Occupational Therapy and Stroke Rehab: Chronic Phase

Goal Bank for Club Members

Each goal is intended as a starting point. The functional motivation behind each goal should be identified collaboratively with the client.

Functional Capacity and ADLs/iADLs

Therapeutic Goals

1. Upper Body Dressing

Within [time frame], the patient will don their dress shirt with a button hook with bilateral hand use and [level/type of assistance] to address bilateral hand use necessary for ADL participation.

2. Combing Hair

By [time frame], the patient will comb their hair using their hemiparetic hand with [level/type of assistance] with a verbal report of satisfaction with hair upkeep to address ADL skills required for their morning grooming routine.

3. Dish Washing

Within [time frame], the patient will dry [# of] dishes with use of the hemiparetic hand to towel dry the dishes and the unaffected hand as the dish stabilizer with [level/type of assistance] after their partner washes the dishes to address caregiver support, functional use of the hemiparetic hand and standing endurance required for iADL participation.

Assessment-Based Goal:

By [time frame], the patient will demonstrate a 1.85 point (minimally detectable change threshold) or greater improvement in the Barthel Index as an indicator of improved ADL performance.

Motor Function

Therapeutic Goals:

1. Sit to Stand

Within [time frame], the patient will perform [# ] sit to stands from an elevated toilet with pushing off from the grab bars with both upper extremities without a rest break with [level/type of assistance] to improve bilateral UE strength and sit to stand capability required for toilet transfers.

2. Dynamic Balance

By [time frame], the patient will transition from use of a reacher with the unaffected upper extremity to pick debris from the floor in a seated position to a partial squat with [level/type of assistance] to pick up debris from the floor with primary use of the unaffected upper extremity for [#] of attempts to address dynamic balance required for home management activities.

3. Postural Training

Within [time frame], the patient will sit on the edge of the chair unsupported in an upright position for at least [time requirement] in preparation for seated dynamic balance or reaching activities with the hemiparetic upper extremity.

Assessment-Based Goal:

By [time frame], the patient will demonstrate a 6.9 point (minimally detectable change threshold) or greater improvement in the Berg Balance Scale as an indicator of a improved balance required for daily activities.

Mobility

Therapeutic Goals:

1. Home Functional Mobility

By [time frame], the patient will ambulate [distance, e.g., meters] with [assistive device/assistance level] in the home to address functional mobility required for ADL and iADL activities in the home.

2. Community Mobility

By [time frame], the patient will ambulate [# of steps] as indicated by her smart watch with [assistive device/assistance level] on a flat, outdoor concrete terrain to address outdoor mobility in their neighborhood and health technology use.

3. Community Mobility in Social Environment

By [time frame], the patient will ambulate [# of steps] as indicated by her smart watch with [assistive device/assistance level] in a social enviornment with a [size] crowd prompting [quantity] changes in direction to address community mobility in social environments, ability to safely change walk path directions and health technology use.

Assessment-Based Goal:

By [time frame], the patient will demonstrate a reduction in time to completed the Timed Up and Go assessment of 2.9 seconds (minimally detectable change threshold) or greater as an indicator of a improved functional mobility required for participation daily activities.

Upper Extremity

Therapeutic Goals:

1. Grasp and Release

Within [time frame], the patient will complete [number] repetitions of a grasp and release activity using [specific object] with the hemiparetic hand to address grip and release ability required for functional activities.

2. Functional Dexterity

By [time frame], the patient will perform [number] repetitions of a [functional activity (e.g., manipulating eating utensils to pick up food items during self-feeding, buttoning a shirt, placing spare change on the counter in a container)] with the hemiparetic hand within [specified time frame] to address the speed of completion of fine motor functional activities in the home.

3. Functional Reaching

By [time frame], the patient will use the hemiparetic limb to safely place [#] [cabinet kitchen object(e.g. cups, bowls,plates)] on the [shelf level(e.g. bottom, middle)] shelf, prompting at least [# of degrees] of shoulder flexion or scaption to address upper extremity range of motion, strength and coordination required for home management activities.

Assessment-Based Goal:

By [time frame], the patient will demonstrate a minimally clinically important difference of a 10-point increase for the Fugl Meyer Assessment for the Upper Extremity to demonstrate improved hemiparetic upper extremity function required for daily activities.

Mood & Cognition

Therapeutic Goals:

1. Adaptive Memory Strategy

By [time frame], the patient will use the hemiparetic hand to hold her phone while the unaffected hand operates the phones speech to text function in order to convert their partner’s verbal recall of grocery list items to a structured grocery list on her smartphone to use as a memory aide with [level/type of cues] to address memory strategies required for grocery shopping.

2. Emotional Regulation

Within [time frame], the patient will accurately identify and verbally label [number] emotions using standardized emotion cards to enhance emotional awareness and address communication deficits due to aphasia.

3. Goal 3: Problem-Solving and Decision Making

By [time frame], the patient will follow a [# of steps] recipe with less than [number of sequencing errors] and [level/type of safety cues] to prepare a meal using both hands with the hemiparetic hand as the stabilizing hand during meal preparation tasks to address executive functioning and hemiparetic hand use during meal preparation.

Assessment-Based Goal:

By [time frame], the patient will obtain a 4.07 score (normative score for patients with moderate stroke or greater in the safety & judgement portion of the Executive Function Performance Test (EFPT) to demonstrate safety skills for living in the home with [level of assistance/supervision].

Visual Perception & Neglect

Therapeutic Goals:

1. Visual Scanning and Item Retrieval

By [time frame], the patient will visually scan a tabletop and locate [number] [specific items(e.g., writing utensils, coins, colored pieces of paper)] placed on the neglected side with[amount/type of cues], then use the hemiparetic hand to transfer each object to a container at midline with [level/type of assistance], to enhance spatial awareness and use of the hemiparetic hand.

2. Visual Scanning, Item Retrieval, and Organization

By [time frame], the patient will visually scan a tabletop and locate all objects placed on the neglected side to [ complete an activity(e.g. write grocery list, make a bowl of oatmeal, complete hair routine)] with [amount/type of cues], then use the hemiparetic hand to transfer each object required for the activity into their personal bag at midline with [level/type of assistance] , to enhance spatial awareness, organization skills and use of the hemiparetic hand.

3. Visual Scanning for Text

By [time frame], the patient will visually scan a menu at a restaurant and locate [#] food dishes that are vegetarian with [amount/type of cues], to address selection of food dishes within her nutritional guidelines set by her nutritionist.

Assessment-Based Goal:

By [time frame], the patient will score above a 129 score on the Behavioral Inattention Test indicating no presence of spatial neglect after completion of visual scanning and neglect therapy session and home programs.

Spasticity

Therapeutic Goals:

1. Weightbearing

By [time frame], the patient will perform standing tabletop weightbearing through her hemiparetic upper extremity while using the unaffected upper extremity to place objects in the cupboard with [level/type of cues] for hemiparetic elbow extension for [time goal] to address techniques to reduce spasticity during functional activities.

2. Neuromuscular Electrical Stimulation

By [time frame], the patient will complete a [time goal] neuromuscular electrical stimulation program [frequency(Hz), ramp time, pulse duration, or preset device program] for the hemiparetic wrist and digit extensors to release the grip around a cylindrical item in preparation for grasp and release activities.

3. Low Load Prolonged Stretch

By [time frame], the caregiver will complete low load prolonged strech of the hemiparetic elbow flexors for [time goal] with [type,amount] cues required for proper body mechanics when performing the stretch for the patient to address caregiver training and home exercise program compliance.

Assessment-Based Goal:

By [time frame], the patient decrease their upper extremity flexor spasticity as noted by a decrease in their Modifed Ashworth Score from 4 to 3, demonstrating a 1 point, clinically significant reduction in spasticity (minimally clinically important difference threshold 0.76).

ADL and Functional Mobility Outcomes

• Mirror Therapy with Task-Oriented Training

  • Considerations: cognition, vision, activity tolerance

  • Practitioners should consider providing MT in conjunction with TOT to improve FM and ADL performance during inpatient rehabilitation or home-based services for adults at all stages of stroke recovery (dose: 15-45 min, 2-6x/wk, for 2-6 wk).

• Aquatic / Hydrotherapy Activity

  • Considerations: access and comfort with aquatic exercise

  • Practitioners could consider providing hydrotherapy in an outpatient or community setting for adults with subacute or chronic stroke to improve ADL and FM outcomes (dose: 2-5 30- to 60-min sessions/wk for 2-8 wk).

• Recreational Interventions (such as music, horse riding, or creative arts activities)

  • Considerations: client interest, ability to grade activity

  • Practitioners could consider using recreational interventions such as music, horseback riding, and other creative arts activities to improve ADL performance of adults poststroke (dose: 90- to 240-min sessions, 2x/wk, for 4-12 wk).

ADL Outcomes

• Stroke Self-Management Interventions

  • Considerations: cognition

  • Practitioners should consider providing a health management intervention for stroke self-management, using a mixture of group, individual, and telephone follow-up, to improve ADL performance of adults post-stroke, during inpatient or outpatient rehabilitation (dose: 20- to 60-min sessions, 1-5x/wk, with telephone follow-up for 6-13 wk)

• CBT Interventions in Group / Individual

  • Considerations: diagnosis of depression; cognition

  • Practitioners could consider providing group or individual CBT, inpatient or in the community, for adults with depression post-stroke to improve ADL performance (dose: 3-40 wk total, 3-40 sessions total).

IADL Outcomes

• Medication Adherence via Text Reminders and Environmental Cues

  • Considerations: additional supports necessary for medication management; comfort with technology (if using text intervention); tailoring environmental cues to client preferences

  • Practitioners could consider providing medication management interventions (text reminders, environmental cues) for people after stroke who live at home to improve medication adherence (dose: 2 in-person sessions or multiple text messages over 8 wk).

• Driving Simulations

  • Considerations: need and desire to drive, cognition, vision

  • Practitioners could consider the use of driving simulation interventions to improve driving performance of people living at home poststroke (dose: 1-hr sessions, 3x/wk, for 5wk).

• Health Empowerment Group with Individual Follow-Up

  • Considerations: supports available for transportation to groups if needed; appropriateness of group environment

  • Practitioners could consider providing a health empowerment intervention to improve IADL performance (short and long term) for people living at home after stroke in the subacute stage (dose: 60-min session, 1x/wk, for 6 wk and home follow-up support).

Social Participation

• Multimodal Stroke Education with Supportive Follow-Up

  • Considerations: presentation of accessible education materials tailored to client’s individual physical needs; cognition

  • Practitioners could provide multimodal stroke education (e.g. written material, lectures) with supportive follow-up (telephone, internet) to improve social participation outcomes for adults after stroke (1 session before discharge and multiple phone and home follow-up (6 mo) or mix of group training 1 hr, 2x/wk, and home training 1.5 hr, 5x/wk, for 3 mo).

• Balance Interventions: Group CBT Interventions for Balance Self-Efficacy and Task-Oriented Balance Training

  • Considerations: fear of falling; appropriateness of group intervention; cognition

  • Practitioners could provide group CBT (45min) addressing balance self-efficacy and task-oriented balance training (45 min) to improve community integration for adults poststroke (dose: 90-min sessions, 2x/wk for 8wk).

• Long-Term Walking, Strength, and Balance Group Intervention

  • Considerations: appropriateness of group activity; ability to follow 2+ step activity instructions; safety/supports in place for safe mobility

  • Practitioners could provide a long-term (6-mo) group intervention in a community setting that includes walking and strength and balance exercises to improve social participation for adults poststroke (dose: 1hr/day 3 days/wk for 6 mo).

Participation in the Caregiver Role

• Problem Solving and Cognitive Behavioral Therapy Techniques in Person and with Telephone Follow-Up

  • Considerations: caregiver reports or demonstrates changes in mood (symptoms of depression related to role)

  • Practitioners should consider providing problem-solving therapy skills training and other CBT techniques (modeling, reinforcement, stress management, reframing negative thoughts) to improve caregiver depression health, and satisfaction (dose: 1-2 in-person sessions [home/inpatient stay] and telephone follow-up for 3-12 mo).

• Problem-Solving Skills Training with Stroke Education

  • Considerations: ability to tailor education and problem solving to meet individual caregiver needs

  • Practitioners should consider using stroke education in addition to problem-solving skills training, during or immediately after discharge from inpatient care, with long-term follow-up (3-6 mo), to improve caregiver outcomes (satisfaction, burden; dose: in-person and remote sessions or remote-only [phone] sessions, weekly or biweekly for 2-6 mo).

• Family Support Organizer: Tailored Long-Term Support Before and After Discharge

  • Considerations: ability of program in current setting

  • Practitioners should consider providing tailored, long-term (9-mo) support (case management, information, discharge, service connections, liaison) to help improve caregiver knowledge, quality of life, and social activity pre- and postdischarge (dose: as needed over 9 mo).

• Problem Solving Without Additional Interventions

  • Considerations: consider additional caregiver needs

  • Practitioners could consider providing in-person problem-solving therapy skills training and long-term telephone follow-up (3 mo), during inpatient care, immediately after discharge, or both (1 3-hr in-person session, weekly in mo 1, biweekly in mo 2, and once in mo 3 postdischarge).

• Skills Training (e.g. ADLs, pressure ulcer prevention, transfers, oral health care): Before and After Discharge In-Home Follow-Up and Post-Discharge In-Home Training with Telephone Follow-Up

  • Considerations: tailor skills training to caregiver needs and capabilities; ensure that skills training reflects individual and family culture and preferences

  • Practitioners could consider providing inpatient skills training (transfers, ADLs, communication, pressure ulcer prevention) for caregivers during the patient’s inpatient stay with an in-person home follow-up postdischarge to improve caregiver burden, quality of life, anxiety, and depression (3-4 30- to 45-min session and 1 home visit).

• Home-Based Long-Term Support and Education (for ADL training, problem solving, identification of caregiver supports, coping, and stress management)

  • Considerations: tailor to individual needs and community access; ability to maintain intervention over time

  • Practitioners could consider providing long-term (6-mo) home visit interventions that include education, ADL training, community resources, stress management, problem-solving and coping strategies to improve caregiver health status, and mobilizing family support and acquiring social support (dose: as needed over 6 mo, average 16 visits, 70-min session).

• Multimodal Long-Term Intervention (individual or group) for Education, Coping, Problem Solving, and Stress Management

  • Considerations: tailor to individual needs and community access; ability to maintain intervention over time

  • Practitioners could consider providing long-term (2-8 mo) multimodal interventions (education, stress, problem-solving, coping) in an individual format, group format, or both to improve caregiver confidence, coping, knowledge, and depression (dose: 1-hr weekly or biweekly session for 2-8 mo).

• Inpatient, Home, and Telephone Follow-Up Intervention Focusing on Preparation for Discharge, Social Functioning, and Quality of Life

  • Considerations: tailor to individual needs; ability to maintain intervention over time

  • Providers could consider providing educational and discharge support from inpatient to home to improve caregiver preparation, social functioning, and quality of life (4-5 30-min inpatient sessions, 1 45-min telephone call, 30-min home visit at 1 wk and 1 mo post discharge).

• Two-Month Telephone Education and Support Group with Individual Stress Reduction Techniques

  • Considerations: ability to participate over an extended period of time

  • Practitioners could consider providing long-term (2-mo) telephone delivered group education sessions to caregivers to improve perceived competence and burden (8 1-hr sessions over 2 mo).

Discharge Suggestions

• Self-management

  • Physical activity, healthy diet, sleep hygiene, well-being, leisure

• Know how to recognize a second stroke (think FAST)

  • F: face drooping

  • A: arm weakness

  • S: speech difficulties

  • T: time to call 911

• Make an emergency action plan