Stroke # hemiplegia, # neurophysiological principles, # Occupational Therapy

1. PRESENTATION AND MANAGEMENT
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CVA results in UMN dysfunction producing hemiplegia or paralysis of one side of the body,
including arms, trunk and sometimes the oral structures too

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4.  STOPPAGE OF BLOOD FLOW (Ischaemic Stroke- usually 75%)
 RUPTURE OF VESSEL (Haemorrhagic Stroke- usually 25%)
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5.  After 3 minutes of Ischaemic or Haemorrhagic stroke, malfunction of the brain occurs
due to reduced oxygen supply, blood and glucose.
 IMPACT OF STROKE:
 Where did it occur in the brain area?
 How much tissue is damagded?
 CAUSED BY:
 Atrial fibrillation (Clot travels)
 Myocardial infarction (Clot on the heart wall is pumped to the brain)
 Atherosclerosis ( Cholesterol plaque gets logged in the artery)
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 Also called as a mini stroke
 Does not usually destroy brain cells or cause
disability
 Could be a warning sign for a major stroke in
the future
 Symptoms go away in 24 hours usually

7.  MODIFIABLE:
 High blood pressure
 Diabetes
 Smoking
 Cholesterol
 NON-MODIFIABLE:
 Age
 Males>Females
 Prior history of stroke or heart disease
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9.  Embolism (travelling clot)
 Thrombotic (built up cholesterol + blood clot)
 Lacunar (HTN causing strain on the blood
vessel walls)
 Watershed stroke (two vessels get blocked
and further blood flow lowers, causing a
bigger area of the brain not getting a proper
blood and oxygen supply)
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10.  One vessel ruptures (bleeding into the
cranium) due to increased pressure
 Death of brain tissue occurs
 Vasospasm of a lot of vessels due to blood
break down products
 Vasospasm can give rise to secondary
stroke
 Caused by Aneurysm or arterial venous
malformation
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HISTORY
Thorough history
of weakness,
headache, vision
or balance loss,
speech
affectations of
trunk and arm
weakness + Co-
morbidities if any
IMAGING
CT Scan
CT Angiography
MRI (more
sensitive than
CT)
LAB
TESTS
CBC
Blood glucose
level
Blood clotting
proteins
Toxicology scan
(to rule out drug
or alcohol abuse)
Additionally, it is also essential to check for motor/sensory loss, special senses, balance &
coordination, higher functions, vitals, reflexes

12.  Anti hypertensives
 Anti platelet
 Anti coagulants- given in ischaemic strokes, stopped in haemorrhagic strokes
 Lipid lowering drugs
 Anti convulsants
 Underlying additional medical condition is treated, if any
 Treatment for atrial fibrillation is started, if present
 Lifestyle changes are recommended
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13.  Carotid endarterectomy
 Carotid stenting
 MERCI retriever for Ischaemic stroke (Mechanical embolus Removal in Cerebral
Ischaemia)
 Suction in ischaemic strokes
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15.  Motor control/ muscle strength
 Balance/Co-ordination/ gait
 Speech/ cognition/perception
 Motor planning/ problem solving
 Breathing capacity/skin integrity
 Bowel/bladder training & hygiene
 Sensation
 Vision
 ADL/ dysphagia
 Interpersonal/ intrapersonal issues
 Social participation/ vocation
 Hand functions/ arm use
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16.  AMPS
 A-ONE
 COPM
 Barthel Index/ FIM
 MMSE
 Glasgow coma
 Jebsen Taylor Hand function assessment
 Berg balance scale
 Beck depression inventory/ Geriatric depression Scale
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17.  ADAPTIVE
 COMPENSATORY
 RESTORATIVE
 REMEDIAL
 MULTI-CONTEXT APPROACH (Transfer of learning)
 Roods, PNF, NDT, Brunnstrom, MRP techniques and approaches have been used
since a long time for rehabilitation but recent studies say, the treatment protocol
proposed should be evidence based, client centered and task oriented
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18.  BIOMECHANICAL
 REHABILITATIVE
 COGNITIVE DISABILITY/BEHAVIOUR
 MOHO
 MOTOR LEARNING
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19.  Body scheme
 Affect
 Cognition
 Emotion
 Language
 Memory
 Motor
 Sensory
 Perception
 Visuospatial
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21.  Recovery- 2 months after a stroke-best, upto 6 months- good, possible recovery upto
2 years
 Rehabilitation should be individualized and in the context of the participant
 Goal setting in therapy, can be in collaboration with the client, family members and
other team members of the rehab team
 Problem areas can be defined by the client, so goals can be set according to the
problem areas
 Clients can make a decision about their occupational functioning
 To plan a treatment, therapist can:
 ASSIGN AN ACTIVITY + OBSERVATION + ACTIVITY ANALYSIS
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23.  Inhibition/Facilitation techniques
 ROM exercises
 Body positioning and alignment
 Muscle strengthening
 Splinting- to maintain joint alignment, to prevent contractures, to provide a functional
position
 If shoulder subluxation persists, sling is provided
 Trunk stability and proximal control should be the focus of the treatment
 Balance and co-ordination activities
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24.  Gait training
 Postural corrections (during activities and family education)
 Weight shifting activities to encourage trunk stability
 Balance activities to be progressed as: Sitting balance sitting balance with weight
shifts  standing control  stepping strategies  gait training  stair climbing
 For upper extremity:
 UE weight bearing to be encouraged, supported reaching activities to be given, hand
function and in-hand manipulation tasks through ADL and purposeful activities
 CIMT to be used to encourage use of affected extremity
 Facial exercises
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25.  Address the side with the hemi neglect
 Teach compensation techniques to protect the involved extremity from mechanical &
thermal injury
 Regular skin inspection
 Object handling- different weights, textures, sizes
 Inspect bony prominences and prevent lying in one position for a long time
 If diplopia is present, patch the affected eye or cover the eye glass
 If vision problems persist, make sure client uses spectacles and good lighting is
available during tasks
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26.  If client presents with memory issues, activities with family/ friends/ rehab team
members or other patients can be given which challenges and helps in retrieval
 Orientation – regularly ask for the people around, time, date, day, place, what did the
client do during the day, yesterday etc
 New tasks- divide it into steps
 Brief and clear instructions to be given, repeat if needed
 Strategies to practice task in another environment to encourage problem solving and
transfer of learning
 Sufficient motivation and praise to build the client’s self confidence
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27.  Identify perceptual deficits and provide activities accordingly
 Eg: Apraxia- teach the right technique, sequence of task, demonstrate and cue if
needed
 If a hemi neglect is present, make sure you actively involve the client’s affected side
during the therapy sessions
 Astereognosis, prosopagnosia, topographical orientation ,Visuo- spatial neglect,
figure-ground, depth perception and other perceptual difficulties could be present in
the client
 Activities to deal with such perceptual deficits should be a part of the therapy session
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28.  Managing emotions and behaviours
 Provide opportunities for success
 Provide feedback for improvement
 Conduct shorter sessions and relaxation for stress management
 Encourage sessions in a safe and comfortable environment
 Include family in the sessions as and when possible
 Observe for any suicidal tendencies- American heart association studies suggest a
32% prevalence of depression among stroke patients; while others give a rate of 61%
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29.  Provide communication aids if needed
 Train the client for receptive and expressive speech deficits if present
 Address problems of dysarthria ( work in collaboration with a SLP for goal setting)
 Provide simple instructions to the client and instruct family members and friends the
same, to avoid frustration
 Encourage gestural communication if needed (Eg: If MCA is involved, patient may
present with a global aphasia so gestural communication can be used)
 Participation in groups to prevent a negative self image
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30.  Check oro-motor control and other problem areas in case of dysphagia
 Feeding techniques, positioning, food textures can be introduced if the client has
dysphagia
 Family members can be advised to elevate the client’s head, turn the head to the
unaffected side and feed, to prevent food pocketing and risk of aspiration
 Dressing can be taught as per the client’s difficulties (Eg: dressing the unaffected area
first, then affected area)
 If ideomotor/ideational dyspraxia is present, tasks like brushing, grooming can be taken
up during therapy sessions
 Teaching safe transfers to prevent falls is necessary
 Providing adaptations, mobility aids and assistive devices if necessary
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31.  Take the client’s interview for the previous job and requirements at the job
 Environmental and job site evaluation is essential
 Job modification can be suggested if needed
 Client is trained for a pre-vocational training session in which tasks pertaining to the
job is addressed and practice of tasks is done (MRP techniques, work conditioning,
work hardening techniques can be used)
 If the client, after training, still is not able to perform the job, consider an alternative job
instead
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32.  Engaging in enjoyable leisure activities is a must
 Client can discuss the hobbies with the therapist
 Encouraging the practice of hobbies, new tasks which are pleasurable can help the
client to shift focus from his/her disability and hence, should be encouraged
 Music, care of a pet, art based activities are found to be therapeutic and help in
maintaining a positive mindset
 Relaxation techniques and breathing exercises in parks can be encouraged which can
help in maintaining a good vital capacity and also help in social interaction and
participation
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35.  Addressing the client’s deficits and problem areas is essential
 Individualized rehabilitation program should be designed
 Adaptations, mobility aids and splints should be provided to the client, if needed and
regular check should be maintained if any changes or modifications are needed
 Goal setting should be done including the client, family members and other rehab
team members
 Rehabilitation and treatment should include the family to achieve maximum success in
the therapy program
 Practicing the tasks in different environments and new situations can help in a better
transfer or learning
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36.  Merck manual of medical information- 2nd edition
 Pedritti’s Occupational therapy- 6th edition
 Willard & Spackman’s Occupational Therapy- 9th edition
 Quick reference to occupational therapy, 2nd edition- Kathlyn Reed
 Medicine prep manual for undergraduates, 4th edition- George Matthew
 Google- images
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