1
Q
what skills does a stroke affect
A
orientaiotn short term memort attention problem solving planning and sequening judgement insight
2
Q
what is attention
A
The ability to redirect thoughts and actions towards a stimulus or event for a defined period of time, despite the presence of extraneous or unrelated stimuli.
3
Q
whats the different types of attention
A
sustained attetnon
selective atenton
alternating attention
divided attenton
4
Q
what is sustain attention
A
maintains focus on relevant information without interference from irrelevant stimuli. Sustained attention requires control over internal and external competing stimuli.
5
Q
what is selective attention
A
maintains attention in the presence of conflicting or competing sensory information. To facilitate or direct thoughts and actions, whilst simultaneously inhibiting our response to interference. Eg looking at an item on the shelf will you be distracted by prices, brands etc
6
Q
what is alternating attention
A
: move attention flexibly between tasks and responds appropriately to the demands of each task. Eg looking for a friends house in a new neighbourhood do you look at the map at the traffic lights and resume drining
7
Q
what is divided attention
A
: responds simultaneously to two or more tasks. Eg preparing a sandwhich at home ad talking to a friend on the phone.
8
Q
clinical signs to impaired attention
A
- Level of alertness – drowsy, fluctuating, easily fatigued?
- Can they finish sentence, give history?
- Do they go off on tangents or lose thread of conversation?
- Do they interrupt conversation/activities with unrelated comments
- Do they have difficulty ignoring distractions (including noise, pain etc)
- Are they unable to do more than one thing at a time
9
Q
strategies to improve attention and concentration
A
- ‘Put blinkers on’ by reduce all possible distractions in the environment
- Take regular rest breaks, have a nap or a walk
- Meditation, deep breathing and other strategies for relaxation
- Plan tasks with a simple step-by-step approach
- Break significant tasks down into small and achievable steps
- Write information down using notes and keep them in specific place
- Use a white board to help organize, plan and store information
- Use ‘association’ techniques e.g. medication on table with every meal
- Get into a structured regular daily routine
- Schedule tasks when levels of energy and alertness are greatest
- Eat a healthy diet and sleep well.
10
Q
what is neglect
A
unilateral neglect is ‘lateralised’ in the sense that patients typically fail to respond to stimuli occurring in the side of space opposite the lesioned hemisphere”.
11
Q
why is understanding neglect important for Occupation Therapy
A
- Major factor limiting occupational performance in Stroke rehab
- People with ULSN have more trouble resuming usual daily activities
- Have poorer recovery of function in the body side that is ‘neglected’
- Have longer hospital and rehab stays
- Increased risk for accidents and injury
12
Q
neglect of specific areas
A
Parietal lobe:
- Primary area:
Self and personal self
- Secondary area: Immediate environment and less complex reactions
- Tertiary area: interpretation of complex environmental input plus 1 and 2
13
Q
types of neglect
A
- Modality - visual, auditory and/or tactile.
- Space - personal, peripersonal (reaching) or extrapersonal (locomotor).
- Object or environment focus.
- Always stronger when the damage is to the right hemsiphere
14
Q
evaluation of neglect
A
- USN (Unilateral Spatial Neglect) problem identification was high, but evidence-based assessment and intervention use were less than optimal
- Behavioural Inattention Test.
- Star cancellation (54 small stars to be crossed, 2 7 on right, 27 on left, 2 prompts. Acceptable range: 52-54)
- Line Crossing
- Line Bisection (each line is scored according to the amount of deviation from the scoring template).
15
Q
mobility assessment of OP in neglect
A
- Does not symmetrically weight-bear while standing.
- Difficulty initiating movement through left side (ie: transferring)
- Does not spontaneously move affected side (despite movement being present).
- Difficulty completing left turns.
16
Q
daily activities assessment of OP neglect
A
- Fails to dress or groom left half of body or does not complete activity.
- Ignores food on left side of plate, does not empty left side of mouth when eating.
- May complete the activity in half the space available (ie: placing biscuits on half the biscuit tray).
- Overly attentive to items/objects on the right side
17
Q
functional assessment of neglect
A
- Impaired general attention and distracted by tasks, events and conversation on right side.
- Requires prompting to care for and attend to self and events on left side.
- Drops items from left hand and does not appear to notice (soap, toothbrush).
- Does not scan environment effectively for hazards when mobilising (overhanging cupboards, objects on floor etc).
18
Q
evaluation of neglect
A
Patients with unilateral neglect can be trialed with one or more of the following interventions:
simple cues to draw attention to the affected side
visual scanning training in addition to sensory stimulation prism adaptation
eye patching
mental imagery training or structured feedback.
19
Q
intervention in cognitive impairment
A
Visual scanning training Trunk rotation Nek muscle vibration Mental imagery training Video feedback training Prism therapy training
20
Q
whats a ischaemic stroke
A
blockage from a clot
21
Q
what are types of ischaemic strokes
A
embolic stroke
thrombotic stroke
22
Q
whats embolic stroke
A
if the blood clots forms somewhere in the body, it can travel in the blood stream to the brain. It gets stuck there and stops blood from getting through
23
Q
whats thrombotic stroke
A
: over time plaques increase in the blood vessels and narrow or blow the artery and stop blood getting through. Eg TIA stroke “mini stroke” signs may disappear after 24 hours but often a warning sign that a stroke may occur.
24
Q
whats a haemorrhagic stroke
A
blood on the brain due to burst of the blood vessel wall. Stops oxygen and nutrients getting to the brain.
25
whats types of hemorrhagic stroke
aneurysm
| arteriovenous malformation
26
what aneurysm stroke
is a weak or thin spot on a blood vessel wall that usually present at birth but is undetectable until they break
27
what is arteriovenous malformation
is a tangled mass of blood vessels, usually present at birth. If it is located in the brain can cause a stroke when the walls burst.
28
what do Occupation Therapy do with stroke victims
• Help stroke survivors manage day to day tasks, such as dressing and showering, as well as helping people to return to work and leisure activities after stroke. Occupational therapists also can also help with thinking or memory problems, and upper limb (hand or arm) problems.
29
acute Occupation Therapy role in stroke management
* Initial assessment**
* Cognitive-Perceptual Screen/Assessment**
* Vision assessment**
* Upper Limb assessment**
* Personal ADL assessment
* Light domestic ADL assessment
* Home Assessment
* Pressure Care/Seating
30
whats the initial assesment involve
* Complete within 1 working day of administration
* May be completed with patient and or family
* Includes: allied health pre morbid assessment (before accident) and OT initial assessment.
31
whats allied health pre morbid assessment
* Previous health status
* Social history
* Previous activities of daily living
* Previous physical function
* Previous cognitive function
* Home environment
* Concerns of patient/family prior to admission
32
whats Occupation Therapy initial assessment
* Current physical status (balance, strength etc)
* Vision**
* Upper Limb** OT/PT upper limb assessment
* Current Occupational Performance
* Cognition/Perception/Behaviour**
* Occupational Performance Issues / Implications for Discharge
* Client / Carer goal
* Plan
33
whats the cogntivite perceptual screening assessment
Assessment:
Arousal (drowsy, alert)
Orientation (day, date, month, year, place)
Attention/Concentration (sustained/divided attention)
Processing speed
Memory and learning
Following Instructions
Insight/Safety awareness (reason for admission)
Problem solving
Planning/sequencing tasks
Behaviour/Mood (agitated, cooperative, motivated
34
whats the vision screening assessment
```
Assessment;
• Always consider premorbid status
• Visual field deficit i.e. homonymous hemianopia, quadrantanopia
• Double Vision / Diplopia
• Nystagmus
• Ptosis
• Visual Scanning
• Visual Neglect
• *Ptosis
• *Diplopia
```
35
upper limb assessment
```
Assessment:
• Shoulder Pain
• Shoulder Subluxation
• PROM
• Tone
• Spasticity
• AROM/Strength
• Sensation
• Coordination
• Appearance (e.g. oedema, redness)
```
36
when should a stroke person be screened for apraxia
Stroke survivors who have suspected difficulties executing tasks but who have adequate limb movement and sensation should be screened for apraxia.
37
when should a stroke survivor visual assessment
All stroke survivors should have an:
• assessment of visual acuity while wearing the appropriate glasses, to check their ability to read newspaper text and see distant objects clearly;
• examination for the presence of visual field deficit (e.g. hemianopia) and eye movement disorders (e.g. strabismus and motility deficit
38
how much time of active therapy should a stroke survivor receive
For stroke survivors with some active wrist and finger extension, intensive constraint-induced movement therapy (minimum 2 hours of active therapy per day for 2 weeks, plus restraint for at least 6 hours a day) should be provided to improve arm and hand use. Trunk restraint may also be incorporated into the active therapy sessions at any stage post-stroke
39
whats the cogntivite perceptual screening assessment
Assessment:
Arousal (drowsy, alert)
Orientation (day, date, month, year, place)
Attention/Concentration (sustained/divided attention)
Processing speed
Memory and learning
Following Instructions
Insight/Safety awareness (reason for admission)
Problem solving
Planning/sequencing tasks
Behaviour/Mood (agitated, cooperative, motivated
40
whats the vision screening assessment
```
Assessment;
• Always consider premorbid status
• Visual field deficit i.e. homonymous hemianopia, quadrantanopia
• Double Vision / Diplopia
• Nystagmus
• Ptosis
• Visual Scanning
• Visual Neglect
• *Ptosis
• *Diplopia
```
41
upper limb assessment
```
Assessment:
• Shoulder Pain
• Shoulder Subluxation
• PROM
• Tone
• Spasticity
• AROM/Strength
• Sensation
• Coordination
• Appearance (e.g. oedema, redness)
```
42
when should a stroke person be screened for apraxia
Stroke survivors who have suspected difficulties executing tasks but who have adequate limb movement and sensation should be screened for apraxia.
43
when should a stroke survivor visual assessment
All stroke survivors should have an:
• assessment of visual acuity while wearing the appropriate glasses, to check their ability to read newspaper text and see distant objects clearly;
• examination for the presence of visual field deficit (e.g. hemianopia) and eye movement disorders (e.g. strabismus and motility deficit
44
how much time of active therapy should a stroke survivor receive
For stroke survivors with some active wrist and finger extension, intensive constraint-induced movement therapy (minimum 2 hours of active therapy per day for 2 weeks, plus restraint for at least 6 hours a day) should be provided to improve arm and hand use. Trunk restraint may also be incorporated into the active therapy sessions at any stage post-stroke
45
what the nine hole peg test
The Nine Hole Peg Test (NHPT) was developed to measure finger dexterity, also known as fine manual dexterity. It can be used with a wide range of populations, including clients with stroke. Additionally, the NHPT is a relatively inexpensive test and can be administered quickly.
46
whats the cognistat
• Neuro-behavioural Cognitive Status Examination
• Aims:
o – To assess intellectual function
o – Often used as a formalised assessment in hospitals on admission if cognitive deficit is suspected
• Record client variables
• Scores are plotted on a profile which illustrates the overall pattern of abilities
Domains assessed:
– Attention, level of consciousness, orientation, assessed independently
– Language (spontaneous speech, comprehension, repetition, naming)
– Constructions
– Memory
– Calculations
– Reasoning (similarities and judgement)
47
whats the RBMT-II assessment
Rivermead Behavioural Memory Test – 2nd Edition
Aims:
– To detect impairment of everyday memory functioning and to monitor treatment progress
Domains assessed:
– Short term, long term, prospective and semantic memory
48
whats the LOTCA assessment
* Loewenstein Occupational Therapy Cognitive Assessment battery for brain injured patients
* Aims: Assess cognitive performance as a base for OT intervention
* Objective measure of clinical change
• 6 domains assessed:
– orientation
– visual perception – spatial perception
– motor praxis
– visuo-motor organization – thinking operations.
49
symptoms of neglect
* The inability to detect stimuli in the affected visual field, opposite to the damaged area of the brain.
* Lack of ability to attend to stimuli in the three spatial fields personal, peri-personal and extra personal.
* A spontaneous deviated head or eyes towards the non-affected side.
* Impairment in features of copying and writing
50
whats the three spatial sectors
personal (bodily space)
peri personal (within reach)
extra personal space (outside of reach)
51
whats personal neglect affect
the patients’ surface of their body. This type of neglect affects bodily functions and can be described as if the person has forgotten about the side of the body affected by neglect. This leads to a number of issues with daily activities and can result in symptoms such as impaired swallowing, dressing and bathing occupations. In some cases, it has seen to affect the inside of the mouth with loss of saliva production on the left side.
52
what's peri-personal neglect affect
is more common than personal and refers to the visual deficits in reaching distance of the patient. While extra personal neglect refers to failing to respond to stimuli such as objects or events outside of the patient reaching distance
53
long term opis for stroke patients
Most recovery occurs during the first weeks following the stroke
Bogousslavsky (2002) mentions that issues that may still be impacting on the survivor include;
Hemiplegia
Continued apraxia
Motor neglect
Affective mood disorders
Stroke can also lead to vascular dementia later in life
54
whats hemianpia vs neglect
hemianopia: is blindness over half of the visual feild
Neglect: unaware of objects or people on one side of their body can still see
55
how to test is it neglect or hemianopia
finger test:
wiggling a finger on each side of the hemisphere if they can recognise when one is moving indivudiaully but unable to if they both are moving this means that they have neglect
56
whats the motor model
Two approaches: Neurodevelopmental approach and contemporary approach
57
what areas are affected if there is a MAC infarct
These regions include the parietal lobe, the temporal lobe, and the internal capsule and thalamus.
58
prognosis for someone experiencing middle cerebral artery infarct
patients with large MCA infarct is poor, with case fatality rates in previous intensive care-based series of nearly 80%. In the modern era, which several recanalization therapies were applied at the very early onset of stroke, the prognosis of these patients would be better.
59
Mca stroke symptoms
Deficits in movement and sensation (contralateral hemiplegia and hemianesthesia)
Difficulty swallowing (dysphagia)
Uninhibited neurogenic bladder
Impaired language ability, including global aphasia, Broca’s aphasia, and Wernicke’s aphasia
Impaired vision and partial blindness (hemianopia)
Poor awareness of deficits
Headaches
Inability to turn eyes towards the affected side
60
what's the anterior cerebra artery supply blood to
frontal lobes
61
whats the middle cerebral artery supply blood to
frontal lobe, temporal lobe and parietal lobe
62
whats the posterior cerebral artery supply blood to
occipital lobe and temporal lobe
63
explain the impact stoke on a persons occupational performance
• Self-care
→ Dysphagia (difficulty swallowing) makes it unsafe/difficult to eat
→ Neglect affects dressing, grooming, eating etc.
→ Decreased upper limb function impacts on ADLs
• Productivity
→ Neglect impacts on work and household tasks
→ Cognitive deficits (eg. inattention and memory problems) could make it difficult to work
→ Vision deficits
64
what type of stroke is an cerebral artery infract
ischaemic stoke as its blocked by a clot
65
whats an Cerebral artery infract
• An MCA infarct is a type of stroke that occurs when the MCA artery becomes blocked
66
risk factors for a MCA infract
→ Lifestyle (eg. smoking, being overweight, physical inactivity, excessive alcohol consumption)
→ Medical (eg. high BP, heart disease, high cholesterol, sleep apnea, age, family history
67
describe the cognitive model
• The cognitive model describes how people’s perceptions of, or spontaneous thoughts about, situations influence their emotional, behavioral (and often physiological) reactions
