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Occupational Therapy and Stroke
Occupational Therapy and Stroke, Second Edition Edited by Judi Edmans
© 2010 Blackwell Publishing Ltd. ISBN: 978-1-405-19266-8
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Occupational Therapy
and Stroke
Second Edition
Edited by
Judi Edmans
On behalf of the Stroke Clinical Forum of the College of Occupational
Therapists Specialist Section Neurological Practice
A John Wiley & Sons, Ltd., Publication
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This edition first published 2010
C 2010 Blackwell Publishing Ltd
Blackwell Publishing was acquired by John Wiley & Sons in February 2007. Blackwell’s publishing
programme has been merged with Wiley’s global Scientific, Technical, and Medical business to form
Wiley-Blackwell.
Registered office
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All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted,
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Library of Congress Cataloging-in-Publication Data
Occupational therapy and stroke / edited by Judi Edmans on behalf of the Stroke Clinical Forum of the College
of Occupational Therapists Specialist Section Neurological Practice. – 2nd ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-4051-9266-8 (pbk. : alk. paper) 1. Cerebrovascular disease–Patients–Rehabilitation.
2. Occupational therapy. I. Edmans, Judi. II. College of Occupational Therapists. Specialist Section
Neurological Practice. Stroke Clinical Forum.
[DNLM: 1. Stroke–therapy. 2. Disabled Persons–rehabilitation. 3. Occupational Therapy–methods.
WL 355 O15 2010]
RC388.5.O33 2010
616.8 1062–dc22
2010003297
A catalogue record for this book is available from the British Library.
R
Set in 10/12.5 pt Times by Aptara
Inc., New Delhi, India
Printed in Malaysia
1
2010
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Contents
List of Contributors
Foreword
Preface
Acknowledgements
1
2
ix
xi
xiii
xv
Introduction
Judi Edmans, Fiona Coupar and Adam Gordon
1
Definition of stroke
Impact of stroke
Symptoms of stroke
Causes of stroke
Classification of stroke
International Classification of Functioning, Disability
and Health
Medical investigations following stroke and TIA
The prevention of recurrence of stroke (secondary
prevention)
Neuroanatomy
Damage that can occur in different areas of the brain
Policy documents relating to stroke
Self-evaluation questions
1
1
2
3
4
4
6
7
9
13
13
23
Theoretical Basis
Janet Ivey and Melissa Mew
24
Introduction
Theoretical constructs
Conceptual models of practice
Frames of reference
Neuroplasticity
Intervention approaches
Self-evaluation questions
24
24
25
27
29
36
47
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Contents
3 The Occupational Therapy Process
Melissa Mew and Janet Ivey
Introduction
The occupational therapy process
Procedural reasoning in different stroke care settings
Professional duties
Self-evaluation questions
4 Early Management
Sue Winnall and Janet Ivey
49
49
49
53
60
63
64
Introduction
Prior to assessment
Initial interview
Initial assessment
Intervention
Equipment
Other impairments impacting on functional ability
Swallowing
Mood
Fatigue
Self-evaluation questions
64
64
66
67
75
75
77
80
81
83
84
5 Management of Motor Impairments
Stephanie Wolff, Thérèse Jackson and Louisa Reid
86
Introduction
Assessment
Management principles and intervention
Therapeutic aims of intervention
Positioning the early stroke patient
Clinical challenges
Upper limb re-education
Avoiding secondary complications
Self-evaluation questions
6 Management of Visual and Sensory Impairments
Melissa Mew and Sue Winnall
Introduction
Visual processing
Somatosensory processing
Auditory processing
Vestibular processing
Olfactory and gustatory processing
Self-evaluation questions
86
86
90
91
91
109
111
112
116
117
117
119
127
137
139
141
142
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Contents
7
8
9
10
vii
Management of Cognitive Impairments
Thérèse Jackson and Stephanie Wolff
144
Definition of cognition
Cognitive functions
Assessment of cognitive functions
Cognitive rehabilitation
Attention
Memory
Language
Motor planning and apraxia
Executive dysfunction
Self-evaluation questions
144
144
144
146
147
149
151
151
155
157
Management of Perceptual Impairments
Louisa Reid and Judi Edmans
158
Introduction
Definition of perception
Normal perception
Perceptual impairments
Perceptual assessment
Intervention
Self-evaluation questions
158
158
158
160
162
165
172
Resettlement
Pip Logan and Fiona Skelly
173
Home visits
Community rehabilitation
Support available after a stroke and self-management
Carers
Younger people
Lifestyle and long-term management
Leisure rehabilitation
Getting out of the house and transport
Driving after stroke
Vocational rehabilitation
Resuming sexual activity
Stroke education
Self-evaluation questions
173
174
177
178
180
180
181
183
185
186
188
189
190
Evaluation
Fiona Coupar and Judi Edmans
191
Record keeping
Standardised assessments
Evidence-based practice (EBP)
191
195
199
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Contents
Outcome measures
Standards
Self-evaluation questions
203
206
207
Appendix: One-Handed Techniques
References
Definitions
Useful Books
Useful Organisations
Index
208
212
229
231
233
241
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List of Contributors
Fiona Coupar, University of Glasgow, Glasgow
Dr Judi Edmans, University of Nottingham, Nottingham
Dr Adam Gordon, University of Nottingham, Nottingham
Janet Ivey, Llwynypia Hospital, RCT, Mid-Glamorgan, South Wales
Thérèse Jackson, NHS Grampian, Scotland
Dr Pip Logan, University of Nottingham, Nottingham
Melissa Mew, Bournemouth University, Bournemouth
Louisa Reid, National Hospital for Neurology and Neurosurgery, London
Fiona Skelly, Community Rehabilitation Team, Rotherham
Sue Winnall, Mile End Hospital, London
Stephanie Wolff, Manchester Royal Infirmary, Manchester
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Foreword
Occupational therapists working with people who have had a stroke will be delighted to
learn that there is a new edition of this popular textbook. The book has again been produced
on behalf of the College of Occupational Therapists Specialist Section Neurological
Practice, under the enthusiastic editorship of Dr Judi Edmans.
Since the last edition, the text has been substantially and comprehensively updated in
terms of the research evidence presented. It has also been placed in the context of national
developments and initiatives in stroke care to span the entire stroke spectrum – from
aetiology through to resettlement and evaluation. However, it still remains a practical
guide, written in user-friendly terms, which provides an excellent reference manual for
both those starting out in the stroke field and established practitioners.
The overall format and structure of the book is clear and logical. The addition of
good-quality illustrations brings the text to life, and many will find the self-evaluation
questions with each chapter useful. Special mention must go to Chapter 1 which provides
a comprehensive background to stroke and to Chapter 4 on early management.
Above all, the book underlines the important and unique role of occupational therapy
in the treatment and care of people with a stroke.
Dr Avril Drummond
Associate Professor in Rehabilitation
University of Nottingham
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Preface
This book is a timely update of the first edition of Occupational Therapy and Stroke
(Edmans et al., 2001). Although targeted for practice in the UK, the first edition sold over
5000 printed copies with countless hits from e-book access worldwide and has proven to
be a well-thumbed and well-known book for occupational therapists working in stroke all
over the world.
Since the last edition of the book, evidence-based quality stroke services have come to
the forefront of the government agenda throughout the UK with the release of national
stroke guidelines, stroke service strategies and initiatives such as the Stroke Research
Networks, the Stroke Association’s annual multidisciplinary UK Stroke Forum conference
and an imminent Stroke-Specific Educational Framework. It is an exciting time to work
in stroke services, and this book is intended to compliment these works to provide a
more in-depth, practical, evidence-based guide for occupational therapy students, newly
qualified occupational therapists, those new to stroke management and those who have
been working in stroke for some time wanting to refresh the foundations of their knowledge
and skills.
The reader will notice substantial changes since the last edition including use of the
International Classification of Functioning Disability and Health [World Health Organisation (WHO), 2002], orientation to updated policy documents (Chapter 1), standards and
audits (Chapter 10), neuroplasticity (Chapter 2), procedural reasoning in different stroke
care settings (Chapter 3) and more detailed user-friendly chapters on early management
and screening (Chapter 4), management of impairments (Chapters 5–8) and resettlement (Chapter 9). Therapeutic/clinical challenges have been integrated into appropriate
sections with self-evaluation questions to support therapists’ commitment to continuous
professional development at the end of each chapter.
Throughout this book, the client or service user is referred to as ‘the patient’, for
ease of terminology, irrespective of whether they are being treated in hospital or in the
community. This by no means undervalues occupational therapists, key principle of clientcentred practice to empower the patient to actively participate in partnership and negotiate
goals in the rehabilitation process (Sumsion, 2000). Similarly, treatments are referred to
as ‘interventions’, remedial approaches are referred to as ‘restorative’ approaches and
compensatory/functional approaches are referred to as ‘adaptive’ approaches.
Thanks are extended to everyone who has assisted in the production of this book.
Particular thanks go to Dr Judi Edmans, whose leadership and tireless efforts have kept
fellow contributors (from the 2009 stroke clinical forum committee members of the
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Preface
College of Occupational Therapists Specialist Section Neurological Practice and returning
authors Thérèse Jackson and Fiona Skelly) on target to reach tight deadlines.
Finally, the reader is reminded that the contents of this book should be reviewed
in light of new ideas, research evidence and practice as they emerge. Suggestions for
improvements to future editions would be gratefully received and should be forwarded
to Dr Judi Edmans, Division of Rehabilitation and Ageing, University of Nottingham
Medical School, Queens Medical Centre, Nottingham NG7 2UH.
Melissa Mew
Stroke Clinical Forum Secretary 2008–09
College of Occupational Therapists
Specialist Section Neurological Practice
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Acknowledgements
I would like to give particular thanks to Melissa Mew for her immense assistance in
editing the book; all the contributors for their contributions and editing suggestions; Dr
Iris Musa and Mary Warren for permitting us to include their figures in the book; the
College of Occupational Therapists Specialist Section Neurological Practice for funding
to enable us to update the book; and last but not least, my long-suffering husband, Mr
Paul Fowler, not only for acting as a model for the dressing photographs but also for his
endless support and patience during the time taken to update this book.
Dr Judi Edmans
Editor
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Chapter 1
Introduction
Judi Edmans, Fiona Coupar and Adam Gordon
This chapter includes:
r
r
r
r
r
r
r
r
Definition, impact, symptoms, causes, classification of stroke
International Classification of Functioning, Disability and Health (ICF)
Medical investigations
Secondary prevention
Neuroanatomy
Damage to different areas of brain
Policy documents: strategies and guidelines
Self-evaluation questions
Stroke is a complex condition where the knowledge base is continuously increasing. There
are constant advances in the understanding of the condition, assessment and intervention
techniques. Occupational therapists are a vital component in the rehabilitation of patients
with this condition. It is vital that they understand the condition itself and the theoretical
basis for intervention.
Definition of stroke
The World Health Organization (WHO) defines stroke as ‘a clinical syndrome, of presumed vascular origin, typified by rapidly developing signs of focal or global disturbance
of cerebral functions lasting more than 24 hours or leading to death’ (WHO, 1978).
Impact of stroke
Stroke is a major public health care concern and has a significant impact on individuals,
their families and wider society. Within the UK, an estimated 150,000 people have a stroke
each year (Office of National Statistics, 2001). Stroke is the third most common cause
of death, after heart disease and cancer, with over 67,000 deaths each year (British Heart
Foundation, 2005). However, the most significant and lasting impact of stroke is long-term
disability. Stroke is the single, greatest cause of complex and severe adult disability in
Occupational Therapy and Stroke, Second Edition Edited by Judi Edmans
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Occupational Therapy and Stroke
the UK (Wolfe, 2000; Adamson et al., 2004). A third of people who have a stroke will
have some long-term disability (National Audit Office (NAO), 2005). Common problems
following stroke include aphasia, physical disability, loss of cognitive and communication
skills, depression and other mental health problems.
In addition to the individual impact, stroke places a significant burden on health and
social services. In England alone, stroke costs the National Health Service (NHS) and
the economy about £7 billion a year: £2.8 billion in direct costs to the NHS, £2.4 billion
of informal care costs (e.g. the costs of home nursing borne by patients’ families) and
£1.8 billion in income lost to productivity and disability (NAO, 2005). Unfortunately,
outcomes in the UK compare poorly internationally, despite our services being among
the most expensive, with unnecessarily long lengths of stay and high levels of avoidable
disability and mortality (Leal et al., 2006).
Symptoms of stroke
The initial symptoms of stroke are (Warlow et al., 2008):
r
r
r
r
r
r
Sudden weakness or numbness of the face, arm or leg on one side of the body.
Sudden loss or blurring of vision in one or both eyes.
Sudden difficulty speaking or understanding spoken language.
Sudden confusion.
Sudden or severe headache with no apparent cause.
Dizziness, unsteadiness or a sudden fall, especially with any of the other signs.
However, there are more specific symptoms that will become apparent to the patient,
family, medical and rehabilitation staff over the following weeks, months and years. These
may include a variety of abnormalities, which will be described further in later chapters.
Face–Arm–Speech Test
The National Stroke Strategy for England (Department of Health (DH), 2007) highlighted
the need to improve public awareness of stroke and the recognition of signs of a stroke,
resulting in the ‘FAST’ acronym being developed by the Stroke Association in partnership
with other stroke organisations and experts.
The awareness campaign highlights that stroke is a medical emergency and time is
essential to protect the brain from excess damage. Therefore, it is essential for people to
recognise the symptoms of stroke and act ‘FAST’ when these are present. The ‘FAST’
acronym represents:
Facial weakness – Can the person smile? Has his or her mouth or eyes drooped?
Arm weakness – Can the person raise both arms?
Speech problems – Can the person speak clearly and understand what you say?
Time to call 999.
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Introduction
3
Anyone exhibiting any of these signs should be treated as an emergency with 999 being
called to get the patient to hospital as quickly as possible, to receive the treatment they
need.
FAST was around before the stroke strategy, although ‘T’ stood for ‘Test all three’
rather than ‘Time to call 999’ (Mohd Nor et al., 2004).
Causes of stroke
The main causes of stroke are as follows.
Ischaemia leading to infarction
This describes impairment of blood supply to part of the brain, resulting initially in
dysfunction and then tissue death (infarction). The causes of cerebral infarct are classified according to the TOAST (Trial of Org 10172 in Acute Stroke Treatment) (Adams
et al., 1993) classification as:
r Large artery occlusion (usually carotid or middle cerebral artery occluded by thrombus
or embolism).
r Cardioembolism (clot from the heart, most commonly the atrial appendages, migrating
to the cerebral arteries, causing blockage and stroke).
r Small vessel occlusion (thrombus or embolism in the smaller cerebral arteries, causing
a lacunar infarct).
r Other aetiologies (e.g. generalised brain underperfusion, causing infarcts in the watershed territories).
Haemorrhage
This is usually intracerebral haemorrhage (i.e. within the body of the brain) but can be
subarachnoid haemorrhage (i.e. between the arachnoid mater and the brain).
Intracerebral haemorrhages are commonly caused by hypertension-related changes
in the small intracerebral arteries but can, less commonly, be caused by aneurysms (outpouchings of the arterial wall) or arteriovenous malformations (abnormal communications
between arteries and veins).
Transient ischaemic attack
Transient ischaemic attack (TIA) is a term used to describe symptoms of stroke, resolving
within 24 hours. This does not represent a completed stroke but is, instead, caused
by transient impairment of tissue blood supply (ischaemia) with subsequent resolution.
These patients are at high risk of proceeding to completed stroke and should be seen by a
physician as an emergency, ideally within 24 hours of presentation (Intercollegiate Stroke
Working Party (ISWP), 2008).
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Occupational Therapy and Stroke
Classification of stroke
Bamford et al. (1991) described a classification of cerebral infarction to help clinicians
identify the part of the brain affected. This classification is based on the signs and
symptoms that patients experience and is now widely used. It is useful because it correlates
to prognosis. Thus, based on a bedside examination, a clinician can make predictions
about survival and long-term dependency in order to inform management decisions and
discussions with patients/relatives.
The Bamford (or Oxford) classification is as follows:
Total anterior circulation stroke (TACS)
All of the following:
– Motor/sensory deficit affecting greater than two-thirds of face/arm/leg.
– Homonymous hemianopia.
– New disturbance of higher cortical function.
Partial anterior circulation stroke (PACS)
– Any two of the components of a TACS.
– Or isolated disturbance of higher cortical function.
– Or limited motor/sensory dysfunction (affecting a single limb or the face alone).
Posterior circulation infarction (POCI)
Any of:
– Cranial nerve palsy and contralateral motor/sensory deficit.
– Bilateral motor/sensory deficit.
– Conjugate eye movement problems.
– Cerebellar dysfunction.
– Isolated homonymous hemianopia.
Lacunar infarction (LACI)
Greater than two-thirds of arm/face/leg affected by:
– Pure motor stroke.
– Or pure sensory stroke.
– Or pure sensorimotor stroke.
– Or ataxic hemiparesis.
Disorders of higher cortical dysfunction commonly include aphasia, decreased level of
consciousness, neglect syndromes, apraxia and agnosia syndromes.
International Classification of Functioning,
Disability and Health
The International Classification of Functioning, Disability and Health (ICF) (WHO, 2002)
was produced by the WHO to replace the International Classification of Impairments,
Disabilities and Handicaps. The ICF is not used exclusively in stroke; however, stroke
patients often present with complex impairments which are a challenge for rehabilitation
teams. The ICF provides a means of understanding and describing health status. It takes
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Introduction
5
Publisher's Note:
Image not available
in the electronic edition
Figure 1.1 Model of disability that is the basis for ICF. (Reproduced by permission from
WHO, 2001, with permission of World Health Organisation, p. 9.)
account of impairments of body structure and function and how these interact with
personal and environmental factors to affect patient’s activities and participation in the
wider world. Figure 1.1 illustrates the interactions between different aspects of the ICF.
The domains of the ICF are as follows:
Body functions: physiological functions of body systems (including psychological
functions), for example, mental, neuromusculoskeletal and movement-related functions
Body structures: anatomical parts of the body such as organs, limbs and their components, for example, nervous system structures and structures related to movements
Impairments (of body function and structure): abnormal body functions and structures
such as a significant deviation or loss, for example, hemiparesis following stroke
Activity: execution of a task or action by an individual, for example, dressing
Activity limitations: difficulties an individual may have in executing activities, for
example being unable to dress due to hemiplegia
Participation: involvement in a life situation, for example, attending a social gathering
Participation restrictions: problems an individual may experience in involvement in
life situations due to the activity limitation, for example, being unable to visit family
and friends due to difficulty dressing
Environmental factors: physical, social and attitudinal environment in which people
live and conduct their lives, for example, legal and social structures, architectural
characteristics, coping styles, social background and experiences
Personal factors: factors unique to the patient, which impact upon their health status,
for example, personality and attitudes.
In ICF the term functioning refers to all body functions, activities and participation,
while disability is similarly an umbrella term for impairments, activity limitation and
participation restrictions.
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Occupational Therapy and Stroke
Medical investigations following stroke and TIA
Medical investigations following stroke and TIA are performed to:
r
r
r
r
Confirm the diagnosis of stroke.
Determine the site and type of stroke.
Establish the cause(s) of the stroke.
Guide treatment to prevent further strokes.
Computerised tomography or magnetic resonance imaging
Imaging (either computerised tomography (CT) or magnetic resonance imaging (MRI))
helps to establish the pathological diagnosis by detecting either cerebral infarction or
haemorrhage. The distinction between haemorrhage and infarction is important as treatment with aspirin or anticoagulants is likely to be indicated for cerebral infarction but
would be contraindicated in cerebral haemorrhage. A CT scan should therefore be performed on all patients within 24 hours of a stroke (ISWP, 2008).
It is also useful for excluding other intracranial pathologies that mimic stroke, for
example, tumours or subdural haematomas. Practice varies with regard to routine scanning
of TIAs; it is, however, increasingly common for physicians to perform a CT scan on
these patients, particularly if there is some concern that the history is long, or atypical.
Modern CT scanners can detect abnormalities within a few hours of a large artery stroke;
however, smaller infarcts can be difficult to detect if scanned early. Another difficulty can
arise when identifying a new acute lesion in a patient with multiple pre-existing strokes.
MRI scanning is more sensitive and specific for diagnosis of stroke than routine CT
and can be used in this context. Diffusion-weighted MRI, in particular, can be used to
separate acute ischaemic strokes – which show up as ‘hot spots’ on this type of image –
from previous cerebral infarcts. MRI is also more useful at imaging the brainstem and
cerebellum because these parts of the brain are surrounded by dense bony structures,
which generate artefacts on CT scanning.
Blood tests
On presentation, a number of blood tests may be completed for a variety of reasons,
including detection of a number of different conditions. Commonly completed blood tests
include the following:
Full blood count: To look for rare conditions which predispose to stroke such as
polycythaemia (increased red cells) and thrombocytosis (increased platelets) and
conditions that predispose to haemorrhage, such as thrombocytopaenia (decreased
platelets).
To exclude leucocytosis (raised white cell count) which might indicate systemic
infection (e.g. aspiration pneumonia) or intracerebral infection mimicking stroke
(e.g. encephalitis, cerebral abscess).
Erythrocyte sedimentation rate (ESR): If this is elevated, it suggests infection, vasculitis or carcinoma and may prompt further investigation.
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Blood sugar: Hypoglycaemia at presentation is a recognised stroke mimic, whilst
diabetes mellitus is a risk factor for stroke. Therefore, all patients should receive a
bedside finger-prick glucose test and formal laboratory glucose level.
Fasting lipids: Hyperlipidaemia is a recognised risk factor for stroke and lipids should
be checked in all patients.
Clotting screen: Coagulation tests are necessary in patients with haemorrhagic stroke.
An international normalised ratio (INR) should be checked urgently in any patient
who has a stroke whilst on warfarin.
Thrombophilia screen: Patients presenting with venous sinus thrombosis should be
checked for an inherited tendency towards clot formation (factor V Leiden, protein C
deficiency, protein S deficiency, lupus anticoagulant). This should only be considered
in arterial thrombosis for younger patients where no alternative risk factor for stroke
is identified (Hankey et al., 2001).
Cardiac investigations
There is a cardiac source of embolism in 20% of cases of cerebral infarction (Sandercock
et al., 1989). Electrocardiogram should therefore be performed in all patients to investigate
atrial fibrillation or evidence of structural heart disease.
Echocardiogram is performed in patients where intracardiac thrombus or structural
heart disease, particularly valvular disease, is suspected. In many centres, it is routine to
do echocardiograms in all patients presenting with atrial fibrillation.
Carotid ultrasound
This is performed to look for internal carotid artery stenosis. The technique involves
imaging of the artery with measurement of blood flow velocity, which allows an estimation
of the degree of vessel stenosis to be made.
Magnetic resonance angiography
This is now used widely in clinical practice. Images can be obtained at the same time as
standard and diffusion-weighted MRI, making the investigation only marginally longer.
It is non-invasive and is therefore preferred to catheter digital subtraction angiography in
most instances.
This procedure is completed to allow 3D reconstructions of the arterial and venous cerebral circulations, which can allow identification of thrombus, arterial stenosis/occlusion
and dissection.
The prevention of recurrence of stroke
(secondary prevention)
Following stroke, many strategies are used to help prevent recurrence. General measures
are recommended in all patients, such as reducing body mass index, adopting a diet low
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in salt and saturated fat, stopping smoking and taking regular exercise. These measures,
particularly smoking cessation, can be highly effective in reducing stroke risk, even in the
absence of medications.
Antiplatelet agents
Based upon current clinical trial evidence, aspirin prescribed after acute stroke will prevent
about 11 strokes for every 1000 patients treated (Chinese Acute Stroke Trial (CAST)
Collaborative Group, 1997; International Stroke Trialists (IST), 1997). The optimal dosage
appears to be between 50 and 150 mg, with higher doses increasing risk of gastrointestinal
bleeding in the longer term without further effect on stroke incidence (Sandercock et al.,
2008). Higher doses are used to reduce stroke risk during the first 2 weeks.
Dipyridamole (Persantin), when used in combination with aspirin, reduces relative
risk of stroke compared with aspirin alone (Halkes et al., 2008). Current recommended
practice in the UK is to prescribe patients 300 mg of aspirin daily for the first 2 weeks
following an ischaemic stroke, with aspirin 75 mg used in conjunction with dipyridamole
following this (ISWP, 2008).
Clopidogrel is an alternative antiplatelet agent, used in combination with aspirin following acute coronary syndromes. This combination, if used following stroke, increases the
risk of cerebral haemorrhage and so tends to be avoided (Diener et al., 2004; Bhatt et al.,
2006). Clopidogrel, used as a single agent, probably conveys some advantage over aspirin
(CAPRIE Steering Committee, 1996) but debate remains as to its cost-effectiveness. In
many areas this treatment is therefore reserved for patients where aspirin cannot be given
due to intolerance.
Blood pressure
Hypertension should be aggressively treated following a stroke. The target blood pressure
following a stroke is 130/80 (ISWP, 2008). Current evidence favours prescription of thiazide diuretics and angiotensin-converting enzyme (ACE) inhibitors over other types of
antihypertensives (PROGRESS Collaborative Group, 2001). Angiotensin receptor blockers (ARBs) are used where ACE inhibitors cannot be tolerated due to cough.
Hyperlipidaemia
There is now good evidence that medications to reduce serum low-density lipoprotein
cholesterol reduce the incidence of stroke (Smilde et al., 2001; Kastelein et al., 2008).
Current data suggest that statin drugs (simvastatin, atorvastatin, rosuvastatin) promote
regression of cholesterol plaques in the carotid arteries (Smilde et al., 2001).
Anticoagulants
Clinical trials have demonstrated the benefit of warfarin in the prevention of stroke in
patients with atrial fibrillation (Mant et al., 2007).
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Introduction
9
There is a risk of haemorrhage for patients taking warfarin, and a careful consideration
of the balance of risks and benefits must be undertaken in any patient where it is to be
commenced. Contraindications include a bleeding tendency (e.g. recent peptic ulceration
or haemorrhagic bladder tumour), high falls risk, alcohol dependency (alcohol interacts
with warfarin) and an inability to follow instructions to take the medicine safely (which
may be the case in cognitive impairment).
Where a patient is not suitable for warfarin, aspirin is used as an alternative. It is,
however, very much inferior to warfarin for stroke prevention in this context.
Carotid endarterectomy
Trials have shown that this operation to widen the internal carotid artery is beneficial
in preventing stroke in symptomatic patients with recent TIA or stroke (Barnett et al.,
1998). It is only recommended for patients with a stenosis of greater than 70% and should
be limited to patients with reasonable functional status and salvageable brain tissue in
the vascular territory under consideration. Therefore, bed-bound patients with large total
anterior circulation strokes are not appropriate for this therapy.
Preventative neurosurgery
Patients who have suffered from haemorrhagic stroke (primary intracerebral haemorrhage,
subarachnoid haemorrhage) and who have an underlying arterial abnormality, such as an
aneurysm or arteriovenous malformation, may benefit from neurosurgical techniques such
as aneurysm clipping or embolisation of arteriovenous malformations.
Neuroanatomy
The brain is divided into four main areas:
r Forebrain
– Cerebrum divides into two hemispheres with four lobes (frontal, parietal, temporal
and occipital lobes) (Figure 1.2).
– Internal capsule (Figure 1.3).
– Basal ganglia (caudate nucleus, globus pallidus and putamen) (Figure 1.4).
– Diencephalon (thalamus and hypothalamus) (Figure 1.3).
r Midbrain (brainstem) (Figure 1.3)
– Mesencephalon (midbrain).
– Pons.
– Medulla oblongata.
r Hindbrain
– Cerebellum (Figure 1.2).
r Spinal medulla (spinal cord) (Figure 1.3)
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Precentral
gyrus
Central
sulcus
Postcentral
gyrus
Parietal lobe
Frontal lobe
Occipital
lobe
Lateral
sulcus
Cerebellum
Temporal lobe
Pons
Medulla oblongata
Figure 1.2 Lateral view of the brain. (Reproduced by permission of Pearson Education Inc
from Martini, 2006, Figure 14-12b, p. 471.)
Left cerebral
hemisphere
Cerebrum
Gyri
• Conscious thought processes,
intellectual functions
• Memory storage and processing
• Conscious and subconscious regulation
of skeletal muscle contractions
Sulci
Fissures
Diencephalon
Thalamus
• Relay and processing
centres for sensory
and motor information
Hypothalamus
• Centres controlling
emotions, autonomic
functions and
hormone production
Cerebellum
Brainstem
Mesencephalon
Spinal
cord
• Processing of visual
and auditory data
• Generation of reflexive
somatic motor
responses
• Maintenance of
consciousness
• Coordinates complex
somatic motor
patterns
• Adjusts output of
other somatic motor
centres in brain
and spinal cord
Pons
• Relays sensory
information to
cerebellum and
thalamus
• Subconscious
somatic and visceral
motor centres
Medulla oblongata
• Relays sensory information to thalamus
and to other portions of the brain stem
• Autonomic centres for regulation of visceral
function (cardiovascular, respiratory and
digestive system activities)
Figure 1.3 The diencephalon and brainstem structures of the brain. (Reproduced by
permission of Pearson Education Inc from Martini, 2006, Figure 14-1, p. 453.)
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Introduction
Head of
caudate nucleus
11
Lentiform nucleus
Tail of caudate
nucleus
Thalamus
Amygdaloid body
(a)
Head of
caudate nucleus
Lateral
ventricle
Corpus
callosum
Internal
capsule
Insula
Amygdaloid
body
Putamen
Lentiform
nucleus
Globus pallidus
Tip of lateral
Anterior
commissure ventricle
(b) Frontal section
Figure 1.4 Frontal section of the brain showing the basal nuclei, internal capsule and
thalamus. (Reproduced by permission of Pearson Education Inc from Martini, 2006,
Figure 14-14a,b, p. 473.)
The arterial supply to the brain (Figures 1.5 and 1.6) is from:
r The anterior circulation comprising two internal carotid arteries which divide into two
major arteries:
– Anterior cerebral artery.
– Middle cerebral artery.
r The posterior circulation comprising two vertebral arteries which lead to:
– Posterior inferior cerebellar artery.
– Basilar artery.
– Posterior cerebral artery.
The anterior circulation can also be divided into right and left circulations, as there
is a carotid artery on each side. Because the vertebral arteries join quite low down the
brainstem, most of the posterior circulation is supplied by a single basilar artery.
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Anterior cerebral
Anterior communicating
Anterior cerebral
Internal carotid (cut)
Posterior communicating
Cerebral
arterial
circle
Posterior cerebral
Middle cerebral
Pituitary gland
Superior cerebellar
Basilar
Anterior inferior cerebellar
Vertebral
Posterior inferior cerebellar
Figure 1.5 Arteries of the brain. (Reproduced by permission of Pearson Education Inc from
Martini, 2006, Figure 21.23, p. 741.)
Territory of
anterior
cerebral artery
Territory of
middle
cerebral artery
Internal capsule
Claustrum
Body of caudate
Thalamus
Putamen
Globus pallidus
Red nucleus
Subthalamic nucleus
Territory of
posterior
cerebral artery
Cerebral peduncle
Territory of anterior choroidal
artery (lower 2/3 of internal
capsule, pallidum, uncus, amygdala,
anterior hippocampus)
Uncus
Territory of penetrating branches
of middle cerebral artery (putamen,
upper internal capsule, lower corona
radiata, body of caudate)
Figure 1.6 Frontal section of the left hemisphere showing the arterial supply. (Reproduced by
permission of McGraw-Hill from Kandel et al., 2000, Figure C-2, p. 1304.)
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13
If each of these circulations existed in isolation, then blockage of either carotid or the
basilar artery would result in extensive, life-threatening infarction. This does not occur,
however, because of anterior and posterior communicating arteries which connect the
brain arteries into an anatomical circle, known as the circle of Willis. Thus when one
vessel is blocked, an alternative (or collateral) blood supply is available.
There is considerable variation between individuals with regard to how effective their
communicating arteries are, and thus collateral circulation, is. Thus carotid, or basilar,
occlusion can result in life-threatening stroke for some individuals and will pass unnoticed
by others. In reality, most patients exist on a spectrum somewhere between these extremes.
This explains why a given vascular abnormality, for example, carotid occlusion, will result
in different severities of stroke in different patients.
Damage that can occur in different areas of the brain
Each hemisphere has specialised functions known as hemispheric lateralisation. For example, the left hemisphere senses and controls movement on the right side of the body
and specialises in language-based skills such as reading, writing and speaking, and performs analytical tasks such as mathematics and logical reasoning. Oppositely, the right
hemisphere senses and controls movements on the left side of the body and is specialised
in more creative, spatial and interpretive skills (Figure 1.7).
Testani-Dufour and Morrison (1997) summarised the arterial supply of the brain and the
results of occlusion to those arteries. They also summarised the functions of the different
areas of the brain and the impairments that can occur as a result of damage (occlusion) to
those areas. This information is collated in Tables 1.1–1.3, but should not be considered
as a definitive list.
Policy documents relating to stroke
Over the past 10 years, stroke has become an increasing priority for UK health system
(Scottish Government, 2002; DH, 2007). This has led to a number of policy documents
being published, all of which aim to reduce stroke incidence, improve services and increase
awareness.
The first notable policy document related specifically to stroke was published by the
DH in 2001.
National Services Framework for older people
The National Services Framework (NSF) for older people (DH, 2001) is a comprehensive
strategy to ensure fair, high-quality, integrated health and social care services for older
people. It is a 10-year programme of action linking services to support independence and
promote good health, specialised services for key conditions and a culture change so that
all older people and their carers are treated with respect, dignity and fairness. This NSF
sets eight standards for the care of older people across health and social services.
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Left Hand
Right Hand
Prefrontal
cortex
Prefrontal
cortex
Speech
centre
Anterior
commissure
Writing
Analysis
by touch
Auditory
cortex
(right ear)
Auditory
cortex
(left ear)
General
interpretive
centre
(language and
mathematical
calculation)
Spatial
visualisation
and analysis
Visual cortex
(right visual field)
Visual cortex
(left visual field)
Left
Hemisphere
Right
Hemisphere
Figure 1.7 Hemispheric lateralisation of the brain. (Reproduced by permission of Pearson
Education Inc from Martini, 2006, Figure 14-6, p. 477.)
Standard five of the NSF is specific to stroke and aims to reduce the incidence of
stroke in the population and ensure that those who have had stroke have prompt access to
integrated stroke care services. This standard sets out four components for the development
of integrated stroke services:
r Prevention, including the identification, treatment and follow-up of those at risk of
stroke.
r Immediate care, including care from a specialist stroke team.
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15
Table 1.1 Areas of the brain and the results of occlusion to arteries in those areas.
Functions
Frontal lobe
• Concentration
• Abstract thought
• Memory
• Judgement
• Ethics
• Insight
• Emotion
• Tact
• Inhibition
• Sequencing thoughts
• Evaluates consequences of actions
• Solves intellectual problems
• Morality
• Motor function
Broca’s area
• Expression of speech
• Word formation
• Articulation
• Pronunciation
• Voice and speech production
Parietal lobe
• Interpretation of sensory input
• Contralateral sensation
– Two-point discrimination
– Pressure
– Weight
– Texture
– Body interpretation
– Orientation
– Pain
– Proprioception
• Recognises nature of complex
objects by touch and form
Impairments
Impairments Anterior Cerebral Artery and
Middle Cerebral Artery
• Memory
• Abstract thinking
• Judgement
• Ethical behaviour
• Emotions
• Insight
• Tact
• Inhibition
• Movement problems, trunk, limbs, eyes
• Non-fluent aphasia
• Oral apraxia
• Sensory impairments
• Unilateral neglect
Temporal lobe
• Auditory area
• Wernicke’s area:
– Receive and discriminate sounds
– Interpretation of sounds
• Olfactory area
• Detailed memories, especially those
involving more than one sensory
modalities (dominant side)
Impairments Middle Cerebral Artery and
Posterior Cerebral Artery
• Wernicke’s aphasia
• Comprehension
• Repetition of speech
• Jargon
• Reading comprehension
Occipital lobe
• Visual reception
• Visual association
• Detects spatial organisation of
vision, shapes, colours, contrasts
• Secondary complex visual
interpretation
• Visual and interpretative disorders
• Contralateral field disorders, e.g.
quadrantanopia/hemianopia
• Partial visual field loss
• Altered perception
(Continued)
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Table 1.1 (Continued )
Functions
Impairments
• Perception of form and meaning
• Eye fixation
Thalamus
• Sensory and motor pathways
contact thalamus except olfactory
pathways
Basal ganglia
• Production of dopamine
• Coordination of muscle movements
and posture
Midbrain
• Synthesises dopamine
• Protects basal ganglia
Pons
• Transmits information from cerebral
cortex to brainstem and between
two hemispheres
• Sensory pathways pass through
pons
• Regulates respiratory system
Medulla
• Blood pressure and respiratory
regulation
• Maintenance of arousal
• Initiation of sleep
•
•
•
•
Contralateral hemiplegia
Contralateral hemisensory impairments
Vertical and lateral gaze
Central post-stroke pain
• Movements and posture disorders, such as:
– Tremor
– Rigidity
– Chorea
– Athetosis
– Dystonia
– Hemiballismus
• Motor visual problems
• Parkinsonism
• Auditory and visual reflexes interrupted
•
•
•
•
Sensory and motor problems
Altered mastication and facial sensations
Altered eye movement and eyelid closure
Altered taste, facial expression, salivation,
equilibrium and hearing
• Respiratory insufficiency
• Persistent vegetative state
• Contralateral sensory and motor
impairments
• Altered postural sense, proprioception,
vibration
• Respiratory insufficiency
• Cardiac/vasomotor dysfunction
• Swallowing
• Head and shoulder movement
• Tongue movement
• Salivation and pharyngeal function
Cerebellum
•
•
•
•
Receives proprioceptive input
Maintains equilibrium
Coordinates automatic movement
Regulates muscle tone
•
•
•
•
•
•
•
Poor coordination and fine dexterity
Gait ataxia
Intention tremor
Diadochokinesia
Dysmetria
Hypotonia
Asthenia
ACA, anterior cerebral artery; MCA, middle cerebral artery; PCA, posterior cerebral artery.
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Table 1.2 Anterior arterial supply of the brain and the results of occlusion to those arteries.
Supplies
Occlusion
Ophthalmic artery
• Orbit
• Optic nerve
• Transient mononuclear blindness (amaurosis fugax)
• Complete unilateral blindness
Anterior choroidal artery
• Deep structures of the brain
(basal ganglia, thalamus,
posterior limb of internal
capsule and medial
temporal lobe)
Anterior cerebral artery
• Anterior three-quarters of
medial surface of cerebral
hemisphere
• Portions of the basal ganglia
• Internal capsule
Middle cerebral artery
• Basal ganglia
• Fibres of internal capsule
• Cortical surfaces of the
parietal, temporal and
frontal lobes
• Contralateral hemiplegia, hemihypesthesia,
homonymous hemianopia
• Contralateral sensory and motor impairments foot
and leg greater than arm
• Face and hand not usually involved
• Incontinence
• Deviation of eyes and head towards lesion
• Contralateral grasp reflex
• Abulic symptoms (apathy, decreased spontaneity,
limited speech)
Left Anterior Cerebral Artery
• Arm apraxia
• Expressive aphasia
Distal Anterior Cerebral Artery
• Contralateral upper and lower extremity weakness
• Contralateral sensory loss in foot
• Motor and/or sensory aphasia
Complete occlusion
• Contralateral gaze palsy
• Hemiplegia
• Hemisensory loss
• Spatial neglect
• Homonymous hemianopia
• Global aphasia (with left hemisphere lesions)
Occlusion superior trunk of Middle Cerebral Artery
• Contralateral hemiplegia
• Hemianaesthesia in face and arm greater than leg
• Ipsilateral deviation of eyes and head
• Broca’s aphasia (with dominant hemisphere lesion)
Occlusion inferior trunk of Middle Cerebral Artery
• Contralateral hemianopia or upper quadrantopia
• Wernicke’s aphasia (usually with left-sided lesions)
• Left visual neglect (usually with right-sided lesions)
• Motor or sensory impairment usually absent
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Table 1.3 Posterior arterial supply of the brain and the results of occlusion to those arteries.
Supplies
Vertebral artery
• Anterolateral parts of the medulla
Posterior–inferior cerebellar artery
• Medulla
• Cerebellum
Basilar artery
• Pons
• Midbrain
Occlusion
Lateral medullary syndrome
• Contralateral impairment pain and
temperature sensation
• Ipsilateral Horner’s syndrome
• Dysphagia
• Decreased gag reflex
• Vertigo
• Nystagmus
• Ataxia
Occlusion medial branch
• Vertigo
• Nystagmus
• Ataxia
• Persistent dizziness
Occlusion lateral branch
• Unilateral clumsiness
• Gait and limb ataxia
• Inability to stand or sudden fall often
• Vertigo
• Dysarthria
• Nystagmus
• Eye deviation
• Limb paralysis
• Bulbar or pseudobulbar paralysis of the
cranial nerve motor nuclei
• Nystagmus
• Eye movement disturbance
• Coma
Complete occlusion
• Locked in syndrome
• Consciousness with complete motor
paralysis, inability to communicate orally or by
gesture
Posterior choroidal artery
• Third ventricle
• Dorsal surface of thalamus
• Not seen
Posterior cerebral artery
• Occipital lobe
• Medial and inferior surface of
temporal lobe
• Midbrain
• Third and lateral ventricles
•
•
•
•
Contralateral hemiplegia
Sensory loss
Ipsilateral visual field impairments
Weakness greater in face and upper
extremities
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Introduction
19
Table 1.3 (Continued )
Supplies
Anterior inferior cerebellar artery
• Cerebellum
• Pons
Superior cerebellar artery
• Cerebellum upper part
• Midbrain
Occlusion
•
•
•
•
•
•
•
•
Vertigo
Nausea
Vomiting
Nystagmus
Tinnitis
Ipsilateral cerebellar ataxia
Horner’s syndrome
Contralateral loss of pain and temperature
sense of arm, trunk and leg
•
•
•
•
•
Ipsilateral cerebellar ataxia
Nausea
Vomiting
Slurred speech
Contralateral loss of pain and thermal sensation
r Early and continuing rehabilitation.
r Long-term support for the stroke patient and their carers.
Stroke strategies
Since the publication of the NSF for older people, specific stroke strategies have been
developed in Scotland 2002/4, England 2007, Wales 2007 and Northern Ireland 2008.
Scotland
The Coronary Heart Disease and Stroke: Strategy for Scotland was published by the
Scottish Government in 2002 and subsequently updated in 2004 (Scottish Government,
2004). This strategy covered:
r
r
r
r
Prevention.
Managed clinical networks (MCNs).
Workforce issues.
Information technology and the development and use of databases.
In relation to stroke care, the main targets included:
r
r
r
r
r
r
Establishing MCNs.
Stroke units.
More rapid imaging.
Manpower plan and training.
National audit.
Improved IT.
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In 2009 a revised action plan was launched for Scotland (Scottish Government, 2009).
It continued to promote the targets set out in the first action plan and subsequent revision,
and developed new targets around:
r Services for stroke
– Public awareness of stroke – FAST campaign.
– Thrombolysis.
– Younger people and stroke – including vocational rehabilitation.
– Early supported discharge.
– Rehabilitation and recovery.
– Stroke Training and Awareness Resources (STARs).
r Improving the quality of care and support
– Information and communication.
– Self-management.
England
The National Stroke Strategy for England published in 2007 is a comprehensive strategy
which summarised a 10 point plan for action (DH, 2007):
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Awareness of stroke.
Preventing stroke.
Involvement of patients.
Acting on the warnings.
Stroke as a medical emergency.
Stroke unit quality.
Rehabilitation and community support.
Participation.
Workforce.
Service improvement.
Quality service markers were put in place to monitor the compliance with the strategy
regarding:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Awareness raising.
Managing risk.
Information, advice and support.
Involving individuals in developing services.
Assessment – referral to specialist.
Treatment for TIA or minor stroke.
Urgent response.
Assessment – immediate structured clinical assessment.
Treatment on a stroke unit.
High-quality specialist rehabilitation.
End-of-life care.
Seamless transfer of care.
Long-term care and support.
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14.
15.
16.
17.
18.
19.
20.
21
Assessment and review after discharge.
Participation in community life.
Return to work.
Networks.
Leadership and skills.
Workforce review and development.
Research and audit.
Wales
The Welsh health circular Improving Stroke Services: A Programme of Work (Welsh
Assembly Government, 2007) summarises the programme of stroke improvements for
Wales in the following three areas:
Preventing strokes
r Public information leaflets.
r Public and health professional education programmes.
r Identification of gaps in local and national resources.
r Referrals to lifestyle initiatives.
r Referral of TIA patients to a one-stop assessment and investigation service.
Improving stroke survival rates
r Commissioning specification for stroke services.
r Action plans to implement the older people’s NSF stroke standards of care.
r Evidence for stroke as a 999 call.
r Protocols and quality requirements.
r Profession-specific audits.
r Introduction or expansion of specialist and consultant staff.
r Dedicated and colocated acute stroke beds.
r Referral to palliative care and end-of-life care, where appropriate.
r Establishment of research programmes for stroke.
Maximising post-stroke-independent living and quality of life
r Development of protocols and quality requirements for rehabilitation assessments
and interventions.
Northern Ireland
In July 2008 revised recommendations for the Northern Ireland stroke strategy were
published in Improving Stroke Services in Northern Ireland (Department of Health, Social
Services and Public Safety, 2008) to make improvements in the key areas of prevention,
treatment and rehabilitation of stroke patients in a modern health service setting. This
document sets out seven standards:
1.
2.
3.
4.
Organisation of stroke services.
Acute stroke care and hospital-based rehabilitation.
Secondary prevention.
Discharge planning.
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5. Community-based care.
6. Palliative care.
7. Communication with patients and carers.
Guidelines
The College of Occupational Therapists (2000a) definition is that:
clinical guidelines outline the nature and level of intervention that is considered best practice,
for specific conditions in specific populations. They are systematically developed statements
which assist clinicians (including Occupational Therapists) and service users in making decisions about appropriate health and social interventions for a specific condition or population.
They are sets of recommendations which are based upon the best available evidence.
That is, guidelines are recommendations based on evidence.
The following evidence-based guidelines have been developed specifically for stroke.
Scotland
Evidence-based guidelines for the care of patients following stroke in Scotland (Scottish
Intercollegiate Guidelines Network, 2002) were developed with sections on:
1.
2.
3.
4.
5.
6.
Organisation of services.
General rehabilitation principles.
Specific management and prevention strategies.
Discharge planning and transfer of care.
Roles of the multidisciplinary team.
Patient issues.
These are currently being updated, with the revised edition expected by late 2010.
The Scottish Intercollegiate Guidelines Network (2008) also published guidelines on
the Management of Patients with Stroke or TIA: Assessment, Investigation, Immediate
Management and Secondary Prevention, which include sections on:
r
r
r
r
r
r
r
r
r
r
Management of suspected stroke or TIA.
Assessment, diagnosis and investigation.
Treatment of ischaemic stroke.
Treatment of primary intracerebral haemorrhage.
Other causes of stroke.
Physiological monitoring and intervention.
Preventing recurrent stroke in patients.
Carotid intervention.
Promoting lifestyle changes.
Provision of information.
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23
England, Wales and Northern Ireland
The Intercollegiate Stroke Working Party of the Royal College of Physicians, London,
published evidence-based guidelines for the care of patients following stroke in England,
Wales and Northern Ireland (ISWP, 2008). The guidelines include sections on:
r
r
r
r
r
r
r
Commissioning.
Systems underlying stroke management.
Acute-phase care.
Secondary prevention.
Recovery phase from impairments and limited activities: rehabilitation.
Long-term management, after recovery.
Profession-specific concise guidelines.
Each section contains many guidelines using the general structure of introduction,
recommendations, evidence and implications of the guideline. Tables of evidence are also
included.
Self-evaluation questions
1.
2.
3.
4.
5.
6.
7.
8.
9.
What is the impact of stroke in the UK?
What are the main symptoms of stroke?
What are the main causes of stroke?
What are the main stroke classifications?
What does the ‘FAST’ acronym stand for?
What medical tests/investigations are common following stroke?
What secondary prevention could be used?
What are the main arteries in the brain?
What specific impairments are associated with injury to the frontal, parietal and
temporal lobes?
10. What are the key elements of the national stroke strategies?
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Chapter 2
Theoretical Basis
Janet Ivey and Melissa Mew
This chapter includes:
r
r
r
r
r
r
Theoretical constructs
Conceptual models of practice
Frames of reference
Neuroplasticity
Intervention approaches
Self-evaluation questions
Introduction
Occupational therapy’s principle concern is with the patient’s occupational identity and
occupational performance. In other words, ‘how individual’s identify themselves and their
future aspirations, their roles and relationships, together with their personal capacity for
fulfilling these within their physical and social environment’ (Duncan, 2006: p. 6). Engagement in occupations, functional occupational performance and positive occupational
identity are required to achieve health, well-being and life satisfaction.
Following stroke, patients may be faced with occupational dysfunction. Occupational
performance capacity may become impaired, impacting on their physical, cognitive and
psychosocial capacity to adapt to effectively meet the demands of and engage in their
usual occupations, thus impinging on their occupational identity, health and well-being.
The role of the occupational therapist is to enable patients to regain competence, reengage in occupations and redevelop a positive occupational identity (Duncan, 2006;
Townsend and Polatajko, 2007).
This chapter focuses on a selection of theoretical constructs (models of practice and
frames of reference) that are used to direct occupational therapy intervention approaches
and enable patients.
Theoretical constructs
Theoretical constructs, such as Conceptual Models of Practice and Frames of Reference,
help to describe and explain occupational function, guide assessments and interventions
Occupational Therapy and Stroke, Second Edition Edited by Judi Edmans
© 2010 Blackwell Publishing Ltd. ISBN: 978-1-405-19266-8
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Theoretical Basis
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and predict outcomes. They also help to define our own professional identity. At times the
difference between Frames of Reference and Models can be confusing but for arguments
sake, Duncan’s (2006) delineations will be used where a Conceptual Model of Practice
is ‘an occupation-focussed theoretical construct or proposition that has been developed
specifically to explain the process and practice of occupational therapy’ (Duncan, 2006:
p. 62). Whereas a Frame of Reference is defined as ‘a theoretical or conceptual idea
that has been developed outside the profession but, with judicious use, is applicable
within occupational therapy (to guide and structure) practice’ (Duncan, 2006: p. 62).
Thus, occupational therapists may have a preference for adhering to a particular model of
practice to help maintain their professional identity. Applied to any occupational model
of practice, occupational therapists will use their core skills or ‘legitimate tools’ to enable
therapeutic change. The core skills of occupational therapy include: therapeutic use of self
to collaborate with the patient; skilled clinical observations; process skills of assessment,
planning and implementing intervention to enable change and evaluation; purposeful use
of activity as a therapeutic tool; occupational analysis and adaptation; environmental
analysis and adaptation; therapeutic use of groups; and use of teaching and learning
principles (Mosey, 1996; Hagedorn, 2000; Duncan, 2006).
In addition, therapists will draw on appropriate frames of reference, depending on the
patient context which will influence the Intervention Approach taken. Specific intervention approaches provide tools to enable change, including assessment tools, intervention
techniques and style of the patient–therapist relationship.
Conceptual models of practice
The Model of Human Occupation (MOHO) (Kielhofner, 2008) considers the complexity of human occupation that behaviour is dynamic and context dependent and that
occupations shape a person’s self-perception and identity. It proposes that people’s participation in occupation is influenced by their own volition (personal causation, values and
interests), habituation (habits and roles) and performance capacity as well as the environment (physical and social including cultural contexts). Actual occupational performance
is then dependent on skills (motor, process and communication and interaction skills) performing occupational forms (or activities) and participation. Participation helps to create
occupational identity and a sense of occupational competence. A positive occupational
identity and sense of personal competence over time in the context of the environment
enable occupational adaptation to be constructed. A number of useful overview, observational, self-report and vocational assessment tools have been developed under this model,
including the MOHOST (MOHO Screening Tool), Assessment of Motor and Process
Skills (AMPS), Interest and Role Checklists and Work Environment Impact Scale.
This model and its associated tools help occupational therapists working with stroke
patients to understand the person and focus on an integrative view of human occupation.
However, therapists are required to draw on other frameworks to understand and address
patient’s performance capacity.
The Canadian Model of Occupational Performance and Engagement (CMOP-E)
(Townsend and Polatajko, 2007) is a social model that considers the spiritual, physical,
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affective and cognitive components of the person whose self-care, productivity and leisure
occupations occur in the context of the physical, institutional, cultural and social environment. The latest amendment specifies the occupational therapy domain of concern
in the dynamic interaction of the person, occupation and environment. It further regards
occupation beyond performance to consider the importance of engagement and inclusion.
The Canadian Occupational Performance Measure (COPM) (Law et al., 2005) was developed from earlier versions of this model, but remains consistent, with the CMOP-E as
a client-centred outcome measure enabling clients to rate importance, performance and
satisfaction with self-care, productivity and leisure activities that they ‘need to’, ‘want to’
or ‘are expected to’ do. This model and tool is useful for occupational therapists working
with stroke patients; however, challenges can arise when therapists are constrained by
inpatient settings or patients’ levels of insight.
Similar but distinctive models emphasising person, environment and occupation
include the Person–Environment–Occupation (PEO) Model (Law et al., 1996) and
Person–Environment–Occupational Performance (PEOP) Model (Baum and Christiansen,
2005).
The Australian Occupational Performance Model (OPM(A)) (Chapparo and Ranka,
1997) describes eight interactive constructs, including occupational performance, occupational roles, occupational performance areas (self-maintenance, rest, leisure and productivity), components of occupational performance (biomechanical, sensorimotor, cognitive,
intra- and interpersonal skills), core elements of performance (mind, body and spirit), the
performance environment (sensory, social, physical and social contexts), time and space.
The Perceive Plan Recall and Perform (PRPP) System of Task Analysis (Chapparo and
Ranka, 1997) was developed as one of the assessment tools within this model.
Activities Therapy (Mosey, 1996) combines psychodynamic, human developmental and behavioural frames of reference. This model suggests that adaptive (compensatory/functional) skills are re/learnt in a developmental sequence to achieve mature
functioning and influenced by the environment and their biological composition. In relation to stroke, this model suggests that dysfunction arises when patients regress in their
sensory integration, cognitive, dyadic interaction, group interaction, self-identity and/or
sexual identity skills. Rehabilitation is based on sequential relearning of adaptive (compensatory/functional) sub-skills through graded occupation and patient’s innate need for
mastery.
The Kawa (River) Model (Lim and Iwama, 2006) is an emerging model from an
Asian perspective which may address cultural biases of existing models (which value
individualism, autonomy and independence) to consider cultural values of collectivism,
social hierarchy and interdependence. Appreciation of non-western perspectives enables
therapists to be truly client-centred. This model emphasises the harmonious interaction of
mind, body, soul, spirit and environment for health and well-being. The western view of
self is decentralised and central focus of occupational therapy is to enable the patient’s life
flow (or river) by achieving harmony between life circumstances and problems (rocks),
the physical and social environment (walls and bottom of the river) and personal attributes
and resources, including values, character, personality special skills, material and immaterial assets and liabilities (driftwood). Thus to enable the patient’s energy (water) to flow,
occupational therapists must prioritise and direct interventions towards utilising existing
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Theoretical Basis
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currents and addressing obstructions, but not necessarily eliminating them, so that the
patient’s life energy (water) can flow. Thus, in stroke rehabilitation, reduction of impairments may not be as significant as it is in western cultures. Maximising patients’ personal
attributes and resources, adapting environments and considering interdependence on family and social participation (social inclusion) may be more meaningful than addressing
impairments and activity limitations.
Frames of reference
Client-Centred Frame of Reference is a humanistic approach which originated with psychotherapist Carl Rogers and was further developed by occupational therapists in Canada
(Canadian Association of Occupational Therapists, 2002; Townsend and Polatajko,
2007). Key concepts of the approach include client autonomy and right to informed
choice; partnership between client and therapist to work together to negotiate therapy
goals and processes; responsibility of the client for his/her own health and ethical responsibility of the therapist to ensure no harm; empowering and enabling clients to achieve
their occupational goals; understanding clients individual contexts through respect and
listening; accessibility of services to meet clients needs; and respect for diversity. It recognises that ‘the client’ might also be the family, carers or institution in addition to the person
referred. Practical strategies for application throughout the OT process have been outlined
(Canadian Association of Occupational Therapists, 2002; Parker in Duncan, 2006: p. 193;
Townsend and Polatajko, 2007). Motivational interviewing is a behaviour change method
that falls under this frame of reference (Miller and Rollnick, 2002).
Biomechanical Frame of Reference is a bottom-up frame of reference, useful
for understanding occupational performance capacity in more detail. It considers the
anatomy and physiology and mechanics of human movement (kinesiology) focusing
on musculoskeletal, neuromuscular and cardiorespiratory systems. Occupational therapy
approaches that fit within this frame of reference include graded activities to improve
movement strength, endurance, range of motion and sensation, work hardening, energy conservation, ergonomics, assistive devices, splinting and joint protection. Thus
approaches to prevent deterioration, restore function or compensate for limitations are
significant here. Nevertheless, the primary assessment and outcome for occupational
therapy should always be in the context of meaningful occupation.
Rehabilitative Frame of Reference draws on medical, physical and social sciences.
It considers rehabilitation as the process of helping patients competently fulfil daily
activities and social roles and focuses on therapists teaching, patients learning adaptive
(compensatory/functional) methods, assistive equipment and environmental modifications
to restore function when underlying impairments cannot be remediated and successful
rehabilitation is dependent on motivation and cognitive skills.
Motor Control Frame of Reference considers the relationship between the central
nervous system in relation to motor function and reacquisition of coordinated skilled
movement but recognises the influence of other systems (sensory input and cognitive processing), environmental context and learning principles (such as attention, feedback, active
participation and goal-directed movement). In comparison to a biomechanical frame of
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reference, emphasis is on muscle tone, reflexes and movement patterns. Many restorative
(remedial) intervention approaches fall under this heading, including Bobath’s neurodevelopmental (normal movement) approach, Carr and Shepherd’s movement science/motor
relearning, Rood, Brunnstrom’s Movement Therapy, Proprioceptive Neuromuscular
Facilitation, Mental imagery and Constraint-Induced Movement Therapy (see ‘Intervention Approaches’ later in this chapter).
Behavioural Frame of Reference considers learning principles arising from stimulusresponse models such as Pavlov’s classical condition and Skinner’s operant conditioning
where behavioural responses to stimuli or triggers can be modified through exposure
and manipulation of the consequences. This frame of reference is useful for behaviour
modification such as desensitisation or reduction of anxiety-related symptoms as well as
for new learning principles such as repetition and positive feedback.
Cognitive Frame of Reference originated in psychiatry and psychoanalytical theory
with the work of Aaron Beck. This frame of reference examines the links between the
patients’ automatic thinking, their behaviour and emotional response. Dysfunctional beliefs, values and thinking may be distorted, unrealistic and unhelpful. These are explored
and challenged to change patients’ perceptions and emotional response to events.
Cognitive-behavioural therapy (CBT) links the cognitive and behavioural frames of
reference together. It utilises a problem-focused approach to explore patients’ underlying thoughts, beliefs and physiological responses associated with specific triggers and the
consequences of dysfunctional behavioural responses that might maintain these. Dysfunctional thinking and beliefs in response to triggers are then challenged to change patient’s
perspectives and more adaptive (compensatory/functional) behaviour can be tested out in
safe environments such as role play, facilitated groups and graded activity scheduling.
Adaptive (compensatory/functional) behaviour is reinforced through patients’ feelings of
self-efficacy, consequences that disprove dysfunctional beliefs and therapist feedback,
which is recorded in activity diaries. Techniques can be deceptively simple and specialist
training is required. Considering its inherent overlap with clinical psychology, Duncan
(2006) further cautions that a cognitive-behavioural frame of reference should be used in
conjunction with an occupation-focussed conceptual model of practice to maintain professional role and identity and to enhance the therapeutic potential of the patient–therapist
partnership.
CBT has been successfully used in mental health for the intervention of anxiety,
depression, personality disorders and substance abuse. It has also been used for chronic
pain and chronic fatigue syndrome (Duncan, 2006). Although CBT appears useful for
stroke patients and is probably employed to some degree during rehabilitation, further
research is required on the effectiveness of CBT strategies with stroke patients (Lincoln
and Flannaghan, 2003).
Psychodynamic Frame of Reference originated with Sigmund Freud’s controversial
theories but has been developed to focus on understanding the relationship between past
experience and present difficulties. It highlights links between unconscious motivations
and emotions which are operationalised through interpersonal interaction, behaviour and
occupation. For example, mechanisms such as repression, denial, projection, reaction
formation, intellectualisation, rationalisation, regression, sublimation and compensation
protect the psyche against anxiety arising from unconscious internal conflict. These
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Theoretical Basis
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internal conflicts and underlying emotions and motivations can be therapeutically
explored and symbolically resolved through creative (projective) activities, meaningful
occupations, reflection, group work processes and therapeutic relationships to achieve a
sense of wellness (Blair and Daniel in Duncan, 2006: p. 233).
Cognitive Perceptual Frame of Reference draws on neuroscience and neuropsychology and focuses on the components and interaction of cognitive and perceptual skills
that impact on occupational performance. Treatment approaches can be categorised into
remedial/bottom-up/skills training or adaptive/top-down/strategy training approaches
recognising the brain’s capacity but limited potential to repair following brain injury
(Feaver and Edmans in Duncan, 2006: p. 277; Kielhofner, 2008). A wide range of
cognitive and perceptual tools and treatment strategies fall under this umbrella (see
Chapters 7 and 8).
In addition to the above theoretical constructs which assist in guiding occupational therapy practice, the emerging theories of neuroplasticity are utilised in current neurological
practice. A knowledge of neuroplasticity can assist the occupational therapist in selecting
an intervention/approach for the individual patient and will assist in clinical reasoning
and justification of the intervention administered.
Neuroplasticity
Despite recognition that post-injury experience could result in adaptive or maladaptive
responses, historically it was believed that neurones in the adult mammal’s central nervous
system (CNS) were ‘hard wired’ like an electrical circuit that could not regenerate or repair
after injury (Gage, 2002). Thus, recovery in neurorehabilitation focussed on strategies that
discouraged maladaptive behaviour and focussed on adaptive functional behaviour and
goal achievement (Cohen, 1999). This was supported by evidence that neurorehabilitation
improved patient outcomes (Intercollegiate Stroke Working Party (ISWP), 2008). However, more recent advances in neuroscience and functional imaging have demonstrated
evidence of neuroplasticity – the brain’s considerable capacity for neural reorganisation
(Nudo and Friel, 1999). Consequently, momentum has escalated for therapists to understand the scientific basis of neurorehabilitation to capitalise on this to enhance true
recovery of function following stroke (Aisen, 1999; Mateer and Kerns, 2000; Pomeroy
and Tallis, 2002b).
From conception to death, neuroplastic changes occur. These can be associated with
normal responses to experiences such as maturation, development and learning (Hallet,
1995; Kotulak, 1998). Therefore, cells are constantly adapting to the challenges of the
internal and external environment (Stephenson, 1996).
Structure of a neurone
The neurone cell is specialised to maintain high rates of protein synthesis and have long
projections from the cell body.
Dendrites are large extensions of the cell body and receive most of the synaptic inputs
into the cell. Neurones may have one or many dendrites, which are typically short and
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Dendrites
Axon hillock
Axon
collaterals
Cell body
Axon
Figure 2.1 Structure of a neurone. (Reproduced with permission from Dr I. Musa, Cardiff
University, personal communication, 2009.)
highly branched, as shown in Figure 2.1. They provide sites for synaptic connection with
other nerve cells and can be regarded as specialised for receiving information.
The information is ‘read out’ at the origin of the axon which is specialised for signal
conduction. Neurones have a single axon arising from the axon hillock and its terminal
forms the presynaptic component of a synapse. Axons may extend to less than a millimetre
to over a meter long; axons often branch and these branches are called axon collaterals.
The axonal mechanism that carries signals over distances is called an action potential.
Information encoded in the action potential is passed on by synaptic transmission.
Neuronal plasticity after injury occurs as a result of one of two main processes: either
the rerouting and subsequent formation of new connections, or neurones substituting
function of damaged neurones to enhance the effectiveness of existing connections (Kidd
et al., 1992). This includes:
r The concepts of synaptic strengthening or potentiation – altering the effectiveness of
synapses (short-term potentiation/long-term potentiation).
r Unmasking of existing silent synapses whose function was previously blocked by
inhibitory influences.
r Sprouting of new axon terminals.
r Changes in dendritic organisation.
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Synaptic transmission
Neurotransmitters may be classified into two broad categories, such as G protein-coupled
or metabotropic receptors and transmitter-gated ion channels. The following discusses
transmitter-gated ion channels and the mechanisms of short-term presynaptic potentiation
and long-term postsynaptic potentiation.
Short-term presynaptic potentiation (STP)
Glutamate is the transmitter that activates several subtypes of postsynaptic receptor.
Calcium ion entry into the presynaptic terminal causes the presynaptic release of glutamate which diffuses across the synaptic cleft binding to the glutamate receptors on the
postsynaptic membrane. When glutamate binds to the (α-amino-3-hydroxyl-5-methyl4-isoxazole-propionate) AMPA receptors on the postsynaptic membrane, this allows a
mixed flow of sodium (Na+ ) and potassium (K+ ) to cross the cell membrane causing
a depolarisation of the postsynaptic membrane called excitatory postsynaptic potential
(Purves et al., 1997).
However, an N-methyl-d-aspartate (NMDA) receptor is voltage gated owing to magnesium (Mg2+ ) at the channel. At the resting membrane, the inward current through the
NMDA is blocked by the magnesium which has bound to the channel. As the membrane
becomes depolarised, the (Mg2+ ) block is displaced from the channel and the current is
free to pass into the cell. This requires constant release of glutamate to maintain the membrane depolarisation. NMDA receptors are therefore voltage dependent (Purves et al.,
1997) (see Figure 2.2).
AMPA receptor
NMDA receptor
Metabotropic glutamate receptor
Presynaptic
axon terminal
Glutamate
Figure 2.2 Short-term presynaptic potentiation. (Adapted from Bear et al . (2007) by Dr I.
Musa, Cardiff University, personal communication, 2009. Reproduced with permission from
Lippincott, Williams & Wilkins.)
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Long-term postsynaptic potentiation (LTP)
Long-term potentiation is commonly associated with learning and plasticity. It occurs at
some synapses but not at others, confirming that synapses vary in their plasticity (Fox,
1995). LTP has also been found significant in long-lasting, activity-dependent changes
in the efficacy of synaptic transmission for the storage of neural information and the
development of functional circuits (Dobkin, 1998).
NMDA receptors also conduct calcium (Ca2+ ) ions; therefore, the magnitude of Ca2+
flux passing through the NMDA receptor channel specifically signals the level of pre- and
postsynaptic coactivation (Bear et al., 2007). Strong NMDA receptor activation and Ca2+
entry into the postsynaptic dendrite bind to calmodulin which activates protein receptor
kinase II. This phosphorylates the AMPA receptors and serves as a signal to insert them
into the postsynaptic membrane and therefore strengthens synaptic transmission. Once
AMPA receptors are inserted, the synapse is no longer silent and no longer requires
simultaneous pre- and postsynaptic activity to elicit excitatory postsynaptic potential
(EPSP) (Figure 2.3).
LTP is also thought to play a role in synaptic refinement, and it can be assumed that
the facilitation of LTP after cortical lesions reflects an underlying mechanism of cortical
reorganisation and recovery (Malenka and Nicoll, 1999). According to Hagermann et al.
(1998), LTP is essential for functional recovery.
Long-term nuclear changes
Long-lasting, long-term potentiation that is associated with learning and memory requires
long-term nuclear changes through activity-driven induction of new gene expression.
Presynaptic
terminal
Glutamate
Simple ionic
receptor
channel
Mg++ expelled
from NMDA
channel
Na+
Na+
Protein kinase C
Ca++
NMDA receptor
channel
Ca++
Ca++/calmodulin
kinase II
Modification of postsynaptic
receptors of release of
retrograde factor
Figure 2.3 Long-term (postsynaptic) potentiation. (Reproduced with permission from Dr I.
Musa, Cardiff University, personal communication, 2009.)
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Theoretical Basis
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Na+
K+
Synthesis of
proteins
Products
of proto-onco
genes
Phosphorylation
of regulatory
proteins
Transcription
of genes
Figure 2.4 Long-term (nuclear) changes through G protein-coupled second messenger
systems. (Reproduced with permission from Dr I. Musa, Cardiff University, personal
communication, 2009.)
It requires the synthesis of new proteins and their affect on the nucleus of the postsynaptic cell through high-frequency stimulation. This stimulation results in the activation
of a receptor-linked second messenger system, which encourages the phosphorylation of
regulatory proteins. These enter the postsynaptic cell nucleus where they transcribe a set of
genes. The genes are then transcribed to the messenger ribonucleic acid molecule (RNA)
which moves into the cell to be translated into the soluble protein – proto-oncogenes.
The first genes initiate the transcription of a second set of genes and then disappear. The
proteins now are large and insoluble. After being synthesised by the ribosomes attached
to the granular endoplasmic reticulum, they move by dendritic transport back to the postsynaptic site where potentiation is now enhanced (Kidd et al., 1992; Purves et al., 1997)
(Figure 2.4).
More research is required into the mechanism responsible for maintaining this very
long-term potentiation though the following suggestions have been made.
Calcium–calmodulin-dependent protein kinase II (CaMKII) consists of four subunits. Calcium activation phosphorylates them, and once the calcium concentration
falls back to its resting level they remain phosphorylated. This is because if a subunit becomes dephosphorylated, it will immediately become automatically phosphorylated by one of the other subunits. Therefore, CaMKII remains persistently active
(Longstaff, 2000).
Other requirements for LTP are associativity and specificity.
Associativity is when weak stimulation of a pathway will not by itself trigger LTP. However, if one pathway is weakly activated at the same time as a neighbouring pathway is
strongly activated, the weak pathway is potentiated. This theory is supported by Hebb
(cited Bear et al., 2007: p. 718): ‘Neurones that fire together wire together, neurones that
fire out of sync loses their link’.
Specificity is when one pathway is stimulated and other pathways connected to the
same neurone are not. Therefore, LTP is specific to activated synapses than all synapses
on a cell (Figure 2.5).
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(a) Specificity
Pathway 1:
Active
Synapse
strengthened
(b) Associativity
Pathway 1:
Strong stimulation
Synapse
strengthened
Pathway 2:
Weak stimulation
Synapse not
strengthened
Synapse
strengthened
Figure 2.5 Long-term potentiation: (a) specificity and (b) associativity. (Reproduced with
permission from Dr I. Musa, Cardiff University, personal communication, 2009.)
Unmasking
Can be considered when designated axons and synapses which are present but not being
used for a particular function. This can be called upon when the ordinary dominant system
fails as unmasking of silent synapses.
Changes in spine morphology may affect dendritic integration of synaptic potentials.
Dendritic spines are the locus of excitatory interaction among central neurones and may be
involved in the extensive synaptic stimulation, which causes long-term potentiation (LTP).
This leads to calcium-dependent phosphorylation of CREB (cAMP response element
binding protein) – which may be associated with synaptic plasticity. Therefore, linking
the phosphorylation of CREB to formation of new dendritic spines could assist in longterm nuclear changes (Murphy and Segal, 1997).
Intervention therefore aims to stimulate the long-distance afferent to take over
from the segmental afferent that has been damaged, that is, the subservient pathway or non-dominant can take over the function of the dominant damaged afferent
(Figure 2.6).
Collateral sprouting
Recovery after brain injury occurs by axons growing branches called collateral sprouting:
homotypic sprouting where a synapse is formed from the same tract or heterotypic
sprouting from another tract (functional recovery is more adversely affected in this case)
(Figure 2.7).
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Stimulated
long-distance
afferent
Damaged
segmental
afferent
Figure 2.6 Unmasking. (Reproduced with permission from Dr I. Musa, Cardiff University,
personal communication, 2009.)
Dendritic growth
Dendritic growth can take place over months and will regrow if stimulated. Studies have
shown that there is a decrease in dendritic growth in dementia patients and those in a
vegetative state thus suggesting – ‘if you don’t use it you lose it’ (Ardent et al., 1997;
Baloyannia, 2009). Kotulak (1998: p. 247) states ‘the brain gets better through use but
rusts with disuse. It is the ultimate use it or lose it machine’.
There is an increase in growth in the dendritic tree with movement and usage.
Research has established that neuroplasticity is modified by experience-dependent activity; reorganisation may be enhanced by enriched environments; repetition is important
to induce and maintain plastic changes; timing may be critical and the importance of active
attention to stimuli (Gage, 2002; Pomeroy and Tallis, 2002b; Turkstra et al., 2003). From
these findings, it may be that to some extent adaptive neuroplasticity was already being
Reactive synaptogenesis
Axonal sprouting
Figure 2.7 Collateral sprouting. (Reproduced with permission from Dr I. Musa, Cardiff
University, personal communication, 2009.)
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driven by therapists following basic learning principles, including, teaching meaningful
skills that were varied, stimulating and graded in difficulty; structuring practice with feedback and review; and training skills to other environments and contexts (Pomeroy and
Tallis, 2002b). However, it alerted therapists to consider the aspects of post-injury rehabilitation experiences influencing neuroplasticity. For example, unstructured, repetitive
task practice during routine self-care could potentially be relatively ‘unattended’ and insufficient to facilitate reorganisation of neural circuitry and maximise functional recovery
(Mateer and Kerns, 2000; Pomeroy and Tallis, 2002b). Moreover in some circumstances,
overuse of the affected limb directly after injury while the system is in shock could expand
cortical lesions (Johansson, 2000).
Neuroplasticity redefined recovery as ‘the ability to accomplish the goal in exactly the
same way as before the injury’ (Almli and Finger in Cohen, 1999: p. 420). The loss of
normal function deprives the CNS of the experiential feedback required to drive adaptive
reorganisation and may subsequently permit maladaptive reorganisation (Pomeroy and
Tallis, 2002a). This increased emphasis on remedial approaches for ‘true neuroplastic
recovery’ early in stroke rehabilitation. In fact it was suggested that ‘restitution of function
in damaged circuits may actually be hindered by compensatory adjustments which may
support adaptive function in the short term, but which result in long-term inhibition of the
activity of damaged circuits (Mateer and Kerns, 2000: p. 108; Cauraugh and Summers,
2005). However, there is limited clinical evidence to suggest that functional compensations
are detrimental to recovery (Cohen, 1999; Lennon et al., 2001; Lennon, 2003).
Intervention approaches
Despite evidence of neuroplasticity, predicting recovery potentials remains challenging.
Some combinations of symptoms will be more amenable to true recovery while other
combinations will have limited capacity, requiring an adaptive (compensatory/functional)
approach to learn to adapt to activity limitations. Thus, occupational therapists will always
need both restorative and adaptive treatment approaches as components of neurorehabilitation. Further, some patients may just want to achieve independence as quickly as possible
and ‘may not be overly concerned about how they perform these activities’ (Lennon et al.,
2001: p. 260).
Restorative approach (remedial approach)
The restorative (remedial) approach relies upon theories of neuroplasticity and the ability
of the brain to reorganise itself (Nirkko et al., 1997; Nudo, 1998; Marshall et al., 2000).
Neurophysiological approaches such as normal movement and motor relearning are
included within the restorative (remedial) approach. Here, the therapist provides controlled
visual, auditory, vestibular, tactile, proprioceptive and kinaesthetic stimulation to promote
normal CNS processing of sensory information. Therefore, normal sensory processing
should help the patient make normal perceptual motor responses required for performance
of functional tasks. This approach therefore aims to reduce the impairment to subsequently
improve activity and participation.
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Neistadt (1990) also classes ‘transfer of training’ under restorative (remedial) approaches. Activities, such as puzzles and pegboards, provide practice in perceptual skills.
It is implicit within this approach that these tasks are appropriately graded to challenge the
patient and encourage the brain to adaptively reorganise itself for successful behaviours.
People with cognitive impairments tend not to be able to transfer learned skills, and
although some minor, short-term effects may be seen, the long-term impact and lack
of transferrable skills tend to make this a time-intensive and less-effective approach for
people with cognitive problems. Restoration of impairments tends to be more successful
for people with motor impairments alone.
Adaptive (compensatory/functional) approach
The adaptive (compensatory/functional) approach focuses on repetition of particular skills
which are normally associated with activities of daily living (ADL). It is based on the
belief that man is a functional animal and his ability to do so is essential for his well-being
(Turner et al., 1996).
Adaptive (compensatory/functional) approaches are traditionally used when restoration
is unlikely and assumes that certain functions will not recover (Zoltan, 2007). Compensation for loss of function is achieved by changing the activity, environment or patient
behaviour by using external assistance, modifying the task or changing the goal or by
practice until the task becomes easier in a variety of environments.
The advantages of this approach are that it is patient-centred, easy to explain, uses
problem solving, meets short-term needs and gives quick results.
The disadvantages of this approach are that the therapist may not consider a range
of options open to the patient and may succumb to organisational pressures for quick
functional results at the expense of maximising true recovery potential for the patient,
leading the therapist to become prescriptive in a ‘one size fits all’ method. It can lead
to negativity by the patient who is asked to recognise a permanent condition and its
limitations without any attempt to remediate the underlying skills.
Cognitive rehabilitation approach
Cognitive rehabilitation therapy is a systematic and functionally oriented approach to
improve cognitive functioning either by restoring cognitive processing skills that are
impaired and/or helping the patient learn new ways to compensate for the impairment(s)
(Malia and Brannagan, 2005; Halligan and Wade, 2007). Cognitive rehabilitation is very
similar to physical rehabilitation but usually involves all of the following:
r Assessment – to determine the specific impairments involved and their functional impact
on occupational performance.
r Education – to develop patients’ and others’ awareness of cognitive strengths and
weaknesses and how they influence occupational performance. Without developing
awareness and self-monitoring skills, the patient will not engage in therapy and will
not be able to independently implement treatment strategies on their own – the ultimate
aim of rehabilitation!
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r Process training – to restore the impaired cognitive skill through targeted practice and
retraining of the skill itself. This is usually completed out of context in pen and paper
tasks to enable patients to consciously focus on the targeted skill and may be given as
homework activities.
r Strategy training – to learn how to use external and internal adaptive strategies to
overcome the impaired skill. This involves targeted rehearsal of the taught strategy in
a variety of contexts.
r Functional activities training – to consciously apply strategies learnt in process and
strategy training in everyday life.
r Evaluation – is required at impairment, activity and participation levels to determine
the effectiveness of intervention.
(Malia and Brannagan, 2005; Halligan and Wade, 2007)
Although in physical rehabilitation simultaneous use of both restorative and adaptive
approaches is used cautiously, in cognitive rehabilitation use of both process and strategy
training simultaneously is encouraged.
Cognitive interventions must be tailored to the individual and are more effective if
interventions are collaboratively worked between patient, carer and therapist. The goals
should be mutually set and functionally relevant to the individual. Therapists should also
use eclectic and multiple approaches to address the effect and emotional components of
cognitive loss (Halligan and Wade, 2007).
Although research population heterogeneity, treatment variability and use of broad outcome measures have limited conclusive recommendations for cognitive rehabilitation to
date, Rohling et al.’s (2009) meta-analysis suggests a few core evidence-based principles
for cognitive rehabilitation, including starting treatment early, older patients (≥ 55 years
old) can still benefit from cognitive rehabilitation and targeted interventions (particularly
for attention and visual spatial neglect) are more effective than generalised interventions.
The reader is referred to key documents regarding details of specific evidence supporting
the effectiveness of cognitive-perceptual rehabilitation of attention, memory, visuospatial
perception, neglect, executive function and praxis skills (Cicerone et al., 2000; Lincoln
et al., 2000; Cappa et al., 2005; Cicerone et al., 2005; Bowen and Lincoln, 2007; das Nair
and Lincoln, 2007; ISWP, 2008; West et al., 2008; Rohling et al., 2009).
Normal movement (Bobath-based approach)
The normal movement approach is the most commonly used restorative approach to physical neurorehabilitation in the UK (Walker et al., 2000; Lennon, 2003). It is also known
as Bobath or neurodevelopmental treatment (NDT) as it was originally founded by the
Bobaths in the 1970s and based on neurodevelopmental reflex-hierarchical theory that
hypothesised spasticity as a product of overactive reflexes. Originally, treatment utilised
reflex inhibiting patterns and progressed patients through a neurodevelopmental sequence
(Bobath, 1990). However, Bobath treatment techniques have changed since the last Bobath
publication in the 1990s. The current ‘Bobath Concept’ of normal movement has evolved
to incorporate present-day knowledge and a systems theory of motor control, motor learning, neural and muscle plasticity and biomechanics (Raine, 2006, 2007; International
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Bobath Instructors Training Association (IBITA), 2008). However, there has been much
debate in the literature regarding the validity and reliability of this evolution which has confounded evidence-based practice (Langhammer, 2001; Brock et al., 2002; Mayston, 2008).
The Normal movement approach is a problem-solving or clinical reasoning process
rather than a series of treatments or techniques, generally requiring a postgraduate level
of training to enable more efficient movement patterns (IBITA, 2008). It is based on the
assumption that ‘too much effort by the patient and overuse of the unaffected side reinforce
abnormal tone and movement of the affected side’ (Lennon, 2001: p. 925). Abnormal
movement leads to inaccuracy, effort, fatigue, compensatory movements, muscle tension,
overuse, pain, injury and ultimately task avoidance and dependency. Thus, the approach
aims to improve disturbances in function, movement and postural control following a
lesion in the CNS by relearning more efficient movement through experience, with active
participation of the patient, which is ultimately goal directed (Lennon, 1996; Raine, 2007).
Key terms
r Base of support: This refers to the supporting surface, the body part in contact with it
and the relationship between the two. In order to accept the base of support, a person
needs movement to relate to it and use it as a reference point.
r Centre of gravity: A constant downward force with which man must develop the ability
to interact, in order to move selectively. It is constant and the effect is felt if displaced.
r Postural set: An alignment of key points in relation to an accepted base of support.
r Balance reactions:
(a) Equilibrium reactions: Automatic adaptations of postural tone in response to gravity
and displacement.
(b) Righting reactions: Sequences of selective movements in patterns in response to displacement. Functionally they allow the loss regaining of midline through trunk righting, head of righting, stepping reactions and protective extension of the upper limbs.
r Normal postural tone: A continuous partial state of muscle contraction which is high
enough to resist gravity and low enough to allow selective movement to take place.
r Associated reactions: Pathological increases in tone, in response to a stimulus, which
are beyond the person’s level of inhibitory control. They reflect a loss of reciprocal
innervation.
r Key points: Areas of the body, such as the head, thorax, pelvis, shoulders, hips, hands
and feet, where postural tone can most easily be changed. Each key point provides a
large source of proprioceptive input to the CNS.
Key points are used to:
(a) Facilitate and control movements; and
(b) Alter postural tone.
Assessment/evaluation
Assessment involves observation and analysis of movement of deviation from normal movement patterns and identification of compensatory strategies. In particular, the
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influence of gravity, relationship with base of support, alignment and relationship of key
points to each other, the ability to move within a posture, transfer weight and to create
another posture, initiation and development of a pattern of movement (selectivity). In
addition, the potential for change is explored through use of handling skills to influence
tone, alignment, fixation, stiffness, etc., as well as use of movement experience, repetition,
speed, voice and environment. As a problem-solving approach, assessment, hypothesis
formation, treatment and evaluation are a constant process.
Techniques/methods
The therapist uses afferent inputs, particularly proprioceptive handling skills of key points
of control, to influence muscle tone and activity, correct alignment, block abnormal movements and facilitate more normal selective movement patterns for goal-directed tasks in
which the patient is an active participant (Lennon, 2001; IBITA, 2008). In addition, therapists use experience of movement, repetition, speed, voice, environmental manipulation
and feedback (British Bobath Tutors Association, 2003). Bobath discourages unsupervised patient practice and/or use of aids that risk adopting abnormal movement patterns;
thus, consistent 24-hour handling is encouraged (Lennon, 1996; van Vliet et al., 2001).
Use of normal movement in improving functional ability
Preparation
Good knowledge/awareness of normal movement is necessary to analyse deviation from
the normal.
r Think about how you do daily activities – What is the normal sequence of movements?
r Prior to session take time to plan and analyse intervention strategy.
Activity analysis
When carrying out in-depth activity analysis of normal movement components of a
functional task, consider the following:
r
r
r
r
Alignment and symmetry of key points.
Ability to move in/out of postures.
Acceptance of base of support.
Balance and ability to transfer weight as opposed to shifting centre of gravity over the
base of support.
r Ability to adopt anticipatory posture requirements, for example, to alter trunk and pelvic
alignment to move a leg or position the hand in relation to the object in preparation for
grasp.
r Is the movement normal in pattern – efficient, selective, effortless and goal directed?
r Identify any abnormal/effortful movement patterns.
– Where is movement initiated from – proximally versus distally?
– Where does movement appear to be blocked?
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r
r
r
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– Where does the patient gain their stability from?
– Where is the effort/instability coming from?
Identify limitations from sensorimotor, neuromuscular and musculoskeletal systems, for
example, proximal stability, pain, oedema, restricted range of motion, tone, sensation,
proprioception, strength, hand function.
Consider the influence of gravity, objects and the environment on movements.
Consider the cognitive-perceptual demands of the task, for example, understanding
goal, motivation, concentration, memory.
Positioning.
During treatment, normalise tone before you start and monitor as you progress. Some
preparation may be needed prior to the ADL. Treatment strategies include the following:
r Negotiate occupational goals so treatment is motivating, meaningful and goal directed.
r Altering postural alignment.
r Changing the base of support (increase BOS to reduce hypertonicity, and decrease BOS
to increase tone if hypotonic). Consider standing, sitting, lying, position of feet, using
arms to prop, backrests.
r Modify the environment, for example, firmness of supporting surface, chair
height/design, object orientation and placement.
r Encourage self-initiation of movement and self-monitoring of abnormal tone/
movement.
r Facilitate key points but do not overhandle – patient should be active in movement
rather than passive.
r Grade activities and treatment time appropriately to be therapeutically challenging
while working within patients’ physical and cognitive capacity.
r Learning principles of task-related training, repetition and practice. Vary object characteristics, task context, speed and directional demands of the activity.
r Give clear visual/verbal/proprioceptive/written instructions and feedback.
r Use equipment to complement normal movement patterns/compensation. ‘Normal activity’ does not utilise aids to independence other than as a last resort. Aids may be
used to minimise effort and disability.
r Maximising carryover and skill acquisition through practice and repetition. Train the
patient, carer and ward staff to monitor and adjust alignment, movement patterns and
environment (where appropriate).
Proprioceptive neuromuscular facilitation
Proprioceptive neuromuscular facilitation (PNF) as a neuophysiological treatment approach was first advocated to American therapists by Knott and Voss in the 1950s. It
is based on Sherrington’s and Kabat’s theories about the reflexive relationships between
agonist and antagonist muscles which can be manipulated to control the contraction
and relaxation of specific muscles groups and thus facilitate normal movement. It also
emphasises that ‘the brain registers total movement and not individual muscle action’
(Schultz-Krohn et al., 2006: p. 748)
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Assessment considers the relationship between proximal and distal functions, agonists
and antagonists, in total patterns of movement observed during functional activities.
Particular observations are made with regard to:
r
r
r
r
r
Balance of tone – Is there an abnormal dominance of flexor or extensor tone?
Alignment – Are body segments aligned in midline or shifted to one side?
Stability and mobility – Is more or less required?
Which sensory input (auditory, visual or tactile) the client is most responsive to?
Which facilitatory technique the client responds to best?
(Schultz-Krohn et al., 2006)
Intervention is goal directed; involves the use of mass movement patterns that are diagonal (crossing midline) and spiral (rotational) in nature; and involves the use of total
patterns of movement and posture (developmental postures). These diagonal movements
and developmental postures are observed in many functional ADL. Thus, treatment activities demand tonal balance and motor control in meaningful tasks that are appropriately
graded. Facilitatory strategies include use of:
r
r
r
r
r
r
r
r
r
r
Verbal commands.
Visual cues.
Tactile cues.
Diagonal placement and use of objects during functional activities.
Stretch to facilitate innervation of the stretched muscle.
Traction and approximation to stimulate joint receptors for carrying and weight-bearing
functions.
Application of maximal resistance that still allows patients to have full range of motion
and smooth coordinated movement to enhance proprioceptive feedback and strength.
Use of repeated contractions and rhythmic initiation to facilitate agonist muscles.
Use of isotonic and isometric contractions of the antagonist to induce subsequent
contraction of the agonist.
Muscle relaxation techniques (such as contract-relax, hold-relax, slow reversal-holdrelax and rhythmic rotation).
(Schultz-Krohn et al., 2006)
Rood approach
This intervention is based on reflexive and hierarchical models of the nervous system.
Use of developmental postures and sensory stimulation applied to muscles and joints are
used to stimulate a motor response that can either facilitate or inhibit muscle tone in
preparation for normal movement. Rood’s concept is therefore based upon the concept of
correct sensory stimulation being applied to the sensory receptors and eliciting the correct
motor reflex which can be utilised in normal movement patterns (Rood, 1962).
Some of these techniques such as icing, brushing hair follicles and tapping the muscle
belly have since been found to be short lived and unpredictable, and thus no longer used
(Schultz-Krohn et al., 2006). Nevertheless the following Rood techniques may still be
useful:
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Facilitatory techniques to increase muscle tone tend to be proprioceptive and include
the following:
r Heavy joint compression where a compression force greater than body weight
is applied by the therapist through the longitudinal axis of the bone to facilitate joint co-contraction. Weighted cuffs, sandbags and weight-bearing can also be
used.
r Quick stretch followed by applying resistance to contracting muscle.
r Vestibular stimulation to influence tone, balance and facilitate protective neck, trunk
and limb extension.
r Vibration has been found to have systemic effects and use of electrical stimulation has
become more favoured.
Inhibitory techniques to reduce muscle tone include the following:
r Neutral warmth provided by insulating body heat with fabrics such as blankets or
neoprene.
r Slow, rhythmic stroking with deep pressure.
r Light joint compression where a compression of body weight or less can inhibit tone
around joints.
r Vestibular stimulation through slow rocking to develop ability to move in and out of
postures.
(Schultz-Krohn et al., 2006)
These techniques are preparatory. Purposeful activity then follows so that the patient
applies the effects of the triggered motor responses during functional activities. The
occupational therapist can also use visual or auditory prompts to encourage the required
responses within intervention.
Movement science
This remedial approach to physical neurorehabilitation is also known as motor relearning
programming (MRP), functional and task-oriented approaches, founded by Carr and
Shepherd in the 1980s (Carr and Shepherd, 1987). It emphasises the practice of the
functional task or action itself as the remedial component promoted by principles of
motor learning, including use of instruction, explanation, manual assistance, visual and
verbal feedback on performance, reinforcement and contextual practice. Thus, it aims to
facilitate motor relearning through use of meaningful activity, feedback and practice. This
approach emphasises neuroplasticity and addresses concerns regarding negative effects of
compensatory use of the affected side, learned non-use and use of adaptive aids on motor
learning by altering task requirements.
Assessment utilises functional task analysis where the patient’s performance is compared to norms and analysed to identify the specific biomechanical components of movement that are problematic. Hypotheses as to the biomechanical reason for altered movement are tested to direct intervention.
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Techniques/methods
The intervention programme involves the following:
r Training the missing or impaired components in relation to a functional task goal using
instruction, verbal and visual feedback and manual guidance.
r Manual guidance may be passive or the therapist may spatially or temporally ‘constrain’
or stabilise parts of the limb to reduce the degrees of freedom that the patient is required
to control. As the patient improves, this ‘constraint’ is reduced and replaced by verbal
guidance or becomes object mediated.
r Feedback will depend on the stage of learning the patient is at, moving from more
extrinsic to more intrinsic sources as patients progress. Fitts and Posner (1967) describe
three stages of learning:
– Cognitive – Patient requires external cues and prompts how to perform the skill
accurately. Mental imagery can also be used here.
– Associative – Patient begins to refine the skill through practice, repetition and intrinsic
sensory feedback.
– Autonomous – The skill becomes automatic for the patient and there is less need
for conscious cognitive processing. The patient starts to generalise the skill across
different environments and transfer the skill to different tasks.
r Task-specific, goal-oriented exercises are emphasised with self-monitored practice of
functional tasks outside of training sessions. Structured learning with involvement of
other staff and patient relatives is encouraged for a consistent approach.
r Transference of training with variation of context to aid motor learning.
r Positioning and muscle stretching to maintain soft tissue length and minimise spasticity
are also utilised.
In physiotherapy practice, MRP is reported to differ to Bobath concept approaches in
the principles of learning followed (degree and type of feedback provided), the type of
stimuli used (degree of use of everyday objects during treatment) and the emphasis on
task-specific practice (Marsden and Greenwood, 2005; van Vliet et al., 2005; ISWP, 2008).
Constraint-induced movement therapy approach
Constraint-induced movement therapy (CIMT) is a behavioural approach that involves
restraint of the unaffected arm with intensive training of the paretic arm conducted by a
clinician using shaping and repetition (Wolf et al., 2006). Shaping involves small steps
of progressing difficulty and activities are designed to enable patients to carry out parts
of a movement sequence; verbal feedback is always positive for any small gains made
(Zoltan, 2007).
Taub (1980) described learnt non-use of the affected upper limb in monkeys whereby
the animal stops using the affected upper limb due to frustration from lack of success. This
learned non-use corresponded to decreased cortical representation. Applying theories of
neuroplasticity, CIMT was found to reverse this effect and improve recovery and function
of the affected upper limb.
There is now a substantial body of evidence supporting this technique and CIMT
is recommended in the National Clinical Guidelines for Stroke (ISWP, 2008). Patients
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should be at least 2 weeks post stroke onset, have at least 10 degrees of voluntary finger
extension, have good cognition and be independently mobile before CIMT is considered
(ISWP, 2008). In trials such as Wolf et al. (2006), Taub et al. (2006) and Fritz et al. (2005),
the patients received 6 hours of CIMT and wore the restraint for 90% of the waking day
for 2 or more weeks. In addition to restraint and intensive task-oriented practice, CIMT
includes the use of a ‘transfer package’ of behavioural methods to facilitate transfer
of training outside the clinical setting. The package includes a behaviour contract (for
both the patient and the caregiver providing support), daily diary of activities to address
psychosocial barriers, Motor Activity log, personalised home skill assignment and daily
home practice (Blanton et al., 2008).
The practicalities of incorporating CIMT into daily practice, both in hospital and in the
community, are a challenge and only a limited number of patients will benefit. However,
the evidence is now clear and therapists must keep this technique in mind for appropriate
patients.
Bilateral arm training/isokinematic training approach
Bilateral arm training is where the unaffected limb facilitates the affected limb in synergistic coordinated voluntary movements and is recommended for subacute and chronic
phases of recovery (Stewart et al., 2006; ISWP, 2008). It is based on theories that contralesional activation may activate the lesioned hemisphere or adaptively strengthen ipsilateral
pathways to facilitate recovery of the affected limb. In contrast to CIMT, patients at all
severity levels may benefit from bilateral arm training to some degree but may require
different training approaches (McCombe Waller and Whitall, 2008).
Occupational therapists should incorporate this approach into the intervention plans of
patients who may benefit. Many activities that occupational therapists traditionally use
could be modified to involve this targeted practice. It is important to remember that in
the research the training was conducted intensively for 50–90 minutes 5 days/week for
between 2 and 8 weeks, which may be difficult to implement in everyday clinical practice
(Stewart et al., 2006).
Mental imagery approach
Mental imagery or mental practice has been described as the internal rehearsal of movements without any physical movements (Jeannerod, 1994; Crammond, 1997). An essential
part of mental imagery is the ability to create clear and powerful images of the task required
on demand. The practice must have functional relevance and meaning to the individual
to enable more successful visualisation. Athletes and musicians are known to use mental
imagery training to improve their performance, that is, athletes mentally practise the body
movements required for particular body actions when the field is not feasible (Ryan and
Simons, 1981).
Little is known about the neurophysiological mechanisms underlying recovery of motor
function following mental practice in patients with stroke. With advances in neuroimaging
techniques, these mechanisms could be better understood and assist in the selection of
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specific intervention strategies either in combination with mental practice or in isolation
(Butler and Page, 2006).
Caldara et al. (2004) evaluated studies on the role of executive motor systems (primary
motor area M1) during imagery. They concluded that primary motor structures are involved
to the same extent in actual or imagined execution and of motor acts and that differences
only take place at the late preparation period and consist of a quantitative modulation
of activity in the structures. Thus, using mental imagery to activate these areas may
maintain neuronal activity that would deteriorate without stimulation and prime pathways
in readiness to promote motor function.
Although there is some evidence that mental imagery is useful following stroke, systematic reviews suggest that further research is required to clarify the content and measurement
of mental imagery (Braun et al., 2006; Zimmermann-Schlatter et al., 2008).
Electromyographic (bio) feedback
Involves the use of external electrodes applied to muscles and instrumentation to convert electrical potentials from muscles into audio or visual information. This augmented
feedback is based on behavioural and motor learning theory where extrinsic feedback is
used to supplement potential impaired intrinsic sensory-perceptual feedback to improve
reacquisition of motor skills. There is some evidence to support its use to augment standard treatment (Woodford and Price, 2007) but routine use outside of clinical trials is not
recommended (ISWP, 2008).
Functional electrical stimulation
Electrostimulation is thought to be beneficial to train and strengthen muscle contractions. However, results remain inconclusive and should not be used routinely outside
specialist clinical trials (Pomeroy et al., 2006; ISWP, 2008). Nevertheless, there is
some evidence for its use to manage persistent subluxed shoulder pain and foot drop
where orthoses are ineffective and improved gait is demonstrated with use (ISWP, 2008).
Robotics
An emerging strategy is the use of electromechanical and robotic devices. Although some
training-specific benefits have been found for improving motor strength, no evidence has
been found for improvements in ADL (Mehrholz et al., 2008). Exploration into robotics
to augment repetitive practice and incorporate more distal limb function is required.
Summary of evidence for approaches
It has been demonstrated that comprehensive occupational therapy intervention for stroke
is effective for reducing activity limitations in personal and extended ADL and improving
social participation (Trombly and Ma, 2002; Steultjens et al., 2003; Walker et al., 2004;
Legg et al., 2007). However, evidence for specific approaches used to achieve these
outcomes or for restoration of impairments is less clear (Ma and Trombly, 2002). There
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is some evidence that adaptive approaches for self-care may be more effective than
restorative approaches, but this conclusion may be confounded by lack of distinction
between stage of recovery and heterogeneous research (Haslam and Beaulieu, 2007).
The majority of evidence for specific treatment approaches is predominantly generic
or physiotherapy based, despite similarities (Booth and Hewison, 2002) and inherent
differences between the disciplines where occupational therapy by its very nature is taskspecific and application of treatment approaches is likely to differ (Ballinger et al., 1999;
De Wit et al., 2006; De Wit, 2007).
Langhorne et al.’s (2009) systematic review of motor recovery after stroke highlights
difficulties, making conclusions from research with heterogeneous populations, varied
intervention protocols and questionable use of sensitive, targeted outcome measures that
consider change at both impairment and functional levels. Nevertheless, approaches that
involve high-intensity, repetitive task-specific practice and feedback on performance may
be particularly influential on recovery.
Thus to be truly evidence based, occupational therapists will need to continue to draw
on appropriate evidence that is specific to their individual patients’ contexts and the setting
in which they work, as evidence to date can only provide broad guidance.
Further, task-specific research is required to guide therapists’ clinical reasoning to
accurately predict patients’ recovery potential and educate patients about choice of specific
treatments. More information is required regarding the characteristics and symptoms of
who benefits, what is it about specific treatments that work, when is the most appropriate
time to implement specific treatments and at what intensity.
Self-evaluation questions
1. What are the similarities and differences, advantages and disadvantages between a
normal movement approach and a motor relearning approach?
2. (a) What conceptual models, frames of reference and intervention approaches do
you use in your practice?
(b) How do they relate? Draw a mind map or conceptual model to describe the
theoretical basis of your practice and how your models, frames of reference and
intervention approaches link together.
(c) Write a reflection on this for your CPD and compare with others in your team.
3. What conceptual models, frames of reference would be useful to consider in your
practice that you do not already use? Draw up a plan of how you could integrate a
new model or frame of reference into your practice.
4. What intervention approaches do you already use in your practice? In a reflection, consider comparing the strengths and limitations of each approach that you
use?
5. What approaches would you like to know more about? Pick one and plan an in-service
training session on it for your colleagues (including a reflection on how it worked
with one of your patients).
6. What are the four main mechanisms of neuronal plasticity?
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7. Within synaptic transmission, what is the mechanism for short-term potentiation
(STP)?
8. Within synaptic transmission, what is the mechanism for long-term potentiation
(LTP)?
9. How does the restorative (remedial) approach relate to neuroplasticity?
10. Select a restorative (remedial) approach and justify its use in utilising the theories of
neuroplasticity.
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Chapter 3
The Occupational Therapy Process
Melissa Mew and Janet Ivey
This chapter includes:
r
r
r
r
The occupational therapy process
Procedural reasoning in different stroke care settings
Professional duties
Self-evaluation questions
Introduction
This chapter focuses on how occupational therapists use the ‘occupational therapy process’ to work systematically from referral through to discharge and follow-up. Further
refinement of procedural clinical reasoning associated with occupational therapy roles
within different settings and phases of working with stroke patients will be considered
before professional duties and competencies are addressed.
The occupational therapy process
Assessment requires the therapist to draw on their theoretical knowledge (conceptual
model and frame of reference) and clinical experience to make a clinical judgement
of what is to be assessed and how. Assessment requires proficient clinical observation
and task analysis skills. It often includes a variety of standardised and non-standardised
measures that inform the occupational therapist about the extent of impairment, activity
and participation limitations while considering the environmental and social contexts,
which enable prioritised goals to be set for intervention (Figure 3.1). It is important at this
stage to understand the patient/carer in relation to their cultural and lifestyle needs. Liaison
with relatives and/or friends, and other professionals involved in the patient’s management,
helps to develop a broad picture of the patient and carer in terms of their needs and
wants. Where possible, methods selected should also assist in evaluating outcomes of
interventions. Clear communication of assessment results to others is a component of
effective assessment (Duncan, 2006).
Goal Setting is a collaborative process between the therapist, patient and their family (where appropriate) involving education and negotiation. Initially, therapists should
Occupational Therapy and Stroke, Second Edition Edited by Judi Edmans
© 2010 Blackwell Publishing Ltd. ISBN: 978-1-405-19266-8
Are your paents receiving
a minimum of 45 mins daily
of each therapy required?
(ISWP, 2008)
Occupaonal Therapy
Works!
(Cochrane Review,
Legg et al., 2006)
Figure 3.1 Occupational therapy interventions in stroke rehabilitation. (Reproduced with permission from College of Occupational Therapists
Specialist Section Neurological Practice, 2008.)
Specialist use of
compensatory strategies, aids
and adaptive devices to
modify activities and/or the
environment to enable
patients to participate in a
full life.
Adaptive OT Intervention
ICF (WHO, 2001)
Participation
(Restriction)
Personal factors
Activities
(Limitation)
Environmental factors
Body Structure and Function
(Impairment )
Are your paents receiving
Occupaonal THERAPY or
just good discharge
planning? (QM 10 DH, 2007)
(QM8 DH, 2007)
Occupaonal therapy differs from
• Physiotherapy (De Wit, 2007)
• Nursing (Booth
., 2001)
• Clinical/neuro psychology
• Social work
15:19
(disorder/disease)
Specialist use of functional
Remedial OT Intervention
activities for targeted
Specialist use of purposeful graded
screening of all stroke
activity as a medium for reducing
patients to identify potential
physical, cognitive-perceptual and
impairments and activity
psychosocial impairments and
limitations requiring
subsequent activity limitations.
intervention.
Health Condition
OT Assessment
Are your patients getting the full benefit?
April 22, 2010
Some cognive-perceptual
loss should be assumed and
potenal impact on
paents’ lifestyles assessed
Are ALL strokes and transient
ischaemic episodes on your
HYPERACUTE unit screened
by a Specialist Occupaonal
Therapist
Occupational Therapy
Hyperacute → Rehabilitation → Community Integration
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ascertain patients’ and their family’s long-term goals or where they see themselves at the
end of therapy. Long-term goals are aspirational, giving patients hope and motivation to
engage in the therapeutic process. If aspirational goals are crushed by realism, patients
may lose all hope and not engage in life or therapy at all. They represent the patient’s
present occupational identity and can change over time as they gain insight into their
strengths and limitations. In contrast short-term goals need to be client-centred and collaborative, specific, measurable, achievable, realistic and timely (SMART). Short-term
goals form the steps needed to work towards the long-term goal. These can be used to
measure outcomes, for example, by using the Goal Attainment Scale (GAS) (Kiresuk
et al., 1994). In addition they allow patients, therapists and team members to maintain
direction, motivation, monitor progress and gain insight into how achievable the longterm goal is or whether the long-term goal needs to be adjusted, thus allowing patients to
transform their occupational identity to a more realistic sense of self.
Interventions enable patients to meet their goals and ultimately aim to reduce activity and participation limitations (Figure 3.1). Rehabilitation has been defined as a
problem-solving and educational process aimed at maximising recovery by using restorative (remedial) approaches to reduce impairments and adaptive (compensatory/functional)
approaches to prevent impairments from translating into functional disability (activity
and participation limitations) (Wade, 1992; Intercollegiate Stroke Working Party (ISWP),
2008).
With inherent focus on occupation, restorative (remedial) approaches may initially appear reductionist and not fit comfortably with some occupational therapists; however, they
are important particularly in the first 6 months to optimise neuroplastic recovery. Furthermore these approaches do still fit in with occupational therapy philosophy as long as they
are clearly linked to occupational performance goals. Adaptive (compensatory/functional)
approaches may involve the analysis and adaptation of the task/activity/occupation itself
or of the physical/social environment to improve occupational performance (Duncan,
2006).
Approaches are selected depending on the conceptual models and frame of reference
that the therapist deems most appropriate and will depend on the patient’s prognosis,
phase of rehabilitation, capacity for impairments to be reduced, consequences on activity
and participation, therapists’ own knowledge and skills limitations and consistency with
the multidisciplinary team’s approach. Therapists should also consider the evidence base
regarding selected approaches, consulting the national clinical guidelines in the first
instance (ISWP, 2008) before lower levels of evidence are considered that apply to the
patient’s context.
Therapists should strive to provide as much therapy as is appropriate to meet patients’
needs and that they are willing and able to tolerate. A minimum of 45 minutes of therapy is
recommended in acute phases with opportunities for repeated practice and generalisation
across tasks (ISWP, 2008).
In both restorative (remedial) and adaptive (compensatory/functional) approaches, occupational therapists more obviously enable patients by using occupation as the ends
(where the end goal of occupational therapy is towards facilitating occupational performance capacity via addressing impacts of ill health). However, occupational therapists
working with stroke patients are strongly encouraged not to lose sight of occupation as the
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means (where the end goal of occupational therapy is towards occupational identity via
processes of engagement and empowerment to improve quality of life). Although these
are by no means mutually exclusive – each can impact on the other – ease with which
both these principles can be employed may be influenced by the setting.
Whatever type of intervention is offered, it is essential that the exit of this period is
clearly signposted by agreed outcomes and the move to the next phase is planned and
understood.
Evaluation of occupational therapy effectiveness ‘is an ethical and professional imperative’ (Duncan, 2006). At the patient level, ongoing evaluation enables the appropriateness of intervention to be monitored, allowing opportunties for adjustment. Evaluation of patient outcomes determines if therapy has been sucessful, whether agreed
goals have been met and whether patients are satisfied with the intervention. Evaluation
should be appropriately aimed at the level of intervention: impairment, activity, participation. At a therapist level, therapists have a professional responsibility to evaluate their
practice against both profession-specific and stroke-specific standards and guidelines.
Therapists also have a responsibility to evaluate their practice through reflection and
other continuing professional development activities whilst considering their efficiency
and cost effectiveness. At a service level, therapists are involved in evaluating services
through clinical and organisational audits and patient and staff feedback.
Transition between services/discharge
Transition between different teams should ensure that all appropriate information be
handed over in a timely manner to prevent unnecessary repetition of services already
provided. Locally agreed sets of terminology, assessment tools, outcome measures and
documentation should be used to facilitate ease of transfer. The patient should be involved
in decision making regarding transfer of care and be offered copies of transfer documents, including information regarding services (ISWP, 2008). In the UK, coordinated
communication between services may include neurovascular clinics, inpatient stroke units
(hyperacute and subacute), early supported discharge or intermediate care teams, community rehabilitation teams (including therapists servicing residential and nursing homes),
private therapists, social services and follow-up monitoring teams such as specialist community teams, the community stroke liaison practitioner (CSLP) and general practitioner
(GP).
When a therapist stops giving rehabilitation, the therapist should:
r Discuss the reasons for this decision with the patient.
r Ensure that any continuing support the patient needs to maintain and/or improve
health is provided. This may include exercises, integration into general community
programmes, information regarding equipment hire and purchase (e.g. Red Cross,
Shopmobility), information leaflets (from Chest Heart Stroke, Stroke Association and
College of Occupational Therapists Specialist Section Neurological Practice), information about stroke/carer support (including local groups, Stroke Association website and
Different Strokes for under 65s).
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r Educate the patient and, if necessary, carers and family how to maintain occupational
performance, health and well-being.
r Provide clear instructions on how to contact the service for reassessment, and outline
what specific events or changes should trigger further contact (ISWP, 2008).
Follow-up
All patients with residual impairments after the initial period of rehabilitation should
be offered a formal 6-monthly review so that appropriate referrals can be made if the
patients experience new problems or their circumstances have changed warranting further therapeutic interventions (ISWP, 2008). This may be by a member of a specialist
multidisciplinary team (MDT), CSLP or GP depending on residual symptoms and stroke
severity.
Particular areas to focus on during follow-up appointments include any changes in
impairment (e.g. cognition), activity (e.g. activities of daily living), participation (e.g.
fatigue), environmental and personal (e.g. mood, stress resistance, social support, quality
of life) circumstances since discharge. Comparison to discharge outcome measures should
be made to determine whether re-referral for burst of therapy or signposting to other
services is required.
Procedural reasoning in different stroke care settings
Clinical or professional reasoning is a science and an art. Understanding the thinking that
guides practice is complicated. All forms of clinical reasoning – scientific (diagnostic
and procedural), narrative, pragmatic, ethical, interactive and conditional reasoning (Boyt
Schell and Schell, 2008) – influence the occupational therapy process no matter in which
settings occupational therapists may work with stroke patients. However, there are some
common patterns of procedural reasoning worth delineating that are associated with different settings, which may help guide therapists new to working with stroke. It should be
noted that these general ‘procedures’ are by no means definitive and will always be influenced by concurrent reasoning about the patient’s unique presentation and circumstances
at the time.
Neurovascular clinics
In response to national guidelines, the number of rapid access neurovascular clinics
(NVCs) for transient ischaemic attacks (TIA) and minor strokes to improve comprehensive stroke services has risen. However, no indicative role for occupational
therapists in NVCs has been outlined in national stroke guidelines (ISWP, 2008; National
Collaborating Centre for Chronic Conditions (NCC-CC), 2008). Nevertheless, it is
argued that occupational therapists have an important role in exploring the functional
implications of issues frequently overlooked by consultants who are medically focussed
and more easily able to pick up the physical symptoms. At this point it should be noted
that the FAST or ABCD scoring systems (Intercollegiate Stroke Working Party (ISWP),
2008) to identify when someone has had a stroke to trigger admission to specialist units
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for multidisciplinary assessment, neglect the subtle cognitive and psychosocial symptoms
that may arise from frontal lesions and even smaller lesions that are not detected by
imaging, but may have a tremendous impact on patients’ well-being and quality of life.
By employing a holistic approach, occupational therapists can expertly screen for
the functional implications of issues frequently overlooked in minor stroke (such as those
arising from hemianopias, fatigue, anxiety/depression, high-level cognitive and high-level
motor impairments). Even for TIAs, occupational therapists may play an important role
in regards to health promotion referring on for adaptive (compensatory/functional) equipment needs and attempting to reduce social isolation, which is commonly experienced in
elderly populations. This enables the occupational therapist to help the consultant signpost
patients for referral to appropriate services. Clearly the cost effectiveness of occupational
therapists in this emerging role has not yet been evidenced and further research is required. In the meantime, therapists are encouraged to promote the role of occupational
therapy in NVCs and to liaise with consultants to establish direct or indirect methods to
improve comprehensive stroke care. For example, therapists may negotiate direct face-toface contact time with patients and carers during clinic appointment or become indirectly
involved in screening by contributing to consultant’s screening assessments that include
impairment, activity, participation, environmental and personal factor concerns with an
on-call bleep or detailed referral procedures in place (that include follow-up phone calls,
referral to community rehabilitation teams, sensory loss teams, social services and support
networks) should functional issues be identified. To support the evidence base regarding
the effectiveness of the role of occupational therapists in NVCs, audit and dissemination
of results through publications, conferences and newsletters is highly recommended.
An example of procedures to consider for occupational therapists working in NVCs is
as follows:
TIAs and minor strokes ∼0–7 days post stroke (ISWP, 2008).
To screen for functional implications arising from minor stroke and
consider health promotion needs in the at-risk population so that
appropriate signposting and referrals can be made.
Assessment: Consider initial symptoms and potential implications using
knowledge of functional anatomy.
As patients are currently in their home environment, they may have
more insight into functional changes than those admitted at time of
event. Thus, screen for changes in functional activities, particularly
high-level ADLs such as outdoor mobility, stairs, bath transfers,
dexterity for managing fasteners, concentration for/understanding
reading, memory, organisation skills to managing finances, fatigue,
mood (anxiety/depression/irritability), worker/productivity role,
maintaining leisure and social interests, coping in dynamic/
community environments, for example, shopping.
Liaise with significant others when patients are being assessed by the
doctors to confirm patient’s report and alert consultant and patient to
significant discrepancies.
Caseload:
Aim:
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Referral to rapid access specialist community/outreach teams.
Referral to community teams/social services/sensory loss teams.
Some functional implications, for example, mood/coping in dynamic
settings may be too early to identify if patients have not participated
in these activities since the event, but alerting patients during the
clinic to liaise with GP if these symptoms should arise and providing
information leaflets should be considered.
Acute stroke units (hyperacute care)
Once patients are admitted to specialist stroke units, occupational therapists should be
involved in screening all patients (ISWP, 2008). It is argued that for the same reason
for screening in NVCs, occupational therapist should also screen TIAs who are admitted
to acute stroke units (ASU). Hence, although guidelines state that occupational therapy
assessment should occur within 4 days of admission (ISWP, 2008), a method of screening
to prioritise and fast track high functioning patients who might be imminently discharged
is required.
General prioritisation of patients admitted should consider:
r
r
r
r
r
r
r
r
r
Imaging (computerised tomography/magnetic resonance imaging) results.
Monitoring for alternate oncology diagnoses; plans for neurosurgical intervention.
Referring onto other teams for non-stroke management and discharge planning.
Is feeding established? (swallow assessment/independence in feeding).
Mobility/transfers/ability to sit out > 2 hours in supported/normal seating.
Patient’s level of alertness.
Continence.
Cognitive/perceptual symptoms.
Communication.
(Poole Hospital NHS Foundation Trust, 2006)
Patients for high priority for occupational therapy intervention on ASU are those:
r Who require a screening assessment to prioritise, for example, via liaison with team,
reviewing medical notes. This may be due to the patient having been admitted or
transferred onto ASU within the last working day. Outcome of prioritisation should
be clearly documented in patient notes with any plans to monitor/review prioritisation
status.
r Whose assessment of premorbid and current cognitive/perceptual function is required,
particularly when the patient is physically able and discharge may be imminent.
r Whose discharge planning requiring occupational therapy intervention is imminent.
r Whose urgent occupational therapy intervention is required for maintenance of function/prevention of deterioration, for example, posture, positioning or oedema management.
(Poole Hospital NHS Foundation Trust, 2005)
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An example of procedures to consider for occupational therapists working in
ASU/hyperacute care (based on Poole Hospital NHS Foundation Trust, (2006), reproduced with their kind permission):
Caseload:
All stroke patients – particularly those of high priority (above) (ISWP,
2008).
Aim:
To provide early screening assessment of stroke patients admitted to
ASU and contribute to MDT decision regarding patient’s potential:
r To be discharged home from ASU with or without ongoing intervention from early
supported discharge/intermediate care/community teams.
r To benefit from inpatient rehabilitation.
r Functional implications post discharge in consideration of home/social situation.
Assessment: Targeted screening assessment informed by imaging results and
clinical experience should be developed.
Minimum assessment for all high priority patients should include the
following:
r Initial interview regarding home situation and past medical/social and occupational
performance history (including personal care, domestic activities, types of meal
preparation for breakfast, lunch and dinner, managing medications, finances,
gardening, driving, leisure interests, productivity/worker role (confirmed with next
of kin or carers if from supported living environment)). Liaise with physiotherapy
regarding need for stairs/steps assessment.
r Functional transfers including bed, chair (note with or without arms), toilet (≈43
cm height), bath (if applicable as may save referral to social services occupational
therapists) with information regarding furniture heights at home particularly if
some amount of effort demonstrated with transfers on ward.
r Upper limb sensorimotor screening including functional active range of
motion/coordination/reported sensation at minimum. If impairments evident,
assess further. Use ability to take shoes/socks on/off, reach behind back to do up
bra or apron bow, reach head with both hands to put on pullover, and ability to
manage fasteners as estimation of physical independence with personal care.
r Visual processing including visual acuity, visual fields, inattention (visual and
tactile), and oculomotor skills (latter especially if pt reports double vision, field
loss or has brainstem/cerebellar/occipital lesions).
r Cognitive/perceptual screening.
If none apparent in conversation/on ward – confirm with nursing staff in function
then. . .
r If patient previously assisted with domestic and community activities and
non-demanding leisure interests – no further assessment required.
r If patient lives alone ± previously independent with domestic, community
activities, driving or has interests that involve higher level cognition, for example,
complete an assessment that includes planning/organising/prioritising/problem
solving. If working age, screen for high-level cognition, executive functions and
information processing speed comparing against normative data.
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If cognitive/perceptual impairments or frontal/parietal/temporal damage is reported,
complete further cognitive perceptual screen.
r Appropriate and relevant functional assessment designed to challenge patients and
reveal potential problems, for example, involving multitasking, coping in dynamic
community environments, if premorbidly appropriate, patient mobile and
approaching discharge. Assess at minimum meaningful functional task requiring
multitasking and problem solving, for example, Kitchen Assessment hot drink +
breakfast/snack (e.g. toast/porridge or sandwich) in unfamiliar kitchen.
From above assessment consider. . .
r Further targeted assessment in light of imaging results, initial symptoms and
screening.
r Personal care assessment simulating home environment, that is, strip
wash/shower/bath where possible.
r Home assessment ± meal preparation ± shopping (particularly for patients
previously independent, living alone and with cognitive/perceptual problems
evident on ward kitchen assessment, which may not be apparent in personal care,
e.g. apraxia).
r 24-hour supervised leave (e.g. supervised by family member informed by the
occupational therapist) especially for high-level cognitive/perceptual problems,
for example, frontal damage, apraxia.
Intervention: If appropriate advise patient of being uninsured to drive without
medical consent.
Restorative (remedial) and adaptive (compensatory/functional)
approaches to facilitate discharge.
Discharge:
Consider referrals to:
r Community stroke liaison practitioner ± occupational therapy follow-up phone
call.
r Early supported discharge schemes/in-reach or out-reach intermediate care.
r Follow-up community occupational therapy (including referrals for mild slowed
thought processing/ high-level attention impairments).
r Sensory loss team (if visual/hearing impairment – possibly premorbid).
r Social services occupational therapist for rails/adaptations/bath equipment.
Subacute/inpatient rehabilitation units
Subacute inpatient rehabilitation forms the focus of most of this book. Particular note
should be made for young strokes to consider family roles.
An example of procedures to consider for occupational therapists working in subacute
stroke inpatient units:
Caseload:
Aim:
1–26 weeks months post stroke (ISWP, 2008).
To provide appropriate restorative (remedial) and adaptive
(compensatory/functional) intervention to facilitate recovery by
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improving performance capacity (reduce impairment and activity
limitations).
To facilitate appropriate discharge planning.
Review prioritisation.
Assessment: More in-depth assessments are required based on results of screening
assessments.
Intervention: Restorative (remedial) and adaptive (compensatory/functional)
approaches.
Acute ‘patients should undergo as much therapy appropriate to their
needs as they are willing and able to tolerate and in the early stages
they should receive a minimum of 45 minutes daily of each therapy
that is required’ (ISWP, 2008: p. 39).
Discharge:
Any person who has limitations on any aspect of personal activities,
especially but not only if acquired as a result of this stroke, should
consider referral to:
r Community stroke liaison practitioner ± occupational therapy follow-up phone
call.
r Early supported discharge schemes/in-reach or out-reach intermediate care.
r Follow-up community occupational therapy.
r Sensory loss team (if visual/hearing impairment – possibly premorbid).
r Social services occupational therapist for rails/adaptations/bath equipment.
r Stroke/carer support groups.
Early supported discharge
Upon leaving hospital, lifestyle often changes considerably by the effects of a stroke. A
person needs to have choice to be empowered in a supportive environment. Resources and
facilities of course vary from region to region. However, any improvement in the links
between hospital and community services can only ease this difficult transition.
An example of procedures to consider for occupational therapists working in early
supported discharge (ESD) and intermediate care teams:
Caseload:
Aim:
Subacute (1–26 weeks) (ISWP, 2008).
To facilitate transition from inpatient to home environment using
appropriate restorative (remedial) and adaptive
(compensatory/functional) strategies.
Assessment: Handover from inpatient team.
Consider impairment and activity levels.
Intervention: See Chapter 9.
Discharge:
Consider referral to:
r Follow-up community occupational therapy.
r Sensory loss team (if visual/hearing impairment – possibly premorbid).
r Social services occupational therapist for rails/adaptations/bath equipment.
r Stroke/carer support groups.
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Community rehabilitation and resettlement
With a push to reduce length of hospital stay and success of ESD teams, the scope of
community rehabilitation to include restorative (remedial) intervention aimed at reducing
impairments alongside adaptive (compensatory/functional) intervention focusing on reducing activity and participation limitations is growing. Consequently, community teams
need to become increasingly skilled and specialist community teams are recommended
for stroke care.
An example of procedures to consider for occupational therapists working in community
rehabilitation teams:
Caseload:
Aim:
Subacute – chronic strokes.
To provide appropriate restorative (remedial) and adaptive
(compensatory/functional) intervention aimed at reducing
impairments, activity and participation limitations in consideration of
affecting environmental and personal factors.
Assessment: Handover from inpatient team.
Consider all levels of assessment as appropriate – particularly activity
participation and personal factors.
Intervention: See Chapter 9.
Occupational performance and occupational identity – Focussed at
reducing impairment (if subacute), reducing activity and participation
limitations, addressing environmental and personal factors.
Empowerment – resuming control of their own affairs – including
work and leisure.
Confidence and self-esteem building groups.
Adjustment to residual disability as well as facilitating a return to
meaningful lives.
Integration into social and voluntary organisations.
Discharge:
Ensure follow-up monitoring systems in place.
Ensure access to ongoing support and advice.
Health promotion
Considering the relationship between occupation and heath it is not surprising that the role
of occupational therapy in primary (targeting the well population to prevent ill health), secondary (targeting at risk groups) and tertiary health promotion (maximising potential for
healthy living) is high on the emerging agenda (College of Occupational Therapists, 2008).
Long-term follow-up studies suggest that stroke patients may deteriorate post discharge
from stroke services and have symptoms of depression (Wilkinson et al., 1997). Health
promotion after stroke may include exercise, nutrition, health behaviour and prevention
of secondary stroke (Rimmer and Hedman, 1998). Occupational therapy intervention for
stroke patients in nursing homes has been found to be effective for reducing deterioration
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in function (Sackley et al., 2006) and lifestyle redesign programmes for the elderly look
promising (College of Occupational Therapists, 2008).
Professional duties
Code of conduct
The College of Occupational Therapists (2005) produced a code of Ethics and Professional
Conduct for use throughout the UK. The title Occupational Therapist is protected by law
and can only be used by those who hold a diploma or degree in occupational therapy
and are eligible for registration with the Health Professions Council (HPC). Occupational
therapy personnel refers to occupational therapists (including managers, educators and
researchers), students and support workers.
The code of conduct is a public statement of values and principles to promote and
maintain high standards of professional behaviour.
The code covers:
r
r
r
r
Patient autonomy and welfare.
Services to patients.
Personal and professional integrity.
Professional competence and standards.
Standards of conduct and performance are also an essential requirement of registration
with the HPC (2007a), which sets out 14 areas that HPC registrants must adhere to,
covering:
r
r
r
r
r
r
r
r
r
r
r
r
r
r
Acting in the best interest of patients.
Confidentiality.
Personal conduct.
Provision of information on conduct and competence.
Up-to-date professional knowledge.
Acting within limits of competency.
Communication.
Supervision of others.
Consent.
Record keeping.
Infection control.
Judgement.
Honesty and integrity.
Advertising.
HPC competencies
The HPC (2007b) also sets out standards of proficiency for occupational therapists for the
safe and effective practice of health professions. The generic standards are set out under
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the headings below but the document also sets out the occupational therapy professionspecific standards; these can be accessed on the HPC website.
Generic standards encompass:
r Professional autonomy and accountability.
r Identification and assessment of health and social care needs.
r Knowledge, understanding and skills.
The NHS knowledge and skills framework (NHS KSF) and the
development review process (applicable to the NHS in England; Health
and personal social services in Northern Ireland; NHS Scotland; and NHS
Wales)
The NHS KSF defines and describes the knowledge and skills which NHS staff need to
apply in their work in order to deliver quality services. It provides a single consistent
comprehensive and explicit framework on which to base review and development for all
staff (Agenda for Change Team, 2004).
The main purpose is to provide an NHS-wide framework that can be used consistently
across the service to support personal development in post, career development and service
development. It has been developed by joint management and staff side working together
using existing competencies to inform developments.
The NHS KSF learning programme, 2004 states that the KSF has been designed so that
there are common descriptions of knowledge and skills that are applicable and transferable
across the NHS, making it simple and easy to implement.
It does not describe people or attitudes, exact knowledge and skills that people need to
develop, job weight or band.
Development review
A KSF outline is developed for every post; the individual is matched against the KSF
outline for their post. Personal development plans are agreed and supported with the
individual learning in a variety of ways. The learning is then evaluated.
The development needs are linked between the individuals needs and the requirements
of the post. The KSF will be used as a recruitment and induction as well as through out
the individuals working life, this should provide a fair and objective framework to base
the review upon, guide development and assist with pay progression in the service. This
process entails an annual review, a personal development plan and the expectation that all
individuals are required to learn and develop.
Career development
This involves building on the development plan particularly after the second gateway; the
KSF will assist in possible development routes. It involves commitment to development
and feedback.
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Service development
The KSF should help individuals understand their role in effective service delivery to
improve patient care.
Skills for health
Skills for Health has directors in regions in England, a director in Scotland, Northern
Ireland and Wales, and a web-based tool of the Sector Skills Council (SSC) for UK health
environment. The aim is to assist in developing solutions for a skilled and flexible UK
workforce in order to improve health and health care. This is achieved via education,
working with policy makers and health employers to profile the UK national workforce
and improve skills available.
There are 25 skills councils licensed by the individual countries’ education ministers.
Their aims are to boost skills and learning addressing any skills shortages and boost
productivity.
Skills for Health has developed competencies to describe what individuals need to do,
what they need to know and which skills they need to carry out an activity. They can be
used across the board – by all health professions, and all levels of staff, whether in the
independent or voluntary sectors or in the NHS. Competences can be used to meet the
demands of the NHS KSF. These competences can be used to develop individuals and
services to improve patient care.
The stroke competencies are mapped against KSF health and well-being dimensions.
Stroke-specific education framework
The UK forum for stroke training has developed an educational framework directing the
elements to be delivered for staff to have the appropriate knowledge, skills and experience
to deliver high-quality care and services for stroke patients.
It is to be mapped across all the UK countries and to guide the achievement of nationally
recognised, quality assured and transferable education and learning in stroke.
The stroke-specific education framework (SSEF) details the knowledge, understanding and skills required to deliver the 16 quality markers of care on the stroke pathway
(England). It covers members of the public, health care, social care, voluntary and independent sector.
The 16 elements are covered in the four areas below:
r
r
r
r
Awareness and information.
Time is brain.
Life after stroke.
Working together/implementation.
The framework will:
r Assist in developing a stroke skilled work force; ensuring quality of care and competencies of stroke staff.
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r Guide the development of programmes to inform and educate the patient, carer and
general public regarding stroke issues.
r Enable individuals and managers to plan continuous professional development.
r Facilitate organisations to make plans and strategies to improve their services.
Self-evaluation questions
1. Does your setting document long-term aspirational goals as well as the short-term
SMART goals? Can this system be improved to enhance patient engagement and
motivation?
2. Does your setting have clinical reasoning guidelines to help guide therapists new to
the area? How might these be further developed?
3. What might a typical occupational therapy pathway look like for your patients in
your setting from referral through to discharge? Consider drawing a flow diagram,
identifying the agencies that you liaise with. Is there anything missing?
4. Who refers to you and who do you discharge to? How might patient transition be
made smoother?
5. Consider what assessments/documents can be shared to improve transition and reduce
duplication.
6. How is health promotion addressed in your practice setting? How might you integrate
this into your own practice?
7. What is the code of conduct for occupational therapists? Select and discuss five areas
that are essential requirements under the code of conduct for HPC registration and its
aims?
8. What is the main purpose of the NHS KSF?
9. In preparing for performance review and career development, how could the KSF
assist you?
10. What is ‘skills for health’ and how could you utilise the tools in developing stroke
competencies for a junior member of staff?
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Chapter 4
Early Management
Sue Winnall and Janet Ivey
This chapter includes:
r
r
r
r
r
r
r
r
Prior to assessment
Initial interview and assessment
Equipment
Communication
Swallowing
Mood
Fatigue
Self-evaluation questions
Introduction
Effective appropriate early management is vital in the care and rehabilitation process of
a patient with a stroke. It permits the gathering of appropriate information to prepare for
the patient’s ongoing assessment and rehabilitation. Key aspects of early management
are gathering relevant information about the patient, completing an effective screen and
assessment to identify key areas for further assessment and rehabilitation. One of the
most important components of early management is observation of the patient, that is,
how the patient performs on the ward or behaves during the initial interview or screening
assessment. Putting all this information together helps to formulate a clear image of the
patient, their impairments, skills, goals, motivations, so this information can be used to
prepare a clear intervention plan.
Prior to assessment
Information gathering
Before assessing the patient, it is important to gather initial information from the medical notes, other professional colleagues or reports/handover from nursing staff on the
ward.
Occupational Therapy and Stroke, Second Edition Edited by Judi Edmans
© 2010 Blackwell Publishing Ltd. ISBN: 978-1-405-19266-8
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Aim
r To gather information to guide, inform and prioritise screening, assessment and intervention.
Basic checklist
Medical history
It is important to document any comorbidities that the patient has as these may affect their
assessment and functional abilities, for example, previous fractures with residual range
of movement or decrease functioning of a joint or chronic cardiac failure that may cause
breathlessness and fatigue.
Social history
The occupational therapist should document with whom the patient lives and what social
networks they have, including their occupation and main roles. These may guide the
initial interview and assist in identifying any major concerns the patient may have, that
will impact on the rehabilitation process, for example, dependents, financial concerns, etc.
Further information may be gained from other members of the multidisciplinary team.
This background information will assist the occupational therapist in formulating a
clinical picture of the patient, prior to their initial interview/assessment.
Examples are – ward staff may report that the patient has ‘confused behaviour’, which
may be an indicator of perceptual problems; a physiotherapist may report that the patient
has difficulty following commands, which could be a language or praxis problem; the
speech and language therapist may indicate the level of comprehension a patient has and
whether yes/no responses are accurate, which will assist the occupational therapist in
deciding how to elicit information in an initial interview.
Current physical mobility
Prior to assessing the patient, the occupational therapist should ascertain how the patient
can be moved and any equipment required. This will help the occupational therapist
prepare for the initial assessment and the opportunity to arrange for assistance of others
if required. A manual handling risk assessment should also be available to ensure patient
and staff safety.
Functional abilities on the ward
Information from ward staff can be invaluable in assisting the occupational therapist in
ascertaining the functional independence of a patient and the consistency in maintaining
this independence.
However, the occupational therapist must always remember that the hospital setting is
an institution and therefore has routines and prompts that are not always available to the
patients in their home. Home environments are also more complex and patients may not
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be able to function at the same level within the home or community. The occupational
therapist must therefore endeavour to simulate the demands of the individual patient’s
particular situation in order to ascertain their abilities. Gaining background information
is therefore essential in planning the screening assessment.
Assessments already completed
The occupational therapist in their information gathering should note any assessments
previously conducted and the outcomes of these; this will save time, prevent the patient
being asked the same questions and assist the occupational therapist in prioritising the
areas for assessment. For example, any cognitive assessments, language screening or
mobility assessments can be utilised by the occupational therapist to analyse and predict
functional problems that the patient may be experiencing in their occupations.
CT scan (computerised tomography also known as CAT scan)
CT scans are invaluable in indicating the area and extent of damage caused to the brain
by a stroke.
The occupational therapist by understanding arterial supplies and the functions of the
lobes of the brain will be prepared for the potential impairments the patient may present
with.
This information can then be used to assist in directing any assessments and underlying
causes for problems in the functional abilities of the patient.
Initial interview
The initial interview may be the first time the occupational therapist actually sees the patient. Structured observations made by the occupational therapist are extremely important
and inform the occupational therapy process, for example, when observing the patient
on the ward, noting how they interact with others, what their posture is like, whether
there are signs of inattention or neglect of a limb. Structured observations such as these
provide clinical indicators of the impairments and functional difficulties a patient could
potentially be experiencing or likely to experience during their rehabilitation. Once the
occupational therapist has engaged with the patient, the patient may perform at a higher
level in an intervention session but might be unable to sustain this level of functioning
throughout the day.
The initial interview can therefore be structured and the environment/venue set up to
enable full participation, taking the above factors into account.
The accuracy of information gained can be affected by cognitive factors such as memory
and attention; communication (aphasia) can also make eliciting accurate information
difficult. Any areas that raise concerns must be checked out for accuracy.
The initial interview should try and ascertain the patients’ pre-morbid level of functioning and their social and physical environments. This is essential in order to assess
the individual’s previous levels of participation and potential for return to this. The
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occupational therapist’s approach to stroke rehabilitation and optimising functional abilities is in accordance with the World Health Organization (WHO, 2001) International
Classification of Functioning (ICF) (see Chapter 1).
The individual’s key roles and tasks undertaken provide the necessary information essential for the occupational therapist to base their assessments and interventions upon.
Undertaking purposeful and meaningful occupations is essential in the occupational therapy process and for patient motivation and participation.
The Occupational Therapy Standards for Stroke (Royal College of Physicians and
College of Occupational Therapists, 2008) state that at the initial interview ‘former levels
of functioning within the areas of self-care, productivity and leisure are discussed with
the stroke survivor’.
To audit the above standards, the Profession Specific Stroke Audit Occupational Therapy Clinical Audit (Royal College of Physicians Profession Specific Audit Group, 2007a)
investigates whether the following components were included in the initial interview:
(a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)
Home situation (physical environment)?
Home situation (sociocultural)?
Pre-stroke level of self-care?
Pre-stroke employment?
Pre-stroke domestic responsibilities?
Pre-stroke leisure activities?
Pre-stroke driving status?
Concerns of the stroke survivor?
Initial assessment
The Occupational Therapy Standards for Stroke (Royal College of Physicians and College
of Occupational Therapists, 2008) state that the initial occupational therapy assessment
should include:
r Appropriate advice on stopping smoking, regular exercise, diet and satisfactory weight,
reducing salt intake, avoiding excess alcohol.
r The needs of younger stroke survivors.
r Assessment of cognitive, motor and functional abilities.
Cognitive and perceptual screening
Cognitive and perceptual screening is a key component of the occupational therapist’s role
in stroke care. Screening is done undertaken to give the therapist more information about a
patient’s function before embarking on a full in-depth assessment. It gives the therapist an
opportunity to make observations and gain an idea of any impairments the patient might
be experiencing. It is particularly important for the ‘walking wounded’ as they can often
appear fine during observation on the ward but with a few directed questions or tasks the
impairments become apparent.
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Aim
r To screen the patient’s cognitive and perceptual capacity to determine the need for
further in-depth assessment.
r To provide an indication of the patient’s attention, memory, safety awareness, judgement, praxis and other cognitive impairments that might impact on other occupational
therapy assessments and interventions.
r To provide an indication of the patient’s visual attention, spatial relations, visual recognition and other perceptual impairments that might impact on other occupational therapy
assessments and interventions.
r Often high-level cognitive and perceptual impairments are not as apparent during daily
tasks in a controlled, routine ward environment so screening might identify concerns
that could otherwise be missed.
Basic checklist of questions or tasks directed at cognitive skills
Level of alertness
r Does the patient engage or participate in conversation or daily tasks?
r Does the patient’s level of alertness fluctuate or change over time?
Orientation
r Can the patient determine time, place and person?
r Is the patient aware of their surroundings and what has happened?
Attention
r Does the patient sustain their attention during conversation?
r Is the patient easily distractible?
r Can the patient alternate their attention effectively to tell you the months of the year
backwards?
Communication
r Does the patient follow 1, 2 or 3 step commands?
r Is the patient able to respond appropriately to questions?
Memory
r Can the patient recall information accurately during the initial interview?
r Does the patient appear to recognise you and what has happened over the recent
days?
r Can the patient remember when their next occupational therapy appointment is?
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Problem solving
r Does the patient need cues to follow out simple tasks?
r Does the patient initiate tasks or engage actively in their environment?
Praxis
r Can the patient copy movements?
r Can the patient demonstrate movements to command?
r Can the patient imitate how to use certain objects?
As well as considering the questions above, observations during functional tasks
are also vital to give an indication as to whether the patient might have a cognitive
impairment.
Observations during functional assessment that might indicate a
cognitive impairment and the need for further assessment
Attention
r Is the patient focussed on the task throughout the activity?
r Is the patient able to switch from one aspect of the task to another without prompts?
r Is the patient able to talk and engage in the task or complete two aspects of the activity
simultaneously?
Information processing
r Does the patient engage in the task at an appropriate speed?
r Does the task break down when there is novel information or with an increase in task
complexity?
Memory
r Does the patient remember what task they are engaged in?
r Can the patient find relevant items needed for a task?
Executive functions
r Is the patient able to initiate, sequence and organise the task appropriately?
r Does the patient display appropriate judgement, problem solving and safety awareness?
Praxis
r Does the patient appear to know what they want to do but are using an ineffective or
inappropriate movement for the task?
r Does the patient use appropriate objects for the task?
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If concerns in any of these areas are identified, further standardised cognitive assessment might be necessary. For detailed information relating to cognitive impairments, see
Chapter 7.
Basic checklist of questions or tasks directed at visual perceptual skills
Visual fields (hemianopia or quadrantanopia)
r Confrontation test – With eyes fixated centrally, a patient with a hemianopia or quadrantanopia is unable to identify a moving finger in affected quadrants or fields.
r Scanning task (e.g. finding all the letter ‘e’s on a page of text) – A patient with
hemianopia often presents with an abbreviated scanning pattern, missing items in
affected visual field.
r Copying a diagram (the patient is presented with a diagram to copy but not told what it
is) – A patient with a visual field impairment often only copies half the diagram unless
they recognise it, in which case they will search the page and complete it.
Visual attention
r Extinction test – Two objects are presented on either side of the patient’s visual field
that is left, right or both – a patient with visual inattention does not identify objects in
the area of reduced attention when presented with objects simultaneously.
r Scanning task – A patient with visual inattention has an abbreviated scanning pattern
but often has a disordered, random scanning pattern (unlike a patient with hemianopia
which is well organised).
r Copying a diagram – A patient with visual inattention only copies half the picture.
r Drawing a clock, including numbers, on command – A patient with visual inattention
often places all the numbers on one side of the clock or only complete one side of the
clock (a patient with hemianopia will only draw a clock with no difficulties).
Other visual perceptual impairments
r Copying a diagram and drawing clock – Is the spacing accurate? Are the diagrams
appropriate to the task?
r Can the patient identify objects when asked? Can they categorise according to colour,
shape, size or usage? Pour water into a glass?
As well as considering the questions above, observations during functional tasks are also
vital to give an indication as to whether the patient might have a perceptual impairment.
Observations during functional tasks that might indicate a perceptual
impairment and the need for further assessment
Visual fields
r Is the patient able to find all the materials they need for the task without prompts? Is
there a delay in searching on their affected side?
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r Does the patient bump into or miss information on their affected side?
r Can the patient read signs or books?
r Does the patient fill in all the information on forms?
Visual inattention
r Does the patient need prompts to search their environment?
r Does the patient appear to have difficulty turning, looking or searching on their affected
side?
r Does the patient bump into objects and have difficulty adjusting to obstacles in their
environment?
r Does the patient have difficulty watching TV, reading, using the telephone or focussing
on the person talking to them?
Other perceptual impairments
r Does the patient misjudge distance or depth?
r Does the patient have difficulty orienting clothing or spatially organising their
workspace?
If concerns in any of these areas are identified, further standardised perceptual assessment might be necessary. For detailed information relating to sensory impairments, see
Chapter 6 and for perceptual impairments, see Chapter 8.
Psychosocial screening
It is important, as a part of the multidisciplinary team, to be aware of and screen for
psychosocial issues, including mood and fatigue.
Aim
r To recognise or identify psychosocial issues to be able to refer to the appropriate
multidisciplinary team member for further assessment and intervention.
r To be aware of psychosocial state and impact on occupational therapy assessment and
intervention.
Observation
r
r
r
r
What is the patient’s emotional state?
Does the patient appear unmotivated? Tired? Depressed? Emotionally labile?
How does the patient react to or engage in therapy?
Variety of mood screens available.
If concerns in any of these areas are identified, further in-depth assessment might
be required and it is recommended that the consultant and multidisciplinary team are
informed. Referral to a psychologist might be required.
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Neurophysical screening
The patient needs to be suitably dressed for this assessment although it is often easier to
fully assess the patient when they are undressed and parts of their body are observable,
particularly their trunk, scapula and shoulder.
Undressing can be used as part of the assessment. It is always best to assess the patient
in whatever position they are initially found in as the occupational therapist’s handling
ability, that is, transfers, etc., will have an impact on the patient’s presentation. It is useful
to gather information about the patient’s movement, etc., before the structured screening
or assessment is commenced. Note, handling and observation are key to an accurate
assessment.
Aim
r To set the scene for further assessment and intervention.
r To build up a picture of the patient as a whole, and how they move.
r To provide information for setting goals in conjunction with the patient and other team
members.
r To provide information from which a baseline for intervention can be formed.
r To identify how the patient moves, attempts to move and what aspects are abnormal.
Motor screening
r How does the patient move?
r Why does the patient move in this way?
In position
r
r
r
r
r
What does the patient’s head do?
Feel the patient’s trunk. Can they change or maintain position?
Feel the patient’s arms. Is their unaffected arm free to move or is there pain?
How is the patient’s arm positioned? Heavy, light, subluxation, active movement?
What is the position, tone and range of movement in the patient’s legs?
Transfers
r
r
r
r
How does the patient get from the chair to the bed? How? Independent?
Presence of associated reactions? With help?
How does the patient get from sitting to lying?
How does the patient get from sitting to standing?
Sitting
r Sitting unsupported. Can the patient achieve this? Does the patient use their arms to
maintain sitting balance?
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Weight-bearing. Is it symmetrical?
Overall posture. Can the patient adapt their posture when handled?
Posture of legs. Falling in? Pulled out?
Position of pelvis and effect on their trunk and upper limb position.
Trunk
r
r
r
r
Can the patient shift their weight laterally?
Is the patient able to correct themselves when they shift weight?
Does the patient have areas of high or low tone?
What is the position of the patient’s scapulae?
Scapula
r Assess the muscles around the scapula – Is there weakness, tightness or tone affecting
the rotation or sitting position?
r Is the scapula moving within normal scapulohumeral rhythm?
Glenohumeral joint
r Assess for subluxation and rotator cuff muscle activity.
r Does the patient’s scapula rotate with movement of the glenohumeral joint?
Upper limb
r Is it functional? Is there selective, voluntary movement?
r Is the patient able to isometrically, concentrically and eccentrically contract to reach,
grasp and place their upper limb?
Feel the patient’s hand
r Gross grasp, fine motor control, arches.
Standing and gait
r Is the patient able to stand? Can they shift their weight on either leg?
r Is the patient symmetrical? Can they maintain static and dynamic standing?
r Is the patient able to move their upper limbs while standing or do they need to use their
upper limbs for support?
For detailed information relating to motor impairments, see Chapter 5.
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Functional assessment
Functional assessments, for example, washing and dressing assessments, kitchen assessments or any other functional tasks are a key tool for screening and assessing patients.
They provide valuable information on a patient’s residual skills, their impairments, as
well as their task performance.
Aim
r Screening tool to identify impairments, skills, performance impairments.
r To provide an opportunity to assess the combination of all the performance components
within a task.
r To provide vital information on how the patient’s impairments impact on their functional
ability.
r To allow an opportunity to identify how a patient is using their residual skills to perform
a familiar task.
r To provide an opportunity for assessment that is not reliant solely on a patient’s understanding or conceptualisation of the task’s requirement due to the familiar nature of the
task and the environmental cues.
Functional screening
The following questions should be considered from a cognitive/perceptual perspective:
r
r
r
r
r
r
r
r
How did the patient approach the task?
Did the patient appear familiar with the task?
Did the patient use any environmental cues?
Was the patient able to problem solve the novel aspects, for example, the weakness in
their limbs or the differences in environment?
How did the patient initiate the task?
Was the patient’s initiation efficient?
Consider the patient’s attention, their focus on the task, their planning and organisation,
completion of the task.
Consider the patient’s search strategy and ability to recognise environmental cues.
The following questions should be considered from a physical/sensory perspective:
r
r
r
r
r
r
What was the patient’s level of endurance?
Was the task effortful?
Did the patient maintain good sitting or standing balance?
Was the patient able to position their body appropriately for the task?
Did the patient perform tasks bilaterally?
Were there any changes in tone during the task?
For detailed information relating to functional impairments, see Chapter 5.
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Intervention
Once the initial screening is completed, it is important to determine if any further assessment is required to decide what intervention is most appropriate for the patient.
Details of how to assess and provide specific intervention for motor, sensory, cognitive
and perceptual impairments are described in Chapters 5–8.
Goal setting should be undertaken, as described in Chapter 3.
Equipment
The assessment for and provision of equipment to stroke patients is generally viewed as
an adaptive (compensatory/functional) method of reducing limitations. Most equipment
is issued following a home assessment visit completed prior to weekend leave and/or
discharge. However, some equipment can be used to facilitate normal movement and
increase independence within the hospital setting. The pros and cons of timing and type
of equipment should be carefully considered in conjunction with the patient, family and
multidisciplinary team.
Wheelchairs
The provision of a wheelchair for a patient following a stroke can be considered for two
main reasons – for correct positioning during early management and for indoor/outdoor
mobility during the rehabilitation stage.
The type of wheelchair appropriate for a stroke patient could include attendantpropelled manual wheelchairs and indoor- or outdoor-powered wheelchairs.
Attendant-propelled manual wheelchairs can be used to achieve better positioning and
to improve sitting balance on the ward, which is not always possible with armchairs or
high seat chairs. A pressure care cushion should always be provided with the wheelchair
and monitored throughout the day by nursing staff and therapists. Access to attendantpropelled wheelchairs adjusted for specific patients can also enable patients to be taken
off the ward by their visitors for often much-needed stimulation. Ideally, a wheelchair
should also be available for the patient to use for outdoor and/or indoor mobility on
weekend leaves and on discharge. In some settings patients are discouraged from trying
to propel themselves with their feet, and self-propelling manual wheelchairs are often
avoided altogether. It is thought that the patient’s muscle tone will increase when using
the unaffected arm and leg in this way. It is best to discuss the approach.
Indoor-powered wheelchairs could be considered for patients with severe physical
disability and those with chronic heart and lung conditions. A patient’s cognition and
visual perception should be fully assessed as part of the wheelchair assessment. The use
of a powered wheelchair in hospital can help increase motivation and might be considered
as an intervention option for spatial awareness problems and inattention.
A combined indoor/outdoor- and outdoor-powered wheelchair would require a full
assessment by the hospital-based occupational therapist and specialised wheelchair
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therapist, carefully taking into consideration the patient’s vision, perception and cognition.
These wheelchairs can be issued to patients with severe, long-term mobility problems.
When assessing any type of wheelchair on a long-term basis, the home environment
and local area in which the patient will be living should always be taken into account. The
access to the patient’s home, the type of accommodation, the width of all internal/external
doorways, the layout of the furniture and other fixtures/fittings, the door thresholds and
the floor coverings should be considered for suitability of a wheelchair.
Toileting
Raised toilet seats and frames (which are safely fixed to the floor) will encourage a patient
to move from sit to stand in a more normal way than pulling on grab rails fixed to a
wall.
Bathing/showering
Many stroke patients with independent sitting balance can manage transfers on and off a
bath board, but a bath seat is generally too difficult due to the amount of effort involved.
This in turn can increase muscle tone and be too strenuous for people with chronic heart
and lung conditions and the frail elderly. Non-slip mats should always be provided or
purchased to be used in conjunction with bath boards/seats. Chairs or seats that are fixed
across the top of the bath for use with a shower or that lower into the bath require less effort
for the stroke patient and carer and are much safer for those with poor sitting balance.
Step-in shower cubicles have limited space for small stools or seats fixed to the wall and
are therefore only accessible to the more mobile stroke patient who can wash themselves
independently whilst standing or sitting on a stool.
Meal preparation
Some kitchen equipment such as large-handled utensils or cutlery issued by occupational
therapists could be used by patients with some return of hand function to encourage
further improvement or facilitate more normal movement. These could be used during
meal preparation sessions in hospital or at home. Many other pieces of equipment are
designed for one-handed use or to make heavy tasks lighter. Spike board, belliclamp, wall
tin opener, battery-operated tin openers that fit on the can and do not require holding, ring
pull cans and buttering board will enable the patient with limited upper limb function to
prepare meals. A kettle tipper and cooking basket and draining spoons make dealing with
boiling water safer and lighter. A trolley can be used by the more mobile patient to carry
hot food.
Fatigue is a major factor to consider when preparing a meal. The layout of the kitchen
and its existing equipment or appliances can be looked at during a home assessment visit.
Some portable items could be moved closer together in order to conserve the patient’s
energy. A perching stool could also help reduce fatigue.
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Eating
During the acute stage, good positioning whilst eating will assist safer feeding and swallowing. Plates that retain heat will keep food warmer for a slow eater. Plateguards and
large-handled mugs with lids reduce the risk of spillage. Dycem mats will keep plates in
place. Large-handled cutlery could be used with the affected hand to encourage further
return of movement. At a later stage, the one-handed patient may require a rocker knife
or a fork with a serrated edge for cutting.
Other impairments impacting on functional ability
Communication
There are three main communication disorders associated with stroke: aphasia/dysphasia,
dysarthria and verbal apraxia.
Aphasia
Aphasia is a disorder of language which can result in difficulty:
r
r
r
r
Understanding what is said.
Expressing things verbally.
Reading.
Writing.
Aphasia results from damage to the language centre in the dominant side of the brain –
usually in right-handed patient, this is the left side.
There are many different patterns of dysphasic impairment. Both understanding and
expression of language are usually affected, albeit to varying degrees.
The speech of a patient with aphasia may show some of the following features:
r Maintained ability to use automatic/social speech, that is greetings, or counting by rote.
r Yes/no responses which are unreliable, either because the question is not understood or
because one is meant/thought but the reverse is said.
r Swearing – usually automatic and unintentional.
r One phrase/word/sound produced whenever speech is attempted.
r Repeating back what has been said/asked (often without understanding).
r A retained ability to sing (because it is controlled by the opposite side of the brain).
r Fluent speech, ‘jargon’, which is difficult to inhibit (this may comprise a mixture of
meaningful and non-meaningful words or may be just a string of sounds).
r Grammatical words, such as ‘the’, ‘a’, ‘to’, etc., are not used.
r Word finding difficulties – some dysphasics may be able to describe something about
a word, but not retrieve the word itself.
The Stroke Association publishes leaflets with advice helpful to patients and to therapists on how to deal with aphasia. Occupational therapists should liaise with speech
and language therapists on ways to encourage return of speech whilst carrying out
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occupational therapy activity with the dysphasic patient, as intensive practice is beneficial. The obvious strategies of writing or signboards should be tried, but are not always
helpful. It is vital that everyone perseveres in trying to understand what he or she is saying.
Gestures and cues should be used to assist the patient who has receptive difficulties to
enable them to participate in intervention. The family or carers should have the situation
explained and be involved in developing ways of communicating.
Understanding
Problems in understanding language will range in severity from virtually no understanding
of spoken language to mild difficulty apparent only when following group conversation
or conversation against a noisy background.
When a patient with aphasia is having severe difficulties understanding what is said,
they compensate by looking out for the following:
r Visual or non-verbal cues – the gestures we use alongside our speech
– body language
– facial expressions
– tone of voice
r Situational cues – things in the environment which help determine what is being asked,
e.g. the tea trolley, drugs trolley, etc.
Understanding can be helped by using demonstration and gesture alongside or instead
of spoken instructions.
Dysarthria
This is a speech disorder caused by damage to the nerves supplying the muscles used
when speaking. It may involve problems with breath control for speech, voice production,
controlling whether air is directed orally or nasally during speech, and articulation of
speech sounds.
It can range in severity from mildly slurred speech to inability to produce any intelligible
speech.
A patient with dysarthria is often able to use alternative means of communication
because their language skills are intact, for example,
r Writing.
r Spelling words out on an alphabet chart.
r Using an electronic communication aid.
Verbal apraxia
This is a disorder affecting the purposeful coordination of muscle movements for speech
production. It is not a language problem, but very often patients with verbal apraxia also
have some degree of aphasia.
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It is characterised by:
r Groping/struggling to achieve the correct sounds for a word or to sequence the sounds
in the right order.
r Awareness of errors and subsequent frustration and repeated attempts.
r Speech produced ‘subconsciously’ or automatically which will be noticeably more
fluent than purposeful speech.
r The speech muscles which are not paralysed and automatic movements are retained,
for example, for eating, drinking, laughing.
Communicating with an aphasic patient
1. Face the patient you are talking to and direct your speech to them at all times.
2. Keep the background noise to a minimum, that is, turn down the television or radio
or take the patient to a quieter room.
3. Alert them to the fact that you are talking to them. Give them time to tune into listening
to you, for example, use their name to focus their attention, or touch them and pause
before speaking, or use a lead-in phrase such as ‘I wanted to tell you . . .’.
4. Slow down your rate of speech slightly, but do not overexaggerate your articulation
or shout.
5. Give time to understand by presenting information in chunks, one piece at a time,
for example, ‘I’ll put your glasses . . . on the table . . . by your bed’ and pausing
frequently.
6. Repeat or rephrase what you have said if you are not understood. Try putting
the most important word at the end of the sentence, for example, ‘What is your
address?’.
7. Stress or emphasise important words in the sentence, for example, ‘Did Christine
ring?’ or ‘Did Christine ring?’.
8. Give clues about what you are saying, for example, use a gesture, or write down
important words, or draw attention to a photograph or an object relating to what you
are saying.
9. Do not change topics quickly – leave plenty of time before moving on to something
new and give time to let the dysphasic patient tune into the new topic.
10. Be specific, for example, ‘I’ll put your clothes in the wardrobe’ not ‘I’ll put them
there’.
11. Take time to be a good listener – keep calm, be alert to the dysphasic patient’s use
of gesture, their facial expressions, etc., listen and watch out for the intention behind
what they are communicating, even if the individual words do not make sense.
12. Encourage methods other than speech – using gesture, drawing on paper or in the air,
writing down the whole or part of a word, pointing to pictures or a choice of written
words.
13. Accept a message conveyed by whatever means is possible – do not then force them
to use a ‘better’ method, for example, do not ask them to repeat ‘I want a drink’ when
they have gestured their need.
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14. Ask questions to guide you to the general topic, for example, ‘Is it to do with home?’
and use your knowledge of the patient’s activities, needs and situation to help you
guess the topic of conversation.
15. Let them know what you have understood. Summarise what you feel has been said to
check you have got it right, for example, ‘I think you are telling me something about
dinner’.
16. Do not pretend to understand. Ask for more information or repetition if you have
not understood. The dysphasic patient will soon realise if you are pretending to
understand and this is likely to lead to more frustration.
17. Help the patient find a particular word by encouraging them to – describe something
about the word, for example, what you do with it, what it looks like, etc., or think of
something associated with the word, for example, a word similar in meaning or the
category (animal, flower, etc.).
Swallowing
Dysphagia is difficulty in safely moving a bolus of food, or liquid, from the mouth to the
stomach without aspirating, and involves chewing and tongue movement, preparing food
for swallowing, as well as the actual swallow. Thorough clinical examination can identify
dysphagia, but can fail to identify patients aspirating. All staff working with the stroke
patient should be aware of the possibility of dysphagia and take appropriate action if they
feel someone may be aspirating. Initial severity does not mean that the patient will not
recover, and reported recovery rates within the first few weeks vary.
Signs that may indicate a swallowing problem include:
r Loss of food or liquid from the mouth, or drooling.
r Difficulty in swallowing saliva, so that drooling is a continual problem.
r Food remaining inside the mouth after eating, often pocketed inside a cheek or across
the roof of the mouth.
r Coughing or choking while eating or drinking.
r Change in voice quality after eating or drinking, often the voice sounds wet or gurgly.
r Breathlessness after eating or drinking.
r Meal times taking longer to finish; often there may be weight loss.
r Someone may complain of food feeling stuck in the throat.
r Frequent pneumonias.
Advice for someone with swallowing problems includes:
r
r
r
r
Always sit as upright as possible when eating or drinking.
Remain upright for 15–20 minutes afterwards.
Avoid noise or other distractions. Do not try to talk and eat at the same time.
Sipping iced water or ice cream, or sucking on iced pops before starting a meal may be
helpful in stimulating swallowing mechanism.
r Take smaller mouthfuls of liquids and food. All food should be chewed well.
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r Ensure a strong swallow between each mouthful, when possible try a second swallow,
or cough to clear the throat.
r Following a stroke someone may tire easily and this may affect the swallow. If meal
times are taking longer and are tiring, try smaller meals, taken more frequently or with
snacks in between.
r If there is a tendency for food to remain in the mouth after eating, clean the mouth after
mealtime with a soft toothbrush or mouthwash.
People with severe dysphagia will be fed through a nasogastric or percutaneous endoscopic gastrostomy (PEG) tube. However, oral feeding is always seen as preferable
when possible, and food consistency can be varied to suit the patient’s swallowing ability,
under the guidance of the speech and language therapist. The patient must be reassessed
at regular intervals.
Food and taste play an important part in our lives and the occupational therapist can
liaise with the speech and language therapist to work on swallowing with changing tastes
and food consistencies. The therapist should ensure the patient is well seated and supported
at meal times, encouraging people to feed themselves and trying to balance dignity with
cleanliness! The Stroke Association leaflet on swallowing difficulties gives good advice
on eating.
The therapist should be aware of swallowing difficulties when working on aspects such
as cleaning teeth, and making drinks and meals.
It is important that all members of the team stress to the patient the importance of their
adapted diet to encourage patient acceptance of what often appears unappealing. This is
especially true for the patient who has to maintain a special diet after discharge.
Mood
Anxiety, depression and emotionalism are likely to make rehabilitation difficult for patients
as they may have decreased motivation to participate in assessments and intervention due
to being preoccupied with their worries and thoughts. DeSouza (1983) also noted that
one of the major factors affecting the success of stroke rehabilitation was the patient’s
own determination and motivation to improve functionally. The nature of depression is
that depressed patients are likely to have a decreased ability for motivation. This finding
was supported by Zigmond and Snaith (1983), who suggested that patients may find
that symptoms of their illness may distress them to such as extent as to lead to a poor
response to intervention. Ebrahim et al. (1987) also demonstrated that mood disturbance
at 6 months post-stroke was strongly associated with functional ability, limb weakness
and with longer hospital stay. This suggests that slow recovery and institutionalisation
may be responsible for mood disturbances.
Similarly, Robinson et al. (1983) found that in 103 patients, the severity of impairment
in functional activities (ADL) and intellectual function was significantly correlated with
the severity of post-stroke depression early after stroke. Sixty-one of the patients in
their study were reassessed after 6 months and were found to have made a significant
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improvement in functional impairment (Robinson et al., 1984). However, the depressed
patients remained more impaired than the non-depressed patients.
A further study by Sinyor et al. (1986) also indicated that depression was common after
stroke. They demonstrated that depression was associated with the level of functional
impairment in 64 depressed stroke patients early after stroke and suggested that it may
cause a negative impact on the rehabilitation process and outcome. They followed up 25
of these patients, 6 months after discharge and still found a significant correlation between
depression and functional status.
All these studies (Robinson et al., 1984; Sinyor et al., 1986; Ebrahim et al., 1987)
used standardised assessments for mood and functional ability but the Robinson et al. and
Sinyor et al. studies had small numbers of patients.
Thus, the effect of any of these impairments has been shown to be associated with functional ability, highlighting the complexity and trauma of stroke. It is therefore important
to consider the effect of these impairments, the ‘invisible consequences of stroke’, when
treating any patient following stroke.
Depression
Depression after a stroke is common but often alleviates as the patient recovers (ISWP,
2008).
The symptoms of depression may include:
r
r
r
r
r
r
r
r
r
r
r
r
r
Negative thoughts.
Irrational beliefs.
Distortion of reality.
Self-blame.
All or nothing attitude.
Low mood.
Poor appetite and weight loss or.
Increased appetite and weight gain.
Disturbed sleep.
Activity alters → lethargic or agitated.
Loss of interest and pleasure.
Poor concentration.
Indecision.
All patients should be screened for depression, including those with aphasia, by careful
observation (ISWP, 2008).
Assessments that may be used include the following:
(a)
(b)
(c)
(d)
Hospital Anxiety and Depression Scale (Zigmond and Snaith, 1983).
Wakefield Depression Inventory (Snaith et al., 1971).
Geriatric Depression Scale (Yesavage et al., 1983).
General Health Questionnaire (Goldberg and Hiller, 1979).
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Patients whose depression is more severe or persistent should be offered anti-depressant
drugs but these should not be used routinely and be monitored and continued for at least
6 months if benefit is achieved (ISWP, 2008).
Intervention may involve counselling, anti-depressants or psychological intervention.
Behavioural intervention could include reinforcing activity, activity scheduling, feedback
of progress, experiencing success or pleasant events. Long-term therapy from a psychologist or psychiatrist may be required for some patients. This will depend on the severity of
the depression and the patient’s ability to cope with the depression. Occasionally patients
may become so depressed that they feel suicidal, in which case, medical advice should
be sought. Some patients may turn to spirituality to assist them in coping with the new
lifestyle forced upon them.
Anxiety
All stroke patients should be screened for anxiety and have the causes of any anxiety
established (ISWP, 2008).
Patients may have anxieties relating to their stroke, for example, fear of having another stroke, fear of epilepsy, fear regarding their future in terms of home, social, sex,
employment.
Hospital Anxiety and Depression Scale (Zigmond and Snaith, 1983) may be used for
assessment.
Intervention may include counselling, tranquillisers or psychological intervention.
Lability (now often called ‘emotionalism’)
Patients may have difficulties controlling their emotions which results in crying or laughing
for any alteration in emotions, which can be very distressing. A common clinical technique
is to ignore it and use distraction.
Patients with severe, persistent or troublesome emotionalism should be given antidepressants whilst monitoring its effectiveness (ISWP, 2008).
Fatigue (Carr and Shepherd, 1987; Laidler, 1994)
Fatigue is part of any illness or traumatic event and can affect the individual physically,
mentally, emotionally or as a mixture of all three. It is usually expected and apparent in
the acute stage following stroke, but can also appear as a persistent problem long after
discharge from hospital.
In the initial stages following stroke, the systems of the body are working to promote
recovery, and the patient has to make a great deal of effort – for example, in working on
sitting or concentrating on a task. Some degree of exhaustion is inevitable, and therapists
should be aware that many patients feel they are being worked too hard and that we do
not understand their situation.
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After discharge, the person feels that because they are ‘better’, they should manage as
before, but those tasks which were once easy now require continuing effort to perform,
for example, getting dressed, holding a conversation or reading a book.
Therapists expect patients to get fatigued, and are encouraged not to overtire them as this
can lead to increased tone, poor performance, reduced motivation and so on. However,
the patient who appears fatigued may not actually be tired following effort. Patients
should be able to tolerate periods of reasonably challenging activity, and the fatigue
which accompanies such activity should easily respond to a period of rest. Fatigue within
normal limits does not affect learning, although it may temporarily affect performance.
Firstly, we should look at the reasons behind why the patient may be complaining about
or showing signs of fatigue, and then address the issues involved. It may be that they are
not sleeping well at night, not able to wake in the day because of medication, be anxious
or depressed, have an infection or other pathological condition, be poorly nourished or
suffering from boredom. This last may well be the most important cause of fatigue!
The patient should not have to use a huge amount of physical effort – the effort should
be on the part of the therapist, with relaxed reciprocation from the patient. Intervention
should involve successful activity, be challenging but not impossible and not cause stress.
Working with therapists involves both physical and mental effort on the patient’s part,
and it can be more effective to change the task than stop and rest when a patient appears
tired. Carr and Shepherd (1987) report studies in normal subjects that show muscle work
performed after a diverting activity was greater than that performed after a rest – and
they report one study with a small group of stroke patients that appeared to support this.
As an alternative to activity or rest, suitable relaxation techniques can be taught to the
patient.
Once discharged from hospital, it can be helpful for the person to understand the
possible causes of their tiredness, and discuss strategies for coping with it. These would
involve keeping active and returning to or developing interests, using energy wisely,
dealing with concerns and depression, organising their day and prioritising, pacing and
delegating activities. Staying cool and keeping work areas well ventilated may also help.
Therapists should be aware of the patient’s sense of fatigue, explain their understanding
of it, and why it may appear that they are ignoring it. By providing a varied and challenging
programme, they will assist the patient in handling fatigue.
Self-evaluation questions
1. Name three things you should consider doing before you attempt a full functional
assessment with a patient.
2. During a functional assessment in the kitchen you notice that the patient is picking
up items and putting them down again or uses the wrong object within the task. What
might be the impairment? Are there any other impairments that might present in a
similar manner? What questions could you ask or what simple tasks could you do to
differentiate between the impairments?
3. If a patient had an attention impairment, what might you notice while observing this
patient? What simple tasks could you do to give you some more information?
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4. If you are assessing a patient in sitting, why is it important to ensure that they are
sitting fully upright while assessing their upper limb? Prompt: Sitting in your chair,
tilt your pelvis into full posterior tilt (slouch) and attempt to lift your arms. Now sit
upright and lift your arms – what was the difference? Analyse why this might occur.
5. Name at least five key areas you need to screen for a stroke patient. Design a basic
screening tool that you might use to cover all the areas if you were given half an hour
to check a patient before going home.
6. What information would be collated by the occupational therapist prior to the initial
assessment that would assist in the assessment process?
7. Discuss how the World Health Organization (WHO) International Classification of
Functioning (ICF) relates to the occupational therapy process in stroke rehabilitation.
8. What signs indicate a patient might have a swallowing impairment and how would
this affect your occupational therapy intervention?
9. Describe the differences between aphasia, dysarthria and verbal apraxia.
10. Describe the symptoms of mood disorders.
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Chapter 5
Management of Motor Impairments
Stephanie Wolff, Thérèse Jackson and Louisa Reid
This chapter includes:
r
r
r
r
r
r
r
r
r
Assessment of motor control
Management principles and intervention
Therapeutic aims of intervention
Positioning the early stroke patient
Self-care and instrumental activities
Clinical challenges
Upper limb re-education
Avoiding secondary complications
Self-evaluation questions
Introduction
The impact of motor impairments on patients can be devastating and the role of the
occupational therapist in managing these problems is vital. This chapter focuses on the rehabilitation phase of managing motor problems and gives an overview of current practice
in the clinical setting although various elements will also be applicable to the community
setting. Main aspects of intervention are covered to equip new clinicians or students with
ideas on how to approach the assessment and intervention of motor impairments. It is
important to note that no one approach has been proven to be the most effective in regaining motor control post stroke; however, specific interventions that have been shown to be
effective with certain groups of patients are discussed in the chapter. The chapter also covers two of the main clinical challenges commonly seen; ataxia and the pusher syndrome.
Finally, the chapter looks at ways of avoiding secondary complications that can occur.
Assessment
The assessment and analysis of patient’s problems set the scene for intervention. There
is no formal assessment procedure. The idea is to build up a picture of the patient
as a whole, and how they move. This is achieved through observation and handling.
Assessments provide information as a baseline for intervention and for setting both long
and short-term goals, in conjunction with other team members. A thorough assessment
Occupational Therapy and Stroke, Second Edition Edited by Judi Edmans
© 2010 Blackwell Publishing Ltd. ISBN: 978-1-405-19266-8
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of motor impairments is essential, in order to understand the impact on functional tasks
and to determine an appropriate and evidence-based intervention plan. Assessments can
be carried out jointly with a physiotherapist in order to avoid the patient undergoing
multiple assessments and to promote working jointly towards common goals; this is a
common practice in many units and community teams.
The following approach to assessment is more likely to occur in hospital in the acute
rehabilitation phase but the principles can apply to patients in any location. In the acute
stages of rehabilitation, the patient may be in bed when first assessed, which can be a
good starting point to observe the patient through all the basic postures, lying, sitting,
standing, transfers and walking. The occupational therapist can then assess the impact of
motor problems within other activities of daily living such as washing and dressing. It
also enables the therapist to risk assess the safest handling approach.
This section focuses on the practicalities of assessment that rely on the observational
skills of the therapist rather than the use of standardised assessments, which have been
discussed later in this chapter.
During the assessment, the following questions should be asked and observations should
be documented appropriately.
How does the patient move?
r
r
r
r
r
r
Does the patient move with effort?
Are the movements disjointed or fluent?
Are there associated reactions present?
Can the patient actually move at all?
How are the movements different from normal?
Remember to take the ageing process, regarding premorbid posture, into account.
Why does the patient move in this way?
r
r
r
r
Is it due to tone? High, low, fluctuating adaptable.
Are there associated reactions? Upper limb and lower limb.
Are there problems with the underlying balance mechanism?
Are there sensory problems leading to poor feedback? (loss of proprioception, loss of
tactile awareness).
r Is there loss of active, selective movement?
r Are there cognitive/perceptual problems? (apraxia, neglect/inattention).
Bed mobility
Before starting consider some practicalities. Check with nursing staff that the patient is
fit to be assessed and are able to actively participate in the session? Can their consent
be gained? Can they follow instructions? Beware of hazards around the bed such as drip
stands, catheters or feeding tubes.
Start by looking at the patient lying supine in bed (lying face up):
r Is the patient able to move their head freely from side to side?
r Is the head turned more to one side than the other? Which side?
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r Is the patient straight or crooked in the bed and is one side of the body very active
compared to the other?
r Does the weaker arm look in a comfortable position or does it look like it is trapped
under the body?
r When you ask the patient to move the weaker arm and leg of the same side, is there
some movement or none?
If there is only a little or no movement, with the patient’s consent (if it can be gained)
gently handle the arm and leg. Does the muscle tone feel heavy and floppy, that is, low
tone or can resistance be felt when moving the joints that does not appear to be voluntary,
that is, high tone? For most stroke patients in the early stages, this will be low tone, but
that can change quickly.
Following initial observations ask the patient to roll from side to side. If the patient
needs help rolling, always make sure there is a second person to help. If the patient is
clearly needing significant help, unless competent in therapeutic handling techniques, do
not continue and use sliding sheets to position patient on their side.
Sitting
At this stage the occupational therapist should have enough information to decide whether
or not to proceed looking at the patient in sitting, on the edge of the bed. Initial assessment
of sitting may however be best carried out with the patient sitting on a plinth in a therapy
gym. Make sure there are enough staff to ensure the patient’s safety.
r
r
r
r
r
r
Observe the patient’s ability to sit unsupported in a static position and maintain balance.
Look at dynamic sitting balance; can the patient reach forward and to the side?
Observe if the patient is sitting on one buttock more than the other.
Is the trunk symmetrical?
Are the scapulas in alignment on both sides?
Carefully examine the affected shoulder for subluxation (see ‘Shoulder’ section later
in this chapter).
r In this posture observe if there are any changes in tone to the affected arm and leg.
r Is the patient overactive with the intact side? Do they appear to be pushing themselves
over-inexplicably to the affected side? If this is the case, refer to the section on the
‘Pusher syndrome’.
Remember if the patient has been assessed sitting on a plinth, it is important to also
assess them sitting on the edge of their bed. Patients in hospital may have airflow mattresses
on their bed for pressure relief, which can make sitting difficult for the patient. However,
even a regular mattress can affect sitting balance compared to the firmness of a plinth.
Transfers
Assessment of transfers includes moving from supine to sitting, bed to chair and chair to
commode or toilet.
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Assessment will establish how the patient moves from one surface to another, how
efficient they are and how safe. It is important to determine the level of assistance the
patient needs. It is also vital for the therapist to know their level of competence when
facilitating transfers. If assessing transfers with someone who is clearly going to need
assistance, it is important to have a second person present, preferably an experienced
therapist.
When assessing transfers, consider the following:
r What is the minimum level of assistance the patient needs to safely complete the
transfer? Be careful not to over- or under-help someone.
r Can they transfer to both the sound and the affected side?
The patient should be assessed in various situations; transferring from a wheelchair to a
plinth is not a satisfactory assessment. Make sure transfers are assessed in the environment
where the patient will be required to do them throughout the day.
Assessment of sitting balance and transfers will inform what recommendations might
be needed for the nursing staff in relation to handling, for example, it will determine if
the patient is suitable for a standing hoist rather than a full hoist. It will inform if they are
safe to transfer to a toilet rather than a commode. Some patients can transfer safely with
one person but cannot maintain their sitting balance safely on a toilet and therefore may
need to transfer to a commode. It contributes to determining whether the patient is safe to
be left alone whilst using the toilet.
Standing
Assess how much facilitation the patient requires to stand from a variety of surfaces and
observe the patient’s alignment in standing.
Consider the following:
r
r
r
r
Are they standing on the affected leg or just on the sound leg?
Can they stand safely in a static position?
Can they reach in standing and maintain their balance and safety?
How long can they stand?
Walking
If the patient is able to walk,
r How far can they walk?
r Are they safe?
If the patient requires assistance with walking, agree on the most appropriate method
of assistance with the physiotherapist.
Assessment of walking should be carried out in different environments that are relevant
to the patient, for example, in open spaces, around cluttered rooms, uneven and even
surfaces. In the community, walking assessment should include going to the shops, post
office, restaurants, etc.
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Activities of daily living
Although assessment in different postures is important, the most relevant assessment of
motor problems from the occupational therapist’s perspective is within more functional
tasks. In the early stages of recovery, these could be getting washed and dressed, grooming
tasks, feeding or simple kitchen activities. In later stages of recovery, this may include
shopping, getting to work or social events.
At the end of assessment, the occupational therapist should be able to identify the
impairments of motor control and be able to relate this to the level of patient independence
in activities of daily living.
Standardised assessments
Standardised assessments are used in clinical practice to identify and quantify problem
areas. These assessments can also be used as outcome measures. The National Clinical
Guidelines for Stroke (Intercollegiate Stroke Working Party (ISWP), 2008) recommend
that
‘All patients should be assessed for motor impairment, and a standardised approach to quantify
the impairment should be used.’
There are various standardised assessments available. There is long-standing debate as
to which of these are the best and currently which assessment is selected often depends
on therapist’s preferences. When using a standardised assessment, it is important to
understand what is being assessed. The results of such assessments should be useful
for planning intervention and setting goals. There are two types of tests that are usually
selected, generic activities of daily living and specific motor performance tests.
The National Clinical Guidelines for Stroke (ISWP, 2008) recommend the Barthel
Index (Mahoney and Barthel, 1965) as a generic activity of daily living scale and the
Motricity Index (Collin and Wade, 1990), the Rivermead Motor Assessment (Lincoln
and Leadbitter, 1979) and the 9 Hole Peg Test (Kellor et al., 1971) as specific motor
performance tests. Many others are available, as listed in the evaluation chapter.
Management principles and intervention
Following a thorough initial assessment, the therapist needs to incorporate the identified
problems into an intervention plan. Although occupational therapists in clinical practice
will take into account all problem areas after the stroke, for example, cognition and
perception, when planning intervention, this chapter concentrates on the intervention that
focuses on motor problems.
The therapist should take into account any available evidence when planning intervention. The ISWP (2008) reviewed the current evidence and their recommendations that
relate to motor impairments that will impact occupational therapy practice are stated in
Section 6.46:
‘Any person who has limitations on any aspect of personal activities, especially but not only
if acquired as a result of this stroke, should: have intervention of identified problems from
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the Occupational Therapist who should also guide and involve other members of a specialist
multidisciplinary team’.
Specific interventions that should be offered (according to need) include:
r The opportunity to practise activities in the most natural (home-like) setting possible.
r Assessment for, provision of and training in the use of equipment and adaptations that
increase safe independence.
r Training of family and carers in helping the patient.
Section 6.47 also relates to extended activities of daily living. Another relevant section
for motor management is 6.16 Task Specific Training, this section states that:
Task-specific training should be used to improve activities of daily living and mobility:
r Standing up and sitting down.
r Gait speed and gait endurance.
These guidelines indicate that intervention plans should incorporate practicing tasks,
particularly personal care tasks; however, it does not go into detail about how this practice
should be targeted. The point of assessing at impairment level is to understand which of
the performance components of a task are affected, thereby explaining why patients are
unable to complete a functional task, for example, a low tone arm affected the patient’s
ability to dress. While the general recommendation is to practise tasks which enable the
occupational therapist to grade specific components that need working on, for example,
work on dressing but focus on incorporating the arm in the task.
Therapeutic aims of intervention
The main aims of occupational therapy intervention regarding motor problems are:
r To promote motor recovery in the most normal or efficient way to increase functional independence by practising graded activities of daily living using a restorative (remedial)
approach.
r To prevent secondary complications such as pain in the shoulder or swelling of the
hand.
r To maximise the patient’s independence in activities of daily living by using an adaptive
(compensatory/functional) approach, when the restorative (remedial) approach is felt
not to be practical or achievable.
r To train carers in safe techniques for handling and carry out risk assessment based on
patients functional level and equipment needs, either in preparation for discharge or as
ongoing rehabilitation in the community.
Positioning the early stroke patient
People are dynamic moving individuals, and when positioning, it is important to consider
the functional activities an individual wishes to achieve, in any given posture. In the early
stages of recovery, when movements are restricted by the effects of their stroke, individuals
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are unlikely to be able to make the postural adjustments required, to maintain a symmetrical posture, without assistance. There are basic principles that can be followed to allow
the individual to perform desired activities while assisting in the recovery process. These
principles will help recovery by maintaining passive range of movement, allowing the individual to use the control they have and providing normal sensory and proprioceptive input.
In bed
In the initial stages following stroke, lying is the position where the individual is most
incapacitated. Their inability to roll, or change position without help or extreme effort,
leaves them with little control over their environment. Those with sensory loss on the
hemiplegic side may fear turning, or lying on the affected side, while lying on the
unaffected side restricts the use of the sound upper limb. Often the individual is nursed
on his/her back; which can restrict visual fields, and may leave the individual unable to
use their upper limb.
There are advantages to the individual spending time in bed in that it is the position
of fullest support. Those with high tone may benefit from returning to bed for periods
during the day to help manage tone. Similarly, those with low tone may be fatigued by
the effort required to maintain their posture against gravity, and may need rest periods
to be built into their day. Correct positioning for sleeping and the early development of
functional bed mobility are advised. There are of course certain disadvantages to patients
spending an excessive amount of time in bed. These include: infections, pressure sores
and other complications. Therefore, it is imperative that patients are moved frequently
and supported to achieve other positions.
How to position in bed
Support should be offered where required to enable the individual to maintain their
position. In side lying this may include support along the back to prevent rolling onto the
back, and to offer proprioceptive indicators to the hemiplegic side. When lying on the
affected side the affected arm may be placed outstretched, with the shoulder protracted.
The lower limb should be slightly flexed with the unaffected side bent over the leg; if
necessary place a pillow under the knee to reduce any adductor tone developing (see
Figures 5.1 and 5.2; shaded side is the affected side).
When lying on the unaffected side the position is reversed; however, the individual
who is unable to roll independently will be more incapacitated in this position, so the call
bell must be within reach (see Figures 5.3 and 5.4). Side lying on the unaffected side is a
position of choice for at least some of the time, for those who have an overactive sound
side. In this position they receive proprioceptive feedback about midline; it facilitates
elongation of the trunk on the sound side and promotes weight-bearing through the
overactive side.
When positioning an individual on their back, it may be necessary to use pillows to
prevent the affected shoulder and hip falling into retraction. Lying on the back is also
a good position to allow the pectoral muscles to be stretched with the arm supported in
abduction (see Figures 5.5 and 5.6). Similar support will be necessary for patients sitting
up in bed (see Figures 5.7 and 5.8).
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Figure 5.1 Positioning in bed, lying on the affected side (left hemiplegic patient). Do ensure
(i) affected shoulder is brought through, (ii) affected leg is extended at hip and slightly flexed at
knee, (iii) there are no objects in the hand or against the sole of the foot, (iv) head is in line with
the body (Edmans et al., 2001).
Figure 5.2 Positioning in bed, lying on the affected side (right hemiplegic patient). Do ensure
(i) affected shoulder is brought through, (ii) affected leg is extended at hip and slightly flexed at
knee, (iii) there are no objects in the hand or against the sole of the foot, (iv) head is in line with
the body (Edmans et al., 2001).
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Figure 5.3 Positioning in bed, lying on the unaffected side (left hemiplegic patient). Do
ensure (i) patient’s head is in line with the body, (ii) patient is in full side lying not quarter turn,
(iii) body is not twisted, (iv) affected shoulder is brought through, (v) arms are kept parallel,
unaffected arm under pillow, (vi) fingers in a neutral position. Do not place any object in the
hand or against the sole of the foot (Edmans et al., 2001).
Figure 5.4 Positioning in bed, lying on the unaffected side (right hemiplegic patient). Do
ensure (i) patient’s head is in line with the body, (ii) patient is in full side lying not quarter turn,
(iii) body is not twisted, (iv) affected shoulder is brought through, (v) arms are kept parallel,
unaffected arm under pillow, (vi) fingers in a neutral position. Do not place any object in the
hand or against the sole of the foot (Edmans et al., 2001).
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Figure 5.5 Positioning in bed, lying on the back (left hemiplegic patient). Do ensure (i) head
is in the middle, (ii) trunk is elongated on affected side, (iii) shoulder is kept forward by a pillow,
(iv) pillow is under hip to prevent retraction of the pelvis and lateral rotation of leg. Do not place
any object in the hand or against the sole of the foot (Edmans et al., 2001).
Figure 5.6 Positioning in bed, lying on the back (right hemiplegic patient). Do ensure (i) head
is in the middle, (ii) trunk is elongated on affected side, (iii) shoulder is kept forward by a pillow,
(iv) pillow is under hip to prevent retraction of the pelvis and lateral rotation of leg. Do not place
any object in the hand or against the sole of the foot (Edmans et al., 2001).
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Figure 5.7 Positioning in bed, sitting up in bed (left hemiplegic patient). Do ensure (i) the
patient is upright with weight evenly distributed on both buttocks, (ii) shoulder is protracted
away from side and forward on a pillow, (iii) legs are straight and not laterally rotated. Do not
place any object in the hand or against the sole of the foot (Edmans et al., 2001).
Figure 5.8 Positioning in bed, sitting up in bed (right hemiplegic patient). Do ensure (i) the
patient is upright with weight evenly distributed on both buttocks, (ii) shoulder is protracted
away from side and forward on a pillow, (iii) legs are straight and not laterally rotated. Do not
place any object in the hand or against the sole of the foot (Edmans et al., 2001).
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It is important to consider mattresses when positioning the patient. A firm, supportive
surface will provide proprioceptive feedback, enable rolling and promote independence
when sitting up. However, pressure areas also need to be monitored. Where hospital
pressure care mattresses are used, the patient is likely to require more assistance to turn
and sit up.
Encouraging the patient to sit up through side lying promotes head righting, weight
transference and a sense of midline.
In a chair
More independence is offered to the early stroke patient in supported sitting and they gain
a more normal visual perspective of their environment. There is scope for the unaffected
arm to be used in a range of functional activities. The trunk muscles begin to be used
actively and the lower limbs begin to form a stable base of support.
It is important to note that sitting is not a passive task; the early patient may develop
inappropriate muscle activity and ‘holding’ postures if they do not receive sufficient
support from the chair or pillows. Those with sensory loss will require pressure areas to
be monitored. Where head control is still lacking, support must be provided.
Armchairs generally provide a back support that is slightly reclined which allows
for more relaxation. Where there is little active muscle control, the patient may have a
tendency to slide forward in the chair. This may encourage excess abdominal activity and
once established will make active extension difficult.
Provision of a wheelchair allows the patient to be easily transported to different places.
A correctly fitted wheelchair provides a more active sitting posture, which encourages
greater freedom of upper limb movements. Pressure relief is an important consideration if
the person is unable to change position without assistance, but this still needs to provide
a stable base.
Points to consider when positioning in a chair
Where possible the individuals’ hips, knees and ankles should be flexed at 90◦ with the
feet on a firm, flat surface. Abduction/adduction of the hip may require wedges to facilitate
the correct alignment.
The armrests should allow the arms to be resting on them without the trunk leaning
to the side. The arm position may be altered between internal and external rotation at
the shoulder, and the forearm between pronation and supination. The arm may also be
positioned on a table in front (see Figures 5.9 and 5.10) or to the side of the patient (see
Figures 5.11 and 5.12). These variations help to maintain passive range of movement
and prevent shortening of the affected muscle groups. Care should be taken to prevent
tightness in the pectoral muscles causing difficulty with dressing in the early stages,
and affect reaching. The hand should be maintained in a functional/neutral position, if
necessary using positioning devices such as pillows, shaped arm rests or splints. Web
space and rotation of the thumb should be passively maintained, in order to preserve
functional viability of the hand.
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Figure 5.9 Positioning in a chair, affected arm supported in front (left hemiplegic patient). Do
ensure (i) arm is well supported on table/pillows, (ii) the feet are flat on the floor/footplates
(Edmans et al., 2001).
Figure 5.10 Positioning in a chair, affected arm supported in front (right hemiplegic patient).
Do ensure (i) arm is well supported on table/pillows, (ii) the feet are flat on the floor/footplates
(Edmans et al., 2001).
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Figure 5.11 Positioning in a chair, affected arm supported at side (left hemiplegic patient).
Do ensure (i) arm is well supported on table/pillows, (ii) the feet are flat on the floor/footplates
(Edmans et al., 2001).
Figure 5.12 Positioning in a chair, affected arm supported at side (right hemiplegic patient).
Do ensure (i) arm is well supported on table/pillows, (ii) the feet are flat on the floor/footplates
(Edmans et al., 2001).
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Many specialist chairs are now available that provide additional postural support such
as lateral supports, head supports, inclined seats and lap straps (to maintain the hips
at 90◦ ). These chairs are normally adaptable for each patient in seat height, length and
incline. Lateral supports need to be adjusted for each patient and staff are aware of how
to position both the patient and the supports each time. Each patient needs to be carefully
monitored for fatigue and pressure relief. If a pressure relief cushion is required, this needs
to be assessed for and incorporated into any seating assessment, taking into account any
postural needs or sitting balance problems.
Perch sitting
When the patient begins to gain some active sitting balance and transfers are progressing, positioning on a perching stool allows for more active sitting, improving dynamic
control of balance, active extension of trunk and weight-bearing through lower limbs.
The upper limbs are freed to perform a greater range of activities. The extra seat height
and position of the pelvis in anterior tilt facilitates easier transfers into the standing position. However, perching stools should only be considered for relatively high functioning
patients.
Points to consider when using a perching stool
Choose a perching stool with the correct amount of support, for example, with
arms/backrest as appropriate. Ensure the affected hip is not retracted. Both feet should
have even weight-bearing and should be placed on a firm flat surface.
Sometimes perch sitting is contraindicated as it can exacerbate abnormal patterns
of movement/positioning, although it may be the only functional option in the long
term.
Self-care activities
All self-care activities should be graded, depending on the patient’s level of functioning.
The therapist should have a clear idea of the goal of the session and spend time preparing
the environment and gathering the necessary items. The following are ideas how each
session can be graded. The focus is on a restorative (remedial) approach, although it is
a common practice to teach some adaptive (compensatory/functional) techniques early,
that is, dressing techniques to maximise early independence.
Interventions involving personal washing
r The emphasis for patients in the early stages post stroke who have no or very poor
sitting balance should be on good positioning in a supported chair. The task should
have low attentional demands so that focus could be just on washing face, combing hair
or shaving with an electric razor.
r As sitting balance improves, focus could be on washing from the waist up. The environment can be manipulated to challenge the patient. Position the patient in front of an
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r
r
r
101
appropriate height sink, the patient’s wheelchair back can be folded down, the therapist
can sit behind the patient and facilitate the trunk as required, and an assistant can help
the patient with the task. The patient can be encouraged to reach forward and to the
side for items. Whilst washing, the patient’s affected arm can be positioned in support
either on the arm of the chair or forward on the sink (as long as good alignment of the
wrist and shoulder can be maintained).
Another progression could be to carry out washing while seated on a plinth; this is an
excellent session to do as a joint intervention with physiotherapy colleagues. However,
it is vital to consider the patient’s dignity and ensure privacy can be maintained. Washing
while seated on the plinth allows the patient to move more freely, it gives the therapist
opportunity to challenge sitting balance even more and allows involvement of the upper
limb to be facilitated. This style of intervention is not recommended if the patient has
perceptual problems and would struggle with carrying out tasks in an environment that
is out of context.
When the patient’s sitting balance has improved and the required assistance with transfers is minimal, the occupational therapist can consider sessions involving washing
the whole body such as showering. Showering can be carried out on a shower chair
or whilst seated on a bath board. If your unit has an extra wide bath board, start with
that one and introduce the normal narrower board when the patient is confident. Swivel
bathers can also be used. For patients who prefer to strip wash, a perching stool can be
considered to increase the challenge. For patients using a bath board, it is recommended
that the sound side of the body is nearest the wall; this is for safety but it also allows
the therapist to facilitate the affected side if required.
If the patient’s overall mobility improves, standing should be incorporated into intervention, for example, standing in the shower or at the sink. The therapist should
still provide facilitation and prompts if required, to achieve active incorporation of the
affected arm and leg.
The ultimate goal would be for the patient to be as independent as possible washing in
a manner of their choice.
Interventions involving dressing
Dressing can be graded in a similar way to washing and, although separated here, should
be part of the same intervention session.
r Patients early post stroke can be taught one-handed dressing techniques (see below)
while seated in a wheelchair or armchair; the session would also focus on the patient’s
sitting balance, trunk control and position and incorporation of the upper limb as
appropriate.
r Patients with improving trunk control could be taught dressing techniques while seated
on a plinth, as mentioned for washing. The plinth is also a good place to teach lower body
dressing techniques. This would also involve practising standing with the necessary
prompts or facilitation.
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r The ultimate goal for dressing would be for the patient to be as independent as possible
in the most normal environment, for example, sitting on the bed or standing in the
bedroom or bathroom.
r Adaptations such as elastic shoe laces or Velcro shoes/trainers are often useful, or
teaching the patient a one-handed method of tying shoe lace is feasible; again these
adaptations should not deter patients from using any return of hand function within
their activities of daily living.
r Clothing styles may change initially in the early stages of learning a dressing technique,
the patient may wear more leisure wear which is easy to slip on until they become
proficient in dressing techniques or their motor/cognitive problems improve, allowing
the individual to dress in their desired style of clothing. Any change of clothing style
must be carefully discussed with the patient in order to maintain the individual’s
autonomy and self-image.
Using adaptive (compensatory/functional) strategies for dressing
Even in the early phase of recovery, occupational therapists can teach patients adaptive
(compensatory/functional) strategies for functional tasks that will improve quality of
life and that are considered not to have a detrimental effect on motor recovery. Most
patients will find a way to compensate in order to meet their basic functional needs so
it is important that the occupational therapist guides this in the most appropriate way.
One-handed dressing techniques are commonly taught.
Dressing the upper body
The patient should lay the garment on their knees so the back is uppermost; they can then
easily see which arm goes into which sleeve. The sleeve hole of the affected arm should
be positioned in such a way that the sleeve hangs down by the affected leg. The patient
should move their affected hand into the sleeve, lean forward and slide the affected arm
down the sleeve. Next, they should pull the sleeve up past the elbow with the sound hand.
Then sitting as upright as possible, the patient should put their sound arm into the other
sleeve and pull the jumper, etc., over their head. The patient may need to be reminded
that clothes can get stuck on the affected shoulder and may need pulling down (see Figure
5.13a–h). Bras can be put on this way also, provided they are elasticated and are fastened
up first. Also ‘crop top’ style bras can be easier to get on.
Some patients may find it easier, when putting a shirt/blouse on, to lay it out with the collar nearest themselves, the inside of the shirt/blouse uppermost and sleeves corresponding
to the appropriate arm (see Figure 5.13i–q).
Dressing the lower body
Whilst seated, the patient should cross their affected leg over the sound leg after which
they can lean forward to put each garment over the affected foot. They should then uncross
their legs and reach down to put the garment over the sound foot. Many patients are unable
to maintain sitting balance whilst moving the sound foot off the ground. These patients
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(a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)
Figure 5.13 (a–q) Dressing top half (photographs for right weakness, reverse for left
weakness). (Reproduced with permission from Dr J. Edmans, University of Nottingham,
personal communication, 2009.)
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(i)
(j)
(k)
(l)
(m)
(n)
(o)
Figure 5.13 (Continued )
(p)
(q)
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should keep the sound heel on the ground, while putting garments over the sound toes
and, then keep the sound toes on the ground while pulling the garment round the sound
heel (see Figure 5.14a–h).
The patient should then stand up, achieve standing balance and pull up garments. If
appropriate, the patient can be facilitated to use the affected upper limb for support, the
therapist needs to ensure that good alignment of the wrist and shoulder is maintained.
For footwear the ideal these days is to have Velcro fastenings or elasticised supportive
slip on style shoes; these types of shoes can now be bought cheaply to suit all age groups
and sexes. Shoelaces can be tied with one hand, following the technique shown in Figure
5.15a–h.
Undressing
Teach patients to undress the opposite way to putting clothes on, the sound side should
be undressed first. With upper body clothing t-shirts and sweaters can be pulled over the
head, although care should be taken around the affected shoulder.
Instrumental activities
These include the following:
r Kitchen tasks.
r Household duties.
When using these activities for treating motor impairments, again a graded approach
should be used. The occupational therapist needs to be creative when thinking of intervention ideas in the occupational therapy kitchen or the home environment and will need to
consider the patient’s preferences and goals, culture, religion and previous roles. Medical
status regarding level of exertion and conditions such as diabetes and dysphagia also need
consideration.
Graded kitchen task
r A patient with poor sitting balance could initially be set up at table top level to carry
out a task. The task chosen can be decided between patient and therapists, but could be
making a hot drink, cereal and toast, baking, etc.
r As the patient improves the challenge can increase, a perching stool could be used and
standing can be incorporated; the patient can be encouraged to reach for items in high
and low cupboards. The therapist can facilitate or prompt the affected arm and leg as
appropriate.
r For mobile patients walking should be assisted as necessary and tasks should involve
moving around the kitchen, transporting items between surfaces.
r Similar grading principles would apply to household tasks such as laundry, cleaning,
gardening, etc. The restorative (remedial) approach should be used but as with dressing
certain adaptive (compensatory/functional) strategies may need to be incorporated to
maximise independence.
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(a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)
Figure 5.14 (a–h) Dressing lower half (photographs for right weakness, reverse for left
weakness). (Reproduced with permission from Dr J. Edmans, University of Nottingham,
personal communication, 2009.)
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(a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)
Figure 5.15 (a–h) Tying shoes laces (photographs for right weakness, reverse for left
weakness). (Reproduced with permission from Dr J. Edmans, University of Nottingham,
personal communication, 2009.)
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r In the kitchen, pieces of equipment are available to assist with the following tasks:
– Stabilising objects – use of non-slip mats, pan holders on the stove, spike boards,
buttering boards, etc.
– Cutting objects – use of food processors, spiked chopping boards, adapted knives,
may be helpful.
– Opening items – electric can openers, mounted jar openers belliclamps.
– Carrying items – use of a trolley or one-handed tray.
– Other equipment that may be useful can be found in various catalogues.
Graded household task
r Tasks such as ironing, laundry, vacuuming and cleaning are excellent activities that can
be graded by the occupational therapist.
r Ironing could be done initially from perch sitting, then progress to standing; the patient’s
affected upper limb should be monitored closely during ironing tasks.
r Vacuuming and cleaning could be used for patients working on higher level balance
skills.
r Some of these tasks can be set up on rehabilitation units, or in-patients can be taken
home for their intervention session. Realistically these activities are more appropriate
for community teams.
One-handed techniques
Although the objective is to restore the patient’s movement and hence function, it is
inevitable that some patients will not make a full recovery. Consequently, such patients
may have to resort to use one-handed techniques to restore function. Suggestions are
included in the Appendix.
Therapeutic activities
In the management of physical problems following stroke, therapeutic restorative (remedial) activities offer the patient movement experience in a controlled environment (see
section on Upper limb re-education later in this chapter). The therapist positions the task
to gain specific movements often related to regaining upper limb function. These sessions
are often done as tabletop activities. The therapist should have a clear idea of the task
they want the patient to participate in and how much help/facilitation they require. The
rationale for the intervention should be explained to the patient. The environment should
be set up to maximise the effect of the intervention, that is, the height of the table the
patient is seated or standing at. Ideas for interventions include:
r
r
r
r
Playing cards, dominoes.
Solitaire, connect 4.
Peg boards, block placing.
Badge making.
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r Writing exercises.
r Turning pages of a newspaper/magazine.
r Computer work, using the mouse.
The therapist should consider the patient’s goals and interests when choosing activities.
Therapists should be imaginative with activities, but should ensure that they target the
movement(s) they want their patient to practise; the more meaningful the activity is for
the patient, the more they are likely to engage in the session.
Clinical challenges
Pusher syndrome/overuse
In the early stages of recovery, one of the most challenging clinical pictures is the patient
with what has long been called ‘pusher syndrome’. Whether or not such a thing could be
classed as a syndrome has been an unresolved debate among clinicians for some time. But
certainly in clinical practice usually following a large non-dominant hemisphere stroke,
patients may exhibit a collection of impairments that fit a similar clinical picture. Davies
(1985) listed the following problems:
r The head is turned to the sound side and is at the same time shifted laterally towards
the sound side. When the patient is sitting, they are unable to relax muscles in order to allow the head to be side flexed towards the affected side, although it moves
freely to the sound side. The eyes are often turned to the sound side as well, and the
patient has difficulty in bringing them to the affected side and then maintaining their
position.
r The patient’s ability to perceive incoming stimuli from the affected side is reduced in
all the perceptual modalities, that is, tactile, visual or auditory.
r Lying supine on a plinth or in bed, the patient shows an elongation of the affected side
from head to foot.
r When lying on the plinth the patient holds onto the edge with the sound hand and is
anxious that they may fall of the edge.
r When both knees are flexed with the feet supported on the bed, they lean towards the
affected side. A marked resistance is felt when trying to turn both knees to the sound
side, that is, as if to lay them on the bed on that side. No resistance is met when rotating
both knees to the affected side.
r In sitting the difficulties become more obvious. The head is held stiffly to the sound
side and the sound side of the trunk shortens markedly. The affected side is elongated
although the weight remains over the affected side. Resistance is encountered when an
attempt is made to transfer the weight over the sound side, with the patient pushing
back with the help of his/her sound hand.
r Transferring the patient into a chair presents difficulties; the patient actively resists
moving towards their sound side.
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r Sitting in a wheelchair the patient adopts a typical posture. The trunk is flexed, the head
is turned to the sound side and the sound arm maintains constant activity, pushing on
the arm of the chair.
r When leaning forward in order to stand up or transfer into bed, the patient pushes
towards the affected side, although the trunk is markedly shortened on the sound side.
The affected foot may slide back under the chair or show no activity at all.
r In standing, the patient’s whole centre of gravity is to the affected side, so that a line
drawn from the sound foot to the sternum would be diagonal to the floor.
r Patients have considerable difficulty in learning to dress themselves and in activities of
daily living in general.
r Many perceptual problems are experienced by patients manifesting the pusher syndrome, and will need to be treated accordingly.
Ideas for intervention
Although this presentation mainly manifests as a physical problem, it has a large cognitive component, usually a problem with spatial attention (see perception chapter) and to
address it effectively in the clinical setting the clinician should always take both into account. However, there are some simple techniques to physically manage the problem. The
key is to re-educate the patient to where their midline is. The problem can manifest while
the patient is lying in bed, in sitting and in standing. A useful technique for this is to use
the environment. Either in the gym or anywhere quiet, position the patient near a wall or
something vertical. The patient understands that the wall is upright and with prompts from
the therapist can then orient themself to midline in either sitting or standing. Facilitation
should be avoided and the therapist should be careful not to over-handle the patient in the
early stages. This is because the patient will think they are being pushed over and will resist
this, compounding the problem. In functional tasks the focus should be on midline orientation. As these patients are usually complex, help should be sought from an experienced
therapist to guide intervention. Patients can overcome this phenomenon with time, but
often they are the patients who have had the largest strokes and functional recovery may be
limited.
Ataxia
Edwards (1996) describes three types of ataxia:
Sensory ataxia
r This is seen in diabetic or alcoholic neuropathy conditions.
r It disrupts the afferent proprioceptive input to the central nervous system.
r Symptoms include wide-based stamping gait with eyes fixed to the ground for visual
feedback.
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Vestibular ataxia
r This is seen in peripheral vestibular conditions or central disorders affecting the vestibular nuclei, for example, medullary strokes.
r Symptoms include disturbances of equilibrium in standing and sitting and may also be
accompanied by vertigo, nystagmus or blurred vision.
Cerebellar ataxia
r
r
r
r
This is seen in lesions affecting the cerebellum.
Symptoms include truncal ataxia and abnormalities of gait and equilibrium.
Dysarthria and nystagmus may occur.
Other symptoms include dysmetria, tremor, dyssynergia and visuomotor incoordination,
dysdiadochokinesia, posture and gait.
Intervention of ataxia
Cerebellar ataxia is the most common seen in stroke. It varies in its presentation from
mild to severe. In the most severe cases, it can be totally debilitating. Patients struggle
with controlling movement in all postures and controlling the affected upper limb in order
to complete the most basic of activities of daily living. Intervention is both restorative
(remedial) and adaptive (compensatory/functional) and occupational therapists need to
be careful to achieve the right balance in their interventions. If possible in occupational
therapy sessions, the therapist should discourage the patient from what is commonly
called ‘fixing’; this is where the patient overcompensates by holding on to surfaces
very rigidly to give them stability. The restorative (remedial) approach is focused on the
patient regaining fluid movements and feeling confident to allow themselves to move.
In patients whose ataxia does not improve, the occupational therapist can teach techniques to compensate. Some common strategies include:
r Using a wheelchair to self propel if walking is not possible (this needs careful assessment
to establish appropriateness).
r Using the sound arm to help control the ataxic arm during tasks such as feeding and
grooming.
r Introduction of weighted items such as cups and cutlery.
r Issuing cups with lids on. There are now many cups on the market that don’t look like
baby cups anymore and can be bought on the high street.
r Stabilising self proximally, for example, hips stabilised against a bench during tasks in
standing, elbows propped on table during fine motor tasks.
Upper limb re-education
It is thought that up to 70% of stroke patients will have their upper limb function affected
and about 40% of those will have no function at all in their arm (Wolf et al., 2006)
Throughout the rehabilitation process, there is a huge focus on the upper limb and a large
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amount of research has been done to try and establish the most effective interventions
for the arm (Wolf et al., 2006). Two techniques described in Chapter 2 (Bilateral Arm
Training/Isokinematic Training and Constraint Induced Movement Therapy) have been
shown to be effective in some patients and can be incorporated into occupational therapy
plans (see Chapter 2). Handling the paretic upper limb should be done with great care
and advice should be sought from experienced therapists when planning interventions.
Avoiding secondary complications
The subluxed shoulder
Post-stroke shoulder pain is reported to be very common, and in some cases the prevalence
of shoulder pain has be reported to be up to 80% of stroke patients (Walsh, 2001); this
however varies on how it has been measured. Shoulder pain can lead to difficulty with
activity participation due to reduced range of movement, that is, washing under the arm.
Shoulder pain additionally can lead to low mood, altered sleep patterns and therefore have
an impact on the patient’s quality of life.
A number of situations can cause shoulder pain, including shoulder subluxation, scapular retraction, abnormal tone either hyper or hypotonicity, sensory changes and poor handling. Shoulder subluxation is caused by low tone around the shoulder, resulting in the
glenohumeral joint being displaced as gravity causes the surrounding soft tissues to be
pulled down and over-stretched.
Assessment
Palpation of the space between the acromion and head of the humerus can be measured by
fingers or centimetres. It is important to assess scapular alignment as a displaced scapular
can cause pain. A malaligned scapular can have an effect on the whole position of the
arm, as can a subluxed shoulder and it is essential to gain a full understanding of how
the arm is presenting. Scapulohumeral rhythm is an essential part of reach and thus the
position of the shoulder has a major influence on the functional use of the upper limb.
Intervention
It is essential to try and determine the cause of shoulder pain to be able to plan the best
intervention. Intervention is focused around maintaining good positioning of the arm at
all times, in lying, sitting and standing. It is still important to facilitate normal range of
movement and this is best carried out with the patient seated in front of a table so their
affected elbow is supported. The patient should be taught scapular gliding exercises so
they can do these regularly throughout the day.
Zorowitz et al. (1996) found that facilitated movements were an effective way of aiding
motor recovery and this can be an effective intervention for shoulder pain. The arm can
be supported in various different ways by a pillow, used in supine, side lying or sitting. In
addition there are trays and lapboards that can attach to wheelchairs but these have been
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found to over-correct the shoulder alignment (Paci et al., 2005), so careful assessment is
needed.
Slings have been used as an alternative and these can also be used in standing. There
are many different types of slings and the position they hold the shoulder in is of variable
quality, as stated in Ada et al. (2005) and Walsh (2001). Slings tend to be difficult to
apply and patients often need assistance to put them on. Functional Electrical Stimulation
(FES) has been found to be effective in the intervention of shoulder subluxation in the
short term but it has not been shown to maintain the effects (Linn et al., 1999). Walsh
(2001) recommends FES should be considered for reducing pain and improving range of
movement and arm function. Physiotherapists may use strapping where the shoulder is
strapped into correct alignment. Hanger et al. (2000) did not find this to be an effective
method of intervention; however, they did find some immediate short-term pain relief. Oral
analgesic medication is a common practice and is often provided before therapy sessions
commence. The intervention of shoulder pain requires a coordinated multidisciplinary
management. Turner-Strokes and Jackson (2002) outlined an integrated care pathway for
the intervention of shoulder pain; a whole team approach is necessary to minimise its
effect on rehabilitation.
Oedema
Post-stroke hand and arm oedema results in an enlargement of the limb with restricted
mobility and functional use. It is thought to be caused by fluid leakage into the interstitium
(tissue space) as a result of ineffective muscle pumping activity on vascular structures
(Artzberger, 2005). When combined with poor positioning and the effects of gravity,
swelling and oedema can occur. Oedema of the hemiplegic arm is commonly seen as
an isolated hand and wrist swelling, but in some cases it can be part of a more complex
‘shoulder hand syndrome’ (Tepperman et al., 1984). The prevalence across the population
with stroke is unclear; however, one cross-sectional study concluded that oedema was
present in 33% of adults with stroke receiving early rehabilitation, with some degree of
swelling noted in up to 73%, and that it was more common in those with more severe
paresis of the hand. It was seen significantly more often in those with hypertonic fingers
and reduced sensation (Boomkamp-Koppen et al., 2005).
Assessment
Early identification is necessary to ensure preventative measures are put in place as soon as
possible. Visual inspection and comparison of the hands is generally sufficient to identify
post-stroke swelling and oedema; however, it is prone to variation and other assessment
methods such as circumferential measurement and volumetric assessment may be used.
Intervention
There is a lack of scientific evidence as to effective ways of reducing post-stroke upper limb
oedema; however, intervention should include a positioning programme which includes
supported elevation of the arm, passive ranging and light retrograde massage and, where
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possible, functional use of the limb. Splinting may be used to support normal alignment of
the hand and wrist and to avoid entrapment which may contribute to swelling. Education
and advice for the patient, family, carers and other staff to manage the effects is also
recommended.
Splinting
Within the literature there is conflicting evidence and opinions on whether to use splinting as a form of intervention. There is a lengthy debate on the theoretical basis for
splinting within neurology. There are two conflicting theories of biomechanical and neurophysiological approaches (Copley and Kuipers, 1999). Biomechanical rationale argues
that splinting is used to prevent and manage length-associated changes in muscles and
connective tissues. The neurophysiological rationale recommends that splinting is used to
inhibit reflexive contracture of the muscle. The decision on whether to splint must be made
on sound clinical reasoning. There are a wide variety of materials and types of splints and
all have different qualities. Splints should not be considered when there is active movement that would be restricted if a splint should be provided. Whatever the approach, there
are many different aims for splints and the reasons why splints may be considered are as
follows:
r
r
r
r
r
Reduction of spasticity.
Reduction of pain.
Reduction of oedema.
To maintain joint position and alignment.
Functional reasons.
Reduction of spasticity
Lannin and Herbert (2003) found a lack of evidence for splinting following stroke. In 2007,
Lannin et al. conducted a randomised control trial and found no evidence to support the
provision of a splint in a neutral or extended position to prevent contracture. The evidence
does not support splinting in the acute phase for spasticity as a method of prevention of
contracture. Regular passive range of movement and stretching is recommended and it is
important to provide teaching to the patient and carer to perform this programme. There
is however a role for splinting as part of a botulinum toxin regime. After the injection,
occupational therapists need to be aware of which muscles groups the splint is to support
and/or inhibit to achieve the ideal position to maximise the effects of the injection. The
type of splint chosen will vary depending on the ideal position, but may include cones or
resting splints in volar, dorsal or mid prone.
When spasticity is preventing hand opening causing difficulty maintaining the hand’s
hygiene, it can lead to a breakdown of skin integrity. In this situation provision of a palm
protector splint should be considered with regular passive range of movement that could
be incorporated to self-care, care plans. Cone splints may also be considered; however, at
times these are too harsh for patients to tolerate and often patients need a softer material.
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Reduction of pain
Following a stroke, pain can occur in various joints although wrist pain is a common
complaint among patients. This can be due to the wrist being in a prolonged flexed
position due to spasticity or flaccidity, leading to overstretching and/or shortening of
muscles. Lannin and Herbert (2003) suggest that regular passive range of movement
is effective in prevention of contracture, and thus splinting for this reason will not be
therapeutic. The therapist should assess each individual patient and after applying good
clinical reasoning, splinting to manage pain may be appropriate. When pain is due to an
overstretch of the wrist, provision of a volar resting splint may be beneficial to prevent
further harm and provide support. This must be alongside regular range of movement.
Maintaining joint alignment
Within the early stages of low tone, the hand may lose the curvatures due to prolonged
resting in a flat position. A resting splint may be considered to maintain the hand’s natural
curves and prevent secondary complications developing. It may be possible however to
maintain the hand’s natural curves through positioning, using rolled up pillowcases placed
in the hand and regular passive range of movement.
Functional aims of splinting
r To improve grasp in functional activities.
r To increase range of movement to open hand easily to enable daily hygiene.
r To use the upper limb pain free within activities.
Types of splinting
There are various different forms of splinting; these include thermoplastic, casting, air
splints and dynamic splints. Thermoplastic wrist splints are commonly used for volar,
dorsal and mid prone resting splints, cones and finger spreaders. As well as static splints
there are dynamic or functional splints. Dynamic splints are supportive and aids initiation
and performance of motion. A dynamic resting splint will allow the fingers to move in flexion during tonal changes. Dynamic splints aim to control unwanted tone which improves
reach, decreases involuntary movements, increases bilateral use and awareness of the arm.
Functional splints allow function in activities; examples of common functional splints are
wrist cock splints, thumb spicas, hand writing splints and wrist supports with universal
cuffs. Casting uses soft and scotch casting material and provides a circumferential support.
Commonly used casts are applied to elbow, ankles and wrists.
Orthotics
The National Clinical Guidelines for Stroke (ISWP, 2008) recommended that an anklefoot orthosis (AFO) should be considered as it is felt that its application would improve
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a patient’s gait or balance. Following assessment by an orthotist, a recommendation for
one of the following may be made:
r An AFO; there are many varieties available including those with a solid ankle, an
articulating ankle or the lighter foot drop splint.
r Callipers are still sometimes used in extreme cases.
r Prescription shoes or slippers.
r Shoe insoles.
Although referrals are often initiated by physiotherapists, an occupational therapist
should be consulted about the practicalities of putting on and taking off the AFO.
Self-evaluation questions
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Why is the assessment of motor impairments important for the occupational therapist?
What are the most important skills required for the assessment of motor problems?
What functional transfers should the occupational therapist assess and why?
Name three standardised assessments the occupational therapist could use to test
motor problems.
The National Clinical Guidelines for Stroke (ISWP, 2008) state three specific interventions that should be offered to patients with motor problems. What are they?
What are the four main aims of occupational therapy intervention with stroke patients
who have motor problems?
Name three clinical challenges that the occupational therapist might meet with patients
who have motor problems.
Name the two evidence-based techniques that should be considered for upper limb
re-education.
How should the occupational therapist address a subluxed shoulder?
What are the four reasons why the occupational therapist may splint an affected upper
limb?
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Chapter 6
Management of Visual and Sensory
Impairments
Melissa Mew and Sue Winnall
This chapter includes:
r
r
r
r
r
r
Visual processing
Somatosensory processing
Auditory processing
Vestibular processing
Olfactory and gustatory processing
Self-evaluation questions
Introduction
The brain is involved in processing a variety of sensory inputs which enable an individual
to see, feel, hear, orientate themselves to, smell and taste the external world and objects
within it. This not only enables individuals to detect stimuli and alert them to danger, but
also enables individuals to make sense of their environment in order to adapt behaviour
and affect changes in the external environment, essential for occupational performance.
A significant proportion of the brain is involved in sensory processing and sensory
impairments are common following stroke. In general, sensory loss arises from lesions
along the sensory pathways from the peripheral nervous system via the contralateral
thalamus to the contralateral sensory cortices, as shown in Figure 6.1. Thus a lesion to the
left thalamus or left primary sensory cortex will result in sensory impairment to the right
side of the body and vice versa: a lesion to the right thalamus or right primary sensory
cortex will result in sensory impairment to the left side of the body.
Lesions to association areas where sensory information is further processed
(Figure 6.1) result in problems interpreting this sensory information – otherwise known
as perceptual impairments. Perceptual impairments, such as the inability to recognise unseen objects through somatosensations alone (astereognosis) or the inability to recognise
objects (visual agnosia), are often more global perceptual problems resulting from extensive communication between hemispheres and hemispheric specialisation. This chapter addresses sensory loss and associated perceptual impairments of visual, somatosensory, auditory, vestibular, olfactory and gustatory sensory processing systems. As visual
processing has a significant influence on occupational performance and is seen as a
key domain of occupational therapy, the visual processing section of this chapter will
Occupational Therapy and Stroke, Second Edition Edited by Judi Edmans
© 2010 Blackwell Publishing Ltd. ISBN: 978-1-405-19266-8
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Primary motor cortex
(precentral gyrus)
Central
sulcus
Primary sensory cortex
(postcentral gyrus)
Somatic motor association
area (premotor cortex)
PARIETAL LOBE
Somatic sensory
association area
FRONTAL LOBE
Visual association area
Prefrontal cortex
OCCIPITAL LOBE
Gustatory cortex
Insula
Lateral sulcus
Visual cortex
Auditory association
area
Auditory cortex
Olfactory cortex
TEMPORAL LOBE
(a)
Frontal
lobes
Limbic
system
Anterior
group
Parietal lobe and
cingulate gyrus
Association areas
of cerebral cortex
Medial group
Lateral group
V e n t r a l
g r o u p
Posterior
group
Pulvinar
Auditory
input
Medial
geniculate
nucleus
Basal
nuclei
Cerebellum
General
sensory
input
Visual
input
Lateral
geniculate
nucleus
(b)
Figure 6.1 (a) Sensory cortices and association areas (visual, primary sensory, auditory,
gustatory and olfactory, (b) thalamic nuclei. (Reproduced with permission from Pearson
Education Inc, adapted from Martini, 2006, Figures 14-15a and 14-09b.)
primarily focus on registration of visual information while visual perception will be
addressed in further detail in Chapter 8.
Throughout this chapter it should be noted that assessment and intervention of sensory
processing impairments should always consider patient’s levels of arousal, alertness and
attention, as this will significantly impact upon the patient’s ability to detect, interpret
and process sensory information (see Chapter 7). If these are not considered, attention
difficulties could be misidentified as sensory loss leading to misdirected intervention plans.
Thus, visual and somatosensory assessments should consider the patient, the environment
and incorporate simultaneous (bilateral) stimuli to assess for sensory inattentions.
Similarly, intervention of sensory impairments should always consider the impact of
medication, time of day, fatigue and environmental distractions so that intervention can
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be timed and graded appropriately to optimise effectiveness. Restorative (remedial) intervention should be applied at high intensity (Byl et al., 2003), particularly in acute stages
to maximise neuroplasticity. However, restorative (remedial) recovery of sensation cannot
be accurately predicted and is likely to be dependent on other factors such as cognitive
ability (Connell et al., 2008) and extent of damage to the sensory pathways. Thus, advice on adaptive (compensatory/functional) strategies should always be prescribed early
on to enable patients to maintain their own safety and maximise independence. Further,
when both restorative (remedial) and adaptive (compensatory/functional) approaches are
implemented at the same time, therapists should emphasise the purpose of each intervention to avoid confusion between approaches so that patients can learn to implement both
approaches during functional activities appropriately and safely.
Visual processing
Vision is one of our primary senses – providing information about the world around us. It
has an important role in our ability to engage in activity and social participation. Our visual
sense gives us information about our environment, allowing us the capacity to interact
effectively and responsively in our environment and with the objects in it, to adjust our
posture and movements and provide vital information to guide our social interaction and
decision making. A stroke can affect a number of aspects of vision from our oculomotor
function and our visual fields to the higher levels of the visual hierarchy such as visual
memory and visual perception.
Functional anatomy
The visual system is a complex structure and, for the purpose of this book, a brief and
simple overview is described to provide a basic understanding of visual processing. For
further, more detailed information, please see the references and recommended reading.
Six extraocular muscles, innervated by the cranial nerves, are attached to each eye with
the role of moving the eyeball. Light passes into the eye through the cornea and lens to
be focussed on the retina. Information about the left visual field hits the medial half of
the retina of the left eye and the lateral half of the right eye. Together this information
travels to the optic chiasm where the information of the left visual field all crosses midline
and heads towards the right visual cortex via the right optic tract. The fibres in the optic
tract then synapse in the right lateral geniculate nucleus. Postsynaptic fibres form the optic
radiation, which then travel onto the cells of the right visual cortex (Figure 6.2). The visual
cortex distinguishes between the colour, line, shape and texture of incoming information.
From the visual cortex in the occipital lobe, information then travels back through
the temporal and parietal lobes (inferior and superior routes, respectively) where the
information is processed and integrated to gather meaning by identifying objects, the
environment and relationships within the visual space. From here it passes to the prefrontal
lobe and the frontal eye fields where this information is used to assist with decision making
and planning.
Following a stroke the effects on vision are dependent on the region of the lesion. One
of the most common visual impairments noted in people following a stroke is visual field
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Left side
Left eye
only
Right side
Binocular vision Right eye
only
Eye
OPTIC
NERVE (II)
Olfactory
tract
Optic
chiasm
Optic
tract
Pituitary
gland
Lateral
geniculate
nucleus
(in thalamus)
Mesencephalon
(cut)
Visual cortex
(in occipital lobes)
Optic projection
fibres
Figure 6.2 Visual pathway. (Reproduced with permission from Pearson Education Inc,
adapted from Martini, 2006, Figures 17-19 and 14-20.)
impairment, often a hemianopia (the loss of one-half of the visual field) which can occur
at any point after the optic chiasm (Figure 6.2). However, diplopia and other oculomotor
disorders commonly occur following brainstem or cerebellar lesions. Scanning, visual
attention, visual memory and other visual perceptual disorders can be seriously and quite
commonly affected by a stroke. These will be addressed in the chapter on perception.
Theory/approaches
The theory and approaches to assessment and rehabilitation are covered in Chapter 2.
However, it is useful to note that the assessment and intervention of particular impairments are often based on theories regarding the functioning of the particular system,
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Ability to create and
retain a picture of
the object in the
mind’s eye
Ability to identify
salient features
to distinguish an
object from its
surroundings
121
Adaptation through vision
Ability to manipulate visual
information mentally and
Visual
integrate it with other sensory
cognition
information to gain knowledge,
solve problems, formulate
Visual memory
plans and make decisions
Pattern recognition
Ability to organise a
thorough search of
the visual scene
Scanning
Ability to attend
to visual
information
Visual attention
Oculomotor
skills
Ability of the eye to move
quickly and accurately, and
maintain foveation and sensory
fusion for binocular vision
Visual
fields
Visual
acuity
Amount of visual surround
that can be seen when a
person looks straight
ahead
Ability to see
clear and precise
images for small
visual detail
Figure 6.3 Visual Adaptation Model. (Reproduced with permission from Mary Warren,
personal communication, adapted from Warren, 1993.)
in this case visual processing. There are two common trains of thought regarding the
functioning of the visual system, one being the simple information which comes through
the eye; the visual information is then integrated within the brain and an understanding
of the visual environment is then produced. The other is based on Warren’s (1993) Visual Adaptation Model, as shown in Figure 6.3, which identifies a hierarchical system
in which visual fields, oculomotor control and visual acuity are at the base (registration of basic visual information), followed by visual attention (one has to attend to the
information coming in to make use of it), scanning (having an ordered, efficient and
complete scanning pattern is essential to picking up all the required information), visual
memory (using past visual memory to categorise incoming information but also to store
this information) and visual cognition (finally making sense of the visual information, in
line with other stimuli to make accurate decisions, judgements and to interact with the
world).
The basis of the Visual Adaptation Model (Warren, 1993) includes:
(a) Oculomotor skills – allow the eyes to move smoothly, in a coordinated manner. This
includes:
r Pursuits – smooth eye movements.
r Saccades – jumping eye movements.
r Ability to track.
r Ability to accommodate (converge/diverge).
r Ability to fixate.
r Alignment.
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Impairments seen in patients following a stroke are diplopia (double vision), nystagmus, reduced depth perception, difficulty tracking and reduced efficiency fixating
or localising.
(b) Visual acuity – resolving power of the eye to produce a clear, accurate image at
different distances.
This includes near and far distance.
Impairments may arise following brainstem lesions affecting oculomotor skills (e.g.
accommodation of the lens to focus the image on the retina and pupil constriction to
regulate the amount of light) or from haemorrhages into the eye where fragile retinal
blood vessels have burst from an increase in blood pressure associated with stroke.
However, the majority of acuity impairments following stroke are due to premorbid
factors such as macular degeneration, glaucoma, diabetic retinopathy, cataracts or
scotomas.
(c) Visual fields – the portion of space that a person can see while he or she is fixating
centrally. This includes:
r Central and peripheral fields.
r Upper and lower quadrants.
Common impairments in patients following a stroke include hemianopia (loss of onehalf of visual field) and quadrantanopia (loss of upper or lower quadrant), as shown in
Figure 6.4.
Defects in
visual field of
Left eye
Right eye
1
Left
Right
2
1
Optic nerve
2
3 Optic
tract
3
Optic chiasm
4
4
Optic
radiation
Lateral
geniculate
body
5
6
5
6
Figure 6.4 Visual field loss and lesion site. (Reproduced with permission from McGraw-Hill,
adapted from Kandel et al., 2000, Figure 27.20, p. 544.)
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Hence assessment and intervention of visual processing needs to take into account these
theories, ensuring the basic eye structures are intact but also that the information is being
processed accurately at all levels.
Assessment
The screening and assessment of visual processing is a key aspect of gathering a holistic
picture of the functioning of a patient following a stroke. However, referral to appropriate specialists for more in-depth assessment of visual problems might be required,
including ophthalmologists (doctors specialising in diagnosing the health of the eye), opticians/optometrists (specialising in assessment and intervention of acuity problems) and
orthoptists (specialising in the assessment and intervention of visual field and oculomotor
impairments). However, occupational therapists have a key role in screening for these
impairments, ensuring patients get the appropriate assessment but also ensuring that the
resulting impairment is noted and incorporated into any further intervention, as vision has
a key role to play in function.
When screening for visual impairments, it is important to do this in an appropriate
environment with limited distractions, suitable lighting and appropriate levels of contrast
for the tasks.
Functional observations
Visual acuity impairments – Difficulty reading, recognising the detail, recognising faces,
squints when trying to focus, increased difficulty performing tasks in dim light.
Oculomotor control impairments – Complains of blurriness or double vision, difficulty
focussing, difficulty reading or watching television, difficulty following fast interactions
in their environment, for example, four-way conversations, turns their head rather than
eyes to fixate on object.
Visual field impairments – Patient bumps into objects, over-compensates when avoiding
obstacles, uses the wall to guide their walking, difficulty reading, difficulty watching
television, difficulty searching for items, gets lost, complaining of something wrong with
their eyes.
Screening
Acuity
r Can the patient read the heading of a magazine?
r Do they complain of blurred vision?
r Can they read a sign in the distance?
Oculomotor control
r
r
r
r
Does the patient have difficulty tracking objects?
Are they able to fixate on an object?
Can they shift their gaze?
Do they see more than one image?
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r Is the patient able to focus on the brightly coloured object presented to them; can they
track this object left/right, up/down, in a figure of 8?
r Can the patient shift his vision/gaze between two objects presented?
r Can they alternate from one point to another?
r Is there any nystagmus centrally or peripherally while tracking?
Visual field – The field of vision when looking straight ahead.
1. Confrontation test – ideally done with two people; however, as it is a crude screen it
can be done by one person to give an indication of any impairments. Sit in front of the
patient covering one of their eyes. Ask the patient to focus on a central point (e.g. the
examiner’s nose). The other examiner stands behind the patient and brings an object
into the patient’s vision at varying heights from the left and right periphery assessing
each of the four quadrants. Ask the patient to indicate when they first see the object
being presented. This is repeated with the other eye covered. Someone with visual
field impairment will not see the object until it comes into their intact peripheral field.
2. Complement the confrontation test with some basic pen and paper tasks, that is,
r Ask the patient to copy a diagram (do not tell them what they are copying or they
will use their visual memory to produce the diagram) – they will copy what they see
which might be the half of the diagram they see.
r Scan across a page of lines of letters and cross out the requested letter – the patient
is likely to cross out all the letters requested on one side of the page. However,
unlike patients with visual inattention impairments, a patient with only visual field
impairment will complete the task in an organised manner, identifying all letters
within the abbreviated field.
It is important to note that patients with visual field impairments often compensate
very quickly for their impairment so it may not be apparent on basic screening but more
complex functional tasks or functional observations in dynamic environments will provide
the information required.
The assessment of a patient’s visual attention, scanning and visual perceptual skills are
dealt with in perceptual impairments chapter.
Intervention
Intervention takes on many forms within occupational therapy but following the International Classification of Functioning, Disability and Health model (World Health
Organization (WHO, 2001)), intervention for visual impairments can be classified under
impairment-based intervention, activity engagement and social participation.
Impairment-based intervention
Often intervention at this level is dependent on and requires referral to professionals
specialised in the different aspects of vision such as the optician and the optometrist.
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Acuity
Intervention for acuity needs to be dealt with by the optician/optometrist; hence a referral
needs to be recommended to your multidisciplinary team for corrective lenses, glasses,
etc.
Oculomotor
Ideally an orthoptist needs to be involved if there are oculomotor impairments – they will
consider options such as occlusion for double vision, prisms, exercises, etc.
Visual field impairments
This cannot be rectified by intervention and adaptive (compensatory/functional) measures
are used to encourage the patient to scan and search within their affected visual field.
Occupational therapists can provide simple tasks such as scanning sheets, telephone
number copying, environmental searching, etc., to encourage scanning into the affected
vision field. An orthoptist may consider use of prisms to compensate, so referral is worth
considering.
Activity engagement
Often patients with visual processing impairments compensate very well and are able to
adapt to their impairments; however, it is the role of therapy to not only increase their
confidence in activity engagement but also their efficiency and reduce the effort required
to complete familiar tasks. Identifying the roles and tasks the patient wants to engage in
is essential, with the intervention being formulated around these tasks.
Intervention could include:
r Engaging the patient in tasks that encourage them to scan their environment.
r Educating the patient on how to develop an efficient search strategy when they wish to
find objects within tasks.
r Involving patients in tasks that require that they use their full visual field and oculomotor
skills such as copying telephone numbers from the telephone book, putting numbers
into the telephone, searching the environment for hidden objects, obstacle courses.
r Involving patients in games that require that they search their full visual field such as
Connect Four or that require them to switch/track objects such as table tennis.
r Using adaptive (compensatory/functional) measures such as reading articles using the
margin as an indicator that they have encompassed the full page or at a more basic level
drawing a line down the margin to ensure the patient scans the page completely.
Social participation
Engaging in the community, which is a dynamic, social and ever-changing visual environment, can be very challenging for someone with visual processing difficulties. They
must be alert and able to be responsive while ensuring their safety. Therapy within the
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area of social participation is essential to ensure a patient continues to engage in their life
roles and the wider environment.
Intervention could include:
r Teaching strategies on how to prepare for unexpected incoming visual information, for
example, before entering a busy room, scan the room and identify the location of key
objects and people and your path through the space.
r Developing safe search strategies, for example, crossing the road – identify the left
curb, follow it along and scan from this curb till the patient sees the other curb. This
ensures they have seen the whole road before crossing.
r Adaptive (compensatory/functional) strategies, for example, request that people do not
sit in your limited visual field space if there are a number of participants talking; reduce
the amount of visual stimulation in the environment when completing tasks.
Review and evaluation
Acute
Within the acute setting the main focus is screening to identify visual processing impairments and alerting the multi-disciplinary team if there are any concerns regarding vision
that may require onward referral. It is also important to educate the patient and family on
the impairments and ensure the patient’s safety is maintained if discharged home, providing education on adaptive (compensatory/functional) strategies if appropriate. It should
be noted that some patients may demonstrate spontaneous recovery of acuity, field and
oculomotor impairments during acute stages, so use of some strategies such as occlusion
should be carefully prescribed and monitored.
Inpatient rehabilitation
Further in-depth assessment might be required and linking further assessment to other
impairments such as visual attention, visual memory and visual perceptual impairments
and their impact. Continuous review during rehabilitation is required, particularly of the
patient’s ability to learn and use the adaptive (compensatory/functional) strategies taught
and noting their ability to adapt to their visual environment during tasks.
Community rehabilitation
By this stage one would hope the patient with visual processing impairments has learnt
to compensate or has been offered the appropriate adaptive (compensatory/functional)
measures to modify their impact. However, this is an important time to review their visual
processing in the more dynamic and wider community environment.
Clinical challenges
When assessing and treating people who have had a stroke, it is sometimes difficult to
differentiate between impairments, which often present with similar functional impairments.
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Some key areas to be alert to include:
r Differentiating between difficulty tracking and visual field loss.
r Differentiating between visual field impairments and visual inattention.
r Occipital lobe impairments, impact on the accuracy of the information reaching the
parietal/temporal lobes for integration, impacting on the visual perception of their
environment even though the parietal/temporal lobes are intact.
r Uncommon disorders such as cortical blindness (total or partial loss of vision in a
normal-appearing eye caused by damage to the occipital lobe) and visual hallucinations
(caused by disruptions to the visual processing pathway and sometimes misdiagnosed
as psychiatric issues rather than neurologically based).
r Visual perceptual, cognitive and speech impairments impacting on accuracy of assessment.
r Visual perceptual, cognitive and speech impairments impacting on ability to learn or
compensate for impairment.
A large number of stroke patients suffer some form of visual processing impairment,
whether that is at the basic sensory input level, discussed here, or the visual attention/visual
perceptual level discussed in the perceptual impairments chapter. Due to the significant
impact visual impairments have on function, it is an important area for occupational
therapist to address.
Somatosensory processing
Functional anatomy
Information regarding pain, temperature, touch, pressure, vibration and proprioceptive
sensations ascend the spinal cord in highly organised tracts. The organisation of these
tracts means that certain sensations travel closely together. For example, pain and temperature ascend together in the lateral spinothalamic tract; fine touch, pressure, vibration and
proprioceptive information ascend in the posterior/dorsal column; whereas crude touch
and pressure ascend in the anterior spinothalamic tract. These tracts synapse in the ventral
nuclei of the contralateral thalamus where sensory information is sorted, determining
which sensations should be consciously perceived. Subsequent projections from the thalamus to the primary sensory cortex in the parietal lobe enable sensations to be perceived
and localised as the primary sensory cortex is functionally organised according to body
parts. Thus, the organisation of the primary sensory cortex can be further mapped into
cortical areas representing the relative sensitivity of different body parts, known as the
sensory homunculus (Figure 6.5). From the primary motor cortex, somatosensory information is further processed in the somatic sensory association area of the parietal lobe
(Figure 6.1). It is here that sensations are recognised.
Lesions along the somatosensory pathways up to and including the thalamus may
result in loss of sensation. Lesions between the thalamus and the primary sensory cortex
may result in sensory loss and inability to localise sensations. Lesions to the association
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Sensory homunculus of
left cerebral hemisphere
Ventral nuclei
in thalamus
MESENCEPHALON
Medial
lemniscus
Nucleus gracilis
and nucleus
cuneatus
MEDULLA OBLONGATA
SPINAL CORD
Fasciculus gracilis
and fasciculus
cuneatus
Dorsal root
ganglion
Fine touch, vibration, pressure, and
proprioception sensations from right side of body
Posterior column pathway
Figure 6.5 Sensory homunculus of the primary sensory cortex. (Reproduced with permission
from Pearson Education Inc, adapted from Martini, 2006, Figure 15-5.)
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areas result in difficulties with recognising and interpreting sensations, leading to clinical
presentations of:
r Astereognosis (the inability to recognise unseen objects through touch).
r Body scheme impairments (difficulty perceiving the position of the body and relationship of body parts) such as
– Somatognosia (lack of awareness of body and relationship of body parts).
– Unilateral neglect (neglect of the affected side of the body or environment).
– Right/left discrimination impairment (difficulty understanding concept of left and
right).
r Body image impairments (lack of mental image of one’s body) (see Perceptual impairments chapter).
Somatosensory impairment is common following stroke. Approximately 50% of stroke
patients experience somatosensory impairment (Carey, 1995). Stereognosis is the most
frequent impairment followed by proprioceptive then tactile sensory impairments (Connell
et al., 2008). However, there is some debate regarding where discriminative sensations
have been reported to be more common and reliability of measures may be a contributing
factor (Carey, 2006).
Functionally, somatosensory processing impairments have significant safety implications, particularly for the detection of protective thermal and pain sensations. In addition,
patients have difficulty regulating grasp for effective object manipulation particularly for
fasteners and writing; are at increased risk of developing learned non-use as spontaneous
use of the affected hand is diminished contributing to further deterioration of motor function; and their ability to relearn skilled movements is affected (Shabrun and Hillier, 2009).
These difficulties may in turn impact on all personal, domestic and community activities
of daily living, sexual and leisure activities and thus participation in life roles (Carey,
2006). Somatosensory impairments are significantly related to stroke severity and activity
limitations, which negatively impact on motor recovery and hospital length of stay (cited
Connell et al., 2008).
Theoretical approach
Despite significant integration along pathways, modalities are often discreetly impaired so
all modalities should be routinely assessed. Contrastingly, adjacent body areas frequently
have the same modalities impaired, suggesting redundancy of some assessments may be
possible (Connell et al., 2008). For example, Busse and Tyson (2009) explored redundancy
of touch, pinprick and pressure assessments. They concluded that if light touch was
intact in the thumb and hand, then no further assessment of the upper limb for light
touch, pinprick and pressure was required. However, redundancy of assessments for other
modalities is yet to be determined. It should be noted for somatosensation, similar to motor
impairments, that both sides can be affected due to ipsilateral pathways (Kim and ChoiKwon, 1996). However, some sensory impairments have been reported ipsilaterally and
thought to contribute to clumsiness in the unaffected limb (Brasil-Neto and de Lima, 2008).
Thus, the affected side should also be assessed if somatosensory impairment is suspected.
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Impaired proprioceptive sensation has been correlated with motor impairment
(Winward et al., 2002). However, pain, touch, localisation and temperature are not
(Winward et al., 2002). This may have implications for assessment and intervention.
Assessment
Functional observations
Patients who appear to be clumsy; drop objects; have difficulty regulating pressure and
maintaining appropriate grips; position their body parts awkwardly or trap limbs in
clothes/bedclothes; frequently injure, bruise, burn or cut themselves; have floating limbs;
neglect their limbs; or have motor impairment, should have further somatosensory assessment. Functional screening assessment could look at the patient’s ability to do up fasteners
such as buttons, zippers, laces, bras, belts, necklaces and apron bows or comb/brush their
hair with and without visual feedback and ability to identify objects in pockets.
Screening
Screening assessment should be completed in the first 2–4 weeks post onset (Winward
et al., 2007). The following upper limb screening process summarises procedures from
the literature (Lincoln et al., 1998b; Stolk-Hornsveld et al., 2006; Connell et al., 2008;
Busse and Tyson, 2009) and is diagramatically summarised in the author’s proposed
Somatosensory Screening Flowchart (Figure 6.6). To avoid subjecting the patient to
unnecessary repetition of tests and to improve therapists use of time, upper and lower
Assess light touch and
proprioception on
affected thumb and hand
Intact
Impaired/absent
Assess sharp blunt,
temperature, tactile
localisation, bilateral
simultaneous touch and
stereognosis (coins/full)
Intact
Complete light touch, proprioceptive
assessments on unaffected and affected upper
limb (consider standardised assessments)
Assess pressure and pinprick bilaterally
(use standardised assessments)
Impaired/absent
(use standardised
assessments)
Intact
Sensation normal
No treatment required
Impaired
Sensation impaired
Safety awareness training
Targeted sensory
rehabilitation with vision
occluded and attention graded
Absent
Sensation absent
Safety awareness training
In acute stage trial sensory
rehabilitation with vision
occluded and full attention
Figure 6.6 Proposed somatosensory screening assessment flowchart.
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extremities should be assessed together in coordination or as a joint assessment with physiotherapists. If sensation is anticipated to be impaired then assessment using standardised
measures is recommended to monitor change and measure outcomes, particularly as the
different modalities are discreet and redundancy of body parts for each modality is still
being explored (Connell et al., 2008). Readers are thus referred to Busse and Tyson (2009)
and Stolk-Hornsveld et al. (2006) for a more comprehensive description.
Tactile sensations
These assessments examine cutaneous sensations of touch, pressure, pain and temperature,
discrimination, localisation and tactile inattention. It should be noted that some conditions
such as attention impairments and diabetes mellitus may affect results.
Light touch:
Pressure:
Pinprick:
Sharp/blunt:
Temperature:
Tactile localisation:
Bilateral simultaneous touch:
Touch (not brush) the skin lightly with a cotton wool
ball, three times at each location in random order. If
light touch of the thumb and hand is normal then no
further points need to be assessed for light touch,
pressure or pinprick (Stolk-Hornsveld et al., 2006;
Busse and Tyson, 2009).
Apply pressure to the skin, using the index finger,
sufficient enough to just deform the skin contour,
three times at each location in random order.
Prick the skin using a cocktail stick, sufficient
enough to just deform the skin contour, three times
at each location in random order.
Only tested if light touch is intact. Stimulate the skin
six times at each location in a random order, three
times with a cocktail stick and three times with the
index finger. The patient must verbally or
non-verbally indicate whether the stimuli are sharp
or blunt.
Touch the skin with the side (not the bottom) of one
of two test tubes, one filled with hot water, another
with cold water. The patient must verbally or
non-verbally indicate whether the stimuli are hot or
cold.
Can be assessed at the same time as pressure (but
only if pressure detection is intact) by asking the
patient to point to the exact spot that has been
touched. Two centimetres of error is allowed and
coating the assessor’s finger with talcum powder to
mark the spot may help.
Only assess if patient can detect pressure. Touch
corresponding sites on one or both sides of the body
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Two-point discrimination:
using the fingertips. The patient must indicate which
side has been touched or if both sides were touched.
This test has been found to be less reliable and
should only be tested if light touch, pressure,
pinprick are normal. Start with a neurotip or
two-point discrimination instrument set with the two
points at 10 mm for index finger and 20 mm for the
thenar eminence. Apply the two points
simultaneously to the skin of the index finger and
then to the thenar eminence for approximately 0.5
second. Ask the patient to indicate if one or two
points are felt. Record the last interval at which two
points are felt. Record:
r Absent – Patient unable to detect two points.
r Impaired – Patient detects two points with an interval of 10 mm on the fingertip
and 20 mm on the thenar eminence.
r Normal – Patient detects two points with an interval of 5 mm on the fingertip
and 12 mm on the thenar eminence (Stolk-Hornsveld et al., 2006).
Proprioception
This is the awareness of sensory information from the muscles, tendons, ligaments and
joints. To demonstrate the procedure, three practice movements are allowed with patient’s
eyes open. Each joint is passively moved with the proximal end stabilised and both
proximal and distal portions held laterally to avoid tactile or pressure input. The thumb
interphalangeal joint is moved through full flexion/extension and wrist is moved through
full range of flexion/extension with the elbow in 150–160◦ extension. The patient verbally
or non-verbally indicates the direction of the movement. If unable to indicate direction,
the patient is asked to identify when movement is taking place. Repeat for each joint three
times. Record:
r Absent – patient does not detect movement taking place.
r Impaired – patient detects movement but direction is not always correct.
r Normal – patient correctly identifies direction of movement on all three occasions.
If proprioception of the thumb and hand is normal then no further joints need to
be assessed (Busse and Tyson, 2009), otherwise elbow flexion/extension and shoulder abduction/adduction (with elbow at 90◦ ) should be assessed by passively ranging
through approximately a quarter of their total range of movement (Stolk-Hornsveld et al.,
2006).
Stereognosis
This is a perceptual skill where unseen and unheard objects can be recognised by
touch alone. It requires integration of tactile and proprioceptive sensations with memory
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recall. However, it should be noted that objects can be correctly identified with some
tactile/proprioceptive impairments as sensations compensate for each other and patients
can ‘cheat’ by gaining auditory cues from tapping objects. Each object is placed in the
patient’s hand for a maximum of 30 seconds. Patients must identify objects by naming,
describing or matching with an identical set. Affected side is tested first. The examiner
may assist the patient to manipulate the object. Objects assessed may include 2p, 10p,
50p, biro, pencil, comb, scissors, sponge, flannel, cup and glass. In terms of grading, coins
are more difficult than comb scissors, cup and sponge (Connell et al., 2008).
Standardised assessments
r Rivermead Assessment of Somatosensory Performance (RASP) assesses pain, light
touch and localisation, temperature discrimination, joint movement detection and movement direction discrimination, bilateral touch discrimination (sensory extinction) and
two-point discrimination using customised clinical instruments. The assessment takes
20–30 minutes to administer and is available from Thames Valley Test Company
(Winward et al., 2002).
r Revised Nottingham Sensory Assessment (rNSA) (Lincoln et al., 1998b) does not require
special expensive equipment. It assesses light touch, temperature, pinprick, pressure,
tactile localisation, bilateral simulations touch to the face, trunk, shoulder, elbow, wrist,
hand, knee ankle and foot. Kinaesthetic sensations including appreciation of movement,
its direction and accuracy of joint position sense are assessed simultaneously. Joints
assessed include the shoulder, elbow, wrist, hand, hip, knee and ankle. Stereognosis is
assessed using 11 everyday objects.
r Erasmus MC Modifications to the (revised) NSA (Stolk-Hornsveld et al., 2006) improves
the reliability of the rNSA by standardisng procedures with defined points of contact
for tactile sensation; defined starting positions, movements and hand grips for testing
proprioception; and omits the less reliable two-point discrimination test. It takes 10–
15 minutes to administer. It assesses light touch, pressure, pinprick, sharp–blunt tactile
sensations to 12 upper extremity points on the fingers, hand, forearm and upperarm and
12 lower extremity points on the toes, foot, leg and thigh. Proprioception is assessed
in the thumb, wrist, elbow, shoulder, big toe, ankle, knee and hip. Detailed procedures
and recording form are free and available as appendices to the article (Stolk-Hornsveld
et al., 2006).
r Stereognosis subtest of the Chessington Occupational Therapy Neurological Assessment Battery (COTNAB) (Tyerman et al., 1986). Useful for comparing sensory information processing speed to normative data.
Further, more reliable tests for tactile and proprioceptive discrimination have been
developed for use in research. For more information on these, please see Carey (2006).
Intervention
Significant tactile, stereognostic and proprioceptive upper limb recovery can occur in
the first 6 months post stroke; however, prognosis for recovery is poorer than in the
lower limb (Connell et al., 2008). Stroke severity is the strongest indicator of impairment
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and recovery and motor performance significantly influences recovery of stereognosis
(Connell et al., 2008). However, there is no recognisable pattern to recovery (Winward
et al. 2007).
Carey (2006) summarises the principles of intervention from successful training programmes which include the following:
r Attention to the sensory stimulus: Active and purposeful exploration of sensory stimuli
r
r
r
r
r
r
r
with attention directed to distinctive features of difference, that is, discrimination is
required.
Repetitive stimulation with and without vision: This allows patients to alternately focus
attention on somatosensory feedback without the visual system taking over versus
gaining visual feedback to calibrate. Sensory stimulation is integral to the preservation
of the primary sensory cortex for functional gains.
Use of targeted sensory tasks that are challenging and motivating, with opportunities
for success.
Anticipation where patient draws on previous experiences of what the stimulus should
feel like.
Focus on the hand.
Graded progression of tasks for the targeted modality from easy to more difficult
discrimination. Variation in stimuli is required for generalisation to novel tasks.
Intensity of training programme.
Feedback on accuracy and execution in line with learning theory. Calibration of perceptions with the other hand and visual feedback may also be important.
Restorative (remedial) intervention at impairment level
Shabrun and Hillier (2009) reviewed the evidence for passive (excludes muscle contraction) and active sensory retraining following stroke. It should be noted that sensory
interventions that combined with motor or other therapies were excluded from the review
and patients included both acute and chronic populations.
r Cutaneous electrical stimulation, for example, TENS machines, delivered at low frequencies (10 Hz) and at sufficient intensity to evoke stroke paresthesia in the target
tissue may improve hand function and dexterity following stroke (Shabrun and Hillier,
2009).
r Active stimulation involving exercises that practice discriminating and localising sensations, stereognosis and proprioception may be beneficial, although results of a metaanalysis are inconclusive (Shabrun and Hillier, 2009). Dosage of researched interventions averages 45 minutes sessions × 3 times per week and has been administered to
both acute and chronic patients.
Carey (1995) reviewed sensory retraining programmes for stroke including Yekutiel
and Guttman’s (1993) sensory rehabilitation programme. Yekutiel and Guttman (1993)
describe a successful 6-week sensory retraining programme for chronic stroke patients
which includes:
r Identifying touch (counting touches administered from proximal to distal).
r Identifying simple continuous touch (identifying direction, number and shape of lines
drawn on the skin with a pencil).
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r Identifying complex continuous touch (identifying letters/numbers drawn on the hand
or arm).
r Texture discrimination (between sandpaper, velvet, paper, wire wool, cotton ball,
smooth plastic, rubber, leather, card).
r Finger identification (identifying finger touched – particularly thumb, index and little
fingers).
r Guided drawing (patient assisted to draw a shape which the carer identifies).
r Thumb localisation (patients affected hand positioned in various places, patient instructed to find the affected thumb with the unaffected hand).
r Distance between hands.
r Position of hand (patients asked to estimate the gap between their hand).
r Thick and thin rods (patients to identify cylindrical rods placed in the fingers ranging
between 5 and 30 mm diameter).
r Weight (identify and compare objects of different weights).
r Shape (identify different shaped objects).
r Size (identify different sized lids).
r Consistency (identify objects of same shape but varying consistency, for example, tennis
ball, plastic ball, squash ball, stress ball, wooden ball).
r Temperature (compare temperatures of metal spoons placed in ice, at room temperature,
warm water, hot water and a plastic spoon).
r Object recognition (recognise everyday objects, for example, comb, brush, spanner,
squash ball, fork, spoon, knife, teaspoon, mug glass).
Further programmes including several research projects under the Study into the Effectiveness of Neurorehabilitation on Sensation (SENSe) programme are currently being
investigated, including a randomised controlled trial on somatosensation training in the
hand following stroke at the National Stroke Research Institute in Australia. Researched
training to date has included:
r Sensory Specific Training which ‘involves repeated presentation of targeted discrimination tasks; progression from easy to diffiuclt discriminations; attentive exploration of
stimuli with vision occluded; use of anticipation trials; feedback on accuracy, method of
exploration and salient features of the stimuli; and use of vision to facilitate calibration
of sensory information’ (Carey et al., 1993; cited Carey, 2006: p. 237).
r Stimulus generalisation training aimed at transfering training effects to novel stimuli
includes ‘addition principles of variation in stimulus and practice conditions, intermittent feedback and tuition of training principles’ (Carey and Matyas, 2005; cited Carey,
2006).
Restorative (remedial) intervention during functional tasks
at activity and participation level
Encouraging some use of the affected limb during functional tasks to improve sensory
feedback may help. If limited movement, encourage limb placing/positioning in tasks and
weight transference. Therapists should consider the dynamic nature of sensory input as
the central nervous system responds to change and switches off when sensory stimulation
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is constant. Other techniques which may enhance normal sensory input include the following:
r Bobath principles of facilitation and use of handling to prevent abnormal movements
and feed correct sensory input into the sensory system may have indirect effects on
sensory improvement during functional tasks.
r Cognitive processing (inattention to tactile stimuli) to utilise attention/information
processing strategies.
r Sensory re-education desensitisation – here the central nervous system is overwhelmed
and is over-responsive to change, so needs to learn to cope with reduced amounts of
input with slower changes.
r Constraint-induced movement therapy – see Chapter 2.
Adaptive (compensatory/functional) intervention
r Adaptive (compensatory/functional) techniques, for example, testing water with the
other hand, using adaptive (compensatory/functional) devices for safety and train patient
to check the position of their limbs.
r Use of vision to compensate.
r Enlarged handles to assist grips, universal splints when attention is divided.
r Safety – education, safety awareness, environmental adaptations.
r Pain – distraction, relaxation, pain clinic, Transcutaneous Electrical Nerve Stimulation
(TENS), splinting (alignment), taping/Functional Electrical Stimulation (FES)/support
for subluxation.
Review and evaluation
If impairment is found following acute assessment, reassessment is recommended at 3
and 6 months post stroke with follow-up assessment as appropriate depending on progress
(Winward et al., 2007).
Clinical challenges
Complex regional pain syndrome (otherwise known as central pain syndrome,
shoulder–hand syndrome, thalamic pain syndrome or Dejerine Roussy) following stroke
appears as a painful, oedematose limb with altered heat and tactile sensations, dystrophic
skin and is prone to non-use and psychological implications such as anxiety and depression (see Chapter 5). Onset following stroke may occur in the shoulder or hand (or both) in
the first 5 months and one-third of these patients may resolve within 1 year (Pertoldi and
di Benedetto, 2005). Onset seems to be related to aetiology of stroke (frequently involving
the thalamus), severity, motor recovery, spasticity, sensory disorders and glenohumeral
subluxation. Although the mechanisms are unclear, the hypersensitivity and interpretation
of non-noxious stimuli to be noxious appears to arise from neurogenic inflammation leading to sensitisation of peripheral and central sensory neurones and variable involvement
of the sympathetic nervous system. Interventions include pharmacology (non-steroidal
anti-inflammatories, tricyclic antidepressants, botulinum toxins), regional anaesthesia,
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neuromodulation, sympathectomy (sympathetic blocks), TENS and electrotherapy, nighttime resting splints (not recommended for daytime), counselling, biofeedback, relaxation
techniques, group therapy and psychotherapy. Exercise and a graded desensitisation programme within perceived pain thresholds may be helpful to gradually habituate patients
to stimuli perceived as noxious. However, there is little evidence to support the efficacy
of these interventions (Pertoldi and di Benedetto, 2005) and referral to specialised pain
clinics is recommended.
Other clinical challenges to somatosensory assessment and intervention include cognitive difficulties, particularly where severe attention impairments such as unilateral neglect
are evident. Here, it may be more beneficial to focus on the cognitive aspects to sensory
processing and adaptive (compensatory/functional) strategies.
Auditory processing
Functional anatomy
Information regarding sound is conveyed from the inner ear via cranial nerve VIII to the
cochlear nuclei in the medulla. Information then decussates to ascend contralaterally to the
inferior colliculus (for reflexive head movements in response to sound) and onto the medial
geniculate nucleus in the thalamus before it projects to the primary auditory cortex in the
temporal lobe (Figure 6.7). Patients with lesions to this pathway may have sensorineural
Auditory cortex
(temporal lobe)
Low-frequency
sounds
Highfrequency
sounds
Thalamus
Cochlea
Lowfrequency
sounds
Medial geniculate
nucleus (thalamus)
Highfrequency
sounds
Vestibular
branch
Inferior colliculus
(mesencephalon)
Motor output
to cranial
nerve nuclei
Cochlear branch
Vestibulocochlear
nerve (VIII)
Cochlear nuclei
Motor output
to spinal cord
through the
tectospinal tracts
Figure 6.7 Auditory processing pathway. (Reproduced with permission from Pearson
Education Inc, adapted from Martini, 2006, Figure 17-31.)
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deafness in one ear, although this is rare due to significant cross midline communication in
the brainstem. Auditory symptoms are associated with brainstem strokes and may include
hearing loss (if bilateral stroke), phantom auditory perceptions (tinnitus/ hallucinations)
and increased sensitivity to sound (Häusler and Levine, 2000). Lesions to the auditory
cortex in the temporal lobe (cortical deafness) may mean that although the patient is
unable to consciously hear sound, they may be able to reflexively respond to sound thus
‘appear’ to hear! Lesions to adjacent association areas (Wernicke’s area) result in patients
being unable to comprehend the meaning of sounds or words, known as receptive aphasia
or agnosias to particular sounds.
Assessment
Functional observations
Occupational therapy assessment of auditory processing impairments should consider:
r Patient’s premorbid hearing and aids used.
r Patient’s and family reports of new hearing impairments.
r The patient’s response to sound conducted via observation during initial interview and
functional tasks. For example, during conversation or in response to an object being
dropped or the patient’s name being called: Does the patient become more alert (detect
sound) and orient towards (locate) sudden or unexpected sounds? Does the patient
understand (recognise) words being said and are they able to follow instructions? Does
the patient demonstrate appropriate response to music and environmental sounds? How
does the patient cope in noisy environments with competing auditory demands, for
example, in the community, crossing roads?
Screening
Screening of auditory processing is important as Edwards et al. (2006) reported 42%
of patients had hearing impairments to conversational tones and 86% of those had not
been identified clinically as having a hearing impairment. Similarly, 35% of patients were
found to have aphasia (receptive and expressive) and 79% of these had not been identified.
Although some hearing difficulties may be premorbid, concerns are raised where the
significant lack of detection may mean that patients are not receiving intervention for new
impairments which may have significant function complications later on particularly for
communication, social, leisure and community participation and hence quality of life.
If new difficulties in auditory processing are suspected, further detailed assessment
should be referred onto the speech and language therapist or audiologist as appropriate.
Intervention
Other disciplines such as speech and language therapy/audiology generally address impairment/restorative (remedial) intervention. Occupational therapists should liaise with
these disciplines regarding recommended strategies and enable patients to incorporate
these into everyday activities. Occupational therapy intervention should primarily focus
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on adaptive (compensatory/functional), activity/participation-based intervention. These
may include liaising with sensory loss teams in social services, investigating home safety
alerting systems such as visual/vibratory alerts for smoke alarms/telephones, strategies
for communication and safety in community, social and leisure tasks such as shopping.
Review and evaluation
Occupational therapy should focus on activity and participation levels of evaluation using appropriate measure that considers management of risks (home safety alerts) and
participation in communication, social, leisure and community activities.
Clinical challenges
Therapists should be acutely aware of the impact that auditory processing impairments
(whether from hearing loss, receptive aphasias or agnosias) may have on following verbal
instructions during all other assessments and the increased simultaneous cognitive demand
placed on patients as they struggle to process auditory information.
Vestibular processing
Functional anatomy
Information regarding orientation and movement of the head in space; hence balance
(equilibrium) is conveyed via the vestibulocochlear nerve (cranial nerve VIII) to the
vestibular nuclei in the brainstem. Here, it is integrated with information from the contralateral ear before information is relayed to the cerebellum, primary sensory cortex and
motor nuclei in the brainstem. Reflexive connections in the brainstem enable coordinated
eye, head and neck movements (via Cranial nerves III, IV, VI and XI) and adjustments
to muscle tone via the descending vestibulospinal tract. Lesions result in nystagmus,
dizziness, impaired equilibrium reactions and balance, awareness of midline, oculomotor
difficulties, impacting on visual processing.
Theory/approaches
Vestibular systems are highly integrated with visual and somatosensory inputs which
contribute to control of balance (Smania et al., 2008). Thus assessment and intervention
of balance must consider the manipulation of visual feedback and somatosensory inputs.
Dysfunction can lead to avoidance of activity and social isolation.
Assessment
Functional observations
Observe balance reactions and reports of dizziness particularly when:
r Vision is occluded, base of support reduced or supporting surfaces are unstable, for
example, taking clothes off overhead in standing or when sitting on the bed, washing
hair, walking over uneven surfaces.
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r Tasks are more complex and patients are mobilising while visually distracted, for
example, meal preparation, community mobility.
r Bending down to put on socks and shoes or pick up dropped items.
Detailed assessment
This is usually carried out by physiotherapists, for example, sensory organisation balance
test (Di Fabio and Badke, 1990; cited Smania et al., 2008), postural sway, balance (with
and without visual feedback) and direct head displacement to test vestibular ocular movements. Occupational therapists should liaise with physiotherapists regarding outcomes of
assessment and recommended intervention approaches to maintain consistency.
Intervention
Physiotherapists generally address the impairment level with restorative (remedial) intervention via vestibular rehabilitation. ‘Vestibular rehabilitation includes exercises to
promote vestibular adaptation and substitution, exercises to habituate symptoms such
as dizziness with head movement, exercises to improve balance and decrease risk for
falls’ (Hall and Herdman, 2006). Occupational therapists should liaise with the physiotherapist regarding recommended strategies and consider application to everyday activities. Occupational therapy intervention should primarily focus on adaptive (compensatory/functional), activity/participation-based strategies including:
r Visual compensation.
r Stabilisation during functional tasks, for example, use of perching stool, chair, stabilising pelvis against benches/sinks, propping through upper limbs.
r Grading activity demands related to weight transfer and dynamic sitting and standing
balance and functional mobility.
r Graded activities requiring independent head/eye movements.
r Functional activities demanding balance that manipulate somatosensory input and visual feedback, such as
– Completing functional tasks with/without shoes on, on different surfaces inside and
outside.
– Graded visual feedback starting from downgraded activities where visual feedback
is utilised and somatosensory feedback from the lower limb is stable to high-level
retraining where somatosensory feedback is variable (e.g. outdoor surfaces) and
vision is occluded.
– Activities which may include reading, tracking objects with/without head movements,
coping in dynamic environments in the community, for example, crossing roads,
shopping, travelling keeping gaze on fixed target and moving head horizontally and
vertically versus moving eyes with head fixed, travelling on buses, in cars, mobility
under more challenging conditions, for example, walking, running, moving, standing
on moving surface.
r Falls prevention.
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Review and evaluation
Occupational therapy should focus on activity and participation levels of evaluation using
appropriate measures that consider dynamic balance, including domestic and community
activities of daily living.
Clinical challenges
Some clinical challenges to successful rehabilitation may include perceptual difficulties such as spatial representation, unilateral spatial neglect (see Chapter 7) and pusher
syndrome (see Chapter 5).
Olfactory and gustatory processing
Functional anatomy
Dysfunction in sense of smell and taste following stroke is rare but has been reported
following lesions affecting the anterior, posterior or middle cerebral arteries (Green et al.,
2008; Moo and Wityk, 1999). The olfactory tract conveys information regarding smell
from the olfactory bulbs to the olfactory cortex located in the medial temporal lobe (Figure
6.1). Information from the tastebuds are conveyed via cranial nerves VII, IX and X to
the solitary nucleus in the medulla. Here they join the somatic sensory neurones to travel
via the thalamus to the gustatory cortex in the anterior insula and adjacent frontal lobe
(Figure 6.1). Connections to the hypothalamus and limbic systems highlight the strong
emotional, behavioural and memory links to smell and taste.
Assessment
As part of the screening assessment, occupational therapists should enquire whether
patients have noticed any deterioration in sense of smell or taste and functionally observe
patient responses to ‘off’ milk or burning food during a kitchen assessment or whether
patients have ‘gone off’ their food.
In liaison with the dietician, further assessment could take into account patient perceptions when smelling pungent odours (like cloves, cinnamon, coffee, vanilla and lemon)
and the four different taste qualities of sweet, sour, salty and bitter (using sugar, lemon,
salt and black coffee for example) (Green et al., 2008).
Intervention
Recovery of smell and taste have been reported in minor strokes (Green et al., 2008) and a
restorative (remedial) approach could be considered on a theoretical basis. However, there
has been no research on this rare patient group to support this. Adaptive (compensatory/
functional) approaches should consider functional implications such as safety (e.g. alerting
to spoiled food, gas, fire and smoke), nutrition and psychosocial implications (Green
et al., 2008).
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Review and evaluation
Occupational therapy evaluation methods should consider activity and participation levels
of occupational performance such as use of Canadian Occupational Performance Measure
(COPM), quality of life (QOL) questionnaires and liaison with nutrition to monitor
nutrition goals.
Self-evaluation questions
1. Draw a concept map to help describe to a well-educated patient (with an interest in
anatomy) their symptoms of a right inferior quadrantanopia. What activities might
this patient have difficulty with?
2. When walking down the corridor, you notice that your patient makes a beeline for the
rail on the wall and appears a little unbalanced. They look at the floor when walking,
stop when people walk past and cannot find their way back to their room.
(a) What areas of visual function might be affected?
(b) What assessments will you do to pinpoint the problem?
(c) How would intervention differ for each ‘diagnosis’?
3. A patient complains of headaches and that when reading the print looks blurry and
sometimes the letters move. When the patient looks at you, you notice that they squint
or shut one eye and tilt their head when they try to look at you.
(a) What areas of visual function might be affected?
(b) What assessments will you do to confirm your hypothesis?
(c) What will you do if this is confirmed?
4. Your patient has a hemianopia. They previously enjoyed shopping, but now dislike
going shopping as they bump into people and struggle to find the items they look for.
What targeted strategies would you recommend to enable your patient to overcome
these challenges and enjoy shopping again?
5. Your patient has a ‘floating’ hand which they struggle to use effectively during
dressing. You suspect there is a sensory impairment.
(a) What areas of sensation might be affected?
(b) What assessments will you do to confirm your hypothesis?
(c) Describe your intervention taking a restorative (remedial) approach and compare this to your intervention taking an adaptive (compensatory/functional)
approach.
6. Your patient tends to drop objects in their affected upper limb during daily activities.
(a) What areas of sensation might be affected?
(b) What assessments will you do to confirm your hypothesis?
(c) Describe your intervention taking a restorative (remedial) approach and compare this to your intervention taking an adaptive (compensatory/functional)
approach.
7. Draw a concept map to describe to a well-educated patient (with an interest in
anatomy) their symptoms of impaired proprioception. What activities might this
patient have difficulty with?
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8. You are assessing a patient’s coordination using the finger nose test and notice that
the patient touches in between their eyes rather than the tip of the nose as instructed,
and makes no attempt to correct this.
(a) Why might this be?
(b) What assessments will you do to confirm your hypothesis?
(c) How might intervention differ between these?
9. Your patient has impaired tactile discrimination. Write up a sensory re-education
programme for a patient’s family to implement.
10. Your patient has oculomotor and vestibular impairments. Describe a restorative (remedial) intervention activity for your patient and how you will grade it.
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Chapter 7
Management of Cognitive Impairments
Thérèse Jackson and Stephanie Wolff
This chapter includes:
r
r
r
r
r
r
Definition of cognition
Cognitive functions
Assessment of cognitive functions
Cognitive rehabilitation
Assessment and intervention strategies for specific functions
Self-evaluation questions
Definition of cognition
Cognition refers to those mental functions which help us to acquire, organise, manipulate
and use information and knowledge. It includes all of our ‘thinking’ processes.
Cognitive functions
Cognitive functions which may be impaired following a stroke include the following:
r Attention – the ability to focus on specific sensory stimuli and suppress distractions.
Attention is required for many other cognitive functions to occur.
r Memory – the ability to retain and recall information.
r Perception – ‘making sense of the senses’ – a cognitive process which is dealt with in
more detail in the next chapter.
r Language – understanding and expression.
r Praxis – motor planning.
r Executive functions – skills which are needed to plan organise and execute a task.
Assessment of cognitive functions
Occupational therapy assessment at any stage of recovery will involve a detailed analysis
of performance skills (motor, sensory, cognitive, psychological and social) and the impact
Occupational Therapy and Stroke, Second Edition Edited by Judi Edmans
© 2010 Blackwell Publishing Ltd. ISBN: 978-1-405-19266-8
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of any impairments on a person’s ability to engage in occupations within a defined
environment (physical, social and cultural). Assessment of cognitive functions is often
carried out as part of an observational assessment of occupational performance using
selected daily living activities, for example, grooming tasks or hot drink preparation.
This can be done in the occupational therapy department, offering an appropriate context,
or in the person’s home or community environment which may offer a more realistic
assessment of their ability.
Timing of assessment is important to consider. In the acute phase of recovery from a
stroke a person may be fatigued and may be dealing with a complex set of recovery issues
which can impact on their emotional and psychological status. Testing specific cognitive
skills at this stage may not give a true reflection of their abilities and it may be advisable
to wait until the rehabilitation phase to do this. If however a cognitive impairment is
questioned the occupational therapist may assess cognitive functions in the acute phase
to determine the extent of the problem, and ensure appropriate follow-up, particularly if
discharge is planned. For further detailed cognitive assessment, the person may also be
referred to a neuropsychologist.
Standardised assessment
Occupational therapists have a vast array of standardised assessments and screening
tools available to them which can be used to contribute to the assessment of cognitive
functions. Standardised, impairment-based assessments aim to provide valid and reliable
assessments of performance skills, that is, specific cognitive components. They should not
be used in isolation, but in combination with observational clinical assessment and clinical
reasoning to ascertain to what extent the cognitive impairment impacts on occupational
performance. It is advisable to be fully familiar with the test manual and validation
processes to understand the extent of the remit for each test. Many of these assessments
are impairment based and caution is advised when interpreting the results as they may not
necessarily be clinically meaningful or relate to a person’s functional performance.
There are some standardised observational assessments of performance, for example,
the ‘Assessment of Motor and Process Skills’ (AMPS) which is used to measure the
quality of ADL performance (Fisher, 2006).
Other standardised assessments and screening tools which can be used to support the
assessment of cognitive functions include (this list is not exhaustive):
r MEAMS – Middlesex Elderly Assessment of Mental State (Golding, 1989)
r COTNAB – Chessington Occupational Therapy Neurological Assessment Battery
(Tyerman et al., 1986)
r RBMT – Rivermead Behavioural Memory Test -III (Wilson et al., 2008)
r CAM – Cognitive Assessment of Minnesota (Rustard et al., 1993)
r BADS – Behavioural Assessment of Dysexecutive Syndrome (Wilson et al., 1996)
r TEA – Test of Everyday Attention (Robertson et al., 1994)
r LOTCA – Lowenstein Occupational Therapy Cognitive Assessment (Itzkovich et al.,
1993).
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Cognitive rehabilitation
Approaches
The main rehabilitative approaches used by occupational therapists, within cognitive
rehabilitation, described in Chapter 2, are:
r Remediation (restoration).
r Adaptive (compensatory/functional).
Occupational therapists tend to favour a functional approach for the rehabilitation of
people with cognitive impairment, including task-specific training and the use of activities
which are meaningful and familiar. A selection of interventions may be required to meet
individual needs.
Intervention
Principles of intervention for the rehabilitation of people with cognitive impairment:
r Goal orientated – the person with cognitive problems is more likely to engage in
rehabilitation if they contribute to the selection of the activities they participate in. Goals
should be meaningful and relevant. Goals direct the content and process of interventions
and must be relevant to the individual’s needs and wishes. Long and short-term goals
are set and they should be, as far as possible ‘SMART’, that is, Specific; Measurable;
Achievable (with some challenge); Realistic (within the environment and resources
available) and Timescales should be set and there should be a regular review of goals
with the patient, family/carer and team. ‘If the patient, their family, and the treating
team are all working towards the same agreed goals, a satisfactory outcome is more
likely’ (Turner-Stokes, 2003).
r Individualised – a selection of strategies and intervention techniques may be required
as people will have individual interests and responses to interventions.
r Educate and include relevant family/carers/friends and significant others – so that they
understand the difficulties a person may be having and can assist with the application
of strategies and provide support.
r Focus on functional improvement – including a way of measuring this improvement,
such as goal attainment and performance measures.
r Include psychological and emotional support – people with cognitive problems can
develop anxiety, depression and a sense of loss of control and self-esteem. These
should be acknowledged and interventions provided to support management of these
problems, such as anxiety management training, relaxation training and medication.
Intervention strategies
r Task-specific training – or functional retraining, stresses the value of the use of specific
and relevant functional tasks. Emphasis is placed on task characteristics, in order to
support behavioural change (Wilson, 1998).
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r Practise – repetition over time and use of retained capacity assists learning.
r Errorless learning – people with brain injury, including stroke, may not learn from their
mistakes so an approach which supports the achievement of a successful outcome by
cueing the correct response is more likely to enhance learning. This has been evidenced
in studies of people with memory problems (Wilson et al., 1994).
r Environmental adaptation – regulation of noise and distractions; clearing environmental
clutter; and adaptations such as message boards.
r Compensation and strategy training – external aids and adapted methods – for example,
use of memory aids such as pagers, diaries and calendars.
r Prompts and instruction – direct instruction and guided assistance may support relearning of skills.
r Restoration/skills training – this has limited support for the restoration of cognitive
problems although some studies of attention have reported improved skills when specific
retraining of basic attention capacity is offered. Retraining tends to be more effective
when embedded in a meaningful and functional context, targeting the specific level of
attention impairment of the individual (Cicerone et al., 2005).
Attention
Attention is required for most other cognitive functions to take place. It is dependent on
an adequate degree of arousal and alertness and helps us to process a large amount of
information on a daily basis. Attention is commonly affected after stroke, especially in
the early stages of recovery.
To help with our understanding of attention it can be useful to think of it in a hierarchy,
as presented by Sohlberg and Mateer (1989) who described different levels of attention:
r Focused – an initial response to fix attention on a specific stimuli, for example, responding to your name being called.
r Sustained – this level relates to the brain’s ability to maintain attention on a single task;
also referred to as concentration, for example, reading a book.
r Selective – this refers to the brain’s ability to filter out unwanted stimuli in order to
attend more closely to detail or something important, for example, looking for someone
in a busy room.
r Alternating – this is the brain’s ability to shift its attention from one thing to another,
for example, listening to a lecture and taking notes.
r Divided – this is about multitasking, doing more than one thing at one time, for example,
driving and talking to a passenger.
Assessment
The aim of assessment is to determine at what level the patient’s attention problems are
most evident; how the problem impacts on occupational performance and if it is affecting
the patient’s behaviour.
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Initially simple screening tests can be used such as asking the patient to count backwards
from 20, or recite the months of the year backwards, or by observing them carrying out
pen and paper tasks. Look for an organised approach to the tasks versus an erratic, random
approach.
Observe the patient carrying out functional tasks; do they become more distractible as
the complexity of a task increases? Can they attend to a single task for a period of time?
Do they stop what they are doing to talk, that is, can the patient walk and talk at the same
time? Can they perform a functional task such as following a recipe and alternate their
attention between reading and carrying out the recipe? Do they miss detail?
Clinicians often report that patients with attention problems can appear impulsive and
at times agitated. These behaviours can be assessed through observation.
Standardised assessments for attention are available such as the Test of Everyday
Attention (Robertson et al., 1994).
Intervention
A functional approach using meaningful tasks can be used. Michel and Mateer (2006)
suggest that intervention should be focused on training specific functional skills rather
than the underlying processes. The National Clinical Guidelines for Stroke (Intercollegiate
Stroke Working Party (ISWP), 2008) recommend that patients receive repeated practice
of activities to treat attention problems. Activities that are meaningful and interesting to
the patient and control the amount of stimuli in the environment should be chosen. For
example, a kitchen session where the patient is asked to make a cup of tea, the therapists
could get all necessary items out on the counter, the patient then only needs to link the
components together without being required to search the kitchen for items. Each time the
session is repeated, an additional search could be introduced such as leaving the milk in
the fridge or cups in the cupboard. As the patients attention improves, the challenge and
complexity of the task can be increased to work on higher levels of attention. Repetitive
tasks at the tabletop can be used, for example, letter cancellation and word searches, as
long as the interventions are providing an appropriate challenge and can be graded as
attention improves.
Adaptive (compensatory/functional) strategies
The National Clinical Guidelines for Stroke (ISWP, 2008) recommend that patients should
be taught strategies to compensate for their reduced attention. If attention continues to
be a problem, strategies can be implemented. This can be done by providing structure
to the patient’s day such as using a diary system. Minimise distraction in the patient’s
environment and ensure the patient has a quiet place they can go to if they become overstimulated as this may manifest in agitated behaviour. Use of prompting to maintain the
patient’s attention during tasks can be useful (prompts can be verbal or visual). These
techniques should be taught to families and carers to alleviate the potential emotional
stress attention problems can bring to both patient and their carers. If the patient is going
home or is at home, safety implications of poor attention should be noted as it will often
present similarly to problems with memory.
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Memory
Memory allows us to retain and recall information for all aspects of daily living. Attention
is essential to allow us to attend to information and select what is to be stored in our
memory systems.
The main processes associated with memory function are as follows:
r Attention – to the information that has to be remembered.
r Encoding – sensory information is converted into meaningful data for storage.
r Storage – in long-term memory systems.
r Consolidation – rehearsal and practice of information to enhance the strength of the
memory.
r Retrieval – accessing information through recall or recognition.
Memory systems
Sensory memory (sensory registration) – allows us to attend to relevant information and
transfer it to our short and long-term memory systems. If not used, the information is
discarded.
Working memory (short-term memory) – a temporary storehouse of information which
is retained for long enough for us to act up on it, for example, dialling a phone number
when looking it up in the phone book. New sensory memories act with stored long-term
memories to manipulate and use information in a meaningful way. If new information is
to be stored as long-term memories, it needs to be consolidated and stored in one of the
long-term memory systems.
Long-term memory – information is processed and stored in different types of long-term
memory systems:
r Semantic memory – knowledge and facts;
r Episodic memory – past events and activities;
r Prospective memory – remembering to do things in the future;
r Procedural memory – learned motor, cognitive and language processes.
Semantic memory, episodic memory and prospective memory are referred to collectively as ‘declarative’ or ‘explicit’ memory, and procedural memory is also known as
‘non-declarative’ or ‘implicit’ memory.
Problems can occur in any one of the memory systems and can affect the ability to form
new memories ‘anterograde amnesia’ or access stored memories ‘retrograde amnesia’.
Assessment
Occupational therapists are interested in the impact of memory problems on a person’s
occupational performance. Assessment at any stage of recovery will involve a detailed
analysis of memory as performance skill impairment and the impact it has on a person’s
ability to engage in their chosen occupations. They will use a variety of observational,
behavioural and standardised assessments to determine the type and extent of the memory
impairment and how it affects a person’s ability to function in daily life.
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Observation of performance in a variety of tasks can help to determine where performance is limited and informs the intervention programme. Observing a person doing
some shopping or having a conversation about the day’s events can indicate areas of
difficulty they may be having and where memory information processing might be breaking down. It is important to consider the impact of the environment during assessment
as people often use cues to prompt them and may have more difficulty in unfamiliar
contexts.
Standardised assessments such as the Rivermead Behavioural Memory Test-III (Wilson
et al., 2008), Doors and People (Baddeley et al., 1994) and the Chessington Occupational
Therapy Neurological Assessment Battery (Tyerman et al., 1986) can be used to establish
a baseline of performance, but should be combined with observational assessments to
determine the extent of difficulty the individual has.
Intervention
Intervention should be individualised, goal orientated and include psychological and
emotional support. A restorative (remedial) approach, whilst of some use for those with
mild problems, has limited effect for those with severe memory problems. The use of
adaptive (compensatory/functional) approaches and assistive devices within the context
of functional activities tend to be more successful (Cappa et al., 2005).
A combination of approaches is recommended and these need to be selected according to where the memory information processing system breaks down and individual
preferences; see Figure 7.1. For example:
Reduce distractions
Eye contact/name
Attention
Encoding
Storage
Use written
lists/instructions
Make meaningful
Recall
Give cues
Consolidation
Rehearse and practice
Figure 7.1 Memory strategies linked with breakdown in memory processing.
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r If attention breaks down, use
– Attention treatment strategies.
– Environmental adaptation – minimise distractions; simplify and organise the
workspace.
r If encoding breaks down, make the information more meaningful, linking to previous
learning or chunking information together
– Internal strategies and prompts – for example, use of mnemonics, visual imagery.
r If the patient is unable to store information, use
– External strategies – for example, written and verbal prompts.
– Compensatory aids – for example, electronic pagers, diaries, notebooks, calendars
and computers.
r If the patient struggles to keep the information in storage, work on consolidation through
rehearsal and practice.
– Errorless learning in practice of tasks to minimise performance errors and enhance
learning.
r If the client has ‘tip of the tongue’ syndrome and has difficulty recalling the information,
give graded clues and prompts to elicit effortful but successful recall to facilitate
memory.
r Support from family, carers, colleagues and friends is required to implement strategies
and provide prompts and support, no matter which approaches are taken.
The National Clinical Guidelines for Stroke (ISWP, 2008) recommend the use of
adaptive (compensatory/functional) techniques to reduce disability, approaches aimed at
directly improving memory and the use of familiar environments when conducting therapy
sessions.
Language
Aphasia may occur following a stroke and this may affect a person’s understanding of the
spoken word, verbal expression, reading and writing. It is usually assessed in more detail
by the speech and language therapist; however, joint sessions between the occupational
therapist and speech and language therapist may be of benefit to help to ascertain what
elements of a person’s performance are due to language difficulties or other cognitive
problems (see Chapter 4).
Motor planning and apraxia
Normal motor planning
Praxis is skilled movement. It is the ability to plan and perform purposeful movement.
It is a cognitive process which relies heavily on the interaction with other cognitive,
perceptual, motor and sensory systems.
Normal motor planning involves the initiation of a movement via external (verbal
command, visual or tactile) input or volitionally. Actions need to be integrated with
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knowledge of object use and if several items are in use, there must be matching of
actions and objects at the correct stage. Actions are often required to be performed in
a specific sequence in order to complete a task successfully. We may at times perform
tasks incorrectly but generally we are able to recognise these errors and correct them; for
example, not putting the car into gear before pressing the accelerator.
A representational model of apraxia initially proposed by Roy and Square (1985) (and
reviewed, as outlined by Roy (1996)), described three systems which allow us to function
effectively: the sensory/perceptual system which differentiates between visual, auditory
and object information; the conceptual system which comprises our knowledge of actions
related to object function and associated sequences of movements related to the use of the
objects; the production system which involves knowledge of the force, time and direction
of action sequences and the translation of these into action.
The concepts of motor programmes and action schemas further support our understanding of motor planning and voluntary activity.
Motor programmes describe a set of motor commands used to achieve a particular
movement and determine the force direction and timing of the movement. They are
stored as motor engrams or action memories for specific movements. Action schemas are
generalised motor programmes which are activated for all movement associated with a
motor pattern. They contain the perceptual, sensory and motor components of a movement
and become established with practice and experience. This describes how a scheme of
movement such as reaching and grasping can be used for several activities such as reaching
for a tin in the cupboard, or reaching for a cup on the table.
Apraxia
Apraxia is a cognitive motor planning disorder. It impacts on a person’s ability to carry out
skilled voluntary movement and cannot be fully accounted for by other cognitive, motor,
sensory or comprehension problems. It has been described as one of the more disabling
effects of stroke or brain injury (Van Heugten et al., 2000).
Several types of apraxia are described in the literature such as dressing apraxia and
constructional apraxia. More recently these have been described as the functional outcome
of a performance breakdown resulting from several types of impairment and should
therefore not be given individual classifications. Most current literature describes two
types of apraxia – ideational and ideomotor.
NB: The terms ‘apraxia’ and ‘dyspraxia’ are used interchangeably by occupational
therapists; however, there is a move towards describing ‘apraxia’ as a disorder of learned
movement seen in adults with acquired injury and ‘dyspraxia’ as a disorder of new learning
seen in children (Grieve and Gnanasekaran, 2008). For this reason we use ‘apraxia’
throughout this text.
Ideational apraxia
Ideational apraxia is a disturbance in the conceptual organisation of actions. It is often associated with the inappropriate use of objects. Visual recognition and perceptual processes
are functioning but the ability to use the object is impaired. The person with ideational
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apraxia may use single action objects appropriately but may have more difficulty when a
sequence of actions for object use is required.
Specific performance errors initially proposed by Miller (1986) are associated with
the two types of apraxia. These errors have been revised by the author of this chapter
(Jackson) as a result of clinical observation:
r Inappropriate object use – for example, use a toothbrush to comb hair, or strike a candle
on the matchbox instead of a match.
r Sequencing errors – for example, buttering bread before toasting it or omitting an
essential stage such as turning the kettle on without putting water in.
r Blending sequences together – for example, making a stirring motion with a spoon of
sugar before putting it in the cup.
r The action overshoots what is necessary – for example, the whole cup is filled with
milk instead of leaving room for the tea.
r The action remains incomplete – for example, the sugar is spooned into the coffee but
not stirred.
r Perseveration – the action may be continued into the next stage of the task even though
it is not required – for example, the teapot is placed on the saucer after the teacup is
placed on the saucer.
Ideomotor apraxia
Ideomotor apraxia is a disorder in the initiation and execution of planned sequences of
movement. The concept of the task is understood but the movements lack the correct force
direction and timing to achieve a motor goal. The person with ideomotor apraxia may be
able to describe an action and at times will perform it automatically, but will generally be
unable to produce it on command. Performance errors initially proposed by Miller (1986)
and adapted by the author of this chapter (Jackson) are:
r Spatial orientation errors – wrong orientation of the arm, for example, waving goodbye
in a forward/backward motion instead of side to side.
r Initiation and timing – for example, hesitation before initiating a movement, often at a
point of transition between movements. Movements may appear rushed or abnormally
slow. Inappropriate force may be seen in relation to the spatial pathway and related
time sequence.
r Errors of the force of movement – poor calibration, for example, bang a cup down on
the table.
r Poor distal differentiation – the overall arm position may be correct but with poor hand
posture – for example, if demonstrating turning a key the hand is held in the wrong
plane when the arm appears correctly aligned.
r Body part used as object – when asked to gesture an action, the person substitutes a
body part for the object – for example, using finger as a toothbrush or hand as a razor.
r Gestural enhancement – an increase in the movement required for an action – for
example, rocking back and forth when demonstrating the use of a hammer.
r Vocalisation (vocal overflow, self-cueing) – verbalisation of a movement – for example,
‘bang, bang’ when demonstrating the use of a hammer.
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r Perseveration – continuation of a movement, when there is no obvious end point, for
example, continuously cleaning shoes, or using the same movement to demonstrate an
action when moved onto the next action, such as making a hammering motion when
demonstrating the use of a spoon (after demonstrating use of a hammer).
r Fragmented response – part of a movement is demonstrated – for example, when
demonstrating drinking the cup is bought to the mouth but not tipped to the lips.
Assessment
Therapists will be primarily interested in how apraxia affects a person’s ability to engage
in meaningful occupations in the areas of self-care, work, domestic and leisure. In order to
assess those functions the occupational therapist will analyse the component parts of the
task to determine where the ability to perform it has broken down. This could be in any
one or more than one of the performance skills of motor, sensory, cognitive psychological
or social aspects. The environment and context in which the task is taking place will also
have an impact on the outcome.
Tate and McDonald (1995) described the ‘vast array of diagnostic tests’ for apraxia
having little more value than being crude but useful screening measures. Butler (2002)
found a lack of correlation between tests of ideomotor apraxia and questioned the validity
of ideomotor apraxia screening tools. Studies of apraxia use different screening tools
and despite finding apraxia, each test may be examining different aspects of the apraxia
syndrome. Butler recommends that until a ‘gold standard’ test of apraxia is found that we
do not just rely on one test of apraxia for diagnosis and that we consider the results of
ADL measures as being more clinically relevant than pure test scores.
Van Heugten et al. (1999) proposed a diagnostic test for apraxia in stroke patients which
was sufficiently discriminative to distinguish between those who had apraxia and those
who did not, but not to identify the subtype of apraxia, that is, ideomotor or ideational.
Subsequent studies of this diagnostic tool recommend it for clinical practice (Zwinkels
et al., 2004); however, like Butler, the authors recommend that test scores are combined
with behavioural observations for a full assessment of apraxia and its impact on daily
living activities.
Standardised assessments of performance such as the AMPS may contribute to the
understanding of the quality and effectiveness of performance (Fisher, 2006). Van Heugten
et al. (2000) used an observational method for the measurement of disability in people
with apraxia using four activities of daily living. The focus was on the point at which the
activity broke down rather than the cause and identified initiation, execution and control
as the notable stages of performance breakdown. This was subsequently used to support
appropriate intervention strategies at the relevant juncture.
Occupational therapists use the identification of performance errors to determine where
an activity is breaking down. Tempest and Roden (2008) found consensus amongst occupational therapists that analysing a person’s performance errors was the best way to
assess apraxia.
By using the errors noted for each type of apraxia, the occupational therapist may
be able to use their clinical observations to identify which type of apraxia a person is
experiencing, and more importantly the impact it has on independent living.
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Intervention
The principles of cognitive rehabilitation, ‘goal orientated; individualised, educate and
include relevant family/carers/friends and significant others; focus on functional improvement; and include psychological and emotional support’ should be used and an adaptive
(compensatory/functional) approach is recommended.
Studies have shown that people with apraxia can improve their functional performance
despite the lasting presence of apraxia, and that adaptive (compensatory/functional) strategies do not impede the recovery of the impairment (Van Heugten et al., 1998; Donkervoort
et al., 2001).
Van Heugten et al. (1998) proposed a ‘strategy training’ programme for people with
apraxia. This was evaluated in a randomised controlled trial and showed short-term improvement in ADL function when comparing it with usual occupational therapy, although
the long-term effect requires further exploration (Donkervoort et al., 2001). Strategy
training aims to improve performance by teaching internal and external compensatory
strategies as part of the occupational therapy programme. As the assessment using ADL
observations breaks the activity down into performance stages of initiation, execution and
control, intervention targets the relevant stage using instruction, assistance and feedback.
If initiation is the problem, instruction is given verbally if the problems are mild and if
the person is experiencing more problems initiating the activity, then the therapist may
for instance hand items to them one at a time. If execution is the problem, specific verbal
or physical guidance is given and if control is a problem or performance errors are not
corrected, then appropriate feedback is given.
Other smaller studies have shown some support for specific interventions:
r ‘Activities in context’ – Clark et al. (1994) conducted a small 3D movement analysis
study which suggested that motor performance and kinematic measures improved when
the person with apraxia was supplied with the appropriate tools for a task and the correct
contextual environment.
r ‘Task-specific training’ – Goldenberg and Hagmaan (1998) found that task-specific
training could restore independence for trained activities. They also found that skills
did ‘not generalise’ to other tasks and performance was retained only when tasks
continued to be ‘practised’’ in daily routines. This was supported in a single case study
by Wilson (1998) who provided a ‘structured’ programme of activity and ‘chaining’ to
retrain specific functional tasks. The activity was broken down into manageable steps
in order to relearn specific tasks. Skills were only retained if the task was practised in
daily routines. This supports the selection of appropriate and meaningful activities to
be used in the occupational therapy programme.
Executive dysfunction
The executive system comprises those high-level cognitive processes which combine to
set goals and to make choices in novel situations (Grieve and Gnanasekaran, 2008). It
refers to the processes by which we plan, organise, initiate, monitor and adjust our thinking
and behaviour (Kay, 1986).
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Ylvisaker and Szekeres (1989) identified component functions of the executive system:
r Realistic goal setting – having insight and awareness of what is achievable according
to own skills and external influences.
r Planning – correct ordering of the steps required to carry out a task successfully.
r Organisation – of the workspace and timing of the task to carry out the plan effectively.
r Self-initiation – starting a task without being prompted.
r Self-directing – continuing a task without prompting.
r Self-inhibiting – being able to stop a behaviour or action to move to another task when
required.
r Self-monitoring/self-correcting – recognising when something needs to be altered or
corrected and taking appropriate action.
r Flexible problem solving – being able to think of more than one solution according to
the demands of the situation.
Executive dysfunction can lead to difficulty formulating goals and maintaining behaviour to complete tasks successfully. People with executive problems may appear
disorganised and lack planning skills. They may not have insight into their difficulties
and may have problems interacting appropriately in various social, community and work
contexts. They may also be unable to correct their mistakes and/or to think laterally.
Assessment
It is important to define the person’s previous level of functioning as this will indicate
to what extent their performance is different from their normal executive skills. This
information can be obtained from family, friends and work colleagues through interview
and written feedback using specific questionnaires.
Observational assessment of the person’s performance of daily tasks can indicate specific executive problems. It is important that the level of skill required for the task is of
sufficient challenge to identify any performance breakdown. Simple, familiar tasks may
be performed correctly but difficulties arise when more complex tasks are introduced. The
therapist may ask the person to complete some more novel tasks which contain several
stages and demand a degree of organisation and planning to achieve a successful outcome.
The executive performance skills noted above can be used as a reference to determine any
areas of difficulty the person may be having.
There are several standardised assessments available, including the BADS (Wilson
et al., 1996). Standardised assessments of executive dysfunction should be used in combination with observational tests of performance as the test results may not always fully
reflect the functional limitations which the person may have.
Intervention
The National Clinical Guidelines for Stroke (ISWP, 2008) recommend that those
with executive dysfunction and activity limitation should be taught adaptive (compensatory/functional) strategies, for example, electronic organisers, written checklists; and
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that family and other staff should be involved in discussions regarding the impairment
and ways of supporting the person.
Cicerone et al. (2005) reviewed the evidence for remediation of executive functioning,
and although the studies were of people with traumatic brain injury the recommendations
can be considered for people who have had stroke. Practice guidelines from this study
include ‘training of formal problem-solving strategies and their application to everyday
situations and functional activities’ and ‘verbal self-instruction, self-questioning and selfmonitoring could be used to promote internalisation of self-regulation strategies’.
Focusing on the functional activities which are limited by specific executive skills are
encouraged, for example:
r Goal setting – specific and meaningful for the person. It is helpful to encourage people
to set their own goals and then review the outcome to develop insight into their own
abilities.
r Planning – activities can be graded to achieve success and gradually improve the
difficulty.
r Organisation – a structured routine can be established with support, and responsibility
for this gradually handed over.
r Self-initiation and self-direction – external aids such as pagers and alarms can assist
with reminders. Taped or written prompts may assist with self-direction.
r Self-inhibition/monitoring and correction – develop strategies to monitor own behaviour
and make appropriate changes. Feedback and discussion can be used to develop a
person’s awareness of their own performance.
r Flexible problem solving – alternating scenarios can be presented and practised to
develop a strategic approach to generating alternative solutions.
Self-evaluation questions
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Define cognition.
What types of cognitive impairments may be observed following a stroke?
Name and describe the five different levels of attention.
What are the four main processes associated with memory function?
Describe the difference between ‘anterograde amnesia’ and ‘retrograde amnesia’.
Describe five performance errors which you may observe in a person who has an
ideational apraxia.
Describe five performance errors which you may observe in a person who has an
ideomotor apraxia.
What are the main performance behaviours you may observe when someone has
executive dysfunction?
What are the two main approaches used by occupational therapists in the management
of people with cognitive impairments?
What are the main intervention principles for the rehabilitation of people with cognitive impairments?
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Chapter 8
Management of Perceptual Impairments
Louisa Reid and Judi Edmans
This chapter includes:
r
r
r
r
r
r
Definition of perception
Normal perception
Perceptual impairments
Perceptual assessment
Intervention of perceptual impairments
Self-evaluation questions
Introduction
Perceptual impairments can have a major impact on occupational performance. This
chapter outlines the types of perceptual impairments that may occur following a stroke,
how to assess these impairments and provide suggestions for intervention techniques.
Definition of perception
The simplest definition of perception is ‘to become aware of by one of the senses’ (Oxford
English Dictionary, 1961), that is, vision, hearing, touch, taste or smell.
Normal perception
How we interpret our environment starts at our inputting stage. The visual system conveys
more information to the brain than any other afferent system. Chapter 6 outlines the
pathways in detail. The primary visual cortex is located in the occipital lobe and most of
the visual information is processed in five visual processing areas which perform varying
visual tasks (Cohen, 1999) (see Figures 8.1 and 8.2):
r ‘Area V1 responds to motion, colour and position’
r ‘Area V2 responds to orientation, direction and colour’
r ‘Area V3 responds to orientation information’
r ‘Area V4 responds to large fields and colour’
r ‘Area V5 responds to unidirectional motion’.
Occupational Therapy and Stroke, Second Edition Edited by Judi Edmans
© 2010 Blackwell Publishing Ltd. ISBN: 978-1-405-19266-8
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Management of Perceptual Impairments
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V3
V1
V2
V4
V5
Figure 8.1 Visual areas. (Reproduced with permission from Lippincott, Williams & Wilkins,
adapted from Bear et al., 2007.)
Visual perception gives meaning to all the information entering our eyes. Grieve and
Gnanasekaran (2008) provide the example of looking around a room to explain the
complexity of processing this information. Each object is isolated from its background,
and from objects around it, the object can be recognised irrespective of the angle and their
distance from us. Figure 8.2 explains the visual pathways within the cortex that enable us
to process all the information that is inputted through our eyes.
The way we perceive images varies from person to person but does not constitute a
perceptual problem. Examples include black and white pictures drawn in such a way
Ventral visual pathway
Dorsal visual pathway
V4
V5
V3
V2
V1
Figure 8.2 Visual pathways. (Reproduced with permission from Lippincott, Williams &
Wilkins, adapted from Bear et al., 2007.)
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that if you see the foreground as being black, you will see one image, but if you see the
foreground as white, you will see another.
Areas of the brain relating to perception
The right hemisphere has a greater role in processing visual and spatial information
than the left hemisphere. Damage to different areas of the brain may result in different
impairments.
Occipital lobe:
r Discrimination of shape, size and depth.
r Object agnosia.
r Prosopagnosia.
Occipitoparietal area:
r Spatial relations.
Right parietal lobe:
r
r
r
r
r
r
Form discrimination.
Apperceptive agnosia.
Anosognosia.
Topographical disorientation.
Spatial relations.
Neglect.
Left parietal lobe:
r Associative agnosia.
r Somatognosia.
Temporal lobe:
r Prosopagnosia.
r Topographical disorientation.
Perceptual impairments
Most individuals take for granted the complex nature of visual and visual–spatial abilities
until these are affected. When damage occurs impairments can lead to difficulty engaging
in simple activities of daily living.
Perceptual impairments can be classified into the following categories (Zoltan, 2007):
1. Body scheme.
2. Visual discrimination.
3. Agnosia.
Zoltan (2007) defines these classifications as:
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Body scheme
Body scheme impairments are a lack of understanding of the relationship of the body
and its parts.
Autopagnosia is a lack of awareness of the body structures and relationships, causing
the patient to confuse sides of the body and body parts.
Unilateral neglect is neglect of the affected side of the body or the environment, for
example, neglecting one side of the body during dressing or neglect food on one side
of a plate.
Anosognosia is a lack of recognition of the presence or severity of the paralysis or
complete denial of illness.
Right left discrimination impairment is difficulty understanding the concept of right
and left.
Finger agnosia is difficulty knowing which finger is touched when there is no sensory
loss.
Visual discrimination
Visual discrimination is the ability to distinguish one object from another; they can be
differentiated by colour, size, shape, pattern, foreground to background and position.
Form discrimination impairment is difficulty in attending to subtle variations in form,
for example, differentiating between a glass, water jug and flower vase.
Depth perception impairment is difficulty judging depths and distances, for example, difficulty navigating stairs and barriers such as walls or doorways or difficulty
knowing when a glass is full when filling it with water.
Figure ground impairment is difficulty in distinguishing the foreground from the background, for example, difficulty finding a white vest or towel on a white sheet or an
item of clothes in a cluttered drawer.
Spatial relations impairment is difficulty in perceiving the position of two or more
objects in relation to oneself or each other, for example, difficulty putting food onto a
spoon and then into the mouth or difficulty in putting the lid on a teapot. It may also
be exhibited as difficulty understanding the concepts of in/out, front/behind, up/down
etc., for example, difficulty finding a cup behind a kettle or putting on at-shirt inside
out.
Topographical disorientation is difficulty understanding and remembering relationships
of places to one another, for example, difficulty in finding one’s way.
Agnosia
Visual agnosia is the inability to recognise visual stimuli despite adequate primary
visual function (visual acuity, oculomotor and visual fields).
Visual object agnosia is difficulty in recognising objects although visual acuity and
visual fields are intact; for example, a patient may fail to recognise relatives or
possessions.
Prosopagnosia is difficulty in recognising differences in faces.
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Simultagnosia is difficulty in absorbing more than one aspect of a whole picture; for
example, a patient may be able to pick out a single letter but unable to read a complete
word.
Colour agnosia is difficultly in recognising colours, for example, of fruits and vegetables.
Metamorphopsia is difficultly in recognising the actual size of objects.
Visual–spatial agnosia is difficulty in perceiving the spatial relationships between
objects or between objects and self, independent of visual object agnosia.
Tactile agnosia (also called astereognosis) is difficulty in recognising objects by handling although tactile, thermal and proprioceptive functions are intact.
Auditory agnosia is difficulty in recognising differences in sounds, including both word
and non-word sounds; for example, a patient may be unable to differentiate between
the sound of a car engine running and the sound of a vacuum cleaner.
Apractognosia is a term given to a collection of impairments which may include body
scheme, apraxia and agnosia problems.
Perceptual assessment
Why assess perceptual ability?
Perceptual problems have been shown to be common following both right and left hemiplegic stroke (Edmans and Lincoln, 1987). These perceptual problems affect the patients’
response to rehabilitation and their ability to perform activities of daily living (Edmans
and Lincoln, 1990; Jesshope et al., 1991; Donnelly et al., 1998) suggesting that if possible
they should be treated.
The objective of assessing perceptual ability is to identify the reason patients are unable
to do certain activities and/or the possible impact on future activities, which in turn will
inform and direct the intervention required for each patient.
Perceptual assessment will clarify whether patients have any perceptual impairments,
including the type(s) of perceptual impairment(s) present and their severity. By clarifying
the impairment(s), therapists are in an informed position to be able to explain to the patient
(and their family/carers) what impact these impairments are likely to have on the patient’s
everyday activities.
When to assess perceptual ability
Perceptual ability should be assessed as early as possible after a patient has had a stroke,
but clarification of impairments may also be needed as the patient undertakes different
activities during their recovery.
Perceptual screening should be conducted within the first few days as part of the therapist’s initial assessment of each patient. This will indicate to the patient and therapist any
potential areas of functional difficulty. A more detailed perceptual assessment should be
conducted later if indicated from screening assessment or functional difficulties. This is
in line with the recommendations of the National Clinical Guidelines for Stroke (Intercollegiate Stroke Working Party (ISWP), 2008), which state:
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‘Cognitive impairments – general
(a) Routine screening should be undertaken to identify the range of cognitive impairments that may occur.
(b) Any patient not progressing as expected in rehabilitation should have a more
detailed cognitive assessment to determine whether cognitive losses are causing
specific problems or hindering progress.
(c) The patient’s cognitive status should be taken into account by all members of the
multidisciplinary team when planning and delivering treatment.
(d) Planning for discharge from hospital should include an assessment of any safety
risks from persisting cognitive impairments.
(e) People returning to cognitively demanding activities (e.g. some work, driving)
should have their cognition assessed formally prior to returning to the activity.
‘Spatial awareness (e.g. neglect)
(a) Any patient with a stroke affecting the right hemisphere should be considered
at risk of reduced awareness on the left, and should be tested formally if this is
suspected clinically.
(b) Any patient with suspected or actual impairment of spatial awareness should have
their profile of impaired and preserved abilities evaluated using a standardised
test battery such as the Behavioural Inattention Test (Wilson et al., 1987). The
diagnosis should not be excluded on the basis of a single test.
‘Perception – visual agnosia
(a) Any person who appears to have difficulty in recognising people or objects
should be assessed formally for visual agnosia.
How to assess perceptual ability
Perceptual ability could potentially be assessed either functionally or by use of standardised assessments.
Functional screening assessment
Functional assessment of activities of daily living, such as personal or domestic activities,
will demonstrate the effect of a mixture of impairments, both physical and cognitive
impairments, upon the patient.
As with the assessment of motor skills the initial assessment commences when the
occupational therapist walks into the bay or room of the patient. The occupational therapist
should observe how the patient is positioned whether in the bed or in the chair/wheelchair.
Observations should include the following:
r Is their head turned towards one side? (This can be a sign of neglect.)
r Is the patient pushing their leg or arm into full extension and pushing themselves over
to their affected side? (This can be a sign of reduced midline awareness.)
When completing an initial assessment, it is important to note how the patient responds
and interprets the therapist’s questions. This may indicate if any potential perceptual
impairments are present, although it will not give an accurate account of which impairment
is causing the difficulty.
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For example, if a patient appears to be neglecting everything on the left side of their body
during a washing and dressing assessment, the therapist would not be able to distinguish
whether this was due to a visual problem of hemianopia, a tactile problem of reduced
sensation or a unilateral neglect.
Standardised screening assessment
When the patient’s previous history has been outlined and functional assessment conducted, standardised assessments should be used as a quick screen for the presence of
perceptual impairments. Examples include:
r Line Bisection test from the Behavioural Inattention Test (Wilson et al., 1987).
r Star/Letter Cancellation from the Behavioural Inattention Test (Wilson et al., 1987).
r Rey Figure Copying test (Rey, 1959; Meyers and Meyers, 1995).
Completing these three basic pen and paper tests along with a baseline assessment
will screen for perceptual impairments. If perceptual impairments are indicated on the
screening assessments, a more detailed assessment of perceptual impairments should be
conducted (see Chapter 10 on the use of standardised assessments).
Baseline assessment
It is important to assess patients in different forms of activities of daily living. This should
follow the screening assessment, which should have identified the possible impairments
that may cause difficulties or inefficiencies in function. This will assist targeting the correct
level of complexity. It is essential to assess the correct complexity level to highlight the
impairments that are impacting on task performance. Mild impairments will not emerge in
a simple level task; therefore, a patient may be able to make a sandwich. However, when
preparing a complex meal perceptual, cognitive impairments may cause inefficiencies of
task performance and therefore cause delay in task completion.
Assessment can take place during any activity of daily living task, for example, meal
times or grooming tasks. When assessing in function it is important to consider the
following:
r
r
r
r
r
r
r
r
Was the patient able to use all items effectively and inefficiently?
How did the patient handle items and did they use any awkward positions?
Was the patient able to see everything?
Did the patient overshoot when reaching for any items?
Did the patient have any delay in finding items?
Could the patient find items in cluttered environments such as a fridge or toiletry bag?
Did the patient find items using touch alone?
Could the patient identify the difference between similar items?
Examples of standardised perceptual assessments
There are many standardised perceptual assessments available, some of which are for
specific impairments only and some are more general. These can be split into three main
categories and examples of each are shown below:
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r Neglect.
r Spatial.
r Multi assessments.
Neglect assessments
r Baking Tray Test (Tham and Tegner, 1996).
r Balloons Test (Edgeworth et al., 1998).
r Behavioural Inattention Test (Wilson et al., 1987).
Spatial assessments
r Location Learning Test (Bucks et al., 2000).
r Rey Figure Copying Test (Rey, 1959; Meyers and Meyers, 1995).
r Visual Object and Space Perception Battery (Warrington and James, 1991).
Multi assessments
r
r
r
r
Cortical Visual Screening Test (James et al., 2001).
Motor Free Visual Perceptual Battery (Ronald et al., 1972).
Occupational Therapy – Adult Perceptual Screening Test (OT-APST) (Cooke, 2005).
Rivermead Perceptual Assessment Battery (Whiting et al., 1985; Lincoln and Edmans,
1989).
r Repeatable Battery for the Assessment of Neurological Status (Randolph, 1998).
Many assessments are available from Pearson Assessment (combining The Psychological Corporation, Thames Valley Test Company and Harcourt Assessment).
Intervention
Intervention of perceptual impairments involves a mixture of restorative (remedial) and
adaptive (compensatory/functional) approaches, the theory of which are explained in
Chapter 2.
The restorative (remedial) approach can be generalised, as practice on a particular
perceptual task will affect the patient’s performance on similar perceptual tasks.
The adaptive (compensatory/functional) approach can be interpreted as repetitive practice of particular tasks, usually activities of daily living, which will make the patient more
independent in these particular tasks.
Occupational therapists use functional tasks as an intervention medium and despite
conducting personal care activities, occupational therapists may still be working at an
impairment level. For example, when working with a patient with neglect the therapist
may move items on a sink from midline to their left side which would be focussing on
the impairment level of the disorder when still working with the media of personal care.
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While working with a restorative (remedial) approach it may be possible to make gains
that generalise into other occupational areas. It is, however, important to be aware of
other impairments that may influence a patient’s ability to respond to a certain approach.
The therapist must consider the patient’s strengths and weaknesses when planning interventions as cognitive impairments. Reduced awareness, changes in mood and visual
disturbance will affect the patient’s ability to respond to intervention.
Neglect is the most common perceptual impairment suffered by stroke patients and
occurs over several sensory systems; vision, touch and auditory. Neglect presents in
different spatial domains and these include the following:
r Body (personal) space – the immediate area of space of the person.
r Reaching (peripersonal) space – the area extending to arm’s reach of the person.
r Far (extrapersonal) space – the area extending far from the person.
The most dramatic and easily observed is the visual form of neglect. Patients with
neglect may fail to shave or dress their left side, fail to read the left side of a word or
sentence, fail to attend to the left side of the sink leading to missing objects placed on the
left, or fail to attend to the left side of their plate. There are related disorders that present
similar to neglect and confuse the identification of the disorder and need to be ruled
out. These include visual field impairment, visual inattention, anosognosia and severely
impaired sensation throughout the left side. Neglect commonly occurs with other visual
perceptual and attention impairments due to the area of the damage leading to this disorder
and these dual impairments need to be taken into account when planning intervention.
Neglect occurs following right hemisphere damage and has been linked to the parietal
lobe and supramarginal gyrus. There are various theories to explain the phenomenon and
it is important to understand these to provide an intervention approach.
Attention-Arousal Theory (Heilman et al., 1993, 1993) outlines damage to structures
responsible for arousal and transmission of sensory information to the cortex leading to
reduced attention to the contralateral side. Neglect is caused by the cortex not receiving
adequate sensory information from the subcortical structures.
Hemisphere Specialisation Theory (Robertson and Lamb, 1991) proposes that there is
a specialised nature to the hemispheres, the left attends to right where the right attends
to both left and right; therefore when the right hemisphere is damaged the left side has
no attention to the left as the left hemisphere only attends to the right. Robertson and
Lamb suggest that the use of left hand leads to improved task performance compared
to right hand use and proposed that this is due to left arm activation which leads to
premotor activation of the right hemisphere. The spatiomotor cueing process (use of the
left hand acts as a cue) enhances attention to the left side. Contralesional limb-based
therapy however is problematic due to left-sided hemiplegia.
Intentional Mechanism Theory (Halligan and Marshall, 1991) proposes that intentional
mechanisms are activated when directing a hand in the contralateral side, that is, the left
hemisphere activates the right hand to the left of midline. Moving the right hand towards
the contralateral side (left side) activated the right hemisphere. Halligan and Marshall’s
theory leads to recommendation of the use of left hand in function in midline and the
contralateral side; however, using the left hand in the ipsilesional side activated the left
hemisphere and cancelling the use of left hand in the contralateral side.
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Disengagement Theory (Posner et al., 1984) proposes decreased attention to the left is
caused by inability to stop attending to objects in the right side. This theory proposes to
reduce stimuli in right visual field and to present objects in midline and move into left
visual field.
Interhemisphere Theory (Kinsbourne, 1977) is based on attentional mechanisms of
each hemisphere which are activated by cognitive and perceptual tasks and neglect is the
imbalance in brain activation. Spatial stimuli activate the right hemisphere and verbal
stimuli activate the left hemisphere. Thus, when the right hemisphere is damaged the
ability to process spatial stimuli is impaired. This theory proposes the need to reduce
imbalance by turning head towards the left, remove left hemisphere stimuli (letters and
numbers) and moving target stimuli from central to left visual field.
General intervention tips
r Consider the grade of the task; the complexity of the task increases the likelihood of
errors.
r Consider the types of prompts, that is, visual, verbal, physical or questioning prompts
and pausing before providing a prompt.
r Consider using written or visual instructions.
r Learning can be achieved through repetition and practice.
r Reinforce positive behaviours rather than negative ones.
r Stage components of the task, that is, break down the task and encourage the patient to
complete one stage at a time.
r Use verbal rehearsal, that is, encourage the patient to talk through the task before
completing it, errors can then be corrected before they are performed.
r Establish patterns and routines.
r Provide consistency in approach.
Specific intervention strategies
Body scheme
Aim: For the patient to be aware of parts of the body and their relationship to each other
and how they are used within function.
Restorative (remedial) strategies
r Ask the patient to verbally identify parts of the body (Johnstone and Stonnington,
2001).
r Encourage the patient to verbalise positions of parts of the body to improve awareness.
r Provide tactile stimulation, for example, rub a rough cloth on the patient’s arm while
naming it before placing their arm through a sleeve (Zoltan, 2007).
r Identify parts of the body before washing or dressing them.
r Incorporate bilateral activities that facilitate normal movement and improve body
scheme (Zoltan, 2007).
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Adaptive (compensatory/functional) strategies
r Provision of instructions that name parts of the body, such as ‘wash your arm’ (Zoltan,
2007).
r If the patient has functional awareness, provide cues such as ‘move the part of the body
that you use to hold things’ instead of ‘move your hand’ (Zoltan, 2007).
Impaired midline awareness
This presentation is often termed the ‘Pusher syndrome’ (for details see Chapter 5).
Patients have a severe misconception of their own upright orientation. Patients experience their own upright as 20◦ tilted to the ipsilesional side. Patients present by pushing
themselves over towards their affected side and are often overactive on their unaffected
side.
Aim: To regain the awareness of midline.
Restorative (remedial) strategies
r For the patient to become aware of midline by using visual feedback, place a mirror in
front of them and instruct the patient to self-correct themselves back to midline.
r In all postural sets, ask the patient to identify the position of their body and describe
their relationship to supporting surface (Karnath and Broetz, 2003).
r Get the patient to move between postural sets and for them to maintain their balance.
Adaptive (compensatory/functional) strategies
r Place pillows on the overactive side to provide extra supporting surfaces to enhance the
patient’s feeling of security.
r When seated in a wheelchair place the hospital bed in a high position on the overactive
side to enhance feelings of security.
r Teach the patient to use vertical structures within the room such as door or window
frames to adjust balance with reference to these markers (Karnath and Broetz, 2003).
Unilateral neglect
Aim: The patient to become aware of both sides of their environment.
Restorative strategies
r Use activities that cross midline, for example, personal care activities.
r During activities of daily living sessions place stimuli on the patient’s affected side and
prompt and encourage them to look over to their affected side. Place necessary items
in midline and to their affected side using cues to locate all items and ask patients
verbalise the location of items to practise spatial scanning.
r Practise shifting attention from left to right. Cue patients to target stimuli in neglected
space to assist attentional shifts.
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r Move necessary items from midline to their affected side, such as the knife in midline
and the butter further into the left side.
r Cancellation tasks such as maze or word searches to practise scanning left to right.
r 2D scanning tasks, that is, paper and pen tasks or more dynamic such as room searches.
r Computer games that require scanning from side to side.
r Tactile stimulation onto the neglected part of the body, using vibration, mildly hot or
cold stimuli (Johnstone and Stonnington, 2001).
Adaptive (compensatory/functional) strategies
r Place objects in midline and gradually move objects further into the patients’ affected
side.
r Approach patients from the midline.
r When reading, anchor the page and draw a red line down the affected side so that
the patient becomes aware of how far across the page to start reading (Johnstone and
Stonnington, 2001).
r Adapt the environment; remove clutter on the affected side (Johnstone and Stonnington,
2001).
r Encourage the patient to turn their plate round to ensure all the meal is eaten. The
National Clinical Guidelines for Stroke (ISWP, 2008) recommend that meal times
should be monitored to ensure that food is not missed.
r Teach the patient to turn their heads to become more aware of the affected side.
Other intervention approaches
Constraint-induced movement therapy
Constraint-induced movement therapy (CIMT) forces the use of the affected side by either
placing a sling or mitt on the unaffected arm (Taub et al., 1998). CIMT attempts to reverse
the learnt non-use of the affected arm; however, to be able to use this technique there needs
to be enough return of movement that would allow the patient to functionally use their
affected hand. CIMT reports to be a useful intervention method for unilateral neglect. For
further details see Chapter 2.
Eye patching
Studies have shown that using glasses that occlude the good (ipsilesional) side of vision
in each eye, the patient is forced to direct their gaze to their contralesional side (Beis
et al., 1999). Compliance with this technique can be difficult as it is the patient’s natural
inclination to gaze towards the occluded side.
Prism glasses
There is evidence of the positive effects of prism adaptation (Parton et al., 2004). A 10◦
rightward horizontal shift of the visual field can be achieved by wearing prism glasses.
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Within studies such as Rossetti et al. (1998), patients were asked to point to a target either
side of midline while wearing the glasses. Following the use of this technique the patients
demonstrated immediate improvements in tests of neglect. McIntosh et al. (2002) have
also shown these improvements to be made post 9 months following stroke. The National
Clinical Guidelines for Stroke (ISWP, 2008) recommend using prisms if the unawareness
is severe and persistent.
Visual discrimination
Aim: To become aware of the relationship of objects to objects or self, to identify foreground from background, position in space and depth and distance.
Restorative (remedial) strategies
r Teach the patient to retrieve items following verbal instructions with spatial concepts,
for example, ‘get the brush on top of the dresser behind the bed’.
r Teach the patent to place different items in different parts of the room.
r Use of tactile kinaesthetic strategies such as guiding the patient to the object.
r Encourage the patient to verbalise the position of parts of the body to improve awareness.
Adaptive (compensatory/functional) strategies
r
r
r
r
r
Organise the objects so that they are in the same place.
Mark drawers where key items are kept.
Encourage the patient to feel and describe objects.
Remove clutter in the environment (Johnstone and Stonnington, 2001).
Place objects on contrasting surfaces, for example, white soap on a dark coloured cloth.
Visual agnosia
Agnosia is the inability to recognise objects even though the elementary visual functions
remain unimpaired (Farah, 1995). Lissauer in 1890 distinguished between two types of
visual agnosia, the apperceptive and associative agnosias. Apperceptive agnosia is where
recognition fails because of impairment of visual perception. Patients do not see objects
normally and cannot therefore respond to them. Associative agnosia is when perception
is intact to allow recognition; however, recognition cannot take place due to impaired
semantic knowledge not confined to vision but confined to the naming of the object.
Patients with apperceptive agnosia are unable to copy drawings or match objects due to
impaired visual perception. Patients with associative agnosias are able to copy drawings
but cannot describe the function of objects (Farah, 1995).
Aim: To be able to identify objects through vision.
Restorative (remedial) strategies
r Present objects in a straight position rather than other orientation.
r Encourage the patient to recognise differences and similarities between items.
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r Start with items that are very different and gradually upgrade to items with subtle
variations, for example, shape, size or colour.
r Encourage the patient to verbalise differences, that is, naming objects and differences
between objects.
Adaptive (compensatory/functional) strategies
r Teach the patient to consider and think critically.
r Utilise verbal strategies where the patient describes the perceptual and functional characteristics of the object to aid retrieval of the object name.
r Use other senses to identify the object, that is, touch, smell or sound.
r Show the object in a natural context.
r Adding texture or edge orientation to objects may assist into providing cues to identification.
r Use premorbid orientation of objects, that is, did they keep a T-shirt kept in the drawer
or on a hanger.
r If categorisation is intact ask the patient to identify which category the object would
belong to.
r Provide labels for objects to maximise independence.
Tactile agnosia (stereognosis)
Aim: To be able to identify objects through touch.
Restorative (remedial) strategies
r Exploratory hand movements for object identification. Explore the object by touching
the surfaces and edges of the object, holding the object in the hand to obtain information
on its size, shape and weight.
Adaptive (compensatory/functional) strategies
r
r
r
r
r
Education of problems and how these affect function.
Utilise other senses, that is, vision and touch from the unaffected hand.
Teach the patient to focus on specific properties of the object.
Use familiar objects within functional tasks.
Use objects within context.
General assessment and intervention plan
A general plan for the assessment and intervention of perceptual impairments is shown
below:
1. Assess perceptual abilities using functional tasks and standardised assessments.
2. Analyse the results and the effect of comprehension, concentration, reasoning (executive function), initiation, memory, anxiety, depression, apraxia, hemianopia/eyesight,
inattention, etc.
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3. Explain the perceptual problems and their likely effects in everyday life to the patient,
their relatives and all staff involved with the patient.
4. Choose the intervention approach to be used, that is, restorative (remedial) or adaptive
(compensatory/functional) or both.
5. Decide which intervention strategies to use.
6. Relate intervention to the patients’ needs.
7. Remember that not everyone likes games and puzzles.
8. Remember we all learn in different ways.
9. Give mental stimulation.
10. Reassess perceptual and functional abilities.
Self-evaluation questions
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Explain the term of perception.
Identify the three areas of perception.
Which areas of the cortex are important for perception?
Describe how to assess for perception on initial assessment.
Define the pros and cons of both functional assessment and standardised assessment
for perceptual impairments.
Describe the intervention approaches for perceptual impairments.
Describe the intervention approaches for impaired midline awareness.
Describe the phenomenon of neglect and identify intervention strategies.
Describe the term visual discrimination and what intervention strategies you may use.
Describe visual agnosia and give two different approaches to intervention.
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Chapter 9
Resettlement
Pip Logan and Fiona Skelly
This chapter includes:
r
r
r
r
r
r
r
r
r
r
r
r
r
Home visits
Community rehabilitation
Support available and self-management
Carers
Younger people
Lifestyle and long-term management
Leisure rehabilitation
Getting out of the house
Driving
Vocational rehabilitation
Resuming sexual activity
Stroke education
Self-evaluation questions
Home visits
Home visits are carried out to assess if a patient is safe to return home and whether the
environment is suitable for them. Sometimes an initial visit without the patient to assess
the environment (often called an access or environmental visit) is advisable, as re-housing
or major adaptations might be required prior to discharge. It is advisable to involve the
family with all home visits. It is good practice for occupational therapists to carry out
home visits with another member of the multidisciplinary team such as a physiotherapist or
community-based therapists (Clarke and Gladman, 1995). Occupational therapy services
will have their own template for writing home visit reports but the following areas should
be assessed during the visit, depending on the type of property, hazards and patient’s
functional abilities:
r Access to property
– Path, steps, rails and whether patient can unlock/open door.
r Outdoor mobility
– Type of equipment and level of assistance.
Occupational Therapy and Stroke, Second Edition Edited by Judi Edmans
© 2010 Blackwell Publishing Ltd. ISBN: 978-1-405-19266-8
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r Indoor mobility
– Type of equipment and level of assistance.
– Hazards such as floor mats, furniture arrangement.
r Transfers
– Chair, wheelchair, bed, toilet, bath, commode.
– Type of transfer and assistance.
– Type of equipment.
r Stairs
– Equipment used and level of assistance.
– Method of ascending/descending stairs.
r Kitchen assessment
– Hot drink/snack preparation.
r Observation of cognitive impairment in functional setting:
– Consider visual perception, short-term memory, executive functions, for example,
through use of appliances such as the telephone, TV, computer, managing a ‘simulated’ emergency situation in the home environment.
r Recommendations
r Action plan
– List who is going to carry out actions and timeframe.
Community rehabilitation
Community rehabilitation is an umbrella title for a number of stroke services in the
community, mostly administered in people’s own homes but can take place in community
centres, health centres, sports centres, care homes and stroke clubs. Most health and local
authorities provide a mixture of services for acute (straight after hospital discharge) and
longer-term rehabilitation. The services available after hospital may be called intermediate
care or early supported discharge and are usually time limited (approximately 6 weeks).
Intermediate care
The Department of Health (DH) defines intermediate care as:
a range of integrated services to promote faster recovery from illness, prevent unnecessary acute hospital admission, support timely discharge and maximise independent living.
(DH, 2002)
Vaughan and Lathlean (1999) cite a more comprehensive and practical definition,
describing intermediate care as:
that range of services designed to facilitate the transition from hospital to home, and from
medical dependence to functional independence, where the objectives of care are not primarily
medical, the patient’s discharge destination is anticipated, and a clinical outcome of recovery
(or restoration of health) is desired.
and
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those services which will help to divert admission to an acute setting through timely therapeutic
interventions which aim to divert a physiological crisis or offer recuperative services at or near
a person’s own home.
The basic principles of intermediate care according to the National Service Framework
for Older People (DH, 2001) are:
r The emphasis on appropriate, person-centred, seamless care.
r The need for robust assessment processes.
r The crucial importance of partnership working between health, social care, housing
and the independent sector.
r Ensuring timely access to specialist services.
r Clear care pathways.
r Use of single assessment process (SAP).
The nature and scope of intermediate care services vary greatly across the country. The
professionals making up the multidisciplinary team, the conditions that patients have and
the length of rehabilitation can vary.
The main types of service are listed below:
Rapid response
The aims of the rapid response service are to facilitate timely hospital discharge and/or
prevent hospital admission. It is a crisis intervention service, which offers intervention for
just a few days, for elderly people following a fall or onset of ill health. Some services
also offer brief intervention for people with palliative care needs.
The service can be offered at home or in a residential setting that may be in a hospital
or a care home. The multidisciplinary team consists of nursing, medical and allied health
professionals. Occupational therapists usually assess activities of daily living, transfers,
moving and handling, provide the necessary equipment and liaise with carers.
Hospital at home/community rehabilitation team
Hospital at home/community rehabilitation teams are multidisciplinary services which
provide intensive rehabilitation at home for anything from 6 to 12 weeks. They offer
patient-centred therapy working towards patient goals. The services can be used to facilitate earlier hospital discharge and prevent inappropriate hospital admission. Occupational
therapists provide a wide range of therapy which includes moving and handling, transfers,
personal/domestic activities of daily living, cognitive rehabilitation, leisure rehabilitation,
driving assessments and community skills.
Residential rehabilitation
Residential rehabilitation services offer intensive rehabilitation for patients resident in a
residential home or a purpose-built intermediate care unit with input from allied health
professionals. These services are usually for further rehabilitation after hospital admission,
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often up to 6 weeks. Occupational therapists focus on the skills patients need to manage
safely at home and will carry out home visits and be involved with discharge planning.
Early supported discharge
Stroke specific early supported discharge has been recommended by the Department
of Health Stroke Strategy (2007) and research has already provided evidence that this
service is successful (Fjaertoft et al., 2004; Langhorne et al., 2005; Torp et al., 2006).
Early supported discharge services aim to accelerate return home and provide intensive
rehabilitation at home following admission to an acute or hyperacute stroke unit. The
general consensus from the research so far is that they should have a multidisciplinary
team which includes nursing, medical, allied health profession and social work staff, but
that the team should be trained in stroke techniques. Time limit again can be between
6 and 12 weeks.
Role of the occupational therapist
The role of the occupational therapist within intermediate care services is either to prepare
patients for returning home or to help them remain in their own home, depending on the
clinical setting. Assessments useful with this patient group are described below:
– Assessment of activities of daily living such as washing/dressing and meal preparation.
– Cognitive/perceptual tests such as Middlesex Elderly Assessment of Mental State
(MEAMS) (Golding, 1989), Visual Object and Space Perception Battery (VOSP)
(Warrington & James, 1991), Rey Osterreith Complex Figure Test (Rey, 1959). It
is advisable to find out which assessments have been completed in previous clinical
settings and use these, if appropriate, to review cognitive impairment.
– Moving and handling risk assessments – to be completed at the start of the rehabilitation
programme.
– Upper limb – assessment of tone, range of movement and sensation.
– Mental health – using scales such as General Health Questionnaire (GHQ) (Goldberg
and Hiller, 1979) or Hospital Anxiety and Depression Scale (HADS) (Zigmond &
Snaith, 1983).
– Driving – assessments such as Stroke Drivers Screening Assessment (SDSA) (Nouri
and Lincoln, 1994) or other cognitive tests such as Behavioural Assessment of Dysexecutive Syndrome (BADS) (Wilson et al., 1996), Test of Everyday Attention (TEA)
(Robertson et al., 1994) and VOSP (Warrington & James, 1991).
– Leisure/work – finding out how the patient spends their day, their hobbies, previous
employment, using leisure questionnaires.
Intervention
Rehabilitation within intermediate care should be patient-centred. Generic goal setting
with the patient can be used to facilitate clear intervention planning. The use of goal-setting
sheets can be used for patient and therapist to complete at regular intervals throughout
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the period of rehabilitation. Goals should be reviewed on a weekly basis and adjusted
accordingly. The important factor is that intermediate care should follow immediately from
the acute rehabilitation and therefore requires a quick assessment of need and immediate
intervention with input on most days. Occupational therapists in these services share
caseloads and patients often hold their own notes. Occupational therapists are expected
to set goals for rehabilitation assistants who may treat the patient twice a day.
The intervention approaches used with stroke patients in intermediate care are often
similar to those used in the acute setting. However, sometimes a more functional approach
for the frail elderly following a stroke is the most appropriate method in order for them
to return or remain at home. Regular practice with washing/dressing, transfers, mobility
and meal preparation using the most appropriate equipment may have the best outcome.
Therapists should work closely with the patient’s families/friends. Home visits are important to fully assess the patient’s ability to return home. Some intermediate care units
have kitchen facilities or a self-contained bedsit for patients to care for themselves with
supervision prior to going home. It is advisable for patients to go home for a few hours,
then for an overnight or weekend stay prior to final discharge home. This transferring of
responsibility from the rehabilitation team to the patient is important if patients are going
to be helped to self-manage their own condition.
Support available after a stroke and self-management
Two-thirds of people who have had a stroke will need some type of support at home over
a period of time. This could be practical support such as help with washing or dressing
or psychological support such as motivational techniques, anxiety management. The
National Clinical Stroke Guidelines (ISWP, 2008) acknowledge that much of the support
will not be provided by health care professionals but will be provided by a mixture
of family, carers, charities, local authorities and dedicated organisations. The support
available varies considerably from location to location, and even within a 5-mile radius
of a large hospital people will be able to access different services. Another complication
is that some services are free and some will charge. For practical help such as getting up
in the morning, assisting with meal times, and helping with getting dressed, most patients
will be assessed by statutory services such as social care and will be recommended for
what was known as ‘home care’. However, increasingly a number of private companies
are being contracted by local authorities and the names of these services differ. On top
of this, a number of private companies are advertising long-term support which people
may access with insurance monies or through pension schemes. Long-term psychological
support for both the patient and the carer is sometimes harder to secure and this is often
what people will ask for when the routine rehabilitation has ceased.
The National Clinical Stroke Guidelines (ISWP, 2008) recommend that health and social
care professionals continue to assess for support needs at regular intervals and ensure that
people are referred to the most suitable organisation or are given the information they need
to refer themselves. This handing over some of the responsibility to the patient is very
important; this encourages patients to self-manage their own condition. Some patients
may be able to organise their own lives after a stroke but some may need support for
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many years and in most cases will get the most benefit from locally provided support.
The National Stroke Strategy (DH, 2007) quality marker 13 recommends that ‘A range
of services are in place that are easily accessible and support the long-term needs of
individuals and their carers’. In reality such services are patchy and often not specific to
stroke; it can take a long time to track down a service that will come and sit with someone
while the carer goes out. Use of the Internet can speed up searching and giving weblinks to
patients or their families can open up a whole new world. Increasingly people are entering
chat rooms and using websites to gain information. A website supported by the DH called
‘healthtalkonline’ allows people to listen and watch stories from other people who have
had a stroke.
For the occupational therapist gathering information about local services and the different criteria needed to access these services can be time consuming. However, within
the team or department knowledge can be shared and a central resource of webpages,
leaflets, telephone numbers and names of helpful people can be useful. One of the good
things to remember when trying to sort out this type of support is that this could be one of
the most important relationships for the stroke patient; they may want to attend the stroke
club for 10 years and this introduction could be the one thing the patient remembers most
from their rehabilitation.
Included here is a list of potential avenues for support that are not provided by the
statutory services. In your area there may be other particular organisations that offer
services such as a community centre, sports centre or church group.
The Stroke Association – Family and Carer Support workers who can visit at home.
Stroke clubs – Usually organised by voluntary workers, The Stroke Association holds
a list. Patients usually attend once a week and the format can be a speaker, lunch and
time to talk to other people who have had a stroke.
Age concern/help the aged – Local services can include befriending and visiting services, advocacy and counselling.
Different strokes – Younger people with stroke can access support through this organisation; local groups provide different services from befriending, financial advice,
clubs and activities.
Carers
The National Clinical Guidelines for Stroke (ISWP, 2008) provide recommendations
for working closely with carers of stroke patients. They define these carers as informal
(unpaid) such as patient’s family and friends.
The guidelines list the following detailed recommendations:
r At all times the patient’s views on the involvement of their family and other carers
should be sought, to establish if possible the extent to which the patient wants family
members involved.
r The carer or every patient with a stroke should be involved with the management process
from the outset, specifically:
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– as an additional source of important information about the patient both clinically and
socially.
– being given accurate information about the stroke, its nature and prognosis and what
to do in the event of a further stroke.
– being given emotional and practical support as required.
With the patient’s agreement, family carers should be involved in all important decisions,
as the patient’s advocate if necessary.
During the rehabilitation phase, carers should be encouraged to participate in an educational programme that:
– explains the nature of stroke and its consequences.
– teaches them how to provide care and support.
– gives them opportunities to practise care with the patient.
– emphasises and reiterates all advice on secondary prevention, especially lifestyle
changes.
At the time of transfer of care to the home setting, the carer should:
– be offered an assessment of their own support needs by social services.
– be offered the support identified as necessary.
– be given clear guidance on how to seek help if problems arise.
After the patient has returned to the home (or residential care) setting, the carer should:
– have their need for information and support reassessed whenever there is a significant change in circumstances (e.g. if the health of either the patient or the carer
deteriorates).
– be reminded on a regular but not frequent basis of how they may seek further help
and support.
There is a variety of support/advice for carers:
r The Stroke Association has valuable information on its website. It runs various services
including a Family Support Service.
r Stroke Support Groups affiliated to Stroke Association and Different Strokes are in operation across the UK. Please refer to their websites for a list of the local branches/support
groups.
r ‘Directgov’, a government website, provides general information about rights/
employment and applying for carers’ allowance. Carers can apply for their allowance,
if they work less than 16 hours per week and provide a specific number of hours per
day of care.
r Carers’ Assessments are carried out by a social worker employed by the local social
services where the need for extra support can be identified.
r Direct payments are available from social services to pay for care if the patient fits the
criteria for a care package but would rather use the money to employ their own carers
where there is often more flexibility in the type of care provided, for example, to assist
with car transfers or shopping. Younger patients may find this the most beneficial way
of receiving care.
r Carers’ charities/organisations provide support, information and campaign for carers’
rights. Contacts include The Carers Information and The Princess Royal Trust for
Carers, although these are not specifically for carers of people with stroke.
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Younger people
A quarter of the 110 000 people who have a stroke in England are under 65 years of
age (National Audit Office, 2005). Every year, 10 000 people under the age of 55 suffer
a stroke – 1000 of these are under the age of 30. Although this number seems small
compared to the older population, this group is important and provide different challenges
for the occupational therapist. They are often in work when they have their stroke, they
may have young children, they may be students, they have many years ahead of them
and they want to live as independently as possible. Additionally there is some research
that indicates that the use of recreational drugs may increase the incidence of stroke in a
younger population (Westover et al., 2007).
For the occupational therapist these issues have to be considered when planning intervention. A younger patient may be able to tolerate longer rehabilitation sessions than
an older patient; they will need vocational rehabilitation from the start, they will want
to know about sex after a stroke and they may suffer from a greater feeling of reduction
in role. Younger stroke patients may have to make massive changes to their lives and
this can take a long time to come to terms with: changes to jobs, loss of a car, changes
to hobbies, breakdowns in personal relationships, depression, and reduction in wealth as
well as any physical changes. Rehabilitation of younger stroke patients will include a
wide multidisciplinary team and may need to be extended over many months.
A great deal of information can be gathered from Different Strokes, a charity set up
by younger people with a stroke for younger people. It provides people a number of
services across the UK. They have a website with links to local clubs and information and
the participants are very active. As well as the rehabilitation programme, occupational
therapists can help younger people with stroke access this website whilst in hospital, they
can introduce them to other younger people and ensure they are provided with vocational
rehabilitation. Different Strokes has been a powerful organisation at lobbing government
to help people back to work, to improve acute care and to get exercise classes available.
Lifestyle and long-term management
The effects of having a stroke are often ongoing and therefore once patients are over the
immediate rehabilitation phase of approximately 6 months, they start looking forward
to resuming their lives as much as possible and making changes to accommodate their
new limitations (Lincoln et al., 1998a). The National Clinical Stroke Guidelines (ISWP,
2008) recommend that people with ongoing limitations after the initial rehabilitation
phase should be offered a 6 monthly review and be provided with further rehabilitation if
clear goals are identified. These review sessions may highlight areas that may have been
previously ignored by the patient such as social participation, leisure, returning to work,
transport and social support. Although occupational therapy input is essential at this time
and has been found to be beneficial in research studies (Walker et al., 2000), the main
emphasis at this point is for patients to start to plan, enquire, lead and be proactive about
their lives, about the information they need and how they are going to undertake activities
without the assistance of health professionals. This does not mean they will be on their
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own: they may be with family, carers or volunteers. The Internet is a mine of information
but some of the best advice will come from other people who have had a stroke. This
can be achieved by attendance at stroke clubs, talking to family, neighbours and websites.
The DIPEx charity has completed interviews with many stroke patients and placed them
in categories on their website. So, for example, if a patient is worried how their stroke is
affecting the family they can listen to experiences of other people with stroke about how
they discussed the stroke with their grandchildren.
Patients may have changed their lives completely; they may have been given specific
advice on diet such as a low-salt, low-fat, low-cholesterol to prevent a recurrent stroke;
they may have given up work, driving and lost contact with friends and family. At about
this time, contact with most rehabilitation services will have ceased and patients may
have been referred for ‘Exercise on Prescription’ as opposed to seeing the physiotherapist
and the occupational therapist will be exploring support from tertiary organisations such
as Connect, Age Concern, The Stroke Association, Stroke Clubs. These life-changing
actions happen over time and people often need support and reassurance to continue to
explore new avenues.
Social participation
People who have had a stroke often feel dependent on others, lack knowledge and with
one-third feeling socially isolated (Young et al., 2003) and one-quarter being depressed
(Hackett et al., 2006), it is not surprising to find that patients have often lost the social
networks they had before the stroke. Occupational therapists can initiate and enable
people to start participating in society but over time people do not want to be always
associated with professionals and they move to groups more normally associated with the
community such as work, family, visiting friends, voluntary groups such as social clubs,
luncheon clubs, hobbies and religious activities. There are vast benefits to improving
social participation on quality of life, personal choice, dignity and ultimately improving
health by easier access to health centres, better physical health through exercise, reduction
in falls through improved muscle strength and balance. One complaint from people with
stroke is that although there are numerous clubs, societies, hobbies groups and written
information about these places, people wanted someone to get them started or help them
return after a break (Drummond and Walker, 1995). Therapists have been successful in
this role but there is no reason to believe that this role could not be undertaken by voluntary
services, a ‘Buddy System’ or rehabilitation assistants. Whoever provides this role must
be knowledgeable about the local facilities, be able to spend time taking the patient and
then be able to sort out transport or use of public transport. This is not a quick process.
Leisure rehabilitation
It is known that participation in leisure decreases after stroke, even for patients with a
good physical recovery (Drummond, 1990). The significance of this reduction lies in the
fact that satisfactory leisure is related to life satisfaction. Consequently, such a decrease
in leisure activity may reflect a decrease in quality of life.
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There is a growing feeling that there is not enough help for patients who have had a
stroke and who wish to resume former hobbies or acquire new interests. Murray et al.
(2003) reporting on the results of a study into long-term outcome after stroke, concluded
that
there is still a need for a longer-term holistic approach to the rehabilitation of stroke patients,
that include leisure activities.
There have been a number of research projects evaluating leisure activities after stroke
with differing results (Drummond and Walker, 1995; Parker et al., 2001). In addition to
this confusion the definition of a leisure activity changes over time. Treadmill training may
appear as an essential but boring exercise to one person but a leisure activity to another.
Some people may equate ‘Leisure’ with laziness and will only describe ‘hobbies’ or what
they ‘do in their free time’. Some people do not always understand the term leisure so
it is advisable to use the term ‘free time’ or ‘interests’ and explain what you mean in
more detail. The definition: ‘activity chosen primarily for its own sake after the practical
necessities of life have been attended to’ (Drummond, 1990) maybe one to consider but
then this removes all household chores and even some do-it-yourself (DIY) activities.
When assessing leisure activities ask patients what they did before their stroke and
whether they would like to return to these or try new hobbies. Using a checklist to keep a
written record of what patients did before their stroke will help to identify areas of interest
and plan a programme. Responses are usually more comprehensive when a checklist
(such as the Amended Nottingham Leisure Questionnaire – Parker et al., 1997) is used.
However, even checklists get out of date and this measure does not include computer
activities such as email, Skype or on-line shopping. Look for common themes from the
list of hobbies such as sporting or crafts as this may help you suggest new ones. Therapists
should value more common everyday activities such as reading, walking and gardening
as much as the more exciting ones. Check the most obvious limitations to participating
in hobbies such as checking if patients need new glasses or hearing aid before assessing
problems with hand function and balance. Following assessment and goal setting it may
become apparent that the patient will need to consider trying new hobbies and the checklist
common themes may help you make suggestions. For example, does someone like solitary
activities, outdoor pursuits, and competitive interests? Remember when planning leisure
rehabilitation not to overlook the most common everyday activities in favour of the more
exciting, eye-catching interests, many people prefer gardening, going for a walk, reading
the paper. However, also remember that those people with good physical recovery from
their stroke may also need assistance to get back to the more strenuous hobbies such as
ballroom dancing, sailing or cycling.
Although this section is almost exclusively dedicated to people in the community
whether at home or in residential care, evidence suggests that patients with a stroke spend
long periods of time in hospital doing nothing (Lincoln et al., 1989). Whilst therapists are
busy providing rehabilitation and organising a return to home, information provided on
the ward in the form of leaflets, CDs, computer programmes or visits from other people
who have had a stroke may spark an interest in a leisure activity that could enhance a
patient’s quality of life.
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There are many national and local organisations that can advise and assist with leisure
activities such as gardening, art, sports, fishing, golfing and holidays. Funding is sometimes available for specialist one-off items. Find out what the patient’s previous occupation was, as many jobs have Benevolent Funds. Many organisations can be found via the
Stroke Association and Different Strokes websites as well as via the search engines on
the Internet. Some are listed below but are not specific to stroke.
Gardening – Gardening advice is available from horticultural charity called Thrive.
Sport – Sportability is a charity that provides sport/challenging pursuits for people with
paralysis such as stroke, spinal cord injury and multiple sclerosis.
Art – Conquest Art provides art classes for the disabled in certain areas of the UK.
Golf – Society of One-Armed Golfers organises golf tournaments.
Fishing – British Disabled Angling Association provides advice and fishing matches.
Occupational therapists can look at ways of adapting specific activities such as embroidery and knitting with equipment for one-handed use. Sometimes these are available in
craft shops but also from catalogues that sell aids/adaptations.
Many people are worried about flying after a stroke. Advice from the Stroke Association
states that there is no absolute ban from flying after a stroke. However, each airline has its
own rules about who it allows on their aeroplanes. The Stroke Association suggests flying
is avoided for 2 weeks post stroke unless it is unavoidable. Oxygen pressure is lower in
the air than at sea level so there is a theoretical risk. There is no need for extra oxygen.
However, sitting in one position for a long time and becoming dehydrated can cause blood
to thicken and thus increase the risk of blood clots forming. If possible, passengers should
walk or stretch legs and drink plenty of water.
Travel insurance needs to be examined closely to check there are no exclusions to travel
or conditions not covered. There are insurance companies who provide cover for people
with specific conditions/disabilities. Information is available from the websites of The
Stroke Association and Different Strokes. It is advisable to inform the airline and airport
of a person’s disability so that assistance can be booked in advance.
Getting out of the house and transport
Many leisure and social activities require transport either to get to an event or to get
supplies. However, even just getting out of the house ‘for the sake of it’ is an important
rehabilitation target after stroke as it improves psychological and functional outcomes.
Half of all people with stroke do not get out of the house as much as they would like even
after rehabilitation (Logan et al., 2001). Community-based research has shown that people
are unable to use information given about outdoor mobility and transport in their area as it
is often given whilst they are in hospital at a time when they thought they would be ‘back
to normal in a couple of days’. It may take someone months to accept that they are never
going to drive again. An occupational therapy outdoor mobility rehabilitation intervention
has been developed and tested in Nottingham (Logan et al., 2004). The study found that
people who had received the new intervention, which involved the patient practising
outside with a therapist, were twice as likely to go out afterwards as those who had
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received the routine rehabilitation programme. The routine programme was verbal advice
and written information. Further evaluation is taking place in other parts of the UK and
Australia. To replicate the intervention in your area, it is important to find rehabilitation
staff who are knowledgeable about local transport services, buses, Dial-A-Ride, taxi,
voluntary transport, community services, scooter, shop mobility, trains, trams, etc. The
patient must want to get out more often and an intervention programme must target one
main type of transport. For example, using the local bus or walking to a friend’s house.
Activity analysis will help break down the activity and then at each session backward
chaining can be used until the patient can complete the activity without the rehabilitation
staff. They do not have to be alone and in fact it may be part of the intervention to get
help for the patient or to use extra money to use a taxi instead of owning a car. One of
the main parts of the intervention is the repetitive practising of the task, actually going
on the bus one stop and getting off, getting back on and going one stop and getting off.
The intervention in the study was provided over an average of six sessions each about 2
hours long. It may seem an intensive intervention but there is evidence that it works and
evidence that giving a leaflet about a Dial-A-Ride service is of no use.
When using public transport, it is often advisable to book in advance so that extra assistance is available, for example, at the train station when changing platforms. Discounts
on fares are available via the Disabled Persons Railcard and local bus passes.
Two of the national breakdown services, the Automobile Association (AA) and the
Royal Automobile Association (RAC), provide information for travel with a disability
in written form and on their websites. The AA publishes a comprehensive leaflet titled
‘Guide for the Disabled Traveller’ which is free to members and available in pdf format
on their website.
There are several travel companies which provide advice or can arrange holidays for
disabled people. Some of those listed on the Internet include companies such as Accessible
Travel, Access Travel and Tourism For All. There are also specialist facilities in the UK
that provide holidays for disabled people and their families such as The Calvert Trust
and The Winged Fellowship. The Stroke Association and Different Strokes can provide
contact details for holidays for the disabled.
Hints and tips to help improve lifestyle, leisure and transport
r Do not be scared of saying you have to go away and think about the problem; there is
always the chance to go back and see a patient after gathering the knowledge.
r Link up patients with similar hobbies and interests; many people use the Internet and
email.
r Encourage help and support from family and friends. Tap into local resources such as
voluntary agencies for additional help.
r Keep a box file of local resources and facilities, for example:
– Local clubs.
– Dial-A-Ride services, voluntary drivers, specialist transport services.
– Travel agencies specialising in holiday accommodation for the disabled.
– Swimming sessions for the disabled.
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– Fishing sites for disabled fishermen.
– Riding-for-the-disabled stables.
Browse through specialist equipment catalogues which may give you more ideas for
hobbies.
Contact national organisations for local contacts if there are difficulties accessing
facilities.
Funding! Consider specific charities and local groups such as the Hospital League of
Friends, and Rotary Clubs for specialist one-off items for individuals. Encourage the
patient’s family to consider buying expensive items, such as gardening equipment for
Birthday or Christmas presents.
Be aware of therapy myths. For example, knitting does not necessarily increase spasticity.
Do not be afraid of taking people outside, even a walk to the neighbours.
Practise activities many times instead of just giving verbal and written information.
Activities may have to be practised over and over again, so it is helpful to enlist the
help of others to prevent therapist boredom, then go back and review the situation.
Driving after stroke
Carter (2006) reported that only 30–40% of people who suffered a stroke were able to
resume driving, as stroke can result in impairments in any combination of the following – memory, attention, decision making, executive functions, visual neglect, visual
perception, communication, sensory and motor function. Therefore, all these functions
should be assessed to establish an individual’s ability to return to driving. The importance of cognitive function on driving ability was highlighted by Morris (2007) as the
ability to ‘perceive, assimilate, organise and manipulate information to enable reasoning
and problem solving’. These skills require visual perception and executive function for
the individual to make sense of the environment. Despite this, there are no documented
standards of cognitive function required for driving published by the Driving Vehicle Licensing Agency (DVLA) and no standardisation of assessments carried out in the Driving
Assessment Centres around the UK (Morris, 2007).
After a stroke or Transient Ischaemic Attack (TIA), patients should not drive for at
least 1 month. After that, if a GP or consultant feels they are fit to drive, then they
can resume. They may assess visual and physical impairments within their surgery but
cognitive ability is often overlooked. However, if the doctor does not believe they are fit
to drive, then the patient must inform DVLA and their insurance company and they must
not drive. The DVLA will send a questionnaire to the patient requesting more information
and asking permission to contact their doctor, if necessary. The DVLA base their decision
on the information patients and GP/consultant provide. They take into consideration the
following factors – permanent damage to vision, problems with memory, concentration
and judgement, slow reactions in an emergency, spasm in a paralysed arm which cannot be
controlled and seizures/convulsions. If the GP/consultant is unable to make the decision
about fitness to drive or it is unclear to DVLA, they will ask a GP to independently
assess on their behalf. If this is inconclusive, DVLA will request an assessment by a local
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accredited mobility centre or, if there is not one near the patient’s home, for a free driving
test. The assessment at an accredited mobility centre is free if DVLA arranges it. They
assess physical, visual and cognitive aspects of driving ability. The Forum of Mobility
Centres has 17 accredited centres across the UK. Their contact details are on their website
or via freephone. They also produce a range of Ricability guides in conjunction with other
organisations that give specific advice on topics such as driving ability and adaptations.
Once the Drivers Medical Unit at DVLA has all the information, it will make a decision
about whether the patient can drive or not which can take a few months. The patient then
needs to inform their insurance company of the decision.
Research has suggested that cognitive ability plays a vital role in driving performance
after brain damage (Nouri et al., 1987). However, there remains some uncertainty about
which cognitive impairment needs to be assessed and what is predictive of driving outcome. Some occupational therapists use the SDSA (Nouri & Lincoln, 1994). However,
an unpublished report by J Sentinella and L Reed on the Department of Transport website
recommends that the SDSA is used as a screening tool in conjunction with other cognitive
assessments. Other therapists use different parts of standardised cognitive assessments
to test memory, executive function, attention and visual perception. These can include
sub-tests from the BADS (Wilson et al., 1996), TEA (Robertson et al., 1994), Visual
Object and Space Perception Battery (VOSP) (Warrington and James, 1991) and Hayling
and Brixton Tests (Burgess and Shallice, 1997). A report can be written following these
assessments and sent to the GP to give him/her further information on a patient’s ability
to drive. It is also advisable for patients to have an eye test after a stroke, particularly
from an optician who carries out a visual field test to look for specific impairments such
as hemianopia.
Blue car badges for disabled parking are available from local councils for a small fee.
Patients need to be on the higher rate of the mobility component of Disability Living
Allowance or the higher rate of Attendance Allowance. In some areas, occupational
therapists working in social services can complete the application forms with patients.
The College of Occupational Therapists have also published guidance on ‘Confidentiality and a service user’s fitness to drive’ (College of Occupational Therapists, 2007,
briefing no. 26).
Vocational rehabilitation
Surveys have found that between 40% and 75% people would like to work (Wozniak and
Kittner, 2002; Different Strokes, 2006). From these papers we would estimate that there
are 13 750 people under 65 years of age who want to work and then there are those over
65 years of age who in the future may wish to remain in employment. Although it is
important financially that as many people as possible can access work (stroke costs £7
billion a year (National Audit Office, 2005)), it is also important that people are able to
undertake education, employment, re-training and voluntary work to improve their quality
of life, fulfil a role in society, avoid low self-esteem and depression.
There is evidence that this can be achieved by offering vocational rehabilitation (VR)
to people after a stroke (Lock et al., 2005). VR is available to enable people to work. It is
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defined as a process ‘whereby those disadvantaged by illness or disability can be enabled
to access, maintain, or return to employment, or other useful occupation’ (Tyerman and
Meehan, 2004). VR is now considered by most to be a skilled intervention technique
that should be completed by people who are trained in this field. Occupational therapists
would seem to be the perfect profession to become experts in this type of rehabilitation but
there are also specialist companies who offer these services. The Government Department
of Work and Pensions (DWP) is taking the lead role in VR at a national level and the
British Society of Rehabilitation Medicine has produced a useful report called Vocational
Rehabilitation, The Way Forward (British Society of Rehabilitation Medicine, 2003)
which provides a good understanding of how VR fits with the DWP and with the NHS.
One of the main reports that has lead to an increase in help available for people who
wish to work has been the Pathways to Work: Helping People into Employment (DWP,
2002). The Job Centre Plus or Job Centre’s employ Disability Employment Advisors to
help disable people select, obtain and keep jobs as well as helping employers develop
good recruitment policies. These advisors have access to a number of programmes that
can assist individuals at different stages. As well as providing a work assessment service
they can advise on training to update and gain new skills and work opportunities in
a supported environment. If the person is already in employment they will liaise with
the employer, assess the work environment and assist with the purchase of necessary
specialised equipment. They will also support the employee back into work.
Usually for people who have had a stroke, it is the rehabilitation team that assesses
the patient in the first place, seek out the relevant local support and talk to the patient
about their work. The Stroke Association’s leaflet Getting Back to Work is a good way
to introduce the topic on the hospital ward or in the community. Traditionally the initial
period of rehabilitation following a stroke concentrated on enabling the patient to return
home to an environment in which he/she could operate as safely and independently
as possible. It has now been recognised that considering and responding to vocational
or work-related issues early in the rehabilitation process can be very beneficial (Royal
College of Physicians, 2004). It is recommended that personalised care plans that aim to
get the stroke survivor fit for work are in place before the person who has had the stroke
leaves hospital. These plans should be in line with pathways for return to work in place at
the local level that in turn are consistent with those determined as appropriate nationally.
There is evidence from other conditions that the vocational status can be protected against
redundancy or retirement by engaging early with employers and VR programmes. The
term work is often only associated with paid employment whereas unpaid work may be
of equal importance to the individual. Unpaid work may include such areas as voluntary
work or being on a committee. Both paid and unpaid work fulfils a diversity of needs for
the individual, and some of the many benefits of work are listed below:
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Increased self-esteem.
Maintenance of routines and habits.
Participation in a productive activity.
Involvement in a socially accepted role that provides value to the community.
Having ‘a reason to get up in the morning’.
Challenging someone to expand their horizons.
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VR is having a great deal of attention at present and although the recognised programmes are directed at people with cardiac illness, mental illness and muscular–skeletal
disabilities, the principals are transferable to people who have had a stroke. In the past
occupational therapists would have organised for the patient to take part in work experience as near to what they would experience when they returned to work. Occupational
therapy departments had heavy and light work shops where mock work conditions could
be used as an assessment, for example, of standing ability, concentration, hand function
and tolerance. It is more often now that stroke patients are treated in their own homes and
do not return to out-patient departments. However, occupational therapists can still assist
the patient in establishing realistic goals and expectations towards work and produce a
written joint plan of action. They can encourage discussion with the family, carers and
employers. Most employers are happy to consider a staged return to work, employing the
patient in a different role or providing additional training or support. Contact with the
employer at an early stage is important in order to establish links. The patient may wish
to do this or may need assistance from the rehabilitation team.
However, entering the paid work environment may not always be realistic, feasible or
desired by the individual. Looking into the voluntary sector may be an alternative solution.
In this case, contact should be made with a target organisation to discuss what positions
are available and how appropriate they are to the individual. Again the components of the
tasks to be undertaken need to be analysed and a plan of action made. Many people who
have had a stroke will take some time to get back to work and they may be assessed with
the Personal Capability Assessment (DWP, 2007) to test their long-term incapacity for
work for social security. The occupational therapist may need to be involved as they are
most likely to know the impairments of individual people who have had a stroke.
Resuming sexual activity
As rehabilitation of stroke patients constantly improves, many new techniques develop
but some activities are often neglected because of lack of research, lack or rehabilitation
knowledge or because patients themselves do not wish to raise the subject. One such area
is a return to their normal sexual activity. Generally, this is not routinely discussed with
patients as part of their rehabilitation, although for many, it plays an important role in
their life and discussion should be included in the assessment process.
There is some information in stroke books, but this is not always readily available to
the patient and their partner and the information is not always applicable to their specific
needs. The Stroke Association can provide a leaflet, entitled “Sex after Stroke” Fact sheet
31 which can be downloaded from their website which includes the main points identified
by patients and partners. This leaflet should be made available to all stroke patients and
their partners both in hospital and in the community and may initiate a conversation about
sexual activity.
Research has observed that after stroke there is a decline in sexuality in both genders,
and partner dissatisfaction is high (Rees et al., 2007). There are many reasons for this
decline: physical changes in the brain that may reduce the sexual urge; physical changes
to the body that may make it difficult to move; psychological changes that make people
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not want to have sex. Stroke can cause physical limitations that influence body positioning
and movement during sex which can lead to a reduction in sexual activity, misery and
frustration. Other physical changes such as incontinence, drooling, emotional liability
may be off-putting to partners and again lead to a reduction in sexual activity. However,
this research goes on to report that for those patients who have had a previous myocardial infarction then little changed after stroke; this may be because pre-existing vascular
disorders had already caused erectile difficulties or because the antihypertensive agents
commonly given to stroke patients inhibit erections, or because some medications such
as beta-blockers also reduce desire. As well as physical difficulties, psychosocial impairments and depression may affect the will to engage in sexual relationships; however, these
may not be recorded till late after stroke as patients may be unwilling to talk about sexual
difficulties. Mood disorders, such as depression and anxiety are commonly observed after
a stroke, frequently affecting sexual relationships and sexual function and conversely,
sexual dysfunction may lead to depression.
After a stroke, generally both patients and partners want to know whether resuming
sexual activity will cause another stroke or epileptic fit and do not know whom to approach for advice. Although there is only a low risk of stroke from sexual excitement
(Wade, 1988), people are unwilling to have sex as they believe it may cause another
stroke. Other reasons for not continuing in sexual activity include lack of interest or
motivation from one or both of the couple; physical incapacity of the patient; difficulty
getting in a comfortable position for both of the couple; difficulty getting their partner aroused and difficulties due to sensory impairments on the patient’s affected side
(Edmans, 1998). Patients and partners reported that they would have liked to receive
information on why problems occurred in resuming sexual activity after a stroke and
how long they were likely to last. Some also reported that they would have liked there to
be more opportunity to discuss their fears and problems, especially after discharge from
hospital.
Sexual activity is a subject which is important to both patients and partners, and should
be included in stroke rehabilitation. However, despite this, it is still not clear cut this
should be part of whose role or whether it should be part of the role of all staff involved in
the rehabilitation of stroke patients. Patients and partners should have the opportunity to
choose who they wish to undertake this role. Occupational therapists are often approached
to discuss sexual activity whilst they are dealing with other personal activities of daily
living. This chance to contribute to part of patient’s lives often ignored, should be embraced
with knowledge and understanding.
Patients and partners need to know that returning to their normal sexual activity is
considered routinely as an aspect of stroke rehabilitation. They also need to know there is
the opportunity to discuss their sexual activity either alone or in couples, at a time which
is appropriate to their needs.
Stroke education
The National Stroke Strategy (DH, 2007) recommends a range of programmes to support
self-management skills after stroke to reduce long-term care costs. Information is also
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available in ‘Supporting People with Long-Term Conditions to Self-Care: A Guide to
Developing Local Strategies and Good Practice’ (DH, 2006).
Patients and carers’ understanding of stroke is often quite poor. Information is available
from The Stroke Association, Chest Heart and Stroke Scotland and Northern Ireland
Chest, Heart and Stroke Association. Occupational therapists can play an important role
in educating patients about their disability, its causes and long-term effects, both on a
formal and informal basis. The aim is to provide information and to empower patients by
allowing greater self-determination, reducing anxiety and improving coping strategies.
Common anxieties include the nature of stroke, fear of recurrence, degree of recovery,
memory/communication problems, driving/fatigue and service provision. When providing
information, therapists should take into consideration the timing of information, patients’
stress levels, their emotional adjustment to their diagnosis and patients’ understanding,
particularly if they have cognitive difficulties. Education is an ongoing process throughout
patients’ period of rehabilitation.
Some rehabilitation services run their own educational programmes for patients and/or
carers on topics such as what a stroke is and its effects. The content of these varies
according to the type of unit or service the patients are attending. There is an organisation
called ‘steppingoutuk’ which runs formal educational programmes over a set number of
sessions for patients and carers. They offer training to health care professionals to run
courses locally. More information is available from their website.
A wide variety of educational information for patients and family about stroke is
available from the two main charities, The Stroke Association and Different Strokes, via
the Internet and in paper format. Some of the Stroke Association leaflets are available in
other languages.
Local support groups can also be a source of information for patients, usually on a
more informal basis. The Stroke Association and Different Strokes have groups in most
areas of the UK.
Self-evaluation questions
1. List who you would contact if your patient needs advice on getting back to gardening.
2. Would you feel confident to take a stroke patient out of the house?
3. Make a rough plan of how an intermediate care service might include specialist stroke
care.
4. Who would you refer a carer to for support?
5. Explain how Intermediate Care can help people who have had a stroke.
6. What advice would you give to someone who asks if they can drive the day after a
stroke?
7. What age of stroke patients does the charity ‘Different Strokes’ cater to?
8. Do all stroke patients have a Home Visit before they leave hospital?
9. Will having sex cause another stroke?
10. At what point of rehabilitation should you start vocational rehabilitation?
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Chapter 10
Evaluation
Fiona Coupar and Judi Edmans
This chapter includes:
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Record keeping
Standardised assessments
Evidence-based practice
Outcome measures
Standards
Audit
Self-evaluation questions
Record keeping
The Public Records Act 1958 (Public Records Office, 1958) states that a medical record
is anything that has been created or gathered as a result of the work of a health care
professional; it is a compilation of data.
The following are all considered as part of a medical record:
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Register.
Prescription, drug chart.
Diary.
X-ray.
Audio, video, dvd.
Rough notes.
The purpose of record keeping is to:
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Form the basis for planning patient care and intervention.
Provide feedback on progress and suggest action.
Meet legal requirements, professional or statutory.
Provide information for clinical management, resource management, evaluation, research, quality assurance.
r Assist in the continuity of care.
r Provide written evidence that a service has been delivered (Quantum Development,
2003).
Occupational Therapy and Stroke, Second Edition Edited by Judi Edmans
© 2010 Blackwell Publishing Ltd. ISBN: 978-1-405-19266-8
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Most complaints within the NHS are made due to the failure in communication. To
ensure patient care is not flawed and communication improved, good record keeping is
an important clinical tool.
Abbreviations should not be used, or if used, the first entry must be written in full,
for example, range of movement (ROM); any alterations made must be done so that the
original test is not erased, additions should be separately dated, signed and timed.
In addition the occupational therapist needs to record any leaflets or pamphlets given
and thank you cards/letters should be kept as evidence of satisfaction at the time. If
leaflets are updated, old ones should be kept and all policies/standards and checklists
achieved.
Within a complaint or claim the occupational therapy records are your defence, remember the quote ‘no note, no defence!’ (Quantum Development, 2003).
The College of Occupational Therapists has produced a core standard of practice
‘Occupational Therapy Record Keeping’ (College of Occupational Therapists, 2000b).
This provides a framework for occupational therapists to develop local standards. The
standards also provide an audit tool to enable individuals to measure their practice and
make any improvements as necessary. The record keeping standard includes:
Professional records
Each patient must have a professional record that is accurate, objective and organised.
The record should be legible without abbreviations; errors must still be readable and are
signed and dated by the occupational therapist.
All entries must be signed and dated by an occupational therapist and student/support
staff entries countersigned. Occupational therapy staff should also be aware of local
policies on record keeping and if electronic records are used staff must be aware of any
guidance on use of the system.
Content
The record should contain all information clearly identifying the patient, reason for
referral other relevant professionals, medical and social history including the views of
the patient and carers. The record must contain information on the occupational therapy
assessment, goals and interventions (including any other relevant information from the
multidisciplinary team). All reports and correspondence including work with carers will
be documented. A discharge summary should be included regarding outcomes and any
future arrangements.
Access
Patients may have access to their records in accordance with legislation and the organisation’s policy. All records must be written in an understandable manner for those who
will have legitimate access to them; these records must be available if required in an
enquiry.
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Confidentiality – storage and disposal
All records must be stored and disposed of in line with the employing organisation,
and the records department must be aware of any occupational therapy notes being stored
separately. All records must be kept for no less than that for NHS records for the equivalent
patient group.
Methods of recording occupational therapy intervention
Occupational therapy case notes can take many forms across a variety of clinical settings.
They can either be unidisciplinary or multidisciplinary. Three of the most commonly
used are: problem-orientated medical records, goal-directed notes and integrated care
pathways.
Problem-orientated medical records (POMR)
These notes consist of four sections – database, problem list, progress notes (SOAPIER –
Subjective, Objective, Analysis, Plan, Intervention, Evaluation and Revision) and discharge summary. The database contains personal and medical information about the
patient. The problem list numbers the specific problems to be addressed by the occupational therapist. The progress notes are only recorded when there is a change or there is
some relevant information to be added. Progress is recorded under the headings:
Subjective – Information obtained from the patient, family or another health care
professional.
Objective – The therapist’s clinical observations and results of assessments-measures.
Analysis – The therapist’s professional opinion of what happened during an intervention
session.
Plan – What will be done next.
Intervention – Measures you have taken to achieve an expected outcome.
Evaluation – An analysis of the effectiveness of your interventions.
Revision – Any changes from the original plan of care.
The discharge summary is placed in the final progress notes and should contain information on personal/domestic activities of daily living, mobility, transfers, cognition,
perception, communication, upper limb function, current problems and future care.
Goal-directed notes
There are many types of goal-directed notes used by occupational therapists on a unidisciplinary and multidisciplinary basis. Goal setting is now commonly used in stroke
rehabilitation within the multidisciplinary team. Goal planning should actively involve
the patient and family/carers. Once the multidisciplinary team has completed their specific assessments, the patient’s problems and needs can be identified, focusing on their
strengths rather than their weaknesses. Long-term and short-term goals can be set. A
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goal must be related to a change in behaviour, be patient-centred, specific, measurable,
achievable, realistic and timely (SMART). When writing a goal, it should clearly state:
1. Who? Who’s goal is it?
2. Does what? What they will do (e.g. component task or activity)?
3. Given what? Under what conditions is the client enabled to achieve the task? (What
is required for the patient to achieve the goal? What is provided by the therapist/
environment? If these conditions are not met the client will be unlikely to be able to
achieve the goal.)
4. How well? What defines a successful outcome? How well is the client expected to
achieve the task? What level/frequency of physical assistance or verbal prompting is
acceptable?
5. By when? In what time frame?
The outcome of a goal can be scored in three possible ways – achieved, partially
achieved or not achieved. If the outcome is one of the latter two, then a variance code can
be applied to explain the reasons why this is the case. These can include issues relating to
the patient, care or staff and internal or external factors.
Another method of goal setting was described by Cook and Spreadbury (1995) in
‘Measuring the outcomes of individualised care’. Goal-Directed Patient Records (GDPR)
have been adapted from POMR. Goals are chosen by the patient instead of listing problems, and are agreed in a contract between themselves and the occupational therapist.
However, the therapist may need to write the goals if the patient is unrealistic or has communication problems. ACTOR (activity, patient’s observations, therapist’s observations,
overall evaluation, re-planning) headings are used for the progress notes. Activity includes
the facts of the activity. Patients’ observations are their subjective comments. Therapists’
observations are objective comments on the therapy carried out. Overall evaluation is the
analysis of intervention. Finally, re-planning is the future plan, which has been set as a
result of the intervention session.
Integrated care pathways
Integrated care pathways are a well-established method of recording care on a multidisciplinary basis with patients following hip replacement or fractured neck of femur. They
have also been used in the care of patients following myocardial infarction and a variety
of surgical and gynaecological procedures. This form of documentation is now being used
by multidisciplinary teams treating patients following stroke.
An integrated care pathway is a record of care that focuses on agreed intervention
and expected outcomes for a given patient diagnosis, symptom or procedure, within
an identified time frame. It should be developed and written by the multidisciplinary
team involved with the delivery of care to the patient. All professionals involved should
have common understandings and ownership of the pathway. Outcomes must be agreed,
achievable and evaluated at every stage. The documentation replaces all existing notes
used by each profession. An integrated care pathway focuses on the ‘routine’ rather than
the exception. When a detour from the care pathway occurs, a variance code is recorded.
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The four codes relate to the patient’s condition, the patient/family circumstances, the
clinical and the internal/external system.
In order for the implementation of an integrated care pathway to be successful, a total
review of care delivery is required – organisational, training, development, effectiveness,
quality, information and communication.
Integrated care pathways can facilitate best practice and aid multidisciplinary communication. They can also be used for research, clinical audit and as a risk management
tool.
An example of an integrated care pathway for stroke rehabilitation on the Nottingham
Stroke Unit has previously been published (Edmans et al., 1997).
Pros and cons of multidisciplinary joint documentation
Positive aspects of joint documentation
r Reduces duplication of notes, for example, front sheets/database, medical history, social
history, case conference information, family case conference information, discharge
plans, washing and dressing, bathing, transfers, walking, home visits, etc., as only one
set of notes written.
r Easier access to each others’ notes as only one set and therefore in one place, that is,
centralises all information about the patient.
r Improves communication as information written in one place by all of the multidisciplinary team.
r One comprehensive set of notes.
r Improves goal setting as goals set weekly at case conference.
r Less repetition of staff asking patients for the same information.
r More focused care planning.
r Improves handover of information between disciplines.
r More coordinated discharge.
r OVERALL EACH PERSON SHOULD WRITE LESS NOT MORE.
Negative aspects of joint documentation
r Difficulty storing records in an accessible place for all professionals to gain access to
staff wanting to write in notes at the same time.
r Fear that detail of each professional’s input will be lost, such as information confidential
to a single discipline, for example, psychologists.
Standardised assessments
The use of standardised assessments (whether screening or detailed) will indicate the
type(s) of impairment(s) present, which may cause functional difficulties to the patient.
The value of standardised assessments is that they should have been rigorously tested
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to ensure they are valid (i.e. appropriate for the purpose and measures it was intended),
reliable (i.e. reproducible and not variable between assessors or over time) and have an
established procedure for administration and scoring with normative data available for
comparison.
A thorough assessment using both standardised assessment and functional assessment
will inform and direct the nature of the intervention required.
Pre-assessment checks
Prior to conducting a standardised assessment, it is important to consider other modalities
that may impact on the patient’s ability to complete the assessment. For example, if a
patient has difficulty with any of the following, they may achieve lower scores on the
assessment, due to impairments other than what is being assessed:
r Vision
– Acuity – clarity of vision.
– Ocular motor skills – ability to move eyes.
– Visual fields.
r Hearing.
r Attention.
r Memory.
r Motivation and engagement.
Choosing assessments
When choosing which assessments to use, it is also important to consider:
r The population involved in the standardisation of the assessment (i.e. was it standardised
with patients after stroke or other conditions, of what age and in what setting).
r Who is permitted to administer the assessment (some assessments can only be administered by psychologists).
r Whether there is evidence of validity and reliability with norms for comparison.
r How easy it is to administer and score the assessment.
r Whether any pre-training is needed to use the assessment.
r How easy it is to transport the assessment.
r How much space and time is needed to administer the assessment.
r The balance between the advantages and disadvantages of the assessment.
Test administration
Prior to assessing patients using standardised assessments, it is recommended to:
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Be familiar with the assessment.
Understand what you are assessing and why.
Check that the patient has their correct glasses, hearing aid, etc.
Check whether the patient requires a visit to the toilet.
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Check that patient understands why they are being assessed.
Prepare the room (preferably quiet, without interruptions or distractions).
Prepare the assessment materials.
Use a clipboard to record the scores out of the patient’s sight.
Record details of the patient’s behaviour and types of errors.
Analysis of assessments
When analysing the assessment results, consider whether there was evidence of any of
the following during the assessment, which may have affected the patient’s performance:
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Comprehension.
Concentration.
Reasoning (executive function).
Memory.
Anxiety.
Depression.
Initiation.
Apraxia.
Hemianopia.
Differential diagnoses
A stroke can affect any area of the brain and the brain controls everything we do. ‘Doing’
requires a number of performance components and sometimes it is difficult to separate out
what performance component has been affected by the stroke or what the key impairment
is. However, some key impairments to look out for, which are often incorrectly identified,
are discussed below.
Poor initiation
Consider aspects such as memory of the task, selective attention, difficulty conceptualising
the task, unable to recognise the environment or objects, poor planning, apraxia.
Poor memory/getting lost
Consider attention to information, aphasia (comprehension or expressive capacity), visual
impairments, visual inattention.
Use of objects
Consider occipital lobe impairments, that is, affects of reduced information regarding
texture, shape, colour, contrast, visual field impairments, visual inattention (not picking
up sufficient information about the object for usage), agnosia, ideational apraxia.
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Behavioural issues
Perceptual impairments (the environment may not make sense to the patient so they do not
know how to behave or might be frightened hence inappropriate behaviours or reactions),
inattention, reduced information processing causing overload.
The list is not exhaustive but it gives an example to highlight the importance to put
together a full picture of the patient, before making sweeping statements or labelling
impairments.
Useful assessments
Intervention and effectiveness
r Assessment of Motor and Process Skills (AMPS) (Fisher, 2006).
r Canadian Occupational Performance Measure (COPM) (Law et al., 2005).
Motor performance
r Motricity Index (Collin and Wade, 1990).
r Rivermead Motor Assessment (Lincoln and Leadbitter, 1979).
r Nine-hole Peg Test (Kellor et al., 1971).
Activities of daily living
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Barthel ADL Index (Mahoney and Barthel, 1965; Collin et al., 1988).
Edmans ADL Index (Edmans and Webster, 1997).
Frenchay Activities Index (Holbrook and Skilbeck, 1983; Wade et al., 1985).
Functional Independence Measure (FIM) (Granger et al., 1986).
Northwick Park ADL Index (Benjamin, 1976).
Nottingham 10 point ADL Scale (Ebrahim et al., 1985).
Nottingham Extended ADL Scale (Nouri and Lincoln, 1987).
Rivermead ADL Assessment (Whiting and Lincoln, 1980; Lincoln and Edmans, 1990).
Sensation
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Erasmus MC Modifications to the (revised) NSA (Stolk-Hornsveld et al., 2006).
Nottingham Sensory Assessment (Lincoln et al., 1998b).
Rivermead Assessment of Somatosensory Performance (RASP) (Winward et al., 2002).
Stereognosis Subtest of the Chessington Occupational Therapy Neurological Assessment Battery (COTNAB) (Tyerman et al., 1986).
Attention
r Test of Everyday Attention (TEA) (Robertson et al., 1994).
Cognition
r COTNAB (Tyerman et al., 1986).
r Cognitive Assessment of Minnesota (CAM) (Rustard et al., 1993).
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r Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) (Itzkovich et al.,
1993).
r Middlesex Elderly Assessment of Mental State (MEAMS) (Golding, 1989).
r Mini-Mental Status Examination (MMSE) (Folstein et al., 1975).
r SF-36 (generic health status measure) (Garratt et al., 1993).
Memory
r Doors and People (Baddeley et al., 1994).
r Rivermead Behavioural Memory Test (RBMT3) (Wilson et al., 2008).
Apraxia
r Kertesz Apraxia Test (Kertesz and Ferro, 1984).
Executive functions
r Behavioural Assessment of the Dysexecutive Syndrome (BADS) (Wilson et al., 1996).
r Hayling and Brixton Tests (Burgess and Shallice, 1997).
Perception
r
r
r
r
r
r
r
r
r
Baking Tray Test (Tham and Tegner, 1996).
Balloons Test (Edgeworth et al., 1998).
Behavioural Inattention Test (BIT) (Wilson et al., 1987).
Location Learning Test (Bucks et al., 2000).
Motor Free Visual Perceptual Battery (Ronald et al., 1972).
Occupational Therapy Adult Perceptual Screening Test (Cooke, 2005).
Repeatable Battery for the Assessment of Neurological Status (Randolph, 1998).
Rey Figure Copying Test (Rey, 1959; Meyers and Meyers, 1995).
Rivermead Perceptual Assessment Battery (RPAB) (Whiting et al., 1985; Lincoln and
Edmans, 1989).
r Visual Object and Space Perception Battery (VOSP) (Warrington and James, 1991).
Anxiety and depression
r
r
r
r
General Health Questionnaire (Goldberg and Hiller, 1979).
Geriatric Depression Scale (Yesavage et al., 1983).
Hospital Anxiety and Depression Scale (Zigmond and Snaith, 1983).
Wakefield Depression Inventory (Snaith et al., 1971).
Driving
r Stroke Drivers Screening Assessment (Nouri and Lincoln, 1994).
Evidence-based practice (EBP)
Evidence-based medicine/practice is defined as the ‘. . .conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual
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patients’ (Sackett et al., 1996). This process involves combining best existing research
evidence, clinical reasoning and patient choice (Haynes et al., 2002).
Why do we need evidence-based practice?
r To ensure the greatest health gain from the available resources.
r To ensure decisions about clinical services and interventions are driven by evidence of
efficacy and cost effectiveness.
r Personal experience and expertise can be misleading.
r To ensure the provision of up-to-date interventions as clinical practice risks becoming
rapidly out of date.
r To provide effective and efficient interventions.
Stages of evidence-based practice
EBP has a number of key stages:
1.
2.
3.
4.
Formulate a clear, relevant and focused question.
Search for research evidence.
Appraise the identified evidence.
Assess clinical applicability of the evidence (incorporating patient values and preferences).
5. Implement findings into clinical practice.
6. Evaluate outcomes.
Formulating a clear, relevant and focused question
EBP always begin with identification of a particular problem or query. In order to complete
EBP, this problem or query should be developed into a clear, focused and well-structured
question. This can be achieved using the PICO structure:
P – Patient or problem
I – Intervention
C – Comparison intervention
O – Outcome
For example, an occupational therapist may have a query relating to the effectiveness
of home visits. Using the PICO structure, a clear and specific question (or questions)
could be developed: Is a home visit more effective than no home visit at ensuring a safe
discharge for stroke patients? A clear, relevant and focused question makes the subsequent
stages of EBP more straightforward. Once you have formed the question, you can think
about what type of question you are asking, that is, is the question related to assessment,
aetiology, prognosis, intervention or prevention. The type of question you ask will affect
the type of research evidence that will provide the best answer and therefore the type of
evidence that you want to search for.
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Searching for the best evidence
Choosing the right evidence is of fundamental importance. There are several sources of
evidence that you may consider using, to answer your question(s); people, textbooks, scientific literature and pre-appraised or secondary sources. Asking colleagues is convenient
and accessible; however, their knowledge may not be evidence-based and they cannot
give an answer to every question. Textbooks provide good background information, but
are often out of date. Therefore evidence from scientific literature and/or pre-appraised or
secondary sources is often required to answer clinical questions. When considering the
evidence it is helpful to consider levels of evidence.
Levels of evidence
Evidence comes in many forms and varies in quality. Depending on the type of question
being asked, different research designs are assessed and ranked in a hierarchy of reliability.
The Centre for Evidence-Based Medicine provides a full hierarchy of evidence relating
to different study designs and highlights the advantages and disadvantages of each study
type.
Usually the type of questions that occupational therapists ask relate to effects of intervention. The hierarchy of evidence relating to these types of question is:
Systematic review of RCTs
Randomised controlled trial
Cohort studies
Case-control studies
Case series
Expert opinion
Randomised controlled trials and the systematic review of several randomised controlled trials are methods which are likely to tell us the effectiveness of a therapy intervention and have become the ‘gold standard’ for judging whether an intervention is beneficial
or harmful (Sackett et al., 1996).
Secondary sources of evidence are commonly considered to be the highest form of
evidence, with expert opinion generally agreed to be the weakest level of evidence.
Secondary or pre-appraised sources of evidence include:
r Guidelines: For example, RCP stroke guidelines, SIGN 64, European Stroke Organisation (ESO) guidelines.
r Evidence-based summaries: For example, Bandolier, Clinical Evidence, Health technology assessments (HTA).
r Systematic reviews: For example, Cochrane Library.
If a question cannot be answered using secondary sources, primary literature should be
searched for. Primary sources of research evidence relates to scientific literature reporting
primary studies. The most efficient method of locating scientific literature is through
searching bibliographic databases such as Medline, Embase or CINAHL. Hand searching
may supplement this process, as some relevant journals may not be indexed within these
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databases. Searching the literature can be daunting; however, librarians are experts in
searching and can assist in locating the appropriate evidence.
If no appropriate randomised controlled trials are available to answer a particular
question, evidence from less robust studies, further down the hierarchy of evidence (cohort
studies/case-controlled studies/case studies/anecdotal evidence) becomes the sources of
evidence. It is important to remember that the lower down the hierarchy, the less reliable
the evidence. Many areas of occupational therapy are still under-researched and therefore
it may be possible that no good quality evidence exists to answer a particular question, in
which case professional judgement has to be relied upon. However, it must be remembered
that lack of evidence is not evidence of no effect.
Appraising the identified evidence
Critical appraisal is the next essential component of EBP and involves assessing and
interpreting evidence. It involves considering the evidence in terms of its validity, results
and clinical relevance. Different study designs require different questions to be asked
to assess the validity and applicability of the evidence. The Centre for Evidence-Based
Medicine and Public Health Resource Unit (PHRU) have examples of critical appraisal
questions for different study designs.
The three questions that generally need to be asked for all study designs are as follows:
r Are the results of the study valid?
r What are the results?
r Are the results applicable to own clinical practice?
Examples of specific questions relating to randomised controlled trials are as follows:
Questions relating to validity
r
r
r
r
Were the patients randomised to different groups?
Were the groups similar at the start of the trial?
Apart from the intervention of interest were the groups treated equally?
Were all patients in the trial accounted for? And were they analysed according to the
group to which they were randomised?
r Were outcome measures objective or were the assessors and clinicians kept ‘blind’ to
which group each participant was in?
Questions relating to the results
r What are the results?
r How precise are the results?
r Do you believe the results?
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Questions relating to applicability
r Can the results be applied to the local population?
r Is the intervention feasible to my setting?
r Do the results of this study fit with other available evidence?
Implementing findings into clinical practice and evaluating outcomes
Following critical appraisal and a decision that the evidence is valid and applicable, this
evidence should then be implemented. The challenge is to apply EBP at the right time, in
the right place and in the right way. However, implementing evidence into practice is not
easy and a number of difficulties have been identified, including size and complexity of
research, developing evidence-based clinical policy, applying evidence due to poor access
to best evidence and guidelines, organisational barriers and low patient compliance with
interventions (Haynes and Haines, 1998).
For implementing evidence into practice, guidelines are an excellent place to start.
Where guidelines are available it is important to examine whether your current practice
complies with the current evidence. If practices are not concurrent with the evidence
what barriers can you identify to implementing the evidence? These barriers may include
limited resources, lack of knowledge and abilities and patient preferences. How might
these be overcome? If we are to offer the most effective interventions then it is essential
that changes are made and the evidence is implemented.
Where no guidelines exist, the EBP process can be followed to answer specific questions. If relevant evidence is located it is then essential that consideration is given to how
recommendations from the evidence may be implemented; for example, pulling together
a group of individuals from different professions to assist in breaking down barriers and
bringing about change. Bringing about change is not easy and a number of barriers still
exist; however, bridging the barriers between research evidence and clinical decision
making is essential. A number of incentives such as accurate summaries of evidence and
guidelines assist in breaking down these barriers.
Once research evidence is implemented it is vital that the impact of this is evaluated
using relevant outcomes.
Outcome measures
The consequences of stroke on an individual’s functioning are often complex and varied in
nature. Stroke not only effects neurological functioning, for example, movement/speech
but may also lead to a dependence in activities of daily living and cognitive and perceptual
difficulties.
To enable effective clinical stroke management and research, careful assessment and
evaluation of functioning is essential. To reflect the complex and varied nature of difficulties encountered after stroke, numerous outcome measures exist to assess the impact and
outcome of stroke (Geyh et al., 2004).
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Outcome measures are tools or instruments used to quantify the change in a patient due
to an intervention, and allow for the evaluation of the effects of interventions to be established. Therefore, the measuring of outcomes is an essential component in determining
therapeutic effectiveness and therefore is central to the provision of EBP (Van der Putten
et al., 1999).
Outcome measures can be classified as condition specific, for example, National Institute for Health Stroke Scale (NIHSS) (Brott et al., 1989); domain specific, for example,
MMSE (Folstein et al., 1975); or generic health status measures, for example, Short Form
(SF-36) (Garratt et al., 1993). Additionally outcome measures can be categorised according to the three categories; body function/structure, activity and participation, within the
International Classification of Functioning (ICF) (WHO, 2002), as shown in Table 10.1
(Duncan et al., 2000; Geyh et al., 2004; Salter et al., 2008).
Table 10.1 Categorisation of outcome measures within the ICF.
Body functions and
structures
Activities
Participation
• Beck Depression
Inventory
•
Action Research Arm
Test
•
Canadian Occupational
• Behavioural Inattention
Test
•
Barthel Index
•
Performance Measure
• Canadian Neurological
Scale
•
Berg Balance Scale
•
London Handicap Scale
• Clock Drawing Test
•
Box and Block Test
•
Medical Outcomes Study
Short-Form 36
• Fugl–Meyer
Assessment
•
Chedoke McMaster
Stroke Assessment Scale
•
Nottingham Health Profile
• General Health
Questionnaire 28
•
Clinical Outcome
Variables Scale
•
Reintegration to Normal
Living Index
• Geriatric Depression
Scale
•
Functional Ambulation
Categories
•
Stroke Adapted Sickness
Impact Profile
• Hospital Anxiety and
Depression Scale
•
Functional Independence
Measure
•
Stroke Impact Scale
• Mini Mental State
Examination
•
Frenchay Activities Index
•
Stroke Specific Quality of
Life
• Modified Ashworth
Scale
•
Motor Assessment Scale
• Motor Free Visual
Perception Test
•
Nine-hole Peg Test
• National Institutes of
Health Stroke Scale
•
Rankin Handicap Scale
• Orpington Prognostic
Scale
•
Rivermead Mobility Scale
•
Timed Up and Go
Presented in Salter et al . (2008) – table based on that presented in Roberts and Counsell (1998) and
Duncan et al . (2000). (Reproduced with permission from EBRSR: Evidence-Based Review of Stroke
Rehabilitation.)
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Table 10.2 Definitions of psychometric properties of a measure.
Criteria
Definition
Appropriateness
The match of the measure to the purpose/question under
study. It must be decided what information is required and
what use will be made of the information gathered (Wade,
1992)
Reliability
The ability of the measure to achieve the same result, if no
real change has occurred. Reliability refers to the
reproducibility and internal consistency of the measure, i.e.
can the measure be repeated and achieve the same results?
Reproducibility – concepts such as test–retest and
interobserver reliability
Validity
The ability to measure what it is intended to measure. There
are different types of validity, including face, content,
construct and criterion. The validity of a measure can be
difficult to determine
Sensitivity/responsiveness
The ability of the measure to measure change overtime.
Floor and ceiling effects can occur in an outcome measure,
i.e. limits to the range of detectable change beyond which
any improvement or deterioration will be identified
Clinical usefulness
How useful is the measure in terms of providing a meaningful
score, i.e. meaningful for patient and therapist
Clinical feasibility
How feasible is the measure in terms of effort, burden,
expense and disruption
Adapted from table in Salter et al . (2008). (Reproduced with permission from EBRSR: Evidence-Based
Review of Stroke Rehabilitation.)
In addition to understanding what construct an outcome measure aims to assess, it is
also necessary to evaluate the measure in terms of appropriateness, validity, reliability,
sensitivity, specificity, clinical usefulness and feasibility in order to inform choice of
outcome measure. These are often referred to as the psychometric properties of a measure.
Definitions of these terms and examples of questions relating to these concepts are outlined
in Table 10.2.
Other considerations
Standardised and non-standardised outcome measures – Standardised outcome measures
have specified, standardised procedures for completion and scoring. These measures will
usually have been tested for validity and reliability to ensure consistency in application
of the measure. Additionally many measures will have been normatively standardised for
scoring, over large populations. This means that therapists can compare patients’ scores
against a normal range and to other patients with similar conditions. Non-standardised
outcome measures have not been subjected to the same rigorous testing procedure and
are therefore often of poor quality, and generalisation of scores from non-standardised
measures is problematic.
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Use of outcome measures – Outcome measures can be used for a number of reasons.
Outcome measures can be used to evaluate:
–
–
–
–
–
–
–
Improvement.
Maintenance, for example, of function.
Reduction, for example, of pain or discomfort.
Prevention, for example, of disability or discomfort.
Development/maturation.
Recovery, for example, of function.
Delay, for example, in rate of deterioration.
Outcome measures should be routinely used by occupational therapists not only to
evaluate their own practices but also to inform and motivate patients and carers and
provide feedback to the multidisciplinary team.
Standards
The College of Occupational Therapists (2000a) define the following terms:
‘Clinical standards are broad statements which relate to the organisation and delivery of
services (rather than actual clinical interventions, which are the subject of clinical guidelines).
Standards provide a defined level of excellence and form a basis for evaluating or auditing
services.
A standard is a key aim, and contains various criteria that must be met. It is taken that each
standard is only achieved when all of the criteria have been met. It is therefore crucial that the
criteria are measurable, and that evidence of each criterions achievement is clarified’.
i.e., statements with criteria, based on evidence-based guidelines.
‘Criteria, being measurable statements, can be subjected to audit, to assess if actual performance meets the expected performance as defined’.
i.e., questions to compare performance to national/local standards.
The following documents, produced by the College of Occupational Therapists Specialist Section Neurological Practice and the Royal College of Physicians Profession Specific
Stroke Audit group, provide the framework for evaluation of occupational therapy stroke
services:
r Occupational Therapy Standards for Stroke Second Edition (Royal College of Physicians and College of Occupational Therapists, 2008) – based on the National Clinical
Guidelines for Stroke 3rd Edition.
r Profession Specific Stroke Audit Occupational Therapy Clinical Audit (Royal College
of Physicians Profession Specific Stroke Audit group, 2007a) – to audit the standards.
r Profession Specific Stroke Audit Organisational Audit (Royal College of Physicians
Profession Specific Stroke Audit group, 2007b) – to audit the standards.
These three documents are all available from the College of Occupational Therapists
Specialist Section Neurological Practice.
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Self-evaluation questions
1. Describe what a medical record is, its purpose and requirements.
2. Describe the different methods that can be used to record occupational therapy intervention and describe their differences.
3. What is evidence-based practice and why do we need it?
4. How do you search and appraise evidence?
5. What are outcome measures and why would you use them?
6. Describe and compare the outcome measures that could be used in your practice.
7. What is the difference between a guideline, a standard and audit?
8. How would you implement stroke standards in your service?
9. How does your service compare with recommended standards?
10. How would you audit your service?
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Appendix: One-Handed Techniques
SELF-CARE ACTIVITIES
Washing
Putting soap onto flannel
Put soap in a soap dish or on a dry cloth and wipe the
flannel over the soap, use liquid soap dispenser or put
shower gel in the water
Wringing out flannel
Put flannel round tap and twist ends of flannel together
pulling flannel tight or use a small flannel and squeeze it
out with one hand
Putting toothpaste on
toothbrush
Put toothbrush on a hard surface with the bristles pointing
up, then put toothpaste on it. Alternatively, hold the
toothbrush handle in the mouth then put toothpaste on it
with the unaffected hand. Flip top lids or pump action
toothpaste dispensers may be easier than screw tops
Opening tube of
toothpaste/hand cream, etc.
Wedge tube between knees or teeth or against solid, fixed
objects and unscrew top with sound hand
Cleaning dentures
Wash dentures in the washbasin, by wedging them in the
plughole or use a suction nail brush stuck to the side of the
wash basin, or soak dentures in sterident overnight
Shaving
Electric razor is the easiest and safest method
Cleaning nails
Use suction nail brush/file
Bathing/showering
Getting in/out of bath
Use bath board and seat with non-slip mat, grab rails may
also be useful
Washing back in bath
Put shower gel in bath water and use plastic jug to tip
water over self
Washing back in shower
Tip shower gel on back of shoulders and water will wash it
down back
Scrubbing back
Use a long-handled sponge or loofa
Drying back
Put loop tag onto one end of towel and attach this to a
hook/similar to fix one end of towel, pull taut across back.
Alternatively, put on a terry-towelling robe after washing
Putting talc on
Hold talc container between legs to open it, hold top end of
talc container and tip it into hand, tip powder into small
bowl and use powder puff or tip powder onto towel and pat
towel with talc onto body
Occupational Therapy and Stroke, Second Edition Edited by Judi Edmans
© 2010 Blackwell Publishing Ltd. ISBN: 978-1-405-19266-8
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Appendix
209
Dressing (see Chapter 5, Figures 5.13–5.15)
Putting on bra/vest/jumper/
dress/shirt/blouse/cardigan/
skirt
Lay garment on knees with the back uppermost, neck
furthest away from body and the sleeves hanging down the
outside of each leg, put affected arm down the sleeve and
pull the sleeve up past elbow, put sound arm into the other
sleeve and pull the jumper, etc. over head
Bras
Bras can be put on as shown above, provided they are
elasticated and are fastened up first; alternatively, they can
be adapted with Velcro to be front opening or use a looser
support/sports bra
Alternative method for
putting on a shirt/blouse
Lay garment on knees with the inside of the shirt/blouse,
etc. uppermost and the neck/collar nearest body, and the
sleeves hanging down the outside of each leg, put affected
arm down the sleeve and pull the sleeve up past elbow, put
sound arm into the other sleeve and pull the jumper, etc.
over head
Putting on tie
a Tuck the narrow end of the tie in the top of the trousers.
This secures the tie at that end
b Wrap the tie round in the normal manner to make the
knot and pull down into position
Alternatively, leave the tie knot made up and loosen tie
slightly to put on or take off over head. If all else fails, ties
can be bought with ‘ready-made’ knots
Removing all upper
garments
Gather each garment up from the back of the neck and
pull it over head, then take arms out of garment
Putting on pants/trousers/
socks/stockings/shoes
Cross affected leg over sound leg and lean forwards to put
each garment over affected foot. Uncross legs and reach
down to put the garment over the sound foot. If unable to
maintain sitting balance whilst moving the sound foot off
the ground, keep the sound heel on the ground, while
putting garments over the sound toes, then keep the
sound toes on the ground while pulling the garment round
the sound heel
Pulling up trouser zips
Hold zip end between thumb and index finger and push
away from lower end of zip by holding lower end of zip taut
with middle, ring and little fingers
Putting on socks
Open aperture with span of hand, reach down and place
over toes
Tying shoe laces
a Tie a knot at one end of the lace and thread it through
eyelets. This secures the lace at that end. If the person
is able to use their right hand, start threading the lace
with the knot on the left, and if the person is able to use
their left hand, start threading the lace with the knot on
the right
b Pull the lace through as tight as is comfortable and loop
the free end of the lace over the last piece of threaded
lace. The smaller the loop is made, the tighter the lace
will be
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c Make a second loop with the free end of the lace then
pass it under the last piece of threaded lace and
through the first loop. The smaller the loop is made, the
tighter the lace will be
d Pull the loop to the outside of the shoe to tighten it
e A second loop can be made (optional) by putting thumb
and index finger through the loop. The second loop is
made by picking up another piece of the loose end of
the lace
f The second loop can be pulled through in the same way
as the first loop
g The excess lace can be tucked down inside the shoe at
the side of the foot
h Alternatively, the excess lace can be threaded through
the lace on the top of the shoe
If unable to tie laces, springer lacers, no-bows or elastic
laces may be used
Loose fitting and stretchy fabrics make the task easier
Adaptations may be made to garment with Velcro to provide wider openings or a long
cord attached to zip fastenings to enable them to be pulled up
INSTRUMENTAL ACTIVITIES
Meal times
Cutting up food
A variety of special cutlery is available, e.g. rocker
knife/cheese knife and non-slip mat under plate
Stopping food moving off the
plate
Use plate guard or plate with a lip
Buttering bread
Use buttering board with non-slip mat underneath to hold
bread steady
Kitchen activities
Stabilising object
Use non-slip mat, pan holder on the stove, spike board,
buttering board, belliclamp or wedge against solid, fixed
objects. A damp jay cloth also works well as a non-slip mat
Cutting up food
Use spiked chopping boards, food processors or adapted
knives
Opening containers
Use electric tin openers, mounted tin or jar openers,
belliclamp or wedge object between knees, etc.
Carrying items
Use trolley or one-handed tray
Meal preparation
There are many pieces of equipment available to assist,
e.g. spike board/vices to hold vegetables whilst peeling or
chopping them
Cleaning and laundry
Hanging up washing
Lower the wash line, throw item over wash line and then
attach pegs or put pegs on first and then over wash line,
then raise the line. Alternatively, use clothes drier
Reaching for objects
Long-handled tools facilitate ease of reach
Picking up items from the
floor
Use an ‘Easy-Reach’, ‘Pick Up Stick’ or ‘Helping Hand’
Moving items around
Use kitchen trolleys
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Appendix
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Household
Stopping telephone, etc.
moving
Put non-slip mat under telephone to stop it moving
Writing
Paper weight or heavy object to hold paper in place or use
spring clipboard
Threading needle
Put needle into pincushion to hold it whilst threading or buy
solid block needle threader
Holding playing cards
Use scrubbing brush/men’s hairbrush, lay on its back and
stand cards in the bristles of the brush
Reading a book
Sit at a table with book open on the table, have a tray on
your knee and hold book open on the tray or buy a book
rest
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References
Ada L, Foongchomcheay A, Cannin C. (2005) Supportive devices for preventing and treating
subluxation of the shoulder after stroke [review]. Cochrane Collaboration, Issue 1.
Adams HP, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL, Marsh EE III. (1993)
Classification of subtype of acute ischaemic stroke. Definitions for use in a multicentre clinical
trial. TOAST. Trial of Org 10172 in acute stroke treatment. Stroke, 24(1):35–41.
Adamson J, Beswick A, Ebrahim S. (2004) Is stroke the most common cause of disability? Journal
of Stroke and Cerebrovascular Diseases, 13:171–7.
Agenda for Change Team (2004) The NHS Knowledge and Skills Framework (NHS KSF) and the
Development Review Process. London: Department of Health.
Aisen ML. (1999) Justifying neurorehabilitation, a few steps forward. Neurology, 52:8–10.
Ardent T, Schindler C, Bruckner MK, Eschrich K, Bigl V, Zedlick D, Marcova L. (1997) Plastic
neuronal remodeling is impaired in patients with Alzheimer’s disease carrying apolipoprotein
epsilon 4 allele. Journal of Neuroscience, 17(2):516–29.
Artzberger S. (2005) A critical analysis of edema control techniques. American Occupational
Therapy Association, Special Interest Section Quarterly, 28(2):1–4.
Baddeley A, Emslie H, Nimmo-Smith I. (1994) Doors and People. London: Pearson Assessment.
Ballinger C, Ashburn A, Low J, Roderick P. (1999) Unpacking the black box of therapy – a pilot
study to describe occupational therapy and physiotherapy interventions for people with stroke.
Clinical Rehabilitation, 13(4):301–9.
Baloyannia SJ. (2009) Dendritic pathology in Alzheimer’s disease. Alzheimer’s and Dementia, 5(4)
Supplement 1:40.
Bamford J, Sandercock P, Dennis M, Burn J, Warlow C. (1991) Classification and natural history
of clinically identifiable subtypes of cerebral infarction. Lancet, 337(8756):1521–6.
Barnett HJ, Taylor DW, Eliasziw M, Fox AJ, Ferguson GG, Haynes RB, Rankin RN, Clagett GP,
Hachinski VC, Sackett DL, Thorpe KE, Meldrum HE, Spence JD. (1998) Benefit of carotid
endarterectomy in patients with symptomatic moderate or severe stenosis. North American
Symptomatic Carotid Endarterectomy Trial Collaborators. New England Journal of Medicine,
339(20):1415–25.
Baum CM, Christiansen CH. (2005) Person–Environment–Occupation–Performance: an
occupation-based framework for practice. In Christiansen CH, Baum CM, Bass-Haugen J
(eds), Occupational Therapy: Performance, Participation, and Well-being. Thorofare: Slack Inc.;
pp. 243–66.
Bear M, Connors B, Paradiso M. (2007) Neuroscience Exploring the Brain. 3rd edn. London:
Lippincott Williams & Wilkins.
Beis JM, Andre JM, Baumgarten A, Challier B. (1999) Eye patching in unilateral spatial neglect:
efficiency of two methods. Archives of Physical Medicine and Rehabilitation, 80(1):71–6.
Occupational Therapy and Stroke, Second Edition Edited by Judi Edmans
© 2010 Blackwell Publishing Ltd. ISBN: 978-1-405-19266-8
P1: SFK/UKS
P2: SFK
ref
BLBK271-Edmans
April 10, 2010
14:57
Trim: 244mm×172mm
References
213
Benjamin J. (1976) The Northwick Park ADL Index. British Journal of Occupational Therapy,
39(12):301–6.
Bhatt DL, Fox KAA, Hacke W, Berger PB, Black HR, Boden WE, Cacoub P, Cohen EA, Creager
MA, Easton JD, Flather MD, Haffner SM, Hamm CW, Hankey GJ, Johnston SC, Mak K-H,
Mas J-L, Montalescot G, Pearson TA, Steg PG, Steinhubl SR, Weber MA, Brennan DM, FabryRibaudo L, Booth J, Topol EJ, for the CHARISMA Investigator (2006) Clopidogrel and aspirin
versus aspirin alone for the prevention of atherothrombotic events. New England Journal of
Medicine, 54(16):1706–17.
Blanton S, Wilsey H, Wolf SL. (2008) Constraint-induced movement therapy in stroke rehabilitation:
perspectives on future clinical applications [review]. NeuroRehabilitation, 23(1):15–28.
Bobath B. (1990) Adult Hemiplegia: Evaluation and Treatment. 3rd edn. Oxford: ButterworthHeinemann.
Boomkamp-Koppen HGM, Visser-Meily JMA, Post MWM, Prevo AJH. (2005) Poststroke hand
swelling and oedema: prevalence and relationship with impairment and disability. Clinical Rehabilitation, 19:552–9.
Booth J, Davidson I, Winstanley J, Waters K. (2001) Observing washing and dressing of stroke
patients: nursing intervention compared with occupational therapists. What is the difference?
Journal of Advanced Nursing, 33(1):98–105.
Booth J, Hewison A. (2002) Role overlap between occupational therapy and physiotherapy during inpatient stroke rehabilitation: an exploratory study. Journal of Interprofessional Care, 16(1):31–40.
Bowen A, Lincoln N. (2007) Cognitive rehabilitation for spatial neglect following stroke. Cochrane
Database of Systematic Reviews, Issue 2.
Boyt Schell BA, Schell JW. (2008) Clinical and Professional Reasoning in Occupational Therapy.
Baltimore, MD: Lippincott Williams & Wilkins.
Brasil-Neto JP, de Lima AC. (2008) Sensory deficits in the unaffected hand of hemiparetic stroke
patients. Cognitive and Behavioral Neurology, 21(4):202–5.
Braun SM, Beurskens AJ, Borm PJ, Schack T, Wade DT. (2006) The effects of mental practice in stroke rehabilitation: a systematic review [review]. Archives of Physical Medicine and
Rehabilitation, 87(6):842–52.
British Bobath Tutors Association (2003) Basic Bobath Course (Adult Hemiplegia): Neurophysiology Handbook. Course Notes. Manchester: Author.
British Heart Foundation (2005) Coronary Heart Disease Statistics. London: British Heart Foundation.
British Society of Rehabilitation Medicine (2003) Vocational Rehabilitation – The Way Forward:
Report of a Working Party. 2nd edn. London: British Society of Rehabilitation Medicine.
Brock K, Jennings K, Stevens J, Picard S. (2002) The bobath concept has changed. (Comment
on critically appraised paper, Australian Journal of Physiotherapy, 48:59). Letters to the editor.
Australian Journal of Physiotherapy, 48:156–7.
Brott T, Adams HP Jr, Olinger CP, Marler JR, Barsan WG, Biller J, Spilker J, Holleran R, Eberle
R, Hertzberg V, Rorick M, Moomaw CJ, Walker M. (1989) Measurements of acute cerebral
infarction: a clinical examination scale. Stroke, 20:964–70.
Bucks RS, Willison JR, Byrne LM. (2000) Location Learning Test. Oxford: Pearson Assessment.
Burgess PW, Shallice T. (1997) The Hayling and Brixton Tests. Bury St. Edmunds, UK: Thames
Valley Test Company.
Busse M, Tyson SF. (2009) How many body locations need to be tested when assessing sensation
after stroke? An investigation of redundancy in the Rivermead Assessment of Somatosensory
Performance. Clinical Rehabilitation, 23(1):91–5.
P1: SFK/UKS
P2: SFK
ref
BLBK271-Edmans
214
April 10, 2010
14:57
Trim: 244mm×172mm
References
Butler A, Page S. (2006) Mental practice with motor imagery, evidence for motor recovery and
cortical reorganisation after stroke. Archives of Physical Medicine and Rehabilitation, 87:2–11.
Butler JA. (2002) How comparable are tests of apraxia? Clinical Rehabilitation, 16:389–39.
Byl N, Roderick J, Mohamed O, Hanny M, Kotler J, Smith A, Tang M, Abrams G. (2003) Effectiveness of sensory and motor rehabilitation of the upper limb following the principles of
neuroplasticity: patients stable poststroke. Neurorehabilitation and Neural Repair, 17(3):176–91.
Caldara R, Deiber MP, Andrey C, Michel CM, Thut G, Hauert CA. (2004) Actual and mental
motor preparation and execution: a spatiotemporal ERP study. Experimental Brain Research,
159(3):389–99.
Canadian Association of Occupational Therapists (CAOT) (2002) Enabling Occupation: An Occupational Therapy Perspective. Revised edn. Ottawa, ON: CAOT Publications ACE.
Cappa SF, Benke T, Clarke S, Rossi B, Stemmer B, van Heugten CM. (2005) EFNS guidelines
on cognitive rehabilitation: report of an EFNS task force. European Journal of Neurology,
12:665–80.
CAPRIE Steering Committee. (1996) A randomised, blinded, trial of clopidogrel versus aspirin in
patients at risk of ischaemic events (CAPRIE). Lancet, 348(9038):1329–39.
Carey L. (2006) Loss of somatic sensation. In Selzer M, Clarke S, Cohen L, Duncan P, Gage F
(eds), Textbook of Neural Repair and Rehabilitation: Medical Neurorehabilitation, Vol II. New
York: Cambridge University Press; pp. 231–47.
Carey LM. (1995) Somatosensory loss after stroke. Critical Reviews in Physical and Rehabilitation
Medicine, 7(1):51–91.
Carey LM, Matyas TA. (2005) Training of somatosensory discrimination after stroke: facilitation of stimulus generalization. American Journal of Physical Medicine and Rehabilitation,
84(6):428–42.
Carey LM, Matyas TA, Oke LE. (1993) Sensory loss in stroke patients: effective training of
tactile and proprioceptive discrimination. Archives of Physical Medicine and Rehabilitation,
74(6):602–11.
Carr JH, Shepherd RB. (1987) A Motor Relearning Programme for Stroke. 2nd edn. London:
Heinemann Physiotherapy.
Carter T. (2006) Fitness to Drive: A Guide for Health Professionals. London: Royal Society of
Medical Press Ltd.
CAST (Chinese Acute Stroke Trial) Collaborative Group. (1997) CAST: randomised placebocontrolled trial of early aspirin use in 20,000 patients with acute ischaemic stroke. Lancet,
349(9066):1641–9.
Cauraugh JH, Summers JJ. (2005) Neural plasticity and bilateral movements: a rehabilitation
approach for chronic stroke. Progress in Neurobiology, 75:309–20.
Chapparo C, Ranka J. (eds) (1997) Occupational Performance Model (Australia): Monograph 1.
Sydney: OP Network – Total Print Control.
Cicerone KD, Dahlberg C, Kalmar K, Langebahn DM, Malec JF, Berquist TF, Giacino JT, Preston
Harley J, Harrington DE, Herzog J, Kneipp S, Laatsch L, Morse PA. (2000) Evidence based
cognitive rehabilitation: recommendations for clinical practice. Archives of Physical Medicine
and Rehabilitation, 81:1596–1615.
Cicerone KD, Dahlberg C, Malec JF, Langenbahn DM, Felicetti T, Kneipp S, Ellmo W, Kalmar K,
Giacino JT, Preston Harley J, Laatsch L, Morse PA, Catanese J. (2005) Evidence based cognitive
rehabilitation: updated review of the literature from 1998 through 2002. Archives of Physical
Medicine and Rehabilitation, 86:1681–92.
Clark MA, Merians AS, Kothari A, Poizner H, Macauley B, Gonzalez Rothi LJ, Heilman KM.
(1994) Spatial deficits in limb apraxia. Brain, 117:1093–106.
P1: SFK/UKS
P2: SFK
ref
BLBK271-Edmans
April 10, 2010
14:57
Trim: 244mm×172mm
References
215
Clarke PA, Gladman JRF. (1995) A survey of pre-discharge occupational therapy home assessments
visits for stroke patients. Clinical Rehabilitation, 9:339–42.
Cohen H. (eds) (1999) Neuroscience for Rehabilitation. 2nd edn. Philadelphia, PA: Lippincott
Williams & Wilkins.
College of Occupational Therapists (2000a) Production of College Documents: Position Statements,
Standards for Practice and Clinical Guidelines. London: College of Occupational Therapists.
College of Occupational Therapists (2000b) Standards for Practice: Occupational Therapy Record
Keeping. London: College of Occupational Therapists.
College of Occupational Therapists (2005) College of Occupational Therapists Code of Ethics and
Professional Conduct. London: College of Occupational Therapists.
College of Occupational Therapists (2007) Briefing No. 26 Confidentiality and a service user’s
fitness to drive. London: College of Occupational Therapists.
College of Occupational Therapists (2008) Health Promotion in Occupational Therapy. London:
College of Occupational Therapists.
Collin C, Wade D. (1990) Assessing motor impairment after stroke: a pilot reliability study. Journal
of Neurology, Neurosurgery and Psychiatry, 53:576–9.
Collin C, Wade DT, Davis S, Home V. (1988) The Barthel ADL Index: a reliability study. International Disability Studies, 10(2):61–3.
Connell LA, Lincoln NB, Radford KA. (2008) Somatosensory impairment after stroke: frequency
of different deficits and their recovery. Clinical Rehabilitation, 22:758–67.
Cook S, Spreadbury P. (1995) Trent occupational therapy clinical audit and outcomes project, Trent
Regional Health Authority, available from College of Occupational Therapists, London.
Cooke D. (2005) Occupational Therapy – Adult Perceptual Screening Test. Brisbane: Function for
Life Pty Ltd.
Copley J, Kuipers K. (1999) Management of Upper Limb Hypertonicity. Texas: Therapy Skill
Builders; pp. 113–16.
Crammond D. (1997) Motor imagery: never in your wildest dreams. Trends Neuroscience, 2012:
54–7.
das Nair R, Lincoln N. (2007) Cognitive rehabilitation for memory deficits following stroke.
Cochrane Database of Systematic Reviews, Issue 3.
Davies P. (1985) Steps to Follow: A Guide to the Treatment of Adult Hemiplegia. Berlin: SpringerVerlag.
De Wit L. (2007) Editorial – are physiotherapy and occupational therapy in stroke rehabilitation
one and the same? Physiotherapy Research International, 12(1):3–4.
De Wit L, Putman K, Lincoln N, Baert I, Berman P, Beyens H, Bogaerts K, Brinkmann N, Connell
L, Dejaeger E, De Weerdt W, Jenni W, Lesaffre E, Leys M, Louckx F, Schuback B, Schupp
W, Smith B, Feys H. (2006) Stroke rehabilitation in Europe: what do physiotherapists and
occupational therapists actually do? Stroke, 7(6):1483–9.
Department of Health (DH) (2001) National Services Framework for Older People. London: Department of Health.
Department of Health (DH) (2002) National Service Framework for Older People. Supporting
Implementation Intermediate Care: Moving Forward. London: Department of Health.
Department of Health (DH) (2006) Supporting People with Long-Term Conditions to Self-Care: A
Guide to Developing Local Strategies and Good Practice. London: Department of Health.
Department of Health (DH) (2007) National Stroke Strategy. London: Department of Health.
Department of Health, Social Services and Public Safety (2008) Improving Stroke Services in
Northern Ireland. Belfast: Department of Health, Social Services and Public Safety.
P1: SFK/UKS
P2: SFK
ref
BLBK271-Edmans
216
April 10, 2010
14:57
Trim: 244mm×172mm
References
Department of Work and Pensions (2002) Pathways to Work: Helping People into Employment.
London: Department of Health.
Department of Work and Pensions (2007) Personal Capability Assessment. London: Department of
Health.
DeSouza LH. (1983) The effects of sensation and motivation on regaining movement control
following stroke. Physiotherapy, 69(7):238–40.
Diener HC, Bogousslavsky J, Brass LM, Cimminiello C, Csiba L, Kaste M, Leys D, MatiasGuiu J, Rupprecht HJ, for MATCH investigators (2004) Aspirin and clopidogrel compared with
clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high-risk patients
(MATCH): randomised, double-blind, placebo-controlled trial. Lancet, 364(9431):331–7.
Di Fabio RP, Badke MB. (1990) Relationship of sensory organization to balance function in patients
with hemiplegia. Physical Therapy, 70(9):542–48.
Different Strokes (2006) Getting Back to Work after Stroke. London: Different Strokes.
Dobkin BH. (1998) Driving cognitive and motor gains with rehabilitation after brain and spinal
cord injury. Current Opinion in Neurology, 11:639–41.
Donkervoort M, Dekker J, Stehmann-Saris F, Deelman B. (2001) Efficacy of strategy training in
left hemisphere stroke patients with apraxia: a randomised clinical trial. Neuropsychological
Rehabilitation, 11(5):549–66.
Donnelly SM, Hextell D, Matthey S. (1998) The Rivermead Perceptual Assessment Battery: its relationship to selected functional activities. British Journal of Occupational Therapy, 61(1):27–32.
Drummond A. (1990) Leisure activity after stroke. International Disability Studies, 12:157–60.
Drummond AE, Walker MF. (1995) A randomised controlled trial of leisure rehabilitation after
stroke. Clinical Rehabilitation, 9:283–90.
Duncan EA. (2006) Foundations for Practice in Occupational Therapy. London: Elsevier Churchill
Livingstone.
Duncan PW, Jorgensen HS, Wade DT. (2000) Outcome measures in acute stroke trials: a systematic
review and some recommendations to improve practice. Stroke, 31:1429–38.
Ebrahim S, Barer D, Nouri F. (1987) Affective illness after stroke. British Journal of Psychiatry,
151:52–6.
Ebrahim S, Noun FM, Barer D. (1985) Measuring disability after a stroke. Journal of Epidemiology
and Community Health, 39:86–9.
Edgeworth J, Robertson IH, McMillan T. (1998) Balloons Test. Oxford: Pearson Assessment.
Edmans J, Goodwin N, Foster A, O’Reilly M, Stout E. (1997) The development of a care pathway
for stroke rehabilitation. British Journal of Therapy and Rehabilitation, 4(10):559–62.
Edmans JA. (1998) An investigation of stroke patients resuming sexual activity. British Journal of
Occupational Therapy, 61(1):36–8.
Edmans JA, Champion A, Hill L, Ridley M, Skelly F, Jackson T, Neale M. (2001) Occupational
Therapy and Stroke. London: Whurr Publishers Ltd.
Edmans JA, Lincoln NB. (1987) The frequency of perceptual deficits after stroke. Clinical Rehabilitation, 1(4):273–81.
Edmans JA, Lincoln NB. (1990) The relation between perceptual deficits after stroke and independence in activities of daily living. British Journal of Occupational Therapy, 53(4):139–42.
Edmans JA, Webster J. (1997) The Edmans ADL index: validity and reliability. Disability and
Rehabilitation, 19(11):465–76.
Edwards DF, Hahn MG, Baum CM, Perlmutter MS, Sheedy C, Dromerick AW. (2006) Screening
patients with stroke for rehabilitation needs: validation of the post stroke rehabilitation guidelines.
Neurorehabilitation and Neural Repair, 20(1):42–8.
P1: SFK/UKS
P2: SFK
ref
BLBK271-Edmans
April 10, 2010
14:57
Trim: 244mm×172mm
References
217
Edwards S. (1996) Neurological physiotherapy, a problem solving approach. London: Churchill
Livingstone.
Farah M. (1995) Visual Agnosia; Disorder of Object Recognition and What They Tell Us About
Normal Vision. Cambridge, MA: MIT Press.
Fisher AG. (2006) Assessment of Motor and Process Skills. 6th edn. Fort Collins, CO: Three Star
Press.
Fitts PM, Posner MI. (1967) Learning and Skilled Performance in Human Performance. Belmont,
CA: Brock-Cole.
Fjaertoft H, Indredavik B, Johnsen R, Lydersen S. (2004) Acute stroke unit care combined with
ESD. Long-term effects on quality of life. A randomised controlled trial. Clinical Rehabilitation,
18(5):580–86.
Folstein MF, Folstein SE, McHugh PRJ. (1975) “ Mini-mental state”. A practical method for grading
the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12(3):189–
98.
Fox K. (1995) The critical period for long-term potentiation in primary sensory cortex. Neuron,
15:485–8.
Fritz SL, Light KE, Patterson TS, Behrman AL, Davis SB. (2005) Active finger extension predicts
outcomes after constraint-induced movement therapy for individuals with hemiparesis after
stroke. Stroke, 36(6):1172–7.
Gage FH. (2002) Neurogenesis in the Adult Brain. The Journal of Neuroscience, 22(3):612–3.
Garratt AM, Ruta DA, Abdulla MI, Buckingham JK, Russell IT. (1993) The SF 36 health survey
questionnaire: an outcome measure suitable for routine use within the NHS? British Medical
Journal, 306(6890):1440–44.
Geyh S, Kurt T, Brockow T, Cieza A, Ewert T, Omar Z, Resch K-L. (2004) Identifying the
concepts contained in outcome measures of clinical trials on stroke using the International
Classification of Functioning, Disability and Health as a reference. Journal of Rehabilitation
Medicine, 44(Suppl.):56–62.
Goldberg DP, Hiller VF. (1979) A scaled version of the general health questionnaire. Physiology
and Medicine, 9:139–45.
Goldenberg G, Hagmaan S. (1998) Therapy of activities of daily living in patients with apraxia.
Neuropsychological Rehabilitation, 8(2):123–41.
Golding E. (1989) The Middlesex Elderly Assessment of Mental State. London: Pearson Assessment.
Granger CV, Hamilton BB, Sherwin FS. (1986) Guide for the use of the uniform data set for medical
rehabilitation. Uniform Data System for Medical Rehabilitation Project Office, Buffalo General
Hospital, New York.
Green TL, McGregor LD, King KM. (2008) Smell and taste dysfunction following minor stroke: a
case report. Canadian Journal of Neuroscience Nursing, 30(2):10–13.
Grieve J, Gnanasekaran L. (2008) Neuropsychology for Occupational Therapists. Oxford: Blackwell
Publishing Ltd.
Hackett M, Chaturangi Y, Parag V, Anderson C. (2006) Frequency and depression after stroke: the
Auckland regional community stroke study. Stroke, 37:2123–8.
Hagedorn R. (2000) Tools for Practice in Occupational Therapy: A Structured Approach to Core
Skills and Processes. London: Churchill Livingstone.
Hagermann G, Redecker C, Neumann-Haeflin T, Freund HJ, Witte OW. (1998) Increased longterm potentiation in the surround of experimentally induced focal cortical infarction. Annals of
Neurology, 44(2):255–8.
P1: SFK/UKS
P2: SFK
ref
BLBK271-Edmans
218
April 10, 2010
14:57
Trim: 244mm×172mm
References
Halkes PH, Gray LJ, Bath PM, Diener HC, Guiraud-Chaumeil B, Yatsu FM, Algra A. (2008)
Dipyridamole plus aspirin versus aspirin alone in secondary prevention after TIA or stroke: a
meta-analysis by risk. Journal of Neurology Neurosurgery and Psychiatry, 79(11):1218–23.
Hall CD, Herdman SJ. (2006) Balance, vestibular and oculomotor dysfunction. In Selzer ME, Clarke
S, Cohen L, Duncan PW, Gage FH (eds), Textbook of Neural Repair and Rehabilitation: Medical
Neurorehabilitation, Vol. II. New York: Cambridge University Press; pp. 298–314.
Hallet M. (1995) The plastic brain. Annals of Neurology, 38(1):4–5.
Halligan P, Wade D. (2007) Effectiveness of rehabilitation for cognitive deficits. Oxford: University
Press.
Halligan PW, Marshall JC. (1991) Left neglect for near but far space in man. Nature, 350:498–500.
Hanger HC, Whitewood P, Brown G, Ball MC, Harper J, Cox R, Sainsbury R. (2000) A randomized controlled trial of strapping to prevent post-stroke shoulder pain. Clinical Rehabilitation,
14:370–380.
Hankey GJ, Eikelboom JW, van Bockxmeer FM, Lofthouse E, Staples N, Baker RI. (2001) Inherited
thrombophilia in ischemic stroke and its pathogenic subtypes. Stroke, 32(8):1793–9.
Haslam TM, Beaulieu K. (2007) A comparison of the evidence for two interventions for self-care
with stroke patients. International Journal of Therapy and Rehabilitation, 14(3):118–28.
Häusler R, Levine RA. (2000) Auditory dysfunction in stroke. Acta Otalaryngol, 120:689–703.
Haynes B, Haines A. (1998) Getting research findings into practice barriers and bridges to evidence
based clinical practice. British Medical Journal, 317:273–6.
Haynes RB, Deveraux PT, Guyatt GH. (2002) Clinical expertise in the area of evidence based
medicine and patient choice. Evidence Based Medicine, 7:36–8.
Health Professions Council (2007a) Standards of Conduct and Performance. London: Health Professions Council.
Health Professions Council (2007b) Standards of Proficiency Occupational Therapists. London:
Health Professions Council.
Heilman KM, Watson RT, Valenstein E. (1993) Neglect and related disorders. In Heilmann KM,
Valenstein E (eds), Clinical Neuropsychology. 3rd edn. New York: Oxford University Press;
pp. 279–336.
Holbrook M, Skilbeck CE. (1983) An activities index for use with stroke patients. Age and Ageing,
12:166–70.
Intercollegiate Stroke Working Party (ISWP) (2008) National Clinical Guideline for Stroke. 3rd
edn. London: Royal College of Physicians.
International Bobath Instructors Training Association (IBITA) (2008) Theoretical Assumptions and
Clinical Practice. Amstelveen: IBITA.
International Stroke Trialists (IST) (1997) A randomised trial of aspirin, subcutaneous heparin, both,
or neither among 19,435 patients with acute ischaemic stroke. The Lancet, 349(9065):1569–81.
Itzkovich M, Elazar B, Averbuch S. (1993) Loewenstein Occupational Therapy Cognitive Assessment. Pequannock, NJ: Maddok Inc.
James M, Plant GT, Warrington EK. (2001) Cortical Visual Screening Test. Oxford: Pearson
Assessment.
Jeannerod M. (1994) The representing brain: neural correlates of motor intention and imagery.
Behaviour Brain Science, 17:187–245.
Jesshope HJ, Clark MS, Smith DS. (1991) The Rivermead Perceptual Assessment Battery: its
application to stroke patients and relationship with function. Clinical Rehabilitation, 5:115–22.
Johansson BB. (2000) Brain plasticity and stroke rehabilitation. The Willis Lecture. Stroke,
31:223–30.
P1: SFK/UKS
P2: SFK
ref
BLBK271-Edmans
April 10, 2010
14:57
Trim: 244mm×172mm
References
219
Johnstone B, Stonnington HH. (2001) Rehabilitation of Neurological Disorders: A Practice Guide
for Rehabilitation Professionals. Hove, UK: Psychological Press.
Kandel ER, Schwartz JH, Jessell JM. (2000) Principles of Neural Science. 4th edn. New York:
McGraw Hill.
Karnath HO, Broetz D. (2003) Understanding and treating “pusher syndrome”. Physical Therapy,
83:1119–25.
Kastelein JJP, Akdim F, Stroes ESG, Zwinderman AH, Bots ML, Stalenhoef AFH, Visseren FLJ,
Sijbrands EJG, Trip MD, Stein EA, Gaudet D, Duivenvoorden R, Veltri EP, Marais AD, de Groot
E, for the ENHANCE Investigators (2008) Simvastatin with or without ezetimibe in familial
hypercholesterolemia. New England Journal of Medicine, 358:1431–43.
Kay T. (1986) Minor Head Injury: An Introduction for Professionals. Vienna, VA: National Head
Injury Foundation, Inc.
Kellor M, Frost J, Silberberg N, Iversen I, Cummings R. (1971) Hand strength and dexterity.
American Journal of Occupational Therapy, 25:77–83.
Kertesz A, Ferro JM. (1984) Lesion size and location in ideomotor apraxia. Brain, 107:921–33.
Kidd G, Laures N, Musa I. (1992) Understanding Neuroplasticity a Basis for Clinical Rehabilitation.
Kent: Edward Arnold.
Kielhofner G. (2008) A Model of Human Occupation: Theory and Application. 4th edn. Baltimore,
MD: Lippincott Williams & Willkins.
Kim JS, Choi-Kwon S. (1996) Discriminative sensory dysfunction after unilateral stroke. Stroke,
27:677–82.
Kinsbourne M. (1977) Hemi-neglect and hemisphere rivalry. In Weinstein EA, Friedland RP (eds),
Hemi-inattention and Hemispheric Specialisation: Advances in Neurology. New York: Raven
Press; pp. 41–9.
Kiresuk TJ, Smith A, Cardillo JE. (1994) Goal Attainment Scaling – Applications, Theory and
Measurement. Mahwah, NJ: Lawrence Erlbaum Associates Inc.
Kotulak R. (1998) Inside the brain: revolutionary discoveries of how the mind works. Preventative
Medicine, 27:246–7.
Laidler P. (1994) Stroke Rehabilitation Structure and Strategy. London: Chapman and Hall.
Langhammer B. (2001) Response in letters to the editor. Clinical Rehabilitation, 15:111–3.
Langhorne P, Coupar F, Pollock A. (2009) Motor recovery after stroke: a systematic review. The
Lancet, 8:741–54.
Langhorne P, Taylor G, Murray G, Dennis M, Andersen C, Bautz-Holter E, Dey P, Indredavik B,
Mayo N, Power M, Rodgers H, Ronning OM, Rudd A, Suwawela N, Widen-Holmgvist L, Wolfe
C. (2005) Early Supported Discharge services for stroke patients: a meta-analysis of individual
patients’ data. Lancet, 365(9458):501–6.
Lannin NA, Cusick A, McCluskey A, Herbert RD. (2007) Effects of splinting on wrist contracture
after stroke: a randomised controlled trial. Stroke, 38(1):111–6.
Lannin NA, Herbert RD. (2003) Is hand splinting effective for adults following stroke? A systematic review and methodological critique of published research. Clinical Rehabilitation, 17:807–
16.
Law M, Baptiste S, Carswell A, McColl M, Polatajko H, Pollock N. (2005) The Canadian Occupational Performance Measure. 4th edn. Toronto: Canadian Association of Occupational Therapists
Publications ACE.
Law M, Cooper B, Strong S, Stewart D, Rigby P, Letts L. (1996) The person–environment–
occupation model: a transactive approach to occupational performance. Canadian Journal of
Occupational Therapy, 63(1):9–23.
P1: SFK/UKS
P2: SFK
ref
BLBK271-Edmans
220
April 10, 2010
14:57
Trim: 244mm×172mm
References
Leal J, Luengo-Fernadez R, Gray A, Petersen S, Rayner M. (2006) Economic burden of cardiovascular disease in the enlarged European Union. European Heart Journal, 27:1610–
1619.
Legg LA, Drummond AE, Langhorne P. (2006) Occupational therapy for patients with problems
in activities of daily living after stroke. Cochrane Database of Systematic Reviews, Issue 4,
CD003585.
Legg L, Drummond A, Leonardi-Bee J, Gladman JR, Corr S, Donkervoort M, Edmans J, Gilbertson
L, Jongbloed L, Logan P, Sackley C, Walker M, Langhorne P. (2007) Occupational therapy for
patients with problems in personal activities of daily living after stroke: systematic review of
randomised trials. British Medical Journal, 335(7626):922.
Lennon S. (1996) The Bobath concept: a critical review of the theoretical assumptions that guide
physiotherapy practice in stroke rehabilitation. Physical Therapy Reviews, 81(3):35–45.
Lennon S. (2001) Gait re-education based on the Bobath concept in two patients with hemiplegia
following stroke. Physical Therapy, 81(3):924–35.
Lennon S. (2003) Physiotherapy practice in stroke rehabilitation: a survey. Disability and Rehabilitation, 25(9):455–61.
Lennon S, Baxter D, Ashburn A. (2001) Physiotherapy based on the Bobath concept in stroke
rehabilitation: a survey within the UK. Disability and Rehabilitation, 23(6):254–62.
Lim KH, Iwama MK. (2006) Emerging Models – An Asian Perspective: The Kawa River Model. In
Duncan E (ed.), Foundations for Practice in Occupational Therapy. Edinburgh: Elsevier Churchill
Livingstone; pp. 161–89.
Lincoln N, Majid M, Weyman N. (2000) Cognitive rehabilitation for attention deficits following
stroke. Cochrane Database of Systematic Reviews, Issue 4.
Lincoln NB, Edmans JA. (1989) A shortened version of the Rivermead Perceptual Assessment
Battery? Clinical Rehabilitation, 3:199–204.
Lincoln NB, Edmans JA. (1990) A re-validation of the Rivermead ADL scale for elderly patients
with stroke. Age and Ageing, 19:19–24.
Lincoln NB, Gamlen R, Thomason H. (1989) Behavioural mapping of patients on a stroke unit.
International Disability Studies, 11:149–54.
Lincoln NB, Gladman JRF, Berman P, Luther A, Challen K. (1998a) Rehabilitation needs of
community stroke patients. Disability and Rehabilitation, 20(12):457–63.
Lincoln NB, Flannaghan T. (2003) Cognitive behavioural psychotherapy for depression following
stroke: a randomized controlled trial. Stroke, 34:111–5.
Lincoln NB, Jackson JM, Adams SA. (1998b) Reliability and revision of the Nottingham sensory
assessment for stroke patients. Physiotherapy, 84(8):358–65.
Lincoln N, Leadbitter D. (1979) Assessment of motor function in stroke patients. Physiotherapy,
65:48–51.
Linn SL, Granat MH, Lees KR. (1999) Prevention of shoulder subluxation after stroke with electrical
stimulation. Stroke, 30:963–8.
Lissauer H. (1890) Ein fall vol seelenblindheit nebst einem beitrag zur theorie derselben (A case
of visual agnosia with a contribution to theory). Archiv fur Psychiatrie, 21:222–70. Translated
in Shallice T, Jackson M. (1988) Lissauer on agnosia. Cognitive Neuropsychology, 5:153–
92.
Lock S, Jordan L, Bryan K, Maxim J. (2005) Work after stroke: focusing on barriers and enablers.
Disability and Society, 20(1):33–47.
Logan P, Gladman J, Radford K. (2001) Use of transport by stroke patients. British Journal of
Occupational Therapy, 64(5):261–4.
P1: SFK/UKS
P2: SFK
ref
BLBK271-Edmans
April 10, 2010
14:57
Trim: 244mm×172mm
References
221
Logan PA, Gladman JRF, Avery AJ, Walker MF, Dyas J, Groom L. (2004) Randomised controlled
trial of an occupational therapy intervention to increase outdoor mobility after stroke. British
Medical Journal, 329:1372–5
Longstaff A. (2000) Instant Notes Neuroscience. Oxford: BIOS Scientific Publishers Ltd.
Ma H, Trombly CA. (2002) A synthesis of the effects of occupational therapy for persons with
stroke, part II: remediation of impairments. The American Journal of Occupational Therapy,
56:260–274.
Mahoney FI, Barthel DW. (1965) Functional evaluation: the Barthel index. Maryland State Medical
Journal, 14:61–5.
Malenka RG, Nicoll RA. (1999) Long term potentiation – a decade of progress. Science,
285:1870–1874.
Malia K, Brannagan A. (2005) How to Do Cognitive Rehabilitation Therapy: A Guide for All of
Us. Parts 1 & 2. Leatherhead: Braintree Training.
Mant J, Hobbs FD, Fletcher K, Roalfe A, Fitzmaurice D, Lip GY, Murray; BAFTA investigators;
Midland Research Practices Network (MidRdC) (2007) Warfarin versus aspirin for stroke prevention in an elderly community population with atrial fibrillation (the Birmingham Atrial
Fibrillation Treatment of the Aged Study, BAFTA): a randomised controlled trial. Lancet,
370(9586):493–503.
Marsden J, Greenwood R. (2005) Physiotherapy after stroke: define, divide and conquer. Journal
of Neurology Neurosurgery and Psychiatry, 76:465–6.
Marshall RS, Perera GM, Lazar RM, Krakauer JW, Constantine RC, DeLaPaz RL. (2000) Evaluation
of cortical activation during recovery from corticospinal tract infarction. Stroke, 31(3):656–61.
Martini FH. (2006) Fundamentals of Anatomy and Physiology. 7th edn. San Francisco: Benjamin
Cummings.
Mateer CA, Kerns KA. (2000) Capitalizing on Neuroplasticity. Brain and Cognition, 42:106–9.
Mayston M. (2008) Editorial: Bobath Concept: Bobath@50: mid-life crisis – What of the future?
Physiotherapy Research International, 13(3):131–6.
McCombe Waller S, Whitall J. (2008) Bilateral arm training: why and who benefits? NeuroRehabilitation, 23:29–41.
McIntosh RD, Rode G, Rossetti Y. (2002) Prism adaptation improves chronic visual and haptic
neglect: a single case study. Cortex, 38:309–20.
Mehrholz J, Platz T, Kugler J, Pohl M. (2008) Electromechanical and robot-assisted arm training
for improving arm function and activities of daily living after stroke. Cochrane Database of
Systematic Reviews, Issue 4.
Meyers JE, Meyers KR. (1995) Rey Figure Copying Test. Florida: PAR Inc.
Michel J, Mateer CA. (2006) Attention rehabilitation following stroke and traumatic brain injury:
a review. Eura Medicophys, 42(1):49–51.
Miller N. (1986) Dyspraxia and Its Management. Kent: Croom Helm Ltd.
Miller WR, Rollnick S. (2002) Motivational Interviewing: Preparing People for Change. New York:
The Guilford Press.
Mohd Nor A, McAllister C, Louw SJ, Dyker AG, Davis M, Jenkinson D, Ford GA. (2004) Agreement between ambulance paramedic- and physician-recorded neurological signs with face arm
speech test (fast) in acute stroke patients. Stroke, 35:1355–59.
Moo L, Wityk RJ. (1999) Olfactory and taste dysfunction after bilateral middle cerebral artery
stroke. Journal of Stroke and Cerebrovascular Diseases, 8(5):353–4.
Morris N. (2007) The importance of cognitive function in driving following stroke. British and Irish
Orthoptic Journal, 4:27–30.
P1: SFK/UKS
P2: SFK
ref
BLBK271-Edmans
222
April 10, 2010
14:57
Trim: 244mm×172mm
References
Mosey AC. (1996) Psychosocial Components of Occupational Therapy. Philadelphia: LippincottRaven Publishers.
Murphy D, Segal M. (1997) Morphological plasticity of dendritic spines in central neurons is
mediated by activation of camp. Response element binding protein. Proceedings of the National
Academy of Sciences of the United States of America, 94(4):1482–7.
Murray J, Young J, Forster A, Ashworth R. (2003) Developing a primary care-based stroke model:
the prevalence of longer-term problems experienced by patients and carers. British Journal of
General Practice, 53(495):803–7.
National Audit Office (2005) Reducing Brain Damage: Faster Access to Better Stroke Care. London:
National Audit Office.
National Collaborating Centre for Chronic Conditions (NCC-CC) (2008) Stroke: National Clinical
Guideline for Diagnosis and Initial Management of Acute Stroke and Transient Ischaemic Attack
(TIA). London: Royal College of Physicians.
Neistadt ME. (1990) A critical analysis of occupational therapy approaches for perceptual deficits
in adults with brain injury. The American Journal of Occupational Therapy, 44(4):299–304.
Nirkko AC, Rösler KM, Ozdoba C, Heid O, Schroth G, Hess CW. (1997) Human cortical plasticity:
functional recovery with mirror movements. Neurology, 48:1090–1093.
Nouri FM, Lincoln NB. (1987) An extended ADL scale for stroke patients. Clinical Rehabilitation,
1:301–5.
Nouri FM, Lincoln NB. (1994) Stroke Drivers Screening Assessment. Nottingham: Nottingham
Rehabilitation.
Nouri FM, Tinson DJ, Lincoln NB. (1987) Cognitive ability and driving after stroke. International
Disability Studies, 9:110–115.
Nudo RJ. (1998) Role of cortical plasticity on motor recovery after stroke. Neurology Report,
22(2):61–7.
Nudo RJ, Friel KM. (1999) Cortical plasticity after stroke: implications for rehabilitation. Revue
Neurologique (Paris), 155(9):713–17.
Office of National Statistics (2001) Stroke incidence and risk factors in a population based cohort
study. Health Statistics Quarterly, (12) Winter:18–26.
Oxford English Dictionary (1961) London: Oxford University Press.
Paci M, Nannetti L, Rinaldi L. (2005) Glenohumeral subluxation in hemiplegia: an overview.
Journal of Rehabilitation Research and Development, 42(4):557–68.
Parker C, Logan PA, Gladman JRF, Drummond AER. (1997) A shortened version of the Nottingham
Leisure Questionnaire. Clinical Rehabilitation, 11:267–68.
Parker CJ, Gladman JRF, Drummond AER, Dewey ME, Lincoln NB, Barer D, Logan PA, Radford KA. (2001) A multicentre randomized controlled trial of leisure therapy and conventional
occupational therapy after stroke. Clinical Rehabilitation, 15:42–52.
Parton A, Malhotra P, Husain M. (2004) Hemispatial neglect. Journal of Neurology Neurosurgery
and Psychiatry, 75:13–21
Pertoldi S, di Benedetto P. (2005) Shoulder-hand syndrome after stroke: a complex regional pain
syndrome. Europa Mediocophysica, 41(4):283–92.
Pomeroy V, Tallis R. (2002a) Neurological rehabilitation: a science struggling to come of age.
Physiotherapy Research International, 7(2):76–89.
Pomeroy V, Tallis R. (2002b) Restoring movement and functional ability after stroke: now and the
future. Physiotherapy, 88(1):3–17.
Pomeroy VM, King LM, Pollock A, Baily-Hallam A, Langhorne P. (2006) Electrostimulation
for promoting recovery of movement or functional ability after stroke. Cochrane Database of
Systematic Reviews, Issue 2.
P1: SFK/UKS
P2: SFK
ref
BLBK271-Edmans
April 10, 2010
14:57
Trim: 244mm×172mm
References
223
Poole Hospital NHS Foundation Trust (2005) Occupational Therapy (Adult Neurorehabilitation
Team): Inpatient Caseload Prioritisation Criteria. Poole: Poole Hospital NHS Foundation Trust.
Poole Hospital NHS Foundation Trust (2006) Occupational therapy (Adult Neurorehabilitation
Team): Acute Stroke Unit Clinical Reasoning Guidelines. Poole: Poole Hospital NHS Foundation
Trust.
Posner MI, Walker JA, Friedrick FJ, Rafal RD. (1984) Effects of parietal injury on convert orientating
of attention. The Journal of Neuroscience, 4:1863–74.
PROGRESS Collaborative Group (2001) Randomised trial of a perindopril-based blood-pressurelowering regimen among 6,105 individuals with a previous stroke or transient ischaemic attack.
Lancet, 358:1033–41.
Public Records Office (1958) Public Records Act, National Archives, Surrey.
Purves D, Augustine GJ, Fitzpatrick D, Katz LC, La Mantia AS, McNamara JO, Williams SM.
(1997) Neuroscience. Sunderland, MA: Sinauer Associates, Inc..
Quantum Development (2003) Documentation and Record Keeping How Might They Look in
Court. Lancs: Quantum Development.
Raine S. (2006) Defining the Bobath concept using the Delphi technique. Physiotherapy Research
International, 11(1):4–13.
Raine S. (2007) The current theoretical assumption of the Bobath Concept as determined by
members of BBTA. Physiotherapy Theory and Practice, 23(3):137–52.
Randolph C. (1998) Repeatable Battery for the Assessment of Neurological Status. Oxford: Pearson
Assessment.
Rees PM, Fowler CJ, Maas CP. (2007) Sexual function in men and women with neurological
disorders. Lancet, 369(9560):512–25.
Rey A. (1959) Le Teste de Copie Figure Complexe. Paris: Edisitons Centre de Psychologie
Appliquee.
Rimmer JH, Hedman G. (1998) Health promotion after stroke: psychological perspective. Topics
in Stroke Rehabilitation, 5(2):30–44.
Roberts L, Counsell R. (1998) Assessment of clinical outcomes in acute stroke trials. Stroke,
29:986–91.
Robertson IH, Ward T, Ridgeway V, Nimmo-Smith I. (1994) Test of Everyday Attention. London:
Pearson Assessment.
Robertson LC, Lamb MR. (1991) Neuropsychological contributions to theories of part/whole
organisation. Cognitive Psychology, 23:299–330.
Robinson RG, Kubos K, Starr LB, Price TR. (1983) A two year longitudinal study of post-stroke
mood disorders: findings during the initial evaluation. Stroke, 14:736–41.
Robinson RG, Starr LB, Price TR. (1984) A two year longitudinal study of mood disorders following stroke: prevalence and duration at six months follow up. British Journal of Psychiatry,
144:256–62.
Rohling ML, Faust ME, Beverly B, Demakis G. (2009) Effectiveness of cognitive rehabilitation
following acquired brain injury: a meta-analytic re-examination of Cicerone et al.’s (2000, 2005)
systematic reviews. Neuropsychology, 23(1):20–39.
Ronald P, Colarusso RP, Hammill DD. (1972) Motor Free Visual Perceptual Battery. Hydesville,
Canada: Psychological and Educational Publications.
Rood M. (1962) The use of sensory receptors to activate, facilitate and inhibit motor response, automatic and somatic. In Stately C (ed.), Developmental Sequence in Approaches to the Treatment
of Patients with Neuromuscular Dysfunction. Dubuque, IA: William C. Brown; pp. 36–27.
Rossetti Y, Rode G, Pisella L. (1998) Prism adaptation to a rightward optical deviation rehabilitates
left hemispatial neglect. Nature, 395:166–9.
P1: SFK/UKS
P2: SFK
ref
BLBK271-Edmans
224
April 10, 2010
14:57
Trim: 244mm×172mm
References
Roy EA. (1996) Hand preference, manual asymmetries and limb apraxia. In Elliot D, Roy EA (eds),
Manual Asymmetries in Motor Control. Boca Raton, FL: CRC Press; pp. 215–36.
Roy EA, Square PA. (1985) Common considerations in the study of limb, verbal and oral apraxia.
In Roy EA (ed.), Neuropsychological Studies of Apraxia and Related Disorders. Amsterdam:
North-Holland; pp. 111–61.
Royal College of Physicians and College of Occupational Therapists (2008) Occupational Therapy
Standards for Stroke: February 2008, available on-line from College of Occupational Therapists
Specialist Section Neurological Practice, London.
Royal College of Physicians. (2004) Vocational assessment and rehabilitation after acquired brain
injury: inter-agency guidelines. In Tyerman A, Meehan M (eds) Inter-Agency Advisory Group
on Vocational Rehabilitation After Brain Injury. London Royal College of Physicians.
Royal College of Physicians Profession Specific Audit Group (2007a) Occupational Therapy Clinical Audit, Version 2. London: College of Occupational Therapists Specialist Section Neurological
Practice.
Royal College of Physicians Profession Specific Audit Group (2007b) Organisational Audit –
Version 2. London: College of Occupational Therapists Specialist Section Neurological
Practice.
Rustard RA, DeGroot TL, Jungkunz ML, Freeberg KS, Borowick LG, Wanttie AM. (1993) The
Cognitive Assessment of Minnesota. London: Psychological Corporation.
Ryan E, Simons J. (1981) Cognitive demand, imagery and frequency of mental rehearsal as factors
influencing acquisition of motor skills. Journal of Sport Psychology, 3:35–45.
Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. (1996) Evidence based
medicine: what it is and what it isn’t. British Medical Journal, 312(7023):71–2.
Sackley C, Wade DT, Mant D, Atkinson JC, Yudkin P, Cardoso K, Levin S, Blanchard Lee V, Reel
K. (2006) Cluster randomized pilot controlled trial of an occupational therapy intervention for
residents with stroke in UK care homes. Stroke, 37(9):2336–41.
Salter KS, Jutai J, Zettler L, Moses M, Foley N, Teasell R. (2008) Evidence Based Stroke Rehabilitation: Outcome Measures in Stroke Rehabilitation. Evidence-Based Review of Stroke
Rehabilitation. London, ON, Canada: Parkwood Hospital.
Sandercock PA, Counsell C, Gubitz GJ, Tseng MC. (2008) Antiplatelet therapy for acute ischaemic
stroke. Cochrane Database of Systematic Reviews, Issue 3.
Sandercock PA, Warlow CP, Jones LN, Starkey IR. (1989) Predisposing factors for cerebral infarction: the Oxfordshire community stroke project. British Medical Journal, 298(6666):75–
80.
Schultz-Krohn W, Royeen CB, McCormack G, Pope-Davis SA, Jourdan JM. (2006) Chapter 30:
Traditional sensorimotor approaches to intervention. In McHugh Pendleton H, Schultz-Krohn
W (eds), Pedretti’s Occupational Therapy for Physical Dysfunction. 6th edn. St. Louis: Mosby
Elsevier; pp. 726–68.
Scottish Government (2002) Coronary Heart Disease and Stroke: Strategy for Scotland. Edinburgh:
Scottish Government.
Scottish Government (2004) Coronary Heart Disease and Stroke Strategy for Scotland: Update
2004. Edinburgh: Scottish Government.
Scottish Government (2009) Better Heart Disease and Stroke Care Action Plan. Edinburgh: Scottish
Government.
Scottish Intercollegiate Guidelines Network (2002) Management of Patients with Stroke: Rehabilitation, Prevention and Management of Complications, and Discharge Planning. Edinburgh:
Scottish Intercollegiate Guidelines Network.
P1: SFK/UKS
P2: SFK
ref
BLBK271-Edmans
April 10, 2010
14:57
Trim: 244mm×172mm
References
225
Scottish Intercollegiate Guidelines Network (2008) Management of Patient with Stroke or TIA: Assessment, Investigation, Immediate Management and Secondary Prevention. Edinburgh: Scottish
Intercollegiate Guidelines Network.
Shabrun SM, Hillier S. (2009) Evidence for the retraining of sensation after stroke: a systematic
review. Clinical Rehabilitation, 23(1):27–39.
Sinyor D, Amato P, Kaloupek DG, Becker R, Goldenberg M, Coopersmith H. (1986) Post-stroke
depression: relationships to functional impairment, copying strategies and rehabilitation outcome.
Stroke, 17(6):1102–7.
Smania N, Picelli A, Gandelfi M, Fiaschi A, Tinazzi M. (2008) Rehabilitation of sensorimotor
integration deficits in balance impairment of patients with stroke hemiparesis: a before/after pilot
study. Neurological Science, 29:313–9.
Smilde TJ, van Wissen S, Wollersheim H, Trip MD, Kastelein JJP, Stalenhoef AF. (2001) Effect of
aggressive versus conventional lipid lowering on atherosclerosis progression in familial hypercholesterolemia (ASAP): a prospective, randomized, double-blind trial. Lancet, 357:577–81.
Snaith RP, Ahmed SN, Mehta S, Hamilton M. (1971) Assessments of the severity of primary
depressive illness. Psychological Medicine, 1:143–9.
Sohlberg MM, Mateer CA. (1989) Introduction to Cognitive Rehabilitation: Theory and Practice.
New York: Guilford Press.
Stephenson R. (1996) Therapeutic consistency following brain lesions. Neuroscience Nursing,
11(11):738–40.
Steultjens EMJ, Dekker J, Bouter LM, van de Nes JCM, Cup EHC, Van Den Ende CHM. (2003)
Occupational therapy for stroke patients: a systematic review. Stroke, 34:676–87.
Stewart KC, Cauraugh JH, Summers JJ. (2006) Bilateral movement training and stroke rehabilitation: a systematic review and meta-analysis. Journal of the Neurological Sciences,
244(1–2):89–95.
Stolk-Hornsveld F, Crow JL, Hendriks EP, Van Der Baan R, Harmeling-van der Wel BC. (2006)
The Erasmus MC modifications to the (revised) Nottingham Sensory Assessment: a reliable somatosensory assessment measure for patients with intracranial disorders. Clinical Rehabilitation,
20:160–172.
Sumsion T. (2000) A revised occupational therapy definition of client-centered practice. British
Journal of Occupational Therapy, 63:304–9.
Tate R, McDonald S. (1995) What is apraxia? The clinician’s dilemma. Neuropsychological Rehabilitation, 5:273–97.
Taub E. (1980) Somatosensory deafferentation research with monkeys: implications for rehabilitation medicine. In Ince L (ed.), Behavioural Psychology in Rehabilitation Medicine: Clinical
Applications. Baltimore, MD: Lippincott Williams & Wilkins; pp. 347–54.
Taub E, Cargo JE, Uswatte G. (1998) Constraint-induced movement therapy: a new approach to
treatment in physical rehabilitation. Rehabilitation Psychology, 43:152–70.
Taub E, Uswatte G, King DK, Morris D, Crago JE, Chatterjee A. (2006) A placebo-controlled trial
of constraint-induced movement therapy for upper extremity after stroke. Stroke, 37(4):1045–9.
Tempest S, Roden P. (2008) Exploring evidence-based practice by occupational therapists when
working with people with apraxia. British Journal of Occupational Therapy, 71(1):33–7.
Tepperman PS, Greyson ND, Hilbert L, Jiminez J, Williams JI. (1984) Reflex sympathetic dystrophy
in hemiplegia. Archives of Physical Medicine and Rehabilitation, 65:442–7.
Testani-Dufour L, Morrison CA. (1997) Brain attack: correlative anatomy. Journal of Neuroscience
Nursing, 29(4):213–22.
Tham K, Tegner R. (1996) Baking tray test. Neuropsychological Rehabilitation 6(1):19–26.
P1: SFK/UKS
P2: SFK
ref
BLBK271-Edmans
226
April 10, 2010
14:57
Trim: 244mm×172mm
References
Torp CR, Vinkler S, Pedersen KD, Hanson FR, Jorgensen T, Olsen J. (2006) Model of hospitalsupported discharge after stroke. Stroke, 37:1514–20.
Townsend EA, Polatajko HJ. (2007) Enabling Occupation II: Advancing and Occupational Therapy
Vision for Health, Well-Being & Justice Through Occupation. Ottawa, ON: Canadian Association
of Occupational Therapists.
Trombly CA, Ma HI. (2002) A synthesis of the effects of occupational therapy for persons with
stroke, Part I: restoration of roles, tasks, and activities. American Journal of Occupational Therapy, 56(3):250–259.
Turkstra LS, Holland AL, Bays G. (2003) The neuroscience of recovery and rehabilitation: what have
we learned from animal research? Archives of Physical Medicine and Rehabilitation, 84:604–
12.
Turner A, Foster M, Johnson S. (1996) Occupational Therapy and Physical Dysfunction. 4th edn.
London: Churchill Livingstone.
Turner-Stokes L. (2003) Goal attainment scaling (GAS) in rehabilitation: a practical guide. Lancet,
361:1757–8.
Turner-Stokes L, Jackson D. (2002) Shoulder pain after stroke: a review of the evidence base to
inform the development of an integrated care pathway. Clinical Rehabilitation, 16:276–98.
Tyerman A, Meehan M. (2004) Vocational Assessment and Rehabilitation after Acquired Brain Injury: inter-agency Guidelines. London: British Society of Rehabilitation Medicine/Royal College
of Physicians.
Tyerman R, Tyerman A, Howard Pl, Hadfield C. (1986) Chessington Occupational Therapy Neurological Assessment Battery. Leicestershire: Nottingham Rehabilitation Supplies.
Van Der Putten JMF, Hobart JC, Freeman JA, Thompson AJ. (1999) Measuring change in disability
after inpatient rehabilitation: comparison of the responsiveness of the Barthel Index and the functional independence measure. Journal of Neurology Neurosurgery and Psychiatry, 66:480–484.
Van Heugten CM, Dekker J, Deelman BG, Stehmann-Saris JC, Kinnebanian A. (1999) A diagnostic
test for apraxia in stroke patients: internal consistency and diagnostic values. The Clinical
Neuropsychologist, 13(2):182–92.
Van Heugten CM, Dekker J, Deelman BG, van Djik AJ, Stehmann-Saris JC, Kinnebanian A.
(1998) Outcome of strategy training in stroke patients with apraxia: a phase II study. Clinical
Rehabilitation, 12(4):294–303.
Van Heugten CM, Dekker J, Deelman BG, van Dijka J, Stehmann-Saris JC, Kinebanian A. (2000)
Measuring disabilities in stroke patients with apraxia: a validation study of an observational
method. Neuropsychological Rehabilitation, 10:401–14.
Van Vliet PM, Lincoln NB, Foxall A. (2005) Comparison of Bobath based and movement science
based treatment for stroke: a randomised controlled trial. Journal of Neurology Neurosurgery &
Psychiatry, 76:503–8.
Van Vliet PM, Lincoln NB, Robinson E. (2001) Comparison of content of two physiotherapy
approaches for stroke. Clinical Rehabilitation, 15:398–414.
Vaughan B, Lathlean J. (1999) Intermediate Care Models in Practice. London: King’s Fund.
Wade DT. (1992) Measurement in Neurological Rehabilitation. Oxford: Oxford University Press.
Wade DT. (1988) Stroke, Practical Guideline for General Practice. Oxford: Oxford Medical Publications.
Wade DT, Legh-Smith J, Hewer RL. (1985) Social activities after stroke. International Rehabilitation
Medicine, 7(4):176–81.
Walker MF, Drummond AER, Gatt J, Sackley CM. (2000) Occupational therapy for stroke patients:
a survey of current practice. British Journal of Occupational Therapy, 63(8):367–72.
P1: SFK/UKS
P2: SFK
ref
BLBK271-Edmans
April 10, 2010
14:57
Trim: 244mm×172mm
References
227
Walker MF, Leonardi-Bee J, Bath P, Langhorne P, Dewey M, Corr S, Drummond A, Gilbertson
L, Gladman JR, Jongbloed L, Logan P, Parker C. (2004) Individual patient data meta-analysis
of randomized controlled trials of community occupational therapy for stroke patients. Stroke,
35:2226–32.
Walsh K. (2001) Management of shoulder pain in patients with stroke Postgraduate Medical Journal
77:645–9.
Warlow C, van Gijn J, Dennis M, Wardlaw J, Bamford J, Hankey G, Sandercock PAG, Rinkel G,
Langhorne P, Sudlow C, Rothwell P. (2008) Stroke: Practical Management. 3rd edn. Oxford:
Blackwell Publishing.
Warren M. (1993) A hierarchical model for the evaluation and treatment of visual perceptional
dysfunction in acquired brain injury, Parts 1 & 2. American Journal of Occupational Therapy,
47(1):55–66.
Warrington E, James M. (1991) Visual Object and Space Perception Battery. Bury St Edmunds:
Thames Valley Test Company.
Welsh Assembly Government (2007) Improving Stroke Services: A Programme of Work.
West C, Bowen A, Hesketh A, Vail A. (2008) Interventions for motor apraxia following stroke.
Cochrane Database of Systematic Reviews, Issue 1.
Westover AN, McBride S, Haley RW. (2007) Stroke in young adults who abuse amphetamines
or cocaine: a population-based study of hospitalized patients. Archives of General Psychiatry,
64(4):495–502.
Whiting S, Lincoln NB, Bhavnani G, Cockburn J. (1985) Rivermead Perceptual Assessment Battery.
Windsor: NFER-Nelson.
Whiting SE, Lincoln NB. (1980) An ADL assessment for stroke patients. British Journal of Occupational Therapy, 43(2):44–6.
Wilkinson PR, Wolfe CDA, Warburton FG, Rudd AG, Howard RS, Ross-Russell R, Beech RR.
(1997) A long-term follow-up of stroke patients. Stroke, 28:507–12.
Wilson BA. (1998) Remediation of apraxia following an anaesthetic accident. In West J, Spinks P
(eds), Case studies in Clinical Psychology. Bristol: John Wright.
Wilson BA, Alderman N, Burgess PW, Emslie H, Evans JJ. (1996) BADS – Behavioural Assessment
of Dysexecutive Syndrome. London: Pearson Assessment.
Wilson BA, Baddeley AD, Evans E, Shiel A. (1994) Errorless learning in the rehabilitation of
memory impaired people. Neuropsychological Rehabilitation, 4:307–26.
Wilson BA, Cockburn J, Halligan PW. (1987) Behavioural Inattention Test. Oxford: Pearson Assessment.
Wilson BA, Greenfield E, Clare L, Baddeley A, Cockburn J, Watson P, Tate R, Sopena S, Nannery R, Crawford JR. (2008) Rivermead Behavioural Memory Test. 3rd edn. London: Pearson
Assessment.
Winward CE, Halligan PW, Wade DT. (2002) The Rivermead Assessment of Somatosensory Performance (RASP): standardization and reliability data. Clinical Rehabilitation, 16:
523–33.
Winward CE, Halligan PW, Wade DT. (2007) Somatosensory recovery: a longitudinal study of the
first 6 months after unilateral stroke. Disability and Rehabilitation, 29(4):293–9.
Wolf SL, Winstein CJ, Miller JP, Taub E, Uswatte G, Morris D, Giuliani C, Light KE, NicholsLason D, for the EXCITE Investigators (2006) Effect of constraint-induced movement therapy
on upper extremity function 3 to 9 months after stroke: the EXCITE randomized clinical trial.
JAMA, 296(17):2095–104.
Wolfe CDA. (2000) The impact of stroke. British Medical Bulletin, 56(2):275–86.
P1: SFK/UKS
P2: SFK
ref
BLBK271-Edmans
228
April 10, 2010
14:57
Trim: 244mm×172mm
References
Woodford HJ, Price CIM. (2007) EMG biofeedback for the recovery of motor function after stroke.
Cochrane Database of Systematic Reviews, Issue 2.
World Health Organization (WHO) (1978) Cerebrovascular Disorders: A Clinical and Research
Classification. Geneva: World Health Organization. Offset Publication.
World Health Organization (WHO) (2001) International Classification of Functioning, Disability
and Health: ICF Short Version. Geneva: World Health Organization, p. 26.
World Health Organization (WHO) (2002) Towards a Common Language for Functioning, Disability and Health: ICF. Geneva: World Health Organization.
Wozniak M, Kittner S. (2002) Return to work after ischemic stroke: a methodological review.
Neuroepidemiology, 21:159–66.
Yekutiel M, Guttman E. (1993) A controlled trial of the retraining of the sensory function of the
hand in stroke patients. Journal of Neurology, Neurosurgery and Psychiatry, 56:241–4.
Yesavage JA, Brink TL, Rose TL, Lum O, Huang V, Adey MB, Leirer VO. (1983) Development and
validation of a geriatric depression screening scale: a preliminary report. Journal of Psychiatric
Research, 17:37–49.
Ylvisaker M, Szekeres SF. (1989) Metacognitive and executive impairments in head injured children
and adults. Topics in Language Disorders, 9(2):34–49.
Young J, Murray J, Forster A. (2003) A review of longer term problems after disabling stroke.
Reviews in Clinical Gerontology, 13:55–65.
Zigmond AS, Snaith RP. (1983) The hospital anxiety and depression scale. Acta Psychiatrica
Scandanavica, 67:361–70.
Zimmermann-Schlatter A, Schuster C, Puhan MA, Siekierka E, Steurer J. (2008) Efficacy of motor
imagery in post-stroke rehabilitation: a systematic review. Journal of NeuroEngineering and
Rehabilitation, 5:8.
Zoltan B. (2007) Vision, Perception and Cognition: A Manual for the Evaluation and Treatment of
the Adult with Acquired Brain Injury. 4th edn. Thorofare, New Jersey: Slack Incorporated.
Zorowitz RD, Hughes MB, Idank D, Ikai T, Johnston MV. (1996) Shoulder pain and subluxation
after stroke: correlation or coincidence? American Journal of Occupational Therapy, 50:194–201.
Zwinkels A, Geusgens C, Van de Sande P, Van Heugten C. (2004) Assessment of apraxia: inter-rater
reliability of a new apraxia test, association between apraxia and cognitive deficits and prevalence
of apraxia in a rehabilitation setting. Clinical Rehabilitation, 218:819–27.
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Definitions
Agnosia: Inability to recognise familiar objects perceived by the senses.
Aphasia: Difficulty understanding language and/or expressing self – as a result of a brain
injury.
Apraxia: Inability to perform certain skilled purposeful movements despite having intact
the relevant motor, sensory and coordination functions.
Ataxia: Loss of coordination and smooth interplay between muscles in the cerebellum
due to damage leading to uncontrolled jerky movement.
Cognition: The ability to use and integrate basic capacities such as perception, language,
memory and thought.
Contracture: Shortening of soft tissues within the joint due to abnormal tonal changes
and prolonged positioning in a fixed posture.
Dysarthria: Weakness or incoordination of the speech muscles, which prevents clear
pronunciation of words.
Dysphagia: Difficulty swallowing.
Dystonia: Asymmetry of involuntary contracting muscles, resulting in unusual contortions of the body.
Flaccidity: Absence of normal tension (tone) in the muscles.
Hemianopia: Damage to the part of the brain which interprets visual information, resulting in blindness of part of the visual field, although the patient’s eyes and optic tracts
are undamaged.
Hemiplegia: Paralysis affecting one side of the body.
Heterotrophic ossification: Appearance of bone in soft tissues – often occurring in
large joints, i.e. elbow, knee, ankle, in patients with severe brain injury and prolonged
unconsciousness.
Liability: Decreased ability to moderate the expression of emotion, e.g. person might
burst into tears without feeling sad, or may laugh inappropriately in an upsetting
situation.
Perception: The process by which we organise and interpret patterns of stimuli (e.g.
visual, auditory, tactile) in the environment.
Perseveration: Continued repetition of movement, word or idea.
Proprioception: The ability to judge movements in the joints of the body.
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Spasticity: More than normal muscle tension (tone).
Stereognosis: The ability to identify objects by touch.
Unilateral Neglect (inattention): Inability to integrate and use perceptions from the left
side of the body or the left side of the environment.
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Useful Books
Ada L, Canning C. (1990) Key Issues in Neurological Physiotherapy. London: Heinemann Medical.
Bear M, Connors B, Paradiso M. (2007) Neuroscience Exploring the Brain. 3rd edn. London:
Lippincott Williams & Wilkins.
Bobath B. (1978) Adult Hemiplegia: Evaluation and Treatment. London: Heinemann Medical
Books Ltd.
Bobath B. (1986) Abnormal Postural Reflex Activity Caused by Brain Lesions. London: Heinemann
Medical Books Ltd.
Boehme R. (1995) Improving Upper Body Control. San Antonio: The Psychological Corporation.
Carr J. (2002) Stroke Rehabilitation: Guidelines for Exercise and Training to Optimize Motor Skill.
3rd edn. Oxford: Butterworth-Heinemann.
Carr J, Shepherd R. (1987) A Motor Relearning Programme for Stroke. Oxford: Heinemann
Physiotherapy.
Cohen L. (1999) Neuroscience for Rehabilitation. Philadelphia: Lippincott, Williams & Wilkins.
Crombie I. (1998) Pocket Guide to Critical Appraisal. London: BMJ Publishing Group.
Davies PM. (1985) Steps to Follow. Berlin: Springer-Verlag.
Davies PM. (1990) Right in the Middle. Berlin: Springer-Verlag.
Davies PM. (1994) Starting Again. Berlin: Springer-Verlag.
Demyer W. (1988) Neuroanatomy. New York: Wiley Medical Publications.
Duncan EA. (2006) Foundations for Practice in Occupational Therapy. London: Elsvier Churchill
Livingstone.
Ebrahim S, Harwood R. (1999) Epidemiology, Evidence and Clinical Practice. 2nd edn. Oxford:
Oxford University Press.
Edwards S. (1996) Neurological Physiotherapy. Edinburgh: Churchill Livingstone.
Greenhalgh T. (1997) How to Read a Paper. London: BMJ Publishing Group.
Grieve J, Gnanasekaran L. (2008) Neuropsychology for Occupational Therapists. Oxford: Blackwell
Publishing Ltd.
Hagedorn R. (1995) Occupational Therapy: Perspectives and Processes. Edinburgh: Churchill
Livingstone.
Halligan P, Wade D. (2007) Effectiveness of Rehabilitation for Cognitive Deficits. Oxford: Oxford
University Press.
Humphreys GW, Riddoch J. (1987) To See But Not to See. A Case Study of Visual Agnosia.
London: Lawrence Erlbaum Associates.
Laidler P. (1994) Stroke Rehabilitation – Structure and Strategy. London: Chapman and Hall.
Langhorne P, Dennis M. (1998) Stroke Units: An Evidence Based Approach. London: BMJ Books.
Occupational Therapy and Stroke, Second Edition Edited by Judi Edmans
© 2010 Blackwell Publishing Ltd. ISBN: 978-1-405-19266-8
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Lezak MD. (1995) Neuropsychological Assessment. New York: Oxford University Press.
Miller E. (1985) Recovery and Management of Neuropsychological Impairments. Chichester: John
Wiley and Sons Ltd.
Miller N. (1986) Dyspraxia and Its Management. Beckenham: Croom Helm.
Ryerson S, Levit K. (1997) Functional Movement Re-education. Edinburgh: Churchill Livingstone.
Sacks O. (1985) The Man Who Mistook His Wife for a Hat. London: Picador.
Scheimann M. (2002) Understanding and Managing Vision Deficits – A guide for Occupational
Therapists. 2nd edn. Thorofare, New Jersey: Slack Incorporated.
Sohlberg M, Mateer C. (1989) Introduction in Cognitive Rehabilitation Theory and Practice. New
York: The Guildford Press.
Springer S, Deutsch G. (1993) Left Brain, Right Brain. Oxford: W.H. Freeman and Company.
Steiner D, Norman G. (1995) Health Measurement Scales. Oxford: Oxford University Press.
Wade DT. (1988) Stroke, Practical Guideline for General Practice. Oxford: Oxford Medical
Publications.
Wade DT. (1992) Measurement in Neurological Rehabilitation. Oxford: Oxford Medical
Publications.
Warlow C, van Gijn J, Dennis M, et al. (2008) Stroke: Practical Management. 3rd edn. Oxford:
Blackwell Publishing.
Zoltan B. (2007) Vision, Perception and Cognition: A Manual for the Evaluation and Treatment of
the Adult with Acquired Brain Injury. 4th edn. Thorofare, New Jersey: Slack Incorporated.
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Useful Organisations
We have included a list of useful organisations but cannot guarantee that their addresses
or websites will not change over time.
Occupational therapy
College of Occupational Therapists
106-114 Borough High Street
Southwark
London
SE1 1LB
England
www.cot.co.uk
Specialist Section Neurological Practice
106-114 Borough High Street
Southwark
London
SE1 1LB
England
www.cot.co.uk/Homepage/Specialist Sections/COTSS - Neurological Practice
Stroke
The Stroke Association
Stroke House
240 City Road
London
EC1V 2PR
England
www.stroke.org.uk
Occupational Therapy and Stroke, Second Edition Edited by Judi Edmans
© 2010 Blackwell Publishing Ltd. ISBN: 978-1-405-19266-8
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Occupational Therapy and Stroke
Chest, Heart and Stroke Scotland
65 North Castle Street
Edinburgh
EH2 3LT
Scotland
www.chss.org.uk
Northern Ireland Chest, Heart and Stroke Association
21 Dublin Road
Belfast
BT2 7HB
Northern Ireland
www.nichsa.com
Different Strokes
Central Services
9 Canon Harnett Court
Wolverton Mill
Milton Keynes
MK12 5NF
England
www.differentstrokes.co.uk
Age Concern
www.ageconcern.org.uk
Help the Aged
www.helptheaged.org.uk
Policies
World Health Organization
www.who.int
Department of Health
www.dh.gov.uk
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Royal College of Physicians
11 St Andrews Place
Regents Park
London
NW1 4LE
England
www.rcplondon.ac.uk
Scottish Intercollegiate Guidelines Network
www.sign.ac.uk
Scottish Government
www.scotland.gov.uk
Scottish Health on the Web (SHOW)
www.show.scot.nhs.uk
Welsh Assembly Government
www.wales.gov.uk
Stroke Services Improvement Plan – Wales
http://new.wales.gov.uk/topics/health/publications/health/circulars/2007/whc2007082?
lang=en
Department of Health, Social Services and Public Safety, Northern Ireland
www.dhsspsni.gov.uk/
European Stroke Organisation (ESO)
www.eso-stroke.org
Skills for Health
2nd Floor
Goldsmiths House
Broad Plain
Bristol
BS2 0JP
England
www.skillsforhealth.org.uk
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Stroke Competencies
www.nes.scot.nhs.uk
Stroke Training and Awareness Resources (STARS)
www.strokecorecompetencies.org
Evidence-Based Practice
Bandolier – www.medicine.ox.ac.uk/bandolier
Clinical evidence – http://clinicalevidence.bmj.com/ceweb/index.jsp
Health technology assessment – www.ncchta.org
Cochrane library – www.thecochranelibrary.org
Critical appraisal skills programme – www.phru.nhs.uk/Pages/PHD/CASP.htm
Effective health care bulletins – www.york.ac.uk/inst/crd/ehcb.htm
Physiotherapy evidence database (PEDro) – www.pedro.fhs.usyd.edu.au
OTseeker – www.otseeker.com/search.aspx
iCAM (Integrating Complementary and Alternative Medicine)
School of Integrated Health
University of Westminster
115 New Cavendish Street
London
W1W 6UW
England
www.wmin.ac.uk
Centre for Evidence Based Medicine
Department of Primary Care
Old Road Campus
Headington
Oxford
OX3 7LF
England
www.cebm.net
Public Health Resource Unit (PHRU)
4150 Chancellor Court
Oxford Business Park South
Oxford
OX4 2GX
England
www.phru.nhs.uk
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Assessments
Pearson Assessment (incorporating The Psychological Corporation and
Thames Valley Test Company)
Pearson Assessment
Halley Court
Jordan Hill
Oxford
OX2 8EJ
England
www.pearson-uk.com
GL Assessment (formerly NFER-Nelson)
The Chiswick Centre
414 Chiswick High Road
London
W4 5TF
England
www.gl-assessment.co.uk
NFER
The Mere
Upton Park
Slough
Berks
SL1 2DQ
England
www.nfer.ac.uk
Leisure
Gardening
Thrive
The Geoffrey Udall Centre
Beech Hill
Reading
RG7 2AT
England
www.thrive.org.uk
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Sport
Sportability
Laynes House
526-528 Watford Way
London
NW7 4RS
England
www.sportability.org.uk
Disability Sport Events
Belle Vue Centre
Pink Bank Lane
Manchester
M12 5GL
England
www.disabilitysport.org.uk
Golf
Society of One-Armed Golfers (SOAG)
www.onearmgolf.org
Fishing
British Disabled Angling Association (BDAA)
9 Yew Tree Road
Delves
Walsall
West Midlands
WS5 4NQ
England
www.bdaa.co.uk
Art
Conquest Art Centre
Cox Lane Day Centre
Cox Lane
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239
West Ewell
Surrey
KT19 9PL
England
www.conquestart.org
Ableize
Virtual library for disability directory of disabled information aids and mobility services
www.ableize.com
Travel and holidays
Accessible Travel and Leisure
Avionics House
Naas Lane
Quedgeley
Gloucester
GL2 2SN
England
www.accessibletravel.co.uk
Access Travel (Lancs) Ltd.
6 The Hillock
Astley
Lancashire
M29 7GW
England
www.access-travel.co.uk
Tourism for All UK
c/o Vitalise
Shap Road Industrial Estate
Shap Road
Kendal
Cumbria
LA9 6NZ
England
www.tourismforall.org.uk
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Index
Activities of daily living (instrumental),
105–8
Household duties, 105–8
Kitchen tasks, 105
Activities of daily living (self-care),
100–5
Dressing, 100–5
Washing, 100–1
Anxiety, 83
Apraxia, 152–5
Assessment, 87–90
Activities of daily living, 90
Bed mobility, 87–8
Sitting, 88
Standardised assessments, 90
Standing, 89
Transfers, 88–9
Walking, 89
Ataxia, 110–1
Attention, 147–48
Auditory processing, 137–39
Assessment, 138
Clinical challenges, 139
Functional anatomy, 137
Functional observations,
138
Intervention, 138–39
Review and evaluation,
139
Screening, 138
Carers, 178–79
Causes of stroke, 3
Haemorrhage, 3
Ischaemia, 3
Transient ischaemic attack, 3
Classification of stroke, 4
Lacunar infarction, 4
Partial anterior circulation stroke, 4
Posterior circulation infarction, 4
Total anterior circulation stroke, 4
Clinical challenges, 109
Cognition definition, 144
Cognitive assessment, 144–7
Cognitive functions, 144
Cognitive rehabilitation, 145–6
Approaches, 145
Intervention, 145
Strategies, 145–6
Communication, 77–80
Community rehabilitation, 174–7
Aphasia, 77–8
Dysarthria, 78
Verbal apraxia, 78–9
Damage that can occur in different areas
of the brain, 13–19
Definition of stroke, 1
Definitions, 229–2
Depression, 82–3
Differential diagnoses, 197–198
Driving after stroke, 185–6
Emotionalism, 83
Equipment, 75–7
Bathing/showering, 76
Eating, 77
Meal preparation, 76
Toileting, 76
Wheelchairs, 75
Occupational Therapy and Stroke, Second Edition Edited by Judi Edmans
© 2010 Blackwell Publishing Ltd. ISBN: 978-1-405-19266-8
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Index
Evidence-based practice (EBP),
199–3
Appraising the identified evidence,
202–3
Evaluating outcomes, 203
Formulating a question, 200
Implementing findings into clinical
practice, 203
Levels of evidence, 201–2
Searching for the best evidence, 201
Stages of evidence-based practice, 200
Executive dysfunction, 155–7
Face-arm-speech test, 2
Fatigue, 83–4
Follow-up, 53
Frames of reference, 27–9
Behavioural frame of reference, 28
Biomechanical frame of reference, 27
Client-centred frame of reference, 27
Cognitive frame of reference, 28
Cognitive perceptual frame of
reference, 29
Motor control frame of reference, 27
Psychodynamic frame of reference,
28–9
Rehabilitative frame of reference, 27
Getting out of the house, 183–5
Home visits, 173–4
Early supported discharge, 176
Hospital at home/community
rehabilitation team, 175
Intermediate care, 174–5
Rapid response, 175
Residential rehabilitation, 175–6
Role of the occupational therapist,
176–7
Impact of stroke, 1
Initial assessment, 67–74
Cognitive and perceptual screening,
67–71
Functional assessment, 74
Functional screening, 74
Motor screening, 72–3
Neurophysical screening, 72
Psychosocial screening, 71
International classification of functioning,
disability and health, 4–5
Intervention, 75
Intervention approaches, 36–46
Adaptive (compensatory/functional)
approach, 37
Bilateral arm training/isokinematic
training approach, 45
Cognitive rehabilitation approach,
37–8
Constraint-induced movement therapy
(CIMT) approach, 44–5
Electromyographic (bio) feedback, 46
Functional electrical stimulation, 46
Mental imagery approach, 45–6
Movement science, 43–4
Normal movement (Bobath-based
approach), 38–41
Proprioceptive neuromuscular
facilitation (PNF), 41–2
Restorative approach (remedial
approach), 36–7
Robotics, 46
Rood approach, 42–3
Lability, 83
Language, 151
Leisure rehabilitation, 181–3
Lifestyle and long-term management,
180–1
Management principles and intervention,
90
Medical investigations following stroke,
6–7
Blood tests, 6
Cardiac investigations, 7
Carotid ultrasound, 7
Computerised tomography, 6
Magnetic resonance angiography, 7
Magnetic resonance imaging, 6
Memory, 149–1
Methods of recording occupational
therapy intervention, 193–5
Goal-directed notes, 193–4
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Index
Integrated care pathways, 194–5
Joint documentation, 195
Problem-orientated medical records
(POMR), 193
Models of practice, 25–7
Activities Therapy, 26
The Australian Occupational
Performance Model (OPM(A)), 26
The Canadian Model of Occupational
Performance and Engagement
(CMOP-E), 25–6
The Kawa (River) Model, 26–7
The Model of Human Occupation
(MOHO), 25
Mood, 81–2
Motor planning and apraxia, 151–2
Neuroanatomy, 9–13
Neurone structure, 29–30
Neuroplasticity, 29
Normal perception, 158–62
Occupational therapy process, 47–52
Assessment, 47
Evaluation, 52
Goal setting, 47–9
Interventions, 51–2
Oedema, 113–4
Olfactory and gustatory processing,
141–3
Assessment, 141
Functional anatomy, 141
Intervention, 141
Review and evaluation, 142
One-handed techniques, 108, 208–11
Outcome measures, 203–6
Perception definition, 158
Perceptual assessment, 162–5
Perceptual impairments, 160–2
Agnosia, 161–2
Body scheme, 161
Visual discrimination, 161
Perceptual intervention strategies, 167–72
Body scheme, 167–68
Constraint-induced movement therapy,
71
243
Eye patching, 169
Impaired midline awareness, 168
Prism glasses, 169–70
Tactile agnosia (stereognosis), 171–2
Unilateral neglect, 168–69
Visual agnosia, 170–1
Visual discrimination, 170
Perceptual intervention theories, 165–7
Attention-arousal theory, 166
Disengagement theory, 167
Hemisphere specialisation theory, 166
Intentional mechanism theory, 166
Interhemisphere theory, 167
Policy documents relating to stroke,
13–23
Guidelines, 22–3
National services framework for older
people, 13–14
Stroke strategies, 19–22
Positioning the early stroke patient, 91–7
In a chair, 93–6
In bed, 92–3
Perch sitting, 96–7
Prior to assessment, 64
Basic checklist, 65–6
Information gathering, 64
Initial interview, 66–7
Procedural reasoning, 53–9
Acute stroke units (ASU) (hyperacute
care), 55–7
Community rehabilitation and
resettlement, 59
Early supported discharge (ESD), 58
Health promotion, 59
Neurovascular clinics, 53–5
Subacute/inpatient rehabilitation units,
57–8
Professional duties, 60–63
Code of conduct, 60
Health Professions Council (HPC)
competencies, 60–61
NHS knowledge and skills framework
(NHS KSF), 61–2
Skills for health, 62
Stroke-specific education framework
(SSEF), 62–3
Pusher syndrome/overuse, 109–10
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Index
Record keeping, 191–3
References, 212–28
Resuming sexual activity, 188–89
Secondary prevention, 7–9
Anticoagulants, 8
Antiplatelet agents, 8
Blood pressure, 8
Carotid endarterectomy, 9
Hyperlipidaemia, 8
Preventative neurosurgery, 9
Social participation, 181
Somatosensory processing, 127–37
Adaptive (compensatory/functional),
136
Assessment, 130
Clinical challenges, 136–7
Functional anatomy, 127–9
Functional observations, 130
Intervention, 133–4
Restorative (remedial), 134–6
Review and evaluation, 136
Screening, 130–3
Standardised assessments, 133
Theoretical approach, 129–30
Splinting, 114–6
Standardised assessments, 90, 195–7
Administration, 196–7
Assessment analysis, 197
Assessment checklist, 196
Assessment choice, 196
Assessment of Motor and Process
Skills (AMPS), 198
Baking Tray Test, 199
Balloons Test, 199
Barthel ADL Index, 198
Behavioural Assessment of the
Dysexecutive Syndrome (BADS),
199
Behavioural Inattention Test (BIT), 199
Canadian Occupational Performance
Measure (COPM), 198
Chessington Occupational Therapy
Neurological Assessment Battery
(COTNAB), 198
Cognitive Assessment of Minnesota
(CAM), 198
Doors and People, 199
Edmans ADL index, 198
Erasmus MC Modifications to the
(revised) NSA, 198
Frenchay Activities Index, 198
Functional Independence Measure
(FIM), 198
General Health Questionnaire, 199
Geriatric Depression Scale, 199
Hayling and Brixton Tests, 199
Hospital Anxiety and Depression scale,
199
Kertesz Apraxia Test, 199
Location Learning Test, 199
Loewenstein Occupational Therapy
Cognitive Assessment (LOTCA),
199
Middlesex Elderly Assessment of
Mental State (MEAMS), 199
Mini-Mental Status Examination
(MMSE), 199
Motor Free Visual Perceptual Battery,
199
Motricity Index, 198
Nine-hole Peg Test, 198
Northwick Park ADL index, 198
Nottingham 10 point ADL scale, 198
Nottingham extended ADL scale, 198
Nottingham Sensory Assessment, 198
Occupational Therapy Adult
Perceptual Screening Test, 199
Repeatable Battery for the Assessment
of Neurological Status, 199
Rey Figure Copying Test, 199
Rivermead ADL assessment, 198
Rivermead Assessment of
Somatosensory Performance
(RASP), 198
Rivermead Behavioural Memory Test
(RBMT3), 199
Rivermead Motor Assessment, 198
Rivermead Perceptual Assessment
Battery (RPAB), 199
SF-36 (generic health status measure),
199
Stroke Drivers Screening Assessment,
199
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Index
Test of Everyday Attention (TEA), 198
Visual Object and Space Perception
Battery (VOSP), 199
Wakefield Depression Inventory, 199
Standards, 206-7
Stroke education, 189–90
Subluxed shoulder, 113–4
Support available, 177–78
Swallowing, 80–81
Symptoms of stroke, 2
Synaptic transmission, 31–6
Collateral sprouting, 34
Dendritic growth, 35–6
Long-term nuclear changes, 32–3
Long-term postsynaptic potentiation
(LTP), 32
Short-term presynaptic potentiation
(STP), 31
Unmasking, 34
Theoretical constructs, 24
Therapeutic activities, 110
Therapeutic aims of intervention, 91
Transition between services/discharge,
52–3
Upper limb re-education, 111
Useful assessments, 198–199
Useful books, 231–2
Useful organisations, 233–39
Vestibular processing, 139–1
Assessment, 139–40
Clinical challenges, 141
Functional anatomy, 139
Functional observations, 140
Intervention, 140
Review and evaluation, 141
Theory/approaches, 139
Visual and sensory impairment,
117–19
Visual processing, 119–27
Activity engagement, 125
Assessment, 123
Clinical challenges, 126–7
Functional anatomy, 119–20
Functional observations, 123
Impairment based, 124–5
Intervention, 124
Review and evaluation, 126
Screening, 123–4
Social participation, 125–6
Theory/approaches, 120–3
Vocational rehabilitation, 186–88
Younger people, 180
245