IV - B.S.

Occupational
Therapy

OT 5 STR: CVA

November 2014

CEREBROVASCULAR ACCIDENT (STROKE)

I.

DEFINITION

CVA, is the sudden occurrence of permanent damage to an area of the brain caused by a
blocked blood vessel or bleeding within the brain. Lesions in the brain may produce a wide
range of neurological deficits such as sensory disturbances, cognitive and perceptual
dysfunction, visual disturbances, personality and intellectual changes and a complex range of
speech and associated language disorders, with focal weakness being the most common
symptom. According to World Health Organization, it is an acute neurologic dysfunction of
vascular origin with signs and symptoms corresponding to the involvement of focal areas of the
brain. In order to be labeled a CVA, neurologic deficits must persist longer than 24 hours.
II.

ETIOLOGY
Stroke, according to Bartels is essentially a disease of the cerebral vasculature in which
failure to supply oxygen to brain cells, which are the most susceptible to ischemic damage,
leads to their death. The syndromes that lead to stroke comprise 2 major categories: ischemic
and hemorrhagic stroke. Ischemic strokes account for the majority of strokes, whereas
hemorrhagic strokes account for less. There are several risk factors, both modifiable and nonmodifiable, that may lead to its occurrence. They are the following:
Modifiable Risk factors:

Hypertension (most
treatable factor)
Heart disease
Smoking

Non-modifiable Risk factors:

Age (main
risk factor)

Diabetes Mellitus
Lifestyle
Alcoholism

Gender
Race

Ethnicity
Heredity

Use of illegal drugs

and
Use of oral
contraceptive

Previous
stroke

III.
EPIDEMIOLOGY

CVA ranks as the third leading cause of death in the U.S. behind heart disease and
cancer, and continues to be a national health problem despite recent advances in medical
technology. On average, a U.S. citizen suffers a stroke every 40 seconds; every 4 minutes
someone dies of a stroke. Of people who suffer a stroke, 28% are younger than 65 years. For
people older than 55, the incidence doubles with each successive decade. Among long term
clients who sustained a stroke, 50% have hemi-paresis, 35% are clinically depressed, 30%

Karen Abinsay

Jet Duria

Sheena Gazzingan

IV - B.S. Occupational
Therapy

OT 5 STR: CVA

November 2014

cannot walk, 26% are found to be dependent in ADL scales, and 26% require home nursing
care, and 19% are aphasic.
IV.
PATHOPHYSIOLOGY
Ischemic Stroke- Ischemia refers to insufficient blood flow to the brain to
meet metabolic demand. Ischemic stroke may be the result of embolism to the
brain from cardiac to arterial sources.
Thrombosis Atherosclerotic plaque formation occurs frequently at major
vascular branching sites, including the common carotid and vertebrobasilar
arteries.
Embolism Thrombus formation within the cardiac chambers is generally
caused by structural or mechanical changes within the heart.
Lacunes Lacunar infarcts are small, circumscribed lesions that measure less
than 1.5 cm in diameter and are located in subcortical regions of the basal
ganglia, internal capsul, pons, and cerebellum.
Hemorrhagic Stroke- Hemorrhagic stroke include subarachnoid and
intracerebral hemorrhages, which account for only 13 % of the total number of
strokes.
Intracerebral Damage can be significant, resulting in increase intracranial
pressure, disruption of multiple neural tracts, ventricular compression, and
cerebral herniation.
Subarachnoid Bleeding that occurs within the dural space around the brain
and fills the basal cistern, is most commonly caused by rapture of a saccular
aneurism.

The Cerebral Arterial Circle (Circle of Willis)

The blood supply to the brain is carried by the internal carotid and

vertebral arteries. The vertebral arteries join to form the basilar artery. Branches
of the internal carotid arteries and basilar artery supply blood to the brain and
complete a circle of arteries around the pituitary gland and the base of the brain
called the cerebral arterial circle. (Braddom)

Karen Abinsay

Jet Duria

Sheena Gazzingan

IV - B.S. Occupational
Therapy

OT 5 STR: CVA

November 2014

V.

ASSESSMENT

Numerous evaluations exist to identify stroke impairments and disability. To help in the
selection and ordering of assessment tools, therapists are guided by models of practice and
evidence-base practice guidelines. Occupational function is the focus in OT, thus assessment of
a patient post stroke begins with determination roles, tasks, and activities important to that
individual. (Trombly)

INSTRUMEN
T
NIH stroke
scale

DESCRIPTION AND USAGE

Canadian
Neurologica
l Scale
Rankin
Scale
Canadian
Occupation
al
Performanc
e Measure
(COPM)
Barthel
Index

Stroke deficit scale that scores 15 items (e.g., consciousness,

vision, extraocular movement, facial control, limb strength,
ataxia, sensation, speech and language)
Stroke deficit scale that scores 8 items (e.g., consciousness,
orientation, speech, motor fxn, facial weakness)

Kohlman
Evaluation
of Living
Skills

Karen Abinsay

Global disability scale with 6 grades indicating degree of

disability
Client0centerd assessment tool based on clients identification of
problems in performance in area of occupation ( clients rate the
importance of self-care, productivity, and leisure skills, as well as
their perception of performance and satisfaction with
performance) used as an outcome measure, as well as a client
satisfaction survey.
Measure of disability in performing BADLs that ranges from 0 to
20 or 0 to 100
( by multiplying each item by 5); includes 10 items: bowels,
bladder, feeding, grooming, dressing, transfer, toileting, mobility,
stairs, and bathing
Living skills evaluation that includes ratings of 17 task (e.g.,
safety awareness, money management, phone book use, money
and bill management)

Jet Duria

Sheena Gazzingan

IV - B.S. Occupational
Therapy

(KELS)
Functional
Independen
ce Measure
(FIM)
Frenchay
Activities
Index
PCG
instrumental
activities of
Daily living
Assessment
of motor
and process
skills

OT 5 STR: CVA

Measure of disability in performing BADLs that includes 18 items

scored on a 7-points scale; includes sub scores for motor and
cognitive fxn, performance areas include self-care, sphincter
control, mobility, locomotion, cognitive, and socialization
15 items IADL scale that evaluates domestic, leisure, work, and
outdoor ax.

IADL evaluation of telephone use, walking, shopping, food

preparation, housekeeping, laundry, public transportation, and
medication management

16 motor skills (e.g., reach , manipulation, calibration,

coordination, posture, mobility) and 20 process skills (e.g.,
attends, organizes, searches and locates, initiates, sequences)
evaluated within the context of cx-choose familiar and culturally
relevant tasks from a list of 50 standardized ax of various
difficulties
Mental status screening test for orientation to time and place,
registration of words, attention, calculation, recall, language, and
visual construction
Level-of-consciousness scales that includes 3 sections scoring
eye opening, motor and verbal responses to voice commands or
pain
Evaluate apraxias, neglect syndromes, body scheme d/o,
organization/sequencing dysfxn, agnosias, and spatial dysfxn via
BADL and mobility tasks; directly correlates impairment and
disability levels of dysfxn.

Mini-Mental
State
Examination
Glasgow
Coma scale

Arnadottir
Occupation
al Therapy
Nuerobehav
ioral
Evaluation
(A-ONE)
Neurobehav
ioral
Cognitive
Status
Examination
Fugl-Meyer
Test
Functional
Test for the
Hemiparetic
Upper
Extremity
Arm Motor

Karen Abinsay

November 2014

Mental status screening test that includes the domains of

orientation, attention, comprehension, naming, construction,
memory, calculation, similarities, judgment, and repetition

Motor fxn evaluation that uses a 3-pts scale to score the domains
of pain, ROM, sensation, volitional mov., and balance
Arm and hand fxn is assessed via 17 hierarchic functional task
based on Brunnstroms view of motor recovery; sample tasks a
folding a sheet, screwing in a light bulb, stabilizing a jar, and
zipping a zipper

Arm fxn evaluated by functional ability and quality of mov.; test

Jet Duria

Sheena Gazzingan

IV - B.S. Occupational
Therapy

Ability Test
(AMAT)
TEMPA

OT 5 STR: CVA

Jebsen Test
of Hand Fxn

Motor
Assessment
Scale
Motricity
Index
Trunk
Control
Test
Berg
Balance
Scale
Tinetti Test
Rivermead
Mobility
Index
Functional
Reach test
Boston
Diagnostic
Aphasia
examination
Western
Aphasia
Battery
Beck
Depression
Inventory
Geriatric
Depression
scale
Family
Assessment
Device

Karen Abinsay

November 2014

involves performance of 28 tasks (e.g., eating with a spoon,

opening a jar, tying a shoelace, using the telephone)
UE performance test composed of 9 standardized tasks (bilateral
and unilateral) measured by 3 criteria: length of execution,
functional rating, and task analysis; sample tasks are handling
coins, picking up a pitcher and pouring water, writing and
stamping an envelope, and unlocking a lock
Hand fxn evaluation; includes 7 test axs: writing a short
sentence, turning over a index card, simulated eating, picking up
small objects, moving empty and weighted cans, and stacking
checkers during timed trials
Motor fxn and eval; includes disability and impairment measures,
arm and hand movements, tone, and mobility 9bed, upright, and
ambulation)
Measures impairments in limb strength with a weighted ordinal
scale
Trunk control evaluated on a 0- to 100-pts scale; tasks used
rolling, supine to sitting and balance sitting

Balance Assessment of 14 items scored on a 0- to 4-pts ordinal

scale

Evaluates balance and gait in the older adult population

Measures bed mobility, sitting, standing, transfers, and walking
on a pass or fail scale

Balance evaluation; objectively measures length of forward reach

in standing posture
Assesses sample speech and language behavior, including
fluency, naming, word finding, repetition, serial speech, auditor
comprehension, reading and writing

Includes an Aphasia Quotient and Cortical quotient scored on

a 100 pts scale; assesses spontaneous speech, repetition,
comprehension, naming, reading and writing
21-item, self-rating scale with attitudinal, somatic, and behavior
components

Self-rated depression scale of 30 items with a yes or no format

Family assessment of problem solving, communication, roles ,

affective responsiveness, affective involvement, behavior control,
and general functioning

Jet Duria

Sheena Gazzingan

IV - B.S. Occupational
Therapy

OT 5 STR: CVA

November 2014

Medical
Outcomes
study/
Short-form
Health
Survey (SF36)
Sickness
Impact
Profile

Quality of life measure that includes the domains of physical

functioning, physical and emotional problems, social fxn, pain,
mental health, vitality, and health perception

Activity
Card
Sort(ACS)

Stroke
Impact
Scale

Quality of life measure in the format of a 136-item scale with 12

subscales that measure ambulation, mobility, body care,
emotion, communication, alertness, sleep, eating, home
management, recreation, social interactions and employment
Uses a Q-sort methodology to assess participation in 80
instrumental, social, and high- and low-physical demand leisure
axs. Cx sort the cards into diff piles to identify axs that were done
before their stroke, axs they are doing less, and those they have
given up since their stroke. The ACS uses card with pictures of
task that people do every day
A stroke specific measure that incorporates fxn and quality of life
intone measure. It is a self-report measure with 59 items and 8
subgroups, including strength, hand function, BADLs and IADLs,
mobility, communication, emotion, memory and thinking, and
participation

VI.
TREATMENT

A careful interpretation of evaluation result helps determine a patients

assets and deficits in areas of occupational functioning. Safety of the patient is a
concern during and after treatment. (Trombly)

Proper bed
positioning

Karen Abinsay

ES/FES
ROME
PREs

Jet Duria

Assistive device
NDTs
PNF

Sheena Gazzingan

VII.

PROGNOSIS
- The best estimate of prognosis can be made only after a thorough and comprehensive
evaluation of the patients medical, neurologic, functional, and psychosocial statuses. The single
most useful predictor of functional outcome is the initial ADL assessment (most commonly FIM
score). Other important variables include age and sitting balance.
- Poor prognosticating factors for functional recovery:
- Prolonged flaccidity
- Late onset of motion (2-4 weeks)
- No voluntary hand movement at 4-6 weeks
- Severe proximal spasticity
- Late return of DTR
- *If no initial movement is noticed during the first 3 weeks, or if motion in1 segment is not
followed within a week by the appearance of motion in a second segment, the prognosis for
full motion is poor.
-