Cerebral Vascular Accident : Occupational Therapy
Helpful Videos [Not Created by BOT]
reThink OT Podcast on Cerebral Vascular Accident
General Information about Cerebral Vascular Accident [CVA/Stroke]
Types of Cerebral Vascular Accidents
CVA Mechanism of Injury
There are two types of cerebral vascular accidents
Occurs when blood vessels BURST (hemorrhagic) or CLOG (ischemic)
- 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. 
- Causes excess blood to come in contact with other brain tissues which is an irritant 
- Can cause the skull to fill up with ruptured blood which then squeezes brain tissues and causing significant damage and pressure 
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]
Evaluations and Progress Notes for a Cerebral Vascular Accident
General Treatment Ideas for Cerebral Vascular Accidents
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]
- 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).
- 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
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
- Range of motion (pending on the level of movement displayed by the client)
- Cross midline
- Education on adapted techniques to use in meaningful activities while they continue in their motor learning plan of care
- 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.
- 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 Field Deficits
- Visual Spatial Deficits
- Unilateral Neglect
- Contraversive Pushing – “pusher syndrome”
- Post-stroke anxiety – an overwhelming sense of worry and fear.
- Interventions for Activity of Daily Living and Instrumental Activities of Daily Living Impairments
- 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
Some Research on Cerebral Vascular Accidents
Research Approach Ideas
Helpful Products and Videos
- 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.
- 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.
- 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.
- 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.
- Godefroy, O., et al., Dysexecutive syndrome: Diagnostic criteria and validation study. Annals of neurology, 2010. 68(6): p. 855-864.
- 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.
- 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.
- Li, S., Spasticity, Motor Recovery, and Neural Plasticity after Stroke. Frontiers in neurology, 2017. 8: p. 120-120.
- Loewen, S. and B. Anderson, Predictors of stroke outcome using objective measurement scales. Stroke, 1990. 21: p. 78-81.
- 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.
- 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.
- 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.
- Ploughman, M., A new era of multiple sclerosis rehabilitation: lessons from stroke. Lancet neurology, 2017. 16(10): p. 768-769.
- 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.
- Trombly, C., K. Levit, and B.J. Myers, Occupational Therapy for Physical Dysfunction. 4th edition
- 1997, Philadelphia: Williams & Wilkins.
- 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.
- 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.
- Mahle, A.J. and A.L. Ward, Adult Physical Conditions: Intervention Strategies for Occupational Therapy Assistants. 2019, Philadelphia, PA: F.A.Davis. 1057.