Student Name: Ashley Moore

Case: #5 Mr. Jones

Date: 2/28/14

1. Diagnosis, Referral, Setting, Reimbursement, LOS

Diagnosis:
Primary diagnoses: Right CVA
Secondary diagnoses: Osteoarthritis
Referral: Mr. Jones Neurologist, Dr. Lewis
Setting: Acute care at the hospital
Reimbursement: Medicare
LOS: 2 sessions/day for 1 week (10 sessions total)
Discharge recommendation: Client will be discharged to Inpatient Rehab at the hospital. He will likely not
make enough progress in his one-week stay in the acute unit to return home due to the number and severity of
deficits that he has. Due to the typical recovery course of CVA, Mr. Jones will likely make a lot of progress
within the first month of therapy. This is a good fit for the fast paced environment of inpatient rehab, rather
than the more slow paced environment of a Skilled Nursing Facility.

5. Diagnosis and Expected Course

6. Scientific Reasoning & Evidence

List the barriers to performance typical of this diagnosis:
Diagnosis:
Right CVA:
Right Cerebral Vascular Accident:
Neglect: Often individuals with a right CVA will
A cerebral vascular accident, or stroke, is an injury of
demonstrate inattention to the left side (or some say
the upper motor neurons that produces
hyper attention to the right side). This can cause
hemiplegia/paralysis of one side of the body. It
difficulty with a wide variety of activities including
occurs when blood flow to a part of the brain stops,
maintaining balance, completing bilateral dressing,
thereby cutting off its oxygen supply and causing
socialization, safety, and more.
brain cells to die. There are two major types of
(Neglect/Inattention PPT from
stroke, ischemia and hemorrhagic. Ischemic stroke
Cognition)
occurs when a blood vessel that supplies blood to the
Apraxia: This is a deficit of motor planning
brain is blocked by a blood clot. A hemorrhagic
purposeful and skilled movement. It can take various
stroke occurs when a blood vessel that supplies blood
forms including ideomotor, ideational, and oral. Mr.
to the brain breaks open and leaks blood into the
Jones seems to demonstrate ideational apraxia, which
brain.
is characterized by difficulty understanding the
The deficits of stroke depend on the arteries affectedpurpose of objects and using items incorrectly. This
The middle cerebral artery causes hemiplegia and
can cause difficulty with self-care and grooming, as
sensory loss on the opposite side of the body,
individuals do not use toothbrushes, combs,
aphasia, apraxia, and more. The anterior cerebral
washrags, etc for their intended purpose. It can also
artery causes hemiparesis, and sensory loss on the
affect meal preparation, eating, home management,
contralateral side, apraxia, behavioral problems, and
dressing, and more.
more. The posterior cerebral artery can cause a
(visual perceptual handout from
variety of visual impairments including homonymous
Cognition)
hemianopsia, visual agnosia, and cortical blindness.
Hemiplegia: The lack of blood flow to the brain
Other arteries that can be are the internal carotid
damages the UMN of the tracts that carry impulses to
artery, basilar artery, the vertebral artery, and one of
muscles. Therefore, the individual loses control of
the cerebellar arteries. People are at an increased risk
various muscles. Hemiplegia can manifest itself in
for stroke if they have are diabetic, above age 55,
various ways (high tone/low tone). Both spastic and
overweight, have high cholesterol, have high blood
flaccid hemipareis cause difficulty with daily
pressure, or smoke.
activities including walking, dressing, self-care, and
The deficits of a stroke also depend on which
more.
hemisphere of the brain was affected. A CVA in the
(Mayo clinic and notes from Ydas lecture on stroke
right hemisphere can cause poor judgment,
rehab)
perceptual changes, impulsivity, decreased
Difficulty talking: CVA impact the way that muscles
awareness, neglect and apraxia. Mr. Jones CVA
in the mouth and throat are able to move. Some
occurred on this side of his brain, therefore, he will
people experience dysarthria (slurred speech) because
likely demonstrate some of these symptoms. Left side
of muscle incoordination. Other individuals

CVAs, on the other had, can cause speech and

language problems, and slow/cautious behavior.
Osteoarthritis:
Osteoarthritis is a degenerative joint condition that is
usually seen in the weight bearing joints of the knees,
hips, and spine. It can affect other joints if an injury
is involved. This chronic condition results when
cartilage in joints deteriorates causing bone to rub
against bone. Mr. Jones is most affected by OA in his
hands and shoulders.
*This diagnosis will not be directly treated, however,
it is helpful to keep in mind in case the client
demonstrates shoulder or hand pain during a therapy
session.
Expected Course:
Right Cerebral Vascular Accident:
Initial symptoms of a CVA arise suddenly and often
without warning and can include a sudden sever
headache, numbness in the face, arm or leg,
confusion, trouble speaking, facial drooping, and
difficulty walking. After the initial onset of
symptoms, the prognosis of a CVA varies widely
depending on how much tissue has been damaged,
how soon the individual received treatment, and what
body functions have been affected. Individuals will
usually experience difficulty thinking, moving, and
talking for weeks to months after their CVA. Some
people improve months to years after their CVA and
about half are able to care for themselves in their
home. However, some are unable to take care of
themselves due to the severity of their deficits. The
prognosis for an ischemic stroke is better than for a
hemorrhagic stroke. People who demonstrate
spasticity are also more likely to regain function than
individuals who have flaccid.
Osteoarthritis:
Typical course of OA begins with cartilage
breakdown and loss of elasticity. In this stage,
cartilage can become more easily damaged by injury
or overuse. Due to cartilage breakdown, the
underlying bone begins change. It may thicken, form
cysts, or body growths. In later stages, small pieces
of bone or cartilage by detach from the joint and the
synovium of the joint will become inflamed causing
further cartilage damage. Early diagnosis and
treatment of OA positively affects its course.
Individual experiences with OA also vary widely
from person to person. The degree of joint
involvement and severity of symptoms are different
in each person with OA as some have very limited
function while others are able to maintain a very
active lifestyle.

experience speech problems because of aphasia.

Expressive aphasia causes difficulty formulating
muscle movement to create speech. Receptive
aphasia causes difficulty understanding speech,
reading, and writing. Regardless of the origin,
difficulty talking can cause problems with a variety
of occupations including communication with others,
job performance, and social participation.
(Mayo Clinic Website)
Emotional Problems: Individuals often have
increased difficulty with managing emotions after a
CVA. Depression is also common after this
diagnosis. Emotional problems can influence an
individuals ability to engage in any occupational
area because of a decreased frustration tolerance for
difficult activities, less motivation, etc.
(Mayo Clinic Website)
Somatosensory problems: Individuals who have had
a stroke may have pain, numbness, or other strange
sensations in their affected limbs. This can affect the
dressing, as clients cannot feel their arm to place it in
a sleeve. It can also negatively affect the ability to
manipulate small objects because clients cannot feel
them (and likely because they also have decreased
motor control).
(Willard and Spackmans chapter on CVA and the
Mayo Clinic Website).
*There are a large variety of other barriers to
performance that occur after a CVA. These depend
largely on the area of the brain that was impacted.
For example, in a PCA CVA, an individual may have
homonymous hemianopsia. This visual impairment
could cause difficulty reading, often running into
things, fear of being in a crowded environment into
the community, etc. Other affected areas of the brain
demonstrate different impairments, barriers to
performance, and levels of severity.
Osteoarthritis:
Pain: This usually increases over the course of the
day because daily activities create stress on the joints.
Therefore, activities that occur towards the end of the
day may be more difficult due to increased pain
levels. Activities that involved weight-bearing joints
are also difficult (standing for extended periods,
walking, etc).
(Willard and Spackmans chapter on OA)
Discomfort before a weather change: It is February;
therefore, there are a likely a lot of winter storms that
could cause an increased level of pain and decreased
function in daily activities.
(Conditions Notes)
Stiffness: This often occurs in the morning, creating
increased difficulty completing morning routines.
(Willard and Spackmans chapter on OA)

*This diagnosis will not be directly treated, however,

it is helpful to keep in mind in case the client
demonstrates shoulder or hand pain during a therapy
session.

7. Practice Models Guiding

Assessment and Treatment
1.
PEO

2.

Motor
Control/Motor
Learning Model

Loss of ROM: Joints are often unable to move

through the full range due to pain, stiffness or bone
spurs. Decreased ROM in these weight-bearing joints
can cause difficulty with trunk rotation during
dressing or bathing.
(Willard and Spackmans chapter on OA)

Rationale
Mr. Jones participation in ADLs and eventually IADLs and preferred hobbies will
increase if modifications are made to the activities themselves, the environment
they are performed in and the way that Mr. Jones engages in them. Below are some
examples of how PEO can be applied to grooming/hygiene.
The activity itself can be changed to lessen the amount of steps required.
The client can use a face wipe instead of a washcloth to complete grooming.
This can be completed in bed, rather than at the sink, which may be helpful
while he is in acute care, depending on his medical stability.
The environment that Mr. Jones completes grooming in can be modified.
Instead of using a white washcloth, which is difficult to distinguish from a
white countertop/sheets, he can use a dark colored washcloth. This will be
easier to locate as the therapist cues Mr. Jones to look the left for it.
The way that Mr. Jones engages in a grooming activity can be modified. A
washrag can be placed in Mr. Jones unaffected hand and the therapist can
use hand over hand assistance to raise the washrag to his face. This allows
Mr. Jones to complete the activity more independently, as the therapist
helps him use the washcloth for the appropriate purpose. Although this type
of strategy can be used early on in the acute unit to allow Mr. Jones to
complete an activity with greater independence. Later on grooming
activities should incorporate the use of both hands whenever possible.
With changes to these three areas, (person, environment and occupation), grooming
will easier to complete. Similar modifications can be made to other activities.
Below are some postulates of the motor learning model that can be applied to Mr.
Jones.
This model supports breaking up occupations in smaller parts initially and
integrating these parts later to promote independence throughout an
occupation. As he is early on in his recovery process, Mr. Jones has a lot of
deficits at this point. Asking him to complete an entire occupation the way
that he did prior to his stroke may be too difficult. Therefore, activities need
to be broken up into components that Mr. Jones can accomplish each step
individually at first.
This model encourages individuals to problem solve their own efficient
ways of completing a task, rather than using a specific strategy that the
therapist suggests as this will promote greater independence. Mr. Jones will
need to formulate movement patterns that allow him to complete activities.
Developing the ability to problem solve the type of movement needed to
complete a task will allow Mr. Jones to be more independent long term as
he can solve movement problems by himself as they arise.
This model encourages the use of repetition while learning a new way of
doing a task so that the individual creates habitual movement patters that
are efficient. Mr. Jones will need lots of practice in order to retrain motor
pathways. Whenever possible, tasks should be included that naturally have
a lot of repetition involved (tooth brushing allows for a repeated back and
forth motion for example).

14. Evaluation: What Assessment tools and other means of assessment will you use?
Top Down Assessment: Prioritize one Occupation to observe the client perform
Observed Occupation
Morning ADL routine:
Brushing teeth

Method/Tool
1. The FIM

2. The MoCA

3. Screening of AROM and

PROM of left upper and lower
extremities

4. Sensory testing with

monofilaments

5. Palpating left UE joints for

subluxation (# of fingers that fit in
the GH joint, palpate and glide
scapula, etc.)

Rationale/How will you use this information

Brushing teeth provides a wide variety of information and is a realistic activity
to complete in this acute setting. It will demonstrate:
Arousal/awareness level: Is he alert enough to complete this activity?
The density of the left neglect: Does he brush his left side at all? Will
he do it with cuing? Does he need hand over hand assistance to
complete left teeth brushing?
Activity tolerance: How long can he brush his teeth? If he stops after
just a few seconds, will he do it for a longer period of time with cuing?
Ideational apraxia across activities: He did not know how to use a
washcloth, but does he know what to do with a toothbrush?
Sitting balance: If the client is up to it, he can sit at the edge of the bed
to complete this activity, which will provide information about the
clients perspective of midline and if it is accurate enough to remain
upright.
Visual Perceptual skills: Does the client have figure-ground
perception? (The ability to distinguish white toothpaste from a white
countertop)
Rationale/What is being Assessed
This assessment is used frequently in hospital settings and will provide
information about how much assistance Mr. Jones needs with several motor
and cognitive areas that may have been impacted by his CVA. At the end of
his one week stay in the acute unit, the FIM can be used to demonstrate how
much progress he has made and in the discharge recommendation process.
How independent or dependent he is will determine which therapy setting will
be most appropriate for him.
People with right CVA often demonstrate cognitive impairments. This
assessment can be used as a quick screening tool to determine which areas
may have a deficit (memory, attention, visuospatial, abstract thought, recall,
etc). This assessment can also be used dynamically as the client may not
understand to purpose of a pen. The therapist can use hand over hand
assistance if necessary to get the client started or just ask him to complete the
verbal sections. Cognitive areas that may have a deficit can be addressed in
therapy and evaluated further to find out more about their extent.
AROM will provide information about whether or not Mr. Jones has any
active movement on his left side, as it currently demonstrates flaccid
appearance that is indicative of very low tone. PROM will indicate if Mr.
Jones has any pain during movement on the left side of his body as this will
affect transfers, bed mobility, etc.
This assessment will identify if Mr. Jones has any sensory deficits on his left
side. If he has any impaired tactile sensation, this indicates that pressure
release and skin checks need to be completed regularly. If sensory deficits are
present, nursing can be notified and Mr. Jones wife could be educated about
pressure sores so that she can remind her husband change positions frequently
and assist in this repositioning process.
Mr. Jones demonstrates the appearance of very low tone/flaccidity; therefore,
tissues can become overstretched causing some subluxation. Subluxation can
affect joint alignment, cause abnormal positioning, and the ability to
participate in weight bearing activities.

6. Star Cancellation Test

The documentation provided indicated that Mr. Jones has some degree of left
neglect. This star cancelation test will indicate the degree/density of this
neglect and provide a more objective assessment that can be used in
documentation for this client than observation. Completing this test at the end
of therapy will also indicate any improvement that Mr. Jones has made in this
area. This test is very simple and does not require a high amount of exertion,
so it is appropriate for this acute setting. However, if the client is unable to
complete it because he cannot use a pencil for its intended purpose (because of
ideational apraxia) the therapist can adapt this assessment so that it does not
require writing by testing visual fields with the rods.

17. Intervention Plan

Barriers:
Supports:
Mr. Jones preferred hobbies that involve very skilled fine motor
Has a supportive wife
movement of both hands, however, he has hemiplegia on the left side
who wants to be
limiting his hand function.
involved in therapy.
Mr. Jones wifes main priority is for her husband to come home, however,
Has a supportive
he will likely not be ready to return home after his week in acute care.
kids/grandkids.
Mr. Jones currently has very low tone (flaccidity), which provides less to
Mr. Jones is receiving
work with in therapy than high tone. (However, it is common for this
OT services early on in
flaccidity to change to spasticity within several days, which will affect the
his diagnosis.
approach that the therapist uses to treat Mr. Jones).
Mr. Jones has a wide
variety of interests,
The acute setting does not allow for a lot of occupation-based intervention.
some of which can be
Mr. Jones has OA, which causes pain in his shoulders and hands. This may
incorporated in therapy.
cause difficulty during weight bearing or when Mr. Jones starts to use his
affected hand again.
Mr. Jones is able to
speak/communicate
Mr. Jones might have pusher syndrome, which will affect transfers, sitting
verbally with the
unsupported, etc. He may need constant support to remain upright during
therapist. He also
sitting and two people may be needed during transfers.
seems aware of what is
Mr. Jones has multiple symptoms/diagnoses that accompany his right
being asked of him,
CVA. Therefore, treatment sessions cannot address hemiplegia only (or
which will be very
left neglect or ideational apraxia)- they need to keep in mind all of Mr.
useful during therapy
Jones deficits. Treatments will not be as effective if they that ask Mr.
as he can respond to the
Jones to use his left side, but do not consider that he may not know how to
OT requests.
use an item required in that activity.
Goals
Practice Model for each goal
1. By D/C, client will utilize left UE as a functional assist during a simple selfcare activity with Mod A for positioning limb.

PEO

STG:
By session 7, Client will complete simple self-care activity on right and left sides
of body with Mod verbal cues to address the left.

PEO

STG:
By session 3, client will weight bear on left UE while reaching for a self-care item
with the right hand with Max A to maintain balance.

Motor Control

2. LTG:
By D/C, client will go from supine to sitting at edge of bed with Mod A to manage
left side and remain upright.

Motor Control

STG:

By session 7, client will weight bear on forearm and elbow in side lying with Mod
A for balance.
STG:
By session 3, client will move from supine to side lying with Max A to manage
left side.

Motor Control

Motor Control

3. LTG:
By D/C, client will partial weight bear on left LE during pivot portion of bed to
commode transfer with Mod A.

PEO

STG:
By session 7, client will maintain a shoulder width distance between feet during
bed to commode transfer with Mod A.

Motor Control

STG:
By session 3, client will remain balanced on the commode during toileting with
Max A.

Motor Control

18. Treatment Sessions: Plan for first two 45 minute treatment sessions:
1. What will you do?

Identify
Approaches

Based on which
goal(s)?

Preparation for activity: The therapist will begin the session by

reintroducing self to Mr. Jones and asking how he is doing to determine if
he is alert and feels well enough to participate in therapy. The therapist will
prep the environment by repositioning any lines appropriately to allow for
this treatment activity. While rearranging the environment, the therapist will
communicate what is happening with Mr. Jones, as this is his personal
space/environment. The therapist will adjust the head of the bed so that Mr.
Jones is sitting more upright and position a tray with a toothbrush,
toothpaste, water, and a bowl within close reaching distance to Mr. Jones. If
possible, the therapist will use items that are high contrast in color to the
tray (green toothpaste, blue toothbrush, etc) so that the items will be easier
to locate.

Establish/Restore By session 7,
Client will
complete simple
self-care activity
on right and left
sides of body
with Mod verbal
cues to address
the left.

By session 3,
client will weight
bear on left UE
while reaching
for a self-care
item with the
right hand with
Max A to
maintain balance.

Activity: The therapist will ask Mr. Jones to brush his teeth and will assist in
this activity depending on Mr. Jones performance. This teeth brushing
activity will be completed dynamically as the therapist will adjust the
activity demands and amount /types of assistance provided depending on
Mr. Jones performance. If he has a difficult time using these items for the
appropriate purpose due to apraxia, the therapist will break the activity into
small steps, verbalizing how to complete each step, and demonstrating or
providing physical assistance as needed. The therapist will provide verbal
cuing to locate teeth brushing items on the left side of the tray and to brush
the left side of his mouth. The therapist will also provide physical assistance
if Mr. Jones is having difficulty opening the toothpaste, squeezing
toothpaste onto brush, completing brushing, etc. At this stage, Mr. Jones
will complete teeth brushing the same way that he did prior to his CVA
(with the potential exception that he might use a different hand, depending
on which one was dominant). We are not sure how much function he will
regain; therefore, he should begin by completing this activity as he usually
does because he may not need to use any compensatory strategies later on.
Also, introducing any AE at this point would be confusing due to apraxia.
Readjusting environment after activity: After the activity is completed, the
therapist will return lines (and any other items) to their original positions
before therapy, place Mr. Jones in a comfortable position in midline, and
ensure that there are no wrinkles in clothing that could cause pressure sores.
Any remaining time will be spent answering questions that Mr. or Mrs.
Jones has (about therapy, length of hospital stay, how Mrs. Jones can assist,
etc). The therapist will ask Mrs. Jones to bring any items from home that her
husband might want to have in his room, as these can be incorporated into
therapy. For example, he may want his own toothbrush instead of a hospital
issued one or he might want to complete LE dressing with a pair of his own
shorts. The therapist will also provide some education for Mrs. Jones
(throughout the session as appropriate or at the end) about how to assist her
husband with some of these self-care activities. For example, she can remind
him to look to the left, address his left side in grooming, help him get started
with an activity by positioning his hand where it needs to be, etc.
2. What will you do?

Identify
Approaches

Based on which
goal(s)?

Preparation for activity: The therapist will prep the environment by

repositioning any lines appropriately to allow for this treatment activity.
While rearranging the environment, the therapist will communicate what is
happening with Mr. Jones, as this is his personal space/environment. This
activity will address bed mobility and some neglect.
Activity: The therapist will facilitate this activity dynamically depending the
clients abilities and performance. The client will move from supine to sitting
at the edge of the bed. The client will complete the motion in steps starting
with rolling, supporting oneself on the elbow/forearm, and then moving to
sitting. Throughout the bed mobility activity, the therapist will assist the
client as needed with the following things:
While weight bearing on the forearm, the therapist will ensure that
the client is not causing joint damage by hanging on the shoulder.
The therapist will assist Mr. Jones with staying balanced in sitting
while keeping his trunk aligned in midline.
The therapist will provide assistance as needed to manage the left
side of the body.
While the client is seated at EOB, the therapist will spend a few minutes
facilitating greater awareness of the left side. Mrs. Jones can sit towards her
husbands left side and talk to her husband or the therapist can point to the
pictures in Mr. Jones room (placed on the left) and ask him questions about
them.
Readjusting environment after activity: The therapist will assist Mr. Jones in
getting back into supine on the bed, return lines (and any other items) to
their original positions before therapy, place Mr. Jones in a comfortable
position in midline, and ensure that there are no wrinkles in clothing that
could cause pressure sores. Any remaining time will be spent answering
questions and discussing Mr. Jones potential for recovery. Mr. and Mrs.
Jones have both experienced a dramatic life change, so it is important to
spend a few minutes storymaking about how his abilities will improve in
order to provide hope for the future.

Establish/Restore By D/C, client

will go from
supine to sitting
at edge of bed
with Mod A to
manage left side
and remain
upright.
By session 7,
client will weight
bear on forearm
and elbow in side
lying with Mod A
for balance.

By session 3,
client will move
from supine to
side lying with
Mod A to
manage left side.