Cerebrovascular Accident/Stroke

• Stroke ranks as the third leading cause of death behind heart disease and cancer.

• On average, a U.S. citizen suffers a stroke every 40 seconds; every 4 minutes someone dies of a stroke.

• Each year, 795,000 people suffer a new or recurrent stroke. Approximately 610,000 strokes are first attacks and 185,000 are recurrent.

• The prevalence of stroke in 2006 was 6,400,000.

• Of people who suffer a stroke, 28% are younger than 65 years. For people older than 55, the incidence of stroke more than doubles with each successive decade.

• The incidence of stroke is about 1.25 times higher in men than in women.

• The aftermath of a stroke is a substantial public health and economic problem, with stroke being a leading cause of serious, long-term disability in the United States.

• Stroke accounts for more than half of all clients hospitalized for acute neurologic disease.

• Among long-term clients who sustained a stroke, 50% have hemiparesis, 30% cannot walk, 26% are found to be dependent in activity of daily living (ADL) scales, 19% are aphasic, 35% are clinically depressed, and 26% require home nursing care.

Ischemia

Ischemia refers to insufficient blood flow to the brain to meet metabolic demand. Ischemic strokes may be the result of embolism to the brain from cardiac or arterial sources. Cardiac sources include atrial fibrillation (pooling of blood in the dysfunctional atrium leads to the production of emboli), sinoatrial disorders, acute myocardial infarction, endocarditis, cardiac tumors, and valvular (both native and artificial) disorders. Cerebral ischemia caused by perfusion failure occurs with severe stenosis of the carotid and basilar arteries, as well as with microstenosis of the small deep arteries.^4,10

Age, gender, race, ethnicity, and heredity are considered nonmodifiable risk factors for ischemic strokes. In contrast, a major focus of stroke prevention and education programs is on the potentially modifiable risk factors discussed in the following list^4,50:

“The realization that the probability of stroke is increased several fold by the presence of multiple risk factors may help the patient to fully appreciate the need for serious risk factor management.”⁴ The responsibility for stroke prevention education (including prevention of recurrence) falls on each member of the stroke rehabilitation team.

Hemorrhage

Hemorrhagic strokes include subarachnoid and intracerebral hemorrhages, which account for only 13% of the total number of strokes.⁴ This type of stroke has numerous causes. The four most common are deep hypertensive intracerebral hemorrhages, ruptured saccular aneurysms, bleeding from arteriovenous malformations, and spontaneous lobar hemorrhages.⁵⁸

Related Syndromes

Cerebral anoxia and aneurysm can also result in hemiplegia. Some of the treatment approaches outlined in this chapter may be applicable to hemiplegia resulting from causes other than CVA or stroke, such as head injuries, neoplasms, and infectious diseases of the brain.

Transient Ischemic Attacks

Vascular disease of the brain can result in a completed stroke or transient ischemic attacks (TIAs). A TIA is characterized by 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. A TIA is seen as a sign of an impending stroke.⁴ Most TIAs occur in people with atherosclerotic disease. Of those who experience TIAs and do not seek treatment, an estimated third will sustain a completed stroke, another third will continue to have additional TIAs without a stroke, and a third will experience no further attacks.⁷⁸ If the TIA is caused by extracranial vascular disease, surgical intervention to restore vascular flow (carotid endarterectomy) may be effective in preventing the stroke and resultant disability.

Internal Carotid Artery

In the absence of adequate collateral circulation, occlusion of the internal carotid artery results in contralateral hemiplegia, hemianesthesia, and homonymous hemianopia.^6,10 Additionally, involvement of the dominant hemisphere (i.e., the cerebral hemisphere containing the representation of speech/language and controlling the arm and leg used preferentially in skilled movements, usually the left 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.^7,10,21 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.^22,31 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.⁶

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.^6,10

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.^6,10,31

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.^6,10,22,31

Vertebrobasilar 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.

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.”⁶³

Law and colleagues⁶² and Pollack⁷³ suggest that therapists implementing this approach to evaluation include the following concepts:

Through the use of these strategies, the evaluation process becomes more focused and defined, clients become immediately empowered, the goals of therapy are understood and agreed on, and a client-tailored treatment plan may be established. The Canadian Occupational Performance Measure⁶³ (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 in performance of areas of occupation.

The COPM would be a good assessment to use with Jasmine. It would give the occupational therapist insight into the occupations that should be prioritized, assist in goal writing, and facilitate treatment planning. In addition, use of the COPM would empower Jasmine as an active participant in the rehabilitation process. When Jasmine completed the COPM, the results identified toilet transfers, computer use, grooming, feeding, and child care as the occupations that she wanted to pursue first—in other words, these occupations would be the focus of her initial OT. Jasmine indicated that gaining mastery in the occupations would make her feel better about herself (“boost my self-esteem”) and give her hope that she could return to work (“and provide for my child”).

Top-Down Approach to Assessment

A top-down approach to the assessment process has been described in the literature⁹² and is applicable to the evaluation of clients who sustained a stroke. Principles of this approach include the following:

A top-down approach to evaluation is in contrast to a bottom-up approach, which first focuses on dysfunction of client factors.⁹²

Effects of Neurologic Deficits on Performance in Areas of Occupation

Using activity analysis and keen observation allows therapists to identify errors during task performance and to analyze the errors and determine the underlying deficits blocking independent functioning. Arnadottir states that “… therapists can benefit from detecting errors in occupational performance while observing ADL and thereby gain an understanding of the impairments affecting the patient’s activity limitation. Therapists can use the information based on observed task performance in a systematic way as a structure for clinical reasoning to help them assess functional independence related to the performance and to subsequently detect impaired neurological body functions. Such information can be important when intervention methods are aimed at addressing occupational errors”⁶ (Figure 33-2).

Because performance of a single functional task (e.g., donning a shirt) requires the use of multiple underlying client factors and performance skills that may have been affected by a stroke, multiple variables may be evaluated in the context of one client-chosen activity (Figure 33-3).^6,7

Standardized Tools

Occupational therapists use assessment tools that are reliable, valid, and sensitive to change. In addition, assessment tools focused on task performance should be used. Tools that are focused on evaluation of client factors in isolation from performance in areas of occupation, that use novel nonfunctional tasks, and that do not consider the effect of environmental context should be interpreted with caution. Tools are available to the occupational therapist that directly relate performance dysfunction observed during ADLs to the effect of underlying skills necessary for independent performance of activities.

The Arnadottir Occupational Therapy Neurobehavioral Evaluation^6,7 (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.^8,9 The Assessment of Motor and Process Skills⁴⁰ (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 provides a summary of standardized assessments used with clients who have sustained a stroke. The A-ONE was used to objectively document the ways that Jasmine’s various impairments (e.g., neglect, spatial relationship dysfunction, loss of motor control, topographic disorientation) affected her ability to perform basic activities of daily living (BADLs) and mobility (e.g., bed mobility, transfers, wheelchair mobility, and walking when applicable). Errors observed and documented included not dressing the left side of her body, not able to locate grooming items on the left side of the sink, and difficulty dressing the lower part of her body and getting out of bed secondary to loss of motor control in her left limbs and trunk.

• Help clients adjust to role and task performance limitations by exploring new roles and tasks.

• Create an environment that includes the common challenges of everyday life.

• Practice functional tasks or close simulations that have been identified as important by participants to find effective and efficient strategies for performance.

• Provide opportunities for practice outside therapy time (e.g., homework assignments).

• Minimize ineffective and inefficient movement patterns.

Inability to Perform Chosen Occupations While Seated

A commonly observed deficit after stroke is loss of trunk and postural control. Impairment of trunk control may lead to the following problems⁴⁵:

Loss of trunk and postural control (i.e., “controlling the body’s position in space for the dual purposes of stability and orientation”⁷⁹) after a stroke may be manifested as an inability to sit in proper alignment, loss of righting and equilibrium reactions, inability to reach beyond the arm span because of lack of postural adjustments, and falling during attempts to function.

Clients who sustained a stroke and lose trunk control need to use the more functional UE for postural support to remain upright and prevent falls. In these cases, the client effectively eliminates the ability to engage in ADLs and mobility tasks because lifting the more functional arm from the supporting surface can result in a fall. “Trunk control appears to be an obvious prerequisite for the control of more complex limb activities that in turn constitute a prerequisite to complex behavioral skills.”⁴² Studies have found trunk control to be a predictor of gait recovery, sitting balance,¹⁷ Functional Independence Measure (FIM) scores,⁴² and scores on the Barthel Index⁸¹ after a stroke.

Specific effects of a stroke on the trunk include the following:

Specific deficits in trunk control are evaluated during observation of task performance (Box 33-1). Observing tasks allows the therapist to evaluate trunk control in many directions (i.e., isometric, eccentric, and concentric control of the trunk muscle groups [extensors, abdominal muscles, and lateral flexors]) and the client’s limits of stability. The phrase limits of stability refers to “boundaries of an area of space in which the body can maintain its position without changing the base of support”⁸⁴ or “an area about which the center of mass may be moved over any given base of support without disrupting equilibrium.”³⁸ The therapist must differentiate between the client’s perceived limits of stability and the actual limits of stability. After a stroke, it is common to experience a disparity between the two because of body scheme disorder, fear of falling, or lack of insight into or awareness of disability. If the client’s perceived limits are greater than his or her actual limits, there is a risk for falls. In other cases, the client’s perceived limits are less than the actual limits. In such instances the client will not attempt more dynamic activities or will rely too greatly on adaptive equipment.

Treatment interventions aimed at increasing the client’s ability to perform chosen tasks in seated postures include the following⁴⁵:

For Jasmine, therapy first focused on her ability to keep her trunk stable (i.e., not moving) while using her limbs to engage in occupations. Occupations that do not require substantial weight shifting while sitting (e.g., hair care, upper body washing, feeding, card playing) were chosen first, followed by those that required progressively more weight shifting in all directions (e.g., wiping after use of the toilet, lower body dressing, scooting, reaching to the floor to pick up shoes, washing her feet). As needed, the therapist provided external support at Jasmine’s shoulders during these activities to increase her confidence, prevent falls, and provide necessary support to compensate for Jasmine’s weakness. As Jasmine improved, more challenging seated activities were chosen and external support was diminished.

Inability to Engage in Chosen Occupations While Standing

An inability to assume and maintain a standing posture has a significant effect on the type of activities in which a person may engage; it may also play a significant role in the eventual discharge destination for a hospitalized client recovering from a stroke. Impaired upright control has been correlated with an increased risk for falls,¹⁰¹ as well as with less than optimal functional outcomes⁶⁶ on the Barthel Index. Because many BADLs and IADLs, work, and leisure skills require control of standing postures, early training in upright control is a necessary component of stroke rehabilitation programs. Postural strategies (e.g., ankle, hip, and stepping strategies) are typically impaired after a stroke.

Similar to the deficits seen while sitting, upright standing postures are characterized by asymmetric weight distribution; unlike deficits occurring while sitting, the weight distribution while standing is seen through the lower extremities,¹⁰¹ in addition to the trunk. Clients who sustained a stroke often experience an inability to bear weight through the affected leg. Reasons for this disability include fear of falling or buckling of the knee, patterns of weakness that will not support the weight of the body, spasticity impeding proper alignment (i.e., plantar flexion spasticity that effectively blocks weight bearing through the sole of the foot),⁴⁴ and perceptual dysfunction.

In addition to asymmetry and an inability to bear weight or shift weight through the affected leg, many clients who have sustained a stroke lose upright postural control and balance strategies. Effective upright control depends on the following automatic postural reactions^36,84,85:

Both loss of postural reactions and an inability to bear and shift weight onto the affected leg will result in such functional limitations as gait deviations or dysfunction; an inability to climb stairs, transfer, and perform upright BADLs and IADLs; and an increased risk for falls. The assessment process provides the therapist with more specific information regarding the cause of the dysfunction. “Specifically, therapists should observe what happens when patients have to move their center of mass over their base of support, move their head, stand on uneven surfaces, function in lower lighting, move from one type of surface to another, or function on a narrower base of support. Therapists should also observe patients’ postural alignment, whether a bias in posture exists and in which direction that bias occurs, patients’ limits of stability, the width between their feet during functional tasks, and what patients do after losing their balance.”³⁶

Treatment strategies aimed at improving the patient’s ability to perform chosen tasks in standing postures include the following^36,84,101:

Jasmine was quickly engaged in activities that required standing despite persistent issues related to sitting balance. Standing was first attempted in front of stable work surfaces (e.g., kitchen counter, sink) to provide a balance point, increase Jasmine’s feeling of security and safety, and highlight the functional relevance of standing. As needed, the therapist stabilized the weak joints (e.g., hip and knee) with manual support, and Jasmine wore an ankle-foot orthotic to protect the integrity of her ankle. As Jasmine improved, she was asked to begin to use the upper part of her body for function while controlling her standing. Examples include wiping the counter, organizing a shelf, and grooming while standing. Progressively more demanding occupations from a standing balance perspective were chosen (e.g., modified games such as volleyball, vacuuming, emptying a dishwasher, stand-pivot transfers), and external manual and environmental support was decreased as Jasmine improved. All occupations were chosen to improve Jasmine’s ability to accept and shift weight through her left lower extremity.

Inability to Communicate Secondary to Language Dysfunction

Stroke may result in a wide variety of speech or language disorders ranging from mild to severe. These deficits occur most frequently with stroke resulting from damage to the left hemisphere of the brain. They can also occur less frequently after damage to the right hemisphere. All persons with stroke should be evaluated by a speech-language pathologist for the presence of speech and language disorders. The speech-language pathologist can provide valuable information to other members of the rehabilitation team and to the family regarding the best techniques for communicating with a particular client. The occupational therapist should continue the work of the speech therapist in the treatment sessions, as appropriate. Carryover may occur in reinforcing communication techniques that the client is learning and in presenting instruction in ways that the client is able to understand and integrate.⁸⁶

The specific speech and language dysfunctions described in the following sections can exist in mild to severe forms and in combination with one another.

Inability to Perform Chosen Occupations Secondary to Neurobehavioral/Cognitive-Perceptual Impairments

A neurobehavioral deficit is defined as “a functional impairment of an individual manifested as defective skill performance resulting from a neurologic processing dysfunction that affects performance components such as affect, body scheme, cognition, emotion, gnosis, language, memory, motor movement, perception, personality, sensory awareness, spatial relations, and visuospatial skills.”⁶ A major responsibility of the occupational therapist treating a client who has sustained a stroke is evaluating which neurobehavioral deficits are blocking independent performance of chosen occupations.

Arnadottir⁶ proposed a relationship among the ability to perform daily activities, neurobehavioral impairments, and the CNS origin of the neurobehavioral dysfunction (a stroke, for the purposes of this chapter). She supports this theory with the following relational statements:

To properly evaluate the effect of neurobehavioral deficits on task performance, the therapist must develop activity analysis skills with the goal of analyzing which components of performance are necessary to achieve an outcome that is satisfactory to the client. Even the simplest of BADL tasks challenges multiple underlying skills (Boxes 33-3 and 33-4; also see Figure 33-3).^6,79

Arnadottir^6,7 proposed a system of observing clients engaged in functional activities in which errors are allowed to occur (as long as they are safe), the errors are analyzed, and finally, impairments that are interfering with performance of tasks are detected so that an appropriate treatment plan can be developed. She cautioned that when the therapist analyzes errors and observed behavior, knowledge of neurobehavior, cortical function, activity analysis, and clinical reasoning must be considered in the results of the evaluation (Table 33-5).

Treatment aimed at counteracting the effects of neurobehavioral dysfunction may be based on an adaptive and compensatory approach or on a restorative and remedial approach.^47,70,72,79 A combination of approaches has also been suggested (Table 33-6).¹

Decisions regarding the selection of a particular treatment approach may be difficult. Neistadt^71,72 suggested evaluating a client’s learning potential in the context of ADL evaluation and training, with a focus on such issues as the number of repetitions needed to learn new approaches to tasks and the type of transfer of learning that is demonstrated.

Toglia⁹¹ has suggested that transfer of learning from one context to another (e.g., transferring skills learned from making a cup of tea in the OT clinic to meal preparation at home) may be facilitated by the therapist through the following methods:

Toglia⁹¹ has identified degrees of transfer of learning. The degree of transfer is defined by the number of task characteristics that differ from those of the original task. Examples of these characteristics are spatial orientation, mode of presentation (e.g., auditory or visual), movement requirements, and environmental context.

A near transfer of learning involves transfer between two tasks that have one or two differing characteristics. Intermediate transfer involves transfer of learning to a task that varies by three to six characteristics. A far transfer involves a task that is conceptually similar but has one or no characteristics in common. Finally, a very far transfer involves the “spontaneous application of what has been learned in treatment to everyday living.”⁹¹

From her review of the literature, Neistadt⁷⁰ reached the following conclusions:

Using a functional and meaningful task as a treatment modality promotes the acquisition of a desired skill, and the therapist may use this task to challenge multiple underlying impairments.^1,47,79 It is up to the therapist to present the task by manipulating the environment in a way that challenges the underlying skills (see Box 33-3). If a compensatory approach is chosen, adaptive techniques are used to counteract the effects of the underlying neurobehavioral deficits (see Box 33-4).

Jasmine’s left-sided neglect had a substantial impact on her ability to perform relevant occupations independently and safely. A variety of strategies were used to improve her ability to attend to the left side. Organized visual scanning was taught during daily activities such as feeding and grooming. Occupations were chosen that required scanning to both the left and the right to be successful (e.g., finding ingredients in the refrigerator, locating the toothbrush on the left side of the sink and toothpaste on the right, reading, describing a room). Vanishing physical and verbal cues were used as Jasmine progressed. Another strategy that was helpful for Jasmine was the use of a left-sided anchor. A red strip of tape was placed on the left side (e.g., the left side of the computer monitor, placemat, sink, book), and Jasmine focused on scanning to the anchor to ensure that she was attending to all of the information required to be successful at performing each occupation. Because Jasmine’s neglect persisted, driving was not an option. Other modes of transportation were considered, including supervised use of public transportation, assistance with transport by friends and neighbors, and local access-a-ride companies. See Chapters 11, 25, and 26.

Inability to Perform Chosen Tasks Secondary to Upper Extremity Dysfunction

Loss of UE control is common after a stroke, with 88% of clients who sustained a stroke having some level of UE dysfunction.⁷⁴ The client’s ability to integrate the affected arm into chosen tasks may be limited by multiple factors, including the following⁴⁶:

Inability to Perform Chosen Tasks Secondary to Visual Impairment

Processing of visual information is a complex act that requires intact functioning of multiple peripheral nervous system and CNS structures to support functional independence. The site of the lesion determines the visual dysfunction and the effect on performance of tasks (Figure 33-9).⁷

Visual dysfunction and its treatment are detailed in Chapter 24. In general, treatment approaches may focus on remediation, such as eye calisthenics, fixations, scanning, visual motor techniques, and bilateral integration. Adaptive techniques are also used, including a change in working distance, the use of prisms, adaptations for driving and reading, changes in lighting, and enlarged print.⁸²

Psychosocial Adjustment

The psychologic consequences of a stroke are substantial. The incidence of depression in this population is 35% according to statistics collected by the American Heart Association.⁴ The highest reported incidence is found in clients in acute and rehabilitation hospitals, and the lowest is in samples of those living in the community following stroke. Other psychologic manifestations that have been documented in survivors of stroke include anxiety, agoraphobia, substance abuse, sleep disorders, mania, aprosody (difficulty expressing or recognizing emotion), behavioral problems (e.g., sexual inappropriateness, verbal outbursts, aggressiveness), lability (alteration between pathologic laughing and crying), and personality changes (e.g., apathy, irritability, social withdrawal).³⁹

A critical role of the occupational therapist is to help the client adjust to hospitalization and, more important, to disability. Much patience and a supportive approach by the therapist are essential. The therapist must be sensitive to the fact that the client has experienced a devastating and life-threatening illness that has caused sudden and dramatic changes in the client’s life roles and performance. The therapist must be cognizant of the normal adjustment process and must gear the approach and expectations of performance to the client’s level of adjustment. Frequently, the client is not ready to engage in rehabilitation measures with wholehearted effort until several months after onset of the disability.

Family education is extremely important throughout the treatment program. Family members are better equipped to assist their loved one in adjusting to disability when they are knowledgeable about the disability and its implications.

Many clients dwell on the possibility of full recovery of function; they should gradually be made aware that some residual dysfunction is likely. The therapist may approach this probability by discussing in objective terms what is known about the prognosis for functional recovery after stroke. It may be necessary to review this information many times before the client begins to apply it to his or her recovery. This education should be done in a way that is honest and yet does not destroy all hope.

Falk-Kessler³⁹ has provided occupational therapists with guidelines related to interventions for the psychologic manifestations of stroke, including the following:

In addition to the aforementioned interventions, it is important to remember that pharmacologic interventions have been shown to be effective in this population and should not be overlooked³⁹ as part of a team approach. Such interventions include but are not limited to antidepressants for depression or for individuals with a pathologic affect, benzodiazepines for generalized anxiety disorder, and neuroleptic medications for those with post-stroke psychosis.²⁶

The OT program should focus on the skills and abilities of the patient. The patient’s attention should be focused, through the performance of activity, on his or her remaining and newly learned skills. The OT program can also include therapeutic group activities for socialization and sharing of common problems and their solutions. The discovery that there are residual abilities and perhaps new abilities and success at performing many daily living skills and activities that were initially thought to be impossible can improve the patient’s mental health and outlook.

• Feeding: Jasmine was unable to cut or open containers secondary to unilateral UE weakness on the left, she had a tendency to eat only the food on the right side of her plate, and she was unable to locate utensils on the left side of the plate. In addition, food remained between her left gums and cheek (“pocketing”) after meals, thereby resulting in oral hygiene issues and putting Jasmine at risk for aspiration.

• Grooming: Jasmine had difficulty opening and applying toothpaste with one hand. She attended only to the right side of her body while grooming, with the left side of her mouth and hair not being cared for during oral and hair care.

• Toilet transfers: Jasmine required moderate physical assistance to transfer to the toilet secondary to an inability to bear weight on her left leg and an inability to control her trunk (she falls laterally when sitting on the toilet). The occupational therapist also noted that when Jasmine “completed” the transfer to the toilet, only the right side of her body was sitting on the toilet. She neglected to include the left side of her body in the transfer and left it in the wheelchair.

• Computer use: During attempts to use the computer, Jasmine became easily frustrated and made comments such as “I feel like a failure” and “I can’t even provide for my child anymore.” Jasmine agreed to attempt to write a letter to her friend on the computer. Multiple mistakes were noted because Jasmine seemed to “not see” the left-sided keys, could not control the shift keys, and generally appeared disorganized in her approach to the task.

• Simulated child care: A weighted doll was used to observe Jasmine’s ability to care for her child. It was quickly decided that this area of occupation would be deferred until Jasmine’s status improved. Jasmine and her occupational therapist made this decision collaboratively on the basis of safety concerns and Jasmine’s emotional status. Jasmine was gravely concerned about her ability to care for her child. The occupational therapist wanted to focus on occupations that Jasmine could master, build her confidence, and upgrade her occupations systematically according to Jasmine’s abilities.

Review Questions

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24. Cailliet, R. The shoulder in hemiplegia. Philadelphia, Pa: FA Davis; 1980.

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