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Stroke of Misfortune or Stroke of Luck:
Understanding Cerebrovascular Accidents through the Lens of Occupational Therapy
Emily E. Carter
Augusta Technical College
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Abstract
Confusion sets in; the face begins to droop, the arms and legs on one side of the body are
irrefutably weak, and speech is virtually impossible. Internally, a fuse has been lit and the
difference between recovery and ruin will be determined by an individual’s capability to
decipher these warning signs. This scenario represents one of many ways in which stroke can
present itself. Let us then examine the types of stroke, the related symptoms, and how a stroke
may impede normal tasks and activities associated with daily life. Who knows, one day your
ability to recognize these signs in yourself or someone else may result in a stroke of luck, rather
than a stroke of misfortune, as early detection is imperative to survival and recovery.
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Table of Contents
Description and Definition .............................................................................................................. 4
Common Signs and Symptoms .................................................................................................... 5
Types of Stroke ........................................................................................................................ 6
Left Brain versus Right Brain Stroke ............................................................................................... 7
Occupational Outlook............................................................................................................. 8-10
Key Terms ......................................................................................................................... 11-12
References ………………………………………………………………………………………………………………………….....13
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Description and Definition
Stroke is, “a rapidly developing episode of focal or global neurological dysfunction
lasting longer than 24 hours or leading to death, and of presumed vascular origin.” (Rowarn H.
Harwood, 2011). It results from blockage of blood flow to the brain, leading to ischemia or
tissue death. Other words used to describe stroke may include cerebrovascular accident or
brain attack. The term transient ischemic attack is oftentimes used in conjunction with stroke.
However, it is important to understand that a transient ischemic attack and a stroke are not the
same. Their clinical features are similar but the duration of the attack sets these two terms
apart. Stroke duration surpasses a 24 hour period whereas a transient ischemic attack lasts 24
hours or less, and is oftentimes referred to as a “mini stroke”.
Understanding stroke is of utmost importance as it is the most common form of adult
disability worldwide. Certain factors increase stroke risk such as gender, race, age, genetics,
demographics, and lifestyle factors. However, stroke does not discriminate and cannot be
based upon these factors alone. Individuals with increased stroke potential include but are not
limited to: women, African Americans, ageing populations, those having a positive family
history of stroke, low socioeconomic status, and having high blood pressure or smoking
(Jonathan Mant, 2011). Because of worldwide efforts to reduce smoking and lower blood
pressure the incidence of stroke is on the decline, however due to the ageing population the
overall rate of stroke remains the same (The Internet Stroke Center , 2013).
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Common Signs and Symptoms
Being able to identify common signs and symptoms of stroke is imperative to vitality of
a stroke victim. The American Stroke Association has invented a simple phrase in order to easily
recall what to look for when a stroke is suspected. The acronym FAST can be related to stroke
assessment. The corresponding letters cue an individual to first observe facial features, denoted
by the letter F. If the face is drooping or sagging, particularly on one side of the body this should
be the first red flag. Secondly, the letter A is used as a reminder to examine arms. If the
individual who is suspected of having a stroke is asked to lift their arms and one of the arms
drifts back downward then a second red flag should be raised. Thirdly, the letter S is used to
represent speech. If that persons is having difficulty speaking or understanding speech then
immediately call 9-1-1 as the last letter T represents time and should serve as a reminder that
every second counts in successful stroke outcomes. Other symptoms not mentioned in the
FAST acronym might include: sudden headache with no apparent cause, sudden trouble
walking, dizziness, loss of balance, loss of coordination, and trouble seeing out of one of both
eyes.
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Types of Stroke
Stroke itself can be thought of as an umbrella term, beneath that umbrella there exits
two major subtypes. They are ischemic and hemorrhagic strokes. Ischemic strokes account for
the vast majority of stroke occurrences and transpires when a blood clot or thrombus forms
resulting in blocked blood flow to the brain. Ischemic strokes are classified as being thrombotic,
embolic, or lacunar in nature. Thrombotic strokes occur when an artery supplying vital nutrients
to the brain are clogged by a blood clot. Embolic strokes are known as “traveling clots”. They
occur when a blood clot forms in the body, breaks off, travels through the circulation, and
eventually gets stuck in the small arteries of the brain obstructing the flow of blood. Lastly,
Lacunar strokes are the result of small infarcts within the deep brain structures and often go
undetected because their small size and minimal neurologic symptoms (Ben J. Atchison, 2012).
In contrast, a hemorrhagic stroke occurs less frequently, tends to be severe, and is
associated with higher rates of early mortality (Jonathan Mant, 2011). The term ‘early
mortality’ is not to be confused with rehabilitation outlook. While death can occur more
frequently with hemorrhagic stroke, once the individual has survived, prognosis of
rehabilitation is better than its ischemic counterpart. A hemorrhagic stroke is caused by a
rupture in a blood vessel or an aneurysm and can be further classified as being an intracerebral
hemorrhage or subarachnoid hemorrhage. An intracerebral hemorrhage results in bleeding
directly into the brain whereas as subarachnoid hemorrhage occurs when blood breaks through
a weakened portion of an aneurysm and fills the area surrounding the brain (Ben J. Atchison,
2012).
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Left Brain versus Right Brain Stroke
Stroke presentation differs from person to person. The damage incurred to the body is
directly related to which portion of the brain the insult occurs. The simplest way in which this
can be discussed is through the terms left brain stroke and right brain stroke. Because of brain
anatomy, the way in which symptoms are exhibited varies. For example, an individual suffering
from a right brain stroke will have inherent difficulty with the left side of the body, this can be
exhibited through left-sided hemiparesis or hemiplegia. Right sided brain injuries have the
potential to impair the learning process, nonverbal communication, behavior, memory, and
attention span (National Stroke Association , 2013). Additionally, visual spatial impairments,
visual memory deficits, and loss of the “big picture” type thinking may occur. In contrast, left
sided brain injuries result in impaired function of the right side of the body and can be exhibited
through right-sided hemiparesis or hemiplegia. Right sided brain injuries have the potential to
impair expressive and receptive language (aphasia) and may cause trouble using facial muscles.
Furthermore, left sided brain injuries have the potential to effect logic and sequencing.
Diffuse brain injuries can also occur, this happens when the injuries are scattered
among both the left and right portions of the brain. This type of insult could result in reduced
thinking speed, confusion, reduced attention and concentration, fatigue, and impaired
cognitive thinking in all areas (Chicago Digital , 2013). Damage strictly limited to the cerebellum
severely limit the body’s ability to coordinate movement (ataxia) and may further inhibit
balance, posture, and coordination. It is important to understand these factors as they directly
influence the type of care an individual on the road to stroke recovery might receive.
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Occupational Outlook
Winston Churchill once said, “Success is not final, failure is not fatal: it’s the courage to
continue that counts” (Allat, 2012). It is almost as if Churchill constructed this phrase to unify
individuals who have suffered a stroke. In some ways, the miracle is not that the individual
survived, but that they had the ability to overcome the aftermath. As with any area of
rehabilitation, a number of specialists may be needed in order for the individual to return to
functional capacity. It is important to note that these specialists, while having their own areas
of expertise, work as a team with the client or patient serving as the common denominator. For
the purposes of this particular document, stroke will be viewed through the lens of
Occupational Therapy. In particular, we will discuss how stroke impacts occupational
performance, or performance of all activities encompassing the individual’s lifestyle which have
purpose and give value and meaning to life.
Stroke has the potential to infiltrate all areas of the body. Imagine the brain as the chief
commander and the remaining parts as soldiers in the anatomy army. If something happens
causing damage that higher center, then any respective body part controlled by the specific
portion of the brain in which the insult occurred could malfunction. Having a stroke could lead
to a decrease in cognitive abilities, for example, the stroke survivor may be unaware that they
even have a disability. This can pose a serious threat because this lack of understanding could
lead to participation in activities that could seriously injure the client. A decrease in cognition
may also further impair the client’s memory, attention span, problem solving, insight, and
organization (Rowarn H. Harwood, 2011). If the individual suffering from these impairments
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was a teen whose occupation was participation in soccer, this task would be virtually
impossible, as this activity requires a high level of cognitive ability.
Additionally, stroke may interfere with mobility. This inability to maneuver is quite
damaging considering that it makes involvement in most occupations extremely difficult, or in
some cases, impossible. For example, the occupation of a child is play. If the child is unable to
effectively mobilize, their ability to engage in these meaningful life activities is diminished. For
adults and children alike, decreased mobility could lead to depression, which is increasingly
common amongst stroke survivors. Nearly all areas of occupation: activities of daily living,
instrumental activities of daily living, work, play leisure, and social participation have the
potential to be negatively impacted by mobility deficits (Jonathan Mant, 2011).
Muscle strength and balance might also be impaired during the aftermath of a
cerebrovascular accident. Deficits in these areas would make simple tasks such as sitting
upright in a chair difficult. Grasping abilities may also be hindered due to decreased muscle
strength. Consider then, how difficult the seemingly small feat of sitting in a chair and bending
over to tie one’s own shoelace might be. While this particular activity may seem small in the
scheme of things, think of all the other tasks that are necessary in order to fully participate in
the many occupations of life.
Impairments in communication also hinder an individual’s ability to perform in areas of
occupation and is a common deficit following a stroke. For example, envision this scenario, an
elderly woman used to volunteer at a local blood bank making phone calls to potential blood
donors but had to discontinue working due to a recent stroke. This area that once provided
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meaning to the life of the senior was directly impacted by stroke. There are so many areas in
which a stroke has the potential to permeate but there is hope in relation to outcome.
This hope resides in the realm of Occupational Therapy whose focus is on return to
occupations. The scenarios listed above, are just a handful of the ways in which a stroke could
devastate the life of the survivor. Thankfully, by way of Occupational Therapy intervention: the
soccer player with decreased cognition, the child who had difficulty engaging in the occupation
of play, the individual who was unable to tie their shoelace, and the senior who had to stop
participating in volunteer work all because they suffered a stroke have the potential to return
to those valuable occupations. Through unwavering efforts from the client and dedication of
the Occupational Therapist, a stroke of misfortune can be molded into a stroke of luck!
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Key Terms
1.) Aneurysm: A large pocket or bubble in a blood vessel that forms a weak spot in the
vessel’s wall, which can be life threatening if it ruptures; some people may have a
genetic tendency to develop aneurysms.
2.) Aphasia: Difficulty speaking or comprehending language; a common occurrence after a
stroke affecting the left hemisphere of the brain, where language is processed.
3.) Dysarthria: A speech disability caused by an injury to the brain centers controlling the
face, mouth, neck, or throat; people so affected may be able to understand speech and
form the right words in their minds but are unable to articulate them.
4.) Dysphagia: A difficulty in swallowing; extremely common after a stroke.
5.) Embolic stroke: A type of stroke that occurs when a blood clots that has formed
elsewhere in the body breaks off and travels through the bloodstream until it blocks an
artery that normally supplies blood to the brain.
6.) Embolus: A fragment of a blood clot that travels from the site where it was formed and
lodges in a vessel in another part of the body, blocking blood flow.
7.) Hemianopia: Defective vision or blindness in one side of the visual field in one or both
eyes; may be caused by an embolic or low-flow transient ischemic attack or stroke in the
posterior cerebral artery region.
8.) Hemiparesis: Muscular weakness on one side of the body; if the right side is affected,
the stroke damaged the left side of the brain.
9.) Hemiplegia: Paralysis limited to one side of the body.
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Hemorrhagic stroke: A type of stroke that occurs when a blood vessel ruptures,
cutting off supply of oxygen and nutrition to part of the brain.
11.)
Hypertension: High blood pressure; a major risk factor for stroke, especially
hemorrhagic and lacunar strokes, because it puts excess stress on the walls of blood
vessels and damages their delicate inner lining.
12.)
Ischemic stroke: A stroke caused by an interruption in the flow of blood to the
brain; almost always caused by a blood clot blocking a blood vessel.
13.)
Lacunar stroke: A small ischemic stroke caused by the blockage of one of the
smaller blood vessels in the brain; the most common effect is weakness or disability on
one side of the body.
14.)
Plaque: A fatty buildup of cholesterol, calcium, and other substances inside a
blood vessel.
15.)
Stroke: A “brain attack”; occurs when a blood vessel supplying the brain
becomes obstructed or tears.
16.)
Subarachnoid hemorrhage: A hemorrhagic stroke that occurs when a blood
vessel on the surface of the brain bursts and bleeds into the space between the brain
and the skull; usually caused by an aneurysm or other blood vessel malformation.
17.)
Thrombus: A blood clot that has formed inside an intact blood vessel.
18.)
Transient ischemic attack (TIA): A brain attack that resolves within 24 hours;
often the first sign of an impending stroke, but may cause damage on its own.
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References
A.D. Killingsworth, L. W. (2006). Theraputty Exercises. Retrieved from OSF Healthcare:
http://library.osfhealthcare.org/PatientEd/Rehabpdf/OTDocuments/NEWOT/Theraputty.pdf
Allat, K. (2012, June 14 ). Retrieved from http://arockystrokerecovery.com/
Ben J. Atchison, D. K. (2012). Conditions in Occupational Therapy . Baltimore: Lippincott Williams &
Wilkins.
Chicago Digital . (2013). Living with Brain Injury . Retrieved from Brain Injury Association of America :
http://www.biausa.org/living-with-brain-injury.htm
Everyday Health Media LLC. (2013). Stroke Glossary . Retrieved from Everyday Health.
Jonathan Mant, M. F. (2011). ABC of Stroke. West Sussex, UK: BMJ Books .
Lieberman D, S. J. (2008). Occupational Therapy Guidelines for Adults with Stroke. Retrieved from
National Guideline Clearinghouse : http://www.guideline.gov/content.aspx?id=15290
Nancy K. Latham, D. U. (2006). Occupational Therapy Activities and Intervention Techniques for Clients
with Stroke in Six Rehabilitation Hospitals. Retrieved from American Journal of Occupational
Therapy : http://ajot.aotapress.net/content/60/4/369.full.pdf
National Stroke Association . (2013). Stroke Symptoms . Retrieved from National Stroke Association :
http://www.stroke.org/site/PageServer?pagename=symp
Rowarn H. Harwood, F. H. (2011). Stroke Care A Practical Manual . New York : Oxford University Press
Inc.
The Internet Stroke Center . (2013). Stroke Statistics . Retrieved from The Internet Stroke Ceneter :
http://www.strokecenter.org/patients/about-stroke/stroke-statistics/