Hand dominance and the functional recovery of the upper extremity in CVA : two case studies

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1 The University of Toledo The University of Toledo Digital Repository Master s and Doctoral Projects Hand dominance and the functional recovery of the upper extremity in CVA : two case studies Shawna K. Semer The University of Toledo Follow this and additional works at: This Capstone Project is brought to you for free and open access by The University of Toledo Digital Repository. It has been accepted for inclusion in Master s and Doctoral Projects by an authorized administrator of The University of Toledo Digital Repository. For more information, please see the repository's About page.

2 Running Head: HAND DOMINANCE Hand Dominance and the Functional Recovery of the Upper Extremity in CVA: Two Case Studies Shawna K. Semer Faculty and Site Mentor: Lynne Chapman, MS, OTR/L, LICDC Occupational Therapy Doctorate Program Department of Rehabilitation Sciences The University of Toledo May 2011 Note: This document describes a Capstone Dissemination project reflecting an individually planned experience conducted under faculty and site mentorship. The goal of the Capstone Experience is to provide the occupational therapy doctoral student with a unique experience whereby he/she can demonstrate leadership and autonomous decision making in preparation for enhanced future practice as occupational therapists. As such, the Capstone Dissemination is not formal research.

3 HAND DOMINANCE 2 Abstract Cerebral vascular accidents (CVA) can have devastating effects on the function of the upper extremity. There is little research in occupational therapy literature considering the effects of hand dominance on the functional recovery of the upper extremity after CVA. The purpose of this case report is to further investigate how specific occupational therapy interventions developed with a focus on hand dominance impact the functional recovery of the upper extremity following a CVA. The Neuro-Developmental Treatment model of practice (Bobath, 1970) and The Ecology of Human Performance framework (Dunn, Brown, & McGuigan, 1994) guided the evaluation and intervention process during this case report. The Modified Version of the Wolf Motor Function Test (Taub, Miller, Novack, Cook, Fleming, Nepomuceno, Connell, & Crago, 1993) and the Bobath Evaluation of Adult Hemiplegia (Bobath, 1970) were used as outcome measures to assess the functional gains of the upper extremity after intervention. Interventions were tailored to each patient s hand dominance; with the patient whose dominant side was affected incorporating the affected upper extremity in bilateral and fine motor occupations. The patient whose non-dominant side was affected participated in interventions while using the affected upper extremity as a gross assist to the dominant upper extremity. Based on the findings of this case study, it can be stated that creating interventions that are specific to hand dominance after stroke have positive functional outcomes for the affected upper extremity.

4 HAND DOMINANCE 3 Introduction Since the beginning of the profession, occupational therapists have worked with patients recovering from cerebral vascular accidents. However, literature focusing on interventions in relation to hand dominance and the functional recovery of the affected upper extremity is scarce. The purpose of this case report is to further investigate how specific occupational therapy interventions developed with a focus on hand dominance impact the functional recovery of the upper extremity following a cerebral vascular accident. The Neuro-Developmental Treatment model of practice (Bobath, 1970) and The Ecology of Human Performance framework (Dunn, Brown, & McGuigan, 1994) guided the evaluation and intervention process during this case report. Two patients from The University of Toledo Medical Center (UTMC) agreed to participate in the case report, one whose dominant side was affected and one whose nondominant side was affected. It should be noted that the following two case studies are not meant to be compared to one another due to the differences in lesion location, diagnoses, age, and spontaneous recovery. However, the case studies are meant to further investigate how specific interventions tailored to the individual s hand dominance effect the functional recovery of the upper extremity following a cerebral vascular accident. Literature Review Hand Dominance. There has been little research conducted in the field of occupational therapy investigating the effect that hand dominance has on the functional recovery of the upper extremity in patients with cerebral vascular accident. Harris and Eng (2006) conducted a study to determine if upper extremity impairment and function in patients with chronic stroke is dependent on whether the

5 HAND DOMINANCE 4 dominant or non-dominant upper extremity was affected. There were a total of 93 community dwelling individuals with stroke who participated in this study. Eighty-five of the participants were right-handed and only eight were left-handed. Forty participants were affected on the right side and 53 were affected on the left side. A total of 42 participants were affected on the dominant side and 51 were affected on the non-dominant side. Outcome measurements included the use of the Modified Ashworth Scale, handheld dynomometry, monofiliments, Brief Pain Inventory, and Chedoke Arm and Hand Living Index. There were no significant differences found for the impairment variables of strength, grip, tone, and sensation between participants who sustained right versus left hemisphere lesion (Harris & Eng, 2006). Pain was different, with participants with right hemisphere lesion reporting more pain (Harris & Eng, 2006). Overall, the results of the study show that individuals with the dominant side affected demonstrated less impairment than the participants with the non-dominant side affected; however, this study did not find an effect on measures of function (Harris & Eng, 2006). According to Harris and Eng (2006, p. 386), Those with the dominant hand affected showed no advantage on scores of function over those with the nondominant hand affected. Once tasks become more complex (e.g., dressing, eating, and bathing), persons with stroke may begin to use compensatory strategies including adaptive equipment, thus minimizing the effect of hand dominance. The authors also discuss how the results of the study may be because individuals with their dominant side affected utilize the upper extremity more frequently after a stroke. Less impairment in the affected upper extremity may be due to more frequent activity than the nondominant upper extremity (Harris & Eng, 2006).

6 HAND DOMINANCE 5 Another study conducted by Rinehart, Singleton, Adair, Sadek, and Haaland (2009) investigated whether right hand preference influences the relative use of both the right and left upper extremity post-stroke. Participants of the study included 29 right-handed patients, 17 with left hemisphere damage (dominant side affected) and 12 with right hemisphere damage (nondominant side affected, and 25 right-handed healthy control subjects. The Arm Motor Ability Test was used as an outcome measure along with wrist accelerometers. The results of the study suggest that the use of the ipsilesional (non-affected side), but not the contralesional (affected side) upper extremity after unilateral stroke is influenced by hand preference in right-handed patients only (Rinehart et al., 2009). Other findings suggest that the right hemisphere damaged patients used their ipsilesional upper extremity (dominant side) alone approximately four times more often than their contralesional upper extremity (non-dominant side) and the left hemisphere damaged patients used their ipsilesional upper extremity (non-dominant side) alone approximately two times more frequently than the contralesional upper extremity (dominant side) (Rinehart et al., 2009). There were also significant differences in ipsilesional and bilateral arm use, but not contralesional arm use, after right hemisphere damage and left hemisphere damage (Rinehart et al., 2009). Neuroplasticity Associated with Upper Extremity Recovery Following CVA. Neuroplasticity is a fairly new phenomenon in the world of neuroscience. For the past two decades, human and animal studies have been conducted to research the cortical and subcortical changes that occur in the brain after an insult. According to Lledo, Alonso, and Grubb (2006), brain plasticity can be referred to the brain s ability to adapt its structure and function during maturation, learning, environmental challenges, or pathology. After an insult, the brain reorganizes itself in relation to recovery of motor function (Schaechter, 2004). This

7 HAND DOMINANCE 6 recovery of motor function can be attributed to the following changes occurring in the brain: increased recruitment of contralesional motor areas, increased activity in non-primary motor areas and the focalization of ipsilesional sensorimotor areas, the changes in functional and effective connectivity between hemispheres, and decreased coupling between ipsilesional supplementary motor area and primary motor area (Wang et al., 2010). Three mechanisms are discussed in Butfisch (2006) that are thought to mediate cortical reorganization following a stroke: the unmasking of existing, but latent horizontal connections, the modulation of synaptic efficacy such as long-term potentiation or long-term depression, and experience dependent increases in dentritic spines and synaptogenesis. Changes in the structure of the brain, such as increased cortical thickness in the ipsilesional sensorimotor area and increased integrity of whole brain white matter also provide evidence of neuroplasticity following a stroke (Wang et al. 2010). Byrnes, Thickbroom, Phillips, Wilson, and Mastagalia (1999) studied the cortical reorganization following a stroke in both acute and chronic stroke cases. The result of the study shows the reorganization of the primary motor cortex with a lateral extension of the cortical hand representation into the face area. The expansion of the cortical area of the affected hemisphere has been shown to occur with increased use of the affected extremity, enhanced sensory feedback from the hand, and during the acquisition of a novel task (Byrnes et al., 1999). This study provides implications to occupational therapy and the rehabilitation of the upper extremity after stroke. Through the use of meaningful and purposeful movements in patients with stroke, which is provided in this case study, cortical changes can occur and functional ability increases.

8 HAND DOMINANCE 7 Diagnoses and Patient Information Case 1. JB is a 17-year-old right-handed male with a diagnosis of an acute right internal capsule ischemic stroke. He was admitted to The University of Toledo Medical Center on 02/07/2011 after experiencing weakness affecting his non-dominant side. JB also has secondary diagnoses of a patent foramen ovale (PFO), dyslipidemia, and attention deficit hyperactivity disorder (ADHD). JB was independent with all of his occupations of daily living (ODL) and instrumental occupations of daily living (IODL) prior to his stroke. He is a junior in high school and participates in theatre, choir, and track. JB is very active in the community and church, where his mother is the pastor. His hobbies include playing video games and listening to music. For this case report, JB was followed throughout both his inpatient and outpatient rehabilitation. After being in acute rehabilitation for three to four days, JB was moved to the inpatient rehabilitation unit where he stayed for only a week before being discharged home. JB had inpatient rehabilitation at The University of Toledo Medical Center (UTMC) and outpatient rehabilitation at The Fulton County Health Center Rehab in Wauseon, Ohio. JB participated in outpatient rehabilitation for a total of three weeks before he was discharged from occupational therapy and physical therapy services. Case 2. VA was also a participant in this case study. He is a 41-year-old right-handed male who was diagnosed with traumatic brain injury and cerebral vascular accident with hemiparesis affecting his dominant side. VA was admitted to The Toledo Hospital on 8/26/10 after being struck by a drunk driver while crossing the street with his friend. VA developed respiratory distress and was intubated and placed on a ventilator. In addition, he sustained a ruptured

9 HAND DOMINANCE 8 thoracic aorta, fractured ribs on the left side, ruptured three thoracic vertebrae, and right cranial nerve VI palsy. He was then transferred to another hospital where he was weaned from the ventilator. He remained there until he was transferred to in-patient rehab hospital at UTMC for comprehensive inpatient rehabilitation on 10/06/10. VA s therapy progress was limited in inpatient rehabilitation due to his frustration, decreased initiation, and refusal to participate in therapy. He was discharged home on 10/25/10 where he lives with his wife and two of his five children. VA started outpatient rehabilitation at the Coghlin Rehabilitation Center UTMC on 10/29/2010 for occupational therapy, physical therapy, and speech therapy. At the time of this case report, VA had occupational therapy and physical therapy three days a week and speech therapy two days a week. He presented initially with severe cognitive deficits, oculomotor control impairments, diplopia, right upper extremity hemiparesis, decreased strength and coordination in both his right and left upper extremities. Models of Practice and Frames of Reference Neuro-Developmental Treatment (Bobath, 1970). The Neuro-Developmental Treatment (Bobath, 1970) model of practice was developed by Karel and Berta Bobath in the 1940 s and was utilized in the treatment of patients with cerebral palsy and hemiplegia. The focus of this model of practice is to minimize abnormal movements and restore normal movements. When treating patients, Berta Bobath identified abnormal stiffness in their affected extremities, asymmetrical body postures, and non-functional stereotypical patterns of movement in the involved side. She discovered that she could help these patients with hemiplegia learn to move more freely and function with less compensation when muscle tone was normalized (Bobath, 1970).

10 HAND DOMINANCE 9 Berta s intervention methods addressed problems of abnormal tone and normal movement while facilitating sensory information to organize and execute. Methods of intervention are referred to as handling techniques. Through the use of handling the therapist certified in the NDT approach can provide specific tactile, proprioceptive, and kinesthetic input to organize the quality of the patient s movements. Handling incorporates two types of techniques: inhibition and facilitation. Inhibition is utilized in treating hypertonicity and subsequent abnormal coordination. The therapist uses inhibition to decrease spasticity and subsequent abnormal movement patterns. Facilitation is used to help patients relearn or learn normal movements. During facilitation, the therapist establishes light contact with key points of control and manually assists the patient with normal patterns of movement (Bobath, 1970). During the evaluation, the therapist determines the patient s functional abilities as well as the limitations. The therapist determines if the patient has abnormal tone, impaired postural control, difficulty isolating selective movement, or loss of or changes in sensation. The information obtained during the evaluation is then used for planning treatment. Using the NDT approach, goals focus on increasing independence in self-maintenance roles, preventing the development of abnormal tone and movements, and increasing motor control on the hemiplegic side (Bobath, 1970). Scientific Evidence of NDT Model to Occupational Therapy. There have been many studies in the past with the purpose of determining the effectiveness of the Neuro-Developmental Treatment (Bobath, 1970) model of practice in rehabilitation after stroke and comparing it to other neurorehabilitation models; however, there has been no clear cut evidence of NDT s effectiveness. According to Ashburn, Partridge, and De Souza (1993), the reason why it is difficult to evaluate the effectiveness of physiotherapy for

11 HAND DOMINANCE 10 adults with hemiplegia is problems with the methodology of the studies. For example, population characteristics such as participants age, time since stroke, and site of lesion offer little homogeneous patient samples. Also interventions and outcome measures promote little homogeneity as well. For this reason, it is difficult to determine who is benefitting from the use of NDT and who is benefitting for other reasons (Ashburn, Partridge, & De Souza, 1993). Paci (2005) conducted a systematic literature review including 15 total trials; six were randomized controlled trials, six were non-randomized controlled trials, and three were case series. Results of the selected trials showed no evidence proving the effectiveness of the NDT model of practice or supporting NDT as the optimal treatment following cerebral vascular accident, neither do the trials show evidence of non-efficacy because of methodological limitations (Paci, 2005). Luke, Dodd, and Brock (2004) conducted a literature review of eight articles to determine the effectiveness of the Bobath concept at reducing upper limb impairments, activity limitations, and participation restrictions after stroke. In regards to upper extremity impairment, one study provided some evidence that interventions based on the NDT model can improve shoulder pain better than cryotherapy; however, after a four week follow up, no significant difference was detected between the two (Partridge, Edwards, Mee, & Van Langenberghe, 1990). The Bobath concept appeared to be no more effective than other approaches at improving motor control (Luke, Dodd, & Brock, 2004). When compared to other models, Dickstein, Hocherman, Pillar, and Shaham (1986, p. 891) found no significant difference between the effect of Bobath intervention, PNF, and functional approaches on active wrist range of movement measured by goniometry. Overall, it was concluded by Luke, Dodd, and Brock (2004) that there is no current evidence to prove NDT is more effective than other approaches.

12 HAND DOMINANCE 11 The Ecology of Human Performance Framework (Dunn, Brown, & McGuigan, 1994). The Ecology of Human Performance (EHP) framework was developed by Dunn, Brown, and McGuigan (1994) occupational therapy staff at the University of Kansas Medical Center. The EHP framework was developed to investigate the relationship between important constructs in the practice of occupational therapy: person, context (temporal, physical, social, and cultural), tasks, performance, and therapeutic intervention, to better understand the domain of human performance (Dunn, Brown, & McGuigan, 1994, p. 598). Ecology is the primary theoretical postulate fundamental to the framework, which is defined as the interaction between person and the environment that affects human behavior. Performance of the individual cannot be understood outside of the context. In this framework, the person includes one s experiences and sensorimotor, cognitive, and psychosocial skills and abilities (Dunn et al., 1994). According to this framework tasks are objective sets of behaviors necessary to accomplish a goal (Dunn et al., 1994, p. 599). Every individual has various different tasks they can choose to engage in. When engaging in the tasks, individuals use their skills and abilities to focus attention on a specific task and they use environmental cues and features to support their performance. When context is used to support occupational performance, the resulting scope of action is called the performance range, which is how the individual perceives the world and the configuration of tasks that the person executes. According to Dunn et al. (1994, p. 599), everyone looks through a context to derive meaning about needs or desires. The EHP framework considers the individual person s life roles which are a constellation of tasks (Dunn et al., 1994). People typically have many different life roles that are based on

13 HAND DOMINANCE 12 their individual skills, abilities, context, and desires. When a person has limited skills and abilities, the person may derive less meaning from the context or may not have the resources necessary to support performance which can result in a limited performance range (Dunn et al., 1994). It is not uncommon for people with limited skills and abilities to be surrounded by an impoverished context. On the other hand, one may have adequate skills and abilities, however, is limited by the contextual environment (Dunn et al., 1994). There are five main components of therapeutic intervention in the EHP framework: establish or restore, alter, adapt, prevent, and create (Dunn et al., 1994). According to Dunn et al., (1994, p. 603), therapeutic intervention is a collaboration among the person, the family, and the occupational therapist directed at meeting performance needs. When attempting to establish or restore, the occupational therapist identifies the person s skills and abilities and the barriers to performance to develop the methods of intervention to remediate the skills (Dunn et al., 1994). Restorative approaches are commonly used to guide interventions in occupational therapy practice. The therapist determines the problems, goals, and methods of intervention that will be utilized. Another therapeutic intervention method reflective of the EHP framework is to alter the context in which the person performs. According to Dunn et al., (1994, p. 603) this intervention emphasizes selecting a context that enables the person to perform with current skills and abilities. The important feature of this intervention method is that the therapist does not establish a goal of correcting the problem, but provides the best match between the person and the context. This intervention method was used for both patients. For JB this intervention method was used to help prepare him for his youth group trip. For VA, the context of the cooking environment was altered to support a successful occupational performance.

14 HAND DOMINANCE 13 Another intervention method that is used in the EHP framework is to adapt the contextual features and task demands to support performance in context (Dunn et al., 1994). When the occupational therapist adapts, he or she designs a more supportive context for the person s performance. This can be done by enhancing a feature within the context or by reducing the feature that can make the task more manageable for the person. This intervention method was used the most during the case study. Another therapeutic intervention method used is to prevent the occurrence or evolution of maladaptive performance in context (Dunn et al., 1994). Oftentimes therapists can prevent negative outcomes from occurring if specific interventions are utilized. In the EHP framework, occupational therapists can design interventions that will change the variables to prevent maladaptive performance (Dunn et al., 1994). These prevention intervention strategies are effective options for individuals who have long-term conditions that can lead to secondary problems. Using this method, the temporal context is relevant to the outcomes of the individual (Dunn et al., 1994). The last therapeutic intervention method that can be used with the EHP framework is creating circumstances that promote more adaptable or complex performance in context (Dunn et al., 1994, p. 604). When using this intervention method, the therapist does not assume that a disability will interfere with performance and provides expertise to enrich contextual and task experiences that will enhance performance. Scientific Evidence of EHP Framework to Occupational Therapy. The Ecology of Human Performance (Dunn et al., 1994) framework provides the profession of occupational therapy with theoretical guidelines to follow for evaluation and intervention while considering the context. There currently is no literature that provides

15 HAND DOMINANCE 14 evidence on the effectiveness of this particular framework. The purpose of the development of the EHP framework was to bring attention to the importance of contextual factors on evaluation and intervention in occupational therapy, not to develop a framework that is superior to others. According to Dunn et al. (1994) there is relevant literature available that discusses the concept of the environment in theoretical occupational therapy. Many theorists in the profession of occupational therapy discuss the interaction between the person and the environment (Fidler & Fidler, 1970; Reilly, 1962; Kielhofner & Burke, 1980; Nelson, 1988). Rationale for Use of NDT Model and EHP Framework. The Neuro-Developmental Treatment (Bobath, 1970) model of practice was chosen for this case study because the basic theoretical principles of this model focus on minimizing abnormal tone and movement patterns. In order to improve function of the upper extremity following a stroke, the normalization of tone and movement patterns must be addressed. The two patients who participated in this case study both experienced abnormal tone and movement patterns, so the NDT approach provided a solid foundation to guide specific interventions to restore function in the affected upper extremity. The Ecology of Human Performance (Dunn, Brown, and McGuigan, 1994) framework was also chosen to guide interventions for this case study because of the framework s specific focus on context. Clinical observation was utilized throughout the case study in a variety of different contexts to get a more holistic view of the patients and how they function in different environments. For example, the patients were observed in the clinic, home, and community settings. Conducting home and community visits with the patients offered a better understanding of their social and cultural context. Dunn, Brown, and McGuigan (1994, p.598) state the only

16 HAND DOMINANCE 15 way to see the person is to look through the context. In order to do this, it was important to consider how the patients interacted in different environments. Case Innovativeness and Creativity This case report focuses on the rehabilitation of the upper extremity after cerebral vascular accident. Specific evaluation tool and interventions were created for each participant in the case report. Two individuals whose stroke affected different sides of the body had interventions created for their recovery based on hand dominance. This case report is innovative based on the fact that there has been little research conducted on the outcomes of specific intervention strategies based on an individual s hand dominance and what side is affected following a stroke. This case report was conducted to raise awareness on the importance of considering hand dominance when developing interventions for individuals with hemiplegia. Evaluation The Modified Version of the Wolf Motor Function Test (Taub, Miller, Novack, Cook, Fleming, Nepomuceno, Connell, & Crago, 1993) The Wolf Motor Function Test (WMFT) was designed to assess motor ability of patients with cerebral vascular accident and traumatic brain injury. This assessment quantifies upper extremity movement ability through timed single and/or multiple joint motions and functional tasks. There are a total of 17 different tasks to be completed that progress from proximal to distal joint movement. Tasks one to six involve timed joint-segment movements and tasks seven to 15 consist of timed integrative functional movements. Quality and speed of movement are rated by the therapist on a functional ability scale ranging from zero to five, with zero indicating the patient does not attempt the movement and five indicating the patient does the movement and it appears normal. See Table 1 for complete scoring information of the Functional Ability Scale.

17 HAND DOMINANCE 16 Studies have been conducted looking at the psychometric properties of the WMFT (Morris, Uswatte, Crago, Cook, & Taub, 2001; Whitall, Savin, Harris-Love, & McCombe Waller, 2006; Wolf, Catlin, Ellis, Link Archer, Morgan, & Piacentino, 2001). These studies have provided evidence of the reliability, validity, and feasibility of the assessment. Morris et al. (2001) determined that the WMFT is an instrument with high inter-rater reliability, internal consistency, test-retest reliability, and adequate stability. The WMFT takes approximately 30 minutes to complete and is simple to administer in the clinical setting. The WMFT was administered as a pre- and post-assessment for both JB and VA to assess the progress of motor recovery of the affected upper extremity. Case 1: JB. The pre-treatment WMFT (Taub et al., 1993) was conducted on 02/14/2011, seven days after his stroke occurred. JB was a patient in the inpatient rehabilitation program at UTMC, but was transported by wheelchair to the Coghlin Rehabilitation Center at UTMC to participate in the testing. The WMFT (Taub et al., 1993) was set up in a quiet room and the administration was videotaped upon written consent from JB and his mother. JB s left upper extremity was tested according to protocol. Jacob scored a four on the Functional Ability Scale for the following tasks: extending elbow, extending elbow with one pound weight, and reaching and retrieving a one pound weight. A Functional Ability Score of three was given for all other tasks, meaning he completed the movement but with synergy and effort. For the strength tasks, JB was able to lift his left upper extremity to the box with a one pound weight on his wrist/forearm, and his grip strength measured at 16 pounds. In the area of speed, JB s quickest recorded time was during task one (forearm to table) and his slowest recorded time for task 12 (stacking checkers).

18 HAND DOMINANCE 17 JB returned as an outpatient to complete the post-treatment assessment of the modified WMFT (Taub et al., 1993) on 03/28/2011, exactly seven weeks post-stroke. Upon postassessment, JB was no longer participating in outpatient occupational or physical therapy near his home as he met all of his goals. JB made significant improvements in both speed and functional ability in all 17 tasks of the modified WMFT (Taub et al., 1993). He received a Functional Ability Score of five for all of the performed tasks, meaning his movements in all tasks appear normal. In the area of speed, JB improved the most on the stacking checkers task with an improvement of seconds. For the strength tasks, JB improved nine pounds on task seven (weight to box) and his grip strength improved 43 pounds, which was almost double his goal for grip strength. See Table 2. for all recorded scores and times for pre-treatment and posttreatment administration of the modified WMFT (Taub et al., 1993). Overall, JB showed significant gains on his affected side (non-dominant) in areas of upper extremity coordination, strength, speed and quality of movement. Improvements in both proximal and distal control were noted as well. During the pre-intervention assessment, JB used excessive effort and experienced flexor synergy while completing the movements. At postintervention assessment, JB no longer displayed flexor synergy and completed each of the 17 tasks using normal movements. Case 2: VA. The pre-treatment assessment was administered on 2/11/2011 in a small quiet room at the Coghlin Rehabilitation Center at UTMC. VA gave written consent for the testing to be videotaped and used for educational purposes. VA s right (dominant side) upper extremity was tested according to the modified WMFT (Taub et al., 1993) protocol. VA required a substantial amount of time to complete all 17 tasks. He was verbally prompted many times during the

19 HAND DOMINANCE 18 assessment to complete each task as quickly as he can. The therapist asked VA if he was completing each task as quickly as possible. His response was I had a stroke on this arm. This is as fast as I can go! Task 13 (flipping cards) took VA the longest to complete of all the tasks with a total time of seconds. He completed task one (forearm to table) the quickest with a total time of 1.73 seconds. VA received a Functional Ability Score of three for the following tasks: forearm to box, extend elbow, extend elbow with weight, hand to table, and hand to box. A Functional Ability Score of three means that VA completed the movement, but it is influenced to some degree by synergy or is performed slowly or with effort. In VA s case, he presented with minimal flexor synergy and he performed the movement very slowly. For the strength tasks, VA was able to lift a two pound weight on his wrist to a box placed on the table. His grip strength for his right upper extremity was 29 pounds. The post-treatment assessment administration of the modified WMFT (Taub et al., 1993) was conducted in the same room as the pre-treatment assessment at UTMC and using the same protocol. VA gave his consent for the student occupational therapist to video tape the assessment. VA made significant improvements in strength, speed, and quality of movement in his dominant affected upper extremity. For speed of movement, VA made significant improvements in all 15 tasks except for task 11 which required picking up a paper clip with his affected upper extremity. VA kept dropping the paper clip and laughing which increased the amount of time to complete the task. VA kept stating during the paper clip task, I can t pick it up! When tasks become challenging for VA he laughs uncontrollably, due to lability from his stroke. With quality of movement, VA improved his Functional Ability Score from four to five on the following tasks: forearm to table, reach and retrieve, stack checkers, flip cards, fold towel,

20 HAND DOMINANCE 19 and lift basket. He improved his Functional Ability Score from three to five on the forearm to box task. VA also improved from a three to four on the following tasks: extend elbow, extend elbow with weight, hand to table, and hand to box. VA s Functional Ability Score stayed the same with a score of four on the tasks requiring gross and fine motor coordination of his affected upper extremity; lifting the can, pencil, and paperclip. During the task requiring him to lift the pop can to his mouth, VA hit his tooth with the can due to his decreased gross motor coordination in his right upper extremity. When lifting the pencil and paperclip, VA had difficulty picking both up quickly. VA had a significant increase in strength on his affected (dominant side) upper extremity. His grip strength improved 15 pounds on his right upper extremity and he was able to lift a 10 pound weight strapped to his forearm to a box on the WMFT placemat, which is an eight pound improvement from the pre-treatment assessment. Overall, VA made significant functional gains on his affected upper extremity; however, he still continues to make improvements and has not yet hit a plateau. During the post-treatment assessment, VA stated that he was doing more around the house; including mowing the lawn for the first time since his brain injury and stroke. He expressed to the student therapist that it was good to get back to cutting the grass, as this was an instrumental occupation of daily living that he performed prior to his injury. Bobath Evaluation of Adult Hemiplegia (Bobath, 1970) Tests for Postural Reactions in Response to Being Moved. This group of tests gives the therapist information regarding the degree and distribution of spasticity or flaccidity the patient has and abnormal movement patterns (Bobath, 1970). During these tests, the therapist moves the patients upper extremity passively in various positions. In a normal response to being moved, the patient would control the upper extremity

21 HAND DOMINANCE 20 and would be able to hold the limb if the therapist let go. If there is spasticity present, the therapist will feel a resistance during passive movements performed against the pattern of spasticity. If the resistance is strong, the therapist can assume the patient cannot perform the movements actively. If the resistance is moderate or occurs only in some parts of the movement, the therapist can predict the patient can perform parts or even the entire movement, but with excessive effort. If there is flaccidity present, the patients limbs will feel heavy; this indicates to the therapist there is an absence on normal postural reflex activity and the patient will be unable to perform the movement actively (Bobath, 1970). Case 1: JB. The Bobath Evaluation of Adult Hemiplegia (Bobath, 1970) was administered 02/14/2011 in the inpatient rehabilitation gym at UTMC. A mat table was utilized to evaluate JB in both supine and sitting to test his postural reactions in response to being passively moved. This test was not conducted in standing due to JB s impaired standing balance. JB presented with minimal flexor spasticity of the left upper extremity. Abnormal resistance was noted when JB s left upper extremity was passively moved in shoulder flexion, abduction, external rotation, supination of the forearm, wrist flexion, and finger flexion. Because the spasticity of the left upper extremity was minimal, the therapist predicted that the patient could perform the movements actively, so the therapist moved on to test voluntary movements of the upper extremity upon request. See Table 3 for complete evaluation. Case 2: VA. The evaluation took place at Coghlin Rehabilitation Center at UTMC in a small treatment room. VA gave consent to video tape the evaluation process for educational purposes. VA was evaluated in all three postures; supine, sitting, and standing. VA s right upper extremity was

22 HAND DOMINANCE 21 moved passively by the therapist. When moved passively in shoulder flexion, abduction, external rotation, and horizontal abduction, minimal abnormal resistance was noted by the therapist. When the patient s right upper extremity was moved in shoulder adduction, internal rotation, and horizontal adduction, abnormal assistance was noted. It can be concluded from this information that flexor spasticity is present; however, minimal. The level of spasticity was minimal, so the patient would then be asked to complete the same movements actively in the next step of the evaluation. Tests for Voluntary Movements Upon Request. This group of tests is performed if the therapist determines the patient is able to complete the movements from the first test actively. The patient will only be able to perform those movements tested in the first section without excessive spasticity or flaccidity. The tests in this section are graded (Grade 1 to 3) from simple to complex and more selective movement patterns. The patient will not only be asked to complete movements of the upper extremity, but to also hold or place the upper extremity (Bobath, 1970). Case 1: JB. Testing for voluntary movements for JB were also conducted in both supine and a seated position. For safety, these positions in standing were not attempted. JB was able to complete all of the grade one movements except for external rotation of the shoulder. When evaluating the arm and shoulder girdle, JB was also able to hold or place his left upper extremity in all of the positions except for external rotation. JB completed all grade two movements as well; however, with excessive effort and compensation at the shoulder. Grade three movements of the upper extremity and shoulder girdle were more difficult for JB to complete. JB was able to partially supinate his left upper extremity by laterally flexing his trunk to compensate for his lack of distal

23 HAND DOMINANCE 22 movement. External rotation also presented as difficult for JB Pt was able to perform all the movements stated above, however with minimal resistance due to mild flexor spasticity. All movements were performed with excessive effort and compensatory movements from the proximal joints (shoulder and trunk). These movements in standing were not tested. See Table 3 for details of evaluation. When testing voluntary movements of the wrist and fingers it was noted that JB was able to actively open his hand to grasp objects in pronation and adduction of the fingers. At this time during JB s recovery he was unable to complete opposition and isolated finger movements. Case 2: VA. Testing for voluntary movements for VA were conducted in supine, sitting, and standing. VA was able to complete almost all movements voluntarily. VA was able to place his right upper extremity (dominant side) in shoulder flexion; however, due to spasticity in his biceps his elbow lacks about 20 degrees of extension. VA displayed compensatory movements with flexor synergy of his right upper extremity during all movements of the upper extremity. VA was able to pronate and supinate his right wrist, but was unable to do it with his elbow extended completely. VA can also externally rotate his affected upper extremity with a slight bend in his elbow. VA was able to complete all of the voluntary movements for the wrist and fingers. Opposition and isolated finger movements were intact. Tests for Balance and other Automatic Protective Reactions. The last set of tests is for balance and automatic protective reactions. Bobath states that automatic postural reactions are part of every voluntary movement, and the postural reflex mechanism underlying voluntary movements must be normal before the patient can be expected to perform normal or more normal movements and skills (Bobath, 1970, p. 46). Balance

24 HAND DOMINANCE 23 reactions are evaluated in different developmental positions including: prone on elbows, sitting, quadruped, kneeling, half-kneeling, and standing. Protective extension and support of the affected upper extremity is also evaluated. Case 1: JB. Testing for balance reactions was first conducted with JB in prone lying on his forearms. When pushed toward his affected side JB was able to remain supported on his forearms; however, when his sound arm was lifted he was not able to remain supported on his left upper extremity. When sitting on the mat with his feet unsupported, JB had good static trunk control and stability even when pushed by the therapist. JB was able to use his affected upper extremity to support himself when pushed by the therapist, but only with his hand in a fist. In quadruped, JB needed support of the therapist to keep his affected elbow in extension. Due to the lack of stability and strength in the left shoulder, other testing in quadruped was not attempted. When pushed in various directions in kneeling, JB was able to move his affected upper extremity minimally. Half-kneeling was not attempted due to difficulty transitioning into the position. When JB was pushed in various directions in standing, he was able to minimally move his affected lower extremity in an attempt to protect himself from falling. Standing on the affected lower extremity was not attempted for safety reasons. When evaluating JB s protective extension of his affected upper extremity deficits were noted. JB was able to move his left upper extremity only minimally to protect himself when pushed in various directions by the therapist. Case 2: VA. VA demonstrated intact balance reactions in all of the developmental positions. Difficulty was noted in the quadruped position when alternately lifting one lower extremity and

25 HAND DOMINANCE 24 the opposite upper extremity simultaneously. VA was not able to hold these positions. When VA was pushed in various directions while in kneeling and half-kneeling he displayed appropriate protective extension of his affected upper extremity. VA s static sitting and standing balance were also intact, with appropriate protective extension of his affected extremity when pushed by the therapist. Difficulty was noted when a pillow was dropped towards VA s head while in supine. Due to his delayed processing time, VA was unable to protect his face when the pillow was dropped toward his face. Clinical Visual Assessment JB s vision was initially assessed as an inpatient and was determined by the occupational therapist to be within normal limits. JB does wear glasses, however, his vision was not affected by his stoke. Therefore, the Clinical Visual Assessment was not utilized with JB. VA s vision was initially assessed by the occupational therapist in the outpatient clinic. The clinical visual assessment was re-administered to assess VA s visual acuity, peripheral vision, and oculomotor control as part of the occupational therapy pre-driving evaluation. VA wears lenses for near vision correction. Visual Acuity. When assessing VA s distance visual acuity using the Snellen Chart at a distance of 20 feet, impairments were noted. VA s binocular distance vision was 20/40. Monocularly his right distance vision was 20/40 minus two and 20/40 for the left eye. VA s near acuity was also tested. Binocular near vision was 20/20 and both his right and left monocular near vision was 20/20. VA wore his new lenses for near vision testing.

26 HAND DOMINANCE 25 Peripheral Vision. Superior, inferior, and right visual fields were all intact. The left peripheral field was slightly limited on the left side approximately 20 degrees. Double simultaneous stimulation was performed using two different colored pencils. VA presented with normal bilateral awareness in the periphery. Oculomotor System. Eye alignment was evaluated using a lighted pen aimed at the bridge of VA s nose. It was noted that VA s right eye was slightly nasally displaced. VA demonstrated full range of motion in bilaterally and when tested monocularly. Convergence was normal. Impairments were noted during saccadic eye movement, with patient searching for target instead of directly fixating on the target. Pursuits were normal; however, horizontal nystagmus was noted. The King-Devick Test was administered to determine VA s scanning abilities. VA required excessive time to complete which demonstrates impairments in visual processing speed. Depth Percepetion. The Stereo Titmus test was administered to determine VA s depth perception for predriving skills. Severe impairments in depth perception were noted as VA was only able to perceive 2/9 items on the test. The angle of stereopsis at 16 inches was 400 seconds; indicating severe impairment. Occupational Therapy Goals Case 1: JB Jacob was initially evaluated for occupational therapy services as an inpatient on the rehabilitation floor at UTMC. In the inpatient setting it was important for JB to complete his basic activities of daily living independently to prepare for returning home. The evaluation

27 HAND DOMINANCE 26 results of the Bobath Evaluation of Adult Hemiplegia (Bobath, 1970) and the modifiedwolf Motor Function Test (Taub et al., 1993) displayed needed focus areas and the following goals were addressed. Goal 1. LTG: Pt. will complete all occupations of daily living independently (including grooming, bathing, and dressing) AEB pt. report in 6-8 weeks. (Met) STG 1: Pt. will independently complete grooming tasks (ie. brushing teeth, washing face, shaving, and putting on deodorant) with less than 2 tactile cues per session to incorporate his left upper extremity into the occupation in an OT session in 2 weeks. (Met) STG 2: Pt. will demonstrate protective reaction of the left upper extremity to improve safety during his daily routine as evidence by patient actively extending elbow when pushed by therapist in 2 out of 2 OT sessions in 2-4 weeks. (Met) Justification: Due to the extreme muscle weakness on his non-dominant upper and lower extremity JB had difficulty tying his shoes, opening and squeezing the toothpaste to brush his teeth, and grasping items with his left hand. To address these issues, during grooming tasks JB s left upper extremity (non-dominant side) was used as a gross assist to stabilize the tube of toothpaste while he unscrewed the cap. JB was able to use his dominant hand to shave and brush his teeth. His left upper extremity was always incorporated into all self-care occupations to prevent learned non-use of the non-dominant upper extremity.

28 HAND DOMINANCE 27 During the initial Bobath Evaluation of Adult Hemiplegia (Bobath, 1970) JB had minimal protective reaction of his left upper extremity. Having protective reactions are very important for safe functional mobility. In order for JB to resume his active lifestyle as a 17-year-old boy (school, leisure, extracurricular) he would need to restore the normal protective reactions of the upper extremity. Goal 2. LTG: Pt. will resume all leisure occupations in 6-8 weeks. (Met) STG: Pt. will incorporate both upper extremities while playing a game on the Playstation with active isolated finger movements to operate the buttons with less than 2 tactile cues from the therapist in an OT session in 2 weeks. (Met) Justification: Being a typical teenage boy, JB enjoyed playing video games Playstation at home, so incorporating this into a goal was important to keep therapy interesting and meaningful to JB. JB had minimal finger movement upon completion of the Bobath Evaluation of Adult Hemiplegia (Bobath, 1970) so using the video games would force JB to use both of his upper extremities and fingers simultaneously. The video game paddles also encouraged JB to use isolated finger movements to operate his character on the game. Goal 3. LTG: Pt. will demonstrate independence in simple meal preparation, for breakfast and lunch, to resume independence with morning routine per pt. report by end of case study. (Met)

29 HAND DOMINANCE 28 STG: Pt. will engage in cooking occupation in standing using left UE as a gross assist (reaching, grasping, transporting, stabilizing items) with normal movement patterns of the left UE in an OT session in 2-4 weeks. (Met) Justification: This goal was incorporated into the intervention plan because it was determined after interviewing both JB and his mother and father that keeping his morning routine the same was important. Prior to his stroke, JB independently prepared his breakfast every morning before school and made himself simple meals while at home using the microwave, toaster, and occasionally the oven. When asked what meal he likes to prepare the most, his response was I like to make pizza rolls! Goal 4. LTG: Pt. will return to driving independently by the end of the case study. (Met) STG: Pt. will complete pre-driving assessment to determine readiness for on-road driving. (Met) Justification: Prior to JB s stroke he was driving to and from school independently every day. He would also drive himself to the multiple extracurricular occupations he participated in. It was expressed by J.B and his family that this was an important occupation to resume as soon as possible so JB could continue to participate in the extracurricular occupations when he returns home from the hospital.