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Cerebral Vascular Accident : Occupational Therapy

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General Information about Cerebral Vascular Accident [CVA/Stroke]

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FAST Acronym to remember signs and symptoms of stroke in occupational therapy

Types of Cerebral Vascular Accidents

CVA Mechanism of Injury

There are two types of cerebral vascular accidents

Types of Cerebral Vascular Accidents

Occurs when blood vessels BURST (hemorrhagic)  or CLOG (ischemic)

 

Hemorrhagic CVA

  • This occurs when a blood vessel ruptures or leaks, most commonly because of hypertension bleeds, malformed blood vessels or veins, aneurysms (blood vessel weakness), or it may be spontaneous. [15]
  • Causes excess blood to come in contact with other brain tissues which is an irritant [15]
  • Can cause the skull to fill up with ruptured blood which then squeezes brain tissues and causing significant damage and pressure [15]

 

Ischemic CVA

 

Embolic Stroke – This occurs when a clot breaks free and travels through a vessel before causing a blockage. This traveling clot, called an embolus, May originate from vascular plaques and deep vein thrombosis  (DVT)

Thrombic Stroke – occurs as a result of buildup inside of the blood vessel, usually through atherosclerotic disease. This buildup occludes (blocks) the artery.

Symptoms Associated with Cerebral Vascular Accidents [CVA/Stroke]

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Evaluations and Progress Notes for a Cerebral Vascular Accident

(S) Subjective

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(O) Objective

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(A) Assessment

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(P) Plan

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General Treatment Ideas for Cerebral Vascular Accidents

Person

Upper Extremity [15]

 

Approaches: motor learning principles of massed practice, whole task practice, variable practice, and delayed thoughtful feedback

 

  • Use Meaningful tasks [ this does not mean occupation-specific tasks, it means ensure that your patient has achieved buy-in with your approach]
  • Strengthening and resistive exercise [if patient has adequate excursion of joint volitionally without compensations]
  • Constraint-induced movement therapy when appropriate
  • Mirror Therapy when appropriate
  • Bilateral training and weight bearing during functional tasks
  • Cognitive remedial therapy
  • Action-observation training and mental imagery as home programs
  • Train the client how to perform self-range of motion exercises and instructing them not to go beyond 90 degrees of shoulder flexion or abduction if inadequate scapulohumeral rhythm is noted
  • Encourage use of the affected upper extremity in all daily tasks

 

Hemiparetic upper extremity

 (Spasticity or high tone is more common) [1, 3, 9]

 

General Information

  • After a neurological event, individuals may have difficulty moving their contralesional extremity (typically experiencing increased spasticity preventing functional movement)
  • A client who has experienced a neurological event that has impacted upper extremity mobility will not experience a functional plateau in the first 1-3 years of rehabilitation. Due to neural plasticity, clients have hope for nervous system repair from the time they are born until their end of life (some exceptions exist).

 

Causes

  • due to injury, upper motor neurons are unable to regulate/communicate with the parasympathetic and sympathetic systems of the peripheral nervous system to regulate tone.

 

 

Main concerns to watch

  • Shoulder subluxation
  • Scapular dysfunction
  • Shoulder hiking of the affected upper extremity with contralateral trunk flexion to perform functional tasks

 

What not to do

  • Use a pulley for range of motion in the presence of shoulder/scapula dysfunction
  • Wrap a hemiparetic limb on an arm bike without proximal support and use the non-affected limb to move it

 

Treatments

Inhibitory techniques or inhibition techniques

      • Prolonged pressure on long flexor tendons of hand
      • Oscillating movements and trunk/limb rotation
      • Weight-bearing positions (quadruped, kneeling)
      • Sustained stretch in upright posture
      • Active contraction of antagonists to spastic muscles
      • E-stim on antagonist of spastic muscles
      • Biofeedback
      • Modalities
  • Repetition
  • Range of motion (pending on the level of movement displayed by the client)
  • Modalities
  • Weightbearing
  • Cross midline
  • Education on adapted techniques to use in meaningful activities while they continue in their motor learning plan of care

 

 

Somatosensory Impairments [15]

 

  • Promote cortical reorganization through neuroplasticity by engaging the somatosensory cortex while engaging the primary motor cortex
  • Motor and somatosensory systems are completely intertwined and reliant on one another for Optimal Performance
  • The same principles can guide intervention for both systems! If you are preforming a mobility-based session, apply the same concepts to the somatosensory system!
  • Stimulation to limbs via different textures or electrical stimulation (TENS unit) : Design a structured stimulation and regulation program for your patient.

 

Cognitive Impairments [15]

 

  • Attention Impairments [ See Video at top of page on attention levels and memory impairments ]
  • Memory Impairments [ See Video at top of page on attention levels and memory impairments ]
  • Executive Functioning Impairments
    • Environmental Management
    • Manipulation of Physiological Factors
    • Training in the selection of cognitive plans
    • Metacognitive strategies 
  • Self-Awareness and Insight Impairments
    • Individual Awareness-enhancing program
    • Experiential Exercises
    • Caregiver Education and Training
    • Functional Tasks for Self-Awareness

 

Visual-Spatial / Perceptual Impairments

 

  • Visual Field Deficits
  • Diplopia
  • Visual Spatial Deficits
  • Unilateral Neglect
  • Contraversive Pushing – “pusher syndrome” 

 

 

Psychosocial Impact of Stroke

 

  • Post-stroke anxiety – an overwhelming sense of worry and fear. 
  • Interventions for Activity of Daily Living and Instrumental Activities of Daily Living Impairments

 

 

Education

  • Disease information, prognosis, and process
  • Potential symptoms and solutions
  • Joint protection (especially if patient is experiencing subluxation or ‘scapular winging’
  • Energy Conservation training across multiple contexts
  • Task simplification
  • Fatigue management
  • Home Exercise Program
Environment

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Occupation

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Some Research on Cerebral Vascular Accidents

Research Approach Ideas

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Helpful Products and Videos

References

References

 

  1. Bruyneel, A.V., Validity and reliability of clinical tests to assess seated balance and transfer tasks for adults with stroke: Literature review. Annals of physical and rehabilitation medicine, 2018. 61: p. e202-e202.
  2. Cauraugh, J.H., et al., Bilateral movement training and stroke motor recovery progress: A structured review and meta-analysis. Human movement science, 2010. 29(5): p. 853-870.
  3. Chen, S.-Y. and C.J. Winstein, A Systematic Review of Voluntary Arm Recovery in Hemiparetic Stroke: Critical Predictors for Meaningful Outcomes Using the International Classification of Functioning, Disability, and Health. Journal of neurologic physical therapy, 2009. 33(1): p. 2-13.
  4. de Oliveira, K.C.R., et al., Overflow using proprioceptive neuromuscular facilitation in post-stroke hemiplegics: A preliminary study. Journal of bodywork and movement therapies, 2019. 23(2): p. 399-404.
  5. Godefroy, O., et al., Dysexecutive syndrome: Diagnostic criteria and validation study. Annals of neurology, 2010. 68(6): p. 855-864.
  6. Gresham, G., T. Phillips, and M. Labi, ADL status in stroke: relative merits of three standard indexes. Arch Phys Med Rehabil, 1980. 61: p. 355-358.
  7. Hatem, S.M., et al., Rehabilitation of Motor Function after Stroke: A Multiple Systematic Review Focused on Techniques to Stimulate Upper Extremity Recovery. Frontiers in human neuroscience, 2016. 10: p. 442-442.
  8. Li, S., Spasticity, Motor Recovery, and Neural Plasticity after Stroke. Frontiers in neurology, 2017. 8: p. 120-120.
  9. Loewen, S. and B. Anderson, Predictors of stroke outcome using objective measurement scales. Stroke, 1990. 21: p. 78-81.
  10. Luft, A.R., et al., Repetitive Bilateral Arm Training and Motor Cortex Activation in Chronic Stroke: A Randomized Controlled Trial. JAMA, 2004. 292(15): p. 1853-1861.
  11. Massie, C.L. and M.P. Malcolm, Instructions emphasizing speed improves hemiparetic arm kinematics during reaching in stroke. NeuroRehabilitation (Reading, Mass.), 2012. 30(4): p. 341-350.
  12. Pintucci, M., et al., Successful treatment of rotator cuff tear using Fascial Manipulation® in a stroke patient. Journal of bodywork and movement therapies, 2016. 21(3): p. 653-657.
  13. Ploughman, M., A new era of multiple sclerosis rehabilitation: lessons from stroke. Lancet neurology, 2017. 16(10): p. 768-769.
  14. Van Criekinge, T., et al., Effectiveness of additional trunk exercises on gait performance: study protocol for a randomized controlled trial. Trials, 2017. 18(1): p. 249-249.
  15. Trombly, C., K. Levit, and B.J. Myers, Occupational Therapy for Physical Dysfunction. 4th edition
  16. 1997, Philadelphia: Williams & Wilkins.
  17. Maier, M., B.R. Ballester, and P.F.M.J. Verschure, Principles of Neurorehabilitation After Stroke Based on Motor Learning and Brain Plasticity Mechanisms. Frontiers in systems neuroscience, 2019. 13: p. 74-74.
  18. Park, M.-O. and S.-H. Lee, Effects of cognitive-motor dual-task training combined with auditory motor synchronization training on cognitive functioning in individuals with chronic stroke: A pilot randomized controlled trial. Medicine (Baltimore), 2018. 97(22): p. e10910-e10910.
  19. Mahle, A.J. and A.L. Ward, Adult Physical Conditions: Intervention Strategies for Occupational Therapy Assistants. 2019, Philadelphia, PA: F.A.Davis. 1057.