Pauline is a 62 year old woman who is 10 years post stroke. She presents with left hemiplegia and complains of pain and discomfort in her left upper extremity. This pain is chronic and unbearable. Pauline is often unable to sleep because the pain she experiences is so great. Upon assessment, Pauline appears to have a one finger downward subluxation of her humerus. In addition, she experiences neuropathic pain that has resulted from the stroke. It is apparent that Pauline has compensated for her hemiplegia by performing all of her activities with her dominant right hand. She ambulates slowly with a cane and uses an ankle foot orthosis (AFO) on her left leg to allow for toe clearance due to drop foot positioning of her lower extremity. Pauline has experienced a number of falls over the past 10 years.

Pauline has made significant adaptations to her ADL to enable independence since she lives alone in a rented apartment. Examples of these include: a suction cutting board and rocker knife for food preparation; use of dycem; rearrangement of her kitchen to promote ease of reaching for items with one hand; and implementation of one handed strategies for dressing such as stretching her sock by donning it on her right foot and then removing the stretched sock to don it on her affected foot.

Pauline works with a pain management team at a clinic in Kingston, where she lives. The team is comprised of a physician, occupational therapist, physiotherapist, nurse, and a psychologist. Pauline has been prescribed medication as a means of managing her pain in the past. Her physician first prescribed acetaminophen, however, as time progressed, she no longer responded to this. She was then prescribed stronger and stronger medication to manage her pain until she was using strong medication that she eventually became addicted to. This frightened Pauline, and she had requested that her physician gradually parse down her dose until she was no longer taking pain medication to manage her symptoms. Instead, Pauline plans to work with the team to use other strategies to cope with her chronic pain.

Until recently, the Occupational Therapist on the pain management team was on maternity leave. During this time, the clinic was unable to recruit another OT, and the position remained vacant, leaving Pauline without a therapist. Two weeks ago, the OT returned from leave, and was alarmed to discover that Pauline had fallen in her bathroom three times in the past two months. At one point, Pauline exacerbated the subluxation of her humerus by quickly grabbing onto the side of the bathtub with her left hand as she fell while trying to exit her bathtub. This further stretched the ligaments in her shoulder joint, compounding the pain in her left UE further.

Pauline’s OT, Sarah, decided to perform an environmental assessment of the bathroom in her apartment. During this assessment, Sarah discovered that Pauline had been using a chair situated between her toilet and bathtub to hold onto while entering and exiting the tub, or to aid her in getting on and off the toilet. Pauline reported that she needs to use this chair for toileting, as the toilet is simply too low. She also reports that if she were not using this chair, it would be impossible to get out of the tub. When asked by Sarah how she uses this chair for the bathtub, Pauline reported that she stabilizes herself by holding the chair with her right hand while entering the tub. To exit, Pauline positions herself so that she is on her knees, then pulls herself to stand with her right arm holding the back of the chair. One of Pauline's falls occurred when her feet slipped on the bottom of the bathtub while pulling herself to stand.

Pauline is beginning to experience pain in her right UE as well, as she uses it frequently to compensate for the loss of function in her left UE. She has not slept for more than 2 hours at a time in the last 3 months, and is feeling exhausted all the time. While Pauline used to be an involved grandmother, she simply doesn’t have the energy to keep up with her 10 & 12 year old grandchildren. When her son calls her, she no longer answers the telephone. Her son comes to her apartment to visit once per week, but he has been frustrated with Pauline because she does not seek contact with him, and often doesn’t answer his telephone calls. He is hurt by this, and this has strained the relationship considerably. Pauline also does not contact her friends anymore, and spends the majority of the day alone in her apartment with her cat. It is simply too difficult to go anywhere, and Pauline is in too much pain to do much of anything.

Pauline has begun to seek treatment for depression and anxiety with a psychiatrist, as well as the psychologist on the pain management team. She has never experienced mental illness before, and believes that her anxiety and depression are the result of her chronic pain and lack of sleep.

Disclaimer: This case study has been based on Pauline, a person featured in the video that accompanies this case study; However, the events described in this case study are entirely fictional, and do not depict actual events. This case study was produced for educational purposes only.