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Left Hemisphere (following stroke)

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Aphasia Common (lack of expressive or receptive speech) Reaction is catastrophic Difficulty processing information in auditory modality Profits more from non-language cues such as pantomime, gestures, and visual images

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Left hemisphere normal

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Dominant for language Analyzes Details Organizes data in conceptual similarities Uses reason and attention to detail Good at verbal memory

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Right Hemisphere normal

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Dominant for visuospatial tasks Synthesizes wholes Organizes data in structural similarities Uses intuition and imagination Good at figural memory

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Right Hemisphere following damage

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Aprosodia common (lack of variation in pitch and rhythm of speech) Reaction is indifference Difficulty processing information in visual modality Profits more from language cues such as verbal elaboration

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Neuroplasticity

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how quickly healthy brain areas take over the functions affected by the stroke

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Levels of Intervention

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acute phase rehabilitation phase re-entry to community phase

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acute phase

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Discharge planning - when client is medically stable Where is the client being discharged to? What supports does the client have/need? The OT can engage the client in: early mobilization (e.g. rolling in bed, sitting on the side of the bed, transferring to wheelchair/commode) return to self-care ( e.g. self-feeding, grooming, dressing) prevention of secondary complications Skin care Watch for signs of pressure sores Bed mobility, transfers, seating, bathing Prevent contractures Splinting AROM and PROM exercises, neurofacilitation Falls prevention Patient and family education

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Rehabilitation Phase

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Focus on recovering lost function and/or developing compensatory strategies to reduce impairments through meaningful activities Improving performance of tasks Improving component abilities Postural Adaptation Upper-Extremity Function Motor-Learning Ability

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Rehab Phase areas of intervention

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targeted areas of intervention: ADL (mobility, transfers, self-care)/IADL training (meal prep, laundry, money management) Neurofacilitation techniques for upper/lower extremity Postural adaptation Visual Dysfunction Cognitive Deficits Adaptive devices Assisting with wheelchair and seating Patient and family education

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Re-entry to community

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Discharge planning - Continuum of care - Assistive devices and seating - Home modifications Education for client and supports - Falls prevention Resuming activities - Tasks/Roles - Productivity/Leisure Linking to community supports Post-discharge monitoring

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Treatment Approaches

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Compensatory - adaptation - used when full restoration is not possible or there is a need to optimize independence using compensatory skills and strategies Remediation - aims to restore impaired body structures or functions

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Treatment approaches for motor behaviour

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neurofacilitation constraint induced movement therapy occupational therapy task oriented approach

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neurofacilitation approaches

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Rood sensorimotor approach (sensory integration) Knott and Voss Proprioceptive neuromuscular facilitation Brunnstrom Movement Therapy Bobath/Neurodevelopmental Treatment

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Neurofacilitation Approaches

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Each approach is different, but share common assumptions The CNS is organized hierarchically (higher centres exerting a controlling influence over lower centres) Normal movement can be facilitated by providing specific patterns of sensory input through the proprioceptive and tactile sensory systems Reflexes are used to inhibit or facilitate motor activity All sensorimotor impairments are from damage sustained in the motor systems

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Constraint Induced Movement Therapy

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Hemiparesis can lead to learned non-use 2 Main Elements: Repetitive, task oriented training of the affected UE 6 hours or more per day Use of the unaffected UE is restrained with mitten or sling for 90% of waking hours. Goal: to counteract the effects of learned non-use Used for motor restoration Based on a theory of brain plasticity and cortical reorganization Difficult to implement Modified CIMT

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Modified CIMT in Practice

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What modified CIMT looks like at Trillium Health Partners in Mississauga: 2 modified CIMT sessions/week for 0.5h-1h + a home modified CIMT program for some clients Circuit-training format, where each activity is performed for 8-10 minutes. As many repetitions of task/activity as possible in time allotted Emphasis on repetition of movements, not the quality of the movement. Use of mitt on the unaffected hand is dependent on client. Modified CIMT Activities: washing dishes; bean bag toss; folding laundry; clean a window or wall; flip over playing cards; place clothes pegs on a rack; open/close jars; wringing out wash cloths; stacking cones; screwing and unscrewing pegs. Some activities are more functional than others!

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Modified CIMT Program Activities

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Washing Wall Bean Bag Toss Shelving Books Overhead Folding Laundry

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Occupational Therapy Task Oriented Approach

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Based on a systems model of motor control and motor learning theory Functional tasks help organize motor behaviour Influenced by PEO model Client behavioural changes reflect attempts to reach functional goals Practice with varied strategies in varied contexts to find solution to motor problem and develop skill Treament Principles: Client-centred focus Active participation from client Occupation-based focus Create natural environment to practice functional tasks/simulations Create opportunities for practice outside of therapy time Incorporate learning theory Remediate a person factor if it impedes functional performance Adapt the environment, modify the task, use assistive devices

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Sensorimotor Intervention: MOBILITY

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Factors that affect mobility post-stroke: Motor loss Muscle weakness Sensation Fatigue Muscle tone Posture Perception Balance difficulties

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Hemiparesis/Hemiplegia Models of Intervention

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Models of Intervention: Compensatory Biomechanical Motor Retraining Neurodevelopmental Treatment Proprioceptive Neuromuscular Facilitation Constraint-Induced Movement Therapy

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Motor Retraining Program (Hemiparesis/Plegia)

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Motor retraining program Self Care: Dressing, Bathing, Grooming, Feeding Productivity: Home Making Washing dishes, putting away groceries, folding laundry, dusting, setting the table, ironing Other work tasks Sorting, counting, stocking shelves, wrapping packages, pushing a cart Task-specific practice of chosen ADL/IADL Encourage normal postural mechanisms and movement patterns Use affected side in functional activities as much as possible

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Compensatory (Hemiparesis/Plegia)

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Compensatory Universal cuffs Enlarged handles Bilateral handles Task-specific compensatory strategies Dressing skills

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Positioning (Hemiparesis/Plegia)

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Positioning Bed positioning Head on pillow to prevent lateral flexion Affected shoulder brought forward Affected arm extended (90o or diagonal to body) Affected hip extended, knee flexed Seated position 90/90/90 Both hands within visual field

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increase bilateral integration (hemiparesis/plegia)

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Increase bilateral integration Increase tactile & visual input Affected side in visual field Activities that require use of both hands Involved side stabilizer→ initiator

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Tone

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Neurofacilitation Low tone/flaccidity -Increase muscle tone -Tactile & sensory Input High tone/spasticity -Inhibit/reduce tone in UE flexors and LE extensors

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Contractures

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Prevention -Proper positioning -PROM/ROM exercises -Electrical stimulation to extensor muscles -Splinting Intervention -Serial casting (1/wk) -Botox injections

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Weakness & Fatigue

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Stroke survivors may experience higher levels of fatigue as their brain begins to heal and they are faced with the challenges of re-learning new tasks Address strengthening only after tone is normalized Grade meaningful endurance tasks

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Impairments in Trunk Control

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Impairments in trunk control include weakness, loss of stability, stiffness, loss of proprioception May lead to: Dysfunction in upper and lower limb control Increased risk for falls Potential spinal deformity and contractures Decreased ADL/IADL independence Decreased sitting and standing tolerance, balance and function

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Trunk Control Treatment Techniques

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Approach: trunk mobilization Reason: to improve ROM in trunk (flexion, extension, lateral flexion and rotation) and maintain spinal flexibility OT Role: Proper trunk alignment Movement patterns that increase ROM Engage in reaching activities Use movable surfaces Physical handling Use ADL, IADL and mobility tasks Adapt environment and/or use supports

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Balance Impairments

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CNS uses input from: visual, vestibular and somatosensory systems to maintain balance Problems with sensation or motor control--> impaired balance --> increased risk for falls

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Balance Intervention Techniques

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Graded task demands that incorporate the following : Body positioning (BofS, foot placement, standing surface) Object placement (position and distance will change direction of movement) Object characteristics (weight, size) Temporal demands (stationary object vs. moving object)

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Treatment Techniques

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Approach: Positioning/Bed Mobility/Mobility Reasoning: Stroke survivors may spend their first few days of recovery in bed The primary goal: prevent skin breakdown, reduce risk for contractures, and encourage joint alignment and comfort

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Gait Impairments

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Limited ROM (spasticity) and strength Difficulty maintaining proper stance and walking Pushing away from affected side Inability to coordinate movements due to proprioceptive and perceptual deficits Inability to maintain balance due to visual and vestibular deficits Foot deformities

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Gait Intervention

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Determine initial walking goals Biomechanical approach typically addressed by physiotherapist Maximize walking by pairing it with other activities Incorporate sideways, forward and backward walking, step up and step down Orthotics Assistive devices

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Seating & Wheelchair Prescription

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OT role: Interview - client needs Perform a supine and seated MAT Assessment Education client on MAT results and mobility options Equipment Trial Funding Sources if Applicable Fitting, Training , Delivery Follow-up

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Goals of Seating System

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Provide postural support Prevent deformity Minimize compensatory postures Maximize pressure distribution Minimize risk for pressure ulcers Enhance distal extremity control Offer comfort and maximize sitting tolerance Maximize ability to perform functional tasks e.g., lap trays

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Cognitive Perceptual Interventions: Executive Functions

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Umbrella term that refers to high-order mental capacities including: initiation, problem solving, planning, organizing, speed of information processing, self-awareness, sequencing, attention, and mental flexibility Executive functioning is critical to activities, such as cooking meals, doing laundry, driving, etc. Impairment usually associated with frontal lobe damage

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Mental Flexibility

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Required to able to organize shapes according to: colour, shape, size, angles/no angles, and shape and size (combination). The ability to to change/shift your strategy or approach in the face of new information Did anyone catch themselves arranging the shapes in the same ways over and over again? This is called perseverative behaviour or perseveration A stroke patient with poor mental flexibility will likely display perseveration Mental flexibility is an executive function!

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Mental Flexibility Intervention

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Have client pull out different combinations of change and/or bills to add up to a certain amount. Practice computer-based exercises that address mental flexibility. Visit http://www.lumosity.com/ for web-based activities, games, and exercises. Therapist can cue client to form new action plans when familiar routines are unproductive or inappropriate

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Attention Intervention

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Have client highlight or underline important information Have client train their attention by doing paper and pencil exercises (e.g., cancellation tasks, word searches, mazes, and crosswords). Have client train their attention skills with computer-based games, activities, and tasks

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Initiation & Sequencing Interventions

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Checklist with tasks in order Client checks off tasks as they complete them Checklist phased out with improvement Post checklists in obvious locations Sensory input (visual, auditory, kinesthetic, and tactile) to elicit motor output e.g., touch and guide the client's arm, and use verbal cueing to cue the client to start dressing

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Problem Solving Interventions

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Teach client how to use the IDEAL acronym when a problem is encountered I: Identify the problem D: Define the problem E: Evaluate all possible solutions A: Act L: Look back (compare solution against problem) Encourage client to ask for help when in doubt

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Planning & organizing Interventions

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Planner or organizer keep track of daily schedule, appointments, create daily to-do lists Tasks can be colour-coded according to priority. e.g., red dots indicate tasks to be done first and blue dots, tasks to be done in the coming week Introduce client to ABC strategy if client has difficulties with planning, organizing, and prioritizing

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ABC Strategy (Planning & Organizing)

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Categorize the following items using the ABC strategy. Column A, should include responsibilities and engagements to be completed that day; Column B, responsibilities to be completed within a week; and Column C, responsibilities in a month's time

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Awareness/Insight Intervention

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Feedback from friends/family members during and after the completion of a task Videotape client performing a task client compares what they say they can do to what they saw Role playing and role reversal with client Family member/friend performs a task with errors that the client would typically make, client identifies the errors Client estimates the difficulty of a task, the time needed to complete the task, the number of errors and/or amount of assistance needed for the task Compare with actual results This strategy encourages prediction

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Processing Speed/Mental Speed Interventions

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Make notes and/or listen selectively when there is too much information to process Ask others to speak slowly and/or to repeat information Take more time to perform a task Mental preparation prior to initiating task Shut out noise and distraction Ask for help and understanding

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Apraxia

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Inability to perform purposeful movements which cannot be accounted for by loss of motor power, sensation or coordination Types: Ideomotor Ideational Oral Constructional Dressing

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Ideomotor Apraxia

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inability to imitate gestures or perform purposeful motor task on command even though the client understands the concept of the task often associated with L hemisphere damage

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Ideational Apraxia

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Inability to carry out complex sequential motor acts

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Ideomotor & ideational apraxia interventions

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Providing proprioceptive, tactile and kinesthetic input prior to and during a task Keep verbal commands to minimum Performance of activities in the most natural environment as possible (e.g., dressing at bedside) Visualization prior to completion of tasks Providing support when client is frustrated Education re: apraxia

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Interventions for Dressing Apraxia

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Can use verbal and/or visual cues to assist with initiation and throughout dressing task Provide tactile/kinesthetic guiding Weight bearing and weight shifting prior to dressing Changing the environment Use labels to distinguish front and back of clothing Color code the garment from right-to-left Education about the impairment and implications

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Intervetions for Oral Apraxia

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Interventions for oral apraxia are done by the speech-language pathologist May involve word repetition Augmentative forms of communication including: assistive technology, paper and pencil

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Interventions for Constructional Apraxia

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Practice 2-D and 3-D table-top activities Provide tactile and kinesthetic cues to the client Hands on guiding Present partially completed task and ask the client to finish it Using various strategies involving multiple senses for instruction Education re: deficits and implications

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Agnosia

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Inability to recognize sensory stimuli Types -Visual (object) agnosia -Visuospatial agnosia -Tactile agnosia -Prosopagnosia -Auditory agnosia (SLP) Defects in a particular sensory channel (e.g., vision, auditory, or tactile) -Defects are rarely seen in isolation

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Visual Agnosia Interventions

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Teach compensation via use of other senses Teach recognition of figures and shapes by kinesthetic sense combined with visual input Teach tracing with eyes and and fingers (e.g., letters) to improve recognition Teach the use of spatial and location cues to recognize objects Teach the use of unique identifying features and idiosyncratic cues to assist with recognition Use the knowledge of relevant and critical features of items to identify objects Use colours, cues, labels or textures on objects (e.g., velcro on phone receiver) Focus attention on depth cues, surface textures and colors in Tx as real objects provide cues based on surface detail Use cues from others to generate strategy (e.g., if during a meal, you cannot find utensils, look at what others are doing)

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Visuospatial Agnosia

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Incorporate other senses (e.g., auditory and tactile) Educate client on deficit and implications Safety concerns as client may misjudge a chair and fall

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Tactile Agnosia interventions

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Combined tactile and visual recognition Begin by practicing the identification of simple objects first. Grade → simple objects to harder objects Use of vision to visual occlusion

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Interventions for prosopagnosia

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Use gait to identify people (speed, sound of shoes) Teaching voice recognition Use localization clues Highlight distinguishing features on the individual (e.g., scar, mustache, hair colour, eye colour, piercings)

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Somatognosia Interventions

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Provide tactile stimulation Practice tasks that reinforce body knowledge Incorporate bilateral activities Appropriate handling techniques to educate on what it feels like for normal movement Identify where the body knowledge breakdown occurs and educate on implications Use client's intact awareness (e.g., spatial, functional) to guide level of cueing

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Finger Agnosia Interventions

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Inputs structured so that repeated sensory inputs are provided to those surfaces to be used for desired task Repeated sensory stimulation should be high intensity (but not aversive) Subsequent to the stimulation, have the client perform functional hand or ADL activity appropriate to their level of function Educate the client about how finger agnosia may influence dexterity and function

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Spatial Dysfunction Interventions

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Positioning is key Increase the client's awareness of the deficits Practice positioning of items in relation to other items on a table top Using colored markers for targets

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Figure Ground Deficit Interventions

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Increasing contrast Increasing clients awareness of deficit Teaching the client to slow down enough during task performance to identify relevant objects/stimuli before handling/manipulating them Adapting the environment Sorting objects (like utensils in a kitchen drawer) is helpful

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Topographical Disorientation Intervention

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Use of visual aids to mark routes Use of maps Verbal cueing

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Memory

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Most memory deficits require some level of compensation Stages of memory formation Attention→ Encoding→ Storage → Retrieval

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Memory Intervention

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Interventions for memory deficits follow same order as the stages for forming memories Attention is addressed first (selecting information to rehearse) then rehearsing to maintain information to store and encode in long-term memory Organization facilitates recall Repetition (with vanishing cues, i.e., grading) Active listening Note taking (lists, calendars, instructions) Rehearsal Association of information Reduce distractions Finish tasks before moving onto the next one Maintain consistent routines

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External Aids for Memory Impairment

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Technology (e.g., auditory reminders on smartphones) Day planners/diaries Watch reminders Use of calendars Purchase electrical appliances that turn off automatically Labeling drawers, cabinets, etc. Store items in the same place (and always return items when finished) Use signs, pictures, or other familiar items to assist client when locating areas within home

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Diplopia Intervention

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AROM exercises Target-following at a distance Eye patch

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Homonymous Hemianopsia

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Lesion to optic tract results in left or right field of vision not processed from each eye (can see half the side of each circle)

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homonymous hemianopsia intervention

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Place commonly used objects on the affected side to promote looking there regularly Practice scanning exercises Place necessary items in field of vision Apply self-discovered compensatory techniques to multiple tasks

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Unilateral Neglect Intervention

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Awareness training Scanning training Lighthouse Strategy (LHS) Limb activation Partial visual occlusion Videotaped feedback of Task Performance Orientation and awareness activities Auditory and tactile direction Environmental Adaptation

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Psychosocial Intervention

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Avoid reacting to emotional or angry outbursts Accept emotions and listen to client Clarify misconceptions, provide orientation aides Watch for signs of depression Promote engagement in meaningful, enjoyable activities Educate client and family on coping strategies connect with community supports

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