to occupational performance. Canadian Journal of

Occupational Therapy, 63(1), 219-234.

Mount, J., Pierce, S. R., Parker, J., DiEgidio, R., Woessner, R., & Spiegel, L. (2007). Trial and error versus

errorless learning of functional skills in patients with acute stroke. NeuroRehabilitation, 22(2),

123-132.

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.

Links to articles:

1.) Law https://journals.sagepub.com/doi/abs/10.1177/000841749906600304

https://doi.org/10.1177%2F000841749906600304

2.) Mount https://core.ac.uk/download/pdf/46965689.pdf

3.) Narayan https://www.tandfonline.com/doi/abs/10.1310/tsr1903-193

Gillen and Kielhofner are textbooks.