OCCUPATIONAL THERAPY EVALUATION REPORT AND INTERVENTION PLAN

Background Information: Client’s initials: K.A

Date of report: 02/02/18 Date of referral: Fall 2017
Date of Birth &/or age: 72
Primary intervention diagnosis/concern: R. CVA
Secondary diagnosis/concern: n/a
Precautions/contraindications: n/a
Reason for referral to OT:
o To improve function in L. UE to increase participation in ADL’s & IADL’s
Student Therapists: Alexa Holguin & Angie Blaser

S: Client reported that he is excited to be here and looking forward to therapy.

O: Client was seen on 01/25/18 and 02/01/18 for comprehensive OT evaluation. The following evaluations were
administered: modified COPM, Modified Ashworth Scale, sensation screenings for (Light touch,
proprioception, stereognosis) and observations of occupational performance.

Canadian Occupational Therapy Measure: is a semi-structured interview that measures client priorities for
intervention.
K.A was given a modified version of the COPM to identify areas of concern in self-care, productivity,
and leisure. K.A ranked the importance of identified occupational performance problems on a scale of 1-10. His
priorities ranked from highest to lowest included: being able to perform yard & household management tasks,
increasing efficiency with dressing, and improving effectiveness for preparing meals for his family.

Level of importance (1-not very important; 10-very important)

1. Participate in Yard/household management tasks (Shoveling snow) (8.5)
2. To get dressed more quickly in the morning (6)
3. Prepare meals for his family (7)

Modified Ashworth Scale (MAS): measures resistance during passive soft-tissue stretching to assess spasticity.

The MAS was performed on K. A’s affected left upper extremity while seated upright to measure degree of
spasticity on his affected side.

Scoring:
0 = no increase in tone
1 = slight increase in muscle tone, manifested by a catch and release or minimal resistance at the end of the
range of motion (ROM) when the affected part is moved in flexion or extension
1+ = slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the
remained of the ROM
2 = more marked increase in muscle tone throughout most of the ROM, but affected part(s) easily moved
3 = considerable increase in muscle tone, passive movement difficult
4= affected part is rigid in flexion or extension

Score 1 Elbow: start position: elbow was fully flexed with forearm in neutral. Movement: elbow was extended
rapidly from maximum possible flexion to maximum possible extension

Score 1 Wrist: start position: elbow extended, forearm in pronation. Movement: wrist was extended rapidly
from maximum possible flexion to maximum possible extension

Score 3 Fingers: start position: elbow extended, forearm in neutral. Movement: fingers were extended rapidly
from maximum possible flexion to maximum possible extension

Using the same protocol, resistance of stretch from pronation to supination was measured as an additional
measure:

Score 2: Wrist: start position: elbow extended, forearm pronated, movement: arm was rotated from maximum
pronation to maximum possible supination.

Sensory Examination: an assessment used to identify areas of abnormal sensation, type and extent of sensory
impairment. A sensory exam involves evaluating different types of sensation including: light touch, pain,
temperature, vibration, proprioception, and cortical sensation (stereognosia).

A condensed sensory exam evaluating light touch, proprioception, and stereognosia, were examined on
the client’s affected and non-affected UE’s. The client was instructed to close his eyes and respond with a “yes”
when he felt the cotton swab lightly touch his forearm, wrist, palm, and fingers. He was able to accurately
discriminate light touch. With the client’s eyes closed, he was able to accurately describe where his wrist and
fingers were in space (“up, neutral, or down”). For sterognosis, the client closed his eyes and was given the
following objects (Key, button, quarter, screw, paperclip) to explore and identify with his L. hand with physical
assistance from the student. He accurately identified all of the objects except the screw and paperclip with his L.
hand, mistaking them for plastic items.

Observation of performance: upper body dressing, feeding, cleaning, complex meal preparation
Dressing
Client was observed during an upper body dressing task while seated at EOB. Prior to the session, he
was contacted and was reminded to bring various types of upper body clothing items (pull over, jacket, button-
up). When he arrived at the session, he mentioned he left the items in the car. Due to his request for modesty, he
was asked to don and doff his snap up shirt that he came into therapy wearing, without removing his undershirt.
During this task he took frequent breaks, his face became flushed, and he made several attempts before he could
flatten out the collar on his shirt. He was independent in doing so, utilizing a modified one-handed dressing
technique (while his L. hand hung by his side with a clenched fist) within 8 minutes. Next, he demonstrated his
ability to tie his R. shoe using a one-handed technique independently.

Simple snack and Feeding

Client reached for plates with his L. hand by hiking his L shoulder, and transported them with two hands
from the cupboards to the table. While transporting a can of fruit from the kitchen counter to the dining table, he
lost grip and dropped the item. While standing at the table, K.A used his R. non-affected hand to manipulate the
can opener and his L. hand to stabilize. He was successful on his first attempt, despite his apprehension to the
task. The client then reached with his hand to peel back the top, cutting his L. thumb and he was given a Band-
Aid and ointment. The subsequent can was opened for him and he was able to independently self-feed. K.A
was given a butter knife to simulate how he uses both UE’s in a cutting task. He proceeded by piercing the
peach with the fork in his R. hand, switching the utensil into his left as he grasped and manipulate the knife with
his non-affected R. hand.

Household cleaning tasks

Client used a swifter to dust/mop the kitchen floor. He was able to do this independently with a modified
grasp. Client displayed concerns in his lack of supination with his L. hand, which makes this grip pattern more
difficult when there is an external load applied (such as in shoveling).

Complex meal preparation

 Client was observed making a complex meal. First, he was taken through a pre-reflection, prompted
with the questions, “how do you think this task will go?”, “do you think you think any aspects will be
challenging”? “will you need help?” K. A responds that he doesn’t foresee any potential challenges. Next, he
was asked to open the Pillsbury dough pizza crust. He used his R. hand to pull the tab and his L. hand as a
stabilizer. When rolling out the dough he required extra time and minimum direct verbal cueing to problem
solve how to roll out the dough smoothly to cover the surface of the pan and how to orient it so the dough
wasn’t twisted in the center. He then was asked, what the next steps would be and he responded with sauce,
peperoni, cheese, and olives. He proceeded to open the jar of pasta sauce independently using his legs to grip
the jar and his R. hand to twist it open. He required physical guidance when opening the meat, as his stabilizing
hand was in line with the scissors, which appeared unsafe. After this, he proceeded to layered his pizza with the
olives under the cheese, deviating from the order he previously mentioned. He transported the pan with two
hands to the oven and attempted to put the pan in, but he had to have moderate physical assistance to safely
place the item on the rack. When using a knife to slice pizza, he required mod. verbal prompts and physical cues
to grasp the knife correctly with his R. hand. While eating, the client was guided through a post reflection. He
did not think the activity was challenging, but when prompted about difficult tasks, he responded that opening
packages has always been hard and at home he would not use his L. hand as much.
Occupational Profile
K.A is a 72-year old retired firefighter who was diagnosed with a R. CVA on July 4th, 2016, two weeks
after he fell and hit his head. He has five grown children and currently resides in a single-family home in Salt
Lake City with his wife and older granddaughter. Since his CVA, K.A has been experiencing hemiparesis, high-
tone, and spasticity in his LUE. Within the past 3-4 months, K.A has regained elbow flexion; However, his L.
hand, “lefty” as he calls it, has maintained its chronic fisted position, negatively impacting its functional use
during ADL’s and IADL’s. K.A reports that at times he feels like he does not have control of the actions of his
L. hand.
K. A’s personal strengths include his light-hearted sense of humor, perseverant nature, and optimistic
attitude. K.A has a wide range of interests including: fly fishing, watching college football, spending time with
family, and assembling puzzles. Current occupations K.A engages in well include: showering, teeth-brushing,
shaving, tying his shoes one handed, donning a loose snap-up shirt with a modified one-handed technique,
driving with an adaptive steering wheel, and communication management. K.A is independent in many
occupations, but is dissatisfied with how much time and physical effort ADL’s, like dressing, and IADL’s, meal
preparation and home & yard maintenance, require. Prior to his injury, K.A volunteered at the LDS temple. He
valued working with his hands to build toys for his grandkids, perform auto work, and care for his lawn, but
these tasks have become too difficult for him to complete on his own.
K.A has many supports in place including: 1) receiving weekly outpatient occupational therapy services
at the Sugarhouse Rehabilitation Center 2) participating in therapeutic recreation (boxing, yoga, ballet & Tai-
chi) at the PT Pro Bono Clinic at the University of Utah 3) having a large extended family who live close by,
and 4) having a supportive church community. Barriers to his occupational performance include 1) reduced
endurance 2) impulsivity 3) impaired LUE coordination and control 4) reduced problem solving and motor
planning and 5) having less opportunities at home to practice independence in the kitchen, as his wife dissuades
him from helping with meal preparation.
K.A was recruited to participate in additional occupational therapy services to gain motor control and
functional use of his LUE to increase participation in meaningful ADL’s and IADL’s. Priorities for intervention
include increasing participation in yard/home maintenance tasks like shoveling snow, increasing efficiency with
dressing routine and improve effectiveness with meal preparation tasks so he can cook a meal for himself and
his family.

A:
Areas of occupation: home/yard management, meal preparation, dressing

Performance skill deficits: Endurance, reach, transporting, lifting heavy objects, manipulating objects with
distal LUE, distal LUE coordination, bilateral integration, crossing midline, fine motor control with distal LUE,
sequencing, attending, pacing, using

Performance patterns: habits: compensates with his RUE for all tasks, hikes L. shoulder when engaging distal
LUE. Uses L. hand as a stabilizer, despite his L hand having a more ambidextrous role in the past. Attends
church every Sunday. Routines: receives outpatient OT on Wednesdays and Thursdays. Participates in weekly
recreation activities with through PT. Roles: grandfather, father, husband, friend.

Client factors: ROM in bilateral shoulders and elbows appear to be functional, limited supination/hand,
dexterity, distal motor control of distal LUE. High tone (spasticity) in LUE impacting ROM and bimanual
coordination. Reduced judgement, increased impulsivity, reduced insight of abilities, reduced problem solving,
motor planning, easily distracted, mild decreased sensation perception on distal LUE
Activity demands:
Contexts:
o Cultural: n/a
o personal: 72, retiree, married
o Temporal: 1 year, 7 months post CVA, within past 3-4 months has regained elbow flexion
o Virtual: uses phone to make calls and text
o Social: has friends, attended stroke camp, member of LDS church, lives with wife and granddaughter,
lives close to extended family, attends outpatient therapies.
o physical- has modified steering wheel knob in his truck so he can drive independently and wears loose-
snap up shirts often.
From the COPM, the client’s priorities were revealed and his concerns about his reduced efficiency with
dressing, yard/home management, and cooking due to his paresis and high tone in his LUE. From the Modified
Ashworth spasticity screening, K. A’s report of improved proximal LUE tone was observed as he was taken
through passive elbow and wrist flexion/extension with minimal resistance. His concerns of limited supination
and hand dexterity were observed and it was noted that these muscles had persisting resistance (tone), making
PROM more difficult. During observation of occupational performance, it was observed that K.A frequently
bumped his L. UE into the table, so further sensory testing was done to see if he could discriminate light touch,
body positioning, and sterognosis. He was able to accurately identify light touch and proprioception, but had
some difficulty with stereognosis, which could have been impacted by his lack of hand dexterity which
inhibited from exploring the objects on his own or he could have minimal sensory perception deficits when
additional sensory cues are not available, such as sight.
During ADL observation, process skill deficits including: sequencing, attending, using objects correctly,
and accommodating were seen. During dressing and cooking, the client demonstrated increased distractibility as
he required frequent verbal prompts to carry out and complete steps in dressing routine. His heightened
distractibility could have been tactfully used to divert attention from a non-preferred task, or it could be
secondary to his stroke. When making pizza, the client was unable to follow the steps he had first repeated, and
appeared to apply toppings in a random order. Client also demonstrated problem solving difficulties with motor
planning to effectively and safely execute opening food packaging, cutting with scissors, and manipulating a
knife as intended. These problem-solving difficulties may be slowing down K. A’s ability to complete tasks
within a reasonable amount of time and appropriate level of physical exertion. Impaired motor skills
(coordination, grip, control, transportation, endurance) were also observed due to high tone and weakness in the
distal LUE impairing performance in bimanual tasks including: dressing, meal preparation, woodworking,
shoveling, etc. Reduced endurance was most evident during dressing, while reaching behind head to pull collar
down while standing upright as he became flushed and took multiple breaks throughout the task.

Supports & barriers

Client has a great number of supports in place. He is very motivated to participate in therapy, has a
supportive family, attends weekly recreation and OT services. He also has a function R. hand which was his
dominant hand, so his autonomy has been persevered for many IADL’s and ADL’s with compensatory
techniques and extra time. Barriers to client’s performance include his high tone, spasticity, weakness in his L.
hand, reduced endurance, impulsivity, and secondary reduced safety judgement which is impacting his ability to
efficiently and effectively perform meaningful ADL’s and IADL’s. Client expresses interest in getting back to
cooking, but he has told us he wife doesn’t include him in meal prep tasks and will often cut up his food for him
when they are eating out.
P:
Treatment approaches:
Task oriented approach to:
o Restore UE movement to enable transfer of cooking materials around kitchen
o Restore UE motor control to improve efficiency with ADL’s and IADL’s
o Compensation: teach energy conservation strategies to increase endurance for ADL’s and IADL’s
o Modify- provide modifications and AE to improve efficiency with securing clothing fasteners and
opening jars/cans/packages (button hooks, AE can opener)

Preparatory tasks to:

o Maintain L UE hand function through routine hand stretching and functional weight bearing

Preissner, K. (2010). Use of the occupational therapy task-oriented approach to optimize the motor performance
of a client with cognitive limitations. American Journal of Occupational Therapy, 64(5), 727-734.

o Summary: The task oriented approach is a preferred intervention method for improving occupational
performance in clients with a diagnosis of CVA. This approach is based on the following
assumptions/postulates 1) functional tasks help to organize motor behavior 2) motor behaviors are a
result of the transaction between an individual and their environment 3) exploration and practice are the
means in which people organize motor patterns. Treatment principles include: helping the client adjust
 to limitations, simulating common challenges that arise in everyday life to target in Tx, practicing
functional tasks to find effective and efficient strategies, minimizing ineffective motor patterns by
remediating, compensating, adapting and reducing activity demands, and using motor learning
principles, etc. After a 4-week team-based intervention, the client in this case was d/c home with her
daughter, met 7/9 ADL goals (transferring, toileting, simple meal prep.etc.), and increased her
participation in meaningful occupations after hospitalization for a CVA.

Seo, N. J., Rymer, W. Z., & Kamper, D. G. (2009). Delays in grip initiation and termination in persons with
stroke: effects of arm support and active muscle stretch exercise. Journal of neurophysiology, 101(6), 3108-
3115.
o This article found active muscle stretch exercise including: flexion/extension of the shoulder, elbow,
wrist and fingers; supination/pronation, thumb abduction and adduction, shoulder abduction/adduction
and external and internal rotation held for five seconds and completed for ten repetitions improved grasp
functioning in paretic UE’s. Following this 30-minute protocol, the time required for an individual to
grip and release an object with their paretic hand reduced by 24% and 32% respectively. Improving the
affected extremities ability to grasp and release objects increases functional use and independence in
ADL’s and IADL’s. Stretching can be used as a preparatory task to provide some grip function during
occupational task performance.

Organizing Model: PEO

o This is a transactional model that assesses the congruence between the person, environment and
occupation by 1. Identifying K. A’s enabling and inhibiting client factors and skills (level of motivation,
degree of spasticity, endurance, dexterity, motor control 2) environmental supports and barriers (AE,
family dynamic, home-layout, available resources and 3) activity demands of dressing, meal prep, and
home/yard management occupations

Complimentary Model: Motor Control/Motor Learning

o By enhancing K. A’s problem-solving abilities to find solutions in daily life and to restore stable motor
patterns in his LUE needed to coordinate and control movements to open food packaging, cut with a
knife/scissors, and incorporate his L hand into bimanual tasks.

Complimentary Model: Rehabilitation

 o Focus on K. A’s current capabilities utilizing the principles of adaption, compensation and/or
modification to promote independence in dressing, meal preparation, and home management tasks.

Complimentary Model:
Dynamic Interactional Model (DIM)
o To improve K. A’s ability to anticipate, monitor, and verify accuracy of performance to increase
participation in meal preparation tasks. In the DIM model, performance is improved by changing the
demands of the activity, the environment, application of strategies, and self-awareness.

Goals:
LTG 1: Within 6 weeks, client will I complete upper body dressing utilizing compensatory strategies within a
reasonable amount of time per client report.

STG 1a: Within 3 weeks client will improve UE bilateral coordination to don a button up shirt with minA and
compensatory strategies as needed.

STG 1b: Within 3 weeks client will improve grip with his L. hand to don a tie with min VP.

LTG 2: Within 6 weeks client will safely prepare a complex stovetop meal with minA.

STG 2a: Within 4 weeks, client will improve problem solving to effectively complete a cooking task in a logical
manner utilizing cognitive strategies.

STG 2b: Within 4 weeks, client will attend to a meal preparation task with 3 or fewer redirections.

Expected frequency, duration, intensity: Client will be seen for 1 hour, 1X per week for 6 weeks.
Location of Intervention: Health professions Education Building (first floor apartment)
Anticipated D/C: 04/13/18

Sign and Date: Alexa Holguin 02/03/18