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1 A Case Study: Cerebrovascular Accident Elizabeth Osborne Saginaw Valley State University 2 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 3 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 4 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 5 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. 6 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 7 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. 8 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 9 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 10 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 Problem list 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: 11 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 12 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. 13 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. 14 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. 15 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.