OT STROKE EDUCATION

WORKBOOK
Published March 2011

Name:
OT STROKE EDUCATION WORKBOOK

ACKNOWLEDGMENTS

The original physiotherapy workbook was designed by a team of St George’s Hospital physiotherapists
led by Aimee Pinto to help both students and rotational staff develop skills and knowledge in the
management of stroke patients. This version has been adapted and amended for use with occupational
therapists.

Contributors to this edition

Kyra Hamilton
Cheryl Edwards
Richelle Greyling
Sushmita Mohapatra
Paul Morris
Maggie Campbell
Jumana Ghor
Margreet Wittink
Karen Chivers
Elaine Hayward
© South London Cardiac and Stroke Network | 2011

Reproduction / modification is authorised only when the source is acknowledged.

Permission to reproduce / modify must be obtained prior to use from the SLCSN via info@slcsn.nhs.uk.

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CONTENTS

Basic neuroanatomy……………………………………………………………………………………………………………………...... 5
Stroke background.................................................................................................................................................................... 8
Medical management of stroke…………………………………………………………………………………………………………… 10
Investigations……………………………………………………………………………………………………………………………….. 12
The multidisciplinary team………………………………………………………………………………………………………………... 18
Guidelines and national initiatives………………………………………………………………………………………………………. 19
Organisation of stroke care in London………………………………………………………………………………………………… 20
Neurological assessment……………………………………………………………………………………………………………….... 22
Respiratory and cardiovascular assessment…………………………………………………………………………………………. 26
Generating a problem list………………………………….………………………………………………………………………..……. 27
Cognition and Perception……………………………………………………………………………………………………………….... 31
Attention and Neglect……………………………………………………………………………………………………………………… 33
Standardised Assessments………………………………………………………………………………………………………………. 40
Outcome measures……………………..………………………………………………………………………………………………….. 41
Vision……………………………………………….…………………………………………………………………………………………. 42
Handling a stroke patient……..…………………………………………………………………………………………………………… 47
Early mobilisation of the stroke patient…….…………………………………………………………………………………………… 49
Equipment ………………………………………………………………………………………………………………………………….... 52
Treatment of the Upper Limb……………………………………………………………………………………………………………… 57
Tone – Assessment and management…..……………………………………………………………………………………………… 60
Splinting………………………………………………………………………………………………………………………..................... 63
Goal Setting …………………………………………………………………………………………………………………………………. 64
Review of Evidence………………………………………………………………………………………………………………………… 65
Glossary…………………………………………………………………………………………………………………………………….... 67
Medications………………………………………………………………………………………………………………………………….. 72
Resources……………………………………………………………………………………………………………………………..……... 73
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INSTRUCTIONS

As you work through the book, there will be different activities to

complete relating to different aspects of stroke care.

The book is designed to allow you to work at your own pace but
you may set some targets for completion with your clinical educator
or senior.

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GUIDANCE FOR COMPLETION

Students:
In your initial objective setting session with your clinical educator, it may be useful to plan which sections of the workbook
you want to look at different stages of your placement. This will differ according to the length of your placement and your
previous experience or knowledge.

Week 1:

Week 2:

Week 3:

Week 4:

Week 5:

Week 6:

Rotational staff:

You may want to work through at your own pace or set yourself targets for your rotation.

Month 1:

Month 2:

Month 3:

Month 4:

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BASIC NEUROANATOMY

What does this

diagram show?

Can you label it?

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What are the basic functions of each part of the brain?

Frontal lobe:

Label the parts of the brain:

Parietal lobe:

Temporal lobe:

Occipital lobe:

Brainstem:

Cerebellum:

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What do these diagrams represent? On this diagrammatic representation of the brain,

shade in the distribution of the ACA, MCA and posterior
circulation:

What is the difference between the two and can you name each one?

Cerebrum

Cerebellum

7 infarct, would they be likely to

If a patient had an ACA
have greater deficits in the upper limb or lower limb and
why?

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STROKE BACKGROUND
What are the definitions of the terms below?
1. Stroke:

2. TIA (Transient Ischaemic Attack):

3. Cerebral infarct:

4. Cerebral haemorrhage:

What percentage of strokes are ischaemic?

What proportion of all strokes are fatal?

What proportion of TIAs will go on to have a stroke within five years?

Does a cerebral embolus or a cerebral thrombus have a better outcome and why?

What type of stroke is more fatal, ischaemic or haemorrhagic?

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What are the main risk factors for the causes of stroke and why are they a risk factor?

1. …………………………………………………………………………………………………………………………………………………...

2. ……………………………………………………………………………………………………………………………………………………

3. ……………………………………………………………………………………………………………………………………………………

4. ……………………………………………………………………………………………………………………………………………………

5. ……………………………………………………………………………………………………………………………………………………

6. ……………………………………………………………………………………………………………………………………………………

7. ……………………………………………………………………………………………………………………………………………………

8. ……………………………………………………………………………………………………………………………………………………

9. ……………………………………………………………………………………………………………………………………………………
Can you work out what type of stroke these patients may have had?

Example 1: Example 2: Example 3

• Left sided weakness affecting the leg • A 65 year old right handed • Altered vision to his left side
and the arm gentleman • Poor short term memory
• Inappropriate social behaviour • Right sided weakness and • Is mobile on ward but poor
• Cognitive Communication disorder parasthesia affecting the arm more orientation, can’t find his way back to
• Urinary and faecally incontinent than the leg his bed from the toilet.
• Hemianopia
• Dysphasia

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MEDICAL MANAGEMENT OF STROKE

A selection of medications are commonly used in early post stroke management including the following :
– Antiplatelet therapy
– Anticoagulants
– Antihypertensives
– Statins

What is the main purpose in the use of these medications post stroke?

What do antiplatelets do?

Can you name 3 commonly used antiplatelet medications?

How do anticoagulants work?

Can you name 3 commonly used anticoagulants?

What is the difference between anticoagulants and thrombolysis?

What is thrombolysis?

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What type of stroke is thrombolysis used in?

How does thrombolysis work?

In what time frame can thrombolysis be used?

When will thrombolysis not be used in a acute stroke?

What is the main benefit of thrombolysis?

What are the implications to the therapists following thrombolysis?

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INVESTIGATIONS

Different types of scans will be used following CVA including CT and MRI which are
covered in the next section of the workbook. A diffusion weighted MRI can also be used
if an infarct cannot be identified on CT or MRI. A new infarct will show up like a light bulb
on the MRI scan in the early stages (see picture).

Why would an MRA/CTA (Angiography) and carotid doppler be carried out?

What is a carotid endarterectomy?

Can you name two cardiac investigations that may be completed and why?

A chest X-ray is also carried out. There are two reasons for this, can you think of them?

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CT AND MRI SCANS

A (CT) scan, uses to take pictures of the head from many different angles. The
pictures provide a detailed, view of specific areas of the brain.
MRI) uses and magnets to produce detailed pictures of the brain’s
structure.
CT scans are usually performed before an MRI scan. Can you think of three reasons for this?

1)

2)

3)
Below is an image of a CT scan and an MRI scan. Can you look at the differences between the two images and work out what
colour bone, fluid and soft tissue would appear as on each image?
CT scan: MRI scan:

Bone – Bone –

Fluid – Fluid –

Soft tissue – Soft tissue –

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Haemoglobin contains iron. Iron is a mineral which is MRI measures the way hydrogen atoms absorb and give off
dense like bone, therefore a bleed (haemorrhage) will electromagnetic energy. Bodies are 60% hydrogen atoms. Water
show up as white on a CT scan. An ischaemic infarct and fat contains lots of hydrogen atoms. Tissues that have the
will lead to a lack of oxygen supplying the brain tissue least hydrogen atoms appear darkest on MRI. Therefore bone will
and will cause the tissue around the lesion to become appear dark and fat will appear white. Blood contains some
necrotic. This will therefore show up darker on a CT hydrogen atoms so it will therefore appear as a grey like colour.
scan. However MRIs can be a bit more complicated as the colour of the
structures can vary depending on whether how the scan is
On the 2 images below draw a circle around the area weighted.
of the lesion and label it an infarct or a haemorrhage.
Can you identify the infarct on this MRI?

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These are 10 images of CT scans at different cross sections. On each CT scan there is an area highlighted. Can you identify the
structure that is highlighted and label each image with the correct letter to match the structure?

a. Spinal cord f. Posterior limb of internal capsule

b. Sylvian fissure g. Corona radiata
c. Cerebellar hemisphere h. Anterior horn of lateral ventricle
d. Body of caudate nucleus i. Sulci
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e. Midbrain j. Thalamus
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You should now be a little more confident with how the different types of strokes show up on a CT scan and where the different
structures within the brain are located.

Identify whether the following CT scans show an image of an infarct or a haemorrhage and describe the area in which the lesion is
located and the circulation involved i.e. ACA, MCA or posterior circulation.

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This is a CT scan of a patient who has had a stroke.

Answer the following true or false questions:

a) The area affected is in the patient’s left cortical hemisphere.

b) The patient has a had a brain haemorrhage.

c) The artery involved is the anterior cerebral artery.

d) The patient is most likely to have greater neurological deficits in the right upper limb as opposed
to the right lower limb but both may be affected.

e) The area of damage is in the frontal region.

f) The patient is likely to have some degree of sensory impairment.

g) The patient may have problems with communication - Broca’s and Wernicke’s areas are usually
located on the
left side of the brain.

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THE MULTIDISCIPLINARY TEAM

Fill in the members of the MDT:

The MDT

During your time on the Acute Stroke Unit arrange a joint session with two other member of the MDT and reflect on your experience.
Date: MDT member: Date: MDT member:
Main learning points: Main learning points:

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GUIDELINES AND NATIONAL INITIATIVES

What is the FAST campaign?

Which guideline was developed for stroke care in London based on the National Stroke Strategy?

From this strategy, complete the following sentences:

• All Londoners should be no more than from a specialist stroke unit.
• On arrival at a HASU, a stroke patient should have a CT scan and access to thrombolysis (if appropriate) within
.
• 100% of patients admitted to a stroke unit should receive an Occupational therapy assessment within of
admission.
• of patients should have face to face sessions of PT, OT and SLT per week as
necessary.
• of patients should have appropriate seating, posture and positioning within of
admission to the unit.

What is the National Sentinel Stroke Audit?

The Workforce Planning Document (Department of Health, 2008) provides a consensus statement on OT intervention after stroke. It
recommends that

What does the Occupational Therapy Concise Guide for Stroke (2008) say about:
• Assessment of general cognitive impairments?

•When a patient who has limitations on any aspect of personal activities should be assessed?

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ORGANISATION OF STROKE CARE WITHIN SOUTH LONDON

What is a HASU and which government guideline outlined the need for them?

How many HASUs are there in London and where are they located?

What is a clinical network?

When were the South London Cardiac and Stroke Networks formed?

Which community health providers and local authorities are included in the South London network?

Which hospitals house the HASUs in the South London Cardiac and Stroke Network? (This includes South East and South West.)

Where are the other stroke units in this network?

If you want to know a patient’s local stroke unit, you can look it up on the London stroke unit lookup ( www.londonsulookup.nhs.uk).
Find out which stroke unit the following patients would come under:
SW12 0PG – CR0 6SY –
SW17 0AD – SE16 6HP –
SM4 6RB – SE11 4TJ –
BR5 2NJ –
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NEUROLOGICAL ASSESSMENT

A good assessment will give you a baseline from which to work, allow accurate identification of the patient’s problems and what is
causing them, allow effective establishment of patient-centred goals and allow you to develop a comprehensive treatment plan.
What might you want to find out in the subjective and objective assessments?

SUBJECTIVE OBJECTIVE

What is the difference between upper motor neurones (UMN) and lower motor neurones (LMN)?

What are the positive and negative features of the UMN syndrome?
POSITIVE NEGATIVE

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Neurological observations:
What are the three sections of the Glasgow Coma Scale (GCS)?

What score on the GCS is classed as a coma?

What other neurological observation will be recorded on the observation chart and why?

Initial physical observations:

What information can you gain from looking at the patient in the bed?

Range of movement and tone:

How would you assess tone?

What is the difference between hypertonia and spasticity?

What is an associated reaction?

When do you need to be particularly careful to assess and monitor range of movement?

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Voluntary Movement:
What are you looking for when watching a patient move?

Balance
What would you look for while assessing a patients sitting balance?

Sensation
How do we assess sensation in stroke patients?

Proprioception:
How do we assess proprioception in stroke patients?

Coordination:
How do we assess coordination in stroke patients?

Cognitive perceptual
What are the functional difficulties a patient might experience with neglect to one side?

What are the signs with a patient with ideomotor apraxia?

Vision
How would you assess a patient with homonymous hemianopia( half visual field loss)?

You also may want to go and investigate how to assess orientation, memory, other cognitive abilities and visuo-perceptual deficits
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What kind of cognitive or communication problems might mean we have to adapt our assessment strategy?

PROBLEMS
THAT MAY
AFFECT
ASSESSMENT

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RESPIRATORY AND CARDIOVASCULAR ASSESSMENT

What would you need to consider regarding the respiratory /CV status prior to an OT assessment?

What is the ischaemic penumbra?

Suggested reading: Turton, A. and Pomeroy, V. (2002) When should upper limb function be trained after stroke? Evidence for and against early
intervention. NeuroRehabilitation 17 pp215-224

Why is it important that a stroke patient is given supplementary oxygen post stroke?
Suggested link http://www.so2s.co.uk/protocol.shtml

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GENERATING A PROBLEM LIST

When producing a problem list for a patient once you have completed their assessment, try to think logically about the order in which
you write things down in order to ensure that you don’t miss anything.
Be as descriptive as possible as another therapist should be able to get an accurate picture of the patient from your problem list.
What sort of things might you put under the following headings?
Impairments:

1. Voluntary activity – Do they have any?

Is it recruited normally but just weak or can they only recruit in certain patterns of activity?
2. Muscle tone – Do they present with any changes in tone?
If so, where?
Is it high, low or a mixture of both?
Do the have any associated reactions with effort, yawning, coughing etc?
(You can group 1 and 2 together to describe a limb eg: Predominantly low tone throughout right upper limb with evidence of
flickers of activity around shoulder with weight bearing tasks but no voluntary movement throughout rest of UL).
3. Range of movement - Are there any limitations to movement?
Are you able to identify why?
Is it due to changes in muscle or joint?
Could it be due to a premorbid problem or is it new?
4. Sensation - Are there any sensory changes and to which modalities? i.e. light touch, pain, temp,
proprioception.
5. Pain - Is the patient reporting pain or producing a pain behaviour in response to any kind of
stimulus?
6. Coordination - Are there any difficulties with coordination?
Are there any signs of ataxia – dysmetria, tremor, dysdiadochokinesia
7. Perception - What is the patients perception of their body like?
Do they have any signs of visual neglect, spatial awareness problems, agnosia, apraxia?
8. Cognition - Are there any problems with attention, visual processing, information processing,
memory, executive functioning?
9. Vision- Has their visual abilities changed? Do they have pre existing conditions?
If applicable; are their glasses still fit for purpose?
Do they have hemianopia? Is this complete, partial, homonymous, quadrantanopia 27 ?
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Activities and Participation

1. Bed mobility - How much assistance does the patient need with rolling, lying to sitting, moving up and down
the bed (independent with ……strategy, prompting, asst x 1, asst x 2)?

2. Sitting balance - How much assistance does the patient need to maintain balance? Are they able to be
dynamic in sitting (i.e. reach, put on shoes, etc.)?

3. Sit to stand - How much assistance does the patient need with sit to stand (independent with strategy,
prompting, asst x 1, asst x 2, an aid)?

4. Transfers - What method and assistance does the patient require with transfers?
Does this differ between in therapy and with the nurses?
Does this differ with the type of transfer i.e. bed to chair versus chair to toilet?

5. Walking - What method and assistance does the patient require with walking?
Does this differ between in therapy and with the nurses?
6. High level balance tasks - Is the patient limited in their ability with TUSS, TUSS tog, TUSS tan, turning, picking
things up form the floor?
7. Upper limb function - Describe any limitations to functional use of the upper limb.
8. Personal Care - What method and assistance does the patient need with grooming, washing, dressing?
Does this differ between in therapy and with the nurses?
9. Kitchen Activities- What method and support is required for the patient to initiate and complete the activity?
10. Employment- If applicable; consider abilities required for job and likelihood of achieving return to work.
11. Home environment- Describe the limitations the patient home environment will have on their functioning.
12. Support- Describe the impact of the patient support system on their likelihood to return home.

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Other:
Are there any other impairments that might influence your treatment but you will not directly be trying to affect?
1. Speech - Does the patient have any aphasia receptive or expressive or dysarthria?
Is English their first language?
2. Swallowing - Does the patient have any dysphagia?
3. Hearing- Does the patient have any hearing deficit?
4. Skin / continence - Are there any problems which might impact on your treatment?
5. Mood - How would you recognise this and assess it. What might the impact be on your intervention

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Have a go at formulating a hypothetical problem list for the following patient:

Impairments:

Activities:

Other:

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Cognition and Perception- Which one is which?

All the mental processes that allow us to recognise,

learn remember and attend to changing information in
the environment.
Answer:

The reception by the brain of information from the senses,

integration of these sensations and the organisation of
them in association with the past experiences to make a
meaningful and functional whole.

Answer :

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Cognition Hierarchy

• This is one hierarchy of

cognition.
Praxis • All components on the
hierarchy merge and
overlap
Object Recognition • The lower functions will
impact on the ones higher
up.
Attention • Label the missing
components of the
hierarchy
Ref: Harrisons Associates Cognition &
Perception Training Course,2005 32
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Attention & Neglect

Attention
Name 5 types of attention:

Neglect
List 5 common signs of neglect:

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Spatial Domains-Label the Picture

• Personal or body space- use

objects in contact with the
body e.g. PADL’s (washing &
dressing)
• Peripersonal or reaching
space- area where objects
are grasped and moved
around the body e.g. DADL’s
(hot drink)
• Extra-personal (locomotor or
far space) – where the whole
body moves around in the
environment or point to or
throw items (e.g. walking
around)
• Label the diagram opposite

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Praxis

• Praxis is a higher order, complex cognitive-motor skill.

• Apraxia is difficult to define but it is a difficulty with completing everyday learned
movements –things that patients were previously able to do
• There are 2 systems involved in praxis :
• There are 2 types of motor apraxia:

List some common apraxia error types:

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Praxis -Terminology
Match up the definitions with the terms they are describing:

A disorder of new learning-

Apraxia
paediatrics

Dyspraxia
A social gesture

Transitive To copy after the stimuli has

stopped
Intransitive
A gesture or action with
meaning to the individual –
Meaningful something they have seen
or done before
Meaningless
To copy at the same time

Pantomime
A random movement or
gesture with no meaning

Delayed Imitation
A gesture with an object

Concurrent Imitation A disorder of learned

movement- an adult
condition

To mime or act out from

memory- with no object

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Executive Function & Memory

There are many different types of memory,
Executive Systems comprise of the
describe each one here:
mental functions needed to formulate
goals, plan how to achieve them and
carry them out effectively.

Executive function disorders can include

many different presentations, list some
common signs here:

Think of some ways you could assess

these.

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Sensation-
Complete the Table
SYSTEM LOCATION FUNCTION ASSESSMENT

Provides information about the

environment & object qualities (touch,
pressure, texture, hard, soft, sharp, dull,
pain, heat, cold )

Inner ear- stimulated by head -Postural Assessment Scale

movements and input from -Tandem stance
other senses, especially visual -Stand on one leg (high level
balance only)
-Timed Unsupported Stand
(TUSS) & eyes closed
-Functional assessment
(kitchen/PADL)
Muscles and joints activated by -Joint Position Sense testing
muscle contractions and -Functional assessment
movement (kitchen/PADL)

Provides information about objects and

persons. Helps us define boundaries as
we move through time and space.

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Sensation-
Complete the Table
SYSTEM LOCATION FUNCTION ASSESSMENT

Provides information about sounds in the

environment (loud, soft, high, low, near,
far)

Chemical receptors in the Ask the patient!

tongue-closely entwined with
the olfactory (smell) system

Provides information about different

types of smell (musty, acrid, putrid,
flowery, pungent)

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Standardised Assessments
Match up the assessments with what they are assessing:

Behavioural Inattention Test Screening of attention skills

Cognitive Assessment of Minnesota Screening of cognitive skills which

may impact on ability to drive
Chessington Occupational Therapy
Neurological Assessment Battery Assessment of visual perception,
constructional ability, sensory motor
and following instructions
Lowenstein Occupational Therapy
Cognitive Assessment
Assessment of orientation,
perception, visuomotor
Rivermead Behavioural Memory Test organisation, thinking operations

Screening of perceptual skills

Rivermead Perceptual Assessment Battery
Assessment of executive skills

Stroke Drivers Screening Assessment

Screening of cognitive skills

BADS
Memory

Test of Everyday Attention

Unilateral Spatial Neglect

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Outcome Measures
Match up the outcome measures with what they are measuring:

Ashworth Scale Power

Sensation
Oxford Scale

Posture
Tardieu Scale

Dressing
ARAT

General Functional Ability

FIM / FAM

Nottingham Sensory
Spasticity

Muscle Tone
Jebsen-Taylor Hand
Test
9 hole peg test Upper Limb Co-ordination

Nottingham Dressing
Upper Limb Function

Motor Assessment
Movement
Scale

Upper Limb Function

Postural
Assessment Scale

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Visual pathway and visual fields

Axons of the ganglion cells

leave the eyeball as the
___ _____. At the
optic chiasma, the medial
fibers of each eye cross
over to the opposite side.
The fiber tracts formed
are called _____ ____.
The optic tracts synapse
with neurons in the
lateral geniculate nucleus
of the thalamus, whose
axons form the optic
radiation, terminating in
the visual cortex of the
________ _____of the
brain.

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Visual pathway and visual fields

• What type of visual deficit might you see post
stroke?

• How would this impact on every day function?

• What are the 4 main areas of assessment for

O.T’s?

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Visual pathway and visual fields

Add the correct

answer to the 4
boxes from the
list below

•Binocular vision
•Reading
•Mobility
•Visual memory

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TREATMENT

How might you approach treating

someone with
• visual acuity,
• visual field deficit
• diplopia .

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Visual perception – OT view

Fill the gaps in the hierarchy

Visuocognition

Adaptation Through Vision

Visual Memory

Attention = Alert + Attending

Pattern Recognition

Scanning
Oculomotor Control / Visual Fields/ Acuity

Reference: Warren M (1993): A hierarchical model for evaluation and treatment of visual perceptual Dysfunction in adult acquired brain injury,
Part 1; American Journal Of OT, Jan 1993, vol. 47, number 1, p 42-54

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HANDLING A STROKE PATIENT

Identify any risks or things you would need to consider before handling this patient:

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What four factors need to be considered prior to assisting a patient to move?

1.
2.
3.
4.

What variable factors may impact on the ability of a patient to carry out the transfer from one day to the next?

Bearing this in mind, what measures should you put in place to minimise the risk to the patient, yourself and other members of
the team?

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Early Mobilisation

Current recommendations are to The decision to seat post stroke

mobilise acute stroke patients in should be based on the
bed and out of bed as early as
possible (ideally within 24 hours) to individual’s physiological
reduce complications homeostasis.
List some complications of
prolonged bed rest: Things to check would be:

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Seating Assessment - Physical

Body Part What are you looking for?
Head
Scapula
Trunk
Upper Limbs
Pelvis
Hips
Knees
Feet
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Seating Assessment -Other

Things to observe
List some things to look out for when doing a seating
assessment:

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EQUIPMENT

The tables on the next two pages cover various manual and therapeutic handling equipment. Can you fill in the pros and cons for
each one and in the “treatment ideas” column, think about when and how you might use each one.

Equipment Pros Cons Treatment ideas

Hoist

Wheelchair

Sliding
board

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Equipment Pros Cons Treatment ideas

Sliding sheet

Arjo

Samhall turner /
rotastand

Electric standing
frame

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What type of wheelchairs would you consider using with stroke patients?

What accessories and cushions could be used with stroke patients?

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Case 1:
• Independent sitting balance
• Power in lower limb 3/5 (R) and 5/5 (L)
• Power in upper limb 0/5 (R) and 5/5 (L)
• Sensory deficit in (R) lower limb: altered sensation, not absent
• BP and HR stable
What methods could you use to transfer this patient and why?

1)
2)
3)
4)

Case 2:
• Assistance of 1 for sitting balance
• Perceptual deficit – unable to maintain midline alignment in sitting
• Inattention/ neglect to the (R) with sensory deficit
• Power (R) lower limb 1-2/5 and (L) lower limb 5/5
• Power (R) upper limb 0/5 and 5/5 (L) lower limb
• Cognitive impairment – limited to one step commands with poor attention and recall

What methods could you use to transfer this patient and why?
1)

2)

3)
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Case Study 3:
Mr B is admitted to the stroke unit following a right MCA stroke.
He has left neglect, anosognosia and has been noted to be quite impulsive during initial assessment.

There is no active movement on his left side, requires two therapists to sit on the
side of the bed due to poor sitting balance head control and fatigues quickly.

Mr B is currently on a NGT feeding regime due to his dysphagia.

Explore the issues and options for Mr B’s wheelchair prescription and seating.

What methods could you use to transfer this patient and why? What else do you need to consider when treating this patient?
1)

2)

3)

4)

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TREATMENT AND MANAGEMENT OF THE UPPER LIMB

The shoulder is a complex joint and is especially vulnerable if it has been affected by a stroke. It is a shallow ball and socket joint
that is dependent on muscle activity for primary stability – rather than bony configuration.

Name the major active stabilisers of the shoulder joint:

Weakness, abnormal tone and impaired coordination of movement can lead to subluxation of the shoulder joint.
Label the types of subluxation below and indicate whether high or low tone would lead to that type of subluxation.

Unopposed Unopposed Unopposed

gravitational pull on pull of internal pull of
arm rotators elevators

is the most common type seen in stroke patients. It can be identified visually (externally or on xray)
or by palpation - by a dip where humeral head has dropped down. It can be measured in fingers for severity of subluxation.

Write down 3 complications of a subluxed shoulder:

1. ……………………………………………………………..
SUBLUXATION WILL NOT RECOVER
2. …………………………………………………………….. UNLESS THE MUSCLES RECOVER and
3. …………………………………………………………….. NEEDS TO BE MANAGED CAREFULLY

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TREATMENT AND MANAGEMENT OF THE UPPER LIMB

Put an X by the things that you SHOULD NOT do with a hemiplegic arm and a √ by the things you SHOULD do:
Make sure the patient is not lying directly on the affected shoulder
Pull a patient up by their affected arm
Pull on the arm when moving a patient in bed
Place a pillow under the affected arm (right up under the shoulder)
Let the arm hang over the edge of the chair
Use the hand as the point of contact when moving a low tone arm with no activity at the shoulder
Support the arm under the elbow when moving/positioning the patient
Careful positioning of the upper limb is very important. What prolonged positions should you avoid?
Why is it important to position the upper limb?

List possible treatment options for the hemiplegic arm:

•…………………………………………………………………………………………….
•…………………………………………………………………………………………….
•…………………………………………………………………………………………….
•…………………………………………………………………………………………….
•…………………………………………………………………………………………….
•…………………………………………………………………………………………….
•…………………………………………………………………………………………….
•…………………………………………………………………………………………….
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Management of upper limb
The loss of upper limb control is common after stroke with 88% clients having some level of UL d
dysfunction. UL evaluation should focus primarily on assessing the clients ability to integrate the
UL into performance of functional tasks, which may be limited by multiple factors such as pain,
contacture and deformity, loss of selective motor control, weakness, loss of postural control,
learned non use, loss of biomechanical alignment, inefficient and ineffective motor patterns etc.

Write down some of the components to List out some of the factors to consider
look at in an upper limb after stroke? while managing an UL after stroke?

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TONE – ASSESSMENT AND MANAGEMENT

Tone is the state of of a muscle.

It is the continuous in muscles that helps to maintain posture.

It ……………... throughout the day and in response to different situations which is normal and does not indicate a problem.

Can you list things that normally increase or decrease a persons muscle tone which we can influence as a therapist:

Increase muscle tone Decrease muscle tone

Can you highlight on the diagram where the neural and the non-neural components of hypertonia are:
CNS
Reflex hyper-excitability
LESION

Altered muscle function HYPERTONIA

Non-CNS factors Altered passive

(eg immobilisation) mechanical properties
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Find the following definitions of spasticity:

Lance (1980)

Pandyan (2005)

Complete the following table showing the features of both Upper Motor Neurone (UMN) and Lower Motor Neurone (LMN) lesions:

UMN Lesion LMN Lesion

Positive features Negative features

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Look at the following paragraphs and work out which structure or system contributing to the maintenance of normal muscle
tone is being described:

A = ...........................................................
The………A………..is a small fusiform structure lying parallel to the extrafusal muscle fibres. It consists of a
stretch receptor inside a skeletal muscle sensitive to the length of the muscle. It contains specialised cells called
intrafusal fibres that have nerve endings wrapped around their central regions. Stretch of the muscle stretches this
central region and activates the …………A……..… Ia afferents. One large muscle may have several dozen
…………A………. endings in it.

B = …………………………………………..
The most important local reflex is the …. ……B………..….. This is also known as the tendon jerk or myotactic
reflex. It is called a….. …B…….….. because there is a direct connection between the afferent and efferent nerve
cells. Only the muscle spindle afferents make a ….. ………B…………….

C = …………………………………………..
The …………C……….…. is the second major proprioceptor in muscle. It is found in musculotendinous junctions.
It is activated by muscle tension (not length). Both the spindle and …………C…………. are activated when a
muscle is passively stretched but the spindle is switched off if the muscle shortens back to its original length. The
………C……..…… is active during passive stretch and also active contraction. The …………C……. is said to be
in series with the muscle and detects tension. It’s main role is to protect muscle against excess load.

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SPLINTING

Splinting is the application of an external force to a limb to prevent

deformity and contracture secondary to the imbalances caused by neurological impairment. (Kuipers and Copley,
1999).

When might you splint? What are the Intrinsic factors influencing clinical
decisions whether to splint?

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Goal setting with the stroke patient

Guidelines:

Healthcare for London: Stroke Strategy, sets a performance standard target (Full) regarding Goal setting for
Stroke patients - Complete the following:

R14 - % of patients with negotiated within of

admission, with appropriately given to them.

Goal setting has commonly been practiced using SMART principles:

S–
M–
A–
R–
T–

However, this method is being used more commonly in conjunction with other methods/programmes by various
organisations.

Why is Goal Setting Important?

How would you go about Goal setting with a patient with Aphasia?

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Review of evidence re therapy

Applied Neuroscience:
Cohen H. (1998) Neurosciences in Rehabilitation. 3rd Ed, Lippincott Williams &
Wilkins

Functional Rehabilitation:
Gillen G (2010). Stroke Rehabilitation: a function based approach. 3rd ed, Mosby.

Motor Recovery and Plasticity:

Schaechter, J.D (2004) Motor rehabilitation and brain plasticity after hemiparetic
stroke. Progress in Neurology 73; 61-72.

Langhorne P, Coupar F, Pollock A. (2009) Motor recovery after stroke: a systematic

review. The Neurol Lancet 68; 741-754

Landers M. (2004) Treatment induced neuroplasticity following focal injury to the

motor cortex. Int J of rehabil Research 27 (1) 1-5

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Abram SG. (2003) Effectiveness of sensory and motor rehabilitation of the upper
limb following the principles of neuroplasticity: patients stable post stroke. Neuro
rehabil neural repair 17 (3) 176-191

Neglect:
Bowen A, Lincoln NB. Cognitive rehabilitation for spatial neglect following stroke.
Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD003586.
DOI: 10.1002/14651858.CD003586.pub2.

Cognition:
Grieve J, Gnanasekaran L. (2008) Neuropsychology for occupational therapists.
3rd Ed. John Wiley & Sons.

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GLOSSARY

IMPAIRMENTS

Define the following terms:

Agnosia –

Agraphia –

Akinesia –

Alexia –

Anosognosia –

Apraxia –

Aphasia –

Receptive aphasia –

Expressive aphasia –

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Ataxia –

Bradykinesia –

Clonus –

Confabulation –

Dysarthria –

Dysdiadochokinesia –

Dysgraphia –

Dysphagia –

Dysmetria -

Dysphonia –

Dyslexia –

Dyspraxia –
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Dystonia –

Echolalia –

Emotional lability –

Hemianopia –

Hypertonicity –

Hypotonicity –

Ischaemic cascade –

Ischaemic penumbra –

Neglect –

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Nystagmus –

Proprioception added
Rigidity –

Spasticity –

Stereognosis -

MEDICAL DISORDERS AND INVESTIGATIONS:

Describe the following terms:

Atrial fibrillation (AF) –

CADASIL -

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Carotid sinus syndrome –

Carotid endarterectomy (CEA) –

Carotid Doppler Ultrasound –

Decompressive craniectomy –

Epilepsy –

Haemorrhagic transformation –

Moyamoya disease –

Postural hypotension –

Thrombolysis –

Todd’s paralysis -

Lacunar infarct -

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MEDICATIONS
What are the main uses for these drugs?

Drug name Main use

Amitriptyline

Aspirin

Gabapentin

Dantrolene

Baclofen

Tizanadine

Alteplase

Metocoplramide, promethazine

Betahistine

Diazepam

Clopidogrel

Statins
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RESOURCES

South London Cardiac and Stroke Network – www.slcsn.nhs.uk

Evidence/Research

 http://www.cochrane.org/reviews/en/ab002840.html

 http://www.library.nhs.uk/default.aspx (requires athens login)

 http://www.evidence.nhs.uk/default.aspx

 http://www.improvement.nhs.uk/stroke/

Guidelines

 http://www.healthcareforlondon.nhs.uk/

 http://www.nice.org.uk/

 www.rcplondon.ac.uk/

 National clinical guideline for stroke (RCP)

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Organisations

 http://www.stroke.org.uk/

 http://www.strokecare.co.uk/

 http://www.headway.org.uk

 http://www.brainandspine.org.uk

 http://www.differentstrokes.co.uk/

Other useful links

 London Stroke Strategy

 http://www.nhs.uk/ACTFAST/Pages/stroke.aspx

 http://www.uksrn.ac.uk/ (The library section contains several links to relevant presentations)

 http://www.ebrsr.com/

 http://bnf.org/bnf/bnf/58/104945.htm

 www.salisburyfes.com

 National Sentinel Stroke Audit Phase II (clinical audit) 2008

 Consensus Statement on Physiotherapy Intervention Following Stroke

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Clinical Trials

 http://www.so2s.co.uk/ - multicentre randomised controlled trial to assess whether routine oxygen improves long-term
outcome after stroke

 http://www.dcn.ed.ac.uk/ist3/ - currently the worlds largest thrombolysis trial, it is a multicentre trial in which St
George’s is one of the centres participating

Suggested reading

 Neuroscience for Rehabilitation, Helen Cohen. Lippincott, Williams & Wilkins, Ohio. Good overview of neuroscience.

 Stroke Medicine, Hugh Markus, Anthony Pereira & Geoffrey Cloud. Oxford Specialist Handbooks.

•Neuropsychology for Occupational Therapists second edition - June Grieve

•Occupational Therapy and Stroke second edition - Judi Edmans

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