CVA GUDZ Complete

IV - B.S. Occupational OT 5 STR: CVA November 2014 Therapy

CEREBROVASCULAR ACCIDENT (STROKE)

I. DEFINITION

CVA, is the sudden occurrence of permanent damage to an area of the brain caused by a blocked blood vessel or bleeding within the brain. Lesions in the brain may produce a wide range of neurological deficits such as sensory disturbances, cognitive and perceptual dysfunction, visual disturbances, personality and intellectual changes and a complex range of speech and associated language disorders, with focal weakness being the most common symptom. According to World Health Organization, it is an acute neurologic dysfunction of vascular origin with signs and symptoms corresponding to the involvement of focal areas of the brain. In order to be labeled a CVA, neurologic deficits must persist longer than 24 hours.

II. ETIOLOGY

Stroke, according to Bartels is “essentially a disease of the cerebral vasculature in which failure to supply oxygen to brain cells, which are the most susceptible to ischemic damage, leads to their death. The syndromes that lead to stroke comprise 2 major categories: ischemic and hemorrhagic stroke.” Ischemic strokes account for the majority of strokes, whereas hemorrhagic strokes account for less. There are several risk factors, both modifiable and non-modifiable, that may lead to its occurrence. They are the following:

Modifiable Risk factors:

Hypertension (most treatable factor)

Heart disease Smoking

Diabetes Mellitus Lifestyle Alcoholism

Use of illegal drugs and

Use of oral contraceptive

Non-modifiable Risk factors:

Age (main risk factor)

Gender Race

Ethnicity Heredity

Previous stroke

III. EPIDEMIOLOGY

CVA ranks as the third leading cause of death in the U.S. behind heart disease and cancer, and continues to be a national health problem despite recent advances in medical technology. On average, a U.S. citizen suffers a stroke every 40 seconds; every 4 minutes someone dies of a stroke. Of people who suffer a stroke, 28% are younger than 65 years. For people older than 55, the incidence doubles with each successive decade. Among long term clients who sustained a stroke, 50% have hemi-paresis, 35% are clinically depressed, 30% cannot walk, 26% are

Karen Abinsay Jet Duria Sheena Gazzingan


found to be dependent in ADL scales, and 26% require home nursing care, and 19% are aphasic.

IV. PATHOPHYSIOLOGY

Ischemic Stroke- Ischemia refers to insufficient blood flow to the brain to meet metabolic demand. Ischemic stroke may be the result of embolism to the brain from cardiac to arterial sources.

Thrombosis – Atherosclerotic plaque formation occurs frequently at major vascular branching sites, including the common carotid and vertebrobasilar arteries.

Embolism – Thrombus formation within the cardiac chambers is generally caused by structural or mechanical changes within the heart.

Lacunes – Lacunar infarcts are small, circumscribed lesions that measure less than 1.5 cm in diameter and are located in subcortical regions of the basal ganglia, internal capsul, pons, and cerebellum.

Hemorrhagic Stroke- Hemorrhagic stroke include subarachnoid and intracerebral hemorrhages, which account for only 13 % of the total number of strokes.

Intracerebral – Damage can be significant, resulting in increase intracranial pressure, disruption of multiple neural tracts, ventricular compression, and cerebral herniation.

Subarachnoid – Bleeding that occurs within the dural space around the brain and fills the basal cistern, is most commonly caused by rapture of a saccular aneurism.

The Cerebral Arterial Circle (Circle of Willis)

The blood supply to the brain is carried by the internal carotid and vertebral arteries. The

vertebral arteries join to form the basilar artery. Branches of the internal carotid arteries and basilar

artery supply blood to the brain and complete a circle of arteries around the pituitary gland and the

base of the brain called the cerebral arterial circle. (Braddom)



V. ASSESSMENT

Numerous evaluations exist to identify stroke impairments and disability. To help in the selection and ordering of assessment tools, therapists are guided by models of practice and evidence-base practice guidelines. Occupational function is the focus in OT, thus assessment of a patient post stroke begins with determination roles, tasks, and activities important to that individual. (Trombly)

INSTRUMENT DESCRIPTION AND USAGENIH stroke scale Stroke deficit scale that scores 15 items (e.g., consciousness, vision,

extraocular movement, facial control, limb strength, ataxia, sensation, speech and language)

Canadian Neurological Scale

Stroke deficit scale that scores 8 items (e.g., consciousness, orientation, speech, motor fxn, facial weakness)

Rankin Scale Global disability scale with 6 grades indicating degree of disabilityCanadian Occupational Performance Measure (COPM)

Client0centerd assessment tool based on clients’ identification of problems in performance in area of occupation ( clients rate the importance of self-care, productivity, and leisure skills, as well as their perception of performance and satisfaction with performance) used as an outcome measure, as well as a client satisfaction survey.

Barthel Index Measure of disability in performing BADLs that ranges from 0 to 20 or 0 to 100 ( by multiplying each item by 5); includes 10 items: bowels, bladder, feeding, grooming, dressing, transfer, toileting, mobility, stairs, and bathing

Kohlman Evaluation of Living Skills (KELS)

Living skills evaluation that includes ratings of 17 task (e.g., safety awareness, money management, phone book use, money and bill management)

Functional Independence Measure (FIM)

Measure of disability in performing BADLs that includes 18 items scored on a 7-points scale; includes sub scores for motor and cognitive fxn, performance areas include self-care, sphincter control, mobility, locomotion, cognitive, and socialization

Frenchay Activities Index

15 items IADL scale that evaluates domestic, leisure, work, and outdoor ax.

PCG instrumental activities of Daily living

IADL evaluation of telephone use, walking, shopping, food preparation, housekeeping, laundry, public transportation, and medication management

Assessment of motor and process skills

16 motor skills (e.g., reach , manipulation, calibration, coordination, posture, mobility) and 20 process skills (e.g., attends, organizes, searches and locates, initiates, sequences) evaluated within the context of cx-choose familiar and culturally relevant tasks from a list of 50 standardized ax of various difficulties

Mini-Mental State Examination

Mental status screening test for orientation to time and place, registration of words, attention, calculation, recall, language, and visual construction



Glasgow Coma scale

Level-of-consciousness scales that includes 3 sections scoring eye opening, motor and verbal responses to voice commands or pain

Arnadottir Occupational Therapy Nuerobehavioral Evaluation (A-ONE)

Evaluate apraxias, neglect syndromes, body scheme d/o, organization/sequencing dysfxn, agnosias, and spatial dysfxn via BADL and mobility tasks; directly correlates impairment and disability levels of dysfxn.

Neurobehavioral Cognitive Status Examination

Mental status screening test that includes the domains of orientation, attention, comprehension, naming, construction, memory, calculation, similarities, judgment, and repetition

Fugl-Meyer Test Motor fxn evaluation that uses a 3-pts scale to score the domains of pain, ROM, sensation, volitional mov., and balance

Functional Test for the Hemiparetic Upper Extremity

Arm and hand fxn is assessed via 17 hierarchic functional task based on Brunnstrom’s view of motor recovery; sample tasks a folding a sheet, screwing in a light bulb, stabilizing a jar, and zipping a zipper

Arm Motor Ability Test (AMAT)

Arm fxn evaluated by functional ability and quality of mov.; test involves performance of 28 tasks (e.g., eating with a spoon, opening a jar, tying a shoelace, using the telephone)

TEMPA UE performance test composed of 9 standardized tasks (bilateral and unilateral) measured by 3 criteria: length of execution, functional rating, and task analysis; sample tasks are handling coins, picking up a pitcher and pouring water, writing and stamping an envelope, and unlocking a lock

Jebsen Test of Hand Fxn

Hand fxn evaluation; includes 7 test axs: writing a short sentence, turning over a index card, simulated eating, picking up small objects, moving empty and weighted cans, and stacking checkers during timed trials

Motor Assessment Scale

Motor fxn and eval; includes disability and impairment measures, arm and hand movements, tone, and mobility 9bed, upright, and ambulation)

Motricity Index Measures impairments in limb strength with a weighted ordinal scaleTrunk Control Test Trunk control evaluated on a 0- to 100-pts scale; tasks used rolling,

supine to sitting and balance sittingBerg Balance Scale Balance Assessment of 14 items scored on a 0- to 4-pts ordinal scaleTinetti Test Evaluates balance and gait in the older adult populationRivermead Mobility Index

Measures bed mobility, sitting, standing, transfers, and walking on a pass or fail scale

Functional Reach test

Balance evaluation; objectively measures length of forward reach in standing posture

Boston Diagnostic Aphasia examination

Assesses sample speech and language behavior, including fluency, naming, word finding, repetition, serial speech, auditor comprehension, reading and writing

Western Aphasia Battery

Includes an “Aphasia Quotient” and “Cortical quotient” scored on a 100 pts scale; assesses spontaneous speech, repetition, comprehension, naming, reading and writing

Beck Depression Inventory

21-item, self-rating scale with attitudinal, somatic, and behavior components

Geriatric Depression scale

Self-rated depression scale of 30 items with a yes or no format

Family Assessment

Family assessment of problem solving, communication, roles , affective responsiveness, affective involvement, behavior control, and general



Device functioningMedical Outcomes study/ Short-form Health Survey (SF-36)

Quality of life measure that includes the domains of physical functioning, physical and emotional problems, social fxn, pain, mental health, vitality, and health perception

Sickness Impact Profile

Quality of life measure in the format of a 136-item scale with 12 subscales that measure ambulation, mobility, body care, emotion, communication, alertness, sleep, eating, home management, recreation, social interactions and employment

Activity Card Sort(ACS)

Uses a Q-sort methodology to assess participation in 80 instrumental, social, and high- and low-physical demand leisure axs. Cx sort the cards into diff piles to identify axs that were done before their stroke, axs they are doing less, and those they have given up since their stroke. The ACS uses card with pictures of task that people do every day

Stroke Impact Scale

A stroke specific measure that incorporates fxn and quality of life intone measure. It is a self-report measure with 59 items and 8 subgroups, including strength, hand function, BADLs and IADL’s, mobility, communication, emotion, memory and thinking, and participation

VI. TREATMENT

A careful interpretation of evaluation result helps determine a patient’s assets and deficits in areas of occupational functioning. Safety of the patient is a concern during and after treatment. (Trombly)

- Proper bed positioning

- ES/FES

- ROME- PREs- Assistive device

- NDTs- PNF

VII. PROGNOSIS

The best estimate of prognosis can be made only after a thorough and comprehensive evaluation of the patient’s medical, neurologic, functional, and psychosocial statuses. The single most useful predictor of functional outcome is the initial ADL assessment (most commonly FIM score). Other important variables include age and sitting balance.

Poor prognosticating factors for functional recovery:- Prolonged flaccidity- Late onset of motion (2-4 weeks)- No voluntary hand movement at 4-6 weeks- Severe proximal spasticity- Late return of DTR*If no initial movement is noticed during the first 3 weeks, or if motion in1 segment is not followed within a week by the appearance of motion in a second segment, the prognosis for full motion is poor.




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CVA GUDZ Complete