Occupational Therapy

Management for
Cerebrovascular
Accidents (CVA)
By-Madhurima Chand
BOT-3rd Year
N.I.L.D, Kolkata
GOALS OF OCCUPATIONAL THERAPY

5. Remediation of
perceptual and
cognitive dysfu
nction.
6. Achieveme
1. Prevention of deformity caused by nt of maximal fu
nctional
independence in
abnormal tone and poor positioning. self care.
7. Facilitation
2. Inhibition of abnormal patterns of of realistic accep
t a nc e o f
a n d a d j u s t m en t
posture and movement. to disability.
8. Improveme
3. Achievement of maximal active ROM, nt of functional
communication
strength and coordination of affected skills and social
interaction.
extremities.
9. Facilitation
4. Achievement of maximal voluntary of reentry to me
aningful
roles in family a
bilateral and unilateral use of affected nd in communit
10. Facilitation y.
extremities in correct functional of a balance betw
e en
work, rest, and
patterns. leisure.
Occupational
therapy
Evaluation
Motor Functions
1. The degree of hypertonicity in a patient
with CVA should be evaluated.
2. The Burnnstorm test can be used to
determine the stages of recovery, the
presence of synergistic movements
and associated reactions.
3. The Bobath method can be used to
evaluate the abnormal movement
patterns, presence of primitive
reflexes, abnormal motor patterns,
abnormal coordination, righting
reactions, equilibrium and protective
reactions and general postural
mechanism.
4. The Joint ROM may be measured or
estimated, but the therapist should be
aware that ROM often is limited by
transient variable degrees of
hypertonicity at any given time.
5. In recording the ROM the therapist
must differentiate between apparent
limitation caused by hypertonicity and
actual limitation caused by structural
changes.
6. When the patient has achieved some
voluntary control of movement.
Spontaneous use of the affected
extremities, should be observed during
the testing and functioning activities,
because this is a good sign of
improving sensory-motor status.
7. Muscle strength should be tested only
if the patient has full selective
movement and doesn’t have abnormal
tone.
8. When there is hypertonicity, it is not
possible to assess accurately the
strength of muscles affected or
muscles acting against those
muscles are hypertonic.
 Sensation
1. Senses of touch, superficial pain,
temperature, pressure as well as
stereognosis and proprioception
should be tested.
2. Olfactory and gustatory sensation
may be tested because these senses
are disturbed in some patients and
often overlooked.
Cognition
1. Cognitive skills such as memory,
attention, initiation, planning and
organization, mental flexibility and
abstraction, insight and impulsivity,
problem solving skills and ability to
do calculations should be evaluated.

Perception
1. Body scheme and motor planning
should be routinely tested.
2. Tests for visual perception problems
such as anopsia, visual spatial
relationship, figure ground
perception, visual attention and
unilateral neglect should be included
in the battery of evaluation procedure.
 Psychosoci
al
1. The OT should ascertain patient’s
Factors
vocational and recreational
histories, role in family and
community, amount of family
support, adjustment to disability,
and frustration tolerance and
coping skills.
2. Regressive behavior and
functioning should be assessed.
3. Patient may deny the necessity to
engage in apparently simplistic
activities.
Communication
and oral motor
function
1. The An oral motor evaluation may be
necessary.
2. Such evaluation helps us to
determine the need of facilitation
and inhibition of oral structures in
a pre feeding program. And the
need for feeding training.
3. Information about speech
impairment can be gained from
these evaluations.
4. The OT should make an assessment
of functional communication
skills, written and spoken
language.
Performance
Skills
1. Performance skills should be
evaluated by interview and more
importantly by actual performance
of test items.
2. Self care and home management
skills, mobility and transfer
techniques, physical endurance
and work related activities.
Occupational ther
apy
Management
 Motor re-training

2. Early Empha
sis on Range o
Motion (ROM): f
The
1. Motor Retraining Approaches: maintenance of i s e s B a s e d on
c
Occupational therapy programs prevention of de
joint ROM and 3. ROM Exer c h e s : ROM
p p ro a
may combine sensorimotor in the early stag
formity is crucial Treatment A t h e p r in c iple s
es of treatment. x e r cis e s a d h ere to
approaches like Brunnstrom, This focus contin e tment
ues indefinitely ch o s e n t r e a
Bobath, and PNF for motor if substantial spo of the an c e , in t h e
r in s t
retraining. The goal is to facilitate voluntary movem
ntaneous approach. Fo a c h,
ent is not r o m a p p r o
movement on the affected side, regained. Techn Brunnst e m o v e m e n t
assiv
develop normal postural reflexes, positioning recom
iques involve positioning, p a t t er n s , t r un k,
mended by hr o ug h s y n e rgy p
and inhibit abnormal reflexes and Bobath and vario t
us passive, ila t e r al s h o u lder
movement patterns. assistive, and se and b t o m a intain
s e r v e
ROM procedure
lf-administered movements
s. ROM.
.
 r d i n g S h o u lder
ega
4. Bobath Approach fo 5. Caution R t i o n:
r Shoulder S u b l u x a
Movement: The Boba Pain and R O M
th approach l p a s siv e
uses bilateral moveme Traditiona o u ld e r a re
h e s h
clasped hands to relea
nt with exercises to t in t h e B o bath,
in s t
se spasticity
and maintain full passiv cautioned aga N F
e shoulder r o m , a n d P
flexion and scapula mo Brunnst r e c t e x e r c is es
Inco r
Specific hand clasping
vement. approaches. g t r a n s f e r s can
techniques nd h a n d lin g durin
and maneuvers are pra a . S u b lu x ation
u m a
regularly to ensure pain
cticed cause joint tra s a c t iv a t in g
o lv e
shoulder ROM.
-free prevention inv p a r t ic u la r ly the
cle s ,
shoulder mus
as p in a t u s , w ith
sup r u r e s by
d p r o c e d
recommende
Brunnstrom.
 x o r S p a st i c ity 8. Therapeutic
7. Fle p a s ticity Activities for
6. Hand Edema Prevention: t: F le x o r s Motor Retrainin
Managemen t o d e f o r m it y, g: Therapeutic
Hemiplegic patients may t he h a n d c an lead activities play a
crucial role in
in
ic e s m a y b e used motor retraining
experience hand edema due to ev
and orthotic d p r e v e n tion. according to the
decreased muscle tone and a n d Bobath, Brunnstr
for protection e r e s t in g om, and PNF
inactivity. Prevention methods e s lik approaches. Acti
Various devic p r e a d e rs are vities involve
include elevation, support on a g e r s bilateral and unil
splints and fin e ff e c t iv e ness ateral tasks,
t t h e trunk rotation, an
wheelchair arm, passive and active discussed, bu n s r e q u ir es d hand
ve n t io retraining, with a
assisted ROM exercises, and of these inter focus on
monitoring of splints and positioning e r r es e a r c h . inhibiting abnorm
furt h al tone and
devices. reflexes while fa
cilitating normal
movement patte
rns.
.
 9. Early Use of Thera
peutic
Activities: Early integra
tion of
therapeutic activities e
nhances
alertness, interest, moti
vation, and
provides opportunities
for
socialization and comm
unication.
Activities are tailored to
the patient's
capabilities, considerin
g motor,
sensory, perceptual, an
d cognitive
dysfunctions.
 Sensory re-training
1.
Sensory Bombardment for
Sensory Retraining: Utilizing
sensory bombardment involving
multiple senses is beneficial for
sensory retraining in certain CVA
patients. Therapists can integrate
touch, visual, and auditory stimuli
during regular activities to
enhance sensory perception.
Weight-bearing on legs, arms,
and trunk is employed to
increase proprioceptive
feedback.
2.
Integration of Sensory and
Motor Retraining: Eggers
advocates integrating sensory
retraining with the motor
retraining using the Bobath
approach. Sensory retraining,
particularly tactile and
kinesthetic reeducation, is
emphasized after normalizing
muscle tone and finding
optimal positions for sensory
reeducation activities.
3.
Graded Treatment Program for
Sensory Deficits: Eggers
describes a graded treatment
program for sensory deficits. It
involves gradually transitioning
from seeing and hearing an
object to relying solely on tactile-
kinesthetic input. The program
includes discrimination of
dissimilar objects, estimation of
quantities through touch,
discrimination between two- and
three-dimensional objects, and
specific object retrieval.

4.
Cutaneous Stimulation for
Perception Tests: Fox studied
the impact of cutaneous
stimulation on selected
perception tests with CVA
patients. The study involved
applying corduroy-covered,
padded, wooden stimulators to
various areas of the patient to
test perception, particularly
finger agnosia. The results were
favorable, but the need for
more research in this area was
highlighted.
5.
Stereognosis Retraining
Programs: Farber and Vinograd,
Taylor, and Grossman described
programs to retrain stereognosis.
These programs involve visual
examination, object manipulation
with both hands, and gradually
progressing to identifying objects
with vision occluded. Ferreri
studied the effect of intensive
stereognostic training on spastic,
cerebral, palsied adults with
positive results, emphasizing the
importance of repetitive sensory
stimulation using different objects.
 Compensatory treatment
Callahan proposed the following guidelines
for patients with PNS dysfunction who lack
protective sensation:
1. Avoid exposure of the involved area to heat,
cold, and sharp objects.
2. When gripping a tool or object, be conscious
of not applying more force than necessary.
3. Beware that the smaller the handle, the less
distribution of pressure over gripping
surfaces. Avoid small handles by building up
the handle or using a different tool whenever
possible.
4. Avoid tasks that require the use of one tool
for long periods, especially if the hand is
unable to adapt by changing the manner of
grip.
5. Change tools frequently at work to rest
tissue areas.
6. Observe the skin for signs of stress,
such as redness, edema, and warmth,
from excessive force or repetitive
pressure, and rest the hand if these
signs occur.
7. If blisters, lacerations, or other wounds
occur, treat them with the utmost care to
avoid further injury to the skin and
possible infection.
8. To keep the skin soft and pliant, follow a
daily routine of skin care, including
soaking and oil massage to lock in
moisture.
 Cognitive re-training

One-Handed Performance and

Assistive Devices: Coordination
Multidisciplinary Approach
Performance Skills and ADL and skill training for one-handed
to Cognitive Rehabilitation:
Training: Occupational therapy performance may be necessary in
Cognitive rehabilitation
plays a primary role in training cases where the dominant upper
involves the collaboration of
Activities of Daily Living (ADL). extremity is affected. The patient
neuropsychologists, speech
Early rehabilitation may include learns to stabilize objects and use
pathologists, and
wheelchair mobility, transfer assistive devices adapted for one-
occupational therapists. The
skills, and basic self-care handed functioning, with the
field has primarily focused on
activities, progressing to more occupational therapist acquiring
head injury patients, and it is
complex skills. The use of and providing training on these
a complex, multidimensional
affected limbs in training is devices.
process that considers the
emphasized, considering motor,
patient's interaction with both
sensory, perceptual, and
human and nonhuman
cognitive deficits.
environments.
Home Evaluation and
Transition to Independence:
As the patient approaches
discharge, the occupational
therapist conducts a home
evaluation and explores
vocational or leisure skills
potential. The therapist
assesses self-care and home
management skills, estimating
the patient's potential for
independent living based on
the severity of the CVA,
rehabilitation success, mental
status, and social factors.
Psychosocial Adjustment Support: The
occupational therapist plays a crucial role in
aiding the patient's adjustment to
hospitalization and disability. Empathy and a
supportive approach are essential,
considering the profound life changes caused
by a devastating illness. The therapist aligns
approach and performance expectations with
the patient's stage of adjustment, addresses
concerns about prognosis, and focuses on the
patient's remaining and newly learned skills
through therapeutic activities. The
occupational therapy program serves as a
real-life laboratory for skill learning and
discovery of abilities, positively impacting the
patient's mental health and outlook.
 Key-points
1. Comprehensive Evaluation: Assess cognition, psychosocial factors, communication, and motor skills for
personalized treatment plans.

2. Motor Re-education: Tailor interventions to retrain motor skills, enhancing movement and functional
independence.

3. Sensory Reeducation: Stimulate senses, improve perception, and retrain the brain post-CNS dysfunction.

4. Compensatory Techniques: Help PNS dysfunction patients adapt, fostering awareness and ensuring safety.

5. Cognitive Re-education: Target cognitive deficits through tailored exercises, promoting mental function
and adaptability.

6. Rehabilitation Phases: Progress from touch retraining to late-stage tactile discrimination for PNS recovery.

7. Factors Affecting Success: Consider CNS damage, recovery, psychosocial factors, and skilled treatment for
success.

8. Occupational Therapists' Role: OTs aid independence, addressing deficits through personalized
interventions and activities.

9. Ongoing Research: Continuous research vital for advancing CVA treatment, improving rehabilitation
Thank You!