Occupational Therapy for Stroke Patients

Occupational therapy interventions and treatment approaches will differ depending on the type and severity of stroke and the practice setting.

The Centers for Disease Control and Prevention reports that every 40 seconds, a person in the United States has a stroke. Strokes are the fifth leading cause of death and disability in the United States according to the American Stroke Association. Given the prevalence of stroke in the U.S., it’s vital for occupational therapy professionals to understand not only the pathology of strokes, but also the benefits of occupational therapy for stroke patients.

Recommended course: Stroke Rehabilitation: Introduction, Evaluation, Treatment and Research

What is a stroke?

Strokes, or cerebrovascular accidents (CVA), are caused by a disturbance of oxygen and blood flow to the brain which results in the death of brain cells. These can cause difficulties with various bodily functions and even lead to death. The risk for stroke also increases with age. Nearly 70% of strokes occur in adults 65 years of age or older.

There are three major types of strokes: ischemic, hemorrhagic and a transient ischemic attack (TIA).

Ischemic strokes

Ischemic strokes are caused by a blood clot that disrupts blood flow to the brain. These account for over 80% of all strokes as reported by the National Heart, Lung and Blood Institute. The primary cause of ischemic strokes is fatty deposits (also called plaques) building up in the arteries. This causes the narrowing of the vessels (stenosis) over time and can result in blockages.

Medical conditions such as hypertension (high blood pressure), diabetes, and other heart and vascular diseases are major risk factors for an ischemic stroke.

Hemorrhagic strokes

A ruptured blood vessel causes a hemorrhagic stroke, which triggers bleeding within the brain. These are less common than ischemic strokes. Due to the make-up of the brain and skull, there is limited space to absorb the additional fluid, which can create an abnormal buildup of pressure within the brain. Hemorrhagic strokes can be caused by a congenital malformation in the brain vasculature, called arteriovenous malformation. An aneurysm in the brain, or the weakened part of the blood vessel wall, may also cause a stroke. These can ultimately rupture or bleed.

Although some risk factors of stroke are uncontrollable (such as age, gender, ethnicity, and congenital conditions), hemorrhagic strokes can also be caused by controllable risk factors, which are aspects of one’s lifestyle that you can control. Included in these are smoking, drugs, obesity, high cholesterol and uncontrolled hypertension due to poor diet and nutrition.

Transient ischemic attack (TIA)

TIAs, also referred to as a ‘mini-stroke’, is a temporary blockage of oxygen and blood flow to the brain. Usually caused by a clot which can dissolve or get dislodged on its own, the symptoms of a TIA are temporary and usually are resolved (disappear) within 24 hours.

However, the symptoms of a TIA can mirror an actual stroke. In fact, a person that has a TIA is at risk of having an actual stroke per reports by the American Heart Association. Causes of TIA can be a clot or blockage in a small blood vessel in the brain, called a lacunar stroke. High blood pressure, diabetes, smoking, atrial fibrillation, heart attack, and a prior history of a stroke or TIA are all risk factors.

Because the obstruction of blood flow and oxygen to the brain is temporary with a TIA, there are usually no lasting disabilities. However, a TIA should serve as a warning to address controllable risk factors to prevent/reduce future occurrences.

Occupational therapy for stroke victims: Major benefits

Occupational therapy for stroke patients can have real benefits. During formative education, occupational therapy practitioners take foundational courses such as neuroscience and/or neuroanatomy to gain important knowledge about the brain and its function. Depending on where the stroke occurred in the brain, and/or where blood flow and oxygen was interrupted, occupational therapy practitioners can use clinical reasoning to deduce what symptoms might present.

Symptoms of and impairments from a stroke can be wide-ranging and include:

• Muscle weakness and paralysis, usually on one side of the body, which can result in facial asymmetry such as an eyelid or lip droop or difficulty moving or detecting sensation in the arms and legs
• Cognitive problems such as disorientation and confusion
• Communication difficulties including speaking and interpreting language
• Problems with vision, including double vision or difficulty seeing
• Dizziness or loss of balance
• Behavioral changes including lack of safety and judgement

Evaluating and assessing a stroke

Healthcare professionals, including therapists providing occupational therapy for stroke patients, often use the following assessments when evaluating and treating an acute stroke:

• National Institute of Health Stroke Scale (NIH, 2021)
• American Heart Association Stroke Outcome Classification (AHA-SOC; Kelly-Hayes et al., 1998)

Healthcare professionals might initially perform these assessments at the scene of an emergency, during transport, or even in the emergency department to get a baseline.

Due to the wide range of symptoms and performance problems, interprofessional practice is the standard of care after a stroke and occupational therapy practitioners play an integral role in the interprofessional treatment team across practice settings.

To assess for hemiparesis (weakness), motor recovery, and other upper extremity functioning levels, occupational therapy practitioners might utilize various standardized assessments. These tests acquire objective data to better inform intervention planning and implementation. These include, but are not limited to:

• Fugl-Meyer Assessment of Motor Recovery
• The Action Research Arm Test
• Chedoke-McMaster Stroke Assessment
• Chedoke Arm and Hand Activity Inventory

To hone in on deficits related to vision and perception, assessments might include:

• Motor-Free Visual Perception Test, 4th Edition
• Behavioral Inattention Test
• Letter Cancellation Test
• Clock Drawing Test

Post-stroke cognitive assessment tools for occupational therapists

The American Heart Association reports that more than 40% of individuals who have had a stroke experience cognitive impairment within one year. To look at cognitive abilities, an occupational therapy practitioner might use the Rivermead Behavioral Memory Test or the Montreal Cognitive Assessment (MOCA). If expressive communication is impaired due to the stroke, some assessments are designed to work around communication barriers, such as the Cognitive Assessment for Stroke Patients (CASP).

Due to the multifaceted consequences that can occur post-stroke, physical health is not the only focus of occupational therapy practitioners. Psychological distress and other comorbidities such as depression can occur post-stroke. The Beck Depression Inventory, which is a self-reported scale, can be a useful tool to measure the severity of depression symptoms.

Treatment approaches and occupational therapy interventions for stroke

Occupational therapy interventions and treatment approaches will differ depending on the type and severity of stroke and the practice setting. The goal is to improve engagement in activities of daily living (eating, bathing, grooming, dressing etc.) and instrumental activities of daily living (home management, meal prep, driving, childcare etc.). In some cases, however, practitioners need to employ preparatory methods and purposeful activities such as repetitive task training to improve specific client factors such as upper extremity and mental function.

Recommended course: Stroke Rehabilitation Maximizing Outcomes: Interventions

Client/family skill training and/or education on adaptive equipment or assistive devices is also common among the stroke population including one-handed techniques or environmental modification to compensate for limited mobility or reduce risk of fall. Visual scanning training might be necessary for people who experience visual-perceptual deficits post-stroke such as visual field cut, unilateral neglect or unilateral attention.

Remediation, compensatory and adaptive approaches might also be used to restore and/or work around functional cognitive deficits such as problems with memory, attention, and safety awareness. If controllable risk factors in the person’s known lifestyle caused the stroke, occupational therapy practitioners can also help promote wellness, and encourage healthy habits, roles and routines, including physical activity, nutrition and medication management.

Occupational therapy practitioners should be familiar with the domain and broad scope of occupational therapy practice as outlined in the Occupational Therapy Practice-Framework, Fourth Edition (American Occupational Therapy Association , 2020).

To stay informed about best practice and evidenced-based guidelines, occupational therapy practitioners should seek out and utilize resources promoted by the AOTA regarding stroke care, including AOTA’s OT Practice Guidelines for Adults with Stroke.