OT 460: CVA

preparatory treatment UE mm re-education occupation based interventions mirror therapy NMES

examples of UE treatment (5)

CT and MRI

2 types of diagnostic imaging that can distinguish ischemic from hemorrhagic lesions and define their location, size, and vascular territory

subarachnoid intracerebral

2 types of hemorrhagic strokes

thrombotic emboic

2 types of ischemic strokes

ischemic hemorrhagic

2 types of strokes

acute phase (immediately following stroke) rehab phase reentry to community stage/stage of continuing adjustment

3 stages for OT services for pts with stroke

internal carotid artery middle cerebral artery anterior cerebral artery posterior cerebral artery

4 common CVA lesion locations

-deep hypertensive intracerebral hemorrhages -ruptured saccular aneurysms (berry aneurysms) -bleeding from arteriovenous malformation -spontaneous lobar hemorrhages

4 most common causes of intracerebral hemorrhage

upper; hemiplegia; contralateral

CVA is a(n) (upper/lower) neuron dysfunction that produces _______________ of one side of the body (ipsilateral/contralateral) to the brain hemisphere of the lesion

cardiac embolic stroke

examples of this type of stroke include atrial fibrillation, sinoatrial disorders, MI, endocarditis, cardiac tumors, ad valvular disorder

arterial embolic stroke

examples of this type of stroke include carotid an basilar arteries that fail with severe stenosis (narrowing of vessel)

embolic stroke

caused by a clot within an artery but forms somewhere other than the brain itself; can be from cardiac or arterial sources; dislodged platelets, cholesterol, or other material that forms at another location, travels in the bloodstream, and blocks a cerebral vessel

-dysfunction in areas of occupation, performance skills, patterns, and client factors -depends on the various pathological conditions resulting in CVA and the anatomical structure involved

effects of CVA

intrinsic recovery

The remediation of neurological impairments, such as the return of movement to a paralyzed limb.

upper extremity function

eval of this should address sensation, mechanical/physiological deterrents to movement, presence and degree of active or voluntary movement, quality of movement, extent of function

ischemic stroke

a clot blocks blood flow to an area of the brain; a blood vessel becomes blocked and the blood supply to that part of the brain is blocked

unilateral neglect

a complex deficit that can affect personal (body) perception as well as near or far extrapersonal space; almost always associated with right parietal lobe damage and is highly predictive of poor functional recovery

aphasia

an acquired multimodality disorder that can result in impaired understanding or input (listening, reading) and/or impaired expression or output (speaking, writing, using gestures); stroke is the leading cause of acquiring this; damage to left cerebral hemisphere

cerebrovascular accident (CVA)

an acute, neurological dysfunction of vascular origin; describes a variety of disorders characterized by the sudden onset of neurological deficits caused by vascular injury to the brain; vascular damage disrupts blood flow, limits oxygen supply to surrounding cells, and leads to brain tissue death or infarction

-chart review, pt. interview, family interview, premorbid status -observation of pt -- how do they look? -orientation -ability to follow directions? (visual/verbal/both?) -postural control: can maintain sitting balance? -head and neck position/control? -UE and LE function (flaccidity, spasticity, subluxation, AROM, PROM, AAROM, coordination, sensation, edema, proprioception, kinesthesia, stereognosis, apraxia, body scheme [neglect, R/L discrimination]) -vision (agnosia, hemianopsia, visual acuity, saccadic eye movement, depth perception, figure ground perception, topographical orientation) -aphasia

assessment of CVA (8)

intracerebral hemorrhagic stroke

bleeding into the brain tissue

hemorrhagic stroke

bleeding occurs inside or around brain tissue; rupture of a small blood vessel in the brain; result from a rupture of a weakened cerebral blood vessel; blood accumulates outside of the vascular space and compresses surrounding brain tissue

hemianopsia

blindness in half the visual field

small vessel thrombotic stroke

blood clot located in smaller, deeper, penetrating arteries; also known as a lacunar stroke

large vessel thrombotic stroke

blood clot located within one of the larger arteries of the brain

home evaluation

can help determine what resources and means a patient has to achieve independence in areas of occupation as well as assessing safety and accessibility

wernicke's aphasia (receptive, fluent aphasia)

characterized by smooth articulation of speech but marked by incorrect word or sound substitutions and the inability to name objects, repeat phrases, or follow commands; auditory comprehension and understanding of language is limited

apraxia of speech

communication problem in which the patient has difficulty initiating and sequencing the movements necessary to produce speech

transition to community phase of stroke care

continuing to seek and find ways to compensate for or adapt to persisting neurological deficits; real work of recovery begins after formal rehab; D/C planning, assist in identifying the most appropriate discharge setting, training the patient/family/caregiver in essential skills, arranging for continuity of care with community services; resume valued roles and tasks, expand rehab into community and look beyond emphasis on BADL to more complex occupations necessary for resuming or adapting work, family, and community roles

cognitive functioning

deficits/disorders in ___________, including problems with attention, orientation, memory, and executive functioning (forming, planning, and executing goals), can result in decreased safety awareness and difficulty learning new techniques for performing tasks, and can also interfere with family and community participation

hemiattention

describes a patient's tendency to ignore objects on one side of the visual field and can occur with or without a measurable visual field deficit

acalculia

difficulty performing simple mathematical tasks

-restoration of blood flow, limiting neuronal damage (anticoagulation drugs, Heparin, TPA) -opening the airway -hydration, IV fluids, -treatment of HTN, co-existing cardiac or other systemic diseases

early medical treatment for CVA (4)

middle cerebral artery (MCA)

example of a location where a large vessel thrombotic stroke may occur

acute stroke care

focuses on determining the cause and site of the stroke, preventing progression of the lesion, reducing cerebral edema, preventing secondary medical complications, and treating acute neurological symptoms

thrombotic stroke

formation of a blood clot within the brain blocking blood flow through the artery; type of ischemic stroke; can be large vessel or small vessel; usually a result of atherosclerosis; stenosis or occlusion of a vessel; typically a gradual process, often with preceding warning signs, such as TIAs

-prevent secondary impairments -restore performance skills -modify activity demands and contexts as necessary -promote a healthy and satisfying lifestyle -maintain available performance and health

general goals of OT intervention with stroke survivors

thrombolytic drugs (such as tPA)

help reestablish blood flow to the brain by dissolving clots in cerebral vessels

-location of lesion -extent of damage -use CT scan, MRI, PET scan, or SPECT (single photon emission computerized tomography) scan

how to diagnose CVA (3)

number of fingers positioned into GH joint by holding forearm/elbow slightly externally rotated

how to measure degree of subluxation of GH joint in UE after stroke

ensure mobility of the scapula on the thoracic wall before elevation of the arm and manually assist upward rotation of the scapula if needed (do not attempt overheard ranges unless the scapula glides freely in upward rotation) the humerus should be externally rotated during abduction to prevent supraspinatus impingement

how to perform PROM on involved arm of stroke pt

right hemiparesis aphasia/communication deficits apraxia/motor planning deficits

impairments associated with L CVA (3)

left hemiparesis visual field deficits or spatial neglect poor insight/judgement impulsive behavior

impairments associated with R CVA (4)

antithrombotics

include antiplatelet drugs and anticoagulation drugs to prevent further clotting or thrombosis

anosognosia

lack of ability to perceive the realities of one's own condition

homonymous hemianopsia

loss of half of visual field in both eyes

hemianesthesia

loss of tactile sensation on one side of body

transient ischemic attack (TIA)

occurs as mild, isolated, or repetitive neurological symptoms that develop suddenly and last from a few minutes to several hours, but not longer than 24 hours; they clear completely

subarachnoid hemorrhagic stroke

occurs when a blood vessel just outside the brain ruptures

shoulder subluxation

malalignment of the GH joint; occurs in approx. 50% of stroke patients; probably caused by the weight of the arm pulling down the humerus when the supraspinatus and deltoid muscles are weak and by weakness of scapular muscles that allows the glenoid cavity to rotate downward; identified by palpation

-prevention of DVT -prevention of respiratory problems and pneumonia -monitoring of BP, HR, and EKG during ADL to determine cardiac response to activity -bowel and bladder dysfunction toileting program or catheterization prn

medical mgt of CVA (4)

aneurysms and ateriovenous malformations

most common types of weakened blood vessels causing hemorrhagic strokes

depression (develops over time, more likely to be seen as treatment progresses)

most frequently reported psychosocial reaction to stroke

apraxia

motor planning deficits of skilled, organized, purposeful movement sequences used to achieve a goal

longer

neurological deficits of a CVA persist (shorter/longer) than 24 hours

broca's (expressive, non-fluent) aphasia

patient can follow commands but cannot name objects, repeat phrases, or convey ideas; speech output is difficult to produce and is characterized by slow, awkward articulation, with limited vocab and grammar usage in the presence of relatively well-preserved auditory comprehension

rehab phase of stroke care

patients who have sustained an acute stroke should receive rehab services if their poststroke functional status is below their prestroke status and if there is potential for improvement; OT's primary role is to enhance client's participation and quality of life through occupation, interventions to improve performance of BADLs

acute phase of rehab

priorities during this phase of rehab include prevent recurrent stroke and complications, mobilize the patient as soon as possible, encourage performance of self-care activities, and provide emotional support to patient and family

motor learning

refers to an individual's acquisition of strategies for solving movement challenges in changing contexts, enabling one to adapt to his or her environment; after stroke, requires regaining an adequate PEO fit for optimal function

postural adaptation

refers to the individual's ongoing ability to achieve, maintain, or restore an upright position against gravity (balance) for stability during activities or changes in body position; status of this in stroke patients is an important starting point for assessing motor skills because it can lead to dysfunctional limb control, increased risk of falls, contracture and deformity, diminished sitting and standing endurance, decreased visual feedback and swallowing effectiveness secondary to head and neck malalignment, and impaired ability to interact with the environment

neuroplasticity

refers to transiently achieved functional changes in the context of learning and recovery, as well as structural changes on the cellular level; includes greater excitability and recruitment of intact neurons in both hemispheres of the brain as a response to stimulation, participation, training, and experience

adaptive recovery

regaining the ability to perform meaningful activities, tasks, and roles without full restorations of neurological function, such as using the unaffected hand for dressing, or walking with a cane or walker.

MCA occlusions

results in contralateral hemiparesis; contralateral hypesthesia; ipsilateral hemianopsia; gaze preference toward the side of the lesion; agnosia; receptive or expressive aphasia (if the lesion occurs in the dominant/left hemisphere); and neglect, inattention and extinction of double simultaneous stimulation (with some nondominant hemisphere/right lesions)

internal carotid artery lesion

results in contralateral hemiplegia; hemianesthesia, and homonymous hemianopsia

PCA occlusions

results in contralateral homonymous hemianopsia; cortical blindness; visual agnosia; altered mental status; and impaired memory

ACA occlusions

results in disinhibition and speech perseveration; primitive reflexes (grasping, sucking, etc.); altered mental status; impaired judgment; contralateral weakness (greater in legs than arms); contralateral cortical sensory deficits; gait apraxia; and urinary incontinence

extensor synergy

scapular protraction, shoulder horizontal adduction and internal rotation, elbow extension, and forearm pronation

flexor synergy

scapular retraction and/or elevation, shoulder abduction and external rotation, elbow flexion, and forearm pronation

dysarthria

speech disorder caused by paralysis, weakness, or incoordination of speech musculature resulting in problems in speech production

true

t/f: occupational performance, particularly BADL, is often used to predict long-term recovery because ADL measures are relatively objective, simple to use, and very relevant to quality of life

true

t/f: stroke is the 3rd leading cause of death in the US and an leading cause of chronic disability among adults

true

t/f: the minimal IADL skills required to stay at home alone include the ability to prepare or retrieve a simple meal, use safety precautions and exhibit good judgement, take medication, and get emergency aid if needed

dominant hemisphere

usually the left hemisphere of brain, is responsible for speech/language and controlling the arm and leg used preferentially in skilled movements; lesions to this hemisphere will result in aphasia, agraphia, and acalculia

non-dominant hemisphere

usually the right hemisphere of brain; lesions will result in visual perceptual dysfunction, unilateral neglect, anosognosia, constructional or dressing apraxia, attention deficits, topographical orientation

non-modifiable: -age, gender, race, ethnicity, heredity modifiable: -HTN -mgt of cardiac diseases -mgt of diabetes -mgt of glucose metabolism -cigarette smoking -excessive alcohol use -illegal drug use -lifestyle factors

what are the non-modifiable and modifiable risk factors for CVA? (non = 5; modifiable = 8)

ischemic is more common hemorrhagic is less common but result in higher mortality rates

which type of stroke is most common? which has a higher mortality rate?

intracerebral hemorrhage

which type of stroke is most likely to result in death or major disability