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A Case Study: Cerebrovascular Accident
Elizabeth Osborne
Saginaw Valley State University
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This case study will focus on the history, diagnosis, observations of and pharmacological
assessment of a client that, for the purposes of protected health information, will be called “Mark”. This
case study will also include a detailed discussion of frames of references and a treatment plan that are
appropriate for Mark. Finally, additional medical or community services that are appropriate for Mark
will be recommended.
Personal data and history
The client, Mark, is receiving occupational therapy services because of left-sided weakness due
to a stroke. The client reported that he sustained two strokes and one heart attack within a six week
period last year. He originally was receiving physical therapy immediately after the stroke and was
“bounced around” to two different outpatient clinics that mainly focused on the use of his leg. He
reported that at one point, a therapist requested that he pick small items out of a sensory bowl, but
other than that, the only upper extremity therapy he received involved the use of an arm bike. The
client specifically requested in the initial evaluation that he not be put on any machines, and he also
insisted that his “shoulder is what needs therapy, not the hand”. Thus, the occupational therapist has
been focusing interventions on regaining strength and range of motion of his left shoulder. Mark is very
interested in travel and motorcycles. He is divorced, but has been in a serious relationship with a woman
for some time, and they live together. He has one pet dog, who he identifies as his baby boy, and he
spends most of his time with his girlfriend and dog, because he is retired. Mark has no medical history,
aside from his recent strokes and heart attack. The client reports that he had been overweight in the
past and upon doctor’s orders, had gone on a diet and lost 60 pounds. The client reports that he has no
pain, and that he is excited to finally see some results in occupational therapy.
Diagnosis and the client
Mark has been diagnosed with left-sided weakness status post a cerebrovascular accident
(CVA/stroke). CVA can be caused by either a blockage or a hemorrhage, termed ischemic or hemorrhagic
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stroke, respectively, although there are several types of stroke categorized under these two main types.
Ischemic strokes account for 80% of stroke cases. Hemorrhagic strokes are associated with a higher rate
of fatality than ischemic, however, individuals who survive a hemorrhagic stroke are reported to have a
higher rate of recovery than those after an ischemic stroke. In either case, blood flow which carries
oxygen and nutrients to the brain is interrupted and brain tissue is traumatized, or dies. Common
symptoms of a currently occurring stroke include sudden numbness or weakness of the face, arm or leg,
especially on one side of the body, sudden confusion, sudden trouble with seeing out of one eye or
both, sudden trouble with walking, dizziness, loss of balance or coordination. A physical exam,
neurological exam and/or neuroimaging can be performed to diagnose an individual with a CVA.
Functional deficits after a stroke can range from very mild to very devastating and should be
assessed on an individual basis. Impairments seen after a stroke include, but are not limited to: motor
dysfunction, sensory dysfunction, visual dysfunction, cognitive dysfunction, psychological dysfunction
and speech/language dysfunction. A patient may be paralyzed on one side of the body, which results in
uncoordinated posture, a disturbance in reflexes, and shoulder subluxation. Sensory dysfunctions
include any tactile, kinesthetic, proprioception, stereognosis, ideational or ideomotor, body scheme, or
motor planning sensory information and integration. Some issues related with visual dysfunction are
hemianopsias, problems with visual scan, search or sequencing, visual agnosia, or visuospatial agnosia
(Agnosia is the inability to recognize something you know). Cognitive dysfunctions include the inability
or decreased ability to problem solve, or give initiation, attention or recognition. Psychological
dysfunctions are denial, depression, emotional lability (changing), lack of volition, perseveration, and
impulsiveness. A person might also experience a speech/language dysfunction. This includes dysarthria,
as well as Wernickes and Brocas aphasias. Weakness or contractures developed because of stroke can
sometimes take a very long time to heal. Several known risk factors for CVA include ethnicity, being over
the age of 65, family history of stroke, obesity, history of smoking (doubles the risk of CVA), and having
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previously had hypertension. Hypertension is the most significant controllable risk factor for stroke and
heart disease.
Knowing the etiology, prognosis, risk factors and deficits associated with stroke is important in
order to implement strategies for gathering information in the initial evaluation and establishing the
treatment plan. It is unknown what type of CVA Mark endured. Discussed in detail later, Mark sustained
weakness to the left side of his body. He has almost no grip strength in the left hand, limited strength in
the left arm, slight trunk instability while walking or completing standing tasks and a shuffled,
asymmetric gait which has been greatly helped by previous physical therapy services received.
Fortunately, Mark does not have any visual, cognitive, speech, psychological or sensory deficits due to
his stroke.
Physical frame of reference
The biomechanical frame of reference is chosen for this individual because he established
biomechanical goals for himself and is purely focused on regaining his motion and strength in the
shoulder and upper arm. The biomechanical frame of reference is a bottom-up approach which involves
focusing on the client factors first, and adding functional occupation to the intervention plan later along,
after the client has regained fundamental skills and can apply that knowledge and experience toward
everyday activities.
The Neurodevelopmental frame of reference is typically used with the stroke population. The
Neurodevelopmental frame of reference was not selected for this individual because he does not yet
possess the motor skills necessary to incorporate keys points of control, handling, or righting activities.
The client is not experiencing any spasticity and the focus of therapy is not on postural instability.
Observation of evaluative elements
According to assessments administered in his evaluation, and conversations held in therapy
sessions, the client’s diagnosis has affected several of his areas of occupation. This case study examines
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the difficulties he experiences in his areas of occupation, performance patterns, performance skills,
context, activity demands, and client factors, as well as the occupational therapy interventions being
implemented. The chart below highlights which areas of occupation he is having difficulty completing
relative to his affected left upper and lower extremities.
Activities of Daily Living (ADLs)
Dressing
Ambulation
Meal preparation and cleanup
Shopping
Work and leisure
Cannot manipulate small objects like buttons, zippers,
snaps or belts. Cannot pick up items, such as shoes/belt.
Walks using a straight can for support. Good static
standing balance.
Unable to open jars, or pick up items. Cannot grasp, carry
or pour from a gallon of milk.
Unable to carry bags or items. Must push a cart
bilaterally, and has difficulty with that sometimes,
because of grip strength.
Client reports difficulty completing tasks at home and
work. He also reports that he cannot participate in
several of his leisure activities, such as motorcycle riding
and golf.
Performance Skills
Motor skills
Mobility
Coordination
Strength and effort
Energy
Performance patterns
Has some difficulty with postural stabilization while
walking and completing tasks. Uses a cane to help
stabilize. Does not have any difficulty with stabilization
while sitting
Walks using a straight cane, has some instability, and
shuffles feet while walking. Reaching and bending is done
very slowly as the client tries to stabilize his arm and
trunk during the process.
Cannot coordinate or manipulate objects using the hand.
The hand and upper extremity do not flow when
performing activities. The client cannot perform activities
involving gross or fine motor actions of the hand.
MMT of 3+/5 in gross arm movements. Client has
problems with pushing, pulling, transporting items, lifting
items, calibrating his speed and force relative to tasks,
and gripping objects.
The client paces himself, but does seem to distract easily.
It is difficult to converse with him without having to give
verbal cues to continue the activity.
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Habits
Roles
The client has a habit of non-use for the upper extremity
and specifically told the occupational therapist in his
initial evaluation that he wants more strength and range
of motion in the shoulder, not the hand. The client has a
habit of losing attention during activities, and giving up
on activities before he should.
The client is divorced, but has been dating a woman for
the past 5 years. He is retired. He identifies his pet dog as
his child.
Context
Cultural
Physical
Social
Personal
Temporal
The client’s family lives in several different areas of the
United States, so travel is very important to him. His
family holds value for outdoor activities and carpentry.
Mark identifies himself as a “man’s man”.
The client lives with his girlfriend near West Branch, MI.
His home is a 1 story home with a walk-in shower. He
uses 2 steps to enter his home from the garage and
reports no difficulty, although he steps very slowly to
maintain stability.
The client reports that his girlfriend completes many of
the household cleaning and cooking activities, although
he wants to participate more in household projects. The
couple attends church periodically and do invite friends
over for dinner or games periodically.
The client is a 62 year old male, retired, who greatly
enjoys motorcycles, his pet dog, and doing things with his
girlfriend.
The client is retired, so he has the time needed to devote
to therapy sessions. He comes to receive occupational
therapy services three times a week.
Activity demands of a typical therapy
session
Objects and their properties
Space demands
Tools used in therapy sessions include the non-slip free
weights ranging from 2-5 pounds, the bar weights with
grip handles ranging from 2-5 pounds for bilateral
exercises, the Velcro dowels for strengthening, and the 3
pound small weighted ball with a hand strap. The only
other equipment used during therapy are the plinths for
range of motion, stretching and scapular mobilization.
The exercise machine was used one time per the
patient’s request.
The space demands for therapy interventions vary, but
activities are performed inside the therapy room on one
of the large or the small plinth, they are done sitting at
the bedside, or standing, and some of the stability and
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Social demands
Sequence and timing
Required actions
Required body functions
strengthening exercises are performed in the hallway
against the large wall. At no time does the space required
for activities need to be any larger than a 3 foot radius
from the client.
Social demands include being able to hold a conversation
with the therapist or student while performing tasks.
Typically, interventions involve a one or two-step activity,
such as wall pushups using a large ball against the wall.
The client is instruction to push down, maintain his
stability in his arms and trunk, and push up, over and
over. Another example of a timing and sequencing
activity involves raising the weighted ball above his head
against the wall in a “12 o clock” position and releasing
the ball from the wall and placing it against the wall again
in the “1 o clock” position, releasing, and again
continuing the same pattern down to the 6 o clock
position to rise back up again, number by number.
The client is required to grip onto the weighted bar and
free weights. His grip strength is very low in his left hand,
so the therapist will compensate by holding his hand over
the weight when lifting free weights. When using the
weighted bar, the client’s right hand helps compensate
for the left hand. He is instructed to try to keep the bar
completely horizontal by using his shoulder muscles on
the left. The client is required to partially grip the
weighted ball, as the strap that goes over the dorsum of
the hand holds the ball in place more than the client
does. The client is required to perform standing pushups
against a large ball.
The client is required to be conscious and alert to
participate in therapy. It is required that the client
understands the expected actions of each activity and it is
required that the client can attend to multi-step
directions. A muscle grade strength of 3+/5 is required to
participate in weighted activities
Client Factors
Specific mental functions
Hearing and vestibular functions
The client does not exhibit sustained or divided attention.
He needs repeated verbal cues to stay on task, especially
if engaging in an activity. He does not appear to have any
difficulty with other mental functions.
The client does have hearing aids and has difficulty
hearing the therapist at times. The hearing dysfunction
does not impair his occupations at home, but does have a
slight impact in therapy with periodic
miscommunications.
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Functions of joints and bones
Muscle functions
Movement functions
Full passive range of motion is available. The client
experiences deficits in active range of motion in his entire
left upper extremity, but therapy is currently focused on
regaining sustained full active range of motion in the left
shoulder.
The muscle power, muscle tone, and muscle endurance
in the left upper shoulder, elbow, forearm, wrist and
composite hand are limited.
Involuntary movement functions are present when the
client reaches outside of midline. The involuntary
movements are presented as shakiness as the client
reaches into shoulder flexion, shoulder abduction,
controlled shoulder adduction, and horizontal shoulder
ab/adduction and when completing PNF patterns. The
client also has impaired gait pattern functions, in that he
has an asymmetric gait that sometimes affects his ability
to perform activities, such as bilateral tasks, when he
cannot use his cane for support.
Occupational therapy intervention approaches being implemented with Mark are focused on
restoring the skills and abilities he previous was capable of. The client’s primary concern is regaining
motion and strength in his shoulder and upper arm, so the current focus of the interventions are
restoration of his shoulder strength, endurance, and joint range of motion functions. Eventually, the
occupational therapist hopes to integrate hand therapy into the intervention plan, but that will depend
on the willingness of the patient to try.
Types of current occupational therapy interventions include therapeutic use of self, and
therapeutic use of occupations and activities through use of preparatory methods, as well as
incorporating consultation and education processes. The occupational therapist and student use their
knowledge of the importance of reminiscing and discussing meaningful topics with the client to
encourage him to participate and show endurance in activities, and to find meaning in therapeutic
exercises. The therapist does not currently implement any occupation-based activities, or purposeful
activities. The therapist implements passive range of motion stretching activities, weighted active range
of motion activities with free weights and weighted bars, and wall push-ups and push-offs as
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preparatory activities. The therapist regularly consults with the client for feedback on what he feels is
working, and what is not working. At one point, the client requested to be put on an arm bike, so the
therapist complied, even though the client had requested not to perform that activity at the beginning
of therapy. The therapist also continually has conversations with the client about his goals and educates
him on how the activities he performs in therapy relate to his personal goals and how they can be
implemented at home.
Types of outcomes intended for Mark include improvement in his occupational performance,
improvement in client satisfaction, improvement in role competence at his home, and an improvement
in his perceived quality of life. Occupational therapy services are implementing interventions to improve
the client’s range of motion, stability and strength in his left shoulder so that he can regain his ability to
complete ADL and IADL activities independently such as meal preparation and dressing. After therapy,
the client should experience an improvement in the role competence of being “man of the house”,
during which he should be able to complete the household projects he wants to accomplish
independently. The client’s satisfaction with the outcome of therapy should be related to his increased
independence with ADL performance and role competence. Mark’s overall quality of life should see an
improvement because of his increased occupational performance, role competence and satisfaction.
Pharmacological assessment
The client refused to give any information on whether or not he is taking any medications
related to his diagnosis or any other conditions. No information regarding medications were included in
his medical chart. Medication lists are important for the occupational therapist to have, because
medications can have an adverse effect on an individual’s performance skills or patterns. Sometimes, it
is beneficial to know the medication list and schedule so that therapy can be scheduled according to
when the client is at his/her peak performance. Because of his history of heart attack and stroke, it is to
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be assumed that the client is on some medication, but being that he is unwilling to disclose that
information for this paper, medication management will be left out of his intervention plan.
Treatment Plan
Asset/strength list
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Problem list
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The client is able to achieve functional
AROM in shoulder flexion/extension,
ab/adduction and horizontal
ab/adduction briefly.
The client is able to stand without use of
his cane to perform standing activities.
The client is able to work on
strengthening exercises because he does
not have any contractures.
The client cannot grip more than 3
pounds of weight, which impairs his
ability to go grocery shopping, or
complete household tasks.
The client is has 0 degrees of radial
deviation in his left hand, which affects
his ability to prepare meals.
The client has 45 degrees of wrist flexion,
which impairs his ability to dress himself.
Goals in relation to the problem list:
1. The client will increase his grip strength in his left hand from 3 pounds to 75 pounds, so that he
can grocery shop for his household, independently, within 14 treatment sessions.
2. The client will increase his range of motion in the wrist from 0 degrees of radial deviation to 20
degrees radial deviation, so that he can prepare a peanut butter and jelly sandwich,
independently, within 10 treatment sessions.
3. The client will increase his left wrist range of motion from 45 degrees of flexion to 80 degrees of
flexion, so that he can perform the activity of dressing himself using his belt, buttons and
tucking in his shirt, independently, within 12 treatment sessions.
Treatment:
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1. Preparatory methods will include NMES treatment for muscle recruitment, because studies
demonstrate the appropriateness of using intramuscular electromyographically controlled
neuromuscular electrical stimulation for facilitating the upper limb motor recovery of chronic
stroke survivors with mild to moderate hemiplegia (Chae, Walker & Pourmehdi, 2001, Hermann,
et al., 2010). A hot pack should be applied to the hand to warm up tissues before passive
stretch of the fingers, thumb and wrist. Joint mobilization of the fingers and thumb is another
preparatory activity that would be beneficial to Mark’s success. To increase grip strength in the
left hand, one purposeful method idea for treatment is to bring in old bicycle handlebars,
possibly with build-up handles for now, to simulate driving a motorcycle until he is able to drive
his own. Gripping the handlebars for 1 minute at a time, should increase his grip strength over
time and should be motivating to him because he loves motorcycles. The client can be
instructed to try performing this activity at home, of sitting on his motorcycle while turned off,
to see how long he can grip onto the handlebars. Another purposeful activity would be to set up
items around the room and list them on a sheet. The client will be informed to navigate the
room and put the items into his bag. This activity will simulate shopping and can be graded using
large or small items, with a light or heavy weight. Of course, the graded clothespin activity could
be implemented into therapy for increasing grip strength as well.
2. At the beginning of the session, radial and ulnar deviation stretch and hot pack would be useful
preparatory activities. Another preparatory activity could include self-range of motion education
and activities to include “windshield wipers” in which the client radially and ulnarly deviates
both of his hands without compensating for movement using his shoulder. Joint mobilization
and/or approximation of all aspects of the wrist is indicated to increase his range of motion in
that area. To help increase the client’s radial deviation from 0 to 20 degrees, the BTE simulator
with the jar top tool will be used. This activity will simulate what the goal is, which is to become
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more independent with making himself a peanut butter and jelly sandwich. The jar lid tool is
very similar to the kinds of tops that Mark will need to manipulate in the kitchen at home. When
participating on the BTE simulator in the beginning of the treatment plan, the BTE resistance
level will be turned down to 0 resistance, and it will progress to more resistance as the client can
tolerate to build strength in the hand and the arm. As the client’s therapy progresses, the
occupation-based activity of opening jars of food could be implemented into the therapy
sessions so the client is sure he can perform the task at home, independently.
3. Preparatory activities for improving Mark’s wrist flexion range of motion include a hot pack over
the whole hand area at the beginning of the treatment session, joint mobilization and
approximation of the carpal joints, passive stretch into wrist flexion and extension, and possibly
NMES to recruit muscle fibers. According to de Jong, Dijkstra, Stewart & Postema (2012), passive
range of motion occurring for longer than a two-week period shows significant improvement in
available active range of motion. Purposeful activities to improve wrist range of motion include
activities on the BTE simulator. Several of the tools, like the screwdriver, can be used to facilitate
wrist flexion. No resistance or very light resistance could be implemented at first, followed by
added resistance as therapy progresses. A dressing board including buttons, snaps, belts and
zippers would be very beneficial to the patient for practice with the small parts of dressing he
has difficulty with. The occupation-based activity of bringing in a large old pair of sweatpants
and a shirt for simulated dressing in the clinic would be very beneficial for the client’s success.
Actually having his clothing to work with will show both the client and the therapist what still
needs work. Catherine Trombly (1995) of the Eleanor Clarke Slagle Lectures discusses and
proves the importance of incorporating occupation based activities in occupational therapy
interventions.
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Other services and recommendations
Physical therapy services to address the remaining gait issues may be appropriate, but the client
seems to be happy with his gait pattern as is. I would explain to the client that physical therapists
would be able to help him address his gait patterns and his slight trunk instability when walking and
performing leaning activities while standing. I would explain that basically, physical therapy services
should make him feel more safe in his body while performing tasks. I would provide information
regarding physical therapy services and outcomes to the client and see if that is something that he is
interested in. The client is enrolled in Medicare, and does have a Medicare social worker to handle
his medical needs and economic problems. Depending on any adaptive equipment discussed at the
end of therapy, such as built up handles, contacting his social worker may be necessary to provide
Mark with the equipment he may need.
Psychological and social impact on therapeutic intervention
The client lives home alone with his girlfriend and his dog, so I think that getting out of the
house and attending therapy three times a week will have a social and psychological impact on
Mark, because it gives him the opportunity to tell his stories to new people, and to learn new things
from people. Attending therapy should boost his mood, because he spends most of his time at
home during the winter. At times, the client appears to have body image issues since his stroke.
Although he is constantly raving about his weight loss, he is sometimes psychologically brought
down by his asymmetric gait and his affected upper arm. The client is very excited to be able to get
back to performing what he identifies as his role in the house (household projects, yardwork, etc.).
His hobbies and interests also have an impact on therapeutic interventions, because interventions
can change to occupation-based activities so that he feels his input is valuable and also sees
meaning and purpose in the activities he participates in while at the clinic.
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Discharge plan
Depending on the success of the client in therapy, additional sessions may be requested. This,
however, may not be an option based on the socioeconomic status of the client. Currently, he is not
participating in any expensive treatment modalities, and as a healthcare professional, it is important
to keep in mind that sometimes it is more helpful to send clients home with “free knowledge” on
how to adapt the home environment on their own, instead of purchasing expensive equipment,
such as manufactured build up handles. The client is motivated in therapy, receives support from
home, and is already seeing improvement in his shoulder functions, so it is not apparent that any
additional factors will be involved when the client is discharged from the facility.
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References
Chae, J., Fang, Z., Walker, M., & Pourmehdi, S. (2001). Intramuscular electromyographically
controlled neuromuscular electrical stimulation for upper limb recovery in chronic hemiplegia.
American Journal of Physical Medicine & Rehabilitiation, 80(12), 935-941.
de Jong, L.,D., Dijkstra, P. U., Stewart, R. E., & Postema, K. (2012). Repeated measurements of arm joint
passive range of motion after stroke: Interobserver reliability and sources of variation. Physical
Therapy, 92(8), 1027-35. Retrieved from
http://search.proquest.com/docview/1033331316?accountid=960
Hermann, V. H., Herzog, M., Jordan, R., Hofherr, M., Levine, P., & Page, S. J. et al. (2010).
Telerehabilitation and electrical stimulation: An occupation-based, client-centered stroke
intervention. The American Journal of Occupational Therapy,64(1), 73-81. Retrieved from
http://search.proquest.com/docview/231971535?accountid=960
Trombly, C. A., (1995). Occupation: Purposefulness and meaningfulness as therapeutic mechanisms.
American Journal of Occupational Therapy, 49, 960-972.