Occupational Therapy for Stroke PDF

Occupational Therapy Intervention for Medical and Neurological Conditions (OTH 2106) LECTURE 1 OCCUPATIONAL THERAPY INTERVENTION FOR STROKE By: Matthew Teo DEFINATION OF STROKE Stroke is essentially disease of the cerebral vasculature in which a failure to supply oxygen to brain cells,...

Occupational Therapy Intervention for Medical and Neurological Conditions (OTH 2106) LECTURE 1 OCCUPATIONAL THERAPY INTERVENTION FOR STROKE By: Matthew Teo DEFINATION OF STROKE Stroke is essentially disease of the cerebral vasculature in which a failure to supply oxygen to brain cells, which are most susceptible to ischemic damage, leads to their death. Etiology: Thromboembolic (85%) Lacunes (localized area) Hemorrhagic (15%) Hemorrhagic strokes account for the remaining 20% of stroke incidents (Burkhardt. A, 2004) TIA PATHOPHYSIOLOGY Symptoms of transient ischemic attack (TIA) include the focal deficits of an ischemic stroke and clearly vascular distribution but TIAs are reversible defects because no cerebral infarction ensues. The cause of TIAs can be thrombotic or embolic and result from a cerebral vasospasm. Effects of TIAs must resolve in less than 24hours. A patient who has had TIA should have complete evaluation of CVA due to 33% of TIA’s have a stroke within 5 years. Treatment for TIAs depends on source of emboli or thrombi and include anticoagulation therapy/surgery. (Burkhardt. A, 2004). Epidemiology of stroke incidences in Malaysia NCDs 3+1: Diabetes, 2.3 million adults hypertension, high (5.1%) in Malaysia cholesterol + obesity live with three NCDs Hypertension Single most important Location CVA is the 3rd most MODIFIABLE RISK FACTOR For Relative Risk 1 for Anterior (Carotid) circulation common cause of 140/90: (65%) death in Malaysia 160/95: RR=4.0 136/84: RR=0.5 Posterior (Vertebrobasilar) 123/76: RR=0.35 circulation (35%)  Diabetes Relative Risk: 1.8-3.0 for stroke Dyslipidemia Relative Risk: 0.7 for stroke if statin started Cigarette smoking Relative Risk: 2.0 Reduces after 2-4 yrs cessation all types of smokers Modifiable Alcohol Increased hemorrhagic strokes with heavy Risk Factors alcohol use Drugs Cocaine most linked to strokes Other drugs: heroin, amphetamines, LSD, PCP, marijuana, phenylpropanolamine, ephedrine, and pseudoephedrine Contraceptives with estrogen > 50 g linked to strokes Current contraceptives use < 50 mg  The vascular territory affected will determine the exact symptoms and clinical behaviour of the lesion: anterior circulation infarct anterior cerebral artery infarct Clinical middle cerebral artery infarct presentation: lacunar infarct striatocapsular infarct Stroke posterior circulation infarct posterior cerebral artery infarct cerebellar infarct brainstem infarct DEFINITION OF THE LEFT CEREBRAL HEMISPHERE Involved in analytical, logical thinking and in symbolic function of language, concept, ideas and numbers. Left sided brain injury resulting in paralyzed right side, problems in: Speech and language Cautious Hesitant Anxious Disorganized when faced with unfamiliar problem Need frequent assurances they doing fine, immediate positive feedback, breaking tasks down into steps and practicing often with aid learning. DEFINITION OF THE RIGHT CEREBRAL HEMISPHERE Responsible for spatial sensation, perception and judgement. Right sided brain injury resulted: Severe visual spatial deficits (hemianopia & left neglect). Deficits in figure ground discrimination Position in space Spatial relationship Body scheme Frequently deny their disability Display impulsivity An inability to abstract Errors in judgement. Upper Motor Neuro Lesion (UMNL)Signs & Symptoms Flexor and extensor synergies pattern UPPER EXTREMITY LOWER EXTREMITY MEDICAL STROKE MANAGEMENT Treatment by physician will vary depending on the location and severity of the lesion, secondary neurological and medical complications. Obtains history from a patient. Perform diagnostic test: computer axial tomography (CAT) scanning & magnetic resonance imaging (MRI) to determine location and extent of the lesion Urinalysis Blood test Electrocardiogram PROGNOSIS Depends on: Stage of recovery when therapy is first initiated Site and severity of the brain lesion Associated medical problems Age Support system Premorbid state History a multiple CVA and continued bowel and bladder incontinence signify a poor prognosis. Younger patients often have a better functional outcome (Marilyn S, 1992). OCCUPATIONAL THERAPY INTERVENTION TO PROMOTE INDEPENDENCE AFTER STROKE Sensory- Activities of Motor motor Daily Living function function Cognitive & Psychosocial Psychological perceptual function function function OCCUPATIONAL THERAPY OBJECTIVES Independent in activities of daily living General Return to meaningful quality of life: work, leisure, socialization Minimizing negative effect of CVA Reduction of impairment Motor weakness Depression Regress cognition Specific Maximizing the function of affected limbs Prevent deformity caused by spasticity/poor positioning Improve communication capability To educate patient and family regarding ongoing treatment and ensure consistent home management of the patient on discharge To assist the patient and the family in adjusting to disability and life changes  Rehabilitating a person to a total / maximum well being through selected functional activity to enable the person to be independent & return back to his/her community Improving function and planning, carrying out some task, which the elder person need to do in daily life……or helping them to do something, which they enjoy and want to do…. In a safe manner/environment OCCUPATIONAL Maintain and/or increase a Stroke patient’s level of functional level is an essential part of being able to THERAPIST: help restore him to highest functional independence as practicable. FRAMES OF REFERENCE Neurodevelopmental Biomechanical Cognitive Frame of Frame of Reference Frame of Reference Reference Sensory Integration Rehabilitation Frame Behavioral Frame of Frame of Reference of Reference Reference  Neurodevelopmental Frame of Reference Biomechanical Frame of Reference Theoretical Base: Theoretical Base: Neurosciences-normalization Physical sciences-kinetics, and integration of biologic kinematics, medicine. processes. Evaluation: Evaluation: Assessment of muscle tone, Assessment of range of motion, limb synergies, automatic manual muscle testing, reactions, gross and fine motor endurance testing. movement strategies. Treatment: Treatment: Reduce deficits through direct Inhibit or excite neural cause and treatment process- mechanisms-use special techniques and equipment to exercise and activuty. normalize biologic processes.  Sensory Integration Frame of Cognitive Frame of Reference Reference Theoretical Base: Theoretical Base: Biologic psychiatric, Developmental, neurosciences- neurosciences, cognitive underlies relation between sensory input and all behavior. A cognitive disability neural integration. reflects impairments in the cognitive functions that guide motor actions. Evaluation: Perceptual testing, observation. Evaluation: Task analysis- selection and Treatment: modification in range of patient’s Use body movement, gross motor ability. and sensory integrative activities. Treatment: Provide tasks to match level of cognitive abilities-environmental compensations.  Rehabilitation Frame of Reference Behavioral Frame of Reference Theoretical Base: Theoretical Base: Medicine, physical sciences-total Psychology –learning occurs capabilities of each individual through interaction with a based on examination of the part. reinforcing environment. Evaluation: Evaluation: Assessment of deficit and Skills checklist capabilities in basic and Observation instrumental activity of daily living, work and leisure and access to the environment. Treatment: Instruct in skills needed to promote Treatment: learning, provided through reinforcement: shaping, chaining, Compensate for disability by task analysis, feedback. learning to live with one’s capabilities in all aspects of life- adapt environment to obtain independence OCCUPATIONAL THERAPY EVALUATION Sensory- Activities of Motor motor Daily Living function function Cognitive & Psychosocial Psychological perceptual function function function Activities of daily living (ADL) and Instrumental of daily living (IADL) Area of evaluation: Basic activities of daily living and Instrumental Activity of Daily Living. Assessment tools: 1. Modified Barthel Index (MBI) 2. Canadian Occupational Performance Measure (COPM) 3. Functional Independence Measure (FIM) 4. KATZ INDEX OF INDEPENDENCE OF ADL 5. Lawton Instrumental Activities of Daily Living (IADL) Scale Competency: Skills in administrating and interpret the results and identify the problem Motor function Area of evaluation: a) Upper limb and lower limb function: i. Range of motion ii. Muscle tone iii. Muscle power (if normal muscle tone) iv. Oedema Assessment tools: 1. Manual muscle testing (MMT) 2. Modified Ashworth Scale 3. Hand assessment kit 4. Gorniometer 5. Measurement tape & volumeter Competency: Skill in the use of assessment tools, interpret the results and identify the problem.  Area of evaluation: b) Hand function: Assessment tools: 1. Jebsen-taylor hand function test 2. O’Conner Tweezers Dexterity Test 3. Purdue Pegboard 4. Minessota hand dexterity test 5. Roeder Manipulative Aptitude Competency: Skill in administrating skill in interpret the results and identify the problem.  Area of evaluation: c) Mobility and Balance Assessment tools: 1. Berg’s Balancing 2. Tinneti Balance Assessment Tools 3. Get up and go test 4. Romberg test Competency: Skill in administrating skill in interpret the results and identify the problem.  Area of evaluation: d) Shoulder subluxation Assessment tools: 1. Clinical examination Competency: Skill in administrating skill in interpret the results and identify the problem. Sensory motor function Area of evaluation: a) Orafacial function Assessment tools: Observation for asymmetrical Competency: Skill in observation  Area of evaluation: b) Visual assessment i. Visual acuity ii. Visual pursuit iii. Hemianopia iv. Convergent v. Unilateral neglect vi. Diplopia Assessment tools: Visual confrontation test Competency: Ability to administer visual confrontation test, analyze results and identify problems.  Area of evaluation: c) Pain Assessment tools: i. Visual Analog Scale (VAS) ii. Pain numerical scale iii. Wong-Baker FACES Scale Competency: Ability to administer the assessment Cognitive & Perceptual Function Assessment tools: i. Mini Mental State Examination (MMSE) ii. Loewenstein Occupational Therapy Cognitive Assessment (LOTCA-2nd edition). iii. Rivermead iv. Chessington Occupational Therapy Neurological Assessment Battery (COTNAB) v. BIVABA Competency: Skill to administer and interpret the results and identify the problem. Psychosocial Function Area of evaluation: Communication capability Assessment tools: Clinical observation Competency: Skill in identifying communication difficulty Psychological Function Assessment tools: i. Premorbid personality ii. Interview and clinical observation iii. Beck Depression Scale iv. Hamilton Depression Scale Competency: Skill in identifying behavior and emotional change METHOD OF ASSESSMENT Standardized observation tests physical intervention assessment  Brunnstrom Stages of Stroke Recovery Flaccid paralysis is present Phasic stretch reflexes are absent or hypoactive Stages 1 Active movement cannot elicited reflexively with a facilitatory stimulus or volitionally Spasticity is present Felt as resistance to passive movement. No voluntary movement is present but a facilitatatory stimulus will elicit the limb Stages 2 synergies reflexively. These limb synergies consist of stereotypical flexor and extensor movements Spasticity is marked The synergistic movements can be elicited voluntarily but are not obligatory Stages 3  Spasticity decreases. Synergy patterns can be reversed if movement takes place in the weaker synergy first. Movement combining antagonistic synergies can be performed when the prime movers are Stages 4 the strong components of the synergy. Spasticity wanes. Evident with rapid movement and at extremes of range Synergy patterns can be revised even if the movement takes place in the strongest synergy first. Stages 5 Movement that utilize the weak components of both synergies acting as prime movers can be performed. Coordination and patterns of movement can be near normal. Spasticity as demonstrated by resistance to passive movement is no longer present. Abnormal patterns of movement with faulty timing emerge when rapid or complex actions are Stages 6 requested. Normal- variety of rapid, age appropriate complex movement patterns are possible with normal timing, coordination, strength and endurance. Stages 7 Normal sensory perceptual motor system. NIHSS stroke severity Score Stroke severity 0 No stroke 1–4 Minor stroke 5–15 Moderate stroke 15–20 Moderate/severe stroke 21–42 Severe stroke INTERVENTION PROGRAMME In-patient rehabilitation programme (