CEREBROVASCULAR

ACCIDENT

CVA

nontraumatic brain injury

occlusion or rupture of cerebral blood vessel that

results in sudden neurologic deficit

loss of motor control, altered sensation, cognitive or

language impairment, disequilibrium, or coma

Epidemiology

third leading cause of death

Male > Female - 65 and 74.

women over 85 years of age

65 years old and above

Asian > US

Risk Factor
Non- modifiable

Age

Sex

Race

Hereditary

Modifiable risk factors

Hypertension

Heart Disease

Smoking

Hypercholesterolemia

Diabetes Mellitus

Lifestyle factors

Etiology

Etiology

Hemorrhagic-15%

It occurs due to bleeding that results from rupture of

specific vessels or arteries in the brain.

Ischemic -85%

It is the result of thrombus formation or embolism to the

brain from cardiac or arterial sources that results to loss of
blood flow/oxygen.

Ischemic stroke

Thrombosis - occlusion of a vessel, usually as a result of

atherosclerosis.

Embolism - dislodged platelets, cholesterol, or other

material that travels in the bloodstream and blocks a vessel.

Lacunar strokes - small, circumscribed lesions that measure

less than 1.5 cm in diameter and are located in subcortical
regions of the basal ganglia, internal capsule, pons, and
cerebellum, thalamus.

Hemorrhagic Stroke

Intracerebral (bleeding into the brain itself)

Subarachnoid (bleeding into an area surrounding the brain)

Both types may be caused by hypertension, arteriovenous

malformation, or aneurysm

AFFECTED AREA

AREA AFFECTED

Thalamus

The lateralisation of the thalamic functions affects both sensory

and motoric aspects.

Infarction or haemorrhage thalamic lesion can develop

somatosensory disturbances and/or central pain in the opposite
hemibody, analgesic or purely algesic thalamic syndrome
characterised by contralateral anaesthesia (or hypaesthesia) or
contralateral weakness, ataxia and, often, persistent
spontaneous pain.

AFFECTED AREA

AREA AFFECTED

Basal ganglia

Basal ganglia are involved in many neuronal pathways having

emotional, motivational, associative and cognitive functions as well.

Involvement of the basal ganglia is related to involuntary and

stereotyped movements or paucity of movements without
involvement of voluntary motor functions.The symptoms differ with
the location of the lesion. The commonest disturbances in basal
ganglia lesions are abulia (apathy with loss of initiative and of
spontaneous thought and emotional responses) and dystonia, which
become manifest as behavioural and motor disturbances,
respectively.

PRESENTATION BASED ON THE

LOCATION OF INFARCTION
Name
Pure motor stroke/hemiparesis
(most common lacunar
syndrome: 33-50%)

Location of infarct
posterior limb of the internal
capsule, basis pontis, corona
radiata

Ataxic hemiparesis (second

most frequent lacunar
syndrome)

posterior limb of the internal

capsule basis pontis and corona
radiate, red nucleus, lentiform
nucleus, SCA infarcts, ACA infarcts

Dysarthria/clumsy hand (ataxic

hemiparesis)

basis pontis, anterior limb or genu

of internal capsule, corona radiata,

basal ganglia and

thalamus, cerebral peduncle
Pure sensory stroke

contralateral thalamus, internal

capsule, corona radiata, midbrain

Mixed sensorimotor stroke

thalamus ,adjacent posterior

internal capsule, lateral pons

Presentation
It is marked by hemiparesis or
hemiplegia that typically affects the
face, arm, or leg of the
contralateral side. Dysarthria,
dysphagia, and transient sensory
symptoms may also be present.
It displays a combination of
cerebellar and motor symptoms,
including weakness and clumsiness,
on the ipsilateral side of the body. It
usually affects the leg more than it
does the arm; hence, it is known
also as homolateral ataxia and
crural paresis. The onset of
symptoms is often over hours or
days.
The main symptoms are dysarthria
and clumsiness (i.e., weakness) of
the hand or
hemiparesis/hemiplegia.
Marked by persistent or transient
numbness, tingling, pain, burning,
or another unpleasant sensation on
one side of the body.
This lacunar syndrome involves
hemiparesis or hemiplegia with

Neurological Complications
and Associated Conditions of
Stroke:
Altered Consciousness

Disorders of Speech and Language

Dysphagia

Cognitive Dysfunction

Altered Emotional State

Perceptual Dysfunction

Bladder and Bowel Dysfunction

Cardiovascular and Pulmonary Dysfunction

Deep Venous Thrombosis and Pulmonary Embolus

Osteoporosis and Fracture Risk.

DIFFERENTIAL DIAGNOSIS

Cerebral Tumor

Seizure

Sepsis

PROGNOSIS

Recovery of function following stroke occurs most rapidly during the

first 13 months, but slower improvement can continue for up to a
year (Wade(1992),. Plateaus in recovery often reflect the
insensitivity of measurement scales to incremental improvements
rather than a patients reduced potential for learning new tasks or
gaining skill (Dobkin, 2005). Multiple studies have shown that
patients more than 1 year post stroke can exhibit substantial motor
and functional improvement after participation in novel rehabilitation
protocols (Page, Gater, & Bach-y-Rita, 2004). Individual stroke
survivors who have successfully resumed life roles or taken on new
ones report the process of recovery as continuing years after onset
of stroke, with gains reported both in component skills and
occupational performance (Buscherhof, 1998; Matola, 2001).

DEMOGRAPHIC DATA
NAME
AGE:

: L.T

74 years old

GENDER:

Female

Diagnosis:

Left Thalamo-ganglionic (Thalamobasal ganglionic area) CVA

HISTORY OF PRESENT ILLNESS

April 29, 2015 in the evening, the client was seen by her daughter
lying in the bathroom in her condominium. The client was seen to have
a wound in her right ear, hand and foot and was not able to move her
right side of her body. The client was immediately brought on
Metropolitan Medical Center. They checked the blood pressure of the
client which is unrecalled. She was immediately admitted to Intensive
care unit and undergone several test (unrecalled). After several test,
the client was diagnosed with L thalamo-ganglionic cerebrovascular
accident and the caregiver stated that the client also experienced
heart attack. The next day after the incident around 3 AM, The client
was already awake and she was able to mouth words but was not able
to produce sound when talking. Around 5 AM, the client had
experienced difficulty in breathing. The doctor suggested to the
caregiver that the client needs to undergo operation (tracheostomy)

HISTORY OF PRESENT ILLNESS

May 2, 2015, the client undergo tracheostomy on the next day.

They stayed at ICU until the 2nd week of May.

May 2015, the oxygen was removed and the doctor gave the
client a referral for an OT and PT session in Metropolitan Medical
Center. The client started to attend OT session daily for
dysphagia management.

June 2015, the NGT was removed and within the same month she
was operated to have a PEG. 1 year PTIE, the client started to
have OT session regarding her UE weakness until now. The client
is currently taking several medicines daily (flumuicil, evetra and
other meds).

MEDICAL HISTORY

According to the caregiver, the client does not have any vices
before and she does not eat too much fatty foods. She prefers to
eat seafood such as fish, shrimp and squid. Her family had no
history of CVA, cancer, diabetes and other condition except for
hypertension. The client also has undergone eye surgery due to
her cataracts. The client was also taking medicine for
hypertension before but not regularly. The daughter of the client
stated that the client has undergone eye surgery due to her
cataracts. The client was also taking medicine for hypertension
before but not regularly.

CHIEF COMPLAINT

The caregiver stated that Hindi pa niya nagagamit yung kanang

kamay niya, tapos sa kaliwang kamay medyo hirap pa siya
isarado ng todo kaya hindi niya masyado matulungan yung sarili
niya sa mga simpleng gawain.

The client mouthed mahina while pointing on her RUE and eto
pa while demonstrating the LOM her L hand.

GOAL

The caregiver stated Yun nga, na matulungan niya yung sarili

niya na kahit makatulong siya sa pangaraw araw na Gawain
katulan ng paliligo at pagsusuklay at yung mag-improve pa yung
kaliwang kamay niya, tsaka medyo magkaron ng improvement
yung kanang kamay niya kahit makatulong lang nang konti kasi
sanay siya dati ng magisa.

The client mouthed Lumakas, Makatulong and she moved her

BUE.

OCCUPATIONAL HISTORY
Work/Vocational History

The client owns a grocery store.

Avocational History (leisure interests and pursuits)

The client used to go to different churches in different places.

She also used to cook and clean her condominium.

ADLS
Premorid

Postmorbid

According to the caregiver, the client

primarily uses her left hand in
handling the shower, reaching and
putting back the shampoo and soap.
The client rinses and lathers
shampoo into her hair. She uses
soap to her body using both of her
hands. She usually takes up to 15
minutes and does it while standing
and independently.

The client was dependent on her

caregiver. During bathing, the caregiver
bathes the client while lying on her bed.
The client just cooperates in raising her
L arm and moving her body from supine
position to sidelying.

Bathing

ADLS
Toileting, Toilet hygiene
According to the caregiver, the client
can remove her undergarments first
before defecating and unzip the pants
and lower down the underwear
before urinating. She does not have
any problem in maintaining toileting
position and in controlling her bowel
movement and urination. When done,
she was also able to grab and use the
bidet using her left hand and her right
hand is used to wash his bum
independently.

The client is diaper clad. The client was

dependent on her caregiver in cleaning
her bum and in changing her diaper. But
she was able to say to the caregiver if
she will defecate or urinate.

ADLS
Dressing
The client was able to dress herself
independently. She usually put the
lower garments first before the upper
garments. She does not have any
problem with putting on her shoes.

The client is dependent on her caregiver in

donning and doffing her hospital gown,
shoes, socks and diaper.

ADLS
Swallowing, eating
She does not have any problem
with swallowing and chewing. She
can tolerate all kinds of food.

The client eats food orally 4 times a

day and 2 times a day in her PEG.
The client can eat yogurt, soup,
vegetables, fish, chopped chicken and
rice. She can also drink water without
spillage.

ADLS
Functional mobility
The client mostly walks within her condo and
experiences no difficulty in transferring objects from
one place to another.

The client is a wheelchair user but needs someone to push

the wheelchair for her.

ADLS
Personal hygiene, Grooming
The client was able to brush her
teeth, comb her hair and cut her nails
independently. The client was
conscious about her grooming and
she was able to apply deodorant and
perfume when going somewhere.

The client was dependent on her

caregiver on her personal grooming. In
brushing, the caregiver is the one who
will pour bactidol on the clients mouth
and the client will gurgle and spit it.
While in cutting nails and combing her
hair, the caregiver is the one who does
it for the client.

IADL
Premorbid
Driving and Community Mobility
The client was used to go to different
churches in different places via public
transportation.

Postmorbid
The client is unable to go out independently.

Health Management
She seldom go to the hospital for checkups
She attends OT and PT session and She takes
and she does not drink her medicine regularly. her medicines regularly with the help of the
But she walks a lot with her church mates
caregiver.
when they have a free time. She also likes to
eat vegetables and fruits.
Meal preparation and clean up
The client often cooks lunch for her children
and grandchildren.

The client was not able to prepare meal due to

her condition.

Religious and Spiritual activities and expression

She always attends mass and religious
activities in different churches.

She cannot go to church anymore.

ACTIVITIES GIVEN

Interview

Gripping and pinching digiflex

Stacking of cones and Elevated stacking cones

Transferring of balls (RCGR)

Theraputty on beads
Picking up chips and cubes

Wristroller

Translation of pegs

Twisting pipe

Putting clothes pin on the clothes pin tower .

Writing activity (name. date, place, birthday and signature)

Evaluation Tool

Sensory Evaluattion

MMT

ROM

Standardized tool

FIM

Ashworth Scale

CLIENT FACTORS- ROM

All ROM of BUE are WNL upon PROM except for:
JOINTS
(LEFT
UNAFFE
CTED
SIDE)
Shoulder
Flexion
Shoulder
Abductio
n
Wrist
Extensio
n
2nd MCP
Flexion
3rd MCP
Flexion
4th MCP
Flexion
5th MCP
Flexion

PROM

AROM

NORMS

CAUSE

0-130

0-90

0-180

Muscle tightness

0-150

0-75

0-180

Muscle tightness

0-55

0-35

0-80

Muscle tightness

0-60

0-60

0-90

Muscle tightness

0-55

0-50

0-90

Muscle tightness

0-55

0-45

0-90

Muscle tightness

0-55

0-50

0-90

Muscle tightness

JOINTS
(AFFFECTE
D- RIGHT)
Shoulder
Flexion
Shoulder
Abduction
Forearm
Supination
Wrist
Extension
2nd MCP
Flexion
3rd MCP
Flexion
4th MCP
Flexion
5th MCP
Flexion
2nd PIP
Flexion
3rd PIP
Flexion
4th PIP
Flexion
5th PIP
Flexion
Thumb
abduction

PROM

AROM

120. 0-60

NORMS

CAUSE

0-180

Muscle tightness and pain

0-150

0-50

0-180

Muscle tightness and pain

0-60

0-40

0-80

Muscle tightness and pain

0-40

0-80

Muscle tightness and pain

0-60

0-45

0-90

Muscle tightness and pain

0-40

0-30

0-90

Muscle tightness and pain

0-20

0-15

0-90

Muscle tightness and pain

0-30

0-20

0-90

Muscle tightness and pain

0-45

0-20

0-100

Muscle tightness and pain

0 -65

0 -40

0-100

Muscle tightness and pain

65 -80

65- 75

0-100

Muscle tightness and pain

50-100

50-80

0-100

Muscle tightness and pain

0-50

0-35

0-70

Muscle tightness and pain

CLIENT FACTORS MUSCLE STRENGTH

MOVEMENT (Affected side)
Shoulder flexion
Shoulder abduction
Elbow flexion
Elbow extension
Wrist flexion
Wrist extension
MCP flexion
MCP extension
IP flexion
MOVEMENT ( Unaffected
side)
Shoulder flexion
Shoulder abduction
Elbow flexion
Elbow extension
Wrist flexion
Wrist extension
MCP flexion
MCP extension
IP flexion
IP extension

GRADE
3-/5
3-/5
4/5
4/5
5/5
1/5
3-/5
5/5
3-/5
GRADE
3-/5
3-/5
5/5
5/5
5/5
3-/5
3-/5
5/5
5/5
5/5

Muscle bulk no atrophy/hypertrophy as compared to (N)

extremity

Muscle tone Normotonic in BUE

Muscle Function
HAND DYNAMOMETER

FUNCTIONAL ASSESSMENT

Affected
Unaffected
Extremity:
Extremity
(R)

Standardized tool is not

available in the center.
Further evaluation needed
to gather the data.

Affected Extremity: (R)

Unaffected Extremity

A. The client was not

able to grip the
yellow digiflex due
to muscle tightness.

P- The client was able

to grip the blue digiflex
10x but was not able to
maintain it

Muscle Function
PINCH GAUGE

FUNCTIONAL ASSESSMENT
(Digiflex was used and functional activity)
Affected
Unaffected Affected
Unaffected
Affected
Unaffected
Extremity: (R)
Extremity
Extremity: (R)
Extremity
Extremity:
Extremity
(Yellow
(Blue digiflex)
(R)

Digiflex)

**0k * **0k 3.2 3.2 3.2 ABSENT- the GOOD- The

g
* g
kg
kg
kg
client was
client was

0
not able to
able to get
Standardized tool is
k
assume,
her beads on
not available in the
g
maintain
the
center. Further
and use
theraputty
evaluation needed to
beads using using tip to
gather the data.
tip to tip FPP. tip FPP. She
It was
was able to
observed
assume,
that there is maintain
difficulty in
and use tip
finger
to tip.
flexion due
to LOM and

Muscle Function

Pad to pad

*<0.7
kg

*<0.7
kg

*<0.7
kg

3.2 kg

3.2 kg

3.2 kg

ABSENT- The client

was not able to
assume, maintain
and use pegs
using pad to pad
FPP. It was
observed that the
client gets the
peg using her
thumb and the
side of the 2nd
proximal phalanx
with noted
difficulty in finger
flexion due to LOM
and muscle
tightness

GOOD- The client

was able to
maintain, assume
and use the pegs
to put it on the
board using pad to
pad.

3.2 kg

3.2 kg

ABSENT The client

was not able to
assume, maintain
and use the wooden
cubes using tripod
FPP. It was observed
to hold the cubes
using her thumb and
the side of the 2nd
proximal phalanx
with noted difficulty
in finger flexion due

GOOD The client

was able to assume,
maintain and use big
chips to shoot on the
hole using lateral FPP
in shooting.

Standardized tool is not

available in the center.
Further evaluation
needed to gather the
data.

*<0.7 kg *<0.7 kg *<0.7 kg 3.2 kg

Lateral
Pinch

Muscle Function
Tripod

*<0.7
kg

*<0.7
kg

*<0.7
kg

3.2
kg

3.2
kg

3.2
kg

ABSENT The
client was not
able to
assume,
maintain and
use the
wooden cubes
using tripod
FPP. It was
observed to
hold the cubes
using her
thumb and the
side of the 2nd
proximal
phalanx with
noted
difficulty in
finger flexion
due to LOM
and muscle
contractures.

GOOD- The
client was able
to assume,
maintain and
use wooden
cubes to
transfer it on
the container
using 1st, 2nd
and 3rd fingers.

Muscle Function
GROSS PREHENSION PATTERN OF
AFFECTED EXTREMITY
Spherical

Cylindrical

Hook

FUNCTIONAL ASSESSMENT
Affected Extremity : (R)
ABSENT - The client was not able to
assume, maintain and use spherical
grasp in holding the ball. It was
observed that the client holds the
ball using mass grasp with noted
difficulty.
ABSENT The client was not able to
assume, maintain and use
cylindrical grasp. It was observed
that the client holds the cone using
mass grasp with noted difficulty in
maintaining it.
ABSENT The client was not able to
assume, maintain and use hook
grasp. It was observed that she
client was not able to flex her finger
to hold the handle of the basket.

Unaffected Extremity
GOOD The client was able to
assume, maintain and use the ball
using spherical grasp without
difficulty.

GOOD- The client was able to

assume, maintain and use the cone
using cylindrical grasp without
difficulty.

GOOD The client was able to

assume maintain and use the
basket using hook grasp without
difficulty.

Muscle Function
IN-HAND MANIPULATION (poor or good)

Affected Extremity : (R)

Finger to palm

POOR- The client was not able to

translate finger to palm due to LOM,
muscle tightness and weakness.

Palm to finger

POOR- The client was not able to

translate palm to finger due to LOM
and muscle tightness.

Shifting

POOR- The client was not able to

move the pegs upward using her
index and thumb due to LOM and
muscle contracture
POOR- The client was not able to
rotate objects due to LOM and
muscle weakness

Simple rotation
Complex rotation

Unaffected Extremity
POOR - The client was able to get the
pegs on the board using her fingers
and translate in to her palm with
noted difficulty in MCP finger flexion
due to muscle tightness
POOR- The client was able to put the
pegs from his palm to finger with
moderate difficulty. There was noted
to have drops due to muscle
tightness
GOOD- The client was able to move
the pegs upward using her index and
thumb.
GOOD The client was able to pick
up the ballpen from the table, rotate
and position it in a writing position.
Complex rotation was not assessed.

Sensory Function
SENSATION
Visual functions
Hearing functions
Vestibular functions
Taste functions
Smell functions
Proprioceptive functions

Touch functions

Client was able to read clearly. Patient has no problems with visual field, visual tracking, oculomotor and
saccades.
There are no problems with hearing since client can hear us clearly. The client can also recognize the sound
with adequacy, determine range of sounds and their origin.
The client has problems with her balance in terms of sitting, standing. She cannot assume the position
independently.
The client said that she was able to taste the food in sweet, sour, bitter and salty foods. Further evaluation is
needed.
The client stated that theres no problem in her sense of smell. Further evaluation is needed.
The client has intact position and movement sense. Client was able to imitate movements done on her affected
side to her unaffected side with her vision directed to the other side where movement is being executed. The
client was also able to identify what movement is done to her arm and hand.
The therapist conducted light touch using cotton bud on random areas of her affected forearm and hands. The
client was able to recognize and localize 7/10 stimuli.

Pain

Using a neurological hammer with sharp and dull end, Lightly applying sharp stimulus by using the end of the
reflex hammer and applying dull stimulus by using the head of the hammer itself. Client was able to identify
5/5 applied sharp stimulus and identify 5/5 dull stimulus on the dorsal side of her hand and FA. Client was able
to identify all sharp (5/5) and dull (5/5) stimulus on the volar area of the hand and FA.

Sensitivity to temperature
and pressure

The therapist conducted deep pressure test for pressured touch using cotton bud on random areas of her
affected forearm and hands. The client was able to recognize and localize 9/10 stimuli.


GLOBAL MENTAL FUNCTIONS
Energy

and Drive

SPECIFIC MENTAL FUNCTION

Memory short term memory

Performance Skills
Poor motor skills:
Aligns
Stabilizes
Positions
Bends
Reaches
Manipulates
Grip

(R)

Coordinates
Moves
Lift

(R)

Walks
Flows(R)
Transports
Calibrates
Endures
Paces

(R)

Performance Skills
Good motor skills on specifically:

Grip (L)

Manipulates (L)

Lifts (L)

Calibrates (L)

Move (L)

Paces (L )

Performance Skills
Process skills:

Navigates (R)

Social Interaction Skills:

Produces speech

Speaks fluenty

Performance Pattern

ROLES

HABITS

RITUALS

PREMORBID

CURRENT

As a mother and grandmother, she is a caring

and loving. She usually cook for her children
and grandchildren.

As a friend, she is trustworthy and reliable.

She always make sure that she does not do
any unnecessary things that may cause
trouble.

The client takes a bath in the evening

The client watches TV before he sleeps.
The client drinks coffee every morning.
The client often go to different churches.
The client likes to cook.

As a mother and grandmother, she is a caring

and loving and a happy person.

As a friend, she is trustworthy. She does not do

any unnecessary things that may cause
trouble.

She believes that nothing is impossible with God

She believes that nothing is impossible with God

The client watches TV before he sleeps.

The client plays every afternoon.

Performance Pattern- Routine

TYPICAL WEEKDAY AND WEEKEND
PREMORBID
TIME
CURRENT
TIME
Client wakes up
4 AM Client wakes up 5 AM

5 AM
5 AM
6 AM
7 AM
8 AM
8 AMAM
9 AM
10 AM

11 AM
8 PM

Breakfast time
Cleans

5 AM 6 AM

her 6 AM 7AM

Breakfast Oral
Takes a Bath

condo

9 Watching TV

7AM 8 AM

Feeding time PEG

Takes a bath

8 AM- 9AM

Playing table top activities

with the caregiver

Going
different
churches/
places

9AM 10 AM
10 AM- 11 AM
11 AM- 12 PM
12 PM 1 PM
to
1 PM 2 PM
2 PM 3 PM
3 PM 5 PM
5 PM 6 PM
6 PM 7 PM
for 7 PM 8 PM

8 PM Cooks
dinner
9 PM
Sleeping time
10 PM

9 PM 10

Occupational Therapy session

Physical Therapy Session
Lunch time - Oral
Sleeping time
Watching TV
Mirienda time - Oral
Physical Therapy session
Dinner time- Oral
Watching TV/Sleeping time
Feeding PEG
Sleeping time

Performance Context - Physical

The client lives alone in
her condo unit at 21st
floor of Wharton
Parksuits 216 Masangkay
St. Mia that is built with
cement and spacious
enough to accommodate
her. It consist of 2
bedrooms, 2 comfort
room, kitchen, dining
area and a living room.

Performance Context - Physical

The client was
inpatient in
Metropolitan Medical
Center. She is currently
staying on the 4th floor
of the hospital. The
room was spacious
enough to
accommodate the
client and the
caregivers. The spacing
is enough for the
wheelchair mobility of
the client. The room of
the client is just beside
the nurse station and a
minute away from the
OT and PT area.

Social Environment

L.T lives alone in her condo unit. She has a good relationship with
all of her 6 children. She always takes time to bond with her
children and grandchildren whenever they come over to her
condo unit. She always wants to make sure that all of her
childrens life is stable. She also has a good relationship with her
neighbors and friends in different churches.

The client was currently staying in Metropolitan Medical Center

with her daughter and grandchildren. She always tries to talk to
her daughter and grandchildren. She was also interacting with
the staff, interns and co-patients in the hospital.

Cultural Context

The client and her family were Roman Catholics. She

always join specific religious activities such as Feast of
Black Nazarene, Holy week celebration, Rosary week
in different churches. Their family is also celebrating
Christmas, New Year, birthday with her whole family
and extended family member annually.

The client and family is celebrating Christmas, New

Year, birthday with some of her family and extended
family member in the hospital.

Person
(client factors
supporting and
hindering
performance)

Strengths(s)

The client has good process and social skills.

Good global & specific mental functions.
Intact sensory function.
Poor grip strength on L hand
Good motor skills on specifically:
-Grip (L)
-Manipulates (L)
-Lifts (L)
-Calibrates (L)
-Move (L)
-Paces (L )
L hand dominant

Weakness(es)

Task

(features of activities/
activity demands)

Task
Task
Task
Task

that
that
that
that

can be done in sitting position

requires use of dominant hand
requires limited range of motion.
requires sensation

Environment
(features of the
environment)

Poor motor skills:

Aligns
Stabilizes
Positions
Bends
Reaches
Manipulates (R)
Grip (R)
Coordinates
Moves
Lift (R)
Walks
Flows(R)
Transports
Calibrates
Endures
Paces
LOM on BUE
Muscle weakness on RUE
Poor in-hand manipulation on L hand specifically palm to
finger, finger to palm.
Absent Grip strength on R hand
Low motivation
Task
Task
Task
Task
Task
Task

that
that
that
that
that
that

requires
requires
requires
requires
requires
requires

in walking/standing
the use of both hand/ R hand
FULL ROM
resistance.
palm to finger & finger to palm.
time limit

Good financial support

Good family support

Restricted environment
Lack of opportunity

PRIORITIZED PROBLEM LIST

LOM on BUE

RUE weakness

Impaired Bilateral coordination

Poor dexterity on L hand

POTENTIAL FOR
OCCUPATIONAL
PARTICIPATION
Patient has guarded potential for occupational participation. The factors that may predict good

quality of life after stroke include family support access to continued rehab services (Brandstater,
2005). Higher levels of social support were found to be predictive of a more rapid rate of recovery
and a greater amount of overall improvement in functioning, even among patients with more
severe stroke (Glass, Belyea, 1993). Her daughter together with her grandchildren, are very
supportive for her daily needs and financial needs. She also attends OT session daily which is a
also a good factor. But the caregivers mindset about staying the client in the hospital can be a
hindrance for the improvement of the client. And according to Trombly, the improvement of stroke
patients after 6 months post-stroke can be expected but very limited. Also, advanced age and the
presence and severity of co-existing disease, such as diabetes, heart disease, and peripheral
vascular disease, can impede optimal functional recovery. In the case of the client, she is already
74 years old, 1 year and 1 month post-stroke and she already experienced 1 heart attack. Last
factor is the will and motivation of the client to be better and go back to her life before the
incident. According to Pickrell, Bongers and Hoven (2015), motivation is not a prerequisite to
physical improvement but significant increase in functional capacity comes from those who have
motivation. In the case of the patient is attending PT and OT sessions but she has a low
motivation.

FOR
Biomechanical FOR

The therapist will use biomechanical FOR to focus on regaining

functional ROM, bilateral coordination of the BUE of the patient
and in strengthening her LUE in order for her to be able to
engage on her areas of occupation since the client can still use
her dominant hand which is her L hand functionally. This FOR can
be useful for her condition in improving her ROM and to maintain
the remaining skills of the client and to prevent deterioration.

TUS
Modes:

Collaborating

Instructing

Encouraging

ENVIRONMENTAL
MODIFICATION TECHNIQUES

The client is positioned on the left side the therapist with the
table in front of them. The place should be spacious enough to be
able to move without restriction when performing the exercises
and activities.

GOALS
Problem 1: LOM on the BUE

LTG: The client will be able to improve ROM necessary for ADL
participation after 6 mos. of OT sessions.

STG1: The client will be able to comb both side of her hair
properly using her L hand within 6 weeks of OT session.

STG2: The client will be able to scrub her head well using L hand
during bathing within 7 weeks of OT session.

STG3: The client will be able to reach the cup on her left and
right side using left hand efficiently within 8 weeks of OT session

STG4: The client will be able to raise her RUE during bathing
and dressing independently within 9 weeks of OT session

TUA
Preparatory

PROM exercises of the BUE AP 10R

AAROM exercises AP of the LUE 10R

Passive stretching of BUE AP 10CH 5sets

Purposeful

Wrist roller exercise FW and BW for 10R 3 sets

Wristisizer (wrist extension on B hands for 5 CH 5 R) (wrist flexion on L hand)

Cone stacking on RUE (R to L)

Elevated cone stacking 10 R on LUE (L to R)

Ball transfer on RUE for 5 r (R to L)

Elevated ball transfer on LUE for 10 R (L to R)

Occupation Based

Feeding using spoon

Combing her hair

Scrub her head during bathing

RCGR of cup

TUG

HANGMAN

Materials, Tools and Equipment: chalkboard, dry erase board, chalk,

dry erase markers
Objective: social interaction skills, letter recognition, cognitive skills, UE
movement.
Choose a word from the a chosen hangman theme based on category.
Write the blank spaces and draw the hangman sign. Ask each person to
choose a letter. If they are unable to verbally say the letter, have them
choose from flashcards or a pre made alphabet sheet. and once they
have identified the word, Ask every group to raise their hands and put
the word in action/gestures. This Game can be played using many
different themes as well.

CLIENT/CAREGIVER/FAMILY
EDUCATION
The caregiver will be told to give the client the opportunity to do simple

task

The client should always be reminded to hold her affected hand in proper
position at all times.

The caregiver will always be reminded to perform the daily exercises of

the client even at her room and to drink her daily medicines on time.

The therapist will also educate the caregiver how to test properly the
blood pressure of the client and deep breathing exercises and to observe
safety precautions at their room to prevent further accidents.

The daughter will also be told to always accompany the client in her
therapy that would help to motivate the client

The caregiver will also be told to remind the client to always wear her
resting hand splint.

RECOMMENDATION

To continue OT sessions daily

To continue her PT and ST session

To have a checkups often with her physician to prevent further

complication and re-occurrence of the condition.

To modify the room

To facilitate cognitive stimulation leisure activities for the client.