James is a 36-year-old male who experienced a middle cerebral artery stroke. James is married and has three children- a 9-year-old daughter, a 3-year-old son and a 6-month-old son. Prior to the accident, James was employed full-time as branch manager at a local bank. He had no occupational performance deficits prior to his injury. He was active in his church and volunteered every Sunday morning as an usher. James was also active at his daughter’s school and in her extra-curricular activities. He was a parent volunteer in her classroom and coached her softball team. James and his family live in a two-story home. There is one step to enter the home. His bedroom is on the second floor. In his free time, James enjoys cooking and woodworking. His woodworking skills are meticulous, and he has built some of the furniture in their home. James and his wife enjoy taking walks and working in the garden together. James’s wife, Lisa, is employed full time as a case manager in the school system. Because they are both employed full time, they share household chores, money management tasks and childcare responsibilities.
Prior Medical History/Comorbidities:
Insulin Dependent Diabetes Mellitus
Hyperlipidemia
Hypertension
Abnormal left ventricular ejection fraction
Implanted Cardioverter Defibrillator
MOTOR:
James is right hand dominant. He presents with right upper extremity hemiparesis. He can flex his digits to grip and extend to release objects, however, has difficulty sustaining his grip for more than 10 seconds. He has difficulty using a pinch grip. He completes all transfers independently. He ambulates with a straight can without assistance in his home. When he is in the community he fatigues quickly and needs to take a rest break after walking about 200 feet. He wears an AFO most of the time, however, because he requires minimal assistance to don the device, he does not always wear it.
The following RUE AROM and Strength measurements were noted:
| RUE Motion | AROM Measurement | Strength |
| Shoulder flexion | 0-130 degrees | 4/5 |
| Shoulder abduction | 0-125 degrees | 4/5 |
| Shoulder external rotation | 0-30 degrees | 3/5 |
| Shoulder internal rotation | 0-25 degrees | 3/5 |
| Elbow flexion | 0-135 degrees | 4/5 |
| Elbow extension | full extension | 4/5 |
| Forearm supination | 0-65 degrees | 4/5 |
| Forearm pronation | 0-70 degrees | 4/5 |
| Wrist flexion | 0-50 degrees | 4/5 |
| Wrist extension | 0-40 degrees | 4/5 |
| Grip Strength (Dynamometer on setting 2) | Measurement: (Average of 3 trials) |
| Right hand | 14.5 lbs. |
| Left hand | 98.7 lbs. |
| Coordination (9-hole peg test) | Score |
| Right hand | 1 minute 2 seconds |
| Left hand | 15.7 seconds |
COGNITION:
Montreal Cognitive Assessment (MoCA)
| Category | Score |
| Visuospatial/Executive Function | 3/5 |
| Naming | 3/3 |
| Attention | 4/6 |
| Language | 3/3 |
| Abstract Thinking | 2/2 |
| Delayed Recall | 2/5 |
| Orientation | 4/6 Total Score: 21/30 |
James’s wife reports that he has trouble keeping track of activities and will often forget scheduled activities. He often forgets where he puts things.
VISION:
James wears glasses. He states that his vision is blurrier since the accident. He does not have any visual field loss.
| Visual Acuity (Snellen Eye Chart) |
| Right eye 20/40 |
| Left eye 20/30 |
| Binocular Vision 20/30 |
ACTIVITIES OF DAILY LIVING:
| ADL Task | Assistance Level | Comments |
| UE Dressing | Minimal Assistance | Assistance to fasten buttons, zippers, snaps |
| LE Dressing | Moderate Assistance | Able to get elastic waist pants and socks on. He requires assist if his pants have a fastener. He requires moderate assistance to don his AFO and slip-on shoes. He is unable to tie his shoes. |
| Grooming | Minimal Assistance | Assistance to shave. He can complete oral hygiene tasks independently. |
| Toileting | Minimal Assistance | Assistance for unfastening/fastening pants. Occasional minimal assistance for thoroughness with hygiene (wiping) following a bowel movement. |
| Bathing | Supervision | Patient only completes bathing tasks when wife is home. She supervises from the other room and does not need to be in the bathroom with him |
| IADL Tasks | Assistance Level | Comments |
| Laundry | Independent | After laundry basket is placed in the laundry room, he can complete the task. He is unable to carry the basket when using a cane. |
| Meal Preparation | Minimal Assistance | Able to complete 3-4 step meal preparation task with minimal assistance to open containers and verbal cues from his wife to remember what steps he has completed. He completes the meal prep tasks sitting down due to limited endurance and standing balance. |
| Vacuuming | ——— | He has not attempted vacuuming due to balance and the use of a cane when walking. |
| Childcare Tasks | Patient has not returned to driving tasks therefore he has not been transporting his children to their activities. He has not returned to coaching or helping in his children’s classroom. He has not returned to helping his children with their homework. | |
| Driving | ——— | Patient has not been released to drive. He states he feels he is ready to being the return to driving process. He is concerned with his ability to control the accelerator/brake with his right foot. |
| Money Management | Supervision | Patient is able to calculate basic change when purchasing items at the store. He completes online bill paying but his wife checks the information he enters before he submits |
| Return to Work | Patient has not yet returned to work. He takes a nap each day and states this does not fit with his prior work schedule. He feels that his problem-solving skills are slower than before and he may not be able to keep up with the speed required at work. His typing is slow due to hemiparesis and his job requires computer use. |
- Based on the evaluation findings list three short term goals and three long term goals that would be appropriate for this patient. Please make sure you link the short term and long-term goals together.
- Based on patient’s impairments list two outcome measures/assessments that you would choose to use during the evaluation. Use the following websites to ensure the outcome measures are valid and reliable in the stroke population.
Rehabilitation Measures | Shirley Ryan AbilityLab (sralab.org)
- Fill out the below chart using the above short-term goals.
| Impairment Addressed | Short Term Goal | Description of Treatment session to Address Goal | How can you grade the activity if it is too easy? If it is too difficult? |
- List two areas of education that would be beneficial to provide to this patient.
- Are there any precautions that you need to be aware of when working with this patient.
- List one community support network that your patient may benefit from.
