Occupational Therapy and Stroke

Second Edition

Edited by

Judi Edmans On behalf of the Stroke Clinical Forum of the College of Occupational Therapists Specialist Section Neurological Practice

A John Wiley & Sons, Ltd., Publication

Occupational Therapy and Stroke

Occupational Therapy and Stroke

Second Edition

Edited by

Judi Edmans On behalf of the Stroke Clinical Forum of the College of Occupational Therapists Specialist Section Neurological Practice

A John Wiley & Sons, Ltd., Publication This edition first published 2010 C ! 2010 Blackwell Publishing Ltd

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Library of Congress Cataloging-in-Publication Data

Occupational therapy and stroke / edited by Judi Edmans on behalf of the Stroke Clinical Forum of the College of 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 Section Neurological Practice. Stroke Clinical Forum. [DNLM: 1. Stroke–therapy. 2. Disabled Persons–rehabilitation. 3. Occupational Therapy–methods. WL 355 O15 2010] RC388.5.O33 2010 616.8"1062–dc22 2010003297

A catalogue record for this book is available from the British Library.

R Set in 10/12.5 pt Times by Aptara! Inc., New Delhi, India Printed in Malaysia

12010 Contents

List of Contributors ix Foreword xi Preface xiii Acknowledgements xv

1Introduction 1 Judi Edmans, Fiona Coupar and Adam Gordon Definition of stroke 1 Impact of stroke 1 Symptoms of stroke 2 Causes of stroke 3 Classification of stroke 4 International Classification of Functioning, Disability and Health 4 Medical investigations following stroke and TIA 6 The prevention of recurrence of stroke (secondary prevention) 7 Neuroanatomy 9 Damage that can occur in different areas of the brain 13 Policy documents relating to stroke 13 Self-evaluation questions 23

2TheoreticalBasis 24 Janet Ivey and Melissa Mew Introduction 24 Theoretical constructs 24 Conceptual models of practice 25 Frames of reference 27 Neuroplasticity 29 Intervention approaches 36 Self-evaluation questions 47 vi Contents

3TheOccupationalTherapyProcess 49 Melissa Mew and Janet Ivey Introduction 49 The occupational therapy process 49 Procedural reasoning in different stroke care settings 53 Professional duties 60 Self-evaluation questions 63

4EarlyManagement 64 Sue Winnall and Janet Ivey Introduction 64 Prior to assessment 64 Initial interview 66 Initial assessment 67 Intervention 75 Equipment 75 Other impairments impacting on functional ability 77 Swallowing 80 Mood 81 Fatigue 83 Self-evaluation questions 84

5ManagementofMotorImpairments 86 Stephanie Wolff, Ther´ ese` Jackson and Louisa Reid Introduction 86 Assessment 86 Management principles and intervention 90 Therapeutic aims of intervention 91 Positioning the early stroke patient 91 Clinical challenges 109 Upper limb re-education 111 Avoiding secondary complications 112 Self-evaluation questions 116

6ManagementofVisualandSensoryImpairments 117 Melissa Mew and Sue Winnall Introduction 117 Visual processing 119 Somatosensory processing 127 Auditory processing 137 Vestibular processing 139 Olfactory and gustatory processing 141 Self-evaluation questions 142 Contents vii

7ManagementofCognitiveImpairments 144 Ther´ ese` Jackson and Stephanie Wolff Definition of cognition 144 Cognitive functions 144 Assessment of cognitive functions 144 Cognitive rehabilitation 146 Attention 147 Memory 149 Language 151 Motor planning and apraxia 151 Executive dysfunction 155 Self-evaluation questions 157

8ManagementofPerceptualImpairments 158 Louisa Reid and Judi Edmans Introduction 158 Definition of perception 158 Normal perception 158 Perceptual impairments 160 Perceptual assessment 162 Intervention 165 Self-evaluation questions 172

9Resettlement 173 Pip Logan and Fiona Skelly Home visits 173 Community rehabilitation 174 Support available after a stroke and self-management 177 Carers 178 Younger people 180 Lifestyle and long-term management 180 Leisure rehabilitation 181 Getting out of the house and transport 183 Driving after stroke 185 Vocational rehabilitation 186 Resuming sexual activity 188 Stroke education 189 Self-evaluation questions 190

10 Evaluation 191 Fiona Coupar and Judi Edmans Record keeping 191 Standardised assessments 195 Evidence-based practice (EBP) 199 viii Contents

Outcome measures 203 Standards 206 Self-evaluation questions 207

Appendix: One-Handed Techniques 208 References 212 Definitions 229 Useful Books 231 Useful Organisations 233 Index 241 List of Contributors

Fiona Coupar, University of Glasgow, Glasgow Dr Judi Edmans, University of Nottingham, Nottingham Dr Adam Gordon, University of Nottingham, Nottingham Janet Ivey, Llwynypia Hospital, RCT, Mid-Glamorgan, South Wales Ther´ ese` Jackson, NHS Grampian, Scotland Dr Pip Logan, University of Nottingham, Nottingham Melissa Mew, Bournemouth University, Bournemouth Louisa Reid, National Hospital for Neurology and Neurosurgery, London Fiona Skelly, Community Rehabilitation Team, Rotherham Sue Winnall, Mile End Hospital, London Stephanie Wolff, Manchester Royal Infirmary, Manchester

Foreword

Occupational therapists working with people who have had a stroke will be delighted to learn that there is a new edition of this popular textbook. The book has again been produced on behalf of the College of Occupational Therapists Specialist Section Neurological Practice, under the enthusiastic editorship of Dr Judi Edmans. Since the last edition, the text has been substantially and comprehensively updated in terms of the research evidence presented. It has also been placed in the context of national developments and initiatives in stroke care to span the entire stroke spectrum – from aetiology through to resettlement and evaluation. However, it still remains a practical guide, written in user-friendly terms, which provides an excellent reference manual for both those starting out in the stroke field and established practitioners. The overall format and structure of the book is clear and logical. The addition of good-quality illustrations brings the text to life, and many will find the self-evaluation questions with each chapter useful. Special mention must go to Chapter 1 which provides acomprehensivebackgroundtostrokeandtoChapter4onearlymanagement. Above all, the book underlines the important and unique role of occupational therapy in the treatment and care of people with a stroke. Dr Avril Drummond Associate Professor in Rehabilitation University of Nottingham

Preface

This book is a timely update of the first edition of Occupational Therapy and Stroke (Edmans et al.,2001).AlthoughtargetedforpracticeintheUK,thefirsteditionsoldover 5000 printed copies with countless hits from e-book access worldwide and has proven to be a well-thumbed and well-known book for occupational therapists working in stroke all over the world. Since the last edition of the book, evidence-based quality stroke services have come to the forefront of the government agenda throughout the UK with the release of national stroke guidelines, stroke service strategies and initiatives such as the Stroke Research Networks, the Stroke Association’s annual multidisciplinary UK Stroke Forum conference and an imminent Stroke-Specific Educational Framework. It is an exciting time to work in stroke services, and this book is intended to compliment these works to provide a more in-depth, practical, evidence-based guide for occupational therapy students, newly qualified occupational therapists, those new to stroke management and those who have been working in stroke for some time wanting to refresh the foundations of their knowledge and skills. The reader will notice substantial changes since the last edition including use of the International Classification of Functioning Disability and Health [World Health Organi- sation (WHO), 2002], orientation to updated policy documents (Chapter 1), standards and audits (Chapter 10), neuroplasticity (Chapter 2), procedural reasoning in different stroke care settings (Chapter 3) and more detailed user-friendly chapters on early management and screening (Chapter 4), management of impairments (Chapters 5–8) and resettle- ment (Chapter 9). Therapeutic/clinical challenges have been integrated into appropriate sections with self-evaluation questions to support therapists’ commitment to continuous professional development at the end of each chapter. Throughout this book, the client or service user is referred to as ‘the patient’, for ease of terminology, irrespective of whether they are being treated in hospital or in the community. This by no means undervalues occupational therapists, key principle of client- centred practice to empower the patient to actively participate in partnership and negotiate goals in the rehabilitation process (Sumsion, 2000). Similarly, treatments are referred to as ‘interventions’, remedial approaches are referred to as ‘restorative’ approaches and compensatory/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 kept fellow contributors (from the 2009 stroke clinical forum committee members of the xiv Preface

College of Occupational Therapists Specialist Section Neurological Practice and returning authors Ther´ ese` Jackson and Fiona Skelly) on target to reach tight deadlines. Finally, the reader is reminded that the contents of this book should be reviewed in light of new ideas, research evidence and practice as they emerge. Suggestions for improvements to future editions would be gratefully received and should be forwarded to Dr Judi Edmans, Division of Rehabilitation and Ageing, University of Nottingham Medical School, Queens Medical Centre, Nottingham NG7 2UH. Melissa Mew Stroke Clinical Forum Secretary 2008–09 College of Occupational Therapists Specialist Section Neurological Practice Acknowledgements

IwouldliketogiveparticularthankstoMelissaMewforherimmenseassistancein editing the book; all the contributors for their contributions and editing suggestions; Dr Iris Musa and Mary Warren for permitting us to include their figures in the book; the College of Occupational Therapists Specialist Section Neurological Practice for funding to enable us to update the book; and last but not least, my long-suffering husband, Mr Paul Fowler, not only for acting as a model for the dressing photographs but also for his endless support and patience during the time taken to update this book. Dr Judi Edmans Editor

Chapter 1 Introduction Judi Edmans, Fiona Coupar and Adam Gordon

This chapter includes: Definition, impact, symptoms, causes, classification of stroke r International Classification of Functioning, Disability and Health (ICF) r Medical investigations r Secondary prevention r Neuroanatomy r Damage to different areas of brain r Policy documents: strategies and guidelines r Self-evaluation questions r Stroke is a complex condition where the knowledge base is continuously increasing. There are constant advances in the understanding of the condition, assessment and intervention techniques. Occupational therapists are a vital component in the rehabilitation of patients with this condition. It is vital that they understand the condition itself and the theoretical basis for intervention.

Definition of stroke

The World Health Organization (WHO) defines stroke as ‘a clinical syndrome, of pre- sumed vascular origin, typified by rapidly developing signs of focal or global disturbance of cerebral functions lasting more than 24 hours or leading to death’ (WHO, 1978).

Impact of stroke

Stroke 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 stroke each year (Office of National Statistics, 2001). Stroke is the third most common cause of death, after heart disease and cancer, with over 67,000 deaths each year (British Heart Foundation, 2005). However, the most significant and lasting impact of stroke is long-term disability. Stroke is the single, greatest cause of complex and severe adult disability in 2 Occupational Therapy and Stroke the UK (Wolfe, 2000; Adamson et al., 2004). A third of people who have a stroke will have some long-term disability (National Audit Office (NAO), 2005). Common problems following stroke include aphasia, physical disability, loss of cognitive and communication skills, depression and other mental health problems. In addition to the individual impact, stroke places a significant burden on health and social services. In England alone, stroke costs the National Health Service (NHS) and the economy about £7 billion a year: £2.8 billion in direct costs to the NHS, £2.4 billion of 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 among the most expensive, with unnecessarily long lengths of stay and high levels of avoidable disability and mortality (Leal et al.,2006).

Symptoms of stroke

The 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. r Sudden loss or blurring of vision in one or both eyes. r Sudden difficulty speaking or understanding spoken language. r Sudden confusion. r Sudden or severe headache with no apparent cause. r Dizziness, unsteadiness or a sudden fall, especially with any of the other signs. r 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. These may include a variety of abnormalities, which will be described further in later chapters.

Face–Arm–Speech Test The National Stroke Strategy for England (Department of Health (DH), 2007) highlighted the 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 partnership with other stroke organisations and experts. The awareness campaign highlights that stroke is a medical emergency and time is essential to protect the brain from excess damage. Therefore, it is essential for people to recognise 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 3

Anyone exhibiting any of these signs should be treated as an emergency with 999 being called to get the patient to hospital as quickly as possible, to receive the treatment they need. 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 stroke

The main causes of stroke are as follows.

Ischaemia leading to infarction This describes impairment of blood supply to part of the brain, resulting initially in dysfunction and then tissue death (infarction). The causes of cerebral infarct are classi- fied according to the TOAST (Trial of Org 10172 in Acute Stroke Treatment) (Adams et al.,1993)classificationas:

Large artery occlusion (usually carotid or middle cerebral artery occluded by thrombus r or embolism). Cardioembolism (clot from the heart, most commonly the atrial appendages, migrating r to the cerebral arteries, causing blockage and stroke). Small vessel occlusion (thrombus or embolism in the smaller cerebral arteries, causing r alacunarinfarct). Other aetiologies (e.g. generalised brain underperfusion, causing infarcts in the water- r shed territories).

Haemorrhage This is usually intracerebral haemorrhage (i.e. within the body of the brain) but can be subarachnoid haemorrhage (i.e. between the arachnoid mater and the brain). Intracerebral haemorrhages are commonly caused by hypertension-related changes in the small intracerebral arteries but can, less commonly, be caused by aneurysms (out- pouchings of the arterial wall) or arteriovenous malformations (abnormal communications between arteries and veins).

Transient ischaemic attack Transient ischaemic attack (TIA) is a term used to describe symptoms of stroke, resolving within 24 hours. This does not represent a completed stroke but is, instead, caused by 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 a physician as an emergency, ideally within 24 hours of presentation (Intercollegiate Stroke Working Party (ISWP), 2008). 4 Occupational Therapy and Stroke

Classification of stroke

Bamford et al. (1991) described a classification of cerebral infarction to help clinicians identify the part of the brain affected. This classification is based on the signs and symptoms that patients experience and is now widely used. It is useful because it correlates to prognosis. Thus, based on a bedside examination, a clinician can make predictions about survival and long-term dependency in order to inform management decisions and discussions with patients/relatives. The Bamford (or Oxford) classification is as follows:

Total anterior circulation stroke (TACS) All of the following: –Motor/sensorydeficitaffectinggreaterthantwo-thirdsofface/arm/leg. –Homonymoushemianopia. –Newdisturbanceofhighercorticalfunction. Partial anterior circulation stroke (PACS) –AnytwoofthecomponentsofaTACS. – 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: –Cranialnervepalsyandcontralateralmotor/sensorydeficit. –Bilateralmotor/sensorydeficit. –Conjugateeyemovementproblems. –Cerebellardysfunction. –Isolatedhomonymoushemianopia. Lacunar infarction (LACI) Greater than two-thirds of arm/face/leg affected by: –Puremotorstroke. – Or pure sensory stroke. – Or pure sensorimotor stroke. – Or ataxic hemiparesis.

Disorders of higher cortical dysfunction commonly include aphasia, decreased level of consciousness, neglect syndromes, apraxia and agnosia syndromes.

International Classification of Functioning, Disability and Health

The 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, stroke patients often present with complex impairments which are a challenge for rehabilitation teams. The ICF provides a means of understanding and describing health status. It takes Introduction 5

Image not available in this electronic edition.

Figure 1.1 Model of disability that is the basis for ICF. (Reproduced by permission from WHO, 2001, with permission of World Health Organisation, p. 9.) account of impairments of body structure and function and how these interact with personal and environmental factors to affect patient’s activities and participation in the wider world. Figure 1.1 illustrates the interactions between different aspects of the ICF. The domains of the ICF are as follows:

Body functions:physiologicalfunctionsofbodysystems(includingpsychological functions), for example, mental, neuromusculoskeletal and movement-related func- tions Body structures:anatomicalpartsofthebodysuchasorgans,limbsandtheircompo- nents, for example, nervous system structures and structures related to movements Impairments (of body function and structure): abnormal body functions and structures such as a significant deviation or loss, for example, hemiparesis following stroke Activity:executionofataskoractionbyanindividual,forexample,dressing Activity limitations:difficultiesanindividualmayhaveinexecutingactivities,for example being unable to dress due to hemiplegia Participation:involvementinalifesituation,forexample,attendingasocialgathering Participation restrictions:problemsanindividualmayexperienceininvolvementin life situations due to the activity limitation, for example, being unable to visit family and friends due to difficulty dressing Environmental factors:physical,socialandattitudinalenvironmentinwhichpeople live and conduct their lives, for example, legal and social structures, architectural characteristics, coping styles, social background and experiences Personal factors:factorsuniquetothepatient,whichimpactupontheirhealthstatus, 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 and participation restrictions. 6 Occupational Therapy and Stroke

Medical investigations following stroke and TIA

Medical investigations following stroke and TIA are performed to:

Confirm the diagnosis of stroke. r Determine the site and type of stroke. r Establish the cause(s) of the stroke. r Guide treatment to prevent further strokes. r Computerised tomography or magnetic resonance imaging Imaging (either computerised tomography (CT) or magnetic resonance imaging (MRI)) helps to establish the pathological diagnosis by detecting either cerebral infarction or haemorrhage. The distinction between haemorrhage and infarction is important as treat- ment with aspirin or anticoagulants is likely to be indicated for cerebral infarction but would be contraindicated in cerebral haemorrhage. A CT scan should therefore be per- formed on all patients within 24 hours of a stroke (ISWP, 2008). It is also useful for excluding other intracranial pathologies that mimic stroke, for example, tumours or subdural haematomas. Practice varies with regard to routine scanning of TIAs; it is, however, increasingly common for physicians to perform a CT scan on these 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 can arise 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 CT and can be used in this context. Diffusion-weighted MRI, in particular, can be used to separate 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 and cerebellum because these parts of the brain are surrounded by dense bony structures, which generate artefacts on CT scanning.

Blood tests On 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 tests include the following:

Full blood count:Tolookforrareconditionswhichpredisposetostrokesuchas polycythaemia (increased red cells) and thrombocytosis (increased platelets) and conditions that predispose to haemorrhage, such as thrombocytopaenia (decreased platelets). To exclude leucocytosis (raised white cell count) which might indicate systemic infection (e.g. aspiration pneumonia) or intracerebral infection mimicking stroke (e.g. encephalitis, cerebral abscess). Erythrocyte sedimentation rate (ESR):Ifthisiselevated,itsuggestsinfection,vas- culitis or carcinoma and may prompt further investigation. Introduction 7

Blood sugar:Hypoglycaemiaatpresentationisarecognisedstrokemimic,whilst diabetes mellitus is a risk factor for stroke. Therefore, all patients should receive a bedside finger-prick glucose test and formal laboratory glucose level. Fasting lipids:Hyperlipidaemiaisarecognisedriskfactorforstrokeandlipidsshould be checked in all patients. Clotting screen:Coagulationtestsarenecessaryinpatientswithhaemorrhagicstroke. An international normalised ratio (INR) should be checked urgently in any patient who has a stroke whilst on warfarin. Thrombophilia screen:Patientspresentingwithvenoussinusthrombosisshouldbe checked for an inherited tendency towards clot formation (factor V Leiden, protein C deficiency, protein S deficiency, lupus anticoagulant). This should only be considered in arterial thrombosis for younger patients where no alternative risk factor for stroke is identified (Hankey et al.,2001).

Cardiac investigations There is a cardiac source of embolism in 20% of cases of cerebral infarction (Sandercock et al.,1989).Electrocardiogramshouldthereforebeperformedinallpatientstoinvestigate atrial fibrillation or evidence of structural heart disease. Echocardiogram is performed in patients where intracardiac thrombus or structural heart disease, particularly valvular disease, is suspected. In many centres, it is routine to do echocardiograms in all patients presenting with atrial fibrillation.

Carotid ultrasound This is performed to look for internal carotid artery stenosis. The technique involves imaging of the artery with measurement of blood flow velocity, which allows an estimation of the degree of vessel stenosis to be made.

Magnetic resonance angiography This is now used widely in clinical practice. Images can be obtained at the same time as standard and diffusion-weighted MRI, making the investigation only marginally longer. It is non-invasive and is therefore preferred to catheter digital subtraction angiography in most instances. This procedure is completed to allow 3D reconstructions of the arterial and venous cere- bral circulations, which can allow identification of thrombus, arterial stenosis/occlusion and dissection.

The prevention of recurrence of stroke (secondary prevention)

Following stroke, many strategies are used to help prevent recurrence. General measures are recommended in all patients, such as reducing body mass index, adopting a diet low 8 Occupational Therapy and Stroke in 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 the absence of medications.

Antiplatelet agents Based upon current clinical trial evidence, aspirin prescribed after acute stroke will prevent about 11 strokes for every 1000 patients treated (Chinese Acute Stroke Trial (CAST) Collaborative Group, 1997; International Stroke Trialists (IST), 1997). The optimal dosage appears to be between 50 and 150 mg, with higher doses increasing risk of gastrointestinal bleeding 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 relative risk of stroke compared with aspirin alone (Halkes et al.,2008).Currentrecommended practice in the UK is to prescribe patients 300 mg of aspirin daily for the first 2 weeks following an ischaemic stroke, with aspirin 75 mg used in conjunction with dipyridamole following this (ISWP, 2008). Clopidogrel is an alternative antiplatelet agent, used in combination with aspirin follow- ing acute coronary syndromes. This combination, if used following stroke, increases the risk of cerebral haemorrhage and so tends to be avoided (Diener et al.,2004;Bhattet 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. In many areas this treatment is therefore reserved for patients where aspirin cannot be given due to intolerance.

Blood pressure Hypertension should be aggressively treated following a stroke. The target blood pressure following a stroke is 130/80 (ISWP, 2008). Current evidence favours prescription of thi- azide diuretics and angiotensin-converting enzyme (ACE) inhibitors over other types of antihypertensives (PROGRESS Collaborative Group, 2001). Angiotensin receptor block- ers (ARBs) are used where ACE inhibitors cannot be tolerated due to cough.

Hyperlipidaemia There is now good evidence that medications to reduce serum low-density lipoprotein cholesterol reduce the incidence of stroke (Smilde et al.,2001;Kasteleinet al., 2008). Current data suggest that statin drugs (simvastatin, atorvastatin, rosuvastatin) promote regression of cholesterol plaques in the carotid arteries (Smilde et al.,2001).

Anticoagulants Clinical trials have demonstrated the benefit of warfarin in the prevention of stroke in patients with atrial fibrillation (Mant et al.,2007). Introduction 9

There is a risk of haemorrhage for patients taking warfarin, and a careful consideration of the balance of risks and benefits must be undertaken in any patient where it is to be commenced. Contraindications include a bleeding tendency (e.g. recent peptic ulceration or haemorrhagic bladder tumour), high falls risk, alcohol dependency (alcohol interacts with warfarin) and an inability to follow instructions to take the medicine safely (which may 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 endarterectomy Trials have shown that this operation to widen the internal carotid artery is beneficial in 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 should be limited to patients with reasonable functional status and salvageable brain tissue in the vascular territory under consideration. Therefore, bed-bound patients with large total anterior circulation strokes are not appropriate for this therapy.

Preventative neurosurgery Patients who have suffered from haemorrhagic stroke (primary intracerebral haemorrhage, subarachnoid haemorrhage) and who have an underlying arterial abnormality, such as an aneurysm or arteriovenous malformation, may benefit from neurosurgical techniques such as aneurysm clipping or embolisation of arteriovenous malformations.

Neuroanatomy

The brain is divided into four main areas:

Forebrain r –Cerebrumdividesintotwohemisphereswithfourlobes(frontal,parietal,temporal and occipital lobes) (Figure 1.2). –Internalcapsule(Figure1.3). –Basalganglia(caudatenucleus,globuspallidusandputamen)(Figure1.4). –Diencephalon(thalamusandhypothalamus)(Figure1.3). Midbrain (brainstem) (Figure 1.3) r –Mesencephalon(midbrain). –Pons. –Medullaoblongata. Hindbrain r –Cerebellum(Figure1.2). Spinal medulla (spinal cord) (Figure 1.3) r 10 Occupational Therapy and Stroke

Precentral Central Postcentral gyrus sulcus gyrus Frontal lobe Parietal lobe

Occipital lobe

Lateral sulcus Cerebellum Temporal lobe Pons Medulla oblongata

Figure 1.2 Lateral view of the brain. (Reproduced by permission of Pearson Education Inc from Martini, 2006, Figure 14-12b, p. 471.)

Left cerebral Gyri Cerebrum hemisphere • Conscious thought processes, intellectual functions Sulci • Memory storage and processing • Conscious and subconscious regulation of skeletal muscle contractions Fissures

Diencephalon Thalamus • Relay and processing centres for sensory and motor information

Hypothalamus • Centres controlling emotions, autonomic functions and hormone production Cerebellum Mesencephalon Brainstem • Coordinates complex • Processing of visual Spinal somatic motor and auditory data patterns • Generation of reflexive cord • Adjusts output of somatic motor other somatic motor responses centres in brain • Maintenance of and spinal cord consciousness

Pons • Relays sensory Medulla oblongata information to • Relays sensory information to thalamus cerebellum and and to other portions of the brain stem thalamus • Autonomic centres for regulation of visceral • Subconscious function (cardiovascular, respiratory and somatic and visceral digestive system activities) motor centres

Figure 1.3 The diencephalon and brainstem structures of the brain. (Reproduced by permission of Pearson Education Inc from Martini, 2006, Figure 14-1, p. 453.) Introduction 11

Head of caudate nucleus Lentiform nucleus

Tail of caudate nucleus Amygdaloid body Thalamus

(a)

Head of Lateral Corpus Internal caudate nucleus ventricle callosum capsule

Insula

Amygdaloid body

Putamen Anterior Tip of lateral Lentiform commissure ventricle nucleus Globus pallidus (b) Frontal section Figure 1.4 Frontal section of the brain showing the basal nuclei, internal capsule and thalamus. (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 two r major arteries: –Anteriorcerebralartery. –Middlecerebralartery. The posterior circulation comprising two vertebral arteries which lead to: r –Posteriorinferiorcerebellarartery. – Basilar artery. –Posteriorcerebralartery. The anterior circulation can also be divided into right and left circulations, as there is a carotid artery on each side. Because the vertebral arteries join quite low down the brainstem, most of the posterior circulation is supplied by a single basilar artery. 12 Occupational Therapy and Stroke

Anterior cerebral Anterior communicating Anterior cerebral Cerebral Internal carotid (cut) arterial Posterior communicating circle Posterior cerebral Middle cerebral Pituitary gland Superior cerebellar Basilar

Anterior inferior cerebellar Vertebral Posterior inferior cerebellar

Figure 1.5 Arteries of the brain. (Reproduced by permission of Pearson Education Inc from Martini, 2006, Figure 21.23, p. 741.)

Territory of Territory of anterior middle cerebral artery cerebral artery

Internal capsule

Claustrum

Body of caudate

Thalamus Putamen Globus pallidus

Red nucleus

Subthalamic nucleus

Territory of Cerebral peduncle posterior cerebral artery Territory of anterior choroidal artery (lower 2/3 of internal capsule, pallidum, uncus, amygdala, Uncus Territory of penetrating branches anterior hippocampus) of middle cerebral artery (putamen, upper internal capsule, lower corona radiata, body of caudate) Figure 1.6 Frontal section of the left hemisphere showing the arterial supply. (Reproduced by permission of McGraw-Hill from Kandel et al.,2000,FigureC-2,p.1304.) Introduction 13

If each of these circulations existed in isolation, then blockage of either carotid or the basilar artery would result in extensive, life-threatening infarction. This does not occur, however, because of anterior and posterior communicating arteries which connect the brain arteries into an anatomical circle, known as the circle of Willis. Thus when one vessel is blocked, an alternative (or collateral) blood supply is available. There is considerable variation between individuals with regard to how effective their communicating arteries are, and thus collateral circulation, is. Thus carotid, or basilar, occlusion can result in life-threatening stroke for some individuals and will pass unnoticed by 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 result in different severities of stroke in different patients.

Damage that can occur in different areas of the brain

Each hemisphere has specialised functions known as hemispheric lateralisation. For ex- ample, the left hemisphere senses and controls movement on the right side of the body and specialises in language-based skills such as reading, writing and speaking, and per- forms analytical tasks such as mathematics and logical reasoning. Oppositely, the right hemisphere senses and controls movements on the left side of the body and is specialised in more creative, spatial and interpretive skills (Figure 1.7). Testani-Dufour and Morrison (1997) summarised the arterial supply of the brain and the results of occlusion to those arteries. They also summarised the functions of the different areas of the brain and the impairments that can occur as a result of damage (occlusion) to those areas. This information is collated in Tables 1.1–1.3, but should not be considered as a definitive list.

Policy documents relating to stroke

Over 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 documents being published, all of which aim to reduce stroke incidence, improve services and increase awareness. The first notable policy document related specifically to stroke was published by the DH in 2001.

National Services Framework for older people The National Services Framework (NSF) for older people (DH, 2001) is a comprehensive strategy to ensure fair, high-quality, integrated health and social care services for older people. It is a 10-year programme of action linking services to support independence and promote good health, specialised services for key conditions and a culture change so that all older people and their carers are treated with respect, dignity and fairness. This NSF sets eight standards for the care of older people across health and social services. 14 Occupational Therapy and Stroke

Left Hand Right Hand

Prefrontal Prefrontal cortex cortex

Speech centre Anterior commissure

Writing Analysis by touch

Auditory Auditory cortex cortex (right ear) (left ear)

General interpretive Spatial centre visualisation (language and and analysis mathematical calculation)

Visual cortex Visual cortex (right visual field) (left visual field)

Left Right Hemisphere Hemisphere

Figure 1.7 Hemispheric lateralisation of the brain. (Reproduced by permission of Pearson Education Inc from Martini, 2006, Figure 14-6, p. 477.)

Standard five of the NSF is specific to stroke and aims to reduce the incidence of stroke in the population and ensure that those who have had stroke have prompt access to integrated stroke care services. This standard sets out four components for the development of integrated stroke services: Prevention, including the identification, treatment and follow-up of those at risk of r stroke. Immediate care, including care from a specialist stroke team. r Introduction 15

Table 1.1 Areas of the brain and the results of occlusion to arteries in those areas.

Functions Impairments

Frontal lobe Concentration Impairments Anterior Cerebral Artery and • Abstract thought Middle Cerebral Artery • Memory Memory • Judgement • Abstract thinking • Ethics • Judgement • Insight • Ethical behaviour • Emotion • Emotions • Tact • Insight • Inhibition • Tact • Sequencing thoughts • Inhibition • Evaluates consequences of actions • • Solves intellectual problems • Morality • Motor function • Broca’s area Expression of speech Movement problems, trunk, limbs, eyes • Word formation • Non-fluent aphasia • Articulation • Oral apraxia • Pronunciation • • Voice and speech production • Parietal lobe Interpretation of sensory input Sensory impairments • Contralateral sensation • Unilateral neglect • –Two-pointdiscrimination • –Pressure –Weight –Texture – Body interpretation – Orientation –Pain –Proprioception Recognises nature of complex • objects by touch and form

Temporal lobe Auditory area Impairments Middle Cerebral Artery and • Wernicke’s area: Posterior Cerebral Artery • –Receiveanddiscriminatesounds Wernicke’s aphasia –Interpretationofsounds • Comprehension Olfactory area • Repetition of speech • Detailed memories, especially those • Jargon • involving more than one sensory • Reading comprehension modalities (dominant side) • Occipital lobe Visual reception Visual and interpretative disorders • Visual association • Contralateral field disorders, e.g. • Detects spatial organisation of • quadrantanopia/hemianopia • vision, shapes, colours, contrasts Partial visual field loss Secondary complex visual • Altered perception • interpretation •

(Continued) 16 Occupational Therapy and Stroke

Table 1.1 (Continued)

Functions Impairments

Perception of form and meaning • Eye fixation • Thalamus Sensory and motor pathways Contralateral hemiplegia • contact thalamus except olfactory • Contralateral hemisensory impairments pathways • Vertical and lateral gaze • Central post-stroke pain • Basal ganglia Production of dopamine Movements and posture disorders, such as: • Coordination of muscle movements • –Tremor • and posture –Rigidity –Chorea – Athetosis –Dystonia –Hemiballismus

Midbrain Synthesises dopamine Motor visual problems • Protects basal ganglia • Parkinsonism • • Auditory and visual reflexes interrupted • Pons Transmits information from cerebral Sensory and motor problems • cortex to brainstem and between • Altered mastication and facial sensations two hemispheres • Altered eye movement and eyelid closure Sensory pathways pass through • Altered taste, facial expression, salivation, • pons • equilibrium and hearing Regulates respiratory system Respiratory insufficiency • • Medulla Blood pressure and respiratory Persistent vegetative state • regulation • Contralateral sensory and motor Maintenance of arousal • impairments • Initiation of sleep Altered postural sense, proprioception, • • vibration Respiratory insufficiency • Cardiac/vasomotor dysfunction • Swallowing • Head and shoulder movement • Tongue movement • Salivation and pharyngeal function •

Cerebellum Receives proprioceptive input Poor coordination and fine dexterity • Maintains equilibrium • Gait ataxia • Coordinates automatic movement • Intention tremor • Regulates muscle tone • Diadochokinesia • • Dysmetria • Hypotonia • Asthenia • ACA, anterior cerebral artery; MCA, middle cerebral artery; PCA, posterior cerebral artery. Introduction 17

Table 1.2 Anterior arterial supply of the brain and the results of occlusion to those arteries.

Supplies Occlusion

Ophthalmic artery Orbit Transient mononuclear blindness (amaurosis fugax) • Optic nerve • Complete unilateral blindness • • Anterior choroidal artery Deep structures of the brain Contralateral hemiplegia, hemihypesthesia, • (basal ganglia, thalamus, • homonymous hemianopia posterior limb of internal capsule and medial temporal lobe)

Anterior cerebral artery Anterior three-quarters of Contralateral sensory and motor impairments foot • medial surface of cerebral • and leg greater than arm hemisphere Face and hand not usually involved Portions of the basal ganglia • Incontinence • Internal capsule • Deviation of eyes and head towards lesion • • Contralateral grasp reflex • Abulic symptoms (apathy, decreased spontaneity, • limited speech) Left Anterior Cerebral Artery Arm apraxia • Expressive aphasia Distal• Anterior Cerebral Artery Contralateral upper and lower extremity weakness • Contralateral sensory loss in foot • Motor and/or sensory aphasia • Middle cerebral artery Basal ganglia Complete occlusion • Fibres of internal capsule Contralateral gaze palsy • Cortical surfaces of the • Hemiplegia • parietal, temporal and • Hemisensory loss frontal lobes • 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 Stroke

Table 1.3 Posterior arterial supply of the brain and the results of occlusion to those arteries.

Supplies Occlusion

Vertebral artery Anterolateral parts of the medulla Lateral medullary syndrome • Contralateral impairment pain and • temperature sensation Ipsilateral Horner’s syndrome • Dysphagia • Decreased gag reflex • Vertigo • Nystagmus • Ataxia • Posterior–inferior cerebellar artery Medulla Occlusion medial branch • Cerebellum Vertigo • • Nystagmus • Ataxia • Persistent dizziness Occlusion• lateral branch Unilateral clumsiness • Gait and limb ataxia • Inability to stand or sudden fall often • Vertigo • Dysarthria • Nystagmus • Eye deviation • Basilar artery Pons Limb paralysis • Midbrain • Bulbar or pseudobulbar paralysis of the • • cranial nerve motor nuclei Nystagmus • Eye movement disturbance • Coma •Complete occlusion Locked in syndrome • Consciousness with complete motor • paralysis, inability to communicate orally or by gesture Posterior choroidal artery Third ventricle Not seen • Dorsal surface of thalamus • • Posterior cerebral artery Occipital lobe Contralateral hemiplegia • Medial and inferior surface of • Sensory loss • temporal lobe • Ipsilateral visual field impairments Midbrain • Weakness greater in face and upper • Third and lateral ventricles • extremities • Introduction 19

Table 1.3 (Continued)

Supplies Occlusion

Anterior inferior cerebellar artery Cerebellum Vertigo • Pons • Nausea • • Vomiting • Nystagmus • Tinnitis • Ipsilateral cerebellar ataxia • Horner’s syndrome • Contralateral loss of pain and temperature • sense of arm, trunk and leg Superior cerebellar artery Cerebellum upper part Ipsilateral cerebellar ataxia • Midbrain • Nausea • • Vomiting • Slurred speech • Contralateral loss of pain and thermal sensation •

Early and continuing rehabilitation. r Long-term support for the stroke patient and their carers. r Stroke strategies Since the publication of the NSF for older people, specific stroke strategies have been developed in Scotland 2002/4, England 2007, Wales 2007 and Northern Ireland 2008.

Scotland The Coronary Heart Disease and Stroke: Strategy for Scotland was published by the Scottish Government in 2002 and subsequently updated in 2004 (Scottish Government, 2004). This strategy covered:

Prevention. r Managed clinical networks (MCNs). r Workforce issues. r Information technology and the development and use of databases. r In relation to stroke care, the main targets included:

Establishing MCNs. r Stroke units. r More rapid imaging. r Manpower plan and training. r National audit. r Improved IT. r 20 Occupational Therapy and Stroke

In 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 r –Publicawarenessofstroke–FASTcampaign. –Thrombolysis. –Youngerpeopleandstroke–includingvocationalrehabilitation. –Earlysupporteddischarge. –Rehabilitationandrecovery. –StrokeTrainingandAwarenessResources(STARs). Improving the quality of care and support r –Informationandcommunication. –Self-management.

England The National Stroke Strategy for England published in 2007 is a comprehensive strategy which 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 strategy regarding: 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 21

14. 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.

Wales The Welsh health circular Improving Stroke Services: A Programme of Work (Welsh Assembly Government, 2007) summarises the programme of stroke improvements for Wales in the following three areas: Preventing strokes Public information leaflets. r Public and health professional education programmes. r Identification of gaps in local and national resources. r Referrals to lifestyle initiatives. r Referral of TIA patients to a one-stop assessment and investigation service. Improvingr stroke survival rates Commissioning specification for stroke services. r Action plans to implement the older people’s NSF stroke standards of care. r Evidence for stroke as a 999 call. r Protocols and quality requirements. r Profession-specific audits. r Introduction or expansion of specialist and consultant staff. r Dedicated and colocated acute stroke beds. r Referral to palliative care and end-of-life care, where appropriate. r Establishment of research programmes for stroke. Maximisingr post-stroke-independent living and quality of life Development of protocols and quality requirements for rehabilitation assessments r and interventions.

Northern Ireland In July 2008 revised recommendations for the Northern Ireland stroke strategy were published in Improving Stroke Services in Northern Ireland (Department of Health, Social Services 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. This document 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 Stroke

5. Community-based care. 6. Palliative care. 7. Communication with patients and carers.

Guidelines The 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 statements which assist clinicians (including Occupational Therapists) and service users in making deci- sions about 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.

Scotland Evidence-based guidelines for the care of patients following stroke in Scotland (Scottish Intercollegiate 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 on the Management of Patients with Stroke or TIA: Assessment, Investigation, Immediate Management and Secondary Prevention,whichincludesectionson:

Management of suspected stroke or TIA. r Assessment, diagnosis and investigation. r Treatment of ischaemic stroke. r Treatment of primary intracerebral haemorrhage. r Other causes of stroke. r Physiological monitoring and intervention. r Preventing recurrent stroke in patients. r Carotid intervention. r Promoting lifestyle changes. r Provision of information. r Introduction 23

England, Wales and Northern Ireland The 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. r Systems underlying stroke management. r Acute-phase care. r Secondary prevention. r Recovery phase from impairments and limited activities: rehabilitation. r Long-term management, after recovery. r Profession-specific concise guidelines. r Each section contains many guidelines using the general structure of introduction, recommendations, evidence and implications of the guideline. Tables of evidence are also included.

Self-evaluation questions

1. 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 and temporal lobes? 10. What are the key elements of the national stroke strategies? Chapter 2 Theoretical Basis Janet Ivey and Melissa Mew

This chapter includes: Theoretical constructs r Conceptual models of practice r Frames of reference r Neuroplasticity r Intervention approaches r Self-evaluation questions r Introduction

Occupational therapy’s principle concern is with the patient’s occupational identity and occupational performance. In other words, ‘how individual’s identify themselves and their future aspirations, their roles and relationships, together with their personal capacity for fulfilling these within their physical and social environment’ (Duncan, 2006: p. 6). En- gagement in occupations, functional occupational performance and positive occupational identity are required to achieve health, well-being and life satisfaction. Following stroke, patients may be faced with occupational dysfunction. Occupational performance capacity may become impaired, impacting on their physical, cognitive and psychosocial capacity to adapt to effectively meet the demands of and engage in their usual occupations, thus impinging on their occupational identity, health and well-being. The role of the occupational therapist is to enable patients to regain competence, re- engage in 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 and frames of reference) that are used to direct occupational therapy intervention approaches and enable patients.

Theoretical constructs

Theoretical constructs, such as Conceptual Models of Practice and Frames of Reference, help to describe and explain occupational function, guide assessments and interventions Theoretical Basis 25 and predict outcomes. They also help to define our own professional identity. At times the difference between Frames of Reference and Models can be confusing but for arguments sake, Duncan’s (2006) delineations will be used where a Conceptual Model of Practice is ‘an occupation-focussed theoretical construct or proposition that has been developed specifically 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 idea that has been developed outside the profession but, with judicious use, is applicable within occupational therapy (to guide and structure) practice’ (Duncan, 2006: p. 62). Thus, occupational therapists may have a preference for adhering to a particular model of practice to help maintain their professional identity. Applied to any occupational model of practice, occupational therapists will use their core skills or ‘legitimate tools’ to enable therapeutic change. The core skills of occupational therapy include: therapeutic use of self to collaborate with the patient; skilled clinical observations; process skills of assessment, planning and implementing intervention to enable change and evaluation; purposeful use of activity as a therapeutic tool; occupational analysis and adaptation; environmental analysis and adaptation; therapeutic use of groups; and use of teaching and learning principles (Mosey, 1996; Hagedorn, 2000; Duncan, 2006). In addition, therapists will draw on appropriate frames of reference, depending on the patient context which will influence the Intervention Approach taken. Specific interven- tion approaches provide tools to enable change, including assessment tools, intervention techniques and style of the patient–therapist relationship.

Conceptual models of practice

The Model of Human Occupation (MOHO) (Kielhofner, 2008) considers the com- plexity of human occupation that behaviour is dynamic and context dependent and that occupations shape a person’s self-perception and identity. It proposes that people’s partic- ipation in occupation is influenced by their own volition (personal causation, values and interests), habituation (habits and roles) and performance capacity as well as the environ- ment (physical and social including cultural contexts). Actual occupational performance is then dependent on skills (motor, process and communication and interaction skills) per- forming occupational forms (or activities) and participation. Participation helps to create occupational identity and a sense of occupational competence. A positive occupational identity and sense of personal competence over time in the context of the environment enable occupational adaptation to be constructed. A number of useful overview, observa- tional, self-report and vocational assessment tools have been developed under this model, including the MOHOST (MOHO Screening Tool), Assessment of Motor and Process Skills (AMPS), Interest and Role Checklists and Work Environment Impact Scale. This model and its associated tools help occupational therapists working with stroke patients 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 address patient’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 Stroke affective and cognitive components of the person whose self-care, productivity and leisure occupations occur in the context of the physical, institutional, cultural and social envi- ronment. The latest amendment specifies the occupational therapy domain of concern in the dynamic interaction of the person, occupation and environment. It further regards occupation beyond performance to consider the importance of engagement and inclusion. The Canadian Occupational Performance Measure (COPM) (Law et al.,2005)wasde- veloped from earlier versions of this model, but remains consistent, with the CMOP-E as aclient-centredoutcomemeasureenablingclientstorateimportance,performanceand satisfaction 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 working with stroke patients; however, challenges can arise when therapists are constrained by inpatient settings or patients’ levels of insight. Similar but distinctive models emphasising person, environment and occupation include the Person–Environment–Occupation (PEO) Model (Law et al.,1996)and Person–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, occupa- tional roles, occupational performance areas (self-maintenance, rest, leisure and produc- tivity), components of occupational performance (biomechanical, sensorimotor, cognitive, intra- and interpersonal skills), core elements of performance (mind, body and spirit), the performance environment (sensory, social, physical and social contexts), time and space. The Perceive Plan Recall and Perform (PRPP) System of Task Analysis (Chapparo and Ranka, 1997) was developed as one of the assessment tools within this model. Activities Therapy (Mosey, 1996) combines psychodynamic, human developmen- tal and behavioural frames of reference. This model suggests that adaptive (compen- satory/functional) skills are re/learnt in a developmental sequence to achieve mature functioning and influenced by the environment and their biological composition. In rela- tion to stroke, this model suggests that dysfunction arises when patients regress in their sensory integration, cognitive, dyadic interaction, group interaction, self-identity and/or sexual identity skills. Rehabilitation is based on sequential relearning of adaptive (com- pensatory/functional) sub-skills through graded occupation and patient’s innate need for mastery. The Kawa (River) Model (Lim and Iwama, 2006) is an emerging model from an Asian perspective which may address cultural biases of existing models (which value individualism, autonomy and independence) to consider cultural values of collectivism, social hierarchy and interdependence. Appreciation of non-western perspectives enables therapists to be truly client-centred. This model emphasises the harmonious interaction of mind, body, soul, spirit and environment for health and well-being. The western view of self is decentralised and central focus of occupational therapy is to enable the patient’s life flow (or river) by achieving harmony between life circumstances and problems (rocks), the physical and social environment (walls and bottom of the river) and personal attributes and resources, including values, character, personality special skills, material and imma- terial assets 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 27 currents and addressing obstructions, but not necessarily eliminating them, so that the patient’s life energy (water) can flow. Thus, in stroke rehabilitation, reduction of impair- ments may not be as significant as it is in western cultures. Maximising patients’ personal attributes and resources, adapting environments and considering interdependence on fam- ily and social participation (social inclusion) may be more meaningful than addressing impairments and activity limitations.

Frames of reference

Client-Centred Frame of Reference is a humanistic approach which originated with psy- chotherapist Carl 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 informed choice; partnership between client and therapist to work together to negotiate therapy goals and processes; responsibility of the client for his/her own health and ethical respon- sibility of the therapist to ensure no harm; empowering and enabling clients to achieve their occupational goals; understanding clients individual contexts through respect and listening; accessibility of services to meet clients needs; and respect for diversity. It recog- nises that ‘the client’ might also be the family, carers or institution in addition to the person referred. 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 method that falls under this frame of reference (Miller and Rollnick, 2002). Biomechanical Frame of Reference is a bottom-up frame of reference, useful for understanding occupational performance capacity in more detail. It considers the anatomy and physiology and mechanics of human movement (kinesiology) focusing on musculoskeletal, neuromuscular and cardiorespiratory systems. Occupational therapy approaches that fit within this frame of reference include graded activities to improve movement strength, endurance, range of motion and sensation, work hardening, en- ergy conservation, ergonomics, assistive devices, splinting and joint protection. Thus approaches to prevent deterioration, restore function or compensate for limitations are significant here. Nevertheless, the primary assessment and outcome for occupational therapy 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 daily activities and social roles and focuses on therapists teaching, patients learning adaptive (compensatory/functional) methods, assistive equipment and environmental modifications to restore function when underlying impairments cannot be remediated and successful rehabilitation is dependent on motivation and cognitive skills. Motor Control Frame of Reference considers the relationship between the central nervous system in relation to motor function and reacquisition of coordinated skilled movement but recognises the influence of other systems (sensory input and cognitive pro- cessing), environmental context and learning principles (such as attention, feedback, active participation and goal-directed movement). In comparison to a biomechanical frame of 28 Occupational Therapy and Stroke reference, emphasis is on muscle tone, reflexes and movement patterns. Many restorative (remedial) intervention approaches fall under this heading, including Bobath’s neurode- velopmental (normal movement) approach, Carr and Shepherd’s movement science/motor relearning, Rood, Brunnstrom’s Movement Therapy, Proprioceptive Neuromuscular Facilitation, Mental imagery and Constraint-Induced Movement Therapy (see ‘Interven- tion Approaches’ later in this chapter). Behavioural Frame of Reference considers learning principles arising from stimulus- response models such as Pavlov’s classical condition and Skinner’s operant conditioning where behavioural responses to stimuli or triggers can be modified through exposure and manipulation of the consequences. This frame of reference is useful for behaviour modification such as desensitisation or reduction of anxiety-related symptoms as well as for new learning principles such as repetition and positive feedback. Cognitive Frame of Reference originated in psychiatry and psychoanalytical theory with the work of Aaron Beck. This frame of reference examines the links between the patients’ automatic thinking, their behaviour and emotional response. Dysfunctional be- liefs, values and thinking may be distorted, unrealistic and unhelpful. These are explored and challenged to change patients’ perceptions and emotional response to events. Cognitive-behavioural therapy (CBT) links the cognitive and behavioural frames of reference together. It utilises a problem-focused approach to explore patients’ underly- ing thoughts, beliefs and physiological responses associated with specific triggers and the consequences of dysfunctional behavioural responses that might maintain these. Dysfunc- tional thinking and beliefs in response to triggers are then challenged to change patient’s perspectives and more adaptive (compensatory/functional) behaviour can be tested out in safe environments such as role play, facilitated groups and graded activity scheduling. Adaptive (compensatory/functional) behaviour is reinforced through patients’ feelings of self-efficacy, consequences that disprove dysfunctional beliefs and therapist feedback, which is recorded in activity diaries. Techniques can be deceptively simple and specialist training is required. Considering its inherent overlap with clinical psychology, Duncan (2006) further cautions that a cognitive-behavioural frame of reference should be used in conjunction with an occupation-focussed conceptual model of practice to maintain pro- fessional role and identity and to enhance the therapeutic potential of the patient–therapist partnership. 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 chronic pain and chronic fatigue syndrome (Duncan, 2006). Although CBT appears useful for stroke patients and is probably employed to some degree during rehabilitation, further research is required on the effectiveness of CBT strategies with stroke patients (Lincoln and Flannaghan, 2003). Psychodynamic Frame of Reference originated with Sigmund Freud’s controversial theories but has been developed to focus on understanding the relationship between past experience and present difficulties. It highlights links between unconscious motivations and emotions which are operationalised through interpersonal interaction, behaviour and occupation. For example, mechanisms such as repression, denial, projection, reaction formation, intellectualisation, rationalisation, regression, sublimation and compensation protect the psyche against anxiety arising from unconscious internal conflict. These Theoretical Basis 29 internal conflicts and underlying emotions and motivations can be therapeutically explored and symbolically resolved through creative (projective) activities, meaningful occupations, reflection, group work processes and therapeutic relationships to achieve a sense of wellness (Blair and Daniel in Duncan, 2006: p. 233). Cognitive Perceptual Frame of Reference draws on neuroscience and neuropsychol- ogy and focuses on the components and interaction of cognitive and perceptual skills that impact on occupational performance. Treatment approaches can be categorised into remedial/bottom-up/skills training or adaptive/top-down/strategy training approaches recognising 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 of cognitive and perceptual tools and treatment strategies fall under this umbrella (see Chapters 7 and 8). In addition to the above theoretical constructs which assist in guiding occupational ther- apy practice, the emerging theories of neuroplasticity are utilised in current neurological practice. A knowledge of neuroplasticity can assist the occupational therapist in selecting an intervention/approach for the individual patient and will assist in clinical reasoning and justification of the intervention administered.

Neuroplasticity

Despite recognition that post-injury experience could result in adaptive or maladaptive responses, historically it was believed that neurones in the adult mammal’s central nervous system (CNS) were ‘hard wired’ like an electrical circuit that could not regenerate or repair after injury (Gage, 2002). Thus, recovery in neurorehabilitation focussed on strategies that discouraged maladaptive behaviour and focussed on adaptive functional behaviour and goal achievement (Cohen, 1999). This was supported by evidence that neurorehabilitation improved patient outcomes (Intercollegiate Stroke Working Party (ISWP), 2008). How- ever, more recent advances in neuroscience and functional imaging have demonstrated evidence of neuroplasticity – the brain’s considerable capacity for neural reorganisation (Nudo and Friel, 1999). Consequently, momentum has escalated for therapists to un- derstand the scientific basis of neurorehabilitation to capitalise on this to enhance true recovery of function following stroke (Aisen, 1999; Mateer and Kerns, 2000; Pomeroy and Tallis, 2002b). From conception to death, neuroplastic changes occur. These can be associated with normal responses to experiences such as maturation, development and learning (Hallet, 1995; Kotulak, 1998). Therefore, cells are constantly adapting to the challenges of the internal and external environment (Stephenson, 1996).

Structure of a neurone The neurone cell is specialised to maintain high rates of protein synthesis and have long projections from the cell body. Dendrites are large extensions of the cell body and receive most of the synaptic inputs into the cell. Neurones may have one or many dendrites, which are typically short and 30 Occupational Therapy and Stroke

Dendrites

Cell body Axon hillock

Axon collaterals Axon

Figure 2.1 Structure of a neurone. (Reproduced with permission from Dr I. Musa, Cardiff University, personal communication, 2009.) highly branched, as shown in Figure 2.1. They provide sites for synaptic connection with other 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 signal conduction. Neurones have a single axon arising from the axon hillock and its terminal forms the presynaptic component of a synapse. Axons may extend to less than a millimetre to 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: either the rerouting and subsequent formation of new connections, or neurones substituting function of damaged neurones to enhance the effectiveness of existing connections (Kidd et al., 1992). This includes:

The concepts of synaptic strengthening or potentiation – altering the effectiveness of r synapses (short-term potentiation/long-term potentiation). Unmasking of existing silent synapses whose function was previously blocked by r inhibitory influences. Sprouting of new axon terminals. r Changes in dendritic organisation. r Theoretical Basis 31

Synaptic transmission Neurotransmitters may be classified into two broad categories, such as G protein-coupled or metabotropic receptors and transmitter-gated ion channels. The following discusses transmitter-gated ion channels and the mechanisms of short-term presynaptic potentiation and 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 gluta- mate which diffuses across the synaptic cleft binding to the glutamate receptors on the postsynaptic membrane. When glutamate binds to the (α-amino-3-hydroxyl-5-methyl- 4-isoxazole-propionate) AMPA receptors on the postsynaptic membrane, this allows a mixed flow of sodium (Na+)andpotassium(K+)tocrossthecellmembranecausing adepolarisationofthepostsynapticmembranecalledexcitatorypostsynapticpotential (Purves et al.,1997). However, an N-methyl-d-aspartate (NMDA) receptor is voltage gated owing to mag- 2 nesium (Mg +)atthechannel.Attherestingmembrane,theinwardcurrentthroughthe NMDA is blocked by the magnesium which has bound to the channel. As the membrane 2 becomes depolarised, the (Mg +)blockisdisplacedfromthechannelandthecurrentis free to pass into the cell. This requires constant release of glutamate to maintain the mem- brane depolarisation. NMDA receptors are therefore voltage dependent (Purves et al., 1997) (see Figure 2.2).

AMPA receptor

NMDA receptor

Metabotropic glutamate receptor

Presynaptic axon terminal Glutamate Figure 2.2 Short-term presynaptic potentiation. (Adapted from Bear et al.(2007)byDrI. Musa, Cardiff University, personal communication, 2009. Reproduced with permission from Lippincott, Williams & Wilkins.) 32 Occupational Therapy and Stroke

Long-term postsynaptic potentiation (LTP) Long-term potentiation is commonly associated with learning and plasticity. It occurs at some 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 changes in the efficacy of synaptic transmission for the storage of neural information and the development of functional circuits (Dobkin, 1998). 2 2 NMDA receptors also conduct calcium (Ca +)ions;therefore,themagnitudeofCa+ flux passing through the NMDA receptor channel specifically signals the level of pre- and 2 postsynaptic coactivation (Bear et al., 2007). Strong NMDA receptor activation and Ca + entry into the postsynaptic dendrite bind to calmodulin which activates protein receptor kinase II. This phosphorylates the AMPA receptors and serves as a signal to insert them into the postsynaptic membrane and therefore strengthens synaptic transmission. Once AMPA receptors are inserted, the synapse is no longer silent and no longer requires simultaneous 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 that the facilitation of LTP after cortical lesions reflects an underlying mechanism of cortical reorganisation and recovery (Malenka and Nicoll, 1999). According to Hagermann et al. (1998), LTP is essential for functional recovery.

Long-term nuclear changes Long-lasting, long-term potentiation that is associated with learning and memory requires long-term nuclear changes through activity-driven induction of new gene expression.

Presynaptic Mg++ expelled terminal from NMDA channel

++ Glutamate + Ca Na NMDA receptor Simple ionic channel receptor channel Na+ Ca++

Protein kinase C Ca++/calmodulin kinase II

Modification of postsynaptic receptors of release of retrograde factor Figure 2.3 Long-term (postsynaptic) potentiation. (Reproduced with permission from Dr I. Musa, Cardiff University, personal communication, 2009.) Theoretical Basis 33

Na+

K+

Synthesis of Phosphorylation proteins of regulatory proteins

Products Transcription of proto-onco of genes genes

Figure 2.4 Long-term (nuclear) changes through G protein-coupled second messenger systems. (Reproduced with permission from Dr I. Musa, Cardiff University, personal communication, 2009.)

It requires the synthesis of new proteins and their affect on the nucleus of the postsy- naptic cell through high-frequency stimulation. This stimulation results in the activation of a receptor-linked second messenger system, which encourages the phosphorylation of regulatory proteins. These enter the postsynaptic cell nucleus where they transcribe a set of genes. 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. The proteins now are large and insoluble. After being synthesised by the ribosomes attached to the granular endoplasmic reticulum, they move by dendritic transport back to the post- synaptic site 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 very long-term potentiation though the following suggestions have been made. Calcium–calmodulin-dependent protein kinase II (CaMKII) consists of four sub- units. Calcium activation phosphorylates them, and once the calcium concentration falls back to its resting level they remain phosphorylated. This is because if a sub- unit becomes dephosphorylated, it will immediately become automatically phospho- rylated by 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. How- ever, if one pathway is weakly activated at the same time as a neighbouring pathway is strongly 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 that fire out of sync loses their link’. Specificity is when one pathway is stimulated and other pathways connected to the same neurone are not. Therefore, LTP is specific to activated synapses than all synapses on a cell (Figure 2.5). 34 Occupational Therapy and Stroke

(a) Specificity (b) Associativity

Pathway 1: Pathway 1: Active Strong stimulation

Synapse Synapse strengthened strengthened

Pathway 2: Weak stimulation

Synapse not Synapse strengthened strengthened

Figure 2.5 Long-term potentiation: (a) specificity and (b) associativity. (Reproduced with permission from Dr I. Musa, Cardiff University, personal communication, 2009.)

Unmasking Can be considered when designated axons and synapses which are present but not being used for a particular function. This can be called upon when the ordinary dominant system fails 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 be involved in the extensive synaptic stimulation, which causes long-term potentiation (LTP). This leads to calcium-dependent phosphorylation of CREB (cAMP response element binding protein) – which may be associated with synaptic plasticity. Therefore, linking the phosphorylation of CREB to formation of new dendritic spines could assist in long- term nuclear changes (Murphy and Segal, 1997). Intervention therefore aims to stimulate the long-distance afferent to take over from the segmental afferent that has been damaged, that is, the subservient path- way or non-dominant can take over the function of the dominant damaged afferent (Figure 2.6).

Collateral sprouting Recovery after brain injury occurs by axons growing branches called collateral sprouting: homotypic sprouting where a synapse is formed from the same tract or heterotypic sprouting from another tract (functional recovery is more adversely affected in this case) (Figure 2.7). Theoretical Basis 35

Stimulated long-distance afferent

Damaged segmental afferent

Figure 2.6 Unmasking. (Reproduced with permission from Dr I. Musa, Cardiff University, personal communication, 2009.)

Dendritic growth Dendritic growth can take place over months and will regrow if stimulated. Studies have shown that there is a decrease in dendritic growth in dementia patients and those in a vegetative 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 but rusts 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 ac- tivity; reorganisation may be enhanced by enriched environments; repetition is important to induce and maintain plastic changes; timing may be critical and the importance of active attention to stimuli (Gage, 2002; Pomeroy and Tallis, 2002b; Turkstra et al., 2003). From these findings, it may be that to some extent adaptive neuroplasticity was already being

Reactive synaptogenesis Axonal sprouting Figure 2.7 Collateral sprouting. (Reproduced with permission from Dr I. Musa, Cardiff University, personal communication, 2009.) 36 Occupational Therapy and Stroke driven by therapists following basic learning principles, including, teaching meaningful skills that were varied, stimulating and graded in difficulty; structuring practice with feed- back and review; and training skills to other environments and contexts (Pomeroy and Tallis, 2002b). However, it alerted therapists to consider the aspects of post-injury reha- bilitation experiences influencing neuroplasticity. For example, unstructured, repetitive task practice during routine self-care could potentially be relatively ‘unattended’ and in- sufficient to 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 expand cortical lesions (Johansson, 2000). Neuroplasticity redefined recovery as ‘the ability to accomplish the goal in exactly the same way as before the injury’ (Almli and Finger in Cohen, 1999: p. 420). The loss of normal function deprives the CNS of the experiential feedback required to drive adaptive reorganisation and may subsequently permit maladaptive reorganisation (Pomeroy and Tallis, 2002a). This increased emphasis on remedial approaches for ‘true neuroplastic recovery’ early in stroke rehabilitation. In fact it was suggested that ‘restitution of function in damaged circuits may actually be hindered by compensatory adjustments which may support adaptive function in the short term, but which result in long-term inhibition of the activity of damaged circuits (Mateer and Kerns, 2000: p. 108; Cauraugh and Summers, 2005). However, there is limited clinical evidence to suggest that functional compensations are detrimental to recovery (Cohen, 1999; Lennon et al., 2001; Lennon, 2003).

Intervention approaches

Despite evidence of neuroplasticity, predicting recovery potentials remains challenging. Some combinations of symptoms will be more amenable to true recovery while other combinations will have limited capacity, requiring an adaptive (compensatory/functional) approach to learn to adapt to activity limitations. Thus, occupational therapists will always need both restorative and adaptive treatment approaches as components of neurorehabili- tation. Further, some patients may just want to achieve independence as quickly as possible and ‘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 ability of the brain to reorganise itself (Nirkko et al., 1997; Nudo, 1998; Marshall et al., 2000). Neurophysiological approaches such as normal movement and motor relearning are included within the restorative (remedial) approach. Here, the therapist provides controlled visual, auditory, vestibular, tactile, proprioceptive and kinaesthetic stimulation to promote normal CNS processing of sensory information. Therefore, normal sensory processing should help the patient make normal perceptual motor responses required for performance of functional tasks. This approach therefore aims to reduce the impairment to subsequently improve activity and participation. Theoretical Basis 37

Neistadt (1990) also classes ‘transfer of training’ under restorative (remedial) ap- proaches. 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 the patient and encourage the brain to adaptively reorganise itself for successful behaviours. People with cognitive impairments tend not to be able to transfer learned skills, and although some minor, short-term effects may be seen, the long-term impact and lack of transferrable skills tend to make this a time-intensive and less-effective approach for people with cognitive problems. Restoration of impairments tends to be more successful for people with motor impairments alone.

Adaptive (compensatory/functional) approach The adaptive (compensatory/functional) approach focuses on repetition of particular skills which are normally associated with activities of daily living (ADL). It is based on the belief 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 restoration is unlikely and assumes that certain functions will not recover (Zoltan, 2007). Compen- sation for loss of function is achieved by changing the activity, environment or patient behaviour by using external assistance, modifying the task or changing the goal or by practice until the task becomes easier in a variety of environments. The advantages of this approach are that it is patient-centred, easy to explain, uses problem solving, meets short-term needs and gives quick results. The disadvantages of this approach are that the therapist may not consider a range of options open to the patient and may succumb to organisational pressures for quick functional 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 lead to negativity by the patient who is asked to recognise a permanent condition and its limitations without any attempt to remediate the underlying skills.

Cognitive rehabilitation approach Cognitive rehabilitation therapy is a systematic and functionally oriented approach to improve cognitive functioning either by restoring cognitive processing skills that are impaired 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 very similar to physical rehabilitation but usually involves all of the following:

Assessment – to determine the specific impairments involved and their functional impact r on occupational performance. Education – to develop patients’ and others’ awareness of cognitive strengths and r weaknesses and how they influence occupational performance. Without developing awareness and self-monitoring skills, the patient will not engage in therapy and will not be able to independently implement treatment strategies on their own – the ultimate aim of rehabilitation! 38 Occupational Therapy and Stroke

Process training – to restore the impaired cognitive skill through targeted practice and r retraining of the skill itself. This is usually completed out of context in pen and paper tasks to enable patients to consciously focus on the targeted skill and may be given as homework activities. Strategy training – to learn how to use external and internal adaptive strategies to r overcome the impaired skill. This involves targeted rehearsal of the taught strategy in avarietyofcontexts. Functional activities training – to consciously apply strategies learnt in process and r strategy training in everyday life. Evaluation – is required at impairment, activity and participation levels to determine r the effectiveness of intervention. (Malia and Brannagan, 2005; Halligan and Wade, 2007)

Although in physical rehabilitation simultaneous use of both restorative and adaptive approaches is used cautiously, in cognitive rehabilitation use of both process and strategy training simultaneously is encouraged. Cognitive interventions must be tailored to the individual and are more effective if interventions are collaboratively worked between patient, carer and therapist. The goals should be mutually set and functionally relevant to the individual. Therapists should also use eclectic and multiple approaches to address the effect and emotional components of cognitive loss (Halligan and Wade, 2007). Although research population heterogeneity, treatment variability and use of broad out- come measures have limited conclusive recommendations for cognitive rehabilitation to date, Rohling et al.’s (2009) meta-analysis suggests a few core evidence-based principles for cognitive rehabilitation, including starting treatment early, older patients ( 55 years ≥ old) can still benefit from cognitive rehabilitation and targeted interventions (particularly for attention and visual spatial neglect) are more effective than generalised interventions. The reader is referred to key documents regarding details of specific evidence supporting the effectiveness of cognitive-perceptual rehabilitation of attention, memory, visuospatial perception, neglect, executive function and praxis skills (Cicerone et al., 2000; Lincoln et al., 2000; Cappa et al., 2005; Cicerone et al., 2005; Bowen and Lincoln, 2007; das Nair and 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 phys- ical neurorehabilitation in the UK (Walker et al., 2000; Lennon, 2003). It is also known as Bobath or neurodevelopmental treatment (NDT) as it was originally founded by the Bobaths in the 1970s and based on neurodevelopmental reflex-hierarchical theory that hypothesised spasticity as a product of overactive reflexes. Originally, treatment utilised reflex inhibiting patterns and progressed patients through a neurodevelopmental sequence (Bobath, 1990). However, Bobath treatment techniques have changed since the last Bobath publication in the 1990s. The current ‘Bobath Concept’ of normal movement has evolved to incorporate present-day knowledge and a systems theory of motor control, motor learn- ing, neural and muscle plasticity and biomechanics (Raine, 2006, 2007; International Theoretical Basis 39

Bobath Instructors Training Association (IBITA), 2008). However, there has been much debate in the literature regarding the validity and reliability of this evolution which has con- founded evidence-based practice (Langhammer, 2001; Brock et al., 2002; Mayston, 2008). The Normal movement approach is a problem-solving or clinical reasoning process rather than a series of treatments or techniques, generally requiring a postgraduate level of training to enable more efficient movement patterns (IBITA, 2008). It is based on the assumption that ‘too much effort by the patient and overuse of the unaffected side reinforce abnormal tone and movement of the affected side’ (Lennon, 2001: p. 925). Abnormal movement leads to inaccuracy, effort, fatigue, compensatory movements, muscle tension, overuse, pain, injury and ultimately task avoidance and dependency. Thus, the approach aims to improve disturbances in function, movement and postural control following a lesion in the CNS by relearning more efficient movement through experience, with active participation of the patient, which is ultimately goal directed (Lennon, 1996; Raine, 2007).

Key terms Base of support:Thisreferstothesupportingsurface,thebodypartincontactwithit r and the relationship between the two. In order to accept the base of support, a person needs movement to relate to it and use it as a reference point. Centre of gravity:Aconstantdownwardforcewithwhichmanmustdeveloptheability r to interact, in order to move selectively. It is constant and the effect is felt if displaced. Postural set:Analignmentofkeypointsinrelationtoanacceptedbaseofsupport. r Balance reactions: r (a) Equilibrium reactions: Automatic adaptations of postural tone in response to gravity and displacement. (b) Righting reactions: Sequences of selective movements in patterns in response to dis- placement. Functionally they allow the loss regaining of midline through trunk right- ing, head of righting, stepping reactions and protective extension of the upper limbs. Normal postural tone:Acontinuouspartialstateofmusclecontractionwhichishigh r enough to resist gravity and low enough to allow selective movement to take place. Associated reactions:Pathologicalincreasesintone,inresponsetoastimulus,which r are beyond the person’s level of inhibitory control. They reflect a loss of reciprocal innervation. Key points:Areasofthebody,suchasthehead,thorax,pelvis,shoulders,hips,hands r and feet, where postural tone can most easily be changed. Each key point provides a large source of proprioceptive input to the CNS. Key points are used to: (a) Facilitate and control movements; and (b) Alter postural tone.

Assessment/evaluation Assessment involves observation and analysis of movement of deviation from nor- mal movement patterns and identification of compensatory strategies. In particular, the 40 Occupational Therapy and Stroke influence of gravity, relationship with base of support, alignment and relationship of key points to each other, the ability to move within a posture, transfer weight and to create another posture, initiation and development of a pattern of movement (selectivity). In addition, the potential for change is explored through use of handling skills to influence tone, alignment, fixation, stiffness, etc., as well as use of movement experience, repetition, speed, voice and environment. As a problem-solving approach, assessment, hypothesis formation, treatment and evaluation are a constant process.

Techniques/methods The therapist uses afferent inputs, particularly proprioceptive handling skills of key points of control, to influence muscle tone and activity, correct alignment, block abnormal move- ments and facilitate more normal selective movement patterns for goal-directed tasks in which the patient is an active participant (Lennon, 2001; IBITA, 2008). In addition, ther- apists use experience of movement, repetition, speed, voice, environmental manipulation and feedback (British Bobath Tutors Association, 2003). Bobath discourages unsuper- vised patient 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 ability Preparation Good knowledge/awareness of normal movement is necessary to analyse deviation from the normal. Think about how you do daily activities – What is the normal sequence of movements? r Prior to session take time to plan and analyse intervention strategy. r Activity analysis When carrying out in-depth activity analysis of normal movement components of a functional task, consider the following: Alignment and symmetry of key points. r Ability to move in/out of postures. r Acceptance of base of support. r Balance and ability to transfer weight as opposed to shifting centre of gravity over the r base of support. Ability to adopt anticipatory posture requirements, for example, to alter trunk and pelvic r alignment to move a leg or position the hand in relation to the object in preparation for grasp. Is the movement normal in pattern – efficient, selective, effortless and goal directed? r Identify any abnormal/effortful movement patterns. r –Whereismovementinitiatedfrom–proximallyversusdistally? –Wheredoesmovementappeartobeblocked? Theoretical Basis 41

–Wheredoesthepatientgaintheirstabilityfrom? –Whereistheeffort/instabilitycomingfrom? Identify limitations from sensorimotor, neuromuscular and musculoskeletal systems, for r example, 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. r Consider the cognitive-perceptual demands of the task, for example, understanding r goal, motivation, concentration, memory. Positioning. r During treatment, normalise tone before you start and monitor as you progress. Some preparation may be needed prior to the ADL. Treatment strategies include the following:

Negotiate occupational goals so treatment is motivating, meaningful and goal directed. r Altering postural alignment. r Changing the base of support (increase BOS to reduce hypertonicity, and decrease BOS r to increase tone if hypotonic). Consider standing, sitting, lying, position of feet, using arms to prop, backrests. Modify the environment, for example, firmness of supporting surface, chair r height/design, object orientation and placement. Encourage self-initiation of movement and self-monitoring of abnormal tone/ r movement. Facilitate key points but do not overhandle – patient should be active in movement r rather than passive. Grade activities and treatment time appropriately to be therapeutically challenging r while working within patients’ physical and cognitive capacity. Learning principles of task-related training, repetition and practice. Vary object char- r acteristics, task context, speed and directional demands of the activity. Give clear visual/verbal/proprioceptive/written instructions and feedback. r Use equipment to complement normal movement patterns/compensation. ‘Normal ac- r tivity’ does not utilise aids to independence other than as a last resort. Aids may be used to minimise effort and disability. Maximising carryover and skill acquisition through practice and repetition. Train the r patient, carer and ward staff to monitor and adjust alignment, movement patterns and environment (where appropriate).

Proprioceptive neuromuscular facilitation Proprioceptive neuromuscular facilitation (PNF) as a neuophysiological treatment ap- proach was first advocated to American therapists by Knott and Voss in the 1950s. It is based on Sherrington’s and Kabat’s theories about the reflexive relationships between agonist and antagonist muscles which can be manipulated to control the contraction and relaxation of specific muscles groups and thus facilitate normal movement. It also emphasises that ‘the brain registers total movement and not individual muscle action’ (Schultz-Krohn et al., 2006: p. 748) 42 Occupational Therapy and Stroke

Assessment considers the relationship between proximal and distal functions, agonists and 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? r Alignment – Are body segments aligned in midline or shifted to one side? r Stability and mobility – Is more or less required? r Which sensory input (auditory, visual or tactile) the client is most responsive to? r Which facilitatory technique the client responds to best? r (Schultz-Krohn et al., 2006) Intervention is goal directed; involves the use of mass movement patterns that are di- agonal (crossing midline) and spiral (rotational) in nature; and involves the use of total patterns of movement and posture (developmental postures). These diagonal movements and developmental postures are observed in many functional ADL. Thus, treatment activ- ities demand tonal balance and motor control in meaningful tasks that are appropriately graded. Facilitatory strategies include use of:

Verbal commands. r Visual cues. r Tactile cues. r Diagonal placement and use of objects during functional activities. r Stretch to facilitate innervation of the stretched muscle. r Traction and approximation to stimulate joint receptors for carrying and weight-bearing r functions. Application of maximal resistance that still allows patients to have full range of motion r and smooth coordinated movement to enhance proprioceptive feedback and strength. Use of repeated contractions and rhythmic initiation to facilitate agonist muscles. r Use of isotonic and isometric contractions of the antagonist to induce subsequent r contraction of the agonist. Muscle relaxation techniques (such as contract-relax, hold-relax, slow reversal-hold- r relax and rhythmic rotation). (Schultz-Krohn et al., 2006)

Rood approach This intervention is based on reflexive and hierarchical models of the nervous system. Use of developmental postures and sensory stimulation applied to muscles and joints are used to stimulate a motor response that can either facilitate or inhibit muscle tone in preparation for normal movement. Rood’s concept is therefore based upon the concept of correct sensory stimulation being applied to the sensory receptors and eliciting the correct motor reflex which can be utilised in normal movement patterns (Rood, 1962). Some of these techniques such as icing, brushing hair follicles and tapping the muscle belly 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 be useful: Theoretical Basis 43

Facilitatory techniques to increase muscle tone tend to be proprioceptive and include the following:

Heavy joint compression where a compression force greater than body weight r is applied by the therapist through the longitudinal axis of the bone to facili- tate joint co-contraction. Weighted cuffs, sandbags and weight-bearing can also be used. Quick stretch followed by applying resistance to contracting muscle. r Vestibular stimulation to influence tone, balance and facilitate protective neck, trunk r and limb extension. Vibration has been found to have systemic effects and use of electrical stimulation has r become more favoured.

Inhibitory techniques to reduce muscle tone include the following:

Neutral warmth provided by insulating body heat with fabrics such as blankets or r neoprene. Slow, rhythmic stroking with deep pressure. r Light joint compression where a compression of body weight or less can inhibit tone r around joints. Vestibular stimulation through slow rocking to develop ability to move in and out of r postures. (Schultz-Krohn et al., 2006)

These techniques are preparatory. Purposeful activity then follows so that the patient applies the effects of the triggered motor responses during functional activities. The occupational therapist can also use visual or auditory prompts to encourage the required responses within intervention.

Movement science This remedial approach to physical neurorehabilitation is also known as motor relearning programming (MRP), functional and task-oriented approaches, founded by Carr and Shepherd in the 1980s (Carr and Shepherd, 1987). It emphasises the practice of the functional task or action itself as the remedial component promoted by principles of motor learning, including use of instruction, explanation, manual assistance, visual and verbal feedback on performance, reinforcement and contextual practice. Thus, it aims to facilitate motor relearning through use of meaningful activity, feedback and practice. This approach emphasises neuroplasticity and addresses concerns regarding negative effects of compensatory use of the affected side, learned non-use and use of adaptive aids on motor learning by altering task requirements. Assessment utilises functional task analysis where the patient’s performance is com- pared to norms and analysed to identify the specific biomechanical components of move- ment that are problematic. Hypotheses as to the biomechanical reason for altered move- ment are tested to direct intervention. 44 Occupational Therapy and Stroke

Techniques/methods The intervention programme involves the following: Training the missing or impaired components in relation to a functional task goal using r instruction, verbal and visual feedback and manual guidance. Manual guidance may be passive or the therapist may spatially or temporally ‘constrain’ r or stabilise parts of the limb to reduce the degrees of freedom that the patient is required to control. As the patient improves, this ‘constraint’ is reduced and replaced by verbal guidance or becomes object mediated. Feedback will depend on the stage of learning the patient is at, moving from more r extrinsic to more intrinsic sources as patients progress. Fitts and Posner (1967) describe three stages of learning: –Cognitive–Patientrequiresexternalcuesandpromptshowtoperformtheskill accurately. Mental imagery can also be used here. –Associative–Patientbeginstorefinetheskillthroughpractice,repetitionandintrinsic sensory feedback. –Autonomous–Theskillbecomesautomaticforthepatientandthereislessneed for conscious cognitive processing. The patient starts to generalise the skill across different environments and transfer the skill to different tasks. Task-specific, goal-oriented exercises are emphasised with self-monitored practice of r functional tasks outside of training sessions. Structured learning with involvement of other staff and patient relatives is encouraged for a consistent approach. Transference of training with variation of context to aid motor learning. r Positioning and muscle stretching to maintain soft tissue length and minimise spasticity r are also utilised. In physiotherapy practice, MRP is reported to differ to Bobath concept approaches in the principles of learning followed (degree and type of feedback provided), the type of stimuli used (degree of use of everyday objects during treatment) and the emphasis on task-specific practice (Marsden and Greenwood, 2005; van Vliet et al., 2005; ISWP,2008).

Constraint-induced movement therapy approach Constraint-induced movement therapy (CIMT) is a behavioural approach that involves restraint of the unaffected arm with intensive training of the paretic arm conducted by a clinician using shaping and repetition (Wolf et al., 2006). Shaping involves small steps of progressing difficulty and activities are designed to enable patients to carry out parts of 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 whereby the animal stops using the affected upper limb due to frustration from lack of success. This learned non-use corresponded to decreased cortical representation. Applying theories of neuroplasticity, CIMT was found to reverse this effect and improve recovery and function of the affected upper limb. There is now a substantial body of evidence supporting this technique and CIMT is recommended in the National Clinical Guidelines for Stroke (ISWP, 2008). Patients Theoretical Basis 45 should be at least 2 weeks post stroke onset, have at least 10 degrees of voluntary finger extension, 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)andFritzet al.(2005), the patients received 6 hours of CIMT and wore the restraint for 90% of the waking day for 2 or more weeks. In addition to restraint and intensive task-oriented practice, CIMT includes the use of a ‘transfer package’ of behavioural methods to facilitate transfer of training outside the clinical setting. The package includes a behaviour contract (for both the patient and the caregiver providing support), daily diary of activities to address psychosocial barriers, Motor Activity log, personalised home skill assignment and daily home practice (Blanton et al., 2008). The practicalities of incorporating CIMT into daily practice, both in hospital and in the community, 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 appropriate patients.

Bilateral arm training/isokinematic training approach Bilateral arm training is where the unaffected limb facilitates the affected limb in syner- gistic coordinated voluntary movements and is recommended for subacute and chronic phases of recovery (Stewart et al., 2006; ISWP, 2008). It is based on theories that contrale- sional activation may activate the lesioned hemisphere or adaptively strengthen ipsilateral pathways to facilitate recovery of the affected limb. In contrast to CIMT, patients at all severity levels may benefit from bilateral arm training to some degree but may require different training approaches (McCombe Waller and Whitall, 2008). Occupational therapists should incorporate this approach into the intervention plans of patients who may benefit. Many activities that occupational therapists traditionally use could be modified to involve this targeted practice. It is important to remember that in the research the training was conducted intensively for 50–90 minutes 5 days/week for between 2 and 8 weeks, which may be difficult to implement in everyday clinical practice (Stewart et al., 2006).

Mental imagery approach Mental imagery or mental practice has been described as the internal rehearsal of move- ments without any physical movements (Jeannerod, 1994; Crammond, 1997). An essential part of mental imagery is the ability to create clear and powerful images of the task required on demand. The practice must have functional relevance and meaning to the individual to enable more successful visualisation. Athletes and musicians are known to use mental imagery training to improve their performance, that is, athletes mentally practise the body movements required for particular body actions when the field is not feasible (Ryan and Simons, 1981). Little is known about the neurophysiological mechanisms underlying recovery of motor function following mental practice in patients with stroke. With advances in neuroimaging techniques, these mechanisms could be better understood and assist in the selection of 46 Occupational Therapy and Stroke specific 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 (primary motor area M1) during imagery. They concluded that primary motor structures are involved to the same extent in actual or imagined execution and of motor acts and that differences only take place at the late preparation period and consist of a quantitative modulation of activity in the structures. Thus, using mental imagery to activate these areas may maintain neuronal activity that would deteriorate without stimulation and prime pathways in readiness to promote motor function. Although there is some evidence that mental imagery is useful following stroke, system- atic reviews suggest that further research is required to clarify the content and measurement of mental imagery (Braun et al., 2006; Zimmermann-Schlatter et al., 2008).

Electromyographic (bio) feedback Involves the use of external electrodes applied to muscles and instrumentation to con- vert electrical potentials from muscles into audio or visual information. This augmented feedback is based on behavioural and motor learning theory where extrinsic feedback is used to supplement potential impaired intrinsic sensory-perceptual feedback to improve reacquisition of motor skills. There is some evidence to support its use to augment stan- dard treatment (Woodford and Price, 2007) but routine use outside of clinical trials is not recommended (ISWP, 2008).

Functional electrical stimulation Electrostimulation is thought to be beneficial to train and strengthen muscle contrac- tions. However, results remain inconclusive and should not be used routinely outside specialist clinical trials (Pomeroy et al., 2006; ISWP, 2008). Nevertheless, there is some evidence for its use to manage persistent subluxed shoulder pain and foot drop where orthoses are ineffective and improved gait is demonstrated with use (ISWP, 2008).

Robotics An emerging strategy is the use of electromechanical and robotic devices. Although some training-specific benefits have been found for improving motor strength, no evidence has been found for improvements in ADL (Mehrholz et al., 2008). Exploration into robotics to augment repetitive practice and incorporate more distal limb function is required.

Summary of evidence for approaches It has been demonstrated that comprehensive occupational therapy intervention for stroke is effective for reducing activity limitations in personal and extended ADL and improving social 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 these outcomes or for restoration of impairments is less clear (Ma and Trombly, 2002). There Theoretical Basis 47 is some evidence that adaptive approaches for self-care may be more effective than restorative approaches, but this conclusion may be confounded by lack of distinction between stage of recovery and heterogeneous research (Haslam and Beaulieu, 2007). The majority of evidence for specific treatment approaches is predominantly generic or physiotherapy based, despite similarities (Booth and Hewison, 2002) and inherent differences between the disciplines where occupational therapy by its very nature is task- specific and 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 highlights difficulties, making conclusions from research with heterogeneous populations, varied intervention protocols and questionable use of sensitive, targeted outcome measures that consider change at both impairment and functional levels. Nevertheless, approaches that involve high-intensity, repetitive task-specific practice and feedback on performance may be particularly influential on recovery. Thus to be truly evidence based, occupational therapists will need to continue to draw on appropriate evidence that is specific to their individual patients’ contexts and the setting in which they work, as evidence to date can only provide broad guidance. Further, task-specific research is required to guide therapists’ clinical reasoning to accurately predict patients’ recovery potential and educate patients about choice of specific treatments. More information is required regarding the characteristics and symptoms of who benefits, what is it about specific treatments that work, when is the most appropriate time to implement specific treatments and at what intensity.

Self-evaluation questions

1. What are the similarities and differences, advantages and disadvantages between a normal movement approach and a motor relearning approach? 2. (a) What conceptual models, frames of reference and intervention approaches do you use in your practice? (b) How do they relate? Draw a mind map or conceptual model to describe the theoretical basis of your practice and how your models, frames of reference and intervention 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 your practice that you do not already use? Draw up a plan of how you could integrate a new model or frame of reference into your practice. 4. What intervention approaches do you already use in your practice? In a reflec- tion, consider comparing the strengths and limitations of each approach that you use? 5. What approaches would you like to know more about? Pick one and plan an in-service training session on it for your colleagues (including a reflection on how it worked with one of your patients). 6. What are the four main mechanisms of neuronal plasticity? 48 Occupational Therapy and Stroke

7. 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 of neuroplasticity. Chapter 3 The Occupational Therapy Process Melissa Mew and Janet Ivey

This chapter includes: The occupational therapy process r Procedural reasoning in different stroke care settings r Professional duties r Self-evaluation questions r Introduction

This chapter focuses on how occupational therapists use the ‘occupational therapy pro- cess’ to work systematically from referral through to discharge and follow-up. Further refinement of procedural clinical reasoning associated with occupational therapy roles within different settings and phases of working with stroke patients will be considered before professional duties and competencies are addressed.

The occupational therapy process

Assessment requires the therapist to draw on their theoretical knowledge (conceptual model and frame of reference) and clinical experience to make a clinical judgement of what is to be assessed and how. Assessment requires proficient clinical observation and task analysis skills. It often includes a variety of standardised and non-standardised measures that inform the occupational therapist about the extent of impairment, activity and 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 this stage to understand the patient/carer in relation to their cultural and lifestyle needs. Liaison with 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 and wants. Where possible, methods selected should also assist in evaluating outcomes of interventions. Clear communication of assessment results to others is a component of effective assessment (Duncan, 2006). Goal Setting is a collaborative process between the therapist, patient and their fam- ily (where appropriate) involving education and negotiation. Initially, therapists should Occupational Therapy Hyperacute → Rehab tat on → Commun ty Integrat on Are your patients getting the full benefit?

Are ALL strokes and transient Occupaonal therapy differs from OT Assessment • Physiotherapy (De Wit, 2007) ischaemic episodes on your • Nursing (Booth ., 2001) Specialist use of functional Remedial OT ntervention HYPERACUTE unit screened • Clinical/neuro psychology by a Specialist Occupaona activities for targeted Specialist use of purposeful graded • Social work Therapist screening of all stroke activity as a medium for reducing patients to identify potential physical cognitive-perceptual and impairments and activity Some cognive-perceptual psychosocial impairments and limitations requiring subsequent activity limitations loss should be assumed and intervention potena impact on Health Condition (disorder/disease) paents’ ifesty es assessed Occupaonal Therapy Body Structure and Function Activities Participation (QM8 DH, 2007) (Impairment ) (Limitation) (Restriction) Works! (Cochrane Review,

Environmental factors Personal factors CF (WHO, 2001) Legg et al., 2006)

Adaptive OT ntervention Specialist use of compensatory strategies aids and adaptive devices to Are your paents receiving modify activities and/or the environment to enable Occupaona THERAPY or Are your paents receiving just good discharge patients to participate in a full life a minimum of 45 mins dai y p anning? (QM 10 DH, 2007) of each therapy required? (SWP, 2008)

Figure 3.1 Occupational therapy interventions in stroke rehabilitation. (Reproduced with permission from College of Occupational Therapists Specialist Section Neurological Practice, 2008.) The Occupational Therapy Process 51 ascertain patients’ and their family’s long-term goals or where they see themselves at the end of therapy. Long-term goals are aspirational, giving patients hope and motivation to engage in the therapeutic process. If aspirational goals are crushed by realism, patients may lose all hope and not engage in life or therapy at all. They represent the patient’s present occupational identity and can change over time as they gain insight into their strengths and limitations. In contrast short-term goals need to be client-centred and col- laborative, specific, measurable, achievable, realistic and timely (SMART). Short-term goals form the steps needed to work towards the long-term goal. These can be used to measure outcomes, for example, by using the Goal Attainment Scale (GAS) (Kiresuk et al.,1994).Inadditiontheyallowpatients,therapistsandteammemberstomaintain direction, motivation, monitor progress and gain insight into how achievable the long- term goal is or whether the long-term goal needs to be adjusted, thus allowing patients to transform their occupational identity to a more realistic sense of self. Interventions enable patients to meet their goals and ultimately aim to reduce ac- tivity and participation limitations (Figure 3.1). Rehabilitation has been defined as a problem-solving and educational process aimed at maximising recovery by using restora- tive (remedial) approaches to reduce impairments and adaptive (compensatory/functional) approaches to prevent impairments from translating into functional disability (activity and participation limitations) (Wade, 1992; Intercollegiate Stroke Working Party (ISWP), 2008). With inherent focus on occupation, restorative (remedial) approaches may initially ap- pear reductionist and not fit comfortably with some occupational therapists; however, they are important particularly in the first 6 months to optimise neuroplastic recovery. Further- more these approaches do still fit in with occupational therapy philosophy as long as they are clearly linked to occupational performance goals. Adaptive (compensatory/functional) approaches may involve the analysis and adaptation of the task/activity/occupation itself or of the physical/social environment to improve occupational performance (Duncan, 2006). Approaches are selected depending on the conceptual models and frame of reference that the therapist deems most appropriate and will depend on the patient’s prognosis, phase of rehabilitation, capacity for impairments to be reduced, consequences on activity and participation, therapists’ own knowledge and skills limitations and consistency with the multidisciplinary team’s approach. Therapists should also consider the evidence base regarding selected approaches, consulting the national clinical guidelines in the first instance (ISWP, 2008) before lower levels of evidence are considered that apply to the patient’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 is recommended in acute phases with opportunities for repeated practice and generalisation across tasks (ISWP, 2008). In both restorative (remedial) and adaptive (compensatory/functional) approaches, oc- cupational therapists more obviously enable patients by using occupation as the ends (where the end goal of occupational therapy is towards facilitating occupational perfor- mance capacity via addressing impacts of ill health). However, occupational therapists working with stroke patients are strongly encouraged not to lose sight of occupation as the 52 Occupational Therapy and Stroke means (where the end goal of occupational therapy is towards occupational identity via processes of engagement and empowerment to improve quality of life). Although these are by no means mutually exclusive – each can impact on the other – ease with which both 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 is clearly signposted by agreed outcomes and the move to the next phase is planned and understood. Evaluation of occupational therapy effectiveness ‘is an ethical and professional im- perative’ (Duncan, 2006). At the patient level,ongoingevaluationenablestheappro- priateness of intervention to be monitored, allowing opportunties for adjustment. Eval- uation of patient outcomes determines if therapy has been sucessful, whether agreed goals have been met and whether patients are satisfied with the intervention. Evaluation should be appropriately aimed at the level of intervention: impairment, activity, partici- pation. At a therapist level, therapists have a professional responsibility to evaluate their practice against both profession-specific and stroke-specific standards and guidelines. Therapists also have a responsibility to evaluate their practice through reflection and other continuing professional development activities whilst considering their efficiency and cost effectiveness. At a service level, therapists are involved in evaluating services through clinical and organisational audits and patient and staff feedback.

Transition between services/discharge Transition between different teams should ensure that all appropriate information be handed over in a timely manner to prevent unnecessary repetition of services already provided. Locally agreed sets of terminology, assessment tools, outcome measures and documentation should be used to facilitate ease of transfer. The patient should be involved in decision making regarding transfer of care and be offered copies of transfer docu- ments, including information regarding services (ISWP, 2008). In the UK, coordinated communication between services may include neurovascular clinics, inpatient stroke units (hyperacute and subacute), early supported discharge or intermediate care teams, commu- nity rehabilitation teams (including therapists servicing residential and nursing homes), private therapists, social services and follow-up monitoring teams such as specialist com- munity teams, 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. r Ensure that any continuing support the patient needs to maintain and/or improve r health is provided. This may include exercises, integration into general community programmes, information regarding equipment hire and purchase (e.g. Red Cross, Shopmobility), information leaflets (from Chest Heart Stroke, Stroke Association and College of Occupational Therapists Specialist Section Neurological Practice), informa- tion about stroke/carer support (including local groups, Stroke Association website and Different Strokes for under 65s). The Occupational Therapy Process 53

Educate the patient and, if necessary, carers and family how to maintain occupational r performance, health and well-being. Provide clear instructions on how to contact the service for reassessment, and outline r what specific events or changes should trigger further contact (ISWP, 2008).

Follow-up All patients with residual impairments after the initial period of rehabilitation should be offered a formal 6-monthly review so that appropriate referrals can be made if the patients experience new problems or their circumstances have changed warranting fur- ther therapeutic interventions (ISWP, 2008). This may be by a member of a specialist multidisciplinary team (MDT), CSLP or GP depending on residual symptoms and stroke severity. Particular areas to focus on during follow-up appointments include any changes in impairment (e.g. cognition), activity (e.g. activities of daily living), participation (e.g. fatigue), environmental and personal (e.g. mood, stress resistance, social support, quality of life) circumstances since discharge. Comparison to discharge outcome measures should be made to determine whether re-referral for burst of therapy or signposting to other services is required.

Procedural reasoning in different stroke care settings

Clinical or professional reasoning is a science and an art. Understanding the thinking that guides practice is complicated. All forms of clinical reasoning – scientific (diagnostic and procedural), narrative, pragmatic, ethical, interactive and conditional reasoning (Boyt Schell and Schell, 2008) – influence the occupational therapy process no matter in which settings occupational therapists may work with stroke patients. However, there are some common patterns of procedural reasoning worth delineating that are associated with dif- ferent settings, which may help guide therapists new to working with stroke. It should be noted that these general ‘procedures’ are by no means definitive and will always be influ- enced by concurrent reasoning about the patient’s unique presentation and circumstances at the time.

Neurovascular clinics In response to national guidelines, the number of rapid access neurovascular clinics (NVCs) for transient ischaemic attacks (TIA) and minor strokes to improve com- prehensive stroke services has risen. However, no indicative role for occupational therapists in NVCs has been outlined in national stroke guidelines (ISWP, 2008; National Collaborating Centre for Chronic Conditions (NCC-CC), 2008). Nevertheless, it is argued that occupational therapists have an important role in exploring the functional implications of issues frequently overlooked by consultants who are medically focussed and more easily able to pick up the physical symptoms. At this point it should be noted that 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 Stroke for multidisciplinary assessment, neglect the subtle cognitive and psychosocial symptoms that may arise from frontal lesions and even smaller lesions that are not detected by imaging, but may have a tremendous impact on patients’ well-being and quality of life. By employing a holistic approach, occupational therapists can expertly screen for the functional implications of issues frequently overlooked in minor stroke (such as those arising from hemianopias, fatigue, anxiety/depression, high-level cognitive and high-level motor impairments). Even for TIAs, occupational therapists may play an important role in regards to health promotion referring on for adaptive (compensatory/functional) equip- ment needs and attempting to reduce social isolation, which is commonly experienced in elderly populations. This enables the occupational therapist to help the consultant signpost patients for referral to appropriate services. Clearly the cost effectiveness of occupational therapists in this emerging role has not yet been evidenced and further research is re- quired. In the meantime, therapists are encouraged to promote the role of occupational therapy in NVCs and to liaise with consultants to establish direct or indirect methods to improve comprehensive stroke care. For example, therapists may negotiate direct face-to- face contact time with patients and carers during clinic appointment or become indirectly involved in screening by contributing to consultant’s screening assessments that include impairment, activity, participation, environmental and personal factor concerns with an on-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 support networks) should functional issues be identified. To support the evidence base regarding the effectiveness of the role of occupational therapists in NVCs, audit and dissemination of results through publications, conferences and newsletters is highly recommended. An example of procedures to consider for occupational therapists working in NVCs is as follows:

Caseload: TIAs and minor strokes 0–7 days post stroke (ISWP, 2008). ∼ Aim: To screen for functional implications arising from minor stroke and consider health promotion needs in the at-risk population so that appropriate signposting and referrals can be made. Assessment: Consider initial symptoms and potential implications using knowledge of functional anatomy. As patients are currently in their home environment, they may have more insight into functional changes than those admitted at time of event. Thus, screen for changes in functional activities, particularly high-level ADLs such as outdoor mobility, stairs, bath transfers, dexterity for managing fasteners, concentration for/understanding reading, 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 the doctors to confirm patient’s report and alert consultant and patient to significant discrepancies. The Occupational Therapy Process 55

Discharge: 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 dynamic settings may be too early to identify if patients have not participated in these activities since the event, but alerting patients during the clinic to liaise with GP if these symptoms should arise and providing information leaflets should be considered.

Acute stroke units (hyperacute care) Once patients are admitted to specialist stroke units, occupational therapists should be involved in screening all patients (ISWP, 2008). It is argued that for the same reason for screening in NVCs, occupational therapist should also screen TIAs who are admitted to acute stroke units (ASU). Hence, although guidelines state that occupational therapy assessment should occur within 4 days of admission (ISWP, 2008), a method of screening to prioritise and fast track high functioning patients who might be imminently discharged is required. General prioritisation of patients admitted should consider:

Imaging (computerised tomography/magnetic resonance imaging) results. r Monitoring for alternate oncology diagnoses; plans for neurosurgical intervention. r Referring onto other teams for non-stroke management and discharge planning. r Is feeding established? (swallow assessment/independence in feeding). r Mobility/transfers/ability to sit out > 2 hours in supported/normal seating. r Patient’s level of alertness. r Continence. r Cognitive/perceptual symptoms. r Communication. r (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, r reviewing medical notes. This may be due to the patient having been admitted or transferred onto ASU within the last working day. Outcome of prioritisation should be clearly documented in patient notes with any plans to monitor/review prioritisation status. Whose assessment of premorbid and current cognitive/perceptual function is required, r particularly when the patient is physically able and discharge may be imminent. Whose discharge planning requiring occupational therapy intervention is imminent. r Whose urgent occupational therapy intervention is required for maintenance of func- r tion/prevention of deterioration, for example, posture, positioning or oedema manage- ment. (Poole Hospital NHS Foundation Trust, 2005) 56 Occupational Therapy and Stroke

An example of procedures to consider for occupational therapists working in ASU/hyperacute care (based on Poole Hospital NHS Foundation Trust, (2006), repro- duced with 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 to ASU and contribute to MDT decision regarding patient’s potential: To be discharged home from ASU with or without ongoing intervention from early r supported discharge/intermediate care/community teams. To benefit from inpatient rehabilitation. r Functional implications post discharge in consideration of home/social situation. Assessment:r Targeted screening assessment informed by imaging results and clinical experience should be developed. Minimum assessment for all high priority patients should include the following: Initial interview regarding home situation and past medical/social and occupational r performance history (including personal care, domestic activities, types of meal preparation for breakfast, lunch and dinner, managing medications, finances, gardening, driving, leisure interests, productivity/worker role (confirmed with next of kin or carers if from supported living environment)). Liaise with physiotherapy regarding need for stairs/steps assessment. Functional transfers including bed, chair (note with or without arms), toilet ( 43 ≈ r cm height), bath (if applicable as may save referral to social services occupational therapists) with information regarding furniture heights at home particularly if some amount of effort demonstrated with transfers on ward. Upper limb sensorimotor screening including functional active range of r motion/coordination/reported sensation at minimum. If impairments evident, assess further. Use ability to take shoes/socks on/off, reach behind back to do up bra or apron bow, reach head with both hands to put on pullover, and ability to manage fasteners as estimation of physical independence with personal care. Visual processing including visual acuity, visual fields, inattention (visual and r tactile), and oculomotor skills (latter especially if pt reports double vision, field loss or has brainstem/cerebellar/occipital lesions). Cognitive/perceptual screening. Ifr none apparent in conversation/on ward – confirm with nursing staff in function then... If patient previously assisted with domestic and community activities and r non-demanding leisure interests – no further assessment required. If patient lives alone previously independent with domestic, community ± r activities, driving or has interests that involve higher level cognition, for example, complete an assessment that includes planning/organising/prioritising/problem solving. If working age, screen for high-level cognition, executive functions and information processing speed comparing against normative data. The Occupational Therapy Process 57

If cognitive/perceptual impairments or frontal/parietal/temporal damage is reported, complete further cognitive perceptual screen. Appropriate and relevant functional assessment designed to challenge patients and r reveal potential problems, for example, involving multitasking, coping in dynamic community environments, if premorbidly appropriate, patient mobile and approaching discharge. Assess at minimum meaningful functional task requiring multitasking 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 and r screening. Personal care assessment simulating home environment, that is, strip r wash/shower/bath where possible. Home assessment meal preparation shopping (particularly for patients ± ± r previously independent, living alone and with cognitive/perceptual problems evident 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 the r occupational therapist) especially for high-level cognitive/perceptual problems, for example, frontal damage, apraxia. Intervention: If appropriate advise patient of being uninsured to drive without medical consent. Restorative (remedial) and adaptive (compensatory/functional) approaches to facilitate discharge. Discharge: Consider referrals to: Community stroke liaison practitioner occupational therapy follow-up phone ± r call. Early supported discharge schemes/in-reach or out-reach intermediate care. r Follow-up community occupational therapy (including referrals for mild slowed r thought processing/ high-level attention impairments). Sensory loss team (if visual/hearing impairment – possibly premorbid). r Social services occupational therapist for rails/adaptations/bath equipment. r

Subacute/inpatient rehabilitation units Subacute inpatient rehabilitation forms the focus of most of this book. Particular note should be made for young strokes to consider family roles. An example of procedures to consider for occupational therapists working in subacute stroke 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 Stroke

improving performance capacity (reduce impairment and activity limitations). To facilitate appropriate discharge planning. Review prioritisation. Assessment: More in-depth assessments are required based on results of screening assessments. Intervention: Restorative (remedial) and adaptive (compensatory/functional) approaches. Acute ‘patients should undergo as much therapy appropriate to their needs as they are willing and able to tolerate and in the early stages they should receive a minimum of 45 minutes daily of each therapy that 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, should consider referral to: Community stroke liaison practitioner occupational therapy follow-up phone ± r call. Early supported discharge schemes/in-reach or out-reach intermediate care. r Follow-up community occupational therapy. r Sensory loss team (if visual/hearing impairment – possibly premorbid). r Social services occupational therapist for rails/adaptations/bath equipment. r Stroke/carer support groups. r

Early supported discharge Upon leaving hospital, lifestyle often changes considerably by the effects of a stroke. A person needs to have choice to be empowered in a supportive environment. Resources and facilities of course vary from region to region. However, any improvement in the links between hospital and community services can only ease this difficult transition. An example of procedures to consider for occupational therapists working in early supported discharge (ESD) and intermediate care teams:

Caseload: Subacute (1–26 weeks) (ISWP, 2008). Aim: To facilitate transition from inpatient to home environment using appropriate 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. r Sensory loss team (if visual/hearing impairment – possibly premorbid). r Social services occupational therapist for rails/adaptations/bath equipment. r Stroke/carer support groups. r The Occupational Therapy Process 59

Community rehabilitation and resettlement With a push to reduce length of hospital stay and success of ESD teams, the scope of community rehabilitation to include restorative (remedial) intervention aimed at reducing impairments alongside adaptive (compensatory/functional) intervention focusing on re- ducing activity and participation limitations is growing. Consequently, community teams need to become increasingly skilled and specialist community teams are recommended for stroke care. An example of procedures to consider for occupational therapists working in community rehabilitation teams:

Caseload: Subacute – chronic strokes. Aim: To provide appropriate restorative (remedial) and adaptive (compensatory/functional) intervention aimed at reducing impairments, activity and participation limitations in consideration of affecting environmental and personal factors. Assessment: Handover from inpatient team. Consider all levels of assessment as appropriate – particularly activity participation and personal factors. Intervention: See Chapter 9. Occupational performance and occupational identity – Focussed at reducing impairment (if subacute), reducing activity and participation limitations, addressing environmental and personal factors. Empowerment – resuming control of their own affairs – including work and leisure. Confidence and self-esteem building groups. Adjustment to residual disability as well as facilitating a return to meaningful lives. Integration into social and voluntary organisations. Discharge: Ensure follow-up monitoring systems in place. Ensure access to ongoing support and advice.

Health promotion Considering the relationship between occupation and heath it is not surprising that the role of occupational therapy in primary (targeting the well population to prevent ill health), sec- ondary (targeting at risk groups) and tertiary health promotion (maximising potential for healthy living) is high on the emerging agenda (College of Occupational Therapists, 2008). Long-term follow-up studies suggest that stroke patients may deteriorate post discharge from stroke services and have symptoms of depression (Wilkinson et al., 1997). Health promotion after stroke may include exercise, nutrition, health behaviour and prevention of secondary stroke (Rimmer and Hedman, 1998). Occupational therapy intervention for stroke patients in nursing homes has been found to be effective for reducing deterioration 60 Occupational Therapy and Stroke in function (Sackley et al., 2006) and lifestyle redesign programmes for the elderly look promising (College of Occupational Therapists, 2008).

Professional duties

Code of conduct The College of Occupational Therapists (2005) produced a code of Ethics and Professional Conduct for use throughout the UK. The title Occupational Therapist is protected by law and can only be used by those who hold a diploma or degree in occupational therapy and are eligible for registration with the Health Professions Council (HPC). Occupational therapy personnel refers to occupational therapists (including managers, educators and researchers), students and support workers. The code of conduct is a public statement of values and principles to promote and maintain high standards of professional behaviour. The code covers:

Patient autonomy and welfare. r Services to patients. r Personal and professional integrity. r Professional competence and standards. r Standards of conduct and performance are also an essential requirement of registration with the HPC (2007a), which sets out 14 areas that HPC registrants must adhere to, covering:

Acting in the best interest of patients. r Confidentiality. r Personal conduct. r Provision of information on conduct and competence. r Up-to-date professional knowledge. r Acting within limits of competency. r Communication. r Supervision of others. r Consent. r Record keeping. r Infection control. r Judgement. r Honesty and integrity. r Advertising. r HPC competencies The HPC (2007b) also sets out standards of proficiency for occupational therapists for the safe and effective practice of health professions. The generic standards are set out under The Occupational Therapy Process 61 the headings below but the document also sets out the occupational therapy profession- specific standards; these can be accessed on the HPC website. Generic standards encompass:

Professional autonomy and accountability. r Identification and assessment of health and social care needs. r Knowledge, understanding and skills. r

The NHS knowledge and skills framework (NHS KSF) and the development review process (applicable to the NHS in England; Health and personal social services in Northern Ireland; NHS Scotland; and NHS Wales) The NHS KSF defines and describes the knowledge and skills which NHS staff need to apply in their work in order to deliver quality services. It provides a single consistent comprehensive and explicit framework on which to base review and development for all staff (Agenda for Change Team, 2004). The main purpose is to provide an NHS-wide framework that can be used consistently across the service to support personal development in post, career development and service development. It has been developed by joint management and staff side working together using existing competencies to inform developments. The NHS KSF learning programme, 2004 states that the KSF has been designed so that there are common descriptions of knowledge and skills that are applicable and transferable across the NHS, making it simple and easy to implement. It does not describe people or attitudes, exact knowledge and skills that people need to develop, job weight or band.

Development review AKSFoutlineisdevelopedforeverypost;theindividualismatchedagainsttheKSF outline for their post. Personal development plans are agreed and supported with the individual learning in a variety of ways. The learning is then evaluated. The development needs are linked between the individuals needs and the requirements of the post. The KSF will be used as a recruitment and induction as well as through out the individuals working life, this should provide a fair and objective framework to base the review upon, guide development and assist with pay progression in the service. This process entails an annual review, a personal development plan and the expectation that all individuals are required to learn and develop.

Career development This involves building on the development plan particularly after the second gateway; the KSF will assist in possible development routes. It involves commitment to development and feedback. 62 Occupational Therapy and Stroke

Service development The KSF should help individuals understand their role in effective service delivery to improve patient care.

Skills for health Skills for Health has directors in regions in England, a director in Scotland, Northern Ireland and Wales, and a web-based tool of the Sector Skills Council (SSC) for UK health environment. The aim is to assist in developing solutions for a skilled and flexible UK workforce 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 workforce and 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 boost productivity. 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 be used across the board – by all health professions, and all levels of staff, whether in the independent or voluntary sectors or in the NHS. Competences can be used to meet the demands of the NHS KSF. These competences can be used to develop individuals and services to improve patient care. The stroke competencies are mapped against KSF health and well-being dimensions.

Stroke-specific education framework The UK forum for stroke training has developed an educational framework directing the elements to be delivered for staff to have the appropriate knowledge, skills and experience to 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 nationally recognised, quality assured and transferable education and learning in stroke. The stroke-specific education framework (SSEF) details the knowledge, understand- ing and 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 inde- pendent sector. The 16 elements are covered in the four areas below:

Awareness and information. r Time is brain. r Life after stroke. r Working together/implementation. r The framework will:

Assist in developing a stroke skilled work force; ensuring quality of care and compe- r tencies of stroke staff. The Occupational Therapy Process 63

Guide the development of programmes to inform and educate the patient, carer and r general public regarding stroke issues. Enable individuals and managers to plan continuous professional development. r Facilitate organisations to make plans and strategies to improve their services. r Self-evaluation questions

1. Does your setting document long-term aspirational goals as well as the short-term SMART goals? Can this system be improved to enhance patient engagement and motivation? 2. Does your setting have clinical reasoning guidelines to help guide therapists new to the area? How might these be further developed? 3. What might a typical occupational therapy pathway look like for your patients in your 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 be made smoother? 5. Consider what assessments/documents can be shared to improve transition and reduce duplication. 6. How is health promotion addressed in your practice setting? How might you integrate this into your own practice? 7. What is the code of conduct for occupational therapists? Select and discuss five areas that are essential requirements under the code of conduct for HPC registration and its aims? 8. What is the main purpose of the NHS KSF? 9. In preparing for performance review and career development, how could the KSF assist you? 10. What is ‘skills for health’ and how could you utilise the tools in developing stroke competencies for a junior member of staff? Chapter 4 Early Management Sue Winnall and Janet Ivey

This chapter includes: Prior to assessment r Initial interview and assessment r Equipment r Communication r Swallowing r Mood r Fatigue r Self-evaluation questions r Introduction

Effective appropriate early management is vital in the care and rehabilitation process of apatientwithastroke.Itpermitsthegatheringofappropriateinformationtopreparefor the patient’s ongoing assessment and rehabilitation. Key aspects of early management are gathering relevant information about the patient, completing an effective screen and assessment to identify key areas for further assessment and rehabilitation. One of the most 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 screening assessment. Putting all this information together helps to formulate a clear image of the patient, their impairments, skills, goals, motivations, so this information can be used to prepare a clear intervention plan.

Prior to assessment

Information gathering Before assessing the patient, it is important to gather initial information from the med- ical notes, other professional colleagues or reports/handover from nursing staff on the ward. Early Management 65

Aim To gather information to guide, inform and prioritise screening, assessment and inter- r vention.

Basic checklist Medical history It is important to document any comorbidities that the patient has as these may affect their assessment and functional abilities, for example, previous fractures with residual range of movement or decrease functioning of a joint or chronic cardiac failure that may cause breathlessness and fatigue.

Social history The occupational therapist should document with whom the patient lives and what social networks they have, including their occupation and main roles. These may guide the initial interview and assist in identifying any major concerns the patient may have, that will 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 a clinical picture of the patient, prior to their initial interview/assessment. Examples are – ward staff may report that the patient has ‘confused behaviour’, which may be an indicator of perceptual problems; a physiotherapist may report that the patient has difficulty following commands, which could be a language or praxis problem; the speech and language therapist may indicate the level of comprehension a patient has and whether yes/no responses are accurate, which will assist the occupational therapist in deciding how to elicit information in an initial interview.

Current physical mobility Prior to assessing the patient, the occupational therapist should ascertain how the patient can be moved and any equipment required. This will help the occupational therapist prepare for the initial assessment and the opportunity to arrange for assistance of others if required. A manual handling risk assessment should also be available to ensure patient and staff safety.

Functional abilities on the ward Information from ward staff can be invaluable in assisting the occupational therapist in ascertaining the functional independence of a patient and the consistency in maintaining this independence. However, the occupational therapist must always remember that the hospital setting is an institution and therefore has routines and prompts that are not always available to the patients in their home. Home environments are also more complex and patients may not 66 Occupational Therapy and Stroke be able to function at the same level within the home or community. The occupational therapist must therefore endeavour to simulate the demands of the individual patient’s particular situation in order to ascertain their abilities. Gaining background information is therefore essential in planning the screening assessment.

Assessments already completed The occupational therapist in their information gathering should note any assessments previously conducted and the outcomes of these; this will save time, prevent the patient being asked the same questions and assist the occupational therapist in prioritising the areas for assessment. For example, any cognitive assessments, language screening or mobility assessments can be utilised by the occupational therapist to analyse and predict functional 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 brain by a stroke. The occupational therapist by understanding arterial supplies and the functions of the lobes of the brain will be prepared for the potential impairments the patient may present with. This information can then be used to assist in directing any assessments and underlying causes for problems in the functional abilities of the patient.

Initial interview

The initial interview may be the first time the occupational therapist actually sees the pa- tient. Structured observations made by the occupational therapist are extremely important and inform the occupational therapy process, for example, when observing the patient on the ward, noting how they interact with others, what their posture is like, whether there are signs of inattention or neglect of a limb. Structured observations such as these provide clinical indicators of the impairments and functional difficulties a patient could potentially be experiencing or likely to experience during their rehabilitation. Once the occupational therapist has engaged with the patient, the patient may perform at a higher level in an intervention session but might be unable to sustain this level of functioning throughout the day. The initial interview can therefore be structured and the environment/venue set up to enable full participation, taking the above factors into account. The accuracy of information gained can be affected by cognitive factors such as memory and attention; communication (aphasia) can also make eliciting accurate information difficult. Any areas that raise concerns must be checked out for accuracy. The initial interview should try and ascertain the patients’ pre-morbid level of func- tioning and their social and physical environments. This is essential in order to assess the individual’s previous levels of participation and potential for return to this. The Early Management 67 occupational therapist’s approach to stroke rehabilitation and optimising functional abil- ities is in accordance with the World Health Organization (WHO, 2001) International Classification of Functioning (ICF) (see Chapter 1). The individual’s key roles and tasks undertaken provide the necessary information es- sential for the occupational therapist to base their assessments and interventions upon. Undertaking purposeful and meaningful occupations is essential in the occupational ther- apy process and for patient motivation and participation. The Occupational Therapy Standards for Stroke (Royal College of Physicians and College of Occupational Therapists, 2008) state that at the initial interview ‘former levels of functioning within the areas of self-care, productivity and leisure are discussed with the stroke survivor’. To audit the above standards, the Profession Specific Stroke Audit Occupational Ther- apy Clinical 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 assessment

The Occupational Therapy Standards for Stroke (Royal College of Physicians and College of Occupational Therapists, 2008) state that the initial occupational therapy assessment should include:

Appropriate advice on stopping smoking, regular exercise, diet and satisfactory weight, r reducing salt intake, avoiding excess alcohol. The needs of younger stroke survivors. r Assessment of cognitive, motor and functional abilities. r Cognitive and perceptual screening Cognitive and perceptual screening is a key component of the occupational therapist’s role in stroke care. Screening is done undertaken to give the therapist more information about a patient’s function before embarking on a full in-depth assessment. It gives the therapist an opportunity to make observations and gain an idea of any impairments the patient might be experiencing. It is particularly important for the ‘walking wounded’ as they can often appear fine during observation on the ward but with a few directed questions or tasks the impairments become apparent. 68 Occupational Therapy and Stroke

Aim To screen the patient’s cognitive and perceptual capacity to determine the need for r further in-depth assessment. To provide an indication of the patient’s attention, memory, safety awareness, judge- r ment, praxis and other cognitive impairments that might impact on other occupational therapy assessments and interventions. To provide an indication of the patient’s visual attention, spatial relations, visual recog- r nition and other perceptual impairments that might impact on other occupational therapy assessments and interventions. Often high-level cognitive and perceptual impairments are not as apparent during daily r tasks in a controlled, routine ward environment so screening might identify concerns that could otherwise be missed.

Basic checklist of questions or tasks directed at cognitive skills Level of alertness Does the patient engage or participate in conversation or daily tasks? r Does the patient’s level of alertness fluctuate or change over time? r

Orientation Can the patient determine time, place and person? r Is the patient aware of their surroundings and what has happened? r

Attention Does the patient sustain their attention during conversation? r Is the patient easily distractible? r Can the patient alternate their attention effectively to tell you the months of the year r backwards?

Communication Does the patient follow 1, 2 or 3 step commands? r Is the patient able to respond appropriately to questions? r

Memory Can the patient recall information accurately during the initial interview? r Does the patient appear to recognise you and what has happened over the recent r days? Can the patient remember when their next occupational therapy appointment is? r Early Management 69

Problem solving Does the patient need cues to follow out simple tasks? r Does the patient initiate tasks or engage actively in their environment? r Praxis Can the patient copy movements? r Can the patient demonstrate movements to command? r Can the patient imitate how to use certain objects? r As well as considering the questions above, observations during functional tasks are also vital to give an indication as to whether the patient might have a cognitive impairment.

Observations during functional assessment that might indicate a cognitive impairment and the need for further assessment Attention Is the patient focussed on the task throughout the activity? r Is the patient able to switch from one aspect of the task to another without prompts? r Is the patient able to talk and engage in the task or complete two aspects of the activity r simultaneously?

Information processing Does the patient engage in the task at an appropriate speed? r Does the task break down when there is novel information or with an increase in task r complexity?

Memory Does the patient remember what task they are engaged in? r Can the patient find relevant items needed for a task? r Executive functions Is the patient able to initiate, sequence and organise the task appropriately? r Does the patient display appropriate judgement, problem solving and safety awareness? r Praxis Does the patient appear to know what they want to do but are using an ineffective or r inappropriate movement for the task? Does the patient use appropriate objects for the task? r 70 Occupational Therapy and Stroke

If concerns in any of these areas are identified, further standardised cognitive assess- ment might be necessary. For detailed information relating to cognitive impairments, see Chapter 7.

Basic checklist of questions or tasks directed at visual perceptual skills Visual fields (hemianopia or quadrantanopia) Confrontation test – With eyes fixated centrally, a patient with a hemianopia or quad- r rantanopia is 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 with r hemianopia often presents with an abbreviated scanning pattern, missing items in affected visual field. Copying a diagram (the patient is presented with a diagram to copy but not told what it r is) – A patient with a visual field impairment often only copies half the diagram unless they 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 field r that is left, right or both – a patient with visual inattention does not identify objects in the area of reduced attention when presented with objects simultaneously. Scanning task – A patient with visual inattention has an abbreviated scanning pattern r but often has a disordered, random scanning pattern (unlike a patient with hemianopia which is well organised). Copying a diagram – A patient with visual inattention only copies half the picture. r Drawing a clock, including numbers, on command – A patient with visual inattention r often places all the numbers on one side of the clock or only complete one side of the clock (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 diagrams r appropriate to the task? Can the patient identify objects when asked? Can they categorise according to colour, r shape, size or usage? Pour water into a glass? As well as considering the questions above, observations during functional tasks are also vital to give an indication as to whether the patient might have a perceptual impairment.

Observations during functional tasks that might indicate a perceptual impairment and the need for further assessment Visual fields Is the patient able to find all the materials they need for the task without prompts? Is r there a delay in searching on their affected side? Early Management 71

Does the patient bump into or miss information on their affected side? r Can the patient read signs or books? r Does the patient fill in all the information on forms? r Visual inattention Does the patient need prompts to search their environment? r Does the patient appear to have difficulty turning, looking or searching on their affected r side? Does the patient bump into objects and have difficulty adjusting to obstacles in their r environment? Does the patient have difficulty watching TV, reading, using the telephone or focussing r on the person talking to them?

Other perceptual impairments Does the patient misjudge distance or depth? r Does the patient have difficulty orienting clothing or spatially organising their r workspace? If concerns in any of these areas are identified, further standardised perceptual assess- ment might be necessary. For detailed information relating to sensory impairments, see Chapter 6 and for perceptual impairments, see Chapter 8.

Psychosocial screening It is important, as a part of the multidisciplinary team, to be aware of and screen for psychosocial issues, including mood and fatigue.

Aim To recognise or identify psychosocial issues to be able to refer to the appropriate r multidisciplinary team member for further assessment and intervention. To be aware of psychosocial state and impact on occupational therapy assessment and r intervention.

Observation What is the patient’s emotional state? r Does the patient appear unmotivated? Tired? Depressed? Emotionally labile? r How does the patient react to or engage in therapy? r Variety of mood screens available. r If concerns in any of these areas are identified, further in-depth assessment might be required and it is recommended that the consultant and multidisciplinary team are informed. Referral to a psychologist might be required. 72 Occupational Therapy and Stroke

Neurophysical screening The patient needs to be suitably dressed for this assessment although it is often easier to fully 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 patient in whatever position they are initially found in as the occupational therapist’s handling ability, that is, transfers, etc., will have an impact on the patient’s presentation. It is useful to gather information about the patient’s movement, etc., before the structured screening or assessment is commenced. Note, handling and observation are key to an accurate assessment.

Aim To set the scene for further assessment and intervention. r To build up a picture of the patient as a whole, and how they move. r To provide information for setting goals in conjunction with the patient and other team r members. To provide information from which a baseline for intervention can be formed. r To identify how the patient moves, attempts to move and what aspects are abnormal. r Motor screening How does the patient move? r Why does the patient move in this way? r In position What does the patient’s head do? r Feel the patient’s trunk. Can they change or maintain position? r Feel the patient’s arms. Is their unaffected arm free to move or is there pain? r How is the patient’s arm positioned? Heavy, light, subluxation, active movement? r What is the position, tone and range of movement in the patient’s legs? r Transfers How does the patient get from the chair to the bed? How? Independent? r Presence of associated reactions? With help? r How does the patient get from sitting to lying? r How does the patient get from sitting to standing? r Sitting Sitting unsupported. Can the patient achieve this? Does the patient use their arms to r maintain sitting balance? Early Management 73

Weight-bearing. Is it symmetrical? r Overall posture. Can the patient adapt their posture when handled? r Posture of legs. Falling in? Pulled out? r Position of pelvis and effect on their trunk and upper limb position. r

Tr unk Can the patient shift their weight laterally? r Is the patient able to correct themselves when they shift weight? r Does the patient have areas of high or low tone? r What is the position of the patient’s scapulae? r

Scapula Assess the muscles around the scapula – Is there weakness, tightness or tone affecting r the rotation or sitting position? Is the scapula moving within normal scapulohumeral rhythm? r

Glenohumeral joint Assess for subluxation and rotator cuff muscle activity. r Does the patient’s scapula rotate with movement of the glenohumeral joint? r

Upper limb Is it functional? Is there selective, voluntary movement? r Is the patient able to isometrically, concentrically and eccentrically contract to reach, r grasp and place their upper limb?

Feel the patient’s hand Gross grasp, fine motor control, arches. r

Standing and gait Is the patient able to stand? Can they shift their weight on either leg? r Is the patient symmetrical? Can they maintain static and dynamic standing? r Is the patient able to move their upper limbs while standing or do they need to use their r upper limbs for support?

For detailed information relating to motor impairments, see Chapter 5. 74 Occupational Therapy and Stroke

Functional assessment Functional assessments, for example, washing and dressing assessments, kitchen assess- ments or 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, as well as their task performance.

Aim Screening tool to identify impairments, skills, performance impairments. r To provide an opportunity to assess the combination of all the performance components r within a task. Toprovidevitalinformationonhowthepatient’simpairmentsimpactontheirfunctional r ability. To allow an opportunity to identify how a patient is using their residual skills to perform r afamiliartask. To provide an opportunity for assessment that is not reliant solely on a patient’s under- r standing or conceptualisation of the task’s requirement due to the familiar nature of the task and the environmental cues.

Functional screening The following questions should be considered from a cognitive/perceptual perspective:

How did the patient approach the task? r Did the patient appear familiar with the task? r Did the patient use any environmental cues? r Was the patient able to problem solve the novel aspects, for example, the weakness in r their limbs or the differences in environment? How did the patient initiate the task? r Was the patient’s initiation efficient? r Consider the patient’s attention, their focus on the task, their planning and organisation, r completion of the task. Consider the patient’s search strategy and ability to recognise environmental cues. r The following questions should be considered from a physical/sensory perspective:

What was the patient’s level of endurance? r Was the task effortful? r Did the patient maintain good sitting or standing balance? r Was the patient able to position their body appropriately for the task? r Did the patient perform tasks bilaterally? r Were there any changes in tone during the task? r For detailed information relating to functional impairments, see Chapter 5. Early Management 75

Intervention

Once the initial screening is completed, it is important to determine if any further assess- ment is required to decide what intervention is most appropriate for the patient. Details of how to assess and provide specific intervention for motor, sensory, cognitive and perceptual impairments are described in Chapters 5–8. Goal setting should be undertaken, as described in Chapter 3.

Equipment

The assessment for and provision of equipment to stroke patients is generally viewed as an adaptive (compensatory/functional) method of reducing limitations. Most equipment is issued following a home assessment visit completed prior to weekend leave and/or discharge. However, some equipment can be used to facilitate normal movement and increase independence within the hospital setting. The pros and cons of timing and type of equipment should be carefully considered in conjunction with the patient, family and multidisciplinary team.

Wheelchairs The provision of a wheelchair for a patient following a stroke can be considered for two main reasons – for correct positioning during early management and for indoor/outdoor mobility during the rehabilitation stage. The type of wheelchair appropriate for a stroke patient could include attendant- propelled manual wheelchairs and indoor- or outdoor-powered wheelchairs. Attendant-propelled manual wheelchairs can be used to achieve better positioning and to improve sitting balance on the ward, which is not always possible with armchairs or high seat chairs. A pressure care cushion should always be provided with the wheelchair and monitored throughout the day by nursing staff and therapists. Access to attendant- propelled wheelchairs adjusted for specific patients can also enable patients to be taken off the ward by their visitors for often much-needed stimulation. Ideally, a wheelchair should also be available for the patient to use for outdoor and/or indoor mobility on weekend leaves and on discharge. In some settings patients are discouraged from trying to propel themselves with their feet, and self-propelling manual wheelchairs are often avoided altogether. It is thought that the patient’s muscle tone will increase when using the unaffected arm and leg in this way. It is best to discuss the approach. Indoor-powered wheelchairs could be considered for patients with severe physical disability and those with chronic heart and lung conditions. A patient’s cognition and visual perception should be fully assessed as part of the wheelchair assessment. The use of a powered wheelchair in hospital can help increase motivation and might be considered as an intervention option for spatial awareness problems and inattention. Acombinedindoor/outdoor-andoutdoor-poweredwheelchairwouldrequireafull assessment by the hospital-based occupational therapist and specialised wheelchair 76 Occupational Therapy and Stroke therapist, 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 environment and local area in which the patient will be living should always be taken into account. The access to the patient’s home, the type of accommodation, the width of all internal/external doorways, the layout of the furniture and other fixtures/fittings, the door thresholds and the floor coverings should be considered for suitability of a wheelchair.

Toileting Raised toilet seats and frames (which are safely fixed to the floor) will encourage a patient to move from sit to stand in a more normal way than pulling on grab rails fixed to a wall.

Bathing/showering Many stroke patients with independent sitting balance can manage transfers on and off a bath 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 heart and lung conditions and the frail elderly. Non-slip mats should always be provided or purchased to be used in conjunction with bath boards/seats. Chairs or seats that are fixed across the top of the bath for use with a shower or that lower into the bath require less effort for 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 and are therefore only accessible to the more mobile stroke patient who can wash themselves independently whilst standing or sitting on a stool.

Meal preparation Some kitchen equipment such as large-handled utensils or cutlery issued by occupational therapists could be used by patients with some return of hand function to encourage further improvement or facilitate more normal movement. These could be used during meal preparation sessions in hospital or at home. Many other pieces of equipment are designed for one-handed use or to make heavy tasks lighter. Spike board, belliclamp, wall tin opener, battery-operated tin openers that fit on the can and do not require holding, ring pull cans and buttering board will enable the patient with limited upper limb function to prepare meals. A kettle tipper and cooking basket and draining spoons make dealing with boiling water safer and lighter. A trolley can be used by the more mobile patient to carry hot food. Fatigue is a major factor to consider when preparing a meal. The layout of the kitchen and 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’s energy. A perching stool could also help reduce fatigue. Early Management 77

Eating During the acute stage, good positioning whilst eating will assist safer feeding and swal- lowing. Plates that retain heat will keep food warmer for a slow eater. Plateguards and large-handled mugs with lids reduce the risk of spillage. Dycem mats will keep plates in place. Large-handled cutlery could be used with the affected hand to encourage further return of movement. At a later stage, the one-handed patient may require a rocker knife or a fork with a serrated edge for cutting.

Other impairments impacting on functional ability

Communication There are three main communication disorders associated with stroke: aphasia/dysphasia, dysarthria and verbal apraxia.

Aphasia Aphasia is a disorder of language which can result in difficulty: Understanding what is said. r Expressing things verbally. r Reading. r Writing. r 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 and expression 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. r Yes/no responses which are unreliable, either because the question is not understood or r because one is meant/thought but the reverse is said. Swearing – usually automatic and unintentional. r One phrase/word/sound produced whenever speech is attempted. r Repeating back what has been said/asked (often without understanding). r Aretainedabilitytosing(becauseitiscontrolledbytheoppositesideofthebrain). r Fluent speech, ‘jargon’, which is difficult to inhibit (this may comprise a mixture of r meaningful and non-meaningful words or may be just a string of sounds). Grammatical words, such as ‘the’, ‘a’, ‘to’, etc., are not used. r Word finding difficulties – some dysphasics may be able to describe something about r a word, but not retrieve the word itself. The Stroke Association publishes leaflets with advice helpful to patients and to ther- apists on how to deal with aphasia. Occupational therapists should liaise with speech and language therapists on ways to encourage return of speech whilst carrying out 78 Occupational Therapy and Stroke occupational therapy activity with the dysphasic patient, as intensive practice is bene- ficial. The obvious strategies of writing or signboards should be tried, but are not always helpful. 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 to enable them to participate in intervention. The family or carers should have the situation explained and be involved in developing ways of communicating.

Understanding Problems in understanding language will range in severity from virtually no understanding of spoken language to mild difficulty apparent only when following group conversation or 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 r –bodylanguage –facialexpressions –toneofvoice Situational cues – things in the environment which help determine what is being asked, r e.g. the tea trolley, drugs trolley, etc. Understanding can be helped by using demonstration and gesture alongside or instead of spoken instructions.

Dysarthria This is a speech disorder caused by damage to the nerves supplying the muscles used when speaking. It may involve problems with breath control for speech, voice production, controlling whether air is directed orally or nasally during speech, and articulation of speech sounds. It can range in severity from mildly slurred speech to inability to produce any intelligible speech. Apatientwithdysarthriaisoftenabletousealternativemeansofcommunication because their language skills are intact, for example, Writing. r Spelling words out on an alphabet chart. r Using an electronic communication aid. r Verbal apraxia This is a disorder affecting the purposeful coordination of muscle movements for speech production. It is not a language problem, but very often patients with verbal apraxia also have some degree of aphasia. Early Management 79

It is characterised by:

Groping/struggling to achieve the correct sounds for a word or to sequence the sounds r in the right order. Awareness of errors and subsequent frustration and repeated attempts. r Speech produced ‘subconsciously’ or automatically which will be noticeably more r fluent than purposeful speech. The speech muscles which are not paralysed and automatic movements are retained, r for example, for eating, drinking, laughing.

Communicating with an aphasic patient 1. Face the patient you are talking to and direct your speech to them at all times. 2. Keep the background noise to a minimum,thatis,turndownthetelevisionorradio or 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 listening to you, for example, use their name to focus their attention, or touch them and pause before 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 articulation or 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 pausing frequently. 6. Repeat or rephrase what you have said if you are not understood. Try putting the most important word at the end of the sentence, for example, ‘What is your address?’. 7. Stress or emphasise important words in the sentence, for example, ‘Did Christine ring?’ or ‘Did Christine ring?’. 8. Give clues about what you are saying,forexample,useagesture,orwritedown important words, or draw attention to a photograph or an object relating to what you are saying. 9. Do not change topics quickly –leaveplentyoftimebeforemovingontosomething new and give time to let the dysphasic patient tune into the new topic. 10. Be specific,forexample,‘I’llputyourclothesinthewardrobe’not‘I’llputthem there’. 11. Take time to be a good listener –keepcalm,bealerttothedysphasicpatient’suse of gesture, their facial expressions, etc., listen and watch out for the intention behind what they are communicating, even if the individual words do not make sense. 12. Encourage methods other than speech –usinggesture,drawingonpaperorintheair, writing down the whole or part of a word, pointing to pictures or a choice of written words. 13. Accept a message conveyed by whatever means is possible –donotthenforcethem to use a ‘better’ method, for example, do not ask them to repeat ‘I want a drink’ when they have gestured their need. 80 Occupational Therapy and Stroke

14. Ask questions to guide you to the general topic,forexample,‘Isittodowithhome?’ and use your knowledge of the patient’s activities, needs and situation to help you guess the topic of conversation. 15. Let them know what you have understood.Summarisewhatyoufeelhasbeensaidto check you have got it right, for example, ‘I think you are telling me something about dinner’. 16. Do not pretend to understand. Ask for more information or repetition if you have not understood. The dysphasic patient will soon realise if you are pretending to understand and this is likely to lead to more frustration. 17. Help the patient find a particular word by encouraging them to –describesomething about the word, for example, what you do with it, what it looks like, etc., or think of something associated with the word, for example, a word similar in meaning or the category (animal, flower, etc.).

Swallowing

Dysphagia is difficulty in safely moving a bolus of food, or liquid, from the mouth to the stomach without aspirating, and involves chewing and tongue movement, preparing food for swallowing, as well as the actual swallow. Thorough clinical examination can identify dysphagia, but can fail to identify patients aspirating. All staff working with the stroke patient should be aware of the possibility of dysphagia and take appropriate action if they feel someone may be aspirating. Initial severity does not mean that the patient will not recover, 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. r Difficulty in swallowing saliva, so that drooling is a continual problem. r Food remaining inside the mouth after eating, often pocketed inside a cheek or across r the roof of the mouth. Coughing or choking while eating or drinking. r Change in voice quality after eating or drinking, often the voice sounds wet or gurgly. r Breathlessness after eating or drinking. r Meal times taking longer to finish; often there may be weight loss. r Someone may complain of food feeling stuck in the throat. r Frequent pneumonias. r Advice for someone with swallowing problems includes:

Always sit as upright as possible when eating or drinking. r Remain upright for 15–20 minutes afterwards. r Avoid noise or other distractions. Do not try to talk and eat at the same time. r Sipping iced water or ice cream, or sucking on iced pops before starting a meal may be r helpful in stimulating swallowing mechanism. Take smaller mouthfuls of liquids and food. All food should be chewed well. r Early Management 81

Ensure a strong swallow between each mouthful, when possible try a second swallow, r or cough to clear the throat. Following a stroke someone may tire easily and this may affect the swallow. If meal r times are taking longer and are tiring, try smaller meals, taken more frequently or with snacks in between. If there is a tendency for food to remain in the mouth after eating, clean the mouth after r mealtime with a soft toothbrush or mouthwash.

People with severe dysphagia will be fed through a nasogastric or percutaneous en- doscopic gastrostomy (PEG) tube. However, oral feeding is always seen as preferable when 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 reassessed at regular intervals. Food and taste play an important part in our lives and the occupational therapist can liaise with the speech and language therapist to work on swallowing with changing tastes and food consistencies. The therapist should ensure the patient is well seated and supported at meal times, encouraging people to feed themselves and trying to balance dignity with cleanliness! The Stroke Association leaflet on swallowing difficulties gives good advice on eating. The therapist should be aware of swallowing difficulties when working on aspects such as cleaning teeth, and making drinks and meals. It is important that all members of the team stress to the patient the importance of their adapted diet to encourage patient acceptance of what often appears unappealing. This is especially true for the patient who has to maintain a special diet after discharge.

Mood

Anxiety, depression and emotionalism are likely to make rehabilitation difficult for patients as they may have decreased motivation to participate in assessments and intervention due to being preoccupied with their worries and thoughts. DeSouza (1983) also noted that one of the major factors affecting the success of stroke rehabilitation was the patient’s own determination and motivation to improve functionally. The nature of depression is that depressed patients are likely to have a decreased ability for motivation. This finding was supported by Zigmond and Snaith (1983), who suggested that patients may find that symptoms of their illness may distress them to such as extent as to lead to a poor response to intervention. Ebrahim et al. (1987) also demonstrated that mood disturbance at 6 months post-stroke was strongly associated with functional ability, limb weakness and with longer hospital stay. This suggests that slow recovery and institutionalisation may be responsible for mood disturbances. Similarly, Robinson et al. (1983) found that in 103 patients, the severity of impairment in functional activities (ADL) and intellectual function was significantly correlated with the severity of post-stroke depression early after stroke. Sixty-one of the patients in their study were reassessed after 6 months and were found to have made a significant 82 Occupational Therapy and Stroke improvement in functional impairment (Robinson et al., 1984). However, the depressed patients remained more impaired than the non-depressed patients. AfurtherstudybySinyoret al. (1986) also indicated that depression was common after stroke. They demonstrated that depression was associated with the level of functional impairment in 64 depressed stroke patients early after stroke and suggested that it may cause a negative impact on the rehabilitation process and outcome. They followed up 25 of these patients, 6 months after discharge and still found a significant correlation between depression 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. and Sinyor et al. studies had small numbers of patients. Thus, the effect of any of these impairments has been shown to be associated with func- tional ability, highlighting the complexity and trauma of stroke. It is therefore important to consider the effect of these impairments, the ‘invisible consequences of stroke’, when treating any patient following stroke.

Depression Depression after a stroke is common but often alleviates as the patient recovers (ISWP, 2008). The symptoms of depression may include:

Negative thoughts. r Irrational beliefs. r Distortion of reality. r Self-blame. r All or nothing attitude. r Low mood. r Poor appetite and weight loss or. r Increased appetite and weight gain. r Disturbed sleep. r Activity alters lethargic or agitated. → r Loss of interest and pleasure. r Poor concentration. r Indecision. r All patients should be screened for depression, including those with aphasia, by careful observation (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 83

Patients whose depression is more severe or persistent should be offered anti-depressant drugs but these should not be used routinely and be monitored and continued for at least 6monthsifbenefitisachieved(ISWP,2008). Intervention may involve counselling, anti-depressants or psychological intervention. Behavioural intervention could include reinforcing activity, activity scheduling, feedback of progress, experiencing success or pleasant events. Long-term therapy from a psycholo- gist or psychiatrist may be required for some patients. This will depend on the severity of the depression and the patient’s ability to cope with the depression. Occasionally patients may become so depressed that they feel suicidal, in which case, medical advice should be sought. Some patients may turn to spirituality to assist them in coping with the new lifestyle forced upon them.

Anxiety All stroke patients should be screened for anxiety and have the causes of any anxiety established (ISWP, 2008). Patients may have anxieties relating to their stroke, for example, fear of having an- other stroke, 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 for assessment. Intervention may include counselling, tranquillisers or psychological intervention.

Lability (now often called ‘emotionalism’) Patientsmayhavedifficultiescontrollingtheiremotionswhichresultsincryingorlaughing for any alteration in emotions, which can be very distressing. A common clinical technique is to ignore it and use distraction. Patients with severe, persistent or troublesome emotionalism should be given anti- depressants whilst 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 in the acute stage following stroke, but can also appear as a persistent problem long after discharge from hospital. In the initial stages following stroke, the systems of the body are working to promote recovery, and the patient has to make a great deal of effort – for example, in working on sitting or concentrating on a task. Some degree of exhaustion is inevitable, and therapists should be aware that many patients feel they are being worked too hard and that we do not understand their situation. 84 Occupational Therapy and Stroke

After discharge, the person feels that because they are ‘better’, they should manage as before, 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 this can lead to increased tone, poor performance, reduced motivation and so on. However, the patient who appears fatigued may not actually be tired following effort. Patients should be able to tolerate periods of reasonably challenging activity, and the fatigue which accompanies such activity should easily respond to a period of rest. Fatigue within normal 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 about or showing signs of fatigue, and then address the issues involved. It may be that they are not sleeping well at night, not able to wake in the day because of medication, be anxious or depressed, have an infection or other pathological condition, be poorly nourished or suffering 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 should be on the part of the therapist, with relaxed reciprocation from the patient. Intervention should 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 appears tired. Carr and Shepherd (1987) report studies in normal subjects that show muscle work performed after a diverting activity was greater than that performed after a rest – and they 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 the patient. Once discharged from hospital, it can be helpful for the person to understand the possible causes of their tiredness, and discuss strategies for coping with it. These would involve keeping active and returning to or developing interests, using energy wisely, dealing with concerns and depression, organising their day and prioritising, pacing and delegating 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 understanding of it, and why it may appear that they are ignoring it. By providing a varied and challenging programme, they will assist the patient in handling fatigue.

Self-evaluation questions

1. Name three things you should consider doing before you attempt a full functional assessment with a patient. 2. During a functional assessment in the kitchen you notice that the patient is picking up items and putting them down again or uses the wrong object within the task. What might be the impairment? Are there any other impairments that might present in a similar manner? What questions could you ask or what simple tasks could you do to differentiate between the impairments? 3. If a patient had an attention impairment, what might you notice while observing this patient? What simple tasks could you do to give you some more information? Early Management 85

4. If you are assessing a patient in sitting, why is it important to ensure that they are sitting 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 sit upright 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 basic screening tool that you might use to cover all the areas if you were given half an hour to check a patient before going home. 6. What information would be collated by the occupational therapist prior to the initial assessment that would assist in the assessment process? 7. Discuss how the World Health Organization (WHO) International Classification of Functioning (ICF) relates to the occupational therapy process in stroke rehabilitation. 8. What signs indicate a patient might have a swallowing impairment and how would this affect your occupational therapy intervention? 9. Describe the differences between aphasia, dysarthria and verbal apraxia. 10. Describe the symptoms of mood disorders. Chapter 5 Management of Motor Impairments Stephanie Wolff, Ther´ ese` Jackson and Louisa Reid

This chapter includes: Assessment of motor control r Management principles and intervention r Therapeutic aims of intervention r Positioning the early stroke patient r Self-care and instrumental activities r Clinical challenges r Upper limb re-education r Avoiding secondary complications r Self-evaluation questions r Introduction

The impact of motor impairments on patients can be devastating and the role of the occupational therapist in managing these problems is vital. This chapter focuses on the re- habilitation phase of managing motor problems and gives an overview of current practice in the clinical setting although various elements will also be applicable to the community setting. Main aspects of intervention are covered to equip new clinicians or students with ideas on how to approach the assessment and intervention of motor impairments. It is important to note that no one approach has been proven to be the most effective in regain- ing motor control post stroke; however, specific interventions that have been shown to be effective with certain groups of patients are discussed in the chapter. The chapter also cov- ers two 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.

Assessment

The assessment and analysis of patient’s problems set the scene for intervention. There is no formal assessment procedure. The idea is to build up a picture of the patient as 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 long and short-term goals, in conjunction with other team members. A thorough assessment Management of Motor Impairments 87 of motor impairments is essential, in order to understand the impact on functional tasks and to determine an appropriate and evidence-based intervention plan. Assessments can be carried out jointly with a physiotherapist in order to avoid the patient undergoing multiple assessments and to promote working jointly towards common goals; this is a common practice in many units and community teams. The following approach to assessment is more likely to occur in hospital in the acute rehabilitation phase but the principles can apply to patients in any location. In the acute stages of rehabilitation, the patient may be in bed when first assessed, which can be a good 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 of motor problems within other activities of daily living such as washing and dressing. It also enables the therapist to risk assess the safest handling approach. This section focuses on the practicalities of assessment that rely on the observational skills of the therapist rather than the use of standardised assessments, which have been discussed later in this chapter. During the assessment, the following questions should be asked and observations should be documented appropriately.

How does the patient move? Does the patient move with effort? r Are the movements disjointed or fluent? r Are there associated reactions present? r Can the patient actually move at all? r How are the movements different from normal? r Remember to take the ageing process, regarding premorbid posture, into account. r Why does the patient move in this way? Is it due to tone? High, low, fluctuating adaptable. r Are there associated reactions? Upper limb and lower limb. r Are there problems with the underlying balance mechanism? r Are there sensory problems leading to poor feedback? (loss of proprioception, loss of r tactile awareness). Is there loss of active, selective movement? r Are there cognitive/perceptual problems? (apraxia, neglect/inattention). r Bed mobility Before starting consider some practicalities. Check with nursing staff that the patient is fit to be assessed and are able to actively participate in the session? Can their consent be gained? Can they follow instructions? Beware of hazards around the bed such as drip stands, 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? r Is the head turned more to one side than the other? Which side? r 88 Occupational Therapy and Stroke

Is the patient straight or crooked in the bed and is one side of the body very active r compared to the other? Does the weaker arm look in a comfortable position or does it look like it is trapped r under the body? When you ask the patient to move the weaker arm and leg of the same side, is there r some 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, low tone 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, but that can change quickly. Following initial observations ask the patient to roll from side to side. If the patient needs help rolling, always make sure there is a second person to help. If the patient is clearly needing significant help, unless competent in therapeutic handling techniques, do not continue and use sliding sheets to position patient on their side.

Sitting At this stage the occupational therapist should have enough information to decide whether or not to proceed looking at the patient in sitting, on the edge of the bed. Initial assessment of sitting may however be best carried out with the patient sitting on a plinth in a therapy gym. 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. r Look at dynamic sitting balance; can the patient reach forward and to the side? r Observe if the patient is sitting on one buttock more than the other. r Is the trunk symmetrical? r Are the scapulas in alignment on both sides? r Carefully examine the affected shoulder for subluxation (see ‘Shoulder’ section later r in this chapter). In this posture observe if there are any changes in tone to the affected arm and leg. r Is the patient overactive with the intact side? Do they appear to be pushing themselves r over-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 also assess them sitting on the edge of their bed. Patients in hospital may have airflow mattresses on 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.

Transfers Assessment of transfers includes moving from supine to sitting, bed to chair and chair to commode or toilet. Management of Motor Impairments 89

Assessment will establish how the patient moves from one surface to another, how efficient they are and how safe. It is important to determine the level of assistance the patient needs. It is also vital for the therapist to know their level of competence when facilitating transfers. If assessing transfers with someone who is clearly going to need assistance, it is important to have a second person present, preferably an experienced therapist. When assessing transfers, consider the following: What is the minimum level of assistance the patient needs to safely complete the r transfer? Be careful not to over- or under-help someone. Can they transfer to both the sound and the affected side? r The patient should be assessed in various situations; transferring from a wheelchair to a plinth is not a satisfactory assessment. Make sure transfers are assessed in the environment where the patient will be required to do them throughout the day. Assessment of sitting balance and transfers will inform what recommendations might be needed for the nursing staff in relation to handling, for example, it will determine if the patient is suitable for a standing hoist rather than a full hoist. It will inform if they are safe to transfer to a toilet rather than a commode. Some patients can transfer safely with one person but cannot maintain their sitting balance safely on a toilet and therefore may need to transfer to a commode. It contributes to determining whether the patient is safe to be left alone whilst using the toilet.

Standing Assess how much facilitation the patient requires to stand from a variety of surfaces and observe the patient’s alignment in standing. Consider the following: Are they standing on the affected leg or just on the sound leg? r Can they stand safely in a static position? r Can they reach in standing and maintain their balance and safety? r How long can they stand? r Walking If the patient is able to walk, How far can they walk? r Are they safe? r If the patient requires assistance with walking, agree on the most appropriate method of assistance with the physiotherapist. Assessment of walking should be carried out in different environments that are relevant to the patient, for example, in open spaces, around cluttered rooms, uneven and even surfaces. In the community, walking assessment should include going to the shops, post office, restaurants, etc. 90 Occupational Therapy and Stroke

Activities of daily living Although assessment in different postures is important, the most relevant assessment of motor problems from the occupational therapist’s perspective is within more functional tasks. In the early stages of recovery, these could be getting washed and dressed, grooming tasks, feeding or simple kitchen activities. In later stages of recovery, this may include shopping, getting to work or social events. At the end of assessment, the occupational therapist should be able to identify the impairments of motor control and be able to relate this to the level of patient independence in activities of daily living.

Standardised assessments Standardised assessments are used in clinical practice to identify and quantify problem areas. These assessments can also be used as outcome measures. The National Clinical Guidelines for Stroke (Intercollegiate Stroke Working Party (ISWP), 2008) recommend that ‘All patients should be assessed for motor impairment, and a standardised approach to quantify the impairment should be used.’ There are various standardised assessments available. There is long-standing debate as to which of these are the best and currently which assessment is selected often depends on therapist’s preferences. When using a standardised assessment, it is important to understand what is being assessed. The results of such assessments should be useful for planning intervention and setting goals. There are two types of tests that are usually selected, generic activities of daily living and specific motor performance tests. The National Clinical Guidelines for Stroke (ISWP, 2008) recommend the Barthel Index (Mahoney and Barthel, 1965) as a generic activity of daily living scale and the Motricity Index (Collin and Wade, 1990), the Rivermead Motor Assessment (Lincoln and Leadbitter, 1979) and the 9 Hole Peg Test (Kellor et al., 1971) as specific motor performance tests. Many others are available, as listed in the evaluation chapter.

Management principles and intervention

Following a thorough initial assessment, the therapist needs to incorporate the identified problems into an intervention plan. Although occupational therapists in clinical practice will take into account all problem areas after the stroke, for example, cognition and perception, when planning intervention, this chapter concentrates on the intervention that focuses on motor problems. The therapist should take into account any available evidence when planning interven- tion. The ISWP (2008) reviewed the current evidence and their recommendations that relate to motor impairments that will impact occupational therapy practice are stated in Section 6.46:

‘Any person who has limitations on any aspect of personal activities, especially but not only if acquired as a result of this stroke, should: have intervention of identified problems from Management of Motor Impairments 91

the Occupational Therapist who should also guide and involve other members of a specialist multidisciplinary team’.

Specific interventions that should be offered (according to need) include: The opportunity to practise activities in the most natural (home-like) setting possible. r Assessment for, provision of and training in the use of equipment and adaptations that r increase safe independence. Training of family and carers in helping the patient. Sectionr 6.47 also relates to extended activities of daily living. Another relevant section for 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. r Gait speed and gait endurance. Theser guidelines indicate that intervention plans should incorporate practicing tasks, particularly personal care tasks; however, it does not go into detail about how this practice should be targeted. The point of assessing at impairment level is to understand which of the performance components of a task are affected, thereby explaining why patients are unable to complete a functional task, for example, a low tone arm affected the patient’s ability to dress. While the general recommendation is to practise tasks which enable the occupational 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 intervention

The main aims of occupational therapy intervention regarding motor problems are: Topromotemotorrecoveryinthemostnormalorefficientwaytoincreasefunctionalin- r dependence by practising graded activities of daily living using a restorative (remedial) approach. To prevent secondary complications such as pain in the shoulder or swelling of the r hand. To maximise the patient’s independence in activities of daily living by using an adaptive r (compensatory/functional) approach, when the restorative (remedial) approach is felt not to be practical or achievable. To train carers in safe techniques for handling and carry out risk assessment based on r patients functional level and equipment needs, either in preparation for discharge or as ongoing rehabilitation in the community.

Positioning the early stroke patient

People are dynamic moving individuals, and when positioning, it is important to consider the functional activities an individual wishes to achieve, in any given posture. In the early stages of recovery, when movements are restricted by the effects of their stroke, individuals 92 Occupational Therapy and Stroke are unlikely to be able to make the postural adjustments required, to maintain a symmet- rical posture, without assistance. There are basic principles that can be followed to allow the individual to perform desired activities while assisting in the recovery process. These principles will help recovery by maintaining passive range of movement, allowing the indi- vidual to use the control they have and providing normal sensory and proprioceptive input.

In bed In the initial stages following stroke, lying is the position where the individual is most incapacitated. 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 the hemiplegic side may fear turning, or lying on the affected side, while lying on the unaffected side restricts the use of the sound upper limb. Often the individual is nursed on his/her back; which can restrict visual fields, and may leave the individual unable to use their upper limb. There are advantages to the individual spending time in bed in that it is the position of fullest support. Those with high tone may benefit from returning to bed for periods during the day to help manage tone. Similarly, those with low tone may be fatigued by the effort required to maintain their posture against gravity, and may need rest periods to be built into their day. Correct positioning for sleeping and the early development of functional bed mobility are advised. There are of course certain disadvantages to patients spending an excessive amount of time in bed. These include: infections, pressure sores and other complications. Therefore, it is imperative that patients are moved frequently and supported to achieve other positions.

How to position in bed Support should be offered where required to enable the individual to maintain their position. In side lying this may include support along the back to prevent rolling onto the back, and to offer proprioceptive indicators to the hemiplegic side. When lying on the affected 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; if necessary place a pillow under the knee to reduce any adductor tone developing (see Figures 5.1 and 5.2; shaded side is the affected side). When lying on the unaffected side the position is reversed; however, the individual who is unable to roll independently will be more incapacitated in this position, so the call bell must be within reach (see Figures 5.3 and 5.4). Side lying on the unaffected side is a position of choice for at least some of the time, for those who have an overactive sound side. In this position they receive proprioceptive feedback about midline; it facilitates elongation of the trunk on the sound side and promotes weight-bearing through the overactive side. When positioning an individual on their back, it may be necessary to use pillows to prevent the affected shoulder and hip falling into retraction. Lying on the back is also agoodpositiontoallowthepectoralmusclestobestretchedwiththearmsupportedin abduction (see Figures 5.5 and 5.6). Similar support will be necessary for patients sitting up in bed (see Figures 5.7 and 5.8). Management of Motor Impairments 93

Figure 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 at knee, (iii) there are no objects in the hand or against the sole of the foot, (iv) head is in line with the 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 at knee, (iii) there are no objects in the hand or against the sole of the foot, (iv) head is in line with the body (Edmans et al., 2001). 94 Occupational Therapy and Stroke

Figure 5.3 Positioning in bed, lying on the unaffected side (left hemiplegic patient). Do ensure (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 the hand 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). Do ensure (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 the hand or against the sole of the foot (Edmans et al., 2001). Management of Motor Impairments 95

Figure 5.5 Positioning in bed, lying on the back (left hemiplegic patient). Do ensure (i) head is 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 place any 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) head is 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 place any object in the hand or against the sole of the foot (Edmans et al., 2001). 96 Occupational Therapy and Stroke

Figure 5.7 Positioning in bed, sitting up in bed (left hemiplegic patient). Do ensure (i) the patient is upright with weight evenly distributed on both buttocks, (ii) shoulder is protracted away from side and forward on a pillow, (iii) legs are straight and not laterally rotated. Do not place 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) the patient is upright with weight evenly distributed on both buttocks, (ii) shoulder is protracted away from side and forward on a pillow, (iii) legs are straight and not laterally rotated. Do not place any object in the hand or against the sole of the foot (Edmans et al., 2001). Management of Motor Impairments 97

It is important to consider mattresses when positioning the patient. A firm, supportive surface will provide proprioceptive feedback, enable rolling and promote independence when sitting up. However, pressure areas also need to be monitored. Where hospital pressure care mattresses are used, the patient is likely to require more assistance to turn and sit up. Encouraging the patient to sit up through side lying promotes head righting, weight transference and a sense of midline.

In a chair More independence is offered to the early stroke patient in supported sitting and they gain amorenormalvisualperspectiveoftheirenvironment.Thereisscopefortheunaffected arm to be used in a range of functional activities. The trunk muscles begin to be used actively 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 develop inappropriate muscle activity and ‘holding’ postures if they do not receive sufficient support from the chair or pillows. Those with sensory loss will require pressure areas to be monitored. Where head control is still lacking, support must be provided. Armchairs generally provide a back support that is slightly reclined which allows for more relaxation. Where there is little active muscle control, the patient may have a tendency to slide forward in the chair. This may encourage excess abdominal activity and once established will make active extension difficult. Provision of a wheelchair allows the patient to be easily transported to different places. Acorrectlyfittedwheelchairprovidesamoreactivesittingposture,whichencourages greater freedom of upper limb movements. Pressure relief is an important consideration if the person is unable to change position without assistance, but this still needs to provide astablebase.

Points to consider when positioning in a chair

Where possible the individuals’ hips, knees and ankles should be flexed at 90◦ with the feet on a firm, flat surface. Abduction/adduction of the hip may require wedges to facilitate the correct alignment. The armrests should allow the arms to be resting on them without the trunk leaning to the side. The arm position may be altered between internal and external rotation at the shoulder, and the forearm between pronation and supination. The arm may also be positioned on a table in front (see Figures 5.9 and 5.10) or to the side of the patient (see Figures 5.11 and 5.12). These variations help to maintain passive range of movement and prevent shortening of the affected muscle groups. Care should be taken to prevent tightness 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, if necessary using positioning devices such as pillows, shaped arm rests or splints. Web space and rotation of the thumb should be passively maintained, in order to preserve functional viability of the hand. 98 Occupational Therapy and Stroke

Figure 5.9 Positioning in a chair, affected arm supported in front (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 5.10 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 99

Figure 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 Stroke

Many specialist chairs are now available that provide additional postural support such as lateral supports, head supports, inclined seats and lap straps (to maintain the hips at 90◦). These chairs are normally adaptable for each patient in seat height, length and incline. Lateral supports need to be adjusted for each patient and staff are aware of how to position both the patient and the supports each time. Each patient needs to be carefully monitored for fatigue and pressure relief. If a pressure relief cushion is required, this needs to be assessed for and incorporated into any seating assessment, taking into account any postural needs or sitting balance problems.

Perch sitting When the patient begins to gain some active sitting balance and transfers are progress- ing, positioning on a perching stool allows for more active sitting, improving dynamic control 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 height and position of the pelvis in anterior tilt facilitates easier transfers into the standing posi- tion. However, perching stools should only be considered for relatively high functioning patients.

Points to consider when using a perching stool Choose a perching stool with the correct amount of support, for example, with arms/backrest as appropriate. Ensure the affected hip is not retracted. Both feet should have even weight-bearing and should be placed on a firm flat surface. Sometimes perch sitting is contraindicated as it can exacerbate abnormal patterns of movement/positioning, although it may be the only functional option in the long term.

Self-care activities All 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 preparing the environment and gathering the necessary items. The following are ideas how each session can be graded. The focus is on a restorative (remedial) approach, although it is acommonpracticetoteachsomeadaptive(compensatory/functional)techniquesearly, 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 poor r sitting balance should be on good positioning in a supported chair. The task should have low attentional demands so that focus could be just on washing face, combing hair or shaving with an electric razor. As sitting balance improves, focus could be on washing from the waist up. The envi- r ronment can be manipulated to challenge the patient. Position the patient in front of an Management of Motor Impairments 101

appropriate height sink, the patient’s wheelchair back can be folded down, the therapist can sit behind the patient and facilitate the trunk as required, and an assistant can help the patient with the task. The patient can be encouraged to reach forward and to the side for items. Whilst washing, the patient’s affected arm can be positioned in support either on the arm of the chair or forward on the sink (as long as good alignment of the wrist and shoulder can be maintained). Another progression could be to carry out washing while seated on a plinth; this is an r excellent 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. Washing while seated on the plinth allows the patient to move more freely, it gives the therapist opportunity to challenge sitting balance even more and allows involvement of the upper limb to be facilitated. This style of intervention is not recommended if the patient has perceptual problems and would struggle with carrying out tasks in an environment that is out of context. When the patient’s sitting balance has improved and the required assistance with trans- r fers is minimal, the occupational therapist can consider sessions involving washing the whole body such as showering. Showering can be carried out on a shower chair or whilst seated on a bath board. If your unit has an extra wide bath board, start with that one and introduce the normal narrower board when the patient is confident. Swivel bathers can also be used. For patients who prefer to strip wash, a perching stool can be considered to increase the challenge. For patients using a bath board, it is recommended that the sound side of the body is nearest the wall; this is for safety but it also allows the therapist to facilitate the affected side if required. If the patient’s overall mobility improves, standing should be incorporated into in- r tervention, for example, standing in the shower or at the sink. The therapist should still provide facilitation and prompts if required, to achieve active incorporation of the affected arm and leg. The ultimate goal would be for the patient to be as independent as possible washing in r amanneroftheirchoice.

Interventions involving dressing Dressing can be graded in a similar way to washing and, although separated here, should be part of the same intervention session.

Patients early post stroke can be taught one-handed dressing techniques (see below) r while seated in a wheelchair or armchair; the session would also focus on the patient’s sitting balance, trunk control and position and incorporation of the upper limb as appropriate. Patients with improving trunk control could be taught dressing techniques while seated r on a plinth, as mentioned for washing. The plinth is also a good place to teach lower body dressing techniques. This would also involve practising standing with the necessary prompts or facilitation. 102 Occupational Therapy and Stroke

The ultimate goal for dressing would be for the patient to be as independent as possible r in the most normal environment, for example, sitting on the bed or standing in the bedroom or bathroom. Adaptations such as elastic shoe laces or Velcro shoes/trainers are often useful, or r teaching the patient a one-handed method of tying shoe lace is feasible; again these adaptations should not deter patients from using any return of hand function within their activities of daily living. Clothing styles may change initially in the early stages of learning a dressing technique, r the patient may wear more leisure wear which is easy to slip on until they become proficient in dressing techniques or their motor/cognitive problems improve, allowing the individual to dress in their desired style of clothing. Any change of clothing style must be carefully discussed with the patient in order to maintain the individual’s autonomy and self-image.

Using adaptive (compensatory/functional) strategies for dressing Even in the early phase of recovery, occupational therapists can teach patients adaptive (compensatory/functional) strategies for functional tasks that will improve quality of life and that are considered not to have a detrimental effect on motor recovery. Most patients will find a way to compensate in order to meet their basic functional needs so it is important that the occupational therapist guides this in the most appropriate way. One-handed dressing techniques are commonly taught.

Dressing the upper body The patient should lay the garment on their knees so the back is uppermost; they can then easily see which arm goes into which sleeve. The sleeve hole of the affected arm should be positioned in such a way that the sleeve hangs down by the affected leg. The patient should move their affected hand into the sleeve, lean forward and slide the affected arm down 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 other sleeve and pull the jumper, etc., over their head. The patient may need to be reminded that clothes can get stuck on the affected shoulder and may need pulling down (see Figure 5.13a–h). Bras can be put on this way also, provided they are elasticated and are fastened up 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 col- lar nearest themselves, the inside of the shirt/blouse uppermost and sleeves corresponding to the appropriate arm (see Figure 5.13i–q).

Dressing the lower body Whilst seated, the patient should cross their affected leg over the sound leg after which they can lean forward to put each garment over the affected foot. They should then uncross their legs and reach down to put the garment over the sound foot. Many patients are unable to 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 left weakness). (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 105 should keep the sound heel on the ground, while putting garments over the sound toes and, then keep the sound toes on the ground while pulling the garment round the sound heel (see Figure 5.14a–h). The patient should then stand up, achieve standing balance and pull up garments. If appropriate, the patient can be facilitated to use the affected upper limb for support, the therapist 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 supportive slip on style shoes; these types of shoes can now be bought cheaply to suit all age groups and sexes. Shoelaces can be tied with one hand, following the technique shown in Figure 5.15a–h.

Undressing Teach patients to undress the opposite way to putting clothes on, the sound side should be undressed first. With upper body clothing t-shirts and sweaters can be pulled over the head, although care should be taken around the affected shoulder.

Instrumental activities These include the following: Kitchen tasks. r Household duties. r When using these activities for treating motor impairments, again a graded approach should be used. The occupational therapist needs to be creative when thinking of interven- tion ideas in the occupational therapy kitchen or the home environment and will need to consider the patient’s preferences and goals, culture, religion and previous roles. Medical status regarding level of exertion and conditions such as diabetes and dysphagia also need consideration.

Graded kitchen task Apatientwithpoorsittingbalancecouldinitiallybesetupattabletopleveltocarry r out a task. The task chosen can be decided between patient and therapists, but could be making a hot drink, cereal and toast, baking, etc. As the patient improves the challenge can increase, a perching stool could be used and r standing can be incorporated; the patient can be encouraged to reach for items in high and low cupboards. The therapist can facilitate or prompt the affected arm and leg as appropriate. For mobile patients walking should be assisted as necessary and tasks should involve r moving around the kitchen, transporting items between surfaces. Similar grading principles would apply to household tasks such as laundry, cleaning, r gardening, etc. The restorative (remedial) approach should be used but as with dressing certain adaptive (compensatory/functional) strategies may need to be incorporated to maximise 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 left weakness). (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 left weakness). (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: r –Stabilisingobjects–useofnon-slipmats,panholdersonthestove,spikeboards, buttering boards, etc. –Cuttingobjects–useoffoodprocessors,spikedchoppingboards,adaptedknives, may be helpful. –Openingitems–electriccanopeners,mountedjaropenersbelliclamps. –Carryingitems–useofatrolleyorone-handedtray. –Otherequipmentthatmaybeusefulcanbefoundinvariouscatalogues.

Graded household task Tasks such as ironing, laundry, vacuuming and cleaning are excellent activities that can r be graded by the occupational therapist. Ironing could be done initially from perch sitting, then progress to standing; the patient’s r affected upper limb should be monitored closely during ironing tasks. Vacuuming and cleaning could be used for patients working on higher level balance r skills. Some of these tasks can be set up on rehabilitation units, or in-patients can be taken r home for their intervention session. Realistically these activities are more appropriate for community teams.

One-handed techniques Although the objective is to restore the patient’s movement and hence function, it is inevitable that some patients will not make a full recovery. Consequently, such patients may have to resort to use one-handed techniques to restore function. Suggestions are included in the Appendix.

Therapeutic activities In the management of physical problems following stroke, therapeutic restorative (reme- dial) activities offer the patient movement experience in a controlled environment (see section on Upper limb re-education later in this chapter). The therapist positions the task to gain specific movements often related to regaining upper limb function. These sessions are often done as tabletop activities. The therapist should have a clear idea of the task they want the patient to participate in and how much help/facilitation they require. The rationale for the intervention should be explained to the patient. The environment should be set up to maximise the effect of the intervention, that is, the height of the table the patient is seated or standing at. Ideas for interventions include:

Playing cards, dominoes. r Solitaire, connect 4. r Peg boards, block placing. r Badge making. r Management of Motor Impairments 109

Writing exercises. r Turning pages of a newspaper/magazine. r Computer work, using the mouse. r 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 the movement(s) they want their patient to practise; the more meaningful the activity is for the patient, the more they are likely to engage in the session.

Clinical challenges

Pusher syndrome/overuse In the early stages of recovery, one of the most challenging clinical pictures is the patient with what has long been called ‘pusher syndrome’. Whether or not such a thing could be classed as a syndrome has been an unresolved debate among clinicians for some time. But certainly 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 towards r the sound side. When the patient is sitting, they are unable to relax muscles in or- der to allow the head to be side flexed towards the affected side, although it moves freely to the sound side. The eyes are often turned to the sound side as well, and the patient has difficulty in bringing them to the affected side and then maintaining their position. The patient’s ability to perceive incoming stimuli from the affected side is reduced in r all 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 side r from head to foot. When lying on the plinth the patient holds onto the edge with the sound hand and is r anxious that they may fall of the edge. When both knees are flexed with the feet supported on the bed, they lean towards the r affected side. A marked resistance is felt when trying to turn both knees to the sound side, that is, as if to lay them on the bed on that side. No resistance is met when rotating both knees to the affected side. In sitting the difficulties become more obvious. The head is held stiffly to the sound r side and the sound side of the trunk shortens markedly. The affected side is elongated although the weight remains over the affected side. Resistance is encountered when an attempt is made to transfer the weight over the sound side, with the patient pushing back with the help of his/her sound hand. Transferring the patient into a chair presents difficulties; the patient actively resists r moving towards their sound side. 110 Occupational Therapy and Stroke

Sitting in a wheelchair the patient adopts a typical posture. The trunk is flexed, the head r is turned to the sound side and the sound arm maintains constant activity, pushing on the arm of the chair. When leaning forward in order to stand up or transfer into bed, the patient pushes r towards 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 line r drawn 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 of r daily living in general. Many perceptual problems are experienced by patients manifesting the pusher syn- r drome, and will need to be treated accordingly.

Ideas for intervention Although this presentation mainly manifests as a physical problem, it has a large cogni- tive component, usually a problem with spatial attention (see perception chapter) and to address it effectively in the clinical setting the clinician should always take both into ac- count. However, there are some simple techniques to physically manage the problem. The key is to re-educate the patient to where their midline is. The problem can manifest while the patient is lying in bed, in sitting and in standing. A useful technique for this is to use the environment. Either in the gym or anywhere quiet, position the patient near a wall or something vertical. The patient understands that the wall is upright and with prompts from the therapist can then orient themself to midline in either sitting or standing. Facilitation should be avoided and the therapist should be careful not to over-handle the patient in the early stages. This is because the patient will think they are being pushed over and will resist this, compounding the problem. In functional tasks the focus should be on midline orien- tation. As these patients are usually complex, help should be sought from an experienced therapist to guide intervention. Patients can overcome this phenomenon with time, but often they are the patients who have had the largest strokes and functional recovery may be limited.

Ataxia Edwards (1996) describes three types of ataxia:

Sensory ataxia This is seen in diabetic or alcoholic neuropathy conditions. r It disrupts the afferent proprioceptive input to the central nervous system. r Symptoms include wide-based stamping gait with eyes fixed to the ground for visual r feedback. Management of Motor Impairments 111

Vestibular ataxia This is seen in peripheral vestibular conditions or central disorders affecting the vestibu- r lar nuclei, for example, medullary strokes. Symptoms include disturbances of equilibrium in standing and sitting and may also be r accompanied by vertigo, nystagmus or blurred vision.

Cerebellar ataxia This is seen in lesions affecting the cerebellum. r Symptoms include truncal ataxia and abnormalities of gait and equilibrium. r Dysarthria and nystagmus may occur. r Other symptoms include dysmetria, tremor, dyssynergia and visuomotor incoordination, r dysdiadochokinesia, posture and gait.

Intervention of ataxia Cerebellar ataxia is the most common seen in stroke. It varies in its presentation from mild to severe. In the most severe cases, it can be totally debilitating. Patients struggle with controlling movement in all postures and controlling the affected upper limb in order to complete the most basic of activities of daily living. Intervention is both restorative (remedial) and adaptive (compensatory/functional) and occupational therapists need to be careful to achieve the right balance in their interventions. If possible in occupational therapy sessions, the therapist should discourage the patient from what is commonly called ‘fixing’; this is where the patient overcompensates by holding on to surfaces very rigidly to give them stability. The restorative (remedial) approach is focused on the patient regaining fluid movements and feeling confident to allow themselves to move. In patients whose ataxia does not improve, the occupational therapist can teach tech- niques to compensate. Some common strategies include: Using a wheelchair to self propel if walking is not possible (this needs careful assessment r to establish appropriateness). Using the sound arm to help control the ataxic arm during tasks such as feeding and r grooming. Introduction of weighted items such as cups and cutlery. r Issuing cups with lids on. There are now many cups on the market that don’t look like r baby cups anymore and can be bought on the high street. Stabilising self proximally, for example, hips stabilised against a bench during tasks in r standing, elbows propped on table during fine motor tasks.

Upper limb re-education

It is thought that up to 70% of stroke patients will have their upper limb function affected and 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 Stroke amount of research has been done to try and establish the most effective interventions for the arm (Wolf et al., 2006). Two techniques described in Chapter 2 (Bilateral Arm Training/Isokinematic Training and Constraint Induced Movement Therapy) have been shown to be effective in some patients and can be incorporated into occupational therapy plans (see Chapter 2). Handling the paretic upper limb should be done with great care and advice should be sought from experienced therapists when planning interventions.

Avoiding secondary complications

The subluxed shoulder Post-stroke shoulder pain is reported to be very common, and in some cases the prevalence of shoulder pain has be reported to be up to 80% of stroke patients (Walsh, 2001); this however varies on how it has been measured. Shoulder pain can lead to difficulty with activity 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 have an impact on the patient’s quality of life. Anumberofsituationscancauseshoulderpain,includingshouldersubluxation,scapu- lar retraction, abnormal tone either hyper or hypotonicity, sensory changes and poor han- dling. Shoulder subluxation is caused by low tone around the shoulder, resulting in the glenohumeral joint being displaced as gravity causes the surrounding soft tissues to be pulled down and over-stretched.

Assessment Palpation of the space between the acromion and head of the humerus can be measured by fingers or centimetres. It is important to assess scapular alignment as a displaced scapular can cause pain. A malaligned scapular can have an effect on the whole position of the arm, as can a subluxed shoulder and it is essential to gain a full understanding of how the arm is presenting. Scapulohumeral rhythm is an essential part of reach and thus the position of the shoulder has a major influence on the functional use of the upper limb.

Intervention It is essential to try and determine the cause of shoulder pain to be able to plan the best intervention. Intervention is focused around maintaining good positioning of the arm at all times, in lying, sitting and standing. It is still important to facilitate normal range of movement and this is best carried out with the patient seated in front of a table so their affected elbow is supported. The patient should be taught scapular gliding exercises so they can do these regularly throughout the day. Zorowitz et al.(1996)foundthatfacilitatedmovementswereaneffectivewayofaiding motor recovery and this can be an effective intervention for shoulder pain. The arm can be supported in various different ways by a pillow, used in supine, side lying or sitting. In addition there are trays and lapboards that can attach to wheelchairs but these have been Management of Motor Impairments 113 found to over-correct the shoulder alignment (Paci et al., 2005), so careful assessment is needed. Slings have been used as an alternative and these can also be used in standing. There are many different types of slings and the position they hold the shoulder in is of variable quality, as stated in Ada et al.(2005)andWalsh(2001).Slingstendtobedifficultto apply 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 the short 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 of movement and arm function. Physiotherapists may use strapping where the shoulder is strapped into correct alignment. Hanger et al.(2000)didnotfindthistobeaneffective method of intervention; however, they did find some immediate short-term pain relief. Oral analgesic medication is a common practice and is often provided before therapy sessions commence. The intervention of shoulder pain requires a coordinated multidisciplinary management. Turner-Strokes and Jackson (2002) outlined an integrated care pathway for the intervention of shoulder pain; a whole team approach is necessary to minimise its effect on rehabilitation.

Oedema Post-stroke hand and arm oedema results in an enlargement of the limb with restricted mobility 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 as an 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 population with stroke is unclear; however, one cross-sectional study concluded that oedema was present in 33% of adults with stroke receiving early rehabilitation, with some degree of swelling noted in up to 73%, and that it was more common in those with more severe paresis of the hand. It was seen significantly more often in those with hypertonic fingers and reduced sensation (Boomkamp-Koppen et al., 2005).

Assessment Early identification is necessary to ensure preventative measures are put in place as soon as possible. Visual inspection and comparison of the hands is generally sufficient to identify post-stroke swelling and oedema; however, it is prone to variation and other assessment methods such as circumferential measurement and volumetric assessment may be used.

Intervention There is a lack of scientific evidence as to effective ways of reducing post-stroke upper limb oedema; however, intervention should include a positioning programme which includes supported elevation of the arm, passive ranging and light retrograde massage and, where 114 Occupational Therapy and Stroke possible, functional use of the limb. Splinting may be used to support normal alignment of the hand and wrist and to avoid entrapment which may contribute to swelling. Education and advice for the patient, family, carers and other staff to manage the effects is also recommended.

Splinting Within the literature there is conflicting evidence and opinions on whether to use splint- ing as a form of intervention. There is a lengthy debate on the theoretical basis for splinting within neurology. There are two conflicting theories of biomechanical and neu- rophysiological approaches (Copley and Kuipers, 1999). Biomechanical rationale argues that splinting is used to prevent and manage length-associated changes in muscles and connective tissues. The neurophysiological rationale recommends that splinting is used to inhibit reflexive contracture of the muscle. The decision on whether to splint must be made on sound clinical reasoning. There are a wide variety of materials and types of splints and all have different qualities. Splints should not be considered when there is active move- ment that would be restricted if a splint should be provided. Whatever the approach, there are many different aims for splints and the reasons why splints may be considered are as follows:

Reduction of spasticity. r Reduction of pain. r Reduction of oedema. r To maintain joint position and alignment. r Functional reasons. r

Reduction of spasticity Lannin and Herbert (2003) found a lack of evidence for splinting following stroke. In 2007, Lannin et al.conductedarandomisedcontroltrialandfoundnoevidencetosupportthe provision of a splint in a neutral or extended position to prevent contracture. The evidence does not support splinting in the acute phase for spasticity as a method of prevention of contracture. Regular passive range of movement and stretching is recommended and it is important to provide teaching to the patient and carer to perform this programme. There is 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 support and/or inhibit to achieve the ideal position to maximise the effects of the injection. The type of splint chosen will vary depending on the ideal position, but may include cones or resting splints in volar, dorsal or mid prone. When spasticity is preventing hand opening causing difficulty maintaining the hand’s hygiene, it can lead to a breakdown of skin integrity. In this situation provision of a palm protector splint should be considered with regular passive range of movement that could be incorporated to self-care, care plans. Cone splints may also be considered; however, at times these are too harsh for patients to tolerate and often patients need a softer material. Management of Motor Impairments 115

Reduction of pain Following a stroke, pain can occur in various joints although wrist pain is a common complaint among patients. This can be due to the wrist being in a prolonged flexed position due to spasticity or flaccidity, leading to overstretching and/or shortening of muscles. Lannin and Herbert (2003) suggest that regular passive range of movement is effective in prevention of contracture, and thus splinting for this reason will not be therapeutic. The therapist should assess each individual patient and after applying good clinical reasoning, splinting to manage pain may be appropriate. When pain is due to an overstretch of the wrist, provision of a volar resting splint may be beneficial to prevent further harm and provide support. This must be alongside regular range of movement.

Maintaining joint alignment Within the early stages of low tone, the hand may lose the curvatures due to prolonged resting in a flat position. A resting splint may be considered to maintain the hand’s natural curves and prevent secondary complications developing. It may be possible however to maintain the hand’s natural curves through positioning, using rolled up pillowcases placed in the hand and regular passive range of movement.

Functional aims of splinting To improve grasp in functional activities. r To increase range of movement to open hand easily to enable daily hygiene. r To use the upper limb pain free within activities. r

Types of splinting There are various different forms of splinting; these include thermoplastic, casting, air splints 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 splints there are dynamic or functional splints. Dynamic splints are supportive and aids initiation and performance of motion. A dynamic resting splint will allow the fingers to move in flex- ion during tonal changes. Dynamic splints aim to control unwanted tone which improves reach, decreases involuntary movements, increases bilateral use and awareness of the arm. Functional splints allow function in activities; examples of common functional splints are wrist cock splints, thumb spicas, hand writing splints and wrist supports with universal cuffs. Casting uses soft and scotch casting material and provides a circumferential support. Commonly used casts are applied to elbow, ankles and wrists.

Orthotics The National Clinical Guidelines for Stroke (ISWP, 2008) recommended that an ankle- foot orthosis (AFO) should be considered as it is felt that its application would improve 116 Occupational Therapy and Stroke apatient’sgaitorbalance.Followingassessmentbyanorthotist,arecommendationfor one of the following may be made: An AFO; there are many varieties available including those with a solid ankle, an r articulating ankle or the lighter foot drop splint. Callipers are still sometimes used in extreme cases. r Prescription shoes or slippers. r Shoe insoles. r Although referrals are often initiated by physiotherapists, an occupational therapist should be consulted about the practicalities of putting on and taking off the AFO.

Self-evaluation questions

1. 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 test motor problems. 5. The National Clinical Guidelines for Stroke (ISWP, 2008) state three specific inter- ventions that should be offered to patients with motor problems. What are they? 6. What are the four main aims of occupational therapy intervention with stroke patients who have motor problems? 7. Name three clinical challenges that the occupational therapist might meet with patients who have motor problems. 8. Name the two evidence-based techniques that should be considered for upper limb re-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 upper limb? Chapter 6 Management of Visual and Sensory Impairments Melissa Mew and Sue Winnall

This chapter includes: Visual processing r Somatosensory processing r Auditory processing r Vestibular processing r Olfactory and gustatory processing r Self-evaluation questions r Introduction

The brain is involved in processing a variety of sensory inputs which enable an individual to see, feel, hear, orientate themselves to, smell and taste the external world and objects within it. This not only enables individuals to detect stimuli and alert them to danger, but also enables individuals to make sense of their environment in order to adapt behaviour and affect changes in the external environment, essential for occupational performance. Asignificantproportionofthebrainisinvolvedinsensoryprocessingandsensory impairments are common following stroke. In general, sensory loss arises from lesions along the sensory pathways from the peripheral nervous system via the contralateral thalamus to the contralateral sensory cortices, as shown in Figure 6.1. Thus a lesion to the left thalamus or left primary sensory cortex will result in sensory impairment to the right side of the body and vice versa: a lesion to the right thalamus or right primary sensory cortex 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 known as perceptual impairments. Perceptual impairments, such as the inability to recognise un- seen objects through somatosensations alone (astereognosis) or the inability to recognise objects (visual agnosia), are often more global perceptual problems resulting from ex- tensive communication between hemispheres and hemispheric specialisation. This chap- ter addresses sensory loss and associated perceptual impairments of visual, somatosen- sory, auditory, vestibular, olfactory and gustatory sensory processing systems. As visual processing has a significant influence on occupational performance and is seen as a key domain of occupational therapy, the visual processing section of this chapter will 118 Occupational Therapy and Stroke

Primary motor cortex Central Primary sensory cortex (precentral gyrus) sulcus (postcentral gyrus) Somatic motor association PARIETAL LOBE area (premotor cortex)

Somatic sensory FRONTAL LOBE association area

Prefrontal cortex Visual association area OCCIPITAL LOBE Gustatory cortex Insula Visual cortex Lateral sulcus Auditory association area Auditory cortex Olfactory cortex TEMPORAL LOBE

(a)

Limbic Frontal Parietal lobe and Association areas system lobes cingulate gyrus of cerebral cortex

Medial group Anterior group Lateral group Posterior Pulvinar Ventral group group Auditory input

Medial geniculate Basal nucleus nuclei General Lateral sensory Visual geniculate Cerebellum input input nucleus (b) Figure 6.1 (a) Sensory cortices and association areas (visual, primary sensory, auditory, gustatory and olfactory, (b) thalamic nuclei. (Reproduced with permission from Pearson Education Inc, adapted from Martini, 2006, Figures 14-15a and 14-09b.) primarily focus on registration of visual information while visual perception will be addressed in further detail in Chapter 8. Throughout this chapter it should be noted that assessment and intervention of sensory processing impairments should always consider patient’s levels of arousal, alertness and attention, as this will significantly impact upon the patient’s ability to detect, interpret and process sensory information (see Chapter 7). If these are not considered, attention difficulties could be misidentified as sensory loss leading to misdirected intervention plans. Thus, visual and somatosensory assessments should consider the patient, the environment and incorporate simultaneous (bilateral) stimuli to assess for sensory inattentions. Similarly, intervention of sensory impairments should always consider the impact of medication, time of day, fatigue and environmental distractions so that intervention can Management of Visual and Sensory Impairments 119 be timed and graded appropriately to optimise effectiveness. Restorative (remedial) inter- vention should be applied at high intensity (Byl et al., 2003), particularly in acute stages to maximise neuroplasticity. However, restorative (remedial) recovery of sensation cannot be accurately predicted and is likely to be dependent on other factors such as cognitive ability (Connell et al., 2008) and extent of damage to the sensory pathways. Thus, ad- vice on adaptive (compensatory/functional) strategies should always be prescribed early on to enable patients to maintain their own safety and maximise independence. Further, when both restorative (remedial) and adaptive (compensatory/functional) approaches are implemented at the same time, therapists should emphasise the purpose of each interven- tion to avoid confusion between approaches so that patients can learn to implement both approaches during functional activities appropriately and safely.

Visual processing

Vision is one of our primary senses – providing information about the world around us. It has an important role in our ability to engage in activity and social participation. Our visual sense gives us information about our environment, allowing us the capacity to interact effectively and responsively in our environment and with the objects in it, to adjust our posture and movements and provide vital information to guide our social interaction and decision making. A stroke can affect a number of aspects of vision from our oculomotor function and our visual fields to the higher levels of the visual hierarchy such as visual memory and visual perception.

Functional anatomy The visual system is a complex structure and, for the purpose of this book, a brief and simple overview is described to provide a basic understanding of visual processing. For further, more detailed information, please see the references and recommended reading. Six extraocular muscles, innervated by the cranial nerves, are attached to each eye with the role of moving the eyeball. Light passes into the eye through the cornea and lens to be focussed on the retina. Information about the left visual field hits the medial half of the retina of the left eye and the lateral half of the right eye. Together this information travels to the optic chiasm where the information of the left visual field all crosses midline and heads towards the right visual cortex via the right optic tract. The fibres in the optic tract then synapse in the right lateral geniculate nucleus. Postsynaptic fibres form the optic radiation, which then travel onto the cells of the right visual cortex (Figure 6.2). The visual cortex distinguishes between the colour, line, shape and texture of incoming information. From the visual cortex in the occipital lobe, information then travels back through the temporal and parietal lobes (inferior and superior routes, respectively) where the information is processed and integrated to gather meaning by identifying objects, the environment and relationships within the visual space. From here it passes to the prefrontal lobe and the frontal eye fields where this information is used to assist with decision making and planning. Following a stroke the effects on vision are dependent on the region of the lesion. One of the most common visual impairments noted in people following a stroke is visual field 120 Occupational Therapy and Stroke

Left side Right side

Left eye Binocular vision Right eye only only

Eye

Olfactory OPTIC tract NERVE (II) Optic Pituitary chiasm gland Optic tract

Lateral geniculate nucleus (in thalamus)

Mesencephalon Visual cortex Optic projection (cut) (in occipital lobes) fibres Figure 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 occur at any point after the optic chiasm (Figure 6.2). However, diplopia and other oculomotor disorders commonly occur following brainstem or cerebellar lesions. Scanning, visual attention, visual memory and other visual perceptual disorders can be seriously and quite commonly affected by a stroke. These will be addressed in the chapter on perception.

Theory/approaches The 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 impair- ments are often based on theories regarding the functioning of the particular system, Management of Visual and Sensory Impairments 121

Adaptation through vision Ability to manipulate visual Ability to create and information mentally and retain a picture of Visual integrate it with other sensory cognition the object in the information to gain knowledge, mind’s eye Visual memory solve problems, formulate plans and make decisions Ability to identify Pattern recognition salient features Ability to organise a to distinguish an thorough search of object from its Scanning the visual scene surroundings Ability to attend Visual attention to visual information Oculomotor Visual Visual skills fields acuity

Ability of the eye to move Amount of visual surround Ability to see quickly and accurately, and that can be seen when a clear and precise maintain foveation and sensory person looks straight images for small fusion for binocular vision ahead visual detail

Figure 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 the functioning of the visual system, one being the simple information which comes through the eye; the visual information is then integrated within the brain and an understanding of the visual environment is then produced. The other is based on Warren’s (1993) Vi- sual Adaptation Model, as shown in Figure 6.3, which identifies a hierarchical system in which visual fields, oculomotor control and visual acuity are at the base (registra- tion of basic visual information), followed by visual attention (one has to attend to the information coming in to make use of it), scanning (having an ordered, efficient and complete scanning pattern is essential to picking up all the required information), visual memory (using past visual memory to categorise incoming information but also to store this information) and visual cognition (finally making sense of the visual information, in line with other stimuli to make accurate decisions, judgements and to interact with the world). The basis of the Visual Adaptation Model (Warren, 1993) includes:

(a) Oculomotor skills – allow the eyes to move smoothly, in a coordinated manner. This includes: Pursuits – smooth eye movements. r Saccades – jumping eye movements. r Ability to track. r Ability to accommodate (converge/diverge). r Ability to fixate. r Alignment. r 122 Occupational Therapy and Stroke

Impairments seen in patients following a stroke are diplopia (double vision), nystag- mus, reduced depth perception, difficulty tracking and reduced efficiency fixating or localising. (b) Visual acuity – resolving power of the eye to produce a clear, accurate image at different 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 to regulate the amount of light) or from haemorrhages into the eye where fragile retinal blood vessels have burst from an increase in blood pressure associated with stroke. However, the majority of acuity impairments following stroke are due to premorbid factors such as macular degeneration, glaucoma, diabetic retinopathy, cataracts or scotomas. (c) Visual fields – the portion of space that a person can see while he or she is fixating centrally. This includes: Central and peripheral fields. r Upper and lower quadrants. Commonr impairments in patients following a stroke include hemianopia (loss of one- half of visual field) and quadrantanopia (loss of upper or lower quadrant), as shown in Figure 6.4.

Defects in visual field of Left eye Right eye

1 Left Right

1 2 2 Optic nerve Optic chiasm 3 Optic tract 3 4

4 Optic Lateral radiation geniculate body 5 5

6 6

Figure 6.4 Visual field loss and lesion site. (Reproduced with permission from McGraw-Hill, adapted from Kandel et al.,2000,Figure27.20,p.544.) Management of Visual and Sensory Impairments 123

Hence assessment and intervention of visual processing needs to take into account these theories, ensuring the basic eye structures are intact but also that the information is being processed accurately at all levels.

Assessment The screening and assessment of visual processing is a key aspect of gathering a holistic picture of the functioning of a patient following a stroke. However, referral to appro- priate specialists for more in-depth assessment of visual problems might be required, including ophthalmologists (doctors specialising in diagnosing the health of the eye), op- ticians/optometrists (specialising in assessment and intervention of acuity problems) and orthoptists (specialising in the assessment and intervention of visual field and oculomotor impairments). However, occupational therapists have a key role in screening for these impairments, ensuring patients get the appropriate assessment but also ensuring that the resulting impairment is noted and incorporated into any further intervention, as vision has akeyroletoplayinfunction. When screening for visual impairments, it is important to do this in an appropriate environment with limited distractions, suitable lighting and appropriate levels of contrast for the tasks.

Functional observations Visual acuity impairments –Difficultyreading,recognisingthedetail,recognisingfaces, squints when trying to focus, increased difficulty performing tasks in dim light. Oculomotor control impairments –Complainsofblurrinessordoublevision,difficulty focussing, difficulty reading or watching television, difficulty following fast interactions in their environment, for example, four-way conversations, turns their head rather than eyes to fixate on object. Visual field impairments –Patientbumpsintoobjects,over-compensateswhenavoiding obstacles, uses the wall to guide their walking, difficulty reading, difficulty watching television, difficulty searching for items, gets lost, complaining of something wrong with their eyes.

Screening Acuity Can the patient read the heading of a magazine? r Do they complain of blurred vision? r Can they read a sign in the distance? r Oculomotor control Does the patient have difficulty tracking objects? r Are they able to fixate on an object? r Can they shift their gaze? r Do they see more than one image? r 124 Occupational Therapy and Stroke

Is the patient able to focus on the brightly coloured object presented to them; can they r track this object left/right, up/down, in a figure of 8? Can the patient shift his vision/gaze between two objects presented? r Can they alternate from one point to another? r Is there any nystagmus centrally or peripherally while tracking? r Visual field –Thefieldofvisionwhenlookingstraightahead.

1. Confrontation test – ideally done with two people; however, as it is a crude screen it can be done by one person to give an indication of any impairments. Sit in front of the patient covering one of their eyes. Ask the patient to focus on a central point (e.g. the examiner’s nose). The other examiner stands behind the patient and brings an object into the patient’s vision at varying heights from the left and right periphery assessing each of the four quadrants. Ask the patient to indicate when they first see the object being presented. This is repeated with the other eye covered. Someone with visual field 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 they r will use their visual memory to produce the diagram) – they will copy what they see which might be the half of the diagram they see. Scan across a page of lines of letters and cross out the requested letter – the patient r is 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 field impairment will complete the task in an organised manner, identifying all letters within the abbreviated field.

It is important to note that patients with visual field impairments often compensate very quickly for their impairment so it may not be apparent on basic screening but more complex functional tasks or functional observations in dynamic environments will provide the information required. The assessment of a patient’s visual attention, scanning and visual perceptual skills are dealt with in perceptual impairments chapter.

Intervention Intervention takes on many forms within occupational therapy but following the In- ternational Classification of Functioning, Disability and Health model (World Health Organization (WHO, 2001)), intervention for visual impairments can be classified under impairment-based intervention, activity engagement and social participation.

Impairment-based intervention Often intervention at this level is dependent on and requires referral to professionals specialised in the different aspects of vision such as the optician and the optometrist. Management of Visual and Sensory Impairments 125

Acuity Intervention for acuity needs to be dealt with by the optician/optometrist; hence a referral needs to be recommended to your multidisciplinary team for corrective lenses, glasses, etc.

Oculomotor Ideally an orthoptist needs to be involved if there are oculomotor impairments – they will consider options such as occlusion for double vision, prisms, exercises, etc.

Visual field impairments This cannot be rectified by intervention and adaptive (compensatory/functional) measures are used to encourage the patient to scan and search within their affected visual field. Occupational therapists can provide simple tasks such as scanning sheets, telephone number copying, environmental searching, etc., to encourage scanning into the affected vision field. An orthoptist may consider use of prisms to compensate, so referral is worth considering.

Activity engagement Often patients with visual processing impairments compensate very well and are able to adapt to their impairments; however, it is the role of therapy to not only increase their confidence in activity engagement but also their efficiency and reduce the effort required to complete familiar tasks. Identifying the roles and tasks the patient wants to engage in is essential, with the intervention being formulated around these tasks. Intervention could include: Engaging the patient in tasks that encourage them to scan their environment. r Educating the patient on how to develop an efficient search strategy when they wish to r find objects within tasks. Involving patients in tasks that require that they use their full visual field and oculomotor r skills such as copying telephone numbers from the telephone book, putting numbers into the telephone, searching the environment for hidden objects, obstacle courses. Involving patients in games that require that they search their full visual field such as r Connect Four or that require them to switch/track objects such as table tennis. Using adaptive (compensatory/functional) measures such as reading articles using the r margin as an indicator that they have encompassed the full page or at a more basic level drawing a line down the margin to ensure the patient scans the page completely.

Social participation Engaging in the community, which is a dynamic, social and ever-changing visual envi- ronment, can be very challenging for someone with visual processing difficulties. They must be alert and able to be responsive while ensuring their safety. Therapy within the 126 Occupational Therapy and Stroke area of social participation is essential to ensure a patient continues to engage in their life roles and the wider environment. Intervention could include: Teaching strategies on how to prepare for unexpected incoming visual information, for r example, before entering a busy room, scan the room and identify the location of key objects and people and your path through the space. Developing safe search strategies, for example, crossing the road – identify the left r curb, follow it along and scan from this curb till the patient sees the other curb. This ensures they have seen the whole road before crossing. Adaptive (compensatory/functional) strategies, for example, request that people do not r sit in your limited visual field space if there are a number of participants talking; reduce the amount of visual stimulation in the environment when completing tasks.

Review and evaluation Acute Within the acute setting the main focus is screening to identify visual processing impair- ments and alerting the multi-disciplinary team if there are any concerns regarding vision that may require onward referral. It is also important to educate the patient and family on the impairments and ensure the patient’s safety is maintained if discharged home, provid- ing education on adaptive (compensatory/functional) strategies if appropriate. It should be noted that some patients may demonstrate spontaneous recovery of acuity, field and oculomotor impairments during acute stages, so use of some strategies such as occlusion should be carefully prescribed and monitored.

Inpatient rehabilitation Further in-depth assessment might be required and linking further assessment to other impairments such as visual attention, visual memory and visual perceptual impairments and their impact. Continuous review during rehabilitation is required, particularly of the patient’s ability to learn and use the adaptive (compensatory/functional) strategies taught and noting their ability to adapt to their visual environment during tasks.

Community rehabilitation By this stage one would hope the patient with visual processing impairments has learnt to compensate or has been offered the appropriate adaptive (compensatory/functional) measures to modify their impact. However, this is an important time to review their visual processing in the more dynamic and wider community environment.

Clinical challenges When assessing and treating people who have had a stroke, it is sometimes difficult to differentiate between impairments, which often present with similar functional impair- ments. Management of Visual and Sensory Impairments 127

Some key areas to be alert to include:

Differentiating between difficulty tracking and visual field loss. r Differentiating between visual field impairments and visual inattention. r Occipital lobe impairments, impact on the accuracy of the information reaching the r parietal/temporal lobes for integration, impacting on the visual perception of their environment even though the parietal/temporal lobes are intact. Uncommon disorders such as cortical blindness (total or partial loss of vision in a r normal-appearing eye caused by damage to the occipital lobe) and visual hallucinations (caused by disruptions to the visual processing pathway and sometimes misdiagnosed as psychiatric issues rather than neurologically based). Visual perceptual, cognitive and speech impairments impacting on accuracy of assess- r ment. Visual perceptual, cognitive and speech impairments impacting on ability to learn or r compensate for impairment.

Alargenumberofstrokepatientssuffersomeformofvisualprocessingimpairment, whether that is at the basic sensory input level, discussed here, or the visual attention/visual perceptual level discussed in the perceptual impairments chapter. Due to the significant impact visual impairments have on function, it is an important area for occupational therapist to address.

Somatosensory processing

Functional anatomy Information regarding pain, temperature, touch, pressure, vibration and proprioceptive sensations ascend the spinal cord in highly organised tracts. The organisation of these tracts means that certain sensations travel closely together. For example, pain and temper- ature ascend together in the lateral spinothalamic tract; fine touch, pressure, vibration and proprioceptive information ascend in the posterior/dorsal column; whereas crude touch and pressure ascend in the anterior spinothalamic tract. These tracts synapse in the ventral nuclei of the contralateral thalamus where sensory information is sorted, determining which sensations should be consciously perceived. Subsequent projections from the tha- lamus to the primary sensory cortex in the parietal lobe enable sensations to be perceived and localised as the primary sensory cortex is functionally organised according to body parts. Thus, the organisation of the primary sensory cortex can be further mapped into cortical areas representing the relative sensitivity of different body parts, known as the sensory homunculus (Figure 6.5). From the primary motor cortex, somatosensory infor- mation is 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 may result in loss of sensation. Lesions between the thalamus and the primary sensory cortex may result in sensory loss and inability to localise sensations. Lesions to the association 128 Occupational Therapy and Stroke

Sensory homunculus of left cerebral hemisphere

Ventral nuclei in thalamus

MESENCEPHALON

Medial Nucleus gracilis lemniscus and nucleus cuneatus MEDULLA OBLONGATA SPINAL CORD

Fasciculus gracilis and fasciculus cuneatus

Dorsal root ganglion

Fine touch, vibration, pressure, and proprioception sensations from right side of body Posterior column pathway Figure 6.5 Sensory homunculus of the primary sensory cortex. (Reproduced with permission from Pearson Education Inc, adapted from Martini, 2006, Figure 15-5.) Management of Visual and Sensory Impairments 129 areas result in difficulties with recognising and interpreting sensations, leading to clinical presentations of:

Astereognosis (the inability to recognise unseen objects through touch). r Body scheme impairments (difficulty perceiving the position of the body and relation- r ship of body parts) such as –Somatognosia(lackofawarenessofbodyandrelationshipofbodyparts). –Unilateralneglect(neglectoftheaffectedsideofthebodyorenvironment). –Right/leftdiscriminationimpairment(difficultyunderstandingconceptofleftand right). Body image impairments (lack of mental image of one’s body) (see Perceptual impair- r ments chapter).

Somatosensory impairment is common following stroke. Approximately 50% of stroke patients experience somatosensory impairment (Carey, 1995). Stereognosis is the most frequent impairment followed by proprioceptive then tactile sensory impairments (Connell et al., 2008). However, there is some debate regarding where discriminative sensations have been reported to be more common and reliability of measures may be a contributing factor (Carey, 2006). Functionally, somatosensory processing impairments have significant safety implica- tions, particularly for the detection of protective thermal and pain sensations. In addition, patients have difficulty regulating grasp for effective object manipulation particularly for fasteners and writing; are at increased risk of developing learned non-use as spontaneous use of the affected hand is diminished contributing to further deterioration of motor func- tion; 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 activities of daily living, sexual and leisure activities and thus participation in life roles (Carey, 2006). Somatosensory impairments are significantly related to stroke severity and activity limitations, which negatively impact on motor recovery and hospital length of stay (cited Connell et al., 2008).

Theoretical approach Despite significant integration along pathways, modalities are often discreetly impaired so all modalities should be routinely assessed. Contrastingly, adjacent body areas frequently have the same modalities impaired, suggesting redundancy of some assessments may be possible (Connell et al., 2008). For example, Busse and Tyson (2009) explored redundancy of touch, pinprick and pressure assessments. They concluded that if light touch was intact in the thumb and hand, then no further assessment of the upper limb for light touch, pinprick and pressure was required. However, redundancy of assessments for other modalities is yet to be determined. It should be noted for somatosensation, similar to motor impairments, that both sides can be affected due to ipsilateral pathways (Kim and Choi- Kwon, 1996). However, some sensory impairments have been reported ipsilaterally and thought 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 Stroke

Impaired 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.

Assessment Functional observations Patients who appear to be clumsy; drop objects; have difficulty regulating pressure and maintaining appropriate grips; position their body parts awkwardly or trap limbs in clothes/bedclothes; frequently injure, bruise, burn or cut themselves; have floating limbs; neglect their limbs; or have motor impairment, should have further somatosensory assess- ment. Functional screening assessment could look at the patient’s ability to do up fasteners such as buttons, zippers, laces, bras, belts, necklaces and apron bows or comb/brush their hair with and without visual feedback and ability to identify objects in pockets.

Screening Screening assessment should be completed in the first 2–4 weeks post onset (Winward et al., 2007). The following upper limb screening process summarises procedures from the 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 proposed Somatosensory Screening Flowchart (Figure 6.6). To avoid subjecting the patient to unnecessary repetition of tests and to improve therapists use of time, upper and lower

Assess light touch and proprioception on affected thumb and hand

Complete light touch, proprioceptive assessments on unaffected and affected upper Impaired/absent limb (consider standardised assessments) Intact

Assess sharp blunt, temperature, tactile Intact localisation, bilateral Assess pressure and pinprick bilaterally simultaneous touch and (use standardised assessments) stereognosis (coins/full)

Impaired/absent Impaired Absent (use standardised assessments) Intact Sensation impaired Sensation absent Sensation normal Safety awareness training Safety awareness training No treatment required Targeted sensory In acute stage trial sensory rehabilitation with vision rehabilitation with vision occluded and attention graded occluded and full attention

Figure 6.6 Proposed somatosensory screening assessment flowchart. Management of Visual and Sensory Impairments 131 extremities should be assessed together in coordination or as a joint assessment with phys- iotherapists. If sensation is anticipated to be impaired then assessment using standardised measures is recommended to monitor change and measure outcomes, particularly as the different modalities are discreet and redundancy of body parts for each modality is still being 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 sensations These assessments examine cutaneous sensations of touch, pressure, pain and temperature, discrimination, localisation and tactile inattention. It should be noted that some conditions such as attention impairments and diabetes mellitus may affect results.

Light touch: Touch (not brush) the skin lightly with a cotton wool ball, three times at each location in random order. If light touch of the thumb and hand is normal then no further points need to be assessed for light touch, pressure or pinprick (Stolk-Hornsveld et al., 2006; Busse and Tyson, 2009). Pressure: 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. Pinprick: Prick the skin using a cocktail stick, sufficient enough to just deform the skin contour, three times at each location in random order. Sharp/blunt: Only tested if light touch is intact. Stimulate the skin six times at each location in a random order, three times with a cocktail stick and three times with the index finger. The patient must verbally or non-verbally indicate whether the stimuli are sharp or blunt. Temperature: Touch the skin with the side (not the bottom) of one of two test tubes, one filled with hot water, another with cold water. The patient must verbally or non-verbally indicate whether the stimuli are hot or cold. Tactile localisation: Can be assessed at the same time as pressure (but only if pressure detection is intact) by asking the patient to point to the exact spot that has been touched. Two centimetres of error is allowed and coating the assessor’s finger with talcum powder to mark the spot may help. Bilateral simultaneous touch: Only assess if patient can detect pressure. Touch corresponding sites on one or both sides of the body 132 Occupational Therapy and Stroke

using the fingertips. The patient must indicate which side has been touched or if both sides were touched. Two-point discrimination: This test has been found to be less reliable and should only be tested if light touch, pressure, pinprick are normal. Start with a neurotip or two-point discrimination instrument set with the two points at 10 mm for index finger and 20 mm for the thenar eminence. Apply the two points simultaneously to the skin of the index finger and then to the thenar eminence for approximately 0.5 second. Ask the patient to indicate if one or two points are felt. Record the last interval at which two points are felt. Record: Absent – Patient unable to detect two points. r Impaired – Patient detects two points with an interval of 10 mm on the fingertip r and 20 mm on the thenar eminence. Normal – Patient detects two points with an interval of 5 mm on the fingertip r and 12 mm on the thenar eminence (Stolk-Hornsveld et al., 2006).

Proprioception This is the awareness of sensory information from the muscles, tendons, ligaments and joints. To demonstrate the procedure, three practice movements are allowed with patient’s eyes open. Each joint is passively moved with the proximal end stabilised and both proximal and distal portions held laterally to avoid tactile or pressure input. The thumb interphalangeal joint is moved through full flexion/extension and wrist is moved through full range of flexion/extension with the elbow in 150–160◦ extension. The patient verbally or 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 three times. Record: Absent – patient does not detect movement taking place. r Impaired – patient detects movement but direction is not always correct. r Normal – patient correctly identifies direction of movement on all three occasions. r If proprioception of the thumb and hand is normal then no further joints need to be assessed (Busse and Tyson, 2009), otherwise elbow flexion/extension and shoul- der abduction/adduction (with elbow at 90◦) should be assessed by passively ranging through approximately a quarter of their total range of movement (Stolk-Hornsveld et al., 2006).

Stereognosis This is a perceptual skill where unseen and unheard objects can be recognised by touch alone. It requires integration of tactile and proprioceptive sensations with memory Management of Visual and Sensory Impairments 133 recall. However, it should be noted that objects can be correctly identified with some tactile/proprioceptive impairments as sensations compensate for each other and patients can ‘cheat’ by gaining auditory cues from tapping objects. Each object is placed in the patient’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 examiner may 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, coins are more difficult than comb scissors, cup and sponge (Connell et al., 2008).

Standardised assessments Rivermead Assessment of Somatosensory Performance (RASP) assesses pain, light r touch and localisation, temperature discrimination, joint movement detection and move- ment direction discrimination, bilateral touch discrimination (sensory extinction) and two-point discrimination using customised clinical instruments. The assessment takes 20–30 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 require r special 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. Joints assessed include the shoulder, elbow, wrist, hand, hip, knee and ankle. Stereognosis is assessed using 11 everyday objects. Erasmus MC Modifications to the (revised) NSA (Stolk-Hornsveld et al., 2006) improves r the reliability of the rNSA by standardisng procedures with defined points of contact for tactile sensation; defined starting positions, movements and hand grips for testing proprioception; and omits the less reliable two-point discrimination test. It takes 10– 15 minutes to administer. It assesses light touch, pressure, pinprick, sharp–blunt tactile sensations to 12 upper extremity points on the fingers, hand, forearm and upperarm and 12 lower extremity points on the toes, foot, leg and thigh. Proprioception is assessed in the thumb, wrist, elbow, shoulder, big toe, ankle, knee and hip. Detailed procedures and recording form are free and available as appendices to the article (Stolk-Hornsveld et al., 2006). Stereognosis subtest of the Chessington Occupational Therapy Neurological Assess- r ment Battery (COTNAB) (Tyerman et al., 1986). Useful for comparing sensory infor- mation processing speed to normative data.

Further, more reliable tests for tactile and proprioceptive discrimination have been developed for use in research. For more information on these, please see Carey (2006).

Intervention Significant tactile, stereognostic and proprioceptive upper limb recovery can occur in the first 6 months post stroke; however, prognosis for recovery is poorer than in the lower limb (Connell et al., 2008). Stroke severity is the strongest indicator of impairment 134 Occupational Therapy and Stroke and recovery and motor performance significantly influences recovery of stereognosis (Connell et al., 2008). However, there is no recognisable pattern to recovery (Winward et al. 2007). Carey (2006) summarises the principles of intervention from successful training pro- grammes which include the following: Attention to the sensory stimulus: Active and purposeful exploration of sensory stimuli r with attention directed to distinctive features of difference, that is, discrimination is required. Repetitive stimulation with and without vision: This allows patients to alternately focus r attention on somatosensory feedback without the visual system taking over versus gaining visual feedback to calibrate. Sensory stimulation is integral to the preservation of the primary sensory cortex for functional gains. Use of targeted sensory tasks that are challenging and motivating, with opportunities r for success. Anticipation where patient draws on previous experiences of what the stimulus should r feel like. Focus on the hand. r Graded progression of tasks for the targeted modality from easy to more difficult r discrimination. Variation in stimuli is required for generalisation to novel tasks. Intensity of training programme. r Feedback on accuracy and execution in line with learning theory. Calibration of per- r ceptions with the other hand and visual feedback may also be important.

Restorative (remedial) intervention at impairment level Shabrun and Hillier (2009) reviewed the evidence for passive (excludes muscle con- traction) and active sensory retraining following stroke. It should be noted that sensory interventions that combined with motor or other therapies were excluded from the review and patients included both acute and chronic populations. Cutaneous electrical stimulation, for example, TENS machines, delivered at low fre- r quencies (10 Hz) and at sufficient intensity to evoke stroke paresthesia in the target tissue may improve hand function and dexterity following stroke (Shabrun and Hillier, 2009). Active stimulation involving exercises that practice discriminating and localising sen- r sations, stereognosis and proprioception may be beneficial, although results of a meta- analysis are inconclusive (Shabrun and Hillier, 2009). Dosage of researched interven- tions averages 45 minutes sessions 3timesperweekandhasbeenadministeredto × both acute and chronic patients. Carey (1995) reviewed sensory retraining programmes for stroke including Yekutiel and Guttman’s (1993) sensory rehabilitation programme. Yekutiel and Guttman (1993) describe a successful 6-week sensory retraining programme for chronic stroke patients which includes: Identifying touch (counting touches administered from proximal to distal). r Identifying simple continuous touch (identifying direction, number and shape of lines r drawn on the skin with a pencil). Management of Visual and Sensory Impairments 135

Identifying complex continuous touch (identifying letters/numbers drawn on the hand r or arm). Texture discrimination (between sandpaper, velvet, paper, wire wool, cotton ball, r smooth plastic, rubber, leather, card). Finger identification (identifying finger touched – particularly thumb, index and little r fingers). Guided drawing (patient assisted to draw a shape which the carer identifies). r Thumb localisation (patients affected hand positioned in various places, patient in- r structed to find the affected thumb with the unaffected hand). Distance between hands. r Position of hand (patients asked to estimate the gap between their hand). r Thick and thin rods (patients to identify cylindrical rods placed in the fingers ranging r between 5 and 30 mm diameter). Weight (identify and compare objects of different weights). r Shape (identify different shaped objects). r Size (identify different sized lids). r Consistency (identify objects of same shape but varying consistency, for example, tennis r ball, plastic ball, squash ball, stress ball, wooden ball). Temperature (compare temperatures of metal spoons placed in ice, at room temperature, r warm water, hot water and a plastic spoon). Object recognition (recognise everyday objects, for example, comb, brush, spanner, r squash ball, fork, spoon, knife, teaspoon, mug glass).

Further programmes including several research projects under the Study into the Ef- fectiveness of Neurorehabilitation on Sensation (SENSe) programme are currently being investigated, including a randomised controlled trial on somatosensation training in the hand following stroke at the National Stroke Research Institute in Australia. Researched training to date has included:

Sensory Specific Training which ‘involves repeated presentation of targeted discrimi- r nation tasks; progression from easy to diffiuclt discriminations; attentive exploration of stimuli with vision occluded; use of anticipation trials; feedback on accuracy, method of exploration and salient features of the stimuli; and use of vision to facilitate calibration of sensory information’ (Carey et al., 1993; cited Carey, 2006: p. 237). Stimulus generalisation training aimed at transfering training effects to novel stimuli r includes ‘addition principles of variation in stimulus and practice conditions, intermit- tent feedback and tuition of training principles’ (Carey and Matyas, 2005; cited Carey, 2006).

Restorative (remedial) intervention during functional tasks at activity and participation level Encouraging some use of the affected limb during functional tasks to improve sensory feedback may help. If limited movement, encourage limb placing/positioning in tasks and weight transference. Therapists should consider the dynamic nature of sensory input as the central nervous system responds to change and switches off when sensory stimulation 136 Occupational Therapy and Stroke is constant. Other techniques which may enhance normal sensory input include the fol- lowing: Bobath principles of facilitation and use of handling to prevent abnormal movements r and feed correct sensory input into the sensory system may have indirect effects on sensory improvement during functional tasks. Cognitive processing (inattention to tactile stimuli) to utilise attention/information r processing strategies. Sensory re-education desensitisation – here the central nervous system is overwhelmed r and is over-responsive to change, so needs to learn to cope with reduced amounts of input with slower changes. Constraint-induced movement therapy – see Chapter 2. r Adaptive (compensatory/functional) intervention Adaptive (compensatory/functional) techniques, for example, testing water with the r other hand, using adaptive (compensatory/functional) devices for safety and train patient to check the position of their limbs. Use of vision to compensate. r Enlarged handles to assist grips, universal splints when attention is divided. r Safety – education, safety awareness, environmental adaptations. r Pain – distraction, relaxation, pain clinic, Transcutaneous Electrical Nerve Stimulation r (TENS), splinting (alignment), taping/Functional Electrical Stimulation (FES)/support for subluxation.

Review and evaluation If impairment is found following acute assessment, reassessment is recommended at 3 and 6 months post stroke with follow-up assessment as appropriate depending on progress (Winward et al., 2007).

Clinical challenges Complex regional pain syndrome (otherwise known as central pain syndrome, shoulder–hand syndrome, thalamic pain syndrome or Dejerine Roussy) following stroke appears as a painful, oedematose limb with altered heat and tactile sensations, dystrophic skin and is prone to non-use and psychological implications such as anxiety and depres- sion (see Chapter 5). Onset following stroke may occur in the shoulder or hand (or both) in the first 5 months and one-third of these patients may resolve within 1 year (Pertoldi and di Benedetto, 2005). Onset seems to be related to aetiology of stroke (frequently involving the thalamus), severity, motor recovery, spasticity, sensory disorders and glenohumeral subluxation. Although the mechanisms are unclear, the hypersensitivity and interpretation of non-noxious stimuli to be noxious appears to arise from neurogenic inflammation lead- ing to sensitisation of peripheral and central sensory neurones and variable involvement of the sympathetic nervous system. Interventions include pharmacology (non-steroidal anti-inflammatories, tricyclic antidepressants, botulinum toxins), regional anaesthesia, Management of Visual and Sensory Impairments 137 neuromodulation, sympathectomy (sympathetic blocks), TENS and electrotherapy, night- time resting splints (not recommended for daytime), counselling, biofeedback, relaxation techniques, group therapy and psychotherapy. Exercise and a graded desensitisation pro- gramme within perceived pain thresholds may be helpful to gradually habituate patients to stimuli perceived as noxious. However, there is little evidence to support the efficacy of these interventions (Pertoldi and di Benedetto, 2005) and referral to specialised pain clinics is recommended. Other clinical challenges to somatosensory assessment and intervention include cogni- tive difficulties, particularly where severe attention impairments such as unilateral neglect are evident. Here, it may be more beneficial to focus on the cognitive aspects to sensory processing and adaptive (compensatory/functional) strategies.

Auditory processing

Functional anatomy Information regarding sound is conveyed from the inner ear via cranial nerve VIII to the cochlear nuclei in the medulla. Information then decussates to ascend contralaterally to the inferior colliculus (for reflexive head movements in response to sound) and onto the medial geniculate nucleus in the thalamus before it projects to the primary auditory cortex in the temporal lobe (Figure 6.7). Patients with lesions to this pathway may have sensorineural

Auditory cortex High- (temporal lobe) frequency Low-frequency sounds Cochlea sounds Thalamus

Low- frequency sounds Medial geniculate nucleus (thalamus) High- frequency Inferior colliculus Vestibular sounds branch (mesencephalon) Cochlear branch Motor output to cranial nerve nuclei Vestibulocochlear nerve (VIII)

Cochlear nuclei

Motor output to spinal cord through the tectospinal tracts

Figure 6.7 Auditory processing pathway. (Reproduced with permission from Pearson Education Inc, adapted from Martini, 2006, Figure 17-31.) 138 Occupational Therapy and Stroke deafness in one ear, although this is rare due to significant cross midline communication in the brainstem. Auditory symptoms are associated with brainstem strokes and may include hearing loss (if bilateral stroke), phantom auditory perceptions (tinnitus/ hallucinations) and increased sensitivity to sound (Hausler¨ and Levine, 2000). Lesions to the auditory cortex in the temporal lobe (cortical deafness) may mean that although the patient is unable 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 patients being unable to comprehend the meaning of sounds or words, known as receptive aphasia or agnosias to particular sounds.

Assessment Functional observations Occupational therapy assessment of auditory processing impairments should consider:

Patient’s premorbid hearing and aids used. r Patient’s and family reports of new hearing impairments. r The patient’s response to sound conducted via observation during initial interview and r functional tasks. For example, during conversation or in response to an object being dropped or the patient’s name being called: Does the patient become more alert (detect sound) and orient towards (locate) sudden or unexpected sounds? Does the patient understand (recognise) words being said and are they able to follow instructions? Does the patient demonstrate appropriate response to music and environmental sounds? How does the patient cope in noisy environments with competing auditory demands, for example, in the community, crossing roads?

Screening Screening 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 not been identified clinically as having a hearing impairment. Similarly, 35% of patients were found 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 the significant lack of detection may mean that patients are not receiving intervention for new impairments which may have significant function complications later on particularly for communication, social, leisure and community participation and hence quality of life. If new difficulties in auditory processing are suspected, further detailed assessment should be referred onto the speech and language therapist or audiologist as appropriate.

Intervention Other disciplines such as speech and language therapy/audiology generally address im- pairment/restorative (remedial) intervention. Occupational therapists should liaise with these disciplines regarding recommended strategies and enable patients to incorporate these into everyday activities. Occupational therapy intervention should primarily focus Management of Visual and Sensory Impairments 139 on adaptive (compensatory/functional), activity/participation-based intervention. These may include liaising with sensory loss teams in social services, investigating home safety alerting systems such as visual/vibratory alerts for smoke alarms/telephones, strategies for communication and safety in community, social and leisure tasks such as shopping.

Review and evaluation Occupational therapy should focus on activity and participation levels of evaluation us- ing appropriate measure that considers management of risks (home safety alerts) and participation in communication, social, leisure and community activities.

Clinical challenges Therapists should be acutely aware of the impact that auditory processing impairments (whether from hearing loss, receptive aphasias or agnosias) may have on following verbal instructions during all other assessments and the increased simultaneous cognitive demand placed on patients as they struggle to process auditory information.

Vestibular processing

Functional anatomy Information regarding orientation and movement of the head in space; hence balance (equilibrium) is conveyed via the vestibulocochlear nerve (cranial nerve VIII) to the vestibular nuclei in the brainstem. Here, it is integrated with information from the con- tralateral ear before information is relayed to the cerebellum, primary sensory cortex and motor nuclei in the brainstem. Reflexive connections in the brainstem enable coordinated eye, head and neck movements (via Cranial nerves III, IV, VI and XI) and adjustments to muscle tone via the descending vestibulospinal tract. Lesions result in nystagmus, dizziness, impaired equilibrium reactions and balance, awareness of midline, oculomotor difficulties, impacting on visual processing.

Theory/approaches Vestibular systems are highly integrated with visual and somatosensory inputs which contribute to control of balance (Smania et al., 2008). Thus assessment and intervention of balance must consider the manipulation of visual feedback and somatosensory inputs. Dysfunction can lead to avoidance of activity and social isolation.

Assessment Functional observations Observe balance reactions and reports of dizziness particularly when:

Vision is occluded, base of support reduced or supporting surfaces are unstable, for r example, taking clothes off overhead in standing or when sitting on the bed, washing hair, walking over uneven surfaces. 140 Occupational Therapy and Stroke

Tasks are more complex and patients are mobilising while visually distracted, for r example, meal preparation, community mobility. Bending down to put on socks and shoes or pick up dropped items. r

Detailed assessment This is usually carried out by physiotherapists, for example, sensory organisation balance test (Di Fabio and Badke, 1990; cited Smania et al., 2008), postural sway, balance (with and without visual feedback) and direct head displacement to test vestibular ocular move- ments. Occupational therapists should liaise with physiotherapists regarding outcomes of assessment and recommended intervention approaches to maintain consistency.

Intervention Physiotherapists generally address the impairment level with restorative (remedial) in- tervention via vestibular rehabilitation. ‘Vestibular rehabilitation includes exercises to promote vestibular adaptation and substitution, exercises to habituate symptoms such as dizziness with head movement, exercises to improve balance and decrease risk for falls’ (Hall and Herdman, 2006). Occupational therapists should liaise with the phys- iotherapist regarding recommended strategies and consider application to everyday ac- tivities. Occupational therapy intervention should primarily focus on adaptive (compen- satory/functional), activity/participation-based strategies including:

Visual compensation. r Stabilisation during functional tasks, for example, use of perching stool, chair, stabilis- r ing pelvis against benches/sinks, propping through upper limbs. Grading activity demands related to weight transfer and dynamic sitting and standing r balance and functional mobility. Graded activities requiring independent head/eye movements. r Functional activities demanding balance that manipulate somatosensory input and vi- r sual feedback, such as –Completingfunctionaltaskswith/withoutshoeson,ondifferentsurfacesinsideand outside. –Gradedvisualfeedbackstartingfromdowngradedactivitieswherevisualfeedback is utilised and somatosensory feedback from the lower limb is stable to high-level retraining where somatosensory feedback is variable (e.g. outdoor surfaces) and vision is occluded. –Activitieswhichmayincludereading,trackingobjectswith/withoutheadmovements, coping in dynamic environments in the community, for example, crossing roads, shopping, travelling keeping gaze on fixed target and moving head horizontally and vertically versus moving eyes with head fixed, travelling on buses, in cars, mobility under more challenging conditions, for example, walking, running, moving, standing on moving surface. Falls prevention. r Management of Visual and Sensory Impairments 141

Review and evaluation Occupational therapy should focus on activity and participation levels of evaluation using appropriate measures that consider dynamic balance, including domestic and community activities of daily living.

Clinical challenges Some clinical challenges to successful rehabilitation may include perceptual difficul- ties such as spatial representation, unilateral spatial neglect (see Chapter 7) and pusher syndrome (see Chapter 5).

Olfactory and gustatory processing

Functional anatomy Dysfunction in sense of smell and taste following stroke is rare but has been reported following lesions affecting the anterior, posterior or middle cerebral arteries (Green et al., 2008; Moo and Wityk, 1999). The olfactory tract conveys information regarding smell from the olfactory bulbs to the olfactory cortex located in the medial temporal lobe (Figure 6.1). Information from the tastebuds are conveyed via cranial nerves VII, IX and X to the solitary nucleus in the medulla. Here they join the somatic sensory neurones to travel via 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 strong emotional, behavioural and memory links to smell and taste.

Assessment As part of the screening assessment, occupational therapists should enquire whether patients have noticed any deterioration in sense of smell or taste and functionally observe patient responses to ‘off’ milk or burning food during a kitchen assessment or whether patients have ‘gone off’ their food. In liaison with the dietician, further assessment could take into account patient percep- tions when 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).

Intervention Recovery of smell and taste have been reported in minor strokes (Green et al., 2008) and a restorative (remedial) approach could be considered on a theoretical basis. However, there has been no research on this rare patient group to support this. Adaptive (compensatory/ functional) approaches should consider functional implications such as safety (e.g. alerting to spoiled food, gas, fire and smoke), nutrition and psychosocial implications (Green et al., 2008). 142 Occupational Therapy and Stroke

Review and evaluation Occupational therapy evaluation methods should consider activity and participation levels of occupational performance such as use of Canadian Occupational Performance Measure (COPM), quality of life (QOL) questionnaires and liaison with nutrition to monitor nutrition goals.

Self-evaluation questions

1. Draw a concept map to help describe to a well-educated patient (with an interest in anatomy) their symptoms of a right inferior quadrantanopia. What activities might this patient have difficulty with? 2. When walking down the corridor, you notice that your patient makes a beeline for the rail 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 and sometimes the letters move. When the patient looks at you, you notice that they squint or 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 dislike going 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 overcome these challenges and enjoy shopping again? 5. Your patient has a ‘floating’ hand which they struggle to use effectively during dressing. 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 com- pare this 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 com- pare this to your intervention taking an adaptive (compensatory/functional) approach. 7. Draw a concept map to describe to a well-educated patient (with an interest in anatomy) their symptoms of impaired proprioception. What activities might this patient have difficulty with? Management of Visual and Sensory Impairments 143

8. You are assessing a patient’s coordination using the finger nose test and notice that the 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-education programme for a patient’s family to implement. 10. Your patient has oculomotor and vestibular impairments. Describe a restorative (re- medial) intervention activity for your patient and how you will grade it. Chapter 7 Management of Cognitive Impairments Ther´ ese` Jackson and Stephanie Wolff

This chapter includes: Definition of cognition r Cognitive functions r Assessment of cognitive functions r Cognitive rehabilitation r Assessment and intervention strategies for specific functions r Self-evaluation questions r

Definition of cognition

Cognition refers to those mental functions which help us to acquire, organise, manipulate and use information and knowledge. It includes all of our ‘thinking’ processes.

Cognitive functions

Cognitive functions which may be impaired following a stroke include the following: Attention – the ability to focus on specific sensory stimuli and suppress distractions. r Attention is required for many other cognitive functions to occur. Memory – the ability to retain and recall information. r Perception – ‘making sense of the senses’ – a cognitive process which is dealt with in r more detail in the next chapter. Language – understanding and expression. r Praxis – motor planning. r Executive functions – skills which are needed to plan organise and execute a task. r Assessment of cognitive functions

Occupational therapy assessment at any stage of recovery will involve a detailed analysis of performance skills (motor, sensory, cognitive, psychological and social) and the impact Management of Cognitive Impairments 145 of any impairments on a person’s ability to engage in occupations within a defined environment (physical, social and cultural). Assessment of cognitive functions is often carried out as part of an observational assessment of occupational performance using selected 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 realistic assessment of their ability. Timing of assessment is important to consider. In the acute phase of recovery from a stroke a person may be fatigued and may be dealing with a complex set of recovery issues which can impact on their emotional and psychological status. Testing specific cognitive skills at this stage may not give a true reflection of their abilities and it may be advisable to wait until the rehabilitation phase to do this. If however a cognitive impairment is questioned the occupational therapist may assess cognitive functions in the acute phase to determine the extent of the problem, and ensure appropriate follow-up, particularly if discharge is planned. For further detailed cognitive assessment, the person may also be referred to a neuropsychologist.

Standardised assessment Occupational therapists have a vast array of standardised assessments and screening tools available to them which can be used to contribute to the assessment of cognitive functions. Standardised, impairment-based assessments aim to provide valid and reliable assessments of performance skills, that is, specific cognitive components. They should not be used in isolation, but in combination with observational clinical assessment and clinical reasoning to ascertain to what extent the cognitive impairment impacts on occupational performance. It is advisable to be fully familiar with the test manual and validation processes to understand the extent of the remit for each test. Many of these assessments are impairment based and caution is advised when interpreting the results as they may not necessarily 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 the quality of ADL performance (Fisher, 2006). Other standardised assessments and screening tools which can be used to support the assessment of cognitive functions include (this list is not exhaustive):

MEAMS – Middlesex Elderly Assessment of Mental State (Golding, 1989) r COTNAB – Chessington Occupational Therapy Neurological Assessment Battery r (Tyerman et al., 1986) RBMT – Rivermead Behavioural Memory Test -III (Wilson et al., 2008) r CAM – Cognitive Assessment of Minnesota (Rustard et al., 1993) r BADS – Behavioural Assessment of Dysexecutive Syndrome (Wilson et al., 1996) r TEA – Test of Everyday Attention (Robertson et al., 1994) r LOTCA – Lowenstein Occupational Therapy Cognitive Assessment (Itzkovich et al., r 1993). 146 Occupational Therapy and Stroke

Cognitive rehabilitation

Approaches The main rehabilitative approaches used by occupational therapists, within cognitive rehabilitation, described in Chapter 2, are:

Remediation (restoration). r Adaptive (compensatory/functional). r Occupational therapists tend to favour a functional approach for the rehabilitation of people with cognitive impairment, including task-specific training and the use of activities which are meaningful and familiar. A selection of interventions may be required to meet individual needs.

Intervention Principles of intervention for the rehabilitation of people with cognitive impairment:

Goal orientated –thepersonwithcognitiveproblemsismorelikelytoengagein r rehabilitation if they contribute to the selection of the activities they participate in. Goals should be meaningful and relevant. Goals direct the content and process of interventions and must be relevant to the individual’s needs and wishes. Long and short-term goals are set and they should be, as far as possible ‘SMART’, that is, Specific; Measurable; Achievable (with some challenge); Realistic (within the environment and resources available) and Timescales should be set and there should be a regular review of goals with the patient, family/carer and team. ‘If the patient, their family, and the treating team are all working towards the same agreed goals, a satisfactory outcome is more likely’ (Turner-Stokes, 2003). Individualised –aselectionofstrategiesandinterventiontechniquesmayberequired r as people will have individual interests and responses to interventions. Educate and include relevant family/carers/friends and significant others –sothatthey r understand the difficulties a person may be having and can assist with the application of strategies and provide support. Focus on functional improvement –includingawayofmeasuringthisimprovement, r such as goal attainment and performance measures. Include psychological and emotional support –peoplewithcognitiveproblemscan r develop anxiety, depression and a sense of loss of control and self-esteem. These should be acknowledged and interventions provided to support management of these problems, such as anxiety management training, relaxation training and medication.

Intervention strategies Task-specific training –orfunctionalretraining,stressesthevalueoftheuseofspecific r and relevant functional tasks. Emphasis is placed on task characteristics, in order to support behavioural change (Wilson, 1998). Management of Cognitive Impairments 147

Practise –repetitionovertimeanduseofretainedcapacityassistslearning. r Errorless learning –peoplewithbraininjury,includingstroke,maynotlearnfromtheir r mistakes so an approach which supports the achievement of a successful outcome by cueing the correct response is more likely to enhance learning. This has been evidenced in studies of people with memory problems (Wilson et al., 1994). Environmental adaptation –regulationofnoiseanddistractions;clearingenvironmental r clutter; and adaptations such as message boards. Compensation and strategy training –externalaidsandadaptedmethods–forexample, r use of memory aids such as pagers, diaries and calendars. Prompts and instruction –directinstructionandguidedassistancemaysupportrelearn- r ing of skills. Restoration/skills training –thishaslimitedsupportfortherestorationofcognitive r problems although some studies of attention have reported improved skills when specific retraining of basic attention capacity is offered. Retraining tends to be more effective when embedded in a meaningful and functional context, targeting the specific level of attention impairment of the individual (Cicerone et al., 2005).

Attention

Attention is required for most other cognitive functions to take place. It is dependent on an adequate degree of arousal and alertness and helps us to process a large amount of information on a daily basis. Attention is commonly affected after stroke, especially in the 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, respond- r ing to your name being called. Sustained – this level relates to the brain’s ability to maintain attention on a single task; r also referred to as concentration, for example, reading a book. Selective –thisreferstothebrain’sabilitytofilteroutunwantedstimuliinorderto r attend more closely to detail or something important, for example, looking for someone in a busy room. Alternating –thisisthebrain’sabilitytoshiftitsattentionfromonethingtoanother, r for example, listening to a lecture and taking notes. Divided – this is about multitasking, doing more than one thing at one time, for example, r driving and talking to a passenger.

Assessment The aim of assessment is to determine at what level the patient’s attention problems are most evident; how the problem impacts on occupational performance and if it is affecting the patient’s behaviour. 148 Occupational Therapy and Stroke

Initially simple screening tests can be used such as asking the patient to count backwards from 20, or recite the months of the year backwards, or by observing them carrying out pen and paper tasks. Look for an organised approach to the tasks versus an erratic, random approach. Observe the patient carrying out functional tasks; do they become more distractible as the 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 same time? Can they perform a functional task such as following a recipe and alternate their attention between reading and carrying out the recipe? Do they miss detail? Clinicians often report that patients with attention problems can appear impulsive and at times agitated. These behaviours can be assessed through observation. Standardised assessments for attention are available such as the Test of Everyday Attention (Robertson et al., 1994).

Intervention Afunctionalapproachusingmeaningfultaskscanbeused.MichelandMateer(2006) suggest that intervention should be focused on training specific functional skills rather than the underlying processes. The National Clinical Guidelines for Stroke (Intercollegiate Stroke Working Party (ISWP), 2008) recommend that patients receive repeated practice of activities to treat attention problems. Activities that are meaningful and interesting to the patient and control the amount of stimuli in the environment should be chosen. For example, a kitchen session where the patient is asked to make a cup of tea, the therapists could get all necessary items out on the counter, the patient then only needs to link the components together without being required to search the kitchen for items. Each time the session is repeated, an additional search could be introduced such as leaving the milk in the fridge or cups in the cupboard. As the patients attention improves, the challenge and complexity of the task can be increased to work on higher levels of attention. Repetitive tasks at the tabletop can be used, for example, letter cancellation and word searches, as long as the interventions are providing an appropriate challenge and can be graded as attention improves.

Adaptive (compensatory/functional) strategies The National Clinical Guidelines for Stroke (ISWP, 2008) recommend that patients should be taught strategies to compensate for their reduced attention. If attention continues to be a problem, strategies can be implemented. This can be done by providing structure to the patient’s day such as using a diary system. Minimise distraction in the patient’s environment and ensure the patient has a quiet place they can go to if they become over- stimulated as this may manifest in agitated behaviour. Use of prompting to maintain the patient’s attention during tasks can be useful (prompts can be verbal or visual). These techniques should be taught to families and carers to alleviate the potential emotional stress attention problems can bring to both patient and their carers. If the patient is going home or is at home, safety implications of poor attention should be noted as it will often present similarly to problems with memory. Management of Cognitive Impairments 149

Memory

Memory allows us to retain and recall information for all aspects of daily living. Attention is essential to allow us to attend to information and select what is to be stored in our memory systems. The main processes associated with memory function are as follows: Attention – to the information that has to be remembered. r Encoding – sensory information is converted into meaningful data for storage. r Storage – in long-term memory systems. r Consolidation – rehearsal and practice of information to enhance the strength of the r memory. Retrieval – accessing information through recall or recognition. r Memory systems Sensory memory (sensory registration) – allows us to attend to relevant information and transfer it to our short and long-term memory systems. If not used, the information is discarded. Working memory (short-term memory) – a temporary storehouse of information which is retained for long enough for us to act up on it, for example, dialling a phone number when looking it up in the phone book. New sensory memories act with stored long-term memories to manipulate and use information in a meaningful way. If new information is to be stored as long-term memories, it needs to be consolidated and stored in one of the long-term memory systems. Long-term memory –informationisprocessedandstoredindifferenttypesoflong-term memory systems: Semantic memory – knowledge and facts; r Episodic memory – past events and activities; r Prospective memory – remembering to do things in the future; r Procedural memory – learned motor, cognitive and language processes. r Semantic memory, episodic memory and prospective memory are referred to collec- tively as ‘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 form new memories ‘anterograde amnesia’ or access stored memories ‘retrograde amnesia’.

Assessment Occupational therapists are interested in the impact of memory problems on a person’s occupational performance. Assessment at any stage of recovery will involve a detailed analysis of memory as performance skill impairment and the impact it has on a person’s ability 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 memory impairment and how it affects a person’s ability to function in daily life. 150 Occupational Therapy and Stroke

Observation of performance in a variety of tasks can help to determine where per- formance is limited and informs the intervention programme. Observing a person doing some shopping or having a conversation about the day’s events can indicate areas of difficulty they may be having and where memory information processing might be break- ing down. It is important to consider the impact of the environment during assessment as people often use cues to prompt them and may have more difficulty in unfamiliar contexts. Standardised assessments such as the Rivermead Behavioural Memory Test-III (Wilson et al., 2008), Doors and People (Baddeley et al., 1994) and the Chessington Occupational Therapy Neurological Assessment Battery (Tyerman et al., 1986) can be used to establish abaselineofperformance,butshouldbecombinedwithobservationalassessmentsto determine the extent of difficulty the individual has.

Intervention Intervention should be individualised, goal orientated and include psychological and emotional support. A restorative (remedial) approach, whilst of some use for those with mild problems, has limited effect for those with severe memory problems. The use of adaptive (compensatory/functional) approaches and assistive devices within the context of functional activities tend to be more successful (Cappa et al., 2005). Acombinationofapproachesisrecommendedandtheseneedtobeselectedaccord- ing to where the memory information processing system breaks down and individual preferences; see Figure 7.1. For example:

Reduce distractions Eye contact/name Attention

Encoding

Use written Storage lists/instructions

Make meaningful

Consolidation Recall

Rehearse and practice Give cues

Figure 7.1 Memory strategies linked with breakdown in memory processing. Management of Cognitive Impairments 151

If attention breaks down, use r –Attentiontreatmentstrategies. –Environmentaladaptation– minimisedistractions;simplifyandorganisethe workspace. If encoding breaks down, make the information more meaningful, linking to previous r learning or chunking information together – Internal strategies and prompts –forexample,useofmnemonics,visualimagery. If the patient is unable to store information, use r – External strategies – for example, written and verbal prompts. – Compensatory aids –forexample,electronicpagers,diaries,notebooks,calendars and computers. If the patient struggles to keep the information in storage, work on consolidation through r rehearsal and practice. – Errorless learning in practice of tasks to minimise performance errors and enhance learning. If the client has ‘tip of the tongue’ syndrome and has difficulty recalling the information, r give graded clues and prompts to elicit effortful but successful recall to facilitate memory. Support from family, carers, colleagues and friends is required to implement strategies r and provide prompts and support, no matter which approaches are taken. The National Clinical Guidelines for Stroke (ISWP, 2008) recommend the use of adaptive (compensatory/functional) techniques to reduce disability, approaches aimed at directly improving memory and the use of familiar environments when conducting therapy sessions.

Language

Aphasia may occur following a stroke and this may affect a person’s understanding of the spoken word, verbal expression, reading and writing. It is usually assessed in more detail by the speech and language therapist; however, joint sessions between the occupational therapist and speech and language therapist may be of benefit to help to ascertain what elements of a person’s performance are due to language difficulties or other cognitive problems (see Chapter 4).

Motor planning and apraxia

Normal motor planning Praxis 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 (verbal command, visual or tactile) input or volitionally. Actions need to be integrated with 152 Occupational Therapy and Stroke knowledge of object use and if several items are in use, there must be matching of actions and objects at the correct stage. Actions are often required to be performed in aspecificsequenceinordertocompleteatasksuccessfully.Wemayattimesperform tasks incorrectly but generally we are able to recognise these errors and correct them; for example, not putting the car into gear before pressing the accelerator. ArepresentationalmodelofapraxiainitiallyproposedbyRoyandSquare(1985)(and reviewed, as outlined by Roy (1996)), described three systems which allow us to function effectively: the sensory/perceptual system which differentiates between visual, auditory and object information; the conceptual system which comprises our knowledge of actions related to object function and associated sequences of movements related to the use of the objects; the production system which involves knowledge of the force, time and direction of action sequences and the translation of these into action. The concepts of motor programmes and action schemas further support our understand- ing of motor planning and voluntary activity. Motor programmes describe a set of motor commands used to achieve a particular movement and determine the force direction and timing of the movement. They are stored as motor engrams or action memories for specific movements. Action schemas are generalised motor programmes which are activated for all movement associated with a motor pattern. They contain the perceptual, sensory and motor components of a movement and become established with practice and experience. This describes how a scheme of movement such as reaching and grasping can be used for several activities such as reaching for a tin in the cupboard, or reaching for a cup on the table.

Apraxia Apraxia is a cognitive motor planning disorder. It impacts on a person’s ability to carry out skilled 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 disabling effects of stroke or brain injury (Van Heugten et al., 2000). Several types of apraxia are described in the literature such as dressing apraxia and constructional apraxia. More recently these have been described as the functional outcome of a performance breakdown resulting from several types of impairment and should therefore not be given individual classifications. Most current literature describes two types of apraxia – ideational and ideomotor. NB: The terms ‘apraxia’ and ‘dyspraxia’ are used interchangeably by occupational therapists; however, there is a move towards describing ‘apraxia’ as a disorder of learned movement seen in adults with acquired injury and ‘dyspraxia’ as a disorder of new learning seen in children (Grieve and Gnanasekaran, 2008). For this reason we use ‘apraxia’ throughout this text.

Ideational apraxia Ideational apraxia is a disturbance in the conceptual organisation of actions. It is often as- sociated with the inappropriate use of objects. Visual recognition and perceptual processes are functioning but the ability to use the object is impaired. The person with ideational Management of Cognitive Impairments 153 apraxia may use single action objects appropriately but may have more difficulty when a sequence of actions for object use is required. Specific performance errors initially proposed by Miller (1986) are associated with the 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 candle r on the matchbox instead of a match. Sequencing errors – for example, buttering bread before toasting it or omitting an r essential stage such as turning the kettle on without putting water in. Blending sequences together – for example, making a stirring motion with a spoon of r sugar before putting it in the cup. The action overshoots what is necessary – for example, the whole cup is filled with r milk instead of leaving room for the tea. The action remains incomplete – for example, the sugar is spooned into the coffee but r not stirred. Perseveration – the action may be continued into the next stage of the task even though r it is not required – for example, the teapot is placed on the saucer after the teacup is placed on the saucer.

Ideomotor apraxia Ideomotor apraxia is a disorder in the initiation and execution of planned sequences of movement. The concept of the task is understood but the movements lack the correct force direction and timing to achieve a motor goal. The person with ideomotor apraxia may be able to describe an action and at times will perform it automatically, but will generally be unable 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 goodbye r in a forward/backward motion instead of side to side. Initiation and timing – for example, hesitation before initiating a movement, often at a r point of transition between movements. Movements may appear rushed or abnormally slow. Inappropriate force may be seen in relation to the spatial pathway and related time sequence. Errors of the force of movement – poor calibration, for example, bang a cup down on r the table. Poor distal differentiation – the overall arm position may be correct but with poor hand r posture – for example, if demonstrating turning a key the hand is held in the wrong plane when the arm appears correctly aligned. Body part used as object – when asked to gesture an action, the person substitutes a r body 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 – for r example, rocking back and forth when demonstrating the use of a hammer. Vocalisation (vocal overflow, self-cueing) – verbalisation of a movement – for example, r ‘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, for r example, continuously cleaning shoes, or using the same movement to demonstrate an action when moved onto the next action, such as making a hammering motion when demonstrating the use of a spoon (after demonstrating use of a hammer). Fragmented response – part of a movement is demonstrated – for example, when r demonstrating drinking the cup is bought to the mouth but not tipped to the lips.

Assessment Therapists will be primarily interested in how apraxia affects a person’s ability to engage in meaningful occupations in the areas of self-care, work, domestic and leisure. In order to assess those functions the occupational therapist will analyse the component parts of the task to determine where the ability to perform it has broken down. This could be in any one or more than one of the performance skills of motor, sensory, cognitive psychological or social aspects. The environment and context in which the task is taking place will also have an impact on the outcome. Tate and McDonald (1995) described the ‘vast array of diagnostic tests’ for apraxia having 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 validity of ideomotor apraxia screening tools. Studies of apraxia use different screening tools and despite finding apraxia, each test may be examining different aspects of the apraxia syndrome. Butler recommends that until a ‘gold standard’ test of apraxia is found that we do not just rely on one test of apraxia for diagnosis and that we consider the results of ADL measures as being more clinically relevant than pure test scores. Van Heugten et al.(1999)proposedadiagnostictestforapraxiainstrokepatientswhich was sufficiently discriminative to distinguish between those who had apraxia and those who 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 (Zwinkels et al., 2004); however, like Butler, the authors recommend that test scores are combined with behavioural observations for a full assessment of apraxia and its impact on daily living activities. Standardised assessments of performance such as the AMPS may contribute to the understanding of the quality and effectiveness of performance (Fisher, 2006). VanHeugten et al.(2000)usedanobservationalmethodforthemeasurementofdisabilityinpeople with apraxia using four activities of daily living. The focus was on the point at which the activity broke down rather than the cause and identified initiation, execution and control as the notable stages of performance breakdown. This was subsequently used to support appropriate intervention strategies at the relevant juncture. Occupational therapists use the identification of performance errors to determine where an activity is breaking down. Tempest and Roden (2008) found consensus amongst oc- cupational therapists that analysing a person’s performance errors was the best way to assess apraxia. By using the errors noted for each type of apraxia, the occupational therapist may be able to use their clinical observations to identify which type of apraxia a person is experiencing, and more importantly the impact it has on independent living. Management of Cognitive Impairments 155

Intervention The principles of cognitive rehabilitation, ‘goal orientated; individualised, educate and include relevant family/carers/friends and significant others; focus on functional improve- ment; 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 performance despite the lasting presence of apraxia, and that adaptive (compensatory/functional) strate- gies do not impede the recovery of the impairment (Van Heugten et al., 1998; Donkervoort et al., 2001). Van Heugten et al.(1998)proposeda‘strategy training’programmeforpeoplewith apraxia. This was evaluated in a randomised controlled trial and showed short-term im- provement in ADL function when comparing it with usual occupational therapy, although the long-term effect requires further exploration (Donkervoort et al., 2001). Strategy training aims to improve performance by teaching internal and external compensatory strategies as part of the occupational therapy programme. As the assessment using ADL observations breaks the activity down into performance stages of initiation, execution and control, 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 if the person is experiencing more problems initiating the activity, then the therapist may for instance hand items to them one at a time. If execution is the problem, specific verbal or physical guidance is given and if control is a problem or performance errors are not corrected, then appropriate feedback is given. Other smaller studies have shown some support for specific interventions: ‘Activities in context’ – Clark et al.(1994)conductedasmall3Dmovementanalysis r study which suggested that motor performance and kinematic measures improved when the person with apraxia was supplied with the appropriate tools for a task and the correct contextual environment. ‘Task-specific training’ –GoldenbergandHagmaan(1998)foundthattask-specific r training could restore independence for trained activities. They also found that skills did ‘not generalise’toothertasksandperformancewasretainedonlywhentasks continued to be ‘practised’’ in daily routines. This was supported in a single case study by Wilson (1998) who provided a ‘structured’ programme of activity and ‘chaining’to retrain specific functional tasks. The activity was broken down into manageable steps in order to relearn specific tasks. Skills were only retained if the task was practised in daily routines. This supports the selection of appropriate and meaningful activities to be used in the occupational therapy programme.

Executive dysfunction

The executive system comprises those high-level cognitive processes which combine to set goals and to make choices in novel situations (Grieve and Gnanasekaran, 2008). It refers to the processes by which we plan, organise, initiate, monitor and adjust our thinking and behaviour (Kay, 1986). 156 Occupational Therapy and Stroke

Ylvisaker and Szekeres (1989) identified component functions of the executive system:

Realistic goal setting – having insight and awareness of what is achievable according r to own skills and external influences. Planning – correct ordering of the steps required to carry out a task successfully. r Organisation – of the workspace and timing of the task to carry out the plan effectively. r Self-initiation – starting a task without being prompted. r Self-directing – continuing a task without prompting. r Self-inhibiting – being able to stop a behaviour or action to move to another task when r required. Self-monitoring/self-correcting – recognising when something needs to be altered or r corrected and taking appropriate action. Flexible problem solving –beingabletothinkofmorethanonesolutionaccordingto r the demands of the situation. Executive dysfunction can lead to difficulty formulating goals and maintaining be- haviour to complete tasks successfully. People with executive problems may appear disorganised and lack planning skills. They may not have insight into their difficulties and may have problems interacting appropriately in various social, community and work contexts. They may also be unable to correct their mistakes and/or to think laterally.

Assessment It is important to define the person’s previous level of functioning as this will indicate to what extent their performance is different from their normal executive skills. This information can be obtained from family, friends and work colleagues through interview and written feedback using specific questionnaires. Observational assessment of the person’s performance of daily tasks can indicate spe- cific executive problems. It is important that the level of skill required for the task is of sufficient challenge to identify any performance breakdown. Simple, familiar tasks may be performed correctly but difficulties arise when more complex tasks are introduced. The therapist may ask the person to complete some more novel tasks which contain several stages 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 any areas of difficulty the person may be having. There are several standardised assessments available, including the BADS (Wilson et al., 1996). Standardised assessments of executive dysfunction should be used in com- bination with observational tests of performance as the test results may not always fully reflect the functional limitations which the person may have.

Intervention The National Clinical Guidelines for Stroke (ISWP, 2008) recommend that those with executive dysfunction and activity limitation should be taught adaptive (compen- satory/functional) strategies, for example, electronic organisers, written checklists; and Management of Cognitive Impairments 157 that family and other staff should be involved in discussions regarding the impairment and ways of supporting the person. Cicerone et al.(2005)reviewedtheevidenceforremediationofexecutivefunctioning, and although the studies were of people with traumatic brain injury the recommendations can be considered for people who have had stroke. Practice guidelines from this study include ‘training of formal problem-solving strategies and their application to everyday situations and functional activities’ and ‘verbal self-instruction, self-questioning and self- monitoring could be used to promote internalisation of self-regulation strategies’. Focusing on the functional activities which are limited by specific executive skills are encouraged, for example: Goal setting – specific and meaningful for the person. It is helpful to encourage people r to set their own goals and then review the outcome to develop insight into their own abilities. Planning – activities can be graded to achieve success and gradually improve the r difficulty. Organisation – a structured routine can be established with support, and responsibility r for this gradually handed over. Self-initiation and self-direction – external aids such as pagers and alarms can assist r with reminders. Taped or written prompts may assist with self-direction. Self-inhibition/monitoring and correction – develop strategies to monitor own behaviour r and make appropriate changes. Feedback and discussion can be used to develop a person’s awareness of their own performance. Flexible problem solving – alternating scenarios can be presented and practised to r develop a strategic approach to generating alternative solutions.

Self-evaluation questions

1. 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 an ideational apraxia. 7. Describe five performance errors which you may observe in a person who has an ideomotor apraxia. 8. What are the main performance behaviours you may observe when someone has executive dysfunction? 9. What are the two main approaches used by occupational therapists in the management of people with cognitive impairments? 10. What are the main intervention principles for the rehabilitation of people with cogni- tive impairments? Chapter 8 Management of Perceptual Impairments Louisa Reid and Judi Edmans

This chapter includes: Definition of perception r Normal perception r Perceptual impairments r Perceptual assessment r Intervention of perceptual impairments r Self-evaluation questions r Introduction

Perceptual impairments can have a major impact on occupational performance. This chapter 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 perception

The simplest definition of perception is ‘to become aware of by one of the senses’ (Oxford English Dictionary, 1961), that is, vision, hearing, touch, taste or smell.

Normal perception

How we interpret our environment starts at our inputting stage. The visual system conveys more information to the brain than any other afferent system. Chapter 6 outlines the pathways in detail. The primary visual cortex is located in the occipital lobe and most of the visual information is processed in five visual processing areas which perform varying visual tasks (Cohen, 1999) (see Figures 8.1 and 8.2): ‘Area V1 responds to motion, colour and position’ r ‘Area V2 responds to orientation, direction and colour’ r ‘Area V3 responds to orientation information’ r ‘Area V4 responds to large fields and colour’ r ‘Area V5 responds to unidirectional motion’. r Management of Perceptual Impairments 159

V3

V1

V2

V4

V5 Figure 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 and Gnanasekaran (2008) provide the example of looking around a room to explain the complexity 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 their distance from us. Figure 8.2 explains the visual pathways within the cortex that enable us to process all the information that is inputted through our eyes. The way we perceive images varies from person to person but does not constitute a perceptual problem. Examples include black and white pictures drawn in such a way

Ventral visual pathway Dorsal visual pathway

V4 V5

V3

V2

V1

Figure 8.2 Visual pathways. (Reproduced with permission from Lippincott, Williams & Wilkins, adapted from Bear et al., 2007.) 160 Occupational Therapy and Stroke that if you see the foreground as being black, you will see one image, but if you see the foreground as white, you will see another.

Areas of the brain relating to perception The right hemisphere has a greater role in processing visual and spatial information than the left hemisphere. Damage to different areas of the brain may result in different impairments. Occipital lobe: Discrimination of shape, size and depth. r Object agnosia. r Prosopagnosia. Occipitoparietalr area: Spatial relations. Rightr parietal lobe: Form discrimination. r Apperceptive agnosia. r Anosognosia. r Topographical disorientation. r Spatial relations. r Neglect. Leftr parietal lobe: Associative agnosia. r Somatognosia. Temporalr lobe: Prosopagnosia. r Topographical disorientation. r Perceptual impairments

Most individuals take for granted the complex nature of visual and visual–spatial abilities until these are affected. When damage occurs impairments can lead to difficulty engaging in 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 161

Body scheme Body scheme impairments are a lack of understanding of the relationship of the body and its parts. Autopagnosia is a lack of awareness of the body structures and relationships, causing the patient to confuse sides of the body and body parts. Unilateral neglect is neglect of the affected side of the body or the environment, for example, neglecting one side of the body during dressing or neglect food on one side of a plate. Anosognosia is a lack of recognition of the presence or severity of the paralysis or complete denial of illness. Right left discrimination impairment is difficulty understanding the concept of right and left. Finger agnosia is difficulty knowing which finger is touched when there is no sensory loss.

Visual discrimination Visual discrimination is the ability to distinguish one object from another; they can be differentiated 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 exam- ple, difficulty navigating stairs and barriers such as walls or doorways or difficulty knowing when a glass is full when filling it with water. Figure ground impairment is difficulty in distinguishing the foreground from the back- ground, for example, difficulty finding a white vest or towel on a white sheet or an item of clothes in a cluttered drawer. Spatial relations impairment is difficulty in perceiving the position of two or more objects in relation to oneself or each other, for example, difficulty putting food onto a spoon and then into the mouth or difficulty in putting the lid on a teapot. It may also be exhibited as difficulty understanding the concepts of in/out, front/behind, up/down etc., for example, difficulty finding a cup behind a kettle or putting on at-shirt inside out. Topographical disorientation is difficulty understanding and remembering relationships of places to one another, for example, difficulty in finding one’s way.

Agnosia Visual agnosia is the inability to recognise visual stimuli despite adequate primary visual function (visual acuity, oculomotor and visual fields). Visual object agnosia is difficulty in recognising objects although visual acuity and visual fields are intact; for example, a patient may fail to recognise relatives or possessions. Prosopagnosia is difficulty in recognising differences in faces. 162 Occupational Therapy and Stroke

Simultagnosia is difficulty in absorbing more than one aspect of a whole picture; for example, apatientmaybeabletopickoutasingleletterbutunabletoreadacomplete word. Colour agnosia is difficultly in recognising colours, for example, of fruits and vegeta- bles. Metamorphopsia is difficultly in recognising the actual size of objects. Visual–spatial agnosia is difficulty in perceiving the spatial relationships between objects or between objects and self, independent of visual object agnosia. Tactile agnosia (also called astereognosis) is difficulty in recognising objects by han- dling although tactile, thermal and proprioceptive functions are intact. Auditory agnosia is difficulty in recognising differences in sounds, including both word and non-word sounds; for example, a patient may be unable to differentiate between the 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 body scheme, apraxia and agnosia problems.

Perceptual assessment

Why assess perceptual ability? Perceptual problems have been shown to be common following both right and left hemi- plegic stroke (Edmans and Lincoln, 1987). These perceptual problems affect the patients’ response to rehabilitation and their ability to perform activities of daily living (Edmans and Lincoln, 1990; Jesshope et al., 1991; Donnelly et al., 1998) suggesting that if possible they should be treated. The objective of assessing perceptual ability is to identify the reason patients are unable to do certain activities and/or the possible impact on future activities, which in turn will inform 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 clarifying the 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’s everyday activities.

When to assess perceptual ability Perceptual 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 different activities during their recovery. Perceptual screening should be conducted within the first few days as part of the thera- pist’s initial assessment of each patient. This will indicate to the patient and therapist any potential areas of functional difficulty. A more detailed perceptual assessment should be conducted later if indicated from screening assessment or functional difficulties. This is in line with the recommendations of the National Clinical Guidelines for Stroke (Inter- collegiate Stroke 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 im- pairments that may occur. (b) Any patient not progressing as expected in rehabilitation should have a more detailed cognitive assessment to determine whether cognitive losses are causing specific problems or hindering progress. (c) The patient’s cognitive status should be taken into account by all members of the multidisciplinary team when planning and delivering treatment. (d) Planning for discharge from hospital should include an assessment of any safety risks 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 considered at risk of reduced awareness on the left, and should be tested formally if this is suspected clinically. (b) Any patient with suspected or actual impairment of spatial awareness should have their profile of impaired and preserved abilities evaluated using a standardised test battery such as the Behavioural Inattention Test (Wilson et al.,1987).The diagnosis 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 objects should be assessed formally for visual agnosia.

How to assess perceptual ability Perceptual ability could potentially be assessed either functionally or by use of standard- ised assessments.

Functional screening assessment Functional assessment of activities of daily living, such as personal or domestic activities, will demonstrate the effect of a mixture of impairments, both physical and cognitive impairments, upon the patient. As with the assessment of motor skills the initial assessment commences when the occupational therapist walks into the bay or room of the patient. The occupational therapist should 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.) r Is the patient pushing their leg or arm into full extension and pushing themselves over r to 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 responds and interprets the therapist’s questions. This may indicate if any potential perceptual impairments are present, although it will not give an accurate account of which impairment is causing the difficulty. 164 Occupational Therapy and Stroke

Forexample,ifapatientappearstobeneglectingeverythingontheleftsideoftheirbody during a washing and dressing assessment, the therapist would not be able to distinguish whether this was due to a visual problem of hemianopia, a tactile problem of reduced sensation or a unilateral neglect.

Standardised screening assessment When the patient’s previous history has been outlined and functional assessment con- ducted, standardised assessments should be used as a quick screen for the presence of perceptual impairments. Examples include: Line Bisection test from the Behavioural Inattention Test (Wilson et al., 1987). r Star/Letter Cancellation from the Behavioural Inattention Test (Wilson et al., 1987). r Rey Figure Copying test (Rey, 1959; Meyers and Meyers, 1995). r Completing these three basic pen and paper tests along with a baseline assessment will screen for perceptual impairments. If perceptual impairments are indicated on the screening assessments, a more detailed assessment of perceptual impairments should be conducted (see Chapter 10 on the use of standardised assessments).

Baseline assessment It is important to assess patients in different forms of activities of daily living. This should follow the screening assessment, which should have identified the possible impairments that may cause difficulties or inefficiencies in function. This will assist targeting the correct level of complexity. It is essential to assess the correct complexity level to highlight the impairments that are impacting on task performance. Mild impairments will not emerge in asimpleleveltask;therefore,apatientmaybeabletomakeasandwich.However,when preparing a complex meal perceptual, cognitive impairments may cause inefficiencies of task performance and therefore cause delay in task completion. Assessment can take place during any activity of daily living task, for example, meal times or grooming tasks. When assessing in function it is important to consider the following: Was the patient able to use all items effectively and inefficiently? r How did the patient handle items and did they use any awkward positions? r Was the patient able to see everything? r Did the patient overshoot when reaching for any items? r Did the patient have any delay in finding items? r Could the patient find items in cluttered environments such as a fridge or toiletry bag? r Did the patient find items using touch alone? r Could the patient identify the difference between similar items? r Examples of standardised perceptual assessments There are many standardised perceptual assessments available, some of which are for specific impairments only and some are more general. These can be split into three main categories and examples of each are shown below: Management of Perceptual Impairments 165

Neglect. r Spatial. r Multi assessments. r

Neglect assessments Baking Tray Test (Tham and Tegner, 1996). r Balloons Test (Edgeworth et al., 1998). r Behavioural Inattention Test (Wilson et al., 1987). r

Spatial assessments Location Learning Test (Bucks et al., 2000). r Rey Figure Copying Test (Rey, 1959; Meyers and Meyers, 1995). r Visual Object and Space Perception Battery (Warrington and James, 1991). r Multi assessments Cortical Visual Screening Test (James et al., 2001). r Motor Free Visual Perceptual Battery (Ronald et al., 1972). r Occupational Therapy – Adult Perceptual Screening Test (OT-APST) (Cooke, 2005). r Rivermead Perceptual Assessment Battery (Whiting et al., 1985; Lincoln and Edmans, r 1989). Repeatable Battery for the Assessment of Neurological Status (Randolph, 1998). r Many assessments are available from Pearson Assessment (combining The Psycholog- ical Corporation, Thames Valley Test Company and Harcourt Assessment).

Intervention

Intervention of perceptual impairments involves a mixture of restorative (remedial) and adaptive (compensatory/functional) approaches, the theory of which are explained in Chapter 2. The restorative (remedial) approach can be generalised, as practice on a particular perceptual task will affect the patient’s performance on similar perceptual tasks. The adaptive (compensatory/functional) approach can be interpreted as repetitive prac- tice of particular tasks, usually activities of daily living, which will make the patient more independent in these particular tasks. Occupational therapists use functional tasks as an intervention medium and despite conducting personal care activities, occupational therapists may still be working at an impairment level. For example, when working with a patient with neglect the therapist may move items on a sink from midline to their left side which would be focussing on the impairment level of the disorder when still working with the media of personal care. 166 Occupational Therapy and Stroke

While working with a restorative (remedial) approach it may be possible to make gains that generalise into other occupational areas. It is, however, important to be aware of other 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 in- terventions as cognitive impairments. Reduced awareness, changes in mood and visual disturbance will affect the patient’s ability to respond to intervention. Neglect is the most common perceptual impairment suffered by stroke patients and occurs over several sensory systems; vision, touch and auditory. Neglect presents in different spatial domains and these include the following: Body (personal) space – the immediate area of space of the person. r Reaching (peripersonal) space – the area extending to arm’s reach of the person. r Far (extrapersonal) space – the area extending far from the person. r The most dramatic and easily observed is the visual form of neglect. Patients with neglect may fail to shave or dress their left side, fail to read the left side of a word or sentence, fail to attend to the left side of the sink leading to missing objects placed on the left, or fail to attend to the left side of their plate. There are related disorders that present similar to neglect and confuse the identification of the disorder and need to be ruled out. These include visual field impairment, visual inattention, anosognosia and severely impaired sensation throughout the left side. Neglect commonly occurs with other visual perceptual and attention impairments due to the area of the damage leading to this disorder and these dual impairments need to be taken into account when planning intervention. Neglect occurs following right hemisphere damage and has been linked to the parietal lobe and supramarginal gyrus. There are various theories to explain the phenomenon and it is important to understand these to provide an intervention approach. Attention-Arousal Theory (Heilman et al., 1993, 1993) outlines damage to structures responsible for arousal and transmission of sensory information to the cortex leading to reduced attention to the contralateral side. Neglect is caused by the cortex not receiving adequate sensory information from the subcortical structures. Hemisphere Specialisation Theory (Robertson and Lamb, 1991) proposes that there is aspecialisednaturetothehemispheres,theleftattendstorightwheretherightattends to both left and right; therefore when the right hemisphere is damaged the left side has no attention to the left as the left hemisphere only attends to the right. Robertson and Lamb suggest that the use of left hand leads to improved task performance compared to right hand use and proposed that this is due to left arm activation which leads to premotor activation of the right hemisphere. The spatiomotor cueing process (use of the left hand acts as a cue) enhances attention to the left side. Contralesional limb-based therapy however is problematic due to left-sided hemiplegia. Intentional Mechanism Theory (Halligan and Marshall, 1991) proposes that intentional mechanisms are activated when directing a hand in the contralateral side, that is, the left hemisphere activates the right hand to the left of midline. Moving the right hand towards the contralateral side (left side) activated the right hemisphere. Halligan and Marshall’s theory leads to recommendation of the use of left hand in function in midline and the contralateral side; however, using the left hand in the ipsilesional side activated the left hemisphere and cancelling the use of left hand in the contralateral side. Management of Perceptual Impairments 167

Disengagement Theory (Posner et al., 1984) proposes decreased attention to the left is caused by inability to stop attending to objects in the right side. This theory proposes to reduce stimuli in right visual field and to present objects in midline and move into left visual field. Interhemisphere Theory (Kinsbourne, 1977) is based on attentional mechanisms of each hemisphere which are activated by cognitive and perceptual tasks and neglect is the imbalance in brain activation. Spatial stimuli activate the right hemisphere and verbal stimuli activate the left hemisphere. Thus, when the right hemisphere is damaged the ability to process spatial stimuli is impaired. This theory proposes the need to reduce imbalance by turning head towards the left, remove left hemisphere stimuli (letters and numbers) 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 of r errors. Consider the types of prompts, that is, visual, verbal, physical or questioning prompts r and pausing before providing a prompt. Consider using written or visual instructions. r Learning can be achieved through repetition and practice. r Reinforce positive behaviours rather than negative ones. r Stage components of the task, that is, break down the task and encourage the patient to r complete one stage at a time. Use verbal rehearsal, that is, encourage the patient to talk through the task before r completing it, errors can then be corrected before they are performed. Establish patterns and routines. r Provide consistency in approach. r Specific intervention strategies Body scheme Aim: For the patient to be aware of parts of the body and their relationship to each other and how they are used within function.

Restorative (remedial) strategies Ask the patient to verbally identify parts of the body (Johnstone and Stonnington, r 2001). Encourage the patient to verbalise positions of parts of the body to improve awareness. r Provide tactile stimulation, for example, rub a rough cloth on the patient’s arm while r naming it before placing their arm through a sleeve (Zoltan, 2007). Identify parts of the body before washing or dressing them. r Incorporate bilateral activities that facilitate normal movement and improve body r scheme (Zoltan, 2007). 168 Occupational Therapy and Stroke

Adaptive (compensatory/functional) strategies Provision of instructions that name parts of the body, such as ‘wash your arm’ (Zoltan, r 2007). If the patient has functional awareness, provide cues such as ‘move the part of the body r that you use to hold things’ instead of ‘move your hand’ (Zoltan, 2007).

Impaired midline awareness This presentation is often termed the ‘Pusher syndrome’ (for details see Chapter 5). Patients have a severe misconception of their own upright orientation. Patients experi- ence their own upright as 20◦ tilted to the ipsilesional side. Patients present by pushing themselves over towards their affected side and are often overactive on their unaffected side. 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 in r front 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 describe r their relationship to supporting surface (Karnath and Broetz, 2003). Get the patient to move between postural sets and for them to maintain their balance. r Adaptive (compensatory/functional) strategies Place pillows on the overactive side to provide extra supporting surfaces to enhance the r patient’s feeling of security. When seated in a wheelchair place the hospital bed in a high position on the overactive r side to enhance feelings of security. Teach the patient to use vertical structures within the room such as door or window r frames to adjust balance with reference to these markers (Karnath and Broetz, 2003).

Unilateral neglect Aim: The patient to become aware of both sides of their environment.

Restorative strategies Use activities that cross midline, for example, personal care activities. r During activities of daily living sessions place stimuli on the patient’s affected side and r prompt and encourage them to look over to their affected side. Place necessary items in midline and to their affected side using cues to locate all items and ask patients verbalise the location of items to practise spatial scanning. Practise shifting attention from left to right. Cue patients to target stimuli in neglected r space to assist attentional shifts. Management of Perceptual Impairments 169

Move necessary items from midline to their affected side, such as the knife in midline r and the butter further into the left side. Cancellation tasks such as maze or word searches to practise scanning left to right. r 2D scanning tasks, that is, paper and pen tasks or more dynamic such as room searches. r Computer games that require scanning from side to side. r Tactile stimulation onto the neglected part of the body, using vibration, mildly hot or r cold stimuli (Johnstone and Stonnington, 2001).

Adaptive (compensatory/functional) strategies Place objects in midline and gradually move objects further into the patients’ affected r side. Approach patients from the midline. r When reading, anchor the page and draw a red line down the affected side so that r the patient becomes aware of how far across the page to start reading (Johnstone and Stonnington, 2001). Adapt the environment; remove clutter on the affected side (Johnstone and Stonnington, r 2001). Encourage the patient to turn their plate round to ensure all the meal is eaten. The r National Clinical Guidelines for Stroke (ISWP, 2008) recommend that meal times should be monitored to ensure that food is not missed. Teach the patient to turn their heads to become more aware of the affected side. r Other intervention approaches Constraint-induced movement therapy Constraint-induced movement therapy (CIMT) forces the use of the affected side by either placing a sling or mitt on the unaffected arm (Taub et al., 1998). CIMT attempts to reverse the learnt non-use of the affected arm; however, to be able to use this technique there needs to be enough return of movement that would allow the patient to functionally use their affected hand. CIMT reports to be a useful intervention method for unilateral neglect. For further details see Chapter 2.

Eye patching Studies have shown that using glasses that occlude the good (ipsilesional) side of vision in each eye, the patient is forced to direct their gaze to their contralesional side (Beis et al., 1999). Compliance with this technique can be difficult as it is the patient’s natural inclination to gaze towards the occluded side.

Prism glasses

There 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 Stroke

Within studies such as Rossetti et al.(1998),patientswereaskedtopointtoatargeteither side of midline while wearing the glasses. Following the use of this technique the patients demonstrated immediate improvements in tests of neglect. McIntosh et al.(2002)have also shown these improvements to be made post 9 months following stroke. The National Clinical Guidelines for Stroke (ISWP, 2008) recommend using prisms if the unawareness is severe and persistent.

Visual discrimination Aim: To become aware of the relationship of objects to objects or self, to identify fore- ground from background, position in space and depth and distance.

Restorative (remedial) strategies Teach the patient to retrieve items following verbal instructions with spatial concepts, r 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. r Use of tactile kinaesthetic strategies such as guiding the patient to the object. r Encourage the patient to verbalise the position of parts of the body to improve awareness. r Adaptive (compensatory/functional) strategies Organise the objects so that they are in the same place. r Mark drawers where key items are kept. r Encourage the patient to feel and describe objects. r Remove clutter in the environment (Johnstone and Stonnington, 2001). r Place objects on contrasting surfaces, for example, white soap on a dark coloured cloth. r Visual agnosia Agnosia is the inability to recognise objects even though the elementary visual functions remain unimpaired (Farah, 1995). Lissauer in 1890 distinguished between two types of visual agnosia, the apperceptive and associative agnosias. Apperceptive agnosia is where recognition fails because of impairment of visual perception. Patients do not see objects normally and cannot therefore respond to them. Associative agnosia is when perception is intact to allow recognition; however, recognition cannot take place due to impaired semantic 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 to impaired visual perception. Patients with associative agnosias are able to copy drawings but 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. r Encourage the patient to recognise differences and similarities between items. r Management of Perceptual Impairments 171

Start with items that are very different and gradually upgrade to items with subtle r variations, for example, shape, size or colour. Encourage the patient to verbalise differences, that is, naming objects and differences r between objects.

Adaptive (compensatory/functional) strategies Teach the patient to consider and think critically. r Utilise verbal strategies where the patient describes the perceptual and functional char- r acteristics of the object to aid retrieval of the object name. Use other senses to identify the object, that is, touch, smell or sound. r Show the object in a natural context. r Adding texture or edge orientation to objects may assist into providing cues to identi- r fication. Use premorbid orientation of objects, that is, did they keep a T-shirt kept in the drawer r or on a hanger. If categorisation is intact ask the patient to identify which category the object would r belong to. Provide labels for objects to maximise independence. r

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 touching r the surfaces and edges of the object, holding the object in the hand to obtain information on its size, shape and weight.

Adaptive (compensatory/functional) strategies Education of problems and how these affect function. r Utilise other senses, that is, vision and touch from the unaffected hand. r Teach the patient to focus on specific properties of the object. r Use familiar objects within functional tasks. r Use objects within context. r General assessment and intervention plan Ageneralplanfortheassessmentandinterventionofperceptualimpairmentsisshown below: 1. Assess perceptual abilities using functional tasks and standardised assessments. 2. Analyse the results and the effect of comprehension, concentration, reasoning (execu- tive function), initiation, memory, anxiety, depression, apraxia, hemianopia/eyesight, inattention, etc. 172 Occupational Therapy and Stroke

3. 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 questions

1. 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 assessment for 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 9 Resettlement Pip Logan and Fiona Skelly

This chapter includes: Home visits r Community rehabilitation r Support available and self-management r Carers r Yo u n g e r p e o p l e r Lifestyle and long-term management r Leisure rehabilitation r Getting out of the house r Driving r Vocational rehabilitation r Resuming sexual activity r Stroke education r Self-evaluation questions r

Home visits

Home visits are carried out to assess if a patient is safe to return home and whether the environment is suitable for them. Sometimes an initial visit without the patient to assess the environment (often called an access or environmental visit) is advisable, as re-housing or major adaptations might be required prior to discharge. It is advisable to involve the family with all home visits. It is good practice for occupational therapists to carry out home visits with another member of the multidisciplinary team such as a physiotherapist or community-based therapists (Clarke and Gladman, 1995). Occupational therapy services will have their own template for writing home visit reports but the following areas should be assessed during the visit, depending on the type of property, hazards and patient’s functional abilities: Access to property r –Path,steps,railsandwhetherpatientcanunlock/opendoor. Outdoor mobility r –Typeofequipmentandlevelofassistance. 174 Occupational Therapy and Stroke

Indoor mobility r –Typeofequipmentandlevelofassistance. –Hazardssuchasfloormats,furniturearrangement. Transfers r –Chair,wheelchair,bed,toilet,bath,commode. –Typeoftransferandassistance. –Typeofequipment. Stairs r –Equipmentusedandlevelofassistance. –Methodofascending/descendingstairs. Kitchen assessment r –Hotdrink/snackpreparation. Observation of cognitive impairment in functional setting: r –Considervisualperception,short-termmemory,executivefunctions,forexample, through use of appliances such as the telephone, TV, computer, managing a ‘simu- lated’ emergency situation in the home environment. Recommendations r Action plan r –Listwhoisgoingtocarryoutactionsandtimeframe.

Community rehabilitation

Community rehabilitation is an umbrella title for a number of stroke services in the community, mostly administered in people’s own homes but can take place in community centres, health centres, sports centres, care homes and stroke clubs. Most health and local authorities provide a mixture of services for acute (straight after hospital discharge) and longer-term rehabilitation. The services available after hospital may be called intermediate care or early supported discharge and are usually time limited (approximately 6 weeks).

Intermediate care The Department of Health (DH) defines intermediate care as:

arangeofintegratedservicestopromotefasterrecoveryfromillness,preventunneces- sary acute 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 from medical dependence to functional independence, where the objectives of care are not primarily medical, the patient’s discharge destination is anticipated, and a clinical outcome of recovery (or restoration of health) is desired. and Resettlement 175

those services which will help to divert admission to an acute setting through timely therapeutic interventions which aim to divert a physiological crisis or offer recuperative services at or near aperson’sownhome.

The basic principles of intermediate care according to the National Service Framework for Older People (DH, 2001) are:

The emphasis on appropriate, person-centred, seamless care. r The need for robust assessment processes. r The crucial importance of partnership working between health, social care, housing r and the independent sector. Ensuring timely access to specialist services. r Clear care pathways. r Use of single assessment process (SAP). r The nature and scope of intermediate care services vary greatly across the country. The professionals making up the multidisciplinary team, the conditions that patients have and the length of rehabilitation can vary. The main types of service are listed below:

Rapid response The aims of the rapid response service are to facilitate timely hospital discharge and/or prevent hospital admission. It is a crisis intervention service, which offers intervention for just a few days, for elderly people following a fall or onset of ill health. Some services also 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 hospital or a care home. The multidisciplinary team consists of nursing, medical and allied health professionals. 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 team Hospital at home/community rehabilitation teams are multidisciplinary services which provide intensive rehabilitation at home for anything from 6 to 12 weeks. They offer patient-centred therapy working towards patient goals. The services can be used to facili- tate earlier hospital discharge and prevent inappropriate hospital admission. Occupational therapists 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 rehabilitation Residential rehabilitation services offer intensive rehabilitation for patients resident in a residential home or a purpose-built intermediate care unit with input from allied health professionals. These services are usually for further rehabilitation after hospital admission, 176 Occupational Therapy and Stroke often up to 6 weeks. Occupational therapists focus on the skills patients need to manage safely at home and will carry out home visits and be involved with discharge planning.

Early supported discharge Stroke specific early supported discharge has been recommended by the Department of Health Stroke Strategy (2007) and research has already provided evidence that this service 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 intensive rehabilitation at home following admission to an acute or hyperacute stroke unit. The general consensus from the research so far is that they should have a multidisciplinary team which includes nursing, medical, allied health profession and social work staff, but that the team should be trained in stroke techniques. Time limit again can be between 6and12weeks.

Role of the occupational therapist The role of the occupational therapist within intermediate care services is either to prepare patients for returning home or to help them remain in their own home, depending on the clinical setting. Assessments useful with this patient group are described below:

–Assessmentofactivitiesofdailylivingsuchaswashing/dressingandmealpreparation. –Cognitive/perceptualtestssuchasMiddlesexElderlyAssessmentofMentalState (MEAMS) (Golding, 1989), Visual Object and Space Perception Battery (VOSP) (Warrington & James, 1991), Rey Osterreith Complex Figure Test (Rey, 1959). It is advisable to find out which assessments have been completed in previous clinical settings and use these, if appropriate, to review cognitive impairment. –Movingandhandlingriskassessments–tobecompletedatthestartoftherehabilitation programme. –Upperlimb–assessmentoftone,rangeofmovementandsensation. –Mentalhealth–usingscalessuchasGeneralHealthQuestionnaire(GHQ)(Goldberg and Hiller, 1979) or Hospital Anxiety and Depression Scale (HADS) (Zigmond & Snaith, 1983). –Driving–assessmentssuchasStrokeDriversScreeningAssessment(SDSA)(Nouri and Lincoln, 1994) or other cognitive tests such as Behavioural Assessment of Dysex- ecutive Syndrome (BADS) (Wilson et al., 1996), Test of Everyday Attention (TEA) (Robertson et al., 1994) and VOSP (Warrington & James, 1991). –Leisure/work–findingouthowthepatientspendstheirday,theirhobbies,previous employment, using leisure questionnaires.

Intervention Rehabilitation within intermediate care should be patient-centred. Generic goal setting with the patient can be used to facilitate clear intervention planning. The use of goal-setting sheets can be used for patient and therapist to complete at regular intervals throughout Resettlement 177 the period of rehabilitation. Goals should be reviewed on a weekly basis and adjusted accordingly. The important factor is that intermediate care should follow immediately from the acute rehabilitation and therefore requires a quick assessment of need and immediate intervention with input on most days. Occupational therapists in these services share caseloads and patients often hold their own notes. Occupational therapists are expected to set goals for rehabilitation assistants who may treat the patient twice a day. The intervention approaches used with stroke patients in intermediate care are often similar to those used in the acute setting. However, sometimes a more functional approach for the frail elderly following a stroke is the most appropriate method in order for them to return or remain at home. Regular practice with washing/dressing, transfers, mobility and 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 im- portant to fully assess the patient’s ability to return home. Some intermediate care units have kitchen facilities or a self-contained bedsit for patients to care for themselves with supervision 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 of responsibility from the rehabilitation team to the patient is important if patients are going to be helped to self-manage their own condition.

Support available after a stroke and self-management

Two-thirds of people who have had a stroke will need some type of support at home over aperiodoftime.Thiscouldbepracticalsupportsuchashelpwithwashingordressing or psychological support such as motivational techniques, anxiety management. The National Clinical Stroke Guidelines (ISWP, 2008) acknowledge that much of the support will not be provided by health care professionals but will be provided by a mixture of family, carers, charities, local authorities and dedicated organisations. The support available varies considerably from location to location, and even within a 5-mile radius of a large hospital people will be able to access different services. Another complication is that some services are free and some will charge. For practical help such as getting up in the morning, assisting with meal times, and helping with getting dressed, most patients will be assessed by statutory services such as social care and will be recommended for what was known as ‘home care’. However, increasingly a number of private companies are being contracted by local authorities and the names of these services differ. On top of this, a number of private companies are advertising long-term support which people may access with insurance monies or through pension schemes. Long-term psychological support for both the patient and the carer is sometimes harder to secure and this is often what people will ask for when the routine rehabilitation has ceased. The National Clinical Stroke Guidelines (ISWP,2008) recommend that health and social care professionals continue to assess for support needs at regular intervals and ensure that people are referred to the most suitable organisation or are given the information they need to refer themselves. This handing over some of the responsibility to the patient is very important; this encourages patients to self-manage their own condition. Some patients may be able to organise their own lives after a stroke but some may need support for 178 Occupational Therapy and Stroke many 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 ‘Arange of services are in place that are easily accessible and support the long-term needs of individuals and their carers’. In reality such services are patchy and often not specific to stroke; it can take a long time to track down a service that will come and sit with someone while the carer goes out. Use of the Internet can speed up searching and giving weblinks to patients or their families can open up a whole new world. Increasingly people are entering chat 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 have had a stroke. For the occupational therapist gathering information about local services and the dif- ferent criteria needed to access these services can be time consuming. However, within the 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 good things to remember when trying to sort out this type of support is that this could be one of the most important relationships for the stroke patient; they may want to attend the stroke club for 10 years and this introduction could be the one thing the patient remembers most from their rehabilitation. Included here is a list of potential avenues for support that are not provided by the statutory services. In your area there may be other particular organisations that offer services such as a community centre, sports centre or church group.

The Stroke Association –FamilyandCarerSupportworkerswhocanvisitathome. Stroke clubs –Usuallyorganisedbyvoluntaryworkers,TheStrokeAssociationholds alist.Patientsusuallyattendonceaweekandtheformatcanbeaspeaker,lunchand time to talk to other people who have had a stroke. Age concern/help the aged –Localservicescanincludebefriendingandvisitingser- vices, advocacy and counselling. Different strokes –Youngerpeoplewithstrokecanaccesssupportthroughthisorgan- isation; local groups provide different services from befriending, financial advice, clubs and activities.

Carers

The National Clinical Guidelines for Stroke (ISWP, 2008) provide recommendations for 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 carers r should be sought, to establish if possible the extent to which the patient wants family members involved. The carer or every patient with a stroke should be involved with the management process r from the outset, specifically: Resettlement 179

–asanadditionalsourceofimportantinformationaboutthepatientbothclinicallyand socially. –beinggivenaccurateinformationaboutthestroke,itsnatureandprognosisandwhat to do in the event of a further stroke. –beinggivenemotionalandpracticalsupportasrequired. Withthepatient’sagreement,familycarersshouldbeinvolvedinallimportantdecisions, r as the patient’s advocate if necessary. During the rehabilitation phase, carers should be encouraged to participate in an edu- r cational programme that: –explainsthenatureofstrokeanditsconsequences. –teachesthemhowtoprovidecareandsupport. –givesthemopportunitiestopractisecarewiththepatient. –emphasisesandreiteratesalladviceonsecondaryprevention,especiallylifestyle changes. At the time of transfer of care to the home setting, the carer should: r –beofferedanassessmentoftheirownsupportneedsbysocialservices. –beofferedthesupportidentifiedasnecessary. –begivenclearguidanceonhowtoseekhelpifproblemsarise. After the patient has returned to the home (or residential care) setting, the carer should: r –havetheirneedforinformationandsupportreassessedwheneverthereisasignif- icant change in circumstances (e.g. if the health of either the patient or the carer deteriorates). –beremindedonaregularbutnotfrequentbasisofhowtheymayseekfurtherhelp and support. There is a variety of support/advice for carers: The Stroke Association has valuable information on its website. It runs various services r including a Family Support Service. Stroke Support Groups affiliated to Stroke Association and Different Strokes are in oper- r ation across the UK. Please refer to their websites for a list of the local branches/support groups. ‘Directgov’, a government website, provides general information about rights/ r 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 per day of care. Carers’ Assessments are carried out by a social worker employed by the local social r services where the need for extra support can be identified. Direct payments are available from social services to pay for care if the patient fits the r criteria for a care package but would rather use the money to employ their own carers where there is often more flexibility in the type of care provided, for example, to assist with car transfers or shopping. Younger patients may find this the most beneficial way of receiving care. Carers’ charities/organisations provide support, information and campaign for carers’ r rights. Contacts include The Carers Information and The Princess Royal Trust for Carers, although these are not specifically for carers of people with stroke. 180 Occupational Therapy and Stroke

Younger people

Aquarterofthe110000peoplewhohaveastrokeinEnglandareunder65yearsof age (National Audit Office, 2005). Every year, 10 000 people under the age of 55 suffer astroke–1000oftheseareundertheageof30.Althoughthisnumberseemssmall compared to the older population, this group is important and provide different challenges for the occupational therapist. They are often in work when they have their stroke, they may have young children, they may be students, they have many years ahead of them and they want to live as independently as possible. Additionally there is some research that indicates that the use of recreational drugs may increase the incidence of stroke in a younger population (Westover et al.,2007). For the occupational therapist these issues have to be considered when planning in- tervention. A younger patient may be able to tolerate longer rehabilitation sessions than an older patient; they will need vocational rehabilitation from the start, they will want to know about sex after a stroke and they may suffer from a greater feeling of reduction in role. Younger stroke patients may have to make massive changes to their lives and this can take a long time to come to terms with: changes to jobs, loss of a car, changes to hobbies, breakdowns in personal relationships, depression, and reduction in wealth as well as any physical changes. Rehabilitation of younger stroke patients will include a wide multidisciplinary team and may need to be extended over many months. AgreatdealofinformationcanbegatheredfromDifferentStrokes,acharitysetup by younger people with a stroke for younger people. It provides people a number of services across the UK. They have a website with links to local clubs and information and the participants are very active. As well as the rehabilitation programme, occupational therapists can help younger people with stroke access this website whilst in hospital, they can introduce them to other younger people and ensure they are provided with vocational rehabilitation. Different Strokes has been a powerful organisation at lobbing government to help people back to work, to improve acute care and to get exercise classes available.

Lifestyle and long-term management

The effects of having a stroke are often ongoing and therefore once patients are over the immediate rehabilitation phase of approximately 6 months, they start looking forward to resuming their lives as much as possible and making changes to accommodate their new limitations (Lincoln et al., 1998a). The National Clinical Stroke Guidelines (ISWP, 2008) recommend that people with ongoing limitations after the initial rehabilitation phase should be offereda6monthlyreviewandbeprovidedwithfurtherrehabilitation if clear goals are identified. These review sessions may highlight areas that may have been previously ignored by the patient such as social participation, leisure, returning to work, transport and social support. Although occupational therapy input is essential at this time and has been found to be beneficial in research studies (Walker et al., 2000), the main emphasis at this point is for patients to start to plan, enquire, lead and be proactive about their lives, about the information they need and how they are going to undertake activities without the assistance of health professionals. This does not mean they will be on their Resettlement 181 own: they may be with family, carers or volunteers. The Internet is a mine of information but some of the best advice will come from other people who have had a stroke. This can 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 them in categories on their website. So, for example, if a patient is worried how their stroke is affecting the family they can listen to experiences of other people with stroke about how they discussed the stroke with their grandchildren. Patients may have changed their lives completely; they may have been given specific advice 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 about this time, contact with most rehabilitation services will have ceased and patients may have been referred for ‘Exercise on Prescription’ as opposed to seeing the physiotherapist and the occupational therapist will be exploring support from tertiary organisations such as Connect, Age Concern, The Stroke Association, Stroke Clubs. These life-changing actions happen over time and people often need support and reassurance to continue to explore new avenues.

Social participation People who have had a stroke often feel dependent on others, lack knowledge and with one-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 social networks they had before the stroke. Occupational therapists can initiate and enable people to start participating in society but over time people do not want to be always associated with professionals and they move to groups more normally associated with the community such as work, family, visiting friends, voluntary groups such as social clubs, luncheon clubs, hobbies and religious activities. There are vast benefits to improving social participation on quality of life, personal choice, dignity and ultimately improving health by easier access to health centres, better physical health through exercise, reduction in falls through improved muscle strength and balance. One complaint from people with stroke is that although there are numerous clubs, societies, hobbies groups and written information about these places, people wanted someone to get them started or help them return after a break (Drummond and Walker, 1995). Therapists have been successful in this role but there is no reason to believe that this role could not be undertaken by voluntary services, a ‘Buddy System’ or rehabilitation assistants. Whoever provides this role must be knowledgeable about the local facilities, be able to spend time taking the patient and then be able to sort out transport or use of public transport. This is not a quick process.

Leisure rehabilitation

It is known that participation in leisure decreases after stroke, even for patients with a good physical recovery (Drummond, 1990). The significance of this reduction lies in the fact that satisfactory leisure is related to life satisfaction. Consequently, such a decrease in leisure activity may reflect a decrease in quality of life. 182 Occupational Therapy and Stroke

There is a growing feeling that there is not enough help for patients who have had a stroke 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, concluded that

there 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 stroke with differing results (Drummond and Walker, 1995; Parker et al.,2001).Inadditionto this confusion the definition of a leisure activity changes over time. Treadmill training may appear 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 what they ‘do in their free time’. Some people do not always understand the term leisure so it is advisable to use the term ‘free time’ or ‘interests’ and explain what you mean in more detail. The definition: ‘activity chosen primarily for its own sake after the practical necessities of life have been attended to’ (Drummond, 1990) maybe one to consider but then 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 and whether they would like to return to these or try new hobbies. Using a checklist to keep a written record of what patients did before their stroke will help to identify areas of interest and plan a programme. Responses are usually more comprehensive when a checklist (such as the Amended Nottingham Leisure Questionnaire – Parker et al.,1997)isused. However, even checklists get out of date and this measure does not include computer activities such as email, Skype or on-line shopping. Look for common themes from the list of hobbies such as sporting or crafts as this may help you suggest new ones. Therapists should value more common everyday activities such as reading, walking and gardening as much as the more exciting ones. Check the most obvious limitations to participating in hobbies such as checking if patients need new glasses or hearing aid before assessing problems with hand function and balance. Following assessment and goal setting it may become apparent that the patient will need to consider trying new hobbies and the checklist common themes may help you make suggestions. For example, does someone like solitary activities, outdoor pursuits, and competitive interests? Remember when planning leisure rehabilitation not to overlook the most common everyday activities in favour of the more exciting, eye-catching interests, many people prefer gardening, going for a walk, reading the paper. However, also remember that those people with good physical recovery from their stroke may also need assistance to get back to the more strenuous hobbies such as ballroom dancing, sailing or cycling. Although this section is almost exclusively dedicated to people in the community whether at home or in residential care, evidence suggests that patients with a stroke spend long periods of time in hospital doing nothing (Lincoln et al., 1989). Whilst therapists are busy providing rehabilitation and organising a return to home, information provided on the ward in the form of leaflets, CDs, computer programmes or visits from other people who have had a stroke may spark an interest in a leisure activity that could enhance a patient’s quality of life. Resettlement 183

There are many national and local organisations that can advise and assist with leisure activities such as gardening, art, sports, fishing, golfing and holidays. Funding is some- times available for specialist one-off items. Find out what the patient’s previous occupa- tion was, as many jobs have Benevolent Funds. Many organisations can be found via the Stroke Association and Different Strokes websites as well as via the search engines on the 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 with paralysis 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 embroi- dery and knitting with equipment for one-handed use. Sometimes these are available in craft shops but also from catalogues that sell aids/adaptations. Many people are worried about flying after a stroke. Advice from the Stroke Association states that there is no absolute ban from flying after a stroke. However, each airline has its own rules about who it allows on their aeroplanes. The Stroke Association suggests flying is avoided for 2 weeks post stroke unless it is unavoidable. Oxygen pressure is lower in the 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 blood to thicken and thus increase the risk of blood clots forming. If possible, passengers should walk or stretch legs and drink plenty of water. Travel insurance needs to be examined closely to check there are no exclusions to travel or conditions not covered. There are insurance companies who provide cover for people with specific conditions/disabilities. Information is available from the websites of The Stroke Association and Different Strokes. It is advisable to inform the airline and airport of a person’s disability so that assistance can be booked in advance.

Getting out of the house and transport

Many leisure and social activities require transport either to get to an event or to get supplies. However, even just getting out of the house ‘for the sake of it’ is an important rehabilitation 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 even after rehabilitation (Logan et al.,2001).Community-basedresearchhasshownthatpeople are unable to use information given about outdoor mobility and transport in their area as it is often given whilst they are in hospital at a time when they thought they would be ‘back to normal in a couple of days’. It may take someone months to accept that they are never going to drive again. An occupational therapy outdoor mobility rehabilitation intervention has been developed and tested in Nottingham (Logan et al.,2004).Thestudyfoundthat people who had received the new intervention, which involved the patient practising outside with a therapist, were twice as likely to go out afterwards as those who had 184 Occupational Therapy and Stroke received the routine rehabilitation programme. The routine programme was verbal advice and written information. Further evaluation is taking place in other parts of the UK and Australia. To replicate the intervention in your area, it is important to find rehabilitation staff who are knowledgeable about local transport services, buses, Dial-A-Ride, taxi, voluntary transport, community services, scooter, shop mobility, trains, trams, etc. The patient must want to get out more often and an intervention programme must target one main 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 backward chaining can be used until the patient can complete the activity without the rehabilitation staff. They do not have to be alone and in fact it may be part of the intervention to get help for the patient or to use extra money to use a taxi instead of owning a car. One of the main parts of the intervention is the repetitive practising of the task, actually going on 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 2 hours long. It may seem an intensive intervention but there is evidence that it works and evidence 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 as- sistance is available, for example, at the train station when changing platforms. Discounts on fares are available via the Disabled Persons Railcard and local bus passes. Two of the national breakdown services, the Automobile Association (AA) and the Royal Automobile Association (RAC), provide information for travel with a disability in 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 format on their website. There are several travel companies which provide advice or can arrange holidays for disabled people. Some of those listed on the Internet include companies such as Accessible Travel, Access Travel and Tourism For All. There are also specialist facilities in the UK that provide holidays for disabled people and their families such as The Calvert Trust and The Winged Fellowship. The Stroke Association and Different Strokes can provide contact 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 is r always 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 and r email. Encourage help and support from family and friends. Tap into local resources such as r voluntary agencies for additional help. Keep a box file of local resources and facilities, for example: r –Localclubs. – Dial-A-Ride services, voluntary drivers, specialist transport services. –Travelagenciesspecialisinginholidayaccommodationforthedisabled. –Swimmingsessionsforthedisabled. Resettlement 185

–Fishingsitesfordisabledfishermen. –Riding-for-the-disabledstables. Browse through specialist equipment catalogues which may give you more ideas for r hobbies. Contact national organisations for local contacts if there are difficulties accessing r facilities. Funding! Consider specific charities and local groups such as the Hospital League of r Friends, and Rotary Clubs for specialist one-off items for individuals. Encourage the patient’s family to consider buying expensive items, such as gardening equipment for Birthday or Christmas presents. Be aware of therapy myths. For example, knitting does not necessarily increase spas- r ticity. Do not be afraid of taking people outside, even a walk to the neighbours. r Practise activities many times instead of just giving verbal and written information. r Activities may have to be practised over and over again, so it is helpful to enlist the help of others to prevent therapist boredom, then go back and review the situation.

Driving after stroke

Carter (2006) reported that only 30–40% of people who suffered a stroke were able to resume driving, as stroke can result in impairments in any combination of the follow- ing – memory, attention, decision making, executive functions, visual neglect, visual perception, communication, sensory and motor function. Therefore, all these functions should be assessed to establish an individual’s ability to return to driving. The impor- tance of cognitive function on driving ability was highlighted by Morris (2007) as the ability to ‘perceive, assimilate, organise and manipulate information to enable reasoning and problem solving’. These skills require visual perception and executive function for the individual to make sense of the environment. Despite this, there are no documented standards of cognitive function required for driving published by the Driving Vehicle Li- censing Agency (DVLA) and no standardisation of assessments carried out in the Driving Assessment Centres around the UK (Morris, 2007). After a stroke or Transient Ischaemic Attack (TIA), patients should not drive for at least 1 month. After that, if a GP or consultant feels they are fit to drive, then they can resume. They may assess visual and physical impairments within their surgery but cognitive ability is often overlooked. However, if the doctor does not believe they are fit to drive, then the patient must inform DVLA and their insurance company and they must not drive. The DVLA will send a questionnaire to the patient requesting more information and asking permission to contact their doctor, if necessary. The DVLA base their decision on the information patients and GP/consultant provide. They take into consideration the following factors – permanent damage to vision, problems with memory, concentration and judgement, slow reactions in an emergency, spasm in a paralysed arm which cannot be controlled and seizures/convulsions. If the GP/consultant is unable to make the decision about fitness to drive or it is unclear to DVLA, they will ask a GP to independently assess on their behalf. If this is inconclusive, DVLA will request an assessment by a local 186 Occupational Therapy and Stroke accredited mobility centre or, if there is not one near the patient’s home, for a free driving test. The assessment at an accredited mobility centre is free if DVLA arranges it. They assess physical, visual and cognitive aspects of driving ability. The Forum of Mobility Centres has 17 accredited centres across the UK. Their contact details are on their website or via freephone. They also produce a range of Ricability guides in conjunction with other organisations 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 decision about whether the patient can drive or not which can take a few months. The patient then needs to inform their insurance company of the decision. Research has suggested that cognitive ability plays a vital role in driving performance after brain damage (Nouri et al.,1987).However,thereremainssomeuncertaintyabout which cognitive impairment needs to be assessed and what is predictive of driving out- come. Some occupational therapists use the SDSA (Nouri & Lincoln, 1994). However, an unpublished report by J Sentinella and L Reed on the Department of Transport website recommends that the SDSA is used as a screening tool in conjunction with other cognitive assessments. Other therapists use different parts of standardised cognitive assessments to test memory, executive function, attention and visual perception. These can include sub-tests from the BADS (Wilson et al., 1996), TEA (Robertson et al., 1994), Visual Object and Space Perception Battery (VOSP) (Warrington and James, 1991) and Hayling and Brixton Tests (Burgess and Shallice, 1997). A report can be written following these assessments and sent to the GP to give him/her further information on a patient’s ability to drive. It is also advisable for patients to have an eye test after a stroke, particularly from an optician who carries out a visual field test to look for specific impairments such as 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 Living Allowance or the higher rate of Attendance Allowance. In some areas, occupational therapists working in social services can complete the application forms with patients. The College of Occupational Therapists have also published guidance on ‘Confiden- tiality and a service user’s fitness to drive’ (College of Occupational Therapists, 2007, briefing no. 26).

Vocational rehabilitation

Surveys have found that between 40% and 75% people would like to work (Wozniak and Kittner, 2002; Different Strokes, 2006). From these papers we would estimate that there are 13 750 people under 65 years of age who want to work and then there are those over 65 years of age who in the future may wish to remain in employment. Although it is important financially that as many people as possible can access work (stroke costs £7 billion a year (National Audit Office, 2005)), it is also important that people are able to undertake education, employment, re-training and voluntary work to improve their quality of 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 187 defined as a process ‘whereby those disadvantaged by illness or disability can be enabled to access, maintain, or return to employment, or other useful occupation’ (Tyerman and Meehan, 2004). VR is now considered by most to be a skilled intervention technique that should be completed by people who are trained in this field. Occupational therapists would seem to be the perfect profession to become experts in this type of rehabilitation but there are also specialist companies who offer these services. The Government Department of Work and Pensions (DWP) is taking the lead role in VR at a national level and the British Society of Rehabilitation Medicine has produced a useful report called Vocational Rehabilitation, 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 who wish 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 to help disable people select, obtain and keep jobs as well as helping employers develop good recruitment policies. These advisors have access to a number of programmes that can assist individuals at different stages. As well as providing a work assessment service they can advise on training to update and gain new skills and work opportunities in asupportedenvironment.Ifthepersonisalreadyinemploymenttheywillliaisewith the employer, assess the work environment and assist with the purchase of necessary specialised equipment. They will also support the employee back into work. Usually for people who have had a stroke, it is the rehabilitation team that assesses the patient in the first place, seek out the relevant local support and talk to the patient about their work. The Stroke Association’s leaflet Getting Back to Work is a good way to introduce the topic on the hospital ward or in the community. Traditionally the initial period of rehabilitation following a stroke concentrated on enabling the patient to return home to an environment in which he/she could operate as safely and independently as possible. It has now been recognised that considering and responding to vocational or work-related issues early in the rehabilitation process can be very beneficial (Royal College of Physicians, 2004). It is recommended that personalised care plans that aim to get the stroke survivor fit for work are in place before the person who has had the stroke leaves hospital. These plans should be in line with pathways for return to work in place at the 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 against redundancy or retirement by engaging early with employers and VR programmes. The term work is often only associated with paid employment whereas unpaid work may be of equal importance to the individual. Unpaid work may include such areas as voluntary work or being on a committee. Both paid and unpaid work fulfils a diversity of needs for the individual, and some of the many benefits of work are listed below:

Increased self-esteem. r Maintenance of routines and habits. r Participation in a productive activity. r Involvement in a socially accepted role that provides value to the community. r Having ‘a reason to get up in the morning’. r Challenging someone to expand their horizons. r 188 Occupational Therapy and Stroke

VR is having a great deal of attention at present and although the recognised pro- grammes are directed at people with cardiac illness, mental illness and muscular–skeletal disabilities, the principals are transferable to people who have had a stroke. In the past occupational therapists would have organised for the patient to take part in work experi- ence as near to what they would experience when they returned to work. Occupational therapy departments had heavy and light work shops where mock work conditions could be used as an assessment, for example, of standing ability, concentration, hand function and tolerance. It is more often now that stroke patients are treated in their own homes and do not return to out-patient departments. However, occupational therapists can still assist the patient in establishing realistic goals and expectations towards work and produce a written joint plan of action. They can encourage discussion with the family, carers and employers. Most employers are happy to consider a staged return to work, employing the patient in a different role or providing additional training or support. Contact with the employer at an early stage is important in order to establish links. The patient may wish to do this or may need assistance from the rehabilitation team. However, entering the paid work environment may not always be realistic, feasible or desired 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 positions are available and how appropriate they are to the individual. Again the components of the tasks to be undertaken need to be analysed and a plan of action made. Many people who have had a stroke will take some time to get back to work and they may be assessed with the Personal Capability Assessment (DWP, 2007) to test their long-term incapacity for work for social security. The occupational therapist may need to be involved as they are most likely to know the impairments of individual people who have had a stroke.

Resuming sexual activity

As rehabilitation of stroke patients constantly improves, many new techniques develop but some activities are often neglected because of lack of research, lack or rehabilitation knowledge or because patients themselves do not wish to raise the subject. One such area is a return to their normal sexual activity. Generally, this is not routinely discussed with patients as part of their rehabilitation, although for many, it plays an important role in their life and discussion should be included in the assessment process. There is some information in stroke books, but this is not always readily available to the patient and their partner and the information is not always applicable to their specific needs. The Stroke Association can provide a leaflet, entitled “Sex after Stroke” Fact sheet 31 which can be downloaded from their website which includes the main points identified by patients and partners. This leaflet should be made available to all stroke patients and their partners both in hospital and in the community and may initiate a conversation about sexual 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 this decline: physical changes in the brain that may reduce the sexual urge; physical changes to the body that may make it difficult to move; psychological changes that make people Resettlement 189 not want to have sex. Stroke can cause physical limitations that influence body positioning and movement during sex which can lead to a reduction in sexual activity, misery and frustration. Other physical changes such as incontinence, drooling, emotional liability may 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 myocar- dial infarction then little changed after stroke; this may be because pre-existing vascular disorders had already caused erectile difficulties or because the antihypertensive agents commonly given to stroke patients inhibit erections, or because some medications such as beta-blockers also reduce desire. As well as physical difficulties, psychosocial impair- ments and depression may affect the will to engage in sexual relationships; however, these may not be recorded till late after stroke as patients may be unwilling to talk about sexual difficulties. Mood disorders, such as depression and anxiety are commonly observed after astroke,frequentlyaffectingsexualrelationshipsandsexualfunctionandconversely, sexual dysfunction may lead to depression. After a stroke, generally both patients and partners want to know whether resuming sexual activity will cause another stroke or epileptic fit and do not know whom to ap- proach for 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 another stroke. Other reasons for not continuing in sexual activity include lack of interest or motivation from one or both of the couple; physical incapacity of the patient; difficulty getting in a comfortable position for both of the couple; difficulty getting their part- ner aroused and difficulties due to sensory impairments on the patient’s affected side (Edmans, 1998). Patients and partners reported that they would have liked to receive information on why problems occurred in resuming sexual activity after a stroke and how long they were likely to last. Some also reported that they would have liked there to be more opportunity to discuss their fears and problems, especially after discharge from hospital. Sexual activity is a subject which is important to both patients and partners, and should be included in stroke rehabilitation. However, despite this, it is still not clear cut this should be part of whose role or whether it should be part of the role of all staff involved in the rehabilitation of stroke patients. Patients and partners should have the opportunity to choose who they wish to undertake this role. Occupational therapists are often approached to discuss sexual activity whilst they are dealing with other personal activities of daily living. This chance to contribute to part of patient’s lives often ignored, should be embraced with knowledge and understanding. Patients and partners need to know that returning to their normal sexual activity is considered routinely as an aspect of stroke rehabilitation. They also need to know there is the opportunity to discuss their sexual activity either alone or in couples, at a time which is appropriate to their needs.

Stroke education

The National Stroke Strategy (DH, 2007) recommends a range of programmes to support self-management skills after stroke to reduce long-term care costs. Information is also 190 Occupational Therapy and Stroke available in ‘Supporting People with Long-Term Conditions to Self-Care: A Guide to Developing Local Strategies and Good Practice’ (DH, 2006). Patients and carers’ understanding of stroke is often quite poor. Information is available from The Stroke Association, Chest Heart and Stroke Scotland and Northern Ireland Chest, Heart and Stroke Association. Occupational therapists can play an important role in educating patients about their disability, its causes and long-term effects, both on a formal and informal basis. The aim is to provide information and to empower patients by allowing 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 providing information, 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 throughout patients’ period of rehabilitation. Some rehabilitation services run their own educational programmes for patients and/or carers on topics such as what a stroke is and its effects. The content of these varies according to the type of unit or service the patients are attending. There is an organisation called ‘steppingoutuk’ which runs formal educational programmes over a set number of sessions for patients and carers. They offer training to health care professionals to run courses locally. More information is available from their website. Awidevarietyofeducationalinformationforpatientsandfamilyaboutstrokeis available from the two main charities, The Stroke Association and Different Strokes, via the Internet and in paper format. Some of the Stroke Association leaflets are available in other languages. Local support groups can also be a source of information for patients, usually on a more informal basis. The Stroke Association and Different Strokes have groups in most areas of the UK.

Self-evaluation questions

1. 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 stroke care. 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 a stroke? 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 10 Evaluation Fiona Coupar and Judi Edmans

This chapter includes: Record keeping r Standardised assessments r Evidence-based practice r Outcome measures r Standards r Audit r Self-evaluation questions r Record keeping

The Public Records Act 1958 (Public Records Office, 1958) states that a medical record is anything that has been created or gathered as a result of the work of a health care professional; it is a compilation of data. The following are all considered as part of a medical record:

Register. r Prescription, drug chart. r Diary. r X-ray. r Audio, video, dvd. r Rough notes. r The purpose of record keeping is to:

Form the basis for planning patient care and intervention. r Provide feedback on progress and suggest action. r Meet legal requirements, professional or statutory. r Provide information for clinical management, resource management, evaluation, re- r search, quality assurance. Assist in the continuity of care. r Provide written evidence that a service has been delivered (Quantum Development, r 2003). 192 Occupational Therapy and Stroke

Most complaints within the NHS are made due to the failure in communication. To ensure patient care is not flawed and communication improved, good record keeping is an 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 the original test is not erased, additions should be separately dated, signed and timed. In addition the occupational therapist needs to record any leaflets or pamphlets given and thank you cards/letters should be kept as evidence of satisfaction at the time. If leaflets are updated, old ones should be kept and all policies/standards and checklists achieved. Within a complaint or claim the occupational therapy records are your defence, remem- ber the 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. The standards also provide an audit tool to enable individuals to measure their practice and make any improvements as necessary. The record keeping standard includes:

Professional records Each 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 are signed and dated by the occupational therapist. All entries must be signed and dated by an occupational therapist and student/support staff entries countersigned. Occupational therapy staff should also be aware of local policies on record keeping and if electronic records are used staff must be aware of any guidance on use of the system.

Content The record should contain all information clearly identifying the patient, reason for referral other relevant professionals, medical and social history including the views of the patient and carers. The record must contain information on the occupational therapy assessment, goals and interventions (including any other relevant information from the multidisciplinary team). All reports and correspondence including work with carers will be documented. A discharge summary should be included regarding outcomes and any future arrangements.

Access Patients may have access to their records in accordance with legislation and the organi- sation’s policy. All records must be written in an understandable manner for those who will have legitimate access to them; these records must be available if required in an enquiry. Evaluation 193

Confidentiality – storage and disposal All 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 stored separately. All records must be kept for no less than that for NHS records for the equivalent patient group.

Methods of recording occupational therapy intervention Occupational therapy case notes can take many forms across a variety of clinical settings. They can either be unidisciplinary or multidisciplinary. Three of the most commonly used are: problem-orientated medical records, goal-directed notes and integrated care pathways.

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 dis- charge summary. The database contains personal and medical information about the patient. The problem list numbers the specific problems to be addressed by the occupa- tional therapist. The progress notes are only recorded when there is a change or there is some relevant information to be added. Progress is recorded under the headings:

Subjective – Information obtained from the patient, family or another health care professional. Objective – The therapist’s clinical observations and results of assessments-measures. Analysis – The therapist’s professional opinion of what happened during an intervention session. 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 in- formation on personal/domestic activities of daily living, mobility, transfers, cognition, perception, communication, upper limb function, current problems and future care.

Goal-directed notes There are many types of goal-directed notes used by occupational therapists on a uni- disciplinary and multidisciplinary basis. Goal setting is now commonly used in stroke rehabilitation within the multidisciplinary team. Goal planning should actively involve the patient and family/carers. Once the multidisciplinary team has completed their spe- cific assessments, the patient’s problems and needs can be identified, focusing on their strengths rather than their weaknesses. Long-term and short-term goals can be set. A 194 Occupational Therapy and Stroke goal 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? (What is 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 to achieve the goal.) 4. How well? What defines a successful outcome? How well is the client expected to achieve the task? What level/frequency of physical assistance or verbal prompting is acceptable? 5. By when? In what time frame?

The outcome of a goal can be scored in three possible ways – achieved, partially achieved or not achieved. If the outcome is one of the latter two, then a variance code can be applied to explain the reasons why this is the case. These can include issues relating to the 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 prob- lems, 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 com- munication problems. ACTOR (activity, patient’s observations, therapist’s observations, overall evaluation, re-planning) headings are used for the progress notes. Activity includes the facts of the activity. Patients’ observations are their subjective comments. Therapists’ observations are objective comments on the therapy carried out. Overall evaluation is the analysis of intervention. Finally, re-planning is the future plan, which has been set as a result of the intervention session.

Integrated care pathways Integrated care pathways are a well-established method of recording care on a multidis- ciplinary basis with patients following hip replacement or fractured neck of femur. They have also been used in the care of patients following myocardial infarction and a variety of surgical and gynaecological procedures. This form of documentation is now being used by multidisciplinary teams treating patients following stroke. An integrated care pathway is a record of care that focuses on agreed intervention and expected outcomes for a given patient diagnosis, symptom or procedure, within an identified time frame. It should be developed and written by the multidisciplinary team involved with the delivery of care to the patient. All professionals involved should have common understandings and ownership of the pathway. Outcomes must be agreed, achievable and evaluated at every stage. The documentation replaces all existing notes used by each profession. An integrated care pathway focuses on the ‘routine’ rather than the exception. When a detour from the care pathway occurs, a variance code is recorded. Evaluation 195

The four codes relate to the patient’s condition, the patient/family circumstances, the clinical and the internal/external system. In order for the implementation of an integrated care pathway to be successful, a total review of care delivery is required – organisational, training, development, effectiveness, quality, information and communication. Integrated care pathways can facilitate best practice and aid multidisciplinary commu- nication. They can also be used for research, clinical audit and as a risk management tool. An example of an integrated care pathway for stroke rehabilitation on the Nottingham Stroke Unit has previously been published (Edmans et al., 1997).

Pros and cons of multidisciplinary joint documentation Positive aspects of joint documentation Reduces duplication of notes, for example, front sheets/database, medical history, social r history, case conference information, family case conference information, discharge plans, washing and dressing, bathing, transfers, walking, home visits, etc., as only one set of notes written. Easier access to each others’ notes as only one set and therefore in one place, that is, r centralises all information about the patient. Improves communication as information written in one place by all of the multidisci- r plinary team. One comprehensive set of notes. r Improves goal setting as goals set weekly at case conference. r Less repetition of staff asking patients for the same information. r More focused care planning. r Improves handover of information between disciplines. r More coordinated discharge. r OVERALL EACH PERSON SHOULD WRITE LESS NOT MORE. r

Negative aspects of joint documentation Difficulty storing records in an accessible place for all professionals to gain access to r staff wanting to write in notes at the same time. Fear that detail of each professional’s input will be lost, such as information confidential r to a single discipline, for example, psychologists.

Standardised assessments

The use of standardised assessments (whether screening or detailed) will indicate the type(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 Stroke to 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 an established procedure for administration and scoring with normative data available for comparison. Athoroughassessmentusingbothstandardisedassessmentandfunctionalassessment will inform and direct the nature of the intervention required.

Pre-assessment checks Prior to conducting a standardised assessment, it is important to consider other modalities that may impact on the patient’s ability to complete the assessment. For example, if a patient has difficulty with any of the following, they may achieve lower scores on the assessment, due to impairments other than what is being assessed: Vision r –Acuity–clarityofvision. –Ocularmotorskills–abilitytomoveeyes. –Visualfields. Hearing. r Attention. r Memory. r Motivation and engagement. r Choosing assessments When choosing which assessments to use, it is also important to consider: The population involved in the standardisation of the assessment (i.e. was it standardised r with 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 admin- r istered by psychologists). Whether there is evidence of validity and reliability with norms for comparison. r How easy it is to administer and score the assessment. r Whether any pre-training is needed to use the assessment. r How easy it is to transport the assessment. r How much space and time is needed to administer the assessment. r The balance between the advantages and disadvantages of the assessment. r Test administration Prior to assessing patients using standardised assessments, it is recommended to: Be familiar with the assessment. r Understand what you are assessing and why. r Check that the patient has their correct glasses, hearing aid, etc. r Check whether the patient requires a visit to the toilet. r Evaluation 197

Check that patient understands why they are being assessed. r Prepare the room (preferably quiet, without interruptions or distractions). r Prepare the assessment materials. r Use a clipboard to record the scores out of the patient’s sight. r Record details of the patient’s behaviour and types of errors. r Analysis of assessments When analysing the assessment results, consider whether there was evidence of any of the following during the assessment, which may have affected the patient’s performance:

Comprehension. r Concentration. r Reasoning (executive function). r Memory. r Anxiety. r Depression. r Initiation. r Apraxia. r Hemianopia. r Differential diagnoses Astrokecanaffectanyareaofthebrainandthebraincontrolseverythingwedo.‘Doing’ requires a number of performance components and sometimes it is difficult to separate out what performance component has been affected by the stroke or what the key impairment is. However, some key impairments to look out for, which are often incorrectly identified, are discussed below.

Poor initiation Consider aspects such as memory of the task, selective attention, difficulty conceptualising the task, unable to recognise the environment or objects, poor planning, apraxia.

Poor memory/getting lost Consider attention to information, aphasia (comprehension or expressive capacity), visual impairments, visual inattention.

Use of objects Consider occipital lobe impairments, that is, affects of reduced information regarding texture, shape, colour, contrast, visual field impairments, visual inattention (not picking up sufficient information about the object for usage), agnosia, ideational apraxia. 198 Occupational Therapy and Stroke

Behavioural issues Perceptual impairments (the environment may not make sense to the patient so they do not know 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 put together a full picture of the patient, before making sweeping statements or labelling impairments.

Useful assessments Intervention and effectiveness Assessment of Motor and Process Skills (AMPS) (Fisher, 2006). r Canadian Occupational Performance Measure (COPM) (Law et al., 2005). r Motor performance Motricity Index (Collin and Wade, 1990). r Rivermead Motor Assessment (Lincoln and Leadbitter, 1979). r Nine-hole Peg Test (Kellor et al., 1971). r Activities of daily living Barthel ADL Index (Mahoney and Barthel, 1965; Collin et al., 1988). r Edmans ADL Index (Edmans and Webster, 1997). r Frenchay Activities Index (Holbrook and Skilbeck, 1983; Wade et al., 1985). r Functional Independence Measure (FIM) (Granger et al., 1986). r Northwick Park ADL Index (Benjamin, 1976). r Nottingham 10 point ADL Scale (Ebrahim et al., 1985). r Nottingham Extended ADL Scale (Nouri and Lincoln, 1987). r Rivermead ADL Assessment (Whiting and Lincoln, 1980; Lincoln and Edmans, 1990). r Sensation Erasmus MC Modifications to the (revised) NSA (Stolk-Hornsveld et al., 2006). r Nottingham Sensory Assessment (Lincoln et al., 1998b). r Rivermead Assessment of Somatosensory Performance (RASP) (Winward et al., 2002). r Stereognosis Subtest of the Chessington Occupational Therapy Neurological Assess- r ment Battery (COTNAB) (Tyerman et al., 1986).

Attention Test of Everyday Attention (TEA) (Robertson et al., 1994). r Cognition COTNAB (Tyerman et al., 1986). r Cognitive Assessment of Minnesota (CAM) (Rustard et al., 1993). r Evaluation 199

Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) (Itzkovich et al., r 1993). Middlesex Elderly Assessment of Mental State (MEAMS) (Golding, 1989). r Mini-Mental Status Examination (MMSE) (Folstein et al., 1975). r SF-36 (generic health status measure) (Garratt et al., 1993). r Memory Doors and People (Baddeley et al., 1994). r Rivermead Behavioural Memory Test (RBMT3) (Wilson et al., 2008). r Apraxia Kertesz Apraxia Test (Kertesz and Ferro, 1984). r Executive functions Behavioural Assessment of the Dysexecutive Syndrome (BADS) (Wilson et al., 1996). r Hayling and Brixton Tests (Burgess and Shallice, 1997). r Perception Baking Tray Test (Tham and Tegner, 1996). r Balloons Test (Edgeworth et al., 1998). r Behavioural Inattention Test (BIT) (Wilson et al., 1987). r Location Learning Test (Bucks et al., 2000). r Motor Free Visual Perceptual Battery (Ronald et al., 1972). r Occupational Therapy Adult Perceptual Screening Test (Cooke, 2005). r Repeatable Battery for the Assessment of Neurological Status (Randolph, 1998). r Rey Figure Copying Test (Rey, 1959; Meyers and Meyers, 1995). r Rivermead Perceptual Assessment Battery (RPAB) (Whiting et al., 1985; Lincoln and r Edmans, 1989). Visual Object and Space Perception Battery (VOSP) (Warrington and James, 1991). r Anxiety and depression General Health Questionnaire (Goldberg and Hiller, 1979). r Geriatric Depression Scale (Yesavage et al., 1983). r Hospital Anxiety and Depression Scale (Zigmond and Snaith, 1983). r Wakefield Depression Inventory (Snaith et al., 1971). r Driving Stroke Drivers Screening Assessment (Nouri and Lincoln, 1994). r Evidence-based practice (EBP)

Evidence-based medicine/practice is defined as the ‘...conscientious, explicit, and ju- dicious use of current best evidence in making decisions about the care of individual 200 Occupational Therapy and Stroke patients’ (Sackett et al., 1996). This process involves combining best existing research evidence, 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. r To ensure decisions about clinical services and interventions are driven by evidence of r efficacy and cost effectiveness. Personal experience and expertise can be misleading. r To ensure the provision of up-to-date interventions as clinical practice risks becoming r rapidly out of date. To provide effective and efficient interventions. r Stages of evidence-based practice EBP 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 prefer- ences). 5. Implement findings into clinical practice. 6. Evaluate outcomes.

Formulating a clear, relevant and focused question EBP always begin with identification of a particular problem or query. In order to complete EBP, this problem or query should be developed into a clear, focused and well-structured question. This can be achieved using the PICO structure:

P–Patientorproblem I – Intervention C–Comparisonintervention O–Outcome

For example, an occupational therapist may have a query relating to the effectiveness of 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 safe discharge for stroke patients? A clear, relevant and focused question makes the subsequent stages of EBP more straightforward. Once you have formed the question, you can think about 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 affect the type of research evidence that will provide the best answer and therefore the type of evidence that you want to search for. Evaluation 201

Searching for the best evidence Choosing the right evidence is of fundamental importance. There are several sources of evidence that you may consider using, to answer your question(s); people, textbooks, sci- entific literature and pre-appraised or secondary sources. Asking colleagues is convenient and accessible; however, their knowledge may not be evidence-based and they cannot give an answer to every question. Textbooks provide good background information, but are often out of date. Therefore evidence from scientific literature and/or pre-appraised or secondary sources is often required to answer clinical questions. When considering the evidence it is helpful to consider levels of evidence.

Levels of evidence Evidence comes in many forms and varies in quality. Depending on the type of question being 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 relating to different study designs and highlights the advantages and disadvantages of each study type. Usually the type of questions that occupational therapists ask relate to effects of inter- vention. The hierarchy of evidence relating to these types of question is: Systematic review of RCTs Randomised controlled trial Cohort studies Case-control studies Case series Expert opinion Randomised controlled trials and the systematic review of several randomised con- trolled trials are methods which are likely to tell us the effectiveness of a therapy interven- tion and have become the ‘gold standard’ for judging whether an intervention is beneficial or harmful (Sackett et al., 1996). Secondary sources of evidence are commonly considered to be the highest form of evidence, 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 Organi- r sation (ESO) guidelines. Evidence-based summaries: For example, Bandolier, Clinical Evidence, Health tech- r nology assessments (HTA). Systematic reviews: For example, Cochrane Library. r If a question cannot be answered using secondary sources, primary literature should be searched for. Primary sources of research evidence relates to scientific literature reporting primary studies. The most efficient method of locating scientific literature is through searching bibliographic databases such as Medline, Embase or CINAHL. Hand searching may supplement this process, as some relevant journals may not be indexed within these 202 Occupational Therapy and Stroke databases. Searching the literature can be daunting; however, librarians are experts in searching and can assist in locating the appropriate evidence. If no appropriate randomised controlled trials are available to answer a particular question, evidence from less robust studies, further down the hierarchy of evidence (cohort studies/case-controlled studies/case studies/anecdotal evidence) becomes the sources of evidence. It is important to remember that the lower down the hierarchy, the less reliable the evidence. Many areas of occupational therapy are still under-researched and therefore it may be possible that no good quality evidence exists to answer a particular question, in which case professional judgement has to be relied upon. However, it must be remembered that lack of evidence is not evidence of no effect.

Appraising the identified evidence Critical appraisal is the next essential component of EBP and involves assessing and interpreting evidence. It involves considering the evidence in terms of its validity, results and clinical relevance. Different study designs require different questions to be asked to assess the validity and applicability of the evidence. The Centre for Evidence-Based Medicine and Public Health Resource Unit (PHRU) have examples of critical appraisal questions 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? r What are the results? r Are the results applicable to own clinical practice? r Examples of specific questions relating to randomised controlled trials are as follows:

Questions relating to validity Were the patients randomised to different groups? r Were the groups similar at the start of the trial? r Apart from the intervention of interest were the groups treated equally? r Were all patients in the trial accounted for? And were they analysed according to the r group to which they were randomised? Were outcome measures objective or were the assessors and clinicians kept ‘blind’ to r which group each participant was in?

Questions relating to the results What are the results? r How precise are the results? r Do you believe the results? r Evaluation 203

Questions relating to applicability Can the results be applied to the local population? r Is the intervention feasible to my setting? r Do the results of this study fit with other available evidence? r

Implementing findings into clinical practice and evaluating outcomes Following critical appraisal and a decision that the evidence is valid and applicable, this evidence should then be implemented. The challenge is to apply EBP at the right time, in the right place and in the right way. However, implementing evidence into practice is not easy and a number of difficulties have been identified, including size and complexity of research, developing evidence-based clinical policy, applying evidence due to poor access to best evidence and guidelines, organisational barriers and low patient compliance with interventions (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 practice complies with the current evidence. If practices are not concurrent with the evidence what barriers can you identify to implementing the evidence? These barriers may include limited resources, lack of knowledge and abilities and patient preferences. How might these be overcome? If we are to offer the most effective interventions then it is essential that changes are made and the evidence is implemented. Where no guidelines exist, the EBP process can be followed to answer specific ques- tions. If relevant evidence is located it is then essential that consideration is given to how recommendations from the evidence may be implemented; for example, pulling together agroupofindividualsfromdifferentprofessionstoassistinbreakingdownbarriersand bringing about change. Bringing about change is not easy and a number of barriers still exist; however, bridging the barriers between research evidence and clinical decision making is essential. A number of incentives such as accurate summaries of evidence and guidelines assist in breaking down these barriers. Once research evidence is implemented it is vital that the impact of this is evaluated using relevant outcomes.

Outcome measures

The consequences of stroke on an individual’s functioning are often complex and varied in nature. Stroke not only effects neurological functioning, for example, movement/speech but may also lead to a dependence in activities of daily living and cognitive and perceptual difficulties. To enable effective clinical stroke management and research, careful assessment and evaluation of functioning is essential. To reflect the complex and varied nature of difficul- ties encountered after stroke, numerous outcome measures exist to assess the impact and outcome of stroke (Geyh et al., 2004). 204 Occupational Therapy and Stroke

Outcome measures are tools or instruments used to quantify the change in a patient due to an intervention, and allow for the evaluation of the effects of interventions to be estab- lished. Therefore, the measuring of outcomes is an essential component in determining therapeutic effectiveness and therefore is central to the provision of EBP (Van der Putten et al., 1999). Outcome measures can be classified as condition specific, for example, National Insti- tute for 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 accord- ing to the three categories; body function/structure, activity and participation, within the International 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 10.1 Categorisation of outcome measures within the ICF.

Body functions and structures Activities Participation

Beck Depression Action Research Arm Canadian Occupational • Inventory • Test • Behavioural Inattention Barthel Index Performance Measure • Test • • Canadian Neurological Berg Balance Scale London Handicap Scale • Scale • • Clock Drawing Test Box and Block Test Medical Outcomes Study • • • Short-Form 36 Fugl–Meyer Chedoke McMaster Nottingham Health Profile • Assessment • Stroke Assessment Scale • General Health Clinical Outcome Reintegration to Normal • Questionnaire 28 • Variables Scale • Living Index Geriatric Depression Functional Ambulation Stroke Adapted Sickness • Scale • Categories • Impact Profile Hospital Anxiety and Functional Independence Stroke Impact Scale • Depression Scale • Measure • Mini Mental State Frenchay Activities Index Stroke Specific Quality of • Examination • • Life Modified Ashworth Motor Assessment Scale • Scale • Motor Free Visual Nine-hole Peg Test • Perception Test • National Institutes of Rankin Handicap Scale • Health Stroke Scale • Orpington Prognostic Rivermead Mobility Scale • Scale • Timed Up and Go • Presented in Salter et al.(2008)–tablebasedonthatpresentedinRobertsandCounsell(1998)and Duncan et al.(2000).(ReproducedwithpermissionfromEBRSR:Evidence-BasedReviewofStroke Rehabilitation.) Evaluation 205

Table 10.2 Definitions of psychometric properties of a measure.

Criteria Definition

Appropriateness The match of the measure to the purpose/question under study. It must be decided what information is required and what use will be made of the information gathered (Wade, 1992) Reliability The ability of the measure to achieve the same result, if no real change has occurred. Reliability refers to the reproducibility and internal consistency of the measure, i.e. can the measure be repeated and achieve the same results? Reproducibility – concepts such as test–retest and interobserver reliability Validity The ability to measure what it is intended to measure. There are different types of validity, including face, content, construct and criterion. The validity of a measure can be difficult to determine Sensitivity/responsiveness The 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 which any improvement or deterioration will be identified Clinical usefulness How useful is the measure in terms of providing a meaningful score, i.e. meaningful for patient and therapist Clinical feasibility How feasible is the measure in terms of effort, burden, expense and disruption

Adapted from table in Salter et al.(2008).(ReproducedwithpermissionfromEBRSR:Evidence-Based Review of Stroke Rehabilitation.)

In addition to understanding what construct an outcome measure aims to assess, it is also necessary to evaluate the measure in terms of appropriateness, validity, reliability, sensitivity, specificity, clinical usefulness and feasibility in order to inform choice of outcome 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 outlined in Table 10.2.

Other considerations Standardised and non-standardised outcome measures – Standardised outcome measures have specified, standardised procedures for completion and scoring. These measures will usually have been tested for validity and reliability to ensure consistency in application of the measure. Additionally many measures will have been normatively standardised for scoring, over large populations. This means that therapists can compare patients’ scores against a normal range and to other patients with similar conditions. Non-standardised outcome measures have not been subjected to the same rigorous testing procedure and are therefore often of poor quality, and generalisation of scores from non-standardised measures is problematic. 206 Occupational Therapy and Stroke

Use of outcome measures –Outcomemeasurescanbeusedforanumberofreasons. Outcome measures can be used to evaluate: –Improvement. –Maintenance,forexample,offunction. –Reduction,forexample,ofpainordiscomfort. –Prevention,forexample,ofdisabilityordiscomfort. –Development/maturation. –Recovery,forexample,offunction. –Delay,forexample,inrateofdeterioration. Outcome measures should be routinely used by occupational therapists not only to evaluate their own practices but also to inform and motivate patients and carers and provide feedback to the multidisciplinary team.

Standards

The College of Occupational Therapists (2000a) define the following terms:

‘Clinical standards are broad statements which relate to the organisation and delivery of services (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 auditing services. Astandardisakeyaim,andcontainsvariouscriteriathatmustbemet.Itistakenthateach standard is only achieved when all of the criteria have been met. It is therefore crucial that the criteria 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 perfor- mance meets 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 Special- ist Section Neurological Practice and the Royal College of Physicians Profession Specific Stroke Audit group, provide the framework for evaluation of occupational therapy stroke services: Occupational Therapy Standards for Stroke Second Edition (Royal College of Physi- r cians and College of Occupational Therapists, 2008) – based on the National Clinical Guidelines for Stroke 3rd Edition. Profession Specific Stroke Audit Occupational Therapy Clinical Audit (Royal College r of Physicians Profession Specific Stroke Audit group, 2007a) – to audit the standards. Profession Specific Stroke Audit Organisational Audit (Royal College of Physicians r Profession Specific Stroke Audit group, 2007b) – to audit the standards. These three documents are all available from the College of Occupational Therapists Specialist Section Neurological Practice. Evaluation 207

Self-evaluation questions

1. Describe what a medical record is, its purpose and requirements. 2. Describe the different methods that can be used to record occupational therapy inter- vention and 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 Techniques

SELF-CARE ACTIVITIES Washing Putting soap onto flannel Put soap in a soap dish or on a dry cloth and wipe the flannel over the soap, use liquid soap dispenser or put shower gel in the water Wringing out flannel Put flannel round tap and twist ends of flannel together pulling flannel tight or use a small flannel and squeeze it out with one hand Putting toothpaste on Put toothbrush on a hard surface with the bristles pointing toothbrush up, then put toothpaste on it. Alternatively, hold the toothbrush handle in the mouth then put toothpaste on it with the unaffected hand. Flip top lids or pump action toothpaste dispensers may be easier than screw tops Opening tube of Wedge tube between knees or teeth or against solid, fixed toothpaste/hand cream, etc. objects and unscrew top with sound hand Cleaning dentures Wash dentures in the washbasin, by wedging them in the plughole or use a suction nail brush stuck to the side of the wash basin, or soak dentures in sterident overnight Shaving Electric razor is the easiest and safest method Cleaning nails Use suction nail brush/file Bathing/showering Getting in/out of bath Use bath board and seat with non-slip mat, grab rails may also be useful Washingbackinbath Putshowergelinbathwateranduseplasticjugtotip water over self Washing back in shower Tip shower gel on back of shoulders and water will wash it down back Scrubbing back Use a long-handled sponge or loofa Drying back Put loop tag onto one end of towel and attach this to a hook/similar to fix one end of towel, pull taut across back. Alternatively, put on a terry-towelling robe after washing Putting talc on Hold talc container between legs to open it, hold top end of talc container and tip it into hand, tip powder into small bowl and use powder puff or tip powder onto towel and pat towel with talc onto body Appendix 209

Dressing (see Chapter 5, Figures 5.13–5.15) Putting on bra/vest/jumper/ Lay garment on knees with the back uppermost, neck dress/shirt/blouse/cardigan/ furthest away from body and the sleeves hanging down the skirt outside of each leg, put affected arm down the sleeve and pull the sleeve up past elbow, put sound arm into the other sleeve and pull the jumper, etc. over head Bras Bras can be put on as shown above, provided they are elasticated and are fastened up first; alternatively, they can be adapted with Velcro to be front opening or use a looser support/sports bra Alternative method for Lay garment on knees with the inside of the shirt/blouse, putting on a shirt/blouse etc. uppermost and the neck/collar nearest body, and the sleeves hanging down the outside of each leg, put affected arm down the sleeve and pull the sleeve up past elbow, put sound arm into the other sleeve and pull the jumper, etc. over head Putting on tie aTuckthenarrowendofthetieinthetopofthetrousers. This secures the tie at that end b Wrap the tie round in the normal manner to make the knot and pull down into position Alternatively, leave the tie knot made up and loosen tie slightly to put on or take off over head. If all else fails, ties can be bought with ‘ready-made’ knots Removing all upper Gather each garment up from the back of the neck and garments pull it over head, then take arms out of garment Putting on pants/trousers/ Cross affected leg over sound leg and lean forwards to put socks/stockings/shoes each garment over affected foot. Uncross legs and reach down to put the garment over the sound foot. If unable to maintain sitting balance whilst moving the sound foot off the ground, keep the sound heel on the ground, while putting garments over the sound toes, then keep the sound toes on the ground while pulling the garment round the sound heel Pulling up trouser zips Hold zip end between thumb and index finger and push away from lower end of zip by holding lower end of zip taut with middle, ring and little fingers Putting on socks Open aperture with span of hand, reach down and place over toes Tying shoe laces aTieaknotatoneendofthelaceandthreaditthrough eyelets. This secures the lace at that end. If the person is able to use their right hand, start threading the lace with the knot on the left, and if the person is able to use their left hand, start threading the lace with the knot on the right bPullthelacethroughastightasiscomfortableandloop the free end of the lace over the last piece of threaded lace. The smaller the loop is made, the tighter the lace will be 210 Occupational Therapy and Stroke

cMakeasecondloopwiththefreeendofthelacethen pass it under the last piece of threaded lace and through the first loop. The smaller the loop is made, the tighter the lace will be d Pull the loop to the outside of the shoe to tighten it eAsecondloopcanbemade(optional)byputtingthumb and index finger through the loop. The second loop is made by picking up another piece of the loose end of the lace fThesecondloopcanbepulledthroughinthesameway as the first loop gTheexcesslacecanbetuckeddowninsidetheshoeat the side of the foot hAlternatively,theexcesslacecanbethreadedthrough the lace on the top of the shoe If unable to tie laces, springer lacers, no-bows or elastic laces may be used Loose fitting and stretchy fabrics make the task easier Adaptations may be made to garment with Velcro to provide wider openings or a long cord attached to zip fastenings to enable them to be pulled up INSTRUMENTAL ACTIVITIES Meal times Cutting up food Avarietyofspecialcutleryisavailable,e.g.rocker knife/cheese knife and non-slip mat under plate Stopping food moving off the Use plate guard or plate with a lip plate Buttering bread Use buttering board with non-slip mat underneath to hold bread steady Kitchen activities Stabilising object Use non-slip mat, pan holder on the stove, spike board, buttering board, belliclamp or wedge against solid, fixed objects. A damp jay cloth also works well as a non-slip mat Cutting up food Use spiked chopping boards, food processors or adapted knives Opening containers Use electric tin openers, mounted tin or jar openers, belliclamp or wedge object between knees, etc. Carrying items Use trolley or one-handed tray Meal preparation There are many pieces of equipment available to assist, e.g. spike board/vices to hold vegetables whilst peeling or chopping them Cleaning and laundry Hanging up washing Lower the wash line, throw item over wash line and then attach pegs or put pegs on first and then over wash line, then raise the line. Alternatively, use clothes drier Reaching for objects Long-handled tools facilitate ease of reach Picking up items from the Use an ‘Easy-Reach’, ‘Pick Up Stick’ or ‘Helping Hand’ floor Moving items around Use kitchen trolleys Appendix 211

Household Stopping telephone, etc. Put non-slip mat under telephone to stop it moving moving Writing Paper weight or heavy object to hold paper in place or use spring clipboard Threading needle Put needle into pincushion to hold it whilst threading or buy solid block needle threader Holding playing cards Use scrubbing brush/men’s hairbrush, lay on its back and stand cards in the bristles of the brush Reading a book Sit at a table with book open on the table, have a tray on your knee and hold book open on the tray or buy a book rest References

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Agnosia: Inability to recognise familiar objects perceived by the senses. Aphasia: Difficulty understanding language and/or expressing self – as a result of a brain injury. Apraxia: Inability to perform certain skilled purposeful movements despite having intact the relevant motor, sensory and coordination functions. Ataxia: Loss of coordination and smooth interplay between muscles in the cerebellum due 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 changes and prolonged positioning in a fixed posture. Dysarthria: Weakness or incoordination of the speech muscles, which prevents clear pronunciation of words. Dysphagia: Difficulty swallowing. Dystonia: Asymmetry of involuntary contracting muscles, resulting in unusual contor- tions of the body. Flaccidity: Absence of normal tension (tone) in the muscles. Hemianopia: Damage to the part of the brain which interprets visual information, result- ing in blindness of part of the visual field, although the patient’s eyes and optic tracts are undamaged. Hemiplegia: Paralysis affecting one side of the body. Heterotrophic ossification: Appearance of bone in soft tissues – often occurring in large joints, i.e. elbow, knee, ankle, in patients with severe brain injury and prolonged unconsciousness. Liability: Decreased ability to moderate the expression of emotion, e.g. person might burst into tears without feeling sad, or may laugh inappropriately in an upsetting situation. 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 Stroke

Spasticity: 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 left side of the body or the left side of the environment. Useful Books

Ada 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 Medical Books Ltd. Bobath B. (1986) Abnormal Postural Reflex Activity Caused by Brain Lesions. London: Heinemann Medical 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: Heinemann Physiotherapy. 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 Churchill Livingstone. 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: Blackwell Publishing Ltd. Hagedorn R. (1995) Occupational Therapy: Perspectives and Processes. Edinburgh: Churchill Livingstone. Halligan P, Wade D. (2007) Effectiveness of Rehabilitation for Cognitive Deficits. Oxford: Oxford University 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 Stroke

Lezak MD. (1995) Neuropsychological Assessment. New York: Oxford University Press. Miller E. (1985) Recovery and Management of Neuropsychological Impairments. Chichester: John Wiley 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 Occupational Therapists. 2nd edn. Thorofare, New Jersey: Slack Incorporated. Sohlberg M, Mateer C. (1989) Introduction in Cognitive Rehabilitation Theory and Practice. New York: 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 Medical Publications. Wade DT. (1992) Measurement in Neurological Rehabilitation. Oxford: Oxford Medical Publications. 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 of the Adult with Acquired Brain Injury. 4th edn. Thorofare, New Jersey: Slack Incorporated. Useful Organisations

We have included a list of useful organisations but cannot guarantee that their addresses or websites will not change over time.

Occupational therapy

College of Occupational Therapists 106-114 Borough High Street Southwark London SE1 1LB England www.cot.co.uk

Specialist Section Neurological Practice 106-114 Borough High Street Southwark London SE1 1LB England www.cot.co.uk/Homepage/Specialist Sections/COTSS - Neurological Practice

Stroke

The Stroke Association Stroke House 240 City Road London EC1V 2PR England www.stroke.org.uk 234 Occupational Therapy and Stroke

Chest, Heart and Stroke Scotland 65 North Castle Street Edinburgh EH2 3LT Scotland www.chss.org.uk

Northern Ireland Chest, Heart and Stroke Association 21 Dublin Road Belfast BT2 7HB Northern Ireland www.nichsa.com

Different Strokes Central Services 9CanonHarnettCourt Wolverton Mill Milton Keynes MK12 5NF England www.differentstrokes.co.uk

Age Concern www.ageconcern.org.uk

Help the Aged www.helptheaged.org.uk

Policies

World Health Organization www.who.int

Department of Health www.dh.gov.uk Useful Organisations 235

Royal College of Physicians 11 St Andrews Place Regents Park London NW1 4LE England www.rcplondon.ac.uk

Scottish Intercollegiate Guidelines Network www.sign.ac.uk

Scottish Government www.scotland.gov.uk

Scottish Health on the Web (SHOW) www.show.scot.nhs.uk

Welsh Assembly Government www.wales.gov.uk

Stroke Services Improvement Plan – Wales http://new.wales.gov.uk/topics/health/publications/health/circulars/2007/whc2007082? lang en =

Department of Health, Social Services and Public Safety, Northern Ireland www.dhsspsni.gov.uk/

European Stroke Organisation (ESO) www.eso-stroke.org

Skills for Health 2nd Floor Goldsmiths House Broad Plain Bristol BS2 0JP England www.skillsforhealth.org.uk 236 Occupational Therapy and Stroke

Stroke Competencies www.nes.scot.nhs.uk

Stroke Training and Awareness Resources (STARS) www.strokecorecompetencies.org

Evidence-Based Practice Bandolier – www.medicine.ox.ac.uk/bandolier Clinical evidence – http://clinicalevidence.bmj.com/ceweb/index.jsp Health technology assessment – www.ncchta.org Cochrane library – www.thecochranelibrary.org Critical appraisal skills programme – www.phru.nhs.uk/Pages/PHD/CASP.htm Effective health care bulletins – www.york.ac.uk/inst/crd/ehcb.htm Physiotherapy evidence database (PEDro) – www.pedro.fhs.usyd.edu.au OTseeker – www.otseeker.com/search.aspx iCAM (Integrating Complementary and Alternative Medicine) School of Integrated Health University of Westminster 115 New Cavendish Street London W1W 6UW England www.wmin.ac.uk Centre for Evidence Based Medicine Department of Primary Care Old Road Campus Headington Oxford OX3 7LF England www.cebm.net

Public Health Resource Unit (PHRU) 4150 Chancellor Court Oxford Business Park South Oxford OX4 2GX England www.phru.nhs.uk Useful Organisations 237

Assessments

Pearson Assessment (incorporating The Psychological Corporation and Thames Valley Test Company) Pearson Assessment Halley Court Jordan Hill Oxford OX2 8EJ England www.pearson-uk.com

GL Assessment (formerly NFER-Nelson) The Chiswick Centre 414 Chiswick High Road London W4 5TF England www.gl-assessment.co.uk

NFER The Mere Upton Park Slough Berks SL1 2DQ England www.nfer.ac.uk

Leisure

Gardening Thrive The Geoffrey Udall Centre Beech Hill Reading RG7 2AT England www.thrive.org.uk 238 Occupational Therapy and Stroke

Sport Sportability Laynes House 526-528 Watford Way London NW7 4RS England www.sportability.org.uk

Disability Sport Events Belle Vue Centre Pink Bank Lane Manchester M12 5GL England www.disabilitysport.org.uk

Golf

Society of One-Armed Golfers (SOAG) www.onearmgolf.org

Fishing

British Disabled Angling Association (BDAA) 9YewTreeRoad Delves Walsall West Midlands WS5 4NQ England www.bdaa.co.uk

Art

Conquest Art Centre Cox Lane Day Centre Cox Lane Useful Organisations 239

West Ewell Surrey KT19 9PL England www.conquestart.org

Ableize Virtual library for disability directory of disabled information aids and mobility services www.ableize.com

Travel and holidays

Accessible Travel and Leisure Avionics House Naas Lane Quedgeley Gloucester GL2 2SN England www.accessibletravel.co.uk

Access Travel (Lancs) Ltd. 6TheHillock Astley Lancashire M29 7GW England www.access-travel.co.uk

Tourism for All UK c/o Vitalise Shap Road Industrial Estate Shap Road Kendal Cumbria LA9 6NZ England www.tourismforall.org.uk

Index

Activities of daily living (instrumental), Transient ischaemic attack, 3 105–8 Classification of stroke, 4 Household duties, 105–8 Lacunar infarction, 4 Kitchen tasks, 105 Partial anterior circulation stroke, 4 Activities of daily living (self-care), Posterior circulation infarction, 4 100–5 Total anterior circulation stroke, 4 Dressing, 100–5 Clinical challenges, 109 Washing, 100–1 Cognition definition, 144 Anxiety, 83 Cognitive assessment, 144–7 Apraxia, 152–5 Cognitive functions, 144 Assessment, 87–90 Cognitive rehabilitation, 145–6 Activities of daily living, 90 Approaches, 145 Bed mobility, 87–8 Intervention, 145 Sitting, 88 Strategies, 145–6 Standardised assessments, 90 Communication, 77–80 Standing, 89 Community rehabilitation, 174–7 Transfers, 88–9 Aphasia, 77–8 Walking, 89 Dysarthria, 78 Ataxia, 110–1 Verbal apraxia, 78–9 Attention, 147–48 Auditory processing, 137–39 Damage that can occur in different areas Assessment, 138 of the brain, 13–19 Clinical challenges, 139 Definition of stroke, 1 Functional anatomy, 137 Definitions, 229–2 Functional observations, Depression, 82–3 138 Differential diagnoses, 197–198 Intervention, 138–39 Driving after stroke, 185–6 Review and evaluation, 139 Emotionalism, 83 Screening, 138 Equipment, 75–7 Bathing/showering, 76 Carers, 178–79 Eating, 77 Causes of stroke, 3 Meal preparation, 76 Haemorrhage, 3 Toileting, 76 Ischaemia, 3 Wheelchairs, 75 242 Index

Evidence-based practice (EBP), Neurophysical screening, 72 199–3 Psychosocial screening, 71 Appraising the identified evidence, International classification of functioning, 202–3 disability and health, 4–5 Evaluating outcomes, 203 Intervention, 75 Formulating a question, 200 Intervention approaches, 36–46 Implementing findings into clinical Adaptive (compensatory/functional) practice, 203 approach, 37 Levels of evidence, 201–2 Bilateral arm training/isokinematic Searching for the best evidence, 201 training approach, 45 Stages of evidence-based practice, 200 Cognitive rehabilitation approach, Executive dysfunction, 155–7 37–8 Constraint-induced movement therapy Face-arm-speech test, 2 (CIMT) approach, 44–5 Fatigue, 83–4 Electromyographic (bio) feedback, 46 Follow-up, 53 Functional electrical stimulation, 46 Frames of reference, 27–9 Mental imagery approach, 45–6 Behavioural frame of reference, 28 Movement science, 43–4 Biomechanical frame of reference, 27 Normal movement (Bobath-based Client-centred frame of reference, 27 approach), 38–41 Cognitive frame of reference, 28 Proprioceptive neuromuscular Cognitive perceptual frame of facilitation (PNF), 41–2 reference, 29 Restorative approach (remedial Motor control frame of reference, 27 approach), 36–7 Psychodynamic frame of reference, Robotics, 46 28–9 Rood approach, 42–3 Rehabilitative frame of reference, 27 Lability, 83 Getting out of the house, 183–5 Language, 151 Leisure rehabilitation, 181–3 Home visits, 173–4 Lifestyle and long-term management, Early supported discharge, 176 180–1 Hospital at home/community rehabilitation team, 175 Management principles and intervention, Intermediate care, 174–5 90 Rapid response, 175 Medical investigations following stroke, Residential rehabilitation, 175–6 6–7 Role of the occupational therapist, Blood tests, 6 176–7 Cardiac investigations, 7 Carotid ultrasound, 7 Impact of stroke, 1 Computerised tomography, 6 Initial assessment, 67–74 Magnetic resonance angiography, 7 Cognitive and perceptual screening, Magnetic resonance imaging, 6 67–71 Memory, 149–1 Functional assessment, 74 Methods of recording occupational Functional screening, 74 therapy intervention, 193–5 Motor screening, 72–3 Goal-directed notes, 193–4 Index 243

Integrated care pathways, 194–5 Eye patching, 169 Joint documentation, 195 Impaired midline awareness, 168 Problem-orientated medical records Prism glasses, 169–70 (POMR), 193 Tactile agnosia (stereognosis), 171–2 Models of practice, 25–7 Unilateral neglect, 168–69 Activities Therapy, 26 Visual agnosia, 170–1 The Australian Occupational Visual discrimination, 170 Performance Model (OPM(A)), 26 Perceptual intervention theories, 165–7 The Canadian Model of Occupational Attention-arousal theory, 166 Performance and Engagement Disengagement theory, 167 (CMOP-E), 25–6 Hemisphere specialisation theory, 166 The Kawa (River) Model, 26–7 Intentional mechanism theory, 166 The Model of Human Occupation Interhemisphere theory, 167 (MOHO), 25 Policy documents relating to stroke, Mood, 81–2 13–23 Motor planning and apraxia, 151–2 Guidelines, 22–3 National services framework for older Neuroanatomy, 9–13 people, 13–14 Neurone structure, 29–30 Stroke strategies, 19–22 Neuroplasticity, 29 Positioning the early stroke patient, 91–7 Normal perception, 158–62 In a chair, 93–6 In bed, 92–3 Occupational therapy process, 47–52 Perch sitting, 96–7 Assessment, 47 Prior to assessment, 64 Evaluation, 52 Basic checklist, 65–6 Goal setting, 47–9 Information gathering, 64 Interventions, 51–2 Initial interview, 66–7 Oedema, 113–4 Procedural reasoning, 53–9 Olfactory and gustatory processing, Acute stroke units (ASU) (hyperacute 141–3 care), 55–7 Assessment, 141 Community rehabilitation and Functional anatomy, 141 resettlement, 59 Intervention, 141 Early supported discharge (ESD), 58 Review and evaluation, 142 Health promotion, 59 One-handed techniques, 108, 208–11 Neurovascular clinics, 53–5 Outcome measures, 203–6 Subacute/inpatient rehabilitation units, 57–8 Perception definition, 158 Professional duties, 60–63 Perceptual assessment, 162–5 Code of conduct, 60 Perceptual impairments, 160–2 Health Professions Council (HPC) Agnosia, 161–2 competencies, 60–61 Body scheme, 161 NHS knowledge and skills framework Visual discrimination, 161 (NHS KSF), 61–2 Perceptual intervention strategies, 167–72 Skills for health, 62 Body scheme, 167–68 Stroke-specific education framework Constraint-induced movement therapy, (SSEF), 62–3 71 Pusher syndrome/overuse, 109–10 244 Index

Record keeping, 191–3 Doors and People, 199 References, 212–28 Edmans ADL index, 198 Resuming sexual activity, 188–89 Erasmus MC Modifications to the (revised) NSA, 198 Secondary prevention, 7–9 Frenchay Activities Index, 198 Anticoagulants, 8 Functional Independence Measure Antiplatelet agents, 8 (FIM), 198 Blood pressure, 8 General Health Questionnaire, 199 Carotid endarterectomy, 9 Geriatric Depression Scale, 199 Hyperlipidaemia, 8 Hayling and Brixton Tests, 199 Preventative neurosurgery, 9 Hospital Anxiety and Depression scale, Social participation, 181 199 Somatosensory processing, 127–37 Kertesz Apraxia Test, 199 Adaptive (compensatory/functional), Location Learning Test, 199 136 Loewenstein Occupational Therapy Assessment, 130 Cognitive Assessment (LOTCA), Clinical challenges, 136–7 199 Functional anatomy, 127–9 Middlesex Elderly Assessment of Functional observations, 130 Mental State (MEAMS), 199 Intervention, 133–4 Mini-Mental Status Examination Restorative (remedial), 134–6 (MMSE), 199 Review and evaluation, 136 Motor Free Visual Perceptual Battery, Screening, 130–3 199 Standardised assessments, 133 Motricity Index, 198 Theoretical approach, 129–30 Nine-hole Peg Test, 198 Splinting, 114–6 Northwick Park ADL index, 198 Standardised assessments, 90, 195–7 Nottingham 10 point ADL scale, 198 Administration, 196–7 Nottingham extended ADL scale, 198 Assessment analysis, 197 Nottingham Sensory Assessment, 198 Assessment checklist, 196 Occupational Therapy Adult Assessment choice, 196 Perceptual Screening Test, 199 Assessment of Motor and Process Repeatable Battery for the Assessment Skills (AMPS), 198 of Neurological Status, 199 Baking Tray Test, 199 Rey Figure Copying Test, 199 Balloons Test, 199 Rivermead ADL assessment, 198 Barthel ADL Index, 198 Rivermead Assessment of Behavioural Assessment of the Somatosensory Performance Dysexecutive Syndrome (BADS), (RASP), 198 199 Rivermead Behavioural Memory Test Behavioural Inattention Test (BIT), 199 (RBMT3), 199 Canadian Occupational Performance Rivermead Motor Assessment, 198 Measure (COPM), 198 Rivermead Perceptual Assessment Chessington Occupational Therapy Battery (RPAB), 199 Neurological Assessment Battery SF-36 (generic health status measure), (COTNAB), 198 199 Cognitive Assessment of Minnesota Stroke Drivers Screening Assessment, (CAM), 198 199 Index 245

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