Stroke Cerebral Vascular Accident. Common Clinical Impairments Lower Motor Neuron Upper Motor Neuron...

Stroke Stroke Cerebral Vascular Cerebral Vascular

AccidentAccident

Common Clinical ImpairmentsCommon Clinical Impairments

Lower Motor NeuronLower Motor Neuron Upper Motor NeuronUpper Motor Neuron

Voluntary Voluntary StrengthStrength

Flaccid weakness, Flaccid weakness, paralysisparalysis

Spastic weaknessSpastic weakness

Stretch Stretch ReflexReflex

Decreased, absentDecreased, absent Hyperactive, Hyperactive, exaggeratedexaggerated

MuscleMuscleToneTone

HypotoniaHypotonia HypertoniaHypertonia

Muscle Muscle AtrophyAtrophy

PresentPresent AbsentAbsent

Muscles Muscles AffectedAffected

Single muscle, small Single muscle, small groupsgroups

Large groupsLarge groups

Medical Management Medical Management

Ischemic Stroke Ischemic Stroke (clotting)(clotting)

AntiplateletsAntiplatelets

Anticoagulants Anticoagulants

““blood thinners”blood thinners”

Hemorrhagic Stroke (bleeding)Hemorrhagic Stroke (bleeding)

Surgical Clipping Surgical Clipping

TreatmentTreatment

deflation of a balloon-like deflation of a balloon-like

bulge in an arterybulge in an artery

Neurological ImpairmentsNeurological Impairments

depending on the location & severity depending on the location & severity

– Left hemisphere = aphasia, apraxia, Left hemisphere = aphasia, apraxia, contralateral hemiplegia/hemiparesis contralateral hemiplegia/hemiparesis

– Right hemisphere = contralateral Right hemisphere = contralateral hemiplegia/hemiparesis, spatial neglect, hemiplegia/hemiparesis, spatial neglect, visual deficits, poor insight/judgment, visual deficits, poor insight/judgment, impulsive behaviors impulsive behaviors

Diagram showing the lobes and Diagram showing the lobes and functions of the brainfunctions of the brain

Prognosis Prognosis Varies from client to client Varies from client to client

Location of the lesionLocation of the lesion

Size of the lesion (larger are worse)Size of the lesion (larger are worse)

Age of client (older is worse for recovery)Age of client (older is worse for recovery)

Recovery:Recovery:– Varies from patient to patientVaries from patient to patient– Improves over timeImproves over time– Improves with therapy Improves with therapy – Recovery within 72 hrs and the first 2 weeks Recovery within 72 hrs and the first 2 weeks

Secondary: factors swelling/edema in the brain Secondary: factors swelling/edema in the brain

Extensions of the original CVAExtensions of the original CVA

Other medical conditions: pneumonia, diabetes, cardiacOther medical conditions: pneumonia, diabetes, cardiac

Prognosis Prognosis Functional recovery Functional recovery

must be observed in Mobility, ADL, IADL, work, leisure, social life, must be observed in Mobility, ADL, IADL, work, leisure, social life, occupational rolesoccupational roles

Factors influencing recovery:Factors influencing recovery:type, site, coexisting diseases, initial motor recovery, history of type, site, coexisting diseases, initial motor recovery, history of stroke, severe visuospatial deficits, severe cognitive deficits, stroke, severe visuospatial deficits, severe cognitive deficits, depression, aphasia, level of consciousness, bowel/urinary depression, aphasia, level of consciousness, bowel/urinary incontinence, poor social support, poor sitting balance. incontinence, poor social support, poor sitting balance.

Factors predicting good recovery:Factors predicting good recovery: married status, motor recovery.married status, motor recovery.

Time frame for recovery:Time frame for recovery:rapid changes in the first 1-3 months, then recovery continues up to rapid changes in the first 1-3 months, then recovery continues up to 1 year1 year

Medical care focus Medical care focus

Immediate care Immediate care – Airway maintenance/oxygenation Airway maintenance/oxygenation – Nutritional intervention Nutritional intervention – Ulcer prevention Ulcer prevention – Treatment of cardiac dysfunction Treatment of cardiac dysfunction – Pharmacological therapies Pharmacological therapies


Acute care Acute care – Clients generally medically unstable Clients generally medically unstable – OT: OT: referral to what is next referral to what is next – Focus on clients going home after Focus on clients going home after

acute care (client & family education acute care (client & family education with focus on basic ADL)with focus on basic ADL)

– Clients who are not going directly to Clients who are not going directly to home focus on occupational areas and home focus on occupational areas and client factors client factors


Inpatient care Inpatient care Clients transferred when stableClients transferred when stable (tolerate 3-hour rehab sessions) (tolerate 3-hour rehab sessions) Evaluate & assist patients in occupational areas to Evaluate & assist patients in occupational areas to

move to homemove to home Home evaluationHome evaluation ADL/ IADL intervention ADL/ IADL intervention Transferred home when safe to perform activities Transferred home when safe to perform activities Clients need some assistance at hClients need some assistance at home ome


Outpatient and home Outpatient and home health care health care

Clients & therapist work on Clients & therapist work on specific activities/goalsspecific activities/goals

Focus on ADL/IADL, work, Focus on ADL/IADL, work, …etc…etc

Home programs should be Home programs should be extremely functional + extremely functional + client/family education so client/family education so that clients can carry on that clients can carry on with their activitieswith their activities

Evaluation: NeurorehabilitationEvaluation: Neurorehabilitation– Clinical observationClinical observation– Clinical interviewClinical interview– Standardized assessmentsStandardized assessments– DocumentationDocumentation

NeurorehabilitationNeurorehabilitation

Stages of Evaluation Stages of Evaluation

Severity determines the evaluation Severity determines the evaluation

A.A.Acute careAcute care

2.2. Occupation areas:Occupation areas: Self-care Self-care Basic mobility within Basic mobility within

functional tasks (e.g., bed functional tasks (e.g., bed mobility) mobility)

Swallowing (speech Swallowing (speech therapists) therapists)

1. Client factors: Sensory processing ROM Muscle tone Cognitive and perceptual


B.B. Inpatient rehabilitationInpatient rehabilitation

1.1. Occupation areas:Occupation areas: Self-care Self-care Basic mobility within Basic mobility within

functional tasks (e.g., bed functional tasks (e.g., bed mobility) mobility)

Swallowing (speech Swallowing (speech therapists) therapists)

Observation

2.2. Hypotheses about client Hypotheses about client factors factors

Hemiplegia Hemiplegia Poor trunk control Poor trunk control Impaired balance Impaired balance Difficulties with attention Difficulties with attention Organization Organization Sequencing Sequencing Visual perception Visual perception


B.B. Inpatient rehabilitationInpatient rehabilitation

Observation

2.2. Hypotheses about client Hypotheses about client factors factors

Hemiplegia Hemiplegia Poor trunk control Poor trunk control Impaired balance Impaired balance Difficulties with attention Difficulties with attention Organization Organization Sequencing Sequencing Visual perception Visual perception

Evaluation

Observation Observation Understanding of Understanding of

neurological impairmentneurological impairment Substantiated by specific Substantiated by specific

assessment of client assessment of client factors factors

Intervention on improving Intervention on improving performance performance

Reduction of impairment Reduction of impairment


C.C. Home/community Home/community

• ADL/IADL, Work , school, leisure, social participation ADL/IADL, Work , school, leisure, social participation • Role Role • EnvironmentEnvironment• Client education Client education

• Home or outpatient servicesHome or outpatient services


ADL (Self-care) assessment toolsADL (Self-care) assessment toolsBarthel Index Barthel Index (Mahoney & Barthel, 1965)(Mahoney & Barthel, 1965)

– Self-report and observation-basedSelf-report and observation-based

Functional Independence Measure [FIM] Functional Independence Measure [FIM] (Keith, 1987) (Keith, 1987)

– Self-report and observation-based Self-report and observation-based

Katz Index of ADL Katz Index of ADL (Katz, 1963) (Katz, 1963)

– Self report Self report


IADL assessment toolsIADL assessment tools

Frenchay Index (self-report)Frenchay Index (self-report)

Philadelphia Geriatric Center IADL scale Philadelphia Geriatric Center IADL scale (performance-based) (performance-based)

Driving assessment ( needs a specialized training Driving assessment ( needs a specialized training in assessment and intervention) in assessment and intervention)

Postural Adaptation Postural Adaptation (balance, trunk (balance, trunk control)control)

Berge Balance Berge Balance ScaleScale

(video) (video)

Assessment of component, abilities, capacities

Head/neckHead/neck: : forward, flexed to weak side/away from weak sideforward, flexed to weak side/away from weak side

Shoulder: Shoulder: uneven height, retracteduneven height, retracted

Spine/trunk: Spine/trunk: curved, thoracic kyphosis, shorted lateral curved, thoracic kyphosis, shorted lateral trunktrunk

Arms: Arms: use of unaffected arm, increase/decreased toneuse of unaffected arm, increase/decreased tone

Pelvis: Pelvis: asymmetrical weight bearing, posterior pelvic tilt, forwardasymmetrical weight bearing, posterior pelvic tilt, forward

LegsLegs: hips in extension or adducted, or externally rotated, : hips in extension or adducted, or externally rotated, feet in front of knees instead of under feet in front of knees instead of under

Common Impairments in sitting posture in Stroke patients


Upper extremities function Upper extremities function SomatosensorySomatosensory (require recognition and attention, it is (require recognition and attention, it is hard to test sensation with patients with aphasia/cognition hard to test sensation with patients with aphasia/cognition impairments). impairments).

Patients with expressive aphasia can nod, gesture, point Patients with expressive aphasia can nod, gesture, point to)to)

Patients with Patients with mild CVA mild CVA have to be tested for have to be tested for discriminatory problems sensation abilities = discriminatory problems sensation abilities = Moberg Pick-Moberg Pick-up Test:up Test: used for people with good motor recovery but used for people with good motor recovery but impaired dexterity impaired dexterity (originally used for RA patients, 12 small (originally used for RA patients, 12 small objects are picked up and time is counted with a objects are picked up and time is counted with a stopwatch)stopwatch)


Upper extremities functionUpper extremities functionMechanical & Physiological component Mechanical & Physiological component – Passive range of motion limitations (PROM): may result by injury, Passive range of motion limitations (PROM): may result by injury,

immobilization (which may also lead to muscle weakness), immobilization (which may also lead to muscle weakness), persistent stereotyped position of joint without movement which persistent stereotyped position of joint without movement which then may cause muscle shortening and eventually contractures in then may cause muscle shortening and eventually contractures in muscles, tendons, and ligaments.muscles, tendons, and ligaments.

– For example, common complications of hemiparesis in the For example, common complications of hemiparesis in the shoulder are adhesion, tendinitis, and bursitis. Moreover, edema shoulder are adhesion, tendinitis, and bursitis. Moreover, edema (reduced circulation & loss of muscle action) may lead to limited (reduced circulation & loss of muscle action) may lead to limited PROM especially in the hand. PROM especially in the hand.

Always compare the ROM of the affected side to Always compare the ROM of the affected side to the unaffected side. the unaffected side.


Upper extremities functionUpper extremities function– Joint malalignmentJoint malalignment (subluxation) (subluxation) – Muscle toneMuscle tone (flaccid, spastic) (flaccid, spastic) – Pain (Visual Analogue Scale)Pain (Visual Analogue Scale)– Edema –in hand Edema –in hand – Shoulder subluxationShoulder subluxation (malalignment of the (malalignment of the

gelnohumeral joint caused by weakness or spasticity of gelnohumeral joint caused by weakness or spasticity of the scapulohumeral or scapular muscles)the scapulohumeral or scapular muscles)


Upper extremities functionUpper extremities function

Inferior/downward subluxation Inferior/downward subluxation (gravity humerus head (HH) down or inferior) (gravity humerus head (HH) down or inferior)

EvaluationEvaluation: patient stand with shoulder freely hanging palpation of separation between : patient stand with shoulder freely hanging palpation of separation between acromin and HH measured in finger width acromin and HH measured in finger width

Anterior subluxation Anterior subluxation (HH anteriorly + hyperextended due to hypertonicity of surrounding muscles)

Evaluation: no clinical method but palpation of a space posterior to the HH suggests anterior subluxation

Superior Subluxation Superior Subluxation (hypertonicity-related: HH locked above, elevated, abducted).

Evaluation: suspected if no space is felt in the acromial space

Inferior SubluxationInferior Subluxation

Anterior Shoulder Subluxation Anterior Shoulder Subluxation

Anterior Shoulder Subluxation Anterior Shoulder Subluxation

Superior Shoulder

Subluxation

Anterior and superior shoulder Anterior and superior shoulder subluxation subluxation


Upper extremities functionUpper extremities functionVoluntary movement: • observe associated reaction, • voluntary movement, • proximal stability for distal mobility, voluntary movement

against gravity, isolated vs mass movements • reciprocal movement (flexion-extension smoothness)• compensatory movement• muscle tension• Fugl-Meyer Assessment of Motor Function (Fugl-Meyer,

1975).



Muscle strengthMuscle strength (Manual Muscle Testing (MMT) : (Manual Muscle Testing (MMT) : traditionally not used with patients with hemiplegia traditionally not used with patients with hemiplegia because spasticity may confound the results because spasticity may confound the results

Reduced Endurance: Reduced Endurance: is the decrease in the ability to is the decrease in the ability to sustain movement or activity for practical amounts of time sustain movement or activity for practical amounts of time which prevents patients from participating in rehabilitation. which prevents patients from participating in rehabilitation. For patients with stroke For patients with stroke fatiguefatigue is a common is a common complicationcomplication teach patient teach patient energy conservation energy conservation techniques and do techniques and do work simplification. work simplification.



a standardized assessment tool for patients with a standardized assessment tool for patients with hemiplegia is thehemiplegia is the

Functional Test for the Hemiplegic/paretic Upper Functional Test for the Hemiplegic/paretic Upper Extremity Extremity

a 7-item test to assess the functional performance of a 7-item test to assess the functional performance of the affected upper extremity. Tasks ranges in their the affected upper extremity. Tasks ranges in their difficultydifficulty

Functional Test for the Functional Test for the Hemiplegic/paretic Upper Extremity Hemiplegic/paretic Upper Extremity


Motor Learning Ability (patient’s ability to learn and Motor Learning Ability (patient’s ability to learn and organize movement for adaptation to the environmentorganize movement for adaptation to the environment

Visual functioning: patients with stroke may show visual Visual functioning: patients with stroke may show visual deficits of homonymous hemianopsia (half of the visual deficits of homonymous hemianopsia (half of the visual field is affected) field is affected) – Unilateral neglect: (right hemisphere damage-parietal lobe lesions) Unilateral neglect: (right hemisphere damage-parietal lobe lesions)

failure to notice, orient or respond to stimuli on one side of visual failure to notice, orient or respond to stimuli on one side of visual space space

– Patients can have hemianpsia without neglect Patients can have hemianpsia without neglect

– Visual field testing???Visual field testing???

Unilateral Neglect


Aphasia : Aphasia : A) fluent aphasiaA) fluent aphasia (lesion in parietal lobe) = receptive aphasia, (lesion in parietal lobe) = receptive aphasia,

Wernicke’s aphasia = losing the ability to repeat phrases, name Wernicke’s aphasia = losing the ability to repeat phrases, name objects, follow commands.objects, follow commands.

B) nonfluent aphasiaB) nonfluent aphasia, expressive aphasia, Broca’s area (lesions in , expressive aphasia, Broca’s area (lesions in parietal lobe) = slow, awkward articulation with reduced vocabulary parietal lobe) = slow, awkward articulation with reduced vocabulary and grammar use = losing ability to name objects, repeat phrases) and grammar use = losing ability to name objects, repeat phrases) they can however follow commands. they can sing a familiar song they can however follow commands. they can sing a familiar song or say a prayer, or swear. or say a prayer, or swear.

They may show agraphia = inability to writeThey may show agraphia = inability to write. .

C) Global aphasia: C) Global aphasia: loss of ability to produce or comprehend speech loss of ability to produce or comprehend speech


Dysarthria = speech disorder = slurred speech, drooling, Dysarthria = speech disorder = slurred speech, drooling, decreased facial expression caused by paralysis or decreased facial expression caused by paralysis or incoordination of speechincoordination of speech

Oral apraxia = inability to initiate and sequence oral movement Oral apraxia = inability to initiate and sequence oral movement

Cognition (memory, judgment, problem-solving, safety (meal Cognition (memory, judgment, problem-solving, safety (meal preparation/transportation), recognition, concentration, preparation/transportation), recognition, concentration, reaction time, learning) reaction time, learning) – Mini Mental Sate Examination (MMSE)Mini Mental Sate Examination (MMSE)– Differentiate between Cognitive and communication/social deficitsDifferentiate between Cognitive and communication/social deficits

Psycosocial: adjustment, motivation, hopelessness, refusal of Psycosocial: adjustment, motivation, hopelessness, refusal of therapy/treatment, anxiety, anger, depression (most reported therapy/treatment, anxiety, anger, depression (most reported and mostly seen in rehab rather than acute responding to grief and mostly seen in rehab rather than acute responding to grief and loss of function), denial, emotional lability (laughing and and loss of function), denial, emotional lability (laughing and crying for no apparent reason) crying for no apparent reason)

Precautions for stroke patients Precautions for stroke patients Acute stage: make sure of medical stability Acute stage: make sure of medical stability

Know the symptoms of current strokeKnow the symptoms of current stroke

Aware of cardiac or respiratory complications Aware of cardiac or respiratory complications (dizziness, breathing difficulties, chest pain, fatigue, (dizziness, breathing difficulties, chest pain, fatigue, altered heart rate)altered heart rate)

Guard against falls, provide supervision Guard against falls, provide supervision

Precautions with insensitive skin, visual field Precautions with insensitive skin, visual field deficit/unilateral neglect deficit/unilateral neglect

Ability to swallow, follow commands during feedingAbility to swallow, follow commands during feeding

Teach patient, family, medical staff about safety Teach patient, family, medical staff about safety

Model of practiceModel of practice

– CompensatoryCompensatoryRehabilitativeRehabilitative

– RestorativeRestorativeBiomechanical (ROM, positioning, etc.) Biomechanical (ROM, positioning, etc.)

DevelopmentalDevelopmental

Neurorehabilitative (Constraint-Induced Movement Neurorehabilitative (Constraint-Induced Movement Therapy) Therapy)

Psychosocial (depression, social support)Psychosocial (depression, social support)


– Traditional Neurorehabilitation ModelsTraditional Neurorehabilitation ModelsPrimary focus: restoration of body functions and Primary focus: restoration of body functions and body structuresbody structures

– Proprioceptive neuromuscular facilitation (Kabat)Proprioceptive neuromuscular facilitation (Kabat)– Stages of motor recovery (Brunnstrom)Stages of motor recovery (Brunnstrom)– Sensorimotor facilitation/inhibition (Rood)Sensorimotor facilitation/inhibition (Rood)– Neurodevelopmental treatment (Bobath)Neurodevelopmental treatment (Bobath)


– Contemporary Neurorehabilitation ModelsContemporary Neurorehabilitation ModelsPrimary focus: restoration of activity and Primary focus: restoration of activity and participationparticipation

– Motor learningMotor learning– Constraint-induced movement therapyConstraint-induced movement therapy– Sensory re-education Sensory re-education – Visual rehabilitationVisual rehabilitation– Cognitive-perceptual retrainingCognitive-perceptual retraining

Examples of Treatment Goals Examples of Treatment Goals

Careful evaluation= appropriate treatment goalsCareful evaluation= appropriate treatment goals

the patient will gain competence in valued and the patient will gain competence in valued and necessary basic ADL/IADL to perform at the necessary basic ADL/IADL to perform at the highest level of independence at home…highest level of independence at home…

……improve postural control to resume ADLimprove postural control to resume ADL

…….gain increased somatoseneory perception to .gain increased somatoseneory perception to perform ADL safely perform ADL safely

……gain strength,… visual function,…. motor gain strength,… visual function,…. motor planning ability planning ability

Treatment-Acute phaseTreatment-Acute phase

1.1. Early mobilization Early mobilization Mobilized as soon as medically stable Mobilized as soon as medically stable

Perform self-care activities ASAP (rolling in bed, Perform self-care activities ASAP (rolling in bed, sitting on the side of the bed, transfer to sitting on the side of the bed, transfer to WC/commode, self-feeding, grooming, dressing)WC/commode, self-feeding, grooming, dressing)

This gives sense of control over environment and This gives sense of control over environment and improve occupational functioning improve occupational functioning

Start discharge planningStart discharge planning


2.2. Lowering risk for secondary complicationsLowering risk for secondary complications • SkinSkin carecare: Pressure sores (comatose, malnourished, obese, : Pressure sores (comatose, malnourished, obese,

incontinent, severe paralysis, spasticity are at great risk): incontinent, severe paralysis, spasticity are at great risk): • Proper transfer, avoid skin friction Proper transfer, avoid skin friction • Proper positioning (bed, sitting) Proper positioning (bed, sitting) • Proper wheelchair seatingProper wheelchair seating• Teach patient and caregiver precautions to avoid injury to Teach patient and caregiver precautions to avoid injury to

insensitive skin insensitive skin • Watch for signs of skin pressure or breakdown (bruising, Watch for signs of skin pressure or breakdown (bruising,

redness, blisters, abrasions, ulceration) over bony areas redness, blisters, abrasions, ulceration) over bony areas


2.2.Lowering risk for secondary complicationsLowering risk for secondary complications • Maintaining soft tissue lengthMaintaining soft tissue length

• Contractures, shortening of skins, tendons, ligaments, muscles, joint Contractures, shortening of skins, tendons, ligaments, muscles, joint capsule, may result from immobilization following strokecapsule, may result from immobilization following stroke

• Risk factors: spasticity, postural malalignment, improper positioningRisk factors: spasticity, postural malalignment, improper positioning• Contracture may be painful, limit functional recovery, restrict Contracture may be painful, limit functional recovery, restrict

movement (preventative program of proper positioning; protect weak movement (preventative program of proper positioning; protect weak UE)UE)

• Resting hand splints Resting hand splints worn at night to prevent shortening, but reassess worn at night to prevent shortening, but reassess splint because it prevents sensory input, discourage active splint because it prevents sensory input, discourage active movement, and can lead to extensor tendon shorteningmovement, and can lead to extensor tendon shortening

• Controlled and frequent movement of body parts is the preferred Controlled and frequent movement of body parts is the preferred method to prevent contractures method to prevent contractures

• If patient can’t perform movement, start with supervised active or If patient can’t perform movement, start with supervised active or active-assistive movement activitiesactive-assistive movement activities

• When active is not possible, PROM at least once dailyWhen active is not possible, PROM at least once daily


2.2.Lowering risk for secondary complicationsLowering risk for secondary complications • Maintaining soft tissue lengthMaintaining soft tissue length

• When performing PROM, ensure proper scapulohumeral rhythm by When performing PROM, ensure proper scapulohumeral rhythm by relaxing and mobilizing the scapula before elevation of the arm and relaxing and mobilizing the scapula before elevation of the arm and by manually assisting upward rotation of the scapula by manually assisting upward rotation of the scapula

• Humerus should be externally rotated during abduction to prevent Humerus should be externally rotated during abduction to prevent impingement of the supraspinatus between the greater tubercle and impingement of the supraspinatus between the greater tubercle and acromion process acromion process

• A study showed that PROM of elbow elicited some of the brain A study showed that PROM of elbow elicited some of the brain activation patterns as active movement in more recovered patients. activation patterns as active movement in more recovered patients.


2.2. Lowering risk for secondary complicationsLowering risk for secondary complications • Fall preventionFall prevention

• Risk factors: advanced age, confusion, impulsive behavior, mobility Risk factors: advanced age, confusion, impulsive behavior, mobility deficits, poor balance/coordination, visual impairments, deficits, poor balance/coordination, visual impairments, communication deficits to ask for assistance communication deficits to ask for assistance

• Preventing falls: detecting and removing environmental hazards, Preventing falls: detecting and removing environmental hazards, optimizing motor control, recommending appropriate adaptive optimizing motor control, recommending appropriate adaptive devices, teaching safety measures to the patient and family devices, teaching safety measures to the patient and family


2.2. Lowering risk for secondary complicationsLowering risk for secondary complications • Patient and family education Patient and family education

• Educate to promote a realistic understanding of stroke Educate to promote a realistic understanding of stroke complications complications

• Involve patient in goal settingInvolve patient in goal setting

• Identify disabilities and residual abilities Identify disabilities and residual abilities

• Simple and brief education sessions during acute given the Simple and brief education sessions during acute given the emotional stress, repeat if necessary emotional stress, repeat if necessary

Treatment-Rehabilitation phaseTreatment-Rehabilitation phase

Depends on patient condition, support, resources Depends on patient condition, support, resources

Patient must be:Patient must be:– medically stablemedically stable– have at least one functional impairmenthave at least one functional impairment– sufficient endurance to sit supported for one hoursufficient endurance to sit supported for one hour– be able to learn and participate actively in sessionbe able to learn and participate actively in session

If criteria not metIf criteria not met continue acute tx continue acute tx

The focus is getting better and recovery (restore The focus is getting better and recovery (restore function) rather than adapting to chronic disability function) rather than adapting to chronic disability


Treatment to improve performance of occupational tasksTreatment to improve performance of occupational tasks– Primary goal is to improve independence in ADL and QOL Primary goal is to improve independence in ADL and QOL – Patients with nonremediable functional deficits should be taught Patients with nonremediable functional deficits should be taught

compensatory methods for performing important tasks and activities, compensatory methods for performing important tasks and activities, using the affected limb when possible and when not, the unaffected using the affected limb when possible and when not, the unaffected limblimb

– Some believe that compensatory (use unaffected) may result in faster Some believe that compensatory (use unaffected) may result in faster recovery and increase confidence and thus cost-effectiverecovery and increase confidence and thus cost-effective

– However others argue that one-handed techniques make the patient However others argue that one-handed techniques make the patient fail to relearn bilateral movements and instead develops unilateral fail to relearn bilateral movements and instead develops unilateral habitshabits

– Skilled OT combine compensatory and restorative tx, Skilled OT combine compensatory and restorative tx, reduce disabilities, and engage patient in meaningful reduce disabilities, and engage patient in meaningful activities activities


Treatment to improve performance of occupational tasksTreatment to improve performance of occupational tasks

Example: putting a front-buttoning shirtExample: putting a front-buttoning shirtJoint and soft tissueJoint and soft tissue integrityintegrity (self-stretching/relaxation for affected (self-stretching/relaxation for affected arm, positioning of arm on surface to avoid over stretching)arm, positioning of arm on surface to avoid over stretching)

Voluntary movement& function of affected UEVoluntary movement& function of affected UE (abducting shoulder (abducting shoulder to put on a sleeve, extending elbow to push the hand through the to put on a sleeve, extending elbow to push the hand through the sleeve, pinching one side of the shirt to stabilize while buttoning sleeve, pinching one side of the shirt to stabilize while buttoning

Somatosensory perceptionSomatosensory perception (texture of the shirt)(texture of the shirt)

Postural adaptationPostural adaptation (anterior pelvic tilt, trunk rotation, weight shifting) (anterior pelvic tilt, trunk rotation, weight shifting)

Visual perceptionVisual perception (visual field, top vs. bottom, finding sleeve opening)(visual field, top vs. bottom, finding sleeve opening)

Cognitive skills/emotionalCognitive skills/emotional (sequence, attention, frustration tolerance, (sequence, attention, frustration tolerance, motivation) motivation)


Treatment to improve performance of occupational tasksTreatment to improve performance of occupational tasks– ADL training is ADL training is gradualgradual (start simple then increase (start simple then increase

difficulty)difficulty)– Bathing and dressing are most difficult Bathing and dressing are most difficult – Dressing (socks, shoe lacing, pulling up pants; motor Dressing (socks, shoe lacing, pulling up pants; motor

deficits affect LE dressing and cognitive-perceptual affect deficits affect LE dressing and cognitive-perceptual affect UE dressing) UE dressing)

– Use adaptive devices only if other methods are not Use adaptive devices only if other methods are not available or can’t be learnedavailable or can’t be learned

– The device should be The device should be reliable and safereliable and safe, provide training , provide training also also

– When the patient improves start with IADL and leisure When the patient improves start with IADL and leisure


Treatment to improve component abilities and Treatment to improve component abilities and capacitiescapacities – Goals based on impairment, purposeful Goals based on impairment, purposeful

– E.g., floor game to improve sitting for E.g., floor game to improve sitting for socks socks donningdonning or resistive grasp activities to or resistive grasp activities to strength muscle to strength muscle to squeeze a tooth paste or squeeze a tooth paste or lemon lemon


Treatment to improve component abilities and capacitiesTreatment to improve component abilities and capacities

Postural adaptation: Postural adaptation: Automatic postural adjustment (esp.trunk balance) is a prerequisite Automatic postural adjustment (esp.trunk balance) is a prerequisite for later successful performance of ADLfor later successful performance of ADL

Teach patient safest, most ready positions for activity Teach patient safest, most ready positions for activity

OT must know patient’s strengths & weaknessesOT must know patient’s strengths & weaknesses

OT tx goals include:OT tx goals include:– Full ROM in trunk and extremities Full ROM in trunk and extremities – Differentiate body parts movement (e.g., rotate shoulder separately Differentiate body parts movement (e.g., rotate shoulder separately

from trunk) from trunk) – Stop/hold movement in midrange for gravitational stability Stop/hold movement in midrange for gravitational stability – Automatically increase/decrease postural tone to support movement Automatically increase/decrease postural tone to support movement – Incorportate transitional movement pattern with the above elements Incorportate transitional movement pattern with the above elements

(side-lying to sitting or supine to sitting) (side-lying to sitting or supine to sitting)



Upper extremity function: Upper extremity function: Bilateral use is crucial Bilateral use is crucial

OT must determine the most interfering impairment OT must determine the most interfering impairment in ADL in ADL

Plan realistic, task-oriented treatment to restore Plan realistic, task-oriented treatment to restore function function



Upper extremity function: Upper extremity function: – Somatosensory deficits Somatosensory deficits

Remedial txRemedial tx: Tactile stimulation: Tactile stimulation patient response patient response exact exact feedbackfeedback practice practice

Compensatory Compensatory tx: substituting intact senses forlost/dysfunctionaltx: substituting intact senses forlost/dysfunctional

OT must decide which one to use (e.g., sensory reeducation is not OT must decide which one to use (e.g., sensory reeducation is not realistic for patients with cognitive and visual neglect problems, or realistic for patients with cognitive and visual neglect problems, or minimal voluntary movement) minimal voluntary movement)

Restorative (sensory reeducation): use tactile stimulation (not Restorative (sensory reeducation): use tactile stimulation (not aversive [increase spasticity and withdrawal] using different aversive [increase spasticity and withdrawal] using different textures in weight bearing surfaces and using objects like cups, textures in weight bearing surfaces and using objects like cups, forksforks can increase sensory input in affected hand can increase sensory input in affected hand

Interventions for sensations Interventions for sensations Problem Interventional

Technique

Absent/lost/impaired protective sensation

(pain sensation )

Compensatory strategies

Hypersensitivity Desensitization Patients who have some sensation and potential for better sensation

(Peripheral nerve injuries)

Sensory reeducation


Treatment to improve component abilities and capacitiesTreatment to improve component abilities and capacities – Mechanical & physiological componentsMechanical & physiological components Continue to maintain soft tissue length and adapt to changes in Continue to maintain soft tissue length and adapt to changes in

pt. pt. Avoid stretching of weak muscles Avoid stretching of weak muscles Hemiplegic shoulder: prevention and management of Hemiplegic shoulder: prevention and management of

symptomssymptoms Sling is controversialSling is controversial (may lead to complications) but used to: (may lead to complications) but used to:

Reduce subluxation (no evidence; may reinforce flexor Reduce subluxation (no evidence; may reinforce flexor spasticity) spasticity) Provide supportProvide supportProtect against traumaProtect against traumaPrevent/reduce pain Prevent/reduce pain


Treatment to improve component abilities and capacitiesTreatment to improve component abilities and capacities OT can use the sling when:OT can use the sling when:

Pain & edema when arm is hanging down Pain & edema when arm is hanging down Balance while standing/walking is enhanced with sling Balance while standing/walking is enhanced with sling Patient is unable to protect arm during movement Patient is unable to protect arm during movement Patient or CG will take care of sling (don/doff) Patient or CG will take care of sling (don/doff)

OT OT CANNOTCANNOT (contraindicated) use the sling when: (contraindicated) use the sling when:Sling hinder active movement in functionSling hinder active movement in functionSling put extra pressure on neck and impair circulation Sling put extra pressure on neck and impair circulation Risk of contractures Risk of contractures Decrease sensory input and increase unilateral disregard Decrease sensory input and increase unilateral disregard


Treatment to improve component abilities and capacitiesTreatment to improve component abilities and capacities – Mechanical & physiological componentsMechanical & physiological components Alternative positioning method Alternative positioning method

Taping shoulder & scapulaTaping shoulder & scapulaWheelchair lapboardWheelchair lapboardArmrest troughsArmrest troughsTable while standing or seating Table while standing or seating Hand in pocket or under belts Hand in pocket or under belts Over-the-shoulder bags while standingOver-the-shoulder bags while standing

Shoulder slings

Shoulder

taping

Wheelchair lapboard

Wheelchair arm trough


Treatment to improve component abilities and capacitiesTreatment to improve component abilities and capacities – Mechanical & physiological componentsMechanical & physiological components Functional Electrical Stimulation (FES): reduce pain but not too Functional Electrical Stimulation (FES): reduce pain but not too

longlong Learn ROM exercises (AROM, AAROM, PROM), stretching, Learn ROM exercises (AROM, AAROM, PROM), stretching,

relaxationrelaxation Avoid the following nonfunctional positions (comfort+ spasticity):Avoid the following nonfunctional positions (comfort+ spasticity):

Shoulder retraction, adduction, internal rotation, elbow flexion, Shoulder retraction, adduction, internal rotation, elbow flexion, forearm pronation, wrist /finger flexion forearm pronation, wrist /finger flexion

Frequent changes in position Frequent changes in position Relearn movement (feel and think the movement)Relearn movement (feel and think the movement) Teaching self-ROM (bilateral): clasp hands and lean forward to Teaching self-ROM (bilateral): clasp hands and lean forward to

floor, push both hands against a table floor, push both hands against a table Close supervision till the patient learn (lack of awareness, who Close supervision till the patient learn (lack of awareness, who

move too quickly, no pain sensation, lack mobile scapula) move too quickly, no pain sensation, lack mobile scapula)


Treatment to improve component abilities and capacitiesTreatment to improve component abilities and capacities – Mechanical & physiological componentsMechanical & physiological components

Hand edema: Hand edema: can lead to pain, reduce movements, can lead to pain, reduce movements,

contractures contractures elevation, retrograde massage, pressure gloves, elevation, retrograde massage, pressure gloves,

contrast baths (vasodilation and vasoconstriction) contrast baths (vasodilation and vasoconstriction)


Treatment to improve component abilities and capacitiesTreatment to improve component abilities and capacities – Voluntary movement and function Voluntary movement and function If functional deficit and some voluntary movementIf functional deficit and some voluntary movement

Encourage patient to use in ADL Encourage patient to use in ADL Try to increase strength, motor control, sensorimotor, functional Try to increase strength, motor control, sensorimotor, functional

performanceperformance Promote functional use ASAP “their arm is dead or useless”Promote functional use ASAP “their arm is dead or useless” ““Learned nonuseLearned nonuse”: patients notice negative consequences of ”: patients notice negative consequences of

efforts to use the affected limb, reinforced by successful efforts to use the affected limb, reinforced by successful compensatory use of the unaffected limb compensatory use of the unaffected limb

The intervention is called “The intervention is called “Force useForce use” or Constraint-Induced ” or Constraint-Induced Movement Therapy Movement Therapy (CIMT) (CIMT)

CIMT CIMT


Treatment to improve component abilities and capacitiesTreatment to improve component abilities and capacities – Voluntary movement and function Voluntary movement and function Endurance, coordination and strengthening exercises Endurance, coordination and strengthening exercises Carefully selected resistive activities to increase strength Carefully selected resistive activities to increase strength Grade:Grade:

The activities and give rest periodsThe activities and give rest periods unilateral unilateral bilateral bilateral Gross hand movementsGross hand movements fine movements fine movements pinch pinch

Coordination is the control of strength, range, speed, direction Coordination is the control of strength, range, speed, direction and timing (quality of movement) and timing (quality of movement)

Treatment-Rehabilitation phaseTreatment-Rehabilitation phaseTreatment to improve component abilities and capacitiesTreatment to improve component abilities and capacities

– Motor learning ability Motor learning ability Learning to perform activities effectively and in several circumstances Learning to perform activities effectively and in several circumstances Teach the patient problem-solving techniques and effective Teach the patient problem-solving techniques and effective

movementsmovements Visual Dysfunction Visual Dysfunction

Active approachActive approach: improve visual skills (visual scanning), or : improve visual skills (visual scanning), or compensatory skills (turning the head to the left)compensatory skills (turning the head to the left)Passive approachPassive approach: modify the environment (put all food on right) : modify the environment (put all food on right) Increase patient’s awareness: share assessment results, give feedbackIncrease patient’s awareness: share assessment results, give feedbackTraining must be specific to function and goals (e.g., patient with Training must be specific to function and goals (e.g., patient with unilateral neglect and hempinopsia who is not interested in writing will unilateral neglect and hempinopsia who is not interested in writing will benefit more form an obstacle course than a paper-and-pencil activitiesbenefit more form an obstacle course than a paper-and-pencil activities

Mirror TherapyMirror Therapy

• Mirror Therapy Mirror Therapy (Mirror Visual (Mirror Visual Feedback)Feedback)– form of motor form of motor

imagery in which a imagery in which a mirror is used to mirror is used to convey visual stimuli convey visual stimuli to the brain through to the brain through observation of one's observation of one's unaffected body part unaffected body part as it carries out a set as it carries out a set of movements.of movements.


Treatment to improve component abilities and capacitiesTreatment to improve component abilities and capacities – Motor learning ability Motor learning ability Speech and language disorders (Suggestions) Speech and language disorders (Suggestions)

Work closely with SLP Work closely with SLP Provide supportive environment in SLP session Provide supportive environment in SLP session Use activity components or objects to pronounce Use activity components or objects to pronounce Read signs or recipes Read signs or recipes Read cooking instructionsRead cooking instructionsAdapt nonverbal communication forms (communication board, Adapt nonverbal communication forms (communication board, gestures, drawing, writing)gestures, drawing, writing)


Treatment to improve component abilities and capacitiesTreatment to improve component abilities and capacities – Motor learning ability Motor learning ability Speech and language disorders Speech and language disorders

Avoid noise like TVAvoid noise like TVDon’t talk or request speech before start of activity Don’t talk or request speech before start of activity Allow enough time for the patient to speak; don’t switch topicsAllow enough time for the patient to speak; don’t switch topicsNever assume patients with aphasia don’t understandNever assume patients with aphasia don’t understandNever ignore or allow others to ignore patientNever ignore or allow others to ignore patientSpeak slowly and clearly; using simple, concise language, don’t Speak slowly and clearly; using simple, concise language, don’t talk down as to a child, don’t talk loudly unless hearing talk down as to a child, don’t talk loudly unless hearing impairmentimpairmentUse demonstration and visual cues Use demonstration and visual cues


Treatment to improve component abilities and capacitiesTreatment to improve component abilities and capacities – Motor learning ability Motor learning ability Motor planning deficits Motor planning deficits

Use compensatory techniquesUse compensatory techniques

(manual guidance of movement, repetitive graded use (manual guidance of movement, repetitive graded use of of objects/context to evoke automatic response, explain objects/context to evoke automatic response, explain components of a task, backward chaining, practice as close components of a task, backward chaining, practice as close as as possible to natural context). possible to natural context). Use language to identify required task, mistakes and sequence Use language to identify required task, mistakes and sequence (e.g., now I have taken the cap off the toothpaste… now I will…) (e.g., now I have taken the cap off the toothpaste… now I will…)


Treatment to improve component abilities and capacitiesTreatment to improve component abilities and capacities – Motor learning ability Motor learning ability Cognitive deficits Cognitive deficits

Retraining of specific skills, compensatory, environmental Retraining of specific skills, compensatory, environmental changes changes E.g., use cues to shape desired behavior, feedback, visual aids E.g., use cues to shape desired behavior, feedback, visual aids

(checklist, maps), simplifying, environmental changes, family (checklist, maps), simplifying, environmental changes, family educating, supervision for safety educating, supervision for safety


Treatment to improve component abilities and capacitiesTreatment to improve component abilities and capacities – Motor learning ability Motor learning ability Psychosocial adjustment Psychosocial adjustment

Healthy emotional adjustment is important to seek and receive Healthy emotional adjustment is important to seek and receive treatment treatment Encourage family to talk about stroke consequencesEncourage family to talk about stroke consequencesMake sure patient and family understand that stroke doesn’t end Make sure patient and family understand that stroke doesn’t end with discharge with discharge Encourage to seek rehabilitation Encourage to seek rehabilitation Recognize signs and symptoms of depression and tell team Recognize signs and symptoms of depression and tell team Teach family about emotional lability Teach family about emotional lability Instruct on deep breathing and redirect attention when getting Instruct on deep breathing and redirect attention when getting emotionalemotionalGroup activity, support groups, social interactions Group activity, support groups, social interactions


– Transition to the community Transition to the community – DischargeDischarge– Patient and family education Patient and family education – Resuming roles Resuming roles – Follow-up, post discharge monitoring Follow-up, post discharge monitoring

Transition to community Transition to community

Discharge planning (patient and family education, roles) Discharge planning (patient and family education, roles) – Plan from beginning Plan from beginning – Identify transition setting (SNF, home…etc) Identify transition setting (SNF, home…etc) – TrainTrain patient, family (education, demonstration, info patient, family (education, demonstration, info– Consider patient’s preference, disability, level of Consider patient’s preference, disability, level of

care, accessibility, safetycare, accessibility, safety– Home visitsHome visits & home treatment programs (before & home treatment programs (before

dressing do the following stretching exercises…etc) dressing do the following stretching exercises…etc) – Focus on and remind patient’s skills and disabilitiesFocus on and remind patient’s skills and disabilities– Fall preventionFall prevention (reduce risk factors) (reduce risk factors)


Discharge planning (patient and family education, roles) Discharge planning (patient and family education, roles) – Reestablish social roles Reestablish social roles – Set reasonable goals for role resumption Set reasonable goals for role resumption – Work: skills training, environment assessment and modification Work: skills training, environment assessment and modification

(aphasia and (aphasia and cognitivecognitive problems) problems)– Predictors for work resumption (young age, education, ADL Predictors for work resumption (young age, education, ADL

mastering) mastering) – Leisure (energy for leisure time) Leisure (energy for leisure time) – Sexuality Sexuality (common problems, normal to have concerns and sexual (common problems, normal to have concerns and sexual

activities are not contraindicated, referrals) activities are not contraindicated, referrals)

– Driving:Driving: important to avoid community isolation, work, after important to avoid community isolation, work, after rehabilitation goals are met and stable, driving aids, test for visual rehabilitation goals are met and stable, driving aids, test for visual abilities (scanning, attention) cognitive (problem-solving, judgment, abilities (scanning, attention) cognitive (problem-solving, judgment, follow directions), follow directions), driving simulator training driving simulator training


Discharge planning (community support and resources) Discharge planning (community support and resources) – Transportation optionsTransportation options– Architectural barriersArchitectural barriers– Help in reintegration in social activities (“may take Help in reintegration in social activities (“may take

years”)years”)– Educational recoursesEducational recourses– Post-discharge monitoring (follow-up): 1 month after Post-discharge monitoring (follow-up): 1 month after

discharge and at regular intervals in the first year discharge and at regular intervals in the first year following stroke following stroke

Evidence-based practice Evidence-based practice

Improvement in impairment doesn’t mean improvement Improvement in impairment doesn’t mean improvement in ADL functionin ADL function

Early rehabilitation brings better results Early rehabilitation brings better results

Task-specific training is more effective Task-specific training is more effective

Use of meaningful objects motivates patients to Use of meaningful objects motivates patients to participate longer in therapy than exercise. participate longer in therapy than exercise.

Timed Up & Go Test (TUG)Timed Up & Go Test (TUG)“Fall Risk Physical Assessment” “Fall Risk Physical Assessment”

Educational videosEducational videos

– Clinical video (1)Clinical video (1)

– Clinical video (2) Clinical video (2)

Lab ExerciseLab Exercise

• Split into groups Split into groups • Discuss the TUG information sheetDiscuss the TUG information sheet• Practice Practice • Score and document results Score and document results • Questions?Questions?

Date post:	26-Dec-2015
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