Reading log 1 (CVA)

If a stroke occurred in the left hemisphere of the brain, what might be a result?

• hemiparesis (contralateral weakness)

• hemiplegia (paralysis)

Impairments are located on the opposite side of the body from the lesion

are motor deficits the only impairments that result from stroke?

no, deficits or impairments may be sensory, cognitive, and perceptual

• visual disturbances

• behavioral changes

• difficulty swallowing (dysphagia)

• changes with speech (dysarthria)

• language difficulties (aphasia)

common etiology of strokes:

• hypertension

• diabetes

• high blood cholesterol

• cigarette smoking

• obesity

• lifestyle factors

types of stroke:

• ischemic (thrombus or embolism) (blood clot)

• hemorrhage (bleed)

• TIA

why do OTs need to know the etiology and types of stroke?

• improve patient health literacy

• address modifiable risk factors to reduce risk of a second stroke

• to provide client centered care

• medical management and treatment

• post-stroke medical intervention and medication understanding (ex: tPA is contraindicated for hemorrhagic stroke)

what are common stroke syndromes OTs must be familiar with?

• ACA

• MCA

  • compete, superior division, inferior division

• internal carotid artery

• posterior cerebral artery

• vertebral basilar artery

after emergency management and treatment, in-hospital management should include the following:

• dysphagia screening before the patient begins to eat, drink, or take oral medications

• establishment of appropriate nutrition, which may necessitate the placement of nasogastric tube

• continued maintenance of BP, body temp, and blood glucose levels

• cardiac evaluation and monitoring as needed

• treatment of any acute complications that may arise

• routine screening for poststroke depression

why is dysphagia screening important?

should occur prior to oral intake of liquid, food, and medications as impaired swallowing can lead to other complications such as pneumonia

what areas will OTs assist the treatment team in monitoring?

• nutrition intake (during feeding and eating interventions)

• BP and body temp

• edema monitoring and management

• prevention and treatment of hemiplegic shoulder pain

• fall prevention

• pressure ulcer prevention and skin integrity maintenance

• monitor for DVT

• monitor for post-stroke depression

what is the most common impairment that impacts occupational performance?

hemiparesis

how does hemiparesis impact occupational performance?

• impairments in trunk and postural control that cause problems when trying to perform activities in both sitting and standing

• UE weakness impacts the ability to use the affected arm and hand

• cognition for visual deficits can complicate engagement and performance

why is trunk and postural control important to assess and address?

• may cause problems with maintaining sitting balance while seated unsupported (static balance)

• may cause problems with maintaining sitting balance while moving or weightlifting to perform a functional task (dynamic)

• limited ability to return to center or midline

• safety/fall risk

• can impact functional mobility such as propelling in w/c

if trunk and postural control is not addressed, what might occur?

• contractures since person with hemiparetic weakness sits asymmetrical and can cause shortening of tissues around the spine

• can affect person’s ability to safely walk and step up or step down

• may observe person put less weight through affected LE

why is postural control strongly correlated with post-stroke function? what assessments are used to measure this?

• even if the hemiparetic arm has some active movement, body position (specifically trunk alignment), impacts function and reach

• anatomical positioning of the pelvis (posterior tilt), lateral asymmetry (obliquity), and kyphosis can all lead to poor articulation of the scapula impacting ROM and function

• frenchay activities index

• Barthel index

what factors impact UE use in the hemiparetic UE?

• weakness

• loss of selective motor control

• somatosensory loss

• muscle tone

what are secondary complications of abnormal or nonuse of the UE?

profound weakness and absence of muscle tone (flaccidity) can cause:

• edema

• subluxation

• overstretching of the GH joint capsule

• muscle imbalances that cause some groups to shorten and others to lengthen

• risk of joint and soft tissue injuries

what may occur after the initial flaccid stage?

• hypertonia

• hyperactive stretch reflexes

• limb posturing

• spasticity (if not managed, can cause skin breakdown in the palm of the hand, contractures, and significant pain

what does the AHA guidelines say about shoulder pain following stroke?

reported incidence is high at around 22% (commonly associated with subluxation, but spasticity may also contribute)

others include:

• older age

• hemiplegia occurring on the left side

• tactile extinction (impaired ability to detect tactile stimuli when applied to affected and unaffected side simultaneously)

• impaired proprioception

• PROM limitations in adduction and ER

• presence of shoulder pain with passive IR

• pain with palpation of biceps tendon or supraspinatus

how do cognitive and perceptual deficits present after CVA?

in clusters based on site of stroke lesion, impact ADL, IADL, functional mobility, return to work, and return to driving

left hemispheric stroke lesion may manifest as: (perceptual and cognitively)

• ideational apraxia

• motor apraxia

• poor organization

• challenges with sequencing

• impaired judgement

right hemispheric stroke lesion may present as: (cognitively and perceptually)

• unilateral spatial neglect

• unilateral body neglect

• decreased attention

• spatial dysfunction

what are some characteristics of aphasia?

• brocas aphasia

• wernickes aphasia

• anomic aphasia

• global aphasia

brocas aphasia

nonfluent aphasia

• slow and effortful speech

• simplified sentences are used

• phrases are short

• comprehension remains intact

wernickes aphasia

fluent aphasia

• articulation is preserved but paraphrasing exists with sound and word substitutions

• comprehension is poor

anomic aphasia

fluent aphasia

• word finding pauses disrupt flow of speech

• sentences are correct and comprehension is good

global aphasia

nonfluent and severe

• both verbal and receptive deficits exist

• comprehension and repetition are poor

what causes dysarthria?

• paralysis

• weakness

• incoordination of the muscles responsible for producing speech

  • impacts articulation, pitch, loudness, quality, and ventilation

• can range from mild to unintelligible

what is speech apraxia?

impairments of motor programming or planning, leading to incorrect sounds, more consonants than vowel errors, use of incorrect words or sounds, etc.

individuals are aware of their errors and often become frustrated by them

what impact do visual impairments have on outcomes?

• 25% present with visual impairments

• lower quality of life scores

• higher levels of depression and anxiety

• lower ADL and mobility functioning scores

why should a stroke be considered a chronic condition?

• more than 30% of survivors indicate impacts on daily function greater than 4 years post stroke

• individuals demonstrate improvement in occupational engagement for several years well into the chronic phase

how do OTs stay up to date to determine the best evaluation and intervention methods to use?

• systematic reviews

• meta analyses

• Cochrane library searches

• AHA/ASA stroke rehabilitation guidelines

• evidence based review of stroke rehabilitation

describe the OT evaluation approach

• client centered

• complete an occupational profile

• collaborate on goal setting

• establish a therapeutic partnership

• combination of top-down and bottom-up approaches

• individualized goals should be consistent with performance-based assessments

how are shoulder subluxations classified?

by the position of the humeral head with respect to the glenoid fossa

• inferior: humeral head is below the glenoid fossa

• anterior: humeral head is anterior to the glenoid fossa

• superior: humeral head is superior to the glenoid fossa and lodged under the acromion

joint mobility restrictions are determined by PROM and goniometric measurements obtained as needed

how is muscle tone assessed?

• passively move the limb to determine resistance to passive stretch

• modified ash worth and modified tardieu scales

• motricity index for grade strength based on clients ability to activate muscles, move against gravity, and tolerate applied resistance

what interventions are recommended to be prioritized at the acute stage of stroke recovery?

positioning to prevent secondary complications such as:

• subluxation

• muscle imbalances

• contractures

• skin breakdown

• pain syndromes

• dysphagia management

• fall prevention

• early mobilization

• initial remediation of client factor impairments that interfere with engagement

what interventions are recommended to be prioritized at the acute stage of stroke recovery?

• continued remediation/restoration coupled with compensation to optimize participation

• skill acquisition to engage in IADL and ADL to plan for discharge back to community

• balance

• mobility

• mental functions

what interventions are recommended to be prioritized at rehabilitation at the subacute and chronic phase?

• optimize IADL independence and performance

• skills needed to return to work and education

• promote engagement in community, leisure, and socialization

what does the AHA/ASA guidelines state regarding treatment of the hemiplegia shoulder?

• proper bed positioning and handling is the first step in promoting motor recovery

• OTs should educate and train patients and family members in proper bed positioning for supine and side lying (both affected and unaffected)

• proper handling should be instructed and used

• avoid shoulder ROM beyond 90 degrees of flexion and abduction unless there is upward rotation of the scapula and ER of the humerus

• avoid overhead pulley exercises

what position should the client be placed (ideally) to assess the UE?

upright position (optimal for function)

what client factors might prevent an upright position for assessment of the UE?

• trunk instability

• poor balance

• other medical/functional issues

what is an alternative position to place the client if they are unable to sit upright for assessment of the UE?

supine in bed with adjusted HOB for supported upright position

what are the issues of scapular mobility and potential harmful consequences of poor handling of the hemiplegic UE?

• scapula does not upwardly rotate when shoulder abduction is greater than 90 degrees

• if the scapula cannot upwardly rotate, the inferior GH ligament will be stretched, causing impingement

• OT must manually rotate the scapula upward to facilitate appropriate kinematic excursion

• common in individuals with no proprioceptive awareness, impaired sensation, or inattention