Occupational Therapy and Stroke

Occupational Therapyand StrokeSecond EditionEdited byJudi EdmansOn behalf of the Stroke Clinical Forum of the College of OccupationalTherapists Specialist Section Neurological PracticeA John Wiley & Sons, Ltd., Publication

Occupational Therapy and Stroke

Occupational Therapyand StrokeSecond EditionEdited byJudi EdmansOn behalf of the Stroke Clinical Forum of the College of OccupationalTherapists Specialist Section Neurological PracticeA John Wiley & Sons, Ltd., Publication

This edition first published 2010C○ 2010 Blackwell Publishing LtdBlackwell Publishing was acquired by John Wiley & Sons in February 2007. Blackwell’s publishingprogramme has been merged with Wiley’s global Scientific, Technical, and Medical business to formWiley-Blackwell.Registered officeJohn Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, United KingdomEditorial offices9600 Garsington Road, Oxford, OX4 2DQ, United Kingdom350 Main Street, Malden, MA 02148-5020, USAFor details of our global editorial offices, for customer services and for information about how to apply forpermission to reuse the copyright material in this book please see our website atwww.wiley.com/wiley-blackwell.The right of the author to be identified as the author of this work has been asserted in accordance with the UKCopyright, Designs and Patents Act 1988.All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted,in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except aspermitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher.Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not beavailable in electronic books.Designations used by companies to distinguish their products are often claimed as trademarks. All brandnames and product names used in this book are trade names, service marks, trademarks or registeredtrademarks of their respective owners. The publisher is not associated with any product or vendor mentioned inthis book. This publication is designed to provide accurate and authoritative information in regard to thesubject matter covered. It is sold on the understanding that the publisher is not engaged in renderingprofessional services. If professional advice or other expert assistance is required, the services of a competentprofessional should be sought.Library of Congress Cataloging-in-Publication DataOccupational therapy and stroke / edited by Judi Edmans on behalf of the Stroke Clinical Forum of the Collegeof 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 SectionNeurological Practice. Stroke Clinical Forum.[DNLM: 1. Stroke–therapy. 2. Disabled Persons–rehabilitation. 3. Occupational Therapy–methods.WL 355 O15 2010]RC388.5.O33 2010616.8 ′ 1062–dc22 2010003297A catalogue record for this book is available from the British Library.Set in 10/12.5 pt Times by Aptara R○ Inc., New Delhi, IndiaPrinted in Malaysia1 2010

ContentsList of ContributorsForewordPrefaceAcknowledgementsixxixiiixv1 Introduction 1Judi Edmans, Fiona Coupar and Adam GordonDefinition of stroke 1Impact of stroke 1Symptoms of stroke 2Causes of stroke 3Classification of stroke 4International Classification of Functioning, Disabilityand Health 4Medical investigations following stroke and TIA 6The prevention of recurrence of stroke (secondaryprevention) 7Neuroanatomy 9Damage that can occur in different areas of the brain 13Policy documents relating to stroke 13Self-evaluation questions 232 Theoretical Basis 24Janet Ivey and Melissa MewIntroduction 24Theoretical constructs 24Conceptual models of practice 25Frames of reference 27Neuroplasticity 29Intervention approaches 36Self-evaluation questions 47

Contentsvii7 Management of Cognitive Impairments 144Thérèse Jackson and Stephanie WolffDefinition of cognition 144Cognitive functions 144Assessment of cognitive functions 144Cognitive rehabilitation 146Attention 147Memory 149Language 151Motor planning and apraxia 151Executive dysfunction 155Self-evaluation questions 1578 Management of Perceptual Impairments 158Louisa Reid and Judi EdmansIntroduction 158Definition of perception 158Normal perception 158Perceptual impairments 160Perceptual assessment 162Intervention 165Self-evaluation questions 1729 Resettlement 173Pip Logan and Fiona SkellyHome visits 173Community rehabilitation 174Support available after a stroke and self-management 177Carers 178Younger people 180Lifestyle and long-term management 180Leisure rehabilitation 181Getting out of the house and transport 183Driving after stroke 185Vocational rehabilitation 186Resuming sexual activity 188Stroke education 189Self-evaluation questions 19010 Evaluation 191Fiona Coupar and Judi EdmansRecord keeping 191Standardised assessments 195Evidence-based practice (EBP) 199

viiiContentsOutcome measures 203Standards 206Self-evaluation questions 207Appendix: One-Handed Techniques 208References 212Definitions 229Useful Books 231Useful Organisations 233Index 241

List of ContributorsFiona Coupar, University of Glasgow, GlasgowDr Judi Edmans, University of Nottingham, NottinghamDr Adam Gordon, University of Nottingham, NottinghamJanet Ivey, Llwynypia Hospital, RCT, Mid-Glamorgan, South WalesThérèse Jackson, NHS Grampian, ScotlandDr Pip Logan, University of Nottingham, NottinghamMelissa Mew, Bournemouth University, BournemouthLouisa Reid, National Hospital for Neurology and Neurosurgery, LondonFiona Skelly, Community Rehabilitation Team, RotherhamSue Winnall, Mile End Hospital, LondonStephanie Wolff, Manchester Royal Infirmary, Manchester

ForewordOccupational therapists working with people who have had a stroke will be delighted tolearn that there is a new edition of this popular textbook. The book has again been producedon behalf of the College of Occupational Therapists Specialist Section NeurologicalPractice, under the enthusiastic editorship of Dr Judi Edmans.Since the last edition, the text has been substantially and comprehensively updated interms of the research evidence presented. It has also been placed in the context of nationaldevelopments and initiatives in stroke care to span the entire stroke spectrum – fromaetiology through to resettlement and evaluation. However, it still remains a practicalguide, written in user-friendly terms, which provides an excellent reference manual forboth those starting out in the stroke field and established practitioners.The overall format and structure of the book is clear and logical. The addition ofgood-quality illustrations brings the text to life, and many will find the self-evaluationquestions with each chapter useful. Special mention must go to Chapter 1 which providesa comprehensive background to stroke and to Chapter 4 on early management.Above all, the book underlines the important and unique role of occupational therapyin the treatment and care of people with a stroke.Dr Avril DrummondAssociate Professor in RehabilitationUniversity of Nottingham

PrefaceThis 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 over5000 printed copies with countless hits from e-book access worldwide and has proven tobe a well-thumbed and well-known book for occupational therapists working in stroke allover the world.Since the last edition of the book, evidence-based quality stroke services have come tothe forefront of the government agenda throughout the UK with the release of nationalstroke guidelines, stroke service strategies and initiatives such as the Stroke ResearchNetworks, the Stroke Association’s annual multidisciplinary UK Stroke Forum conferenceand an imminent Stroke-Specific Educational Framework. It is an exciting time to workin stroke services, and this book is intended to compliment these works to provide amore in-depth, practical, evidence-based guide for occupational therapy students, newlyqualified occupational therapists, those new to stroke management and those who havebeen working in stroke for some time wanting to refresh the foundations of their knowledgeand skills.The reader will notice substantial changes since the last edition including use of theInternational Classification of Functioning Disability and Health [World Health Organisation(WHO), 2002], orientation to updated policy documents (Chapter 1), standards andaudits (Chapter 10), neuroplasticity (Chapter 2), procedural reasoning in different strokecare settings (Chapter 3) and more detailed user-friendly chapters on early managementand screening (Chapter 4), management of impairments (Chapters 5–8) and resettlement(Chapter 9). Therapeutic/clinical challenges have been integrated into appropriatesections with self-evaluation questions to support therapists’ commitment to continuousprofessional development at the end of each chapter.Throughout this book, the client or service user is referred to as ‘the patient’, forease of terminology, irrespective of whether they are being treated in hospital or in thecommunity. This by no means undervalues occupational therapists, key principle of clientcentredpractice to empower the patient to actively participate in partnership and negotiategoals in the rehabilitation process (Sumsion, 2000). Similarly, treatments are referred toas ‘interventions’, remedial approaches are referred to as ‘restorative’ approaches andcompensatory/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 keptfellow contributors (from the 2009 stroke clinical forum committee members of the

xivPrefaceCollege of Occupational Therapists Specialist Section Neurological Practice and returningauthors Thérèse Jackson and Fiona Skelly) on target to reach tight deadlines.Finally, the reader is reminded that the contents of this book should be reviewedin light of new ideas, research evidence and practice as they emerge. Suggestions forimprovements to future editions would be gratefully received and should be forwardedto Dr Judi Edmans, Division of Rehabilitation and Ageing, University of NottinghamMedical School, Queens Medical Centre, Nottingham NG7 2UH.Melissa MewStroke Clinical Forum Secretary 2008–09College of Occupational TherapistsSpecialist Section Neurological Practice

AcknowledgementsI would like to give particular thanks to Melissa Mew for her immense assistance inediting the book; all the contributors for their contributions and editing suggestions; DrIris Musa and Mary Warren for permitting us to include their figures in the book; theCollege of Occupational Therapists Specialist Section Neurological Practice for fundingto enable us to update the book; and last but not least, my long-suffering husband, MrPaul Fowler, not only for acting as a model for the dressing photographs but also for hisendless support and patience during the time taken to update this book.Dr Judi EdmansEditor

Chapter 1IntroductionJudi Edmans, Fiona Coupar and Adam GordonThis chapter includes: 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 questionsStroke is a complex condition where the knowledge base is continuously increasing. Thereare constant advances in the understanding of the condition, assessment and interventiontechniques. Occupational therapists are a vital component in the rehabilitation of patientswith this condition. It is vital that they understand the condition itself and the theoreticalbasis for intervention.Definition of strokeThe World Health Organization (WHO) defines stroke as ‘a clinical syndrome, of presumedvascular origin, typified by rapidly developing signs of focal or global disturbanceof cerebral functions lasting more than 24 hours or leading to death’ (WHO, 1978).Impact of strokeStroke 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 strokeeach year (Office of National Statistics, 2001). Stroke is the third most common causeof death, after heart disease and cancer, with over 67,000 deaths each year (British HeartFoundation, 2005). However, the most significant and lasting impact of stroke is long-termdisability. Stroke is the single, greatest cause of complex and severe adult disability in

2 Occupational Therapy and Strokethe UK (Wolfe, 2000; Adamson et al., 2004). A third of people who have a stroke willhave some long-term disability (National Audit Office (NAO), 2005). Common problemsfollowing stroke include aphasia, physical disability, loss of cognitive and communicationskills, depression and other mental health problems.In addition to the individual impact, stroke places a significant burden on health andsocial services. In England alone, stroke costs the National Health Service (NHS) andthe economy about £7 billion a year: £2.8 billion in direct costs to the NHS, £2.4 billionof 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 amongthe most expensive, with unnecessarily long lengths of stay and high levels of avoidabledisability and mortality (Leal et al., 2006).Symptoms of strokeThe initial symptoms of stroke are (Warlow et al., 2008): 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. Thesemay include a variety of abnormalities, which will be described further in later chapters.Face–Arm–Speech TestThe National Stroke Strategy for England (Department of Health (DH), 2007) highlightedthe 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 partnershipwith other stroke organisations and experts.The awareness campaign highlights that stroke is a medical emergency and time isessential to protect the brain from excess damage. Therefore, it is essential for people torecognise 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.

Introduction 3Anyone exhibiting any of these signs should be treated as an emergency with 999 beingcalled to get the patient to hospital as quickly as possible, to receive the treatment theyneed.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 strokeThe main causes of stroke are as follows.Ischaemia leading to infarctionThis describes impairment of blood supply to part of the brain, resulting initially indysfunction and then tissue death (infarction). The causes of cerebral infarct are classifiedaccording to the TOAST (Trial of Org 10172 in Acute Stroke Treatment) (Adamset al., 1993) classification as: Large artery occlusion (usually carotid or middle cerebral artery occluded by thrombusor embolism). Cardioembolism (clot from the heart, most commonly the atrial appendages, migratingto the cerebral arteries, causing blockage and stroke). Small vessel occlusion (thrombus or embolism in the smaller cerebral arteries, causinga lacunar infarct). Other aetiologies (e.g. generalised brain underperfusion, causing infarcts in the watershedterritories).HaemorrhageThis is usually intracerebral haemorrhage (i.e. within the body of the brain) but can besubarachnoid haemorrhage (i.e. between the arachnoid mater and the brain).Intracerebral haemorrhages are commonly caused by hypertension-related changesin the small intracerebral arteries but can, less commonly, be caused by aneurysms (outpouchingsof the arterial wall) or arteriovenous malformations (abnormal communicationsbetween arteries and veins).Transient ischaemic attackTransient ischaemic attack (TIA) is a term used to describe symptoms of stroke, resolvingwithin 24 hours. This does not represent a completed stroke but is, instead, causedby 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 aphysician as an emergency, ideally within 24 hours of presentation (Intercollegiate StrokeWorking Party (ISWP), 2008).

4 Occupational Therapy and StrokeClassification of strokeBamford et al. (1991) described a classification of cerebral infarction to help cliniciansidentify the part of the brain affected. This classification is based on the signs andsymptoms that patients experience and is now widely used. It is useful because it correlatesto prognosis. Thus, based on a bedside examination, a clinician can make predictionsabout survival and long-term dependency in order to inform management decisions anddiscussions 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 ofconsciousness, neglect syndromes, apraxia and agnosia syndromes.International Classification of Functioning,Disability and HealthThe 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, strokepatients often present with complex impairments which are a challenge for rehabilitationteams. The ICF provides a means of understanding and describing health status. It takes

Introduction 5Image not available in this electronic edition.Figure 1.1 Model of disability that is the basis for ICF. (Reproduced by permission fromWHO, 2001, with permission of World Health Organisation, p. 9.)account of impairments of body structure and function and how these interact withpersonal and environmental factors to affect patient’s activities and participation in thewider 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 psychologicalfunctions), for example, mental, neuromusculoskeletal and movement-related functionsBody structures: anatomical parts of the body such as organs, limbs and their components,for example, nervous system structures and structures related to movementsImpairments (of body function and structure): abnormal body functions and structuressuch as a significant deviation or loss, for example, hemiparesis following strokeActivity: execution of a task or action by an individual, for example, dressingActivity limitations: difficulties an individual may have in executing activities, forexample being unable to dress due to hemiplegiaParticipation: involvement in a life situation, for example, attending a social gatheringParticipation restrictions: problems an individual may experience in involvement inlife situations due to the activity limitation, for example, being unable to visit familyand friends due to difficulty dressingEnvironmental factors: physical, social and attitudinal environment in which peoplelive and conduct their lives, for example, legal and social structures, architecturalcharacteristics, coping styles, social background and experiencesPersonal 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 andparticipation restrictions.

6 Occupational Therapy and StrokeMedical investigations following stroke and TIAMedical investigations following stroke and TIA are performed to: 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 imagingImaging (either computerised tomography (CT) or magnetic resonance imaging (MRI))helps to establish the pathological diagnosis by detecting either cerebral infarction orhaemorrhage. The distinction between haemorrhage and infarction is important as treatmentwith aspirin or anticoagulants is likely to be indicated for cerebral infarction butwould be contraindicated in cerebral haemorrhage. A CT scan should therefore be performedon all patients within 24 hours of a stroke (ISWP, 2008).It is also useful for excluding other intracranial pathologies that mimic stroke, forexample, tumours or subdural haematomas. Practice varies with regard to routine scanningof TIAs; it is, however, increasingly common for physicians to perform a CT scan onthese 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 canarise 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 CTand can be used in this context. Diffusion-weighted MRI, in particular, can be used toseparate 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 andcerebellum because these parts of the brain are surrounded by dense bony structures,which generate artefacts on CT scanning.Blood testsOn 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 testsinclude the following:Full blood count: To look for rare conditions which predispose to stroke such aspolycythaemia (increased red cells) and thrombocytosis (increased platelets) andconditions that predispose to haemorrhage, such as thrombocytopaenia (decreasedplatelets).To exclude leucocytosis (raised white cell count) which might indicate systemicinfection (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, vasculitisor carcinoma and may prompt further investigation.

Introduction 7Blood sugar: Hypoglycaemia at presentation is a recognised stroke mimic, whilstdiabetes mellitus is a risk factor for stroke. Therefore, all patients should receive abedside finger-prick glucose test and formal laboratory glucose level.Fasting lipids: Hyperlipidaemia is a recognised risk factor for stroke and lipids shouldbe 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 patientwho has a stroke whilst on warfarin.Thrombophilia screen: Patients presenting with venous sinus thrombosis should bechecked for an inherited tendency towards clot formation (factor V Leiden, protein Cdeficiency, protein S deficiency, lupus anticoagulant). This should only be consideredin arterial thrombosis for younger patients where no alternative risk factor for strokeis identified (Hankey et al., 2001).Cardiac investigationsThere is a cardiac source of embolism in 20% of cases of cerebral infarction (Sandercocket al., 1989). Electrocardiogram should therefore be performed in all patients to investigateatrial fibrillation or evidence of structural heart disease.Echocardiogram is performed in patients where intracardiac thrombus or structuralheart disease, particularly valvular disease, is suspected. In many centres, it is routine todo echocardiograms in all patients presenting with atrial fibrillation.Carotid ultrasoundThis is performed to look for internal carotid artery stenosis. The technique involvesimaging of the artery with measurement of blood flow velocity, which allows an estimationof the degree of vessel stenosis to be made.Magnetic resonance angiographyThis is now used widely in clinical practice. Images can be obtained at the same time asstandard and diffusion-weighted MRI, making the investigation only marginally longer.It is non-invasive and is therefore preferred to catheter digital subtraction angiography inmost instances.This procedure is completed to allow 3D reconstructions of the arterial and venous cerebralcirculations, which can allow identification of thrombus, arterial stenosis/occlusionand dissection.The prevention of recurrence of stroke(secondary prevention)Following stroke, many strategies are used to help prevent recurrence. General measuresare recommended in all patients, such as reducing body mass index, adopting a diet low

8 Occupational Therapy and Strokein 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 theabsence of medications.Antiplatelet agentsBased upon current clinical trial evidence, aspirin prescribed after acute stroke will preventabout 11 strokes for every 1000 patients treated (Chinese Acute Stroke Trial (CAST)Collaborative Group, 1997; International Stroke Trialists (IST), 1997). The optimal dosageappears to be between 50 and 150 mg, with higher doses increasing risk of gastrointestinalbleeding 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 relativerisk of stroke compared with aspirin alone (Halkes et al., 2008). Current recommendedpractice in the UK is to prescribe patients 300 mg of aspirin daily for the first 2 weeksfollowing an ischaemic stroke, with aspirin 75 mg used in conjunction with dipyridamolefollowing this (ISWP, 2008).Clopidogrel is an alternative antiplatelet agent, used in combination with aspirin followingacute coronary syndromes. This combination, if used following stroke, increases therisk 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. Inmany areas this treatment is therefore reserved for patients where aspirin cannot be givendue to intolerance.Blood pressureHypertension should be aggressively treated following a stroke. The target blood pressurefollowing a stroke is 130/80 (ISWP, 2008). Current evidence favours prescription of thiazidediuretics and angiotensin-converting enzyme (ACE) inhibitors over other types ofantihypertensives (PROGRESS Collaborative Group, 2001). Angiotensin receptor blockers(ARBs) are used where ACE inhibitors cannot be tolerated due to cough.HyperlipidaemiaThere is now good evidence that medications to reduce serum low-density lipoproteincholesterol reduce the incidence of stroke (Smilde et al., 2001; Kastelein et al., 2008).Current data suggest that statin drugs (simvastatin, atorvastatin, rosuvastatin) promoteregression of cholesterol plaques in the carotid arteries (Smilde et al., 2001).AnticoagulantsClinical trials have demonstrated the benefit of warfarin in the prevention of stroke inpatients with atrial fibrillation (Mant et al., 2007).

Introduction 9There is a risk of haemorrhage for patients taking warfarin, and a careful considerationof the balance of risks and benefits must be undertaken in any patient where it is to becommenced. Contraindications include a bleeding tendency (e.g. recent peptic ulcerationor haemorrhagic bladder tumour), high falls risk, alcohol dependency (alcohol interactswith warfarin) and an inability to follow instructions to take the medicine safely (whichmay 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 endarterectomyTrials have shown that this operation to widen the internal carotid artery is beneficialin 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 shouldbe limited to patients with reasonable functional status and salvageable brain tissue inthe vascular territory under consideration. Therefore, bed-bound patients with large totalanterior circulation strokes are not appropriate for this therapy.Preventative neurosurgeryPatients who have suffered from haemorrhagic stroke (primary intracerebral haemorrhage,subarachnoid haemorrhage) and who have an underlying arterial abnormality, such as ananeurysm or arteriovenous malformation, may benefit from neurosurgical techniques suchas aneurysm clipping or embolisation of arteriovenous malformations.NeuroanatomyThe brain is divided into four main areas: Forebrain– Cerebrum divides into two hemispheres with four lobes (frontal, parietal, temporaland 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). Midbrain (brainstem) (Figure 1.3)– Mesencephalon (midbrain).– Pons.– Medulla oblongata. Hindbrain– Cerebellum (Figure 1.2). Spinal medulla (spinal cord) (Figure 1.3)

10 Occupational Therapy and StrokeFrontal lobePrecentralgyrusCentralsulcusPostcentralgyrusParietal lobeOccipitallobeLateralsulcusTemporal lobePonsCerebellumMedulla oblongataFigure 1.2 Lateral view of the brain. (Reproduced by permission of Pearson Education Incfrom Martini, 2006, Figure 14-12b, p. 471.)Cerebrum• Conscious thought processes,intellectual functions• Memory storage and processing• Conscious and subconscious regulationof skeletal muscle contractionsDiencephalonThalamus• Relay and processingcentres for sensoryand motor informationHypothalamus• Centres controllingemotions, autonomicfunctions andhormone productionMesencephalon• Processing of visualand auditory data• Generation of reflexivesomatic motorresponses• Maintenance ofconsciousnessLeft cerebralhemisphereBrainstemSpinalcordGyriSulciFissuresCerebellum• Coordinates complexsomatic motorpatterns• Adjusts output ofother somatic motorcentres in brainand spinal cordPons• Relays sensoryinformation tocerebellum andthalamus• Subconscioussomatic and visceralmotor centresMedulla oblongata• Relays sensory information to thalamusand to other portions of the brain stem• Autonomic centres for regulation of visceralfunction (cardiovascular, respiratory anddigestive system activities)Figure 1.3 The diencephalon and brainstem structures of the brain. (Reproduced bypermission of Pearson Education Inc from Martini, 2006, Figure 14-1, p. 453.)

Introduction 11Head ofcaudate nucleusLentiform nucleusAmygdaloid bodyTail of caudatenucleusThalamus(a)Head ofcaudate nucleusLateralventricleCorpuscallosumInternalcapsuleInsulaAmygdaloidbodyLentiformnucleusPutamenGlobus pallidusAnterior Tip of lateralcommissure ventricle(b) Frontal sectionFigure 1.4 Frontal section of the brain showing the basal nuclei, internal capsule andthalamus. (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: The anterior circulation comprising two internal carotid arteries which divide into twomajor arteries:– Anterior cerebral artery.– Middle cerebral artery. 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 thereis a carotid artery on each side. Because the vertebral arteries join quite low down thebrainstem, most of the posterior circulation is supplied by a single basilar artery.

12 Occupational Therapy and StrokeAnterior cerebralInternal carotid (cut)Middle cerebralPituitary glandBasilarAnterior communicatingAnterior cerebralPosterior communicatingPosterior cerebralSuperior cerebellarCerebralarterialcircleVertebralAnterior inferior cerebellarPosterior inferior cerebellarFigure 1.5 Arteries of the brain. (Reproduced by permission of Pearson Education Inc fromMartini, 2006, Figure 21.23, p. 741.)Territory ofanteriorcerebral arteryTerritory ofmiddlecerebral arteryInternal capsuleClaustrumBody of caudateThalamusGlobus pallidusPutamenRed nucleusSubthalamic nucleusCerebral peduncleTerritory of anterior choroidalartery (lower 2/3 of internalcapsule, pallidum, uncus, amygdala,anterior hippocampus)UncusTerritory ofposteriorcerebral arteryTerritory of penetrating branchesof middle cerebral artery (putamen,upper internal capsule, lower coronaradiata, body of caudate)Figure 1.6 Frontal section of the left hemisphere showing the arterial supply. (Reproduced bypermission of McGraw-Hill from Kandel et al., 2000, Figure C-2, p. 1304.)

Introduction 13If each of these circulations existed in isolation, then blockage of either carotid or thebasilar artery would result in extensive, life-threatening infarction. This does not occur,however, because of anterior and posterior communicating arteries which connect thebrain arteries into an anatomical circle, known as the circle of Willis. Thus when onevessel is blocked, an alternative (or collateral) blood supply is available.There is considerable variation between individuals with regard to how effective theircommunicating arteries are, and thus collateral circulation, is. Thus carotid, or basilar,occlusion can result in life-threatening stroke for some individuals and will pass unnoticedby 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 resultin different severities of stroke in different patients.Damage that can occur in different areas of the brainEach hemisphere has specialised functions known as hemispheric lateralisation. For example,the left hemisphere senses and controls movement on the right side of the bodyand specialises in language-based skills such as reading, writing and speaking, and performsanalytical tasks such as mathematics and logical reasoning. Oppositely, the righthemisphere senses and controls movements on the left side of the body and is specialisedin more creative, spatial and interpretive skills (Figure 1.7).Testani-Dufour and Morrison (1997) summarised the arterial supply of the brain and theresults of occlusion to those arteries. They also summarised the functions of the differentareas of the brain and the impairments that can occur as a result of damage (occlusion) tothose areas. This information is collated in Tables 1.1–1.3, but should not be consideredas a definitive list.Policy documents relating to strokeOver 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 documentsbeing published, all of which aim to reduce stroke incidence, improve services and increaseawareness.The first notable policy document related specifically to stroke was published by theDH in 2001.National Services Framework for older peopleThe National Services Framework (NSF) for older people (DH, 2001) is a comprehensivestrategy to ensure fair, high-quality, integrated health and social care services for olderpeople. It is a 10-year programme of action linking services to support independence andpromote good health, specialised services for key conditions and a culture change so thatall older people and their carers are treated with respect, dignity and fairness. This NSFsets eight standards for the care of older people across health and social services.

14 Occupational Therapy and StrokeLeft HandRight HandPrefrontalcortexPrefrontalcortexSpeechcentreAnteriorcommissureWritingAuditorycortex(right ear)Generalinterpretivecentre(language andmathematicalcalculation)Visual cortex(right visual field)Analysisby touchAuditorycortex(left ear)Spatialvisualisationand analysisVisual cortex(left visual field)LeftHemisphereRightHemisphereFigure 1.7 Hemispheric lateralisation of the brain. (Reproduced by permission of PearsonEducation Inc from Martini, 2006, Figure 14-6, p. 477.)Standard five of the NSF is specific to stroke and aims to reduce the incidence ofstroke in the population and ensure that those who have had stroke have prompt access tointegrated stroke care services. This standard sets out four components for the developmentof integrated stroke services: Prevention, including the identification, treatment and follow-up of those at risk ofstroke. Immediate care, including care from a specialist stroke team.

Introduction 15Table 1.1Areas of the brain and the results of occlusion to arteries in those areas.FunctionsFrontal lobe• Concentration• Abstract thought• Memory• Judgement• Ethics• Insight• Emotion• Tact• Inhibition• Sequencing thoughts• Evaluates consequences of actions• Solves intellectual problems• Morality• Motor functionBroca’s area• Expression of speech• Word formation• Articulation• Pronunciation• Voice and speech productionParietal lobe• Interpretation of sensory input• Contralateral sensation– Two-point discrimination– Pressure– Weight– Texture– Body interpretation– Orientation– Pain– Proprioception• Recognises nature of complexobjects by touch and formTemporal lobe• Auditory area• Wernicke’s area:– Receive and discriminate sounds– Interpretation of sounds• Olfactory area• Detailed memories, especially thoseinvolving more than one sensorymodalities (dominant side)Occipital lobe• Visual reception• Visual association• Detects spatial organisation ofvision, shapes, colours, contrasts• Secondary complex visualinterpretationImpairmentsImpairments Anterior Cerebral Artery andMiddle 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 neglectImpairments Middle Cerebral Artery andPosterior Cerebral Artery• Wernicke’s aphasia• Comprehension• Repetition of speech• Jargon• Reading comprehension• Visual and interpretative disorders• Contralateral field disorders, e.g.quadrantanopia/hemianopia• Partial visual field loss• Altered perception(Continued)

16 Occupational Therapy and StrokeTable 1.1(Continued)Functions• Perception of form and meaning• Eye fixationThalamus• Sensory and motor pathwayscontact thalamus except olfactorypathwaysBasal ganglia• Production of dopamine• Coordination of muscle movementsand postureMidbrain• Synthesises dopamine• Protects basal gangliaPons• Transmits information from cerebralcortex to brainstem and betweentwo hemispheres• Sensory pathways pass throughpons• Regulates respiratory systemMedulla• Blood pressure and respiratoryregulation• Maintenance of arousal• Initiation of sleepImpairments• 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 motorimpairments• Altered postural sense, proprioception,vibration• Respiratory insufficiency• Cardiac/vasomotor dysfunction• Swallowing• Head and shoulder movement• Tongue movement• Salivation and pharyngeal functionCerebellum• Receives proprioceptive input• Maintains equilibrium• Coordinates automatic movement• Regulates muscle tone• Poor coordination and fine dexterity• Gait ataxia• Intention tremor• Diadochokinesia• Dysmetria• Hypotonia• AstheniaACA, anterior cerebral artery; MCA, middle cerebral artery; PCA, posterior cerebral artery.

Introduction 17Table 1.2SuppliesAnterior arterial supply of the brain and the results of occlusion to those arteries.OcclusionOphthalmic artery• Orbit• Optic nerveAnterior choroidal artery• Deep structures of the brain(basal ganglia, thalamus,posterior limb of internalcapsule and medialtemporal lobe)Anterior cerebral artery• Anterior three-quarters ofmedial surface of cerebralhemisphere• Portions of the basal ganglia• Internal capsuleMiddle cerebral artery• Basal ganglia• Fibres of internal capsule• Cortical surfaces of theparietal, temporal andfrontal lobes• Transient mononuclear blindness (amaurosis fugax)• Complete unilateral blindness• Contralateral hemiplegia, hemihypesthesia,homonymous hemianopia• Contralateral sensory and motor impairments footand 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 aphasiaDistal Anterior Cerebral Artery• Contralateral upper and lower extremity weakness• Contralateral sensory loss in foot• Motor and/or sensory aphasiaComplete 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

18 Occupational Therapy and StrokeTable 1.3SuppliesPosterior arterial supply of the brain and the results of occlusion to those arteries.OcclusionVertebral artery• Anterolateral parts of the medullaPosterior–inferior cerebellar artery• Medulla• CerebellumBasilar artery• Pons• MidbrainPosterior choroidal artery• Third ventricle• Dorsal surface of thalamusPosterior cerebral artery• Occipital lobe• Medial and inferior surface oftemporal lobe• Midbrain• Third and lateral ventriclesLateral medullary syndrome• Contralateral impairment pain andtemperature sensation• Ipsilateral Horner’s syndrome• Dysphagia• Decreased gag reflex• Vertigo• Nystagmus• AtaxiaOcclusion medial branch• Vertigo• Nystagmus• Ataxia• Persistent dizzinessOcclusion 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 thecranial nerve motor nuclei• Nystagmus• Eye movement disturbance• ComaComplete occlusion• Locked in syndrome• Consciousness with complete motorparalysis, inability to communicate orally or bygesture• Not seen• Contralateral hemiplegia• Sensory loss• Ipsilateral visual field impairments• Weakness greater in face and upperextremities

Introduction 19Table 1.3(Continued)SuppliesAnterior inferior cerebellar artery• Cerebellum• PonsSuperior cerebellar artery• Cerebellum upper part• MidbrainOcclusion• Vertigo• Nausea• Vomiting• Nystagmus• Tinnitis• Ipsilateral cerebellar ataxia• Horner’s syndrome• Contralateral loss of pain and temperaturesense of arm, trunk and leg• Ipsilateral cerebellar ataxia• Nausea• Vomiting• Slurred speech• Contralateral loss of pain and thermal sensation Early and continuing rehabilitation. Long-term support for the stroke patient and their carers.Stroke strategiesSince the publication of the NSF for older people, specific stroke strategies have beendeveloped in Scotland 2002/4, England 2007, Wales 2007 and Northern Ireland 2008.ScotlandThe Coronary Heart Disease and Stroke: Strategy for Scotland was published by theScottish Government in 2002 and subsequently updated in 2004 (Scottish Government,2004). This strategy covered: 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: Establishing MCNs. Stroke units. More rapid imaging. Manpower plan and training. National audit. Improved IT.

20 Occupational Therapy and StrokeIn 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: 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). Improving the quality of care and support– Information and communication.– Self-management.EnglandThe National Stroke Strategy for England published in 2007 is a comprehensive strategywhich summarised a 10 point plan for action (DH, 2007):1. Awareness of stroke.2. Preventing stroke.3. Involvement of patients.4. Acting on the warnings.5. Stroke as a medical emergency.6. Stroke unit quality.7. Rehabilitation and community support.8. Participation.9. Workforce.10. Service improvement.Quality service markers were put in place to monitor the compliance with the strategyregarding:1. Awareness raising.2. Managing risk.3. Information, advice and support.4. Involving individuals in developing services.5. Assessment – referral to specialist.6. Treatment for TIA or minor stroke.7. Urgent response.8. Assessment – immediate structured clinical assessment.9. Treatment on a stroke unit.10. High-quality specialist rehabilitation.11. End-of-life care.12. Seamless transfer of care.13. Long-term care and support.

Introduction 2114. Assessment and review after discharge.15. Participation in community life.16. Return to work.17. Networks.18. Leadership and skills.19. Workforce review and development.20. Research and audit.WalesThe Welsh health circular Improving Stroke Services: A Programme of Work (WelshAssembly Government, 2007) summarises the programme of stroke improvements forWales in the following three areas:Preventing strokes Public information leaflets. Public and health professional education programmes. Identification of gaps in local and national resources. Referrals to lifestyle initiatives. Referral of TIA patients to a one-stop assessment and investigation service.Improving stroke survival rates Commissioning specification for stroke services. Action plans to implement the older people’s NSF stroke standards of care. Evidence for stroke as a 999 call. Protocols and quality requirements. Profession-specific audits. Introduction or expansion of specialist and consultant staff. Dedicated and colocated acute stroke beds. Referral to palliative care and end-of-life care, where appropriate. Establishment of research programmes for stroke.Maximising post-stroke-independent living and quality of life Development of protocols and quality requirements for rehabilitation assessmentsand interventions.Northern IrelandIn July 2008 revised recommendations for the Northern Ireland stroke strategy werepublished in Improving Stroke Services in Northern Ireland (Department of Health, SocialServices 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. Thisdocument sets out seven standards:1. Organisation of stroke services.2. Acute stroke care and hospital-based rehabilitation.3. Secondary prevention.4. Discharge planning.

22 Occupational Therapy and Stroke5. Community-based care.6. Palliative care.7. Communication with patients and carers.GuidelinesThe 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 statementswhich assist clinicians (including Occupational Therapists) and service users in making decisionsabout 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.ScotlandEvidence-based guidelines for the care of patients following stroke in Scotland (ScottishIntercollegiate Guidelines Network, 2002) were developed with sections on:1. Organisation of services.2. General rehabilitation principles.3. Specific management and prevention strategies.4. Discharge planning and transfer of care.5. Roles of the multidisciplinary team.6. Patient issues.These are currently being updated, with the revised edition expected by late 2010.The Scottish Intercollegiate Guidelines Network (2008) also published guidelines onthe Management of Patients with Stroke or TIA: Assessment, Investigation, ImmediateManagement and Secondary Prevention, which include sections on: 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.

Introduction 23England, Wales and Northern IrelandThe 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: 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 alsoincluded.Self-evaluation questions1. What is the impact of stroke in the UK?2. What are the main symptoms of stroke?3. What are the main causes of stroke?4. What are the main stroke classifications?5. What does the ‘FAST’ acronym stand for?6. What medical tests/investigations are common following stroke?7. What secondary prevention could be used?8. What are the main arteries in the brain?9. What specific impairments are associated with injury to the frontal, parietal andtemporal lobes?10. What are the key elements of the national stroke strategies?

Chapter 2Theoretical BasisJanet Ivey and Melissa MewThis chapter includes: Theoretical constructs Conceptual models of practice Frames of reference Neuroplasticity Intervention approaches Self-evaluation questionsIntroductionOccupational therapy’s principle concern is with the patient’s occupational identity andoccupational performance. In other words, ‘how individual’s identify themselves and theirfuture aspirations, their roles and relationships, together with their personal capacity forfulfilling these within their physical and social environment’ (Duncan, 2006: p. 6). Engagementin occupations, functional occupational performance and positive occupationalidentity are required to achieve health, well-being and life satisfaction.Following stroke, patients may be faced with occupational dysfunction. Occupationalperformance capacity may become impaired, impacting on their physical, cognitive andpsychosocial capacity to adapt to effectively meet the demands of and engage in theirusual occupations, thus impinging on their occupational identity, health and well-being.The role of the occupational therapist is to enable patients to regain competence, reengagein 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 andframes of reference) that are used to direct occupational therapy intervention approachesand enable patients.Theoretical constructsTheoretical constructs, such as Conceptual Models of Practice and Frames of Reference,help to describe and explain occupational function, guide assessments and interventions

Theoretical Basis 25and predict outcomes. They also help to define our own professional identity. At times thedifference between Frames of Reference and Models can be confusing but for argumentssake, Duncan’s (2006) delineations will be used where a Conceptual Model of Practiceis ‘an occupation-focussed theoretical construct or proposition that has been developedspecifically 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 ideathat has been developed outside the profession but, with judicious use, is applicablewithin occupational therapy (to guide and structure) practice’ (Duncan, 2006: p. 62).Thus, occupational therapists may have a preference for adhering to a particular model ofpractice to help maintain their professional identity. Applied to any occupational modelof practice, occupational therapists will use their core skills or ‘legitimate tools’ to enabletherapeutic change. The core skills of occupational therapy include: therapeutic use of selfto collaborate with the patient; skilled clinical observations; process skills of assessment,planning and implementing intervention to enable change and evaluation; purposeful useof activity as a therapeutic tool; occupational analysis and adaptation; environmentalanalysis and adaptation; therapeutic use of groups; and use of teaching and learningprinciples (Mosey, 1996; Hagedorn, 2000; Duncan, 2006).In addition, therapists will draw on appropriate frames of reference, depending on thepatient context which will influence the Intervention Approach taken. Specific interventionapproaches provide tools to enable change, including assessment tools, interventiontechniques and style of the patient–therapist relationship.Conceptual models of practiceThe Model of Human Occupation (MOHO) (Kielhofner, 2008) considers the complexityof human occupation that behaviour is dynamic and context dependent and thatoccupations shape a person’s self-perception and identity. It proposes that people’s participationin occupation is influenced by their own volition (personal causation, values andinterests), habituation (habits and roles) and performance capacity as well as the environment(physical and social including cultural contexts). Actual occupational performanceis then dependent on skills (motor, process and communication and interaction skills) performingoccupational forms (or activities) and participation. Participation helps to createoccupational identity and a sense of occupational competence. A positive occupationalidentity and sense of personal competence over time in the context of the environmentenable 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 ProcessSkills (AMPS), Interest and Role Checklists and Work Environment Impact Scale.This model and its associated tools help occupational therapists working with strokepatients 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 addresspatient’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,

26 Occupational Therapy and Strokeaffective and cognitive components of the person whose self-care, productivity and leisureoccupations occur in the context of the physical, institutional, cultural and social environment.The latest amendment specifies the occupational therapy domain of concernin the dynamic interaction of the person, occupation and environment. It further regardsoccupation beyond performance to consider the importance of engagement and inclusion.The Canadian Occupational Performance Measure (COPM) (Law et al., 2005) was developedfrom earlier versions of this model, but remains consistent, with the CMOP-E asa client-centred outcome measure enabling clients to rate importance, performance andsatisfaction 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 workingwith stroke patients; however, challenges can arise when therapists are constrained byinpatient settings or patients’ levels of insight.Similar but distinctive models emphasising person, environment and occupationinclude the Person–Environment–Occupation (PEO) Model (Law et al., 1996) andPerson–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, occupationalroles, 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), theperformance environment (sensory, social, physical and social contexts), time and space.The Perceive Plan Recall and Perform (PRPP) System of Task Analysis (Chapparo andRanka, 1997) was developed as one of the assessment tools within this model.Activities Therapy (Mosey, 1996) combines psychodynamic, human developmentaland behavioural frames of reference. This model suggests that adaptive (compensatory/functional)skills are re/learnt in a developmental sequence to achieve maturefunctioning and influenced by the environment and their biological composition. In relationto stroke, this model suggests that dysfunction arises when patients regress in theirsensory integration, cognitive, dyadic interaction, group interaction, self-identity and/orsexual identity skills. Rehabilitation is based on sequential relearning of adaptive (compensatory/functional)sub-skills through graded occupation and patient’s innate need formastery.The Kawa (River) Model (Lim and Iwama, 2006) is an emerging model from anAsian perspective which may address cultural biases of existing models (which valueindividualism, autonomy and independence) to consider cultural values of collectivism,social hierarchy and interdependence. Appreciation of non-western perspectives enablestherapists to be truly client-centred. This model emphasises the harmonious interaction ofmind, body, soul, spirit and environment for health and well-being. The western view ofself is decentralised and central focus of occupational therapy is to enable the patient’s lifeflow (or river) by achieving harmony between life circumstances and problems (rocks),the physical and social environment (walls and bottom of the river) and personal attributesand resources, including values, character, personality special skills, material and immaterialassets and liabilities (driftwood). Thus to enable the patient’s energy (water) to flow,occupational therapists must prioritise and direct interventions towards utilising existing

Theoretical Basis 27currents and addressing obstructions, but not necessarily eliminating them, so that thepatient’s life energy (water) can flow. Thus, in stroke rehabilitation, reduction of impairmentsmay not be as significant as it is in western cultures. Maximising patients’ personalattributes and resources, adapting environments and considering interdependence on familyand social participation (social inclusion) may be more meaningful than addressingimpairments and activity limitations.Frames of referenceClient-Centred Frame of Reference is a humanistic approach which originated with psychotherapistCarl 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 informedchoice; partnership between client and therapist to work together to negotiate therapygoals and processes; responsibility of the client for his/her own health and ethical responsibilityof the therapist to ensure no harm; empowering and enabling clients to achievetheir occupational goals; understanding clients individual contexts through respect andlistening; accessibility of services to meet clients needs; and respect for diversity. It recognisesthat ‘the client’ might also be the family, carers or institution in addition to the personreferred. 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 methodthat falls under this frame of reference (Miller and Rollnick, 2002).Biomechanical Frame of Reference is a bottom-up frame of reference, usefulfor understanding occupational performance capacity in more detail. It considers theanatomy and physiology and mechanics of human movement (kinesiology) focusingon musculoskeletal, neuromuscular and cardiorespiratory systems. Occupational therapyapproaches that fit within this frame of reference include graded activities to improvemovement strength, endurance, range of motion and sensation, work hardening, energyconservation, ergonomics, assistive devices, splinting and joint protection. Thusapproaches to prevent deterioration, restore function or compensate for limitations aresignificant here. Nevertheless, the primary assessment and outcome for occupationaltherapy 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 dailyactivities and social roles and focuses on therapists teaching, patients learning adaptive(compensatory/functional) methods, assistive equipment and environmental modificationsto restore function when underlying impairments cannot be remediated and successfulrehabilitation is dependent on motivation and cognitive skills.Motor Control Frame of Reference considers the relationship between the centralnervous system in relation to motor function and reacquisition of coordinated skilledmovement but recognises the influence of other systems (sensory input and cognitive processing),environmental context and learning principles (such as attention, feedback, activeparticipation and goal-directed movement). In comparison to a biomechanical frame of

28 Occupational Therapy and Strokereference, 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/motorrelearning, Rood, Brunnstrom’s Movement Therapy, Proprioceptive NeuromuscularFacilitation, Mental imagery and Constraint-Induced Movement Therapy (see ‘InterventionApproaches’ later in this chapter).Behavioural Frame of Reference considers learning principles arising from stimulusresponsemodels such as Pavlov’s classical condition and Skinner’s operant conditioningwhere behavioural responses to stimuli or triggers can be modified through exposureand manipulation of the consequences. This frame of reference is useful for behaviourmodification such as desensitisation or reduction of anxiety-related symptoms as well asfor new learning principles such as repetition and positive feedback.Cognitive Frame of Reference originated in psychiatry and psychoanalytical theorywith the work of Aaron Beck. This frame of reference examines the links between thepatients’ automatic thinking, their behaviour and emotional response. Dysfunctional beliefs,values and thinking may be distorted, unrealistic and unhelpful. These are exploredand challenged to change patients’ perceptions and emotional response to events.Cognitive-behavioural therapy (CBT) links the cognitive and behavioural frames ofreference together. It utilises a problem-focused approach to explore patients’ underlyingthoughts, beliefs and physiological responses associated with specific triggers and theconsequences of dysfunctional behavioural responses that might maintain these. Dysfunctionalthinking and beliefs in response to triggers are then challenged to change patient’sperspectives and more adaptive (compensatory/functional) behaviour can be tested out insafe environments such as role play, facilitated groups and graded activity scheduling.Adaptive (compensatory/functional) behaviour is reinforced through patients’ feelings ofself-efficacy, consequences that disprove dysfunctional beliefs and therapist feedback,which is recorded in activity diaries. Techniques can be deceptively simple and specialisttraining is required. Considering its inherent overlap with clinical psychology, Duncan(2006) further cautions that a cognitive-behavioural frame of reference should be used inconjunction with an occupation-focussed conceptual model of practice to maintain professionalrole and identity and to enhance the therapeutic potential of the patient–therapistpartnership.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 chronicpain and chronic fatigue syndrome (Duncan, 2006). Although CBT appears useful forstroke patients and is probably employed to some degree during rehabilitation, furtherresearch is required on the effectiveness of CBT strategies with stroke patients (Lincolnand Flannaghan, 2003).Psychodynamic Frame of Reference originated with Sigmund Freud’s controversialtheories but has been developed to focus on understanding the relationship between pastexperience and present difficulties. It highlights links between unconscious motivationsand emotions which are operationalised through interpersonal interaction, behaviour andoccupation. For example, mechanisms such as repression, denial, projection, reactionformation, intellectualisation, rationalisation, regression, sublimation and compensationprotect the psyche against anxiety arising from unconscious internal conflict. These

Theoretical Basis 29internal conflicts and underlying emotions and motivations can be therapeuticallyexplored and symbolically resolved through creative (projective) activities, meaningfuloccupations, reflection, group work processes and therapeutic relationships to achieve asense of wellness (Blair and Daniel in Duncan, 2006: p. 233).Cognitive Perceptual Frame of Reference draws on neuroscience and neuropsychologyand focuses on the components and interaction of cognitive and perceptual skillsthat impact on occupational performance. Treatment approaches can be categorised intoremedial/bottom-up/skills training or adaptive/top-down/strategy training approachesrecognising 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 ofcognitive and perceptual tools and treatment strategies fall under this umbrella (seeChapters 7 and 8).In addition to the above theoretical constructs which assist in guiding occupational therapypractice, the emerging theories of neuroplasticity are utilised in current neurologicalpractice. A knowledge of neuroplasticity can assist the occupational therapist in selectingan intervention/approach for the individual patient and will assist in clinical reasoningand justification of the intervention administered.NeuroplasticityDespite recognition that post-injury experience could result in adaptive or maladaptiveresponses, historically it was believed that neurones in the adult mammal’s central nervoussystem (CNS) were ‘hard wired’ like an electrical circuit that could not regenerate or repairafter injury (Gage, 2002). Thus, recovery in neurorehabilitation focussed on strategies thatdiscouraged maladaptive behaviour and focussed on adaptive functional behaviour andgoal achievement (Cohen, 1999). This was supported by evidence that neurorehabilitationimproved patient outcomes (Intercollegiate Stroke Working Party (ISWP), 2008). However,more recent advances in neuroscience and functional imaging have demonstratedevidence of neuroplasticity – the brain’s considerable capacity for neural reorganisation(Nudo and Friel, 1999). Consequently, momentum has escalated for therapists to understandthe scientific basis of neurorehabilitation to capitalise on this to enhance truerecovery of function following stroke (Aisen, 1999; Mateer and Kerns, 2000; Pomeroyand Tallis, 2002b).From conception to death, neuroplastic changes occur. These can be associated withnormal responses to experiences such as maturation, development and learning (Hallet,1995; Kotulak, 1998). Therefore, cells are constantly adapting to the challenges of theinternal and external environment (Stephenson, 1996).Structure of a neuroneThe neurone cell is specialised to maintain high rates of protein synthesis and have longprojections from the cell body.Dendrites are large extensions of the cell body and receive most of the synaptic inputsinto the cell. Neurones may have one or many dendrites, which are typically short and

30 Occupational Therapy and StrokeDendritesAxon hillockCell bodyAxoncollateralsAxonFigure 2.1 Structure of a neurone. (Reproduced with permission from Dr I. Musa, CardiffUniversity, personal communication, 2009.)highly branched, as shown in Figure 2.1. They provide sites for synaptic connection withother 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 signalconduction. Neurones have a single axon arising from the axon hillock and its terminalforms the presynaptic component of a synapse. Axons may extend to less than a millimetreto 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: eitherthe rerouting and subsequent formation of new connections, or neurones substitutingfunction of damaged neurones to enhance the effectiveness of existing connections (Kiddet al., 1992). This includes: The concepts of synaptic strengthening or potentiation – altering the effectiveness ofsynapses (short-term potentiation/long-term potentiation). Unmasking of existing silent synapses whose function was previously blocked byinhibitory influences. Sprouting of new axon terminals. Changes in dendritic organisation.

Theoretical Basis 31Synaptic transmissionNeurotransmitters may be classified into two broad categories, such as G protein-coupledor metabotropic receptors and transmitter-gated ion channels. The following discussestransmitter-gated ion channels and the mechanisms of short-term presynaptic potentiationand 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 glutamatewhich diffuses across the synaptic cleft binding to the glutamate receptors on thepostsynaptic membrane. When glutamate binds to the (α-amino-3-hydroxyl-5-methyl-4-isoxazole-propionate) AMPA receptors on the postsynaptic membrane, this allows amixed flow of sodium (Na + ) and potassium (K + ) to cross the cell membrane causinga 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(Mg 2+ ) at the channel. At the resting membrane, the inward current through theNMDA is blocked by the magnesium which has bound to the channel. As the membranebecomes depolarised, the (Mg 2+ ) block is displaced from the channel and the current isfree to pass into the cell. This requires constant release of glutamate to maintain the membranedepolarisation. NMDA receptors are therefore voltage dependent (Purves et al.,1997) (see Figure 2.2).AMPA receptorNMDA receptorMetabotropic glutamate receptorPresynapticaxon terminalGlutamateFigure 2.2 Short-term presynaptic potentiation. (Adapted from Bear et al. (2007) by Dr I.Musa, Cardiff University, personal communication, 2009. Reproduced with permission fromLippincott, Williams & Wilkins.)

32 Occupational Therapy and StrokeLong-term postsynaptic potentiation (LTP)Long-term potentiation is commonly associated with learning and plasticity. It occurs atsome 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 changesin the efficacy of synaptic transmission for the storage of neural information and thedevelopment of functional circuits (Dobkin, 1998).NMDA receptors also conduct calcium (Ca 2+ ) ions; therefore, the magnitude of Ca 2+flux passing through the NMDA receptor channel specifically signals the level of pre- andpostsynaptic coactivation (Bear et al., 2007). Strong NMDA receptor activation and Ca 2+entry into the postsynaptic dendrite bind to calmodulin which activates protein receptorkinase II. This phosphorylates the AMPA receptors and serves as a signal to insert theminto the postsynaptic membrane and therefore strengthens synaptic transmission. OnceAMPA receptors are inserted, the synapse is no longer silent and no longer requiressimultaneous 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 thatthe facilitation of LTP after cortical lesions reflects an underlying mechanism of corticalreorganisation and recovery (Malenka and Nicoll, 1999). According to Hagermann et al.(1998), LTP is essential for functional recovery.Long-term nuclear changesLong-lasting, long-term potentiation that is associated with learning and memory requireslong-term nuclear changes through activity-driven induction of new gene expression.PresynapticterminalMg ++ expelledfrom NMDAchannelSimple ionicreceptorchannelGlutamateNa +Na +Ca ++Ca ++NMDA receptorchannelProtein kinase CCa ++ /calmodulinkinase IIModification of postsynapticreceptors of release ofretrograde factorFigure 2.3 Long-term (postsynaptic) potentiation. (Reproduced with permission from Dr I.Musa, Cardiff University, personal communication, 2009.)

Theoretical Basis 33Na + K +Synthesis ofproteinsPhosphorylationof regulatoryproteinsProductsof proto-oncogenesTranscriptionof genesFigure 2.4 Long-term (nuclear) changes through G protein-coupled second messengersystems. (Reproduced with permission from Dr I. Musa, Cardiff University, personalcommunication, 2009.)It requires the synthesis of new proteins and their affect on the nucleus of the postsynapticcell through high-frequency stimulation. This stimulation results in the activationof a receptor-linked second messenger system, which encourages the phosphorylation ofregulatory proteins. These enter the postsynaptic cell nucleus where they transcribe a set ofgenes. 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. Theproteins now are large and insoluble. After being synthesised by the ribosomes attachedto the granular endoplasmic reticulum, they move by dendritic transport back to the postsynapticsite 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 verylong-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 concentrationfalls back to its resting level they remain phosphorylated. This is because if a subunitbecomes dephosphorylated, it will immediately become automatically phosphorylatedby 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 isstrongly 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 thatfire out of sync loses their link’.Specificity is when one pathway is stimulated and other pathways connected to thesame neurone are not. Therefore, LTP is specific to activated synapses than all synapseson a cell (Figure 2.5).

34 Occupational Therapy and Stroke(a) Specificity(b) AssociativityPathway 1:ActivePathway 1:Strong stimulationSynapsestrengthenedSynapsestrengthenedPathway 2:Weak stimulationSynapse notstrengthenedSynapsestrengthenedFigure 2.5 Long-term potentiation: (a) specificity and (b) associativity. (Reproduced withpermission from Dr I. Musa, Cardiff University, personal communication, 2009.)UnmaskingCan be considered when designated axons and synapses which are present but not beingused for a particular function. This can be called upon when the ordinary dominant systemfails 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 beinvolved in the extensive synaptic stimulation, which causes long-term potentiation (LTP).This leads to calcium-dependent phosphorylation of CREB (cAMP response elementbinding protein) – which may be associated with synaptic plasticity. Therefore, linkingthe phosphorylation of CREB to formation of new dendritic spines could assist in longtermnuclear changes (Murphy and Segal, 1997).Intervention therefore aims to stimulate the long-distance afferent to take overfrom the segmental afferent that has been damaged, that is, the subservient pathwayor non-dominant can take over the function of the dominant damaged afferent(Figure 2.6).Collateral sproutingRecovery after brain injury occurs by axons growing branches called collateral sprouting:homotypic sprouting where a synapse is formed from the same tract or heterotypicsprouting from another tract (functional recovery is more adversely affected in this case)(Figure 2.7).

Theoretical Basis 35Stimulatedlong-distanceafferentDamagedsegmentalafferentFigure 2.6 Unmasking. (Reproduced with permission from Dr I. Musa, Cardiff University,personal communication, 2009.)Dendritic growthDendritic growth can take place over months and will regrow if stimulated. Studies haveshown that there is a decrease in dendritic growth in dementia patients and those in avegetative 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 butrusts 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 importantto induce and maintain plastic changes; timing may be critical and the importance of activeattention to stimuli (Gage, 2002; Pomeroy and Tallis, 2002b; Turkstra et al., 2003). Fromthese findings, it may be that to some extent adaptive neuroplasticity was already beingReactive synaptogenesisAxonal sproutingFigure 2.7 Collateral sprouting. (Reproduced with permission from Dr I. Musa, CardiffUniversity, personal communication, 2009.)

36 Occupational Therapy and Strokedriven by therapists following basic learning principles, including, teaching meaningfulskills that were varied, stimulating and graded in difficulty; structuring practice with feedbackand review; and training skills to other environments and contexts (Pomeroy andTallis, 2002b). However, it alerted therapists to consider the aspects of post-injury rehabilitationexperiences influencing neuroplasticity. For example, unstructured, repetitivetask practice during routine self-care could potentially be relatively ‘unattended’ and insufficientto 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 expandcortical lesions (Johansson, 2000).Neuroplasticity redefined recovery as ‘the ability to accomplish the goal in exactly thesame way as before the injury’ (Almli and Finger in Cohen, 1999: p. 420). The loss ofnormal function deprives the CNS of the experiential feedback required to drive adaptivereorganisation and may subsequently permit maladaptive reorganisation (Pomeroy andTallis, 2002a). This increased emphasis on remedial approaches for ‘true neuroplasticrecovery’ early in stroke rehabilitation. In fact it was suggested that ‘restitution of functionin damaged circuits may actually be hindered by compensatory adjustments which maysupport adaptive function in the short term, but which result in long-term inhibition of theactivity of damaged circuits (Mateer and Kerns, 2000: p. 108; Cauraugh and Summers,2005). However, there is limited clinical evidence to suggest that functional compensationsare detrimental to recovery (Cohen, 1999; Lennon et al., 2001; Lennon, 2003).Intervention approachesDespite evidence of neuroplasticity, predicting recovery potentials remains challenging.Some combinations of symptoms will be more amenable to true recovery while othercombinations will have limited capacity, requiring an adaptive (compensatory/functional)approach to learn to adapt to activity limitations. Thus, occupational therapists will alwaysneed both restorative and adaptive treatment approaches as components of neurorehabilitation.Further, some patients may just want to achieve independence as quickly as possibleand ‘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 abilityof the brain to reorganise itself (Nirkko et al., 1997; Nudo, 1998; Marshall et al., 2000).Neurophysiological approaches such as normal movement and motor relearning areincluded within the restorative (remedial) approach. Here, the therapist provides controlledvisual, auditory, vestibular, tactile, proprioceptive and kinaesthetic stimulation to promotenormal CNS processing of sensory information. Therefore, normal sensory processingshould help the patient make normal perceptual motor responses required for performanceof functional tasks. This approach therefore aims to reduce the impairment to subsequentlyimprove activity and participation.

Theoretical Basis 37Neistadt (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 thepatient and encourage the brain to adaptively reorganise itself for successful behaviours.People with cognitive impairments tend not to be able to transfer learned skills, andalthough some minor, short-term effects may be seen, the long-term impact and lackof transferrable skills tend to make this a time-intensive and less-effective approach forpeople with cognitive problems. Restoration of impairments tends to be more successfulfor people with motor impairments alone.Adaptive (compensatory/functional) approachThe adaptive (compensatory/functional) approach focuses on repetition of particular skillswhich are normally associated with activities of daily living (ADL). It is based on thebelief 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 restorationis unlikely and assumes that certain functions will not recover (Zoltan, 2007). Compensationfor loss of function is achieved by changing the activity, environment or patientbehaviour by using external assistance, modifying the task or changing the goal or bypractice until the task becomes easier in a variety of environments.The advantages of this approach are that it is patient-centred, easy to explain, usesproblem solving, meets short-term needs and gives quick results.The disadvantages of this approach are that the therapist may not consider a rangeof options open to the patient and may succumb to organisational pressures for quickfunctional 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 leadto negativity by the patient who is asked to recognise a permanent condition and itslimitations without any attempt to remediate the underlying skills.Cognitive rehabilitation approachCognitive rehabilitation therapy is a systematic and functionally oriented approach toimprove cognitive functioning either by restoring cognitive processing skills that areimpaired 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 verysimilar to physical rehabilitation but usually involves all of the following: Assessment – to determine the specific impairments involved and their functional impacton occupational performance. Education – to develop patients’ and others’ awareness of cognitive strengths andweaknesses and how they influence occupational performance. Without developingawareness and self-monitoring skills, the patient will not engage in therapy and willnot be able to independently implement treatment strategies on their own – the ultimateaim of rehabilitation!

38 Occupational Therapy and Stroke Process training – to restore the impaired cognitive skill through targeted practice andretraining of the skill itself. This is usually completed out of context in pen and papertasks to enable patients to consciously focus on the targeted skill and may be given ashomework activities. Strategy training – to learn how to use external and internal adaptive strategies toovercome the impaired skill. This involves targeted rehearsal of the taught strategy ina variety of contexts. Functional activities training – to consciously apply strategies learnt in process andstrategy training in everyday life. Evaluation – is required at impairment, activity and participation levels to determinethe effectiveness of intervention.(Malia and Brannagan, 2005; Halligan and Wade, 2007)Although in physical rehabilitation simultaneous use of both restorative and adaptiveapproaches is used cautiously, in cognitive rehabilitation use of both process and strategytraining simultaneously is encouraged.Cognitive interventions must be tailored to the individual and are more effective ifinterventions are collaboratively worked between patient, carer and therapist. The goalsshould be mutually set and functionally relevant to the individual. Therapists should alsouse eclectic and multiple approaches to address the effect and emotional components ofcognitive loss (Halligan and Wade, 2007).Although research population heterogeneity, treatment variability and use of broad outcomemeasures have limited conclusive recommendations for cognitive rehabilitation todate, Rohling et al.’s (2009) meta-analysis suggests a few core evidence-based principlesfor cognitive rehabilitation, including starting treatment early, older patients (≥ 55 yearsold) can still benefit from cognitive rehabilitation and targeted interventions (particularlyfor attention and visual spatial neglect) are more effective than generalised interventions.The reader is referred to key documents regarding details of specific evidence supportingthe effectiveness of cognitive-perceptual rehabilitation of attention, memory, visuospatialperception, neglect, executive function and praxis skills (Cicerone et al., 2000; Lincolnet al., 2000; Cappa et al., 2005; Cicerone et al., 2005; Bowen and Lincoln, 2007; das Nairand 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 physicalneurorehabilitation in the UK (Walker et al., 2000; Lennon, 2003). It is also knownas Bobath or neurodevelopmental treatment (NDT) as it was originally founded by theBobaths in the 1970s and based on neurodevelopmental reflex-hierarchical theory thathypothesised spasticity as a product of overactive reflexes. Originally, treatment utilisedreflex inhibiting patterns and progressed patients through a neurodevelopmental sequence(Bobath, 1990). However, Bobath treatment techniques have changed since the last Bobathpublication in the 1990s. The current ‘Bobath Concept’ of normal movement has evolvedto incorporate present-day knowledge and a systems theory of motor control, motor learning,neural and muscle plasticity and biomechanics (Raine, 2006, 2007; International

Theoretical Basis 39Bobath Instructors Training Association (IBITA), 2008). However, there has been muchdebate in the literature regarding the validity and reliability of this evolution which has confoundedevidence-based practice (Langhammer, 2001; Brock et al., 2002; Mayston, 2008).The Normal movement approach is a problem-solving or clinical reasoning processrather than a series of treatments or techniques, generally requiring a postgraduate levelof training to enable more efficient movement patterns (IBITA, 2008). It is based on theassumption that ‘too much effort by the patient and overuse of the unaffected side reinforceabnormal tone and movement of the affected side’ (Lennon, 2001: p. 925). Abnormalmovement leads to inaccuracy, effort, fatigue, compensatory movements, muscle tension,overuse, pain, injury and ultimately task avoidance and dependency. Thus, the approachaims to improve disturbances in function, movement and postural control following alesion in the CNS by relearning more efficient movement through experience, with activeparticipation of the patient, which is ultimately goal directed (Lennon, 1996; Raine, 2007).Key terms Base of support: This refers to the supporting surface, the body part in contact with itand the relationship between the two. In order to accept the base of support, a personneeds movement to relate to it and use it as a reference point. Centre of gravity: A constant downward force with which man must develop the abilityto interact, in order to move selectively. It is constant and the effect is felt if displaced. Postural set: An alignment of key points in relation to an accepted base of support. Balance reactions:(a) Equilibrium reactions: Automatic adaptations of postural tone in response to gravityand 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. Normal postural tone: A continuous partial state of muscle contraction which is highenough to resist gravity and low enough to allow selective movement to take place. Associated reactions: Pathological increases in tone, in response to a stimulus, whichare beyond the person’s level of inhibitory control. They reflect a loss of reciprocalinnervation. Key points: Areas of the body, such as the head, thorax, pelvis, shoulders, hips, handsand feet, where postural tone can most easily be changed. Each key point provides alarge source of proprioceptive input to the CNS.Key points are used to:(a) Facilitate and control movements; and(b) Alter postural tone.Assessment/evaluationAssessment involves observation and analysis of movement of deviation from normalmovement patterns and identification of compensatory strategies. In particular, the

40 Occupational Therapy and Strokeinfluence of gravity, relationship with base of support, alignment and relationship of keypoints to each other, the ability to move within a posture, transfer weight and to createanother posture, initiation and development of a pattern of movement (selectivity). Inaddition, the potential for change is explored through use of handling skills to influencetone, alignment, fixation, stiffness, etc., as well as use of movement experience, repetition,speed, voice and environment. As a problem-solving approach, assessment, hypothesisformation, treatment and evaluation are a constant process.Techniques/methodsThe therapist uses afferent inputs, particularly proprioceptive handling skills of key pointsof control, to influence muscle tone and activity, correct alignment, block abnormal movementsand facilitate more normal selective movement patterns for goal-directed tasks inwhich the patient is an active participant (Lennon, 2001; IBITA, 2008). In addition, therapistsuse experience of movement, repetition, speed, voice, environmental manipulationand feedback (British Bobath Tutors Association, 2003). Bobath discourages unsupervisedpatient 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 abilityPreparationGood knowledge/awareness of normal movement is necessary to analyse deviation fromthe normal. Think about how you do daily activities – What is the normal sequence of movements? Prior to session take time to plan and analyse intervention strategy.Activity analysisWhen carrying out in-depth activity analysis of normal movement components of afunctional task, consider the following: 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 thebase of support. Ability to adopt anticipatory posture requirements, for example, to alter trunk and pelvicalignment to move a leg or position the hand in relation to the object in preparation forgrasp. Is the movement normal in pattern – efficient, selective, effortless and goal directed? Identify any abnormal/effortful movement patterns.– Where is movement initiated from – proximally versus distally?– Where does movement appear to be blocked?

Theoretical Basis 41– Where does the patient gain their stability from?– Where is the effort/instability coming from? Identify limitations from sensorimotor, neuromuscular and musculoskeletal systems, forexample, 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, understandinggoal, motivation, concentration, memory. Positioning.During treatment, normalise tone before you start and monitor as you progress. Somepreparation may be needed prior to the ADL. Treatment strategies include the following: Negotiate occupational goals so treatment is motivating, meaningful and goal directed. Altering postural alignment. Changing the base of support (increase BOS to reduce hypertonicity, and decrease BOSto increase tone if hypotonic). Consider standing, sitting, lying, position of feet, usingarms to prop, backrests. Modify the environment, for example, firmness of supporting surface, chairheight/design, object orientation and placement. Encourage self-initiation of movement and self-monitoring of abnormal tone/movement. Facilitate key points but do not overhandle – patient should be active in movementrather than passive. Grade activities and treatment time appropriately to be therapeutically challengingwhile working within patients’ physical and cognitive capacity. Learning principles of task-related training, repetition and practice. Vary object characteristics,task context, speed and directional demands of the activity. Give clear visual/verbal/proprioceptive/written instructions and feedback. Use equipment to complement normal movement patterns/compensation. ‘Normal activity’does not utilise aids to independence other than as a last resort. Aids may beused to minimise effort and disability. Maximising carryover and skill acquisition through practice and repetition. Train thepatient, carer and ward staff to monitor and adjust alignment, movement patterns andenvironment (where appropriate).Proprioceptive neuromuscular facilitationProprioceptive neuromuscular facilitation (PNF) as a neuophysiological treatment approachwas first advocated to American therapists by Knott and Voss in the 1950s. Itis based on Sherrington’s and Kabat’s theories about the reflexive relationships betweenagonist and antagonist muscles which can be manipulated to control the contractionand relaxation of specific muscles groups and thus facilitate normal movement. It alsoemphasises that ‘the brain registers total movement and not individual muscle action’(Schultz-Krohn et al., 2006: p. 748)

42 Occupational Therapy and StrokeAssessment considers the relationship between proximal and distal functions, agonistsand antagonists, in total patterns of movement observed during functional activities.Particular observations are made with regard to: 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 totalpatterns of movement and posture (developmental postures). These diagonal movementsand developmental postures are observed in many functional ADL. Thus, treatment activitiesdemand tonal balance and motor control in meaningful tasks that are appropriatelygraded. Facilitatory strategies include use of: 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-bearingfunctions. Application of maximal resistance that still allows patients to have full range of motionand 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 subsequentcontraction of the agonist. Muscle relaxation techniques (such as contract-relax, hold-relax, slow reversal-holdrelaxand rhythmic rotation).(Schultz-Krohn et al., 2006)Rood approachThis intervention is based on reflexive and hierarchical models of the nervous system.Use of developmental postures and sensory stimulation applied to muscles and joints areused to stimulate a motor response that can either facilitate or inhibit muscle tone inpreparation for normal movement. Rood’s concept is therefore based upon the concept ofcorrect sensory stimulation being applied to the sensory receptors and eliciting the correctmotor reflex which can be utilised in normal movement patterns (Rood, 1962).Some of these techniques such as icing, brushing hair follicles and tapping the musclebelly 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 beuseful:

Theoretical Basis 43Facilitatory techniques to increase muscle tone tend to be proprioceptive and includethe following: Heavy joint compression where a compression force greater than body weightis applied by the therapist through the longitudinal axis of the bone to facilitatejoint co-contraction. Weighted cuffs, sandbags and weight-bearing can also beused. Quick stretch followed by applying resistance to contracting muscle. Vestibular stimulation to influence tone, balance and facilitate protective neck, trunkand limb extension. Vibration has been found to have systemic effects and use of electrical stimulation hasbecome more favoured.Inhibitory techniques to reduce muscle tone include the following: Neutral warmth provided by insulating body heat with fabrics such as blankets orneoprene. Slow, rhythmic stroking with deep pressure. Light joint compression where a compression of body weight or less can inhibit tonearound joints. Vestibular stimulation through slow rocking to develop ability to move in and out ofpostures.(Schultz-Krohn et al., 2006)These techniques are preparatory. Purposeful activity then follows so that the patientapplies the effects of the triggered motor responses during functional activities. Theoccupational therapist can also use visual or auditory prompts to encourage the requiredresponses within intervention.Movement scienceThis remedial approach to physical neurorehabilitation is also known as motor relearningprogramming (MRP), functional and task-oriented approaches, founded by Carr andShepherd in the 1980s (Carr and Shepherd, 1987). It emphasises the practice of thefunctional task or action itself as the remedial component promoted by principles ofmotor learning, including use of instruction, explanation, manual assistance, visual andverbal feedback on performance, reinforcement and contextual practice. Thus, it aims tofacilitate motor relearning through use of meaningful activity, feedback and practice. Thisapproach emphasises neuroplasticity and addresses concerns regarding negative effects ofcompensatory use of the affected side, learned non-use and use of adaptive aids on motorlearning by altering task requirements.Assessment utilises functional task analysis where the patient’s performance is comparedto norms and analysed to identify the specific biomechanical components of movementthat are problematic. Hypotheses as to the biomechanical reason for altered movementare tested to direct intervention.

44 Occupational Therapy and StrokeTechniques/methodsThe intervention programme involves the following: Training the missing or impaired components in relation to a functional task goal usinginstruction, verbal and visual feedback and manual guidance. 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 requiredto control. As the patient improves, this ‘constraint’ is reduced and replaced by verbalguidance or becomes object mediated. Feedback will depend on the stage of learning the patient is at, moving from moreextrinsic to more intrinsic sources as patients progress. Fitts and Posner (1967) describethree stages of learning:– Cognitive – Patient requires external cues and prompts how to perform the skillaccurately. Mental imagery can also be used here.– Associative – Patient begins to refine the skill through practice, repetition and intrinsicsensory feedback.– Autonomous – The skill becomes automatic for the patient and there is less needfor conscious cognitive processing. The patient starts to generalise the skill acrossdifferent environments and transfer the skill to different tasks. Task-specific, goal-oriented exercises are emphasised with self-monitored practice offunctional tasks outside of training sessions. Structured learning with involvement ofother staff and patient relatives is encouraged for a consistent approach. Transference of training with variation of context to aid motor learning. Positioning and muscle stretching to maintain soft tissue length and minimise spasticityare also utilised.In physiotherapy practice, MRP is reported to differ to Bobath concept approaches inthe principles of learning followed (degree and type of feedback provided), the type ofstimuli used (degree of use of everyday objects during treatment) and the emphasis ontask-specific practice (Marsden and Greenwood, 2005; van Vliet et al., 2005; ISWP, 2008).Constraint-induced movement therapy approachConstraint-induced movement therapy (CIMT) is a behavioural approach that involvesrestraint of the unaffected arm with intensive training of the paretic arm conducted by aclinician using shaping and repetition (Wolf et al., 2006). Shaping involves small stepsof progressing difficulty and activities are designed to enable patients to carry out partsof 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 wherebythe animal stops using the affected upper limb due to frustration from lack of success. Thislearned non-use corresponded to decreased cortical representation. Applying theories ofneuroplasticity, CIMT was found to reverse this effect and improve recovery and functionof the affected upper limb.There is now a substantial body of evidence supporting this technique and CIMTis recommended in the National Clinical Guidelines for Stroke (ISWP, 2008). Patients

Theoretical Basis 45should be at least 2 weeks post stroke onset, have at least 10 degrees of voluntary fingerextension, 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 dayfor 2 or more weeks. In addition to restraint and intensive task-oriented practice, CIMTincludes the use of a ‘transfer package’ of behavioural methods to facilitate transferof training outside the clinical setting. The package includes a behaviour contract (forboth the patient and the caregiver providing support), daily diary of activities to addresspsychosocial barriers, Motor Activity log, personalised home skill assignment and dailyhome practice (Blanton et al., 2008).The practicalities of incorporating CIMT into daily practice, both in hospital and in thecommunity, 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 appropriatepatients.Bilateral arm training/isokinematic training approachBilateral arm training is where the unaffected limb facilitates the affected limb in synergisticcoordinated voluntary movements and is recommended for subacute and chronicphases of recovery (Stewart et al., 2006; ISWP, 2008). It is based on theories that contralesionalactivation may activate the lesioned hemisphere or adaptively strengthen ipsilateralpathways to facilitate recovery of the affected limb. In contrast to CIMT, patients at allseverity levels may benefit from bilateral arm training to some degree but may requiredifferent training approaches (McCombe Waller and Whitall, 2008).Occupational therapists should incorporate this approach into the intervention plans ofpatients who may benefit. Many activities that occupational therapists traditionally usecould be modified to involve this targeted practice. It is important to remember that inthe research the training was conducted intensively for 50–90 minutes 5 days/week forbetween 2 and 8 weeks, which may be difficult to implement in everyday clinical practice(Stewart et al., 2006).Mental imagery approachMental imagery or mental practice has been described as the internal rehearsal of movementswithout any physical movements (Jeannerod, 1994; Crammond, 1997). An essentialpart of mental imagery is the ability to create clear and powerful images of the task requiredon demand. The practice must have functional relevance and meaning to the individualto enable more successful visualisation. Athletes and musicians are known to use mentalimagery training to improve their performance, that is, athletes mentally practise the bodymovements required for particular body actions when the field is not feasible (Ryan andSimons, 1981).Little is known about the neurophysiological mechanisms underlying recovery of motorfunction following mental practice in patients with stroke. With advances in neuroimagingtechniques, these mechanisms could be better understood and assist in the selection of

46 Occupational Therapy and Strokespecific 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 (primarymotor area M1) during imagery. They concluded that primary motor structures are involvedto the same extent in actual or imagined execution and of motor acts and that differencesonly take place at the late preparation period and consist of a quantitative modulationof activity in the structures. Thus, using mental imagery to activate these areas maymaintain neuronal activity that would deteriorate without stimulation and prime pathwaysin readiness to promote motor function.Although there is some evidence that mental imagery is useful following stroke, systematicreviews suggest that further research is required to clarify the content and measurementof mental imagery (Braun et al., 2006; Zimmermann-Schlatter et al., 2008).Electromyographic (bio) feedbackInvolves the use of external electrodes applied to muscles and instrumentation to convertelectrical potentials from muscles into audio or visual information. This augmentedfeedback is based on behavioural and motor learning theory where extrinsic feedback isused to supplement potential impaired intrinsic sensory-perceptual feedback to improvereacquisition of motor skills. There is some evidence to support its use to augment standardtreatment (Woodford and Price, 2007) but routine use outside of clinical trials is notrecommended (ISWP, 2008).Functional electrical stimulationElectrostimulation is thought to be beneficial to train and strengthen muscle contractions.However, results remain inconclusive and should not be used routinely outsidespecialist clinical trials (Pomeroy et al., 2006; ISWP, 2008). Nevertheless, there issome evidence for its use to manage persistent subluxed shoulder pain and foot dropwhere orthoses are ineffective and improved gait is demonstrated with use (ISWP, 2008).RoboticsAn emerging strategy is the use of electromechanical and robotic devices. Although sometraining-specific benefits have been found for improving motor strength, no evidence hasbeen found for improvements in ADL (Mehrholz et al., 2008). Exploration into roboticsto augment repetitive practice and incorporate more distal limb function is required.Summary of evidence for approachesIt has been demonstrated that comprehensive occupational therapy intervention for strokeis effective for reducing activity limitations in personal and extended ADL and improvingsocial 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 theseoutcomes or for restoration of impairments is less clear (Ma and Trombly, 2002). There

Theoretical Basis 47is some evidence that adaptive approaches for self-care may be more effective thanrestorative approaches, but this conclusion may be confounded by lack of distinctionbetween stage of recovery and heterogeneous research (Haslam and Beaulieu, 2007).The majority of evidence for specific treatment approaches is predominantly genericor physiotherapy based, despite similarities (Booth and Hewison, 2002) and inherentdifferences between the disciplines where occupational therapy by its very nature is taskspecificand 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 highlightsdifficulties, making conclusions from research with heterogeneous populations, variedintervention protocols and questionable use of sensitive, targeted outcome measures thatconsider change at both impairment and functional levels. Nevertheless, approaches thatinvolve high-intensity, repetitive task-specific practice and feedback on performance maybe particularly influential on recovery.Thus to be truly evidence based, occupational therapists will need to continue to drawon appropriate evidence that is specific to their individual patients’ contexts and the settingin which they work, as evidence to date can only provide broad guidance.Further, task-specific research is required to guide therapists’ clinical reasoning toaccurately predict patients’ recovery potential and educate patients about choice of specifictreatments. More information is required regarding the characteristics and symptoms ofwho benefits, what is it about specific treatments that work, when is the most appropriatetime to implement specific treatments and at what intensity.Self-evaluation questions1. What are the similarities and differences, advantages and disadvantages between anormal movement approach and a motor relearning approach?2. (a) What conceptual models, frames of reference and intervention approaches doyou use in your practice?(b) How do they relate? Draw a mind map or conceptual model to describe thetheoretical basis of your practice and how your models, frames of reference andintervention 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 yourpractice that you do not already use? Draw up a plan of how you could integrate anew 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 youuse?5. What approaches would you like to know more about? Pick one and plan an in-servicetraining session on it for your colleagues (including a reflection on how it workedwith one of your patients).6. What are the four main mechanisms of neuronal plasticity?

48 Occupational Therapy and Stroke7. 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 ofneuroplasticity.

Chapter 3The Occupational Therapy ProcessMelissa Mew and Janet IveyThis chapter includes: The occupational therapy process Procedural reasoning in different stroke care settings Professional duties Self-evaluation questionsIntroductionThis chapter focuses on how occupational therapists use the ‘occupational therapy process’to work systematically from referral through to discharge and follow-up. Furtherrefinement of procedural clinical reasoning associated with occupational therapy roleswithin different settings and phases of working with stroke patients will be consideredbefore professional duties and competencies are addressed.The occupational therapy processAssessment requires the therapist to draw on their theoretical knowledge (conceptualmodel and frame of reference) and clinical experience to make a clinical judgementof what is to be assessed and how. Assessment requires proficient clinical observationand task analysis skills. It often includes a variety of standardised and non-standardisedmeasures that inform the occupational therapist about the extent of impairment, activityand 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 thisstage to understand the patient/carer in relation to their cultural and lifestyle needs. Liaisonwith 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 andwants. Where possible, methods selected should also assist in evaluating outcomes ofinterventions. Clear communication of assessment results to others is a component ofeffective 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 TherapyHyperacute → Rehab tat on → Commun ty Integrat onAre your patients getting the full benefit?Are ALL strokes and transientischaemic episodes on yourHYPERACUTE unit screenedby a Specialist OccupaonaTherapistSome cognive-perceptualloss should be assumed andpotena impact onpaents’ ifesty es assessed(QM8 DH, 2007)OT AssessmentSpecialist use of functionalactivities for targetedscreening of all strokepatients to identify potentialimpairments and activitylimitations requiringinterventionHealth Condition(disorder/disease)Body Structure and Function(Impairment )Environmental factorsActivities(Limitation)Personal factorsRemedial OT nterventionSpecialist use of purposeful gradedactivity as a medium for reducingphysical cognitive-perceptual andpsychosocial impairments andsubsequent activity limitationsParticipation(Restriction)CF (WHO, 2001)Occupaonal therapy differs from• Physiotherapy (De Wit, 2007)• Nursing (Booth ., 2001)• Clinical/neuro psychology• Social workOccupaonal TherapyWorks!(Cochrane Review,Legg et al., 2006)Are your paents receivingOccupaona THERAPY orjust good dischargep anning? (QM 10 DH, 2007)Adaptive OT nterventionSpecialist use ofcompensatory strategies aidsand adaptive devices tomodify activities and/or theenvironment to enablepatients to participate in afull lifeAre your paents receivinga minimum of 45 mins dai yof each therapy required?( SWP, 2008)Figure 3.1 Occupational therapy interventions in stroke rehabilitation. (Reproduced with permission from College of Occupational TherapistsSpecialist Section Neurological Practice, 2008.)

The Occupational Therapy Process 51ascertain patients’ and their family’s long-term goals or where they see themselves at theend of therapy. Long-term goals are aspirational, giving patients hope and motivation toengage in the therapeutic process. If aspirational goals are crushed by realism, patientsmay lose all hope and not engage in life or therapy at all. They represent the patient’spresent occupational identity and can change over time as they gain insight into theirstrengths and limitations. In contrast short-term goals need to be client-centred and collaborative,specific, measurable, achievable, realistic and timely (SMART). Short-termgoals form the steps needed to work towards the long-term goal. These can be used tomeasure outcomes, for example, by using the Goal Attainment Scale (GAS) (Kiresuket al., 1994). In addition they allow patients, therapists and team members to maintaindirection, motivation, monitor progress and gain insight into how achievable the longtermgoal is or whether the long-term goal needs to be adjusted, thus allowing patients totransform their occupational identity to a more realistic sense of self.Interventions enable patients to meet their goals and ultimately aim to reduce activityand participation limitations (Figure 3.1). Rehabilitation has been defined as aproblem-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 (activityand participation limitations) (Wade, 1992; Intercollegiate Stroke Working Party (ISWP),2008).With inherent focus on occupation, restorative (remedial) approaches may initially appearreductionist and not fit comfortably with some occupational therapists; however, theyare important particularly in the first 6 months to optimise neuroplastic recovery. Furthermorethese approaches do still fit in with occupational therapy philosophy as long as theyare clearly linked to occupational performance goals. Adaptive (compensatory/functional)approaches may involve the analysis and adaptation of the task/activity/occupation itselfor of the physical/social environment to improve occupational performance (Duncan,2006).Approaches are selected depending on the conceptual models and frame of referencethat the therapist deems most appropriate and will depend on the patient’s prognosis,phase of rehabilitation, capacity for impairments to be reduced, consequences on activityand participation, therapists’ own knowledge and skills limitations and consistency withthe multidisciplinary team’s approach. Therapists should also consider the evidence baseregarding selected approaches, consulting the national clinical guidelines in the firstinstance (ISWP, 2008) before lower levels of evidence are considered that apply to thepatient’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 isrecommended in acute phases with opportunities for repeated practice and generalisationacross tasks (ISWP, 2008).In both restorative (remedial) and adaptive (compensatory/functional) approaches, occupationaltherapists more obviously enable patients by using occupation as the ends(where the end goal of occupational therapy is towards facilitating occupational performancecapacity via addressing impacts of ill health). However, occupational therapistsworking with stroke patients are strongly encouraged not to lose sight of occupation as the

52 Occupational Therapy and Strokemeans (where the end goal of occupational therapy is towards occupational identity viaprocesses of engagement and empowerment to improve quality of life). Although theseare by no means mutually exclusive – each can impact on the other – ease with whichboth 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 isclearly signposted by agreed outcomes and the move to the next phase is planned andunderstood.Evaluation of occupational therapy effectiveness ‘is an ethical and professional imperative’(Duncan, 2006). At the patient level, ongoing evaluation enables the appropriatenessof intervention to be monitored, allowing opportunties for adjustment. Evaluationof patient outcomes determines if therapy has been sucessful, whether agreedgoals have been met and whether patients are satisfied with the intervention. Evaluationshould be appropriately aimed at the level of intervention: impairment, activity, participation.At a therapist level, therapists have a professional responsibility to evaluate theirpractice against both profession-specific and stroke-specific standards and guidelines.Therapists also have a responsibility to evaluate their practice through reflection andother continuing professional development activities whilst considering their efficiencyand cost effectiveness. At a service level, therapists are involved in evaluating servicesthrough clinical and organisational audits and patient and staff feedback.Transition between services/dischargeTransition between different teams should ensure that all appropriate information behanded over in a timely manner to prevent unnecessary repetition of services alreadyprovided. Locally agreed sets of terminology, assessment tools, outcome measures anddocumentation should be used to facilitate ease of transfer. The patient should be involvedin decision making regarding transfer of care and be offered copies of transfer documents,including information regarding services (ISWP, 2008). In the UK, coordinatedcommunication between services may include neurovascular clinics, inpatient stroke units(hyperacute and subacute), early supported discharge or intermediate care teams, communityrehabilitation teams (including therapists servicing residential and nursing homes),private therapists, social services and follow-up monitoring teams such as specialist communityteams, the community stroke liaison practitioner (CSLP) and general practitioner(GP).When a therapist stops giving rehabilitation, the therapist should: Discuss the reasons for this decision with the patient. Ensure that any continuing support the patient needs to maintain and/or improvehealth is provided. This may include exercises, integration into general communityprogrammes, information regarding equipment hire and purchase (e.g. Red Cross,Shopmobility), information leaflets (from Chest Heart Stroke, Stroke Association andCollege of Occupational Therapists Specialist Section Neurological Practice), informationabout stroke/carer support (including local groups, Stroke Association website andDifferent Strokes for under 65s).

The Occupational Therapy Process 53 Educate the patient and, if necessary, carers and family how to maintain occupationalperformance, health and well-being. Provide clear instructions on how to contact the service for reassessment, and outlinewhat specific events or changes should trigger further contact (ISWP, 2008).Follow-upAll patients with residual impairments after the initial period of rehabilitation shouldbe offered a formal 6-monthly review so that appropriate referrals can be made if thepatients experience new problems or their circumstances have changed warranting furthertherapeutic interventions (ISWP, 2008). This may be by a member of a specialistmultidisciplinary team (MDT), CSLP or GP depending on residual symptoms and strokeseverity.Particular areas to focus on during follow-up appointments include any changes inimpairment (e.g. cognition), activity (e.g. activities of daily living), participation (e.g.fatigue), environmental and personal (e.g. mood, stress resistance, social support, qualityof life) circumstances since discharge. Comparison to discharge outcome measures shouldbe made to determine whether re-referral for burst of therapy or signposting to otherservices is required.Procedural reasoning in different stroke care settingsClinical or professional reasoning is a science and an art. Understanding the thinking thatguides practice is complicated. All forms of clinical reasoning – scientific (diagnosticand procedural), narrative, pragmatic, ethical, interactive and conditional reasoning (BoytSchell and Schell, 2008) – influence the occupational therapy process no matter in whichsettings occupational therapists may work with stroke patients. However, there are somecommon patterns of procedural reasoning worth delineating that are associated with differentsettings, which may help guide therapists new to working with stroke. It should benoted that these general ‘procedures’ are by no means definitive and will always be influencedby concurrent reasoning about the patient’s unique presentation and circumstancesat the time.Neurovascular clinicsIn response to national guidelines, the number of rapid access neurovascular clinics(NVCs) for transient ischaemic attacks (TIA) and minor strokes to improve comprehensivestroke services has risen. However, no indicative role for occupationaltherapists in NVCs has been outlined in national stroke guidelines (ISWP, 2008; NationalCollaborating Centre for Chronic Conditions (NCC-CC), 2008). Nevertheless, it isargued that occupational therapists have an important role in exploring the functionalimplications of issues frequently overlooked by consultants who are medically focussedand more easily able to pick up the physical symptoms. At this point it should be notedthat 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

54 Occupational Therapy and Strokefor multidisciplinary assessment, neglect the subtle cognitive and psychosocial symptomsthat may arise from frontal lesions and even smaller lesions that are not detected byimaging, but may have a tremendous impact on patients’ well-being and quality of life.By employing a holistic approach, occupational therapists can expertly screen forthe functional implications of issues frequently overlooked in minor stroke (such as thosearising from hemianopias, fatigue, anxiety/depression, high-level cognitive and high-levelmotor impairments). Even for TIAs, occupational therapists may play an important rolein regards to health promotion referring on for adaptive (compensatory/functional) equipmentneeds and attempting to reduce social isolation, which is commonly experienced inelderly populations. This enables the occupational therapist to help the consultant signpostpatients for referral to appropriate services. Clearly the cost effectiveness of occupationaltherapists 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 occupationaltherapy in NVCs and to liaise with consultants to establish direct or indirect methods toimprove comprehensive stroke care. For example, therapists may negotiate direct face-tofacecontact time with patients and carers during clinic appointment or become indirectlyinvolved in screening by contributing to consultant’s screening assessments that includeimpairment, activity, participation, environmental and personal factor concerns with anon-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 supportnetworks) should functional issues be identified. To support the evidence base regardingthe effectiveness of the role of occupational therapists in NVCs, audit and disseminationof results through publications, conferences and newsletters is highly recommended.An example of procedures to consider for occupational therapists working in NVCs isas follows:Caseload: TIAs and minor strokes ∼0–7 days post stroke (ISWP, 2008).Aim: To screen for functional implications arising from minor stroke andconsider health promotion needs in the at-risk population so thatappropriate signposting and referrals can be made.Assessment: Consider initial symptoms and potential implications usingknowledge of functional anatomy.As patients are currently in their home environment, they may havemore insight into functional changes than those admitted at time ofevent. Thus, screen for changes in functional activities, particularlyhigh-level ADLs such as outdoor mobility, stairs, bath transfers,dexterity for managing fasteners, concentration for/understandingreading, 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 thedoctors to confirm patient’s report and alert consultant and patient tosignificant discrepancies.

The Occupational Therapy Process 55Discharge: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 dynamicsettings may be too early to identify if patients have not participatedin these activities since the event, but alerting patients during theclinic to liaise with GP if these symptoms should arise and providinginformation leaflets should be considered.Acute stroke units (hyperacute care)Once patients are admitted to specialist stroke units, occupational therapists should beinvolved in screening all patients (ISWP, 2008). It is argued that for the same reasonfor screening in NVCs, occupational therapist should also screen TIAs who are admittedto acute stroke units (ASU). Hence, although guidelines state that occupational therapyassessment should occur within 4 days of admission (ISWP, 2008), a method of screeningto prioritise and fast track high functioning patients who might be imminently dischargedis required.General prioritisation of patients admitted should consider: 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: 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 ortransferred onto ASU within the last working day. Outcome of prioritisation shouldbe clearly documented in patient notes with any plans to monitor/review prioritisationstatus. Whose assessment of premorbid and current cognitive/perceptual function is required,particularly when the patient is physically able and discharge may be imminent. Whose discharge planning requiring occupational therapy intervention is imminent. Whose urgent occupational therapy intervention is required for maintenance of function/preventionof deterioration, for example, posture, positioning or oedema management.(Poole Hospital NHS Foundation Trust, 2005)

56 Occupational Therapy and StrokeAn example of procedures to consider for occupational therapists working inASU/hyperacute care (based on Poole Hospital NHS Foundation Trust, (2006), reproducedwith 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 toASU and contribute to MDT decision regarding patient’s potential: To be discharged home from ASU with or without ongoing intervention from earlysupported discharge/intermediate care/community teams. To benefit from inpatient rehabilitation. Functional implications post discharge in consideration of home/social situation.Assessment: Targeted screening assessment informed by imaging results andclinical experience should be developed.Minimum assessment for all high priority patients should include thefollowing: Initial interview regarding home situation and past medical/social and occupationalperformance history (including personal care, domestic activities, types of mealpreparation for breakfast, lunch and dinner, managing medications, finances,gardening, driving, leisure interests, productivity/worker role (confirmed with nextof kin or carers if from supported living environment)). Liaise with physiotherapyregarding need for stairs/steps assessment. Functional transfers including bed, chair (note with or without arms), toilet (≈43cm height), bath (if applicable as may save referral to social services occupationaltherapists) with information regarding furniture heights at home particularly ifsome amount of effort demonstrated with transfers on ward. Upper limb sensorimotor screening including functional active range ofmotion/coordination/reported sensation at minimum. If impairments evident,assess further. Use ability to take shoes/socks on/off, reach behind back to do upbra or apron bow, reach head with both hands to put on pullover, and ability tomanage fasteners as estimation of physical independence with personal care. Visual processing including visual acuity, visual fields, inattention (visual andtactile), and oculomotor skills (latter especially if pt reports double vision, fieldloss or has brainstem/cerebellar/occipital lesions). Cognitive/perceptual screening.If none apparent in conversation/on ward – confirm with nursing staff in functionthen... If patient previously assisted with domestic and community activities andnon-demanding leisure interests – no further assessment required. If patient lives alone ± previously independent with domestic, communityactivities, driving or has interests that involve higher level cognition, for example,complete an assessment that includes planning/organising/prioritising/problemsolving. If working age, screen for high-level cognition, executive functions andinformation processing speed comparing against normative data.

The Occupational Therapy Process 57If cognitive/perceptual impairments or frontal/parietal/temporal damage is reported,complete further cognitive perceptual screen. Appropriate and relevant functional assessment designed to challenge patients andreveal potential problems, for example, involving multitasking, coping in dynamiccommunity environments, if premorbidly appropriate, patient mobile andapproaching discharge. Assess at minimum meaningful functional task requiringmultitasking and problem solving, for example, Kitchen Assessment hot drink +breakfast/snack (e.g. toast/porridge or sandwich) in unfamiliar kitchen.From above assessment consider... Further targeted assessment in light of imaging results, initial symptoms andscreening. Personal care assessment simulating home environment, that is, stripwash/shower/bath where possible. Home assessment ± meal preparation ± shopping (particularly for patientspreviously independent, living alone and with cognitive/perceptual problemsevident on ward kitchen assessment, which may not be apparent in personal care,e.g. apraxia). 24-hour supervised leave (e.g. supervised by family member informed by theoccupational therapist) especially for high-level cognitive/perceptual problems,for example, frontal damage, apraxia.Intervention: If appropriate advise patient of being uninsured to drive withoutmedical consent.Restorative (remedial) and adaptive (compensatory/functional)approaches to facilitate discharge.Discharge: Consider referrals to: Community stroke liaison practitioner ± occupational therapy follow-up phonecall. Early supported discharge schemes/in-reach or out-reach intermediate care. Follow-up community occupational therapy (including referrals for mild slowedthought processing/ high-level attention impairments). Sensory loss team (if visual/hearing impairment – possibly premorbid). Social services occupational therapist for rails/adaptations/bath equipment.Subacute/inpatient rehabilitation unitsSubacute inpatient rehabilitation forms the focus of most of this book. Particular noteshould be made for young strokes to consider family roles.An example of procedures to consider for occupational therapists working in subacutestroke inpatient units:Caseload: 1–26 weeks months post stroke (ISWP, 2008).Aim: To provide appropriate restorative (remedial) and adaptive(compensatory/functional) intervention to facilitate recovery by

58 Occupational Therapy and Strokeimproving performance capacity (reduce impairment and activitylimitations).To facilitate appropriate discharge planning.Review prioritisation.Assessment: More in-depth assessments are required based on results of screeningassessments.Intervention: Restorative (remedial) and adaptive (compensatory/functional)approaches.Acute ‘patients should undergo as much therapy appropriate to theirneeds as they are willing and able to tolerate and in the early stagesthey should receive a minimum of 45 minutes daily of each therapythat 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, shouldconsider referral to: Community stroke liaison practitioner ± occupational therapy follow-up phonecall. Early supported discharge schemes/in-reach or out-reach intermediate care. Follow-up community occupational therapy. Sensory loss team (if visual/hearing impairment – possibly premorbid). Social services occupational therapist for rails/adaptations/bath equipment. Stroke/carer support groups.Early supported dischargeUpon leaving hospital, lifestyle often changes considerably by the effects of a stroke. Aperson needs to have choice to be empowered in a supportive environment. Resources andfacilities of course vary from region to region. However, any improvement in the linksbetween hospital and community services can only ease this difficult transition.An example of procedures to consider for occupational therapists working in earlysupported discharge (ESD) and intermediate care teams:Caseload: Subacute (1–26 weeks) (ISWP, 2008).Aim: To facilitate transition from inpatient to home environment usingappropriate 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: Follow-up community occupational therapy. Sensory loss team (if visual/hearing impairment – possibly premorbid). Social services occupational therapist for rails/adaptations/bath equipment. Stroke/carer support groups.

The Occupational Therapy Process 59Community rehabilitation and resettlementWith a push to reduce length of hospital stay and success of ESD teams, the scope ofcommunity rehabilitation to include restorative (remedial) intervention aimed at reducingimpairments alongside adaptive (compensatory/functional) intervention focusing on reducingactivity and participation limitations is growing. Consequently, community teamsneed to become increasingly skilled and specialist community teams are recommendedfor stroke care.An example of procedures to consider for occupational therapists working in communityrehabilitation teams:Caseload:Aim:Assessment:Subacute – chronic strokes.To provide appropriate restorative (remedial) and adaptive(compensatory/functional) intervention aimed at reducingimpairments, activity and participation limitations in consideration ofaffecting environmental and personal factors.Handover from inpatient team.Consider all levels of assessment as appropriate – particularly activityparticipation and personal factors.Intervention: See Chapter 9.Occupational performance and occupational identity – Focussed atreducing impairment (if subacute), reducing activity and participationlimitations, addressing environmental and personal factors.Empowerment – resuming control of their own affairs – includingwork and leisure.Confidence and self-esteem building groups.Adjustment to residual disability as well as facilitating a return tomeaningful lives.Integration into social and voluntary organisations.Discharge:Ensure follow-up monitoring systems in place.Ensure access to ongoing support and advice.Health promotionConsidering the relationship between occupation and heath it is not surprising that the roleof occupational therapy in primary (targeting the well population to prevent ill health), secondary(targeting at risk groups) and tertiary health promotion (maximising potential forhealthy living) is high on the emerging agenda (College of Occupational Therapists, 2008).Long-term follow-up studies suggest that stroke patients may deteriorate post dischargefrom stroke services and have symptoms of depression (Wilkinson et al., 1997). Healthpromotion after stroke may include exercise, nutrition, health behaviour and preventionof secondary stroke (Rimmer and Hedman, 1998). Occupational therapy intervention forstroke patients in nursing homes has been found to be effective for reducing deterioration

60 Occupational Therapy and Strokein function (Sackley et al., 2006) and lifestyle redesign programmes for the elderly lookpromising (College of Occupational Therapists, 2008).Professional dutiesCode of conductThe College of Occupational Therapists (2005) produced a code of Ethics and ProfessionalConduct for use throughout the UK. The title Occupational Therapist is protected by lawand can only be used by those who hold a diploma or degree in occupational therapyand are eligible for registration with the Health Professions Council (HPC). Occupationaltherapy personnel refers to occupational therapists (including managers, educators andresearchers), students and support workers.The code of conduct is a public statement of values and principles to promote andmaintain high standards of professional behaviour.The code covers: 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 registrationwith the HPC (2007a), which sets out 14 areas that HPC registrants must adhere to,covering: 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 competenciesThe HPC (2007b) also sets out standards of proficiency for occupational therapists for thesafe and effective practice of health professions. The generic standards are set out under

The Occupational Therapy Process 61the headings below but the document also sets out the occupational therapy professionspecificstandards; these can be accessed on the HPC website.Generic standards encompass: Professional autonomy and accountability. Identification and assessment of health and social care needs. Knowledge, understanding and skills.The NHS knowledge and skills framework (NHS KSF) and thedevelopment review process (applicable to the NHS in England; Healthand personal social services in Northern Ireland; NHS Scotland; and NHSWales)The NHS KSF defines and describes the knowledge and skills which NHS staff need toapply in their work in order to deliver quality services. It provides a single consistentcomprehensive and explicit framework on which to base review and development for allstaff (Agenda for Change Team, 2004).The main purpose is to provide an NHS-wide framework that can be used consistentlyacross the service to support personal development in post, career development and servicedevelopment. It has been developed by joint management and staff side working togetherusing existing competencies to inform developments.The NHS KSF learning programme, 2004 states that the KSF has been designed so thatthere are common descriptions of knowledge and skills that are applicable and transferableacross the NHS, making it simple and easy to implement.It does not describe people or attitudes, exact knowledge and skills that people need todevelop, job weight or band.Development reviewA KSF outline is developed for every post; the individual is matched against the KSFoutline for their post. Personal development plans are agreed and supported with theindividual learning in a variety of ways. The learning is then evaluated.The development needs are linked between the individuals needs and the requirementsof the post. The KSF will be used as a recruitment and induction as well as through outthe individuals working life, this should provide a fair and objective framework to basethe review upon, guide development and assist with pay progression in the service. Thisprocess entails an annual review, a personal development plan and the expectation that allindividuals are required to learn and develop.Career developmentThis involves building on the development plan particularly after the second gateway; theKSF will assist in possible development routes. It involves commitment to developmentand feedback.

62 Occupational Therapy and StrokeService developmentThe KSF should help individuals understand their role in effective service delivery toimprove patient care.Skills for healthSkills for Health has directors in regions in England, a director in Scotland, NorthernIreland and Wales, and a web-based tool of the Sector Skills Council (SSC) for UK healthenvironment. The aim is to assist in developing solutions for a skilled and flexible UKworkforce 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 workforceand 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 boostproductivity.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 beused across the board – by all health professions, and all levels of staff, whether in theindependent or voluntary sectors or in the NHS. Competences can be used to meet thedemands of the NHS KSF. These competences can be used to develop individuals andservices to improve patient care.The stroke competencies are mapped against KSF health and well-being dimensions.Stroke-specific education frameworkThe UK forum for stroke training has developed an educational framework directing theelements to be delivered for staff to have the appropriate knowledge, skills and experienceto 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 nationallyrecognised, quality assured and transferable education and learning in stroke.The stroke-specific education framework (SSEF) details the knowledge, understandingand 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 independentsector.The 16 elements are covered in the four areas below: Awareness and information. Time is brain. Life after stroke. Working together/implementation.The framework will: Assist in developing a stroke skilled work force; ensuring quality of care and competenciesof stroke staff.

The Occupational Therapy Process 63 Guide the development of programmes to inform and educate the patient, carer andgeneral public regarding stroke issues. Enable individuals and managers to plan continuous professional development. Facilitate organisations to make plans and strategies to improve their services.Self-evaluation questions1. Does your setting document long-term aspirational goals as well as the short-termSMART goals? Can this system be improved to enhance patient engagement andmotivation?2. Does your setting have clinical reasoning guidelines to help guide therapists new tothe area? How might these be further developed?3. What might a typical occupational therapy pathway look like for your patients inyour 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 bemade smoother?5. Consider what assessments/documents can be shared to improve transition and reduceduplication.6. How is health promotion addressed in your practice setting? How might you integratethis into your own practice?7. What is the code of conduct for occupational therapists? Select and discuss five areasthat are essential requirements under the code of conduct for HPC registration and itsaims?8. What is the main purpose of the NHS KSF?9. In preparing for performance review and career development, how could the KSFassist you?10. What is ‘skills for health’ and how could you utilise the tools in developing strokecompetencies for a junior member of staff?

Chapter 4Early ManagementSue Winnall and Janet IveyThis chapter includes: Prior to assessment Initial interview and assessment Equipment Communication Swallowing Mood Fatigue Self-evaluation questionsIntroductionEffective appropriate early management is vital in the care and rehabilitation process ofa patient with a stroke. It permits the gathering of appropriate information to prepare forthe patient’s ongoing assessment and rehabilitation. Key aspects of early managementare gathering relevant information about the patient, completing an effective screen andassessment to identify key areas for further assessment and rehabilitation. One of themost 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 screeningassessment. Putting all this information together helps to formulate a clear image of thepatient, their impairments, skills, goals, motivations, so this information can be used toprepare a clear intervention plan.Prior to assessmentInformation gatheringBefore assessing the patient, it is important to gather initial information from the medicalnotes, other professional colleagues or reports/handover from nursing staff on theward.

Early Management 65Aim To gather information to guide, inform and prioritise screening, assessment and intervention.Basic checklistMedical historyIt is important to document any comorbidities that the patient has as these may affect theirassessment and functional abilities, for example, previous fractures with residual rangeof movement or decrease functioning of a joint or chronic cardiac failure that may causebreathlessness and fatigue.Social historyThe occupational therapist should document with whom the patient lives and what socialnetworks they have, including their occupation and main roles. These may guide theinitial interview and assist in identifying any major concerns the patient may have, thatwill 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 aclinical picture of the patient, prior to their initial interview/assessment.Examples are – ward staff may report that the patient has ‘confused behaviour’, whichmay be an indicator of perceptual problems; a physiotherapist may report that the patienthas difficulty following commands, which could be a language or praxis problem; thespeech and language therapist may indicate the level of comprehension a patient has andwhether yes/no responses are accurate, which will assist the occupational therapist indeciding how to elicit information in an initial interview.Current physical mobilityPrior to assessing the patient, the occupational therapist should ascertain how the patientcan be moved and any equipment required. This will help the occupational therapistprepare for the initial assessment and the opportunity to arrange for assistance of othersif required. A manual handling risk assessment should also be available to ensure patientand staff safety.Functional abilities on the wardInformation from ward staff can be invaluable in assisting the occupational therapist inascertaining the functional independence of a patient and the consistency in maintainingthis independence.However, the occupational therapist must always remember that the hospital setting isan institution and therefore has routines and prompts that are not always available to thepatients in their home. Home environments are also more complex and patients may not

66 Occupational Therapy and Strokebe able to function at the same level within the home or community. The occupationaltherapist must therefore endeavour to simulate the demands of the individual patient’sparticular situation in order to ascertain their abilities. Gaining background informationis therefore essential in planning the screening assessment.Assessments already completedThe occupational therapist in their information gathering should note any assessmentspreviously conducted and the outcomes of these; this will save time, prevent the patientbeing asked the same questions and assist the occupational therapist in prioritising theareas for assessment. For example, any cognitive assessments, language screening ormobility assessments can be utilised by the occupational therapist to analyse and predictfunctional 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 brainby a stroke.The occupational therapist by understanding arterial supplies and the functions of thelobes of the brain will be prepared for the potential impairments the patient may presentwith.This information can then be used to assist in directing any assessments and underlyingcauses for problems in the functional abilities of the patient.Initial interviewThe initial interview may be the first time the occupational therapist actually sees the patient.Structured observations made by the occupational therapist are extremely importantand inform the occupational therapy process, for example, when observing the patienton the ward, noting how they interact with others, what their posture is like, whetherthere are signs of inattention or neglect of a limb. Structured observations such as theseprovide clinical indicators of the impairments and functional difficulties a patient couldpotentially be experiencing or likely to experience during their rehabilitation. Once theoccupational therapist has engaged with the patient, the patient may perform at a higherlevel in an intervention session but might be unable to sustain this level of functioningthroughout the day.The initial interview can therefore be structured and the environment/venue set up toenable full participation, taking the above factors into account.The accuracy of information gained can be affected by cognitive factors such as memoryand attention; communication (aphasia) can also make eliciting accurate informationdifficult. Any areas that raise concerns must be checked out for accuracy.The initial interview should try and ascertain the patients’ pre-morbid level of functioningand their social and physical environments. This is essential in order to assessthe individual’s previous levels of participation and potential for return to this. The

Early Management 67occupational therapist’s approach to stroke rehabilitation and optimising functional abilitiesis in accordance with the World Health Organization (WHO, 2001) InternationalClassification of Functioning (ICF) (see Chapter 1).The individual’s key roles and tasks undertaken provide the necessary information essentialfor the occupational therapist to base their assessments and interventions upon.Undertaking purposeful and meaningful occupations is essential in the occupational therapyprocess and for patient motivation and participation.The Occupational Therapy Standards for Stroke (Royal College of Physicians andCollege of Occupational Therapists, 2008) state that at the initial interview ‘former levelsof functioning within the areas of self-care, productivity and leisure are discussed withthe stroke survivor’.To audit the above standards, the Profession Specific Stroke Audit Occupational TherapyClinical Audit (Royal College of Physicians Profession Specific Audit Group, 2007a)investigates whether the following components were included in the initial interview:(a) Home situation (physical environment)?(b) Home situation (sociocultural)?(c) Pre-stroke level of self-care?(d) Pre-stroke employment?(e) Pre-stroke domestic responsibilities?(f) Pre-stroke leisure activities?(g) Pre-stroke driving status?(h) Concerns of the stroke survivor?Initial assessmentThe Occupational Therapy Standards for Stroke (Royal College of Physicians and Collegeof Occupational Therapists, 2008) state that the initial occupational therapy assessmentshould include: Appropriate advice on stopping smoking, regular exercise, diet and satisfactory weight,reducing salt intake, avoiding excess alcohol. The needs of younger stroke survivors. Assessment of cognitive, motor and functional abilities.Cognitive and perceptual screeningCognitive and perceptual screening is a key component of the occupational therapist’s rolein stroke care. Screening is done undertaken to give the therapist more information about apatient’s function before embarking on a full in-depth assessment. It gives the therapist anopportunity to make observations and gain an idea of any impairments the patient mightbe experiencing. It is particularly important for the ‘walking wounded’ as they can oftenappear fine during observation on the ward but with a few directed questions or tasks theimpairments become apparent.

68 Occupational Therapy and StrokeAim To screen the patient’s cognitive and perceptual capacity to determine the need forfurther in-depth assessment. To provide an indication of the patient’s attention, memory, safety awareness, judgement,praxis and other cognitive impairments that might impact on other occupationaltherapy assessments and interventions. To provide an indication of the patient’s visual attention, spatial relations, visual recognitionand other perceptual impairments that might impact on other occupational therapyassessments and interventions. Often high-level cognitive and perceptual impairments are not as apparent during dailytasks in a controlled, routine ward environment so screening might identify concernsthat could otherwise be missed.Basic checklist of questions or tasks directed at cognitive skillsLevel of alertness Does the patient engage or participate in conversation or daily tasks? Does the patient’s level of alertness fluctuate or change over time?Orientation Can the patient determine time, place and person? Is the patient aware of their surroundings and what has happened?Attention Does the patient sustain their attention during conversation? Is the patient easily distractible? Can the patient alternate their attention effectively to tell you the months of the yearbackwards?Communication Does the patient follow 1, 2 or 3 step commands? Is the patient able to respond appropriately to questions?Memory Can the patient recall information accurately during the initial interview? Does the patient appear to recognise you and what has happened over the recentdays? Can the patient remember when their next occupational therapy appointment is?

Early Management 69Problem solving Does the patient need cues to follow out simple tasks? Does the patient initiate tasks or engage actively in their environment?Praxis Can the patient copy movements? Can the patient demonstrate movements to command? Can the patient imitate how to use certain objects?As well as considering the questions above, observations during functional tasksare also vital to give an indication as to whether the patient might have a cognitiveimpairment.Observations during functional assessment that might indicate acognitive impairment and the need for further assessmentAttention Is the patient focussed on the task throughout the activity? Is the patient able to switch from one aspect of the task to another without prompts? Is the patient able to talk and engage in the task or complete two aspects of the activitysimultaneously?Information processing Does the patient engage in the task at an appropriate speed? Does the task break down when there is novel information or with an increase in taskcomplexity?Memory Does the patient remember what task they are engaged in? Can the patient find relevant items needed for a task?Executive functions Is the patient able to initiate, sequence and organise the task appropriately? Does the patient display appropriate judgement, problem solving and safety awareness?Praxis Does the patient appear to know what they want to do but are using an ineffective orinappropriate movement for the task? Does the patient use appropriate objects for the task?

70 Occupational Therapy and StrokeIf concerns in any of these areas are identified, further standardised cognitive assessmentmight be necessary. For detailed information relating to cognitive impairments, seeChapter 7.Basic checklist of questions or tasks directed at visual perceptual skillsVisual fields (hemianopia or quadrantanopia) Confrontation test – With eyes fixated centrally, a patient with a hemianopia or quadrantanopiais unable to identify a moving finger in affected quadrants or fields. Scanning task (e.g. finding all the letter ‘e’s on a page of text) – A patient withhemianopia often presents with an abbreviated scanning pattern, missing items inaffected visual field. Copying a diagram (the patient is presented with a diagram to copy but not told what itis) – A patient with a visual field impairment often only copies half the diagram unlessthey recognise it, in which case they will search the page and complete it.Visual attention Extinction test – Two objects are presented on either side of the patient’s visual fieldthat is left, right or both – a patient with visual inattention does not identify objects inthe area of reduced attention when presented with objects simultaneously. Scanning task – A patient with visual inattention has an abbreviated scanning patternbut often has a disordered, random scanning pattern (unlike a patient with hemianopiawhich is well organised). Copying a diagram – A patient with visual inattention only copies half the picture. Drawing a clock, including numbers, on command – A patient with visual inattentionoften places all the numbers on one side of the clock or only complete one side of theclock (a patient with hemianopia will only draw a clock with no difficulties).Other visual perceptual impairments Copying a diagram and drawing clock – Is the spacing accurate? Are the diagramsappropriate to the task? 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 alsovital to give an indication as to whether the patient might have a perceptual impairment.Observations during functional tasks that might indicate a perceptualimpairment and the need for further assessmentVisual fields Is the patient able to find all the materials they need for the task without prompts? Isthere a delay in searching on their affected side?

Early Management 71 Does the patient bump into or miss information on their affected side? Can the patient read signs or books? Does the patient fill in all the information on forms?Visual inattention Does the patient need prompts to search their environment? Does the patient appear to have difficulty turning, looking or searching on their affectedside? Does the patient bump into objects and have difficulty adjusting to obstacles in theirenvironment? Does the patient have difficulty watching TV, reading, using the telephone or focussingon the person talking to them?Other perceptual impairments Does the patient misjudge distance or depth? Does the patient have difficulty orienting clothing or spatially organising theirworkspace?If concerns in any of these areas are identified, further standardised perceptual assessmentmight be necessary. For detailed information relating to sensory impairments, seeChapter 6 and for perceptual impairments, see Chapter 8.Psychosocial screeningIt is important, as a part of the multidisciplinary team, to be aware of and screen forpsychosocial issues, including mood and fatigue.Aim To recognise or identify psychosocial issues to be able to refer to the appropriatemultidisciplinary team member for further assessment and intervention. To be aware of psychosocial state and impact on occupational therapy assessment andintervention.Observation 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 mightbe required and it is recommended that the consultant and multidisciplinary team areinformed. Referral to a psychologist might be required.

72 Occupational Therapy and StrokeNeurophysical screeningThe patient needs to be suitably dressed for this assessment although it is often easier tofully 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 patientin whatever position they are initially found in as the occupational therapist’s handlingability, that is, transfers, etc., will have an impact on the patient’s presentation. It is usefulto gather information about the patient’s movement, etc., before the structured screeningor assessment is commenced. Note, handling and observation are key to an accurateassessment.Aim To set the scene for further assessment and intervention. To build up a picture of the patient as a whole, and how they move. To provide information for setting goals in conjunction with the patient and other teammembers. To provide information from which a baseline for intervention can be formed. To identify how the patient moves, attempts to move and what aspects are abnormal.Motor screening How does the patient move? Why does the patient move in this way?In position 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 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 Sitting unsupported. Can the patient achieve this? Does the patient use their arms tomaintain sitting balance?

Early Management 73 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 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 Assess the muscles around the scapula – Is there weakness, tightness or tone affectingthe rotation or sitting position? Is the scapula moving within normal scapulohumeral rhythm?Glenohumeral joint Assess for subluxation and rotator cuff muscle activity. Does the patient’s scapula rotate with movement of the glenohumeral joint?Upper limb Is it functional? Is there selective, voluntary movement? Is the patient able to isometrically, concentrically and eccentrically contract to reach,grasp and place their upper limb?Feel the patient’s hand Gross grasp, fine motor control, arches.Standing and gait Is the patient able to stand? Can they shift their weight on either leg? Is the patient symmetrical? Can they maintain static and dynamic standing? Is the patient able to move their upper limbs while standing or do they need to use theirupper limbs for support?For detailed information relating to motor impairments, see Chapter 5.

74 Occupational Therapy and StrokeFunctional assessmentFunctional assessments, for example, washing and dressing assessments, kitchen assessmentsor 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, aswell as their task performance.Aim Screening tool to identify impairments, skills, performance impairments. To provide an opportunity to assess the combination of all the performance componentswithin a task. To provide vital information on how the patient’s impairments impact on their functionalability. To allow an opportunity to identify how a patient is using their residual skills to performa familiar task. To provide an opportunity for assessment that is not reliant solely on a patient’s understandingor conceptualisation of the task’s requirement due to the familiar nature of thetask and the environmental cues.Functional screeningThe following questions should be considered from a cognitive/perceptual perspective: 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 intheir 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: 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.

Early Management 75InterventionOnce the initial screening is completed, it is important to determine if any further assessmentis required to decide what intervention is most appropriate for the patient.Details of how to assess and provide specific intervention for motor, sensory, cognitiveand perceptual impairments are described in Chapters 5–8.Goal setting should be undertaken, as described in Chapter 3.EquipmentThe assessment for and provision of equipment to stroke patients is generally viewed asan adaptive (compensatory/functional) method of reducing limitations. Most equipmentis issued following a home assessment visit completed prior to weekend leave and/ordischarge. However, some equipment can be used to facilitate normal movement andincrease independence within the hospital setting. The pros and cons of timing and typeof equipment should be carefully considered in conjunction with the patient, family andmultidisciplinary team.WheelchairsThe provision of a wheelchair for a patient following a stroke can be considered for twomain reasons – for correct positioning during early management and for indoor/outdoormobility during the rehabilitation stage.The type of wheelchair appropriate for a stroke patient could include attendantpropelledmanual wheelchairs and indoor- or outdoor-powered wheelchairs.Attendant-propelled manual wheelchairs can be used to achieve better positioning andto improve sitting balance on the ward, which is not always possible with armchairs orhigh seat chairs. A pressure care cushion should always be provided with the wheelchairand monitored throughout the day by nursing staff and therapists. Access to attendantpropelledwheelchairs adjusted for specific patients can also enable patients to be takenoff the ward by their visitors for often much-needed stimulation. Ideally, a wheelchairshould also be available for the patient to use for outdoor and/or indoor mobility onweekend leaves and on discharge. In some settings patients are discouraged from tryingto propel themselves with their feet, and self-propelling manual wheelchairs are oftenavoided altogether. It is thought that the patient’s muscle tone will increase when usingthe unaffected arm and leg in this way. It is best to discuss the approach.Indoor-powered wheelchairs could be considered for patients with severe physicaldisability and those with chronic heart and lung conditions. A patient’s cognition andvisual perception should be fully assessed as part of the wheelchair assessment. The useof a powered wheelchair in hospital can help increase motivation and might be consideredas an intervention option for spatial awareness problems and inattention.A combined indoor/outdoor- and outdoor-powered wheelchair would require a fullassessment by the hospital-based occupational therapist and specialised wheelchair

76 Occupational Therapy and Stroketherapist, 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 environmentand local area in which the patient will be living should always be taken into account. Theaccess to the patient’s home, the type of accommodation, the width of all internal/externaldoorways, the layout of the furniture and other fixtures/fittings, the door thresholds andthe floor coverings should be considered for suitability of a wheelchair.ToiletingRaised toilet seats and frames (which are safely fixed to the floor) will encourage a patientto move from sit to stand in a more normal way than pulling on grab rails fixed to awall.Bathing/showeringMany stroke patients with independent sitting balance can manage transfers on and off abath 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 heartand lung conditions and the frail elderly. Non-slip mats should always be provided orpurchased to be used in conjunction with bath boards/seats. Chairs or seats that are fixedacross the top of the bath for use with a shower or that lower into the bath require less effortfor 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 andare therefore only accessible to the more mobile stroke patient who can wash themselvesindependently whilst standing or sitting on a stool.Meal preparationSome kitchen equipment such as large-handled utensils or cutlery issued by occupationaltherapists could be used by patients with some return of hand function to encouragefurther improvement or facilitate more normal movement. These could be used duringmeal preparation sessions in hospital or at home. Many other pieces of equipment aredesigned for one-handed use or to make heavy tasks lighter. Spike board, belliclamp, walltin opener, battery-operated tin openers that fit on the can and do not require holding, ringpull cans and buttering board will enable the patient with limited upper limb function toprepare meals. A kettle tipper and cooking basket and draining spoons make dealing withboiling water safer and lighter. A trolley can be used by the more mobile patient to carryhot food.Fatigue is a major factor to consider when preparing a meal. The layout of the kitchenand 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’senergy. A perching stool could also help reduce fatigue.

Early Management 77EatingDuring 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 andlarge-handled mugs with lids reduce the risk of spillage. Dycem mats will keep plates inplace. Large-handled cutlery could be used with the affected hand to encourage furtherreturn of movement. At a later stage, the one-handed patient may require a rocker knifeor a fork with a serrated edge for cutting.Other impairments impacting on functional abilityCommunicationThere are three main communication disorders associated with stroke: aphasia/dysphasia,dysarthria and verbal apraxia.AphasiaAphasia is a disorder of language which can result in difficulty: 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 andexpression of language are usually affected, albeit to varying degrees.The speech of a patient with aphasia may show some of the following features: Maintained ability to use automatic/social speech, that is greetings, or counting by rote. Yes/no responses which are unreliable, either because the question is not understood orbecause one is meant/thought but the reverse is said. Swearing – usually automatic and unintentional. One phrase/word/sound produced whenever speech is attempted. Repeating back what has been said/asked (often without understanding). A retained ability to sing (because it is controlled by the opposite side of the brain). Fluent speech, ‘jargon’, which is difficult to inhibit (this may comprise a mixture ofmeaningful and non-meaningful words or may be just a string of sounds). Grammatical words, such as ‘the’, ‘a’, ‘to’, etc., are not used. Word finding difficulties – some dysphasics may be able to describe something abouta word, but not retrieve the word itself.The Stroke Association publishes leaflets with advice helpful to patients and to therapistson how to deal with aphasia. Occupational therapists should liaise with speechand language therapists on ways to encourage return of speech whilst carrying out

78 Occupational Therapy and Strokeoccupational therapy activity with the dysphasic patient, as intensive practice is beneficial.The obvious strategies of writing or signboards should be tried, but are not alwayshelpful. 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 toenable them to participate in intervention. The family or carers should have the situationexplained and be involved in developing ways of communicating.UnderstandingProblems in understanding language will range in severity from virtually no understandingof spoken language to mild difficulty apparent only when following group conversationor 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: Visual or non-verbal cues – the gestures we use alongside our speech– body language– facial expressions– tone of voice 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 insteadof spoken instructions.DysarthriaThis is a speech disorder caused by damage to the nerves supplying the muscles usedwhen speaking. It may involve problems with breath control for speech, voice production,controlling whether air is directed orally or nasally during speech, and articulation ofspeech sounds.It can range in severity from mildly slurred speech to inability to produce any intelligiblespeech.A patient with dysarthria is often able to use alternative means of communicationbecause their language skills are intact, for example, Writing. Spelling words out on an alphabet chart. Using an electronic communication aid.Verbal apraxiaThis is a disorder affecting the purposeful coordination of muscle movements for speechproduction. It is not a language problem, but very often patients with verbal apraxia alsohave some degree of aphasia.

Early Management 79It is characterised by: Groping/struggling to achieve the correct sounds for a word or to sequence the soundsin the right order. Awareness of errors and subsequent frustration and repeated attempts. Speech produced ‘subconsciously’ or automatically which will be noticeably morefluent than purposeful speech. The speech muscles which are not paralysed and automatic movements are retained,for example, for eating, drinking, laughing.Communicating with an aphasic patient1. 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 radioor 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 listeningto you, for example, use their name to focus their attention, or touch them and pausebefore 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 articulationor 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 pausingfrequently.6. Repeat or rephrase what you have said if you are not understood. Try puttingthe most important word at the end of the sentence, for example, ‘What is youraddress?’.7. Stress or emphasise important words in the sentence, for example, ‘Did Christinering?’ or ‘Did Christine ring?’.8. Give clues about what you are saying, for example, use a gesture, or write downimportant words, or draw attention to a photograph or an object relating to what youare saying.9. Do not change topics quickly – leave plenty of time before moving on to somethingnew 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 themthere’.11. Take time to be a good listener – keep calm, be alert to the dysphasic patient’s useof gesture, their facial expressions, etc., listen and watch out for the intention behindwhat 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 writtenwords.13. Accept a message conveyed by whatever means is possible – do not then force themto use a ‘better’ method, for example, do not ask them to repeat ‘I want a drink’ whenthey have gestured their need.

80 Occupational Therapy and Stroke14. 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 youguess the topic of conversation.15. Let them know what you have understood. Summarise what you feel has been said tocheck you have got it right, for example, ‘I think you are telling me something aboutdinner’.16. Do not pretend to understand. Ask for more information or repetition if you havenot understood. The dysphasic patient will soon realise if you are pretending tounderstand and this is likely to lead to more frustration.17. Help the patient find a particular word by encouraging them to – describe somethingabout the word, for example, what you do with it, what it looks like, etc., or think ofsomething associated with the word, for example, a word similar in meaning or thecategory (animal, flower, etc.).SwallowingDysphagia is difficulty in safely moving a bolus of food, or liquid, from the mouth to thestomach without aspirating, and involves chewing and tongue movement, preparing foodfor swallowing, as well as the actual swallow. Thorough clinical examination can identifydysphagia, but can fail to identify patients aspirating. All staff working with the strokepatient should be aware of the possibility of dysphagia and take appropriate action if theyfeel someone may be aspirating. Initial severity does not mean that the patient will notrecover, and reported recovery rates within the first few weeks vary.Signs that may indicate a swallowing problem include: Loss of food or liquid from the mouth, or drooling. Difficulty in swallowing saliva, so that drooling is a continual problem. Food remaining inside the mouth after eating, often pocketed inside a cheek or acrossthe roof of the mouth. Coughing or choking while eating or drinking. Change in voice quality after eating or drinking, often the voice sounds wet or gurgly. Breathlessness after eating or drinking. Meal times taking longer to finish; often there may be weight loss. Someone may complain of food feeling stuck in the throat. Frequent pneumonias.Advice for someone with swallowing problems includes: 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 behelpful in stimulating swallowing mechanism. Take smaller mouthfuls of liquids and food. All food should be chewed well.

Early Management 81 Ensure a strong swallow between each mouthful, when possible try a second swallow,or cough to clear the throat. Following a stroke someone may tire easily and this may affect the swallow. If mealtimes are taking longer and are tiring, try smaller meals, taken more frequently or withsnacks in between. If there is a tendency for food to remain in the mouth after eating, clean the mouth aftermealtime with a soft toothbrush or mouthwash.People with severe dysphagia will be fed through a nasogastric or percutaneous endoscopicgastrostomy (PEG) tube. However, oral feeding is always seen as preferablewhen 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 reassessedat regular intervals.Food and taste play an important part in our lives and the occupational therapist canliaise with the speech and language therapist to work on swallowing with changing tastesand food consistencies. The therapist should ensure the patient is well seated and supportedat meal times, encouraging people to feed themselves and trying to balance dignity withcleanliness! The Stroke Association leaflet on swallowing difficulties gives good adviceon eating.The therapist should be aware of swallowing difficulties when working on aspects suchas cleaning teeth, and making drinks and meals.It is important that all members of the team stress to the patient the importance of theiradapted diet to encourage patient acceptance of what often appears unappealing. This isespecially true for the patient who has to maintain a special diet after discharge.MoodAnxiety, depression and emotionalism are likely to make rehabilitation difficult for patientsas they may have decreased motivation to participate in assessments and intervention dueto being preoccupied with their worries and thoughts. DeSouza (1983) also noted thatone of the major factors affecting the success of stroke rehabilitation was the patient’sown determination and motivation to improve functionally. The nature of depression isthat depressed patients are likely to have a decreased ability for motivation. This findingwas supported by Zigmond and Snaith (1983), who suggested that patients may findthat symptoms of their illness may distress them to such as extent as to lead to a poorresponse to intervention. Ebrahim et al. (1987) also demonstrated that mood disturbanceat 6 months post-stroke was strongly associated with functional ability, limb weaknessand with longer hospital stay. This suggests that slow recovery and institutionalisationmay be responsible for mood disturbances.Similarly, Robinson et al. (1983) found that in 103 patients, the severity of impairmentin functional activities (ADL) and intellectual function was significantly correlated withthe severity of post-stroke depression early after stroke. Sixty-one of the patients intheir study were reassessed after 6 months and were found to have made a significant

82 Occupational Therapy and Strokeimprovement in functional impairment (Robinson et al., 1984). However, the depressedpatients remained more impaired than the non-depressed patients.A further study by Sinyor et al. (1986) also indicated that depression was common afterstroke. They demonstrated that depression was associated with the level of functionalimpairment in 64 depressed stroke patients early after stroke and suggested that it maycause a negative impact on the rehabilitation process and outcome. They followed up 25of these patients, 6 months after discharge and still found a significant correlation betweendepression 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. andSinyor et al. studies had small numbers of patients.Thus, the effect of any of these impairments has been shown to be associated with functionalability, highlighting the complexity and trauma of stroke. It is therefore importantto consider the effect of these impairments, the ‘invisible consequences of stroke’, whentreating any patient following stroke.DepressionDepression after a stroke is common but often alleviates as the patient recovers (ISWP,2008).The symptoms of depression may include: 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 carefulobservation (ISWP, 2008).Assessments that may be used include the following:(a) Hospital Anxiety and Depression Scale (Zigmond and Snaith, 1983).(b) Wakefield Depression Inventory (Snaith et al., 1971).(c) Geriatric Depression Scale (Yesavage et al., 1983).(d) General Health Questionnaire (Goldberg and Hiller, 1979).

Early Management 83Patients whose depression is more severe or persistent should be offered anti-depressantdrugs but these should not be used routinely and be monitored and continued for at least6 months if benefit is achieved (ISWP, 2008).Intervention may involve counselling, anti-depressants or psychological intervention.Behavioural intervention could include reinforcing activity, activity scheduling, feedbackof progress, experiencing success or pleasant events. Long-term therapy from a psychologistor psychiatrist may be required for some patients. This will depend on the severity ofthe depression and the patient’s ability to cope with the depression. Occasionally patientsmay become so depressed that they feel suicidal, in which case, medical advice shouldbe sought. Some patients may turn to spirituality to assist them in coping with the newlifestyle forced upon them.AnxietyAll stroke patients should be screened for anxiety and have the causes of any anxietyestablished (ISWP, 2008).Patients may have anxieties relating to their stroke, for example, fear of having anotherstroke, 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 forassessment.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 laughingfor any alteration in emotions, which can be very distressing. A common clinical techniqueis to ignore it and use distraction.Patients with severe, persistent or troublesome emotionalism should be given antidepressantswhilst 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 inthe acute stage following stroke, but can also appear as a persistent problem long afterdischarge from hospital.In the initial stages following stroke, the systems of the body are working to promoterecovery, and the patient has to make a great deal of effort – for example, in working onsitting or concentrating on a task. Some degree of exhaustion is inevitable, and therapistsshould be aware that many patients feel they are being worked too hard and that we donot understand their situation.

84 Occupational Therapy and StrokeAfter discharge, the person feels that because they are ‘better’, they should manage asbefore, 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 thiscan lead to increased tone, poor performance, reduced motivation and so on. However,the patient who appears fatigued may not actually be tired following effort. Patientsshould be able to tolerate periods of reasonably challenging activity, and the fatiguewhich accompanies such activity should easily respond to a period of rest. Fatigue withinnormal 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 aboutor showing signs of fatigue, and then address the issues involved. It may be that they arenot sleeping well at night, not able to wake in the day because of medication, be anxiousor depressed, have an infection or other pathological condition, be poorly nourished orsuffering 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 shouldbe on the part of the therapist, with relaxed reciprocation from the patient. Interventionshould 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 appearstired. Carr and Shepherd (1987) report studies in normal subjects that show muscle workperformed after a diverting activity was greater than that performed after a rest – andthey 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 thepatient.Once discharged from hospital, it can be helpful for the person to understand thepossible causes of their tiredness, and discuss strategies for coping with it. These wouldinvolve keeping active and returning to or developing interests, using energy wisely,dealing with concerns and depression, organising their day and prioritising, pacing anddelegating 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 understandingof it, and why it may appear that they are ignoring it. By providing a varied and challengingprogramme, they will assist the patient in handling fatigue.Self-evaluation questions1. Name three things you should consider doing before you attempt a full functionalassessment with a patient.2. During a functional assessment in the kitchen you notice that the patient is pickingup items and putting them down again or uses the wrong object within the task. Whatmight be the impairment? Are there any other impairments that might present in asimilar manner? What questions could you ask or what simple tasks could you do todifferentiate between the impairments?3. If a patient had an attention impairment, what might you notice while observing thispatient? What simple tasks could you do to give you some more information?

Early Management 854. If you are assessing a patient in sitting, why is it important to ensure that they aresitting 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 situpright 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 basicscreening tool that you might use to cover all the areas if you were given half an hourto check a patient before going home.6. What information would be collated by the occupational therapist prior to the initialassessment that would assist in the assessment process?7. Discuss how the World Health Organization (WHO) International Classification ofFunctioning (ICF) relates to the occupational therapy process in stroke rehabilitation.8. What signs indicate a patient might have a swallowing impairment and how wouldthis affect your occupational therapy intervention?9. Describe the differences between aphasia, dysarthria and verbal apraxia.10. Describe the symptoms of mood disorders.

Chapter 5Management of Motor ImpairmentsStephanie Wolff, Thérèse Jackson and Louisa ReidThis chapter includes: 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 questionsIntroductionThe impact of motor impairments on patients can be devastating and the role of theoccupational therapist in managing these problems is vital. This chapter focuses on the rehabilitationphase of managing motor problems and gives an overview of current practicein the clinical setting although various elements will also be applicable to the communitysetting. Main aspects of intervention are covered to equip new clinicians or students withideas on how to approach the assessment and intervention of motor impairments. It isimportant to note that no one approach has been proven to be the most effective in regainingmotor control post stroke; however, specific interventions that have been shown to beeffective with certain groups of patients are discussed in the chapter. The chapter also coverstwo 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.AssessmentThe assessment and analysis of patient’s problems set the scene for intervention. Thereis no formal assessment procedure. The idea is to build up a picture of the patientas 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 longand short-term goals, in conjunction with other team members. A thorough assessment

Management of Motor Impairments 87of motor impairments is essential, in order to understand the impact on functional tasksand to determine an appropriate and evidence-based intervention plan. Assessments canbe carried out jointly with a physiotherapist in order to avoid the patient undergoingmultiple assessments and to promote working jointly towards common goals; this is acommon practice in many units and community teams.The following approach to assessment is more likely to occur in hospital in the acuterehabilitation phase but the principles can apply to patients in any location. In the acutestages of rehabilitation, the patient may be in bed when first assessed, which can be agood 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 ofmotor problems within other activities of daily living such as washing and dressing. Italso enables the therapist to risk assess the safest handling approach.This section focuses on the practicalities of assessment that rely on the observationalskills of the therapist rather than the use of standardised assessments, which have beendiscussed later in this chapter.During the assessment, the following questions should be asked and observations shouldbe documented appropriately.How does the patient move? 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? 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 oftactile awareness). Is there loss of active, selective movement? Are there cognitive/perceptual problems? (apraxia, neglect/inattention).Bed mobilityBefore starting consider some practicalities. Check with nursing staff that the patient isfit to be assessed and are able to actively participate in the session? Can their consentbe gained? Can they follow instructions? Beware of hazards around the bed such as dripstands, catheters or feeding tubes.Start by looking at the patient lying supine in bed (lying face up): Is the patient able to move their head freely from side to side? Is the head turned more to one side than the other? Which side?

88 Occupational Therapy and Stroke Is the patient straight or crooked in the bed and is one side of the body very activecompared to the other? Does the weaker arm look in a comfortable position or does it look like it is trappedunder the body? When you ask the patient to move the weaker arm and leg of the same side, is theresome 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, lowtone 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, butthat can change quickly.Following initial observations ask the patient to roll from side to side. If the patientneeds help rolling, always make sure there is a second person to help. If the patient isclearly needing significant help, unless competent in therapeutic handling techniques, donot continue and use sliding sheets to position patient on their side.SittingAt this stage the occupational therapist should have enough information to decide whetheror not to proceed looking at the patient in sitting, on the edge of the bed. Initial assessmentof sitting may however be best carried out with the patient sitting on a plinth in a therapygym. Make sure there are enough staff to ensure the patient’s safety. 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 laterin this chapter). In this posture observe if there are any changes in tone to the affected arm and leg. Is the patient overactive with the intact side? Do they appear to be pushing themselvesover-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 alsoassess them sitting on the edge of their bed. Patients in hospital may have airflow mattresseson 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.TransfersAssessment of transfers includes moving from supine to sitting, bed to chair and chair tocommode or toilet.

Management of Motor Impairments 89Assessment will establish how the patient moves from one surface to another, howefficient they are and how safe. It is important to determine the level of assistance thepatient needs. It is also vital for the therapist to know their level of competence whenfacilitating transfers. If assessing transfers with someone who is clearly going to needassistance, it is important to have a second person present, preferably an experiencedtherapist.When assessing transfers, consider the following: What is the minimum level of assistance the patient needs to safely complete thetransfer? Be careful not to over- or under-help someone. Can they transfer to both the sound and the affected side?The patient should be assessed in various situations; transferring from a wheelchair to aplinth is not a satisfactory assessment. Make sure transfers are assessed in the environmentwhere the patient will be required to do them throughout the day.Assessment of sitting balance and transfers will inform what recommendations mightbe needed for the nursing staff in relation to handling, for example, it will determine ifthe patient is suitable for a standing hoist rather than a full hoist. It will inform if they aresafe to transfer to a toilet rather than a commode. Some patients can transfer safely withone person but cannot maintain their sitting balance safely on a toilet and therefore mayneed to transfer to a commode. It contributes to determining whether the patient is safe tobe left alone whilst using the toilet.StandingAssess how much facilitation the patient requires to stand from a variety of surfaces andobserve the patient’s alignment in standing.Consider the following: 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?WalkingIf the patient is able to walk, How far can they walk? Are they safe?If the patient requires assistance with walking, agree on the most appropriate methodof assistance with the physiotherapist.Assessment of walking should be carried out in different environments that are relevantto the patient, for example, in open spaces, around cluttered rooms, uneven and evensurfaces. In the community, walking assessment should include going to the shops, postoffice, restaurants, etc.

90 Occupational Therapy and StrokeActivities of daily livingAlthough assessment in different postures is important, the most relevant assessment ofmotor problems from the occupational therapist’s perspective is within more functionaltasks. In the early stages of recovery, these could be getting washed and dressed, groomingtasks, feeding or simple kitchen activities. In later stages of recovery, this may includeshopping, getting to work or social events.At the end of assessment, the occupational therapist should be able to identify theimpairments of motor control and be able to relate this to the level of patient independencein activities of daily living.Standardised assessmentsStandardised assessments are used in clinical practice to identify and quantify problemareas. These assessments can also be used as outcome measures. The National ClinicalGuidelines for Stroke (Intercollegiate Stroke Working Party (ISWP), 2008) recommendthat‘All patients should be assessed for motor impairment, and a standardised approach to quantifythe impairment should be used.’There are various standardised assessments available. There is long-standing debate asto which of these are the best and currently which assessment is selected often dependson therapist’s preferences. When using a standardised assessment, it is important tounderstand what is being assessed. The results of such assessments should be usefulfor planning intervention and setting goals. There are two types of tests that are usuallyselected, generic activities of daily living and specific motor performance tests.The National Clinical Guidelines for Stroke (ISWP, 2008) recommend the BarthelIndex (Mahoney and Barthel, 1965) as a generic activity of daily living scale and theMotricity Index (Collin and Wade, 1990), the Rivermead Motor Assessment (Lincolnand Leadbitter, 1979) and the 9 Hole Peg Test (Kellor et al., 1971) as specific motorperformance tests. Many others are available, as listed in the evaluation chapter.Management principles and interventionFollowing a thorough initial assessment, the therapist needs to incorporate the identifiedproblems into an intervention plan. Although occupational therapists in clinical practicewill take into account all problem areas after the stroke, for example, cognition andperception, when planning intervention, this chapter concentrates on the intervention thatfocuses 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 thatrelate to motor impairments that will impact occupational therapy practice are stated inSection 6.46:‘Any person who has limitations on any aspect of personal activities, especially but not onlyif acquired as a result of this stroke, should: have intervention of identified problems from

Management of Motor Impairments 91the Occupational Therapist who should also guide and involve other members of a specialistmultidisciplinary team’.Specific interventions that should be offered (according to need) include: The opportunity to practise activities in the most natural (home-like) setting possible. Assessment for, provision of and training in the use of equipment and adaptations thatincrease safe independence. Training of family and carers in helping the patient.Section 6.47 also relates to extended activities of daily living. Another relevant sectionfor 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: Standing up and sitting down. 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 practiceshould be targeted. The point of assessing at impairment level is to understand which ofthe performance components of a task are affected, thereby explaining why patients areunable to complete a functional task, for example, a low tone arm affected the patient’sability to dress. While the general recommendation is to practise tasks which enable theoccupational 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 interventionThe main aims of occupational therapy intervention regarding motor problems are: To promote motor recovery in the most normal or efficient way to increase functional independenceby practising graded activities of daily living using a restorative (remedial)approach. To prevent secondary complications such as pain in the shoulder or swelling of thehand. To maximise the patient’s independence in activities of daily living by using an adaptive(compensatory/functional) approach, when the restorative (remedial) approach is feltnot to be practical or achievable. To train carers in safe techniques for handling and carry out risk assessment based onpatients functional level and equipment needs, either in preparation for discharge or asongoing rehabilitation in the community.Positioning the early stroke patientPeople are dynamic moving individuals, and when positioning, it is important to considerthe functional activities an individual wishes to achieve, in any given posture. In the earlystages of recovery, when movements are restricted by the effects of their stroke, individuals

92 Occupational Therapy and Strokeare unlikely to be able to make the postural adjustments required, to maintain a symmetricalposture, without assistance. There are basic principles that can be followed to allowthe individual to perform desired activities while assisting in the recovery process. Theseprinciples will help recovery by maintaining passive range of movement, allowing the individualto use the control they have and providing normal sensory and proprioceptive input.In bedIn the initial stages following stroke, lying is the position where the individual is mostincapacitated. 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 thehemiplegic side may fear turning, or lying on the affected side, while lying on theunaffected side restricts the use of the sound upper limb. Often the individual is nursedon his/her back; which can restrict visual fields, and may leave the individual unable touse their upper limb.There are advantages to the individual spending time in bed in that it is the positionof fullest support. Those with high tone may benefit from returning to bed for periodsduring the day to help manage tone. Similarly, those with low tone may be fatigued bythe effort required to maintain their posture against gravity, and may need rest periodsto be built into their day. Correct positioning for sleeping and the early development offunctional bed mobility are advised. There are of course certain disadvantages to patientsspending an excessive amount of time in bed. These include: infections, pressure soresand other complications. Therefore, it is imperative that patients are moved frequentlyand supported to achieve other positions.How to position in bedSupport should be offered where required to enable the individual to maintain theirposition. In side lying this may include support along the back to prevent rolling onto theback, and to offer proprioceptive indicators to the hemiplegic side. When lying on theaffected 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; ifnecessary place a pillow under the knee to reduce any adductor tone developing (seeFigures 5.1 and 5.2; shaded side is the affected side).When lying on the unaffected side the position is reversed; however, the individualwho is unable to roll independently will be more incapacitated in this position, so the callbell must be within reach (see Figures 5.3 and 5.4). Side lying on the unaffected side is aposition of choice for at least some of the time, for those who have an overactive soundside. In this position they receive proprioceptive feedback about midline; it facilitateselongation of the trunk on the sound side and promotes weight-bearing through theoveractive side.When positioning an individual on their back, it may be necessary to use pillows toprevent the affected shoulder and hip falling into retraction. Lying on the back is alsoa good position to allow the pectoral muscles to be stretched with the arm supported inabduction (see Figures 5.5 and 5.6). Similar support will be necessary for patients sittingup in bed (see Figures 5.7 and 5.8).

Management of Motor Impairments 93Figure 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 atknee, (iii) there are no objects in the hand or against the sole of the foot, (iv) head is in line withthe 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 atknee, (iii) there are no objects in the hand or against the sole of the foot, (iv) head is in line withthe body (Edmans et al., 2001).

94 Occupational Therapy and StrokeFigure 5.3 Positioning in bed, lying on the unaffected side (left hemiplegic patient). Doensure (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 thehand 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). Doensure (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 thehand or against the sole of the foot (Edmans et al., 2001).

Management of Motor Impairments 95Figure 5.5 Positioning in bed, lying on the back (left hemiplegic patient). Do ensure (i) headis 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 placeany 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) headis 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 placeany object in the hand or against the sole of the foot (Edmans et al., 2001).

96 Occupational Therapy and StrokeFigure 5.7 Positioning in bed, sitting up in bed (left hemiplegic patient). Do ensure (i) thepatient is upright with weight evenly distributed on both buttocks, (ii) shoulder is protractedaway from side and forward on a pillow, (iii) legs are straight and not laterally rotated. Do notplace 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) thepatient is upright with weight evenly distributed on both buttocks, (ii) shoulder is protractedaway from side and forward on a pillow, (iii) legs are straight and not laterally rotated. Do notplace any object in the hand or against the sole of the foot (Edmans et al., 2001).

Management of Motor Impairments 97It is important to consider mattresses when positioning the patient. A firm, supportivesurface will provide proprioceptive feedback, enable rolling and promote independencewhen sitting up. However, pressure areas also need to be monitored. Where hospitalpressure care mattresses are used, the patient is likely to require more assistance to turnand sit up.Encouraging the patient to sit up through side lying promotes head righting, weighttransference and a sense of midline.In a chairMore independence is offered to the early stroke patient in supported sitting and they gaina more normal visual perspective of their environment. There is scope for the unaffectedarm to be used in a range of functional activities. The trunk muscles begin to be usedactively 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 developinappropriate muscle activity and ‘holding’ postures if they do not receive sufficientsupport from the chair or pillows. Those with sensory loss will require pressure areas tobe monitored. Where head control is still lacking, support must be provided.Armchairs generally provide a back support that is slightly reclined which allowsfor more relaxation. Where there is little active muscle control, the patient may have atendency to slide forward in the chair. This may encourage excess abdominal activity andonce 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 encouragesgreater freedom of upper limb movements. Pressure relief is an important consideration ifthe person is unable to change position without assistance, but this still needs to providea stable base.Points to consider when positioning in a chairWhere possible the individuals’ hips, knees and ankles should be flexed at 90 ◦ with thefeet on a firm, flat surface. Abduction/adduction of the hip may require wedges to facilitatethe correct alignment.The armrests should allow the arms to be resting on them without the trunk leaningto the side. The arm position may be altered between internal and external rotation atthe shoulder, and the forearm between pronation and supination. The arm may also bepositioned on a table in front (see Figures 5.9 and 5.10) or to the side of the patient (seeFigures 5.11 and 5.12). These variations help to maintain passive range of movementand prevent shortening of the affected muscle groups. Care should be taken to preventtightness 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, ifnecessary using positioning devices such as pillows, shaped arm rests or splints. Webspace and rotation of the thumb should be passively maintained, in order to preservefunctional viability of the hand.

98 Occupational Therapy and StrokeFigure 5.9 Positioning in a chair, affected arm supported in front (left hemiplegic patient). Doensure (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).

Management of Motor Impairments 99Figure 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).

100 Occupational Therapy and StrokeMany specialist chairs are now available that provide additional postural support suchas lateral supports, head supports, inclined seats and lap straps (to maintain the hipsat 90 ◦ ). These chairs are normally adaptable for each patient in seat height, length andincline. Lateral supports need to be adjusted for each patient and staff are aware of howto position both the patient and the supports each time. Each patient needs to be carefullymonitored for fatigue and pressure relief. If a pressure relief cushion is required, this needsto be assessed for and incorporated into any seating assessment, taking into account anypostural needs or sitting balance problems.Perch sittingWhen the patient begins to gain some active sitting balance and transfers are progressing,positioning on a perching stool allows for more active sitting, improving dynamiccontrol 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 heightand position of the pelvis in anterior tilt facilitates easier transfers into the standing position.However, perching stools should only be considered for relatively high functioningpatients.Points to consider when using a perching stoolChoose a perching stool with the correct amount of support, for example, witharms/backrest as appropriate. Ensure the affected hip is not retracted. Both feet shouldhave even weight-bearing and should be placed on a firm flat surface.Sometimes perch sitting is contraindicated as it can exacerbate abnormal patternsof movement/positioning, although it may be the only functional option in the longterm.Self-care activitiesAll 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 preparingthe environment and gathering the necessary items. The following are ideas how eachsession can be graded. The focus is on a restorative (remedial) approach, although it isa common practice to teach some adaptive (compensatory/functional) techniques early,that is, dressing techniques to maximise early independence.Interventions involving personal washing The emphasis for patients in the early stages post stroke who have no or very poorsitting balance should be on good positioning in a supported chair. The task shouldhave low attentional demands so that focus could be just on washing face, combing hairor shaving with an electric razor. As sitting balance improves, focus could be on washing from the waist up. The environmentcan be manipulated to challenge the patient. Position the patient in front of an

Management of Motor Impairments 101appropriate height sink, the patient’s wheelchair back can be folded down, the therapistcan sit behind the patient and facilitate the trunk as required, and an assistant can helpthe patient with the task. The patient can be encouraged to reach forward and to theside for items. Whilst washing, the patient’s affected arm can be positioned in supporteither on the arm of the chair or forward on the sink (as long as good alignment of thewrist and shoulder can be maintained). Another progression could be to carry out washing while seated on a plinth; this is anexcellent 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. Washingwhile seated on the plinth allows the patient to move more freely, it gives the therapistopportunity to challenge sitting balance even more and allows involvement of the upperlimb to be facilitated. This style of intervention is not recommended if the patient hasperceptual problems and would struggle with carrying out tasks in an environment thatis out of context. When the patient’s sitting balance has improved and the required assistance with transfersis minimal, the occupational therapist can consider sessions involving washingthe whole body such as showering. Showering can be carried out on a shower chairor whilst seated on a bath board. If your unit has an extra wide bath board, start withthat one and introduce the normal narrower board when the patient is confident. Swivelbathers can also be used. For patients who prefer to strip wash, a perching stool can beconsidered to increase the challenge. For patients using a bath board, it is recommendedthat the sound side of the body is nearest the wall; this is for safety but it also allowsthe 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 shouldstill provide facilitation and prompts if required, to achieve active incorporation of theaffected arm and leg. The ultimate goal would be for the patient to be as independent as possible washing ina manner of their choice.Interventions involving dressingDressing can be graded in a similar way to washing and, although separated here, shouldbe part of the same intervention session. 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’ssitting balance, trunk control and position and incorporation of the upper limb asappropriate. Patients with improving trunk control could be taught dressing techniques while seatedon a plinth, as mentioned for washing. The plinth is also a good place to teach lower bodydressing techniques. This would also involve practising standing with the necessaryprompts or facilitation.

102 Occupational Therapy and Stroke The ultimate goal for dressing would be for the patient to be as independent as possiblein the most normal environment, for example, sitting on the bed or standing in thebedroom or bathroom. Adaptations such as elastic shoe laces or Velcro shoes/trainers are often useful, orteaching the patient a one-handed method of tying shoe lace is feasible; again theseadaptations should not deter patients from using any return of hand function withintheir activities of daily living. 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 becomeproficient in dressing techniques or their motor/cognitive problems improve, allowingthe individual to dress in their desired style of clothing. Any change of clothing stylemust be carefully discussed with the patient in order to maintain the individual’sautonomy and self-image.Using adaptive (compensatory/functional) strategies for dressingEven in the early phase of recovery, occupational therapists can teach patients adaptive(compensatory/functional) strategies for functional tasks that will improve quality oflife and that are considered not to have a detrimental effect on motor recovery. Mostpatients will find a way to compensate in order to meet their basic functional needs soit is important that the occupational therapist guides this in the most appropriate way.One-handed dressing techniques are commonly taught.Dressing the upper bodyThe patient should lay the garment on their knees so the back is uppermost; they can theneasily see which arm goes into which sleeve. The sleeve hole of the affected arm shouldbe positioned in such a way that the sleeve hangs down by the affected leg. The patientshould move their affected hand into the sleeve, lean forward and slide the affected armdown 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 othersleeve and pull the jumper, etc., over their head. The patient may need to be remindedthat clothes can get stuck on the affected shoulder and may need pulling down (see Figure5.13a–h). Bras can be put on this way also, provided they are elasticated and are fastenedup 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 collarnearest themselves, the inside of the shirt/blouse uppermost and sleeves correspondingto the appropriate arm (see Figure 5.13i–q).Dressing the lower bodyWhilst seated, the patient should cross their affected leg over the sound leg after whichthey can lean forward to put each garment over the affected foot. They should then uncrosstheir legs and reach down to put the garment over the sound foot. Many patients are unableto maintain sitting balance whilst moving the sound foot off the ground. These patients

Management of Motor Impairments 103(a)(b)(c)(d)(e)(f)(g)(h)Figure 5.13 (a–q) Dressing top half (photographs for right weakness, reverse for leftweakness). (Reproduced with permission from Dr J. Edmans, University of Nottingham,personal communication, 2009.)

104 Occupational Therapy and Stroke(i)(j)(k)(l)(m)(n)(o) (p) (q)Figure 5.13(Continued)

Management of Motor Impairments 105should keep the sound heel on the ground, while putting garments over the sound toesand, then keep the sound toes on the ground while pulling the garment round the soundheel (see Figure 5.14a–h).The patient should then stand up, achieve standing balance and pull up garments. Ifappropriate, the patient can be facilitated to use the affected upper limb for support, thetherapist 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 supportiveslip on style shoes; these types of shoes can now be bought cheaply to suit all age groupsand sexes. Shoelaces can be tied with one hand, following the technique shown in Figure5.15a–h.UndressingTeach patients to undress the opposite way to putting clothes on, the sound side shouldbe undressed first. With upper body clothing t-shirts and sweaters can be pulled over thehead, although care should be taken around the affected shoulder.Instrumental activitiesThese include the following: Kitchen tasks. Household duties.When using these activities for treating motor impairments, again a graded approachshould be used. The occupational therapist needs to be creative when thinking of interventionideas in the occupational therapy kitchen or the home environment and will need toconsider the patient’s preferences and goals, culture, religion and previous roles. Medicalstatus regarding level of exertion and conditions such as diabetes and dysphagia also needconsideration.Graded kitchen task A patient with poor sitting balance could initially be set up at table top level to carryout a task. The task chosen can be decided between patient and therapists, but could bemaking a hot drink, cereal and toast, baking, etc. As the patient improves the challenge can increase, a perching stool could be used andstanding can be incorporated; the patient can be encouraged to reach for items in highand low cupboards. The therapist can facilitate or prompt the affected arm and leg asappropriate. For mobile patients walking should be assisted as necessary and tasks should involvemoving around the kitchen, transporting items between surfaces. Similar grading principles would apply to household tasks such as laundry, cleaning,gardening, etc. The restorative (remedial) approach should be used but as with dressingcertain adaptive (compensatory/functional) strategies may need to be incorporated tomaximise independence.

106 Occupational Therapy and Stroke(a)(b)(c)(d)(e)(f)(g)(h)Figure 5.14 (a–h) Dressing lower half (photographs for right weakness, reverse for leftweakness). (Reproduced with permission from Dr J. Edmans, University of Nottingham,personal communication, 2009.)

Management of Motor Impairments 107(a) (b) (c)(d)(e)(f)(g)(h)Figure 5.15 (a–h) Tying shoes laces (photographs for right weakness, reverse for leftweakness). (Reproduced with permission from Dr J. Edmans, University of Nottingham,personal communication, 2009.)

108 Occupational Therapy and Stroke 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 Tasks such as ironing, laundry, vacuuming and cleaning are excellent activities that canbe graded by the occupational therapist. Ironing could be done initially from perch sitting, then progress to standing; the patient’saffected upper limb should be monitored closely during ironing tasks. Vacuuming and cleaning could be used for patients working on higher level balanceskills. Some of these tasks can be set up on rehabilitation units, or in-patients can be takenhome for their intervention session. Realistically these activities are more appropriatefor community teams.One-handed techniquesAlthough the objective is to restore the patient’s movement and hence function, it isinevitable that some patients will not make a full recovery. Consequently, such patientsmay have to resort to use one-handed techniques to restore function. Suggestions areincluded in the Appendix.Therapeutic activitiesIn the management of physical problems following stroke, therapeutic restorative (remedial)activities offer the patient movement experience in a controlled environment (seesection on Upper limb re-education later in this chapter). The therapist positions the taskto gain specific movements often related to regaining upper limb function. These sessionsare often done as tabletop activities. The therapist should have a clear idea of the taskthey want the patient to participate in and how much help/facilitation they require. Therationale for the intervention should be explained to the patient. The environment shouldbe set up to maximise the effect of the intervention, that is, the height of the table thepatient is seated or standing at. Ideas for interventions include: Playing cards, dominoes. Solitaire, connect 4. Peg boards, block placing. Badge making.

Management of Motor Impairments 109 Writing exercises. Turning pages of a newspaper/magazine. 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 themovement(s) they want their patient to practise; the more meaningful the activity is forthe patient, the more they are likely to engage in the session.Clinical challengesPusher syndrome/overuseIn the early stages of recovery, one of the most challenging clinical pictures is the patientwith what has long been called ‘pusher syndrome’. Whether or not such a thing could beclassed as a syndrome has been an unresolved debate among clinicians for some time. Butcertainly 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: The head is turned to the sound side and is at the same time shifted laterally towardsthe sound side. When the patient is sitting, they are unable to relax muscles in orderto allow the head to be side flexed towards the affected side, although it movesfreely to the sound side. The eyes are often turned to the sound side as well, and thepatient has difficulty in bringing them to the affected side and then maintaining theirposition. The patient’s ability to perceive incoming stimuli from the affected side is reduced inall the perceptual modalities, that is, tactile, visual or auditory. Lying supine on a plinth or in bed, the patient shows an elongation of the affected sidefrom head to foot. When lying on the plinth the patient holds onto the edge with the sound hand and isanxious that they may fall of the edge. When both knees are flexed with the feet supported on the bed, they lean towards theaffected side. A marked resistance is felt when trying to turn both knees to the soundside, that is, as if to lay them on the bed on that side. No resistance is met when rotatingboth knees to the affected side. In sitting the difficulties become more obvious. The head is held stiffly to the soundside and the sound side of the trunk shortens markedly. The affected side is elongatedalthough the weight remains over the affected side. Resistance is encountered when anattempt is made to transfer the weight over the sound side, with the patient pushingback with the help of his/her sound hand. Transferring the patient into a chair presents difficulties; the patient actively resistsmoving towards their sound side.

110 Occupational Therapy and Stroke Sitting in a wheelchair the patient adopts a typical posture. The trunk is flexed, the headis turned to the sound side and the sound arm maintains constant activity, pushing onthe arm of the chair. When leaning forward in order to stand up or transfer into bed, the patient pushestowards 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. In standing, the patient’s whole centre of gravity is to the affected side, so that a linedrawn from the sound foot to the sternum would be diagonal to the floor. Patients have considerable difficulty in learning to dress themselves and in activities ofdaily living in general. Many perceptual problems are experienced by patients manifesting the pusher syndrome,and will need to be treated accordingly.Ideas for interventionAlthough this presentation mainly manifests as a physical problem, it has a large cognitivecomponent, usually a problem with spatial attention (see perception chapter) and toaddress 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. Thekey is to re-educate the patient to where their midline is. The problem can manifest whilethe patient is lying in bed, in sitting and in standing. A useful technique for this is to usethe environment. Either in the gym or anywhere quiet, position the patient near a wall orsomething vertical. The patient understands that the wall is upright and with prompts fromthe therapist can then orient themself to midline in either sitting or standing. Facilitationshould be avoided and the therapist should be careful not to over-handle the patient in theearly stages. This is because the patient will think they are being pushed over and will resistthis, 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 experiencedtherapist to guide intervention. Patients can overcome this phenomenon with time, butoften they are the patients who have had the largest strokes and functional recovery may belimited.AtaxiaEdwards (1996) describes three types of ataxia:Sensory ataxia This is seen in diabetic or alcoholic neuropathy conditions. It disrupts the afferent proprioceptive input to the central nervous system. Symptoms include wide-based stamping gait with eyes fixed to the ground for visualfeedback.

Management of Motor Impairments 111Vestibular ataxia This is seen in peripheral vestibular conditions or central disorders affecting the vestibularnuclei, for example, medullary strokes. Symptoms include disturbances of equilibrium in standing and sitting and may also beaccompanied by vertigo, nystagmus or blurred vision.Cerebellar ataxia 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 ataxiaCerebellar ataxia is the most common seen in stroke. It varies in its presentation frommild to severe. In the most severe cases, it can be totally debilitating. Patients strugglewith controlling movement in all postures and controlling the affected upper limb in orderto complete the most basic of activities of daily living. Intervention is both restorative(remedial) and adaptive (compensatory/functional) and occupational therapists need tobe careful to achieve the right balance in their interventions. If possible in occupationaltherapy sessions, the therapist should discourage the patient from what is commonlycalled ‘fixing’; this is where the patient overcompensates by holding on to surfacesvery rigidly to give them stability. The restorative (remedial) approach is focused on thepatient regaining fluid movements and feeling confident to allow themselves to move.In patients whose ataxia does not improve, the occupational therapist can teach techniquesto compensate. Some common strategies include: Using a wheelchair to self propel if walking is not possible (this needs careful assessmentto establish appropriateness). Using the sound arm to help control the ataxic arm during tasks such as feeding andgrooming. Introduction of weighted items such as cups and cutlery. Issuing cups with lids on. There are now many cups on the market that don’t look likebaby cups anymore and can be bought on the high street. Stabilising self proximally, for example, hips stabilised against a bench during tasks instanding, elbows propped on table during fine motor tasks.Upper limb re-educationIt is thought that up to 70% of stroke patients will have their upper limb function affectedand 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

112 Occupational Therapy and Strokeamount of research has been done to try and establish the most effective interventionsfor the arm (Wolf et al., 2006). Two techniques described in Chapter 2 (Bilateral ArmTraining/Isokinematic Training and Constraint Induced Movement Therapy) have beenshown to be effective in some patients and can be incorporated into occupational therapyplans (see Chapter 2). Handling the paretic upper limb should be done with great careand advice should be sought from experienced therapists when planning interventions.Avoiding secondary complicationsThe subluxed shoulderPost-stroke shoulder pain is reported to be very common, and in some cases the prevalenceof shoulder pain has be reported to be up to 80% of stroke patients (Walsh, 2001); thishowever varies on how it has been measured. Shoulder pain can lead to difficulty withactivity 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 havean impact on the patient’s quality of life.A number of situations can cause shoulder pain, including shoulder subluxation, scapularretraction, abnormal tone either hyper or hypotonicity, sensory changes and poor handling.Shoulder subluxation is caused by low tone around the shoulder, resulting in theglenohumeral joint being displaced as gravity causes the surrounding soft tissues to bepulled down and over-stretched.AssessmentPalpation of the space between the acromion and head of the humerus can be measured byfingers or centimetres. It is important to assess scapular alignment as a displaced scapularcan cause pain. A malaligned scapular can have an effect on the whole position of thearm, as can a subluxed shoulder and it is essential to gain a full understanding of howthe arm is presenting. Scapulohumeral rhythm is an essential part of reach and thus theposition of the shoulder has a major influence on the functional use of the upper limb.InterventionIt is essential to try and determine the cause of shoulder pain to be able to plan the bestintervention. Intervention is focused around maintaining good positioning of the arm atall times, in lying, sitting and standing. It is still important to facilitate normal range ofmovement and this is best carried out with the patient seated in front of a table so theiraffected elbow is supported. The patient should be taught scapular gliding exercises sothey can do these regularly throughout the day.Zorowitz et al. (1996) found that facilitated movements were an effective way of aidingmotor recovery and this can be an effective intervention for shoulder pain. The arm canbe supported in various different ways by a pillow, used in supine, side lying or sitting. Inaddition there are trays and lapboards that can attach to wheelchairs but these have been

Management of Motor Impairments 113found to over-correct the shoulder alignment (Paci et al., 2005), so careful assessment isneeded.Slings have been used as an alternative and these can also be used in standing. Thereare many different types of slings and the position they hold the shoulder in is of variablequality, as stated in Ada et al. (2005) and Walsh (2001). Slings tend to be difficult toapply 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 theshort 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 ofmovement and arm function. Physiotherapists may use strapping where the shoulder isstrapped into correct alignment. Hanger et al. (2000) did not find this to be an effectivemethod of intervention; however, they did find some immediate short-term pain relief. Oralanalgesic medication is a common practice and is often provided before therapy sessionscommence. The intervention of shoulder pain requires a coordinated multidisciplinarymanagement. Turner-Strokes and Jackson (2002) outlined an integrated care pathway forthe intervention of shoulder pain; a whole team approach is necessary to minimise itseffect on rehabilitation.OedemaPost-stroke hand and arm oedema results in an enlargement of the limb with restrictedmobility 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 asan 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 populationwith stroke is unclear; however, one cross-sectional study concluded that oedema waspresent in 33% of adults with stroke receiving early rehabilitation, with some degree ofswelling noted in up to 73%, and that it was more common in those with more severeparesis of the hand. It was seen significantly more often in those with hypertonic fingersand reduced sensation (Boomkamp-Koppen et al., 2005).AssessmentEarly identification is necessary to ensure preventative measures are put in place as soon aspossible. Visual inspection and comparison of the hands is generally sufficient to identifypost-stroke swelling and oedema; however, it is prone to variation and other assessmentmethods such as circumferential measurement and volumetric assessment may be used.InterventionThere is a lack of scientific evidence as to effective ways of reducing post-stroke upper limboedema; however, intervention should include a positioning programme which includessupported elevation of the arm, passive ranging and light retrograde massage and, where

114 Occupational Therapy and Strokepossible, functional use of the limb. Splinting may be used to support normal alignment ofthe hand and wrist and to avoid entrapment which may contribute to swelling. Educationand advice for the patient, family, carers and other staff to manage the effects is alsorecommended.SplintingWithin the literature there is conflicting evidence and opinions on whether to use splintingas a form of intervention. There is a lengthy debate on the theoretical basis forsplinting within neurology. There are two conflicting theories of biomechanical and neurophysiologicalapproaches (Copley and Kuipers, 1999). Biomechanical rationale arguesthat splinting is used to prevent and manage length-associated changes in muscles andconnective tissues. The neurophysiological rationale recommends that splinting is used toinhibit reflexive contracture of the muscle. The decision on whether to splint must be madeon sound clinical reasoning. There are a wide variety of materials and types of splints andall have different qualities. Splints should not be considered when there is active movementthat would be restricted if a splint should be provided. Whatever the approach, thereare many different aims for splints and the reasons why splints may be considered are asfollows: Reduction of spasticity. Reduction of pain. Reduction of oedema. To maintain joint position and alignment. Functional reasons.Reduction of spasticityLannin 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 theprovision of a splint in a neutral or extended position to prevent contracture. The evidencedoes not support splinting in the acute phase for spasticity as a method of prevention ofcontracture. Regular passive range of movement and stretching is recommended and it isimportant to provide teaching to the patient and carer to perform this programme. Thereis 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 supportand/or inhibit to achieve the ideal position to maximise the effects of the injection. Thetype of splint chosen will vary depending on the ideal position, but may include cones orresting splints in volar, dorsal or mid prone.When spasticity is preventing hand opening causing difficulty maintaining the hand’shygiene, it can lead to a breakdown of skin integrity. In this situation provision of a palmprotector splint should be considered with regular passive range of movement that couldbe incorporated to self-care, care plans. Cone splints may also be considered; however, attimes these are too harsh for patients to tolerate and often patients need a softer material.

Management of Motor Impairments 115Reduction of painFollowing a stroke, pain can occur in various joints although wrist pain is a commoncomplaint among patients. This can be due to the wrist being in a prolonged flexedposition due to spasticity or flaccidity, leading to overstretching and/or shortening ofmuscles. Lannin and Herbert (2003) suggest that regular passive range of movementis effective in prevention of contracture, and thus splinting for this reason will not betherapeutic. The therapist should assess each individual patient and after applying goodclinical reasoning, splinting to manage pain may be appropriate. When pain is due to anoverstretch of the wrist, provision of a volar resting splint may be beneficial to preventfurther harm and provide support. This must be alongside regular range of movement.Maintaining joint alignmentWithin the early stages of low tone, the hand may lose the curvatures due to prolongedresting in a flat position. A resting splint may be considered to maintain the hand’s naturalcurves and prevent secondary complications developing. It may be possible however tomaintain the hand’s natural curves through positioning, using rolled up pillowcases placedin the hand and regular passive range of movement.Functional aims of splinting To improve grasp in functional activities. To increase range of movement to open hand easily to enable daily hygiene. To use the upper limb pain free within activities.Types of splintingThere are various different forms of splinting; these include thermoplastic, casting, airsplints 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 splintsthere are dynamic or functional splints. Dynamic splints are supportive and aids initiationand performance of motion. A dynamic resting splint will allow the fingers to move in flexionduring tonal changes. Dynamic splints aim to control unwanted tone which improvesreach, decreases involuntary movements, increases bilateral use and awareness of the arm.Functional splints allow function in activities; examples of common functional splints arewrist cock splints, thumb spicas, hand writing splints and wrist supports with universalcuffs. Casting uses soft and scotch casting material and provides a circumferential support.Commonly used casts are applied to elbow, ankles and wrists.OrthoticsThe National Clinical Guidelines for Stroke (ISWP, 2008) recommended that an anklefootorthosis (AFO) should be considered as it is felt that its application would improve

116 Occupational Therapy and Strokea patient’s gait or balance. Following assessment by an orthotist, a recommendation forone of the following may be made: An AFO; there are many varieties available including those with a solid ankle, anarticulating ankle or the lighter foot drop splint. Callipers are still sometimes used in extreme cases. Prescription shoes or slippers. Shoe insoles.Although referrals are often initiated by physiotherapists, an occupational therapistshould be consulted about the practicalities of putting on and taking off the AFO.Self-evaluation questions1. Why is the assessment of motor impairments important for the occupational therapist?2. What are the most important skills required for the assessment of motor problems?3. What functional transfers should the occupational therapist assess and why?4. Name three standardised assessments the occupational therapist could use to testmotor problems.5. The National Clinical Guidelines for Stroke (ISWP, 2008) state three specific interventionsthat should be offered to patients with motor problems. What are they?6. What are the four main aims of occupational therapy intervention with stroke patientswho have motor problems?7. Name three clinical challenges that the occupational therapist might meet with patientswho have motor problems.8. Name the two evidence-based techniques that should be considered for upper limbre-education.9. How should the occupational therapist address a subluxed shoulder?10. What are the four reasons why the occupational therapist may splint an affected upperlimb?

Chapter 6Management of Visual and SensoryImpairmentsMelissa Mew and Sue WinnallThis chapter includes: Visual processing Somatosensory processing Auditory processing Vestibular processing Olfactory and gustatory processing Self-evaluation questionsIntroductionThe brain is involved in processing a variety of sensory inputs which enable an individualto see, feel, hear, orientate themselves to, smell and taste the external world and objectswithin it. This not only enables individuals to detect stimuli and alert them to danger, butalso enables individuals to make sense of their environment in order to adapt behaviourand affect changes in the external environment, essential for occupational performance.A significant proportion of the brain is involved in sensory processing and sensoryimpairments are common following stroke. In general, sensory loss arises from lesionsalong the sensory pathways from the peripheral nervous system via the contralateralthalamus to the contralateral sensory cortices, as shown in Figure 6.1. Thus a lesion to theleft thalamus or left primary sensory cortex will result in sensory impairment to the rightside of the body and vice versa: a lesion to the right thalamus or right primary sensorycortex 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 knownas perceptual impairments. Perceptual impairments, such as the inability to recognise unseenobjects through somatosensations alone (astereognosis) or the inability to recogniseobjects (visual agnosia), are often more global perceptual problems resulting from extensivecommunication between hemispheres and hemispheric specialisation. This chapteraddresses sensory loss and associated perceptual impairments of visual, somatosensory,auditory, vestibular, olfactory and gustatory sensory processing systems. As visualprocessing has a significant influence on occupational performance and is seen as akey domain of occupational therapy, the visual processing section of this chapter will

118 Occupational Therapy and StrokeSomatic motor associationarea (premotor cortex)Primary motor cortex(precentral gyrus)CentralsulcusPrimary sensory cortex(postcentral gyrus)PARIETAL LOBEFRONTAL LOBESomatic sensoryassociation areaPrefrontal cortexGustatory cortexInsulaLateral sulcusOlfactory cortexTEMPORAL LOBEVisual association areaOCCIPITAL LOBEVisual cortexAuditory associationareaAuditory cortex(a)LimbicsystemFrontallobesParietal lobe andcingulate gyrusAssociation areasof cerebral cortexAnteriorgroupMedial groupLateral groupV e n t r a lg r o u pPosteriorgroupPulvinarAuditoryinputBasalnucleiCerebellumGeneralsensoryinputVisualinputMedialgeniculatenucleusLateralgeniculatenucleus(b)Figure 6.1 (a) Sensory cortices and association areas (visual, primary sensory, auditory,gustatory and olfactory, (b) thalamic nuclei. (Reproduced with permission from PearsonEducation Inc, adapted from Martini, 2006, Figures 14-15a and 14-09b.)primarily focus on registration of visual information while visual perception will beaddressed in further detail in Chapter 8.Throughout this chapter it should be noted that assessment and intervention of sensoryprocessing impairments should always consider patient’s levels of arousal, alertness andattention, as this will significantly impact upon the patient’s ability to detect, interpretand process sensory information (see Chapter 7). If these are not considered, attentiondifficulties could be misidentified as sensory loss leading to misdirected intervention plans.Thus, visual and somatosensory assessments should consider the patient, the environmentand incorporate simultaneous (bilateral) stimuli to assess for sensory inattentions.Similarly, intervention of sensory impairments should always consider the impact ofmedication, time of day, fatigue and environmental distractions so that intervention can

Management of Visual and Sensory Impairments 119be timed and graded appropriately to optimise effectiveness. Restorative (remedial) interventionshould be applied at high intensity (Byl et al., 2003), particularly in acute stagesto maximise neuroplasticity. However, restorative (remedial) recovery of sensation cannotbe accurately predicted and is likely to be dependent on other factors such as cognitiveability (Connell et al., 2008) and extent of damage to the sensory pathways. Thus, adviceon adaptive (compensatory/functional) strategies should always be prescribed earlyon to enable patients to maintain their own safety and maximise independence. Further,when both restorative (remedial) and adaptive (compensatory/functional) approaches areimplemented at the same time, therapists should emphasise the purpose of each interventionto avoid confusion between approaches so that patients can learn to implement bothapproaches during functional activities appropriately and safely.Visual processingVision is one of our primary senses – providing information about the world around us. Ithas an important role in our ability to engage in activity and social participation. Our visualsense gives us information about our environment, allowing us the capacity to interacteffectively and responsively in our environment and with the objects in it, to adjust ourposture and movements and provide vital information to guide our social interaction anddecision making. A stroke can affect a number of aspects of vision from our oculomotorfunction and our visual fields to the higher levels of the visual hierarchy such as visualmemory and visual perception.Functional anatomyThe visual system is a complex structure and, for the purpose of this book, a brief andsimple overview is described to provide a basic understanding of visual processing. Forfurther, more detailed information, please see the references and recommended reading.Six extraocular muscles, innervated by the cranial nerves, are attached to each eye withthe role of moving the eyeball. Light passes into the eye through the cornea and lens tobe focussed on the retina. Information about the left visual field hits the medial half ofthe retina of the left eye and the lateral half of the right eye. Together this informationtravels to the optic chiasm where the information of the left visual field all crosses midlineand heads towards the right visual cortex via the right optic tract. The fibres in the optictract then synapse in the right lateral geniculate nucleus. Postsynaptic fibres form the opticradiation, which then travel onto the cells of the right visual cortex (Figure 6.2). The visualcortex distinguishes between the colour, line, shape and texture of incoming information.From the visual cortex in the occipital lobe, information then travels back throughthe temporal and parietal lobes (inferior and superior routes, respectively) where theinformation is processed and integrated to gather meaning by identifying objects, theenvironment and relationships within the visual space. From here it passes to the prefrontallobe and the frontal eye fields where this information is used to assist with decision makingand planning.Following a stroke the effects on vision are dependent on the region of the lesion. Oneof the most common visual impairments noted in people following a stroke is visual field

120 Occupational Therapy and StrokeLeft sideRight sideLeft eyeonlyBinocular visionRight eyeonlyEyeOlfactorytractPituitaryglandOPTICNERVE (II)OpticchiasmOptictractMesencephalon(cut)Visual cortex(in occipital lobes)Lateralgeniculatenucleus(in thalamus)Optic projectionfibresFigure 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 occurat any point after the optic chiasm (Figure 6.2). However, diplopia and other oculomotordisorders commonly occur following brainstem or cerebellar lesions. Scanning, visualattention, visual memory and other visual perceptual disorders can be seriously and quitecommonly affected by a stroke. These will be addressed in the chapter on perception.Theory/approachesThe 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 impairmentsare often based on theories regarding the functioning of the particular system,

Management of Visual and Sensory Impairments 121Ability to create andretain a picture ofthe object in themind’s eyeAbility to identifysalient featuresto distinguish anobject from itssurroundingsOculomotorskillsAdaptation through visionVisualcognitionVisual memoryPattern recognitionScanningVisual attentionVisualfieldsAbility to manipulate visualinformation mentally andintegrate it with other sensoryinformation to gain knowledge,solve problems, formulateplans and make decisionsVisualacuityAbility to organise athorough search ofthe visual sceneAbility to attendto visualinformationAbility of the eye to movequickly and accurately, andmaintain foveation and sensoryfusion for binocular visionAmount of visual surroundthat can be seen when aperson looks straightaheadAbility to seeclear and preciseimages for smallvisual detailFigure 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 thefunctioning of the visual system, one being the simple information which comes throughthe eye; the visual information is then integrated within the brain and an understandingof the visual environment is then produced. The other is based on Warren’s (1993) VisualAdaptation Model, as shown in Figure 6.3, which identifies a hierarchical systemin which visual fields, oculomotor control and visual acuity are at the base (registrationof basic visual information), followed by visual attention (one has to attend to theinformation coming in to make use of it), scanning (having an ordered, efficient andcomplete scanning pattern is essential to picking up all the required information), visualmemory (using past visual memory to categorise incoming information but also to storethis information) and visual cognition (finally making sense of the visual information, inline with other stimuli to make accurate decisions, judgements and to interact with theworld).The basis of the Visual Adaptation Model (Warren, 1993) includes:(a) Oculomotor skills – allow the eyes to move smoothly, in a coordinated manner. Thisincludes: Pursuits – smooth eye movements. Saccades – jumping eye movements. Ability to track. Ability to accommodate (converge/diverge). Ability to fixate. Alignment.

122 Occupational Therapy and StrokeImpairments seen in patients following a stroke are diplopia (double vision), nystagmus,reduced depth perception, difficulty tracking and reduced efficiency fixatingor localising.(b) Visual acuity – resolving power of the eye to produce a clear, accurate image atdifferent 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 toregulate the amount of light) or from haemorrhages into the eye where fragile retinalblood vessels have burst from an increase in blood pressure associated with stroke.However, the majority of acuity impairments following stroke are due to premorbidfactors such as macular degeneration, glaucoma, diabetic retinopathy, cataracts orscotomas.(c) Visual fields – the portion of space that a person can see while he or she is fixatingcentrally. This includes: Central and peripheral fields. Upper and lower quadrants.Common impairments in patients following a stroke include hemianopia (loss of onehalfof visual field) and quadrantanopia (loss of upper or lower quadrant), as shown inFigure 6.4.Defects invisual field ofLeft eyeRight eyeLeftRight1Optic chiasm21Optic nerve3Optictract423OpticradiationLateralgeniculatebody54566Figure 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.)

Management of Visual and Sensory Impairments 123Hence assessment and intervention of visual processing needs to take into account thesetheories, ensuring the basic eye structures are intact but also that the information is beingprocessed accurately at all levels.AssessmentThe screening and assessment of visual processing is a key aspect of gathering a holisticpicture of the functioning of a patient following a stroke. However, referral to appropriatespecialists 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) andorthoptists (specialising in the assessment and intervention of visual field and oculomotorimpairments). However, occupational therapists have a key role in screening for theseimpairments, ensuring patients get the appropriate assessment but also ensuring that theresulting impairment is noted and incorporated into any further intervention, as vision hasa key role to play in function.When screening for visual impairments, it is important to do this in an appropriateenvironment with limited distractions, suitable lighting and appropriate levels of contrastfor the tasks.Functional observationsVisual 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, difficultyfocussing, difficulty reading or watching television, difficulty following fast interactionsin their environment, for example, four-way conversations, turns their head rather thaneyes to fixate on object.Visual field impairments – Patient bumps into objects, over-compensates when avoidingobstacles, uses the wall to guide their walking, difficulty reading, difficulty watchingtelevision, difficulty searching for items, gets lost, complaining of something wrong withtheir eyes.ScreeningAcuity Can the patient read the heading of a magazine? Do they complain of blurred vision? Can they read a sign in the distance?Oculomotor control 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?

124 Occupational Therapy and Stroke Is the patient able to focus on the brightly coloured object presented to them; can theytrack this object left/right, up/down, in a figure of 8? Can the patient shift his vision/gaze between two objects presented? Can they alternate from one point to another? 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 itcan be done by one person to give an indication of any impairments. Sit in front of thepatient covering one of their eyes. Ask the patient to focus on a central point (e.g. theexaminer’s nose). The other examiner stands behind the patient and brings an objectinto the patient’s vision at varying heights from the left and right periphery assessingeach of the four quadrants. Ask the patient to indicate when they first see the objectbeing presented. This is repeated with the other eye covered. Someone with visualfield 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, Ask the patient to copy a diagram (do not tell them what they are copying or theywill use their visual memory to produce the diagram) – they will copy what they seewhich might be the half of the diagram they see. Scan across a page of lines of letters and cross out the requested letter – the patientis 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 fieldimpairment will complete the task in an organised manner, identifying all letterswithin the abbreviated field.It is important to note that patients with visual field impairments often compensatevery quickly for their impairment so it may not be apparent on basic screening but morecomplex functional tasks or functional observations in dynamic environments will providethe information required.The assessment of a patient’s visual attention, scanning and visual perceptual skills aredealt with in perceptual impairments chapter.InterventionIntervention takes on many forms within occupational therapy but following the InternationalClassification of Functioning, Disability and Health model (World HealthOrganization (WHO, 2001)), intervention for visual impairments can be classified underimpairment-based intervention, activity engagement and social participation.Impairment-based interventionOften intervention at this level is dependent on and requires referral to professionalsspecialised in the different aspects of vision such as the optician and the optometrist.

Management of Visual and Sensory Impairments 125AcuityIntervention for acuity needs to be dealt with by the optician/optometrist; hence a referralneeds to be recommended to your multidisciplinary team for corrective lenses, glasses,etc.OculomotorIdeally an orthoptist needs to be involved if there are oculomotor impairments – they willconsider options such as occlusion for double vision, prisms, exercises, etc.Visual field impairmentsThis cannot be rectified by intervention and adaptive (compensatory/functional) measuresare used to encourage the patient to scan and search within their affected visual field.Occupational therapists can provide simple tasks such as scanning sheets, telephonenumber copying, environmental searching, etc., to encourage scanning into the affectedvision field. An orthoptist may consider use of prisms to compensate, so referral is worthconsidering.Activity engagementOften patients with visual processing impairments compensate very well and are able toadapt to their impairments; however, it is the role of therapy to not only increase theirconfidence in activity engagement but also their efficiency and reduce the effort requiredto complete familiar tasks. Identifying the roles and tasks the patient wants to engage inis essential, with the intervention being formulated around these tasks.Intervention could include: Engaging the patient in tasks that encourage them to scan their environment. Educating the patient on how to develop an efficient search strategy when they wish tofind objects within tasks. Involving patients in tasks that require that they use their full visual field and oculomotorskills such as copying telephone numbers from the telephone book, putting numbersinto the telephone, searching the environment for hidden objects, obstacle courses. Involving patients in games that require that they search their full visual field such asConnect Four or that require them to switch/track objects such as table tennis. Using adaptive (compensatory/functional) measures such as reading articles using themargin as an indicator that they have encompassed the full page or at a more basic leveldrawing a line down the margin to ensure the patient scans the page completely.Social participationEngaging in the community, which is a dynamic, social and ever-changing visual environment,can be very challenging for someone with visual processing difficulties. Theymust be alert and able to be responsive while ensuring their safety. Therapy within the

126 Occupational Therapy and Strokearea of social participation is essential to ensure a patient continues to engage in their liferoles and the wider environment.Intervention could include: Teaching strategies on how to prepare for unexpected incoming visual information, forexample, before entering a busy room, scan the room and identify the location of keyobjects and people and your path through the space. Developing safe search strategies, for example, crossing the road – identify the leftcurb, follow it along and scan from this curb till the patient sees the other curb. Thisensures they have seen the whole road before crossing. Adaptive (compensatory/functional) strategies, for example, request that people do notsit in your limited visual field space if there are a number of participants talking; reducethe amount of visual stimulation in the environment when completing tasks.Review and evaluationAcuteWithin the acute setting the main focus is screening to identify visual processing impairmentsand alerting the multi-disciplinary team if there are any concerns regarding visionthat may require onward referral. It is also important to educate the patient and family onthe impairments and ensure the patient’s safety is maintained if discharged home, providingeducation on adaptive (compensatory/functional) strategies if appropriate. It shouldbe noted that some patients may demonstrate spontaneous recovery of acuity, field andoculomotor impairments during acute stages, so use of some strategies such as occlusionshould be carefully prescribed and monitored.Inpatient rehabilitationFurther in-depth assessment might be required and linking further assessment to otherimpairments such as visual attention, visual memory and visual perceptual impairmentsand their impact. Continuous review during rehabilitation is required, particularly of thepatient’s ability to learn and use the adaptive (compensatory/functional) strategies taughtand noting their ability to adapt to their visual environment during tasks.Community rehabilitationBy this stage one would hope the patient with visual processing impairments has learntto compensate or has been offered the appropriate adaptive (compensatory/functional)measures to modify their impact. However, this is an important time to review their visualprocessing in the more dynamic and wider community environment.Clinical challengesWhen assessing and treating people who have had a stroke, it is sometimes difficult todifferentiate between impairments, which often present with similar functional impairments.

Management of Visual and Sensory Impairments 127Some key areas to be alert to include: Differentiating between difficulty tracking and visual field loss. Differentiating between visual field impairments and visual inattention. Occipital lobe impairments, impact on the accuracy of the information reaching theparietal/temporal lobes for integration, impacting on the visual perception of theirenvironment even though the parietal/temporal lobes are intact. Uncommon disorders such as cortical blindness (total or partial loss of vision in anormal-appearing eye caused by damage to the occipital lobe) and visual hallucinations(caused by disruptions to the visual processing pathway and sometimes misdiagnosedas psychiatric issues rather than neurologically based). Visual perceptual, cognitive and speech impairments impacting on accuracy of assessment. Visual perceptual, cognitive and speech impairments impacting on ability to learn orcompensate 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/visualperceptual level discussed in the perceptual impairments chapter. Due to the significantimpact visual impairments have on function, it is an important area for occupationaltherapist to address.Somatosensory processingFunctional anatomyInformation regarding pain, temperature, touch, pressure, vibration and proprioceptivesensations ascend the spinal cord in highly organised tracts. The organisation of thesetracts means that certain sensations travel closely together. For example, pain and temperatureascend together in the lateral spinothalamic tract; fine touch, pressure, vibration andproprioceptive information ascend in the posterior/dorsal column; whereas crude touchand pressure ascend in the anterior spinothalamic tract. These tracts synapse in the ventralnuclei of the contralateral thalamus where sensory information is sorted, determiningwhich sensations should be consciously perceived. Subsequent projections from the thalamusto the primary sensory cortex in the parietal lobe enable sensations to be perceivedand localised as the primary sensory cortex is functionally organised according to bodyparts. Thus, the organisation of the primary sensory cortex can be further mapped intocortical areas representing the relative sensitivity of different body parts, known as thesensory homunculus (Figure 6.5). From the primary motor cortex, somatosensory informationis 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 mayresult in loss of sensation. Lesions between the thalamus and the primary sensory cortexmay result in sensory loss and inability to localise sensations. Lesions to the association

128 Occupational Therapy and StrokeSensory homunculus ofleft cerebral hemisphereVentral nucleiin thalamusMESENCEPHALONNucleus gracilisand nucleuscuneatusMediallemniscusMEDULLA OBLONGATASPINAL CORDFasciculus gracilisand fasciculuscuneatusDorsal rootganglionFine touch, vibration, pressure, andproprioception sensations from right side of bodyPosterior column pathwayFigure 6.5 Sensory homunculus of the primary sensory cortex. (Reproduced with permissionfrom Pearson Education Inc, adapted from Martini, 2006, Figure 15-5.)

Management of Visual and Sensory Impairments 129areas result in difficulties with recognising and interpreting sensations, leading to clinicalpresentations of: Astereognosis (the inability to recognise unseen objects through touch). Body scheme impairments (difficulty perceiving the position of the body and relationshipof 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 andright). Body image impairments (lack of mental image of one’s body) (see Perceptual impairmentschapter).Somatosensory impairment is common following stroke. Approximately 50% of strokepatients experience somatosensory impairment (Carey, 1995). Stereognosis is the mostfrequent impairment followed by proprioceptive then tactile sensory impairments (Connellet al., 2008). However, there is some debate regarding where discriminative sensationshave been reported to be more common and reliability of measures may be a contributingfactor (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 forfasteners and writing; are at increased risk of developing learned non-use as spontaneoususe 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 activitiesof daily living, sexual and leisure activities and thus participation in life roles (Carey,2006). Somatosensory impairments are significantly related to stroke severity and activitylimitations, which negatively impact on motor recovery and hospital length of stay (citedConnell et al., 2008).Theoretical approachDespite significant integration along pathways, modalities are often discreetly impaired soall modalities should be routinely assessed. Contrastingly, adjacent body areas frequentlyhave the same modalities impaired, suggesting redundancy of some assessments may bepossible (Connell et al., 2008). For example, Busse and Tyson (2009) explored redundancyof touch, pinprick and pressure assessments. They concluded that if light touch wasintact in the thumb and hand, then no further assessment of the upper limb for lighttouch, pinprick and pressure was required. However, redundancy of assessments for othermodalities is yet to be determined. It should be noted for somatosensation, similar to motorimpairments, that both sides can be affected due to ipsilateral pathways (Kim and Choi-Kwon, 1996). However, some sensory impairments have been reported ipsilaterally andthought 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.

130 Occupational Therapy and StrokeImpaired 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.AssessmentFunctional observationsPatients who appear to be clumsy; drop objects; have difficulty regulating pressure andmaintaining appropriate grips; position their body parts awkwardly or trap limbs inclothes/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 fastenerssuch as buttons, zippers, laces, bras, belts, necklaces and apron bows or comb/brush theirhair with and without visual feedback and ability to identify objects in pockets.ScreeningScreening assessment should be completed in the first 2–4 weeks post onset (Winwardet al., 2007). The following upper limb screening process summarises procedures fromthe 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 proposedSomatosensory Screening Flowchart (Figure 6.6). To avoid subjecting the patient tounnecessary repetition of tests and to improve therapists use of time, upper and lowerAssess light touch andproprioception onaffected thumb and handIntactImpaired/absentComplete light touch, proprioceptiveassessments on unaffected and affected upperlimb (consider standardised assessments)Assess sharp blunt,temperature, tactilelocalisation, bilateralsimultaneous touch andstereognosis (coins/full)IntactAssess pressure and pinprick bilaterally(use standardised assessments)IntactSensation normalNo treatment requiredImpaired/absent(use standardisedassessments)ImpairedSensation impairedSafety awareness trainingTargeted sensoryrehabilitation with visionoccluded and attention gradedAbsentSensation absentSafety awareness trainingIn acute stage trial sensoryrehabilitation with visionoccluded and full attentionFigure 6.6Proposed somatosensory screening assessment flowchart.

Management of Visual and Sensory Impairments 131extremities should be assessed together in coordination or as a joint assessment with physiotherapists.If sensation is anticipated to be impaired then assessment using standardisedmeasures is recommended to monitor change and measure outcomes, particularly as thedifferent modalities are discreet and redundancy of body parts for each modality is stillbeing 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 sensationsThese assessments examine cutaneous sensations of touch, pressure, pain and temperature,discrimination, localisation and tactile inattention. It should be noted that some conditionssuch 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 woolball, three times at each location in random order. Iflight touch of the thumb and hand is normal then nofurther 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, sufficientenough to just deform the skin contour, three timesat each location in random order.Only tested if light touch is intact. Stimulate the skinsix times at each location in a random order, threetimes with a cocktail stick and three times with theindex finger. The patient must verbally ornon-verbally indicate whether the stimuli are sharpor blunt.Touch the skin with the side (not the bottom) of oneof two test tubes, one filled with hot water, anotherwith cold water. The patient must verbally ornon-verbally indicate whether the stimuli are hot orcold.Can be assessed at the same time as pressure (butonly if pressure detection is intact) by asking thepatient to point to the exact spot that has beentouched. Two centimetres of error is allowed andcoating the assessor’s finger with talcum powder tomark the spot may help.Only assess if patient can detect pressure. Touchcorresponding sites on one or both sides of the body

132 Occupational Therapy and Strokeusing the fingertips. The patient must indicate whichside has been touched or if both sides were touched.Two-point discrimination: This test has been found to be less reliable andshould only be tested if light touch, pressure,pinprick are normal. Start with a neurotip ortwo-point discrimination instrument set with the twopoints at 10 mm for index finger and 20 mm for thethenar eminence. Apply the two pointssimultaneously to the skin of the index finger andthen to the thenar eminence for approximately 0.5second. Ask the patient to indicate if one or twopoints are felt. Record the last interval at which twopoints are felt. Record: Absent – Patient unable to detect two points. Impaired – Patient detects two points with an interval of 10 mm on the fingertipand 20 mm on the thenar eminence. Normal – Patient detects two points with an interval of 5 mm on the fingertipand 12 mm on the thenar eminence (Stolk-Hornsveld et al., 2006).ProprioceptionThis is the awareness of sensory information from the muscles, tendons, ligaments andjoints. To demonstrate the procedure, three practice movements are allowed with patient’seyes open. Each joint is passively moved with the proximal end stabilised and bothproximal and distal portions held laterally to avoid tactile or pressure input. The thumbinterphalangeal joint is moved through full flexion/extension and wrist is moved throughfull range of flexion/extension with the elbow in 150–160 ◦ extension. The patient verballyor 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 threetimes. Record: Absent – patient does not detect movement taking place. Impaired – patient detects movement but direction is not always correct. 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 tobe assessed (Busse and Tyson, 2009), otherwise elbow flexion/extension and shoulderabduction/adduction (with elbow at 90 ◦ ) should be assessed by passively rangingthrough approximately a quarter of their total range of movement (Stolk-Hornsveld et al.,2006).StereognosisThis is a perceptual skill where unseen and unheard objects can be recognised bytouch alone. It requires integration of tactile and proprioceptive sensations with memory

Management of Visual and Sensory Impairments 133recall. However, it should be noted that objects can be correctly identified with sometactile/proprioceptive impairments as sensations compensate for each other and patientscan ‘cheat’ by gaining auditory cues from tapping objects. Each object is placed in thepatient’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 examinermay 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, coinsare more difficult than comb scissors, cup and sponge (Connell et al., 2008).Standardised assessments Rivermead Assessment of Somatosensory Performance (RASP) assesses pain, lighttouch and localisation, temperature discrimination, joint movement detection and movementdirection discrimination, bilateral touch discrimination (sensory extinction) andtwo-point discrimination using customised clinical instruments. The assessment takes20–30 minutes to administer and is available from Thames Valley Test Company(Winward et al., 2002). Revised Nottingham Sensory Assessment (rNSA) (Lincoln et al., 1998b) does not requirespecial 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. Jointsassessed include the shoulder, elbow, wrist, hand, hip, knee and ankle. Stereognosis isassessed using 11 everyday objects. Erasmus MC Modifications to the (revised) NSA (Stolk-Hornsveld et al., 2006) improvesthe reliability of the rNSA by standardisng procedures with defined points of contactfor tactile sensation; defined starting positions, movements and hand grips for testingproprioception; and omits the less reliable two-point discrimination test. It takes 10–15 minutes to administer. It assesses light touch, pressure, pinprick, sharp–blunt tactilesensations to 12 upper extremity points on the fingers, hand, forearm and upperarm and12 lower extremity points on the toes, foot, leg and thigh. Proprioception is assessedin the thumb, wrist, elbow, shoulder, big toe, ankle, knee and hip. Detailed proceduresand recording form are free and available as appendices to the article (Stolk-Hornsveldet al., 2006). Stereognosis subtest of the Chessington Occupational Therapy Neurological AssessmentBattery (COTNAB) (Tyerman et al., 1986). Useful for comparing sensory informationprocessing speed to normative data.Further, more reliable tests for tactile and proprioceptive discrimination have beendeveloped for use in research. For more information on these, please see Carey (2006).InterventionSignificant tactile, stereognostic and proprioceptive upper limb recovery can occur inthe first 6 months post stroke; however, prognosis for recovery is poorer than in thelower limb (Connell et al., 2008). Stroke severity is the strongest indicator of impairment

134 Occupational Therapy and Strokeand recovery and motor performance significantly influences recovery of stereognosis(Connell et al., 2008). However, there is no recognisable pattern to recovery (Winwardet al. 2007).Carey (2006) summarises the principles of intervention from successful training programmeswhich include the following: Attention to the sensory stimulus: Active and purposeful exploration of sensory stimuliwith attention directed to distinctive features of difference, that is, discrimination isrequired. Repetitive stimulation with and without vision: This allows patients to alternately focusattention on somatosensory feedback without the visual system taking over versusgaining visual feedback to calibrate. Sensory stimulation is integral to the preservationof the primary sensory cortex for functional gains. Use of targeted sensory tasks that are challenging and motivating, with opportunitiesfor success. Anticipation where patient draws on previous experiences of what the stimulus shouldfeel like. Focus on the hand. Graded progression of tasks for the targeted modality from easy to more difficultdiscrimination. 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 perceptionswith the other hand and visual feedback may also be important.Restorative (remedial) intervention at impairment levelShabrun and Hillier (2009) reviewed the evidence for passive (excludes muscle contraction)and active sensory retraining following stroke. It should be noted that sensoryinterventions that combined with motor or other therapies were excluded from the reviewand patients included both acute and chronic populations. Cutaneous electrical stimulation, for example, TENS machines, delivered at low frequencies(10 Hz) and at sufficient intensity to evoke stroke paresthesia in the targettissue may improve hand function and dexterity following stroke (Shabrun and Hillier,2009). Active stimulation involving exercises that practice discriminating and localising sensations,stereognosis and proprioception may be beneficial, although results of a metaanalysisare inconclusive (Shabrun and Hillier, 2009). Dosage of researched interventionsaverages 45 minutes sessions × 3 times per week and has been administered toboth acute and chronic patients.Carey (1995) reviewed sensory retraining programmes for stroke including Yekutieland Guttman’s (1993) sensory rehabilitation programme. Yekutiel and Guttman (1993)describe a successful 6-week sensory retraining programme for chronic stroke patientswhich includes: Identifying touch (counting touches administered from proximal to distal). Identifying simple continuous touch (identifying direction, number and shape of linesdrawn on the skin with a pencil).

Management of Visual and Sensory Impairments 135 Identifying complex continuous touch (identifying letters/numbers drawn on the handor arm). Texture discrimination (between sandpaper, velvet, paper, wire wool, cotton ball,smooth plastic, rubber, leather, card). Finger identification (identifying finger touched – particularly thumb, index and littlefingers). Guided drawing (patient assisted to draw a shape which the carer identifies). Thumb localisation (patients affected hand positioned in various places, patient instructedto find the affected thumb with the unaffected hand). Distance between hands. Position of hand (patients asked to estimate the gap between their hand). Thick and thin rods (patients to identify cylindrical rods placed in the fingers rangingbetween 5 and 30 mm diameter). Weight (identify and compare objects of different weights). Shape (identify different shaped objects). Size (identify different sized lids). Consistency (identify objects of same shape but varying consistency, for example, tennisball, plastic ball, squash ball, stress ball, wooden ball). Temperature (compare temperatures of metal spoons placed in ice, at room temperature,warm water, hot water and a plastic spoon). 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 Effectivenessof Neurorehabilitation on Sensation (SENSe) programme are currently beinginvestigated, including a randomised controlled trial on somatosensation training in thehand following stroke at the National Stroke Research Institute in Australia. Researchedtraining to date has included: Sensory Specific Training which ‘involves repeated presentation of targeted discriminationtasks; progression from easy to diffiuclt discriminations; attentive exploration ofstimuli with vision occluded; use of anticipation trials; feedback on accuracy, method ofexploration and salient features of the stimuli; and use of vision to facilitate calibrationof sensory information’ (Carey et al., 1993; cited Carey, 2006: p. 237). Stimulus generalisation training aimed at transfering training effects to novel stimuliincludes ‘addition principles of variation in stimulus and practice conditions, intermittentfeedback and tuition of training principles’ (Carey and Matyas, 2005; cited Carey,2006).Restorative (remedial) intervention during functional tasksat activity and participation levelEncouraging some use of the affected limb during functional tasks to improve sensoryfeedback may help. If limited movement, encourage limb placing/positioning in tasks andweight transference. Therapists should consider the dynamic nature of sensory input asthe central nervous system responds to change and switches off when sensory stimulation

136 Occupational Therapy and Strokeis constant. Other techniques which may enhance normal sensory input include the following: Bobath principles of facilitation and use of handling to prevent abnormal movementsand feed correct sensory input into the sensory system may have indirect effects onsensory improvement during functional tasks. Cognitive processing (inattention to tactile stimuli) to utilise attention/informationprocessing strategies. Sensory re-education desensitisation – here the central nervous system is overwhelmedand is over-responsive to change, so needs to learn to cope with reduced amounts ofinput with slower changes. Constraint-induced movement therapy – see Chapter 2.Adaptive (compensatory/functional) intervention Adaptive (compensatory/functional) techniques, for example, testing water with theother hand, using adaptive (compensatory/functional) devices for safety and train patientto check the position of their limbs. Use of vision to compensate. Enlarged handles to assist grips, universal splints when attention is divided. Safety – education, safety awareness, environmental adaptations. Pain – distraction, relaxation, pain clinic, Transcutaneous Electrical Nerve Stimulation(TENS), splinting (alignment), taping/Functional Electrical Stimulation (FES)/supportfor subluxation.Review and evaluationIf impairment is found following acute assessment, reassessment is recommended at 3and 6 months post stroke with follow-up assessment as appropriate depending on progress(Winward et al., 2007).Clinical challengesComplex regional pain syndrome (otherwise known as central pain syndrome,shoulder–hand syndrome, thalamic pain syndrome or Dejerine Roussy) following strokeappears as a painful, oedematose limb with altered heat and tactile sensations, dystrophicskin 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) inthe first 5 months and one-third of these patients may resolve within 1 year (Pertoldi anddi Benedetto, 2005). Onset seems to be related to aetiology of stroke (frequently involvingthe thalamus), severity, motor recovery, spasticity, sensory disorders and glenohumeralsubluxation. Although the mechanisms are unclear, the hypersensitivity and interpretationof non-noxious stimuli to be noxious appears to arise from neurogenic inflammation leadingto sensitisation of peripheral and central sensory neurones and variable involvementof the sympathetic nervous system. Interventions include pharmacology (non-steroidalanti-inflammatories, tricyclic antidepressants, botulinum toxins), regional anaesthesia,

Management of Visual and Sensory Impairments 137neuromodulation, sympathectomy (sympathetic blocks), TENS and electrotherapy, nighttimeresting splints (not recommended for daytime), counselling, biofeedback, relaxationtechniques, group therapy and psychotherapy. Exercise and a graded desensitisation programmewithin perceived pain thresholds may be helpful to gradually habituate patientsto stimuli perceived as noxious. However, there is little evidence to support the efficacyof these interventions (Pertoldi and di Benedetto, 2005) and referral to specialised painclinics is recommended.Other clinical challenges to somatosensory assessment and intervention include cognitivedifficulties, particularly where severe attention impairments such as unilateral neglectare evident. Here, it may be more beneficial to focus on the cognitive aspects to sensoryprocessing and adaptive (compensatory/functional) strategies.Auditory processingFunctional anatomyInformation regarding sound is conveyed from the inner ear via cranial nerve VIII to thecochlear nuclei in the medulla. Information then decussates to ascend contralaterally to theinferior colliculus (for reflexive head movements in response to sound) and onto the medialgeniculate nucleus in the thalamus before it projects to the primary auditory cortex in thetemporal lobe (Figure 6.7). Patients with lesions to this pathway may have sensorineuralAuditory cortex(temporal lobe)Low-frequencysoundsHighfrequencysoundsThalamusCochleaMedial geniculatenucleus (thalamus)Inferior colliculus(mesencephalon)Motor outputto cranialnerve nucleiVestibularbranchHighfrequencysoundsCochlear branchVestibulocochlearnerve (VIII)LowfrequencysoundsCochlear nucleiMotor outputto spinal cordthrough thetectospinal tractsFigure 6.7 Auditory processing pathway. (Reproduced with permission from PearsonEducation Inc, adapted from Martini, 2006, Figure 17-31.)

138 Occupational Therapy and Strokedeafness in one ear, although this is rare due to significant cross midline communication inthe brainstem. Auditory symptoms are associated with brainstem strokes and may includehearing loss (if bilateral stroke), phantom auditory perceptions (tinnitus/ hallucinations)and increased sensitivity to sound (Häusler and Levine, 2000). Lesions to the auditorycortex in the temporal lobe (cortical deafness) may mean that although the patient isunable 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 patientsbeing unable to comprehend the meaning of sounds or words, known as receptive aphasiaor agnosias to particular sounds.AssessmentFunctional observationsOccupational therapy assessment of auditory processing impairments should consider: Patient’s premorbid hearing and aids used. Patient’s and family reports of new hearing impairments. The patient’s response to sound conducted via observation during initial interview andfunctional tasks. For example, during conversation or in response to an object beingdropped or the patient’s name being called: Does the patient become more alert (detectsound) and orient towards (locate) sudden or unexpected sounds? Does the patientunderstand (recognise) words being said and are they able to follow instructions? Doesthe patient demonstrate appropriate response to music and environmental sounds? Howdoes the patient cope in noisy environments with competing auditory demands, forexample, in the community, crossing roads?ScreeningScreening 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 notbeen identified clinically as having a hearing impairment. Similarly, 35% of patients werefound 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 thesignificant lack of detection may mean that patients are not receiving intervention for newimpairments which may have significant function complications later on particularly forcommunication, social, leisure and community participation and hence quality of life.If new difficulties in auditory processing are suspected, further detailed assessmentshould be referred onto the speech and language therapist or audiologist as appropriate.InterventionOther disciplines such as speech and language therapy/audiology generally address impairment/restorative(remedial) intervention. Occupational therapists should liaise withthese disciplines regarding recommended strategies and enable patients to incorporatethese into everyday activities. Occupational therapy intervention should primarily focus

Management of Visual and Sensory Impairments 139on adaptive (compensatory/functional), activity/participation-based intervention. Thesemay include liaising with sensory loss teams in social services, investigating home safetyalerting systems such as visual/vibratory alerts for smoke alarms/telephones, strategiesfor communication and safety in community, social and leisure tasks such as shopping.Review and evaluationOccupational therapy should focus on activity and participation levels of evaluation usingappropriate measure that considers management of risks (home safety alerts) andparticipation in communication, social, leisure and community activities.Clinical challengesTherapists should be acutely aware of the impact that auditory processing impairments(whether from hearing loss, receptive aphasias or agnosias) may have on following verbalinstructions during all other assessments and the increased simultaneous cognitive demandplaced on patients as they struggle to process auditory information.Vestibular processingFunctional anatomyInformation regarding orientation and movement of the head in space; hence balance(equilibrium) is conveyed via the vestibulocochlear nerve (cranial nerve VIII) to thevestibular nuclei in the brainstem. Here, it is integrated with information from the contralateralear before information is relayed to the cerebellum, primary sensory cortex andmotor nuclei in the brainstem. Reflexive connections in the brainstem enable coordinatedeye, head and neck movements (via Cranial nerves III, IV, VI and XI) and adjustmentsto muscle tone via the descending vestibulospinal tract. Lesions result in nystagmus,dizziness, impaired equilibrium reactions and balance, awareness of midline, oculomotordifficulties, impacting on visual processing.Theory/approachesVestibular systems are highly integrated with visual and somatosensory inputs whichcontribute to control of balance (Smania et al., 2008). Thus assessment and interventionof balance must consider the manipulation of visual feedback and somatosensory inputs.Dysfunction can lead to avoidance of activity and social isolation.AssessmentFunctional observationsObserve balance reactions and reports of dizziness particularly when: Vision is occluded, base of support reduced or supporting surfaces are unstable, forexample, taking clothes off overhead in standing or when sitting on the bed, washinghair, walking over uneven surfaces.

140 Occupational Therapy and Stroke Tasks are more complex and patients are mobilising while visually distracted, forexample, meal preparation, community mobility. Bending down to put on socks and shoes or pick up dropped items.Detailed assessmentThis is usually carried out by physiotherapists, for example, sensory organisation balancetest (Di Fabio and Badke, 1990; cited Smania et al., 2008), postural sway, balance (withand without visual feedback) and direct head displacement to test vestibular ocular movements.Occupational therapists should liaise with physiotherapists regarding outcomes ofassessment and recommended intervention approaches to maintain consistency.InterventionPhysiotherapists generally address the impairment level with restorative (remedial) interventionvia vestibular rehabilitation. ‘Vestibular rehabilitation includes exercises topromote vestibular adaptation and substitution, exercises to habituate symptoms suchas dizziness with head movement, exercises to improve balance and decrease risk forfalls’ (Hall and Herdman, 2006). Occupational therapists should liaise with the physiotherapistregarding recommended strategies and consider application to everyday activities.Occupational therapy intervention should primarily focus on adaptive (compensatory/functional),activity/participation-based strategies including: Visual compensation. Stabilisation during functional tasks, for example, use of perching stool, chair, stabilisingpelvis against benches/sinks, propping through upper limbs. Grading activity demands related to weight transfer and dynamic sitting and standingbalance and functional mobility. Graded activities requiring independent head/eye movements. Functional activities demanding balance that manipulate somatosensory input and visualfeedback, such as– Completing functional tasks with/without shoes on, on different surfaces inside andoutside.– Graded visual feedback starting from downgraded activities where visual feedbackis utilised and somatosensory feedback from the lower limb is stable to high-levelretraining where somatosensory feedback is variable (e.g. outdoor surfaces) andvision 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 andvertically versus moving eyes with head fixed, travelling on buses, in cars, mobilityunder more challenging conditions, for example, walking, running, moving, standingon moving surface. Falls prevention.

Management of Visual and Sensory Impairments 141Review and evaluationOccupational therapy should focus on activity and participation levels of evaluation usingappropriate measures that consider dynamic balance, including domestic and communityactivities of daily living.Clinical challengesSome clinical challenges to successful rehabilitation may include perceptual difficultiessuch as spatial representation, unilateral spatial neglect (see Chapter 7) and pushersyndrome (see Chapter 5).Olfactory and gustatory processingFunctional anatomyDysfunction in sense of smell and taste following stroke is rare but has been reportedfollowing lesions affecting the anterior, posterior or middle cerebral arteries (Green et al.,2008; Moo and Wityk, 1999). The olfactory tract conveys information regarding smellfrom the olfactory bulbs to the olfactory cortex located in the medial temporal lobe (Figure6.1). Information from the tastebuds are conveyed via cranial nerves VII, IX and X tothe solitary nucleus in the medulla. Here they join the somatic sensory neurones to travelvia 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 strongemotional, behavioural and memory links to smell and taste.AssessmentAs part of the screening assessment, occupational therapists should enquire whetherpatients have noticed any deterioration in sense of smell or taste and functionally observepatient responses to ‘off’ milk or burning food during a kitchen assessment or whetherpatients have ‘gone off’ their food.In liaison with the dietician, further assessment could take into account patient perceptionswhen 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).InterventionRecovery of smell and taste have been reported in minor strokes (Green et al., 2008) and arestorative (remedial) approach could be considered on a theoretical basis. However, therehas been no research on this rare patient group to support this. Adaptive (compensatory/functional) approaches should consider functional implications such as safety (e.g. alertingto spoiled food, gas, fire and smoke), nutrition and psychosocial implications (Greenet al., 2008).

142 Occupational Therapy and StrokeReview and evaluationOccupational therapy evaluation methods should consider activity and participation levelsof occupational performance such as use of Canadian Occupational Performance Measure(COPM), quality of life (QOL) questionnaires and liaison with nutrition to monitornutrition goals.Self-evaluation questions1. Draw a concept map to help describe to a well-educated patient (with an interest inanatomy) their symptoms of a right inferior quadrantanopia. What activities mightthis patient have difficulty with?2. When walking down the corridor, you notice that your patient makes a beeline for therail 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 andsometimes the letters move. When the patient looks at you, you notice that they squintor 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 dislikegoing 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 overcomethese challenges and enjoy shopping again?5. Your patient has a ‘floating’ hand which they struggle to use effectively duringdressing. 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 comparethis 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 comparethis to your intervention taking an adaptive (compensatory/functional)approach.7. Draw a concept map to describe to a well-educated patient (with an interest inanatomy) their symptoms of impaired proprioception. What activities might thispatient have difficulty with?

Management of Visual and Sensory Impairments 1438. You are assessing a patient’s coordination using the finger nose test and notice thatthe 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-educationprogramme 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.

Chapter 7Management of Cognitive ImpairmentsThérèse Jackson and Stephanie WolffThis chapter includes: Definition of cognition Cognitive functions Assessment of cognitive functions Cognitive rehabilitation Assessment and intervention strategies for specific functions Self-evaluation questionsDefinition of cognitionCognition refers to those mental functions which help us to acquire, organise, manipulateand use information and knowledge. It includes all of our ‘thinking’ processes.Cognitive functionsCognitive functions which may be impaired following a stroke include the following: Attention – the ability to focus on specific sensory stimuli and suppress distractions.Attention is required for many other cognitive functions to occur. Memory – the ability to retain and recall information. Perception – ‘making sense of the senses’ – a cognitive process which is dealt with inmore detail in the next chapter. Language – understanding and expression. Praxis – motor planning. Executive functions – skills which are needed to plan organise and execute a task.Assessment of cognitive functionsOccupational therapy assessment at any stage of recovery will involve a detailed analysisof performance skills (motor, sensory, cognitive, psychological and social) and the impact

Management of Cognitive Impairments 145of any impairments on a person’s ability to engage in occupations within a definedenvironment (physical, social and cultural). Assessment of cognitive functions is oftencarried out as part of an observational assessment of occupational performance usingselected 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 realisticassessment of their ability.Timing of assessment is important to consider. In the acute phase of recovery from astroke a person may be fatigued and may be dealing with a complex set of recovery issueswhich can impact on their emotional and psychological status. Testing specific cognitiveskills at this stage may not give a true reflection of their abilities and it may be advisableto wait until the rehabilitation phase to do this. If however a cognitive impairment isquestioned the occupational therapist may assess cognitive functions in the acute phaseto determine the extent of the problem, and ensure appropriate follow-up, particularly ifdischarge is planned. For further detailed cognitive assessment, the person may also bereferred to a neuropsychologist.Standardised assessmentOccupational therapists have a vast array of standardised assessments and screeningtools available to them which can be used to contribute to the assessment of cognitivefunctions. Standardised, impairment-based assessments aim to provide valid and reliableassessments of performance skills, that is, specific cognitive components. They should notbe used in isolation, but in combination with observational clinical assessment and clinicalreasoning to ascertain to what extent the cognitive impairment impacts on occupationalperformance. It is advisable to be fully familiar with the test manual and validationprocesses to understand the extent of the remit for each test. Many of these assessmentsare impairment based and caution is advised when interpreting the results as they may notnecessarily 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 thequality of ADL performance (Fisher, 2006).Other standardised assessments and screening tools which can be used to support theassessment of cognitive functions include (this list is not exhaustive): MEAMS – Middlesex Elderly Assessment of Mental State (Golding, 1989) COTNAB – Chessington Occupational Therapy Neurological Assessment Battery(Tyerman et al., 1986) RBMT – Rivermead Behavioural Memory Test -III (Wilson et al., 2008) CAM – Cognitive Assessment of Minnesota (Rustard et al., 1993) BADS – Behavioural Assessment of Dysexecutive Syndrome (Wilson et al., 1996) TEA – Test of Everyday Attention (Robertson et al., 1994) LOTCA – Lowenstein Occupational Therapy Cognitive Assessment (Itzkovich et al.,1993).

146 Occupational Therapy and StrokeCognitive rehabilitationApproachesThe main rehabilitative approaches used by occupational therapists, within cognitiverehabilitation, described in Chapter 2, are: Remediation (restoration). Adaptive (compensatory/functional).Occupational therapists tend to favour a functional approach for the rehabilitation ofpeople with cognitive impairment, including task-specific training and the use of activitieswhich are meaningful and familiar. A selection of interventions may be required to meetindividual needs.InterventionPrinciples of intervention for the rehabilitation of people with cognitive impairment: Goal orientated – the person with cognitive problems is more likely to engage inrehabilitation if they contribute to the selection of the activities they participate in. Goalsshould be meaningful and relevant. Goals direct the content and process of interventionsand must be relevant to the individual’s needs and wishes. Long and short-term goalsare set and they should be, as far as possible ‘SMART’, that is, Specific; Measurable;Achievable (with some challenge); Realistic (within the environment and resourcesavailable) and Timescales should be set and there should be a regular review of goalswith the patient, family/carer and team. ‘If the patient, their family, and the treatingteam are all working towards the same agreed goals, a satisfactory outcome is morelikely’ (Turner-Stokes, 2003). Individualised – a selection of strategies and intervention techniques may be requiredas people will have individual interests and responses to interventions. Educate and include relevant family/carers/friends and significant others – so that theyunderstand the difficulties a person may be having and can assist with the applicationof strategies and provide support. Focus on functional improvement – including a way of measuring this improvement,such as goal attainment and performance measures. Include psychological and emotional support – people with cognitive problems candevelop anxiety, depression and a sense of loss of control and self-esteem. Theseshould be acknowledged and interventions provided to support management of theseproblems, such as anxiety management training, relaxation training and medication.Intervention strategies Task-specific training – or functional retraining, stresses the value of the use of specificand relevant functional tasks. Emphasis is placed on task characteristics, in order tosupport behavioural change (Wilson, 1998).

Management of Cognitive Impairments 147 Practise – repetition over time and use of retained capacity assists learning. Errorless learning – people with brain injury, including stroke, may not learn from theirmistakes so an approach which supports the achievement of a successful outcome bycueing the correct response is more likely to enhance learning. This has been evidencedin studies of people with memory problems (Wilson et al., 1994). Environmental adaptation – regulation of noise and distractions; clearing environmentalclutter; and adaptations such as message boards. Compensation and strategy training – external aids and adapted methods – for example,use of memory aids such as pagers, diaries and calendars. Prompts and instruction – direct instruction and guided assistance may support relearningof skills. Restoration/skills training – this has limited support for the restoration of cognitiveproblems although some studies of attention have reported improved skills when specificretraining of basic attention capacity is offered. Retraining tends to be more effectivewhen embedded in a meaningful and functional context, targeting the specific level ofattention impairment of the individual (Cicerone et al., 2005).AttentionAttention is required for most other cognitive functions to take place. It is dependent onan adequate degree of arousal and alertness and helps us to process a large amount ofinformation on a daily basis. Attention is commonly affected after stroke, especially inthe 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: Focused – an initial response to fix attention on a specific stimuli, for example, respondingto your name being called. 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. Selective – this refers to the brain’s ability to filter out unwanted stimuli in order toattend more closely to detail or something important, for example, looking for someonein a busy room. 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. Divided – this is about multitasking, doing more than one thing at one time, for example,driving and talking to a passenger.AssessmentThe aim of assessment is to determine at what level the patient’s attention problems aremost evident; how the problem impacts on occupational performance and if it is affectingthe patient’s behaviour.

148 Occupational Therapy and StrokeInitially simple screening tests can be used such as asking the patient to count backwardsfrom 20, or recite the months of the year backwards, or by observing them carrying outpen and paper tasks. Look for an organised approach to the tasks versus an erratic, randomapproach.Observe the patient carrying out functional tasks; do they become more distractible asthe 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 sametime? Can they perform a functional task such as following a recipe and alternate theirattention between reading and carrying out the recipe? Do they miss detail?Clinicians often report that patients with attention problems can appear impulsive andat times agitated. These behaviours can be assessed through observation.Standardised assessments for attention are available such as the Test of EverydayAttention (Robertson et al., 1994).InterventionA functional approach using meaningful tasks can be used. Michel and Mateer (2006)suggest that intervention should be focused on training specific functional skills ratherthan the underlying processes. The National Clinical Guidelines for Stroke (IntercollegiateStroke Working Party (ISWP), 2008) recommend that patients receive repeated practiceof activities to treat attention problems. Activities that are meaningful and interesting tothe patient and control the amount of stimuli in the environment should be chosen. Forexample, a kitchen session where the patient is asked to make a cup of tea, the therapistscould get all necessary items out on the counter, the patient then only needs to link thecomponents together without being required to search the kitchen for items. Each time thesession is repeated, an additional search could be introduced such as leaving the milk inthe fridge or cups in the cupboard. As the patients attention improves, the challenge andcomplexity of the task can be increased to work on higher levels of attention. Repetitivetasks at the tabletop can be used, for example, letter cancellation and word searches, aslong as the interventions are providing an appropriate challenge and can be graded asattention improves.Adaptive (compensatory/functional) strategiesThe National Clinical Guidelines for Stroke (ISWP, 2008) recommend that patients shouldbe taught strategies to compensate for their reduced attention. If attention continues tobe a problem, strategies can be implemented. This can be done by providing structureto the patient’s day such as using a diary system. Minimise distraction in the patient’senvironment and ensure the patient has a quiet place they can go to if they become overstimulatedas this may manifest in agitated behaviour. Use of prompting to maintain thepatient’s attention during tasks can be useful (prompts can be verbal or visual). Thesetechniques should be taught to families and carers to alleviate the potential emotionalstress attention problems can bring to both patient and their carers. If the patient is goinghome or is at home, safety implications of poor attention should be noted as it will oftenpresent similarly to problems with memory.

Management of Cognitive Impairments 149MemoryMemory allows us to retain and recall information for all aspects of daily living. Attentionis essential to allow us to attend to information and select what is to be stored in ourmemory systems.The main processes associated with memory function are as follows: Attention – to the information that has to be remembered. Encoding – sensory information is converted into meaningful data for storage. Storage – in long-term memory systems. Consolidation – rehearsal and practice of information to enhance the strength of thememory. Retrieval – accessing information through recall or recognition.Memory systemsSensory memory (sensory registration) – allows us to attend to relevant information andtransfer it to our short and long-term memory systems. If not used, the information isdiscarded.Working memory (short-term memory) – a temporary storehouse of information whichis retained for long enough for us to act up on it, for example, dialling a phone numberwhen looking it up in the phone book. New sensory memories act with stored long-termmemories to manipulate and use information in a meaningful way. If new information isto be stored as long-term memories, it needs to be consolidated and stored in one of thelong-term memory systems.Long-term memory – information is processed and stored in different types of long-termmemory systems: Semantic memory – knowledge and facts; Episodic memory – past events and activities; Prospective memory – remembering to do things in the future; Procedural memory – learned motor, cognitive and language processes.Semantic memory, episodic memory and prospective memory are referred to collectivelyas ‘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 formnew memories ‘anterograde amnesia’ or access stored memories ‘retrograde amnesia’.AssessmentOccupational therapists are interested in the impact of memory problems on a person’soccupational performance. Assessment at any stage of recovery will involve a detailedanalysis of memory as performance skill impairment and the impact it has on a person’sability 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 memoryimpairment and how it affects a person’s ability to function in daily life.

150 Occupational Therapy and StrokeObservation of performance in a variety of tasks can help to determine where performanceis limited and informs the intervention programme. Observing a person doingsome shopping or having a conversation about the day’s events can indicate areas ofdifficulty they may be having and where memory information processing might be breakingdown. It is important to consider the impact of the environment during assessmentas people often use cues to prompt them and may have more difficulty in unfamiliarcontexts.Standardised assessments such as the Rivermead Behavioural Memory Test-III (Wilsonet al., 2008), Doors and People (Baddeley et al., 1994) and the Chessington OccupationalTherapy Neurological Assessment Battery (Tyerman et al., 1986) can be used to establisha baseline of performance, but should be combined with observational assessments todetermine the extent of difficulty the individual has.InterventionIntervention should be individualised, goal orientated and include psychological andemotional support. A restorative (remedial) approach, whilst of some use for those withmild problems, has limited effect for those with severe memory problems. The use ofadaptive (compensatory/functional) approaches and assistive devices within the contextof functional activities tend to be more successful (Cappa et al., 2005).A combination of approaches is recommended and these need to be selected accordingto where the memory information processing system breaks down and individualpreferences; see Figure 7.1. For example:AttentionReduce distractionsEye contact/nameEncodingMake meaningfulStorageUse writtenlists/instructionsRecallConsolidationGive cuesRehearse and practiceFigure 7.1Memory strategies linked with breakdown in memory processing.

Management of Cognitive Impairments 151 If attention breaks down, use– Attention treatment strategies.– Environmental adaptation – minimise distractions; simplify and organise theworkspace. If encoding breaks down, make the information more meaningful, linking to previouslearning or chunking information together– Internal strategies and prompts – for example, use of mnemonics, visual imagery. 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, calendarsand computers. If the patient struggles to keep the information in storage, work on consolidation throughrehearsal and practice.– Errorless learning in practice of tasks to minimise performance errors and enhancelearning. 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 facilitatememory. Support from family, carers, colleagues and friends is required to implement strategiesand provide prompts and support, no matter which approaches are taken.The National Clinical Guidelines for Stroke (ISWP, 2008) recommend the use ofadaptive (compensatory/functional) techniques to reduce disability, approaches aimed atdirectly improving memory and the use of familiar environments when conducting therapysessions.LanguageAphasia may occur following a stroke and this may affect a person’s understanding of thespoken word, verbal expression, reading and writing. It is usually assessed in more detailby the speech and language therapist; however, joint sessions between the occupationaltherapist and speech and language therapist may be of benefit to help to ascertain whatelements of a person’s performance are due to language difficulties or other cognitiveproblems (see Chapter 4).Motor planning and apraxiaNormal motor planningPraxis 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 (verbalcommand, visual or tactile) input or volitionally. Actions need to be integrated with

152 Occupational Therapy and Strokeknowledge of object use and if several items are in use, there must be matching ofactions and objects at the correct stage. Actions are often required to be performed ina specific sequence in order to complete a task successfully. We may at times performtasks incorrectly but generally we are able to recognise these errors and correct them; forexample, not putting the car into gear before pressing the accelerator.A representational model of apraxia initially proposed by Roy and Square (1985) (andreviewed, as outlined by Roy (1996)), described three systems which allow us to functioneffectively: the sensory/perceptual system which differentiates between visual, auditoryand object information; the conceptual system which comprises our knowledge of actionsrelated to object function and associated sequences of movements related to the use of theobjects; the production system which involves knowledge of the force, time and directionof action sequences and the translation of these into action.The concepts of motor programmes and action schemas further support our understandingof motor planning and voluntary activity.Motor programmes describe a set of motor commands used to achieve a particularmovement and determine the force direction and timing of the movement. They arestored as motor engrams or action memories for specific movements. Action schemas aregeneralised motor programmes which are activated for all movement associated with amotor pattern. They contain the perceptual, sensory and motor components of a movementand become established with practice and experience. This describes how a scheme ofmovement such as reaching and grasping can be used for several activities such as reachingfor a tin in the cupboard, or reaching for a cup on the table.ApraxiaApraxia is a cognitive motor planning disorder. It impacts on a person’s ability to carry outskilled 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 disablingeffects of stroke or brain injury (Van Heugten et al., 2000).Several types of apraxia are described in the literature such as dressing apraxia andconstructional apraxia. More recently these have been described as the functional outcomeof a performance breakdown resulting from several types of impairment and shouldtherefore not be given individual classifications. Most current literature describes twotypes of apraxia – ideational and ideomotor.NB: The terms ‘apraxia’ and ‘dyspraxia’ are used interchangeably by occupationaltherapists; however, there is a move towards describing ‘apraxia’ as a disorder of learnedmovement seen in adults with acquired injury and ‘dyspraxia’ as a disorder of new learningseen in children (Grieve and Gnanasekaran, 2008). For this reason we use ‘apraxia’throughout this text.Ideational apraxiaIdeational apraxia is a disturbance in the conceptual organisation of actions. It is often associatedwith the inappropriate use of objects. Visual recognition and perceptual processesare functioning but the ability to use the object is impaired. The person with ideational

Management of Cognitive Impairments 153apraxia may use single action objects appropriately but may have more difficulty when asequence of actions for object use is required.Specific performance errors initially proposed by Miller (1986) are associated withthe two types of apraxia. These errors have been revised by the author of this chapter(Jackson) as a result of clinical observation: Inappropriate object use – for example, use a toothbrush to comb hair, or strike a candleon the matchbox instead of a match. Sequencing errors – for example, buttering bread before toasting it or omitting anessential stage such as turning the kettle on without putting water in. Blending sequences together – for example, making a stirring motion with a spoon ofsugar before putting it in the cup. The action overshoots what is necessary – for example, the whole cup is filled withmilk instead of leaving room for the tea. The action remains incomplete – for example, the sugar is spooned into the coffee butnot stirred. Perseveration – the action may be continued into the next stage of the task even thoughit is not required – for example, the teapot is placed on the saucer after the teacup isplaced on the saucer.Ideomotor apraxiaIdeomotor apraxia is a disorder in the initiation and execution of planned sequences ofmovement. The concept of the task is understood but the movements lack the correct forcedirection and timing to achieve a motor goal. The person with ideomotor apraxia may beable to describe an action and at times will perform it automatically, but will generally beunable to produce it on command. Performance errors initially proposed by Miller (1986)and adapted by the author of this chapter (Jackson) are: Spatial orientation errors – wrong orientation of the arm, for example, waving goodbyein a forward/backward motion instead of side to side. Initiation and timing – for example, hesitation before initiating a movement, often at apoint of transition between movements. Movements may appear rushed or abnormallyslow. Inappropriate force may be seen in relation to the spatial pathway and relatedtime sequence. Errors of the force of movement – poor calibration, for example, bang a cup down onthe table. Poor distal differentiation – the overall arm position may be correct but with poor handposture – for example, if demonstrating turning a key the hand is held in the wrongplane when the arm appears correctly aligned. Body part used as object – when asked to gesture an action, the person substitutes abody part for the object – for example, using finger as a toothbrush or hand as a razor. Gestural enhancement – an increase in the movement required for an action – forexample, rocking back and forth when demonstrating the use of a hammer. Vocalisation (vocal overflow, self-cueing) – verbalisation of a movement – for example,‘bang, bang’ when demonstrating the use of a hammer.

154 Occupational Therapy and Stroke Perseveration – continuation of a movement, when there is no obvious end point, forexample, continuously cleaning shoes, or using the same movement to demonstrate anaction when moved onto the next action, such as making a hammering motion whendemonstrating the use of a spoon (after demonstrating use of a hammer). Fragmented response – part of a movement is demonstrated – for example, whendemonstrating drinking the cup is bought to the mouth but not tipped to the lips.AssessmentTherapists will be primarily interested in how apraxia affects a person’s ability to engagein meaningful occupations in the areas of self-care, work, domestic and leisure. In order toassess those functions the occupational therapist will analyse the component parts of thetask to determine where the ability to perform it has broken down. This could be in anyone or more than one of the performance skills of motor, sensory, cognitive psychologicalor social aspects. The environment and context in which the task is taking place will alsohave an impact on the outcome.Tate and McDonald (1995) described the ‘vast array of diagnostic tests’ for apraxiahaving 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 validityof ideomotor apraxia screening tools. Studies of apraxia use different screening toolsand despite finding apraxia, each test may be examining different aspects of the apraxiasyndrome. Butler recommends that until a ‘gold standard’ test of apraxia is found that wedo not just rely on one test of apraxia for diagnosis and that we consider the results ofADL measures as being more clinically relevant than pure test scores.Van Heugten et al. (1999) proposed a diagnostic test for apraxia in stroke patients whichwas sufficiently discriminative to distinguish between those who had apraxia and thosewho 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 (Zwinkelset al., 2004); however, like Butler, the authors recommend that test scores are combinedwith behavioural observations for a full assessment of apraxia and its impact on dailyliving activities.Standardised assessments of performance such as the AMPS may contribute to theunderstanding of the quality and effectiveness of performance (Fisher, 2006). Van Heugtenet al. (2000) used an observational method for the measurement of disability in peoplewith apraxia using four activities of daily living. The focus was on the point at which theactivity broke down rather than the cause and identified initiation, execution and controlas the notable stages of performance breakdown. This was subsequently used to supportappropriate intervention strategies at the relevant juncture.Occupational therapists use the identification of performance errors to determine wherean activity is breaking down. Tempest and Roden (2008) found consensus amongst occupationaltherapists that analysing a person’s performance errors was the best way toassess apraxia.By using the errors noted for each type of apraxia, the occupational therapist maybe able to use their clinical observations to identify which type of apraxia a person isexperiencing, and more importantly the impact it has on independent living.

Management of Cognitive Impairments 155InterventionThe principles of cognitive rehabilitation, ‘goal orientated; individualised, educate andinclude 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 performancedespite the lasting presence of apraxia, and that adaptive (compensatory/functional) strategiesdo not impede the recovery of the impairment (Van Heugten et al., 1998; Donkervoortet al., 2001).Van Heugten et al. (1998) proposed a ‘strategy training’ programme for people withapraxia. This was evaluated in a randomised controlled trial and showed short-term improvementin ADL function when comparing it with usual occupational therapy, althoughthe long-term effect requires further exploration (Donkervoort et al., 2001). Strategytraining aims to improve performance by teaching internal and external compensatorystrategies as part of the occupational therapy programme. As the assessment using ADLobservations breaks the activity down into performance stages of initiation, execution andcontrol, 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 ifthe person is experiencing more problems initiating the activity, then the therapist mayfor instance hand items to them one at a time. If execution is the problem, specific verbalor physical guidance is given and if control is a problem or performance errors are notcorrected, then appropriate feedback is given.Other smaller studies have shown some support for specific interventions: ‘Activities in context’ – Clark et al. (1994) conducted a small 3D movement analysisstudy which suggested that motor performance and kinematic measures improved whenthe person with apraxia was supplied with the appropriate tools for a task and the correctcontextual environment. ‘Task-specific training’ – Goldenberg and Hagmaan (1998) found that task-specifictraining could restore independence for trained activities. They also found that skillsdid ‘not generalise’ to other tasks and performance was retained only when taskscontinued to be ‘practised’’ in daily routines. This was supported in a single case studyby Wilson (1998) who provided a ‘structured’ programme of activity and ‘chaining’toretrain specific functional tasks. The activity was broken down into manageable stepsin order to relearn specific tasks. Skills were only retained if the task was practised indaily routines. This supports the selection of appropriate and meaningful activities tobe used in the occupational therapy programme.Executive dysfunctionThe executive system comprises those high-level cognitive processes which combine toset goals and to make choices in novel situations (Grieve and Gnanasekaran, 2008). Itrefers to the processes by which we plan, organise, initiate, monitor and adjust our thinkingand behaviour (Kay, 1986).

156 Occupational Therapy and StrokeYlvisaker and Szekeres (1989) identified component functions of the executive system: Realistic goal setting – having insight and awareness of what is achievable accordingto own skills and external influences. Planning – correct ordering of the steps required to carry out a task successfully. Organisation – of the workspace and timing of the task to carry out the plan effectively. Self-initiation – starting a task without being prompted. Self-directing – continuing a task without prompting. Self-inhibiting – being able to stop a behaviour or action to move to another task whenrequired. Self-monitoring/self-correcting – recognising when something needs to be altered orcorrected and taking appropriate action. Flexible problem solving – being able to think of more than one solution according tothe demands of the situation.Executive dysfunction can lead to difficulty formulating goals and maintaining behaviourto complete tasks successfully. People with executive problems may appeardisorganised and lack planning skills. They may not have insight into their difficultiesand may have problems interacting appropriately in various social, community and workcontexts. They may also be unable to correct their mistakes and/or to think laterally.AssessmentIt is important to define the person’s previous level of functioning as this will indicateto what extent their performance is different from their normal executive skills. Thisinformation can be obtained from family, friends and work colleagues through interviewand written feedback using specific questionnaires.Observational assessment of the person’s performance of daily tasks can indicate specificexecutive problems. It is important that the level of skill required for the task is ofsufficient challenge to identify any performance breakdown. Simple, familiar tasks maybe performed correctly but difficulties arise when more complex tasks are introduced. Thetherapist may ask the person to complete some more novel tasks which contain severalstages 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 anyareas of difficulty the person may be having.There are several standardised assessments available, including the BADS (Wilsonet al., 1996). Standardised assessments of executive dysfunction should be used in combinationwith observational tests of performance as the test results may not always fullyreflect the functional limitations which the person may have.InterventionThe National Clinical Guidelines for Stroke (ISWP, 2008) recommend that thosewith executive dysfunction and activity limitation should be taught adaptive (compensatory/functional)strategies, for example, electronic organisers, written checklists; and

Management of Cognitive Impairments 157that family and other staff should be involved in discussions regarding the impairmentand 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 recommendationscan be considered for people who have had stroke. Practice guidelines from this studyinclude ‘training of formal problem-solving strategies and their application to everydaysituations and functional activities’ and ‘verbal self-instruction, self-questioning and selfmonitoringcould be used to promote internalisation of self-regulation strategies’.Focusing on the functional activities which are limited by specific executive skills areencouraged, for example: Goal setting – specific and meaningful for the person. It is helpful to encourage peopleto set their own goals and then review the outcome to develop insight into their ownabilities. Planning – activities can be graded to achieve success and gradually improve thedifficulty. Organisation – a structured routine can be established with support, and responsibilityfor this gradually handed over. Self-initiation and self-direction – external aids such as pagers and alarms can assistwith reminders. Taped or written prompts may assist with self-direction. Self-inhibition/monitoring and correction – develop strategies to monitor own behaviourand make appropriate changes. Feedback and discussion can be used to develop aperson’s awareness of their own performance. Flexible problem solving – alternating scenarios can be presented and practised todevelop a strategic approach to generating alternative solutions.Self-evaluation questions1. Define cognition.2. What types of cognitive impairments may be observed following a stroke?3. Name and describe the five different levels of attention.4. What are the four main processes associated with memory function?5. Describe the difference between ‘anterograde amnesia’ and ‘retrograde amnesia’.6. Describe five performance errors which you may observe in a person who has anideational apraxia.7. Describe five performance errors which you may observe in a person who has anideomotor apraxia.8. What are the main performance behaviours you may observe when someone hasexecutive dysfunction?9. What are the two main approaches used by occupational therapists in the managementof people with cognitive impairments?10. What are the main intervention principles for the rehabilitation of people with cognitiveimpairments?

Chapter 8Management of Perceptual ImpairmentsLouisa Reid and Judi EdmansThis chapter includes: Definition of perception Normal perception Perceptual impairments Perceptual assessment Intervention of perceptual impairments Self-evaluation questionsIntroductionPerceptual impairments can have a major impact on occupational performance. Thischapter 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 perceptionThe simplest definition of perception is ‘to become aware of by one of the senses’ (OxfordEnglish Dictionary, 1961), that is, vision, hearing, touch, taste or smell.Normal perceptionHow we interpret our environment starts at our inputting stage. The visual system conveysmore information to the brain than any other afferent system. Chapter 6 outlines thepathways in detail. The primary visual cortex is located in the occipital lobe and most ofthe visual information is processed in five visual processing areas which perform varyingvisual tasks (Cohen, 1999) (see Figures 8.1 and 8.2): ‘Area V1 responds to motion, colour and position’ ‘Area V2 responds to orientation, direction and colour’ ‘Area V3 responds to orientation information’ ‘Area V4 responds to large fields and colour’ ‘Area V5 responds to unidirectional motion’.

Management of Perceptual Impairments 159V3V1V2V4V5Figure 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 andGnanasekaran (2008) provide the example of looking around a room to explain thecomplexity 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 theirdistance from us. Figure 8.2 explains the visual pathways within the cortex that enable usto process all the information that is inputted through our eyes.The way we perceive images varies from person to person but does not constitute aperceptual problem. Examples include black and white pictures drawn in such a wayVentral visual pathwayDorsal visual pathwayV4V5V3V2V1Figure 8.2 Visual pathways. (Reproduced with permission from Lippincott, Williams &Wilkins, adapted from Bear et al., 2007.)

160 Occupational Therapy and Strokethat if you see the foreground as being black, you will see one image, but if you see theforeground as white, you will see another.Areas of the brain relating to perceptionThe right hemisphere has a greater role in processing visual and spatial informationthan the left hemisphere. Damage to different areas of the brain may result in differentimpairments.Occipital lobe: Discrimination of shape, size and depth. Object agnosia. Prosopagnosia.Occipitoparietal area: Spatial relations.Right parietal lobe: Form discrimination. Apperceptive agnosia. Anosognosia. Topographical disorientation. Spatial relations. Neglect.Left parietal lobe: Associative agnosia. Somatognosia.Temporal lobe: Prosopagnosia. Topographical disorientation.Perceptual impairmentsMost individuals take for granted the complex nature of visual and visual–spatial abilitiesuntil these are affected. When damage occurs impairments can lead to difficulty engagingin 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:

Management of Perceptual Impairments 161Body schemeBody scheme impairments are a lack of understanding of the relationship of the bodyand its parts.Autopagnosia is a lack of awareness of the body structures and relationships, causingthe patient to confuse sides of the body and body parts.Unilateral neglect is neglect of the affected side of the body or the environment, forexample, neglecting one side of the body during dressing or neglect food on one sideof a plate.Anosognosia is a lack of recognition of the presence or severity of the paralysis orcomplete denial of illness.Right left discrimination impairment is difficulty understanding the concept of rightand left.Finger agnosia is difficulty knowing which finger is touched when there is no sensoryloss.Visual discriminationVisual discrimination is the ability to distinguish one object from another; they can bedifferentiated 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 difficultyknowing 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 anitem of clothes in a cluttered drawer.Spatial relations impairment is difficulty in perceiving the position of two or moreobjects in relation to oneself or each other, for example, difficulty putting food onto aspoon and then into the mouth or difficulty in putting the lid on a teapot. It may alsobe exhibited as difficulty understanding the concepts of in/out, front/behind, up/downetc., for example, difficulty finding a cup behind a kettle or putting on at-shirt insideout.Topographical disorientation is difficulty understanding and remembering relationshipsof places to one another, for example, difficulty in finding one’s way.AgnosiaVisual agnosia is the inability to recognise visual stimuli despite adequate primaryvisual function (visual acuity, oculomotor and visual fields).Visual object agnosia is difficulty in recognising objects although visual acuity andvisual fields are intact; for example, a patient may fail to recognise relatives orpossessions.Prosopagnosia is difficulty in recognising differences in faces.

162 Occupational Therapy and StrokeSimultagnosia is difficulty in absorbing more than one aspect of a whole picture; forexample, a patient may be able to pick out a single letter but unable to read a completeword.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 betweenobjects or between objects and self, independent of visual object agnosia.Tactile agnosia (also called astereognosis) is difficulty in recognising objects by handlingalthough tactile, thermal and proprioceptive functions are intact.Auditory agnosia is difficulty in recognising differences in sounds, including both wordand non-word sounds; for example, a patient may be unable to differentiate betweenthe 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 bodyscheme, apraxia and agnosia problems.Perceptual assessmentWhy assess perceptual ability?Perceptual problems have been shown to be common following both right and left hemiplegicstroke (Edmans and Lincoln, 1987). These perceptual problems affect the patients’response to rehabilitation and their ability to perform activities of daily living (Edmansand Lincoln, 1990; Jesshope et al., 1991; Donnelly et al., 1998) suggesting that if possiblethey should be treated.The objective of assessing perceptual ability is to identify the reason patients are unableto do certain activities and/or the possible impact on future activities, which in turn willinform 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 clarifyingthe 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’severyday activities.When to assess perceptual abilityPerceptual 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 differentactivities during their recovery.Perceptual screening should be conducted within the first few days as part of the therapist’sinitial assessment of each patient. This will indicate to the patient and therapist anypotential areas of functional difficulty. A more detailed perceptual assessment should beconducted later if indicated from screening assessment or functional difficulties. This isin line with the recommendations of the National Clinical Guidelines for Stroke (IntercollegiateStroke Working Party (ISWP), 2008), which state:

Management of Perceptual Impairments 163‘Cognitive impairments – general(a) Routine screening should be undertaken to identify the range of cognitive impairmentsthat may occur.(b) Any patient not progressing as expected in rehabilitation should have a moredetailed cognitive assessment to determine whether cognitive losses are causingspecific problems or hindering progress.(c) The patient’s cognitive status should be taken into account by all members of themultidisciplinary team when planning and delivering treatment.(d) Planning for discharge from hospital should include an assessment of any safetyrisks 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 consideredat risk of reduced awareness on the left, and should be tested formally if this issuspected clinically.(b) Any patient with suspected or actual impairment of spatial awareness should havetheir profile of impaired and preserved abilities evaluated using a standardisedtest battery such as the Behavioural Inattention Test (Wilson et al., 1987). Thediagnosis 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 objectsshould be assessed formally for visual agnosia.How to assess perceptual abilityPerceptual ability could potentially be assessed either functionally or by use of standardisedassessments.Functional screening assessmentFunctional assessment of activities of daily living, such as personal or domestic activities,will demonstrate the effect of a mixture of impairments, both physical and cognitiveimpairments, upon the patient.As with the assessment of motor skills the initial assessment commences when theoccupational therapist walks into the bay or room of the patient. The occupational therapistshould observe how the patient is positioned whether in the bed or in the chair/wheelchair.Observations should include the following: Is their head turned towards one side? (This can be a sign of neglect.) Is the patient pushing their leg or arm into full extension and pushing themselves overto 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 respondsand interprets the therapist’s questions. This may indicate if any potential perceptualimpairments are present, although it will not give an accurate account of which impairmentis causing the difficulty.

164 Occupational Therapy and StrokeFor example, if a patient appears to be neglecting everything on the left side of their bodyduring a washing and dressing assessment, the therapist would not be able to distinguishwhether this was due to a visual problem of hemianopia, a tactile problem of reducedsensation or a unilateral neglect.Standardised screening assessmentWhen the patient’s previous history has been outlined and functional assessment conducted,standardised assessments should be used as a quick screen for the presence ofperceptual impairments. Examples include: Line Bisection test from the Behavioural Inattention Test (Wilson et al., 1987). Star/Letter Cancellation from the Behavioural Inattention Test (Wilson et al., 1987). Rey Figure Copying test (Rey, 1959; Meyers and Meyers, 1995).Completing these three basic pen and paper tests along with a baseline assessmentwill screen for perceptual impairments. If perceptual impairments are indicated on thescreening assessments, a more detailed assessment of perceptual impairments should beconducted (see Chapter 10 on the use of standardised assessments).Baseline assessmentIt is important to assess patients in different forms of activities of daily living. This shouldfollow the screening assessment, which should have identified the possible impairmentsthat may cause difficulties or inefficiencies in function. This will assist targeting the correctlevel of complexity. It is essential to assess the correct complexity level to highlight theimpairments that are impacting on task performance. Mild impairments will not emerge ina simple level task; therefore, a patient may be able to make a sandwich. However, whenpreparing a complex meal perceptual, cognitive impairments may cause inefficiencies oftask performance and therefore cause delay in task completion.Assessment can take place during any activity of daily living task, for example, mealtimes or grooming tasks. When assessing in function it is important to consider thefollowing: 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 assessmentsThere are many standardised perceptual assessments available, some of which are forspecific impairments only and some are more general. These can be split into three maincategories and examples of each are shown below:

Management of Perceptual Impairments 165 Neglect. Spatial. Multi assessments.Neglect assessments Baking Tray Test (Tham and Tegner, 1996). Balloons Test (Edgeworth et al., 1998). Behavioural Inattention Test (Wilson et al., 1987).Spatial assessments Location Learning Test (Bucks et al., 2000). Rey Figure Copying Test (Rey, 1959; Meyers and Meyers, 1995). Visual Object and Space Perception Battery (Warrington and James, 1991).Multi assessments 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). Repeatable Battery for the Assessment of Neurological Status (Randolph, 1998).Many assessments are available from Pearson Assessment (combining The PsychologicalCorporation, Thames Valley Test Company and Harcourt Assessment).InterventionIntervention of perceptual impairments involves a mixture of restorative (remedial) andadaptive (compensatory/functional) approaches, the theory of which are explained inChapter 2.The restorative (remedial) approach can be generalised, as practice on a particularperceptual task will affect the patient’s performance on similar perceptual tasks.The adaptive (compensatory/functional) approach can be interpreted as repetitive practiceof particular tasks, usually activities of daily living, which will make the patient moreindependent in these particular tasks.Occupational therapists use functional tasks as an intervention medium and despiteconducting personal care activities, occupational therapists may still be working at animpairment level. For example, when working with a patient with neglect the therapistmay move items on a sink from midline to their left side which would be focussing onthe impairment level of the disorder when still working with the media of personal care.

166 Occupational Therapy and StrokeWhile working with a restorative (remedial) approach it may be possible to make gainsthat generalise into other occupational areas. It is, however, important to be aware ofother 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 interventionsas cognitive impairments. Reduced awareness, changes in mood and visualdisturbance will affect the patient’s ability to respond to intervention.Neglect is the most common perceptual impairment suffered by stroke patients andoccurs over several sensory systems; vision, touch and auditory. Neglect presents indifferent spatial domains and these include the following: Body (personal) space – the immediate area of space of the person. Reaching (peripersonal) space – the area extending to arm’s reach of the person. Far (extrapersonal) space – the area extending far from the person.The most dramatic and easily observed is the visual form of neglect. Patients withneglect may fail to shave or dress their left side, fail to read the left side of a word orsentence, fail to attend to the left side of the sink leading to missing objects placed on theleft, or fail to attend to the left side of their plate. There are related disorders that presentsimilar to neglect and confuse the identification of the disorder and need to be ruledout. These include visual field impairment, visual inattention, anosognosia and severelyimpaired sensation throughout the left side. Neglect commonly occurs with other visualperceptual and attention impairments due to the area of the damage leading to this disorderand these dual impairments need to be taken into account when planning intervention.Neglect occurs following right hemisphere damage and has been linked to the parietallobe and supramarginal gyrus. There are various theories to explain the phenomenon andit is important to understand these to provide an intervention approach.Attention-Arousal Theory (Heilman et al., 1993, 1993) outlines damage to structuresresponsible for arousal and transmission of sensory information to the cortex leading toreduced attention to the contralateral side. Neglect is caused by the cortex not receivingadequate sensory information from the subcortical structures.Hemisphere Specialisation Theory (Robertson and Lamb, 1991) proposes that there isa specialised nature to the hemispheres, the left attends to right where the right attendsto both left and right; therefore when the right hemisphere is damaged the left side hasno attention to the left as the left hemisphere only attends to the right. Robertson andLamb suggest that the use of left hand leads to improved task performance comparedto right hand use and proposed that this is due to left arm activation which leads topremotor activation of the right hemisphere. The spatiomotor cueing process (use of theleft hand acts as a cue) enhances attention to the left side. Contralesional limb-basedtherapy however is problematic due to left-sided hemiplegia.Intentional Mechanism Theory (Halligan and Marshall, 1991) proposes that intentionalmechanisms are activated when directing a hand in the contralateral side, that is, the lefthemisphere activates the right hand to the left of midline. Moving the right hand towardsthe contralateral side (left side) activated the right hemisphere. Halligan and Marshall’stheory leads to recommendation of the use of left hand in function in midline and thecontralateral side; however, using the left hand in the ipsilesional side activated the lefthemisphere and cancelling the use of left hand in the contralateral side.

Management of Perceptual Impairments 167Disengagement Theory (Posner et al., 1984) proposes decreased attention to the left iscaused by inability to stop attending to objects in the right side. This theory proposes toreduce stimuli in right visual field and to present objects in midline and move into leftvisual field.Interhemisphere Theory (Kinsbourne, 1977) is based on attentional mechanisms ofeach hemisphere which are activated by cognitive and perceptual tasks and neglect is theimbalance in brain activation. Spatial stimuli activate the right hemisphere and verbalstimuli activate the left hemisphere. Thus, when the right hemisphere is damaged theability to process spatial stimuli is impaired. This theory proposes the need to reduceimbalance by turning head towards the left, remove left hemisphere stimuli (letters andnumbers) and moving target stimuli from central to left visual field.General intervention tips Consider the grade of the task; the complexity of the task increases the likelihood oferrors. Consider the types of prompts, that is, visual, verbal, physical or questioning promptsand pausing before providing a prompt. Consider using written or visual instructions. Learning can be achieved through repetition and practice. Reinforce positive behaviours rather than negative ones. Stage components of the task, that is, break down the task and encourage the patient tocomplete one stage at a time. Use verbal rehearsal, that is, encourage the patient to talk through the task beforecompleting it, errors can then be corrected before they are performed. Establish patterns and routines. Provide consistency in approach.Specific intervention strategiesBody schemeAim: For the patient to be aware of parts of the body and their relationship to each otherand how they are used within function.Restorative (remedial) strategies Ask the patient to verbally identify parts of the body (Johnstone and Stonnington,2001). Encourage the patient to verbalise positions of parts of the body to improve awareness. Provide tactile stimulation, for example, rub a rough cloth on the patient’s arm whilenaming it before placing their arm through a sleeve (Zoltan, 2007). Identify parts of the body before washing or dressing them. Incorporate bilateral activities that facilitate normal movement and improve bodyscheme (Zoltan, 2007).

168 Occupational Therapy and StrokeAdaptive (compensatory/functional) strategies Provision of instructions that name parts of the body, such as ‘wash your arm’ (Zoltan,2007). If the patient has functional awareness, provide cues such as ‘move the part of the bodythat you use to hold things’ instead of ‘move your hand’ (Zoltan, 2007).Impaired midline awarenessThis presentation is often termed the ‘Pusher syndrome’ (for details see Chapter 5).Patients have a severe misconception of their own upright orientation. Patients experiencetheir own upright as 20 ◦ tilted to the ipsilesional side. Patients present by pushingthemselves over towards their affected side and are often overactive on their unaffectedside.Aim: To regain the awareness of midline.Restorative (remedial) strategies For the patient to become aware of midline by using visual feedback, place a mirror infront of them and instruct the patient to self-correct themselves back to midline. In all postural sets, ask the patient to identify the position of their body and describetheir relationship to supporting surface (Karnath and Broetz, 2003). Get the patient to move between postural sets and for them to maintain their balance.Adaptive (compensatory/functional) strategies Place pillows on the overactive side to provide extra supporting surfaces to enhance thepatient’s feeling of security. When seated in a wheelchair place the hospital bed in a high position on the overactiveside to enhance feelings of security. Teach the patient to use vertical structures within the room such as door or windowframes to adjust balance with reference to these markers (Karnath and Broetz, 2003).Unilateral neglectAim: The patient to become aware of both sides of their environment.Restorative strategies Use activities that cross midline, for example, personal care activities. During activities of daily living sessions place stimuli on the patient’s affected side andprompt and encourage them to look over to their affected side. Place necessary itemsin midline and to their affected side using cues to locate all items and ask patientsverbalise the location of items to practise spatial scanning. Practise shifting attention from left to right. Cue patients to target stimuli in neglectedspace to assist attentional shifts.

Management of Perceptual Impairments 169 Move necessary items from midline to their affected side, such as the knife in midlineand the butter further into the left side. Cancellation tasks such as maze or word searches to practise scanning left to right. 2D scanning tasks, that is, paper and pen tasks or more dynamic such as room searches. Computer games that require scanning from side to side. Tactile stimulation onto the neglected part of the body, using vibration, mildly hot orcold stimuli (Johnstone and Stonnington, 2001).Adaptive (compensatory/functional) strategies Place objects in midline and gradually move objects further into the patients’ affectedside. Approach patients from the midline. When reading, anchor the page and draw a red line down the affected side so thatthe patient becomes aware of how far across the page to start reading (Johnstone andStonnington, 2001). Adapt the environment; remove clutter on the affected side (Johnstone and Stonnington,2001). Encourage the patient to turn their plate round to ensure all the meal is eaten. TheNational Clinical Guidelines for Stroke (ISWP, 2008) recommend that meal timesshould be monitored to ensure that food is not missed. Teach the patient to turn their heads to become more aware of the affected side.Other intervention approachesConstraint-induced movement therapyConstraint-induced movement therapy (CIMT) forces the use of the affected side by eitherplacing a sling or mitt on the unaffected arm (Taub et al., 1998). CIMT attempts to reversethe learnt non-use of the affected arm; however, to be able to use this technique there needsto be enough return of movement that would allow the patient to functionally use theiraffected hand. CIMT reports to be a useful intervention method for unilateral neglect. Forfurther details see Chapter 2.Eye patchingStudies have shown that using glasses that occlude the good (ipsilesional) side of visionin each eye, the patient is forced to direct their gaze to their contralesional side (Beiset al., 1999). Compliance with this technique can be difficult as it is the patient’s naturalinclination to gaze towards the occluded side.Prism glassesThere 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.

170 Occupational Therapy and StrokeWithin studies such as Rossetti et al. (1998), patients were asked to point to a target eitherside of midline while wearing the glasses. Following the use of this technique the patientsdemonstrated immediate improvements in tests of neglect. McIntosh et al. (2002) havealso shown these improvements to be made post 9 months following stroke. The NationalClinical Guidelines for Stroke (ISWP, 2008) recommend using prisms if the unawarenessis severe and persistent.Visual discriminationAim: To become aware of the relationship of objects to objects or self, to identify foregroundfrom background, position in space and depth and distance.Restorative (remedial) strategies 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’. Teach the patent to place different items in different parts of the room. Use of tactile kinaesthetic strategies such as guiding the patient to the object. Encourage the patient to verbalise the position of parts of the body to improve awareness.Adaptive (compensatory/functional) strategies 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 agnosiaAgnosia is the inability to recognise objects even though the elementary visual functionsremain unimpaired (Farah, 1995). Lissauer in 1890 distinguished between two types ofvisual agnosia, the apperceptive and associative agnosias. Apperceptive agnosia is whererecognition fails because of impairment of visual perception. Patients do not see objectsnormally and cannot therefore respond to them. Associative agnosia is when perceptionis intact to allow recognition; however, recognition cannot take place due to impairedsemantic 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 toimpaired visual perception. Patients with associative agnosias are able to copy drawingsbut cannot describe the function of objects (Farah, 1995).Aim: To be able to identify objects through vision.Restorative (remedial) strategies Present objects in a straight position rather than other orientation. Encourage the patient to recognise differences and similarities between items.

Management of Perceptual Impairments 171 Start with items that are very different and gradually upgrade to items with subtlevariations, for example, shape, size or colour. Encourage the patient to verbalise differences, that is, naming objects and differencesbetween objects.Adaptive (compensatory/functional) strategies Teach the patient to consider and think critically. Utilise verbal strategies where the patient describes the perceptual and functional characteristicsof the object to aid retrieval of the object name. Use other senses to identify the object, that is, touch, smell or sound. Show the object in a natural context. Adding texture or edge orientation to objects may assist into providing cues to identification. Use premorbid orientation of objects, that is, did they keep a T-shirt kept in the draweror on a hanger. If categorisation is intact ask the patient to identify which category the object wouldbelong to. Provide labels for objects to maximise independence.Tactile agnosia (stereognosis)Aim: To be able to identify objects through touch.Restorative (remedial) strategies Exploratory hand movements for object identification. Explore the object by touchingthe surfaces and edges of the object, holding the object in the hand to obtain informationon its size, shape and weight.Adaptive (compensatory/functional) strategies 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 planA general plan for the assessment and intervention of perceptual impairments is shownbelow:1. Assess perceptual abilities using functional tasks and standardised assessments.2. Analyse the results and the effect of comprehension, concentration, reasoning (executivefunction), initiation, memory, anxiety, depression, apraxia, hemianopia/eyesight,inattention, etc.

172 Occupational Therapy and Stroke3. 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 questions1. Explain the term of perception.2. Identify the three areas of perception.3. Which areas of the cortex are important for perception?4. Describe how to assess for perception on initial assessment.5. Define the pros and cons of both functional assessment and standardised assessmentfor perceptual impairments.6. Describe the intervention approaches for perceptual impairments.7. Describe the intervention approaches for impaired midline awareness.8. Describe the phenomenon of neglect and identify intervention strategies.9. Describe the term visual discrimination and what intervention strategies you may use.10. Describe visual agnosia and give two different approaches to intervention.

Chapter 9ResettlementPip Logan and Fiona SkellyThis chapter includes: 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 questionsHome visitsHome visits are carried out to assess if a patient is safe to return home and whether theenvironment is suitable for them. Sometimes an initial visit without the patient to assessthe environment (often called an access or environmental visit) is advisable, as re-housingor major adaptations might be required prior to discharge. It is advisable to involve thefamily with all home visits. It is good practice for occupational therapists to carry outhome visits with another member of the multidisciplinary team such as a physiotherapist orcommunity-based therapists (Clarke and Gladman, 1995). Occupational therapy serviceswill have their own template for writing home visit reports but the following areas shouldbe assessed during the visit, depending on the type of property, hazards and patient’sfunctional abilities: Access to property– Path, steps, rails and whether patient can unlock/open door. Outdoor mobility– Type of equipment and level of assistance.

174 Occupational Therapy and Stroke Indoor mobility– Type of equipment and level of assistance.– Hazards such as floor mats, furniture arrangement. Transfers– Chair, wheelchair, bed, toilet, bath, commode.– Type of transfer and assistance.– Type of equipment. Stairs– Equipment used and level of assistance.– Method of ascending/descending stairs. Kitchen assessment– Hot drink/snack preparation. 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. Recommendations Action plan– List who is going to carry out actions and timeframe.Community rehabilitationCommunity rehabilitation is an umbrella title for a number of stroke services in thecommunity, mostly administered in people’s own homes but can take place in communitycentres, health centres, sports centres, care homes and stroke clubs. Most health and localauthorities provide a mixture of services for acute (straight after hospital discharge) andlonger-term rehabilitation. The services available after hospital may be called intermediatecare or early supported discharge and are usually time limited (approximately 6 weeks).Intermediate careThe Department of Health (DH) defines intermediate care as:a range of integrated services to promote faster recovery from illness, prevent unnecessaryacute 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 frommedical dependence to functional independence, where the objectives of care are not primarilymedical, the patient’s discharge destination is anticipated, and a clinical outcome of recovery(or restoration of health) is desired.and

Resettlement 175those services which will help to divert admission to an acute setting through timely therapeuticinterventions which aim to divert a physiological crisis or offer recuperative services at or neara person’s own home.The basic principles of intermediate care according to the National Service Frameworkfor Older People (DH, 2001) are: The emphasis on appropriate, person-centred, seamless care. The need for robust assessment processes. The crucial importance of partnership working between health, social care, housingand the independent sector. Ensuring timely access to specialist services. Clear care pathways. Use of single assessment process (SAP).The nature and scope of intermediate care services vary greatly across the country. Theprofessionals making up the multidisciplinary team, the conditions that patients have andthe length of rehabilitation can vary.The main types of service are listed below:Rapid responseThe aims of the rapid response service are to facilitate timely hospital discharge and/orprevent hospital admission. It is a crisis intervention service, which offers intervention forjust a few days, for elderly people following a fall or onset of ill health. Some servicesalso 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 hospitalor a care home. The multidisciplinary team consists of nursing, medical and allied healthprofessionals. 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 teamHospital at home/community rehabilitation teams are multidisciplinary services whichprovide intensive rehabilitation at home for anything from 6 to 12 weeks. They offerpatient-centred therapy working towards patient goals. The services can be used to facilitateearlier hospital discharge and prevent inappropriate hospital admission. Occupationaltherapists 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 rehabilitationResidential rehabilitation services offer intensive rehabilitation for patients resident in aresidential home or a purpose-built intermediate care unit with input from allied healthprofessionals. These services are usually for further rehabilitation after hospital admission,

176 Occupational Therapy and Strokeoften up to 6 weeks. Occupational therapists focus on the skills patients need to managesafely at home and will carry out home visits and be involved with discharge planning.Early supported dischargeStroke specific early supported discharge has been recommended by the Departmentof Health Stroke Strategy (2007) and research has already provided evidence that thisservice 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 intensiverehabilitation at home following admission to an acute or hyperacute stroke unit. Thegeneral consensus from the research so far is that they should have a multidisciplinaryteam which includes nursing, medical, allied health profession and social work staff, butthat the team should be trained in stroke techniques. Time limit again can be between6 and 12 weeks.Role of the occupational therapistThe role of the occupational therapist within intermediate care services is either to preparepatients for returning home or to help them remain in their own home, depending on theclinical 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). Itis advisable to find out which assessments have been completed in previous clinicalsettings and use these, if appropriate, to review cognitive impairment.– Moving and handling risk assessments – to be completed at the start of the rehabilitationprogramme.– Upper limb – assessment of tone, range of movement and sensation.– Mental health – using scales such as General Health Questionnaire (GHQ) (Goldbergand Hiller, 1979) or Hospital Anxiety and Depression Scale (HADS) (Zigmond &Snaith, 1983).– Driving – assessments such as Stroke Drivers Screening Assessment (SDSA) (Nouriand Lincoln, 1994) or other cognitive tests such as Behavioural Assessment of DysexecutiveSyndrome (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, previousemployment, using leisure questionnaires.InterventionRehabilitation within intermediate care should be patient-centred. Generic goal settingwith the patient can be used to facilitate clear intervention planning. The use of goal-settingsheets can be used for patient and therapist to complete at regular intervals throughout

Resettlement 177the period of rehabilitation. Goals should be reviewed on a weekly basis and adjustedaccordingly. The important factor is that intermediate care should follow immediately fromthe acute rehabilitation and therefore requires a quick assessment of need and immediateintervention with input on most days. Occupational therapists in these services sharecaseloads and patients often hold their own notes. Occupational therapists are expectedto set goals for rehabilitation assistants who may treat the patient twice a day.The intervention approaches used with stroke patients in intermediate care are oftensimilar to those used in the acute setting. However, sometimes a more functional approachfor the frail elderly following a stroke is the most appropriate method in order for themto return or remain at home. Regular practice with washing/dressing, transfers, mobilityand 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 importantto fully assess the patient’s ability to return home. Some intermediate care unitshave kitchen facilities or a self-contained bedsit for patients to care for themselves withsupervision 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 ofresponsibility from the rehabilitation team to the patient is important if patients are goingto be helped to self-manage their own condition.Support available after a stroke and self-managementTwo-thirds of people who have had a stroke will need some type of support at home overa period of time. This could be practical support such as help with washing or dressingor psychological support such as motivational techniques, anxiety management. TheNational Clinical Stroke Guidelines (ISWP, 2008) acknowledge that much of the supportwill not be provided by health care professionals but will be provided by a mixtureof family, carers, charities, local authorities and dedicated organisations. The supportavailable varies considerably from location to location, and even within a 5-mile radiusof a large hospital people will be able to access different services. Another complicationis that some services are free and some will charge. For practical help such as getting upin the morning, assisting with meal times, and helping with getting dressed, most patientswill be assessed by statutory services such as social care and will be recommended forwhat was known as ‘home care’. However, increasingly a number of private companiesare being contracted by local authorities and the names of these services differ. On topof this, a number of private companies are advertising long-term support which peoplemay access with insurance monies or through pension schemes. Long-term psychologicalsupport for both the patient and the carer is sometimes harder to secure and this is oftenwhat people will ask for when the routine rehabilitation has ceased.The National Clinical Stroke Guidelines (ISWP, 2008) recommend that health and socialcare professionals continue to assess for support needs at regular intervals and ensure thatpeople are referred to the most suitable organisation or are given the information they needto refer themselves. This handing over some of the responsibility to the patient is veryimportant; this encourages patients to self-manage their own condition. Some patientsmay be able to organise their own lives after a stroke but some may need support for

178 Occupational Therapy and Strokemany 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 rangeof services are in place that are easily accessible and support the long-term needs ofindividuals and their carers’. In reality such services are patchy and often not specific tostroke; it can take a long time to track down a service that will come and sit with someonewhile the carer goes out. Use of the Internet can speed up searching and giving weblinks topatients or their families can open up a whole new world. Increasingly people are enteringchat 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 havehad a stroke.For the occupational therapist gathering information about local services and the differentcriteria needed to access these services can be time consuming. However, withinthe 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 goodthings to remember when trying to sort out this type of support is that this could be one ofthe most important relationships for the stroke patient; they may want to attend the strokeclub for 10 years and this introduction could be the one thing the patient remembers mostfrom their rehabilitation.Included here is a list of potential avenues for support that are not provided by thestatutory services. In your area there may be other particular organisations that offerservices 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 holdsa list. Patients usually attend once a week and the format can be a speaker, lunch andtime 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.CarersThe National Clinical Guidelines for Stroke (ISWP, 2008) provide recommendationsfor 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: At all times the patient’s views on the involvement of their family and other carersshould be sought, to establish if possible the extent to which the patient wants familymembers involved. The carer or every patient with a stroke should be involved with the management processfrom the outset, specifically:

Resettlement 179– as an additional source of important information about the patient both clinically andsocially.– being given accurate information about the stroke, its nature and prognosis and whatto 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 educationalprogramme 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 lifestylechanges. 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 significantchange in circumstances (e.g. if the health of either the patient or the carerdeteriorates).– be reminded on a regular but not frequent basis of how they may seek further helpand support.There is a variety of support/advice for carers: The Stroke Association has valuable information on its website. It runs various servicesincluding a Family Support Service. Stroke Support Groups affiliated to Stroke Association and Different Strokes are in operationacross the UK. Please refer to their websites for a list of the local branches/supportgroups. ‘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 perday of care. Carers’ Assessments are carried out by a social worker employed by the local socialservices where the need for extra support can be identified. Direct payments are available from social services to pay for care if the patient fits thecriteria for a care package but would rather use the money to employ their own carerswhere there is often more flexibility in the type of care provided, for example, to assistwith car transfers or shopping. Younger patients may find this the most beneficial wayof receiving care. Carers’ charities/organisations provide support, information and campaign for carers’rights. Contacts include The Carers Information and The Princess Royal Trust forCarers, although these are not specifically for carers of people with stroke.

180 Occupational Therapy and StrokeYounger peopleA quarter of the 110 000 people who have a stroke in England are under 65 years ofage (National Audit Office, 2005). Every year, 10 000 people under the age of 55 suffera stroke – 1000 of these are under the age of 30. Although this number seems smallcompared to the older population, this group is important and provide different challengesfor the occupational therapist. They are often in work when they have their stroke, theymay have young children, they may be students, they have many years ahead of themand they want to live as independently as possible. Additionally there is some researchthat indicates that the use of recreational drugs may increase the incidence of stroke in ayounger 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 thanan older patient; they will need vocational rehabilitation from the start, they will wantto know about sex after a stroke and they may suffer from a greater feeling of reductionin role. Younger stroke patients may have to make massive changes to their lives andthis can take a long time to come to terms with: changes to jobs, loss of a car, changesto hobbies, breakdowns in personal relationships, depression, and reduction in wealth aswell as any physical changes. Rehabilitation of younger stroke patients will include awide 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 upby younger people with a stroke for younger people. It provides people a number ofservices across the UK. They have a website with links to local clubs and information andthe participants are very active. As well as the rehabilitation programme, occupationaltherapists can help younger people with stroke access this website whilst in hospital, theycan introduce them to other younger people and ensure they are provided with vocationalrehabilitation. Different Strokes has been a powerful organisation at lobbing governmentto help people back to work, to improve acute care and to get exercise classes available.Lifestyle and long-term managementThe effects of having a stroke are often ongoing and therefore once patients are over theimmediate rehabilitation phase of approximately 6 months, they start looking forwardto resuming their lives as much as possible and making changes to accommodate theirnew limitations (Lincoln et al., 1998a). The National Clinical Stroke Guidelines (ISWP,2008) recommend that people with ongoing limitations after the initial rehabilitationphase should be offereda6monthlyreviewandbeprovidedwithfurtherrehabilitation ifclear goals are identified. These review sessions may highlight areas that may have beenpreviously ignored by the patient such as social participation, leisure, returning to work,transport and social support. Although occupational therapy input is essential at this timeand has been found to be beneficial in research studies (Walker et al., 2000), the mainemphasis at this point is for patients to start to plan, enquire, lead and be proactive abouttheir lives, about the information they need and how they are going to undertake activitieswithout the assistance of health professionals. This does not mean they will be on their

Resettlement 181own: they may be with family, carers or volunteers. The Internet is a mine of informationbut some of the best advice will come from other people who have had a stroke. Thiscan 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 themin categories on their website. So, for example, if a patient is worried how their stroke isaffecting the family they can listen to experiences of other people with stroke about howthey discussed the stroke with their grandchildren.Patients may have changed their lives completely; they may have been given specificadvice 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 aboutthis time, contact with most rehabilitation services will have ceased and patients mayhave been referred for ‘Exercise on Prescription’ as opposed to seeing the physiotherapistand the occupational therapist will be exploring support from tertiary organisations suchas Connect, Age Concern, The Stroke Association, Stroke Clubs. These life-changingactions happen over time and people often need support and reassurance to continue toexplore new avenues.Social participationPeople who have had a stroke often feel dependent on others, lack knowledge and withone-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 socialnetworks they had before the stroke. Occupational therapists can initiate and enablepeople to start participating in society but over time people do not want to be alwaysassociated with professionals and they move to groups more normally associated with thecommunity such as work, family, visiting friends, voluntary groups such as social clubs,luncheon clubs, hobbies and religious activities. There are vast benefits to improvingsocial participation on quality of life, personal choice, dignity and ultimately improvinghealth by easier access to health centres, better physical health through exercise, reductionin falls through improved muscle strength and balance. One complaint from people withstroke is that although there are numerous clubs, societies, hobbies groups and writteninformation about these places, people wanted someone to get them started or help themreturn after a break (Drummond and Walker, 1995). Therapists have been successful inthis role but there is no reason to believe that this role could not be undertaken by voluntaryservices, a ‘Buddy System’ or rehabilitation assistants. Whoever provides this role mustbe knowledgeable about the local facilities, be able to spend time taking the patient andthen be able to sort out transport or use of public transport. This is not a quick process.Leisure rehabilitationIt is known that participation in leisure decreases after stroke, even for patients with agood physical recovery (Drummond, 1990). The significance of this reduction lies in thefact that satisfactory leisure is related to life satisfaction. Consequently, such a decreasein leisure activity may reflect a decrease in quality of life.

182 Occupational Therapy and StrokeThere is a growing feeling that there is not enough help for patients who have had astroke 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, concludedthatthere 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 strokewith differing results (Drummond and Walker, 1995; Parker et al., 2001). In addition tothis confusion the definition of a leisure activity changes over time. Treadmill training mayappear 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 whatthey ‘do in their free time’. Some people do not always understand the term leisure soit is advisable to use the term ‘free time’ or ‘interests’ and explain what you mean inmore detail. The definition: ‘activity chosen primarily for its own sake after the practicalnecessities of life have been attended to’ (Drummond, 1990) maybe one to consider butthen 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 andwhether they would like to return to these or try new hobbies. Using a checklist to keep awritten record of what patients did before their stroke will help to identify areas of interestand 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 computeractivities such as email, Skype or on-line shopping. Look for common themes from thelist of hobbies such as sporting or crafts as this may help you suggest new ones. Therapistsshould value more common everyday activities such as reading, walking and gardeningas much as the more exciting ones. Check the most obvious limitations to participatingin hobbies such as checking if patients need new glasses or hearing aid before assessingproblems with hand function and balance. Following assessment and goal setting it maybecome apparent that the patient will need to consider trying new hobbies and the checklistcommon themes may help you make suggestions. For example, does someone like solitaryactivities, outdoor pursuits, and competitive interests? Remember when planning leisurerehabilitation not to overlook the most common everyday activities in favour of the moreexciting, eye-catching interests, many people prefer gardening, going for a walk, readingthe paper. However, also remember that those people with good physical recovery fromtheir stroke may also need assistance to get back to the more strenuous hobbies such asballroom dancing, sailing or cycling.Although this section is almost exclusively dedicated to people in the communitywhether at home or in residential care, evidence suggests that patients with a stroke spendlong periods of time in hospital doing nothing (Lincoln et al., 1989). Whilst therapists arebusy providing rehabilitation and organising a return to home, information provided onthe ward in the form of leaflets, CDs, computer programmes or visits from other peoplewho have had a stroke may spark an interest in a leisure activity that could enhance apatient’s quality of life.

Resettlement 183There are many national and local organisations that can advise and assist with leisureactivities such as gardening, art, sports, fishing, golfing and holidays. Funding is sometimesavailable for specialist one-off items. Find out what the patient’s previous occupationwas, as many jobs have Benevolent Funds. Many organisations can be found via theStroke Association and Different Strokes websites as well as via the search engines onthe 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 withparalysis 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 embroideryand knitting with equipment for one-handed use. Sometimes these are available incraft shops but also from catalogues that sell aids/adaptations.Many people are worried about flying after a stroke. Advice from the Stroke Associationstates that there is no absolute ban from flying after a stroke. However, each airline has itsown rules about who it allows on their aeroplanes. The Stroke Association suggests flyingis avoided for 2 weeks post stroke unless it is unavoidable. Oxygen pressure is lower inthe 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 bloodto thicken and thus increase the risk of blood clots forming. If possible, passengers shouldwalk or stretch legs and drink plenty of water.Travel insurance needs to be examined closely to check there are no exclusions to travelor conditions not covered. There are insurance companies who provide cover for peoplewith specific conditions/disabilities. Information is available from the websites of TheStroke Association and Different Strokes. It is advisable to inform the airline and airportof a person’s disability so that assistance can be booked in advance.Getting out of the house and transportMany leisure and social activities require transport either to get to an event or to getsupplies. However, even just getting out of the house ‘for the sake of it’ is an importantrehabilitation 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 evenafter rehabilitation (Logan et al., 2001). Community-based research has shown that peopleare unable to use information given about outdoor mobility and transport in their area as itis often given whilst they are in hospital at a time when they thought they would be ‘backto normal in a couple of days’. It may take someone months to accept that they are nevergoing to drive again. An occupational therapy outdoor mobility rehabilitation interventionhas been developed and tested in Nottingham (Logan et al., 2004). The study found thatpeople who had received the new intervention, which involved the patient practisingoutside with a therapist, were twice as likely to go out afterwards as those who had

184 Occupational Therapy and Strokereceived the routine rehabilitation programme. The routine programme was verbal adviceand written information. Further evaluation is taking place in other parts of the UK andAustralia. To replicate the intervention in your area, it is important to find rehabilitationstaff who are knowledgeable about local transport services, buses, Dial-A-Ride, taxi,voluntary transport, community services, scooter, shop mobility, trains, trams, etc. Thepatient must want to get out more often and an intervention programme must target onemain 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 backwardchaining can be used until the patient can complete the activity without the rehabilitationstaff. They do not have to be alone and in fact it may be part of the intervention to gethelp for the patient or to use extra money to use a taxi instead of owning a car. One ofthe main parts of the intervention is the repetitive practising of the task, actually goingon 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 2hours long. It may seem an intensive intervention but there is evidence that it works andevidence 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 assistanceis available, for example, at the train station when changing platforms. Discountson fares are available via the Disabled Persons Railcard and local bus passes.Two of the national breakdown services, the Automobile Association (AA) and theRoyal Automobile Association (RAC), provide information for travel with a disabilityin 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 formaton their website.There are several travel companies which provide advice or can arrange holidays fordisabled people. Some of those listed on the Internet include companies such as AccessibleTravel, Access Travel and Tourism For All. There are also specialist facilities in the UKthat provide holidays for disabled people and their families such as The Calvert Trustand The Winged Fellowship. The Stroke Association and Different Strokes can providecontact details for holidays for the disabled.Hints and tips to help improve lifestyle, leisure and transport Do not be scared of saying you have to go away and think about the problem; there isalways the chance to go back and see a patient after gathering the knowledge. Link up patients with similar hobbies and interests; many people use the Internet andemail. Encourage help and support from family and friends. Tap into local resources such asvoluntary agencies for additional help. 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.

Resettlement 185– Fishing sites for disabled fishermen.– Riding-for-the-disabled stables. Browse through specialist equipment catalogues which may give you more ideas forhobbies. Contact national organisations for local contacts if there are difficulties accessingfacilities. Funding! Consider specific charities and local groups such as the Hospital League ofFriends, and Rotary Clubs for specialist one-off items for individuals. Encourage thepatient’s family to consider buying expensive items, such as gardening equipment forBirthday 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 thehelp of others to prevent therapist boredom, then go back and review the situation.Driving after strokeCarter (2006) reported that only 30–40% of people who suffered a stroke were able toresume driving, as stroke can result in impairments in any combination of the following– memory, attention, decision making, executive functions, visual neglect, visualperception, communication, sensory and motor function. Therefore, all these functionsshould be assessed to establish an individual’s ability to return to driving. The importanceof cognitive function on driving ability was highlighted by Morris (2007) as theability to ‘perceive, assimilate, organise and manipulate information to enable reasoningand problem solving’. These skills require visual perception and executive function forthe individual to make sense of the environment. Despite this, there are no documentedstandards of cognitive function required for driving published by the Driving Vehicle LicensingAgency (DVLA) and no standardisation of assessments carried out in the DrivingAssessment Centres around the UK (Morris, 2007).After a stroke or Transient Ischaemic Attack (TIA), patients should not drive for atleast 1 month. After that, if a GP or consultant feels they are fit to drive, then theycan resume. They may assess visual and physical impairments within their surgery butcognitive ability is often overlooked. However, if the doctor does not believe they are fitto drive, then the patient must inform DVLA and their insurance company and they mustnot drive. The DVLA will send a questionnaire to the patient requesting more informationand asking permission to contact their doctor, if necessary. The DVLA base their decisionon the information patients and GP/consultant provide. They take into consideration thefollowing factors – permanent damage to vision, problems with memory, concentrationand judgement, slow reactions in an emergency, spasm in a paralysed arm which cannot becontrolled and seizures/convulsions. If the GP/consultant is unable to make the decisionabout fitness to drive or it is unclear to DVLA, they will ask a GP to independentlyassess on their behalf. If this is inconclusive, DVLA will request an assessment by a local

186 Occupational Therapy and Strokeaccredited mobility centre or, if there is not one near the patient’s home, for a free drivingtest. The assessment at an accredited mobility centre is free if DVLA arranges it. Theyassess physical, visual and cognitive aspects of driving ability. The Forum of MobilityCentres has 17 accredited centres across the UK. Their contact details are on their websiteor via freephone. They also produce a range of Ricability guides in conjunction with otherorganisations 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 decisionabout whether the patient can drive or not which can take a few months. The patient thenneeds to inform their insurance company of the decision.Research has suggested that cognitive ability plays a vital role in driving performanceafter brain damage (Nouri et al., 1987). However, there remains some uncertainty aboutwhich 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 websiterecommends that the SDSA is used as a screening tool in conjunction with other cognitiveassessments. Other therapists use different parts of standardised cognitive assessmentsto test memory, executive function, attention and visual perception. These can includesub-tests from the BADS (Wilson et al., 1996), TEA (Robertson et al., 1994), VisualObject and Space Perception Battery (VOSP) (Warrington and James, 1991) and Haylingand Brixton Tests (Burgess and Shallice, 1997). A report can be written following theseassessments and sent to the GP to give him/her further information on a patient’s abilityto drive. It is also advisable for patients to have an eye test after a stroke, particularlyfrom an optician who carries out a visual field test to look for specific impairments suchas 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 LivingAllowance or the higher rate of Attendance Allowance. In some areas, occupationaltherapists working in social services can complete the application forms with patients.The College of Occupational Therapists have also published guidance on ‘Confidentialityand a service user’s fitness to drive’ (College of Occupational Therapists, 2007,briefing no. 26).Vocational rehabilitationSurveys have found that between 40% and 75% people would like to work (Wozniak andKittner, 2002; Different Strokes, 2006). From these papers we would estimate that thereare 13 750 people under 65 years of age who want to work and then there are those over65 years of age who in the future may wish to remain in employment. Although it isimportant financially that as many people as possible can access work (stroke costs £7billion a year (National Audit Office, 2005)), it is also important that people are able toundertake education, employment, re-training and voluntary work to improve their qualityof 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

Resettlement 187defined as a process ‘whereby those disadvantaged by illness or disability can be enabledto access, maintain, or return to employment, or other useful occupation’ (Tyerman andMeehan, 2004). VR is now considered by most to be a skilled intervention techniquethat should be completed by people who are trained in this field. Occupational therapistswould seem to be the perfect profession to become experts in this type of rehabilitation butthere are also specialist companies who offer these services. The Government Departmentof Work and Pensions (DWP) is taking the lead role in VR at a national level and theBritish Society of Rehabilitation Medicine has produced a useful report called VocationalRehabilitation, 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 whowish 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 tohelp disable people select, obtain and keep jobs as well as helping employers developgood recruitment policies. These advisors have access to a number of programmes thatcan assist individuals at different stages. As well as providing a work assessment servicethey can advise on training to update and gain new skills and work opportunities ina supported environment. If the person is already in employment they will liaise withthe employer, assess the work environment and assist with the purchase of necessaryspecialised equipment. They will also support the employee back into work.Usually for people who have had a stroke, it is the rehabilitation team that assessesthe patient in the first place, seek out the relevant local support and talk to the patientabout their work. The Stroke Association’s leaflet Getting Back to Work is a good wayto introduce the topic on the hospital ward or in the community. Traditionally the initialperiod of rehabilitation following a stroke concentrated on enabling the patient to returnhome to an environment in which he/she could operate as safely and independentlyas possible. It has now been recognised that considering and responding to vocationalor work-related issues early in the rehabilitation process can be very beneficial (RoyalCollege of Physicians, 2004). It is recommended that personalised care plans that aim toget the stroke survivor fit for work are in place before the person who has had the strokeleaves hospital. These plans should be in line with pathways for return to work in place atthe 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 againstredundancy or retirement by engaging early with employers and VR programmes. Theterm work is often only associated with paid employment whereas unpaid work may beof equal importance to the individual. Unpaid work may include such areas as voluntarywork or being on a committee. Both paid and unpaid work fulfils a diversity of needs forthe individual, and some of the many benefits of work are listed below: 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.

188 Occupational Therapy and StrokeVR is having a great deal of attention at present and although the recognised programmesare directed at people with cardiac illness, mental illness and muscular–skeletaldisabilities, the principals are transferable to people who have had a stroke. In the pastoccupational therapists would have organised for the patient to take part in work experienceas near to what they would experience when they returned to work. Occupationaltherapy departments had heavy and light work shops where mock work conditions couldbe used as an assessment, for example, of standing ability, concentration, hand functionand tolerance. It is more often now that stroke patients are treated in their own homes anddo not return to out-patient departments. However, occupational therapists can still assistthe patient in establishing realistic goals and expectations towards work and produce awritten joint plan of action. They can encourage discussion with the family, carers andemployers. Most employers are happy to consider a staged return to work, employing thepatient in a different role or providing additional training or support. Contact with theemployer at an early stage is important in order to establish links. The patient may wishto do this or may need assistance from the rehabilitation team.However, entering the paid work environment may not always be realistic, feasible ordesired 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 positionsare available and how appropriate they are to the individual. Again the components of thetasks to be undertaken need to be analysed and a plan of action made. Many people whohave had a stroke will take some time to get back to work and they may be assessed withthe Personal Capability Assessment (DWP, 2007) to test their long-term incapacity forwork for social security. The occupational therapist may need to be involved as they aremost likely to know the impairments of individual people who have had a stroke.Resuming sexual activityAs rehabilitation of stroke patients constantly improves, many new techniques developbut some activities are often neglected because of lack of research, lack or rehabilitationknowledge or because patients themselves do not wish to raise the subject. One such areais a return to their normal sexual activity. Generally, this is not routinely discussed withpatients as part of their rehabilitation, although for many, it plays an important role intheir life and discussion should be included in the assessment process.There is some information in stroke books, but this is not always readily available tothe patient and their partner and the information is not always applicable to their specificneeds. The Stroke Association can provide a leaflet, entitled “Sex after Stroke” Fact sheet31 which can be downloaded from their website which includes the main points identifiedby patients and partners. This leaflet should be made available to all stroke patients andtheir partners both in hospital and in the community and may initiate a conversation aboutsexual 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 thisdecline: physical changes in the brain that may reduce the sexual urge; physical changesto the body that may make it difficult to move; psychological changes that make people

Resettlement 189not want to have sex. Stroke can cause physical limitations that influence body positioningand movement during sex which can lead to a reduction in sexual activity, misery andfrustration. Other physical changes such as incontinence, drooling, emotional liabilitymay 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 myocardialinfarction then little changed after stroke; this may be because pre-existing vasculardisorders had already caused erectile difficulties or because the antihypertensive agentscommonly given to stroke patients inhibit erections, or because some medications suchas beta-blockers also reduce desire. As well as physical difficulties, psychosocial impairmentsand depression may affect the will to engage in sexual relationships; however, thesemay not be recorded till late after stroke as patients may be unwilling to talk about sexualdifficulties. Mood disorders, such as depression and anxiety are commonly observed aftera 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 resumingsexual activity will cause another stroke or epileptic fit and do not know whom to approachfor 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 anotherstroke. Other reasons for not continuing in sexual activity include lack of interest ormotivation from one or both of the couple; physical incapacity of the patient; difficultygetting in a comfortable position for both of the couple; difficulty getting their partneraroused and difficulties due to sensory impairments on the patient’s affected side(Edmans, 1998). Patients and partners reported that they would have liked to receiveinformation on why problems occurred in resuming sexual activity after a stroke andhow long they were likely to last. Some also reported that they would have liked there tobe more opportunity to discuss their fears and problems, especially after discharge fromhospital.Sexual activity is a subject which is important to both patients and partners, and shouldbe included in stroke rehabilitation. However, despite this, it is still not clear cut thisshould be part of whose role or whether it should be part of the role of all staff involved inthe rehabilitation of stroke patients. Patients and partners should have the opportunity tochoose who they wish to undertake this role. Occupational therapists are often approachedto discuss sexual activity whilst they are dealing with other personal activities of dailyliving. This chance to contribute to part of patient’s lives often ignored, should be embracedwith knowledge and understanding.Patients and partners need to know that returning to their normal sexual activity isconsidered routinely as an aspect of stroke rehabilitation. They also need to know there isthe opportunity to discuss their sexual activity either alone or in couples, at a time whichis appropriate to their needs.Stroke educationThe National Stroke Strategy (DH, 2007) recommends a range of programmes to supportself-management skills after stroke to reduce long-term care costs. Information is also

190 Occupational Therapy and Strokeavailable in ‘Supporting People with Long-Term Conditions to Self-Care: A Guide toDeveloping Local Strategies and Good Practice’ (DH, 2006).Patients and carers’ understanding of stroke is often quite poor. Information is availablefrom The Stroke Association, Chest Heart and Stroke Scotland and Northern IrelandChest, Heart and Stroke Association. Occupational therapists can play an important rolein educating patients about their disability, its causes and long-term effects, both on aformal and informal basis. The aim is to provide information and to empower patients byallowing 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 providinginformation, 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 throughoutpatients’ period of rehabilitation.Some rehabilitation services run their own educational programmes for patients and/orcarers on topics such as what a stroke is and its effects. The content of these variesaccording to the type of unit or service the patients are attending. There is an organisationcalled ‘steppingoutuk’ which runs formal educational programmes over a set number ofsessions for patients and carers. They offer training to health care professionals to runcourses locally. More information is available from their website.A wide variety of educational information for patients and family about stroke isavailable from the two main charities, The Stroke Association and Different Strokes, viathe Internet and in paper format. Some of the Stroke Association leaflets are available inother languages.Local support groups can also be a source of information for patients, usually on amore informal basis. The Stroke Association and Different Strokes have groups in mostareas of the UK.Self-evaluation questions1. 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 strokecare.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 astroke?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?

Chapter 10EvaluationFiona Coupar and Judi EdmansThis chapter includes: Record keeping Standardised assessments Evidence-based practice Outcome measures Standards Audit Self-evaluation questionsRecord keepingThe Public Records Act 1958 (Public Records Office, 1958) states that a medical recordis anything that has been created or gathered as a result of the work of a health careprofessional; it is a compilation of data.The following are all considered as part of a medical record: Register. Prescription, drug chart. Diary. X-ray. Audio, video, dvd. Rough notes.The purpose of record keeping is to: 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. Assist in the continuity of care. Provide written evidence that a service has been delivered (Quantum Development,2003).

192 Occupational Therapy and StrokeMost complaints within the NHS are made due to the failure in communication. Toensure patient care is not flawed and communication improved, good record keeping isan 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 theoriginal test is not erased, additions should be separately dated, signed and timed.In addition the occupational therapist needs to record any leaflets or pamphlets givenand thank you cards/letters should be kept as evidence of satisfaction at the time. Ifleaflets are updated, old ones should be kept and all policies/standards and checklistsachieved.Within a complaint or claim the occupational therapy records are your defence, rememberthe 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. Thestandards also provide an audit tool to enable individuals to measure their practice andmake any improvements as necessary. The record keeping standard includes:Professional recordsEach 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 aresigned and dated by the occupational therapist.All entries must be signed and dated by an occupational therapist and student/supportstaff entries countersigned. Occupational therapy staff should also be aware of localpolicies on record keeping and if electronic records are used staff must be aware of anyguidance on use of the system.ContentThe record should contain all information clearly identifying the patient, reason forreferral other relevant professionals, medical and social history including the views ofthe patient and carers. The record must contain information on the occupational therapyassessment, goals and interventions (including any other relevant information from themultidisciplinary team). All reports and correspondence including work with carers willbe documented. A discharge summary should be included regarding outcomes and anyfuture arrangements.AccessPatients may have access to their records in accordance with legislation and the organisation’spolicy. All records must be written in an understandable manner for those whowill have legitimate access to them; these records must be available if required in anenquiry.

Evaluation 193Confidentiality – storage and disposalAll 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 storedseparately. All records must be kept for no less than that for NHS records for the equivalentpatient group.Methods of recording occupational therapy interventionOccupational therapy case notes can take many forms across a variety of clinical settings.They can either be unidisciplinary or multidisciplinary. Three of the most commonlyused are: problem-orientated medical records, goal-directed notes and integrated carepathways.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 dischargesummary. The database contains personal and medical information about thepatient. The problem list numbers the specific problems to be addressed by the occupationaltherapist. The progress notes are only recorded when there is a change or there issome relevant information to be added. Progress is recorded under the headings:Subjective – Information obtained from the patient, family or another health careprofessional.Objective – The therapist’s clinical observations and results of assessments-measures.Analysis – The therapist’s professional opinion of what happened during an interventionsession.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 informationon personal/domestic activities of daily living, mobility, transfers, cognition,perception, communication, upper limb function, current problems and future care.Goal-directed notesThere are many types of goal-directed notes used by occupational therapists on a unidisciplinaryand multidisciplinary basis. Goal setting is now commonly used in strokerehabilitation within the multidisciplinary team. Goal planning should actively involvethe patient and family/carers. Once the multidisciplinary team has completed their specificassessments, the patient’s problems and needs can be identified, focusing on theirstrengths rather than their weaknesses. Long-term and short-term goals can be set. A

194 Occupational Therapy and Strokegoal 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? (Whatis 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 toachieve the goal.)4. How well? What defines a successful outcome? How well is the client expected toachieve the task? What level/frequency of physical assistance or verbal prompting isacceptable?5. By when? In what time frame?The outcome of a goal can be scored in three possible ways – achieved, partiallyachieved or not achieved. If the outcome is one of the latter two, then a variance code canbe applied to explain the reasons why this is the case. These can include issues relating tothe 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 communicationproblems. ACTOR (activity, patient’s observations, therapist’s observations,overall evaluation, re-planning) headings are used for the progress notes. Activity includesthe facts of the activity. Patients’ observations are their subjective comments. Therapists’observations are objective comments on the therapy carried out. Overall evaluation is theanalysis of intervention. Finally, re-planning is the future plan, which has been set as aresult of the intervention session.Integrated care pathwaysIntegrated care pathways are a well-established method of recording care on a multidisciplinarybasis with patients following hip replacement or fractured neck of femur. Theyhave also been used in the care of patients following myocardial infarction and a varietyof surgical and gynaecological procedures. This form of documentation is now being usedby multidisciplinary teams treating patients following stroke.An integrated care pathway is a record of care that focuses on agreed interventionand expected outcomes for a given patient diagnosis, symptom or procedure, withinan identified time frame. It should be developed and written by the multidisciplinaryteam involved with the delivery of care to the patient. All professionals involved shouldhave common understandings and ownership of the pathway. Outcomes must be agreed,achievable and evaluated at every stage. The documentation replaces all existing notesused by each profession. An integrated care pathway focuses on the ‘routine’ rather thanthe exception. When a detour from the care pathway occurs, a variance code is recorded.

Evaluation 195The four codes relate to the patient’s condition, the patient/family circumstances, theclinical and the internal/external system.In order for the implementation of an integrated care pathway to be successful, a totalreview 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 managementtool.An example of an integrated care pathway for stroke rehabilitation on the NottinghamStroke Unit has previously been published (Edmans et al., 1997).Pros and cons of multidisciplinary joint documentationPositive aspects of joint documentation Reduces duplication of notes, for example, front sheets/database, medical history, socialhistory, case conference information, family case conference information, dischargeplans, washing and dressing, bathing, transfers, walking, home visits, etc., as only oneset of notes written. Easier access to each others’ notes as only one set and therefore in one place, that is,centralises all information about the patient. Improves communication as information written in one place by all of the multidisciplinaryteam. One comprehensive set of notes. Improves goal setting as goals set weekly at case conference. Less repetition of staff asking patients for the same information. More focused care planning. Improves handover of information between disciplines. More coordinated discharge. OVERALL EACH PERSON SHOULD WRITE LESS NOT MORE.Negative aspects of joint documentation Difficulty storing records in an accessible place for all professionals to gain access tostaff wanting to write in notes at the same time. Fear that detail of each professional’s input will be lost, such as information confidentialto a single discipline, for example, psychologists.Standardised assessmentsThe use of standardised assessments (whether screening or detailed) will indicate thetype(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

196 Occupational Therapy and Stroketo 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 anestablished procedure for administration and scoring with normative data available forcomparison.A thorough assessment using both standardised assessment and functional assessmentwill inform and direct the nature of the intervention required.Pre-assessment checksPrior to conducting a standardised assessment, it is important to consider other modalitiesthat may impact on the patient’s ability to complete the assessment. For example, if apatient has difficulty with any of the following, they may achieve lower scores on theassessment, due to impairments other than what is being assessed: Vision– Acuity – clarity of vision.– Ocular motor skills – ability to move eyes.– Visual fields. Hearing. Attention. Memory. Motivation and engagement.Choosing assessmentsWhen choosing which assessments to use, it is also important to consider: The population involved in the standardisation of the assessment (i.e. was it standardisedwith patients after stroke or other conditions, of what age and in what setting). Who is permitted to administer the assessment (some assessments can only be administeredby psychologists). Whether there is evidence of validity and reliability with norms for comparison. How easy it is to administer and score the assessment. Whether any pre-training is needed to use the assessment. How easy it is to transport the assessment. How much space and time is needed to administer the assessment. The balance between the advantages and disadvantages of the assessment.Test administrationPrior to assessing patients using standardised assessments, it is recommended to: 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.

Evaluation 197 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 assessmentsWhen analysing the assessment results, consider whether there was evidence of any ofthe following during the assessment, which may have affected the patient’s performance: Comprehension. Concentration. Reasoning (executive function). Memory. Anxiety. Depression. Initiation. Apraxia. Hemianopia.Differential diagnosesA 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 outwhat performance component has been affected by the stroke or what the key impairmentis. However, some key impairments to look out for, which are often incorrectly identified,are discussed below.Poor initiationConsider aspects such as memory of the task, selective attention, difficulty conceptualisingthe task, unable to recognise the environment or objects, poor planning, apraxia.Poor memory/getting lostConsider attention to information, aphasia (comprehension or expressive capacity), visualimpairments, visual inattention.Use of objectsConsider occipital lobe impairments, that is, affects of reduced information regardingtexture, shape, colour, contrast, visual field impairments, visual inattention (not pickingup sufficient information about the object for usage), agnosia, ideational apraxia.

198 Occupational Therapy and StrokeBehavioural issuesPerceptual impairments (the environment may not make sense to the patient so they do notknow 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 puttogether a full picture of the patient, before making sweeping statements or labellingimpairments.Useful assessmentsIntervention and effectiveness Assessment of Motor and Process Skills (AMPS) (Fisher, 2006). Canadian Occupational Performance Measure (COPM) (Law et al., 2005).Motor performance Motricity Index (Collin and Wade, 1990). Rivermead Motor Assessment (Lincoln and Leadbitter, 1979). Nine-hole Peg Test (Kellor et al., 1971).Activities of daily living 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 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 AssessmentBattery (COTNAB) (Tyerman et al., 1986).Attention Test of Everyday Attention (TEA) (Robertson et al., 1994).Cognition COTNAB (Tyerman et al., 1986). Cognitive Assessment of Minnesota (CAM) (Rustard et al., 1993).

Evaluation 199 Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) (Itzkovich et al.,1993). Middlesex Elderly Assessment of Mental State (MEAMS) (Golding, 1989). Mini-Mental Status Examination (MMSE) (Folstein et al., 1975). SF-36 (generic health status measure) (Garratt et al., 1993).Memory Doors and People (Baddeley et al., 1994). Rivermead Behavioural Memory Test (RBMT3) (Wilson et al., 2008).Apraxia Kertesz Apraxia Test (Kertesz and Ferro, 1984).Executive functions Behavioural Assessment of the Dysexecutive Syndrome (BADS) (Wilson et al., 1996). Hayling and Brixton Tests (Burgess and Shallice, 1997).Perception 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 andEdmans, 1989). Visual Object and Space Perception Battery (VOSP) (Warrington and James, 1991).Anxiety and depression 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 Stroke Drivers Screening Assessment (Nouri and Lincoln, 1994).Evidence-based practice (EBP)Evidence-based medicine/practice is defined as the ‘...conscientious, explicit, and judicioususe of current best evidence in making decisions about the care of individual

200 Occupational Therapy and Strokepatients’ (Sackett et al., 1996). This process involves combining best existing researchevidence, clinical reasoning and patient choice (Haynes et al., 2002).Why do we need evidence-based practice? To ensure the greatest health gain from the available resources. To ensure decisions about clinical services and interventions are driven by evidence ofefficacy and cost effectiveness. Personal experience and expertise can be misleading. To ensure the provision of up-to-date interventions as clinical practice risks becomingrapidly out of date. To provide effective and efficient interventions.Stages of evidence-based practiceEBP has a number of key stages:1. Formulate a clear, relevant and focused question.2. Search for research evidence.3. Appraise the identified evidence.4. 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 questionEBP always begin with identification of a particular problem or query. In order to completeEBP, this problem or query should be developed into a clear, focused and well-structuredquestion. This can be achieved using the PICO structure:P – Patient or problemI – InterventionC – Comparison interventionO – OutcomeFor example, an occupational therapist may have a query relating to the effectivenessof 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 safedischarge for stroke patients? A clear, relevant and focused question makes the subsequentstages of EBP more straightforward. Once you have formed the question, you can thinkabout 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 affectthe type of research evidence that will provide the best answer and therefore the type ofevidence that you want to search for.

Evaluation 201Searching for the best evidenceChoosing the right evidence is of fundamental importance. There are several sources ofevidence that you may consider using, to answer your question(s); people, textbooks, scientificliterature and pre-appraised or secondary sources. Asking colleagues is convenientand accessible; however, their knowledge may not be evidence-based and they cannotgive an answer to every question. Textbooks provide good background information, butare often out of date. Therefore evidence from scientific literature and/or pre-appraised orsecondary sources is often required to answer clinical questions. When considering theevidence it is helpful to consider levels of evidence.Levels of evidenceEvidence comes in many forms and varies in quality. Depending on the type of questionbeing 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 relatingto different study designs and highlights the advantages and disadvantages of each studytype.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 RCTsRandomised controlled trialCohort studiesCase-control studiesCase seriesExpert opinionRandomised controlled trials and the systematic review of several randomised controlledtrials are methods which are likely to tell us the effectiveness of a therapy interventionand have become the ‘gold standard’ for judging whether an intervention is beneficialor harmful (Sackett et al., 1996).Secondary sources of evidence are commonly considered to be the highest form ofevidence, with expert opinion generally agreed to be the weakest level of evidence.Secondary or pre-appraised sources of evidence include: Guidelines: For example, RCP stroke guidelines, SIGN 64, European Stroke Organisation(ESO) guidelines. Evidence-based summaries: For example, Bandolier, Clinical Evidence, Health technologyassessments (HTA). Systematic reviews: For example, Cochrane Library.If a question cannot be answered using secondary sources, primary literature should besearched for. Primary sources of research evidence relates to scientific literature reportingprimary studies. The most efficient method of locating scientific literature is throughsearching bibliographic databases such as Medline, Embase or CINAHL. Hand searchingmay supplement this process, as some relevant journals may not be indexed within these

202 Occupational Therapy and Strokedatabases. Searching the literature can be daunting; however, librarians are experts insearching and can assist in locating the appropriate evidence.If no appropriate randomised controlled trials are available to answer a particularquestion, evidence from less robust studies, further down the hierarchy of evidence (cohortstudies/case-controlled studies/case studies/anecdotal evidence) becomes the sources ofevidence. It is important to remember that the lower down the hierarchy, the less reliablethe evidence. Many areas of occupational therapy are still under-researched and thereforeit may be possible that no good quality evidence exists to answer a particular question, inwhich case professional judgement has to be relied upon. However, it must be rememberedthat lack of evidence is not evidence of no effect.Appraising the identified evidenceCritical appraisal is the next essential component of EBP and involves assessing andinterpreting evidence. It involves considering the evidence in terms of its validity, resultsand clinical relevance. Different study designs require different questions to be askedto assess the validity and applicability of the evidence. The Centre for Evidence-BasedMedicine and Public Health Resource Unit (PHRU) have examples of critical appraisalquestions for different study designs.The three questions that generally need to be asked for all study designs are as follows: Are the results of the study valid? What are the results? Are the results applicable to own clinical practice?Examples of specific questions relating to randomised controlled trials are as follows:Questions relating to validity 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 thegroup to which they were randomised? Were outcome measures objective or were the assessors and clinicians kept ‘blind’ towhich group each participant was in?Questions relating to the results What are the results? How precise are the results? Do you believe the results?

Evaluation 203Questions relating to applicability Can the results be applied to the local population? Is the intervention feasible to my setting? Do the results of this study fit with other available evidence?Implementing findings into clinical practice and evaluating outcomesFollowing critical appraisal and a decision that the evidence is valid and applicable, thisevidence should then be implemented. The challenge is to apply EBP at the right time, inthe right place and in the right way. However, implementing evidence into practice is noteasy and a number of difficulties have been identified, including size and complexity ofresearch, developing evidence-based clinical policy, applying evidence due to poor accessto best evidence and guidelines, organisational barriers and low patient compliance withinterventions (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 practicecomplies with the current evidence. If practices are not concurrent with the evidencewhat barriers can you identify to implementing the evidence? These barriers may includelimited resources, lack of knowledge and abilities and patient preferences. How mightthese be overcome? If we are to offer the most effective interventions then it is essentialthat 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 howrecommendations from the evidence may be implemented; for example, pulling togethera group of individuals from different professions to assist in breaking down barriers andbringing about change. Bringing about change is not easy and a number of barriers stillexist; however, bridging the barriers between research evidence and clinical decisionmaking is essential. A number of incentives such as accurate summaries of evidence andguidelines assist in breaking down these barriers.Once research evidence is implemented it is vital that the impact of this is evaluatedusing relevant outcomes.Outcome measuresThe consequences of stroke on an individual’s functioning are often complex and varied innature. Stroke not only effects neurological functioning, for example, movement/speechbut may also lead to a dependence in activities of daily living and cognitive and perceptualdifficulties.To enable effective clinical stroke management and research, careful assessment andevaluation of functioning is essential. To reflect the complex and varied nature of difficultiesencountered after stroke, numerous outcome measures exist to assess the impact andoutcome of stroke (Geyh et al., 2004).

204 Occupational Therapy and StrokeOutcome measures are tools or instruments used to quantify the change in a patient dueto 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 determiningtherapeutic effectiveness and therefore is central to the provision of EBP (Van der Puttenet al., 1999).Outcome measures can be classified as condition specific, for example, National Institutefor 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 accordingto the three categories; body function/structure, activity and participation, within theInternational 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 10.1Categorisation of outcome measures within the ICF.Body functions andstructures Activities Participation• Beck DepressionInventory• Behavioural InattentionTest• Canadian NeurologicalScale• Action Research Arm • Canadian OccupationalTest• Barthel Index • Performance Measure• Berg Balance Scale • London Handicap Scale• Clock Drawing Test • Box and Block Test • Medical Outcomes StudyShort-Form 36• Fugl–MeyerAssessment• General HealthQuestionnaire 28• Geriatric DepressionScale• Hospital Anxiety andDepression Scale• Mini Mental StateExamination• Modified AshworthScale• Motor Free VisualPerception Test• National Institutes ofHealth Stroke Scale• Orpington PrognosticScale• Chedoke McMasterStroke Assessment Scale• Clinical OutcomeVariables Scale• Functional AmbulationCategories• Functional IndependenceMeasure• Nottingham Health Profile• Reintegration to NormalLiving Index• Stroke Adapted SicknessImpact Profile• Stroke Impact Scale• Frenchay Activities Index • Stroke Specific Quality ofLife• Motor Assessment Scale• Nine-hole Peg Test• Rankin Handicap Scale• Rivermead Mobility Scale• Timed Up and GoPresented in Salter et al. (2008) – table based on that presented in Roberts and Counsell (1998) andDuncan et al. (2000). (Reproduced with permission from EBRSR: Evidence-Based Review of StrokeRehabilitation.)

Evaluation 205Table 10.2CriteriaDefinitions of psychometric properties of a measure.DefinitionAppropriatenessReliabilityValiditySensitivity/responsivenessClinical usefulnessClinical feasibilityThe match of the measure to the purpose/question understudy. It must be decided what information is required andwhat use will be made of the information gathered (Wade,1992)The ability of the measure to achieve the same result, if noreal change has occurred. Reliability refers to thereproducibility and internal consistency of the measure, i.e.can the measure be repeated and achieve the same results?Reproducibility – concepts such as test–retest andinterobserver reliabilityThe ability to measure what it is intended to measure. Thereare different types of validity, including face, content,construct and criterion. The validity of a measure can bedifficult to determineThe 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 whichany improvement or deterioration will be identifiedHow useful is the measure in terms of providing a meaningfulscore, i.e. meaningful for patient and therapistHow feasible is the measure in terms of effort, burden,expense and disruptionAdapted from table in Salter et al. (2008). (Reproduced with permission from EBRSR: Evidence-BasedReview of Stroke Rehabilitation.)In addition to understanding what construct an outcome measure aims to assess, it isalso necessary to evaluate the measure in terms of appropriateness, validity, reliability,sensitivity, specificity, clinical usefulness and feasibility in order to inform choice ofoutcome 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 outlinedin Table 10.2.Other considerationsStandardised and non-standardised outcome measures – Standardised outcome measureshave specified, standardised procedures for completion and scoring. These measures willusually have been tested for validity and reliability to ensure consistency in applicationof the measure. Additionally many measures will have been normatively standardised forscoring, over large populations. This means that therapists can compare patients’ scoresagainst a normal range and to other patients with similar conditions. Non-standardisedoutcome measures have not been subjected to the same rigorous testing procedure andare therefore often of poor quality, and generalisation of scores from non-standardisedmeasures is problematic.

206 Occupational Therapy and StrokeUse 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 toevaluate their own practices but also to inform and motivate patients and carers andprovide feedback to the multidisciplinary team.StandardsThe College of Occupational Therapists (2000a) define the following terms:‘Clinical standards are broad statements which relate to the organisation and delivery ofservices (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 auditingservices.A standard is a key aim, and contains various criteria that must be met. It is taken that eachstandard is only achieved when all of the criteria have been met. It is therefore crucial that thecriteria 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 performancemeets 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 SpecialistSection Neurological Practice and the Royal College of Physicians Profession SpecificStroke Audit group, provide the framework for evaluation of occupational therapy strokeservices: Occupational Therapy Standards for Stroke Second Edition (Royal College of Physiciansand College of Occupational Therapists, 2008) – based on the National ClinicalGuidelines for Stroke 3rd Edition. Profession Specific Stroke Audit Occupational Therapy Clinical Audit (Royal Collegeof Physicians Profession Specific Stroke Audit group, 2007a) – to audit the standards. Profession Specific Stroke Audit Organisational Audit (Royal College of PhysiciansProfession Specific Stroke Audit group, 2007b) – to audit the standards.These three documents are all available from the College of Occupational TherapistsSpecialist Section Neurological Practice.

Evaluation 207Self-evaluation questions1. Describe what a medical record is, its purpose and requirements.2. Describe the different methods that can be used to record occupational therapy interventionand 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?

Appendix: One-Handed TechniquesSELF-CARE ACTIVITIESWashingPutting soap onto flannelWringing out flannelPutting toothpaste ontoothbrushOpening tube oftoothpaste/hand cream, etc.Cleaning denturesShavingCleaning nailsBathing/showeringGetting in/out of bathWashing back in bathWashing back in showerScrubbing backDrying backPutting talc onPut soap in a soap dish or on a dry cloth and wipe theflannel over the soap, use liquid soap dispenser or putshower gel in the waterPut flannel round tap and twist ends of flannel togetherpulling flannel tight or use a small flannel and squeeze itout with one handPut toothbrush on a hard surface with the bristles pointingup, then put toothpaste on it. Alternatively, hold thetoothbrush handle in the mouth then put toothpaste on itwith the unaffected hand. Flip top lids or pump actiontoothpaste dispensers may be easier than screw topsWedge tube between knees or teeth or against solid, fixedobjects and unscrew top with sound handWash dentures in the washbasin, by wedging them in theplughole or use a suction nail brush stuck to the side of thewash basin, or soak dentures in sterident overnightElectric razor is the easiest and safest methodUse suction nail brush/fileUse bath board and seat with non-slip mat, grab rails mayalso be usefulPut shower gel in bath water and use plastic jug to tipwater over selfTip shower gel on back of shoulders and water will wash itdown backUse a long-handled sponge or loofaPut loop tag onto one end of towel and attach this to ahook/similar to fix one end of towel, pull taut across back.Alternatively, put on a terry-towelling robe after washingHold talc container between legs to open it, hold top end oftalc container and tip it into hand, tip powder into smallbowl and use powder puff or tip powder onto towel and pattowel with talc onto body

Appendix 209Dressing (see Chapter 5, Figures 5.13–5.15)Putting on bra/vest/jumper/dress/shirt/blouse/cardigan/skirtBrasAlternative method forputting on a shirt/blousePutting on tieLay garment on knees with the back uppermost, neckfurthest away from body and the sleeves hanging down theoutside of each leg, put affected arm down the sleeve andpull the sleeve up past elbow, put sound arm into the othersleeve and pull the jumper, etc. over headBras can be put on as shown above, provided they areelasticated and are fastened up first; alternatively, they canbe adapted with Velcro to be front opening or use a loosersupport/sports braLay garment on knees with the inside of the shirt/blouse,etc. uppermost and the neck/collar nearest body, and thesleeves hanging down the outside of each leg, put affectedarm down the sleeve and pull the sleeve up past elbow, putsound arm into the other sleeve and pull the jumper, etc.over heada Tuck the narrow end of the tie in the top of the trousers.This secures the tie at that endb Wrap the tie round in the normal manner to make theknot and pull down into positionRemoving all uppergarmentsPutting on pants/trousers/socks/stockings/shoesPulling up trouser zipsPutting on socksTying shoe lacesAlternatively, leave the tie knot made up and loosen tieslightly to put on or take off over head. If all else fails, tiescan be bought with ‘ready-made’ knotsGather each garment up from the back of the neck andpull it over head, then take arms out of garmentCross affected leg over sound leg and lean forwards to puteach garment over affected foot. Uncross legs and reachdown to put the garment over the sound foot. If unable tomaintain sitting balance whilst moving the sound foot offthe ground, keep the sound heel on the ground, whileputting garments over the sound toes, then keep thesound toes on the ground while pulling the garment roundthe sound heelHold zip end between thumb and index finger and pushaway from lower end of zip by holding lower end of zip tautwith middle, ring and little fingersOpen aperture with span of hand, reach down and placeover toesa Tie a knot at one end of the lace and thread it througheyelets. This secures the lace at that end. If the personis able to use their right hand, start threading the lacewith the knot on the left, and if the person is able to usetheir left hand, start threading the lace with the knot onthe rightb Pull the lace through as tight as is comfortable and loopthe free end of the lace over the last piece of threadedlace. The smaller the loop is made, the tighter the lacewill be

210 Occupational Therapy and Strokec Make a second loop with the free end of the lace thenpass it under the last piece of threaded lace andthrough the first loop. The smaller the loop is made, thetighter the lace will bed Pull the loop to the outside of the shoe to tighten ite A second loop can be made (optional) by putting thumband index finger through the loop. The second loop ismade by picking up another piece of the loose end ofthe lacef The second loop can be pulled through in the same wayas the first loopg The excess lace can be tucked down inside the shoe atthe side of the footh Alternatively, the excess lace can be threaded throughthe lace on the top of the shoeIf unable to tie laces, springer lacers, no-bows or elasticlaces may be usedLoose fitting and stretchy fabrics make the task easierAdaptations may be made to garment with Velcro to provide wider openings or a longcord attached to zip fastenings to enable them to be pulled upINSTRUMENTAL ACTIVITIESMeal timesCutting up foodA variety of special cutlery is available, e.g. rockerknife/cheese knife and non-slip mat under plateStopping food moving off the Use plate guard or plate with a lipplateButtering breadUse buttering board with non-slip mat underneath to holdbread steadyKitchen activitiesStabilising objectCutting up foodOpening containersCarrying itemsMeal preparationCleaning and laundryHanging up washingReaching for objectsPickingupitemsfromthefloorMoving items aroundUse non-slip mat, pan holder on the stove, spike board,buttering board, belliclamp or wedge against solid, fixedobjects. A damp jay cloth also works well as a non-slip matUse spiked chopping boards, food processors or adaptedknivesUse electric tin openers, mounted tin or jar openers,belliclamp or wedge object between knees, etc.Use trolley or one-handed trayThere are many pieces of equipment available to assist,e.g. spike board/vices to hold vegetables whilst peeling orchopping themLower the wash line, throw item over wash line and thenattach pegs or put pegs on first and then over wash line,then raise the line. Alternatively, use clothes drierLong-handled tools facilitate ease of reachUse an ‘Easy-Reach’, ‘Pick Up Stick’ or ‘Helping Hand’Use kitchen trolleys

Appendix 211HouseholdStopping telephone, etc.movingWritingThreading needleHolding playing cardsReading a bookPut non-slip mat under telephone to stop it movingPaper weight or heavy object to hold paper in place or usespring clipboardPut needle into pincushion to hold it whilst threading or buysolid block needle threaderUse scrubbing brush/men’s hairbrush, lay on its back andstand cards in the bristles of the brushSit at a table with book open on the table, have a tray onyour knee and hold book open on the tray or buy a bookrest

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DefinitionsAgnosia: Inability to recognise familiar objects perceived by the senses.Aphasia: Difficulty understanding language and/or expressing self – as a result of a braininjury.Apraxia: Inability to perform certain skilled purposeful movements despite having intactthe relevant motor, sensory and coordination functions.Ataxia: Loss of coordination and smooth interplay between muscles in the cerebellumdue 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 changesand prolonged positioning in a fixed posture.Dysarthria: Weakness or incoordination of the speech muscles, which prevents clearpronunciation of words.Dysphagia: Difficulty swallowing.Dystonia: Asymmetry of involuntary contracting muscles, resulting in unusual contortionsof the body.Flaccidity: Absence of normal tension (tone) in the muscles.Hemianopia: Damage to the part of the brain which interprets visual information, resultingin blindness of part of the visual field, although the patient’s eyes and optic tractsare undamaged.Hemiplegia: Paralysis affecting one side of the body.Heterotrophic ossification: Appearance of bone in soft tissues – often occurring inlarge joints, i.e. elbow, knee, ankle, in patients with severe brain injury and prolongedunconsciousness.Liability: Decreased ability to moderate the expression of emotion, e.g. person mightburst into tears without feeling sad, or may laugh inappropriately in an upsettingsituation.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.

230 Occupational Therapy and StrokeSpasticity: 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 leftside of the body or the left side of the environment.

Useful BooksAda 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 MedicalBooks Ltd.Bobath B. (1986) Abnormal Postural Reflex Activity Caused by Brain Lesions. London: HeinemannMedical 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: HeinemannPhysiotherapy.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 ChurchillLivingstone.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: BlackwellPublishing Ltd.Hagedorn R. (1995) Occupational Therapy: Perspectives and Processes. Edinburgh: ChurchillLivingstone.Halligan P, Wade D. (2007) Effectiveness of Rehabilitation for Cognitive Deficits. Oxford: OxfordUniversity 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.

232 Occupational Therapy and StrokeLezak MD. (1995) Neuropsychological Assessment. New York: Oxford University Press.Miller E. (1985) Recovery and Management of Neuropsychological Impairments. Chichester: JohnWiley 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 OccupationalTherapists. 2nd edn. Thorofare, New Jersey: Slack Incorporated.Sohlberg M, Mateer C. (1989) Introduction in Cognitive Rehabilitation Theory and Practice. NewYork: 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 MedicalPublications.Wade DT. (1992) Measurement in Neurological Rehabilitation. Oxford: Oxford MedicalPublications.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 ofthe Adult with Acquired Brain Injury. 4th edn. Thorofare, New Jersey: Slack Incorporated.

Useful OrganisationsWe have included a list of useful organisations but cannot guarantee that their addressesor websites will not change over time.Occupational therapyCollege of Occupational Therapists106-114 Borough High StreetSouthwarkLondonSE1 1LBEnglandwww.cot.co.ukSpecialist Section Neurological Practice106-114 Borough High StreetSouthwarkLondonSE1 1LBEnglandwww.cot.co.uk/Homepage/Specialist Sections/COTSS - Neurological PracticeStrokeThe Stroke AssociationStroke House240 City RoadLondonEC1V 2PREnglandwww.stroke.org.uk

234 Occupational Therapy and StrokeChest, Heart and Stroke Scotland65 North Castle StreetEdinburghEH2 3LTScotlandwww.chss.org.ukNorthern Ireland Chest, Heart and Stroke Association21 Dublin RoadBelfastBT2 7HBNorthern Irelandwww.nichsa.comDifferent StrokesCentral Services9 Canon Harnett CourtWolverton MillMilton KeynesMK12 5NFEnglandwww.differentstrokes.co.ukAge Concernwww.ageconcern.org.ukHelp the Agedwww.helptheaged.org.ukPoliciesWorld Health Organizationwww.who.intDepartment of Healthwww.dh.gov.uk

Useful Organisations 235Royal College of Physicians11 St Andrews PlaceRegents ParkLondonNW1 4LEEnglandwww.rcplondon.ac.ukScottish Intercollegiate Guidelines Networkwww.sign.ac.ukScottish Governmentwww.scotland.gov.ukScottish Health on the Web (SHOW)www.show.scot.nhs.ukWelsh Assembly Governmentwww.wales.gov.ukStroke Services Improvement Plan – Waleshttp://new.wales.gov.uk/topics/health/publications/health/circulars/2007/whc2007082?lang=enDepartment of Health, Social Services and Public Safety, Northern Irelandwww.dhsspsni.gov.uk/European Stroke Organisation (ESO)www.eso-stroke.orgSkills for Health2nd FloorGoldsmiths HouseBroad PlainBristolBS2 0JPEnglandwww.skillsforhealth.org.uk

236 Occupational Therapy and StrokeStroke Competencieswww.nes.scot.nhs.ukStroke Training and Awareness Resources (STARS)www.strokecorecompetencies.orgEvidence-Based PracticeBandolier – www.medicine.ox.ac.uk/bandolierClinical evidence – http://clinicalevidence.bmj.com/ceweb/index.jspHealth technology assessment – www.ncchta.orgCochrane library – www.thecochranelibrary.orgCritical appraisal skills programme – www.phru.nhs.uk/Pages/PHD/CASP.htmEffective health care bulletins – www.york.ac.uk/inst/crd/ehcb.htmPhysiotherapy evidence database (PEDro) – www.pedro.fhs.usyd.edu.auOTseeker – www.otseeker.com/search.aspxiCAM (Integrating Complementary and Alternative Medicine)School of Integrated HealthUniversity of Westminster115 New Cavendish StreetLondonW1W 6UWEnglandwww.wmin.ac.ukCentre for Evidence Based MedicineDepartment of Primary CareOld Road CampusHeadingtonOxfordOX3 7LFEnglandwww.cebm.netPublic Health Resource Unit (PHRU)4150 Chancellor CourtOxford Business Park SouthOxfordOX4 2GXEnglandwww.phru.nhs.uk

Useful Organisations 237AssessmentsPearson Assessment (incorporating The Psychological Corporation andThames Valley Test Company)Pearson AssessmentHalley CourtJordan HillOxfordOX2 8EJEnglandwww.pearson-uk.comGL Assessment (formerly NFER-Nelson)The Chiswick Centre414 Chiswick High RoadLondonW4 5TFEnglandwww.gl-assessment.co.ukNFERThe MereUpton ParkSloughBerksSL1 2DQEnglandwww.nfer.ac.ukLeisureGardeningThriveThe Geoffrey Udall CentreBeech HillReadingRG7 2ATEnglandwww.thrive.org.uk

238 Occupational Therapy and StrokeSportSportabilityLaynes House526-528 Watford WayLondonNW7 4RSEnglandwww.sportability.org.ukDisability Sport EventsBelle Vue CentrePink Bank LaneManchesterM12 5GLEnglandwww.disabilitysport.org.ukGolfSociety of One-Armed Golfers (SOAG)www.onearmgolf.orgFishingBritish Disabled Angling Association (BDAA)9 Yew Tree RoadDelvesWalsallWest MidlandsWS5 4NQEnglandwww.bdaa.co.ukArtConquest Art CentreCox Lane Day CentreCox Lane

Useful Organisations 239West EwellSurreyKT19 9PLEnglandwww.conquestart.orgAbleizeVirtual library for disability directory of disabled information aids and mobility serviceswww.ableize.comTravel and holidaysAccessible Travel and LeisureAvionics HouseNaas LaneQuedgeleyGloucesterGL2 2SNEnglandwww.accessibletravel.co.ukAccess Travel (Lancs) Ltd.6 The HillockAstleyLancashireM29 7GWEnglandwww.access-travel.co.ukTourism for All UKc/o VitaliseShap Road Industrial EstateShap RoadKendalCumbriaLA9 6NZEnglandwww.tourismforall.org.uk

IndexActivities of daily living (instrumental),105–8Household duties, 105–8Kitchen tasks, 105Activities of daily living (self-care),100–5Dressing, 100–5Washing, 100–1Anxiety, 83Apraxia, 152–5Assessment, 87–90Activities of daily living, 90Bed mobility, 87–8Sitting, 88Standardised assessments, 90Standing, 89Transfers, 88–9Walking, 89Ataxia, 110–1Attention, 147–48Auditory processing, 137–39Assessment, 138Clinical challenges, 139Functional anatomy, 137Functional observations,138Intervention, 138–39Review and evaluation,139Screening, 138Carers, 178–79Causes of stroke, 3Haemorrhage, 3Ischaemia, 3Transient ischaemic attack, 3Classification of stroke, 4Lacunar infarction, 4Partial anterior circulation stroke, 4Posterior circulation infarction, 4Total anterior circulation stroke, 4Clinical challenges, 109Cognition definition, 144Cognitive assessment, 144–7Cognitive functions, 144Cognitive rehabilitation, 145–6Approaches, 145Intervention, 145Strategies, 145–6Communication, 77–80Community rehabilitation, 174–7Aphasia, 77–8Dysarthria, 78Verbal apraxia, 78–9Damage that can occur in different areasof the brain, 13–19Definition of stroke, 1Definitions, 229–2Depression, 82–3Differential diagnoses, 197–198Driving after stroke, 185–6Emotionalism, 83Equipment, 75–7Bathing/showering, 76Eating, 77Meal preparation, 76Toileting, 76Wheelchairs, 75

242 IndexEvidence-based practice (EBP),199–3Appraising the identified evidence,202–3Evaluating outcomes, 203Formulating a question, 200Implementing findings into clinicalpractice, 203Levels of evidence, 201–2Searching for the best evidence, 201Stages of evidence-based practice, 200Executive dysfunction, 155–7Face-arm-speech test, 2Fatigue, 83–4Follow-up, 53Frames of reference, 27–9Behavioural frame of reference, 28Biomechanical frame of reference, 27Client-centred frame of reference, 27Cognitive frame of reference, 28Cognitive perceptual frame ofreference, 29Motor control frame of reference, 27Psychodynamic frame of reference,28–9Rehabilitative frame of reference, 27Getting out of the house, 183–5Home visits, 173–4Early supported discharge, 176Hospital at home/communityrehabilitation team, 175Intermediate care, 174–5Rapid response, 175Residential rehabilitation, 175–6Role of the occupational therapist,176–7Impact of stroke, 1Initial assessment, 67–74Cognitive and perceptual screening,67–71Functional assessment, 74Functional screening, 74Motor screening, 72–3Neurophysical screening, 72Psychosocial screening, 71International classification of functioning,disability and health, 4–5Intervention, 75Intervention approaches, 36–46Adaptive (compensatory/functional)approach, 37Bilateral arm training/isokinematictraining approach, 45Cognitive rehabilitation approach,37–8Constraint-induced movement therapy(CIMT) approach, 44–5Electromyographic (bio) feedback, 46Functional electrical stimulation, 46Mental imagery approach, 45–6Movement science, 43–4Normal movement (Bobath-basedapproach), 38–41Proprioceptive neuromuscularfacilitation (PNF), 41–2Restorative approach (remedialapproach), 36–7Robotics, 46Rood approach, 42–3Lability, 83Language, 151Leisure rehabilitation, 181–3Lifestyle and long-term management,180–1Management principles and intervention,90Medical investigations following stroke,6–7Blood tests, 6Cardiac investigations, 7Carotid ultrasound, 7Computerised tomography, 6Magnetic resonance angiography, 7Magnetic resonance imaging, 6Memory, 149–1Methods of recording occupationaltherapy intervention, 193–5Goal-directed notes, 193–4

Index 243Integrated care pathways, 194–5Joint documentation, 195Problem-orientated medical records(POMR), 193Models of practice, 25–7Activities Therapy, 26The Australian OccupationalPerformance Model (OPM(A)), 26The Canadian Model of OccupationalPerformance and Engagement(CMOP-E), 25–6The Kawa (River) Model, 26–7The Model of Human Occupation(MOHO), 25Mood, 81–2Motor planning and apraxia, 151–2Neuroanatomy, 9–13Neurone structure, 29–30Neuroplasticity, 29Normal perception, 158–62Occupational therapy process, 47–52Assessment, 47Evaluation, 52Goal setting, 47–9Interventions, 51–2Oedema, 113–4Olfactory and gustatory processing,141–3Assessment, 141Functional anatomy, 141Intervention, 141Review and evaluation, 142One-handed techniques, 108, 208–11Outcome measures, 203–6Perception definition, 158Perceptual assessment, 162–5Perceptual impairments, 160–2Agnosia, 161–2Body scheme, 161Visual discrimination, 161Perceptual intervention strategies, 167–72Body scheme, 167–68Constraint-induced movement therapy,71Eye patching, 169Impaired midline awareness, 168Prism glasses, 169–70Tactile agnosia (stereognosis), 171–2Unilateral neglect, 168–69Visual agnosia, 170–1Visual discrimination, 170Perceptual intervention theories, 165–7Attention-arousal theory, 166Disengagement theory, 167Hemisphere specialisation theory, 166Intentional mechanism theory, 166Interhemisphere theory, 167Policy documents relating to stroke,13–23Guidelines, 22–3National services framework for olderpeople, 13–14Stroke strategies, 19–22Positioning the early stroke patient, 91–7In a chair, 93–6In bed, 92–3Perch sitting, 96–7Prior to assessment, 64Basic checklist, 65–6Information gathering, 64Initial interview, 66–7Procedural reasoning, 53–9Acute stroke units (ASU) (hyperacutecare), 55–7Community rehabilitation andresettlement, 59Early supported discharge (ESD), 58Health promotion, 59Neurovascular clinics, 53–5Subacute/inpatient rehabilitation units,57–8Professional duties, 60–63Code of conduct, 60Health Professions Council (HPC)competencies, 60–61NHS knowledge and skills framework(NHS KSF), 61–2Skills for health, 62Stroke-specific education framework(SSEF), 62–3Pusher syndrome/overuse, 109–10

244 IndexRecord keeping, 191–3References, 212–28Resuming sexual activity, 188–89Secondary prevention, 7–9Anticoagulants, 8Antiplatelet agents, 8Blood pressure, 8Carotid endarterectomy, 9Hyperlipidaemia, 8Preventative neurosurgery, 9Social participation, 181Somatosensory processing, 127–37Adaptive (compensatory/functional),136Assessment, 130Clinical challenges, 136–7Functional anatomy, 127–9Functional observations, 130Intervention, 133–4Restorative (remedial), 134–6Review and evaluation, 136Screening, 130–3Standardised assessments, 133Theoretical approach, 129–30Splinting, 114–6Standardised assessments, 90, 195–7Administration, 196–7Assessment analysis, 197Assessment checklist, 196Assessment choice, 196Assessment of Motor and ProcessSkills (AMPS), 198Baking Tray Test, 199Balloons Test, 199Barthel ADL Index, 198Behavioural Assessment of theDysexecutive Syndrome (BADS),199Behavioural Inattention Test (BIT), 199Canadian Occupational PerformanceMeasure (COPM), 198Chessington Occupational TherapyNeurological Assessment Battery(COTNAB), 198Cognitive Assessment of Minnesota(CAM), 198Doors and People, 199Edmans ADL index, 198Erasmus MC Modifications to the(revised) NSA, 198Frenchay Activities Index, 198Functional Independence Measure(FIM), 198General Health Questionnaire, 199Geriatric Depression Scale, 199Hayling and Brixton Tests, 199Hospital Anxiety and Depression scale,199Kertesz Apraxia Test, 199Location Learning Test, 199Loewenstein Occupational TherapyCognitive Assessment (LOTCA),199Middlesex Elderly Assessment ofMental State (MEAMS), 199Mini-Mental Status Examination(MMSE), 199Motor Free Visual Perceptual Battery,199Motricity Index, 198Nine-hole Peg Test, 198Northwick Park ADL index, 198Nottingham 10 point ADL scale, 198Nottingham extended ADL scale, 198Nottingham Sensory Assessment, 198Occupational Therapy AdultPerceptual Screening Test, 199Repeatable Battery for the Assessmentof Neurological Status, 199Rey Figure Copying Test, 199Rivermead ADL assessment, 198Rivermead Assessment ofSomatosensory Performance(RASP), 198Rivermead Behavioural Memory Test(RBMT3), 199Rivermead Motor Assessment, 198Rivermead Perceptual AssessmentBattery (RPAB), 199SF-36 (generic health status measure),199Stroke Drivers Screening Assessment,199

Index 245Test of Everyday Attention (TEA), 198Visual Object and Space PerceptionBattery (VOSP), 199Wakefield Depression Inventory, 199Standards, 206-7Stroke education, 189–90Subluxed shoulder, 113–4Support available, 177–78Swallowing, 80–81Symptoms of stroke, 2Synaptic transmission, 31–6Collateral sprouting, 34Dendritic growth, 35–6Long-term nuclear changes, 32–3Long-term postsynaptic potentiation(LTP), 32Short-term presynaptic potentiation(STP), 31Unmasking, 34Theoretical constructs, 24Therapeutic activities, 110Therapeutic aims of intervention, 91Transition between services/discharge,52–3Upper limb re-education, 111Useful assessments, 198–199Useful books, 231–2Useful organisations, 233–39Vestibular processing, 139–1Assessment, 139–40Clinical challenges, 141Functional anatomy, 139Functional observations, 140Intervention, 140Review and evaluation, 141Theory/approaches, 139Visual and sensory impairment,117–19Visual processing, 119–27Activity engagement, 125Assessment, 123Clinical challenges, 126–7Functional anatomy, 119–20Functional observations, 123Impairment based, 124–5Intervention, 124Review and evaluation, 126Screening, 123–4Social participation, 125–6Theory/approaches, 120–3Vocational rehabilitation, 186–88Younger people, 180