The Challenges in Stroke-Care Nomenclature

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 Dr. Melissa Kimmerling EdD, MOT, OTR/L is the Program Director for the Master of Occupational Therapy Program at NMC. Dr. Kimmerling has clinical experience in acute care, rehabilitation, skilled nursing, outpatient, and home health. She is the elected Vice President of Policy and Advocacy for the Nebraska Occupational Therapy Association (NBCOT).

Throughout my career in occupational therapy education, I've witnessed significant changes in educational standards, degree levels, and the broader healthcare system. Amidst this ever-evolving landscape, one constant has been the persistent uncertainty experienced by students when preparing to work with clients who have suffered neurologic injuries, such as strokes. The challenge they face is in grasping conditions like hemiparesis and spasticity and translating that knowledge into a functional understanding of how the affected upper extremity would perform.

In my fourth year of full-time teaching, I dedicated substantial effort to revamping the stroke care content within one of my courses. Given that many occupational therapy graduates find themselves in patient care settings where they may encounter stroke survivors, I recognized the paramount importance of this content. During my research, I stumbled upon a groundbreaking article titled "Development and Preliminary Reliability of the Functional Upper Extremity Levels (FUEL)" by Van Lew, Geller, Glazman, Capasso, Dicembri, and Pinto Zipp (2015). This article resonated deeply with me and the educational challenges I had been grappling with.

 The authors eloquently pointed out the absence of "common nomenclature or classification tools to measure and describe recovery of the upper extremity after stroke" (p. 1), echoing the concerns I'd been hearing from students for years. They often questioned, "With so many tools using different terminology, how are we expected to keep it all straight? How can we truly understand its implications for occupational performance?"

 Promptly, I incorporated the Functional Upper Extremity Level (FUEL) classification tool into my curriculum, and the impact was nearly immediate. Students began to perceive how they could conduct evidence-based assessments, work within both top-down and bottom-up assessment models, and, simultaneously, utilize a nomenclature that emphasized the upper extremity's role in occupational performance. Their note-writing improved, they crafted short-term goals aligned with typical neurologic recovery, and they consistently centered occupation in their approach. They even began integrating this nomenclature into their occupational therapy vernacular, a development that thrilled me.

 However, a challenge emerged when we received feedback from fieldwork sites suggesting that students were using unfamiliar or inappropriate terminology. Faced with this dilemma, I undertook a thorough analysis of my approach. Should I remove the tool from the curriculum, leave it be, or educate students differently? Ultimately, I concluded that the tool's reliability, validity, and its capacity to ensure that occupation remained a focal point in our assessments, documentation, and goal-setting warranted its continued inclusion in the curriculum.

 Rather than removing it, I resolved to raise awareness of this classification system within the broader practice community. I invite you to explore this tool alongside me, and in the meantime, I encourage you to delve into the original article that initially drew me to this invaluable resource. I look forward to potentially meeting you in November!


 Van Lew, S., Geller, D., Feld-Glazman, R., Capasso, N., Dicembri, A., & Pinto Zipp, G. (2015). Development and preliminary reliability of the functional upper extremity levels (FUEL). American Journal of Occupational Therapy, 69(6), doi: 10.5014/ajot.2015.016006