Cerebrovascular Accident PDF

# **Cardiovascular Accident** ## **Objectives** - Break CVA myths - Define CVA - Differentiate the different types of CVA and stroke from heat stroke - Know the signs and symptoms of CVA - To know the basic knowledge of the medical treatment - To understand the importance of the role of OT in the t...

# **Cardiovascular Accident** ## **Objectives** - Break CVA myths - Define CVA - Differentiate the different types of CVA and stroke from heat stroke - Know the signs and symptoms of CVA - To know the basic knowledge of the medical treatment - To understand the importance of the role of OT in the treatment of clients who had stroke/CVA ## **I. Definition** - **WHO:** acute dysfunction of vascular origin with symptoms and signs corresponding to the involvement of focal areas in the brain. - Results in upper motor neuron dysfunction = hemiplegia - Contralateral to the hemisphere of the brain with the lesion ### **Accompanying variety of dysfunctions:** - Sensory disturbances - Cognitive and perceptual dysfunction - Visual disturbances - Personality and intellectual changes - Complex range of speech - Associated language disorders The neurologic deficits must persist longer than 24 hours to be labeled a CVA. ## **II. Etiology** ### **Non-modifiable risk factors:** - Age (even youngsters!) - Gender - Race - Ethnicity - Heredity For ischemic strokes ### **Modifiable risk factors:** - Hypertension - Cardiac diseases - Diabetes and glucose metabolism - Cigarette smoking - Excessive use of alcohol - Use of illegal drugs - Lifestyle factors - Obesity - Physical inactivity - Diet - Emotional stress ## **III. Types** Bartels: "disease of a cerebral vasculature in which failure to supply oxygen to the brain cells, which are the most susceptible to ischemic damage, lead to their death" - **Hemorrhagic** - a rupture of the vessel - **Ischemic** - atherosclerosis - **Ischemic Stroke** - anoxia, thrombus - **Hemorrhagic Stroke** - hemorrhage, a rupture of the vessel - **Ischemia** - Insufficient blood flow to the brain to meet metabolic demands. - **Ischemic Stroke** - May be the result of embolism to the brain from cardiac or arterial sources. - **Hemorrhage** - rupture in a weakened blood vessel in the brain - **Hemorrhagic Stroke** - Include subarachnoid and intracerebral hemorrhages, account for only 13% of the total number of strokes. - Common causes: - Deep hypertensive intrecerebral hemorrhages - Ruptured saccular aneurysm - Bleeding from arteriovenous malformations - Spontaneous lobular hemorrhages - **Transient Ischemic Attacks** - Temporary blockage of blood flow to the brain - **Transient Ischemic Attacks (TIAs) ARE WARNING-STROKES** - **Transient Ischemic Attacks** - Mild, isolated, or repetitive neurologic symptoms that develop suddenly, last from a few minutes to several hours but not longer than 24 hours, and clear completely. Sign of an impending stroke. Mostly in people with atherosclerotic disease. ### **It's important to consider conditions including (but not limited to):** - **Atrial fibrillation (AF or Afib)** - an irregular heartbeat that puts the patient at a 5x greater risk for stroke. Afib may be detected by monitoring the heart’s rhythm over time. - **Patent Foreman Ovale (PFO)** - a hole between the heart’s chambers that usually closes naturally by adulthood. - **Thrombophilias** - blood clotting disorders. - **Large-artery atherosclerosis** - a buildup of fats, cholesterol and other substances in and on artery walls. ## **How do we know if it’s stroke?** ## **Signs and Symptoms** - Knowing the signs and symptoms of a stroke is the first step to ensuring medical help is received immediately. For each minute a stroke goes untreated and blood flow to the brain continues to be blocked, a person loses about 1.9 million neurons. This could mean that a person’s speech, movement, memory, and so much more can be affected. ### **SUDDEN** Symptoms: - numbness or weakness of face, arm or leg, especially on one side of the body - confusion, trouble speaking, or understanding - trouble seeing in one or both eyes - trouble walking, dizziness, loss of balance or coordination - severe headache with no known cause ## **Act FAST** FAST is an easy way to remember and identify the most common symptoms of a stroke. Recognition of stroke and calling 9-1-1 will determine how quickly someone will receive help and treatment. Getting to a hospital rapidly will more likely lead to a better recovery. ### **F - FACE** - Ask the person to smile. - Does one side of the face droop? ### **A - ARMS** - Ask the person to raise both arms. - Does one arm drift downward? ### **S - SPEECH** - Ask the person to repeat a simple phrase. - Is their speech slurred or strange? ### **T - TIME** - If you observe any of these signs, call 9-1-1 immediately. ## **IV & V. Clinical Features and Problem Areas** - **Internal carotid artery** - In the absence of adequate collateral circulation, occlusion of the internal carotid artery results in contralateral hemiplegia, hemianesthesia, and homonymous hemianopia. - Additionally, involvement of the dominant hemisphere is associated with aphasia, agraphia or dysgraphia, acalculia or dyscalculia, right-left confusion, and finger agnosia. - Involvement of the nondominant hemisphere is associated with visual perceptual dysfunction, unilateral neglect, anosognosia, constructional or dressing apraxia, attention deficits, and loss of topographic memory. - **Middle Cerebral Artery** - Involvement of the middle cerebral artery (MCA) is the most common cause of stroke. - Ischemia in the area supplied by the MCA results in contralateral hemiplegia with greater involvement of the arm, face, and tongue; sensory deficits; contralateral homonymous hemianopia; and aphasia if the lesion is in the dominant hemisphere. - There is pronounced deviation of the head and neck toward the side on which the lesion is located. - Perceptual deficits such as anosognosia, unilateral neglect, impaired vertical perception, visual spatial deficits, and perseveration are seen if the lesion is in the nondominant hemisphere. - **Anterior Cerebral Artery** - Occlusion of the anterior cerebral artery (ACA) produces contralateral lower extremity weakness that is more severe than that of the arm. - Apraxia, mental changes, primitive reflexes, and bowel and bladder incontinence may be present. - Total occlusion of the ACA results in contralateral hemiplegia with severe weakness of the face, tongue, and proximal arm muscles and marked spastic paralysis of the distal end of the lower extremity. - Cortical sensory loss is present in the lower extremity. - Intellectual changes such as confusion, disorientation, abulia, whispering, slowness, distractibility, limited verbal output, perseveration, and amnesia may be seen. - **Posterior Cerebral Artery** - The scope of posterior cerebral artery (PCA) symptoms is potentially broad and varied because this artery supplies the upper brainstem region, as well as the temporal and occipital lobes. - Possible results of PCA involvement depend on the arterial branches affected and the extent and area of cerebral compromise. - Some possible outcomes are sensory and motor deficits, involuntary movement disorders (e.g., hemiballism, postural tremor, hemichorea, hemiataxia, intention tremor), memory loss, alexia, astereognosis, dysesthesia, akinesthesia, contralateral homonymous hemianopia or quadrantanopia, anomia, topographic disorientation, and visual agnosia - **Cerebellar Artery System** - Occlusion of the cerebellar artery results in ipsilateral ataxia, contralateral loss of pain and temperature sensitivity, ipsilateral facial analgesia, dysphagia and dysarthria caused by weakness of the ipsilateral muscles of the palate, nystagmus, and contralateral hemiparesis - **Vertibrobasilar Artery System** - A stroke in the vertebrobasilar artery system affects brainstem functions. - The outcome of the stroke is some combination of bilateral or crossed sensory and motor abnormalities, such as cerebellar dysfunction, loss of proprioception, hemiplegia, quadriplegia, and sensory disturbances, along with unilateral or bilateral involvement of cranial nerves III to XII. ## **VI. OT Intervention** ### **Client-Centered Assessments** - Client-centered practice is an approach to providing occupational therapy which embraces a philosophy of respect for, and partnership with, people receiving services. - Client-centered practice recognizes the autonomy of individuals, the need for client choice in making decisions about occupational needs, the strengths clients bring to a therapy encounter, the benefits of client-therapist partnership, and the need to ensure that services are accessible and fit the context in which a client lives. **Law and colleagues and Pollack suggest that therapists implementing this approach to evaluation include the following concepts:** - Recognizing that recipients of OT are uniquely qualified to make decisions about their occupational functioning - Offering the client a more active role in defining goals and desired outcomes - Making the client-therapist relationship an interdependent one to enable the solution of performance dysfunction - Shifting to a model in which occupational therapists work with clients to enable them to meet their own goals - Evaluation (and intervention) focusing on the contexts in which clients live, their roles and interests, and their culture - Allowing the client to be the “problem definer” so that the client will in turn become the “problem solver" - Allowing the client to evaluate his or her own performance and set personal goals **The Canadian Occupational Performance Measure (COPM)** is a standardized tool that uses a client-centered approach to allow the recipient of treatment to identify areas of difficulty, rate the importance of each area, and rate his or her satisfaction with current performance. - It is a particularly useful tool to use with clients who sustained a stroke because of the multiple and extensive problems that this population experiences performance of areas of occupation. ### **VI. Interventions** ### **Top-Down Approach to Assessment** - A top-down approach to the assessment process has been described in the literature and is applicable to the evaluation of clients who sustained a stroke. **Principles of this approach include the following:** - Inquiry into role competency and meaningfulness is the starting point for evaluation. - Inquiry is focused on the roles that are important to the client who sustained a stroke, particularly those in which the client was engaged before the stroke. - Any discrepancy of roles in the past, present, or future is identified to help determine a treatment plan. - The tasks that define a person are identified, as well as whether those tasks can be performed and the reasons that the tasks are problematic. - A connection is determined between the components of function and occupational performance. ### **Standardized Tools** - **The Arnadottir Occupational Therapy Neurobehavioral Evaluation (A-ONE)** objectively documents the way that dysfunction of client factors (e.g., left-sided neglect, apraxia, and spatial dysfunction) affects self-care and mobility tasks. - The A-ONE has more recently been referred to as the ADL focused Occupation-based Neurobehavioral Evaluation. - **The Assessment of Motor and Process Skills (AMPS)** uses predominantly instrumental activities of daily living (IADLs) to evaluate underlying performance skills related to the completion of various IADLs (e.g., reaching, grasping, and posture) and process skill dysfunction (e.g., using items and searching and locating). ## **TABLE 33-3 | Assessments Used with Clients Who Sustained a Stroke** | Instrument | Description and Usage | | :---------------- | :-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | | NIH Stroke Scale | Stroke deficit scale that scores 15 items (e.g., consciousness, vision, extraocular movement, facial control, limb strength, ataxia, sensation, speech and language) | | Canadian Neurological Scale | Stroke deficit scale that scores 8 items (e.g., consciousness, orientation, speech, motor function, facial weakness) | | Rankin Scale | Global disability scale with 6 grades indicating degrees of disability | | Canadian Occupational Performance Measure (COPM) | Client-centered assessment tool based on clients' identification of problems in performance in areas of occupation (clients rate the importance of self-care, productivity, and leisure skills, as well as their perception of performance and satisfaction with performance) | | Barthel Index | Measure of disability in performing BADLs that ranges from 0 to 20 or 0 to 100 (by multiplying each item by 5); includes 10 items: bowels, bladder, feeding, grooming, dressing, transfer, toileting, mobility, stairs, and bathing | | Kohlman Evaluation of Living Skills (KELS) | Living skills evaluation that includes ratings of 17 tasks (e.g., safety awareness, money management, phone book use, money and bill management) | | Functional Independence Measure (FIM) | Measure of disability in performing BADLs that includes 18 items scored on a 7-point scale; includes subscores for motor and cognitive function; performance areas include self-care, sphincter control, mobility, locomotion, cognition, and socialization | | Frenchay Activities Index | 15-item IADL scale that evaluates domestic, leisure, work, and outdoor activities | | PCG Instrumental Activities of Daily Living | IADL evaluation of telephone use, walking, shopping, food preparation, housekeeping, laundry, public transportation, and medication management | | Assessment of Motor and Process Skills | 16 motor skills (e.g., reach, manipulation, calibration, coordination, posture, mobility) and 20 process skills (e.g., attends, organizes, searches and locates, initiates, sequences) evaluated within the context of client-chosen IADL skills; clients choose familiar and culturally relevant tasks from a list of 50 standardized activities of various difficulties | | Mini-Mental State Examination | Mental status screening test for orientation to time and place, registration of words, attention, calculation, recall, language, and visual construction | | Glasgow Coma Scale | Level-of-consciousness scale that includes 3 sections scoring eye opening, motor, and verbal responses to voice commands or pain | | Arnadottir Occupational Therapy Neurobehavioral Evaluation (A-ONE) | Evaluates apraxias, neglect syndromes, body scheme disorders, organization/sequencing dysfunction, agnosias, and spatial dysfunction via BADL and mobility tasks; directly correlates impairment and disability levels of dysfunction | | Neurobehavioral Cognitive Status Examination | Mental status screening test that includes the domains of orientation, attention, comprehension, naming, construction, memory, calculation, similarities, judgment, and repetition | | Fugl-Meyer Test | Motor function evaluation that uses a 3-point scale to score the domains of pain, range of motion, sensation, volitional movement, and balance | | Functional Test for the Hemiparetic Upper Extremity | Arm and hand function is assessed via 17 hierarchic functional tasks based on Brunnstrom's view of motor recovery; sample tasks are folding a sheet, screwing in a light bulb, stabilizing a jar, and zipping a zipper | | Arm Motor Ability Test (AMAT) | Arm function evaluated by functional ability and quality of movement; test involves performance of 28 tasks (e.g., eating with a spoon, opening a jar, tying a shoelace, using the telephone) | | TEMPA | Upper extremity performance test composed of 9 standardized tasks (bilateral and unilateral) measured by 3 criteria: length of execution, functional rating, and task analysis; sample tasks are handling coins, picking up a pitcher and pouring water, writing and stamping an envelope, and unlocking a lock | | Jebsen Test of Hand Function | Hand function evaluation; includes 7 test activities: writing a short sentence, turning over index cards, simulated eating, picking up small objects, moving empty and weighted cans, and stacking checkers during timed trials | | Motor Assessment Scale | Motor function evaluation; includes disability and impairment measures, arm and hand movements, tone, and mobility (bed, upright, and ambulation) | | Motricity Index | Measures impairments in limb strength with a weighted ordinal scale | | Trunk Control Test | Trunk control evaluated on a 0- to 100-point scale; tasks used: rolling, supine to sitting, and balanced sitting | | Berg Balance Scale | Balance assessment of 14 items scored on a 0- to 4-point ordinal scale | | Tinetti Test | Evaluates balance and gait in the older adult population | | Rivermead Mobility Index | Measures bed mobility, sitting, standing, transfers, and walking on a pass or fail scale | | Functional Reach Test | Balance evaluation; objectively measures length of forward reach in the standing posture | | Boston Diagnostic Aphasia Examination | Assesses sample speech and language behavior, including fluency, naming, word finding, repetition, serial speech, auditory comprehension, reading and writing | | Western Aphasia Battery | Includes an "Aphasia Quotient" and "Cortical Quotient" scored on a 100-point scale; assesses spontaneous speech, repetition, comprehension, naming, reading, and writing | | Beck Depression Inventory | 21-item, self-rating scale with attitudinal, somatic, and behavioral components | | Geriatric Depression Scale | Self-rated depression scale of 30 items with a yes or no format | | Family Assessment Device | Family assessment of problem solving, communication, roles, affective responsiveness, affective involvement, behavioral control, and general functioning | | Medical Outcomes Study / Short-Form Health Survey (SF-36) | Quality-of-life measure that includes the domains of physical functioning, physical and emotional problems, social function, pain, mental health, vitality, and health perception | | Sickness Impact Profile | Quality-of-life measure in the format of a 136-item scale with 12 subscales that measure ambulation, mobility, body care, emotion, communication, alertness, sleep, eating, home management, recreation, social interactions, and employment | | Activity Card Sort (ACS) | Uses a Q-sort methodology to assess participation in 80 instrumental, social, and high- and low-physical demand leisure activities. Clients sort the cards into different piles to identify activities that were done before their stroke, activities they are doing less, and those they have given up since their stroke. The ACS uses cards with pictures of tasks that people do every day | | Stroke Impact Scale | A stroke-specific measure that incorporates function and quality of life into one measure. It is a self-report measure with 59 items and 8 subgroups, including strength, hand function, BADLs and IADLs, mobility, communication, emotion, memory and thinking, and participation | *Recommended in the Agency for Health Care Policy and Research's Clinical Practice Guidelines #16, Post-Stroke Rehabilitation, 1995. BADL, basic activities of daily living, IADL, instrumental activities of daily living. ## **ANY QUESTIONS?**