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Lara Albano, Patricia Gelling, Gretchen Kempf, Dominique Keogh, Laura Mammato, Megan McCarthy, Laura Van Volkenburg

and Christina Weiss May 7, 2013

Diagnosis: astrocytoma; s/p craniotomy at NYU Date of onset: 12/24/13 Date of treatment: 2/4/13 Rehab diagnosis: brain tumor with right internal capsule stroke after surgery Precautions: falls, diplopia, and foot drop Prior level of function: independent in all daily activities Pt. stated goal: To be a normal person againTo play piano, swim, and bowl. Chief complaint of symptoms: weakness in both UEs, vision difficulties, and difficulty getting around outside and at home.

History

of present illness:

Pt. underwent a craniotomy at NYU 12/24/12 secondary to an aggressive brain tumor Pt. suffered a right internal capsule stroke with left progressive lower extremity spasticity Brain tumor was diagnosed after MRI secondary to falls, rapid onset of upper extremity weakness, and double vision Tumor was not removed and requires monitoring for increase growth

Hand dominance: Right Area of pain: posterior shoulder capsule on left and left side of vertebral border of scapula since the surgery was performed Nature: dull and achy Duration: intermittent Intensity on average: 5-6 out of 10 PMH: Unremarkable Social and Work history: Resides in a two-story home with parents and two sisters. Pt. is homeschooled. Mother is home during the day. Pt. enjoys swimming, shopping, outdoors, playing the piano, and scrapbooking. Pt. has chores she is responsible for but unable to do at present time. Driving status: non-driver at present time

PROM in left and right UE is WNL AROM in right UE is WNL for everything except shoulder abduction and flexion Fair plus L forearm supination/pronation, L wrist radial/ulnar deviation, R shoulder extension, internal rotation and external rotation, and R elbow flexion/extension Good minus in R forearm pronation/supination, R wrist flexion/extension, and R wrist radial/ulnar deviation Tone is normal in trunk and left and right UE, and Bethany has isolated joint movement with near normal coordination Good control of head position in midline Sensation is fully intact Bethany is independent in: feeding, grooming, clothing management, bed mobility, and toileting. Bethany is modified independent in dressing and bathing

Precautions: Falls; Diplopia; Foot Drop Pain: Left posterior shoulder capsule and left side vertebral border of scapula. Described as dull and achy intermittently with an average of 5-6 on the pain scale. Movement Analysis: Bilateral weakness in upper extremities (left more affected) Slight ataxia and delayed fine and gross movement patterns Scapular Position: Left-side depressed, protracted, downwardly rotated Trunk Position: Posterior pelvic tilt. Increased weight bearing on right side with elongation there, shortening on left Vision difficulties: diplopia (corrective lenses assist); decreased depth perception Grasp: Decreased in left hand Most affected IADLs: Homemaking tasks and functional mobility/transfers

Left UE (involved side) AROM (PROM is WNL)

Shoulder

Wrist

Abduction: 0-75 (norm 0-180) Extension: 0-15 (norm 0-80) Flexion: 0-60 (norm 0-180) Flexion: 0-50 (norm 0-80) Extension: 0-40 (norm 0-60) Radial deviation: 0-10 (norm 0-20) Internal Rotation: 0-20 (norm 0-70) Ulnar deviation: 0-20 (norm 030) External Rotation: 0-35 (norm 0-90) Thumb Elbow Palmar abduction: 0-45 Flexion/extension: 0-120 Radial abduction: 0-35 (norm 0-150) MCP: 0-40 (norm 0-50) Forearm IP: 0-50 (norm 0-80)

Pronation: WFL (norm 0-80) Supination: 0-35 (norm 0-80)

Digits: WFL

Right UE (PROM is WNL) Shoulder


Abduction: 0-145 (norm 0-180) Flexion: 0-140 (norm 0-180)

*Rest of R UE AROM is WNL* Distal Palmar crease measurement and finger opposition are WNL

Fair plus : forearm pronation/supination, wrist radial/ulnar deviation Fair: elbow flexion/extension, wrist flexion/extension Poor minus: shoulder flexion/extension, shoulder abduction, shoulder internal/external rotation

Good minus : wrist flexion/extension, wrist radial/ulnar deviation, forearm pronation/supination Fair plus : elbow flexion/extension, shoulder extension, shoulder internal/external rotation Fair: shoulder abduction, shoulder flexion
Right UE Strength

Left UE Strength (involved side)

Fatigue
ADLs

noted throughout ADL evaluation

Feeding = Independent Grooming = Independent UE & LE Dressing = Modified Independence Bathing = Modified Independence Clothing Management = Independent Toileting = Independent

ADL -Functional Mobility = Minimal Assist/Contact Guard -Bed Transfer = Contact Guard -Toilet Transfer = Contact Guard -Tub Transfer = Contact Guard -Bed Mobility = Independent
IADLs All homemaking tasks (cooking, cleaning, laundry, shopping, and financial management) required Max Assistance.

Pain

Analog Scale ROM/MMT Trunk and UE Neurological Assessment

normal tone on right and left side

Modified

Ashworth Scale for Grading Spasticity


No increase in muscle tone

UE

Neurological Assessment

Head in midline with good control, scapular depression, downward rotation and protraction, posterior pelvic tilt and elongation on the right side.

Hand strength gross grasp: Right-50 lbs. Left-25 lbs. lateral pinch: Right-12 lbs. Left-4 lbs. 3 jaw chuck: Right-14 lbs. Left-6 lbs. tip to tip pinch: Right-8 lbs. Left-3 lbs.

hole peg test


Right-45 secs. Left-2 min. 10 sec.

Minnesota

Placement

Right-2 min. 15 sec. Left-5 min. 14 sec.

FIM
Visual

Screening

Has corrective lenses, but diplopia is present with decreased depth perception

Berg

Functional Balance Scale

To evaluate Bethanys sitting and standing balance.

Beck

Depression Inventory

21-question multiple choice self-report inventory widely used for measuring depression. This can assess Bethanys level of depression and psychosocial status after her brain tumor, craniotomy and stroke.

Patient will increase her endurance, requiring less than 3 rest breaks during a therapeutic activity to assist with leisure activities.
Patient will increase tip-to-tip pinch in her L hand by 3-5lbs to assist with putting her contacts in. Increase bilateral shoulder strength by a half grade to assist with UE and LE dressing and transfers. Decrease pain from 5/10 to 2/10 to allow more independence in overhead dressing and transfers.

Patient will improve gross grasp of her L hand by 10-15 lbs to increase from maximum assistance to moderate assistance with home chores.
Increase AROM in proximal L UE by at least 10-15 degrees to assist with engagement in shopping activities. Patient will maintain sitting in midline for 2 minutes to increase trunk control for playing the piano. Increase lateral pinch by 2-3 lbs to assist with scrapbooking.

Patient

will increase AROM of her proximal L shoulder to WFL to participate in shopping activities. Patient will be able to independently don and doff her bra. Patient will increase functional mobility (bed, toilet, tub transfers) from CG to independence. Patient will improve from mod to CG in homemaking tasks.

Wii

bowling. Upgrade: Pt will stand for the entirety of activity. Downgrade: Pt will sit on firm exercise ball. Rationale: Pt will engage in Wii bowling game as she has previously expressed interest in the sport

Trunk Control Posterior pelvic tilt Grip strength Fatigue Increase L UE ROM

Pt and therapist will go on a shopping outing to pts favorite store. Pt will have to try on a shirt, bra, and her choice of bottoms to purchase for a birthday outfit. Upgrade: Pt may try on multiple outfits as well as accessorize (i.e. earrings). Downgrade: Pt will only need to try on a bra to avoid fatigue. Rationale:

Work on pinches (tip to tip & lateral) for jewelry and buttons, snaps etc. UE strength and ROM UE & LE dressing Endurance

Pt. will participate in a scrapbooking activity, (squeezing the glue, holding paper, removing/placing stickers). She will make a collage of photos and decorate to place in her scrapbook. Upgrade: Doing scrapbooking while sitting on the firm exercise ball, (instead of chair), to work on posture and posterior pelvic tilt. Using thinner writing materials (pens instead of markers). Downgrade: Use thicker stickers, (foam, etc.), or rub on. Use glue stick instead of squeeze tube glue. Rationale:

decrease hand weakness increase fine motor skills (pinch strengths) posterior pelvic tilt/trunk control endurance

Pt.

will participate in aquatic therapy through swimming and using water weights. Upgrade: Increase the weight resistance, increase number of repetitions for each exercise, exercise in a deeper depth of pool Downgrade: Decrease weight resistance, decrease number of repetitions for each exercise, participate in shallower end of pool Rationale:

improve left UE ROM Endurance UE strength

Pt will make meal of grilled cheese and tomato soup. She will need to manipulate a triangle can opener and demonstrate kitchen safety when working with the stove. Upgrade: Therapist will not provide any physical assistance (i.e. opening cupboards, supplies, etc.) Downgrade: Therapist will assist in activity by laying out the ingredients, loosening jar, and starting can opening process. Rationale:

Increase grip strength Moving from max assist to min assist in cooking/homemaking skills Increase AROM of shoulder

Pt will use an arm bike as well as work with theraputty. Upgrade: Pt will need to increase amount of time on arm bike and use a higher resistive theraputty. Downgrade: Pt will decrease amount of time on arm bike and use a lower resistive theraputty. Rationale:

Increase trunk control Increase fine motor skills Increase arm strength

These are needed to increase her participation in the leisure activity of being able to play a 3 minute song on the piano.

Activity: Patient will sit upright on an exercise ball while reaching only with her left hand for differently weighted canned goods on a low-level shelving unit and placing them on a countertop. Upgrade: Shelves placed at various heights/reaching for objects placed in multiple locations (i.e. fridge, cupboard)/patient completes activity in standing. Downgrade: Patient can be seated on a stationary chair, decreasing the number of shelves, decreasing the number of objects patient must reach, decreasing the distance between the objects on the shelves Rationale: Increasing L UE AROM, strength, coordination, grip strength, trunk control and balance, depth perception

Biomechanical Model: focus on balance, strength, ROM, endurance Model Of Human Occupation: volition-values, interests; habituation-habits, roles (daughter, student, sister); performance capacity (occupational participation, performance, and skills) Motor Control Model: to determine ways for pt to create optimal performance in activities Lifestyle Performance Model: examines relationships of the pt to activity patterns to reach needs and fulfillment

American Occupational Therapy Association. (2008). The reference manual of the official documents of the occupational therapyassociation. (14th ed.). Bethesda, MD: The American Occupational Therapy Association. Becks Depression Inventory. Retrieved from http://www.cawt.com/Site/11/Documents/Members/Evaluation/BeckDe pressionInventory1.pdf Berg Balance Test. Retrieved from http://www.fallpreventiontaskforce.org/pdf/BergBalanceScale.pdf Internet Stroke Center. Berg Balance Scale. Retrieved from http://www.strokecenter.org/wp-content/uploads/2011/08/berg.pdf Internet Stroke Center. Hamilton Rating Scale for Depression. Retrieved from http://www.strokecenter.org/wpcontent/uploads/2011/08/hamilton.pdf
Kielhofner, G. (2009). Conceptual Foundations of occupational therapy practice. (4th ed.) Philadelphia, PA: F.A. Davis Company Radomski, M.V, Trombly, C.A. (2008). Occupational therapy for physical dysfunction. 6th ed. Baltimore, MD: Lippincott Williams & Wilkins.