Occupational Therapy and Stroke Rehab: Subacute Phase

Goal Bank for Club Members

Functional Capacity and ADLs/iADLs

Therapeutic Goals:

1. Upper Body Dressing

Within [time frame], the patient will independently don a light jacket using task-specific training to facilitate bilateral arm use.

2. Meal Preparation

By [time frame], the patient will prepare a simple meal using both hands with supervision, to improve meal preparation capability.

3. Personal Hygiene

Within [time frame], the patient will brush their teeth independently to improve fine motor skills and sensory integration

Assessment-Based Goal:

By [time frame], the patient will demonstrate a 1.85-point or greater improvement on the Barthel Index (minimally detectable change), reflecting increased independence in basic self-care activities.

Motor Function

Therapeutic Goals:

1. Sit to Stand Transitions

Within [time frame], the patient will perform sit to stand transitions independently from a standard chair to enhance lower body strength.

2. Walking Practice

By [time frame], the patient will walk 50 meters with modified independence during an ADL or iADL activity.

3. Stair Navigation

Within [time frame], the patient will ascend and descend 10 steps using a handrail with minimal assistance.

Assessment-Based Goal:

By [time frame], the patient will achieve a 10-point increase on the Fugl-Meyer Assessment for motor function, indicating enhanced overall motor recovery.

Mobility

Therapeutic Goals:

1. Wheelchair Navigation

Within [time frame], the patient will independently maneuver a wheelchair through a course with turns and doorways, using spatial awareness and propulsion techniques.

2. Balance Maintenance

By [time frame], the patient will maintain balance while standing for 5 minutes with minimal support.

3. Functional Transfers

Within [time frame], the patient will perform a bed to chair transfers independently.

Assessment-Based Goal:

By [time frame], the patient will exhibit a 5-point improvement on the Berg Balance Scale, signifying better balance for safe transfers and mobility.

Upper Extremity

Therapeutic Goals:

1. Grasp and Release

By [time frame], the patient will perform grasp and release exercises with various objects for 5 minutes, to increase dexterity.

2. Object Manipulation

Within [time frame], the patient will sort and organize at least five grocery items into a pantry using both hands with minimal assistance to improve bilateral upper extremity integration.

3. Reaching and Retrieving

Within [time frame], the patient will safely reach for and retrieve items from different heights to enhance movement accuracy and reach.

Assessment-Based Goal:

By [time frame], the patient will improve by ≈5.7 points on the Action Research Arm Test, reflecting greater arm and hand functional use in daily activities.

Mood & Cognition

Therapeutic Goals:

1. Problem Solving

By [time frame], the patient will independently solve daily problems encountered during therapy activities, improving cognitive flexibility through cognitive-behavioral strategies.

2. Memory Aids

Within [time frame], the patient will effectively use a memory aide to recall therapy schedules with minimal cognitive assistance.

3. Safety Awareness

By [time frame], the patient will identify potential safety hazards in the home environment with minimal cognitive assistance, therefore enhancing environmental awareness.

Assessment-Based Goal:

By [time frame], the patient will report a 5-point reduction on the Patient Health Questionnaire-9, indicating decreased depressive symptoms and improved emotional well-being.

Visual Perception & Neglect

Therapeutic Goals:

1. Visual Scanning Techniques

By [time frame], the patient will use at least two visual scanning techniques with minimal assistance to identify objects in their peripheral vision, improving spatial awareness through targeted exercises.

2. Neglect Management

Within [time frame], the patient will perform lotion application to the bilateral upper limbs that require attention to the neglected side, using a mirror and visual cueing to decrease symptoms of neglect.

3. Spatial Orientation

By [time frame], the patient will navigate the nursing facility cafeteria using compensatory strategies to manage visual-spatial deficits with 5 or less cognitive cues.

Assessment-Based Goal:

By [time frame], the patient will complete the Line Bisection Test with <10% deviation from true center, demonstrating improved visuospatial attention for ADLs.

Spasticity

Therapeutic Goals:

1. Stretching and Positioning

By [time frame], the patient will engage in daily stretching routines focusing on the hemiparetic limb to reduce muscle tone, guided by neuromuscular techniques with minimal physical assistance.

2. Functional Use of Spastic Limb

Within [time frame], the patient will use their spastic upper limb to assist with bathing of the bilateral thighs with emphasis on elbow extension to address flexor spasticity.

3. Spasticity Monitoring

By [time frame], the patient will self-monitor and record levels of spasticity daily, learning to adjust their activities and brace use accordingly with 5 or less cognitive cues.

Assessment-Based Goal:

By [time frame], the patient will reduce spasticity in the hemiparetic upper extremity, as evidenced by a decrease in the Modified Ashworth Scale score from 4 to 3, following a regimen of weight-bearing exercise and prolonged stretch techniques for the affected arm.

Treatment Interventions with Notes for Club Members

Interventions to Improve ADLs and Functional Mobility

• 🟡 Sensory Retraining

  • Considerations: sensation tolerance

  • Recommendations: Practitioners could consider providing various types of sensory retraining to improve ADL performance for leg somatosensory impairment for people in inpatient rehabilitation (dose: varies; 20-45 min sessions, 2-5x/wk, for 2-9 wk)

• 🟢 Mirror Therapy with Task-Oriented Training

  • Considerations: cognition, vision, activity tolerance

  • Recommendations: Practitioners should consider providing mirror therapy in conjunction with task-oriented training to improve functional mobility and ADL performance during inpatient rehab or home-based services for adults at all stages of stroke recovery (dose: 15-45 min, 2-6x/wk, for 2-6 wk)

• 🟡 Action Observation with Task-Oriented Training

  • Considerations: activity tolerance, vision, cognition (attention)

  • Recommendations: Practitioners could consider providing action observation along with task-oriented training to improve ADLs and functional mobility of adults with acute and subacute stroke (dose: 20-90 min/session, 3-6 days/wk, for 3-8wk)

• 🟢 Balance Training as Intervention to Support Occupation

  • Considerations: pain, activity tolerance

  • Recommendations: Practitioners should consider providing balance training to improve ADLs (inpatient rehab setting) and functional mobility (inpatient rehab and other settings) for adults with subacute and chronic stroke (dose: 2-62 hr, 5x/wk for 5wk)

• 🟢 Mental Imagery with Task-Oriented Training

  • Considerations: cognition (attention, abstraction)

  • Recommendations: Practitioners should consider the use of mirror imaging, using video, audio, or images of specific movements or tasks, as an adjunct to task-oriented training for adults with stroke at all stages of recovery to improve functional mobility in the short term (dose: <6wk; 12-40 5- to 30-min sessions over 4-6wk)

• 🟡 Home-Based ADL Training Before Discharge from Inpatient Rehabilitation

  • Considerations: access/facility policies and programs, patient comfort

  • Recommendations: Practitioners could consider providing home-based ADL training before discharge from inpatient rehabilitation and home-based care after discharge to improve ADL and mobility performance (dose: 1-hr sessions, 1-3x/wk until discharge, 1-hr sessions 1-5x/wk for 4 wk after discharge)

• 🟡 Home-Based ADL Training and Education

  • Recommendations: Practitioners could consider providing home-based ADL training and education to improve ADL performance for people post-stroke discharged from acute care (2-hr sessions, 1x/wk, for 6wk)

• 🟡 OT-Provided ADL Training Strategies

  • Recommendations: Practitioners could consider using OT ADL training strategies (remediation, adaptation, technology, environmental modification) to improve ADL performance of people post-stroke and all stages of recovery (dose unspecified)

• 🟡 CBT Interventions in Group/Individual

  • Considerations: diagnosis of depression, cognition

  • Recommendations: 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)

• 🟡 Activity-Based Interventions (Computer-Based Training for Visual Scanning Training and Optokinetic Stimulation, Mental Practice, Mirror Therapy, Voluntary Trunk Rotation, and Vestibular Rehabilitation)

  • Considerations: unilateral spatial neglect

  • Recommendations: Practitioners could consider providing activity-based interventions (computer-based training for visual scanning training and optokinetic stimulation, mental practice, mirror therapy, voluntary trunk rotation, vestibular rehabilitation) for adults with unilateral spatial neglect post stroke to improve ADL performance (dose: 5-30 sessions, 2-10x/wk, 1hr 45 min to 30 hr, for 4 days-5wk)

Interventions to Improve IADL Outcomes

• 🟢 CIMT or CIMT in Combination with Other Interventions: self-regulation, trunk restraint, robotic therapy, shaping, adaptive, and repetitive practice of functional tasks

  • Considerations: understanding of intensity of intervention and active choice to participate; activity tolerance; positioning; frustration tolerance

  • Recommendations: Practitioners should consider providing CIT alone or in combination with other interventions (self-regulation, trunk restraint, robotic therapy) during inpatient rehabilitation to improve IADL performance and mobility after stroke (dose: 1-2hr sessions, 5x/wk, 2-4 wk)

Interventions to Improve Social Participation

• 🟡 Medication Adherence Via Text Reminders and Environmental Cues

  • Considerations: additional supports necessary for medication management; comfort with technology; tailoring environmental cues to client preferences

  • Recommendations: 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)

• 🟡 Health Empowerment Group with Individual Follow-Up

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

  • Recommendations: 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).

• 🟡 Multimodal Stroke Education with Supportive Follow-Up

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

  • Recommendations: Practitioners could provide multimodal stroke education (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 1hr, 2x/wk, and home training 1.5 hr, 5x/wk, for 3 mo

• 🟡 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)

  • Recommendations: 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

  • Recommendations: 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

  • Recommendations: 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

  • Recommendations: 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 post discharge).

• 🟡 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

  • Recommendations: 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).

• 🟡 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

  • Recommendations: 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).