Title: Occupational therapy intervention CVA with right side hemiplegic patient.

Abstract:

This case report focuses on the rehabilitation of Mst.Shaleya khatun a 53-

year-old female with a history of hypertension, who suffered a sudden
onset of right-sided weakness and loss of speech, disoriented due to
ischemic stroke Following her hospitalization and, Mst. Shaleya khatun was
referred for outpatient physical therapy, speech therapy, and occupational
therapy. The assessment process revealed deficits in motor function, and
activities of daily living (ADLs). Instrumental activities of daily living(IADLs).
The therapeutic problem list was formulated, and outcome planning was
established to address Mst. Shaleya khatun goals. Evidence-based
interventions, including task-specific training, repetitive task-oriented
programs, and education on safety and adaptation, were implemented.

Keyword: Cerebro vascular accident(CVA),Ataxia, Clonus, Rehabilitation,Ischemic

stroke, occupational therapy, speech therapy, physical therapy.

Introduction:

This case report focuses on the rehabilitation of Mst. Shaleya khatun a 53-
year-old female who is suffered by ischemic stroke resulting in right-sided
weakness and speech difficulties.

Stroke is an embolus and an embolic stroke (when the clot originates

elsewhere in the body and travels to the brain, becoming wedged in a
vessel that supplies the brain with blood).
As mentioned above, a stroke caused by a blood clot is referred to as an
ischemic stroke. Ischemia is a lack of blood flow to an organ, whereas
'hyponoxia' or 'anoxia' (other common terms) is the interrupted oxygen
supply to the brain. The area of the brain damaged by the loss of oxygen is
called the 'infarct'.

It may be helpful to know that the medical profession classify ischaemic

strokes by their cause. Ischaemic strokes originate, for the most part,
outside of the brain. In some cases, there may have been a problem within
the blood itself (e.g. sickle cell disease); there may exist a blood vessel
disorder (e.g. arteritis); or the stroke may have occurred as the result of a
build-up of atherosclerotic plaque which reduced blood flow to the brain.
However, most ischaemic strokes are caused by a blood clot. The blood clot
and any subsequent stroke is then often categorised again as either:

a thrombus and a thrombotic stroke (when the clot blocks a vessel that
supplies an area of the brain with blood)(Refarence:)

Mst. Shaleya khatun history of hypertension is the most prevalent risk

factor for stroke. Stroke causes and haemodynamic consequences are
heterogeneous which makes the management of blood pressure in stroke
patients complex requiring an accurate diagnosis and precise definition of
therapeutic goals.

Ischemic stroke is a medical condition characterized by a sudden

disruption of blood flow to a part of the brain, resulting in a lack of
oxygen and nutrients to that area. Common clinical features or
symptoms of ischemic stroke include:
1.Sudden and severe headache: Some strokes may cause a sudden, severe
headache, common in ischemic strokes.

2.Weakness or numbness: Often on one side of the body, which can affect
the face, arm, or leg. This can result in a drooping face, difficulty in lifting an
arm, or dragging of one leg when walking.

3.Trouble speaking or understanding speech: Aphasia, a language

disorder, can occur, making it difficult for the person to communicate
effectively or understand what others are saying.

4.Difficulty with vision: Blurred vision, double vision, or loss of vision in

one or both eyes can occur.

5.Sudden dizziness or loss of balance: Patients may experience

unsteadiness, vertigo, or a sudden feeling of being off balance.

6.Trouble walking: Coordination and balance problems can make it

challenging to walk or maintain a stable gait.

7.Confusion or altered mental status: People with ischemic stroke may

become disoriented, have trouble thinking clearly, or experience memory
problems.

8.Severe headache with nausea and vomiting: While this is more

common in hemorrhagic strokes, it can also occur in some cases of large
ischemic strokes.

9.Difficulty swallowing: Dysphagia, or difficulty swallowing, can occur in

some cases due to weakness in the muscles involved in swallowing.

10.Loss of consciousness: In severe cases, an ischemic stroke can lead to

loss of consciousness or coma.
Risk factor of Hypertension:

 Age: The risk of hypertension increases with age, especially in

individuals over 65.
 Family History: If you have a family history of hypertension, you may
be at a higher risk.
 Obesity: Being overweight or obese puts added strain on your heart
and increases blood pressure.
 Lack of Physical Activity: A sedentary lifestyle can lead to
hypertension. Regular exercise helps regulate blood pressure.
 Unhealthy Diet: High salt (sodium) and low potassium intake, as well
as excessive alcohol consumption, can contribute to hypertension.
 Stress: Chronic stress can raise blood pressure over time.
 Smoking: Tobacco use and exposure to secondhand smoke can
increase blood pressure.
 Chronic Conditions: Certain medical conditions like diabetes and
kidney disease can increase the risk of hypertension.
 Sleep Apnea: This sleep disorder is linked to hypertension.
 Certain Medications: Some medications, such as certain birth control
pills, decongestants, and steroids, can raise blood pressure.
 Hormonal Factors: Hormonal changes, such as those associated with
pregnancy and menopause, can influence blood pressure.

Ataxia:

Ataxia is a neurological condition that affects a person's coordination and

balance. This disorder, often misunderstood and underdiagnosed, can have
a significant impact on one's daily life.

Types of Ataxia:

There are several types of ataxia, each with its own distinct characteristics:
  Hereditary Ataxia: This type is typically caused by genetic mutations
and tends to run in families. Examples include Friedreich's ataxia and
spinocerebellar ataxia.
 Acquired Ataxia: This form of ataxia is not inherited but develops
due to factors like injury, infection, or exposure to toxins. Alcohol
abuse can also lead to acquired ataxia.
 Idiopathic Late-Onset Cerebellar Ataxia (ILOCA): This is a term
used when the cause of ataxia is unknown, and it typically occurs later
in life.

Symptoms of Ataxia:

 The primary symptom of ataxia is difficulty with coordination and

balance.
 Other common symptoms include:
 slurred speech
 muscle weakness

Clonus:

Clonus is a neurological condition characterized by repetitive, rhythmic, and

involuntary muscle contractions or spasms.

It typically occurs in response to a rapid stretch of a muscle, and it can

affect various parts of the body, including the limbs and neck. Clonus can
be a sign of an underlying neurological problem and should be evaluated
by a healthcare professional for proper diagnosis and management.
Treatment options may include addressing the underlying cause and
medications to reduce muscle spasms.
Patient information:

Mst.Shaleya khatun a 53-year-old female with a history of hypertension.

She presented with sudden onset of right-sided weakness and loss of
speech, balance. She first went to NICD hospital then she was referred to
NINSH. she was prescribed medicine and advice for imaging test
(MRI).Immediately following after stroke she made rapid progress in speech
recovery but then right side weakness persisted. Mst. Shaleya lives with her
husband, she was house wife.

Clinical findings:

On physical examination, Mst. Shaleya khatun exhibited several relevant

findings. Her right arm showed limited extension in the wrist and fingers.
She displayed decreased control and coordination of the right arm,
particularly when attempting movements above shoulder level or engaging
in fine motor tasks. Additionally, mild clonus was observed, resulting in
delays in initiating and sequencing multistep tasks. These physical
examination findings highlighted the impairments and challenges faced by
the patient in his motor functions by her stroke.

Timeline:

Date Events
17-07-22 Onset od symptoms
17-07-22 Hospitalization
18-07-22 Discharge
11-09-23 Outpatient Assessment
11-09-23 Intervention start
Follow up
Diagnostic Assessment:

Diagnostic Assessment:

a) Diagnostic methods in this case included:

- Physical examination (PE): The physical examination was conducted to

assess motor function, coordination, sensory, balance, and cognitive
abilities.

- Laboratory testing: Laboratory tests, including blood test, RBC, Bio-

chemistry test, Urine RME, creatinine.

- Imaging: Imaging tests such as a magnetic resonance imaging (MRI), X-

ray were likely performed to confirm the diagnosis of a ischemic stroke and
assess the extent of brain damage.

- Questionnaires: Modified oxford muscle grade testing system were used

to assess the impact of ischemic stroke on the patient’s muscle strength:

b) Diagnostic challenges:

- Financial challenges: The patient's financial status may have posed

challenges in accessing diagnostic tests and treatment due to limited
resources or inability to afford the required healthcare services.

- Language/cultural challenges: Patient Then has speech difficulty on

slurned speech and that create challenges, for communication and
Sometime the local Language of her also creates challenges for us

c) Diagnostic reasoning including other diagnoses considered:

Considering the patient's presentation of right-sided weakness, speech

difficulties, trable inseeing, losss of balance and coordination sconfirmed
through imaging, the primary diagnosis was likely related to the
ischemic.Other possible differential diagnoses may have been considered,
such as ischemic stroke, intracerebral hemorrhage, or transient ischemic
 attack (TIA).However, based on the provided information, the primary
diagnosis aligned with the patient's clinical presentation.

d) Prognostic characteristics:
The prognosis for an ischemic stroke can vary widely depending on factors
such as the extent of brain damage, the location of the stroke, the patient's
age, and their overall health. Generally, early medical intervention and
rehabilitation can significantly improve outcomes. Some people may
recover completely, while others may experience long-term disabilities. It's
important for patients to follow their healthcare provider's guidance and
engage in rehabilitation to maximize their chances of recovery. Prognosis
should be discussed with a medical professional who can provide specific
information based on an individual's case.

Therapeutic Intervention
a) Types of intervention:

- Non-pharmacological interventions:

 Bobath (weight bearing)

o Scapula mobilization
o Reflex inhibition Pattern
o Foot preparation
 Brunnstrom:
o Sleep position
o Recovery of voluntary control of arm
o Retraining hand and wrist control

* Task oriented approach

  Roods approach
o Facilitation technique :Light touch or stroking on
trapezius and triceps

- Pharmacological interventions:

Rovant - Mixed dyslipidaemia, homozygous familial hyper

cholesterolaemia that prevents stroke

Bigomet 500 mg- Tablet is a medicine used to control high Blood

sugar levels. It is the first referred medicine effectively used in
people with type Il Diabetes.

Ecoprin 75mg -tablet is an antiplatelet medicine used to treat

and prevent heart attacks, strokes and heart related onset pain.

PANDRO 20 mg: Panprio tablet is reduce acid production in the a

medicine ored to stomach

Olmidip 20mg: A tablet used in the treatment of hypertension. 8)

Alphapness er 2. It is normally used together with other Blood
Pressure. This medicine works by widening the blood vessels so
that Blood passes through them mone easily.

Denuar: Upper respiratory tract infections e.g. pharyngitis,

tonsillitis, sinusitis Lower respiratory tract infections e.g. acute
bronchitis and acute exacerbations of chronic bronchitis.

Renova: This medication is used to improve the appearance of the

skin by reducing fine lines and wrinkles, reducing roughness, and
improving skin color
 b) Administration of intervention:

- The antispastic drugs were administered according to the prescribed

dosage and schedule, although exact details were not provided.

- The patient took one pill of Bigomet 500mg per day to manage their
diabetes.

- The high blood pressure medication was also taken once a day.

c) Changes in intervention (with rationale):

Specific changes in the interventions were not mentioned in the provided

information. However, it is common for therapeutic interventions to be
regularly assessed and modified based on the patient's progress, response,
and individual needs.

Follow-up and Outcomes

Throughout the follow-up visits, the patient's clinical course showed

significant progress in various aspects. Clinician and patient-assessed
outcomes consistently indicated improvements in the patient's functional
abilities, quality of life, and overall well-being. The patient reported
increased independence in activities of daily living (ADLs) and instrumental
activities of daily living (IADLs), as well as improved motor function in the
both affected arms.

Follow-up test results were generally positive, reflecting the positive impact
of the therapeutic interventions. The “MODIFIED ASHWORTH SCALE FOR
HYPERTONICITY” showed improvement in the patient's upper extremity
 function and overall ischemic stroke impairments. Additionally, laboratory
test results indicated well-managed controlled blood pressure levels.

Intervention adherence was assessed through regular therapy sessions and

patient reports. The patient actively participated in the prescribed
therapeutic interventions, including Bobath, Brunstrum , Task oriented,
Rood Approach. They demonstrated good adherence to the recommended
dosage of pharmacological interventions, including antispastic drugs,
metformin for diabetes, and the high blood pressure medication.
Tolerability was assessed through patient feedback, and no significant
issues or adverse effects were reported during the follow-up visits.

No significant adverse or unanticipated events were documented during

the follow-up visits. The patient's response to the interventions was overall
positive, and the treatment plan was well-tolerated without any notable
complications or unexpected side effects.

Overall, the follow-up visits highlighted the patient's remarkable progress

in functional outcomes, improved adherence to interventions, favorable test
results, and the absence of adverse events. These positive findings
reinforced the effectiveness of the chosen therapeutic interventions and the
patient's commitment to their treatment plan.

Discussion

The strengths of the management in this case include the comprehensive

and multidisciplinary approach taken to address the patient's needs. The
involvement of physical therapists, occupational therapists, and speech and
language therapists allowed for a holistic treatment plan that targeted the
patient's physical, speech and functional deficits. The use of evidence-based
interventions, such as and task-oriented, Bobath, Brunnstrom and roods
approach demonstrated the application of current research in stroke
rehabilitation. The regular follow-up visits and assessments helped track the
pat Biomechanical Frame of Reference: This focuses on improving physical
functioning by addressing issues related to strength, range of motion, and
endurance. It's often used for clients with musculoskeletal or orthopedic
conditions.

A frame of reference uses theories to guide evaluation and assessment and

application to the practice. The frame of reference provides a structure for
identifying relevant theories and then based on this information, outlines
guidelines that occupational therapists use when assessing and providing
intervention.

Cognitive-Behavioral Frame of Reference: This addresses cognitive and

emotional factors affecting a person's ability to engage in meaningful
activities. It's used for clients with mental health or cognitive impairments.

Psychosocial Frame of Reference: This considers social and emotional

factors that influence a person's ability to participate in daily life activities.
It's relevant for clients with emotional or behavioral challenges.

Neurodevelopmental Frame of Reference: This is often used with clients

who have neurological conditions or developmental disorders. It focuses on
facilitating normal movement patterns and postural control.

Model of Human Occupation (MOHO): MOHO is a comprehensive frame

of reference that considers a person's volition (motivation), habituation
(routines and habits), and performance capacity (physical and mental
abilities).

Sensory Integration Frame of Reference: This is used for clients with

sensory processing disorders, aiming to help them effectively process
sensory information to improve participation in daily activities. patient's
progress and make necessary adjustments to the treatment plan.

However, there were some limitations to the management of this case.

One limitation was the financial constraint experienced by the patient,
which may have impacted the availability and access to certain
interventions or resources. The patient's language and cultural background
could have presented communication challenges, requiring the need for
interpreters or culturally sensitive approaches to ensure effective care.
Additionally, the generalizability of the findings may be limited due to the
uniqueness of the patient's individual circumstances.

The relevant medical literature pertaining to this case includes studies on

stroke rehabilitation, specifically focusing on the use of CIMT, mirror
therapy, and task-oriented approaches. These interventions have been
shown to be effective in improving motor function, functional outcomes,
and quality of life in individuals with stroke. The medical literature also
emphasizes the importance of multidisciplinary care and the role of family
involvement in promoting successful outcomes in stroke rehabilitation.

The rationale for the conclusions drawn in this case report is based on the
patient's clinical course, the assessments conducted, and the documented
progress observed over the course of the management. The patient's
improvement in physical function, cognitive abilities, and activities of daily
living, as well as their positive response to interventions, supports the
efficacy of the chosen treatment strategies.

The main "take-away" lessons from this case report include the importance
of a multidisciplinary approach in stroke rehabilitation, tailored
interventions that address specific deficits, and the significance of family
involvement and support in the patient's recovery. The use of evidence-
based interventions, such as Bobath, Brunstrum , Task oriented, Rood
 Approach can contribute to improved motor function and functional
outcomes. The case highlights the need for cultural and linguistic sensitivity
in healthcare delivery to ensure effective communication and
understanding. Additionally, the successful management of this case
reinforces the value of regular follow-up visits, assessments, and
individualized treatment plans in promoting positive outcomes in stroke
rehabilitation.

Patient Perspective:

The patient in this case report expressed motivation and satisfaction

with the treatment provided by the multidisciplinary team. The patient
expressed satisfaction with Bobath, Brunstrum, Task oriented, Rood Approach
intervention and reported noticeable improvements in her daily life activities. She
found the therapy challenging but rewarding, and she appreciated the tailored
approach that focused on her specific goals.

Informed Consent:

The patient had provided written consent, indicating that they were
adequately informed about the treatment options and voluntarily agreed to
participate. The patient's motivation and satisfaction were important factors that
contributed to the success of the interventions and overall patient outcomes. The
obtained written consent served as documentation of the patient's agreement to
undergo the recommended interventions, ensuring their autonomy and respect for
their rights. The patient's positive experience and consent exemplified the
collaborative and patient-centered approach that was taken in their care.

This case report focuses on the rehabilitation of Mst. Shaleya khatun a 53-
year-old female who is suffered by ischemic stroke resulting in right-sided
weakness, speech difficulties and balance problem for more than one year.
She first went to NICD hospital then she was referred to NINSH. she was
prescribed medicine and advice for imaging test (MRI).Immediately
following after stroke she made rapid progress in speech recovery but then
 right side weakness persisted. The assessment process in outpatient unit
revealed upper limb functional limitation such as grasping, reaching and
also other motor deficits. Clonous is also observed for several time that
takes time to initiate any activity. These intervention has provided during
therapy session

 Bobath (weight bearing)

o Scapula mobilization

o Reflex inhibition Pattern

o Foot preparation

 Brunstrom:

o Sleep position

o Recovery of voluntary control of arm

o Retraining hand and wrist control

 Task oriented approach

 Roods approach

o Facilitation technique :Light touch or stroking on

trapezius and triceps

The patient in this case report expressed motivation and satisfaction with
the treatment provided by the multidisciplinary team. The patient expressed
satisfaction with Bobath, Brunstrum, Task oriented, Rood Approach
intervention and reported noticeable improvements in her daily life activities. She
found the therapy challenging but rewarding, and she appreciated the tailored
approach that focused on her specific goals
Refarence:

stroke survivor by Andy Mccann

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6477925/

https://www.mayoclinic.org/diseases-conditions/stroke/symptoms-
causes/syc-20350113
 Problem list Long-term Goal Short-term Goal Treatment plan
Problem list : Long term goal: Short term Treatment plan:
1.Activities of Daily Living Client will be able goal: Adjunctive method :
(ADL): Client required to perform" Client’s muscle Positioning
maximum assistance Activity in daily tone and hand Bed mobility
( according to FIM 2) washing living " with function will Standing practice
hand, eating, combing hair minimal support be improve 2. Enabling activity :
with dominated hand . after 30 days of after 10 days Task oriented
2.Instrumental activity of daily therapy session. of therapy approach
living(IADL): session. Carr & sephard
Client required maximum - sitting balance
assistance (according to FIM 2) - standing, dynamic
in health management and standing balance.
maintenance with dominated 3. Purposeful
hand. activity :
Difficulty taking food hand to -Feeding practice
mouth due to lack of gross or with tools
fine motor control. modification.
Limited ROM in finger joints. -Dressing
Client required total techniques.
assistance ( according to FIM 4.Occupational
1) in safety and emergency performance & role:
maintenance and shopping. -ADLs
3.Rest and sleep: Client -Home
required maximum assistance ( modifications.
according to FIM 2) for sleep
preparation. eg. Preparing the
bed for sleeping.
4.Work: client required
maximum assistance
( according to FIM 2) in
voluntary participation.
5.Education : Client required
total assistance (according to
FIM 1) informal personal
educational needs or interests
exploration.
6.Play: Client required maximal
assistance ( according to FIM
2)
Difficulty in grasp and reaching
activity due to spastic muscle
tone and less of joint ROM.
7.Leisure :
Client required maximal
assistance ( according to FIM)
in obtaining, using and
maintaining equipment and
supplies needed for leisure
participation.
.Grasp and manipulating of toy
is difficult due to limited upper
limb mobility and hand
function.
.Reaching activity is difficult
due to frozen shoulder.
8.Social participation :
Required total assistance
( according to FIM 1)
Engaging in activity that result
in successful interaction at the
community
level( neighbourhood,
Organization, religious or
spiritual group).
 SOPA NOTE

Patient name: Shuva Akter

Age : 23 Year

Diagnosis : Right side hemiplegia

Date : 07/09/23

Subject :

Patient reported that patient can not perform eating, dressing, brushing, toileting
activity. Patient has limited hand function also has Problem in reaching, sleeping
and sleep time bed making activity etc

Objective :

1. weight bearing technique.

2. Reaching activity.

3. Muscle tone measure.

4. Sensory test assessment.

5. Synergistic pattern test.

6. Balance

7. observed secondary complication.

8. Hand function measurement.

9. communication skills ( vision, hearing, Language, emotional status)

10. Vitals(Blood pressure measuring, pulse cheak)

Analysis:

1. To teach and guide about patients condition.

2. Therapeutic education and knowledge.

3. Reaching activity.

4. Walking throught caregivers support.

5. Lack of therapeutic and communication skill in caregiver.

Plan:

1. Transferring from bed to chair/wheelchair

2. postural management.

3. Bobath approach:

*Truck rotation

*Shoulder mobilization

*Weight bearing technique

*Facilitation Technique

4. Range of motion practice

5. Motivation
 SOAP Note

Patient's name: Mst.shaleya khatun

Age : 53

Diagnosis : Ischemic stroke

Date : 11/09/23

Subjective :

Caregiver reported that patient have -

1. Right side numbness.

2. Diabetes.

3. Heart disease.

4. High blood pressure.

Patient can perform bathing, eating, toileting, sleeping,dressing with moderate

Support.

Objective:

1. Patient has right side hemiplegia

2. Spastic muscle tone.

3. Speech difficulty.

4. High blood Pressure.

5. Pulse rate normal.(62 beat/mint)

6. Sensory test is normal.

7. Observed secondary complications.

Analysis :

According to assessment, subjective and objective - patient's cognitive function

and emotional status was good which enhance her performance. Clonous was
observed for several times during stretching session.

Plan:

1.Passive stretching will provide for 2 set of 15-30 seconds of affected arm.

2.Finger and wrist extension will provide for 2 sets of 15-30 second on affected
side.

3. Scapular mobilization will provide on affected arm for 5 min.

4. Weight bearing on affected arm will provide.

 SOAP Note

Patient's name: Mst.shaleya khatun

Age : 53

Diagnosis : Ischemic stroke

Date : 12/09/23

Subjective:

During this session the patient mentioned that she can't perform eating, dressing,
brushing, toileting activity. She can't do her own activity by herself. She had also
slight pain in her shoulder and knee.

Objective:

1.patients consent was taken before starting therapy session.

2.patient was motivated and cooperated.

3.passive stretching was provided in wrist and finger joint,10sets of 15-20 sec at
right side.

4.strengthening exercise was provided through weight bearing practice for 5

minutes with taking rest.

5.scapula mobilization was provided for 5minutes

On right side.

6.weight bearing on affected arm was provided while reaching activity was done
by unaffected arm from various positions.

7.Transfering,bed mobility and sleep position was practiced with concern of

patient and her caregiver

9.home advice was provided to do weight bearing practice.

Analysis:

Based on the assignment, subjective and objective it is evident that patient

requires upper limb stretching to improve gross motor activity and function of
upper limb. Clonous was observed for several times during stretching session.

Plan:

A series of upper limb stretching exercises for the patient:

1.wrist stretch,2 set of 15-30 seconds of affected side

2.Finger extension streten, 2set of 15-30 seconds on affected side.

3.scapula mobilization Will be provided on the affected arm for 5 mins.

4.weight bearing on affected arm will be provided during reaching activity.

5.complex cylindrical grasp board will be used to enhance her reaching and
grasping activity.
 SOPE NOTE

Patient's name: Mst.Shaleya khatun

Age : 53

Diagnosis : Ischemic Stroke

Date : 13/09/23

Subjective :

During this session-

1.patient feel better than previous day.

2.practice her guiden exercise at home.

3. The patient mentioned that she was motivated to regain strength and hand
function.

4.She feel less pain in her shoulder and hip.

Objective :

1. She was cooperated.

2. Her emotional status was good.

3.Slight improve her hand function activity.

4.Weight bearing activity

5. Improve her reaching activity.

6.Provided passive stretching in wrist and hand joint.

7.Pinch, grasp practice provided by instructing the patient to use her finger to
pick and reaching by complex cylindrical grasp board.
Analysis : Based on assessment, subjective and objective, it is evident that
patient required upper limb stretching on right hand and grasp released and
guiden activity to improve her muscle tone and ROM for further functional
activity.

Plan:

1. Passive stretching of finger, wrist reaching activity.

2. Will use weight bearing technique for muscle relaxation.

3.Will use scapula mobilization.

4. Active assisted stretching of shoulder by flexion, extension, abduction,

adduction.

5. Complex cylindrical grasp board will be used to enhance reaching

activity and grasping.
 SOPE NOTE

Patient's name: Mst.Shaleya khatun

Age : 53

Diagnosis : Ischaemic Stroke

Date : 14/09/23

Subjective:

During this the patient reported that she is feeling better since the initial
assessment. The caregiver mentioned that she has following the home exercise
program. She is also motivated to regain strength and function.

Objective:

-patients consent was taken before started therapy session.

-patient was motivated and cooperater.

-transferring, bed mobility and sleep position was practiced with concern of
patient and her caregiver.

-passive stretching was provided in wrist and finger joint, 10 sets of 15-30 sec at
right side

-strengthening exercise was provided through weight bearing practice for 5min
with taking rest.

-scapula mobilization was provided for 5 minutes on right side.

-weight bearing on affected arm was provided while reaching arm was provided
while reaching activity was done by ineffected arm for various position.

-home advice was provided to do weight bearing practice.

Analysis:

Based on the assessment, subjective and objective it is individual that patient

required upper limb stretching to improve gross motor activity and function of
upper limb.

Plan:

-scapula mobilization will be provided on the effected arm for 5min.

-wrist stretching, 2set of 15-30 sec

-finger extemsor strength, 2set of 15-30 sec on effective side.

-weight bearing on effected arm will be provided during reaching activity.

- reach and grasp practice.

 SOPE NOTE

Patient's name: Mst.Shaleya khatun

Age : 53

Diagnosis : Ischemic Stroke

Date : 16/09/23

Subjective:

During this the patient reported that she is feeling better since the initial
assessment. The caregiver mentioned that she has following the home exercise
programme. She is also motivated to regain strength and function.

Objective:

-patients consent was taken before started therapy session.

-patient was motivated and cooperater.

-transferring, bed mobility and sleep position was practiced with concern of
patient and her caregiver.

-passive stretching was provided in wrist and finger joint, 10 sets of 15-30 sec at
right side

-strengthening exercise was provided through weight bearing practice for 5min
with taking rest.

-scapula mobilization was provided for 5 minutes on right side.

-weight bearing on affected arm was provided while reaching arm was provided
while reaching activity was done by ineffected arm for various position.

-home advice was provided to do weight bearing practice.

Analysis:

Based on the assessment she has clonus rythmic shaking movement. Never trap
on bicep muscle flexion always guiden movement. Don't keep the hand on
forearm. Ball use for foot balance.

Plan:

-scapula mobilization will be provided on the effected arm for 5min.

-wrist stretching, 2set of 15-30 sec

-finger extemsor strength, 2set of 15-30 sec on effective side.

-weight bearing on effected arm will be provided during reaching activity.

- reach and grasp practice.

 SOPE NOTE

Patient's name: Mst.Shaleya khatun

Age : 53

Diagnosis : Ischemic Stroke

Date : 18/09/23

Subjective:

During the third session the patient reported that she is feeling a bit better since
the initial assessment.The caregiver mentioned that she has following the home
exercise program.she is also motivated to regain strength and function.

Objective:

1.patients consent was taken before starting therapy session.

2.patient was motivated and cooperated.

3.passive stretching was provided in wrist and finger joint,10sets of 15-20 sec at
right side.

4.strengthening exercise was provided through weight bearing practice for 5

minutes with taking rest.

5.scapula mobilization was provided for 5minutes

On right side.

6.weight bearing on affected arm was provided while reaching activity was done
by unaffected arm from various positions.

7.Transfering,bed mobility and sleep position was practiced with concern of

patient and her caregiver

8.Clonous was observed for several times during stretching session.

9.home advice was provided to do weight bearing practice.

Analysis: Based on the assignment, subjective and objective it is evident that
patient requires upper limb stretching to improve gross motor activity and
function of upper limb.

Plan: A series of upper limb stretching exercises for the patient:

1.wrist stretch,2 set of 15-30 seconds of affected side

2.Finger extension streten, 2set of 15-30 seconds on affected side.

3.scapula mobilization Will be provided on the affected arm for 5 mins.

4.weight bearing on affected arm will be provided during reaching activity.

5.complex cylindrical grasp board will be used to enhance her reaching and
grasping activity.
 SOPE NOTE

Patient's name: Mst.Shaleya khatun

Age : 53

Diagnosis : Ischemic Stroke

Date : 19/09/23

Subjective: During session the patient reported that she is feeling much better
since the initial assessment.The caregiver mentioned that she has following the
home exercise program.she is also motivated to regain strength and function.

Objective:

1.patients consent was taken before starting therapy session.

2.patient was motivated and cooperated.

3.passive stretching was provided in wrist and finger joint,10sets of 15-20 sec at
right side.

4.strengthening exercise was provided through weight bearing practice for 5

minutes with taking rest.

5.scapula mobilization was provided for 5minutes On right side.

6.weight bearing on affected arm was provided while reaching activity was done
by unaffected arm from various positions.

7.Transfering,bed mobility and sleep position was practiced with concern of

patient and her caregiver

9.home advice was provided to do weight bearing practice.

Analysis:

Based on the assignment, subjective and objective it is evident that patient

requires upper limb stretching to improve gross motor activity and function of
upper limb.

Plan:

A series of upper limb stretching exercises for the patient-

1. wrist stretch,3 set of 15-30 seconds of affected side

2. Finger extension streten, 2set of 15-30 seconds on affected side.

3. scapula mobilization Will be provided on the affected arm for 5 mins.

4. weight bearing on affected arm will be provided during reaching activity.

5. complex cylindrical grasp board will be used to enhance her reaching and
grasping activity.