1. 1. UNIVERSITI TEKNOLOGI MARA (UiTM) AZIMAH BINTI HASSAN 940507-02-5320 DIPLOMA IN OCCUPATIONAL THERAPY
2. 2. DEFINITION OF CVA Sudden death of some brain cells due to lack of oxygen when the blood flow to the brain is impaired by blockage or rupture of an artery to the brain. A CVA is also referred to as a stroke. Retrieved from www.thestrokefoundation.com Symptoms of stroke depend on area of brain affected
3. 3. DISRUPTION IN MIDDLE CEREBRAL ARTERY Contralateral hemiplegia Contralateral hemisensory loss Ideational apraxia Depression Lack of judgement
4. 4. TYPES OF CVA TIA (Transient Ischemic Attack) - known as mini stroke - temporary blockage of artery Ischemic - blockage of artery - 2 types: embolic and thrombotic Hemorrhagic - ruptured of blood vessel - 2 types: intra-cerebral and subarachnoid
5. 5. BRUNNSTROMS RECOVERY STAGES OF HAND STAGE III Mass grasp or hook grasp. No voluntary finger extension. No voluntary release. STAGE II Little or no active finger flexion STAGE I Flaccidity STAGE VI All types of prehension. STAGE V Palmar prehension (spherical and cylindrical grasp). Voluntary finger extension in variable ROM. STAGE IV Lateral prehension (thumb release). Semivoluntary finger extension in small ROM.
6. 6. DEMOGRAPHIC DATA Name : Mrs Y Address : Kg. Baru, Gurun Age : 56 Years Old Sex : Female Race : Chinese Religion : Buddha Marital Status : Widow Job : Plumbing contractor Date of Onset : 10/12/2014 @ 8.30pm Date of Admission : 10/12/2014 @ 9.17pm Date of referral : 22/12/2014 Dominant Hand : Right Hand Affected Hand : Left Hand Diagnosis : Right MCA Ischemic Stroke with Left Hemiparesis
7. 7. CASE HISTORY Patient had a stroke at her home Experienced numbness and weakness at her left arm Attempted to go to the bathroom and collapsed on the floor Noticed by her maid as the left side of her face was drooping Admitted to primary care hospital for almost 2 weeks Presented with right frontal-parietal infarct through CT scan Faced difficulty to move the left side of her body Movement gradually returned, but currently she still has weakness on her left extremity.
8. 8. MEDICAL HISTORY Patient had underlying hypertension Exhibited reactive depression since her recent hospitalization Prescribed with - Atenolol 50 mg PO bid - Clonidine 0.1 mg PO bid - Aspirin 325 mg PO qd Referred to occupational therapy service after second week post-admission
9. 9. WORK HISTORY Previously worked as a plumbing contractor Provides plumbing service and installation for residential and commercial customers Experienced tired and stress with her commitment: - obtaining licenses - preparing written work cost estimates and negotiate contracts
10. 10. SOCIAL HISTORY Before recent hospitalization, patient lived alone at her home in an urban neighborhood Spent her weekend by participating in martial art class Often went for holiday with her children when they return home Developed several interests including reading magazines and cooking
11. 11. FAMILY HISTORY + 59 y/0 56 y/0 32 y/0 29 y/0 24 y/0 Patient is a widow and has three children All of her children are working and live in cities One of her children live in nearby town and visits weekly Has history of hypertension from maternal side
12. 12. EVALUATION
13. 13. SUBJECTIVE ASSESSMENT GENERAL APPEARANCE - Patient came to department with her maid. - Patient appeared neat and tidy. SPEECH - Patient spoke coherently with adequate quantities of speech. EYE CONTACT - Patient able to make eye contact with therapist and others. MOBILITY - Patient ambulated to department by using quadripod walking stick
14. 14. OBJECTIVE ASSESMENT
15. 15. Occupational Performance Area Assessments ADL Modified Barthel Index (MBI) Work Role Checklist Leisure Interest Checklist Occupational Performance Component Assessments Cognitive Mini Mental State Examination Sensory Light touch 2 - point discrimination Pain Semmes-Weinstein Monofilaments Test 2 Point Discriminator Visual Analog Scale (VAS) Neuromuscular Range of Motion (ROM) Muscle strength Muscle tone Balance Coordination Upper Extremity Hand ROM and Wrist Chart Manual Muscle Testing (MMT) Modified Ashworth Scale (MAS) Berg Balance Scale Coordination test Psychological Beck s Depression Inventory Psychosocial Interview and observation
16. 16. OCCUPATIONAL PERFORMANCE AREA
17. 17. Activity Criteria Initial assessment Personal hygiene Unable to perform the task (0) Substantial help required (1) Moderate help required (3) Minimal help required (4) Fully independent (5) 3 Bathing 5 Feeding Unable to perform the task (0) Substantial help required (2) Moderate help required (5) Minimal help required (8) Fully independent (10) 10 Toilet 10 Stair climbing 8 Dressing 8 Bowel control 10 Bladder control 10 Chair/bed transfer Unable to perform the task (0) Substantial help required (3) Moderate help required (8) Minimal help required (12) Fully independent (15) 12 Ambulation 15 Total 92/100 i. Activity of Daily Living (ADL) by using MBI
18. 18. MBI INTERPRETATION Minimal dependency level Total hours of help required per week is less than 10 hours In personal hygiene (clipping nails), patient has difficulty to clip nail at her right hand due to poor strength at left wrist and finger musculature In dressing, patient has difficulty to don blouse due to poor strength at her left upper extremity In stair climbing, patient need moderate assistance and supervision due to poor balance
19. 19. ii) Work by using Role Checklist Before recent hospitalization, patient was a plumbing contractor However, after having stroke patient stopped working and stayed at home with her maid According to Role Checklist, patient does not want continue to work Role Past Present Future Student Worker Volunteer Caregiver Home maintainer Friend Family member Religious participant Hobbyist Participant in organization
20. 20. iii) Leisure by using Interest Checklist According to Interest Checklist, patient still interested to involve in: participating martial art class during weekend with other peers cooking and reading magazines during free time
21. 21. OCCUPATIONAL PERFORMANCE COMPONENT
22. 22. DOMAIN COMMENT SCORE ORIENTATION Year, date, day, month = Client able to state season. Place = Client recognize and know where she is. 5/5 5/5 REGISTRATION Client can names 3 different object (bed, apple, shoe) in the first trial 3/3 ATTENTION & CALCULATION Client need to calculate 20 - 3 for 5 times. Client able to give 5 correct answer s respectively 5/5 RECALL Client able to recall 3 objects correctly. 3/3 LANGUAGE Able to name object (pencil & watch). Able to repeat Tidak mungkin dan tidak mustahil. Able to follow instruction given ambil kertas dengan tangan kanan, lipat dua dan letakkan di atas lantai. Client able to read tutup mata anda and follow what it said. Client able to make a sentence. Client able to copy picture exactly. 2/2 1/1 3/3 1/1 1/1 1/1 TOTAL SCORE Interpretation, : mild to moderate cognitive impairment. 30/30 ( Source : www.medicine.uiowa.edu/igec/tools/cognitive/MMSE.pdf )
23. 23. i. SENSORY Color Monofilament size Force in grams (g) Cutaneous Sensory Perception Green 2.83 0.07 Normal light touch Blue 3.61 0.2 Diminished light touch Purple / pink 4.31 2.0 Diminished protective sensation Red 4.56 4.0 Loss of protective sensation Orange 6.65 200 Untestable
24. 24. Light Touch by using Semmes-Weinstein Monofilaments Test - Patient perceived 3.61 at major part of both hands due to numbness - Pain by using Visual Analog Numerical Scale (VAS) - Patient marked score 0/10 during rest at left upper limb - Patient marked score 1/10 during passive shoulder flexion due to stiffness Ulnar nerve Median nerve Radial nerve Right hand Palmar Dorsal 3.61 3.61 2.83 3.61 3.61 3.61 Left hand Palmar Dorsal 3.61 3.61 2.83 3.61 2.83 3.61
25. 25. ii. NEURO-MUSCULOSKELETAL Range of Motion - patient has full AROM and PROM at right extremity - patient has limited AROM at left upper limb - patient has full PROM at left upper limb and both lower limb
26. 26. Muscle strength through MMT (Manual Muscle Testing) Location Flexion Extension Upper limb Score Score Shoulder 2/5 2/5 Elbow 2/5 2/5 Wrist 2/5 1/5 Fingers 1/5 1/5
27. 27. Muscle Tone by using Modified Ashworth Scale GRADE DESCRIPTION 0 Normal tone 1 Slight increase in muscle tone, manifested by catch and release at the end of ROM when the affected part is moved in flexion or extension 2 Slight increase in muscle tone manifested by catch, followed by minimal resistance through out the remainder (less than half of the ROM) 3 More marked increase in muscle tone through most of the ROM but affected part easily moved 4 Considerable increase in muscle tone, passive movement difficult 5 Affected part rigid in flexion and extension Patient is categorized in Grade 3 Patient has marked increase in muscle tone through most of the ROM but the left upper limb is easily moved
28. 28. Balance by Using Berg Balance Scale Sitting to standing 1 Standing unsupported 3 Sitting with back unsupported but feet supported on floor on a stool 4 Standing to sitting 4 Transfers 3 Standing unsupported with eyes closed 3 Standing unsupported with feet together 1 Reaching forward with outstretched arm while standing 1 Pick up object form the floor from a standing position 1 Turning behind over left and right shoulders while standing 1 Turn 360 degrees 1 Place alternate foot on step or stool while standing unsupported 0 Standing unsupported one foot in front 0
29. 29. Interpretation : According to the result, patient scored 22 in which she has medium fall risk 41 56 Low fall risk 21 40 Medium fall risk 0 20 High fall risk
30. 30. Coordination Test (non-equilibrium tests) Test Right Left Comment Finger to nose / - Unable to test affected hand due to hypertoneFinger to therapist finger / - Finger to finger / - Unable to test affected hand due to hypertoneAlternate nose to finger / - Finger opposition / - Unable to test affected hand due to hypertone Mass grasp / - Pronation/supination / - Rebound test of holmes / - Tapping (hand) / - Drawing a circle (hand and foot) / - Fixation/position holding (upper and lower limb) / -
31. 31. iii. Psychological Function through Becks Depression Inventory According to the assessment, patient has mild mood disturbance. iv. Psychosocial function through interview Patient has good relationship with family members. Patient spends time alone at home during weekend. Patient has fair coping skills. Patient has fair self control.
32. 32. PATIENTS ASSETS Patient is compliance with occupational therapy program Patient does not has financial problem Patient able to adhere with the instruction Patient able to communicate well with others
33. 33. PROBLEMS IDENTIFICATION Occupational performance area (OPA) 1. Has difficulty to perform in ADL In personal hygiene (cutting nails), patient has difficulty to cut nails due to poor strength of wrist and fingers musculature In dressing , patient has difficulty to don due to poor muscle strength In stair climbing, patient needs moderate assistance and supervision due to poor balance 2. Unable to perform in previous leisure activity specifically in martial art class and cooking due to physical limitation
34. 34. Occupational performance component (OPC) 1. Exhibits hypertonic at left upper limb 2. Exhibits poor muscle strength at left upper limb 3. Exhibits limited joint AROM at left upper limb 4. Exhibits poor hand function at left upper limb 5. Exhibits poor muscle strength at left lower limb
35. 35. FORMULATING AIMS Short term goal To normalize muscle tone at left upper limb To facilitate muscle strength at left upper limb To elicit joint AROM at left upper limb To enhance hand function at left upper limb To promote muscle strength at left lower limb Long term goal To promote functional independence in ADL specifically in personal hygiene, dressing and stairs climbing
36. 36. TREATMENT APPROACH Biomechanical FOR The approach is focused on addressing basic client factor to improve occupational performance. Intervention is in the form of exercises, splinting or orthopedic approach in which the outcome must reflect engagement in occupation. (Pedretti, 2006) In this case, biomechanical approach is use to ensure patient get maximum level of functioning of left upper limb in order to enable patient performing activity daily living as usual.
37. 37. Neurodevelopmental FOR The approach is emphasized on normalizing muscle tone, inhibiting primitive reflexes and facilitating normal postural reactions. In this case, the treatment is implemented by handling techniques with the application of weight bearing over the affected limb. In addition, the use of normal pattern of coordinated movements is encouraged at both sides of body and avoidance of any sensory input that may adversely affect muscle tone. (Pendleton & Schultz-krohn,2006)
38. 38. Rehabilitation FOR The approach is focused on client ability to return to the fullest physical, mental, social, vocational and economic functioning as is possible. Treatment are focused on avoiding and reducing impairment of the effected hand by using adaptation and give purposeful, meaningful activity to the patient. (Pedretti , 2006)
39. 39. TREATMENT IMPLEMENTATION
40. 40. Problem 1 Exhibits hypertonic at left upper limb Aim To normalize muscle tone at left upper limb Intervention Technique / Modalities Inhibition technique Method (Weight bearing) 1. Place patient in sitting position 2. Facilitate shoulder movement with elbow extension 3. Elicit flexion and extension of elbow once shoulder control increase 4. Weight shifting is applied to promote weight bearing at the involved extremity Duration 5 10 minutes Grading Increase the number of repetitions Precaution Aware with wrist pain caused by mal-alignment of carpals Rationale Weight bearing is a postural support can prevent tissue shortening of the elbow, wrist, and finger flexor. It can also be used to strengthening the scapula musculature and the triceps.
41. 41. Problem 2 Poor muscle strength at left upper limb Aim To promote muscle strength at left upper limb Intervention Technique / Modalities Bilateral isokinetic training Method (Hand cycling) Place the affected hand on the pedal Maintain slight elbow flexion Start pedaling with graded resistance Grading Increase the resistance by adding weight load to the equipment Increase the duration of the cycling period Precaution The affected hand should be carefully positioned to prevent skin irritation Rationale The intervention emphasizes the use of bilateral arm movement with ADLs and is hypothesized to be more functional than unilateral arm. It activates the damaged hemisphere through inter-hemispheric connections simultaneously. (C.P Latimer, et al., 2010)
42. 42. Problem 3 Limited AROM at left upper limb Aim To elicit AROM at left upper limb Intervention Technique / Modalities Active assisted exercise Method (Shoulder arch) - Place shoulder arch in front of patient - Instruct patient to bring the ring with the affected hand along the arch - Repeat the activity Precaution Avoid perform the activity in prolonged time to prevent additional stress on shoulder and neck Grading Increase the resistance by increasing the arch height Rationale In order to improve ROM and strength, forceful exercise is necessary to use which is there has some type of force that was used to body part when soft tissue is either near on the available length (Pendelton & Schultz-Krohn,2006)
43. 43. Problem 4 Poor hand function at left upper limb Aim To enhance hand function at left upper limb Intervention Technique / Modalities Task Specific Training Technique Method (Stacking cone) 1. Ensure patient is sitting on the chair 2. Instruct patient to hold the cone with both hand. 3. Move the cone across midline from right to left. Then move back the cone from left to right. 4. Repeat the activity 5. Therapist should guide the patient on holding the cone to promote normal pattern of coordinated movement Grading Increase the task repetitions Increase the durations of activity Rationale Task specific, low intensity regiments designed to improve use and function of the affected limbs have reported significant improvements. (Page, 2003)
44. 44. Problem 5 Poor muscle strength at left lower limb Aim To enhance muscle strength at left lower limb Intervention Technique / Modalities Functional strength training (FST) Method (Static cycling) Ensure patient sit on the seat safely Place the affected leg on the paddle with bandage to avoid falling Monitor patient to perform cycling within certain duration Grading Increasing the duration of the cycling period Rationale Strengthening interventions increase strength, improve activity and do not increase spasticity. (Ada et al., 2006)
45. 45. Problem 6 Has difficulty to perform in ADL Difficulty in personal hygiene (nail cutting) at left hand due to inability in grasping and pinching Aim To promote functional independence in ADL specifically in personal hygiene Intervention Technique / Modalities Compensatory technique through adaptive equipment Method Use large grip nail clippers for comfortable handling Precaution Ensure the equipment is safe to use
46. 46. Problem 7 Has difficulty to perform in ADL Difficulty in dressing (donning clothes) at left arm due to inability to pinch and grasp with lack of ability to reach Aim To promote functional independence in ADL specifically in dressing Intervention Technique / Modalities Compensatory technique through one - handed technique Method 1. Position shirt on lap with inside facing up and collar toward chest 2. Place involved arm into the sleeve by the unaffected arm 3. Pull shirt up onto arm past elbow 4. Insert unaffected arm into sleeve 5. Adjust shirt on affected side up and onto shoulder 6. Lean forward, duck head and pass shirt over it 7. Adjust the shirt Precaution Encourage patient to wear larger shirt and keep buttons fastened before donning to avoid frustration. Self buttoning is a labor intensive and frustrating task for patient with hemiplegia (Mary&Catherine, 2008)
47. 47. Problem 8 Has difficulty to perform in ADL Difficulty in mobility (stair climbing) due to decreased weight bearing at left lower limb Aim To promote functional independence in ADL specifically in mobility (stair climbing) Intervention Technique / Modalities Stair climbing technique with assistive device Method Ascending 1. The unaffected lower extremity leads up 2. The cane and affected lower extremity follows Descending 1. The effected lower extremity and cane lead down 2. The unaffected lower extremity follows Precaution Aware with the surface of the floor to prevent trip over Grading Increasing the endurance by facilitating duration of the stair climbing
48. 48. REASSESSMENT GENERAL APPEARANCE - Patient came to department with her maid. - Patient appeared neat and tidy. SPEECH - Patient spoke coherently with adequate quantities of speech. EYE CONTACT - Patient able to make eye contact with therapist and others. MOBILITY - Patient ambulated to department by using quadripod walking stick
49. 49. Activity Criteria Initial assessment Personal hygiene Unable to perform the task (0) Substantial help required (1) Moderate help required (3) Minimal help required (4) Fully independent (5) 4 Bathing 5 Feeding Unable to perform the task (0) Substantial help required (2) Moderate help required (5) Minimal help required (8) Fully independent (10) 10 Toilet 10 Stair climbing 8 Dressing 10 Bowel control 10 Bladder control 10 Chair/bed transfer Unable to perform the task (0) Substantial help required (3) Moderate help required (8) Minimal help required (12) Fully independent (15) 15 Ambulation 12 Total 94/100 Activity of Daily Living (ADL) by using MBI (Modified Barthel Index)
50. 50. OCCUPATIONAL PERFORMANCE COMPONENT (OPC) Pain by using Visual Analog Numerical Scale (VAS) Patient marked score 0/10 during rest at left upper limb Patient marked score 0/10 during passive shoulder flexion
51. 51. Balance by Using Berg Balance Scale Sitting to standing 3 Standing unsupported 4 Sitting with back unsupported but feet supported on floor on a stool 4 Standing to sitting 4 Transfers 4 Standing unsupported with eyes closed 4 Standing unsupported with feet together 1 Reaching forward with outstretched arm while standing 2 Pick up object form the floor from a standing position 1 Turning behind over left and right shoulders while standing 2 Turn 360 degrees 1 Place alternate foot on step or stool while standing unsupported 2 Standing unsupported one foot in front 0
52. 52. Interpretation : According to the result, patient scored 32 in which she has medium fall risk 41 56 Low fall risk 21 40 Medium fall risk 0 20 High fall risk
53. 53. Weight bearing exercise Passive stretching (PROM exercise) Trunk control exercise Bridging technique HOME PROGRAMMES
54. 54. FUTURE PLAN Hand function training Coordination training Balance training Gait training
55. 55. PROGNOSIS Medical Based on medical review, patient prognosis is good where: Patient is compliance with the medicine Rehabilitation Based on Occupational Therapy (OT) aspect, patient prognosis is good where: Patient shows improvement in performing ADL . Patient is compliance with the appointment of treatment. Patient is motivated to perform passive and active exercise at home.
56. 56. REFERENCES Catherine A. Trombly, Occupational Therapy Dysfunction 4th Edition Creek, J., & Lougher, L. (2011). Occupational Therapy and Mental Health (4th ed.). China: Churchill Livingstone Elsevier. Davies, P. M. (1985). Step To Follow : A Guide to the Treatment of Adult Hemiplegia Based on the Concept of K. and B. Bobath. New York, America: Springer-Verlag Gillen, G., & Burkhardt, A. (2004). Stroke Rehabilitation : A Function-Based Approach(2nd ed.). United States, America: Mosby, Inc. Hopkins. H.L, Smith. H.D (1993) 8th edition. Willard and spaceman's Occupational Therapy. Lippincott Co: Philadelphia Pendleton, H. M. H., & Schultz- Krohn, W. (2006). Pedrettis Occupational Therapy:Practice for physical dysfunction: St.Louis, MO: Mosby Sawner, K. A., & La Vigne, J. M. (1992). Brunnstrom's Movement Therapy in Hemiplegia : A Neurophysiological Approach (2nd ed.). United States, America: Lippincott Williams & Wilkins. Turner. A. (1981) The Practice of Occupational Therapy. Churchill Livingstone: Edinburgh