Case Study/ Therapeutic
activity
BY: STACEY DAHM MSOT/S ‘15
Patient Profile
 68 y.o. R handed Male
 HX: HTN, DM, CAD, A-fib, acoustic neuroma,
arthritis, RUE rotator cuff injury
 I in ADLs/IADLS PTA.
 Reason for Admission: Mobility and ADL
dysfunction secondary to L internal capsule
thrombotic infarction
 Presentation: R hemiparesis, dysarthria
Internal Capsule
 Internal Capsule:
contains a concentration
of white matter projection
fibers: both ascending and
descending

Separates the caudate nucleus
and thalamus from the
lentiform nucleus
Infarction of the Posterior Limb
•Primarily contains the
corticospinal tract
•Blood Supply:
Middle cerebral artery &
internal carotid artery
Research Related to Internal Capsule Infarction
 Axonal injury in the internal capsule correlates with
motor impairment after stroke.
 Posterior limb of the internal capsule lesions led to an
initially severe motor impairment followed by excellent
recovery.
 Lesions of the internal capsule were associated with a
significantly lower probability of return of isolated
hand motor function than lesions of the cortex,
subcortex and corona radiata.
Clinical Presentation
 LUE ROM/MMT: WFL
 RUE AROM:



Shoulder flexion: 55
Shoulder Abduction: 20
Elbow flexion: 65
 RUE PROM:






Shoulder to 90
Increased tone
Balance: Impaired
Cognition: Intact
Vision: Intact
Sensation: Intact
Left
Right
Grip Strength
95
25
Lateral Pinch
19
11
3-point Pinch
17
Unable
9-hole Peg test
30
Unable
Impact on Daily Living
FIM
Eating
5
Grooming
5
UE Dressing
2
LE Dressing
3
Bathing
3
Toileting
2
Toilet Transfer
4
Tub/ Shower Transfer
4
 Lives with wife in 2 story
home + basement

14 stairs
 Walk-in shower with
grab bars and shower
chair
 Retired business owner;
continues to do side
work
 Leisure: grilling,
photography, computers
Personal Goal:
 To gain strength in my hand and arm and to be
able to grab things.
OT Treatment Plan
 ADL Retraining
 Endurance Building
 Energy Conservation
 Equipment Recommendation/ Training
 Functional Transfers (Bed)
 HEP
 Patient/ Family Training
 UE A/PROM
 UE strengthening, FMC
 Standing balance/ tolerance
Theory behind Tx Plan
 Restore & Adapt
 Motor Control Theories




Purposeful movement as part of an activity
Interaction between the person, task, and environment
Implicit and Explicit feedback
Evidence for:
Massed Practice
 Random Practice
 Whole Practice

 Biomechanical Theory


Addresses the quality of movement in occupations
Aims: Prevent deterioration, Restore function, Compensate for loss
of movement
Application of TX
 ADL Retraining:
1-handed dressing techniques vs. task specific training
Home Safety Education/ Family Training with Wife and Son
HEP: Theraputty
AAROM, self-PROM
 Increased tone in RUE
Functional Reach-Grasp-Release Activities
 Sitting: from table to raised shelf
 Standing: moving items to/from countertop and cabinet
 Used a variety of shaped/ weighted items
 Pt. required rest breaks secondary to fatigue/ frustration





Results of Tx Plan
Initial
Goal
Discharge
Eating
5
6
6
Grooming
5
5
5
UE Dressing
2
5
5
LE Dressing
3
5
5
Bathing
3
5
5
Toileting
3
5
5
Toilet Transfer
4
5
5
Tub/ Shower
Transfer
4
5
5
Clinical improvements
Pre
Post
Shoulder Flexion 55
65
Shoulder
Abduction
20
62
Elbow Flexion
65
145
Grip Strength
25
25
Lateral Pinch
11
15.5
3-point Pinch
0
13
9-hole Peg test
Unable
Excessiv
e time
(>4min)
 Improved balance
 Improved ROM/MMT in
all RUE joints/planes.
 Continues to display
RUE
strength/coordination
deficits, balance deficits,
and decreased
independence with
ADLs.
Gap/Intervention
 Pt. continues to show difficulty with finger
extension/release of objects during functional tasks (ex.
Putting away toothpaste)

Personal Goal: “To gain strength in my hand and arm and
to be able to grab things.”
 Already doing functional reach and manipulation tasks

Add cognitive component to distract; increase repetitions/ variety
 Central aims of Intervention: To improve finger
extension and functional release of objects for increased
hand manipulation during functional activities.
Intervention - Checkers
 Biomechanical Components of Activity:





Reaching for checkers
 Shoulder flexion
Grasping checkers
 Finger flexion
Releasing checkers
 Finger extension
Pushing checkers
 DIP/PIP finger extension
Flipping over checkers
 Additional components:



Social interaction
Cognition (attention; problem-solving; sequencing)
Coordination
Evidence Behind Intervention
 Grasp is typically more impaired than reach in patients with
hemiparesis.
 Successful grasping of objects will not occur with inability to extend
fingers and thumb.
 Follows Motor Learning and Biomechanical Theories
 Resistive movement incorporates more muscle fibers than non-
resistive.
 EMG study showed extensor digitorum was recruited in velcro
checkers activity.
Upgrades and Downgrades
 Upgrades:
 Increase resistance with Velcro
 Add arm weights
 Perform from standing
 Downgrades:
 Use non-Velcro side of board
 Play game with fewer pieces
 Just have pt. move pieces across the board
References
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Ada L, et al.: Task-specific training of reaching and manipulation.
Butefisch, C., Hummelsheim, H., Denzler, P., Mauritz, K. (1994). Repetitive training of isolated
movements improves the outcome of motor rehabilitation of the centrally paretic hand. Journal
of the neurological sciences, 130(1). 59-68.
Fries, W., Danek, A., Scheidtmann, K., Hamburger, C. (1993). Motor recovery following capsular
stroke: Role of descending pathways from multiple motor areas. Brain, 116(2). 369-382.
Gesior C, Mann D (1986). Finger Extension Game, American Journal of Occupational Therapy,
40(44-48).
Hanlon, R. (1996). Motor learning following unilateral stoke. Physical Medicine and
Rehabilitation, 77(8). 811-815.
Lang, C., DeJong, S., Beebe, J. (2009). Recovery of thumb and finger extension and its relation to
grasp performance after stroke. J Neurophysiol, 102(1), 451-459.
Pendlebury, S.T., Blamire, A.M., Lee, M.A., Styles, P., Matthews, P.M. (1999). Axonal injury in the
internal capsule correlates with motor impairment after stroke. Stroke, 30. 956-962.
Schiemanack, S.K., Kwakkel, G., Post, M., Kappelle, L.J., Prevo, A. (2008). Impact of internal
capsule lesions on outcome of motor hand function at one year post-stroke. J Rehabil Med, 40.
96-101.
Trombly C, Cole J. (1979). Electromyographic study of four hand muscles during selected
activities. Am J Occup Ther 33(7): 440-449.
Trombly C, Quintana L. (1983). Activity Analysis: Electromyographic and
electrogoniometric verification, Occup Ther J Research 3(2): 104-120.