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  



Abnormal left ventricular ejection fraction

Implanted Cardioverter Defibrillator


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 MotionAROM Measurement Strength
Shoulder flexion0-130 degrees4/5
Shoulder abduction0-125 degrees4/5
Shoulder external rotation0-30 degrees3/5
Shoulder internal rotation0-25 degrees3/5
Elbow flexion0-135 degrees4/5
Elbow extensionfull extension4/5
Forearm supination0-65 degrees4/5
Forearm pronation0-70 degrees4/5
Wrist flexion0-50 degrees4/5
Wrist extension0-40 degrees4/5
Grip Strength (Dynamometer on setting 2)Measurement: (Average of 3 trials)
Right hand14.5 lbs.
Left hand98.7 lbs.
Coordination (9-hole peg test)Score
Right hand1 minute 2 seconds
Left hand15.7 seconds


Montreal Cognitive Assessment (MoCA)

Category Score
Visuospatial/Executive Function3/5
Abstract Thinking2/2
Delayed Recall2/5
Orientation4/6                    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.


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


ADL TaskAssistance Level Comments
UE DressingMinimal AssistanceAssistance to fasten buttons, zippers, snaps
LE DressingModerate AssistanceAble 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.
GroomingMinimal AssistanceAssistance to shave. He can complete oral hygiene tasks independently.
ToiletingMinimal AssistanceAssistance for unfastening/fastening pants. Occasional minimal assistance for thoroughness with hygiene (wiping) following a bowel movement.
BathingSupervisionPatient 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 TasksAssistance Level Comments
LaundryIndependentAfter 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 PreparationMinimal AssistanceAble 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 ManagementSupervisionPatient 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.
  1. 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 AddressedShort Term GoalDescription of Treatment session to Address GoalHow 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.

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