Medical History

Mary was 55 years of age when she experienced a left sided stroke in 2006, resulting in weakness (hemiplegia) of her right limbs. Her affected arm and leg were difficult to manage on a daily basis due to biomechanical and soft tissue changes which resulted in pain. Mary also had expressive and receptive dysphasia. Prior to the stroke, Mary lived an active life teaching students Spanish, she also had an interest in painting, aromatherapy and reading tarot cards.

Social History

Mary lived in a converted barn with her only daughter and son in law. Her daughter was her main carer. Her son in law worked from home but was often away on business. When possible, Mary enjoyed quality time with her family. Mary's extended family lived abroad in Central America which is where Mary originally came from.

Presenting Problems

Occupational Therapy was requested two years post stroke. Mary's daughter was concerned that activities of daily living were not improving. These activities included personal care, transfers and mobility. Communication was also a problem. An initial interview and assessment identified the following difficulties:

  • Mary had a dense right hemiplegic arm which was proving a challenge to manage on a daily basis
  • Mary was inconsistent with her personal care and required physical assistance
  • Morning routine was dominated by breakfast and personal care activities leaving little time for enjoyable activities
  • Mary was unable to access her garden due a large step to negotiate
  • Communication difficulties were ongoing, this resulted in an uncertainty by her daughter that Mary's needs were being met

A rehabilitative approach to intervention was taken to support Mary in gaining an optimum level of function. Mary required:

  • assessment of upper limb and provision of splints if appropriate
  • physical and cognitive assessment when performing personal care activities
  • The family required advice and support regarding balancing occupations in Mary's life
  • assessment of the environment to enable Mary to utilise all areas of her home independently
  • Advice regarding Mary's communication

Provision and management of splints

Spasticity in Mary's affected upper limb was partly being managed by injection therapy. It was important that any changes to the limb were managed with appropriate splints to ensure maximum benefits post injections were achieved. Mary was advised on an appropriate splint which would maintain a good resting position of her arm.

A soft roll splint was fabricated to maintain a resting position of her hand. All splints were monitored over time and altered to maximise Mary's range of movement. Positioning of upper limb was also agreed. Over time, Mary was able to tolerate wearing her splints for longer periods during the day and her fingers were more relaxed and extended.

Personal care activities

Mary on occasions would lose track of her daily sequence or routine. She also needed assistance to select clothing and open cosmetic jars.

A personal care sequence chart was prepared for her with visual prompts to enable her to follow a daily routine and help her maintain her concentration. On further assessment it was identified that Mary showed no other significant cognitive difficulties that would hinder her performing this task independently. Mary's daughter agreed to gradually step back from Mary enabling her to perform the task, assisting only when required.

Mary was advised on compensatory techniques to use which would enable her to dress using her unaffected arm and hand. Over time Mary succeeded in completing this task consistently within a reasonable time which then enabled her to fulfil other tasks and pursue other activities.

Role of carer versus role of daughter

It was felt the role of carer encroached on mother/daughter relationship. Mary's care needs seemed to take over and little time was left for the both of them to enjoy quality time together. After much deliberation, it was agreed that a carer be appointed who could also support Mary achieve independence with activities.

The occupational therapist advised on agencies to contact and supported the family with ongoing discussions with them. Help was provided in putting together a person specification outlining essential and desirable qualities expected from a carer. The occupational therapist also interviewed a candidate with Mary and her daughter.

An induction programme was designed and implemented to assist the carer familiarise with Mary's care needs. Mary's carer gradually became more involved with Mary supporting her as she pursued her goals and other interests. The occupational therapist reviewed goals with Mary and her daughter and new goals were agreed.

Aids and adaptations

Mary was unable to tend to a raised flower bed which could only be accessed via a wide patio door with a steep step. There was no wall to position a grab rail and this resulted in Mary always needing physical assistance when negotiating the step.

The occupational therapist provided information about the charity Remap, who produce custom made equipment for people with disabilities. A referral was completed and dimensions taken of the area. In due course, a free standing hand rail was manufactured and positioned outside the patio door. Mary was then able to independently access and exit the garden area.

Mary's daughter also needed further advice regarding bathroom aids to increase Mary's independence and safety when bathing. The occupational therapist showed the family a wide range of bathroom aids available to enable an informed decision about what was best needed.

Communication

Communication was a concern for Mary's daughter however their bond was such that it appeared both understood each other via non verbal communication. Mary did appear to understand her daughter and responded appropriately when requests were made and would often express a yes or no answer when asked anything. Mary's responses were also consistent. The occupational therapist was able to share information regarding counselling services for people who have had a stroke and who have communication difficulties.

Declan McNichol

Bill Young

Angela Gordon

Birgit Rathje-Vale