Medications Commonly Used to Treat Stroke and its Comorbidities

OTHER
MEDICAL
DRUG USE DOSAGE ROUTE SIDE EFFECTS ISSUES

Antispasmodics/Spasmolytics
Carisoprodol (Soma) Skeletal muscle relaxant 350 mg tid and PO Drowsiness, ataxia, tremor, nausea/
qhs vomiting (N/V), tachycardia
Chlorzoxazone Skeletal muscle relaxant 250 to 500 mg PO Drowsiness, dizziness, N/V,
(Parafon Forte) tid-qid angioedema
Cyclobenzaprine Decrease muscle spasm 10 mg tid PO Drowsiness, dry mouth, dizziness,
(Flexeril) via brainstem N/V, angioedema
Diazepam (Valium) Central nervous system 2 to 10 mg bid- PO Drowsiness, ataxia, urinary Avoid in first
(CNS) depressant qid retention, anxiety trimester
Methocarbamol Skeletal muscle relaxant 1 to 1.5 g qid PO Drowsiness, dizziness, N/V,
(Robaxin) headache (HA)
Orphenadrine Skeletal muscle relaxant 100 mg bid PO, IV Drowsiness, dry mouth, dizziness,
(Norflex/Norgesic) 60 mg every HA, weakness
12 hours IV

Antispastics
Baclofen (Lioresal) Skeletal muscle relaxant 5 to 20 mg PO Drowsiness, dizziness, weakness,
tid-qid N/V, confusion
Dantrolene sodium Skeletal muscle relaxant 25 mg qd to PO, IV Drug-induced hepatitis
(Dantrium) 100 mg qid
Diazepam (Valium) CNS depressant, 2 to 10 mg PO Drowsiness, ataxia, urinary Avoid in first
skeletal muscle bid-qid retention, anxiety trimester
relaxant
Tizanidine (Zanaflex) Central alpha 4 to 8 mg PO Asthenia, drowsiness, ataxia, Rare cardiac events
2 adrenergic agonist; tid-qid abnormal liver function tests,
central skeletal muscle dry mouth
relaxant
Anticonvulsants
Beclamide (Beclase) Grand mal, 990 to 1980 mg/ PO Drowsiness, ataxia, aphonia,
psychomotor seizures day agitation, leukopenia
Carbamazepine Grand mal, partial 300 to 600 mg PO N/V, dizziness, complete blood Therapeutic level
(Tegretol) complex, mixed bid count (CBC) changes, 6 to 12 mcg/ml
seizures; neuropathic drowsiness, unsteadiness
pain
Clonazepam CNS depressant, a 0.5 mg tid to PO Drowsiness, ataxia, aphonia,
(Klonopin) benzodiazepine; 5 mg qid agitation, confusion, anemia
neuropathic pain
Diazepam (Valium) CNS depressant, for 5 to 10 mg IV IV Respiratory arrest, hypotension, Total dose IV up to
status epilepticus push bradycardia 30 mg
Ethosuximide Suppresses 3 cycle/sec 500 mg up to PO Anorexia, N/V, lethargy, Not in pregnancy/
(Zarontin) spike, petit mal seizures 1000 mg/day incoordination, CBC changes nursing
Ethotoin (Peganone) Grand mal, partial 2 to 3 g/day in PO Ataxia, sedation, HA, N/V, cardiac Monitor blood
complex seizures 4 to 6 doses dysrhythmias counts, blood level
15 to 50 mcg/ml
Felbamate (Felbatol) Partial seizures Up to 2400 to PO Anorexia, gastrointestinal (GI) Monitor liver
3600 mg/day in discomfort, fever, acute liver function
divided doses failure, bone marrow suppression
Gabapentin Partial seizures, social 900 to 1800 mg PO Ataxia, sedation, mania, lability,
(Neurontin) phobia total in tid mood alterations, rare edema
divided doses and hypertension (HTN)
 OTHER
MEDICAL
DRUG USE DOSAGE ROUTE SIDE EFFECTS ISSUES

Anticonvulsants—cont’d
Lamotrigine Partial seizures 200 to 500 mg/ PO Leukopenia, anemia, disseminated Must stop
(Lamictal) day intravascular coagulation, immediately in
hepatitis, Stevens-Johnson presence of rash
syndrome
Levetiracetam Grand mal, partial, Maximum daily PO Somnolence, asthenia, infection,
(Keppra) psychomotor seizures dose of 3000 ng dizziness
Phenobarbital CNS depressant 50 to 100 mg tid PO, IV HA, vertigo, confusion, N/V, 15 mg/kg IV in
(Luminal) serum 15-40 respiratory depression; status epilepticus
mcg/ml respiratory arrest with IV
Phenytoin (Dilantin) Grand mal, 100 mg tid PO, IV Ataxia, sedation, HA, N/V, cardiac Level: 10 to
psychomotor seizures; dysrhythmias 20 mcg/ml
neuropathic pain
Primidone (Mysoline) Barbiturate; grand mal, 250 mg tid to PO Ataxia, sedation, HA, N/V, Level: 5 to
focal, psychomotor 500 mg qid irritability 12 mcg/ml
seizures
Valproic acid Absence seizures; 1000 to PO Ataxia, sedation, HA, N/V, Avoid in pregnancy
(Depakote/ neuropathic pain 3000 mg/day aggression
Depakene)

Antihypertensives
ACE inhibitors Antihypertensive PO, IV Nephrotic syndrome
Alpha-blockers Antihypertensive, PO, IV Syncope, sedation, HA, urinary
(Minipress, etc.) control of sympathetic retention
dystrophy
Beta-blockers Antihypertensive PO, IV Congestive heart failure,
bradycardia, hypotension,
peripheral vascular disease
(PVD)
Calcium channel Antihypertensive PO, IV Dizziness, HA, hypotension
blockers
Direct vasodilators Antihypertensive PO, IV Tachycardia, hypotension, HA
Diuretics Antihypertensive PO, IV Metabolic/electrolytes, cramps,
hypotension, renal failure
Postganglionic Antihypertensive PO, IV Diarrhea, hypotension, depression
neuron inhibitors
Antidepressants
Fluoxetine (Prozac) Antidepressant 20 to 80 mg PO Anxiety, tremor, insomnia, nausea,
qd-bid diarrhea
MAO inhibitors Antidepressant PO Dizziness, vertigo, HA, Patient must avoid
constipation, HTN tyramine/
tryptophan
Sertraline (Zoloft) Antidepressant 50 to 200 mg PO Anxiety, tremor, insomnia, nausea,
qd-bid diarrhea
Tricyclics (e.g., Antidepressant, pain PO Myocardial infarction (MI), Best for continuous
amitriptyline) control adjuvant hypotension, seizures, neuropathic pain
confusion, leukopenia,
parathesias, N/V, coma,
constipation, hepatitis

Continued on back endsheets

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 Glen Gillen, EdD, OTR, FAOTA
Associate Professor of Clinical Occupational Therapy
Programs in Occupational Therapy
Columbia University
College of Physicians and Surgeons;
Honorary Adjunct Associate Professor
of Movement Sciences and Education
Teachers College
New York, New York
3251 Riverport Lane
St. Louis, Missouri 63043

STROKE REHABILITATION: A FUNCTION-BASED APPROACH,

THIRD EDITION ISBN: 978-0-323-05911-4
Copyright © 2011, 2004, 1998 by Mosby, Inc., an affiliate of Elsevier Inc.

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Library of Congress Cataloging-in-Publication Data

Stroke rehabilitation : a function-based approach / Glen Gillen. -- 3rd ed.

   p. cm.
Includes bibliographical references and index.
ISBN 978-0-323-05911-4 (hardcover : alk. paper)
1. Cerebrovascular disease--Patients--Rehabilitation. I. Gillen, Glen.
RC388.5.S85625 2011
616.8’1--dc22
2010026437

Vice President and Publisher: Linda Duncan

Executive Editor: Kathy Falk
Managing Editor: Jolynn Gower
Publishing Services Manager: Anitha Rajarathnam
Project Manager: Mahalakshmi Nithyanand
Book Designer: Maggie Reid

Printed in the United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2

 Contributors

Guðrún Árnadóttir, PhD, MA, BOT Karen A. Buckley, MA, OT/L

Private Practitioner, Associate Professor Clinical Assistant Professor
Division of Occupational Therapy, Faculty of Health Department of Occupational Therapy
University of Akureyri, Iceland; New York University
Coordinator of Occupational Therapy Research and New York, New York
Development Projects, Occupational Therapy
Grensás, Landspítali, University Hospital Helen S. Cohen, EdD, OTR, FAOTA
Reykjavík, Iceland Associate Professor
Bobby R. Alford Department of Otorhinolaryngology
Sandra M. Artzberger, MS, OTR, CHT, CLT and Communicative Sciences
Lecturer, Consultant, Hand Therapist Baylor College of Medicine
Rocky Mountain Physical Therapy Houston, Texas
Pagosa Springs, Colorado
Salvatore DiMauro, MD
Wendy Avery, MS, OTR/L Lucy G. Moses Professor of Neurology
Occupational Therapist College of Physicians and Surgeons
Amedisys Home Health Columbia University
Bluffton, South Carolina New York, New York

Matthew N. Bartels, MD, MPH Susan M. Donato, OTR/L

Assistant Professor of Clinical Rehabilitation Medicine Occupational Therapist
Columbia University Merrimack Special Education Collaborative
New York, New York Chelmsford, Massachusetts

Clare C. Bassile, EdD, PT Catherine A. Duffy, OTR/L

Assistant Professor of Clinical Physical Therapy Advanced Clinician, Occupational Therapy Department
Physical Therapy Program New York-Presbyterian Hospital
Columbia University Columbia University Medical Center;
New York, New York Instructor in Clinical Occupational Therapy,
Programs in Occupational Therapy
Carolyn M. Baum, PhD, OTR, FAOTA Columbia University
Associate Professor of Occupational Therapy and New York, New York
Neurology
Washington University School of Medicine Janet Falk-Kessler, EdD, OTR, FAOTA
St. Louis, Missouri Associate Professor of Clinical Occupational Therapy
Director, Programs in Occupational Therapy
Heather Edgar Beland, MS, OTR/L Columbia University
Staff Therapist New York, New York
Englewood Hospital and Medical Center
Englewood, New Jersey Jessica Farman, MS, OTR/L
Director of Rehabilitation
Birgitta Bernspång, PhD, OT Belmont Manor Nursing Center
Professor of Occupational Therapy Belmont, Massachusetts
Department of Community Medicine and Rehabilitation
Umeå University
Umeå, Sweden
iii
iv Contributors

Susan E. Fasoli, ScD, OTR/L Stephanie Milazzo, MA, OTR, CHT

Clinical Instructor Director of Rehabilitation
Physical Medicine and Rehabilitation Rehab Resources Unlimited
Harvard Medical School Ossining, New York
Cambridge, Massachusetts;
Rehabilitation Manager Barbara E. Neuhaus, EdD, OTR
Rehabilitation Services Adjunct Associate Professor (Retired)
Newton Wellesley Hospital Programs in Occupational Therapy
Newton, Massachusetts Columbia University
New York, New York
Glen Gillen, EdD, OTR, FAOTA
Associate Professor of Clinical Occupational Therapy Susan L. Pierce, OTR, CDRS
Programs in Occupational Therapy Certified Driver Rehabilitation Specialist
Columbia University Adaptive Mobility Services, Inc.
College of Physicians and Surgeons; Orlando, Florida
Honorary Adjunct Associate Professor of Movement
Sciences and Education Karen Halliday Pulaski, MS, OTR/L
Teachers College Trauma Team Supervisor
New York, New York Inpatient Rehabilitation
Moses Cone Health Systems
Sheila M. Hayes, BSN, MS, PT Greensboro, North Carolina
Convent of Mary the Queen
Yonkers, New York Ashwini K. Rao, EdD, OTR/L
Assistant Professor of Clinical Physical Therapy
Leslie A. Kane, MA, OTR/L Physical Therapy Program
Manager of Occupational Therapy Department of Rehabilitation Medicine
New York-Presbyterian Hospital and Columbia Columbia University
University Medical Center; New York, New York
Instructor in Clinical Occupational Therapy
Programs in Occupational Therapy Karen Riedel, PhD, CCC-SLP
Columbia University Director Speech-Language Pathology Department
New York, New York Rusk Institute of Rehabilitation Medicine
New York University Medical Centers
Megan Kirshbaum, PhD New York, New York
Founder and Executive Director
Through the Looking Glass; Judith Rogers, OTR/L
Co-Director Pregnancy and Birthing Specialist
The National Center for Parents with Disabilities Parenting Equipment Specialist
and their Families Through the Looking Glass
Berkeley, California Berkeley, California

Josefine Lampinen, MSc Kerry Brockmann Rubio, MHS, OTR/L

Council Certified Specialist in Occupational Therapy Lead Occupational Therapist
Norrlands University Hosptial Maria Parham Hospital
Umeå, Sweden Henderson, North Carolina

Virgil Mathiowetz, PhD, OTR, FAOTA Patricia A. Ryan, MA, OTR/L

Associate Professor Senior Occupational Therapist
Program in Occupational Therapy Department of Occupational Therapy
University of Minnesota New York-Presbyterian Hospital
Minneapolis, Minnesota Columbia University Medical Center;
Instructor in Clinical Occupational Therapy
Programs in Occupational Therapy
Columbia University
New York, New York
 Contributors v

Joyce S. Sabari, PhD, OTR, FAOTA Jocelyn White, BSc (OT)

Associate Professor and Chair Senior Occupational Therapist
Occupational Therapy Program Royal Perth Hospital
State University of New York—Downstate Medical Shenton Park Campus
Center Perth, Western Australia
Brooklyn, New York
Timothy J. Wolf, OTD, MSCI, OTR/L
Mary Shea, MA, OTR, ATP Instructor in Occupational Therapy and Neurology
Clinical Manager, Wheelchair Clinic Program in Occupational Therapy
Kessler Institute for Rehabilitation Washingon University
West Orange, New Jersey St. Louis, Missouri

Celia Stewart, PhD, MS, CCC-SLP

CONTRIBUTORS TO PREVIOUS EDITIONS
Department Chair
Associate Professor
Lorraine Aloisio
Communicative Sciences and Disorders
Beverly K. Bain
Steinhardt School of Culture, Education, and Human
Ann Burkhardt
Development
Judith Dicker Friedman
New York University
Michele G. Hahn
New York, New York
Lauren Joachim
Christine M. Johann
Jennie W. Sullivan, OTR/L
Steve Park
Occupational Therapist
Denise A. Supon
East Tennessee Children’s Hospital
Jeffery L. Tomlinson
Knoxville, Tennessee
Nancy C. Whyte
Carolyn A. Unsworth, PhD, BAppSc (OccTher),
AccOT, OTR
Associate Professor
School of Occupational Therapy
La Trobe University
Bundoora, Victoria, Australia
 

To: Peg & Ed
 Preface

The third edition of Stroke Rehabiliation: A Function-Based and case studies have been provided as learning tools. A text
Approach strives to be the most up-to-date text on this that can appeal to the basic learner and the specialist alike,
topic, incorporating state of the art tools and techniques this book is a good investment for any clinician who plans
to maximize function and quality of life for those living to work with neurologically impaired persons—specifically,
with stroke. This edition’s contributors include expert adults who have had a stroke. This text spans the contin-
clinicians, researchers, and scientists from across the uum of care—from acute to long-term management—in a
United States of America, Australia, Iceland, and Sweden. variety of roles and settings.
Contibutors are experts in various disciplines, including The first five chapters provide the necessary medical
neurology, occupational therapy, physiatry, physical ther- and therapeutic foundations that should be the basis of
apy, psychology, and speech and language pathology. any intervention plan. Chapter 1 has been expanded to
The current text combines aspects of background not only include medical management but also a compre-
medical information, a comprehensive review of stan- hensive approach to acute stroke rehabilitation because
dardized and nonstandardized evaluation procedures and current practice dictates that rehabilitation services begin
assessments, treatment techniques, and evidence-based within 24 hours of stroke in many cases. Acute care evalu-
interventions. It contains the most up-to-date research on ations and interventions are clearly delineated for those
stroke rehabilitation from a variety of rehabilitation set- working in intensive care units, step down units, and the
tings and professions without losing its holistic perspec- acute hospital settings. The information in Chapter 2,
tive on the overall care of the people whose lives we as Psychological Aspects of Stroke Rehabilitation, as well
clinicians touch. as in Chapter 3, Improving Participation and Quality of
This text has overarching themes. First and foremost, Life Through Occupation, should be implicit in any
clinicians are provided with specific suggestions to main- therapeutic interaction with this population. Chapters 4,
tain a client-centered approach when working with stroke Task-Oriented Approach to Stroke Rehabilitation, and 5,
survivors. Furthermore, clinicians are challenged to use Activity-Based Intervention in Stroke Rehabilitation, pro-
the most up-to-date treatment approaches (including vide readers with an overall view of current therapeutic
both remediation and adaptation approaches) to decrease approaches and should be understood before the chapters
impairments, prevent secondary complications, improve on specialized topics are read.
the client’s ability to perform meaningful activities, and, Chapters 6 through 15 focus on the motor control
most important, decrease participation restrictions and aspects of stroke rehabilitation. Chapter 6, Approaches to
improve quality of life. Motor Control Dysfunction: An Evidence-Based Review,
Although this book is written primarily by occupational provides the reader with critical information to evaluate
therapists, it is an appropriate reference for a variety of traditional and current practice approaches. Specific top-
rehabilitation professionals, including physiatrists, physi- ics related to motor control that are covered include trunk
cal therapists, speech and language pathologists, rehabili- control (Chapter 7), balance (Chapter 8), vestibular dys-
tation nurses, social workers, vocational counselors, and function (Chapter 9), comprehensive approaches to upper
therapeutic recreation specialists. The immense value of extremity function and management (Chapter 10), use
an interdisciplinary team approach when working with the of cutting-edge technology to improve limb function
stroke survivor population cannot be overestimated. This after stroke (Chapter 11), acute and subacute edema con-
text may also be beneficial to therapists who practice virtu- trol (Chapter 12), splinting of the neurological upper
ally alone in the community or as a case manager because extremity (Chapter 13), functional mobility (Chapter 14),
its research on the specific topic of stroke rehabilitation is and gait (Chapter 15).
comprehensive. The terms patient and client have been The following five chapters provide readers with
used interchangeably; it is recognized that stroke rehabili- insight into managing simple and complex visual, percep-
tation can take place in multiple settings. tual, cognitive, and speech/language impairments that
Educators and students can use this text in the classroom interfere with daily function. Chapters focus on assess-
setting. Key terms, chapter objectives, review questions, ment and interventions related to visual and spatial skills

vii
viii Preface

(Chapter 16), clinical reasoning during assessment and can build their philosophies for intervention with the
treatment planning for those with cognitive and percep- stroke population.
tual deficits (Chapter 17), standardized assessment of the
impact of cognitive-perceptual impairments on meaning- ACKNOWLEDGMENTS
ful tasks (Chapter 18), function-based approaches to man-
aging and evaluating cognitive and perceptual deficits I am grateful for all I have learned from the hundreds
(Chapter 19), and management of speech and language of stroke survivors I have interacted with over the past
deficits (Chapter 20). 21 years. It is my hope that this text will make a positive
This text contains comprehensive chapters on specific impact on improving the quality of life of those living with
aspects of daily living after a stroke, such as driving, sexu- stroke. I am grateful to all of the professionals from my
ality, leisure, instrumental activities of daily living, re- own community, across the country, and internationally
sumption of parenting roles after stroke, mobility, and for their contributions to this book. They accepted my
self-care. Specific interventions highlighted include dys- challenge to put their knowledge and skill base into
phagia management, home adaptation, and wheeled mo- words. Their dedication to this project will inspire future
bility and seating prescription. Finally, two stroke survi- generations of clinicians and researchers
vors who share their thoughts, frustrations, and experiences I continue to appreciate the dedication and persistence
provide readers with invaluable insights to the stroke of the staff at Elsevier for supporting my work for over a
recovery process. decade, specifically Kathy Falk, Megan Fennell, Jolynn
It is my hope that this text will challenge practicing Gower, and Melissa Kuster.
clinicians to consider their present approaches to stroke
rehabilitation and serve as a foundation on which students Glen Gillen
 Contents

1 Pathophysiology, Medical Management, and 14 Functional Mobility, 350

Acute Rehabilitation of Stroke Survivors, 1 Leslie A. Kane and Karen A. Buckley
Matthew N. Bartels, Catherine A. Duffy, and Heather
15 Gait Awareness, 389
Edgar Beland
Clare C. Bassile and Sheila M. Hayes
2 Psychological Aspects of Stroke
16 Managing Visual and Visuospatial
Rehabilitation, 49
Impairments to Optimize Function, 417
Janet Falk-Kessler
Glen Gillen
3 Improving Participation and Quality of Life
17 How Therapists Think: Exploring Therapists’
through Occupation, 66
Reasoning When Working with Patients
Timothy J. Wolf and Carolyn M. Baum
Who Have Cognitive and Perceptual
4 Task-Oriented Approach to Stroke Problems Following Stroke, 438
Rehabilitation, 80 Carolyn A. Unsworth
Virgil Mathiowetz
18 Impact of Neurobehavioral Deficits on
5 Activity-Based Intervention in Stroke Activities of Daily Living, 456
Rehabilitation, 100 Guðrún Árnadóttir
Joyce S. Sabari
19 Treatment of Cognitive-Perceptual Deficits:
6 Approaches to Motor Control Dysfunction: A Function-Based Approach, 501
An Evidence-Based Review, 117 Glen Gillen and Kerry Brockmann Rubio
Ashwini K. Rao
20 Managing Speech and Language Deficits
7 Trunk Control: Supporting Functional after Stroke, 534
Independence, 156 Celia Stewart and Karen Riedel
Glen Gillen
21 Enhancing Performance of Activities of Daily
8 Overview of Balance Impairments: Functional Living, 553
Implications, 189 Birgitta Bernspång and Josefine Lampinen
Susan M. Donato and Karen Halliday Pulaski
22 Parenting after Stroke, 583
9 Vestibular Rehabilitation and Stroke, 210 Judith Rogers and Megan Kirshbaum
Helen S. Cohen
23 Driving and Community Mobility as an
10 Upper Extremity Function Instrumental Activity of Daily Living, 598
and Management, 218 Susan L. Pierce
Glen Gillen
24 Dysphagia Management, 629
11 Rehabilitation Technologies to Promote Wendy Avery
Upper Limb Recovery after Stroke, 280
25 Sexual Function and Intimacy, 648
Susan E. Fasoli
Jessica Farman and Judith Dicker Friedman
12 Edema Control, 307
26 Seating and Wheeled Mobility Prescription, 665
Sandra M. Artzberger and Jocelyn White
Mary Shea and Christine M. Johann
13 Splinting Applications, 326
27 Home Evaluation and Modifications, 693
Stephanie Milazzo and Glen Gillen
Catherine A. Duffy

ix
x Contents

28 Activities of Daily Living Adaptations: 30 A Survivor’s Perspective, 748

Managing the Environment with One-Handed Salvatore DiMauro
Techniques, 716
31 A Survivor’s Perspective II: Stroke, 752
Patricia A. Ryan and Jennie W. Sullivan
Barbara E. Neuhaus
29 Leisure Participation after Stroke, 735
Glen Gillen
 chapter 1

Pathophysiology, Medical
Management, and Acute
Rehabilitation of Stroke
Survivors

key terms
acute management hemorrhagic stroke stroke diagnosis
decubitus ulcer intensive care unit (ICU) stroke management
early mobilization ischemic stroke stroke prevention

chapter objectives
After completing this chapter, the reader will be able to accomplish the following:
1. Describe the pathophysiology of stroke.
2. Explain the diagnostic workup of stroke survivors.
3. Understand the medical management of various stroke syndromes.
4. Describe interventions to prevent the recurrence of stroke and its complications.
5. Understand normal and abnormal responses to acute stroke rehabilitation.
6. Be familiar with standardized assessments used during acute stroke rehabilitation.
7. Implement a comprehensive treatment that is safe for the acute and ICU settings.
8. Write appropriate goals for the acute and ICU settings.
9. Be able to prevent secondary complications such as skin breakdown and contracture after stroke.

Pathophysiology and Medical Management

of Stroke stroke is the second leading cause of mortality in developed
nations with 4.5 million deaths every year.109 An estimated
Matth ew N. B artels 550,000 strokes occur each year, resulting in 150,000
deaths and more than 300,000 individuals with significant
PREVALENCE AND IMPACT OF STROKE disability.119 The United States has an estimated 3 million
stroke survivors today, which is double the number of
Stroke remains the third leading cause of mortality survivors 25 years ago.54 The economic impact of stroke
in the United States after cardiovascular disease and cancer, in 2007 was estimated at $62.7 billion, markedly increased
accounting for 10% to 12% of all deaths.15,127 Globally, from the estimate in 2001 of $30 billion, of which $17 billion

1
2 Stroke Rehabilitation

were direct medical costs and $13 billion were indirect costs PATHOGENESIS AND PATHOLOGY
from lost productivity.119 Fortunately, modern medical in- OF STROKE
terventions (mostly risk factor modifications) have de-
creased stroke mortality by approximately 7% per year Definition and Description of Stroke Syndromes
in industrialized nations since 1970.15 The advances con- Stroke. Stroke is essentially a disease of the cerebral
tinue, but with increased cost of care for more advanced vasculature in which a failure to supply oxygen to brain
treatments. cells, which are the most susceptible to ischemic dam-
age, leads to their death. The syndromes that lead to
EPIDEMIOLOGY OF STROKE stroke compose two broad categories: ischemic and
hemorrhagic stroke. Ischemic strokes account for ap-
Stroke is essentially a preventable disease with known, proximately 80% of strokes, whereas hemorrhagic
manageable risk factors.16 The established risk factors strokes account for the remaining 20%.128
for stroke include hypertension, cigarette smoking, obe-
sity, elevated serum fibrinogen levels, diabetes, a seden- Transient Ischemic Attack. Symptoms of a transient
tary lifestyle, and the use of contraceptives with high ischemic attack (TIA) include the focal deficits of an
doses of estrogen.101 The most important and easily ischemic stroke within a clearly vascular distribution,
treated of these risk factors is systolic hypertension. In but TIAs are reversible defects because no cerebral in-
the Multiple Risk Factor Intervention Trial, 40% of farction ensues. The causes of TIAs can be thrombotic
strokes were attributed to systolic blood pressures greater and embolic and could result from a cerebral vasospasm.
than 140 mm Hg.130 Stroke incidence also increases ex- By definition, the effects of TIAs must resolve in less
ponentially with aging, with an increase in stroke from than 24 hours. Since 35% of patients who have had a
three in 100,000 individuals per year in the third and TIA will have a stroke within five years, they should have
fourth decades of age to 300 in 100,000 individuals per a complete evaluation for cerebrovascular disease and
year in the eighth and ninth decades of life.16 Eighty- sources of embolism.167 The treatment of TIAs depends
eight percent of stroke deaths occur among persons aged on the source of the emboli or thrombi and can include
65 years or older15 Table 1-1 outlines modifiable and anticoagulation therapy and/or surgery.
nonmodifiable risks.
Stroke prevention interventions have reduced mortal- Ischemic Stroke
ity in industrialized nations primarily through treating An ischemic stroke is the most common form of stroke
hypertension in the elderly. Another cause of decreased with various causes. The one common endpoint among
mortality has been the establishment of dedicated stroke all the different subtypes of ischemic strokes is that injury
units that can prevent acute death and later development results from tissue anoxia caused by an interruption of
of life-threatening complications. cerebral blood flow.

Table 1-1
Modifiable and Nonmodifiable Risks
TYPE OF RISK RELATIVE RISK (PER 1000 PERSONS)

Modifiable risks
Hypertension 4.0 to 5.0
Cardiac disease 2.0 to 4.0
Atrial fibrillation 5.6 to 17.6
Diabetes mellitus 1.5 to 3.0
Cigarette smoking 1.5 to 2.9
Alcohol abuse 1.0 to 4.0
Hyperlipidemia 1.0 to 2.0
Nonmodifiable risks
Age 1 to 2/1000 at age 45– to 54–years-old to 20/1000
at age 75– to 84–years-old
Gender 1.2 to 2.1
Race (black or Hispanic) 2.0
Heredity 1.8 to 3.1
 Chapter 1 • Pathophysiology, Medical Management, and Acute Rehabilitation of Stroke Survivors 3

Embolic Stroke. Cerebral embolic strokes are the most which are tumors of the heart endocardium. In addition,
common subtype of ischemic stroke. Embolic strokes embolic infarctions also may result from cardiac and tho-
usually are characterized by an abrupt onset, although racic surgery.83
they also can be associated with stuttering symptoms. Cardiac emboli usually (80% of the time) occlude
Usually no heralding events occur, such as TIAs or the middle cerebral artery, 10% of cardiac emboli occlude
previous small strokes evolving into larger strokes.83 the posterior cerebral artery, and the rest occlude the
A warning with microemboli that cause smaller events vertebral artery or its branches.83 Anterior cerebral artery
are uncommon, and the usual clue to a possible embolic embolization from the heart is rare. The severity of the
source is a completed stroke.128 The source of approxi- clinical syndrome is related to the size of the embolus. An
mately 40% of embolic strokes is unknown, even after embolus of 3 to 4 mm can cause a large stroke by occlud-
the common sources have been evaluated extensively. ing the larger brain arteries. Blood clots undergo lysis
Most embolic strokes of known cause occur after emboli over a few days with the establishment of recanalization
that are cardiac in origin.27 The second most common through the clot. Because clots naturally lyse, a stroke can
sources of emboli are atherothrombotic lesions that convert from ischemic to hemorrhagic when reperfusion
result in artery-to-artery embolisms. These lesions can distal to the occlusion is present, because the blood vessels
be in the aorta, the carotid and vertebrobasilar systems, in the ischemic distribution may no longer be intact. This
and, less frequently, smaller arteries. can lead to leakage from these damaged arteries, arteri-
oles, and capillaries, leading to a phenomenon called
Sources of Emboli hemorrhagic conversion. The possibility of hemorrhagic
Cardiac Sources. Cardiac emboli can develop from conversion contraindicates the use of anticoagulation
numerous areas in the heart. Cardiac dysrhythmias, struc- therapy as initial treatment for large embolic strokes.
tural anomalies, and acute infarctions are the usual sources Vascular Sources. Strokes vascular in origin are far
of emboli. The most common source of an embolism less common than cardiac strokes but are still one major
is the classical pattern of thrombosis in the left atrium type of embolic stroke. The sources of vascular emboli are
of patients with atrial fibrillation. The usual mechanism usually atheromatous plaques in the walls of the aorta,
of thrombus formation in atrial fibrillation is by clot carotid arteries, or smaller vessels in the cerebral circula-
formation in the left atrial appendage. This then breaks tion. Platelet activation and the formation of a fibrin clot
off and creates an embolus that can move through the can occur rapidly. The most common areas affected by
arterial system. Patients older than 60 years are particu- the emboli of the vascular system are the same as those
larly prone to this type of embolization. Embolism is not affected by cardiac sources of emboli. The most common
limited to the brain, and infarction can occur in the kid- areas for ulcerated plaques in the cerebral blood supply
neys, peripheral tissues, or any other location. are the aorta and the proximal internal carotid artery.
The most common cardiac structural cause of a cerebral The plaques in the carotid artery can be visualized by
embolism is due to a myocardial infarction.83 In patients Doppler sonography of the carotid artery system.128
with left ventricular infarcts, particularly anterior wall and Paradoxical Sources. Congenital atrial septal defects
apical infarctions, the endocardial damage associated with can create the opportunity for emboli to cross from the
a subendocardial or transmural infarction is an excellent right-sided (venous) circulation to the left-sided (arterial)
nidus (a focal point where bacteria or other infectious circulation, a rare source of cerebral emboli. A common
agents thrive) for thrombus formation. The emboli most source of paradoxical embolic material is deep venous
often develop during the first several weeks after the infarc- thrombosis (DVT). The modern techniques of transesoph-
tion, although the risk for developing them can persist ageal echocardiography with a “bubble study” help identify
for much longer. patients at risk for this condition. One performs a bubble
Valvular heart disease also can result in thrombi, but study by injecting a small bolus of air into the venous circu-
they more frequently develop after valve replacement lation while the echocardiographer observes the heart. If the
rather than result directly from the native valve. More air bolus, which is seen easily, has no portion cross over to
commonly the native valvular heart disease causes the the left-sided circulation, then no shunt is present. If the
patient to be in atrial fibrillation and then to develop an bubbles cross into the left-sided circulation, then a shunt is
embolus. Mechanical heart valves (e.g., St. Jude valves) possible. One of the most common atrial shunting abnor-
are much more likely to cause emboli than porcine (tissue) malities is a patent foramen ovale. In young patients or
valves, so patients with the mechanical type always patients who have had TIAs or strokes, the treatment of
continue to receive anticoagulation therapy. choice is surgical repair of the lesion.
Much less common sources of cardiac emboli are the Unknown Sources. Thrombi of unknown source often
vegetations resulting from bacterial endocarditis. These occur in patients with known hypercoagulability syndromes.
emboli cause small septic infarcts called mycotic aneurysms, These syndromes can result from acquired diseases (e.g.,
which are at high risk of conversion to hemorrhagic infarcts. lupus anticoagulant and metastatic tumors) or inborn errors
Other rare causes of cardiac emboli are atrial myxomas, of the coagulation system (e.g., protein S and C deficiencies).
4 Stroke Rehabilitation

Surgery or medication therapies such as estrogen replace- and the first stage of atherosclerosis is formed. Calcification
ment can induce iatrogenic causes of hypercoagulable states. and narrowing with resultant turbulent flow follow. In this
Even when the patient is known to be in a hypercoagulable setting of turbulent flow, plaque ulceration can become a
state, the source of the emboli may remain unknown. In site for thrombus formation. If the thrombus forms and is
many patients the entire workup is unrevealing. degraded rapidly, a transient ischemic phenomenon can oc-
cur, which is the setting of a TIA. Classically, the symptoms
Thrombotic Stroke of internal carotid disease include amaurosis fugax and
A thrombotic stroke can result from a variety of causes, monocular blindness. If the clot does not break up or lyse, a
but most causes are related to the development of abnor- cerebral infarction can occur. The size and severity of the
malities in the arterial vessel wall. Atherosclerosis, arteritis, infarction depends on available collateral circulation and the
dissections, and external compression of the vessels are size of the occluded vessel. In patients with extensive ath-
causes. In addition, some patients with hematological disor- erosclerotic disease, however, a limited amount of collateral
ders develop thrombosis. The spectrum of disease includes circulation is available, and the sparing from collateral cir-
stroke and TIA, and often the difference between a throm- culation may be limited.
botic and an embolic stroke may be difficult to determine.
Thrombosis and embolism are often both present, espe- Atherothrombotic Disease. The most common site for
cially in patients with atherosclerotic disease. The exact the development of atherosclerosis and the subsequent
mechanism of infarction from thrombosis is still being development of atherothrombosis that leads to TIAs
debated, but atherosclerosis does play a significant role. and stroke in the anterior circulation is the origin of the
Hypertension with associated microtrauma of the arterial carotid artery and in the posterior circulation is the top
intima is thought to play a role, as is hypercholesterol- of the basilar artery. Other sites of atherosclerosis in-
emia.104,128 TIAs may result from the formation of micro- clude the carotid siphon and the stems (bases) of the
thrombi and their embolization. Large vessel thrombosis middle cerebral artery, anterior cerebral artery, and ori-
can also occur in extracranial vessels, such as the vertebral gin of the basilar artery.51 The atheromatous plaques
and carotid arteries, leading to devastating strokes.117 are sources of emboli that can cause distal symptoms
in a TIA or stroke. These embolic events are similar
Pathophysiology. Atherosclerotic plaque formation is events from other embolic sources. Table 1-2 lists com-
greatest at the branching points of major vessels and forms mon stroke syndromes, and Figs. 1-1 to 1-3 explain
in areas of turbulent flow. Chronic hypertension is a com- the anatomy of these strokes. Atherosclerotic disease
mon precursor, and damage to the intimal wall may be fol- is screened most readily by carotid Doppler ultrasonog-
lowed by lymphocyte infiltration. Foam cells then develop, raphy and transcranial Doppler imaging. Magnetic

Table 1-2
Common Stroke Syndromes
ANATOMICAL DISTRIBUTION STROKE SYNDROME

Common carotid artery Often resembles middle cerebral artery (MCA) but can be
asymptomatic if circle of Willis is competent
Internal carotid artery Often resembles MCA but can be asymptomatic if circle of Willis is
competent
Middle cerebral artery
Main stem Contralateral hemiplegia
Contralateral hemianopia
Contralateral hemianesthesia
Head/eye turning toward the lesion
Dysphagia
Uninhibited neurogenic bladder
Dominant hemisphere
Global aphasia
Apraxia
Nondominant hemisphere
Aprosody and affective agnosia
Visuospatial deficit
Neglect syndrome
 Chapter 1 • Pathophysiology, Medical Management, and Acute Rehabilitation of Stroke Survivors 5

Table 1-2
Common Stroke Syndromes—cont’d

ANATOMICAL DISTRIBUTION STROKE SYNDROME

Upper division Contralateral hemiplegia; leg more spared

Contralateral hemianopia
Contralateral hemianesthesia
Head/eye turning toward the lesion
Dysphagia
Uninhibited neurogenic bladder
Dominant hemisphere
Broca (motor) aphasia
Apraxia
Nondominant hemisphere
Aprosody and affective agnosia
Visuospatial deficit
Neglect syndrome
Lower division Contralateral hemianopia
Dominant hemisphere
Wernicke aphasia
Nondominant hemisphere
Affective agnosia

Anterior cerebral artery (ACA)

Proximal (precommunal) segment (A1) Can be asymptomatic if circle of Willis is competent, but if both
ACAs arise from the same stem, then:
Profound abulia (akinetic mutism)
Bilateral pyramidal signs
Paraplegia
Postcommunal segment (A2) Contralateral hemiplegia; arm more spared
Contralateral hemianesthesia
Head/eye turning toward the lesion
Grasp reflex, sucking reflex, gegenhalten
Disconnection apraxia
Abulia
Gait apraxia
Urinary incontinence
Anterior choroidal artery
Contralateral hemiplegia
Hemianesthesia
Homonymous hemianopsia

Posterior cerebral artery

Proximal (precommunal) segment (P1) Thalamic syndrome:
Choreoathetosis
Spontaneous pain and dysesthesias
Sensory loss (all modalities)
Intention tremor
Mild hemiparesis
Thalamoperforate syndrome:
Crossed cerebellar ataxia
Ipsilateral third nerve palsy
Weber syndrome:
Contralateral hemiplegia
Ipsilateral third nerve palsy
Contralateral hemiplegia
Paralysis of vertical eye movement
Contralateral action tremor

Continued
6 Stroke Rehabilitation

Table 1-2
Common Stroke Syndromes—cont’d

ANATOMICAL DISTRIBUTION STROKE SYNDROME

Postcommunal segment (P2) Homonymous hemianopsia

Cortical blindness
Visual agnosia
Prosopagnosia
Dyschromatopsia
Alexia without agraphia
Memory deficits
Complex hallucinations
Vertebrobasilar syndromes
Superior cerebellar artery Ipsilateral cerebellar ataxia
Nausea/vomiting
Dysarthria
Contralateral loss of pain and temperature sensation
Partial deafness
Horner syndrome
Ipsilateral ataxic tremor
Anterior inferior Ipsilateral deafness
cerebellar artery Ipsilateral facial weakness
Nausea/vomiting
Vertigo
Nystagmus
Tinnitus
Cerebellar ataxia
Paresis of conjugate lateral gaze
Contralateral loss of pain and temperature sensation
Medial basal midbrain (Weber syndrome) Contralateral hemiplegia
Ipsilateral third nerve palsy
Tegmentum of midbrain (Benedikt syndrome) Ipsilateral third nerve palsy
Contralateral loss of pain and temperature sensation
Contralateral loss of joint position sensation
Contralateral ataxia
Contralateral chorea
Bilateral basal pons (locked-in syndrome) Bilateral hemiplegia
Bilateral cranial nerve palsy (upward gaze spared)
Lateral pons (Millard-Gubler syndrome) Ipsilateral sixth nerve palsy
Ipsilateral facial weakness
Contralateral hemiplegia
Lateral medulla (Wallenberg syndrome) Ipsilateral hemiataxia
Ipsilateral loss of facial pain and sensation
Contralateral loss of body pain and temperature sensation
Nystagmus
Ipsilateral Horner syndrome
Dysphagia and dysphonia

resonance angiography (MRA) and carotid and cerebral atherothrombotic or lipohyalinotic blockage of one of
angiography can further elucidate lesions, which can be these arteries. The development of disease in these
treated surgically or medically. arteries correlates closely with the presence of chronic
hypertension and diabetic microvascular disease.107,128
Lacunar Syndrome. A lacunar stroke occurs in one of These are small vessels, 100 to 300 m in diameter, that
the perforating branches of the circle of Willis, the branch off the main artery and penetrate into the deep
middle cerebral artery stem, or the vertebral or basilar gray or white matter of the cerebrum.107 The resulting
arteries. The occlusion of these vessels results from the infarcts are from 2 mm to 3 cm in size and account for
 Chapter 1 • Pathophysiology, Medical Management, and Acute Rehabilitation of Stroke Survivors 7

Anterior communicating artery pons, (2) pure sensory stroke from an infarct in the ven-
trolateral thalamus, (3) ataxic hemiparesis from an infarct
A2 segment Anterior
cerebral in the base of the pons or the genu of the internal cap-
A1 segment artery sule, and (4) pure motor hemiparesis with motor apraxia
resulting from an infarct in the genu of the anterior limb
Circle of Willis
of the internal capsule and the adjacent white matter in
Middle cerebral
the corona radiata. Recovery from a lacunar stroke often
Internal
artery carotid can be dramatic, and in some individuals, near complete
artery or complete resolution of deficits can occur in several
weeks or months. In patients who have had multiple la-
Posterior cunar infarcts, a syndrome characterized by emotional
communicating instability, slow abulia (impairment in or loss of volition),
artery
Posterior and bilateral pyramidal signs known as pseudobulbar
cerebral palsy will develop. This diagnosis is based on the symp-
artery
toms and the use of computerized tomography (CT) or
magnetic resonance imaging (MRI). MRI is especially
Basilar artery useful in this situation for detecting small lesions in the
deep brain structures or brainstem; the ability of CT to
see lesions clearly in these areas is limited.29
Vertebral
arteries Hemorrhagic Conversion. As a sequela of an embolic or
ischemic infarction, a purely ischemic infarct may con-
Figure 1-1 Circle of Willis and cerebral circulation.
vert into a hemorrhagic lesion. Thrombi can migrate,
lyse, and reperfuse into an ischemic area, leading to small
roughly 20% of all strokes. These types of strokes usually hemorrhages (petechial hemorrhages) because the dam-
evolve over a few hours and sometimes can be heralded aged capillaries and small blood vessels no longer main-
by transient symptoms in lacunar TIAs. Lacunar strokes tain their integrity. These damaged areas then can co-
can cause recognizable syndromes (Table 1-3). The basic alesce (combine) and form a hemorrhage into ischemia.83
lacunar syndromes are (1) pure motor hemiparesis from These conversions are more common in large infarcts,
an infarct in the posterior limb of the interior capsule or such as an occluded middle cerebral artery, or in a large

Medial prerolandic
artery
Secondary
motor Motor cortex
area Medial rolandic artery
Pericallosal
Sensory cortex
artery

Callosomarginal Parieto-occipital
artery artery

Frontopolar
artery
Calcarine
artery

Medial Visual cortex

orbitofrontal
artery Posterior thalamic artery
Anterior
communicating Anterior temporal artery
artery
Posterior Posterior
communicating cerebral stem
artery
Figure 1-2 Medial view of brain with anterior and posterior cerebral artery circulation and
areas of cortical function.
8 Stroke Rehabilitation

Rolandic artery
Sensory cortex
Motor cortex
Anterior parietal artery
Prerolandic
artery Posterior parietal
artery

Wernicke
aphasia area

Visual
radiation
Broca
area

Visual
cortex

Lateral
orbitofrontal
artery Angular
artery

Superior division
middle cerebral
artery Posterior
temporal artery
Anterior
temporal artery
Figure 1-3 Lateral view of brain with middle cerebral artery and its branches and areas of
cortical function.

Table 1-3
Lacunar Stroke Syndromes infarction in the distribution of a lenticulostriate artery.
and Their Anatomical Sites In patients who have large infarcts with possibility of
LACUNAR
hemorrhage, anticoagulation therapy is not used because
SYNDROME ANATOMICAL SITES of the risk of hemorrhagic conversion. These types of
hemorrhages have characteristics in common with hem-
Pure motor Posterior limb of internal capsule orrhagic strokes.
Basis pontis
Pyramids Hemorrhagic Stroke
Pure sensory Ventrolateral thalamus Hemorrhagic strokes have numerous causes. The four
Thalamocortical projections most common types are deep hypertensive intracerebral
Ataxic hemiparesis Pons
hemorrhages (ICHs), ruptured saccular aneurysms,
Genu of internal capsule
Corona radiata
bleeding from an arteriovenous malformation (AVM),
Cerebellum and spontaneous lobar hemorrhages.83
Motor hemiparesis Genu of the anterior limb of the
with apraxia internal capsule Hypertensive Bleed. Hypertensive cerebral hemorrhages
Corona radiata usually occur in four sites: the putamen and internal capsule,
Hemiballismus Head of caudate the pons, the thalamus, and the cerebellum. Usually these
Thalamus hemorrhages develop from small penetrating arteries in
Subthalamic nucleus the deep brain that have had damage from hypertension.
Dysarthria/clumsy Base of pons The pathological features of hypertension include lipohya-
hand Genu of anterior limb of the linosis (fat infiltration of pathologically degenerated tissue)
internal capsule
and Charcot-Bouchard aneurysms.50 The usual hyperten-
Sensory/motor Junction of the internal capsule
and thalamus
sive ICH develops over the span of a few minutes but
Anarthric Bilateral internal capsule occasionally can take as long as 60 minutes. Unlike ischemic
pseudobulbar infarcts, hemorrhagic bleeds do not follow the anatomical
distribution of blood vessels but dissect through tissue
 Chapter 1 • Pathophysiology, Medical Management, and Acute Rehabilitation of Stroke Survivors 9

planes spherically. This commonly leads to severe damage events. Because lobar bleeds occur far from the thalamus
and complications, such as hydrocephalus and mass shift and the brainstem, coma and stupor are much less com-
(movement of brain tissues to one side to accommodate mon than they are in patients with hypertensive ICHs.
the volume of the hemorrhage).83,128 Within 48 hours of Headaches are also common and can help differentiate
the hemorrhage, macrophages begin to phagocytize the lobar bleeds from ischemic strokes, which they can
hemorrhage at its outer margins. Patients with a cerebral resemble so closely.126 Detection of a hemorrhage on a
hemorrhage often experience a rapid recovery within CT scan or MRI is the best way to distinguish these two
the first two to three months after the hemorrhage. ICHs entities.
usually occur while patients are awake and often while they
are under emotional stress. Vomiting and headache are Saccular Aneurysm and Subarachnoid Bleed. A saccular
associated commonly with ICH and are unique features that aneurysm rupture is the most common cause of a
differentiate ICHs from ischemic strokes. Table 1-4 outlines subarachnoid hemorrhage (SAH).150 Saccular aneurysms
the four major hypertensive ICH syndromes. occur at the bifurcation (branching) points of the large
arteries in the brain and are most commonly found in the
Lobar Intracerebral Bleed. Lobar hemorrhages are ICHs anterior portion of the circle of Willis.83 An estimated
that occur outside the basal ganglia and thalamus in 0.5% to 1% of normal individuals harbor saccular aneu-
the white matter of the cerebral cortex. These types of rysms.158 Despite the high number, bleeding from them is
hemorrhages and hypertension are not correlated clearly; rare (6 to 16 per 100,000). Unlike other stroke syndromes,
the most common underlying condition in patients however, the incidence of SAH has not declined since
with this type of ICH is the presence of AVMs.83 Other 1970.102 The rupture risk correlates best with the size
associated conditions include bleeding diatheses, tumors of the aneurysm. Aneurysms smaller than 3 mm have little
(e.g., melanoma or glioma), aneurysms in the circle of chance of hemorrhage, whereas aneurysms 10 mm or
Willis, and a large number of idiopathic cases.49 Patients larger have the greatest chance of rupture.95 SAH usually
with lobar ICH initially have acute onset of symptoms, is characterized by acute, abrupt onset of a severe
and most lobar ICHs are small enough to cause discrete headache of atypical quality.102 These headaches are often
clinical syndromes that may resemble focal ischemic the most severe that patients have ever experienced.

Table 1-4
The Four Major Hypertension Intracerebral Hemorrhage Syndromes
TYPE STRUCTURES INVOLVED CLINICAL SYNDROME COMMENTS

Putamenal Internal capsule Contralateral hemiplegia Most common

Basal ganglia Coma in large infarcts
Eyes deviate away from lesion
Can have stupor/coma with brainstem compression
Decerebrate rigidity
Thalamic Thalamus Contralateral hemiplegia
Internal capsule Prominent contralateral sensory deficit for all
modalities
Aphasia if dominant (left) thalamus involved
Homonymous visual field defect
Gaze palsies
Horner syndrome
Eyes deviate downward
Pontine Pons Coma Can lead to a locked-in
Brainstem Quadriparesis syndrome
Midbrain Decerebrate rigidity
Severe acute hypertension
Death
Cerebellar Cerebellum Nausea and vomiting Nystagmus and limb
Ataxia ataxia are rare
Vertigo/dizziness
Occipital headache
Gaze toward the lesion
Occasional dysarthria and dysphagia
10 Stroke Rehabilitation

A brief loss of consciousness, nausea and vomiting, focal Posttraumatic Hemorrhagic Stroke. A traumatic brain
neurological deficits, and a stiff neck at the onset of symp- injury commonly results in hemorrhagic damage to the
toms also may occur. The diagnosis is based on clinical brain in addition to ischemic and other injuries. The four
suspicion, subarachnoid blood found on the CT scan, major types of injury caused by traumatic brain injury
or blood found in the cerebrospinal fluid from a spinal include SAH and ICH, diffuse axonal injury, contusions,
tap. One determines the definitive location of the and anoxic injury from hypoperfusion (decreased flow
aneurysm by cerebral angiography. in the vessels) and hypoxemia (decreased oxygen level).
The development of further delayed neurological This combination of injuries leads to a constellation of
deficits results from three major events: rerupture, hydro- findings that mixes the features of a number of individual
cephalus, and cerebral vasospasm. Rerupture occurs in ischemic and hemorrhagic injuries.
20% to 30% of cases within one month if treatment is not
aggressive, and rebleeding has an associated mortality rate Other Causes of Stroke and Strokelike Syndromes
of up to 70%.102 Hydrocephalus occurs in up to 20% of Arterial and Medical Disease. Numerous medical condi-
cases, and aggressive management often is required. tions can result in arterial system diseases and lead
Chronic hydrocephalus is also common and often re- to thrombosis and thromboembolism. Some conditions
quires permanent cerebrospinal fluid drainage (shunting). may cause disease in the cerebral vasculature (Table 1-5).
Vasospasm also is a common problem after SAHs, occur-
ring in approximately 30% of cases.102 The normal time Strokelike Syndromes. A number of conditions in addi-
course for vasospasm is an onset in three to five days, peak tion to TIAs and cerebral infarctions can cause transient
narrowing in five to 14 days, and resolution in two to four paralysis. These conditions generally resolve spontane-
weeks. In half of cases, the vasospasm is severe enough ously with no long-term sequelae. The most common
to cause a cerebral infarction with resulting stroke or cause of transient hemiparesis is Todd paralysis, which
death. Even with modern management, 15% to 20% of develops postictally (after a seizure). Todd paralysis results
patients who develop vasospasms still suffer strokes from neurotransmitter depletion and neuronal fatigue in
or die.96 A permanent ischemic deficit develops in focal areas of the brain caused by the extremely high
approximately 50% of patients with symptomatic vaso- neuronal firing rate during a seizure.37 Patients usually
spasms after SAHs.69 Vasospasm therefore must be treated regain function within 24 hours. Another common cause
rapidly and as aggressively as possible to prevent perma- of focal neurological deficits is migraine headaches. These
nent ischemic damage. headaches are actually thought to result from cerebral
vasospasms, but an actual ischemic infarct rarely if ever
Arteriovenous Malformation. AVMs are found occurs. The deficits resolve with the resolution of the
throughout the body and can occur in any part of the migraine and are not permanent.
brain. They are usually congenital and consist of an
abnormal tangle of blood vessels between the arterial Cerebral Neoplasm. Obviously, cerebral neoplasms
and venous systems. They range from a few millimeters (whether primary or metastatic) can lead to focal neuro-
in size to large masses that can increase cardiac output logical deficits that resemble a stroke. The treatment
because of the amount of their blood flow. The larger of the sequelae and the long-term management of
AVMs in the brain tend to be found in the posterior the deficits are the same as they are in stroke patients.
portions of the cerebral hemispheres.50 AVMs occur Treating the primary lesions is the focus of the acute care.
more frequently in men, and if found in one family Often the initial symptoms are seizures and ICHs.
member, they have a tendency to be found in other
members. AVMs are present from birth, but bleeding STROKE DIAGNOSIS
most often occurs in the second and third decades of
life. Headaches and seizures are common symptoms, as The diagnosis of stroke and differentiation of stroke from
is hemiplegia. Half of AVMs initially occur as ICHs. strokelike syndromes is based on the clinical presentation
Although rebleeding in the first month is rare, rebleed- and physical examination of the patient. The examiner
ing is common in larger lesions as more time passes. needs to differentiate a true stroke from syndromes that can
Contrast CT, MRA, and MRI are useful noninvasive mimic a stroke, such as Todd paralysis, seizures, multiple
tests, whereas cerebral angiography is the best test for sclerosis, tumors, and metabolic syndromes. Most often,
delineating the nature of the lesion. The management the patient’s symptoms in the emergency room include
of these lesions is accomplished best by a team ap- an acute onset of weakness or other neurological deficits.
proach, a combination of surgical treatment and inter- The patient history can help identify the risk factors
ventional angiography for definitive management. for stroke and the nature of the lesion. The physical
Treatment of hydrocephalus and increased intracranial examination includes a general medical examination and a
pressure is the same as treatment for SAH and ICH. neurological examination. Only after a diagnosis of stroke
 Chapter 1 • Pathophysiology, Medical Management, and Acute Rehabilitation of Stroke Survivors 11

Table 1-5
Medical Conditions That Cause Arterial System Disease
CONDITION FEATURES* TREATMENT

Vasculitic/inflammatory
Systemic lupus erythematosus Most commonly associated vasculitis with Treat lupus
stroke Anticoagulation with warfarin
Vasculitic, thrombotic, and embolic events
occur
Greater than 50% recurrence rate
Antiphospholipid antibody may play a role
Binswanger disease Rare condition No clear treatment
Diffuse subcortical infarction Anticoagulation
Diffuse lipohyalinosis of small arteries
Scleroderma Stroke in 6% of patients No clear treatment
Antiphospholipid antibody may play a role Anticoagulation
Periarteritis nodosa Can cause a CNS vasculitis Treat underlying condition
Can cause embolic stroke
Temporal arteritis Can cause a CNS vasculitis Treat underlying condition
Can cause embolic stroke
Wegener granulomatosis Can cause a CNS necrotizing vasculitis Treat underlying condition
Can cause thrombotic stroke
Takayasu arteritis Can cause embolic stroke Treat underlying condition
Anticoagulation
Isolated angiitis of the CNS Rare primary CNS vasculitis Treat underlying condition
Headache, multiinfarct dementia, lethargy
Fibromuscular dysplasia Mostly in young women Anticoagulation
Often asymptotic Surgical dilation of the carotid
Can be associated with TIA and stroke arteries (if necessary)
Moyamoya disease Vasooclusive disease of the large intracra- Role of anticoagulation controversial
nial arteries because of risk of hemorrhage
Mainly in Asian population Role of surgery controversial
Cause of strokes in children and young
adults

Hypercoagulable state
Antiphospholipid antibodies Associated with recurrent thrombosis Anticoagulation with warfarin
Embolic and thrombotic strokes occur
Oral contraceptive agents Relative risk increased 4 times over Stop oral contraceptives
controls
Thought to be caused by hypercoagulability
Sickle cell disease Microvascular occlusion caused by sickled No good treatments exist
cells
Seen in 5% to 17% of patients with sickle
cell disease
Polycythemia Vascular occlusion caused by increased Treat underlying cause (if known)
viscosity and hypercoagulability
Inherited thrombotic Include many familial clotting Treat abnormality (if possible)
tendencies abnormalities Anticoagulation

*CNS, Central nervous system; TIA, transient ischemic attack.

Continued
12 Stroke Rehabilitation

Table 1-5
Medical Conditions That Cause Arterial System Disease—cont’d
CONDITION FEATURES* TREATMENT

Others
Venous thrombosis Seen in meningitis, hypercoagulable states, Anticoagulation
and after trauma May need surgical decompression
Increased intracranial pressure, headache,
seizures
Focal neurological signs, especially in legs
more than arms
Diagnosed with angiography
Arterial dissection More common in children and young Surgical treatment as needed
adults Anticoagulation after acute state
May present with TIA
Often preceded by trauma, mild to severe

based on the clinical history and examination can a further between gray and white matter and sulcal effacement.
diagnostic evaluation be performed. Modern technology Acute bleeding, however, is visible on CT scanning and
has improved the tools available for the accurate diagnosis can be present in as many as 39% to 43% of patients.29
of stroke and includes an armamentarium of imaging stud- By definition, hemorrhagic infarction occurs within
ies to identify the exact nature of the lesions that may cause 24 hours of infarction, and hemorrhagic transformation
neurological deficits. Each imaging study available has ben- occurs after 24 hours of infarction. The cause of the
efits and limitations that are useful to know for assessing a hemorrhagic change is thought to result from reperfu-
patient who has had a stroke. The stroke evaluation also sion into areas of damaged capillary endothelium and
should include an evaluation for the cause of the stroke. is common in large infarcts with extensive injury.
Hemorrhagic transformation occurs equally in all
Cerebrovascular Imaging distributions of infarcts113 and is not associated neces-
The main tool used in stroke diagnostic evaluations is sarily with hypertension or with older age.27 Hemor-
cerebral imaging, which historically included pneumoen- rhagic transformation can be detected in the acute
cephalography and other studies no longer performed. phase by CT; in this case, one should not use anticoagu-
CT is probably the most common and the best known of lants because they may increase in the severity of
the studies. MRI is now more common and has some the cerebral hemorrhage.
advantages over CT, but availability and cost are still In the subacute phase, the findings from CT clearly
prohibitive in some areas. Positron emission tomography show the development of cerebral edema within three
scans and single-photon emission CT scans are just being days, which then fades over the next two to three weeks;
introduced and may have a role in stroke diagnosis. then a decrease in the signal intensity occurs over the
infarction. This decrease corresponds with the change
Computerized Axial Tomography from the positive mass effect (swelling) of the acute phase
CT is a readily available and useful technique that has to the negative mass effect (shrinkage) of the chronic
become the standard for the evaluation of a patient phase. The infarct actually may be difficult to see again in
experiencing an acute onset of stroke. The most impor- two to three weeks but is clearly visible with the addition
tant functions of CT scanning in an acute patient are of contrast material. Long-term parenchymal enhance-
ruling out other conditions (e.g., tumor or abscess) and ment develops, which is consistent with the scar forma-
helping identify whether evidence exists of hemorrhage tion that becomes the permanent CT finding. The loss
into the infarction. In the acute phase of stroke, most of tissue volume (negative mass effect) and the permanent
CT scans are actually negative with no clear evidence scar tissue are the characteristic features of a chronic
of abnormalities. A negative immediate CT scan with infarct (Figs. 1-4 to 1-8).
an acute neurological deficit determined by physical
examination actually can verify the impression of stroke Magnetic Resonance Imaging
because it rules out tumors, hemorrhages, and other MRI is now as commonly used in acute patients as CT,
brain lesions. The few changes seen in an acute stroke because cost and availability have improved. The MRI
by CT are subtle and can include loss of distinction also has the advantage of allowing earlier detection of
 Chapter 1 • Pathophysiology, Medical Management, and Acute Rehabilitation of Stroke Survivors 13

R L R L

Figure 1-4 Magnetic resonance image of brain without gado- Figure 1-6 Computerized tomography scan of the brain with-
linium demonstrates an acute large left basal ganglia infarct. An out contrast demonstrates a large, previous, left middle cerebral
acute infarct on the image appears white and is indicated by artery distribution infarction. Loss of mass of brain tissue has
arrows. occurred with dilated ventricles. Bleeding or acute infarction is
not evident.

infarcts and, as more acute interventions have become

R L common, allows for better evaluation of the course of
acute treatment. Newer techniques such as diffusion-
weighted averaging have been used to help in the identi-
fication of early infarcts.58, 141 MRI also can rule out other
conditions and can screen for acute bleeding. In addition,
MRI can be more sensitive for detecting cerebral infarc-
tions in acute patients. Magnetic resonance images are
created by mapping out the relaxation of protons after the
imposition of a strong magnetic field. These images are
then taken in two ways: T1- and T2-weighted images. In
T1 images, fat and tissues with similar proton densities
are enhanced (bright). In T2 images, water and tissues
rich in water are enhanced. As in CT scans, sulcal efface-
ment can be seen, but hyperintensity is also evident in
affected areas on the T1-weighted images. Magnetic reso-
nance images can show meningeal enhancement over
the dura, which occurs in 35% of acute stroke cases.44
MRI also can detect hemorrhage in much the same way as
CT does.
The subacute changes of edema and mass effect can be
Figure 1-5 Magnetic resonance image of the brainstem and seen with MRI, and use of contrast may be necessary to
cerebellum without gadolinium demonstrates an acute right elucidate an infarct in the two- to three-week window.
pontine infarct. The infarct appears white and is indicated by MRI has an advantage in determining a hemorrhage in a
arrows. late stage because it can detect the degradation products
14 Stroke Rehabilitation

of hemoglobin (hemosiderin deposits) and show hemor-

R L rhage areas well after CT can no longer detect a bleed.
The changes on MRI in a chronic infarction are similar to
those on a CT scan.
Positron Emission Tomography and Single-Photon
Emission Computerized Tomography Scanning
Positron emission tomography and single-photon emission
CT scanning are new techniques available only at selected
centers. They have no clear role in the acute-stage evalua-
tion of stroke.2 In the subacute and chronic stages of stroke,
these techniques help to distinguish between infarcted
and noninfarcted tissue and can help delineate areas of
dysfunctional but potentially salvageable brain tissue. These
studies can also be used to try to assess brain function in
the chronic setting. However, because of cost, limited
availability, and an unclear definition of their use, they are
essentially only research tools and do not have a role in the
routine management of stroke patients.

WORKUP FOR CAUSE OF STROKE

Figure 1-7 Computed tomography scan of the brain without
The workup for the diagnosis of stroke is aimed at an-
contrast demonstrates a large subacute left middle cerebral artery
swering three main questions:
distribution infarction, indicated by the hollow arrows. No loss
1. Is the stroke thrombotic or embolic?
of brain tissue mass has occurred compared with Fig. 1–6.
2. Does an underlying cause require treatment?
Evidence of acute bleeding is in the basal ganglia on the left,
3. Do any risk factors require modification?
which is white on the scan and is indicated with solid arrows.
Transcranial and Carotid Doppler
Transcranial and carotid Doppler studies allow for nonin-
vasive visualization of the cerebral vessels. The advantages
are that they provide useful therapeutic information on
the state of the cerebral vessels and the blood flow to the
brain. Approximately one third of patients who have had
ischemic strokes that are cardiac in origin have significant
cerebrovascular disease.25 Patients with symptoms or
evidence of posterior circulation disease are tested best
with a transcranial Doppler study, including examination
of the vertebrobasilar system. The cost is low compared
with other tests such as MRA or cerebral angiography,
which has significant associated morbidity and mortality.
The evidence of carotid disease can help shape the
patient’s treatment plan and can encourage pursuit of
definitive treatments such as carotid endarterectomy.

Magnetic Resonance Angiography

MRA is used to evaluate patients with stroke symptoms to
detect any vascular abnormalities that may have caused
the stroke or to look for alterations of cerebral blood flow
that may have resulted from an embolic or thrombotic
event. This is a very common noninvasive technique and
Figure 1-8 Computed tomography scan of the brain without is often done at the time of the MRI scan to assess the
contrast demonstrates a large, acute left thalamic hemorrhage. extent of cerebral injury; MRA is able to image vessels
The acute bleeding in the thalamus on the left is white on the similarly to classical angiography.160 The newer tech-
scan and is indicated with arrows. niques of MRA have sensitivity for detection of 86% to
 Chapter 1 • Pathophysiology, Medical Management, and Acute Rehabilitation of Stroke Survivors 15

90%111 for detection of severe stenosis, and the earlier Hemoglobin

issues of relatively low specificity of 64%13,79 (due to over- Females: Males:
detection by the earlier techniques) is now in the range of 12-16 g/100 mL 14-18 g/100 mL
89% to 96% for studies done with contrast enhanced White blood cells Platelets
MRA.77 Despite these advantages, the spatial resolution is 3-11 140-500
still less than traditional angiography, which may be an (in thousands) Hematocrit (in thousands)
Females: 37%-47%
issue in cases where surgical management is planned. Males: 40%-54%
However, with constantly improving techniques and Figure 1-9 Complete blood count.
increased field strengths and parallel imaging, high
resolution MRA may soon equal the resolution seen in
CT angiography.65
Table 1-6
Electrocardiography Medical Studies Used to Clarify Diagnoses
Electrocardiography is used to evaluate patients with in Stroke Evaluation
stroke symptoms to detect dysrhythmias (which may be a
source of embolic material) or myocardial infarction or SPECIALIZED STUDIES ASSOCIATED
TO EVALUATE STROKE CONDITIONS
other acute cardiac events that may be related to an acute
stroke. Proteins S and C Hypercoagulable state
Anticardiolipin antibodies Lupus erythematosus,
Echocardiography (lupus anticoagulant) hypercoagulable state
In patients with a history of cardiac disease and stroke, Erythrocyte sedimentation Collagen vascular disease
echocardiography usually is warranted. The types of rate
cardiac disease that usually cause emboli and should be Rheumatoid factor Lupus erythematosus,
investigated with an echocardiograph include congestive collagen vascular disease
Antinuclear antibody Lupus erythematosus,
heart failure, valvular heart disease, dysrhythmias, and a
collagen vascular disease
recent myocardial infarction. In some individuals, a
Hemoglobin Polycythemia
patent foramen ovale (the fetal opening between the Sickle cell preparation Sickle cell disease
right and left sides of the heart) persists into adulthood Hemoglobin Sickle cell disease
and can be the source of a paradoxical embolus from the electrophoresis
venous circulation that crosses from the right atrium into Blood and tissue cultures Infectious emboli
the left atrium. A transesophageal echocardiogram can
then be useful in combination with a bubble study to
assess for a right-to-left shunt. This specialized study also
can visualize parts of the heart better in the search for
emboli in areas such as the left atrial appendage when the progresses (Fig. 1-9). Table 1-6 provides a sample of some
standard transthoracic echocardiogram is inconclusive. of these studies and their associated conditions.
Blood Work
MEDICAL STROKE MANAGEMENT
The standard acute evaluation of the stroke patient
includes a complete screening set of blood analyses, Principal Goals
including hematological studies, serum electrolyte levels As in the medical management of all patients, the care of
(ionizing substances such as sodium and potassium), and stroke management requires good general patient care.
renal (e.g., serum creatinine) and hepatic chemical All phases include caring for the conditions the patient
analyses (liver function tests). The typical hematological may have and preventing medical complications and
evaluation has a complete blood count, platelet count, anticipating needs that will arise as the patient pro-
prothrombin time, and partial thromboplastin time. These gresses through the acute phase into the convalescent,
studies help to rule out other causes of strokelike symp- rehabilitative, and long-term maintenance phases after
toms, to diagnose complications, and to allow for a base- stroke. Care for acute patients is provided best in a spe-
line analysis before the initiation of therapies such as cialized stroke unit that commonly deals with the issues
anticoagulation. The blood chemistry analyses allow and concerns unique to these patients.2,102 Outcome
metabolic abnormalities to be ruled out, as do the renal studies have demonstrated the benefit of these units in
and hepatic chemistry analyses. The latter part of the the care of stroke patients.91 Medical rehabilitation units
stroke evaluation can involve numerous specialized tests also have been shown to be beneficial in the improve-
chosen according to the clinical symptoms and develop- ments of outcomes in the subacute and convalescent
ment of the differential diagnosis as the evaluation phases.
16 Stroke Rehabilitation

recanalization and reperfusion of occluded vessels reduces

Acute Stroke Management the infarction area. The theoretical benefit also exists of
In management of acute stroke patients, basic medical preventing clot propagation and recurring vascular throm-
needs have to be addressed and to include essentials such bosis. The risks associated with the use of these treatments
as airway protection, maintenance of adequate circulation, includes hemorrhagic conversion, hemorrhage, and in-
and the treatment of fractures or other injuries and condi- creased cerebral edema, all of which are associated with
tions present at the time of admission. The neurological worse outcomes.90 Current research has not established
management of the acute stroke problems focus on iden- a clear advantage to the use of aspirin or heparin in acute
tifying the cause of the stroke, preventing progression of stroke patients, but these agents still are commonly used in
the lesion, and treating acute neurological complications. the hope that they may decrease injury from acute stroke.
Some specific approaches apply to treatment of each of Aspirin, an irreversible antiplatelet agent, is administered
the different types of stroke. when symptoms appear. Heparin is administered intrave-
nously in a continuous infusion.71 Both of these agents are
General Principles started only after determination by CT or MRI that no
The general principles of acute stroke management in- hemorrhage is associated with the stroke. Ticlopidine,
clude attempting to stop progression of the lesion to limit another antiplatelet agent, has been even less studied,
deficits, reducing cerebral edema, decreasing the risk of and its role, if any, in acute stroke treatment is unclear.
hydrocephalus, treating seizures, and preventing compli- A recent metaanalysis of the trials of heparin and oral
cations such as DVT or aspiration that may lead to severe anticoagulation therapy in acute stroke treatment showed
illness. (See the previous sections for a discussion of the a marginal benefit from treatments with anticoagulation
studies used in acute patients to diagnose stroke.) Once compared with no treatment at all.135 Currently, numerous
the type of lesion has been defined, specific treatment can large, multicentric studies in the United States and Europe
be instituted. Although numerous studies have been are examining the best approach to the antithrombotic
performed and are underway on the reduction of stroke treatment of stroke that should provide better guidance as
mortality or disability,136 no routine medical or surgical their results become known in the next few years.
treatment has been shown to be effective. Currently, more
aggressive methods such as angioplasty and thrombolysis Thrombolytic Therapy. Thrombolytic therapy is
are being studied, and the results of these trials are ex- attractive as a therapy for acute stroke, because it opens
pected to lead to treatments that actually will improve the up occluded cerebral vessels and immediately restores
outcomes for individuals who have had strokes. blood flow to ischemic areas. However, a problem in
The basic principles in the approach to the treatment of using these agents in stroke treatment is that the treat-
acute stroke include an attempt to achieve improvement in ment must start in six hours from onset of symptoms to be
cerebral perfusion by reestablishing blood flow, decreasing therapeutic. Most patients are symptomatic at a much
neuronal damage at the site of ischemia by modifying the later stage, and even if they have symptoms early enough,
pathophysiological process, and decreasing edema in the a rapid workup to rule out a cerebral bleed must be per-
area of damaged tissue (which often can lead to secondary formed before initiation of therapy. The successful use of
damage to nonischemic brain tissue). Many pharmaco- these agents—primarily urokinase, streptokinase, and tis-
logical and surgical treatments have been targeted toward sue plasminogen activator—in the treatment of myocar-
at least one of these areas. Depending on the stroke mech- dial ischemia has aroused interest in similar use of these
anism, the agents and techniques of choice are used. agents for acute stroke treatment. The mechanism of ac-
tion of these agents is to cause fibrin breakdown in the
Ischemic Stroke clots that have been formed and thus to lead to lysis of the
In patients who have had ischemic strokes, the restoration occlusions in the blood vessels. Reviews of thrombolytic
of blood flow and the control of neuronal damage at the therapy for stroke treatment have shown some reduction
area of ischemia are of the highest priority. In large in mortality, but no definitive answer is available to date
strokes, edema can play a significant role, and mass shift concerning efficacy.163 Currently, streptokinase is out of
can even lead to hydrocephalus. The pharmacological favor because of increased mortality and morbidity from
therapies are divided broadly into antithrombotic, throm- intracranial hemorrhage,123,156 but tissue plasminogen
bolytic, neuroprotective, and antiedema therapies. The activator, a more specific thrombolytic agent, has been
surgical therapies include endarterectomy, extracranial- able to achieve favorable results. The National Institute
intracranial bypass, and balloon angioplasty. of Neurological Disorders and Stroke trial was the cor-
nerstone trial in approval of treatment of acute ischemic
Pharmacological Therapies stroke with thrombolytics.3,6,103,157 The trial was a double-
Antithrombotic Therapy (Antiplatelet and Anti- blind, placebo-controlled trial that revealed an improve-
coagulation). The principal rationale behind the use of ment in early outcomes in 24 hours of treatment
antiplatelet and anticoagulation agents is that rapid and demonstrated an increase in symptom-free survival
 Chapter 1 • Pathophysiology, Medical Management, and Acute Rehabilitation of Stroke Survivors 17

from 38% (placebo) to 50% (treatment) at three months. have not shown any clear benefits from treatment with
The strict use of a three-hour window from the onset of these agents,108 and none of them currently are used rou-
symptoms and the rigid blood pressure guidelines of the tinely for stroke treatment.
National Institute of Neurological Disorders and Stroke In animal experiments, glutamate antagonists decrease
trial are probably contributors to the excellent outcomes; the size of infarction area in stroke.90 However, the few
the exact treatment protocols are still being defined. On studies done in human beings have been inconclusive and
reexamination at one year, the treated patients continued have shown serious neuropsychiatric side effects.33
to show a benefit, and this has encouraged the use of this Gangliosides may reduce ischemic damage by counter-
agent in selected groups.87 Other thrombolytic agents acting toxic amino acids in ischemic tissue. Despite the
such as alteplase also have shown benefit and are being many studies that have been performed, no clearly demon-
used routinely. The results are at the same level of effec- strated benefits have resulted from use of these agents.33
tiveness as tissue plasminogen activator.5 Unfortunately, The free-radical scavengers include 21-amino steroids
the three-hour window of efficacy limits the number of (lazaroids), ascorbic acid (vitamin C), and tocopherol
individuals who can receive benefit, and studies to expand (vitamin E). They have not been well-evaluated, and some
the window of intervention to have hours or more have studies to establish their clinical use are being under-
not shown clear benefits.30,64 In the patient with stroke taken.90 However, vitamin E has been demonstrated
beyond three hours, the currently recommended inter- clinically to reduce the risk of heart disease, so secondarily
ventions are mostly limited to the use of anticoagulants its use may decrease the risk of stroke.
and antiplatelet agents to prevent further events.103 Fur-
ther active investigation continues to search for effective Agents for Cerebral Edema. Agents that reduce cere-
treatments in this large group of individuals with late bral edema include corticosteroids, mannitol, glycerol,
presentation of stroke. vinca alkaloids, and piracetam. All the studies done on
persons receiving steroids122 after an acute stroke demon-
Other Treatments for Altering Cerebral Perfusion. strated no clear benefits, and steroid use creates a risk
A number of different treatments aimed at lowering blood of diabetes and DVT.62 Use of the other agents also has
viscosity or cerebral perfusion have been used, including no clear benefit in the treatment of acute stroke and are
hemodilution with agents such as dextran, albumin, and also not routinely used.
hetastarch. None of the 12 studies reviewed by Asplund
demonstrated any clear benefit.9 Similarly, studies of Cooling Therapy. An exciting new development in the
prostacyclins and several different types of cerebral vaso- treatment of acute stroke has been the initiation of cool-
dilators have also shown no clear evidence of increased ing therapy on presentation with the induction of a medi-
survival rates or improvement in outcomes after treat- cal coma to limit the extent of brain injury after stroke. In
ment.90 Research continues to be active in these areas, but most patients who present with stroke, there is a natural
so far none of these alternative treatments for increasing tendency for the body temperature to be elevated between
cerebral perfusion has yielded a favorable outcome. 4% and 25%, which is associated with increased injury
and poorer outcomes.18,35 Studies have shown that injury
Neuroprotective Agents. Neuroprotective agents could be slowed with supercooling, and the technique has
are medications that can alter the course of metabolic been used in surgery to help limit injury and to prolong
events after the onset of ischemia and therefore have the safe surgical time in both neurosurgical and cardiotho-
potential to reduce stroke damage. No agent has shown racic procedures.28,131,139 The pooled analysis of existing
clear benefits among this group of treatments. These studies does not yet provide convincing evidence that
agents include calcium channel blockers, naloxone, gan- death or long-term disability are significantly changed
gliosides, glutamate antagonists, and free-radical scaven- from the application of mechanical or pharmacological
gers. Each of these agents has had promise in the theo- cooling, but the therapy is just starting to be used on a
retical or laboratory realm, but none has proved to be larger scale, and new research findings published in the
clinically efficacious. next several years may show a benefit to routine cooling
The use of naloxone, a narcotic antagonist, is based on of acute stroke victims.
the in vitro observation that naloxone has neuroprotective
effects. Unfortunately, the clinical trials to date have not Surgical Therapies
demonstrated any benefit.33 The therapeutic rationale of Endarterectomy. A carotid endarterectomy is the
using calcium channel blockers is that they prevent injury surgical opening of the carotid arteries to remove plaque.
to ischemic neurons by preventing calcium influx, which This therapy has been shown to be useful in preventing
decreases metabolic activity in the neuron.90 Initial hope recurrent strokes or development of stroke in individuals
was that the treatment results for SAH, in which ni- with TIAs, but it has not been used to treat acute stroke.
modipine decreases secondary ischemia, would be similar In theory, the opening of the carotids could subject ischemic
for stroke. Unfortunately, the results of several studies areas and their blood vessels to excessive pressure from
18 Stroke Rehabilitation

restored blood flow and lead to hemorrhage.40 Concerns treatments include the use of orally administered nimodi-
about using major anesthesia in a patient with a new pine, a calcium channel blocker shown to improve outcomes
stroke makes this surgery too risky to treat acute stroke. of patients who have had an SAH with vasospasm. The
results of using other calcium channel antagonists are un-
Extracranial-Intracranial Bypass. Despite the ini- clear. The use of hypertension/hypervolemia/hemodilution
tial attraction of bringing extracranial blood flow into the has been recommended by some studies. Creating more
intracranial vessels through the use of bypass procedures, volume than normal results in hypertension. The stretch
the large trial done in the 1980s demonstrated no im- caused by the volume stimulates the smooth muscle
provement in patient outcomes, and the procedure has pressure receptors that line the vessels. These receptors
been largely abandoned.47 inhibit muscle action by a protective response, and the
blood vessel dilates to accommodate the increased volume.
Balloon Angioplasty. Despite its efficacy in opening Hypertension/hypervolemia/hemodilution is most effective
blocked coronary arteries in patients with heart disease in preventing vasospasm after surgically clipping the aneu-
and its successful treatment of acute myocardial infarc- rysm. Significant cardiac and hemodynamic risks are associ-
tion, the use of balloon angioplasty in acute stroke has not ated with this therapy, so intensive care unit (ICU) monitor-
been studied. Clinical centers are actively investigating its ing is required.102
possible uses.

Hemorrhagic Stroke PREVENTION OF STROKE RECURRENCE

In patients who have had a hemorrhagic stroke, the size and Ischemic Stroke
location of the lesion determines the overall prognosis; su- In general, the strategies to prevent recurrence of ischemic
pratentorial lesions greater than 5 cm have a poor progno- stroke can be divided into two areas: risk factor modification
sis, and brainstem lesions of 3 cm are usually fatal.49 In these (which also applies to primary prevention) and secondary
cases, the control of edema is important, and the techniques prevention to treat the underlying cause of stroke in indi-
previously described can be used. In patients with SAH, the viduals with a history of stroke. Following is a discussion of
treatment regimen is usually more aggressive and focuses on the secondary interventions that can be used to prevent
several issues, which include the control of intracranial pres- recurrence of stroke.
sure, prevention of rebleeding, maintenance of cerebral
perfusion, and control of vasospasm. Hypertension. Although the treatment of hypertension is
an important primary preventive measure in the manage-
Prevention of Rebleeding. Before 1980, six weeks of bed ment of stroke, whether blood pressure reduction
rest were prescribed routinely for the care of patients with after stroke is beneficial has not been proved definitively.
acute SAH to prevent rebleeding. In 1981 a study demon- The transient rise in blood pressure after stroke usually
strated that bed rest was inferior to surgical treatment, settles without intervention.164 Because of the uncertainty
lowering of blood pressure, and carotid ligation.158 about whether overaggressive treatment of acute elevated
Antihypertensive medications for the prevention of blood pressure is harmful, definitive antihypertensive
rebleeding are still controversial, and no consensus exists therapy probably should be delayed for two weeks.90
as to their use. Carotid ligation used to be popular, but At that time, one should follow the usual recommenda-
more recent reevaluations of the benefits of the technique tions regarding adequate control of hypertension because
have not been as conclusive, and because of its surgical some evidence indicates that it is beneficial. This seems
risks, direct repair of the aneurysm is a better choice. especially appropriate in patients who have had a lacunar
Antifibrinolytic agents have been studied and have been stroke because the development of multiple lacunae is
beneficial for low-risk patients in whom surgery must be related to uncontrolled blood pressure.
delayed, but they seem to increase the risk of ischemic
events. The placement of intraluminal coils, balloons, and Antiplatelet Medications. In patients who have had a
polymers has shown some benefit in the short-term TIA or stroke, long-term use of aspirin has been shown to
prevention of rebleeding, but the long-term efficacy is decrease the incidence of death, myocardial infarction,
still unclear, and the techniques remain experimental.102 and recurrent events by up to 23%.7 The doses of aspirin
Because the risk of rebleeding is also very high in in numerous studies have ranged from 30 mg to 600 mg;
post-SAH seizures, even though the incidence of seizure all doses resulted in a 14% to 18% reduction in recurrent
is low, the recommendation is that patients receive cerebral events, but gastrointestinal complications in-
antiseizure medications for prophylaxis. creased with the higher doses.1,48,153 In general, a standard
dosage of one regular adult aspirin (325 mg a day) is the
Control of Vasospasm. The treatment of vasospasm is usual treatment for recurrent ischemic stroke. Studies are
important for the reasons previously outlined. The current underway that compare the efficacy of warfarin versus
 Chapter 1 • Pathophysiology, Medical Management, and Acute Rehabilitation of Stroke Survivors 19

aspirin in treating ischemic stroke; the results of these treatment for preventing recurrence includes treating the
studies are not yet available. Ticlopidine is another anti- vasculitis or terminating anticoagulant use.128
platelet medication effective in reducing the incidence of The secondary prevention of recurrent stroke and
recurrent stroke.81 Ticlopidine is most efficacious in SAH of AVMs and/or aneurysms includes surgical man-
women, patients who are not helped by aspirin therapy, agement of the lesions (the treatment of choice). Clipping
and patients with vertebrobasilar symptoms, hyperten- or microsurgical dissection of the lesions is performed
sion, diabetes, and no severe carotid disease.62 whenever possible and as soon as the patient is able safely
to undergo the procedure.102,149 In surgically unresectable
Anticoagulation. The incidence of recurrent stroke and lesions, alternatives include sclerotherapy, coating, trap-
TIA in patients with atrial fibrillation is approximately ping, and proximal arterial occlusion.102
7% per year. For patients who have atrial fibrillation with
cardiac sources of emboli, warfarin is the clear treatment PREVENTION OF COMPLICATIONS
of choice; this is true for primary and secondary preven- AND LONG-TERM SEQUELAE
tion. Although aspirin has some preventive effects, it is
not as efficacious. In the presence of structural cardiac General Principles
disease or atrial fibrillation, aspirin should be used only To prevent complications and long-term sequelae after a
to treat patients in whom warfarin anticoagulation is stroke, maximizing function, decreasing morbidity, and
contraindicated.90 preventing rehospitalization from a complication are
The odds ratio for recurrence is approximately 0.36 in important. Prevention of these complications begins on
those treated with warfarin versus control and 0.84 for the day the patient arrives at the hospital with symptoms
those treated with aspirin versus control.45 However, of acute stroke. Many complications are associated with
problems exist with warfarin anticoagulation in the el- bed rest in general, but some are specific to stroke.
derly. Cognitive and compliance difficulties can lead to an
increase in complications. Unclear issues in anticoagula- Musculoskeletal Complications
tion use include when to start anticoagulants after stroke, Contractures. Contractures are periarticular motion im-
the safety of anticoagulants in clinical practice, and the pairments that result from loss of elasticity in the periar-
optimum anticoagulant blood level. Several studies are ticular tissues, which include muscles, tendons, and liga-
currently examining these questions. ments. Contractures can occur in any immobilized joint
but are particularly prevalent in the paretic limbs after a
Treatment of Dysrhythmias or Underlying Disease. Ob- stroke. In fact, only 10% of stroke patients recover limb
viously, primary and secondary prevention should treat strength and mobility rapidly enough to avoid developing
the underlying cause of the ischemic stroke. Prevention contractures.63 Shoulder pain, contractures, and muscle
can include cardioversion to normal sinus rhythm and pain occur in 70% to 80% of patients who have had a
treatment with antidysrhythmic medications, and treat- hemiplegic stroke.128 Chapter 10 addresses the manage-
ment of underlying medical conditions if they can be ment and related issues of the hemiplegic shoulder. Con-
found. Unfortunately, only a small proportion of patients tractures also occur in other areas and begin to be prob-
who have had TIAs and strokes can benefit from these lematic within a few days of onset or several days after the
specific treatments. stroke when symptoms of immobility and spasticity may
begin to develop. Usually contractures occur in a pattern
Carotid Endarterectomy. The surgical treatment of of flexion, adduction, and internal rotation; muscles that
carotid artery stenosis has been shown to be beneficial in span two joints are more susceptible to contracture for-
recent studies of stroke recurrence in patients with se- mation.66 To prevent shortening of the connective tissue
verely (greater than 70%) stenosed carotid arteries.12,46 in muscles and joints, an active range of motion (ROM)
The data on the intermediate group of patients (stenosis program must be initiated. Because certain muscles span
from 30% to 70%) are being collected. For patients with two joints, joints must be positioned to allow full physio-
high-grade stenosis, carotid endarterectomy reduces logical stretch of the muscles involved. Once a contrac-
the range of stroke risk from 22% to 26% down to 8% ture is present, the mainstay of treatment is gradual,
to 12%. prolonged stretch. The minimal treatment is a sustained
stretch greater than 30 minutes.84 Other treatments in-
Hemorrhagic Stroke clude splinting, deep-heating modalities,23 and possible
The mainstay of ICH prevention is controlling systolic and surgical release for long-standing, tight contractures66
diastolic hypertension. No clear benefit exists for one group (see Chapter 13).
of treatment agents versus another as long as adequate
hypertension control is maintained. In patients in whom Osteoporosis. Bone is a metabolically active tissue normally
the ICH follows vasculitis or the use of anticoagulants, the in a state of equilibrium between active bone resorption
20 Stroke Rehabilitation

and deposition. The ratio of bone formation to bone Falls. Falls are of particular concern in survivors of stroke.
resorption is influenced by the stressors to which the bone These patients are at increased risk of hip fracture because
is subjected, a relationship known as Wolff law.23 The lack of developed osteoporosis, and the acuity of their balance,
of weight-bearing and normal stress on long bones on the visual perceptions, and spatial perceptions is decreased.
hemiplegic side of a stroke patient leads to a predominance The increased risk of falls has been documented in several
of bone resorption. This loss of bone mass can start as early studies and is greater in patients who have had a right
as 30 hours after the beginning of immobility155 and with hemispheric stroke.36,106,118 Fall prevention should empha-
bed rest can be as high as 25% to 45% in 30 to 36 weeks.39 size balance and cognitive training, removing environ-
In patients who have had a stroke, osteoporosis is often mental hazards, and using adaptive devices. (These mea-
worse, and the rate of hip fracture is far higher on the side sures are reviewed in Chapters 8, 14, 15, 19, 27, and 28.)
of the hemiplegia.67
Osteoporosis prevention is accomplished best with Neurological Complications
measures that include active weight-bearing exercise Seizures. Seizures after strokes have been documented
and active muscle contraction. Medical therapies for since the nineteenth century. The incidence of late-onset
individuals at risk for osteoporosis should be initiated. seizures (epilepsy) in the individuals who have had strokes
Therapies include bone-forming agents, calcium and ranges from 6% to 18%,59,162 whereas the incidence of
vitamin D supplementation, hormone replacement, and early seizures is approximately 10%, with reports ranging
other measures as needed. Box 1-1 shows some of the from 3% to 38%.14,168 The risk for seizures is highest
medical treatments available for osteoporosis. right after stroke; 57% of seizures occur in the first week,
and 88% of all seizures after strokes occur in the first
Heterotopical Ossification. Heterotopical ossification is year.14 Seizures are more common in patients who have
the deposition of calcium in the form of mature bone in had an SAH; 85% of these seizures are early seizures.148
the soft tissues. The condition is not particularly common The timing of seizures that occur after stroke varies
after stroke but occurs with increased incidence after trau- according to the mechanism of injury. The timing of
matic brain injury. The incidence ranges from 11% to seizures after thrombotic and embolic strokes appears
76% in various studies.17 Spasticity is associated with the about equal. Patients with SAH have more seizures soon
development of heterotopical ossification as are long- after the stroke, whereas patients with ICH are more
bone fractures and a prolonged coma. Symptoms of het- similar to patients with ischemic stroke and may have
erotopical ossification usually develop one to three months more late-onset seizures.168
after injury with pain and limited ROM.24 The diagnosis The treatment and management of seizures associated
is based on clinical examination, elevated alkaline phos- with stroke are usually straightforward, and monotherapy
phatase levels in the serum, and a positive bone scan. often produces adequate results. If the patient only has
Treatment for heterotopical ossification includes active acute-onset seizures in the setting of his or her stroke,
ROM; no studies indicate that the condition is caused or the patient often does not require long-term antiseizure
worsened by active ROM exercises.17 Pharmacological medication. A single, brief seizure or a nongeneralizing
treatment options include the use of etidronate disodium local seizure also can often be managed conservatively.
and nonsteroidal antiinflammatory drugs.24 Other treat- If seizures do require treatment, a single agent usually
ments include radiation therapy and, for refractory cases suffices and is beneficial, because the drug interactions
after the lesion has matured, surgical excision of the are fewer, and the compliance is better with monother-
heterotopical ossification. Performance of ROM exercises apy. Carbamazepine and phenytoin are the preferred
after surgery is particularly important. Low-dose radia- agents for treating epilepsy after stroke. Management of
tion or etidronate disodium can also be used to prevent the medication requires close follow-up to ensure
recurrence.34 that the desired outcome is achieved: an asymptomatic,
seizure-free patient. Excessive medication can lead to a
number of symptoms (Box 1-2). Inadequate control
Box 1-1 of the condition leads to additional seizures. For situa-
Treatments for Osteoporosis tions in which seizures become refractory to treatment,
one must remember several factors.168 Intercurrent ill-
■ Bone forming agents (etidronate and others) ness or metabolic disarray that lowers the seizure thresh-
■ Estrogen replacement
old may make the seizures more frequent and difficult to
■ Calcitonin
■ Calcium supplementation
treat. Patient compliance may be a problem, especially if
■ Vitamin D supplementation the stroke created cognitive and behavioral deficits. Pro-
■ Fluoride supplementation gressive lesions or new infarcts are also causes of increas-
■ Weight-bearing exercises ing seizure frequency. Finally, a stroke that occurs in
highly epileptogenic areas—such as the hippocampus,
 Chapter 1 • Pathophysiology, Medical Management, and Acute Rehabilitation of Stroke Survivors 21

Box 1-2 numerous, and they need to be tailored to each patient to

Signs of Excessive Antiseizure Medication find the best balance of side effects and efficacy. The most
commonly used agents are baclofen, dantrolene sodium,
■ Lethargy and diazepam. These medications and a representative
■ Drowsiness sample of the other medications used to treat patients
■ Depression who have had a stroke are presented in the table of medi-
■ Nystagmus cations and their side effects on the inside cover of the
■ Ataxia
book. Other treatments for severe spasticity that are more
■ Irritability
■ Distractibility
invasive include phenol blocks and neurolysis, botulinum
■ Poor cognition toxin (Botox) injections, and implantable baclofen pumps.
■ Poor memory Botox injections and baclofen pumps are still experimen-
tal approaches, and ongoing studies will elucidate their
future roles (see Chapter 10).

the parietooccipital cortex surrounding the rolandic fis- Other Complications

sure, and calcarine cortex—may engender refractory epi- Deconditioning. Physiological deconditioning in patients
lepsy and require combination therapy. Table 1-7 lists the after a stroke results from the acute medical illness and
common seizure medications and their side effects. the associated bed rest and immobility that may result.
Table 1-8 lists some of the effects of deconditioning.
Hydrocephalus. Hydrocephalus can occur acutely, espe- All of these factors can alter the ability of the patient to
cially in patients with SAH and ICH as discussed previously, recover. Therefore, to get the patient out of bed and
or it can develop symptoms insidiously later. Hydrocephalus to increase activity as early and aggressively as possible is
is usually heralded by the gradual onset of a triad of symp- important.
toms, including lethargy with decreased mental function,
ataxia, and urinary incontinence. Once hydrocephalus is Psychological Complications. Stroke is a major life event
suspected, one should perform a CT scan promptly because and is associated with significant alterations in the individ-
the increasing size of the ventricles is readily visible. Once ual’s well-being and independence. Negative emotional
diagnosed, one should surgically place a ventricular shunt. reactions are common in patients following a stroke152
The procedure is well-tolerated and can lead to resolution and can have a significant effect on the patient’s eventual
of all the symptoms of hydrocephalus if performed promptly. outcome. After a stroke, patients may go through the
Patients with an occluded shunt have symptoms that mimic four stages of bereavement described by Worden.172 These
the initial symptoms of hydrocephalus. include accepting the loss, experiencing the pain of the
loss, adjusting to a new environment in which previous
Spasticity. Spasticity is defined as a motor disorder abilities are missing, and investing in new activities. Not all
characterized by a velocity-dependent increase in tonic patients become depressed, and this lack of depression
stretch reflexes with exaggerated tendon jerks. Spasticity does not necessarily mean the patient is in denial.173
results from hyperexcitability of the stretch reflex Denial is a normal defense mechanism, and as long as it
(which is one component of the upper motor neuron does not interfere with the rehabilitative process, it is not
syndrome).89 In a normal recovery after a flaccid stroke, a concern.152 The indifference reaction, a persistent denial
an initial period occurs with little resistance to passive reaction, is more common in patients who have had a
motion of the muscles and joints. Approximately right-sided stroke than a left-sided stroke.53
48 hours after the stroke, tendon reflexes and muscle Another common consequence of stroke is emotional
resistance to passive motion begin to return.66 Spasticity lability, which is rapidly shifting from one extreme emotion
is most pronounced in the flexor muscles and occurs to another. Approximately 20% of patients have emotional
throughout the hemiplegic side. The lower extremity lability six months after a stroke, and up to 10% have
later develops a component of extensor spasticity that lability for one year. Emotional lability is more common in
can assist with function, whereas the upper extremity patients with pseudobulbar palsy and right hemispheric
spasticity is usually in a flexor pattern.10 strokes, particularly if the patient is depressed.74
The management of spasticity includes encouraging Anxiety is also common after stroke and is more frequent
voluntary movement, ROM exercises, and a functional in patients with left hemispheric strokes94 and cortical
rehabilitative approach.66 The research data on the differ- lesions.144 Many sources of anxiety exist, including financial
ent neurorehabilitative treatment approaches do not affairs, family issues, and a fear of dying or recurrent stroke.
define clearly which approach is most effective, so an Reassurance and constant positive feedback during re-
individualized approach to treating each patient is the best habilitation can help, and in severe cases, treatment
course. Pharmacological treatments for spasticity are with anxiolytics and psychological support may be needed.
22 Stroke Rehabilitation

Table 1-7
Medical Management of Seizures: Drug Therapy

MEDICATION SIDE EFFECTS PRINCIPAL USES

Phenytoin Ataxia Tonic-clonic (grand mal)

Incoordination Partial
Confusion
Rash
Gum hyperplasia
Hirsutism
Osteomalacia
Carbamazepine Ataxia Tonic-clonic (grand mal)
Dizziness Partial
Diplopia
Vertigo
Bone marrow suppression
Hepatotoxicity
Phenobarbital Sedation Tonic-clonic (grand mal)
Ataxia Partial
Confusion
Dizziness
Depression
Decreased libido
Rash
Primidone Same as phenobarbital Tonic-clonic (grand mal)
Partial
Valproic acid Ataxia Absence (petit mal)
Sedation Atypical absence
Tremor Myoclonic
Bone marrow suppression Tonic-clonic (grand mal)
Hepatotoxicity
Weight gain
Transient alopecia
Clonazepam Ataxia Absence (petit mal)
Sedation Atypical absence
Lethargy Myoclonic
Anorexia
Ethosuximide Ataxia Absence (petit mal)
Lethargy
Rash
Bone marrow suppression

Fortunately, outbursts and aggressive behavior are rare of the stroke. The consequences of depression after
after a stroke, but when they occur, they are more com- stroke are numerous: hospital stays are longer,42 cognitive
mon in patients with left-sided infarcts who are more impairment is greater,125 and motivation decreases.140
aware of their deficits. The approach to management of Depression is more common in patients with left cortical
these outbursts should not include restraints and threats lesions145 and lesions close to the frontal poles and is
but should be based on avoiding excessive frustration in shorter in patients with subcortical and brainstem lesions.
the patient by removing emotional triggers and alternat- Depression after stroke often is treated best with antide-
ing easy and difficult tasks.152 pressant medications.152 In patients who are unable to
Depression is common after stroke, developing in 20% tolerate antidepressants, are unresponsive to therapy, or
to 50% of stroke survivors, with 30% being the most have active suicidal ideation, electroconvulsive therapy
commonly accepted figure.152 The depression can be a can be a last resort.110 (See Chapter 2 for more informa-
reaction to the stroke or a neuropsychological sequela tion about the psychological effects of stroke.)
 Chapter 1 • Pathophysiology, Medical Management, and Acute Rehabilitation of Stroke Survivors 23

Table 1-8 also benefit from condom catheters. The goal of all
Deconditioning Effects of Stroke of these therapies is to maintain continence and prevent
urinary tract infections and other complications such as
Musculoskeletal Atrophy skin breakdown from skin maceration.
↓ Strength of tendons, liga-
ments, bones, and muscles
Depression
Skin Breakdown and Decubitus Ulcers. Pressure ulcer
Anxiety formation is a serious health problem in debilitated
Sleep disturbance and immobilized patients. After a stroke, patients are at
Cardiovascular ↓ Stroke volume particular risk for pressure ulcers because they have
↑ Heart rate numerous factors contributing to skin breakdown. Abnor-
↓ VO2 max mal sensation, contracture, malnutrition, immobility, and
↑ Respiratory rate muscle and soft-tissue atrophy often develop and may be
↓ Lean body mass complicated by advanced age. Prevention of pressure
↑ Body fat ulcers, rather than treatment of developing ulcers, should
Orthostatic hypotension be the focus of care. Preventive measures include frequent
Neurological/emotional Sensory deprivation
repositioning, keeping skin clean and dry, maintaining an
↓ Balance
↓ Coordination
adequate level of nutrition, and, especially in high-risk
Fatigue patients, using pressure-relief mattresses.132 Once pres-
Genitourinary Diuresis sure ulcers have formed, in addition to strictly observing
Difficulty voiding the preventive and pressure relieving measures previously
Endocrine Impaired glucose tolerance noted, treatments include meticulous wound care with a
Altered regulation of variety of agents and possibly surgical reconstruction.
hormones
Body composition and Nitrogen loss Dysphagia. Swallowing disorders are common after a
metabolism Calcium loss stroke. Dysphagia is more common in the elderly, with an
Potassium loss incidence of 25% to 45%.59,61 Aspiration can lead to
Phosphorus loss
pneumonia, and a decreased eating ability can lead to
Sulfur loss
dehydration and malnutrition. Chapter 24 covers the
details of the pathology of aspiration and the methods of
its treatment.

Urinary Tract Dysfunction. Urinary incontinence is Aspiration. Aspiration causes chemical pneumonitis
common after stroke, affecting 51% to 60% of patients,20 that can lead to a secondary bacterial infection. Because
and can cause difficulties with rehabilitation, influence numerous anaerobic organisms are in the mouth, aspira-
eventual discharge location, and place stress on caregiv- tion pneumonia can develop into an anaerobic abscess.92
ers.43 One month and six months after stroke, 29% and Such abscesses occur less frequently in edentulous
14% of patients, respectively, still have urinary inconti- individuals because they have less oral flora and can occur
nence.11 The usual pathophysiology of incontinence is in up to a third of cases in hospitalized patients.97
detrusor hyperreflexia, which is common in patients with The treatment of choice is to reduce the risk of aspiration
cortical lesions. The incontinence assessment includes and to administer antibiotics. Examining a radiographic
a thorough history of the urinary symptoms and can film for evidence of abscess cavities and the sputum
include urodynamic studies to help define the problem. for organisms can help one develop a specific medical
Incontinence treatment includes timed voiding and use of treatment. Sputum culture growth often requires up to
pharmacological agents and intermittent catheterization. three or four days, so initial treatment is often empirical
If these treatments do not work, incontinence may need to and should be the administration of a wide-spectrum
be treated by indwelling catheterization. This is performed antibiotic that is effective against hospital-acquired or-
on patients who cannot independently self-catheterize ganisms (which are often resistant to certain antibiotics)
and do not have caretakers who can provide this care or on and anaerobic bacteria.92 The usual course of antibiotics
patients who have physical barriers such as urethral stric- is seven to 10 days, but cavitary pneumonia may require
tures that prevent regular catheterizations. Unfortunately, far longer treatment for eradication of the organism.93
indwelling catheters have a high incidence of associated Determination of which specific antibacterial agents to
urinary tract infections. Male patients also may use use depends on the resistance patterns in the institution in
external condom catheters, which can provide socially which the aspiration takes place; the infectious disease
acceptable continence when the individual is traveling team at that institution should make the decision about
or physically active. Patients with continuous dribbling which antibiotics to use.
24 Stroke Rehabilitation

Deep Venous Thrombosis. DVT is a common problem DVT.73 Objective testing for DVT has venography as the
after stroke and has an incidence of 23% to 75% de- gold standard, but this procedure is associated with
pending on the severity of the stroke. Most of the mor- significant risks, including anaphylaxis and causing DVT.
bidity and mortality associated with DVT results from More commonly used risk-free procedures are impedance
venous thromboembolism (VTE). Pulmonary embolism plethysmography, which is a noninvasive test that
after stroke has an incidence of 10% to 29% and a mor- measures volume changes in the leg with circumferential
tality rate of 10%.19 The formation of DVT is caused by calf electrodes,75 and Doppler ultrasound, which is also a
the triad of risk factors outlined by Virchow postulates: noninvasive test that uses a handheld probe to detect
altered blood flow, damage to the blood vessel wall, and blood flow in deep leg veins.166 Doppler ultrasound and
altered blood coagulability. Box 1-3 lists the common impedance plethysmography have similar sensitivities and
risk factors for DVT. Of the risk factors for DVT, stasis specificities for DVT detection, but Doppler ultrasound
is one of the most important. After a stroke, DVT is is not as portable and has a higher cost than impedance
10 times more common in the paretic leg.165 DVT usu- plethysmography.19
ally begins in the calf, and although the emboli from The clinical diagnosis of pulmonary embolism is also
calf thrombi are not dangerous, these thrombi propa- unreliable, and only 30% of patients with pulmonary
gate in about 20% of cases, and about 50% of the embolism have clinical DVT, even though 70% have
proximal deep venous thrombi embolize. About 20% of venographic evidence of DVT.19 The symptoms of
symptomatic pulmonary emboli are fatal.134 After a submassive pulmonary embolism overlap with the symp-
stroke, ambulation in itself is not preventive in the sub- toms of many other pulmonary conditions, including
acute setting: pulmonary embolism occurred in 57% of tachypnea, tachycardia, rales, hemoptysis, pleuritic chest
ambulatory patients in the rehabilitation setting.147 pain, pleural effusion, general malaise, bronchospasm,
Lower extremity and pelvic DVT are the most com- and fever. In patients with massive pulmonary embolism
mon, but proximal upper extremity DVT also can oc- with greater than 60% of the pulmonary circulation
cur, although it is rare. All of the diagnostic and man- obstructed, patients are critically ill and develop heart
agement issues discussed in the section on VTE that failure, circulatory collapse, hypotension, and coma
follows applies to this condition as well. and can die suddenly.147 The gold standard for testing
The diagnosis of DVT in the clinical setting is unreli- for pulmonary embolism is the pulmonary angiogram,
able,19 and many patients with life-threatening embolism but its use is associated with significant morbidity
and thrombosis have no clinical symptoms of DVT. Other and mortality. The preferred noninvasive test is the
patients with swelling and tenderness may not have DVT ventilation/perfusion scan.105
at all and may have any of a number of other diagnoses. The best approach to VTE is to prevent DVT. The
The differential diagnosis of lower extremity pain and National Institutes of Health Consensus Conference on
swelling includes trauma, fracture, gout, cellulitis, and the Prevention of Venous Thrombosis and Pulmonary
superficial phlebitis. The usual clinical signs of DVT in- Embolism recommends using low doses of subcutane-
clude pain and tenderness, swelling, the presence of ously administered heparin in all stroke patients with no
Homans sign (elicited by dorsiflexion of the ankle while hemorrhagic components.121 In all other patients, exter-
the knee is flexed resulting in pain in the calf), superficial nal pneumatic calf compression is recommended. More
venous distention, a palpable cord, and fever. Some of recently, low-molecular-weight heparin has been intro-
these signs, such as Homans, are unreliable indicators. duced and actually may be more effective than standard
Homans sign is present in less than one third of patients heparin for DVT prophylaxis.72 Low doses of warfarin
with DVT and is present in half of patients without for DVT prophylaxis in stroke patients has not been
well-studied, but its use in other conditions has proved
its effectiveness in DVT reduction. Dextran, aspirin,
Box 1-3 and static compression stockings are not effective for
Risk Factors for DVT preventing DVT.19 Physical treatments alone, such as
ROM exercises, have not been studied. Ambulatory pa-
■ Immobilization tients must be able to walk at least 50 feet to have a re-
■ Postoperative state duction in risk of DVT,21 but as previously stated, the
■ Age 40 years risk of pulmonary embolism in ambulatory patients is
■ Cardiac disease
still significant.147 The length of time prophylaxis should
■ Limb trauma
■
continue is still not definite, but evidence shows that
Coagulation disorders
■ Obesity continuing prophylaxis well into the subacute phase is
■ Advanced neoplasm warranted.19
■ Pregnancy The treatment of VTE (DVT and pulmonary embo-
lism) is based on preventing pulmonary embolism, which
 Chapter 1 • Pathophysiology, Medical Management, and Acute Rehabilitation of Stroke Survivors 25

can be fatal. A patient who is identified with acute VTE is 7.5 mm Hg increase in diastolic pressure is a 46% increase
started on intravenous (IV) heparin as long as no contra- in stroke incidence and a 29% increase in coronary heart
indications to anticoagulation exist.70 The effectiveness of disease (CHD). Reducing blood pressure in hypertensive
the heparin is determined by monitoring the partial patients has been shown to decrease the risk of stroke sig-
thromboplastin time, and the heparin is adjusted to a dose nificantly, with an average reduction of 5.8 mm Hg leading
between 1.5 and 2.5 times control. In a patient with only to a reduction in stroke incidence of 42% but only a 14%
DVT, warfarin can be started on the first day, and the reduction in CHD incidence.32 Because these trials only
heparin can be discontinued when the warfarin dose is spanned two to five years, the reduction in stroke incidence
therapeutic as measured by the increase in the prothrom- is a direct result of decreased blood pressure and not an
bin time or international normalized ratio. Targets are a alteration in atherogenesis (production of plaque in the
prothrombin time of 1.25 to 1.5 times control or an inter- arteries), which would take longer to develop.169 Systolic
national normalized ratio of 2 to 3.19 In patients with blood pressure is also a factor; the treatment of isolated
pulmonary embolism, warfarin may be started a few days systolic hypertension (160 mm Hg) has been shown to
later, and after management of the acute stage, the patient reduce the incidence of stroke by 36% and CHD by 27%
keeps receiving it longer; patients with DVT receive war- over 4.5 years.120 Treating all forms of hypertension in the
farin for approximately three months, and patients with older age groups is therefore essential because they are at
pulmonary embolism, for six months.72 All patients who increased risk for stroke, and most strokes occur in this age
recently have been diagnosed with VTE are placed on bed group. Screening for hypertension and aggressively treat-
rest initially and usually are allowed to become mobile ing systolic and diastolic hypertension should be the cor-
two days after the partial thromboplastin time has become nerstone of any primary prevention program for stroke.
therapeutic.76 The rehabilitation of patients with VTE
who are beginning treatment should continue at the bed Cigarette Smoking
side, and, in the case of patients with lower extremity The results of the Framingham Study and the Nurses’
DVT, the rehabilitation program should include activity Health Study demonstrate that the cessation of cigarette
of daily living (ADL) training, upper extremity programs, smoking should lead to a prompt reduction in stroke mor-
communication work, and dysphagia treatments. tality.31,171 Risk of CHD decreases by 50% in one year and
reaches the level of a nonsmoker’s risk in five years. Smok-
FUTURE TRENDS IN MEDICAL STROKE ing increases stroke risk by 40% in men and 60% in women
MANAGEMENT (with no other risk factors being considered), and it seems
to follow that smoking cessation leads to a reduction in
Improved Primary Stroke Prevention stroke risk similar to the reduction in CHD incidence.
Because the treatments for stroke are so limited and the
deficits that can result are so devastating, the primary Cardiac Dysrhythmia and Myocardial Infarction
prevention of stroke has to be the essential strategy to CHD, atrial fibrillation, and congestive heart failure lead
decrease morbidity and mortality from stroke. With a to an increased incidence of stroke.169 Preventing these
good understanding of the risk factors for stroke, risk fac- conditions by modifying their associated risk factors leads
tor modification can be targeted at groups and individuals to a reduction in incidence of stroke. In addition, treating
who are at risk. Table 1-1 lists the preventable and patients who have established dysrhythmias and conges-
nonpreventable risk factors for stroke. Fortunately, many tive heart failure with anticoagulants such as warfarin de-
of the risk factors are the same as those for myocardial creases the incidence of stroke (as explained previously).
infarction and vascular disease leading to death, so the
modification of stroke risk factors also decreases the risk Blood Lipids
of cardiac-related morbidity and mortality. Due to greater The development of carotid artery atherosclerotic disease
awareness and risk factor modification and largely through has been shown to be related to the levels of serum lip-
the treatment of blood pressure, a decline of greater than ids.133 However, to relate accelerated atherosclerosis
50% in the stroke mortality rate has occurred in the past clearly to an increase in the incidence of stroke has been
20 years.169 Each of the modifiable risk factors are consid- difficult because other pathologies related to serum lipids
ered separately. have been observed. Levels of total serum cholesterol less
than 160 mg/dL seem to be associated with ICH and
Hypertension SAH, whereas higher levels of serum cholesterol are
Diastolic and systolic hypertension are each independently associated with atherothrombosis. No relationship has
and strongly implicated in causing stroke. Hypertension been demonstrated between cholesterol and lacunar
increases the risk of stroke in all age groups of men and strokes.169 This unusual relationship of low serum lipids
women.169 In fact, no threshold level of blood pressure and higher hemorrhagic infarct has been demonstrated in
exists below which the risk curve plateaus.98 For every Japan and also recently in the United States in the group
26 Stroke Rehabilitation

of patients studied in the Multiple Risk Factor Interven- history and physical. Routine blood pressure screening
tion Trial.78,124 Because of the ambiguity of these data, should be included in all evaluations, and patients who
a clear statement of guidelines for the management of have hypertension should be treated. A stroke risk profile
cholesterol to reduce incidence is difficult to make. has been assembled from the Framingham Study data and
can be used by physicians170 (e.g., to help a physician de-
Diabetes cide which borderline hypertensive patients to treat).
The rate of atherosclerosis development in coronary, Education can start in the physician’s office and be contin-
femoral, and cerebral vessels is increased in diabetics. ued by all the other health professionals with whom the
Stroke is increased 2.5 to 4 times in diabetics compared patient comes into contact. If the community at large is
with nondiabetics.86 In the Framingham Study, glucose educated about the risk factors of stroke, those individuals
intolerance (a blood sugar greater than 150 mg/mL) is who are at highest risk can seek out the attention they
only a significant, independent contributor to stroke in require. This model has been implemented and supported
older women and is greater for women than men at any through research such as the Agency for Health Care
age.80 Because of the associated risk of stroke, careful Policy and Research Smoking Cessation Clinical Practice
management of diabetes in addition to all other risk fac- Guidelines.116
tors is prudent.

Oral Contraceptives PART TWO: Introduction to Acute Stroke

Rehabilitation
In female patients over the age of 35 who have other
stroke risk factors, oral contraceptive use is associated Ca t h e r in e A. Du f f y
with increased incidence of stroke.142 The relative risk He a t h e r Edg a r B e la n d
for oral contraceptive users is approximately five times
greater if they are already in the high-risk group. With The neuro-ICU may be the starting point of occupational
the use of lower estrogen formulation oral contracep- therapy (OT) evaluation and treatment. Many patients
tives, the risk has decreased substantially in recent are evaluated, by an occupational therapist, within
years.143 That the incidence of fatal SAH increased in 48 hours of a stroke. The ICU environment is often
oral contraceptive-using women with concomitant fast paced with the focus on monitoring the individual
smoking is noteworthy; in the group over age 35 the patient’s medical status. The primary goals of any neuro-
incidence is four times higher.52 Therefore, the recom- ICU are to stabilize the patient medically, progress the
mendation is that women over the age of 35 avoid using patient neurologically, and support the patient and family
oral contraceptives, and younger women who smoke through this neurological crisis.137 Medical testing and
should be advised of the increased risks associated with procedures take precedence over any OT treatment.
concurrent oral contraceptive use. Scheduling OT services may be difficult, treatments may
be interrupted, and flexibility is necessary.
Alcohol
Heavy alcohol consumption is related to an increase THE IMPORTANCE OF EARLY INTERVENTION
in stroke and stroke deaths, whereas light to moderate
alcohol consumption is associated with a reduced There are many common complications associated with a
incidence of CHD.38,85 Alcohol is clearly related to hem- prolonged ICU stay, which include but are not limited
orrhagic stroke events, but the association with thrombo- to deconditioning, muscle weakness, contractures, skin
embolic events is not definite. Regardless, patients at risk impairments, depression, anxiety, and reduced quality of
for stroke should avoid heavy alcohol consumption. life.60 Early OT, engaging in ADL and mobilization, can
increase a patient’s level of consciousness, enhance overall
Physical Activity mental well-being, and foster functional indepen-
Despite the clear benefits of physical activity in the reduc- dence.129,146 Occupational therapists provide a variety
tion of CHD morbidity and mortality, no clear associa- of treatments in the ICU, including, but not limited to,
tion exists between physical activity and the incidence of evaluations, splinting, positioning, cognitive retraining,
stroke.114,115 self-care, and functional mobility training.

Public Education
TEAM APPROACH
The primary goal of primary and secondary prevention
programs should be to educate individuals about risk There are many members of the neuro-ICU/acute care
factors and then to teach them the way to modify their team, and the team may vary among settings. They include
risks. During routine visits, a physician should be able a primary team of physicians led by an attending neurolo-
to identify at-risk patients through a combination of a gist specializing in critical care. Depending on each case,
 Chapter 1 • Pathophysiology, Medical Management, and Acute Rehabilitation of Stroke Survivors 27

there may be neurosurgeons also involved in patient care. patient’s neurological status deteriorate. Once the
At teaching hospitals, a team of residents may also make patient has been medically cleared for OT evaluation,
medical decisions regarding the patients. Along with the a review of the patient’s medical chart should be com-
occupational therapist, the ancillary team consists of nurs- pleted. The therapist can glean information relating
ing, including the primary nurse and nurse practitioner, to any precautions and complications that may interfere
social workers, nutritionist, speech and language patholo- with the OT treatment (Box 1-4).
gist, and physical therapist (Table 1-9). An occupational
therapist treating patients in this environment must foster MONITORING THE ICU/ACUTE STROKE
these relationships to safely treat patients. SURVIVOR
The relationship between the primary physician,
nurse, and the occupational therapist is particular Any therapist treating in the ICU should not only be aware
important. Daily communication with the physicians, of the medical and nursing priorities in the ICU, but also of
residents, and primary nurse is necessary prior to how to monitor the patient during OT treatment. The
initiating an evaluation or treatment session due to the therapist needs to be competent in reading ICU monitors
fluctuating physical condition in the ICU phase of and handling ICU related drains and lines, so that appropri-
hospitalization.4,137 Physicians, nursing, or the occupa- ate parameters and precautions are adhered to during the
tional therapist, using their own clinical judgment will treatment session. Common monitors, drains, lines, and
determine if intervention should be delayed should a clinical implications are listed later.

Table 1-9
Members of the ICU/Acute Team

MEMBER ROLE

Attending physician Leads the medical team is medical decision-making. May lead
team rounds. Usually interacts with patient at least once a day.
Resident At a teaching hospital, residents are responsible for the day to
day, hour to hour care of patients. May be on the unit at all
times to answer clinical questions regarding patients.
Nursing Multiple responsibilities include but are not limited to:
administering medications, ADL assist, education, positioning,
and monitoring neurological status.
Nurse practitioner In some facilities, nursing practitioners take the place of
residents, writing orders and providing medical decision-
making when needed.
Nutritionist Usually the nutritionist evaluates the patient on a PRN
(as needed) basis. Most patients in the ICU receive a nutrition
consult when they are placed on tube feedings. The
nutritionist, along with the physicians, will determine which
type of tube feeding a patient should receive, along with the
speed at which the feedings should be administered.
Social worker In the ICU, the social workers are also usually a PRN service
providing support to family members and beginning the
discussion of discharge planning.
Speech and Speech and language pathologists can provide a twofold service
language in the ICU setting. They may provide therapy services in the
pathologist form of language and communication evaluation and treat-
ment. They may also provide bed side swallowing evaluations,
along with the occupational therapist. See Chapters 20 and 24.
Physical therapist The physical therapist provides bed side physical therapy
services in the form of therapeutic exercise, mobility, and
gait training if appropriate. Along with the occupational
therapist, he or she also contributes to discharge planning.
See Chapter 15.
28 Stroke Rehabilitation

Box 1-4
Initiating Treatment
1. Check to make sure occupational therapy orders are
active. This should be done prior to each and every
treatment session
2. Review the patient’s medical record. The therapist
should evaluate the medical record for potential
reasons to hold a patient from therapy. Such reasons
may be a change in mental status, development of
a deep vein thrombosis or pulmonary embolism,
or expansion of the stroke. Every facility has different
standards for when therapy is to be held.
3. Review the patient’s current status with the medical A
team. Using clinical reasoning the therapist will deter-
mine if the patient is appropriate for an OT session.
The therapist should clear any treatment with the pa-
tient’s nurse to determine if all medical information
reviewed from the medical record is most current.
4. Begin evaluation and treatment with a gross
assessment of mental status, strength, and vital signs.
Great discrepancies from what is reported in the
medical record should be reported to the nurse
and treatment suspended. Proceed with therapy as
indicated.

Basic ICU Monitor B

Most ICU patients are connected to a monitor that allows Figure 1-10 A, ICU monitoring system, indicating heart rate
constant display of all vital signs (Fig. 1-10). These include 80 beats per minute, blood pressure 128/65 (mean arterial pres-
blood pressure, telemetry reading (which include heart sure 90), oxygen saturation 99, respiratory rate 39. B, ICU
rate and rhythm), respiratory rate, and oxygen saturation monitoring system. This system monitors heart rate (106) and
percentages. For normal versus abnormal vital sign oxygen saturation (98%).
responses to exercises, refer to Table 1-10. Blood pressure
can be monitored either noninvasively (automated pres-
sure cuff) or by invasive measures, such as an arterial line
reading (also referred to as an A-line). A common insertion avoid clamping the catheter; doing so could result in a
site for an A-line is either the radial or femoral artery backup of urine in the bladder. The bag, which collects
(Fig. 1-11). With radial artery placement, passive ROM the urine, needs to be at a lower level than the patient’s
of the wrist should be avoided; with femoral artery bladder for the urine to flow in the correct direction.
placement, no hip ROM is allowed, resulting in bed rest.
External Ventricular Drain. The external ventricular drain
Telemetry (EVD) is a small tube surgically inserted into the ventricles
Telemetry detects both the heart rate and rhythm and of the brain, which drains cerebral spinal fluid (CSF)
displays this reading on the monitor. Bed side telemetry is (Fig. 1-12). The tube is connected to a device that measures
similar to an electrocardiogram (ECG). An ECG is read the amount of this fluid. This procedure is used when the
by placing 12 electrical leads to read heart rate and intracranial pressure is elevated, and the drain may be
rhythm while the bed side telemetry uses either three or clamped for short periods of time by nursing only. Due to
five leads. The primary nurse will set both heart rate and specific calibration, function of the drain, and accuracy in
rhythm parameters on the monitor. Should the rate and measurement the head of the bed must be elevated to a spe-
rhythm become abnormal, an alarm will sound. Physical cific level. Unless the drain is clamped, the head of the bed
activity should be monitored accordingly. may not be changed, and patients should not be mobilized.
Common Lines and Drains Intracranial Pressure Monitoring Catheter. The intracra-
Foley Catheter. A Foley catheter is indwelling and is used nial pressure monitoring catheter (ICP) is a catheter passed
to drain urine from the bladder. The therapist should through a burr hole and placed in the ventricles of the brain.
 Chapter 1 • Pathophysiology, Medical Management, and Acute Rehabilitation of Stroke Survivors 29

Table 1-10
Vital Sign Responses
NORMAL RESPONSE ABNORMAL RESPONSE EXCEPTIONS
VITAL SIGN TREATMENT TO TREATMENT TO THE RULES

Heart rate
Normal heart rate 60 Slow and gradual in- Increase in heart rate At times patients may not be able to
to 100 beats per minute crease in heart rate greater than 20 beats tolerate an increase in heart rate that
Many patients may have a with activity up to per minute. A decrease deviates from their baseline. At other
resting heart rate outside 20 beats higher per in heart rate or a times, with young, otherwise healthy,
the normal value. minute. change in heart patients, the team may allow the
Determine the patient’s rhythm. therapist to work patients beyond an
maximum heart rate increase of 20 beats per minute. Some
(220age)146 prior to medications may cause a blunted heart
treatment to assess whether rate response.
or not it is safe to proceed.
Blood pressure
Normal blood pressure: Slow, gradual, and Increase or decrease in Many times in the ICU, a patient’s
systolic less than slight increase in systolic blood pressure blood pressure is maintained high
120 mm Hg, diastolic less systolic blood greater than 20 points (i.e., 200/100) to profuse the brain.
than 80 mm Hg. pressure with and a decrease of dia- It is important to check with the team
Again many patients may activity. No change stolic pressure greater prior to holding therapy. However,
have a resting blood or slight decrease than 10 points.137 as a general rule, if a patient’s systolic
pressure above or below in diastolic blood pressure is greater than 200
what is considered normal. pressure. and diastolic pressure is greater than
Check the patient’s chart to 100, check with the team prior to
determine what the treatment.
patient’s blood pressure
ratings have been over the
past few vital sign cycles.
Determine from there if it
is safe to proceed.

Oxygen saturation
Normal range: 92% to 100% Slight drop or Drop in O2 saturation In some cases, the team will allow
on room air or on supple- increase in O2 below 92% (unless the therapist to titrate the patient’s
mental O2. saturation. that is baseline). O2 needs to the activity by increasing
O2 via nasal cannula. It is important
to remember that O2 is considered a
medication, and a written order from
the MD is needed to change patient’s
O2 consumption.

O2, oxygen.

It is used with injuries such as hemorrhages, aneurysms, or Spinal Drain. A spinal drain is a catheter placed in the
head trauma that may lead to brain swelling and elevation of lumbar spine to drain CSF. It can be used for the treat-
the intracranial pressure. This monitor measures any ment of CSF leak or to drain excess CSF fluid. The lum-
changes in intracranial pressure. The head of the bed is el- bar drain should be set to drain below the level of the leak.
evated to a set point (usually 30 to 45 degrees), as the intra- When the drain is open and is draining CSF, the spinal
cranial pressure will increase when the head of the bed is drain is set at a determined level next to the bed. At this
lowered. Passive therapy, such as splinting or positioning, time, when the drain is opened, patients are placed flat on
may be implemented with physician approval. Generally, their back to allow for drainage. Patients with this
ADL treatment and mobilization is held at this time. drain may get up and out of bed and may engage in ADL
30 Stroke Rehabilitation

Percutaneous Endoscopic Gastrostomy. A percutaneous

endoscopic gastrostomy is a tube inserted surgically with an
endoscope through the mouth and into the stomach, exit-
ing out through the stomach wall and dermis (Fig. 1-13).
Precautions for both feeding tubes include elevating
the head of bed to 30 degrees or greater while administer-
ing the tubes to prevent aspiration. Depending upon the
hospital guidelines, the therapist may be allowed to turn
off the feeding prior to the therapy session, but it is rec-
ommended that the primary care nurse be consulted prior
to doing so, for patient safety (see Chapter 24).
Ventilator
At times stroke can result in respiratory failure. When this
Figure 1-11 Arterial (A) line in the radial artery. (Photo cour- is the case, patients often require a ventilator to assist them
tesy of Millie Hepburn Smith.) with or to perform the act of breathing for them (Figs. 1-14
and 1-15). When a ventilator is used, the patient also re-
quires an artificial airway. In the first few days after acute
stroke, a ventilator can be connected to the patient via an
endotracheal tube. A breathing tube is then placed into the
patient’s mouth and positioned down into the patient’s lung
systems. If a patient is unable to be weaned from the venti-
lator, a tracheotomy will be performed. In this procedure,
an opening is cut in the patient’s trachea and a small endo-
tracheal tube is placed in the opening, which is then at-
tached to the vent via long tubing. Early mobilization of
patients on ventilators is encouraged.112 A recent random-
ized controlled trial138 emphasized that early OT/physical
therapy (PT) for those ventilated and critically ill is both
beneficial and safe, resulting in better functional outcomes,
decreased delirium, and more ventilator-free days.
Once the therapist is confident to handle the lines, leads,
Figure 1-12 Exit site for an external ventricular drain on top and monitors in the ICU, the patient’s tolerance of the OT
of skull. (Photo courtesy of Millie Hepburn Smith.) intervention should be monitored carefully. Vital signs
should be observed during the entire treatment session and
should be documented at the beginning, at mid-portion, and
treatment only when the drain has been clamped by the at end of treatment. In addition to vital signs, the therapist
nurse. While the drain is open to drain CSF, the patient must also watch for changes in the patient’s neurological
must remain on bed rest. status during treatment, which may include changes in

Intravenous Line. IV lines are inserted into the periph-

eral veins and are generally used to administer IV fluids
and medications. Because these lines are superficial, care
should be taken not to place pressure from the positioning
materials or splints directly over the area in order to avoid
obstructed or dislodgment.

Feeding Tubes
In the event that a stroke patient is unable to swallow
effectively or appears to be a high aspiration risk, alternate
methods are used for nutrition intake.

Nasogastric Tube. A nasogastric tube (NGT) is placed

through the nostril down the esophagus to the stomach
for liquid feeds to pass. It is generally used as a short-term Figure 1-13 Percutaneous endoscopic gastrostomy in abdomen.
alternative for nutritional intake. (Photo courtesy of Millie Hepburn Smith.)
 Chapter 1 • Pathophysiology, Medical Management, and Acute Rehabilitation of Stroke Survivors 31

engage in ADL tasks secondary to medical status or

sedation. Table 1-11 outlines some of the standardized
assessments used during acute rehabilitation.

INTERVENTIONS FOR ACUTE STROKE

REHABILITATION
The following sections will describe potential interventions
for those in the ICU/acute stage of stroke rehabilitation.

Splinting
The primary goals at this early phase of splinting are to:
1. Correct any biomechanical malalignment and
protect joint integrity.
2. Prevent shortening of soft tissues and development
of contractures.
3. Maintain skin integrity.
Develop an appropriate wearing schedule to prevent
learned nonuse behavior patterns. Splint-wearing at night
may be more appropriate than day use, particularly if the
Figure 1-14 This is a commonly used ventilator in the ICU patient has begun to initiate movement or attempts to
setting. The occupational therapist needs to be aware of the vent incorporate the hand or upper extremity in functional
setting and alarms while working with the patient. activities. A wearing schedule should be practical to
achieve compliance (Box 1-5; See Chapter 13).

Positioning
Because of the medical complexity of the ICU/acute stroke
survivor, many of these patients spend most, if not all,
of their time confined to bed. Therefore, positioning has
because an integral part of OT treatment plan. The occupa-
tional therapist will work to develop a positioning schedule
for each individual positioning. The occupational therapist
must rely on other members of the interdisciplinary team,
including nursing and physical therapists, and the patient’s
family members, if able, to carry out this portion of the
treatment plan (Figs. 1-16 and 1-17).
Different members of the interdisciplinary team have
different priorities when it relates to positioning. A primary
goal of the team in regards to positioning is to prevent skin
Figure 1-15 The patient is properly positioned on a trach breakdown. The occupational therapist is encouraged to
collar and is currently being weaned from the ventilator. teach the team how to position the patient not only to
prevent skin breakdown but also to reduce the risk of
contractures and encourage joint alignment, and comfort.
decorticate or decerebrate posturing, tone, pupils, and/or in The occupational therapist should develop a turning
speech.137 Patient subjective complaints must be considered. schedule for each patient. Patients should alternately be
If any changes in the patient’s status occur, terminate treat- positioned on the affected side, the nonaffected side, and
ment and inform the medical team immediately. supine. A clock drawn with specific positions can be used as
a reminder for the nursing team. See Chapter 10.
ASSESSMENTS USED IN ACUTE STROKE When the patient is being positioned, the patient’s
REHABILITATION lines and leads should be carefully observed for they
provide vital medications and monitoring of each patient.
There are a variety of standardized assessments available82 Careful adjustments need to be made for head of the bed
to the occupational therapist in the hospital setting. In the restrictions from feeding tubes or ICP/EVD. When a
acute/ICU setting, it is imperative for the occupational patient is being positioned with femoral arterial lines, care
therapist to evaluate motor skills, cognitive function, and should be taken to avoid hip flexion, and the wrists of
ADL. At times it may not be feasible for a patient to patients with radial A-lines should be maintained in a
Table 1-11

32
Standardized Assessments Used during Acute Rehabilitation

ASSESSMENT DESCRIPTION SCALES/SCORES LIMITATIONS

Stroke Rehabilitation
NIH Stroke Standardized Prognostic The NIHSS is a 15-item neurological 0  No stroke No evaluation of functional tasks.
Scale22 Scale examination for stroke patients used 1–4  Minor stroke
Total time to administer: in many hospitals by physicians, 5–15  Moderate stroke
10 minutes nurses, and therapists. It evaluates 15–20  Moderate to severe stroke
levels of consciousness, language, 21–42  Severe stroke
neglect, visual fields, eye movement,
motor strength, ataxia, dysarthria,
and sensation.22
MINI FIM61 Standardized functional Evaluation of functional tasks such as Patient receives a score between 0–7 for Secondary to the medical com-
outcome measure. self-care, transfers, mobility, and each functional task. A score of 7 indi- plexity of ICU patients, many
Total time to administer: cognition cates independence while a score of of the ADL or mobility sections
greater than 30 minutes 1 indicates total assist, and a score of may not be able to be
0 indicates the task has not taken completed.
place. The Mini FIM includes 7 items
from the full 18 item FIM instrument.
Glasgow Standardized prognostic This scale is used in numerous hospi- Each category is given a numeric re- No evaluation of functional tasks.
Coma scale. tals by both doctors and therapists. It sponse with 1 being no response. The
Scale154 Total time to administer: evaluates best eye opening response, responses are added together to create
10 minutes best verbal response, and best motor a final score. A score of less than 3 in-
response.21 dicates vegetative state, 3–8 severe
disability, 9–12 moderate disability,
and 13–15 indicates mild injury.154
Orpington Standardized prognostic An evaluation of upper extremity mo- The numerical scores of each section No evaluation of functional tasks.
Prognostic scale. tor function, proprioception, bal- are added together for the final score. The cognitive evaluation is
Scale88 Total time to administer: ance, and cognition Lower scores indicate less impair- given verbally and therefore
5 to 10 minutes ment. requires language and speech,
eliminating patients with
aphasia.
Barthel Standardized outcome Evaluation of functional tasks such as Patient receives a score between 0–100, Secondary to the medical com-
Index100 measure. eating, grooming, bathing, bowel 0 indicating total dependence and 100 plexity of ICU patients, many
Total time to administer: and bladder management, toilet use, total independence with the evaluated of the ADL or mobility sections
greater than 30 minutes dressing, mobility, transfers, and activities. may not be able to be com-
stairs. pleted (such as eating, toileting,
and/or stairs).
JKF Coma Standardized measure. The scale consists of 23 items within The lowest item on each scale repre- No evaluation of functional tasks
Recovery Total time to administer: six subscales, evaluating auditory, vi- sents reflexive activity, while the high-
Scale56,57 15 minutes. sual, motor, oral motor, communica- est items represent higher level cogni-
tion, and arousal. tive behaviors.
 Chapter 1 • Pathophysiology, Medical Management, and Acute Rehabilitation of Stroke Survivors 33

Box 1-5
Common Splints Used in Acute Stroke
Rehabilitation
Resting hand splint May be fabricated for the
individual but also are
available prefabricated.
Cone splint May prevent long finger
flexor tightness when
used in conjunction with
a wrist extension device
and also maintain skin
integrity (preventing skin
maceration).
Adjustable inflatable Contains an air bladder in
hand splint the palmar surface, which Figure 1-17 Side lying position, with patient positioned on the
can be adjusted to achieve affected side. Pillow placed under affected upper extremity to
the level of stretch placed maintain proper alignment of the head of the humerus.
on the long finger flexors.
It may be an appropriate
choice for the patient
neutral position. Foley and rectal tubes should be moved
who has had more than
one stroke and to the same side to which the patient is positioned.
demonstrates increased While in the ICU, many patients require a ventilator to
muscle tone. This type of provide respiratory assistance. These patients can also be
splint is prefabricated. positioned side to side and supine. Care should be taken
Blanket/towel roll An alternative to a thermo- when moving ventilation tubes. There are many extra ar-
plastic elbow extension or ticular handles that allow for addition mobility of the patient
drop arm splint. It is on a ventilator. If these articular handles do not provide
rolled around the patient’s enough length to position a patient in the proper alignment,
arm to help prevent discuss with the respiratory therapist regarding switching
elbow flexion contractures.
the ventilator from side to side every other day or so.
See Chapter 13
and Fig. 1–16. Functional Activity Suggestions during the Acute
Phase
Bed Mobility
Rolling to the Affected Side. Rolling to the affected
side promotes early active trunk control and may increase
awareness of the weaker side.

Rolling to the Unaffected Side. Rolling to the unaf-

fected side promotes awareness and initial management
of the weak upper extremity by teaching the patient to
passively guide the arm across the trunk (Fig. 1-18).

Maintaining Side Lying. A rolled pillow placed at

the midthoracic spine to the lumbar area may assist the
patient in maintaining the side-lying position. A towel roll
can be placed under the patient’s waist to provide a stretch
to the shortened trunk. A primary goal is to assure proper
spine alignment, to avoid pressure build up over the bony
prominences in the lower extremities (knees and ankles),
and to position the scapula in protraction if the patient is
positioned on the weakened side.

Figure 1-16 Patient’s arm positioned with towel roll to in- Bridging. Bridging strengthens the back and hip ex-
crease elbow extension. tensors. From a functional perspective, this movement
34 Stroke Rehabilitation

Figure 1-18 Bed level activities. Rolling to the unaffected side Figure 1-19 While the patient sits on the edge of the bed, a bed
and engaging the affected arm in early reaching task and at the side chair is used to facilitate upper extremity weight-bearing
same time engaging affected trunk and lower extremity muscles. activities.

aids in getting on and off the bed pan, can be used during
lower body dressing, and also assists moving the lower
body toward the side of the bed in anticipation of assum-
ing a sitting position.

Side Lying to Sitting toward the Affected Side. Side

lying to sitting toward the affected side promotes early
stage weight-bearing on the weak upper extremity. The
therapist needs to ensure that the shoulder is properly
aligned, and the patient will usually require assistance
with initiation of the movement.

Side Lying to Sitting toward the Unaffected

Side. Therapists need to be mindful that the involved
shoulder remains in a forward position during the motion
Figure 1-20 Forearm weight-bearing on bed side table while
of side lying to sitting toward the unaffected side.
patient dangles off edge of bed.
Weight-Bearing for Function
Upper extremity weight-bearing activities may be done
while the patient is side lying as mentioned previously,
during bed mobility, or for stabilizing items. It can also be
accomplished using the bed side table during meals or
grooming tasks. The arm or back rest of a chair can be
incorporated in the treatment plan for positioning and
setup for weight-bearing (Figs. 1-19 and 1-20). The pa-
tient should be taught to push off with both upper ex-
tremities when moving from sit to stand. Weight-bearing
as a postural support can reverse or prevent tissue short-
ening of the elbow, wrist, and finger flexors. It can also be
used to strengthen the scapula musculature and the tri-
ceps. Arm extended weight-bearing can be done in front
of the sink during grooming or be done in front of the bed
side table while reaching for items nearby (Fig. 1-21).
For the lower extremity, bed level activities include: Figure 1-21 Supported standing with bed side table to facili-
bridging, sitting at the edge of the bed with both feet on tate upper extremity involvement in activity. Early upright ADL
the floor, and early transfer training once patients are training can be initiated, and weight shifting through the lower
medically stable. extremities is encouraged.
 Chapter 1 • Pathophysiology, Medical Management, and Acute Rehabilitation of Stroke Survivors 35

Graded Sitting and Standing Activities may require the assistance of more than one person to gain
Supported Sitting in Bed. For the supported sitting in the patient’s confidence and safety. The therapist should
bed position, the head of the bed should gradually be raised assure appropriate alignment of both lower extremities
in approximately 30- to 40-degree increments to avoid an with feet placed firmly on the floor and then have the pa-
orthostatic hypotensive response. As the patient tolerates tient begin with several partial sit-to-stand trials. Assess
the change in degrees of elevation, the therapist should how the weaker lower extremity reacts to weight-bearing,
continue to monitor vital signs. If there appears to be no provide appropriate blocking or support to prevent col-
change in the patient’s blood pressure, the therapist should lapse, and check vital signs while the patient is upright.
continue to elevate the head of the bed to approximately
80 degrees. Sitting at a slightly reclined position is less tax- Supported Standing in Front of a Raised Bed. To
ing on the patient’s energy and requires less recruitment of initiate supported standing in front of a raised bed, the
the neck, trunk, and back musculature to maintain an up- therapist should position the patient in a chair that faces
right position. At this point, the patient should be engaged the side of the bed. With appropriate assistance, the
in functional activities, such as feeding, light grooming, therapist should stand the patient and sit in a chair on the
upper body bathing and dressing, and leisure activities. patient’s weakened side to support the hip and knee exten-
sors. In this standing position, the patient may practice
Supported Sitting in a Chair. If the patient is well- early weight shifting through the lower extremities and
supported and can endure sitting in a chair at the bed side, bear weight on the upper extremities in either forearm or
“sitting tolerance” or “out of bed tolerance” can be increased. arm extended positions (see Fig. 1-21).
Pillows may be useful at this early stage to support the lum-
bar spine and weaker upper extremity. When a therapist is EDEMA MANAGEMENT
placing a pillow under the upper extremity, he or she should
make sure the shoulder alignment is in neutral. Adequate Evaluate the potential cause if edema is present. Discuss
postural support may reduce pain and fatigue. Focus of treat- with nursing whether the swelling may be associated with
ment can include but is not limited to the patient performing the presence of a blood clot or an IV infiltrate. Check
self-care tasks, visual scanning activities, and weight-bearing to see if the patient’s limb is cool or warm to the touch,
through the upper and lower extremity. observe the skin color, and assess the firmness of the
swelling (soft, fluidlike, or pitting).
Unsupported Sitting. Unsupported sitting may be In the ICU, the preferred method for treating edema is
done in the bed in a “tailor” (crossed legged) position, de- positional elevation, as compression garments or ace
pending on the amount of ROM the patient has in the wraps may not be appropriate due to various IVs and line
lower extremities. The head of the bed can be elevated, but access needed by nursing. The extended limb should be
should not touch the back of the patient. It is used as a positioned above the heart. Active or active assistive ROM
safety catch should the patient lose his or her balance in a should be encouraged and followed by manual massage
posterior direction. Pillows may be propped against the bed (Fig. 1-22). See Chapter 12.
rails to protect the patient if he or she leans or falls laterally
to the weaker side. While seated in this position, the pa- SHOULDER MANAGEMENT
tient can practice righting himself or herself or maintaining
a midline position, and the patient should then be engaged Many patients may experience upper extremity edema,
in functional activities as tolerated. pain, humeral head subluxation, and/or impingement af-
ter a stroke. Many of the upper extremity interventions
Unsupported Sitting at the Edge of the Bed with provided in the ICU/acute stage are prophylactic mea-
Feet Dangling. In this position, the patient can be sures to prevent these problems.
challenged with increased demands on alignment, trunk To protect the shoulder against potential pain and
control, and forward and lateral weight shifts. Scooting to subluxation, the team should be educated in proper roll-
the edge of the bed can be introduced in anticipation ing techniques and bed mobility, so they can avoid pull-
of progressing to sit to stand. Postural control may be ing on the extremity. The team should be instructed to
noticeably improved once the patient’s feet contact the roll the patient by placing the hands on the trunk rather
floor. The therapist should ensure equal weight-bearing than pulling on the extremity. Signage can be hung be-
on both lower extremities. See Chapter 7. hind the patient’s bed indicating the patient may have
shoulder subluxation and informing the team to not pull
Sit to Stand: Pretransfer Phase. To prepare for the on the patient’s arm (Box 1-6).
sit-to-stand pretransfer phase, therapists should ensure that Due to the medical complexity of the ICU/acute pa-
all lines and IVs have enough length to eliminate tient, most are not getting out of bed to the chair for
pulling or tension. Increasing the surface height the prolonged periods or engaging in prolonged upright ac-
patient rises from will require less work. This transition tivities. While supine, out of bed in a chair, or dangling at
36 Stroke Rehabilitation

INCREASING SPATIAL AWARENESS

BY ARRANGING THE ENVIRONMENT
Although the ICU environment may be more restrictive
than a rehabilitation setting, there are subtle yet important
interventions that can be implemented to increase spatial
awareness. Strategically place items of common use, such as
the television remote control, on the involved side while
providing cues to assist the patient in locating them. Stra-
tegically place food items on the meal tray during feeding
to encourage scanning and locating desired items to eat.
Verbal cues should be diminished as the patient’s awareness
increases. Reverse the position of the bed, if able, so that
the patient’s involved space is stimulated (e.g., facing the
Figure 1-22 Patient’s affected upper extremity positioned in hallway instead of facing a blank wall). Position the bed side
towel roll and elevated on pillow to prevent and decrease edema. table and phone on the neglected or weaker side of the
patient. Use brightly colored bands tied to the bed side rails
on the involved side as cues to attend to this side. Hang
Box 1-6 pictures of family and friends on the involved side while
Patient with Right Shoulder Subluxation providing cues for the patient to locate them.
Please do not pull on patient’s arm. Please contact occu-
pational therapy at 555–8724 with questions or concerns. EARLY COGNITIVE MANAGEMENT
Patients may spend numerous days to weeks in the ICU.
A well-known phenomenon called ICU psychosis can
the bed side, support for a weak shoulder can be provided develop within days of being admitted to the ICU.55,99
via proper positioning. ICU psychosis has been defined as a fluctuating state of
consciousness characterized by fatigue, distraction, con-
Supine fusion, disorientation, restlessness, clouding of conscious-
Provide support to the affected upper extremity with ness, incoherence, fear, anxiety, excitement, hallucina-
pillows and/or towels. The occupational therapist must tions, and delusions.41 Many factors related to the ICU
use clinical judgment to determine proper positioning environment can contribute to the development of ICU
for each patient. However, as a general rule, the affected psychosis. Some include psychosocial stress, sleep depri-
scapula should be protracted, the arm in a forward vation, sensory overload or underload, and immobiliza-
position, with the wrist neutral and fingers extended.26 tion.41 Many patients are unable to differentiate between
day and night secondary to lighting in most ICU.41
Edge of Bed The occupational therapist can assist the primary nursing
The affected upper extremity is supported on the bed side team in a variety of ways to help lessen the effects of ICU
table or on numerous pillows. psychosis. Some measures that nursing may implement are
providing tactile and verbal stimulation, involvement of the
Out of Bed in a Chair patient in his or her care, and supplying effective rest
The affected upper extremity is supported on the bed side periods.99 The occupational therapist can minimize envi-
table, on numerous pillows, or on the arm support of the ronmental monotony and mobilize and engage the patient
chair. in familiar self-care tasks. When providing a patient with
Most ICU/acute patients do not require supplemental OT services, communication with patient via gentle touch
shoulder supports such as sling, clavicle strap, and/or and voices can help calm patients. Incorporating music and
taping. These supports may be used once patients are massage into OT treatments can also help reduce anxiety,
performing ADL upright and are spending more time out fear, and depression.99 See Box 1-7 for treatment ideas.
of bed. See Chapter 10.
In addition to positioning, the occupational therapist SKIN PROTECTION AND PREVENTION
will provide the ICU patient with passive and active ROM OF BREAKDOWN
and will engage the affected upper extremity in functional
tasks. The therapist should mind lines and leads while Skin breakdown and development of pressure ulcers are
providing these services. When an A-line is present in the common complications associated with an ICU/acute
radial artery, wrist flexion/extension should be avoided. admission. After stroke, patients are at risk for developing
 Chapter 1 • Pathophysiology, Medical Management, and Acute Rehabilitation of Stroke Survivors 37

Box 1-7 assist with facilitating a communication system that is

Treatment Ideas to Manage ICU Psychosis consistently used by other staff and family members
(Box 1-8; see Chapter 20).
■ Mobilize and engage in self-care.
■ Engage patient in time appropriate tasks
(if it is 8 am complete oral care with window shades
DYSPHAGIA SCREENING
open and lights on). Acute swallowing difficulties or dysphagia are often
■ Use a calm gentle voice and touch when engaging
associated with stroke.159 The risk of aspiration is high
patients.
■ Decrease or increase sensory stimulation during
and often leads to pneumonia. Other medical complica-
OT treatment session depending on patient’s needs. tions associated with dysphagia include malnutrition
■ Educate patient’s family in orientating patient not and dehydration.
only to date and place but also to time of day. During the initial admission to the hospital, patients
■ Keep clocks and calendars in view. may be placed on “NPO” (nothing by mouth) precautions.
Under these circumstances an NGT is usually inserted
through the nose and down the esophagus to the stomach.
If the patient is conscious, the occupational therapist
pressure ulcers due to prolonged bed rest and immobility. may initiate a swallowing or dysphagia screening at the
Other risk factors include poor circulation, poor nutri- bed side.
tion, edema, low level of arousal, confusion, and inconti- Before beginning the assessment, the therapist should
nence.8 Pressure management and skin protection should be aware of the patient’s level of alertness, fatigue, and
become a part of each treatment session. See Table 1-12 ability to follow commands, as these factors may signifi-
for a review of the stages of pressure ulcers. cantly influence the ability to participate safely. An oral
Prevention of skin breakdown is a team responsibility. motor examination should precede administration of
The occupational therapist has a unique set of skills to foods and liquids. The assessment should begin with the
assist the team in protecting the patient’s skin. The oc- patient seated with the head of the bed elevated. If an oral
cupational therapist is often the first team member to suction device is available at the bed side, it should be
mobilize patient and can observe the entire body for signs turned on (Box 1-9; Fig. 1-25).
of skin breakdown. Areas of concern for the ICU patient Based on the results of the bed side assessment, in-
include sacrum, occiput, heels, greater trochanter, and strumental testing may be necessary to further evaluate
elbows. Therapist can suggest elbow and heel pads to the phases of swallowing that cannot be seen at a bed side
protect these areas from pressure and friction. Heels oral motor examination. If the patient appears to have
can also be floated via positioning or multipodis boots adequate oral and swallowing function and a physician’s
(Fig. 1-23). The therapist can develop positioning devices order has been obtained, a feeding trial may be initiated
to assist the nurse with elevating pressure on the occiput using graded food textures and liquids of various thickness
(Fig. 1-24) and the sacrum. The occupational therapist (Box 1-10; see Chapter 24).
can also recommend specialized mattresses to best serve
the patient’s needs. SELF-CARE TRAINING

COMMUNICATION Training in ADL is an integral part of OT treatment. It is

important to engage the patient in self-care tasks as soon
For the patient unable to communicate verbally, whether as they are medically stable.
due to mechanical ventilation or aphasia, alternative Energy expenditure is often an issue for the low level
methods of communication will be necessary. Options patient, so grading the self-care task is as important as the
may include use of a communication board. Single word choice of activity. The acute patient may also be limited
choice or pictures that represent feelings or needs can by IVs, lines, and artificial ventilation. If the patient is
be placed strategically on a small poster board. Exam- having difficulty managing secretions, begin by teaching
ples may include Nurse, Doctor, Pain, Thirst, etc., to them how to use an oral suctioning device. Using an
which the patient can then point. Alphabet boards are adapted call light to request assistance from nursing is also
generally not used, as they require energy and time for an appropriate goal.
the patient to “spell” words. For the aphasic patient, For those with limited motor return, the upper ex-
words might be eliminated altogether. Other alterna- tremity should at least be used as a stabilizer. ADL
tives may include signals for Yes/No questions, such as compensatory strategies can be initiated. If the patient
head nodding or thumbs up or down, and an eye blink demonstrates active movement, the upper extremity
system. Working in conjunction with the speech- should be incorporated into the self-care task (see
language pathologist, the occupational therapist may Chapter 28).
38 Stroke Rehabilitation

Table 1-12
Pressure Ulcer Stages
STAGE DESCRIPTION ADDITIONAL INFORMATION

Stage I Intact skin with nonblanchable redness of a local- The area may be painful, firm, soft, warmer, or
ized area usually over a bony prominence. Darkly cooler as compared to adjacent tissue. Stage I may
pigmented skin may not have visible blanching; its be difficult to detect in individuals with dark skin
color may differ from the surrounding area. tones. May indicate “at risk” persons (a heralding
sign of risk).
Stage II Partial thickness loss of dermis presenting as a Presents as a shiny or dry shallow ulcer without
shallow open ulcer with a red pink wound bed, slough or bruising. This stage should not be used
without slough. May also present as an intact to describe skin tears, tape burns, perineal dermati-
or open/ruptured serum-filled blister. tis, maceration, or excoriation. Bruising indicates
suspected deep tissue injury.
Stage III Full thickness tissue loss. Subcutaneous fat may The depth of a stage III pressure ulcer varies by
be visible, but bone, tendon, or muscle are not anatomical location. The bridge of the nose, ear,
exposed. Slough may be present but does not occiput, and malleolus do not have subcutaneous
obscure the depth of tissue loss. May include tissue, and stage III ulcers can be shallow.
undermining and tunneling. In contrast, areas of significant adiposity can
develop extremely deep stage III pressure ulcers.
Bone/tendon is not visible or directly palpable.
Stage IV Full thickness tissue loss with exposed bone, The depth of a stage IV pressure ulcer varies by
tendon, or muscle. Slough or eschar may be anatomical location. The bridge of the nose, ear,
present on some parts of the wound bed. Often occiput, and malleolus do not have subcutaneous
include undermining and tunneling. tissue, and these ulcers can be shallow. Stage IV
ulcers can extend into muscle and/or supporting
structures (e.g., fascia, tendon, or joint capsule),
making osteomyelitis possible. Exposed
bone/tendon is visible or directly palpable.
Unstageable Full thickness tissue loss in which the base of the Until enough slough and/or eschar is removed to
ulcer is covered by slough (yellow, tan, gray, expose the base of the wound, the true depth, and
green, or brown) and/or eschar (tan, brown, therefore stage, cannot be determined. Stable (dry,
or black) in the wound bed. adherent, intact without erythema or fluctuance)
eschar on the heels serves as “the body’s natural
(biological) cover” and should not be removed.

Courtesy of National Pressure Ulcer Advisory Panel

Figure 1-23 This technique is termed “floating the patient Figure 1-24 Cervical roll used to keep occiput off the bed to
heels.” It is used while supine in bed to maintain skin integrity decrease pressure that may cause breakdown. The roll allows for
and to prevent breakdown. head/neck rotation in both directions.
 Chapter 1 • Pathophysiology, Medical Management, and Acute Rehabilitation of Stroke Survivors 39

Box 1-8 Box 1-9

Communication Keypoints Oral Motor Screening
■ Use a normal tone and volume of voice. Avoid shouting ■ Observe for the presence of facial asymmetry. Facial
at the patient or talking to them in an infantile manner. drooping or weakness is common in association with
■ Give the patient enough time to respond to the question. the weaker extremities. Foods can pocket in the cheek
■ Try to stay on the same subject. of the weakened side.
■ Gesture whenever possible and provide tactile cues ■ Observe mouth and lip closure. Can the patient purse his
as appropriate. or her lips? Have him or her attempt to blow air into his
■ Speak slowly and directly to the patient’s face. or her cheeks while keeping his or her lips pursed.
■ Simplify questions to Yes/No Observe if air escapes through one side of the mouth.
■ Try to reduce background noise to eliminate ■ Request the patient to stick out his or her tongue. Does
distraction. Close the door and turn off the radio or it drift or deviate to one side? Can he or she lick his or
television. her lips and perform lateral movements with the tongue?
■ Only one person should communicate with the patient ■ Use a long stick swab to assess the patient’s sensation
at one time. both extra- and intra-orally.
■ Be aware of signs of frustration by observing facial ■ Use a tongue depressor to assess the patient’s gag
expressions. reflex. Is it present, absent, or delayed?
■ Check the soft palate. Use a flashlight to ask the
patient to open mouth and say the word “AH.”
Observe for soft palate elevation.
The initial position may be with the head of the bed ■ Assess the patient’s vocal quality. Is it gurgly or wet?
elevated. This position provides support of the head Can the patient “clear” his or her voice? Secretions
and trunk. Vital signs should be monitored throughout may pool or linger around the vocal cords. Is there
the activity. As patients progress, they might be positioned hoarseness of the voice? If so, it may be due to
in sitting at the edge of the bed. Demands are greater as inadequate closure of the vocal cords.
patients must maintain their balance while performing the ■ Can the patient demonstrate a volitional cough?
task. Once a patient is able to tolerate sitting at the edge Assess the strength of the cough. Is it adequate to
of the bed, the progression should lead to performing clear the airway?
■ Is the patient managing his or her own secretions? Does
tasks seated in a chair. If the patient is able to stand for
short periods, then appropriate self-care activities should he or she choke or cough on his or her own secretions?
Observe whether the swallow is present or delayed.
be performed in standing, such as brushing teeth at the
■ A standardized bed side swallowing assessment is
sink or combing hair. Chaining the tasks together will recommended (Fig. 1-25).
demand more tolerance. Self-care tasks can be graded
from simple to complex (Box 1-11).

FAMILY TRAINING patients are too medically complex for the family to pro-
vide additional therapy services. Such patients may re-
The primary purpose of family training in the ICU/acute quire constant monitoring during physical activity, while
setting is to allow for the patient to engage in as many other patients may have lines and leads that require a
therapeutic activities as possible immediately following the nurse or therapist to handle.
neurological event. Family members should be empowered After evaluation patients, family members should be
to assist their loved ones to achieve their therapy goals. instructed in the following.
Occupational therapists may spend as much time educating ■ Safely moving noncomplex lines and leads. These
the family as they do treating the patients. When training may be noninvasive a blood pressure cuff, an O2
family members, the therapist should demonstrate the tasks monitor, an IV, and, in certain cases, A-lines.
and then provide an opportunity for the family member to ■ Positioning of affected extremities
attempt the tasks. Positive feedback should be provided ■ Splint wearing schedule, donning and doffing the
with corrections given as needed. Families should be pro- splint, and performing skin checks
vided with written instructions for any tasks they are asked ■ ROM for elbow, wrist, and hand
to carry out. During one OT session, no more than three ■ Setting up environment for patient during ADL
tasks should be given to the family members. This will tasks supine and interacting with patient on affected
ensure greater carryover of the tasks provided. The follow- side (in the case of neglect or sensory loss)
ing are suggestions for a family training scheduled in the As treatment progresses, the family can be further engaged
ICU/acute setting. in the treatment and trained in the following areas:
Occupational therapists must use their clinical reason- ■ Shoulder management: Families must be educated in
ing when providing family training. Many ICU/acute care positioning of the involved upper extremity in bed,
40 Stroke Rehabilitation

Name:
GUSS Date:
(GUGGING SWALLOWING SCREEN) Time:

1. Preliminary Investigation/Indirect Swallowing Test

YES NO
Vigilance (The patient must be alert for at least 15 minutes) 1ⵧ 0ⵧ
Cough and/or throat clearing (voluntary cough) 1ⵧ 0ⵧ
(Patient should cough or clear his or her throat twice)
Saliva Swallow: 1ⵧ 0ⵧ
• Swallowing successful
• Drooling 0ⵧ 1ⵧ
• Voice change (hoarse, gurgly, coated, weak) 0ⵧ 1ⵧ
SUM: (5)
1−4  Investigate further1
5  Continue with part 2

2. Direct Swallowing Test (Material: Aqua bi, flat teaspoon, food thickener, bread)
In the following order: 1→ 2→ 3→
SEMISOLID* LIQUID** SOLID***
DEGLUTITION:
• Swallowing not possible 0ⵧ 0ⵧ 0ⵧ
• Swallowing delayed 1ⵧ 1ⵧ 1ⵧ
( 2 sec) (Solid textures  10 sec)
• Swallowing successful 2ⵧ 2ⵧ 2ⵧ
COUGH (involuntary):
(before, during, or after swallowing − until
3 minutes later)
• Yes 0ⵧ 0ⵧ 0ⵧ
• No 1ⵧ 1ⵧ 1ⵧ
DROOLING:
• Yes 0ⵧ 0ⵧ 0ⵧ
• No 1ⵧ 1ⵧ 1ⵧ
VOICE CHANGE:
(listen to the voice before and after
swallowing − Patient should speak ”O”)
• Yes 0ⵧ 0ⵧ 0ⵧ
• No 1ⵧ 1ⵧ 1ⵧ
SUM: (5) (5) (5)
1−4  Investigate 1−4  Investigate 1−4  Investigate
further1 further1 further1
5  Continue 5  Continue 5  Normal
liquid solid

SUM: (Indirect Swallowing Test AND Direct Swallowing Test) (20)

* First administer 1/3 up to a half teaspoon Aqua bi with food thickener (pudding-like
consistency). If there are no symptoms apply 2-5 teaspoons. Assess after the 5th spoonful.
** 3, 5, 10, 20 ml Aqua bi − if there are no symptoms continue with 50 ml Aqua bi (Daniels et
al., 2000; Gottlieb et al., 1996) Assess and stop the investigation when one of the criteria is
observed.
*** Clinical; dry bread; FEES; dry bread which is dipped in colored liquid
1 Use functional investigations such as Videofluoroscopic Evaluation of Swallowing (VFES),
Fiberoptic Endoscopic Evaluation of Swallowing (FEES)

Figure 1-25 The Gugging Swallowing Screen. (From Trapl M, Enderle P, Nowotny M,
et al: Stroke 38 (11):2948–2952, 2007.)
 Chapter 1 • Pathophysiology, Medical Management, and Acute Rehabilitation of Stroke Survivors 41

GUSS
(Gugging Swallowing Screen)
Guss − EVALUATION
RESULTS SEVERITY CODE RECOMMENDATIONS
20 Semisolid/ Slight/no • Normal diet
liquid and solid dysphagia • Regular liquids (First time under supervision of the
texture minimal risk SLT or a trained stroke nurse!)
successful of aspiration
15−19 Semisolid and Slight dysphagia • Dysphagia diet (pureed and soft food)
liquid texture with a low risk • Liquids very slowly − one sip at a time
successful of aspiration
and solid • Functional swallowing assessments such as
unsuccessful Fiberoptic Endoscopic Evaluation of Swallowing
(FEES) or Videofluoroscopic Evaluation of
Swallowing (VFES)
• Refer to Speech and Language Therapist (SLT)
10−14 Semisolid Moderate Dysphagia diet beginning with
swallow dysphagia
• Semisolid textures such as baby food and additional
successful and with a risk
parenteral feeding.
liquids of aspiration
unsuccessful • All liquids must be thickened!
• Pills must be crushed and mixed with thick liquid.
• No liquid medication!
• Further functional swallowing assessments (FEES,
VFES)
• Refer to Speech and Language Therapist (SLT)

Supplementation with nasogastric tube or parenteral

0−9 Preliminary Severe dysphagia • NPO (non per os  nothing by mouth)
investigation with a high risk • Further functional swallowing assessment (FEES,
unsuccessful of aspiration VFES)
or semisolid • Refer to Speech and Language Therapist (SLT)
swallow
unsuccessful Supplementation with nasogastric tube or parenteral
Figure 1-25, cont’d

Box 1-10
Symptoms of Potential Dysphagia
■ Facial weakness
■ Weak tongue movements
■ Poor lip closure
■ Drooling Box 1-11
■ Coughing on secretions Grading ADL during Acute Stroke
■ Poor or wet voice quality Rehabilitation
■ Residual food accumulation in mouth
SIMPLE COMPLEX

Sitting with back Sitting with back unsupported

during bed mobility, for transfers, during ADL activi- supported
ties, and while upright. Family members can be in- Finger feeding Feeding with utensils
structed to don and doff shoulder supports if needed. Drinking from a cup Pouring liquids and drinking
■ ADL training: Family members can be trained in with a straw
Brushing teeth with Brushing and cleaning
setting up the environment using the bed side table,
set-up dentures
giving simple verbal cues, and providing physical Washing face with Washing face and upper body
cues to engage the affected upper extremity. If the cloth
patient is to go home directly from the acute care Donning pullover Donning a button-down shirt
setting, family training of both compensatory and shirt
remedial techniques for ADL trainings should be Donning shorts in Donning pants while standing
initiated. bed with bridging to pull up
42 Stroke Rehabilitation

■ Shoulder ROM: Once family members are educated not only performing self-care activities but also of en-
on how to safely handle a subluxed shoulder, they abling the patient to participate in life. Examples of short-
can also be educated to passively range the affected term goals are listed in Box 1-12.
shoulder to 90 degrees of forward flexion. In some
cases, occupational therapists can use their clinical DISCHARGE PLANNING
judgment and teach the family to perform over head
ROM if they can maintain proper alignment of the As part of the multidisciplinary team, the occupational
head of the humerus. therapist should assist and provide input for the patient’s
■ Positioning: After the family is educated in upper discharge plan.151 The patient’s family, support system, and
extremity positioning, they should be involved in the the patient’s ultimate destination of home and into the com-
patient’s positioning schedule. A physically able munity should be taken into consideration. The goal is for
family member should be trained in proper body the patient to be safe and as independently functioning as
mechanics during bed positioning. If a family mem- possible. There are several options available for immediate
ber is unable to physically complete the positioning disposition from the ICU and acute care setting (Box 1-13).
himself, he should be educated on the turning Careful consideration should be taken when consulting
schedule and proper positioning. In addition to po- with the physician and social worker. If the patient appears
sitioning supine, family should be educated in the in need and could benefit from inpatient rehabilitation, the
proper position of the affected upper extremity primary care physician may request a physiatry consulta-
while out of bed in a chair. This position should be tion. At this point, the occupational therapist may com-
determined on a case-by-case basis depending on the municate his or her clinical observations on the patient’s
specific needs of each patient. progress since admission to the acute care setting.
■ Transfer training: If a patient is to be discharged
from the acute care setting to home transfer, train- SUMMARY
ing may be appropriate.
In summary acute stroke rehabilitation is multifaceted.
GOAL SETTING IN ACUTE CARE Interventions focus on prevention of secondary complica-
tions, such as learned nonuse, contracture, and aspiration,
Setting appropriate short-term goals can be challenging and on early attempts at remediation of impairments. Two
in the ICU and acute care environments. Mobility goals overarching goals include maximizing participation in
should not be omitted as part of the occupational thera- appropriate ADL and acting with the team to assure
pist’s treatment plan as these mobility skills are a part of proper discharge planning.

Box 1-12
Acute Goal Setting
Samples of short-term goals for pa- Patient will withdraw from noxious stimuli 1 out of 3 times.
tients with low arousal or in coma Patient will open eyes when name is called 1 out of 3 times.
Patient will turn head away from tactile stimuli.
Patient will tolerate resting hand splint schedule for 2 hours.
Patient will tolerate lying on the affected side.
Samples of short-term goals for early Patient will tolerate sitting in upright in bed at a 60 degree angle for 30 minutes in
stroke rehabilitation preparation for engaging in self-care.
Patient will roll in bed with maximum assistance.
Patient will tolerate splint wearing schedule for 2-4 hour periods (if appropriate).
Patient will remove a wash cloth from his or her face independently.
Patient will wash face with minimal assistance.
Patient will manage oral secretions with an oral suctioning device with minimal
assistance.
Patient will use call light for nursing attention independently.
Patient will tolerate dangling at the bed side for 15 minutes with close supervision
in preparation for self-care training.
Patient will feed self 25% to 50% of a meal independently.
Patient will brush teeth with set-up assistance.
Patient will don hospital gown with moderate assistance.
Patient will tolerate sitting in a chair for 60 minutes.
 Chapter 1 • Pathophysiology, Medical Management, and Acute Rehabilitation of Stroke Survivors 43

Box 1-13
Discharge Planning
Inpatient In this setting the patient must be able to tolerate a minimum 3 hours of therapy 6 days per
rehabilitation week. The therapy is more aggressive, and length of stay is usually shorter than other settings.
The patient’s length of stay is dependent upon the rate of progress and attaining established
goals.
Subacute This setting usually occurs in a skilled nursing facility. The patient may receive 90 minutes of
rehabilitation therapy 5 times per week. The length of stay may be longer dependent upon tolerance and
progress in therapy. Medical insurance coverage may also dictate how long the patient can
remain in a subacute center.
Home care services In some instances, a patient may recover enough function to return home with services. In this
case, a referral for visiting nurse and therapy services may be recommended.
Outpatient therapy If the patient has sufficient recovery to return home and can enter and exit the home with ease,
outpatient therapy may be an appropriate option for discharge planning.

CASE STUDY 1 Another CT scan is performed on the third hospital

Ischemic Stroke: Management of Acute Case day, which reveals a clear, acute infarct in the right
and Complications with Workup temporoparietal area with associated edema and no
mass effect or hemorrhage, so the neurologist recom-
G.H. is a 76-year-old woman who has a history of hyper- mends an extended workup. Carotid Doppler images
tension and diabetes mellitus and had a myocardial in- are normal, and the electrocardiogram indicates stabil-
farction two years ago. She arrives at her local emergency ity, but the echocardiogram reveals that G.H. has a
room four hours after an acute onset of weakness in her decreased ejection fraction of 25% with a visible apical
left arm and leg. She fell at home after trying to get up, thrombus in the area of her previous myocardial infarc-
and it was only after her neighbors heard her calls for tion. The neurologist and cardiologist concur on anti-
help that the emergency services rescue team came to her coagulation with heparin followed by conversion to
aid. On admission to the emergency room, she has warfarin. Anticoagulant therapy is initiated, and the
an elevated blood pressure of 200/100 and is alert and aspirin is no longer administered.
oriented. Her initial physical examination reveals left- On the sixth hospital day, G.H. is started success-
sided weakness and sensory loss that is greater in her arm fully on warfarin, her hemiparesis has improved, and
than her leg. The emergency room team has the impres- she is able to move her leg against gravity and with
sion that she has an acute stroke in evolution, so an gravity eliminated. However, she is still unable to swal-
emergency CT scan is ordered. The initial blood work low safely and still has an NGT. G.H. is accepted for
and electrocardiogram are unremarkable. While she is in inpatient rehabilitation and is transferred to the reha-
the CT scanner, the on-call resident is paged and asked bilitation service on the eighth hospital day.
to come see her because the radiology technician notes G.H.’s rehabilitation course is notable because of
that she has become unable to move while in the ma- swelling and pain in her left leg, which is found by
chine. She now has a dense left hemiplegia. Because of duplex Doppler scanning to result from a DVT.
fear of stroke progression, she is admitted to the ICU. Because she developed the thrombosis while receiving
Review of the CT scan shows some mild effacement adequate anticoagulation medication, she has an um-
of the sulci on the right side of the brain and no brella filter placed in her inferior vena cava to prevent
other clear abnormalities. The neurological consultant development of a pulmonary embolus. G.H. becomes
advises that G.H.’s treatment that night be conservative severely depressed and after consultation with the
and supportive and recommends that G.H. be given an psychiatry service begins receiving antidepressant
enteric-coated aspirin each day. By the next morning, medication, which has good results. G.H. progresses in
she has had no further progression of her symptoms but therapy, but her left shoulder becomes painful because
has flaccid left hemiplegia and hemineglect. She re- of a shoulder-hand syndrome, which responds well to
mains medically stable during the next several days but aggressive therapeutic intervention. She also develops
is unable to achieve adequate oral intake and has to have a progressive increase in skeletal muscle activity,
an NGT placed for enteral feeding. A physiatric con- particularly in her left hand, which can only be kept
sultation is obtained, and physical and occupational under control with aggressive ROM exercises. At the
therapy is started at the bed side in the ICU.
Continued
44 Stroke Rehabilitation

CASE STUDY 1 The neurological and neurosurgical team, patient,

Ischemic Stroke: Management of Acute Case and family have a discussion and decide that surgical
and Complications with Workup—cont’d clipping of the aneurysm is the best approach to treat-
ing the lesion. C.C. is scheduled for operative inter-
time of her discharge, she is able to move short dis-
vention the next day. However, in the middle of the
tances with a hemiwalker and needs assistance with
night, he suddenly loses consciousness and stops
dressing her lower extremities and setting up for her
breathing. He has a cardiac arrest but is resuscitated
basic ADL.
successfully. An emergency CT scan reveals a large
G.H.’s one-year follow-up is notable for the con-
recurrent hemorrhage that extends into the cerebral
tinuing intractable painful spasticity in her left arm, so
cortex and a herniated brainstem. Aggressive treat-
treatment with Botox is instituted and results in ade-
ments are instituted, but despite all measures the her-
quate pain relief. She remains stable until five years
niation progresses, and C.C. lapses into an irreversible
after her stroke when she suffers a fall with a subse-
coma. One week later C.C. is declared brain dead, and
quent hip fracture. Evaluation of bone density shows
according to his family’s wishes, his organs are donated
accelerated osteoporosis in the left hip. She needs
for transplantation.
left hip hemiarthroplasty but is unable to regain her
previous level of function, despite aggressive therapy,
and finally has to be admitted to a nursing home when REVIEW QUESTIONS
discharged from the hospital.
1. Which stroke risk factors are considered modifiable?
2. Which procedures are used to diagnose a stroke?
CASE STUDY 2 3. Which clinical signs indicate a patient is receiving ex-
Hemorrhagic Stroke: Management of Acute Case cessive seizure medication?
with Workup 4. What are the risk factors and recommended treat-
ments for DVTs?
C.C. is a 25-year-old man who works as a sales man- 5. Other than neurological, what are the common com-
ager in a local retail store. While dismissing a store plications that follow a stroke?
clerk whom he caught stealing from the store safe, he
suddenly complains of a severe headache, sinks to the
chair in his office, and slumps over to the right. Within REFERENCES
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 j a n et f al k-kes s l er

chapter 2

Psychological Aspects
of Stroke Rehabilitation

key terms
anxiety cultural factors personality traits
caregivers defense mechanisms self-efficacy
coping depression

chapter objectives
After completing this chapter, the reader will be able to accomplish the following:
1. Understand the psychological manifestations of stroke in both children and adults.
2. Understand how a variety of psychological impairments affect the recovery process.
3. Understand how personality traits impact rehabilitation.
4. Understand the effect of stroke on family members and those in the caregiver role.
5. Understand the importance of participation in recovery.

Understanding the relationship between psychological In addition, pediatric stroke and the psychological con-
factors and stroke is a complex undertaking. Anxiety, de- sequences that may result are reviewed.
pression, aggression, and emotional lability are commonly It is well-documented that nearly 800,000 persons
seen in persons who have sustained a stroke, as each takes each year suffer a stroke, and of those it is the first attack
its toll on adjustment and each affects functional outcome. for almost 600,000.60 These statistics are especially
Psychiatric conditions restrict recovery and restrain qual- significant when considering that there is a decrease in
ity of life, making assessment and treatment of paramount stroke incidence, particularly in high income countries,
importance. When considering the psychological conse- due to attention to cardiovascular risk factors.32 In the
quences of stroke, observing physiological changes, United States, stroke continues to be a leading cause of
and emotional reactions to this life-altering event, one’s death, yet more than four million stroke individuals who
personality constructs and cultural background play a role have had a stroke survive.60 Stroke is a leading cause of
in recovery and outcome. The purpose of this chapter disability and has a major impact on participation as it
is to review the relationship between stroke and its psy- compromises activities of daily living (ADL) and social
chological consequences in adults; the impact on the roles.22 Stroke survivors, even in this climate of health
family’s and on the caregiver’s well-being; and how to care change, continue to receive and to benefit from
understand the implications for occupational therapy. services offered by occupational therapists.80

49
50 Stroke Rehabilitation

Stroke is a leading cause of disability and death in tobacco and alcohol use, and decreased physical activity,
individuals over 65-years-old, but 25% of those with stroke and to physiological risk factors (e.g., hypertension).69,128
are younger,14 as stroke can occur at any age. In addition Even so, evidence indicates that personality traits may be
to stroke afflicting adults, it has been estimated that stroke associated with increased risk for stroke. Longitudinal
affects children at a rate of at least two to three per 100,000.46 population based studies have been conducted linking
These statistics are further compounded by the significant emotion to stroke onset. One study showed that partici-
psychological impact of stroke on the survivors and their pants with a pattern of outward expression of anger were
families. twice as likely to sustain a stroke compared with even-
It is well established that adults who have sustained tempered individuals; individuals with a pattern of inward
a stroke are at high risk for psychological consequences. expression and those who were able to control their anger
As many as 30% to 50% of stroke survivors have been were not at any higher risk for stroke.29 Another study
estimated to have had some significant psychological also linked anger to stroke, but only in the younger par-
disorder following stroke,96 even in the absence of a ticipants, suggesting that the influence of anger on stroke
disabling condition.91 In fact, the risk for developing a decreases as one ages.128 Individuals with psychological
psychological disorder persists long after the stroke distress are at greater risk for fatal stroke,69 as are those
event.127 Given the profound impact psychological disor- who reported high, frequent levels of stress. No relation-
ders have on recovery, understanding the relationship, the ship exists between reported stress levels and nonfatal
range, and the effect these disorders have on individuals stroke. The speculation is that individuals with better
with stroke is paramount, for psychological factors may coping skills may be able to handle stressful situations and
be antecedents, consequences, and/or reactions to the may have fewer associated lifestyle risk factors, thereby
traumatic neurological experience. reducing their risk.116
Clearly, a complex relationship exists between psycho-
logical factors and medical conditions, and “Psychologi- PRESTROKE PSYCHOLOGICAL FACTORS
cal Factors Affecting Medical Condition” is even recog- AS PREDICTORS OF RECOVERY
nized as a diagnostic category.1 Undesirable psychological AND REHABILITATION
features may have an adverse effect on recovery and out-
come or may place an individual at risk for an unwanted A series of studies have been done that examine prestroke
outcome. Specific psychological symptoms, such as anxi- personality and psychological variables on poststroke
ety or depression; specific personality traits or coping recovery and rehabilitation. In one study, a history of either
styles, such as aggressive personality traits29,128; maladap- an affective disorder or an anxiety disorder was demon-
tive health behaviors, such as tobacco or alcohol abuse; strated to put a person at increased risk for developing
and stress-related physiological responses,116 have been major depression. The severity of the depression symptoms
linked to stroke.69 also depended on a personal or family history of affective or
Stress of illness and disability affects not only the anxiety disorders.74 Personality traits, such as introversion
person but also one’s family. An unexpected serious and and depression, may increase the mortality risk following a
disabling illness results in the need for all family members stroke,75 as may a history of depression.100 An impaired
to cope and find new ways of relating to one another. social relationship with a significant other before a stroke
Previously established roles, authority relationships, also puts individuals at significant risk for depression
family-based activities, and occupations may change,71 during the acute phase following a stroke and during the
resulting in a structural shift that puts the entire family long term after the stroke.99
at risk for significant distress. Due to the disability, the Personality factors are associated with the ability to re-
potential for increased alienation of the individual and of sume independence. As a character trait, individual’s self-
the family adds to the psychological distress already being esteem has been linked with recovery and independence,13
experienced.48 When a stroke happens to a child, the and as such is critical to consider in the rehabilitation
implications can be devastating for the family92 and can process.119 Personality factors along with occupational
result in increased mental health disorders in a parent.39 status, educational level, workplace accommodation, and
occupational choice play a significant role in the ability to
PSYCHOLOGICAL FACTORS return to work.71 One’s ability to handle life events, classi-
AS PREDICTORS OF STROKE fied into coping strategies, also affects one’s ability to re-
sume daily living function. Individuals with a preference
The examination of psychological factors as predictors for active coping styles or with an extrovert personality
of stroke has received attention. This area of inquiry is trait show greater improvements in activities of daily living
difficult to investigate because the psychological variables function than those individuals with passive or avoidant
typically identified are linked to lifestyle behaviors con- coping styles. These individuals are speculated to be more
sidered risk factors for coronary heart disease, such as highly motivated and have a more realistic appraisal of
 Chapter 2 • Psychological Aspects of Stroke Rehabilitation 51

their potential, which results in improved activities of daily and possible social alienation can give rise to reactions
living function.27 of grief, anger, guilt, and fear,31 all of which contribute
to a sense of social stigma46 and produce a myriad
EMOTIONAL REACTION TO STROKE of feelings that contribute to depression and anxiety.
Indeed, stroke has been suggested to be “an overwhelming
For any individual hospitalized after a traumatic event, psychological event that triggers a depressive episode in
a barrage of emotion is likely to develop. When faced with predisposed individuals.”125
an acute illness with chronic consequences, compounded If an individual seeks treatment early enough in the
by being acutely aware of the physical changes occurring development of a nonhemorrhagic stroke, medication is
and by being surrounded by a foreign and controlling available that may halt the progression of the stroke and
environment adds to ones emotional reaction.38 During an even reverse the damage to the brain. However, the
acute phase of the illness, one is concerned with survival, medication available is not without potentially fatal
is often confused with what is happening, and may be consequences. Whether the individual or the individual’s
the recipient of poor communication from hospital staff. family makes the decision for treatment with the medica-
This results in feelings of being overwhelmed; in ex- tion, if the outcome is poor, the family may be left with
periences of loss of control over personal care, which feelings of anger and guilt in addition to feelings of grief.
affects one’s sense of dignity; and often in experiences of If the individual delayed seeking treatment and did not
the hospital environment being dissatisfying, inadequate, avail himself or herself of potential medication, family
and insensitive.17 During the rehabilitation phase, an members may attribute blame to the patient for the
individual’s anxiety may increase if one is not progressing condition with which they now must cope.110
as quickly as one hoped. Depression and social isolation Certainly physical recovery plays a major role in
may set in, as family members need to resume normalcy one’s emotional reaction and in psychological adaptation.
and may not visit as often as they initially did.17 Fear and The actual experience of stroke, as it is happening, brings
anxiety, a sense of powerlessness, and even psychological forth fear of the unknown and distress that this experience
regression can result from stressors that include a threat actually is occurring. Although the initial recovery phase
to one’s integrity, dependence on strangers, separation may be marked by some improvement in one’s physical
from home and family, fear of loss of approval, fear of loss status, a plateau period during which progress is slowed
of control, fear of loss of control of body parts, and guilt. often follows and may lead to frustration and sadness.
The initial loss of control (not knowing what is happen- One’s emotional recovery is marked by a mix of emotions,
ing), integrity (wearing a hospital gown or using a bedpan), including uncertainty, hope, loss of control, anger, and
and freedom (given a schedule to follow, transported by frustration. Social recovery similarly is challenged, as one
others, told what to eat and when to eat) are values under- needs to adjust to changing roles, isolation, and the per-
scored by society and, when challenged, further add to ceived dissonance between past and current/future life.10
stigma, shame, and a sense of isolation.92 This experience Lack of control over one’s body, fear and shock of the
of hospitalization contributes to a diminished sense of self. rapidity of the physical changes, and feelings of loss
When patients face discharge from the hospital and/or around three particular areas—activities, abilities, and
rehabilitation program, they may feel abandoned by the independence—contribute to the emotional challenge of
medical system. Reality of their abilities with their ADL accepting that one’s life is changed in significant ways.42
and instrumental ADL, the role changes that occur, and One may argue that for individuals to make the transition
their participation in their activities may all be very chal- toward recovery, they must assess the psychological mean-
lenging. They experience loss, especially around driving ing of loss as it relates to self-concept. How might the loss
(as is symbolizes independence, self-esteem, social sup- of ability as it affects activity engagement affect one’s per-
port, participation), previously enjoyed hobbies and activi- sonal meaning of quality of life?11 To eventually accept a
ties, loss of role, and loss of future plans. They may also changed self, one’s self-concept goes through a process of
feel unattractive and self-conscious as change in their rela- transformation.
tionship with their partner occurs.17 See Chapters 23, 25, Framed in terms of stages, issues of recovery reflect the
and 29. interplay among physical recovery, emotional recovery,
As one’s condition begins to stabilize, emotional and psychological adaptation. Although progress takes
reactions continue. Research has shown that depression different forms for each individual, survivors tend to
and other psychological conditions may result from deal with common themes, and each has its impact on
physiological damage caused by stroke and from an adaptation. It has been suggested that the transition from
emotional consequence of the often resultant physically a healthy being to a stroke survivor occurs in stages. Keep-
disabling condition and subsequent social disruption. ing in mind that stroke survivors are often discharged
One’s reaction to illness and disability, to loss of home relatively quickly, there is great impact on family
function, to change in body image, and to role change members and consequently everyone’s role transition.119
52 Stroke Rehabilitation

To have a successful transition, there are stages in which PERSONALITY CHANGE FOLLOWING
the survivor and the family go through. One model sug- STROKE
gests stages that include denial, which protect one from
initial overwhelming emotion; grieving (as distinguished While it has been noted that a change in personality may
from depression), in which one mourns the loss of follow a stroke, and this may be related to lesion location,8
function; role transition, to include “care-receiver”; the the change is characterized as any of the following types:
development of optimal independence, which includes aggressive, disinhibition, paranoid, labile, and apathetic.33
compensatory techniques and adjustment to a new body; Although some of the symptoms may appear to be con-
rebuilding a social support system; and reintegration sistent with the signs and symptoms of specific psychiatric
into the community via instrumental ADL.11 It has also conditions, they often emerge as negative emotions or
been suggested that there are three domains in recovery: behaviors that do not meet the criteria for particular diag-
physical, psychological, and social. Important to these noses. These can range from euphoria to uncontrollable
domains is self-worth, which is related to participation tears, from worry to agitation, from disinterest to hostil-
and to quality of life. While stroke has great impact on ity, or from paranoia and guarded behavior to excessive
cognition and physical function, it is also critical to address dependency. Despite the behavioral expression of these
self-image and sense of being (psychological domain), emotions, they tend not to reflect an underlying mood
and changes in relationships (social domain). As family and may add to the embarrassment experienced by
members also change roles due to stroke, it is important to the patient.8 These behavioral changes are particularly
promote a positive self-concept and positive social difficult for the caregiver to manage, and they do not
support; both will have an impact on function.119 The goal respond to medication.33
with each of these models is toward acceptance of any re- Apathy is a common change that occurs, with some
maining disability and the return to a satisfying quality of studies suggesting between 20% to 40% of stroke survivors
life. See Chapter 3. Emotional reaction following stroke display some apathetic behavior.33 Although apathy can
has significant implications for recovery. Feelings of be a symptom of depression, it can also be a separate
helplessness or hopelessness affect survival rate,63 apathy construct, occurs more frequently than depression, and
affects functional ability,47 and depression and anxiety affects rehabilitation and recovery.43 By its very nature, the
affect function and recovery.2,14-16,45,50 impact of apathy on energy and motivation clearly effects
One’s cultural background also may play a role in engagement in the recovery and rehabilitative process.
how one copes with illness, disability, and rehabilitation.
As stated earlier, cultural values and attitudes may DEPRESSION
devalue any form of dependency. Consequently, a dis-
ability may add to feelings of alienation. From a cultural Among the most significant considerations in under-
perspective, psychological conditions also may be viewed standing the characteristics and consequences of stroke is
as a weakness of character. This further stigmatizes the the relationship of depression to onset, recovery, and
individual and leads to the avoidance of acknowledging rehabilitation of persons with stroke. Because of the
feelings and of being treated.70 neurophysiological changes and because of the reaction to
Health professionals, without intending to do so, the consequences of stroke, depression has major implica-
may become enablers of the loss of personal identity tions for the course of recovery. Despite the causes of
and dignity and contribute to a diminished self-esteem. depression, assessment and treatment of depression
When an individual is referred to in terms of a disabling affects psychological, functional, and medical health.
condition (e.g., “a right hemi”), one’s dignity and sense of The relationship between cerebrovascular disease and
personal worth are challenged. This adds to what may depression has long been studied. Depression is both a
be emerging as a damaged sense of self within the context risk factor for stroke33,55 and a major consequence of
of social stigma. Many individuals go to great lengths stroke.126 For nearly three quarters of a century, the
to conceal their disabilities from others to avoid being assumption held that depression following a stroke was
identified as having had a stroke.90 Although much has related only to the functional and social consequences of
been written regarding the negative emotional reaction the disability and not to the neurological damage of the
to stroke, the suggestion also has been made that for indi- stroke itself. Three decades ago, however, a study com-
viduals whose lives ordinarily are characterized by crises, pared depression in individuals with stroke to individuals
dealing with the consequences of stroke is not considered with orthopedic conditions, with both groups matched for
an extraordinary event but just another life change.89 functional ability. The significant increase of depression
Although this challenges the general assumption that in the group with stroke led the researchers to believe that
anyone who has experienced a stroke also will experience depression was related to something more than a reaction
grief, loss, and distress,96 considering the context of one’s to functional inability.35 More recent studies show that
life in which stroke occurs is important.66 depression in stroke can occur at any time; during the
 Chapter 2 • Psychological Aspects of Stroke Rehabilitation 53

acute phase, or two to three years later; and may not Depression also may be characterized by isolative
reflect functional independence.127 It is also often accom- behavior and irritable, angry, or hostile expression.
panied by anxiety.4 With the acknowledgment that depres- These symptoms can occur to a lesser extent and have
sion is a major complication for individuals with stroke, a less debilitating effect. When the symptoms are less
attention is paid to both the prevention and treatment of frequent and less severe, one may have a dysthymia
poststroke depression.41,126 disorder or minor depression.1 A history of depression
During the past three decades, links have been made has been noted to be a risk factor for stroke,30 a risk that
between lesion location and depression onset. Past studies may exceed the general risk by two to three times.55
have noted that an association exists between lesion It also is a risk factor for not surviving a stroke.30 Even
location, particularly left anterior lesions, with onset of an attitude of helplessness affects one’s survival rate.58
depression during the acute phase; and an increased Other psychological diagnoses sometimes are confused
severity of depression the closer the lesion is to the left with depression, can occur concomitantly, and have a
frontal pole,62,96 and right parietal lesions with depression prevalence rate of between 19% and 22%. These diagnoses
during the subacute period.99 Studies suggest that there is include apathy (low motivation and/or energy) and various
not only a neuroanatomical basis of depression following anxiety disorders.99
stroke;79 but also a pathophysiological basis for depression, Any form of depression can occur at any time following
which may result from a chemical change following stroke, and the symptoms used to diagnose depression may
brain infarction.99,101 This avenue of inquiry continues, depend on whether the depression onset is early or late.87,114
with attention recently being paid to lesions associated Regardless of onset or symptom clusters, poststroke
with vascular depression.100 Lesion location is not without depression, whether related to the clinical diagnosis of
controversy, however. Studies have demonstrated that depression or with the number of clinically significant
depression occurs in individuals without regard to symptoms associated with depression,33,41,55,127 has been
location of lesion;79 often occurs within the acute phase found to negatively affect the physical recovery from
(first three months);4 and despite its etiology (biological or stroke16 and independence in ADL.15,16
psychosocial),115 is a significant consequence of stroke and
requires treatment.116 It is important to view poststroke ANXIETY DISORDERS
depression as multifactorial when planning treatment.115
Whether poststroke depression is characterized by It is well-documented that a significant comorbidity exists
depressive features or meets criteria for major depres- between poststroke depression and anxiety.14 Anxiety
sion,33 there are implications for recovery and rehabilita- disorders, most commonly generalized anxiety disorder,
tion. Associated with poorer outcomes, as reflected by can emerge during any phase of recovery, from the acute
overall functional impairment, diminished quality of life, phase to the rehabilitation phase. Like depression, the
and mortality,76 depression is specifically linked with in- cause may vary. Although compelling evidence suggests
creased impairment in ADL and is linked with more anxiety is often a reaction to loss of anticipated or actual
severe neurological deficits.50 Any form of depression has functional ability,14 other evidence links early onset with
an effect on functional status in individuals with stroke a previous history of psychiatric conditions.33 It also may
and that depressive symptoms; even in the absence of any accompany poststroke depression.33
depression diagnosis, it affects functional status.45 The Some instances of anxiety may have an anatomical
duration of depression varies from months to years.6,14,62 basis and may be associated with left hemisphere lesions.4
Depression accompanied by cognitive impairment has a Emotional lability, characterized by extreme expression
longer duration.42 Any poststroke depression that does of emotion such as crying or laughing, but without
not remit leads to a poorer, long-term functional out- the underlying feelings of sadness or depression, occurs
come.15,16,88 In addition, changes in social support add to independent of depression and may be associated with
depression.17 lesions in the anterior regions of the cerebral hemi-
Poststroke depression is characterized by unrelenting spheres.99 Excessive worrying, restlessness, irritability
feelings of sadness, anhedonia, helplessness, worthless- and/or tension, and catastrophic reactions (sudden onset
ness, and/or hopelessness; loss of pleasure or interest of anxiety, hostility, or crying) may be linked with lesion
in all activities; change in appetite, weight, or sleep location, specifically the left posterior internal capsule,
pattern; psychomotor retardation or agitation; loss of left cortex, and left anterior subcortex, respectively.99
energy; loss of concentration; or suicidal ideation.14,33 Regardless of its cause, anxiety tends to remain stable
Indeed, suicidal ideation, although prevalent in indi- over time, while depression may decrease.76 Anxiety,
viduals with a variety of acute medical conditions,53 is if coupled with depression, impairs functional ability; and
also prevalent in medical conditions that become chronic. by itself, affects quality of life and social functioning.2,33
For individuals with stroke, the prevalence of suicidal Recent attention has been paid to recognizing post
ideation increases over time.52 traumatic stress disorder (PTSD) in stroke survivors.
54 Stroke Rehabilitation

When conceptualizing stroke as an emotionally traumatic and distinguishing one from the other is sometimes
event, it is easy to see why it may give rise to symptoms difficult. Some evidence suggests that depression leads
consistent with PTSD. It has been estimated that PTSD to cognitive impairment81 that might be classified as a
occurs in as many as 30% of stroke survivors, the greatest pseudodementia9 and that these conditions can benefit
risks related to number of previous strokes one has had, a from adequate treatment of depression.31
premorbid negative affect,72 and cognitive appraisals that Cognitive ability is linked with one’s ability to live
also tend to be negative.34,72 The onset of PTSD tends to independently, as it is directly related to one’s ability
occur shortly after the stroke event, as the risk diminishes to learn skills, have insight into one’s condition, and
with time. Anxiety and depression is not predictive of to participate in the overall rehabilitation process.119
PTSD, although there is an association between number Not surprisingly, cognitive ability is a significant predictor
and severity of PTSD symptoms.72 of functional outcome and the ability to live indepen-
Catastrophic reactions in which individuals experience dently.64,119 See Chapters 17, 18, and 19.
sudden and extreme feelings of anxiety are related to anxi- Being able to control one’s emotions is an important
ety disorders. Although these reactions typically occur characteristic, and emotional responses to situations or
after the acute poststroke phase, the responses may be in events are expected. Yet, for many stroke survivors, patho-
reaction to frustration and depression and have implica- logical laughter or crying occurs. It has been estimated that
tions for rehabilitation.14 Catastrophic reactions are distin- between 11% to 40% have this involuntary expression of
guished from emotional lability in that an underlying emotion, an expression unrelated to a situation or event.33
emotion is associated with it. The affect expressed with Discreet expression of emotion is exhibited by many
emotional lability, that is, sudden outbursts of laughter or stroke survivors. While some have been associated
crying, is not associated with one’s mood.75 with personality change, it has also been argued that
emotions may be early indicators of psychological
OTHER PSYCHOLOGICAL/EMOTIONAL disorders. These emotions include sadness, passivity,
CONDITIONS aggressiveness, indifference, disinhibition, denial, and
adaptation. While a previous psychiatric history is linked
Psychotic conditions are rare consequences of stroke, but with these emotions, family history is not linked, nor is
they can occur. Symptoms can include delusions and hal- degree of impairment. Linking emotional behaviors to
lucinations,94 paranoia, and mania.59 Poststroke mania, lesion location is inconclusive.3
for example, may occur in up to 2% of stroke survivors It has been noted that people with stroke have a
and might be related to a previous history.33 There is lowered self-esteem. Self-esteem, which reflects one’s
some evidence that associates these symptoms with pre- sense of worth, may assist or inhibit one’s emotional ad-
existing neuroanatomical risk factors, older age,94 and justment to illness and disability.121 While it may coexist
lesion location.99 Most psychotic conditions that emerge with depression, it should also be viewed as a separate
after stroke are believed to emerge in individuals with a entity. Addressing issues of self-esteem has implications
history of psychotic conditions or in individuals predis- for recovery and function. Table 2-1 identifies the prev-
posed to developing these conditions.8 alence of some of these disorders.
Poststroke dementia, also known as multiinfarct
dementia or vascular dementia, has been diagnosed in BIOLOGICAL INTERVENTION
many individuals, although the consistency of diagnostic
criteria has not been applied.95 Depending upon the A number of factors are associated with the cause of psycho-
criteria used, anywhere from 6% to 32% of stroke logical conditions following stroke. Social and psychological
survivors may have signs of dementia.104 This is especially stressors play a major role in the development of these
important, as the risk for dementia even 10 years conditions, as do anatomical lesions. Despite the debate
poststroke is higher than in the nonstroke population.104 regarding the primary cause of psychological conditions,
Poststroke dementia occurs more frequently in those over leading some to conclude that no evidence supports a single
60-years-old.104 It has been argued that memory loss need theory on the origin of psychological conditions in persons
not be a criteria for dementia, particularly when one’s with stroke;125 no debate exists regarding the importance of
executive functioning is impaired and one’s mental speed taking a bio-psycho-social approach in understanding and
is diminished. It has also been argued that dementia may treating stroke, as psychological conditions take their toll on
have a slow onset, starting with cognitive disorders of the recovery and functional ability.
nondementia type.95 Medication is not sufficient to counter the effect of
Cognitive deficits, even those not associated with de- stroke on daily function,16 but it is a critical weapon in the
mentia, are common consequences of stroke.119 Although treatment of psychological conditions. Without regard to
cognitive deficits may be related directly to lesion, the the cause of the conditions, a number of studies have been
effect between depression and cognition is interactive, conducted to determine the use of psychopharmacological
 Chapter 2 • Psychological Aspects of Stroke Rehabilitation 55

Table 2-1
Psychiatric Conditions Associated with Stroke
APPROXIMATE
APPROXIMATE PREVALENCE RATE
CONDITION PREVALENCE RATE IN ADULTS IN CHILDREN FEATURES

Poststroke 35%14 21%67 Features consistent with major (20% to

depression Suicidal ideation: 23%4,102 in adults) or minor (21%102 in
7% during acute phase adults) depression
11% within 2 years after stroke56
Apathy 22% (half with no depression — Low motivation and/or energy
comorbidity109 Affects rehab and recovery, and happens
more frequently than depression43
Personality change 20% to 40%33 17%67 Aggressive, disinhibited, paranoid, labile,
and apathetic types of changes
Anxiety disorders Generalized anxiety disorder: 31%67 Excessive anxiety and worry
21% to 28% during acute
phase,2
22% 3 months after stroke2
13% with no depression
comorbidity2
PTSD: 30%72 Reexperiencing symptoms
State of worry: 14%12 Expressed anxiety but not fulfilling
generalized anxiety disorder criteria
Emotional lability: 18%73 Awareness of uncontrollable emotion
(pathological laughing or crying)
inconsistent with mood
Catastrophic reaction: 19%109 Sudden onset of anxiety, hostility,
or crying
Attentional deficit 46%67, 68 This includes inattention and apathy
hyperactivity
disorder
Dementia 6% to 32%104 — Cognitive deficits, including executive
function, mental speed,
and memory loss
Poststroke mania 2%33 — Mood and thought disturbance

PTSD, post traumatic stress disorder.

agents in treating psychological conditions. Antidepres- COPING WITH ILLNESS, RECOVERY,

sants have been used in individuals with depression or AND REHABILITATION
with pathological affect; benzodiazepines have been used
for generalized anxiety disorder, with limited success The relationship between psychosocial factors and sus-
because of side effects; and poststroke psychosis appears to taining a stroke is compounded by the role emotion,
respond to neuroleptic medication.14,33 personality, and culture have in how one copes with trau-
A Cochrane review has examined the effect of medica- matic illness. Defense mechanisms, which serve to pro-
tion on preventing and treating poststroke depression.41 tect the individual from the overwhelming emotions that
While many of the studies reviewed through metaanalysis may arise, may add to one’s difficulty in coping with
have limitations that preclude definite recommendations, illness and disability.78 Defense mechanisms typically
it appears that medication will not prevent poststroke used include denial, which negates the reality of what is
depression,41 but may be useful treating poststroke happening and has happened; avoidance, in which the
depression.41 The opposite may be true for psychosocial individual is aware of what is happening and has hap-
interventions; it may be useful in preventing depression,41 pened but avoids the implications; regression, in which
but not in treating depression.41 Using medication, one exhibits increased emotion and/or increased depen-
however, should be done with caution, as side effects can dent behavior not characteristic of one’s developmental
have significant consequences.41 level; compensation, in which one becomes adept in an
56 Stroke Rehabilitation

area to counter an inability of another area; rationaliza- rehabilitation outcomes: ability for reality testing, ability
tion, which provides reasons or excuses for not being able to self-reflect, and ability to acknowledge and grieve for
to accomplish tasks or goals; and diversion of feelings, in loss.9 Individuals who have sustained a significant
which unacceptable feelings are altered into socially ap- physical illness or injury are struggling with emotional
propriate behaviors.31 How defenses are used also can crises and revert to using characteristics from past situa-
give rise to how one is viewed by the treating therapist. tions.38 Understanding personality and its role in coping
The therapist may misinterpret behavior guided by mal- is critical for rehabilitation, for different styles promote
adaptive defense mechanisms and label the individual as functional adjustment and improved quality of life.27
a difficult patient.78 Culture is a major determinant of one’s beliefs and at-
As the chronicity of the disability becomes apparent, titudes, plays a major role in how one perceives illness and
the individual and one’s social network must deal with the disability, and may influence how one interacts with
long-term effects of the stroke. Most immediate is the health care providers. The meaning one ascribes to illness
perceived change in oneself. Because role, lifestyle, and and how one behaves toward illness may be a function of
where one is in one’s life cycle affect one’s emotional personal and cultural health traditions. Assuming the sick
reaction, trauma brings forth changes in what one can do role, which demands that one adjust to the role of patient
and in how one sees oneself. Although time may enable and then relinquish that role to resume independence,
one to develop the adaptive defenses necessary to deal may be determined culturally. For some, one’s cultural
with the anxiety surrounding illness, disability, and the background may promote motivation toward rehabilita-
unknown, one’s psychological adaptation may be under- tion and recovery; for others, it might obstruct progress.
mined if the symptoms are not alleviated. The resultant Culture dictates how one interacts in any social organiza-
reaction to stress is often a universal loss of self-esteem tion (a clinic or hospital is a social organization); how and
followed by depression. Maladaptive uses of defenses when one communicates; how one deals with personal
may then ensue.111 space, particularly as others intrude on it; and how one
Psychological adjustment to illness and disability also considers future goals.108 Cultural habits may influence
depends on personality constructs; consequently, individu- how one expresses oneself and, if one is reserved, may
als who have had strokes need to be understood from be misperceived as one being unmotivated, guarded, or
the perspective of their character traits, their cultural disrespectful.70 Like personality traits, one’s cultural hab-
background, and the psychological consequences that are its may be expressed as a means to deal with stressful
reactionary and physiologically based. Some evidence exists situations.
that personality characteristics play a role in the develop- It may seem logical for an individual who has suffered
ment of stroke, in the recovery from stroke, and in how one a stroke to be open with health care providers with one’s
participates in treatment. feelings, goals, and concerns. In patient-centered practice,
Almost a half a century ago, it was suggested that health care professionals expect to rely on patients to
personality constructs characterize how one copes inform and instruct them as they evaluate and plan treat-
with illness and engages in treatment, and that health ment for optimal occupational performance. However,
care professionals should understand and adapt their some cultures prefer the health care provider to assume
interactive styles based on the patient’s character.49 somewhat of an authoritarian role,57 others may express
One approach to understanding personality is by using respect through the avoidance of eye contact yet expect
the classification system typical of those with personality the health care provider to be solicitous in recognition of
disorders, such as the dependent and overdemanding social worthiness,37 and others may appear mistrustful and
personality, the controlling personality, or the dramatic uncommunicative.70
personality. How individuals use those characteristics Having a disability that challenges one’s independence
to cope with the stress and anxiety associated with is particularly difficult for those individuals for whom inde-
illness can assist the therapist implement treatment.78 pendence, control, and individuality are important values.70
For example, patients with compulsive personalities who Indeed, these attributes eventually may motivate one in
ask for details and facts will benefit when the therapist the rehabilitative process but initially make it more
provides adequate information to calm any anxiety, and difficult to deal with a trauma that robs one of these values.
when the therapist encourages the patient to take charge In addition, culture often prescribes the roles one assumes
of certain aspects of treatment.38 A second approach to in a social or family structure. For these individuals, coping
understanding personality is based on coping styles used with role change becomes even more challenging.
in stressful situations. This approach allows one to shape The psychological conditions so prevalent following
the rehabilitation process so that it reflects the patients’ stroke are particularly difficult for individuals to deal with
coping style.19,96 A third approach is to identify whether if their cultural heritage is intolerant of psychological
an individual has certain emotional characteristics, conditions. Although some cultural groups rely on verbal
characteristics which are thought to reflect positive expression and take pride in expressing their feelings,
 Chapter 2 • Psychological Aspects of Stroke Rehabilitation 57

others are embarrassed to discuss personal issues with As previously noted, individuals with depression
outsiders,70 feel guilty if they share feelings with strang- have difficulty with self-efficacy, and individuals with
ers, view any mental condition as one that would bring poststroke depression have more negative cognitions than
shame on a family, and expect only willpower and charac- do individuals without depression who have had a stroke.
ter to overcome psychological problems.57 Psychological Although individuals with stroke tend to focus on what
issues for some are viewed from a spiritual context, with they can no longer do, they may not recognize those
the expectation of spiritual interventions.37 For others, qualities and abilities they do have.96 Given the effective-
psychological issues are expressed in physical terms; ness of cognitive behavioral approaches in treating
headaches or backaches, for example, may be how one depression, cognitive behavioral approaches have been
communicates depression.56 For many individuals, the suggested to be efficacious with poststroke depression.81
ability to accept treatment for a mental health condition Self-esteem deals with one’s perception of one’s own
happens only when all other interventions have failed.57 worth. An adequate sense of self leads to pride of
Cultural attitudes add to the emotional reaction one accomplishment and active participation in the recovery
might have to the physical consequences of stroke and process. Coping strategies focused on personal worth and
make one more resistant to understanding the psycho- control help diminish the stress related to illness. These
logical implications. One also must remember that not strategies include taking positive action to regain control
everyone from a particular cultural heritage shares the of one’s life.10 Use of adaptive coping strategies that have
stereotypical cultural beliefs. The imperative, therefore, is worked in the past30,78,96 also promotes adaptation.
that all health care providers understand what the mean- Social support has a major influence on motivation.
ing of illness and recovery is for individuals, from their By not feeling isolated or abandoned, one is more likely
particular personal and cultural perspectives. to consider the future and work toward goals. The impor-
tance of social support to the recovery process cannot be
RECOVERY understated. Individuals are able to cope better with their
changed self and show adequate self-esteem when their
One of the most important contributors to any recovery social environment is perceived as adequate. Social support
process is motivation. Although psychological conditions, is considered essential in the initial recovery stage follow-
particularly depression and apathy, are often characterized ing stroke.102 Psychological adaptation and improvement in
by low motivation, personal traits influence one’s determi- function, even if affected by depression, is fostered when
nation toward recovery. family is involved in rehabilitation efforts.42
Four factors affect motivation: locus of control, self- One of the measures of quality of life is social participa-
efficacy, self-esteem, and social support.25 Locus of tion.22,63 If health is influenced by satisfaction with
control deals with where one places the influence of one’s what one does, then engaging in and feeling competent in
future. If, for example, individuals believe they can influ- activity participation, both social and ADL, is often a posi-
ence their health by eating right, exercising, and so on, tive sign.24 Yet despite the return of or compensation for
then those individuals are viewed as having an internal physical or cognitive functioning, most patients who have
locus of control. Individuals with an internal locus of sustained a stroke report a decreased involvement in social
control are thought to be more self-motivated. Self- activities.42,82 Although there is some evidence that engag-
efficacy relates to one’s confidence in what one can do. A ing in activities lessens as one ages and evaluating reduced
strong sense of self-efficacy motivates an individual to- participation in an older individual who has survived stroke
ward accomplishing a goal. Too strong a sense of self- from the context of normal aging is useful,22 participation
efficacy, however, may be reflected in misjudging one’s should always be a goal. Not being content with how one
capabilities, leading to frustration and anger. uses one’s time may reflect difficulty reengaging in mean-
Promoting individual control over lifestyle and by ingful occupations and may contribute to either boredom
focusing on what one can do and work toward indeed may or depression.24 Diminished participation may also result
mediate the negative effects of disability and may promote from changed body image, the stigma of evident disability,
psychological adaptation.96,112 This is consistent with the and dependence on others for transportation as isolation
social cognition model of setting personal goals within the and frustration results.42 Although physical changes may set
context of appropriate outcome expectations, a model used in motion the factors that can decrease social involvement,
successfully in rehabilitation.97 Developing or maintaining a the resultant inability to resume previously held roles,
positive emotional outlook may mediate depression and inability to work, and diminished social interaction may
lead to better functional outcomes.84 Also important in the have the greatest impact on quality of life.10,82 Attention to
transition to recovery is an emphasis on health promotion. social involvement after rehabilitation becomes especially
Because stroke survivors sometimes return to an unhealthy important in the maintenance of function and in leading a
lifestyle,97 fostering the psychological skills that can meaningful and fulfilling life . Participation may reflect one’s
promote self-efficacy becomes even more important. ability to do for oneself.5 See Chapter 3.
58 Stroke Rehabilitation

Equally important, families are expected to cope with The caregiver/spouse, particularly if female, is at higher
the immediate health needs and subsequent rehabilitation risk for depression due to diminished social interaction
needs of the family member who has had the stroke, and with friends and family.54 Caregiver strain does not seem
sometimes they feel unsupported. This is especially true to change over time.47
if there is poor communication between health care pro- Taking on the role of caregiver, whether forced or by
fessionals and family members, or when family member’s choice, has emotional consequences for the caregiver, and
knowledge about the stroke survivor is ignored or deval- functional consequences for the stroke survivor. Emotional
ued.86 Entire families undergo role and status change, and health of the carer will impact the patient’s functional
for family members to experience depression and anxiety is outcome,40,122 just as the patient’s functional status may
not unusual.122 Depression in the primary support person is impact the carer’s emotional well-being.28,47,88 The carer’s
higher than in the general population.36 Families as a whole emotional health also impacts other family members, and
also perceive a decreased quality of life because their social emotional or behavioral consequences may be exhibited by
and leisure activities are affected when a family member has children.123
had a stroke.82 In addition, they are now meeting health Many studies have been done to ascertain the relation-
care needs and not affection needs, which further affects ship of caregiver strain with factors such as hours spent in
their well-being. The shift in one’s relationship can pro- the caregiver role and physical and cognitive functional
mote tension; a spouse no longer shares occupations, but status of the patient. Studies on the relationship of burden
instead assists with ADL.24 When the needs of the family to personal strain/stress and role strain have mixed results.
are addressed, an individual is better able to handle com- Some studies support the notion that decline in the care-
munity reintegration. Family members need honest infor- giver’s health correlates with hours of caregiving,28
mation, must have accessible health professionals, and must the survivor’s decreased ADL function, negative health
receive support for themselves.118 Although social support status,28,47,77 decreased cognitive ability, and compromised
for family members influences how satisfied they are with communication skills.93 There is also evidence that
quality of life, the ability to problem-solve shapes depres- caregivers of relatively functional stroke survivors, i.e.,
sive behavior.41 good physical and cognitive function, also have a high
Children of stroke survivors can be especially vulnera- incidence of depression.113 If there is a preexisting depres-
ble. Often, children participate in caregiving activities. sion, it worsens as caregiver responsibilities increase.28
For some children, this has positive consequences, as This supports the notion that all caregivers, regardless of
they may feel needed and responsible in a mature way;117 the health and functional status of the survivor, are at risk
however, between 30% and 50% of children of survivors for emotional distress.
exhibit behavior problems.124 Specifically influencing how When the caregiver is a family member, one maintains
well a child of a stroke survivor does is the health status of three roles: caregiver, that client in the health care system,
the healthy parent, rather than the severity of the stroke and family member.122 These roles add to the psychological
and the health of the stroke survivor.123,124 Caregiver burden the carer experiences.40 The role shifts required are
strain and/or depression is linked with emotional health shifts that affect the entire family, and as family function
in the child.123 Children, regardless of the severity of affects the stroke survivor’s outcomes, intervention must
the parent’s stroke, benefit from support from health include a focus on the family needs.122
care professionals.123 Exhibited behavioral problems and The American Occupational Therapy Association
depression can improve over time.117,124 has underscored the importance of addressing caregiver
needs.85 Much of the research on caregiver intervention
Caregiver’s Emotional Well-Being is compatible with occupational therapists’ domain
It is becoming more and more apparent that the emo- of practice and should be considered when treating
tional health of caregivers, who are usually family mem- the stroke survivor. This research is not specific to
bers, is being compromised. Often referred to as caregiver Western countries, as caregiver strain is not bound by
burden or strain, the health status of caregiver impacts culture.77,93,113 Two areas for intervention have been
patient outcome, both functionally and emotionally. delineated: social support and participation, and coping
Although most caregivers are women and family mem- strategies.
bers,40 men assume this role as well. The caregiver is Social support is critical for caregivers.28,118 Whether
at great risk for stress, depression, and anxiety.122 providing resources to assist the caregiver in carrying out
This may result from feelings of confinement and being responsibilities, resources to provide respite, or resources
overwhelmed with responsibilities,47 having decreased to simply give emotional support,28,40,47 maintaining one’s
energy, lack of sleep, dealing with ADL,28 the sudden quality of life helps reduce or even prevent depression
change in how one’s family functions, changes in personal in the carer.36 Social support plays an important role in
plans, the overall experience of loss,47,122 and even unreal- reducing caregiver strain,40,41 and assessing one’s social
istic expectation caregivers have in what to expect.24 network is the first step toward intervention.
 Chapter 2 • Psychological Aspects of Stroke Rehabilitation 59

Social participation is equally important. Women may Pediatric stroke is distinguished from adult stroke in
be particularly vulnerable to the effects of decreased social other ways as well. Lifestyle, such as smoking, and risk
participation, as assuming the role of caregiver may rep- factors, such as high blood pressure, are not associated
resent a dramatic shift from one’s social routine.54 Reports with childhood stroke;2 some studies report functional
of participation of carers of patients from many diagnoses recovery to be better in children than adults due to the
have noted that social participation and involvement plasticity of the brain,46 while other studies suggest
with meaningful occupations contribute to the caregiver’s almost all children who survive stroke have residual
well-being.28,44 Community reintegration and social par- impairments42 as the immature brain is more vulnerable
ticipation of survivors also helps caregivers.47 to damage;51 and survivors of childhood arterial ischemic
Various models of interventions for caregivers have stroke have poor outcomes.7 Finally, lesion location does
been proposed and are all aimed at reducing and decreasing not seem to influence cognitive or psychological out-
burden. Each pays attention to social support and partici- come.2 While the most prevalent psychiatric disorder in
pation. While studies support almost any intervention as adults is poststroke depression, which occurs in over 30%
positive in improving the psychological health of the carer of the cases,14 attentional deficit hyperactivity disorder is
and reducing the negativity associated with caring, the most prevalent in children, occurring in 46% of the
the studies themselves are not methodologically rigorous. cases.68 Children have impairments that affect a variety of
This has implications for the findings, but intervention functional domains and that limit activity involvement,39
should be provided, as there are positive effects.26 and when stroke is compounded by any number of psy-
Coping strategies also contribute to the emotional health chiatric conditions, their functional ability is significantly
of the carer and begin when the stroke occurs. Just as the impaired.67
stroke survivor’s personality and culture contribute to one’s The psychological implications of pediatric stroke
reaction to illness, they also have implications for how the may best be understood when considering that
individual handles stress and anxiety. Maladaptive coping estimates of between 50% to 80% of all surviving
styles, such as denial and self-blame, used by the caregiver children have attention, behavior, and quality of life
lead to depression, but so might positive coping strategies, deficits.36,21 Being able to return to and complete
particularly early in the recovery process.93 For example, school50,51 is a goal for many survivors and appears to be
positive coping styles can include planning, active coping, an indicator of function. Nonetheless, psychological
acceptance, and positive reframing. If planning is based manifestations are apparent in many children and affect
on unrealistic expectations during the acute phase when functional outcome.
progress is unpredictable, depression can develop.93 None- It has been suggested that the child’s emotional health
theless, coping strategies have been effective in helping the is related to the parent’s well-being, and that social emo-
caregiver adjust. tional function and activity limitation are linked to a
Emotion-focused strategies may be effective when parent’s increased emotional distress.39 In addition, a fam-
dealing with problems. Positive coping styles122,40 versus ily history of psychological conditions is an important
pessimism and negative styles may reduce stress, and risk factor for a child’s psychiatric disorder.67 A high
addressing social problems may be more effective than rate of attentional deficit hyperactivity disorders (46%),
social support.40 Helping the carer set realistic goals when anxiety disorders (31%), and mood disorders including
solving problems is also effective.40,83,122 depression (21%) occur in children.67 Parents also report
a personality change67,86 and an increase of emotional
Children with Stroke difficulty and behavioral change.21,86 Children who have
Too often pediatric stroke is overlooked, and as a result, a psychological disorder following stroke are more im-
has not been extensively studied.51 Two to three paired functionally than those with stroke who do not
children in 100,000 are diagnosed each year,46 although have a psychological disorder.67 These children are more
that estimate may be low,65 as studies have suggested a impaired in IQ testing, academic functioning, and social
rate as high as of 13 in 100,000 children, and one in functioning.67
5000 live births.2 Typically associated with clinical Despite the barriers, children with stroke tend to have
conditions, such as congenital heart disease, sickle cell a good quality of life,21 and many if not most return to
anemia, and infection,2,61,98 nearly three quarters of school.46 However, social functioning remains a concern,
pediatric cases have no known preexisting condition.61 because of the residual intellectual and language chal-
Compounding the ability to diagnose children are lenges.46 These children especially benefit when treat-
“silent brain lesions” that may occur in as many as 20% ment is oriented toward “sameness,” i.e., to ensure that
of children with sickle cell anemia,98 which affect the child perceives oneself not a different from one’s
cognition and behavior, and conditions that “mimic” peers, but similar in both function and in appearance.7
stroke, such as hemiplegic cerebral palsy, and com- Acceptance by one’s social peer group is an important
plicated migraine or seizure.2 rehabilitation goal.
60 Stroke Rehabilitation

OCCUPATIONAL THERAPY PRACTICE that professionals use to determine functional ability is

typically related to physical performance, whereas patients
Throughout this chapter, reference has been made to the use quality of life measures.10
effect of psychological conditions and psychiatric disor-
ders on recovery and rehabilitation. Personality traits80 The Therapeutic Relationship
and levels of stress,69,94 have been linked with mortality There is some evidence that psychosocial intervention
rates from stroke, as have severe forms of depression.30 may indeed prevent poststroke depression.41 Given this,
Personality traits related to self-esteem and coping style it is paramount to consider every interaction between
have been linked with ability to resume independence.13,27 the patient and therapist as a context for assessment and
Participation in meaningful activities may be the best intervention.96 The relationship that develops presents
indicator of recovery.5,19,22,28,46 an ongoing opportunity to consider personal and social
Depression and anxiety have perhaps the greatest needs, to clarify and refine goals, and to address the
impact on recovery and rehabilitation. Depression has ambient emotional conditions affecting progress. The
been linked in general with recovery from stroke, with relationship between therapist and patient may even
deficits in physical function,50 and with deficits in impair- predict positive functional outcome.9 The therapeutic
ment in daily living.15,16,88 Even depressive symptoms relationship begins the moment the patient and thera-
without a clear diagnosis are linked to poorer functional pist interact. This may precede face-to-face contact,
status.45 The presence of anxiety also reduces functional as each may have preconceived notions of what to
ability and diminishes social networks.3 expect. These notions may impede the therapeutic pro-
Assessment and treatment of psychological conditions cess if they lead to inaccurate or unrealistic assump-
and psychiatric disorders is critical when working with tions, or they may facilitate the process if they promote
individuals who have had a stroke and with their families. the awareness of conditions and contexts that must be
As reviewed elsewhere, studies have repeatedly demon- considered.
strated that medication is effective in the prevention84 and Fundamental to the relationship is respect, trust,
treatment of these conditions16 but should be coupled concern for dignity, honesty, and the ability to be empa-
with psychological and social interventions. thetic.106 As the therapist and patient work to develop a
In 2008, the American Occupational Therapy Associa- collaboration that can result in optimal occupational
tion published its Occupational Therapy Practice Framework, performance, each needs to engage in the therapeutic
2nd edition.103 Critical to the framework, which delineates process to provide meaning and value for the patient.
the focus of practice and links evaluation and intervention Above all, this engagement is based on respecting the
with occupation, is the interdependency of performance patient’s individuality, making it possible for the patient
in areas of occupation, skills, and patterns with context/ to identify valued goals, and maintaining sensitivity for
environment, activity demands, and client factors. Key to the fears, concerns, frustrations, and disappointments
the practice of occupational therapy is the understanding that emerge. A significant communicative tool in this
of how illness or disability affects occupation and how en- relationship is empathy: the ability to convey an under-
gagement in occupation depends on the interaction of standing of another’s condition. Not to be confused
physical, psychological, emotional, and social conditions. with sympathy, pity, or identification, each of which
When using the framework as a guide, one is compelled can interfere with the therapeutic relationship,20 empa-
to evaluate all the patterns and skills necessary to engage thy advances the helpful nature of the relationship.
in activity and occupation.103 Ability to engage in everyday Conveying empathy, along with informing patients of
activities leads to participation in patient-selected contexts the processes and rationale behind treatment, anticipat-
and results in satisfactory quality of life. Because quality of ing possible difficulties or obstacles, and soliciting social
life is measured through physical, psychological, and social support from family or friends, improves cooperation
indicators,63,120 the areas identified within this chapter and compliance in treatment.107
require attention: personality traits; cultural attitudes and
beliefs; psychological and cognitive consequences of stroke; Evaluation
emotional reactions to illness, disability, and recovery; and Evaluating the psychological conditions in an individual
social context and support. This information has a direct with stroke should be part of every therapist’s assessment
bearing on the occupational profile developed, and it procedures. In addition to using specific measurement
affects physical, psychological, and social functioning and tools that target psychological and cognitive functions,
the potential for independence. the therapist should seek to answer a series of questions
The patient-centered focus of practice103 is consistent via interview of the patient and family and through obser-
with what should be the focus of evaluation and interven- vation. This process may be a challenge, particularly
tion. Patients measure success not by the therapist’s stan- if speech, language, or visual spatial impairments are
dards but by their personal goals.42 Indeed, the benchmarks evident.
 Chapter 2 • Psychological Aspects of Stroke Rehabilitation 61

Psychological conditions may present at any time ■ Is he/she particularly personable, and does the
and with varying degrees of intensity. A change when patient use charm to form relationships with the
participating in treatment (e.g., sudden disinterest in ac- therapist?
tivities or goals, decreased energy, difficulty concentrat- ■ Does he/she dwell on difficulties and suffering and
ing, increased worrying or agitation, or change in inter- not react positively to good news?
personal interactions) may be indicators of the onset of ■ Does he/she overreact to criticism or feedback?
depression or anxiety. ■ Does he/she act in a superior manner or seem
The mental status examination provides the initial and entitled to special status?
the ongoing evaluation of mental states. In addition to the ■ Is he/she aloof, uninvolved, or appear excessively
examination providing a beginning assessment of a patient’s calm?
cognitive state (orientation, memory, and attention), it pro- In addition to identifying personality styles, being able
vides the therapist with an assessment of mood and affect, to identify who can and cannot cope may depend on
speech and perceptual disturbances, thought processes, a series of exhibited characteristics.38 Table 2-2 lists
concentration ability, abstract thinking, judgment and in- the traits that reflect positive and negative coping
sight, and reliability.105 Although one’s mental state can characteristics.
change from day to day, it is an important indicator of psy- To assess the meaning of illness, from a personal
chological functioning and provides the therapist with an perspective and from a cultural perspective, is impor-
understanding of the patient factors and performance skills tant. The meaning of health and illness may be related
that must be considered when planning treatment. to having the physical and emotional capacity to do
Character style plays a role in how one approaches what one wants to do, when one wants to do it, and
illness and recovery, and as a result, understanding a brings forth behaviors that support one’s attitudes
patient’s style should affect how the therapist interacts and values.108 Personality and mental conditions
with the patient. If, for example, one is excessively may influence this assessment; depression, for example,
dependent, the patient may be fearful of being left alone, may lessen one’s energy, interest, and commitment to
abandoned, or unprotected and would benefit from the engage in treatment or plan for the future. In addition,
therapist’s ability to set limits while conveying the intent how one values and manages time and space, illness and
to help. For those who require details and facts, the loss, role and family, and work and leisure; how one
therapist should provide adequate information to calm interacts with others; and most importantly, how one
any anxiety, while encouraging the patient to take charge defines self-worth may be determined culturally.70,108
of certain aspects of treatment.38 Giving the patient a Part of this process, however, is the recognition that the
structured way of keeping track of progress outside of therapist is using one’s own culture and personality
the treatment session would engage the patient in a pro- through which to consider the patient, to define illness
ductive way. and health, and to develop a therapeutic relationship.
The following questions reflect the different personality Just as understanding the patient’s personal and cultural
styles that one may exhibit:38 view of illness and health is important to maintain a
■ Does he/she need/demand special attention or appear truly objective patient-centered approach, the therapist
particularly dependent? has an obligation for self-reflection on these same areas
■ Does he/she seek out as many facts as possible about to avoid imposing one’s own values and attitudes on
the illness or recovery? evaluation and treatment.

Table 2-2
Characteristics of Coping38
POSITIVE CHARACTERISTICS NEGATIVE CHARACTERISTICS

Focused on immediate problems Intolerant of others

Flexible optimism Excessive use of defenses such as denial
Resourceful in selecting strategies or rationalization
Conscious of emotions that can Impulsive judgments
impair judgment Rigid or inflexible
Tendency toward preconceived notions
Passive
62 Stroke Rehabilitation

that are as unexpected as they are difficult. One is asked to

Intervention relearn the activities one has always taken for granted, to
Much has been presented on the likelihood of psy- assume new roles that may be unfamiliar or that challenge
chological conditions emerging at any point of the one’s self-worth, and to rewrite the future. Although
recovery and rehabilitation process. Indeed, such patients aspire to return to their prestroke existence, their
conditions can emerge after one is discharged home. struggles are compounded by the emotional reactions to
While emotional needs should be addressed during the loss of activities, abilities, and independence,42 by the
rehabilitation, it is vital to assess one’s emotional status potential of social stigma,88 and for some, by the real pres-
near discharge,17 as fears reemerge. Emotional distress ence of psychiatric conditions.14
of any sort, depression, and difficulty accepting one’s The psychological effects of stroke, whether directly
condition all lead to diminished participation.23 This is related to the neurological insult or related to the emo-
of concern since numerous studies have noted that tional reaction to a disabling condition, must be assessed
meaningful engagement in activities and participation in and treated to ensure optimal functional performance.
one’s community affects the stroke survivor’s quality of Because stroke survivors are concerned not only with
life5,10,24,63,82,119 and diminishes caregiver strain.28,44,47 what they can do, but also with how others perceive and
The ability to cope with trauma and life-altering accept them,96 addressing the psychological, social, and
events is important in one’s recovery. Coping strategies physical concerns with equal value results in a satisfactory
have been found to influence rehabilitation with many quality of life.
chronic conditions and may be affected by personality.18
Coping may be focused on the meaning of an event or
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 ti m o th y j . wo l f
c a ro l yn m . bau m

chapter 3

Improving Participation
and Quality of Life through
Occupation

key terms
client-centered care participation quality of life
occupation

chapter objectives
After completing this chapter, the reader will be able to accomplish the following:
1. Describe key concepts of participation, occupation, and quality of life in stroke.
2. Understand key measures occupational therapists can use to address participation,
occupation, and quality of life in practice.
3. Address participation in the continuum of care from the acute episode to community
reintegration.
4. Describe barriers that threaten participation and quality of life.
5. Identify the key role that therapists have in fostering participation through occupation.

CONCEPTS CENTRAL TO ENABLING Participation must be considered across the life span. A child
PARTICIPATION plays with friends, engages in sports, goes to school, and is a
member of a family; an adult participates in family, work,
In the Occupational Therapy Practice Framework, second leisure, and community activities; an older adult may want to
edition, the definition of “participation” is adopted from the continue to work, to travel, to do volunteer work, and to
World Health Organization definition in the International spend time with family. These activities reflect the individu-
Classification of Functioning, Disability, and Health (ICF) al’s desire to participate fully in society, performing the oc-
and is said to be the “involvement in a life situation.”2,59 The cupations that are meaningful and important to them
term participation encompasses the concepts of personal Participation is supported or limited by the physiologi-
independence and social and community integration.59 cal, psychological, cognitive, sensory, and motor capacities

66
 Chapter 3 • Improving Participation and Quality of Life through Occupation 67

of the individual. Likewise, participation is supported or things that persons do every day.”16 Occupations have
limited by environmental factors. Obvious environmental purpose, and perhaps most importantly, they have mean-
factors include the physical and social factors associated ing for the person engaged in them. When individuals
with accessibility and access to social support; others in- engage in occupations, they are engaged in activities that
clude governmental and organizational policies, especially are directed by goals or are purposeful, are performed in
as they affect employment. situations or contexts that influence them, can be identi-
Participation is easily taken for granted. Being able to fied by the doer and others, and are meaningful.15
do what one wants to do, go where one wants to go, and Occupations usually are classified into general catego-
have freedom in the choice of activities at the time ries; the most common classifications fall into the do-
at which one wants do them is central to personal inde- mains of work (or productivity), play or leisure, and
pendence. Participation can be compromised after a self-maintenance (also referred to as self-care and instru-
stroke. Others obviously see that an individual’s participa- mental tasks). These categories account for the cycle of
tion will be difficult if mobility problems impair balance activities that constitutes the typical day, regardless of
or if the individual uses a wheelchair and faces stairs, the culture being studied.39
narrow doorways, and steep inclines. What may not be
so obvious are impairments not so visible, such as spatial Work
neglect, depression, and loss of executive control. Work contributes significantly to life satisfaction, well-being,
In recent years, the concept of participation has become self-worth, and social identity following stroke.4,30,46,52 Work
much more visible, for it is a central concept in the new Oc- is difficult to classify, for what is work to one may be play or
cupational Therapy Practice Framework, second edition leisure to another. Primeau points out that some may derive
(Framework-II) and ICF. Within the Framework-II, sup- relaxation and enjoyment in performing household chores,
porting health and participation through in engagement in whereas others detest the experience.44 She asks readers to
occupation is defined as the overarching goal of occupa- consider professional athletes who are paid well to exhibit
tional therapy intervention.2 The ICF defines health as the their skills in tennis, golf, baseball, hockey, and other sports.
interaction of body function with engagement in activity These same occupations are pursued by amateurs as freely
and participation as influenced by environmental factors and chosen recreational and leisure pastimes. The Canadian
personal choice (Fig. 3-1).59 The link between health and Association of Occupational Therapists has used the term
participation, as defined by these two frameworks, will productivity as a more useful alternative to work. Productivity
eventually lead professionals from all of the health fields to is defined as “those activities and tasks which are done to
eventually organize their services to support participation. enable the person to provide support to the self, family, and
One must understand some key concepts to practice with society through the production of goods and services.”12
participation as a central concept and outcome. These terms
include occupation, client-centered care, and quality of life. Play/Leisure
Play is a term used interchangeably with leisure to describe
OCCUPATION the nonwork activities of adults in addition to play as the
chosen activities of children. Takata asks one to consider
To participate fully in a life that has meaning, indepen- that play is not defined by specific behaviors or activities
dence, and choice, the individual engages in “occupations.” but rather by attitudes and behavioral styles.47 Because of
Occupation has been defined as the “ordinary and familiar these characteristics, playfulness (or moments of play) can
be experienced during (or enfolded within) work. Play
and leisure must be considered central to the activities of
individuals following stroke.
Health condition
(disorder/disease)
Leisure is thought to be a class of activities carried out
in discretionary time.22 Freedom of choice in participation
without a particular goal other than enjoyment seems to be
the defining characteristics of leisure activity.25 No one can
Body function Activities Participation
(Impairments) (Activity limitation) (Participation restriction) imagine lives devoid of play or leisure, and neither should
a person who has had a stroke. That person’s engagement
in play and leisure should be enabled with tools, skills, and
Environmental Personal environments (see Chapter 29).
factors factors
Self-Care
Figure 3-1 Interaction of components of the ICF. (From Those activities necessary for maintenance of the self
International Classification of Functioning, Disability, and within the environment constitute another major classi-
Health, 2001: World Health Organization, pg. 18, Figure 1.) fication of occupation. Often included in this category
68 Stroke Rehabilitation

are activities related to personal care (eating, grooming, for success must be fostered as well, so that these persons
and hygiene), getting around (mobility), and communi- are motivated to face their daily challenges.
cating. For a person to be self-reliant in any community, Occupation is a concept that must be understood in
a level of competence is required that enables the terms of planning and describing the activities of an
accomplishment of tasks beyond those of basic self-care individual; it provides an important process that can
(which are referred to as physical self-maintenance). and should be used in the rehabilitation program to
For this reason, M. Powell Lawton identified the use of improve a person’s recovery. Box 3-1 highlights key
the telephone, food preparation, housekeeping, laundry, statements that identify the importance of occupation;
shopping, money management, driving or use of trans- these can be translated directly into outcomes that
portation, and medication management as important practitioners can address today as they plan client-
daily activities and proposed the term instrumental ac- centered care.
tivities of daily living (ADL) to describe them35
(see Chapters 14, 21, 22, 23, and 28). CLIENT-CENTERED CARE
Often when persons are hospitalized, the focus is
on achieving independence in self-care. Christiansen Clients who have had strokes need support to return
suggested that self-care tasks must be viewed as neces- to their lives as they lived them before the stroke. They
sary from a societal point of view.14 Although eating and require services that help them build endurance, increase
hygiene tasks are essential for survival and health, dress- movement and strength, increase awareness, obtain
ing and grooming are important to social interaction assistive devices such as wheelchairs and self-care tools,
and participation. Some expect persons to care for them- acquire accessible housing, and gain access to barrier-free
selves. Sometimes therapists go too far in expecting workplaces and communities. These needs challenge
an individual to perform self-care; some individuals rehabilitation professionals to extend their interventions
prefer to spend their time in other occupations and beyond the clients’ immediate impairments to focus on
accept the help of others to do basic self-care. Therapists their long-term health needs by helping them develop
are familiar with the use of personal attendants with healthy behaviors to improve their health and well-being
persons following spinal cord injuries; persons who have and to minimize long-term health care costs associated
had a stroke benefit from a personal attendant, so that with dysfunction.7
they have choice in how they spend their time in occupa- Rehabilitation traditionally has occurred in institutions
tions more important and meaningful to them. and is a time-limited process aimed at helping a person
A discussion of occupation cannot be complete with- with a stroke reach an optimum level of self-care function.
out a discussion of self-efficacy and self-determination. This approach labels the recipient of service as a patient,
Bandura used the term self-efficacy to describe the extent has led the patient to understand that the therapist would
to which successes or failures influence expectations of
future success or failure.3 The experience of success in
doing things (occupations) contributes to a positive
sense of oneself as effective or competent. In contrast, a Box 3-1
negative view of self and one’s ability to influence events The Importance of Occupation
can lead to perceptions of helplessness. Gage and
■ Occupation is the vehicle to acquire, maintain,
Polatajko observed that perceived self-efficacy has
or redevelop skills necessary to fulfill occupational
been shown to influence perseverance and well-being roles and to provide satisfaction.20
and that it can be modified through successful ■ The lack of occupation leads to a breakdown in habits
experiences.21 and physiological deterioration, which lead to loss of
According to self-determination theory, intrinsic ability and competency to support daily life.28
sources of motivation lead persons to encounter new ■ Individuals with cognitive loss who remain engaged in
challenges.45 An important (and logical) part of this theory occupations retain higher levels of functional status
is the claim that settings in which persons experience suc- and demonstrate fewer disturbing behaviors.6
cess helps them feel good about themselves. This enables ■ Engagement in individually motivating and ongoing
persons to face their daily challenges more readily and in occupations supplies sustenance for survival, safety,
the process to develop an understanding of who they are and enhanced health.54
■ Meaningful occupations provide individuals with
and their place in the world.
exercise to maintain homeostasis and to keep body
Following stroke, many individuals are not able to parts and neuronal physiology and mental capacities
engage in their occupations as they have in the past. functioning at peak efficiency and enable maintenance
Therapy must create the environment for learning and development of satisfying and stimulating social
that fosters a person’s view of self so that successful expe- relationships.54
riences can be experienced and sustained. Opportunities
 Chapter 3 • Improving Participation and Quality of Life through Occupation 69

fix the problem, and has led the therapist to expect patients and how they want to do it. In other words, they were
and their families to comply with his or her recommenda- expressing terms that relate to life satisfaction, well-being,
tions.38 This approach does not reflect client-centered and participation.
care. Within the Framework-II, client-centered care must Rehabilitation professionals must think about their
begin with the occupational therapist gathering informa- clients in terms of what will be the outcome of services
tion to understand what is currently important and as they affect the daily lives of the clients they serve, not
meaningful to the client before beginning to address any merely the outcome achieved in a short-term goal. The
impairments.2 To move from the traditional approach to a client’s perceived quality of life is increasingly being
client-centered approach, practitioners must shift from used as a determinant of outcome in health care.2 Qual-
focusing on impairments to understanding why problems ity is not achieved with improved strength, range, co-
occur, what the client views as a problem, and what might ordination, and balance but by having meaningful rela-
be done about them. tionships, having a job, being a good parent, and
A client-centered approach requires a different orien- engaging in leisure interests, all which depend on having
tation, one that engages the assistance and support of a cognitive capacity, strength, endurance, and mobility
therapist to facilitate the client’s problem-solving and and may require new skills and new ways of doing
goal achievement.38 In a client-centered program, the things.
practitioner and the client bring important information The concept of life satisfaction is subjective; what is
to the partnership. For clients to understand why the satisfying to one is not necessarily satisfying to another.
practitioner is involved in their care and what they can The concept reminds one of the importance of im-
expect to achieve through therapy is as important as for plementing a client-centered plan to help the person
the therapist to understand the issues and needs of the do what he or she wants and needs to do. The concepts
clients. For clients to understand the scope of the thera- central to life satisfaction are happiness, having plans
pist’s knowledge is also important. The client’s knowl- for the future, and engaging in meaningful interests and
edge of his or her condition and experience with the experiences.42 All of these concepts are threatened when
problem must become clear for the relationship to prog- an individual’s life changes abruptly with a stroke.
ress. If a person has a cognitive limitation, the person Well-being is one of the concepts that contributes to
selected to be the guardian or caretaker must participate the individual’s perception of quality of life. In addition to
in treatment planning7 to ensure protection of the happiness, well-being includes the person’s perception of
client’s rights. confidence and self-esteem. Wilcock encourages practi-
Early in the interaction, practitioners should obtain tioners to consider relationships (including social friends,
information from clients about their perception of the family, partnerships, neighbors, and strangers) and the
problem, needs, and goals. The implementation of a availability of surroundings (including home, school, place
client-centered approach requires the use of a top-down of worship, peace, and weather and terrain) as central to
approach37,49 in which clients identify what they perceive the individual’s perception of well-being.54 The World
to be the important issues causing them difficulty in carry- Health Organization Quality of Life Group defines qual-
ing out their daily activities in work, self-maintenance, ity of life as one’s perceptions of one’s position in life in the
leisure, and rest.7 context of the culture and value systems in which one lives
A client-centered approach requires practitioners to and in relation to one’s goals, expectations, standards, and
view clients in the contexts of their lives and help them not concerns.61
only to acquire the skills to handle the immediate issues Being able to go where one wants to go and do what
influencing their health but to also learn strategies and link one wants to do is central to personal freedom. Partici-
with community resources that promote, protect, and pation should be the ultimate goal of medical and reha-
improve their health over the long term. This approach bilitative care and social services, for it describes the
extends from the agency or institution into the community, extent to which a person is engaged in life situations in
requiring the practitioner to take an active role in advocat- a societal context.59 Interventions must help clients
ing for healthy communities by removing attitudinal, eco- participate in daily life, enabling them to develop the
nomical, and physical barriers.7 skills or build the adaptive strategies to do what is nec-
essary for them to carry out their occupational roles.
QUALITY OF LIFE Practitioners carrying out their roles and doing what
clients want and need them to do makes it possible for
How do we think about the quality of our lives? In a them to play a role in the clients’ life satisfaction and
recent discussion the authors had with students, not one sense of well-being. Such an approach contributes to
student mentioned quality of life issues related to his or the health and well-being of clients, and collectively to
her health. Students’ descriptions included being satisfied society, for it enables quality in the lives of those
with their lives and doing what they want to do when served.
70 Stroke Rehabilitation

With the revisions to the ICF, activity and participa- they are doing less often, and those they have given up
tion have become issues central to care and must be since their stroke. The Activity Card Sort uses cards with
included in treatment planning.59 Effective rehabilitation pictures of tasks that people do in their daily lives.
treatment begins with a sound assessment. In addition to These activities are documented in categories of
determining the physical, cognitive, and psychological instrumental, leisure, and social activities. Different
problems resulting from stroke, one must determine the versions of the card sort are available for the different
client’s prior activities to establish the individual’s identity, contexts in which rehabilitation is occurring. The insti-
so the person’s interests are clear to all members of tutional version (for use in hospitals and nursing homes)
the team, for these interests serve to motivate the person sorts 89 cards into categories of activities done before
during the rehabilitation. illness and not done afterward. The recovering version
identifies activities not done before the illness or injury,
ASSESSMENT OF PARTICIPATION those given up because of illness, those one is beginning
to do again, and those activities the client is doing now.
A variety of measures are available to determine a client’s All versions allow one to determine a current activity
prior level of activity.33 Traditionally, therapists have level. The card sort takes approximately 30 minutes to
relied on activity checklists and open-ended interviews to administer and results in a score of percent of activities
obtain information regarding participation before stroke. retained. The Activity Card Sort has been found to be a
Unfortunately, these interviews are limited by the client’s reliable and valid measure and is available in several
memory. Measures have been developed to provide culture-specific formats.27
therapists with a systematical and consistent method The Canadian Occupational Performance Measure, or
for evaluating participation. One such measure is the COPM, is an interview used to assess a client’s perception
Activity Card Sort, second edition, developed by Baum and of recovery and goals.32,34 The COPM is based on a
Edwards (Fig. 3-2).5 The Activity Card Sort uses a sorting client-centered practice framework. The COPM crosses
methodology to assess participation in 89 instrumental, all diagnoses and is not specific to any age group. The three
social, and high- and low-demand physical leisure activi- primary areas identified are self-care, productivity, and
ties. Clients sort the cards into different piles to identify leisure. The interview allows identification of problem
activities that were done before stroke, those activities areas. Satisfaction and importance of the problem areas are

A B

C D
Figure 3-2 Sample cards from the Activity Card Sort. A, Sorting the cards. B, Computer
card. C, Cooking card. D, Dishwashing card.
 Chapter 3 • Improving Participation and Quality of Life through Occupation 71

rated on a scale from 1 to 10. The COPM takes approxi- energy/vitality, social functioning, emotional role limita-
mately 45 minutes to administer, but time can vary greatly tions, and mental health.
with the interview. For this reason, the test may be difficult Another quality of life scale is the Stroke Impact Scale
with individuals with cognitive deficits. Despite the length (SIS). The SIS is a stroke-specific measure that incorpo-
and cognitive difficulty, the assessment validity is good, rates function and quality of life into one measure.31 The
and the COPM is a client-centered tool that facilitates SIS III is a self-report measure including 59 items that
development of treatment plans and therapeutic goals.13 form eight subgroups: strength, hand function, basic and
The Community Integration Questionnaire was origi- instrumental ADL, mobility, communication, emotion,
nally designed for individuals with traumatic brain injury memory and thinking, and participation. Duncan and col-
and is particularly useful with younger stroke clients.55 leagues have found the SIS to be valid, reliable, and sensi-
The Community Integration Questionnaire measures tive to change in stroke populations.19 Furthermore, the
handicap as a function of community integration.36 The SIS is reliable when responses are provided by proxy.18
questionnaire has 15 items including questions such as The Stroke Adapted Sickness Impact Profile (SA-SIP) is a
“Who does the shopping in your household?” and “How shortened form of the more commonly known Sickness
many times a month do you leave the house to go shop- Impact Profile.9,51 The SA-SIP has 30 true/false statements
ping?” Four scores are calculated: home integration, regarding a person’s function and stroke-related symptoms.
community integration, productivity, and a total score. The statements are separated into seven categories: body
Each item has a possibility of three responses, with re- care and movement, social interaction, mobility, emotional
sponses weighted numerically. A higher score indicates behavior, household management, alertness behavior, and
greater independence. ambulation. The SA-SIP has good reliability and validity
The World Health Organization Quality of Life Scale
ASSESSMENT OF QUALITY OF LIFE (WHOQOL-BREF)40 was derived from the original
WHOQOL-100. It includes 26 items as compared to
The stroke outcome literature historically has reported the original with 100 items. It produces scores for four
survival from stroke. Medical advances may prolong domains related to quality of life: physical health, psy-
life, but knowing how individuals feel regarding their chological health, social relationships, and environment.
lives after stroke is important.39 A normal neurological It also includes one facet on overall quality of life
examination may not equate to good quality of life for and general health. It has been translated into multiple
the client. Therefore, well-designed quality of life mea- languages (Table 3-1).
sures are essential.
The Reintegration to Normal Living57,58 was developed BARRIERS TO PARTICIPATION AND QUALITY
to document reentry into everyday life following a sud- OF LIFE
den illness or event. The instrument is a functional sta-
tus measure that quantitatively assesses the degree of Once the practitioners identify problems with participa-
reintegration to normal living achieved by clients after tion and quality of life, they must address barriers
illness or trauma and is useful for individuals with phys- to resumption of activities, which can be divided into
ical or cognitive disabilities. The Reintegration to Nor- several subgroups, including disability in basic and
mal Living assesses global function and the individual’s complex instrumental ADL, decreased cognition,
satisfaction with basic self-care, in-home mobility, lei- impaired motor function and balance, limited mobility,
sure activities, travel, and productive pursuits. The client urinary incontinence, poor speech and language func-
is provided with 11 statements. Some examples include tion, depression, decreased resource use, environmental
“I am able to participate in recreational activities,” inaccessibility, and diminishing social and community
“I assume a role in my family that meets my needs and support. Each is discussed to highlight how rehabilita-
those of the other family members,” and “I am comfort- tion can address the issues that may limit an individual’s
able with how my self-care needs are met.” The test can participation after stroke.
be completed using a pencil and paper format or an in- Persons who have had a stroke have impairments
terview format. Reliability and validity have been estab- that limit their ability to participate in activities outside
lished for persons with stroke. the home. To go to the grocery store or to church, the
The Medical Outcomes Study 36-item Short-Form Health individual must be dressed. Dinner with friends requires
Survey, or SF-36, is the most commonly used life satis- the motor ability to feed oneself, the cognitive capacity to
faction scale.53 The SF-36 has been used extensively carry on a conversation, and the judgment to select the
with many diagnoses, including stroke, and is quick and appropriate diet. Difficulty with instrumental or more
easy to administer. The SF-36 is a self-report measure complex ADL affects the person’s ability to return to
of eight subcategories: physical functioning, physical work, to drive, to manage finances, or to take the bus.
role limitations, bodily pain, general health perceptions, See Chapters 21 and 23.
72 Stroke Rehabilitation

Table 3-1
Summary of Tests and Availability
TIME TO
NAME OF TEST REFERENCE ADMINISTER SOURCE

Participation measures
Activity Card Sort 5 30 minutes American Occupational Therapy Association, AOTA
Press
Canadian Occupational 13 approx 45 Law M, Baptiste S, Carswell A, et al: Canadian occupa-
Performance Measure minutes tional performance measure manual, ed 3, Ottawa, 1998,
CAOT Publications ACE.
Community Integration 55 10 minutes Willer B, Rosenthal B, Kreutzer JS, et al: Assessment of
Questionnaire community integration following rehabilitation for
traumatic brain injury, J Head Trauma Rehabil
8(2):75–87, 1993.
Quality of life measures
Stroke Adapted Sickness 51 15 minutes van Straten A, de Haan RJ, Limburg M, et al: A stroke-
Impact Profile adapted 30–item version of the Sickness Impact Profile
to assess quality of life (SAS-SIP30), Stroke
28(11):2155–2161, 1997.
Stroke Impact Scale 19 30 minutes User agreement and forms available at the following
Version 3 website: www2.kumc.edu/coa/SIS/Stroke-Impact-
Scale.htm.
Reintegration to Normal 57 10 minutes Wood-Dauphinee SL, Opzoomer MA, Williams JI, et
Living al: Assessment of global function: the Reintegration to
Normal Living Index, Arch Phys Med Rehabil
69(8):583–590, 1988.
Medical Outcomes Study 53 15 minutes RAND Corporation, Santa Monica, California.
Short-Form Health
Survey (SF-36)

World Health Organiza- 40 10 minutes World Health Organization, 1993

tion Quality of Life Scale
(WHOQOL-BREF)

Even in the absence of motor impairment, a cognitive trip to the kitchen for a drink of water is a daunting task.
deficit can greatly impair the ability of an individual to Taking out the trash or resuming bowling may provoke
return to tasks done before the stroke.23 Cognitive deficits enough fear to stop these activities. Addressing balance
incorporate areas of attention, orientation, perception, impairments in the hospital setting may not transfer to
praxis, visuomotor organization, memory, executive func- ability in the community, so testing of the individual’s
tion, problem solving, planning, reasoning, and judg- abilities outside of a sheltered rehabilitation clinic is es-
ment.29 Tatemichi and colleagues showed that cognitive sential. Decreased motor function and coordination con-
dysfunction was a significant predictor for dependent liv- tributes to poor participation in prior activities by limiting
ing after discharge and found that quality of life is related the ability to write, cut food, or resume playing tennis. See
to sequential aspects of behavior.48 Reading the newspa- Chapters 8 and 9.
per, watching a movie, finding items on a grocery list, or For individuals with limited mobility, home and
knowing what to do if lost in the mall can be a challenge community access is problematic. Difficulty with stairs
for some individuals following stroke.26 Clients often re- or the inability to ambulate long distances limits the
port feeling overwhelmed with things that came auto- scope of activities for survivors of stroke. A home visit
matically before the stroke. See Chapters 17, 18, and 19. before discharge is recommended to resolve any im-
Impaired balance is cited in the literature as a key vari- mediate issues with inaccessibility, as individuals com-
able to independence in the community because of an in- monly receive equipment that does not fit in their
creased risk of falls. For someone with impaired balance, a homes. Obstacles including stairs, furniture, power
 Chapter 3 • Improving Participation and Quality of Life through Occupation 73

cords, lighting, and noise affect the ability to partici- lationships, changes in physical activities, and elaborate
pate in activities inside and outside of the home. For planning and forethought before activities that previously
working clients, job site evaluations are necessary for could be done spontaneously.24,41
vocational success. For a full-time mother, this may Although physical and cognitive impairments con-
include a comprehensive evaluation of the home and strain the subjective well-being of stroke survivors liv-
learning what tasks she performs to fulfill her roles. See ing in the community, social resources can moderate
Chapters 14 and 27. the adverse effects of residual disabilities. Survivors
Speech and language deficits occur in as many as 40% who have adequate social support are less affected by
of individuals with strokes.1 Poor speech and language functional dependence.17 Social supports have been
functions deter clients from situations in which conversa- found to be associated with a higher quality of life in
tion is unavoidable. Persisting consequences adversely stroke survivors.29 Social participation is defined as so-
affect quality of life, ranging from loss of employment to cially oriented sharing of resources and is an essential
feelings of isolation and depression. Therefore, address- component of quality of life.11 Therefore, poor re-
ing language barriers and educating clients and families source use may be predictive of decreased quality of life
in compensatory strategies alleviates some distress associ- following stroke. Individuals without family or close
ated with speech and language deficits. Occupational friends have difficulty reintegrating into prior roles af-
therapists should address participation issues in addition ter stroke. Many family members and friends must re-
to the interventions provided by speech language turn to their prior roles several weeks after their loved
pathologists. See Chapter 20. one’s stroke. This produces a gradual decrease in sup-
Depression is another common barrier to participa- port over time. This decrease often occurs when home
tion after stroke. The cause may be directly biologi- health staff have discharged the client, and additional
cal, depending on the location of the lesion in the resources such as transportation are required for outpa-
brain or may be a reaction to a sudden catastrophic tient therapy, grocery shopping, and medical appoint-
event in the client’s life. Depression may affect par- ments. This is a critical time for case management to
ticipation and long-term outcomes adversely, 1 and it secure the support of community organizations, trans-
has been associated with longer hospital length of portation agencies, and outpatient therapy services.
stay, poor performance in ADL, and decreased social- Too often, home health care is discontinued without
ization. Emotional issues such as fear and depression further referral to a nearby outpatient facility. Although
can lead to decreased reintegration into previous roles clients are no longer homebound following home care
and occupations and to decreased quality of life. Fol- services, they are often in need of further rehabilitation
lowing a life-altering event such as a stroke, a person to address the cognitive and emotional issues to help
may fear additional illness, injury, or another stroke. them return to activities, tasks, and roles in the family,
For this reason, clients may be hesitant to leave their work, and the community.
homes and resume prior roles. In a study by Clarke The overarching barrier to addressing these limita-
and colleagues, community-dwelling stroke survivors tions in participation following stroke is the fact that
reported a lower sense of well-being than their healthy rehabilitation services are overly focused on addressing
community-residing counterparts.17 Clients and their the motor and self-care impairments. Therefore, the
families should be educated regarding risk factors of needs of the younger, less neurologically impaired
stroke rehabilitation strategies and medical manage- stroke survivors are typically overlooked. This was con-
ment following a stroke. Additional education may firmed in a recent study conducted by the Cognitive
decrease anxiety regarding a future stroke. Referral to Rehabilitation Research Group (CRRG) at Washington
a psychologist may be indicated for some individuals. University School of Medicine who assessed all indi-
See Chapter 2 . viduals with stroke being served by Barnes-Jewish Hos-
Urinary incontinence is a barrier to participation pital Stroke Service over a 10-year period. The CRRG
frequently overlooked by rehabilitation teams, although it found that in their stroke population (N⫽7740):
is generally agreed to have a considerable effect on a (1) 45% of the patients are under the age of 65-years-
person’s quality of life and well-being. Between 9% and old and nearly 27% are under the age of 55-years-old;
40% of the individuals with stroke develop inconti- (2) of all the patients who had strokes, 49% had a mild
nence.10,43 Incontinence has been identified as a predictor stroke, 32.8% had moderate strokes, 17.9% had a se-
for nursing home placement and is associated with poor vere stroke, and 6% did not live, as defined by the
recovery from stroke.10 Studies in the general population National Institute of Health Stroke Scale (NIHSS);
have shown that incontinence is associated with depres- and (3) of the individuals who had a mild to moderate
sion50 and higher levels of anxiety.8 Urinary incontinence stroke, 71% were discharged directly home, were dis-
often leads to a reduction in social activities and re- charged with home services only, or were discharged
74 Stroke Rehabilitation

with outpatient services only, because they did not balance. Translating these deficits to real-life tasks in-
typically display motor or self-care deficits.56 These creases the tangibility for clients and their families and
same individuals have been found to report problems in facilitates the transition through other avenues of care.
their ability to reintegrate into their prestroke activi- Each level of rehabilitation encompasses increasingly
ties, community roles, and work following their stroke.56 complex tasks in varying contexts.
Since it is known that all of the limitations discussed In some instances, clients do not move through
previously can result from a stroke, it is absolutely es- acute care quickly. If treatment time is available, per-
sential in a client-centered stroke rehabilitation model formance of basic tasks is critical. The most basic of
to identify these limitations across the continuum of self-care is required to go to church, to school, or to
care in order to best support clients. work. The acute setting is ideal for beginning of basic
ADL including bathing, transfers, eating, and toileting,
HOW TO FOSTER PARTICIPATION as they are identified as meaningful for the client. Some
THROUGHOUT THE CONTINUUM OF CARE clients may choose to have an attendant help them
with basic ADL. In such cases, goals can evolve around
No one method of treatment fosters participation in all other client-centered tasks. Goals should include items
avenues of rehabilitative care. The stroke team requires important to the client, such as talking on the phone
commitment and creativity to address the issue. The specific or visiting with family. Emotional attachment to such
modality applied is not what enhances participation activities is great, and a loss or decrease in indepen-
(and hopefully quality of life). Enhancement comes through dence can produce an emotional response that increases
the activities selected and the contexts in which they disability (see Chapter 1).
are performed. Only with a client-centered plan and the
incorporation of meaningful activities in rehabilitation INPATIENT REHABILITATION
can the team foster participation to bring meaning to the
individual in the rehabilitation program. According to the Agency for Healthcare Quality and
Research, rehabilitation seeks to help the person with
ACUTE CARE disabilities achieve the highest possible degree of per-
formance. Rehabilitation is comparable to school in which
In the acute care setting, acting as a triage team member the client is provided an opportunity for instruction,
is essential. This requires a thorough assessment battery. support, protected practice, education, reassurance, direct
Identifying all the impairments that can improve per- assistance, and feedback. This is the “planned withdrawal”
formance in this setting allows for better discharge of support in which services are provided as needed and
planning. Detailed evaluation improves the therapists’ are removed when no longer needed. The modalities of
abilities to identify impairments from severe to subtle. inpatient rehabilitation treatment are no different from
Too often, assessments in the acute care setting are brief, acute care therapy or outpatient therapy; however, the
increasing the potential for error in discharge placement, tasks progress to be more difficult. Once the client has
because at times it is difficult to assess the presence mastered a task in a therapeutic context, the conditions
or absence of the more subtle complex impairments are altered to more real-life situations. Inherent in this
(i.e., cognitive dysfunction) in the acute care setting. progression is that the client is the leader. The therapist
If it is not possible to do a complete assessment, then it is must recognize the need for preparing clients to go home
imperative for the team member to recommend a follow- beyond using basic ADL performance as a discharge
up assessment before discharge. Sending the individual criterion, because this prepares clients to do well inside
home with a “clean bill of health” when in fact these their homes but does not prepare clients to shop, go to
subtle impairments may be present can have a devastating work, or to baby-sit a grandchild. The key to remember
effect on the mental and physical health of the individual. in the goal-setting process is the full range of tasks
The assessment in this phase of treatment must include and roles to which the client is returning. Furthermore,
not only basic measures of motor impairment, cognition, a prior level of function must be established and well-
and language, but also those of higher level functions, documented. An occupational history makes it possible to
including balance, visual perception, and executive integrate prior activities into the care plan. If the stroke is
function. These elements are key to successful reentry impairing prior function, the impairment is treatable and
into the community, participation in roles and activities reimbursable. If the prior level of function is documented
done before the stroke, and maintenance of quality of only in terms of basic self-care, clients will not have access
life. Often the most problematic deficits are those not to rehabilitation to return them to community life. By
physically obvious. Clients and families are less likely identifying what the person did before admission, one
to understand the impact of poor memory, impaired identifies goals to achieve after the prior level of function
judgment, decreased language function, and limited is achieved. The therapist has more time to achieve those
 Chapter 3 • Improving Participation and Quality of Life through Occupation 75

goals once an independent level of self-care is achieved. OUTPATIENT THERAPY

Response to treatment is better if the client is put in the
context of something important to them. For example, A good outpatient program involves a multidisciplinary
a client wants to work on writing. The practitioner team working with the client to achieve maximum
provides handwriting exercises every day to complete as independence in all aspects of life the client indicates
homework. However, the client never completes the as important. Outpatient therapy forces the client to
homework. The client often is labeled unmotivated maintain a schedule of therapies, get ready in time for the
or uncooperative. The key question to ask is the type of appointment, arrange transportation to and from the
writing the client enjoys. Does the client keep a journal? appointment, and follow through with home programs
Does the client enjoy crossword puzzles? These require jointly designed with the therapists. To get to therapy,
different writing skills. the client must have the physical endurance to participate
When a client enters inpatient rehabilitation, an ongo- in the preparation, the travel, and the therapy itself.
ing evaluation of capacities and client goals is imperative. The cognitive process involves initiation, planning, atten-
Through identification of higher-level tasks, clients can tion, organization, and sequencing. Before the client
be challenged outside the walls of the rehabilitation hos- reaches the door of the clinic, therapy has already begun.
pital. For example, a client walks down the hallway of the A complete assessment includes an inventory of activi-
hospital. What is the response of the other therapists, ties, responsibilities, and roles the client likes to do and
nurses, and housekeepers in the hallway? What if, one needs to do every day. Clients can identify the activities
week after discharge, an individual is negotiating a most important to them. Often outpatient therapy is
shopping mall? Will the persons in the mall have the same difficult because of the broad spectrum of possibilities for
response as the hospital staff? A colleague of the author clients in this setting. Generating a list of the client’s top five
once referred to this concept as “rehab without walls;” goals is recommended. From that point, additional goals
providing rehabilitation in the community rather than can be formulated. In this setting, vocational issues can be
restricting it to the hospital setting is the best preparation addressed. Meeting with the client’s employer is important
for life after discharge. to address barriers in the workplace. Meeting with and
educating the caregiver assists with the identification of
HOME HEALTH barriers the client may not see in the home. Addressing
social support issues with family and friends is also im-
The advantage to home health therapy is that the inter- portant. An important strategy is to find activities that
vention takes place in the setting where the skills will are enjoyable to the client and the caregiver, so they can be
be applied as they are being learned. One of the obvious involved in activities that they enjoy doing together.
goals of home health is to identify the physical barriers
to the client’s success in the home environment. COMMUNITY REINTEGRATION
However, identification of the cognitive and perceptual
barriers that limit performance in the home setting is As depicted in Fig. 3-3, an often overlooked but important
critical. In addition, clients may perform better in a component to the continuum of care is taking rehabilitation
familiar environment. As in inpatient rehabilitation, services out into the community. With the age of stroke
therapeutic activities should evolve around client- decreasing, the population of individuals having strokes is
centered goals and may include yard work, laundry, increasing engaged in community roles and in particular
or cooking. The therapist has a dual role in home health employment. Inherent in these roles is the need to address
therapy. In addition to helping remediate impairments more complex activities such as driving, home management,
from the stroke, the therapist modifies the environment self-management of symptoms, and physical activity.
to achieve maximum participation in goals. The envi- In order to provide client-centered care, this stage in the
ronmental approach also involves educating those in continuum must be addressed.
the home to the person’s capabilities and how they
can enable the person to be active to continue the CASE STUDY
recovery and help the person gain self-management
Improving Participation through Occupation
skills. Preparing the client in the home environment
is the first step in preparing the client for community Rosemary awoke one Saturday morning with slurred
reentry. The downfall of home health therapy is the lack speech and difficulty walking. She decided to return to
of peer support from other stroke clients and minimal bed for additional rest. After sleeping for several more
client-team interaction. Referral of the client to outpa- hours, she awoke with left-sided weakness and facial
tient therapy or a community support group once the droop, worsening speech, and an inability to walk. She
client is no longer restricted to the home setting is lived alone, was not married, and had no children. She
recommended. Continued
76 Stroke Rehabilitation

Stroke Rehabilitation

Institutional Services Community Resources

Triage Treatment Physical Activity Social/Peer Support Productivity

Fitness center Religious activities School

Home health
Therapeutic pool Family activities Work
Acute Rehabilitation
Exercise classes Community activities Volunteer work
care Skilled nursing
Hobbies Homemaking
Outpatient
Sports Parenting
Clubs
Friendship activities

Rehabilitation Initiatives

Opportunity for motor training Strategies to support performance

Strategies to support communication Family and patient training
Self-management skills Driving assessment and training
Home assessment/management Return to work training and accommodations

Figure 3-3 Continuum of care in stroke rehabilitation.

CASE STUDY shower was located on the second floor. She had no
family locally. Her home was located within walking
Improving Participation through Occupation—cont’d
distance of the doctor and a large grocery store.
promptly called 911. When paramedics reached her, Rosemary was a violinist in a local quartet and taught
the dysarthria was severe and she had complete left violin on the side. She had few friends other than those
hemiplegia. She was oriented to her name and where in the group with whom she worked. In addition, she
she was but not to the date. In the emergency room, was driving (and using public transportation), cooking,
Rosemary was determined to have sustained a large shopping, and managing her finances independently
right middle cerebral artery stroke. She was admitted before her stroke. Because of these responsibilities and
immediately to the hospital and was referred to the her lack of support at discharge, the team decided Rose-
stroke team for evaluation and treatment. mary would benefit from inpatient rehabilitation.
Rosemary’s deficits included the following. She was On admission to inpatient rehabilitation, Rosemary
unable to move her left arm or leg. She could roll in bed was evaluated by nursing, physical therapy, occupational
to her left side using the bed rail, but required maximum therapy, and speech therapy staff members. She required
assistance to roll to the right. She was dependent with moderate to maximum assistance with basic ADL and
her transfers and basic ADL. She had a left visual inat- transfers. She required 100% assistance to walk using a
tention and decreased sensation on the left side of her walker and an ankle/foot orthotic. She was able to move
body. She was sleepy and was unable to work with a from her bed to a chair and back with 75% assistance.
therapist for more than 30 minutes at a time. Her memory was good; however, she indicated that her
Over her first few days in the hospital, Rosemary attention was not, and she appeared easily distracted in
began to improve. She was able to tolerate more time in the clinic. She was oriented to person, place, date, and
therapy. She could support herself while sitting on the situation. Her speech remained slurred, but her swallow
edge of the bed and began to play an active role in her was normal. Rosemary’s endurance improved greatly.
ADL. Rosemary was able to move from her bed to a She continued to show subtle signs of a left visual
chair with 75% assistance from the nursing and therapy inattention, and her left arm continued to be weak
staff. She was tolerating sitting up in bed and a chair for throughout. Manual muscle tests indicated strength
extended periods throughout the day. The team met at the shoulder and elbow was 3⁄5. Strength in the wrist
to determine the course of Rosemary’s rehabilitation. and hand was 2⁄5. Sensation was normal to pin prick and
At the team meeting, Rosemary’s living alone in a temperature. She was diagnosed with depression and
two-story home located in the city was revealed. was treated medically. The only interests stated in her
Multiple steps were required to enter. She had two chart included playing and teaching violin and playing
bathrooms in the house; however, the bathroom with a bridge.
 Chapter 3 • Improving Participation and Quality of Life through Occupation 77

Following initial evaluation, the team met to discuss coordination distally. She was able to balance a simu-
her goals and plans for discharge. Although she was lated checkbook, prepare simple meals independently
improving daily, her ability to live alone was question- (she was most comfortable with the microwave), and
able because of her poor balance, limited attention, and play her violin, but she could not drive. Rosemary had
decreased strength. Rosemary and the team set goals difficulty with higher-level tasks involving complex
for her to be independent with basic ADL and transfers sequencing and organization, and performing multiple
from her bed, the bathtub, and the car. The team chose tasks at once was difficult for her.
to address her ability to grocery shop and prepare a Rosemary transferred to a residential facility for two
simple meal in the microwave. The case manager months before returning home. At that time, she was
discussed these goals with Rosemary, and she agreed referred to outpatient therapy. Rosemary remained
with the team’s priorities. unable to drive but was proficient at using public trans-
At her second week of inpatient rehabilitation, portation. She was independent with most basic and
Rosemary was able to dress herself independently instrumental ADL. A friend would pick her up weekly
using an adaptive strategy. She was walking with some to take her to the grocery store. Her motor status was
assistance using an ankle/foot orthotic and a walker. unchanged from her inpatient rehabilitation discharge.
She was able to prepare a bowl of cereal, a sandwich, She continued to show 4⁄5 muscle strength proximally
and a microwave dinner. She was taken on trips to the and improved coordination in her hand and fingers.
gift shop and grocery store to evaluate her ability to Her speech was normal, and speech therapy was not
follow a list, obtain objects on the list, and exchange required. Her higher-level executive functions were
money correctly. These trips were overstimulating to nearly normal. Her balance continued to be problem-
Rosemary, and her depression worsened. She missed atic, but she was walking with a straight cane and an
her music and felt that her only love in life was the ankle/foot orthotic. A comprehensive evaluation of her
violin. She lived close to the hospital but did not activities and quality of life revealed the following. Her
have close friends or family to get her violin. Rosemary Activity Card Sort showed that she had retained only
desperately wanted to do a home visit and wanted to 35% of the activities she had done before the stroke,
get her violin; however, the team thought it would with the greatest loss in the areas of social
increase her depression because her motor impairment activity and high-demand leisure activity. Rosemary’s
would make it impossible for her to play. Despite the priorities indicated by the Activity Card Sort included
discouragement of the team, one of the therapists the following (in order of importance): playing a musi-
brought in a violin for Rosemary to play. The therapist cal instrument (her violin), driving, shopping, visiting
went to a quiet treatment room with Rosemary. with friends, and traveling. The Stroke Adapted
Although Rosemary was hesitant, she removed the Sickness Impact Profile (SA-SIP) revealed a score of
violin from the case and asked the therapist to leave 15 out of 30. Her score was in the midrange, indicating
the room. She did not want anyone else to hear her at- a decreased quality of life. Some of the problematic
tempts to play the violin for the first time. As the thera- areas included “body care and movement,” “mobility,”
pist closed the door, she could see the fear on Rosemary’s and “ambulation.” Rosemary received a score of 28 on
face. The therapist returned to the room after 10 min- the Reintegration to Normal Living Index. The scor-
utes. What she heard was amazing. When she opened ing range of the index is from 11 to 55. A lower score
the door, Rosemary was playing the violin. Her face indicates lower satisfaction. Rosemary’s score was in
beamed with pride as the team came in to hear her play. the midrange, indicating some difficulty. Low scores
What they all felt was impossible was the key motivator included items regarding travel, spending days
for Rosemary. She began to practice several times a day. occupied with work that is important, getting around
At week 3 of her impatient rehabilitation, the team the community, and being comfortable in the company
decided that Rosemary’s progress had reached a plateau of others. The Community Integration Questionnaire
and that it was time to schedule discharge. Rosemary indicated some severe difficulties in areas of home,
did not want to burden her small group of friends. social, and productivity. Rosemary’s home integration
She made the decision to transfer to a residential score was a 3.6 out of 10 points, her social integration
facility until her status improved. At discharge, she was score was a 3 out of 12 points, her productivity score
independent with ADL using some adaptive strategies was a 1 out of 6 points, and her total score was 7.75 out
and independent with transfers using adaptive equip- of 28 points, indicating a poor level of independence.
ment. Some assistance was required with walking using The team met with Rosemary to set her goals for
a quad cane and an ankle/foot orthotic, her speech outpatient therapy. Scores from her assessments
remained slurred, and her facial droop persisted. were discussed. Rosemary identified that her primary
Muscle strength throughout her arm was 4⁄5, with poor barriers to satisfaction were her decreased ability to
Continued
78 Stroke Rehabilitation

CASE STUDY REFERENCES

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 v irg i l m ath i o wetz

chapter 4

Task-Oriented Approach
to Stroke Rehabilitation

key terms
model of motor behavior motor learning task-oriented treatment
motor control task-oriented evaluation strategies
motor development framework

chapter objectives
After completing this chapter, the reader will be able to accomplish the following:
1. Describe the motor behavior (i.e., motor control, motor learning, and motor
development) theories and model that support the occupational therapy task-oriented
approach to persons after stroke.
2. Describe the evaluation framework for the occupational therapy task-oriented approach
and identify specific assessments that are consistent with the approach.
3. Describe general treatment principles for the occupational therapy task-oriented
approach and their application to persons after stroke.
4. Given a case study of a person after stroke, describe occupational therapy task-oriented
approach evaluation and treatment strategies that you would use.

This chapter provides a theoretical foundation for the The theoretical assumptions of the neurophysiological
occupational therapy (OT) task-oriented approach or approaches, which include Rood sensorimotor approach,71
a function-based approach for persons after stroke. Knott and Voss proprioceptive neuromuscular facilita-
Mathiowetz and Bass-Haugen56 proposed this approach tion,48 Brunnstrom movement therapy,12 and Bobath neu-
in 1994 based on the motor behavior/motor control, rodevelopmental treatment8,9 were based on the empirical
motor development, and motor learning-theories and experience and research of their time. However, as the
research of that time. Motor behavior, OT theories, and motor behavior theories changed in the 1980s and 1990s,
research have evolved since then, so the OT task-oriented the assumptions of the neurophysiological approaches
approach has evolved as well.5,54 This chapter represents were challenged,34,77 and alternative approaches were pro-
the most recent thinking regarding this approach. posed.14,15,40,54-56 Recently the theoretical assumptions of

80
 Chapter 4 • Task-Oriented Approach to Stroke Rehabilitation 81

the neurodevelopmental treatment approach were up- of what the information available in the environment
dated with current motor behavior theories.42 However, means to a specific person.30
many of the neurodevelopmental treatment techniques Bernstein7 also recognized the importance of the
have changed little, despite the changed theoretical environment and personal factors other than the central
assumptions. This may reflect the fact that neurodevelop- nervous system in motor behavior. He explained the
mental treatment was developed empirically first, and role that a particular muscle has in a movement is influ-
then theoretical assumptions of the time were used enced by the context or circumstances and described
to explain why it might work. In contrast, the OT task- three potential sources of variability in muscle function.
oriented approach evaluation and interventions strategies Variability is due to anatomical factors. For example,
emerged primarily from its theoretical assumptions from kinesiology one knows that in a standing position,
(see Chapter 6). the shoulder flexor muscles contract concentrically to
bring the humerus to the 90-degree position. However,
THEORETICAL ASSUMPTIONS AND MODEL in the prone position with one’s arm at one’s side, shoul-
UNDERLYING THE OCCUPATIONAL THERAPY der extensor muscles contract eccentrically until reach-
TASK-ORIENTED APPROACH ing the 90-degree position. Thus, which muscles are
activated depends on the initial position of the body.
Systems Model of Motor Control Another example relates to extending the shoulder from
In the past 25 to 30 years, new models of motor control the 90-degree position when standing. If one wants
have evolved from the ecological approach to percep- to extend it quickly or against resistance, the shoulder
tion and action29,83 and from the study of complex, extensor muscles contract. In contrast, if one extends
dynamical systems in mathematics and the sciences.33 the shoulder slowly against no resistance, the shoulder
The new models emphasize the interaction between flexor muscles contract eccentrically, and the shoulder
persons and their environments and suggest that motor extensor muscles do not need to contract at all. In both
behavior emerges from persons’ multiple systems inter- cases, the role of the muscle is determined by the
acting with unique tasks and environmental contexts.62 context in which it is used. A second source of variabil-
“Thus, the systems model of motor control is more ity is due to mechanical factors. Many nonmuscular
interactive or heterarchical and emphasizes the role forces, such as gravity and inertia, determine the degree
of the environment more than the earlier reflex- to which a muscle needs to contract. For example, a
hierarchical model.”54 muscle must exert much less force if contracting in a
In the systems model, the nervous system is viewed gravity-eliminated plane rather than against gravity.
differently from earlier reflex-hierarchical models. Likewise, the contraction of the elbow extensor muscles
Instead of being the primary system controlling move- would be different if the shoulder were extending or
ment, the nervous system now is considered only one flexing at the same time because of the effects of inertia.
system among many systems that affect motor behavior. Again, the effect of a muscle contraction is related
“The nervous system itself is organized heterarchically to the context. A third source of variability is due to
such that higher centers interact with the lower centers physiological factors. “When higher centers send down
but do not control them. Closed-loop and open-loop a command for a muscle to contract, middle and lower
systems work cooperatively and both feedback and feed- centers have the opportunity to modify the command.
forward control are used to achieve task goals.”54 Lower and middle centers receive peripheral sensory
The central nervous system interacts with multiple feedback. Thus, the impact of the command on the
personal and environmental systems as a person attempts muscle will vary depending on the context and degree of
to pursue a functional goal. influence of the middle and lower centers. As a result,
the relationship between higher center or executive
Ecological Approach to Perception and Action commands and muscle action is not a one-to-one.”54
The ecological approach “emphasizes the study of inter- Mathiowetz and Wade57 also demonstrated the in-
action between the person and the environment during fluence of context (informational support available in
everyday, functional tasks and the close linkage between the environment) on movement. They reported that a
perception and action (i.e., purposeful movement).”54 natural informational support condition (e.g., eating
Gibson described the role of functional goals and the applesauce with a spoon) elicited a smoother and more
environment in the relationship between perception and direct movement pattern than an impoverished in-
action. He stated that direct perception involves the formational support condition (e.g., pretending to eat
active search for affordances30 or the functional use of applesauce with a spoon without any of the objects).
objects for a person with unique personal characteristics.87 Many have taken a dynamical systems view as a means
Therefore, Gibson’s concept of affordances recognizes to explain the complex person-environment interactions
the close linkage between perception and action in terms that occur in everyday life.
82 Stroke Rehabilitation

shift from one preferred movement pattern to another

Dynamical Systems Theory is marked by discrete, discontinuous transitions. These
The study of dynamical systems originated in the disci- changes in only one or several personal or environmental
plines of mathematics, physics, biology, chemistry, psy- systems (i.e., control parameters) can contribute to
chology, and kinesiology and has been applied to the transitions in motor behavior.18 In conclusion, no inher-
professions of OT, physical therapy, nursing, adapted ent ordering of systems exists in terms of their influence
physical education, and some areas of medicine.13,53 Such on motor behavior, and systems themselves are subject
study has influenced the development of a systems model to change over time.
of motor control as well. Dynamical systems theory
proposes that behaviors emerge from the interaction of SYSTEMS VIEW OF MOTOR DEVELOPMENT
many systems and subsystems. Because the behavior is
not specified but is emergent, it is considered to be self- A systems view of motor development suggests that
organizing.46 Despite the many degrees of freedom or ways changes over time are caused by multiple factors or sys-
of performing a task available to persons, they tend to use tems such as maturation of the nervous system, biome-
relatively stable patterns of motor behavior.81 For exam- chanical constraints and resources, and the impact of
ple, when one walks or brushes the teeth, one has many the physical and social environment.38,54 For example,
choices in how to perform the task, yet one tends to Thelen and Fisher80 reported that the disappearance
use preferred patterns. These relatively stable patterns of of the stepping reflex at 4- to 5-months-old is due to
motor behavior, which are unique to each person, provide multiple factors internal and external to the child. Inter-
evidence of self-organization. nal factors included the strength of the leg muscles,
Behavior can shift between periods of stability and weight of the legs, and arousal level of the child. Exter-
instability throughout life. For example, behaviors can nal factors included the varying effects of gravity in
change from being stable to being less stable as a result of different environments. Thus, maturation of the ner-
a stroke or aging. In fact, “it is during unstable periods, vous system alone cannot explain this change in devel-
characterized by a high variability of performance, that opmental behavior. A systems view also suggests that
new types of behaviors may emerge either gradually or normal development does not follow a rigid sequence,
abruptly. These transitions in behavior, called phase shifts, as the motor milestones would suggest. In fact, children
are changes in preferred patterns of coordinated behavior follow variable developmental sequences because of
to another.”54 A gradual phase shift occurs when an infant their unique personal characteristics and environmental
progresses from walking while holding on to a parent’s contexts. If the traditional developmental sequences are
hands to walking without a helping hand over several no longer sufficient as a guide for working with chil-
months. An abrupt phase shift in prehension pattern dren, then they are certainly not appropriate as a guide
occurs when a person changes from picking up a small for working with adults after stroke.85
object such as a peanut to picking up a large object such In addition, the systems view suggests that behaviors
as a large coffee mug. How can these phase shifts or observed after central nervous system damage result from
changes in behavior be explained? patients’ attempts to use their remaining resources to
In the dynamical systems view, control parameters are achieve functional goals. For example, the flexor pattern of
variables that shift behavior from one form to another. spasticity often seen after stroke is due to various factors in
They do not control the change but act as agents for addition to spasticity, such as weakness, inability to recruit
reorganization of the behavior into a new form.38 Control appropriate muscles, biomechanical principles related
parameters are gradable in some way. In the infant to lever arms, and/or soft-tissue tightness. Thus, when
example, the degree of parental support influenced the inefficient/ineffective movement patterns are seen after
change or phase shift from walking with support to walk- stroke, therapists need to consider multiple factors as
ing without support. As parental support decreases, potential contributing variables (see Chapter 10).
infants need to rely more on their own ability to maintain
balance and need to increase their strength to support CONTEMPORARY VIEW OF MOTOR
and control their own body weight in an upright position. LEARNING
In the other example, increasing the size of the object to
be grasped elicited the change in prehension pattern from Schmidt75 defined motor learning as “a set of processes
tip prehension to cylindrical grasp. Consequently, object associated with practice or experience leading to relatively
size also is considered a control parameter. permanent changes in the capabilities of responding.”
Explanations of changes in motor behavior in the Thus, recent motor learning theories acknowledge that
systems model of motor control are different from earlier behavior changes observed during practice may be only
reflex-hierarchical models. Thelen79 stated that an im- temporary. As a result, contemporary motor learning
portant characteristic of a system perspective is that the research not only evaluates learning after the acquisition
 Chapter 4 • Task-Oriented Approach to Stroke Rehabilitation 83

phase (i.e., immediate effects) but also after a retention and without stroke. Chapter 5 provides additional discus-
phase (i.e., short-term or long-term effects) or a transfer sion of the application of motor learning principles to
test (i.e., ability to generalize to new task), and thus new stroke rehabilitation.
ways of thinking about motor learning have emerged.
Motor learning research supports the idea that random SYSTEMS MODEL OF MOTOR BEHAVIOR
practice (i.e., repetitive practice of several tasks in a varied
sequence within a practice session) is better than blocked The model in Fig. 4-1 has been updated to include
practice (i.e., repetitive practice of the same task within terminology from the Occupational Therapy Practice
a practice session).76 Similarly, practicing variations of the Framework.1 The figure depicts the theoretical basis of
same tasks in varied contexts is better than practicing the OT task-oriented approach. The model illustrates
the same task in the same context. In addition, practicing the interaction between the person (client factors,
the whole task rather than parts of a task usually is performance skills, and performance patterns) and their
better, especially if the parts are interdependent or environment (context and activity demands). Occupa-
relatively fast.73 tional performance tasks (i.e., activities of daily living
McNevin, Wulf, and Carlson58 summarized some [ADL], instrumental activities of daily living [IADL],
additional principles. When persons are learning a new work, education, play/leisure, rest, and sleep) and role
task such as golfing, they should focus on the movement performance (social participation) emerge from the in-
effects (external focus on the golf club head) rather teraction between the systems of the person (cognitive,
than on their own arm movements (internal focus). Self- psychosocial, and sensorimotor) and the systems of the
controlled practice (i.e., a person being trained decides environment (physical, socioeconomical, and cultural).
when and how feedback is given and whether assistive Changes in any one of these systems or subsystems
devices are used) is better than instructor-controlled
practice. Finally, dyad training, in which a person is able
Role performance
to alternate observing and practicing a task, is beneficial (social participation)
to learning a new task.
Research on the role of feedback in learning demon-
strates that physical and verbal guidance enhanced Occupational performance task
immediate performance but interfered with long-term (Performance in areas of occupation)
learning.73 Winstein and Schmidt88 reported that 50%
feedback (i.e., feedback after half of the trials) was better
than 100% feedback. Faded or decreasing feedback
was better than increasing feedback. Finally, summary
feedback after multiple trials is better than immediate Cognitive Physical
feedback after every trial.74 In all cases, less feedback was
better than more feedback. Psycho- Cultural
Most research on motor learning has been performed social
on persons without disabilities using a brief, contrived Sensori- Socio-
task in laboratory environments. Therefore, therapists motor economic
need to be cautious about applying these principles to
persons with disabilities performing functional tasks in
Person Environment
everyday, natural environments. (client factors, (context and
However, several studies have explored whether motor performance skills, and activity demands)
learning principles can be applied to persons after stroke. performance patterns)
Hanlon37 provided some evidence that random practice Figure 4-1 The systems model of motor behavior, which sup-
was better than blocked practice. Merians and colleagues59 ports the occupational therapy task-oriented approach, emphasizes
reported that practice in a condition with reduced that occupational performance tasks and role performance emerge
augmented feedback was beneficial for performance from an interaction of the person and their environment. In
consistency but not for accuracy for persons with and addition, any occupational performance task affects the person
without stroke. Dean and Shepherd19 reported that and environment. A continuous interaction occurs between role
task-related training using variable practice and varied performance and occupational performance tasks. These interac-
contexts improved balance ability during seated reaching tions are ongoing across time. (Adapted from Mathiowetz V,
activities. Finally, Fasoli and colleagues22 reported that Bass-Haugen J: Assessing abilities and capacities: motor behavior.
externally focused (task-related) instructions resulted In Radomski MV, Latham CAT, editors: Occupational therapy for
in faster and more forceful movements than internally physical dysfunction, ed 6, Baltimore, 2008, Lippincott Williams &
focused (movement-related) instructions for persons with Wilkins.)
84 Stroke Rehabilitation

can affect occupational performance tasks and/or role “Occupational therapists believe the roles that persons
performance. “In some cases, only one primary factor want and need to fulfill determine the occupational per-
might determine occupational performance. In most formance tasks and activities they need to do. Conversely,
cases, occupational performance tasks emerge from the the tasks and activities persons are able to do determine
interaction of many systems. The on-going interactions what roles they are able to fulfill.”54 Box 4-1 summarizes
between all components of the model reflect its heterar- the assumptions of the OT task-oriented approach.
chical nature.”54
In addition, any occupational performance task affects EVALUATION FRAMEWORK USING
the environment in which it occurs and the person acting. THE OCCUPATIONAL THERAPY
For example, if a patient with hemiplegia becomes TASK-ORIENTED APPROACH
independent in driving by using assistive technology and
adaptive strategies, the patient’s ability to drive would free The therapist conducts the evaluation using a top-down
family members from needing to provide transportation approach as suggested by Latham.49 Box 4-2 gives a frame-
for appointments and social events. The patient would work for evaluation. Evaluation efforts focus initially on
be able to resume the role of driver and the task of role performance and occupational performance tasks
driving, which were likely meaningful to the patient’s life. because they are the goals of motor behavior. A thorough
Thus the occupational performance task of driving affects understanding of the roles that a patient wants, needs, or
persons and objects in the environment (i.e., assistive is expected to perform and of the tasks needed to fulfill
technology added to the car). The task also affects the those roles enables therapists to plan meaningful and
person and the associated components. The ability to motivating treatment programs. After a patient has identi-
be less dependent on the family may affect the patient’s fied the most important role and occupational perfor-
self-esteem positively (i.e., psychosocial subsystem). mance limitations, therapists use task analysis to identify
The process of driving “provides the patient the opportu- which subsystem of the person or environment is limiting
nity to solve problems and to discover optimal strategies functional performance. This process may indicate the
for performing tasks. This influences a client’s cognitive need for evaluation of selected subsystems of the person or
and sensorimotor subsystems and the ability to perform environment.25 The emphasis on role and occupational
other functional tasks.”54 performance in the OT task-oriented approach is consis-
The specific components (subsystems) of the systems, tent with the idea that OT evaluation should be primarily
which influence occupational performance tasks, may be at the participation and activities level rather than the
framed in OT terminology.1,2 Components of the cogni- impairment level, using World Health Organization90
tive (mental) system include orientation, attention, mem- terminology. The therapist needs to use qualitative and
ory, problem-solving, sequencing, learning, and general- quantitative measures during the evaluation process.86
ization ability. Components of the psychosocial system “Therefore, therapists use interviews, skilled observations,
include a person’s interests, coping skills, self-concept,
interpersonal skills, self-expression, time management,
emotional regulation, and self-control skills that could Box 4-1
affect occupational performance tasks. Strength, endur- Assumptions of the Occupational Therapy
ance, range of motion, sensory functions and pain, Task-Oriented Approach Based on a Systems
perceptual function, and postural control are components Model of Motor Behavior
associated with the sensorimotor system. The environ-
■ Personal and environmental systems, including the
ment includes physical, socioeconomical, and cultural
central nervous system, are heterarchically organized.
characteristics of the task itself and the broader environ- ■ Functional tasks help organize behavior.
ment. Components of the physical environment system ■ Occupational performance emerges from the
include objects, tools, devices, furniture, plants, animals, interaction of persons and their environment.
and the natural and built environments, which could limit ■ Experimentation with various strategies leads to
or enhance task performance. The social supports optimal solutions to motor problems.
provided by the family, friends, caregivers, social groups, ■ Recovery is variable because patient factors and
community, and financial resources are components of the environmental contexts are unique.
socioeconomical system, which could influence choice in ■ Behavioral changes reflect attempts to compensate
activities. Finally, components of the cultural system and to achieve task performance.
include customs, beliefs, activity patterns, behavioral
standards, and societal expectations, which also could Data from Mathiowetz V, Bass-Haugen J: Assessing abilities and
affect occupational performance tasks. capacities: motor behavior. In Radomski MV, Latham CAT, edi-
tors: Occupational therapy for physical dysfunction, ed 6,
The inclusion of role performance in this systems
Baltimore, 2008, Lippincott Williams & Wilkins.
model reflects an OT, not a motor behavior perspective.
 Chapter 4 • Task-Oriented Approach to Stroke Rehabilitation 85

Box 4-2
Evaluation Framework for the Occupational Therapy Task-Oriented Approach Based on a Systems
Model of Motor Behavior
Role performance (social participation) Roles: Worker, student, volunteer, home maintainer, hobbyist/amateur,
participant in organizations, friend, family member, caregiver,
religious participant, other?
Identify past roles and whether they can be maintained or need to be
changed.
Determine how future roles will be balanced.
Occupational performance tasks (areas ADL: bathing, feeding, bowel and bladder management, dressing,
of occupation) functional mobility, and personal hygiene and grooming
IADL: home management, meal preparation and cleanup, care of
others and pets, community mobility, shopping, financial management,
and safety procedures
Work and/or education: employment seeking, job performance, volunteer
exploration and participation, retirement activities, and formal and
informal educational participation.
Play/leisure: exploration and participation
Rest and sleep: preparation and participation
Task selection and analysis What client factors, performance skills and patterns, and/or contexts
and activity demands limit or enhance occupational performance?
Person (client factors; performance skills Cognitive: orientation, attention span, memory, problem solving,
and patterns) sequencing, calculations, learning, and generalization
Psychosocial: interests, coping skills, self-concept, interpersonal skills,
self-expression, time management, and emotional regulation and
self-control
Sensorimotor: strength, endurance, range of motion, sensory functions
and pain, perceptual function, and postural control
Environment (context and activity Physical: objects, tools, devices, furniture, plants, animals, and built
demands) and natural environment
Socioeconomic: social supports: family, friends, caregivers, social groups,
and community and financial resources
Cultural: customs, beliefs, activity patterns, behavior standards, and
societal expectations

Adapted from Mathiowetz V, Bass-Haugen J: Assessing abilities and capacities: motor behavior. In Radomski MV, Latham CAT, editors:
Occupational therapy for physical dysfunction, ed 6, Baltimore, 2008, Lippincott Williams & Wilkins.

and standardized assessments to evaluate their clients. such as “How have roles changed since the disability?”
Although the client is the primary source of information, “How have family members reacted to these changes?”
other sources including the client’s records, caregivers, “Is there role flexibility when needed?” and “How com-
family members, and the client’s environment contribute petently do members perform roles?” The therapist may
as well.”54 The evaluation framework is described in more need to adjust these questions to the patient’s level of
detail subsequently. understanding. The patient and significant others must
The first step in the evaluation process is to assess role participate in the evaluation of role performance when-
performance. “Therapists must determine which roles ever possible.
clients had prior to the onset of disability, and which The therapist may assess role performance using a
roles they can and cannot do at this time.”54 A discussion nonstandardized, semistructured interview. However, a
of roles that patients want or must do in the future helps standardized assessment tool such as the Role Check-
determine which roles are most important to them. In list4,63 is suggested. The Role Checklist is a self-report,
addition, therapists need to explore ways that role changes written inventory designed for adolescent, adult, or
have affected or will affect patients and their families, geriatric populations. In Part One, patients check the
especially the primary caregivers. Jongbloed, Stanton, 10 roles (Fig. 4-2) that they have performed in the past,
and Fousek45 recommended that therapists ask questions are performing in the present, and plan to perform in the
86 Stroke Rehabilitation

future. In Part Two, patients rate the value of each role The therapist may use other assessment tools to
to them on a scale from “not at all valuable,” “somewhat gather information on role performance. For example,
valuable,” to “very valuable.” The Role Checklist takes the Occupational Performance History Interview-II
10 to 15 minutes to complete and has evidence of reli- (OPHI-II)47 is a broad, semistructured assessment of
ability and validity (see Fig. 4-2). occupational life history including work, leisure, and

ROLE CHECKLIST

NAME AGE DATE

SEX:  MALE  FEMALE ARE YOU RETIRED?  YES  NO

MARITAL STATUS:  SINGLE  MARRIED  SEPARATED  DIVORCED  WIDOWED

The purpose of this checklist is to identify the major roles in your life. The checklist, which is divided
into two parts, presents 10 roles and defines each one.

PART I
Beside each role indicate, by checking the appropriate column, if you performed the role in the past,
if you presently perform the role, and if you plan to perform the role in the future. You may check more
than one column for each role. For example, if you volunteered in the past, do not volunteer at present,
but plan to in the future, you would check the past and future columns.

ROLE PAST PRESENT FUTURE

STUDENT:
Attending school on a part-time or full-time basis.
WORKER:
Part-time or full-time paid employment.
VOLUNTEER:
Donating services, at least once a week, to a hospital,
school, community, political campaign, and so forth.
CAREGIVER:
Responsibility, at least once a week, for the care of
someone such as a child, spouse, relative, or friend.
HOME MAINTAINER:
Responsibility, at least once a week, for the upkeep of the
home such as housecleaning or yard work.
FRIEND:
Spending time or doing something, at least once a week,
with a friend.
FAMILY MEMBER:
Spending time or doing something, at least once a week,
with a family member such as a child, spouse, or other
relative.
RELIGIOUS PARTICIPANT:
Involvement, at least once a week, in groups or activities
affiliated with one’s religion (excluding worship).
HOBBYIST/AMATEUR:
Involvement, at least once a week, in a hobby or amateur
activity such as sewing, playing a musical instrument,
woodworking, sports, the theater, or participation in a club
or team.
PARTICIPANT IN ORGANIZATIONS:
Involvement, at least once a week, in organizations such
as civic organizations, political organizations, and so forth.
OTHER:
A role not listed which you have performed, are presently
performing, and/or plan to perform. Write the role on the
line above and check the appropriate column(s).

Figure 4-2 Role Checklist. (Courtesy of Frances Oakley, MS, OTR, FAOTA.)
 Chapter 4 • Task-Oriented Approach to Stroke Rehabilitation 87

PART II
The same roles are listed below. Next to each role, check the column that best indicates how
valuable or important the role is to you. Answer for each role, even if you have never performed
or do not plan to perform the role.

ROLE NOT AT ALL SOMEWHAT VERY

VALUABLE VALUABLE VALUABLE
STUDENT:
Attending school on a part-time or full time basis.
WORKER:
Part-time or full-time paid employment.
VOLUNTEER:
Donating services, at least once a week, to a hospital,
school, community, political campaign, and so forth.
CAREGIVER:
Responsibility, at least once a week, for the care of
someone such as a child, spouse, relative, or friend.
HOME MAINTAINER:
Responsibility, at least once a week, for the upkeep of
the home such as housecleaning or yard work.
FRIEND:
Spending time or doing something, at least once a
week, with a friend.
FAMILY MEMBER:
Spending time or doing something, at least once a
week, with a family member such as a child, spouse, or
other relative.
RELIGIOUS PARTICIPANT:
Involvement, at least once a week, in groups or
activities affiliated with one’s religion (excluding worship).
HOBBYIST/AMATEUR:
Involvement, at least once a week, in a hobby or
amateur activity such as sewing, playing a musical
instrument, woodworking, sports, the theater, or
participation in a club or team.
PARTICIPANT IN ORGANIZATIONS:
Involvement, at least once a week, in organizations
such as civic organizations, political organizations, and
so forth.
OTHER:
A role not listed which you have performed, are
presently performing, and/or plan to perform. Write
the role on the line above and check the appropriate
column(s).

Figure 4-2, cont’d

daily life activities. One part of it explores life roles, The second step in the evaluation process is the assess-
whereas other parts explore interests, values, organiza- ment of occupational performance tasks: ADL, IADL,
tion of daily routines, goals, perceptions of ability, work, education, and play/leisure (see Box 4-2). “Because
and environmental influences. The complete OPHI-II roles, tasks, activities, and their contexts are unique to
takes about 50 minutes and has evidence of reliability each person, a client-centered assessment tool such as the
and validity. The OPHI-II includes information not Canadian Occupational Performance Measure (COPM)50
only on role performance but also on occupational per- is recommended.”54 The COPM uses a semistructured
formance tasks, which are the next step of the evaluation interview to measure a patient’s self-perception of occupa-
process. In conclusion, after patients have identified the tional performance over time. First, patients identify
roles that they want or need to perform, they more eas- problem areas in self-care, productivity, and leisure.
ily can identify the tasks and activities needed to fulfill Second, they rate the importance of each problem area,
each role. which assists therapists in setting treatment priorities.
88 Stroke Rehabilitation

Third, patients rate their own performance and their more successful. Quantitative and qualitative measures
satisfaction with their performance on the five most are needed to evaluate the process of task performance.
important problem areas. Therapists may use these The third step in the evaluation process involves task
performance and satisfaction ratings again as outcome selection and analysis. The tasks selected for observation
measures, measuring change across time. If therapists should be ones that patients have identified as important
are concerned that a patient cannot rate performance but difficult to do. Task analysis requires therapists to
accurately because of a cognitive impairment or age, observe their patients performing one or more occupa-
therapists may use direct observation of selected activities tional performance tasks. In most cases, observation of
or a caregiver interview to verify the information. performance happens as part of the second step described
The information elicited by the COPM is unique to each previously. Therapists use task/activity analysis to evalu-
patient and the individual’s environment, which is an es- ate activity demands, context, patient factors, performance
sential part of the OT task-oriented approach (Fig. 4-3). skills, and performance patterns to determine whether a
Another recommended measure of occupational per- match exists that enables persons to perform occupational
formance specific to ADL and IADL is the Assessment tasks within a relevant environment. If the person is un-
of Motor and Process Skills (AMPS).24 The assessment able to perform the task, therapists attempt to determine
is client-centered because the person chooses two or which person or environment subsystems are interfering
three ADL or IADL tasks to be performed, which with occupational performance. “In dynamical systems
ensures that the task or activity is familiar and relevant theory, these are considered the critical control parame-
to the person being evaluated. The purpose of the AMPS ters or the variables that have the potential to shift behav-
is “to determine whether or not a person has the neces- ior to a new level of task performance.”54 Each person has
sary motor and process skills to effortlessly, efficiently, unique strengths, limitations, and environmental context
safely and independently perform the ADL tasks needed after a stroke. Therefore, the critical control parameters
for community living.”24 The AMPS is appropriate that support or limit occupational performance tasks are
for persons from diverse backgrounds and with diverse also unique. An effective intervention strategy for one
needs and interests because it has been standardized person after stroke may not be effective for the next
internationally and cross-culturally. “A unique feature of person. Another concept of dynamical systems theory is
the AMPS is that it can adjust, through Rasch analysis, that critical control parameters also change as persons and
for the difficulty of tasks performed and the severity of their environments change over time. Therefore, an in-
the rater who scores the client’s performance. In addi- tervention that worked well early in a patient’s rehabilita-
tion, it allows a therapist to compare the performance of tion might not work well late in the rehabilitation process
clients who performed one set of tasks on initial evalua- or vice versa.
tion with the results of a re-evaluation on a different The identification of critical control parameters is the
set of tasks.”54 The primary limitation of the AMPS is most challenging part of the evaluation process. However,
that it requires a five-day training workshop to learn evidence in the research literature indicates that some
how to administer the assessment in a reliable and valid variables or subsystems of the person and/or environment
way. Computer software to score the AMPS is provided are potential critical control parameters for persons
as part of the workshop. Finally, the AMPS assists in after stroke. Gresham and colleagues36 reported that
the next step in the evaluation process, because it re- psychosocial and environmental factors were significant
quires observation of patients performing occupational determinants of functional deficits in persons for the long
performance tasks (see Chapter 21). term after stroke. In a review, Gresham and colleagues35
While evaluating occupational performance tasks, reported that 11% to 68% of persons experience depres-
“therapists must observe both the outcome and the pro- sion after stroke, with 10% to 27% meeting the criteria
cess (i.e., the preferred movement patterns, their stability for major depression. In the cognitive area, Galski and
or instability, the flexibility to use other patterns, effi- colleagues28 reported that for persons after stroke, “defi-
ciency of the patterns, and ability to learn new strategies) cits in cognition, particularly higher-order cognitive abil-
to understand the motor behaviors used to compensate ities (e.g., abstract thinking, judgment, short-term verbal
and to achieve functional goals.”54 Determining the sta- memory, comprehension, orientation) play an important
bility of the motor behavior is important to determine the role in determining length of stay and in predicting
feasibility of achieving behavioral change in treatment. functional status at the end of hospital stay.” In the
“Behaviors that are very stable will require a great amount sensorimotor area, weakness,65 fatigue,44 impaired motor
of time and effort to change. Behaviors that are unstable function,6 and visuospatial deficits82 are associated with
are in transition, the optimal time for eliciting behavioral poorer functional outcomes. For example, Bernspang and
change.”54 Thus, when behaviors are more stable, a colleagues6 reported that motor function measured with
compensatory approach may be most appropriate; when the Fugl-Meyer Assessment27 was correlated moderately
behaviors are unstable, a remediation approach may be (r  0.64) with self-care ability.
 Chapter 4 • Task-Oriented Approach to Stroke Rehabilitation 89

STEP 1A: Self-Care IMPORTANCE

Personal Care
STYLING & COMBING HAIR 8
(e.g., dressing, bathing, DRESSING IN A TIMELY MANNER 6
feeding, hygiene)

Functional Mobility GETTING UP SAFELY FROM BATHTUB 8

(e.g., transfers,
indoor, outdoor)

Community Management
(e.g., transportation,
shopping, finances)

STEP 1B: Productivity

Paid/Unpaid Work
(e.g., finding/keeping
a job, volunteering)

Household Management
CHANGING SHEETS 9
(e.g., cleaning, doing PREPARING MEALS FOR FAMILY 10
laundry, cooking)
FOLDING TOWELS 2

Play/School
(e.g., play skills,
homework)

STEP 1C: Leisure

Quiet Recreation SEWING 8

(e.g., hobbies,
crafts, reading)
NEEDLEPOINT 5
MAKING X-MAS WREATHS 5

Active Recreation
PLAYING WITH GRANDKIDS ON THE FLOOR 9
(e.g., sports, BOWLING 4
outings, travel)

Socialization
(e.g., visiting, phone calls,
parties, correspondence)

Figure 4-3 Identifying problems and rating importance via the Canadian Occupational Perfor-
mance Measure. (Modified from Law M, Baptiste S, Carswell A, et al: Canadian Occupational
Performance Measure, Toronto, 1994, CAOT Publications ACE.)
90 Stroke Rehabilitation

Practitioners must use the aforementioned literature determine how subsystem of the person and the environ-
on potential control parameters with caution. Most of ment might affect occupational performance.
these were correlation studies, which indicate relation- The fourth step in the evaluation process is to perform
ships between these variables and functional perfor- specific assessments of client factors, performance
mance, but they do not prove a causal link. In addition, skills, and performance patterns, which are thought to be
most correlations were moderate or low, which suggests critical control parameters. The critical control variables
that any one variable explains a relatively small percent- are the only ones that need to be evaluated. “The evalua-
age of the variance associated with functional perfor- tion of selected variables according to the OT task-
mance. However, Reding and Potes70 provided evidence oriented approach contrasts with bottom-up approaches
that as the number of impairments increased, functional that evaluate all component variables. This selective
outcomes decreased. “Thus, multiple variables contrib- approach eliminates the need to evaluate variables that
ute to functional performance for most persons with have little functional implication and saves therapists’
central nervous system dysfunction. The challenge is to time, which is critical for cost containment.”54
identify those variables that are most critical to your Occupational therapists use a variety of assessments
clients.”54 to evaluate patient factors, performance skills, and perfor-
Bobath9 suggested that spasticity is the primary cause mance patterns that support or constrain occupational
of motor deficits in persons after stroke and that weakness performance. Some assessments were designed to examine
and decreased range of motion are due to spastic antago- one or more impairments within the context of occupa-
nists. However, evidence is increasing that indicates that tional performance. The Arnadottir OT-ADL Neurobe-
spasticity is not a critical control parameter.11 For exam- havioral Evaluation (A-ONE)3 facilitates evaluation of
ple, Sahrmann and Norton72 reported electromyography perceptual and cognitive systems within the context of ADL
findings that indicated movements were not limited (see Chapter 18 for details). From a task-oriented perspec-
by antagonist stretch reflexes (spasticity) but were limited tive, this is a preferred assessment tool because it links
by delayed initiation and cessation of agonist contraction. impairments more closely to occupational performance. In
Similarly, Fellows, Kaus, and Thilmann23 found no rela- contrast, most assessments of impairments are conducted
tionship between movement impairments and passive independent of occupational performance.
muscle hypertonia in the antagonist muscles. O’Dwyer, The fifth step of the evaluation process is evaluation of
Ada, and Neilson64 found no relationship between spastic- the environment: context and activity demands. The inclu-
ity and either weakness or loss of dexterity. “Thus, re- sion of physical, social, and cultural environments in Amer-
search evidence challenges the assumption that spasticity ican Occupational Therapy Association2 uniform terminol-
causes the weakness and decreased range of motion often ogy acknowledges their important impact on occupational
seen in persons with central nervous system dysfunc- performance. A number of OT theories16,21,51,78 emphasize
tion.”54 Recently, the Neuro-Developmental Treatment the importance of assessing environmental context as part of
Association acknowledged this change in thinking: “There the overall evaluation process. See Radomski68 and Cooper
is not a direct relationship between spasticity and con- and colleagues17 for specific assessments of environmental
straints on motor impairments or functional performance, contexts. See Chapter 27.
as the Bobaths first proposed”42 (see Chapter 10).
After identifying the critical control parameters TREATMENT PRINCIPLES USING
that support or constrain occupational performance, the THE OCCUPATIONAL THERAPY
therapist must assess the interactions of these systems. TASK-ORIENTED APPROACH
Consider two patients who have complete loss of volun-
tary control of their dominant hand. The role and Help Patients Adjust to Role and Task Performance
occupational performance tasks of the patient as a worker Limitations
may or may not be affected. If the worker were an Many patients are not able to continue some of the roles
automobile mechanic, the interaction of this personal and tasks that they performed before their strokes. This is
limitation with the activity demands of the work environ- a frustrating and sometimes depressing situation for many
ment would likely make the task of repairing a car engine persons after stroke. Therapists can help by exploring
difficult or impossible to perform. However, if the worker alternative ways of fulfilling roles and of performing the
were a self-employed writer, the person could learn associated tasks. Therapists also can explore potential
to use a one-handed keyboard with the nondominant new roles and new tasks. For example, in the case study
hand and could continue writing because the interaction presented at the end of this chapter, an important role
of performance skills and activity demands would not for G.W. was continuing to help his son on the farm.
interfere with role and task performance. This part of The therapist helped the patient identify the tasks with
the evaluation requires the therapist to use qualitative which he had helped in the past and which ones would be
and quantitative assessments and clinical reasoning to impossible or difficult to perform in the future. For G.W.,
 Chapter 4 • Task-Oriented Approach to Stroke Rehabilitation 91

heavy or bilateral tasks (e.g., moving bales of hay and that “engagement in purposeful activity produces better
repairing heavy equipment) would fit this category. Brain- quality of movement than concentration on movement
storming about alternative tasks that he could do unilater- per se.” Nelson and colleagues61 demonstrated that after
ally or relatively light tasks (e.g., record keeping) that stroke, persons who performed an occupationally embed-
he could still perform would enable him to continue his ded exercise had significantly greater supination active
role as an assistant to his son. Inclusion of the son in this range of motion than persons who did rote exercises.
discussion was important, because he had suggestions These studies support the idea that the use of functional
that G.W. had not considered. tasks has beneficial therapeutic effects.
Higgins39 suggested that persons need to practice func-
Create an Environment That Uses the Common tional, everyday activities to find the most effective and
Challenges of Everyday Life efficient way of doing the activity. Because persons are
Therapists need to be creative in creating environments unique, their performance patterns and levels of skill vary.
within their clinical settings that provide typical chal- Therefore, therapists should not expect that one way of
lenges. Some facilities have purchased more real-life performing a task would be the most effective and effi-
environments such as Easy Street, whereas other facilities cient way of performing a task for all patients. Thus,
have remodeled their clinics to simulate environments in therapists should encourage patients to experiment to
which patients typically have to interact. Some have find the most effective and efficient way of performing
created small apartments to create a more realistic envi- functional tasks. In one evidence-based review, the au-
ronment, in contrast to a typical hospital room, in which thors concluded, “There is strong evidence that patients
patients can interact before being discharged. Home care benefit from exercise programmes in which functional
settings are ideal situations for following this treatment tasks are directly and intensively trained.”84
principle because the patient’s own environment and
objects can be used for therapy. Provide Opportunities for Practice Outside
A stroke unit provides a more effective environment of Therapy Time
for improving functional outcomes.43 The physical envi- Therapists need to recognize that the amount of time
ronment is set up to enable patients to function more they have to work with a patient is short relative to the
independently. Patients are encouraged to wear their own total time in a day. Therefore, enticing patients to con-
clothing instead of hospital gowns. Thus, they are con- tinue therapy on their own time is important. Therapists
fronted with the common clothing of everyday life. can provide homework assignments for patients to work
In addition, staff members are trained to encourage inde- on their own. If homework is given, follow-up is impor-
pendent behaviors. In G.W.’s case, nursing staff on the tant, and therapists should ask their patients how their
previous unit had assisted him in dressing and bathing. homework went. What worked for the patients, and what
On the rehabilitation unit, nursing staff would encourage did not work for them? Effective communication with
him to perform as many self-care tasks as possible. In ad- other rehabilitation staff and family members is crucial,
dition, most rehabilitation units have patients eat together so that their attempts to be helpful do not reduce the
in a dining area instead of in their own rooms. This is a opportunities for patients to practice outside of therapy
more typical way of eating, plus it facilitates social interac- time. Most important is for therapists to help patients find
tion and support from others struggling with many of the new ways to use their involved extremity, even if it is only
same problems. In addition, dining with others facilitates to stabilize objects. A good homework assignment is to
learning from and problem-solving with each other. challenge the patient to find a new way to use the involved
arm each day.26 Ultimately, the goal is to get patients to
Practice Functional Tasks or Close Simulations use their involved arm without thinking about it.
to Find Effective and Efficient Strategies
for Performance Use Contemporary Motor Learning Principles
In all cases, the therapist must use the functional tasks and in Training or Retraining Skills
activities that have been identified as important and mean- Therapists should consider the following three motor
ingful to their patients. This demonstrates to patients that learning principles:
the therapist has listened to them and respects their ■ Use random and variable practice within natural
choices and priorities. As a result, patients more easily contexts in treatment.
understand the relevance of therapy to their lives. ■ Provide decreasing amounts of physical guidance
Use of functional, natural tasks rather than rote exer- and verbal feedback.
cise in treatment is important. A number of studies have ■ Develop task analysis and problem-solving skills of
demonstrated that the kinematics of movement are patients so that they can find their own solutions to
different when one performs a real task instead of rote occupational performance problems in home and
exercise.57,91 A metaanalytical review52 provided evidence community environments.
92 Stroke Rehabilitation

Although blocked or repetitive practice of the same task therapist should remember that the same solution does
normally is not recommended, such practice may be help- not work for all patients (see Chapter 5).
ful or necessary when a patient is first learning the re-
quirements of a new task.74 However, therapists should Minimize Ineffective and Inefficient Movement
shift to random and variable practice schedules as soon Patterns
as possible to enhance motor learning. Random practice As described previously, during observation of a patient
involves practicing more than one task within a session performing an occupational performance task, therapists
(i.e., avoiding repetitive practice of the same task). attempt to identify what may be critical personal or envi-
Variable practice involves experimenting with different ronmental factors that are interfering with effective and
tools for completing a task, with different location of the efficient movement patterns. The following strategies are
tools relative to the person, or with varied environments ways that therapists can intervene to reduce ineffective
for performing a task. In addition, patients should and inefficient movement.
practice tasks in their natural context whenever possible.
Therefore, ADL tasks normally done in a patient’s room Remediate a Client Factor (Impairment) if it is the
should be practiced there rather than in the OT clinic. Critical Control Parameter. When therapists identify
Even better would be patients practicing ADL tasks in person factors in the cognitive, psychosocial, or senso-
their own homes. rimotor systems as possible critical control parameters,
When therapists are beginning to teach patients new then they should attempt to remediate those factors,
tasks or new ways to perform previously learned tasks, assuming that is possible. For example, Flinn26 identified
they may need to provide some physical guidance and decreased strength as one critical control parameter
verbal feedback.73 However, guidance and feedback should that interfered with occupational performance tasks for a
be tapered off quickly so that the person does not become person after stroke. Thus, she attempted to remediate this
dependent on them. For a therapist not to provide guid- sensorimotor variable through the use of exercise and
ance and feedback when a patient is struggling to perform increased use of the involved extremity for functional
a task is difficult. However, providing physical guidance tasks. For this person, the use of exercise was meaningful
prevents patients from learning how to use their remain- because she saw a clear connection between her exercise
ing resources to get the job done, and providing immedi- program and her ability to use her involved arm and hand
ate and frequent feedback prevents patients from learning for everyday tasks. The therapist also encouraged her to
how to use their own feedback mechanisms to monitor use her involved extremity whenever possible in therapy
and evaluate their own performance. If patients are un- and for various homework assignments.
aware of a deficit (e.g., neglect to use involved extremity In the case of G.W., decreased strength, impaired
in a task), the use of a videotape of their performance can sensation, and neglect of the left upper extremity were
supplement their usual feedback mechanisms.69 By the identified as possible control parameters. Therefore,
time a patient is approaching discharge, therapists should attempts to remediate these factors were warranted in this
be providing minimal guidance or feedback. The thera- case. However, sometimes remediation of a potential
pist should remember that the goal of rehabilitation is to control parameter is impossible because of the severity
train the patient to be independent without the therapist’s of the disease process or limited time available for therapy.
presence. In such cases, a more compensatory approach to treat-
In a related issue, patients need to learn how to analyze ment is indicated.
tasks and to problem-solve on their own. If the therapist
always analyzes tasks for patients and solves all their prob- Adapt the Environment, Modify the Task, Use Assistive
lems, the patients will not learn how to do those things Technology, and/or Reduce the Effects of Gravity.
themselves. In the limited therapy time available, prepar- For many patients, the quickest and most effective
ing patients for all possible tasks, activities, and environ- approach to improving occupational performance is to
ments that they will confront after they are discharged is adapt the task and/or the environment. For example,
impossible. The therapist’s role is to train patients how to Gillen31 described a patient with severe limitations in
do task analysis and problem-solving during the rehabili- self-care activities following multiple sclerosis and ataxia.
tation process, so that by the time they are discharged, Tremor, impaired postural control, paraparesis, and
they are capable of doing those things on their own. From decreased endurance limited his occupational per-
early in rehabilitation, the therapist should involve pa- formance. The patient’s priority was to gain access to the
tients in task analysis and guide them through the process. community and community resources. He did not have
As occupational problems are addressed, the therapist adequate motor control to operate a manual chair or to
should keep patients involved in trying to find solutions to control a standard power chair. Therefore, a specialized
problems. Therapists should encourage experimentation power chair was prescribed that provided optimal head
to find the optimal solution for that specific person. The and trunk stability, allowed independent tilting, included
 Chapter 4 • Task-Oriented Approach to Stroke Rehabilitation 93

a joystick with tremor-dampening electronics, and a self-imposing some form of freezing of body segments.39
forearm trough to provide maximal stability to the arm As a result, their performance appears stiff and uncoordi-
controlling the joystick. A volar wrist splint provided nated. With practice, the performance becomes smoother
additional stability to the wrist. With training in varied and more coordinated as the restrictions on the degrees of
environments, the patient improved from total assis- freedom decrease. Unfortunately, some persons with
tance in mobility to minimal supervision. Thus, the use central nervous system damage are not able to constrain
of assistive technology, task modification, and training in the degrees of freedom at their joints. For example, Gillen
varied environments was the most efficient and effective identified poor postural stability and tremor as interfering
means of improving the mobility independence of this with the functional performance of a person with multiple
patient. sclerosis and ataxia. He speculated “that performance
For G.W., a standard bath chair enabled independent would be improved by increasing postural stability and
and safe tub transfers. For shoe tying, G.W. preferred decreasing the number of joints (decreasing the degrees
the use of Kno-Bows, an adapted device, for fastening of freedom) required to participate in chosen tasks.”32
his shoes rather than learning one-handed shoe tying. Therefore, he used orthotic devices, assistive technology,
For cutting meat, an enlarged-handled fork was tried to and adaptive positioning of the trunk and upper extremity
encourage use of the left hand. However, this was to help his patient constrain the degrees of freedom and
not feasible at the time, so a rocker knife was prescribed. to increase stability, which enabled improved ADL
Thus a variety of adapted devices increased the ADL performance. Thus, the occupational performance of
independence of G.W. a patient with tremor was enhanced by strategies to
For patients unable to raise their arms up against decrease the degrees of freedom at those joints.
gravity (i.e., grade 2 shoulder flexion and shoulder ab-
duction muscles), the use of technology that minimizes For Persons Who Do not Use Returned Function in
the effects of gravity on their arms may help strengthen Their Involved Extremities, Use Constraint-Induced
those weak muscles and enable increased functional Therapy. A growing body of literature supports the ben-
performance. The use of body weight support during eficial effects of constraint-induced movement therapy
treadmill training has resulted in increased lower (CIMT) for persons after stroke with active wrist exten-
extremity strength and increased ambulation ability of sion and active finger extension.10,60,89 The original CIMT
person’s poststroke.84 Unfortunately, there has been involves intensive therapy (i.e., about six hours per day
limited application of this concept to the upper ex- for 10 days in a two-week period) while the less involved
tremity. Devices such as mobile arm supports with arm is constrained by a sling or glove. As a result, par-
elevation assist (e.g., Jaeco Multilink Elevation Assist) ticipants are forced to use their involved extremity to
or deltoid aide counterbalanced slings (e.g., Swedish complete functional tasks, and thus CIMT counteracts
Help Arm or Mobility Arm) minimize the effects of the learned nonuse seen in many persons after stroke.
gravity on a patient’s arm and can be graded to provide CIMT is consistent with two assumptions of the OT
less assistance as the person increases in strength. When task-oriented approach: “functional tasks help organize
these patients have some hand function, these devices behavior and experimentation with various strategies
can be used effectively for task-specific training. When leads to optimal solutions to motor problems”54 (see
these patients have limited hand function, the Armeo or Chapters 6 and 10).
T-WREX (www. hocoma.com) may be effective devices. In most clinical settings, CIMT as originally proposed
They enable patients with upper extremity weakness would not fit into the current structure of inpatient
and limited grasp and release to exercise their arm while rehabilitation programs and current reimbursement
using virtual reality simulated functional activities practices. However, there is growing evidence that a less
such as grocery shopping and cleaning a stove top. intense (i.e., less times per day) and more distributed
These task-specific activities can be adjusted to each (i.e., spread out longer than two weeks) form of CIMT is
patient’s ability, and they motivate patients to use the also effective.20,66,92 Thus, modified CIMT can be used
available function in their arms and hands.41 These within current rehabilitation programs. However, after
devices that minimize the effects of gravity on a patient’s stroke many persons do not meet the minimal eligibility
arm have the potential to increase upper extremity requirements during their initial rehabilitation, so most
strength and to improve functional performance. CIMT programs are conducted on an outpatient basis
However, more research is needed to evaluate their for persons who are six months or more poststroke and
effectiveness. See Chapters 11 and 28. who have sufficient return of function to benefit from
CIMT. No evidence indicates that CIMT is effective for
For Persons with Poor Control of Movement, Constrain persons without some active wrist and finger extension.
the Degrees of Freedom. Persons learning a new task In the case of G.W., with the neglect of his involved
initially restrict the degrees of freedom at their joints by extremity, he would not be a good candidate for CIMT
94 Stroke Rehabilitation

now because he does not have sufficient active wrist and

The COPM was administered to evaluate occupa-
finger extension to benefit. At a later time, when that
tional performance tasks. The following five tasks were
function does return, a trial of CIMT would be indicated.
rated as most important to him: dressing, bathing,
Chapters 6 and 10 contain more detailed discussions
driving, gardening, and helping his son on the farm.
of CIMT. For a more detailed discussion of the OT
His performance and satisfaction for these tasks were
task-oriented approach treatment, see Bass-Haugen,
rated low. However, he had not had the opportunity
Mathiowetz, and Flinn.5
to try the latter three tasks since his stroke, and nursing
staff assisted him with dressing and bathing. He re-
SUMMARY ported that he was independent in sink hygiene tasks,
feeding (except for cutting meat), and toileting (except
This chapter describes an OT task-oriented approach for
for pulling up and fastening trousers). He could ambu-
persons after stroke and describes the theoretical basis for
late 10 feet with a large, quad-based cane with moder-
and assumptions of the approach, based on contemporary
ate assistance. His wife did all the grocery shopping
motor control, motor learning, and motor development
and cooking. G.W. had helped his wife with the laun-
literature. The chapter also provides a top-down evalua-
dry. He was unsure whether he would be able to play
tion framework that emphasizes the importance of evalu-
cards in the men’s club now.
ating role and occupational performance tasks first and
Dressing and bathing were chosen as tasks to be ob-
then the selective assessment of personal and environ-
served on the following day. G.W. was not able to dress
mental factors. In addition, the chapter describes the ap-
himself independently primarily because of inability to
plication of treatment principles to various patient prob-
use and/or neglect in using his left upper extremity.
lems and, finally, includes a case study describing the
When cued to use his left arm, he demonstrated some
application of the OT task-oriented approach to a specific
voluntary control of his left shoulder and elbow and lim-
person after stroke.
ited movement in the wrist and fingers. He complained
of numbness in his left hand. During the bathing assess-
CASE STUDY ment, he needed assistance getting into and out of a tub.
However, he could transfer in and out of the tub using a
Occupational Therapy Task-Oriented Approach
standard transfer bench. Once in the tub, he could con-
for a Stroke Survivor
trol the water and bathe himself with one hand. He
G.W. is a 69-year-old retired farmer who suffered a demonstrated good sitting balance during these activi-
right cerebral vascular accident with resultant left hemi- ties, and he could stand independently when he could
paresis five days ago. He was admitted to the acute care hold onto something with his right arm. He complained
hospital and was then transferred to the rehabilitation about the amount of time and energy it took him to per-
unit today. form self-care tasks. He demonstrated no evidence of
From the chart, it was learned that he is now medi- cognitive or perceptual deficits except for some neglect
cally stable. He is taking angiotensin-converting en- of his left arm and left visual space. Based on these obser-
zyme inhibitors for high blood pressure and Coumadin vations, it appeared that sensorimotor factors (decreased
for prevention of a second stroke. He has been living in strength, endurance, range of motion, sensation, and
a small town with his wife since moving from their farm neglect) were potential causes of limitations in occupa-
three years ago. His son, daughter-in-law, and their tional performance tasks, so these factors were selected
three children are farming in the local community. for further evaluation. In contrast, cognitive and psycho-
social factors appeared to be potential supports for in-
Initial Evaluation creased independence. In addition, it appeared that
The Role Checklist was administered to evaluate modification of the environment (e.g., use of adaptive
G.W.’s role performance. Although retired, he contin- equipment such as a bath chair, Kno-Bows for shoe fas-
ued to help out his son part-time as needed on the teners, and rocker knife) could be used to enable occupa-
farm. He did most of the home maintenance, including tional performance tasks. However, more information
the yard and a small garden. He attended church was needed regarding his home and community environ-
regularly, was a member of the men’s club, and volun- ment to prepare for his discharge to home.
teered for the annual church dinner. In addition to Tables 4-1 and 4-2 show the results of manual mus-
his son who farms, he has another son and daughter, cle testing, passive range of motion, and hand strength
who are married and live within a two-hour drive. assessments for the left upper extremity only.
He has eight grandchildren. He and his wife enjoyed Sensory testing indicated a loss of protective sensa-
traveling with another retired couple from their tion and diminished light touch in the left hand
church. (Semmes-Weinstein monofilaments) and impaired
 Chapter 4 • Task-Oriented Approach to Stroke Rehabilitation 95

proprioception in the left forearm, wrist, and hand. A Community Environment

line bisection test showed moderate visual neglect of Their house is located one block from their church and
the left side. four blocks from the downtown area, which includes
a grocery store, drug store, barber shop, post office,
Home Environment liquor store, and a small cafe. Their small town has no
G.W. and his wife live in a small two-story home. clothing or hardware store. They must drive 20 miles
Their bedroom, bathroom, kitchen, living room, to a larger town for these supplies and medical care.
and dining room are on the main floor. The upstairs Their son’s farm is located five miles from their house.
has two bedrooms, a bathroom, and storage space. The church has a split-level entrance with 10 steps to
The washer and dryer are located in the basement. church level and 10 steps to the basement where the
The front and back of the home have five steps with a men’s club meets. Fortunately, the church installed a
handrail on one side only. They have a one-car chair glide to assist persons with mobility problems to
detached garage that is close to the house. They have a get into church. However, no chair glide is available for
10-year-old car with a stick shift. They have a 10  20 the basement level. At this time, he knows that he can-
foot vegetable and flower garden in their backyard. not get up and down 10 steps, and this is a concern.
Their home is paid for, and they receive modest After a discussion of the evaluation results, the
checks from Social Security and some farm rental patient and therapist agreed on the following goals.
income from their son. If they stay healthy, their income
is adequate for what they want to do. However, they are Week 1 Treatment Plan
worried that if one or both of them were to become 1. Increase active use of the left upper extremity dur-
disabled and require nursing home care, then their ing ADL and leisure tasks (i.e., avoid neglect and
income would not be sufficient to cover expenses. learned nonuse of the left arm and hand).
Continued

Table 4-1
Manual Muscle Testing and PROM Assessment
LEFT UPPER LEFT UPPER
EXTREMITY MMT PROM EXTREMITY MMT PROM

Shoulder flexion 2 0–155 Pronation 2 0–75

Shoulder abduction 2 0–155 Supination 3 0–80
Shoulder external 2 0–45 Wrist flexion 2 0–80
rotation
Shoulder internal 2 0–70 Wrist extension 1 0–45
rotation
Elbow flexion 3 0–150 Finger and thumb 3 Full
flexion
Elbow extension 2 0–150 Finger and thumb 1 Full
extension

MMT, Manual muscle test; PROM, passive range of motion (units in degrees).

Table 4-2
Hand Strength Assessment
HAND STRENGTH RIGHT HAND INTERPRETATION LEFT HAND INTERPRETATION

Grip 102# WNL 3# BNL

Key pinch 19# WNL 2# BNL
Palmar pinch 17# WNL 1# BNL

BNL, below normal limits; WNL, within normal limits.

96 Stroke Rehabilitation

CASE STUDY
Week 2 Treatment Plan
Occupational Therapy Task-Oriented Approach 1. Explore the possibility of driving and continued
for a Stroke Survivor—cont’d gardening.
2. Increase independence in ADL and leisure tasks. 2. Finalize plans for discharge to home, including
3. Begin planning for discharge to home and ordering and installing adapted devices.
for possible roles for him on his son’s farm. 3. Finalize home program and follow-ups.
The patient became aware through the evaluation The patient was evaluated on some aspects of
process that he tended to neglect his left arm and hand driving using a modified car. He was able to transfer in
and was motivated to improve its function. Thus, he was and out of the car with moderate supervision. He was
open to experimenting with using his left upper extrem- discouraged that he was not able to push in the clutch
ity to assist during functional tasks. He was taught one- with his left foot. He preferred driving a stick shift but
handed dressing techniques with reminders to use his left could see that a car with an automatic transmission
arm and hand as much as possible. For example, G.W. would be easier for him. He agreed to discuss getting a
was encouraged to raise his left arm as he slid his shirt on different car with his wife and son. Other adaptations
and to use his left hand to stabilize his shirt and pants that might make driving easier and safer were explored.
while buttoning. Various options for tying his shoes were The issue of neglect of his left visual field was discussed
explored. He chose to use Kno-Bows because of the ease and evaluated using a driving simulator. He did have
of using them compared with alternatives. A rocker knife problems (i.e., simulated crashes) because of neglect.
was chosen to enable independent cutting of meat. The It was decided that additional practice with the simula-
therapist communicated with his wife and nursing staff tor and other activities to improve his visual scanning
on what he was able to do relative to ADL tasks and what were necessary before he could drive again.
adapted equipment (e.g., bath chair) he needed to G.W. continued to use various leisure and ADL ac-
be independent. G.W. was independent in bathing him- tivities to increase active use of his left arm and hand.
self when the bath chair was available to him. Set-up of the activities was structured to require in-
He expressed some concern about slipping and falling creased visual scanning as he did these activities.
when he would get home. Plans were made to order the Although G.W. continued to improve in his walking
grab bars, bath chair, and nonskid bath mat. and stair-climbing ability, it was decided that a second
In addition, various leisure activities including card handrail should be installed at both entrances to the
playing were explored. He was able to pull cards home and in the basement and upstairs stairways. His
toward himself with his left hand but was unable to son agreed to arrange for someone to do this. In addi-
pick them up or hold them. A cardholder was tion, he agreed to install grab bars in the bathroom and
prescribed so that he could play cards immediately. in the hallway between the bathroom and bedroom.
Although he only had a mild interest in playing check- Sometimes, G.W. needed to use the bathroom at night.
ers, he found out that he could slide enlarged checkers Although he was improving in his performance on
with his left hand and was willing to work at this the driving simulator, he was told that he was not yet
activity to improve his left arm and hand function. safe to drive. G.W. was referred to a regional driving
During one session, his son and wife came to discuss center, which evaluates and trains persons with disabili-
his roles at home and on his son’s farm. Both of them ties in safe driving. His wife or son would drive him
suggested that they could get help for the things that until he could drive again.
he could not do. Although G.W. agreed that there A home program was developed with a variety of
were some tasks he could no longer do or did not care tasks and activities that required the use of his left arm
to do, he still wanted to do some gardening and to help and hand. He was now approaching the level of func-
with some things on the farm. He did not want just to tion that made him an appropriate candidate for CIMT.
sit around and watch television. After brainstorming Unfortunately, access to this type of program was not
what roles and tasks might still be possible, the discus- feasible for G.W. because of distance and money. The
sion shifted to adapted strategies and equipment that therapist explained the concept of CIMT and devel-
might be needed to make these tasks possible. oped a modified program that G.W. could do on his
At the end of the first week, he was able to perform own. The modified program was adapted from a small
all ADL task with minimal supervision (i.e., reminders study by Page and colleagues67 and provided some evi-
to use his left hand and to search his left visual space). dence that an outpatient program of CIMT could be
He could now walk 30 feet with his cane and was prac- beneficial. Three outpatient follow-ups were scheduled
ticing going up and down steps in physical therapy. to monitor and upgrade his home program.
 Chapter 4 • Task-Oriented Approach to Stroke Rehabilitation 97

performance: supporting best practice in occupational therapy, Thorofare,

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 jo yce s . s abari

chapter 5

Activity-Based Intervention
in Stroke Rehabilitation

key terms
function declarative learning closed tasks
capacity procedural learning variable motionless tasks
performance implicit learning open tasks
neural plasticity explicit learning mechanical constraints to
learned nonuse generalization/transfer of learning movement
constraint induced movement intrinsic feedback self-monitoring skills
therapy (cimt) extrinsic feedback metacognition
learning knowledge of performance task/activity analysis
training (kp feedback) postural set
practice knowledge of results postural adjustments
kinesiological linkages (kr feedback) dissociation between body
generalized motor programs practice conditions segments
cognitive strategies repetitive practice activity synthesis
strategies for community blocked practice practice challenges
participation contextual interference compensatory adaptations

chapter objectives
After completing this chapter, the reader will be able to accomplish the following:
1. Apply the principles of the International Classification of Function and the Occupational
Therapy Practice Framework to occupational therapy intervention for stroke survivors.
2. Understand implications of neuroscience studies of plasticity and constraint induced
movement therapy to activity based interventions in stroke rehabilitation.
3. Design effective practice opportunities for stroke survivors to recover motor, cognitive,
and participation skills.
4. Understand the basis of interventions designed to enhance stroke survivors’ potential to
achieve maximal recovery.
5. Apply principles of activity analysis and synthesis when designing occupational therapy
intervention for stroke survivors.

100
 Chapter 5 • Activity-Based Intervention in Stroke Rehabilitation 101

With advances in medical intervention and societal of function and includes impairment, activity limitation,
attitudes toward people with disabilities, rehabilitation and/or participation restriction. In its discussion of activity
expectations and outcomes for stroke survivors are and participation, the ICF distinguishes between capacity
continuously improving. In recent years, evidence from (the theoretical potential to perform) and performance in a
the neuroscience and rehabilitation research literature, person’s actual, current context. This distinction is crucial
and shifts in thinking about the definition of health and in occupational therapy with stroke survivors. Demon-
wellness, have provided increasing support for two major strated improvements within a treatment setting are mere
tenets of occupational therapy with stroke survivors: that changes in capacity. Clearly, the goal must be to promote
recovery of function can be enhanced through the generalization of regained skills for improvements in actual
therapeutic use of task-based challenges, and that a return performance.
to a meaningful lifestyle after a stroke is contingent on ICF integrates medical and social models of disability.
complex interactions between multiple factors. While appreciating the medical model’s value in promot-
This chapter presents concepts from the International ing change within an individual, ICF also recognizes that
Classification of Function (ICF),64 the Occupational social and environmental factors influence performance.
Therapy Practice Framework,2 the Occupational Therapy Occupational therapists share this dual orientation in
Practice Guidelines for Adults with Stroke,44 and research stroke rehabilitation. Depending on a person’s current
literature to provide an evidence-based foundation for potential for skill recovery, occupational therapists adapt
the efficacy of activity-based intervention with stroke tasks and environments to promote optimal practice
survivors. In addition, this chapter presents an introduc- conditions for internal change or to facilitate task per-
tion to salient concepts about practice and learning from formance within constraints of insurmountable physical
the motor learning literature. Finally, this chapter applies or cognitive limitations.
the evidence to provide occupational therapists with
guidelines for using activity-based intervention in stroke Occupational Therapy Practice Framework
rehabilitation. The occupational therapy profession applauds both
the vision and semantics of ICF. Accordingly, the Oc-
BACKGROUND CONCEPTS AND EVIDENCE cupational Therapy Practice Framework44 is structured
to synchronize with ICF and thus to highlight that
International Classification of Function long-standing values within our profession are consis-
The ICF reflects a current understanding that health rep- tent with contemporary views about health and quality
resents far more than the absence of disease (Fig. 5-1). of life.
Function, a dynamic interaction between health conditions The Occupational Therapy Practice Framework
and contextual factors, is ICF’s yardstick for measuring suc- provides practitioners with a foundation for designing
cessful rehabilitation outcomes. According to ICF, function and implementing multidimensional services that enable
is the integrated totality of one’s body function, activity, and clients to participate in self-selected life activities within
participation. The term disability is used as the antithesis their homes, families, and communities. The Domain
of Occupational Therapy2 requires therapists to include
the following components in assessment, planning,
treatment, and outcomes:
■ Client factors
Health condition
(disorder or disease) ■ Activity demands
■ Context
■ Performance patterns
■ Performance skills
Body functions and Activities Participation ■ Actual performance of tasks and roles in real-life
structures
situations
Consistent with ICF’s dual orientation to medical and
social concerns, occupational therapy intervention con-
siders two groups of factors: those within the individual
Environmental Personal (client factors, performance patterns, and performance
factors factors skills) and those within the environment (activity demands
and context). Some factors contribute to a particular
Figure 5-1 Interactions between components of International person’s capacity to engage in self-selected occupations;
Classification of Function. (From World Health Organization: others do not. Some factors are amenable to change;
International classification of functioning, disability, and health others are not. A client may wish to change some factors
[ICF], Geneva, Switzerland.) and may have no incentive to change others. For each
102 Stroke Rehabilitation

individual, the skilled occupational therapist determines communication. The American Occupational Therapy
the unique constellation of impact, potential, and desire. Association (AOTA) has published practice guidelines
Intervention promotes change in those internal and related to a variety of client populations and areas of
external factors that the therapist and client have occupational therapy intervention. The Occupational
collaboratively identified as treatment goals (Fig. 5-2). Therapy Practice Guidelines for Adults With Stroke44
Stroke is a complex condition. Depending upon the presents extensive evidence from research literature in the
nature of the cerebrovascular accident (CVA) and immedi- neurosciences and in clinical rehabilitation that provide
ate medical care, residual neuropathology varies widely significant support for the value of introducing individu-
among individuals. Consequently, related impairments and alized task-based challenges to improve motor, cognitive,
potentials for improvement differ significantly. Each person and occupational performance in stroke survivors.
presents with a unique lifetime history of roles, activities,
temporal patterns, and culture. Each person and family has NEUROSCIENCE STUDIES OF BRAIN
unique constraints that govern their willingness to change PLASTICITY
long-standing routines and environments.
Various chapters in this text explore ways occupational It is common knowledge that necrotic tissue in the
therapists intervene, both to promote change within mammalian central nervous system does not regenerate.4
an individual and to adapt external factors to promote This is the greatest challenge in stroke rehabilitation,
compensation. The ultimate goal of both interventions is as compared to rehabilitation for individuals with
participation in valued life activities. A comprehensive injuries to the peripheral nervous system or to the
occupational therapy program for any stroke survivor musculoskeletal system, where we expect ultimate re-
will artfully target both internal and external factors. covery of damaged tissue. Even so, countless stroke
The interaction between internal and external factors is survivors experience significant recovery of motor,
complex indeed. Improvements in motor and cognitive language, and cognitive function.
skills alone, unaccompanied by adaptations to family Early, spontaneous recovery is typically attributed to
structure or physical accessibility, may fail to lead to an resolution of temporary pathophysiology in regions of
outcome of full, meaningful participation. Correspond- the affected hemisphere indirectly damaged by stroke-
ingly, an overreliance on compensation, without provid- related sequelae described in Chapter 1. A stroke is a
ing stroke survivors opportunities to improve internal catastrophic physiological event. In addition to cell death
skills, seriously limits clients from reaching their ultimate in those neurons deprived of oxygen, indirect damage
potentials for engagement in a wide variety of life roles. includes changes in cerebral blood flow, cerebral metabo-
lism, edema, and cascading degeneration along neural
Occupational Therapy Practice Guidelines pathways. The concept of diaschisis, coined by the 19th
for Adults with Stroke century Russian neurologist von Monakow has continued
Practice guidelines are developed by many health pro- to influence neurologists and neuroscientists.9,40,48
fessions to promote the use of evidence-based interven- Diaschisis, or transient inhibition, spreads to remote sites
tions for the goals of improving client care, enhancing in the fiber pathways leading from the site of injury.
consumer satisfaction, and facilitating interdisciplinary As diaschisis resolves over time, neural activities return
to the temporarily suppressed regions, and the stroke
survivor experiences return of function. Diaschisis is
a probable explanation for the shift to spontaneous in-
Activity demands nervation of some flaccid muscles so often seen in the
early weeks after a stroke. The phenomenon of “learned
nonuse”, articulated by Taub and colleagues39,55 repre-
Impact of the person’s Performance sents a person’s inability to functionally use this reemerg-
activity performance patterns ing motor activation. Occupational therapy intervention
Client factors Potential fo change
can prevent or reverse learned nonuse through interven-
Person’s desire Performance
for change skills tions described in Chapter 10.
Neuroscience researchers are actively exploring a
variety of potential recovery mechanisms after central
Context nervous system damage. The possibility of plasticity,
or reorganization of undamaged systems in the brain, has
Figure 5-2 The occupational therapist’s clinical reasoning generated a growing body of positive research findings.
process. In determining treatment goals, the therapist considers These studies of humans and other mammals have
the three factors in the center square for each of the surrounding provided significant evidence that recovery of function
domain areas. after brain lesions is associated with recruitment of brain
 Chapter 5 • Activity-Based Intervention in Stroke Rehabilitation 103

regions not typically activated for a specified function.10 More importantly, they reported significant differences in
These studies consistently find that reorganization of the actual amount of use of the affected upper limb,
neural mechanisms is a dynamic process that is influenced as compared to control subjects. A note of caution about
by the person’s active efforts to meet environmental and the use of CIMT in the early stage of stroke recovery
task demands.26,30 emerges from acute animal studies. Studies with lesioned
Depending on the extent of neuropathology, all stroke rats27,42 have found that forced use with these animals dur-
survivors have varying potentials for spontaneous recovery ing the first seven days after injury leads to degeneration
and reorganization of neural mechanisms. Using principles of surrounding, surviving neural tissue.
presented in this and subsequent chapters, the occupa- Proponents of CIMT have never claimed that their
tional therapist determines: approach reverses paralysis. In addition to intact cognitive
■ Each client’s current potential to relearn motor and function, criteria for participation in constraint programs
cognitive skills include the minimum requirements that participants
■ How to match task-based challenges to each person’s exhibit at least 10-degrees of active extension at the wrist,
current potential metacarpophalangeal, and interphalangeal joints, and
■ How to modify each person’s environment to demonstrate ability to maintain standing balance without
provide the appropriate balance between challenge upper extremity support.62,63 CIMT is clearly an approach
and compensation for a select category of stroke patients; but the principles
have been successfully applied to several other protocols,
CONSTRAINT INDUCED MOVEMENT which are described in Chapter 10.
THERAPY In essence, CIMT “forces” the individual to practice
using a paretic limb, and thus provides the central nervous
Constraint Induced Movement Therapy (CIMT), which system with appropriate challenges for reorganization of
has yielded the strongest outcomes evidence of any motor control. There is another aspect to CIMT never
treatment in the history of stroke rehabilitation,62,63 discussed by its proponents, and that may have signifi-
provides significant support for the therapeutic value of cance for occupational therapy intervention with stroke
activity-based practice for improving motor function in survivors. There is a hypothesized link with Seligman’s
a select group of stroke survivors. CIMT evolved from “theory of learned helplessness.”49 First discovered in
the theory of learned nonuse, which postulates that dogs and later tested in numerous studies of humans,50
potential motor recovery after unilateral brain lesions is this theory postulates that, after repeated exposure to situ-
limited by a learned overreliance on the unaffected ations in which actions are ineffective, organisms become
limbs. Immediately after brain injury, contralateral passive, even when future actions could be effective. After
flaccidity limits functional use of the affected arm and an initial period of flaccidity following a stroke and subse-
leg. Because motor function remains unaffected on quent relearning of one-handed task performance, many
the opposite side, most stroke survivors compensate by stroke survivors remain essentially unaware of a return
relying exclusively on the unaffected limbs to perform of motor potential. Several factors might explain this
tasks. This theory of learned nonuse may explain why phenomenon:
upper limb recovery lags behind lower limb recovery. ■ The person has no reason to try to use the arm
Although each attempt to stand or walk requires bilat- and thus remains ignorant about emerging motor
eral activity in the legs, many upper limb activities potential.
may be accomplished by using the unaffected side ■ The person notices isolated abilities to perform
exclusively. specific movements, but doesn’t know how to
In CIMT, physical constraint to the unaffected upper use these movements for integrated functional
limb is provided in an effort to reverse the effects of performance.
learned nonuse. The typical research protocol has been ■ The person experiences mechanical constraints that
for subjects who are at least one year poststroke to wear a limit the capacity to use the recovering paretic limb
mitt on the unaffected arm to remind them not to use this in a functional way.
limb during virtually all waking hours for two weeks. For those stroke survivors who meet the qualifying
On each of the 10 weekdays, subjects spend six hours in a criteria, CIMT may be an effective way to improve
rehabilitation program in which they are challenged motor performance. For those whose recovery is more
with individualized task challenges that elicit repetitive limited, the concept of learned nonuse may still be help-
practice in using their paretic arm and hand. In controlled ful toward structuring effective therapeutic intervention.
double blind studies at three to nine months62 and two Furthermore, the extensive literature about neuroplastic-
years after intervention,63 subjects who participated in ity and CIMT supports the need for therapists to be
CIMT performed significantly better than control experts about the role of practice and learning when
participants in the speed and quality of their movement. providing evidence-based intervention to stroke clients.
104 Stroke Rehabilitation

PRACTICE AND LEARNING Although these linkages are described in a variety of

ways,5,46,51 motor control theorists and kinesiologists agree
Goals of Training and Learning that they promote optimal mechanical interactions
Learning and training are two distinct phenomena, each between muscles and body segments.
with its own required style of practice. The goal of training Often, stroke survivors have lost the automatic kinesio-
is to memorize a prescribed solution to a selected task chal- logical linkages associated with efficient movement.13,59
lenge, whereas the goal of learning is to develop one’s own This may be a result of limited mobility of body segments,
solution, which can be applied in a variety of situations. weakness of specific muscular components, or loss of the
Based on each client’s abilities and role demands, the occu- motor program that links muscles or joints during a given
pational therapist determines whether the therapeutic goal movement sequence. Several automatic kinematic link-
will be to promote training or learning. In therapeutic train- ages are commonly observed during optimal movement,
ing, practice entails repetitive performance of a designated but are unavailable to many stroke survivors:
sequence of behaviors. Task performance must occur in the ■ Pain-free shoulder abduction through the full range
actual setting in which the individual plans to perform the of motion relies on scapulohumeral rhythm, a kine-
task, because there is no evidence that skills acquired matic linkage between the scapula and humerus41
through training can be successfully applied in different (Fig. 5-3).
environmental contexts.52,57 ■ The deltoid and rotator cuff muscles are kinetically
Learning and training are both internal phenomena linked to ensure that the deltoid fibers produce
that cannot be observed directly. Therapists assume that the desired rotary force on the humerus. Without
training has occurred if performance of a specific task this linkage, an attempt to abduct the shoulder will
improves and persists over time. Therapists assume learn- instead result in a nonfunctional upward shrug of the
ing has occurred when a person is able to apply a new set shoulder41 (Fig. 5-4).
of skills within a variety of situations.46,51 Whenever pos- ■ Glenohumeral external rotation is automatically linked
sible, occupational therapy attempts to promote learning with end-range humeral flexion and abduction.41
of motor and cognitive skills that will provide the indi- ■ Grasp patterns are automatically linked with wrist
vidual with an infinite number of choices for task and role extension to allow for efficient use of extrinsic finger
engagement. Practice for learning requires active engage- muscles.41
ment in tasks that require problem-solving and imple- ■ Lumbopelvic rhythm provides for appropriate in-
mentation of effective foundational strategies. Therefore, teractions between movements at the lumbar spine
before providing practice opportunities to stroke survi- and adjoining pelvis. When rising to stand from a
vors, occupational therapists must first prepare the clients seated position, for example, forward trunk motion
with underlying motor, cognitive, and social foundational is most efficiently initiated at the hips and is accom-
strategies. panied by simultaneous pelvic anterior tilt.41 See
Chapter 14.
Foundational Strategies for Task Performance Kinesiological linkages can be conceptualized as general-
Kinesiological Linkages and Generalized Motor ized motor programs (GMPs).31,33,46 These “prestructured
Programs sets of central commands” govern a particular class of
When the neuromuscular system is functioning optimally, actions. GMPs are designed to be modified in response
a person can rely on automatic kinematic and kinetic link- to continuous changes in environmental and task param-
ages to serve as a foundation for functional movements. eters. Therefore, a unique pattern of activity, with core

Figure 5-3 Kinematic linkage: scapulohumeral rhythm.

 Chapter 5 • Activity-Based Intervention in Stroke Rehabilitation 105

Occupational therapy intervention begins with helping

Rotator cuff
patients develop insight about these deficits through a
muscles program that challenges them to estimate task difficulty,
Deltoid predict outcomes, and evaluate personal performance.20,56
Deltoid
muscle muscle Then the occupational therapist teaches general process-
ing strategies that are practiced in a variety of contexts:
■ Occupational therapists structure treatment to help
A B
clients develop several types of cognitive strategies.
Figure 5-4 Kinetic linkage: relationship between deltoid and ■ Prioritizing information before beginning a task is a
rotator cuff muscles. A, Deltoid muscle force acting alone. strategy that can be applied to activities as varied
B, Deltoid and rotator cuff muscles working together. as grocery shopping (using a list, coupons, and
the weekly circular), doing a work-related task, or
foundational characteristics, emerges whenever the GMP planning a family outing.
is executed. For illustration purposes, a forehand tennis ■ Clustering related information together may be a
swing may be conceptualized as a GMP. Foundational useful strategy for a student attempting to master
kinesiological relationships comprise a GMP, but an a difficult subject or for a person trying to remember
athlete alters the force characteristics, timing, and spatial what to purchase in the pharmacy.
details of the forehand swing, depending upon the speed, ■ Blocking out irrelevant details is a foundational
force, and direction of the tennis ball’s trajectory and the strategy necessary for reading a map and managing
player’s intentions regarding how to return the ball to monthly bills.
the opponent. When designing therapeutic interventions ■ A left-to-right scanning strategy can be used to find
to improve functional motor performance in stroke a certain item in a bathroom cabinet and to check
survivors, therapists determine the GMPs for general typing for errors. Maintaining a daily notebook of
categories of movement, such as reach, grasp, balance, things to do and to remember is a strategy with wide
standing up, and sitting down. An occupational therapist applications in a range of situations.
determines which kinesiological linkages are impaired ■ Additional strategies and their applications are
and intervenes by assisting with reestablishing these discussed in Chapters 17, 18, and 19. Each individual
general foundations for optimal motor performance. tests the strategies introduced by the therapist to
Motion analysis studies of rolling, getting out of bed, determine whether they are effective and in which
standing up from a sitting position, and moving the arms situations they can be successfully applied.
provide useful information that can help an occupational
therapist determine which components are essential in a Strategies for Community Participation
variety of performance contexts.12,51 The social and emotional challenges of coping after a
stroke are as demanding as the motor and cognitive
Cognitive Strategies challenges (see Chapters 2 and 3). Just as therapeutic
Just as kinematic linkages serve as foundational strategies interventions can improve strategies essential for moving
for efficient movement, cognitive processing strategies and for processing information, so too can occupational
provide individuals with a framework for interpreting and therapists help stroke survivors develop a core of effective
acting on complex information in a variety of situations. strategies that will help them negotiate their interactions
These strategies are organized approaches that assist a with others and return to full participation within their
person in selecting relevant cues from the environment communities. Therapists should introduce practice of
and planning the most appropriate response.57,58 these strategies early in the rehabilitation process. This
Depending on the nature and location of the pathol- helps stroke survivors understand that they can realisti-
ogy associated with the CVA, a stroke survivor may cally expect to continue engaging in activities and roles
demonstrate impairments in selecting and implement- that bring quality to their lives, regardless of the amount
ing appropriate cognitive strategies for accomplishing of motor recovery.
complex tasks. If these impairments are severe, they will
limit performance of routine self-care tasks. Minimal to Types of Learning
moderate impairments become more apparent when Procedural and Declarative Learning
the individual attempts to resume more demanding Occupational therapists structure practice opportunities
occupations such as home management, work, or school according to the type of learning goal. Declarative learn-
activities. Toglia and Golisz have been particularly ing is needed for tasks in which language skills are used to
influential in designing evaluation and treatment pro- organize complex sequences of action.4 Learning a new
tocols to guide occupational therapists in this aspect of recipe or a multistep dance routine may require that
intervention.19,56,57 a person be able to consciously express the processes to be
106 Stroke Rehabilitation

performed. Mental rehearsal is an effective technique for survivors with structured practice opportunities to
enhancing declarative learning. During mental rehearsal, maximize emerging skills. This is not nearly as simple as
the individual practices the sequence by reviewing it it sounds. When people practice maladaptive strategies,
silently or by verbalizing the steps in their appropriate they “learn” patterns of behavior that may be counter-
order. Most skill development in stroke rehabilitation, productive to future improvements in functional per-
however, can be characterized as procedural learning, formance. To provide appropriate practice opportunities,
which is achieved through task practice in a series of therapists must be able to clearly envision the intended
varying contexts. For example, a person learns to maneu- practice outcomes and to skillfully manipulate a variety of
ver a wheelchair through a process of procedural learning. factors within each practice session. These factors in-
Skill develops through opportunities to experiment with clude instructions, feedback, activity parameters, salient
different combinations of arm or arm and leg movements conditions within the practice environment, and practice
to achieve propulsion in a variety of directions and speeds. schedules. Furthermore, therapists must recognize the
Similarly, activities requiring balance or reach and grasp importance of practice during daily activities outside of
require procedural learning. Chapters 8 and 10 present therapy sessions and structure feasible independent prac-
therapeutic interventions for promoting development of tice opportunities for patients. Subsequent chapters will
these procedural skills. emphasize ways occupational therapists structure these
factors and their interactions so that stroke survivors can
Implicit and Explicit Learning Processes engage in practice that yields desired learning for func-
Gentile16 and others6 propose that individuals use two tional outcomes.
distinct but interdependent processes during the acquisi-
tion of functional motor skills. An explicit learning pro- Promoting Generalization of Learning
cess, which is consciously driven, guides the kinematics of Three stages of learning are important in the occupational
the movement. Gentile hypothesizes that people use an therapy process46:
explicit process to develop a “ballpark” match between the 1. The acquisition phase occurs during initial instruction
shape or direction of their movements and the environ- and practice of a skill (e.g., the initial treatment
mental requirements for achieving the goal. External sessions in which a person learns to use the left arm
guidance and feedback is likely to have a beneficial impact for functional reach).
upon the explicit learning process. Schmidt46 refers to 2. The retention phase occurs after the initial practice
such intervention as an “instructional set,” in which the period as individuals are asked to demonstrate how
person is given a general idea or image of the task to be well they perform the newly acquired skill; therapists
learned. often refer to this as carryover (e.g., a patient’s ability
An implicit learning process guides the kinetics of the to perform previously learned reaching activities).
movement or the dynamics of force generation. This aspect 3. In the transfer phase the individual must use the skill
of movement requires appropriate selection of muscle in a new context (e.g., the patient’s ability to incorpo-
contraction patterns, which is determined by accurate rate a reaching strategy when getting dressed or
predictions of how external forces will affect the move- preparing a meal). The stroke survivor can generalize
ment. Implicit learning requires a self-organizing process the strategies learned in the therapy setting and use
and may take longer to develop than explicit learning. them in real-life situations.
Furthermore, implicit learning lies beyond conscious Literature about skill acquisition presents several con-
awareness and is unlikely to be augmented by external cepts helpful in guiding therapeutic intervention that
guidance or feedback.11,38 Historically, neurorehabilitation promotes generalization of learning. These concepts can
interventions that attempted to directly influence implicit be categorized into three major groups: type of feedback,
aspects of motor performance, such as muscle recruitment development of underlying strategies, and practice con-
or force modulation, have failed to achieve functional out- ditions (Fig. 5-5).
comes. Following evidence from motor learning research,
therapists should attempt to influence implicit learning by Type of Feedback
providing appropriate opportunities for effective practice. Feedback, or information about a response, can be intrinsic
or extrinsic, concurrent or terminal, and can provide
Amount of Practice knowledge of performance (KP) or knowledge of results
Practice is a critical component to learning. Educators, (KR). Intrinsic feedback is a result of an individual’s
therapists, and neuroscientists universally agree that the own proprioceptive, tactile, vestibular, visual, and auditory
amount of practice affects success in skill development.46,60 sensory systems. Often after a stroke, somatosensory
Effective protocols in stroke rehabilitation15,34,35,62,63 all function is impaired, which limits the effectiveness of
share the common characteristic of maximizing the intrinsic feedback about motor performance. Extrinsic
amount of practice. Occupational therapy provides stroke feedback from a therapist or feedback technology can
 Chapter 5 • Activity-Based Intervention in Stroke Rehabilitation 107

Knowledge of Results. KR is feedback about the

FEEDBACK/
STRATEGY
PRACTICE outcome of an action in terms of accomplishing a goal.
INSTRUCTIONS CONDITIONS This information can serve as a basis for correcting
• Variable errors for more effective performance on future trials.
• Capacity to generate
intrinsic feedback
• Random Results of laboratory research with healthy subjects
A foundational set • High contextual indicates that frequent, accurate, immediate KR tends to
• Low extrinsic KR
of guidelines that interference
feedback
guide action in a • Match with task promote improved performance during the acquisition
• Ballpark instructions
about desired
variety of situations category of the phase but poorer performance during the retention
functional goal and transfer stages of learning.45,61 Similarly, bandwidth
kinematics
• Naturalistic setting
• Instructions to focus
• Self-selected KR, in which feedback is provided only when the per-
on activity demands
practice challenges formance response is outside a given range of acceptable
performance, also leads to better generalization of learn-
ing.61 Schmidt46 provides the following theoretical
GENERALIZATION OF LEARNING explanation of these findings. When limited KR is
provided during acquisition, individuals must rely on
Figure 5-5 Factors that contribute to generalization of relevant cues provided by intrinsic mechanisms to im-
learning. KR, Knowledge of results. prove their performance on future trials, and they tend
to develop less dependency on extrinsic feedback. Based
on these findings, it is wise for therapists to limit the
provide useful supplementary information to facilitate early immediacy and frequency of KR feedback during stroke
awareness and learning. However, extrinsic feedback must rehabilitation. Furthermore, therapists are advised to
be gradually decreased for generalization to occur.46 require that patients determine how effectively they
Concurrent feedback is provided during task per- performed therapeutic tasks. To generalize their knowl-
formance. It includes intrinsic somatosensory feedback edge for use in situations outside the treatment context,
and ongoing verbal or manual guidance by a therapist. stroke survivors need to learn ways to assess their own
Terminal, or summary, feedback is given after task com- performance of functional activities.
pletion.47 There are no published studies that compare
the effectiveness of concurrent and terminal feedback, but Strategy Development
research has established that excessive external concurrent Strategies are organized plans or sets of rules that guide
feedback is clearly distracting to the learner.47 action in a variety of situations. New knowledge is more
likely to be generalized for use after the acquisition phase
Knowledge of Performance. KP feedback is informa- if the individual learns a foundational strategy that can be
tion about the processes used during task performance, applied to performance of multiple tasks.52
such as the way a person moves the pelvis or scapula or Therapeutic approaches that advocate the importance
whether an appropriate cognitive or social strategy has of strategy formulation during task performance13,57 seek
been implemented. Individuals with intact proprioceptive to develop selected motor or cognitive linkages through
systems receive concurrent, intrinsic KP feedback as they engagement in a series of tasks that, at a superficial level,
move. Stroke survivors, however, may no longer have ac- may seem unrelated. Each task, however, requires use of
cess to this continuous supply of information. Extrinsic the selected strategy. To ensure generalization of the
KP can be provided before a task is initiated. For example, strategy, the selected underlying skill is practiced repeat-
a therapist can guide a person into assuming a postural set edly in a variety of contexts during a treatment session.
that will facilitate motor performance or in planning a For example, the therapeutic goal may be to develop a
strategy that will enhance performance of a cognitively selected lumbopelvic linkage as a GMP for forward reach
demanding task. Research literature examining persons in sitting and standing up from a seated position. The ses-
without neurological impairments53,66 and stroke survi- sion may begin with the therapist moving the patient’s
vors14 indicates that a focus on internal performance fac- pelvis so that the person understands the kinematic model
tors may be counterproductive to learning. Instructing of action. The therapist may then ask the patient to sit on
the learner to focus on relevant information in the envi- a therapy ball, which is rocked forward and backward
ronment (such as the distance or shape of a goal object) using anterior and posterior pelvic movement. After this,
seems to be more effective than directing the learner’s at- the seemingly unrelated task of reaching for objects from
tention internally toward the key elements of a particular the seated position will emphasize that the patient anteri-
movement pattern or sequence.14 The skillful therapist orly tilt the pelvis by directing attention to “keeping your
must structure selected parameters within the practice back straight” and “bringing your nose over your toes.”
tasks to “press” the individual toward using an intended Finally, the patient will practice standing up and sitting
movement pattern. down on a variety of surfaces, with an emphasis one the
108 Stroke Rehabilitation

same lumbopelvic interactions previously practiced in in the future. The therapist’s major roles are to structure
different contexts. Research findings from studies with the activity progression and guide patients in developing
healthy participants provide support for the use of this insights and strategies. See Chapter 19.
approach for learning the invariant structure of a GMP.18,33
In the terminology of motor learning science, these Practice Conditions
studies found that a constant or blocked practice schedule Several aspects of practice conditions have been studied
of the underlying GMP, using varied practice parameters, under both laboratory and clinical conditions. Occupa-
leads to enhanced transfer benefits. tional therapists can use these findings to structure
Carr and Shepherd’s program for optimizing motor practice conditions in stroke rehabilitation programs.
function after stroke12,13 uses five major techniques to The key is to structure conditions during the acquisition
assist patients with developing motor strategies: (1) verbal phase that will produce optimal retention and transfer of
instruction, (2) visual demonstration, (3) manual guid- the learned skills.
ance, (4) accurate and timely feedback, and (5) consistency
of practice. In addition, patients develop skill in providing Practice Schedules. During blocked (or repetitive)
themselves with intrinsic feedback about the kinematics practice, patients practice one task until they master it.
of their motor performance. Outcome studies39 of indi- This is followed by practice of a second task until it is also
viduals recovering from stroke provide support for this mastered. Random (or variable) practice requires patients
program’s efficacy.12,13 to attempt multiple tasks or variations of a task before
Toglia56,57 and Golisz19 developed a systematic ap- they have mastered any one of the tasks. In addition, the
proach to promote generalization of cognitive strategies, various trials are performed in a random order. Subjects
in which the therapist grades treatment by changing cer- who participate in variable practice perform better on
tain characteristics of a task but leaving the underlying transfer tests than subjects who participate in repetitive
strategy the same. The following example illustrates a practice.21 A study of stroke outpatients found that
treatment sequence designed to facilitate learning and random practice was more effective than blocked practice
generalization of a strategy for categorizing information: for long-term retention of improvements in reach and
The initial task is the first activity performed by the manipulation skills.22 An explanation is that variable
patient, such as sorting a deck of playing cards into a red practice facilitates generalization by preventing individu-
group (hearts and diamonds) and a black group (spades als from developing context-dependent inflexibility when
and clubs). Near transfer is an alternate form of the initial using a newly learned skill.
task. Using the previous example, the person might be
instructed to sort the playing cards into four groups Contextual Interference. Contextual interference
according to their suits or two groups of odd and even refers to factors in the learning environment that increase
numbers. the difficulty of initial learning.7 Research studies con-
Intermediate transfer has a moderate number of sistently find that higher levels of contextual interference
changes in task parameters but still has some similarities promote retention and generalization (transfer) of newly
to the initial task. For example, the same person may learned skills.8,29,54 These findings are typically explained
be asked to create three categories for sorting a stack of with the hypothesis that initial obstacles to skill acquisition
photographs for eventual placement in a photo album. prevent individuals from developing context-dependent
Far transfer introduces an activity conceptually the same inflexibility when using the learned skill in new situations.7
as but physically different from the initial task. Now the Another explanation is that high contextual interference
person may be asked to organize a collection of magazines forces a person to use greater versatility in learning strate-
into groups based on general interest areas (e.g., news, gies in order to overcome the difficulty of initial practice
sports, fashion) for display in a clinic waiting room. during the acquisitional learning phase.28 Limited KR
Very far transfer requires spontaneous use of the new feedback is one example of contextual interference that has
strategy in daily functional activities. Before traveling to a already been discussed. Blocked and random practice
neighborhood mall, the person may be asked to catego- schedules, described previously, are examples of low and
rize items on a shopping list based on the type of store in high contextual interference, respectively. Although
which they can most likely be purchased. blocked practice may lead to quicker skill acquisition,
This “multicontext approach” emphasizes the use of random practice results in greater retention and general-
self-assessment and intrinsic KP feedback. Before at- ization.46
tempting a new task, patients estimate their performance
accuracy and efficiency and determine similarities and Whole versus Part Practice. Therapists may intui-
differences between the current task and previous activi- tively believe that it will be easier for a client to learn small
ties. After completing a task, patients evaluate their segments of a task than the task in its entirety. However,
performance and identify techniques that may be helpful breaking a task into its component parts for teaching
 Chapter 5 • Activity-Based Intervention in Stroke Rehabilitation 109

purposes is useful only if the task can be naturally divided consistent over time. Brushing teeth or getting into and
into units that reflect the inherent goals of the task.37 out of a bathtub are examples of closed tasks that may
One reason for this is that continuous skills (or whole-task be goals for stroke survivors. The best strategy for devel-
performance) are easier to remember than discrete oping skill in a specific closed task is to develop a narrow
responses. For example, once people have learned to ride a and consistent method of performance through repetitive
bicycle or play tennis, they will retain these motor skills practice of the task.
even without practicing them for many years. On the other Variable motionless tasks also involve interacting
hand, segmented, laboratory-type motor skills may be with a stable and predictable environment, but specific
acquired easily but are less likely to be retained over time. features of the environment are likely to vary between
Therefore, therapists are advised to teach tasks in their performance trials. Drinking is an example of a variable
entirety rather than in artificial segments. For example, motionless task because the type of mug, glass, or cup
for best retention and generalization, the task of putting on used, and the amount the container is filled will vary in
a shirt is best taught all at once rather than in different different situations. Dressing is another example because
portions during consecutive therapy sessions. If it is people’s wardrobes consist of clothing of varying fabrics,
difficult for a stroke survivor to master all the steps simul- dimensions, and styles. To achieve independence in a
taneously, the therapist can cue the patient or can provide variable motionless task, a patient must learn more than
manual guidance for selected aspects of the task (as is used one method of performance. The therapist must provide
in backward chaining instruction). The patient will become individuals with opportunities to solve the activity’s motor
accustomed to completing the task during each trial. problems in a wide variety of contexts.
The therapist’s assistance can be gradually decreased as In consistent motion tasks, an individual must deal with
practice sessions continue. environmental conditions in motion during an activity
performance; the motion is consistent and predictable
Practice in Natural Settings. Transferring skills between trials. Stepping on to or off of an escalator
learned during training to real-life situations is signifi- or moving through a revolving door are examples of con-
cantly influenced by the degree of similarity between the sistent motion tasks. Patients need practice that will enable
practice environment and the actual environment.36 Wu them to accurately match the timing of their actions to
and colleagues65 provided specific support for the value of the predictable changes of the moving objects in the
using real task performance during therapy sessions to environment.
improve motor control in stroke survivors. Their motion Open tasks require people to make adaptive decisions
analysis studies of persons with and without stroke about unpredictable events because objects within
compared the kinematic parameters of reach patterns the environment are in random motion during task
when participants reached forward to perform a func- performance. These activities require appropriately
tional task and when they reached forward with no timed movements and spatial anticipation of where the
functional goal. Participants in both the neurologically relevant objects will be moving. For example, a passen-
intact and poststroke groups performed better when real ger who is sitting in a moving train must maintain
objects were available to shape the reach performance. balance when the supporting surface is moving unpre-
Skills for performing tasks such as dressing or bathing dictably. When crossing a street, a person must antici-
are best generalized when the skills have been acquired in pate the speed and rhythm of both pedestrians and
a setting that resembles the environment in which the oncoming traffic. When playing most ball games,
activity will ultimately be performed. Occupational ther- people must predict the speed and direction of the ball
apy clinics with simulated home and community environ- to position themselves in the right place at the right
ments will promote better generalization of performance time. Research has shown that the skills required
area skills than clinics in which practice of daily tasks is for successful open-task performance cannot be learned
contrived. However, many stroke survivors can never through repetitive practice in a stationary environ-
generalize what they learn in simulated settings; in these ment.24,25 Natural practice in an unpredictable environ-
cases, home-based occupational therapy is required. ment seems to be the best strategy for developing skill
in open-task performance.
Different Practice Conditions for Different Task
Categories. Gentile16 postulated that motor activities Applying Background Concepts to Using
can be classified into four general categories based on Activity-Based Intervention in Occupational
environmental pacing conditions and variability between Therapy with Stroke Clients
successive trials. Practice conditions for learning will vary Prerequisites to Engaging in Activity-Based Practice
depending on the task category. Depending on the extent of the neuropathology, each
Closed tasks are activities in which the environment is stroke survivor has a hypothetical, unknown potential
stable and predictable and methods of performance are for recovery of function. Although practice is crucial, a
110 Stroke Rehabilitation

variety of factors may impede a person’s capacity to standing positions. The strategy of fixating the pelvis on
benefit from practice opportunities: the lumbar spine or the scapula on the thorax may have
■ Mechanical constraints to movement the short-term benefit of enhancing a person’s sense of
■ Inadequate self-monitoring skills postural security. A negative consequence is that these
■ Inadequate task analysis and problem-solving skills habitual postures lead to difficulty dissociating the pelvis
■ Low expectations for goal achievement and scapula from adjacent proximal structures. This lack
A skilled therapist prepares each patient to engage in activ- of sufficient limb girdle mobility subsequently interferes
ity-based practice by directing interventions toward maxi- with the kinematics of upper and lower extremity move-
mizing each factor described in the following sections. ment. Current therapeutic approaches advocate the early
introduction of techniques to enhance balance and pos-
Freedom from Mechanical Constraints to Movement tural control.13,51 In addition to the inherent advantages of
Stroke survivors encounter several mechanical constraints postural security, early recovery of appropriate balance
that limit their ability to move and force them to develop strategies may prevent postural habits that can compro-
alternative movement strategies. Selected muscle weak- mise a stroke survivor’s future potential to use reemerging
ness and loss of automatic control over complex postural muscle function for functional arm and leg movement.
adjustments are primary impairments, directly related to See Chapters 7, 8, and 14.
the stroke pathology. Other mechanical constraints, such Other secondary impairments, such as edema and
as soft-tissue contracture and changes in joint alignment, pain, seriously limit a person’s potential for movement or
are secondary to changes in posture and loss of mobility functional activity engagement. Therapists are responsi-
associated with stroke.12,13,43 As secondary impairments, ble for preventing and minimizing mechanical constraints
these losses are preventable and reversible with timely to movement before introducing practice opportunities
interventions. for improving motor control. See Chapter 12.
Muscles lose their natural distensibility when they
cease to be passively lengthened by antagonist muscles Foundational Strategies
or an external force. This loss of passive muscle length As previously discussed, developing foundational strate-
may lead to malalignments in posture that contribute gies is valuable as an intervention approach designed to
to a continuing spiral of increasing and additional abnor- maximize generalization of learned skills. GMPs are
malities in soft-tissue flexibility. Without active or critical for a variety of motor actions. In addition,
passive movement, the person is at risk of developing foundational strategies for classes of cognitive and
fixed limitations of joint motion and alignment.12,13,43 social skills enable stroke survivors to meet current and
These problems can be prevented by establishing appro- unanticipated, future activity demands. Explicit learn-
priate postural alignment while lying down, sitting, and ing, combined with structured demands to enhance
standing. In addition, shortly after a stroke, individuals self-monitoring of salient features in a desired strategy,
are instructed to follow daily routines to maintain establishes an underlying framework for a foundational
optimal muscle length through the practice of a variety strategy. Implicit learning, through participation in
of motor tasks. These interventions are discussed in selected, graded task challenges, promotes development
Chapters 7, 10, 14, and 26. of higher order skills associated with the strategy.
Fluid, efficient movement requires a mechanical capac- Practice opportunities for implementing a strategy
ity for dissociation between body segments. Although under varying parameters promotes flexibility in modi-
body segments may be kinematically linked during certain fying the strategy to accommodate to ever changing
actions, each segment must also be free to move indepen- environmental demands.
dently of its adjacent structures. Scapular-humeral rhythm
requires full dissociation between the scapula and thorax. Self-Monitoring Skills
Coordinated shoulder movements require that the Stroke survivors face the challenge of resuming their
humerus freely move independently of the scapula. A full lives in a body quite different from the one they inhab-
repertoire of trunk activity requires mobility between the ited before; sensory information may be difficult to
thoracic and lumbar spine and between the pelvis and interpret, muscles may no longer work in effortless
lumbar spine. Stroke survivors often experience loss of synchrony, and postural preparation for movement may
dissociation between adjacent body segments. This may no longer be automatic.
occur simply because of losses in soft-tissue distensibility, Before stroke survivors can begin to learn effective
or it may be linked to maladaptive motor strategies people strategies for movement and task performance, they need
develop in a subconscious effort to solve other problems. to become acutely aware of the way their bodies work,
For example, individuals with postural adjustment deficits which movements are possible at different body segments,
resulting from stroke often feel insecure about their when their postures are optimally aligned, and when they
ability to maintain balance, even in routine sitting or are efficiently “set” to perform particular activities. These
 Chapter 5 • Activity-Based Intervention in Stroke Rehabilitation 111

understandings are critical for redeveloping appropriate presents. Only then can effective strategies be chosen to
kinesiological linkages that will serve as motor founda- “solve the problems”44 inherent in the infinite variety of
tions for task performance. tasks encountered while actively engaging in meaningful
Metacognition1 is the knowledge and regulation of life roles.
personal cognitive processes and capacities. It includes While reading subsequent chapters in this text, it
an awareness of personal strengths and limitations and should be remembered that occupational therapists strive
the ability to evaluate task difficulty, plan ahead, choose to develop patients’ insight and problem-solving skills,
appropriate strategies, and shift strategies in response regardless of whether the intervention relates to balance,
to environmental cues. The multicontext approach to gross motor function, limb movement, visual skills,
cognitive perceptual impairment emphasizes developing neurobehavioral performance, or daily living tasks.
insight about personal deficits (and strengths) as a
first step toward developing strategies for functional Expectation for Goal Achievement
performance after brain injury. See Chapter 19. Stroke is a catastrophic event, often leading to depres-
Understanding the concept of metacognition is impor- sion and despair. Suddenly, a person finds himself in an
tant for understanding movement as well. Before individu- unfamiliar body. His arms and legs no longer respond to
als can generalize the way to use scapulohumeral rhythm in willed commands. Small movements pose a threat to
tasks requiring functional reach, they must first understand balance. Simple tasks are impossible to perform.
the amount of mobility their unaffected scapula has. Then Studies of recovery after brain damage consistently
they must acknowledge when their affected scapula is not show that a drive to perform functional tasks serves as the
moving freely so that they can develop internal feedback challenge that may be crucial for cortical remodeling.
mechanisms that will enable them to correct their scapula Most stroke survivors want desperately to move, but in
movements when those movements are insufficient for the first few weeks after the CVA, their flaccid muscles
accomplishing a given task. The ultimate goal is to use this prohibit them from acting on this desire. By the time
personal knowledge of movement to change the founda- diaschisis begins to subside, many of them have learned
tional strategy used for reaching tasks in a variety of not to expect anything of their paretic limbs. They settle
contexts. “The individual’s degree of effectiveness in the for letting others help them perform daily tasks, or they
learning process (and thus in problem solving in general) settle for accomplishing activities without the contribu-
will be limited by his or her ability for critical self-analysis tions of their paretic arm or leg.
and environmental analysis in light of the problems en- Occupational therapists play a critical role in empow-
countered and by his or her ability to generate and control ering stroke survivors to be active agents in their recovery
the solutions to these problems.”25 and to return to valued activity engagement. Without
Finally, stroke survivors must know how to monitor making false promises, the therapists can challenge their
their own recovery of motor function. As illustrated in patients to be vigilant for incremental returns in function.
the theory of learned nonuse, many individuals fail to Without implying that full motor recovery is essential to
use the hemiparetic arms, even when muscle activity is a meaningful life style, they can encourage their patients
available. Therapists can teach patients how to actively to look for ways to use small improvements in functional
check for changes in ability to recruit specific muscles. ways. Without blaming future limitations in recovery on
Therapy sessions must be viewed as opportunities the stroke survivor, therapists can teach the patients ways
for stroke survivors to share their new discoveries with to prevent secondary impairments, and to thus maximize
their therapists. In turn, the occupational therapist their own potentials for recovery, whatever that potential
structures activities for the patient to practice emerging might be.
skills, both during the therapy session and as “home- It is a serious error to present occupational therapy
work” challenges. as “therapy for your arm.” Statistically, far fewer stroke
survivors experience significant motor recovery in
Task Analysis and Problem-Solving Skills arm use, as compared to lower limb function.23,32 When
Occupational therapists have always recognized that they occupational therapy’s focus is on the broader goals
need to be skillful at analyzing tasks. Task analysis enables of returning to independent, safe performance of valued
an occupational therapist to establish treatment goals, activities, patients can take pride in their reemerging
synthesize treatment activities, and develop compensatory abilities in a variety of physical, cognitive, and social
strategies.2 Rehabilitation professionals realize more domains. Those fortunate enough to detect emerging
often that clients must also learn to analyze activities. innervation to muscles of the arm and hand should
Without this skill, the clients would be perpetually depen- be challenged to translate this motor recovery into
dent on their therapists for successful task achievement. functional performance. Those who do not enjoy such
A stroke survivor must learn to determine which motor, motor return must be presented with other goals toward
cognitive-perceptual, and psychological challenges a task which they will direct their serious efforts.
112 Stroke Rehabilitation

STRUCTURING ACTIVITY DEMANDS set themselves in several ways. Both feet must be posi-
TO PROVIDE EFFECTIVE PRACTICE tioned on the floor in an appropriate base of support;
OPPORTUNITIES perpendicular angles are established at the ankle, knee, and
hip joints; and the pelvis is tilted anteriorly to free the
Activity-based intervention is a foundation of occupational lumbar spine for forward movement.13,51
therapy in stroke rehabilitation. During the evaluation When standing, people automatically change the
process, an occupational therapist determines: configuration of their bases of support in anticipation of
■ Which activities are important to the stroke survivor the direction toward which they expect to shift their body
as determined by the individual’s roles, interests, and weight. If they plan to shift forward, as is done when reach-
anticipated environment ing ahead, they will establish an anterior-posterior base
■ Which activities the stroke survivor can or cannot of support. If they plan to shift to the left or right, as is done
perform when stepping laterally to position their bodies in front
■ Which internal and external factors impede the sur- of a bathtub, they will establish a medial-lateral base of
vivor’s ability to complete the identified activities support. Persons with hemiplegia often assume postural
During treatment, occupational therapists use activities in support bases inappropriate for the upcoming activity.
two major ways. The occupational therapist facilitates future task perfor-
1. Some activities may be designed to provide structured mance by determining and then instructing the individual
challenges to improve internal skills. For example, an in choosing appropriate postural sets for specific activities.
occupational therapist may engage a stroke survivor For example, assuming the most efficient postural set
in a modified card game. Depending on the skill- for standing in front of a toilet can determine whether a
related goals for this individual, the occupational man will be able to safely urinate independently.
therapist may structure the activity so that it requires Just as appropriate postural sets are important pre-
forward reach with a hemiparetic arm. Alternatively, cursors to efficient motor performance, preplanning is
the card game may require the person to place the also instrumental in determining the success of cogni-
cards along a wide horizontal surface while standing. tively or visually challenging tasks. Activity analysis in-
This modification in activity parameters provides cludes a determination of preliminary cognitive strate-
opportunities for learning balance strategies while gies that will facilitate task performance. For example, a
shifting the center of gravity in a lateral direction. person with right hemisphere dysfunction may experi-
2. Other activities are designed to provide practice of ence difficulty in spatially orienting a blouse or slacks
actual task performance in real-life situations. Exam- for independent dressing. The individual may be un-
ples include direct practice in performing a morning aware that, prior to the stroke, he used a quick and au-
self-care routine or getting into and out of an automo- tomatic process to visualize and orient the garments in
bile. Practice of individualized roles in real-life situa- relation to the body segments. The occupational thera-
tions is critical, but typically unfeasible during therapy pist’s skill in activity analysis enables this person to de-
sessions. Therefore, therapists need to structure home- velop a “set up” strategy, such as lining up each garment
work assignments for stroke survivors to practice at before attempting to complete the additional steps of
home and to discuss at the next therapy session. dressing.
Task Analysis Analyzing Activity Requirements for Weight Shift
An occupational therapist assesses tasks of daily living in and Balance
the environmental context in which the individual plans Postural adjustments that serve as balance mechanisms
to perform each task. The therapist determines which during weight shift are often impaired after stroke.13,43,51
skills are necessary for task performance and compares Understanding a task’s inherent balance challenges is
this analysis to the functional strengths and limitations critical for developing treatment goals and compensatory
exhibited by an individual stroke survivor. This task strategies. Success in shifting weight during activity per-
analysis enables the occupational therapist to plan an in- formance can be facilitated greatly through appropriate
dividualized treatment program that will improve relevant postural sets. The importance of this class of prerequisite
performance skills and enable the person to use compen- skills is important when bathing. If patients use a tub
satory strategies to overcome those limitations that show bench, they will need to posturally set themselves for a
weak potential for significant improvement. posterior weight shift from stand to sit onto the bench.
Once sitting, they will need to rotate their pelvis and
Analyzing an Activity’s Requirements for Postural Set bring both legs into the tub. The next step will be to shift
The occupational therapist determines the optimal “pos- their weight laterally, while sitting, to position themselves
tural set” for performing a selected motor task. To perform on the tub bench. A forward weight shift will often be
the simple act of standing up, individuals must posturally required to adjust the water, and significant challenges to
 Chapter 5 • Activity-Based Intervention in Stroke Rehabilitation 113

a lateral weight shift when sitting may be presented when for each individual stroke survivor. See Chapters 15, 27,
patients must wash their genitals. If patients step into the and 28.
bathtub and stand under a shower, they must posturally
set themselves for a lateral weight shift for entrance and Using Activity to Assess a Client’s Skills
exit to and from the tub or shower. Reaching up and down Activity analysis enables occupational therapists to eval-
from the standing position will be a critical performance uate skill levels through observation of patients as they
component for safe, independent completion of this activ- participate in selected tasks. The Árnadóttir OT-ADL
ity. These performance component skills may be practiced Neurobehavioral Evaluation (A-ONE)3 provides a sys-
often in other contexts, such as in activities that require tematic framework for assessing cognitive and percep-
similar balance adjustments while sitting and standing. tual function through structured observations of activi-
However, they must ultimately be practiced in the context ties of daily living performance. This tool is discussed
in which the actual bathing activity will take place. further in Chapter 18.
Carr and Shepherd’s program for optimizing motor
Analyzing Activity Requirements function after stroke12,13 describes a therapeutic strategy
for Dissociation between Body Segments for evaluating motor skills in the context of task per-
Difficulty with dissociation between body segments is formance. The therapist analyzes a patient’s performance
commonly associated with stroke.13,43,51 The occupational of a specific task and compares it with the optimal
therapist assesses the type and magnitude of such kinesiology associated with that task. A major focus of
dissociations in each analyzed performance area task. For this analysis is to identify those factors that serve as
example, to put on shoes and socks, patients must be able obstacles (or blocks) to moving in efficient kinesiological
to dissociate their pelvis from the lumbar spine to anteri- patterns. When some patients with hemiparesis try to
orly and posteriorly tilt the pelvis to cross one leg over reach forward to grasp for a cup, they tend to use the
the other. They will also need to dissociate their lumbar entire shoulder girdle as one tightly bound unit instead
from their thoracic spine to achieve the trunk rotation of disassociating the scapula from the thorax or the
required to reach their left hand to their right foot. If humerus from the scapula.
they use their paretic arm to assist with the task, disas- Intervention strategies are directly determined from
sociation between the scapula and thorax will be task analysis. In the previous example, the therapist would
required, as will disassociation between the humerus and provide passive mobilization to reduce mechanical
scapula. Determination of these requirements through constraints and to enhance the patient’s internal awareness
activity analysis guides treatment and helps the stroke of available scapular motion. The patient would then
survivor understand the therapist’s rationale for choice of practice reaching forward in a variety of contexts while the
treatment methods. therapist provides manual guidance and structures place-
ment of goal objects to maximize appropriate kinematic
Other Aspects of Task Analysis linkages. Strong backgrounds in kinesiology and move-
Various tasks require different levels of motor planning ment analysis are helpful to the therapist when implement-
and motor sequencing. For patients with impairments in ing a motor relearning approach.
these areas, the therapist will determine the nature of
each of their challenges within specific performance area Helping Patients Develop Their Own Skills in Activity
activities. Finally, when stroke survivors demonstrate Analysis
impairments in visuospatial or cognitive skills, the An ultimate goal in stroke rehabilitation is for individuals
occupational therapist will carefully analyze each task’s to learn the strategy of analyzing activities in reference to
unique challenges and assist individuals in developing their own functional strengths and impairments. During
strategies to meet these specific performance component the occupational therapy process, therapists share their
requirements. strategies for activity analysis and challenge patients to
Activity analysis also enables the occupational therapist develop their own skills in this area. Midway through the
to determine strategies for task performance that will treatment process, therapists present new tasks and require
promote efficient movement patterns and be least likely to the stroke survivors to analyze each task’s inherent perfor-
contribute to the development of secondary impairments. mance requirements. In addition, occupational therapists
Strategies for relaxing excessive skeletal muscle activity and encourage individuals to develop their own alternative
preventing abnormal postures are described in Chapters 10 strategies for task performance. The therapist’s major role
and 13. The occupational therapist instructs the stroke at this stage is to provide feedback about the safety and
survivor to incorporate these strategies into the routine efficacy of the person’s ideas. Before treatment is termi-
performance of daily activities. In addition, activity analysis nated, stroke survivors should develop skill in activity
assists the therapist in determining which compensatory analysis so that they have the confidence and capability to
strategies or adaptive equipment will be most effective attempt an infinite variety of new tasks and roles.
114 Stroke Rehabilitation

provide to promote internal change within stroke

Activity Selection and Synthesis survivors? What interventions do occupational therapists
Occupational therapists select activities and modify task provide to change factors in a stroke survivor’s external
demands: environment?
■ To structure specific practice components within an 2. How do “patterns of use” influence central nervous
activity, with the goal of improving internal skills system reorganization after injury? What are implica-
■ To adapt tasks so they will be easier or safer to tions to occupational therapy intervention with stroke
perform, according to each individual’s demonstrated survivors?
internal capacities, limitations, and interests 3. Which stroke survivors are candidates for CIMT?
The following game of dominoes is an example of modi- How can the theory of learned nonuse influence
fying activity parameters to elicit specific demands for occupational therapy intervention for other stroke
motor practice. With full knowledge by the patient that survivors?
the primary purpose of engaging in this game is to prac- 4. From your knowledge of kinesiology, give specific
tice skills of forward reach and lateral pinch, the therapist examples of kinematic or kinetic linkages during
modifies the height and distance of the table surface to normal movement.
provide sufficient, but not excessive, challenges to the 5. Give two examples of strategies for community
GMP for forward reach. The therapist purposely places participation that will be valuable for stroke survivors
the dominoes on their sides, rather than flat, to encourage to develop.
external rotation at the glenohumeral joint and supination 6. What aspects of motor skills are learned through
at the forearm. The therapist also considers the interac- implicit learning processes? What occupational
tion between the person’s balance adjustments and ability therapy interventions are most effective in facilitating
to control increasing numbers of degrees of freedom in implicit learning?
movements of the hemiparetic arm. Based on prior and 7. What is contextual interference and how does it affect
ongoing assessment, the therapist determines whether the retention and transfer of learning? Describe three ways
person will perform the task while sitting or standing, an occupational therapist can modify feedback or
and the amount of shift in center of gravity that will be practice schedules to promote contextual interference.
required by positioning of the dominoes on the table. 8. What are the necessary substrates for stroke survivors
When an occupational therapist modifies an activity to meet their maximal potential for recovery? How can
to facilitate current performance, the focus is on external therapeutic intervention influence these substrates?
adaptations to compensate for unchanging internal limi- 9. Describe the difference between modifying activities
tations. Such modifications are discussed in Chapters 27 to promote practice for skill recovery and modifying
and 28. It is important for therapists to understand that activities to help stroke survivors compensate for
both types of activity modification may be appropriate current limitations.
for a single individual. It is equally important that the
stroke survivor clearly understands the purpose of each
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 a s h wi n i k. rao

chapter 6

Approaches to Motor
Control Dysfunction:
An Evidence-Based Review

key terms
body weight support and tread- evidence-based practice robot-aided motor training
mill training neurotherapeutic approach task-oriented approach
constraint induced movement
therapy

chapter objectives
After completing this chapter, the reader will be able to accomplish the following:
1. Understand principles of evidence-based practice and criteria of evaluating research.
2. Understand the rationale behind the various techniques described in this chapter.
3. Evaluate the evidence testing the effectiveness of the approaches in stroke rehabilitation.

The therapeutic professions are in the midst of a para- importance stems from the need to choose the best
digm shift with regard to stroke rehabilitation. This chap- (most effective and current) available intervention
ter examines the evidence for a traditional approach in techniques, which is a fundamental ethical responsibil-
stroke rehabilitation (Bobath approach or neurodevelop- ity of clinical practice. Sackett coined the term
mental treatment [NDT]). The overwhelming lack of evidence-based medicine and defined it as “the conscien-
evidence for this approach has led to the articulation of a tious, explicit, and judicious use of current best
new clinical paradigm based on a functional task-oriented evidence in making decisions about the care of indi-
approach. Evidence for specific therapeutic applications vidual patients. The practice of evidence-based medi-
within this task-oriented paradigm is evaluated to help cine means integrating individual clinical expertise
determine the best (most effective) practices for rehabili- with the best available external clinical evidence from
tation of sensorimotor dysfunction following stroke. systematic research.”72
Evidence-based rehabilitation is the application of the
UNDERSTANDING EVIDENCE-BASED principles of evidence-based medicine to problems in the
PRACTICE field of rehabilitation. According to Law,44 evidence-based
rehabilitation practice is based on a self-directed learning
Evidence-based practice has become integrated in model in which practitioners must take responsibility for
occupational therapy (OT) and physical therapy continuously evaluating their techniques in an effort to
(PT) education and practice in the past few years. Its improve them.

117
118 Stroke Rehabilitation

Mohide56 identified three basic components of evidence- blinding; (7) measures of a key outcome obtained from
based practice: at least 85% of subjects; (8) intention to treat analysis;
1. Best research evidence: A first step in evidence- (9) between-group statistical comparisons reported;
based practice is to identify rigorous, clinically rel- (10) point estimate and measures of variability for at
evant research studies that apply to the clinical least one key outcome measure.
problem at hand. For this chapter, this would imply For this evidence-based review, the selected studies
an examination of the best available evidence in the had a score of at least 4/10 on the PEDro score, which
rehabilitation of sensorimotor dysfunction follow- is used as an indicator of good quality studies. The
ing stroke. PEDro scale was used because its validity and reliability
2. Clinical expertise: The second step is using one’s are established.51
clinical expertise and experience to identify patients’ Before reviewing the evidence, a brief description of
strengths and weaknesses and the risks and benefits research designs is provided to help the reader understand
of potential interventions. Once the clinician has the terms used in the evidence tables. For more detailed
identified the best research evidence, the next step descriptions of research designs, the reader is referred to
is to determine if the techniques described in studies Helewa and Walker26 and Law.44
apply to the individual patient, given his or her Randomized controlled trials or randomized clinical
strengths and weaknesses. A focus on the inclusion trials (RCT) are the most rigorous way of determining
and exclusion criteria that the studies used is impor- whether a cause-and-effect relationship exists between
tant to determine if the individual patient in ques- treatment and outcomes. Some of the important features
tion would benefit from the techniques. of randomized trials are:
3. Patient values: The final step is to incorporate a ■ Random assignment of subjects to experimental and
patient’s values into clinical decision-making. control groups. Randomization ensures that groups
This chapter examines the best research evidence for are similar at the beginning of intervention.
stroke rehabilitation. To do so requires first defining cri- ■ Subject, therapist, and tester blinding: Patients and
teria by which clinical outcome studies were evaluated. experimenters should remain unaware of which
treatment was given until the study is completed in
CRITERIA FOR EVALUATING RESEARCH order to prevent bias.
■ All intervention groups are treated identically except
ARTICLES
for the experimental treatment.
For each specific intervention technique, the authors A cohort study involves studying groups of individuals
searched databases (such as Medline, Pubmed, CINAHL, who share some common characteristics, such as positive
PEDro) for randomized controlled trials (or high quality history of stroke. In this case, subjects are not allocated
nonrandomized studies with low bias) published in the to different groups at random, making them less rigorous
past decade, i.e. between 1999 and 2009. The analysis was than RCT.
restricted to studies published in English. The before-and-after design is a study of one group of
Once studies describing clinical trials on the effec- patients without a control group. When a control group
tiveness of specific techniques were chosen, two criteria is included, the design is called case control design. Because
were used to rank each study. The first ranking criteria the control group in this case consists of healthy subjects,
were developed by the Centre for Evidence Based the two groups are different at the outset of the study.
Medicine, Oxford, UK.11 The criteria are based on Descriptive designs are not rigorous but are useful in
guidelines proposed by Sackett.72 In this framework, describing a disorder in detail.
research articles are ranked as follows: (1a) systematic
review of randomized clinical trials; (1b) individual ran- PARADIGM SHIFTS IN STROKE
domized clinical trial with narrow confidence interval; REHABILITATION
(2a) systematic review of cohort studies; (2b) individual
cohort study or low quality randomized clinical trial; The therapeutic professions of OT and PT have wit-
(3a) systematic review of case-control studies; (3b) indi- nessed two paradigm shifts related to the treatment of
vidual case-control study; (4) case series, poor quality neurological dysfunction. According to Gordon,22 para-
cohort and case-control studies; (5) expert opinion. digm shifts within therapeutic practice can occur for two
The second criterion was the Physiotherapy Evi- reasons: (1) because the theoretical model underlying a
dence Database (PEDro) score.12 In this 10-point scale, therapeutic approach does not fit with current knowledge,
one point is scored if each of the following criteria are and (2) because existing approaches do not appear ade-
satisfied: (1) random allocation of subjects; (2) alloca- quate to solve clinical problems. The past 60 years have
tion concealment; (3) baseline similarity across groups; witnessed two distinct paradigm shifts in the treatment of
(4) subject blinding; (5) therapist blinding; (6) tester stroke.
 Chapter 6 • Approaches to Motor Control Dysfunction: An Evidence-Based Review 119

The first shift occurred in the years immediately fol- stroke. Reflex inhibitory movement patterns, which
lowing World War II; at that time the dominant thera- were opposite to the pattern of spasticity observed
peutic paradigm was muscle reeducation, which was used in patients, were used to prevent learning of abnor-
extensively to treat peripheral nerve disorders such as mal movements.
poliomyelitis. Although useful for polio, muscle reeduca- 5. Sequelae of stroke can be understood through a
tion was not adequate to treat individuals with disorders neurophysiological explanation. This assumption
of the upper motor neuron, such as paresis following means that sensorimotor impairments seen after
stroke. As a result, a few therapists began studying how stroke result primarily from the damaged motor
the nervous system controls movements and began to ap- system.
ply these principles into clinical practice. This approach The original principles that defined Bobath approach
heralded the development of techniques such as proprio- have been adapted and tailored to suit the current knowl-
ceptive neuromuscular facilitation, Bobath approach or edge of the functioning of the central nervous system.53
neurodevelopmental treatment (NDT), Brunnstrom Core theoretical assumptions of the Bobath approach
movement therapy and sensory integration, to name a few includes an appreciation of task and context specificity of
of the prominent approaches. motor learning (a concept associated with a task-oriented
approach), neuroplasticity, systems approach that high-
The Neurotherapeutic Approaches: lights the interaction of the person, task, and environ-
The First Paradigm Shift ment in producing functional behavior.34,69 This amal-
Principles of Neurotherapeutic Approaches. Although gam of old and new conceptual principles have produced
each neurotherapeutic approach is different from each a high variability and confusion in practice patterns
other, all approaches share some common elements.22,23 among therapists using the Bobath approach.53
This section and the subsequent review of the evidence
focuses on the Bobath approach/NDT because this ap- Outcome Studies on Neurotherapeutic Techniques. This
proach historically has been the most widely used in section evaluates the evidence for the effectiveness of the
stroke rehabilitation. However, the assumptions un- Bobath approach in stroke rehabilitation. Table 6-1 pre-
derlying the Bobath approach also hold true for the sents the details of seven RCT and two high quality
other approaches mentioned previously. Some of the nonrandomized trials that compared the effectiveness of
common elements of the neurotherapeutic approaches the Bobath approach with usual care, task-oriented ther-
are as follows: apy, or orthopedic approach. The studies in the evidence
1. The central nervous system is organized hierarchi- table are listed chronologically.
cally, with higher centers such as the cerebral cortex
exerting a controlling influence over the lower cen- Timing of Therapy. Of the nine studies related to
ters (such as the spinal cord). When a deficit occurs NDT, two included patients in the acute stage,41,42 three
in the motor system, more primitive forms of move- included patients in the subacute stage,67,86,91 two studies
ment (such as reflexive postures and movements), included patients in the acute and subacute stages,24,25 one
controlled by the lower centers (spinal cord and study included patients in the subacute or chronic stage,97
brainstem), are released from their normal inhibi- and one study included patients from acute, subacute, and
tion from the higher centers.7 Thus, treatment chronic stages.81
within this framework was aimed at reestablishing
control by the higher centers. Outcomes Measures. Three of the nine studies on
2. Normal movement can be facilitated by providing the Bobath approach measured outcomes at the impair-
specific patterns of sensory input, particularly ment level only.67,81,86 Given the importance of testing
through the proprioceptive and tactile sensory sys- outcomes at multiple levels of the International Classifi-
tems. Under this assumption, sensory stimulation cation of Function (ICF) model, it is important that
was proposed to produce long-term effects of rees- a majority of studies (six) included outcomes at the
tablishing normal sensorimotor neural connections. impairments and activity levels.24,25,41,42,91,97 Outcome
3. Recovery from brain damage follows a predictable measures at the impairment level ranged from quantita-
sequence that mimics normal development. Treat- tive analysis of gait, Arm Research Action Test, Nine or
ment used developmental postures in an effort to Ten Hole Peg Test, Stroke Impairment Assessment
facilitate recovery. This principle has since been Scale, Berg Balance Scale, Modified Ashworth Scale, six-
eliminated in current concepts of Bobath therapy.69 minute walk test, and Stroke Rehabilitation Assessment
4. Reflexes were used to facilitate or inhibit motor ac- of Movement. The most common outcome measures at
tivity. Experience of normal movement patterns the activity limitation level were the Barthel index, Ex-
must be provided so that the patient does not learn tended ADL Scale, Motor Assessment Scale, and River-
abnormal patterns of posture and movement after mead Motor Assessment.
Text continued on p.124
 120
Stroke Rehabilitation
Table 6-1
Evidence Table for the Neurodevelopmental Treatment/Bobath Approach

AIMS DESIGN, SUBJECTS,

AUTHOR/ AND OXFORD RATING, COMPARISON
YEAR RATIONALE AND PEDRO SCORE INTERVENTION INTERVENTION ASSESSMENT OUTCOMES RESULTS COMMENTS

Langhammer Compare Double blind RCT; Bobath therapy MRP (N33) 3 days post- 1. MAS Both groups Well-designed
et al, 2000 outcome of 61 patients acute (N28); admission, 2. SMES improved at study; MRP
Bobath stage 5 days a week for 3 weeks, 3. BI 3 months on better than
therapy with 1b; duration of and 4. NHP MAS, SMES, Bobath ap-
motor 6/10 hospital stay 3 months 5. Length of and Barthel In- proach
learning poststroke stay, assis- dex. MRP had
program tive device better im-
provement on
MAS and had
shorter hospi-
tal stay.
Langhammer Evaluate Double blind RCT; Bobath therapy Motor Learning 1 and 4 year 1. MAS, No difference in Initial benefit
et al, 2003 effectiveness 61 patients acute (N28); Program follow-up of 2. SMES mortality rate; of MRP not
of Bobath and stage No intervention (N33); patients 3. BI motor function maintained
MRP 1 and 2b; following ini- No intervention from Lang- 4. Notting- decreased from in the long
4 years after 4/10 tial therapy following ini- hammer et ham year 1 to year term, partly
stroke during acute tial therapy al, 2000 Health 4 on MAS and because
stage during acute Profile SMES for both therapy was
stage 5. Length of groups; inde- discontin-
stay, assis- pendence in ued.
tive de- ADL de-
vice, mor- creased; QOL
tality better at 1 and
6. BBS 4 years than at
3 months
Tang et al, Compare Bo- RCT; Bobath therapy POWM therapy Pretreatment 1. Mini Both groups im- Well designed
2005 bath approach 47 patients acute, (N22); 50 (N25); using and post- Mental proved on study; NDT
(NDT) with subacute, or min. sessions cognitive skills treatment State STREAM; not as good
POWM chronic stage; 5 week; mat to focus atten- Exam; POWM better as active
therapy 2b; activity, sitting, tion and train 2. STREAM than Bobath willed move-
6/10 standing, walk- memory on overall ment ther-
ing, stair score, mobility, apy, a form
climbing; focus and lower ex- of task-
on movement tremity scores oriented
normalization of STREAM approach
Wang et al, Compare Bo- Single blind RCT; Bobath treat- Orthopedic ap- Pretreatment 1. SIAS Lower function- No follow-up
2005 bath therapy 44 patients at sub- ment (N21) proach (N23) and post- 2. MAS ing group im- assessment;
with orthope- acute or chronic included nor- included pas- treatment; 3. BBS proved with ei- did not ad-
dic approach stage; subjects cat- malization of sive, active, as- 4. SIS ther Bobath or dress ceiling
egorized by func- tone, postural sistive exercise; orthopedic ap- effect for
tion into spasticity reeducation, practice of proach; Bobath MAS, BBS,
group manual facilita- functional ac- group had bet- and SIS
(Brunnstrom stage tion, key points tivities (rolling, ter scores on scores.
2 to 3), or relative of control; sitting, trans- SIAS tone and Bobath group
recover stage 40 min, 5  fers, walking) SIS; marginally
(Brunnstrom stage week for 40 min, 5  higher function- better than

Chapter 6 • Approaches to Motor Control Dysfunction: An Evidence-Based Review

4 to 5); 4 weeks week for ing group im- orthopedic
2b; 4 weeks proved with ei- treatment,
5/10 ther treatment, which is not
Bobath group a treatment
had better of choice in
scores on MAS stroke.
Van Vliet Compare Double blind RCT; Bobath (N60) Movement Sci- Pretreatment, 1. RMA At baseline Bo- Baseline dif-
et al, 2005 Bobath with 120 patients at sub- Median 23 min/ ence (N60), 1, 3, and 6 2. MAS, Sec- bath group had ferences
Movement acute stage; day; no details median months ondary: better lower between
Science 1b; on treatment, 23 min/day; after ran- 3. Ten-hole extremity groups; time
approach 6/10 manual strat- no details on domization. peg test scores on the spent with
egy used. treatment, 4. 6 min RMA, MS therapist not
Treatment con- cognitive walk, 4. group had bet- equivalent
tinued as long strategy used; Modified ter upper limb across
as patients re- treatment con- Ashworth RMA scores. groups. Bo-
quired tinued as long Scale Bobath group bath therapy
as patients 5. Notting- spent more no different
required ham time with ther- than move-
Sensory apist, MS ment science
Assess- group spent approach.
ment more time with Duration of
6. BI PT Assistant. therapy less
7. EADL No differences than stan-
seen in any dard practice
outcomes
across the two
groups.

Continued

121
 122
Stroke Rehabilitation
Table 6-1
Evidence Table for the Neurodevelopmental Treatment/Bobath Approach—cont’d

AIMS DESIGN, SUBJECTS,

AUTHOR/ AND OXFORD RATING, COMPARISON
YEAR RATIONALE AND PEDRO SCORE INTERVENTION INTERVENTION ASSESSMENT OUTCOMES RESULTS COMMENTS

Platz et al, Evaluate effect Single blind RCT, Bobath group Arm BASIS Pretreatment 1. Arm mo- Arm BASIS Well-
2005 of augmented multicenter; 60 (N20) fo- group (N20) and post- tor section group per- designed
exercise ther- subacute patients; cused on con- received repeti- treatment of Fugl formed better study;
apy; compare 1b; 8/10 trol of muscle tive training of Myer test than Bobath Bobath ther-
Bobath with tone, recruit- arm movement 2. ARAT group on Fugl apy not as
Arm BASIS ment of arm with to im- 3. Ashworth Myer motor effective as
training during prove ROM Scale for score, ARAT, repetitive
(repetitive functional tasks (45 min/day, elbow and Ashworth training of
training to (45 min/day, 4 weeks); flexors scale; Bobath arm move-
restore ROM) 4 weeks) Usual treatment group was sim- ment;
(N20) had ilar to usual Bobath
ADL, arm ac- treatment approach
tivities, stance similar to
and gait, usual care
speech, and
cognition
(30 min/day,
4 weeks)
Hafsteinsdot- Investigate Nonrandomized Bobath group Control group Pretreatment, 1. BI (12 Bobath group Despite limi-
tir et al, effects of parallel design, (N223) re- (N101) re- 12 month or death received higher tation of
2005 Bobath multicenter; ceived inter- ceived conven- follow-up defined as number of nonrandom-
therapy/NDT 324 patients with vention from tional PT and poor out- sessions. At ization, this
on functional acute and subacute nurses and PTs OT treatment; come) 12 months, is the most
status and stroke (1 year); trained in the no details of 2. SIP higher per- definitive
quality of life 2b; Bobath treatment 3. Visual centage of sub- study on the
in acute and 5/10 approach; no provided Analog jects in Bobath lack of effect
subacute details of treat- Scale group had of the Bo-
stroke ment provided poor outcome; bath
no differences approach
were seen in
quality of life
between
groups.
Hafsteinsdot- Investigate ef- Nonrandomized Bobath group Control group Pretreatment 1. SF-36 No differences Nonrandom-
tir et al. fects of Bo- parallel design, (N223) re- (N101) re- and post- 2. CES-D between ized study;
2005 bath therapy multicenter; ceived inter- ceived conven- treatment, 6 3. Visual An- groups in large study
on depression, 324 patients with vention from tional PT and and 12 alog Scale shoulder pain clearly shows
shoulder pain acute and subacute nurses and PTs OT treatment; month for pain and quality of no benefit of
and quality of stroke (1 year); trained in the no details of follow-up life. Fewer Bobath
life in acute 2b; Bobath ap- treatment patients in approach
and subacute 5/10 proach; no provided Bobath group on shoulder
stroke details of treat- depressed at 1 pain and
ment provided year follow-up quality of
life

Chapter 6 • Approaches to Motor Control Dysfunction: An Evidence-Based Review

Thaut et al, Compare effec- Single blind RCT; Bobath group RAS group Pretreatment 1. Quantita- RAS group had Well-designed
2007 tiveness of 78 patients at sub- practiced gait (N-43) prac- and post- tive Gait greater im- RCT;
RAS with acute stage; without rhyth- ticed gait with treatment Analysis provement on Bobath ap-
Bobath 1b; mic cues metronome (velocity, all four gait proach not
approach/ 7/10; (N35); and music; cadence, measures and as effective
NDT for gait 30 min/day, 30 min/day, stride patient satis- as RAS for
training 5 days/week, 5 days/week, length, faction gait training
for 3 weeks for 3 weeks swing
symmetry)

ADL, Activities of daily living; ARAT, Action Research Arm Test; BBS, Berg Balance Scale; BI, Barthel Index; CESD, Center for Epidemiological Studies Depression Scale; EADL, Ex-
tended Activities of Daily Living Scale; MAS, Motor Assessment Scale; MRP, Motor Learning Program; NDT, neurodevelopmental treatment; NHP, Nottingham Health Profile; OT,
occupational therapy, POWM, problem oriented willed movement; PT, physical therapy, QOL, quality of Life; RAS, rhythmic auditory stimulation; RCT, Randomized Controlled trial;
RMA, Rivermead motor assessment; ROM, range of motion; SIAS, Stroke Impairment Assessment Scale; SIP, Sickness Impact Profile; SIS, Stroke Impact Scale; SMES, Sodring Motor
Evaluation Scale; STREAM, Stroke Rehabilitation Assessment of Movement

123
124 Stroke Rehabilitation

Study Designs. The designs included in this review techniques within the newly emerging paradigm of task-
were seven RCT and two high-quality nonrandomized oriented training.
parallel design studies with a large number of subjects. All
the studies were classified as either 1b or 2b on the Oxford Functional Task-Oriented Training:
levels of evidence scale. The Second Paradigm Shift
The second paradigm shift in the treatment of neurologi-
Results of the Review. Of the nine trials examining cal disorders began in the 1990s. Therapists began to re-
the effect of Bobath approach, one compared Bobath to gard neurotherapeutic approaches with less optimism.
an orthopedic approach to stroke rehabilitation,97 two The dissatisfaction with the neurotherapeutic approaches
studies compared Bobath with usual care including con- is due, in part, to the fact that retraining normal move-
ventional PT and OT24,25 and the other five compared ment patterns do not carry over into the performance of
Bobath approach with the task-oriented approach41,42,67,86,91 functional daily living skills, which is the ultimate goal of
or a variant of a task-oriented approach called the prob- rehabilitation. In addition, there is a greater demand on
lem oriented willed movement therapy.81 therapists to use interventions that have demonstrated ef-
The Bobath approach was marginally better than an fectiveness. Evidence that demonstrates a lack of effec-
orthopedic approach,97 which is not the therapy of choice tiveness of neurotherapeutic approaches, particularly the
in stroke rehabilitation. When compared with conven- Bobath approach, has led to the development of novel
tional PT and OT, Bobath approach was no better for training regimens based on what has been termed the
impairment or activity limitation outcomes.24,25 When task-oriented approach.75
compared with a task-oriented approach, which repre-
sents a novel approach to stroke rehabilitation, Bobath Principles of the Functional Task-Oriented Approach.
approach was clearly less effective in four of the six stud- The task-oriented approach is based on a systems model
ies.41,67,81,86 There were two exceptions to this pattern: one of motor control and theories of motor learning. The ap-
study42 found no differences in outcomes evaluated at one proach attempts to understand the problems faced by the
and four years after the initial therapy was administered, nervous system to control movements. This field of motor
perhaps because patients did not receive therapy in the neuroscience represents a multidisciplinary approach to
interim period. The other study91 had methodological understanding motor control and learning from the per-
limitations that may explain the lack of differences. For spectives of neurophysiology, biomechanics, and behav-
instance, at baseline testing, there were differences across ioral sciences. Within this framework, motor control is
the two groups, the amount of time patients spent with understood as an attempt by the nervous system to adapt
the therapist was not the same, and finally the duration of movements to constraints imposed by the mechanics of
therapy was much less compared with all other studies. the motor apparatus (including length, mass of limbs, and
Despite these two studies, the evidence overwhelmingly intersegmental dynamics of moving segments), constraints
points to the lack of effectiveness of the Bobath approach imposed by the environment (open or closed environ-
when compared with a task-oriented approach. ment), and constraints imposed by the behavioral context.
Studies on motor control often analyze movements at the
Implications for Practice. Three recent systematic biomechanical and behavior levels. See Chapters 4 and 5
reviews have reported no evidence for the superiority of for a detailed description.
the Bobath approach.34,48,62 The present review extends Chapter 4 provides the reader with a more compre-
the results of the previous systematic reviews to demon- hensive description of the task-oriented approach. What
strate that the use of the Bobath approach needs to be follows is a brief description of some of the incipient
reconsidered in stroke rehabilitation. principles of treatment, based on suggestions by Carr
In the past few years, an attempt has been made among and Shepherd10 and Gentile.21 Within this framework,
proponents of neurofacilitation approaches to integrate the responsibility of the therapist as a teacher of motor
established techniques of NDT with the language of skills is to select contextually appropriate functional
newly emerging knowledge in motor control and motor tasks, vary task parameters to ensure greater transfer of
learning. This is readily seen in a recent text describing learning, structure practice schedules to encourage ac-
the theoretic basis of NDT.30,34 Although this is typical tive participation of the patients, structure the environ-
during paradigm shifts, the amalgamation of old tech- ment so that all regulatory conditions of a given task are
niques with new theoretical knowledge is not useful either present, and provide feedback. To apply a task-oriented
theoretically (since established Bobath techniques are not approach to treatment successfully, therapists need to
consistent within the new paradigm of motor control and become familiar with analyzing tasks and the processes
learning) or for clinical practice (since numerous studies underlying skill acquisition. The following two sections
have demonstrated that there is indeed little evidence). evaluate the literature on task-oriented approach to
The challenge for therapists is to design and evaluate stroke rehabilitation.
 Chapter 6 • Approaches to Motor Control Dysfunction: An Evidence-Based Review 125

Outcome Studies Using a Task-Oriented Approach. For recent reviews,31,70 there is very good evidence for the
the purpose of this review, the author chose eleven RCT effectiveness of this approach in comparison with tradi-
that explicitly tested a task-oriented intervention for tional therapy, Bobath approach, or immobilization.
rehabilitation of upper limb function (Table 6-2). Length These studies demonstrate that improvement in motor
of the training programs across the studies varied from skills and function depends on contextually appropriate
two to six weeks, the number of sessions ranging from task-specific practice of functional skills. Given that this
10 to 20. approach is relatively new, additional RCT with larger
number of subjects are needed. It will also be important
Timing of Intervention. Of the eleven trials, one to have control groups that receive dose equivalent stan-
study tested patients in the acute stage,58 five tested pa- dard care.
tients in the subacute stage,5,16,17,60,100 one study trained A number of studies were not included under the gen-
patients in the acute and subacute stages,38 and four tested eral category of task-oriented approach because these
patients in the chronic stage.29,54,87,88 studies tested a specific type of task-oriented therapy
called constraint-induced movement therapy (CIMT),
Outcome Measures. Four of the eleven studies only described in detail in the subsequent section.
measured outcomes at the impairment level,16,54,60,88
whereas six studies measured outcomes at the impairment Constraint-Induced Movement Therapy
and activity limitation levels.5,17,38,58,87,100 Only one study Rationale and Principles. Constraint-induced move-
measured outcomes at all three levels of the ICF model.29 ment therapy is a term used for a family of intervention
Variables at the impairment level commonly tested were techniques that aim to decrease the effects of learned non-
gait velocity, endurance, ground reaction forces, kinematic use of a paretic limb. This family of techniques involves
variables in reaching, Action Research Arm Test, and posi- two basic features: (1) discouraging the use of the unaf-
tron emission tomography (PET) scan. Variables related to fected or less affected limb through verbal prompt but
activity limitation were measured using the 36-item Short- more often by applying some form of restraint to the un-
Form Health Survey, Barthel index, and the Functional affected limb with a sling, splint, or a mitten, and (2) in-
Ambulation Classification. The only outcome at the par- tensive training of the paretic arm through active partici-
ticipation level was the OARS-IADL and SF-36. pation in functional activities.8,89,90
Some authors have proposed that the inability to move
Study Designs Used. All eleven studies included in the paretic limb may arise, at least in part, from a phe-
the review were RCT, of which three were rated as 1b and nomenon termed learned nonuse. The proposal is based on
the other eight rated as 2b, according to the Oxford crite- experiments in which deafferentation was performed in
ria. The PEDro score ranged from 4 to 8, indicating that one limb in primates through dorsal rhizotomy.82 Follow-
all were high quality studies. ing surgery, monkeys did not use their affected limbs be-
cause of the lack of sensory feedback, and they preferen-
Results of the Review. Task-oriented training dem- tially used their unaffected limbs. When the monkeys
onstrated positive outcome when compared with immobi- were forced to use their affected limbs, greater recovery
lization,38 resistance training,87,88 Bobath approach,58,100 of movement was seen. This indicates that the inability to
and usual PT and OT.16,60 Task-oriented therapy was ef- use the affected limb may be a behavioral learned re-
fective in the acute (one study) and subacute stages of sponse to paresis. See Chapters 4, 5, and 10.
stroke (five out of six studies). In the chronic stage, two
studies documented effectiveness primarily for lower Outcome Studies. In the past decade, a large number
functioning subjects.54,87 One study did not find arm of studies have been conducted on the effects of CIMT. As
training better than lower limb training,29 and one study seen in Table 6-3, eighteen RCT and one dose-equivalent
found modest gains.88 placebo-controlled trial were identified. All nineteen stud-
Table 6-2 shows substantial evidence to suggest that ies scored either 1b or 2b on the Oxford levels of evidence
task-oriented training leads to improvement of out- scale, and the PEDro score ranged from 4 to 8 out of a
comes at the impairment and activity limitation levels. score of 10. This indicates that all studies were high qual-
However, since some studies showing a positive effect of ity trials. CIMT studies are unique because all studies were
task-oriented therapy tested outcomes at the impair- careful in subject selection: all subjects included required a
ment level only, it will be useful for future randomized minimum of 10-degrees of active extension at the metacar-
trials to include outcome measures at multiple levels of pophalangeal joint and 20-degrees of active extension at
the ICF model. the wrist. In addition, a number of studies excluded pa-
tients with excessive spasticity and sensory deficits. The
Clinical Implications. The present review of task- narrow specification of inclusion and exclusion criteria
oriented training studies confirms the results of two may have led to the selection of a highly homogeneous
Text continued on p.142
 126
Table 6-2

Stroke Rehabilitation
Evidence Table for Task-Oriented Training
AIMS DESIGN, SUBJECTS,
AUTHORS AND OXFORD RATING, COMPARISON OUTCOME
AND YEAR RATIONALE PEDRO SCORE INTERVENTION INTERVENTION ASSESSMENT MEASURES RESULTS COMMENTS

Kwakkel et al, Evaluated Single blind RCT; Arm training Control group Stroke onset, 1. BI All groups were Well-designed
1999 different 101 subjects with group (N33) (N37) had weekly for 2. FAC similar at base- study; func-
intensities acute stroke (<14 practiced func- their upper and 10 weeks, 3. ARAT line; compared tional train-
of func- days of stroke); tional skills lower limbs then once in with control ing of upper
tional 1b; such as reach- immobilized by 2 weeks group, arm and lower
training of 7/10 ing, grasping, a pressure from week training group limb skills
the lower punching a ball; splint 11–20; 26 had better scores produced
and upper leg training week on dexterity; leg task specific
limbs in group (N31) follow-up training group improve-
acute and practiced sit- had better scores ment.
subacute ting, standing on ADL, walk-
stroke and weight ing and dexterity
bearing exer- for all assess-
cises in sitting ments until 20
and standing; weeks; At 26
30 min/day; 5 weeks, arm and
days/week for leg training
20 weeks groups had bet-
ter score on dex-
terity.
Nelles et al, Investigate RCT; Experimental Control group Pretreatment 1. PET Experimental Small sample;
2001 the effects 10 subjects with group (N5) (N5) received and post- regional group showed a task-oriented
of inten- subacute stroke received task- nonspecific re- treatment cerebral trend for greater training pro-
sive arm (30 days) and 5 oriented train- habilitation blood flow improvement on motes neuro-
training on healthy control ing including program in- 2. FM FM and NIHSS nal plasticity;
neuronal subjects; practice of cluding ROM, 3. NIHSS compared with however,
plasticity 2b; reaching for ob- stretching, control group; task-oriented
in subacute 4/10 jects in different soft-tissue Experimental group im-
stroke directions, to mobilization; group had provement
different dis- 45 minutes/day, greater activa- was not sig-
tances; 5 days a week tion of bilateral nificantly dif-
45 minutes/day, 5 for 3 weeks of inferior pari- ferent on
days a week for etal and premo- clinical out-
3 weeks tor areas and comes com-
contralateral pared with
sensorimotor control
cortex. group
Mudie et al, Compare ef- RCT blocked ran- Task related Bobath group Pretreatment 1. Balance in Weight distribu- Small sample;
2002 fects of domization using group (N10) (N10) re- and post- sitting using tion was better task-related
task- 2:1 ratio; practiced reach- ceived tone treatment, 2 the BPM for BPM, Bo- training or
related 40 subjects with ing to func- normalization, and 12 week 2. Balance in bath, and con- balance train-
reach acute stroke; tional objects trunk and pel- follow-up standing us- trol groups at ing with
training, 2b; beyond arm vic ROM, and ing the BPM the end of treat- feedback
Bobath 4/10 length in sit- balance in 3. BI ment; all four better for
training, ting; sitting; Bobath groups improved sitting sym-
and feed- Feedback train- group received at 2 week metry in the
back train- ing group standard OT follow-up; BPM long term
ing on (N10) trained and PT; and task-related

Chapter 6 • Approaches to Motor Control Dysfunction: An Evidence-Based Review

sitting on reaching to control group group main-
weight dis- targets and (N10) re- tained improve-
tribution were provided ceived only ment at 12
error feedback standard OT weeks; BPM,
using the BPM; and PT task related
both groups re- treatment; training and
ceived OT and daily treatment control group
PT; for two weeks performed
daily treatment better on BI
for two weeks
Thielman Compare ef- RCT; Task-related PRE group Pretreatment 1. Kinematic Low level subjects Small sample;
et al, 2004 fectiveness 12 subjects with group (N 6) (N6) prac- and post- measures in the task- lower func-
of task-re- chronic stroke (5 practiced reach- ticed whole treatment (movement related group tioning
lated train- to 18 months); ing to func- arm pulls using time, peak improved on the subjects
ing and 2b; tional objects a theraband in velocity, RMA; no train- benefited
PRE in 4/10 with the trunk sitting; move- movement ing effect was most from
chronic restrained in ment amplitude units, curvi- seen for MAS; task-related
stroke sitting; was similar to linearity Low level sub- training
35 minutes/day, 3 task-related ratio) jects in task-
days/week for 4 group; 2. MAS related group
weeks 35 minutes/day, 3. RMA improved hand
3 days/week for curvilinearity
4 weeks after training

Continued

127
 128
Stroke Rehabilitation
Table 6-2
Evidence Table for Task-Oriented Training—cont’d

AIMS DESIGN, SUBJECTS,

AUTHORS AND OXFORD RATING, COMPARISON OUTCOME
AND YEAR RATIONALE PEDRO SCORE INTERVENTION INTERVENTION ASSESSMENT MEASURES RESULTS COMMENTS

Winstein Evaluate Nonblinded RCT; Task-related SC group Pretreatment 1. FM Task-related Well-designed

et al, 2004 effects of 60 subjects with training group (N20) in- and post- 2. FTHUE training and ST study; task-
task- acute or subacute (N20) re- cluded facilita- treatment, 6 3. FIM groups had bet- related train-
related stroke (2 to 35 ceived SC plus tion, neuro- and 9 ter FM and Iso- ing was bet-
training days); repetitive prac- muscular month metric torque at ter than ST
and 1b; tice of func- electric stimu- follow-up posttreatment in the long-
strength 6/10 tional tasks; lation, stretch- primarily in less term
training ST group ing, using an severe patients;
(ST) in (N20) re- NDT approach Isometric torque
acute and ceived SC plus and ADL improvement
subacute resistive move- training. was maintained
stroke ments using at 9 months
theraband;
Both groups re-
ceived therapy
1 hour/day,
5 days/week for
4 weeks
Blennerhasset Investigate Single blind RCT; Upper limb Mobility group Pretreatment 1. Six-minute Upper limb group Well-designed
et al, 2004 whether 30 subjects with group (N15) (N15) re- and post- walk test performed bet- study shows
additional subacute stroke (11 received usual ceived usual treatment, 6 2. TUG ter on the MAS the task spec-
practice of to 49 days); PT for 1 hour/ PT for 1 hour/ month 3. Step Test and JTHFT; ificity of
upper or 2b; day, 5 days/ day, 5 days/ follow-up 4. MAS lower limb training;
lower limb 8/10 week, and addi- week, and addi- 5. JTHFT group had better small sample
task im- tional circuit tional training mobility scores
proves training involv- on bikes and on the TUG
function in ing practice of treadmill, and
subacute functional tasks; practice of sit-
stroke 1 hour/day, 5 to-stand, obsta-
days/week for 4 cle course
weeks walking, stand-
ing balance;
1 hour/day,
5 days/week for
4 weeks
Desrosiers Evaluate Single blind; Experimental Control group Pretreatment 1. FM Both groups im- Task training
et al, 2005 effect of 47 subjects with group (N20) (N21) re- and post- 2. Grip proved as a re- did not en-
arm train- subacute stroke (10 received usual ceived usual treatment strength sult of therapy; hance motor
ing pro- to 47 days); OT and PT, OT and PT, 3. Manual dex- no differences function
gram (uni- 2b; plus practiced plus functional terity (Box were seen be- above usual
lateral and 6/10 symmetrical activities to en- and Block tween groups and custom-
bilateral) bilateral and hance strength, Test) ary care in
in subacute unilateral func- active assistive 4. PPT subacute
stroke tional tasks; and passive 5. Finger to stroke
45 minutes/day, movements; Nose Test
4 days/week for 45 minutes/day, 6. TEMPA

Chapter 6 • Approaches to Motor Control Dysfunction: An Evidence-Based Review

5 weeks 4 days/week for 7. FIM
5 weeks
Higgins Evaluate ef- Single blind RCT; Arm training Mobility training Pretreatment 1. Box and No differences Well-designed
et al, 2006 ficacy of a 91 subjects with group (N47) (N44) prac- and post- Block Test were seen be- study; upper
task- chronic stroke practiced func- ticed functional treatment 2. NHPT tween groups on limb task-
oriented (< 1 year); tional upper mobility and 3. TEMPA motor perfor- oriented in-
program 1b; limb tasks; balance tasks; 4. Grip mance or func- tervention no
on arm 8/10 1.5 hours/day, 3 1.5 hours/day, 3 Strength tion at posttreat- better than
function in days/week for 6 days/week for 6 5. STREAM ment lower limb
chronic weeks weeks 6. BI intervention
stroke 7. Older
Americans
Resources
and Services
Scale
(OARS-
IADL)
8. SF-36
9. Geriatric
Depression
Scale

Continued

129
 130
Stroke Rehabilitation
Table 6-2
Evidence Table for Task-Oriented Training—cont’d

AIMS DESIGN, SUBJECTS,

AUTHORS AND OXFORD RATING, COMPARISON OUTCOME
AND YEAR RATIONALE PEDRO SCORE INTERVENTION INTERVENTION ASSESSMENT MEASURES RESULTS COMMENTS

Michaelson Compare ef- Double blind RCT; TR group Control group Pretreatment 1. FM TR group did Task-related
et al, 2006 fects of 30 subjects with (N15) prac- (N15) prac- and post- 2. TEMPA better on FM training
task- chronic stroke (6 ticed functional ticed functional treatment, 3. Isometric and increased using TR im-
related to 48 months); unimanual and unimanual and 1-month force elbow extension proves motor
training 2b; bimanual reach- bimanual follow-up 4. Manual dex- range at posttest function in
with TR 7/10 ing tasks; trunk reaching tasks; terity (Box and follow-up; low function-
compared movement re- 1 hour/day, and Block both groups ing subjects;
with train- strained with 3 days/week for Test) improved on small sample
ing with- belts; 5 weeks 5. Kinematic TEMPA and
out TR in 1 hour/day, 3 analysis Box and Block
chronic days/week for (trunk dis- test
stroke 5 weeks placement
and elbow
extension
range)
Dean et al, Compare ef- Single blind RCT; Task-related Control group Pretreatment 1. Sitting abil- Maximum reach Small sample;
2007 fects of 12 subjects with reaching group (N5) received and post- ity (maxi- distance was well-designed
task- subacute stroke (<3 (N6) received regular PT and treatment, mum reach higher for task- study show-
related months); regular PT and sham treatment 6 month distance for related reaching ing that task-
reaching 2b; additional sit- (completing follow-up forward and after treatment related
training 7/10 ting training cognitive ma- across and at follow- training is
with sham protocol (coor- nipulation tasks reaches in up; movement better for
training on dination of in sitting); sitting) time and peak sitting ability
sitting trunk and arm 0.5 hours/day, 2. Sitting qual- vertical force and quality
ability and in reaching; 5 days/week ity (reach were better for
quality in loading of af- over 2 weeks movement task-related
subacute fected foot, pre- time, average reaching at
stroke vention of mal- peak vertical posttreatment;
adaptive force task-related
strategies); through af- reaching group
0.5 hours/day, fected foot) had better carry
5 days/week over (peak verti-
over 2 weeks cal force in
standing)
Thielman Compare ef- RCT; Task-related Control group Pretreatment 1. Kinematic Task-related Small sample;
et al, 2008 fect of 11 subjects with training group (N6) prac- and post- analysis of training group task-related
task-re- chronic stroke (6 (N5) prac- ticed arm treatment arm move- had straighter training leads
lated train- months); ticed reaching movements ment (ampli- hand path and to modest
ing with 2b; movements to against resis- tude, time to lower decelera- gains in arm
RE on 5/10 objects placed tance of thera- peak velocity, tion time after function
reaching in at different dis- band in sitting movement training; both
chronic tances and di- with TR; time, wrist groups improved
stroke rections; TR in 45 minutes/day, displacement on the FM and
sitting; 3 days/week for and curvilin- active ROM; no
45 minutes/day, 3 4 weeks; earity ratio) improvement on

Chapter 6 • Approaches to Motor Control Dysfunction: An Evidence-Based Review

days/week for 4 2. WMFT WMFT
weeks 3. F
4. Active ROM

ADL, Activities of daily living; ARAT, Action Research Arm Test; BI, Barthel Index; BPM, balance performance monitor; FAC, Functional Ambulation Category; FIM, Functional
Independence Measure; FM, Fugl-Myer Assessment; FTHUE, Functional Test of the Hemiparetic Upper Extremity; JTHFT, Jebsen Taylor Hand Function Test; MAL, Motor Activity
Log; MAS, Modified Ashworth Scale; NDT, neurodevelopmental therapy; NHPT, None Hole Peg Test; NIHSS, National Institute of Health Stroke Scale; OT, occupation therapy; PET,
positron emission tomography; PPT, Purdue Pegboard Test; PRE, progressive resistive training; PT, physical therapy; RMA, Rivermead Motor Assessment; RCT, randomized controlled
trial; RE, resistive exercise; ROM, range of motion; SC, standard care; ST, strength training; STREAM, Stroke Rehabilitation Assessment of Movement; TEMPA, Upper Extremity
Performance test; TR, trunk restraint; TUG, Timed UP and Go; WMFT, Wolf Motor Function Test.

131
 132
Stroke Rehabilitation
Table 6-3
Evidence Table for Constraint-Induced Movement Therapy

AIMS DESIGN, SUBJECTS,

AUTHORS AND OXFORD RATING, COMPARISON OUTCOME
AND YEAR RATIONALE PEDRO SCORE INTERVENTION INTERVENTION ASSESSMENT MEASURES RESULTS COMMENTS

Dromerick Examine if Single blind RCT; OT treatment fo- Standard OT Pretreatment 1. ARAT ARAT scores Low dosage
et al, CIMT is 20 subjects with cused on ADL, treatment in- and post- 2. BI were higher for CIMT (2 hours)
2000 more effec- acute stroke functional upper cluding com- treatment 3. FIM CIMT group at shows improve-
tive than (14 days); limb training pensatory treat- discharge; no ment only in im-
conventional 2b; with affected ment for ADL, differences were pairment level
therapy in 5/10 arm; unaffected upper limb seen for BI measures in acute
acute stroke hand in padded strength, ROM, score; CIMT stroke;
mitten for 6 and positioning; group had small sample
hours a day; 2 hours/day, 5 higher scores on
2 hours/day, days/week for 2 the FIM UL
5 days/week for weeks dressing
2 weeks
Page et al, Test efficacy Single blind, multi- Modified CIMT Traditional ther- Two pre- 1. FM Modified CIMT Modified CIMT,
2002 of modified ple baseline RCT; group (N7) apy group treatment, 2. ARAT group improved based on distrib-
CIMT in 14 subjects with treated in 30 (N4) received post- 3. MAL more than tra- uted practice
subacute subacute stroke min OT sessions OT and PT treatment ditional therapy over 10 weeks,
stroke (1 to 6 months for functional based on Pro- and no therapy better than tradi-
poststroke); training of up- prioceptive group on FM, tional therapy
2b; per limb using Neuromuscular ARAT, and based on PNF or
4/10 shaping; 30 min Facilitation; and MAL no therapy in
PT sessions to compensatory subacute stage;
improve balance training; small sample size
and mobility; Control group
less affected (N6) received
limb restrained no therapy;
in hemisling for 1 hour/day,
5 hours of fre- 3 days/week for
quent arm use 10 weeks
each day;
1 hour/day,
3 days/week for
10 weeks
Witten- Determine if Single blind RCT; CIMT included Control group Pretreatment 1. WMFT No differences CIMT produced
berg CIMT is 16 subjects with task-oriented received passive and post- 2. MAL were seen on increased use of
et al, more effec- chronic stroke training of up- therapy and task treatment 3. AMPS WMFT and the affected arm
2003 tive than (12 months since per limb; re- performance us- and 4. PET AMPS. CIMT but this did not
less inten- stroke); straint of unaf- ing unaffected 6 month 5. TMS had better per- result in de-
sive control 2b; fected limb hand; follow-up formance on creased impair-
intervention 6/10 using hand 3 hours/day dur- MAL. ment or im-
in changing splint and sling; ing weekdays No differences proved function
motor func- 6 hours/day dur- and no therapy were seen across despite greater
tion and ing weekdays on weekend groups on phys- intensity of
brain physi- and 6 hours/day over 10 consec- iological mea- CIMT;

Chapter 6 • Approaches to Motor Control Dysfunction: An Evidence-Based Review

ology in on weekend utive days sures small sample
chronic over 10 consec-
stroke utive days
Suputti- Evaluate the Single blind RCT; CIMT group Control group Pretreatment 1. ARAT Both groups im- CIMT produces
tada effectiveness 69 patients with (N 33) treated (N 36) treated and post- 2. Hand grip proved on the greater improve-
et al, of CIMT on chronic stroke in groups of 3 to in groups of 3 treatment strength primary out- ment in hand
2004 hand dexter- (1 to 10 years since 4; practice of to 4; therapy 3. Pinch come (ARAT), function, grip
ity in stroke); functional tasks based on Bo- strength with CIMT and pinch
chronic 1b; with affected bath approach group showing strength com-
stroke 6/10 hand; unaffected including prac- more improve- pared with
hand in glove; tice of bimanual ment; CIMT Bobath approach
6 hours/day, tasks; group had of comparable
5 days/week for 6 hours/day, 5 greater im- intensity and
2 weeks days/week for 2 provement on duration
weeks hand and pinch
strength

Continued

133
 134
Table 6-3
Evidence Table for Constraint-Induced Movement Therapy—cont’d

Stroke Rehabilitation
AIMS DESIGN, SUBJECTS,
AUTHORS AND OXFORD RATING, COMPARISON OUTCOME
AND YEAR RATIONALE PEDRO SCORE INTERVENTION INTERVENTION ASSESSMENT MEASURES RESULTS COMMENTS

Page et al, Determine ef- Single blind, multi- Modified CIMT Traditional ther- Two pretreat- 1. FM Modified CIMT Modified CIMT,
2004 ficacy of ple baseline RCT; group (N7) apy group ment and 2. ARAT group improved distributed over
modified 17 subjects with treated in 30 (N4) received posttreat- 3. MAL more than tra- 10 weeks, is bet-
CIMT as chronic stroke min OT sessions OT and PT ment ditional therapy ter than tradi-
compared ( 1 year); for functional based on PNF; group on FM, tional therapy
with tradi- 2b; training of up- and compensa- ARAT, and based on PNF or
tional ther- 6/10 per limb using tory training; MAL. Control no therapy; small
apy or no shaping and control group group per- sample size
therapy in approximation; (N6) received formed worse at
chronic 30 min PT ses- no therapy; posttreatment
stroke sions to improve 1 hour/day,
balance and mo- 3 days/week for
bility and upper 10 weeks
limb stretching;
less affected
limb restrained
in hemisling for
5 hours of
frequent arm
use each day;
1 hour/day,
3 days/week for
10 weeks
Page et al, Compare ef- Single blind, multi- Modified CIMT Traditional Two pretreat- 1. FM Modified CIMT Small sample;
2005 fectiveness ple baseline RCT; (N5) included rehabilitation ment and 2. ARAT group per- No statistical
of modified 10 subjects with practice of func- (N5) included posttreat- 3. MAL formed better analysis;
CIMT to acute stroke tional tasks with stretching, ment than traditional
traditional (14 days); affected upper weight bearing, rehabilitation
rehabilita- 2b; limb; unaffected manual dexter- group on FM,
tion in acute 5/10 hand was re- ity exercises and ARAT, and
stroke strained in a ADL training MAL
padded mitt for with unaffected
5 hours/day of limb;
frequent time 0.5 hours/day,
use; 3 times/week
0.5 hours/day, for 10 weeks
3 times/week for
10 weeks
Wolf et al, Compare ef- Single blind RCT; CIMT group re- Usual and cus- Pre treatment 1. WMFT CIMT group Control group
2006 fects of 222 stroke patients ceived shaping, tomary care and post 2. MAL showed greater received less
CIMT ver- (12 months) practice of ranged from no treatment, 3. SIS improvement therapy, no stan-
sus custom- 1b; functional tasks treatment to or- 4, 8, and than controls on dardization of
ary care in 6/10 and additional thotics, OT and 12 month WMFT (log control group
subacute practice at home PT either at follow-up performance treatment;
and chronic (N106); unaf- home, day time, functional large sample size;
stroke pa- fected limb in program ability) at post- multicenter trial;
tients in instrumented treatment; greater effect of
multisite mitt worn for CIMT group CIMT may be
trial 90% of waking showed more due to massed

Chapter 6 • Approaches to Motor Control Dysfunction: An Evidence-Based Review

hours; 6 hours/ improvement practice
day, 5 days/week than controls on
for 2 weeks MAL at 12
months; no
differences
WMFT func-
tional ability at
12 months
Taub et al, Compare ef- Placebo controlled CIMT group Control group Pretreatment 1. MAL The CIMT Groups not ran-
2006 fectiveness trial; 41 patients (N21) prac- (N20) re- and post- 2. AAUT group had more domized and not
of CIMT chronic stroke ticed functional ceived general treatment, 3. WMFT females, in- similar at
with dose (1 year) assigned tasks with fitness program week 1, 2, creased arm baseline;
equivalent to groups in paretic limb, including 3, 4, 3 strength and CIMT is more ef-
placebo con- blocks; received shaping strength, bal- months, better mood at fective than
trol group 2b; and perfor- ance, stamina and 2 year baseline; CIMT dose-equivalent
in chronic 4/10 mance feedback; training, and follow-up group had bet- control treat-
stroke unaffected limb relaxation ter scores after ment in chronic
in resting hand exercises; treatment on stroke
splint for 90% 6 hours/day; MAL, AAUT
of waking hours; 5 days/week for and WMFT
6 hours/day; 2 weeks performance
5 days/week for time; no differ-
2 weeks ence were seen
in functional
ability; im-
provement
maintained up
to 2 years

Continued

135
 136
Table 6-3

Stroke Rehabilitation
Evidence Table for Constraint-Induced Movement Therapy—cont’d

AIMS DESIGN, SUBJECTS,

AUTHORS AND OXFORD RATING, COMPARISON OUTCOME
AND YEAR RATIONALE PEDRO SCORE INTERVENTION INTERVENTION ASSESSMENT MEASURES RESULTS COMMENTS

Boake Evaluate the RCT; 23 patients CIMT group Control group Pre-treat- 1. FM of Both groups Same dosage did
et al, effectiveness with subacute practiced reach- practiced daily ment and motor improved on not highlight
2007 of CIMT on stroke ing, grasping, living tasks with post treat- recovery primary out- benefit of CIMT;
motor func- (<14 days of lifting, and plac- either hand to ment 3- to 2. Grooved come (FM); no small sample size
tion of the stroke); ing objects with improve 4-month Pegboard differences be-
upper limb 2b; affected hand strength, muscle follow-up Test tween groups at
in subacute 6/10 (N10); shap- tone and ROM 3. MAL posttreatment or
stroke ing and approxi- (N13); 4. Transcra- follow-up;
mation; 3 hours/day; nial Mag- CIMT group
unaffected limb in 6 days/week for netic Stim- reported better
mitt for 90% of 2 weeks ulation outcome in
waking hours; quality of
3 hours/day; movement
6 days/week for during ADL
2 weeks performance;
no differences in
motor threshold
at posttreatment
or follow-up
Wu et al, Evaluate ef- Single blind RCT; Modified CIMT Traditional reha- Pretreatment 1. Kinematic Modified CIMT Well designed
2007a fect of 30 subjects with (N15) received bilitation group and post- analysis of group had lower study; modified
mCIMT on chronic stroke (12 OT treatment (N15) treatment arm move- movement time CIMT better
motor con- to 36 months); including received OT ment and displace- than Bobath
trol of upper 1b; practice of using Bobath 2. MAL ment and higher approach for
limb and 7/10 functional tasks approach 3. FIM percentage of improving arm
functional using shaping, including bal- movement time kinematics and
change in and normaliza- ance, stretching, at peak velocity; functional gains
chronic tion of tone; weight-bearing modified CIMT in chronic stroke;
stroke unaffected hand of affected limb; had better arm no follow-up
restrained in a fine motor tasks use and quality assessment
mitt for 5 hours/ and ADL skills of movement in
day at time of using unaffected MAL and better
frequent use; arm; FIM scores
2 hours/day, 2 hours/day,
5 days/week for 5 days/week for
3 weeks 3 weeks
Wu et al. Examine ben- RCT single blind; mCIMT (N13) Traditional reha- Pre- 1. FM mCIMT group Small sample; no
2007 b efits of 26 elderly subjects received OT bilitation group treatment, 2. FIM performed bet- follow up;
mCIMT on (65 years) with treatment in- (N13) re- post- 3. MAL ter on FM, Modified CIMT
motor and subacute or cluding practice ceived OT treatment 4. Stroke Im- FIM, MAL and better than Bo-
daily func- chronic stroke of functional using Bobath pact Scale SIS compared bath approach
tion, quality (0.5–31 months); tasks using shap- approach in- (SIS) with traditional for improving
of life in 2b; ing, and normal- cluding balance, rehabilitation hand function
elderly 6/10 ization of tone; stretching, and quality of life
patients unaffected hand weight bearing in elderly sub-
with sub- restrained in a of affected limb; jects with stroke
acute and mitt for 5 hours/ fine motor tasks

Chapter 6 • Approaches to Motor Control Dysfunction: An Evidence-Based Review

chronic day at time of and ADL skills
stroke frequent use; using unaffected
mCIMT 2 hours/ arm;
day, 5 days/week 2 hours/day, 5
for 3 weeks days/week for 3
weeks
Wu et al, Evaluate ef- RCT single blind; Modified CIMT Traditional reha- Pretreatment 1. Kinematic Modified CIMT Well-designed
2007c fect of mod- 47 subjects with (N24) received bilitation group and post- analysis of group had lower study; modified
ified CIMT chronic stroke OT treatment (N23) treatment arm move- movement time, CIMT better
on motor (3 weeks to including prac- received OT ment displacement, than Bobath
control of 37 months); tice of func- using Bobath 2. FM and movement approach for
upper limb 2b; tional tasks us- approach in- 3. MAL units; modified improving arm
and func- 6/10 ing shaping and cluding balance, CIMT had bet- kinematics and
tional normalization of stretching, ter arm use and functional gains
change in tone; unaffected weight-bearing quality of move- in subacute and
subacute hand restrained of affected limb; ment in MAL chronic stroke;
and chronic in a mitt for fine motor tasks and better FM no follow-up
stroke 5 hours/day at and ADL skills scores assessment
time of frequent using unaffected
use; arm;
Modified CIMT 2 hours/day,
2 hours/day, 5 days/week for
5 days/week for 3 weeks
3 weeks

Continued

137
 138
Stroke Rehabilitation
Table 6-3
Evidence Table for Constraint-Induced Movement Therapy—cont’d

AIMS DESIGN, SUBJECTS,

AUTHORS AND OXFORD RATING, COMPARISON OUTCOME
AND YEAR RATIONALE PEDRO SCORE INTERVENTION INTERVENTION ASSESSMENT MEASURES RESULTS COMMENTS

Lin et al, Evaluate ef- Single blind RCT; Modified CIMT Traditional reha- Pretreatment 1. Kinematic Modifieds CIMT Modified CIMT
2007 fect of mod- 32 subjects with (N15) received bilitation group and post- analysis group had lower better than Bo-
ified CIMT chronic stroke (13 OT treatment (N17) re- treatment of arm reaction time bath approach
on motor to 26 months); including prac- ceived OT movement and higher for improving
control of 2b; tice of func- using Bobath 2. MAL percentage of arm kinematics
upper limb 6/10 tional tasks us- approach in- 3. FIM movement time and functional
and func- ing shaping and cluding balance, at peak velocity; gains in chronic
tional normalization of stretching, modified CIMT stroke; no
change in tone; unaffected weigh-bearing group had bet- follow-up
chronic hand restrained of affected limb; ter arm use and assessment;
stroke in a mitt for fine motor tasks quality of move- small sample
5 hours/day at and ADL skills ment in MAL
time of frequent using unaffected and better FIM
use; arm; scores
Modified CIMT 2 hours/day,
2 hours/day, 5 5 days/week for
days/week for 3 3 weeks
weeks
Myint Compare the Single blind RCT; CIMT upper limb OT and PT us- Pretreatment 1. Functional While both Well-designed
et al, effects of 43 patients at sub- training with ing an Bobath and post- test for groups im- study; CIMT
(2008) CIMT with acute stage (2 to OT including approach in- treatment hemipa- proved at post- better than
control 16 weeks post- shaping, task- cluding biman- and 12 retic upper test and follow- Bobath approach
treatment in stroke); oriented train- ual tasks, week extremity up, CIMT in subacute
outpatient 2b; ing (N 23); strengthening, follow-up 2. Action group per- stroke;
subacute 7/10 unaffected limb ROM, position- Research formed better small sample size;
stroke placed in shoul- ing and mobil- Arm Test on all impair- no benefit of
der sling ity training (ARAT) ment level CIMT on
4 hours/day, (N 20); 3. Motor Ac- outcome mea- functional skills
5 days/week for 4 hours/day tivity Log sures at 12 week
2 weeks 5 days/week for (MAL) follow-up. No
2 months 4. Nine-hole differences seen
Peg Test on BI at 12 week
5. Barthel follow-up
Index
Dahl et al, Examine fea- Double blind RCT; CIMT in groups Standard PT and Pretreatment 1. WMFT CIMT group Small sample size,
(2008) sibility and 30 patients at sub- including prac- OT including and post- 2. MAL showed greater CIMT group re-
effect of acute and chronic tice of ADL and upper and lower treatment 3. FIM improvement ceived more
CIMT com- stage (2 weeks leisure skills, extremity train- and 6 4. SIS than control treatment than
pared with post stroke); (N18); ing for 55 min- month group at posttest control group.
traditional 1b, unaffected limb in utes and robot follow-up on WMFT and Since no differ-
rehabilita- 8/10 mitt; exposure for MAL, but differ- ences seen at
tion in the 6 hours /day, 5 minutes at ences washed 6 months, CIMT
short-term 5 days/week for each session; out at 6 month not better than
and long- 2 weeks 30 minutes/day, follow-up. Both conventional
term in an 5 days/week for groups improved treatment in the

Chapter 6 • Approaches to Motor Control Dysfunction: An Evidence-Based Review

inpatient 2 weeks comparably on long-term
setting SIS.
Sawaki Determine if Single blind RCT; CIMT (N 15) Control group Pretreatment 1. WMFT Both groups im- CIMT resulted in
et al, CIMT is 30 subjects with included uni- (N15) re- and post- 2. TMS proved on modest improve-
2008 more effec- subacute stroke manual skill ceived usual and treatment WMFT CIMT ment only in grip
tive than (3 to 9 months acquisition and customary care and 4- group had bet- strength did not
less inten- since stroke); functional train- ranging from month ter grip strength lead to improve-
sive control 2b; ing (object no treatment to follow-up at posttreatment ment in function
intervention 5/10 manipulation); application of and follow-up; or cortical reor-
in changing restraint of un- orthotics or OT no differences ganization
motor func- affected limb us- and PT; seen across
tion and ing hand splint no information groups on other
brain physi- and sling; on dosage; ther- WMFT items
ology in no information on apy given for or TMS
subacute dosage; therapy 10 consecutive measures
stroke given for 10 weekdays
consecutive
weekdays
Brogårdh Examine the RCT 24 patients CIMT mitt group CIMT no Mitt Pretreatment 1. Modified Both groups im- There is no effect
et al, effect of us- (1 to 3 months wore mitt for group had and post- Motor As- proved their of wearing a mitt
2009 ing a mitt poststroke); 90% of waking training includ- treatment, 3 sessment hand and arm during CIMT in
during 2b; hours; ing practice of month scale function but no subacute stroke
CIMT in 6/10 training included fine motor follow-up 2. Sollerman differences were
subacute practice of fine skills, strength Hand seen between
stroke motor skills, training, function groups post-
strength train- stretching; test treatment or at
ing, stretching; 3 hours/day; 5 3. 2-point follow-up
3 hours/day; 5 days/week for discrimina-
days/week for 2 weeks tion test
2 weeks 4. MAL

Continued

139
 140
Stroke Rehabilitation
Table 6-3
Evidence Table for Constraint-Induced Movement Therapy—cont’d
AIMS DESIGN, SUBJECTS,
AUTHORS AND OXFORD RATING, COMPARISON OUTCOME
AND YEAR RATIONALE PEDRO SCORE INTERVENTION INTERVENTION ASSESSMENT MEASURES RESULTS COMMENTS

Lin et al, Compare Single blind RCT; Modified CIMT Control group Pretreatment 1. FM Modified CIMT Modified CIMT
2009 modified 32 subjects with group (N16) (N16) re- and post- 2. FIM group per- better than Bo-
CIT inter- subacute and received OT ceived OT fo- treatment 3. MAL formed better bath approach in
vention with chronic stroke (6 with functional cused on Bo- 4. NEADL on FM, FIM improving motor
a dose- to 40 months post- training of up- bath approach 5. SIS (self-care and function and
matched stroke); per limb using and functional locomotion) and quality of life in
control in- 1b; shaping, nor- task training SIS (ADL, mo- subacute and
tervention 7/10 malization of and weight- bility, and hand chronic stroke
in chronic tone; unaffected bearing; function), on
stroke hand in mitt for unaffected hand the mobility
5 hours/day; in mitt for domain of the
modified CIMT 5 hours/day; NEADL
2 hours/day, control group
5 days/week for 2 hours/day,
3 weeks 5 days/week for
3 weeks
Dromerick Compare Single blind RCT; Dose matched Traditional OT Pretreatment 1. ARAT All three groups Excellent study;
et al, CIMT with 52 subjects with CIMT group group (N17) and post- 2. NIHSS improved on CIMT was no
2009 traditional stroke (28 days (N19) received including com- treatment, 3 3. FIM the ARAT; no more effective
OT and ex- of admission to in- 2 hours of shap- pensatory tech- month 4. SIS differences were than control OT
amine if ef- patient rehabilita- ing (5 days/week niques for follow-up seen between of same intensity;
fect of tion); for 2 weeks) and ADL, ROM, control and high intensity
CIMT is 1b; wore a mitt for strengthening; dose matched CIMT led to less
dose depen- 7/10 6 hours/day; upper limb bi- CIMT group; improvement in
dent in very higher intensity lateral activities; high intensity upper limb func-
early stroke CIMT group 2 hours/day, CIMT had tion.
(N16) received 5 days/week for lower gains on

Chapter 6 • Approaches to Motor Control Dysfunction: An Evidence-Based Review

3 hours (5 days/ 2 weeks ARAT; no dif-
week for 2 ferences seen
weeks) of shap- across groups
ing and wore a on FIM score;
mitt 90% of SIS score was
waking hours; highest for the
both groups dose matched
practiced func- CIMT group at
tional tasks. 90 days

AAUT, Actual Amount of Arm Use Test; ADL, activities of daily living; AMPS, Assessment of Motor and Process Skills; ARAT, Action Research Arm Test; BI, Barthel Index; CIMT,
Constraint Induced Movement Therapy; FIM, Functional Independence Measure; FM, Fugl-Myer Assessment; MAL, Motor Activity Log; MAS, Modified Ashworth Scale; NDT,
neurodevelopmental therapy; NEADL, Nottingham Extended Activities of Daily Living Scale; NIHSS, National Institute of Health Stroke Scale; OT, occupational therapy; PET, posi-
tron emission tomography; PNF, Proprioceptive Neuromuscular Facilitation; PT, physical therapy; RCT, randomized controlled trial; RMA, Rivermead Motor Assessment; ROM, range
of motion; SIS, Stroke Impact Scale; TMS, Transcranial Magnetic Stimulation; WMFT, Wolf Motor Function Test; UL, upper limb

141
142 Stroke Rehabilitation

group of patients most likely to recover from stroke based found CIMT to be more effective than general fitness.
on spontaneous recovery.32,36 However, the results of this study have to interpreted with
There was tremendous variability in the form of CIMT caution as there were differences between groups at base-
and the dosage of intervention. Seven of the nineteen trials line, and subjects were not randomized. In the acute stage,
tested the standard version of CIMT, which included six CIMT is no more effective than dose equivalent func-
hours of practice in each session. The other three trials of tional OT treatment. Higher dose CIMT was less benefi-
standard CIMT included either two hours,18 three hours,9 cial as compared with low dose CIMT.19 In the subacute
or four hours of training in each session.59 However, all the stage, when CIMT is compared with dose equivalent
ten trials of standard CIMT provided massed practice over functional training, both interventions result in similar
10 sessions across two weeks. Nine trials tested a modified improvement (see Table 6-3).
version of CIMT, in which practice was distributed over
sessions ranging from 12 to 30. Modified CIMT trials Clinical Implications. CIMT appears to be a benefi-
have been designed to replicate therapeutic dosage similar cial approach, but future studies need to compare CIMT
to standard practice. However, as Table 6-3 demonstrates, with dose equivalent functional task-oriented training,
there is tremendous variability in dosage, ranging from which is shown to be effective. Such a study may address
30 minutes to six hours of practice per session. the criticism that the improvements demonstrated are due
Since one of the major principles of CIMT is constraint to a nonspecific effect of increased intensity of treatment
of the unaffected hand, all studies included some form of rather than to a specific effect of constrained-induced
constraint using a mitt, sling, hemisling, or splint. There training. Most of the studies reported in Table 6-3 used a
was a large variability across studies in terms of the hours standard CIMT training protocol in which training was
of restraint (from five hours to 90% of waking hours). massed over a period of two weeks and was compared with
a control group that received less intense conventional
Timing of Intervention. Four CIMT trials were training or ineffective traditional approaches, such as the
conducted in the acute stage,6,18,19,66 four trials were con- Bobath approach. Studies using a modified CIMT proto-
ducted in the subacute stage,9,59,63,73 and six trials were col, while demonstrating some benefits, had the limitation
conducted in the chronic stage.46,65,80,85,101,104 Five trials of small sample size or comparison with traditional ther-
included subjects both in the subacute and the chronic apy known to be less effective (Bobath approach).
stage.14,46a,103,105,106 According to Taub and Uswatte,84 the improvements
seen with CIMT could be a result of massing of practice.
Outcome Measures. Most of the studies reviewed Given that similar positive results have been obtained by
measured outcomes at the impairment and activity limita- increasing the intensity of traditional therapy, van der
tion level. Typical instruments used to measure impair- Lee90 argues that using traditional therapeutic procedures
ment level measures were the Action Research Arm Test that often may be less frustrating to patients than CIMT
(which measures upper limb dexterity), the Fugl-Meyer may be just as effective.
Assessment (which measures the ability of the arm to
move against the typical synergistic pattern), the Wolf Robot-Aided Motor Training for Upper Limb Function
Motor Function Test (which quantifies motor function Rationale and Principles. A recent addition to the
after stroke), PET scan, and Transcranial Magnetic Stim- arsenal of techniques for stroke rehabilitation is the use
ulation. Activity limitation was measured by measures of robotic manipulators for providing training of arm
such as the Rehabilitation Activities Profile (based on the movements. Robot manipulators have been used success-
ICF and, which assesses disability and handicap), Motor fully in experimental paradigms that attempted to eluci-
Activity Log (which measures actual amount of use and date the mechanisms underlying normal motor control
quality of movement), Barthel index, and the Functional and learning74 and also to clarify mechanisms underlying
Independence Measure (which measures activity limita- disorders of upper limb movements in patients with
tion). Participation restriction was measured by adminis- movement disorders.76
tration of the Stroke Impact Scale in a few studies. The rationale for using a robotic device in rehabilita-
tion is to decrease the labor-intensive nature of therapy
Results of the Review. The results are equivocal at and to provide a device that could be used for quantitative
present. CIMT is clearly better than the Bobath approach evaluation and treatment.40 Proponents of this approach
either in the subacute or chronic stages. When compared contend that current therapeutic evaluations are usually
with usual care or conventional functional OT and PT, subjective and that therapists spend much time on one-
CIMT is more beneficial in studies where the CIMT on-one interaction with patients. The idea is to have de-
group received a higher dosage of therapeutic interven- vices available at rehabilitation centers for use when the
tion. When compared with dose equivalent functional patient is not in therapy sessions. Given that patients
training, CIMT does not seem more effective. The one spend a large percentage of time outside therapist interac-
exception was the study by Taub and colleagues85 who tion, an attempt at facilitating practice during this time
 Chapter 6 • Approaches to Motor Control Dysfunction: An Evidence-Based Review 143

should be beneficial. Robot-assisted training attempts to think of testing robotic devices as an adjunct to therapy
provide intensive practice of repetitive and stereotyped rather than as a primary method of therapy delivery. Be-
movements. See Chapter 11 for a full discussion of this fore additional RCT are implemented, the rationale and
topic. experimental procedures need to be clarified. For in-
stance, at present, robot training provides practice of
Outcome Studies. A review of studies testing the ef- pointing movements (movements of the shoulder and
fectiveness of robot assisted training revealed ten RCT, as elbow) on the horizontal plane. In an effort to isolate
listed in Table 6-4. Typical training with this approach movements to these two joints, the trunk and distal ex-
involves the patient making horizontal plane movements tremities are often stabilized by constraints producing
while grasping the handle of the robot manipulator. Tar- rather unnatural conditions for practice of arm move-
get locations and patient movement are displayed on a ments. Functional reaching movements involve coordi-
computer screen in front of the patient. Typically, patients nated movement of the trunk-arm complex and of the
are trained to produce movements of the shoulder and wrist-hand complex. Whether practice of isolated compo-
elbow joints while the wrist and hand joints and the trunk nents of the shoulder-elbow complex would transfer to
are immobilized with restraints. The robot is typically real-world situations is unclear, given the task-specific
programmed to either passively move the paretic limb or nature of transfer of training. The responsibility of thera-
produce an assistive force during movements. The num- pists is to select appropriate, challenging functional tasks,
ber of sessions (12 to 60) and the total training time (eight vary task parameters, progress to more difficult tasks, and
hours to 300 hours) varied tremendously across studies. test for transfer. Given the complexity of therapeutic
training, robot manipulators can perhaps serve best by
Timing of Intervention. Two studies tested patients providing quantitative evaluation of impairments rather
in the acute stage,52,68 four studied patients in the subacute than as a therapeutic tool.
stage,20,28,50,93 and four studies tested patients at the
chronic stage.15,33,49,95 Body Weight Support and Treadmill Training
to Improve Gait
Outcome Measures. Most of the studies reviewed Rationale and Principles. Approximately half the
measured outcome variables at the impairment and activ- individuals who suffer a stroke do not recover their ability
ity limitation levels. The exceptions were studies that to walk independently.32 Given that independent walking
tested outcomes only at the impairment level.15,28 Typical is a necessary prerequisite to successful community rein-
instruments used to measure impairments included the tegration, not surprisingly gait training has occupied an
Fugl-Meyer Assessment, Action Research Arm Test, important role in therapeutic practice following stroke.
Trunk Control Test, and kinematic analysis of arm move- Gait training following stroke involves practice of indi-
ment. Instruments used to measure activity limitation vidual segments of walking, practice of walking over
were the Functional Independence Measure, Chedoke- ground with assistance of therapists and/or assistive de-
McMaster Stroke Scale, and the Barthel index. vices, or more recently, practice of walking on a treadmill
with partial body weight support.
Results of the Review. The results of effectiveness of Experiments on animals have shown that the basic neu-
robot assisted training are fairly clear; when compared ral circuitry for producing the rhythmic alternating move-
with robot exposure,20,92 traditional therapy using the ments of the lower limb is at the spinal cord level. Loco-
Bobath approach49,50,52 or neuromuscular facilitation,15,28 motor training with weight support of the hindlimbs has
robot training is more effective in improving function. been shown to improve gait to near normal levels in cats
This result can be explained by the fact that subjects in the whose spinal cords have been transected at thoracic levels,
robot groups received more training of upper limb move- thereby isolating lower cord segments from the rest of the
ments compared with the control groups. However, when central nervous system.2 In fact, patients with spinal cord
robot assisted training is compared with dose equivalent injury have been shown to improve after treadmill training
functional training, robot assisted training offers no ad- with body weight support.99 Apart from the limited early
ditional benefits.33,68,95 evidence of the benefit of treadmill training in patients
with spinal cord injury, the rationale for this approach is
Clinical Implications. The results highlight that ro- that it removes some of the biomechanical and equilibrium
bot assisted training offers no advantage to functional constraints of weight-bearing and facilitates walking by
training with a therapist. Its effectiveness is limited to activation of spinal locomotor circuits. See Chapter 15.
studies where robot assisted training was compared with
traditional approaches that have been shown to be inef- Outcome Studies. A review of studies testing the ef-
fective (such as the Bobath approach). Given the expense fectiveness of body weight support training revealed six
and extensive training of personnel to use the robot de- RCT listed in Table 6-5. Typical training with this ap-
vice, and its limited effectiveness, it may be beneficial to proach involves beginning gait training on a treadmill by
Text continued on p.152
 144
Stroke Rehabilitation
Table 6-4

Evidence Table for Robot-Assisted Therapy

AIMS DESIGN, SUBJECTS,
AUTHORS AND OXFORD RATING, COMPARISON OUTCOME
AND YEAR RATIONALE PEDRO SCORE INTERVENTION INTERVENTION ASSESSMENT MEASURES RESULTS COMMENTS

Volpe Test whether RCT; Robot training in- Robot exposure; Beginning 1. FM Experimental Robot training
et al, additional 56 patients in sub- volved pointing 1 hour/week on and end of 2. MSS group had bet- group had
2000 robotic acute stage to a series of tar- robot training 3. Motor Power ter motor out- more train-
training of 2b; gets using mo- (5 weeks) Score come related ing. Results
the paretic 7/10 tion at shoulder, 4. FIM to shoulder show limited
limb en- elbow, or both and elbow improve-
hances mo- joints; movements ment in
tor outcome 1 hours, 5 days a and better FIM function. No
in subacute week for 5 weeks scores than follow-up
stroke control group
Lum et al, Compare RCT; Standard rehabili- Standard rehabil- Beginning of 1. FM Robot-assisted Small sample
2002 robotic 27 subjects, chronic tation and robot- itation (Bobath training, 2. BI group had size, robot
training hemiparesis aided therapy approach) for one month, 3. FIM (self-care larger im- training bet-
with con- (6 months), 2b, that included 55 minutes and end of and transfer provements on ter than
ventional 6/10 pointing move- robot exposure training sections) proximal FM Bobath ap-
PT (NDT) ments involving for 5 minutes at (2 months) 4. Strength mea- at 1 and 2 proach at
in chronic shoulder and el- each session; and 6 sured through months and improving
stroke bow joints, 1 hour session/ month force trans- higher FIM proximal
1 hour session/day day for 24 days follow-up ducer scores at movements
for 24 days 5. Reaching 6 months
kinematics
Fasoli Examine RCT retrospective, Robot training Robot exposure Beginning of 1. FM Robotic group Control group
et al, effects of 56 patients with group (N 30) group (N26) training, 2. MSS performed bet- did not re-
2004 robotic sub-acute stroke received passive received train- during 3. MRC test of ter on the FM, ceive dose
training in (3 weeks); or active assistive ing for 1 hour/ training and motor power Motor Status equivalent
subacute 2b; practice of pla- week; subjects at discharge 4. FIM Score, and practice; ro-
stroke 6/10 nar arm move- practiced planar MRC test of botic therapy
ments involving arm movements motor power; better than
the shoulder and without both groups robotic
elbow joints with assistance improved exposure on
the MIT-Manus; scores on FIM; impairment
1 hour/day, 5 days/ no differences level mea-
week for 5 weeks were seen sures
across groups
Daly et al, Compare ef- RCT; In-motion robot Functional neu- Beginning of Baseline, end of The robot group Small sample
2005 fects of 12 chronic stroke training romuscular training, treatment and showed im- size;
task-ori- patients (1.5 hours/day) stimulation (1.5 end of 6 month follow provement on addition of
ented plus (12 months) focused on hours/day) in- training (12 up the AMAT, the robot train-
robotic 2b; shoulder and el- volving wrist weeks) and 1. AMAT func- AMAT shoul- ing to func-
therapy in 5/10 bow movement and finger acti- 6 month tional ability der-elbow, FM, tional
chronic accuracy and vation. Subjects follow-up 2. AMAT and movement training is
stroke pa- smoothness. also practiced shoulder- accuracy and beneficial
tients Subjects also functional elbow smoothness; for improv-
practiced func- upper limb 3. AMAT wrist- the stimulation ing perfor-
tional upper tasks (3.5 hand group im- mance at the

Chapter 6 • Approaches to Motor Control Dysfunction: An Evidence-Based Review

limb tasks hours/day). 4. FM coordina- proved on impairment
(3.5 hours/day). Training for tion scale AMAT wrist- level.
Training for 5 hours/day, 5 5. Target hand
5 hours/day, days/week accuracy
5 days/week for for 12 weeks. 6. Movement
12 weeks. smoothness
Hesse Compare RCT; Standard rehabili- Standard rehabil- Beginning of 1. FM upper AT group had Well-
et al, computer- 44 subacute stroke tation based on itation based on training, extremity higher BI score designed
2005 ized AT patients Bobath approach Bobath end of 2. MRC Scale at baseline; study; no
with ES in (4 8 weeks); (45 minutes of approach training 3. MAS FM, MRC functional
subacute 1b; PT, 30 minutes (45 minutes of (6 weeks) scores outcomes
stroke 7/10 of OT), plus PT, 30 minutes and improved more measured;
patients practice with of OT), plus 3-month for AT group additional
arm trainer for electrical stim- follow-up robot
pronation- ulation of wrist training
supination and extension improved
wrist flexion and movements; motor per-
extension move- 20 min/day, formance
ments; 20 min/ 5 days/week for
day, 5 days/week 6 weeks
for 6 weeks

Continued

145
 146
Stroke Rehabilitation
Table 6-4
Evidence Table for Robot-Assisted Therapy—cont’d
AIMS DESIGN, SUBJECTS,
AUTHORS AND OXFORD RATING, COMPARISON OUTCOME
AND YEAR RATIONALE PEDRO SCORE INTERVENTION INTERVENTION ASSESSMENT MEASURES RESULTS COMMENTS

Lum et al, Compare RCT; Three groups of Conventional Beginning of 1. FM upper Baseline differ- Small sample
2006 unilateral 30 subacute patients robot training; therapy training, extremity ences in MAS size per
and bilateral (1 to 5 months unilateral, bilat- (Bobath ap- end of 2. MSS and MSS group;
robotic poststroke); eral or combined proach); training (4 3. FIM scores; com- baseline
training 2b; group had 50 1 hour/day for weeks) and 4. Motor Power bined robot differences;
with con- 4/10 minutes of robot 4 weeks 6 month exam group better no functional
ventional training; follow-up scores on FM improve-
PT in 1 hour/day for and MSS score ment
subacute 4 weeks at 4 weeks but
stroke not at 6
months; no
improvement
on FIM
Kahn et al, Examine RCT; Active-assistive Training of free 3 tests before 1. Pointing No baseline dif- Small sample
2006 effects of 19 patients with robot training reaching (unas- training; 3 movement ferences be- size; no ben-
active- chronic stroke including reach- sisted) move- tests after outcomes in- tween groups; efit of robot
assistive (1 year); ing to different ments; training; 6 cluding stiff- both groups training
robot 2b; directions; 24 sessions month ness, range, improved over prac-
training in 4/10 24 sessions (45 min) over 8 follow-up speed, ROM speed; tice of
chronic (45 min) over weeks smoothness smoothness reaching
stroke 8 weeks and straight- better for movements.
ness control group No func-
2. Chedoke Mc- tional out-
Master score comes tested
3. Rancho Los
Amigos Func-
tional Test
time to
completion
Masiero Examine RCT; Standard PT and Standard PT and Beginning of 1. MRC score Robot training Robot group
et al, effects of 35 patients with OT (Bobath OT (Bobath training, 2. FM well tolerated; had higher
2007 additional acute stroke treatment); addi- treatment); ad- end of 3. FIM robot group per- baseline
early ro- (1 week); tional training ditional robot training 4. Trunk control formed better FIM score;
botic ther- 1b; with NeRebot, (NeRebot) (5 weeks); test on FM, FIM, control
apy on 6/10 active assisted exposure; 3 and 8 5. MAS proximal MRC group had
impairments shoulder and el- 1 hour/week for month scores at the less expo-
and func- bow movements; 5 weeks follow-up end of train- sure than
tional re- 4 hours/week for ing; experimen-
covery 5 weeks on follow up tal group;
benefits sus- robot ther-

Chapter 6 • Approaches to Motor Control Dysfunction: An Evidence-Based Review

tained on FM, apy may
MRC deltoid complement
and FIM early reha-
bilitation
Rabadi Determine RCT; Robot group Control group Beginning 1. FM All three groups Robotic ther-
et al, the effect of 30 subjects with (N10) used the (N10) re- and end of 2. MSS improved on apy not bet-
2008 activity acute stroke MIT-Manus to ceived OT in- training 3. FIM total FM, MSS, and ter than
based ther- (4 weeks); practice passive cluding ROM 4. FIM motor FIM scores. functional
apy using 2b; and active assis- and active 5. FIM cognitive No differences OT training
either an 6/10 tive planar movements were seen in acute
ergometer, movements during func- across groups. stroke
robotic de- involving the tional activity; OT group had
vice or oc- shoulder and el- 640 movements better scores
cupational bow joints; 1024 in 40 min ses- on the FIM
therapy in movements in sion, 5 days/ and FM com-
acute stroke 40 min session, week for pared with er-
5 days/week for 12 days, in gometer and
12 days addition to robotic groups
Ergometer group standard reha-
(N10) used a bilitation for
bidirectional 3 hours/day.
pedal for aerobic
exercise of the
upper limb; 2200
movements in
40 min session,
5 days/week for
12 days.
Both groups re-
ceived, in addi-
tion, standard
rehabilitation for
3 hours/day.

147
Continued
 148
Stroke Rehabilitation
Table 6-4
Evidence Table for Robot-Assisted Therapy—cont’d
AIMS DESIGN, SUBJECTS,
AUTHORS AND OXFORD RATING, COMPARISON OUTCOME
AND YEAR RATIONALE PEDRO SCORE INTERVENTION INTERVENTION ASSESSMENT MEASURES RESULTS COMMENTS

Volpe Compare in- RCT; Robot group Therapy group Pretreatment 1. FM Shoulder Both groups im- Robot train-
et al, tensive PT 21 patients with (N11) used the (N10) prac- and post- elbow proved over ing no bet-
2008 with robotic chronic stroke MIT-Manus to ticed active treatment, 2. FM wrist duration of ter than
training in (6 months); practice passive assistive and 3 month hand treatment and task-
chronic 2b; and active assis- goal directed follow-up 3. MAS maintained im- oriented
stroke 6/10 tive planar functional arm 4. SIS provement at training in
movements in- movements; 5. ARAT 3 months; no chronic
volving the treatment based differences be- stroke
shoulder and on motor learn- tween groups
elbow joints; ing approach;
1 hour/day, 1 hour/day,
3 days/week for 3 days/week for
6 weeks 6 weeks

AMAT, Arm Motor Ability Test; ARAT, Action Research Arm Test; AT, arm trainer; BI, Barthel index; ES, electrical stimulation; FIM, Functional Independence Measure; FM,
Fugl-Myer Assessment; MAS, Modified Ashworth Scale; MIT, Massachusetts Institute of Technology; MRC, Medical Research Council score; MSS, Motor Status Score; NDT,
neurodevelopmental treatment; OT, occupational therapy; PT, physical therapy; RCT, randomized controlled trial; RMA, Rivermead Motor Assessment; ROM, range of motion;
SIS, Stroke Impact Scale;
Table 6-5
Evidence Table for Treadmill Training with Body Weight Support
AIMS DESIGN, SUBJECTS,
AUTHORS AND OXFORD RATING, COMPARISON OUTCOME
AND YEAR RATIONALE AND PEDRO SCORE INTERVENTION INTERVENTION ASSESSMENT MEASURES RESULTS COMMENTS

Nilsson Compare walk- Double blind RCT; Treadmill training Walking training Pretreatment 1. FIM Both groups Good study
et al, ing training 73 patients at sub- with BWS (N 37); and post- 2. FM improved per- RCT 10-
2001 over ground acute stage (N 36); 30 minutes/day treatment, 3. FAC formance on month follow-
(based on a (8 weeks); 30 minutes/day 5 days/week for 10 month 4. Walking ve- the FIM, up; no benefit

Chapter 6 • Approaches to Motor Control Dysfunction: An Evidence-Based Review

motor re- 1b; 5 days/week for 2 months follow-up locity (10 walking veloc- of BWS
learning 7/10 2 months meters) ity, FAC, and training
approach) 5. BBS balance. No
with tread- differences
mill training were seen
in subacute across groups.
stroke stage
da Cunha Compare BWS RCT; Supported Control group Pretreatment 1. FAC Differences Small sample
et al, treadmill 13 patients in treadmill (N7) received and post- 2. Gait speed were seen in size; no
2002 training and subacute stage training group regular PT, treatment 3. Walking dis- walking en- follow-up;
typical ther- (6 weeks) (N6) received OT, which in- tance ergy cost and BWS not
apy with only 20 minutes/day regular PT cluded gait 4. Energy walking dis- more effective
typical 5 days/week for which included training and expenditure tance. No than regular
therapy 3 weeks stair climbing stair climbing; differences therapy
2b; and walking on 3 hours/day of were seen for
4/10 uneven surfaces total therapy; other out-
and supported come mea-
treadmill sures.
training;
3 hours/day of total
therapy; 20 min/
day treadmill
training

Continued

149
 150
Stroke Rehabilitation
Table 6-5
Evidence Table for Treadmill Training with Body Weight Support—cont’d
AIMS DESIGN, SUBJECTS,
AUTHORS AND OXFORD RATING, COMPARISON OUTCOME
AND YEAR RATIONALE AND PEDRO SCORE INTERVENTION INTERVENTION ASSESSMENT MEASURES RESULTS COMMENTS

Werner Compare BWS RCT crossover trial; BWS treadmill Electromechani- Pretreatment, Measured at Both groups Good study.
et al, treadmill 30 patients in sub- training (N15); cal gait trainer 1, 2, 3, 4, 5 baseline, improved in electrome-
2002 training with acute stage 15 to 20 min/day (N15); weeks of 6 wks and 6 weeks; sub- chanical
electrome- (4 to 12 weeks);  7 days/week 15 to 20 min/day treatment, 6 months. jects in elec- trainer as good
chanical gait 2b;  6 weeks.  7 days/week posttreat- 1. FAC tromechanical as BWS tread-
trainer in 7/10  6 weeks. ment, 6 2. Gait Velocity trainer group mill training
subacute month 3. RMA had better and requires
stroke pa- follow-up 4. MAS FAC scores at fewer
tients 6 weeks; and therapists.
required use
of 1 therapist
assistance;
treadmill
group re-
quired 2
therapist
assistance;
no differences
between
groups at
6 months.
Barbeau Compare Single blind RCT; BWS (with 2 ther- Treadmill train- Pretreatment Baseline, end of Both groups Moderate
and treadmill 100 chronic sub- apists) treadmill ing without and post- training improved quality study
Visintin, training plus acute patients (1 to training with BWS; 20 min treatment, (6 weeks) and over 6 weeks; shows that
2003 BWS with 5 months); 40% of body  4 days/week 3 month 3 month greater im- BWS may be
treadmill 2b; weight support;  6 weeks follow-up follow-up provement appropriate for
training with- 4/10 20 min  4 days/ 1. BBS seen in BWS severely im-
out BWS in week  6 weeks 2. STREAM group for se- paired patients
subacute 3. Overground verely im- in chronic
stroke walking paired stage
speed; patients on
4. Endurance all outcomes.
(walk dis-
tance)
Sullivan Compare BWS Single blind RCT; BWS with 30% to Limb loaded Pretreatment Baseline, after BWS treadmill High quality
et al, with lower 80 chronic stroke 40% weight; cycling  UE; and post- 12 and 24 groups im- study; shows
2007 extremity patients (4 months Group 1 hour session, treatment, treatment ses- proved on that task-
strength to 5 years); 1: BWS  UE 4  week, 6 month sions; 6 month self-selected specific BWS
training in 1b; 2. BWS  UE 6 weeks follow-up follow-up; and fast training bene-
chronic 7/10 3. BWS  Lower 1. Overground walking ficial for
stroke extremity pro- self selected speed; chronic stroke
gressive resis- walking speed whereas limb patients com-
tive exercise; 2. Fast walking loaded cycle pared with
1 hour session, speed group im- resistive
4  week, 3. 6–minute proved only cycling.

Chapter 6 • Approaches to Motor Control Dysfunction: An Evidence-Based Review

6 weeks walk distance on 6 min
4. FM walk distance
5. SIS; and flexor
6. SF-36; torque after
7. Lower ex- 24 sessions
tremity peak and at 6
torque month
follow-up
Yen et al, Examine ef- RCT nonblinded; 50 min PT session 50 min PT ses- Pretreatment Baseline and PT + BWS Study shows
2008 fects of addi- 14 chronic stroke (stretching, sion (stretch- and post- post- group im- that additional
tional BWS patients strengthening, ing, strength- treatment treatment; proved their training using
training on (6 months); balance, over- ening, balance, 1. BBS BBS score, BWS improves
motor perfor- 2b; ground walking) overground 2. Gait analysis gait speed balance, gait
mance and 7/10 2 to 5 sessions/ walking) 2 to (GAITRite); and step and cortical
cortical week for 4 weeks 5 sessions/week 3. Cortical area length and excitability.
excitability  BWS (30 min for 4 weeks and motor decreased Did not test
session 3 days/ threshold motor additional PT
week for using TMS threshold; in control
4 weeks) with control group, so im-
1 to 2 therapists group im- provements
proved in may be a result
gait speed of nonspecific
and cadence. additional
training

BBS, Berg Balance Scale; BWS, body weight support; FAC, Functional Ambulation Classification; FIM, Functional Independence Measure; FM, Fugl-Meyer Assessment; MAS,
Modified Ashworth Scale; OT, occupational therapy; PT, physical therapy; RCT, randomized controlled trial; RMA, Rivermead Mobility Assessment; SIS, Stroke Impact Scale;
STREAM, Stroke rehabilitation assessment of movement; TMS, Transcranial Magnetic Stimulation; UE, upper extremity ergometry.

151
152 Stroke Rehabilitation

supporting the body in a harness. The initial support body weight support training may be in the case of se-
given was generally 40% of the body weight, which is verely impaired patients who may benefit from relearn-
gradually decreased as the patient improves. The length ing the walking movement patterns without being en-
of training ranged from 12 to 42 sessions conducted cumbered with controlling their body weight and forward
across four to eight weeks. In two of the studies, body progression.
weight support treadmill training was coupled with gait
training. SUMMARY
Timing of Intervention. Treadmill training was initi- A challenging yet exciting period for stroke rehabilita-
ated in the subacute stage in four studies3,13,61,98 and in the tion is occurring as occupational and physical therapists
chronic stage in two studies.79,107 are being asked to provide training based on sound sci-
entific principles and with demonstrated effectiveness.
Outcome Measures. Most of the studies reviewed The lack of support for traditional neurotherapeutic ap-
measured outcome variables at the impairment and activ- proaches, such as Bobath approach, recent advances in
ity limitation levels. Only one study measured outcomes understanding of motor control and dyscontrol, and
at all three levels of the ICF.79 Typical instruments used to emerging technologies have facilitated a second para-
assess impairment level measures were the Stroke Reha- digm shift toward a functional task-oriented approach.
bilitation Assessment of Movement (which evaluates vol- At present, the literature suggests that task-oriented
untary movement of the limbs and mobility), Berg Bal- training of the upper limb and functional walking train-
ance Scale (which evaluates balance during sitting and ing is the most effective method in stroke rehabilitation.
standing activities), walking speed, distance and endur- The challenge for the next decade is to develop more
ance, the Fugl-Meyer Assessment (which evaluates loco- creative, functional, task-oriented intervention tech-
motor function and control, sensory quality, and balance), niques that will maximize the independent functioning
and kinematic analysis of walking. Instruments used to of patients within their natural contextual settings10 and
measure activity limitation were the Functional Indepen- to test these techniques in a systematical manner at dif-
dence Measure, Functional Ambulation Classification ferent stages of the recovery process, in different prac-
(which quantifies amount of assistance needed in walk- tice settings, and at different intensities. Most likely, no
ing), and the Rivermead Motor Assessment. Instruments one technique will offer a panacea for stroke rehabilita-
used to measure participation limitation were Stroke Im- tion given the varied nature of impairments and activity
pact Scale and SF-36. limitations.

Results of the Review. When compared with func- ACKNOWLEDGMENTS

tional training of ambulation or training with an electro-
mechanical trainer, body weight supported treadmill The author dedicates this chapter to the memory of his
training was no more effective, all interventions produc- uncle Dr. Sangameshwar who lost his battle to stroke dur-
ing similar, but positive, outcomes. When compared with ing the writing of this chapter. The author acknowledges
control groups that did not have training of walking, body Glen Gillen and Clare Bassile for helpful discussions.
weight support was more effective in outcomes related to
walking and balance. When body weight support was REVIEW QUESTIONS
added to the PT intervention, it was more effective.107
However, this benefit may be the result of additional 1. What is evidence-based practice?
training since the control group did not receive dose 2. What are the principles of evidence-based practice?
equivalent therapy. The clearest evidence for the benefit 3. What are the criteria for reviewing articles on treat-
of body weight support treadmill training was seen for ment outcomes?
severely impaired patients.3 4. Describe the most common research designs used in
outcome studies.
Clinical Implications. The review suggests that 5. What are some of the basic principles of neurothera-
training of walking and balance may be task-specific, and peutic approaches?
body weight support treadmill training may not be more 6. Is there evidence to support the application of neuro-
effective compared with functional training without therapeutic approaches?
body weight support. When examined in the context of 7. What are some of the basic principles of the functional
the high cost associated with body weight support ap- task-oriented approach?
paratus, and the number of therapists required to admin- 8. Describe the evidence to support the task-oriented ap-
ister therapy, functional training may be more cost- proach, CIMT, treadmill training and body weight
effective and equally beneficial. The only indication for support, and robot-assisted training.
 Chapter 6 • Approaches to Motor Control Dysfunction: An Evidence-Based Review 153

22. Gordon J: Assumptions underlying physical therapy intervention:

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 g l en g i l l en

chapter 7

Trunk Control: Supporting

Functional Independence

key terms
activities of daily living static balance trunk
limits of stability postural control anticipatory postural control
hemiplegia dynamical balance stability

chapter objectives
After completing this chapter, the reader will be able to accomplish the following:
1. Understand the functional anatomy of the trunk.
2. Understand the control requirements for various movement patterns and activities.
3. By activity analysis, understand key components of trunk control required for
independence in various activities of daily living.
4. Comprehensively evaluate trunk control and its effect on function.
5. Implement interventions to improve and compensate for loss of trunk control.

Loss of trunk control commonly occurs in patients ■Impaired ability to interact with the environment
who have had a stroke and persists into the chronic ■Visual dysfunction resulting from head/neck
stage of recovery.52 The recovery of trunk control is malalignment
varied, but during the first month after stroke, signifi- ■ Symptoms of dysphagia because of proximal mal-
cant improvements may be observed. In contrast to alignment
common beliefs, the time course of recovery of the ■ Decreased independence in activities of daily living
trunk is similar to the recovery of arm, leg, and func- (ADL) and other meaningful tasks
tional ability.51 ■ Decreased sitting and standing tolerance, balance,
Impairments in trunk control include weakness (both and function
contralesional and, to a lesser extent, ipsilesional), loss of For a comprehensive review of this topic, see Chapters 4
stability, stiffness, and loss of proprioception, and may and 5 for incorporating task-oriented, learning and envi-
lead to the following: ronmental strategies into treatment plans focused on
■ Dysfunction in upper and lower limb control improving trunk control, Chapter 8 for a complete over-
■ Increased risk of falls view of the multiple variables that affect balance skills,
■ Potential for spinal deformity and contracture Chapter 10 for a review on the interdependence of trunk

156
 Chapter 7 • Trunk Control: Supporting Functional Independence 157

control and upper extremity function, and Chapter 14 for paretic side was 32.1%, which was significantly less than
an overview of mobility impairments. the mean lateral flexion force on the nonparetic side. His
Regaining trunk control has been a major focus of stroke study further demonstrated a statistically significant cor-
rehabilitation for many years. Until more recently, the ma- relation between sitting balance and strength of the lateral
jority of the literature focusing on trunk control/postural trunk flexors.
control was based on expert clinicians’ observations of and Bohannon9 also studied the recovery of trunk muscle
treatment philosophies about trunk dysfunction after strength after stroke in 28 subjects. Subjects’ strength was
stroke. The traditional approaches to treatment7,8,17,22,40 tested in a variety of directions, including forward flexion,
have emphasized improved trunk control as a key element movement toward the paretic side, and movement toward
of focus in the stroke population, and this focus continues the nonparetic side. Statistical analysis demonstrated that
as therapists integrate current models of motor control and trunk muscle strength increased significantly over time.
learning (see Chapters 4 and 6). The greatest recovery was in the direction of forward
flexion. This study again verified a strong correlation be-
AN OVERVIEW OF COMMON TRUNK tween trunk muscle strength and sitting balance at the
IMPAIRMENTS THAT MAY INTERFERE initial and final assessments.
WITH DAILY FUNCTION Esparza and colleagues23 examined hemispheric spe-
cialization and the coordination of arm and trunk move-
While motor control studies after stroke focus primarily ments during pointing in subjects with strokes. They
on upper extremity function and/or gait (see Chapters 10 concluded that arm and trunk timing was disrupted com-
and 15), there is a body of descriptive evidence that aims pared with healthy controls, temporal coordination of
to give clinicians insight into the various specific trunk trunk and arm recruitment is mediated bilaterally by each
impairments observed after stroke. hemisphere, and that the differences they found in the
Dickstein and colleagues20 examined anticipatory pos- range of trunk displacement between subjects with right
tural adjustment in trunk muscles during the performance and left lesions suggest that left hemisphere plays a
of upper and lower limb flexion tasks in patients with greater role than the right in controlling complex arm-
hemiparesis secondary to stroke. The researchers re- trunk movements.
corded electromyographic activity of the lumbar erector Ryerson and colleagues43 documented trunk position
spinae and of the latissimus dorsi muscles bilaterally dur- sense impairments in those with poststroke hemiparesis.
ing flexion of either arm and from the two rectus ab- Specifically, individuals exhibited greater trunk reposi-
dominis and obliquus externus muscles during flexion of tioning error than age-matched controls. Based on this
either hip. The authors documented impairments in the finding, the authors recommended trunk position sense
activity of trunk muscles in the hemiparetic subjects. This retraining emphasizing sagittal and transverse movements
was manifested in the reduced activity level of the lateral as a potential poststroke intervention strategy to improve
trunk muscles, in delayed onset, and in reduced synchro- trunk balance and control.
nization between activation of pertinent muscular pairs. In addition to the mentioned studies, several studies
Further, they documented that these impairments were have focused on documenting electromyographic activity
associated with motor and functional deficits. in normal subjects during a variety of tasks including trunk
Bohannon, Cassidy, and Walsh11 have studied trunk displacements.1,5,19,25,50,58 See Basmajian’s and DeLuca’s5
muscle strength impairments after stroke (specifically classic text for a comprehensive review of electromyo-
forward and lateral trunk flexion strength). Their study graphic studies performed during functional tasks.
included 20 patients with stroke and resultant hemiparesis
and 20 control subjects. Trunk strength was measured FUNCTIONAL TRUNK ANATOMY
with a handheld dynamometer; subjects were seated up-
right during the study. Results indicated that trunk Skeletal System
strength, whether lateral or forward, was significantly This section reviews the bony components of trunk
decreased in the patients relative to controls. The greatest anatomy, including articulations and range of motion
difference in strength was in forward flexion strength. (ROM).
The patients demonstrated trunk weakness on the paretic
side relative to the nonparetic side. The conclusion was Vertebral Column. The vertebral column is made up of
that trunk muscle strength was impaired multidirection- 26 vertebrae, which are classified as follows:
ally in the stroke population. ■ Cervical: 7
Bohannon10 studied 11 stroke patients and evaluated ■ Thoracic: 12
lateral trunk flexion strength and the effect of trunk ■ Lumbar: 5
muscle strength on sitting balance and ambulation. His ■ Sacral: 5 (fused into one bone, the sacrum)
results indicated that the mean lateral flexion force on the ■ Coccygeal: 4 (fused into one or two bones, the coccyx)
158 Stroke Rehabilitation

As a whole, the vertebral column from sacrum to skull is

equivalent to a joint with three degrees of freedom33 in
the directions of flexion and extension, right and left lat-
eral flexion, and axial rotation. Kapandji33 has documented
the ROM throughout the vertebral column (Table 7-1). Cervical
curvature
An understanding of spinal alignment is necessary for
effective evaluation and treatment planning. Normal
alignment of the vertebral column implies that the appro-
priate spinal curvatures are present. In the sagittal plane, Thoracic
curvature
the vertebral column shows four curvatures33 (Table 7-2
and Fig. 7-1).

Pelvis
According to Kapandji,33 “The bony pelvis constitutes the
base of the trunk. It supports the abdomen and links the
vertebral column to the lower limbs. It is a closed osteo- Lumbar
articular ring made up of three bony parts and three curvature
joints.” The three bony parts include the two iliac bones
and the sacrum. The three joints of the pelvis include two
sacroiliac joints and the symphysis pubis. It is critical to
Sacral
remember that because of the firmness of the sacroiliac curvature
and lumbosacral junctions, every pelvic movement is

Table 7-1
Range of Motion of the Vertebral Column Figure 7-1 Lateral view of spine with spinal curvatures.
MOVEMENT RANGE OF MOTION
accompanied by a realignment of the spine predominantly
Flexion Cervical: 40 degrees in the lumbar region.47
Thoracolumbar: 105 degrees
Pelvic tilt can occur anteriorly or posteriorly. In an
Total: 145 degrees
Extension Cervical: 75 degrees
anterior tilt, the anterior superior iliac spines of the ilia
Thoracolumbar: 60 degrees migrate anteriorly to the foremost part of the symphysis
Total: 135 degrees pubis. This pelvic motion accentuates the lumbar curve
Lateral flexion Cervical: 35 to 45 degrees and results in increased hip flexion. In contrast, posterior
Thoracic: 20 degrees pelvic tilt results in a “flattening” of the lumbar curve
Lumbar: 20 degrees and an increase in hip extension. Lateral pelvis tilting
Total: 75 to 85 degrees results in a height discrepancy of the iliac crests and is
Rotation Cervical: 45 to 50 degrees accompanied by lateral spine flexion and a lateral rib
Thoracic: 35 degrees cage displacement.
Lumbar: 5 degrees
Total: 85 to 90 degrees
Rib Cage
The rib cage is formed by the sternum, costal cartilage,
ribs, and the bodies of the thoracic vertebrae. The rib
Table 7-2 cage protects the organs in the thoracic cavity, assists in
respiration, and provides support for the upper extremi-
Spinal Curvatures ties. During inspiration the ribs are elevated, and during
POSTERIOR MOVEMENT
expiration the ribs are depressed.
Although each rib has its own ROM (occurring pri-
CURVATURE CONVEX CONCAVE
marily at the costovertebral joint), rib cage shifts occur
Sacral (fixed) X
with movement of the vertebral column. During column
Lumbar X extension, the rib cage migrates anteriorly, and the ribs
Thoracic X are elevated. During spinal flexion, the rib cage moves
Cervical X posteriorly, and the ribs are depressed. Lateral flexion
results in a right or left shift of the rib cage in the frontal
 Chapter 7 • Trunk Control: Supporting Functional Independence 159

plane. Finally, rotation of the vertebral column results in When this muscle is activated and not opposed by the
one side of the rib cage moving posteriorly and movement extensors, the pelvis and sternum are approximated, the
of the opposite side anteriorly in the transverse plane. pelvis is pulled into a posterior tilt, and the lumbar curves
flatten. Because of its multisegmental arrangement, the
Muscular System rectus abdominis can contract in part or as a whole, mak-
Muscles of the Abdominal Wall ing a variety of postures possible. De Troyer’s work19
The general functions of the abdominal muscles are as demonstrated that “abdominal muscle recruitment which
follows: naturally occurs in response to posture in most individuals
■ Abdominal viscera support does not uniformly involve the whole of the muscles.”
■ Respiration assistance The rectus abdominis (and the other muscles of the
■ Trunk control in the directions of flexion, lateral trunk) require a stable origin to function efficiently.17
flexion, and rotation This stable origin can be the pelvis or thorax, depending
Although these muscles are situated primarily on the an- on the posture and which part of the trunk is moving.
terior aspect of the trunk, they also are situated laterally Davies17 further explains, “The pelvis is stabilized in ly-
and slightly posteriorly, forming a girdle around the abdo- ing, sitting, and standing by the activity of the muscles
men. The abdominal muscles consist of three groups: the around the hips, and in sitting and lying the stabilization
rectus abdominis, the obliques (internal and external), and is helped by the weight of the legs themselves. Stabiliza-
the transversus abdominis (Fig. 7-2). tion of the thoracic origin for activities in which the ab-
dominals contract to move or prevent movements of the
Rectus Abdominis. The rectus abdominis consists of pelvis requires selective extension of the thoracic spine.”
right and left sides that are separated by a fibrous band Davies further points out that the abdominal muscles can-
called the linea alba, which runs from the xiphoid process not function effectively when their origin and insertion
to the pubis. are approximated (e.g., in patients with an exaggerated
The proximal attachment is the xiphoid process of the thoracic kyphosis). Winzeler-Mercay and Mudie57 noted
sternum and adjacent costal cartilage, whereas the distal at- weakness based on electromyographic recordings in the
tachments are the pubic bones near the pubic symphysis.47 rectus abdominis after stroke during dynamic trunk move-
The muscle is palpated easily in the following two ments such as donning shoes. The weakness was noted
cases: particularly on the involved side. Similarly, Tanaka,
1. When the subject is supine and is asked to lift the Hachisuka, and Ogata49 found that peak torque of the
head and shoulders off the support surface in a flexors was significantly less than in healthy controls.
straight plane (sit-up) The rectus abdominis can be self-palpated by assuming
2. During backward sway in sitting or standing position a recumbent posture in a chair (slumping in the chair) and
then pulling up and forward to an aligned position. One
should notice that the burst of activity diminishes when
leaning forward (shoulders move in front of hips).

Obliques. The obliques consist of three interwoven

muscles: internal obliques, external obliques, and transver-
sus abdominis.

Serratus
External Obliques. The external oblique forms the su-
anterior External perficial layer of the abdominal wall. Its fibers run an
oblique oblique course superoinferiorly and lateromedially.33 The
External muscle is lateral to the rectus abdominis and covers the
oblique Tendinous anterior and lateral regions of the abdomen. The attach-
inscription
Transversus ments are as follows:47
abdominis Rectus ■ Proximal attachment: Anterolateral portions of
abdominis
ribs where the muscle interdigitates with serratus
Internal Linea alba anterior and slips from latissimus dorsi
oblique
■ Distal attachment: Upper fibers run down and for-
ward and attach to an aponeurosis that connects
them to the linea alba; lower fibers attach to the
crest of the ilium
If the external oblique contracts unilaterally, the trunk
Figure 7-2 Anterior anatomy of trunk with resected layers. rotates to the opposite side. Therefore, if one rotates to
160 Stroke Rehabilitation

the left, the right external oblique is active and vice versa. Weakness of this muscle permits bulging of the anterior
Bilateral contraction assists in trunk flexion and a resul- abdominal wall, thereby indirectly leading to an increase
tant posterior pelvic tilt. This muscle is also active during in lordosis.38 The therapist may palpate this muscle be-
straining and coughing.47 The muscle is palpated easily tween the lower ribs and the crest of the ilium during
while rotating the trunk to the opposite side. forced expiration.

Internal Obliques. The internal obliques also are lo- Posterior Trunk Muscles
cated laterally and are covered by the external obliques. The posterior trunk muscles include the quadratus lum-
In essence, the internal obliques constitute the second borum, the erector spinae group, and latissimus dorsi
layer of muscles on the abdominal wall. This muscle cov- (Fig. 7-3). The actions of this group of muscles include
ers the same area as the external oblique, but its fibers trunk extension, lateral flexion, rotation of the trunk, and
cross those of the external oblique. Attachments are as assistance with balancing the vertebral column.
follows:47
■ Proximal attachment: Inguinal ligament, crest of Quadratus Lumborum. The quadratus lumborum is
ilium, and thoracolumbar fascia lateral and posterior (i.e., on the posterior abdominal
■ Distal attachments: Pubic bone, an aponeurosis wall); it lies between the psoas major and the erector
connecting to linea alba, and last three or four ribs spinae group. The attachments are as follows:47
This muscle groups is activated during trunk rotation, ■ Proximal attachment: Crest of ilium
but contraction occurs toward the same side (i.e., rota- ■ Distal attachments: Twelfth rib and transverse
tion to the left occurs following contraction of the left processes of first to third lumbar vertebrae
internal oblique). Clearly the external and internal The main action of this muscle is to assist in “hip hik-
obliques are synergists in the action of trunk rotation. ing.” Therefore, the muscle is active during lateral
The right external and left internal oblique work to- trunk flexion. The easiest way to palpate the quadratus
gether to rotate the trunk to the left and vice versa. “The lumborum is to have the subject prone, to palpate supe-
efficient action of the muscles of one side of the abdomi- rior and lateral to the iliac crest, and to ask the subject
nal wall is therefore very much dependent upon the fixa- to hike the hip.
tion or anchorage provided by the activity of the muscles
on the other side, particularly for activities involving ro- Erector Spinae Group. The erector spinae group of
tation of the trunk.”16 muscles is a large mass that fills the spaces between the
Tanaka, Hachisuka, and Ogata49 examined trunk rota- transverse and spinous processes of the vertebrae and
tion performance in poststroke hemiplegic subjects and extends laterally covering a large portion of the posterior
found significantly lower muscle performance in the sub- thorax. Multiple muscles make up this group, and they
jects compared with the health controls. No differences are named according to attachments, shape, and action.
were found when comparing right and left rotation in Muscles such as the transversospinales, the interspinales,
terms of angular velocities, the side of hemiplegia, or gen-
der, but muscle performance in both directions was de-
creased compared with controls.
The internal obliques are difficult to palpate. However,
the therapist may feel tension under the fingertips when
palpating the lateral abdominal wall on the side toward
which the trunk is rotating. This tension is due in part to
activation of the internal obliques.

Transversus Abdominis. The transversus abdominis Latissimus Iliocostalis

is the deepest layer of the abdominal wall. Its fibers run dorsi Longissimus Erector
transversely, and the muscle has been called the corset thoracis spinae
muscle because it encloses the abdominal cavity like a External Spinalis
corset. Attachments are as follows:47 abdominal
oblique Quadratus
■ Proximal attachments: Lower ribs, thoracolumbar
lumborum
fascia, crest of the ilium, and inguinal ligament Internal
abdominal
■ Distal attachments: Via an aponeurosis fuses with oblique
other abdominal muscles into linea alba
The main action of the transversus abdominis is forced
compression; the muscle acts like a girdle to flatten the
abdominal wall and compress the abdominal viscera. Figure 7-3 Posterior anatomy of trunk.
 Chapter 7 • Trunk Control: Supporting Functional Independence 161

the longissimus, and the iliocostalis are included in this For example, after washing feet, the trunk is straight-
group. ened from a bent-over position by concentric con-
Collectively, these muscles connect the back of the skull traction of the back extensors (the uppermost mus-
to the posterior iliac crest and sacrum. Unopposed contrac- cles). Therefore, the muscles are shortening actively.
tion of the back extensors approximates the head and the The one exception to the rule that the uppermost
sacrum. The pelvis is pulled into an anterior tilt (accentuat- muscles are active during this type of contraction is
ing the lumbar curve), and the ribs are forced to flare. bridging. In this case, movement does occur in a di-
These muscles also contract during lateral flexion (to bal- rection opposite the pull of gravity (back and buttocks
ance the abdominals), and they may assist in trunk rotation moving away from the support surface), but the un-
during unilateral contraction (e.g., assist the trunk with derside muscles (the extensors) are contracting con-
rotating to the ipsilateral side). The therapist easily can centrically and are responsible for the success of this
palpate this muscle group with patients in the prone posi- task. Concentric contractions are used functionally to
tion if the head and shoulders are lifted from the support reposition the trunk during or after task completion.
surface;47 palpation also is possible during forward sway in 2. Preventing movement that would occur because of
sitting or standing. The therapist easily can palpate the gravitational pull: This type of muscle contraction
lower back extensors during low back extension (accentuat- (usually isometric) prevents falling toward the pull
ing the lumbar curve) while the patient is sitting. of gravity, stabilizes the trunk for successful comple-
Winzeler-Mercay and Mudie57 found increased activity tion of tasks, and forms the basis of many balance
in the erector spinae on both sides during work activities reactions. During lower extremity washing, the
(such as reaching and donning shoes) and at rest. This back extensors contract to stabilize (isometrically
increased activity was particularly evident on the involved hold) the trunk as one washes the lower leg, allow-
side. They hypothesized that this abnormal response ing proximal stabilization for distal function. As a
might reflect a disruption of cortical influences on motor note, when one leans all of the way forward (ex-
unit activity. Similarly, Tanaka, Hachisuka, and Ogata48 treme flexion), the back extensors become inactive,
found that peak torque of the extensors was significantly and the vertebral ligaments become responsible for
less than in healthy controls. holding the trunk in this posture.5
3. Controlling the speed of trunk movements in the
Latissimus Dorsi. The latissimus dorsi is superficial direction of gravitational pull: In this type of con-
and covers the posterior/lateral trunk. Its attachments in- traction, the muscles are contracting eccentrically
clude the following:47 (in controlled and active elongation). The muscles
■ Proximal attachments: Spinous processes of T6 responsible for this contraction are on the side of
down, dorsolumbar fascia, posterior crest of ilium, the trunk that is opposite the pull of gravity. When
lower ribs, interdigitations with external oblique; fi- one leans forward to wash the feet during lower
bers converge toward axilla, passing over the inferior body washing, the back extensors contract eccentri-
angle of the scapula. cally to control the speed and range of the forward
■ Distal attachments: Tendon attaches to crest of lesser trunk movement. This muscle contraction has a
tubercle of humerus, proximal to the teres major. braking effect as the large mass of the trunk moves
Acting unilaterally, the latissimus dorsi adducts, extends, into the pull of gravity.
and internally rotates the humerus and laterally flexes the The previous examples show that functional indepen-
trunk (approximates the shoulder and the pelvis). Bilateral dence requires control of all three trunk muscle contrac-
contraction helps hyperextend the spine and anteriorly tilt tions and combinations. Successful treatment plans must
the pelvis. include activities that elicit a variety of trunk muscle con-
tractions. Self-care training inherently challenges a vari-
MOTOR CONTROL CONSIDERATIONS ety of trunk postures and muscle contractions.

Trunk Muscle Contractions Musculoskeletal Components

To achieve full trunk control and to use this control dur- Control of the trunk depends on several musculoskeletal
ing functional tasks, patients must regain the ability to variables including ROM, biomechanical alignment,
contract their trunk muscles under three different circum- strength, and muscle length. These variables are interde-
stances outlined by Davies.17 The task of lower extremity pendent and can create a vicious circle in stroke patients.
bathing from a seated position illustrates these points:
1. Contracting to move opposite the pull of gravity: Postural Malalignment
When the trunk is moving in a direction that is op- Stroke patients commonly assume postural malalignments
posite to gravitational pull, the muscles on the upper- that first must be identified via observations and palpa-
most side of the trunk are contracting concentrically. tions. After identification, the causative factors must be
162 Stroke Rehabilitation

determined before determining the most appropriate in- from the body, one side of the body from the other, and
tervention (Table 7-3). the upper trunk from the lower trunk. Instead, patients
Prolonged postural malalignment results in muscle often appear stiff, have nonfluid movements, and move
shortening on one side of the trunk and muscle over- their body segments as a unit
stretching on the opposite side. For example, a posterior Examples of dissociation during functional tasks in-
pelvic tilt with lumbar flexion results in shortening of the clude upper trunk rotation with lower trunk stability
anterior musculature and elongation (overstretching) of while reaching for toilet paper, counterrotation of the
the posterior muscles. Lateral flexion on the right side trunk during ambulatory activities, and upper trunk rota-
results in muscle shortening on the right side and muscle tion with concurrent lower trunk lateral flexion to in-
elongation on the left side of the trunk. crease the range of reach beyond the arm span when
Postural malalignment may occur because of unilateral reaching for a phone positioned on the left side of a desk
weakness (specifically around the pelvis), unbalanced skel- with the right hand.
etal muscle activity, perceptual dysfunction and an inabil- Difficulty with dissociation/postural stiffness may re-
ity to perceive midline, and soft-tissue shortening. sult from soft-tissue tightness, bony contracture, or ef-
Prolonged postural malalignment can result in soft- forts by the patient to decrease the degrees of freedom in
tissue shortening, loss of ROM, and an inability to gener- the trunk45 during functional activities. It is critical to
ate enough force to contract the muscle group in ques- determine why the person is not able to dissociate. A
tion. The total force of muscle (active tension) is high at typical clinical problem is determining if trunk stiffness
the rest length of the muscle (i.e., when the trunk is and lack of dissociation is due to soft-tissue tightness
aligned properly) and less when the muscle is tested at (which may require soft tissue stretching and mobiliza-
shorter lengths. Therefore, the force-generating mecha- tion) or if the person is freezing the degrees of freedom
nism within the muscle works optimally at the rest length in an effort to maintain stability (which requires core
of the muscle38 (i.e., a symmetrical and aligned trunk). stabilization activities). One method to differentiate the
cause is to provide various levels of postural support, for
Managing Stiffness and the Degrees of Freedom example, sitting in a high back chair versus sitting unsup-
Problem ported on a therapy table, or side lying versus sitting
Mohr40 states, “Normal control in any body part demands unsupported. If the underlying cause of the stiffness is
the ability to dissociate (separate) different parts of the related to freezing the degrees of freedom, substantial
body.” She gives the examples of dissociating the head differences will be noted for both passive and active

Table 7-3
Common Postural Alignments and Potential Causes
Posterior pelvic tilt/lumbar spine flexion ■ Weakness in back lower back extensors
(loss of the lumbar curve) ■ Abdominal weakness (as this position requires little abdominal control)
■ Generalized weakness in the trunk
■ Shortened or overactive hamstrings mechanically pulls the pelvis into a
posterior tilt.
Pelvic obliquity characterized by unequal ■ Shortened or overactive muscle activity on one side of the trunk
weight-bearing through the ischial ■ Weakness on one side of the trunk
tuberosities ■ Visual-perceptual deficits (i.e., unilateral neglect or impaired processing of
body and spatial relationships)
Increased kyphosis ■ Weakness in back lower back extensors
■ Abdominal weakness (as this position places the persons weight anteriorly,
i.e., a position that requires little abdominal control)
■ Exacerbation of premorbid kyphosis
Sitting off midline and/or lateral spine ■ Shortened or overactive muscle activity on one side of the trunk
flexion ■ Weakness on one side of the trunk
■ Visual-perceptual deficits (i.e., unilateral neglect or impaired processing of
body and spatial relationships)
Rib cage rotation ■ Asymmetrical strength in the trunk rotators (i.e., oblique musculature)
■ Overactive unilateral trunk rotators
Head/neck malalignment (rotation away ■ Unilateral neglect
from and lateral flexion toward the ■ Shortened or overactive neck musculature such as the sternocleidomastoid
involved side)
 Chapter 7 • Trunk Control: Supporting Functional Independence 163

movements under the various conditions of postural sup- shift of the shoulders results in extensor activation,
port. In the situations in which the patient has the most whereas a subtle posterior shift of the shoulders re-
support (side lying and supported seating), he or she will sults in trunk flexor activation.
be able to “free” the degrees of freedom and move with 3. The therapist should evaluate the trunk in a variety
increased ease and fluidity, and will be able to separate of postures that coincide with ADL. Trunk adjust-
body parts. If the same person is placed in a condition of ments are task specific; therefore, a trunk evalua-
decreased postural support, the system will respond by tion of a patient who is supine should include ac-
“freezing” the degrees of freedom, and stiffness will tivities such as rolling, assuming/maintaining side
emerge. lying, bridging, and transitions to sitting (see
Chapter 14). Evaluations of seated patients should
Motor Adaptation include activities such as upper and lower extrem-
Concerning motor adaptation, Smith, Weiss, and ity dressing, scooting, and bathing; evaluations of
Lehmkuhl47 state, “Normal postural control requires the standing patients should include reaching for items
ability to adapt responses to changing tasks and environ- in medicine cabinets, on bookshelves, and in
mental demands. This flexibility requires the availability kitchen cabinets (see Chapter 8).
of multiple movement strategies and the ability to select
the appropriate strategy for the task and environment. EVALUATION PROCESS
The inability to adapt movements to changing task de-
mands is a characteristic of many patients with neuro- Subjective Interview
logical disorders. Patients become fixed in stereotypical Therapists should question patients about their perceived
patterns of movement, showing a loss of movement flex- stability limits. Stability limits have been defined as the
ibility and adaptability.” “boundaries of an area of space in which the body can
Motor adaptation can occur in response to an external maintain its position without changing the base of sup-
perturbation or in anticipation of potentially destabiliz- port.”47 Patients’ perceived stability limits may or may not
ing forces. Unexpected external perturbations include be consistent with their actual limits. If patients’ perceived
bumping into someone in a crowded lobby, being in a limits of stability are greater than their actual limits, they
vehicle that unexpectedly turns or decelerates, and being are at risk for falls. If their perceived limits of stability are
on a moving platform, such as an escalator, that stops less than their actual limits, they may be reluctant to at-
unexpectedly. tempt tasks with progressively greater demands on their
Activities that lead to trunk movements in anticipation postural system (e.g., lower extremity dressing without
of destabilizing forces (i.e., internal perturbations) include assistive devices and picking up objects from the floor
reaching for a heavy book on a shelf, reaching beyond the without a reacher).
arm span, and preparing to push or pull a chair into place. Perceived stability limits may have a direct correla-
Shumway-Cook and Woollacott46 point out that anticipa- tion with observed neurobehavioral deficits. Body
tory postural control depends heavily on previous experi- scheme disorders commonly occur in the stroke popula-
ence and learning. Research focusing on anticipatory tion. These deficits include body neglect, somatoagno-
postural responses during reach activities is presented in sia, and impaired right/left discrimination.2 Ayres3 has
Chapter 10. defined body scheme as a postural model on which
movements are based. Knowledge of body parts and
GENERAL CONSIDERATIONS their relationships are necessary for deciding what and
FOR EVALUATION AND TREATMENT where to move and in what way to perform.2 Spatial
OF THE TRUNK relation deficits including spatial neglect, depth percep-
tion, and spatial relation disorders also may have an ef-
Therapists should consider the following points during fect on patients’ perceived stability limits (gaining and
evaluation of the trunk and treatment planning: regaining midline orientation and position in space) (see
1. Proper evaluation and treatment of the trunk result Chapter 18).
from use of keen observational skills. Patients Other components of the subjective interview in-
should be undressed (shirtless or in sports bra or clude determining patients’ insights into their trunk
bathing suit top), so that movements are more eas- malalignments and their ability to perceive and assume
ily observed during functional tasks. Clothing folds, midline positions.43 The therapist’s goal in this inter-
wrinkles, and crooked seams can lead to incorrect view is to gain insight into the patients’ ability to make
observations. accurate observations about their postural dysfunction.
2. The therapist must realize that the slightest change in This is difficult for many patients because trunk control
posture can change trunk muscle activity and align- does not occur at a conscious level in the majority of
ment completely.16 For example, a subtle anterior daily tasks.
164 Stroke Rehabilitation

specifically evaluate trunk control after stroke and are there-

Standardized Assessments fore highly recommend for this area of practice/research,
The use of valid and reliable tools is always recommended. while the others are comprehensive measures that include
The following section reviews available measurement instru- items related to the trunk. See Table 7-4 for a review of the
ments related to trunk control. The first three instruments psychometric properties of these three measures.

Table 7-4
Psychometric Properties of the Trunk Control Test and Two Trunk Impairment Scales
PSYCHOMETRIC TRUNK IMPAIRMENT SCALE TRUNK IMPAIRMENT
CHARACTERISTICS TRUNK CONTROL TEST (VERHEYDEN) SCALE (FUJIWARA)

Number of items 4 17 7
Score of each item 0, 12, or 25 0 to 1, 0 to 2, or 0 to 3 0 to 3
Total score range 0 to 100 0 to 23 0 to 21
Test-retest Not available Kappa and weighted kappa values, Not available
reliability percentage of agreement, ICC
(kappa between 0.46 and 1, % of
agreement between 82% and
100%, ICC between 0.87 and 0.96)
Interrater reliability Spearman rho correlation Kappa and weighted kappa values, Weighted kappa values
coefficient (r  0.76) percentage of agreement, ICC (between 0.66 and 1)
(kappa between 0.7 and 1, % of
agreement between 82% and
100%, ICC between 0.85 and
0.99)
Measurement error Not available Inter- and test-retest examiner Not available
measurement error (inter: 1.84 to
1.84, test-retest: 2.90 to 3.68)
Responsiveness Not available Not available Standardized response mean
value (0.94)
Internal consistency Cronbach  (0.83 and 0.86) Cronbach  (between 0.65 and 0.89) Rasch analysis (all but three
items showed mean square
fit statistic within 1.3)
Content validity Not available Literature review, observing stroke Principal component analy-
patients, clinical experience and sis (three factors identified)
discussion with specialists in stroke
rehabilitation
Construct validity Correlation with gross motor Correlation with Barthel Index Not available
function subscale of the (r  0.86)
Rivermead Motor Assess-
ment (between 0.70 and 0.79)
Concurrent validity Not available Correlation with Trunk Control Correlation with Trunk
Test (r  0.83) Control Test (r  0.91)
Predictive validity Significant predictor on ad- Significant predictor on admission Significant predictor on
mission of (motor part of of Barthel Index score at six admission of motor part of
the) FIM at discharge (R2 months poststroke (unpublished the FIM at discharge
 0.54 when predicting data) (added R2  0.09)
FIM, R2  0.71 when
predicting motor FIM)
Discriminant ability Not available Significant differences between Not available
stroke patients and healthy
individuals (P  0.0001)

FIM, Functional Independence Measure; ICC, intraclass correlation.

From Verheyden G, Nieuwboer A, Van de Winckel A, De Weerdt W: Clinical tools to measure trunk performance after stroke: a
systematic review of the literature. Clin Rehabil 21(5):387-394, 2007.
 Chapter 7 • Trunk Control: Supporting Functional Independence 165

Trunk Control Test and righting reflexes both on the affected and the unaf-
The Trunk Control Test14 examines four functional move- fected sides. The seven items are scored on four-point
ments: roll from supine to the weak side, roll from supine scale with 0 indicated poor performance and 3 indicated
to the strong side, sitting up from supine, and sitting on best performance28 (Box 7-1 and Table 7-7).
the edge of the bed for 30 seconds (feet off the ground).
Each of the four tasks are scored as follows: 0, unable to Postural Assessment Scale for Stroke Patients
perform with assistance; 12, able to perform but in an The Postural Assessment Scale for Stroke Patients in-
abnormal manner; and 25, able to complete movement cludes items related to trunk control. Overall, the scale
normally. The range of scores is 0 to 100. contains 12 four-point items graded from 0 to 3. Higher
The Trunk Control Test has been shown to be sensi- scores indicate better performance. Items include sitting
tive to change in assessing recovery of stroke patients, to without support, standing with and without support,
correlate with the Functional Independence Measure, and standing on the nonparetic leg, standing on the paretic
to predict motor Functional Independence Measure items leg, supine to affected side, supine to nonaffected side,
at discharge better than motor Functional Independence supine to sit, sit to supine, sit to stand, stand to sit, and
Measure Scores.12,14 In addition, Duarte and colleagues21 standing and picking up a pencil from the floor. The Pos-
found that the Trunk Control Test significantly correlated tural Assessment Scale for Stroke Patients has been found
with length of stay, discharge motor Functional Indepen- to be highly valid and reliable during the first three
dence Measure scores, gait velocity, walking distance, and months after stroke.6
the Berg Balance Scale. They also found that the Trunk Five items have been suggested31 to measure trunk
Control Test predicted 52% of the variance in length of control: sitting without support, supine to affected side,
stay and 54% of the discharge Functional Independence supine to nonaffected side, supine to sitting on the edge
Measure (Table 7-5). of the bed, and sitting to supine. Recent work on this in-
strument has demonstrated that while the tool can predict
Trunk Impairment Scale (A) performance in ADL at one year poststroke, a ceiling ef-
This scale evaluates motor impairment of the trunk after fect was noted at various points in recovery indicating a
stroke. The tool scores static (3 items), dynamical sitting limited discriminative ability between individuals and a
balance (10 items), and trunk coordination (4 items). It limited responsiveness over the first six months after
also aims to score the quality of trunk movement and to stroke.56
be a guide for treatment. The scores range from a mini-
mum of 0 to a maximum of 2353 (Table 7-6). Chedoke-McMaster Stroke Assessment
The Chedoke-McMaster Stroke Assessment is used to as-
Trunk Impairment Scale (B) sess physical impairment and disability in clients with
This tool consists of seven items. Abdominal muscle stroke. It has two components including the Impairment
strength and verticality items were derived from the Stroke Inventory (which determines the presence and severity of
Impairment Assessment Set, and the other five items con- physical impairments in the six dimensions of shoulder
sist of the perception of trunk verticality, trunk rotation pain, postural control, arm, hand, foot, and leg quantified
muscle strength on the affected and the unaffected sides, in a seven-point staging system) and the Activity Inventory
(which measures the client’s functional ability). The Activ-
Table 7-5 ity Inventory has two components: the Gross Motor Func-
tion Index (with items including moving in bed and trans-
Trunk Control Test
ferring to a chair) and the Walking Index (with items
SCORING including walking on rough ground and climbing stairs).
0—UNABLE TO The maximum score that a client can obtain is 100 as there
12—ABLE TO DO WITH are 14 items with a seven-point scale and a two-point score
NONMUSCULAR HELP
TESTS (ON BED) 25—NORMAL awarded for age-appropriate walking distance.30
1. Rolling to weak side
Motor Assessment Scale
2. Rolling to strong side
The Motor Assessment Scale12 is a comprehensive assess-
3. Balance in sitting position
4. Sitting up from lying ment of motor behavior and includes items related to
down trunk control. Overall, the scale consists of eight items:
supine to side-lying (onto intact side), supine to sit, bal-
anced sitting, sit to stand, walking, upper arm function,
From Collin C, Wade D: Assessing motor impairment after
stroke: a pilot reliability study. J Neurol Neurosurg Psychiatry hand movements, and advanced hand activities. Each item
53(7):576-579, 1990. is scored on seven-point scale from 0 to 6. Higher scores
indicate better performance.
Table 7-6
Trunk Impairment Scale (A)

The starting position for each item is the same. The patient is sitting on the edge of a bed or treatment table without back
and arm support. The thighs make full contact with the bed or table, the feet are hip width apart and placed flat on the
floor. The knee angle is 90. The arms rest on the legs. If hypertonia is present the position of the hemiplegic arm is
taken as the starting position. The head and trunk are in a midline position.
If the patient scores 0 on the first item, the total score for the TIS is 0. Each item of the test can be performed three times.
The highest score counts. No practice session is allowed. The patient can be corrected between attempts. The tests are
verbally explained to the patient and can be demonstrated if needed.

ITEM

Static sitting balance

1. Starting position Patient falls or cannot maintain starting position for 10 seconds 0
without arm support
Patient can maintain starting position for 10 seconds 2
If score  0, then Trunk Impairment Scale (TIS) total score  0
2. Starting position Patient falls or cannot maintain starting position for 10 seconds 0
without arm support
Therapist crosses the unaffected leg over the Patient can maintain starting position for 10 seconds 2
hemiplegic leg
3. Starting position Patient falls 0
Patient crosses the unaffected leg over the Patient cannot cross legs without arm support on bed or table 1
hemiplegic leg Patient crosses the legs but displaces the trunk more than 10 cm 2
backward or assists crossing with the hand
Patient crosses the legs without trunk displacement or assistance 3
Total static sitting balance /7
Dynamical sitting balance
1. Starting position Patient falls, needs support from an upper extremity, or the elbow 0
does not touch the bed or table
Patient is instructed to touch the bed or table Patient moves actively without help, elbow touches bed or table 1
with the hemiplegic elbow (by shortening the If score  0, then items 2 and 3 score  0
hemiplegic side and lengthening the unaf-
fected side) and return to the starting position
2. Repeat item 1 Patient demonstrates no or opposite shortening/lengthening 0
Patient demonstrates appropriate shortening/lengthening 1
If score  0, then item 3 scores  0
3. Repeat item 1 Patient compensates. Possible compensations are: (1) use of upper 0
extremity, (2) contralateral hip abduction, (3) hip flexion (if elbow
touches bed or table further than proximal half of femur), (4) knee
flexion, (5) sliding of feet
Patient moves without compensation 1
4. Starting position Patient falls, needs support from an upper extremity, or the elbow 0
does not touch the bed or table
Patient is instructed to touch the bed or table Patient moves actively without help, elbow touches bed or table 1
with the unaffected elbow (by shortening the If score  0, then items 5 and 6 score  0
unaffected side and lengthening the hemiple-
gic side) and return to the starting position
5. Repeat item 4 Patient demonstrates no or opposite shortening/lengthening 0
Patient demonstrates appropriate shortening/lengthening 1
If score  0, then item 6 scores  0
6. Repeat item 4 Patient compensates. Possible compensations are: (1) use of upper 0
extremity, (2) contralateral hip abduction, (3) hip flexion (if elbow
touches bed or table further than proximal half of femur), (4) knee
flexion, (5) sliding of feet
Patient moves without compensation 1
7. Starting position Patient demonstrates no or opposite shortening/lengthening 0
Patient is instructed to lift pelvis from bed or Patient demonstrates appropriate shortening/lengthening 1
table at the hemiplegic side (by shortening If score  0, the item 8 scores  0
the hemiplegic side and lengthening the unaf-
fected side) and return to the starting position
 Chapter 7 • Trunk Control: Supporting Functional Independence 167

Table 7-6
Trunk Impairment Scale (A)—cont’d

ITEM

8. Repeat item 7 Patient compensates. Possible compensations are: (1) use of upper 0
extremity, (2) pushing off with the ipsilateral foot (heel loses con-
tact with the floor)
Patient moves without compensation 1
9. Starting position Patient demonstrates no or opposite shortening/lengthening 0
Patient is instructed to lift pelvis from Patient demonstrates appropriate shortening/lengthening 1
bed or table at the unaffected side (by If score  0, then item 10 scores  0
shortening the unaffected side and length-
ening the hemiplegic side) and return to the
starting position
10. Repeat item 9 Patient compensates. Possible compensations are: (1) use of upper 0
extremity, (2) pushing off with the ipsilateral foot (heel loses
contact with the floor)
Patient moves without compensation 1
Total dynamical sitting balance /10
Coordination
1. Starting position Hemiplegic side is not moved three times 0
Patient is instructed to rotate upper trunk Rotation is asymmetrical 1
6 times (every shoulder should be moved Rotation is symmetrical 2
forward 3 times), first side that moves must
If score  0, then item 2 scores  0
be hemiplegic side, head should be fixated
in starting position
2. Repeat item 1 within 6 seconds Rotation is asymmetrical 0
Rotation is symmetrical 1
3. Starting position Hemiplegic side is not moved three times 0
Patient is instructed to rotate lower trunk Rotation is asymmetrical 1
6 times (every knee should be moved Rotation is symmetrical 2
forward 3 times), first side that moves must
If score  0, then item 4 scores  0
be hemiplegic side, upper trunk should be
fixated in starting position
4. Repeat item 3 within 6 seconds Rotation is asymmetrical 0
Rotation is symmetrical 1
Total coordination /6
Total trunk impairment scale /23

From Verheyden G, Nieuwboer A, Mertin J, et al: The Trunk Impairment Scale: a new tool to measure motor impairment of the trunk
after stroke, Clin Rehabil 18(3):326-334, 2004.

Fugl-Meyer Assessment that all three tests showed acceptable levels of reliability,
The Fugl-Meyer Assessment27 evaluates five areas: joint mo- validity, and responsiveness with the Postural Assessment
tion and pain, balance, sensation, upper extremity motor Scale for Stroke Patients showing slightly better psycho-
function, and lower extremity motor function. The balance metric characteristics. The reader is referred to Chapter 8
subscale includes seven functions related to postural control: for a review of other standardized assessments of postural
sit without support, protective reactions on affected and control. In addition, the reader should review Chapter 21
nonaffected sides, stand with support, stand without support, concerning use of the Assessment of Motor and Process
stand on nonaffected leg, and stand on affected leg. Skills. The assessment includes motor skill items such as
Mao and colleagues39 compared the psychometric prop- stabilizes, aligns, and positions. The Assessment of Motor
erties of the balance subscale of the Fugl-Meyer Assess- and Process Skills is unique and highly recommended, for
ment, the Berg Balance Scale (see Chapter 8), and the Pos- the therapist can gather information related to motor skills
tural Assessment Scale for Stroke Patients. They concluded during ADL performance.
168 Stroke Rehabilitation

Box 7-1
Trunk Impairment Scale (B)
Trunk Impairment Scale Items and Criteria for Scoring
PERCEPTION OF TRUNK VERTICALITY
While the patient is sitting on the edge of a bed or on a chair without a backrest, with the feet off the ground, the examiner
holds both sides of the patient’s shoulders and makes the patient’s trunk deviate to the right and left. The examiner asks the
patient to indicate when he or she feels the trunk is in a vertical position. The examiner then records the degree of trunk angle
deviation from the vertical line drawn from the midpoint of the Jacoby line.
0  The angle is 30 degrees.
1  The angle is 30 degrees and 20 degrees.
2  The angle is 20 degrees and 10 degrees.
3  The angle is 10 degrees.

TRUNK ROTATION MUSCLE STRENGTH ON THE AFFECTED SIDE

The patient is asked to roll the body from the supine position to the unaffected side. The arms should be crossed in front of
the chest and legs kept extended. The patient is asked to roll his or her body without pushing the floor with his or her limbs
or pulling on the bed clothes. Isometric contractions for stabilization and other muscles than external oblique (e.g., pectoralis
major) activation during rolling are allowed.
0  No contraction is noted in external oblique muscles on the affected side.
1  External oblique muscle contraction is visible on the affected side, but the patient cannot roll his or her body.
2  The patient can lift the affected side scapula but cannot fully rotate the body.
3  The patient can fully rotate the body.

TRUNK ROTATION MUSCLE STRENGTH ON THE UNAFFECTED SIDE

The patient is asked to roll the body from the supine position to the affected side. Scoring is the same as for the trunk rotation
muscle strength on the unaffected side.

RIGHT REFLEX ON THE AFFECTED SIDE

The patient sits on the edge of a bed or a chair without a backrest. The examiner pushes the patient’s shoulder laterally (about
30 degrees) to the unaffected side and scores according to the degree of the reflex elicited on the affected side of the patient’s trunk.
0  No reflex is elicited.
1  The reflex is poorly elicited, and the patient cannot bring his or her body back to the erect position as before.
2  The reflex is not strong, but the patient can bring his or her body back to the erect position almost as before.
3  The reflex is strong enough, and the patient can immediately bring his or her body back to the erect position as before.

RIGHTING REFLEX ON THE UNAFFECTED SIDE

The examiner pushes the patient’s shoulder laterally (about 30 degrees) to the affected side. Scoring is the same as for the right-
ing reflex on the affected side.

STROKE IMPAIRMENT ASSESSMENT SET VERTICALITY

0  The patient cannot maintain a sitting position.
1  A sitting position can only be maintained while tilting to one side, and the patient is unable to correct the posture to
an erect position.
2  The patient can sit vertically when reminded to do so.
3  The patient can sit vertically in a normal manner.

STROKE IMPAIRMENT ASSESSMENT SET ABDOMINAL MUSCLE STRENGTH

Stroke Impairment Assessment Set abdominal muscle strength is evaluated with the patient resting in a 45-degree semireclin-
ing position in either a wheelchair or a high-back chair. The patient is asked to raise the shoulders off the back of the chair and
assume a sitting position.
0  Unable to sit up
1  The patient can sit up provided there is no resistance to the movement.
2  The patient can come to a sitting position despite pressure on the sternum by the examiner.
3  The patient has good strength in the abdominal muscles and is able to sit up against considerable resistance.

From Fujiwara T, Liu M, Tsuji T, et al: Development of a new measure to assess trunk impairment after stroke (trunk impairment scale): its
psychometric properties. Am J Phys Med Rehabil 83(9):681-688, 2004.
 Chapter 7 • Trunk Control: Supporting Functional Independence 169

Table 7-7
Comparison of the Trunk Impairment Scale (B) and the Trunk Control Test
CONTENT TRUNK IMPAIRMENT SCALE TRUNK CONTROL TEST

Practicality
No. of items 7 4
Score of each item 0 to 3 0, 12, 25
Score range 0 to 21 0 to 100
Reliability
Interrater reliability Yes, weighted kappa Yes, Spearman rank correlation
Internal consistency Yes, Rasch analysis (mean square fit index) Yes, Cronbach 
Validity
Content validity Yes, principal component analysis No
Construct validity Yes, Rasch analysis (logits) Yes, correlation of individual items
Concurrent validity Yes, with TCT Yes, with RMA GF
Predictive validity Yes, discharge Functional Independence Yes, discharge FIM motor score
Measure motor score

FIM, Functional Independence Measure.

RMA GF, Rivermead Motor Assessment gross function scores.
From Fujiwara T, Liu M, Tsuji T, et al: Development of a new measure to assess trunk impairment after stroke (trunk impairment scale):
its psychometric properties. Am J Phys Med Rehabil 83(9):681-688, 2004.

Observations of Trunk Alignment/Malalignment Another example of a commonly observed malalignment

For the purposes of this chapter, observations concern the is trunk shortening on the side affected by the stroke. The
seated posture. The patient’s trunk should be exposed as patient may assume this posture for several reasons:
much as possible, and the patient should be asked to “sit ■ Inactive shoulder elevators on the side affected by
up nice and straight and gently rest your hands in your the stroke that let the shoulder depress16
lap.” (Table 7-8 outlines the ideal alignment of the trunk ■ Increased muscle activity of the scapula depressors
and extremities and common asymmetries observed after that pull the shoulder down on the affected side
stroke during static sitting.) ■ Perceptual dysfunction resulting in an inability to find
Following the evaluation of postural malalignments midline, bearing the most weight on the stronger side
during static sitting, the therapist should begin to hypoth- and resulting in a shortening of the affected side
esize the cause of these malalignments. Causes may in- ■ Increased muscle activity or shortening of the affected
clude increased skeletal muscle activity on one side of the lateral flexors resulting in a shortening response
trunk, inability to recruit muscle activity or weakness, ■ Fear of shifting weight to the affected side, with the
soft-tissue shortening, fixed deformity, body scheme dis- majority of weight on stronger side, resulting in
order, and inability to perceive midline. shortening of the affected side
The therapist must remember that observed postures Following the observation of the patient in a static pos-
may be caused by more than one impairment (see Table ture, the occupational therapist must observe trunk re-
7-3). For example, stroke patients tend to sit in a posterior sponses during functional activities. The two most effec-
pelvic tilt position with resultant hip extension and tho- tive methods of making these observations are observing
racic spine flexion. This posture may result from one of or patients during self-care and mobility in a variety of posi-
a combination of the following: tions and controlled reach pattern activities (Table 7-9).
■ Weakness or lack of activity in the trunk extensors, During functional reach patterns, trunk responses are
especially in the lower back required to provide proximal stability for distal function,
■ Fixed contracture of the hamstrings and/or thoracic enhance the ability to interact with the environment by
spine increasing reaching distance (i.e., extend the arm span
■ Abdominal weakness: The mentioned posture changes with an appropriate trunk response), and prevent falls.
the center of gravity and decreases the potential to fall An individual’s reaching ability is limited to within the
backward. The abdominal muscles are primarily re- arm span by static trunk postures. When an object is
sponsible for preventing backward sway, therefore placed beyond arm’s length (e.g., on a floor, across a din-
assuming a flexed posture reduces the chance of hav- ing table, or under a sink), a trunk response is required to
ing to activate the abdominals to prevent falls. pick up the object successfully.
170 Stroke Rehabilitation

Table 7-8
Typical Alignment and Common Malalignments after Stroke
NORMAL ALIGNMENT COMMON MALALIGNMENT

Pelvis Equal weight-bearing through both ischial Asymmetrical weight-bearing

tuberosities Posterior pelvic tilt
Neutral to slight anterior tilt Unilateral retraction
Neutral rotation
Vertebral column Straight from posterior view Scoliosis
Appropriate curves from lateral view Loss of lumbar curve; increased thoracic kyphosis
Shortening on one side; elongation on opposite side
Rib cage Neutral in terms of lateral tilt Lateral tilt
Neutral rotation Flaring on one side
Alignment over pelvis and under shoulders Unilateral retraction
Shoulders Symmetrical height Asymmetrical height
Alignment over pelvis Unilateral retraction
Head/neck Neutral Protraction
Flexion to weak side
Rotation away from weak side
Upper extremities Resting in lap; if weight-bearing, effortless Use of stronger extremity as postural support to maintain
and symmetrical alignment
Too little or too much activity in more involved extremity
Lower extremities Hips at 90 degrees Hips toward extension because of posterior pelvic tilt
Knee aligned with hips Hip adduction resulting in knee contact
Feet in full contact with floor, accepting “Windswept” hips
weight; feet under knees Feet not equally bearing weight, or “pushing”; foot
placed in front of knee

In general, picking up an object from the floor or from based on the work of Mohr,40 Boehme,8 Davies,16 and
in front of an individual requires an anterior trunk shift. Basmajian and DeLuca.5
Picking up objects placed beyond the arm span to the
right or left of the individual requires a lateral weight shift Trunk Flexor Control
from the trunk primarily onto one of the ischial tuberosi- The trunk flexors are evaluated by the five different meth-
ties. Retrieving objects placed behind the trunk requires a ods that follow:
posterior weight shift. Rotational trunk responses result 1. Patients assume a seated, upright position. The ther-
from reaching across the midline or for objects posterior apist asks them to move their shoulders behind their
to the shoulders or hips. hips slowly and with control (Fig. 7-4, A); this move-
The therapist’s goals while observing the patient per- ment pattern occurs in the sagittal plane, is initiated
form functional reach patterns are the following: from the upper trunk,40 and elicits an eccentric con-
■ Ensure that trunk and upper extremity patterns are traction of the trunk flexors.25,50 Holding the end
coordinated to result in successful task completion. range of this posture results in an isometric contrac-
■ Note any fall potential. tion of the trunk flexors. Observations should include
■ Note asymmetries during reaching. resistance to movement, fall potential, and symmetry
■ Objectively evaluate the perceived and actual stabil- of the posterior weight shift. Unilateral weakness
ity limits of the patient. causes the weak side to become posterior to the
■ Note in which directions the patient is or is not able stronger side (i.e., it results in rotation of the trunk).
to reach beyond the arm span. 2. From the end position of the first movement pattern,
■ Note factors such as trunk stiffness and decreased the therapists asks patients to move their shoulders
ROM. forward so that they are sitting in proper alignment
within the sagittal plane (see Fig. 7-4, B ); this move-
Evaluation of Specific Trunk Movement Patterns ment pattern is achieved by a concentric contraction
In addition to performing each movement pattern, the of the trunk flexors.25 The therapist should note sym-
reader should refer to the appropriate figures while read- metry during the movement pattern. Unilateral weak-
ing this section. The following evaluation procedures are ness causes the stronger side to lead the pattern.
Table 7-9
Effects of Object Positioning on Trunk Movements and Weight Shifts during Reaching Activities*
POSITION OF OBJECT TRUNK RESPONSE/WEIGHT SHIFT

Straight ahead at forehead level, past arm’s length Trunk extension, anterior pelvic tilt
Anterior weight shift

On floor, between feet Trunk flexion

Anterior weight shift

To side at shoulder level, past arm’s length Left trunk shortening, right trunk elongation, left hip hiking
Weight shift to right

On floor, below right hip Right trunk shortening, left trunk elongation
Weight shift to right

*These examples are for a patient with left hemiplegia. The left-hand column indicates where to position objects during a reaching task
(using the right upper extremity). The right-hand column indicates the resultant trunk position and weight shift.

Continued
Table 7-9
Effects of Object Positioning on Trunk Movements and Weight Shifts during Reaching
Activities—cont’d
POSITION OF OBJECT TRUNK RESPONSE/WEIGHT SHIFT

Behind right shoulder, at arm’s length Trunk extension and rotation (right side posteriorly)
Weight shift to right

At shoulder level, to left of left shoulder Trunk extension and rotation (left side posteriorly)
Weight shift to left

On floor, to left of left foot Trunk flexion and rotation (left side posteriorly)
Weight shift to left

Above head, directly behind Trunk extension, shoulders move behind hips
Posterior weight shift
 Chapter 7 • Trunk Control: Supporting Functional Independence 173

the patient to roll by lifting one shoulder up and

across the trunk in a position of trunk flexion and
rotation. This movement pattern also gives the
therapist insight into the antigravity control of the
flexors (primarily the obliques).38
5. Although the first four movement patterns to test
flexor control were initiated by the patient, testing
the response of the flexors to being moved by the
therapist also is useful. The therapist lifts the lower
legs of the patient into a position of increased hip
flexion. For the patient to refrain from falling back-
A B ward, the trunk flexors must be activated isometri-
cally (see Fig. 7-4, D).
As a rule of thumb the trunk flexors are activated in the
seated position when the shoulders move posterior to the
hips (backward sway), when the trunk is moving away
from the support surface (supine starting point), and dur-
ing rotational activities.

Trunk Extensor Control

The following four movement patterns are used to evalu-
ate trunk extensor control during seated activities and
bridging.
C D 1. To start this movement pattern, the patient assumes
Figure 7-4 Trunk flexor control. Dotted lines indicate trunk a flexed spine posture with a posterior pelvis tilt (the
starting position, solid lines indicate trunk final position, arrows resting posture for many stroke survivors). The pa-
indicate movement direction, and plus signs indicate muscle tient initiates the movement with the lower trunk
groups primarily responsible for control of pattern. (Skeletal and pelvis40 and assumes an extended spine posture
muscle activity occurs on both sides of the trunk; that is, recipro- with a neutral to slight anterior tilt, which accentu-
cal innervation.) ates the lumbar curve (Fig. 7-5, A). The patient
completes the movement pattern by a concentric
contraction of the trunk extensors, which is the
trunk pattern required for forward reach.
3. In an aligned, seated position, patients assume a con- 2. Patients assume an aligned, seated starting position
trolled lumbar flexion posture (posterior tilt with and are asked to keep their spine straight as they lean
flattening of the lumbar curve and spinal flexion) forward, keeping the shoulders in front of the hips in
(see Fig. 7-4, C ). Mohr40 states that this movement the sagittal plane (see Fig. 7-5, B). They assume this
pattern is initiated by the lower trunk and pelvis. If this posture by an eccentric contraction of the trunk
pattern is performed actively, the final posture is as- extensors,5,25,50 and if they hold the posture between
sumed by concentric flexor contraction. Patients also the middle to end range, the back extensors isometri-
may achieve this posture by a relaxation response of cally contract. The patient has unilateral weakness if
the low back extensors, so the therapist should palpate the trunk moves forward asymmetrically. Unilateral
the flexors to ensure the pattern is due to active move- weakness causes the weaker side to lead the move-
ment. At the end range of this pattern—posterior tilt ment pattern (e.g., to fall into gravity). If the move-
and spinal flexion (a recumbent posture)—little to no ment continues in a forward direction (e.g., patient
muscle activity exists, and patients maintain this pos- reaches down to the floor), the back extensors be-
ture by support of their vertebral ligaments.5 come inactive at the end range, and the tension of the
4. The therapist also should evaluate control of the vertebral ligaments maintains the position.5
trunk flexors when the patient is supine (during roll- 3. While patients are in the end posture of the second
ing and bed mobility activities). While the patient is movement pattern, the therapists asks them to move
in a supine position, the therapist asks the patient to their shoulders back to assume a seated, aligned
sit up in a straight plane. This movement pattern, position (see Fig. 7-5, C ). To assume this posture,
which is controlled primarily by the rectus abdomi- the trunk extensors contract concentrically, although
nis, allows the therapist to evaluate antigravity con- the hip extensors initiate the movement;5,50 this
trol of the trunk flexors. The therapist also can ask movement occurs in the sagittal plane.
174 Stroke Rehabilitation

A B C
Figure 7-5 Trunk extensor control. Dotted lines indicate trunk starting position, solid lines
indicate trunk final position, arrows indicate movement direction, and plus signs indicate
muscle groups primarily responsible for control of pattern. (Skeletal muscle activity occurs on
both sides of the trunk; that is, reciprocal innervation.)

4. The therapist also should test the back extensors by and the upper trunk initiates lateral flexion toward
observing the patient in a bridge posture. While the the floor with the shoulder approximating the hip
patient is in a supine position with the hips and (Fig. 7-6A). The end posture (one of ipsilateral trunk
knees flexed, the therapist asks the patient to assume shortening) occurs by an eccentric contraction of the
a bridge position, which is accomplished by a con- side of the elongating trunk.40,50 In Fig. 7-6, A, the
centric contraction of the back and hip extensors16 right side of the trunk is shortening, but the pre-
and is maintained by an isometric contraction of the dominant control is on the left side, which is elon-
same muscles. The release of the posture is con- gating eccentrically. Holding this posture between
trolled by eccentric contraction of the back and hip the middle and end ranges allows evaluation of iso-
extensors. metric lateral flexion control. Therapists should
As a rule of thumb, in the seated posture the back exten- evaluate both sides of the trunk using this movement
sors are active during anterior weight shifts (in which the pattern.
shoulders move in front of the hips), during correction of 2. While patients are in the end position of the first
posture to a position of alignment from an anterior weight movement pattern, the therapist asks them to
shift, and during bridging activities. realign themselves by sitting up straight (see Fig.
7-6, B ). The trunk is realigned by a concentric con-
Control of the Lateral Flexors traction of the lateral flexors38 (the left lateral
Lateral flexion occurs in the coronal plane; therefore, a flexors in Fig. 7-6, B ).
balance of control between the flexors and extensors is 3. The last movement pattern evaluates lateral flex-
required to maintain movement. Electromyographic stud- ion, which initiates the movement from the lower
ies have demonstrated that dorsal and ventral muscles trunk and pelvis.40 This movement pattern allows
coactivate during lateral flexion.50 Electromyographic ac- reach beyond the arm span in the frontal plane.
tivity of the right and left erector spinae has been docu- During this movement, the majority of weight is
mented during lateral trunk flexion.5,25 shifted to one ischial tuberosity; the shoulder and
Mohr40 states, “Two different movement strategies oc- hip approximate in this pattern. In the resulting
cur when you reach down to the side: (1) the initiation posture the trunk is elongated on the weight-
may occur in the upper trunk and the ipsilateral spine bearing side, and trunk shortening occurs on the
shortens, or (2) the movement can be initiated with your nonweight-bearing side (see Fig. 7-6, C ). The
lower trunk and pelvis, resulting in ipsilateral elongation.” predominant control comes from concentric con-
Three movement patterns are used to evaluate control of traction of the lateral flexors on the shortening
lateral trunk flexion: side. Fig. 7-6, C, illustrates the contraction on the
1. The first movement pattern is initiated from an right side of the trunk. The therapist must evalu-
aligned, seated position. The pelvis remains stable, ate both sides of the trunk.
 Chapter 7 • Trunk Control: Supporting Functional Independence 175

A B C

Figure 7-6 Lateral flexor control. Dotted lines indicate trunk starting position, solid lines
indicate trunk final position, arrows indicate movement direction, and plus symbols indicate
muscle groups primarily responsible for control of pattern. (Skeletal muscle activity occurs on
both sides of the trunk; that is, reciprocal innervation.)

Rotation Control
Concerning rotation control, Kapandji33 states, “Rotation
of the vertebral column is achieved by the paravertebral
muscles and the lateral muscles of the abdomen. Unilat-
eral contraction of the paravertebral muscles causes only
weak rotation… During rotation of the trunk, the main
muscles involved are the oblique muscles. Their mechan-
ical efficiency is enhanced by their spiral course around
the waist and by their attachments to the thoracic cage
away from the vertebral column, so that both the lumbar
and lower thoracic vertebral columns are mobilised.”
During rotation of the trunk to the left, the right external
and left internal obliques are activated (Fig. 7-7). The fi-
bers of both of these muscles run in the same direction
and are synergistic. Basmajian’s4 review of the literature IO
EO
on electromyography demonstrates that bilateral activity
in the extensors at the thoracic level is evident during
rotation.
Mohr40 states, “Stroke patients will very rarely rotate
because normal rotation requires extensors and flexors to
be active simultaneously on opposite sides of the trunk.”
Rotational trunk control depends on muscle fixation on
one side of the trunk, resulting in efficient muscle action
on the opposite side.
Trunk rotation can occur in two positions: flexion with
rotation and extension with rotation.7 Mohr40 points out
that rotation can be initiated by the upper trunk or the Figure 7-7 Rotation control. IO, Internal oblique; EO, exter-
lower trunk/pelvis. Rotation control is evaluated by five nal oblique. (From Kapandji IA: The physiology of the joints, vol 3,
movement patterns:8,40 The trunk and vertebral column, New York, 1974, Churchill
1. In the first movement pattern, the patient sits upright, Livingstone.)
and the pelvis remains stable on the support surface.
The patient reaches across midline so that the shoul- obliques and contraction of the back extensors (espe-
der moves toward the opposite hip (e.g., reaching cially at the thoracic level). The therapist must evalu-
with the right arm across the body toward the floor). ate both sides of the trunk.
The result is a position of flexion and rotation. The 2. In the second movement pattern, the upper trunk
primary control is by concentric contraction of the remains stable, and the lower trunk and pelvis
176 Stroke Rehabilitation

initiate a forward movement on one side (e.g., tasks that include multiple variables. The situational
scooting forward). The result is a position of ex- context and task demands determine which components
tension with rotation. of trunk control are necessary for successful task perfor-
3. In the third movement pattern the patient reaches mance. Box 7-2 has an example of task variables that af-
behind at the shoulder level (upper trunk initiation), fect trunk control patterns.
and the resulting posture is rotation and extension. The list of trunk control variations during ADL per-
4. The fourth movement pattern involves initiating a formance in the following section are not considered ex-
backward shift with the lower trunk and pelvis haustive, but are guidelines for observing trunk patterns
(scooting backward) while shifting to one side and and inherent variations during various tasks. The reader
rotating the opposite side posteriorly; this posture is should mimic performing each task to ensure understand-
flexion with rotation. ing of the posture descriptions (Table 7-10).
5. The final movement pattern is similar to a pattern
reviewed in the section on trunk flexion control. Upper Extremity Dressing
The patient is supine and initiates a segmental roll Pullover Shirt. Putting on a pullover shirt requires
by lifting the shoulders up from the support surface the following movements:
and toward the opposite side of the body. This pat- ■ Trunk flexion: Required for the patient to manipulate
tern is controlled by a concentric contraction of the the shirt in the lap and reach down toward the lap to
abdominal muscles (the obliques). insert an arm into the sleeve
■ Trunk extension: Observed as the patient realigns the
Trunk Control during Activities of Daily Living trunk, continues to pull up the sleeve, and inserts the
There is a clear relationship between the loss of trunk head into the shirt
control and the loss of functional independence. Conclu- ■ Trunk rotation with extension: May be necessary for
sions from empirical research include: reaching posteriorly and adjusting the orientation
■ Franchignoni, Tesio, and Ricupero26 stated that of the shirt and/or tucking the shirt into the
trunk control appears to be an obvious prerequisite pants
for the control of more complex limb activities that,
in turn, constitute a prerequisite for complex behav- Button-Down Shirt. Putting on a button-down shirt
ioral skills. requires the following movements:
■ Hsieh and colleagues31 affirmed that strong evidence ■ Trunk flexion: Used to orient the shirt correctly on
exists for the predictive value of trunk control on the lap for preparation of donning and to guide
comprehensive ADL, and they recommended early the arm into the sleeve when the trunk is inclined
assessment and management of trunk control after forward
stroke. ■ Trunk extension: Required to realign the trunk from
■ Karatkas and colleagues34 concluded that trunk flex- the previous position
ion and extension muscle weakness in unihemi- ■ Trunk rotation with extension: Used to reach with the
spheric stroke patients can interfere with balance, more functional arm behind the head and to the op-
stability, and functional disability. posite shoulder to grasp the collar of the shirt and
■ Verheyden and colleagues52 asserted that measures pull it to the opposite side (Fig. 7-8); also used to
of trunk performance are significantly related with
values of balance, gait, and functional ability.
The previous section focused on select movement pat-
terns of the trunk. Evaluating the trunk in this manner is Box 7-2
useful for identifying specific problem areas and focusing
Variables of Eating That Affect Required
treatment plans. However, the impact that impaired
Trunk Control Patterns
trunk control has on functional tasks is more relevant to
all rehabilitation professionals. Most, if not all, of the ■ Size of table
reviewed movement patterns (and combinations of them) ■ Type of seating surface (e.g., presence of armrests or
are used during ADL performance. Therefore, the evalu- backrest, cushions, chair height, distance person is
ation of trunk control can take place during skilled obser- from table)
■ Placement of items such as condiments, utensils, and
vations of ADL.
serving bowls (e.g., near or far, right or left)
For clarification, an infinite number of variations are ■ Type of food (e.g., hot soup, cold fruit)
observed in movement patterns during task perfor- ■ Solitary or group dining (e.g., may get assistance with
mance. Therefore, the focus of evaluation and treatment passing needed items)
should be on observing, evaluating, and treating the pa- ■ Errors (e.g., dropping fork, spilling beverage)
tient in a variety of different environments and with
 Chapter 7 • Trunk Control: Supporting Functional Independence 177

Table 7-10
Trunk Control to Support Participation

ACTIVITY POSSIBLE NECESSARY MOVEMENTS

Bridging Bridging requires trunk extension, which is necessary at the trunk and hips to assume a functional bridge po-
sition. (The height of the bridge depends on the task. For example, bridging to use a bedpan requires more
extension than bridging to don/doff pants.) See Chapter 14.
Scooting Scooting requires the following movement:
■ Trunk flexion and extension: Must be balanced for successful scooting. (The efficiency of the scooting
pattern is compromised if the patient maintains a flexed trunk with a posterior pelvic tilt or a hyperex-
tended trunk.)
■ Lateral flexion: Lower trunk initiation is used to clear the buttocks from the support surface, which is
required to advance the hip forward.
■ Trunk rotation with extension: Lower trunk initiation allows the patient to achieve the goal of scooting
forward
Toileting Using the toilet requires the following movements:
■ Lateral flexion: Lower trunk initiation may be used depending on the sequence of clothing management
for toileting and the type of transfer being used (for example, if patients are performing a sit-pivot transfer,
clothing usually is managed from the seated position. Therefore, lateral flexion is necessary so that pants
and underwear can clear the hips/buttocks); may also be used for wiping after toileting.
■ Trunk rotation with extension: Used to reach across the body for toilet paper
■ Trunk flexion: May be used for self-catheterization, application of a condom-style catheter, management
of feminine hygiene products, and wiping after toileting
Bathing Bathing requires the following movements:
(seated ■ Trunk flexion and extension: Required to reach toward the lower extremities and then realign
on a tub ■ Trunk rotation: Trunk rotation with flexion is used to reach down toward the opposite lower extremity
seat or for lower leg and foot washing; trunk rotation with extension may be used when reaching posteriorly to
bench). wash back and neck. (In general, trunk rotation is used when reaching across the midline of the trunk. The
amount of flexion and extension depends on the area of the body being washed [e.g., flexion for lower body
washing; extension for upper body washing].)
■ Lateral flexion: Lower trunk initiation is required to wash the perineum and rectal areas; upper trunk ini-
tiation may be used to wash the sides of the lower legs or to pick up a bar of soap from the bottom of the
tub. (Bathing activities place extra demands on trunk control because of the slippery nature of the support
surface.)
Grooming Oral care Hygiene of the mouth requires the following movements:
■ Trunk flexion: Isometric control commonly used to position the head over the sink to
preventing spillage of toothpaste and saliva onto clothing; increased trunk flexion for
expectorating (toothpaste and mouthwash) after completion of tooth brushing
■ Trunk extension: Used to realign body from previous position; also used to reach for
supplies in a medicine cabinet over a sink and during gargling
■ Trunk rotation with flexion: May be used to reach toward and adjust the faucet opposite
the arm being used
Hair care Hair care requires the following movements:
■ Trunk flexion or extension: May be used isometrically during hair washing; trunk flex-
ion is used if patients prefer to lean forward and allow the lather to be rinsed off in front
of them; trunk extension (and head/neck extension) is used if patients prefer to lean back
and allow the lather to be rinsed off behind them; both may be used during hair combing
to accentuate the position of the head and optimally position the brush or comb to make
contact with the scalp.
■ Lateral flexion: May be used during hair washing or combing (initiated by upper trunk)
as the head is tilted to the right or left side; also may be used for optimal head placement.
178 Stroke Rehabilitation

Table 7-10
Trunk Control to Support Participation—cont’d
ACTIVITY POSSIBLE NECESSARY MOVEMENTS

Dressing Upper Pullover shirt

extremity Putting on a pullover shirt requires the following movements:
■ Trunk flexion: Required for the patient to manipulate the shirt in the lap and reach down
toward the lap to insert an arm into the sleeve
■ Trunk extension: Observed as the patient realigns the trunk, continues to pull up the
sleeve, and inserts the head into the shirt
■ Trunk rotation with extension: May be necessary for reaching posteriorly and adjusting
the orientation of the shirt and/or tucking the shirt into the pants
Button-down shirt
Putting on a button-down shirt requires the following movements:
■ Trunk flexion: Used to orient the shirt correctly on the lap for preparation of donning
and to guide the arm into the sleeve when the trunk is inclined forward
■ Trunk extension: Required to realign the trunk from the previous position
■ Trunk rotation with extension: Used to reach with the more functional arm behind
the head and to the opposite shoulder to grasp the collar of the shirt and pull it to the
opposite side (see Fig. 7-8); also used to move the second arm through the sleeve and tuck
the shirt into the pants
■ Trunk flexion: Used as the patient attempts to button the shirt; more often used as
relaxation position (a slumped posture) rather than an active flexion pattern
Lower Putting on pants, underwear, shoes, and socks requires the following movements:
extremity ■ Trunk flexion: Required to reach down toward the feet (see Fig. 7-9)
(seated) ■ Trunk rotation with flexion: Required to reach the more functional arm toward the
opposite foot
■ Trunk extension: Required to realign the trunk from the previous positions
■ Lateral flexion: Required when using a crossed-leg method to don/doff pants, underwear,
or footwear (the crossed-leg position shifts the patients’ center of gravity posteriorly,
placing increased demand on the abdominal muscles [i.e., controlling the trunk in flexion
while preventing a posterior fall]) (see Fig. 7-10); also required to pull pants and
underwear up or down over the buttocks and hips successfully
Eating Eating requires the following movements:
■ Trunk flexion and extension: Used in varying degrees with a hand-to-mouth pattern in which an
anterior weight shift of the trunk toward the table occurs (see Fig. 7-11) to position the mouth over the
plate as food enters. (The degree to which this weight shift occurs depends on the type of food being
eaten. Food that is hot or liquid requires increased flexion toward the plate or bowl. The increased flexion
reduces the distance the food must be transported, thereby reducing spillage opportunities.)
■ Trunk rotation: May be used in flexion and extension to reach for condiments that are across the midline
of the trunk
■ Lateral flexion: Lower trunk initiation may be used in reaching for condiments that are positioned to
the side of the place setting and beyond arm’s length and also may be used with trunk rotation postures
(see Fig. 7-12); upper trunk initiation may be used when reaching for an object that drops on the floor to
the side of the patient.

move the second arm through the sleeve and tuck movements:
the shirt into the pants ■ Trunk flexion: Required to reach down toward the
■ Trunk flexion: Used as the patient attempts to button feet (Fig. 7-9)
the shirt; more often used as relaxation position ■ Trunk rotation with flexion: Required to reach the
(a slumped posture) rather than an active flexion more functional arm toward the opposite foot
pattern ■ Trunk extension: Required to realign the trunk from
the previous positions
Lower Extremity Dressing (Seated). Putting on pants, ■ Lateral flexion: Required when using a crossed-leg
underwear, shoes, and socks requires the following method to don/doff pants, underwear, or footwear
 Chapter 7 • Trunk Control: Supporting Functional Independence 179

Figure 7-8 Trunk control during upper extremity dressing. Figure 7-10 Trunk adjustments during lower extremity
dressing.

■ Trunk extension: Used to realign body from previous

position; also used to reach for supplies in a medi-
cine cabinet over a sink and during gargling
■ Trunk rotation with flexion: May be used to reach to-
ward and adjust the faucet opposite the arm being
used

Hair Care. Hair care requires the following move-

ments:
■ Trunk flexion or extension: May be used isometrically
during hair washing; trunk flexion is used if patients
prefer to lean forward and allow the lather to be
rinsed off in front of them; trunk extension (and head/
neck extension) is used if patients prefer to lean back
and allow the lather to be rinsed off behind them;
both may be used during hair combing to accentuate
the position of the head and optimally position the
Figure 7-9 Trunk control during lower extremity dressing.
brush or comb to make contact with the scalp
■ Lateral flexion: May be used during hair washing or
combing (initiated by upper trunk) as the head is
(the crossed-leg position shifts the patients’ center of tilted to the right or left side; also may be used for
gravity posteriorly, placing increased demand on the optimal head placement
abdominal muscles [i.e., controlling the trunk in
flexion while preventing a posterior fall]) (Fig. 7-10); Eating
also required to pull pants and underwear up or Eating requires the following movements:
down over the buttocks and hips successfully ■ Trunk flexion and extension: Used in varying degrees
with a hand-to-mouth pattern in which an anterior
Grooming weight shift of the trunk toward the table occurs
Oral Care. Hygiene of the mouth requires the fol- (Fig. 7-11) to position the mouth over the plate as
lowing movements: food enters. (The degree to which this weight shift
■ Trunk flexion: Isometric control commonly used to occurs depends on the type of food being eaten.
position the head over the sink to preventing spillage Food that is hot or liquid requires increased flexion
of toothpaste and saliva onto clothing; increased toward the plate or bowl. The increased flexion re-
trunk flexion for expectorating (toothpaste and duces the distance the food must be transported,
mouthwash) after completion of tooth brushing thereby reducing spillage opportunities.)
180 Stroke Rehabilitation

■ Trunk rotation: Trunk rotation with flexion is used

to reach down toward the opposite lower extremity
for lower leg and foot washing; trunk rotation with
extension may be used when reaching posteriorly
to wash back and neck. (In general, trunk rotation
is used when reaching across the midline of the
trunk. The amount of flexion and extension de-
pends on the area of the body being washed [e.g.,
flexion for lower body washing; extension for upper
body washing].)
■ Lateral flexion: Lower trunk initiation is required to
wash the perineum and rectal areas; upper trunk
initiation may be used to wash the sides of the lower
legs or to pick up a bar of soap from the bottom of
the tub. (Bathing activities place extra demands on
trunk control because of the slippery nature of the
Figure 7-11 Trunk control while eating.
support surface.)

Toileting. Using the toilet requires the following

movements:
■ Trunk rotation: May be used in flexion and extension ■ Lateral flexion: Lower trunk initiation may be used
to reach for condiments that are across the midline depending on the sequence of clothing manage-
of the trunk ment for toileting and the type of transfer being
■ Lateral flexion: Lower trunk initiation may be used used (for example, if patients are performing a sit-
in reaching for condiments that are positioned to pivot transfer, clothing usually is managed from the
the side of the place setting and beyond arm’s length seated position. Therefore, lateral flexion is neces-
and also may be used with trunk rotation postures sary so that pants and underwear can clear the
(Fig. 7-12); upper trunk initiation may be used hips/buttocks.); may also be used for wiping after
when reaching for an object that drops on the floor toileting.
to the side of the patient. ■ Trunk rotation with extension: Used to reach across
the body for toilet paper
Bathing (Seated on a Tub Seat or Bench). Bathing re- ■ Trunk flexion: May be used for self-catheterization,
quires the following movements: application of a condom-style catheter, manage-
■ Trunk flexion and extension: Required to reach toward ment of feminine hygiene products, and wiping
the lower extremities and then realign after toileting

Bridging. Bridging requires trunk extension, which is

necessary at the trunk and hips to assume a functional
bridge position. (The height of the bridge depends on
the task. For example, bridging to use a bedpan requires
more extension than bridging to don/doff pants.) See
Chapter 14.

Scooting. Scooting requires the following movement:

■ Trunk flexion and extension: Must be balanced for suc-
cessful scooting (The efficiency of the scooting pat-
tern is compromised if the patient maintains a flexed
trunk with a posterior pelvic tilt or a hyperextended
trunk.)
■ Lateral flexion: Lower trunk initiation is used to clear
the buttocks from the support surface, which is re-
quired to advance the hip forward.
■ Trunk rotation with extension: Lower trunk initiation
Figure 7-12 Trunk adjustments while reaching for utensils or allows the patient to achieve the goal of scooting
condiments. forward.
 Chapter 7 • Trunk Control: Supporting Functional Independence 181

TREATMENT TECHNIQUES TO ENHANCE on pelvic tilt and resultant trunk postures. When the feet
TRUNK CONTROL DURING TASK are positioned under the knees and toward the chair, an
PERFORMANCE anterior pelvic tilt and trunk extension are enhanced. The
opposite is also true: when the feet are positioned in front
Assuming an Appropriate Starting Posture of the knees and the knees are extended, a posterior pelvic
Before initiation of tasks and retraining of trunk control, tilt and resulting trunk flexion are enhanced.
the trunk must be in a proper biomechanical alignment. More recently, there is further empirical evidence that
Therapists should observe patients anteriorly, posteriorly, a neutral spine/starring position should be encouraged
and laterally to detect deviations from normal alignment from both a neuromuscular and functional perspective.
(see Table 7-8). Cholewicki and colleagues13 demonstrated that antago-
Physically or verbally cueing patients to assume an ap- nistic trunk flexor-extensor muscle coactivation was pres-
propriate starting posture should place them in a position ent around the neutral spine posture in healthy individu-
of readiness for function-optimal symmetry in the trunk als, and this coactivation increased with added mass to the
that is usually in midline, depending on the task (Box 7-3). torso. Gillen and colleagues29 examined the effects of
This neutral starting posture is similar to the position various seated trunk postures on upper extremity func-
the trunk and lower extremities assume when a person tion. Fifty-nine adults were tested using the Jebsen Taylor
begins a typing task. Hand Function Test while in three different trunk pos-
An aligned and upright trunk posture has been shown tures. Significant mean differences between the neutral
to recruit muscle activity in the trunk. Floyd and Silver’s versus the flexed and laterally flexed trunk postures were
electromyographic studies25 demonstrated that a “slumped” noted during selected tasks. Specifically, dominant hand
position while sitting (simultaneous trunk flexion and ex- performance during the tasks of feeding and lifting heavy
tension of the hip joint) resulted in trunk extensor relax- cans was significantly slower while the trunk was flexed
ation. In contrast, sitting upright in a chair without a and laterally flexed than when performed in the neutral
backrest resulted in increased activity of the erector spinae trunk position. Performance of the nondominant hand
muscle group. This muscle activity persisted as long as the during the tasks of picking up small objects, page turning,
trunk remained in extension, despite adjustments of the and the total score was slower while the trunk was flexed
head and shoulders. A “slumped” posture, which consists compared with performance in the neutral trunk position.
of trunk flexion, posterior pelvic tilt, and resulting hip ex- These findings support the assumption that neutral trunk
tension, is observed commonly during evaluation of pos- posture improves upper extremity performance during
ture in the stroke population; the position requires mini- daily activities, although the effect is not consistent across
mal skeletal muscle activity. tasks.
Andersson and Ortengren’s review of the literature1 Patients should be encouraged to feel the difference
demonstrated that the position of the feet had an effect on between an aligned and a malaligned posture. The patient
the myoelectric activity of the trunk extensors. Knee flex- should be able to assume an appropriate posture auto-
ion (causing the feet to come toward the chair) increased matically. Demonstration of the effect that a slumped
muscle activity in the trunk, whereas knee extension re- posture has on reaching activities performed with the side
sulted in a decrease in muscle activity. Stroke patients less affected by the stroke may be helpful. Patients may
commonly assume a seated posture in which their feet realize that the distance and quality of their reach is en-
(especially the more affected lower extremity) are posi- hanced when they are sitting in a proper alignment.
tioned on the floor in front of their knees (e.g., in knee Although the use of mirrors for visual feedback may be
extension). The position of the feet tends to have an effect appropriate for some patients, mirrors should be used
with caution for patients with neurobehavioral deficits.
Another technique for assisting patients with gaining
Box 7-3 symmetry is to have the therapist positioned in front of
Seated Position of Readiness for Function the patient and to assume the patient’s postures to provide
feedback for the patient. Therapists should slowly correct
■ Pelvis is in neutral to anterior tilt their posture, instructing the patient to mimic the move-
■ Equal weight-bearing on both ischial tuberosities ment. The therapist may state, “Keep your shoulders in
■ Trunk erect and midline with appropriate spinal line with mine” or “Keep your forehead at the same level
curves
as mine.”
■ Shoulders symmetrical and over the hips
■ Head/neck neutral
Mohr40 emphasizes use of activities that encourage
■ Hips slightly above the level of the knees rotation and lateral flexion to gain midline control: “the
■ Knees in line with the hips active movements of the trunk into rotation and lateral
■ Feet equally weight-bearing and underneath the knees flexion are caused by the same muscles that flex and
extend the trunk. The different movements occur as a
182 Stroke Rehabilitation

result of different interactions of these muscles with remain stable on the support surface for optimal
each other . . . In order for patients to achieve midline stretch (lateral flexion).
postural control, the therapist must work with the pa- 5. While sitting, patients hold their more affected
tient in the higher levels of lateral and rotational planes wrist and reach to the floor between their feet. The
of movement.” therapist also encourages them to allow their head
to drop and dangle (flexion).
Maintaining or Increasing Trunk Range of Motion 6. While supine, patients assume a bridge posture and
through Mobilization and Movement hold the position as able (extension).
Concerning ROM in the trunk, Mohr40 states, “If there is 7. While sitting, patients practice lifting their hip from
not full range in all trunk movements (flexion extension, the support surface. This movement can be en-
lateral flexion, and rotation), it will be more difficult to hanced by having the patient reach up and to the
gain full control of the trunk. Any lack of ROM in the side with the opposite upper extremity. Reaching
trunk will lead to decreased function.” beyond the arm span in this posture requires lateral
Although limited ROM in the extremities is commonly flexion for the reach pattern to be successful (lateral
evaluated and treated, the ROM in the spine often is over- flexion).
looked. After acute strokes, patients lose the ability to
shift their weight and make postural adjustments. Evalu- Using Various Postures
ating patients who have trunks influenced completely by Therapists may use various postures as an adjunct treat-
gravity and who demonstrate only static trunk postures is ment during patients’ performance of functional tasks.
common. In these cases, prolonged immobilization of the Therapists should select postures based on specific patient
trunk because of loss of control can result in loss of soft- needs. The chosen posture should accentuate and chal-
tissue elasticity, joint play, and ultimately function. These lenge the movement and control patterns interfering with
problems, compounded by inappropriate trunk position- independent performance of life activities. If the patient is
ing and support in upright postures, lead to a cycle of not engaging in a specific activity (self-care tasks, games,
immobility, soft-tissue changes, loss of range, and im- and adapted sports), the use of these postures in isolation
paired functional abilities. is not encouraged. Examples of varying postures include
Specific trunk mobilization techniques are beyond the the following:
scope of this chapter but are discussed in the litera- ■ Seated with legs crossed: Use of this posture is ap-
ture.8,16,22,40 Just as therapists train patients to perform propriate for patients whose inability to control lat-
self-ROM activities for their extremities, therapists must eral flexion and flexion patterns and to shift their
promote patient awareness of trunk mobility and educate weight is preventing functional independence. Work-
them about specific movement patterns that maintain ing with patients in this posture encourages weight
and/or increase their trunk ROM. Following are examples transference to one ischial tuberosity and has the
of movement patterns that patients can perform to meet added effect of challenging abdominal control. This
this goal: occurs because the crossed leg is in a position of hip
1. While supine, patients flex their hips and knees as if flexion. When the hips are flexed, the traction on the
preparing to bridge. Patients are instructed to keep hamstrings tends to tilt the pelvis posteriorly,33 re-
their shoulders flat on the bed and simultaneously al- sulting in a posterior shift in the center of gravity.
low their knees to fall slowly from one side and then Abdominal control therefore is required to prevent a
the other. This movement pattern encourages disso- posterior loss of balance. Participation in tasks such
ciation from the upper and lower trunk (rotation). as lower extremity dressing, lower body washing, and
2. While supine, patients keep their hips and knees activities such as modified volleyball place extra de-
straight while cradling their more affected upper mands on patients who are in this position.
extremity. The goal is to lift and rotate the upper ■ Sitting in front of a table while bearing weight
trunk as if initiating a roll with the upper trunk on both forearms: Ryerson and Levit44 recommend
(rotation). this posture during the acute stage of hemiplegia
3. While sitting, patients cradle their more affected when little postural control is evident. In this pos-
upper extremity against their chest. The therapist ture, patients use their upper extremities as a point
encourages patients to move the upper trunk in a of proximal stability. The therapist should stress that
twisting motion without letting the pelvis move the arm should be active and the trunk should not be
(rotation). allowed to “hang” on an inactive arm. Patients are
4. While sitting, patients practice moving from an encouraged to practice anterior, posterior, and lat-
upright posture to a posture of lateral flexion on one eral shifting in this posture to reestablish postural
side so that they are bearing weight on their fore- control; coordinate trunk, scapula, and humerus pat-
arm to the side of their trunk. The pelvis should terns; and to establish weight-bearing of the upper
 Chapter 7 • Trunk Control: Supporting Functional Independence 183

extremities. Because both arms are engaged in a ■ In 62% of pushers, symptoms resolved by six weeks,
weight-bearing activity, patient participation in whereas in 21%, pushing symptoms persisted at
functional tasks is difficult. Immediately following three months.
use of this posture, the therapist must engage the ■ Motor recovery and functional abilities at three
patient in a follow-up activity such as reaching to months were significantly lower among the pushers
ensure the postures can be incorporated into ADL. compared with the nonpushers.
■ Prone on elbows: Although effective for gaining ■ Pushers also had a significantly longer hospital
trunk extension, this position should be used with length of stay (89 days versus 57 days).
caution. The position may compromise respiratory ■ Motor and functional recovery improved signifi-
status, cause shoulder pain if upper extremity align- cantly over the three-month study period for both
ment is not considered, and be generally uncomfort- pushers and nonpushers.
able for older stroke patients. The position may be ■ Although the pushers had greater lengths of stay in
effective for some patients and may be a required both acute care and rehabilitation facilities, they
posture for some transitional movements such as were discharged home with similar frequency to the
floor-to-chair transfers. nonpushers.
■ Kneeling: This posture is appropriate for patients Perennou and colleagues42 investigated whether the
having trouble in gaining trunk/hip extension. Pa- pusher syndrome affects only the trunk for which gravita-
tients also may find this posture uncomfortable, but tional feedback is given by somesthetic information, or
it may be necessary for transitional patterns. the head as well (gravitational information given by the
■ Variations on the degree of hip flexion while vestibular system). The results of their pilot study indi-
seated: Changing the position of the lower extremi- cated that that the pusher syndrome does not result from
ties can challenge the performance of specific trunk disrupted processing of vestibular information but from a
patterns. Being in a position with the knees below higher-order disruption in the processing of somesthetic
the hips, such as sitting on a high stool, decreases the information originating in the left hemibody, which could
amount of hip flexion and has a tendency to place be an extinction phenomenon. The authors felt that this
the trunk in increased extension. disruption leads pushers actively to adjust their body pos-
Conversely, positioning the patient with the knees ture to a subjective vertical bias to the side opposite the
above the hips (increasing the amount of hip flexion) lesion.
results in a position of trunk flexion and a posterior Pedersen and colleagues41 also examined the pusher
weight shift, which places greater demands on the syndrome. The study examined the incidence of the syn-
trunk flexors. drome, the relation of this syndrome to neurobehavioral
deficits, and the effect of the syndrome on the rehabilita-
Treating the “Pusher Syndrome” or Contraversive tion process in 327 patients. The study revealed a 10%
Pushing incidence and found no significant differences in hemine-
The “pusher syndrome” is a phrase coined by Davies,19 glect or anosognosia in patients with and without ipsilat-
who derived the name from what she felt was the most eral pushing. The study discovered that patients who
striking aspect of this syndrome: the patient pushes heav- demonstrated ipsilateral pushing required 3.6 weeks lon-
ily toward the hemiplegic side in all positions and resists ger to reach the same outcome as patients who did not
any attempt at passive correction (i.e., a correction that demonstrate ipsilateral pushing. Of note in this study are
would bring the weight toward or over the midline of the the Barthel index scores at admission and discharge. On
body to the unaffected side). This phenomenon has been admission, patients who demonstrated ipsilateral pushing
documented in patients with both right and left hemi- scored an average of 13.7 on the Barthel index compared
spheric lesions. Further analysis has revealed that the with 46.8 for patients without evidence of pushing. On
brain structure typically damaged in patients with pusher discharge, the average score for pushers was 43.9 com-
syndrome is the left or right posterolateral thalamus.36 pared with 66.8 for patients without pushing. The dis-
Danells and colleagues15 defined pushing as “resistant charge scores (in terms of ADL function) of the patients
to accepting weight on and actively ‘push’ away from the who were pushers were still below the admission scores
nonparetic side.” The authors identified pushers (n65) for patients who did not push.
from stroke patients with moderate to severe hemiparesis Davies17 summarizes the typical signs of the pusher
and examined longitudinal changes in symptoms, level of syndrome as the following:
impairment, and functional independence. Assessments ■ Head turned away from affected side and laterally
were performed within 10 days postonset, at six weeks, flexed toward stronger side
and at three months. The authors found: ■ Decreased ability to perceive stimuli from affected
■ At one week after stroke, 63% of patients demon- side
strated features of pushing. ■ Lack of facial expression
184 Stroke Rehabilitation

■ Poor breath control with monotone, hypophonic Unfortunately at this point, specific interventions are
voice based on anecdotal evidence only, but they may still be
■ An elongated affected side helpful to clinicians. Davies17 recommends the following
■ Evidence of pushing with stronger leg while supine specific treatments for the pusher syndrome:
■ Holding onto side of bed or mat as if falling ■ Restore head movements: maintain full passive
■ Shortening of stronger side of trunk with elongation ROM, stretch, and encourage active ROM by scan-
of hemiplegic side while sitting ning activities.
■ Marked resistance to attempts to transfer weight to ■ Activate the side flexors (see activities described in
stronger side previous sections).
■ Pushing with stronger arm and leg to more affected ■ Use functional activities to regain midline while
side standing.
■ Difficulty transferring, especially to stronger side Karnath and Broetz37 recommend the following interven-
■ All weight shifted to affected side while standing; tion sequence:
leaning against therapist’s supporting arm or flexing ■ Realize the disturbed perception of erect body
forward at hips position.
■ Hemiplegic leg adduction (scissors) when walking; ■ Visually explore the surroundings and the body’s
difficulty taking a step with affected leg because of relation to the surroundings. Ensure that the patient
an inability to shift weight to stronger side sees whether he or she is oriented upright. The
Pushing can be quantified via the Scale for Contraversive therapist should use visual aids that give feedback
Pushing (SCP).35 It is scored 0 to 6 with higher the scores about body orientation (i.e., the therapist’s arm) and
indicating a greater severity of pushing. There are three work in a room containing many vertical structures,
domains (posture, extension, and resistance) that are as- such as door frames, windows, pillars, and so on.
sessed for both sitting and standing positions (i.e., six ■ Learn the movements necessary to reach a vertical
scored items) (Box 7-4). Using a cut score of greater than body position.
0 in each section appears to increase the agreement of ■ Maintain the vertical body position while perform-
clinical and SCP observations and has been suggested.4 ing other activities.

Box 7-4
The Scale for Contraversive Pushing
(A) Posture (symmetry of spontaneous posture) Sitting Standing
Score 1  severe contraversive tilt with falling to the contralesional side  
Score 0.75  severe contraversive tilt without falling  
Score 0.25  mild contraversive tilt without falling  
Score 0  no tilt/upright body orientation  
Total (max  2):
(B) Extension (use of the arm/leg to extend the area of physical contact to the ground)
Score 1  performed already in rest  
Score 0.5  performed not until position is changed  
Score 0  no extension  
Total (max  2):
(C) Resistance (resistance to passive correction of posture to an upright position)
Score 1  resistance is shown  
Score 0  resistance is not shown  
Total (max  2):

Max, maximum.
Translated from Karnath HO, Ferber S, Dichgans J: The origin of contraversive pushing. Neurology 55(9):1298-1304, 2000.
Note: For section B: For sitting, ask the patient to glide the buttocks on the mattress toward the nonparetic side, to transfer from bed to
wheelchair toward the nonparetic side, or both. For standing, ask the patient to start walking. If pushing already occurs when the patient is
rising from the sitting position, section B is given the value of 1 for standing.
For section C: Touch the patient at the sternum and the back. Give the following instructions: “I will move your body sideward. Please
permit this movement.”
 Chapter 7 • Trunk Control: Supporting Functional Independence 185

A hands-on approach does not seem to be effective with the activity should be placed, and deciding on the charac-
patients who have the pusher syndrome; therapists’ at- teristics of the objects the patient is reaching for (number
tempts to assist patients with gaining midline by handling of objects, weight of the objects, and whether objects re-
is met by further patient resistance. Manipulating the quire one or two hands). Table 7-11 includes examples of
environment and providing external cues (verbal) seem to activity placement and resulting trunk response.
be more effective. Examples include the following: Dean and Shepard18 investigated, via a randomized
■ Have patients reach with their stronger upper ex- placebo-controlled trial of task-related training after
tremity for objects beyond their arm span to encour- stroke, the effect of a training program designed to im-
age a weight shift to the stronger side. prove the ability to balance in sitting after stroke. The
■ Provide verbal cues to realign the trunk, such as, training program was designed to improve sitting balance
“Bring your head toward mine” and “Bring your left and involved emphasis on appropriate loading of the af-
shoulder toward the wall.” fected leg while at the same time practicing reaching tasks
■ Provide a target toward which patients can move using the unaffected hand to grasp objects located beyond
their trunk and maintain the position as long as pos- arm’s length. The reaching tasks were performed under
sible. For example, place a bolster on patients’ stron- varied conditions. Changing the location of the object
ger side, and cue them to lean against the bolster and that the subject was reaching for varied the distance and
hold the position. direction of reach. Seat height, movement speed, object
■ Remove surfaces from which to push. For example, weight, and extent of thigh support were also varied. In-
raise the hospital bed or therapy table, so that the creasing the number of repetitions and complexity of the
person’s foot is not on the floor and place a movable tasks advanced the training. The authors found that after
surface (e.g., small ball) under the less affected foot training, subjects were able to reach faster and farther,
to prevent pushing. increase load through the affected foot, and increase acti-
Further empirical intervention studies are needed in this vation of affected leg muscles compared with the control
area of practice. group (highlighting the critical contribution of the lower
extremities in promoting sitting balance). The experi-
Engaging in Reaching Tasks mental group also improved in sit to stand. The control
Therapists can use placement of objects in reaching ac- group did not improve in reaching or sit to stand, and fi-
tivities as a way to place a variety of demands on the trunk. nally, neither group improved in walking. See Tables 7-9
The key to eliciting a trunk response is to place the object and 7-11 for suggestions to grade reaching tasks.
slightly beyond the arm’s reach. Fisher24 observes that
when subjects without brain injuries reach, they anteriorly Using Movable Surfaces
tilt the pelvis, slightly extend the upper back, and move Several authors have advocated the use of movable surfaces
the trunk in the direction of the arm. Patients with brain to challenge trunk control.8,16,32 Movable surfaces used in
injuries do not incorporate trunk movements into arm treatment include items such as therapy balls, bolsters, and
movements and reach only to arm’s length as they main- rocker boards. Movable surfaces can be used in treatment
tain a slumped posture. in a variety of ways, including the following:
Therapists have the ability to control the desired re- ■ To grade the difficulty of the task
sponse by the way they set up the activity. Setting up the ■ To challenge the patient to maintain control of the
activity includes placing items required during ADL in surface without outside assistance (challenge isomet-
specific places, choosing the appropriate environment ric patterns)
(e.g., kitchen with upper and lower shelves, bookcase, desk ■ To allow the patient to respond to the therapist’s
space, meal table), deciding how far beyond the arm span perturbation of the movable surface

Table 7-11
Examples of Grading Activities during Reaching Tasks
EASIER MORE DIFFICULT

Sitting surface Firm and stable surface Cushioned or unstable surface

Full thigh support Partial thigh support
Object Within arm’s reach Beyond arm’s reach
Light (e.g., a pencil) Heavy (e.g., bag of flour)
Use of arms Reach with one arm Reach with both arms
External support Maximum via therapist, bolsters, and so on None
Prediction Predictable (e.g., lift stationary object) Unpredictable (e.g., catch a ball)
186 Stroke Rehabilitation

■ To allow the patient to initiate moving the surface ■ Reaching for objects on the floor that are on the side
■ To enhance stretching and mobilization of the trunk of the patient
by using a particular surface such as a large ball The majority of ADL and mobility tasks encompass a
■ To add variety to treatment sessions variety of postures and movements. For the mentioned
■ To focus on isolated trunk control strategies to be effective, therapists should initially focus
Use of movable surfaces may be appropriate for patients patients’ attention on the desired components of trunk
who are experiencing difficulty controlling their trunk in movements. As the patient progresses, the obvious goal is
environments with external perturbations (e.g., trains, for the trunk responses to be relearned and become auto-
automobiles, and buses). Although movable surfaces are matic.
used commonly in the clinic, research concerning the ef-
fectiveness of this type of treatment compared with other Therapeutic Exercise
types is lacking. One may argue that when patients master A recent pilot randomized controlled trial55 (N  33)
trunk control on a movable surface (a difficult situation), documented that conventional occupational and physical
their control will improve on less demanding surfaces therapy combined with additional trunk exercises aimed
(surfaces that do not move). Unfortunately, this argument at improving sitting balance and selective trunk move-
is not supported by current research that advocates task- ments has a positive effective on the selective performance
specific training. of lateral flexion after stroke. Specifically, the experimen-
tal group received 10 hours of additional trunk exercises
Handling that included:
Handling is a common technique used in the clinic. This ■ Supine exercises with legs bent and meet on the
intervention commonly is associated with neurodevelop- therapy table: anterior/posterior pelvic movements,
mental therapy7 and may allow the patient to feel the bridging, and trunk rotation, initiated from the up-
desired movement pattern, gain range, assist weak move- per and lower trunk
ment patterns, and provide external support to prevent ■ In sitting: flexion and extension of the trunk with-
falls. To be effective, the patient must be aware of the goal out moving the trunk forward or backward, flexion/
associated with handling, and the therapist should use extension of the lumbar spine, flexion/extension of
handling within the context of a functional task. In addi- the hips with the trunk extended, lateral flexion of
tion, the handling from the therapist should be graded to the trunk initiated from the shoulder and pelvic
allow the patient to perform as much of the movement girdle, upper and lower trunk rotation, and scooting
pattern as possible. A variety of texts that review specific forward and backwards.
techniques of handling are available.7,8,16,17,22,32 Although
handling is commonly used, research does not support use Adapting the Environment
of this technique (see Chapter 6). Some patients may have little improvement in trunk con-
trol. Environmental adaptations are necessary for these
Using Activities of Daily Living and Mobility Tasks patients to enhance independent performance. Examples
Clearly the most effective tools that occupational thera- include
pists can use to help patients regain trunk control are ■ Use of outside supports can help maintain trunk
self-care, instrumental ADL, and mobility tasks. stability while the extremities are engaged in func-
The therapist first must perform a thorough evaluation tional tasks. Supports such as lateral supports, ante-
as described in previous sections. Following the evalua- rior chest straps, arm chairs, pillows and cushions for
tion, therapists and patients should identify the most prob- propping, and lap trays are examples of equipment
lematic movement patterns that occur during the patients’ used to compensate for compromised trunk control
daily activities. At this point, therapists use their activity (see Chapter 26).
analysis skills to choose appropriate tasks that incorporate ■ Rearrangement of the environment can decrease
the desired patterns and postures as described previously. demands on the trunk. Placing required equipment
For example, if the identified problematic patterns are within the patient’s reach (arm reach) not only in-
lateral flexion and lateral weight shifts, therapists may creases independence but also may prevent falls.
choose the following activities for the patient to practice: Storing dishes on the counter instead of in a cabinet,
■ Lower extremity dressing placing utensils in front of the patient, and keeping
■ Weight shifting for pressure relief grooming items on top of the sink instead of in a
■ Scooting medicine cabinet are examples of this strategy.
■ Assuming a sitting position from side-lying position ■ Provision of adaptive equipment is a common strat-
■ Reaching for objects that are positioned above and egy to increase independent performance and mini-
to the side of the patient opposite the side where mize safety risks. ADL equipment issued to com-
lateral flexion is desired pensate for poor trunk control may include the
 Chapter 7 • Trunk Control: Supporting Functional Independence 187

following: long-handled shoe horns, elastic laces,

she brought food to her mouth. Although spillage still
adapted bath brushes, soap on a rope, reachers, tub
occurred, it happened less frequently, with the food
seats, and commodes. See Chapter 28 for more in-
falling to the plate or table and not in her lap.
formation on adaptive devices.
As S.G. progressed, the therapist was able to sit next
■ Home modifications such as grab bars and bed rails
to or in front of her during activities. She engaged in
also may be indicated. See Chapter 27 for a full re-
graded reaching activities in which the distance S.G.
view of home adaptations and equipment recom-
was required to reach was increased progressively. Ac-
mendations.
tivities included reaching to lower shelves in the refrig-
erator and reaching for objects positioned at specific
CASE STUDY levels (e.g., knee level, midshin level, and floor level).
Regaining Trunk Control after a Stroke On discharge from inpatient rehabilitation, S.G.
was able to perform all basic ADL with distant supervi-
S.G. is a 64-year-old female who came to the rehabili-
sion and without assistive devices, reach to the floor
tation unit after a right middle cerebral artery cerebro-
when she propped her upper trunk with her more af-
vascular accident. The following data were collected
fected forearm against her knees, and eat indepen-
from the initial evaluation (specific to the trunk):
dently by using a rocker knife to cut her food, with
■ Sensation was intact.
spillage occurring only 10% of the time.
■ Static postural malalignments included posterior
pelvic tilt, retracted left rib cage, and increased
weight-bearing on left ischial tuberosity. REVIEW QUESTIONS
■ Dynamical posture was difficult to assess because the
patient was afraid to move. The patient could not 1. What is considered an aligned posture in preparation
reach beyond her arm span when reaching with her for engagement in functional tasks? What are the com-
right arm. She had a tendency to fall backward and mon deviations from this posture after stroke?
to the left during lower extremity dressing and when 2. Name three ADL tasks that require control in the ro-
reaching for objects behind her. tation plane.
■ S.G.’s personal occupational therapy goals were to 3. What are advantages and disadvantages of using mov-
be able independently to don her shoes, be able to able surfaces in trunk control treatment?
reach for objects she had dropped without falling, 4. What are appropriate treatment activities for patients
and decrease the amount of spillage that occurred who lack trunk extensor control?
during meals. 5. Explain the reason an appropriate starting alignment is
The initial treatment plan included adapting her considered a prerequisite for initiating functional ac-
wheelchair with lateral supports (which were removed tivities.
when she was supervised by friends, family, and staff) 6. Which trunk patterns are required for donning a button-
and a lumbar roll to maintain optimal alignment while down shirt?
functioning in the wheelchair, trunk mobilizations
(specifically in the directions of extension and lateral
flexion to both sides), activities to recruit abdominal REFERENCES
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 s u s an m . do n ato
k a re n h al l i day pu l as ki

chapter 8

Overview of Balance
Impairments: Functional
Implications

key terms
balance center of mass limits of stability
base of support gaze stabilization posture

chapter objectives
After completing this chapter, the reader will be able to accomplish the following:
1. Identify the systems involved in balance, and understand the assessment and evaluation
of component balance skills and balance during functional activity.
2. Provide examples of treatment plans and ideas based on specific balance dysfunctions to
allow the therapist to implement focused intervention.
3. Participate in the development of goals and documentation systems with emphasis on the
setting for service delivery and the effect of the current health care environment.

THEORY support of the body against gravity.22,32 In this model, bal-

ance deficits result from eliminating higher central nervous
Balance is the ability to control the center of mass over the system control, resulting in the release of spinal and supra-
base of support within the limits of stability; balance results spinal reflexes. This model has declined in popularity in
in the maintenance of stability and equilibrium. A person’s recent years because common opinion embraces the idea
ability to maintain balance in any position depends on a that the nervous system more likely is comprised of com-
complex integration of multiple systems. Many theories plex interactions of multiple systems rather than organized
have been proposed to explain the ability to maintain bal- as a distinct hierarchy. See Chapter 4.
ance. In the now outdated reflex or hierarchical model, The systems or distributed control model introduced
balance was considered the interaction of reflexes and reac- by Bernstein describes balance as a complex interaction
tions, which are organized hierarchically, that result in the of musculoskeletal and neural systems.50 The ability to

189
190 Stroke Rehabilitation

maintain balance is specific to and modified around the head). The canals are capable of detecting movement in
constraints of the environment and task. Within this sys- all planes because all three are oriented in different
tem a disruption of balance (or instability) results from a planes (Fig. 8-1). Input from the semicircular canals in-
malfunction in or disruption of any one or more of the fluences postural responses and drives compensatory eye
elements of the postural control system. Likewise, bal- movements.
ance is maintained through the interaction of sensory The otolith is composed of the utricle and saccule.
organization and postural control systems. The informa- Together they are responsible for determining changes in
tion is combined and integrated in the central nervous head position in the linear plane or translational move-
system. ment of the head. Specifically, the utricle responds to head
tilt and translations along the horizontal plane. In addi-
SENSORY ORGANIZATION tion, the utricle appears to play an important role in
producing small, torsional eye movements, which keep
According to the systems model, information from three the eyes level when the head is tilted laterally. This helps
sensory systems is used for maintaining balance. Informa- with maintaining postural control and vertical orientation
tion from the visual, vestibular, and somatosensory sys- in space. The saccule appears to be instrumental in de-
tems is critically important. tecting vertical translations of the head.
The visual system (see Chapter 16) provides informa- In addition to these three systems, individuals’ internal
tion regarding vertical orientation and visual flow. Visual representations or perceptions influence the interactions
or optical flow information, which describes movement of of information. Each individual possesses an internal per-
an image on the retina, is important input that aids detec- ception related to the task, themselves, and the environ-
tion of personal and environmental movement. Informa- ment, which in turn influences sensory interactions and
tion provided by the visual system can be ambiguous and responses.
must be compared with other sensory information to de- To use sensory information appropriately, each indi-
termine accuracy. For example, a person sitting in a sta- vidual develops what is referred to as a sensory strategy. A
tionary car next to another stationary car at a red light sensory strategy is formulated when the central nervous
then may receive optical flow information that indicates system integrates, evaluates, and selects information re-
the other car is moving backward. This information alone ceived from the visual, somatosensory, and vestibular
is not adequate for determining which vehicle is moving; systems. The information is evaluated according to in-
it only reveals relative movement. The information must ternal and external constraints, including availability of
be compared with the other sensory information to deter- sensory information and the accuracy of environmental
mine which car has moved. information. Information evaluation also may depend on
Somatosensory information is comprised of cutaneous the occurring movement strategy occurring. The devel-
and pressure receptors on the soles of the feet and of opment of a sensory strategy results in a sensory-motor
muscle and joint receptors. This information helps deter- interaction. The central nervous system determines the
mine characteristics of and the relationship of the indi- most efficient use of sensory input, which then allows for
vidual to the support surface. During most tasks, somato- generation of appropriate motor output to complete the
sensory information may be the most heavily relied on
input in the adult population. Like visual input, somato-
sensory input can be ambiguous. For example, dorsiflex- Anterior (superior)
ion at the ankle indicates that the body is displaced ante- semicircular duct
riorly over the base of support. However, when standing Lateral
membranous
on an incline, this ankle position may coincide with mid- Utricle
ampulla
line posture. The individual must consider other senses to
determine which position is accurate. Lateral
semicircular
Information from the vestibular system helps deter- duct
mine head position and head motion in space relative to Cochlear
duct
gravity. This information generally plays a minor role in
balance control, unless somatosensory and visual inputs
are inaccurate or unavailable. The vestibular system is
the only sensory reference that is not ambiguous because Saccule
Posterior
it depends on gravity, which is consistent in the environ- Endolymphatic semicircular
ment. The vestibular system (see Chapter 9) is composed duct duct
of the otolith and semicircular canals. The semicircular Posterior
canals sense angular acceleration, which is a change in membranous ampulla
velocity along a curved path (e.g., shaking or nodding the Figure 8-1 The semicircular canals.
 Chapter 8 • Overview of Balance Impairments: Functional Implications 191

necessary task or reach a desired goal. This rapid process

is not detectable when no deficits exist.

POSTURAL CONTROL
An individual’s ability to maintain equilibrium depends
not only on accurate evaluation and use of sensory in-
formation but also on the implementation of effective
movement strategies. Movement strategies are stereo-
typed or synergistic patterns used to maintain the center
of mass over the base of support; they are characterized
as automatic, not reflexive or voluntary. Movement A B
strategies occur too quickly to be under voluntary con-
trol but are too slow to be considered reflexive. Syner-
gistic movement patterns are useful in that they reduce
the degrees of freedom, thus decreasing the response
time. Postural actions are reduced or absent when an
individual uses an external support such as a cane or
countertop to help maintain postural control. Auto-
matic postural responses include ankle, hip, and step-
ping strategies.47
An ankle strategy is used to maintain the center of mass
over the base of support when movement is centered on C 1 2 3
the ankles. Knee, hip, and trunk stability is necessary for Figure 8-2 Automatic postural reactions: ankle, hip, and step-
this strategy to be effective. Ankle strategies are used to ping strategies. (From Cameron MH, Monroe LG: physical reha-
control small, slow swaying motions. They are effective bilitation: evidence-based examination, evaluation, and intervention,
when the surface area is firm and long in relation to foot St. Louis, 2007, Saunders.)
length. Muscular activation while using the ankle strategy
occurs in a distal to proximal sequence. Timing of muscu-
lar contractions is important to generate sufficient torque takes a step to widen the base of support. This is the strat-
about the ankles and to maintain adequate stability at the egy used effectively when taking each step while walking.
hips, knees, and trunk. Ankle strategies frequently are The person shifts weight outside the existing base of sup-
used during “quiet” standing. For example, this strategy is port and takes a step to bring the base of support back
effective in controlling the small, slow swaying motions under the center of mass (Fig. 8-2).
that occur when a person stands in line (e.g., at a bank or Each of the preceding movement strategies is a reactive
grocery store). response to center of mass movement. Anticipatory con-
Hip movement that maintains or restores equilibrium trol is postural muscular activity that precedes and de-
is a hip strategy. This strategy is most effective in main- creases center of mass movement. Previous experience
taining stability when the support surface is short in rela- weighs heavily in the determination of the appropriate
tion to foot length or is compliant. Hip movement is used sequence and degree of muscle activity required to main-
to control large or rapid swaying motions or when an tain stability when anticipating a perturbation. Because
ankle strategy is ineffective (i.e., unable to occur rapidly anticipatory activities precede destabilization, misperceiv-
enough or generate adequate torque). Muscle activation ing the needed amount of muscle activity may result in
while using hip strategies occurs in a proximal to distal too much or too little correction. For example, when per-
sequence. This strategy is used more frequently than an- sons pull a door open, they initiate a posterior weight shift
kle strategies when the center of mass approaches the to counteract the weight of the door. If the weight of the
outer limits of the base of support and is more effective door is lighter than anticipated, too much correction
because of the ability to generate greater speed and range. might occur and may result in a posterior perturbation of
An example of a situation in which persons would use a balance.
hip strategy would be a circumstance that requires them
to stand on a narrow beam. CENTRAL NERVOUS SYSTEM STRUCTURES
When ankle and hip strategies are or are perceived to
be ineffective, the base of support is expanded in the di- Maintaining equilibrium involves the precise integra-
rection of center of mass movement, resulting in the use tion of sensory information and the generation of ap-
of what is called a stepping strategy. In this case the person propriate and effective motor responses. Specific central
192 Stroke Rehabilitation

nervous system structures are responsible for perform- The basal ganglia receive information from the cortex and
ing these complex tasks. The cerebellum is the primary cerebellum and then output information to the motor
integrating and modulating force in balance control. cortex via the thalamus. The basal ganglia work closely
The cerebellum receives information from structures with the cerebellum and are believed to influence the se-
such as the cortex, basal ganglia, spinocerebellar tract, quencing of automatic postural reactions including the
vestibular nuclei, and vestibular pathways. Input is ankle, hip, and stepping strategies previously discussed.
modulated, interpreted, and sent out to the cortex; basal The continuous postural adjustments that play a role in
ganglia; thalamus; fourth, fifth, and sixth cranial nerves; smooth, coordinated movement are also controlled by the
vestibular nuclei and pathways; and indirectly to the basal ganglia. Examples of disorders involving the basal
spinal cord, providing the regulatory input needed to ganglia include but are not limited to rigidity, bradykinesia
control movement. Damage to any one of these struc- (slowness of movement), akinesia, resting or intention
tures can result in difficulties with balance and postural tremors, chorea, and athetosis.
control. Through this complex network of central ner- The brainstem also is involved in balance control
vous system interactions the cerebellum facilitates because it houses the vestibular nuclei, which receive
smooth coordination of movement. The cerebellum input from the cerebellum and the vestibular system.
influences the timing and synergy of muscle groups dur- Information is output to the vestibulospinal tract, ocu-
ing synergistic movements and muscle tone or stiffness. lomotor complex, cerebellum, and parietal lobe. The
Symmetrical, appropriate, balanced skeletal muscle ac- brainstem is instrumental in the integration of the ves-
tivity is necessary for maintaining postural alignment tibular input and influences compensatory eye move-
and is required for smooth, coordinated movements and ments (Table 8-1).
stability. An example of a disorder involving the cerebel-
lum is ataxia (poor coordination of agonist and antago- COMPREHENSIVE EVALUATION
nist muscles that results in jerky, poorly controlled
movements). An individual with cerebellar dysfunction A comprehensive evaluation is crucial in helping the
might have an unsteady gait or visual disturbances. See therapist understand specific balance problems patients
Chapter 15. may be experiencing. A comprehensive evaluation always
The basal ganglia are also involved in integrating infor- should include a subjective client interview, an assessment
mation used for postural control and in a series of complex of balance skills within the context of meaningful func-
pathways, much of the exact nature of which is uncertain. tional tasks, and an assessment of balance component

Table 8-1
Central Nervous System Structures Involved in Balance Control
INDICATION
STRUCTURE INPUT OUTPUT FUNCTION OF DYSFUNCTION

Cerebellum Cortex Cortex Integrates and modulates Ataxia

Basal ganglia Basal ganglia information. Unsteady gait
Spinocerebellar Thalamus Regulates input to control Visual disturbance
tract Cranial nerves: movement.
Vestibular nuclei IV, V, VI Influences muscle tone/
Vestibular pathways Vestibular nuclei stiffness.
Vestibular pathways Inputs timing and synergy
of muscle groups during
synergistic movements.
Basal ganglia Cortex Motor cortex Sequences automatic postural Rigidity
Cerebellum Thalamus reactions. Bradykinesia
Akinesia
Tremors (resting/intention)
Chorea
Athetosis
Brainstem Cerebellum Vestibulospinal tract Integrates vestibular input. Dysfunctional compensatory
Vestibular system Oculomotor complex Initiates compensatory eye eye movements
Cerebellum movements. Vestibular dysfunction
Parietal lobe
 Chapter 8 • Overview of Balance Impairments: Functional Implications 193

skills. Evaluations may vary depending on the acuteness of customized treatment plan. The therapist’s atten-
the neurological insult, severity of the stroke, and setting dance to the specifics of performing tasks and to the
in which care is provided (e.g., acute care, inpatient reha- order in which tasks occur is important for treat-
bilitation, skilled nursing facility/subacute unit, outpatient ment planning and goal setting purposes.
rehabilitation, or home health care). 3. Prior functional status
The therapist must have a thorough understanding of
Subjective Interview the patient’s functional level before the stroke. This
When conducting a subjective interview, the clinician portion of the interview should include information
must keep in mind that patients who have had an acute such as the following:
stroke may not be able to provide accurate information ■ Whether the patient ambulated independently and
during the interview process due to cognitive and/or lan- what device if any was necessary for ambulation
guage impairments. Clinicians may need to use other ■ Whether the patient required any assistance with
sources of information, including family members, sig- performing daily tasks and, if so, what specific help
nificant others, and information from the medical chart to did was required
supplement, clarify, or verify information a patient pro- ■ Whether the patient was able to function indepen-
vides. Patients may improve in their ability to provide dently in the community (including specifics about
information as cognitive and language deficits improve. activities) and whether any change in activity was
Patients often also demonstrate a greater awareness of experienced in the past six months. Attention should
their situation and surroundings as they improve and be- be focused on life roles the patient was engaged in
come more fully integrated into the home and community (e.g., spouse, caregiver, parent, grandparent, etc.).
environments. 4. Patient’s perspective of current functioning
Subjective patient interviews allow patients to describe This area may be difficult for patients who have just
in their own words and from their own perception just had a stroke, but understanding what patients consider
how the stroke has affected their level of functioning. The as problems resulting from balance deficits and what
interview should allow the therapist to obtain the follow- goal areas are relevant for the patient is important for
ing information about the patient: the therapist to grasp. Early in the rehabilitation pro-
1. Premorbid health history cess, patients may cite self-care and mobility as prob-
The patient’s premorbid health history can have a sig- lem areas. Later, when patients are receiving home
nificant impact on prognosis and thus appropriate health or outpatient services, they may no longer expe-
goals. Having a thorough understanding of any pre- rience difficulty in these basic areas but may cite prob-
morbid conditions that could affect a patient’s balance lems with household or community activities. This
functioning is important for the therapist. Examples portion of the interview is important for determining
include diabetic neuropathies, vision disturbances, ver- patients’ awareness level about the way their balance
tigo, prior stroke or head injuries, prior lower extrem- deficit limits their participation in normal activities and
ity range of motion or strength problems, or other for determining appropriate and meaningful goals.
orthopedic issues such as lower back dysfunction. Clinically, occupational therapists use a different
2. Prior lifestyle approach to evaluation than other allied health profes-
As more details are added to this portion of the inter- sionals. After a complete review of the medical chart
view, the therapist will be better equipped to create an and a subjective interview, occupational therapists
individualized treatment plan to meet the individual would next assess functional activities that are mean-
patient needs. The interview should include informa- ingful and relative to a specific patient based on the
tion such as the following: patient’s perception, the life roles a patient engages in
■ What time does the patient generally wake each and the specific functional goals important to the pa-
morning? tient. Following assessment of functional activity, the
■ Did the patient bathe at sponge level, shower level, occupational therapist would then complete a full as-
or bathtub level? A sponge bath may indicate a prior sessment of component skills necessary to complete
history of balance issues that resulted in a fear of these activities. This process is more fully discussed
falling in the shower. later in this chapter. However, for the purposes of this
■ Did the patient need to take rest breaks or spread his chapter, the reader will first be introduced to the vari-
or her basic activities of daily living out of a period ous component areas that should be assessed and that
of time? Again, this may indicate a premorbid issue are specifically related to balance. A therapist must
with endurance related to balance. have a comprehensive understanding of the component
■ What household chores did the patient engage in? skills that contribute to typical balance in order to ef-
Outlining a schedule of a typical day at home may fectively engage in skilled clinical observation during
be helpful to the therapist in designing goals and a assessment of functional activity.
194 Stroke Rehabilitation

Component Assessment
Component assessment focuses on numerous isolated skills
and processes that contribute to balance. Thorough range
of motion testing of active and passive range of motion,
particularly of the trunk and lower extremities, must be
completed and helps determine whether a patient has any
biomechanical constraints that might have an effect on
postural control. The therapist must evaluate the patient’s
strength and appropriate patterns of skeletal muscle activ-
ity, particularly of the lower extremities and trunk, to deter-
mine neuromotor influences on postural control. The
A
therapist also must examine the sensory systems that play a
role in maintaining equilibrium. One such system is the
visual system (see Chapter 16) and includes visual acuity
and oculomotor function assessments. Oculomotor func-
tion includes eye movements such as voluntary movements,
smooth pursuits, saccadic eye movements, and gaze stabili-
zation. Assessment of sensation, particularly of the lower
extremities, is also critical and should include light touch,
deep pressure, proprioception, and kinesthesia assessments.
Assessment should focus on both the ability for the patient
to interpret the sensory stimulation and the ability for the
brain to organize and use the sensory information available.
The vestibular system is a third system that should be fully
assessed. The function of the vestibular system is to provide B Trunk
information about head position and head motion in space Scoliosis Kyphosis rotation
relative to gravity. The vestibular system is difficult to Figure 8-3 A, Correct alignment during sitting. B, Common
evaluate in isolation but is discussed more fully within the asymmetries assumed after stroke.
context of sensory organization. The reader is also referred
to Chapter 9 for a more in-depth review of vestibular as-
sessment and rehabilitation.
As an occupational therapist, the clinician must examine
more complex tasks that integrate the specific balance com-
ponents. The therapist should evaluate patients’ postural
alignment while they are seated and standing. Skilled ob-
servation while a patient is engaged in functional activity is
critical in performing these and subsequent assessments.
Symmetrical alignment and appropriate positioning of
body parts over the base of support are the goals. The
therapist should note any asymmetry in alignment or bias
over the base of support. In general, the posture for static
standing or the “starting or ready position” should be sym-
metrical; the head should be in midline, centered over the
shoulders; the shoulders should be centered and aligned
over the pelvis; under “normal” conditions, the feet should
be approximately hip distance apart; and the pelvis should
be centered over the base of support created by the feet
(Figs. 8-3 and 8-4). Postural alignment and symmetry is
directly related to what specific activity a patient is engaged
in as well. This means as a patient begins to move and en-
gage in functional activity, the alignment and symmetry A B
will change to allow the patient to complete the activity. Figure 8-4 A, Correct alignment during standing. B, Flexed
For example, the postural alignment and symmetry needed posture. (Note hip/knee flexion, kyphosis, forward head posture,
to unload a dishwasher and put dishes away in an overhead and change in center of gravity.)
 Chapter 8 • Overview of Balance Impairments: Functional Implications 195

cabinet is different than if the patient is vacuuming the liv- ellipse a patient perceives he or she can move; patients
ing room rug. Skilled observation requires the therapist to may underestimate or overestimate this area. If patients
have a solid understanding of both activity analysis and underestimate the limit, usually due to fear of falling, it
postural alignment and symmetry relative to that activity. results in an inability to weight shift normally to complete
Each individual also possesses an area about which the the activity. If the patient overestimates this area, usually
center of mass may be moved over any given base of sup- due to sensory or perceptual deficits, it results in a fall.
port without disrupting equilibrium. This is referred to as The limits of stability may be measured in a number of
the limits of stability. Assessment of patients’ ability to ways. An experienced evaluator with a strong understand-
move within their limits of stability and noting the sym- ing of typical limits of stability might ask patients to shift
metry and extent of those limits is necessary. Because of their weight as far as they can in all directions and then
the biomechanical constraints of the foot and ankle, the observe and note the patients’ ability to move over their
limits are greatest in the anterior/posterior direction and base of support. The therapist also may ask patients to
smaller in the lateral direction. The greatest degree of perform a task that requires the center of mass to move
movement usually occurs anteriorly. The area created by over the base of support while observing their perfor-
the limits of stability is in the form of an ellipse (Fig. 8-5). mance. Several computerized pressure plate systems on
Therapists need to assess both actual and perceived limits the market are able to compute an individual’s “normal”
of stability. Actual limits of stability are the true ellipse limits of stability based on height by force plate analysis.
that a patient can achieve relative to foot length and avail- The therapist then can compare normal and actual fig-
able motor control. Perceived limits of stability are the ures. These pieces of equipment are costly and are not
available in all clinics. It is crucial that therapists deter-
mine if the patient is actually shifting the center of mass
over the base of support or substituting abnormal move-
ment patterns, such as bending at the hips or shifting at
the shoulders, in an attempt to accomplish the task.

Postural Control System

Information regarding biomechanical and neuromuscular
parameters available to the patient has been established
through the comprehensive component evaluation. Inte-
gration and the effectiveness of these capabilities in the
central nervous system are tested by assessing automatic
postural responses; patients must be exposed to condi-
tions that normally would elicit particular responses.
Ankle strategies are most effective when used with a
firm support surface that is long in relation to foot length.
They are used to control small, slow swaying motions.
A For an initial assessment, the patient should be standing
on a firm surface with the feet approximately hip distance
apart. The therapist should note oscillations about the
ankles. If the patient is able to perform this task effec-
tively, increasing the demands of the task by narrowing
the base of support may be necessary. The therapist may
ask patients to place their feet together to decrease the
size of the base of support, narrow the limits of stability,
and increase the need to control center of mass oscilla-
tions. The therapist should note increased use of ankle
strategies, and if swaying increases in speed or magnitude,
the patient may initiate a hip strategy.47 Individuals should
be able to maintain their balance in this position with an
ankle strategy and perhaps with minimal use of a hip strat-
egy. Not using ankle strategies or using stepping strate-
gies in this position indicates a disturbance in the ability
B to generate automatic postural responses.
Figure 8-5 Limits of stability. A, Lateral view. B, Anterior Several methods exist for assessing hip strategies. Hip
view. strategies are most effective when used with a support
196 Stroke Rehabilitation

surface that is short in relation to foot length, the support and often are combined with force plates that can mea-
surface is compliant, or ankle strategies are (or are per- sure motor responses to test conditions (to a degree).
ceived to be) ineffective. Simulation of each of these con- The sensory organization portion of the apparatus usu-
ditions should result in the use of a hip strategy. For ally consists of a safety harness, movable foot plate, and a
higher level patients, the therapist may ask the patient to movable visual screen that surrounds the subject. Test
stand on a 4-inch balance beam so that only the middle of conditions also have been simulated in the clinic by using
the foot receives support. Ankle strategies are ineffective 4-inch medium-density foam as a compliant surface, and
under these circumstances because adequate torque can- a visual “dome” that encompasses the patient’s visual field
not be produced around the ankle when the support sur- and is worn on the head.48
face is this short. The therapist should note use of primar- The first condition for testing sensory organization al-
ily anterior/posterior hip strategies. Attempts to use ankle lows subjects to receive accurate input from all sensory
strategies only or any use of stepping strategies indicates systems. Patients stand on a firm support surface with
a dysfunction in the ability to generate an appropriate their eyes open, and the therapist records responses.
hip strategy. Compliant support surfaces also result in During the second condition, the therapist asks pa-
use of hip strategies in “normal” subjects. The therapist tients to close their eyes, which deprives them of visual
can simulate this condition by having the patient stand input. Therefore, only somatosensory and vestibular in-
on a 4-inch-thick piece of medium-density foam. Ade- puts are available to help patients maintain equilibrium.
quate torque around the ankles is not possible under this Under this test condition, patients may have a postural
condition, and the patient uses hip strategies in all planes/ response if conflicting information is received from the
directions. As stated previously, excessive attempts to use available sources or the individual is accustomed to rely-
ankle strategies or exclusive use of stepping strategies in- ing heavily on visual input.
dicates dysfunction. In the third test condition, patients wear the visual
The therapist may assess lateral hip strategies by hav- screen or dome and thus receive conflicting visual infor-
ing the patient assume a tandem stance (a heel-toe posi- mation. The screen or dome is “sway referenced,” which
tion in which one foot is directly in front of the other). means that it moves along with the individual’s naturally
This position significantly narrows the lateral limits of occurring sway and provides the visual system with the
the base of support; because ankle strategies have a lim- illusion that no sway is occurring: optical flow input indi-
ited lateral range of effectiveness, the patient uses hip cates that the environment and the individual are station-
strategies. This position on a firm support surface would ary. In this test condition, the support surface is firm and
not be challenging enough to elicit hip strategy use in fixed, so somatosensory and vestibular information is
some patients. These patients could perform the same accurate; although visual information is available, it is in-
task on a 4-inch balance beam to further narrow the base accurate. The patient must check and evaluate incoming
of support. sensory information and use only the accurate informa-
When one assesses use of hip strategies in any of these tion. Too heavy a reliance on visual input might result in
conditions, observation of strategy sequence is important. increased sway caused by delayed identification of the
The therapist also should note the effectiveness of the need to adjust to spontaneous sway.
target strategy. Use of ineffective strategies (i.e., loss of The fourth condition uses a sway-referenced support
balance) indicates that a particular strategy has failed. surface; the support surface is sway referenced to natu-
The therapist may elicit use of the stepping strategy47 rally occurring sway. The therapist also may use the 4-
by further challenging the postural control system (e.g., inch foam to provide inaccurate somatosensory informa-
by combining all of the previous test conditions). For ex- tion. Under these circumstances, visual and vestibular
ample, the therapist may ask patients to stand with feet information are accurate, and somatosensory information
together or in tandem on a compliant surface. A delay in is available but inaccurate. Once again, an inappropriate
or lack of a stepping strategy that results in a loss of bal- postural response indicates an inability to use accurate
ance indicates dysfunction. (See Fig. 8-2.) information or identify and censor inaccurate somatosen-
sory information.
Sensory Organization The fifth and sixth test conditions are the most com-
In addition to automatic postural response assessments, plex and require patients to use vestibular information.
assessments of sensory organizational abilities are also During the fifth test condition, patients must close their
important. In other words, therapists must assess pa- eyes, which deprive them of visual information. The sup-
tients’ abilities to organize and evaluate the orientation- port surface is sway referenced or foam is used, thus the
ally correct sense used to generate appropriate responses. only accurate information that helps maintain postural
Six test conditions are considered acceptable for thor- control is vestibular. Difficulty maintaining balance may
oughly assessing sensory organization. Computerized result from a disturbance in the vestibular system or abil-
tests of sensory organization are available commercially ity to integrate the information.
 Chapter 8 • Overview of Balance Impairments: Functional Implications 197

The sixth test condition uses sway-referenced visual

and somatosensory information; vestibular information is Balance Assessments
the only accurate input. Disruption of the postural con- In addition to those mentioned, numerous other func-
trol may result because of the inability to evaluate the tional balance assessments have been developed.21,24,34,47
information (a more difficult process because two systems A large body of evidenced based research is available for
are providing inaccurate information) or a disruption of many of these assessments. Discussed next is a brief over-
the central or peripheral vestibular system48 (Fig. 8-6). view of the more commonly used standardized or formal
This hierarchy of test conditions (Table 8-2) allows assessments used with either the stroke population or the
therapists to assess the ability of the central nervous sys- neuro population in general. It is at times difficult to bal-
tem to integrate information appropriately. The hierarchy ance the restricted amount of time clinicians have with
is also a method for determining whether a person is rely- their patients with the need to use more standardized and
ing too heavily on a particular source of information. formal assessments tools to assist with such things as pre-
These tests also can provide preliminary information dicting length of stay, establishing appropriate treatment
about vestibular system function and may indicate a need plans and long term goals, justification of skilled interven-
for further testing. tion, recommendations for adaptive equipment, risk of

Visual condition
Fixed Eyes closed Sway-referenced
Fixed

1 2 3
Support condition
Sway-referenced

4 5 6

Figure 8-6 Test of sensory organization. (From Cameron MH, Monroe LG: Physical
rehabilitation: evidence-based examination, evaluation, and intervention, St. Louis, 2007,
Saunders.)
198 Stroke Rehabilitation

Table 8-2
Test of Sensory Organization
TEST ACCURATE SENSORY INACCURATE OR ABSENT
CONDITION INFORMATION SENSORY INFORMATION

1 Visual, vestibular, somatosensory

2 Somatosensory, vestibular Absent vision
3 Somatosensory, vestibular Inaccurate vision
4 Visual, vestibular Inaccurate somatosensory
5 Vestibular Absent vision, inaccurate
somatosensory
6 Vestibular Inaccurate vision, inaccurate
somatosensory

falls, and discharge planning. Each venue of care and each counts backward from 20. The Tug Manual again re-
provider of service must weigh and decide for themselves quires the same basic activity while the patient carries a
what tools are most useful and most efficient for their full glass of water. These three subtests have established
specific patient population. There is no one single assess- cut-offs to assist the therapist in predicting likelihood of
ment tool that clinicians can use to fully assess balance, falls under different conditions and therefore can be use-
and therefore clinicians should consider using a variety of ful in recommnendations.1,46 Performance is rated on a
tools. somewhat nonspecific 5-point scale. This test is used
The Berg Balance Scale4 is by far the most commonly with the older adult population and, because of its vary-
used balance assessment. This assessment tool can assist ing rating criteria, the criteria should be evidence-based
with predicting fall risk, determining lengths of stays, and and consistent in use within a facility if used as an assess-
determining adaptive equipment and discharge planning ment tool.42
recommendation.1,7,23,30,35,51,56,61 The test does not help The Clinical Test of Sensory Organization and Bal-
the therapist in determining why patients might lose their ance,49 which was described previously, uses six test con-
balance and therefore is limited in its ability to assist with ditions to assess an individual’s ability to access, use, and
treatment planning. The test examines a number of fac- organize sensory information. Within this formalized
tors, such as unsupported sitting and standing, transfers, procedure, the therapist times the tests, measures the
reaching forward, picking objects up from the floor, turn- amount of sway, and records complete loss of balance
ing 360 degrees, and standing on one foot, and each is falls. This test is also appropriate for use in children,
graded on a 5-point scale. The assessment outlines the patients with hemiplegia,19 and patients with vestibular
specific scoring criteria. This test examines many aspects disorders.15
of balance and has been shown to have high interrater This formalized assessment provides specific infor-
reliability and validity in older adults.5,7,14,35,51 This test mation to the therapist about why patients may lose
has been developed primarily for and used with the older their balance and is therefore is very useful in developing
population and stroke patients.3,14,51 The Berg can be time individualized treatment plans. This test can be time
consuming, however. A new, shorter version of the Berg, consuming, however (see Fig. 8-6).
referred to as the Berg Balance Scale 3P (7 item) Test, has The functional reach test21 requires the patient to
been developed. Tasks in the shortened version include stand next to a wall with a yardstick placed parallel to the
reaching forward with outstretched arm, standing with floor. The patient is asked to reach as far forward as pos-
eyes closed, standing with one foot in front, turning to sible, and the reach length is measured. This test is quick
look behind, retrieving object from floor, standing on one and easy to perform and does not require expensive
foot, and sitting to standing. Available research suggests equipment. Test/retest and interrater reliability are
that this shortened version demonstrates similar psycho- high.21,51,62 The test has been used with a variety of popu-
metric properties as the original Berg Assessment.14,60 lations spanning children through the elderly.20,21,62 The
The Timed Up and GO (i.e., TUG) test is another disadvantage of this examination is that it only measures
common, highly used evaluation. The TUG has three one functional task and only assesses skills in the anterior
subtests. The TUG Alone requires the patient to stand direction.63
up from a chair with armrests, walk a short distance, turn The Postural Assessment Scale for Stroke Patients
around, return to the chair, and sit again.34 The TUG (PASS)9,30,35 tests the ability for patients to maintain a
Cognitive requires the same activity while the patient given posture as well as to maintain equilibrium while
 Chapter 8 • Overview of Balance Impairments: Functional Implications 199

changing positions. Specifically, this test is a 12-item test evaluation information. The therapist should devise a
that looks at various postures and transitions of postures comprehensive treatment plan to improve specific balance
including lying, sitting, and standing, and uses a 0-3 rat- deficits and ultimately assist the patient with transitioning
ing scale. Research indicates that this test has high con- to a more independent lifestyle.
struct validity, high correlation with functional measures
such as the Functional Independence Measure, high in- Assessment of Balance in Relation to Function
terrater reliability, and test-retest qualities. This test is Occupational therapists should complete the initial as-
most predictive in the first 30 days poststroke and takes sessment of function in relation to balance in the same
approximately 10 minutes to administer. A short form of way they assess all functional activities. A thorough un-
the PASS has been developed and tested, and it contains derstanding of typical movement and excellent observa-
only five items and uses the 0-3 scale for scoring; initial tion skills are essential when assessing balance through
research indicates that the short form may also demon- functional activity. As with any skill therapists acquire,
strate high interrater reliability and validity.13,60 these abilities develop and improve as the therapists gain
The Activities Specific Balance Confidence Scale experience. Patients should attempt the activity, and ther-
(ABCS)9,41,44,45 is a patient perception test that attempts to apists should determine whether patients can do the task,
capture the patient’s view of his or her disability related to the quality of the performance, and whether patients are
functional activities and perceived fall risk. It is a 16-item unsuccessful and why. Therapists may not have deter-
test that asks patients to score their perception of their mined the specific balance deficits yet, but they can look
risk of falling when engaging in a particular task. This test for a pattern of dysfunction. Observations during func-
is best used in an outpatient or home health setting. Re- tional activities should focus on when patients lose and do
search suggests that perception of fall risk may be posi- not lose their balance. Therapists should then determine
tively related to functional mobility and greater commu- what might be causing the loss of balance.
nity reintegration.41,45 The Falls Efficiency Scale (FES) is Specifically, therapists should observe what happens
also a confidence assessment scale used in much the same during functional activities when patients have to move
manner.40 their center of mass over their base of support, move their
The Brunnel Balance Assessment Scale (BBAS) is a head, stand on uneven surfaces, function in lower light-
scale that measures balance at three levels: sitting, stand- ing, move from one type of surface to another, or function
ing, and stepping. The entire assessment scale can be ad- on a narrower base of support. Therapists also should
ministered at the same time, or it may be administered in observe patients’ postural alignment, whether a bias in
sections. The advantage of this assessment is that it can be posture exists and in which direction that bias occurs,
used repetitively as the patient progresses in mobility; patients’ limits of stability, the width between their feet
because of this, the assessment easily lends itself to one during functional tasks, and what patients do after losing
that can be used across an entire continuum of care and their balance (e.g., use ankle, hip, or step strategy or no
across a wide range of patients with varying levels of mo- strategy at all). The initial contact with patients engaged
bility. Research suggests that this assessment tool demon- in functional tasks should involve only observations (and
strates high reliability and validity and is a potentially guarding for safety). Therapists must allow patients to
useful predictive validity.55,57 “fail” or lose their balance in a safe way, so that they can
The Motor Assessment Scale (MAS) is a relatively determine what patients do during functional tasks.
lengthy assessment (15 to 60 minutes depending on the The specific functional tasks to be used during evalua-
patient’s participation) that focuses on supine to sidelying, tion depends on what the patient’s goals are at the time of
supine to sitting edge of bed, sitting balance, sit to stand, intervention and the setting in which treatment is being
walking, and effect of upper arm function, hand move- received. Stroke survivors may receive rehabilitation ser-
ments, and advanced hand movements on balance. It uses vices in a number of settings. Inpatient settings would in-
a 1- to 6-point scale. This assessment is reliable, valid, and clude acute care, acute inpatient rehabilitations settings, a
sensitive to change over time.23,25,56 Disadvantages include skilled nursing facility or a subacute unit within a hospital
the amount of time needed to administer the test, espe- or skilled nursing facility. Follow-up services may be re-
cially with more mobile patients and a more in-depth ceived by home health therapists or in an outpatient reha-
training needed for consistent therapist use. Advantages bilitation setting. Often, patients will initially receive
are similar to the Brunnel Balance Assessment Scale. home health services and then transition to an outpatient
The assessment and treatment of balance disorders for center based on individual need and patient progress.
recovering stroke patients are complex. Therapists need Determination of where a patient receives services de-
to understand the balance system and have a comprehen- pends on many factors, including medical necessity, ability
sive way to assess balance function and dysfunction. They to tolerate at least three hours of therapy a day, discharge
then determine realistic short- and long-term goals that plan and availability for a 24-hour caregiver, availability of
are appropriate for each patient based on diagnostic and transportation, and health insurance policies.
200 Stroke Rehabilitation

As lengths of stays in all inpatient settings have dra- rather than an exercise program with activities that are
matically shortened, as have the number of approved visits meaningless to them. Therapists should incorporate mul-
for outpatient and home health services, it is imperative tiple goals into each treatment session.
for therapists to be aware of what the focus should be, Because of current, ongoing changes in health care
based on the venue of care in which they work, the pa- reimbursement, therapists’ collaboration with patients to
tients’ goals, and the discharge plan and situation. Acute focus treatment around goals that enable discharge home,
and inpatient therapists usually focus on bathing and often with family supports, is crucial. This approach
dressing; basic transfers including bed, toilet, and shower allows patients to transition as quickly as possible to less
(if applicable); and basic home management tasks if the restrictive environments. Failure to focus on goals may
patient will be required to complete these tasks at dis- result in patients being discharged to more restrictive
charge. Given that the average length of stay in acute care environments that allow less independent lifestyles (e.g.,
is three to five days and the average length of stay in an to a nursing home instead of home or an assisted living
inpatient rehab setting is 14 days, patients rarely return arrangement). Therapists should also focus on treating
home independent in these basic areas. This means that specific balance deficits to develop an individualized treat-
many outpatient or home health therapists may still need ment plan that will assist patients with becoming indepen-
to focus on basic self-care and mobility tasks. As the pa- dent as soon as possible. The balance between remedia-
tient progresses, outpatient and home health therapists tion versus compensation will be influenced by many
may also have the opportunity to address home manage- factors, including patient prognosis for recovery, the dis-
ment tasks such as meal preparation, cleaning, and doing charge environment (physical environment and the avail-
laundry, and community tasks such as grocery shopping, ability of a caregiver), and the period in which a therapist
banking, going to church, using public transportation, is given to work with a patient.
and participating in leisure activities. See Chapters 3 and
21. Patients receiving services in a skilled nursing facility ESTABLISHING GOALS AND TREATMENT
may be eligible to receive up to a 100 days of therapy PLANS
services; given this, the focus of treatment for therapists
and patients in this setting would begin with basic self- Setting goals for patients with balance disorders can be
care and mobility and, as the patient progresses, graduate difficult. Therapists must have a thorough understanding
to addressing home management tasks and community of patients’ specific neuropathological condition. Al-
reentry activities as appropriate. though a complete neuroanatomy review is beyond the
After therapists have had an opportunity to observe scope of this chapter, appropriate resources are listed in
patients during functional activities, they should begin to the references. Several factors contribute to whether pa-
develop hypotheses about the reasons patients are losing tients receive a positive or poor prognosis and may in-
their balance during various activities. The component clude size and location of the lesion and any secondary
evaluation and the diagnostic information can assist ther- factors that have developed, such as extensions of the
apists in determining whether their hypotheses are sub- original stroke, brain edema, and anoxia. The clinical
stantiated. For example, patients may lose their balance presentation of the patient following a stroke will also af-
when attempting to put on their pants while standing. fect the ability for patients to make realistic progress; for
Therapists may hypothesize that the loss of balance re- example, a patient with a pure motor stroke would likely
sults from a poor ability to shift weight accurately, poor have a better prognosis for recovery than a patient who
postural alignment when attempting to shift weight, and also has sensory and cognitive impairments. Typically, the
a lack of lateral hip strategy used when standing on one more skill areas influenced, the poorer the prognosis. Age
leg. These hypotheses can be supported by testing pa- and prior lifestyle of the patient may also affect prognosis.
tients’ limits of stability, evaluation of their postural align- The previous medical history must also be considered for
ment, and assessment of whether they are using an avail- determining eventual functional outcomes. Factors to
able hip strategy. These steps allow therapists to develop consider include any prior stroke, a history of alcohol use,
individualized treatment plans and set realistic short- and any head trauma, diabetic neuropathies, age-related
long-term goals for each patient. changes (such as the loss of inner ear hairs), orthopedic
Therapists must keep in mind that they do not treat issues and balance problems (such as vertigo). Prior prob-
balance deficits separately from other deficits a stroke lems may interfere with a patient’s ability to compensate
survivor may have. The treatment of balance dysfunction for the new neurological insult.
obviously is affected by any existing cognitive, visual per- Ideally, a treatment team consists of an otolaryngolo-
ceptual, motor, or sensory deficits, such as memory defi- gist or neurologist, a physical therapist, an occupational
cits or a left neglect. For example, patients with cognitive therapist, the patient, and the patient’s family (if appli-
deficits undoubtedly benefit more from a treatment pro- cable). The occupational therapist is not responsible
gram that incorporates familiar, repetitive functional tasks for prognosticating, but to set realistic goals and an
 Chapter 8 • Overview of Balance Impairments: Functional Implications 201

appropriate treatment plan, the therapist must have in- consideration all of the factors discussed previously
put from the otolaryngologist or neurologist concerning when choosing a treatment plan. Tub seats and reachers
prognosis. If therapists are not fortunate enough to work may be appropriate for patients with orthopedic limita-
directly with an otolaryngologist, they should contact tions or who have a poor prognosis for recovery of bal-
the neurologist treating the patient for the stroke. Oc- ance function; however, introducing too many devices
cupational therapists also must work closely with physi- too early in treatment may in fact hinder recovery of
cal therapists to ensure that the treatment plans of both balance function. For example, if patients are given tub
disciplines support and reinforce each other rather than benches or shower seats and are never given the oppor-
work against or duplicate each other. tunity to attempt to stand for brief periods in the
After receiving the prognosis, the therapist must de- shower, they may not be able to reach their full level of
cide whether to design a treatment plan that focuses on independence. This is not to suggest that devices should
remediation, compensation, or both. The plan may be not be considered or recommended—numerous patients
affected greatly by the setting in which the therapist pro- are able to function only because of their adaptive
vides treatment, the amount of time a therapist has to equipment and devices—it is only to suggest that when
work with a patient, and, if it is inpatient setting, the planning treatment, therapists should be aware of the
discharge plan. If the prognosis indicates considerable implications of using each device. Therapists may con-
improvement within two weeks, a therapist providing sider training patients to use devices outside of therapy
inpatient services may decide to emphasize remediation that provide greater independence but limit their use
initially and then compensation just before discharge to during actual therapy sessions. Patients then can main-
ensure that the patient is functional in basic tasks. A tain their independence while still working toward im-
therapist providing outpatient treatment for the same proving their balance. Therapists may help patients
patient may focus solely on remediation because the pa- function more safely and become more active, even if
tient already has established a safe way to function in the they continue to use a device. Decisions regarding
environment and is now focusing on improving balance equipment, as with all treatment decisions, should be
deficits. If a patient has a poor prognosis for recovery of carefully thought-out relative to each individual patient.
balance function, the inpatient therapist may emphasize See Chapter 28.
compensation early in treatment to ensure functional Using functional activities and emphasizing functional
success at discharge, especially if the support at home is outcomes always have been basic principles of occupa-
an elderly spouse. A patient’s cognitive status also signifi- tional therapy, and they are now beginning to be em-
cantly affects when compensatory devices are introduced braced by many other disciplines. Hsieh and colleagues27
into treatment. A patient with memory loss requires stated that using added-purpose occupation is motivating
more repetition and time to learn to use a walker while during performance. They added that numerous studies
performing kitchen tasks than a patient without memory suggest that using meaningful tasks in treatment improves
loss. Introducing devices and training the patient and his movement and performance.6,26,28,29,31,36-38,43,52,53,64,65 Tra-
or her family or significant other in their use early in ditional treatment of balance disorders has been focused
treatment is more likely to facilitate learning specific on exercise with the hope and assumption that patients
techniques. would carry over what they learned in exercise into daily
Despite the decision therapists make regarding com- function. Although occupational therapists always have
pensation versus remediation, therapists need to under- centered treatment on functional activities, during the
stand the implications of prescribing use of compensatory past few decades therapists may have treated daily activi-
devices for patients with balance deficits. When a walker ties as secondary in their attempt to integrate older neu-
or cane is introduced into treatment before a patient is rophysiological treatment approaches. Currently available
even given a chance to function without it, the therapist information supports the use of functional tasks as pri-
cannot accurately assess the patient’s ability to remediate mary intervention tools (Boxes 8-1 and 8-2). The tasks
the balance deficits. A walker or cane instantly increases specifically should address the balance component distur-
the base of support and thus decreases the demand on the bances that have been identified during evaluation, so that
patient’s balance system to improve. It also greatly changes occupational therapists can provide individualized and
the way in which a patient moves during functional ac- functional treatment.
tivities and alters normal movement. The patient no lon-
ger has to shift weight in a normal way. Instead, weight is TREATING ASYMMETRICAL WEIGHT
shifted through the upper extremities during ambulation. DISTRIBUTION
Postural muscle activity has been shown to be altered
even with light upper extremity support. See Chapter 15. Patients who have had a stroke often have an impaired
Therapists must make informed decisions about us- ability to control their center of mass over their base of
ing equipment during treatment. They must take into support, both in sitting and standing. These patients often
202 Stroke Rehabilitation

Box 8-1 common form of treatment for asymmetrical weight-

Sample Treatment Activities and Goals While bearing and poor postural control is using passive and
in Standing Postures active weight shifting. This treatment traditionally has
been provided in the form of exercise or introduction of
■ Static standing (no engagement in activity) graded by outside perturbations to encourage postural reactions.
timed tolerance for the posture The underlying assumption is that practicing the repeti-
■ Static standing while holding a glass of water tion of postural adjustments will result in long-term im-
■ Standing while fastening shirt closures
provements in balance during functional sitting balance,
■ Retrieving an object (graded by size and weight of
ambulation, and functional activities.18 Numerous authors
object) from a shelf at chest level
■ Retrieving an object from a shelf at knee level (graded have advocated the use of passive and active weight shift-
by weight and size of object) ing as a viable treatment approach.8,10,11,59 If patients are
■ Pulling up pants from ankles while standing not able actively to shift their weight, they initially may
■ Setting table, including covering table with table cloth need guidance from the therapist and assistance with
■ Opening refrigerator and retrieving object from top moving in effective patterns. Ultimately, patients also
shelf must be able to actively shift their weight. Active weight
■ Opening refrigerator and retrieving object from shifting requires postural adjustments that are intrinsic to
bottom shelf the activity being performed.18 Patients must be able to
■ Removing shoes while standing initiate and execute a skilled weight shift that is an appro-
■ Donning pajama pants while standing
priate response to the perturbation actually experienced
■ Picking up phone book from floor
to maintain balance. Patients who experience difficulty
■ Placing full pet food bowl on floor
■ Retrieving pot or pan from lower cabinet with perceiving weight shifts and limits of stability may
overestimate or underestimate the amount of weight shift
required to adjust to the perturbation. Other patients may
These treatment activities do not necessarily represent a
know a weight shift is needed, but may not be able to ex-
progression of difficulty.
ecute the coordinated motor movements and timing to
make it effective.
Treatment for patients should focus on value-added
occupations specific to individual patients. The therapist
Box 8-2 can use information gained during the patient interview
Sample Treatment Activities and Goals to determine in which performance areas a patient is ex-
for Ambulatory Patients periencing balance deficits (e.g., weight shifting in sitting
to don socks, donning pants while standing or reaching
■ Carrying empty shopping bag 30 feet (graded by
into a lower cabinet during meal preparation) and which
distance and surface)
■ Carrying bag of groceries 30 feet (graded by weight, activities the patient values. Occupational therapists must
distance, and surface) perform task analyses to determine which weight shifts
■ Carrying a half-full glass of water 30 feet are required to complete the tasks patients want to per-
■ Carrying a full glass of water 30 feet form. The therapist also should consider information
■ Carrying a full cup on a saucer 30 feet from the component evaluation (e.g., poor ability to shift
■ Walking upstairs without upper extremity support center of mass laterally and anteriorly when reaching up
■ Walking upstairs carrying laundry basket to a high cabinet in the kitchen) when making the treat-
ment plan.
These treatment activities do not necessarily represent a The Royal College of Physicians in their recommenda-
progression of difficulty. tions for stroke care have included information that skills
gained within therapy should be integrated into daily life
activities.58 Incorporating active weight shifting into a spe-
cific activity or using weight shifting that is inherent to
assume an asymmetrical posture during activities that re- successful completion of an activity allows patients to learn
quire static and dynamical balance skills. Asymmetrical more normal postural responses to particular activities;
posture and poor upright stability have been correlated therapists should not assume training has transferred from
with an increased risk for falls.63 In addition, an unstable an exercise to an activity. Therapists also must be sure that
upright posture also has been correlated with diminished the type of weight shifting they are asking patients to do is
functional assessment on the Barthel index.33 Wu and col- appropriate for particular tasks. Patients then are able to
leagues63 indicated that one functional goal in rehabilitat- incorporate an anticipatory set based on the specific task,
ing persons with hemiplegia should be “to improve sym- an important component of motor learning. It has been
metrical characteristics of postural control.” The most postulated that learning or relearning strategies that
 Chapter 8 • Overview of Balance Impairments: Functional Implications 203

reduce simultaneous cognitive demands may be beneficial compile the required information from all assessment
for stroke rehabilitation.39 Activities can be graded by the procedures and to establish an appropriate treatment
amount of weight shifting required, size of the base of sup- plan. Any particular patient following a stroke may
port, and complexity of the task. Weight shifting can occur present with a conglomerate of functional neuromotor
due to present anticipatory controls (e.g., shifting the cen- deficits, cognitive impairments, and somatosensory or-
ter of gravity laterally to prepare to don pants while stand- ganization difficulties. Careful consideration of the set-
ing) or outside perturbations (e.g., getting on or off an ting of treatment, length of stay, discharge plan, and
escalator). Weight shifts also can occur in response to family support should also be taken into account when
movement initiated by the upper extremities (e.g., putting planning treatment. Collaboration among other disci-
a table cloth on a table). The therapist can make these plines is critical to a successful treatment as well.
activities more difficult by gradually increasing the force Inclusion of the manipulation of sensory information
required by the upper extremities to perform the task (e.g., into treatment of stroke survivors has been shown to in-
picking up an empty suitcase and then a full suitcase). crease functional balance.2 Because of careful analysis of
Breaking down activities into a hierarchy of tasks ranging the results of the sensory organization test, the therapist
from simple to more complex is advisable, and treatment should be able to identify functional tasks that place pa-
should involve selection of tasks based on patients’ abilities tients at risk for loss of balance; these activities can be-
and their typical daily activities. For example, the task of come part of the treatment plan (Table 8-3). Patients who
making a bed requires numerous weight shifts but may not lose their balance while transitioning from linoleum to
necessarily be an appropriate activity for a patient who did carpet in their house usually perform poorly under testing
not make beds before the stroke. conditions forcing them to maintain balance on uneven
Patients may be able to use a variety of feedback surfaces. Likewise, patients who lose their balance while
mechanisms to improve symmetrical postural alignment. walking in a mall or busy area with a great deal of periph-
Therapists can instruct them to use somatosensory infor- eral movement usually perform poorly under the testing
mation about pressure they receive through their feet conditions forcing them to maintain their balance while
while weight shifting (if sensation is intact). If patients receiving conflicting visual input. Therapists need to ob-
have a lateral bias, the therapist needs to cue them. For serve patients’ performances during component testing
example, a therapist can cue a patient with an anterior or and functional tasks. Therapists also must determine pos-
posterior bias to locate foot pressure in relation to the sible compensations or strategies patients may use when
balls of the feet. Caution should be used in attempting to one or more systems are impaired. Patients with somato-
use too much conscious cognitive control over these auto- sensory dysfunctions usually become visually-dependent,
matic responses; asserting cognitive effort has been shown whereas patients with visual disturbances usually become
to slow motor learning. The ultimate goal is to develop an dependent on surfaces. Patients with vestibular dysfunc-
automatic motor response absent of conscious control. tions may become visually- or surface-dependent. These
The therapist also may instruct patients to use visual compensatory strategies can work for patients in isolated
information. Therapists may need to use a mirror for pa- environments but prevent true independence and result in
tients with a posterior bias so that the patients can see a higher risk for falls for patients who are active in the
they are drifting away from the mirror. This method may home and/or community. Patients often limit their par-
be most appropriate when performing self-care tasks that ticipation in home activities or simply stop going out into
normally involve the use of a mirror. the community to compensate for balance deficits, which
results in social isolation or depression. The therapist can
Treatment Planning and Sensory Organization obtain this information from the initial patient interview.
As stated previously, the central nervous system uses After determining which systems are impaired, thera-
information from the visual, vestibular, and somatosen- pists should identify activities that are both important to
sory systems to maintain balance. Shumway-Cook and the patient and involve those systems. Those impaired
Horak49 stated that the central nervous system uses this systems can be challenged gradually by controlling the
feedback to monitor the relationship between the posi- conditions in which the activities are performed. Surface-
tion of the body in space and the forces acting on it. dependent patients may be more likely to lose their bal-
The therapist must incorporate information obtained ance when transitioning from one surface to another in
from all of the component balance assessments, includ- the home (e.g., from the kitchen linoleum to the living
ing the test of sensory organization, into the treatment room carpet). Carrying an object from the kitchen into
planning process. The therapist usually will be able to the living room may be a functional task that places pa-
establish a correlation among functional observations, tients at risk for loss of balance. Therapists can develop a
the component assessments, and the test for sensory treatment plan that initially requires patients to practice
organization. Occupational therapists are in a unique holding an item while standing on an uneven surface. The
position and require astute critical thinking skills to next step would be to have patients reach for an item
204 Stroke Rehabilitation

Table 8-3
Correlation of Component Testing and Functional Activities
SENSORY INFORMATION* STRATEGIES TASK

1. Difficulty with 4, 5, and 6 Absent hip strategy Standing on carpet while opening a lower
(sway reference support) drawer with flexed hips and knees;
walking outside on grass or beach and
picking up object off ground; getting on
or off escalator or moving sidewalk
2. Difficulty with 2, 3, 5, and 6 Excessive ankle/step strategies Walking in mall; scanning items in
(visual conflict) kitchen cabinets; scanning items in
grocery store; hanging clothes on line
out of basket; rinsing shampoo out of
hair while in shower with eyes closed
and head tipped backward
3. Difficulty with 5 and 6 Delayed strategies Getting up at night to go to bathroom
(must rely on vestibular input) (e.g., walking in low light down
carpeted hallway and transitioning to
linoleum in bathroom); walking in dark
movie theater down incline while
searching for seat
4. Difficulty with 4, 5, and 6 None or delayed lateral hip strategies Standing on one foot to don pants;
standing in near tandem to reach up or
down into cabinet; walking from one
point to another; standing in near
tandem to pick something up off of
floor (e.g., cat’s dish)

*Numbers refer to test conditions (see Table 8-2).

while standing on an uneven surface. Patients would then the central nervous system they are falling forward when
carry an item as they transitioned from an uneven surface they are not).
to an even surface and vice versa. These particular pa- Patients may be at risk for losing their balance when
tients also would be at risk for loss of balance during other getting up in the middle of the night to get a drink or go
functional tasks that are required for community (beyond to the bathroom, walking in a movie theater, or taking a
the household) ambulation. Sidewalks, gravel, grass, and nighttime stroll outside if they are too reliant on their vi-
sand are all uneven surfaces. The somatosensory informa- sion. Treatment plans can be developed that require pa-
tion received from the feet of surface-dependent patients tients to perform various activities in low lighting or with
remains unchecked and may indicate to the central ner- obscured vision. Common examples of this include clos-
vous system that the patients are falling. A balance reac- ing the eyes in the shower while rinsing out shampoo,
tion that is inappropriate to the task (e.g., walking on an stepping from a brightly lit environment into a darker
uneven surface) but appropriate to the information the environment, and carrying a glass of liquid while walking
central nervous system is receiving and processing may (patients must keep their eyes on the glass rather than on
result. Therapists first should have patients practice sim- the floor and the environment to make sure they do not
ple functional tasks on uneven surfaces and then increase spill the contents). Even walking while engaged in con-
the challenge by asking them to engage in more complex versation can be difficult for visually-dependent patients
tasks while transitioning to and from uneven and even because persons normally look at one another rather than
surfaces. The tasks should be meaningful to patients and the environment while talking.
related to their lifestyles. Patients also may lose their balance during functional
Visually dependent patients often are at risk for loss of activities if they have difficulty with head-eye coordination
balance when their vision is obscured for any reason (e.g., and gaze stabilization. Activities such as walking in a busy
when they are in the dark or poorly lit areas) or the central mall, scanning the grocery store shelves for items, and plac-
nervous system receives “false” visual information (e.g., ing groceries on various shelves can cause loss of balance.
peripheral images of persons walking past patients telling The central nervous system is unable to override the false
 Chapter 8 • Overview of Balance Impairments: Functional Implications 205

visual information that results from these tasks, and thus particular activities. Therapists should see a correlation
the patients feel like they are losing their balance. Patients between functional activity observations and the results of
then institute postural reactions that are incongruent with component testing. This information can be used to de-
the actual events that are occurring. Therapists can develop termine which functional activities may place patients at
treatment plans that challenge patients’ ability to maintain risk for loss of balance. The identified activities then may
gaze stability during functional activities requiring coordi- become part of the treatment plan (see Table 8-3).
nated head-eye movements. Because these strategies are automatic, the therapist
Patients with impaired vestibular function are gener- should perform careful activity analysis in treatment plan-
ally visually- and surface-dependent, although they usu- ning in order for the treatment activities to elicit the ap-
ally rely more heavily on one system. Patients with pre- propriate response. Therapists can elicit ankle strategies by
morbid health issues may be more reliant on one system asking patients to engage in tasks requiring small weight
for a predetermined reason. For example, patients with shifts on solid support surfaces that are larger than their
diabetic neuropathies may be more visually dependent feet. For example, patients could reach up into a cabinet to
because they do not have access to somatosensory infor- put away groceries or put away laundry on a shelf in a
mation through their lower extremities. Most traditional closet. Therapists can extract hip strategies by asking pa-
treatment approaches have relied on graded, repetitive tients to engage in tasks requiring larger weight shifts on
head movements in the form of exercise to improve ves- narrow bases of support. These tasks could include playing
tibular functions.12,17 Cohen and colleagues16 outline a toss and catch on a balance beam. Therapists also can ac-
treatment approach that incorporates this basic premise quire hip strategies by asking patients to reach into drawers
into functional activity. They stress that treatment activi- or cabinets without locking their knees in extension; hip
ties must include head movements and positions that elicit flexion is necessary to counteract the resulting anterior
the vestibular dysfunction during assessment. They also weight shift (Fig. 8-7). Therapists can attain step strategies
stress that activities must be interesting to patients; their by engaging patients in activities that require them to make
use may assist patients with relating to real-life experi- weight shifts outside of their base of support, such as hit-
ences. Suggested activities include retrieving towels in a ting a tennis ball against a wall or reaching out of their base
basket on the floor and hanging them on an overhead of support to pick up work boots off the floor.
clothesline, ambulating in the hallways while scanning
and describing objects placed at various heights, playing OTHER FACTORS AFFECTING TREATMENT
badminton, and dribbling a basketball back and forth PLANNING
across the room. A thorough and accurate assessment of
the specific impaired balance deficit is necessary to design Therapists must consider other factors that may impair
the most efficacious treatment plan. See Chapter 9. patients’ balance while functioning. A common factor of-
Throughout this process, careful consideration of ten overlooked, especially early in the rehab process, is
safety and fall risks must also be considered, especially endurance. When patients are treated in an inpatient set-
when treatment occurs in home care or on an outpatient ting, they often are not asked to complete the entire task.
basis. Thorough patient and family education outlining For example, when bathing or dressing, the therapist un-
the reasons for particular difficulties and safety modifica- intentionally may “help” patients who are bathing or
tions to reduce the risk of falls while treatment is ongoing dressing by gathering their clothes or getting towels. Inpa-
is essential. For example, a person living at home with tient settings also often have large periods between therapy
unreliable somatosensory feedback and on overreliance sessions when patients are not engaged in activity. There-
on visual information may need to have night lights or fore, a day in an inpatient setting may ask the patient to
hallway lights left on to ensure safe walking to the bath- participate in activity between one to four hours, but this
room at night. See Chapter 14. may not accurately reflect patients’ daily home life related
to the amount or timing of activity a patient engages in.
RETRAINING BALANCE STRATEGIES In an inpatient setting, patients usually have breakfast
brought to them and often eat it in bed. They then may
As discussed previously, part of the balance assessment is have a break before occupational therapists arrive to ad-
evaluating what patients do to regain their balance. Three dress self-care tasks. Patients then may have another
strategies were outlined as normal balance strategies: an- break before physical therapists arrive to address gait ac-
kle, hip, and step strategies. A component assessment al- tivities. This type of schedule can result in an inaccurate
lows therapists to determine whether a strategy is being picture of patients’ independence and clearly does con-
used, the amount of delay in strategy use (and therefore sider whether patients’ endurance levels will affect their
its effectiveness), and whether the strategy is appropriate. balance at home. Therapists need to devise a treatment
Therapists must be able to complete skilled, accurate task plan that resembles the patients’ typical day at home as
analyses to determine which strategy should be used in closely as possible.
206 Stroke Rehabilitation

role level. It should also include a detailed clinical im-

pression that links diagnosis, specific impairments, co-
morbidities, current level of function, and anticipated
level of function relative to the discharge plan from a
particular venue of care. The written evaluation should
include a description of the treatment plan based on
patient-specific impairments, short- and long-term goals,
and patient outcomes, which must be functional and
measurable. Because of the current climate of managed
health care, documentation should be as streamlined as
possible and easily understood by any person who ac-
cesses the information, including other team members,
A case managers, third-party payers, patients, and family
members. The documentation format should span the
continuum of care where possible and should be adjusted
easily to meet the patient’s needs and for the setting in
which intervention is being provided (e.g., acute care,
inpatient rehabilitation, or outpatient clinic). Standard-
ized and formal assessments and treatment interventions
should be supported by evidenced-based research as
much as possible. Uniformity and consistency of use of
evaluation and documentation tools should be a priority
if providing care within a continuum.
Documentation tools, if developed appropriately, can
help structure thought processes and reinforce clinical
B reasoning skills in the areas of assessment, treatment plan-
ning, and the establishment of goals. The true “skill” of
Figure 8-7 A, Knees are hyperextended and locked during
the therapist lies in the ability to assess, synthesize, and
functional activity, with weight shifted forward onto the upper
develop appropriate overall plans for a specific patient.
extremities. Upper extremities are used as a base of support
The more specific the documentation requires the clini-
rather than for function. B, Hips and knees are flexed (as during
cian to be, the more directed the treatment plan and goals
hip strategy use) to allow center of mass to remain over lower
will be. As length of stays become shorter, it becomes
extremity base of support. Upper extremities are free to be used
imperative for a documentation tool to function not only
for function.
as a recording tool, but also as a guide to any therapist
using the document, including the novice therapist or the
student. Documentation should encompass and reflect
Other factors that can influence a patient’s balance dur- information from standardized and formal assessments,
ing functional activities are cognitive and visual percep- functional status, specific impairment deficits, treatment,
tion impairments. Familiar, functionally based activities and goals. Documentation tools should be reliable, valid,
can help to reduce the effects of these impairments, but sensitive, and specific. They should also reflect real-life
clearly occupational therapists must address these issues situations.
during treatment as well. Documentation tools should also easily and quickly
Medical factors such as fluctuating blood pressures, convey progress to the reader. Often, the setting deter-
fluctuating blood sugar levels, infections, metabolic dis- mines the frequency of intermittent assessment notes,
turbances, and medications also can affect a patient’s bal- but each visit or treatment session should be recorded,
ance skills. Any significant changes that therapists observe and evidence of progression should be demonstrated. In
should be reported immediately to the physician. See the event that a patient fails to progress, documentation
Chapter 1. should be able to clearly demonstrate why the patient is
not progressing, and the intervening timely adjust-
DOCUMENTATION ments in treatment planning, goal setting, and dis-
charge planning that are occurring in response to the
Accurate and thorough documentation should include a lack of progress. Every setting is unique, so therapists
full written evaluation, including a detailed diagnosis at should develop documentation formats that meet the
the impairment level, activity participation level, and life needs of the patients served in each particular setting
 Chapter 8 • Overview of Balance Impairments: Functional Implications 207

and ensure that documentation focuses on functional

to standing tasks and incorporating these same prin-
outcomes.
ciples into standing tasks. The therapist selected parts
of self-care tasks that did not require large weight
SUMMARY shifts (e.g., combing her hair, washing her face, and
selecting clothing from her closet) and focused on
The assessment and treatment of balance disorders for
maintaining midline. The therapist helped M.J. learn
recovering stroke patients are complex. Therapists need
to use visual and somatosensory information when
to understand the balance system and have a comprehen-
possible to provide information about her position in
sive way to assess balance function and dysfunction. They
space. M.J. was discharged home with continued needs
then determine realistic short- and long-term goals that
in the areas of functional balance skills. Patient and
are appropriate for each patient based on diagnostic and
family education focused on appropriate use of adap-
evaluation information. The therapist should devise a
tive equipment, environmental modifications, and
comprehensive treatment plan to improve specific balance
safety in the home.
deficits and ultimately assist the patient in transitioning to
Following discharge from acute rehabilitation,
a more independent lifestyle.
home care and outpatient therapy services contin-
ued. As M.J. improved her ability to achieve and
CASE STUDY maintain midline during additional static standing
Improving Function Through Balance Retraining tasks, the therapist began to introduce tasks requir-
ing a more significant weight shift from right to
M.J. is 58-year-old female who was diagnosed with a
left (e.g., putting on her shirt while standing, reach-
right middle cerebral artery stroke. She was assessed
ing for objects on the sink, and getting objects out of
first by an inpatient rehabilitation occupational thera-
the closet that were placed to elicit a left weight
pist who determined that the patient had difficulty
shift). Emphasis was placed on assisting M.J. with
controlling her balance during bathing, grooming, and
developing an awareness of her actual limits of sta-
dressing. The patient stated that she wanted to per-
bility. As M.J.’s control improved, the therapist also
form all of these activities independently. The therapist
focused on narrowing her base of support to the
noted that M.J. had a postural bias to the right in both
more normal site dictated by particular activities.
sitting and standing, used a wide base of support when
M.J. improved to the point that she could maintain
standing during functional tasks, and was unable to
midline and actively shift weight laterally during
control her center of gravity when shifting her leg to
self-care activities without assistance from the thera-
the left to complete a task. M.J. was able to support
pist. Upon discharge from outpatient therapy, M.J.
weight on her left lower extremity. Sensation was im-
was provided with a comprehensive home program
paired but not absent in her left lower extremity. M.J.’s
designed to continue to challenge and improve mo-
perceived limits of stability were not congruent with
tor control involved in balance skills.
her actual limits of stability. She underestimated her
ability to shift weight to the left and thus could not
complete tasks that required her to shift weight to the REVIEW QUESTIONS
left. When assisted with a left weight shift, M.J. was
not able to control the shift because of poor coordina- 1. Name the three sensory systems involved in balance
tion and timing of muscle activation. Because she lost control and describe their roles.
control whenever she shifted weight to the left, M.J. 2. What purpose do automatic postural responses serve
compensated by maintaining an asymmetrical postural in balance control?
alignment. When asked to shift her weight actively to 3. What is the role of the cerebellum in balance control?
the left, M.J. altered her postural alignment by at- 4. What composes a component assessment of balance
tempting to shift her shoulders rather than her center skills?
of mass. 5. Describe three balance assessments.
Inpatient rehabilitation treatment initially centered 6. Why should a therapist observe a patient during
on assisting M.J. in relearning appropriate motor re- functional activity? What information should be
sponses in sitting. Activities that involved reaching gathered?
and intrinsically incorporated weight shifts to the left 7. In what way does a therapist determine the focus of
were used. Activities of daily living were incorporated treatment (e.g., remediation or compensation)?
with facilitation of midline posture, and weight shifts 8. In what way does the treatment of balance deficits by
during this functional task were used. She progressed occupational therapy differ from traditional physical
therapy treatment?
208 Stroke Rehabilitation

26. Heck S: The effect of purposeful activity on pain tolerance. Am J

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 hel en s . co h en

chapter 9

Vestibular Rehabilitation
and Stroke

key terms
endolymph vestibular labyrinth wallenberg syndrome
otoliths vestibular rehabilitation
semicircular canals vestibuloocular reflex

chapter objectives
After completing this chapter, the reader will be able to accomplish the following:
1. Understand key components of the anatomy and physiology of the vestibular system.
2. Understand stroke syndromes that are associated with vestibular signs and symptoms.
3. Understand general concepts of vestibular rehabilitation.

The vestibular system is one of the special senses; it has last of the special senses to be discovered, and many peo-
receptors on the head and signals the brain via a cranial ple still do not understand it.
nerve. The end organs for the vestibular system, the ves-
tibular labyrinths, detect head acceleration, or a change in OVERVIEW OF THE VESTIBULAR SYSTEM
the rate at which the head is moving. This information is
converted to a velocity signal (velocity is speed plus direc- Peripheral Vestibular Labyrinth
tion), so the signal received by the brain really represents A detailed discussion of the anatomy and physiology of
the speed and direction at which the head moves. The the vestibular system is beyond the scope of this chapter.
labyrinths are located within cavities inside the temporal The vestibular system has been reviewed many times in
bones of the skull on either side of the head, so the end journal articles and textbooks. For excellent reviews, the
organs are inaccessible from the outside world. One can- reader is encouraged to examine other texts. 3,5,7,9,11,24 To
not see it or otherwise examine it without drilling into the put the topic of this chapter in context requires a brief
temporal bone to expose it. Because the end organ is not reviews of some main points about the vestibular system.
obvious and because the roles of the vestibular system— The vestibular labyrinth has two sets of motion detec-
contributions to postural control, oculomotor control, tors: three semicircular canals (lateral, posterior, and su-
and spatial orientation, and modulation of some auto- perior) that act as rotatory accelerometers to detect turn-
nomic function—are subtle, the vestibular system was the ing motions of the head, and two saclike otoliths (utricle

210
 Chapter 9 • Vestibular Rehabilitation and Stroke 211

and saccule) that act as linear accelerometers to detect (imagine a curved tube approximately the width of a
linear acceleration of the head (Fig. 9-1). Since gravity is hair on your head), so they provide a large amount of
a fixed linear acceleration, the otoliths also detect static resistance to any fluid that fills it. The canals are then
tilt with reference to gravity. This gravitational signal is filled with a thick fluid known as endolymph. Endolymph
very important for spatial orientation, because it acts as an has a high specific gravity, so it has high inertia. The
earth-fixed reference. inertial properties of endolymph and the high resistance
This information, and the complex anatomical struc- of the canals, combined, mean that the vestibular system
tures associated with it, is needed to keep the head erect is not sensitive to extremely slow head movements. It is
and see where one are going as one moves through space, somewhat responsive to slow head movements, but it
plots a course toward a particular location or target, and responds most accurately to moderate to rapid head
generates appropriate autonomic responses when one movements in the range of 0.1 to 7.0 Hz. Not surpris-
encounters a perturbation; that is, when one is inadver- ingly, this frequency bandwidth is the range of most
tently thrown off balance for some reason. These motor normal head movements. When an individual rotates
skills help some lower animals capture and eat their prey his or her head, while shaking his or her head “no,” tiny
and help other animals avoid becoming prey. These skills cilia attach to specialized hair cells, located on a minis-
serve similar purposes in humans as they move through cule hillock that blocks one end of the canal, and bend
space, while avoiding or encountering obstacles, per- backward in response to movement of the endolymph
forming purposeful activities that involve manipulating over the gelatinous cup or cupula into which they
objects while they move their heads in all planes. People protrude. This motion of the cilia starts a chain of
with impaired vestibular systems complain of vertigo and events within the hair cells in which ions are exchanged;
poor spatial navigation skills, blurred vision, impaired the cell membrane either hyperpolarizes or depolarizes.
postural control, and nausea and other signs of auto- If the cell membrane depolarizes, then neurotransmitter
nomic involvement. is released, and the adjacent vestibular nerve fires which
signals to the related neurons in the vestibular nuclei,
Inertial Mechanism located in the medulla, that the person turned his or
The mechanism of the vestibular labyrinth is based on her head.
the principle of inertia, that is, that an object remains at In the otoliths, the hair cells are located in patches
rest until an asymmetrical force acts on it, and then it either in the base of the utricle or on the side of
continues to move until another asymmetrical force acts the saccule. Their cilia protrude into the otoconial
on it to stop it. The semicircular canals are narrow membrane, which is a protein matrix containing many
Superior Vestibular

Vestibular nerve
ganglion

Superior (anterior) Superior

Inferior

ampullar nerve saccular

e rior
Sup nerve Facial nerve
Lateral
ampullar Saccular
nerve nerve
Endolymphatic
duct Cochlear nerve
ior
ter

e
cl
s

tri
Po

le

U
u
al

cc
ter

Sa
La

Cochlea
Ductus
Posterior reuniens Spiral ganglion
ampullar nerve
Figure 9-1 Gross anatomy of the vestibular labyrinth. (From Brödel M: Three unpublished
drawings of the anatomy of the human ear, Philadelphia, 1946, Saunders.)
212 Stroke Rehabilitation

microscopic crystals of calcium carbonate known as canals and the utricle. These areas drain into the ante-
otoconia. The otoconia act as an inertial mass. The rior vestibular vein. The common cochlear artery bifur-
otoconial membrane slides back and forth over the cilia cates and forms the cochlear artery and the posterior
in response to linear acceleration. For example, when a vestibular artery (PVA). The PVA innervates the poste-
person accelerates his or her car going forward, the rior semicircular canal and the saccule. These areas
otoconial membrane virtually slides backward over the drain into the posterior vestibular vein. Both veins join
underlying cilia, bending them backward and com- with the vein from the round window, elsewhere in the
mencing the transduction process described in the inner ear, and form the vestibulocochlear vein, eventu-
preceding paragraph. ally draining into the cochlear aqueduct and then the
inferior petrosal sinus. Other small veins from the semi-
Innervation and Blood Supply circular canals join to form the vein of the vestibular
All of this hardware in the temporal bone is supplied by aqueduct, eventually draining into the lateral venous
nerves and arteries. The vestibular labyrinth is innervated sinus (Fig. 9-2).
by the vestibular nerve, which is half of cranial nerve VIII. Interruption to the blood supply to the vestibular laby-
The vestibular nerve has two branches. The superior rinth can cause the usual manifestations of vestibular
branch innervates the superior and horizontal semicircu- weakness, including vertigo, disequilibrium, blurred vi-
lar canals and the utricle, and the inferior branch inner- sion, and nausea. The blood supply can be interrupted by
vates the posterior canal and the saccule. ischemia or infarction. When the AVA is involved, the
The arterial supply to the vestibular labyrinth is simi- patient does not have hearing loss, since the loss of blood
lar to the innervation. The entire labyrinth receives its supply is distal to the bifurcation of the labyrinthine ar-
blood supply from one artery, the anterior inferior cer- tery. When the labyrinthine artery is involved, hearing
ebellar artery (AICA), which is a branch off the basilar loss is more likely. During the acute phase of sudden,
artery. A major branch from the AICA, the labyrinthine dramatic, and incapacitating symptoms, which may last
artery, supplies the entire inner ear. Inside the inner ear, hours to days, patients are treated with palliative care.
it bifurcates to form the common cochlear artery and After the acute phase is over, patients who have not com-
anterior vestibular artery (AVA). The AVA supplies the pensated spontaneously may be referred for vestibular
area primarily innervated by the superior vestibular rehabilitation. These patients are often rehabilitated
nerve, i.e., the superior and horizontal semicircular successfully.

Anterior inferior
cerebellar artery
Labyrinthine artery Anterior vestibular
(Internal auditory artery) artery Vein of the vestibular
Common cochlear artery aqueduct
Proper cochlear artery
(Spiral modiolar artery)

Saccular artery
Posterior vestibular
Anterior spiral vein artery and vein

Posterior spiral vein

Vestibulo-cochlear artery
Vestibular ramus

Vein of the cochlear

Cochlear ramus aqueduct
Vein of the round
window
Figure 9-2 Arterial supply to the vestibular labyrinth. (Modified from Nabeya D: Study
in comparative anatomy of blood-vascular system of internal ear in mammalian and in homo,
Acta Schol Med Imp Kioto 6:1, 1923.)
 Chapter 9 • Vestibular Rehabilitation and Stroke 213

head movement. Patients with unilateral vestibular weak-

Central Projections ness caused by peripheral or central lesions often com-
The vestibular nerve projects to the vestibular nuclei in the plain of blurred vision during head movement, due to
rostral medulla (Fig. 9-3). The projection has some spatial decreased amplitude of the VOR. Also, some patients
specificity in that different nerves project to different areas with central vestibular lesions have other unusual or ab-
of the vestibular nuclei. From there projections project to normal eye movement patterns. Neurologists sometimes
the dentate and fastigial nuclei of the cerebellum. Eventu- use these patterns of eye movements to help localize cer-
ally those signals make their way to the flocculus, nodulus, ebellar and brainstem lesions.
and ventral uvula in the cerebellar vermis, the so-called A few pathways, which are still poorly mapped, ascend
vestibulocerebellum. Projections out of the cerebellum re- via the thalamus to some poorly defined, probably small
turn to the vestibular nuclei. From there, some signals de- areas in the cerebral cortex, mostly around some auditory
scend the vestibulospinal tracts to cervical and lumbosacral projection areas in the temporal lobe, near the junction of
levels of the spinal cord. Those pathways are involved in the temporal and parietal lobes and into the insula8,22 (see
postural control and are especially important in the absence Fig. 9-3). The functions of these projections are not clear,
of vision. Patients with vestibular weakness caused by pe- but they may mediate the conscious perception of motion
ripheral or central lesions often have impaired balance. or the vestibular contributions to spatial orientation. For
After receiving input from oculomotor-related neurons example, reports in humans have shown that stimulation
in other nuclei, other tracts ascend the medial longitudi- to those brain regions in patients undergoing neurosur-
nal fasciculus in a complex set of crossed and uncrossed gery elicits a sense of motion.26,40 Lesions to the postero-
pathways to synapse on the nuclei from cranial nerves III, lateral thalamus impair upright body orientation30 and
IV, and IV. Those cranial nerves control the extraocular cause perceived tilt of the visual vertical and deviations of
muscles of the eyes, so those vestibuloocular pathways the eyes.44 Lesions to the putative vestibular cortex impair
control the vestibuloocular reflex (VOR). The VOR is an spatial perception by affecting perception of the subjec-
eye movement made in response to head movement, tive visual vertical.43 Research on the ascending projec-
which stabilizes the position of the eye in space. The head tions from the vestibular nuclei has progressed consider-
is relatively large and sits atop a flexible neck, so as an ably with improvements in brain mapping techniques, so
individual moves his or her body through space, the head the vestibular thalamic projections and vestibular cortical
moves. To see clearly while the person moves the head, he projections will probably be mapped and studied more
or she generates the VOR in the direction opposite the thoroughly in the future.

Fastigial
neurons
Accessory Cerebellum
Purkinje optic
cells system

Juxtarestiform body

Superior vestibular Cell group Y

nucleus Otolith organs

Semicircular
canals
Lateral vestibular
nucleus
Scarpa
ganglion

Inferior vestibular Cranial

nucleus nerve
VIII
Commissural
Spinal cord fibers

Medial vestibular
A nucleus
Figure 9-3 Central vestibular projections. Closed cell bodies are excitatory, and open cell
bodies are inhibitory. A, Afferent projections of the vestibular nerve.
214 Stroke Rehabilitation

Head rotation vestibulocerebellum, part of the rostral pons, the middle

cerebellar peduncle, and cranial nerve VII (facial nerve)
Compensatory and cranial nerve VIII. The PICA is a branch off the
eye movement
rostral section of the vertebral artery. It supplies the
lateral medulla and part of the cerebellum, including
Nose
part of the vermis, where the nodulus and ventral uvula
Lateral
rectus
Medial are located (Fig. 9-4). The vestibular cortical projection
rectus
muscle muscle
is probably supplied by the middle cerebral artery off the
branches that supply the temporal lobe. Since the ves-
Abducens tibular cortex is still being investigated, the exact blood
Oculomotor nerve III nerve supply may be a matter for some debate.

Medial
Endolymph
longitudinal STROKE SYNDROMES
movement
fasciculus
In approximately 20% of patients who complain of vertigo,
in general, the cause is vascular in nature (stroke, vertebro-
Abducens Scarpa
ganglion basilar migraine headache, or transient ischemic attack).39
nucleus
Vestibular lesions in stroke patients, as indicated by com-
plaints of vertigo, are rare, however. In one study of 474
confirmed strokes in which patients were hospitalized, only
S 2% complained of vertigo.36 More than half of all brain-
Utricle Horizontal
stem strokes are in the pons,23 and strokes in that area can
semicircular cause lesions of the vestibular nuclei. Of the overall popula-
L canal tion of patients seen in the emergency department and
subsequently admitted for stroke, however, the percentage
M of patients presenting with vertigo is quite small.32
I Lateral Medullary Syndrome
The most common stroke of the vestibular system, first
Commissural fibers reported in the late 19th century,34 is lateral medullary
Vestibular nuclear complex:
syndrome, also known as Wallenberg syndrome.3 This
S = Superior nucleus
L = Lateral nucleus syndrome is caused by a stroke of either the PICA or
M = Medial nucleus AICA. Therefore, it is a lateral brainstem stroke. Because
B I = Inferior nucleus both arteries that supply the vestibular nuclei also supply
Figure 9-3, cont’d B, Projections mediating the horizontal other areas, lateral medullary syndrome is manifested by
vestibulo-ocular reflex. Continued mixed sensory and motor loss, including vertigo, latero-
pulsion, disequilibrium, ataxia, contralateral loss of pain
and temperature sensation in the trunk and limbs, and the
A fourth set of projections, also still poorly mapped, following ipsilateral signs: facial numbness, Horner syn-
are involved in mediating some aspects of autonomic drome (drooping of the upper eyelid, constriction of the
function. Therefore, some patients with vestibular weak- pupil, and decreased sweating), and dysphagia. Involve-
ness complain of autonomic signs such as nausea, sweat- ment of the PICA also includes hoarseness and skew de-
ing, increased heart rate, or anxiety.1,2 Recent research has viation of the eyes. Involvement of the AICA also includes
shown differential uses of rotational and linear vestibular ipsilateral tinnitus, hearing loss, facial weakness, and re-
inputs in modulating muscle sympathetic nerve activity duced peripheral vestibular responses on objective diag-
vs. skin sympathetic nerve activity.12 For a good review of nostic tests. These patients have vertigo, difficulty stand-
vestibular autonomic mechanisms and clinical implica- ing and walking, sensory loss on the ipsilateral side of the
tions, see the paper by Yates and Bronstein.42 face and on the contralateral side of the body, difficulty
speaking and swallowing, abnormal eye movements, and
Central Arterial Supply hearing impairments. In addition to thrombosis and ische-
The vestibular nuclei receive their blood supply from mia, dissection of the vertebral artery caused by sports
the anterior and posterior cerebellar arteries (AICA and injuries or by chiropractic manipulation of the neck can
PICA, respectively). The AICA arises from the basilar cause this syndrome.37
artery and supplies the cerebellopontine angle, part of Lateral medullary syndrome is relatively common.
the anterior cerebellum, part of the vermis and the These patients may be referred for rehabilitation, although
 Chapter 9 • Vestibular Rehabilitation and Stroke 215

Ventral posterolateral nucleus

and posterior nuclear group

Precentral gyrus Central sulcus

Area 3a Postcentral gyrus

Area 2v Intraparietal
sulcus

Lateral sulcus
D
Areas 3a, 2v
Superior vestibular nucleus
Lateral vestibular nucleus
Inferior vestibular nucleus
Medial vestibular
C nucleus
Figure 9-3, cont’d C, Vestibulo-cortical projections. D, Likely vestibular projection areas in
the cerebral cortex. (From Dickman JD: The vestibular system. In Haines DE, editor: Funda-
mental neuroscience, New York, 1997, Churchill Livingstone.)

Posterior cerebral
artery
Superior cerebellar
artery

Anteroinferior cerebellar
Basilar artery
artery
Anterior Posteroinferior cerebellar
spinal artery artery
External carotid artery
Internal carotid
artery
Vertebral artery

Subclavian
artery Subclavian artery

Innominate artery

Aorta

Figure 9-4 Arterial supply to the subcortical central vestibular areas. (From Baloh RW:
Dizziness, hearing loss, and tinnitus: the essentials of neurotology, Philadelphia, 1983, FA Davis.)
216 Stroke Rehabilitation

many of them recover spontaneously. No studies have reduce or eliminate vertigo when present, to reduce os-
evaluated the effectiveness of rehabilitation in this popula- cillopsia (illusory movement of the visual world) when
tion, but these patients usually respond well to therapy. present, to improve safety and to decrease falls (see
Therapy should involve functional skills, balance therapy, Chapter 14), and, as in all rehabilitation, to increase in-
and habituation exercises to reduce vertigo, which are the dependence. Habituation exercises and activities involve
kinds of exercises used to reduce vertigo in patients with repetitive rotations of the head to elicit vertigo in an at-
peripheral vestibular disorders.25,31 tempt to desensitize the system to the sensation. Current
practice incorporates a visual target, i.e., the patient
Cerebellar Infarcts should be looking at something while moving the head.
Cerebellar lesions without involvement in the brainstem Therefore, tasks involving repetitive head movements
can be caused by occlusion of the PICA, AICA, or verte- (sorting tasks in which the containers are on different
bral artery. These patients are rarely seen for vestibular sides) are therapeutic. A recent metaanalysis indicates
rehabilitation. According to noted authorities Baloh and that habituation treatments are effective, although they
Harker, the acute episodes of vertigo, disequilibrium, and have not been tested in stroke patients.27 This area of
nausea accompanied by typical cerebellar signs, of ataxia, practice is dynamic, and new research studies continue to
disdiadochokinesia, and gaze nystagmus are often fol- expand our understanding of treatment in this specialty,16
lowed by edema of the cerebellum.4 Cerebellar edema can so the interested therapist should search the literature
be fatal because, when the cerebellum becomes com- periodically to learn what is new.
pressed, the nearby brainstem structures can be damaged BPPV is a very common peripheral vestibular
unless the area is surgically decompressed. disorder35,41 and might occur when small vessels are com-
promised. This disorder occurs when otoconia, small par-
Lesions of Vestibular Areas in Cerebral Cortex ticles of calcium carbonate located in the otoliths of the
Strokes affecting just the insular cortex are rare. One vestibular labyrinth, become displaced from the utricle in
paper reported that, of 4,800 new strokes in a database, one of the semicircular canals. Theoretically, disease of the
four (less than 0.001%) were restricted to the insula. The small vessels that supply the vestibular labyrinth could
three patients with anterior insula lesions all had tran- damage the membrane that holds these particles in place
siently poor balance, and some had transient aphasia and and allow them to be released into the semicircular canals.
dizziness.13 These people all recovered spontaneously. Also, in the emergency department, the physician may not
More frequently, vertigo and balance problems can be be able to differentiate the acute symptoms of stroke from
part of the syndrome seen in large middle cerebral artery the acute symptoms of vestibular disorder. Therefore,
strokes. In that case, general principles of vestibular reha- some patients are admitted to the stroke unit but are later
bilitation should be incorporated in the rehabilitation found to have BPPV. For this reason, some therapists in
treatment plan as needed. a stroke rehabilitation unit may need to treat patients
with BPPV. The “repositioning maneuvers” used to treat
VESTIBULAR REHABILITATION BPPV are quite effective and are easily learned,17,21,28,38 so
the astute stroke therapist should learn these techniques.
Although isolated central vestibular impairments are un- Central positional vertigo has been described in the litera-
usual, patients with strokes sometimes present with symp- ture.6,29 If a stroke patient appears to have BPPV but does
toms of vestibular disorder along with their other symp- not respond to repositioning treatments, the therapist
toms. Any patient who complains of vertigo should be should consult the neurologist to determine if the patient’s
evaluated to determine if the problem is central or periph- symptoms might be central in origin.
eral. A detailed discussion of vestibular rehabilitation is Graduated balance training exercises and activities are
beyond the scope of this chapter, but many reviews of this used when patients complain of disequilibrium. These
topic have been published. The American Occupational programs usually increase in difficulty from standing still
Therapy Association has defined the necessary entry-level to standing on an unstable surface to moving through
skills for this subspecialty.14 A brief overview of this topic space while moving the head about and manipulating ob-
follows. jects. Movement in anteroposterior, mediolateral, and
Intervention such as habituation exercises and activi- off-axis planes should be incorporated.
ties for vertigo,15,18,19,27 balance therapy, repositioning Patients with vertigo and balance problems are at risk for
maneuvers for benign paroxysmal positional vertigo falling, so therapy should involve some discussion of home
(BPPV),28 functional skills training (see Chapters 7 modifications, such as bathtub seats, bathroom grab bars,
and 8), adaptive safety equipment, and home modifica- night lights, and tacking down throw rugs (see Chapter 27).
tions (see Chapters 27 and 28) can be incorporated into These issues can be incorporated into discharge planning
the treatment plan for stroke rehabilitation as needed. for most stroke patients seen as inpatients or during routine
The goals of vestibular rehabilitation are usually to discussions during outpatient care.
 Chapter 9 • Vestibular Rehabilitation and Stroke 217

21. Epley JM: The canalith repositioning procedure: for treatment of

REVIEW QUESTIONS benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg
107(3):399–404, 1992.
1. What is the most common stroke to disrupt the func- 22. Fasold O, von Brevern M, Kuhberg M, et al: Human vestibular
tion of the vestibular system? List the symptoms asso- cortex as identified with caloric stimulation in functional magnetic
ciated with this stroke. resonance imaging. Neuroimage 17(3):1384–393, 2002.
2. What are the signs and symptoms of a cerebellar 23. Fritschi JA, Reulen HJ, Spetzler RF, Zabramski JM: Cavernous
stroke? malformations of the brain stem. A review of 139 cases. Acta Neuro-
chirurgica 130(1-4):35–46, 1994.
3. What are the two major goals of a vestibular rehabilita- 24. Furman JM, Cass SP: Vestibular disorders: a case-study approach,
tion program after a stroke? New York, 2003, Oxford.
4. What are the specific interventions used to improve 25. Furman JM, Whitney SL: Central causes of dizziness. Phys Ther
function during a vestibular rehabilitation program? 80(2):179–187, 2000.
26. Hawrylyshyn PA, Rubin AM, Tasker RR, et al: Vestibulo-thalamic
projections in man—a sixth primary sensory pathway. J Neurophys
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29–33, 1999. (4):CD005397, 2007.
2. Balaban CD, Thayer JF: Neurological bases for balance-anxiety 28. Hilton M, Pinder D: The Epley (canalith repositioning) manoeuvre
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New York, 1996, Oxford University Press. 29. Johkura K: Central paroxysmal positional vertigo: isolated dizziness
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5. Baloh RW, Honrubia V: Clinical neurophysiology of the vestibular 13936, 2000.
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6. Brandt T: Positional and positioning vertigo and nystagmus. bilitation for cerebellar stroke. Stroke 32(2):530–534, 2001.
J Neurol Sci 95(1):3–28, 1990. 32. Kerber KA, Brown DL, Lisabeth LD, et al: Stroke among patients
7. Brandt T: Vertigo: its multisensory syndromes, ed 2, London, 1999, with dizziness, vertigo, and imbalance in the emergency depart-
Springer. ment: a population-based study. Stroke 37(1):2484–2487, 2006.
8. Brandt T, Dieterich M, Danek A: Vestibular cortex lesions affect the 33. Deleted.
perception of verticality. Ann Neurol 35(4):403–412, 1994. 34. Lysakowski A, McCrea RA, Tomlinson RD: Anatomy of vestibular
9. Brandt T, Dietrich M, Strupp M: Vertigo and dizziness: common com- end organs and neural pathways. In Cummings CW, Fredrickson
plaints, London, 2005, Springer. JM, Krause CJ, et al, editors: Otolaryngology: head & neck surgery,
10. Brödel M: Three unpublished drawings of the anatomy of the human ear, St. Louis, 1998, Mosby.
Philadelphia, 1946, Saunders. 35. Neuhauser HK, von Brevern M, Radtke A, et al: Epidemiology of
11. Bronstein AM, Lempert T: Dizziness: a practical approach to diagnosis vestibular vertigo: a neurotologic survey of the general population.
and management, New York, 2007, Cambridge. Neurology 65(6):898–904, 2005.
12. Carter JR, Ray CA: Sympathetic responses to vestibular activation 36. Rathore SS, Hinn AR, Cooper LS, et al: Characterization of inci-
in humans. Am J Physiol Regul Integr Comp Physiol 294(3): dent stroke signs and symptoms: findings from the Atherosclerosis
R681–R688, 2008. Risk in Communities Study. Stroke 33(11):2718–2721, 2002.
13. Cereda C, Ghika J, Maeder P, Bogousslavsky J: Strokes restricted to 37. Saeed AB, Shuaib A, Al-Sulaiti G, Emery D: Vertebral dissection:
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14. Cohen HS, Burkhardt A, Cronin GW, et al: Specialized knowledge Can J Neurol Sci 27(4):292–296, 2000.
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practice. Am J Occ Ther 60(6):669–678, 2006. maneuver. Adv Otorhinolaryngol 42:290–293, 1988.
15. Cohen H, Kane-Wineland M, Miller LV, Hatfield CL: Occupation 39. Solomon D: Distinguishing and treating causes of central vertigo.
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yngol Head Neck Surg 112(4):526–532, 1995. 40. Tasker RR, Organ LW: Stimulation mapping of the upper human
16. Cohen HS: Disability and rehabilitation in the dizzy patient. auditory pathway. J Neurosurg 38(3):320–325, 1973.
Curr Opin Neurol 19(1):49–54, 2006. 41. von Brevern M, Radtke A, Lezius F, et al: Epidemiology of benign
17. Cohen HS, Kimball KT: Effectiveness of treatments for benign paroxysmal positional vertigo. A population based study. J Neurol
paroxysmal positional vertigo of the posterior canal. Otol Neurotol Neurosurg Psychiatry 78(7):710–715, 2007.
26(5):1034–1040, 2005. 42. Yates BJ, Bronstein AM: The effects of vestibular system lesions on
18. Cohen HS, Kimball KT: Increased independence and decreased autonomic regulation: observations, mechanisms, and clinical impli-
vertigo after vestibular rehabilitation. Otolaryngol Head Neck Surg cations. J Vestib Res 15(3):119–129, 2005.
128(1):56–66, 2003. 43. Yelnik AP, Lebreton FO, Bonan IV, et al: Perception of verticality after
19. Cohen HS, Kimball KT: Changes in gait ataxia and balance after ves- recent cerebral hemispheric stroke. Stroke 33(9):2247–2253, 2002.
tibular rehabilitation. Otolaryngol Head Neck Surg 130:418–425, 2004. 44. Zwergal A, Buttner-Ennever J, Brandt T, Strupp M: An ipsilateral
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mental neuroscience, New York, 1997, Churchill Livingstone. Brain 131(Pt 11):2928–2935, 2008.
 g l en g i l l en

chapter 10

Upper Extremity Function

and Management

key terms
biomechanical alignment learned nonuse shoulder supports
complex regional pain syndrome manipulation spasticity
(modified) constraint-induced motor control subluxation
movement therapy orthopedic injuries task-specific training
contracture pain weakness
deformity positioning weight-bearing
function postural control
impingement reaching

chapter objectives
After completing this chapter, the reader will be able to accomplish the following:
1. Develop evidence-based treatment plans to regain upper extremity function with
functional task-related training.
2. Understand the application of adjunct treatments for the upper extremity after stroke,
including treatments such as positioning, shoulder supports, electrical stimulation,
biofeedback, and stretching programs.
3. Choose functional treatment activities appropriate to the level of available motor control.
4. Understand evaluation and treatment procedures for patients with symptoms of pain
syndromes and implement pain prevention protocols into current treatment plans.
5. Identify the common biomechanical malalignments of the upper extremity and trunk after
stroke and recognize their effect on function.
6. Prevent secondary complications such as pain, contracture, and learned nonuse.

218
 Chapter 10 • Upper Extremity Function and Management 219

Impaired upper extremity function is one of the most choice between conventional and new approaches, the
common and challenging sequelae of a stroke. The Co- occupational therapist should consider the following
penhagen stroke study included 515 stroke patients, 71% questions: Is this treatment effective? How does it work
of whom received occupational and physical therapy and and on what principles is it based? Is it accomplishing
69% of whom had mild to severe upper extremity dys- what is needed for this patient? Are some of the older
function on admission; all treatment plans included a treatment methods more solidly based, more effective, or
focus on upper extremity function.132 Obviously, numer- cheaper? Are there other better ways to meet this patient’s
ous hours of therapy are spent on this area, as are numer- needs?” This holds true today as new technologies are
ous dollars. This chapter highlights problems associated being developed in an effort to improve upper extremity
with upper extremity function after a stroke, research outcomes after stroke. See Chapter 11.
that has been published on upper extremity function/
dysfunction after stroke, and suggested evaluation and DEFINITIONS AND CLASSIFICATIONS
treatment techniques that focus on acquiring functional
use of the extremity and preventing pain syndromes A review of the literature on upper extremity function
and deformities. Readers should review the concepts in reveals a consistent problem: the lack of a definition for
Chapters 4 to 9 and Chapters 11 and 12 for a complete the word function. This may be attributed to the fact that
overview of topics related to upper extremity function a variety of disciplines are contributing information.
and motor control. From an occupational therapy perspective, function re-
fers to using the upper extremity to support engagement
OVERVIEW OF OCCUPATIONAL THERAPY in meaningful occupations. The International Classifica-
PERSPECTIVE tion of Function of the World Health Organization is a
helpful classification system that includes the following
“I want to use my arm again” is a goal that occupational categories:
therapists hear from stroke survivors during almost ■ Impairment of body systems and body structure:
every evaluation. For therapists to assist patients with examples include paresis, spasticity, sensory loss, and
meeting this goal, a thorough understanding of the decreased postural control
various problems associated with upper extremity dys- ■ Activity limitations: dysfunction in task performance
function after stroke is required. The therapist has the such as activities of daily living (ADL) and leisure
responsibility to stay informed of (and contribute to) tasks
the new developments in and information about upper ■ Participation restrictions: factor that limits or pre-
extremity function. vents fulfillment of a role (e.g., parent or worker)195
Current models of motor control encompass a variety Hughlings Jackson’s classification of observed symptoms
of neuromotor, biomechanical, behavioral, cognitive, en- after a central nervous system lesion is another system
vironmental, and learning processes. Mathiowetz and helpful for evaluating and treating the upper extremity
Bass-Haugen121 have compared and contrasted the vari- after stroke. Jackson, a nineteenth-century neurologist,
ous models of motor control therapy in the past and pres- classified symptoms as positive or negative.
ent. Research comparing the effectiveness of various ap- Positive symptoms are spontaneous, exaggerated dis-
proaches is lacking. However, clearly the current motor turbances of normal function and react to specific external
behavior research supports a treatment technique well stimuli. They include spasticity, increased deep tendon
known to occupational therapists: the use of function- reflexes, and hyperactive flexion reflexes. In contrast, the
based tasks and/or task-specific or task-related training. negative symptoms are deficits of normal behavior or
See Chapters 4, 5, and 6. performance. Negative symptoms include loss of dexter-
The use of functional activities has formed the basis of ity, loss of strength, and restricted ability to move.107,108
occupational therapy since its inception.125 However, the In the past, the major focus of therapeutic interven-
complex problems that interfere with upper extremity tions was to decrease the positive symptoms associated
function may require an integrated treatment approach with brain lesions. Therapists worked under the assump-
that uses functional tasks as the intervention foundation tion that a cause-and-effect relationship existed between
and hands-on approaches/modalities (e.g., mobilization, the two groups of symptoms. It has become clear that
soft-tissue elongation, and biofeedback) as adjuncts to the alleviation of positive symptoms (e.g., spasticity)
intervention. does not automatically result in an increased ability to
As the body of knowledge concerning motor behavior move. Therapists therefore must take a broader view
continues to grow, therapists must analyze research find- when identifying and treating upper extremity problems.
ings their own clinical practices critically. Burgess38 re- A focus on only the positive symptoms (e.g., normalizing
minds “A danger in times of transition and rapid change tone) does not result directly in increased function. See
is a distraction from basic principles. When faced with a Chapter 6.
220 Stroke Rehabilitation

ACTIVITY ANALYSIS OF SELECT UPPER side, a variety of adjustments may have to be made to
EXTREMITY TASKS allow visualization of the cover of the book or call num-
ber (Fig. 10-1).
The following examples illustrate the complexity of upper
extremity function and should assist in the evaluation Weight-Bearing Task/Closed Chain Activity
process. The weight-bearing task described requires the patient
to use one arm as a postural support (i.e., extended-arm
Reaching Task/Open Chain Activity weight-bearing to support function) on a kitchen table
The reaching task described requires the patient to reach while the other arm and hand wipe the table. As men-
for a book on a shelf that is at forehead level. First, initia- tioned previously, motivation and purpose are required.
tion of any movement pattern requires a motivational The motivation may be hunger (so the table must be
drive to perform; therefore, the activity must have an in- cleaned in preparation for a meal), extrinsic (e.g., visi-
herent purpose. The motivation behind and purpose of tors), or work-related (e.g., table space needed to balance
this activity may be to further knowledge, enhance leisure the checkbook or prepare a lecture). Because the weight-
time, or pass a midterm examination. To complete this bearing arm is being used as a postural support, a variety
activity successfully, the patient must process appropriately of postural adjustments occur in the arm. The weight-
the visual/perceptual information collected during the bearing arm is active during the task; the active skeletal
scanning process before initiating the reach pattern. Be- muscles include (but are not limited to) the scapula
cause the item is above eye level, neck extension with muscles biased toward protraction and stabilizing, the
concurrent right and left lateral head and neck rotation elbow extensors, the lower extremities, and the trunk
and sufficient ocular range of motion (ROM) are required. muscles. The amount of skeletal muscle activity in the
A person collects a variety of visual information during arm may decrease because of fatigue, resulting in a
visual scanning that helps identify particular characteristics “locked” elbow, an inactive scapula biased toward an el-
of the book (e.g., call number, title, color, and size). This evated position and retraction, and the trunk inactive and
information is interpreted by several visual/perceptual “hanging” on the arm.
processes (e.g., figure ground, color discrimination, and The arm wiping the table must stay active (closed chain
depth perception). See Chapters 16 and 18. with superimposed movement) and endure the entire activ-
Before initiation of the reach pattern the lower ex- ity if the task is going to be successful. The shoulder com-
tremities and trunk undergo several postural adjustments plex of this arm glides the hand and sponge along the table
to provide stabilization (anticipatory reactions). The anti- surface, so the upper extremity is supported by the environ-
gravity shoulder muscles prepare to bring the arm to shelf ment and is moving simultaneously. The amount of force
level, and the hand is prepositioned and oriented to pre- and pressure exerted on the hand depends on the demands
pare for grasping. While the reach pattern is being per- of the task (e.g., wiping crumbs or cleaning off dried syrup).
formed, the scapula protracts and rotates upward by the A variety of weight shifts occur during this activity, and
combination actions of the serratus anterior and upper they are affected by the size of the table and amount of
and lower trapezius muscles. The rotator cuff keeps the pressure needed by the wiping hand to accomplish the task.
humerus in a position biased toward external rotation and
seats the head of the humerus in the glenoid fossa. The
lower extremities and trunk stay active and stable during
the performance of the pattern and may assist with a
weight shift toward the shelves depending on the body
position.
When the hand makes contact with the book, it is
molded to the spine of the book, and the pattern of func-
tion is reversed (eccentrically) to return the book to the
side of the body. After the person removes the book from
the shelf, the grasp and pattern of skeletal muscle re-
cruitment may be adjusted depending on the weight of
the book. Although this activity pattern is preplanned
based on prior experience, the book may be lighter or
heavier than anticipated, so adjustments must be made in
response to the feedback. (For example, attempting to
pick up a supposedly full suitcase that is actually empty
results in an exaggerated lifting motion that may cause a
loss of balance.) While the book is being returned to the Figure 10-1 Reaching task.
 Chapter 10 • Upper Extremity Function and Management 221

The degree and variety of motor output is specific to the assessment will take place. Many available assessments
demands of the task. such as the Fugl-Meyer Assessment only evaluate the im-
As with all upper extremity tasks, multiple visual/ pairment level and do not include information regarding
perceptual processes are required for successful comple- how the upper extremity is used during daily occupations.
tion of this task. These processes are used to locate the Many use contrived or simulated functional tasks.
crumbs on the table, clean both sides of the table, and
determine when the task is complete (i.e., when the table Motor Activity Log (Self-Report)
is clean) (Fig. 10-2). The Motor Activity Log is a self-report questionnaire
(report by patient or family) related to actual use of the
SELECTED EVALUATION TOOLS involved upper extremity outside of structured therapy
time. It uses a semistructured interview format. Quality of
Evaluation tools that are standardized, reliable, and valid movement (“How well” scale) and amount of use (“How
can be overlooked no longer. Many therapists continue to much” scale) are graded on a 6-point scale. At present,
use piecemeal evaluations that do not incorporate the use there are 14, 28, and 30 item versions of the tool. Sample
of functional tasks and rely too heavily on evaluation of items include hold book, use a towel, pick up a glass,
impairments. write/type, and steady myself, etc.179-181
Beyond validity and reliability, when choosing assess-
ments, clinicians must consider time factors, level of Manual Ability Measure (MAM-36) (Self-Report)
motor function, the purpose of the evaluation (clinical, The 36-item Manual Ability Measure (MAM-36) is a new
research, or both), and the environment in which the Rasch-developed, self-report disability outcome measure.
It contains 36 gender neutral, common performed every-
day hand tasks. The patient is asked to report the ease or
difficulty of performing such items. It used a 4-point rat-
ing scale, with 1 indicating “Unable” (I am unable to do
the task all by myself), 2 indicating “Very hard” (It is very
hard for me to do the task and I usually ask others to do it
for me unless no one is around), 3 indicating “A little
hard” (I usually do the task myself, although it takes lon-
ger or more effort now than before), and 4 indicating
“Easy” (I can do the task without any problem). The
MAM-36 can be accessed.49 A look-up table from raw
scores to converted 0-100 Rasch measures is available.48

ABILHAND Questionnaire (Self-Report)

A The ABILHAND questionnaire asks clients to use a
3-point scale (0  impossible, 2  easy) to rate how dif-
ficult it would be to complete 23 bimanual tasks (e.g.,
hammering a nail, wrapping a gift, thread a needle, file
nails, cut meat, peel onions, open jar, etc.). Grip strength,
motricity, dexterity, and depression are significantly cor-
related with the ABILHAND measures.144

Assessment of Motor and Process Skills

The therapists evaluate motor and process skills68,69 within
the context of basic ADL and instrumental activities of
daily living (IADL). The quality of the person’s ADL per-
formance is assessed by rating the effort, efficiency, safety,
and independence of 16 ADL motor and 20 ADL process
B
skill items, while the person is doing chosen, familiar, and
Figure 10-2 A, Using the right upper extremity as a postural life-relevant ADL tasks. There are more than 100 tasks to
support while the left upper extremity is supported by the table choose from, thus promoting a client-centered approach
but moving. Intervention for the involved upper extremities to assessment. Examples of evaluated motor skills include
should include engaging the patient in activities that use the up- posture, mobility, coordination, strength, reach, manipu-
per extremities to support task performance. B, An alignment lation, grip, lifting, effort, and energy expenditure. See
that fosters minimal upper extremity activity. Compare with A. Chapter 21.
222 Stroke Rehabilitation

Arm Motor Ability Test Action Research Arm Test

The Arm Motor Ability Test (AMAT) has been used to The Action Research Arm Test consists of 19 items in
determine the effectiveness of constraint-induced move- four categories: pinch, grasp, grip, and gross movement.
ment therapy (CIMT) and includes 13 unilateral and The test is short (approximately 10 minutes). Items are
bilateral tasks. Sample items include tying a shoe, open- graded on a 4-point scale. Scores for each subtest range
ing a jar, wiping up spilled water, using a light switch, from 0 (unable to perform any task) to 6 (able to perform
using utensils, and drinking. The therapist times task all six tasks). Performance is rated on a 4-point scale rang-
performance and rates movement quality on a 6-point ing from 0 (unable to perform) to 3 (performs normally).
scale. The test is appropriate for evaluating motor skills The test is most useful for patients with some distal func-
in high-level clients with active wrist and finger exten- tion. The tasks included are contrived.117
sion. However, most of the AMAT activities are too
difficult and frustrating for persons with little motor Motor Assessment Scale
recovery.102,146 Developed by Carr and Shepherd, the Motor Assessment
Scale44 has been found to be highly reliable, with an aver-
Wolf Motor Function Test age interrater correlation of 0.95 and a 0.98 average test/
The Wolf Motor Function Test has been used to docu- retest correlation. This evaluation includes sections on
ment the outcomes related to CIMT and includes a vari- upper arm function, hand movements, and advanced hand
ety of tasks such basic reaching tasks (e.g., lifting arm activities. The upper arm function section includes move-
from lap to table, extending elbow with and without a ment patterns without tasks; the hand sections incorpo-
weight attached) and more functional activities that in- rate the use of objects. Each item is scored on a 7-point
volve fine motor control (e.g., picking up a pencil, turning scale.
a key in a lock). All tasks but one are unilateral and ap-
propriate for both the dominant and nondominant arm. Box and Block Test
As many tasks do not require distal control, it is appropri- The number of wooden blocks (2.52.52.5 cm) that can
ate for people with a more involved upper extremity. The be transported from compartment of box to another in
therapist times task performance and qualitatively grades one minute is counted.120,145
movement.191
Nine-Hole Peg Test
Chedoke Arm and Hand Activity Inventory A measure of dexterity, the Nine Hole Peg Test consists of
Chedoke Arm and Hand Activity Inventory is a functional a plastic console with a shallow round dish to contain the
measure with 13 items that are assessed using a 7-point pegs on one end of the console and the nine-hole peg-
quantitative scale, similar to that of the FIM instrument board on the opposite end. Time taken to complete the test
(e.g., 1  total assist and 7  independent). It yields a is measured as the patient grasps nine pegs and places them
total raw sum of 91 (minimum score  13) that can be in and removes them from the holes on the console.136
converted to a percentage. Sample items include opening
a jar of coffee, dialing 911, zipping a zipper, carrying a bag Functional Test for the Hemiplegic/Paretic Upper
up the stairs, and drying back with towel.12,13 Extremity
Although this evaluation188 is based on Brunnstrom’s view
Jebsen Test of Hand Function that motor recovery takes place in a specific sequence, it
The Jebsen Test of Hand Function97 includes the perfor- does involve functional tasks associated with daily living.
mance of seven test activities: writing a short sentence, This test has been found to be highly correlated with
turning over index cards, picking up small objects and scores on the Fugl-Meyer Assessment and requires ap-
placing them in a container, stacking checkers, simulat- proximately 30 minutes to administer. It consists of 17
ing eating, moving empty large cans, and moving test items arranged in seven levels according to difficulty.
weighted large cans during timed trials. The original Examples of tasks evaluated include folding a sheet, stabi-
paper is based on data collected from 360 normal sub- lizing a jar, hooking and zipping a zipper, screwing in a
jects and patients, including patients with hemiparesis light bulb, and placing a box on a shelf.
resulting from a stroke. The mean times and standard
deviations for normal subjects (with their dominant and Upper Extremity Performance Test for the Elderly/
nondominant hand) are published in the paper. The test Test d’Evaluation des Membres Supérieurs de
is standardized and reliable and does not have a practice Personnes Agées (TEMPA)
effect. Therapists must be aware that some of the tasks This test consists of four unilateral (pick up and move a
are simulated activities, and some tasks cannot be con- jar, pick up a pitcher and pour water into a glass, handle
sidered ADL tasks. coins, and move small objects) and five bilateral (open a
 Chapter 10 • Upper Extremity Function and Management 223

jar and take a spoonful of coffee, unlock a lock and open on motor control supporting the use of tasks performed in
a pill container, write on an envelope and place a stamp on context-specific situations (see Chapters 4 through 6.)
it, tie a scarf around your neck, and shuffle and deal play- Functional tasks in therapy include occupations that re-
ing cards) functional tasks. It includes speed of execution quire upper extremity weight-bearing for postural sup-
and functional ratings. The functional rating is related to port, reaching, carrying, lifting, grasping, and manipulat-
level of independence and uses a 4-point scale.60 ing of common objects. These types of activities clearly
carry over into daily life tasks and are comprehensive
Frenchay Arm Test enough to treat a variety of problem areas. The impor-
This quick test includes five items, such as hair combing tance of using occupation-embedded interventions as op-
with the weak arm and drinking water. Items are graded posed to rote exercise has been established.111,198 Indeed
as successful or unsuccessful.87 descriptions of the most effective interventions after stroke
include task specific, repetitive, intense, active, evidence-
Motricity Index based, and function-based. Further task-specific training
This test includes a brief impairment measure of upper should be relevant to the patient and context, be randomly
extremity function after stroke. Items include pinch ordered from a practice perspective, be repetitive and in-
strength, elbow flexion, and abduction.51 volve massed practice, focus on whole task practice, and be
positively reinforced (Fig. 10-3 and Table 10-1).89
Rivermead Motor Assessment (Arm Section)
This text is part of a comprehensive battery and contains Task-Oriented Reaching and Manipulation
15 items related to motor recovery of the arm. Sample The events leading up to a simple voluntary movement
items include protracting a shoulder girdle while supine, such as reaching for a glass of water involve multiple com-
picking up a piece of paper from the table in front and plex processes. Ghez74 classifies these processes as follows.
releasing five times, cutting putty on a plate with a knife First, the person needs to identify the glass and its position
and fork, and placing string around the head and tying a in space. This first step encompasses a variety of visual and
bow in the back. The scores are dichotomous: success (1) perceptual processes. Second, the person needs to select a
or failure (0).115 plan of action to bring the glass to the mouth. Ghez points
out that this step involves specifying which body parts are
Fugl-Meyer Assessment (Upper Extremity Motor needed and in which direction they should move. To do
Function) this, the person must evaluate the location of the glass in
Familiarity with this impairment-based test is helpful be- relation to the position of the hand and body. The infor-
cause the test is used in many research papers to docu- mation collected allows the motor system to determine the
ment improvement in function. The assessment is based appropriate trajectory of the hand. The last step is the ex-
on the motor recovery model developed by Twitchell and ecution of the response. Multiple commands are sent to
on Brunnstrom’s idea that motor recovery occurs in a the motor neurons specifying the temporal sequence of
specific sequence of steps. Improved motor function is muscle activation, the forces to be developed, the changes
considered a deviation from stereotypical synergies de- in joint angles, the orientation of the hand to fit the glass,
fined by Brunnstrom in this test. The test does not involve and the coordination of the shoulder with the distal arm to
the use of functional tasks. Sections include ROM, sensa- ensure that the glass will be grasped on contact and im-
tion, balance, upper extremity, and lower extremity. Items mediately. Multiple problems can interfere with these
are graded on a 3-point scale.72 three steps, including the issues discussed in the previous
section, visual dysfunction, and praxis deficits.
USE OF THE INVOLVED UPPER EXTREMITY Two components of upper extremity function have
TO SUPPORT TASK PERFORMANCE: been described by Jeannerod95,96: the transportation com-
SUGGESTIONS FOR INTERVENTION ponent, which includes the trajectory of the arm between
the starting position and the object, and the manipulation
The foundation of occupational therapy is built on pa- component, which is the formation of grip by combined
tients taking an active role in their own recovery by par- movements of the thumb and the index finger during arm
ticipating in functional activities. In the past, many thera- movement.
pists, while attempting to apply neurophysiological In her study of reaching deficits in subjects with left
principles to treatment, have limited their use of this mo- hemiparesis, Trombly177 used kinematic analysis and elec-
dality in favor of more passive techniques that are applied tromyography to document impairments in voluntary arm
to the patient (e.g., brushing, icing, and neurodevelop- movements. Her analysis demonstrated that the ability to
mental treatment–based handling techniques performed reach smoothly and with coordination was significantly
separately from functional tasks). Occupational therapy less in the impaired arms than in the unimpaired arms.
now has come full circle, with the most current research The continuous movement strategy used during reaching
Text Continued on p.230
224 Stroke Rehabilitation

A B

C D

E F

G
Figure 10-3 A to G, Task-oriented interventions: using the impaired upper extremity to sup-
port participation after stroke. (Courtesy of Yvette Hachtel, JD, MEd, OTR/L)
 Chapter 10 • Upper Extremity Function and Management 225

Table 10-1
Managing the Poststroke Upper Extremity Using Evidence from Systematic Reviews, Meta-analyses,
and Randomized Controlled Trials
INTERVENTION DESIGN/SUBJECTS CONCLUSIONS

Task-related/ A randomized controlled trial comparing standard Compared with SC participants, those in the
specific practice care (SC), functional task practice (FTP), and FTP and ST groups had significantly greater
strength training (ST).189 increases in upper extremity function and
strength, and decreased upper extremity im-
pairment in the short-term. In the long-term,
those in the FTP group benefited the most.
A prospective, randomized, single blind clinical Both groups improved significantly between
trial recruited 30 stroke subjects into either an pre- and posttests on all of the mobility mea-
upper limb or a mobility group. All subjects sures, while only the upper limb group made a
received their usual rehabilitation and an addi- significant improvement on the Jebsen Test of
tional session of task-oriented practice using a Hand Function and Motor Assessment Scale
circuit class format.17 upper arm items.
A systematic review of task-oriented training after “Studies of task-related training showed benefits
stroke.151 for functional outcome compared with tradi-
tional therapies. Active use of task-oriented
training with stroke survivors will lead to
improvements in functional outcomes and
overall health-related quality of life.” The
authors recommended “creating opportunities
to practise meaningful functional tasks outside
of regular therapy sessions.”
Double-blind randomized control trial. Interven- “TR training led to greater improvements in
tion group (TR group) received progressive impairment and function compared with C.
object-related reach-to-grasp training with Improvements were accompanied by increased
prevention of trunk movements. Control group active joint range and were greater in initially
(C) practiced tasks without trunk restraint.126 more severe patients. In these patients, TR
decreased trunk movement and increased
elbow extension, whereas C had opposite
effects (increased compensatory movements).
In TR, changes in arm function were
correlated with changes in arm and trunk
kinematics.”
An investigation of the effects of different intensi- Greater intensity of leg rehabilitation improved
ties of arm and leg rehabilitation training on the functional recovery and health-related
functional recovery of activities of daily living functional status, and greater intensity of arm
(ADL), walking ability, and dexterity of the rehabilitation resulted in improvements in
paretic arm, in a single-blind randomized dexterity.
controlled trial.105
Constraint A systematic review that found 13 randomized Findings were positive in all studies, but the
induced controlled trials, 4 of which were excluded minimal clinically important difference,
movement because they aimed at comparing different defined as a change of at least 10% of the
therapy (CIMT) intensity of CIMT.26 maximum score of the scale used, was reached
only in smaller ones, which may have been
influenced by patients’ characteristics.

Continued
226 Stroke Rehabilitation

Table 10-1
Managing the Poststroke Upper Extremity Using Evidence from Systematic Reviews, Meta-analyses,
and Randomized Controlled Trials—cont’d
INTERVENTION DESIGN/SUBJECTS CONCLUSIONS

A placebo-controlled trial of CIMT in patients After CIMT, patients showed large to very large
with mild to moderate chronic motor deficit improvements in the functional use of their
after stroke. The study compared CIMT to a more affected arm in their daily lives. The
placebo group that received a program of physi- changes persisted over the 2 years tested.
cal fitness, cognitive, and relaxation exercises for Placebo subjects showed no significant
the same length of time and with the same changes.
amount of therapist interaction as the
experimental group.172
A prospective, single-blind, randomized, multisite Among patients who had a stroke within the
clinical trial conducted at 7 U.S. academic previous 3 to 9 months, CIMT produced
institutions.193 statistically significant and clinically relevant
improvements in arm motor function that
persisted for at least 1 year.
Modified con- Thirty-two patients were randomized to receive In addition to improving functional use of the
straint induced mCIMT or traditional rehabilitation for three affected arm and daily functioning, mCIMT
movement ther- weeks.112 improved motor control strategy during
apy (mCIMT)* goal-directed reaching.
This study compared a mCIMT intervention with Compared with the control group, the mCIMT
a dose-matched control intervention that group exhibited significantly better perfor-
included restraint of the less affected hand and mance in motor function, level of functional
assessed for differences in motor and functional independence, mobility of extended ADL, and
performance and health-related quality of life. health-related quality of life after treatment.
N  32.113
A single-blinded randomized controlled trial After intervention, significant differences were
compared mCIMT to a time-matched exercise observed on the Action Research Arm Test and
program for the more affected arm or a no- Motor Activity Log Amount of Use and
treatment control regimen.137 Quality of Movement scales, all in favor of the
mCIMT group.
Twenty-six patients received either mCIMT The mCIMT group exhibited significantly
or traditional rehabilitation for a period of greater improvements in motor function, daily
3 weeks.196 function, and health-related quality of life than
the traditional rehabilitation group. In addi-
tion, those in the mCIMT group perceived
significantly greater percent of recovery after
treatment than patients in the traditional
rehabilitation group.
Thirty stroke patients were randomly assigned to Significant differences in favor of mCIMT were
either an mCIMT or a control group.201 found in 6 elements of the Wolf Motor
Function Test.
Mental practice A systematic review of 15 studies of mental The results of the majority of the studies suggest
practice focused on decreasing impairment and mental practice has a positive effect on upper
improving function in the poststroke upper limb recovery at both the impairment and
extremity.135 functional levels. However, it is unclear
whether the improvements seen are retained
over time, or how broad the effects are in
terms of improving perceived occupational
performance.

* Treatment protocols vary greatly and are discussed in Table 10-3.

 Chapter 10 • Upper Extremity Function and Management 227

Table 10-1
Managing the Poststroke Upper Extremity Using Evidence from Systematic Reviews, Meta-analyses,
and Randomized Controlled Trials—cont’d
INTERVENTION DESIGN/SUBJECTS CONCLUSIONS

A randomized placebo controlled trial of mental Those receiving mental practice showed
practice of specific arm movements.139 significant reductions in affected arm impair-
ment and significant increases in daily arm
function. Those in the group receiving mental
practice exhibited new ability to perform
valued activities.
Combined A randomized trial comparing mCIMT versus All subjects exhibited reductions in affected arm
mCIMT and mCIMT plus mental practice.138 impairment and functional limitation. Those in
mental practice the mCIMT plus mental practice group exhib-
ited significantly larger changes on both move-
ment measures after intervention.
Electromyographic Subjects were randomly assigned to EMG bio- “The results showed that there were statistically
(EMG) feedback or placebo EMG biofeedback groups. significant improvements in all variables in
biofeedback Both treatments were applied 5 times a week for both groups, but the improvements in active
a period of 20 days. In addition, the patients in range of motion and surface EMG potentials
both groups received an exercise program.7 were significantly greater in the EMG biofeed-
back group at the end of the treatment.”
The purpose of this study was to assess electro- “The results indicate that electromyographic
myographic biofeedback efficacy through meta- biofeedback is an effective tool for neuromus-
analysis. Eight studies met the inclusion criteria cular reeducation in the hemiplegic stroke
(N  192). Their average effect size was 0.81. patient.”
The 95% confidence interval for the effect size
was 0.5 to 1.12.161
Electrical The meta-analysis examined the efficacy of surface “Analysis found that, when added to conven-
stimulation electrical stimulation for the prevention or tional therapy, electrical stimulation prevented
reduction of shoulder subluxation after stroke. on average 6.5 mm of shoulder subluxation
Seven (four early and three late) trials met the (weighted mean difference, 95% CI 4.4 to 8.6)
inclusion criteria.3 but only reduced it by 1.9 mm (weighted mean
difference, 95% CI 2.3 to 6.1) compared
with conventional therapy alone. Therefore,
evidence supports the use of electrical stimula-
tion early after stroke for the prevention of,
but not late after stroke for the reduction of,
shoulder subluxation.”
A randomized trial (N 46). The treatment group “Data suggest that neuromuscular stimulation
received surface neuromuscular stimulation to enhances the upper extremity motor recovery
produce wrist and finger extension exercises. of acute stroke survivors. However, the sample
The control group received placebo stimulation size in this study was too small to detect any
over the paretic forearm.47 significant effect of neuromuscular stimulation
on self-care function.”
This meta-analysis examined the effectiveness of This analysis suggests that electrical stimulation
electrical stimulation of subluxation, shoulder produces positive results including improving
pain, range of motion and functional use. The subluxation, pain, range of motion, and func-
study included 5 papers with 8 data points.84 tional use.

Continued
228 Stroke Rehabilitation

Table 10-1
Managing the Poststroke Upper Extremity Using Evidence from Systematic Reviews, Meta-analyses,
and Randomized Controlled Trials—cont’d
INTERVENTION DESIGN/SUBJECTS CONCLUSIONS

A systematic review of randomized trials related to The review found no significant change in pain
poststroke shoulder pain. Four trials (a total of incidence or change in pain intensity after elec-
170 subjects) fitted the inclusion criteria.150 trical stimulation treatment compared with
control. There was a significant treatment
effect in favor of electrical stimulation for
improvement in pain-free range of passive
humeral lateral rotation. In these studies,
electrical stimulation reduced the severity of
glenohumeral subluxation, but there was no
significant effect on upper limb motor recovery
or upper limb spasticity The authors noted that
there does not appear to be any negative effects
of electrical stimulation at the shoulder.
EMG-triggered This systematic literature search was performed to “A positive effect of electrical stimulation was
neuromuscular identify clinical trials evaluating the effect of reported for 13 patient groups. Positive results
stimulation electrical stimulation. The authors specifically were more common when electrical stimula-
examined the relationship between outcomes and tion was triggered by voluntary movement
characteristics of the stimulation. 19 clinical rather than when non-triggered electrical stim-
trials were included, and the results of 22 patient ulation was used.”
groups were evaluated.59 The authors concluded that “triggered electrical
stimulation may be more effective than non-
triggered electrical stimulation in facilitating
upper extremity motor recovery following
stroke.”
This meta-analysis assessed the effect of EMG- The meta-analysis revealed a significant overall
triggered neuromuscular stimulation on arm and mean effect size (delta0.82, S.D.0.59).
hand functions, specifically the focus was on These improved wrist extension motor
wrist extension.25 capabilities findings support EMG-triggered
neuromuscular stimulation as an effective
poststroke protocol.
A randomized trial to assess the efficacy of “Subjects treated with EMG-stim exhibited
EMG-triggered neuromuscular stimulation significantly greater gains in Fugl-Meyer
(EMG-stim) in enhancing upper extremity (27.0 vs 10.4; p  .05), and FIM (6.0 vs 3.4;
motor and functional recovery of acute stroke p  .02) scores compared with controls.” Data
survivors.71 suggest that EMG-stim enhances the arm
function of acute stroke survivors.”
Bilateral upper A systematic review and meta-analysis of 11 stud- “These findings indicate that bilateral movement
extremity ies of bilateral arm training after stroke.168 training was beneficial for improving motor re-
training covery post-stroke.” “These meta-analysis find-
ings indicate that bilateral movements alone or
in combination with auxiliary sensory feedback
are effective stroke rehabilitation protocols
during the sub-acute and chronic phases of
recovery.”
 Chapter 10 • Upper Extremity Function and Management 229

Table 10-1
Managing the Poststroke Upper Extremity Using Evidence from Systematic Reviews, Meta-analyses,
and Randomized Controlled Trials—cont’d
INTERVENTION DESIGN/SUBJECTS CONCLUSIONS

A randomized, single-blind training study compar- Both groups had significant improvements on
ing bilateral (practice of bilateral symmetrical the Motor Status Scale and measures of
activities) to unilateral training (performed the strength. The bilateral group had significantly
same activity with the affected arm only). The greater improvement on the Upper Arm Func-
activities consisted of reaching-based tasks that tion scale. Both bilateral and unilateral training
were both rhythmic and discrete.170 are efficacious for moderately impaired chronic
stroke survivors. Bilateral training may be
more advantageous for proximal arm function.
A randomized controlled trial. Subjects random- BAT may uniquely improve proximal upper limb
ized to distributed CIMT, bilateral arm training motor impairment. In contrast, distributed
(BAT), or a control intervention of less specific CIMT may produce greater functional gains
but active therapy.114 for the affected upper limb in subjects with
mild to moderate chronic hemiparesis.
Mirror therapy A randomized trial to evaluate the effects of mir- In our group of subacute stroke patients, hand
ror therapy on upper extremity motor recovery, functioning improved more after mirror ther-
spasticity, and hand-related functioning of inpa- apy, in addition to a conventional rehabilitation
tients with subacute stroke.199 program, compared with a control treatment
immediately after 4 weeks of treatment and at
the 6-month follow-up, whereas mirror ther-
apy did not affect spasticity.
A randomized trial to evaluate the effect of a “In the subgroup of 25 patients with distal
therapy that includes use of a mirror (MT) to plegia at the beginning of the therapy, MT
simulate the affected upper extremity with the patients regained more distal function than
unaffected upper extremity early after stroke CT patients. Furthermore, across all patients,
compared to a control (CT).62 MT improved recovery of surface sensibility.
Neither of these effects depended on the side
of the lesioned hemisphere. MT stimulated
recovery from hemineglect.”
Strengthening Systematic review with meta-analysis of random- Strengthening interventions increase strength,
interventions for ized trials. 21 trials were identified and 15 had improve activity, and do not increase spasticity.
weakness data that could be included in the meta-analysis.2 These findings suggest that strengthening pro-
grams should be part of rehabilitation after
stroke.
A review of poststroke strengthening trials.141 “While the number of studies is limited, emerg-
ing evidence suggests that persons with post-
stroke weakness can improve strength through
resistance exercise in the absence of negative
side effects, including exacerbation of hyperto-
nia. Moreover, these improvements in strength
appear to transfer to functional improvements.
Still, many unresolved issues remain. The
potential for strength training to improve the
overall outcomes of rehabilitation for persons
with poststroke hemiplegia warrants further
investigation.”
Positioning A randomized trial to determine the efficacy of At least 30 minutes a day of positioning the
positioning the affected shoulder in flexion and affected shoulder in external rotation should be
external rotation to prevent contracture shortly started as soon as possible for stroke patients
after stroke.5 who have little activity in the upper arm.
230 Stroke Rehabilitation

activities was lost, movement time was longer, peak veloc- Box 10-1
ity occurred earlier, and indications of weakness were Exner Classification of Manipulation Tasks
present.
In a follow-up study, Trombly176 documented the ob- TRANSLATION
served improvements in her subjects’ reaching abilities. The object in the hand moves from the finger surface to
Her findings indicated that the amplitude of peak velocity the palm or vice versa.
improved over time. The level of muscular activity did not
SHIFT
improve, but the discontinuity of movements decreased.
From her findings, Trombly hypothesized that therapy Movement occurs at the finger and thumb pads by alter-
that allows relearning of sensorimotor relationships is nating thumb and radial finger movements (e.g., moving
warranted for some patients. She stated that the “level and a coin near the distal interphalangeal joints farther out to
the pads of the fingers).
pattern of muscle activity of these subjects depended on
the biomechanical demands of the task rather than any SIMPLE ROTATION
stereotypical neurological linkages between muscles.” The object is turned or rolled between the finger pads and
From a treatment perspective, research by Trombly thumb pad by alternating thumb and finger movements
and Wu178 concluded that “Goal-directed reach enabled (e.g., unscrewing a jar lid).
persons with stroke to display characteristics typical of
COMPLEX ROTATION
reach to a target by persons who have not had a stroke
better than reaching out in space. These findings support The object is rotated, which requires isolated, indepen-
the occupational therapy practice of using objects in a dent movements of the finger or thumb. The object is
functional context to improve coordinated movement. turned between 180 degrees and 360 degrees (e.g., turn-
However, the nature of the objects to be used requires ing a paper clip so that correct end can be placed on a
piece of paper).
further study.”
Van Vliet and colleagues185 studied subjects in the early
months after a stroke. The subjects were able to improve
their reaching kinematics during a three- to four-week preparing to write one’s name) enhanced quality of
period; they progressed toward normal performance. Pro- movement performance more than imagery-based occu-
viding the subjects with a meaningful task (e.g., drinking pation (e.g., pretending to pick up a pen and preparing to
from a cup) helped them perform the reach-to-grasp sign one’s name) and exercise (e.g., moving the arm for-
movement. ward). Their data suggested that material-based occupa-
Jeannerod96 stated that “Formation of the finger grip tion resulted in decreased reaction time, movement time,
during the action of grasping a visual object involves two and movement units. Although this study was performed
main functional requirements, the fulfillment of which on normal subjects, they inferred that material-based oc-
will determine the quality of the grasp. First, the grip cupation may be used to elicit efficient and economical
must be adapted to the size, shape, and use of the object preprogrammed movement for performing tasks.
to be grasped. Second, the relative timing of the finger In a study of fine motor coordination training, Neistadt133
movements must be coordinated with that of the other examined the effects of constructing puzzles and perform-
component of prehension by which the hand is trans- ing kitchen activities on fine motor coordination in a
ported to the spatial location of the object.” Jeannerod group of brain-injured men. Her results demonstrated that
observed that finger posturing anticipates the real grasp the subjects in the functional meal preparation group
and occurs during transportation of the hand. This shap- showed significantly greater improvements in dominant
ing of the hand is a mechanism independent of the ma- hand dexterity, which is used for picking up small objects,
nipulation itself. If treatment programs focused on im- than the subjects in the tabletop puzzle activity group. Her
proved function of the upper extremity are to be designed, findings suggested that functional activities are more effec-
then they must include a variety of common objects with tive (not to mention more meaningful) than tabletop
different shapes, sizes, and textures to affect this reaching activities for fine motor coordination training in the brain-
component. injured population.
Exner,66 who defined in-hand manipulation as the pro- Sietsema and colleagues163 studied brain-injured pa-
cess of adjusting objects being grasped in the hand, devel- tients engaged in rote exercise tasks and occupationally
oped a classification system to assist the therapist in activ- embedded tasks (e.g., reaching out to control a computer
ity choice, despite the system not being standardized on game). Their subjects had “mild to moderate spasticity” on
stroke survivors (Box 10-1 outlines Exner classification evaluation. Their results indicated that the game elicited
system). significantly more ROM during the reach pattern perfor-
Wu, Trombly, and Lin198 demonstrated that using mance than the rote exercise. Their study supported the
material-based occupation (e.g., picking up a pen and hypothesis that occupationally embedded interventions
 Chapter 10 • Upper Extremity Function and Management 231

promote increased performance. The authors hypothe- Box 10-2

sized that the game provided motivating feedback that Activities to Retrain Reach Patterns
enhanced performance.
At this point, research has confirmed that the demands ■ With the patient positioned in a supine posture, the
and goals of the task influence motor output.198 For ex- therapist supports the weight of the distal extremity
ample, the characteristics of an item being carried across with a handhold position. The patient attempts to
a kitchen influence factors such as how fast a person hold various positions and/or to follow the move-
ments of the therapist’s hand. This activity is appro-
moves, whether one or two hands are used to grip the
priate for the early motor recovery stage. The degrees
object, how close to the body the item is carried, and how of freedom are minimized (with trunk and scapula
stable the arms are held. In daily life, there are many ex- being supported by the supine posture), and the thera-
amples of the ways in which movement in daily activities pist eliminates the weight of the patient’s extremity,
is influenced by the environment (e.g., carrying empty ice maximizing the potential for skeletal muscle recruit-
trays or full trays, a half-glass of wine or a full cup of ment. This activity is easily taught to family members.
coffee, one paper plate or a stack of china plates). ■ Position the patient in side lying with the patient’s
Rosenbaum and Jorgensen153 have demonstrated that arm supported on a table. Practice reaching in multi-
the goal of the task influences motor output. Their sub- ple directions for various objects or towards various
jects were asked to reach for a cylinder and stand it on targets while the weight of the limb is supported on
one end or the other. Depending on the goal of the task the table.
■ The patient stands or sits in front of a table with a
(e.g., which side they were to stand the cylinder on),
hand resting on a dust cloth on top of the table. The
subjects reached with a pronated or supinated grasp patient focuses on gliding the hand across the table.
pattern. Box 10-2 provides sample activities used to re- The critical pattern consists of humeral flexion,
train reach patterns. See Chapters 4 and 5. scapula protraction, and elbow extension. The cloth
reduces friction, and the weight of the arm is sup-
Weight-Bearing to Support Function ported on the table (e.g., reach with support).
The use of weight-bearing tasks has long been advocated ■ The patient is seated, and objects are positioned on
in patients after stroke. Upper extremity weight-bearing the floor in front of patient. The patient reaches for
has been suggested anecdotally for achieving a variety of objects on the floor. This downward reach pattern
therapeutic goals, including inhibiting hypertonus by enhances scapula protraction, humeral flexion, and
moving the body proximally against the distal upper ex- elbow extension by nature of the position of the
objects. As the patient gains more control, the objects
tremity55 and stimulating upper extremity extension dur-
are raised up to the midshank level, then the knee
ing protective responses.19 Brouwer and Ambury37 con- level, and then the waist level, systematically increas-
cluded that upper extremity weight-bearing normalizes ing the motor demands of the task.
corticospinal facilitation of motor units in stroke pa- ■ The patient is engaged in the foregoing reach patterns
tients. They hypothesized that the mechanism respon- while therapist provides resistance to the functional
sible for their results was a sustained increase in motor pattern by tying an elastic band around the palm.
cortical excitability through augmented afferent input. The therapist is behind the patient holding the oppo-
McIllroy and Maki122 and Marsden, Merton, and site end of the band and is able to grade the level of
Morton118 documented that if the upper extremity is used as resistance.
■ During the reach activities, the demands of the distal
a postural support (e.g., during weight-bearing), postural
responses to the movements of the opposite arm occur components of movement are systematically increased
(e.g., increasing manipulation requirements). Exam-
throughout the weight-bearing upper extremity and to
ples include pouring water and opening jars.
other perturbations of posture. Their paper also demon-
strated that postural responses from the triceps only oc-
curred when the hand was in contact with a firm object.
Although from a neurophysiological perspective, the
effect of weight bearing on upper extremity control (e.g. support during activities requiring standing such as doing
the “normalization of tone” and “inhibition of spasticity”) the laundry or preparing a meal).
remains controversial and unproven, the use of weight- Therapists also can use weight-bearing activities to ad-
bearing patterns is still necessary for treating the upper dress impairments that interfere with function. The prob-
extremity after a stroke if the goal of treatment is to im- lem of soft-tissue shortening in the long flexors can be
prove functional performance. Examples include using the prevented or reversed by bearing weight on extended
more affected upper extremity in a weight-bearing pattern wrists with extended digits to maintain or increase tissue
and as a postural support while manipulating clothing length. If evaluation reveals that weakness in the extremity
during toileting activities or to enhance participation in is having a limiting effect on function, the therapist can use
IADL (e.g., using the more affected extremity as a postural extended-arm weight-bearing activities to strengthen the
232 Stroke Rehabilitation

triceps and scapula musculature if the weight-bearing ac- trol. See Table 10-1 for a review of evidence related to
tivities are performed in appropriate alignment and the task related training.
weight-bearing pattern remains active during the activity.
To ensure appropriate alignment, the therapists GOALS, TASK CHOICES, AND
should avoid severe internal rotation, forced elbow ex- INTERVENTIONS TO PROMOTE FUNCTION
tension, and an inactive trunk in patients.156 During
weight-bearing activities, maintenance of palmar hand The following goals are examples of treatment activities
arches is important for maintaining biomechanical align- for different levels and combinations of functional recov-
ment and enhancing active patterns. The points of con- ery. Using goals and treatments interchangeably ensures a
tact between the weight-bearing surface and the hand task-specific approach to intervention. These examples
include the thenar eminence, hypothenar eminence, should not be interpreted as progression in recovery. Al-
metacarpal heads, and palmar surfaces of the phalan- though previous assumptions were that proximal recovery
ges.100 The arch should be maintained so that therapists of abilities precedes distal recovery of abilities, this is not
can insert a finger between the web space and the first always the case. The following activities are graded by in-
metacarpal head and slide it under the hand until they creasing the degrees of freedom (e.g., increasing the num-
make contact with the hypothenar eminence. ber of planes of movement that are controlled and inte-
Although the more affected arm is in a weight-bearing grating hand use), the level of antigravity control, and the
position, the less involved extremity should be engaged in objects used in the task. An important note is that the cog-
activities that promote weight shifting in all directions nitive demands of the task have a substantial effect on the
(Fig. 10-4). Weight-bearing activities can be performed level of upper extremity function. Readers should not con-
by the forearm or an extended arm, depending on the sider this list hierarchical. For example, weight-bearing is
demands of the task and the level of available motor con- not a prerequisite to reaching, because the neurological

B C
Figure 10-4 A to C, Weight-bearing during daily occupations.
 Chapter 10 • Upper Extremity Function and Management 233

and biomechanical demands are different. Patients need Weight-bearing with superimposed motion (e.g., hand does
to be engaged in a variety of tasks that require the use of not leave support surface but slides and pulls objects)
the upper extremity in a variety ways and engaged in task- ■ Patient irons and/or dusts with more affected upper
specific training. extremity while stabilizing upper body with less af-
Focused attention on the more affected upper extremity (no fected upper extremity.
active movement) ■ Patient uses affected upper extremity to lock wheel-
■ Patient washes upper extremity during upper body chair brakes with brake extensions.
bathing activities. ■ Patient uses more affected upper extremity to smooth
■ Patient attends to upper extremity while rolling by out laundry.
passively guiding upper extremity across trunk when ■ Patient uses more affected upper extremity to wax
preparing to roll. and buff car.
■ Patient prevents arm from dangling while seated in ■ Patient uses more affected upper extremity to push
chair. shopping cart or rolling walker.
■ Patient positions upper extremity on table during ■ Patient uses affected upper extremity to apply body
mealtime. lotion.
Prevention goals ■ Patient uses affected upper extremity to wash a mir-
■ Patient stretches arm correctly by reaching to floor ror or window.
and maintaining this position after difficult tasks re- Antigravity shoulder movements without hand function
sult in arm posturing. ■ Patient initiates roll with more affected upper ex-
■ Patient’s family demonstrates proper guarding tech- tremity.
niques for a mobile patient. ■ Patient lifts more affected upper extremity into shirt
■ Patient’s caretaker demonstrates proper positioning sleeve.
of patient in bed. ■ Patient lifts more affected upper extremity to coun-
■ Patient’s caretaker demonstrates proper technique to tertop.
transfer patient from one surface to another (e.g., ■ Patient pushes drawer closed with back of more af-
not by lifting under the axillas). fected hand.
Forearm weight-bearing as a stabilizer ■ Patient turns off light switch with side of more af-
■ Patient stabilizes checkbook with upper extremity fected hand.
while writing checks. Initial hand movement (static grasp) with limited shoulder
■ Patient stabilizes cutting board with upper extremity movement (in lap or on work-surface activities)
during meal preparation. ■ Patient adjusts shirt cuff with more affected upper
■ Patient holds magazine open with upper extremity extremity.
while doing crossword puzzle. ■ Patient holds book in lap with both hands while
Using upper extremity for assistance during transitions reading.
■ Patient uses upper extremity for assistance with as- ■ Patient stabilizes fruits or vegetables with affected
suming sitting position from side-lying position. hand while cutting with less affected hand.
■ Patient uses upper extremity to push up into stand- ■ Patient holds shopping bag with more affected up-
ing position. per extremity during ambulation.
■ Patient uses upper extremity to reach back before ■ Patient holds washcloth with more affected upper
sitting. extremity and washes mid to lower body.
■ Patient uses upper extremity to lower trunk to Reach patterns with hand activity
mat when assuming supine posture from sitting ■ Patient picks up sock from floor with more affected
posture. upper extremity.
Incorporating upper extremity as a postural support when ■ Patient retrieves item from under sink cabinet with
sitting and standing (extended-arm weight-bearing with stabi- more affected upper extremity.
lized hands-on support surface) ■ Patient opens medicine cabinet with more affected
■ Patient uses upper extremity to assist with lateral upper extremity.
shifting while relieving pressure. ■ Patient retrieves item from top shelf of medicine
■ Patient stabilizes upper body with affected upper cabinet with more affected upper extremity.
extremity while wiping and dusting table or ironing ■ Patient drinks out of a cup with more affected upper
with less affected upper extremity. extremity.
■ Patient uses more affected upper extremity as a sta- Advanced hand activities
bilizer on a grab bar while manipulating clothing ■ Patient holds coins in affected palm and slides them
with less affected upper extremity during toileting. to finger tips.
■ Patient stabilizes upper body with upper extremity ■ Patient types 15 words per minute with both upper
while grooming at sink. extremities.
234 Stroke Rehabilitation

■ Patient signs check with more affected upper ex-

tremity. Constraint-Induced Movement Therapy (Traditional
■ Patient picks up and reorients paperclip with af-
and Modified Protocols)
fected upper extremity. The term learned nonuse was coined by Taub.171 The
A benchmarking outcomes system is suggested to track learned nonuse phenomenon originally was identified
and communicate progress (Box 10-3). Table 10-2 pro- in primate studies and later was applied to chronic
vides further suggestions for choosing tasks for a variety stroke patients. With deafferentation of a single fore-
of levels of function. limb of a monkey, the animal would not use that limb in

Box 10-3
The Australian Therapy Outcome Measures (AusTOMs) for Occupational Therapy: Upper Limb Use
The ability to use one or both upper limbs during activities ACTIVITY LIMITATION (AS APPROPRIATE TO AGE)
of daily living include gross and fine manipulative skills and Activity limitation results from difficulty in the performance
hand and arm use. This may comprise lifting and moving a of an activity. Activity is the execution of a task by an indi-
heavy object while walking; picking up and using a pencil; vidual. Assess the individual’s ability to use both upper limb/s
grasping, using, and releasing objects such as keys, buttons, for tasks and what the client can actually do, e.g., if the client
or taps; throwing and catching an object; and pushing, pull- can do all tasks independently with one arm, then score as 5.
ing, twisting, and turning objects. 0 Does not use upper limb/s. Unable to lift, move, ma-
Scoring: You are able to use half-points. nipulate, use upper limb/s. Full assistance required.
IMPAIRMENT OF EITHER STRUCTURE 1 Severe limitation in using upper limb/s. Maximum assis-
OR FUNCTION (AS APPROPRIATE TO AGE) tance required. Enough function to prevent further injury or
to minimize functional restrictions, e.g., shoulder can be
Impairments are problems in body structure (anatomical) or slightly abducted to enable clothes to be put on. Client com-
function (physiological or psychological) as a significant devia- pletes some of the movement required for activity.
tion or loss. Impairments may be mental (cognitive/perceptual), 2 Moderate/severe limitation in using upper limb/s. Needs
sensory, cardiovascular/respiratory, digestive/metabolic/endo- a person to give some hands on assistance, or requires con-
crine systems, neurological movement, or musculoskeletal. A stant verbal prompting. Can initiate gross motor movements,
variety of impairments may affect ability to use upper limbs but difficulty with end of range movements and fine motor
(if only one upper limb is affected, then rate the severity of im- control, e.g., consistently spills contents of cup; functional
pairments affecting this limb; if both are affected, then rate pencil grip but unable to write or form legible letters, can
both). Considering all the impairments an individual may have draw. Able to use upper limb for gross function only, such as
that affect upper limb use, assess the level of severity of these. stabilizing/or able to perform fine grasp but cannot manage
Base your assessment on typical presentation of the individual’s gross movements.
impairment(s) in an appropriate environment. 3 Moderate limitation in using upper limb/s. Requires ver-
0 The most severe presentation of impairment/s., bal cueing, supervision or set-up. Generally, gross movements
e.g., very dense hemiplegia, severe fixed contractures, un- intact, poor fine motor/dexterity, e.g., reaching for clothesline
bearable pain, or most severe presentation of cognitive independently, requiring assistance to manipulate peg on line.
impairment Inconsistent completion, e.g., picks up half-full lightweight
1 Severe presentation of impairment/s, e.g., dense hemi- cup with handles with occasional spills; illegible writing.
plegia, severely restricted range of movement, severe pain, or 4 Mild limitation in using upper limb/s. Able to do but
severe cognitive impairment lacking in quality, or extra time required, e.g., clumsy, unreli-
2 Moderate/severe presentation of impairment/s, e.g., able grasp/release, reduced carrying capacity, weaker grasp,
moderate to severe hemiplegia, moderate to severely re- mildly reduced coordination and dexterity, reduced reach, de-
stricted range of movement, moderate to severe pain, or creased efficiency and fluency of movement, e.g., holds and
moderate to severe cognitive impairment raises standard full cup with external support (table, other
3 Moderate presentation of impairment/s, e.g., moderate arm); completes legible writing although may display de-
hemiplegia, moderately restricted range of movement, mod- creased quality/slow speed/reduced fluency.
erate pain, or moderate cognitive impairment 5 No limitation in using upper limb/s. Able to lift, move,
4 Mild presentation of impairment/s, e.g., mild hemiple- manipulate, use hand and arm to complete functional tasks
gia, mildly restricted range of movement (e.g., morning stiff- bilaterally or unilaterally. May or may not use aids or adaptive
ness), mild pain, or mild cognitive impairment equipment such as prosthesis/orthosis, or enlarged/lightweight
5 No impairment/s of structure or function. All structures handle. Completes upper limb activities in reasonable time.
and functions intact. No pain. Affected arm equal to unaf- You must also make a rating of the client’s participation
fected arm or norms. Restriction and Distress/Wellbeing.

From Unsworth CA, Duncombe D: AusTOMs for occupational therapy, ed 2, Melbourne, 2007, La Trobe University. Copyright © 2007 by La
Trobe University. www.latrobe.edu.au/austoms
 Chapter 10 • Upper Extremity Function and Management 235

Table 10-2 the ability to extend the metacarpophalangeal and in-

Suggestions for Categorizing Upper terphalangeal joints at least 10 degrees, extend the
Extremity Tasks wrist 20 degrees, and walk without an assistive device.
They had to have grossly intact cognitive function, no
CATEGORY TASKS excess spasticity, be right-arm dominant, and be less
than 75-years-old.
No functional use Teach shoulder protection Patients were assigned to a control or an experimen-
Self range of motion tal group. The experimental group underwent forced-
Positioning use/CIMT in which the intact limb was placed in a
Postural support/ Bed mobility assist
sling and resting-hand splint. The restraint was worn at
weight-bearing Support upright function (work,
(forearm or leisure, activities of daily living) all times during waking hours except when toileting,
extended arm) Support during reach with opposite when napping, and at times when balance might be
hand compromised. The restraint was worn for 14 days.
Stabilize objects Each weekday, patients received therapy and were given
Supported reach Wiping a table a variety of tasks—such as eating with utensils, playing
(hand on work Ironing ball, playing Chinese checkers and dominoes, writing,
surface) Polishing and sweeping—to perform with the paretic limb for six
Sanding hours throughout the day.
Smoothing out laundry The treatment of the control group focused on in-
Applying body lotion
creasing attention to the paretic limb. This group was told
Washing body parts
that they had more potential in their extremities than they
Vacuuming
Locking wheelchair brakes were using. Therapists performed passive ROM activities,
Reach Multiple possibilities to engage up- and patients performed ROM activities daily for 15 min-
per extremity into activities of utes. The affected limb was not given any training for
daily living, leisure, and mobility; active movement.
grade tasks by height/distance Each group was evaluated before and after intervention
reached, weight of object, speed, with a variety of arm function evaluations and a self-
and accuracy reported Motor Activity Log. The experimental group
had significantly faster mean performance speeds from
the evaluations, increased quality of movement, and an
increased ability to use the extremity in ADL. These im-
provements were reevaluated two years later; they were at
an unrestricted (free) environment. The monkey’s ini- least maintained if not increased. Although the compari-
tial attempts to use the limb resulted in failures (e.g., son group made subtle gains after intervention, the gains
dropping food, losing balance, and falling). The mon- were not retained for the follow-up evaluation. Taub and
keys in this study soon found that they could function in colleagues171 concluded that the motor ability of stroke
their environment with three limbs instead of four. patients who met their inclusion criteria could be in-
Continued attempts to use the affected limb led to re- creased significantly by the interventions effective for
peated failures at attempted tasks; the effect was sup- overcoming learned nonuse.
pression of any desire to use that limb. The monkeys Wolf and colleagues192 researched forced-use treat-
learned not to use the limb to avoid failure, which ment in 25 chronic hemiplegic and stroke patients with
masked any future recovery of limb function. Taub and minimal to moderate extensor muscle function. The
colleagues171 pointed out that in a free situation, the CIMT program lasted for two weeks, with the intact limb
monkeys did not learn that they could regain use of the being restrained during waking hours. The authors noted
forelimb as they recovered function. When the intact significant changes in performance of 19 of the 21 tasks
forelimb was restrained, the monkeys were forced to use that were evaluated, with most changes persisting for one
the affected side. This technique converted a useless year after the study. The authors concluded that learned
limb into one capable of function. nonuse does occur in select patients with neurological
Taub171 hypothesized that the nonuse or limited deficits and that this behavior can be reversed through
use of an affected upper extremity in human beings af- application of a CIMT paradigm.
ter stroke could in some cases result from a similar Van der Lee and colleagues182 completed an observer-
phenomenon of learned suppression. To test this hy- blinded randomized clinical trial with 66 chronic stroke
pothesis, Taub171 studied nine patients with chronic patients who were randomized to two weeks of CIMT or
(i.e., greater than one year after stroke) hemiplegia. To a comparison of equally intensive bimanual training based
be included in this study, patients had to demonstrate on two weeks of neurodevelopmental therapy. One week
236 Stroke Rehabilitation

after the last treatment session, the authors found a sig- groups. No subject withdrew because of pain or frustra-
nificant difference in effectiveness in favor of CIMT group tion. The authors concluded that CIMT during acute
compared with the neurodevelopmental therapy group, rehabilitation is feasible. Furthermore, CIMT was associ-
after correction for baseline differences, on the Action ated with less arm impairment at the end of the trial.
Research Arm Test and the Motor Activity Log amount of Page and colleagues140 examined the feasibility and ef-
use score. One-year follow-up effects were observed only ficacy of a modified CIMT protocol administered on an
for the Action Research Arm Test. The authors also found outpatient basis. Their protocol was developed to be
that the differences in treatment effect for the Action Re- more consistent with therapy scheduling and reimburse-
search Arm Test and the Motor Activity Log amount of ment patterns, in other words, more user friendly and
use scores were clinically relevant for patients with sensory feasible from the therapist’s perspective. They examined
disorders and hemineglect, respectively. six patients who were in a subacute stage of stroke recov-
The EXCITE trial193 was a prospective, single-blind, ery and who exhibited learned nonuse. The patients were
randomized, multisite study and included 222 patients assigned to one of three groups; two patients received
with stroke. Subjects were randomized to either cus- half-hour physical and occupational therapy sessions three
tomary care or constraint-induced therapy. Constraint- times a week for 10 weeks while they simultaneously had
induced therapy consisted of two components applied their unaffected arms and hands restrained five days per
over a two-week period; subjects performed intense week during five hours identified as times of frequent use;
practice of functional tasks using the affected hand for two patients received regular therapy, and two control
six hours per day plus subjects reduced use of the unaf- patients received no therapy. Outcomes were measured by
fected hand by covering it with a mitt for at least 90% the Fugl-Meyer Assessment of motor recovery, the Action
of waking hours. The trial found significantly positive Research Arm Test, the Wolf Motor Function Test, and
results that were maintained in the long term. Outcome the Motor Activity Log. Patients receiving modified
measures included: CIMT exhibited substantial improvements on the Fugl-
■ The Wolf Motor Function Test, which showed a Meyer Assessment, Action Research Arm Test, the Wolf
52% reduction in time to complete its tasks, signifi- Motor Function Test and reported increases in amount
cantly better than the 26% reduction found in those and quality of use of the limb based on the Motor Activity
in the customary care group. Log. Patients receiving traditional or no therapy exhib-
■ The Motor Activity Log, which showed a 76% in- ited no improvements. The author concluded that modi-
crease in quantity and a 77% increase in quality of fied CIMT may be an efficacious method of improving
arm use, each significantly better than the 43% and function and use of the affected arms of patients exhibit-
41% respective increases found in the customary ing learned nonuse. See Table 10-3 for CIMT protocols.
care group. In addition to the apparent functional improvements in
Dromerick, Edwards, and Hahn63 questioned whether a the select group of patients who are appropriate for a trial of
CIMT program could be implemented in the acute stroke CIMT, researchers have demonstrated that CIMT pro-
population (two weeks after stroke) and whether this in- duces long-term alteration in brain function. This is the first
tervention was more effective than traditional upper ex- documented cortical-level change associated with a therapy-
tremity interventions (control group) during the acute induced improvement in the rehabilitation of movement
period. The research team enrolled 23 subjects in a pilot after neurological injury. Liepert and colleagues110 investi-
randomized, controlled trial that compared CIMT with gated whether CIMT could produce treatment-induced
traditional therapies. Treatment plans were designed to plastic changes/reorganization of the motor cortex in the
make sure that patients in both groups received equivalent human brain. Using focal transcranial magnetic stimulation,
time and intensity of treatment directly, and an occupa- the authors mapped cortical motor output area of a hand
tional therapist supervised the program. The subjects re- muscle on both sides in 13 stroke patients in the chronic
ceived routine interdisciplinary stroke rehabilitation, ex- stage of their illness before and after a 12-day-period of
cept for the CIMT that occurred during the regularly CIMT. The authors found the following:
scheduled occupational therapy sessions. Individualized ■ Before treatment, the cortical representation area of
and circuit-training techniques were used in both groups. the affected hand muscle was significantly smaller
All subjects received study treatment for two hours per than the contralateral side.
day, five days per week, for two consecutive weeks. Twenty ■ After treatment, the muscle output area in the af-
subjects completed the trial. The CIMT group had sig- fected hemisphere was significantly enlarged, corre-
nificantly higher scores on the Action Research Arm Test sponding to a greatly improved motor performance
and pinch subscale scores. Differences in the mean grip, of the paretic limb.
grasp, and gross movement subscale scores of the Action ■ Shifts of the center of the output map in the affected
Research Arm Test did not reach statistical significance. hemisphere suggested the recruitment of adjacent
ADL performance was not significantly different between brain areas.
 Chapter 10 • Upper Extremity Function and Management 237

Table 10-3
Tested Constraint-Induced Movement Therapy Protocols
TRADITIONAL PROTOCOL MODIFIED PROTOCOLS

The EXCITE trial defined the intervention as: Page and colleagues137 described the following protocol consisting of
“Participants in the intervention group were 2 components. “The first component consisted of half-hour, one-
taught to apply an instrumented protective on-one sessions of more affected arm therapy occurring 3 days per
safety mitt and encouraged to wear it on their week during a 10-week period. This component included shaping in
less-impaired upper extremity for a goal of which operant conditioning was applied in such a way that subjects
90% of their waking hours over a 2-week pe- received positive verbal encouragement to more fully perform
riod, including 2 weekends, for a total of selected motor skills with their more affected arm. Shaping was
14 days. On each weekday, participants re- applied with 2 or 3 upper-limb activities (e.g., writing, using a fork)
ceived shaping (adaptive task practice) and chosen by the subjects with help from their therapist. In the second
standard task training of the paretic limb for component of the mCIT intervention, during the same 10-week
up to 6 hours per day. The former is based on period, subjects’ less affected arms were restrained every weekday
the principles of behavioral training that can for 5 hours identified as a time of frequent arm use, as identified by
also be described in terms of motor learning the subjects with assistance from the therapist. Their arms were
derived from adaptive or part-task practice. restrained using a cotton hemi-sling, while their hands were placed
Standard task practice is less structured (i.e., in mesh, polystyrene-filled mitts with Velcro straps around the
repetition of tasks is not conducted as individ- wrist.”
ual trials of discrete movements); it involves Lin and colleagues112 defined their protocol as “restraint of the
functional activities performed continuously less affected limb combined with intensive training of the affected
for a period of 15 to 20 minutes (e.g., eating, limb for 2 hours daily 5 days per week for 3 weeks and restraint
writing).” 193 of the less affected hand for 5 hours outside of the rehabilitation
training.”
Sterr and colleagues167 defined their protocol as 14 consecutive
days; constraint of unaffected hand for a target of 90% of waking
hours with 3 hours of shaping training with the affected hand
per day. To note they concluded that: “The 3-hour CIMT train-
ing schedule significantly improved motor function in chronic
hemiparesis, but it was less effective than the 6-hour training
schedule.”

■ In follow-up examinations up to six months after review of evidence related to constraint induced move-
treatment, motor performance remained at a high ment therapy (Box 10-4). See Chapter 6.
level.
■ At follow-up, the cortical area sizes in the two hemi- Managing Inefficient and Ineffective Movement
spheres became almost identical, representing a re- Patterns
turn of the balance of excitability between the two Being unable to move effectively and therefore unable to
hemispheres toward a normal condition. interact with the environment is one of the most devastat-
Taub and colleagues171 summarized by stating that if the ing sequelae of stroke. The loss of the ability to move ef-
“neural substrate for a movement is destroyed by CNS fectively is a negative stroke symptom.
injury, no amount of intervention designed to overcome The movement patterns of stroke survivors have long
learned nonuse can be successful in helping recover lost been discussed in the literature. Controversy continues
function. However, many stroke patients . . . have consid- over the nature of these patterns. These movement pat-
erably more motor ability available than they utilize. The terns have been described as reflex based, a release of
suppression of this additional motor capacity is set up by abnormal synergies, the result of reversed inhibition or
unsuccessful attempts at movement in the acute poststroke the release of lower patterns of activity from higher in-
phase . . . increased motor activity should then become hibitory control, and as learned patterns of movement.
increasingly possible, but the suppression of movement Mathiowetz and Bass-Haugen121 point out that more
remains unabated and inhibits use of the limb. However, if contemporary models of motor control describe patterns
individuals are correctly motivated to use this unexpressed developing after central nervous system damage as re-
ability, they will be able to do so.” See Table 10-1 for a sults of attempts to use remaining resources to achieve
238 Stroke Rehabilitation

Box 10-4
Summary of Constraint-Induced Movement Therapy
■ Use to counteract learned nonuse. Hypothesized causes ■ Activity choices and therapist’s interventions. Select tasks
of learned nonuse include therapeutic interventions that address the motor deficits of the individual patient,
implemented during the acute period of neurological assist the patient to carry out parts of a movement
suppression after stroke, an early focus on adaptations to sequence if the patient incapable of completing the move-
meet functional goals, negative reinforcement experi- ment on is his or her own at first, providing explicit ver-
enced by the patients as they unsuccessfully attempt to bal feedback and verbal reward for small improvements in
use the affected limb, and positive reinforcement experi- task performance, use modeling and prompting of task
enced by using the less involved hand and/or use of performance, use tasks that are of interest and motivating
successful adaptations. to the patient, ignore regression of function, and use
■ Motor inclusion criteria. Control of the wrist and digits is tasks that can be quantified related to improvements.
necessary to engage in this type of intervention. Current ■ Outcome measures. The Motor Activity Log (actual use
and past protocols have used the following inclusion cri- outside of structured therapy or “real-world use”), Arm
teria: 20 degrees of extension of the wrist and 10 degrees Motor Ability Test, Wolf Motor Function Test, and the
of extension of each finger; or 10 degrees extension of the Action Research Arm Test have been used to document
wrist, 10 degrees abduction of the thumb, and 10 degrees outcomes.
extension of any two other digits; or able to lift a wash ■ Cortical reorganization. Constraint-induced movement
rag off a table using any type of prehension and then therapy is the first rehabilitation intervention demon-
release it. It is clear that distal function (particularly wrist strated to induce changes in the cortical representation of
and digit extension) is a critical factor in being a candi- the affected upper limb.
date for the intervention. Therapists should focus on ■ The continued rigorous research that has been and con-
these movements early and intensely. Potential interven- tinues to be carried out to demonstrate the effectiveness/
tions to regain this motor control included electrical efficacy of constraint-induced movement therapy should
stimulation, mental practice, and activities that require be used as a gold standard for other rehabilitation inter-
distal extension such as reaching for large objects. ventions that are used traditionally (e.g., neurodevelop-
■ Main therapeutic factor. Massed practice and shaping of mental therapy) but have little or no research support.
the affected limb during repetitive functional activities ■ Based on available evidence, constraint-induced move-
appears to be the therapeutic change agent. “There is ment therapy appears to be an effective intervention for
thus nothing talismanic about use of a sling or other con- stroke survivors who have learned nonuse and who fit the
straining device on the less-affected limb.”173 motor inclusion criteria.

occupational performance. They give the example of a Ada and colleagues1 hypothesize that muscle weakness
typical flexor pattern (scapula retraction, internal rota- or paralysis effectively immobilize the upper limb, which
tion, elbow/wrist/digit flexion) in the upper extremity; results in soft-tissue contracture. The immobility causes
the pattern can stem from factors other than spasticity, length-associated changes in muscles, and persistent po-
such as the inability to recruit appropriate muscles, sitioning results in contracture. These changes in the
weakness, soft-tissue tightness, and perceptual deficits. upper limb result in compensatory movements that gen-
Carr and Shepherd42 state that “muscles that are held erate strong neural connections after frequent repetition,
persistently in a shortened position not only develop ensuring that the compensatory or adaptive movement
contracture but also appear ‘easier’ for the patients to patterns become learned rather than more effective and
activate. . . . In the stroke patient such activity appears to efficient.
become habitual, certain muscle groups, apparently those A Russian neurologist, Nicoli Bernstein, emphasized a
whose mechanical advantages are greatest (because of early task-oriented view of motor performance and intro-
their shortened length), contracting persistently to the duced the concept that purposeful movement is organized
disadvantage of others.” The therapist can observe this to solve motor problems and the concept of degrees of
phenomenon if a patient is reaching out to a target. Many freedom.158 He hypothesized that the principal problem
patients have difficulty with the protraction, elbow exten- faced by the central nervous system was the large number
sion, and wrist and digit extension patterns of this task. If of joints and muscles in the human body and the infinite
the therapist observes the patients who have been in a combinations of muscle action. For example, the upper
resting posture (e.g., seated in a wheelchair) for a pro- extremity has multiple degrees of freedom if the number
longed time, the shortened muscles include the retractors, of planes through which each joint moves are combined.
elbow flexors, and wrist and digit flexors. When contemplating the combinations of degrees of
 Chapter 10 • Upper Extremity Function and Management 239

freedom in the trunk, scapula, and shoulder to the hand, or substituting flat-hand stabilization for a hand grasp).70
it becomes evident that task of controlling them is phe- Gillen76,77 has demonstrated a variety of methods to im-
nomenal. Bernstein states that “The coordination of a prove task performance in clients with central nervous
movement is the process of mastering redundant degrees system dysfunction by manipulating the degrees of free-
of freedom of the moving organ, that is, its conversion to dom via positioning, splinting, movement retraining, and
a controllable system.”158 Bernstein views motor control equipment. Further research is required with the stroke
as a person’s ability to coordinate kinematic linkages that population.
limit degrees of freedom. See Chapter 5. Many of the inefficient movement patterns in stroke
Flinn70 uses the example of gymnasts learning a new survivors may result from attempting tasks beyond their
maneuver to apply the concept of degrees of freedom to a level of motor control (Fig. 10-5). Many therapists have
task. Gymnasts limit the degrees of freedom in the task by watched patients with newly developed motor control
holding some joints rigid while focusing on one specific proudly show how they can “lift their arm.” Of course,
body part (e.g., foot placement). Although the gymnasts the resulting movement is a stereotypical pattern used by
initially may appear stiff, as they become able to control stroke survivors. Mathiowetz and Bass-Haugen121 sug-
more degrees of freedom, the stiffness disappears and gest that the use of these movement patterns is evidence
movement relaxes. This example can be applied to learn- of attempts to use remaining systems to complete tasks.
ing how to roller-blade, ice-skate, or perform a new swim- They give the example of a patient with weak shoulder
ming stroke. Sabari158 discusses a patient with hemiplegia flexors trying to lift an arm. The patient flexes the elbow
who does not dissociate the pelvis from the lumbar spine when trying to raise the arm because this movement
or scapula from the thorax, which may be an effort to strategy shortens the lever arm and makes shoulder flex-
decrease the degrees of freedom. ion easier. This phenomenon can be observed in those
With this concept in mind, many of the ineffective with other diagnoses that result in proximal weakness
movement patterns observed in patients can be attributed (Fig. 10-6).
to attempts to control the degrees of freedom. Therapists Based on these concepts, the roles of the occupational
need to consider this during treatment planning when therapist in treating inefficient and ineffective upper ex-
choosing activities. The degrees of freedom must be con- tremity patterns are the following:
trolled carefully by stabilizing or eliminating use of some ■ To use skills of activity analysis to guide patients’
of the joints and therefore decreasing the number of joints participation in functional upper extremity tasks that
involved (e.g., supporting the distal extremity on a table correspond to their level of motor control

A B C
Figure 10-5 A, When asked to reach, this patient uses a stereotypical flexor pattern. Note
trunk lateral flexion, scapula adduction, humeral abduction, and distal flexion. B, When the
position of the activity is changed to correspond with the available motor control, and the
patient is given a goal (e.g., “Pick up the bottle”), movement pattern is more effective and
efficient. C, Another position change of same activity results in forward reach with less impact
of compensations seen in A. The patient reaches with wrist extension, and his hand is preposi-
tioned for successful task completion. The purpose of the activity drives motor output.
240 Stroke Rehabilitation

or a combination of components) related to upper

extremity function are blocking improvements in
occupational performance (e.g., ADL, IADL, work,
and leisure)
■ To provide function-based activities that focus on
improving the identified problem area in an effort to
improve task performance
■ To provide opportunities to use available motor con-
trol throughout the day. Strategies include using
devices that unweight the weak upper extremity so
that movement can be accessed (Fig. 10-7), provid-
ing bedside and home-based activity programs as
A opposed to only exercise programs, and explicitly
teaching stroke survivors how the upper extremity
should be used throughout the course of the day to
support participation (Fig. 10-8).
In terms of treatment, Mathiowetz and Bass-Haugen121
suggest that therapists help the patients “find the optimal
strategy for achieving functional goals.” Goals can be
achieved by altering the task requirements, altering the
environmental context, and by guiding remediation of the
component deficits that interfere with functional perfor-
mance. The most powerful tools occupational therapists
have for intervention are functional activities. Although
functional activities have formed the basis of treatment
since the profession was developed, only recently has the
true impact of functional tasks been evaluated in this area
B
of intervention (Fig. 10-9). See Chapter 4.
Figure 10-6 Compensatory movements from proximal weak-
ness. A, This person’s is status post left brain damage resulting
in right sided weakness including right scapula instability. Com-
pensatory strategies used to lift her arm include lateral trunk
flexion, trunk rotation, scapula adduction and elevation, and el-
bow flexion. These compensatory movement strategies act to
decrease the degrees of freedom, provide proximal stability, and
shorten the lever arm of the upper extremity. This person has
relatively preserved elbow extension strength, which she cannot
use during this movement as it will create a longer lever arm and
a loss of control. In the recent past, this movement pattern was
attributed to abnormal flexor tone placing the treatment focus
on decreasing tone in the antagonistic muscle groups (i.e., elbow
flexors). A more current treatment approach includes interven-
tions related to proximal strengthening and practice of graded
reach patterns ( i.e., a focus on the weak agonists). B, This man
is using very similar compensatory movements as the woman in
A, although his diagnosis is a right rotator cuff tear. The ineffi-
cient and ineffective movement patterns and the compensatory
movements are secondary to proximal weakness.
Figure 10-7 Suspension arm sling. Unweighting the upper
extremity may promote increased use during the day. The
■ Through this process, to enable patients to interact therapist must consider ways in which the patient can move and
with the environment using their more affected up- use the upper extremity outside of therapy. Caution: When
per extremity evaluating patients using this device, the therapist must make
■ To use evaluation skills to determine which impair- sure that the movement is being generated by the upper extrem-
ments (e.g., loss of postural control, weakness, pain, ity as opposed to swinging the arm by moving the trunk.
 Chapter 10 • Upper Extremity Function and Management 241

Daily Planner

8:00 am: Out of bed Use right arm to push up from side lying to
sitting position. Use both arms to push up
to stand.
8:15 am: Bathroom • Use right hand to squeeze out toothpaste
(push down through tube while the tube is
resting on sink).
• Use right arm to stabilize yourself while
standing at sink.
• Use right arm to stabilize on grab bar
during clothing management.
• Use wash mitt on right hand to wash legs
and chest while sitting on tub bench.
9:15 am: Breakfast • Use right arm as a stabilizer (ex. stabilize
bread when spreading butter with left hand;
stabilize fruit while cutting with left hand).
• Wipe crumbs off table with right hand after
breakfast.
10:00 am: Watching television • Hold remote in right hand while watching
television.
• Perform prescribed stretching program
during commercials.
11:00 am: Email and computing Use right arm to control mouse when
navigating websites.
11:30 am: Errands/shopping Hold tote bag using right arm. Loop the tote
bag across your forearm and keep your
elbow flexed.
12:30 am: Lunch with friends • Keep right arm positioned on table as
opposed to in your lap.
• Use right arm to turn menu pages.
• Hold napkin in right hand until you are
ready to use it.
Etc.

Figure 10-8 Daily planner to promote upper extremity function throughout the day.

SELECTED ADJUNCT INTERVENTIONS USED contraction training, and a control group. Training re-
WITH A TASK-ORIENTED APPROACH sulted in a maximum voluntary contraction force increase
of 22% in the imagining group, 30% in the contraction
Mental Practice/Imagery group, and 3.7% in the control group. This study demon-
The use of imagery in treatment has received an increas- strated that strength increases can be achieved without
ing amount of support in the literature. Using imagery muscle activation. Early strength increases appear to re-
and mental practice has been shown to do the following: sult from practice efforts on central motor programming.
■ Activate the cortical representation and musculature This study adds to the increasing evidence that the neural
the correlates with the imagined movements origin of strength increases before muscle hypertrophy.
■ Improve learning and performance In an early study focused on improving upper extrem-
■ Reorganize the motor cortex ity function after stroke, Page139 hypothesized that imag-
Yue and Cole202 proposed a method for increasing skeletal ery use combined with traditional occupational therapy
muscle strength. Healthy subjects were separated into could enhance motor recovery in patients with upper ex-
three groups: those receiving imagining training (i.e., tremity hemiparesis. He provided eight chronic stroke
training in which the person imagines a muscle is con- patients with a four-week course of occupational therapy
tracting but is not activating the muscle), those receiving and imagery (a 20-minute audio tape that consisted of
242 Stroke Rehabilitation

Figure 10-9 Reaching activities used to challenge available motor con-

trol appropriately. A, When attempting to lift both arms, this man uses
an ineffective and inefficient movement pattern. He recruits his available
scapula elevators, elbow flexors, trunk extensors, and head/neck exten-
sors. Although it may appear that he lacks elbow extension or that his
elbow flexors are “spastic” or “overactive,” muscle testing in supine yields
a grade of 4 out of 5 for all elbow musculature. His lack of ability to use
elbow extension in this movement may indicate an attempt to shorten the
lever arm and control the degrees of freedom. B and C, Using leisure and
work tasks that are more appropriate to this man’s level of motor control.
Both activities are considered supported reach because the hand is in
contact with the work surface. Note that the upper extremity patterns are
more effective and efficient. D, The therapist provides graded physical
E assist to complete the task as increased biomechanical demands are made
using the incline of the car. E and F, Grading the reaching in space activ-
ity using gravity to make the task progressively more difficult.
 Chapter 10 • Upper Extremity Function and Management 243

relaxation followed by cognitive visual images related to scapular and humeral rotation with a forward reach pat-
the upper extremity being used in weight-bearing tasks tern, and reinforcement of functional patterns in the el-
and functional tasks that were practiced in occupational bow, forearm, and hand.
therapy). This group was compared with eight controls Tries175 presented a case study outlining the applica-
that received only occupational therapy. He concluded tions of biofeedback for a left-sided hemiplegic patient.
that the patients who received occupational therapy and Her case study illustrated that despite sensory, cognitive,
imagery had significantly more improved function as and perceptual impairments, this patient had significant
measured by the upper extremity section of the Fugl- clinical upper limb functional improvements when com-
Meyer Assessment. Since then, multiple studies have bining EMG biofeedback and traditional occupational
documented the effectiveness of this adjunctive interven- therapy.
tion. See Table 10-1 for a review of evidence related to Greenberg and Fowler80 compared kinesthetic bio-
mental practice (Box 10-5). feedback (feedback information pertaining to actual move-
ment of a body part rather than the activity of muscle fi-
Electromyographic Biofeedback bers) to conventional occupational therapy. Their results
Electromyographic (EMG) biofeedback shows promise indicated that kinesthetic biofeedback was equally as
and should be studied further for its potential use in treat- therapeutic as but no more effective than conventional
ing upper extremity dysfunction after stroke. Biofeedback occupational therapy for increasing elbow extension in
is provided by electronic instruments that measure and hemiplegic subjects.
give information about neuromuscular or autonomic ac- Crow and colleagues53 studied two groups (a group
tivity in the form of auditory or visual feedback signals. receiving biofeedback and a control group) of 20 patients.
Tries’ review175 of the literature included a variety of The patients were studied before and after six weeks of
rationales for integrating this noninvasive modality, in- treatment and during a follow-up visit six weeks later.
cluding training voluntary inhibition of spastic muscles Although the groups did not differ significantly before
and restoring muscle balance, into an upper extremity treatment, the biofeedback group improved significantly
program. Tries175 outlined specific techniques for scap- on arm-function evaluations. At the six-week follow-up,
ula mobility and stability, humeral rotation, integrating the beneficial effects were discovered not to have per-
sisted in the experimental group.
Schleenbaker and Mainous161 concluded from their
Box 10-5 meta-analysis that biofeedback is an effective tool in neuro-
muscular reeducation for executing ADL. The use of EMG
Summary: Using Mental Practice to Improve biofeedback warrants further investigation into its use as an
Upper Extremity Function after Stroke adjunct tool to enhance upper extremity function in select
■ During mental practice, an internal representation of patients with hemiparesis. See Table 10-1 for a review of
the movement is activated and the execution of the evidence related to EMG biofeedback.
movement repeatedly mentally simulated, without
physical activity, within a chosen context. It is used for Electrical Stimulation
the goal-oriented improvement or stabilization of a Electrical stimulation has been used in poststroke upper
given movement.33 It is cognitive rehearsal of a motor extremity rehabilitation for many years. Potential uses
act or task.94
have included reduction of shoulder subluxation, reduc-
■ Provides opportunity to promote repetitive task
tion of pain, improved motor control, and increasing use
practice
■ Most commonly, the mental practice intervention is of the involved extremity. In general, the effects of electri-
administered via audiotape. The audiotapes consist of cal stimulation have been the most consistent at improving
a few minutes of relaxation and focusing followed by limb impairments such as ROM and reducing pain. The
several minutes of mental practice of tasks such as effects on function and ADL have received less attention
turning pages in a book, drinking from a cup, writing, and have been inconsistent. See Table 10-1 and Table 10-4
etc. The length of the audiotapes have varied from for an evidenced-based review of electrical stimulation.
approximately 10 to 20 minutes.
■ Consistent and positive outcomes have been docu- Electromyographic-Triggered Electrical Stimulation
mented, including decreased upper extremity im- Electrical stimulation can be triggered by voluntary move-
pairment, increased upper extremity function, and
ment or nontriggered. EMG-triggered stimulation detects
increase in everyday use of the limb outside of struc-
tured therapy.135
underlying muscle activity when it reaches a threshold
■ Data from psychophysical, neurophysiological, and level prior to providing the stimulation. The stroke survi-
brain imaging studies support the existence of a simi- vor must voluntarily activate the correct muscles prior to
larity between executed and imagined actions.94 the stimulation facilitating the motor response. This type
of stimulation assures that the intervention is not passive
244 Stroke Rehabilitation

Pain Guarding/static positioning

Upper extremity dysfunction

• Inability to incorporate upper extremity into activities of daily living
• Ineffective/inefficient/stereotyped movement patterns
• Contracture/deformity

Ineffective/inefficient recruitment
of skeletal muscle activity: Soft-tissue shortening

• Increased activity at rest

• Inability to recruit activity
• Imbalanced muscle activity

Figure 10-10 Complexity and interdependence of causes of upper extremity dysfunction.

in nature. Triggered electrical stimulation may be more use either functional tasks or repetitive arm movements.
effective than nontriggered electrical stimulation in facili- This technique has been combined with auditory rhyth-
tating upper extremity motor recovery following stroke.59 mic cuing and neuromuscular stimulation. Some re-
This intervention has been shown to be effective at im- search has concluded that the technique may be more
proving wrist extension, a key movement to be considered beneficial for those with proximal limb involvement. See
a candidate for some task oriented approaches such as Tables 10-1 and 10-5 for an evidence-based review of
CIMT. See Table 10-1 for an evidence-based review of bilateral training. See Box 10-6 for a sample protocol.
EMG-triggered electrical stimulation.
Mirror Therapy
Bilateral Training A relatively new intervention, this intervention appears to
Recently, bilateral training (i.e., patients practice identical be cost-efficient and is able to be done independently.
activities with both upper limbs simultaneously) has been Yavuzer and colleagues199 describe the intervention as
proposed as a strategy to improve upper limb control and “During the mirror practices, patients were seated close
function post stroke.130a The theory and rationale as to to a table on which a mirror (3535 cm) was placed verti-
why the intervention may be effective has been described cally. The involved hand was placed behind the mirror
as follows: “Control of bilaterally identical synchronous and the noninvolved hand in front of the mirror. The
movement appears to occur centrally through bilaterally practice consisted of nonparetic-side wrist and finger flex-
distributed neural networks linked via the corpus callosum ion and extension movements while patients looked into
and involving cortical and subcortical areas. These net- the mirror, watching the image of their noninvolved hand,
works indicate a common facilitatory drive to both motor thus seeing the reflection of the hand movement pro-
cortices thought to lead to tight temporal and spatial cou- jected over the involved hand. Patients could see only the
pling of limb movement observed during bilaterally identi- noninvolved hand in the mirror; otherwise, the nonin-
cal synchronous voluntary movement. Beneficial effects of volved hand was hidden from sight. During the session
bilateral training in stroke are assumed to arise from this patients were asked to try to do the same movements with
coupling effect in which the nonparetic limb provides a the paretic hand while they were moving the nonparetic
template for the paretic limb in terms of movement char- hand” (Fig. 10-11). See Table 10-1 for an evidence-based
acteristics, facilitating restoration of movement.”129 Stoykov review of mirror training.
and Corcos169 further reviewed neural mechanisms medi-
ating bilateral training including recruitment of the ipsilat- IMPAIRMENTS TO CONSIDER DURING
eral corticospinal track, increased control from the con- EVALUATION AND INTERVENTION
tralesional hemisphere, and a normalization of inhibitory
mechanism. Evaluation and intervention of the upper extremity are
Although some findings have been inconsistent, a re- complex tasks that require an understanding of multiple
cent meta-analysis and randomized controlled trials have systems. Therapists need to remain open-minded about
demonstrated improvement. Protocols vary but typically their interventions and consider the complexity of causes
Table 10-4
Effectiveness of Electrical Stimulation to Decrease Arm Impairment and Improve Function
after Stroke
d OR
EFFECT
STUDY SAMPLE TREATMENT OUTCOME SIZE WEIGHT DW r INDEX

Chantraine et al. N  115 Both groups rehab using At six months .23
(1999) 57 (exp.) Bobath approach Exp. ROM improved .48 29.16 14.00 .18
58 (ctrl.) Exp. Five weeks of FES on Subluxation reduced .36 29.52 10.63 .23
muscles surrounding Pain reduced .48 29.16 14.00
shoulder
Faghri et al. (1994) N  26 Experimental group After six weeks of treatment .82 6.00 4.92 .38
13 (exp.) received FES to shoulder exp. group had significant
13 (ctrl.) muscles reduction in subluxation
Cauraugh et al. N  11 Both received 30 minutes Post treatment, functional 1.53 2.00 3.06 .61
(2000) 7 (exp.) passive ROM, stretching. prehension and grasp in
4 (ctrl.) Exp. ETNES (1 sec. ramp hemiplegic hand improved
up 5 sec. biphasic stim.
50 Hz, 1 sec. ramp down,

Chapter 10 • Upper Extremity Function and Management

stim.) Range 14-29mA
Wang, Chan, & N  32 postonset: Exp. Groups both short and Exp. Group, short duration 1.51 3.11 4.70 .60
Tsai (2000) 16 short duration long duration, FES 6hr/day showed improved sublux- .90 3.63 3.27 .41
16 long duration for six weeks ation, long duration no
(each randomly as- improvement
signed to exp. and
ctrl. (8,8)
Linn, Granat, & N  40 Exp. 4 weeks of electrical Less subluxation at end of .77 9.31 7.17 .36
Lees (1999) Exp. 20 stimulation treatment period
Ctrl. 20
Sum  111.89 23.12 3.0
(avg. .375)
d.   dw/ w 23.12/111.89  .21
95% Confidence Interval d. / 1.96 √1w .21  1.96* .09 .21  1.96* .09 low .04 to high .38
Success rate (Rosenthal, 1991) .50  avg. r/2  69% Treatment Group .50  avg.r/2  31% Control Group
From Hardy J, Salinas S, Blanchard SA, Aitken MJ: Meta-analysis examining the effectiveness of electrical stimulation in improving functional use of the upper limb in stroke
patients. Phys Occup Ther Geriatr 21(4):61-78, 2003.

245
246 Stroke Rehabilitation

Table 10-5
Characteristics of Each Study Used in the Meta-Analysis by Stewart and Colleagues168
MEAN MEAN TIME
TOTAL AGE: LESION POSTSTROKE TRAINING LENGTH TREATMENT
STUDY N YEARS LOCATION (MONTHS) DURATION OF STUDY PROTOCOL

Mudie and 8 69.4 Right  6 4.3 Time  N/A 8 weeks Single: bilateral tasks
Matyas Left  2 (40 sessions)
Mudie and 4 N/A N/A N/A Time  N/A 6 weeks Single: bilateral tasks
Matyas (30 sessions)
Whitall and 14 63.8 Right  7 66.9 Time  6 weeks Coupled: AUD 
colleagues Left  7 50 min (18 sessions) bilateral movements
Cauraugh and 25 63.7 Right  12 39.1 Time  4 days over Coupled: ANS 
Kim Left  13 90 min 2 weeks bilateral movements
Cauraugh and 26 66.4 Right  15 33.6 Time  4 days over Coupled: ANS 
Kim Left  11 90 min 2 weeks bilateral movements
Lewis and 6 58.7 Right  5 16.2 33 trials 4 weeks Single: bilateral tasks
Byblow Left  1 (20 sessions)
McCombe-Waller 20 N/A N/A 12 Time  6 weeks Coupled: AUD 
and colleagues 50 min (18 sessions) bilateral movements
Stinear and 9 62 Right  3 16.22 Time  4 weeks Single: bilateral
Byblow Left  6 60 min (20 sessions) training
Luft and 21 61.5 Right  14 50.3 (median) Time  6 weeks Coupled: AUD 
colleagues Left  7 50 min (18 sessions) bilateral movements
Cauraugh and 26 64.2 Right  15 50.1 Time  4 days over Coupled: ANS 
colleagues Left  6 90 min 2 weeks bilateral movements
Summers and 12 61.7 Right  4 62.2 50 trials 6 days Single: bilateral
colleagues Left  8 training

List is in chronological order.

Note. Single  only bilateral training; Coupled  two protocols simultaneously presented; AUD  auditory rhythmic cuing;
ANS  active neuromuscular stimulation.
From Stewart KC, Cauraugh JH, Summers JJ: Bilateral movement training and stroke rehabilitation: a systematic review and meta-analysis.
J Neurol Sci 244(1-2):89-95, 2006.

that interfere with upper extremity use (Fig. 10-10). Many the trunk and lower extremities were activated before
of the various problems associated with upper extremity (by 90 milliseconds) the anterior deltoid, the primary
function overlap and build on each other. The following muscle used to perform this motion. The subjects then
paragraphs review common impairments in stroke survi- were evaluated in the supine position while performing the
vors that may or may not interfere with integrating the same task. No lower extremity activation was detected in
upper extremity into daily occupations. this position (i.e., a different pattern of postural adjust-
ments). The following conclusions can be inferred from
Impaired Postural Control this study:
Improving proximal stability to enhance distal mobility 1. Postural adjustments are task-specific.
has long been a tenet of occupational therapy interven- 2. Training of the upper extremity in the supine posi-
tions. Postural adjustments stabilize supporting body parts tion does not automatically carry over to activities
while other parts (e.g., the upper extremities) are being performed while sitting or standing (if postural con-
moved.73 The following studies describe the effect of pos- trol is a limiting factor).
tural adjustments on arm function. 3. Having different disciplines treat one particular half
In the classic study by Belenkii, Gurfinkle, and Paltsev,16 of the body is detrimental to patients’ progress be-
unimpaired subjects who were evaluated while standing cause upper extremity function depends on postural
were asked to raise their arm to a horizontal position after support from the lower extremities and trunk.
they heard an external signal. Various EMG studies were Bouisset and Zattara29 replicated the previous study and
performed to trace the pattern of muscle activation. The demonstrated that an upward and forward trunk move-
results demonstrated that the postural muscle synergies of ment resulting from spine and/or lower limb extension
 Chapter 10 • Upper Extremity Function and Management 247

Box 10-6
Example of Bilateral Training Protocol
TASK PROTOCOL

UNILATERAL TREATMENT ACTIVITIES BILATERAL TREATMENT ACTIVITIES

1. Pushing and pulling activity (open/close drawer) 1. Pushing/pulling with both arms (open/close 2 identical
drawers)
Rhythmic task Rhythmic task
2. Wipe a table with a towel using the affected arm 2. Wipe a table with both arms using both arms symmetrically
Discrete task Discrete task
3. One arm cycling using BTE 181 3. Bilateral in-phase cycling using BTE
Rhythmic task Rhythmic task
4. Reaching and placing objects. Moving small and 4. Bilateral reaching and placing objects. Moving 2
medium-sized grocery items from kitchen counter to identical small or medium-sized grocery objects from
shelves using only affected arm countertop to shelf with both hands
Discrete task Discrete task
5. Shoulder and elbow coupling. Aim to target with 5. Bilateral shoulder and elbow coupling. Aim with both
affected hand in various areas of work space (using hands to parallel targets (using varying levels of arm
varying levels of arm support, postural sets, and positions support, postural sets, and positions in respect to
in relation to gravity). Includes a total of 4 subtasks gravity). Includes a total of 4 subtasks
Rhythmic task Rhythmic task
6. Elbow extension during horizontal reach 6. Bilateral elbow extension during horizontal reach
Rhythmic task Rhythmic task

From Stoykov ME, Lewis GN, Corcos DM: Comparison of bilateral and unilateral training for upper extremity hemiparesis in stroke,
Neurorehabil Repair 23(9):945-953, 2009.

precedes upper limb movement. This movement pattern is

familiar to therapists who cue their patients to focus on
spinal extension and the associated anterior pelvic tilt
while treating arm function.
Horak and colleagues88 compared postural adjustments
of subjects with and without hemiplegia during a variety
of tasks with different parameters. The hemiplegic sub-
jects demonstrated the same sequence of muscle activa-
tion as the subjects without hemiplegia, although activity
on the hemiparetic side was delayed. In addition, the
hemiparetic individuals were not capable of making rapid
movements with the unimpaired arm. This was hypothe-
sized to result from a delay in the anticipatory activity of
the contralateral hemiplegic muscles. This study dispels
the myth of “good” and “bad” sides after a stroke, espe-
cially when postural control is compromised.
In their study of postural adjustments during arm
movements, Cordo and Nashner52 were able to demon-
strate that when subjects’ postural stability was increased
(e.g., by outside shoulder support or placing a finger
lightly on a support rail), postural activity was reduced,
Figure 10-11 Mirror training. Set-up for mirror therapy: The and voluntary movement enhanced. This concept is cru-
patient’s affected arm is hidden behind the mirror. While he is cial to understand when treating upper extremity dys-
moving his unaffected arm, he is watching its mirror image as if function. As support is increased, the postural demands
it were the affected one. of the task are decreased and vice versa. The therapist
248 Stroke Rehabilitation

can control the patient’s level of postural stability by “synergy patterns.” Bourbonnais and colleagues31 demon-
manipulating the following treatment environment fac- strated that the patterns of activity in the elbow flexor
tors: positioning—supine to sitting to standing; type of muscles were not consistent with established synergistic
support surface—stationary or unstable surfaces; posi- patterns. Weakness of the upper extremity musculature
tioning of objects used in activities—near or far, base of plays a major role in upper extremity dysfunction, most
support, and amount of external stability. likely more than the positive symptoms after stroke.
Cordo and Nashner52 also made a critical distinction Muscle weakness is reflected by the inability of patients to
between associated postural adjustments that precede vol- generate normal levels of muscle force.30 Stroke survivors
untary movements (e.g., reaching) and automatic postural who have written about their experiences focus on the
adjustments that follow external perturbations (e.g., stand- difficulty in force production. Brodal35 reflected on his
ing on a bus that stops at a light or being moved by the own stroke: “It was a striking and repeatedly made obser-
therapist). Training in one type of adjustment cannot be vation that the force needed to make a severely paretic
assumed to carry over into other types of adjustments. muscle contract is considerable. . . . Subjectively this is
Woollacott, Bonnet, and Yabe194 demonstrated that their experienced as a kind of mental force, a power of will. In
subjects’ postural activity varied depending on the task be- the case of a muscle just capable of being actively moved
ing performed (pushing, pulling) and whether they received the mental effort needed was very great.”
information in advance regarding the goal of the task. Bourbonnais and Vanden Noven30 reviewed the physi-
Massion119 points out that voluntary movements are ological changes in the nervous system that contribute to
“accompanied by postural adjustments which show three muscle weakness in patients with hemiparesis. They sum-
main characteristics: (1) they are ‘anticipatory’ with re- marized specific changes at the motor neuron and muscle
spect to movement and minimize the perturbations of levels that decrease a patient’s ability to produce force.
posture and equilibrium due to the movement, (2) they Box 10-7 summarizes these changes.
are adaptable to the conditions in which the movement Bohannon and colleagues21 found that static strength
is executed, and (3) they are influenced by the instruc- deficits of the shoulder medial rotator and elbow flexor
tions given to the subject concerning the task to be muscles did not correlate with antagonist muscle spastic-
performed.” ity. They concluded that therapists might determine the
Postural control disorders in stroke patients have been capacity for force production for an agonist muscle based
well-documented. Lee109 emphasized the detrimental im- on its own tone rather than that of its antagonist.
pact that postural dysfunction has on free arm movements Gowland and colleagues79 studied agonist and antago-
and therefore ADL. Although a variety of muscles can nist activity during upper limb movements in stroke
serve as postural stabilizers, postural control of the trunk patients and concluded that treatment should be aimed at
is critical for upper extremity function.19 See Chapter 7. improving motor neuron recruitment rather than reduc-
Occupational therapists must use their activity analysis ing antagonist activity. In their study, patients who could
skills to help patients develop the missing trunk control not perform select upper extremity tasks had EMG values
components. (See Table 7-9 for examples of the effects of significantly and consistently lower than those of patients
object positioning on trunk control and weight shifting who were successful at the task.
during reaching activities.) Functional mobility patterns Indeed recent empirical evidence highlights the rela-
requiring increased trunk control (e.g., scooting) should tionship between weakness and loss of function. Findings
be incorporated into treatment plans for upper extremity include:
function. See Chapter 14. ■ In a study of 93 community dwelling stroke sur-
Postural control evaluations should be performed vivors, Harris and Eng85 concluded that paretic
within the context of upper extremity tasks such as reach-
ing or performing ADL and IADL. Evaluating postural
control separately does not provide the therapist with suf-
ficient information for intervention. (See Chapters 7 and Box 10-7
8 for more information related to postural control.) Physiological Changes Contributing
to Weakness
Weakness
■ Motor neuron changes: loss of agonist motor units,
Until relatively recently, the impact of weakness (a nega-
changes in recruitment order of motor units, and
tive symptom) on stroke patients’ functional status has changes in the firing rates of motor units
long been ignored. The motor control deficits in patients ■ Nerve changes: changes in peripheral nerve conduction
previously were attributed exclusively to spasticity, which ■ Muscle changes: changes in the morphological and
resulted in treatment focused on inhibiting the spasticity. contractile properties of motor units and in the me-
Many therapists considered upper extremity muscle tests chanical properties of muscles
for strength difficult to interpret because of common
 Chapter 10 • Upper Extremity Function and Management 249

upper limb strength had the strongest relationship 2/5 to the 4/5 and 5/5 ranges), improved hand func-
with variables of activity and best explained upper tion, and improved grip strength scores. Identifying
limb performance in ADL. Grip strength was also the underlying problems (in this case, weakness and
a factor. an inability to control excess degrees of freedom) is
■ A longitudinal study of 27 stroke survivors found of utmost importance when planning treatment
that weakness was the main and only contributor to strategies.
activity limitations as opposed to spasticity or con- ■ Bütefisch and colleagues39 examined the effect of a
tracture.6 standardized training on movements of the affected
■ Chae and colleagues46 described the relationship hand in 27 hemiparetic patients using a multiple
between poststroke upper limb muscle weakness baseline approach. The training consisted of re-
and cocontraction, and clinical measures of upper petitive hand and finger flexions and extensions
limb motor impairment and physical disability. The against various loads and was carried out twice daily
authors measured EMG activity of the paretic and during 15-minute periods. Grip strength, peak
nonparetic wrist flexors and extensors of 26 chronic force of isometric hand extensions, peak accelera-
stroke survivors. Upper limb motor impairment and tion of isotonic hand extensions, and contraction
physical disability were assessed with the Fugl- velocities as indicators of motor performance sig-
Meyer motor assessment and the arm motor ability nificantly improved during the training period.
test. They concluded that muscle weakness and de- Additionally, 24 out of 27 patients improved on the
gree of cocontraction correlate significantly with Rivermead Motor Assessment. The authors further
motor impairment and physical disability in upper challenged traditional therapy (the Bobath con-
limb hemiplegia. cept) aimed at reducing enhanced muscle tone
■ Mercier and Bourbonnais123 compared the relative without reinforcing the activity in centrally paretic
strength of different muscle groups of the paretic up- hand. In the study, patients undergoing this treat-
per limb and assess the relationship with motor per- ment approach alone did not experience a signifi-
formance. The maximal active torques of five muscle cant improvement in the motor capacity of the
groups were measured in both upper limbs. Upper hand. The authors emphasized the importance of
limb function was assessed using the Box and Block frequent movement repetition for the motor reha-
Test, the Finger-to-Nose Test, the Fugl-Meyer Test, bilitation of the centrally paretic hand and chal-
and the TEMPA. They concluded that “the relative lenge conventional therapeutic strategies that focus
forces for shoulder flexion and handgrip are the best on spasticity reduction instead of early initiation of
predictors of the upper limb function.” Additionally, active movements.
they concluded that the results “do not confirm clas- ■ Sterr and Freivogel166 “assessed whether intensive
sical clinical teaching regarding the distribution of training increases spasticity and leads to the develop-
weakness following stroke (e.g., proximal to distal ment of ‘pathologic movement patterns,’ a concern
gradient; extensors more affected than flexors) but often raised by Bobath-trained therapists. The au-
support the hypothesis that strength is related to the thors used a baseline-control repeated-measures test
function of the paretic upper limb.” to study 29 patients with chronic upper limb hemi-
From a treatment planning perspective, integrating paresis who received daily shaping training. Their
strengthening interventions is imperative in efforts to re- results suggest that training has no adverse effects on
gain limb function. Bohannon and Smith23 analyzed muscle tone and movement quality.”2
strength deficits in stroke patients and verified that muscle ■ A systematic review of multiple studies concluded
strength improves in stroke patients with hemiplegia who that “Strengthening interventions increase strength,
are undergoing rehabilitation. Empirical evidence sup- improve activity, and do not increase spasticity.
ports the use of strengthening interventions in this popu- These findings suggest that strengthening programs
lation without deleterious effects: should be part of rehabilitation after stroke.”
■ Flinn70 presented a case study of a young female with ■ In their strength training study after stroke, Badics
left-sided hemiplegia. Her treatment program fo- and colleagues10 concluded that “The extent of
cused on participating in graded functional tasks that strength gain was positively correlated with the in-
systematically increased the motor demands on the tensity and the number of exercising units. Muscle
more affected upper extremity. Her task-oriented tone, which was abnormally high at baseline, did not
treatment program was augmented by resistive exer- further increase in any one case. The results of this
cises using elastic tubing. Substantial results after six study showed that targeted strength training signifi-
months of therapy included improved level of occu- cantly increased muscle power in patients with mus-
pational performance in ADL and IADL, improved cle weakness of central origin without any negative
manual muscle test scores (which increased from effects on spasticity.”
250 Stroke Rehabilitation

■ In their review of weakness and strengthening post

stroke, Patten and colleagues141 identified nine trials Spasticity
of progressive resistive training after stroke. They Spasticity, which is a positive symptom according to
concluded “All of these studies reported positive Jackson classification system, has been a subject of debate
adaptations to strength training . . . With one excep- by various authors. Although an abundance of research
tion, all studies strongly suggest positive effects of has been done on spasticity, disagreements still exist about
strength training on various indices of functional its definition, physiological basis, treatment, and evalua-
outcome . . .” They further concluded that “while tion. Glenn and Whyte75 define spasticity as “a motor
insufficient data exist to draw firm conclusions at disorder with persistent increase in the involuntary reflex
this time, functional effects of strengthening appear activity of a muscle in response to stretch. Four specific
persistent. Four of the available studies evaluated phenomena may be variably observed in the constellation
effects of strength training on spasticity and found of spasticity: hypertonia (frequently velocity dependent
no deleterious effects.” and demonstrating the clasp-knife phenomenon), hyper-
The debate about which type of muscle contraction active (phasic) deep tendon reflexes, clonus, and spread of
(eccentric, concentric, or isometric) is the most effec- reflex responses beyond the muscle stimulated.” In addi-
tive in strengthening patients has been long-standing. tion, Babinski sign is characteristic, and hyperactive tonic
Muscle groups need to contract in a variety of ways to neck or vestibular reflexes may be present.116
complete functional tasks successfully. For example, Several different phenomena commonly observed in
when a person reaches for a can of soup on a high stroke rehabilitation including hyperactive stretch re-
shelf, the shoulder musculature must contract (con- flexes, increased resistance to passive movement, pos-
centrically) to bring the hand to the level of the shelf, turing of the extremities, excessive cocontraction, and
maintain the contraction (isometrically) to locate the stereotypical movement synergies are clumped together
correct item, and control the weight of the arm and in the category of spasticity. Spasticity has become a
item in gravity (eccentrically) as the can is placed with catchall term for a variety of problems. Rather than be-
control on the countertop. ing a specific symptom, spasticity is related to a variety
In a study of dynamical muscle strength training in of neural and nonneural factors. Therefore, spasticity
stroke patients, Engardt and colleagues65 found that cannot be treated uniformly by surgical, physical, or
eccentric contractions were more effective than con- pharmacological procedures. Spastic paresis is a com-
centric contractions. Twenty patients with hemiparesis monly used term that implies a cause-and-effect rela-
resulting from strokes participated in activities that tionship (i.e., a cause-and-effect relationship between
elicited concentric or eccentric contractions. After the positive and negative symptoms). This belief has been
treatment, significant improvements resulted in the challenged recently.
relative strength of paretic muscles during eccentric Preston and Hecht147 provide further information re-
and concentric actions in the group that was trained garding the clinical presentation of spasticity to include
solely with eccentric contractions (i.e., eccentric train- the following:
ing increased the strength of both types of contrac- ■ Patients having difficulty initiating rapid alternating
tions); this was not true for the group that only received movements
concentric contraction training. Therefore, the authors ■ Abnormally timed EMG activation of the agonist
determined eccentric contraction training to be more and antagonist
advantageous and efficient (Box 10-8). See Table 10-1 ■ Fluctuation of spasticity as a result of a change in
for a review of evidence-based interventions related to position
strengthening. ■ Usual patterns include upper extremity flexion and
lower extremity extension
Bobath18 stated that there is “An intimate relationship
between spasticity and movement . . . spasticity must be
Box 10-8 held responsible for much of the patient’s motor deficit.”
Task Parameters That Can Be Manipulated Treatment techniques were based on “helping the patient
to Increase Strength gain control over the released patterns of spasticity by
their inhibition.” Patients were treated under the assump-
■ Gravity: eliminated, assisted, against
tion that “Weakness of muscles may not be real, but rela-
■ Weight of objects used during tasks
■
tive to the opposition by spastic antagonists.” A variety of
Amount of external support (e.g., slide hand across
table versus reach into space) studies have been published that refute these assumptions.
■ External resistance (e.g., weights, elastic bands, See Chapter 6.
resistance from therapist’s hands) Sahrmann and Norton159 studied normal subjects
and subjects with upper motor neuron symptoms. The
 Chapter 10 • Upper Extremity Function and Management 251

movement pattern studied was alternating flexion and Box 10-9

extension of the elbow. The analysis of their EMG find- The Ashworth Scales
ings showed that the primary cause of impaired move-
ment was not antagonist stretch reflexes but was limited ASHWORTH SCALE*
and prolonged agonist contraction recruitment and de- 1 Normal tone
layed cessation of agonist contractions after movement 2 Slight hypertonus; noticeable catch when limb is
had stopped. Rather than focusing treatment on inhibit- moved
ing spasticity, therapists should train patients to perform 3 More significant hypertonus, but affected limb still
alternating movement patterns (e.g., hand-to-mouth moves easily
patterns) efficiently. 4 Moderate hypertonus; difficulty with passive movement
Fellows, Kaus, and Thilmann67 studied the importance 5 Severe hypertonus; rigid limb
of hyperreflexia and paresis on voluntary arm movements MODIFIED ASHWORTH SCALE†
in normal subjects and subjects with spasticity resulting 0 No increase in muscle tone
from a unilateral ischemic cerebral lesion. The subjects 1 Slight increase in muscle tone, manifested by a catch
with spasticity showed a lower maximum movement and release or by minimal resistance at the end of the
velocity; the more marked the paresis, the greater the re- range of motion when the affected part is moved in
duction in maximum velocity. No relationship was found flexion or extension
between the degree of voluntary movement impairment 1 Slight increase in muscle tone, manifested by a catch,
and level of passive muscle hypertonia in the antagonist. followed by minimal resistance throughout the re-
The conclusion was that agonist muscle paresis, rather mainder (less than half) of range of motion
than antagonist muscle hypertonia, had the most signifi- 2 More significant increase in muscle tone throughout
cant effect on impaired voluntary movement. most of the range of motion but affected part is
moved easily.
In their study on overcoming limited elbow movement
3 Considerable increase in muscle tone; difficult passive
in the presence of antagonist hyperactivity, Wolf and movement
colleagues190 concluded that functional elbow improve- 4 Affected part in rigid flexion or extension
ments could be made without first training the patient
specifically to inhibit hyperactivity.
*From Ashworth B: Carisoprodol in multiple sclerosis. Practitioner
Landau108 performed pharmacological interventions 192:540, 1964.
that effectively abolished the hyperactive stretch reflexes †From Bohannon RW, Smith MB: Interrater reliability of a
in his patients. This intervention did not result in a cor- modified Ashworth scale of muscle spasticity. Phys Ther
responding improvement in motor behavior. 67(2):206-207, 1987.
Ada, O’Dwyer, and O’Neill6 examined the relation-
ship between the motor impairments (spasticity and
weakness) and their impact on physical activity. They
specifically aimed to study the contribution of weakness
and spasticity to contracture, and the contribution of all The response of a spastic muscle to stretch has been
three impairments to limitations in physical activity dur- argued not to be the same during passive and active move-
ing the first 12 months after stroke. The authors followed ment. In addition, spasticity is a multidimensional prob-
27 stroke survivors for one year. They found that “the lem that incorporates neural and nonneural components
major independent contributors to contracture were (e.g., altered soft-tissue compliance). Therefore, some
spasticity for the first four months after stroke (p  authors have questioned the usefulness of test measures
0.0001-0.10) and weakness thereafter (p  0.01-0.05). such as the Ashworth Scale and are investigating a more
However, the major and only independent contributor to comprehensive evaluation of spasticity.
limitations in physical activity throughout the year was Although the research on spasticity does not support
weakness (p  0.0001-0.05).” “For the first time, from a focusing treatment on suppressing stretch reflexes, it does
longitudinal study, the findings show that spasticity can support treatment focusing on preventing secondary
cause contracture after stroke, consistent with the pre- structural muscle changes in patients with spasticity.
vailing clinical view. However, weakness is the main con- Hufschmidt and Mauritz’s study90 suggested that spas-
tributor to activity limitations.” tic contracture is the result of degenerative changes (e.g.,
In the traditional evaluation of spasticity, the therapist atrophy and fibrosis) and changes of the passive and con-
moves the patient’s limb quickly in a direction opposite to tractile muscle properties.
the pull of the muscle group being tested, and the exam- In their study on spastic and rigid muscles, Dietz,
iner feels for a resistance to the movement. The gold Quintern, and Berger61 concluded that the actual muscle
standard for rating resistance is the Ashworth Scale9 or fibers undergo changes, which explains the increased
the Modified Ashworth Scale24 (Box 10-9). muscle tone in spastic patients.
252 Stroke Rehabilitation

For treating patients with spasticity, Perry142 em- Box 10-10

phasized early mobilization and assistance with devel- Treatment of Spasticity
oping evolving motor control into effective function.
These two interventions result in minimal contrac- ■ Prevent pain syndromes.
tures and prevent improper use of patients’ available ■ Guide appropriate use of available motor control.
■ Maintain soft-tissue length.
control mechanisms. Hummelsheim and colleagues91
■ Avoid using excessive effort during movement.
studied the results of sustained stretch in spastic pa-
■ Encourage slow and controlled movements.
tients. They found that sustained muscle stretch of
■ Teach specific functional synergies during tasks.
approximately 10 minutes led to significant reduction ■ Avoid use of repetitive compensatory movement
in the spastic hypertonus in the elbow, hand, and fin- patterns.
ger flexors. They hypothesized that this benefit is due ■ Keep spastic muscles on stretch via positioning or
to stretch receptor fatigue or adaptation to the new orthotics to prevent contracture.
extended position. ■ Teach the patient or caretaker specific stretching
Little and Massagli116 also emphasized using a stretch- techniques targeted at the spastic muscles.
ing program incorporating pain prevention and patient ■ Use activities to enhance the agonist/antagonist
education focusing on the adverse effects of spasticity relationship.
■ Refer when appropriate for pharmacological or
(contracture), use of slow movements, and importance of
daily stretching. surgical interventions.147
In addition to the mentioned techniques, specific mo-
dalities and their physiological bases have been described
in the literature and include local cooling, vibration
therapy, and electrical stimulation. ing hand use in patients with relatively preserved distal
Perry142 summarized the effective rehabilitation of a motricity and in increasing comfort in patients with
patient with spasticity by using five categories: contrac- severe global disorders. Similarly, Bakheit and col-
ture minimization, realistic planning, muscle strength leagues11 completed a randomized controlled trial to
preservation and restoration, enhancement of returning assess the efficacy of Botox in decreasing spasticity in
control, and substitution for permanent functional loss. stroke survivors. They concluded that treatment with
Carr, Shepherd, and Ada43 summarized their treatment Botox reduced muscle tone in patients with poststroke
approach based on the assumption that clinical spasticity upper limb spasticity.
is a manifestation of length-associated muscle changes While the positive effect at the impairment level (i.e.,
and disordered motor control: “The development of spas- reduction of spasticity) has been well-documented, the
ticity will be less severe if soft-tissue length can be main- effect on functional limitations is not as clear.164,183 As
tained and if motor training emphasizes elimination of spasticity increases, the risk for soft-tissue shortening is
unnecessary muscle force and training muscle synergies as heightened, which in fact may lead to a vicious circle
part of specific actions.” of problems such as spasticity, soft-tissue shortening,
Again, the point must be emphasized that many of overrecruitment of shortened muscles, and increased
the observed phenomena that occur during treatment stretch reflexes. Secondary problems that may occur if
should not be attributed automatically to spasticity and the spasticity is not managed in a therapy program in-
require more in-depth evaluations and treatment plans clude the following:
(Box 10-10; Table 10-6). ■ Deformity of the limbs, specifically the distal upper
Preston and Hecht147 have comprehensively reviewed limb (elbow to digits)
the literature related to spasticity management, includ- ■ Impaired upright function caused by soft-tissue con-
ing topics such as oral and intrathecal medications, tracture (e.g., plantar flexion contractures resulting
nerve blocks, orthopedic surgery, and neurosurgical in a loss of the ankle strategies required to maintain
interventions. upright stance)
Nerve blocks are being used increasingly as an adjunct ■ Tissue maceration of the palm
therapy in the rehabilitation process. Preston and Hecht147 ■ Pain syndromes resulting from loss of normal joint
differentiated between short-term blocks such as procaine kinematics. These syndromes are usually related to
and bupivacaine used to diagnose and assist in the evalua- soft-tissue contracture blocking full joint excursion.
tion process and long-term blocks such as phenol and A typical example of this issue is the loss of full pas-
botulinum toxin type A (Botox). sive external rotation of the glenohumeral joint. At-
Rousseaux, Kozlowski, and Froger154 assessed the ef- tempts at forced abduction in these cases results in a
ficacy of Botox treatment on disability, especially in painful impingement syndrome of the tissues in the
manual activities, and attempted to identify predictive subacromial space.
factors of improvement in 20 patients with stroke. They ■ Impaired ability to manage basic ADL tasks, specifi-
concluded that botulinum toxin A is efficient in improv- cally upper extremity dressing and bathing of the
 Chapter 10 • Upper Extremity Function and Management 253

Table 10-6
Suggested Interventions for Problems Commonly Thought to Be Caused by Spasticity*
OBSERVATIONS DURING TREATMENT SUGGESTED INTERVENTIONS

Posturing of upper extremity—usually Upper extremity posturing indicates that the task is difficult for the patient.
consisting of retraction, posterior trunk Treatment should include increasing the efficiency of task performance by
rotation, internal rotation, elbow building in trunk and lower extremity control, incorporating the upper ex-
flexion, and wrist and digit flexion— tremity into the task (e.g., by bilateral ironing or using arm as postural sup-
during difficult tasks (e.g., gait, port), and teaching the patient to relax the upper extremity after difficult tasks.
transfers, and dressing)
Stereotypical flexor patterns when Evaluate components of movement pattern and identify factors that limit
attempting to move arm against gravity efficient movement (e.g., weakness, postural dysfunction, malalignment,
and inappropriate task choice). Provide activities that elicit the missing
components of movement pattern.
Flexion posture when resting Implement a contracture prevention program. Provide adequate positioning
and teach safe, self range-of-motion exercises.
“Catch” felt during quick-stretch Do not assume that this phenomenon is resulting in observed movement
evaluation of upper extremity dysfunction. Instead, interpret it as a red flag warning that soft-tissue
shortening may be present or developing.

*This table represents a variety of functional limitations and problems traditionally considered to be the direct result of spasticity.
Although sometimes interconnected, these problems stem from different sources and must be treated accordingly.

affected hand and axilla when flexor posturing is out that contracture is associated with loss of elasticity
present and fixed shortening of involved tissues. Contracture may
■ Loss of reciprocal arm swing during gait activities occur in a variety of soft-tissues including the following:
■ Risk for falls because of postural malalignment78 skin, subcutaneous tissue, muscle, tendon, ligament, joint
In summary, although reducing spasticity does not appear capsule, vessels, and nerves.
to result in automatic improvements related to function, Halar and Bell82 categorized contracture as arthrogenic
therapists must manage spasticity to prevent soft-tissue (resulting from cartilage damage, joint incongruency, or
contracture, prevent deformity, and maintain a flexible capsular fibrosis), soft-tissue related (skin, tendons, liga-
and mobile arm. ments, subcutaneous tissue), and myogenic (shortening of
the muscle by intrinsic or extrinsic factors). The therapist
Loss of Soft-Tissue Elasticity (Contractures must consider the difference between myogenic and joint
and Deformities) contracture, especially if the muscle spans two or more
Contracture in stroke patients results from immobiliza- joints (e.g., the wrist and hand). The therapist can differ-
tion and may be attributed to spasticity (particularly dur- entiate contractures by flexing the proximal joint and not-
ing the first four months after stroke) and weakness there- ing the resulting position of the distal joints. Joint con-
after,6 improper positioning, postural malalignment, a tracture is not affected by changes in proximal joint
lack of variation in limb postures (e.g., prolonged sling position. See Chapter 13.
use), or a combination of various factors. The formation Booth27 reviewed the physiological and biochemical
of contractures indicates a poor prognosis for limb func- effects of immobilization on muscle. His findings indicate
tion. Perry142 discussed the vicious circle of contracture that muscle strength rapidly declines during limb immo-
and spasticity: “contractures stiffen tissues, immobility bilization because of a decrease in muscle size; muscle fa-
creates contractures. Spasticity preserves the contracture tigability increases rapidly after immobilization. His ob-
by excluding the intramuscular fibrous tissues from the servations also indicate that muscle atrophy in immobilized
stretching force.” limbs begins rapidly, and a decrease in muscle size is
Botte, Nickel, and Akeson28 have reviewed the litera- greatest in the early phases of immobilization.
ture correlating spasticity and contracture. As the stroke
patient progresses to a state of spasticity, the increased Passive Range of Motion. Soft-tissue and joint mobiliza-
activity of the spastic muscles may result in characteristic tion are the treatments of choice for preventing contrac-
posturing of the limb, resulting in increased stiffness of ture. The benefits of mobilization include maintenance of
the soft-tissue surrounding the joint and the eventual for- joint lubrication,28 prevention of secondary orthopedic
mation of fixed contracture. The authors further pointed problems (impingements), maintenance of soft-tissue
254 Stroke Rehabilitation

length, and possible reduction of spasticity by acting on the therapist should stabilize the proximal body part well.
the nonneural components of spasticity. The therapist may distract the joint slightly during the
Contracture is prevented by deliberate and frequent stretch to prevent soft-tissue impingement. The therapist
limb movement, with active movement being preferred must monitor scapula position during passive ROM ac-
over passive when possible. Perry142 pointed out that it is tivities. If necessary, the therapist should support the
essential to move the patient through complete ROM and scapula in a position of protraction and upward rotation.
not just the middle ranges. Therapists must determine In addition, the therapist must support the humerus in an
what a full ROM is for each patient and must consider external rotation position. The elbow crease should be
age-related factors. Determining the full ROM on the less facing up (not medially toward the trunk) to ensure
affected side may be helpful. A joint that moves or is proper alignment (Fig. 10-12).
moved through its full ROM several times daily develops
almost no deformities. Although the therapist should Positioning. Positioning is another effective means of
maintain the patient’s ability to participate in all ranges of maintaining soft-tissue length and can be used to promote
trunk and upper extremity activities, the therapist should low-load, prolonged stretch. Therapists must address
pay particular attention to the following ranges: positioning needs of patients while they are in bed or
■ The mobility of the scapula on the thoracic wall with wheelchairs/armchairs (see Chapter 26) and anytime they
emphasis on protraction and upward rotation should are in a recumbent position. Effective positioning encour-
be maintained because this range is critical in the ages proper joint alignment, variations in joint position,
prevention of soft-tissue impingement in the sub- comfort, and the maintenance of stretch in areas at risk
acromial space during overhead movements of the for contracture. Common areas of concern during patient
arm and in preparation for forward reach patterns. positioning include head and neck alignment, trunk align-
Overhead ranges should not be attempted unless the ment, glenohumeral joint alignment, scapula alignment,
scapula is freely gliding in upward rotation. maintenance of abduction, external rotation, elbow exten-
■ Maintaining external (lateral) rotation of the gleno- sion, and maintenance of long flexor length.
humeral joint allows abduction of the arm as the A thorough literature review comparing authors’ strat-
humerus rotates laterally to permit the greater tu- egies on bed positioning has been published.41 This re-
berosity of the humerus to clear the acromial pro- view found no consensus on some issues and multiple
cess. Bohannon and colleagues,22 Ikai and col- discrepancies on strategies. Many of the positioning pro-
leagues,93 and Zorowitz and colleagues203 concluded tocols are based on the principle of inhibiting primitive
that loss of external rotation ROM was the factor reflexes, a topic of considerable debate.
most significantly correlated to shoulder pain. Patients are engaged in therapy only a portion of the
■ Elbow extension is important because the majority of day. Studies have shown that patients in rehabilitation
stroke patients favor elbow flexion as a rest posture.
■ The therapists also should maintain wrist extension
with concurrent radial deviation. During wrist ROM
exercises, therapists must realize that the range of
wrist deviation is at a maximum when the wrist is
slightly flexed and a minimum when the wrist is fully
flexed. Wrist extension is at a maximum during neutral
deviation and a minimum during ulnar deviation.100
■ Composite flexion of the digits leads to collateral
ligament elongation. Therapists must maintain this
length to prevent deformity and prepare the hand
for return of motor function.
■ Composite extension of the wrist and digits results
in long flexor elongation.
■ Digits ranged in intrinsic plus (metacarpophalangeal
flexion and interphalangeal extension) and intrinsic
minus (metacarpophalangeal extension and inter-
phalangeal flexion).
Halar and Bell82 recommended active ROM and passive Figure 10-12 Passive range of motion activities with strict at-
ROM combined with a terminal stretch at least twice per tention to the biomechanical alignment of the scapulothoracic
day if contracture is beginning to develop. Therapists and glenohumeral joints. Therapist’s right hand assists with
must use low-load prolonged stretch if a contracture has mobilization (upward rotation) of the scapula, while left arm
developed (see Chapter 13). During the terminal stretch, keeps humerus externally rotated.
 Chapter 10 • Upper Extremity Function and Management 255

units spend almost half of their days engaged in passive not use general, generic strategies for bed positioning;
pursuits including sitting unoccupied and lying in bed.15 instead, they should evaluate each patient’s positioning
Therefore, patients at risk for developing contracture needs individually.
because of limb immobilization are good candidates for
participation in a positioning program in addition to Patient Management of the Extremity. Strategies to
therapy. teach patients safe ROM activities they can perform
The positioning suggestions in Box 10-11 are based on themselves need to be initiated as soon as patients are
Carr and Kenney’s review41 of the positioning literature medically stable. Although the clasped-hand position fol-
and highlights the consensus of reviewed authors. lowed by overhead movements of both extremities has
Although the positioning suggestions in Box 10-11 been advocated by some authors, this position may not be
represent the consensus of many authors, major areas of the most effective, especially for trauma prevention. This
intervention are missing, which result in the controver- movement pattern does not account for factors such as
sies surrounding this area of intervention. For example, scapula-humeral rhythm (especially if weakness, malalign-
glenohumeral joint support remains controversial. Al- ment, or tightness around the scapula exists), overzealous
though most authors agree that the scapula should be patients who do not or cannot respect their pain, or criti-
protracted with a pillow, no consensus exists about sup- cal shoulder biomechanics. Many patients observed per-
port of the humerus. If only the scapula is protracted forming this type of ROM activity have their trunk hyper-
with a pillow, the humerus takes on a position of relative extended, scapula retracted, and humerus internally
extension. Therefore, only support of both the scapula rotated. This type of alignment does not correspond with
and humerus achieves the original goal of proper joint an ROM pattern that emphasizes forward flexion of the
alignment (Fig. 10-13). humerus; it promotes proximal patterns (e.g., retraction)
At this point, no definitive studies support one type of that should be discouraged (Fig. 10-14). Recommended
positioning more than another with few exceptions. Ada techniques for patients performing ROM activities by
and colleagues5 determined that positioning patients in themselves safely include the following:
supine with the affected shoulder abducted to 45-degrees 1. “Towel on table”: The patient is seated at a table
and the elbow flexed to 90-degrees and placed in maxi- with both arms on top of a towel. The less affected
mum comfortable external rotation, with towels or pil- arm guides the towel around the table, with the
lows to support the forearm 30 minutes per day prevented majority of movement occurring in the trunk and
contracture of the internal rotators. Occupational thera- from hip flexion. The patient’s goal is to “polish
pists must decide what their intervention goals are and the table” while holding positions at the end of
critically analyze their effectiveness. Therapists should desired ROM. The farther the patient’s chair is

Box 10-11
Suggested Bed Positioning
POSITIONING OF PATIENT
On unaffected side ■ Head/neck: neutral and symmetrical
■ Affected upper limb: protracted and forward on pillow-wrist
neutral, fingers extended, and thumb abducted
■ Trunk: aligned
■ Affected lower limb: hip forward, flexed, and supported; knee
forward, flexed, and supported
On affected side ■ Head/neck: neutral and symmetrical
■ Affected upper limb: protracted forward with elbow ex-
tended, hand supinated, wrist neutral, fingers extended, and
thumb abducted
■ Trunk: straight and aligned
■ Affected lower limb: knee flexed
■ Unaffected lower limb: knee flexed and supported by pillows
In supine ■ Head/neck: slight flexion
■ Affected upper limb: protracted and slightly abducted with
external rotation with wrist neutral and fingers extended
■ Trunk: straight and aligned
■ Affected lower limb: hip forward on pillow; nothing against
soles of the feet
256 Stroke Rehabilitation

A B
Figure 10-13 A, Bed positioning with only the scapula supported. The humerus takes on a
position of relative extension, with the head of the humerus migrating anteriorly. B, Proper
support of scapula and humerus ensures proper biomechanical alignment of shoulder joint.

Figure 10-15 “Towel on table.” Therapist is training patient

to perform safe self range-of-motion activity. As the patient
pushes the towel toward bottle, range of motion is gained in
Figure 10-14 Because of multiple biomechanical concerns (e.g., humeral flexion, scapular protraction, and elbow extension
impingement), self-overhead range of motion is discouraged. (which are ranges required for functional reach). Much of the
range is gained by hip and trunk flexion.

positioned from the table, the greater the ROM. and places it into positions of horizontal abduction
This technique not only enhances the range of the and adduction. Increased horizontal adduction on
glenohumeral and elbow joint but also encourages the more affected side encourages scapula protrac-
scapula protraction and weight-shifting. Excessive tion. This technique also encourages trunk rotation
effort is minimized because the towel assists the (Fig. 10-16).
movement (Fig. 10-15). 3. While seated or standing, the patient reaches down
2. “Rock the baby”: The patient’s less affected arm to the floor and allows both arms to dangle. This
cradles the more affected arm, lifts it to 90 degrees, position encourages extension of the elbow, wrist,
 Chapter 10 • Upper Extremity Function and Management 257

and digits and forward flexion of the humerus with

scapula protraction. The activity is an especially
useful technique for patients after they have per-
formed an excessively difficult activity (e.g., gait,
transfer, or dressing) that results in stereotypical
arm posturing (Fig. 10-17).
4. While seated or standing, the patient places the
more affected extremity onto a table or counter so
that the forearm is bearing the weight. With the
extremity in this position, the patient turns
the trunk away from the supported extremity. As
the trunk turns farther away and is enhanced
by the posterior reach of the less affected arm, the
external rotation of the more affected shoulder
increases (Fig. 10-18).
A 5. Davis57 has advocated rolling over the protracted
scapula (from supine to side lying) several times to
mobilize the scapula.
6. If the scapula of a patient is mobile and stays mobile,
the range of abduction and external rotation may be
increased by having the patient lie supine, placing
the hands behind the head, and allowing the elbows
to fall toward the bed (Fig. 10-19). This is a common
resting position for an individual who has unim-
paired upper extremity function. This technique
should be used judiciously and only for patients who
move slowly, respect pain, and have a mobile scapula.
Therapists may use the five techniques outlined pre-
viously for almost all patients because they inher-
ently follow biomechanical principles.
7. Avoid the use of overhead pulleys.104

C
Figure 10-16 “Rock the baby.” The patient lifts upper extrem- Figure 10-17 Patient performs self range-of-motion activity
ity to chest level (A) and abducts (B) and adducts (C) horizon- by reaching to floor. This pattern is especially effective after a
tally, allowing trunk rotation. difficult task that results in stereotypical posturing.
258 Stroke Rehabilitation

sides of the joints, and focus on activities that encourage

ROMs that are commonly decreased in stroke patients
(e.g., external rotation, forward flexion, abduction, and
protraction) should be incorporated into a comprehen-
sive upper extremity program. (See Chapter 13 for other
adjunct treatments to prevent or correct soft-tissue
shortening.)

SHOULDER-HAND SYNDROME/COMPLEX
REGIONAL PAIN SYNDROME TYPE I
Shoulder-hand syndrome (SHS) is classified as a reflex
sympathetic dystrophy disorder or complex regional pain
syndrome type I. The painful lesion that precipitates SHS
is a proximal trauma such as a shoulder, neck, or rib cage
injury or a visceral source such as stroke. The syndrome
begins with severe pain and progresses to stiffness in the
shoulder and pain throughout the extremity. Other symp-
Figure 10-18 External rotation of the left glenohumeral joint
toms include moderate to considerable swelling of the
is achieved by reaching to side and behind with opposite arm.
wrist and hand, vasomotor changes, and atrophy.106 If
untreated, SHS may result in a frozen shoulder and per-
manent hand deformity.34
Although the cause of SHS remains obscure, most
authors associate it with a change in the autonomic
nervous system (primarily sympathetic).50 A study by
Braus, Krauss, and Strobel34 suggested that the SHS in
hemiplegic patients is initiated by a peripheral lesion
(e.g., a tissue or nerve injury). The authors hypothe-
sized that increased neural activity after a peripheral
injury or inflammation leads to a central sensitization
responsible for the severe pain associated with SHS.
Autopsy data collected by the authors confirmed mi-
crobleeding in the area of the suprahumeral joint of the
affected side. If the underlying cause is in fact periph-
eral, then prevention programs theoretically would be
effective.
The reported incidence of SHS varies from 27%34 to
25%174 to 12.5%58 to 1.56%.143 Males seem to be slightly
more affected than females.58,174 The majority of patients
with SHS symptoms have partial motor loss, moderate or
Figure 10-19 Internal rotators stretch to be used judiciously
severe sensory loss, and varying degrees of spasticity.58
for patients who respect their own pain. This rest posture is ef-
Associated risk factors include subluxation, considerable
fective at maintaining external rotation and abduction of the
weakness, moderate spasticity, deficits in confrontational
glenohumeral joint. If range is lacking, the humerus can be sup-
field testing (following hemianopsia or neglect), and al-
ported with a towel until patient gains increased external rota-
tered shoulder biomechanics that may compromise the
tion and horizontal abduction.
suprahumeral joint structures.34
Daviet and colleagues56 examined 71 patients with
hemiplegia; 34.8% had a complex regional pain syndrome
type I. They identified four main clinical factors in the
The ultimate strategy used to decrease contracture and prognosis of complex regional pain syndrome type I as
maintain ROM is encouraging functional use of the trunk motor deficit, spasticity, sensory deficits, and initial coma.
and upper extremity. A person who has never had a stroke They also concluded that shoulder subluxation, unilateral
maintains ROM of an extremity by incorporating it into neglect, and depression did not seem to be determinant
ADL. Activities that eliminate maladaptive positions dur- predictive factors of complex regional pain syndrome type
ing activities, improve balanced muscle activity on both I severity.
 Chapter 10 • Upper Extremity Function and Management 259

Three stages of SHS have been described (Box 10-12). Therapists should prevent SHS, so that it will not have
Davis and colleagues58 outlined the major diagnostic to be treated. Davis57 has developed a prevention protocol
criteria for SHS based on the following clinical symptoms: that focuses on the following:
■ Shoulder: loss of ROM and pain during abduction, ■ Therapists gaining full understanding of the anat-
flexion, and external rotation movements omy and physiology of normal and hemiplegic
■ Elbow: no signs or symptoms shoulders
■ Wrist: intense pain during extension movements, ■ Proper handling of the upper extremity, including
dorsal edema, and tenderness during deep palpation avoiding arm traction during mobility, ADL, and
■ Hand: edema over metacarpals and no tenderness gait activities; supporting the arm as necessary, pre-
■ Digits: moderate fusiform edema, intense pain venting prolonged arm dangling, and using the
during flexion of the metacarpophalangeal and trunk and scapula rather than the arm as support
proximal interphalangeal joints, and loss of skin during transitional movements
lines ■ Staff education focusing on the mentioned handling
The Tepperman and colleagues174 study concluded that techniques
metacarpophalangeal tenderness during compression ■ Mobilizing the scapula to ensure gliding when rais-
was the most valuable clinical sign of reflex sympathetic ing or performing ROM activities with the arm
dystrophy, with a predictive value of 100%. Vasomotor ■ Family education focusing on proper extremity han-
changes and interphalangeal tenderness had the next dling and transfer techniques; training families not
highest predictive value at 72.7%. Therapists must re- to guard at the affected upper extremity during am-
member that many of the mentioned signs and symp- bulation (because a balance loss would result in an
toms can be found in stroke patients without SHS. If a automatic reflex—grabbing the patient’s arm)
patient has several characteristic signs and symptoms, ■ Edema control that begins as soon as signs of it are
one safely can make a diagnosis on clinical grounds observed (see Chapter 12)
alone.50 Although the diagnosis for SHS is primarily ■ Training patients to take responsibility for protect-
clinical, the most effective way to confirm its presence is ing their affected arm
to use a differential neural blockade. The physician may Davis and colleagues58 hypothesize that therapists can
use a stellate ganglion block to alleviate the symptoms, control certain factors contributing to SHS. One factor is
which interrupts the abnormal sympathetic reflex; the the extravasation of intravenous fluids. The team should
diagnosis of SHS is confirmed if the block alleviates infuse intravenous fluids into the less affected arm if pos-
symptoms. sible; if not, fluids should be infused proximal to the wrist
on the affected side. This strategy prevents infiltration
around the needle and a possible edema syndrome. An-
other contributing factor is poor positioning. Therapists
Box 10-12 should position patients so that they cannot roll over onto
the affected arm, pin it down, and compromise circula-
Stages of Shoulder-Hand Syndrome/Complex tion. The other factor is immobilization of a painful
Regional Pain Syndrome Type I shoulder by the patient. Davis57 wrote, “In this sense, a
STAGE 1 painful shoulder (but not necessarily SHS) can evolve into
SHS through immobility and consequent circulatory
The patient complains of shoulder and hand pain, tender-
ness, and vasomotor changes (with symptoms of discolor- problems. Therefore, proper management of the hemi-
ation and temperature changes). Chances of reversal are plegic patient in order to prevent trauma to the shoulder
high at this stage. is critical.”
In a recent prospective, two-part study performed by
STAGE 2 Braus, Krauss, and Strobel,34 a prevention protocol was
The patient has early dystrophic limb changes, muscle implemented that focused on protecting the affected
and skin atrophy, vasospasm, hyperhidrosis (increased upper extremity from trauma. All patients, relatives, and
sweating), and radiographic signs of osteoporosis. At this members of the therapy and medical teams received
stage, shoulder-hand syndrome becomes increasingly detailed instructions when patients initially were hospi-
difficult to treat.
talized to avoid peripheral injuries to the affected limb.
STAGE 3 Wheelchair and bed positioning were modified to en-
Patients rarely have pain and vasomotor changes, but they sure no pain resulted from improper positioning. Pas-
do have soft-tissue dystrophy, contracture (including a sive movements of the upper extremity were not made
frozen shoulder and clawed hand), and severe osteoporo- unless the scapula was fully mobilized. Any activity or
sis. At this stage, shoulder-hand syndrome is irreversible. position that caused pain was changed immediately, and
no infusions into the veins of the hemiplegic hands were
260 Stroke Rehabilitation

performed. These strategies alone decreased the inci- which can be accomplished by the therapist or having the
dence of SHS from 27% to 8%. patient roll onto the protracted scapula from the supine to
If symptoms of SHS begin to develop, therapists the side-lying position, also has been described.
should make an early diagnosis and begin aggressive treat- Research is beginning to show that peripheral lesions
ment. In the study by Braus, Krauss, and Strobel,34 pa- are the cause of SHS in stroke patients, so interventions
tients who already had definite SHS symptoms were should incorporate this knowledge. Inappropriate ROM
placed in an experimental group (that received a 14-day exercises (e.g., overhead ROM activities in patients with-
treatment with low doses of orally administered cortico- out scapula mobility or overzealous exercise) and mishan-
steroids and daily therapy) or a placebo group (that re- dling during ADL (e.g., pulling on the affected arm dur-
ceived placebo medication and daily therapy). Of the ing transfers, bathing, dressing, and bedtime activities) are
36 patients in the experimental group, 31 were free of factors to consider. In addition to evaluating and treating
symptoms after 10 days of treatment. Chu, Petrillo, and SHS, occupational therapists play a major role in staff
Davis50 and Davis57 also have advocated use of orally ad- education. All staff and family members who physically
ministered corticosteroids with therapy. move patients need to be aware of appropriate techniques
Kondo and colleagues103 tested and published a proto- so as to prevent injuries.
col for controlled passive movement by trained therapists
and restriction of passive movement by the patients to Superimposed Orthopedic Injuries
prevent shoulder hand syndrome (Box 10-13). Orthopedic problems associated with stroke have been well-
Therapy intervention should be symptom specific. documented. These complications have a negative impact
Therapists must alleviate edema immediately and maintain on functional outcomes, prolong rehabilitation, and are one
joint mobility while preventing pain.104,187 Davies55 advo- of the main causes of upper extremity pain syndromes after
cates using activities that result in increased upper extrem- stroke. Indeed a recent magnetic resonance imaging (MRI)
ity ROM but actually result from trunk and hip flexion study of 89 chronic stroke survivors documented:162
(e.g., towel exercises, pushing away a therapy ball while ■ Thirty-five percent of subjects exhibited a tear of at
seated, and reaching to the floor). Mobilizing the scapula, least one rotator cuff, biceps, or deltoid muscle.

Box 10-13
Protocol to Prevent Shoulder Hand Syndrome
The protocol shown below is for prevention of shoulder- 3. Metacarpophalangeal (MCP) joint and interphalangeal
hand syndrome in patients in the early stages of recovery af- (IP) joint of finger and thumb
ter cerebrovascular accident (CVA). Both therapist and pa- The proximal joint should be supported and held in a
tient should follow the instructions and restrictions to passive neutral position during passive movement of the distal joint.
movement for the first 4 months after CVA. Active move- Only 1 joint should be moved at a time. During finger flex-
ment, however, need not be restricted if the patient can move ion, the wrist must be supported and be held in a neutral
his or her affected fingers and arm, because active movement position. During finger extension, the wrist must be kept in
effectively diminishes hand edema and stiffness. flexed position.

PASSIVE RANGE OF MOTION EXERCISES PASSIVE MOVEMENT BY THE PATIENT

PERFORMED BY THE THERAPIST
1. Shoulder joint
1. Shoulder joint The patient should not use the nonaffected arm to move
The shoulder joint should not be moved beyond 90 de- his or her affected shoulder passively. Active movement is
grees during abduction and flexion. External and internal encouraged but the range of motion should not go beyond
rotation should be performed in the adducted position. If the 90 degrees of abduction and flexion. External and internal
patient complains of pain in a certain position, the exercise rotation should be performed in the adducted position.
must be stopped. During the next session, the therapist 2. Elbow joint, forearm (pronation/supination), wrist joint
should not attempt to move the arm beyond the position that There are no restrictions for these joints. Active move-
produced pain during the previous session. ment is encouraged.
2. Elbow joint, forearm (pronation/supination), wrist joint 3. MCP joint and IP joint of fingers and thumb
There is no restriction to passive movement of these joints The patient should not use the nonaffected arm to move
by the therapist, but if the patient complains of pain in a certain his or her affected fingers and thumb passively. Active move-
position, the exercise must be stopped. During the next session, ment of the affected fingers and thumb is encouraged.
the therapist should not attempt to move the joint beyond this
position that produced pain during the previous session.

From Kondo I, Hosokawa K, Soma M et al: Protocol to prevent shoulder-hand syndrome after stroke. Arch Phys Med Rehabil 82(11):
1619–1623, 2001.
 Chapter 10 • Upper Extremity Function and Management 261

■ Fifty-three percent of subjects exhibited tendinopa- understanding of joint alignment can prevent impinge-
thy of at least one rotator cuff, biceps, or deltoid ment during treatment.
muscle. Nepomuceno and Miller134 found seven rotator cuff
■ The prevalence of rotator cuff tears increased with tears and one a transverse bicipital tendon tear in 24 sub-
age. jects with painful hemiplegic shoulders. None of the pa-
■ In approximately 20% of cases, rotator cuff and del- tients had premorbid pathological conditions of the shoul-
toid muscles exhibited evidence of atrophy. Atrophy der. With one exception, all patients with soft-tissue
was associated with reduced motor strength and re- lesions had left-sided hemiplegia. (This study did not
duced severity of shoulder pain. evaluate the presence of visual field loss or neglect.)
Therapists should note that a relationship between
Rotator Cuff and Biceps Tendon Lesions. The rotator rotator cuff age and wear has been documented. After
cuff guides and leads the movements of the shoulder joint. age 50-years-old, the percentage of lesions significantly
The cuff supplies the strength needed to complete the increases.
ROM in the shoulder joint and seats the head of the hu-
merus into the glenoid fossa. Adhesive Changes. Adhesive changes in the hemiplegic
Najenson, Yacubovic, and Pikielni131 studied 32 hemi- shoulder are considered to result from immobilization,
plegic patients with severe upper limb paralysis; 18 pa- synovitis, or metabolic changes in joint tissue. Hakuno
tients served as controls by having their less affected side and colleagues81 studied adhesive changes in hemiplegic
evaluated. Forty percent of the patients had a rotator cuff shoulders and found that hemiplegia had a significant in-
tear on the affected side. None of the patients had com- fluence on the prevalence of adhesive changes in the
plaints about the affected shoulder before the stroke. shoulder. Adhesive changes were found in 30% of pa-
Only 16% of the patients in the control group had rup- tients’ affected glenohumeral joints as opposed to 2.7%
tured rotator cuffs on the less involved side; all three on the less involved side.
seemed to be long-standing tears. Rizk and colleagues152 examined 30 hemiplegic patients
Najenson, Yacubovic, and Pikielni131 also discussed by arthrography of the shoulder and found that 23 patients
the pathophysiology of a rotator cuff tear in hemiplegic had capsular constriction typical of frozen shoulder (adhe-
patients. Many older patients are predisposed to rotator sive capsulitis). Therefore, the authors advocated early
cuff ruptures because of degenerative changes associated passive ROM for the shoulder.
with aging. Cuff tears commonly result from impinge- Roy, Sands, and Hill155 used the following clinical
ment of the cuff between the greater tuberosity and ac- criteria for adhesive capsulitis: shoulder pain, external
romial arch (Fig. 10-20), which occurs when the hu- rotation of less than 20 degrees, and abduction of less
merus is forced into abduction without external rotation than 60 degrees. Ikai and colleagues93 concluded that
(e.g., during inappropriate passive ROM activities or adhesive capsulitis is a main cause of shoulder pain and
activities that are not sensitive to shoulder biomechanics documented adhesive changes in 74% of subjects in
[reciprocal pulleys]). Therapists who have a thorough their study via shoulder arthrogram. They recom-
mended that “correct positioning and shoulder ROM
exercises are advisable in hemiplegic patients with
shoulder subluxation.”
Acromion
Brachial Plexus Injury. Kaplan and colleagues101 identi-
Supraspinatus fied brachial plexus injury in five of 12 patients in their
Coracoid study. All five had EMG evidence indicating neuropathy
of the upper trunk of the brachial plexus on the side af-
fected by the stroke. The deltoid, biceps, and infraspina-
tus muscles were involved. Moskowitz and Porter130 also
summarized the findings in five stroke survivors with
“traction neuropathies” of the upper trunk of the brachial
plexus.
Merideth, Taft, and Kaplan124 reviewed the diagnostic
Bursa and treatment procedures for stroke survivors with brachial
plexus injuries. Physical examination findings included
Figure 10-20 Impingement of soft tissues located in subacro- flaccidity and atrophy of the supraspinatus, infraspinatus,
mial space. Impingement occurs between the head of humerus deltoid, and biceps muscles in the affected upper extrem-
and acromion/coracoid. Impingement occurs during forced hu- ity with increased muscle tone or distal movement (an
meral flexion/abduction without concurrent upward rotation of atypical pattern of recovery). EMG criteria for diagnosing
scapula and/or external rotation of humerus. brachial plexus injuries include the finding of fibrillation
262 Stroke Rehabilitation

potentials in the muscles innervated by the upper trunk of incidence of trauma was increased. He found no correla-
the brachial plexus. tion between shoulder pain and subluxation, spasticity,
Treatment of these patients included positioning and strength, or sensation.
passive and active ROM activities. During active ROM Joynt99 identified the subacromial area as a pain-
activities, Effects of gravity were monitored to prevent producing location in a significant number of cases. Of
further traction. Using a positioning pillow, the affected 28 patients who received a subacromial injection of 1%
upper extremity was positioned as follows: externally ro- lidocaine, more than half obtained moderate or significant
tated 45 degrees, 90 degrees of elbow flexion, and forearm pain relief and improved ROM. The author suggested
neutral. Patients used slings while ambulating and were that physical agent modalities, steroid injections, and
educated not to sleep on their affected side, which could careful ROM activities focusing on impingement preven-
result in compression and traction injuries to the upper tion were significant in reducing pain.
trunk. (Many authors encourage sleeping on the affected The subacromial area is prone to trauma during therapy
side if this pathological condition is not present.) A major and patient handling. The subacromial space includes the
component of the treatment program was the education supraspinatus tendon, long head of the biceps, and sub-
of the patient, staff, and families regarding proper care acromial bursa40 (Fig. 10-21). All of these structures are
and positioning of the upper extremity. prone to impingement and inflammation. Structure im-
pingement can develop easily in hemiplegic patients dur-
Pain Syndromes ing ROM activities because the normal scapulohumeral
Although pain syndromes have been discussed previously rhythm becomes impaired. If the scapula is not rotated
in the context of orthopedic injuries and SHS, their impact upward (by therapist’s manipulation or active control), the
on functional recovery is significant, so this section specifi- humerus becomes blocked by the acromion and causes
cally reviews the literature on hemiplegic shoulder pain. impingement, inflammation, and pain (see Fig. 10-20).
The incidence of shoulder pain in hemiplegic patients Combined motions of scapula retraction with forward
has been reported to be as high as 72%.22,155,184 Roy, flexion should be avoided to prevent impingement. In-
Sands, and Hill155 identified strong associations between stead, the scapula should glide freely and be protracted and
hemiplegic shoulder pain and prolonged hospital stays, upwardly rotated during upper extremity activities. Ob-
arm weakness, poor recovery of arm function, ADL, and jects for reaching activities should be placed in front or
lower rates of discharge to the home. Those responsible below waist level of the patient to encourage humeral for-
for stroke patients have the onus to be aware of hemiple- ward flexion with scapular protraction. Indeed, Dromerick
gic shoulder pain and to diagnose, relieve, and prevent and colleagues64 designed a study to clarify the patho-
this syndrome. Although shoulder pain is obviously not physiology of hemiplegic shoulder pain by determining
the only variable leading to prolonged hospital stays, it is the frequency of abnormal shoulder physical diagnosis
a potentially preventable variable over which occupational signs and the accuracy of self-report. They found:
therapists have much control. ■ Weakness of shoulder flexion, extension, or abduc-
Pain can limit patient’s activities, such as rolling in bed, tion was present in 94% of subjects.
transferring, putting on a shirt or blouse, and bending to ■ Neglect was found in 29%.
reach the feet to put on shoes and socks. The occurrence ■ Pain was present by self-report in 37%.
of shoulder pain also has been linked to depression.160
The literature concerning hemiplegic shoulder pain is
confusing at times and often contradictory. The following Acromion
review was obtained from a selection of articles from a
Coracoacromial ligament
variety of disciplines. The focus of the review is clinical
correlations associated with hemiplegic shoulder pain. Deltoid
In their study of 55 patients, Roy, Sands, and Hill155 muscle Coracoid
found positive correlations between hemiplegic shoulder Supraspinatus
pain and “glenohumeral malalignment without descent of
the humeral head” and between hemiplegic shoulder pain Bursa
and reflex sympathetic dystrophy (SHS). The study did not
confirm a strong association between spasticity (measured
by the Ashworth Scale) and hemiplegic shoulder pain.
Joynt99 found significant correlations between loss of Biceps brachii
motion and shoulder pain and questioned the relationship tendon (long
head) Subscapularis
between neglect/perceptual dysfunction and pain. His
left-sided hemiplegic subjects had a higher incidence of
shoulder pain, which led him to question whether the Figure 10-21 Subacromial space.
 Chapter 10 • Upper Extremity Function and Management 263

■ The most common findings on physical examination of external rotation of the hemiplegic shoulder, spasticity,
(proactive tests and palpation) was bicipital tendon and weakness) to shoulder pain. In their study of 50 pa-
tenderness (54%), followed by supraspinatus tender- tients, 36 had shoulder pain. Range of shoulder external
ness (48%). rotation was considered the factor related most signifi-
■ The Neer sign was positive in 30%. cantly to shoulder pain. They hypothesized that hemiple-
■ 28% had the triad of bicipital tenderness, supraspi- gic shoulder pain was in part a manifestation of adhesive
natus tenderness, and the Neer sign. capsulitis. In this study, only patients with full external
■ Self-reported pain was a poor predictor of abnor- rotation were free of pain. The suggested treatment was
malities elicited on the examination maneuvers, even elimination of inflammation and maintenance of ROM.
in those without neglect. Hecht86 treated 13 patients with limited ROM and
Some patients may develop inflammation around the bi- shoulder pain with percutaneous phenol blocks to the
ceps tendon and supraspinatus insertion because of im- nerves of the subscapularis (a major shoulder internal ro-
pingements. Palpation skills are important for determining tator). Immediate and significant improvements were ob-
which structures are involved (Fig. 10-22). To palpate the served in the flexion, abduction, and external rotation
biceps tendon, the therapist palpates the acromion and ROMs; pain relief also was noted. This study indicates
drops one finger to the anterior shoulder; the biceps ten- that the subscapularis is a key muscle and should be ad-
don lies in the groove between the greater and lesser tu- dressed during treatment focusing on maintaining soft-
berosities of the humerus. If the patient feels pain on ap- tissue length. The subscapularis muscle may tighten in
plication of pressure, the biceps tendon probably has been patients with the previously mentioned pain syndrome. If
affected. (Passively rotating the humerus while palpating the humerus resists external rotation with the arm at the
assists the therapist with locating the tuberosities.) side during evaluation, the therapist can presume the sub-
To palpate the supraspinatus tendon, the therapist pal- scapularis to be a factor contributing to the deformity.
pates the acromion, but this time drops one finger to the Similarly, subscapularis injection of botulinum toxin A
lateral shoulder right below the center of the acromion. If appears to be of value in the management of shoulder pain
pressure or slight friction elicits pain, the supraspinatus in spastic hemiplegic patients.200 These studies adds more
most likely has been affected. support to the concept of focusing on maintaining the
Bohannon and colleagues22 studied the relationship of range of humeral external rotation to prevent resulting
five variables (age, time since onset of hemiplegia, range complications.
Bohannon and Andrews20 studied 24 patients in an ef-
fort to establish a relationship between subluxation and
pain. Despite the emphasis placed on reduction of sublux-
ation, the relationship between shoulder pain and sublux-
ation has not been established. Their study did not find an
association between shoulder pain and subluxation (which
was defined in this study as the separation between the
acromion and the humeral head). A study by Arsenault
and colleagues8 also found no significant relationship be-
tween subluxation and shoulder pain.
A more recent study by Zorowitz and colleagues203 also
focused on the correlation between subluxation and pain.
Results showed that shoulder pain did not correlate with
age, vertical or horizontal subluxation, shoulder flexion,
abduction, or Fugl-Meyer Assessment scores, but it did
correlate with the degree of shoulder external rotation.
Wanklyn, Forster, and Young186 also found an association
between reduced external rotation and hemiplegic shoul-
der pain, with an incidence as high as 66%. This associa-
tion was believed to be due to abnormal muscle tone or
structural changes, namely adhesions. Similarly, Ikai and
others93 evaluated 75 subjects and found no correlation
between subluxation and pain.
Kumar and colleagues104 demonstrated a positive cor-
Figure 10-22 Palpation point. The x on left anterior) is palpa- relation between shoulder pain and therapy programs
tion point for long head of biceps. The x on right (more lateral) that did not consider biomechanical shoulder alignment
is palpation point for supraspinatus tendon. during treatment. Patients were assigned to one of three
264 Stroke Rehabilitation

exercise groups: ROM initiated by the therapist, skate- Box 10-14

board treatment, and overhead pulley treatment. Of the Hemiplegic Shoulder Pain Prevention
patients who developed pain during the treatment pro-
grams, 8% were in the ROM group, 12% in the skate- ■ Maintain and/or increase passive glenohumeral joint
board group, and 62% in the overhead pulley group. The external rotation.
■ Maintain scapula mobility on the thorax.
probable cause of this discrepancy was soft-tissue damage
■ Avoid passive or active shoulder movements beyond
resulting from forced abduction without external rota-
90 degrees (flexion and abduction) unless the scapula
tion. This study showed that poorly prescribed activities
is gliding toward upward rotation and sufficient exter-
by the therapist could be the cause of pain syndromes. nal rotation is available. These two movements are
This study found no significant relationship between necessary to prevent shoulder impingement.
subluxation and pain. ■ Educate the patient, family, and staff about potential
In a three-year study of 219 hemiplegic patients, Van complications related to an unstable shoulder.
Ouwenaller, Laplace, and Chantraine184 found that 85% ■ Teach patients and caregivers proper management
of the patients who developed pain had spasticity (an in- during activities of daily living to avoid shoulder trac-
creased myotactic reflex) compared with 18% of flaccid tion and forced overhead movements. Specific activi-
patients. They also found that 50% of the patients who ties that should be addressed include applying
developed pain had anteroinferior subluxations (which deodorant, transfers, guarding during ambulation,
were not defined). The authors advocated use of muscle bathing the axilla, and upper body dressing.
■ Educate patients regarding different types
relaxation techniques for the shoulder girdle.
(e.g., stretch versus sharp) of pain. Avoid sharp pain
Jensen98 attributed shoulder pain to traumatic tendini- during any shoulder movements or activities.
tis resulting from unskilled and strenuous joint treatment ■ Provide positioning to prevent a dangling upper
during ADL (e.g., bathing, dressing, and bed mobility) extremity. Assess shoulder positions in bed, in
and bilateral ROM activities of more than 90 degrees re- wheelchair, and during upright function.
sulting in “jamming [of] soft-tissue against the acromion ■ Avoid activities that may cause impingements such as
resulting in lesions” (see Fig. 10-20). Jensen suggested the use of overhead pulleys, forced overhead self range of
following precautions: educating all staff members, plac- motion, or overaggressive passive range of motion by
ing signs over patients’ beds to warn staff of the shoulder the therapist.
instability, supporting the arm during the acute stage,
avoiding treatment that may cause soft-tissue impinge-
ment, having a thorough understanding of shoulder anat-
omy, and dissuading use of pulley exercises and self-ROM The first area to observe is the patient’s pelvis and its
activities. effect on spinal alignment. Patients typically bear weight
Lastly, Wanklyn, Forster, and Young186 found a 27% asymmetrically through their pelvis (by one ischial tuberos-
increased incidence of shoulder pain in dependent pa- ity accepting more weight than the other), which results
tients after discharge, which may reflect improper han- in lateral spine flexion. This lateral flexion causes the
dling at home by caregivers. They suggested a greater trunk musculature to become shortened on the nonweight-
emphasis on patient and caregiver education regarding bearing side and lengthened on the weight-bearing side55
proper transfer techniques and correct handling of the (Fig. 10-23). At the same time, patients tend to assume a
hemiplegic arm (Box 10-14). posterior pelvic tilt, which results in spinal flexion. Again the
result is a muscle imbalance, with the anterior musculature
Loss of Biomechanical Alignment (abdominals) becoming shortened and the posterior muscles
Immediately after a stroke, patients lose their ability to (extensors) becoming elongated. Davies55 hypothesized that
maintain upright control and become malaligned because patients sit with posterior pelvic tilt to compensate for weak
of the effects of gravity, weakness, and muscle imbalance. abdominals. Patients assume this “safe” posture to prevent
Occupational therapists must be able to identify mal- themselves from falling backward. The spinal flexion that
alignments to treat upper extremity dysfunction effec- results from the posterior tilt leads to loss of natural lumbar
tively. The following section discusses common trunk and spine lordosis and accentuated thoracic spine kyphosis.
upper extremity alignment problems and reviews activi- Abdominal weakness (especially the obliques) results in
ties to counteract the adverse effects of malalignment. a destabilization of the rib cage. A lack of balance between
the obliques results in trunk and rib cage rotation.100 See
Loss of Pelvic/Trunk Alignment. After a stroke, patients Chapter 7.
commonly lose their ability to perform postural adjust-
ments and maintain postural alignment because of weak- Loss of Scapula Alignment. Upper extremity malalign-
ness, a loss of equilibrium, and righting reactions; the ment commonly results from pelvic and trunk malalign-
trunk assumes an asymmetrical posture.18,19,55 ments. When in a resting position, the scapula is flush on
 Chapter 10 • Upper Extremity Function and Management 265

Figure 10-23 Asymmetrical trunk posture in patient with

left hemiplegia. Note the left trunk shortening, right trunk
elongation/overstretching, rib cage shift, loss of scapula sta- B
bility on rib cage, relative downward rotation of scapula, in-
creased weight-bearing on right ischial tuberosity, and shoul-
der asymmetry (left hemiplegia).

the rib cage (the scapulothoracic joint) and upwardly

rotated. When one palpates the scapula, the distance
between the inferior angle and the vertebral column
should be greater than the distance between the medial
border of the scapular spine and the vertebral column100
(Fig. 10-24). In the resting position the glenoid fossa of
the scapula faces upward, forward, and outward. There-
fore, the trunk and rib cage must be stable to support the
scapula properly. In hemiplegic patients, the scapula Figure 10-24 Normal resting posture of the scapula in upward
loses its orientation on the thoracic wall and assumes a rotation. A is the distance (in finger breadths or centimeters)
position of relative downward rotation.40 from the medial border of the spine of the scapula to the verte-
Cailliet40 described several events that result in a bral column. B is the distance from the inferior angle of the
downwardly rotated scapula (Fig. 10-25), such as lateral scapula to the vertebral column. Distance B should be greater
flexion toward the hemiparetic side. The lateral flexion than distance A if the scapula is aligned appropriately. If A equals
may be due to trunk weakness, perceptual dysfunction B or A is greater than B, then the scapula has assumed a position
that results in an inability to perceive midline, or excess of relative downward rotation.
activity in unilateral trunk flexors (i.e., latissimus dorsi).
Downward rotation also can be caused by unopposed
muscle activity that depresses and downwardly rotates the the scapula on the rib cage; the seating of the humeral
scapula (i.e., rhomboids, levator scapulae, and latissimus head in the fossa by the supraspinatus; possible support
dorsi) or by generalized weakness in the muscles that ori- from the superior capsule; and contraction of the deltoid
ent the scapula in a position of upward rotation (i.e., ser- and cuff muscles when passive support is eliminated by
ratus anterior, upper and lower trapezius). slight abduction of the humerus.40 Cailliet stated that any
change in these factors may play a role in causing sublux-
Loss of Glenohumeral Joint Alignment. Thus far the loss ation (Fig. 10-26).
of pelvic/trunk, rib cage, and scapula control have been Basmajian’s EMG studies14 confirmed that the supra-
reviewed. All of the aforementioned alignment changes spinatus prevents downward migration of the humeral
have an effect on the stability and alignment of the gleno- head when a downward load is applied to the upper ex-
humeral joint. The mechanisms of glenohumeral joint tremity (e.g., when a person holds a briefcase). Authors
subluxation remains controversial. As reviewed by Cailliet40 previously believed that the deltoid performed this func-
and Basmajian,14 the following factors assist in maintaining tion, but the deltoid actually shows no activity during this
glenohumeral joint stability: the angle of the glenoid fossa function. The author pointed out that the supraspinatus is
when facing forward, upward, and outward; the support of a horizontally positioned muscle that runs through the
266 Stroke Rehabilitation

X
A
C

Y
B
D

A B C
Figure 10-25 A, Scapular alignment with a straight spine (xy glenoid angle). B, Paresis with
downward rotation of scapula (AB glenoid angle). C, Relative downward rotation of scapula
with functional scoliosis (CD glenoid angle). (From Cailliet R: The shoulder in hemiplegia,
Philadelphia, 1980, FA Davis.)

supraspinous fossa and can be effective only if the scapula

is oriented correctly on the thorax.
A The upward orientation of the glenoid fossa creates a
C H
“cradle” for the humeral head. As the humerus is pulled
downward, it is forced to move laterally by the slope of
the fossa.14 The supraspinatus (and superior portion of
the capsule) prevents this lateral movement and therefore
X downward migration. Basmajian14 also pointed out that
S
this mechanism is not effective if the humerus is abducted.
This position predisposes patients to subluxation by elim-
inating the described mechanism. Many patients are posi-
tioned so that their humerus is abducted slightly because
of the lateral trunk flexion toward the more affected side
or due to passive positioning.
The relationship between scapula rotation and inferior
Y subluxation has been challenged. Prevost and colleagues148
G
evaluated both shoulders of 50 stroke survivors with infe-
rior subluxations using tridimensional radiograph. Results
included the following:
■ The affected and nonaffected shoulders were differ-
ent in terms of the vertical position of the humerus
B D vis-a-vis the scapula.
Figure 10-26 Possible biomechanics of subluxation from mal- ■ The orientation of the glenoid cavities was also dif-
alignment. Line AB indicates an aligned spine (the goal of treat- ferent; the subluxed one faced less downward.
ment). Instead the spine assumes a position of lateral flexion ■ The angle of abduction of the arm of the affected
(curve CB). The scapula downwardly rotates (GH), resulting in a side was significantly greater than on the nonaf-
downward angulation of the glenoid fossa (XY). Because of the fected side, but the relative abduction of the arm was
scapula position, the supraspinatus (S) loses its mechanical line on the same order of magnitude for both sides.
of pull, making it ineffective and prone to overstretching. The ■ No significant relationship existed between the
result is a subluxation of the glenohumeral joint. (Modified from orientation of the scapula and the severity of the
Cailliet R: Shoulder pain, Philadelphia, 1990, FA Davis.) subluxation.
 Chapter 10 • Upper Extremity Function and Management 267

■ The abduction of the humerus was weakly (r  0.24) ■ No significant correlation was found between scapu-
related to the subluxation, which partly explained lar or humeral orientation and glenohumeral sublux-
the weak association found between the relative ab- ation in either group.
duction of the arm and the subluxation. Chaco and Wolf45 confirmed that the supraspinatus did
Overall, the authors concluded that the position of the not respond to loading in the hemiplegic patients they
scapula and the relative abduction of the arm cannot be studied. Although not immediate, subluxation developed
considered important factors in the occurrence of inferior later in the study in the patients who remained flaccid.
subluxation in hemiplegia. They inferred that the joint capsule holds the head of the
Similarly, Culham, Noce, and Bagg54 examined 17 sub- humerus in relation to the glenoid fossa, but unless the
jects with high tone and 17 subjects with low tone based supraspinatus starts responding, it cannot prevent sublux-
on the Ashworth Scale. Linear and angular measures of ation indefinitely. Therefore, subluxation appears to be
scapular and humeral orientation were calculated from caused by the weight of the arm and mechanical stretch to
tridimensional coordinates of bony landmarks collected the joint capsule and traction to unresponsive shoulder
using an electromagnetic device with subjects in a seated musculature.
position with arms relaxed by their sides. Glenohumeral Ryerson and Levit156,157 described three patterns of
subluxation was measured from radiographs. They found subluxation in the glenohumeral joint. They emphasized
the following: that the therapist must assess trunk posture, determine
■ The scapula was farther from the midline and lower the position of the scapula on the trunk, evaluate scapular
on the thorax on the affected side in the low-tone mobility and rhythm, and examine the alignment and
group. mobility of the glenohumeral joint before setting treat-
■ Glenohumeral subluxation was greater in the low- ment goals for the shoulder. Table 10-7 reviews Ryerson
tone group. and Levit’s subluxation classifications, including inferior,
■ The scapular abduction angle was significantly anterior, and superior subluxations.
greater on the nonaffected side in the low-tone Hall, Dudgeon, and Guthrie83 assessed the validity of
group compared with the affected side in this group three clinical measures (palpation, arm length discrep-
and with the nonaffected side in the high-tone ancy, and thermoplastic jig measurement) for evaluating
group. shoulder subluxation in adults with hemiplegia resulting
■ In the high-tone group, no differences were found from a stroke. These measures were combined with
between the affected and nonaffected sides in the anterior/posterior radiographic examinations of the hemi-
angular or linear measures. plegic shoulder; results indicated that palpation had the

Table 10-7
Subluxation/Malalignment Patterns in the Upper Extremity after Stroke
TRUNK SCAPULA HUMERAL DISTAL EXTREMITY MOVEMENT
ALIGNMENT ALIGNMENT ALIGNMENT ALIGNMENT AVAILABLE

Inferior Lateral flexion to Downwardly Relative abduction Elbow extension and Scapula elevation and
subluxation weak side rotated and internal pronation internal rotation
rotation; humeral
head below inferior
lip of fossa
Anterior Increased extension, Downwardly Hyperextension and Elbow flexion and Shoulder elevation,
subluxation lateral flaring, or rotated and internal rotation; pronation or humeral internal
rotation of rib elevated, humeral head supination rotation and
cage winging inferior and forward hyperextension,
relative to fossa and elbow flexion
Superior Elements of flexion Elevated and Internal rotation and Supination and wrist Shoulder elevation,
subluxation and extension; rib abducted abduction; humeral flexion abduction, and
cage flaring head lodged under internal rotation;
coracoid elbow/wrist flexion

Data from Ryerson S, Levit K: Glenohumeral joint subluxations in CNS dysfunction. NDTA Newsletter Nov 1988; and Ryerson S, Levit K:
The shoulder in hemiplegia. In Donatelli RA, editor: Physical therapy of the shoulder, ed 2, New York, 1991, Churchill Livingstone.
268 Stroke Rehabilitation

highest correlation with successful subluxation evaluation. should solidify the interdependence between the trunk
In their technique for palpating subluxation, the patient is and upper extremity. Any malalignments in the proximal
seated with the upper extremity unsupported at the side in segments have deleterious effects on the upper extremity
neutral rotation; trunk stability was maintained during the (Fig. 10-27).
evaluation. During palpation, the therapist measured sub- The musculature acting on the shoulder has proximal
luxation by palpating the subacromial space (the distance points of attachment. A group of upper extremity muscles
between the acromion and the superior aspect of the hu- (the trapezius, rhomboids, serratus anterior, and levator
meral head) with the index and middle fingers. The au- scapulae) runs between the trunk and scapula, and another
thors concluded that their findings provided cautious op- (the pectoralis and latissimus dorsi) runs between the trunk
timism in terms of measuring and identifying subluxation. and humerus. Another group of muscles (the deltoid, rota-
Prevost and colleagues149 also validated that palpation is a tor cuff, and coracobrachialis) attaches from the humerus
reliable measurement tool in the evaluation of sublux- to the scapula. These attachments emphasize the interde-
ation. One should note that the evaluator should palpate pendence of trunk alignment and extremity control.
both shoulders for comparison. Mohr127 pointed out that biomechanical malalignment
Hall, Dudgeon, and Guthrie83 used a 0 (no sublux- produces a pattern of movement that looks like stereo-
ation) to 5 (21⁄2 finger widths of subluxation) scale during typical patterns used by patients with spasticity. For ex-
their study. Bohannon and Andrews20 used a 3-point scale ample, patients who gain early control of scapula eleva-
to demonstrate interrater reliability for measuring sublux- tion and humeral abduction continue to use this pattern
ation: none, 0; minimal, 1; and substantial, 2. and also flex the trunk, resulting in more elevation and
abduction. As the scapula tips forward, it predisposes the
Loss of Distal Alignment. Shoulder alignment problems humerus to internal rotation and extension because of its
directly effect the alignment and control of the distal ex- position in the fossa. The distal arm follows into elbow
tremity. Boehme19 states that rotational movements of the flexion, pronation, and wrist and digit flexion. The author
forearm “occur at the proximal end with the radius rotat- stated that if a normal individual only activates the scapula
ing on a vertical axis . . . the ulnar head is displaced, . . . the elevators with humeral abductors, the resulting pattern
mechanics are made possible by concurrent external rota- looks similar to the patterns used by stroke survivors.
tion of the humerus.” The typical alignment of the hu- These alignment problems need to be addressed before
merus after stroke is one of internal rotation, which and throughout the treatment session. Therapists should
blocks forearm rotation. correct them by mobilization techniques, positioning, and
Kapandji100 states that when the elbow is flexed (a typi- appropriate activity choices. The therapist needs to en-
cal posture), pronation is reduced to 45 degrees. Boehme19 sure alignment during ROM activities and maintain ap-
points out that when the wrist is bound by flexion and ul- propriate alignment during functional activities. For ex-
nar deviation (the typical posture of the CVA patient), ample, the alignment of the trunk and pelvis of patients
control of forearm rotation also is blocked. who are trying to feed themselves has a direct effect on
Wrist motion can become limited by virtue of its own the quality of the extremity movement pattern. Even in
alignment. The range of deviation is at its minimum when persons without a known neuropathological condition,
the wrist is in flexion and at its maximum when the wrist the quality of the eating activity clearly is compromised if
is in a neutral position or slight flexion. Flexion and exten- they assume a forward flexed and laterally flexed static
sion ranges of the wrist are at a minimum when the hand posture rather than an aligned and active trunk posture.
has an ulnar deviation and at a maximum when the hand Ryerson and Levit156 suggest patients perform activi-
has a neutral deviation.100 ties that maintain enhanced trunk alignment and simulta-
A loss of palmar arches in the hand results in an inferior neously coordinate movements of the scapula, trunk, and
movement of the metacarpals followed by a distal hyperex- humerus.
tension of the metacarpophalangeals and flexion of the
proximal interphalangeal joints and distal interphalangeal Shoulder Supports
joints, the typical claw-hand posture. See Chapter 13. Shoulder supports include any devices used to align, pro-
tect, or support an affected proximal limb. Shoulder sup-
Interdependence of Trunk and Limb Alignment. Ana- ports include bed-positioning devices, adaptations to seat-
tomically, therapists must remember that only one bony ing systems, and slings. The use of shoulder supports,
attachment connects the entire limb to the axial skele- especially slings, has been debated in the literature for at
ton, the sternoclavicular joint. (The scapulothoracic least 30 years. A recent review concluded that “There is
joint is not a true joint; the scapula rides on the thoracic insufficient evidence to conclude whether slings and
cage and is maintained by muscular attachments only.) wheelchair attachments prevent subluxation, decrease
Therefore, the clavicle serves as an anatomical link be- pain, increase function or adversely increase contracture
tween the shoulder complex and trunk. This point in the shoulder after stroke.”4
 Chapter 10 • Upper Extremity Function and Management 269

Costovertebral Sternoclavicular
Acromioclavicular
Costosternal

Suprahumeral Glenohumeral

Scapulocostal

Figure 10-27 Shoulder anatomy. Seven joints make up the shoulder complex. The sterno-
clavicular joint is the only bony attachment of the shoulder to the trunk, with the clavicle
serving as a bridge between the trunk and shoulder. Skeletal alignment of the shoulder joint
depends on trunk alignment and stability. For example, if the pelvis becomes malaligned (pel-
vic obliquity), the vertebral column, the rib cage, and other components lose their alignment
(see Fig. 10-23).

Much of the debate is fueled by the variety of available market that assist in realigning the scapula on the rib cage.
slings, the controversy regarding their effectiveness, when Therefore, slings cannot be prescribed to “reduce a sub-
and how they should be used, and whether they add to the luxation.” They may lift the head of the humerus to the
already numerous complications resulting from an ex- level of the glenoid fossa, but the scapular and trunk
tremity affected by stroke. alignments (the key to correcting shoulder malalignment)
Boyd and Gaylard32 published the results of their survey remain impaired. This reduction may be seen as treating
of Canadian occupational therapists who prescribe slings. a symptom of a larger problem. The therapist must realize
The respondents most frequently indicated that the goals that they may find cases in which treating this symptom is
of using a sling were to decrease and prevent subluxation appropriate. Analysis is critical for determining which
and pain. The respondents frequently measured the ef- goals certain interventions are achieving. Palpating the
fectiveness of their interventions by the level of resulting subluxation before and after the sling is donned is not suf-
pain relief, subluxation assessments, and the amount of ficient. The therapist must evaluate the effect (if any) of
hand swelling. Less frequent measures of effectiveness in- the sling on the more proximal segments.
cluded ROM, spasticity, and body awareness. In their review of the literature, Smith and Okamoto165
In light of the previously proposed cause of subluxation identified desirable and undesirable features of slings.
(see Loss of Biomechanical Alignment), Cailliet40 sug- Proper positioning of the humeral head in addition to
gested that if the goal of treatment is to provide glenohu- humeral abduction, external rotation, and elbow exten-
meral joint stability, then the device must support the sion are cited as desirable positions as opposed to humeral
scapula on the rib cage with the glenoid fossa facing up- adduction, internal rotation, and elbow flexion. The latter
ward, forward, and outward and must compensate for a positions typically cause problems in the maintenance of
lack of support by the rotator cuff and possibly the supe- tissue length in the stroke population. The sling also
rior capsule. At this point, no slings are available on the should permit the impaired extremity to provide postural
270 Stroke Rehabilitation

support when the patient is seated and should allow self- acrylic plastic lap tray on a wheelchair, a wheelchair-
ROM. In terms of positioning, the sling should provide mounted arm trough, a conventional triangular sling
neutral wrist support, unobstructed hand function, finger (which is much like an arm cast support), and the Hook
abduction, and scapula protraction and elevation. Hemi Harness (which has two adjustable shoulder cuffs
Smith and Okamoto165 emphasized that if a therapist with a suspension strap that are tightened while the af-
expects compliance with sling use, comfort, cosmetic ap- fected arm is lifted, resulting in shoulders of equal height).
peal, and easy donning and doffing are crucial. The au- Anteroposterior radiographs of 10 subjects demonstrated
thors published a checklist to assist therapists in analyzing that the conventional sling, lap tray, and arm trough were
the slings they provide. The percentage of therapists us- effective in decreasing the width of the glenohumeral
ing slings has been reported to be as high as 94%,32 de- space to normal. The Bobath roll and the Hook Hemi
spite the fact no definitive studies support or reject the use Harness were not effective in reducing the subluxation.
of slings. Several studies have compared and contrasted The authors pointed out that although the conventional
the effectiveness of various supports. Zorowitz and col- sling decreased the subluxation, it reinforced the flexor
leagues204 compared the following four supports: pattern found in the upper extremity.
1. The single-strap hemisling: The strap has two cuffs Brook and colleagues36 compared the effects of three
that support the elbow and wrist. The arm is held in supports: the Bobath sling, an arm trough/lap board, and
a position of adduction, internal rotation, and elbow the Harris hemisling (which has two straps and cuffs that
flexion. cradle the elbow and wrist, holding the arm in a position
2. The Bobath roll: This strap includes a foam roll that is of adduction, internal rotation, and elbow flexion). The
placed in the affected axilla beneath the proximal hu- Harris hemisling resulted in good vertical correction; in
merus. The shoulder is maintained in a position of comparison the Bobath sling did not correct the sublux-
abduction and external rotation with elbow extension. ation as well, the arm trough/lap board was less effective
3. The Rolyan humeral cuff sling: This figure-of-eight and tended to overcorrect, and the Bobath sling tended to
strap system has an arm cuff that is sized to fit dis- distract the joint horizontally.
tally on the humerus of the affected arm. The An important note is that none of the mentioned stud-
shoulder is positioned in slight external rotation. ies discussed scapular or trunk alignment; they only ad-
4. The Cavalier shoulder support: This type of sup- dressed the glenohumeral joint.
port provides bilateral axillary support and consists Hurd, Farrell, and Waylonis92 alternately placed 14
of bilateral straps that are positioned along the hu- patients into a control group (which used no sling) or
meral head and integrated posteriorly into a brace treatment group (which used a sling). These patients were
that rests between the scapula. treated identically in all other respects. The patients were
In this study, 20 patients were evaluated in the listed sup- evaluated initially and again two to three weeks later and
ports with anteroposterior shoulder radiography. The three to seven months later. No appreciable difference in
authors evaluated the vertical, horizontal, and total asym- shoulder ROM, shoulder pain, or subluxation was found
metries of glenohumeral joint subluxation compared with between the treated or control groups. No evidence of
the opposite shoulder. In terms of vertical asymmetry, the increased incidence of peripheral nerve or plexus injury
single-strap hemisling corrected the vertical displace- was noted in the control group. The authors concluded
ment, the Cavalier support did not alter vertical displace- that the hemisling does not need to be used uniformly by
ment, and the remaining supports significantly reduced all patients with a flaccid limb after a stroke. They sug-
but did not correct vertical displacement. gested that a sling might be useful when used with dis-
Although as a group, the subjects had no significant crimination but did not elaborate on this point.
horizontal asymmetry when no supports were used, the Some authors have suggested that slings be prescribed
Bobath roll and the Cavalier support produced a significant to prevent overstretching of soft tissue. Chaco and Wolf45
lateral displacement of the humeral head of the more af- proposed that permanent subluxation of the glenohu-
fected shoulder. This fact is of interest because one pro- meral joint could be prevented by avoiding loading on the
posed goal of a sling is to decrease or prevent subluxation; joint when the limb is flaccid. They concluded that the
this study demonstrated that equipment not well-researched joint capsule holds the head of the humerus in relation to
actually may cause shoulder asymmetry in patients who the fossa when the supraspinatus is not responding but
previously had none. cannot prevent subluxation for an unlimited time unless
In terms of total asymmetry, the Rolyan humeral the cuff responds.
cuff sling was the only support that significantly de- If the joint capsule is prevented from stretching during
creased (although it did not eliminate) total subluxation the stage in which the limb is flaccid, patients may have a
asymmetry. better opportunity to develop adequate muscle function
Moodie, Brisbin, and Morgan128 evaluated the effec- to maintain joint alignment. Kaplan and colleagues101
tiveness of five shoulder supports: the Bobath roll, an advised using a sling during the flaccid stage to prevent
 Chapter 10 • Upper Extremity Function and Management 271

distraction of the joint resulting in a possible brachial ■ Therapists must evaluate each patient’s clinical pic-
plexus injury. ture. Therapists need to weigh the pros and cons of
Some therapists have suggested that sling use may in- slings and clarify the goal of sling use (Box 10-15).
crease body neglect and interfere with body image, al- Following prescription of the sling, the therapist
though this hypothesis has not been researched. Although must reevaluate the effectiveness of the sling (i.e.,
they have not been specifically related to sling use, the determine whether the sling truly is meeting the
learned nonuse studies of Taub, Uswatte, and Pidikiti173 predetermined goal).
may influence therapists’ decisions about whether to pre- ■ Therapists must become familiar with a variety of
scribe a sling, especially for a patient in the acute phase. slings. One particular sling will not meet the needs
Zorowitz204 stated that “although supports are com- of every patient (Fig. 10-28).
monly used during the rehabilitation of stroke survivors, ■ Therapists should continue to investigate the
there is no absolute evidence that supports prevent or use of alternative means to support the more
reduce long-term shoulder subluxation when spontaneous affected extremity during activities performed in
recovery of motor function occurs, or that a support will the upright position, such as putting the hand in
prevent supposed complications of shoulder subluxation. a pocket, receiving support from an over-the-
Without proper training in the use of a support, stroke shoulder bag, using functional electrical stimula-
survivors may face potential complications such as pain tion, and adding scapular or humeral taping/
and contracture.” Although the literature does not give strapping protocols to present treatment plans. A
definitive answers about when or whether to use slings, recent review concluded that “There is some evi-
one can infer the following guidelines: dence that strapping the shoulder delays the onset
■ Therapists should minimize sling use during the of pain but does not decrease it, nor does it in-
rehabilitation process. crease function or adversely increase contrac-
■ Slings may be useful for supporting the more affected ture.”4 There are a variety of taping/strapping
extremity during initial transfer and gait training. techniques suggested. Optimal protocols require
■ Slings that position the extremity in a flexor pattern further analysis. (Fig. 10-29).
should never be worn unless the patient is in an up- One may infer from the literature that the most effective
right posture; in these cases, they should be worn way to reduce the level of subluxation is to provide the pa-
only for select activities (initial mobility training) tient with activities that enhance trunk and scapula align-
and short periods. This type of sling should never be ment, activate the rotator cuff, and enhance functional use
worn by patients in recumbent postures. of the extremity during weight-bearing and reach patterns.

Box 10-15
Considerations when Prescribing a Sling
PROS CONS

■ Protects patient from injury during transfers. ■ May contribute to neglect of body scheme disorders.
■ Allows therapist freedom to control trunk and lower ■ May contribute to learned nonuse.
extremities during initial gait, transfer, and upright ■ May hold upper extremity in a shortened position
function training. (e.g., internal rotators, adductors, and elbow flexors).
■ May prevent soft-tissue stretching (e.g., supraspinatus ■ Fosters dependence on passive positioning.
and capsular stretching). ■ May initiate shoulder-hand syndrome development
■ Prevents prolonged dangling of extremity. (i.e., immobility leading to swelling, shortening, and pain)
■ May relieve pressure on ■ May predispose patient to shoulder pain from shortened
neurovascular bundle (brachial plexus/brachial artery). internal rotators.
■ Supports weight of arm. ■ Does not reduce the amount of subluxation because the
alignment of the scapula and trunk are not affected.
■ Approximates head of humerus to malaligned scapula.
■ Prevents reciprocal arm swing while walking.
■ Prevents arm function (e.g., postural support and carrying)
in upright postures.
■ Blocks sensory input.
■ Prevents balance reactions of the upper extremity.
■ May block spontaneous use of the upper extremity.
■ Places no motor demands on the upper extremity.
272 Stroke Rehabilitation

A B C
Figure 10-28 A, Pouch sling. Sling is only to be used for short periods with patients in up-
right postures and frees therapist’s hands to control trunk and lower extremities. This sling may
be appropriate for initial phases of walking, transfer, and upright function training. B, Shoulder
saddle sling. Sling supports distal weight of extremity and can be worn under clothing. This
style of sling can be worn all day because it does not block distal function or hold extremity in
a flexor pattern. C, The GivMohr Sling (www.givmohrsling.com, 505-292-1144). (A and B
courtesy of Sammons Preston Rolyan, Inc, Bolingbrook, Ill.)

GENERAL TREATMENT PRINCIPLES

Therapists should consider the following treatment
principles:
■ Maintain a client-centered approach to the treat-
ment of upper extremity dysfunction.
■ Evaluate and plan treatments that focus on improv-
ing occupational performance.
■ Focus treatment on task-specific training.
■ Incorporate resistance training into treatment
plans.
■ Maintain mobility (upward rotation and protrac-
tion) of the scapula and humeral external rotation to
prevent pain syndromes and prepare for return of
function.
■ Maintain soft-tissue length and joint mobility in
the trunk, head, and neck, and more affected upper
extremity.
■ Provide appropriate positioning strategies for times
when patients are not involved in activities and are
Figure 10-29 Taping/strapping is being used more commonly in recumbent postures.
to treat shoulder instability. Further research is required to de- ■ Provide opportunities for patients to use the upper
termine its effectiveness. extremity outside of structured therapy time.
 Chapter 10 • Upper Extremity Function and Management 273

■ Train all caregivers (staff and family) in the appro-

priate handling of the more affected upper extremity pattern of humeral internal rotation, pronation, and
during ADL and mobility. wrist flexion.
■ Evaluate and treat any pain syndrome immediately Passive range of motion was within normal limits
and consistently until symptoms are alleviated. after the scapula was mobilized and gliding with the
■ Guide appropriate usage of available motor control exception of lacking 20 degrees of external rotation. No
by providing functional activities that correspond to evidence of spasticity was found on quick stretch. J.C.’s
the patient’s level of recovery. Discourage participa- muscle grades were grossly 2 out of 5; scapula and hu-
tion in activities that require extra effort. merus (except external rotation), 0 out of 5; elbow, 3 out
■ Grade activities systematically and with control to of 5; forearm, 2 out of 5; wrist, 1 out of 5; finger flexion,
increase level of control and functional use. 3 out of 5; finger extension, 2 out of 5; and finger
■ Prevent learned nonuse by incorporating the upper abduction/adduction, 1 out of 5. J.C. did not have selec-
extremity into daily life immediately after the tive control of his extremity; instead he moved in gross
stroke. patterns. He was not able to incorporate his left upper
■ Encourage patients to take responsibility for the extremity into his ADL on initial evaluation. Limita-
protection, maintenance, and improvement of their tions to J.C.’s ability to use his upper extremity were
more affected upper extremity. identified as inefficient movement patterns (“stereo-
■ Avoid the use of aggressive passive range of motion typical”) due to loss of postural control, weakness, and
(PROM) and overhead pulleys. trunk and upper extremity malalignments.

CASE STUDY Week 1 Goals and Treatments

Treatment goals for the first week were as follows:
Upper Extremity Function after Stroke
1. Roll independently while protecting the left up-
J.C. is a 60-year-old male who suffered a right middle per extremity.
cerebral artery stroke one week before referral. J.C. was 2. Stretch independently (using the towel-on-table
in his usual state of good health until he experienced a program).
sudden onset of left-sided weakness. Before this inci- 3. Independently position the left upper extremity
dent, J.C. had just sold his antique store to enjoy retire- on a table while eating and performing leisure
ment. J.C. lives alone, and his interests include reading, activities.
gardening, watching movies, wine tasting, and restoring 4. Independently relieve pressure by lateral weight
furniture. J.C.’s evaluation and occupational therapy shifting in the wheelchair. (J.C. was instructed to
treatment plan (focusing on improved upper extremity perform this in front of the dining table with
function for this study) were as follows. both forearms supported on the table.)
At this stage, J.C. also was provided with a half swing-
Initial Evaluation away lap tray and bed positioning items, including a
J.C. was alert and oriented, followed complex com- pillow for under his left scapula and left elbow.
mands, had no evidence of cognitive-perceptual deficits Treatment focused on left upper extremity protection
with the exception of questionable difficulty with activi- during transitional movements and reaching activities
ties incorporating spatial relations components, and had using the right upper extremity in all directions, with a
intact sensation. His resting sitting posture consisted of a focus on trunk responses and inclusion of rotational ac-
posteriorly tilted pelvis with minimal functional kypho- tivities to recruit abdominal muscle activity. Activities
sis, increased weight-bearing on the left ischial tuberos- such as repotting plants were used because they required
ity, right trunk shortening, and a posteriorly rotated left a variety of reach patterns and were previously enjoyed
rib cage. J.C. required minimal assistance with postural by J.C. At this point the left upper extremity was used to
adjustments while performing reaching tasks with the stabilize objects (e.g., the bag of soil).
right upper extremity. At rest, his left scapula was rotated J.C. was given a polystyrene plastic cup and asked to
downward and had minimal winging. The left glenohu- support his forearm on his lap tray, place the cup up-
meral joint had an anterior-inferior subluxation. side down into his left hand, and practice releasing it.
When asked to demonstrate any arm function, J.C. As the task became easier, he turned the cup right side
attempted to lift his arm against gravity with a resulting up to increase the difficulty level. During therapy,
pattern of active lateral trunk flexion to the right, active treatment focused on controlling the distal arm from
scapula retraction and elevation, and active humeral the mouth to the table (eccentrically) with his elbow
abduction; during this attempted movement, the distal supported on the table and the therapist supporting the
extremity fell passively into gravity with a resulting humerus with J.C.’s hand empty.
Continued
274 Stroke Rehabilitation

CASE STUDY REVIEW QUESTIONS

Upper Extremity Function after Stroke—cont’d
1. Which factors contribute to glenohumeral joint sub-
Weeks 2 and 3 Goals and Treatments luxation?
Treatment goals for the second and third weeks were as 2. Which factors contribute to a painful shoulder condi-
follows: tion after a stroke?
1. Independently hold a toothpaste tube in the left 3. In what way does biomechanical malalignment of the
hand while unscrewing the cap with the right hand. trunk and upper extremity contribute to ineffective
2. Lift the arm from the lap to the lap tray without and inefficient movement patterns?
the right upper extremity assisting. 4. Describe the learned nonuse phenomenon and treat-
3. Independently stretch the left wrist and digits ments aimed at its prevention or reversal.
into extension. 5. Which factors contribute to a malaligned scapula?
At this stage, J.C. progressed to assuming standing pos- 6. Describe a treatment progression aimed at increasing
tures in front of a work surface. Activities included buff- manipulation patterns.
ing tables and sliding papers across the table past arm’s 7. What are the components of a task-oriented approach
length with the left upper extremity to encourage scapula to improving upper limb function?
protraction. Wiping the table (hand-over-hand) and fo-
cusing on patterns to the far left were used to maintain
soft-tissue length and encourage external rotation. As the REFERENCES
task became easier, J.C. held the towel in his left hand 1. Ada L, Canning CG, Call JH, et al: Task-specific training of reaching
and wiped the table using only his left upper extremity. and manipulation. In Bennett KMB, Castiello U, editors: Insights into
the reach to grasp movements, Amsterdam, 1994, Elsevier Science.
2. Ada L, Dorsch S, Canning CG: Strengthening interventions in-
Weeks 3 and 4 Goals and Treatments
crease strength and improve activity after stroke: a systematic re-
Treatment goals for the third, fourth, and fifth weeks view. Aust J Physiother 52(4):241–248, 2006.
were as follows: 3. Ada L, Foongchomcheay A: Efficacy of electrical stimulation in pre-
1. Locking wheelchair brakes independently with venting or reducing subluxation of the shoulder after stroke: a meta-
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 su s an e. f as o l i

chapter 11

Rehabilitation Technologies
to Promote Upper Limb
Recovery after Stroke

key terms
adjunctive interventions haptics robot assisted therapy
backdrivability impedance technology
degrees of freedom

chapter objectives
After completing this chapter, the reader will be able to:
1. Discuss the rationale for using rehabilitation technologies and theories that have guided
their development.
2. Describe similarities and differences among different technology devices, specifically how
they work and what they might add to the therapist’s repertoire of treatment tools.
3. Evaluate results of empirical studies on the use of rehabilitation technologies for the
paretic upper limb after stroke.
4. Identify considerations for choosing rehabilitation technologies for clinical use, including
their potential benefits and limitations.

Rehabilitation technologies to improve motor control devices to relatively simple spring-driven wrist/hand or-
after neurological injury have undergone tremendous thoses. Theories guiding technology development, re-
growth during the past 15 years. Two forces in rehabilita- search findings, and considerations for technology use in
tion medicine have provided impetus for this technology clinical practice are discussed.
development. The first is evidence of cortical reorganiza-
tion in response to movement therapy after stroke. The RATIONALE FOR DEVELOPMENT
second is the high cost of health care and significant re-
ductions in rehabilitation services that have occurred in Rehabilitation scientists are concerned about the lack of
recent years.38 This chapter provides an overview of reha- empirical evidence on treatment efficacy and its impact on
bilitation technologies, ranging from complex robotic motor recovery and functional outcomes after stroke.

280
 Chapter 11 • Rehabilitation Technologies to Promote Upper Limb Recovery after Stroke 281

At present, they do not have the knowledge needed to rather than the activity level, aimed at task execution and
predict which treatment interventions, dose, or intensity functional performance. The state of robotic development
elicit the best functional outcomes for a particular patient. has dictated this focus, as robots used in clinical trials have
Rehabilitation scientists are working diligently to quantify primarily exercised the paretic shoulder and elbow during
the “active ingredients” of various treatments, so they can reaching movements while the wrist and hand are sup-
make use of the most effective and efficient therapy meth- ported by the device.
ods when delivering clinical care to patients. Motor learning approaches to conventional stroke re-
Rehabilitation technologies can provide quantifiable habilitation have evolved to emphasize task-oriented
and repeatable treatment interventions and allow us to training aimed at increasing upper limb function and pa-
better measure the import of our interventions on im- tient participation in valued roles and routines.48 This
pairements of motor function.18 For example, robotic task-oriented approach, in which skill-related tasks are
devices can quantify changes in motor functions during practiced in natural contexts, has resulted in faster and
stroke rehabilitation by gathering kinematic and kinetic better treatment outcomes than traditional methods, such
data related to variables such as speed and accuracy of task as Bobath’s neurodevelopmental therapy.27 See Chapters 4
completion, smoothness of reach, or forces exerted during and 6. Recent trials of robot-assisted therapies have incor-
training. Movement scientists continue to explore these porated a task-oriented training approach in conjunction
data to further the understanding of how changes in mo- with other motor learning principles. For example, the
tor control may contribute to increased functional use of Armeo and HOWARD devices provide task-oriented
a paretic limb after stroke. training via virtual games during upper limb therapy, and
Rehabilitation technologies are not expected to replace can allow interaction with real and virtual objects during
occupational or physical therapists, but they will become repetitive, robot-assisted therapy. Studies have shown that
part of their treatment arsenal to optimize functional per- the training of virtual tasks can lead to significant gains in
formance after a disabling event. Although the present motor performance during real world activities (see
cost of these novel technologies is high, larger scale pro- Brewer and colleagues6 for review). As technological
duction is expected to lower costs for clinical use in the advances continue, rehabilitation technologies will be
future. Proponents of rehabilitation technologies predict better equipped to deliver task-oriented therapies more
that these tools will help to reduce or control rehabilita- aligned with current rehabilitation practice and directed
tion costs by providing intensive movement therapies toward the ICF activity level of performance.
with minimal supervision by a therapist, which is impor-
tant at a time when patients receive less therapy after ROBOT ASSISTED THERAPY
neurological injuries, such as stroke, despite research evi-
dence that more therapy is better.38 The use of this tech- Two main classes of rehabilitation robots have been devel-
nology may help to shorten inpatient hospitalizations and oped. Robots such as the Assistive Robotic Manipulator
enhance outpatient services, which hopefully will lead to (ARM) (www.exactdynamics.nl) allow the user to compen-
improved long-term functional outcomes. sate for lost skills when the potential for motor recovery is
poor. The purpose of this chapter is to review a second class
THEORIES GUIDING TECHNOLOGY of robots, which provide repetitive, task-specific training to
DEVELOPMENT help restore lost motor function. Unlike constraint-induced
movement therapy (CIMT), robot-assisted technologies
Rehabilitation technology is a new and growing field, expe- are appropriate for persons with moderate to severe motor
riencing some of the same developmental challenges seen impairments.
during the history of conventional rehabilitation practice. Rehabilitation robots to restore lost motor function
Its development has been strongly influenced by motor can be categorized by how the device is controlled or ac-
learning principles, in particular massed practice and ex- tivated and how the user interface is designed. Robots for
plicit learning paradigms.6 For example, rehabilitation ro- the upper limb can be broadly classified into three types:
botics are designed to produce highly intensive upper limb active systems, with actuators that provide movement as-
training that is quantifiable, easily graded, cognitively chal- sistance along a defined trajectory; passive systems that
lenging, and goal-directed. Motor learning principles guide support the limb during movement attempts; and interac-
their delivery of feedback with regard to knowledge of per- tive systems in which actuators or motors are combined
formance (e.g., via haptics), and knowledge of results, via with impedance and control strategies that allow the ro-
graphs, changes in the virtual tasks and environment, and bot to react to the patient’s movement attempts.
other forms of feedback. To date, robotic therapy trials The way in which the robot assists with movement af-
have focused on improving motor performance at the In- fects how the robot “feels” to the user during therapy. Low
ternational Classification of Functioning, Disability, and impedance interactive robots such as the MIT-MANUS
Health (ICF) level aimed at body structures and functions, are highly “back-drivable” and compliant to a client’s
282 Stroke Rehabilitation

attempts to move, allowing precise and objective measures during conventional therapy. Although MIT-MANUS is
of motor performance. Active robots that use pneumatic capable of providing passive, active-assistive, and active
actuators or “muscles” to power the device (e.g., Hand and resistive modes of therapy, the majority of studies
Mentor) are not as responsive to the patient’s movement have investigated the effects of active-assistive robotic
attempts, because the mechanics of the robot create a therapy on motor recovery after stroke. The adaptive al-
more viscous response, similar to moving through honey. gorithm used in recent studies allows the robot to adjust
Passive robotic systems offer varied forms of nonpowered the amount of guidance or assist provided to the patient
assistance with elastic bands or springs that support the based on his/her individual needs.
limb against gravity during movement attempts. Examples Proof of concept studies began in the mid-1990s, with
include the Therapy Wilmington Robotic Exoskeleton a focus on the effects of intensive robot-assisted senso-
(T-WREX) and Armeo devices described later. rimotor therapy for individuals in inpatient rehabilitation
The user/robot interface is another consideration when during the first weeks poststroke.1 Since then, investiga-
selecting rehabilitation robots for clinical use. End-effector tions have primarily included persons with chronic and
robots, such as the MIT-MANUS and Mirror Image Mo- moderate to severe motor impairments more than six
tion Enabler (MIME), are typically attached to the person’s months after stroke. In this research, participants typically
hand or forearm at a single point of contact. These robots received one hour of robotic therapy three times per week
are easily adjusted to different arm lengths, but do not con- for six weeks, performing approximately 18,000 repetitive
trol movement torques at individual joints. In contrast, the reaching movements over the course of therapy.
structure of exoskeletal robots more closely resembles hu- As a whole, these studies indicate that treatment inten-
man anatomy and allows separate control of torques ap- sity and task specificity play a critical role in upper limb
plied to each joint. Exoskeletal robots, such as the interac- robot-assisted therapy. Reductions in motor impairment
tive ARMin, require more effort when adapting them to after MIT-MANUS training were task-specific in that the
different body sizes because each robot link must be ad- largest gains were observed in the exercised shoulder and
justed to match the length of the user’s upper and lower elbow vs. the unexercised wrist and hand.12,50 Compari-
arm.34 The therapeutic games used to visually direct the sons of robot vs. therapist directed therapy of equal inten-
patient’s movement attempts during robot-assisted therapy sity by Volpe and colleagues51 revealed no significant
also vary in their degree of complexity, ranging from simple group differences in motor outcomes (see Table 11-1).
stimuli to virtual environments designed to simulate func- Stein and colleagues44 revealed that patients engaged in
tional task performance. active-assistive or progressive-resistive training with the
The discussion that follows is arranged from high to MIT-MANUS robot had similar gains in motor perfor-
low tech, starting with more complex, low impedance mance over the course of treatment (see Table 11-1). In this
robots to simpler wrist hand orthoses. Proximal devices study, the level of initial severity vs. type of robotic therapy
are presented before distal technologies. During this had a differential effect on motor outcomes. Individuals
review, readers are encouraged to consider needs specific who were better able to reach the robotic therapy targets at
to their patient mix and clinical setting, and potential study admission had larger gains in motor control on the
goals for intervention. Controlled studies that compare Fugl-Meyer Assessment (FMA), regardless of treatment
rehabilitation technologies to other forms of therapy are Text continued on p.296
highlighted in Table 11-1.

MIT MANUS and InMotion2 Robots

The most widely studied rehabilitation robot is the MIT-
MANUS and its successor the InMotion2 (Interactive
Motion Technologies, Watertown, MA). During therapy,
the client is seated at the robot workstation and the paretic
hand is positioned in a customized arm support attached to
the end-effector (i.e., handle) of the robot arm. Therapy
involves repetitive goal-directed, planar reaching tasks that
emphasize shoulder and elbow movements. As clients at-
tempt to move the robot’s handle toward designated tar-
gets, the computer screen in front of them gives visual
feedback of the target location and movement of the robot
handle (Fig. 11-1).
The low impedance controller of the MIT-MANUS is Figure 11-1 InMotion2 planar robot to exercise the paretic
highly compliant when interacting with the client’s arm, shoulder and elbow with wrist and hand supported. (Courtesy of
similar to hand-over-hand assistance from a therapist Hermano Igo Krebs.)
Table 11-1
Post-Stroke Upper Limb Technology: Evidence Summary

Chapter 11 • Rehabilitation Technologies to Promote Upper Limb Recovery after Stroke

PRIMARY
AUTHORS STUDY DESIGN OUTCOME MEASURES
AND YEAR AIM/HYPOTHESIS AND SUBJECTS INTERVENTION AND RESULTS COMMENTS RATING

Aisen and Does intensive sup- Controlled trial Exp: 4–5 hrs of goal- Functional Indepen- Focused robotic ther- III
colleagues, 1997 plemental robotic N ⫽ 20 directed move- dence Measure apy had task-specific
therapy improve Subacute inpatients ment therapy with (FIM), Fugl-Meyer training effects on
motor outcomes in rehabilitation MIT-MANUS. Assessment (FMA), shoulder and elbow
after stroke? hospital. Control: Weekly or Motor Status Scale motor recovery.
biweekly contact (MSS), Motor Power Additional therapy
with MIT- (MP) (shoulder and provided by robot
MANUS: no elbow) yielded higher trends
active assist from FIM: no significant in motor scores.
robot. group differences. Separate study (Volpe
Both received All subjects showed im- and colleagues, 1999)
conventional proved motor scores. showed that robot
rehabilitation. Non-significant (NS) group participants
group differences continued to show
on MP and FMA al- significant gains in
though change scores motor scores as
greater in exp group. compared to control
Exp group gains were at 3 years (n ⫽ 12 of
significantly better original 20 subjects).
on MSS shoulder
and elbow subscore
(p ⫽ 0.002). No
change on wrist and
hand items.

Continued

283
 284
Table 11-1
Post-Stroke Upper Limb Technology: Evidence Summary—cont’d

Stroke Rehabilitation
PRIMARY
AUTHORS STUDY DESIGN OUTCOME MEASURES
AND YEAR AIM/HYPOTHESIS AND SUBJECTS INTERVENTION AND RESULTS COMMENTS RATING

Alon, Levitt, H: Functional Elec- Controlled trial Control: standard- Box and Block test, Length of time exercis- II
and McCarthy, trical Stimulation N ⫽ 15 ized task-specific light object subtest ing and compliance at
2007 (FES) with task- Subacute rehabilita- occupational and of Jebsen Taylor Test, home not monitored
specific training can tion inpatients who physical therapy Modified Fugl-Meyer No follow-up evalua-
enhance recovery of continued program program Test (excluding tions completed to
upper limb function at home post d/c (OT/PT) Exp: same reflex items and test for sustained
when begun during standardized tasks coordination/speed effects
inpatient rehabilita- as control synchro- — max score ⫽ Total time of interven-
tion and continued nized with NESS 54 points) tion differed across
for 12 wks. H-200 e-stim for Statistically significant groups, as FES group
activation of wrist/ and large effects seen received additional
finger flexors and on all measures favor- e-stim without exer-
extensors ing FES group cise for about 2 hrs
Two 30 min Mean scores on modi- daily
sessions/5 days/wk fied FMA after
for 12 wks. FES 12 wks of treatment
group received were 49.3 (⫾ 5.1)
additional e-stim for FES,
without concur- 40.6 (⫾ 8.2)
rent exercises for control group.
Coote, To compare effects of Series of single case Robot mediated FMA, Motor Assess- Different response to III
Murphy, robot mediated studies using ran- therapy delivered ment Scale, and ac- treatment was seen
Harwin, and therapy with Haptic domized multiple 30 mins 3⫻/wk tive range of motion across the 20 subjects
Stokes, 2008 Master to sling sus- baseline design with for 3 wks (AROM) at shoulder and can be attributed
pension exercises ABC or ACB order Haptic Master Modest recovery trends to group heterogene-
for persons with N ⫽ 20 delivered virtual were seen across ity (time poststroke,
hemiparesis Time poststroke training with measures. baseline impairment).
poststroke ranged from 3 mos visual and haptic Overall, rate of recov- Intervention was more
to 75 mos. feedback ery was greater beneficial to subjects
Suspension sling during robot- who scored ⬎20 on
group practiced mediated therapy. baseline FMA.
single plane Optimal duration of
reaching exercises intervention is likely
for same dose and higher than that
frequency delivered during this
trial; further research
needed to examine
best dose and timing.
Hesse and To compare effects of Randomized Robot group FMA Bilateral training and II
colleagues, 2005 repetitive exercises controlled trial performed 800 Secondary Medical higher number of
with Bi-Manu- N ⫽ 44 participants repetitions/session Research Council repetitions may have
Track robotic arm with severe UE of unilateral and (MRC) motor power contributed to larger
trainer to repetitive paresis (initial FMA bilateral forearm and Modified gains in robot group.
EMG initiated elec- score ⬍18) 4 to and wrist Ashworth Scale.
trical stimulation 8 wks poststroke exercises. FMA and MRC were
(ES) of paretic wrist (subacute) ES group per- significantly better at
extensors. formed 60 to d/c in robot trained
80 repetitions group. Gains were

Chapter 11 • Rehabilitation Technologies to Promote Upper Limb Recovery after Stroke

wrist/extension maintained at 3 mo
exercises/session. follow-up.
Both groups
received these
interventions
20 min/5 days/wk
for 6 wks.
All subjects received
conventional OT/
PT based on neu-
rodevelopmental
principles 4 to
5 days/wk.

Continued

285
 286
Stroke Rehabilitation
Table 11-1
Post-Stroke Upper Limb Technology: Evidence Summary—cont’d
PRIMARY
AUTHORS STUDY DESIGN OUTCOME MEASURES
AND YEAR AIM/HYPOTHESIS AND SUBJECTS INTERVENTION AND RESULTS COMMENTS RATING

Housman To compare motor RCT All participated in FMA: upper limb T-WREX computer II
and colleagues , training with N ⫽ 34 participants 24 1–hour sessions subtest, Rancho generated games en-
2009 Therapy ⬎6 mos poststroke 3⫻/wk for 8 to Functional Test for abled repetitive task-
Wilmington with moderate to 9 wks. the Hemiplegic specific practice.
Robotic Exoskeletor severe hemiparesis T-WREX group: Upper Extremity, Tasks included simu-
(T-WREX) to (FMA score ⱖ10 completed 3 reps Motor Activities Log lated grocery shop-
conventional and ⱕ30) of 10 computer (quality and amount ping, cleaning a
table-top home generated therapy of use), Flock of Birds stove-top, and playing
exercise program games each ses- motion system to basketball.
sion. Gravity sup- assess free reach Feedback of task per-
port was decreased No significant between formance from T-
as tolerated every group differences WREX games en-
3rd session. except greater 6-mo hanced motivation
Control group re- gain on FMA favored and awareness of
ceived conven- T-WREX group progress.
tional self-ROM Satisfaction survey re-
exercises, active vealed that subjects in
assistive ROM, both groups found
and AROM with T-WREX less boring
towel exercises and more beneficial
during table-top than conventional
and prescribed table-top exercises.
ADL activities.
Kahn and To compare effects of RCT Robot group per- Chedoke-McMaster Significant gains in II
colleagues, 2006 active assistive N ⫽ 19 persons formed active as- Stroke Assessment both groups suggest
exercise delivered at least 1 year sistive range of Scale that repetitive task-
via ARM Guide to poststroke motion (AAROM) Rancho Los Amigos specific practice was
free reaching reaching exercises Functional Test for key to improved
voluntary exercise with ARM Guide Hemiparetic UE. motor recovery.
with paretic arm to targets located Biomechanical assess- ARM Guide therapy
at limits of ment of limb stiffness did not provide
subject’s reach. and supported reach. detectable benefit
Free-reach group Flock of Birds to beyond that achieved

Chapter 11 • Rehabilitation Technologies to Promote Upper Limb Recovery after Stroke

performed measure unsupported with unassisted prac-
matched number free reach tice. Authors question
of reaches to same No significant group whether type of assist
targets as robot differences. Both provided by ARM
group. All move- groups improved in Guide was optimal.
ments were mea- ROM and velocity of Unclear whether indi-
sured with Flock supported arm viduals not involved
of Birds. movements and in clinical research
Subjects in both decreased time to would perform high
groups were in- complete functional number of unassisted
structed to reach tasks. Free reach movements during
as fast as possible group improved independent home
toward targets. significantly more in program.
movement smooth-
ness. Gains were
sustained at 6-mo
follow-up.

Continued

287
 288
Stroke Rehabilitation
Table 11-1
Post-Stroke Upper Limb Technology: Evidence Summary—cont’d
PRIMARY
AUTHORS STUDY DESIGN OUTCOME MEASURES
AND YEAR AIM/HYPOTHESIS AND SUBJECTS INTERVENTION AND RESULTS COMMENTS RATING

Luft and To compare effects of RCT Both groups re- FMA upper limb Changes in brain activa- II
colleagues, 2004 bilateral arm training N ⫽ 21 participants ceived 1-hour subtest, Wolf Motor tion were found in
with bilateral arm with chronic motor therapy sessions Function Test, BATRAC group, but
training with rhyth- impairments. 3⫻/wk for 6 wks. University of not DMTE group.
mic auditory cveing BATRAC training Maryland Arm Authors also report that
(BATRAC) to dose- involved repetitive Questionnaire for BATRAC group had
matched therapeutic bilateral pushing/ Stroke (UMAQS). significantly greater
exercises based on pulling motion Functional Magnetic gains on FMA when
neurodevelopmental (symmetrical and Resonance Imaging 3 BATRAC subjects
treatment (NDT) asymmetrical) in (fMRI). with no change in
approach response to No significant group cortical activation
Authors hypothesized auditory cues. differences on clinical were eliminated from
that BATRAC Control group measures. analysis. However,
would be associated received dose Movement of paretic this assertion com-
with cortical matched arm in BATRAC pares patients who
reorganization of therapeutic group led to signifi- experienced cortical
sensorimotor cortex. exercises (DMTE) cant increase in changes (BATRAC
based on NDT contralesional n⫽9) to those who
principles. hemisphere activa- did not (DMTE
tion, but no change in n ⫽ 12).
ipsilesional cortex.
Lum and To compare effects of RCT All subjects received FMA upper limb and Although time in ther- II
colleagues, 2002 robot-assisted N⫽27 subjects with 24 1-hr therapy sensory subtests, apy was equal across
therapy with Mirror motor impairments sessions over Barthel Index and groups, movement
Image Motion ⬎6 mos poststroke 2 months. FIM transfers, repetition was greater
Enabler (MIME) Robot group prac- shoulder and elbow in robot group.
robot to conven- ticed 12 point- strength, free reach Faster rate of motor
tional therapy based to-point reaching kinematics. improvement was
on NDT principles movements Robot group had larger observed in robot
focused on shoul- gains in proximal group, which may be
der and elbow items on FMA, important clinical

Chapter 11 • Rehabilitation Technologies to Promote Upper Limb Recovery after Stroke

movements. Four strength, and reach benefit if replicated in
modes of robot extent. At 6-mo other studies.
assisted move- follow-up, no
ment: PROM, significant group
AAROM, active- differences remained
constrained on FMA, but robot
(against robot group had higher
resistance) viscous, FIM improvements.
and bimanual
(robot assists
paretic arm to
mirror unaffected).
Control group: con-
ventional NDT
approach empha-
sizing muscle
reeducation based
on sensorimotor
approach to
control motor
output. Time was
spent on UE use
during graded
functional asks.

Continued

289
 290
Stroke Rehabilitation
Table 11-1
Post-Stroke Upper Limb Technology: Evidence Summary—cont’d
PRIMARY
AUTHORS STUDY DESIGN OUTCOME MEASURES
AND YEAR AIM/HYPOTHESIS AND SUBJECTS INTERVENTION AND RESULTS COMMENTS RATING

Lum and To confirm results of RCT All subjects received Measures: FMA, Motor Gains on FMA were II
colleagues, 2006 clinical trial with N ⫽ 30 15 1-hour sessions Status Score, Motor task-specific, in that
chronically impaired Subacute stroke over 4 wks. Power, FIM proximal scores (not
subjects to those in (1 to 5 mos. post 4 Exp Groups: At discharge: distal) improved with
subacute stage of onset): Robot Unilateral Robot Combined therapy
motor recovery and Robot Bilateral performed better Using an MCID of
to identify essential Robot Combined than NDT control on 10%, gains at d/c on
therapeutic features (unilateral and FMA impairment measures
of MIME therapy. bilateral) Significant gains in were clinically signifi-
Authors hypothe- Conventional both unilateral and cant in unilateral and
sized that bilateral Therapy (NDT) combined groups but combined modes.
mode would no significant group Patients with moderate
produce greater differences on FMA, impairments benefit-
gains than unilateral Motor Power, or FIM ted most from robotic
mode. Smallest change in training.
FMA, motor power,
and FIM seen in
bilateral only group
At 6-mo follow-up,
no group differences
remained.
Stein and To examine whether Controlled study All subjects received FMA Contrary to traditional III
colleagues, 2004 progressive resistive N ⫽ 47 individual 1 therapy 3⫻/wk for Modified Ashworth theories of motor
training provides to 5 years poststroke 6 wks with Scale recovery, resistance
incremental benefits Subjects qualified for InMotion2 robot. Robot measures of training did not exac-
over active assistive resistance training Both groups: arm force generation in erbate spasticity in
robot-aided upper if able to reach all was supported in paretic arm. the paretic arm.
limb therapy after robot targets unas- wrist hand Subjects in all groups Limitation: functional
stroke sisted at baseline orthosis attached showed gains on use of limb during
and 3 wk interim to robot handle. FMA and maximal daily activities was
force generated. not directly

Chapter 11 • Rehabilitation Technologies to Promote Upper Limb Recovery after Stroke

assessments. The same training
Qualifying subjects tasks were used by No group differences measured.
were randomly both groups. in outcome measures.
assigned to either Active-assistive Participants with better
the progressive training group: motor control at
resistive or robot provided baseline showed
active-assistive assist to reach greater gains on
robot groups. targets as needed. FMA, regardless of
Resistance group: treatment group.
reaching move-
ments were
performed against
robot resistance.
Amount of resis-
tance was based on
robotic measures
of subject’s
strength.
Participants in each
group completed
approximately
18,000 movement
repetitions over
course of therapy.

Continued

291
 292
Stroke Rehabilitation
Table 11-1
Post-Stroke Upper Limb Technology: Evidence Summary—cont’d
PRIMARY
AUTHORS STUDY DESIGN OUTCOME MEASURES
AND YEAR AIM/HYPOTHESIS AND SUBJECTS INTERVENTION AND RESULTS COMMENTS RATING

Takahashi Robotic therapy Controlled trial ANA-A group: Action Research Arm Findings indicate dose II
and colleagues, would improve N ⫽ 13 adults with trained with robot Test (ARAT), Box dependent benefit for
2008 motor function in stroke at least 3 mos in active nonassist and Blocks Test, active assist robotic
patients with prior to enrollment mode for first Fugl-Meyer arm therapy.
chronic motor with resulting right 7.5 days and active motor scale ANA-A group showed
deficits after stroke. upper extremity assist mode in last fMRI and EMG some significant gains
A higher dose of (RUE) weakness 7.5 days of Both groups showed on primary measures
active assist therapy treatment significant gains on during treatment in
mode would lead to AA group: used all measures: those in active nonassist mode
greater behavioral robot in active AA group improved (robot motors not
gains. assist mode for all significantly more active). Supports
A movement 15 days than ANA-A group. importance of
performed by the Each subject re- fMRI showed increased challenging, repeti-
paretic upper limb ceived 15 daily sensorimotor cortex tive task practice
during therapy sessions over activation for prac- fMRI findings indicate
would show 3 wks, each ticed grasp/release task-specific cortical
increased represen- ⬃1.5 hrs long. task, but not for non- reorganization:
tation in the stroke Practice of various practiced supination/ impact on generaliza-
affected primary open/close tasks pronation. tion of training needs
sensorimotor with real or virtual further study
cortex, while objects displayed
movement not per- on computer
formed would not. monitor
Taub and To test the effective- Controlled trial. All subjects wore Wolf Motor Function Amount of therapist III
colleagues, 2005 ness of the N ⫽ 27 persons with padded safety mitt Test; Motor supervision did not
AutoCITE device chronic motor on less affected Activity Log affect outcomes:
that automates impairments after hand 90% of Large and significant partial supervision
CIMT when only stroke (⬎1 year waking hours over gains on both with AutoCITE was
partially supervised postonset) 2-wk period. outcome measures as effective as nonau-
by therapists. Subjects were as- Subjects received observed for all tomated, therapist de-
Participants in signed to 1 of training with 3 groups with no livered intervention.
3 groups received 3 groups in AutoCITE between group This technology has
supervision from a alternating blocks. 3 hrs/day on each differences. potential to increase

Chapter 11 • Rehabilitation Technologies to Promote Upper Limb Recovery after Stroke

therapist 100%, All subjects had mini- weekday. Gains on MAL at therapist efficiency by
50%, or 25% of mum of 20-degree Subjects in reduced 1 mo and long-term allowing partially
training time. wrist extension and supervision groups follow-up were also supervised treatment
10-degree finger received therapist significant (p ⬍0.001) of more than one pa-
extension in paretic guided shaping, tient simultaneously.
hand with impaired encouragement, or No control group
functional use for feedback to sup- receiving only mitt
ADL plement computer constraint on less
Subjects who received monitor for either affected hand
100% supervision 25% or 50% of
were treated during treatment time.
prior study (see
Lum and colleagues,
2004).

Continued

293
 294
Stroke Rehabilitation
Table 11-1
Post-Stroke Upper Limb Technology: Evidence Summary—cont’d
PRIMARY
AUTHORS STUDY DESIGN OUTCOME MEASURES
AND YEAR AIM/HYPOTHESIS AND SUBJECTS INTERVENTION AND RESULTS COMMENTS RATING

Volpe and Examined whether RCT All subjects received FMA Task-specific effects II
colleagues, 2000 additional N ⫽ 56 persons ad- standard OT and Motor Status Score of training were
sensorimotor train- mitted to inpatient PT. Motor Power observed without
ing with robotic rehabilitation on Robot group: 1 hr/ FIM generalization to
device enhanced average 2 wks day, 5 days/wk for As a whole, subjects in wrist and hand
upper limb motor poststroke minimum of both groups showed (untrained
outcome (subacute) 25 sessions. significant gains on in robot therapy).
InMotion2 robot all measures, except Duration of inpatient
provided repetitive FMA for wrist and rehabilitation was
active-assistive hand. longer than current
exercises focused Robot trained group practice.
on shoulder and had significantly
elbow reaching greater gains in
movements. shoulder and elbow
Control group: items on the Motor
Exposure to robot Status Score and in
1⫻/week. Half of Motor Power, and
trials were significantly greater
performed with gains on FIM.
unimpaired arm.
Robot motors
were not active:
patient used unim-
paired arm to
assist when paretic
limb could not
complete task.
Volpe and To compare effects of RCT Matched session du- FMA (separated into Intensity of therapist- II
colleagues, 2008 a standardized N⫽ 21 participants ration, number proximal and distal delivered in this study
therapist-delivered with upper limb and timing of subtests), Motor was greater than
intensive physical motor impairments treatments: 1 hr Power of shoulder traditional outpatient
therapy program 6 or more mos sessions, 3⫻/wk and elbow, Modified therapy.
with robotic-driven poststroke for 6 wks Ashworth Scale. Dis-
protocol Therapist-delivered ability scales included
treatment included Stroke Impact Scale,
static stretching, Action Research Arm
active assisted Test (ARAT).

Chapter 11 • Rehabilitation Technologies to Promote Upper Limb Recovery after Stroke

exercise, goal No significant group
directed planar differences: statisti-
reaching tasks cally significant
based on Carr and changes observed in
Shepherd princi- both groups on FMA
ples; incorporating for shoulder and
NDT techniques. elbow and Motor
Robot group: Adap- Power that was
tive active-assistive sustained at 3 mo
treatment using follow-up. No change
InMotion2 robot. in distal FMA scores
Treatment in- for wrist and hand.
volved repetitive No significant im-
planar reaching provements on
tasks focusing on disability measures or
shoulder and group differences on
elbow control. Modified Ashworth
Scale.

CIMT, Constraint-induced movement therapy; DMTE, dose-matched therapeutic exercise; MCID, minimum clinically important difference; RCT, randomized controlled trial.

295
296 Stroke Rehabilitation

group. Although prior investigations have supported the

use of compensatory strategies for persons with severe mo-
tor impairments after stroke,4 gains observed across robotic
therapy studies indicate a potential for improvement in
persons with moderate to severe motor impairments.
A report of two pilot studies with the MIT-MANUS
compared robot-assisted therapy (as described previously) to
“functionally-based” robotic therapy in persons with moder-
ate to severe motor impairments. This functionally-based
therapy trained both reach and grasp/release during virtual
or object present tasks. Although greater gains were reported
for the robot-assisted therapy group, participants who re-
ceived “functionally-based” therapy improved more on wrist A
and hand items of the Fugl-Meyer Assessment.24 Study
limitations include fewer movement repetitions and the
treatment context during “functionally-based” robotic ther-
apy (i.e., training occurred within the confines of the robot’s
workspace). The authors proposed that persons with moder-
ate to severe motor impairments after stroke may benefit
more from robotic therapy focused on motor functions vs.
activity-based skills training. Future studies on the relation-
ship between stroke severity, focus of robot-assisted therapy
(e.g., ICF impairment vs. activity level), and functional out-
comes will both inform clinical practice patterns and guide
insurance resource allocation for therapy practice.
Finally, a comparison of proximal robot-assisted therapy
with the MIT-MANUS to distal training via a three degree
of freedom (DOF) forearm and wrist robot showed that
distal robot assisted therapy led to a greater transfer of skill
to proximal limb segments than vice-versa.25 This small B
study implies that the sequence of treatment tasks may also Figure 11-2 The Mirror Image Motion Enabler (MIME) robot
be important, a finding that challenges conventional theo- can be used for unilateral or bilateral movement therapy. (From
ries that support proximal to distal training after stroke. Kahn LE, Lum PS, Rymer WZ, et al: Robot-assisted movement
Mirror Image Motion Enabler training for the stroke-imparied arm: does it matter what the ro-
bot does? J Rehabil Res Dev 43(5) 631–642, Aug/Sept 2006.)
The MIME is an industrial PUMA robot reconfigured for
rehabilitation that provides passive, active-assistive, ac-
tive-resisted, and bimanual training of the upper limb. Its shoulder and elbow items of the FMA during the two
controller is not as compliant to a patient’s weak attempts month treatment period. However, no between-group
to move as the MIT-MANUS described previously, so the differences were found in FMA scores for the unexercised
MIME is not as sensitive for recording changes in motor wrist and hand during this time. In both studies, gains in
performance over the course of treatment. During MIME the robot and conventional therapy groups were equiva-
therapy, the patient sits at the robot workstation, and his lent at the six month follow-up. The authors proposed
or her forearm and hand are supported in a splint attached that conventional therapy led to greater carryover of
to the robot manipulator (Fig. 11-2). The training exer- home exercise programs, which resulted in continued
cises include a core set of 12 targeted reaching motions gains in this group after the intervention trial.
that emphasize shoulder and elbow movements in three- In those who received robot assisted therapy, the type
dimensional space. of robot intervention produced different motor outcomes.
In two influential studies, Lum and colleagues29,30 Subacute patients who received bilateral training did not
compared the effects of MIME upper limb robotic ther- improve as much as those who had unilateral or combined
apy to conventional treatment based on Bobath’s neuro- unilateral and bilateral training. Persons who received this
developmental approach. Persons in both chronic and combined robot training in the subacute and chronic
subacute stages of motor recovery after stroke were exam- studies showed an accelerated rate of motor recovery on
ined (see Table 11-1). Lum found that subjects who re- clinical scales. The increased effort required during the
ceived robotic therapy had statistically greater gains on combined treatment likely contributed to these gains.
 Chapter 11 • Rehabilitation Technologies to Promote Upper Limb Recovery after Stroke 297

Although further research is needed to verify this effect, offered, based on the person’s performance. Testing is
the accelerated motor recovery is an important consider- underway to compare motor outcomes of subjects who
ation during clinical practice. participate in free reaching tasks vs. guided-force training
with the ARM Guide. As rehabilitation technologies con-
ARM Guide tinue to develop, scientists expect to learn much more
The Assisted Rehabilitation and Measurement (ARM) about the types of training that best meet an individual’s
Guide is a robotic device that applies and measures assis- needs for motor recovery.
tive or resistive forces while the user performs reaching When thinking about clinical use of robotic devices, it
movements along a linear track.39 The patient’s paretic is important to consider the degree to which successful
arm is supported in a forearm trough that is attached to practice of arm exercises influences adherence to exercise
the track and actuated or controlled by the robot motors. programs and contributes to gains in functional use. A
The patient is asked to initiate reaching movements with home exercise program in which the patient is asked to
the paretic arm, and the robot motors provide assistance repeatedly reach toward challenging target locations is
when the person is unable to move along the desired tra- likely to be met with frustration and limited engagement.
jectory. The device is statically counterbalanced, so it re- Rehabilitation technologies can offer exercise programs
duces gravitational forces on the arm during movement that motivate, offer a relatively high degree of success and
attempts, and a small margin of error is allowed before the reinforcement, and give feedback concerning gains in mo-
robot provides assistance. The track can be oriented at tor performance.
various angles to allow reaching into different regions of
the workspace. Targets are located at the limit of the pa- Haptic Master
tient’s reach with elbow extended and shoulder flexed as The Haptic Master is a three DOF robot that provides
much as possible without pain.22 gravity assistance for the paretic arm while the user sits at
Kahn and colleagues compared active assistive reach- a workstation. A free moving elbow splint attached to an
ing exercises with the ARM Guide to free, unsupported overhead frame supports the arm, and a passive mecha-
reach to the same target locations.22 The research aimed nism supports the hand and allows for supination and
to compare the effects of robot-assisted movement ther- pronation and wrist flexion and extension. All exercises
apy with the ARM Guide to free reaching voluntary exer- occur in a virtual environment while force and position
cises in persons with chronic upper limb paresis after sensors enable interaction with virtual tasks such as reach-
stroke (see Table 11-1). The frequency, dose, and duration ing to a supermarket shelf or pouring a drink. The Haptic
of practice were identical across treatment groups. Par- Master has been used for task-oriented training in a three
ticipants in both groups showed similar gains in range of dimensional virtual environment as in the GENTLE/S
motion (ROM) and speed of supported reaching and project3,10 or with real object manipulation as done with
in the time needed to complete functional tasks on the the Activity of Daily Living Exercise Robot (ADLER).20
Rancho Los Amigos Functional Test of Upper Extremity Depending on the user’s movement abilities, three differ-
Function. This indicated that repetitive movement train- ent therapy modes can be selected: passive, active assisted,
ing, regardless of how it was administered, was a key or active. In addition to visual feedback, haptic feedback
stimulus for the observed motor recovery. The only sig- from the robot provides the user with the feeling of in-
nificant group difference in this experiment was that creased resistance when movements stray from the pro-
greater improvement in the smoothness of unsupported grammed trajectory.
reaching movements occurred in free reaching group. Two clinical trials with the Haptic Master have shown
One possible explanation is that the unsupported reaching modest reductions in upper limb impairment on the
exercise involved a greater degree of error correction as FMA following 30 minutes of therapy three times a
subjects practiced moving toward targets, supporting mo- week.10,42 The authors attributed greater gains following
tor learning principles that emphasize the importance of robotic therapy to the repetitive practice of task-oriented
error detection and recognition. movements with performance feedback from the Haptic
The authors proposed that the type of assistance pro- Master (see Coote and colleages10 and Table 11-1). Their
vided by the ARM Guide may not have been optimal and assertion that cortical reorganization and movement ki-
have since begun testing a novel guided-force training nematics are optimized when persons are engaged in
program. When this training program detects misdi- challenging and meaningful tasks is supported by prior
rected forces during reach (e.g., from a strong flexor research and is an important consideration when using
synergy), it stops the movement, provides visual feedback rehabilitation technologies during clinical practice. The
of the misdirection, and guides the person to activate use of individualized task-oriented training in natural
muscle groups in appropriate combinations to reach the environments, as emphasized in occupational therapy
desired target.21 This guided-force training is also capa- practice, is gaining greater attention in the rehabilitation
ble of adapting the amount of assistance or resistance technology literature.48
298 Stroke Rehabilitation

REO
The Reo Therapy System (Motorika Ltd., Israel) is a
widely marketed upper limb robot with little supporting
research evidence published in peer reviewed journals.
During Reo therapy the user performs computer gener-
ated games with the paretic hand attached to the robot
arm. The robot provides upper limb assistance and feed-
back while the user performs reaching movements from a
seated position at the work station. Patients have reported
satisfaction with the Reo therapy program49 when com-
bined with conventional inpatient therapies. A pilot study
with 10 outpatient participants reported gains in Fugl- Figure 11-3 ARMin III exoskeletal robot with a healthy test
Meyer scores between 2 to 11 points following two to subject. (Courtesy of the National Rehabilitation Hospital.)
three one-hour sessions a week, with decreased perceived
exertion and reductions in shoulder pain and upper limb
spasticity as measured by the Modified Ashworth Score.35 is presently undergoing clinical investigations. Although
Time poststroke and initial level of severity were not re- the evidence is pending, this robot holds promise for pro-
ported. Although additional studies are needed, initial viding high quality, task-oriented stroke rehabilitation in
work indicates that the Reo is well tolerated and may the future.
contribute to positive motor outcomes poststroke.
T-WREX and ARMeo
ARMin The T-WREX is a passive, body powered orthosis for the
The ARMin is an exoskeletal, low impedance robot de- upper limb that was based on an earlier device developed
signed for repetitive, task-oriented upper limb therapy after for persons with muscular dystrophy.37 It was adapted for
stroke. The interactive assistance it provides is based on individuals with stroke-induced motor impairments to al-
“patient-cooperative” control strategies that allow patient- low a lower cost, safe option for semiautonomous upper
driven movements while the robot gives support only as limb training. Easily adjusted elastic bands provide a safe
needed (vs. preprogrammed levels of assistance). This form method of passively supporting the limb to allow greater
of control is expected to increase the intensity of practice active ROM and reach. The T-WREX enables naturalis-
while gamelike training scenarios enhance patient motiva- tic movement across two thirds or more of a normal
tion to engage in repetitive training. Haptic, visual, and workspace while the user engages in task-oriented virtual
auditory feedbacks are provided during patient use. games, such as moving apples from a produce shelf to a
The increased DOFs afforded by the ARMin and other shopping cart. Electronic sensors detect arm movement
exoskeletal devices (e.g., the T-WREX and Armeo dis- and hand grasp, allow the user to interact with the thera-
cussed later) more closely mimic task-oriented therapy peutic games, and provide quantitative feedback about
provided by rehabilitation clinicians.34 Although passive reach and grasp performance. A modified version of the
nonmotorized devices (e.g., T-WREX, Armeo) support T-WREX, the Armeo (Hocoma A.G., Switzerland) is
the arm against gravity and are intrinsically safer and less commercially available for clinic use (Fig. 11-4).
expensive, they cannot assist movements that the patient
is unable to perform (e.g., elbow extension). However, the
exoskeletal ARMin can apply and control torques at each
joint individually when assistance is needed due to in-
creased muscle tone or poor isolated movement.34
Clinical testing of the ARMin robot with patients after
stroke has been reported for three individuals with moder-
ate to severe motor impairments.33 This pilot study by Nef
and colleagues found that ARMin exoskeletal therapy led
to modest but significant gains in motor function as evi-
dent on the FMA, with no change on the Barthel Index or
Action Research Arm Test. Nef and colleagues33 proposed
that the threes DOFs allowed by the ARMin I device
may have limited task-oriented training and functional
outcomes. A newer model, the ARMin III (Fig. 11-3), Figure 11-4 Armeo body powered orthosis with virtual train-
allows six to seven DOFs during upper limb training and ing task. (Courtesy Hocoma AG, Switzerland.)
 Chapter 11 • Rehabilitation Technologies to Promote Upper Limb Recovery after Stroke 299

Housman and colleagues17 reported results of a ran-

domized control trial in which conventional table-top ex-
ercises were compared to T-WREX training in persons
with chronic, moderate to severe upper limb paresis (see
Table 11-1). In this study, the amount of weight support
provided by the T-WREX orthosis was rarely decreased to
less than 50% of the weight of the arm. Despite the high
degree of gravity assist during training, effects did general-
ize to upper limb movements in nonweight-supported
conditions, as seen by significant improvements in the
FMA and Motor Activity Log scores. The amount of
change measured on the FMA was comparable to that seen
in studies of active devices, including the MIT-MANUS
and MIME robots. This further suggests that highly re-
petitive movement therapy is a key stimulus to neuromo- Figure 11-5 Hand Mentor device combines pneumatic “muscle”
tor recovery after stroke.17 activation with electromyography to provide active assistive
The study also found that subjects could perform therapy for wrist and fingers. (Courtesy of Kinetic Muscles, Inc.)
T-WREX exercises with only brief direct supervision
from a therapist (four minutes for each hour of therapy),17
so the T-WREX has good potential for cost effective,
semiautonomous practice of upper limb motor tasks user could not reach the target position during the active
within clinical and home settings. Participants in both training mode, the pneumatic muscle inflated to assist
treatment groups found the novel T-WREX intervention wrist movements. Study participants spent up to two ad-
more enjoyable and motivating than conventional table- ditional hours doing repetitive task practice of function-
top exercises typically prescribed as a home program ally oriented tasks with the paretic arm. The level of dif-
after stroke. ficulty increased gradually, and participants selected
activities for training. Gains reported at the end of inter-
HAND ROBOTS vention included faster speed of performance on some
Wolf Motor Function Test items; increased active ROM
Development of robots to assist with wrist and hand re- in the shoulder, wrist, and thumb; better isolation of up-
training has lagged behind that of shoulder and elbow per limb motions; and a slight decrease in maximum grip
devices, largely due to the complexity of control needed force.14,41 Despite limited evidence of efficacy, the Hand
to assist with grasp and release. Two robots that have been Mentor has been used more frequently in rehabilitation
empirically tested are the Hand Mentor (Kinetic Muscles clinics in recent years. Certainly, empirical studies are
Inc., Tempe, AZ) and the Hand Wrist Assistive Rehabili- needed to more closely examine the potential uses and
tation Device (HOWARD) developed at the University benefits of this technology.
of California, Irvine. The Hand Wrist Assistive Rehabilitation Device
The Hand Mentor is a repetitive motion device (“HOWARD”) is another pneumatically actuated robot
designed for home and clinical use (Fig. 11-5). It uses a that assists with repetitive grasp and release movements.46
pneumatic artificial muscle to extend the wrist and fingers While seated at a computer monitor, the subject’s paretic
and provides electromyographic (EMG) biofeedback of hand is secured to the robotic device, and the forearm is
muscle activation via light emitting diodes displayed on a supported in a padded splint. HOWARD controls flexion/
small screen. Its purpose is to inhibit flexor tone of the extension of the four fingers about the metacarpophalan-
wrist and fingers, provide neuromuscular reeducation, geal (MCP) joint; flexion/extension of the thumb at the
and increase ROM and strength of the paretic wrist and MCP joint; and flexion/extension of the wrist (Fig. 11-6).
fingers. Joint angle sensors allow for real time control of virtual
In two single case studies, Hand Mentor training was hand movements displayed on the monitor, and the back-
combined with repetitive task practice to improve driveable control allows the patient to move freely when
upper limb function in persons seven and 11 months post- the robot is not engaged in active assistance. The palmar
stroke.14,41 Intervention occurred four hours per day, surface of the hand is left unobstructed to allow for grasp-
either three or five days a week, over a three-week period. ing practice of both virtual and real objects. Takahashi and
During two hours of each session, Hand Mentor training colleagues demonstrated HOWARD’s effectiveness in pro-
included use of EMG biofeedback to reduce abnormal moting motor recovery and cortical reorganization in per-
muscle tone in the wrist and fingers, and two active motor sons with chronic motor impairments after stroke46 (see
control modes to elicit wrist flexion and extension. If the Table 11-1). HOWARD’s unique capability to combine
300 Stroke Rehabilitation

Figure 11-7 Bi-Manu-Track bilateral arm training device.

(Courtesy of Dr. Stefan Hesse.)

received electrical stimulation, Hesse and colleagues16

found that subjects who performed BI-MANU-
TRACK training four to eight weeks poststroke had
significant improvements on the FMA and in muscle
power scores for the paretic arm (see Table 11-1).
However, persons in the bilateral training group en-
B
gaged in 10 times more movement repetitions than did
Figure 11-6 Hand Wrist Assistive Rehabilitation Device those who received electrical stimulation. Follow-up
(HOWARD) can be used with virtual and actual training tasks. research needs to examine whether the significant
(Courtesy of Steven C. Cramer, MD.) group differences were due to the greater number of
movement repetitions or to the bilateral nature of the
repetitive robot-assisted training with the rich sensory ex- training. A similar BI-MANU-TRACK protocol for
perience of grasping and holding real objects represents persons with chronic motor impairments15 revealed
another step toward more closely aligning robotic technol- less change in motor performance of the paretic arm
ogy with current rehabilitation theories that emphasize than was seen in the subacute group. This suggests
task-oriented training. that the timing of intervention is important for this
form of therapy.
BILATERAL ARM TRAINING The Bilateral Arm Training with Rhythmic Auditory
Cuing (BATRAC) trainer is another device used for
A number of studies have examined the effects of repetitive repetitive bilateral upper limb therapy. BATRAC ther-
bilateral training on upper limb motor recovery. This apy involves moving two unyoked handles forward
research has shown that bimanual practice can have a facili- and backward in a reaching motion, both symmetrically
tating effect on the paretic arm after stroke, with movement and asymmetrically in response to auditory cues set at
of the nonaffected upper limb stimulating ipsilateral corti- individually determined rates. A single group pilot
cospinal projections to the paretic arm. Two rehabilitation study by Whitall and colleagues52 showed gains in
devices, the BI-MANU-TRACK and Bilateral Arm Train- Fugl-Meyer scores, speed of arm movements, and use
ing with Rhythmic Auditory Cuing (BATRAC) trainers, of the paretic arm for supportive roles during bilateral
have undergone a fair amount of study. tasks after 18 sessions of therapy over a six-week pe-
The BI-MANU-TRACK is a one DOF computer- riod. These improvements were largely sustained eight
assisted arm trainer that allows bimanual practice of weeks posttraining. However, when Luft and col-
supination and pronation and wrist flexion and exten- leagues28 compared subjects who received NDT-based
sion (Fig. 11-7).15 Exercises can be performed passively exercises to those treated by BATRAC, they found no
or actively, and isometric resistance can be added at significant group differences on clinical measures but
the start of active exercise, based patient’s ability level did see changes in brain activation in the BATRAC
and needs. When compared to a control group that group (see Table 11-1).
 Chapter 11 • Rehabilitation Technologies to Promote Upper Limb Recovery after Stroke 301

Other BATRAC research by Richards and colleagues40 brace that is powered by rechargeable batteries in a por-
examined effects of a condensed BATRAC protocol, in table control pack. The treating therapist selects the ap-
which treatment was delivered to persons with mild propriate location for the sensing electrode and sets a
chronic impairments during two-hour and 15-minute virtual spring that counterbalances the powered assistance
sessions, four times a week for two weeks. The condensed of the device, which allows the device to assist with the
protocol led to small gains on the Motor Activity Log but desired movement (e.g., elbow flexion) and aids return to
no change in motor impairment or speed, as measured by the starting position when the EMG stimulus subsides
the FMA and Wolf Motor Function Test. It appears that and the person relaxes. The Myomo device controls the
persons with severe motor impairments may benefit amount of force generated based on the amplitude of the
more from BATRAC training than those with milder EMG signal, which results in movement assistance that is
impairments, and that the distribution of training ses- proportional to the patient’s effort.43
sions is an important consideration when using this de- The Myomo e100 is a portable, exoskeletal device that
vice. Other studies also have reported smaller gains in can be used in different settings, unlike robotic devices
motor recovery when patients engaged in a compressed limited to a fixed work station. It allows for the training of
treatment schedule.13 This is an important consideration basic functional tasks, such as pushing up from an arm
for clinicians faced with limited insurance coverage for chair or reaching for a light switch. However, it only as-
patients following stroke. Evidence concerning optimal sists elbow motions and does not directly address im-
timing and distribution of treatment is sorely needed. paired supination/pronation or distal function. At this
Although this bilateral training research may contrib- time, its weight makes it inappropriate for use by persons
ute to the knowledge of neuromotor recovery mecha- with glenohumeral subluxation and weak shoulder con-
nisms poststroke, clinically relevant limitations of these trol. Data from a small pilot study for patients with severe
devices include the lack of patient feedback and focus on chronic upper limb paresis after stroke showed modest,
impairment (not activity level) changes in performance. but statistically significant gains in upper limb scores on
The effect of this bilateral training on functional use of the FMA.45
the paretic arm and real life outcomes is unknown.
McCombe Waller and colleagues32 recommended that HANDMASTER
specific bilateral training exercises be matched to the pa-
tient’s baseline characteristics, and that the contribution The Handmaster, marketed as the NESS H200 Hand
of supportive role functions by the paretic arm be further Rehabilitation System (Bioness, Valencia, CA) is a nonin-
examined during unilateral and bilateral tasks. Research vasive, advanced neuroprosthesis used for the treatment
studies that include bilateral task analysis and assessment of upper limb paresis following stroke, traumatic brain
of interlimb coordination could play an important role in injury, or C5-C6 spinal cord injury. It contains a custom-
clarifying ways in which motor function of the paretic arm fit orthosis that uses functional electrical stimulation
changes during the course of intervention.32 (FES) to provide neuromuscular reeducation, to sequen-
tially activate muscle groups in the forearm, and to elicit
FUNCTIONAL ELECTRICAL STIMULATION active grasp and release in the paretic hand.
Research studies indicate that FES has the potential to
Functional electrical stimulation (FES) is another techno- benefit persons with subacute and chronic upper limb
logical advancement designed to facilitate motor recovery paresis after stroke. An evidence-based review by Chan8
after neurological insult. A number of studies have been revealed that patients who performed FES in conjunction
published on neuromuscular electrical stimulation (NMES) with active practice of functional tasks outperformed
and FES. FES is actually a subcategory of NMES and re- those involved with task-oriented training alone or sham
fers to the use of NMES to substitute for an orthosis while stimulation. This outcome was reinforced by Alon and
assisting with a functional activity, such as holding a glass colleagues2 in a study of the NESS H200 during subacute
to drink.5 See Chapter 10. inpatient rehabilitation (see Table 11-1). Chan’s review8
also discovered that treatment protocols varied across
MYOMO studies, but the stimulation parameters did not appear
crucial in determining motor outcomes. This is likely re-
The Myomo e100 NeuroRobotic system (Myomo, Inc., lated to variations in residual motor abilities, degree of
Boston, MA) is a wearable device that assists with elbow spasticity, and the duration and frequency of treatment
flexion and extension of the paretic arm. It uses a novel across study samples. Cauraugh and Kim7 proposed that
surface EMG control mechanism to detect and amplify FES works to improve voluntary initiation of movements
signals generated by a stroke survivor’s muscles. The in the impaired limb by decreasing the processing time
Myomo device includes a surface electrode that is placed needed for stimulus identification and response initiation.
over the biceps or triceps muscle and a motorized elbow FES with the NESS H200 was suitable for persons with
302 Stroke Rehabilitation

mild to moderate upper limb dysfunction after stroke, and suggests that the SaeboFlex orthosis has good potential to
was reported to be well tolerated by those engaged in provide low-cost, repetitive motor training to persons
home programs. As with all present rehabilitation tech- with moderate motor impairments after stroke.
nologies, the high cost of the NESS H200 may present a
barrier to its widespread use after stroke. AUTOCITE
The AutoCITE was developed to automate CIMT for
OTHER DEVICES FOR REPETITIVE TASK individuals with mild to moderate motor impairments
PRACTICE after stroke.31 It is comprised of a computer, chair, and
eight task devices arranged on four work surfaces in a
SAEBO modified cabinet. The training tasks are derived from
The SaeboFlex is a high-tech, dynamic orthosis devel- those used in therapist-mediated CIMT and include
oped to address the difficulty that many stroke survivors reaching, tracing, peg board use, supination/pronation,
have in opening their paretic hand after stroke. This or- threading, arc and rings, finger tapping and object flip-
thosis consists of a forearm cuff attached to a dorsal hand ping (Fig. 11-9). While the user sits at the workspace,
platform that anchors two spring attachments. Individual instructions are given via a computer monitor, and device
finger sleeves are placed over the distal phalanges and sensors monitor performance. Several types of feedback
then are attached to the spring attachments via a high and encouragement are provided, including the number
tensile line to provide assistance with finger and thumb of successful repetitions and time for task completion.
extension (Fig. 11-8). A small phase 1 trial tested the fea- The AutoCITE is another technological device designed
sibility of using this orthosis in 13 individuals with chronic to provide semiautonomous, repetitive task practice and re-
upper limb motor impairments.11 The training protocol, duce health care costs. Taub and colleagues47 reported that
based on systems theory and motor learning principles, patients with chronic mild to moderate upper limb paresis
emphasized repetitive practice, active problem solving who trained with the AutoCITE had significant gains in mo-
and use of the hand to promote motor recovery of tor ability and real world use, as indicated by improved
the upper limb. Other interventions provided during the scores on the Wolf Motor Function Test and Motor Activity
SaeboFlex training period included strengthening exer- Log. The authors found no significant difference in treat-
cises, ROM, and electrical stimulation to wrist and finger ment outcome among subjects who received therapist super-
extensors. Significant gains in upper limb measures were vision for 25%, 50%, or 100% of the AutoCITE treatment
found after five days of intensive treatment. Although time (see Table 11-1). Taub and colleagues concluded that
further research on its efficacy is indicated, this trial AutoCITE training with limited therapist supervision was as
effective as one-on-one CIMT.
In addition to three hours of AutoCITE training five
days a week, all participants were asked to wear a padded
safety mitt on their less-affected hand for 90% of waking
hours during the two-week trial period. This study did not
include a control group that received only the mitt con-
straint. It is possible that these participants improved merely
because of increased hand use during waking hours vs. the
time spent on AutoCITE training (supervised or unsuper-
vised). Future research may well address this question.

CLINICAL USE OF REHABILITATION

TECHNOLOGIES
The rehabilitation technologies discussed previously offer
a wide range of treatment options for persons with upper
limb paresis after stroke. Choosing the “right” technology
for a particular patient during clinical practice involves an
appreciation for key features of the device, the patient’s
level of function, and therapeutic goals.

Key Features to Consider

Key considerations when choosing technologies for pa-
Figure 11-8 The SaeboFlex orthosis provides dynamic assistance tient treatment after stroke include the type of assistance
during gross grasp and release activities. (Courtesy of Saebo, Inc.) and DOFs afforded by the device, whether it is portable
 Chapter 11 • Rehabilitation Technologies to Promote Upper Limb Recovery after Stroke 303

A B C

D E F

G H
Figure 11-9 AutoCITE activities for persons with mild to moderate impairments after stroke.
(From Taub E, Lum PS, Hardin P, et al: Automated delivery of CI therapy with reduced effort
by therapists. Stroke 36(9):1301-1304, 2005.)

or stationary (e.g., requires treatment space for a work- The present rehabilitation devices are most appro-
station), and the amount of training needed to safely and priately used as an adjunct to therapist-rendered inter-
effectively administer movement therapy. The device vention. Technologies are best at providing intensive
should be easily programmed to meet the patient’s needs practice while the therapist emphasizes use of the pa-
as motor recovery occurs and allow for semiautonomous retic arm during valued everyday tasks. Because indi-
training, which can enhance therapist productivity while vidual devices are not currently able to assist with of all
the patient engages in CIMT. Many robotic devices pro- DOFs needed for task-oriented training, some research-
vide quantitative measures of motor functions such as ers have advocated for the use of robotic “gyms”23 or an
movement speed, accuracy, and forces generated. These “integrated suite of low cost robotic and computer assis-
objective measures can complement activity and partici- tive technologies.”19 The therapist’s expertise in upper
pation level evaluation findings, and can be used when limb function and task analysis is essential when select-
documenting treatment plans and progress toward goals. ing rehabilitation technologies and establishing treat-
Ease and time for treatment set-up are other important ment plans that effectively combine technology-driven
considerations when selecting these tools for the clinic. and therapist-rendered interventions.
304 Stroke Rehabilitation

Certainly the organization’s rehabilitation agenda, pa- that modular robotic systems may be particularly well-
tient caseload, and cost strongly influence decisions to suited for addressing this question. Modular systems can
purchase rehabilitation technologies for clinical use. In deliver training to individual limb segments or can combine
addition, barriers to therapist and physician acceptance robot components to allow practice of tasks that involve
deserve attention: specific concerns include treatment ef- greater DOFs. However, current modular systems are lim-
ficacy, equipment expense, and lack of time to evaluate ited in their ability to provide true “task-oriented” training
technology options for stroke rehabilitation.6 In terms of because they do not allow the practice of contextually-rich
efficacy, research studies have begun to show that reha- virtual or actual tasks. While these modular tools may be
bilitation technologies can offer benefits not easily key to identifying what form of movement therapy is best
achieved by additional conventional therapy. For example, for which patient, clinicians should use a combination of
patients who had robot-assisted therapy early after stroke empirical evidence, clinical experience, and practice theory
showed an accelerated rate of motor recovery when com- when deciding which technology features are best suited for
pared to a control group that received conventional ther- their rehabilitation patients.
apy.29 Although this study showed no group differences When selecting rehabilitation technologies, the thera-
after six months, it is likely that accelerated motor recov- pist also should assure that the feedback provided by the
ery during inpatient rehabilitation could contribute to device is clear, easily interpreted by the patient and clini-
improved functional use of the upper limb and positively cian, and pertinent to the patient’s goals for improved
impact self-care performance and patient satisfaction at motor function. The therapeutic device should offer a
hospital discharge. variety of metrics relevant to functional task performance.
Colombo9 asserted that patients with greater motor im-
Level of Function and Therapeutic Goals pairments could benefit more from feedback regarding
Many factors influence a patient’s ability to benefit from the efficacy of movement attempts. Conversely, patients
rehabilitation of the paretic arm after stroke. Critical fac- with higher level motor functioning could expect to ben-
tors include the level of neurological damage and result- efit more from feedback concerning movement accuracy
ing motor impairment, and the individual’s ability to en- or force control.9 A patient’s therapeutic goals may be bet-
gage successfully in therapeutic activities aimed at ter addressed when the clinician has a clear understanding
improving motor function. Rehabilitation technologies of the types of feedback and forms of intervention that
can be easily programmed to ensure a certain level of suc- best promote functional motor recovery.
cess for patients with a wide range motor abilities. This As research unfolds, specific treatment protocols to
feature can enhance patient motivation and independent more efficiently and effectively address patient needs
carryover of exercise programs. Although researchers are across levels of function will help to guide the integration
working to identify “active ingredients” needed for the of technology-driven and therapist-rendered rehabilita-
learning and acquisition of motor functions after stroke, tion. Thoughtful treatment planning for technology
the “best” rehabilitation and technology choice for a driven rehabilitation is no different from that of conven-
given level of motor function is not well-established. It is tional therapies. It just requires an understanding of the
not safe to assume that one treatment approach, or one therapy options made available by these technologies.
form of rehabilitation technology, is optimal for all pa-
tients with hemiparesis. SUMMARY
Clinical practice illustrates the need for different tech-
niques and treatment strategies for patients with minimal The focus of conventional therapies during recent years
vs. moderate to severe levels of motor impairment. Un- has shifted from analytical training methods directed at
fortunately, therapist-rendered interventions are difficult impairments in motor function to an emphasis on task-
to quantify or reproduce across treatment sessions. Reha- oriented training for the upper limb.48 The development
bilitation robots are able to objectively measure the of rehabilitation technologies, although still in its infancy,
amount and type of assistance provided during therapy, is following a similar trend. Potential benefits include
and to track changes in motor functions that occur during controllable treatment intensity, repetition, task-specific
the course of treatment. Clinicians can use these measures practice, and sensory-motor feedback to enhance knowl-
to judge the effectiveness of treatment, and to learn more edge of performance and results.
about how changes in motor functions might translate to The research presented in this chapter generally sup-
activity level performance. ports the use of rehabilitation technologies to improve
Although many advocate for rehabilitation technologies upper limb motor functions after stroke. Although sys-
able to deliver task-oriented training across multiple DOFs,48 tematic reviews of robot-assisted therapies have
it is not known whether this approach would be as effective substantiated task-specific training effects at the ICF
for persons with mild or with moderate to severe motor impairment level, these have not generalized to arm
impairments after stroke. Krebs and colleagues23 proposed and hand use during activities of daily living.26-36 As
 Chapter 11 • Rehabilitation Technologies to Promote Upper Limb Recovery after Stroke 305

technology-aided distal training and task-oriented in- 8. Chan CKL: A preliminary study of functional electrical stimulation in
terventions are further developed and therapists become the upper limb rehabilitation after stroke: An evidence-based review.
HKJOT 18(2): 52–58, 2008.
more experienced with integrating technology-driven 9. Colombo R, Pisano FM Micera S, et al: Assessing mechanisms of
and therapist-rendered interventions, the effects of the recovery during robot-aided neurorehabilitation of the upper limb.
activity and participation level functions are expected to Neurorehabil Neural Repair 22(1): 50–63, 2008.
improve. Ultimately, rehabilitation technologies are an- 10. Coote S, Murphy B, Harwin W, et al: The effect of the GENTLE/S
ticipated to provide cost effective treatment options and robot-mediated therapy system in arm function after stroke. Clin
Rehabil 22(5): 395–405, 2008.
to help to inform clinicians about the “active ingredi- 11. Farrell JF, Hoffman HB, Snyder JL, et al: Orthotic aided training of
ents” key to effective and efficient rehabilitation for the paretic upper limb in chronic stroke: Results of a phase I trial.
persons after stroke. NeuroRehabilitation 22(2): 99–103, 2007.
12. Fasoli SE, Krebs HI, Stein J, et al: Robotic therapy for chronic motor
impairments after stroke: follow-up results. Arch Phys Med Rehabil
REVIEW QUESTIONS 85(7):1106–11, 2004.
13. Finley, MA, Fasoli, SE, Dipietro, L, et al: Short duration upper
1. Describe the difference between active and passive re- extremity robotic therapy in stroke patients with severe upper
habilitation robots and provide an example of each. extremity motor impairment. J Rehabil Res Dev 42(5):683–692,
2. List the hand robots reviewed in this chapter and dis- 2005.
cuss research findings. Why has the development of 14. Frick EM, Alberts JL: Combined use of repetitive task practice and
an assistive robotic device in a patient with subacute stroke. Phys
shoulder/elbow robots exceeded that of distal robots Ther 86(10):1378–1386, 2006.
for the wrist and hand? 15. Hesse S, Schulte-Tigges G, Konrad M, et al: Robot-assisted arm
3. Which rehabilitation technology would you choose for trainer for the passive and active practice of bilateral forearm and
a patient with mild motor impairments after stroke? wrist movements in hemiparetic stroke. Arch Phys Med Rehabil
Explain the therapy approach you would take and why. 84(6):915–920, 2003.
16. Hesse S, Werner C, Pohl M, et al: Computerized arm training im-
4. The studies in Table 11-1 compared the effectiveness proves the motor control of the severely affected arm after stroke.
of rehabilitation technologies with conventional ther- Stroke 36(9):1960–1966, 2005.
apy methods. Discuss one or two ways that you might 17. Housman SJ, Scott KM, Reinkensmeyer DJ: A randomized con-
use this evidence to guide your therapy for persons trolled trial of gravity-supported, computer-enhanced arm exercise
with moderate upper limb impairments after stroke. for individuals with severe hemiparesis. Neurorehabil Neural Repair
23(5):505–514, 2009.
5. There are many factors to consider when choosing 18. International classification of functioning, disability and health: ICF,
rehabilitation technologies for use in the clinic. What Geneva, 2001, World Health Organization.
considerations are especially important for your set- 19. Johnson MJ, Feng X, Johnson LM, et al: Potential of a suite of robot/
ting and what device(s) would you select based on computer-assisted motivating systems for personalized, home based
these factors? stroke rehabilitation. J Neuroeng Rehabil 4:6, 2007.
20. Johnson MJ, Wisneski KJ, Anderson J, et al: Development of
ADLER: The activities of daily living exercise robot, BioRob
2006. The First IEEE/RAS-EMBS International Conference on
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7. Cauraugh JH, Kim SB: Stroke motor recovery: Active neuromuscular with severe hemiparesis. Neurorehabil Neural Repair 22(2):111–121,
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27. Langhammer B, Stanghelle JK: Bobath or motor relearning pro- 40. Richards LG, Senesac CR, Davis SB, et al: Bilateral arm training
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292(15):1853–1861, 2004. 42. Seelen, HAM, Geers RPJ, Soede, M, et al: Training of arm-hand
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A follow up study. J Rehabil Res Dev 43(5):631–642, 2006. 43. Stein J : e100 NeuroRobotic system. Expert Rev Med Devices
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32. McCombe Waller S, Whitall J: Bilateral arm training: Why and 46. Takahashi CD, Der-Yeghiaian L, Le V, et al: Robot-based hand motor
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33. Nef T, Quinter G, Muller R, et al: Effects of arm training with 47. Taub E, Lum PS, Hardin P, et al: AutoCITE Automated delivery of
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Neurodegener Dis 6(5–6):240–251, 2009. 1304, 2005.
34. Nef T, Guidali M, Riener R: ARMin III – arm therapy exoskeleton 48. Timmermans AAA, Seelen HAM, Willmann RD, et al: Technology
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35. Padova J, Werner L, Mahoney R: Pilot trial of a robot-assisted upper technology design. J Neuroeng Rehabil 6:1, 2009.
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36. Prange GB, Jannink MJA, Groothuis-Oudshoorn CGM, et al: cular training of sub-acute stroke patients. A feasibility study.
Systematic review of the effect of robot-aided therapy on recovery Eur J Phys Rehabil Med 44(4):431–435, 2008.
of the hemiparetic arm after stroke. J Rehabil Res Dev 43(2): 50. Volpe, BT, Krebs, HI, Hogan, N, et al: A novel approach to stroke
171–184, 2006. rehabilitation: Robot-aided sensorimotor stimulation. Neurology
37. Rahman T, Sample W, Selliktar R, et al: A body-powered functional 54(10):1938–1944, 2000.
upper limb orthosis. J Rehabil Res Dev 37(6):675–680, 2000. 51. Volpe BT, Lynch D, Rykman-Berland A, et al: Intensive sensorimotor
38. Reinkensmeyer DJ, Emken JL, Cramer SC: Robotics, motor learning arm training mediated by therapist or robot improves hemiparesis in
and neurologic recovery. Annu Rev Biomed Eng 6:497–525, 2004. patients with chronic stroke. Neurorehabil Neural Repair 22(3):305–
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 s a n dra m . artzberg er
j o cel yn wh i te

chapter 12

Edema Control

key terms
complex edema thoracic duct neuroprosthesis
venous and lymphatic congestion diaphragmatic breathing terminus
dependency theory complex regional pain syndrome
type I

chapter objectives
After completing this chapter, the reader will be able to accomplish the following:
1. Describe the proposed three theories of types of stroke hand edema and relate them to
appropriate criteria for clinical treatment technique selection.
2. Provide neurological and anatomical rationales for treatment selection.
3. Be familiar with current research outcomes of treatment techniques for stroke hand
edema reduction and be able to implement and expand data for clinical application
problem-solving
4. Integrate realistic edema reduction expectations into treatment planning from material
read in the case studies.

Research indicates that poststroke hand edema can There is no consensus on the etiology of poststroke
range from 16%21 to 82.8%49 depending on the defini- hand edema38 or on the most effective management tech-
tion of edema, length of time since stroke occurred, nique.7,23 Therefore, there are few guidelines for occupa-
and study design and methodology. Research also tional therapists to employ with their clients. It is widely
reports a broad range of time during which edema may acknowledged that edema, particularly in the subacute and
develop, often from two weeks to two months chronic stages, affects a client’s range of movement, sensa-
poststroke.43 There are numerous theories regarding tion, dexterity, and function. There are also correlations
the development of edema. Boomkamp-Koppen and between edema and joint fibrosis and, in stroke, there is
colleagues7 found that the loss of muscle activity, increasing evidence on the relationship between edema
hyposensibility, and hypertonia link to edema, with hy- and Chronic Regional Pain Syndrome (CRPS).30 Occupa-
pertonia being the most significant predictor of hand tional therapists need to maximize their input into the
edema. multidisciplinary team to prevent CRPS and to minimize

307
308 Stroke Rehabilitation

these barriers to rehabilitation.43 It is also imperative to

consider the impact of stroke on movement, cognition, Anatomical Overview of the Venous and Lymphatic
perception, communication, and psychological aspects of Systems Related to Stroke Hand Edema and its
individuals. These areas form the basis for most rehabilita- Etiology
tion poststroke, with edema and sensation often being The venous congestion and limb dependency theory is
lower priorities. However, given the limitations imposed most relevant to the treatment techniques this chapter
by stroke on the above areas, one must consider how these will present. Thus, it is important to take an anatomical
impairments may interplay with edema management and look at the vascular system, which consists of both arterial
functional outcomes, such as neglect, strength, and learned and venous structures and the lymphatics. Both vascular
nonuse (Fig. 12-1). structures, the venule and lymphatic capillaries, remove
This chapter will focus on exploring available research excess fluid from the interstitium and can be simultane-
regarding the etiology and treatment of poststroke hand ously activated in specific instances. Yet depending on the
edema and will present it in a format to enable the thera- type of edema, in certain instances, each system must ac-
pist to apply research data to clinical problem solving. tivate in its own unique way in order to reduce edema.
Both the venous and lymphatic systems neurologically are
ETIOLOGY OF STROKE HAND EDEMA controlled by the autonomic nervous system.17,35 How-
ever, both systems rely on the muscle motor pump to re-
The edema that therapists treat is defined as an excess ac- move tissue fluid from the interstitium.17,35 Thus, with
cumulation of fluid in the interstitium. It occurs on the total or partial lack of motor function to an arm post-
capillary level (microcirculation level) when there is an stroke, swelling occurs.
imbalance of pressure between the arterioles, venules, and Venous and lymphatic absorption of tissue fluid occurs
interstitium, or an obstruction of the lymphatic sys- on the microcirculation level. In the interstitium (inter-
tem.17,50 This is also known as an imbalance in Starlings stitial spaces), the arterial and venule histologically join
Equilibrium. It is important to note that the vascular sys- in an arc. The initial lymphatic (also called a lymphatic
tem refers not only to the venous and arterial capillaries capillary or lymphatic net) is independent from the ven-
but also to the lymphatic capillaries. All these structures ule arterial arc, it is a “netlike” structure in the intersti-
influence poststroke arm edema. tium and is much larger than the venule.17,28 On this
A review of the literature has resulted in two major microcirculation level, plasma proteins, fluid, electro-
theories of poststroke hand edema: sympathetic vasomo- lytes, nutrients, and a few other elements are excreted
tor dysfunction due to the stroke, and venous congestion. from the arteriole, because it has a pressure of 35 mm Hg.6
The concept of vasomotor dysfunction as part of the These are the substances needed for surrounding cell
stroke autonomic disturbance theory was proposed as metabolism. Ninety percent of what remain from the
early as 1930.55 This theory has been expanded on in light metabolism are small molecules that enter the venule via
of more recent research,34 though, the role of the sympa- the process of osmosis and diffusion.27,28 The remaining
thetic vasomotor dysfunction deletion of post stroke hand 10% of the molecules, such as plasma proteins, are too
edema formation remains unclear.38 The second theory large to be absorbed by the venule and must be absorbed
proposes that poststroke hand edema results from venous by the lymphatic capillaries. The artery system via arteri-
congestion due to lack of, or decreased, limb motor func- ole filtration and diffusion excretes tissue fluid into the
tion and dependency positioning.38 Aspects of both of interstitium.28 From the interstitium there are two struc-
these theories will be presented in the chapter when rela- tures, venules and lymphatic capillaries, that join with
tive to a specific treatment technique. larger veins and lymphatic structures to bring fluid back
to the heart (Fig. 12-2).17
The absorption process by the venule and lymphatic
capillaries differ from each other. The wall of a venule
is thin and absorbs small molecules via osmosis and
diffusion.17 Thus, elevation, light retrograde massage,
muscle contraction, and compression will facilitate this
absorption.
Lymphatic molecule absorption in the interstitium be-
gins in the one cell initial lymphatic capillary that, most
superficially, is part of a netlike structure located in the der-
mis layer of tissue. This initial lymphatic capillary is pencil
shaped (tube closed on one end) and lined with one layer of
Figure 12-1 Combined edema eight weeks post cerebrovascu- overlapping endothelia cells (Fig. 12-3).28 Anatomically,
lar accident. fluid cannot be physically “pushed” into the lymphatic
 Chapter 12 • Edema Control 309

6 6
CO2 O2 7

1 2

5
10%

90%

4
3

7 6 3
2 1

6 7
4
5

CO2 O2
5 Figure 12-3 Incorporation of the lymph capillary into the in-
1 Pulmonary artery Pulmonary terstitium: 1, Arterial section of the blood capillary. 2, Venous
2 Pulmonary veins circulation
3 Heart section of the blood capillary. 3, Lymph capillary. 4, Open inter-
4 Aorta - arterial system
Systemic cellular groove-swinging tip. 5, Fibrocyte. 6, Anchor filaments.
5 Capillaries
6 Venous system
circulation 7, Intercellular space. (From Foldi M, Foldi E, Kubil S: Textbook
7 Lymph vessels and lymph nodes of lymphology for physicians and lymphedema therapists, Munich,
Figure 12-2 Blood and lymph circulatory systems space. (From 2003, Urban & Fischer Verlag).
Foldi M, Foldi E, Kubil S: Textbook of lymphology for physicians and
lymphedema therapists, Munich, 2003, Urban & Fischer Verlag.)

capillaries, nor does it move from the interstitium by osmo- toward the subclavian veins. These pressure changes in
sis into the lymphatic capillary. Tissue fluid and large mol- the thoracic duct then create a vacuum (suction), pulling
ecules can only be absorbed by the lymphatic capillary when lymph from peripheral structures centrally.14,35,36 The re-
changes occur in interstitial fluid pressure or by movement sult is fluid from the periphery moves out of the area, and
of the elastic anchor filaments that extend from an endothe- edema is reduced distally in a domino effect. Once the
lial cell to connective tissue.28,35 Then the junctions of these lymph enters the subclavian veins, it then becomes part of
over lapping endothelial cells open like a trap door admit- the venous system and continues on to lungs, heart, and
ting large molecules from the interstitium into the pencil other parts of the body.
shaped lymphatic capillary.28,35 These pressure changes oc- The differences and similarities of the venous and lym-
cur with movement of skin, light compression, muscle con- phatic system of fluid absorption from the interstitium
traction, and respiration.14,28 The elastic anchor filaments should be considered when choosing the appropriate
extending from connective tissue to the endothelial junc- edema reduction technique for poststroke arm and hand
tions will open the junction flaps when pressure is put on edema.
their elastic filaments, such as from fluid congestion in the
interstitium.17 Three Proposed Theories of Etiology and Types
Lymphatic absorption is stimulated by respiration. The of Stroke Hand Edema
deepest and largest lymphatic structure is the thoracic An in-depth exploration of the types of Complex Stroke
duct. It lies anterior to, and parallels, the spinal column Hand Edema theories is necessary in order to make treat-
running from L2 to T4.56 Changes in thoracic pressure ment choices.
cause a proximal negative pressure vacuum and draws
fluid proximally from the periphery. This is also called the Dependency Edema Theory
pulmonary pump.17 The thoracic duct operates according Dependency edema is due to a combination of the in-
to hydrodynamic laws.35 Therefore, inhalation and exha- volved flaccid or hemiparetic upper extremity hanging in
lation from diaphragmatic breathing cause changes in the a dependent position, plus potentially the impairment of
thoracic duct pressure drawing the lymph within the duct sympathetic controlled muscle function.38,55 Thus tissue
310 Stroke Rehabilitation

fluid pools distally. Often consistent elevation, daily light in the colloidal osmotic pressure in the interstitium. This
retrograde massage, and a light compression glove and/or causes an imbalance in Starling equilibrium resulting in
elastic stockinette tube on the arm will reduce this edema. an excess of plasma proteins trapped in the interstitium
However, even after diligently following these methods, for a prolonged period. Casley-Smith and Gaffney16 found
edema can persist. How much does this persistent edema that when excess plasma proteins stayed in the intersti-
relate to prolonged trunk immobility, lack of scapular tium 64 days or longer, they caused chronic inflammation.
movement, and lack of thoracic pressure changes? Fibroblasts are activated by the proteins trapped in the
This initial edema consists of small molecules that are tissue and produce collagenous tissue.32 This in turn can
readily absorbed by the venous system. However, the ve- lead to the eventual shortening, scarring, and possible fi-
nous system has a maximum volume capacity. When this brosing of soft tissue and joints.12,15 Only the lymphatic
capacity is reached, the lymphatic system will carry off the system can remove the excess plasma proteins. Thus, the
excess. Often, the lymphatic system is referred to as the lymphatic system has to be specifically activated to reduce
overflow system. Dependent venous edema has a soft the trapped plasma proteins and break the cycle to pain,
“spongy feel” when pitted, rebounds quickly; and often scarring, and possible fibrosis of tissue.
reduces easily with elevation. This type of edema is often
seen when poststroke edema first becomes evident. Chronic Regional Pain Syndrome Edema*
Reflex Sympathetic Dystrophy (RSD), the original term
Combined Edema Theory used in literature and is now known as Chronic Regional
When the lymphatic system acts as a safety valve or over- Pain Syndrome (CRPS) Type I, may be seen post stroke
flow system for the venous system, it carries out of the in- (central lesion damage).41,52 In the literature, Shoulder
terstitium both the small molecule products that the venous Hand-Syndrome (SHS) is used synonymously with CRPS
system usually absorbs and the large molecules only re- Type I.41 CRPS Type II has the same clinical symptoms
moved by the lymphatic system. The lymphatic system also but occurs because of peripheral nerve involvement.41 It is
has a maximum load capacity. When the system reaches defined as an exaggerated pain response to injury charac-
this capacity, there will be lymphatic congestion. Clinically, terized by intense pain, trophic changes, and vasomotor
lymphatic congestion presents as viscous and has a very changes in the involved limb.52 CRPS progresses through
slow rebound time from being pitted of 20 to 30 seconds or three phases, each causing increased hand dysfunction.
more. At this point, the stroke edema is a combined venous Clinically, in the first phase the hand presents as edema-
and lymphatic edema that minimally reduces with eleva- tous, hyperesthetic, warm, perspiring, having burning
tion. Elevation alone will not reduce lymphatic congestion, pain, tenderness at the wrist and finger joints, and an in-
because the large molecules do not go into the lymphatic creased blood flow to the extremity.30,52 Poststroke edema
capillary via osmosis and the overlapping endothelia cells occurs most frequently between two and four months af-
surrounding the lymphatic capillary have to be stimulated ter the stroke, as does the occurrence of RSD (CRPS
to open and close. With combined edema, the reduction Type I).30,31 However, clients who developed RSD during
treatment has to be a combination of lymphatic proximal this period showed a greater degree of edema than the
trunk stimulation (muscle contraction, diaphragmatic non-RSD edematous stroke hands.30 Another possible
breathing), superficial tissue stimulation (creating absorp- predictor of RSD researchers found was hand swelling
tion into the initial lymphatics), and elevation to aid in ve- occurring during the first month poststroke.30
nous (low protein) return. The statistics for development of CRPS poststroke
range anywhere from 1.56 %52 to 25%49 of stroke hand
Minor Trauma Edema (Inflammatory Subacute edema cases, using both clinical evidence and a three-
Edema) Theory phase triple bone scan. This great range of statistics oc-
Minor trauma to tissue is often caused by the arm or hand curs because of timing of inclusion factors, methods of
being bumped, getting caught on something, or from evaluation, when treatment began, and the type of treat-
overzealous and improper exercise by the client or care- ment received. The researchers documenting the 1.56%
giver.8,18,30,33 This accidental trauma often occurs due to incidence concluded that their incidence of CRPS was
an impaired visual field or perception, neglect, lack of low because rehabilitation poststroke began early at 16
limb position in space awareness, decreased sensation, and days after the first stroke, and treatment included proper
from learned nonuse once motor function returns. In- positioning, early mobilization, and sensory stimulation.52
flammation from trauma becomes a third component to
persistent edema. On a microvascular level, trauma causes
high capillary permeability leading to a wound healing *The most current term for the syndrome discussed here is Complex
sequence in the involved joints and tissue. If the limb is Regional Pain Syndrome. In the recent past, this syndrome was referred
to as Reflex Sympathetic Dystrophy (RSD) and Shoulder Hand Syn-
already congested due to a dependency and/or a com- drome (SHS). The terms are synonymous here. The terms that were
bined venous and lymphatic overload, there is an increase used in the original cited papers are being maintained.
 Chapter 12 • Edema Control 311

Therapists can play a critical role in early identification

and possible prevention or reversing of CRPS Type I.
When evaluating and treating clients, occupational thera-
pists should scan for neglect, sensory impairments, shoul-
der subluxation, and decreased visual field awareness.
Pertoldi and colleagues41 found that the presence of these
increased the risk of CRPS. Also, early initiation of a
treatment program to prevent trauma (proper position- A
ing, functional use, and mobilization) to the involved
shoulder and extremity is critical to preventing CRPS I.
See Chapter 10.
In a detailed review of research from 1973 to 1998 on
the etiology and treatment of poststroke hand edema and
SHS, it was found that the shoulder was only involved in
half the cases with a swollen painful hand.23 Thus, a new
term of wrist-hand syndrome has been coined.23 This same
study found that in SHS, trauma causes aseptic joint
inflammation.23

EDEMA EVALUATION METHODS

Volumetric Measurement B C
Volumetric measurement is a water displacement method
Figure 12-4 Volumeter, collection beaker, and graduated cyl-
measuring hand and lower arm composite mass. The con-
inder used to perform volumetric hand edema assessments.
tainer called a volumeter is filled with enough room tem-
(From Fess, E: Documentation: essential elements of an upper
perature water to flow out the container spout. When the
extremity assessment battery. In Mackin EJ, Callahan AD,
water stops dripping out the spout, the client submerges
Osterman AL, et al, editors: Rehabilitation of the hand and upper
his or her arm into the volumeter with the palm facing him
extremity, ed 5, St Louis, 2002, Mosby.)
or her, thumb facing the spout, and the web between the
middle and ring fingers resting on the plastic stop bar. The
therapist holds a beaker to catch the flowing water from
the spout and then measures it in a graduated cylinder a spring loaded device. These devices will give a more
(Fig. 12-4). Care must be taken that the client does not consistent pull on the tape and therefore provide a more
lean his or her arm against the side of the volumeter or reliable, repeatable measurement. Circumferential mea-
move the arm while water displacement is taking place, the surements have the advantage of showing site specific
container and cylinder sit on flat level surfaces, and mea- changes in edema. Jeweler’s rings can also be used to cir-
surements are consistently taken seated or standing and at cumferentially measure digits
same time of day and after same amount of activity. Tests
have shown the volumeter measurements to be accurate Cognitive and Perceptual Assessments
within 10 mL, or 1% of the volume of the hand, when fol- Occupational therapists are skilled in prioritizing person-
lowing the manufacturers’ directions.53 Measurements are centered goals and addressing the many personal and envi-
then taken of the uninvolved hand for comparison sake. ronmental factors that alter function poststroke. Cognition
This method shows generalized, not site specific, changes and perception may affect a client’s ability to integrate the
in edema. A 12-mL change over time is considered clini- affected limb into normal tasks and to understand their role
cally significant.48 Volumetric measuring has shown to be in preventing or managing edema (see Chapters 18 and 19).
more accurate than visual inspection for determining pres- The caregiver may need education on how these areas in-
ence of edema because it shows small increments of fluence function and a person’s ability to follow an edema
change.43 Clinically, it can be difficult to consistently posi- management program, such as the importance of position-
tion the client with a flaccid or spastic hand. ing, safe ranging, and gentle edema massage.

Circumferential Measurement Upper Limb Assessments

Results from using a nonweighted or spring loaded tape Many clinics use an upper limb or neurophysical screen to
measure can vacillate greatly because of the inconsistency comment on range, strength, shoulder integrity, coordina-
of tension put on the tape. The preference is to use a tion, pain, and edema, among other things. When con-
measuring tape with a weight on one end, or one having ducting a standardized assessment of upper limb quality of
312 Stroke Rehabilitation

movement or function, it is important to consider not only hand edema begins two to four months poststroke, and
how motor recovery may affect the outcome, but also how CRPS has been observed to start at the same time but
edema may influence the results. Further discussion of up- tends to be more extensive.30
per limb assessments can be found in Chapter 10. Tissue in early stages of CRPS Type I presents
as edematous, hyperesthetic, warm, perspiring, red
Sensibility Testing and white blotching of skin, pain and tenderness of
There is an old saying, “an insensitive hand is a blind the wrist and finger joints, having a constant burning
hand.” Hand insensitivity or decreased sensation facili- pain, and having an increased in blood flow to the
tates decreased use and possible injury to the extremity, extremity.30
which can be further complicated by a unilateral neglect. ■ Swelling from a blood clot
The monofilament method tests for the degree of sensi- This is rare in the upper extremity, but a therapist
bility present and can indicate a sensory deficit ranging must be suspicious of any sudden onset of swelling that is
from decreased light touch to loss of protective sensation accompanied by pain with a specific muscle movement,
and to loss of deep touch. Various size monofilaments on including tenderness and warmth. Do not treat the client;
individual rods are slowly pressed against the tissue until seek physician advice immediately.
the monofilament bends, and then the monofilament is ■ Swelling from an infection
slowly lifted from the skin. Once the monofilament bends, Infected tissue acutely presents as red, warm, swollen,
no further pressure can be exerted. If the client doesn’t and painful to touch or movement, and often the client
detect “touch” from the monofilament, the therapist then has a fever. If there is an infected open wound, the drain-
uses a larger size monofilament for the next test. The age may be opaque and have a pungent odor, in addition
client’s vision is occluded during the test. to the proceeding symptoms. Seek physician help imme-
Testing is important because edema puts pressure on diately. Do not treat the limb until the physician has given
nerve endings decreasing sensibility. As edema decreases the approval to resume treatment.
sensitivity should improve. Results can be related to safety Routinely check for excessively dry skin from sensory
and activity of daily living (ADL) function. It is imperative impairment. Dry skin cracks and can be a source for bac-
to follow directions for accurate, reliable, and repeatable terial infections.
testing. Checking for sensibility can be an important pre- ■ Swelling from a mastectomy
dictor of edema. Boomkamp-Koppen and colleagues7 Check client’s history regarding having had a mastec-
found that poststroke clients with hyposensibility, hyper- tomy in the past. Approximately 15% to 20% of clients
tonia, and motor impairment were 50% more likely to develop lymphedema postmastectomy node removal.42
develop edema. However, because there is a decrease in the number of
lymphatic structures, clients are always at risk to develop
Rebound Test lymphedema. A stroke survivor with dependent edema
This is a subjective test, but gives an indication if con- involving the arm on the mastectomy side could poten-
gested edema is softening and decreasing from an area. tially compromise the deficient lymphatic system and
The therapist places a one ounce weight or the weight of cause lymphedema. If this occurs, a therapist certified in
his or her thumb (enough weight to begin blanching the manual lymphatic drainage techniques must be sought out
therapist’s finger nail) on the edematous area and counts to treat the lymphedema.
to 10. This light pressure creates a pit in the edema. ■ Swelling from cardiac problems or from low protein
Then the therapist counts the time the tissue takes to edemas such as renal dysfunction, malnutrition, and
rebound to the height of the adjacent tissue. Lymph con- liver disease
gested tissue presents as slow to rebound and is clinically Swelling from cardiac problems, such as chronic
seen as significant with a 20- to 30- second rebound or heart disease or congestive heart failure (CHF), can be
slower. After doing edema reduction treatment, the test characterized by bilateral ankle swelling, and the tissue
is repeated. If the rebound time is faster, then it is as- is often slightly pinkish. Therapists should check the
sumed that there has been some lymph decongestion in client’s chart regarding a possible cardiac condition.
the area. Edema reduction massage should not be performed be-
This is a quick easy test to do between more objective cause of the potential to send too much fluid back to the
circumferential or volumetric measurements. It must be heart and further compromising the heart. This type of
noted that tissue that does not pit is usually fibrotic. edema has to be controlled medically. Edema from renal
disease, liver disease, and malnutrition is a low protein
Edematous Tissue Visual and Tactile Evaluation edema.27 This too has to be reduced by medication.
■ Check for early signs of CRPS type I swelling Edema reduction massage can potentially overload and
Edema present one month poststroke should be decrease the function of the already compromised or-
watched closely for early signs of CRPS Type 1. Most gans in this case.
 Chapter 12 • Edema Control 313

CURRENT POSTSTROKE HAND EDEMA quickly increases the symptoms such as dysesthesia and
TREATMENT METHODS further blanching of the finger tips.10 Also, extreme eleva-
tion of the right upper extremity, especially in supine, to
Manual Lymphatic and Venous Absorption reduce edema would not be advisable if the client had a
Stimulation Methods comorbidity of right-sided heart weakness.10 This could
Elevation and Retrograde Massage potentially send fluid faster into the right side of the heart
In the early stages of poststroke edema, elevation and than it can be pumped into the left side to be reoxygen-
light retrograde massage followed by use of an elastic ated, thus further compromising the heart.
glove on the hand and cotton/elastic stockinette tube on
the arm, if needed, can be effective for reducing hand/arm Manual Edema Mobilization
edema. The rationale is that elevation decreases arterial Manual Edema Mobilization (MEM) was first introduced
hydrostatic pressure and thus reduces the flowing of fluid by Artzberger in 1995 with subsequent publications.1-5,29,44
into the interstitial spaces.14,50 The elastic glove and It recognizes that swelling that lasts longer than one week
stockinette give light pressure to prevent or lessen refill- and presents as slow to rebound, i.e., 20 to 30 seconds or
ing of tissue. An active muscle pump is needed to inter- more to reach surrounding tissue height when pitted, indi-
mittently compress venous and lymphatic structures to cates a lymphatic congested system. MEM teaches specific
return fluid back toward the heart. Without an active or concepts to stimulate and quickly decongest the lymphatic
fully functioning muscle pump, dependent limb edema system for postorthopedic trauma and poststroke extrem-
results. Furthermore, over time the volume of fluid in- ity edema. Treatment begins in the trunk, creating a vac-
creases distally and less edema reduces with elevation and uum drawing peripheral lymph proximally, toward the
compression. At this point, it is theorized that both the trunk. Treatment for the sedentary patient begins with
venous and lymphatic systems have reached their maxi- pretreatment exercises of stretching for the trunk and
mum capacity, and a combined edema situation exists. shoulders to facilitate proximal decongestion. The MEM
program is initiated with diaphragmatic breathing, trunk
Clinical Treatment Considerations. Avoid having exercise, and light trunk massage, and then proceeds dis-
the elastic glove or elastic/cotton stockinette tube being tally in sections toward the hand. Active or passive exercise
too tight and collapsing the initial lymphatics. This of muscles in each section just massaged is essential to
would prevent absorption of fluid from the interstitium. pump the lymph proximally. At the end, along with distal
One clinical guideline is to be able to stretch the glove to proximal exercise, light flow massage from hand to arm
one eighth of an inch out from either side of a digit. The to the trunk is completed. Keys to success include dia-
elastic/cotton stockinette tube should be firm but still phragmatic breathing, starting treatment at the trunk, ex-
allow a therapist’s hands to fit under the stockinette at the ercise at specific intervals, use of a technique called MEM
tightest point. The goals are to provide compression, not Pump Points, light massage strokes, a home self-massage
to collapse the initial lymphatic net along without caus- and exercise program, and low stretch bandaging and/or
ing tissue trauma with application and removal. Both the chip bags as needed. This is designed exclusively for the
venous and lymphatic systems take fluid out of the inter- patient with an intact lymph system (not status post mas-
stitium, but lymphatic absorption is stimulated in ways tectomy where nodes have been removed). Treatment
previously discussed. If sensory or vascular insufficiencies usually takes 20 minutes and is incorporated into a patient’s
exist in the involved arm and hand, the therapist must regular treatment program. The MEM technique includes
take appropriate precautions. specific guidelines and precautions, especially for the
Anecdotally, therapists have seen distal hand edema stroke survivor who often has many comorbidities, so tak-
reduction while doing extensive active, active-assistive ing a formal two-day MEM course is necessary.
trunk and scapular work. Anatomically, this is logical be- When poststroke edema no longer reduces with eleva-
cause trunk and scapular movement activates changes in tion, light retrograde massage, and compression, it is
thoracic pressures and thus activates the thoracic duct theorized that both the venous and lymphatic systems are
pump of the lymph system. Thus, applying the elastic overloaded, and a combined edema exists. Thus, there has
glove and cotton/elastic stockinette tube on the extremity to be a specific activation of the lymphatic system to help
immediately following active trunk and scapular exercise reduce this type of edema. MEM is an appropriate treat-
prevents or lessens refill after an edema reduction has ment providing there are no medical contraindications
been achieved. relative to the technique. The following paragraphs will
When elevating the arm, precautions should be taken if elaborate the key elements of MEM.
the client has medical conditions such as right-sided heart
weakness or Raynaud disease. The latter diagnosis involves Manual Edema Mobilization Begins at the
arterial vascular insufficiency, so elevation of the extremity Trunk. This follows the previously discussed hydraulic,
further decreases the blood flow to the extremity and vacuum principle of first moving lymph centrally into the
314 Stroke Rehabilitation

venous system (subclavian veins), which then draws lymph Flow “U”s begin at the distal end of the segment just
proximally from the periphery. Diaphragmatic breathing cleared and end proximal to where clearing started, hope-
facilitates this process through changes in thoracic duct fully at a set of nodes. Only one, not five, “U”s are done
pressure that then moves lymph proximally.14 Diaphrag- in each section of the segment. These are repeated five
matic breathing entails breathing air through the nose times from the distal end of the segment and ending
into the lower abdomen that pushes the naval area out- proximal to where clearing started. This action is believed
ward, and then slowly exhaling through pursed lips, to stimulate absorption, help to prevent refluxing of
bringing the lower abdomen inward. lymph, and create a proximal flow.
Because the “flowing” concept can be difficult to teach
Exercise Muscles in Area Just Massaged. According a patient for his or her home program, the term sweep is
to Guyton and Hall,27 the collector lymphatics move used. The patient is instructed to very lightly slide his or
lymph ten to thirty times faster with exercise. MEM light her fingers and palm over the involved extremity, starting
massage techniques facilitate absorption of large mole- distally and moving proximally (Fig. 12-6).
cules, permeable only to the lymph system, into the initial
lymphatic net by exercising muscles under the tissue just Manual Edema Mobilization Pump Points. The
massaged. This muscle pumping moves lymph faster upper extremity has five specific pump point locations,
through the system, and theoretically space is created for which are sites of lymph nodes or bundles of lymphatic
more absorption. structures (initial and collector lymphatics). A therapist
uses both hands to simultaneously massage a set of nodes
Light Massage Strokes. Since 65 mm Hg pressure39 and lymphatic bundles in a “U” shaped pump pattern (see
has been shown to begin collapsing the initial lymphatic Figs. 12-7 and 12-8). Clinically, these seem to provide a
net where absorption begins in the dermis layer of tissue, faster flow of lymph versus the usual “clear” and “flow”
therapists are instructed to use a pressure no greater than technique, especially for patients with the combined type
half the weight of their hand. To quote a stroke survivor of edema. Because of the effect, an increased volume of
being taught a home program, “light is right.” Strokes are lymph flow could have another existing medical condi-
“U” shaped beginning proximally (top of the “U”), mov- tions, such as cardiac and pulmonary. It is necessary to
ing the skin distally, and then back upward to where be- complete a MEM course because pump point application
gun. It is emphasized that the hand does not slide on the is thoroughly discussed for the stroke survivor. Box 12-1
skin but remains in place moving the skin over underlying lists the upper extremity pump points.
structures. Terms used in the massage performed by the
therapist are clear and flow. Manual Edema Mobilization Home Self-
Clearing “U”s consist of five “U”s done in each of three Management Program. A home MEM program is es-
segments of a section of an extremity, i.e., volar forearm. sential to keep lymphatic structures open, and lymph
In this case, the “U”s start proximal at the elbow and end
at the wrist (Fig. 12-5) These stimulate absorption into
the initial and collector lymphatics.

Figure 12-5 Manual Edema Mobilization forearm “clear”

(A through C) and “flow.” (C through A). Figure 12-6 Manual Edema Mobilization “sweep.”
 Chapter 12 • Edema Control 315

Box 12-1
The Five MEM Upper Extremity Pump Point
Hand Placement Areas
1. First hand is placed on deltoid pectoral node area of
trunk and anterior deltoid of upper arm. Second hand
is placed on teres minor, posterior axilla, and poste-
rior deltoid of upper arm. A praying hands position
(Fig. 12–7).
2. First hand is placed on teres minor, posterior axilla,
and posterior deltoid of upper arm, as in Pump Point
One. Second hand is placed on medial side of antecu-
bital crease of elbow—elbow node location. Middle
finger lies across antecubital crease and thumb on
back of arm above elbow.
Figure 12-7 Manual Edema Mobilization Pump Point 1. 3. First hand is placed on medial antecubital crease as in
Pump Point Two. Second hand is placed on the
posterior of the upper arm just above the back of the
elbow (Fig. 12–8).
4. First hand is placed on antecubital crease as in Pump
Points two and three. Second hand is placed on the
volar forearm at wrist.
5. First hand is placed at the volar forearm at the wrist.
Second hand is on the dorsum of the hand.

areas of excessive swelling, especially areas of hard tissue.

They consist of various densities of foam pieces one inch
in size placed in a cotton stockinette with the ends sewn
shut (Fig. 12-9). It is theorized that hard tissue is softened
due to the neutral warmth that builds up under the foam
pieces.4 See Bandaging Methods Section for ideal lymph
Figure 12-8 Manual Edema Mobilization Pump Point 3. flow temperatures. It appears that the various densities of
the foam further help to soften and stimulate lymphatic
uptake because of the tissue pressure differentiation they
flowing for long-term edema reduction. Patients are cause.
given a simplified version of the program the therapist
used in the clinic. Often simple proximal to distal node Clinical Treatment Considerations. MEM tech-
massage from trunk to elbow, “sweeping” from hand to niques have been shown to reduce edema.44 However, for
uninvolved axilla, and exercise of the arm and trunk is the flaccid extremity, this reduction will not last because
enough. These can easily be incorporated into the pa- the lymphatic system, like the venous system, needs an
tient’s ADL tasks, such as daily hygiene and functional active muscle pump system to continually move the
upper limb retraining, e.g., wiping the table. lymph.22 Light massage and passive exercise both put a
stretch on the anchor filaments of the initial lymphatics
Low Stretch Bandages. Low stretch bandages look (lymphatic net) and alter interstitial pressure, which will
like the high stretch bandages often used postsports open the junctions of the endothelial cells, admitting mol-
injury, frequently called ACE bandages; however, low ecules into the initial lymphatic. From there the collector
stretch bandages have no elastic fibers and are 100% cot- lymphatics have a peristaltic pumping action that is con-
ton. Because they have minimal stretch, they facilitate a trolled by the sympathetic and parasympathetic systems
“pumping” action on the initial lymphatic net with muscle to conduct the lymph proximally.17 However, some au-
contraction and relaxation.14 For more details, see the thors believe that the autonomic system can be neuro-
Bandaging Methods section. logically impaired by the stroke.55 This combined with
lack of an active muscle pump causes lymph congestion.
Chip Bags. Chip bags are often placed under low Proximal trunk exercise and diaphragmatic breathing
stretch bandages or an elastic/cotton stockinette tube on stimulate the lymphatic system and will draw lymph
316 Stroke Rehabilitation

A B
Figure 12-9 Foam “chips” and chip bag.

proximally.14 Thus, even without knowing MEM tech- Clinical Treatment Considerations. Low stretch
niques, a therapist can reduce the lymphatic congestion bandages create a pump action facilitating lymphatic
with diaphragmatic breathing, extensive trunk and scapu- absorption and prevent tissue refill.14 The neutral warmth
lar exercise and activation of the proximal noninvolved (body temperature) that builds up under bandages soft-
musculature. The decongestion then facilitates peripheral ens indurated (hard) tissue facilitating fluid absorption.
lymph absorption. By reducing edema, the occupational Kurz36 states that the ideal temperatures to facilitate
therapist may improve the patient’s perception and aware- lymph flow is between 22 degrees and 41 degrees C
ness of the affected upper limb and increase the functional (71.6 F and 105.8 F). Please note that temperatures
dexterity of the hand. Providing a clear and meaningful above 98.6 F or 37 degrees C will increase blood flow to
home program may increase the patient’s ownership of his the area and increase edema, so a therapist would not use
or her occupational therapy program. these high temperatures when trying to reduce edema.
Most importantly, when applied properly, the short
Bandaging Methods stretch bandages do not collapse the lymphatic net,
There are two types of bandaging systems: elastic (high which prevents excess tissue fluid absorption, and they
stretch) and low elastic (low stretch).14 Both look alike can be worn during periods of rest. Unfortunately, low
in thickness and color, but the low elastic (low stretch) stretch bandages are not often practical and have limita-
bandages are usually 100% cotton and have no elastic tions for poststroke hand and arm edema, because they
fibers.14 The Casley-Smiths14 point out that the initial can potentially cause neurovascular problems or can
lymphatic net will only pump when compressed against limit function when applied too tightly by an untrained
something solid such between a contracting muscle and person; if an active muscle movement causes the desired
a solid counter-force (low elastic bandage). A tissue pres- excess tissue fluid absorption, the extremity loses girth,
sure differentiation, or pumping action, is created facili- the bandages have to be reapplied, and most stroke sur-
tating lymphatic absorption with muscle contraction vivors require assistance to reapply bandages due to their
against a counter-force (the lymphatic net is caught be- cognitive, perceptual, or motor limitations; and ban-
tween the contracting muscle and the resistive bandage) dages may limit sensory retraining.
and then relaxation of the muscle. The Casley-Smiths14 When there is minimal to no active muscle contrac-
refer to low stretch bandages as having “high-working tion, a cotton/elastic stockinette tube is more practical for
and low resting pressures.” An elastic bandage stretches stroke edema. Because the cotton stockinette tube is elas-
and does not produce this counter-force. tic, it only prevents or lessens tissue fluid refill, and, if
Low stretch bandages are “rolled on,” not pulled tight, loose enough, it will not collapse the initial lymphatic net.
in order not to collapse the initial lymphatic net. Miller To ensure that an elastic/cotton stockinette tube is not too
and Seale39 found that the initial lymphatic net begins tight, the therapist should be able to get both hands in the
to close as 60 mm Hg pressure and is completely closed at tube on either side of the patient’s arm.
75 mm Hg pressure. Graduated pressure with low stretch Rolling down of the elastic/stockinette tube can be
bandages is thus obtained not by pulling tightly, but by a problem. Suggested ways to prevent this include:
layers of bandages in an area. (1) Double the elastic stockinette tube, but make sure
 Chapter 12 • Edema Control 317

that the pressure is not too tight; (2) Loosely place a to- interstitial pressure, all facilitating opening of the endothe-
tally stretched out 3 inch-wide piece of Coban circumfer- lial cell junctions and absorption of fluid into the lymphatic
entially 1 inch below the proximal end of the elastic net. It has been suggested that the CPM might have more
stockinette tube and “cuff” the 1 inch proximal end over pumping and drainage action on the dorsal hand lymphat-
the Coban (Fig. 12-10). This can also be done with a ics if it was set to flex metacarpophalangeal (MCP) joints to
loosely placed one inch foam splinting strap instead of near normal flexion range.22 Because the CPM is on the
the Coban. To achieve graded compression, place one hand, increased attention the involved limb may be noted
piece of the cotton/elastic stockinette tube, for instance, during that period of usage.
from palm to elbow and a second smaller piece from
palm to mid-forearm. Then stitch the two pieces to- Pneumatic Pump and Air Splints
gether enabling the patient or caregiver to pull it on in Pneumatic intermittent compression pumps were first
one piece. When introducing bandaging, therapists must introduced to reduce venous leg edema, such as from
educate and closely monitor the patient and caregiver for varicose veins, and were then expanded to usage with the
appropriate application to prevent rolling down of the lymphedematous extremity. Leduc37 reported that pneu-
elastic/cotton stockinette tube that would then increase matic pumps only force water back into blood and do not
distal swelling. Chip bags can be placed under the elastic/ remove excessive protein from tissues. In 1999 Roper and
cotton stockinette tube to soften hard edema or to pre- colleagues47 reported on their study of 37 clients with
vent refill at a specific site. stroke hand edema who received a two two-hour session
two times a day of intermittent pneumatic compression
Continuous Passive Motion for one month. Compression was 50 mm Hg. They found
In 1990 Giudice25 published an article reporting hand no change in hand volume in the treated group.47
edema reduction outcomes comparing 30 minutes of hand
elevation and 30 minutes of hand elevation with continu- Clinical Treatment Considerations, Rationale,
ous passive motion (CPM). Eleven of the 16 subjects had and Potential Future Research Ideas.
hemiplegia. Edema reduction was significantly greater 1. A Casley-Smith and Bjorlin13 research study con-
with the combination of elevation and the use of the CPM cluded that 45 mm Hg pump pressure would not col-
machine. However, when the CPM was discontinued, the lapse the initial lymphatics. Would a graded sequential
edema returned to its former rate.25 pump, meaning progressive chamber pressures from
More extensive use and evaluation of use of the CPM 40 mm Hg at the hand to 10 mm Hg at the axilla, be
machine was reported by Dirette and Hinojosa in 1994.20 more effective versus 50 mm Hg pressure up the en-
In their ABA single subject design study, two clients tire arm?
one month poststroke received CPM treatment for 2. Did the Roper and colleagues47 study include early or
two hours daily for one week. Results showed a continuous combined edema?
significant reduction of edema during the treatment week. 3. If it were combined edema, would central trunk clear-
During the withdrawal week, the edema increased, leveled ing performed before pumping positively affect the
off, but did not return to evaluation week edema volume. results? Recently new pumps have been developed that
use lower pressures and begin massage at the trunk.
Clinical Treatment Considerations and Rationale. Would these be more effective because they start
The CPM provides gentle and nonexcessive motion to the drainage centrally, massage in a proximal to distal seg-
hand, thus eliminating microscopic tearing of tissue that ment sequence, and then distal to proximal? Raines
can lead to edema and potential fibrosis of tissue and joints. and colleagues45 found that the pneumatic pumps
The passive movement stretches the elastic anchor fila- could only reduce edema, even temporarily, only if the
ments of the initial lymphatic net and causes changes of venous drainage is normal. According to the vasomo-
tor dysfunction theory of stroke edema development,
venous drainage is impaired.55
If a pneumatic pump is used, precautions should be ob-
served. It should not be used if there is a blood clot or
any suspicion of a clot, infection, cellulitis, symptoms of
CHF or chronic obstructive pulmonary disease, dizzi-
ness, lightheadedness, or headaches.14 Beta blockers in
combination with pumping have been known to cause
hypotension.11 The pneumatic pump or air splints should
not be used on stroke clients who are on anticoagulant
Figure 12-10 Cotton/elastic stockinette tube with proximal medications that can drop their platelet level below
Coban. 120,000 mm.19
318 Stroke Rehabilitation

Clinically, the rationale of using air splints to reduce external rotation only after fully mobilizing the scapula;
edema should be evaluated and appropriately applied. having not only the therapist perform the motion during
They provide single chamber circumferential compres- treatment, but having other hospital services do so when
sion that can push fluid both distal and proximal because handling the involved limb as part of their treatment, such
there is no grading of compression. The air splint com- as computerized tomography, electroencephalography, or
pression pushes tissue fluid back into the interstitium, when relatives assist with care; and avoiding needle sticks
which may work to reduce edema in the early stages when in the involved hand/arm.8
it is a low protein edema. Also, the neutral warmth that In their research article, Kondo and colleague33 in-
builds up under the plastic splint could soften indurated cluded a passive exercise protocol for both the therapist
tissue. However, when the edema becomes a combined and client to follow to prevent SHS. This article de-
edema, this method will only push fluid out of the inter- tailed a controlled passive movement regimen by a
stitium temporarily. The hydrophilic plasma proteins re- trained therapist and restriction of passive movement
main in the lymph, because anatomically they cannot be by the client for a minimum of four months poststroke.
physically “pushed out.” They will reattract the water Restricted passive motion not only included shoulder-
molecule, and swelling will return. In fact, if the pressure scapula protective ROM, but also included preventing
is above 40 mm Hg, it could collapse the lymphatic net. the client from repeatedly hyperextending his fingers,
which causes trauma to the finger joints. Clients with
Splinting impaired sensation were more likely to excessively
There is some evidence that splinting reduces edema. range or hyperextend their fingers.33 Another study
Garcies and colleagues26 found that a custom-made lycra also showed that the hand stayed edematous, even if the
garment with flexible plastic inserts when worn three client had active motor return and did not use it.7 Fur-
hours a day provided a continuous stretch of spastic thermore, studies have shown that prolonged position-
muscles and reduced edema. There are some clinical ar- ing of the wrist and fingers in flexion will exacerbate
guments for the use of a wrist cock up splint to reduce swelling, because it impedes venous and lymphatic flow
edema, to protect joints, and to minimize pain.24 Burge at the wrist.7
and colleagues9 conducted a randomized trial of a neutral Avoiding microtrauma to tissue is difficult if the client
functional realignment orthosis on 30 clients with sub- also has unilateral neglect and/or visual field deficits. Wee
acute hemiplegia, with the orthosis group wearing it for and colleagues54 found that 80% of those with shoulder-
six hours a day. They found the orthoses prevented pain hand problems had unilateral neglect. They concluded
but had little effect on edema or mobility. They also that the neglect predisposed the client to shoulder-hand
stated that they used circumferential measurements as problems.54
directed by Leibovitz.9 Microscopic tearing of tissue that occurs from re-
peated mishandling and mispositioning of a nonfunc-
Clinical Treatment Considerations and Rationale. tioning to a minimum functioning arm causes trauma to
The splint used by Gracies26 allowed for restricted move- tissue. This will cause a wound healing sequence to oc-
ment, thus preventing overzealous passive movement of cur to the involved joints and tissue. With the invasion
the hand and arm to cause trauma edema. Also, the ability of excess plasma proteins into tissue from trauma to a
to move the hand while it is in the splint helps to increase hand or arm with a preexisting diminished motor func-
attention to the affected limb. Consideration should also tion and/or dependency edema, the cycle to possible fi-
be given to the role the combination of the elastic lycra brosis is established. Only the lymphatic system can re-
and muscle contraction play to move low protein edema move these excess plasma proteins and thus has to be
from the periphery centrally or in preventing further fill- specifically stimulated.
ing of tissue. See Chapter 13.
Clinical Treatment Considerations and Rationale.
Exercise and Positioning Diligence is recommended to avoid causing tissue inflam-
Research regarding poststroke development of SHS, mation during all aspects of client care and rehabilitation.
CRPS, and elbow-hand syndrome repeatedly show that The client, family, nursing, nursing assistants, and even
the incidence can be reduced by half or more if inflamma- x-ray and lab technicians from the facility have to be
tion of tissue can be avoided.7,8,30,33 Braus and colleagues8 trained in proper handling and positioning of the arm at all
reduced the frequency of SHS from 27% to 8% in their times during treatment and care, including bed mobility
study by extensively educating everyone involved in client and walking. Pain to the involved limb has to be avoided
care on how to prevent trauma to the involved shoulder or immediately corrected, such pain as from improper
and extremity. Their regimen included immediately positioning. Education and repeated use of educational
repositioning the hand/arm/shoulder if pain occurred; material is essential. Suggestions include: wheelchair lap
performing passive humeral motions of abduction and tables should be at the appropriate height or include an
 Chapter 12 • Edema Control 319

arm wedge to support the affected limb in neutral; when the extremity, but absorption begins with central clearing
moving the flaccid arm, even for bed positioning, support as described previously.
and glide the scapula at the same time; do not pull the af- For the client who has some motor return, emphasize
fected arm during transfers and bed mobility; begin proper the importance of frequent short hand exercise sessions
scapular and shoulder ROM glides as soon as possible after and functional usage throughout the day to reduce hand
the stroke; position on pillows to support the shoulder edema. Relate exercise to functional tasks. Boomkamp-
complex; support the arm and shoulder during transfers Koppen and colleagues7 found hand edema in 17.6% of
and ambulation to prevent stretching on the shoulder cap- their clients who had good hand function. They con-
sule or dependent arm positioning; thoroughly and repeat- cluded that these clients were unwilling to perform active
edly educate the client and family not to exuberantly exer- exercises with the hemiparetic hand as much as the non-
cise the shoulder, wrist, and fingers, and to force extremes involved hand. Hemi neglect, visual field limitations,
of range; all personnel involved with client care must glide sensory limitations, and “learned” neglect all contribute
the scapula concurrently while the humerus is moved to nonuse.
when working with the client; and prevent wrist and fin- Clients with unilateral neglect have to be taught
gers from assuming a flexed position for a prolonged pe- various compensation methods or use of safety devices
riod of time. to prevent microtrauma to the involved arm. Suggested
Diligently avoid head, arm, and trunk positioning or methodologies have included modifications of the
exercise that can cause tissue inflammation of the brachial home and work environments to enable safe functional
plexus. CRPS Type II involves peripheral nerve lesions. task performance; position in space awareness cuing
Overzealous shoulder capsule stretching or prolonged sub- and sensory cuing; auditory warning signals; and
luxation of the glenohumeral joint can cause brachial plexus proprioceptive and visual correction techniques (see
inflammation and potential nerve damage that could po- Chapter 19).
tentially lead to CRPS Type II.41 See Chapter 10.
Scalenus anticus syndrome is a cervical neurovascular Electrical Stimulation
(brachial plexus and subclavian artery) impingement syn- Over the last 25 years, there has been considerable inter-
drome involving the scalenus anticus muscle. It is facili- est in and evolving research and clinical usage of Short
tated by prolonged sitting with a forward head position, Term Electrical Stimulation for neurological stimulation
inwardly rolled shoulders, and flexion of the spine causing poststroke for pain reduction, muscular stimulation,
cervical and brachial plexus inflammation.10 Clients pre- muscle strengthening, and tone reduction. Recognizing
sent with mild neck and shoulder pain including tingling the role the venous and lymphatic systems play for reduc-
sensation in the fingers.51 A corrective position is achieved ing edema and the effect the muscle pump has on these
by positioning the clients pelvis into a neutral tilt, placing two systems to reduce edema, Faghri22 designed a re-
a small rolled pillow or towel at the lower back to get a search study using neuromuscular stimulation (NMES)
lumbar curve, which will then facilitate a normal shoulder to facilitate the muscle pump for edema reduction in the
external rotation position and head alignment above the flaccid/paralyzed edematous poststroke hand. His study
trunk. showed that edema reduction with 30 minutes of NMES
Clients who complain of bilateral arm pain, paraesthe- of the flaccid/paralyzed wrist and finger flexors and ex-
sia, and arm weakness with activities that require over- tensors was significantly greater than 30 minutes of limb
head reaching should be evaluated for thoracic outlet elevation alone. However, when the NMES was discon-
syndrome (TOS). For the client who has decreased pro- tinued, the edema returned to its former volume in the
prioceptive or kinesthetic sensation in the involved arm, limb. This study is very significant because it addresses
an activity such as weight-bearing on that arm with an the two theories of stoke edema: neurological impair-
unsupported shoulder girdle having poor scapula stability ment and dependency edema due to lack of an active
could cause or exacerbate a TOS.10 Furthermore, a client muscle motor pump.
who repeatedly over stretches the arm above the shoulder
without scapular gliding not only can cause microscopic Neuroprosthetic Functional Electrical Stimulation.
tearing of the shoulder capsule soft-tissue structures, but Faghri’s22 study involved only 30 minutes of treatment
could cause an impingement and inflammation at the daily, and edema reduction occurred with electrically in-
thoracic outlet as well. duced muscle contraction. A study done by Ring and
Begin treatment sessions with diaphragmatic breathing Rosenthal also showed a result of edema reduction.46 This
(or activities that cause changes in thoracic pressure such study involved clients six months poststroke, using one
as laughing) and extensive trunk and scapular exercise to group with a flaccid hand and a second group with some
activate the lymphatic pump centrally drawing venous motor return in the involved hand. In addition to their
and lymphatic fluid forward. Remember that even passive regular therapy, the subjects wore a neuroprosthesis on
exercise anatomically stimulates lymphatic absorption in their involved forearm/palm for 50 minutes three times
320 Stroke Rehabilitation

daily for six weeks. This neuromuscular stimulator stimu- position the shoulder complex in normal alignment or
lated five forearm muscles, activating the wrist and facilitated scapulohumeral rhythm to minimize pain
fingers, and the stimulation modes alternated finger and trauma.
flexion and extension. Those with some motor return
were encouraged to actively carry out movement during Clinical Treatment Considerations and Rationale.
stimulation, such as grasp and release. Results for the flac- Occupational therapists are in the position to select
cid extremity group showed greater decrease in spasticity meaningful tasks with their clients for therapy and to set
and greater improvement in proximal limb active ROM, specific functional goals. As the lymphatic system is acti-
compared to the control group. The group with some vated by muscle pumping, the use of the affected upper
motor return demonstrated significant gains in hand limb in normal tasks within a safe range of movement will
function, a decrease in spasticity, and increased facilitate lymphatic flow. Reinforcing to the client and
voluntary motion, as compared to the control group. Out- caregivers what activities, or parts of activities, a client can
comes also showed that existing hand edema reduced in undertake with the affected upper limb can assist in this
the neuroprosthesis study group but not in the control process.
group. Long-term continuance of the gains made by
usage of the neuroprosthesis unit was not assessed in SUMMARY
this study. The authors cite a similar study40 of clients
in the flaccid hand category that showed all gains made It is essential to screen for and address poststroke upper
were lost within two weeks once the stimulation was limb edema as soon as possible. By effectively managing
removed. edema the incidence of CRPS Type I, pain, stiffness,
and possible joint contractures can be reduced. How-
Clinical Treatment Considerations and Rationale. ever, most important, edema must decrease in order to
Neurologically, usage of a multihour electrical stimula- facilitate functional arm and hand usage for occupation,
tion device shows much promise for the clients with especially as motor function return occurs. Unfortu-
hand spasticity, a hemiparetic hand, or flaccid hand. nately, there is no specific consensus on which of the
More research is needed to determine the optimum discussed treatment technique is most effective for re-
lengths for daily and total usage to get the longest carry ducing poststroke hand edema.7,23,38 However, it is
over when the treatment is discontinued. This will help hoped that this chapter will give therapists a foundation
the treating therapist decide if this treatment is appli- for client treatment planning, critical problem-solving,
cable for their particular poststroke clients with hand and a basis to do further research of techniques.
edema.
Use of neuroprosthesis devices promotes gentle active
and passive motion and does not cause microtrauma to CASE STUDIES
tissue. Potentially multihour usage of the device helps to
In this Australian setting, clients receive intensive neu-
lessen hemineglect if the client uses it for functional
rological rehabilitation as directed by a multidisci-
tasks.
plinary team. The occupational therapist’s role is to
evaluate and maximize performance in activities of
Functional Activities
daily living, domestic roles, community safety, driving,
Edema and the associated deficits it causes, such as re-
work, and leisure. Numerous treatment frameworks
duced sensation and range of movement, may limit a
are used. In these three case studies, the author pro-
person’s integration of the affected limb into normal
vided intensive edema treatment to address functional
tasks and may reinforce learned nonuse. Occupational
goals.
therapists can grade and provide cuing in daily func-
tional tasks to address the cognitive, perceptual, sen- Evaluation Criteria
sory, and motor aspects of performance, and can facili- All edema measurements were conducted by the same
tate use of the affected limb. Through task analysis, occupational therapist to increase intrarater reliability.
occupational therapists can highlight to a client what It was clinically reasoned that a volumeter was not a
the client can do to maximize independence and reduce reliable way of measuring edema given the limitations
the impact of edema. Boomkamp-Koppen and col- of consistently positioning the stroke upper limb. Cir-
leagues7 found a significant relationship between edema cumferential measurements were chosen to increase
and hand function when paresis was controlled in a consistency of measurement and to identify change in
statistical analysis. Clinically, edema may mask the mo- anatomical regions. Measurements of the affected limb
tor and sensory potential of the upper limb may and were taken at consistent landmarks with the client’s
limit progress of a client’s goals. Gilmore and col- limb in the same position.
leagues24 advocated the use of purposeful activities that
 Chapter 12 • Edema Control 321

CASE STUDY 1 traditional retrograde massage was used on the hands

Subacute Stroke with Hemiplegia and Motivation and fingers to facilitate further clearance. S.O. could
use the technique on his fingers himself, and he re-
S.O. was 56-years-old when he suffered a left basal
ported that his arm felt “lighter” by the end of the sec-
ganglia and corona radiata stroke. Two weeks after his
ond session. The therapist noted post-MEM a decrease
stroke, he was transferred from an acute hospital to a
in flexor skeletal muscle activity, improved supination
specialized neurological rehabilitation setting. His
to wash his face, and an increase in wrist skin folds.
main deficits were right hemiplegia, mild dysarthria,
By the final two sessions, S.O.’s right hand was the
mild expressive aphasia, and mild memory impairment.
same temperature as his left (fluid decongestion had
He was right dominant. Prior to the stroke, S.O. lived
occurred as the edema reduced), the circumference of
independently in a country town and worked in the
his elbow and axilla had reduced by 1.3 and 5.4 cm
mining industry operating machinery. He enjoyed
respectively, and there was a reduction in flexor activ-
dancing and socializing and was motivated to return to
ity. S.O. had increased range of finger abduction and
independent living and driving.
adduction, thumb extension, and composite flexion,
Approximately two months poststroke, S.O. devel-
which he could use in grooming tasks. S.O.’s primary
oped edema in his right arm that did not respond to
occupational therapist was aware of MEM treatment
elevation and massage alone. The primary occupa-
principles and continued to use these when working
tional therapist identified S.O. as a good candidate for
with S.O. As he noted improvements, S.O. began to
MEM because his edema was limiting grasp and ma-
complete his self-MEM program three times a day
nipulation and release of objects, he had no medical
without prompting by his occupational therapist.
contraindications limiting participation in MEM, and
MEM was a technique that S.O. could indepen-
he had the cognitive ability to complete a self-MEM
dently use and what he preferred when compared to
program. He was motivated to participate in all aspects
the medical suggestion of bandaging, which was
of therapy and hospital life. S.O. was concerned that
likely to restrict his progress in grooming. It ap-
his edema was “holding him back” from using his arm;
peared that the combination of diaphragmatic breath-
for example, he felt that he could not grasp a flannel
ing, stretches, flowing (“sweeping”) up the arm, and
shirt as his fingers felt “. . . like sausages.” At initial as-
elevation contributed greatly to the reduction of
sessment, S.O. had nonpitting edema over his hand
edema and subsequent functional goals. There were
and upper limb, and his hand was hot to touch (an in-
reductions of over 1 cm at the wrist and MCP joints
dication of tissue fluid congestion as no infection was
and small changes over the digits. At the time of writ-
present). Sensation was grossly intact, and he had some
ing, S.O. had returned to independent living and was
minor shoulder pain. Elbow extension was normal, but
beginning to have the dexterity to write with his
his wrist and finger extension were limited by his
dominant hand.
edema and increased flexor skeletal muscle activity. He
was independent in self-care in the ward and used an
electric wheelchair for mobility. CASE STUDY 2
During the first session, S.O. was educated regard-
Chronic Stroke with Minimal Hand Movement
ing the theoretical background of MEM and treatment
and Increased Skeletal Muscle Activity
progressed through Pump Point Two. The importance
of light and “U” shaped strokes were emphasized, K.P. was 55-years-old when he had a left middle cere-
rather than the rough massaging of “up and down” the bral watershed infarct at home. After acute and reha-
dorsum of the hand that he had been doing in an effort bilitation inpatient stays, K.P. could walk independently
to reduce his swelling. S.O. was advised to complete a and was discharged home to live with his supportive
basic home program three times a day, which consisted long-term partner, who supervised him with ADL.
of diaphragmatic breathing, exercises, axilla and termi- Prior to his stroke, K.P. worked as a bus driver and en-
nus massage (supraclavicular area), and sweeping, in joyed visiting his young granddaughter, woodworking,
addition to his standard occupational therapy and and sailing. K.P. received home-based occupational
physiotherapy sessions. An edema glove was tried, but therapy and was then referred for outpatient occupa-
S.O. did not tolerate it, saying it was uncomfortable. tional therapy. K.P. was then four months poststroke
Instead, he used a foam wedge on his wheelchair arm and was beginning to achieve active upper limb move-
trough to elevate his arm as much as possible. ment in his affected right arm. He was left dominant.
In the second session, the therapist noted that there K.P. was driven by his partner for an hour each way,
was increased flexor skeletal muscle activity in the fore- twice a week to attend occupational therapy and physio-
arm. MEM was used on all five Pump Points, and therapy. K.P. had memory deficits and reduced attention.
Continued
322 Stroke Rehabilitation

CASE STUDY 2
Chronic Stroke with Minimal Hand Movement
and Increased Skeletal Muscle Activity—cont’d
His partner used prompting with K.P. at home and had
set up cue cards to assist in routine tasks around the
house. His primary occupational therapy goal was to use
his right hand in leisure activities. K.P. presented with
poor trunk, shoulder, and head symmetry, both with
standing and sitting. His rehabilitation had been limited
by his lack of awareness, body positioning, and attention.
As K.P. developed elbow extension and finger extension,
a short thumb postsplint was fabricated for him to use for Figure 12-11 KP’s right hand before treatment.
functional grasp.
It was noted that K.P. had significant pitting edema
at his hand and wrist, which would fluctuate and ap-
peared to restrict wrist extension and contributed to
poor upper limb, head, and trunk dissociation and clo-
nus in his upper arm. By this stage, K.P. was six months
poststroke. Five MEM sessions were provided by the
author to assist the primary occupational therapist. At
the first session, subluxations were noted at the shoul-
der and wrist, and there was pitting edema over the
dorsum of the hand. The first MEM session focused on
treatment to Pump Point 3 and education for K.P.’s
partner on the importance of light massage strokes. See
Figs. 12-7 and 12-8 in Box 12-1. K.P. and his partner
were motivated to continue therapy at home and were
taught a basic MEM home program to do at least twice Figure 12-12 KP’s right hand edema after four Manual Edema
a day. Mobilization treatment sessions.
At the second session, MEM was expanded to in-
clude all pump points and the hand. Wrist and elbow
extension range increased after the second session to
enable reaching to furniture and large objects, and an
extension lag had improved by 10 degrees. K.P. also
increase in skin folds was noted. After the third session,
reported some improvement in sensation in his hand.
there was no pitting edema. His partner reported that
Overall, the greatest edema changes were evident at
they were doing the home program at least once a day
the thumb and index finger. It appeared that the exer-
and that she was encouraging K.P. to use his hand in
cises and caregiver education on MEM were of great
activities.
benefit to K.P. At time of writing, K.P. had achieved a
On the fourth session, slight pitting at the MCP
lateral pinch grasp and was working on leisure goals.
joints was noted, and K.P.’s partner reported that they
He and his partner still did MEM at home if his
had done less of the home program, so treatment fo-
edema increased.
cused on Pump Points 4 and 5, rather than the fingers.
Particular emphasis was placed on wrist and hand
pump points and treatment of his fingers to facilitate
grasp. See Figs. 12-11 and 12-12 for pre- and post- CASE STUDY 3
MEM views of K.P.’s hand and body position. These
Chronic Stroke with Neuropathic Pain
sessions were complemented by facilitated reaching to
objects, sliding items, and separation of the forearm T.W. was 56-years-old when he had a left middle ce-
flexor and extensor muscle bodies. rebral artery stroke, nine months prior to receiving
By the final session, it was noted that most gains intensive edema treatment. After acute rehabilitation,
were maintained, and there was no pitting edema. T.W. was transferred to a specialist neurological reha-
Other benefits included a reduction of overactive bilitation ward for one month, primarily to address
skeletal muscle activity at the wrist, and K.P.’s elbow his expressive and receptive aphasia and apraxia. At
 Chapter 12 • Edema Control 323

discharge, he was independent in ADL, mobility and

had developed some communicative skills. The ward
multidisciplinary team then referred T.W. for home-
based therapy for four weeks, followed by further
outpatient occupational therapy.
T.W.’s goals included using cutlery bilaterally, in-
creased ease of bed mobility, to shop and cook inde- D D
pendently, and use a computer mouse. T.W. presented
with severe expressive aphasia, moderate receptive C C
aphasia, ideational apraxia, and gross upper limb move-
ment, but also poor strength and dexterity, reduced B B
sensation, right sided neuropathic pain, and chronic
edema. Formal cognitive assessment was limited due to A A
T.W.’s aphasia; however, reduced speed of processing
and reduced scanning efficiency were evident in func- Figure 12-13 Manual Edema Mobilization Posterior “V” “clear”
tional tasks. T.W. also attended outpatient physio- (A through D) and “flow” (D through A).
therapy, speech pathology, and an education center.
Prior to his stroke, T.W. lived independently in
another state and had retired. He was involved in darts
and enjoyed fishing and sports. Poststroke, T.W. de- and emphasis was placed on low functional reach
cided to move back to the same state as his family and and shoulder movements. He was also provided with a
live with his mother. His mother completed the major- elastic/cotton stockinette tube to wear with the glove
ity of the domestic ADL. T.W. was not motivated to and ideas to increase his hand use.
resume any domestic or household maintenance roles By the third session and reported daily following
himself and was socially isolated. He reported little of his home program, T.W. no longer had brawny
community involvement and tended to stay home to edema, and there was an increase in skin folds, par-
watch TV or go on the computer. The outpatient team ticularly over the dorsal web spaces. MEM was done
was concerned regarding his loss of roles. at all pump points and the posterior Big “V” (see
T.W.’s pain and edema continued to limit his reha- Fig. 12-13). Functional activities were used at the
bilitation, and he was identified as a candidate for in- end of treatment, including grasp and release of a cup
tensive MEM at five months poststroke. At initial as- and practice of a computer mouse. On the fourth ses-
sessment, T.W. presented with chronic neuropathic sion, there was an increase in pretreatment measure-
pain and dystrophic changes. His mobility and overall ments, but this may have been due to the hot weather
task efficiency were limited by his guarded pain pos- on that day and an apparent increase in T.W.’s neu-
tures. Brawny, pitting edema was evident throughout ropathic pain. The increase in pain only occurred
the hand, restricting his function to gross grasp. T.W. once and reduced with MEM. Light bandaging was
reported neuropathic pain down his entire right side also tried overnight to reduce distal edema. On the
and was initially tense during therapist’s contact. He final session for the case study, T.W. indicated that
reported less pain as each session progressed and al- the bandaging was tolerable, but it did not result in
ways tolerated light touch. significant measurable change.
Treatment on the first session was MEM up to After five intensive edema treatment sessions, T.W.
Pump Point 2 and the posterior Big “V” (Fig. 12-13). had maintained reduction of his wrist and MCP joints
T.W. was provided with an off-the-shelf Isotoner glove edema. Edema at his axilla continued to respond well
to wear at night and a basic home program of exercises, to treatment, but gains were not maintained between
deep breathing, terminus and axilla massage, and sessions. Treatment involved MEM to all pump points,
sweeping. Between the first and second sessions, T.W.’s the hand, the posterior Big “V,” and the neck. Sternal
primary occupational therapist used MEM with him nodes were not treated due to an extensive scar. MEM
and reported reduction of nearly 1 cm at the wrist and was progressed gradually due to medical contraindica-
MCP joints. On the second session, T.W. reported that tions, although his consultant approved of the inter-
he had done his home program once in the four days vention. Progress was enhanced by trunk stretches and
between sessions and had not used his affected arm in functional movement within pain, and was limited by
many bilateral tasks. T.W. had significant edema pool- aphasia, pain, and learned nonuse. T.W. reported doing
ing behind his scapula and poor scapula stability during his home exercise and MEM program, but only once
reaching tasks. MEM was conducted to Pump Point 4, every few days. Edema changed from brawny to only
Continued
324 Stroke Rehabilitation

8. Braus D, Krauss J, Strobel J: The shoulder-hand syndrome after

CASE STUDY 3
stroke: a prospective clinical trial. Ann Neurol 36(5):728–733, 1994.
Chronic Stroke with Neuropathic Pain—cont’d 9. Burge E, Kupper D, Finckh A, et al: Neutral functional realignment
orthosis prevents hand pain in clients with subacute stroke: a ran-
pitted on the ulnar side of the hand, and the skin at the domized trial. Arch Phys Med Rehabil 89(10):1857–1862, 2008.
upper arm had improved color and temperature. There 10. Burkhardt, A: Edema control. In Gillen G, Burkhardt A editors:
was a slight functional increase in T.W.’s right grip Stroke rehabilitation: a function-based approach, ed 2, St Louis, 2004,
strength, and his elbow extension lag had decreased Mosby.
11. Burkhardt, A: High stakes from the clinical horizons in the treatment
from 10 degrees to neutral, without any passive rang- of lymphedema —to Pump or not pump. Occupational Therapy Forum
ing or facilitation at the elbow joint. T.W.’s primary 44:1–5, 1990.
occupational therapist continued with once to twice 12. Casley-Smith JR: Modern treatment of lymphoedema. Modern
weekly sessions focusing on the above and functional Medicine of Australia 35(5):70-83, 1992.
hand use. 13. Casley-Smith JR, Bjorlin M: Some parameters affecting the removal
of oedema by massage—mechanical or manual. In Calsey-Smith JR,
T.W. was discharged three months later from all Piller NB, editors: Progress in Lymphology X, Adelaide, 1985, Univ
outpatient services, given his limited involvement with Adelaide Press.
home programs and limited progress. However, his 14. Casley-Smith JR, Casley-Smith JR: Modern treatment for lymphoedema,
pincer grip had improved, and he was able to pick up ed 5, Adelaide, 1997, Lymphoedema Association of Australia.
a glass and use a computer. T.W. was referred to a 15. Casley-Smith JR, Casley-Smith JR: The pathophysiology of lymph-
oedema and the action of benzo-pyrones in reducing it. Lymphology
community-based acquired brain injury service for 21(3):190: 190–194, 1988.
long-term follow-up, with goals of commencing volun- 16. Casley-Smith JR, Gaffney RM: Excess plasma proteins as a cause of
teer work and resuming leisure interests. The occupa- chronic inflammation and lymphodema: quantitative electron micros-
tional therapist recommended that T.W. be referred to copy. J Pathol 133(3):243–272, 1981.
a pain specialist as his neuropathic pain contributed 17. Chikly, B: Silent waves: theory and practice of lymph drainage therapy,
Scottsdale, AZ, 2001, I.H.H.
to learned nonuse. 18. Davis PM: Steps to follow with hemiplegia, ed, 2, Berlin, 2000, Springer.
19. Davis PM: Steps to follow: a guide to the treatment of hemiplegia,
Heidelberg, 1985, Springer-Verlag.
20. Dirette D, Hinojosa J: Effects of continuous passive motion on the
REVIEW QUESTIONS edematous hands of two persons with flaccid hemiplegia. Am J
Occup Ther 48(5):403–409, 1994.
1. Describe two key points unique to each of the three 21. Exton-Smith A, Crockett D: Nature of oedema in paralysed limbs
proposed theories of types of poststroke hand edema. of hemiplegic patients. BMJ 2(5056):1280–83, 1957.
2. Treatment of poststroke hand edema is often impeded 22. Faghri P: The effect of neuromuscular stimulation-induced muscle
by what other neurological and sensory conditions? contraction versus elevation on hand edema in CVA patients.
3. Since trauma to the arm or hand poststroke could lead J Hand Ther 10(1):29–34, 1997.
23. Geurts A, Visschers B, van Limbeek J, Ribbers G: Systematic review
to edema and/or CRPS, list five ways that caregivers and of aetiology and treatment of post-stroke hand oedema and shoulder-
treating staff can prevent trauma to the involved arm. hand syndrome. Scand J Rehab Med 32(1):4–10, 2000.
4. Describe how a functional treatment approach can 24. Gilmore P, Spaulding S, Vandervoort, A: Hemiplegic shoulder pain:
decrease edema. implications for occupational therapy treatment. Can J Occup Ther
71(1):36–46, 2004.
25. Giudice, ML: Effects of continuous passive motion and elevation on
hand edema. Am J Occup Ther 44(10):914–921, 1990.
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1. Artzberger S: Edema reduction techniques: a biological rationale for dynamic lycra splints on upper limb in hemiplegic patients. Arch
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Quarterly 28(2):1–3, 2005. 29. Howard S, Krishnagiri S: The use of manual edema mobilization for
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concept. SAJHT 1:1(edoc) 2003. (4):291–301, 2001.
4. Artzberger S: Manual edema mobilization: treatment for edema in the 30. Iwata M, Kondo I, Sato Y, et al: Prediction of reflex sympathetic
subacute hand. In Mackin E, Callahan A, Skirven T, et al, editors: Reha- dystrophy in hemiplegia by evaluation of hand edema. Arch Phys
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5. Artzberger S: Edema control: new perspectives. American Occupational 31. Iwata M, Kondo I, Sato Y: Considerations on hand edema in
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20:1, 1997. 32. Kasseroller R: Compendium of Dr. Vodder’s manual lymph drainage,
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34. Korpelainen J, Sotaniemi K., Myllyla U: Autonomic nervous system 45. Raines J, O’Donnell T, Kalisher L, et al: Selection of patients with
disorders in stroke. Clin Autonom Res 9(6):325–333, 1999. lymphedema for compression therapy. Am J Surg 133(4):430–437,
35. Kubik, S: Anatomy of the lymphatic system. In Foldi M, Foldi E, 1977.
Kubik, S, editors: Textbook of lymphology for physicians and lymphedema 46. Ring H, Rosenthal N: Controlled study of neuroprosthetic func-
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Heidelberg, Germany 1997, Haug. 47. Roper TA, Redford S, Raymond CT: Intermittent compression for
37. Leduc A, Bastin R, Bourgeois P: Lymphatic reabsorption of proteins the treatment of the oedematous hand in hemiplegic stroke: a ran-
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Amsterdam, 1988b, Elsevier, Excerpta Med Int Cong Ser 779:591– 48. Stanley BG, Tribuzi SM: Concepts in hand rehabilitation, Philadelphia,
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38. Leibovitz, A, Baumoehl Y, Roginsky Y, et al: Edema of the paretic 49. Tepperman PS, Greyson ND, Hilbert L, et al: Reflex sympathetic
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44(1):37–42, 2007. 50. Vasudevan S, Melvin J: Upper extremity edema control: rationale of
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 s t e ph an i e m i l azzo
g l en g i l l en

chapter 13

Splinting Applications

key terms
alignment function prevention
biomechanics low-load prolonged stress splinting
clinical reasoning neurophysiological approach thermoplastics
contracture orthotics

chapter objectives
After completing this chapter, the reader will be able to accomplish the following:
1. Identify a variety of splinting options.
2. Review positive and negative aspects of commonly used splints.
3. Summarize the published research for splinting and persons who have had strokes.
4. Present rationales for splinting that consider current concepts of motor control, including
biomechanical principles.
5. Critically analyze and reconsider the present approach to splinting, evaluating, and
developing interventions for each extremity based on individual findings.

Any discussion of splinting of the upper extremity after ■ Splints are used to correct biomechanical malalign-
stroke produces debate among occupational therapists. ment, restoring muscles to normal resting length
The use of splints after stroke can be traced as far back as and protecting joint integrity. This biomechanical
1911.37 Since then the debate about whether to splint and correction may result in a decrease in excessive skel-
about the rationales for splinting has continued. etal muscle activity.
The following principles guide splinting decisions for ■ Splints are used to position the hand to assist in
patients after stroke: functional activities.
■ Splints are used to maintain or increase the length ■ Splints may be used to promote independence in
of soft tissues (e.g., muscles, tendons, and liga- specific areas of occupation.
ments) by preventing or lengthening shortened tis- ■ Splints compensate for weakness by providing exter-
sues and preventing overstretching of antagonist nal support, blocking the pull of muscle groups that
soft tissue. have lost a balanced agonist-antagonist relationship,

326
 Chapter 13 • Splinting Applications 327

and altering the resting alignment of the joints to concepts. See Chapter 6 for a comprehensive review of
enhance functional postures. these issues.
The use of one splinting rationale (i.e., never splinting, In general, a current review of the empirical literature
always splinting, only using resting splints, etc.) for those related to stroke cannot support or refute the use of
after stroke is not effective because of the variety of pat- splints. There are few well-designed studies, and most
terns of impairments that occur after stroke. Each indi- have methodological flaws. Nonetheless, conclusions
vidual must be evaluated separately to determine if there from current reviews include:
are splinting needs. The sequelae of stroke are multilay- ■ Steultjens and colleagues43 systematically reviewed
ered, encompassing a variety of symptoms and problem five studies (two randomized controlled trials, two
areas. The complexity of these problems has served as fuel case control trials, and one crossover trial) that
for the splinting debate and the controversies surround- evaluated the effect of splinting on muscle tone.
ing splinting. They found that all studies were of low method-
ological quality and that none of the studies pre-
HISTORICAL PERSPECTIVE sented significant results of the measures used.
They concluded that there is insufficient evidence
Neuhaus and colleagues37 have published a review of the that splinting is effective for decreasing muscle
splinting literature covering a 100-year period. Their re- tone.
view has documented two different approaches to splint- ■ In their review of studies aimed at testing the effects
ing: the biomechanical approach and the neurophysiolog- of splinting on reducing tone, Ma and Trombly27
ical approach. concluded that “In summary, based on study of a
The biomechanical perspective considers issues such as total of only 35 participants with stroke, we can
soft-tissue lengthening, prevention of contracture and make no conclusive statement about splinting and its
deformity, maintenance of biomechanical alignment, and effect on spasticity. However, it appears that splint-
effects on the nonneural components of spasticity. In con- ing for less time is the most beneficial. Research us-
trast, the neurophysiological perspective considers reflex ing much larger samples is needed.” They also stated
inhibition, effects on the neural basis of spasticity, facilita- that “best evidence” indicates that, although com-
tion through sensory input, and inhibition through posi- monly used, treatments using splints to decrease
tioning and sensory input. spasticity may be ineffective, and recommend that
Earlier publications (from the early 1900s to the the treatment not be used.
1950s) emphasized a biomechanical approach, whereas ■ Based on a review of three studies, Tyson and
literature after World War II emphasized a shift toward Kent49 concluded that “An upper limb orthosis
the neurophysiological frame of reference. During this does not affect on upper limb function, range of
time, therapists (Rood, Bobath, Knott, and Voss) devel- movement at the wrist, fingers or thumb, nor pain.”
oped theories based on neurophysiological principles. It should be noted that these three studies involved
Many of the neurophysiological theorists clearly were a mixed group of participants, and none of the
opposed to splinting; others did not mention splinting studies recruited participants who had functioning
at all as part of their treatment regimens. Rood (as cited upper limbs.
by Stockmeyer46) stated that spasticity may be increased ■ Lannin and Herbert23 assessed the effectiveness of
“by activating sensory stimuli of touch, pressure, and hand splinting on the hemiplegic upper extremity
stretch, which result in undesirable contraction of following stroke via a systematic review. They ap-
muscle.” praised 19 studies for content. Sixty-three percent
The neurophysiological perspective is currently being were reports of case series, and 21% were ran-
seriously questioned because of a lack of research support, domized controlled trials. They concluded that
and a shift is occurring toward a more comprehensive and there is insufficient evidence to either support or
current understanding of motor behavior. Nevertheless, refute the effectiveness of hand splinting for adults
many styles of splints and rationales are still based on following stroke. They also stated that the “lim-
neurophysiological principles. ited research and a lack of a no-splint control
To date, research does not support one style of splint group in all trials to date limit the usefulness of
as superior to another. Many of the statements and prin- these results.”
ciples documented by the originators of the neurophysi- Clearly well-designed studies are critical to help thera-
ological theories have been accepted as fact. In light of pists make informed decisions about this intervention. At
current understanding of motor control, these state- this point, each patient/client must be evaluated individu-
ments need to be analyzed and researched critically be- ally based on their clinical presentation. Clinical reason-
fore further splinting interventions are based on these ing suggestions follow.
328 Stroke Rehabilitation

DORSAL VERSUS VOLAR SPLINTING Charait7 recommended splinting using dorsal-based ap-
pliances.
Splint fabrication and points of contact are areas of con- McPherson and colleagues32 compared dorsal and vo-
tinuing debate. The following studies have investigated lar resting splints for the reduction of hypertonus. They
this controversy. assigned 10 subjects with hypertonic wrist flexors to the
Zislis53 compared the effects of two different wrist-hand dorsal or volar group. For the purposes of the study, the
splints on a patient with spastic hemiplegia. The author authors defined hypertonus as “the plastic, viscous, and
used simultaneous electromyographic (EMG) recordings elastic properties of the muscle resistant to stretch and
of the flexors and extensors in the forearm to provide an with a tendency to return a limb to a particular abnormal
objective measure of muscle activity. EMG readings were resting posture.” They used a spring-weighted scale to
taken with no splint, with a dorsal-based splint (which kept take measurements to assess the effectiveness of the
the wrist neutral, fingers adducted and extended, and splints in reducing hypertonicity. The results indicated no
thumb free) used in hopes of facilitating the extensors, and significant difference between the volar and dorsal splints
with a volar-based splint (which kept the wrist neutral, in the reduction of hypertonus. As an aside, the authors
fingers extended and abducted, and thumb free). found a correlation between age and reduction in hyper-
Zislis’ results53 indicated that extensor muscle activity tonus. The older subjects in the study demonstrated
was not altered in any of the three situations, although gradual but not statistically significant decline in hyperto-
flexor activity was varied. With no splint, flexor activity nus, whereas the younger adults demonstrated significant
was exaggerated compared with extensor activity. The decline in hypertonus over 6 weeks.
dorsal splint greatly increased the flexor activity, even Other studies have not compared dorsal and volar
more so than when no splint was worn. Finally, the volar- splinting specifically but instead have evaluated the effects
based splint diminished flexor activity and achieved a state of one or the other. Kaplan21 evaluated 10 patients who
of “balanced physiological activity between flexor and wore dorsal wrist splints. His study set out to “determine
extensor muscle groups.” whether prolonged therapy with a dorsal splint will in-
Zislis53 drew the following conclusions from the pa- hibit or diminish hyperreflexia or stretch reflex and at the
tient he studied: same time increase muscular power by sensorimotor
■ Dorsal facilitation of the extensor was not evident, stimulation.” The splint used in this study positioned the
although dorsal facilitation of the flexors did occur. wrist and fingers in extension and supported the thumb in
■ Flexor inhibition from volar cutaneous receptors abduction. Most of the subjects wore the splints at least
may occur. eight hours per day, and Kaplan noted that many patients
■ Abduction and extension of the fingers may produce required several serial splints to increase the stretch on
flexor inhibition. the flexors gradually. Patients were evaluated with EMG,
Therefore, Zislis53 recommended the use of volar-based strength testing, and hand function evaluation before and
splints with extension and abduction of the fingers. after splint application. The subjects in this study demon-
Charait7 observed 20 patients in her study of dorsal ver- strated “improvement in strength and function of muscle,
sus volar “functional position splints.” In the splinted posi- with a decrease in the stretch reflex and spasticity . . . when
tion, the wrist varied from less than neutral to 30 degrees, a dorsal splint was properly applied in treatment of hemi-
the thumb was abducted and opposed, and the fingers were plegia involving an upper extremity.”
positioned at 45 degrees of finger flexion at the metacarpo- Brennan5 studied the effects of volar-based splints on
phalangeal (MCP) and proximal interphalangeal (PIP) his subjects. At the end of his study the patients who wore
joints. the volar-based wrist and hand splints demonstrated in-
Charait7 observed the amount of spasticity and volun- creased range of passive movement in which no resistance
tary movement in both groups. In the group wearing vo- to stretch could be felt.
lar splints, four patients showed no change in spasticity or In their study of positioning devices on normal and
voluntary motion, and six experienced increased spastic- spastic hands, Mathiowetz, Bolding, and Trombly30 dem-
ity. In the group wearing dorsal splints, one patient onstrated that a volar-based resting splint increased EMG
showed no change, one experienced a considerable in- activity as the subjects performed a grasping activity on
crease in spasticity, and eight had decreased spasticity the contralateral side. They noted that the volar splint “is
(four of these also exhibited increased active finger and the least desirable positioning device while the hemiple-
wrist extension). The author drew the following conclu- gic subject is doing any activity that requires a compara-
sions from her observations: ble effort to squeezing 50% maximal voluntary contrac-
■ Volar pressure facilitates flexor muscles. tion of grip.”
■ Dorsal pressure with decreased volar contact facili- The variability in the aforementioned studies makes
tates the extensors. decisions regarding dorsal-versus volar-based treatment
■ Prolonged stretch enhances inhibition. difficult to reach based on available research. Therapists
 Chapter 13 • Splinting Applications 329

must still evaluate each patient individually to determine evoke less EMG activity than no device. According
the effect of variables on splinting outcomes. Moreover, to the authors, the belief that this splint decreases spas-
the studies discussed in this chapter used a variety of out- ticity shortly after application needs to be questioned
come measures, varied in their methodologies, and imple- seriously.
mented variable definitions and styles of splints. The finger spreader may be useful in maintaining the
length of the flexors; however, wrist position is not con-
REVIEW OF SPLINTS COMMONLY USED sidered with this splint, and the therapist must be aware of
FOR PATIENTS AFTER STROKE the wrist position. To control this problem, the therapist
may combine the finger spreader with a standard wrist
This section reviews positive and negative aspects of extension splint. Because the splint is subtle in terms of
splints frequently used by occupational therapists; avail- corrective forces, it may be indicated for patients with low
able research is discussed. Several of the following splints tolerance for other, more cumbersome devices and for
were developed based on a now outdated understanding patients with low pain thresholds. Donning and doffing
of motor function. Some of the splints still may be useful procedures are straightforward for the confused patient
and effective, although the rationale for their use may no (Fig. 13-1).
longer be based on the original purpose of the splint.
Firm Cone
Finger Spreader (Finger Abduction Splint) The firm cone can be fabricated of low-temperature plas-
The finger spreader (finger abduction splint) is fabricated tic or purchased commercially; it is based on the tradi-
of foam rubber and positions the fingers and thumb in tional theories of Rood. Rood’s theory (as interpreted by
abduction. According to Bobath,3 the purpose of the Stockmeyer46) states that firm and prolonged pressure
splint is to “obtain extension of wrist and fingers. . . . over the flexor surface of the palm and fingers results in
Abduction not only facilitates extension of the fingers, but an inhibition of the long flexors. A more current under-
also reduces flexor spasticity throughout the whole standing of the mechanism of this splint from a biome-
arm. . . . It has a better and more dynamic effect than the chanical and functional perspective is that the cone is
use of a (standard) splint and reduces the possibility of positioned to place stretch on the shortened long flexors
edema.” One should note that Bobath’s rationale is not and is graded progressively to increase stress to the soft
consistent with the current understanding of motor con- tissues to promote a more normal resting length. The
trol and related neurological principles. cone initially is positioned with the narrow end of the
A sturdier version of this splint (fabricated of low- cone toward the radial side of the hand in the web space
temperature plastic) was proposed by Doubilet and if the hand is excessively tight. As the hand begins to relax
Polkow.9 They recommended wearing the splint only from the directed stress, the ideal biomechanical position is
during the day. Their paper includes anecdotal evi- for the cone to be positioned opposite to the initial posi-
dence of the effectiveness of the splint. tion; that is, the wide end of the cone is placed in the ra-
The finger abduction splint was worn by fifteen pa- dial side of the hand in the web space, and the narrow end
tients who were two to six months post stroke, these is placed in the ulnar side of the hand (Fig. 13-2). The
patients exhibited moderate to severe spasticity of the therapist can use strapping material to hold the cone in
fingers and wrist, decreased range of motion, and place. This device was included in the study by Mathio-
edema in the wrist and hand. After one week of using wetz, Bolding, and Trombly;30 the researchers found that
the splint plus standard treatment in the therapy ses- the cone did not evoke significantly less EMG activity
sions a moderate reduction of spasticity was seen in during contralateral resisted function.
these patients.
Doubilet and Polkow9 concluded that the splint
results are promising and warrant continued trial and
experimentation.
Mathiowetz, Bolding, and Trombly30 objectively eval-
uated the finger abduction splint in a study investigating
the effects of a variety of splints on the distal muscle
activity of normal and hemiplegic subjects. Subjects
wore the splints while performing resistive activities
with the opposite hand. The results indicated “signifi-
cantly greater EMG activity for the finger spreader
compared to no device in the flexor carpi radialis of nor-
mal subjects during grasping” with the contralateral
hand. In hemiplegic subjects, the finger spreader did not Figure 13-1 Bobath finger spreader (finger abduction splint).
330 Stroke Rehabilitation

activation of paretic agonist muscles and reciprocal inhi-

bition of antagonist musculature.
The orthokinetic cuffs are fabricated of ribbed elastic
bandage material applied circumferentially around vari-
ous aspects of the patient’s upper extremity and are held
on the arm by fasteners. Half of the cuff is designed to be
elastic (the active field), and the other half of the cuff is
sewn to reduce the stretch (the inactive field). The active
A field is worn over the muscle belly to be activated, and the
inactive field is placed over the antagonist.
Neeman and Neeman have published several studies33-36
on the effectiveness of these cuffs in the rehabilitation of
the upper extremity after stroke. They concluded that use
of the cuffs results in pronounced restoration of agonist-
antagonist muscle balance, increased active range of mo-
tion (ROM) throughout the extremity, and increased ability
to participate in functional tasks.
The orthokinetic cuffs have been subjected to the
B greatest number of efficacy studies, all showing positive
Figure 13-2 A and B, Firm cone.
results. Fabrication guidelines are stated clearly in the
cited studies, and the cuffs are applied easily and are
comfortable.
The neurophysiological rationale for the orthokinetic
Neurophysiological principles aside, the cone may be cuff has not been established fully. The active field may
an effective positioning device for patients who have de- produce cutaneous stimulation and activate the extero-
veloped contracture in the long flexors. Combined ap- ceptors of the skin and Ia afferent neurons of the muscle
plications of the cone with a standard wrist-extension spindle. The inactive field seems to provide sustained
splint, controlling the stretch on the wrist and digit flex- deep pressure, which may produce an inhibitory response
ors separately, are feasible. The size of the cone and the (Fig. 13-3).
angle of wrist extension can be graded as the patient’s
status improves. Orthokinetic Wrist Splint
Another practical use of the cone is in the prevention The dynamic design of the orthokinetic wrist splint is
of maceration of tissue in patients with moderate to severe based on the concepts of Rood (as cited in Stockmeyer46).
flexion of the digits. The maintenance of flexor length is Components of the splint include a firm cone in the palm
required for hygiene and cosmesis. Similar to the use of of the hand, a volar-based forearm support, elastic straps
the finger abduction splint, the use of the cone in isolation to secure the forearm support by acting as orthokinetic
does not provide wrist support, thus predisposing the cuffs, and a wrist hinge.22 This splint has been recom-
wrist to a flexed posture. Donning and doffing procedures mended for patients with flexor hypertonicity who have at
are straightforward. least minimal voluntary extensor activity. However, no
data support the effectiveness of this splint (Fig. 13-4).
Orthokinetic Orthotics
According to Neeman and Neeman,34 the term orthoki-
netic orthosis “describes a cuff-shaped dynamic orthopae-
dic appliance which does not include rigid polymer or
metal components. It does not apply any extraneous
modulating force or constraint, in contrast to the typical
splint.” The orthokinetic cuffs designed by Blashy and Figure 13-3 Orthokinetic orthotics.
Fuchs-Neeman1 have been used for almost 40 years for
patients with muscle weakness, muscle paresis, and re-
sulting agonist-antagonist imbalance. The action of these
orthoses is “exerted through internal restoration of neu-
romuscular balance between agonist and antagonist mus-
culatures, by input of mild neural stimuli to mechanore-
ceptors in specifically targeted skin areas.”1 The designers
state that the neurophysiological mechanism involves Figure 13-4 Orthokinetic wrist splint.
 Chapter 13 • Splinting Applications 331

Spasticity Reduction Splint

The spasticity reduction splint was developed by Snook44
and is based on the Bobath3 principle of reflex-inhibiting
patterns that has not been supported by current research.
The splint is fabricated of low-temperature plastic. The
forearm support is dorsal based and continues into a volar- Figure 13-5 Spasticity reduction splint.
based finger support. The wrist is positioned in 30 degrees
of wrist extension; the MCP joints are at 45 degrees of flex-
ion. The interphalangeal (IP) joints are extended fully, the pressure to the area to which they are applied. The pres-
fingers are abducted with separators, and the thumb is posi- sure of the splints should not exceed 40 mm Hg.42 Accord-
tioned in abduction and extension. Snook44 notes that if a ing to Poole and colleagues,42 “inflatable splints have been
flexion contracture is present, the wrist may be positioned at used with patients who have had a stroke to reduce tone,
neutral or slightly less than neutral without producing a facilitate muscle activity around a joint, facilitate sensory
significant effect on the effectiveness of the splint. input, control edema, and reduce pain.” Their article in-
Snook44 recommended an intermittent wearing sched- cludes a review of the neurophysiological rationales for the
ule, observing that “a decrease in tone is usually seen al- use of inflatable splints.
most immediately upon splint application; however, after Three studies have been published of investigations of
an extended period of wearing time, tone tends to gradu- the effectiveness of inflatable splints on patients who have
ally increase.” had strokes. The earliest was a case study by Bloch and
Snook’s original article described fabrication and pro- Evans;2 its results indicated a reduction in spasticity and
vided clinical observations and case studies. Research was an increase in hand ROM.
not included in this article. Snook44 concluded that based Nicholson38 (as cited by Poole and Whitney41) treated
on preliminary findings, the spasticity reduction splint has patients for one week with inflatable splints along with
an effect “on the reduction and normalization of tone” weight-bearing patterns. At the end of the treatment
and should be considered as a therapeutic tool when the protocol, no improvements had occurred in sensation,
therapist is dealing with a spastic hand. strength, and ROM.
McPherson31 evaluated the effect of this splint on five Likewise, Poole and colleagues42 treated 18 persons
severely and profoundly handicapped subjects (no patients and assigned them to splint or nonsplint treatment proto-
who had strokes were included in this study). His results cols. The splinted group wore the splint for 30 minutes
demonstrated a significant reduction in hypertonicity af- five days a week for three weeks. The splinted patients did
ter four weeks of splint use. He further stated that the not perform activities with the splinted extremity. The
effects of the splint were not permanent; after the splints authors’ results indicated no statistically significant differ-
were removed, hypertonicity increased. The author mea- ences in mean change in upper extremity sensation, pain,
sured “the force of spastic wrist flexors in pounds of pull and motor function between the splinted and nonsplinted
on a spring weighted scale.” groups.
The fabrication guidelines for this splint are outlined Although inflatable pressure splints do not seem to
in Snook’s article.44 Compliance in wearing schedules may elicit the effects originally proposed, some therapists may
be problematic because the splint is bulky and the wrist consider using this style of splint to enhance functional
and hand are held in an extreme range. Many patients performance during weight-bearing activities (Fig. 13-6).
require assistance donning the splint, depending on the In essence, this splint can be used to control the degrees
level of flexion posturing in their hands. of freedom in the upper extremity, thereby promoting
Although the principles that this splint was based on functional use during daily activities.
originally are out of date, this splint maintains a stretch
to the musculature that traditionally becomes shortened Wrist Extension Splints
in patients after stroke. It may be useful as an adjunct to Wrist splints are commonly used in stroke populations to
treatment focusing on the maintenance of soft-tissue prevent wrist contracture and to stabilize the wrist to pro-
length. Further research is required on patients after vide the fingers a steady base from which they can func-
cerebrovascular accident (CVA) to document this splint’s tion. Lannin and colleagues25 aimed to determine whether
effectiveness (Fig. 13-5). wearing a hand splint, which positions the wrist in either
a neutral or an extended position, reduces wrist contrac-
Pressure Splints (Air Splints) ture in adults with hemiplegia after stroke (N⫽63). The
The use of inflatable pressure splints as adjuncts to therapy subjects were randomized to either a control group (rou-
was first advocated by Johnstone.19 These splints are com- tine therapy) or one of two intervention groups (routine
mercially available and exert continuous or intermittent therapy and splint in either a neutral or an extended wrist
332 Stroke Rehabilitation

extension) for a maximum of 12 hours each night for the

duration of the four-week intervention period. Outcomes
included length of the wrist and extrinsic finger flexor
muscles measured via torque-controlled range of wrist ex-
tension with the fingers extended, the Motor Assessment
Scale, and pain via a visual analog scale. The authors found
that the effects of splinting were statistically nonsignificant
and clinically unimportant, and they concluded that “an
overnight splint-wearing regimen with the affected hand in
the functional position does not produce clinically benefi-
cial effects in adults with acquired brain impairment.”
The resting splint is used commonly in clinics. Al-
though the splint may be effective in the long-term for
patients after stroke, therapists must analyze critically the
effects of this splint on the patient with acute and sub-
acute impairments. This splint blocks any automatic and
Figure 13-6 Inflatable pressure splint. voluntary attempts at movement, thereby promoting
learned nonuse. It completely covers the surface of the
hand (thus preventing sensory input) and gives full passive
position). Participants in the neutral splint group wore a support to the wrist and digits, which may be contrary to
hand splint, which positioned the wrist in zero degrees to treatment programs attempting to train patients to be
10 degrees extension, and those in the extension splint responsible for the positioning and ranging of their hands.
group wore a hand splint, which positioned the wrist in a Therapists need to consider alternatives to this splint.
comfortable end-of-range position (greater than 45 de- Mathiowetz, Bolding, and Trombly30 demonstrated
grees wrist extension) with the MCP and IP joints ex- that the use of a volar-based resting splint increased EMG
tended. The splints were worn overnight for, on average, activity in hemiplegic subjects who were performing
between nine and 12 hours, for four weeks. The outcome grasping tasks with the opposite extremity. They con-
was extensibility of the wrist and long finger flexor mus- cluded that this type of volar splint “is the least desirable
cles (angle of wrist extension at a standardized torque). positioning device while the hemiplegic subject is doing
The authors concluded that splinting the wrist in either any activity that requires a comparable effort to squeezing
the neutral or extended wrist position for four weeks did fifty percent maximal voluntary contraction of grip.”
not reduce wrist contracture after stroke. Resting splints can be custom fabricated; they also are
available commercially. The therapist may consider night-
Resting Splints time use of the resting splint for prevention of soft-tissue
The resting splint can be dorsal or volar based. The sug- contracture, but this style of splint should not be worn
gested position is 20 to 30 degrees of wrist extension, during daytime because it completely blocks spontaneous
MCP joints at 40 to 45 degrees of flexion, IP joints in 10 function, sensory input, and self-management of the hand
to 20 degrees of flexion, and thumb in opposition to the and may promote learned nonuse (Fig. 13-7).
index finger.29
One of the most important aspects of clinical reasoning Tone and Positioning Splint
is that each patient must be evaluated and treated indi- The tone and positioning splint is semidynamic and is
vidually, and these goniometrics should be used as a commercially available from Smith & Nephew Rolyan.
guideline only. The goal is to adjust the splint to promote The splint supports the thumb in abduction and extension
a low-load prolonged stress (LLPS) to achieve a more with a neoprene glove. The tone and positioning splint
advantageous biomechanical position as necessary. includes an elastic strap that is wrapped spirally up the
Lannin and colleagues24 evaluated the effects of four forearm, providing a dynamic assist into pronation and
weeks of hand splinting on the length of finger and wrist supination. Data supporting the effectiveness of this splint
flexor muscles, hand function, and pain in people with ac- are not available.
quired brain damage via randomized, assessor-blinded trial.
They examined 28 adults, all within six months of injury.
Subjects in both experimental (n⫽17) and control (n⫽11)
groups participated in routine therapy-motor training for
upper limb use and upper limb stretches five days a week.
The experimental group also wore an immobilizing hand
splint in the functional position (10 to 30 degrees wrist Figure 13-7 Resting pan splint and submaximal range splint.
 Chapter 13 • Splinting Applications 333

Casey and Kratz6 have published a paper on the thumb Stern45 cautioned that, “For this splint to be of any
abduction supinator splint. This splint is similar in design to value, the patients must be able to use the affected hand
the commercially available tone and positioning splint. for grasp and release, their main problem being adduction
Their paper included fabrication guidelines and recom- of the thumb, which prevents sufficient opening of the
mended a wearing schedule of three to four hours on, and hand to allow for palmar grasp.” Patients with fixed ad-
then 30 minutes to one hour off to allow the skin to be ex- ductor contracture are less likely to benefit.
posed to the air. They recommended using the splints on Research evaluating the effectiveness of this splint in
patients with mild to moderate spasticity without severe the adult population is lacking. Currie and Mendiola8
contractures: those who posture in a pattern of forearm pro- evaluated the effectiveness of a variation of this type of
nation, with a fisted hand, and with the thumb in the palm. splint on five children with “mild to moderate spastic
The tone and positioning splint and thumb abduction hemiplegic cerebral palsy.” These children exhibited a
supinator splint may present difficulties to patients learn- cortical thumb (adducted thumb) at rest, and their hand
ing to don and doff splints independently. These splints functions were limited to a “raking” ulnar type of prehen-
are designed to be used to enhance positioning and to be sion pattern.
worn during functional activities. They may be particu- With the use of this splint, all five children’s resting
larly effective if worn during activities that result in ste- thumb patterns were enhanced, and their prehension pat-
reotypical posturing of the limb (e.g., gait and transfers). terns improved to a radial grasp, usually in a three jaw
They also may be effective during upper extremity activi- chuck or large cylindrical prehension pattern, depending
ties because the digits are free to move (Fig. 13-8). on the size of the object being manipulated (Fig. 13-9).

Thumb Loop and Thumb Abduction Splint Hand-Based Thumb Abduction Splint
Variations of the thumb abduction splint have been pro- If the patient has controlled wrist movement in flexion
posed by several authors.8,16,45 The papers cited in the and extension (not necessarily full wrist ROM, but some
references include fabrication guidelines; the splint is isolated control) but continues to have flexor activity in-
commercially available. The thumb abduction splint is fluencing the digits, a hand-based thumb abduction C-
considered a semidynamic splint, and the focus of posi- spacer splint may be useful during functional activities.
tioning is on thumb and wrist alignment. The strapping The splint is custom fabricated from thermoplastic mate-
material used in the fabrication of this splint positions the rial. The thumb abduction splint positions the thumb in
thumb in abduction and aligns the wrist in a position of an enhanced prehension pattern for manipulation of ob-
slight radial wrist extension. The hand is placed in a posi- jects during grasp and release activities (Fig. 13-10).
tion that enhances prehension, manipulation, and release
of objects, and provides the freedom of movement needed MacKinnon Splint
for bilateral coordination.16 Although the MacKinnon splint was developed for the
Stern45 stated that another indication for use is during pediatric population, it may be indicated at times for the
any activity involving effort, particularly when perform- adult population. The splint includes a dorsal-based fore-
ing fine activities with the unaffected limb results in in- arm support that wraps three fourths of the distal half of
creased thumb adduction on the affected side. There- the forearm, a dowel placed in the palm of the hand to
fore, this splint has been suggested for positioning and provide pressure on the MCP heads, and rubber tubing
enhancement of functional performance.

Figure 13-8 Rolyan tone and positioning splint. (Courtesy Figure 13-9 Rolyan thumb loop and thumb abduction splint.
Smith & Nephew Rolyan, Germantown, WI.) (Courtesy of Smith & Nephew Rolyan, Germantown, WI.)
334 Stroke Rehabilitation

Serpentine Splint
The serpentine splint must be custom fabricated from
thermoplastic materials. The splint was originally de-
signed for use with pediatric patients with cerebral palsy
who had difficulty grasping objects. The splint is adapted
easily to the adult with neurological impairments. The
Figure 13-10 Hand-based thumb abduction splint to be used serpentine splint provides sufficient thumb abduction
when wrist control returns; thumb requires abduction assistance support, positions the hand and wrist in a more optimal
for functional opposition activities. position for function, and allows “active wrist function
in the child with moderately increased tone.”47 The de-
signers of the splint feel that the serpentine splint inhib-
attaching the dowel to the dorsal forearm support; the its the thumb-in-palm reflex by using the thumb abduc-
fingers are left free to assume functional patterns. tion position.
The goal of this splint is to release the overactive finger The authors have used an adaptation of the serpentine
flexors and adductor pollicis to gain balanced muscle ac- splint with several patients after CVA, with positive out-
tion of the wrist. The paper by MacKinnon, Sanderson, comes. The serpentine splint can be used for patients with
and Buchanan28 included fabrication guidelines and ob- mild to moderate increased skeletal muscle activity (it is
servations of approximately 30 children who used the not recommended for the flaccid hand). This splint is
splint and gained improved hand awareness, increased never recommended for hands that exhibit severe in-
use, and decreased spasticity when the splint was removed. creases in skeletal muscle activity for the reasons outlined
Research regarding the effectiveness of this splint is not previously in this chapter.
available, and it has not been documented for use with the The wrist is positioned in 20 to 30 degrees of exten-
adult patient recovering from CVA (Fig. 13-11). sion, the thumb is positioned in 30 to 40 degrees of ab-
duction, and the material continues two thirds of the
Submaximal Range Splint length proximally up the forearm. The splint positions
The submaximal range splint was described by Peterson;40 the hand in a more functional position for grasping exer-
its design is based on the clinical observation that muscles cises and activities.47 The splint is worn during the day for
splinted on full stretch or maximal ROM increased in activities and wrist support and is removed at night. The
tightness. serpentine splint requires maximal assistance for applica-
The splint is fabricated in the fashion of a resting tion and moderate assistance for removal and is a practical
hand splint. The splint should position the distal ex- alternative to more conventional static splints. Because
tremity with the thumb in partial opposition to the index the splint is an open splint, it is less confining; it also is
finger, the MCP and PIP joints in 45 degrees of flexion, lightweight and allows for air circulation, which results in
with distal interphalangeal (DIP) joint extension, and decreased perspiration, decreased skin maceration, and
the wrist in 10 to 20 degrees of extension; the splint reduced potential for skin breakdown. When fabricating
should provide pressure to the palmar arch. If the pa- this splint, the therapist places the roll in the palm, then
tient cannot achieve this ideal range, each joint should wraps it around the ulnar aspect of the hand, forms it over
be positioned in five to 10 degrees less than the available the dorsum of the hand through the web space, brings the
range.10 Fabrication guidelines are the same as those for roll over the thenar eminence and under the base of the
a resting hand splint. thumb, and continues wrapping the material two thirds of
No research is available that evaluates the effectiveness the way up the forearm. The seam made by rolling the
of this splint, but the precautionary statements about the splint material should face away from the skin to prevent
resting hand splint are similar to those for this splint de- skin irritation and breakdown (Fig. 13-12).
sign (see Fig. 13-7).
Drop-Out Splint
The drop-out splint is a custom-fabricated splint designed
to decrease elbow contractures that may be common in
the patient after stroke. The splint is designed from ther-
moplastic material positioned volarly on the humerus,
distal to the axilla; it extends into the palm of the hand
proximal to the distal palmar crease. The splint is fabri-
cated with the shoulder and humerus externally rotated
and the forearm in as much supination as possible. It is
Figure 13-11 MacKinnon splint. customized with a gentle stretch to the contracted elbow
 Chapter 13 • Splinting Applications 335

belly of the splint must be directly under the PIP joint axis
for the splint to be effective. The authors have found this
splint to be effective for flexion contractures of the PIP
joint from approximately 15 degrees of contracture to 35
degrees of contracture. A PIP joint contracture of more
than 35 degrees requires dynamic splinting.11 The belly
gutter splint is used at the beginning of treatment for one
hour on and one hour off. Gradually, as the contracture
decreases, the time may be extended to as much as four
hours, but as always, close monitoring of the splint is man-
datory (Fig. 13-14).
Figure 13-12 Serpentine splint. Inflatable Hand Splint
The inflatable hand splint, which is commercially avail-
able, is marketed for contracture management of the
joint (not to the point of discomfort) using the LLPS population in the chronic stages of stroke rehabilitation.
principles in the section Treatment of Joint Contractures The splint consists of an adjustable volar-based wrist sup-
with Low-Load Prolonged Stress. The splint is used dur- port that is easily adjusted to achieve the desired range of
ing rest periods to maximize the low-load prolonged extension. The palmar aspect of the splint is an air bladder
stretch to the elbow. The elbow contracture is measured that can be inflated or deflated easily, depending on the
with a goniometer before application of the splint and desired stretch and level of contracture. The splint is eas-
checked weekly to allow appropriate adjustments of the ily donned and is comfortable (Fig. 13-15).
splint for increased extension as needed. As with all splints The therapist must consider many issues when pre-
used in the patient who has had a stroke, but especially for scribing or designing a splint for use on persons after
splints using the low-load prolonged stretching principles, stroke. The following section exposes therapists to the
the therapist must monitor the upper extremity frequently complexity of issues to be considered during the splinting
for skin maceration and breakdown (Fig. 13-13). evaluation.
Belly Gutter Splint for Proximal Interphalangeal
Joint Flexion Contractures
The belly gutter splint is a static PIP extension splint cus-
tom fabricated from thermoplastic material. Many PIP ex-
tension splints are commercially available. Joint Jack, LMB
Wire-foam, and safety-pin splints, which apply two points
of volar pressure to make a perpendicular pull on the in-
volved segments, are a few. If the flexion contracture is
greater than 35 degrees, these splints are not effective. Dy-
namic extension splints and the belly gutter splint provide
traction tension at a 90-degree angle to the phalanx. The
belly gutter splint provides the 90-degree angle pull by in- Figure 13-14 Belly gutter splint for proximal interphalangeal
corporating a convex belly in the middle of the gutter.52 joint flexion contractures.
When fabricating and applying this splint, the therapist
must place the Velcro strap directly over the PIP joint; the

Figure 13-15 DeRoyal’s Pucci Air-T Inflatable Hand Orthosis.

Figure 13-13 Drop-out splint. (Manufactured and distributed by DeRoyal.)
336 Stroke Rehabilitation

CONSIDERATIONS IN PRESCRIBING From their review of the literature, Gossman, Sahrman,

AND DESIGNING A SPLINT FOR THE DISTAL and Rose14 concluded that “evidence from experimental
EXTREMITY AFTER STROKE studies and clinical observations clearly indicates that
muscle is an extremely mutable (prone to change) tissue.
Spasticity Change is more pronounced when a muscle is shortened
Many commonly used splints are applied in the hope that than when it is lengthened. The changes can be deleteri-
they will inhibit spasticity with a result of improved func- ous, but they are reversible, a condition that can be used in
tion. As outlined in Chapter 10, the cause-and-effect rela- correcting movement dysfunction.”
tionship between spasticity and function has not been Halar and Bell15 stated that if mild contractures have
supported in available research. formed, prolonged stretches for 30 minutes are effective.
The link between spasticity and contracture has been More severe contractures may require longer sustained
well-documented; see Chapter 10. Therefore, splinting of stretch through splinting. They recommended application
patients who are experiencing distal spasticity may be indi- of heat before splinting to decrease the viscous properties of
cated to prevent painful contractures and loss of tissue connective tissue and maximize the effects of stretching.
length. This differentiation is important if therapists are to During the splinting evaluation, the therapist must as-
analyze objectively the effectiveness of the splints provided. sess the differences between extrinsic and intrinsic tight-
Hummelsheim and colleagues17 have demonstrated that ness and joint contractures. Therapists must understand
prolonged stretch resulted in “a significant reduction in the the biomechanical mechanism of the extrinsic flexors and
spastic hypertonus in elbow, hand and finger flexors” of extensors. To review, when the wrist and digits are in
the 15 patients they studied. Spasticity was measured by the composite flexion (i.e., all joints are flexed), the extensors
Ashworth Scale. The EMG recordings included in their are stretched fully and the flexors are slack. In contrast,
study objectively demonstrated that late EMG potentials when the wrist and digits are in composite extension (i.e.,
are reduced or disappear after sustained muscle stretch. all joints are extended), the flexors are stretched fully and
The authors hypothesized that “the beneficial effect result- the extensors are slack (Fig. 13-16).
ing from sustained muscle stretch is due to stretch receptor Fess and Philips11 suggested altering wrist posture to
fatigue or adaptation to the new extended position.” detect extrinsic soft-tissue involvement. If extrinsic tight-
Although this study was based on manual stretching ness is evident, changing the wrist posture from slight ex-
techniques, the same principles may be applied to splint- tension to flexion results in an increase in the ROM of the
ing. Therefore, splinting may be used as an adjunct to digits (the tenodesis effect). In contrast, if ROM limita-
interventions aimed at relaxing the distal extremity. tions are caused by a pathological condition of the joint, an
Feldman10 recommended early splinting interventions altered wrist position does not affect the ROM. Evaluation
for patients with spasticity; treatment should begin before procedures for assessing extrinsic tightness are as follows:
the spasticity becomes severe. She stated that “the longer (1) extend the wrist with the digits flexed, and (2) maintain
tonal influences are left to bear on the joints, the greater the the wrist in extension and attempt to extend the digits. If
risk for contractures and other complications.” Feldman
also warned that patients with severe spasticity should not
be considered for splinting programs. These patients are at
risk for skin breakdown, edema, and circulatory impair-
ment. Instead, Feldman recommended interventions with
spasticity medication and nerve blocks for these patients
(see Chapter 10). A
Soft-Tissue Shortening
Many of the wrists and hands that therapists evaluate are
immobilized. This immobilization may be because of
weakness, static splinting for prolonged periods, excessive
skeletal muscle activity, or contracture. The deleterious
effects of immobilization begin to occur soon after im-
mobilization begins.
Consequences of prolonged positioning following im- B
mobilization include anatomical, biochemical, and physi- Figure 13-16 Normal excursion of the flexor and extensor
ological changes. Specific changes include the number of muscles acting on the wrist and hand. A, Wrist and digits flexed:
sarcomeres, protein content, loss of muscle weight, the extensors are fully stretched (elongated) and the flexors are slack
amount of passive and active soft-tissue tension, decreased (shortened). B, Wrist and digits extended: flexors are fully
aerobic function, and type I and II fiber atrophy.14 stretched (elongated) and extensors are slack (shortened).
 Chapter 13 • Splinting Applications 337

composite extension can be achieved, then the extrinsic

flexors have full excursion. If the digits cannot be extended
while the wrist is in extension, the evaluation must con-
tinue to determine whether the limitation is related to a
pathological joint condition or extrinsic flexor tightness.
The evaluation continues as follows: (3) flex the wrist and
determine if the excursion of the digits toward extension
(tenodesis) is increased. If so, the limitation is due to ex-
trinsic flexor tightness. If no change in available digit ex-
tension occurs, the pathological condition of the joint is
the limiting factor48 (Fig. 13-17).
A B
In terms of the biomechanics of the intrinsic mecha-
Figure 13-18 Normal excursion of the intrinsic muscles (lum-
nism, when the MCP joints are flexed and the IP joints
bricales). A, When the metacarpophalangeal joints are flexed
are extended (intrinsic plus), the intrinsic muscles are
and the interphalangeal joints are extended (“intrinsic plus”), the
shortened. In contrast, when the MCP joints are extended
intrinsic muscles are in a shortened position. B, When the meta-
and IP joints are flexed, the intrinsic muscles are fully
carpophalangeal joints are extended and the interphalangeal
stretched (Fig.13-18).
joints are flexed (“intrinsic minus”), the intrinsic muscles are
Fess and Philips11 suggested evaluating intrinsic
elongated.
tightness by holding the MCP joint in extension and

attempting to flex the PIP joint; full passive flexion of

the PIP joint is absent if the intrinsic muscles have be-
come tight. With intrinsic tightness, however, one may
possibly attain full passive PIP joint flexion with the
MCP joint in flexion (Fig. 13-19).
Many patients also develop contracture of the extensor
A tendons. Therapists must determine whether the altera-
B tion of the position of the MCP joint affects the amount
of flexion obtained at the PIP joint. If shortening or adhe-
sion of the extensor has occurred, the therapist is able to
flex the PIP joint further with the MCP joint extended
than with it flexed.48 This phenomenon occurs because
C D extension relaxes the extensor system, whereas flexion
builds up the passive tension.
Collateral ligament tightness of the PIP joint limits
PIP joint motion regardless of the position of the MCP
joint.18 The testing is performed by flexing the PIP joint
with the MCP joint extended and again with it flexed; if
PIP joint motion is limited in both testing positions, the
E collateral ligaments of the PIP joint have shortened
Figure 13-17 Testing for extrinsic shortening. A, The thera- (Fig. 13-20) and splinting of the PIP joint is indicated.
pist extends the wrist with the digits flexed. This position par- A dynamic PIP extension splint is used if the contrac-
tially elongates the long flexors. B, The therapist maintains the ture is greater than 35 degrees; a static PIP extension
wrist in extension and extends the digits. If composite extension splint is used if the contracture is less than 35 degrees.11
can be achieved, the extrinsic flexors have full excursion and the A combination of both splints sometimes is used; the
evaluation is complete. C, If the therapist cannot extend the dynamic splint is applied for the more severe contrac-
wrist and digits fully simultaneously, the evaluation must con- ture, and a static extension splint is worn after the con-
tinue to determine whether the limitation is related to a patho- tracture is reduced to less than 35 degrees.
logical joint condition or extrinsic flexor tightness. D, The Loss of active flexion of the DIP joint may be caused
therapist flexes the wrist to determine if excursion of the digits by joint contracture or contracture of the oblique reti-
toward extension (tenodesis) is increased. If so, the limitation is nacular ligament. The therapist performs the oblique
due to extrinsic flexor tightness. E, If no change in available digit retinacular ligament tightness test by passively flexing the
extension occurs while the wrist is flexed, the pathological joint DIP joint with the PIP joint in extension and then repeat-
condition (i.e., bony contracture) is the limiting factor. ing the test with the PIP joint in flexion. If more motion
338 Stroke Rehabilitation

A B C
Figure 13-19 Testing for intrinsic shortening. A, The therapist holds the metacarpophalan-
geal joints in extension and attempts to flex the proximal interphalangeal joints. If the therapist
can achieve this position, then full excursion of the intrinsic muscles is present. The evaluation
is complete. B, If therapist cannot achieve full passive flexion of the proximal interphalangeal
joint while the metacarpophalangeal joints are extended, the intrinsic muscles have become
tight. C, With intrinsic tightness, however, the therapist possibly may attain full passive proxi-
mal interphalangeal flexion with the metacarpophalangeal joint in flexion.

Figure 13-21 Oblique retinacular ligament. (Redrawn from

Tubiana R: The hand, Philadelphia, 1981, Saunders.)
Figure 13-20 Proximal interphalangeal joint contracture. Col-
lateral ligament tightness limits proximal phalangeal joint mo-
tion, regardless of the position of the metacarpophalangeal joint.
(From Hunter JM, Mackin E, Callahan A: Rehabilitation of the
hand: surgery and therapy, ed 4, St Louis, 1995, Mosby.)

occurs when the PIP joint is flexed than when it is ex-

tended, a shortening or contracture of this ligament has
occurred (Fig. 13-21). If equal loss of flexion occurs with
the PIP joint flexed or extended, a joint contracture is
evident.18 Contracture of the DIP joint with decreased Figure 13-22 Flexion (“Buddy”) strap.
DIP flexion can be treated with the use of a flexion strap
with the MCP, PIP, and DIP joints in as much flexion as
possible. This strap can be fabricated from Velcro strap- joint integrity. If a joint has become contracted, the joint
ping and is commercially available (Fig. 13-22). The pa- capsule becomes stiff, the synovial fluid becomes thick-
tient can use the strap intermittently during the day for ened from nonmovement, and the ligaments around one
one hour on and one hour off. side of the joint become shortened, whereas the ligaments
on the other side become lax. Soft-tissue involvement in
Treatment of Joint Contractures with Low-Load contractures includes shortened tendons and skeletal
Prolonged Stress muscle. High-load brief stretch manual therapy alone
Neuromuscular dysfunction is a common cause of physi- does not achieve plastic elongation of tissues over time.12
ological joint restriction and contractures.26 Splints are LLPS involves holding the tissues in a low-lengthened
used to maintain or lengthen soft tissues and maintain position for a total end range time. A low-lengthened
 Chapter 13 • Splinting Applications 339

position is a passive position with a low-load stress (in next task (e.g., dressing) before noticing the problem, re-
which the patient feels a slight stress but one that he or sulting in the potential for tissue damage.
she can tolerate for a significant amount of time, i.e., three Another common alignment problem that puts pa-
to four hours total end range time). The total end range tients at risk for injury occurs if upper extremity position-
time increases over time to an ideal of six to eight hours. ing devices are ineffective. Many patients are prescribed
The soft tissue grows, not stretches, to the new length- half or full lap trays to provide upper extremity support
ened position.26 while they are seated in their wheelchairs. In many cases,
Current literature supports LLPS as the preferred the supported extremity slides between the lapboard
method of lengthening shortened tissues. The common and the patient’s trunk, pinning the wrist in extreme
clinical practice of stretching contractures manually with flexion. Depending on patient and staff awareness, this
high brief-load periods for one to two minutes is contra- position unfortunately may be maintained for prolonged
indicated in the literature.26 The elongation accomplished periods. Injury also can lead to pain and swelling, which
by manual stretch alone shortens when the force is re- in turn may trigger the initial symptoms of shoulder-hand
laxed. Manual therapy prepares tissues but must be fol- syndrome.
lowed with splinting and activities to affect permanent
changes.12 Biomechanical Alignment
A study by Light and colleagues26 tested knee contrac- The position a hand assumes at rest (the resting posture)
tures using high-load brief stretch or LLPS on 11 geriat- has been documented by several authors. A summary of
ric patients. All subjects had bilateral knee contractures; this posture is as follows:
high-load brief stretch was the treatment for one knee, ■ Forearm midway between pronation and supination29
and LLPS was the treatment for the other. The LLPS in ■ Wrist at 10 to 15 degrees of extension11
this study was accomplished by traction. LLPS produced ■ Thumb in slight extension and abduction with
a greater overall increase in passive ROM than did the the MCP and IP joints flexed approximately 15 to
high-load brief stretch. 20 degrees
Splinting to provide an LLPS is a noninvasive, non- ■ Digits posture toward flexion, exhibiting greater
stressful, and ideally painless treatment.26 The treatment composite flexion toward the ulnar side of the hand
for joint stiffness and contracture is stress, which involves ■ Second metacarpal aligned with the radius
intensity (amount of effort), duration (amount of time), ■ Palmar arches maintained (see the following section)
and frequency (amount of repetition).12 Although all these ■ Hand exhibiting “dual obliquity”
stress factors are important, duration is the most impor- The therapist must consider the concept of dual obliquity
tant for LLPS, the optimal time being six to eight hours. when evaluating the alignment of the hand. Because of a
This optimal duration usually must be built up slowly, successive decrease in the length of the metacarpals from
beginning with one to two hours. As the joint contracture the radial to the ulnar side, objects held in the hand as-
decreases, the splint must be readjusted regularly (usually sume two oblique angles.39 For example, if a pencil is held
weekly) to increase prolonged stress. LLPS is the princi- in the palm across the metacarpal heads (eraser toward the
ple used in some of the splints mentioned previously in ulnar side) and the forearm is held in pronation resting on
this chapter, including the elbow drop-out splint, the the table, the examiner can identify two oblique angles.
belly gutter splint, and any dynamic splinting. As with all The first angle is observed with the pencil point angled
splinting, but especially in using LLPS splinting for pa- upward in relation to the wrist joint axis. The second
tients with sensory impairments, therapists must monitor oblique angle is observed on examination of height of
patients using these splints for skin breakdown. each end of the pencil. The radial side is held higher than
the ulnar side, that is, the pencil is not parallel to the table
Injury to the Extremity (Fig. 13-23).
Because of decreased motor control and perceptual dys- The obliquity of the palmar transverse arch follows a
function (e.g., body neglect and somatoagnosia), many line from “the second to the fifth metacarpal head and
patients are at risk for injuries to the already compromised forms an angle of seventy-five degrees with the axis of the
extremity. Many times these patients assume malaligned third ray.”48 Therefore, from a biomechanical perspective,
upper extremity patterns for prolonged periods. A com- the firm cone splint discussed earlier for a moderately
mon example may be observed during bed mobility train- relaxed hand should be placed with the narrow end in the
ing. Patients assume sitting postures from side lying and ulnar side and the wide end on the radial side, following
end up bearing their weight through the dorsum of their the normal obliquity.
hands with the wrist flexed. This posture puts patients at The therapist must note deviations from the resting
risk of developing traumatic synovitis, increased edema, posture; they assist in the design of the splint. Thera-
and pain. The patient, depending on the level of aware- pists must consider that patients may differ slightly
ness, may maintain this maladaptive posture during the from the normal resting posture because of heredity,
340 Stroke Rehabilitation

Loss of Palmar Arches

A familiar alignment problem in patients after stroke is
the loss of palmar arches, or the development of a “flat-
tened hand.” The maintenance of the palmar arches is
crucial for hand function.4 Kapandji20 outlines the arches
of the hand as follows (Fig. 13-24):
■ Transverse arch: This structure consists of two arches
and includes the carpal arch, which corresponds to
the concavity of the wrist and is continuous with the
Figure 13-23 Dorsally, the consecutive metacarpal heads cre- distal metacarpal arch formed by the metacarpal
ate an oblique angle to the longitudinal axis of the forearm. heads. The carpal arch is rigid, whereas the metacar-
Distally, the fisted hand exhibits an ulnar metacarpal descent pal arch is mobile and adaptable. The long axis of
that creates an oblique angle in the transverse plane of the fore- the transverse arch crosses the lunate, capitate (the
arm. (From Fess EE, Philips CA: Hand splinting: principles and “keystone” of the carpal arch11), and the third meta-
methods, ed 2, St Louis, 1987, Mosby.) carpal bones. Boehme4 states that the functional
significance of this arch stems from its forming the
hand into a gutter, bringing together the radial and
habits, and job descriptions; examining the opposite ulnar borders of the hand. This arch can widen or
hand is helpful in determining the “normal” resting narrow the surface area of the hand.
posture for each patient.22 ■ Longitudinal arch: This arch includes the carpometa-
The distal extremity assumes several typical alignment carpophalangeal arches. These arches are formed for
deviations after stroke. These deviations and their conse- each finger by the corresponding metacarpal bones
quences include the following: and phalanges. Kapandji20 notes that the arches are
1. Wrist flexion following decreased skeletal muscle
activity. This common posture (most often observed
in the flaccid stage) produces a variety of pathologi-
cal processes. A hand positioned in wrist flexion
results in the following: flattening of the palmar
arches, passive extension of the fingers due to teno-
desis action, shortened collateral ligaments because
of the extended digits, narrowing of the web space,11
inability to perform the grasping function (flexor
action of the thumb and digits reinforced by exten-
sion of the wrist),48 blockage of ulnar and radial A
deviation of the wrist when it is in flexion,20 over-
stretching of the wrist extensors and dorsal liga-
ments,48 shortening of the long flexors, and a ten-
dency to develop an edema syndrome.
2. Extreme ulnar deviation. The posture of ulnar de-
viation results in a variety of compounded prob-
lems. A wrist positioned in extreme ulnar deviation
produces the following: effective blockage of wrist
extension,20 shortening of the ulnar deviators and
overstretching of the radial deviators, and shifting
of the proximal and distal rows of carpal bones.48 B
3. Wrist and digit flexion. This posture may occur fol- Figure 13-24 A, Side view of the longitudinal and transverse
lowing excessive skeletal muscle activity and soft- arches of the hand. The shaded areas show the fixed part of the
tissue shortening. This posture results in the following: skeleton. B, The thumb forms, along with the other digits, four
loss of normal tenodesis function (wrist extension oblique arches of opposition. The most useful and functionally
with digit flexion and adduction, wrist flexion with important arch is between the thumb and index finger, used for
digit extension and abduction), shortening of the ex- precision grip. The farthest arch, between the thumb and little
trinsic flexors with resultant overstretching of the finger, ensures a locking mechanism on the ulnar side of the
extensors, potential for skin maceration, and painful hand in power grips. (From Tubiana R, Thomine JM, Mackin E:
contracture and deformity. Examination of the hand and wrist, St Louis, 1996, Mosby.)
 Chapter 13 • Splinting Applications 341

concave on the palmar surface; the “keystone” of each palmar surface of the hand. To be effective and give full
arch lies at the level of the MCP joint. According to support to the metacarpals, the splint must conform to the
Boehme,4 in its simplest form, this arch supports a arches and be contoured to the individual’s hand. Com-
basic cylindrical grasp. If the arches are expanded, the mercially available splints are not effective for this type of
hand is longer. This arch allows the palm to flatten intervention because they do not take into account the
and cup itself around objects.11 variability of arches.
■ Oblique arches: These arches are formed by the For patients with hyperextended MCPs and flexed PIP
thumb during opposition with the other fingers. joints (i.e., claw-hand deformity), a dorsal MCP exten-
Kapandji20 states that the most important of these sion restriction splint can be fabricated in thermoplastic
arches is the one linking the thumb and index finger; material to eliminate deformity and increase function
the most extreme is the one linking the thumb and the (Fig. 13-26).
little finger. These arches are obviously crucial in the
opposition of the digits. Learned Nonuse
Patients lose their arches after stroke for a variety of Current research (see Chapter 10) has demonstrated the
reasons, including edema in the dorsum of the hand that existence of a component of upper extremity dysfunction
biomechanically forces the metacarpals inferiorly, inac- resulting from a learned phenomenon of nonintegration
tivity of the wrist and hand, prolonged and extreme wrist of the hand into functional tasks. This process likely be-
flexion (resulting in a flattening of the arches), and inap- gins in the early stages after stroke, before any functional
propriate support of the hand during weight-bearing recovery has commenced. Patients learn to compensate
activities.4 with their unaffected sides, thereby repressing any return
During evaluation of splinting, therapists should ex- of function on the hemiplegic side.
amine the arches of the hand and compare them with Many CVA protocols call for splinting immediately
those of the unaffected hand. In the dorsal surface of a after stroke. Some facilities have standing orders for
normal hand at rest, the MCP joints form an arch with splinting in their acute services. Current research indi-
the apex at the third metacarpal (i.e., the third metacarpal cates that early splinting in the early poststroke phase
head is higher than the others are) (see Fig. 13-24). Many may be detrimental. The splint gives a message that an
patients have a flattened arch (i.e., the MCP joints lose outside device is responsible for the maintenance and
their arches), and in response the proximal phalanges improvement of the affected hand. Because the hand is
hyperextend. This posture puts the patient at risk for supported and aligned through outside means, the pa-
developing a permanent claw-hand deformity and effec- tient does not attend to the hand, stretch the wrist and
tively blocks opposition of the thumb (Fig. 13-25). hand, or attempt to integrate it into functional tasks.
In these cases, splinting may be indicated to give out- Early splinting may predispose patients to a learned non-
side support to the arches through upward pressure on the use phenomenon. A sign that a patient is predisposed to
learned nonuse is the observation that a patient, after
cueing, can integrate functional return during a therapy
session but does not integrate this new function outside
the sessions. The therapist must balance interventions
for contracture prevention with activities that encourage
functional use of the hand, thereby negating the effects of
learned nonuse. Splinting for contractures can be used at
night instead of during the day to prevent learned nonuse
behavior patterns.

Figure 13-25 Flattening of the palmar arches resulting from

hand paralysis. Hyperextension of the metacarpophalangeal
joints and flexion of the proximal and distal interphalangeal
joints occur because of an imbalance of the extrinsic flexor and
extensor systems. (From Hunter JM, Mackin E, Callahan A:
Rehabilitation of the hand: surgery and therapy, ed 4, St Louis, A B
1995, Mosby.) Figure 13-26 Anticlaw splint. A, Dorsal view. B, Palmar view.
342 Stroke Rehabilitation

DECISION-MAKING PROCESS ■ If the answer is no, splinting may be indicated, al-

though the therapist must consider that splinting a
The therapist must evaluate all of the following areas hand without functional recovery may block the
when deciding whether to splint and choosing the type initial motor return (sometimes automatic reactions
of splint to fabricate. This section is designed to help and protective responses) or the patient’s initial at-
guide the therapist’s clinical reasoning in making splint- tempts at function.
ing decisions. 6. Evaluate potential for soft-tissue injury: Is evidence of
1. Evaluate cognitive and perceptual status: Does the skin maceration and laceration in the palm of the hand
patient attend to the extremity during the day (attend- and lateral aspect of the thumb from extreme flexion
ing includes self-ranging, rubbing, positioning, and apparent?
protecting)? Is the patient alert for the greater portion ■ If the answer is yes, the therapist seriously must
of the day? consider splinting to prevent further damage and
■ If the answer is yes, the patient may be able to main- enhance the healing process; wrist extension
tain ROM and alignment in the extremity without splints with distal cones or palm guards are rec-
the use of splints; the therapist should consider not ommended.
splinting. ■ If the answer is no, the therapist should consider not
■ If the answer is no, neglect, decreased attention, so- splinting.
matoagnosia, and decreased alertness and arousal 7. Evaluate biomechanical alignment: Are deviations
may place the patient at risk for contracture and from the standard resting position of the hand evi-
malalignment; splinting therefore may be indicated. dent? Does realigning the hand result in increased
2. Evaluate soft tissue tightness: Does the patient have relaxation?
full composite flexion and extension? Can the patient ■ If the answer is yes, the therapist should consider
be ranged into a full intrinsic minus/intrinsic plus splinting to improve resting alignment of the ex-
position? Does the patient have full and pain-free tremity to prevent shortening and overstretching of
range of wrist motion, especially extension and radial soft tissue.
deviation? ■ If the answer is no, the therapist should consider not
■ If the answer is yes, the therapist should consider not splinting.
splinting. Treatment should focus on teaching the 8. Evaluate sensation: Does the patient have sensory im-
patient and family techniques to maintain this range pairments?
and prevent pain and contracture. ■ If the answer is yes, the therapist should consider the
■ If the answer is no, splinting may be indicated to amount of cutaneous surface area that is covered by
improve or at least maintain soft-tissue length. The splinting. The splint may end up blocking the little
splint should be designed to place the shortened soft sensory input the hand is receiving. A general goal
tissues on prolonged stretch. for the involved extremity is to maximize sensory
3. Evaluate joint contracture: Splinting is necessary input. If sensation is impaired, extra precautions are
to ameliorate joint contracture and prevent further necessary for careful, custom splint fabrication and
deformity. diligent, ongoing monitoring of the skin condition
4. Evaluate learned nonuse: Does the patient integrate by the therapist, patient, and family for any break-
the extremity into functional tasks in the clinic without down or maceration, which the patient may not de-
carryover into nontherapy hours? tect. This is especially important if cognitive deficits
■ If the answer is yes, the therapist should consider not are present.
splinting. In this situation, the patient does have 9. Evaluate edema: Does the patient have distal edema?
distal function; this function should not be impeded ■ If the answer is yes, the therapist should consider
by splinting. The splint may in fact feed into the whether a splint will support a flexed wrist with the
learned nonuse cycle. goal of counteracting the dependent positioning of
5. Evaluate function: Does the patient exhibit distal mo- the hand, thereby decreasing or preventing further
tor control (including gross patterns) that can be inte- edema. Will the immobilization of the splint in-
grated into activities of daily living and instrumental crease the edema by blocking the “pumping action”
activities of daily living? of muscles generated by active ROM? Patients with
■ If the answer is yes, the therapist should consider not edema tend to lose digit flexion, thereby keeping
splinting or should choose a splint that enhances the the collateral ligaments in a shortened position.
functional return (e.g., a basic wrist extension splint Will the splint block digit flexion, thereby exacer-
to provide a stable proximal segment for the digits to bating this problem? Will the splint impinge on
work from or a simple opponens splint to improve neuromuscular structures and further limit hemo-
fine motor control). dynamic function?
 Chapter 13 • Splinting Applications 343

10. Evaluate posturing: Does the patient posture in per- followed by neutral deviation with slight wrist ex-
sistent flexion? tension for the next splint. The therapist must re-
■ If the answer is yes, the therapist should consider member that with an extremely tight or contracted
splinting to maintain stress on soft tissues. Re- hand, all deformities cannot be addressed simulta-
checking of biomechanical alignment is essential; neously; if simultaneous correction is attempted,
proximal realignment may relax the hand. compliance with splinting may be jeopardized be-
■ If the answer is no, the therapist should consider cause of the discomfort level and skin breakdown.
not splinting. 8. Educate patients about the realistic goals and expec-
tations of the use of a splint. Many patients wear
GENERAL SPLINTING GUIDELINES their splints for prolonged periods with the hope
that the splint will “make their hand better.” Most
Therapists should consider the following guidelines re- patients interpret “better” as a return in function.
garding splinting: However, this may not be the case for all patients;
1. Check for abnormal pressure points, especially over therefore, the patient should be aware of the reasons
bony prominences (e.g., ulnar head). that the splint was prescribed. No splint should be
2. Decide during which activities and periods the pa- worn continuously.
tient will wear the splint. The splint must be evalu-
ated or fabricated while the patient is in the most GENERAL FABRICATION GUIDELINES
difficult posture and performing the most stressful
activities if the effectiveness of the splint is to be Many splinting materials are commercially available to-
evaluated. For example, fabricating a splint while day. They are thermoplastic materials; some have more
the patient is seated and relaxed may result in a rubber content base than others do. The rubber content
good fit with a relaxed hand. However, if the patient base materials tend to have increased conformability and
then leaves therapy to prepare a meal at home, the drape compared with pure thermoplastic materials, but
therapist may find the patient’s hand “clawing” and they may be more difficult to handle because of their
flexing out of the splint. If the splint was fabricated draping quality.
with the patient standing and with the appropriate Thermoplastic materials generally have a greater mem-
level of stretch, this phenomenon may not be a ory capacity than do the rubber-based thermoplastics.
problem. Memory indicates the capability of the material to return
3. Splint for comfort. Pain and pressure responses to its original shape after the reheating that occurs during
may increase the patient’s bias toward stereotypical fabrication of the splint. Some therapists prefer the ther-
posturing. moplastics because of the memory capacity. The thermo-
4. Patients need to experience full ROM. Use posi- plastics are available in perforated and solid forms. Perfo-
tioning splints only as adjuncts to a comprehensive rated materials are recommended to allow for
upper extremity program. breathability and decrease the possibility of skin macera-
5. Monitor full ROM. Many patients have been pro- tion (especially with patients with sympathetic nerve
vided with resting hand splints to prevent flexion changes and sensory impairments). The therapist must
contractures only to end up with extension contrac- take care when using maxiperforated thermoplastics to
tures, or “intrinsic lock.” eliminate sharp edges after cutting the material. The
6. Make wearing schedules practical to ensure patient edges must be heated with a heat gun and turned down to
compliance. smooth the edging; the edges may also be covered with
1
7. Therapists must have reasonable expectations for ⁄16-inch solid material cut into 1-inch wide but long
splints. An extremely tight hand may require several pieces, heated in water, and then applied to the edging.
serial splints to achieve a desired position. Splints The therapist also may use a thin layer of moleskin to
designed to provide correction at more than one smooth the edges of perforated material.
joint can lead to added deformity if excessive skele- The thermoplastic materials and rubber-based ther-
tal muscle activity is present. For example, attempt- moplastics are available in various thicknesses ranging
ing to position the wrist and digits into extension from 1⁄8-inch, 3⁄32-inch, 1⁄12-inch, and 1-inch; the most
may create a clawing effect in the digits as a result common width is 1⁄8-inch. Some of the splinting materials
of the amount of stretch at the wrist and digits.50 A are available in a wide range of colors; these may help
severely malaligned hand may respond best if the draw attention to the involved limb and prevent the splint
therapist only focuses on one particular aspect of from being lost in hospital bedding. Color also may en-
the malalignment (proximal first). For example, hance compliance. Several vendors offer precut splint
counteracting the extreme ulnar deviation in this blanks and kits. These products can be cut to size for cus-
type of extremity may be the goal of the first splint, tomization and to decrease the amount of splinting time
344 Stroke Rehabilitation

required for fabrication. Prefabricated splints also are weight of the hand and the excess force created by in-
available for many splinting needs, but some may be dif- creased distal flexor activity, the forearm trough should be
ficult to customize. The authors do not recommend some two thirds of the length of the forearm to provide a suf-
of the commercially available spring wire splints for pa- ficient lever.
tients with sensory impairments because these splints may
apply too much pressure that the patient will not be able Palmar Support
to detect. Custom-fabricated splints are the splints of Many patients with neurological involvement have flat-
choice for patients with sensory impairments. tened arches at the MCP joints, with resultant clawing of
Velcro strapping materials are now available in multi- the digits. This malalignment usually occurs in patients
ple colors. Velfoam, a padded strapping material, is highly with little or no skeletal muscle activity in the affected
recommended for the patient with sensory impairments hand. In molding the splint into the palmar arch in these
because it is a softer strapping material. cases, the therapist can use the thumb to mold a letter
Splint padding does not compensate for a poorly fitted T pattern over the palmar surface of the splint. The base
splint and increases the pressure within the splint. Splint of the T runs longitudinally through the center of the
padding is recommended to cushion fingers at the point palm, whereas the top of the T runs across the metacarpal
of contact of the thermoplastic material in dynamic splints heads. The base of the T should connect to the top of the
only. Splint padding is available under different trade T at the third MCP head. The T shape is molded into the
names. Splint padding materials only increase the pres- palm to enhance the arch. To ensure sturdy arch support,
sure of an ill-fitting splint, and when used in this way, may the splint must progress distal to the distal palmar crease
also be hot and uncomfortable for the patient and may and does not need to clear the thenar eminence in a hand
increase the possibility of skin maceration because of the without movement. The therapist should reevaluate the
increased perspiration that the padding may cause in a patient frequently for returning motor control and should
patient. adjust the splint as needed. If the patient exhibits con-
Splinting the extremity of a patient with neurological trolled digit flexion, the distal end of the splint needs to
involvement is sometimes difficult if severely increased be rolled back proximal to the distal palmar crease so that
skeletal muscle activity is evident in the upper extremity. returning function is not blocked. If the patient begins to
Maintaining the desired alignment and molding the exhibit thumb function, the palmar support surface of the
splinting material may be almost impossible. The assis- splint must again be rolled back to clear the thenar emi-
tance of another person for positioning usually is indi- nence and therefore not block active movement.
cated for a proper fit. Pattern-making also may be difficult After splint fabrication, the therapist evaluates the
with this type of patient. The fabrication of a gross pat- palmar support section of the splint by checking that the
tern on the unaffected hand and reversal of the pattern for dual obliquity of the hand is maintained, the third meta-
transfer to the splinting material are helpful at times. carpal head is the apex of the arch formed by the meta-
The therapist must make allowances for bony promi- carpal heads, and the hand is not “flattened” in the splint
nences by cutting around or flaring the splinting material (Figs. 13-27 and 13-28).
over the prominence. A helpful hint for flaring out the
material is to place a spot of dark lipstick over the bony Wrist Support
prominence (on the patient’s skin); place the cooled, al- When molding and evaluating the wrist component of a
ready formed splint on the patient; and remove the splint. splint for the patient after stroke, the therapist must con-
The lipstick now will be on the splint in the exact spot at sider alignment:
which the splint requires flaring. ■ The third metacarpal should lie midway between the
During the use of thermoplastic materials in splinting, radius and ulna in a neutral deviated hand. Many
the placement of curve in the material increases the ten- hands with neurological involvement have a ten-
sile strength of the material to approximately 20 times dency to assume a position of ulnar deviation. Splint
that of straight material. This is helpful to remember in modifications to the wrist component include raising
the fabrication of dynamic outriggers from thermoplastic the border of the splint that lies lateral to the fifth
material or the creation of an additional roll in the mate- metacarpal. This modification effectively blocks the
rial as a spine or support. ulnar deviation (Fig. 13-29).
■ The wrist should be supported between zero and

SPECIFIC FABRICATION GUIDELINES 20 degrees of extension. Gillen and colleagues13

examined the effect of various wrist positions on
Forearm Support upper extremity function in adults wearing a wrist
If the splint prescribed for a patient includes a forearm immobilizing splint. The Jebsen Taylor Test of
trough, basic splinting principles call for the trough to Hand Function was administered to 20 adults with-
cover two thirds of the forearm. To compensate for the out upper extremity impairment to determine the
 Chapter 13 • Splinting Applications 345

Figure 13-29 The lateral aspect of the splint is built up along

the fifth metacarpal effectively to block ulnar deviation.

effects, if any. The test was administered three con-

secutive times. Each time the subject wore a com-
mercially available wrist extension splint that posi-
tioned the wrist in zero degrees (neutral), 15 degrees,
or 30 degrees of wrist extension. Wrist angles were
confirmed via goniometry. The order in which the
B
wrist angles were tested was randomized to control
Figure 13-27 Variations on palmar support fabrication. A, Full for fatigue and practice effects. The results of this
palmar support (material progresses past the distal palmar crease study indicated that there was no significant differ-
and gives the thumb support over the first metacarpal). B, As ence between the tested wrist positions (0 degrees,
function returns, the distal and thenar aspects of the splint are 15 degrees, 30 degrees) when using the nondomi-
rolled back to allow for joint excursion during functional tasks. nant hand to perform activities while wearing a
The T shape is molded into the palmar aspect of the splint. wrist splint. However, significant differences were
found when wearing various angled wrist splints to
perform functional activities with the dominant
hand albeit only for select tasks (feeding and stack-
ing checkers). During the feeding subtest, partici-
pants performed at a significantly faster rate when
their dominant wrists were positioned in 15 degrees
of extension as compared to performance with a
neutral wrist. During the stacking checkers subtest,
participants performed at a significantly faster rate
when their wrists were positioned in neutral when
compared with when they were positioned in
30 degrees of extension. Nonetheless, the final deci-
sion depends on which angle allows the maximal
amount of function or (if the hand is not functional)
which angle in this range decreases the usual abnor-
mal flexor activity in the digits. (Many patients’
digits relax if they are realigned proximally.) In
Figure 13-28 Molding the T support into the splint. The base some cases, the splint may be fabricated in some
of the T runs longitudinally through the palm, whereas the top degree of flexion. This may be required if contrac-
of the T supports the metacarpal arch. The base of the T inter- ture of the extrinsic flexors is evident and the goal is
sects the top of the T at the third metacarpal head. Palmar sup- systematically to lengthen the flexors with serial
port is accurate if the arches of the hand are maintained, and the splinting. In these cases, each subsequent splint
third metacarpal head is superior to the metacarpal heads of should be molded with an increased stretch on the
digits two and four. flexors. For example, the first splint may be molded
346 Stroke Rehabilitation

in 20 degrees of wrist flexion; the next in 10 degrees

of flexion, neutral wrist; and finally in some degree
of extension. Therapists must remember that if the
goal is to lengthen the extrinsic flexors, wrist and
digit support is required.
■ After molding the splint, the therapist should check
that the hand is not in a position of medial or lat-
eral rotation (neutral) compared with the forearm.
Many patients who exhibit excessive skeletal muscle
activity develop a tendency for the hand to rotate
medially or laterally in relation to the forearm. The
hand should be positioned in the splint so that the
fifth metacarpal is aligned with the ulna instead of
lying inferior to the ulna (the hand is laterally ro- Figure 13-30 Full support provided to the distal extremity.
tated in relation to the forearm) or lying superior to This style of splint is recommended only if alternative attempts
the ulna (the hand is medially rotated in relation to of proximal realignment do not relax the hand. This splint is
the forearm). recommended for night use only.

Digit Support
The therapist should use a digit support platform only as
a last resort. The therapist must include a digit support Prefabricated Splints
platform in the splint if the patient exhibits excessive In cases in which prefabricated splints are indicated,
flexor activity in the digits that cannot be otherwise con- therapists must take great care to ensure proper fitting.
trolled and if the patient is being splinted for contracture Patients should not be encouraged to purchase splints
management. If the splint includes a digit platform, day- “off the shelf” without a therapist’s input because of the
time use of the splint is discouraged. potential complications. Examples of commonly used
If a patient exhibits excessive flexor activity, the thera- and useful prefabricated splints include air-assist splints
pist first should try a forearm and wrist splint that en- for LLPS (see Fig. 13-15), a Multi Podus ankle/foot or-
hances alignment. In many patients, a proximal realign- thosis (Fig. 13-32), and elbow splints to provide stretch
ment of the joints and a prolonged state of accommodation (Fig. 13-33).
of muscles to their resting length relaxes the hand. Ther-
apists can evaluate this phenomenon by manually realign- SUMMARY
ing the joints with their hands and evaluating whether a
relaxation response occurs. When designing or fabricating a splint for a patient after
If a digit support platform is necessary, the digits stroke, the therapist must consider each patient individu-
should not be overstretched to the point that a “clawing” ally; no set of rules applies to all patients with neurologi-
of the hand or a “bottoming out” of the metacarpals cal impairments. No definitive answers or protocols are
occurs. The therapist must ensure that the palmar arch available. The reader is encouraged to consider the ques-
remains intact when the digits are stretched onto the plat- tions in the decision-making section of this chapter to
form (Fig. 13-30). guide clinical reasoning, because the therapist must con-
sider so many factors in treatment.
Thumb Support Any hand with a malalignment or deformity results in
In the nonfunctional hand, the thumb should be sup- an overstretching of the soft tissues (muscles, ligaments)
ported in a position midway between palmar and radial on one side of the joint and shortening of the soft tissues
abduction. This position can be maintained by the previ- on the opposite side. All treatment, including splinting,
ously described palmar support, which also supports the should be instituted after consideration of this phenome-
first metacarpal; if the splint is rolled back to clear the non and should aim to preserve the length and balance of
thenar eminence, the thumb cannot be supported in this soft tissue on either side of the joint. This treatment pre-
position (see Fig. 13-27). pares the hand for possible future integration into func-
If the thumb is functional, the splinted position is dic- tional activities and prevents permanent deformity.
tated by evaluation of the position of thumb that is the All splints applied to patients after stroke, especially
most effective at enhancing function with the thumb in patients with increased skeletal muscle activity and de-
opposition. Fig. 13-31 describes the clinical reasoning creased sensation who are being treated with the princi-
process followed for deciding on the type and style of ples of LLPS, must be monitored continually by thera-
splint to fabricate. pists, nursing staff, and family members to assess for skin
 Chapter 13 • Splinting Applications 347

• Support full palmar surface.

• Progress material beyond distal palmar crease.
y
vit • Support first metacarpal with material over thenar eminence.
a cti
• Mold into palmar surface.
cle ion
mus unct
f
No No
• Roll material below distal palmar crease if volitional flexion is noted.
Return of
Palmar support • Roll material to clear thenar eminence if active thumb range of
function
Ex motion is noted.
mu ce
scl ssiv
ea e
ctiv • Support full palmar surface for biomechanical alignment.
ity
• Progress palmar support material distally into a finger platform if
muscle relaxation cannot be achieved by proximal realignment.

• Support in neutral deviation.

ty
t ivi • Support in neutral rotation.
ac • Splint in 0 degrees to 20 degrees of extension.
c le tion
s c
mu fun
No No • Remove splint during functional activities to encourage active use.
Return of (Splint may continue to be effective during transitional movements
Wrist support and rest periods to prevent poor positioning resulting in overstretched
function
E extensors and to prevent injury [i.e., if neglect is present].)
mu xce
scl ssiv
ea e • Build up splint’s lateral surface (at fifth metacarpal) to block
ctiv
ity ulnar deviation.
• Position in neutral rotation.
• Splint in 0 degrees to 20 degrees of extension (based on position that
relaxes digits).
• Initially fabricate splint in slight wrist fiexion if goal is contracture reduction
(e.g., serial splinting).
• Do not overstretch flexors. Prevent “clawing” out of splint.

• Ideally, leave fingers free to encourage self-maintenance of range and

maximize sensory input.
y
vit • Evaluate for contracture risk: arthritic changes, neglect, impaired attention.
a cti
If risks are present, a finger platform may be required at night to
cle ion
mus unct maintain soft-tissue length and joint play.
f
No No
Return of • Leave fingers free to engage in functional tasks during waking hours.
Finger support
function • Finger platform may be required at night if patient’s flexor activity
Ex is dominant.
mu ce
scl ssiv
ea e • Attempt relaxation of fingers by proximal realignment (e.g., of wrist
ctiv
ity or palm). If relaxation occurs, leave fingers free for self-ranging.
• If flexor activity persists, use a finger platform during the night.

• Support thumb between palmar/radial abduction by palmar support at

y
vit the first metacarpal.
a cti
cle ion • Maintain web space.
m us unct
f
No No
Return of
Thumb support • Roll back palmar surface to allow maximum thumb mobility.
function
E
mu xce
scl ssiv
ea e
ctiv
ity • Maintain thumb in position of palmar/radial abduction and thumb
interphalangeal extension; this position may enhance relaxation.

Figure 13-31 Fabrication decisions: clinical reasoning. A volar-based forearm trough that
supports two thirds of the forearm with sides parallel to the radius and ulna serves as the base
splint in this decision-making process.
348 Stroke Rehabilitation

REVIEW QUESTIONS
1. What is the normal resting posture of the hand? What
are the common malalignments observed after a
stroke?
2. What precautions should be followed when splinting a
patient after stroke?
3. What is the recommended rationale for splinting the
patient after stroke?
4. How does the therapist differentiate among intrinsic
Figure 13-32 Multi Podus Phase II System (Restorative Care tightness, extrinsic tightness, and joint contracture
of America). This orthosis allows the ankle to be positioned in- when evaluating for a splint?
crementally towards neutral. The total range is from 40 degrees 5. What are the advantages of LLPS versus high-load
of plantar flexion to 10 degrees of dorsiflexion. brief stretch?

REFERENCES
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18. Hunter JM, Mackin E, Callahan A: Rehabilitation of the hand: surgery
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20. Kapandji IA: In The physiology of the joints, ed 5, Upper limb, vol 1, 36. Neeman RL, Neeman M: Rehabilitation of a post stroke patient
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29. Malick MH: Manual on static hand splinting, ed 5, Pittsburgh, 1985, 46. Stockmeyer S: An interpretation of the approach of Rood to the treat-
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32. McPherson JJ, Kreimeyer D, Aalderks M, et al: A comparison of 49. Tyson SF, Kent RM: Orthotic devices after stroke and other non-
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33. Neeman RL, Liederhouse JJ, Neeman M: A multidisciplinary effi- 50. Wilson D, Caldwell C: Central control insufficiency. III. Disturbed
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34. Neeman RL, Neeman M: Efficacy of orthokinetic orthotics for 51. Woodson AM: Proposal for splinting the adult hemiplegic hand to
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35. Neeman RL, Neeman M: Orthokinetic orthoses: clinical efficacy 52. Wu SH: A belly gutter splint for proximal interphalangeal joint
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 l es l i e a. kan e
k aren a. bu ckl ey

chapter 14

Functional Mobility

key terms
bed mobility scooting transitional movements
environmental conditions task-specific training trunk control
mobility transfers upright function

chapter objectives
After completing this chapter, the reader will be able to accomplish the following:
1. Recognize the impact of impairment on mobility tasks.
2. Analyze specific movement patterns observed during mobility tasks and common
compensatory strategies.
3. Use a function-based approach to retraining mobility patterns.
4. Understand the impact of environmental changes on mobility tasks.
5. Understand how to structure the environment to promote learning of mobility tasks.
6. Understand how to use specific strategies to promote learning of mobility tasks.
7. Understand fall risks.

TERMINOLOGY
a wheelchair to a car, and involves varied methods of
Many terms have been used in occupational therapy prac- achievement.
tice to describe an individual’s ability to change the posi-
tion of the body in space and move within the environ- OVERVIEW OF THE LITERATURE
ment. Mobility broadly refers to movements that result in
a change of body position or location. The term bed mobil- Within the literature, numerous studies have carefully
ity has been used interchangeably with gross mobility examined mobility functions of the adult in relation to
within the rehabilitation setting and traditionally has in- gait and locomotion. Unfortunately, few studies have ex-
cluded tasks such as rolling to both sides, rolling to side amined functional mobility tasks. The analysis of the
lying, moving from a sitting to a supine position and vice normal sit-to-stand sequence of movement has received
versa, and moving from sitting to standing. Transfer refers attention and is reviewed later in this chapter.19,20,30,82,83
to movement from one surface to another such as from a Rising from bed has been examined in relation to age
bed to a wheelchair, from a wheelchair to a toilet, or from differences and the most common movement strategies

350
 Chapter 14 • Functional Mobility 351

selected.36 This research demonstrates that age-related which these areas are addressed may be limited by time
trends occur across the life span, but great variety remains constraints imposed by the venue of treatment. Clinicians
evident in the selection of specific movement strategies. A working within an acute care setting often emphasize ba-
limitation of this study is that the oldest age group exam- sic bed mobility tasks to prepare the patient for indepen-
ined was the 50- to 59-year-old group; thus, information dence in grooming, bathing, and dressing activities (see
concerning older adults most at risk for stroke was not Chapter 1). Within a rehabilitation setting, occupational
included. A study of normal adult rolling patterns also has therapists may have the opportunity to approach func-
shown that adults exhibit great variability in the selection tional mobility more comprehensively in relation to more
of movement patterns. In addition, the authors of this advanced tasks such as community mobility and tasks re-
study have noted indications that a developmental se- lated to specific work and home-management require-
quence of movement patterns exists but is not inclusive of ments. The occupational therapist determines goals of
all individuals. Clearly many aspects of functional mobil- treatment with the patient, contingent on imminent and
ity still warrant further investigation.91 future plans to resume responsibility for activities de-
manding advanced mobility.
FUNCTIONAL MOBILITY: RELATIONSHIP The task-related approach of occupational therapy to
TO ACTIVITIES AND PARTICIPATION intervention to improve functional mobility is consistent
with present motor learning research emphasizing the im-
Occupational therapists have always approached func- portant role environment plays in the organization of move-
tional mobility from the perspective that individual ele- ment to solve motor problems (see Chapters 4 to 6).10,39
ments involved in changing the position of the body were Impairments of body functions and structures and per-
necessary to achieve competency in broad areas of occu- formance skills have been used to assess abilities in the
pation. Improvement in activities of daily living (ADL), patient with hemiplegia. Each patient has different
instrumental activities of daily living (IADL), education, strengths, abilities, and impairments that affect the per-
work, play, leisure, and social participation has always formance of functional mobility. A patient may have
been the ultimate goal of occupational therapy. The strong neuromusculoskeletal and movement-related func-
American Occupational Therapy Association, in “Practice tions but demonstrate significant impairment in mental
Framework: Domain and Process,” describes functional functions of sequencing complex movements (e.g.,
mobility as “moving from one position or place to another apraxia). Alternately, a patient may have several problems
(during performance of everyday activities), such as in- affecting the neuromusculoskeletal system, including de-
bed mobility, wheelchair mobility, transfers (wheelchair, creased alignment and postural stability that interfere
bed, car, tub, toilet, tub/shower, chair, floor). Performing with the ability to roll efficiently toward the nonaffected
functional ambulation and transporting objects.”4 side. Nevertheless, such a patient may demonstrate the
Within the Practice Framework, functional mobility is ability to learn new strategies to sequence movement to
presented as a separate activity category of basic ADL, in accomplish the task.
which mobility functions occur relative to taking care of
one’s own body. INFLUENCE OF CONTEXTUAL FACTORS
Alternatively, in the International Classification of Func- ON FUNCTIONAL MOBILITY
tioning, Disability and Health, the World Health Organiza-
tion presents mobility as a separate domain under the Contextual factors represent a variety of interrelated con-
broader category of Activities and Participation. Mobility ditions and situations that may influence an individual’s
“is about moving by changing body position or location or ability to become proficient in performing mobility tasks.
by transferring from one place to another, by occupying, Personal and environmental factors affect the patient with
moving or manipulating objects, by walking, running or hemiplegia and may support or impede performance.
climbing, and by using various forms of transportation.”97 Personal factors are unique to the individual’s life and
In this more global perspective, mobility is presented living situation and influence the selection of mobility
as much more than a function of personal self-care. Mo- interventions. The occupational therapist considers fac-
bility is viewed as essential to enabling an individual to tors such as age, gender, race, and social background.
engage in a full range of life areas and is central to en- When considering the age of an individual who has
abling the individual to participate in life situations. sustained a stroke and assessing expectations of the poten-
In planning comprehensive treatment programs, the tial for functional mobility, the therapist must use caution.
occupational therapist should be mindful that functional Many factors besides age contribute to the differences in
mobility is not just relevant to performing self-care tasks the abilities older adults exhibit in functional mobility.
but is necessary to permit engagement in education, work The reader is encouraged to explore the literature exam-
opportunities, community life, recreation, leisure, reli- ining the effect of aging on postural control and life span
gious pursuits, and domestic life. In practice, the extent to mobility.
352 Stroke Rehabilitation

Certainly the patient’s stage in the life cycle more the current motor learning literature. The postural ad-
clearly guides assessment and interventions in the consid- justments necessary to roll and come to a seated position
eration of overall mobility needs. The young patient with to engage in self-care tasks can be learned only in the
hemiplegia who attends college has specific mobility context of task performance1,21 and in the expected envi-
needs. Sit-to-stand movements must be accomplished in ronment.39,40
changing environments and under varying conditions. The treatment of a patient with hemiplegia often oc-
For example, using public transportation, which may be curs on a continuum from acute care through community
moving or stationary; rising from a low seat at a football reintegration. Many treatment environments impose con-
stadium; sitting down in a crowded and darkened movie straints that limit the therapist’s interventions. For exam-
theater; and getting into a truck present different chal- ple, in intensive care unit settings, therapists must con-
lenges. These mobility tasks are not unique to young tend with multiple lines, monitors, and alarms (see
persons, however. The retired person who enjoys travel- Chapter 1). Ideally the relearning of motor skills and tasks
ing frequently and visiting family members also has spe- should occur in the actual environment in which the task
cial mobility needs. will be performed.22,69
Social and cultural variations also have an effect on the Societal environmental factors directly influence the
success of functional mobility interventions. The thera- patient’s ability to resume participation in IADL and in-
pist must consider culturally derived boundaries of inter- clude systems within the community or society that can
action,57 because the therapist must frequently work assist the individual to resume an active lifestyle outside of
within an intimate distance during mobility retraining.43 one’s immediate living situation.
The physical environment in which interventions occur
also affects the patient’s willingness to participate ac- FUNCTIONAL MOBILITY: THE OUTCOME
tively. Some patients prefer treatment to occur in the OF MULTIPLE PROCESSES
privacy of their hospital rooms, whereas others are more
comfortable with these “close encounters” occurring in Functional mobility requires the successful interaction of
the open space of a therapeutic gymnasium. The patient, a number of systems. Carrying out skilled rolling, sitting,
family, significant individuals, and therapist have percep- and standing does not depend solely on the integrity of
tions and beliefs founded on their cultural conditionings. the neuromusculoskeletal system. Occupational therapists
Similarities and differences of belief may occur in three must be mindful of the interdependence of various sen-
areas influencing the success of functional mobility re- sory, perceptual, and cognitive functions in the execution
training: the perceived state of health and illness, the of these tasks and create evaluation tools that respect this
perceived relevance of therapeutic interventions, and the relationship, such as the Árnadóttir Occupational Ther-
belief that functional mobility is relevant to resuming apy Neurobehavioral Evaluation (see Chapter 18).This
previous occupations.60 awareness ensures more comprehensive assessment than
The therapist’s ability to listen to personal needs and do evaluations that look at motor behaviors in isolation.
appreciate individual values helps ensure success.60 The Occupational therapists’ knowledge and expertise in task
degree of independence a patient finds acceptable must be analysis render them uniquely qualified to evaluate and
self-determined. The therapist must remember that cul- plan treatment to improve functional mobility skills while
tural variations influence patient participation and suc- keeping all the patient’s needs in mind.
cessful outcomes of home programs.4,60,65 Individual differences and variations in movement
Environmental factors are external to the individual strategies may be related to factors such as the patient’s
and are considered at two levels, individual and societal. build (short, tall, obese, thin) and performance patterns
Individual environmental factors include the immediate before the stroke (i.e., the patient was a trained athlete,
environment of the individual, which can be viewed as the dancer, physically inactive, occasional exerciser, or
hospital or clinical venue, and the natural environments. physical laborer). Additionally, each patient presents
Environment determines a patient’s function. The patient with individual habits, routines, and roles that influ-
with hemiplegia may be able to roll to either side and ence movement.29 The psychological state may indeed
come to a seated position on a mat or plinth within the be reflected in movement (e.g., inhibitions or lack
clinical setting and engage in donning and doffing of up- thereof and reactive depression about the current situ-
per extremity clothing. However, in bed within a home ation). Pain from preexisting conditions or pain as
setting, the patient may not be able to roll as efficiently or secondary impairment to the stroke may affect move-
come to a seated position without some assistance. ment patterns. These individual differences and their
Grooming and dressing tasks may not be practical be- effects on functional mobility have been explored in the
cause of changes in the height and firmness of the sup- literature.91 The occupational therapist must be cogni-
porting surface. These occurrences and the reasons un- zant of these factors and others in assessment and treat-
derlying the performance deficits are well-represented in ment planning.
 Chapter 14 • Functional Mobility 353

IMPAIRMENT OF BODY FUNCTIONS for locomotion that can be applied to all functional mobil-
AND STRUCTURES AND SKILLS ity tasks:
1. Progression or movement in a desired direction
Many sequelae associated with a stroke impede perfor- 2. The ability to stabilize the body against the forces
mance of functional mobility tasks. The occupational of gravity
therapist uses basic knowledge of body functions and 3. The ability to make changes in movement in rela-
structures, performance skills, and impairments as a means tion to specific tasks within different environments
to organize assessment of an individual’s capacity for func- This view of functional mobility is congruent to a systems
tional mobility. The following table summarizes impair- approach for analyzing and explaining normal movement,
ments resulting from stroke and their effects on perfor- which emphasizes the interaction of the individual, task,
mance of functional mobility skills (Table 14-1). and environment.84

FUNCTIONAL MOBILITY TASKS ACTIVITIES IN THE SUPINE POSITION

Functional mobility tasks occur throughout the daily rou- The performance of supine activities is often associated
tine under varying circumstances within changeable envi- with the acute stages of the rehabilitation process. Bridg-
ronments. Each task requires the individual to stabilize ing, rolling, and movement from side lying-to-sit are ba-
the body in space or exhibit dynamic postural control. sic functional mobility tasks that are necessary to the
Das and McCollum27 identified three major requirements provision of nursing care and movement of the client

Table 14-1
Managing Impairments that Affect Functional Mobility
IMPAIRMENTS OBSERVED
DURING TREATMENT SUGGESTED STRATEGIES/INSTRUCTIONS

Reduced visual field Teach compensation by reinforcing head-turning during functional mobility
tasks. See Chapter 16.
Reduced perceptual processing Anticipate that patients may misperceive distance between themselves and
supporting surfaces. Help the patient to reappraise distances prior to moving.
See Chapter 16.
Reduced arousal Arousal can vary over the course of the day. Monitor for optimal state of arousal
to determine when treatment should be carried out. Observe for signs of
diminishing arousal during therapy. See Chapter 19.
Reduced attention Work in distraction-free environments. Use patient’s room prior to using the
therapy rooms. Gradually introduce stimuli into treatment as the patient
tolerates. See Chapter 19.
Reduced awareness of impairments Heighten awareness of impairments. Engage patients before they attempt the
activity as to how they feel they can execute the activity; posttask ask the
patients for feedback on performance; consider use of videotaped feedback.
See Chapter 19.
Unilateral inattention Increase attention to the affected side and engage extremities wherever possible.
See Chapter 19.
Reduced learning Use “Show” versus “Tell” when teaching functional mobility tasks.
Reduced problem-solving May manifest in novel situations; offer varying practice conditions (i.e., rolling
on a mat or in a bed with sheets and a blanket) to provide opportunities to
develop strategies for solving movement challenges.
Reduced language/communication Avoid speaking in a loud voice. Give the patient ample time to respond.
Observe the patient for signs of fatigue or anxiety. Encourage self-expression
through gestures, if necessary. If the patient has comprehension problems, ask
simple, short questions and augment verbal with pantomime and gestures. Use
tactile cueing. See Chapter 20.
Reduced pragmatics Minimize distractions. Use demonstration and do not rely on self-report.
Provide feedback on statements irrelevant to the situation.
Reduced motor planning Use tactile-kinesthetic cues. Keep environment and context appropriate to task.
See Chapter 19.
354 Stroke Rehabilitation

from a bed to a wheelchair. However, these mobility se- Patient attempts to place the affected leg usually result in
quences are also important in enabling the client to par- a mass pattern of movement characterized by hip flexion
ticipate in a wide range of life areas. For example, consider and external rotation and supination of the foot. The pa-
the individual who chooses to lie on a beach to enjoy the tient’s inability to stabilize the pelvis while attempting this
sun and surf. The soft surface of the sand may require the movement results in increased extension of the lumbar
individual to assume a bridge position to shift his or her spine combined with forced extension of the nonaffected
position if rolling is inadequate. Supine activities require side into the supporting surface. Another possible reason
the individual to gain control of flexor and extensor pat- for the increase in the extension of the lumbar spine is
terns of the trunk, which can be viewed as a prerequisite tightness of the hip flexors,86 although this is unlikely in
for more advanced trunk positions. the early stages after stroke unless the patient exhibited
tightness before sustaining the stroke.
Bridging The therapist can assist the patient to assume the
Analysis of Movement. In the functional mobility task of crook-lying position. The therapist encourages the pa-
bridging, the back and hip extensors support the body tient to assist with active flexion of the unaffected leg and
against the forces of gravity. The arch formed when the may be required to assist and hold the required crook-
upper back and feet are in contact with the supporting lying position. Active flexion on the affected leg helps
surface is maintained by the activation of muscles located position the pelvis forward and may promote active hold-
on the underside of the arch. Use of the arms or legs in- ing of the affected leg in a flexed position.53 The therapist
creases the demands placed on the trunk musculature. may provide downward pressure on the flexed knee of the
When an arm or leg is raised (as in attempts to dress), the affected side to ensure appropriate foot placement.13
muscles located above the arch (the oblique abdominal Active bridging can be used to improve selective ex-
muscles) must become active to support the limb.28 tension of the hip and abdominal muscle activity. As the
patient lifts the buttocks from the supporting surface,
Selected Problems. The mobility task of bridging is a the therapist should make sure the patient does not use
challenge for patients with hemiplegia because of loss of excessive extensor activity, which is characterized by ex-
activity in the extensors and the abdominal muscles. This tension of the hips, overarching of the back, and pushing
problem, when combined with early return of extensor of the head into the supporting surface. To improve se-
activity, results in ineffective and inefficient movement lective movement, the therapist encourages the patient
patterns. to initiate the movement by actively tilting the pelvis
Observations in supine indicating decreased abdominal upward. The therapist may need to prepare the patient
activity include the following: for this movement (Fig. 14-1). After tilting the pelvis
■ Outward flaring of the ribcage (that is, the affected forward, the patient lifts the buttocks off the surface
side rides higher in the cavity because the abdominal while holding the pelvis level. The therapist may assist
muscles do not tether the ribcage downward) this movement by placing one hand under the hemiple-
■ Shortening of the neck resulting from unopposed gic hip and one hand on the abdominals. If the feet are
elevation of the shoulder girdle
■ Hypotonic appearance of the abdomen
■ Shift of the umbilicus to the nonaffected side
■ Reduced proximal stability effecting the lower ex-
tremities
■ Difficulty moving or maintaining the position of the
lower extremity due to reduced proximal stability

Treatment Strategies. Bridging is an important position

that the patient should be instructed to assume early in
the intervention process. Bridging is a mobility function
necessary for the use of a bedpan, reduction of pressure
on the buttocks, and movement within the bed (bed
scooting).53
The patient with hemiplegia may have trouble in as-
suming the crook-lying position and forming a bridge Figure 14-1 In bridging, one should avoid increased extensor
because of a variety of underlying causes. The lack of se- activity that results in arching of the back. To assist with selec-
lective muscle activity on the affected side, caused by the tive movement of the pelvis, the therapist cues the gluteal region
use of mass patterns, prevents the patient from combining and the lower abdominals. This sequence may be applied first to
the necessary hip components of flexion and adduction.13 the unaffected side and then to the hemiplegic side.
 Chapter 14 • Functional Mobility 355

positioned close to the body, the therapist also may

guide the femoral condyles forward toward the feet
while applying downward pressure (Fig. 14-2).
After the patient can maintain this position, the next
step is to lift the unaffected foot off the surface while
maintaining the pelvis level. The therapist should observe
any asymmetries or rotation of the pelvis. The therapist
must not permit the patient to drop the unaffected side to
gain more stability. This task is difficult for the patient
with hemiplegia because it places demands on the oblique
abdominal muscles22,29,86 and the other weakened core
trunk muscles. Bridging can be graded according to the
patient’s ability to control movements selectively. Place-
ment of the feet further away from the buttocks requires
a greater degree of selective activity to maintain knee
flexion with hip extension.29 Alternate lifting of the feet
Figure 14-3 Lifting a leg off the supporting surface places in-
off the supporting surface while maintaining the level of
creased demands on the abdominal muscles because the pelvis
the pelvis requires increased muscular activity and greater
must be held up. The therapist asks the patient to lift the unaf-
coordination (Figs. 14-3 and 14-4).86
fected foot off the bed so that all the patient’s weight is placed
Bridging can be used to move up in bed and don pants
on the affected side. The patient must maintain the pelvis in a
while in a supine position. Therapists should instruct
level position. This patient is experiencing difficulty maintaining
caregivers in the appropriate techniques to ensure that
the optimal pelvic position (left hemiplegia).

Figure 14-4 This patient has less difficulty in lifting the

hemiplegic side (left hemiplegia).

these movements are transferred into the patient’s daily

life routine. The occupational therapist can incorporate
B
these movement strategies while training the patient in
Figure 14-2 A, As the patient gains selective control over the self-care activities.
pelvis, the therapist can provide downward pressure through
the knees and guide the femoral condyles forward toward the Rolling
feet. B, The therapist asks the patient to lift the buttocks off the Analysis of Movement. Rolling is an important part of
bed. Physical assistance can be diminished as the patient gains bed mobility and an essential part of many other tasks.
control. Research has demonstrated that normal adults use a
356 Stroke Rehabilitation

variety of movement strategies to roll from supine to Rolling to the Hemiplegic Side: Selected Problems and
prone.72 Treatment Strategies. The patient with hemiplegia fre-
One of the most common movement strategies used by quently rolls over using an extensor pattern to initiate
young adults in rolling from supine to prone includes a the movement sequence because of lack of flexor control
lift-and-reach arm pattern. Movement of the head and of the trunk and the early return of extensor activity.
trunk is initiated by the shoulder girdle; a unilateral lift of The patient relies on the unaffected side to push against
the leg also occurs. Rotation of the spine, which results in the supporting surface, resulting in an arching of the
dissociation of the shoulder and pelvic girdles, is not ob- axial spine as the body is thrust forward in the direction
served (Fig. 14-5).72 This rotation was once assumed a of the roll.
prerequisite to attaining the ability to roll in a normal pat- Davies28 suggested that rolling activities can be used to
tern of movement.13 promote active flexion of the trunk and achieve subse-
The most important finding of this study72 is that quent improvement in active control of the trunk muscu-
normal adults have a repertoire of movements available lature. The need exists balance the concentric and eccen-
to them, unlike patients after stroke, who are limited to tric contractions of the trunk muscles in proportion to the
stereotypical patterns of movement.26 The environ- change in force exerted by gravity as the patient changes
mental conditions of this study were limited to rolling position.
on an exercise mat, and the subjects were asked to roll The hemiplegic arm requires protection before rolling
“as fast as you can.” Thus, the variety of patterns ob- to the affected side is practiced. The therapist can provide
served may relate to the temporal demands and implied this protection by prepositioning the arm, assisting the
goal of the task. The strategies used to roll for speed patient in bringing the shoulder and arm forward, and
may differ significantly from the strategies used to tar- giving physical support to the hemiplegic arm while
get a particular object in the environment. Therapists standing on the affected side.
who work with patients with hemiplegia must consider The patient is encouraged to lift the unaffected arm
the rolling surface (environment), the goal of changing and leg up and forward across the body; this movement is
the position of the body while supine, and future mo- consistent with the pattern identified by Richter, Van
bility goals such as attaining supine-to-sit. Thus, thera- Sant, and Newton.72 This movement should occur with-
pists must determine movement sequences most suit- out the patient pushing against the supporting surface
able for ensuring safety and achieving the goal of the with the unaffected foot (Fig. 14-6). The patient may re-
movement. Rotation of the spine during rolling is just peat this movement by returning to the supine position. A
one strategy that may be useful in providing a greater part of or the whole leg should be held in abduction and
variety of movement possibilities for the patient with slowly lowered to the surface as the patient returns to the
hemiplegia.22,28,29 supine position.

Figure 14-5 Research has determined that a common form of rolling observed in adults is
initiated by a lift-and-reach above shoulder level; the shoulder girdle leads the movement, and
a unilateral lift of the lower extremity follows. Many subjects also use a unilateral push of the
lower extremity. A great variety of patterns is observed because of individual differences in build
and strength and in the support surface.
 Chapter 14 • Functional Mobility 357

Figure 14-7 Rolling toward the unaffected side. The patient

should avoid using the back extensors to bring the lower ex-
tremity forward while neglecting the hemiplegic arm (left
Figure 14-6 Rolling toward the hemiplegic side (left hemiplegia)
hemiplegia).
is accomplished by lifting the unaffected leg over the hemiplegic
side without pushing off the bed surface. The therapist assists with
movement of the shoulder and pelvic girdles.

As the patient gains control of this movement se-

quence, the next step is to lift the head from the surface to
assist with initiation of movement. As the patient turns,
the head is rotated toward the direction of the movement.
Throughout the sequence, physical assistance should de-
crease as changes in the patient’s ability to control move-
ment occur.

Rolling to the Unaffected Side: Selected Problems and

Treatment Strategies. Rolling to the unaffected side may
be more difficult for the patient with hemiplegia. The
movement is frequently initiated by an extensor pattern
that includes extension of the head, neck, and back. The Figure 14-8 Early in the rehabilitation process, the therapists
patient relies on extension of the back to bring the hemi- instructs the patient with left hemiplegia to use the stronger
plegic leg over the trunk in a pattern of extension that hand to assist in bringing the shoulder forward; the therapist
may be viewed as an inefficient compensatory strategy. positions the hemiplegic leg in hip and knee flexion to avoid an
The affected arm may be left behind as the patient rolls extensor pattern.
(Fig. 14-7).29
When teaching patients to roll to the unaffected side,
the therapist’s goals are to decrease maladaptive compen- knee flexion, which decreases reliance on the extensor
satory strategies contributing to inefficient movement and compensatory pattern. An alternative method is to flex
to enhance more effective and efficient patterns of move- both legs to roll.13,29
ment. The patient may be instructed to use the stronger
arm (Fig. 14-8) to bring the hemiplegic arm up and for- Supine-to-Sit
ward while the therapist attempts verbally or physically to Analysis of Movement. The transitional movement from
cue the movement of the pelvis and lower extremity. The supine-to-sit may be achieved through a variety of move-
therapist supports the affected leg while assisting with ment strategies. Adults have a tendency to use a momen-
anterior movement of the pelvis (Fig. 14-9). tum strategy to achieve the goal (Fig. 14-10). Their move-
Repetition of this sequence may assist with learning. ments are smooth and efficient as they “bound” out of
The therapist encourages the patient to lift the affected bed, off the couch, or out of a chair. A momentum strat-
leg off the supporting surface and lower it slowly after egy requires forces within the trunk to be generated and
returning to the supine position. This strategy is used to transferred to the lower extremities to initiate the rolling
assist the patient in maintaining a slight degree of hip and sequence. Trunk muscles must contract concentrically to
358 Stroke Rehabilitation

this strategy. This method provides increased stability

because concentric and eccentric forces are required in
increments. Increased effort (force) must be used if mo-
mentum is lacking.20,22,29,72,81
Evidence exists to support that older adults use their
upper limbs to assist the trunk musculature when moving
from supine-to-sit.3 Thus, therapists need to consider the
movement strategies and positioning of the arms when
retraining the supine-to-sit sequence. A great variety of
movement possibilities to achieve a supine-to-sit sequence
remains. The described sequence often is used spontane-
ously by patients after stroke and by the therapists as a
method of instruction.22 This sequence is referred to as
side lying-to-sit for the remainder of this chapter.

Selected Problems. Movement from the side lying to

Figure 14-9 Assistance can be decreased as the patient gains
seated position becomes a challenge for the patient after
control of the movement. The therapist assists with knee flexion
stroke because of the combined effects of limited muscular
and protraction of the shoulder (left hemiplegia).
activity and maladaptive compensatory strategies. Patients
lack appropriate postural alignment and stability.22,28 The
lack of flexor control of the trunk and early return of ex-
initiate and propel the movement; eccentric muscle con- tensor activity interfere with the patient’s ability to grade
tractions provide control. The reciprocal shortening and concentric and eccentric muscle activity effectively relative
lengthening of muscle contractions provide maintained to the changing forces of gravity.28 If inadequate control of
stability. the trunk musculature is evident, the patient must rely on
Many older adults demonstrate a tendency to use a compensatory strategies that may include overuse of the
force control strategy (Fig. 14-11). The individual trans- unaffected arm or leg or exaggerated use of head move-
fers forces from one body part to another as graduated ments. The patient applies these compensatory strategies
changes in position occur. Rolling to side lying, then instead of effective lateral movements of the neck and
pushing up with the upper extremities, and swinging the trunk. When side lying, the patient flexes the head forward
lower extremities over the side of the bed is an example of instead of laterally and uses the unaffected arm to move

Figure 14-10 The most common movement strategy used by adults to get out of bed relies
on momentum. Strategies vary greatly.
 Chapter 14 • Functional Mobility 359

Figure 14-11 A force control strategy for getting out of bed has the individual performing the
task in two parts: the patient moves from supine to side lying and then pushes to a seated posi-
tion. This strategy is useful for patients who exhibit reduced stability functions.

the body away from the supporting surface. The forward the patient first learns to control movement into gravity
movement of the head may be a compensatory strategy to using eccentric muscle activity.28 The physical environ-
shift the center of gravity forward. The patient may be ment and the patient’s premorbid preferences for move-
unable to combine lateral flexion and extension of the ment sequences also may influence the methods selected.
trunk because of lack of selective muscle activity. Hooking Patients may benefit from learning more than one method
of the unaffected leg under the affected leg to lift and to move more effectively in different environments.
lower the leg over the side of the bed is yet another com-
pensatory strategy many patients are instructed to per- Side Lying-to-Sit Toward the Affected Side. The thera-
form. This strategy prevents selective movement of the pist assists the patient in lifting the hemiplegic leg over
pelvis in an anterior and lateral direction.22,28 The patient the side of the bed; the head, neck, and upper thorax are
with hemiplegia experiences difficulty whether rising from brought forward, requiring the neck to flex laterally.
the hemiplegic or the unaffected side because of the prob- Concurrently the nonaffected arm must be brought
lems presented. across the body and placed on the bed. The unaffected
Additionally, while changing positions, the patient may leg also must be lifted over the side of the bed as the
not exhibit appropriate head-righting responses; this defi- patient pushes down with the hand. The movement of
cit requires the patient to flex the neck laterally while the unaffected leg as the patient simultaneously pushes
controlling eccentric muscle activity on the opposite side. with the hand adds a momentum strategy to this move-
Furthermore, the patient also may be unable to move or ment sequence; the weight of the leg assists the patient
place the affected limbs appropriately in preparation for in attaining a seated posture. The therapist may need to
transitional movement or may neglect the affected limbs assist with bringing the unaffected shoulder forward
entirely. over the base of support of the body. The therapist may
place hands on the shoulder and pelvic girdle to give
Treatment Strategies. Many methods are suggested to support and to assist with movement of the unaffected
retrain the patient in the supine-to-sit movement se- leg (Fig. 14-12). As the patient gains some control over
quence. One method suggests that patients with hemiple- this movement, the therapist may provide support to just
gia be taught initially to roll toward the affected side to the unaffected shoulder and pelvis (Fig. 14-13). The
decrease the amount of effort required and to reduce mal- therapist can use verbal cues or downward pressure on
adaptive strategies such as pulling and pushing to achieve the shoulder physically to cue lateral flexion of the trunk
the seated position.22 Others suggest that the patient with and appropriate head righting. To reverse this sequence,
hemiplegia be instructed to rise from both sides early in the patient may require assistance with lifting the hemi-
treatment to prevent associated reactions.12,28,29 Another plegic leg onto the bed. Care should be directed toward
option is for the patient to start the movement sitting maintaining the hemiplegic shoulder in a forward posi-
upright and learn to lie down first. This method may de- tion as the patient turns and lowers the body to the bed
crease the force gravity exerts on the trunk musculature as surface.28
360 Stroke Rehabilitation

Figure 14-12 The therapist uses one arm around the patient’s Figure 14-14 Propping of the affected upper extremity as the
shoulders while the other hand provides downward pressure to patient prepares to assume the seated position. The therapist is
the pelvis to assist with weight transfer in movement to a seated assisting with lateral flexion of the unaffected side while observing
position (left hemiplegia). for appropriate head and trunk alignment on the affected side.

example; however, the placement of the therapist’s hands

to assist movement changes. The therapist should in-
struct the patient to lift the affected arm while lifting the
unaffected leg over the side of the bed. The therapist as-
sists with movement of the affected leg forward and over
the edge of the bed as the patient lifts the head, neck, and
upper thorax over the sound arm (Fig. 14-15). The

Figure 14-13 When the patient is able to control the trunk

muscles actively, the therapist can decrease assistance. The
therapist may cue lateral flexion of the head and trunk by pro-
viding downward pressure to the shoulder and pelvic girdles of
the unaffected side.

When assuming a sitting position from the affected

side, the patient is active in the trunk, particularly while
bearing weight on the affected upper extremity; therapists
should be mindful of this. Furthermore, the therapist may
have to cue movement of the trunk on both sides to pro-
mote the correct sequence of lateral flexion and extension
responses (Fig. 14-14).

Side Lying-to-Sit Toward the Unaffected Side. The Figure 14-15 Rising from the unaffected side. For patients
sequence of movement in side lying-to-sit toward the who require significant support, the therapist places one hand
unaffected side remains the same as that in the previous on the scapula while assisting with movement of the legs.
 Chapter 14 • Functional Mobility 361

therapist needs to ensure that the hemiplegic shoulder Analysis of Movement

remains in a forward position as the patient begins to
push down with the unaffected side. A movement se- For controlled movement in sitting the ability to bear and
quence that begins as a force control strategy can with shift weight anteriorly, posteriorly, laterally, and in a ro-
increased motor control of the head, neck, and trunk tary pattern must be present. This suggests that the con-
become a momentum strategy. centric and eccentric abilities of the trunk flexors and ex-
Patients demonstrating a lack of lateral flexion of the tensors and the ability to activate these muscle groups
neck require preparatory interventions. The patient selectively relative to the task demand must be present.
should be positioned side lying on the unaffected side For example, for controlled anterior weight shift through
with the head on the bed (Fig. 14-16, A). The patient the pelvis, the need for concentric contraction of the low
lifts the head with the therapist’s assistance as needed back extensors and an associated eccentric contraction of
(Fig. 14-16, B). The therapist then asks the patient to the trunk flexors (abdominals) is evident. In a posterior
lower the head to the bed; this movement requires ec- weight shift through the pelvis, the need for concentric
centric contraction of the lateral flexors. This maneuver contraction of the trunk flexors and an associated eccen-
is followed by active lifting of the head, which requires tric contraction of the trunk extensors is evident. With
concentric muscle contractions. The therapist should lateral weight shift through the pelvis the trunk extensors
not permit the patient to rotate or flex forward while and flexors work together concentrically (shortening) on
performing this task. A visual target such as an alarm the nonweight-bearing side and eccentrically (lengthen-
clock, television, or family picture may assist in estab- ing) on the weight-bearing side.13 During trunk rotation,
lishing this task-related goal.22 the primary muscles involved are the oblique muscles.
Additional interventions to promote lateral flexion
and extension of the trunk, which are necessary to per- Selected Problems
form side lying-to-sit, are described in the section on The trunk is crucial in postural control. Many patients
sitting. display difficulty with voluntary trunk control in sitting
following the stroke. Messier and colleagues63 looked at
ACTIVITIES IN SITTING trunk flexion in sitting poststroke and noted decreased
displacement of the center of pressure and lower extrem-
The ability to maintain a seated position and perform ity weight-bearing through the feet. They felt that this
ADL safely and efficiently is a goal many occupational was probably indicative of minimal anterior tilt of the
therapists seek with their patients (see Chapter 7). In the pelvis, and most of the trunk motion initiating from the
acute stages after stroke, the therapist should begin to upper trunk.63
work on control of sitting and standing with the patient as There is electromyography (EMG) evidence to support
soon as possible to promote the ability to manage the alterations in trunk muscle activity following stroke. Trunk
upright position and increase overall visual input in func- velocity during flexion and extension is lower following
tional positions.22 stroke compared to normal subjects.33 With the addition of

A B
Figure 14-16 A, To encourage active control of the lateral neck muscles, the patient first
learns to control eccentric contraction while lowering the head to the bed. B, This is followed
by active lateral neck flexion while raising the head.
362 Stroke Rehabilitation

voluntary arm and leg movements, there is delayed onset of muscle and activate it. However, the patients themselves
contraction and reduced activation of paretic trunk mus- must use these gains immediately particularly in the
cles.33 In contrast to Dickstein and associates’ findings, context of a functional activity; otherwise, carryover is
Winzeler-Mercay and Mudie96 found that muscle activity doubtful (Figs. 14-17 and 14-18).
in the paretic rectus abdominis and erector spinae follow-
ing stroke were the same as normal subjects during forward
and backward voluntary sway and reaching, but for the task
of donning the shoes, the rectus abdominus showed re-
duced activity. The erector spinae activation was much
higher in the stroke group during all postural activities.96
The therapist must begin an assessment on functional
capabilities in this area by close examination of the patient’s
ability to control movements in sitting (see Chapter 7). A
full appreciation of the normal ranges of motion (ROMs)
within the spine is useful when comparing patients with
hemiplegia and the patterns they use with the normal
population. The therapist must be cognizant that these
ranges decrease with age; ascertaining the baseline from
which these patients were operating before the onset of
hemiparesis is important. Mohr64 emphasized the impor- A
tance of establishing a patient’s ROM in spinal extension
and flexion, lateral flexion, and rotation before treatment
is implemented. This provides the therapist with informa-
tion needed to decide whether interventions should in-
clude increasing ranges in these areas with the goal of
promoting activation by the patient in these patterns for
function. Davies28 also recommended this approach. For
example, passive mobilization of the lumbar spine for lat-
eral flexion may be an important preparatory treatment to
working on increased trunk control in activities requiring
a lateral weight shift such as side lying-to-sit. The thera-
pist, having encouraged increased mobility in this plane,
can progress to facilitation of the appropriate muscle con- B
tractions needed to hold and move into this position by
Figure 14-17 A, Reaching for toast combines patterns of trunk
placing the hand in the patient’s axilla and assisting the side
lateral flexion and extension. B, Using the right affected arm to bear
to lengthen while placing the other hand on the patient’s
weight on the armrest results in scapula depression, which contrib-
opposite trunk to guide shortening on that side. Con-
utes to the shortening of the trunk muscles on the right side.
versely, many clinicians with a motor learning perspective
suggest that the therapist set up the environment to create
a natural situation that places increased demand on trunk
muscles for function.
A deeper look at the location of movement and the way
it is initiated is necessary before proceeding in evaluation.
Mohr64 provided guidance by categorizing trunk move-
ments in sitting by dividing them into movements initi-
ated from the upper trunk versus the lower trunk. Mohr
further analyzed anterior, lateral, and posterior weight
shifts in each of these categories and then provided func-
tional examples for each movement pattern.

Functional Activities in Sitting

Task-oriented functional practice must follow all
“preparatory” trunk activity such as mobilization. Fol-
lowing hands-on treatment, one hopefully will see gains Figure 14-18 A pet therapy dog is used to encourage trunk
in passive mobility or the patient’s ability to “find” the flexion and weight-bearing on the affected left arm and leg.
 Chapter 14 • Functional Mobility 363

Gentile37 proposed two distinct processes that mediate as donning and doffing pants in a seated position. From a
skill learning: an explicit process and an implicit process. mobility perspective, it allows the individual to approach
In the explicit process, patients consciously involve them- the edge of a supporting surface to transfer.
selves with shaping the movements to achieve a specific
goal. In the implicit process, the main concern is the Selected Problems. As indicated previously, problems with
dynamic of force generation, which is not under the con- passive restriction in the trunk and the inability to activate
scious control of the patient. Implicit processes rely on trunk muscles selectively are of primary concern with this
the interplay of muscle contractions against the passive activity and may preclude the appropriate balance reac-
components affected by gravity and joint torques. Gen- tions needed for success and safety. The patient must have
tile suggested that for the explicit process to occur, thera- intact skin on the buttocks to practice scooting.
pists can use information consciously available to the
patient and provide coaching such as around how a Treatment Strategies. Verbal or physical cueing to assist
movement is organized and features in the environment. patients with scooting can be accomplished in a variety of
For implicit learning to occur, therapists must challenge ways, depending on the level of involvement of the indi-
themselves creatively to set up the environment to elicit vidual. The therapist may elicit the desired movement
a response from the patient that produces force genera- pattern through a series of contacts in which the therapist
tion as a byproduct of the functional activity in which first cues a lateral weight shift and then places the hand on
they are engaged. Clearly, the therapist must set up op- the patient’s pelvis to cue forward advancing of the hip on
portunities for practice for the greatest benefit to occur the nonweight-bearing side.12 The therapist then changes
to the learner. hands to cue forward movement of the opposite buttock
Dean and Shepherd30 designed a study specifically to (Fig. 14-19). Patients with more profound physical in-
look at the efficacy of task-related training, which proves volvement may require added assistance by the therapist,
to be an excellent example of using explicit and implicit particularly in advancing the buttock (Fig. 14-20).
learning processes in treatment. Their intent was to in-
crease the distance stroke patients could perform forward Transfers
reach in sitting and to note the contribution of the affected Analysis of Movement. The ability to move from a given
lower limb to support and balance in this activity. Twenty surface to an adjacent surface safely and efficiently is a
subjects were used in this study, and they had to be a primary goal in treatment for many of the patients with
minimum of one year poststroke. They were randomized whom occupational therapists work. This maneuver re-
into two groups—an experimental group that received quires enough forward flexion of the trunk over the feet
treatment involving reaching forward for natural objects to allow the individual to pivot about the feet and sit on
beyond arm’s length (in a gradual progression) and a con- the nearby surface.
trol group that received sham training with cognitive tasks
within arm’s length. EMG, videotaping, and two force Selected Problems. Patients with neglect who attempt to
plates (to evaluate the amount of lower extremity force transfer often succeed in transporting only half the body
generated during the activity and sit-to-stand) were used onto the supporting surface. Additionally, the left foot
before and after training to gain objective measures. After may be neglected, and the patient may be oblivious to
training, subjects were capable of reaching farther and proper left foot placement before transferring.
faster, suggesting that the affected lower limb was assisting Many patients require considerable help to maintain a
more in support. Furthermore, the researchers noted that flat foot on the floor. This may be because of unilateral
subjects demonstrated improved force generation of the inattention, poor sensation on the affected side, shortened
affected lower limb in sit-to-stand. The explicit learning trunk muscles resulting in asymmetrical sitting, and short-
process subjects were engaged in was demonstrated by the ening of the calf muscles on the affected side.
problem-solving and practicing of forward reaching far-
ther and farther. The implicit learning process was activat- Treatment Strategies. Bobath12 and Davies29 described the
ing the lower extremity in the process.30,37 anterior weight shift that can be facilitated through contact
on the patient’s pelvis or scapulae. Carr and Shepherd22
Scooting recognized the same forward weight shift and encouraged
Analysis of Movement. Scooting, or “butt walking,” in- patients to move the shoulders forward during active
volves the transfer of weight over first one buttock and participation in transfers (Fig. 14-21). All four therapists
then the other, creating overall movement of the body described ways the therapist may use manual contact to
anteriorly in a seated position.12 Appropriate elongation the knee to draw the knee forward and encourage weight-
of the trunk on the weight-bearing side and shortening on bearing on the hemiplegic side.
the nonweight-bearing side is required. This movement Patients have varying degrees of motor control for this
pattern is useful for a number of functional activities such activity. The therapist needs to create an environment in
364 Stroke Rehabilitation

B C
Figure 14-19 Scooting is an important skill for moving to the edge of a bed or seat and can
be a useful movement pattern in activity of daily living tasks such as donning pants in a seated
position. A, The patient begins in symmetrical sitting. B, The therapist can encourage scooting
by first cueing a lateral weight shift and then advancing the nonweight-bearing buttock to move
anteriorly (C).

which the patient has enough guarding by the therapist from one surface to another. As the patient gains greater
to make training safe and enough “room” to try to make strength and control over balance, the therapist may re-
the transfer with as little assistance as possible. This is duce this level of assistance to a lighter hold around the
not always easy to do, and some patients inevitably re- pelvis and then the scapula.
quire much assistance to transfer. However, the more the Patients tend to be taught stand-pivot or modified
patient can be encouraged to do, the more the patient stand-pivot (sit-pivot) transfers. Many therapists train
learns during the session. Consistent grading of the level stand-pivot transfers for the presumed benefits they afford
of assistance a patient requires (i.e., minimal, moderate, in getting the patient into an upright position and putting
or maximal) is important in measuring progress and com- full weight on the involved lower extremity. However,
municating to other staff members the amount of help these transfers do not resemble the maneuvers performed
required by the patient to carry out the task. by normal subjects in moving from one surface to the other
In the initial stages of transfer training, a patient may (i.e., coming to a full stand or turning and sitting down on
require maximal assistance, and the therapist may need to an adjacent surface). As Shumway-Cook and Woollacott84
clasp both hands around the pelvis to pivot the patient pointed out, stand-pivot transfers may be more difficult
 Chapter 14 • Functional Mobility 365

Figure 14-20 Patients requiring a more direct contact to scoot

can be guided first by the therapist to advance the buttock.

Figure 14-22 Foot placement prior to transfer.

activities. The therapist may position both knees around

the patient’s affected knee physically to assist a forward
weight shift onto the lower extremity and to guard against
buckling at the patient’s knee. For patients requiring less
cueing and guarding, the therapist may assist the knee by
placing a hand on the patient’s distal femur and gently
pulling anteriorly and then down toward the floor as the
patient takes weight on the leg.
The role of the arms in this training process has be-
come controversial. Bobath12 and Davies29 supported
using clasped hands in front of the body to facilitate a
forward weight shift, placing the arms on a stool, chair,
or other supporting surface. However, a study by Carr
and Gentile19 examined the role of the upper extremi-
Figure 14-21 To teach a patient to perform a squat-pivot ties in sit-to-stand and determined that “fixing” the
transfer, the therapist should encourage the appropriate amount arms (by holding a rod as subjects in the study did) had
of anterior weight shift by instructing the patient to move the a tendency to cause an increase in what was described as
shoulders forward. extension force (the force needed by the lower extremi-
ties to extend the body into an upright position) and a
decrease in momentum of the body during sit-to-stand;
because they do not allow the patient to use a momentum this determination may have implications for transfers.
strategy; the need to come to a stand instead of pivoting The authors advocated that patients work on increasing
blocks the benefits the momentum strategy provides. When strength in the lower extremities (particularly in exten-
training pivot transfers, foot placement is important. One sion) to enhance functioning in sit-to-stand. They con-
foot is slightly in front of the other at the outset and is tended that although patients tend to use the hands to
adjacent to the surface to which the patient is moving push down on the armrests of a chair to stand or alter-
(Fig. 14-22). With environmental constraints or more ad- natively swing the arms forward to assist horizontal and
vanced patients, a stand-and-step transfer may be used. vertical propulsion of the body mass, these strategies
Promoting weight shift onto the affected lower ex- cannot be used in varying environmental conditions19
tremity is important during transfers and sit-to-stand (Figs. 14-23 to 14-27).
366 Stroke Rehabilitation

B C
Figure 14-23 A, Use of a grab bar can encourage a forward weight shift in a transfer requiring
greater physical assistance. B, Positioning and proper handling can be difficult with space con-
straints. This requires problem-solving for the therapist, patient, and caregiver. C, While this
patient may require moderate physical assistance to perform the transfer, he is actively encour-
aged to use the movements he is capable of in the transfer, in this case, thoracic extension.

A study by Gillen and Wasserman40 analyzed how alter- Sixty-four percent of patients were inconsistent with the
ing the environmental context of a transfer activity af- same transfer task between the two environments, while
fected mobility performance in patients receiving inpatient 36% of the patients transferred consistently in the two
rehabilitation. They compared performance in transfers environments, as per the FIM data. Therapists asked to
carried out in a traditional clinic setting and in a more provide FIM data early in the inpatient rehabilitation stay
naturalistic apartment-like setting. Twenty-five partici- must never assume that performance in the clinic equals
pants carried out four transfer tasks in each environment: performance in other environments.
two bedside commode transfers and two bed-to-chair
transfers. The Functional Independence Measure (FIM) Sit-to-Stand
was used to provide the level of assistance required in Analysis of Movement. Sit-to-stand can be divided into
transfers. different phases, depending on the description of the re-
Their findings revealed that environment plays a role in searcher (Fig. 14-28). Shepherd and Gentile82 described
mobility performance. Forty-four percent of the patients sit-to-stand using the terms preextension phase, a phase char-
performed better in the traditional clinic setting. Twenty acterized by the beginning of the movement to the position
percent performed better in the simulated apartment. in which the thighs are off the surface; and extension phase,
 Chapter 14 • Functional Mobility 367

the phase from the thighs-off position through the end of

movement (full stand). Shenkman and colleagues81 de-
scribed four phases in sit-to-stand (Fig. 14-29). Phase 1
(Fig. 14-30, A) is referred to as the flexion momentum
phase and is used to generate the initial momentum for ris-
ing. During this phase, the center of mass is within the base
of support, and eccentric contractions of the erector spinae
are required to control forward motion of the trunk. Phase 2
(Fig. 14-30, B) begins as the individual leaves the chair seat
and ends at maximal ankle dorsiflexion. Forward momen-
tum of the upper body is transferred to forward and upward
momentum of the total body. The center of mass now
moves from within the base of support of the chair to the
feet. By definition, the phase is unstable and requires co-
Figure 14-24 A typical short sliding board and a Beasy board. activation of hip and knee extensors. Phase 3 (Fig. 14-30, C)
These devices can be used to assist patients who have greater is an extension phase during which the body rises to its
physical needs.

B C
Figure 14-25 A, Early practice with car transfers may take place using a simulated car in the
clinic and where possible should progress to an actual vehicle. B, Controlled descent into gravity
requires coactivation of the abdominal muscles (flexors) and back extensors to avoid injury in a
constrained space. C, The patient is shown how to manage the affected leg during the transfer.
368 Stroke Rehabilitation

B C
Figure 14-26 A to C, Sequence of transfer to tub bench.

full upright position by expansion of the hips and knees. position (with the ankle in approximately 75 degrees
The stability requirements are not as great as in phase 2 of dorsiflexion).
because the center of mass is well within the base of support 2. Initiating active trunk flexion from the erect posi-
of the feet. Phase 4 (Fig. 14-30, D) is a stabilization phase tion and encouraging the individual to swing the
in which complete extension of the hips and knees occurs. trunk forward at a reasonable speed allows for the
Regardless of the way researchers divide the task, an ap- greatest generation of extension force in the lower
preciation of the biomechanics of this movement pattern is limbs to raise the body vertically.
crucial in training and in understanding potential problems 3. Increased velocity of trunk flexion facilitates exten-
that occur in hemiplegia. sor force in the lower limbs.
Carr and Shepherd20 outlined key factors that influence 4. Constraint of the arms (as in holding the hemiplegic
the way sit-to-stand is executed in normal individuals. The arm forward while attempting sit-to-stand) results
therapist must consider the role of foot position, the start- in increased time producing sufficient lower limb
ing position of the trunk, the speed of movement, and the extensor forces to stand.
role of the upper limbs in balance and propulsion. Carr Janssen, Bussman, and Stam51 reviewed key factors affect-
and Shepherd stated that: ing sit-to-stand by searching the literature for the most
1. Sit-to-stand is accomplished most easily when the frequently mentioned determinants, and they found that
initial starting position of the foot is in a posterior chair height, use of armrests, and foot position significantly
 Chapter 14 • Functional Mobility 369

B C

D E
Figure 14-27 A, Teaching the patient and caregiver how to get up safely from the floor is
important before discharge to the community. B, The therapist instructs this patient with
right-sided weakness to assume a side-sitting position on the left arm and hip. C, The thera-
pist or caregiver assists the patient at the pelvis to assume weight on his knees. She uses a
surface immediately in front of the patient to allow for arm support. D, The patient now is
supported fully on his hands and knees. She prepares him for the next stage by asking him
to shift his weight to his left. E, When the patient shifts weight over to the left knee, he is
able to move his weaker right leg into a half-kneeling position. Continued
370 Stroke Rehabilitation

F G
Figure 14-27, cont’d F, From the half-kneeling position the patient assumes a standing posi-
tion and begins to shift his weight to sit on the adjacent surface. G, The patient is seated safely.

Figure 14-28 Sit-to-stand viewed laterally.

influence the ability to carry out sit-to-stand. Use of a

higher chair resulted in decreased movements needed at
the knee and hip, while using armrests reduced the move-
ments needed at the hip. Repositioning the feet from ante-
rior to posterior reduced the maximum mean extension
movements at the hip.

Selected Problems. As mentioned in the previous section,

patients may have difficulty maintaining their feet flat on
the floor because of poor sensation, unilateral inattention,
or shortening of the trunk and calf muscles.
Difficulties with spatial relations and praxis have been
noted during transfer training, regardless of whether the
therapist is training the patient for pivot transfers or sit-
to-stand. Certain patients lean backward instead of for-
ward while the therapist is attempting to transfer. These
patients’ actions are unpredictable and often run counter
Figure 14-29 Sit-to-stand viewed anteriorly. to those expected after instruction from the therapist.
 Chapter 14 • Functional Mobility 371

A B

C D
Figure 14-30 A, Phase 1 of sit-to-stand. B, Phase 2 of sit-to-stand. C, Phase 3 of sit-to-stand.
D, Phase 4 of sit-to-stand.

As Arnadottir6 noted, transfers also reveal problems with certain tasks such as transfers, sit-to-stand, and am-
with organizing and sequencing and conditions such as bulation. These patients tend to collapse midway through
ideational apraxia. These problems may become evident the task, sometimes without warning, and reduced muscle
when a patient attempting to rise from bed omits the ap- strength, per se, does not appear to be the cause. Imper-
propriate steps of handling the bedclothes in preparation sistence, in most studies, has been found to correlate more
to transfer (see Chapter 18). with right-hemisphere lesions than with left-hemisphere
Motor impersistence, a term first introduced by Fisher35 lesions.35,54
to describe failure to persist at various tasks such as eye The manner in which the sit-to-stand movement pat-
closure, breath holding, conjugate gaze, and tongue pro- tern is executed may reveal who is at risk for falls.
trusion may explain some patients’ inabilities to persevere Cheng and colleagues23 found that when comparing
372 Stroke Rehabilitation

stroke survivors who had a history of falls against stroke Because getting the feet back and under in sit-to-stand
survivors who had no history of falls, the differences is so important, training patients to move to the edge of
were clear in measurable parameters such as body the supporting surface is necessary for optimal foot place-
weight distribution. Stroke patients with a history of ment. This enables forward flexion of the trunk and
falls executed the task of sit-to-stand asymmetrically, movement of the center of mass over the base of support.
taking much more weight on their sound side.23 This A patient who attempts to stand without appropriate foot
suggests that, certainly from the point of view of safety placement will encounter difficulty (Fig. 14-35).
concerns, stroke survivors need as many opportunities Normal subjects frequently use a momentum strategy
as possible to develop better control of their affected in mobility skills as a way to move with less energy re-
lower limbs in sit-to-stand. quirements and hence with greater efficiency. Momentum
strategy is used frequently in rising from bed, and no ces-
Treatment Strategies. Bobath12 described the need to sation of movement occurs. The momentum strategy can
begin training patients in sit-to-stand from a high seat be used in a modified way with appropriate patients who
(Fig. 14-31, A), progressing gradually to lower seats or a have sustained a stroke, because it allows them to use the
plinth (Fig. 14-31, B). Similarly, the environment can be force generated by forward flexion to take them into an
used to change the demands required to transition from upright position. They then need adequate stability when
sit to stand (Fig. 14-32). Other studies have substantiated their thighs are off the supporting surface to prevent them
her assertion, including the conclusion that high-surface from falling forward. Momentum provides the patient
chairs can decrease significantly the joint ROMs needed with a strategy to move but by definition requires in-
at the hip and knee and the strength requirements to lift creased control of stability functions. Patients with poor
the body.18,85 trunk control or significant cognitive impairments are not
Verbal or physical cues may be required to promote candidates for using such a strategy. When introducing
appropriate weight-bearing on the affected lower the momentum strategy in therapy, the therapist must
extremity as recommended for transfer training. In adequately guard the patient to prevent a possible fall.
Fig. 14-33, the therapist’s assistance provides much Practicing forward reach while sitting appears to im-
stability for the patient. In Fig. 14-34, the therapist prove the ability of the affected foot to accept weight
needs only to cue the patient through the distal femur and improves weight-bearing in sit-to-stand activities.30
to get the desired response. These were Dean and Shepherd’s30 conclusions from

A B
Figure 14-31 A, During the initial stages of learning, patients may find standing from a high
surface easier. Among other things this provides the patient with a feeling of success. B, The
patient can attempt lower surfaces after becoming more skillful. Varying the surfaces from
which patients practice standing is important to promote learning and enables the patient to
cope with varying situations that arise in the real world.
 Chapter 14 • Functional Mobility 373

A B C

D E F
Figure 14-32 A-F, Training sit-to-stand and transfers using a variety of functional seating
surfaces.

their study using individuals who were at least one year designed by Dean and Shepherd.30 Participants in the
poststroke. Dean and colleagues31 have since looked at control group completed a sham sitting training proto-
the effects of sitting training in the acute stages follow- col involving cognitive manipulative tasks.
ing a stroke. In this study, the researchers provided a Sitting ability, the main outcome measure, was signifi-
two-week sitting training protocol that improved sitting cantly improved as measured by the average maximum
ability as measured by distances reached and quality as reach distance during forward and across reaches, com-
measured by reaching performance. They also explored pared with the control group. In addition, the quality of
whether the two-week sitting training protocol benefited reach improved in the experimental group, as evidenced
patients’ ability to stand up and walk, and they further by use of the standardized “reach to grasp and drink from
examined if any gains were maintained six months fol- a glass” task in forward and across directions. The carry-
lowing training. This study was set up as a randomized over to standing up was evident, but not to walking, and
placebo-controlled clinical trial (CCT) involving six ex- there was some evidence of effectiveness of the interven-
perimental and six control group subjects, all having tions six months later.31
sustained a stroke in under three months. Participants in The operative word for improving sit-to-stand perfor-
the experimental group received the training protocol mance appears to be practice. A randomized controlled
374 Stroke Rehabilitation

B C
Figure 14-33 A, The therapist promotes weight bearing on the patient’s affected lower ex-
tremity in sit-to-stand by placing the knees around the patient’s affected knee, drawing the
patient forward (B), and discouraging “buckling” when the patient achieves the standing posi-
tion (C).

study by Britton and colleagues16 looked at the amount of weekdays for two weeks (in addition to their rehabilitation
practice that could be carried out by a physical therapy program) while the members of the control group re-
assistant in 30 minutes a day over a two-week period in a ceived upper extremity therapy.
stroke rehabilitation unit and its potential effects on sit- Results showed that the provision of 30 minutes of
to-stand. Eighteen patients all requiring supervision in practicing sit-to-stand resulted in a mean of 50 stands per
sit-to-stand were divided evenly into experimental and day above what was practiced in the routine rehabilitation
control groups. The experimental group practiced sit-to- program. The researchers noted a significant mean differ-
stand and leg strengthening exercises for 30 minutes on ence of 10% body weight taken through the affected foot
 Chapter 14 • Functional Mobility 375

A B
Figure 14-34 Patients with greater motor control still may require some cueing to equalize
the weight-bearing between the lower extremities if they have a tendency to stand up using
their unaffected side more than the other. A, The therapist places a hand on the distal femur of
the affected lower extremity, draws the knee anteriorly, and then applies downward pressure as
the patient comes to stand (B).

after one week of the program. In addition, the control

group showed reduced weight through the affected leg
while the experimental group showed increased weight on
the affected leg.16 The findings of this study indicate that
rehabilitation practitioners need to provide as many op-
portunities as possible for practicing newly acquired skills.
This will require creative solutions and reassessment of
current models of treatment delivery.

ACTIVITIES IN STANDING
Analysis of Movement
The ability to stand is a goal many patients with hemiple-
gia want to achieve because the drive to be upright is
strong. Patients should be provided the opportunity to
practice standing and shifting their centers of gravity in all
directions and reaching for functional objects in the envi-
ronment. The trunk responses needed for controlled sit-
ting (i.e., selective lengthening and shortening depending
on the requirements of the task) also are needed for con-
trolled standing; however, these trunk responses are car-
ried out over a much narrower base of support.

Selected Problems
Figure 14-35 Foot placement is important in sit-to-stand. Standing may prove challenging for patients with severe
Note how far forward this individual’s feet are as he attempts to hemiplegia who have only one side of the body available
stand. to use for movement; moving with one half of the body is
376 Stroke Rehabilitation

stressful work. The slow, laborious effort of standing and

attempting to move in this position causes an increase in
posturing and skeletal muscle activity. Movements often
are lacking in spontaneity and must occur at a conscious
level for the patient. Postural deviations noted in sitting in
these patients become even more exaggerated in standing.
For example, the patient who tends to “fix” the upper
limb to stay upright while sitting will present with greater
fixation of the upper limb when challenged in the stand-
ing position.
Studies have shown that the role of the paretic leg typi-
cally reflects its contribution in compensatory strategies,
rather than in the restoration of support functions and
equilibrium reactions.32,73 This speaks to the need to train
weight-bearing over the affected leg in reaching and sit-
to-stand activities as mentioned previously in this chapter.
Postural control performance in individuals with stroke
is affected by attentional tasks.9,73 This implies a high degree
of cognitive vigilance on the part of the patient to maintain
balance, and whenever there is a demand on cognitive sys-
tems, there may be a risk for losing postural control.

Treatment Strategies
As stated previously, standing as early as possible if medi-
cal clearance is permitted is ideal for patients. Standing
helps increase the patient’s level of arousal and can be
motivating. Bobath,12 Davies,29 and Carr and Shepherd22 Figure 14-36 A wall can be a helpful starting place in teaching
emphasized the need to help the patient stand so that a patient to maintain a standing position. The wall can assist the
body segments are aligned properly and weight is ac- patient to achieve alignment of body parts in what can be a
cepted through the affected lower extremity. For some frightening position to assume. However, the wall does not sub-
patients, accomplishing this requires all of their attention stitute for the need to learn to stand and function in open space.
and energy. Therefore, the therapist should be mindful of
the need (at least initially) to train the patient to stand and
take weight on the affected lower extremity in a quiet, the pelvis (with one hand on each side) offers optimal
minimally distracting environment. This may be even control to guide the weight shift, and the therapist gradu-
more critical for patients with attention disorders mani- ally can taper the amount of guidance required as the pa-
festing as distractibility, impulsivity, and irritability with tient begins to activate more.
increased stimulation. As noted earlier, the therapist must Free-standing balance should be attempted as soon as
consider the need to incorporate competing stimuli into possible (see Chapter 8). Standing while simultaneously
therapy gradually; otherwise, the therapist cannot assert scanning the environment or having a conversation with
that functional balance has been achieved. the therapist is challenging and meaningful (Fig. 14-37).
Achieving weight shift in standing requires a substan- A progression to standing and reaching prepares the
tial amount of cueing by the therapist, because patients patient to be able to perform personal self-care and IADL
often are fearful of standing on the affected leg due to safely and efficiently in a standing position. The patient
reduced muscle strength, postural control, and sensation. needs to practice reaching in all directions in functional
Visual disturbances also may make standing a frightening environments (Fig. 14-38). As Carr and Shepherd22 out-
activity for the patient. lined, this should include reaching overhead, to the side,
Early in treatment, the use of a wall (Fig. 14-36) may backward, and down, progressing to unilateral and bilat-
be desirable to offer the patient substantial support; how- eral reaching to the floor. Task-specific training provides
ever, this should not be used to train functional reach in the patient with the opportunity to develop strategies to
standing, because postural muscle activity in the legs is solve problems encountered in standing.
reduced (with the help of the wall) when the patient A commonly held view about asymmetrical hemiparetic
makes an arm movement. A manually guided approach is gait is that it may be subject to amelioration by balance
useful to help the patient learn the desired end of the training emphasizing weight-bearing on the paretic lower
movement pattern. Contact by the therapist directly on extremity. However, a study by Winstein and colleagues,93
 Chapter 14 • Functional Mobility 377

with patients is important and should be practiced as of-

ten as sit-to-stand. Gaining control in sit-to-stand does
not translate to stand-to-sit.

Falls Prevention
It has been identified that falls in the elderly have been
associated with underlying precipitants, such as intrinsic
factors (related to physiological changes, pathological
conditions, and adverse medication effects) and situational
factors (length of stay in institutional settings, time of fall-
ing, and availability of caretakers).71 These factors apply
similarly to the stroke population as well.
Falling can be a major complication during stroke re-
habilitation. Nyberg and Gustafson67 studied the inci-
dences, characteristics, and consequences of falls in an
inpatient rehabilitation setting. They sampled 161 pa-
tients consecutively admitted for geriatric stroke rehabili-
tation. They found that 62 patients (39%) sustained a fall,
and 39 patients (24%) suffered more than one fall. Most
of these falls occurred during transfers or from sitting in
a wheelchair or some other type of furniture.
Nyberg and Gustafson67 further noted that extrinsic
factors (slips, trips, furniture moving, etc.) accounted for
17 falls (11%), while intrinsic factors were involved in 49
falls (32%). Intrinsic factors were specifically related to
impaired balance, motor issues such as the legs giving
Figure 14-37 The therapist cues weight shifting in standing
way, and cognitive impairments such as perceptual issues
while encouraging the patient to scan the environment. Stand-
and distraction or inattention. Six falls (4%) involved frac-
ing and looking around a room can prove challenging for pa-
tures or other serious injury. The authors concluded that
tients in the initial stages of learning to stand.
falls constitute a significant problem in stroke rehabilita-
tion, and fall prevention strategies must be developed and
incorporated into rehabilitation programs.67
in which hemiparetic subjects received specific balance It appears that fear of falling in stroke patients has a
training with a specially designed feedback device, revealed relationship to a history of earlier falls and functional
that balance in standing may be improved, but no carry- characteristics of these individuals, as noted by a study
over into a more symmetrical gait pattern occurs. This conducted by Andersson and colleagues.5 The study in-
suggests that skill acquisition has a task-specific nature, cluded 140 patients who had been treated in a stroke unit
and therapists cannot assume progress achieved in one skill during a 12-month period. The Falls Efficacy Scale,
area can be carried over or transferred to another. This Swedish version (FES-S) and tests of motor ability, func-
finding calls into question many commonly held beliefs tional mobility, and balance were used to evaluate factors
about the use of developmental progression to increase contributing to fear of falling. In univariate analysis, there
functional capabilities in upright positions. was a significant association between increased age, fe-
Sit-to-stand and stand-to-sit may be the same in cer- male sex, previous falls, visual and cognitive impairment,
tain basic ways. However, the key differences have impli- low mood, and impaired physical functioning with low
cations for treatment. First, movement duration has been fall-related self-efficacy. In multivariate analysis, only a
found to be longer in stand-to-sit than in sit-to-stand.56,83 history of previous falls and physical function remained
In stand-to-sit, lower limb extensors are working in a significant. Fear of falling was associated significantly with
flexed position and execute the task by eccentric (length- poor physical function and previous falls. The findings in
ening) rather than concentric (shortening) the way they this study support the importance of offering fall preven-
do in sit-to-stand. Controlling the descent is a difficult tion programs to stroke survivors, whether they have
task for muscles with compromised strength, and cer- sustained a fall or not.5
tainly in the initial stages following stroke, many patients This study raises the important topic of excess disability.
with hemiplegia sit by letting go and almost collapsing Excess disability is defined as the restriction of ADL be-
into a seated position, rather than executing a smooth, yond that which the person is physically and cognitively
controlled descent into a seat. Practicing stand-to-sit capable of performing. This concept has been gaining
 A

B C

D E
Figure 14-38 Training for weight shifting and reaching in standing should occur within a
functional context because task-specific training is most beneficial to the learner. Reaching up
(A), forward (B), backward (C), reaching down (D), and toward the floor (E). These patterns
are among the many patterns of movement the patient should practice within functional ac-
tivities. Occupational therapists are uniquely qualified with their expertise in task analysis to
train patients to perform basic and instrumental activities of daily living.
 Chapter 14 • Functional Mobility 379

increased attention in the public health literature over the ADJUNCT TECHNIQUES TO ENHANCE SKILL
past few decades. ACQUISITION
Even among the general aging population, there is
evidence of excess disability created by the fear of falling. Feedback
Yardley and Smith98 explored feared consequences of fall- Patients rely on feedback for performance of all mobility
ing with over 200 community-living people over the age tasks. For example, before initiating a transfer, a patient
of 75 years. Their findings showed many individuals had uses visual information about the appropriate position of
a loss of functional independence and damage to their the limbs before movement begins. As the patient begins
identities from the fear of falling. Fears were correlated to rise from the seated position, the somatosensory system
with avoidance of activity (after adjusting for age, sex, and provides information about the forces exerted and the
recent falling history) and predicted further avoidance in ongoing changes in limb position. On completion of this
activity months later.98 task, the results of the sequence provide additional feed-
Lach58 reported that having two or more falls, feeling back. The patient uses the feedback given to gain a sense
unsteady, and reporting fair or poor health status were of how it felt to rise to a standing position. Was it effi-
independent risk factors for developing fear of falling. cient? Was it difficult? This information gained during or
Bruce and colleagues17 saw that fear of falling is common after the mobility sequence is termed movement-produced
in healthy, high-functioning older women and is indepen- feedback.78
dently associated with reduced levels of participation in As discussed in Chapter 5, feedback is divided into two
recreational physical activity. broad categories: intrinsic and extrinsic (augmented). In-
It is clear that a program of falls prevention for stroke trinsic is information from the sensory systems while ex-
survivors, starting in the inpatient rehabilitation setting, trinsic (augmented) is information that supplements sen-
is important to help these individuals develop strategies sory information such as verbal directives provided by the
for dealing with changes in physical and cognitive func- therapist.78 For example, the therapist tells the patient to
tioning. These programs also have the potential to help “straighten your hips and stand tall,” as the patient rises to
address fear of falling that may exist whether or not the stand at a sink for grooming.
patients have actually fallen. Feedback is important to the rehabilitation process,
To date, there are no publicized randomized controlled and the therapist should carefully select the type of feed-
trials (RCTs) researching the effectiveness of falls preven- back provided, the amount, and the schedule. Feedback
tion strategies in stroke survivors. The Falls Prevention should be distinguished from encouragement, which fa-
After Stroke Survivors Return Home (FLASSH) study8 is cilitates continued participation of the patient in the mo-
an RCT seeking to evaluate stroke survivors now living at bility task. “Try more” or “Keep going!” are examples of
home, who have been discharged from inpatient rehabili- encouragement that recognize the patient’s effort. Forms
tation. The patients present at a high risk for falling and of feedback for coming to the stand position would
will participate in a multifactorial prevention program. In include: “Good job. You were able to stand at the sink”
the future, the results of this study will be important to (knowledge of results [KR]) or “Next time you need to
contributing to the evidence-based practice in fall preven- lean forward more before rising”(knowledge of perfor-
tion programs. mance [KP]). Gentile38,39 described two kinds of aug-
As of the writing of this chapter, there are a number of mented feedback that are illustrated in two examples:
web-based fall prevention resources available (Box 14-1). 1. Knowledge of results: defined as knowledge of in-
formation about the performer-environment inter-
action
Box 14-1 2. Knowledge of performance: defined as knowledge
of information about movement
Fall Prevention Websites
Gentile suggested that the demands of the task best dic-
National Center for Injury Prevention and Control, tate the most effective form of feedback. Activities that
CDC: Preventing Falls: How to Develop Community- can be characterized according to the taxonomy of tasks
Based Fall Prevention Programs for Older Adults: www. as closed and consistent motion tasks require information
cdc.gov/ncipc/preventingfalls/ about the movement to be transmitted from the instruc-
National Council on Aging, Center for Healthy Aging: tor to the learner. For example, when training a patient in
National Action Plan: www.healthyagingprograms.org/
rolling over in bed or achieving sit-to-stand from a wheel-
content/asp?sectionid⫽69
chair, the provision of feedback about placement of the
Creative Practices in Home Safety Assessment and
Modification Study: www.healthyagingprograms.org/content. extremities and maintenance of alignment is useful. Using
asp?sectionid⫽31&ElementID⫽568&FromSEarchResult⫽ Gentile’s taxonomy, tasks that can be categorized as open
creative and variable motionless tasks are performed under chang-
ing environmental conditions. These tasks require that
380 Stroke Rehabilitation

feedback to the learner should focus on directing atten- this would include the therapist who spontaneously says
tion to environmental factors that may influence selection “great job” when a patient performs a transfer just because
of movement strategies and patterns. For example, stand- he or she made it to the transfer surface, even though the
ing up while on a bus requires anticipation of the motion feet were not positioned correctly or the hips were not
of the bus, movement of persons in the immediate envi- adequately extended. This feedback may negatively affect
ronment, and consideration of changing space constraints. performance and learning. Patients may discount their own
See Chapter 5. abilities to assess performance and to identify errors be-
Almost all of the research investigating the efficacy cause of the powerful influence a therapist’s feedback can
of feedback has emphasized knowledge of results focus- have on shaping future efforts.
ing on the relative frequency and timing of delivery. Many therapists videotape patients to provide informa-
Winstein and Schmidt95 compared the performance of tion about performance and measure improvement in skill.
two groups and the frequency of feedback. In this study, This can prove useful, particularly with patients who may
one group received feedback on a fading schedule (50% lack awareness about their performance (see Chapter 19).
of the trials) while the other group received feedback on The use of videotape as a form of augmented feedback is
100% of the trials. The study found that during the not new to the rehabilitation process, but the increased
acquisition phase, the group receiving 100% frequency ease in taping with a wide variety of commercially available
had a slight advantage; however, it also found that the products has increased the viability. A videotape captures
group receiving 50% frequency performed better on a the client’s movement, features in the environment that
delayed retention test. The investigators proposed that are stable and do not change, and the everyday spontane-
the decreased KR provided to the 50% group encour- ous occurrences that require immediate adaptations. Vid-
aged development of alternative strategies, while the eotaping may be instrumental to assisting clients in devel-
group receiving 100% feedback may have come to rely oping flexible movement strategies that can solve the
too heavily on the KR. movement dilemmas encountered during participation in
In another study, Lavery and Suddon59 compared sum- routine tasks.
mary and immediate feedback and the effects on transfer of Research supports that just showing a video tape does
skills. The study explored the results of the schedule of not influence performance; it must be supplemented with
feedback and performance of three groups of subjects. One structured feedback by the clinician. Videotape has been
group received immediate feedback on every trial, a second used to improve awareness of performance and to assist
group received summary (at the end of a block of 20 trials), patients in identifying behaviors that impede performance
and a third group received both types of feedback. At the in clients exhibiting unilateral neglect. The therapist
end of the acquisition trials, the groups receiving feedback identifies salient features, provides verbal feedback during
after each trial (groups 1 and 3) performed better than review of the videotapes, and focuses the patient’s atten-
group 2. When groups were compared on a subsequent tion to details.87 Hodges, Chua, and Franks46 identified
transfer test where no feedback was provided, group 2’s that videotape may be used to augment the learning of
(summary feedback) performance was significantly better complex motor skills and may contribute to retention of
than groups 1 or 3. At first glance, summary feedback ap- these skills.
pears more effective than immediate feedback. Schmidt
and Lee78 suggested that the results indicate that immedi- Mental Practice
ate KR is detrimental to learning, based on the findings A substantial body of research suggests that mental prac-
that group 3, which received both immediate and summary, tice can improve learning of new motor skills in healthy
did not perform as well as group 2. They hypothesized that individuals and, as a result, has been getting increased at-
too much information and overreliance on the immediate tention in the rehabilitation literature.50 The past several
KR were disadvantageous to learning information. Alterna- years have seen an increase in research conducted on the
tively, summary KR encourages the subject to develop efficacy of mental practice with a stroke population.
strategies that are flexible and suitable to transfer. The find- Braun and colleagues14 conducted a systematic literature
ings of these two studies give cause for reflection on the search of studies published through August 2005. These
degree, frequency, and timing on when the therapist should included four RCTs, one CCT, two patient series, and
provide feedback during mobility training. Winstein92 pos- three case reports. The studies examined the use of four
ited that less information feedback creates an environment different mental practice strategies with most tasks in-
conducive to facilitating the learner to develop problem- volving mental rehearsal of arm movements. They noted
solving strategies. Information about movement and per- that studies were limited in size and determined that no
formance of mobility tasks should be precise and should definite conclusions could be made except that further
identify movements that are critical to efficiency and safety. research is needed for a clear definition of the content of
At all times, a therapist should avoid “liberal” use of feed- mental practice and standardized measurements of out-
back and inaccurate or untruthful feedback. An example of comes.14
 Chapter 14 • Functional Mobility 381

Braun and colleagues15 set out to provide a frame- EVALUATION TOOLS

work for integrating mental practice into therapy by
looking at the available evidence and theory. Drawing Many therapists perform a subjective assessment of func-
on sports literature and their own experiences, they tional mobility based on clinical observation. However, it is
described five steps to facilitate the patient’s imagery advantageous to use a recognized evaluation tool to support
capabilities: (1) assessing mental capacity to learn imag- the need for services, to document progress, and to assess
ery technique, (2) establishing the nature of mental treatment efficacy. Table 14-2 includes a list of relevant
practice, (3) teaching imagery technique, (4) embedding tools for evaluating mobility functions. Currently the only
and monitoring imagery technique, and (5) developing standardized evaluation for mobility skills is Carr and
self-generated treatments.15 Shepherd’s Motor Assessment Scale for Stroke Patients.20
This test assesses the following eight areas:
Manual Guidance 1. Supine to side lying
Manual guidance is a technique frequently used during 2. Supine to sitting over side of bed
the rehabilitation process, which is often described as as- 3. Balanced sitting
sisting the patient to “feel” the appropriate movement 4. Sitting to standing
pattern or to position the patient in a desired posture us- 5. Walking
ing physical handling techniques. The degree of manual 6. Upper arm function
guidance provided and when it is supplied remains a con- 7. Hand movements
troversial subject. Two types of manual guidance have 8. Advanced hand activities
been identified in the literature: passive movement and The advantages of the Motor Assessment Scale include
spatiotemporal constraint (physical restriction); both the following:
forms are often incorporated during mobility train- 1. It tests recovery specific for the patient recovering
ing.48,49,62 For example, during the mobility task of roll- from stroke.
ing toward the affected hemiplegic side, the paretic arm 2. It takes less time to administer and infringes little
is often passively moved and placed in a safe position on treatment time.
in preparation for the patient to move his or her body 3. It is simple to administer and has objective and clear
over the prepositioned arm. Another application of this descriptions of criteria for rating patients.
strategy occurs when a patient attempts to roll toward 4. It is sensitive to changes in patients’ motor recovery
the nonaffected side. The therapist passively moves the status and therefore is useful in describing patient
paretic arm up and across the body before the patient progress over time.
attempts to move the trunk. The passive movement of The FIM was developed by the Uniform Data System at
the arm is thought to serve as a “guide” for the patient to the State University of New York at Buffalo as a standard-
gain an understanding of what actions are necessary to ized way for professionals to evaluate patient progress re-
effectively roll (e.g., scapular protraction or flexion of the garding levels of assistance needed to perform personal
humerus). Likewise, spatial constraint is also used during self-care, functional mobility, communication, cognition,
retraining of many mobility tasks such as sit-to-stand and social interaction. Each area is graded on a scale of 1 to
or transfer training. A therapist may stabilize a part of a 7, with a score of 1 indicating total dependence and 7 indi-
limb while the patient attempts to control only part of cating complete independence. The areas of functional
the limb (limit the degrees of freedom). An example of mobility covered in this test include transfers to bed, chair,
spatial-restraint during the sit-to-stand sequence is when toilet, tub, locomotion, and stairs. This test is used in reha-
the therapist applies an external force to stabilize the foot bilitation centers across the United States and has been
on the floor, thus enabling the patient to optimally use found to have good to excellent reliability.41,42
any muscular activity generated by the quadriceps com- The Assessment of Motor and Process Skills is a stan-
bined with the extensor forces of the hip, knee, and ankle dardized test created by occupational therapists that si-
to rise vertically to the standing position. multaneously evaluates motor and process skills to pre-
The use of manual guidance during intervention dict effect on the ability to perform IADL. Such an
needs to occur with careful consideration of the research evaluation tool, if developed for functional mobility
findings that have identified significant concerns about skills, would prove invaluable for occupational therapists
the benefits or efficacy of the techniques.78,79 The litera- (see Chapter 21).
ture supports that guidance may be most effective during
the acquisition of motor skills, when the requirements ANTICIPATING CHANGING ENVIRONMENTS
and demands of the task are new to the learner. The
literature also recommends that therapists attempt to The ultimate goal of functional mobility retraining is to
integrate active practice trials with interspersed passive have the patient resume the roles and activities associated
guidance.94 with the lifestyle before the stroke. This goal presumes
382 Stroke Rehabilitation

Table 14-2
Tools for Evaluating Mobility Functions
ASSESSMENT/AUTHOR POPULATION/PURPOSE SOURCE/CONTACT

Activities-Specific Balance Adults with balance deficits: evaluate balance Contact: Anita Myers
Confidence Scale (ABC)70 confidence in daily activities. A 16-item scale Department of Health Studies
in a questionnaire format and Gerontology, University
of Waterloo, Waterloo, ON
N2L 3G1
Falls Efficacy Scale (FES) Elderly individuals in a community setting: survey
(1990)89 related to perceived self-confidence
connected to daily activities
Frenchay Activities Index47 Adults: to assess function in adults status
poststroke: ADL and IADL
Functional Independence Adults with various impairments: measures Uniform Data System for
Measure (FIM)41 functional status; reflects the impact of Medical Rehabilitation.
disability on the individual and on human 270 Northpointe Parkway,
and economical resources in the community. Suite 300, Amherst, NY 14228
18 activities, 13 with a motor emphasis re- (716) 817-7800
lated to self-care, 5 with a cognitive emphasis
involving communication
Home Falls and Accidents Adults at risk of falling: to identify environment
Screening Tool and functional safety at home
(HOME-FAST)61
Environment Checklist
Melville-Nelson Self-Care Adults in subacute rehabilitation and nursing http://hsc.utoledo.edu/allh/ot/
Assessment (SCA)66 homes: to assess self-care skills including bed melville.html
mobility, transfers, toileting, personal hy-
giene, and bathing
Morse Fall Scale (MFS) Adults with balance deficits: rapid and simple Contact: Janice M. Morse.
method of assessing a patient’s likelihood of Pennsylvania State University,
falling. Acute care hospital and long-term School of Nursing, 201 Health
inpatient settings and Human Development East,
University Park,
PA 16802-6508
Stroke Impact Scale (SIS), Adults: measures stroke recovery in 8 domains: Langdon Center on Aging.
(SIS-16)34 strength, hand function, mobility, ADL, University of Kansas Medical
emotion, memory, communication, and Center Mail Stop 1005, 3901
social participation Rainbow Boulevard, Kansas
City, KS 66160. (913) 588-1203
www2.kumc.edu/coa/SIS/
Stroke-Impact-Scale.htm
Timed Get Up and Go Adults with balance deficits
(TGUG)68
Tinnetti Balance Test of the Adults with balance deficits
Performance-Oriented
Assessment of Mobility
Problems
(Tinnetti)88
Trunk Control Test25 Adults with stroke: assess the motor impairment
in a patient who has had a stroke. Rolling,
balance in sitting, and sit up from lying
down
Westmead Home Safety Older adults at risk of falling: to identify fall
Assessment24 hazards in the home
 Chapter 14 • Functional Mobility 383

that patients need to transfer reacquired mobility skills to adequate stability of the trunk musculature because it may
environments unique to the individual lifestyle and par- facilitate independent performance.22 A momentum strat-
ticipation patterns. The treatment setting presents a pre- egy or a combination of momentum and force control
dictable environment in which the physical aspects of may be introduced if stability of the trunk is evident. Mo-
therapeutic equipment and furnishings remain unchanged mentum is more efficient, requires less muscular activity,
from one treatment session to another. The patient’s and approximates more normal-looking movement.
home environment also may be viewed as predictable be- Not all patients can achieve a momentum strategy, but
cause of the patient’s familiarity with the surroundings. many patients may attempt to do their own in the home
The physical layout and home furnishings change little environment, particularly if it was their preferred method
over time, even if home modifications are introduced. of movement before the stroke. Therapists need to an-
Nevertheless, therapists frequently observe problems as ticipate this possibility and explore momentum as an al-
the patient attempts to make the transition from the treat- ternative before discharge. Transition from a force control
ment setting to the home environment. Unexpected prob- to a momentum strategy requires simple, concise instruc-
lems occur within the closed home environment, and tion to move quickly without stopping the movement.
community-based activities challenge the individual’s abil- The therapist may use manual cues at the shoulder girdle
ity to solve newly encountered problems. The occupa- to ensure safety, and demonstration by the therapist is also
tional therapist is well-qualified to address these dilemmas helpful. The practice of momentum strategies also may
through task analysis of occupations and careful consider- prepare the patient to control movement during stressful
ation of the environmental contexts in which each task is life situations that occur unexpectedly and require quick
performed.75 The patient recovering from stroke is re- transitional movements.
quired to generalize and adapt mobility skills learned in
the clinic setting to meet the changing environmental Practice Conditions
demands encountered on discharge. This generalization To prepare the patient to resume the previous lifestyle,
and adaptation occurs through the interaction among the occupational therapist must consider carefully the
multiple systems: perceptual, cognitive, sensory, and mo- conditions under which practice takes place. The goal of
tor. This chapter previously presented specific strategies intervention is to maximize retention and transfer of ac-
for ameliorating performance impairments influencing quired skills to everyday life situations the patient will
functional mobility. These strategies should be incorpo- encounter.44 The therapist must increase the demands of
rated throughout the intervention process as a means to the learning context during practice to prepare the patient
attain generalization and encourage participation in life to respond to unpredictable events. Chapter 5 presented
situations or IADL on discharge. an overview of factors the therapist considers when struc-
turing the practice conditions in stroke rehabilitation.
Strategy Development The following are considerations specific to functional
The research examining normal movement sequences has mobility retraining.
found great variety in the movement patterns used to
perform each mobility task. A single pattern may be iden- Blocked and Random Practice. Blocked practice in func-
tified as occurring more frequently during rolling, al- tional mobility retraining is the rote practice of mobility
though many subjects use alternative patterns that are functions in sequence. For example, the patient initially
equally effective. Similarly, the methods described to re- practices rolling to the unaffected side, then to the af-
train patients to roll over also vary. No single correct fected side, and then to the seated position. Repetition of
strategy is available to achieve this mobility task. Strategy experiences and a degree of mastery must occur at each
development is more than learning to use a normal pat- level before the patient proceeds to the next level of skill.
tern of movement; it results from the patient’s exploration This method of structuring practice initially may assist
of movement possibilities in relation to tasks occurring in the patient in gaining proficiency during the practice ses-
different environments.84 Thus, the occupational thera- sion but is not effective in preparing the patient to engage
pist may use several methods of instruction while assisting in self-care tasks in which changes in the position of the
the patient in learning movement limitations and deter- body occur randomly in response to task requirements.
mining future mobility potentials.75,84 The two primary For example, the patient rolls to the left to reach for a
strategies for functional mobility include a force control brush on the table; it is just beyond reach. The patient
strategy and a momentum strategy.26 Early in the inter- rolls back to supine and assumes a bridge position, push-
vention process, patients may benefit from instruction in ing upward in bed. The patient then rolls again and is able
a force control strategy to prevent secondary impairments to grasp the brush. Random practice of mobility tasks
of fixations and resultant development of inappropriate improves learning, retention, and the ability to solve mo-
compensatory strategies.12,20,22,28,29 This method of in- tor problems encountered in life situations.80 Schmidt76
struction also is preferred for patients who do not have recommended that randomized practice be incorporated
384 Stroke Rehabilitation

throughout the intervention process. Mobility tasks

should be interspersed with other tasks such as ADL
training in which the patient must make transitional
movements in a natural context. The trial-and-error ex-
ploration of functional mobility in this context initially
may prove difficult for the patient. Progress may be slow,
and the therapist may be tempted to instruct the patient
in a single movement strategy to speed progress. Varying
the practice conditions increases the contextual interfer-
ence, facilitating generalization as the patient relies on
multiple processes and promoting the development of
versatile motor strategies.52,90
Schmidt noted one exception in which a part-to-whole
method of practice may be beneficial. Early in the inter-
vention process, when the patient is acquiring founda- Figure 14-39 Requiring the patient to roll in response to the
tional skills, practicing of component movements may be buzzer of an alarm clock while under a heavy quilt is an example
necessary. For example, the patient initially may need to of how a therapist regulates the spatial and temporal character-
gain control of lateral flexion of neck and trunk muscles istics of the environment.
before these movements can be incorporated into the side
lying-to-sit sequence. Schmidt suggested that as soon as
patients are able to perform these component movements, is that movement is self-paced and no temporal con-
they should be integrated immediately into programs straints are placed.
emphasizing random practice.76 This method of practice The therapist’s role as a regulator can be equated with
can be used only with mobility functions that are readily the degree of assistance or handling provided. The thera-
divided into natural component parts.77,92 pist initially may give significant physical assistance and
use a variety of adjunct techniques to promote perceptual,
Varying the Practice Conditions for Specific Tasks. Gen- cognitive, and sensory processing. As the patient regains
tile’s taxonomy of motor tasks38,39 is useful for determin- control of movements in desired sequences, physical as-
ing the most appropriate practice conditions for each sistance and the amount of cueing is reduced gradually or
mobility task. Objects, persons, and the spatial temporal eliminated.75
characteristics of each task influence the motor strategies
selected. Sabari75 suggested that the occupational therapy Variable Motionless Tasks
process inherently considers the importance of the regu- Bed mobility becomes a variable motionless task if the
latory conditions to task performance. Occupational ther- therapist is not present to regulate certain features of the
apists frequently adapt and regulate the environment to environment. Patients preparing to get out of bed inde-
facilitate mobility functions, as in adjusting the height of pendently may find the pillows and bed linens in disarray,
a bed in preparation for a transfer (Figs. 14-39 and 14-40). making movement difficult; the bed guard rails are low-
Similarly, the amount of verbal cues and physical assis- ered, the top of the bed remains slightly elevated, and the
tance is adjusted to foster independent performance and height of the bed may be too high. Simultaneously the
skill development. Sabari also directed attention to the patient may be receiving verbal encouragement to “hurry
crucial role occupational therapists assume as regulators up.” Without the therapist present to structure the envi-
throughout mobility retraining. ronment, the patient may experience difficulty and may
use compensatory strategies incompatible with the resto-
Closed Tasks ration of performance component deficits. The patient
Early in the treatment process, most functional mobility may hook the unaffected leg under the affected leg and
tasks may be considered closed, and the environmental use the hands to pull up to a seated position.
features are regulated easily to improve performance. This comparison illustrates the way overstructuring
Rolling over and coming to a seated position in a hospital the environment does not prepare the patient recovering
bed occurs on a stationary surface. The therapist can from stroke to develop flexible motor strategies. The pa-
regulate the environment further by positioning pillows tient needs to have opportunities to process information
and bed linens appropriately, raising the bed guard rails, and acquire the ability to solve future problems.2,76 Abreu1
adjusting the height of the bed, limiting the number of studied the effects of environmental regulation on pos-
persons moving around the patient’s bed, and positioning tural control and found that unpredictable environments
the body in a fairly static position to assist the patient if elicited improved control. These findings are contrary to
needed. Another important characteristic of a closed task beliefs occupational therapists have held concerning the
 Chapter 14 • Functional Mobility 385

conveyor belts. Most functional mobility tasks do not

meet this criterion.

Open Tasks
Many advanced mobility skills meet the criterion of an
open task in which the spatial and temporal parameters
of movement are determined by events occurring in the
environment. Open tasks require more precise timing of
movement, and the patient is challenged to anticipate
and react to unexpected events. Sit-to-stand on a moving
train, plane, or bus are examples of open tasks. Practice
of these tasks should occur in the actual environment
whenever possible.45,75 Patients who are physically ca-
A pable of attempting these advanced skills should be en-
gaged in them while in the rehabilitation setting when-
ever possible.
Patients who do not have adequate foundational
skills while hospitalized can benefit from interventions
to improve future potential for the acquisition of ad-
vanced mobility skills. Patients need to be introduced
to unpredictable environments in which they have the
opportunity to explore movement strategies and de-
velop problem-solving abilities. Early in the interven-
tion process, the therapist’s handling techniques to
prepare and assist the patient can be modulated using
different degrees of tactile, proprioceptive, and kines-
thetic input as the patient engages in functional mobil-
ity tasks. For example, as the patient learns to transfer,
the therapist can vary the sensory cues and amount of
assistance.11 Responding to changes in sensory input
may be helpful in the development of anticipatory pos-
tural adjustments.84
B
SUMMARY
Figure 14-40 A and B, Varying the sitting surface when prac-
ticing sit-to-stand and stand-to-sit assists the patient to learn The performance of functional mobility tasks should not
flexible strategies. occur in isolation, as in a gross mobility mat program.
Practice of mobility skills while the patient is engaged in
life tasks presents opportunities to solve unexpected
grading of tasks from simple to complex and the structur- problems that arise as the patient manipulates different
ing of environments from predictable to unpredictable. objects and encounters changing support surfaces and
Abreu1 postulated that the results of this study indicate changing temporal demands. The following are some
that both types of environments should be incorporated suggestions for altering the regulatory features in the
concurrently in the intervention process. The therapist clinical environment.
may regulate the environment but not on all trials. Per-
haps the height of the bed is adjusted and the guard rails Rolling
are elevated on one trial, whereas the next session may ■ Practice rolling on a narrow surface such as a sofa.
require the patient to instruct the therapist verbally in the ■ Encourage abrupt change in direction, as in reversing
arrangement of the immediate surroundings in prepara- the movement in midstream.
tion for the mobility task. ■ Practice rolling under a heavy quilt.
■ Try rolling with an object such as a newspaper in the
Consistent Motion Tasks hand.
During consistent motion tasks, the pace of the environ- ■ Attempt propping to side lying to adjust pillows.
ment remains the same and the environment moves. ■ Practice rolling in a darkened room.
These tasks are associated with mechanical devices such as ■ Ask the patient to roll quickly.
386 Stroke Rehabilitation

7. What does the research show regarding the use of

Side Lying-to-Sit practice in rehabilitation?
■ Attempt side lying-to-sit with an immediate reach 8. How can the therapist structure the practice of func-
pattern. tional mobility tasks, considering the venue of care?
■ Practice side lying-to-sit on a narrow surface. 9. What factors contribute to fall risk in stroke patients?
■ Try modifying the sequence to get out of a chaise
lounge chair.
■ Practice side lying-to-sit on a soft surface such as a sofa. REFERENCES
■ Ask the patient to come to sitting as “fast as they can.” 1. Abreu BC: The effect of environmental regulations on postural
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tional therapy. Am J Occup Ther 45(7):439–448, 1987.
■ Use varying seat surfaces:
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6. What implications for treatment may be derived from 23. Cheng PT, Wu SH, Liaw MY, et al: Symmetrical body weight dis-
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 Chapter 14 • Functional Mobility 387

24. Clemson L: Home fall hazards: a guide to identifying fall hazards in the 49. Holding DH, Macrae AW: Guidance restriction and knowledge of
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 c l are c. bas s i l e
s h ei l a m . h ayes

chapter 15

Gait Awareness

key terms
assistive devices gait patterns proprioceptive deficits
cerebellar strokes hemiplegic gaits visual impairments
contraversive pushing orthotic devices
gait analysis perceptual deficits

chapter objectives
After completing this chapter, the reader will be able to accomplish the following:
1. Understand normal gait components.
2. Identify common gait deviations after a stroke.
3. Understand the basics of gait retraining.
4. Identify and describe commonly used orthoses and assistive devices.

In the management of a stroke survivor, gait analysis terminology, evaluation techniques, and rationale for
and gait training traditionally have been the responsibility treatment of other disciplines.
of physical therapists. Because of the interdisciplinary The physical therapist should perform a thorough ex-
approach used to rehabilitate the stroke survivor, much amination before gait analysis and retraining. This exami-
sharing of information occurs between team members nation includes factors such as range of motion, posture
regarding the patient’s functional and mobility status. and bony alignment, strength, motor control, coordina-
Occupational and physical therapists often “cotreat” to tion, sensation, and balance. The therapist notes any defi-
enhance problem-solving regarding specific barriers to cits in these areas and is then ready to observe and analyze
independence in activities of daily living. gait and to speculate on which of the deficits may be con-
Just as physical therapists have much to gain by famil- tributing to a specific gait deviation. The therapist can
iarizing themselves with terminology and treatments used address specific deficits with appropriate treatment inter-
by occupational therapists (e.g., in the area of perceptual ventions and modalities.
motor deficits), occupational therapists should benefit Gait analysis is the objective documentation of
from having a basic understanding of normal gait compo- gait71 and ranges in complexity from observational assess-
nents, common gait deviations after a stroke, and gait re- ment to quantitative analysis using instrumented gait
training. An integrated approach to treatment of the analysis systems. These systems can include tools such as
stroke survivor necessitates a working knowledge of the videotaping, three-dimensional motion analysis, dynamic

389
390 Stroke Rehabilitation

electromyograms, and force plates. A variety of such Sagittal plane Coronal plane
quantitative systems is available and differs widely in
sophistication and price.11,60
Kinematic analysis evaluates movement patterns, in-
cluding the movement of the body, and specific angles
between body segments (joint angles) as the body moves
through the gait cycle. Observational gait analysis is a Pelvis
Flexion

qualitative method of kinematic analysis. When kinemat-
Extension Adduction  Abduction
ics is measured by instrumented analysis, it is considered
Flexion
a quantitative gait analysis.60 Observational gait analysis is Extension

the visual inspection of walking.88 Although not as reliable 
Dorsiflexion

as quantitative gait analysis, observational gait analysis is Adduction Abduction
the method most often used by practitioners. Most physi- Plantar flexion
cal therapists do not have access to highly technical evalu-
Transverse plane
ation equipment, although videotaping is now more com-
monly available. Perry developed a systematic method for
observational gait analysis that helps standardize this
evaluation.77
Observational gait analysis is an acquired skill that re- Pelvis

quires much practice and repetition. The physical thera- Thigh
pist must learn how to look at nine different points on the
body (head, shoulders, arms, trunk, pelvis, hips, knees, Thigh 
ankles, and feet) while simultaneously comparing the ob- Shank
served gait with normal gait features, in three body planes. Shank
 Internal rotation = 
When one is first learning gait analysis, observation of as Foot
many normal gaits as possible is necessary. When one is
first performing observational gait analysis in the clinic,
the recommendation is that the physical therapist choose
patients who can tolerate walking for several minutes. Talus
This allows the therapist to apply Perry’s approach to  Supination
Dorsiflexion Calcaneus
viewing trunk and limb excursions during the gait cycle. Pronation
Observational gait analysis should take place in the
  Eversion
sagittal and frontal planes. The frontal or coronal view
must include anterior and posterior vantage points. Cer- Plantar flexion Inversion
tain motions such as leg rotation and foot abduction and
adduction take place in the transverse or horizontal plane, Figure 15-1 System of naming angular motion. (From Inman
although the therapist usually is not in a position to ob- VT, Ralston HJ: Human walking, Philadelphia, 1981, Williams
serve motion specifically in this plane. In normal gait, & Wilkins.)
most movement occurs in the sagittal plane, whereas in
abnormal gait, many of the deviations are observed as advancing through space. Thus the gait cycle of one leg
compensations in the frontal (coronal) and transverse (hor- can be divided into two phases: the stance phase (in which
izontal) planes71 (Fig. 15-1). the leg is in contact with the ground) and the swing phase
(in which the leg is off the ground). The stance phase
TERMINOLOGY makes upto 60% of the gait cycle, and the swing phase
makes upto 40% (Fig. 15-2). In a normal gait, the opposite
Physical therapists must first familiarize themselves with leg also is going through a gait cycle simultaneously (i.e.,
the components of the normal gait cycle and with the has a stance phase and a swing phase). Each leg has two
terminology used to describe these components before periods at the beginning and end of stance when the op-
they can analyze the gait of a person who has had a stroke. posite leg is also in contact with the ground. These are
A cycle begins when the heel of one foot touches the called the periods of double support. Together they account
ground and ends after the leg and body have advanced for 10% of the initial stance phase and 10% of the end of
through space and time and the heel of that same foot hits stance for both legs.
the ground again. The phases of swing and stance are further divided
The cycle includes a period when the leg is in contact into substages. The language used to describe these
with the ground, which is followed by a period when it is subdivisions uses the traditional terms or the terms
 Chapter 15 • Gait Awareness 391

Double Double
support support
(10%) (10%)
Stance Swing
(60%) (40%)
10% 30% 50% 70% 85%

Loading Terminal Initial Terminal

Midstance Preswing Midswing
response stance swing swing
Toe
off

Stride
(100%)
Figure 15-2 Phases of gait cycle and their proportions as percentages of gait cycle. (From
Ounpuu S: Evaluation and management of gait disorders, New York, 1995, Marcel Dekker.)

developed at Rancho Los Amigos Medical Center documenting change over time. Velocity measures are
(Table 15-1). Because the terms are similar, physical traditionally taken during a standard 10 minute walk test
therapists often use a mixture of old and new terms and show improvement for physical therapists that do not
unless the facility in which they work advocates strict have access to the instrumented gait analysis systems
adherence to one terminology. Most physical therapists mentioned previously.
are familiar with the Rancho Los Amigos terminology It is important for therapists to have reference values
because of the abundance of research, literature, and from the healthy able-bodied population for cadence (100
gait assessment forms that have been produced by the to 120 steps/min) and velocity (1.2 to 1.5 m/sec) at their
pathokinesiology service and physical therapy depart- disposal, so a quick comparison with their patients’ values
ment at that facility.73 can be made if one has the goal of recovery.23 In addition,
The Rancho Los Amigos definition of swing phase is comparing an individual’s cadence and velocity measure at
divided into the substages of initial swing, midswing, and two points in time may help to document improvement
terminal swing. The stance phase is divided into initial objectively.
contact, loading response, midstance, terminal stance, and Improvements in cadence and velocity also can be an
preswing (Fig. 15-3). Within these substages, the physical indication of functional improvement and limb recovery.
therapist observes the joint displacements and movements A study of hemiplegic patients by Harro and Giuliani43
occurring at the trunk, pelvis, hip, knee, ankle, and toes. showed positive correlations between high scores (greater
Fig. 15-4 illustrates the phases of the gait cycle and the than 90) on the motor portion of the Fugl-Meyer motor
corresponding normal joint displacements that occur as assessment scale and the ability to increase walking speeds.
the body moves through the sagittal plane. Richards and colleagues83 studied 18 hemiplegic subjects
Other terms used in describing gait cycles are stride, divided into three subgroups: slow, intermediate, and fast
step, cadence, and velocity. A stride is equal to a gait cycle walkers. They found that the fast walkers had movements
(i.e., from heel strike of one leg to the next heel strike of and muscle activations more like those of able-bodied
the same leg). Stride can refer to distance (stride length) subjects than the slow or intermediate speed walkers.
or time (stride time) in the gait cycle of one leg. A step is In recent years, the six-minute walk test has been used
described as the distance (step length) or time (step time) in the stroke population. While it was first used in the
from the heel strike of one leg to the heel strike of the cardiopulmonary population to assess functional capacity,6
opposite leg (Fig. 15-5). its utility in the stroke population has been demonstrated.
Dean and other separate investigators have consistently
RELIABLE GAIT PARAMETERS reported that this population’s ambulation endurance is
very limited.26,58 The initial ambulation speed is not main-
Cadence is the number of steps or strides per unit of time. tained throughout the six-minute walk test, and an individ-
Walking velocity equals speed: the distance walked di- ual’s final walk distance is both lower than predicted from
vided by time. Because time-distance variables are the their 10-minute walk velocity and below the value used to
components of gait that can be measured most reliably, identify heart transplant patients.26 Thus, emphasizing the
therapists can use them in assessing improvement in need to measure and train for both ambulation speed and
stroke patients.39,83,84 For example, persons who have had endurance in this population.
a stroke with a resulting hemiparesis typically walk with a Shaughnessy and colleagues have shown that monitor-
slower than normal gait.56,67 Routine recording of the ca- ing step activity throughout the day using a portable micro-
dence and velocity of these patients is an objective way of processor is another tool for demonstrating improvement
392 Stroke Rehabilitation

Table 15-1
Gait Terminology
TRADITIONAL RANCHO LOS AMIGOS

Stance phase Heel strike: The beginning of the stance phase Initial contact: The beginning of the stance phase
when the heel contacts the ground; the same as when the heel or another part of the foot contacts
initial contact the ground
Foot flat: Occurs immediately following heel strike Loading response: The portion of the first double
when the sole of the foot contacts the floor; support period of the stance phase from initial
occurs during loading response contact until the contralateral extremity leaves the
ground
Midstance: The point at which the body passes Midstance: The portion of the single limb support
directly over the reference extremity stance phase that begins when the contralateral
extremity leaves the ground and ends when the
body is directly over the supporting limb
Heel off: The point following midstance when the Terminal stance: The last portion of the single limb
heel of the reference extremity leaves the ground; support stance phase that begins with heel rise
occurs prior to terminal stance and continues until the contralateral extremity
contacts the ground
Toe off: The point following heel off when only the Preswing: The portion of stance that begins the
toe of the reference extremity is in contact with second double support period from the initial
the ground contact of the contralateral extremity to lift off of
the reference extremity
Swing phase Acceleration: The portion of beginning swing from Initial swing: The portion of swing from the point
the moment the toe of the reference extremity when the reference extremity leaves the ground to
leaves the ground to the point when the reference maximum knee flexion of the same extremity
extremity is directly under the body
Midswing: The portion of the swing phase when Midswing: The portion of the swing phase from
the reference extremity passes directly below the maximum knee flexion of the reference extremity
body: extends from the end of acceleration to the to a vertical tibial position
beginning of deceleration
Deceleration: The swing portion of the swing phase Terminal swing: The portion of the swing phase
when the reference extremity is decelerating in from a vertical position of the tibia of the
preparation for the heel strike reference extremity to just before initial contact

From O’Sullivan SB, Schmitz TJ, editors: Physical rehabilitation assessment and treatment, Philadelphia, 1994, FA Davis.

Initial Loading Midstance Terminal Preswing Initial Midswing Terminal

contact response (MSt) stance (Psw) swing (MSw) swing
(IC) (LR) (TSt) (ISw) (TSw)
Figure 15-3 Phases of gait cycle shown with corresponding body position for sagittal plane
motion. (From Ounpuu S: Evaluation and management of gait disorders, New York, 1995,
Marcel Dekker.)

in ambulation tolerance.87 They demonstrated an 80% Perry has shown that ambulation speed differentiates
improvement in step activity across a three-month outpa- level of ambulatory functioning and that individuals am-
tient rehabilitation period. Clinicians could monitor step bulatory in the community (0.58 m/sec) ambulate at
activity during the course of a day by placing pedometers speeds higher than independent household ambulators
on their patients. (0.4 m/sec) do. She has further classified levels within
 Chapter 15 • Gait Awareness 393

Weight Single limb Swing limb

acceptance support advancement

Reference
limb IC LR MSt TSt PSw ISw MSw TSw

Opposite PSw PSw ISw/MSw MSt

TSw IC/LR MSt TSt
limb

Trunk Erect

5˚ 5˚ 5˚ 5˚ 5˚ 5˚
Pelvis Forward Forward 0˚ Backward Backward Backward 0˚ Forward
rotation rotation rotation rotation rotation rotation

20˚
Hip 25˚ 25˚ 0˚ Apparent 0˚ 15˚ 25˚ 25˚
flex flex hyperext flex flex flex

0˚ 15˚ 0˚ 0˚ 40˚ 60˚ 25˚ 0˚

Knee
flex flex flex flex

0˚ 10˚ 5˚ 10˚ 20˚ 10˚ 0˚ 0˚

Ankle Plantar Dorsiflex Dorsiflex Plantar Plantar
flex flex flex

Toes 0˚ 0˚ 0˚ 30˚ MTP 60˚ MTP 0˚ 0˚ 0˚

Ext Ext

Figure 15-4 Range of motion summary. (Courtesy Rancho Los Amigos Medical Center
Physical Therapy Department and Pathokinesiology Laboratory, Downey, CA)

household (most and least limited) and community Hemiplegic Gaits

(most and least limited) ambulation based on speed and The type of gait of a person who has had a stroke depends
independence of ambulation while performing activities on where in the brain the insult has occurred and which
in the home and outside.78 Common threads to commu- systems are affected, such as motor, sensory, balance, co-
nity ambulation were increased ambulation distance/ ordination, perceptual, and visual systems. If a motor area
endurance, the ability to change level and terrain irregu- in the cortex or a motor track is involved, hemiplegia or
larity, obstacle avoidance, and the manual handling of hemiparesis is manifested in the contralateral limbs. The
loads. All these threads are essential for successful full location of the infarction within these areas determines
access community ambulation. Thus, when they work on whether the arm or the leg is more impaired. Not all
gait recovery in the stroke population, therapists must stroke patients are hemiplegic or hemiparetic, nor do all
routinely take quantified measures of gait speed and en- hemiparetic patients have the same degree of motor defi-
durance during a variety of ambulation tasks to assess cits. Unfortunately, the term hemiplegic gait frequently is
household and community ambulation feasibility and applied to all individuals with hemiparesis, although many
reentry. varieties and degrees of deficits exist.39 Individuals who
394 Stroke Rehabilitation

Right Left Right

heel heel heel
contact contact contact

R. step L. step R. step

length length length
Cycle length
(stride)
Figure 15-5 Distance dimensions in a gait cycle. R., Right, L.,
left. (From Inman VT, Ralston HJ: Human walking, Philadelphia,
1981, Williams & Wilkins.)

have suffered ischemia in areas of the brain supplied by

the anterior cerebral artery usually have greater deficits
in the leg. Those with ischemic lesions in areas supplied Figure 15-6 Genu recurvatum in midstance caused by a rigid
by the middle cerebral artery have greater arm involve- plantar flexion contracture (greater than 15 degrees). Tibia is
ment, although leg weakness is usually also present in prevented from advancing forward, driving the knee posteriorly
varying degrees. Middle cerebral artery infarctions are the into recurvatum, impeding progression, and reducing momen-
most common type of stroke.16 The gait deviations seen tum. (From Adams J, Perry J: Human walking, Philadelphia,
with these lesions are those most often described by the 1994, Williams & Wilkins.)
generic term hemiplegic gait. Following are descriptions of
some of the more common alterations. problem may be compounded by pelvic retraction. Other
During the stance phase of the hemiparetic leg, a pa- patients may display the opposite scenario during mid-
tient may exhibit “foot flat” or even a “forefoot first” at stance on the paretic leg; knee flexion may be excessive in
the initial contact instead of a heel strike with adequate the sagittal plane, with concurrent excessive dorsiflexion
ankle dorsiflexion. The patient also may exhibit plantar and hip flexion.3,17,60,70
flexion (forefoot first) and supination (in the frontal plane) In the frontal plane, lateral trunk lean may be excessive
at initial contact and then begin to bear weight precari- over the ipsilateral leg during midstance or a positive
ously on the lateral border of the foot.17,39,60,70 Trendelenburg sign may be evident, both of which indi-
During the loading response, while the patient is still in cate weak hip abductors of the stance leg. A positive
double limb support, weight is being “loaded,” or accepted, Trendelenburg sign is present when excessive lateral dis-
onto the leg. Normally, 10 to 15 degrees of knee flexion is placement of the pelvis occurs over the stance leg, with
needed to absorb the forces of momentum and body an excessive lowering of the pelvis on the contralateral
weight. This flexion may be absent, in which case the knee swing leg.63,71
remains extended or even hyperextends (genu recurvatum) During the terminal stance phase, which is still a pe-
during midstance, as the body moves forward. In this in- riod of single limb support, normal hip extension may be
stance, no tibial advancement occurs over the foot because absent along with the ability to transfer weight onto the
no dorsiflexion is occurring at the ankle (Fig. 15-6). forefoot in preparation for push off. Dorsiflexion at the
Midstance begins the period of single limb support. In ankle joint may continue to be excessive or diminished.
addition to knee hyperextension, the therapist also may Lack of heel rise can occur in the sagittal plane, combined
observe trunk and hip flexion as the body attempts to with excessive dorsiflexion, and the contralateral leg makes
move its center of mass forward over a stiff knee. The initial contact early.3,39,60,71
 Chapter 15 • Gait Awareness 395

The preswing phase is the final stance stage and the no abduction, adduction, or external or internal rotation
second double support period. A lack of knee flexion (nor- occurs in the frontal plane during the swing phase.73
mally between 30 and 40 degrees) often occurs in the pa- The limited knee flexion in the preswing phase persists
retic leg, accompanied by a lack of ankle joint plantar into the initial swing phase and often throughout the en-
flexion at the end of preswing.3,17,70,73 tire swing phase. The toe drag first seen in the initial
Many of the deviations observed in the hemiparetic swing phase may continue because of the decreased knee
limb during stance can contribute to a decreased step length swing but also may be a consequence of decreased hip
by the opposite leg. The body is not able to complete its flexion and decreased ankle dorsiflexion. The patient can
normal excursion forward because of lack of movement, initiate compensatory hip hiking at this stage to assist with
or ineffective movement, of the pelvis, hip, knee, or ankle clearing the toes as the leg advances.3,39,60,66,70 Other com-
of the hemiparetic limb. The opposite limb may “step to” pensations used to counteract toe drag are increased hip
instead of stepping past the paretic limb. Step length also and knee flexion or vaulting by the opposite (stance) leg.
can be reduced in the hemiparetic leg. Vaulting occurs when the person rises up on the toes of
The therapist sometimes can see the swing phase of the stance foot for better clearance of the swing leg.3
the paretic limb as a mass flexion movement instead of a In the midswing phase, the pelvis may remain retracted
series of sequential flexion movements.39,56 More often instead of rotating forward to neutral. Hip hiking and leg
the swing phase is characterized by a stiff-legged swing, circumduction may continue, especially if knee flexion
with a decrease in hip flexion and in the velocity and and dorsiflexion remain limited. Dorsiflexion may be de-
amount of reciprocal knee flexion and extension. The creased or absent, with the ankle assuming a plantar-
velocity of the entire paretic limb is often decreased.39,66 flexed (foot-drop) position. The foot may supinate during
The decrease in hip flexion, together with the lack of midswing because of an imbalance in ankle dorsiflexor
knee flexion and dorsiflexion, often results in circumduc- muscle function17,24,60,73 (see Fig. 15-7). Normally, the
tion to advance the stiff limb.3,39,56,63,70,73 Circumduction anterior tibialis and long toe extensors dorsiflex the foot
occurs when the patient swings the leg through in a semi- symmetrically. Some stroke patients have overactive ante-
circle and is most noticeable when looking at the patient rior tibialis muscles and weak long toe extensors, causing
in the frontal plane (Fig. 15-7). The patient combines the medially placed anterior tibialis tendon to pull the
external rotation and abduction at the hip to lift the leg foot into supination.24
out to the side and then adducts and often internally ro- As the limb progresses toward the terminal swing
tates the leg to bring it back in.63 In a normal gait pattern, phase, many patients are unable to extend the knee while
simultaneously flexing the hip and ankle. Instead, knee
extension is decreased, and the foot initially contacts the
ground with the knee flexed.60,66 The pelvis still may be
retracted or may not have rotated forward past neutral.
This, in addition to the decrease in knee extension, results
in a decreased step length by the paretic leg. Other sub-
jects may exhibit knee extension with plantar flexion dur-
ing the terminal swing phase, instead of the normal dorsi-
flexion seen in preparation for upcoming heel strike.39,73
In other persons, adduction of the hip with knee extension
can be so pronounced as to cause the swing leg to cross in
front of the stance foot. Patients literally end up tripping
over themselves.

CAUSES OF GAIT DEVIATIONS

One cannot overemphasize that the causes of the aforemen-
tioned observed gait deviations may vary from patient to pa-
tient. For example, a common deviation at initial contact is
foot flat or forefoot first instead of heel strike. This abnor-
mality could result from weak dorsiflexor muscles,29,30,56,59,73
Figure 15-7 Supination of foot during swing phase resulting excessive activity of the plantar flexors,3,55,56,73 a decreased
from uninhibited activity in the tibialis anterior. Circumduction ability to perform fast reciprocal movements,39,53,56 disrup-
of hip is also present during this swing phase. (From Davies P: tion in the central generation of preprogrammed muscle
Steps to follow: the comprehensive treatment of patients with hemiple- activation,45 noncontractile soft tissue tightness in the
gia, New York, 2000, Springer-Verlag.) plantar flexors,3,21,29,73 or a pathological condition of the
396 Stroke Rehabilitation

ankle joint. Even when soft tissue tightness and joint lose BMD as well, although at a slower rate compared to
contractures are ruled out, hypotheses vary and often con- the other side (4% at 12 months). Studies reported that
flict about the precipitating factor. This is especially true when BMD loss rate was analyzed across the first year,
when the issue of voluntary versus reflex skeletal muscle the most loss occurred within the first seven months in
activation is addressed. A number of recent papers and pub- both the paretic (10%) and nonparetic legs (2%) of
lications provide an abbreviated review of the literature on stroke survivors.46,47,82
this topic.21,29,34,39,43,44,52,53,56 Jorgensen46,47 has demonstrated that ambulatory sta-
tus and weight-bearing load on the paretic limb after
OSTEOPOROSIS stroke affect the rate of BMD loss. Using the 6 level or-
dinal scale for the Functional Ambulation Category
Stroke survivors have a fourfold increased risk of falling (FAC) to qualify ambulation status, a linear relationship
compared to the healthy community dwelling popula- of ambulation assistance to BMD loss was demonstrated.
tion.64 Falls in this population have an increased risk, from Thus, if subjects ambulated independently or with assis-
1.2% to 6%, of resulting in fractures to the distal radius, tance (FAC 2 to 6) within the first two weeks after stroke,
humeral head, and hip.15,81,100 Fractures occur predomi- subjects lost less BMD at one year (2%) compared to
nantly on the paretic side and hip fractures in particular those who achieved ambulation by two months (7%) and
and accelerate the downward spiral toward increased to those still nonambulatory at two months (10%).47 In
morbidity and mortality.80,81 Risk factors for fracture in- addition, the amount of weight on the paretic limb dur-
clude reduced mobility, strength of the paretic leg, and ing 30 seconds of static standing was linearly related to
reduced bone mineral density (BMD).82 In Chapter 14, walking onset after stroke. Subjects who walked within
falls in the stroke population are explored; however, an two weeks of stroke had a higher percentage of body
analysis of the timeline for bone density demineralization weight (51%) loaded through the paretic limb versus
is warranted so interventions to minimize this loss and those who walked by seven months (43%) and those
possibly lessen the fracture risk can be developed. immobile at seven months (35%).46
In the spinal cord injury (SCI) population, bone de- BMD loss has been demonstrated for the paretic upper
mineralization occurs within the first three months and lower limb throughout the first year after stroke. The
postinjury and proceeds up to 16 months after injury. upper extremity loss occurs sooner than the lower extrem-
The demineralization has been attributed to prolonged ity loss, but both limbs show significant loss that could
bedrest, immobility, and lack of muscle contraction and contribute to fracture risk during a fall. Early ambulation
gravitational loading below the level of SCI.37,101 In the after stroke has been shown to modulate bone demineral-
stroke population, investigations of BMD loss have been ization of the paretic limb during the first year. Therapists
compared within a limb and between limbs (paretic vs. should use interventions that promote independent am-
nonparetic) in longitudinal fashion for up to 12 months bulation as early as possible after stroke with the knowl-
after stroke.46,47,82 The rate of bone demineralization edge that the sooner independent ambulation is achieved,
over the first year and the factors that might alter the loss the less bone loss occurs.
are explored next.
As early as one month after stroke, significant BMD TREATMENT INTERVENTIONS
loss for the paretic upper limb (UL) compared to the
nonparetic UL has been shown for the humerus (4%) The physical therapist first addresses deficits identified
and total arm (4%).82 The paretic limb’s distal radius loss during the physical assessment that are contributing to
reaches significance when compared to the other side at the abnormal gait, such as decreased range of motion and
four months (3%). However, all three sites of the paretic strength. Interventions can include basic modalities and
UL continue to decline over the year (total arm 3%, therapeutic exercise and a variety of approaches to address
humerus 14%, distal radius 3%), which puts the paretic the lack of movement and voluntary control. Many inter-
UL at risk for fracture if used to break a fall. The non- ventions are based on theories that advocate facilitation of
paretic UL’s distal radius demonstrates a 2% increase in normal movement and sensory stimulation of the patient
BMD for the first year, which may be attributed to in- by the therapist. In this context, the patient is a passive
creased loading activity associated with the nonparetic recipient of the therapist’s efforts. However, during the
UL during ambulation, although this hypothesis has not past 20 years, therapists gradually have shifted away from
been tested. using these more traditional therapeutic approaches to
Ranmnemark and colleagues82 demonstrated that, at using the motor control perspective. The motor control
four months after stroke, a significant BMD loss for the approach also is based on a theoretical model, but it does
proximal femur had already occurred in the paretic limb not advocate specific treatment techniques that are done
(6%), and loss continued throughout the remainder of by the therapist to the patient. In the motor control
the first year (12%). The nonparetic limb appeared to model the main task of the therapist is not to facilitate
 Chapter 15 • Gait Awareness 397

normal movement but to structure the environment in improved, the fast group (2.0 m/hr) made the most gains
such a way that the patient actively will relearn to use the in overground walking speed. This speaks to the specific-
affected limbs functionally. The motor control relearning ity of speed training and suggests that training should
theory is based on research from a variety of fields: neu- occur at the speed to with the therapist wants the patient
rophysiology, muscle physiology, biomechanics, and psy- ultimately ambulate.
chology.20,42 Patients are believed to learn by actively An additional innovation to the BWS device is the in-
trying to solve problems (see Chapter 6). Therefore, corporation of an electric stimulation component during
therapists should structure tasks to promote acquisition of gait training. However, when compared to overground
the movements needed to solve specific motor control ambulation training, both groups of chronic stroke survi-
problems in a variety of situations (see Chapters 4 and 5). vors made similar gains in walking velocity and endur-
This pertains not only to patients with a hemiplegic gait ance.75 Ada’s group2 in their study of treadmill vs. over-
but also to patients with motor control deficits described ground walking programs found similar results in a
in the following sections. community dwelling population of stroke survivors, and
In the last ten years, the research directed at improving Nilsson’s group62 corroborated these results in acute
gait function in patients after stroke have supported a stroke survivors, which suggests that the practice of am-
basic tenet of motor skill acquisition. In order to improve bulation is the common critical element for patients al-
gait functioning, the individual must practice the task of ready somewhat ambulatory.
gait. The part practice intervention of weight shifting Dean25 in her pilot study and Salbach85 in a larger
activities in standing with two feet in contact with the study found that training individuals in upright dynamic
ground was not superior to the conventional neurodevel- activities through a circuit system was more beneficial
opmental treatment (NDT) based physical therapy inter- than no treatment or conventional treatment. The
vention at improving gait.102 Thus, suggesting that im- circuit included stations for walking overground at
provements in gait may not be amenable to part practice comfortable and fast speeds, walking over obstacles,
in standing positions where 2 feet are always in contact transitions of sit-to-stand from varying height chairs,
with the ground. dynamic upright balance activities, and lower extremity
The question becomes if ambulation practice is re- strengthening activities performed in standing. Bassile9
quired to improve ambulation, then how much practice demonstrated that an obstacle ambulation training pro-
does a patient require to improve gait? The recent litera- gram was feasible and improved the gait and quality of
ture shows that at least twenty minutes of ambulation life in chronic stroke survivors. Lastly, Duncan’s specific
practice is the minimum amount of time per session home-based therapy program for acute stroke survivors
needed to note improved ambulation. Table 15-2 shows that incorporated dynamic balance and LE strengthen-
that the amount of practice for any of the ambulatory in- ing performed in upright along with ambulation
tervention groups is a considerable increase from what is and aerobic training was found to be better than stan-
presently observed in the rehabilitation clinic. This in- dard of care.31
crease in time on task results in significant gains in over- In conclusion to this section, some common interven-
ground walking speed and endurance. tion themes are noted. First the task of ambulation must be
Recent ambulatory intervention advancements have practiced for much longer periods in the clinical setting if
been the use of body weight support treadmill training one wishes to improve this function. Results of this longer
(BWSTT), task-related circuit training, BWS  electric practice yield improved ambulation endurance (distance)
stimulation, overground walking practice, obstacle training, and speed (velocity). Ambulation practice should occur at
and home-based exercise programs (see Table 15-2). Visitin faster speeds to meet community ambulation activities.
and Barbeau96 first demonstrated that BWSTT was better Both LE strength and balance (see Chapter 8) play a role in
than non-BWS walking for recent stroke survivors. At the ambulation enhancement, and the literature supports the
end of a six week inpatient rehabilitation unit stay, those notion that performing task specific practice in upright
individuals who received BWSTT ambulated at a faster dynamic postures along with ambulation practice, not in
overground speed (0.34 m/sec) than individuals who re- place of it, contributes to enhanced locomotion.
ceived the non-BWS (0.25 m/sec) (control group). At the
three-month retention, while both groups continued to im- OTHER ABNORMAL GAIT PATTERNS
prove, the BWSTT group was clearly superior (0.52 m/sec)
to the control group (0.30 m/sec) (Fig. 15-8). The list of abnormal gait patterns that can appear after
Sullivan’s group91 demonstrated that the speed which stroke is too extensive to be covered completely in a single
therapists train ambulation may be a critical factor in en- chapter. Therefore, what follows are examples of abnor-
hancing ambulation recovery. While BWSTT was per- mal gaits that are particularly challenging to the physical
formed for all groups, the training speeds for each group therapist. Each deficit results from damage in the particu-
was different (fast vs. slow vs. variable). While all groups lar part of the brain described.
Table 15-2
Evidence-Based Gait Interventions Poststroke

INTERVENTION TREATMENT ASSESSMENT OUTCOME

DESIGN POPULATION GROUPS DURATION TIMES MEASURES RESULTS

RCT-3 Chronic CVA BWSGT  ES 20 min/day  Baseline, post 10 MWT, 6MWT, All 3 groups improved significantly across time
groups75 pts on inpt BWSGT 3 wks completion dynamic balance No difference between the groups
rehab Overground 55 min/day of 6 month time, MMAS
n45 walking trad. PT retention
RCT-2 Chronic CVA LE circuit 1 hr/ session Baseline, post 10 MWT, 6MWT, step LE circuit group improved significantly more
groups pts outpatient training 3 sessions/wk completion test,TUG than the other group on 10 MWT, 6 MWT
pilot setting UE training  4 wks 2 month Sit-to-stand with force and step test at completion and retention
study25 n12 retention plates LE circuit group improved peak vertical GRF
through affected leg
RCT-3 Chronic CVA BWSTT-slow 20 min/session Baseline, middle, 10 MWT All 3 groups improved significantly baseline to
groups91 pts outpatient BWSTT-fast 3 sessions/wk post completion completion and continued to improve at
setting BWSTT-variable  4 wks 1 month and 3 1-month retention
n24 month retention Fast group made most improvement
RCT-2 Subacute CVA Therex group 90 min/session Baseline, post Isometric peak torque Both groups improved significantly across time
groups31 pts home care Usual care 3 sessions/wk completion (ankle, knee, grip) Therex group improved significantly more
n92  12 wks Fugl Meyer (lower ext. than usual care for Berg, peak VO2
motor score) 10 MWT, 6 MWT
Berg Balance Scale,
Functional Reach test
Wolf motor function test, 10
MWT, 6 MWT, peak VO2
RCT-2 Chronic CVA Walking 3/wk  4 wks Baseline, post 10 MWT, 6 MWT, Significantly improved 10 MWT and
groups2 pts (treadmill/ 30 min completion Sickness Impact 6 MWT compared to placebo group
n29 overground) walking/ Profile
Home exercise session
placebo
RCT-2 Chronic CVA LE tasks 3/wk  6 wks Baseline, post 6 MWT, 5 MWT, TUG, LE task group improved significantly for all
groups85 pts outpatient UE tasks completion Berg Balance Scale measures at completion
setting
n91
RCT-2 Subacute CVA BWSTT 4 sessions/wk Baseline, post Berg Balance Scale, BWSTT group improved significantly
groups96 pts inpt rehab No BWSTT  6 wks completion STREAM, 10 MWT, for all measures at completion
n100 3 trials/ 3 month walk endurance Both groups improved at 3 month retention
session retention (320 m) compared to completion, but BWSTT group
or  20 min improved more than no BWSTT
Experimental Chronic CVA Obstacle 2 sessions/wk Baseline, post 6 MWT, 10 MWT, MMAS Significant improvement noted in all measures
group9 pts ambulation plus  4 wks completion (walking except SF36-RPt at completion
n56 overground 1 month section), SF36-PFt, SF36-PFt and 10 MWT maintained at
ambulation retention SF36-RPt 1 month

BWSGT, body weight support gait training; BWSTT, body weight support treadmill training; CVA, cerebiovascular accident; LE, lower extremity; MMAS, Modified Motor Assessment Scale;
MWT, minute walk test; MWT, meter walk test; PT, physical therapy; RCT, randomized controlled trial; SF-36-PFt, Short Form Health Survey: Physical Function; SF36-RPt: Short Form
Health Survey: Role Physical; STREAM, Stroke Rehabilitation Assessment of Movement; TUG, timed up and go; UE, upper extremity. VO2, maximal oxygen consumption;
 Chapter 15 • Gait Awareness 399

the feet apart to increase stability. Any attempt to bring

the feet together or walk with one foot directly in front
of the other causes loss of balance. Ataxia or dysmetria of
the limbs is not common.
Damage to the anterior lobe, especially the medial as-
pect, causes a disruption in the sensory input (via the spi-
nocerebellar tracts) that is related to agonist-antagonist
muscle activity. Lower limb ataxia or dysmetria is also
present, but upper limb ataxia is usually absent. Lesions in
a cerebellar hemisphere result in ipsilateral limb dysmetria
or hypotonia, in addition to other deficits. Although the
damage does not affect postural stability, the gait appears
ataxic and staggering because of the limb dysmetria.60
The cerebellum is supplied by three main arteries: the
posterior inferior cerebellar artery, the anterior inferior
cerebellar artery, and the superior cerebellar artery. These
arteries are part of the posterior circulation—the verte-
brobasilar system. The posterior inferior cerebellar artery
is a branch of the vertebral artery, whereas the anterior
inferior cerebellar artery and superior cerebellar artery
Figure 15-8 LiteGait System. (From Mobility Research, are branches of the basilar artery. Chapter 1 describes in
LiteGait, PO Box, 3141, Tempe, AZ 85280; 1-800-332-WALK; detail the territories supplied by these arteries and their
www.litegait.com.) associated areas.4,5 In general, these arteries supply the
areas of the cerebellum that their names imply, in addition
to parts of the brainstem. Some areas of vascularization in
the cerebellum overlap because of the many free cortical
Cerebellar Strokes anastomoses5 (Fig. 15-9). Although one artery may supply
A person who has an infarct in the cerebellum caused by one particular lobe predominantly, this overlapping may
occlusion or hemorrhage of a vertebral or a cerebellar result in additional blood coming from the distal branches
artery may exhibit completely different gait deviations of another artery. However, as a rule, the superior cere-
than a hemiparetic patient. The cerebellum is composed bellar artery supplies the superior cerebellar peduncle, the
of three parts or lobes: the flocculonodular lobe, the ante- anterior inferior cerebellar artery supplies the middle
rior lobe, and the posterior lobe. The flocculonodular lobe
also is called the vestibulocerebellum because most of its
input is from the vestibular nuclei in the pons. The ante-
rior lobe also is known as the spinocerebellum because most 2
of its input is from the spinocerebellar tracts via the infe-
rior cerebellar peduncle and the superior cerebellar pe- 1
duncle. The posterior lobe also is known as the neocerebel- 3 3
lum and contains most of the cerebellar hemispheres. The
hemispheres receive their major input from the cortex via 4
8
the middle cerebellar peduncle.
In addition, the cerebellum can be divided longitudi- 7
nally into functional zones perpendicular to the horizon- 6 7
9 6
tal fissures dividing the lobes. The medial structure is 5
the vermis. Adjacent to the vermis, on either side, is the
pars intermedia (intermediate section) of the cerebellar
hemisphere. Lateral to this is the bulk of the cerebellar Figure 15-9 Lateral view of cerebellar arteries. 1, Superior
hemisphere. cerebellar artery; 2, medial branch of superior cerebellar artery;
Gait is influenced most by the flocculonodular and 3, lateral branch of superior cerebellar artery; 4, anterior inferior
anterior lobes. Consequently, infarcts in these areas lead cerebellar artery; 5, posterior inferior cerebellar artery; 6, medial
to difficulty maintaining a proper stance and walking.65 branch of posterior inferior cerebellar artery; 7, lateral branch of
Damage to the flocculonodular lobe (vestibulocerebel- posterior inferior cerebellar artery; 8, basilar artery; 9, vertebral
lum) causes head and neck ataxia. Truncal tremor is often artery. (From Bogousslavsky J, Caplan L, editors: Stroke syn-
severe. The patient often uses a wide-based stance with dromes, Cambridge, UK, 1995, Cambridge University Press.)
400 Stroke Rehabilitation

cerebellar peduncle, and the posterior inferior cerebellar Balance retraining should encourage active problem-
artery supplies the inferior cerebellar peduncle.5 solving by the patient (see Chapter 8). Being held upright
A cerebellar stroke resulting from occlusion of the pos- by the therapist while walking does not promote func-
terior inferior cerebellar artery usually is referred to in the tional independence. Likewise, assistive devices that re-
literature as a lateral medullary syndrome (Wallenberg syn- quire upper extremity weight-bearing (e.g., walkers) may
drome)12,38,95 because it was believed that the posterior prevent loss of balance but do not promote functional
inferior cerebellar artery supplied the lateral medulla and improvement because they do not challenge the patient to
parts of the cerebellum. Recently this term has been dis- relearn balance control.7,13 The patient is merely stabi-
puted, based on evidence that the lateral medulla is sup- lized externally and is not required to use or integrate
plied less frequently by the posterior inferior cerebellar postural reflexes.
artery than previously thought.4 If the lateral medulla is Activities that require active weight shifting and goal-
spared, an infarct of the posterior inferior cerebellar artery oriented reaching are encouraged and practiced while the
territory is apparent as a headache on the ipsilateral side, patient is standing (see Chapter 14). The therapist can
vertigo, nausea and vomiting, nystagmus, and limb and introduce progressively more challenging exercises and
gait ataxia. If the lateral medulla is involved, the foregoing activities as the patient becomes more adept.7 Initially,
signs and symptoms are present. In addition, interruption some patients benefit from walking with their nonaffected
of the sympathetic nerve fibers can cause Horner syn- side next to a high mat. The hand of the nonaffected side
drome. Cranial nerves V, IX, and X also are affected.4,94 is placed on the surface of the mat for support. The pa-
Involvement of cranial nerves V, IX, and X results in tient can advance the dysmetric limb more easily if the
ipsilateral loss of pain and temperature in the face (V), opposite (sound side) hip maintains contact with the high
dysphagia (IX), and dysphonia (X). Pain and temperature mat during stance. Later, the patient uses a cane only to
may be decreased on the opposite side of the body be- prevent loss of balance or as a cue to shift weight to the
cause of the interruption of the ascending spinothalamic less affected side, not as a maximal assistive device.
tracts. This combination of cerebellar and medullary
signs constitutes Wallenberg lateral medullary syndrome. Contraversive Pushing/Pusher Syndrome
In either type of posterior inferior cerebellar artery in- An unusual motor behavior that hemiplegic patients
farct, the inferior cerebellar peduncle and the inferior sometimes display in the clinic is ipsilateral pushing. The
aspect of the cerebellum are affected. The result is ipsi- patients tend to push away from the unaffected side in any
lateral limb ataxia and gait ataxia.4,94 In addition, the pa- position. Davies24 described the syndrome in 1985 and
tient tends to fall to the side of the lesion (ipsilateral axial called it the pusher syndrome. The original description of
lateropulsion) and has difficulty shifting weight toward the pusher syndrome was based solely on a practitioner’s
the contralateral leg.4 observation and was most often thought to be associated
Earlier texts reported that posterior inferior cerebellar with left hemiplegia and perceptual deficits (especially left
artery infarcts are the most common,12 but recent findings neglect), left visual field neglect with or without homony-
have shown that superior cerebellar artery infarcts occur mous hemianopsia, impaired body scheme and body im-
as frequently.4,5 Superior cerebellar artery infarcts have age, and visuospatial deficits.24 Recent research activity
several different clinical manifestations. Dysarthria is one has attempted to identify the neural correlates and mech-
of the most frequent. Limb dysmetria, gait ataxia, and anisms for this clinical disorder. Unilateral lesions of the
ipsilateral axial lateropulsion are also common symp- posterior lateral thalamus have been implicated in recent
toms.4 Anterior inferior cerebellar artery infarcts are the imaging studies.49,51 Also, diminished perfusion for the
least common. In addition to vertigo and ataxia, tinnitus intact areas of inferior frontal, middle temporal, and infe-
and deafness are present. Auditory involvement and pe- rior parietal lobes have resulted in pusher syndrome.92
ripheral facial palsy are classic signs of anterior inferior The original description of the pusher syndrome was
cerebellar artery infarcts, which differentiate them from based solely on a practitioner’s observation. The behavior
superior cerebellar artery or posterior inferior cerebellar was seen in as many as 10% of the 327 stroke patients in
artery infarcts.4,94 the study by Pedersen, Wandell, and Jorgensen.74 The
Gait retraining after a cerebellar stroke is focused on syndrome appears in both right and left hemisphere dam-
relearning the way to correct balance losses. Patients first age.50,74 Neglect and aphasia are also highly associated
must learn the point in space where their center of gravity with pushing behavior.50
is positioned optimally over their base of support for sta- Karnath and colleagues have suggested through their
bility. Then they must relearn the way to realign their research that the task of the brain areas damaged or
center of gravity constantly with their base of support. receiving low perfusion in patients with pusher syn-
This task is most difficult during ambulation when the drome appears to be control of upright body pos-
center of gravity is shifted anterior to the base of support ture.49,50,92 They demonstrated that patients with pusher
as the body moves forward.93 syndrome show normal perception of visual vertical but
 Chapter 15 • Gait Awareness 401

a severe tilt of perceived body posture in relation to specific use with patients who demonstrate contraversive
gravity. While seated in a tilting chair, patients with pushing. Karnath48 proposed that, since patients’ percep-
pusher syndrome oriented their bodies upright when tion of visual vertical are intact but their perception of
they were actually 18 degrees tilted towards the side of body vertical is inaccurate, the patients must use the visual
the brain lesion. However, they were able to orient the vertical to align their bodies. They must be taught that
visual world vertically appropriate. In addition, they the visual alignment information is correct and the body’s
were able to align their bodies to earth’s vertical when perception (feeling) of alignment is incorrect. This can be
they used visual cues from the laboratory surroundings. done through visual feedback of their bodies aligned to an
In the dark, they were also able to orient to visual verti- external vertical axis. For example, patients can align their
cal, suggesting that both visual and vestibular inputs trunks to the vertical axis in a mirror with tape along the
were unaffected. 24 vertical line bisecting their body halves. Patients can also
Karnath and Broetz48 have identified three characteristic use door and window frames to align their trunks. How-
behaviors associated with pusher syndrome (see Chapter 7 ever, they may require external feedback from the thera-
for the Clinical Assessment Scale for Contraversive Push- pist simultaneously with a “conscious awareness” that
ing). First, the patient’s longitudinal body axis is tilted to- balance is achieved in this position. Using the visual verti-
ward the paretic side when sitting or standing. Second, the cal axis for postural alignment takes care of a behavior
patient actively pushes (abduction and extension of arm or seen with pusher syndrome.
leg) with the nonaffected extremities, which results in a During dynamic activities such as transferring sit to
lean toward the hemiplegic side and loss of balance. Third, stand and ambulation, the unaffected upper and lower
the patient resists any attempt by the examiner to correct extremities are called into play to assist with the activity.
the tilted body axis. Active pushing by the nonaffected extremities in a lat-
The rehabilitation literature is scant on outcomes and eral direction toward the hemiplegic side occurs, and
intervention.72,74,76 Karnath51 found patients with pusher often the patient falls to this side when transferring,
syndrome have a good prognosis. The behavior was rarely standing, or walking if not prevented from doing so by
observed after six months of stroke. However, rehabilita- the therapist.
tion did take 3.6 weeks longer for the patients with con- The second intervention has been used by clinicians
traversive pushing as compared to other stroke patients to but has not been evaluated systematically in the clinic.
achieve similar functional outcomes. Therapists should remove all firm pushing surfaces from
Gait training for patients with contraversive pushing is patient contact during activities. Thus, when performing
a definite challenge, as is transfer training. During sit-to- sitting activities, the feet may be unsupported initially. In
stand activities, some patients project themselves quickly sitting and standing, the patient is not allowed to hold a
out of a chair toward their hemiparetic side. If left un- firm external support with the nonaffected hand, so assis-
guarded, they fall. Transferring toward the stronger side tive devices and parallel bars are counterproductive. For
is difficult because they always push away from that side. example, the patient may be asked to hold a cup of water
Although easier, transfers toward the hemiparetic side are while transferring from sit-to-stand. When standing or
dangerous because of the lack of motor control on that transferring, the patient might be asked to simultaneously
side. Standing requires assistance to prevent falling to the perform reach, grasp, and place activities with the nonaf-
weak side. fected upper extremity. The items are retrieved or placed
Walking with an assistive device, such as a cane in the on movable surfaces (e.g., hospital tray table or rolling
stronger hand, is initially unproductive, because these stools). This intervention eliminates the success of the
patients tend to use the cane to push themselves toward pushing arm in destabilizing the patient, and the therapist
the hemiparetic leg. They appear unable actively to shift can assist the patient to realign the vertical axis of body
weight onto the strong leg. The more these patients are more easily. If the patient can perform these activities
supported (to prevent falling to the paretic side), the more while preferentially shifting their center of mass toward
they push into the helper. the nonaffected side while receiving external visual and
Gait retraining is based on the same principles dis- verbal feedback about vertical alignment then he or she
cussed in the ataxic gaits section. Patients must relearn the can consciously be aware of what body positions create
way to adjust their center of gravity over their base of sup- stability (e.g., objects are placed or retrieved from midline
port while standing. The patients must regain proper and in the direction of the nonaffected side).
positioning of their trunk in relation to gravitational Relearning to maintain balance while walking is a for-
forces so their center of mass stays within the limits of midable task for patients with ipsilateral pushing. The
their strength and base of support (cone of stability). This degree of difficulty in relearning to maintain balance
implies a need for conscious awareness of their loss of bal- while walking is compounded by changes in somatic sen-
ance. Trial and error is encouraged to promote active sation, strength, motor control, and feedback circuits fol-
problem-solving. Two interventions are suggested for lowing the infarction. Patients must regain some control
402 Stroke Rehabilitation

of trunk in dynamic standing activities before ambulation cord, which cross in the medulla and ascend in the medial
can proceed safely. Visual and tactile goals can be helpful. lemniscus to the thalamus and then to the cortex.
Having patients walk around a high mat or table while Middle cerebral artery strokes can impair awareness
observing themselves in a mirror vertically bisected with of proprioception at the cortical level. Although all sen-
a tape may cue patients where to shift their weight to sations can be affected, proprioception and two-point
avoid falling. The use of parallel bars is discouraged; pa- discrimination are usually more impaired than pain and
tients must learn to weight shift with the trunk to correct temperature perception.12 The deficits are manifested in
balance losses and not merely to pull on a bar to remain the contralateral arm and leg. Cerebellar artery strokes
upright. If safe for both patient and therapist, using the cause loss of the unconscious, rapid proprioceptive in-
mirror and ambulating in free space may be possible with put required for the smooth, automatic movements of
the therapist guarding and stabilizing the affected lower gait. Loss of sensory input regarding agonist-antagonist
limb and trunk side. Patients can advance to using a cane muscle activity disrupts the continuous modulation of
once they have mastered trunk control. Hands-on tech- these muscles that is required for coordinated gait
niques used by the therapist to facilitate movement are movements.
discouraged. The patients simply will push into the hands A study by Kusoffsky, Wadell, and Nilsson54 found that
of the therapist. patients with proprioceptive loss after cortical stroke were
At times, leg weakness interferes with a pusher syn- able to regain a greater amount of function in the leg than
drome patient’s ability to relearn postural control and in the arm. One explanation they gave for this was that
weight shifting. Davies24 advocated splinting the hemi- gait greatly depends on centrally generated activation pat-
paretic knee in extension while having the patient work terns, and these patterns in turn do not depend on periph-
on active weight shifting during functional standing eral sensory mechanisms. These central pattern genera-
activities. Splinting the knee this way might increase tors originate in the spinal cord and are controlled by
loading in the affected patient’s affected leg while stand- locomotor centers in the brainstem. These centers are
ing. One can assume that the added stability somehow influenced by the cerebellum, the basal ganglia, and the
reassures patients and gives them time to assess accu- cerebral cortex.40 The physical therapist can take advan-
rately whether they are balanced. Perhaps the degrees tage of this phenomenon by emphasizing functional gait
of freedom have been limited, allowing patients to con- as much as possible, as with BWSTT.
centrate on one task, weight shifting, to achieve a func- Along with vestibular and visual input, propriocep-
tional goal without having to concern themselves with tive information contributes to a patient’s ability to
an unstable knee. At this time, only speculations can be maintain a stable upright position. Input from muscle
made about what reduces the pushing tendency and spindles and joint receptors provides valuable informa-
why. Although treatment techniques were suggested for tion not only about the position of a limb in space but
gait training patients with contraversive pushing, no also about the environment.45,93 The ability to react to
controlled studies have been done to verify their effi- uneven surfaces or changes in ground texture depends
cacy, and they are based solely on this and other practi- on this input, and its impairment puts a patient at
tioners’ clinical experiences. higher risk of falling. Coordinated limb movements
may be decreased, and the person may be unable to
Proprioceptive Deficits judge the step length or limb joint excursions needed
Loss of sensation after a stroke can compound motor for maneuvering in the environment.
deficits. In particular, loss of proprioception can greatly Vision can help to compensate for the proprioceptive
impede motor recovery after stroke.32 Proprioception is loss.38,45,69,93 As with other deficits, the physical therapist
conveyed to the cerebellum and to the cerebral cortex. should encourage a problem-solving approach. The pa-
Information about joint position and muscle activity is tient must learn consciously to use visual input, which was
sent to both, but the information projected to the cerebel- not necessary before. Occasionally mirrors are useful, al-
lum is not recorded as conscious perception. The infor- though the therapist should evaluate these aids individu-
mation is used to ensure coordinated limb movements. In ally for each patient. Mirrors can hinder as often as they
contrast, the information sent to the cortex can be per- help patients, especially those with visuospatial deficits.
ceived consciously and provides awareness of limb posi- The therapist’s role is to provide a variety of settings
tion and movement.38 in which the person can practice using visual cues. In ad-
Proprioceptive input from muscle spindles, joint re- dition, biofeedback can be used to provide auditory cues.
ceptors, and cutaneous touch receptors reaches the cere- One type of biofeedback unit is a limb load monitor that
bellum through the inferior cerebellar peduncle via the can signal a person when the foot contacts the ground.
ipsilateral dorsal spinocerebellar tracts. The same infor- Standard biofeedback units provide information about
mation reaches the somatosensory area of the cerebral the force of muscle contraction during strengthening
cortex via the ipsilateral posterior columns of the spinal exercises (see Chapter 10).
 Chapter 15 • Gait Awareness 403

Visual Deficits Orthotic Interventions

Visual impairments from strokes also can affect gait. An orthosis (from the Greek adjective orthos, meaning
The most common visual deficit in hemiplegic patients “straight”) is an external device that improves a person’s
is homonymous hemianopsia,95 which occurs when function when applied to a body part.57 The more com-
an infarction involves the optic tract, the lateral genic- monly used term for an orthosis is a brace. Orthoses now
ulate body, or the optic radiation to one occipital cor- are named according to the joints they encompass. Short
tex. A branch of the internal carotid artery, the anterior leg braces are known as ankle-foot orthoses (AFOs). A long
choroidal artery, supplies most of the optic tract and leg brace is known as a knee-ankle-foot orthosis (KAFO) or
the optic radiation, with some coverage by branches of a hip-knee-ankle-foot orthosis if it contains a hip joint and a
the middle cerebral artery and the posterior cerebral knee joint. The newer terminology is more descriptive
artery.95 The visual cortex is supplied mainly by the and specific and avoids confusion.
posterior cerebral artery but also is supplied by some Orthotic devices are prescribed by a physician and fab-
middle cerebral artery collaterals.18 Homonymous ricated by an orthotist. The physical therapist provides
hemianopsia also can result from an isolated occlusion input to the physician and orthotist about which tempo-
of the calcarine branch of the posterior cerebral artery, rary devices have been assessed in the clinic before a per-
but in this case, no concurrent hemiplegia or hemisen- manent orthosis is prescribed. The physical therapist is
sory loss occurs.36 also responsible for gait training the individual with the
When homonymous hemianopsia is present, visual in- orthotic device. Training includes donning and doffing
formation about one half of a person’s environment is instructions, skin inspections, and patient education as
missing. The temporal half of the visual field of one eye well as the actual gait training.
and the nasal half of the visual field of the other eye are Orthotic devices are classified in four categories: stabi-
absent. Loss of the left half of the visual field accompanies lizing (supportive), functional (assistive), corrective, and
left hemiplegia, and loss of right visual field accompanies protective. All orthoses are used to increase function.
right hemiplegia. As mentioned previously, balance is Stabilizing and functional orthoses are the two types
maintained by an intricate communication network be- most often used with stroke survivors. Stabilizing orthoses
tween the visual, vestibular, and proprioceptive systems. If are used to prevent unwanted motion such as plantar flex-
vision is impaired, one aspect of this network is function- ion at the ankle or knee buckling. Functional orthoses
ing abnormally. The ability to maintain balance is at risk have an element that compensates for lost muscle strength
if the patient does not learn to use other systems for feed- by assisting with movement. Stabilizing orthoses are not
back about the environment.22 intended as a way to correct a fixed deformity in an adult;
Self-awareness of the visual deficit is crucial for pa- they only can stabilize and accommodate a deformity.
tients. They must test this new awareness in a variety of Corrective orthoses are used to correct or realign parts of
situations and environments to ensure safety on discharge a limb. They are used for infants and young children to
from the hospital and maximize functional independence help correct flexible skeletal deformities. These orthoses
(see Chapter 16). should not be used to correct a fixed deformity in an adult.
A stabilization orthosis can be used, but only to support
Perceptual Deficits the fixed deformity. Protective orthoses protect a portion
Perceptual deficits such as left neglect or visual neglect of a limb from weight-bearing forces (e.g., a limb with a
are neurobehavioral deficits that can affect gait. These fracture).35
phenomena and their manifestations, causes, and clinical The orthotist adheres to basic physical principles
implications are discussed elsewhere (see Chapters 18 and when fabricating an orthosis to control a weak joint. An
19).10,36 Ipsilateral pushing also may be classified as a neu- orthosis that provides three points of pressure is the most
robehavioral deficit. common type.90 One of the three forces is directed to-
Hemineglect and hemianopsia are separate entities ward the joint itself, and the other two end forces are
that can often coexist.8 Likewise, neglect and sensory loss directed opposite to the main force (Fig. 15-10). This
can develop together or independently. Communication principle is important for the occupational therapist to
between the occupational and physical therapists con- learn because of its relevance to adaptive shoe equip-
cerning a patient’s perceptual status is a necessity and ment. Fig. 15-10, B illustrates the three points of pres-
helps determine the best treatment approach to maxi- sure used with an AFO that is providing a dorsiflexion
mize function and ensure consistency of treatment inter- assist. The main point of pressure is on the dorsum of the
ventions. Information obtained from formal testing by foot. The two counter pressures are at the posterior calf
the occupational therapist can provide valuable insights and the distal plantar surface of the foot. Elastic laces,
for the physical therapist formulating the gait retraining often used to facilitate donning a shoe with stroke survi-
program. vors, eliminate the main point of pressure and result in
404 Stroke Rehabilitation

A B C

Figure 15-10 A, Three points of pressure of an ankle-foot orthosis with dorsiflexion stop.
B, Three points of pressure of a dorsiflexion assist ankle-foot orthosis. C, Three points of
pressure of a locked knee-ankle-foot orthosis. (These illustrations are diagrammatic only.)

loss of orthotic effectiveness. Therefore, elastic laces An AFO is the most commonly used orthosis for pa-
should not be used with dorsiflexion-assist braces. Elastic tients with a hemiplegic gait and is the most appropri-
laces should be used cautiously with solid ankle AFOs ate.60,77,98 An AFO can affect knee motion and ankle
that prevent dorsiflexion (see Fig. 15-10, A) because the motion. Knee buckling can be reduced, in stance, by ad-
foot needs to be held snugly in the AFO and shoe. This justing the amount of dorsiflexion at the ankle joint.
is especially true if plantar flexion spasticity is present. Similarly, knee hyperextension (genu recurvatum) can be
Another orthotic principle states that the longer the avoided by controlling the amount of plantar flexion.
lever arms, the less force needs to be applied at the three Therefore, the therapist can avoid using a heavier KAFO
points of pressure. Therapists need to consider bony land- to control the knee.
marks and superficial nerves when implementing these Plastic orthoses usually are made from high-temperature
principles.90 The orthotic joint axis of motion should be thermoplastic materials such as polypropylene. They re-
aligned with the skeletal joint; otherwise, abnormal pres- quire high temperatures for molding and therefore are
sures can be applied in the wrong areas, such as under calf shaped over a model, such as a plaster cast impression of the
bands, with movement or positioning.35,90 patient’s leg. They are more resistant to continued stress
Orthotic devices can be made of a variety of materials, than the low-temperature thermoplastics used for UL
the most common of which are metal and plastic. Plastic orthoses.
orthoses are in total contact with a limb and are worn The simplest and most commonly used plastic AFO
inside the shoe. Metal orthoses are attached to a shoe and is the posterior leaf splint or spring35 (Fig. 15-11, A ). The
held in place on the limb with straps or bands. leaf spring is used when the main gait deviation is “foot
 Chapter 15 • Gait Awareness 405

types have been designed more specifically for use

with adult hemiplegics.61 The common denominator is
the flexibility allowed by these orthoses, in the foot and
in the ankle. In theory, this flexibility allows more nor-
mal weight-bearing contacts on the plantar surface of
the foot throughout stance, which promotes normal mo-
bility in the foot during stance rather than having the
foot held in one position. Mueller and colleagues61
documented the foot-loading patterns obtained when
using two different tone-inhibiting AFOs. They assessed
biomechanical alignment and foot stability, and one
orthosis—the dynamic ankle-foot orthosis—was found
C to have had significant effects at the lateral forefoot with
A B
respect to force. The authors concluded that this effect
Figure 15-11 A, Posterior leaf splint or posterior leaf orthosis. might support the medial longitudinal arch of the foot
B, Modified ankle-foot orthosis. C, Solid ankle-foot orthosis. and increase the stability of the forefoot as it is loaded.
They theorized that this in turn might allow the forefoot
to be loaded at a faster velocity. They did not investigate
drop” during the swing phase. The orthosis functions as a the effects of correct biomechanical alignment on muscle
dorsiflexion assist device because of its flexibility. The electromyographic activity.
plastic of the calf portion is displaced in stance and then The use of this type of AFO is based on the same prin-
springs back to a 90-degree angle during swing. The ankle ciples that underlie the use of serial casting.19,28 Both were
joint is held at this 90-degree angle during swing. Foot believed, by some practitioners, to reduce abnormal mus-
drop and toe drag are avoided. This orthosis, however, cle activity. However, the scientific literature so far does
does not afford any mediolateral stability at the ankle not confirm that the prolonged stretch afforded by serial
joint. If this is of concern, then the therapist can try a casting has a central inhibitory effect.1,14,19,27,97 Changes in
more substantial orthosis. sarcomere number and connective tissue caused by im-
A modified AFO has a wide calf upright with lateral mobilization, positioning, and stretch can influence mus-
trimline borders that are just posterior to the malleoli cle contraction force.1,14,21,41 In addition, muscle length
(Fig. 15-11, B). Usually the foot plate encompasses more also can influence the manifestation of hyperreflexia.1,20,21
of the lateral and medial borders of the foot. This results Perhaps these mechanical properties of muscle are influ-
in more control of calcaneal and forefoot inversion and enced by tone-inhibiting orthoses. By promoting better
eversion. The increased width of the calf portion offers biomechanical alignment and normal muscle length, these
somewhat more resistance to plantar flexion in swing AFOs may exert an effect on peripheral rather than cen-
and stance. tral factors that, over time, could otherwise augment
The most supportive AFO is the solid ankle AFO stretch reflexes. Further research is needed—especially
(Fig. 15-11, C). The lateral trim lines extend even far- long-term, controlled studies—to investigate the many
ther forward, anterior to the malleoli. Because of its variables that influence motor control and muscle func-
construction, the solid ankle AFO is designed to pre- tion. The term tone inhibiting may have to be reconsidered
vent ankle motion and foot motion in any plane. The until a more complete and universally accepted definition
device controls dorsiflexion, plantar flexion, inversion, of tone exists along with what contributes to normal and
and eversion. abnormal tone.
A variety of hinged plastic AFOs are now available to Metal orthoses were the main type of orthotic devices
allow certain motions and to block others. The ankle joint used before the 1970s.35 Metal AFOs still are used for
components are too numerous to mention, and newer certain stroke survivors who cannot tolerate the total con-
components are being designed continuously. The ortho- tact of a plastic AFO for whatever reason. The compo-
tist can use different combinations of joints and stops to nents usually consist of two metal uprights attached to an
allow, limit, or prevent movement. For example, the thera- ankle joint. The metal is usually aluminum, but some-
pist may wish to allow dorsiflexion past neutral (90 degrees) times heavier steel is needed for control. The ankle joint
in stance to allow normal tibial advancement over the foot is attached to a stirrup that is fastened beneath the heel of
but block plantar flexion at neutral to prevent foot drop in the shoe. The proximal ends of the upright are attached
swing and knee hyperextension in stance. to a calf band.
Another group of plastic AFOs is referred to as tone- The metal ankle joint is usually a single- or double-
inhibiting AFOs. Most of these AFOs initially were de- channel (chamber) type (Fig. 15-12). Other types of
signed for use with children with cerebral palsy.28 Several ankle joints are described in detail elsewhere.21,35,56
406 Stroke Rehabilitation

Screws

Screw
Anterior
Pin and/or chamber Pins and/or springs
springs

A B
Figure 15-12 A, Single-channel (chamber) metal ankle joint. B, Double-channel (chamber)
metal ankle joint.

A single-channel ankle joint can assist dorsiflexion with a

spring placed in the channel. Plantar flexion also can be
limited to prevent genu recurvatum by placing a pin in
the channel. A double-channel ankle joint can prevent
dorsiflexion and plantar flexion by using pins in both
channels. Small screws hold the pins in the chambers.
The degree of dorsiflexion or plantar flexion (i.e., the
ankle joint angle) can be determined by the degree to
which the pins are driven into the channels by tightening
the screws. Springs and pins can be used in combination
to stop one movement and assist another.
The metal uprights attached to the ankle joint and stir-
rup offer a certain amount of foot and ankle mediolateral
control. However, if additional support is needed (e.g., to
prevent severe foot inversion), a strap can be added that
applies pressure to the lateral malleolus in a medial direc-
tion and is secured around the medial upright. Because it
prevents varus positioning of the ankle, the strap is called
a varus correction strap. Force can be applied in the oppo-
site direction with a strap to prevent foot eversion and a
valgus foot position. This strap then is called a valgus cor-
rection strap. A varus correction strap is more common.
Figure 15-13 Veterans Administration Prosthetic Center
The simplest type of metal AFO is the Veterans Ad-
orthosis for dorsiflexion assist.
ministration Prosthetic Center shoe clasp orthosis, which
consists of a single narrow metal upright that attaches to
the heel counter of a shoe with a metal clasp and a calf A KAFO combines the features of an AFO with a knee
strap (Fig. 15-13). The orthosis offers dorsiflexion assist joint and (in the case of a metal orthosis) metal uprights
only, with no mediolateral or plantar flexion control. that extend proximally up the thigh. Thigh bands secure
Occasionally a KAFO with knee locks may be pre- the KAFO on the upper leg. The simplest knee joint is a
scribed for a patient who requires additional knee control. hinge, and the most common locks to maintain knee ex-
However, the additional weight, the prevention of normal tension are drop ring locks.35 The thigh component of
knee joint excursions during swing, and increased energy plastic KAFOs usually is made of the same thermoplastic
cost caused by these factors greatly limit the potential for material as the AFO component. Metal and plastic com-
functional ambulation.60,77,98 In addition, donning and binations also can be used.33,35,56
doffing a KAFO are difficult for hemiplegic patients (see As previously mentioned, KAFOs are seldom used for
Fig. 15-10, C ).98 hemiparetic patients. Occasionally, a preexisting knee joint
 Chapter 15 • Gait Awareness 407

deformity or ligamentous laxity is exacerbated by walking

because of the now weak muscular support. In such in-
stances, no alternative may be available to using a KAFO to
allow minimal household ambulation. A KAFO or a knee
extension splint sometimes is used as an initial training
device to enhance stability. These are used only as tempo-
rary measures and not as long-term orthotic devices.20,60,98
The physical therapist has the responsibility of reeval-
uating the orthotic device on an ongoing basis, especially
in the outpatient or home therapy setting. In this era of
decreased length of hospital stays, patients sometimes are
prescribed an orthotic device while still in the early stages
of recovery. As motor control improves, the orthotic de-
vice may need to be modified or discontinued to allow
more active movement by the patient.

ASSISTIVE DEVICES
The assistive devices most commonly used with stroke
patients are canes, walkers, and occasionally two crutches.
Hemiparetic patients whose balance is impaired mini-
mally and who have functional strength in the opposite
upper extremity may use a cane. Two crutches or a walker
require at least some functional use of both upper ex-
tremities. Both devices provide more external stability,
with the walker providing more stability than the crutches. Figure 15-14 Straight cane.
The main function of a cane is to increase the base of sup-
port and thereby improve balance.86 The base of support
is increased by providing another contact with the floor.
Canes also decrease the need for abductor muscle tension
to stabilize the pelvis in stance on the paretic side.68,86
This in turn helps to prevent dropping of the contralat-
eral pelvis (a positive Trendelenburg sign) in stance when
the cane is used in the hand opposite the hemiparetic leg.
Using the opposite hand also helps simulate the reciprocal
arm and leg movements of a normal gait.
A variety of canes are on the market, ranging from a
simple wooden straight cane to a tripod “walk cane” (also
called a hemiwalker). At a level in between these two canes
are the narrow- and wide-based quadruped canes (quad
canes) (Figs. 15-14 to 15-17). Widening the base of sup-
port provides more stability. Physical therapists may be-
gin training with a wide-based cane because of hemipare-
sis and impaired balance. They should advance patients as
quickly as possible to the least amount of assistance re-
quired to ensure a safe, stable gait. Patients often are kept
inadvertently on a maximally wide base of support cane
when it is no longer needed. This prevents the patient Figure 15-15 Wide-based quad cane.
from maximizing functional ambulation for two reasons:
(1) normal weight shifting to the hemiparetic leg is lim-
ited, and (2) cadence is slower than it is with a smaller Two crutches occasionally are used: axillary or (more
device86 or no device. The key word is safety. Maximum often) forearm (Lofstrand) crutches (Fig. 15-18). Certain
use of the involved leg should be encouraged along with cerebellar stroke patients or others who have impaired
normal trunk and pelvic movement, if patient safety is not balance but functional use of both arms and hands may
compromised. be trained with these devices. These patients require the
408 Stroke Rehabilitation

Figure 15-16 Narrow-based quad cane.

Figure 15-18 Lofstrand crutch.

may use walkers when it is necessary for them to transport

objects around the house (e.g., in the kitchen).
Standard walkers are the most stable assistive devices
because they provide four points of contact with the
ground. The base of support is greatly increased. A variety
of walkers are available as well. In addition to standard
walkers with four legs, rolling walkers with front wheels
only, with four wheels, and platform attachments are also
available. Rolling walkers allow a more normal reciprocal
gait, but the therapist must take care to prevent the walker
from “running away” with the patient. A stroke survivor
with insufficient arm and hand strength to lift a walker
may have the ability to maintain a grip on the rolling
walker and push it forward. Some walkers have pressure-
sensitive brakes that prevent forward movement when the
patient pushes down on the walker.
As mentioned in the cerebellar stroke section, pos-
tural control sometimes is sacrificed for stability when a
walker is used. The patient has no need to relearn bal-
Figure 15-17 Hemiwalker or walk cane. ance and control if the walker provides needed support.
As mentioned, safety is the ultimate concern. If safe,
extra postural support afforded by the second crutch but functional ambulation is not possible without a walker,
have enough motor control to be able to advance the then safe, independent ambulation with a walker is the
crutches reciprocally. preferred choice.
Therapists may use walkers for training stroke patients The type of gait pattern taught to the stroke survivor
who have functional use of both arms and hands but need depends on a number of factors, including balance,
greater outside support than that afforded by two crutches. strength, and coordination.68,86 The therapist also should
Occasionally a walker may allow functional use of a hemi- consider cognitive and perceptual deficits, including
paretic arm even though balance is sufficient with a cane. apraxias.
In this case, the patient also should practice gait training Smidt and Mommens89 suggested terminology for
with a cane to promote optimum postural control. If pa- describing walking patterns. Point refers to the number
tients have sufficient control of the paretic arms, they also of contacts made with the floor, including with feet and
 Chapter 15 • Gait Awareness 409

assistive devices, during the forward progression of the Progression

gait cycle (Figs. 15-19 and 15-20). For example, a four- Begin
point contralateral gait indicates that two feet and two new Begin
assistive devices (such as canes being advanced one at a cycle cycle Start
time) are being used (see Fig. 15-20, A). The more con- 3
tacts on the floor at any given moment, the more stable 2 R
Four point
the person is while walking. In addition, the pattern can contralateral
4 L (two devices)
be called a delayed pattern if the assistive device is ad- 1 1
vanced before the limbs. Delayed patterns provide more A
stability than moving a limb concurrently with an assis-
tive device. Following are the most common gait pat- Delayed two point
2 R
terns taught to stroke patients. contralateral
3 L (left hand, right foot)
1 1
GAIT PATTERNS B
Two-Point Contralateral Gait Pattern Using One
Device 3 R Delayed two point
2 L (ipsilateral—left)
Hemiparetic patients with a nonfunctional arm often are 1 1
taught a two-point contralateral gait pattern using one C
assistive device. A device, such as a cane, is held in the
1 1
unaffected hand. The cane and the paretic leg are ad-
3 R Delayed three
vanced together (one point), and then the unaffected leg point—left
2 L
is advanced alone (second point) (see Fig. 15-19, B). The 1
cane may be advanced first and then the paretic limb fol- D
lowed by the unaffected limb for a more stable pattern.
Figure 15-20 A to D, Diagrammatic view of assisted gaits.
(From Smidt G, Mommens MA: Gait patterns. Phys Ther
Progression 60(5):553, 1980.)
Begin
new Begin
cycle cycle Start
This pattern is a delayed contralateral two-point gait
2 pattern (see Fig. 15-20, B). In Figs. 15-19, B and 15-20, B
1 1 R Two point contralateral
the right leg is the hemiparetic leg.
2 L (two devices)
1 1
Four-Point Contralateral Gait Pattern Using Two
A Devices
The devices used in a four-point contralateral gait pattern
1 1 R Two point contralateral
could be canes or crutches. The therapist might choose
2 L (left hand, right foot) this type of gait for stroke patients who have functional
1 1 use of all four limbs but have impaired balance. They re-
B quire bilateral support but are able to advance each device
(two points) and each leg (two points) individually and
2 R
reciprocally. Although this is a stable gait pattern, it is not
Two point ipsilateral
1 1 L (left hand, left foot) used often with hemiparetic patients. Sometimes a patient
1 1 recovering from a cerebellar stroke will be taught this pat-
C tern to encourage coordinated reciprocal arm and leg
movements and postural control.
1 1
2 R Two-Point Contralateral Gait Pattern Using Two
Three point—left
1 1 L
Devices
1 1
D If the previously mentioned patients regain sufficient
postural control, they might be advanced to using a two-
Figure 15-19 A to D, Diagrammatic view of assisted gaits. point contralateral pattern (see Fig. 15-19, A). They
(From Smidt G, Mommens MA: Gait patterns. Phys Ther still would be using two crutches or canes but would be
60(5):553, 1980.) moving one device and the opposite leg simultaneously
410 Stroke Rehabilitation

(one point) followed by the other device and opposite leg

(second point). Three-Point Gait Pattern Using Two Devices
Three-point gait patterns seldom are used with stroke
Five-Point Gait Pattern Using One Device patients and are used more often with patients who have
Therapists may train patients with a walker if they have orthopedic conditions requiring weight relief on one leg
functional control of all four extremities but require (see Figs. 15-19, D, and 15-20, D).
greater trunk control than that afforded by a cane. For
example, certain patients who have had cerebellar strokes GUARDING TECHNIQUES
may never recover adequate postural stability to be able
to use two canes. A walker allows the patient to use five The goal of gait training after stroke is to have the patient
points of contact: the four legs of the walker and one walk as efficiently, safely, and independently as possible.
of the patient’s legs. The patient advances the walker To promote optimum functional ambulation, it is impor-
simultaneously with one leg and then places all four of tant for the patient to experience postural instability and
the walker legs firmly on the floor at the same time as to relearn the way to correct these imbalances.
the patient’s foot. This pattern is called a five-point gait With this in mind, the therapist must be as close to
pattern (Fig. 15-21, B). If the patient moves the walker patients as necessary to prevent them from falling or
first, followed by the patient’s leg, the pattern is called a injuring themselves and yet not inhibit them from
five-point delayed gait pattern (Fig. 15-21, A). Other au- learning the way to right themselves. Therapists must
thors refer to this gait pattern as a “3-1-point” or “mod- allow patients to take some risks without jeopardizing
ified 3-point” pattern.79 The basic sequence is the same, the patients’ safety or their own safety. This is not an
however. easy task, especially for new therapists. The ultimate
Therapists may train previously mentioned patients horror for any therapist is having a patient fall. Obvi-
with a rolling walker. They may choose this device for ously, until therapists are comfortable with patients and
two reasons: (1) the walker is in constant contact with the know how much, if any, outside support they need,
floor while being advanced, therefore affording maximal guarding too much is better than guarding too little.
postural control; and (2) the walker is in constant motion, Regardless, the goal always should be safe, optimal
and the patient is able to take equal step lengths and to function, and the therapist needs to reevaluate on an
increase speed. With the standard walker, the patient is ongoing basis how much guarding is needed and in what
forced to use a “step-to” type of gait pattern (the walker type of setting and on what type of surface activities
is advanced, then the foot, then the other foot) that pre- should be performed.
vents a normal stride and limits velocity.89 In making the Hemiparetic patients walking with a cane most often
decision to use a rolling walker, the physical therapist are guarded on the weaker side. The therapist stands
also must consider the patient’s ability to control the slightly posterior and lateral to the affected side.79,86 The
continuous forward motion of the walker, as mentioned therapist is then in the best position to assist the patient.
previously. Should patients lose their balance or stumble, they may
have difficulty preventing a fall to the weaker side because
of decreased sensation and decreased strength and control
Progression of the paretic leg. The therapist can control patients with
Begin the hand closest to them at the hip or pelvis and can con-
new Begin trol patients’ shoulder and trunk with the other hand if
cycle cycle Start necessary.
1 1 1 1
The use of gait belts or guarding belts varies from
3 R Delayed five
therapist to therapist and from institution to institution,
2 L point—left but most facilities advocate their use in the initial stages of
1 1 1 1 gait training and on stairs. The patient’s safety is of the
A utmost concern. At times, a patient is uncontrollable
without a gait belt. Other times, the belt can be a hin-
1 1 1 1
drance to patients relearning postural control if the thera-
2 R Five
1 1 L point—left pist is inadvertently tugging on the belt with every step.
1 1 1 1 Therapists must evaluate each patient individually. The
B size of the patient in comparison to the therapist also may
need to be considered. The therapist should decide which
Figure 15-21 A and B, Diagrammatic view of assisted gaits. anticipatory actions need to be taken to protect the pa-
(From Smidt G, Mommens MA: Gait patterns. Phys Ther tient from harm based on clinical assessment and sound
60(5):554, 1980.) judgment.
 Chapter 15 • Gait Awareness 411

When guarding a patient who is ascending stairs, the

putamen in the territory supplied by the lenticulostri-
therapist is positioned posterior and to the weaker side.
ate branches of the right middle cerebral artery. The
The patient should be trained using a railing at the stron-
cause of the infarct was probably an embolus of car-
ger side. Initially, the therapist may teach the patient to
diac origin that developed after the mitral valve re-
ascend one step at a time, leading with the stronger leg.
pair. H.C. was prescribed anticoagulant medication
When the patient is descending, the therapist stands in
and was stabilized medically. Twelve days later, he was
front of and lateral to the affected side so as to provide
transferred to the rehabilitation unit of the same
assistance if the patient’s knee buckles. Using the railing,
medical center.
the patient steps down one step at a time, leading with the
On admission to the rehabilitation unit, H.C. had
paretic leg. A patient who regains functional strength of
symptoms of a pure motor syndrome with left upper
the paretic leg may advance to the step-over-step method
extremity weakness that was greater than the left leg
of stair climbing, with close guarding by the therapist.
weakness, minimal left lower facial droop, and no sen-
Ascending and descending stairs with only a cane or two
sory loss. He was alert and oriented and most coopera-
canes is difficult and requires excellent balance. Some
tive although somewhat deconditioned because of the
home environments may necessitate such training, but it
previous cardiac surgery.
should be undertaken with sufficient guarding, and the
Physical assessment revealed normal passive range
therapist carefully should weigh the safety risks.
of motion of the left arm and leg, although both legs
Guarding techniques need to be taught to family
manifested tight hamstrings and could perform only a
members as soon as possible during inpatient rehabilita-
straight leg raise to barely 60 degrees. A finger-width
tion. Family participation in gait training provides the
subluxation was present in the left shoulder. Strength
opportunity for practice and repetition of newly learned
testing revealed that the left arm was grossly 2 to 3 out
techniques.
of 5 throughout. He was able to extend the left knee
completely while sitting (3 out of 5), but the hip flexors
CASE STUDY were weaker (2 out of 5). He exhibited no isolated vol-
Gait Training after Stroke untary ankle movement, although dorsiflexion was 2
out of 5 with simultaneous flexion of the hip and knee,
This case study in no way reflects the patient’s whole and plantar flexion was 2 out of 5 during simultaneous
treatment program because emphasis also is placed on extension of these proximal joints. He did not at that
increasing strength and function in the trunk and left time (or ever) exhibit any spasticity in the limbs during
arm and in the leg. In addition, frequent sessions of passive testing by the therapist, with the exception of
cotreating by the occupational and physical therapists mild, unsustained ankle clonus. He exhibited no ankle
occurred to enhance communication about specific edema despite the leg weakness and previous vein graft
treatment concerns (e.g., the subluxed shoulder) and for the coronary artery bypass graft surgery.
functional goals. His gait was evaluated initially while he was walking
H.C. is a 54-year-old male who was admitted to the around a high mat with his right side next to the mat,
emergency room of a university medical center with sud- using his right arm and the mat to “unload” the left leg.
den onset of left-sided weakness. Two weeks earlier, he During static standing, he required contact guarding
had undergone a mitral valve repair and a single coronary and verbal cues to extend the left hip and knee actively.
artery bypass with a left saphenous vein graft. He had had He had a tendency to bear most of his weight on the
an uneventful postoperative recovery course and was stronger right leg. When cued to stand with equal
discharged to his home and prescribed a -blocker. weight on both legs, he was unable to maintain an up-
On admission, the neurological workup and results right posture and would fall to the left because the knee
included: (1) a computerized tomography scan of the would buckle. He required minimal assistance to main-
head showing early lucency in the right subcortical tain the hip and knee in extension when bearing weight
area; (2) noninvasive flow studies (on the second day) symmetrically.
showing accelerated flow velocities in the right middle Initially he was able to take 10 steps around the mat
cerebral artery suggestive of stenosis and normal flows with minimal assistance. His gait analysis was as
in the anterior cerebral arteries, posterior cerebral ar- follows: Uneven step lengths were observed; the left
teries, and basal artery; and (3) a transesophageal echo- was greater although less controlled than the right.
cardiogram revealing trace mitral regurgitation, nor- The shorter step with the right leg resulted in a “step-
mal left ventricular function, and no intracardiac or to” type of gait pattern—the right leg stepping to meet,
aortic mass or thrombus. instead of pass, the left leg. He exhibited a decrease in
The attending neurologist concluded that H.C. single-limb stance time on the left leg. His cadence was
had suffered an infarct in the right corona radiata and slow—approximately 40 steps per minute.
Continued
412 Stroke Rehabilitation

CASE STUDY
either of these abnormal positions even if he could not
Gait Training after Stroke—cont’d
always prevent them.
During the left leg stance, the heel did not strike at H.C. quickly advanced from ambulation around the
initial contact; the foot was flat. The loading response high mat to ambulation with a narrow-based quad cane
resulted in excessive knee flexion that was greater and then a straight cane. He had the advantage of recov-
than the normal 10 to 15 degrees. To prevent buck- ering much of his hip extension and abduction strength,
ling in midstance, the knee snapped back into hyper- which meant he did not require a large degree of outside
extension (genu recurvatum). Instead of bringing his support from an assistive device for these muscles.
body forward by allowing the tibia to advance over Functional training included standing balance re-
the foot (dorsiflexion), he kept the ankle angle fixed training in single-limb and double-limb weight-bearing
and flexed the hip and trunk over the foot. He did not positions. Modified versions of activities that the pa-
push off at the end of stance. Instead, he quickly took tient previously had enjoyed (soccer) and a few new
a short step with the right leg to unload the left one ones (golf putting and baseball) were introduced. H.C.
as soon as possible. practiced ambulation in a variety of environments and
Because the resulting right leg position was next to on both even and uneven terrains in preparation for
the left leg instead of beyond it, the left leg was unable discharge. H.C. even practiced getting through busy
to assume the normal preswing position of hip exten- revolving doors.
sion and 40-degree knee flexion (see Fig. 15-4). Instead, After 6 weeks of inpatient rehabilitation, H.C.
the left hip and knee were in full extension, and he was was evaluated for a permanent AFO. His left leg
forced to initiate swing on the left from this position. strength had improved enough to allow him to iso-
During the swing phase of the left leg, H.C. exhib- late dorsiflexion and plantar flexion in any position
ited decreased hip and knee flexion and a foot drop grossly in the 2 out of 5 range, ankle inversion and
because of the weak dorsiflexors. This resulted in his eversion in the 2 out of 5 range, and toe flexion and
toes scraping the floor. He displayed mild lateral trunk extension in the 1 out of 5 range. His hip flexors
flexion to the right in an attempt first to initiate swing improved minimally to 2 out of 5, and knee exten-
from the previously mentioned abnormal preswing sion also improved minimally to 3 out of 5.
position and then to clear the toes throughout the During ambulation, H.C. continued to manifest
swing phase. knee recurvatum in stance and did not push off at the
H.C. was put on a program of active assistive range end of stance because of weak plantar flexors. During
of motion and strengthening exercises for the left arm swing, he continued to exhibit a foot drop and toe drag.
and leg. Treatment of the leg emphasized functional The physiatrist, physical therapist, and orthotist per-
strengthening in weight-bearing positions (e.g., sit-to- formed a joint observational gait analysis. Because of
stand exercises for hip and knee strengthening). the continued plantar flexor and dorsiflexor weakness
During the initial stage of gait training, a posterior during the swing and stance phases and less than nor-
leaf splint orthosis was used to assist with dorsiflexion mal knee extension strength, they decided that H.C.
during the swing phase on the left side. This splint was required minimal knee control and ankle control from
chosen to encourage a more efficient swing phase and an AFO. In addition, the weak ankle invertors and ever-
to discourage the patient from leaning to the right to tors necessitated mediolateral control by an orthosis.
clear the left leg during swing. Because of its flexibil- Therefore a posterior leaf splint was deemed insuffi-
ity, the posterior leaf splint did not restrict activity at cient. However, because H.C. was continuing to prog-
the left ankle or knee during stance. Although the ress and did not require maximum support at the knee,
knee was unstable, H.C. was still in the early stages of a solid ankle AFO was also inappropriate. The general
recovery. Sacrificing mobility for stability (i.e., block- consensus was that H.C. should be allowed to have as
ing any ankle dorsiflexion and knee flexion in stance) much movement at the ankle as possible without jeop-
was not beneficial. Doing so would have forced him to ardizing his safety to promote development of a normal
move compensatorily because it is normal to dorsiflex gait pattern.
up to 10 degrees at the ankle during midstance and For this reason the team decided to order a hinged
terminal stance. The therapist offered close supervi- polypropylene AFO with free dorsiflexion at the ankle
sion to contact guarding at the knee because of possi- and a plantar flexion stop at 90 degrees. The hinged ankle
ble knee buckling resulting from excessive dorsiflex- with free dorsiflexion allowed him to move the tibia nor-
ion. H.C. was taught to be aware of the difference mally over the foot (dorsiflexion) in midstance and termi-
between excessive knee flexion and recurvatum. He nal stance. The plantar flexion stop at 90 degrees pre-
was soon able to identify correctly when he was in vented foot drop in swing and recurvatum in stance. The
 Chapter 15 • Gait Awareness 413

gait. Although patients who received training improved

orthosis improved his gait by allowing the normal joint their standing symmetry significantly, training did not
excursions at the knee and ankle in stance while prevent- translate into improved weight shifting during ambula-
ing abnormal movements in stance and swing. The pro- tion. This study clearly demonstrates the hazards of as-
motion of normal joint excursions at the ankle in stance suming that transfer of training occurs from a part of one
allowed him to take equal step lengths with both legs. functional task to another. For example, it would be con-
On discharge to his home, H.C. was able to ambu- venient to assume that the techniques used to improve the
late independently indoors with a straight cane and the standing balance of a patient with contraversive pushing
hinged AFO, but he required supervision outdoors. He will improve the ability to walk. However, no evidence as
was able to ascend and descend stairs step-over-step us- yet supports this theory. Further research such as that of
ing a railing and ascend and descend curbs and ramps Weinstein and colleagues99 is imperative for therapists to
with the straight cane, all with distant supervision. He validate the rationales for their treatment procedures for
could perform simple home exercises independently for stroke patients. To do otherwise denies the patient the
left leg and arm strengthening. He returned to work most beneficial treatment approach.
as a full-time university professor and continued with The case study was unusual because the patient exhib-
outpatient physical therapy three times a week for six ited no spasticity and had voluntary, isolated control of all
months after discharge. He regained full functional use muscles but had decreased strength. However, several
of the left upper extremity including finger function authors questioned the role of spasticity in preventing
(albeit with decreased coordination), fine motor con- normal movement1,20,21,44 and pointed to weakness as the
trol, and strength. He also continued to receive occupa- more limiting factor. Spasticity is well-known to increase
tional therapy for several months as an outpatient. the incidence of muscle contracture and thereby alter the
biomechanical efficiency of a muscle.1,20,21,29,41,44 In this
respect, only the ankle joint was at risk and minimally so.
SUMMARY The patient was a model patient for other reasons. He was
not cognitively impaired, and he was motivated to return
The aim of this chapter is to familiarize the occupational to work. He was aware (although grudgingly at times) of
therapist with processes used by physical therapists during the need for faithful adherence to a regular exercise pro-
gait evaluation and training of patients who have had a gram of repeated practice of newly learned motor skills.
stroke. The most common type of gait disorders are those Therapists always should be aware of the need for care-
resulting from a middle cerebral artery infarction. ful physical assessment, individualized treatment pro-
The application of orthotic devices is not an exact sci- grams that are based on research findings, and ongoing
ence. To assume that a particular abnormal gait always reevaluation of the effectiveness of the treatment program
requires one specific type of orthotic device is not accu- in promoting optimum function.
rate. Therapists must evaluate devices on an individual
trial basis. Use of a specific device or pattern requires in- REVIEW QUESTIONS
dividualized attention.
Those well-versed and experienced in motor control 1. What constitutes a gait cycle?
research20,39,42,44,99 believe that the trend in physical therapy 2. What are the phases and subphases of the gait cycle?
is moving away from earlier theoretical models of treat- 3. What are step, stride, and cadence?
ment techniques and toward a motor control model. The 4. What tests would you perform to assess gait speed
emphasis is no longer on specific treatment techniques to and gait endurance?
“facilitate” movement but on active problem-solving by the 5. What type of cerebral infarct is associated with the
patient to promote skilled movement and motor relearn- typical “hemiplegic gait”?
ing. The practice of specific tasks is to be emphasized dur- 6. What are some of the variables that can cause a de-
ing intervention. Treatment programs need to be based on viation from the normal joint excursions during a gait
specific motor control deficits, which may require modifi- cycle?
cation or emphasis in the practice of a task which is mean- 7. In what way does the motor control model differ
ingful to the patient and which takes place in numerous from the more traditional theoretical models under-
environments. All of the gait intervention research pre- lying the different therapeutic techniques?
sented in this chapter support this model. 8. How might ambulation recovery be related to hip
One can no longer assume that certain treatment tech- osteoporosis?
niques are effective. Effectiveness needs to be validated by 9. What are some of the manifestations of a posterior
research. As presented earlier, Weinstein and colleagues99 inferior cerebellar stroke?
examined the effect that balance-training and weight 10. What makes treatment of patients demonstrating
shifting activities during standing had on the hemiplegic contraversive pushing so challenging?
414 Stroke Rehabilitation

11. What helps compensate for proprioceptive loss after 19. Carlson: A neurophysiological analysis of inhibitive casting. Phys
stroke? Occup Ther Pediatr 4(4):31–42, 1984.
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 g l en g i l l en

chapter 16

Managing Visual
and Visuospatial Impairments
to Optimize Function*

key terms
accommodation hemianopsia stereopsis
diplopia orthoptics strabismus
field cut pursuits vergence
fixation saccades
figure ground impairment spatial relations

chapter objectives
After completing this chapter, the reader will be able to accomplish the following:
1. Understand how visual information is processed by the central nervous system.
2. Understand how everyday living is affected if visual and spatial impairments are present.
3. Be aware of procedures to perform a visual screening after a brain injury.
4. Implement at least five intervention strategies focused on decreasing activity limitations
and participation restrictions for those living with visual and spatial impairments.

“Vision is our dominant sense: More than just sight is mea- VISUAL PROCESSING DURING FUNCTIONAL
sured in terms of visual acuity; vision is the process of deriving ACTIVITIES
meaning from what is seen. It is a complex, learned, and
developed set of functions that involve a multitude of skills. The visual system is commonly impaired after brain
Research estimates that eighty to eighty five percent of our damage. Typical visual impairments include visual field
perception, learning, cognition and activities are mediated deficits, loss of ocular alignment or control, diplopia, and
through vision.” 41 changes in visual acuity.2,47 Further complex impairments
include spatial relations impairments as is discussed later,
visual agnosia (see Chapter 19), neglect of visual informa-
*This chapter is predominantly excerpted from Gillen G: Cognitive and tion contralateral to the brain injury (see Chapter 19),
perceptual rehabilitation: optimizing function. Elsevier, 2009, St. Louis. and so on. In order for one to use vision to support

417
418 Stroke Rehabilitation

participation in daily activities, visual information must visual search is supported by rapid intermittent eye move-
be correctly received and recognized (Table 16-1). ments (saccades) that occur when the eyes fix on one point
The ultimate function of visual processing is to support after another in the visual field. Each eye is controlled by
participation in daily activities via appropriate motor and/ six muscles (Fig. 16-2). These muscles in turn are con-
or cognitive response. A relationship exists between visual trolled by three cranial nerves (cranial nerve III or oculo-
impairments after acquired brain damage and difficulties motor, IV or trochlear, VI or abducens).
with activities of daily living (ADL), increased risk of falls, The frontal eye fields within the premotor cortex sup-
and poor rehabilitation outcome.17 Visual processing in- port visual search and guide gaze shifts. The image
volves a complex system of peripheral and central struc- “lands” on the nasal hemiretina of the left eye and the
tures. Compromised integrity of any of the structures temporal hemiretina in the right eye once the milk is lo-
impedes functional performance. To illustrate this com- cated in the left visual field. The information is mobilized
plexity, the following examination of processing visual posteriorly via the optic nerve. At the point of the optic
information is based on the example of searching for a chiasm, information from the right eye’s temporal
gallon of milk that is stored in the left side of the refrig- hemiretina remains ipsilateral in the right hemisphere,
erator. Fig. 16-1 outlines the visual pathways within the and the information from the left eye’s nasal hemiretina
central nervous system. crosses into the right hemisphere.2,58 Therefore, visual
Once the refrigerator is opened, a variety of eye move- information from the left visual field is processed in the
ments occur to locate the milk. This usually systematic right hemisphere. The optic tract projects to the lateral

Table 16-1
Visual Skills and Their Associated Functions and Resulting Dysfunctions after Stroke2
VISUAL SKILL VISUAL FUNCTION VISUAL AND PERCEPTUAL DYSFUNCTIONS

Visual acuity Clarity of vision at near point and distance; Vision blurred in one or both eyes consistently or
20/20 refraction inconsistently; visual fatigue; task incompletion

Accommodation Process of focusing whereby the lens changes Blurred vision; inattention; poor concentration;
curvature so that various viewing distances eyestrain; visual fatigue
remain clear
Visual fields The peripheral area of vision up, down, in, and Inability to read or starting to read in the middle of
out when both eyes are positioned straight the page; ignoring of food on one half of the plate;
forward difficulty orienting to stimuli in specific areas of space
Oculomotor Ability of both eyes to move within the six Excessive head movement; frequent loss of place;
range of mo- cardinal positions of gaze (right, left, inferior, skipping of lines; poor attention span; slow copying;
tion; fixation; superior, inferior oblique, superior oblique); difficulty when driving, reading, writing; difficulty
saccades and maintenance of gaze for 10 seconds; small tracking in all planes
pursuits precise eye jumps; following a moving stimulus
Vergence The ability to bring the eyes together smoothly Difficulty focusing; decreased depth perception;
and automatically along the midline to observe difficulty and confusion in interpreting space;
objects singly at near distance (convergence) decreased eye-hand coordination in self-care
or to move the eyes outward for single vision and hygiene; difficulty in driving, sports,
of distant objects (divergence) communication, and ambulation
Strabismus Deviation of one eye or one eye at a time from Esotropia (inward turn); exotropia (outward turn);
the object of regard, where the eye not in use hyperopia (upward turn); hypopia (downward turn);
is turned double vision or suppression; decreased eye-hand
coordination during mobility tasks; overreaching or
underreaching; difficulty with reading and near tasks
Functional Ability to read or write from left to right Omitting letters, words, numbers; losing place when
scanning precisely and smoothly without errors returning to next line; exaggerated head movement;
using finger as pointer; abnormal working distance
Color Ability to perceive colors Muddy or impure color; color may fade out; difficulty
perception finding items by color
Stereopsis Depth perception and its relationship to Problematic binocular system; deficits in three-
spatial judgment dimensional perception; decreased spatial judgment,
especially in fine motor areas
 Chapter 16 • Managing Visual and Visuospatial Impairments to Optimize Function 419

Right visual
Visual field
Left visual
At this point the visual information has reached the
hemifield hemifield primary visual cortex in the occipital lobe around the cal-
carine fissure involved in reception of the visual informa-
Nasal tion. If damage occurs bilaterally around the calcarine
Temporal
hemiretina fissure, the presentation is usually that of cortical blind-
hemiretina of the eye
Temporal ness.3,5 Those living with cortical blindness can usually
Optic nerve hemiretina of the eye
detect lights and movement but otherwise the visual im-
Optic nerve
Optic tract pairment is severe. Following the processing that occurs
Optic chiasm
Lateral in the primary visual cortex, the visual information is mo-
geniculate body Optic tract bilized to the visual association cortex. Two pathways
Lateral allow for sophisticated examination of incoming visual
Optic radiation
geniculate body information:2,3,5,58
Posterior corpus 1. The ventral stream or inferior occipitotemporal
callosum Optic radiation
pathway functions include object recognition via
Occipital cortex: Occipital cortex: vision, perception of color (e.g., the milk is in a red
right hemisphere left hemisphere
A container), recognition of shapes and forms (the
milk is in a rectangular carton), and size discrimina-
Visual Superior optic tion (a quart of milk is smaller than a half gallon).
association radiation
cortex Information from this pathway helps to answer the
question, “What am I looking at?”
2. The dorsal stream or the superior occipitoparietal
pathway functions include visuospatial perception
(the milk is on the top shelf toward the left and
Central behind the butter) and detection of movement. In-
B Primary visual Inferior Visual
cortex visual Peripheral optic stimulus formation from this pathway helps to answer the
field vision
radiation question: “Where is the object located?”
Figure 16-1 The visual pathways. A, Inferior view depicting flow
of information from the visual fields to the visual cortex (visual VISUAL SCREENING
fields  180 degrees). B, Medial view of components of the visual
cortex and visual processing. (A, From Aloisio L: Visual dysfunc- Several authors have described the components of a vision
tion. In Gillen G, Burkhardt A, editors: Stroke rehabilitation: a screening.2,55,56 Prior to developing an intervention plan,
function-based approach, ed 2, St Louis, 2004, Mosby. B, From a clinician must determine whether difficulties engaging
Árnadóttir G: The brain and behavior: assessing cortical dysfunction in functional activities are due to a visual deficit, a cogni-
through activities of daily living, St Louis, 1990, Mosby). tive or perceptual deficit, or a combination of both. Many
dysfunctional behaviors observed or mistakes made dur-
ing attempts at performing a functional activity can be
geniculate nucleus of the thalamus because the lateral attributed to one or several underlying impairments that
geniculate nucleus is the principal subcortical structure must be differentiated. A person who is having difficulty
that carries visual information to the cortex.58 The optic searching for paperclips in a cluttered drawer may be pre-
radiation “fans out” and carries the visual information to senting with poor visual acuity (a decrease in the clarity of
the primary visual cortex around the calcarine fissure in vision) versus living with figure-ground impairment (the
the occipital lobe. inability to differentiate foreground from background),
During the radiation, fibers carrying information from necessitating visual acuity testing prior to developing an
the inferior visual field run posteriorly through the pari- intervention plan. Similarly, a person who misses the glass
etal lobe, whereas fibers carrying information from the when pouring juice from a container may be presenting
superior visual field loop around the temporal lobe on with a spatial relations impairment related to judging
their way to the visual cortex in the occipital lobe.2,58 Any depth or distance versus living with diplopia (double-
lesion in this retino-geniculate-cortical pathway will re- vision) versus living with monocular vision (information is
sult in a loss of visual fields (Fig. 16-3). The distribution only obtained via one eye). Finally, not being able to iden-
(e.g., nasal, temporal, inferior, superior, homonymous) of tify an object on a bathroom sink by vision alone may be
the visual field loss is usually determined by the point of an issue related to decreased visual acuity versus living
injury. The function of the pathway discussed thus far is with a figure-ground impairment (e.g., not able to identify
to move the visual information from the retina to the a white bar of soap on a white sink) versus living with poor
cortex, and the direction of flow is primarily anterior to contrast sensitivity versus not recognizing the visual in-
posterior. formation received by the cortex (visual agnosia).
420 Stroke Rehabilitation

Superior view

Lateral
Lateral view rectus

Trachlea Lateral rectus Superior rectus Superior oblique

Medial
rectus
Levator (cut)
Superior
oblique
Optic
nerve Superior
rectus

A B
Inferior oblique Inferior rectus
Figure 16-2 The origins and insertions of the extraocular muscles. A, Lateral view of the left
eye with the orbital wall cut away. B, Superior view of the left eye with the roof of the orbit cut
away. (From Goldberg ME: The control of gaze. In Kandel ER, Schwartz JH, Jessell TM,
editors: Principles of neural science, ed 4, New York, 2000, McGraw-Hill.)

A correlation study of adults who sustained a stroke ■ Pursuits: The ability to smoothly and accurately
and received occupational therapy examined the rela- track or follow a moving object (e.g., watching your
tionship between basic visual functions (defined as acu- dog run through the yard).
ity, visual field deficits, oculomotor skills, and visual at- ■ Saccades: The ability to quickly and accurately look
tention or scanning) and higher level visual-perceptual or scan from one object to another (e.g., reading or
processing skills such as visual closure and figure- watching a soccer game and trying to locate a certain
ground discrimination. The study suggested that a player).
positive relation exists (r0.75) between basic visual ■ Accommodation: The ability to accurately focus on
functions and visual-perceptual processing skills. The an object of regard, sustain focusing of the eyes, and
authors further concluded that the results suggest that change focusing when looking at different distances
evaluation of visual-perceptual processing skills must (e.g., maintaining focus when you look from up from
begin with assessment of basic visual functions so that a textbook to a clock and back to the textbook).
the influence of these basic visual functions on perfor- ■ Vergence: The ability to accurately aim the eyes at
mance in more complex tests can be taken into consid- an object of regard and to track an object as it moves
eration.47 Therefore, it is recommended that a visual toward and away from the person (e.g., watching
screening occur prior to or in conjunction with a full people walking toward you [convergence] and away
cognitive and perceptual evaluation (Box 16-1). Exam- from you [divergence] in the mall).
ples of components of a visual screening include near The Brain Injury Visual Assessment Battery for Adults
and far acuity, visual field testing, ocular range of mo- (biVABA)55 is an example of a battery that includes stan-
tion or control, ocular alignment, contrast sensitivity, dardized assessments for evaluation of the visual functions
and the like. These skills are often considered the foun- important in ensuring that visual perceptual processing is
dation skills for visual processing.2,53,54 accurately completed:
Specific visuomotor abilities that should be assessed ■ Visual acuity (distant and reading)
include the following: ■ Contrast sensitivity function
■ Fixation: The ability to steadily and accurately gaze ■ Visual field
at an object of regard (e.g., examining the detail of a ■ Oculomotor function
painting in a museum). ■ Visual attention and scanning
 Chapter 16 • Managing Visual and Visuospatial Impairments to Optimize Function 421

Defects in
visual field of
Left eye Right eye

1
Left Right

1 2
2 Optic
Optic nerve
chiasm
3 Optic 3
tract
4
4
Optic Lateral
radiation geniculate
body
5 5

6
6

Figure 16-3 Deficits in the visual field produced by lesions at various points in the visual
pathway. The level of a lesion can be determined by the specific deficit in the visual field. In the
diagram of the cortex, the numbers and the visual pathway indicate the sites of lesions. The
deficits that result from lesions at each site are shown in the visual field maps on the right as
black areas. Deficits in the visual field of the left eye represent what an individual would not see
with the right eye closed rather than deficits of the left visual hemifield. (1) A lesion of the right
optic nerve causes a total loss of vision in the right eye. (2) A lesion of the optic chiasm causes
a loss of vision in the temporal halves of both visual fields (bitemporal hemianopsia). Because
the chiasm carries crossing fibers from both eyes, this is the only lesion in the visual system that
causes a nonhomonymous deficit in vision (i.e., a deficit in two different parts of the visual field
resulting from a single lesion). (3) A lesion of the optic tract causes a complete loss of vision in
the opposite half of the visual field (contralateral hemianopsia). In this case, because the lesion
is on the right side, vision loss occurs on the left side. (4) After leaving the lateral geniculate
nucleus the fibers representing both retinas mix in the optic radiation. A lesion of the optic
radiation fibers that curve into the temporal lobe (Meyer loop) causes a loss of vision in the
upper quadrant of the opposite half of the visual field of both eyes (upper contralateral quadran-
tic anopsia). (5) and (6) Partial lesions of the visual cortex lead to partial field deficits on the
opposite side. A lesion in the upper bank of the calcarine sulcus (5) causes a partial deficit in the
inferior quadrant of the visual field on the opposite side. A lesion in the lower bank of the cal-
carine sulcus (6) causes a partial deficit in the superior quadrant of the visual field on the op-
posite side. A more extensive lesion of the visual cortex, including parts of both banks of the
calcarine cortex, would cause a more extensive loss of vision in the contralateral hemifield. The
central area of the visual field is unaffected by cortical lesions (5) and (6), probably because
the representation of the foveal region of the retina is so extensive that a single lesion is unlikely
to destroy the entire representation. The representation of the periphery of the visual field is
smaller and hence more easily destroyed by a single lesion. (From Wurtz RH, Kandel ER:
Central visual pathways. In Kandel ER, Schwartz JH, Jessell TM, editors: Principles of neural
science, ed 4, New York, 2000, McGraw-Hill.)
422 Stroke Rehabilitation

Box 16-1
Components of a Vision Screening
The following is a description of vision screening processes, which should be administered in a well-illuminated room free of
glare and reflection.
1. Distance Visual Acuity
Equipment: Distance acuity chart (Snellen chart), occluder or eyepatch, 20-foot measure
Setup: Fixate distance acuity chart on a well-lighted wall at client’s eye level 20 feet away.
Procedure: Cover the client’s left eye with occluder or patch. Ask the client to identify letters on the 20/40 line. If the
client appears confused by the lines and letters, cover all other lines on the chart and expose only the line being used.
If necessary, expose only one letter at a time. If the client continues to have problems, attempt to test visual acuity
using the Lea Symbols Test. Continue until the individual misses more than 50% of the letters on a line. Cover the
client’s right eye with occluder or patch and repeat the steps. Record acuity as last line in which the individual can
successfully identify more than 50% of the letters.
Functional implications: If visual acuity is poorer than 20/40 or if a two-line difference or more is evident between the
two eyes, a referral is necessary and corrective lenses may need to be prescribed.
2. Near/Reading Visual Acuity
Equipment: Near acuity chart, occluder or eyepatch, 16-inch measure
Setup: Hold a near acuity chart in a well-lit room 16 inches away.
Procedure: The test card is held 16 inches from the person being tested. The test is performed with the client wearing his
or her corrective lenses if they are normally used. Binocular vision is tested. The smallest size able to be read correctly
is recorded.
Functional implications: The results of the test will give an idea of the detail that can be discriminated. Near tasks include
craft and leisure activities, personal care and hygiene, some work tasks, and reading.
3. Ocular Mobility
Equipment: Penlight
Setup: Have client sit facing therapist. Penlight should be approximately 12 inches from the eyes. Do not shine the light
directly into the eyes; instead direct the light so that it is pointing slightly above eye level at the brow.
Procedure: Ask the client to follow the penlight and move it in a large H pattern to the extremes of gaze. Then move the
penlight in a large O pattern. Allow the client to fixate on the light for 10 seconds before moving it.
Functional implications: Observation of pursuits should be smooth and precise without anticipating responses. Note visual
fatigue or stress and whether the client reports diplopia (double vision). Observe whether the client looks away, loses
the target, or squints or blinks excessively. Inability to attend to visual tasks, difficulty reading or completing writing
tasks, and problems with spatial orientation during walking may be displayed.
4. Near Point of Convergence
Equipment: Penlight and ruler
Setup: Practice this procedure on a partner to determine when the penlight is positioned at 2, 4, and 6 inches from an
individual’s eyes.
Procedure: Slowly move the penlight toward the client at eye level and between the eyes, making sure not to shine the
light in the eyes. Ask the client to keep the eyes on the light and state when two lights are seen. After this occurs, move
the light another inch or two closer and then begin to move it away. Ask the client to state when only one light is seen.
Watch the eyes carefully and observe whether they stop working together as a team—one eye may drift outward.
Record the distance at which the client reports double vision and the recovery to single vision.
Functional implications: Double vision should occur within 2 to 4 inches of the eyes. A recovery to single vision should
occur within 4 to 6 inches. A client with a binocular vision problem may not report double vision because the eye that
turns out is suppressed. Thus all eye movements should be observed before screening.
5. Stereopsis
Equipment: Viewer-free random dot test
Setup: Individual’s head position should be vertical. If any head tilt occurs, it negates this screening.
Procedure: Hold the viewer-free random dot test 16 inches from the client’s eyes and ask the client to describe what he or
she sees. A person with stereopsis should report seeing a square box in the upper left, an E on the upper right, a circle
on the lower left, and a blank box on the lower right. Give the client about 20 to 30 seconds to observe targets. If the
client has difficulty, try tilting the target slightly to the left or right.
Functional implications: The client should be able to identify all three symbols correctly. A client with constant strabismus
is unable to identify any of the shapes. Clients with less severe strabismus or phoria may have normal responses. Some
people may report double vision on this task, which suggests strabismus.
 Chapter 16 • Managing Visual and Visuospatial Impairments to Optimize Function 423

Box 16-1
Components of a Vision Screening—cont’d
6. Accommodation
Equipment: Isolated letters and occluder or eyepatch
Setup: Make a target by photocopying the near visual acuity chart, cutting out the 20/30 targets, and taping them to a
tongue depressor. Place one target on each side of the tongue depressor so that you have two screening targets.
Procedure: Patch the left eye. Hold the tongue depressor with the 20/30 target about 1 inch in front of the right eye.
The client should be unable to identify the stimulus on the tongue depressor at this distance. Slowly move the target
away and ask the client to report as soon as the target is identifiable. Using a ruler, measure and record the distance
at which the person is able to identify the stimulus. Divide 40 by the measurement to determine the amplitude of
accommodation. If the client is able to identify the target at 8 inches, divide 40 by 8, which equals 5 diopters. To
compare the amplitude of accommodation to the expected amplitude for the client’s age, use the following formula:
expected amplitude  18  one third the client’s age. The following are examples of the way to use this equation:
A 9-year-old child:
Expected amplitude18(1⁄3[9]) Expected amplitude18315 diopters
A 45-year-old adult:
Expected amplitude18(1⁄3[45]) Expected amplitude18153 diopters
Functional implications: The amplitude of accommodation should be 2 diopters of the expected finding for the client to
pass the screening test. Observe all eye movements. Problems include blurred vision, poor concentration, inattention,
visual fatigue, and eyestrain.
7. Saccades
Equipment: Two fixators with red and green targets and scanning chart
Setup: Have the client keep the head erect and vertical.
Procedure: Hold two tongue depressors (one with a red target and one with a green target) 16 inches from the client’s
face and about 4 inches from the midline. Give the following instructions: “When I say red, look at the red target.
When I say green, look at the green target. Do not look until I tell you.” Have the client look from one target to the
other five round-trips or for 10 fixations.
Functional implications: Adults without visual impairment should perform perfectly. Any mistake denotes problems with
saccadic function, and the client will require further evaluation. Poor saccades result in poor concentration and
attention and difficulty reading and writing.
8. Visual Fields: The Confrontation Test
Equipment: Occluder or eyepatch, black dowels with white targets (are other contrasting colors) on the ends or a
wiggling finger
Setup: Make sure the client is seated facing the examiner.
Procedure:
1. One-examiner presentation—the client holds the occluder over the left eye. Wiggle a finger out to the side and ask the
client to say “now” when the movement of the wiggling finger is first detected. The client should look at the therapist’s
nose the entire time and ignore any arm movement. Begin with the hand slightly behind the client about 16 inches
away from the head. Slowly bring the hand forward while wiggling a finger. Continue randomly testing different
sections of the visual field in 45-degree intervals around the visual field. Proceed to the left eye, asking the client to
occlude the right eye. If using the dowel technique, slowly bring it in from the side until the client reports seeing the
small pin at the end of the dowel.
2. Two-examiner presentation—examiner one stands behind the seated client and examiner two sits facing the client
about 30 inches in front so that the face of the examiner and client are at the same level.
Test each eye individually, being careful to patch the other eye. Examiner two closes one eye and instructs the client to
“fixate and keep looking at my open eye. Examiner one will show you one or more fingers very quickly. Don’t try to
look at the fingers. Keep looking at my open eye and when you see a finger or fingers, tell me how many you see.”
Examiner one presents one or two fingers randomly for a one-second duration to each quadrant of the visual field of the
client’s unpatched eye. The fingers in the upper quadrant point down, and those in the lower quadrant point up. The
fingers are presented 18 inches from the client and at approximately 20 degrees from the line of fixation.

Data from Aloisio L: Visual dysfunction. In Gillen G, Burkhardt A, editors: Stroke rehabilitation: a function-based approach, ed 2, St Louis,
2004, Mosby; Gianutsos R, Suchoff IB: Visual fields after brain injury: management issues for the occupational therapist. In Scheiman M,
editor: Understanding and managing vision deficits: a guide for occupational therapists, Thorofare, NJ, 1997, Slack; Gutman SA, Schonfeld AB:
Screening adult neurologic populations, ed 2, Bethesda, Md, 2009, AOTA Press; and Warren M: Evaluation and treatment of visual deficits
following brain injury. In Pendleton H, Schultz-Krohn W, editors: Pedretti’s occupational therapy: practice skills for physical dysfunction, ed 6,
St Louis, 2006, Elsevier Science/Mosby.
424 Stroke Rehabilitation

MANAGING VISUAL ACUITY IMPAIRMENTS of finding necessary objects. For example, finding a
white sock on a patchwork quilt is much more diffi-
Assessment of visual acuity has been described in Box 16-1. cult than finding the same sock on a solid colored
Visual acuity refers to clarity and sharpness of sight. It is bedspread.
commonly measured using the Snellen chart (or text cards ■ Decrease clutter and organize the environment: A
for near acuity) and noted, for example, as 20/20, 20/60, focus should be placed on a having necessary objects
20/200, and so on. Modifications such as using picture placed out neatly and not overlapping.
charts or a “tumbling E” chart are available for those with ■ Increase size: Commercially available magnification
aphasia. A visual acuity of 20/20 means that a person can devices, labeling with bold markers, reprinting in-
see detail from 20 feet away the same as a person with nor- structions or daily planners in larger fonts, changing
mal eyesight would see from the same distance. If a person personal computer settings to a larger font are just a
has a visual acuity of 20/60, that person is said to see detail few example of this intervention.
from 20 feet away the same as a person with normal eye-
sight would see it from 60 feet away. Visual acuity becomes MANAGING VISUAL FIELD DEFICITS
impaired in various refractive conditions (i.e., impaired fo- WITH AN EMPHASIS ON HEMIANOPSIA
cusing of the image on the retina), the most typical being
myopia (nearsighted), hyperopia (farsighted), astigmatism The visual fields extend approximately 65 degrees upward,
(mixed), and presbyopia (age-related decrease in acuity).2 75 degrees downward, 60 degrees inward, and 95 degrees
Chia and associates9 found that noncorrectable visual acu- outward when the eye is in the forward position.15 Aloisio2
ity impairment (defined as acuity less than 20/40) was as- summarized that:
sociated with reduced functional status and well-being, as ■ The visual fields are essential areas of the visual sys-
measured by the Medical Outcomes Study Short Form-36 tem that allow the individual to orient effectively to
(SF-36) (a measure of quality of life, see Chapter 3). Tsai stimuli in specific areas of space.
and colleagues51 documented a relationship between poor ■ In terms of function, they are used when driving,
visual acuity and depression using the Geriatric Depression walking, reading, eating, and in all daily living
Scale. Visual impairment was specifically associated with skills.
feelings of worthlessness and hopelessness. ■ In terms of impairment, inferior field loss causes dif-
A decrease in visual acuity can result in multiple diffi- ficulty with mobility, including poor balance, ten-
culties in all functional domains. Examples include diffi- dency to trail behind others when walking, walking
culty reading labels on pill bottles, doing crosswords, un- next to walls and touching them for balance, trouble
safe driving, increased fall risk, and so on. A focus on this seeing steps or curbs, shortened and uncertain stride
impairment is warranted to improve participation in daily while walking, and trouble identifying visual land-
activities. In general, if visual acuity is worse than 20/40, marks. In addition, superior field deficit causes dif-
a referral to an eye care specialist is warranted for evalua- ficulty in seeing signs, reading, and writing; misread-
tion of prescriptive lenses.2 Other interventions are in line ing of words, poor accuracy, slow reading rate,
with low-vision rehabilitation techniques. They are prag- inability to follow lines of text, and inaccurate check
matic yet effective and have been outlined by Warren:56 writing are additional difficulties.
■ Increase illumination: In general, increasing the Hemianopsia, or hemianopia or hemiopia, means “half-
amount of light can improve function. Particular at- blindness” or a loss of half the fields of vision in both
tention should be placed on areas of high risk, where eyes.38 Homonymous visual field impairments are seen
activities requiring precision are performed such as frequently in the clinic after an acquired brain injury.
cooking, sorting pills into a pill box, and needle- Thirty percent of all clients with stroke and 70% of those
work. Task-specific lighting is recommended. War- with a stroke involving the posterior cerebral artery pres-
ren warns about maintaining the balance between ent with hemianopsia. In addition, those with subarach-
increasing the amount and intensity of illumination noid hemorrhages, intracerebral bleeds, and head trauma
while not increasing glare and recommends halogen, also commonly present with this impairment.34
fluorescent, and full-spectrum lights to eliminate Zhang and coworkers60 examined the medical records
casting shadows. of more than 900 people presenting with visual field loss.
■ Increase contrast: Specifically background colors The authors found that 37.6% were complete homony-
that contrast with objects used for function. Exam- mous hemianopsias, whereas 62.4% were incomplete.
ples are purchasing colored soap to place on a white Homonymous quadrantanopsia (29%) was the most
sink, using dark placemats and white dishes, and common type of incomplete hemianopsia, followed by
placing strips of colored tape on the edge of steps. homonymous scotomatous defects (13.5%), partial hom-
■ Decrease background pattern: Increased patterns on onymous hemianopsia (13%), and homonymous hemi-
household objects can further increase the difficulty anopsia with macular sparing (7%). The causes of
 Chapter 16 • Managing Visual and Visuospatial Impairments to Optimize Function 425

homonymous hemianopsias included stroke (69.6%), head recommended that visual field rehabilitation strategies
trauma (13.6%), tumor (11.3%), after brain surgery should most likely be initiated early after injury.
(2.4%), demyelination (1.4%), other rare causes (1.4%), The most objective test for mapping the available field
and unknown etiology (0.2%). The authors found that the is perimetry. This automated test is usually conducted
lesions were most commonly located in the occipital lobes while the person being tested is seated and looking
(45%) and the optic radiations (32.2%). Almost every type straight ahead at a central target. The person is instructed
of hemianopsia was found in all lesion locations along the to press a buzzer when he or she becomes aware of a small
retrochiasmal visual pathways. light within the visual field. The accuracy of the test de-
The amount and distribution of visual field loss (i.e., pends on the person’s being alert and able to concentrate
nasal, temporal, inferior, superior, homonymous) de- on the central target. The results from this test are printed
pends on the location of the lesion. If the optic nerve it- out by the computer, objectively mapping blind spots in
self is damaged (i.e., the area between the retina and the the visual field. A screening technique that grossly mea-
optic chiasm), the presentation will be that of monocular sures the visual fields is a confrontation test, which is de-
visual loss. Damage to the optic tract will result in con- scribed in Box 16-1. Although it is common for hemi-
tralateral hemianopsia. If damage occurs posterior to the anopsia to occur in conjunction with neglect, there exists
lateral geniculate body, the typical presentation is that of a double dissociation between the two impairments—each
either quadrantanopsia or hemianopsia depending on the can occur separately or can coexist. As compared with
lesion site (see Fig. 16-3). Although the characteristics of those living with neglect, awareness of visual filed deficits
visual field defects can be helpful in lesion location, spe- tends to be better. Nonetheless, clients may benefit from
cific visual field defects do not always indicate specific awareness training to make connections between how this
brain locations.60 impairment will affect a variety of functional activities and
Zihl62 summarized that those living with hemianopsia to understand the importance of compensating for it (see
cannot process visual information as compared with those Chapter 19).
with intact visual fields. Specifically, they demonstrate Several interventions are available to those living
numerous visual refixations, have inaccurate saccades and with visual field loss. The methods are compensatory in
disorganized scanning, require longer visual search times, nature. These methods include learning oculomotor
and omit relevant objects in the environment. In addition, compensation strategies, strengthening the person’s at-
they focus on their intact hemifield; their saccades are less tention to the blind hemifield, improving the ability to
regular, less accurate, and too small to allow rapid, orga- direct gaze movements toward the involved side, ex-
nized scanning or reading.35 The majority of basic and ploring the involved side more efficiently, improving
instrumental ADL have the potential to be adversely af- saccadic exploration toward the blind hemifield, using
fected without proper intervention. Reading may be par- prisms, and so on.*
ticularly problematic. For example, in those living with a Some of the most useful approaches to the treatment
complete right homonymous hemianopsia, rightward sac- of hemianopsia are based on compensating for visual field
cades during text reading are disrupted (“hemianopsic loss by oculomotor compensation. This training involves
alexia”), which interrupts the motor preparation of read- psychophysical techniques aimed at strengthening the
ing saccades during text reading.25 client’s attention to the blind hemifield and improving his
In terms of recovery, Zhang and coworkers59 longitu- or her ability to explore the visual field with saccadic
dinally followed 254 clients with homonymous hemi- movement.6 Kerkhoff18 suggests three types of saccadic
anopsia secondary to a variety of brain lesions. The au- training: train people to make broader searches (“visual
thors documented spontaneous visual field deficit recovery search field”) in the blind hemifield, train people to make
in less than 40% of the cases. They also noted that the large-scale eye movements toward the blind hemifield,
likelihood of spontaneous recovery decreased with in- and train people to make small-scale eye movements with
creasing time from injury to initial visual field testing the goal of improving reading.
(p  0.0003). The probability of improvement was related In terms of specifically training reading, the minimum
to the time since injury (p  0.0003) with a 50% to 60% visual field required for reading is 2 degrees to the left and
chance of improvement for cases tested within one month right of fixation. This is the area where the text is seen
after injury. This chance for improvement decreased to clearly and covers 10 to 12 letters of print at a distance of
about 20% for cases tested at six months after surgery. In 25 cm. For fluent reading, the visual span must be ex-
most cases, the improvements occurred within the first tended in the reading direction up to 5 degrees or 15 let-
three months after injury. The authors warned that spon- ters. People with hemianopsia need a minimum of 5 de-
taneous improvement after six months should be inter- grees to both sides of fixation to read normally. Less than
preted with caution because it may be secondary to im-
provement of the disease or to improvement in the client’s
ability to perform visual field testing reliably. They *References 18, 34, 35, 56, 61, 62.
426 Stroke Rehabilitation

that amount affects people differently based on whether were distributed across the board in four horizontal lines
they are living with a right or a left hemianopsia. Less with 10 lights in each line. Clients sat 1.5 m away from
than 5 degrees preempts proper reading of a given line the board so that visual fields of subjects were filled out
of text by those with right hemianopia and decreases by the board. The subject’s heads were kept midline.
the ability to locate the beginning of the next line of text When the stimulus of the light was presented, the sub-
by those with left hemianopsia.48-50 Those with right jects reacted by pressing a button. Training was carried
hemianopsia tend to perform worse on reading tasks out under two conditions: (1) subjects were required to
and take longer to respond to treatment. Pambakian and fixate on a central point on the board and to react to
Kennard35 suggest teaching to perceive each word as a single visual stimuli, and (2) multiple stimuli were ran-
whole before reading it. They specifically suggest that domly presented on the board. Clients were asked to
those with left hemianopsia should shift their gaze first to identify a target stimulus (e.g., square of four lights) in
the beginning of the line and the first letter of every word each hemifield with use of exploratory eye movements,
in that line. In contrast, those with right-sided hemianop- but without head movements. Detection of and reaction
sia are discouraged to read a word before they have shifted time to visual stimuli were measured during the two con-
their gaze to the end of it. Wang57 reported the case of a ditions. The subjects showed an improvement of detec-
65-year-old woman who presented with a right homony- tion and reaction time during condition two, but mini-
mous hemianopsia secondary to a left occipital lobe tu- mum or no change during condition one. Improvements
mor. She was most concerned about her inability to read were maintained eight months after training. ADL skills
sheet music and developed an effective compensatory also improved in all clients. Of note was that the size of
strategy to improve her reading ability. By turning her scotoma (blind area) on computerized perimetry re-
sheet at right angles (i.e., left-to-right became above-to- mained stable. Training improved detection of and reac-
below), she could read a line almost as well as prior to the tion to visual stimuli without a change of the visual field
loss of vision. Another possible intervention to assist those impairment.
with hemianopsia to participate fully in reading tasks is to Pambakian and coworkers34 suggested three steps to
teach the use of a ruler to assist in keeping track of each improving visual exploration. People with hemianopsia
line of reading and using the ruler to increase the accuracy should first practice making large, quick saccades (of am-
of the saccadic eye movements. plitude 30 to 40 degrees) into their blind field, to enhance
Specifically training visual search strategies is also the overshoot of the target. They are then taught to scan
recommended. Pambakian and associates36 examined 29 for targets among distracters in a systematic way. Finally,
subjects with homonymous visual field deficits. Using a these strategies are practiced during real-world activities.
videotape, visual search images were projected on a televi- These strategies have been tested by Zihl,61 whose subjects
sion in subjects’ homes for 20 sessions over a one-month increased their visual field searches from 10 to 30 degrees
period. Prior to beginning the search, subjects fixated on after four to eight sessions. More recently, Kerkhoff and
a target in the middle of the screen. Random targets were colleagues19 had similar findings after examining 92 people
projected among distracters, and subjects indicated when with hemianopsia and 30 with additional neglect. Treat-
they appeared. During the training they were encouraged ment focused on the practice of large saccades to targets in
to not move their heads. The researchers found that the their blind hemifield. Additional focus was on adopting a
subjects had significantly shorter mean reaction times re- systematic scanning strategy, either horizontal or vertical
lated to visual search after training (p  0.001). The im- scanning. The subjects also practiced searching for targets
provements were confined to the training period and on projected slides. Training was carried for 30 sessions,
maintained at follow-up. In addition, subjects performed and the mean search field size increased from 15 to 35
ADL tasks significantly faster after training and reported degrees in those living with hemianopsia. Those with ne-
significant subjective improvements. The researchers glect required 25% more training over two to three
found no enlargement of the visual field, but there was a months to achieve a similar result. At follow-up, almost
small but significant enlargement of the visual search two years later, there were no further significant changes.
fields. Findings led the authors to conclude that people The effect of the treatment was independent of variables
with homonymous field deficits can improve visual search such as time since lesion, type of field defect, field sparing,
with practice and that the underlying mechanism may and client age. Two noteworthy findings were that those
involve the adoption of compensatory eye movement with more severe impairments benefited most from train-
strategies. ing and that the mean number of required treatment
Compensatory visual field training has been tested by sessions increased dramatically with the frequency and
Nelles and colleagues.31 The authors examined 21 sub- extent of head movements during training. Pambakian and
jects with hemianopsia. Compensatory visual field train- Kennard35 noted that this finding contradicts the assump-
ing was accomplished using a 1.25 by 3.05 m training tion that head movements are helpful to the compensatory
board with right- and left side-wings. Forty red lights mechanisms for those with hemianopsia as is sometimes
 Chapter 16 • Managing Visual and Visuospatial Impairments to Optimize Function 427

claimed. The concept of using excessive head movements ■ Worse while viewing objects far away (usually found
to compensate for a visual field deficit warrants further in conjunction with impaired abduction or diver-
investigation. gence of the eyes)
Optical devices such as prisms also have been used for ■ Worse while viewing near objects (usually found in
those with visual field loss. When a prism is applied to glasses, conjunction with impaired adduction or convergence)
it shifts the peripheral image toward the central area of the Binocular diplopia is most likely caused by “ocular mis-
retina. Rossi and associates43 examined the effects of using alignment” that can be gross or subtle and warrants inves-
15-diopter press on Fresnel prisms on subjects with homony- tigation as to the cause by an optometrist or neurooph-
mous hemianopsia and neglect. They found significant im- thalmologist. The most common causes of misalignment
provements on impairment tests of visual perception such as of the visual axes are extraocular muscle dysfunction (see
the Motor Free Visual Perception Test, Line Bisection, and Fig. 16-2).11
Letter Cancellation tests. They found no difference in ADL Ocular alignment should be evaluated in those living
and mobility scores as measured by the Barthel Index. These with diplopia. Strabismus, or tropia, is a visible turn of
findings make sense because the improvements were found one and may result in double vision. The person is un-
only in tabletop measures (i.e., measures that by definition do able to keep the eye straight with the power of fusion. In
not encompass large visual fields). The visual image is only strabismus one eye may turn outward (exotropia), in-
subtly shifted when wearing a prism, perhaps not enough ward (esotropia), upward (hypertropia), or downward
to make a positive change in activities such as gait or wheel- (hypotropia).2 Strabismus may be noncomitant strabis-
chair mobility, which require broader visual scans. Tabletop mus (the amount of misalignment depends on which
ADL have not been objectively tested, but based on these direction the eyes are pointed) or comitant (the amount
findings perhaps activities such as balancing a checkbook, of turn is always the same regardless of whether the per-
doing a crossword puzzle, or leisure reading may be positively son is looking up, down, right, left, or straight ahead).
affected. On the other hand, several problems are related to Newly acquired strabismus from a neurological insult is
wearing prisms, including double vision, a potential blocking usually noncomitant (i.e., the eye turn changes depend
of the central field, discomfort, disturbances in spatial orien- on the direction in which the eyes are looking). Aloiso2
tation, and confusion from the distorted visual image. Prisms states that “strabismic disorder may result in an inability
may consist of a straight-edged segment of press-on prism to judge distance, underreaching or overreaching for
applied to the side of the field loss on both lenses or round objects, covering or closure of one eye, double vision,
prisms applied to the lens over one eye. Consultation with head tilt or turn, ‘spaced-out’ appearance, difficulty
an optometrist, ophthalmologist, or neuro-opthamologist reading, and avoidance of near tasks.” The term phoria is
mandatory. used when there is tendency for the eye to deviate but is
controlled with muscular effort. It is not noticeable
MANAGING DIPLOPIA when a person is focusing on an object.56 The eyes re-
main straight as long as fusion is present.
Diplopia, or double vision, is an all too common visual In terms of assessing diplopia, scanning assessments
impairment after a neurological event. During intact pro- such as convergence and ocular range of motion or ocular
cessing of visual information, when people look at an mobility should be examined to help determine the weak
object with both eyes, the visual image falls on the fovea ocular muscle(s).2,15 Ocular mobility and convergence as-
(a spot located in the center of the macula, which is re- sessments as described in Box 16-1 should be evaluated to
sponsible for sharp central vision) in each eye, and a single determine the available ocular range of motion and the
image is perceived. When the eyes are not in alignment, observed range of motion lags. During the assessment,
the object we are looking at falls on the fovea in one eye the clinician should be aware of the corresponding mus-
and on an extrafoveal location in the other eye. When this cles responsible for the patterns of movements:
occurs, two images are perceived (i.e., binocular diplo- ■ The medial rectus adducts and rotates the eyes
pia).37,44 Diplopia typically resolves completely with mon- inward.
ocular vision (i.e., covering one eye). If diplopia is present ■ The lateral rectus abducts and rotates the eyes
with monocular viewing, it is unlikely to be neurological outward.
in origin.44 Diplopia may present as the following:11,44 ■ The superior rectus uses elevation and intorsion to
■ Horizontal (secondary to impaired abduction or ad- move the eyes upward.
duction of an eye involving the lateral or medial ■ The inferior rectus uses depression and extorsion to
rectus or both) move the eyes downward.
■ Vertical (secondary to impaired elevation or depres- ■ The superior oblique uses depression and intorsion
sion of the eye) to rotate the eye downward and outward.
■ Worse in a particular directional gaze (suggestive of ■ The inferior oblique uses elevation and extorsion to
ocular motility being impaired in that direction) rotate the eye upward and outward (see Fig. 16-2).2,14
428 Stroke Rehabilitation

In addition, the cranial nerves that innervate the various ahead, up, downstairs, right, left, reading, any position).
muscles should be considered. The lateral rectus is inner- The diplopia questionnaire score then ranges from 0 (no
vated by the abducens nerve (cranial nerve VI). The me- diplopia) to 25 (constant diplopia everywhere) and can
dial, inferior, and superior recti and the inferior oblique easily be rescaled to 0 to 100 by multiplying the score by
muscles are innervated by the ocular motor nerve (cranial 4 (Fig. 16-4).
nerve III). The superior oblique muscle is innervated by In terms of interventions, the overall goal of managing
the trochlear nerve (cranial nerve IV).2,14 diplopia is to establish clear and comfortable binocular
Involvement of cranial nerve III results in exotropia, single vision to support engagement in meaningful activi-
exophoria, convergence insufficiency, accommodative in- ties. A typical way to manage diplopia is to apply a patch
sufficiency, ptosis, and a fixed and dilated pupil. The af- (i.e., full occlusion or “pirate patching”) over one eye.
fected eye is in a down and out position. Damage to the This technique does in fact result in single vision but
cranial nerve IV results in hypertropia, vertical diplopia, causes several other problems: issues related to cosmesis
and limited downward gaze. Finally damage to cranial and self-image, imposed loss of peripheral vision, eye fa-
nerve VI manifests as esotropia, esophoria, divergence tigue, rendering the person monocular, mobility impair-
insufficiency, horizontal diplopia, and limited abduction ments, and safety concerns. Therefore, this technique is
of the affected eye.2,11 not recommended for long-term use.
In terms of assessment, the Cover-Uncover Test is More recently partial visual occlusion has been used.
based on evoking a fixational eye movement and is appro- Proper use of partial occlusion can result in comfortable
priate for those living with diplopia. If a person is living single vision without the negative side effects of full oc-
with an ocular misalignment, only one of the eyes fixates clusion, particularly preserving peripheral vision. The
on the particular object while the other eye deviates. If the “spot patch” is a type of partial visual occlusion. It is a
fixating eye is covered, the deviating eye must refixate in round patch made of translucent tape that is placed on the
order to align with the particular object. In the cover- inside of the client’s glasses (corrective or nonprescriptive
uncover test, the person fixates on a distant object, then lens) and directly in the line of sight. The size of the spot
covers one eye. The examiner observes whether the un- patch is approximately 1 cm in diameter, but this varies
covered eye makes a fixational movement and notes the based on clinical presentation. In general, use the smallest
direction of the movement. Then the occluder is removed size possible that decreases double vision. The spot patch
and placed in front of the other eye. Again the examiner is effective in eliminating double vision because it blurs
observes for fixational movements of the uncovered eye. central vision in the partially occluded eye.40
If both eyes are aligned, no movement will be seen during Another suggested method for partial visual occlusion
the cover-uncover test (i.e., the test is negative). A positive is to apply a strip of opaque material such as surgical tape
test is documented if the uncovered eye moves to take up to the nasal field of one eye (i.e., the peripheral field is left
fixation. If refixation is observed, it can be assumed that unoccluded) over prescriptive or nonprescriptive glasses.56
under binocular viewing conditions the eye is not aligned Similar to the spot patch, this technique results in single
with fixation, and a deviation is present. Based on the di- vision while sparing the peripheral field. The clinician
rection of the affected eyes, movement when the nonaf- applies strips of tape systematically to a pair of glasses
fected eye is covered can indicate the type of misalign- starting at the nasal field and progressively toward the
ment. Inward movement of the uncovered eye indicates
an exotropia, whereas an outward movement is an esotro-
pia. A vertical deviation may be either a hypotropia or a Score if Score if Score if
Score
hypertropia, depending on whether the eye moves up or Gaze position Always Sometimes Never
down.2,11,56 The Alternate Cover Test is more dissociating Straight ahead in
6 3 0
distance
than the Cover-Uncover Test, and it may demonstrate
Up 2 1 0
phoria more readily.11 In the Alternate Cover Test, the eyes
Downstairs 4 2 0
are rapidly and alternately occluded—from one eye to the 0
Right 4 2
other and then back again. This procedure causes break- Left 4 2 0
down of the binocular fusion mechanism and will reveal Reading 4 2 0
refixation movements of each eye now of uncovering. If Any position 1 1 0
no tropia is present and the uncovered eye shows refix- If "always," to all
ation during the alternate cover test, the client presents above, can you 1
get rid of it?
with phoria.
Holmes and coworkers16 developed a valid, reliable, Total
and responsive questionnaire to quantify diplopia. This Figure 16-4 Diplopia questionnaire. (From Holmes JM, Leske
self-report measure asks, “Do you always, sometimes, or DA, Kupersmith MJ: New methods for quantifying diplopia.
never see double?” for seven gaze positions (straight Ophthalmology 112[11]: 2035-2039, 2005.)
 Chapter 16 • Managing Visual and Visuospatial Impairments to Optimize Function 429

center until a single image is obtained. In general, when Scheiman and associates45 compared vision therapy/
using occlusion as an intervention strategy, the nondomi- orthoptics, pencil pushups, and placebo vision therapy/
nant eye is occluded.56 To determine the nondominant orthoptics as treatments for symptomatic convergence
eye, have the person focus on a far target through a 1- insufficiency in adults ranging from ages 19- to 30-years-
inch-diameter hole cut in the center of a piece of white old by way of a randomized multicenter trial. The inter-
paper. Ask the person to close one eye at a time. Depend- vention lasted 12 weeks. There were three arms of the
ing on which eye is closed, the target will be visible trial. The first arm was pencil pushups, in which the sub-
through the hole. For example, if the person closes the ject was instructed to hold a pencil at arm’s length directly
right eye and the left can still see the target through the between his or her eyes, and an index card was placed on
hole, the left eye is dominant. When the same person the wall 6 to 8 feet away. Each subject was instructed to
closes the left eye while looking through the paper, the look at the tip of the sharpened pencil and to try to keep
target will not be seen with the right eye. Both versions of the pencil point single while moving it toward the nose. If
partial visual occlusion warrant further empirical investi- one of the cards in the background disappeared, the per-
gation (Fig. 16-5). son was instructed to stop moving the pencil and blink his
Optical aids such as prisms have been suggested for or her eyes until both cards were present. The client was
those with diplopia. Fresnel press-on plastic prisms may told to continue moving the pencil slowly toward the nose
be helpful for clients with binocular diplopia up to until it could no longer be kept single and then to try to
40 prism diopters in magnitude. The prisms are available regain single vision. If the person was able to regain single
in 1-diopter increments from 1 to 10 and then in 12, 15, vision, he or she was asked to continue moving the pencil
20, 25, 30, 35, and 40 diopters.44 Rucker and Tomsak closer to the nose. If single vision could not be regained,
recommended placing the Fresnel prism in front of the the client was instructed to start the procedure again. The
paretic eye and on only one lens of a person’s glasses to exercises were performed 20 times, three times per day
minimize blurring of vision. Prisms can be temporary (approximately 15 minutes per day) for 12 weeks.
(press-on plastic versions) or permanent (ground into the In the second arm, the vision therapy/orthoptics group
lens) depending on the trajectory of recovery. Further received therapy administered by a trained therapist dur-
empirical testing of this intervention related to diplopia ing a weekly, 60-minute office visit, with additional proce-
that occurs secondary to brain injury is necessary. dures to be performed at home for 15 minutes a day, five
The support for eye exercises (orthoptics) in the litera- times per week for 12 weeks. The exercise protocol46 in-
ture is limited to improving convergence insufficiency.20,45 cluded accommodative facility, Brock string exercises,
vectograms, computer-assisted orthoptics, and so on.
In the third arm—the placebo office-based vision
therapy/orthoptics—clients received therapy administered
by a trained therapist during a 60-minute office visit
and were prescribed procedures to be performed at home,
15 minutes, five times per week for 12 weeks. The proce-
dures were designed to simulate real vision therapy/
orthoptics procedures without the expectation of affecting
vergence, accommodation, or saccadic function. Examples
included using stereograms monocularly to simulate ver-
gence therapy, computer vergence therapy with no ver-
gence changes, and monocular prism (instead of plus and
minus lenses) to simulate accommodative treatment.
The authors found that only clients in the vision
therapy/orthoptics group demonstrated statistically and clin-
ically significant changes in the near point of convergence
(p  0.002) and positive fusional vergence (p  0.001). In
addition, clients in all three treatment groups demonstrated
statistically significant improvement in symptoms with
Figure 16-5 Visual occlusion techniques for diplopia. Top: Full 42% in office-based vision therapy/orthoptics, 31% in
visual occlusion (e.g., “pirate patch”) will result in the person office-based placebo vision therapy/orthoptics, and 20% in
seeing one image, but secondary complications include loss of home-based pencil push-ups. Although the vision therapy/
peripheral vision, body image issues, and so on. Middle and orthoptics group was the only treatment that produced
lower figures represent partial visual occlusion such as spot clinically, more than half of the clients in this group were still
patching with translucent tape (middle) and occluding the nasal symptomatic at the end of treatment; however, their symp-
field of the nondominant eye. toms were significantly reduced.
430 Stroke Rehabilitation

Rawstron and colleagues42 systematically reviewed the The majority of common instruments to measure the
current evidence regarding the efficacy of eye exercises. presence of spatial dysfunction use two-dimensional
The authors reviewed 43 refereed studies (14 were clinical contrived tasks such as overlapping figures, design copy-
trials [10 controlled studies], 18 review articles, two his- ing, and so on. The Motor Free Visual Perception Test
torical articles, one case report, six editorials or letters, and (MVPT)10 is only one example of this level of impair-
two position statements from professional colleges). Based ment testing. The ability of these types of test to predict
on their review, the authors summarized that “eye exer- performance of everyday tasks performed in context is
cises have been purported to improve a wide range of not clear, and results should be interpreted with cau-
conditions including vergence problems, ocular motility tion.8,29 Specifically validity data have not been collected
disorders, accommodative dysfunction, amblyopia, learn- comparing MVPT scores with real-world tasks requir-
ing disabilities, dyslexia, asthenopia, myopia, motion sick- ing visual perception.29 For example, a retrospective
ness, sports performance, stereopsis, visual field defects, study examined21 individuals living with a stroke who
visual acuity, and general well-being. Small controlled tri- completed the MVPT and an on-road driving evalua-
als and a large number of cases support the treatment of tion. The MVPT scores ranged from 0 to 36, with a
convergence insufficiency. Less robust, but believable, evi- higher score indicating better visual perception. A struc-
dence indicates visual training may be useful in developing tured on-road driving evaluation was performed to de-
fine stereoscopic skills and improving visual field remnants termine fitness to drive. A pass or fail outcome was de-
after brain damage. As yet there is no clear scientific evi- termined by the examiner based on driving behaviors.
dence published in the mainstream literature supporting The author’s results indicated that, using a score on the
the use of eye exercises in the remainder of the areas re- MVPT of less than or equal to 30 to indicate poor
viewed, and their use therefore remains controversial.” visual-perception and more than 30 to indicate good vi-
sual perception, the positive predictive value of the
VISUOSPATIAL AND SPATIAL RELATIONS MVPT in identifying those who would fail the on-road
IMPAIRMENTS test was 60.9%. The corresponding negative predictive
value was 64.2%. The authors concluded that the pre-
Participating in daily living tasks in a meaningful and safe dictive validity of the MVPT is not sufficiently high to
manner relies on higher-order visual processing such as warrant its use as the sole screening tool in identifying
perceiving depth, interpreting spatial relations, and dif- those who are unfit to undergo an on-road evaluation.21
ferentiating foreground from background, for example. An error analysis approach has been suggested to docu-
(Table 16-2). Visuospatial impairments are reportedly one ment the effects of impairments on daily living skills.3,5,52
of the most common impairments observed after stroke The Árnadóttir OT-ADL Neurobehavioral Evaluation
with a prevalence reported as high as 38%.32 These defi- (A-ONE)3-5 is one of a select group of standardized as-
cits have also been reported in those living with Hunting- sessments that document the effects of spatial impair-
ton disease,26 Parkinson disease,28 traumatic brain injury,30 ments on daily living tasks such as mobility, feeding,
and multiple sclerosis.39 grooming, and dressing. Specific impairment test items
The presence of visuospatial impairments has been as- that are scored based on functional observations include
sociated with a significant increase in falls,33 decreased spatial relations, visuospatial agnosia, impaired right and
performance of basic ADL and mobility after stroke as left discrimination, and topographic orientation (see
measured by the Barthel Index,32 impairments in both Chapter 18). The Assessment of Motor and Process Skills
ADL and motor function in those living with Parkinson (AMPS)12,13 may be used to document functional limita-
disease,27 and difficulties with dressing such as putting tions of those living with a variety of impairments, includ-
one’s arm in the correct sleeve52 (Fig. 16-6). ing visual and spatial impairments (see Chapter 21). The
A qualitative study22 of those living with visuospatial Structured Observational Test of Function (SOTOF)23,24
impairments documented “three main themes comprising is a valid and reliable tool that assesses the following:
six characteristics of how the physical world was experi- ■ Occupational performance (deficits in simple ADL)
enced in a new, unfamiliar, and confusing way that inter- ■ Performance components (perceptual, cognitive,
fered with the participants’ occupational performance and motor, and sensory impairment)
with their experiences of being an individual ‘self-person.’” ■ Behavioral skill components (reaching, scanning,
Specific everyday problems that the participants reported grasp, sequence)
included confusion related to space and objects, difficulty ■ Neuropsychological deficits (spatial relations apraxia,
reaching for objects, feelings that one’s arms were too agnosia, aphasia, spasticity, memory loss)
short, not being able to figure out how to get one’s body ■ Specific visual and spatial impairments (in addition
into a car, feeling unsafe, familiar objects now being unfa- to the above impairments), including figure-ground
miliar, difficulty finding everyday objects, and difficulties discrimination, position in space, form constancy,
with wheelchair maneuvering, for example. spatial relations, depth and distance perception,
 Chapter 16 • Managing Visual and Visuospatial Impairments to Optimize Function 431

Table 16-2
Visual-Spatial Skills and Their Relationship to Function
FUNCTIONAL ACTIVITIES
SKILL DEFINITION REQUIRING THE SKILL COMMENTS

Depth The processes of the visual Pouring water into a glass, catching Relies primarily on binocular
perception system that interprets depth a ball, stepping up or down a curb, vision but also relies on
(stereopsis) information from a viewed reaching for cooking equipment monocular cues (light and
scene and builds a three- with accuracy during meal shading, color, relative size).
dimensional understanding preparation, parking a car, etc. Those living with monocular
of that scene vision and strabismus will have
difficulty perceiving depth.
Spatial relations Ability to process and Orienting clothing to your body, Rule out ideational and mo-
interpret visual applying paste to a toothbrush, tor apraxia (see Chapter 18)
information about where orienting/aligning your body in
objects are in space; the space during a transfer, orienting
process of relating objects dentures and glasses to your body
to each other and the self Indoor and outdoor mobility during
wayfinding, performing math tasks
and calculations
Right/left Ability to use/apply the Following directions related to per- Differentiate between
discrimination concepts of left and right sonal space (e.g., “Dress your right personal and extrapersonal
arm first”), applying concepts during confusion related to right/
mobility (“Make a left turn after the left
occupational therapy clinic”)
Topographic The ability to use visuospa- Finding your way via ambulation,
orientation tial (and memory) skills to wheeled mobility, or driving in
support wayfinding or familiar environments; learning
route finding new routes
Figure-ground Inability to distinguish Locating a white napkin on a white Rule out decreased visual
discrimination objects in the foreground table, finding a scissors in a clut- acuity and related basic
(foreground from from objects in the tered drawer, locating a shirtsleeve visual skills
background background on a monochromatic shirt, finding
discrimination) a person in a crowded room, stair
climbing (e.g., differentiating when
one step ends)

Data from Árnadóttir G: The brain and behavior: assessing cortical dysfunction through activities of daily living, St Louis, 1990, Mosby;
Árnadóttir G: Impact of neurobehavioral deficits on activities of daily living. In Gillen G, Burkhardt A, editors: Stroke rehabilitation:
a function-based approach, ed 2, St Louis, 2004, Mosby; Greene JD: Apraxia, agnosias, and higher visual function abnormalities. J Neurol
Neurosurg Psychiatry 76(Suppl 5):25-34, 2005; Gutman SA, Schonfeld AB: Screening adult neurologic populations, ed 2, Bethesda, Md, 2009,
AOTA Press; Mazzocco MM, Singh BN, Lesniak-Karpiak K: Visuospatial skills and their association with math performance in girls
with fragile X or Turner syndrome. Child Neuropsychol 12(2):87-110, 2006; Nori R, Grandicelli S, Giusberti, F: Visuo-spatial ability and
wayfinding performance in real-world. Cogn Processing 7(5):135-137, 2006.

visual acuity, visual attention, visual scanning, vi- ■ Which perceptual, cognitive, motor, and sensory
sual filed loss, and neglect. These impairments are impairments are present?
detected by the structured observation of simple ■ Why is function impaired?
ADL (eating from a bowl, pouring a drink and Although presented here, the SOTOF is appropriate for
drinking, upper body dressing, washing and drying a variety of the problem areas.
hands). Despite the prevalence of these impairments and the
This relatively quick tool aims to answer the following substantial effect on function, little empirical evidence is
questions: available to guide interventions focused on decreasing
■ How does the subject perform ADL tasks? activity limitations and participation restrictions. It has
■ What behavioral skill components are intact? Which been suggested that a functional approach is the most
have been affected by neurological damage? appropriate intervention for this population.4,52 This may
432 Stroke Rehabilitation

A B

C D
Figure 16-6 Spatial impairments: the effect on everyday living. A, Difficulties in differenti-
ating foreground from background. The client has trouble finding the sleeve of a unicolor
shirt. B, The client is unable to find the right armhole. C, The client may start at the wrong
hole, placing her arm through the neckhole instead of the left sleeve. D, The client is unable
to guide the paralyzed arm into the right hole. Pulling more on the shirt at the top of the arm
than under it will result in the arm going past the right hole. This deficit can also be related
to perseveration.
 Chapter 16 • Managing Visual and Visuospatial Impairments to Optimize Function 433

E F

G H
Figure 16-6, cont’d E, The client’s arm goes through the neckhole instead of the armhole.
F, The client matches buttons incorrectly with buttonholes. G, The client puts both legs
through the same leghole. H, The client notices that the pants are turned wrong front to
back, with the label at the front, and attempts to correct the mistake by turning the pants
with the leg in the leg hole. Ideation also interferes with the client’s performance in attempt-
ing to correct for the error. See Chapter 18. Continued
434 Stroke Rehabilitation

K
Figure 16-6, cont’d I, The client puts the glasses on upside down. J, The client leans back-
ward instead of forward while the therapist attempts to transfer her to a wheelchair. Such a
client can be dangerous for the therapist if she is unaware of the problem because the client’s
actions are unpredictable and often the opposite of what is expected. K, Spatial-relation
difficulties manifested in underestimation of distances when reaching for the cup. (From
Árnadóttir G: The brain and behavior: assessing cortical dysfunction through activities of daily living,
St Louis, 1990, Mosby.)

consist of task-specific training, strategy training, and proposed an integrated functional approach. In this
environmental modifications (Table 16-3). It also has approach, areas of occupation and context are used to
been suggested that interventions that consist of engag- challenge processing skills. With this integrated func-
ing clients in everyday occupations that are presented to tional approach, treatment may be focused on a subcom-
challenge the underlying impairment should be incorpo- ponent skill such as spatial, but daily occupations are used
rated into treatment.1,4,7 Abreu and colleagues1 have as the modality. Box 16-2 lists potential activity choices.
 Chapter 16 • Managing Visual and Visuospatial Impairments to Optimize Function 435

Table 16-3
Potential Strategies to Improve Function in Those Living with Visuospatial Impairments
DOMAIN OF FUNCTION POTENTIAL INTERVENTIONS*

Dressing Deemphasize visual demonstrations during dressing training. Focus on verbal descriptions to
retrain the task.
Decrease the use of spatial-based language (i.e., “under,” “over,” “right,” “left,” “behind”) when
teaching dressing skills. For example, instead of saying “Your left arm is in the right sleeve,” say
“Wrong sleeve” or “Other sleeve.”
Use cues that facilitate insight into the spatial impairment and that assist in strategy develop-
ment. For example, if a person puts on the shirt backward, start with a general cue such as,
“Are you sure you are finished?” then progress to more specific cues.
Use clothing that provides cues that can be used to orient the article of clothing to the body. A
monochromatic blue T-shirt may be more difficult to orient correctly compared with a base-
ball jersey in which the sleeves are a different color than the body of the shirt.
Teach spatial orientation strategies before the client starts to dress, for example, using the label
to differentiate front from back or finding a decal on the front shirt.
Use an audiotape (i.e., does not rely on visual skills) to cue the sequence of dressing.
The therapist should sit next to and parallel to the person relearning how to dress so that they
are working in the same spatial plane.
Meal preparation Use tactile feedback to increase accuracy when reaching for needed objects (e.g., slide hand
across the counter to reach for a pot).
Decrease clutter. Keep drawers organized to improve foreground from background discrimination.
Use contrasting colors such as dark dishes on a white counter and vice versa.
Label or color code needed items or ingredients that are difficult to recognize.
Organize the kitchen so that cooking equipment is always in the same place. This decreases the
amount of time spent search and locating objects.
Place a piece of colored tape at the edge of the countertop.
Place colored tape on the handle of the refrigerator and stove controls to ease in spatial localization.
Use tactile cues before pouring. For example, find the lip of the measuring cup by touch before
pouring oil into it.
Encourage the person to work slowly to ensure safety.
Label cabinets based on contents.

*May be applied to other functional domains as well; all require further empirical testing.

Box 16-2
Examples of Functional Activities Presumed to Challenge Visuospatial Skills* Based on Activity
Analysis
Wrapping a gift Board games such as checkers
Dressing Stair climbing
Reaching for groceries on shelves of varying distances Sports activities such as playing catch, basketball, or golf
Wayfinding/route finding in familiar and new environments Sorting silverware or coins
Setting a table Using a mouse on a computer
Watering plants Playing videogames
Making a bed Crossword puzzles
Sorting laundry Organizing a workspace such as desk or kitchen counter
Folding clothing

*Note: This relationship requires further empirical testing.

436 Stroke Rehabilitation

17. Jones SA, Shinton RA: Improving outcome in stroke patients with
REVIEW QUESTIONS visual problems. Age Ageing 35(6):560–565, 2006.
1. Name three compensatory interventions that may be 18. G Kerkhoff: Neurovisual rehabilitation: recent developments and
used for a person with decreased performance in future directions. J Neurol Neurosurg Psychiatry 68(6):691–706, 2000.
19. Kerkhoff G, Münssinger U, Haaf E, et al: Rehabilitation of hom-
grooming secondary to spatial impairment. onymous scotomas in clients with postgeniculate damage of the
2. What are the components of a visual screening? visual system: saccadic compensation training. Restor Neurol Neurosci
3. Describe the clinical reasoning process to determine 4:245–254, 1992.
why a person cannot locate a spoon in a utensil drawer. 20. Kerkhoff G, Stogerer E: Recovery of fusional convergence after
4. Describe three different methods of visual occlusion that systematic practice. Brain Inj 8(1):15, 1994.
21. Korner-Bitensky NA, Mazer BL, Sofer S, et al: Visual testing for
may be used with a person presenting with diplopia. readiness to drive after stroke: a multicenter study. Am J Phys Med
5. What are the potential impairments and the effect on Rehabil 79(3):253–259, 2000.
function if a person develops a pathology that adversely 22. Lampinen J, Tham K: Interaction with the physical environment in
affects the dorsal stream (occipitoparietal pathway)? everyday occupation after stroke: a phenomenological study of per-
sons with visuospatial agnosia. Scand J Occup Ther 10(4):147–156,
2003.
23. Laver AJ: Clinical reasoning with simple perceptual impairment. In
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 c a ro l yn a. u n s wo rth

chapter 17

How Therapists Think:

Exploring Therapists’
Reasoning When Working
with Patients Who Have
Cognitive and Perceptual
Problems Following Stroke

key terms
clinical reasoning narrative reasoning procedural reasoning
conditional reasoning novice therapist tacit knowledge
expert therapist phenomenological generalization reasoning
interactive reasoning pragmatic reasoning worldview

chapter objectives
After completing this chapter, the reader will be able to accomplish the following:
■ Define clinical reasoning, and identify and define the main forms of clinical reasoning.
■ Describe the differences between a more phenomenological approach versus a more
biomedical approach to patient care.
■ Describe how an understanding of clinical reasoning can enhance practice in the area of
cognitive and perceptual dysfunction with patients following stroke.
■ Provide examples of situations in which a therapist might use procedural, interactive,
conditional, and pragmatic reasoning.
■ List the five stages in the development of expertise and the key features of each phase.
■ Successfully work through the Review Questions at the conclusion of this chapter.

438
 Chapter 17 • How Therapists Think 439

This chapter reviews how a therapist uses clinical reason- . . . what I respond to immediately or note for future
ing in the context of practice with patients who have reference.
cognitive and perceptual problems following stroke. Be- . . . the way I try to understand my client as a human
cause this chapter provides an overview of research litera- being.
ture in the field of clinical reasoning, the content relates . . . how I draw on my knowledge of previous clients,
to therapists working with all patient groups. However, their difficulties and successful and unsuccessful so-
the case example that illustrates the text is specific to pa- lutions.
tients with cognitive and perceptual problems following . . . the way I draw on my theoretical knowledge and
stroke. The chapter examines the different forms of clini- apply this in practice.
cal thinking such as scientific versus the phenomenologi- . . . the stories I share with other therapists about our
cal approaches to patient care and then explores in detail clients, the therapy we provide and how we feel
the kinds of reasoning popularly identified in occupa- about it.
tional therapy literature, including narrative, procedural, . . . the way I consider the total picture including how
interactive, conditional, and pragmatic reasoning. Influ- much therapy time I can spend with the client, finan-
ences on clinical reasoning also are explored, such as the cial reimbursement issues, and the support available
therapist’s worldview. Because many academics and thera- from the client’s family.
pists agree that the use of case studies that demonstrate . . . the process of deciding what course of action to
expert reasoning provides excellent opportunities for stu- take with the client, and how I modify or change this
dents to develop their own reasoning skills, the reasoning over time.
processes of an expert therapist obtained during the au- The way I reason has changed over time, due to greater
thor’s research in this field are used to illustrate the text. experience and mentoring from expert occupational ther-
The final section of the chapter examines how clinical apists and other health professionals. The way I reason in
reasoning skills develop as students or new graduates my OT [occupational therapy] practice makes me differ-
progress over time from novice to expert. Occupational ent from other health professionals.”*
therapists can use this information to make expert clinical
reasoning more explicit and therefore easier for students Development of Clinical Reasoning in Occupational
and novice therapists to learn and incorporate in their Therapy
practice. Throughout the chapter, the term clinical rea- Rogers and Masagatani55 conducted the first empirical
soning is used. However, more recently, occupational study of clinical reasoning in occupational therapy in
therapists are adopting the term professional reasoning 1982. The following year, Rogers53 delivered an Eleanor
since clinical reasoning may be associated with a more Clarke Slagle lecture that focused on clinical reasoning.
medically based approach.57 This lecture, coupled with a presentation by Donald
Schön (an expert in the analysis of professional practice)
WHAT IS CLINICAL REASONING? to the American Occupational Therapy Association
Commission on Education, stimulated the American
Definition of Clinical Reasoning Occupational Therapy Research Foundation to set up
Clinical reasoning may be defined as the thinking processes the Clinical Reasoning Study. The study was designed by
of therapists when undertaking a therapeutic practice. an anthropologist (Mattingly) and several occupational
Although occupational therapists have written extensively therapists including Fleming, Gillette, and Cohen and
about clinical reasoning over the past 20 years, they are was influenced greatly by Schön as the consultant on the
still just beginning to understand what clinical reasoning project.45 The study ran between 1986 and 1990 and was
is and its importance to practice. Mattingly and Fleming44 reported extensively in the special issue on clinical rea-
described clinical reasoning as a practical know-how that soning of the American Journal of Occupational Therapy
puts theoretical knowledge into practice and a complex in November 1991. In 1994, Mattingly and Fleming44
(yet often commonsense) way of thinking to find what is published this work in a book. The content of this
best for each patient. chapter draws on the foundation laid by Mattingly and
Unsworth66 stated, “To me, clinical reasoning is how I Fleming in the Clinical Reasoning Study and extends
think and make decisions when I’m planning to be with a these ideas using research and theoretical literature from
client, when I’m with a client, and afterwards when I re- the past 10 years from Sweden, the United Kingdom,
flect on therapy. It involves intuition, judgment, empathy, Australia, and North America.
and common sense.
Clinical reasoning is . . .
. . . how I think about what the client is telling me and *Reprinted with permission from Unsworth CA: Cognitive and percep-
what I observe. tual disorders: a clinical reasoning approach to evaluation and intervention,
. . . what I pay attention to and ignore. Philadelphia, 1999, FA Davis.
440 Stroke Rehabilitation

proach,32 the neurofunctional approach,26 or the compen-

Clinical Reasoning and Theory satory or rehabilitation approach.21,74 The evolving theory
The first consideration is the use of clinical reasoning to of clinical reasoning seems to interface smoothly with all
explore the practical theories of the profession. One of the of these conceptual practice models. A clinical reasoning
aims of the Clinical Reasoning Study was to make explicit approach cannot replace any model, and yet such an ap-
the tacit knowledge contained in the practical theories proach can be used to complement these models and add a
used by the therapists studied. The study argued that this different perspective to clinical work. Using a clinical rea-
tacit knowledge could be shared if a language to describe soning approach with an umbrella and specific practice
therapists’ reasoning could be developed. Hence the study model ensures that the therapist acknowledges and can
aimed to examine the types of reasoning processes used by describe scientific and phenomenological approaches to
therapists to use their many practical theories. patient care (as are described next) and has a language to
Mattingly and Fleming44 made the distinction between describe the kinds of thinking that guides practice, includ-
espoused theories and theories-in-use. Espoused theories ing why one chooses a particular practice model. Fig. 17-1
are those held true by the discipline. These theories are depicts this relationship between a generic occupational
intelligent speculations about the workings of a particular therapy (umbrella) conceptual practice model, specific con-
phenomenon, which then usually are tested out and refined ceptual practice models, and clinical reasoning.
through research. Theories-in-use, or practical theories,
are those generated by practice. Although many scientists CLINICAL REASONING WITH PATIENTS
do not support the notion that theory can arise from prac- WHO HAVE COGNITIVE AND PERCEPTUAL
tice, researchers such as Mattingly and Fleming44 and PROBLEMS FOLLOWING STROKE
Schön61 believe this is possible. Many of these practical
theories pass verbally among therapists when working to- At some point in their careers most occupational thera-
gether, and they often guide therapists in their day-to-day pists work with patients who have cognitive and percep-
practice. Theories-in-use generally are accompanied by a tual problems. One of the largest groups of patients with
large fund of tacit knowledge. Often therapists cannot such problems is the group of stroke survivors. The
describe what they are doing or why; their expert knowl- American Heart Association4 estimates that each year ap-
edge is tacit. While this knowledge remains undocumented, proximately 795,000 Americans will have a stroke. Docu-
it cannot be used to contribute to the fund of knowledge mented evidence indicates that at any one time over three
for the profession. Hence a language to describe how and million persons in the United States have a stroke-related
why therapists use certain techniques or communicate in disability that requires ongoing management and care.4
particular ways is needed. Global estimates of incidence of cognitive and perceptual
In addition to the way clinical reasoning can be used to problems following stroke vary enormously because of
explore the practical theories of the profession, one also differences in assessments used, populations studied, and
must consider that the construct of clinical reasoning is time since stroke onset. However, Kong, Chua, and Tow36
itself developing into a theory. Knowledge of clinical rea-
soning has been growing steadily over the past 20 years
and is evolving slowly into a theory derived from practice. Clinical Reasoning
If clinical reasoning surfaces into a theory, what is the re-
OT Theories
lationship between this and other theories or frameworks such as MOHO
that guide occupational therapy practice? Kielhofner35 CMOP
described conceptual practice models as bodies of knowl-
edge developed in occupational therapy for its practice.
such as such as such as
However, whereas some models can be applied to many Dynamic Retraining Neuro-
patient groups, some are more targeted for patients such as Interaction Approach functional
with particular problems. Hence, Stanton, Thompson- Cognitive Approach Approach
such as
Franson, and Kramer63 described some conceptual prac- Disabilities Quadraphonic
Model Approach
tice models as generic and others as specific to the patients’
problem areas. To think about these generic models
as umbrella models, such as the Canadian Model of
Occupational Performance11,38 or the Model of Human
Occupation,34 is useful. In the field of cognitive and per-
ceptual dysfunction, an umbrella conceptual practice Figure 17-1 Relationship between the evolving theory of
model is used with a specific practice model such as the clinical reasoning and other conceptual practice models. CMOP,
Cognitive Disabilities Model,2 the dynamic interaction ap- Canadian Model of Occupational Performance; OT, Occupa-
proach,32 the quadraphonic approach,1 the retraining ap- tional therapy; MOHO, Model of Human Occupation.
 Chapter 17 • How Therapists Think 441

estimate that approximately 41.5% of persons who expe- these problems and seek answers with colleagues can
rience stroke and are more than 75-years-old experience practice develop.
some deficit in this area. Closer examination of specific
impairments shows that up to two thirds of individuals CASE STUDY: SALLY AND SAM
with acute right-hemisphere stroke demonstrate signs of
unilateral neglect50 and that 23% of patients have more The next section deals specifically with the different types
lasting experience of this problem.51 The incidence of of clinical reasoning therapists use. To illustrate these dif-
apraxia is reported to be lower, with estimates of approxi- ferent types of thinking, clinical reasoning examples from
mately 30% of patients with left hemisphere damage ex- Sally are provided. Sally is an expert occupational thera-
periencing problems.17 When occupational therapists pist working with a 28-year-old male patient, Sam, who
work with patients after stroke, the language of clinical experienced cognitive and perceptual problems along
reasoning can aid them in describing their practical and with motor weakness on his right side following a left-
espoused theories (and how these translate into day-to- sided anterior communicating artery stroke. Sally is the
day therapy) to colleagues, students, and the patient and senior therapist in a team of eight therapists at a rehabili-
patient’s family. Descriptions of the key types of reasoning tation facility with 60 beds. She manages a caseload of
that form this language are described in the next section. patients with neurological problems following stroke,
The conceptual practice model that the therapist head injury, or disease processes such as Parkinson. The
adopts guides the kinds of evaluations and interventions examples of Sally’s reasoning are based on research tran-
that the therapist will undertake,66,71 and the section on scripts in which Sally retrospectively described her ther-
Procedural Reasoning describes this in more detail. For apy sessions with Sam.68 Three transcripts were recorded,
example, a therapist who uses a remedial or bottom-up one following an initial outpatient evaluation session with
approach such as the retraining approach32 assumes that Sam, another following a typical treatment session, and a
remediation of function is possible, and this fundamental third when Sam was being discharged from regular outpa-
belief helps shape all the reasoning that follows. Such tient services. Hence transcript excerpts are headed with
therapists believe that reorganization of brain activity is Evaluation, Intervention, or Discharge Session. These
possible following stroke. Reorganization refers to the transcripts have been modified (and pseudonyms used) to
ability of the central nervous system to reconfigure and protect the identity of the patient and therapist or more
adapt itself in various biological and functional ways to clearly to illustrate a particular form of reasoning. Sally’s
perform an activity. In contrast, a therapist who uses an description of Sam together with details of his impair-
adaptive, or top-down, framework such as the compensa- ments, therapy goals, and the occupational issues he faces
tory or rehabilitation approach21,74 to patient care believes are outlined in the following section, which examines the
that the therapist needs to work with patients in the ev- difference between chart talk and narrative reasoning.
eryday occupations the patients want and need to do and
that the environment can be modified or that compensa- A LANGUAGE TO DESCRIBE THE TYPES
tory strategies can be used to assist patients to complete OF CLINICAL REASONING
tasks. The therapist starts at the top, which is the desired
occupation rather than working with the patient on the This section explores the different types or modes of
underlying performance components. When using a top- clinical reasoning. Although several different types of
down approach, the therapist does not assume generaliza- reasoning are described, these types fit into a more bio-
tion of compensation strategies taught from one activity medical or a more phenomenological approach to patient
to another.66 care. As described by Mattingly,41 the profession of oc-
Theoretical information provides only the starting cupational therapy deals in two practice spheres, the
point for therapy. Many writers suggest that only through biomedical sphere that focuses on the mechanical body
clinical practice can clinical practice develop and creative and the social, cultural, and psychological sphere that
solutions be found for problems that are not mentioned in concerns the meaning of the illness to the person. Hence,
texts.12,60 When problems or obstacles arise in therapy, Mattingly referred to occupational therapy as the two-
occupational therapists need to be able to reason to reach body practice. Usually, these more scientific versus more
a solution. For example, theoretically, therapists know to phenomenological approaches to patient care coexist
assess the patient’s sensation to exclude these problems uneasily. However, Mattingly noted that many occupa-
before the assessment of complex perceptual problems. tional therapists seem to be able to shift rapidly and easily
But what if the patient has insufficient or unreliable lan- between thinking about the patient’s disease processes
guage, making sensory testing impossible? What if the (body as a machine or the physical body) and the patient’s
patient is depressed and refuses to undergo sensory test- illness experience (the lived body). Mattingly described
ing? Only through learning about clinical reasoning and how some therapists can integrate these two approaches
developing a language to help therapists reason through so seamlessly that “biomechanical means may be used to
442 Stroke Rehabilitation

achieve phenomenological ends or the reverse.” The Evaluation Session, Part 1. “Basically the idea behind
synthesis of these two perspectives into what is called this initial outpatient session is just looking at basic home
best practice in occupational therapy also reflects the independence for Sam. He was discharged home a couple
paradigm shifts the professions has undergone over the of days ago, so he is back here every day at the moment as
past 40 years. an outpatient. It was actually a self-discharge. We were
Therapists require different types of reasoning when heading toward that anyway, and the plan was for Sam to
working in these two different spheres and need different live in a bungalow or trailer on his family’s property. He
ways of communicating this reasoning. When occupa- used to live in a trailer at the back of their property, but
tional therapists are talking about the patient’s medical this has rotted out and they’ve pulled it down. They [his
problem, they are more likely to use a kind of language family] actually have a very small house, and it’s just not
that Mattingly and Fleming44 described as chart talk. In really appropriate for him to be living there since he has
contrast, when the therapist thinks about the patient as a teenage stepsiblings, and he is a very independent young
person who also has a medical problem, the therapist is man; he wants to have his own space, which you can really
more likely to reason in what Mattingly and Fleming de- understand for a young man, so the idea for him is either
scribed as the narrative form. Mattingly42 described oc- to get a bungalow at the back of his family property again
cupational therapy clinical reasoning as being “largely or go to a community-based group home. However, that
tacit, highly imagistic, and deeply phenomenological hasn’t worked out yet, and so Sam is in the family home
mode of thinking.” Mattingly therefore suggested that for the moment. Sam had his stroke six weeks ago. He was
narrative reasoning is the best basis for most clinical rea- in intensive care for three days, indicating the severity of
soning in occupational therapy. Narrative reasoning the infarct, which was in the left anterior communicating
means that stories are told or created to assist the thera- artery. The CT [computerized tomography] scan revealed
pist to make sense of what is happening with the patient. a reasonably large lesion area, and, consistent with his le-
When thinking about the patient as a person, his or her sion, Sam experiences difficulties with walking, and he is
illness experience, and what therapy will mean for the using a 3-point stick. He also has reduced movement in
patient’s present life and future, therapists commonly his right arm, and particularly, he has difficulty using his
think and talk in the narrative form. These two ways of hand since the movements are slowed and his grasp is
communicating clinical reasoning are described next. reduced. He’s also got some moderately severe cognitive
problems.
Narrative Reasoning and Chart Talk “Sam, prior to his stroke, was unemployed, was a drug
Therapists use narratives or stories to convey their think- user, and didn’t have a lot that interested him in his life
ing to other professionals, students and novice therapists, other than playing the guitar, so in terms of finding ac-
and patients. Viewed in this light, narrative reasoning is a tivities that are meaningful for him, it’s been quite hard,
way of reporting or giving words to the other forms of and we spent some really worthwhile time in therapy us-
clinical reasoning, which are discussed later in this sec- ing the Interest Checklist and found that cooking is one
tion.64 Narrative reasoning is also a form of phenomeno- activity he loves. He is really motivated; he is a terrific
logical understanding. Narratives can take the form of guy; he’s really cooperative and tries really hard and seems
storytelling or story creation. Storytelling can reveal how to always understand the rationale, even though I always
the therapist treats and interacts with the patient and can explain to him why we are doing what we are doing. So I
be used to explain how the therapist perceives the patient suppose the two reasons why we chose this cooking activ-
to be managing the disability. Storytelling is most pre- ity for today are one, looking toward him in the long-term
dominant when therapists are carrying out the day-to-day developing a repertoire of basic meals he can prepare in
procedures of evaluating and treating patients, trying to his own place, and also because it specifically works on
understand the patient as a person, and what is happening improving his planning and problem-solving skills, atten-
in therapy.3 Story creation, however, involves creating a tion, and his standing tolerance.”
picture of the future with the patient that includes setting In contrast to narrative, reasoning is the kind of lan-
goals to work toward in therapy. Story creation is more guage therapists use when speaking with colleagues
common when therapists envision a future for the patient, about a patient’s biomedical problems. Although the
or engage in conditional reasoning (described in detail foregoing example is largely in the narrative form, Sally
later). However, the story created for therapy usually does does slip into another kind or more factual description
not proceed without the need for revision, and experi- when she talks about Sam’s medical problems. Mattingly
enced therapists are adept in changing the therapeutic and Fleming44 reported that when therapists discussed
story midstream.40 In the following example, Sally tells procedural aspects of the patient’s physical condition,
the story of Sam to the researcher. The emphasis of this shared treatment goals, and planned evaluations and
narrative is on Sam as a person rather than the medical interventions, they were more likely to use chart talk and
aspects of Sam’s stroke. scientific forms of reasoning. During these discussions,
 Chapter 17 • How Therapists Think 443

therapists tended to use a biomechanical way of under- patient’s cooperation and understand the person’s re-
standing the patient’s problems. For example, in the fol- sponse to the treatment using interactive reasoning.22
lowing excerpt, Sally discusses aspects of Sam’s splinting Therapists also seem to engage in considering the pa-
regimen using chart talk. tient’s condition and how it could alter over time and to
imagine how the patient’s past, present, and future could
Intervention Session, Part 1. “A lot of the focus with be facilitated by occupational therapy intervention. Flem-
Sam in the past few weeks has been on him getting func- ing and Mattingly25 argued that experienced therapists
tional use of his right hand, which is his dominant hand. were able to use these forms of reasoning in rapid succes-
He’s actually got quite increased muscle tone as you can sion or use different forms almost simultaneously. Flem-
see there. He has a night splinting regimen, and going ing22 suggested that “Reasoning styles changed as the
back a few weeks ago, he basically forgot he had a right therapist’s attention was drawn from the clinical condition
hand; he just wasn’t initiating using it, and he quickly to another feature of the problem, and to how the person
taught himself to be left dominant. So we’re really pleased feels about the problem, almost simultaneously, using dif-
with the progress he’s making in extending his wrist and ferent thinking styles; and they did not ‘lose track of’ their
MCP [metacarpophalangeal] and PIP [proximal interpha- thoughts about aspects of a problem as those components
langeal] finger joints. We are talking about his splint at were temporarily shifted to be the background while an-
the moment because I did quite a radical change to the other aspect was brought into the foreground.”
splint last Friday, and I was asking him if it was giving him Although Mattingly and Fleming44 identified these
any pain because it does give him a little bit of pain as we three modes of reasoning together with narrative reason-
have been gradually increasing the extension of his wrist ing, subsequent theoretical and empirical publications
and of his fingers. He told me he took it off midway have suggested that these might not be the only forms of
through the first night, but that he has been able to wear reasoning used. In fact, occupational therapists and other
it through the last couple of nights.” allied health scientists have now documented multiple
Although therapists usually write case notes in the brief types of clinical reasoning including scientific, diagnostic,
and factual language of chart talk, chart talk and narrative pragmatic, management, collaborative, predictive, ethical,
reasoning possibly may be interwoven when therapists intuitive, propositional, and patient-centered.30,39,54,56 In
describe the patient. This idea was suggested previously this chapter, only the most commonly described forms of
when noting that occupational therapists seem to be able reasoning are presented, together with comments on their
to weave between a biomedical and phenomenological interrelationship. Hence, this chapter explores narrative,
understanding of the patient. In the first transcripts from scientific, procedural, interactive, conditional, pragmatic
Sally, one can see how she slips between discussing Sam as reasoning, and a newly identified form of reasoning
a person and describing the facts of his stroke. Research termed generalization reasoning.
evidence also supports that therapists interweave these
forms of reasoning when discussing and describing their Procedural Reasoning. Therapists use procedural rea-
patients.67,69-70 soning when thinking about the patient’s problems and
the kinds of evaluation, intervention, and outcome mea-
The Therapist with the Three-Track Mind surement procedures to use. Whereas interactive and
Mattingly and Fleming44 suggested that when describing conditional reasoning are based more in the phenomeno-
the patient’s biomedical problems, therapists tended to logical sphere and therefore are narrative forms of reason-
use chart talk. The kind of reasoning that supports this ing, procedural reasoning is based more in the biomedical
sphere of patient care draws on scientific reasoning. More sphere and therefore draws on scientific reasoning. Scien-
specifically, Fleming23 referred to this kind of thinking in tific reasoning almost exclusively forms the basis for
occupational therapy as procedural reasoning. When rea- medical reasoning and decision-making. Scientific rea-
soning in the narrative form and considering the meaning soning is the process of hypothesis generation and testing
of the illness for the patient (when using a phenomeno- that generally is referred to as hypothetico-deductive rea-
logical perspective to patient care), occupational thera- soning. This form of reasoning most often is used to make
pists use two other types of reasoning, which Fleming la- a diagnosis of the patient’s medical condition. Although
beled interactive and conditional reasoning. occupational therapists are more concerned with identify-
Fleming23 also suggested that therapists seem to be ing the patient’s occupational problems rather than the
able to think in these reasoning tracks simultaneously. medical diagnosis, therapists do draw on the ideas of sci-
Hence the phrase, “the therapist with the three-track entific reasoning when reasoning procedurally.
mind” was coined. Therapists seem to monitor the proce- In the medical decision-making literature, terms such
dural aspects of the treatment, such as the evaluations and as diagnosis, prognosis and prescription, cue identification,
interventions to be used with the patient and how the hypothesis generation, cue interpretation, and hypothesis evalua-
patient is performing, while being able to elicit the tion are used commonly.20 However, in the occupational
444 Stroke Rehabilitation

therapy literature, terms such as problem identification and driven by providing evidence to support the evaluations
goal setting are more common. When determining what and interventions therapists select to use with patients.
the patient’s problems might be and selecting appropriate Therefore, an occupational therapist reasons procedur-
interventions, Fleming22 identified that therapists were ally when asking, “What evidence is there to support the
involved in a variety of procedural reasoning strategies treatments I offer?”
and methods of thinking. These methods of thinking In the following example that illustrates procedural
include the four-stage model of problem-solving, which reasoning, Sally describes setting up a cooking task with
is based on the hypothetico-deductive reasoning, goal- Sam.
oriented problem-solving, task environment, and pattern
recognition of the medical model. Each of these methods Intervention Session, Part 2
of thinking is described briefly. Interviewer: I notice you just set up the fry pan, so tell me
Procedural reasoning generally begins with problem about that.
identification, and Elstein, Shulman, and Sprafka20 devel- Sally: Yes. I basically set it up due to the timeframe for this
oped a four-stage model of problem-solving that focuses session and the demands on Sam. We’ve been gradually
on problem identification. Fleming suggests that thera- upgrading the task demands on Sam, but today I said to
pists may use this model when determining the patient’s Sam that I would set the fry pan up and also because
occupational problems. reaching that would be extremely hard for him. He
The four stages in this model are as follows: would have to lean right over the table, and also I was
1. Cue acquisition: The therapist gathers cues or pieces planning to put the rice on to cook, just to let him focus
of information about the patient and the patient’s on the one task today.
difficulties. Interviewer: So, you would do the rice, and he would do
2. Hypothesis generation: The therapist generates sev- the stir-fry vegetables in the pan?
eral plausible explanations for the observed cues. Sally: Yes and that’s sort of been from past experience
3. Cue interpretation: The therapist compares each because when he has to attend to two things, he will
hypothesis with the cue set and selects the most forget one of them, like the rice. So once we sort of feel
logical or best hypotheses to explain the cues. that he’s managing cooking one dish well, then we’ll
4. Hypothesis evaluation: Finally, the therapist asks upgrade it and include the second dish, the rice, and we
what the best hypothesis is by evaluating which cues would probably have something like a prompt sign on
generally are thought to be necessary for selecting the table for him to remind him to check the rice and
each hypothesis and for the presence of critical cues also the timer, which we always use.
for selecting each hypothesis. In this way, one hy- In the example of procedural reasoning, Sally talks about
pothesis should be identified as the best. some of the difficulties that Sam has with the cooking task
All problem-solving in occupational therapy is goal di- because of his memory and planning difficulties. How-
rected so that therapists and patients work together to ever, more that just looking at Sam’s problems, in this
ensure the patient can participate in desired and needed transcript excerpt, Sally goes on to incorporate into the
occupations. Although therapy is conducted mostly in activity her understanding of how Sam learns. This kind
clinical environments, therapists think constantly about of reasoning is referred to as interactive reasoning and is
translating what is being accomplished into the patient’s described in the next section.
home environments. Hence procedural reasoning also is
concerned with considering the environment in which Intervention Session, Part 3
the task is conducted. Pattern recognition refers to a Sally: I think with Sam, he’s the sort of guy that learns
therapist’s ability to identify the kinds of patient cues and from repetition. So, by letting him go in and make
features that occur together. For example, a therapist mistakes—you will see later, he comes back to the table
who observes a patient go several times to get the neces- and I’ve actually let him come back without the can
sary toiletries for the morning bathroom routine may opener and all those things—so that’s a way for him to
question whether the patient has a planning and organi- stop and think what he needs.
zation problem or difficulties with memory. However,
adding this information to many other observations Interactive Reasoning
of difficulties with planning, judgment, and problem- Therapists use interactive reasoning to consider the best
solving prompts the therapist to consider difficulties with approach to communicate with the patient and to under-
executive functions. The ability to recognize patterns of stand the patient as a person. In the Clinical Reasoning
cues and behaviors becomes part of the therapist’s tacit Study, Mattingly and Fleming44 found that although thera-
knowledge.22 The therapist recognizes these patterns pists reported their procedural practices, they did not re-
without needing actually to think through or articulate port their interactions with the patient. Hence, the authors
the emerging trend. Finally, current practice culture is referred to interactive reasoning as the underground
 Chapter 17 • How Therapists Think 445

practice. Therapists often see patients at difficult times in life easier, I will do.” He will say, “I’m a bit slack,” and
their lives; their health or well-being is challenged, and that’s his personality. I was having a joke with him be-
they may be experiencing their body in a new way. This fore saying, “At least I believed in you,” because now
can be frightening for the patient, who may respond with he’s doing his shoelaces independently. I just said to
confusion or anger. The skilled therapist needs the ability him, “Imagine if we got you elastic shoelaces. You
to communicate effectively with the patient so as to share would look a bit silly out there with these big elastic
information about the patient’s progress and prognosis, shoelaces.” So joking around with him has worked re-
and the therapist can gain an understanding of how the ally well.
patient perceives the disability and views the future.44 In this example, Sally talks about joking around with Sam
However, because many patients who experience stroke as a way of building a shared language between them and
also have a clinical lack of insight to their problems, the gaining his cooperation in therapy. In the following ex-
therapist faces the additional difficulty of collaborating ample, Sally elaborates further on this use of humor in
with patients who may not have any understanding of their therapy.
problems. Therapists need to take extra care with these
patients to establish meaningful and realistic goals. Intervention Session, Part 5. “Yes, and I use humor
In its most simple form, interactive reasoning is con- as well. That’s the approach I often take with people but
cerned with how the therapist communicates with the especially with people like Sam, who are really laid back
patient. In the following example, Sally reasons about the and low key; that really works well. Sam responds much
way she interacts with Sam to make sure he can follow better to a friendship sort of approach, just encourage-
through with what she wants him to do. ment, rather than the dictator sort of approach. That’s not
something Sam goes for. In fact, he bumps up against that
Evaluation Session, Part 2 approach, and I think that’s been a pattern throughout his
“I’m just sort of basically explaining to Sam the actual life. . . . With Sam in particular, like I said, sort of having
movement I want him to do. Often, if I can, I try to de- our own private joke, like I say, “I’m the hand police,” and
crease the verbal cues and actually look at giving some so if I see him not using his hand, I only have to say “hand
physical cues as well. That carries right over to all of his police,” and we can have a bit of a laugh. And we can also
program. So, for example, when we do personal care, I laugh a bit at some of the failures he’s had, and you obvi-
really have to use a combination of both physical cues and ously have to pick the people you do that with. You
verbal prompting. I’m certainly trying to decrease that. I wouldn’t do that with someone who has got poor insight,
think with Sam and a lot of patients with stroke or brain but Sam has excellent insight. But, like I said, that’s my
injuries, it just takes much longer for them to respond. It approach with a lot of people, but with other people you
just doesn’t go in as quickly as it does with us. My strategy just don’t use it because it’s not appropriate, and they get
with Sam at the moment is give him the instruction or very upset if you sort of stir them up a little bit, but with
prompt him and then give him some time to respond, and Sam, no, he’s not problem at all.”
then go on to give him some physical guidance as well.” Using a variety of authors’ works, Mattingly and
More than just basic communication, interactive rea- Fleming44 put together a list of purposes for which inter-
soning is also about understanding the patient as a person active reasoning is used:
who has interests, needs, values, and problems, so that the 1. Engage the patient in therapy.43
therapist can understand the disability from the patient’s 2. Know the patient as a person.13
perspective. Interactive reasoning stems from the way 3. Understand the patient’s disability from the patient’s
therapists value the patient as an individual and the ther- point of view.43
apist’s deeply held humanistic beliefs. In the following 4. Individualize the therapy for the patient to match
example, Sally indicates that she understands Sam as an the treatment goals with the person, disability, and
easygoing person who might want to take the easy way, experience of the disability.24
even though he often can achieve more than he thinks. 5. Convey a sense of acceptance/trust/hope to the
patient.37
Intervention Session, Part 4 6. Break tension through humor.62
Sally: That’s another one of the jokes we have. He’s been 7. Build a shared language of actions and meanings.15
asking me for months about having elastic shoelaces, 8. Monitor how the treatment session goes24 and dem-
and I just said, “No way, you’re not having elastic shoe- onstrate interest in the patient and the patient’s
laces. You don’t need them.” concerns without indicating disapproval or distaste
Interviewer: How does he know about them? of the condition.10
Sally: I don’t know. He just came out of the blue one day, Hence, interactive reasoning is concerned with collaborat-
and I said, “Who told you about those?” And he is the ing with the patient as a partner in the therapy process.
kind of guy that will say to you, “Anything to make my Together the therapist and patient must devise goals that are
446 Stroke Rehabilitation

meaningful to the patient and that also serve to promote the “6. Exchanging personal stories. Exchanging personal
patient’s occupational functioning. Humor seems to be one experiences is another powerful way to develop a
way to facilitate patients to collaborate in the therapy pro- bond with a client. Mattingly and Fleming[44] found
cess, and Mattingly and Fleming44 discussed several other this was commonly used by clinicians to engage the
strategies that therapists use to engage patients in this clients in therapy, and that clinicians were usually
collaboration. These strategies include the following: aware of the value of this strategy.”*
“1. Creating choices. Therapists try to engage clients in Sally talks about the importance of patients choosing their
therapy by providing choices in relation to problem own therapy activity. This illustrates the point made be-
areas the client wants to work on, and the specific fore about creating choices for the patient and supports
occupations or activities they might use in therapy. the idea of a patient-centered practice.
“2. Individualizing treatment. A therapy program that
is uniquely tailored for the client, through both the Intervention Session, Part 6. “Now we’re upgrading
ingenuity of the therapist and the involvement of his program, and we have a hand function group that Sam
the client, generally keeps the client engaged in will start coming to. In this group we are looking at a lot
therapy. While the goals of therapy for a client of active wrist and finger extension because that’s what he
with a memory problem may be quite similar, the really needs to work on, and a lot of gross grasp because
way the therapy program is structured, and the he really has trouble extending his third, fourth, and fifth
activities that the client and therapist choose are fingers at this stage. Even in the hand function group,
usually different for each client. although I don’t actually run it, two of the other OTs
“3. Structuring success. Therapists often structure, or [occupational therapists] do; it’s actually fantastic, and the
manipulate therapy to provide the client with therapists find out what it is the person who wants to do.
opportunities for success, and thus promote their We have had people in the group eating using chopsticks
alliance. Therapists are often in the business of in their other hand or practicing putting CDs in and out
revealing problems, and then working with the cli- of their player. We really try and keep people motivated
ent to reduce their impact. Unless the client has by choosing their own therapy activities, and it’s a really
some successes along the way, it is very hard to great fun group that people get a lot out of, I think, more
keep the client motivated, or to maintain a positive than doing therapy on a one-to-one basis. A lot of my
relationship with the client. Therapists often talk patients, from my experience working here, if they can’t
about keeping the client optimally challenged. see or understand why they are doing a stupid exercise,
This includes pushing the client to achieve, but not you just lose them. As I said, we really try to emphasize
so far that he fails. This has been described as the here that patients choose meaningful activities.”
‘just right challenge.’[9,16] Finally, the following transcript excerpt shows an ex-
“4. Joint problem solving. Another approach thera- ample of how Sally structures the therapy session to ensure
pists use to facilitate client engagement in therapy that Sam has some success. The motivating effect of this
is to ask the client to help them in the problem success pushes patients forward in their therapy programs.
solving process. For example, if the therapist has
difficulty in using a piece of equipment, or in Evaluation Session, Part 3. “We’ve just finished
devising a strategy for a transfer, calling on the cli- making toasted cheese sandwiches with Sam, and he did
ent for his input enables him to take a strong and so well. And I made sure that Sam could do nearly all of
active role in therapy if only for a short time. this activity, since I’m challenging him with the stir-fried
“5. Gift exchange. The final two strategies that vegetables, so its good to balance this a bit with a cooking
Mattingly and Fleming[44] found [that] therapists task that he can complete successfully. I was telling him
use to build an alliance with their clients were how well his right hand is working now, and he was like
more personal in nature. The researchers found so many other patients who say. ‘Gosh, couldn’t I use my
that therapists would go out of their way, or their hand at the start?’ and we’ll say, ‘No,’ and they’ll just be
formal roles to do something nice for the client amazed, so yes, having this success in an activity just keeps
such as bake a cake for a client’s birthday. In this them going, I think.”
way the therapist shows a willingness to care for
the client in a more personal way. In exchange, Conditional Reasoning. Conditional reasoning was the
clients often feel more committed to co-operate in last mode identified in the Clinical Reasoning Study. In
therapy. Clients may also give gifts to the therapist. describing the emergence of this mode, Fleming22 wrote,
These may be as simple as a flower, a few words of
thanks or a hug, all of which demonstrate their *Reprinted with permission from Unsworth CA: Cognitive and
personal thanks for the therapists’ involvement in perceptual disorders: a clinical reasoning approach to evaluation and
their treatment. intervention, Philadelphia, 1999, FA Davis.
 Chapter 17 • How Therapists Think 447

“Later we realized that there was a third type of reasoning budge from that. You know, when it comes down to the
that therapists employed when they thought of the whole crunch, he just can’t resist the temptation.
problem within the context of the person’s past, present, “So, essentially the two things we are trying to do at
and future; and within personal, social and cultural con- the moment is one, structure all of his time, since its when
texts. This was an especially useful form of reasoning, he’s bored that he starts smoking drugs and things. Sec-
which therapists used when they wanted to, as they say, ondly, looking into attendant care so that he has someone
‘individualize’ the treatment for the particular person. We helping him to live in a shared house, because if we look
called this ‘conditional reasoning’ because it took the at him coming to our transitional living house, which is
whole condition into account.” just across the road here, and I was also, at the end of the
Conditional reasoning takes the whole of the patient’s session, discussing with him the increased responsibilities
condition into account as the therapist considers the that would be on him, and he is a very capable young man.
patient’s temporal contexts (past, present, and future), He can make basic meals for himself now. Like, you didn’t
and his personal, cultural, and social contexts. Fleming22 see him walk in, but he is now mobile with a stick, which
proposed that this form of reasoning is based in the he is hardly using. He has really well exceeded all of our
cultural and social processes of understanding one’s self expectations for someone with such a serious stroke. He
and others and is used when the therapist wishes to un- still has ongoing cognitive impairments with things like
derstand the patient from a phenomenological perspec- memory and problem-solving and planning, but with rep-
tive. A therapist uses this form of reasoning in trying to etition and things, he can really learn to do things himself.
understand what is meaningful to patients in their world It’s really hard at the moment until we find out whether
by imagining what their life was like before the illness there’s a bed available in one of the nearby group share
or disability, what it is like now, and what it could be like houses. He is quite keen about that idea, but still his fa-
in the future. In the following transcript excerpt, Sally vored option is for himself to get a trailer or a bungalow
thinks through the issues surrounding Sam’s life at on his family block.”
home and what the future holds. This example not only Fleming22 described the third form of reasoning as the
illustrates conditional reasoning (e.g., discussing how most elusive. Conditional reasoning is not always con-
Sam’s condition has changed and on what his residential scious and therefore is more difficult to get at, understand,
care situation is conditioned) but also shows aspects of and describe. Conditional reasoning requires more than a
what some authors describe as ethical reasoning,5 where simple knowledge of the patient’s condition; it also calls
Sally imagines how Sam might behave in different resi- for an understanding of how the condition has affected
dential settings and how his drug use may affect other the individual’s work, social situation and leisure, and view
residents. of self. Fleming22 reported that therapists who were more
interested in patients’ medical conditions or occupational
Discharge Session, Part 1. “Now, we’re talking therapy treatment procedures than the patients them-
about a big issue for Sam at the moment; it’s the break- selves did not seem to use conditional reasoning. This is
down of his residential situation at home. He’s still in his often the case with less experienced therapists who are
parents’ house, but he can’t stay there much longer, and still grappling with the patients’ medical conditions and
they want him out. It’s really hard because a lot of the are still learning about putting an occupational therapy
residential settings [supervised housing such as nursing treatment program together. Hence conditional reason-
homes] are too low level for him, or the ones that he ing seems to be more pervasive in the thinking of experts
could live in and have day-to-day contact with someone rather than novice therapists.28,67
in attending care support, there’s no vacancies or he To convey a sense of the patient’s past, present, and
doesn’t like them, and the other issue with him is if he future and to map out how therapy is progressing, the
goes into a group home, other people are at risk. He ac- therapist may remind the patient (and self) of a time when
tually, unfortunately, shares his drugs around, and most the patient could not do a task or activity. This may be
of these houses have young men with brain injuries, and particularly useful when therapy is progressing slowly or
so we have a responsibility to ensure, you know—they some of the routine aspects have become boring. Impor-
can’t obviously make an informed decision about whether tantly, these reminders show the patient and therapist
to take the drugs Sam offers them. With Sam it’s a pre- how the condition is progressing and that together they
morbid thing, and essentially we have come to the real- may yet reach their shared vision of the future.22 For ex-
ization he is not going to change. He’s tried drug coun- ample, to encourage Sam, Sally talks about how much
seling, then we had a consultant, then social workers have improvement he has made and how this helps him toward
tried, his mum has tried, and she is tearing her hair out, his goal of independent living.
but he just—it’s something he likes to do no matter what
we say. He acknowledges there is a high risk of psychotic Intervention Session, Part 7. “I’m just saying to
incidences and all these things, but he just doesn’t really him, ‘Sam, you’ve made such great progress.’ I remind
448 Stroke Rehabilitation

him of when he first started in the kitchen and his en- also reasoned pragmatically about how Sam’s residential
durance really limited how long he could work, and we options were constrained by the number of available sup-
used to make really simple meals like toasted sand- ported community housing places.
wiches. And now he can make a stir-fry, and he can use Time pressures are another common source of prag-
his right hand to stabilize very effectively when he matic reasoning. Therapists must consider what can be
chops vegetables, and how he can concentrate for much achieved in one session or across the patient’s admission.
longer on the job. I find Sam responds really well to Therapists feel the pressure of patients waiting for them
reminders of how far he’s come and how far this will get and having to treat more than one patient at a time. Sally
him in the future in terms of living in a more indepen- also talks about having to share therapy time when the
dent home environment, and that’s a real motivator to patient is at his or her best.
keep going in therapy.”
To summarize, Mattingly and Fleming44 use the term Evaluation Session, Part 5. “We are trying to gradually
conditional in three different ways. In its most simple form, increase his endurance, but you get to the stage where his
the therapist thinks about the patient’s whole condition face is going to fall into his cereal, [and] there’s no point.
and the meaning attached to this. The therapist also You just have to sort of respect that fatigue and also re-
thinks about how the patient’s condition could change and spect the role of the other therapists, because if I see him
what this would mean for the patient, and finally the first, it’s not fair if I exhaust the guy, and everyone else
therapist thinks about whether the imagined life will be gets nothing out of him, either in physical therapy or
achieved and realizes that this is conditioned on the pa- neuropsych. assessment or whatever it may be.”
tient’s participation in the therapy program and the shared The author’s empirical research has shown that al-
image of the future. though many instances of pragmatic reasoning were found
in the transcripts relating to the therapist’s practice con-
Pragmatic Reasoning text, few related to the therapist’s personal context.69
Schell and Cervero56 reviewed Fleming’s23 conceptualiza- Hence one really must question whether pragmatic rea-
tion of the three tracks of clinical reasoning and postu- soning is in fact only concerned with the practice context
lated theoretically that this account of reasoning neglected and whether the therapist’s personal context is not related
the reasoning surrounding the environmental influences to clinical reasoning but to something else.
that affect thinking and the therapist’s personal context.
They referred to these kinds of reasoning as pragmatic Worldview
reasoning. They suggested that organizational, political, Worldview is a useful term to describe the influence of
and economical constraints and opportunities affect a the therapists’ personal views about life on their thinking
therapist’s ability to provide an occupational therapy ser- and reasoning. Although Schell and Cervero56 proposed
vice, as do personal motivation, values, and beliefs. In that these personal belief and values form the personal
the following example, Sally describes how at the facility context component of pragmatic reasoning, one has dif-
in which she works, she must use the Functional Indepen- ficulty imagining that therapists could reason actively
dence Measure (Adult FIM, 1995) as an outcome with their deeply held sociocultural beliefs.69 Rather,
measure.27 personal context seems to be something that influences
clinical reasoning. The term worldview seems to be the
Evaluation Session, Part 4. “Last week just before Sam’s best way to describe the factors that make up one’s per-
discharge from inpatient care, I rescored his FIM and sonal context.72,76 Worldview commonly is understood
discussed that with the team as well. We use FIM as one as an individual’s underlying assumptions about life and
of our outcome measures here. I don’t really mind doing reality.31 Hence it encompasses the therapist’s ethics,
it, but like I have no choice anyway since that’s what man- values, beliefs, faith and spirituality, and motivation. If
agement has said we’ll do.” the therapist’s worldview influences reasoning, then the
Therapy often is constrained or promoted by issues over therapist also must acknowledge that this may be a posi-
which the therapist may have little control, such as reim- tive or negative influence. Therapists also must recog-
bursement for service, the kinds of services and equipment nize that they have varying degrees of insight to the in-
that can be provided given the patient’s length of stay, fluence of their worldviews on reasoning and therefore
whether the patient can afford to purchase equipment, and varying ability to modulate this influence if desired. The
the kinds of services available in the community for the most popular method of researching clinical reasoning is
patient on discharge.69 Another important note is that for the researcher to ask the therapist to tell what he or
pragmatic reasoning as influenced by the environmental/ she is thinking about after a therapy session has ended.68
practice context appears to interface directly with thera- As mentioned previously, in the author’s research, it was
pists’ procedural, interactive, and conditional reasoning. In discovered that therapists rarely if ever revealed any in-
the earlier example, when reasoning conditionally, Sally formation about their worldviews or how this influenced
 Chapter 17 • How Therapists Think 449

their reasoning. This is not surprising given that world- it appears to go beyond simple pattern recognition of a
view beliefs are deeply held and that individuals find that set of cues. Therapists seem to reason initially about a
they cannot, or may not want to, articulate these beliefs. particular issue or scenario with a patient, then reflect
Hence, it is difficult to research and gain an understand- on their general experiences related to the situation
ing of the influence of worldview on clinical reasoning.69 (i.e., making generalizations), and then refocus the rea-
However, in some brief glimpses to her worldview, Sal- soning on the patient. This seems to occur in rapid suc-
ly’s transcripts did reveal the personal satisfaction she cession, as in the following excerpt in which Sally rea-
gains from working with patients who have neurological sons interactively about how she is communicating with
problems. the patient.

Evaluation Session, Part 6. “I think OTs [occupational Intervention Session, Part 8. “Often, if I can, I try to
therapists] are really great at empowering people and help decrease the verbal cues and actually look at giving some
them to feel they are in control and they have some say. I physical cues as well. That carries right over to all of his
think OTs do that better than a lot of other profes- program. Physically, even though he has significant prob-
sions. . . . I love to work with people with disabilities, so I lems in all areas in terms of transfers and bed mobility
think if you actually enjoy the contact and seeing people and everything. So, for example, when we do personal
achieve things, it’s such a rewarding job. That comes care, I really have to use a combination of both physical
across in your approach.” cues and verbal prompting. I’m trying to certainly de-
The transcripts also revealed Sally’s disappointment crease that. I think with Sam and a lot of patients with
that Sam cannot achieve what she considers his potential stroke or brain injuries, it just takes much longer for
because of drug use. them to respond. It just doesn’t go in a quickly as it does
with us. My strategy with Sam at the moment is give him
Discharge Session, Part 2. “Even though he’s motivated the instruction or prompt him and then give him some
and you can say, ‘Sam, you’ve just made such amazing time to respond, and then go on to give him some physi-
gains,’ when he does use drugs, he just loses all his cogni- cal guidance as well.”
tion basically. He sits there, and his mother reports he In summary, this generalization form of reasoning
spaces out for 24 hours at a time, and it’s a real shame. I seems to enrich the other reasoning modes and also seems
have seen this fellow going from being full assistance in to be used more frequently by expert rather than novice
absolutely every activity of daily living to being fully inde- therapists.70
pendent in personal care, basic domestic activities, and
basic community activities, so he really has done remark- Embodied Knowledge
ably well, so it’s a bit disappointing. You try not to dwell This chapter has explored the clinical reasoning and
on it too much, but it is disappointing from a therapist’s thinking that underpins occupational therapy practice.
point of view because you think he could just keep on However, this reasoning is a product of cognitive or men-
improving, but the drug use is holding him back, but at tal processes and body experiences. Therapists’ bodies
the same time that’s his life.” obtain a great deal of information as they work with cli-
Although Mattingly and Fleming44 did not describe ents. For example, their bodies tell them about the client’s
worldview specifically or its relationship to clinical rea- smell, and the feel of their muscles and how their body
soning, their text is rich with descriptions of how the moves in ways that the therapists’ own bodies recognize
therapist’s personal qualities, abilities, or style influences or “know” but that they might not be able to put into
therapy. Further research is required, perhaps using inter- words. This is referred to as embodied knowledge.58 In
view techniques, to explore the relationship of therapists’ the case study illustrating this chapter, Sally described
worldview to clinical reasoning.69 how she would automatically smell Sam as soon as he ar-
rived at therapy to help determine if he had been smok-
Generalizing Form of Reasoning ing drugs. Although occupational therapists have long
Finally, in each of the forms of reasoning discussed be- recognized the importance of information from their
fore (procedural, interactive, conditional, and prag- bodies about their clients, the embodied nature of clinical
matic), research has shown that therapists seem to draw reasoning is a relatively new area for research in occupa-
on their experiences to enrich the kind of reasoning in tional therapy.
which they are engaged.70 Rather than being described
as a separate form of reasoning, this form of reasoning Putting It All Together: A Summary of the Different
seems to be an extension of the other forms. The author Modes of Reasoning
calls this generalization reasoning. Although generaliza- Before summarizing the different kinds of clinical reason-
tion reasoning has similarities to simple pattern recog- ing and influences on reasoning such as worldview, explo-
nition (as described in relation to pragmatic reasoning), ration of the interaction of the three tracks of clinical
450 Stroke Rehabilitation

reasoning is important. Although some researchers exam-

ine procedural, interactive, and conditional reasoning in WORLDVIEW
isolation from each other,28 it seems that these forms of
reasoning can occur in rapid succession or even simulta-
neously. As described earlier, Fleming22 described how Procedural P
reasoning
(GR)
PI

PIC
I Interactive
reasoning
(GR)
therapists can think in “many tracks simultaneously.” For PC
C
Conditional
CI

example, Fleming23 writes “in using conditional reason- reasoning (GR)

ing, the therapist appears to reflect on the success or [ SNcairernattiifviec rreeaassoonniinngg [

failure of the clinical encounter from both the procedural (client driven)
and interactive standpoints and attempts to integrate the
two.” Although the notion of the simultaneous use of the Pragmatic reasoning
(context driven)
three tracks should not be taken too literally, therapists
certainly can see evidence in their clinical reasoning tran-
scripts of the rapid blending of different modes of reason-
ing. For example, Sally uses all three forms of reasoning
in the following brief explanation of one aspect of her
therapy session. Procedural reasoning is underlined, con-
ditional reasoning is in bold, and interactive reasoning is
italicized.

Intervention Session, Part 9. “Another thing I’m work-

ing on with Sam is his speed. He’s very slow to process Figure 17-2 The relationship between the different forms of
information and therefore slow in executing tasks, and I clinical reasoning within the patient-centered practice of occu-
find that he also tends to self-distract a fair bit by chatting. But pational therapy. GR, Generalized reasoning. (From Unsworth
at the same time that’s hard because I’m Sam’s case man- CA: Clinical reasoning: how do pragmatic reasoning, worldview
ager, which means that I monitor his whole program, and and client-centredness fit? Br J Occup Ther 67[1], 10-19, 2004.)
since he’s just gone home, we have been having long chats
about how he was coping at home since I want to find out
how he’s doing and what he’s having difficulty with, phenomenological forms of thinking and therefore can be
whether he’s following through by making his own described as narrative forms of reasoning (such as interac-
breakfast and using his dressing aids and things like tive and conditional reasoning). At this level, the therapist’s
that, so in a way I’m distracting him a little bit, but he has to reasoning is basically driven by the patient (such as the
learn to cope with distractions in his environment.” patient’s strengths and weaknesses, goals, and desires). Fi-
The relationship between the three main modes of rea- nally, at the most basic level of operation, which is similar
soning can be illustrated by the use of a Venn diagram in to the brainstem, is pragmatic reasoning. Similar to funda-
which the three circles each represent a different mode of mental brain functions such as breathing, pragmatic rea-
reasoning and yet show that each mode does not occur in soning involves thinking related to things over which
isolation from the others.70 These three forms of reason- therapists often do not have much control. For example,
ing are related to the other modes described in this chap- the therapist reasons pragmatically about what might be
ter, as illustrated in Fig. 17-2.69 Fig. 17-2 presents the re- achieved with a particular patient given the patient’s maxi-
lationships between the different forms of reasoning, or mum length of stay, which often is dictated by the payment
influences on clinical reasoning, using the analogy of the or reimbursement system. In contrast to the patient-driven
basic structures of the brain. Starting at the top of this forms of reasoning described previously, pragmatic rea-
figure is worldview. This was described previously in the soning is context driven. Generalized reasoning can occur
chapter as an influence on reasoning rather than a form of in connection with procedural, interactive, conditional,
reasoning. Worldview is at the top of the diagram because and pragmatic reasoning. The arrows that flow around
it influences all the modes of reasoning, and like the idea Fig. 17-2 indicate that each influence on reasoning or form
of higher cortical function, worldview represents fairly of reasoning influences the others to a greater or lesser
sophisticated thinking that includes one’s morals, ethics, extent. Finally, one must acknowledge that this representa-
and sociocultural perspective. The next level of the brain tion of clinical reasoning operates within the patient-
can be described crudely as the engine or working areas. centered practice of occupational therapy. In other words,
Hence, this is where the main forms of reasoning (proce- this diagram assumes that therapists practice within a
dural, interactive, and conditional) occur, as illustrated patient-centered framework. Hence, the client’s goals,
using a Venn diagram. These forms of reasoning are more values, beliefs, and life experience are at the forefront of
scientific (such as procedural reasoning) or draw more on the therapist’s reasoning and drive the therapy process.
 Chapter 17 • How Therapists Think 451

CLINICAL REASONING AND EXPERTISE In addition, because occupational therapists reason in

narratives, therapy is like telling or creating a story.44
Differences between the Clinical Reasoning Mattingly and Fleming44 suggested that expert therapists
of Novice and Expert Therapists have a greater capacity than novices to make revisions to
Over the past 15 years, research in health sciences the story as therapy progresses.
has shown consistently that experts have better general Other differences between novices and experts include
problem-solving and clinical reasoning skills than novice the way experts reason intuitively and have more tacit
therapists.65 The occupational therapy literature contains a knowledge. This contrasts to the reasoning of a new prac-
wealth of information about the differences in the clinical titioner, which seems to require conscious effort. Strong
reasoning of novice and expert therapists14,28,52,64 and and colleagues64 reported that experts viewed gaining an
how students can improve their reasoning skills.12,33,46-49 understanding of their patients in terms of their illness
The purpose of this section is to review what is known about and disability and of patients’ perceptions of the effect of
the clinical reasoning of expert therapists and strategies to these on their lives as more important than did student
enhance clinical reasoning so that students and novice therapists. Students placed a higher value on knowledge
therapist can hasten their own journey to expert status. and understanding of the patient’s problems, whereas ex-
Like most skills, clinical reasoning can be graded pert therapists placed more emphasis on good communi-
along a continuum. Different points along the contin- cation skills. Hallin and Sviden28 also found that expert
uum are marked by certain characteristics that indicate therapists seemed to have an excellent understanding of
an individual’s skill level. Dreyfus and Dreyfus18,19 pre- the patient.
sented a five-stage model of skill acquisition based on Finally, my research on the differences between the
their study of chess players and airline pilots. They sug- clinical reasoning of novices and experts67 found that ex-
gested that as students develop a skill, they pass through perts make complex skills look simple. The experts in this
five stages of proficiency: novice, advanced beginner, study were articulate and able to present the clinical rea-
competent, proficient, and expert. Benner6 and Benner soning that supported their therapy with confidence.
and Tanner8 incorporated this model in their studies of Similar to the findings of Mattingly and Fleming,44 Hallin
the acquisition of skill in nursing, and since that time, and Sviden,28 and Benner, Hooper-Kyriakidis, and
most health science research regarding clinical reasoning Stanard,7 experts seem to draw on their past experiences
incorporates the Dreyfus and Dreyfus model. Benner6 when planning and executing therapy and use this knowl-
suggested that as a therapist passes through the five edge to anticipate patient performance and modify or
stages of proficiency, changes in three aspects of skilled change the therapy plan as needed. In addition, although
performance occur. A shift in reliance from abstract prin- the students in this study had had recent exposure to lit-
ciples to past experiences occurs, a change in perception erature on patient-centered practice, the expert therapists
of the situation occurs (i.e., a shift from perceiving appeared to have embraced this concept and were incor-
all parts of the picture equally to viewing the whole situ- porating this approach in their work. Robertson52 also
ation in which only parts are relevant), and a change noted this trend. Finally, expert therapists seemed to have
from detached observer to involved performer occurs. a greater capacity to undertake an activity that met several
Based on the work of Dreyfus and Dreyfus,18 Benner,6 patient goals or were more likely to be doing several
and Benner and Tanner,8 Table 17-1 outlines the stages things with the patient at once. Rather than suggesting
in the development of expertise and some of the charac- that they were impatient or pressured by time, this finding
teristics of therapists at each stage. indicated an efficiency of time use that novices had not yet
Research with occupational therapists and other allied developed.
health professions has revealed a variety of aspects of
clinical reasoning processes that differ between novices Enhancing the Student’s Clinical Reasoning Skills
and experts. For example, Collins and Affeldt14 suggested The progression of a therapist from novice to expertise is
that whereas novices tend to focus on one aspect of a situ- not assured. Although some therapists reach competent
ation and one observation triggers one association, ex- or proficient practice levels of expertise, they may never
perts can focus on many aspects of a situation and a single attain expert status. In addition, as can be understood
observation can trigger multiple associations. Although a from the foregoing examples, expertise is not necessarily
more experienced therapist may reason holistically and reflected in the depth or breadth of experience nor years
react quickly to a problem with a total solution, a novice of practice. Therefore, a relatively young therapist might
may reason step by step and react more slowly to a prob- possibly possess an intuitive grasp of the situation, gener-
lem with only a partial solution. Robertson52 supported ate therapy from patient-generated cues, recognize pa-
this empirically through research that found that more tient strengths and weaknesses based on past experience,
experienced therapists had more integrated problem rep- and thus be considered an expert. This section presents a
resentations (that is, a well-organized body of knowledge). summary of ideas from occupational therapy literature
452 Stroke Rehabilitation

Table 17-1
Stages and Characteristics in the Development of Expertise
STAGE THERAPIST CHARACTERISTICS

1. Novice Novices do not have experience of the situations in which they will be involved. To enter the
clinic and gain experience in these areas, students are taught about theories, principles, and
specific patient attributes.
A novice is usually rigid in the application of these rules, principles, and theories. However, rules
cannot guide the therapist to do all the things that need to be done in the multitude of
situations and contexts in which the therapist works.6 A clinician can acquire only “context-
dependent judgment” through participation in real situations.49
2. Advanced beginner Advanced beginners have been involved in enough clinical situations to realize, or to have had
pointed out to them, the recurring themes and information on which reasoning is based. An
advanced beginner may begin to modify rules, principles, and theories to adapt them to the
specific situation.
Advanced beginners do what they are told or what the text dictates as the correct procedure but
may have difficulty prioritizing in more unusual circumstances those parts of the procedure
that are least important or those aspects that are vital.
Advanced beginners have to concentrate on remembering the rules and therefore have less
ability to apply them flexibly.
Dreyfus and Dreyfus18 suggest that an awareness of the client as a person beyond the technical
concerns does not usually develop until the student has advanced to this stage.
3. Competent Competent therapists are able to adjust the therapy to the specific needs of the patient and the
situation but may have difficulty altering initial treatment plans. Benner6 suggests that
therapists are competent once they are consciously aware of the outcome of their actions. This
is typical of a therapist who has been in the job for 2 to 3 years. However, a competent
therapist is said to lack the speed and flexibility of the proficient therapist. Efficiency and
organization are achieved at this stage through conscious or deliberate planning.
4. Proficient Proficient therapists are flexible and are able to alter treatment plans as needed. Proficient
therapists have a clear understanding of the patient’s whole situation rather than an
understanding of the components alone. Proficient practitioners have a perception of the
situation based on experience rather than deliberation. Given that the proficient therapist
has a perspective of the overall situation, components that are more and less important stand
out, and the therapist can focus on the problem areas.
5. Expert Expert therapists approach therapy from patient-generated cues rather than preconceived
therapeutic plans. Experts anticipate and quickly recognize patient strengths and weaknesses
based on their experience with other patients. The expert therapist does not need to rely on
rules and guidelines to take appropriate action but rather has an intuitive grasp of the situation.
Experts often find it difficult to explain this intuition.49

From Unsworth CA: Cognitive and perceptual disorders: a clinical reasoning approach to evaluation and intervention, Philadelphia, 1999,
FA Davis.

that examines how students and novice therapists can with knowledge of clinical reasoning techniques.46,66
improve their clinical reasoning and thus hasten their In these courses, scientific and procedural forms of
journey from novice to expert. More specific details of reasoning can dominate to the extent that insufficient
teaching strategies to enhance student’s development of attention is paid to the patient’s experience of the dis-
clinical reasoning skills may be found in Higgs29 and ability, priorities, and life story.49
Neistadt.46 ■ Spend time reflecting on the patient’s experience of
The following list provides example strategies for nov- the illness and disability and the patient’s percep-
ice and student therapists to try that will assist them better tions of how these affect his or her life. One might
in honing clinical reasoning skills. achieve this after a patient interview in which the
■ Learn about clinical reasoning and the different modes student/therapist asks the patient about what the
of reasoning. When undertaking cognitive and per- disability means to him or her and its effect on
ceptual dysfunction coursework, try to integrate this life.59,64
 Chapter 17 • How Therapists Think 453

■ Use case scenarios from experts to make expert care. Using this language helps novice and expert thera-
therapist reasoning and hypothesis generation more pists to explain practice to colleagues and patients and
explicit. In this way, students can learn to model helps therapists to articulate more clearly their goals and
their practice on an expert’s.52 Students can generate the methods used to reach them. In the challenging area
their own case studies and work in pairs to describe of treating patients with cognitive and perceptual prob-
evaluation and treatment processes and thus facili- lems following stroke, the ability to communicate the
tate self-evaluation and critical reflection.46 As clinical reasoning that supports practice is particularly
Mattingly and Fleming’s study44 revealed, mentoring important. The chapter concluded by presenting an
from an expert therapist is just as influential as overview of what we know about the differences between
formal education is on a novice’s practice. novice and expert practice and the role of clinical reason-
■ Note significant similarities and differences between ing in expert practice and highlighted techniques that
patients and reflect on how these differences can novice therapists can use to hasten their journey from
influence treatment.14 novice to expert therapist status.
■ Develop relationships among data so that treatment
planning is guided by a thorough understanding of ACKNOWLEDGMENT
the problem situation.52
■ Explore probable consequences of treatments before I would like to thank Sheridan Vines (BAppSc.[Occ.
enactment.14 Ther], AccOT) for sharing her rich knowledge and intu-
Finally, an important way to enhance student develop- itions during a clinical reasoning research program con-
ment of clinical reasoning skills is to provide them with ducted through the School of Occupational Therapy,
structured ways to reflect on their clinical encounters. A La Trobe University. Thanks also to Geoffrey Campbell
key aspect of clinical reasoning is the ability to reflect on (graphic designer at Amanda Roach Designs, Windsor,
what has been experienced in therapy and to go forward Melbourne), who patiently translated my drawings of the
in response to this reflection. Having told stories, novice relationship between the different modes of clinical rea-
therapists need time to reflect on their meaning and sig- soning into Fig. 17-2.
nificance. Expert reasoning relies on the ability to reflect
on, and learn from, therapeutic encounters as an individ- REVIEW QUESTIONS
ual and from sharing experiences with other therapists.
Much has been written in the medical61 and education 1. What is clinical reasoning in occupational therapy?
literature73,75 regarding the training of doctors and teach- 2. Describe the difference between narrative and scien-
ers to be reflective. Also important is teaching occupa- tific forms of reasoning. How do Fleming’s three tracks
tional therapy students and novice therapists to become of reasoning relate to narrative and scientific forms?
more reflective by writing diary entries following therapy 3. Using first-person writing style, write a short narrative
sessions and providing opportunities to reflect on their about one of your clinical encounters with a patient.
therapy encounters with more experienced occupational Reflect on this encounter and identify in the margins
therapists. what kinds of reasoning you were using at different
times during the session.
SUMMARY 4. The case study used to illustrate the chapter described
Sally and Sam. Sam recently had discharged himself to
Occupational therapists who work with patients who home. Imagine that Sam was married with a child
have cognitive and perceptual problems following stroke rather than single and that he had returned home to
often find themselves working in environments domi- this environment. Also consider that Sam was working
nated by the medical model. This means that in subtle or as a printer before his stroke and that he is keen to get
more obvious ways, occupational therapist do not always back to this and does not use drugs. Write a chart re-
fit in with the approach taken by the rest of the team. port of your outpatient goals for Sam (i.e., a one para-
Although most occupational therapists seem to marry graph summary that could be placed in Sam’s medical
scientific and phenomenological approaches to patient record). Then write a short narrative indicating your
care successfully in practice, explaining this practice to therapy aspirations for what you and Sam hope to
others may prove more difficult. These explanations are achieve over the next two months. Indicate the kind of
hindered by the tacit nature of much of this knowledge. future you predict for Sam and what kind of treatment
This chapter has explored the ways that therapists think activities you might use.
and reason. Using Mattingly and Fleming’s foundation 5. What are some of the hallmarks of clinical expertise?
work44 in this field, the chapter has presented a language 6. What are three approaches novice therapists can use to
to describe the clinical reasoning that supports the more hasten their journey from novice to expert therapist
scientific and phenomenological approaches to patient status?
454 Stroke Rehabilitation

25. Fleming MH, Mattingly C: Giving language to practice. In Mattingly

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 g u ðrú n ár n adó tti r

chapter 18

Impact of Neurobehavioral
Deficits on Activities of Daily
Living

key terms
A-ONE body neglect neurobehavior
activities of daily living client factors occupational performance
activity analysis clinical reasoning perseveration
agnosia context praxis
aphasia deficit-specific approach spatial neglect
areas of occupation executive control functions spatial relations
assessment methods ideational apraxia task analysis
body functions motor apraxia top-down approach

chapter objectives
After completing this chapter, the reader will be able to accomplish the following:
1. Establish a relationship between neurobehavioral concepts and task performance.
2. Apply the theory on which the Árnadóttir OT-ADL Neurobehavioral Evaluation (A-ONE)
is based as a structure for clinical observations of stroke patients.
3. Provide conceptual and operational definitions for neurobehavioral impairments and
disability.
4. Apply clinical reasoning skills based on the A-ONE theory for hypothesis testing.
5. Relate the International Classification of Functioning, Disability and Health and the Occupational
Therapy Practice Framework, 2nd Edition, to the concepts used in the A-ONE.
6. Provide examples of how strokes can cause different patterns of impairments affecting
task performance.

456
 Chapter 18 • Impact of Neurobehavioral Deficits on Activities of Daily Living 457

Referrals to occupational therapy for patients who have tasks. The eight main groups of body functions in the
had a stroke are usually made when the resulting impair- Framework-II based on the International Classification of
ments are suspected to affect activity performance. When Functioning, Disability and Health (ICF),77 a document de-
neurobehavioral impairments result from a stroke, they veloped by the World Health Organization, include a
can affect the performance of daily activities. This chap- group of mental functions (affect, cognition, perception)
ter contains discussions on the effect of neurobehavioral divided into global functions and specific functions; a
impairments on activity performance. Topics such as oc- group of sensory functions and pain; neuromusculoskele-
cupational performance, neurobehavior, function of the tal and movement-related functions; cardiovascular, he-
cerebral cortex, activity limitation, patterns of impair- matological, immunological, and respiratory functions;
ment resulting from different types of strokes, and ap- voice and speech functions; digestive, metabolic, and en-
plication of clinical reasoning during assessment are dis- docrine functions; genitourinary and reproductive func-
cussed. However, before considering these issues, the tions; and functions of skin and related structures. Each of
following questions might be useful to consider: What these groups can be subdivided into smaller units or fac-
are activities of daily living (ADL)? What is neurobehav- tors. Table 18-1 shows important aspects of the domain of
ior? What is neurobehavioral impairment? How is neu- occupation as presented in the Framework-II, in view of
robehavior related to activity performance? How is the the main themes of this chapter—neurobehavior and
effect of neurobehavioral impairments on activity perfor- ADL—and relates the Framework’s terminology to the
mance detected? classification systems of the ICF and items used in
the Árnadóttir OT-ADL Neurobehavioral Evaluation
ACTIVITIES OF DAILY LIVING (A-ONE).6 The A-ONE has more recently been referred
to as the ADL-focused Occupation-based Neurobehav-
ADL are defined by the U.S. Department of Health and ioral Evaluation.12,14
Human Services72 as basic daily activities such as eating, The ICF describes two parts: functioning and disabil-
grooming, toileting, and dressing. The Center for Dis- ity, and contextual factors. Each of these parts has two
ease Control and Prevention refers to ADL as “bathing or components. Functioning and disability includes the com-
showering, dressing, eating, getting in or out of bed or ponents of body structures and body functions referring
chairs, using the toilet, including getting to the toilet, and to anatomical parts of the body and functioning of body
getting around inside the home.”25 The Occupational structures that can become impaired; activities (referring
Therapy Practice Framework: Domain and Process, 2nd Edi- to execution of task or activity by an individual) and par-
tion (Framework-II),4 defines ADL as activities “that are ticipation (involvement in a live situation), thus referring
oriented toward taking care of one’s own body.” These to capacity and performance that can become limited or
activities include, similarly to the definitions mentioned restricted; and environmental factors that can act as fa-
previously, bathing or showering, bowel and bladder man- cilitators and barriers of performance.77 As can be seen in
agement, dressing, eating, feeding, functional mobility, Table 18-1, the ICF does not differentiate between activ-
personal hygiene and grooming, and toilet hygiene. Thus ity and participation, nor does it use the terms ADL and
all three definitions agree on characterizing ADL as self- IADL tasks. Rather, what has been referred to as ADL
care tasks and functional mobility. Additionally personal earlier in this section spans several terms classified under
device care and sexual activity are included in the Frame- activities and participation, i.e., self-care tasks, mobility,
work’s definition of ADL. To locate ADL within the and communication.
whole domain of occupational therapy, ADL are classified
as one of eight areas of occupation, according to the NEUROBEHAVIOR: THE PROCESS
Framework-II. The other seven areas of occupation are OF LINKING OCCUPATION
instrumental activities of daily living (IADL): rest and TO NEURONAL ACTIVITY
sleep, education, work, play, leisure, and social participa-
tion. In addition to areas of occupation, five other aspects According to Árnadóttir,10,17 neurobehavior is defined as
of the domain of occupational therapy to which occupa- behavior based on neurological function. Neurobehavior
tional therapists attend during the process of providing can be linked to occupation (defined as a series of actions in
services are defined in the Framework-II. These are client which one is engaged)35 and occupational performance
factors, performance skills, performance patterns, con- (defined as accomplishment of selected activity resulting
texts, environments, and activity demands. from the dynamical transaction among the person, context,
Client factors, including body functions and structures, and activity in the Framework-II),4 as elements of neurobe-
values, beliefs and spirituality, are the foundation of havior include different types of sensory stimuli evoked by
human performance, according to the Framework-II. different tasks. These stimuli are processed by different
These fundamental factors residing from within the indi- mechanisms of the central nervous system (CNS) and re-
vidual are required for successful performance of different sult in different types of behavioral responses. Feedback
Text continued on p.462
 458
Stroke Rehabilitation
Table 18-1
Comparison of Terms Used in Different Classifications Systems

FRAMEWORK-II ICF A-ONE

Areas of occupation Activities and participation Activity performance; activities of daily Activity limitation: errors in task per-
■ Activities of daily living* ■ Self-care* living (ADL)* formance and possible limitation/
■ Dressing* ■ Dressing* ■ Dressing restriction of independence
■ Personal hygiene and ■ Washing* ■ Put on shirt/upper body resulting in required assistance
grooming* ■ Caring for body parts* garments ■ Supervision needed during task
■ Personal device care ■ Toileting* ■ Put on pants performance
■ Toilet hygiene* ■ Eating* ■ Put on socks ■ Verbal assistance needed during
■ Bathing, showering* ■ Drinking* ■ Put on shoes task performance
■ Bowel and bladder ■ Looking after one’s health ■ Manipulate fastenings ■ Physical assistance needed during
management ■ Communication* ■ Grooming and hygiene task performance
■ Functional mobility* ■ Mobility* ■ Wash face and upper body
■ Eating* ■ Changing and maintaining body ■ Comb hair
■ Feeding* position* ■ Shave beard/apply cosmetics
■ Sexual activity ■ Changing, moving, and handling ■ Brush teeth
■ Instrumental activities of daily objects ■ Perform toilet hygiene
living ■ Walking and moving* ■ Bathe or shower
■ Rest and sleep ■ Moving around using transportation ■ Transfers and mobility
■ Education ■ Domestic life areas ■ Sit up in bed
■ Work ■ Interpersonal interactions and relation- ■ Transfers from sitting
■ Play ships ■ Maneuver around
■ Leisure ■ Major life areas ■ Transfer to toilet
■ Social participation ■ Education ■ Transfer to tub
■ Work and employment ■ Feeding
■ Economic life ■ Drink from glass/cup
■ Community, social, and civic life ■ Use fingers to bring food to
■ General tasks and demands mouth
■ Learning and applying knowledge ■ Bring food to mouth by fork or
purposeful sensory experiences spoon
■ Activity limitation ■ Use knife to cut and spread
■ Participation restriction ■ Communication
■ Comprehension
■ Expression
Performance skills Activities and participation Observed and used in reasoning about Addressed in comments but not
■ Motor and praxis skills ■ Learning and applying knowledge body functions and their effect on labeled in a standardized way
■ Sensory-perceptual skills ■ Basic learning activity performance, but not specifi-
■ Emotional regulation skills ■ Applying knowledge cally addressed as items
■ Cognitive skills
Performance patterns Activities, participation, and personal Habits and routines are noted and used Addressed in comments but not
■ Routines contextual factors in reasoning about body functions, labeled specifically
■ Roles ■ General tasks and demands (routines) but not specifically addressed as items
■ Habits ■ Habits included under personal factors
■ Rituals and not classified in ICF
■ Limited participation
Context and environment Contextual factors Contextual factors Contextual restrictions
■ Environment ■ Environmental factors ■ Environmental factors: their ■ Environmental factors and
■ Physical ■ Physical environment influence on activity performance is possible restrictions are considered
■ Social ■ Social environment considered and helping aids used are and listed.
■ Context ■ Attitudinal environment listed. ■ Personal factors considered and
■ Cultural ■ Personal factors ■ Personal factors considered for listed during ADL performance:
■ Personal ADL: ■ Age
■ Temporal ■ Age ■ Gender

Chapter 18 • Impact of Neurobehavioral Deficits on Activities of Daily Living

■ Virtual ■ Gender ■ Profession
■ Social Background ■ Social background
■ Profession
Client factors (based on ICF; see Body functions* Central nervous system function Neurobehavioral dysfunction/
next column) ■ Neuromusculoskeletal and movement- ■ Motor function impairments
■ Body functions* related functions: ■ Motor dysfunction
■ Body structures ■ Functions of joints and bones ■ Diminished strength
■ Muscle functions* ■ Altered tone: spasticity/rigidity/
■ Power (strength) flaccidity
■ Tone (flaccid/spastic) ■ Athetosis, tremor, or
■ Endurance ■ Involuntary movements
■ Movement functions* ■ Motor perseverations
■ Motor reflex ■ Motor impersistence
■ Involuntary movement reaction ■ Dysarthria
(righting and supporting reactions)
■ Control of voluntary movement
(eye-hand coordination, bilateral
integration, eye-foot coordination)
■ Involuntary movement functions
(tremors, ticks, motor perseveration)
■ Gait pattern functions

Continued

459
 460
Table 18-1

Stroke Rehabilitation
Comparison of Terms Used in Different Classifications Systems—cont’d

FRAMEWORK-II ICF A-ONE

■ Sensory functions* and pain ■ Sensory reception and simple gnosis ■ Agnosia
■ Proprioception ■ Tactile
■ Touch/temperature ■ Proprioceptive/kinesthetic ■ Astereognosis
■ Seeing (visual acuity, visual fields) ■ Visual ■ Visual agnosia
■ Hearing ■ Auditory ■ Auditory agnosia related to
comprehension
■ Vestibular
■ Taste
■ Smell
■ Pain
■ Mental functions (affective, cognitive, ■ General performance ■ Impaired general performance
perceptual)
■ Global mental function:
■ Consciousness* ■ Alertness ■ Impaired alertness
■ Orientation (to person, place, time, ■ Orientation is considered under
self, and others)* memory and topographical
disorientation
■ Sleep ■ Initiative ■ Impaired initiative
■ Motivation ■ Impaired motivation
■ Temperament and personality* ■ Temperament and personality are
■ Energy and drive (motivation,* considered in relation to emotional
impulse control,* interests,* values) functions
■ Specific mental function:
■ Attention* ■ Attention ■ Attention and arousal dysfunctions
■ Impaired alertness
■ Altered attention
■ Distractibility
■ Performance latency
■ Memory* ■ Memory ■ Memory dysfunction
■ Working and short-term
memory
■ Long-term memory
■ Orientation
■ Confabulation
■ Mental functions of sequencing ■ Praxis ■ Apraxia
complex movement (praxis)* ■ Ideation ■ Ideational apraxia
■ Sequencing and timing of activity ■ Motor apraxia
steps ■ Impaired organization and
■ Programming of motor movement sequencing of activity steps
 ■ Perception* ■ Spatial relations ■ Spatial relations dysfunction
■ Foreground/background ■ Spatial relations impairment
■ Depth/distances ■ Topographic disorientation
■ Body scheme ■ Body scheme dysfunction
■ Anosognosia
■ Somatoagnosia
■ Unilateral body neglect
■ Auditory agnosia ■ Comprehension
■ Thought* (recognition, categoriza- ■ Higher cognitive and executive ■ Cognitive disturbances
tion, generalization, awareness of functions ■ Lack of judgment
reality, logical/coherent thought, ■ Judgment ■ Decreased insight
appropriate thought content) ■ Insight ■ Concrete thinking
■ Higher-level cognition* (judgment, ■ Abstract thinking ■ Confusion
insight, abstraction, organization and

Chapter 18 • Impact of Neurobehavioral Deficits on Activities of Daily Living

planning, concept formation, time
management, problem solving)
■ Calculation
■ Psychomotor functions
■ Experience of self and time functions
■ Emotional functions ■ Emotional functions ■ Emotional disturbances
■ Apathy
■ Depression
■ Lability
■ Euphoria
■ Irritability
■ Aggression
■ Frustrations
■ Restlessness
■ Mental functions of language* ■ Language functions ■ Language dysfunction
(reception and expression) ■ Comprehension ■ Sensory (Wernicke’s)
■ Voice and speech functions ■ Expression ■ Aphasia
■ Articulation functions ■ Jargon aphasia
■ Fluency and rhythm of language ■ Anomia
functions ■ Paraphasia
■ Alternative vocalization functions ■ Expressive (Broca’s)
■ Impairments ■ Aphasia
■ Body structures ■ Dysarthria
■ Nervous system*

*Item relates to A-ONE terminology.

From Árnadóttir G: A-ONE training course: lecture notes, Reykjavík, Iceland, 2009, Guðrún Árnadóttir. Material drawn from Occupational therapy practice framework: domain and
process (2nd ed.), Am J Occup Ther 62(6):625–683, 2008; World Health Organization: The international classification, of functioning, disability and health—ICF, Geneva, 2001,
WHO; and The brain and behavior: assessing cortical dysfunction through activities of daily living, St Louis, 1990, Mosby. Selected samples related to occupational performance with a
specific focus on activities of daily living and neurology.
A-ONE, Árnadóttir OT-ADL Neurobehavioral Evaluation; FRAME WORK-II; Occupational Therapy Practice Framework; Domain and Process 2nd Edition; ICF Intrernational Classifica-

461
tion of Functioning, Disability and Health.
462 Stroke Rehabilitation

from the responses affects new sensory stimuli.”6,9 Neu- DETECTING THE EFFECT
robehavior therefore includes the different types of perti- OF NEUROBEHAVIORAL DEFICITS
nent neurological body functions necessary for performing ON ACTIVITY PERFORMANCE
different aspects of occupation. “All tasks provide sensory
stimuli. Some functions relate to the reception of sensory The therapist can detect occupational errors through ob-
stimuli, others to CNS processing of that information in- servation of occupational performance, with these errors
cluding for example different functions associated with indicating the effect of neurobehavioral deficits on task
perception, cognition, emotion, and praxis. Additional performance. Subsequently, the therapist can hypothesize
functions relate to different behavioral responses, such as about the impaired body functions that caused the error.
affect and movement. The mechanism of nervous-system As neurobehavioral deficits often interfere with indepen-
processing and neurobehavior leading to occupational per- dence, therapists can benefit from detecting errors in oc-
formance is a complex interaction where different combi- cupational performance while observing ADL and thereby
nations of factors are involved depending on the task.”6,9,17 gain an understanding of the impairments affecting the
Fig. 18-1 illustrates the elements of neurobehavior. A patient’s activity limitation.
neurobehavioral deficit has been defined by Árnadóttir6,17 as a Therapists can use the information based on observed
functional impairment of an individual manifested as defec- task performance in a systematic way as a structure for
tive task performance resulting from a neurological pro- clinical reasoning to help them assess functional indepen-
cessing dysfunction that influences body functions such as dence related to the performance and to subsequently
affect, body scheme, cognition, emotion, gnosis, language, detect impaired neurological body functions. Such infor-
memory, motor movement, perception, personality, praxis, mation can be important when intervention methods are
sensory awareness, spatial relations, and visuospatial skills. aimed at addressing occupational errors6 during any of
Árnadóttir10,17 further defined occupational error as any the following types of intervention programs classified by
deviations from flawless responses when performing occu- Fisher36 as adaptive, acquisitional, and restorative occupa-
pation. Indications of neurobehavioral impairments that tion, or occupation-based education programs, i.e., pro-
limit ADL task performance are based on detection of oc- grams for families or caregivers of persons with neuro-
cupational errors through task analysis of the observed logical impairments. This method therefore allows the
ADL performance. The observed errors are subsequently therapist to analyze the nature or cause of a functional
classified and scored by use of operational definitions of problem that requires occupational therapy intervention,
neurobehavioral impairments included in the A-ONE test as recommended by Holm and Rogers,42,60 and so make
manual. the analysis from the view of occupations.

Neurobehavior

Sensory CNS Behavioral

stimuli processing responses

• Tactile • Sensory • Movement/

• Proprioceptive integrative motoric
• Kinesthetic • Perceptual • Thought
• Vestibular • Cognitive • Emotions/
• Glandular/ glandular acts
• Visual
emotional
• Auditory
• Gustatory
• Olfactory

Feedback
Figure 18-1 Elements of neurobehavior include different types of sensory stimuli. These
stimuli are processed by different mechanisms in the central nervous system (CNS) and result
in different types of behavioral responses. Feedback from the responses affects new sensory
stimuli. (Adapted from Llorens LA: Activity analysis: agreement among factors in a sensory
processing model. Am J Occup Ther 40(2):103, 1986.)
 Chapter 18 • Impact of Neurobehavioral Deficits on Activities of Daily Living 463

The use of different terms and definitions related to impairments and the theoretical definitions of functional
“analysis” in the field of occupational therapy is rather in- and dysfunctional behavior. An example might explain
consistent and can lead to confusion. The following defini- this process better. A meaningful task, such as eating, calls
tions were in mind when writing this chapter. Activity for a goal directed, purposeful response. Various context
analysis has commonly been referred to as the process of and environmental factors are involved, such as food and
examining activities in detail by breaking them into their cutlery, and body functions such as visuospatial relation-
components in order to understand and evaluate the activ- ships, muscle tone, and emotional state. Carrying out the
ity. Therapists study body functions that are needed to behavior required to eat requires different body functions.
perform specific tasks and the effects impaired body func- When analyzed with the required factors in mind, the
tions have on task performance.6,46 Activity analysis can be quality of the response reveals information not only about
based on particular theories and conceptual frameworks or independence in ADL but also regarding neurobehavioral
focused on specific body functions.27,70 Performance anal- impairments—the problems that interfere with indepen-
ysis is defined by Fisher36 as the “observational evaluation dence, such as misjudging distances when reaching out for
of the quality of a person’s occupational performance” tak- a cup or not knowing how to use cutlery6 (Fig. 18-2).
ing into account how effectively the goal directed actions
are performed. Task analysis, on the other hand, refers to Function of the Cerebral Cortex: The Foundation
interpretation of cause be it related to body functions, of Task Performance
context, or environmental factors. Latham70 discussed Occupational therapists observe performance of daily ac-
performance focused activity analysis. The therapist in this tivities regularly as they work with stroke survivors. With
analysis observes the person perform role related occupa- the use of clinical reasoning combined with task analysis,
tions. The role includes tasks that are divided into several detection of impaired neurological body functions is pos-
activities that are subsequently separated into actions that sible. These functions are necessary for optimal task per-
are based on capacities. Performance focused activity formance. Subsequently, therapists can detect the type
analysis examines these from the top-down by observing and degree of severity of neurobehavioral impairments
the person perform. that interfere with activity performance. For forming hy-
When applying the A-ONE principles to evaluate oc- potheses from ADL observation and errors affecting per-
cupational performance and subsequently dysfunctional formance, the therapist commonly draws on his or her
body functions that limit the performance, the therapist neurological knowledge and relates the body functions to
applies different types of clinical reasoning, according functional areas of the brain responsible for different neu-
to Árnadóttir.7,17 These are interactive reasoning, as inter- ronal processing functions. Many body functions are
action between the client and therapist takes place; and based on neurological function, which takes place at dif-
procedural reasoning,51 which is also termed diagnostic42,60 ferent levels of the CNS. According to Árnadóttir,6
or scientific reasoning23 and refers to hypothesis formation several CNS areas may contribute to a particular type of
following interpretation of cues about the nature of prob- neuronal processing, resulting in simultaneous or parallel
lems that interfere with occupational performance. When processing at different locations, which contributes to the
using the A-ONE, the therapist observes performance of development of the same body functions. During activity
an ADL task and while classifying level of assistance performance, different types of processing may take place
needed identifies observed errors in performance. The simultaneously. Neuronal processing in the brain varies
errors can subsequently be used in the clinical reasoning in complexity. It is common to view three levels of
process required for analyzing the task, as they can con- functional complexity in the cortex based on Luria’s
tribute to hypotheses about different impairments and theories,47,48 which are usually called primary, secondary,
possible manifestations of CNS dysfunction. They are and tertiary cortical zones or projection areas.
used to help identify the cause of the dysfunction. During
the instrument development of the A-ONE, information Functional Localization for Neurological Processing
based on neurologically focused activity analysis, used to of Body Functions
determine which body functions are necessary for perfor- During task analysis, the therapist draws on information
mance of the ADL tasks and task analysis based on behav- about neurological functions in the clinical reasoning pro-
ioral observations of persons with neurological dysfunc- cess when forming and testing hypotheses about impaired
tions, were used to operationalize impairments. The functions; a short summary of functional localization fol-
analyses were performed to determine how dysfunction of lows. Fig. 18-3 illustrates location of different cortical
specific neurological body functions is revealed by neu- areas, the shades indicating primary, secondary, and ter-
robehavioral responses and occupational errors during tiary projection areas. The frontal lobes are responsible for
performance of activities. For clinical reasoning during motor functions, including motor speech; motor praxis;
the A-ONE focused task analysis, the therapist keeps in emotions; intelligence; cognition including attention and
mind different possible neurological body functions and working memory; and executive control functions such as
464 Stroke Rehabilitation

Performance impairments

Presentation of
a meaningful
task Cognitive Perceptual
impairment impairment

Life-space
influences

Task performance
dysfunction: lack of
independence in feeding

Why?

Activity analysis

Ideational Spatial relation

apraxia impairment
indicating a indicating a
dysfunction dysfunction of
of cognitive a perceptual
performance sensorimotor
component component

Figure 18-2 Cognitive and perceptual dysfunction leading to ideational apraxia and spatial
relations impairment revealed by performance errors observed during feeding and detected by
task analysis. (Adapted from Árnadóttir G: The brain and behavior: assessing cortical dysfunction
through activities of daily living, St Louis, 1990, Mosby.)
 Chapter 18 • Impact of Neurobehavioral Deficits on Activities of Daily Living 465

Primary motor
Premotor cortex Primary somesthetic
cortex sensory cortex
Somesthetic sensory association cortex
Dorsolateral prefrontal
cortex
Higher order visual cortex
Orbitofrontal area
of prefrontal cortex Parieto-temporal-occipital
association cortex
Primary auditory cortex Visual association cortex
Temporal pole Primary visual cortex
A Higher order auditory cortex Auditory association cortex

Premotor Primary motor

cortex cortex
Primary somesthetic
Dorsolateral sensory cortex
prefrontal
cortex Sensory association
cortex
Orbitofrontal area of
prefrontal cortex Visual association
cortex
Temporal pole
Primary visual
Olfactory cortex
B cortex Limbic association
cortex

Orbitofrontal area
of prefrontal
cortex

Temporal pole

Limbic association
cortex

C Primary visual cortex

Figure 18-3 Functional organization of the cerebral cortex. A, Lateral surface. B, Medial
surface. C, Inferior surface. The different shades refer to primary, secondary, and tertiary func-
tional areas of the cortex. The darkest shades are primary areas, the medium shades are second-
ary areas, and the lightest shades are tertiary areas. (From Árnadóttir G: The brain and behavior:
assessing cortical dysfunction through activities of daily living, St Louis, 1990, Mosby.)

ideation, intention, judgment, and motivation. This refers sensory functions and specific mental functions related
to neuromusculoskeletal and movement-related functions, to visual perception), and the temporal lobes process audi-
including muscle and movement functions, according tory information and long-term memory, emotion, and
to the ICF terminology; voice and speech functions; motivation. These functions are classified by the ICF as
and global and specific mental functions. The parietal sensory functions of hearing, voice, and speech functions;
lobes are concerned with the processing of somesthetic global mental functions of temperament and personality;
information—and more complex sensory input from dif- and specific mental functions of memory, perception of
ferent sources, which includes sensory reception of somes- hearing, and emotional functions. Table 18-2 summarizes
thetic information—and specific mental functions related the functions of the different cortical lobes of the brain
to memory and sequencing of complex movement and to and relates them to primary, secondary, and tertiary func-
perception and emotional functions, according to the ICF. tional areas in these lobes. As indicated in the table, several
The occipital lobes process visual information (i.e., visual functional areas in different lobes may contribute to a
466 Stroke Rehabilitation

Table 18-2
Functions of the Cerebral Cortex
FUNCTIONAL AREA ANATOMICAL AREA NEUROLOGICAL BODY FUNCTIONS

Frontal lobes
Primary motor area ■ Precentral gyrus ■ Execution of movement
Secondary association ■ Premotor cortex ■ Planning and programming of movement
area ■ Frontal eye field ■ Sequencing, timing, and organization of movement
■ Broca’s area in the left ■ Voluntary eye movements
inferior frontal gyrus ■ Programming of motor speech
■ Supplementary motor area ■ Intention of movement
Tertiary association ■ Orbitofrontal and dorso- ■ Ideation
area lateral prefrontal cortex ■ Concept formation
■ Abstract thought
■ Intellectual functions
■ Sequencing, timing, and organization of action and
behavior
■ Initiation and planning of action
■ Judgment
■ Insight
■ Intention
■ Attention
■ Alertness
■ Personality
■ Working memory
■ Emotion
Parietal lobes
Primary somesthetic ■ Postcentral gyrus ■ Fine touch sensation, proprioception,
sensory area kinesthesia
Secondary ■ Superior parietal lobule ■ Coordination, integration, and refinement of sensory input
somesthetic ■ Tactile localization and discrimination
sensory association ■ Stereognosis
area
Tertiary association ■ Inferior parietal lobule ■ Gnosis: recognition of received tactile, visual, and auditory
area input
■ Praxis: storage of programs or visuokinesthetic motor
engrams or praxicons necessary for motor sequences
■ Body scheme: postural model of body, body parts, and their
relation to the environment
■ Spatial relations: processing related to depth, distance, spatial
concepts, position in space, and differentiation of foreground
from background
Occipital lobes
Primary visual ■ Calcarine fissure ■ Visual reception (from the opposite visual field)
sensory area
Visual association area ■ Brodmann areas 18 and 19 ■ Synthesis and integration of visual
information
■ Perception of visuospatial relationships
■ Formation of visual memory traces
■ Prepositional construction of language
comprehension and speech
 Chapter 18 • Impact of Neurobehavioral Deficits on Activities of Daily Living 467

Table 18-2
Functions of the Cerebral Cortex—cont’d
FUNCTIONAL AREA ANATOMICAL AREA NEUROLOGICAL BODY FUNCTIONS

Temporal lobes
Primary auditory ■ Superior temporal gyrus ■ Auditory reception
sensory area
Secondary ■ Superior and middle tem- ■ Language comprehension
association area poral gyri (Wernicke’s ■ Sound modulation
area) ■ Perception of music
■ Auditory memory
Tertiary association ■ Temporal pole, ■ Long-term memory
area parahippocampus ■ Learning of higher-order visual tasks and auditory patterns
■ Emotion
■ Motivation
■ Personality
Limbic lobes
Tertiary association ■ Orbitofrontal cortex in ■ Attention
area frontal lobe, temporal ■ Motivation
pole, and parahippocam- ■ Emotions
pus in the temporal lobe ■ Long-term memory
■ Cingulate gyrus in
frontal and parietal lobes

Adapted from Árnadóttir G: The brain and behavior: assessing cortical dysfunction through activities of daily living, St Louis, 1990, Mosby.

particular neurological function. Therefore, different cor- movement, which can be related to the neuromusculo-
tical areas may be responsible for processing particular skeletal and movement-related functions of the ICF.
neurological body functions. Although function can be The result of praxis is motor execution. The ideation
related to different anatomical areas, one must remember involved in praxis requires function of the frontal lobes
that plasticity permits deviations from the usual localiza- (prefrontal and premotor areas) and of areas around the
tion sites under certain conditions such as injury or devel- lateral fissure. The formulas for movement (praxicons)
opmental abnormality. are stored in the left inferior part of the parietal lobe,40
When considering CNS localization of body functions the left hemisphere in general being superior in storing
necessary for task performance, the therapist must keep in routinely used codes.39 Access to the left inferior pari-
mind that the cortex does not function in isolation. The etal lobe is needed for either side of the body to move.
cortex communicates by various pathways with other Information flows from this area to the premotor area,
CNS areas such as the thalamus, the basal ganglia, cere- which programs movement before the information is
bellum, and brainstem that also contribute to neuronal conveyed to the primary motor cortex in the left hemi-
processing. sphere (which controls execution of movements of the
right side of the body). The premotor cortex on the left
Processing of Praxis side connects with the premotor cortex of the right side
Although certain neurological functions can be assigned by way of the anterior fibers of the corpus callosum and
to specific cortical or subcortical locations within lobes, in turn relays the visuokinesthetic motor information to
several CNS areas help process particular neurological the right hemisphere. The right premotor cortex pro-
body functions. Árnadóttir6 summarized neurological grams movements and instructs the adjacent primary
information resulting in several processing models indi- motor cortex on the execution of movement of the left
cating processing sites of different functions in the cor- side of the body (Fig. 18-4).
tex. One example is the processing model for praxis.
Praxis takes place in two steps:18 ideation, referring to PROCESSING DURING TASK PERFORMANCE
concept formation related to an activity and classified by
the ICF as specific mental function related to thought Motor praxis (as described previously) is only one type of
and higher level cognition including sequencing of neurological body function related to neurobehavior. The
complex movement; and planning and programming of type of body function and the degree of involvement
468 Stroke Rehabilitation

Left hemisphere Right hemisphere

Primary motor Sensory-motor Primary motor area
Supplementary area feedback Supplementary
motor area Tactile and proprioceptive motor area
information Premotor
Premotor area Visuokinesthetic area
motor engrams

Orbitofrontal
Visual
prefrontal
information
cortex Orbitofrontal
Superior Auditory Sensory-motor prefrontal
Arcuate feedback Superior
A temporal area information temporal area area
fasciculus

Premotor
Premotor cortex
cortex
Primary motor Primary motor
cortex cortex

Angular and
supramarginal gyri

B Left hemisphere Right hemisphere

Figure 18-4 Processing of motor praxis. A, Active functional areas of the left and right hemi-
spheres during praxis. B, Transverse view of the most commonly accepted sequential processing
model of motor praxis.40 (From Árnadóttir G: The brain and behavior: assessing cortical dysfunction
through activities of daily living, St Louis, 1990, Mosby.)

depend on the task performed. As mentioned, several Information from all three pathways travels from the
processing mechanisms may be involved simultaneously pertinent primary receptive areas to secondary and ter-
in the performance of a particular activity. Árnadóttir has tiary areas where further processing takes place. Attention
demonstrated this through analysis of task such as brush- processes, memory processes, emotions, and higher-order
ing hair.6 A person sitting in front of a mirror by a sink thought are brought into play. The sensory information is
where the brush is located has at least three routes by integrated with previous experiences, and responses are
which sensory information related to this particular task planned. A response may be emotional or motoric, result-
will reach the cortex. The person notes the brush visually, ing in different processing mechanisms depending on the
and this information travels through the visual pathway to nature of the response. Simultaneous processing of infor-
the primary visual cortex where it is synthesized and fur- mation takes place as information from the different sec-
ther analyzed by the association areas. Memories and ondary association areas is fed into the limbic system, the
ideational processes are brought into play; as a result, the tertiary association areas in the prefrontal lobe, and the
person gets the idea to want to brush the hair. Similarly, temporal pole, where higher cognitive functions includ-
when the person is instructed verbally to brush the hair, ing emotion and memory take place. Different fiber con-
this auditory input travels over the auditory pathway to nections in a hemisphere, between hemispheres, and be-
the primary auditory area of the cortex in the temporal tween the cortex and other CNS structures play important
lobe where it is processed by the association areas. Subse- roles in this processing.
quently, the input is compared with information in mem- During processing, ideation, intent to perform an ac-
ory stores, yielding an idea based on the auditory informa- tion, and preparation of a sequenced plan of action occur;
tion. The third pathway is somesthetic. A person who all result in flow of information to the primary motor
grasps or is handed a brush receives tactile and proprio- cortex and ultimately in the functional response of picking
ceptive information, which (after it reaches the primary up the brush. This process requires praxis. The intention
sensory cortex in the parietal lobe) is analyzed by the as- to perform an action is relayed to the frontal lobes and
sociation areas and integrated with prior experiences. supplementary motor areas. From the lower left parietal
 Chapter 18 • Impact of Neurobehavioral Deficits on Activities of Daily Living 469

lobe (which houses movement formulas also called visuo- including paralysis of the contralateral body side, muscle
kinesthetic motor engrams or, more recently, praxicons), weakness, and spasticity. The distribution of impairments is
information travels to the left premotor cortex (which is related to lesion localization in the primary motor cortex.
responsible for planning and sequencing of movement) on Table 18-3 includes definitions of impairments or dysfunc-
its way to the middle part of the primary motor cortex of tion of neurological body functions and relates these to
the frontal lobe in the left hemisphere (which is respon- different cerebral lobes.6,17
sible for movement performed by the right hand). A series The parietal lobes process somatosensory and complex
of feedback movement interactions and readjustments fol- sensory information from multimodal stimuli. When a
low. This series is based on continuous sensory informa- dysfunction of the parietal lobes occurs, impairments re-
tion from the activity. During the complex process of lated to different functional areas may develop, and these
performing “simple” activity, other responses (e.g., emo- can be related to dysfunctions of body functions, in par-
tional and verbal) may be elicited. Such responses require ticular somesthetic sensory functions and specific mental
function of processing areas different from the ones men- functions.6 Dysfunction of the inferior parietal lobe, which
tioned previously. Fig. 18-5 illustrates some of the pro- processes information from the secondary association ar-
cessing components that take place during the activity of eas of all three posterior lobes, for example, may lead to
brushing hair. Observation of task performance that re- impairments related to perceptual and motor processing
sults from this kind of neuronal processing and analysis of of body functions, in particular specific mental functions
the errors detected by observation during the perfor- related to sequencing of complex movement, memory,
mance may reveal substantial information about function and perception. These impairments include bilateral
and subsequent dysfunction of the cerebral cortex. Thera- motor- and ideational apraxia, if the left inferior parietal
pists’ neurological knowledge is important and needs to lobe is involved, because the movement formula or praxi-
be incorporated into their clinical reasoning when form- cons are stored in this area. Spatial relations disorders also
ing hypotheses about impairments and differentiating may be present when the right hemisphere is involved.
between hypotheses. These disorders have been defined conceptually as diffi-
culties in relating objects to each other or to the self. Such
DYSFUNCTION OF THE ACTIVITIES difficulties may include difficulties with foreground and
OF DAILY LIVING AREA OF OCCUPATION background perception, depth and distance perception,
DUE TO STROKE perception of form constancy and perception of position
in space. Further dysfunction of the right inferior parietal
A stroke may affect neurological body functions. Dys- lobe may lead to body scheme disturbances including
function of these factors may interfere subsequently with unilateral body neglect. Unilateral spatial neglect may
primary ADL. Neurobehavioral impairments may be re- also be present.6 See Table 18-3 for definitions of terms
lated to dysfunction of neurological body functions, and different lesion sites.
which have been classified into four groups according to The occipital lobe houses primary and secondary pro-
the ICF.77 These groups are (1) neuromuscular functions, cessing areas for visual information. The tertiary area for
(2) sensory functions and pain, (3) mental functions, and visual processing is located mainly in the inferior parietal
(4) voice and speech functions. These functions have lobe. If a dysfunction of the occipital lobe occurs, impair-
been related previously to concepts used in the A-ONE ments are related to visual sensory functions and specific
theory in Table 18-2. Concepts may be defined in two mental functions related to perception of visual informa-
ways. Conceptual definition is general and abstract, but tion referring to the ICF.17 Lesions of the association area,
an operational definition refers to how particular con- for example, cause visual agnosia. Different types of visual
cepts are measured and observed (e.g., test items with agnosias exist, including visual object agnosia; visuospatial
which particular concepts can be measured). The content agnosia, which is a spatial relations disorder of visual
of the following sections are based on concepts from the origin; prosopagnosia; color agnosia; and associative visual
A-ONE. agnosia.6 Visual object agnosia is defined conceptually as
the inability of a patient to recognize, name, or demon-
Conceptual Definitions of Terms strate use of objects seen and results from distorted visual
The frontal lobes process functions related to neuromuscu- perception, regardless of visual acuity.65 The affected per-
loskeletal and movement-related body functions including son can see and describe the components of the object but
muscle and movement functions, according to the ICF cannot recognize the object itself (see Table 18-3 for ad-
terminology; voice and speech functions; and global and ditional definitions of terms and lesion sites).6
specific mental functions.17 Dysfunction of the frontal The temporal lobes are involved with two types of
lobes, for example, may affect neuromusculoskeletal body processing—auditory and limbic—that can be related to
functions processed in the primary motor and premotor sensory functions of hearing, voice and speech functions,
areas. Subsequently, the therapist may observe impairments global mental functions of temperament and personality,
Text continued on p.476
470 Stroke Rehabilitation

Sensory information

Tactile stimuli
(touch brush)

Visual stimuli Auditory stimuli

(see brush) (instruction)

Memory processes
Attention processes
Emotional processes
Higher-order thought
Ideation/intention
Praxis processing
and motivation
necessary for
reaching out for
the brush with
the right hand

Continuous feedback-
movement interaction Motor output
based on continuous
feedback from the activity

Figure 18-5 Different cortical areas involved in processing of various client factors during an
activities of daily living task. A person sitting by a sink preparing for grooming is asked to brush
her hair. Note that three types of sensory stimulation can lead to performance. (From Árnadóttir
G: The brain and behavior: assessing cortical dysfunction through activities of daily living, St Louis, 1990,
Mosby.)
Table 18-3
Cortical Impairments as Related to Anatomical Location and Definitions of Terms*
IMPAIRMENT AND CORTICAL LOCATION CONCEPTUAL DEFINITION OPERATIONAL DEFINITION

Anosognosia ■ Right inferior parietal lobule ■ Denial or lack of awareness of a paretic ■ Does not identify a paralyzed body part as
■ Specific sensory thalamic extremity accompanied by lack of insight own
nuclei, reticular formation, regarding the paralysis ■ May deny it completely as a separate object or
basal ganglia ■ Paralyzed extremities may be referred to as recognize it and reject it (e.g., patient may
■ Prefrontal and premotor objects or perceived out of proportion to complain about “somebody’s” arm and not
frontal lobe62 other body parts. recognize it as own)
Apathy ■ Prefrontal cortex ■ Shallow affect, psychomotor slowing, blunted ■ Has a lack of emotion or feeling during
■ Posterior internal capsule, emotional responses, lack of interest in the activity performance and communication, lack
basal ganglia62 environment and inaction of interest in things that generally are found

Chapter 18 • Impact of Neurobehavioral Deficits on Activities of Daily Living

■ Medial forebrain bundle and exciting, and indifference during performance
reticular formation
Impaired attention ■ Prefrontal cortex, thalamus, ■ Inability to attend to or focus on a specific ■ Does not continue an activity
reticular formation stimulus ■ Does not attend to instruction or activity
■ Possible distraction from presence of other ■ Does not attend to mistakes
irrelevant environmental stimuli ■ May focus attention on irrelevant details and
■ Inability to screen out irrelevant stimuli not on global environment
Confabulations ■ Prefrontal cortex ■ Unconscious fabrication of stories or excuses ■ Does not remember what happened during
to fill in memory gaps weekend and comes up with an explanation
■ May be within limits of reality or patient may not grounded in reality
not consider rules of reality and then will be
identified easily
■ Associated with lack of inhibitions and lack of
judgment, as well as memory problems
Confusion ■ Prefrontal and diffuse ■ Lack of ability to think clearly, resulting in ■ Talks about past as present
dysfunction—bilateral disturbed awareness and orientation ■ Talks out of context
■ Thalamus and reticular regarding time, place, and person ■ Not oriented to time and place
formation ■ Impaired interpretation of external environ-
ment and slowed responses to verbal stimuli29
■ Cognitive disturbance
Depression ■ Left frontal lobe and left ■ Affective disorder manifested as sadness, ■ Has sad affect or expression during activity
basal ganglia, right frontal hopelessness, or loss of general interest in performance
and right parietal lobes62 usual performance
■ May be accompanied by loss of appetite, loss
of energy, sleeping disorders, and feelings of
worthlessness

*Conceptual definitions of some common impairments seen in individuals with cerebrovascular accidents and examples of operational definitions from the A-ONE instrument. Relation
of impairments to dysfunctional central nervous system areas is simplified. Adapted from Árnadóttir G: A-ONE training course: lecture notes, Reykjavík, Iceland, 2009-2010.

471
Continued
Table 18-3

472
Cortical Impairments as Related to Anatomical Location and Definitions of Terms—cont’d
IMPAIRMENT AND CORTICAL LOCATION CONCEPTUAL DEFINITION OPERATIONAL DEFINITION

Stroke Rehabilitation
Distractibility ■ Prefrontal cortex, reticular ■ Diversion of attention ■ Becomes distracted by environmental stimuli
formation such as conversation in next room or some-
body entering the room
Field dependency ■ Prefrontal cortex ■ Uninhibited, inadequate, and irrelevant ste- ■ Becomes distracted from particular task per-
reotypical actions that replace selective goal formance by specific stimuli (e.g., is washing
directed actions corresponding to specific hands, suddenly sees denture brush, and in-
tasks corporates it into the hand-washing activity by
■ Impulsiveness related to elementary orienting scrubbing the hands with the denture brush)
reflex49 ■ Note two components of field dependency:
■ Field dependency thus has a dysfunction of distraction and perseveration.
an attention component and perseverative
component.
Frustration ■ Prefrontal cortex, ■ An appearance of agitation and intolerance in ■ Becomes excited or intolerant when trying
hypothalamus behavior that may be manifested emotionally, hard to perform or unable to perform (may be
verbally, or physically manifested emotionally, verbally, or physically)
Homonymous ■ Primary visual cortex around ■ Loss of a visual hemifield contralateral to a ■ Has visual field defect to visual field that is
hemianopsia calcarine fissure in either cerebral lesion contralateral to a cerebral lesion
hemisphere ■ Is usually aware of deficit and tries to comp-
ensate for it by using head movements to scan
both visual fields
Ideational apraxia ■ Prefrontal and premotor ■ A breakdown of knowledge of knowing what ■ Does not know what to do with toothbrush,
cortex in either hemisphere, is to be done to perform that results from toothpaste, or shaving cream
left inferior parietal lobule, loss of a neuronal model or a mental repre- ■ Uses tools inappropriately (e.g., smears the
and corpus callosum sentation about the concept required for toothpaste on face)
performance ■ Sequences activity steps incorrectly so that
■ Lack of knowledge regarding object use there are errors in end result of tasks (e.g.,
■ Also refers to sequencing of activity steps or puts socks on top of shoes)
use of objects in relation to each other
(NOTE: Therapist should rule out compre-
hension difficulties)
Impaired initiative ■ Prefrontal cortex and supple- ■ Inability to initiate performance of an activity ■ Sits without initiating an activity
mentary motor cortex28— when need to perform is present ■ Can describe activity performance but displays
predominantly right inertia in initiating it
hemisphere
Decreased insight ■ Prefrontal cortex ■ Insight—a discovery stage, with increasing ■ Does not have insight into disease or disability
awareness of the whole self ■ Does not make realistic statement regarding
■ Decreased insight—lack of insight into future plans
personal condition and disability ■ Makes unrealistic comments regarding
disability
Irritability ■ Prefrontal cortex— ■ Excessive sensitivity to stimulation ■ Appears annoyed
particularly orbitofrontal ■ Includes quick excitability manifested as ■ May verbally indicate dislike or be physically
cortex and hypothalamus annoyance, impatience, or anger agitated out of proportion to stimulus that
evoked behavior
Impaired judgment ■ Prefrontal cortex ■ Inability to make realistic decisions based on ■ Does not turn off water taps after washing
environmental information ■ Does not put brakes on wheelchair and makes
■ Unable to make use of feedback from own unsafe transfers
errors ■ Goes to dining room without dressing or
combing hair
■ Does not care whether clothes are turned
inside out or back to front, even when those
facts have been pointed out
Lability ■ Prefrontal cortex ■ Pathological emotional instability ■ Has mood swings

Chapter 18 • Impact of Neurobehavioral Deficits on Activities of Daily Living

■ Alternating states of gladness and sadness, ■ Cries or laughs inappropriately
including inappropriate crying
Impaired motivation ■ Prefrontal cortex, particularly ■ Lack of willingness to perform, with or ■ Does not initiate or continue an activity unless
orbitofrontal cortex, medial without a perceived need really accepting the need, although physical
forebrain bundle, and ability to perform is present (e.g., does not
hypothalamus attempt to eat at mealtimes and may refuse to
participate in activity)
■ Refuses to get up in morning or perform ac-
tivities, although physically able to perform
and has been motivated previously to perform
by same activities
Motor apraxia ■ Premotor frontal cortex of ■ Loss of access to kinesthetic memory patterns ■ Has difficulties related to motor planning
either hemisphere, left so that purposeful movement cannot be (e.g., cannot sequence and plan movements
inferior parietal lobe, corpus achieved because of defective planning and necessary to adjust grasp on a hairbrush when
callosum, basal ganglia, and sequencing of movements, even though idea moving it from one side of head to other to
thalamus and the purpose of task are understood turn the bristles toward hair)
■ Used as a synonym for ideomotor apraxia
Impaired motor ■ Primary motor cortex, ante- ■ Flaccidity, decreased strength, rigidity, spas- ■ Has difficulty stabilizing objects such as
function rior internal capsule, basal ticity, ataxia, athetosis, tremor containers that must be opened
ganglia, thalamus, and cere- ■ Has difficulty reaching unaffected axilla when
bellum washing
■ Has difficulty dressing because of a paralyzed
arm or inability to button because of tremor

Continued

473
 474
Stroke Rehabilitation
Table 18-3
Cortical Impairments as Related to Anatomical Location and Definitions of Terms—cont’d

IMPAIRMENT AND CORTICAL LOCATION CONCEPTUAL DEFINITION OPERATIONAL DEFINITION

Impaired ■ Prefrontal cortex ■ Inability to organize thoughts with activity ■ Has difficulties sequencing and timing steps of
organization steps properly sequenced (component of ide- an activity
and sequencing ational apraxia but can occur separately as the ■ Does not complete one activity step before
first indication of impairment in a progressive starting another (e.g., does not take off glasses
disease process or last step of regressing before taking off a T-shirt with a tight neck
ideational problems) hole; puts on shoes before putting on the
trousers; washes too quickly, resulting in poor
performance)
Paraphasia ■ Prefrontal cortex or left ■ Expressive speech defect characterized by ■ Replaces words with incorrect similar or dis-
lateral temporal lobe misuse or replacement of words or phonemes similar words (e.g., may identify an apple as an
during active speech orange because both are fruits)
Perseveration ■ Premotor and/or prefrontal ■ Repeated movements or acts during func- ■ Repeats movements or acts and cannot stop
cortex tional performance as a result of difficulty in them once initiated (e.g., attempts to put on
shifting from one response pattern to another shirt without any progress—may pull a long
■ Refers inertia on initiation or termination of sleeve up arm past wrist [premotor
performance47,48 perseveration]; moves comb toward mouth
■ Prefrontal perseveration—repetition of whole instead of hair after having brushed teeth
actions or action components [prefrontal perseveration])
■ Premotor perseveration—compulsive
repetition of the same movement
Restlessness ■ Prefrontal cortex ■ Uneasiness, impatience, inability to relax ■ May be impatient (e.g., cannot wait for
therapist to start an activity)
■ May have trouble staying in one place during
activity
Short-term ■ Limbic system and limbic as- ■ Lack of registration and temporary storing of ■ Does not remember instructions throughout
memory loss sociation cortex in orbito- information received by different sensory evaluation
frontal areas or temporal memory modalities, be it somatosensory, ■ May have to be reminded to comb hair several
lobes auditory, or visual times
■ Refers to working memory in that a person
must keep different aspects in mind while
working on different memory tasks such as
reasoning, comprehension, and learning
■ Length of working or short-term memory
depends on nature of assignments
Somatoagnosia ■ Right inferior parietal lobule ■ Disorder of body scheme ■ Puts legs into armholes or arms into legholes
■ Diminished awareness of body structure and ■ Brushes mirror image of teeth instead of own
failure to recognize own body parts and their teeth or washes mirror image of face instead
relationship to each other80 of own face
■ Difficulty relating own body to objects in ■ Attempts to dress the therapists arm
external environment
Somesthetic ■ Postcentral gyrus in either ■ Loss of tactile sensation, proprioception, or ■ Has difficulty manipulating objects because of
sensory loss parietal lobe, posterior inter- kinesthesia lack of sensation
nal capsule, specific thalamic ■ Is aware of sensory loss and tries to compen-
sensory nuclei sate (e.g., using visual clues)
Spatial relations ■ Usually right inferior parietal ■ Difficulty relating objects to each other or to ■ Is unable to find armholes, legholes, or
impairment lobule self bottom of shirt
■ Synonymous with visuospatial agnosia when ■ Pulls sleeve in wrong direction

Chapter 18 • Impact of Neurobehavioral Deficits on Activities of Daily Living

such difficulties are due to visuospatial ■ Overestimates or underestimates distances
impairment when reaching for objects
Topographic ■ Inferior parietal lobule or ■ Difficulty finding way in space due to ■ Does not know way to bedroom or bathroom
disorientation occipital association cortex amnestic or agnostic problems
■ Manifested as problems finding way in
familiar surroundings or learning new routes
Unilateral body ■ Inferior parietal lobule, right ■ Failure to report, respond, or orient to a ■ Does not dress affected body side
neglect cingulate gyrus, prefrontal unilateral stimulus presented to body side ■ Does not pull shirt all the way down on
cortex, reticular formation, contralateral to a cerebral lesion affected side
specific sensory thalamic ■ Can result from defective sensory processing ■ Gets shirt stuck on affected shoulder and does
nuclei, posterior internal or attention deficit, which causes ignorance not try to correct it or does not realize what is
capsule or impaired use of extremities (used as a wrong
synonym for unilateral body inattention)
■ Usually affects left side of body
Unilateral spatial ■ Inferior parietal lobule, right ■ Inattention to or neglect of visual stimuli pre- ■ Does not account for objects in visual field on
neglect cingulate gyrus, prefrontal sented in extrapersonal space of side contra- affected side—usually left side
cortex, reticular formation, lateral to a cerebral lesion because of visual ■ When moving, runs into furniture, doorways,
specific sensory thalamic perceptual deficits or impaired attention41 or walls located in affected visual field
nuclei, posterior internal ■ It may occur independently of visual deficits
capsule or with hemianopsia80 (synonymous with
unilateral visual neglect)

Courtesy G. Árnadóttir, Reykjavík, Iceland.

475
476 Stroke Rehabilitation

and specific mental functions of memory, perception of therefore may result from unilateral body neglect or ide-
hearing, and emotional functions. The lateral sides of the ational apraxia, depending on the situation. Therefore the
hemispheres house primary and secondary processing following examples are to be used only as guidelines.
sites for auditory stimuli and perceptual processing of Clinical reasoning and knowledge of neurobehavioral
such information. The tertiary processing area for these impairments and how the impairments group together in
functions is located in the inferior part of the parietal different diagnostic categories are crucial for effective dif-
lobe.17 A lesion of the auditory association cortex in the ferentiation and classification of impairments.
left hemisphere, for example, can cause anomia because
the memory stores for nouns are located in this area. Ano- Personal Hygiene and Grooming Performance Area.
mia is loss of the ability to name objects or retrieve names Three activities listed in the Framework-II are included in
of persons; the person does have fluent speech. As previ- the grooming and hygiene domain of the A-ONE: per-
ously mentioned, Table 18-3 relates defined impairments sonal hygiene and grooming, toilet hygiene, and bathing
to dysfunction of different cortical and subcortical areas. or showering. The performance of grooming and hygiene
activities comprises several tasks; for example, washing the
Manifestation of Neurobehavioral Impairments face and body and bathing or showering; performing oral
during Task Performance: Operational Definitions hygiene (including brushing teeth); combing hair; shaving;
of Concepts applying cosmetics, deodorants, or perfumes; and per-
Operational definitions are how concepts are measured forming toilet hygiene. These tasks may be affected by
and observed. Following is a review based on Árnadóttir’s dysfunction of different body functions, resulting in vari-
operational definitions of terms6 from the A-ONE re- ous behavioral outcomes. Dysfunction of neuromusculo-
garding how one can detect neurobehavioral impairments skeletal and movement-related functions can result in pa-
during task performance in the areas of grooming and ralysis, muscle weakness, and spasticity. Paralysis or muscle
hygiene, dressing, functional mobility, and eating. Each of weakness may be manifested as difficulty in washing the
these performance areas comprises several tasks. For suc- affected arm or axilla (Fig. 18-6, A). The individual may
cessful completion of each of the tasks, involvement of need to learn to use one-handed techniques to overcome
several neurological body functions is necessary. Dysfunc- the impairment. Adapted equipment also may be needed
tion of body functions resulting in the previously defined for the individual to reach body parts such as the back or,
impairments is manifested differently during performance. if balance is poor, the feet. Stabilizing objects may be a
The following examples indicate the effect of different problem; the individual may need a nonslip pad under the
impairments on task performance manifested by occupa- soap. While brushing teeth, the person may have problems
tional errors in the various performance areas. This re- opening the tube of toothpaste and may need to learn to
view refers to the terms used in the classification systems compensate by stabilizing it between the knees or teeth.
of the Framework and the ICF (see Table 18-3 for concep- The same applies to other containers and the opening of
tual and operational definitions of terms). Some impair- lids. If the individual uses dentures, an adapted toothbrush
ments affect specific ADL areas. Other impairments are or a suction brush for stabilization may be necessary (see
more pervasive and may appear in any ADL performance Chapter 28).
area or may need to be addressed specifically. One must Dysfunction of sensory functions can result in impaired
keep in mind that behavior is flexible and neurobehavioral tactile and proprioceptive sensation, astereognosis, or
impairments are complex. The following behavioral ex- hemianopsia with a loss of a visual field, or a loss of part of
amples are guidelines for detecting impairments. How- a visual field may be present. Problems with tactile sensa-
ever, they cannot be taken for granted without knowledge tion, proprioception, or stereognosis affect object manipu-
of neurobehavior, cortical function, activity and task anal- lation. An individual with such problems who does not
ysis, and clinical reasoning because similar behaviors may suffer from inattention or neglect will be aware of the im-
result from different impairments at times. Thus the be- pairment and attempt to compensate for it (e.g., by using
havior of not washing one arm during the task of washing vision for sensory feedback). If a part of a visual field is
the upper part of the body may be caused by unilateral defective or hemianopsia is present, an individual may have
body neglect when it occurs in an individual with right to compensate by turning the head. If an individual only
hemisphere dysfunction. However, an individual with left has this impairment and not neglect, the individual will be
hemisphere dysfunction may need assistance to wash the aware of the problem and will be able to describe it, with
affected arm, partly because of motor paralysis, and also insight into the dysfunction, and compensate for it.
may need guidance to wash the other arm and body parts Dysfunction of sequencing complex movement, classi-
because of ideation problems and difficulty in organizing fied as specific mental functions, can lead to motor apraxia
and sequencing the activity steps of the task. The patient and motor perseveration. Individuals with motor apraxia
also may have comprehension difficulties, which compli- have difficulty with motor planning; they may have diffi-
cates the situation. The behavior of not washing an arm culty adjusting the grasp of a razor when moving from
A B

C D

E F

G H
Figure 18-6 Dysfunction of neurological client factors manifested during grooming and hy-
giene tasks. A, Paralysis results in difficulty washing the affected axilla. B, Motor apraxia makes
manipulation of razor difficult. C, Prefrontal perseveration, a part from the previous task of
brushing the teeth, is perseverated during combing so that the comb is moved toward the
mouth instead of the hair. D, Spatial relations impairment results in underestimation of dis-
tances when the individual attempts to place toothpaste on a toothbrush. E, Unilateral body
inattention during shaving. Aftershave lotion spills from a bottle held in left hand while indi-
vidual is reaching with right hand to face and looking into mirror. F, Somatoagnosia. Woman
cannot differentiate between a mirror image and her own body when brushing her teeth.
G, Ideational apraxia. Man does not know what to do with shaving cream. H, Lack of judgment.
Water has been left running with the washcloth in the sink, producing a safety hazard.
478 Stroke Rehabilitation

one side of the face to another or when moving the razor In unilateral spatial inattention or neglect, the indi-
to the chin. This requires sequencing and planning of fine vidual randomly may locate all items in the affected vi-
finger and wrist movements so that the razor is turned sual field only when accidentally seeing them or may not
toward the face for effective use (see Fig. 18-6, B). Simi- notice an object at all in the affected visual field and does
larly, motor apraxia may influence the ability to comb or not systematically compensate for the impairment by
brush hair. The performance may be adequate on the side rotating the head as required. An individual with so-
where the individual starts brushing but when moving the matoagnosia cannot differentiate between the mirror
brush to the other side of the head or to the back, the image and self. An individual thus affected may attempt
individual has difficulty adjusting the hand movements to wash the mirror image of the face instead of the actual
required to turn the brush toward the hair. Manipulating face (see Fig. 18-6, F ). These individuals may not be able
a toothbrush and other items may be similarly difficult to differentiate between their own body parts and those
and manifested as “clumsiness.” of others. For example, an individual may grab another
Premotor perseveration may be manifested as repeti- person’s arm and attempt to use it to hold onto objects.
tion of the movements of washing the face; the individual Somatoagnosia is defined in the A-ONE as a severe dys-
cannot stop the movements and take the washcloth to function that usually is accompanied by ideational apraxia
other body parts. Prefrontal perseveration is persevera- and often by spatial relation disorders.
tion of whole acts. The affected individual, having com- Dysfunctions of global and specific mental functions with
pleted one task such as brushing the teeth, begins another an effect on grooming and hygiene tasks include ideational
activity such as combing but perseverates a part of the apraxia, organization and sequencing problems related to
previous action program. As a result, the individual ap- activity steps, impaired judgment, decreased level of arousal,
proaches the mouth with the comb (see Fig. 18-6, C ). lack of attention, distraction, field dependency, impaired
If a dysfunction of the perceptual processing aspect of memory, and impaired intention. Ideational apraxia may ap-
the specific mental functions is present, a spatial relation pear during grooming and hygiene activities; an individual
disorder, difficulty with left-right discrimination, unilat- may not know what to do with the toothbrush, toothpaste,
eral body inattention or neglect, unilateral visual inatten- or shaving cream or may use these items inappropriately
tion or neglect, anosognosia, or somatoagnosia may be (e.g., smear toothpaste over the face or spray the shaving
expected. Spatial relation disorder may be manifested cream over the sink; (see Figure 18-6, G ). An individual with
during hygiene and grooming tasks as difficulty in deter- organization and sequencing difficulties only may have the
mining distances. An individual reaching for a toothbrush general idea of how to perform but may have problems tim-
may overestimate or underestimate its distance. When the ing and sequencing activity steps. Such a patient may not
individual squeezes toothpaste onto the toothbrush, the complete one activity step before starting another or may
paste may end up beside the brush (see Fig. 18-6, D). perform activities too quickly due to problems in timing ac-
When trying to stabilize objects, the individual may reach tivity steps, resulting in a poor performance.
next to the object, resulting in ineffective performance. Lack of judgment may appear as an inability to make
For example, an individual may reach with the washcloth realistic decisions based on environmental information,
into the space next to the water faucet instead of under the providing that perception of those impulses is adequate.
faucet. When manipulating objects such as dentures, the An individual so affected may leave the sink area without
individual may have problems determining the top from turning off the water taps or may leave the wash cloth in
the bottom part of the dentures and the front from the the sink, not noticing that the water level is increasing and
back and left from right. threatening to overflow (see Fig. 18-6, H ).
Impairments related to neglect or inattention can re- Field dependency has an attention component and a
sult from dysfunction of the specific mental function of perseveration component. Individuals with this dysfunc-
perception or attention. In unilateral body neglect, or tion may be distracted from performing a particular task
inattention, the individual does not use the affected limb by specific stimuli that they are compelled to act on or
according to available control. For example, the individual incorporate into the previous activity. For example, if an
may not use the arm for stability while attempting to open individual with field dependency sees a denture brush
a bottle. An individual with unilateral body neglect may while washing the hands, then that person may incorpo-
not wash the affected side but washes other body parts rate the brush into the activity and scrub the hands with
systematically. The same may apply to other tasks as well, the denture brush.
such as shaving and combing, in that the individual only An individual with short-term memory problems may
attends to one side of the face or hair. A man holding an not remember the sequence of activity steps or instruc-
aftershave bottle in the left hand while looking at his own tions throughout activity performance. The therapist may
face in the mirror and reaching with the right hand to the have to remind an individual several times to comb the
face may tilt the bottle without noticing it and spill the hair, even though the individual does not have compre-
liquid (see Fig. 18-6, E ). hension problems.
 Chapter 18 • Impact of Neurobehavioral Deficits on Activities of Daily Living 479

Lack of initiation may occur during performance of affecting this performance area can result in paralysis of
grooming and hygiene tasks; the individual may sit by the a body side. Individuals with one-sided paralysis must
sink without performing, even after being asked to wash. learn one-handed dressing techniques (Fig. 18-7, A ).
With repeated instructions to begin, the individual may Dysfunction of the mental factor of sequencing complex
indicate that the activity is about to start, yet nothing hap- movement can manifest as perseveration. Premotor perse-
pens. After several such incidents and if the therapist asks veration may appear during dressing; the individual is un-
for a plan, the individual may state a detailed plan of ac- able to stop movements that have been initiated. For ex-
tion in which the water will be turned on, the washcloth ample, when the individual is placing an arm in a sleeve, the
will be picked up and put under the running water, soap individual may keep pulling the arm into the sleeve until
will be put on the cloth, and washing will begin. The in- the end of the sleeve is up to the elbow or shoulder. Simi-
dividual has a plan of action but cannot start the plan. larly the person may repeatedly pull up on a sock, even
This impairment may be associated with ideational prob- though it has already covered the foot (see Fig. 18-7, B ).
lems as well. Defective specific mental function factor of perception
may result in spatial relation disorders such as difficulty
Dressing Performance Area. The dressing performance figuring out the front and back, the inside and outside,
includes the tasks of dressing the upper part of the body, and the top and bottom of an article of clothing. Although
including putting on items such as underwear, T-shirts, the individual knows that the shirt goes on the upper part
pullovers, sweaters, shirts, bras, cardigans, or dresses; of the body and tries to get the arm through the sleeve,
dressing the lower part, such as putting on pants, socks, the arm may go through the neckhole instead of the sleeve
pantyhose, and shoes; and manipulating fasteners, such as or in the right sleeve instead of the left. An individual may
zippers, buckles, laces, or Velcro. Following are some place both legs in the same leghole (see Fig. 18-7, C ) or
examples of the effect of neurobehavioral impairments may not perceive that one of the legholes is turned inside
on task performance in this area. Dysfunction of neuro- out. Right-left disorientation can be related to visuospa-
musculoskeletal and movement-related body function tial problems; for example, an individual may put the right

A B
Figure 18-7 Dysfunction of neurological client factors manifested during dressing tasks.
A, Paralysis requires use of one-handed dressing techniques. B, Premotor perseveration
results in repetitions of movements so that the leghole may be pulled up to the knee; the
patient pulls the sock repeatedly, although it is already in place. Continued
480 Stroke Rehabilitation

C D

E F
Figure 18-7, cont’d C, Spatial relations impairment, in which the patient places both legs
in the same leghole. D, Somatoagnosia. Woman attempts to dress the therapist’s arm instead
of her own. E, Unilateral body neglect. Man attempts to hang up his gown without having
undressed his left arm. F, Field dependency. The sight of a comb distracts a woman in the
middle of a dressing task. Woman discontinues dressing and begins combing.

shoe on the left foot. An individual with spatial relation place his or her legs into the armholes of a shirt. Thus, the
disorder may pull the sleeve in the wrong direction when individual has problems with differentiating his or her
attempting to put on a shirt. The individual may be un- own body from the therapist’s body and relating objects to
able to tie shoelaces because of difficulty handling the corresponding body parts. This is not only a spatial rela-
spatial relations aspects of manipulating shoestrings. Vel- tion problem but also a defect in body image. An indi-
cro fastenings on shoes may be folded back on themselves vidual with only a visuospatial problem cannot find the
instead of being passed through the D-loop before being correct armhole but realizes that a shirt is related to the
folded backward. Somatoagnosia may manifest as a pa- upper body. This realization is not evident in individuals
tient attempting to dress a therapist’s arm instead of his or with somatoagnosia because of his or her body scheme
her own (see Fig. 18-7, D) or when he or she attempts to dysfunction.
 Chapter 18 • Impact of Neurobehavioral Deficits on Activities of Daily Living 481

G H
Figure 18-7, cont’d G, Ideational apraxia. Man knows that the T-shirt should go under the
sweater but does not know how to accomplish the goal. H, Organization and sequencing
impairment. Man puts on socks and shoes before trousers, resulting in difficulties donning
trousers.

Unilateral body neglect may be severe, or less severe on a sweater. Difficulty arises when the person realizes the
unilateral body inattention may be present. In severe T-shirt or undershirt has not been put on under the
cases an individual may not dress or undress the affected sweater. The individual may not be able to plan the neces-
arm. The individual may even leave the arm in the arm- sary activity steps to correct the mistake. The T-shirt may
hole when undressing and attempt to hang the shirt on a be tucked down the neckhole instead of the sweater being
clothes peg on the wall, not cognizant that the arm is removed and the activity started over (see Fig. 18-7, G ).
still in the armhole (see Fig. 18-7, E ). However, the An individual with ideational apraxia also may attempt to
problem is not always this severe or apparent. At times put a sock on over a shoe. An individual who only has
the shirt may get stuck on an affected shoulder without organization and sequencing problems might put shoes
the individual noticing it, or the shirt may not be pulled on before putting on trousers (see Fig. 18-7, H ). However,
properly down on the affected side. An individual with the general ideas of how to put the clothes on and where
unilateral visual neglect or inattention may not put on they fit are intact. Organization and sequencing problems
clothes that are placed in the left visual field because may appear when an individual dresses the unaffected arm
they remain unnoticed. before the affected one and then runs into difficulty dress-
Dysfunction of global and specific mental functions ing the affected arm. The therapist also may detect im-
may be seen as field dependency, ideational problems, or paired judgment during dressing performance. An indi-
impaired judgment. Field dependency is illustrated by an vidual may be improperly dressed in the hallways or the
individual in the middle of the activity of putting on a dining area, indicating a lack of social judgment. Spatial
sweater. Having placed both arms through the correct relation disorder also may affect dressing performance.
armholes and the neck through the neckhole, the patient An affected individual may not be able to differentiate the
is distracted by the sight of a comb. The activity of dress- front and the back of the clothes. Trousers may be put on
ing subsequently is discontinued immediately as the indi- with the front pockets and fastenings turned backward.
vidual grabs the comb and starts combing his or her hair. Because these spatial relations deficits are of visual origin,
After combing, the individual may or may not go back to the affected individual may not be able to identify the
the task of putting on the shirt (see Fig. 18-7, F ). A person mistakes. However, when a therapist points out that the
might not know what to do with the clothes or how to put trousers are backwards, an individual with a lack of judg-
them on. A person with ideational apraxia may be able to ment might comment that it does not matter how the
perform certain activities automatically, such as putting trousers are worn. A subject with intact judgment would
482 Stroke Rehabilitation

attempt to make corrections, ask for assistance, or other- continue wheeling and moving after reaching the desired
wise indicate a desire to have the performance corrected. destination.
Dysfunctions of the specific mental functions percep-
Functional Mobility Performance Area. The perfor- tual factor may result in spatial relation disorders in which
mance area of functional mobility includes the tasks of the affected individual may misjudge distances. The indi-
rolling over and sitting up in a bed, transferring to and vidual may park a wheelchair too far from a bed or chair
from a bed, transferring to and from a chair, transferring for a transfer. An individual with unilateral body neglect
to and from a toilet, transferring to and from a bathtub or or inattention may not account for the affected body side
a shower, and moving from one room to another. The when moving. Such an individual may hit furniture with
previously defined impairments may interfere with the the affected arm or walk into obstacles such as doorways.
tasks of this performance area (see Chapter 14). Following When transferring from the bed to a chair, an individual
are some examples of how these dysfunctions may be may only move the unaffected side to the chair, leaving
manifested. the affected side in bed or off the chair (see Fig. 18-8, B).
If a dysfunction of the neuromusculoskeletal and move- An individual with severe neglect also may have the im-
ment-related functions, such as paralysis is present, it af- pairment of anosognosia. These individuals may deny that
fects strength and control of one body side and thus affects they are paralyzed or that their affected arm or side is a
mobility and balance. An individual therefore may need part of themselves. The affected limb may be referred to
assistance with transfers, require a wheelchair or walking as an object, or these individuals may claim that someone
aids, or require supervision or personal assistance for mo- else’s arm is lying in bed with them. One man with
bility (Fig. 18-8, A). anosognosia was heard to comment that he was going to
Dysfunction of the specific mental functions of se- occupational therapy and that he would “need to bring
quencing complex movement may lead to perseveration the arm along,” because the occupational therapist
and motor apraxia as previously mentioned. Individuals “always works on the arm.” Unilateral spatial neglect
with premotor perseveration may not be able to stop the or inattention refers to the phenomenon in which the
movements of wheeling a wheelchair; as a result, they individual does not account for visual stimuli from the

A B
Figure 18-8 Dysfunction of neurological client factors manifested during functional mobil-
ity tasks. A, Paralysis affects strength and balance. Individuals require assistance when trans-
ferring from bed. A wheelchair is needed for mobility. B, Unilateral body neglect. Woman
only moves intact body side over to wheelchair and leaves affected side in bed.
 Chapter 18 • Impact of Neurobehavioral Deficits on Activities of Daily Living 483

C D

E F
Figure 18-8, cont’d C, Unilateral spatial neglect. Woman wheels into a garbage can in a
neglected left visual field. D, Ideational apraxia. Woman does not know how to propel the
wheelchair and pushes down on the armrest instead of the wheel. E, Organization and se-
quencing impairment. Woman does not lift off the blanket before sitting up in bed. F, Orga-
nization and sequencing impairment and ideational apraxia. Woman attempts to walk away
from bed without having moved the blanket.
484 Stroke Rehabilitation

affected visual field. The individual may walk or wheel movement according to the ICF classification system may
into obstacles such as garbage cans, furniture, doorways, spill soup when moving the spoon from the bowl to the
or other individuals (see Fig. 18-8, C ). Topographic dis- mouth, a task that requires much significant adjustment of
orientation, in which the person has visuospatial problems fine finger and wrist movements to keep the spoon level.
or memory problems regarding spatial locations also may Motor apraxia may result in “clumsy movements” when
be present. The individual does not know the way to dif- spreading butter, resulting in problems manipulating the
ferent, familiar locations such as the bathroom, dining knife (Fig. 18-9, A ). Premotor perseveration is demon-
room, bedroom, or therapy department. strated when an individual cannot stop the movements of
If a dysfunction of the global and specific mental fac- bringing the spoon to the mouth from the bowl after hav-
tors is present, ideational apraxia or organization and se- ing finished the soup. Another example is the continua-
quencing problems may occur during transfers and mo- tion of chewing movements after the food has dissolved in
bility tasks. Individuals with ideational apraxia may not the mouth. Prefrontal perseveration, or perseveration of
know how to get into bed. They literally may throw actions rather than movements (a cognitive factor), may
themselves into the bed. An individual may not know how manifest when an individual who has finished eating yo-
to wheel a wheelchair and may push down repeatedly on gurt with a spoon reaches out for the spoon again to use
the armrest (see Fig. 18-8, D). (However, the therapist it to get a sip of milk from a glass rather than drink di-
should rule out attention problems.) An individual with rectly from the glass (see Fig. 18-9, B ).
organization and sequencing problems may sit up in bed Dysfunction of specific mental perceptual factors af-
without taking off the blanket but will remove the blanket fecting eating behavior may result in spatial relation disor-
before standing up (see Fig. 18-8, E ). However, an indi- ders; an individual trying to stabilize a slice of bread to
vidual with additional ideational apraxia may sit up with- butter it may misjudge distance and grab the plate instead
out lifting the blanket off and then attempt to stand up of the bread (see Fig. 18-9, C ). The individual may also
and walk away without moving the blanket, thus produc- overestimate or underestimate distances and reach beside
ing a safety hazard (see Fig. 18-8, F ). An individual with the cup instead of grabbing the cup. Unilateral body ne-
organization and sequencing problems only may not put glect may occur during eating when the individual does
on wheelchair brakes before transferring or take them off not use the hand in a natural relation to its available func-
before moving. This particular performance difficulty tion. Individuals may start eating bread using the left hand,
might occur when memory problems are present as well. “forget” that the bread is in the hand, and proceed to eat
If memory problems without impaired judgment are pres- other items as the hand holding the bread slides off the
ent, the results of the unsafe transfers (e.g., instability) table (see Fig. 18-9, D). Unilateral spatial neglect may
may remind these individuals to lock the brakes. manifest in that the individual may not attend to objects or
food in the affected visual field. For example, an individual
Eating Performance Area. Neurobehavioral impair- may not notice a fork in the left visual field and attempts
ments or dysfunction of the previously mentioned body to solve the problem by grabbing the next person’s fork
functions may affect dysfunction of eating performance, located by a plate in the right visual field (see Fig. 18-9, E ).
such as chewing and swallowing, drinking from a glass or Individuals may not eat food located in the affected visual
a cup, eating without utensils (only using the fingers), eat- field, although they enjoy that particular type of food.
ing with a fork or a spoon, and using a knife to cut or Dysfunction of global and specific mental function fac-
spread. Many of these tasks are accomplished earlier in tors may result in ideational apraxia in which the affected
the developmental sequence than some of the tasks men- individual does not know which utensils to use or how to
tioned previously. use them. The individual may simplify the activity by us-
A dysfunction of the neuromusculoskeletal and ing the fingers to eat meat instead of a fork. The person
movement-related factors may result in paralysis of one also may misuse objects. An individual may attempt to eat
side of the body, resulting in poor sitting balance and use the soup with a knife. Activity steps may be left out of the
of only one arm. Tactile and proprioceptive sensation in sequence, resulting in defective performance. An affected
the affected hand and arm may be impaired because of individual may not take the shell off an egg before at-
defective sensory functions. All these impairments may tempting to eat it or may not peel an orange before biting
affect eating tasks that require sitting balance and bilateral it. An individual may have the proper object in hand but
integration of the arms (e.g., stabilizing a slice of bread may not know how to use it for the situation at hand: the
while buttering it or a slice of meat while cutting it, eating individual may open a teabag, remove the tea leaves, and
an egg, or peeling an orange). Because of the impairments, place them in the cup instead of placing the bag in the cup.
these eating tasks may require different performance tech- Individuals may misuse objects; for example, they may
niques, helping aids, or personal assistance. sprinkle salt on the butter container (see Fig. 18-9, F ).
An individual with motor apraxia classified as dysfunc- Field dependency may be manifested during feeding ac-
tion of the specific mental factor of sequencing complex tivities. Individuals may start grabbing food items before
A B

C D

E F
Figure 18-9 Dysfunction of neurological client factors manifested during feeding and eating
tasks. A, Motor apraxia makes manipulation of a knife difficult when buttering bread. B, Pre-
frontal perseveration. Man continues to move the spoon toward the glass instead of drinking
from it, after having used the spoon to eat yogurt. C, Spatial relations impairment. Woman
attempts to stabilize a piece of bread but misjudges distances and grabs the side of the plate
instead. D, Unilateral body neglect. Man does not attend to a piece of bread in left hand; hand
slides unnoticed off the table, and man grabs another slice with right hand. E, Unilateral spatial
neglect. Man does not notice fork in his left visual field but solves problem by borrowing a fork
from the next plate in the right visual field. F, Ideational apraxia. Man does not know what salt
is used for and shakes it over butter container.
486 Stroke Rehabilitation

having positioned themselves properly at the table. Indi- subdivided into thrombosis, or blood flow obstruction
viduals also may grab items as they are seen, although the caused by a local process in one or more blood vessels;
items are inappropriate for the activity at hand. embolism, in which blood flow obstruction is caused by
materials from distant parts of the vascular system; and
Pervasive Impairments. According to the A-ONE decreased systemic perfusion, or hypoperfusion, in which
classification,6,8,17 impairments can be classified as spe- low systemic perfusion pressure results in reduced blood
cific or pervasive in relation to activity performance. flow.6,24,72
The impairments described in the previous sections and Hemorrhage is subdivided into subarachnoid hemor-
affecting specific tasks of an ADL domain are classified rhage, which occurs at the surface of the brain and intra-
as specific because they are observed in relation to the cerebrally, and intraparenchymal hemorrhage, or bleed-
particular task, whereas other impairments are not task- ing in the cerebral tissue.2,6,24 Each type of stroke results
specific. Thus some impairments are not necessarily in different patterns of impairment. The type of impair-
tied to a particular performance area but can occur in ment and severity depend mainly on the anatomical loca-
relation to any performance area. Emotional and affec- tion of the lesion.3,24 These further depend on the rate of
tive disturbance classified by ICF as global mental func- arterial occlusion, adequacy of the collateral circulation,
tions, such as apathy, depression, frustration, irritability, resistance of brain structures to ischemia,24 duration and
aggression, and lack of motivation, are examples of this severity of ischemia, hematoma size, and underlying
because they may affect task performance in different mechanism of hypoperfusion79 and on edema.
areas of occupation. Dysfunction of different arteries leads to different
As stated earlier, different impairments have different patterns of impairments. If the middle cerebral artery,
effects on task performance. The behavioral examples for example, is occluded, affecting blood supply to the
described in this chapter are intended as guidelines to as- lateral aspect of the hemisphere, the impairments vary
sist therapists in detecting impairments revealed by errors depending on which branches of the artery and which
observed during task performance for assessment pur- hemisphere is affected. If the insult affects the upper
poses. This information, used with the appropriate theo- trunk of the middle cerebral artery, which supplies
retical background and clinical reasoning, is important in the lateral aspects of the frontal and parietal lobes,
determining intervention strategies. Occasionally, differ- hemiplegia is expected on the contralateral body side,
entiation between impairments with similar behavioral especially of the face and arm, along with hemisensory
manifestations may be difficult, particularly for less expe- loss, including tactile and proprioceptive information.
rienced therapists. Knowledge of neurological function This type of insult also may cause impairment of a visual
and of how impairments are grouped in different diagnos- field to the opposite site of the lesion. If the right
tic categories may be valuable for clinical reasoning in hemisphere is impaired, unilateral neglect of space and
such instances. body may result, as well as attention deficits, including
unilateral body inattention and unilateral spatial inat-
PATTERNS OF IMPAIRMENTS RESULTING tention, anosognosia, spatial relation dysfunction, uni-
FROM STROKES lateral motor apraxia of the left side (if not paralyzed),
lack of judgment, lack of insight, field dependency, and
In a preceding section, neurobehavioral impairments organization of behavior and activity steps. Emotional
were defined and related to different cortical areas. In- disturbances such as apathy, lability, and depression also
volvement of dysfunction affecting neurological body may be present. If the left hemisphere is involved,
functions depends on various pathological conditions speech and language functions may be impaired, and
resulting in stroke and the different anatomical areas in- bilateral motor apraxia may be observed. Ideational
volved. The cerebral blood supply depends mainly on apraxia and perseverations and emotional disturbances
three arteries in each hemisphere: the middle and ante- such as depression and frustration may be a conse-
rior cerebral arteries, which are branches of the internal quence. If the lower trunk of the middle cerebral artery
carotid artery, and the posterior cerebral artery, which is is affected, visual field defect of the contralateral visual
a branch of the basilar artery, formed by the union of the field, Wernicke’s aphasia caused by involvement of the
vertebral arteries.45 Two major types of cerebrovascular left hemisphere, and emotional disturbances may be
dysfunction cause neurological lesions: (1) ischemia, or present.6,24 Table 18-4 indicates patterns of impairments
insufficient blood supply to the brain, which is responsi- as they relate to dysfunction of different cerebral arter-
ble for 70% to 80% of all strokes, and (2) hemorrhage, or ies and systemic hypoperfusion, a diffuse cerebral dys-
bleeding, caused by a ruptured blood vessel, which ac- function affecting the watershed regions or the border
counts for the remaining 15% to 20% of strokes.2,6,24,72 zones in the periphery of the major cerebral arteries,
Hemorrhage results in swelling and compression of brain and different CNS areas, because of various vascular
tissue. Different subtypes of strokes occur. Ischemia is pathological conditions (see Chapter 1).
 Chapter 18 • Impact of Neurobehavioral Deficits on Activities of Daily Living 487

Table 18-4
Cerebral Artery Dysfunction: Cortical Involvement and Patterns of Impairment
ARTERY LOCATION POSSIBLE IMPAIRMENTS

Middle cerebral artery: Lateral aspect of frontal and ■ Dysfunction of either hemisphere
upper trunk parietal lobe ■ Contralateral hemiplegia, especially of the face and
the upper extremity
■ Contralateral hemisensory loss
■ Visual field impairment
■ Poor contralateral conjugate gaze
■ Ideational apraxia
■ Lack of judgment
■ Perseveration
■ Field dependency
■ Impaired organization of behavior
■ Depression
■ Lability
■ Apathy
■ Right hemisphere dysfunction
■ Left unilateral body neglect
■ Left unilateral visual neglect
■ Anosognosia
■ Visuospatial impairment
■ Left unilateral motor apraxia
■ Left hemisphere dysfunction
■ Bilateral motor apraxia
■ Broca’s aphasia
■ Frustration
Middle cerebral artery: Lateral aspect of right tem- ■ Dysfunction of either hemisphere
lower trunk poral and occipital lobes ■ Contralateral visual field defect
■ Behavioral abnormalities
■ Right hemisphere dysfunction
■ Visuospatial dysfunction
■ Left hemisphere dysfunction
■ Wernicke’s aphasia

Middle cerebral artery: Lateral aspect of the ■ Impairments related to both upper and lower trunk
both upper and lower trunks involved hemisphere dysfunction as listed in previous two sections

Continued
488 Stroke Rehabilitation

Table 18-4
Cerebral Artery Dysfunction: Cortical Involvement and Patterns of Impairment—cont’d
ARTERY LOCATION POSSIBLE IMPAIRMENTS

Anterior cerebral artery Medial and superior aspects ■ Contralateral hemiparesis, greatest in foot
of frontal and parietal ■ Contralateral hemisensory loss, greatest in foot
lobes ■ Left unilateral apraxia
■ Inertia of speech or mutism
■ Behavioral disturbances

Internal carotid artery Combination of middle ■ Impairments related to dysfunction of middle and
cerebral artery distribu- anterior cerebral arteries as listed previously
tion and anterior cerebral
artery
Anterior choroidal artery, Globus pallidus, lateral ■ Hemiparesis of face, arm, and leg
a branch of the internal geniculate body, posterior ■ Hemisensory loss
carotid artery limb of the internal cap- ■ Hemianopsia24
sule, medial temporal lobe
Posterior cerebral artery Medial and inferior aspects ■ Dysfunction of either side
of right temporal and ■ Homonymous hemianopsia
occipital lobes, posterior ■ Visual agnosia (visual object agnosia, prosopagnosia,
corpus callosum and color agnosia)
penetrating arteries to ■ Memory impairment
midbrain and thalamus ■ Occasional contralateral numbness
■ Right side dysfunction
■ Cortical blindness
■ Visuospatial impairment
■ Impaired left-right discrimination
■ Left side dysfunction
■ Finger agnosia
■ Anomia
■ Agraphia
■ Acalculia
■ Alexia

Basilar artery proximal Pons ■ Quadriparesis

■ Bilateral asymmetrical weakness
■ Bulbar or pseudobulbar paralysis (bilateral paralysis of
face, palate, pharynx, neck, or tongue)
■ Paralysis of eye abductors
■ Nystagmus
■ Ptosis
■ Cranial nerve abnormalities
■ Diplopia
■ Dizziness
■ Occipital headache
■ Coma24
 Chapter 18 • Impact of Neurobehavioral Deficits on Activities of Daily Living 489

Table 18-4
Cerebral Artery Dysfunction: Cortical Involvement and Patterns of Impairment—cont’d
ARTERY LOCATION POSSIBLE IMPAIRMENTS

Basilar artery distal Midbrain, thalamus, and ■ Papillary abnormalities

caudate nucleus ■ Abnormal eye movements
■ Altered level of alertness
■ Coma
■ Memory loss
■ Agitation
■ Hallucination24
Vertebral artery Lateral medulla and ■ Dizziness
cerebellum ■ Vomiting
■ Nystagmus
■ Pain in ipsilateral eye and face
■ Numbness in face
■ Clumsiness of ipsilateral limbs
■ Hypotonia of ipsilateral limbs
■ Tachycardia
■ Gait ataxia24
Systemic hypoperfusion Watershed region on lateral ■ Coma
side of hemisphere, hippo- ■ Dizziness
campus and surrounding ■ Confusion
structures in medial ■ Decreased concentration
temporal lobe ■ Agitation
■ Memory impairment
■ Visual abnormalities caused by disconnection from
frontal eye fields
■ Impaired eye movements
■ Weakness of shoulder and arm
■ Gait ataxia24

CLINICAL REASONING INVOLVED IN USING an activity step out of the performance, or (4) ideational
THE A-ONE apraxia, in which the person does not have an idea of what
to do with the shirt or how to put it on. In addition to
As mentioned in an earlier section of this chapter, the considering definitions of terms when choosing the ap-
therapist applies different types of clinical reasoning when propriate hypotheses, or determining which impairment
applying the A-ONE principles to evaluate task perfor- is most likely to cause the particular activity limitation,
mance and dysfunctional body functions that limit the the therapist keeps in mind indications of impairments
performance. Further exploration is necessary in relation during other activities because these might support a par-
to the reasoning that goes into the A-ONE. When ob- ticular hypothesis. The neurological information on func-
serving dressing performance, the therapist may detect a tional localization and patterns of impairments as related
critical cue such as not dressing one arm. The therapist to different diagnoses or different cerebral arteries de-
interprets this cue, and other cues, by using previously scribed in the previous section also would be included in
described conceptual and operational definitions from the the reasoning and hypothesis formation. Thus, if the
theory behind the A-ONE instrument and forms hypoth- patient (1) knows in general how to use objects, not to
eses. Possible hypotheses might be (1) lack of somesthetic mention if the patient can state a plan of action for the
sensory input from the arm, (2) unilateral body neglect— activity performance, but does not use the left hand ac-
in which the person does not attend, usually to the left cording to muscle strength, or (2) has other impairments
arm—that may or may not be paralyzed, (3) organization that fit with the picture of right hemisphere dysfunction
and sequencing problems in which the person is leaving such as spatial relations impairment, one would probably
490 Stroke Rehabilitation

suspect unilateral body neglect or inattention to body side Process Skills34 (see Chapter 21). Most authors agree that
as a result of right hemisphere dysfunction. The therapist standardized assessments have established, during their
would consider sensation in the arm because this may developmental process, uniform standards regarding as-
or may not be defective if neglect or inattention exists sessment conditions, materials, and instructions for col-
and could affect arm use. The therapist also would check lecting and analyzing information that must be followed
insight into activity limitations and occupational errors precisely. Furthermore, particular assessments may re-
by using operational definitions from the pervasive scale. quire specific training programs.5,19,20,58,61 The develop-
If sensory loss exists, the patient is aware of the problem ment of conceptual and operational definitions can fur-
and how it affects performance. If neglect or inattention ther be considered an important aspect of providing
exists, the patient will not be aware consistently of the uniform standards.
impairment and its effect on activity performance. If, Determining for which purpose information is needed
however, cues indicate the patient is having difficulties is a crucial prerequisite for choosing an evaluation method.
with object use in other activities as well, cannot state a For gathering information for goal setting and choice of
plan of action, or has language problems that might indi- intervention, either standardized or nonstandardized
cate a defect in inner language and problems forming a evaluations may serve the desired purpose. However, if
plan of action, one might conclude that the impairment of the purpose is to measure change in performance, stan-
ideational apraxia limits the dressing performance. Thus, dardized methods are not enough. Most instruments used
the therapist might hypothesize that ideational apraxia in rehabilitation have ordinal scales. Such scales can be
caused by left hemisphere dysfunction might be the na- used as a base for descriptions of performance, but in or-
ture of the problem that interferes with task perfor- der to measure performance interval scales are manda-
mance.17 This information may be useful combined with tory.22,52,78 Thus, in rehabilitation, increased emphasis is
other types of reasoning such as conditional reasoning51 being placed on use of scales that have measurement
(see Chapter 17) when making decisions regarding inter- properties67 both for clinical and research use. Such scales
vention methods, as discussed later.17 allow for measuring change over time and comparisons of
different groups.
ASSESSMENT METHODS In contrast to the nonstandardized method reviewed
earlier in this chapter and based on the A-ONE, the
Occupational therapists use basically two evaluation and A-ONE instrument, a criterion based method, is stan-
intervention approaches when working with patients with dardized; that is, it includes detailed administration and
neurological conditions: deficit-specific approach, also scoring instructions. Several studies of validity and reli-
termed bottom-up, restorative, or remedial approach; and ability have been conducted to ensure the A-ONE does
functional adaptation or compensation approach, also re- what its developer claims it does and that it measures the
ferred to as top-down, or adaptive approach. Evaluation traits consistently (Table 18-5). The instrument requires a
tools used when applying the deficit-specific approach are training seminar for therapists to ensure reliability.17,63
aimed at the impaired body structures and functions, us- The original development of the instrument was based on
ing the ICF terminology. The evaluation tools of the traditional psychometric methods and use of ordinal
functional approach target the activity level or occupa- scales, as the purpose was to gather useful information for
tional performance. Today, different authors within oc- goal setting and intervention ideas, not to evaluate change.
cupational therapy emphasize the importance of focusing Increased demand for evidence-based practice and effi-
on task performance or occupational functioning in a top- cacy in rehabilitation services call for instruments with
down fashion when assessing patients rather than focusing measurement potential. For this reason, the new test
on impairments.13,36,38,54 They also stress the importance theory was used to revalidate the A-ONE and explore if
of using standardized evaluation methods that relate oc- the original ordinal scales could be converted to interval
cupational performance to body functions,13,36,38,42,50 or scales. The ADL scale of the A-ONE has successively
performance skills.21 been Rasch analyzed, and development of conversion
The previous sections have described how the therapist tables to convert the ordinal scores recorded after obser-
can detect neurobehavioral impairments during observa- vation of ADL performance to interval scores is taking
tion of task performance by the use of task analysis based place.12 Interval scales have also recently been constructed
on the A-ONE theoretical framework. Functional assess- based on the ordinal neurobehavioral impairment scales
ments may include nonstandardized and standardized of the A-ONE, by application of Rasch analysis.14 Thus,
observations. According to Unsworth,71 a nonstandard- the revalidated A-ONE instrument permits comparison
ized hypothesis testing approach for evaluation could be between patients in addition to monitoring of progress,
useful for therapists who have not had the chance to com- regardless of which trained therapist administers and in-
plete the required training for standardized assessments terprets the evaluation. The results provide useful infor-
such as the A-ONE and the Assessment of Motor and mation to guide the choice of intervention method based
Table 18-5
Instrument Development and Samples of A-ONE Reliability and Validity Studies
CONTRIBUTION TO
STUDY PURPOSE DESIGN AND SUBJECTS RESULTS INSTRUMENT DEVELOPMENT

Traditional Psychometric Studies

6
Interrater reliability Provide interrater reliability Four occupational therapists Average kappa coefficient Establishment of interrater
for the scales of the rated 20 patients (␬)  0.84 reliability
A-ONE. (2 therapists at the time).

Chapter 18 • Impact of Neurobehavioral Deficits on Activities of Daily Living

Sample of convenience.
Interrater reliability11 Provide interrater reliability Five therapists evaluated Functional Independence (FI) scale: Establishment of interrater
for the scales of the 20 videotapes of 4 children ICC  0.98 reliability
A-ONE. and 16 disabled adults. Kendall   0.92
␬w  0.9
Neurobehavioral Specific
Impairment Subscale (NBI
specific scale):
ICC  0.93
␬w  0.74
Item correlations6 Examine interitem Scores from 89 subjects with Item correlations within domains Support for the theoretical
correlations cortical neurological diag- ranged from r  0.3 to 0.9. statement of neurobehavioral
noses on the FI scale were Item correlations across domains dysfunction affecting perfor-
correlated within and across ranged from r  0.1 to 0.8 mance in self-care activities,
domains. Subsequently Item correlations across scales resulting in diminished
scores obtained from the FI (independence/neurobehavior) independence.
scale were correlated with were significant for 75% of
scores of the NBI specific comparisons.
subscale
Exploratory factor6 Explore factors. Contribute Factor analysis: varimax Three factors emerged from the Contribution to construct
analysis. to construct validity rotation. 89 subjects with FI scale. validity.
CNS diagnoses Two factors emerged from the
Neurobehavioral Specific
Impairment Subscale.

Continued

491
 492
Stroke Rehabilitation
Table 18-5
Instrument Development and Samples of A-ONE Reliability and Validity Studies—cont’d
CONTRIBUTION TO
STUDY PURPOSE DESIGN AND SUBJECTS RESULTS INSTRUMENT DEVELOPMENT

Traditional Psychometric Studies

Item correlations63 Explore construct validity 60 subjects with and without Items from the 4 domains of dress- Contribution to construct
neurological diagnoses ing, grooming and hygiene, trans- validity.
fers and mobility, and eating had
high item correlations ranging
from 0.82 to 0.93. Correlations
for items in the communication
domain to items in other domains
were unacceptable.
Concurrent validation63 Explore concurrent validity Scores from 60 subjects on Correlations of A-ONE FI scale Contribution to concurrent
the FI scale of the A-ONE and Barthel Index, r  0.85. validation
and Barthel Index were Correlations of A-ONE NBI scores
compared. and Mini Mental State Examina-
Scores from 42 subjects on tion (MMSE), r 0.7
the NBI scale of the
A-ONE and Mini Mental
State Examination (MMSE)
were compared.
Concurrent validation37 Explore if persons diag- Prospective study of perfor- Only one ADL item out of 20 Contribution to concurrent
nosed with right and left mance of 42 subjects diag- showed difference between sub- validity and construct validity
cerebral vascular accidents nosed with right and left jects with R stroke and L stroke.
perform differently on the stroke (R stroke, L stroke) Significant difference was obtained
scales of the A-ONE. between groups for the impair-
Explore which NBI items ments of unilateral body and spa-
interfere most frequently tial neglect, motor and ideational
with ADL apraxia and organization and
sequencing. Most frequently de-
tected items were: “organization
and sequencing,” “spatial relations
impairment,” unilateral body
neglect, Wernicke’s aphasia, and
Broca’s aphasia.
Concurrent validation55 To explore association of Results from the A-ONE hy- Kappa coefficients revealed: Contribution to concurrent
therapists hypothesis pothesis for 21 stroke and A-ONE to CT scans   0.75 validity and construct validity
about lesion location transient ischemic attack A-ONE to CMEEG   0.63
based on clinical subjects were compared to CT to CMEEG   0.53
observations and results results of computerized to-
of technological evaluation mography (CT scans) and
methods computerized mapping of
electroencephalography
(CMEEG)

New test theory, Rasch analysis

Rasch analysis of the Explore the internal scale Retrospective design includ- Unidimentionality of items on the Contribution to internal
ADL scale12 validity and structure of ing 209 persons with stroke ADL scale of the A-ONE can be validation of the ADL scale
the ADL scale of the or dementia achieved with minor revision of (construct validity).

Chapter 18 • Impact of Neurobehavioral Deficits on Activities of Daily Living

A-ONE with need for the instrument.
revision in mind. Revision would increase power of
Examine possibility of the instrument as a tool to
converting the ordinal measure change.
A-ONE ADL scale to an Information for conversion tables.
interval scale and revising
the instrument.
Rasch analysis of the Explore the internal scale Retrospective design includ- Unidimentionality of items on the Contribution to internal valida-
NBI scale.14 validity and structure of ing 206 persons with stroke NBI scale of the A-ONE can be tion of the NBI scale (construct
the NBI scale of the or dementia. Items were achieved with specific scales for validity).
A-ONE with need for dichotomized. different diagnostic groups.
revision in mind. Revision would increase power of
Examine possibility of the instrument as a tool to
converting the ordinal measure change.
A-ONE NBI scale to an Information for conversion tables.
interval scale and revising
the instrument.
Further Rasch analysis Explore the internal scale Retrospective design includ- Unidimentionality of items on the Contribution to internal
of the NBI scale for validity and structure of ing 422 persons diagnosed ADL scale of the A-ONE can be validation of the NBI scale
different diagnostic different versions of the with stroke and 216 persons achieved for combined diagnostic
groups15,16 NBI scale for combination with R stroke and groups.
of different diagnostic L stroke. Revision would increase power of
groups. Examining the the instrument as a tool to mea-
research use of scales for sure change and compare individ-
combined diagnostic uals from different groups.
groups Information for conversion tables

Courtesy G. Árnadóttir, Reykjavík, Iceland.

From Árnadóttir G: A-ONE training course: lecture notes, Reykjavík, Iceland, 2009-2010.
CNS, Central nervous system; FI, Functional Independence; NBI, Neurobehavioral Impairment.

493
494 Stroke Rehabilitation

on strengths and weaknesses of the patient, from the per- efficacy of treatment in research studies.50 A therapist in-
spective of task performance and body functions. terested in applying a deficit-specific approach to evaluate
The way in which the A-ONE provides information on dysfunction of body functions (e.g., muscle strength and
task performance dysfunction in different ADL domains tone, motor apraxia, spatial relations, neglect, and mem-
and the neurobehavioral impairments that might affect ory) has a choice of applying test batteries or evaluations
ADL performance, becomes evident by exploring the case aimed at specific impairments. Examples of test batteries
study that follows this review. The therapist first fills in used by occupational therapists to evaluate a range of
scores for the level of assistance needed for task perfor- impairments in patients with stroke are the Lowenstein
mance. Observations are written in the comments and Occupational Therapy Cognitive Assessment (LOTCA)43
reasoning sections about ineffective actions observed as and the Rivermead Perceptual Assessment Battery
errors in task performance. Subsequently the therapist (RPAB).73 Examples of standardized deficit-specific tests
reasons, based on the content of the observed errors, available for evaluating some of the impairments men-
about the type of impairment responsible for the error. tioned in the case presented in Fig. 18-10 are the Behav-
The neurobehavioral impairment is then scored based on ioral Inattention Test (BIT)76 for unilateral neglect or
whether the impairment is present or not and how much inattention; the Motor-Free Visual Perception Test—
assistance is needed to complete the task. Vertical (MVPT—V),53 a deficit-specific evaluation that
The case study illustrated in Fig. 18-10 describes a pa- could be used to examine presence of spatial relations im-
tient who sustained a right hemispheric stroke. The A- pairments; the Test of Every Day Attention (TEA)59 for
ONE assessment was used to evaluate ADL performance attention deficits; the Behavioral Assessment of the Dysex-
and the type and severity of neurobehavioral impairments ecutive Syndrome (BADS)74 for evaluating prefrontal dys-
that interfered with task performance. The study demon- function; Rivermead Behavioral Memory Test (RBMT)75
strates how neurobehavioral impairment interferes with for everyday memory functions; the Self-Reporting Aware-
ADL performance and how the two types of dysfunction— ness Test1 and the Assessment of Awareness of Disability68
impaired neurological body functions and their effect on for evaluating insight; a test for imitating gestures30 used
task performance—may be evaluated by different scales of to evaluate ideomotor apraxia; and a test for ideational
the same assessment. apraxia.31 See Chapter 19.
The case study presents an individual who needs physi- Several studies have explored the relationship of scores
cal assistance with all items in the dressing domain of the from ADL instruments to scores from different cognitive,
Functional Independence Scale of the A-ONE (Fig. 18-10, perceptual, and motor instruments for different reasons.
A). The limitations in ADL task performance resulting in These include examination of the associations between
diminished independence are related to several neurobe- disability and impairment, search for prognostic factors
havioral impairments including unilateral body neglect, useful for rehabilitation, and establishment of ecological
spatial relations impairment, unilateral spatial neglect, or- validity for different scales. Sample size, type and number
ganization and sequencing problems, and left hemiplegia of items, scales, and psychometric methods used vary con-
(as indicated by scores on the Neurobehavioral Specific siderably in these studies. However, most of the obtained
Impairment Subscale of the A-ONE). The dressing do- results support the notion that impairments and lowered
main is one of five domains on the Functional Indepen- ADL function are associated, although the reported
dence Scale of the A-ONE. Summary sheets from the A- strength of the association varies between studies. Cor-
ONE indicating scores in the other functional domains and relations of scores from cognitive and perceptual scales to
different neurobehavioral impairments are also shown (see ADL scales most frequently range from small to moderate
Fig. 18-10, B and C). A subsequent evaluation performed (r  0.2 to 0.6).26,32,33,38,66 Correlations of motor functions
three months later indicated observed improvement in to ADL scores sometimes reach higher values than cogni-
ADL performance. Measures of person ability were ob- tive and perceptual comparisons.45,66 Gillen38 pointed out
tained by comparing the raw scores to conversion tables. in his consideration for evaluation of those with func-
Comparison of the ability measures from the initial evalu- tional limitations secondary to neurological impairments
ation (0.58 logits) to the follow-up evaluation (2.39 logits) that separate evaluations of cognitive and motor tasks re-
revealed significant improvement (1.81 logits) in the mag- veal different results from using tasks that combine differ-
nitude of the measures. ent body functions. Further, the performance of more
Some authors have suggested use of deficit-specific tests than one task at the time, as is often the case in natural
as a follow-up of the functional evaluation under specific context as opposed to deficit-specific testing situations,
conditions. These conditions include circumstances in may lead to worse performance. Thus, it is emphasized
which the therapist has difficulties defining deficits, when here that information from deficit-specific tests cannot
a new therapist needs to refine observation skills,56,57 when replace information from observation in a natural context.
therapists require an aid in quantification of the severity Further, no other evaluation format can replace observa-
of the deficit,57 and/or when the therapist needs to report tion of task performance in natural settings.6,13,36
 Chapter 18 • Impact of Neurobehavioral Deficits on Activities of Daily Living 495

Functional Independence Scale and

Neurobehavioral Specific Impairment Subscale

Ms. Wilson
Name ________________________________________________________________ 6/13/03
Date __________________________

Independence Score (IP): Neurobehavioral Score (NB):

4  Independent and able to transfer activity to 0  No neurobehavioral impairments observed.

other environmental situations. 1  Able to perform without additional information, but some
3  Independent with supervision. neurobehavioral impairment is observed.
2  Needs verbal assistance. 2  Able to perform with additional verbal assistance, but
1  Needs demonstration or physical assistance. neurobehavioral impairment can be observed during
0  Unable to perform. Totally dependent on assistance. performance.
3  Able to perform with demonstration or minimal to considerable
physical assistance.
4  Unable to perform due to neurobehavioral impairment. Needs
maximum physical assistance.
List helping aids used:

• Wheelchair
• Nonslip for soap and plate
• Adapted toothbrush
• Velcro fastening on shoes

Primary ADL activity Scoring Comments and reasoning

Dressing IP Score
Shirt (or dress) 4 3 2 1 0 Include one armhole, fix shoulder
Pants 4 3 2 1 0 Find correct leghole
Socks 4 3 2 1 0 One-handed technique, balance
Shoes 4 3 2 1 0 Balance
Fastenings 4 3 2 1 0 Match buttonholes, Velcro through loop
Other

NB Impairment NB Score
Motor apraxia 0 1 2 3 4
Ideational apraxia 0 1 2 3 4
Unilateral body neglect 0 1 2 3 4 Leaves out left body side
Somatoagnosia 0 1 2 3 4
Spatial relations 0 1 2 3 4 Finding correct holes, front/back
Unilateral spatial neglect 0 1 2 3 4 Leaves out items in left visual field
Abnormal tone: right 0 1 2 3 4
Abnormal tone: left 0 1 2 3 4 Sitting balance/bilateral manipulation
Perseveration 0 1 2 3 4
Organization/sequencing 0 1 2 3 4 For activity steps
Other
Note: All definitions and scoring criteria for each deficit are in the evaluation manual.
A
Figure 18-10 A, Árnadóttir OT-ADL Neurobehavioral Evaluation (A-ONE): sample from
the dressing domain of the Functional Independence Scale and the Neurobehavioral Specific
Impairment Subscale for Ms. Wilson. Continued
496 Stroke Rehabilitation

Árnadóttir OT-ADL
Neurobehavioral Evaluation
(A-ONE)

Name Ms. Wilson Date 6–13–03

Birthdate 4–15–1943 Age 60

Gender Female Ethnicity Caucasian

Dominance Right Profession Dressmaker

Medical Diagnosis:
Right CVA 6/20/03. Ischemia.

Medications:

Social Situation:
Lives alone in an apartment building on third floor
Has two adult daughters

Summary of Independence:
Needs physical assistance with dressing, grooming, hygiene, transfer, and mobility tasks because of left-sided paralysis and
perceptual and cognitive impairments. Is more or less able to feed herself if meals have been prepared. No problems with personal
communication, although perceptual impairments will affect reading and writing skills. Also has lack of judgment and memory
impairment, which affect task performance. Is not able to live alone at this stage. If personal home support becomes available, will
need a home evaluation because of physical limitation and wheelchair use. Needs recommendations regarding removal of
architectural barriers or suggestions for alternative housing. Unable to return to previous job as a dressmaker.

Functional Independence Score (optional)

Function Total Score % Score

Dressing 1,1,1,1,1  5/20

Grooming and hygiene 1,2,1,1,3,0  8/24

Transfer and mobility 1,1,1,1,1  5/20

Feeding 4,4,4,3  15/16

Communication 4,4  8/8

B
Figure 18-10, cont’d B, A-ONE ADL summary sheet.
 Chapter 18 • Impact of Neurobehavioral Deficits on Activities of Daily Living 497

List of Neurobehavioral Impairments Observed:

Specific impairment D G T F C Pervasive Impairment ADL Pervasive Impairment ADL

Motor Apraxia Astereognosis Restlessness
Ideational Apraxia Visual Object Agnosia Concrete Thinking
Unilateral Body Neglect 3 3 3 1 Visual Spatial Agnosia Decreased Insight
Somatoagnosia Associative Visual Agnosia Impaired Judgment
Spatial Relations 3 3 3 1 Anosognosia Confusion
Unilateral Spatial Neglect 2 2 3 1 R/L Discrimination Impaired Alertness
Abnormal Tone: Right Short-Term Memory Impaired Attention
Abnormal Tone: Left 3 3 3 1 Long-Term Memory Distractibility
Perseveration Disorientation Impaired Initiative
Organization 2 2 2 1 Confabulation Impaired Motivation
Topographic Disorientation 3 Lability Performance Latency
Other Euphoria Absentmindedness
Sensory Aphasia Apathy Other
Jargon Aphasia Depression Field Dependency
Anomia Aggressiveness
Paraphasia Irritability
Expressive Aphasia Frustration

Use ( ) for presence of specific impairments in different ADL domains (D = dressing, G = grooming, T = transfers, F = feeding,
C = communication) and for presence of pervasive impairments detected during the ADL evaluation.

Summary of Neurobehavioral Impairments:

Needs physical assistance for most dressing, grooming, hygiene, transfer, and mobility tasks because of left-sided paralysis, spatial
relations impairments (e.g., problems differentiating back from front of clothes and finding armholes and legholes), and unilateral body
neglect (i.e., does not wash or dress affected side) finding. Does not attend to objects in the left visual field and needs verbal cues for
performance. Also needs verbal cues for organizing activity steps. Does not know her way around the hospital. Does not have insight
into how the CVA affects her ADL and is thus unrealistic in day-to-day planning. Has impaired judgment resulting in unsafe transfer
attempts. Leaves the water running after hygiene and grooming activities if not reminded to turn it off. Is emotionally labile and appears
depressed at times. Is not oriented regarding time and date. Presents with impaired attention, distraction, and defective short-term
memory requiring repeated verbal instructions.

Treatment Considerations:

Occupational Therapist:

A-ONE Certification Number:

C
Figure 18-10, cont’d C, A-ONE neurobehavioral summary sheet. (Courtesy G. Árnadóttir,
Reykjavík, Iceland.)
498 Stroke Rehabilitation

SUMMARY 4. What is the difference between expected impairments

in the presence of a right middle cerebral artery dys-
The information in this chapter has provided guidelines function compared with expected impairments of a left
for the observation of stroke patients during task perfor- middle cerebral artery dysfunction?
mance with the purpose of detecting impairments that 5. How might impairments of the left middle cerebral
interfere with independent performance. The concep- artery limit task performance in dressing?
tual and operational definitions provided in this text,
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 g l en g i l l en
k e r r y bro ckm an n ru bi o

chapter 19

Treatment of Cognitive-
Perceptual Deficits:
A Function-Based Approach

key terms
apraxia integrated functional approach problem-solving
attention memory spatial relations
cognition neurobehavior unilateral neglect
concrete thinking organization/sequencing
executive dysfunction perception
poor insight/awareness perseveration

chapter objectives
After completing this chapter, the reader will be able to accomplish the following:
1. Understand the different approaches to treatment of cognitive and perceptual
impairments and be aware of research conducted on each approach.
2. Integrate performance-based assessments to guide intervention planning.
3. Discuss different treatment approaches to individual neurobehavioral impairments.
4. Realize the relevance and importance of occupation-based activities in the treatment of
cognitive and perceptual impairments.

Few things are more interesting or frustrating to a thera- therapists is to determine what can be done to improve
pist than observing a stroke survivor with severe neglect the performance in activities for stroke patients with pro-
or apraxia attempting unsuccessfully to perform an activ- cessing impairments.
ity. Cognitive and perceptual (processing) impairments This chapter focuses on assessment and interventions
can severely impair a person’s ability to participate in ev- for those living with functional deficits secondary to
eryday activities. Frequently, the priority for occupational cognitive/perceptual impairments. It reviews studies and

501
502 Stroke Rehabilitation

other literature on treatment approaches and discusses impact on the stroke survivor’s quality of life.62 Unfortu-
suggestions for treating processing impairments that nately, many times in current practice, participation restric-
frequently are found in persons who have sustained a tions are deemphasized, whereas impairment or activity
stroke. The reader should review Chapters 17 and 18 for limitation is stressed. Therapists must strive to provide ser-
a full overview of this topic. vice in all three areas of need while promoting issues rele-
vant to the patient’s quality of life. See Chapter 3.
NEUROBEHAVIOR Treatment approaches to perceptual or cognitive im-
pairments generally are classified in one of two categories:
Neurobehavior has been defined as any behavioral response (1) the functional or adaptive approach or (2) the remedia-
resulting from central nervous system processing. Neu- tion or restoration approach.34 The functional or adaptive
robehavior is considered the basis of performance in approach underscores techniques to assist the patient in
activities of daily living (ADL).6 In this chapter, neurobe- adapting to deficits, changing the environmental parame-
havior refers to cognitive and perceptual components ters of a task to facilitate function, and using a person’s
of behavior, including praxis, attention, memory, spatial strengths to compensate for loss of function. Remediation,
relations, sequencing, and problem-solving. or restoration, highlights the use of techniques to facilitate
recovery of the actual cognitive or perceptual skills af-
TREATMENT APPROACHES fected by the stroke. Each approach has strengths and
limitations, and therapists often use both approaches dur-
Approaches to stroke rehabilitation can be directed at the ing stroke rehabilitation (Table 19-1).
level of impairment, activity limitations, or participation
restrictions. Impairment refers to body dysfunction; activity Functional/Adaptation Approach
limitation, to task performance dysfunction; and participation The functional approach uses repetitive practice in par-
restriction, to problems in life situations. Approaches aimed ticular activities, usually daily living tasks, to help the
at the level of participation restrictions have the greatest patient become more independent. This approach is

Table 19-1
Traditional Classifications of Interventions
REMEDIATION ADAPTATION

Also known as a restorative or transfer of training Also known as a functional approach

approach
Focused on the decreasing impairment(s) Focused on decreasing activity limitations and participation
restrictions
Focused on the cause of the functional limitation. Focused on the symptoms of the problem
Assumes cortical reorganization takes place
Typically uses deficit-specific cognitive and perceptual Typically uses practice of functional activities chosen based on
retraining activities chosen based on the pattern of what the person receiving services wants to do, needs to do, or
impairment has to do in his or her own environment
Examples of interventions: cognitive and perceptual Examples of interventions: meal preparation, dressing, generating
table-top “exercises,” parquetry blocks, specialized a shopping list, balancing a checkbook, finding a number in the
computer software programs, cancellation tasks, phonebook, environmental adaptations (i.e., placing all neces-
block designs, pegboard design copying, puzzles, sary grooming items on the right side of the sink for a person
sequencing cards, gesture imitation, picture with neglect), compensatory strategy training approaches
matching, design copying (i.e., using a scanning strategy such as the “Lighthouse
Strategy” to improve attention to the left side of the environ-
ment for those living with; an alarm watch to remember to take
a medication for those with memory impairment)
Requires the ability to learn and generalize the Using a compensatory strategy requires insight to the functional
intervention strategies to a real world situation deficits and accepting that the impairment is relatively permanent.
Environmental modifications do not require insight or learning
on the part of the person receiving services.
Assumes that improvement in a particular Does not assume that the underlying impairment is even affected
cognitive-perceptual activity will “carryover” to by the intervention
functional activities

From Gillen, G. Cognitive and perceptual rehabilitation: optimizing function, St. Louis, 2009, Mosby/Elsevier.
 Chapter 19 • Treatment of Cognitive-Perceptual Deficits: A Function-Based Approach 503

designed to treat symptoms rather than the cause of the required for the patient to perform those activities. The
dysfunction.33 Some occupational therapists believe their most important assumption is that improved task per-
role in cognitive and perceptual rehabilitation lies solely formance of table-top activities will be carried over to
in the realm of a functional approach, involving training improved performance in functional activities.25,33,67
in compensatory techniques and only with tasks directly Although this approach has been successful when used
related to functional performance.76 This approach ap- in the initial stages of treatment,33 most studies show only
pears most compatible with research indicating that fam- short-term results, generalization only to similar tasks,104
ily members and financial providers rank independence in or little effectiveness from remedial training for neurobe-
ADL as the highest priority for rehabilitation.29,72 havioral impairments.33,44 For this approach to be success-
Therapists use the functional approach to train pa- ful, treatment sessions must be frequent and lengthy.
tients to function by compensating. An example of com- Neistadt67 believes that only those patients who show
pensation is the use of an alarm watch to remind someone transfer of learning to tasks that are different in multiple
with poor memory to take medication. Compensation characteristics are appropriate candidates for the reme-
circumvents the problem. Some therapists believe the use dial approach to processing impairments. Therapists
of compensation should be limited to patients who have widely agree that practice of a subcomponent skill, such
accepted the permanence of the perceptual or cognitive as problem-solving or attention to task, must occur in
deficit.77 Only persons who can benefit from compensa- multiple contexts for successful transfer of learning.116
tion should be taught these strategies; they must have a According to Neistadt,68 therapists always should train
basic understanding of their skills and the permanence of for transfer of skills because the patient’s home environ-
their limitations because the use of compensation for dis- ment is always different from the clinical setting. Those
ability requires that the individual recognize the need to who can transfer learning only to similar tasks should be
compensate. The patient must be a self-starter, must be restricted to a functional/adaptive approach to maximize
goal directed, have insight/awareness of the functional their training potential.66
consequences of his or her impairments, and must want to
learn new strategies. Successful compensation requires Recommended Approach
practice, repetition, and overlearning of the strategies.116 Determination of the appropriate treatment approach for
Environmental adaptation is more appropriate for those the stroke patient with processing impairments relies on
who cannot use compensatory strategies because of poor the results of the assessment. Important questions in-
insight of disability. Adaptation involves changing the char- clude the following:
acteristics of the task or environment. This technique is used ■ Does the patient have the potential to learn?
in patients with poor learning potential. An example of ad- ■ Is the patient aware of errors during task performance;
aptation is the use of contrasting colors for a plate and place- and if so, does the patient have the potential to seek
mat for someone with figure-ground difficulties. Establish- solutions to those errors?
ing a routine and constant environment with repeated If the patient has poor learning potential or poor aware-
participation in familiar activities is often the most successful ness and is unlikely to benefit from the use of cues or
strategy for these individuals. The adaptive approach relies task modification, a strictly functional approach involv-
on caregivers to implement treatment strategies.116 ing domain-specific training would be recommended.101
A significant limitation of the functional approach is the Domain-specific training requires little or no transfer of
task specificity of the strategies and lack of generalizability learning (generalizability) and involves repetitive per-
to other tasks.25 For example, the use of an alarm timer to formance of a specific functional task using a system of
take medications on time does not help the patient remem- vanishing cues. (Vanishing cues are cues that are provided
ber a repertoire of other activities, such as to take a shower, at every step of task performance but then gradually are
start meal preparation, or get to a doctor’s appointment, removed. The goal is to establish a program in which
unless the patient specifically has been trained to do so. the patient can successfully perform the task with a
minimum number of cues.) This type of training is hy-
Remedial Approach perspecific, and the learning associated with it persists
Remediation (or restoration or transfer of training) only if the task and environmental characteristics re-
emphasizes restoration of the function or skill lost due main unchanged.
to the stroke. Remedial treatment relies on several Traditionally the therapist has used a restorative or
assumptions: the cerebral cortex is malleable and can functional approach; however, Abreu and colleagues1 have
adapt, and the brain can repair and reorganize itself proposed an integrated functional approach to treatment
after injury. Practice and repetition are assumed to re- using principles from both approaches simultaneously. In
sult in learning. In turn, learning results in a more or- this approach, areas of occupation and context are used
ganized, functional system. Another assumption is that to challenge processing skills. Because individuals engage
table-top activities, such as pegboard tasks or computer in occupations as integrated wholes—not as separate
activities, directly affect the underlying processing skills attention machines, categorizers, or memory coders—
504 Stroke Rehabilitation

treatments that are not aimed at real life contexts are ASSESSMENT DECISIONS
irrelevant to real life. With this integrated functional ap-
proach, treatment may be focused on a subcomponent The assessment of the impact of cognitive and percep-
skill such as sustained attention, but daily occupations are tual deficits on daily function is a complex process (see
used as the modality. For example, a self-feeding task can Chapter 18). To increase the efficiency and use of this
be used to improve sustained attention to task. Mealtime process, the following recommendations are made:
is often distracting. Eating can be a difficult task if atten- ■ As opposed to pen and paper/table-top measures,
tion deficits are present. A system of vanishing cues and a performance-based assessments are recommended.
gradual increase in the amount of environmental distrac- See Table 19-2 and other samples within this chapter
tion can be used to address inattention to task and activity for examples. Pen and paper or “table-top” assess-
participation. ments typically include items that attempt to detect
The use of a functional approach is supported by today’s the presence of a particular impairment (i.e., deficit-
health care industry, which seeks documentation of pa- specific). Test items are usually contrived and are usu-
tient’s functional competence in ADL. Only cost-effective ally nonfunctional tasks such as copying geometrical
interventions that directly affect functional status are forms, pegboard constructions, constructing block
embraced in today’s health care environment. designs, matching picture halves, drawing tasks, se-
Any functional task can be used to address a myriad of quencing pictures, remembering number strings, can-
neurobehavioral impairments. For occupational therapists cellation tasks, identifying overlapping figures, com-
to use their skills in activity analysis to evaluate an activity pleting body puzzles, etc. It may be argued that this
for its effectiveness in addressing particular cognitive or type of test has low ecological validity. Does the abil-
perceptual deficits is imperative. Box 19-1 contains an ity to sequence a series of picture cards predict the
example of using everyday function to address neurobe- ability to plan, cook, and clean up a family meal? Does
havioral performance skills. failure to accurately create a three-dimensional block

Box 19-1
Tooth-Brushing Task: Treatment of Neurobehavioral Impairments
SPATIAL RELATIONS/SPATIAL POSITIONING ATTENTION
■ Attention to task (for greater difficulty, distractions such
■ Positioning of toothbrush and toothpaste while
applying paste to toothbrush as conversation, flushing toilet, or running water may
■ Placement of toothbrush in mouth be added)
■ Refocus on task after distraction
■ Positioning of bristles in mouth
■ Placement of toothbrush under faucet FIGURE-GROUND
■ Distinguishing white toothbrush and toothpaste from
SPATIAL NEGLECT
■ Visual search for and use of toothbrush, toothpaste, and sink
cup INITIATION/PERSEVERANCE
■ Visual search and use of faucet handle ■ Initiation of task on command
■ Cleaning parts of mouth for appropriate period of time
BODY NEGLECT
■ Brushing of affected side of mouth and then moving bristles to another part of mouth
■ Discontinuation of task when complete
MOTOR APRAXIA
■ Manipulation of toothbrush during task VISUAL AGNOSIA
■ Use of touch to identify objects
performance
■ Manipulation of cap from toothpaste PROBLEM-SOLVING
■ Squeezing of toothpaste onto toothbrush ■ Search for alternatives if toothpaste or toothbrush is
IDEATIONAL APRAXIA missing
■ Appropriate use of objects (toothbrush, toothpaste, cup)
during task
ORGANIZATION/SEQUENCING
■ Sequencing of task (removal of cap, application of
toothpaste to toothbrush, turning on water, and putting
toothbrush in mouth)
■ Continuation of task to completion
 Chapter 19 • Treatment of Cognitive-Perceptual Deficits: A Function-Based Approach 505

Table 19-2
Selected Performance-Based and Self-Report Assessments for Use with Those Experiencing
Limitations in Daily Function Secondary to Cognitive and Perceptual Impairments
INSTRUMENT INSTRUMENT DESCRIPTION

Comprehensive assessments
Árnadóttir Occupational Structured observation of basic ADL including feeding, grooming and hygiene, dressing,
Therapy-ADL transfers, and mobility to detect the impact of multiple underlying impairments
Neurobehavioral Provides information related to how neurobehavioral deficits affect everyday living
Evaluation (A-ONE)6,7 Includes items related to ideational apraxia, motor apraxia, unilateral body neglect,
See Chapter 18. somatoagnosia, spatial relations dysfunction, unilateral spatial neglect, perseveration,
organization and sequencing dysfunction, topographical disorientation, motor control
impairments, agnosias (visual object, associative visual object, visual spatial), anosognosia,
body scheme disturbances, emotional/affective disturbances, impaired attention and
alertness, memory loss, etc.
Requires training
Assessment of Motor and An observational assessment used to measure the quality of a person’s ADL assessed by
Process Skills (AMPS)36,37 rating the effort, efficiency, safety, and independence of 16 motor and 20 process skill
See Chapter 21. items
Includes choices from 85 tasks
Provides information related to everyday function
Requires training
Brief measure of cognitive functional performance
Kettle Test46 Provides a brief performance-based assessment of an instrumental ADL task designed to
tap into a broad range of cognitive skills. The task consists of making two hot beverages
that differ in two ingredients (one for the client and one for the therapist).
The electric kettle is emptied and disassembled to challenge problem-solving skills and
safety judgment, and additional kitchen utensils and ingredients are placed as distracters
to increase attention demands.
Assessing apraxia
ADL Observations to measure Structured observation of four activities: washing face and upper body, putting on a shirt
disabilities in those with or blouse, preparing food, an individualized task chosen by the occupational therapist
apraxia106,107 Scored based on initiation, execution, and control
The ADL Test for those with Observation of spreading margarine on bread, putting on a T-shirt, brushing teeth, or
apraxia41 putting cream on hands
Scores based on reparable or fatal errors relate to selection of objects, movements, or
sequencing
Assessing unilateral neglect
Catherine Bergego Scale Examines the presence of neglect related to direct observation of functional activities such
(CBS)9,18 as grooming, dressing, feeding, walking, wheelchair navigation, finding belongings,
positioning self in a chair. Has been used as a self-assessment with results compared with
therapist’s ratings to objectify anosognosia (awareness)
Measures personal and extrapersonal neglect
Behavioral Inattention Test Assessment for unilateral neglect using 6 pen-and-paper tests and 9 behavioral tests.
(BIT)45,113 Behavioral tests consist of simulated tasks.
Comb and razor/compact Analyzes attention to both sides of the body during hair combing followed by simulating
test19,64 shaving or applying makeup
Each task is 30 seconds.
Wheelchair collision test75 The person is asked to propel a wheelchair to pass four chairs arranged in two rows.
Screening tool only
Baking Tray Task5,99 Clients are asked to spread out 16 cubes on a 75 ⫻ 50 cm board or A4 paper
(8.27 ⫻ 11.69 inches) “as if they were buns on a baking tray.” Simulated task
Fluff test28 24 white cardboard circles are adhered to various areas on a person’s clothing (15 on the
left side of the body and 9 on the right).
The person must find and remove the targets from the clothing.

Continued
506 Stroke Rehabilitation

Table 19-2
Selected Performance-Based and Self-Report Assessments for Use with Those Experiencing
Limitations in Daily Function Secondary to Cognitive and Perceptual Impairments—cont’d

INSTRUMENT INSTRUMENT DESCRIPTION

Assessing impairments of attention

Test of Everyday Attention80 Considered an ecologically valid test of various types of everyday attention such as
sustained attention, selective attention, attentional switching, and divided attention
Includes several subtests. It is one of the few tests of attention that simulates everyday life
tasks. The test is based on the imagined scenario of a vacation trip to the Philadelphia
area of the United States.
Cognitive Failures Self-report measure of the frequency of lapses of attention and cognition in daily life.
Questionnaire21 Includes items related to memory, attention, and executive dysfunction.
Assessing executive function imapirments
Executive Function Perfor- Assesses executive function deficits during the performance of real world tasks (cooking
mance Test (EFPT)12 oatmeal, making a phone call, managing medications, and paying a bill). The test uses a
structured cueing and scoring system to assess initiation, organization, safety, and task
completion and to develop cuing strategies.
Multiple Errands Test2,30,58,85 Tasks include purchasing 3 items, picking up an envelope from reception, using telephone,
posting the envelope, writing down four items (i.e., price of a candy bar), meeting
assessor, and informing assessor that the test was completed.
Behavioural Assessment of Includes items that are sensitive to those skills involved in problem solving, planning, and
Dysexecutive Syndrome organizing behavior over an extended preiod of time. The battery is designed to access
(BADS)111,114 capacities that are typically required in everyday living using simulated tasks. It includes
the six subtests that represent different executive abilties such as cognitive flexibility,
novel problem solving, planning, judgment and estimation, and behavioral regulation.
Assessing memory loss
Rivermead Behavioral Ecologically valid test of everyday memory. Uses simulations of everyday memory tasks.
Memory Test112 The original version is used for those with moderate to severe impairments while an ex-
tended version is available for those with subtle memory loss. Modifications are available
for those with perceptual, language, and mobility impairments.
Everyday Memory Subjective report of everyday memory. A metamemory questionnaire. Self-report or via
Questionnaire81,93,95 proxy.
Prospective and Retrospective Measure of prospective and retrospective failures in everyday life. Self-rated or
Memory Questionnaire55,88 proxy-rated. Norms are published.

design from a two-dimensional cue card mean that an be an appropriate starting point, but the findings might
individual will not be able to dress or bathe indepen- underestimate the impairment. Sbordone82 emphasized
dently? The use of this type of assessment procedure that the typical assessment environment (a quiet room
as the basis for clinical assessment needs to be ques- without environmental distracters) is not the real world.
tioned if the goal of the cognitive and perceptual as- Specific concerns with a typical testing environment
sessment is to determine if/how impairment(s) will include:
affect functioning in the real world. In contrast, a per- ■ Conditions of testing are set up in such a way as to
formance-based test uses functional activities com- optimize performance.
monly engaged in during daily life as the method of ■ Distraction-free
assessment. The use of structured observations to de- ■ Overstructured
tect underlying impairments is a not only clinically ■ Clear and immediate feedback is provided.
valid 6,84,93,107 but provides the clinician with detailed ■ Time demands are minimized.
information regarding how the underlying impair- ■ Repeated and clarified instructions to optimize per-
ments directly impacts task performance. formance.
■ The environment chosen to conduct the assessment must ■ Problems with task initiation, organization, and
be carefully considered. Typically these assessments are follow-through are minimized as the clinician provides
conducted in a quiet room, free of distractions. This may multiple cues for task progression, and the tests tend to
 Chapter 19 • Treatment of Cognitive-Perceptual Deficits: A Function-Based Approach 507

include discrete items that are performed one at a time accurately read an 81⁄2 by 11 inch menu, the same
as opposed to a sequence of events.17 strategy should be consistently and progressively
practiced to read a newspaper, followed by reading
TREATMENT CONSIDERATIONS the labels on spices in a spice rack, followed by a
street sign, etc.
Therapists must consider many factors while preparing a ■ Practice the same task and strategies in multiple
treatment plan. A stroke survivor may not have the same natural environments.101,102,103 Practice of organized
needs as a person with a closed-head injury, encephalitis, visual scanning for an inpatient should be done in
or a gunshot wound to the head. All have brain injury, but the therapy clinic, in the person’s hospital room, in
they have different patterns of behavior and recovery. the facility’s lobby and gift shop, in the therapist’s
Likewise, one must remember that no two stroke survi- office, etc.
vors are alike. Each person with a stroke is a unique indi- ■ Include metacognitive training in the intervention
vidual with special needs, goals, and problems. plan to improve awareness.
Toglia101,102,103 identified a continuum related to the trans-
Environment fer of learning and emphasized that generalization is not
The importance of the environment or setting in which an all or none phenomenon. She discussed grading tasks to
treatment takes place cannot be underestimated. Patients promote generalization of learning from those that are
plan and perform ADL differently73 at home than in the very similar to those that are very different. Toglia’s101,103
clinical setting.69 Exposure to different environments and criteria for transfer included:
contexts requires patients to adapt strategies and solve ■ Near transfer. Only one to two of the characteristics
problems,51 leading to greater independence in a variety are changed from the originally practiced task. The
of situations. tasks are similar, such as making coffee as compared
The adaptation of purposeful activities to ensure suc- to making hot chocolate or lemonade.103
cess is important in occupational therapy (OT). Success ■ Intermediate transfer. Three to six characteristics
depends on the therapist’s ability to analyze the activities are changed from the original task. The tasks are
and the patients’ strengths, weaknesses, and needs to pre- somewhat similar, such as making coffee as com-
sent the most relevant and challenging activity. pared to making oatmeal.
■ Far transfer. The tasks are conceptually similar but
Generalization share only one similarity. The tasks are different, such
One of the biggest challenges to providing interventions as making coffee as compared to making a sandwich.
to this population is the issue of generalizing or transfer ■ Very far transfer. The tasks are very different, such
of what is learned in therapy sessions to other real world as making coffee as compared to setting a table.
situations. Examples include generalizing the use of the Based on her research and review of the literature,
skills learned on an inpatient rehabilitation related to Neistadt67 suggested that only those individuals who have
meal preparation to making a meal at home on discharge, the ability to perform far and very far transfers of learning
use of a scanning strategy used to read a newspaper article are candidates for the remedial approach to cognitive and
or to locate an item of clothing in a closet, or use of tactile perceptual rehabilitation. She suggested that, on the other
feedback to identify objects on a meal tray or when shop- hand, those who are only capable of near and intermediate
ping for grooming items. The consistent perspective on transfers of learning are candidates for the adaptive ap-
the idea of generalization is that it will not occur sponta- proach, as described earlier. Similarly, near transfers seem
neously but will instead need to be addressed explicitly in to be possible for all individuals regardless of severity of
an intervention plan.66,90,101,102,103 brain damage, while intermediate, far, and very far trans-
Suggestions have been made in the literature to en- fers may be possible only for those with localized brain
hance generalization of cognitive and perceptual rehabili- lesions and preserved abstract thinking, and with those
tation techniques: who have been explicitly taught to generalize.67 While
■ Avoid repetitively teaching the same activity in the these statements should continue to be tested empirically,
same environment.101,102,103 Consistently practicing they give clinicians guidelines related to intervention
bed mobility and wheelchair transfers in a person’s planning.
hospital room does not guarantee that the skill will
generalize to the ability to transfer to a toilet in a NEUROBEHAVIORAL IMPAIRMENTS
shopping mall. IN THE STROKE POPULATION
■ Practice the same strategy across multiple tasks (see
Chapter 5). For example, if the “lighthouse strategy” Processing impairments in the stroke population are part
(see later in this chapter) is successfully used during of an interactive process involving the patient, the activ-
the treatment of an individual with spatial neglect to ity at hand, and the context in which the task is being
508 Stroke Rehabilitation

performed.103 Cognition and perception are a dynamical learn from others’ mistakes, practice monitoring their own
process, constantly changing and reacting to internal and behavior, and see that their problems are not unique.
external stimuli. Therapists must address neurobehav-
ioral impairments in the context of the situation and ac- TREATMENT APPROACHES FOR SPECIFIC
cording to the person’s needs and goals. This is why a NEUROBEHAVIORAL IMPAIRMENTS
generic, general approach does not work for the patients
included in this population. Therapists rarely observe perceptual or cognitive deficits
Neurobehavioral impairments often are noted in stroke in isolation. Usually these deficits overlap and are difficult
survivors. Lesions from a stroke may cause localized loss to interpret because of their complexity. Little research
of function such as language comprehension. More often, has been conducted or published on outcomes of specific
strokes cause a variety of neurobehavioral impairments treatment approaches for isolated perceptual and cogni-
associated with the severity of the infarct. General treat- tive deficits, with the possible exceptions of memory im-
ment strategies for persons with cognitive and perceptual pairments and unilateral neglect. However, therapists
impairments after stroke are addressed next. Commonly continue to assess these impairments individually, and us-
noted neurobehavioral impairments are discussed indi- ing a combination of general and specific treatment ap-
vidually later in the chapter. proaches to neurobehavioral impairments does help
sometimes. With this thought in mind, information on
INTERVENTION STRATEGIES distinct treatment approaches related to specific impair-
ments follows.
Activity Processing
Activity processing is especially helpful in cognitive reha- Decreased Awareness
bilitation because the therapist discusses the purpose and Most authors recommend that self-awareness should
results of the activity with the patient. The therapists can be evaluated before initiating an intervention program
discern awareness by the patient from feedback provided focused on retraining living skills. Findings from stan-
during and after activity participation. Activity processing dardized evaluations of self-awareness will clearly guide
enhances the patient’s metacognition (knowledge of one’s intervention choices. For example, a person who exhibits
own cognitive ability and ability to monitor one’s own insight into an everyday memory deficit may be a candi-
performance) and general knowledge. Activity processing date for teaching compensatory strategies such as using a
emphasizes the purpose of the activity in the rehabilita- diary or notebook However, a person who does not real-
tion process.23 For example, when practicing spatial posi- ize he or she is presenting with a severe unilateral neglect
tioning during a dressing task, the therapists should in- may not be able to learn compensatory strategies but may
struct the patient on the spatial requirements for each step require environmental modifications (e.g., all clothing
of the activity and the purpose of using the dressing task hung on the right side of the closet) to improve everyday
to improve spatial skills. As the patient performs the task, function. In addition, ascertaining the level of insight to
the patient and the therapist should discuss performance a disability is one factor that may determine how moti-
and strategies to perform the activity. vated one is to participate in the rehabilitation process. In
the most simplistic interpretation, one must be aware and
Behavior Modification concerned about a deficit in everyday function to be mo-
Use of behavior modification techniques such as prompting, tivated to participate in what may be a long and difficult
shaping (reinforcing responses that increasingly resemble rehabilitation process.
the sought-after behavior), and contingent reinforcement A variety of assessment measures are typically recom-
(reward contingent on an appropriate response) are com- mended to ascertain a person’s level of self-awareness,
mon in the stroke and/or brain injury population. Behavior including questionnaires (self or clinician rated);
modification techniques with intermittent praise and rein- interviews; rating scales; functional observations; com-
forcement to improve independence in daily activity have parisons of self-ratings and ratings made by others such
been successful.43,53 as significant others, caretakers, or rehabilitation staff;
and comparisons of self-ratings and ratings based on
Group Treatment objective measures of function or cognitive constructs.
Group treatment in the stroke population is often effec- In addition, naturalistic observations can provide further
tive. It can yield situations more like real life, because they information related to how decreased awareness inter-
are less structured and can generate unpredictable events feres with performance of everyday tasks.
and provide distractions. In a group, patients can get feed- Simmond and Fleming86,87summarized that a compre-
back from their peers (which is often more meaningful), hensive and clinically relevant assessment should:
share similar experiences, and exchange problem-solving ■ Be preceded by an assessment of intellectual aware-
and coping strategies. Group treatment allows patients to ness (e.g., the Self-Awareness of Deficits Interview)
 Chapter 19 • Treatment of Cognitive-Perceptual Deficits: A Function-Based Approach 509

as intellectual awareness seems to be a prerequisite questionnaires and rating scales, interviews with the
to online awareness. client and significant others, and observations (strat-
■ Allow a client to rate his or her own performance egy use, use of prediction, self-evaluation, error re-
before, during, and after the assessment. sponse, and response to feedback).
■ Use meaningful activities. 4. Does the individual consciously or unconsciously accom-
■ Use activities that allow enough flexibility to chal- modate changes in functioning? This question may be
lenge clients. answered via interviews with the client and signifi-
■ Be goal focused. The assessment findings should be cant others, and through observations (strategy use,
used to work toward acceptance of a disability fol- use of prediction, self-evaluation, error response,
lowed by interventions to improve function. and response to feedback).
Sohlberg89 further suggested that five assessment ques- 5. What are the consequences of awareness? Similar to
tions should be answered to comprehensively manage a question 4, this may be answered via interviews
lack of awareness. Sohlberg’s suggestions for resources to with the client and significant others, and through
answer each question follow as well: observations (strategy use, use of prediction,
1. What is an individual’s knowledge or understanding of self-evaluation, error response, and response to
strengths and deficits? Sohlberg suggested gleaning feedback).
information from standardized questionnaires and See Table 19-3 for a summary of assessments used to as-
rating scales, and interviews with the client and sig- certain level of awareness.
nificant others. Use of prompts and cues is key to successful cognitive
2. How much of the problem is denial versus organically- and perceptual rehabilitation. Cues can be faded by re-
based unawareness? This complicated question may ducing the number, frequency, or specificity of the
be answered via a review of medical history, cogni- prompts.117 For example, a therapist initially may provide
tive assessment, standardized questionnaires and detailed cues at every step of task performance, such as
rating scales, interviews with the client and signifi- “Look to the left to find the soap.” Cues should be ta-
cant others, observations (strategy use, use of pre- pered and should become less detailed as the patient pro-
diction, self-evaluation, and error response), and gresses (e.g., “Have you remembered all the steps?”).
response to feedback. Therapists should provide prompts and cues in a calcu-
3. Is unawareness generalized or modality specific and does it lated and graded fashion. The use of cues and prompts is
accompany other cognitive impairments? Similar to the part of cognitive and perceptual rehabilitation and is an
previous question, Sohlberg recommended collect- essential way of facilitating patient insight, error detec-
ing data from multiple sources including a review of tion, and strategy development (Table 19-4). See Box 19-2
medical history, cognitive assessment, standardized for awareness training interventions.

Table 19-3
Recommended Measures of Awareness
INSTRUMENT AND AUTHOR VALIDITY COMMENTS

Self-Awareness of Deficits Correlated with the Self-Regulation Skills Measures intellectual awareness via a
Interview38 Interview and the Awareness Questionnaire rating scale
Correlated with work status Rated by clinicians
Discriminates between those with brain
injury and spinal injury
Self-Regulation Skills Discriminates between brain injured and Rated by clinicians
Interview71 non-brain injured subjects for awareness As area of difficulty is determined by the
Correlated with the Self-Awareness of Defi- client, it requires a level of intellectual
cits Interview and Health and Safety Scale awareness and includes items related to
Correlated with work status emergent and anticipatory awareness.
Awareness Interview4 Correlated in the expected direction with Measures intellectual awareness via a dis-
the Wechsler Adult Intelligence Scale crepancy score compared with perfor-
and measures of temporal disorientation mance on standardized neurological tests
Assessment of Awareness of A Rasch analysis suggested acceptable scale Used in conjunction with the Assessment
Disability97,98 validity, construct validity, and person of Motor and Process Skills (AMPS)
response validity
510 Stroke Rehabilitation

Table 19-4 with severely apraxic patients using compensatory strategy

Prompting Procedures training for ADL skills and therefore negates the idea that
severely apraxic patients have poor potential for improve-
PROMPTS RATIONALE ment. Box 19-3 lists general treatment guidelines for
patients with apraxia. See Box 19-4 for a specific example of
“How do you know this Refocuses patient’s atten- a performance-based assessment.
is the right answer/ tion to task performance If physical guiding of the limbs is used during a task, in-
procedure?” or “Tell me and error detection.
corporate the suggested principles of guiding,22 including:
why you chose this Can patient self-correct
■ Place their hands over the patient’s whole hand,
answer/procedure.” with a general cue?
“That is not correct. Can Provides general feedback down to the fingertips.
■ Keep talking to a minimum.
you see why?” about error but is not
specific ■ Guide both sides of the body when possible.
Can patient find error and ■ Move along a supported surface to give the patient
initiate correction? maximal tactile feedback.
“It is not correct Provides specific feedback ■ Involve the whole body in the task to challenge
because . . .” about error posture.
Can patient correct error ■ Provide changes in resistance during the activity.
when it is pointed out? ■ Allow the patient to make mistakes to give opportu-
“Try this [strategy]” (e.g., Provides patient with
nities to solve problems (Figs. 19-1 and 19-2).
going slower, saying each a specific, alternate
Encourage tactile exploration of functional objects and
step out loud, verbalizing approach
a plan before starting, or Can patient use strategy tools to enhance performance as somatosensory feedback
using a checklist) given? from the tool may play a role in organizing movements.42
Task is altered. “Try it Modifies task by one Related to the above, object affordances (the functional
another way.” parameter. Can patient use of particular objects within a context) positively affects
perform task? Begin motor performance.42 Using meaningful objects and tasks
again with grading of will yield better results than movements performed in
prompting described isolation.61 As those with apraxia have compromised learn-
previously. ing of old and new tasks, increased repetitions and practice
will be necessary. Goals should be scaled accordingly. En-
Adapted from Toglia JP: Attention and memory. In Royen CB, courage practice of learned skills outside of therapy and
editor: AOTA self-study series: cognitive rehabilitation, Rockville, throughout the day. For those with ideomotor apraxia,
Md, 1993, American Occupational Therapy Association; experiment with decreasing the degrees of freedom (i.e.,
and Toglia JP: Generalization of treatment: a multicontext
approach to cognitive perceptual impairment in adults with
number of joints) used to perform the task (i.e., encourage
brain injury. Am J Occup Ther 45(6):505, 1991. a woman who is attempting to apply makeup to keep her
elbow on the table). Grade the number of tools and dis-
tracters used in a task (i.e., finger feeding [no tools], fol-
lowed by eating applesauce with only a spoon available,
Apraxia followed by eating applesauce with the choice of one to
According to Ayres,8 praxis is one of the most important three utensils, followed by eating a meal requiring the
connections between brain and behavior; it is what allows choice of various tools for different aspects of the task
persons to interact with the physical world. Apraxia is a [spoon to stir coffee, knife to cut and spread butter, etc.],
dysfunction of purposeful movement that does not result followed by a meal with the necessary and usual utensils
primarily from motor, sensory, or comprehension impair- and distracter tools such as comb and toothbrush).40
ments.6 Although many different types of apraxia have ■ Grade the number of steps of an activity via chaining
been named and defined, the labels used to classify them procedures. The whole task should be completed for
are not universally accepted.11 For relevance in this chap- each trial.
ter, however, they fit into two general categories: motor ■ Grade the number of tasks that will be performed in
and ideational apraxia. See Chapter 18 for examples of succession such as during a morning routine.
how the various types of apraxia affect daily living skills. ■ Use clear and short directions.
Patients with apraxia are often unaware of their ■ Use multiple cues to elicit functions: visual demon-
deficits,96 creating a dilemma for planning therapeutic in- stration, verbal explanation, tactile guiding.
terventions. However, one study concluded that patients ■ Demonstrate the task while sitting parallel to the
with more severe cognitive (and motor) impairments person with apraxia to help develop a visual model of
showed the most significant improvement in ADL.108 The the task.
study demonstrated the obvious potential for improvement ■ Encourage verbalization of what to do.
 Chapter 19 • Treatment of Cognitive-Perceptual Deficits: A Function-Based Approach 511

Box 19-2
Suggestions for Improving Awareness
Have clients perform tasks of interest and then provide them with feedback about their performance. The goal is to have clients
monitor and observe their behavior more accurately so that they can make more realistic predictions about future performance
and gain insight into their strengths and weaknesses.
Encourage self-questioning during a task and self-evaluation after a task (e.g., “Have I completed all of the steps needed?”).
Provide methods of comparing functioning pre- and postinjury to improve awareness.
Use prediction methods. Have the client estimate various task parameters such as difficulty, time needed for completion,
number of errors, and/or amount assistance needed before, during, or after a task and compare with actual results.
Help clients develop and appropriately set their personal goals.
Allow clients to observe their own performance during specific tasks (i.e., via videotape) and compare actual performance to
what they state they can do.
Group treatments and peer feedback may be used because one person can receive feedback on performance from multiple
individuals.
Use role reversals. Have the therapist perform the task, make errors, and have the client detect the errors.
The development of a strong therapeutic alliance is critical in managing both denial and lack of self-awareness. This alliance
should be open and based on trust. Coaching clients to make better choices and understand how defensive strategies affect daily
function.
Use familiar tasks that are graded to match the person’s cognitive level (“just the right challenge”) to develop self-
monitoring skills and error recognition.
Provide education related to deficit areas for clients and families.
Integrate experiential feedback experiences. This method has been called “supported risk taking” and “planned failures” and
is used during daily activities to gently demonstrate impairments. High levels of therapist supported are mandatory during this
intervention.
Monitor for increased signs of depression and anxiety as awareness increases.
Increase mastery and control during performance of daily tasks to increase awareness.
Use emotionally neutral tasks to increase error recognition.
Use tasks that offer “just the right challenge” to increase error recognition/correction.
Provide feedback in a sandwich format (negative comments are preceded and followed by positive feedback).

Data from Fleming JM, Strong J, Ashton R: Cluster analysis of self-awareness levels in adults with traumatic brain injury and relationship to
outcome. J Head Trauma Rehabil 13(5):39-51, 1998; Klonoff PS, O’Brien KP, Prigatano GP, et al: Cognitive retraining after traumatic brain
injury and its role in facilitating awareness. J Head Trauma Rehabil 4(3):37-45, 1989; Lucas SE, Fleming JM: Interventions for improving
self-awareness following acquired brain injury. Austr Occup Ther J 52(2):160-170, 2005; Prigatano GP: Disturbances of self-awareness and
rehabilitation of patients with traumatic brain injury: a 20-year perspective. J Head Trauma Rehabil 20(1):19-29, 2005; Sherer M, Oden K,
Bergloff P, et al: Assessment and treatment of impaired awareness after brain injury: implications for community re-integration. NeuroReha-
bilitation 10:25-37, 1998; Tham K, Tegner R: Video feedback in the rehabilitation of patients with unilateral neglect. Arch Phys Med Rehabil
78(4):410-413, 1997; Toglia J: A dynamic interactional approach to cognitive rehabilitation. In Katz N, editor: Cognition and occupation across
the life span, Bethesda, Md, 2005, AOTA Press; Toglia JP: Generalization of treatment: a multicontext approach to cognitive perceptual im-
pairment in adults with brain injury. Am J Occup Ther 45(6):505-516, 1991; and Toglia J, Kirk U: Understanding awareness deficits following
brain injury. NeuroRehabilitation 15(1):57-70, 2000.

Further Interventions for Apraxia observations (see Box 19-4). Specifically, interventions
The following paragraphs summarize evidenced-based focused on errors related to:
interventions for those living with functional limitations ■ Initiation: inclusive of developing a plan of action
secondary to apraxia. and selection of necessary and correct objects
■ Execution: performance of the plan
Strategy Training. van Heugten and colleagues105 ■ Control: inclusive of controlling and correcting the
described an intervention study designed for use by oc- activity to ensure an adequate result
cupational therapists and based on teaching patients strat- Difficulties related to initiation were treated via specific
egies to compensate for the presence of apraxia. In addi- instructions. Instructions were hierarchical in nature and
tion to interest checklists, the decision as to which activities could include verbal instructions, alerting the patient
to focus on was a joint decision between the therapist and with tactile or auditory cues, gesturing, pointing, hand-
patient. The focus of the intervention was determined by ing objects starting the activity together, etc. Assistance
the specific problems observed during standardized ADL was the intervention provided when problems related to
512 Stroke Rehabilitation

Box 19-3 of the intervention. While the intervention did not

Potential Interventions for Those Living with explicitly focus on decreasing the apraxic impairment,
Functional Limitations Secondary to Apraxia the strategy training approach during participation in
functional activities decreased both activity limitations
Use functional tasks (previously learned and new tasks and severity of impairment.
that are necessary to perform secondary to neurological Donkervoort and colleagues32 also tested this interven-
impairments) for the interventions, i.e., an individualized tion via a large randomized clinical trial comparing usual
task-specific approach.
OT to strategy training integrated into usual OT. After
“Tap into” an individual’s routines and habits.
intervention, those receiving strategy training improved
Collaborate with the client and his or her significant
others/caregivers in order to choose the tasks to focus on significantly on ADL observations (small to medium ef-
and become the goals of therapy, i.e., a client-centered fect size) and the Barthel Index (medium effect size) as
approach. compared to those who received usual care.
Practice these activities in the appropriate environ- A posthoc analysis of Donkervoort and colleagues data
ments and at the appropriate time of day, i.e., context- performed by Geusgens and colleagues39 focused on whether
specific with full contextual cues. or not the strategy training approach resulted in transfer of
Use strategy training interventions to develop internal training to untrained tasks. The analyses revealed that both
or external compensations during the performance of intervention groups (traditional OT and traditional OT
functional activities. combined with strategy training) demonstrated significantly
Focus interventions based on the errors made during
improved scores on nontrained tasks. Change scores of the
the task: initiation, execution, and or control, i.e., error-
nontrained activities were significantly larger in the strategy
specific interventions.
Practice functional activities with vanishing cues. training group as compared to usual OT.
Provide graded assistance via providing graded instruc-
tions, assistance, or feedback during task performance. Errorless Completion and Training of Details.
Practice functional activities using errorless learning Goldenberg and Hagman42 tested a method of specifically
(preempting the error via assistance) approaches. training ADL for those living with apraxia. They specifi-
cally examined spreading margarine on a slice of bread,
putting on a T-shirt, and brushing teeth or applying hand
cream. When an activity was being trained, the focus was
execution of the activity occurred. Also hierarchical, as- on errorless completion of the whole activity. As opposed
sistance could range from various types of verbal assist, to trial and error learning, errorless learning or comple-
stimulating verbalization of steps, naming the steps of the tion is a technique in which the person learns the activity
activity, to physical assistance such as guiding movements by doing it. The therapist intervenes to prevent errors
(see Figs. 19-1 and 19-2). Feedback is provided when from occurring during the learning process. Specific in-
patients have difficulty with control (i.e., patients do not terventions included:
detect or correct the errors they make during the activity) ■ Guiding the hand through a difficult aspect of the
and can be verbal feedback related to the results of per- activity (see Figs. 19-1 and 19-2)
formance, verbal feedback focused on having the patient ■ Sitting beside the patient (parallel position) and do-
use a variety of senses to evaluate the results, or physical ing the same action simultaneously with the patient
feedback focused on knowledge of results. The specific ■ Demonstrating the required action and asking the
strategy training intervention protocol is included in patient to copy it afterwards
Box 19-5. The strategy training approach for apraxia has In addition, the intervention focused on training of de-
been tested with promising results.32 tails. This was aimed at directing the patient’s attention
A pretest/posttest study design105 demonstrated sig- to “the functional significance of single perceptual de-
nificant improvements and large effects for three differ- tails and to critical features of the actions associated with
ent ADL measures (Barthel Index; a standardized evalu- them” (p.133).42 Specific difficult steps of the activity
ation of personal hygiene, dressing, preparing food, and were trained using this approach. To promote knowl-
a patient chosen activity; and an ADL questionnaire edge of object use, key details of ADL objects, such as
that was filled out by both therapists and patients). In the bristles on a toothbrush and the teeth on a comb,
addition, significant improvements were documented were explored and examined. Actions connected to the
on tests of apraxia (small to medium effects) and motor details were then practiced (i.e., searching for and posi-
function (small effects). Improved ADL function was tioning a shirt sleeve for a person with dressing difficul-
still significant after correcting for the improvement on ties) outside of therapy. Specific necessary motor actions
the apraxia measures, motor measure, and time post- were also practiced in other activities and contexts (i.e.,
stroke. Of the patients in this study, 84% perceived squeezing paint from tubes as a similar action as squeez-
complete recovery or substantial improvement because ing toothpaste).
 Chapter 19 • Treatment of Cognitive-Perceptual Deficits: A Function-Based Approach 513

Box 19-4
Assessment of Disabilities in Stroke Patients with Apraxia
OBSERVATION AND SCORING OF ACTIVITIES OF DAILY LIVING
Purpose:
■ To assess the presence of disabilities resulting from apraxia
■ To gain an insight in the style of action of the patient and the sort of errors made
■ To prepare treatment goals for specific training

Method:
The therapist observes the following activities and scores the findings for each activity and each aspect.
1. Personal hygiene: washing the face and upper body
2. Dressing: putting on a shirt or blouse
3. Feeding: preparing and eating a sandwich
4. The therapist chooses an activity that is relevant for the patient or standard at the department

I. Score of independence
0—The patient is totally independent, can function without any help in any situation.
1—The patient is able to perform the activity but needs some supervision.
—The patient needs minimal verbal assistance to perform adequately.
—The patient needs maximal verbal assistance to perform adequately.
2—The patient needs minimal physical assistance to perform adequately.
—The patient needs maximal physical assistance to perform adequately.
3—The patient cannot perform the task despite full assistance.

II. The course of an activity

In every aspect, the patient can encounter problems; however, for each aspect only one score can be entered.
A. Initiation
0—There are no observable problems: the patient understands the instruction and initiates the activity.
1—The verbal instruction has to be adapted or extended.
—The therapist has to demonstrate the activity.
—It is necessary to show pictures or write down the instructions.
—The objects needed to perform the task have to be given to the patient.
2—The therapist has to initiate the activity together with the patient.
—The activity has to be modified in order to be performed adequately.
3—The therapist has to take over.
B. Execution
0—There are no observable problems; the activity is performed correctly.
1—The patient needs verbal guidance.
—Verbal guidance has to be combined with gestures, pantomime, and intonation.
—Pictures of the proper sequence of action have to be shown.
2—The patient needs physical guidance.
3—The therapist has to take over.
C. Control
0—There are no observable problems; the patient does not need feedback.
1—The patient needs verbal feedback about the result of the performance.
—The patient needs physical feedback about the result of the performance.
2—The patient needs verbal feedback about the execution.
—The patient needs physical feedback about the execution.
—It is necessary to use mirrors or video recordings.
3—The therapist has to take over.

From van Heugten C, Dekker J, Deelman B et al: Assessment of disabilities in stroke patients with apraxia: internal consistency and inter-
observer reliability. Occup Ther J Res 19(1):55-73, 1999.
514 Stroke Rehabilitation

continuing the task) or fatal errors (the patient is unable to

proceed without help, or the task is completed but did not
fulfill its purpose). Across the whole group, the number of
fatal errors decreased significantly while the number of
reparable errors did not significantly change.

Direct Training of the Whole Activity versus

Exploration Training. Goldenberg and colleagues41
developed and compared two therapy interventions aimed
at restoring the ability to engage in complex ADL for
those living with apraxia. Exploration training focused on
having patients infer function from structure and solve
mechanical problems embedded in tasks. During treat-
ment, the therapist directed the patient’s attention to
functionally significant details of the object (i.e., prongs
on a fork, serrations on a butter knife, bristles on a tooth-
brush). The therapist explained the functional significance
via verbal, gestural, and pointing cues. The patients did
not practice use of the tools. Specific interventions related
to exploration training included explanation, touching,
and comparing objects with photographs.
Figure 19-1 Patient is guided through a hair-brushing task. The direct training focused on the patient carrying out
the whole activity with a minimum of errors. The tech-
nique is similar to errorless completion as reviewed previ-
ously and includes guided movements, with the therapist
sitting beside the patient to perform the task simultane-
ously. During the training, particularly difficult compo-
nents of the activity were practiced, but the whole activity
was always completed. Specific interventions for direct
training included guided performance of the whole activ-
ity, passive guidance, guidance by example, and rehearsal
of steps.
Goldenberg and colleagues41 tested these interventions
related to the training of four complex ADL. The authors
found that exploration training had no effect on perfor-
mance, while direct training resulted in a significant re-
duction of errors and the amount of assist required to
complete the task. Follow-up three months later revealed
that gains were maintained.

Task-Specific Training. Poole74 examined the abil-

ity of those living with apraxia to master the technique
of one-handed shoe tying (commonly a necessary skill to
be mastered after brain injury). She compared those liv-
ing with a stroke without apraxia, those living with
stroke with apraxia, and healthy adults. The task was
Figure 19-2 Guiding of the patient’s hand along a supported taught using published standardized procedures via dem-
surface (leg) as he reaches for a shoe. onstration and simultaneously verbalizing instructions.
Repetition was used until the task was achieved. The
mean number of trials to learn the task was higher for
Goldenberg and Hagman42 tested this intervention by those with apraxia (M ⫽6.4) as compared to those stroke
examining 15 patients with apraxia with repeated measures survivors without apraxia (M ⫽3.2) versus healthy con-
of ADL function. Success of therapy was based on the re- trols (M ⫽1.2).While the number of trial required to
duction of errors of specific tasks. The authors differenti- learn the task was greater, the majority of those with
ated between reparable errors (the patients succeeds in apraxia were able to retain the task.
 Chapter 19 • Treatment of Cognitive-Perceptual Deficits: A Function-Based Approach 515

Box 19-5
Protocol for Strategy Training for Those Living with Functional Deficits Secondary to Apraxia
The specific interventions are built up in a hierarchical order, depending on the patient’s level of functioning. The therapist
can use instructions, assistance, and feedback.

INSTRUCTIONS
The occupational therapist can give the following instructions:
■ Start with a verbal instruction.
■ Shift to a relevant environment for the task at hand.
■ Alert the patient by:
■ Touching
■ Using the patient’s name
■ Asking questions about the instruction
■ Use gestures, point to the objects.
■ Demonstrate (part of) the task.
■ Show pictures of the activity.
■ Write down the instruction.
■ Place the objects near the patient, point to the objects, put the objects in the proper sequence.
■ Hand the objects one at a time to the patient.
■ Start the activity together with the patient one or more times.
■ Adjust the task to make it easier for the patient.
■ Finally, take over the task because all efforts did not lead to the desired result.

ASSISTANCE
The following forms of assistance can be given by the therapist:
■ There is no need to assist the patient during the execution of the activity.
■ Verbal assistance is needed:
■ By offering rhythm and not interrupting performance.
■ To stimulate verbalization of the steps in the activity.
■ To name the steps in the activity or name the objects.
■ To direct the attention to the task at hand.
■ Use gestures, mimics, and vary intonation in your speech.
■ Show pictures of the proper sequence of steps in the activity.
■ Physical assistance is needed:
■ By guiding the limbs.
■ In positioning the limbs.
■ To use the neurodevelopmental treatment method.
■ To use aids to support the activity.
■ To take over until the patient starts performing.
■ To provoke movements.
■ Finally, take over the task.

FEEDBACK
Feedback can be offered in the following ways:
■ No feedback is necessary because the result is adequate.
■ Verbal feedback is needed in terms of the result (knowledge of results).
■ Verbal feedback by telling the patient to consciously use the senses to evaluate the result (tell the patient see, hear, feel,
smell, or taste).
■ Physical feedback is needed in terms of the result (knowledge of results):
■ To evaluate the posture of the patient.
■ To evaluate the position of the limbs.
■ To support the limbs.
■ Physical feedback is given by pointing or handing the objects to the patient.
■ Verbal feedback is needed in terms of performance (knowledge of performance).
■ Physical feedback is needed in terms of performance (knowledge of performance).
■ Place the patient in front of a mirror.
■ Make video recordings of the patient’s performance and show the recordings.
■ Take over the control of the task and correct possible errors.

From van Heugten C, Dekker J, Deelman B, et al: Outcome of strategy training in stroke patients with apraxia: a phase II study. Clin Rehabil
12(4):294-303, 1998.
516 Stroke Rehabilitation

Wilson110 documented a task-specific training program neglect in 10% to 13.2% of those they examined. They
for a young woman status post an anoxic brain injury. The concluded that right neglect caused by left hemispheric
program focused on two tasks: drinking from a cup and involvement is an elusive phenomenon and is less con-
sitting on a chair followed by positioning it correctly at sistent than right hemispheric neglect. In addition, the
the table. Functional performance was improved for this frequency of occurrence of right neglect was, as ex-
woman via the techniques of breaking down the steps of pected, much lower than that reported in a study using
the tasks followed by practice of the steps, chaining pro- the same assessment battery in right brain damage
cedures, and verbal mediation. The author noted that stroke clients.
generalization to untrained tasks was not evident. Unilateral neglect can present with or without a con-
current visual field cut (see Chapter 16 and Table 19-5).
Perseveration In addition, neglect can interfere with attending to per-
Perseveration is demonstrated by the inability to shift sonal space (body neglect), near space, and/or far space
from one concept to another or to change or cease a be- (Table 19-6). Therefore, the recommended assessment
havior pattern once having started it. Perseveration also method is a performance-based approach to give the
refers to the inability to translate knowledge into action therapist multiple opportunities to evaluate the impact of
(initiation of a task). The person is “stuck in set”—unable neglect on tasks that occur in the various aspects of space.
to discard the previous set of behaviors—or is unable to Examples include the A-ONE (see Chapter 18) and the
“activate” for a new situation. The person stuck in set at- Catherine Bergego Scale (Fig. 19-3). Evidenced interven-
tempts to solve another problem with information rele- tions to decrease the functional impact of neglect include
vant to a previous problem. the following.
Bringing perseveration to a conscious level and train-
ing the patient to inhibit the perseverative behavior has Awareness Training
been successful.48 Other strategies include redirecting Tham and coworkers98 developed an intervention to im-
attention, assisting the patient in initiating a new move- prove awareness related to the effect of neglect on func-
ment or task, and engaging the patient in tasks that in- tional performance. Purposeful and meaningful (for the
volve repetitive action (e.g., washing the face or body, participant) daily occupations were used as therapeutic
stirring food, or sanding wood) to promote successful change agents to improve awareness of disabilities. Spe-
task participation. cific interventions include the following:
■ Encourage the participants to choose motivating
Unilateral Neglect tasks as the modality of intervention.
Unilateral neglect has been defined as “the failure to re- ■ Discuss task performance. Examples include encour-
port, respond, or orient to novel or meaningful stimuli aging the participants to describe their anticipated
presented to the side opposite a brain lesion, when this difficulties, to link their earlier experiences of dis-
failure cannot be attributed to either sensory or motor ability to new tasks, and to plan how they would
defects.”47 Unilateral neglect is most often seen when handle new situations; and asking the participants to
right-side brain damage occurs; therefore, the most fre- evaluate and describe their performance and to think
quent clinical presentation is that of left unilateral neglect. about whether they could improve performance by
Although the mechanisms underlying neglect are still doing the task in another way.
debated, a common hypothesis is that neglect is related to ■ Provide feedback about the observed difficulties
attention-based impairments and has been described as a including verbal feedback (describe to the partici-
lateralized attention deficit. Behaviors observed during pant difficulties with reading and understanding the
everyday activities lend support to the attentional hypoth- text in the left half of the page of the newspaper),
esis, including the following: visual feedback (give visual guidance to show the
■ Not being aware of incoming stimuli on the side op- “neglected” text in the left half of the page), and
posite the brain lesion (e.g., hypoattentive to the left physical guidance.
side) ■ When participants could describe their difficulties, the
■ A bias in attention to information presented on same therapists and participants discussed compensatory
side of the lesion (e.g., hyperattentive to the right techniques that could improve task performance.
side) ■ The participant performed the task again, using the
■ Not being able to disengage from right-side stimuli. newly learned compensatory techniques.
The fact that those living with neglect most often present ■ The home environment was used to confront diffi-
with left neglect also supports the attentional hypothesis culties in familiar settings.
because the right hemisphere is thought to be dominant ■ Video feedback was used (see later).
for attention. That being said, right unilateral neglect ■ Interviews were used to reflect on and heighten
is possible.92 Beis and associates15 documented right awareness.
 Chapter 19 • Treatment of Cognitive-Perceptual Deficits: A Function-Based Approach 517

Table 19-5
Suggestions to Differentiate between Neglect and Visual Field Loss Based on Analysis of Behaviors
VISUAL FIELD LOSS NEGLECT

Objectively tested via confrontation testing (screening) Objectively tested using a battery of assessments to identify body/
or via formalized perimetry testing (see Chapter 16) personal, extrapersonal (near and far), and motor neglect
Awareness of deficits emerge early in the recovery Lack of awareness is more severe and persistent.
process.
Compensatory strategies such as head turning are Compensatory interventions are difficult, may require
observed early and relatively easily taught. multiple sessions, or may not be effective.
Postural alignment is usually not affected. Postural alignment of the head, neck, and trunk may bias
toward the right side.
Sensory-based deficit Attention-based deficit
Visual deficit only Multiple sensory systems may be involved (visual, auditory, tactile).
Effective compensatory strategies result in positive Functional outcomes tend to be poor as compared to those
functional outcomes. without neglect.
Cortical representation of the “whole real world” is Decreased representation of the left side of space while
intact. describing a room from memory
Movement into both hemifields is not affected. Resistance to moving actively (akinesia) or passively into the left
field
Long delays related to moving into the affected field (hypokinesia)
Extinction is not present. Extinction may be present.
Early leftward eye movements noted Rightward-biased eye movements
Not fully effective but consistent scanning patterns Haphazard scanning patterns biased to the right
Comparatively, not as severe a deficit A severe deficit related to functional outcome, rehabilitation
needs, and caregiver burden

Scanning Training ■ The LHS is introduced as a strategy for helping people

Scanning training has long been considered a critical as- pay better attention to their left and right and is ex-
pect of intervention programs for those with neglect. plained fully. The person is shown a simple line draw-
Scanning training has been documented to include the ing of the Cape Hatteras lighthouse, with the light
following: beams and top lights highlighted with a yellow marker.
■ Rotation activities (trunk, head/neck) The person is told to imagine that his or her eyes and
■ Scanning while static head were like the light inside the top of the lighthouse,
■ Scanning while mobile (ambulation or wheelchair sweeping to the left and to the right of the horizon to
navigation) guide ships to safety. The person is then asked to think
■ Using perceptual anchors (the left arm on the table about what would happen if the lighthouse only pro-
or a brightly colored strip of tape on the left side of vided light to the right (or left) side of the ocean and
an activity) horizon. The therapist probes for consequences of the
■ Specific reading, writing, and mathematical calcula- lighthouse illuminating only one side.
tions training ■ The picture of the lighthouse is placed on the table
to the right and in front of the person.
Lighthouse Strategy (LHS) ■ The therapist then introduces a task requiring full
The specific intervention is outlined as follows:65 scanning of the left and right fields. The person is
■ A cancellation test is administered during the initial asked to close the eyes while the therapist sets up
evaluation. objects across the table in front of the person. The
■ The test is scored, and the person is shown the let- person is asked to find these objects.
ters missed on the test. ■ Each time an object is missed, the person is asked to
■ The therapist makes introductory statements such turn the head “like a lighthouse, left and right, like
as, “I teach a strategy to help people pay better this” while the therapist demonstrates the proper de-
attention to their left [or right]. See how you gree and pace of head turning. The person is shown
missed these on this side? I can help you fix this how to line the tip of the chin first with the top of the
problem.” right and then the top of the left shoulder.
518 Stroke Rehabilitation

Table 19-6 clients to make even small movements with some part of
Spatial Aspects of Neglect during Functional the left side of their body if these movements are per-
Activities* formed in the left hemispace. In general, the principle
behind this approach is to “find” the affected limb and
TYPE OF FUNCTIONAL ACTIVITY encourage movements of the affected limb in the ne-
NEGLECT DIFFICULTIES glected hemispace (i.e., spatiomotor cueing). It is hy-
pothesized that these movements lead to summation of
Personal or Does not shave left side of face
activation of affected receptive fields of two distinct but
body neglect Does not comb left side of head
Does not apply makeup to left side of
linked spatial systems for personal and extrapersonal
face space, resulting in improvements in attentional skills and
Does not wash or dry left side of body appreciation of spatial relationships on the affected
Does not integrate left side of body side.52,79 A counter hypothesis is that the movements in
during bed mobility and transfers the left hemispace serve as perceptual cues such as an
Does not use left side of body anchor. Studies have demonstrated a reduction in the
Near Cannot find objects on left side of sink severity of neglect when subjects actively engage their
extrapersonal Cannot find objects on left side of desk left hand in a task.
(peripersonal Inability to read
[within arms’ Inability to locate numbers on the left
Partial Visual Occlusion
reach]) side of the phone
In a randomized study, Beis and colleagues14 examined
neglect Does not eat food on left side of the
plate 22 subjects with left unilateral neglect. Interventions in-
Cannot find wheelchair brakes on left cluded the use of right half-field patches (n ⫽ 7), a right
side of the chair monocular patch (n ⫽ 7), and a control group (n ⫽ 8).
Far Cannot locate clock on left side of wall Patches were worn throughout the day during inpatient
extrapersonal Gets lost easily during ambulation or rehabilitation. Results of paired comparison tests showed
neglect wheelchair mobility significant differences between the control group and the
Cannot navigate doorways group with the half-eye patches for the total Functional
Difficulty watching TV Independence Measure score and objective measures of
Cannot locate source of voices displacements of the right eye in the left field. No signifi-
cant differences were found between the control group
*Spatial neglect includes both near and far extrapersonal and the group with the right monocular patch.
space.
From Gillen G: Cognitive and perceptual rehabilitation:
Videotaped Feedback of Task Performance
optimizing function, St. Louis, 2009, Mosby/Elsevier.
Using videotaped feedback of task performance has been
suggested as a strategy to decrease the effects of unilateral
neglect. When viewing one’s own performance on a TV
screen during video playback, one can see and attend to
■ The person is then asked to find the objects again, the neglected left side on the right side of the TV monitor
this time using the LHS. (i.e., neglect behaviors can be observed in the non-
■ A tactile cue such as a light tap on the left shoulder neglected space). This may be a key therapeutic factor. In
may be given in addition to the verbal cue. usual care, the therapist describes the neglect behavior,
■ The person is asked to notice how many more ob- but the person with neglect may not be able to “see” his
jects can be seen when the LHS is used. or her mistakes. Visualizing the mistakes, followed by
■ A copy of the lighthouse poster is placed on the wall processing them with the therapist, may help insight
of the person’s room, to the right of the bed. building and subsequent strategy formation.
■ All therapists are given copies of the poster and
asked to use it to cue the person when task perfor- Environmental Adaptation
mance requires attention to both the right and left Some people will not recover spontaneously or respond
fields (i.e., grooming, feeding, mobility.). to “active” interventions such as teaching a new strategy
to perform a task. Similarly, those who have poor aware-
Limb Activation ness and insight and who don’t respond to awareness
Limb activation is based on the idea that any movement training may not respond to interventions that require
of the contralesional side may function as a motor stimu- self-generated compensatory strategies. In these cases, a
lus, activating the right hemisphere and improving person’s functional performance may be enhanced by
neglect. It has been shown across a series of studies that implementing and teaching caregivers or family mem-
unilateral neglect can be improved by encouraging bers environmental strategies (Table 19-7).
 Chapter 19 • Treatment of Cognitive-Perceptual Deficits: A Function-Based Approach 519

0 1 2 3

1. Forgets to groom or shave the left part of his/her face ⵧ ⵧ ⵧ ⵧ

2. Experiences difficulty in adjusting his/her left sleeve or slipper ⵧ ⵧ ⵧ ⵧ

3. Forgets to eat food on the left side of his/her plate ⵧ ⵧ ⵧ ⵧ

4. Forgets to clean the left side of his/her mouth after eating ⵧ ⵧ ⵧ ⵧ

5. Experiences difficulty in looking towards the left ⵧ ⵧ ⵧ ⵧ

6. Forgets about a left part of his/her body (e.g., forgets to put his/her upper ⵧ ⵧ ⵧ ⵧ
limb on the armrest, or his/her left foot on the wheelchair rest, or forgets
to use his/her left arm when he/she needs to)

7. Has difficulty in paying attention to noise or people addressing him/her ⵧ ⵧ ⵧ ⵧ

from the left

8. Collides with people or objects on the left side, such as doors or furniture ⵧ ⵧ ⵧ ⵧ
(either while walking or driving a wheelchair)

9. Experiences difficulty in finding his/her way towards the left when ⵧ ⵧ ⵧ ⵧ

traveling in familiar places or in the rehabilitation unit

10. Experiences difficulty finding his/her personal belongings in the room or ⵧ ⵧ ⵧ ⵧ

bathroom when they are on the left side

Total score (/30)

0=no neglect; 1=mild neglect; 2=moderate neglect; 3=severe neglect
Figure 19-3 Catherine Bergego Scale. A test of functional neglect including personal, peri-
personal, and extrapersonal aspects of neglect. Score of 0 is given if no spatial bias is noted.
Score of 1 is given when the patient always first explores the right hemispace before going
slowly and hesitatingly toward the left space and shows occasional left sided omissions. Score
of 2 is given if the patient shows clear and constant left-sided omissions and collisions. Score of
3 is given when the patient is totally unable to explore the left hemispace. (From Bergego C,
Azouvi P, Samuel C, et al: Validation d’une échelle d’évaluation fonctionnelle de l’héminégligence
dans la vie quotidienne: l’échelle CB. Ann Readapt Med Phys 38:183-189, 1995.)

Organization/Sequencing Deficits figure-ground, position in space, spatial relations, and

The ability to organize thoughts requires the integration of form and space constancy skills. Topographical disorien-
multiple skills, including praxis, sequencing, and problem- tation also is classified sometimes as part of spatial rela-
solving. Sequencing refers to the ability to plan and carry out tions syndrome. Recommendations for spatial impair-
events in proper order, progression, and time.6 Sequencing ments include training patients to move slowly through
and organization deficits represent the breakdown of a their environments, encouraging patients to touch objects
complex integration of skills, including use of sensory feed- in the environment frequently, teaching patients to handle
back and organization. Patients with sequencing and orga- objects by the base, and using verbal cues or feedback in-
nization deficits can be trained to use a daily planner, tape stead of gestures.70 Perceptual impairments are often dif-
recordings, or cue cards (depending on whether they per- ficult for families to understand. Educating the caregivers
form better with auditory or visual cues) to help sequence about these disorders and instructing them on how they
the steps of daily tasks. Gradually increasing the number of can help their loved ones (Box 19-7) is especially impor-
steps in a task can increase a patient’s tolerance and ability tant. See Chapter 16.
to perform more complex tasks (Box 19-6). Note those liv-
ing with ideational apraxia will also present with organiza- Spatial Relation Dysfunction
tion and sequencing deficits. Spatial relation dysfunction is an impairment in relating
objects to one another or to the self. Some examples of
Spatial Relations Syndrome functional activities for patients with spatial deficits in-
Spatial relations syndrome is the label given to disorders clude identification and orientation of clothing during a
with impairment in the perception of spatial relationship dressing activity. This includes matching buttons and but-
of objects. These disorders include impairments with tonholes together on a shirt or working on the ability to
520 Stroke Rehabilitation

Table 19-7 Box 19-6

Sample Environmental Strategies to Improve SEQUENCING DEFICITS: TIPS FOR FAMILY
Function in Those with Neglect MEMBERS
FUNCTION STRATEGIES ■ Frustration and error can be lessened by step-by-step
directions written in a simple format (e.g., a checklist).
Feeding Place food, utensils, napkin, etc., on ■ Maps and diagrams may be useful.
the right side of plate and placemat. ■ Visual aids often prove helpful, especially when
Note: This intervention may be com- combined with verbal instructions or physical guiding.
bined with the use of cue on the left ■ Frequent, routine practice should help reinforce the
side of the placemat such as a colored sequencing of daily activities.
anchor (strip of tape or nonslip
material) and/or the person’s left arm
on the table to be used as a spatiomo-
tor cue. Situate person at the table so Box 19-7
that other diners are biased to the PERCEPTUAL PROBLEMS: TIPS FOR FAMILY
right to enhance socialization. MEMBERS
Table games Rotate the person’s chair 45 degrees to
the left to place key game items in ■ Overstimulation from visual information may increase
the intact field. Situate person at the the problem.
table so that other players are biased ■ Getting rid of unnecessary objects and equipment
to the right. lessens the demands on the patient and simplifies the
Home Organize closets, drawers, refrigerator, task. For example, the table-top should be cleared of
management etc. so that the person’s necessary objects that look alike so that the patient does not
items are on the right. confuse them.
Bed side care Call bell always placed on right. Orient ■ Slowing down while reaching for an object or walking
bed so that incoming stimuli into a new area is usually helpful.
(doorway, television, seating) are in
the right field.*
Mobility Colored markers on furniture that be
an obstacle; signs posted on right side working on the computer can be an effective, challenging,
of hall, i.e., “Turn left here” and meaningful modality.

*In the acute stages, this may be controversial because the Spatial Positioning Impairment
therapist may want to “force” the person to respond to the The concept of spatial positioning involves accurate place-
left side of the environment.
ment or positioning of objects, including body parts. That
From Gillen G: Cognitive and perceptual rehabilitation:
optimizing function, St. Louis, 2009, Mosby/Elsevier. impairment may be associated with impaired propriocep-
tion, however. This disorder is linked with language com-
prehension. Concepts such as above, in, and under are inter-
preted according to position in space and language skills.
orient shoelaces during a one-handed tie. Wheelchair Treatment for spatial positioning impairment should
transfers require the ability to position the body in rela- include increasing the patient’s awareness of the impair-
tion to a bed or other object and spatial orientation to ment and teaching compensatory strategies. Matching
maneuver wheelchair brakes and armrests in the correct colored markers for correct placement of objects can be
direction. Simple meal preparation is another activity that helpful. Treatment ideas include having the patient prac-
requires spatial orientation and positioning because of tice placing a glass on top, in front, to the right, and to the
tasks as locating and selecting needed items, stirring food, left of a plate on command, placing certain objects (cups
and setting the table.50 or utensils) in a row and having the patient identify which
The use of the computer for visuospatial retraining has object is in a position different from those of the others.
little or no effect on visuospatial skills and no carryover to If language skills are impaired, the patient can be asked to
functional activities.44 Thus the use of computer programs create a place setting from a model. Repetition of specific
aimed solely at addressing visuospatial skill retraining ap- spatial concepts, with emphasis on attention to detail and
pears to be an ineffective remediation technique. A com- compensatory strategies (e.g., Velcro shoe strap goes to-
puter screen provides information as a two-dimensional ward the colored marker), may be helpful.
image. Spatial relation impairment is a three-dimensional Treatment techniques for right-left discrimination prob-
problem. For persons who use the computer for work or lems include providing activities that stress right and left
leisure, however, the use of the keyboard or mouse while differences, such as dressing and grooming. In addition,
 Chapter 19 • Treatment of Cognitive-Perceptual Deficits: A Function-Based Approach 521

therapists may use color or other markers to distinguish the specific sensory modality, treatment usually focuses on
right from the left side of items such as clothing and shoes. teaching the patient to use the intact sensory modalities. For
example, in tactile agnosia—the inability to recognize ob-
Figure-Ground Impairment jects by handling them—the patient is taught to use visual,
Figure-ground deficits involve the inability to distinguish olfactory, and auditory senses to recognize objects (Box 19-8
the foreground from the background. Treatment strategies and Box 19-9).
for figure-ground deficits should include teaching the pa-
tient to be cognitively aware of the deficit and to slow down Memory Impairments
enough during task performance to identify all the relevant Although memory impairments are not as common in
objects or stimuli before handling or manipulating them. persons who have sustained strokes as they are in those
The environment can be adapted to make it simple and with closed-head injuries, dementia, or encephalitis, dif-
uncluttered (e.g., organizing drawers or shelves). The use ficulty retaining information is nonetheless common in
of stark contrast between objects (e.g., the plate and table the stroke population.
during mealtime) is helpful for patients with this disorder. Human memory is composed of multiple and distinct
Sorting objects such as utensils from a kitchen drawer or systems10,90 that are required to support daily activities
nuts and bolts from a toolkit can be a good therapeutic and participate in the community. Examples include re-
activity; the sorting can be made more difficult with the membering your significant other’s birthday, remember-
addition of smaller and larger objects, thereby adding the ing to take your medications, remembering to feed the
element of size discrimination. The sorting should have a dog, remembering how to type, remembering events that
purpose, such as using the utensils for a cooking task. occurred during a vacation, and so on. Even this “simple”
list of memory tasks requires intact functioning of multi-
Topographical Disorientation ple memory systems and includes knowledge of facts and
Topographical disorientation is difficulty finding direction events, procedures, and remembering future intentions.
in space.6 The use of compensatory techniques and envi- Clearly, memory serves as a key cognitive support to fa-
ronmental adaptation, progressively reduced as the patient cilitate independent living.
demonstrates learning, is often successful in the treatment The steps or stages of memory have been well-
of this disorder. Therapists can use markers such as col- documented.10,90 The flow of these stages follows
ored dots to identify a route the patient must travel every (Table 19-8):
day. The therapist gradually removes cues as the patient
Attention 0 Encoding 0 Storage 0 Retrieval
memorizes the route. One successful treatment program
described by Borst and Peterson20 used the patient’s intact
skills of right-left discrimination and language to assist Box 19-8
with functional mobility. In this treatment program, the
patient practiced following directional instructions (e.g., Difficulties during Everyday Function
“Go left at the next door.”). The patient then was asked to and Agnosia
draw the path from room to room on a map of the clinical VISUAL (OBJECT) AGNOSIA
area. Such an exercise would be especially helpful in the Inability to find the razor on the sink despite adequate
home setting. At first the therapist may need to assist the scanning abilities. The razor can only be located by touch.
patient with correctly orientating the map with each turn.
The therapist should withdraw verbal cues slowly. Next, VISUOSPATIAL AGNOSIA
the patient should attempt to go from room to room with Misjudging the distance while reaching for a cup resulting
only brief glances at the map. The last step is to withdraw in an inappropriate endpoint (i.e., the hand end up several
the use of the map altogether. Generalization of this type inches from the cup)
of treatment is unlikely; therefore, treatment should take Difficulties orienting a shirt to one’s body. See
place only in the most meaningful environment. Chapter 16.

TACTILE AGNOSIA
Agnosia
Difficulty with clothing fasteners despite intact motor
Agnosia typically is defined as the inability to recognize sen- function
sory stimuli. Agnosia presents as a defect of one particular Inability to recognize objects that are in one’s pockets
sensory channel, such as visual, auditory, or tactile. Exam- unless vision is also used
ples include finger agnosia, visual agnosia, somatoagnosia,
simultanagnosia, and tactile agnosia. These disorders are
Data from Árnadóttir G: The brain and behavior: assessing cortical
rarely seen in isolation, and little data have been published dysfunction through activities of daily living, St Louis, 1990,
regarding treatment techniques for agnosia. However, be- Mosby.
cause the defining principle of agnosia is impairment of one
522 Stroke Rehabilitation

Box 19-9
More Interventions for Agnosia, Based on the Literature
VISUAL AGNOSIA
Teach compensation via the use of other senses such as tactile information.
Teach awareness of deficits focusing on consequences of the impairments because those with visual agnosia may underesti-
mate the consequences of the deficit.83
Teach recognition of figures and shapes by kinesthetic sense combined with visual information.96
Teach tracing with eyes and fingers such as tracing letters to improve recognition.96
Moving an object or moving the head relative to an unrecognizable object and tracing the outline may facilitate recogni-
tion.54 Encourage head movements when examining objects and encourage observing items related to depth cues.27,100
Teach the use of spatial and location cues to recognize objects, people, etc. Examples include organizing a bedroom or
classroom so that needed objects are assigned to specific spatial locations such as school clothes on the right side of the dresser
and casual clothes on the left.83 Teach the use of unique identifying features and idiosyncratic cues to assist recognition (e.g.,
color or shape).83 Use knowledge of relevant and critical features to identify objects. For example, when looking for Swiss
cheese in the refrigerator, focus on color (white) and shape (cube shaped) to narrow down the number of objects that must be
examined.
Teach a piecemeal reconstruction approach using feature-by-feature analysis.83
Teach reliance on verbal memory skills and verbal reasoning to interpret the piecemeal visual information into a whole
(e.g., “it’s a person, no it’s a dress, it’s short, it must be a shirt”).83
Use color cues, labels, or textures on objects or environments (e.g., Velcro on the phone receiver or red tape on
doorknobs).24,60
Encourage overt verbalization of the visual characteristics of objects before producing a name.26
Practice identification of real objects vs. line drawings. Real objects are more easily recognized than drawings or pictures.
Focus attention to depth cues, surface texture, and colors.100 Real objects provide cues based on surface detail (different lumi-
nance and textures), color shades, and provide depth information.27
Use landmarks such as a sofa to route find.60
Use cues from other people to help generate a strategy. For example, if during a meal one cannot find utensils, watching
others during the meal may help locate these items.60

ALEXIA
Read via letter tracing.24
Trace letters on the palm of the hand.
Use books on tape.
Text to speech software programs such as Kurzweil 1000 or RealSpeak.

PURE WORD DEAFNESS

Teach use of contextual cues, intonation, gestures, and facial expressions.24
Use written directions and information.

PROSOPAGNOSIA
Use gait clues to identify people (e.g., speed, sound of shoes).83
Teach voice recognition.13,83
Using clothing sounds or clues to recognize.13 Use localization clues (e.g., Ann sits behind me in the classroom, and John is
to my right).83
Highlight distinguishing features such as eye color, a scar, or mustache.24

TOPOGRAPHICAL DISORIENTATION SECONDARY TO AGNOSIA AND RELATED DISORDERS

Teach navigation in home environments by always starting at the same point such as the front door.24
Focus on past memories of the home to assist in navigation or relearning directions using kinesthetic and vestibular cues.
Use color markers on key rooms (e.g., a blue circle is my room).
Teach the use of kinesthetic memory for route finding such as the number of turns or steps.83

TACTILE AGNOSIA AND/OR ASTEREOGNOSIS

Begin practicing with identifying simple shapes via tactile information. Practice recognition of two-dimensional and three-
dimensional objects because recognition may not be consistent.78
Use combined tactile and visual recognition.

From Gillen G: Cognitive and perceptual rehabilitation: optimizing function, St. Louis, 2009, Mosby/Elsevier.
 Chapter 19 • Treatment of Cognitive-Perceptual Deficits: A Function-Based Approach 523

Table 19-8
Stages of Memory
STAGE OF MEMORY DESCRIPTION NEUROANATOMICAL AREA OF FUNCTION

Attention The processes that allow a person to gain access Brainstem

to and use incoming information. Inclusive of Thalamic structures
alertness, arousal, and various attention processes Frontal lobes
such as selective attention.
Encoding How memories are formed. An initial stage of Dorsomedial thalamus
memory that analyzes the material to be Frontal lobes
remembered (visual vs. verbal characteristics of Language system (e.g., Wernicke area)
information). Correct analysis of information is Visual system (e.g., visual association areas)
required for proper storage of the information.
Storage How memories are retained Hippocampus
Transfer of a transient memory to a form or location Bilateral medial temporal lobes
in the brain for permanent retention/access
Retrieval How memories are recalled Searching for or Frontal lobe
activating existing memory traces

Data from Sohlberg MM, Mateer CA: Memory theory applied to intervention. In Sohlberg MM, Mateer CA, editors: Cognitive rehabilitation:
an integrative neuropsychological approach, New York, 2001, Guilford Press.

A variety of memory impairments have been documented memory book. The training sequence they proposed incor-
and each impact daily function differently (Table 19-9). porates principles of learning theory and procedural mem-
Interventions focused on those with memory deficits ory skills, which may be preserved in many clients with even
can be categorized as restorative approaches to improve severe memory impairments. Their paper described the
underlying memory deficits, strategy training, use of non- components of a functional memory book. In addition, they
electronic memory aids, and electronic memory aids or explained a three-stage approach to using the notebook.
assistive technology. Techniques aimed at improving the ■ Acquisition or how to use it
underlying memory impairment such as memory drills ■ Application or where and when to use it
have been unsuccessful in terms of generalizing to mean- ■ Adaptation or how to update it and use it in novel
ingful activities. An improvement may be detected on a situations
laboratory-based measure of memory without a corre- Sohlberg and Mateer90 highlighted that successful mem-
sponding change in daily function or subjective memory ory book training takes time, requires that all staff and
reports. family need to be trained in its use, that the person carry
As will be discussed later, the most promising interven- the book at all times, and that its use is individualized and
tions to improve function in those living with memory function-based. They documented the effectiveness of
deficits rely at least partially on compensatory techniques. this approach to memory book training via a case study in
When using a compensatory approach, choosing the cor- which the intervention was successfully used to support
rect system of compensation is critical. Kime57 suggested daily living and employment, despite persistent memory
a comprehensive evaluation that includes the following: deficits.
■ Severity of injury Donaghy and Williams31 suggested that the diary or
■ Severity of memory impairment notebook include a pair of pages for each day of the week.
■ Presence of comorbidities including physical impair- The notebook is set up to aid scheduling things to do in the
ments, language deficits, and other cognitive deficits future and record activities done in the past. Within each
■ Social supports pair of pages, the left-hand page contains two columns: one
■ Client needs (e.g., will the system be used for work, with a timetable for the day, and the other with the to-do
home management) items. The right-hand page contains the memory log. A
“Last Week” section at the back stores previous memory
Memory Notebooks and Diaries log entries. A full year calendar allows for appointments to
Sohlberg and Mateer90 published a systematic, structured be recorded. Donaghy and Williams31 published their
training sequence for teaching individuals with severe mem- training protocol and two case studies to support use of the
ory impairments to independently use a compensatory notebook.
524 Stroke Rehabilitation

Table 19-9
Terminology Related to Memory Impairments
TERM DEFINITION EXAMPLES OF EVERYDAY BEHAVIORS

Anterograde A deficit in new learning. An inability to recall Not able to recall staff names, easily gets lost
amnesia information learned after acquired brain damage. secondary to topographical disorientation, not able
An inability to form new memories after brain to recall what occurred in therapy this morning,
damage occurs difficulty learning adaptive strategies to compensate
for memory loss
Retrograde Difficulty recalling memories formed and stored Inability to remember autobiographical information
amnesia prior to the disease onset. May be worse for (address, social security number, birth order), not
recent events as opposed to substantially older able to remember historical events (war, presiden-
memories tial elections, scientific breakthroughs), and/or per-
sonally experienced events (weddings, vacations)
Short-term Storage of limited information for a limited Difficulty remembering instructions related to the
memory amount of time use of adaptive equipment, not able to remember
the names of someone just introduced at a dinner
party, not able to remember “today’s specials” in a
restaurant
Working Related to short-term memory and refers to Unable to remember and use the rules of the game
memory actively manipulating information in short-term while playing a board game, not able to perform
storage via rehearsals calculations mentally while balancing the check-
book, difficulty remembering and adapting a recipe.
Long-term Relatively permanent storing of information with May affect declarative memory of knowledge,
memory unlimited capacity episodes, and facts or nondeclarative memories
(LTM) such as those related to skills and habits
Nondeclara- Knowing how to perform a skill, retaining Driving, playing sports, hand crafts, learning to use
tive/ previously learned skills and learning new skills. adaptive ADL equipment or a wheelchair.
implicit or Form of LTM
procedural
memory
Declarative/ Knowing that something was learned, verbal See episodic and semantic memory.
explicit retrieval of a knowledge base such as facts, and
memory remembering everyday events. Includes episodic
and semantic information. Form of LTM (see
following)
Episodic Autobiographical memory for contextually specific Remembering the day’s events, what one had for
memory events. Personally experienced events. Form of breakfast, occurrences on the job, the content of
declarative LTM therapy sessions
Semantic Knowledge of the general world, facts, linguistic Remembering the dates of holidays, the name of the
memory skill, and vocabulary. (Note: may be spared after president, dates of world events
injury.) Form of declarative LTM
Explicit Explicit memories consist of memories from Remembering places and names, and various words.
memory events that have occurred in the external world. See declarative memory.
Information stored in explicit memory is about a
specific event that happened at a specific time
and place.
Implicit Does not require conscious retrieval of the past. Memory of skills, habits, and subconscious processes.
memory Knowledge is expressed in performance without See nondeclarative memory.
the person being aware of possessing this
knowledge. Consists of memories necessary to
perform events and tasks, or to produce a specific
type of response.
Prospective Remembering to carry out future intentions Remembering to take medications, return phone
memory calls, buy food, pick up children from school, mail
the bills. A critical aspect of memory to support
everyday living
 Chapter 19 • Treatment of Cognitive-Perceptual Deficits: A Function-Based Approach 525

Table 19-9
Terminology Related to Memory Impairments—cont’d
TERM DEFINITION EXAMPLES OF EVERYDAY BEHAVIORS

Metamemory Awareness of your own memory abilities Knowing when you need to compensate for memory
capacity (making a list of errands, shopping list,
writing down a new phone number or driving
directions), recognizing errors in memory

Data from Baddeley AD: The psychology of memory. In Baddeley AD, Kopelman MD, Wilson BA, editors: The essential handbook of
memory disorders for clinicians, Hoboken, NJ, 2004, John Wiley; Bauer RM, Grande L, Valenstein E: Amnesic disorders. In Heilman KM,
Valenstein E, editors: Clinical neuropsychology, ed 4, New York, 2003, Oxford University Press; Markowitsch HJ: Cognitive neuroscience
of memory. Neurocase 4(6):429-435, 1998; and Sohlberg MM, Mateer CA: Memory theory applied to intervention. In Sohlberg MM,
Mateer CA, editors: Cognitive rehabilitation: an integrative neuropsychological approach, New York, 2001, Guilford Press.

Errorless Learning and the person being taught the skill must demon-
Errorless learning is a learning strategy that is in contrast strate it. After each trial, prompts are withdrawn and
to trial and error learning or errorful learning. Interven- the technique progresses until all of the steps are
tions using an errorless learning approach are based on learned. The authors found that this technique was
differences in learning abilities. People with memory im- beneficial for learning names by first letter–cued
pairments typically remember their own mistakes as re- recall as compared to trail and error.
sults of their own action more successfully than they re- ■ Forward chaining: Also used to teach multiple step
member the corrections to their mistakes occurring via tasks. The therapist prompts or demonstrates the
explicit means (e.g., a therapist’s cue). People may remem- first step on the first trial, the first two steps on the
ber their mistakes but not the correction. With errorless second trial, and continues until the whole sequence
learning, a person learns something by saying or doing it, is remembered.
rather than being told or shown by someone. In addition, ■ Combined imagery with errorless learning: Associations
the person is not given the opportunity to make a mistake between faces and names were taught by having the
(i.e., there are no mistakes to be remembered). The hy- subject create a mental image based on facial features;
pothesis is that reduction or prevention of incorrect or for example, the wave in the person’s hair looks like a
inappropriate responses facilitates memory performance. W; his name is Walter. The authors documented im-
The technique is straightforward and involves preventing proved free recall of names using this technique.
clients from making any errors during learning via physi- The authors’ results suggest that tasks and situations that
cal and verbal support or cues from the therapist, reduc- facilitate retrieval of implicit memory for the learned ma-
ing the use of trial and error and avoiding mistakes. terial (e.g., learning names with a first letter cue) will
Evans and colleagues35 presented nine experiments, in benefit from errorless learning methods, whereas those
three study phases, which tested the hypothesis that learn- that require the explicit recall of novel associations (such
ing methods that prevent the making of errors (errorless as learning routes or programming an electronic orga-
learning) will lead to greater learning than trial and error nizer) will not benefit from errorless learning. The more
learning methods among those who are memory impaired severely memory-impaired clients benefited to a greater
because of acquired brain injury. Errorless learning tech- extent from errorless learning methods than those who
niques include the following: were less severely memory impaired, but the authors cau-
■ Providing the correct answer immediately: For example, tioned that this may apply only when the interval between
when showing a picture of unfamiliar face, the learning and recall is relatively short.
therapist would ask, “What is this person’s name?
His name begins with M; his name is Michael.” The Assistive Technology
authors found that this technique was beneficial for Several studies have documented the success of using
remembering names by first letter–cued recall as simple assistive technology to compensate for memory
compared to learning names by trial and error. loss and improve daily function (Box 19-10). Interven-
■ Backward chaining: Used to teach multistep tasks. In tions for those with memory impairments must consider
this approach the therapist shows or prompts all of social networks as well. Including significant others in all
the steps of the task. On the next trial, all of the steps interventions may be the key factor to ensure success
except for the last one are demonstrated or prompted (Box 19-11).
526 Stroke Rehabilitation

Box 19-10 Box 19-11

Assistive Technology for Those with Memory Strategies for Significant Others Living
Loss with Those Living with Memory Impairment
after Stroke
Handheld computers
Paging systems Understand that in many cases this impairment may not
Voice recorders be reversible.
Personal data assistants Become very familiar with the specific type of compen-
Alarm watches satory memory strategies that have been prescribed.
Smartphones Keep daily schedules as consistent as able. Stick with
Electronic pill box habits and routines.
Microwave with preset times Simplify the environment by decreasing clutter and
Adaptive stove controls to turn off an electric stove keeping the living areas organized.
after a certain period of time or when heat becomes exces- Decrease excessive environmental stimuli.
sive Help by organizing calendars, clocks, and reminders
A phone with programmable memory buttons (affix posted around the house.
pictures to the buttons) Be proactive in identifying potential safety issues.
A phone with buttons programmed to speak the name Use short and direct sentences.
of the person being called Make sure that the most important information comes
A key locator attachment at the beginning the sentence.
Tape recorders used to cue a behavioral sequence such Highlight, cue, and emphasize key aspects of commu-
as morning care nication (i.e., repeat, point.)
Avoid conversations that rely on memory (i.e., keep
From Gillen G: Cognitive and perceptual rehabilitation: optimizing conversations in the present).
function, St. Louis, 2009, Mosby/Elsevier. Repetition of sentences may be inevitable.
Summarize conversations.
Remember that in many cases, intelligence may re-
main intact.
Attention Deficits Keep “a place for everything and everything in its
Attention is an essential element in successful task per- place.”
formance. Poor ability to attend to a task often is misin- Use photographs, souvenirs, and other appropriate
terpreted as a lack of motivation or neglect. Accurate items to help access memories.
assessment of an attention impairment is important to Understand that fatigue, stress, sleep disorders, and
depression can exacerbate memory loss.
implementing appropriate treatment techniques. One
Keep back-up items (glasses, spare keys, etc.).
method that may be helpful in managing attention prob- Help create to-do lists. Remind loved ones to check it
lems is changing the way occupational therapists speak off or highlight the item when the task is completed.
to patients. The goal is to couple the patient’s attention Label items, drawers, and shelves.
with the intended action; instructions should be in the
logical sequence of the action. Instead of instructing a
patient to “Scoot forward,” the therapist would say,
“Your bottom [pause]. Move it forward to the edge of the Attention has been described as having four distinct
chair.” The wording should correspond with the order domains: alertness, selective attention, sustained atten-
in which the steps are to be executed and should allow tion, and divided or alternating attention. Therapists
the patient to attend to each step. The pause is impor- must train patients in each domain skill individually, and
tant to allow the patient enough time to shift focus and generalization from one domain to another should not be
process the information.25 expected after training.63
Use of systematic training incorporating a series of
tasks with progressively increasing attentional demands Selective Attention Impairment
has resulted in improvements in memory and attention to The ability to focus on relevant stimuli while screening out
task,16 although other studies have failed to demonstrate irrelevant stimuli is referred to as selective attention. Training
support for remedial training in attention.102 patients to react to certain environmental cues and ignore
Family members often are frustrated when their loved distractions may improve selective attention. For example,
ones are distracted easily or are unable to focus on a task. the therapist can ask a patient to follow audio-recorded in-
Family members must be informed that stroke survivors structions for a hygiene task (or meal preparation, if a more
do not behave erratically on purpose. Teaching the family complex task is desired). After the patient is able to com-
the way to create a supportive environment is important plete the task successfully, the therapist can add elements of
(Box 19-12). distraction, such as a radio or television, one by one.
 Chapter 19 • Treatment of Cognitive-Perceptual Deficits: A Function-Based Approach 527

Box 19-12 initially require the patient to shift attention from one
Attention Deficits: Strategies for Clinicians stimulus to another. For example, a simple activity may
and Caretakers consist of participating in a ceramics painting project (in
which the patient alternates attention from the paint to
Avoid overstimulating/distracting environments. ceramic vase); a more complex task would be to have the
Face away from visual distracters during tasks. patient perform a dressing task while watching the news
Wear earplugs. on television and having the patient repeat important
Shop or go to restaurants at off-peak times.
daily events after completing the task. Initially, tasks
Use filing systems to enhance organization.
should require only attention shifts between two focal
Label cupboards and drawers.
Reduce clutter and visual distracters. points. As the patient successfully completes these tasks,
Use self-instruction strategies. the therapist should use activities incorporating more fo-
Use time pressure management strategies. cal points (e.g., a meal preparation task in which focus
Teach self-pacing strategies. must alternate among planning, following directions,
Control the rate of incoming information. searching for supplies, monitoring other foods, timing,
Self-manage effort and emotional responses during and place setting).
tasks.
Teach monitoring or shared attentional resources when Concrete Thinking
multitasking. Inflexible thought processes characterize persons who use
Manage the home environment to decrease auditory
concrete thinking. They have difficulty generalizing in-
and visual stimuli. Keep radios and phones turned off.
formation from one situation to another and rely heavily
Close doors and curtains. Keep surfaces, cabinets, closets,
and refrigerators organized and uncluttered. on available sensory information.
Use daily checklists for work, self-care, and instrumen- Persons with impaired abstraction skills usually have
tal activities of daily living. poor ability to recognize and learn the cognitive and
perceptual skills needed for a specific task. Therefore,
they may benefit only from learning splinter (nongener-
Data from Cicerone KD: Remediation of “working attention” in
mild traumatic brain injury. Brain Inj 16(3):185-195, 2002; Fasotti alizable) skills in treatment and may demonstrate train-
L, Kovacs F, Eling Paul ATM et al: Time pressure management ing only in those tasks that are similar to those learned.67
as a compensatory strategy training after closed head injury. Box 19-13 reviews suggestions for family members to
Neuropsychol Rehabil 10(1)47:-65, 2000; Michel JA, Mateer CA: facilitate communication and task performance with this
Attention rehabilitation following stroke and traumatic brain in-
population.
jury, a review. Eura Medicophys 42(1):59-67, 2006; and Webster JS,
Scott RR: The effects of self-instructional training on attentional
Executive Function Impairments
deficits following head injury. Clin Neuropsychol 5(2):69-74, 1983.
Executive functions is an umbrella term that refers to com-
plex cognitive processing requiring the coordination of
Sustained Attention Impairment several subprocesses to achieve a particular goal.34a This
Sustained attention is the ability to maintain attention over term has been defined as “a product of the coordinated
a period. Focusing and sustaining attention is improved by operation of various processes to accomplish a particular
gradually increasing the attentional demands of activities, goal in a flexible manner”38a or “those functions that en-
through choosing activities with longer duration and addi- able a person to engage successfully in independent, pur-
tional distractions. For example, a task such as combing posive, self-serving behavior.”60a These higher-order
hair in a quiet bathroom without a mirror initially may re- mental capacities allow one to adapt to new situations and
quire less than 30 seconds of focused attention to complete
(and have few inherent distractions). As the patient success-
fully completes these types of tasks, the therapist should Box 19-13
choose activities that require focused attention to detail and COGNITIVE INFLEXIBILITY: TIPS FOR FAMILY
have more distractions (e.g., straight razor shaving task MEMBERS
with the radio playing in the background). Some support
■ Make statements and questions as simple and uncom-
exists for providing specific training for attention to im-
prove alertness and sustained attention, but no evidence plicated as possible.
■ Explain the reasons for certain procedures. The per-
exists that attention training affects functional abilities.63
son may have difficulty understanding the long-term
effects of therapy or medical procedures. Explain
Alternating Attention Impairment these with smaller goals that are easier to accomplish.
Alternating attention is shifting focus from one stimulus ■ If possible, structure tasks so they consist of a series of
to another. For the brain-injured population, the therapist related tasks rather than many unrelated tasks.
should plan graded activities from simple to complex that
528 Stroke Rehabilitation

achieve goals. They include multiple specific functions Box 19-14

such as decision-making, problem-solving, planning, task Categories of Interventions for Those Living
switching, modifying behavior in the light of new infor- with Impairments of the Executive Functions
mation, self-correction, generating strategies, formulat-
ing goals, and sequencing complex actions.12,60a Clearly Environmental modifications: Examples include using
these executive functions support engagement in daily life antecedent control, manipulating the amount of distrac-
activities and participation in the community, most im- tions and structure in the environment, organizing work
and living spaces, and ensuring balance of work, play, and
portant during new, nonroutine, complex, and unstruc-
rest.
tured situations.60a (Table 19-10). Intervention approaches
Compensatory strategies: Examples include the use of
for these problems are somewhat lacking in the stroke external cueing devices such as checklists, electronic pag-
survivor population. Available information is summarized ers, use of reminder systems, organizers.
in Boxes 19-14 and 19-15. Task-specific training: Training of specific functional
skills and routines including task modifications.
GOALS Training in metacognitive strategies to promote a
functional change by increasing self-awareness and
The ability to document OT evaluation and treatment in- control over regulatory processes: These include self-
formation appropriately is more important than ever. The instruction strategies, teaching problem-solving, and goal
insurance industry reimburses for OT services according to management training.
information provided to them through documentation; the
goals set for a patient are critical to the support of the plan Data from Cicerone KD, Giacino JT: Remediation of executive
of care by the insurance company. Functional outcomes function deficits after traumatic brain injury. NeuroRehabilitation
2(3):12-22, 1992; Sohlberg MM, Mateer CA: Management of
have gained increasing support and, in many cases, are re-
dysexecutive symptoms. In Sohlberg MM, Mateer CA, editors:
quired by insurance companies for reimbursement. There- Cognitive rehabilitation: an integrative neuropsychological approach,
fore, goals should be meaningful and sustainable; they must New York, 2001, Guilford Press; and Worthington A: Rehabili-
be valued and carried out by the patient outside the clinical tation of executive deficits: the effect on disability. In Halligan
environment. Examples include: PW, Wade, DT, editors: Effectiveness of rehabilitation for cognitive
deficits, Oxford, 2005, Oxford University Press.
■ Patient will properly sequence dressing tasks involv-
ing the legs with fewer than two verbal cues in three
out of three trials.
■ Patient will use grab bars or other objects for stabil-
ity and safety during dressing task with close super-
vision in three out of three trials. ■ Patient will demonstrate appropriate and indepen-
dent use of pillbox for medication schedule in three
out of three trials.
Table 19-10 ■ Patient will prepare a shopping list from a recipe
Examples of Executive Functions Related with all needed ingredients with minimal assist in
to Everyday Living: Preparing a Salad two out of three trials.
■ Patient will independently use 75% of objects and
EXECUTIVE eat 75% of food placed on left side of midline, with-
FUNCTION ASSOCIATED TASKS
out verbal cues, in three out of three trials.
Initiation Starting the task at the appropriate time ■ Patient will prepare a simple, familiar meal with
without overreliance on prompts 80% recognition of errors in three out of five trials
Organization Organizing the work space and perform- with close supervision.
ing the task efficiently (e.g., gathering ■ Patient will use objects appropriately in hygiene
necessary vegetables at the same time tasks without assistance in two out of three trials.
from the refrigerator) ■ Patient will attend to and perform all steps of audio-
Sequencing Sequencing the steps of the task appro- cued grooming task in three out of three trials with
priately (e.g., gather tools and vegeta-
distant supervision.
bles, wash vegetables, chop and slice
■ Patient will plan and participate in community ac-
vegetables, mix in bowl, add dressing)
Problem- Solving the problem of using a knife that tivities once a week in three out of five trials with
solving is too dull to slice supervision.
 Chapter 19 • Treatment of Cognitive-Perceptual Deficits: A Function-Based Approach 529

Box 19-15
Further Strategies to Manage Functional Deficits Secondary to Dysexecutive Symptoms*
1. Organize living and work spaces such as:
■ Labeling and organizing drawers, cabinets.
■ Organizing shelves in kitchen cabinets and the refrigerator based on categories (e.g., by meal, food category, products
used together).
■ Use paper-based organization systems such as organizers, calendars, and appointment books.
■ Color code or use in/out tray systems for work and home tasks (e.g., blue dots indicate priority work such as bills to be
paid, or files in the bottom tray can be reviewed next week).
■ Use organizing technology such as personal data assistants, alarm watches, handheld organizers, and personal informa-
tion manager software (these may include e-mail applications, a calendar, task and contact management, note taking,
and a journal).
■ Post lists of usual and typical sequenced tasks in appropriate locations (e.g., a morning ADL routine posted on the
bathroom mirror, night tasks such as lock the door and make lunch posted on the nightstand, arrive-at-work tasks such
as check e-mail and phone messages posted on the computer screen).
■ Use timer functions while cooking.
2. Decrease environmental distractions.
■ Keep office door closed.
■ Use “do not disturb” signs when appropriate.
■ Turn off background radio and television.
■ Shut window blinds.
■ Keep workspaces (desks, kitchen counters, coffee tables) clear of clutter.
■ Use phone-answering systems.
■ Post office hours.
3. Plan and organize the day
■ Avoid multitasking
■ Families should establish structured routines (e.g., dinner at 7 pm each day, laundry is done on Saturday mornings).
■ Avoid situations in which multiple people are speaking at once.
■ Use clear and concise instructions.
■ Integrate relaxation breaks throughout the day.
■ Establish several “check your work and progress” points throughout the day (time to tick off checklists for completed
tasks, check organizer for tasks that still need to be completed).

Data from Cicerone KD, Giacino JT: Remediation of executive function deficits after traumatic brain injury. NeuroRehabilitation 2(3):12-22,
1992; Sohlberg MM, Mateer CA: Management of dysexecutive symptoms. In Sohlberg MM, Mateer CA, editors: Cognitive rehabilitation: an
integrative neuropsychological approach, New York, 2001, Guilford Press; and Worthington A: Rehabilitation of executive deficits: the effect on
disability. In Halligan PW, Wade, DT, editors: Effectiveness of rehabilitation for cognitive deficits, Oxford, 2005, Oxford University Press.

CASE STUDY 1
side of space to find needed objects or use both arms
Neurobehavioral Deficits after Stroke to practice use of the left side of the body. (This was
G.W., a 49-year-old man, was working as a security achieved through use of guiding techniques because
guard at a prison when he sustained a massive right no independent movement of left arm was present.)
middle cerebral artery stroke. He was hospitalized for Diminishing verbal cues were used for G.W. to learn
seven days and subsequently received OT on an outpa- to attend to the left side of his body and left side of
tient basis. G.W.’s neurobehavioral deficits initially in- space during functional task performance. G.W.’s
cluded severe left-side spatial and body neglect, anosog- greatest initial impediment was his steadfast denial
nosia, and difficulty with spatial relationships, along with that his left arm and leg belonged to him (known as
hemiparesis, resulting in total dependence in mobility anosognosia). Fortunately, this denial diminished and
and all ADL except eating (for which he needed moder- was no longer present four weeks after the stroke.
ate assistance). Techniques such as matching color markers were
Initial treatment plans focused on setting up func- minimally successful in treating spatial deficits. How-
tional activities such as eating, grooming, hygiene, and ever, adaptive devices, such as elastic shoelaces (to pre-
dressing. G.W. was required visually to scan the left vent the need spatially to execute one-handed shoelace
Continued
530 Stroke Rehabilitation

CASE STUDY 1 REVIEW QUESTIONS

Neurobehavioral Deficits after Stroke—cont’d
1. How is the integrated functional approach different
tying), and compensatory strategies, such as slowing from traditional functional approaches, and why is it
down movements and keeping hands on supported sur- the recommended approach for cognitive and percep-
faces while reaching, were highly successful in increas- tual impairments?
ing G.W.’s independence in daily task performance. 2. What neurobehavioral components are required to
As G.W.’s awareness of his disability improved, use of perform a hair grooming task? How can this task be
awareness questioning was emphasized. G.W. initially used in the treatment of motor apraxia?
was questioned after (and then before) each task; he later 3. How can caregivers adapt environments to assist loved
learned to ask himself questions such as, “What do I do ones with cognitive or perceptual impairments?
before I start?” “Do I see everything I need?” “Is there 4. What are two interventions that can be used to in-
anything I forgot?” and “Did I pay attention to my left crease function in those living with unilateral neglect?
side?” Awareness questioning was the most successful Apraxia? Memory loss?
technique for improving G.W.’s ability to achieve inde-
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76. Radomski MV: Cognitive rehabilitation: advancing the stature of ness of disabilities in clients with unilateral neglect. Am J Occup
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82. Sbordone RJ: Limitations of neuropsychological testing to predict 105. van Heugten C, Dekker J, Deelman B, et al: Outcome of strategy
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83. Schiavetto A, Decaile J, Flessas J, et al: Childhood visual agnosia: a 106. van Heugten C, Dekker J, Deelman B, et al: Assessment of
seven-year follow-up. Neurocase 3(1):1–17, 1997. disabilities in stroke patients with apraxia: internal consistency
84. Schwartz MF, Segal M, Veramonti T, et al: The Naturalistic Action and inter-observer reliability. Occup Ther J Res 19(1):55–73,
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Neuropsychol Rehabil 12(4):311–339, 2002. 107. van Heugten C, Dekker J, Deelman B, et al: Measuring disabilities
85. Shallice T, Burgess PW: Deficits in strategy application following in stroke patients with apraxia: a validity study of an observational
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86. Simmond M, Fleming JM: Occupational therapy assessment of self- 108. van Heugten CM, Dekker J, Deelman BG, et al: Rehabilitation of
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109. Deleted. 114. Wilson BA, Evans JJ, Emslie H, et al: The development of an
110. Wilson BA: Remediation of apraxia following an anaesthetic acci- ecologically valid test for assessing patients with dysexecutive
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Bristol UK, 1988, John Wright. 115. Wu C, Trombly C, Tickle-Degnen L: Effects of object affordances
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1989. Gillen, G. Cognitive and Perceptual Rehabilitation: Optimizing Func-
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test of visuospatial neglect. Arch Phys Med Rehabil 68(2):98–102, Katz, N. (Ed.): Cognitive and Occupation Throughout the Lifespan.
1987. Bethesda, AOTA, 2005.
 cel i a s tewart
karen ri edel

chapter 20

Managing Speech
and Language Deficits
after Stroke

key terms
anarthria conduction aphasia spastic dysarthria
anomic aphasia dysarthria transcortical motor aphasia
aphasia fluent aphasia transcortical sensory aphasia
Broca’s aphasia locked-in syndrome unilateral upper motor neuron
Cognitive communication mutism dysarthria
disorder nonfluent aphasia Wernicke’s aphasia

learning objectives
After completing this chapter, the reader will be able to accomplish the following:
1. Understand the impact of communication impairment following stroke.
2. Be aware of the incidence and prevalence of communication disorders.
3. Understand the various types of communication problems following stroke.
4. Understand the presentation and management of various communication disorders.

Communication disorders have a devastating effect not only better outcomes in the survivor’s life participation. The
on the rehabilitative process, but on the overall quality of chapter begins with a discussion about communication in
life of the stroke survivor.35,50 The objectives of this chapter general, and is followed by a description of the nature and
are, first, to inform the occupational therapist and others the range of communication problems associated with
regarding communication disorders found in stroke to in- stroke and the incidence and prevalence of communication
crease the effectiveness of their intervention and, second, to disorders. Some guidelines provided may be helpful for the
discuss the ways in which the speech-language pathologist occupational therapist in enhancing communication with
and occupational therapist can work collaboratively to foster patients following stroke.

534
 Chapter 20 • Managing Speech and Language Deficits after Stroke 535

SCOPE OF COMMUNICATION of personal identity. For some, these changes in communi-

cation alter one’s roles in life and influence one’s sense of
Communication is simply the transfer of information personal identity.27,68,94 These reactions and the reactions
from one individual to another.12,22,35 Human communi- of friends and family are crucial considerations in the over-
cation in all of its many forms fits within this definition, all management plan.
but for members of a human community, communication Families of persons with communication impairment
in all of its forms has much more meaning.17,64 Humans’ following stroke are more prone to difficulties in psy-
individual personality is displayed in their style of com- chosocial adaptation than those with similar physical
munication. They use gestures, facial expression, and vo- changes but intact communication.27,35 Although family
cal emphasis to convey more than facts. Their various members’ responses are individual and wide-ranging,
modes of communication signify engagement and inten- their coping patterns are established prior to the onset of
tion in their interaction with others. In addition, they stroke and are found to be rather stable.27,35,104 A greater
communicate differently at home than they do in negoti- than normal burden is placed on the caregiver when in-
ating the tasks of daily life in the community. Further- dividuals require significant assistance in expressing
more,* their social interactions with their friends require themselves.27,35,52
different communicative skills than those required in Living successfully with communication impairments
most work settings. requires adaptations in life and consciously making
The intricacy of human communication is compounded choices.27,35,104 These qualities are embedded in the per-
by the range and variety of skills with which they com- son’s personality and also in the coping strategies of the
municate.64 Society’s emphasis on communication has patient’s significant others. Qualities of resilience in the
expanded with advances in communication technology. face of challenges include the ability to maintain a dis-
To be a successful communicator, one must not only be tinct sense of self throughout the recovery process and
able to speak and comprehend spoken messages, but also not allowing for the development of overdependency.53,70
understand and produce written and electronically trans- Having a caregiver that can be flexible in changing roles,
mitted information.8 One cannot view communication in both in assuming the role of caregiver and relinquishing
a vacuum of merely sender and receiver.31 Cultural values, the role when appropriate, facilitates successful adapta-
not only those associated with different languages and tion. Staying engaged in life helps one avoid boredom
ethnic groups but with each life setting, have their own and depression.70,104 Understanding that one can be val-
rules of interaction, which are internalized by the com- ued and participate in life even with significant commu-
munication partners.21,44,67,76 nication impairment is essential.35,71,104 Openness to ven-
turing out and having fun or pursuing something new is
IMPACT OF COMMUNICATION IMPAIRMENT also a characteristic of those who live successfully follow-
FOLLOWING STROKE ing stroke.70,104
Cultural responses are relevant to the patient’s willing-
The reaction of the stroke survivor to communication ness to participate in rehabilitation. The stroke survivor
impairment is unique to the individual. The very sudden- has internalized the values of his or her society for speech
ness of a stroke may overwhelm one’s sense of well- and communication function.94 When communication
being.94 The alteration of communication in the first few disorders are identified, the survivor may fear that he or
days and weeks following the “brain attack” results in a she is mentally challenged.68 Family and friends hold
range of emotions, from sheer terror in some individuals similar cultural values and, as the closest group to the
to indifference in those with little awareness of their defi- patient, may reinforce the sense of incompetence by mak-
cits.63,66 These responses depend on a variety of factors, ing rehabilitation decisions without the survivor’s input
including the locus and extent of the lesion, the nature of and unwittingly adding to the shame and embarrass-
the deficits, the accompanying medical and physical prob- ment.35,68 The fact that it is difficult to overcome and ad-
lems, and the individual’s personality characteristics.68 In dress these cultural biases argues for education of various
addition, the premorbid abilities of persons with commu- types in multiple languages.15,108 The need for current
nication disorders vary across the continuum, from those information in many languages about stroke is increasing
whose livelihood and identity are defined by speaking sev- with the steady expansion of the multilingual popula-
eral languages, writing books, and/or giving speeches to tion.15 Furthermore, access to medical care, to social set-
those whose identity is based on activities other than spo- tings, and to vocational options is constrained by the in-
ken language.27,68 Many stroke survivors describe issues of teraction of social, cultural, and linguistic factors.15
loneliness, social isolation, loss of independence/privacy, Grassroots organizations, such as the National Stroke As-
restricted activities, loss of work/income, and social stig- sociation, American Stroke Association,4 and Aphasia As-
matization.94,95 Sarno95 has stated that the loss of commu- sociation, are attempting to modify these misconceptions
nication in aphasia, for example, is a loss of personhood or about stroke and communication disorders. In addition,
536 Stroke Rehabilitation

the National Aphasia Association86 is confronting the in the strength, speed, range steadiness, tone, or
stigmatization that society gives to individuals who exhibit accuracy of movements required for control of the
an obvious speech problem through raising awareness and respiratory, resonatory, articulatory, and prosodic
by providing education in many languages.86 aspects of speech production. The reasonable patho-
physiologic disturbances are due to central or periph-
INCIDENCE AND PREVALENCE eral nervous system abnormalities and most often
OF COMMUNICATION DISORDERS reflect weakness; spasticity; incoordination; involun-
tary movements; or excessive, reduced, or variable
Valid statistical information about the incidence of speech muscle tone.”33
and language disorders following stroke is not available. 2. Aphasia is an acquired communication disorder
However, according to the American Heart Association,3 caused by brain damage, characterized by an im-
in 2006 there were around 6.5 million stroke survivors pairment of language modalities: speaking, listen-
alive, and “on average, every 40 seconds someone in the ing, reading, and writing; it is not the result of a
United States has a stroke.”3 The percentage of strokes sensory or motor deficit, a general intellectual defi-
that have the initial symptom of speech and/or language cit, confusion, or a psychiatric disorder.47
issues is unknown. Around 25% to 40% of acute strokes 3. Cognitive-communication disorders encompass
result in aphasia, according to the National Aphasia As- difficulty with any aspect of communication af-
sociation.86 However, the presence of aphasia may not be fected by disruption of cognition. Communication
the most common communication symptom following may be verbal or nonverbal and includes listening,
stroke. The incidence and prevalence of dysarthria and speaking, gesturing, reading, and writing in all
cognitive communicative impairment following stroke are domains of language (phonological, morphologi-
unavailable and may be more common and debilitating cal, syntactic, semantic, and pragmatic). Cogni-
than aphasia.33 tion includes cognitive processes and systems
It is almost impossible to quantify the percentage of (e.g., attention, perception, memory, organiza-
persons with communication problems. Included in the tion, executive function). Areas of function af-
well-publicized “stroke warning signs” is the presence of fected by cognitive impairments include behav-
changes in speech.4 Medical records of hospital admis- ioral self-regulation, social interaction, activities
sions for stroke often include patient complaints of of daily living, learning and academic perfor-
“slurred speech.” Many of these initial speech symptoms mance, and vocational performance.110
disappear shortly after, but other subtle changes in com-
munication may be undetected by both the patient and THE ROLE OF THE SPEECH-LANGUAGE
health care professionals.77 This lack of concern is under- PATHOLOGIST ACROSS THE CONTINUUM
standable in the initial stages, since the focus is on acute OF CARE
medical treatment, preserving life, and intervening to
preserve brain function, thus mitigating possible long- The field of speech-language pathology has a relatively
term disability.79 Consequently, the less obvious changes long history of investigating, defining, and treating com-
in cognitive communicative function are not of para- munication disorders. However, the treatment of stroke-
mount concern. The reduced hospital stay for patients related communication disorders by speech-language pa-
with stroke, and the shortened admission to acute and thology is relatively recent and grew out of a medical
subacute rehabilitation results in limited access to treat- specialty in physical rehabilitation (physiatry).95 Physical
ment, and under the best of current practices, this leaves rehabilitation as a specialty had its beginning after World
many patients either unidentified or undertreated.56 War II.10,39,97 Prior to World War II, little attempt had
been made to ameliorate debilitating conditions such as
THE TYPES OF COMMUNICATION those following stroke. The experience of treating the war
PROBLEMS FOUND IN STROKE injured revealed the positive effects of physical treatment
and pointed to the need for rehabilitation of similarly
Stroke results in three general categories of communica- disabled individuals in the civilian population.10,39 The
tion disorders: dysarthria, aphasia, and cognitive commu- field of speech-language pathology, along with occupa-
nicative impairment.28,33 Each type of disorder is associ- tional therapy, physical therapy, psychology, and social
ated with a particular site of the damage in the peripheral work were seen as integral to the team approach, which
and central nervous system. Although these three types characterized the new field of physiatry (Physical Medi-
can and do occur together, they will be discussed as sepa- cine and Rehabilitation).20,42,97,111
rate categories. The inclusion of speech-language pathology into the
1. Dysarthria is “a collective name for a group of neu- rehabilitation model greatly expanded its scope of practice.
rologic speech disorders resulting from abnormalities Most people now take for granted that the rehabilitation
 Chapter 20 • Managing Speech and Language Deficits after Stroke 537

team is the optimal model for stroke management.20,111 The of respiration, phonation, resonation, and articulation
focus of rehabilitation medicine goes beyond other medical may be reflected in speech, which is the primary modality
specialties in three ways: (1) its concern for the “whole” of human communication.28 The resulting speech disor-
person rather than the illness or condition for which service ders that may emerge following stroke include unilateral
was required, (2) the notion of “living with a condition” and upper motor neuron dysarthria, spastic dysarthria, anar-
“maximizing function” as opposed to curing chronic condi- thria, and ataxic dysarthria.33
tions, and (3) the inclusion of a psychosocial perspective that
recognizes that the stroke happens not only to the survivor, Unilateral Upper Motor Neuron Dysarthria
but also to the family and friends.96 The hallmark of reha- One of the easiest speech pathologies to identify, and
bilitation has been its focus on function, and the contribu- probably the most common speech disorder following
tion of that model to speech-language pathology is to focus stroke, is known as “unilateral upper motor neuron dysar-
on functional communication.104,112 thria,” which is relatively mild and often resolves in the
Currently, stroke management is spoken of in terms of weeks following stroke.33,35,38 This impairment in the pre-
a continuum of care and a multiple phase process. Stroke cision of consonant articulation is due to unilateral changes
management begins in the emergency department with a in muscle tone and accompanying weakness of the mus-
focus on rapid medical treatment and extends to years cles of the speech mechanism.33,38,82
poststroke as the survivor learns to live with chronic im- The speech-language pathologist evaluates the impact
pairments.48,111 The speech-language pathologist may in- of this disorder on intelligibility of speech and effective-
tervene at various points in this continuum. The settings ness of communication.82,114 Although unilateral upper
include the emergency department, acute medical hospi- motor neuron dysarthria may occur after either left or
tal stay, acute rehabilitation, home care, outpatient and right hemisphere strokes, the specific abilities probed and
long-term care, and community integration.56 In each of assessment tools selected depend on the location of the
these settings, the role of the speech-language pathologist stroke.33,38 When the dysarthria persists as part of the se-
changes. Although in all settings they begin with an quelae of right brain stroke, it involves not only the ac-
evaluation of motor control of the speech mechanism, an curacy of articulation but also changes in voicing and de-
assessment of language function, and an analysis of cogni- livery that include rate and inflection of speech.34,38,49,82
tive factors affecting communication, the comprehensive- There is often an accompanying lack of facial affect.
ness of the evaluation and the focus of treatment or man- Sometimes these patients are somewhat hypoaroused and
agement varies.48,57 Rehabilitation services that facilitate lethargic.32 These characteristics may influence the qual-
the process of integration into the community and as- ity of communication almost as much as the motor speech
sumption of vocational/avocational endeavors are limited. disorder.33,38
While speech-language pathologists are focusing on “life There are many opportunities for collaboration be-
participation” activities for individuals with aphasia,16 al- tween occupational therapy and speech-language pathol-
most no attention is given to the process of integration for ogy with patients who have right brain injured unilateral
those with other communication disorders. upper motor neuron dysarthria.42 Individuals with this
dysarthria, though fairly intelligible, are often unaware of
THE MANAGEMENT OF COMMUNICATION when they are not being understood.33,38 In partnership
DISORDERS with the speech-language pathologist, the occupational
therapist may provide feedback to patients and increase
Major Dysarthrias Associated with Stroke their awareness of the deviations in their speech output.42
Normal speech production requires the exquisite coordi- Because many right brain injured patients are concrete in
nation of a large number of muscle groups, which control their interpretation of what is said to them, it is helpful for
respiration, phonation (voice production), resonation, the feedback to be specific and concrete. For example, say,
and articulation.28,31 The complexity of the control is due “I had difficulty understanding you because your voice
to established movement patterns that are unique to each was not loud enough” rather than simply requesting that
language and are automatic. For example, the respiratory the patient repeat what was said. For the individual with a
cycle is modified to have an increased duration during right gaze preference and left neglect, reinforcement by
speech, and the vocal folds vibrate more quickly at the all members of the team to look at the speaker when com-
end of questions to raise the pitch.11 Conversational ar- municating may increase communication effectiveness.
ticulation involves approximately 500 different oral Given the change in awareness and reasoning, collabora-
shapes per minute, and even a minor deviation in control tive treatment and reinforcement of goals increases the
patterns can influence the precision of speech produc- transfer of learning.33,38 See Chapter 19.
tion.31 Remarkably, the average speaker performs these Following a left stroke of the unilateral upper motor
actions automatically with no awareness or conscious neuron pathways, aphasia (language disorder) may ac-
planning.28 Any disturbance in the control of movements company the dysarthria.24,33 Without aphasia, the stroke
538 Stroke Rehabilitation

survivor with left unilateral upper motor neuron dysar- extra time for the speech process; (2) validate (confirm)
thria may function fully in life participation, even with that the message was understood by repeating back what
persisting motor speech deficits, as long as speech is in- was said and thus give the patients a sense of control by
telligible to the listener. Diagnosis of a concurrent lan- confirming that they have been understood; (3) recognize
guage difficulty is sometimes obscured by the dysarthria that increasing spasticity in one part of the body (e.g., the
and requires a comprehensive examination to identify upper extremity) may result in increased stiffness in the
subtle language changes.33,38 These language disorders speech mechanism, and therefore do not expect speech
are discussed later in this chapter. On the other hand, during activities that increase spasticity; and (4) remind
individuals with left hemisphere unilateral upper motor patients that the emotional lability is not within their
neuron dysarthria may appear to have a language disor- control. Sometimes therapists have provided a notice to
der when none is present.33 They may speak less fre- listeners that the patient’s crying does not necessarily
quently, use shorter phrases, simplify sentences, but in mean that he or she is sad, but that crying “just happens.”
fact not show any language dysfunction when formally Occupational therapists can assist the patient’s recovery of
assessed. These reductions in speech may simply reflect a Communication effectiveness by addressing team goals
motor speech disability rather than an underlying lan- that target the previous behaviors.42
guage problem.
Anarthria and Locked-In Syndrome (Brainstem
Spastic Dysarthria (Bilateral Upper Motor Neuron and Bilateral Midbrain Lesions)
Dysarthria) In order to provide appropriate care to individuals with-
The impact of bilateral upper motor lesion strokes on out speech, differential diagnosis must distinguish among
communication is substantial and is not simply the addi- anarthria, locked-in syndrome, and mutism.26,28,33,85 Anar-
tion of the two upper motor neuron dysarthrias, but is a thria is the absence of speech due to severe motor speech
different speech disorder. Historically, this dysarthria is impairment.33 Duffy reported that this condition is differ-
associated with the term “pseudobulbar palsy.”28,38 Accord- ent from mutism, which is due to a cognitive dysfunction
ing to Darley and associates,28 there are four muscular limiting the production of speech.33 When the profound
abnormalities that affect function in pseudobulbar palsy: impairment of speech is accompanied by immobility of
spasticity,* weakness, limited range of movement, and the body except for vertical eye movements, the disorder
slowness of movement. is called locked-in syndrome. Duffy described locked-in
The patient with spastic dysarthria has a strained- syndrome as a “special and dramatic manifestation of an-
strangulated hoarse (rough) low-pitched voice.28,33,38,82 arthria.”33 Intact language generation is often demon-
He speaks slowly, with effort and extreme hypernasality strated once a communicative system is established. In his
and is monotonal in his delivery. Due to the absence of personal account, The Diving Bell and the Butterfly, Jean-
the sensitive coordination of timing of the onset of voic- Dominique Bauby7 described blinking to indicate letters
ing, often his articulation of /p/ is said as a /b/, and simi- of the alphabet as the communication partner spoke the
lar confusions exist with /t - d/ and /k - g/.28 These de- letters. When working with individuals without speech,
viations in speech affect intelligibility and efficiency of the speech-language pathologist must determine the pres-
communication. Individuals with spastic dysarthria tend ence or absence of cognitive/linguistic function.
to speak rarely, not because they are necessarily aphasic, Medical treatment for locked-in syndrome has changed
but because of the effort that is required to speak. In ad- significantly over time.85 Individuals with this rare condi-
dition, these patients manifest a flat affect but also display tion have a better long-term survival rate than in the
emotional outbursts in the form of emotional lability.33,38 past.33 Those who survive over many months require in-
Speaking of even mildly emotional topics may trigger tensive rehabilitation to maximize their function. Estab-
laughing or crying in inappropriate contexts. This lability lishing a basic communication system of “yes” and “no” is
is known as “pseudobulbar affect.”28,38 The location of the the first step and may be based on an eye blink system.65
brain damage determines whether language function is Once this is established, one can move on to more elabo-
spared or affected. Because of bilateral damage, these rate communication systems including letter boards and
patients may have considerable upper extremity limita- electronic systems. The painstaking effort described by
tions affecting their ability to gesture, write, and use a Bauby is greatly reduced when more sophisticated aug-
computer.28 mentative and alternative communicative assistive devices
There are some general guidelines to follow when are used. This technology is continuing to be developed
working with individuals with spastic dysarthria:28,33,72 and a brain computer interface may be available that al-
(1) acknowledge the effort needed to speak by providing lows individuals without movement to communicate by
using electroencephalography activity to control a cursor
*Note: Medical treatments such as baclofen or surgical treatments such on a computer screen.109 Augmentative communication is
as dorsal rhizotomy that reduce general body spasticity are known to an area where occupational therapists and speech-
improve motor speech production.75 language pathologists work closely together. The most
 Chapter 20 • Managing Speech and Language Deficits after Stroke 539

important message for treatment of individuals with others are.28,33 The most common mixed motor speech
locked-in syndrome is that they may be intact cognitively disorder is a combination of an upper motor neuron dys-
and linguistically. Therefore, it is important that staff use arthria affecting the right side of the oral musculature and
natural adult speech and language because patients react apraxia of speech.33 This combination occurs frequently
to style and tone of communication.35 In addition, to en- in left middle cerebral artery strokes, and its symptoms
sure that the patient is included in all decisions about care, are addressed in the discussion of aphasia. Moreover,
staff should address the patient and the caregivers about single brainstem strokes might produce a mixed flaccid,
the particulars of the rehabilitation plans.42 spastic, and cerebellar dysarthria. This combination oc-
Some patients who are initially without speech prog- curs because of the closeness of the upper and lower
ress to the point where they have some vocalization and motor neuron brain structures and the proximity to cer-
some mobility of the upper or lower extremities.65 Small ebellar control circuits.33
movements can be used to activate a switch for alternative
communication. The emerging voice production is effort- LANGUAGE DISORDERS ASSOCIATED
ful, strained, and similar to the voice heard in individuals WITH STROKE
with spastic dysarthria.28,33 Even when the vocalization is Occupational therapists often question the speech-
limited to one sound, the individual can use the sound to language pathologist about the complex and fascinating
call out to the caregiver. More articulate speech may not syndromes of acquired language disorders known as apha-
be possible, but some develop a small repertoire of words sia. Patients with aphasia say unusual and, at times, bizarre
that are intelligible to familiar listeners. Communication things. For example, a patient may make up a meaningless
can be enhanced by using the same strategies as identified word (neologism) and use it as if it is a real word or take a
for spastic dysarthria. The key points to remember are real word and use it inappropriately (paraphasia).43 Symp-
(1) give the patient lots of time to respond, (2) collaborate toms such as a verbal stereotypy (saying a recurrent utter-
with the speech-language pathologist in designing low- ance such as “keep the key” or “ho doe ho doe ho doe”
tech tools that are visually and spatially accessible to the with appropriate melody and intonation) are remarkable
patient who has limitations in upper extremity functions, phenomena.35,43 A patient with aphasia reports that he
(3) indicate that you have understood the message by “knows exactly what I want to say, but the words don’t
repeating it, and (4) validate the patient’s cognitive com- come out.” The person with aphasia searches for the
petence by treating the individual in an appropriately number word to indicate the number of children he has
mature manner.92 and is forced to start with “one...two” and say the whole
series until he arrives at the number word that he is trying
Ataxic Dysarthria (Cerebellar Lesions) to say.35,43
Most cases of ataxic dysarthria are not the result of stroke. The unevenness of communication issues among the
Nevertheless, vascular lesions primarily in the posterior various language modalities is confusing to the profes-
inferior cerebellar artery and anterior inferior cerebellar sional unfamiliar with aphasia.35,43 For example, a pa-
artery may result in ataxic dysarthria.28,33 Furthermore, tient may write normally but be unable to read what
ataxic dysarthria in stroke is rare. The primary speech he or she has written, or a patient may not understand
symptoms are slow rate, abnormal prosody, and intermit- a word or sentence when spoken, but immediately “gets
tently imprecise articulation.14,28,33 Typically the patient’s it” when it is written down.35,43 These unexpected com-
cognition is intact, but speech, though intelligible, may binations of language strengths and weaknesses pose
sound quite bizarre and unnatural.14,28,33,38 challenges to the rehabilitation professional. Another
Rehabilitation of these communicative disorders is issue surrounds the term “expressive” aphasia, which
dependent on the patient’s age and vocational and avoca- leads one to believe that there is no “receptive” compo-
tional needs. The person may be more concerned with nent when in fact for most patients, the difficulty
physical dysfunction than the speech changes, as the understanding language is the most functionally limit-
limb ataxia affects the ability to write, type, or use a ing component of the syndrome.43 Reduced auditory
computer mouse. These graphomotor disorders may af- comprehension keeps persons with aphasia from re-
fect more of the individual’s ability to communicate and turning to their work environment, participating com-
require more intervention than the motor speech disor- fortably in some social events, and enjoying language-
ders. See Chapter 10. Team treatment with this type of based activities such as television, movies, and reading.55
dysarthria should recognize that these individuals prob- The communication partner is prone to overestimate
ably have intact cognitive and language skills. the patient’s comprehension of spoken language be-
cause the patient often appears to understand.37 This
Mixed (Any Combination of the Previous Conditions) misconception is a reflection of the aphasic person’s
Multiple strokes can affect various components of the mo- socially appropriate affect and response to the environ-
tor speech system and result in mixed dysarthria. Certain ment and can lead to misunderstandings and miscom-
combinations of dysarthria are more likely to occur than munication.37
540 Stroke Rehabilitation

Historically, aphasiologists have categorized aphasias precentral gyrus, clarifying the connection of this syndrome
differently depending on their particular bias.35,43 In the with the reductions in motor control in the right upper ex-
last half of the twentieth century, the most common cat- tremity.43,61,62,80,105 In the acute stage, these patients may be
egorization system was based on a classical typology mute.43 Their speech production may evolve over the next
which used the fluency of speech production and spoken few weeks to a few automatic expressions and perhaps a
language comprehension attributes to group the types of spoken “Yes.”43 These patients are typically alert, aware of
language issues.43 These classical groups are Broca’s, their surroundings, and frustrated by the absence of
Transcortical Motor, Wernicke’s, Conduction, Transcor- speech.13,61 Their preserved affect can mislead the untrained
tical Sensory, and Anomic aphasias. The most severe form observer to overestimate the language competency of the
is global aphasia and results from large or multiple lesions patient.100 The five main features of the evolving pattern are
of the left hemisphere. Most modern aphasiologists sim- awkward labored articulation, difficulty initiating speech,
plify this classification into two general forms: nonfluent reduced utterance length, telegraphic speech, and reduction
and fluent aphasia.43 It is understood that pure forms of in melodic contours.13,43 The following is an example of a
any of these types are relatively rare (Table 20-1). patient with Broca’s aphasia describing the “Cookie Theft
Picture.”43 See Fig 20-1.
Broca’s Aphasia “Boy . . . Cuh . . . Cuh . . . Cookie . . . girl . . . mama . . .
Broca’s aphasia, which many refer to as “expressive” aphasia, kay . . . water . . . sinking . . . ice . . . ay . . . ch . . . ch . . .
is regularly associated with a middle cerebral artery stroke no . . . water . . . sinking . . . ee . . . why?” Given the limited
affecting the third frontal convolution of the frontal lobe flow of speech, one would think that little is being commu-
(classical Broca’s area, Brodmann’s areas 44 and 47)1,25,26,40 nicated. However, the words are substantive and appropri-
and extending into the white matter, the internal capsule. ate, so that giving the patient with Broca’s aphasia time and
This lesion is anterior to the inferior portion of the using context to anticipate content allows the individual to

Table 20-1
General Suggestions for Improving Post stroke Communication
GUIDELINES FOR ENHANCEMENT OF COMMUNICATION

To enhance expression ■ Use phrase “I know you know___” to show that you understand that the problem is one
of expression, not knowledge.
■ Give person to time to talk.
■ Tolerate patient’s silence, but encourage person to take part in the conversation.
■ Talk about personally relevant topics and shared experiences.
■ Engage patient’s family/friends in providing topics.
■ Talk about items in the immediate environment.
■ Accept and encourage nonverbal expression (gestures, facial expression).
■ Keep paper and pencil handy.
■ Provide choices when necessary.
■ Acknowledge breakdowns in communication and encourage patient to repair.
To enhance comprehension ■ Identify hearing loss.
■ Slow the rate of your speech, but maintain normal intonation.
■ Reduce distractions (noise free, visually simple environment).
■ Use face-to-face communication.
■ Use short phrases interspersed with appropriate pauses.
■ Use simple direct sentences.
■ Signal topic shifts and provide a context for the next topic, e.g., “On another topic . . . .”
■ Use visual props when needed.100
■ Write down important words or instructions.
■ Identify communication breakdowns and use repair strategies (rephrase, use simpler
word, slow rate of speech, etc.).
■ Emphasize important words.
■ Simplify written instructions for homework.
■ Have only one person (or few persons) talk at a time .

Adapted from Hedge,51 and Simmons-Mackie,103

 Chapter 20 • Managing Speech and Language Deficits after Stroke 541

Figure 20-1 The Cookie Theft picture. (From Goodglass H, Kaplan E, Barresi B: The assess-
ment of aphasia and related disorders, ed 3, Philadelphia, 2001, Lea & Febiger.)

be successful in communicating substance.35,42,61,95 In addi- verify that the patient with Broca’s aphasia comprehends
tion, using visual stimuli, key words, or simple pictures to communication to him, no matter how intact the social
supplement context and accepting gestures and drawing behavior appears.
makes it possible for the patient with severe Broca’s aphasia Reading and writing are also impaired in patients with
to communicate not only thoughts and feelings but also Broca’s aphasia.61 Patients with severe Broca’s aphasia
specific information.18,71,99,101 read the content words (nouns and verbs) and guess at the
The comprehension of spoken language in Broca’s or overall meaning of the sentences.43 Their ability to read
nonfluent aphasia is better than the production of speech, improves over time, but the elements of asyntactic com-
but it is far from perfect, at least in the early stages of the prehension limit reading of most adult level reading mate-
condition.43,61 Comprehension tends to improve faster in rial. Writing is impaired not only by the motor compo-
these types of aphasia than in other forms.61,62 Probably nent, since the patient may have limited use of the
the major error made in working with patients with dominant right hand, but also because of the language
Broca’s aphasia is to overestimate the patient’s adequacy of component.61 Spelling and letter formation may be ex-
comprehending spoken language.51 Some of the signs of tremely difficult. The use of computer-assisted programs
overestimation are “the patient fails to carry out the ac- may be helpful but are sometimes difficult. Some patients
tivities that I have told him, and he understands every- improve sufficiently to use computer-based typing, text
thing I say” or “the patient comes at the wrong time . . . too messaging and e-mailing to communicate with friends.60
early or too late . . .” Many patients with Broca’s aphasia Recovery with Broca’s aphasia has a longer course than
do not process spoken number words. Providing a written with other types of aphasia.6 In the authors’ clinical expe-
appointment slip helps ensure that the patient with apha- rience, persons with Broca’s aphasia can continue to im-
sia understands the scheduled appointment time. Com- prove their communication skills long after the acute
munication can be further enhanced by using simple, stages. This improvement corresponds with an ameliora-
clear direct adult sentences.51 Breakdowns of comprehen- tion of the motor component associated with Broca’s
sion occur with complex grammar (tense, number, nega- aphasia (i.e., apraxia of speech) and a gradual improve-
tion, comparison, words relating to space) that may be ment in speech comprehension.93 If in the early stages,
difficult for the patient.30 One needs to provide process- the aphasia is mild, and it may improve to a relatively mild
ing time for comprehension of more complex lan- anomic aphasia or resolve almost completely.62,95
guage,51,61,101 which can be done by inserting pauses be- In the authors’ experience, occupational therapists often
tween phrases or thought groups. It is a good idea to address functional language-based daily tasks. For example,
542 Stroke Rehabilitation

following written instructions on medication, reading writ- the occupational therapist might choose to do so with
ten instructions for upper extremity exercises, or following the patient’s permission.
written recipes in the kitchen all have elements that can be Prognosis for individuals with apraxia of speech ranges
most impaired in nonfluent aphasia. Any activity involving depending on the severity of the apraxia and the underly-
numbers (e.g., check writing and reconciliation of a bank ing linguistic disorders.38 However, patients with good
account) may be impossible for the person with Broca’s comprehension tend to improve over a longer period and
aphasia to complete. It is important to set realistic therapy clear to a milder version of apraxia of speech.38,107 Slow
goals with respect to these tasks. Whenever possible, col- speech, intermittent articulation errors, and reduced pro-
laboration with the speech-language pathologist may be sodic variation may persist in the chronic state.38,107 Nev-
helpful when planning compensatory and supportive tech- ertheless, their communication is effective. The authors
niques to facilitate these language-based activities. find that these individuals can become the advocates for
public awareness of aphasia, because they are intensely
Apraxia of Speech focused on the alteration of their speech and its impact on
Apraxia, a common speech disorder resulting from a their lives. See Table 20-2.
middle cerebral artery stroke, is controversial,2 because
aphasiologists have described it differently according to Transcortical Motor Aphasia
different theoretical biases. Duffy33 listed 25 different Transcortical motor aphasia is a rare type of aphasia is due
terms for apraxia of speech that researchers have used to to a small subcortical lesion superior to Broca’s area, or to
define it. Many speech-language pathologists, including a lesion outside of the anterior language areas of the left
Duffy, view it as a separate specific type of motor speech hemisphere.26,40 Because of the location of the lesion in the
disorder independent of aphasia.33 However, in the au- frontal lobe, transcortical motor aphasia includes both lan-
thors’ experience, this motor disorder that is not dysar- guage and cognitive components. The person with trans-
thria usually occurs with a nonfluent Broca’s aphasia or cortical motor aphasia has difficulty spontaneously initiat-
mixed dysarthria. Speech production is effortful, slow, and ing speech but repeats even long sentences effortlessly and
dysrhythmic, resulting in impaired prosodic variation accurately.43,62 Consequently, the listener is required to
(i.e., melody of speech).28,33,38 The cardinal feature articu- initiate the topic and to structure the question in order to
latory effort is visible and is apparent groping for the ar- facilitate a verbal response.2,69,92 For example, when asked
ticulatory positioning and sequencing.33,38 These patients an open-ended question such as “what did you do yesterday?”
are generally aware and frustrated by their speech disor- the patient is known to say, “ I . . . I . . . I can’t . . . I can’t . . .
der and say things such as “I know what I want to say but yesterday . . . I did many things.” However, when asked to
it will not come out.”13,28,33 In addition, these individuals describe a picture, the output is in the form of a simple
have great difficulty imitating words and phrases.28,33,38 declarative sentence that is usually grammatically correct,
In general, these individuals are highly motivated to appropriate, but lacking in elaboration.
improve their speech and are unusually focused on their The main communication problem in transcortical
speech production.28,33,38 In the authors’ experience, their motor aphasia is maintaining the flow of fluent speech,
concentration on the speech component can be so strong which is due to an underlying difficulty organizing the
that it supersedes their interest in other therapies and content of communication.89 This form of aphasia dis-
overrides efforts to ameliorate other linguistic distur- plays cognitive failures that result in limited and disor-
bances. Although it would seem reasonable to introduce ganized output both in speech and writing.92 However,
supplementary or communicative alternatives (i.e., a com- comprehension of spoken language or even syntactically
munication book or a computerized communication de- complex sentences are often well-preserved.43 Fre-
vice), the authors find that these patients initially reject quently, reading comprehension and oral reading are
these devices. Interestingly, younger patients who are fa- also excellent.59
miliar with text messages and e-mail are more receptive to The patient with transcortical motor aphasia may be
facilitating their communication through these avenues. indifferent to the reduction in his communication.13 In
It is helpful for the occupational therapist to remem- the authors’ experience, the patient’s apathy elicits frustra-
ber that these patients may have a subtle language com- tion in the staff working with him or her because they may
prehension disorder despite their appearing to be com- overestimate his or her ability to perform. The staff may
pletely cognitively intact.28,33,38 Their struggle may be expect the patient to initiate the use of a memory book, to
alleviated by providing additional time to communicate, structure a meaningful activity, or to set priorities for
giving verbal choices, using supplementary written ma- daily activities, none of which this patient can do without
terial, and having an attitude of calmness around their prompting. The authors have found that the patient re-
communication.33,38 Typically, the listener is counseled quires structure and repetition to perform and constant
not to provide a word when it is known what the indi- prompting to initiate and follow through with tasks. The
vidual is attempting to say, but in this case, for efficiency, patient’s lack of appreciation of the goals of therapy and
 Chapter 20 • Managing Speech and Language Deficits after Stroke 543

Table 20-2
Suggestions for Improving Communication: Broca’s Aphasia and Apraxia
BROCA’S APHASIA: SPEECH GUIDELINES FOR COMMUNICATION
AND LANGUAGE SYMPTOMS* ENHANCEMENT†

May be mute at onset Give patient plenty of time to speak

Impaired “flow” of speech Encourage participation in conversation
Halting and hesitant speech Encourage patient to use alternate means of
Impaired prosody and intonation communication (gesture, drawing)
Awkward effortful articulation Use visual supports (key words, word books)
Short simple utterances Ask the person to tell you if he or she wants you to fill in
Telegraphic style the missing words
Intact content with poor sentence structure If you do not understand what the person is saying, let
and grammar him or her know
Self-correction of errors Pay close attention to body language and facial expression
Aware of errors and frustrated Try not to over estimate comprehension
Impaired speech repetition Write down numbers (time, date, address, etc.)
Impaired comprehension Avoid using semantically reversible sentences like “the
Dyslexia (reading problems) girl was hit by the boy”
Dysgraphia (writing problems) Simplify grammatical structures when you do ADL tasks,
Dyscalculia (calculation problems) (e.g., before/after, negatives, comparatives)
Ask SLP regarding level of reading comprehension
before giving written instructions
Highlight key words
Pair written words with auditory stimuli (electronic
books)
Enlarge print as necessary
Provide model for written material

APRAXIA OF SPEECH: SPEECH GUIDELINES FOR COMMUNICATION

AND LANGUAGE SYMPTOMS‡ ENHANCEMENT ‡

May be mute at onset Strategies for enhanced expression are the same as the
Speech symptoms are often similar to the previous ones previously listed
symptoms listed with the addition of: For the patient with severe apraxia of speech augmenta-
Sequential speech movements are difficult tive and alternative devices may be considered
(diadochokinesis) May not require the modifications for comprehension
Sound clusters simplified (“splash” becomes indicated previously
“ . . . plash”)
Errors increase as a function of increased word length
Heightened awareness of speech errors
High level of frustrations
Fairly preserved speech comprehension

* Adapted from Goodglass and associates43 and Hedge.51

† Adapted from Hedge51 and Simmons-Mackie.103
‡ Adapted from Duffy.33
SLP, Speech-language therapist.

inability to connect the procedures to the goals impedes vocational activities. These deficits most likely reflect
his ability to respond to treatment.2,42,69 dysexecutive function that may be more debilitating than
If the transcortical motor aphasia is mild in the early the language disorder.9
stages, it may resolve to an anomic variety.43,92 Neverthe- The occupational therapist can facilitate communication
less, the authors have found that persistence in the reduc- with the patient who has transcortical motor aphasia by
tion of speech initiation and organization of discourse structuring the communication environment and providing
may prevent the patient from resuming normal social and many cues for communication. Despite the preservation of
544 Stroke Rehabilitation

some communication modalities, the individual is depen- awareness of the erroneousness of output).43 Although
dent on the listener to initiate, maintain, and repair conver- speech is produced with normal fluency and prosody, the
sation breakdowns.69 In addition, the patient will need content is severely limited.43 Speech contains a mixture of
prompting to use his or her calendar, notebook, and other real words and neologisms (made up new words) and usu-
augmentative systems. See Table 20-3. ally is empty of meaning.13,45 The severe reduction in
nouns and verbs and vagueness of content is reflected in
Fluent Aphasias (Wernicke’s, Conduction, the following example. When shown the Cookie Theft
Transcortical Sensory, and Anomic) picture43 (Fig. 20-1), a patient said “had that before . . .
Fluent syndromes are relatively common among elderly chories . . . this guy is a messo . . . she is okay. He has a
poststroke patients. These individuals may not be referred mess on . . . all over here. She is just stupid. Oh, what is
for occupational therapy if they do not present with con- that? That’s just . . . those are nice, pretty . . . and that’s a
current difficulties in daily living. However, some of these mess and then goots (cups). He’s pretty stupid. She is okay.
patients have a right visual field cut, and they may eventu- She’s cute. This is inside . . . outside.” These patients have
ally find their way to occupational therapy for evaluation been incorrectly labeled confused or demented, or diag-
and treatment. The major language characteristics of flu- nosed with having psychiatric disorders when in fact the
ent aphasia are the ease of speech production and the syndrome of aphasia causes the bizarre output.74
normal utterance length.43 Various types and severities of In the early stages, a patient with Wernicke’s aphasia
speech characteristics are found among the fluent syn- may be unaware of his or her language disorder, deny that
dromes. In addition, a variety of speech comprehension, he or she has had a stroke, and confabulate the reason for
reading, and writing deficits may occur.43 the hospitalization.13,43,45 Since a patient is unable to un-
derstand what is being asked of him or her and is unaware
Wernicke’s Aphasia of his or her deficits, initial language testing may make
The diagnosis of Wernicke’s aphasia rests on a triad of little or no sense to him or her.13,29,45 The patient’s will-
characteristics, including fluent paraphasic speech, re- ingness to participate in therapy increases as spontaneous
duced speech comprehension, and anosognosia (lack of recovery of language occurs and he or her develops more
insight into the nature of his or her communication prob-
lem.29,45 He or she begins to have a nagging awareness of
Table 20-3 something amiss in the process of communication, but he
or she may not recognize that the communicative break-
Suggestions for Improving Communication: down is due to aphasia.
Transcortical Motor Aphasia People with Wernicke’s aphasia are said to have “recep-
tive aphasia.” This term suggests that their communica-
TRANSCORTICAL
MOTOR APHASIA: GUIDELINES FOR tion difficulty is simply a failure to understand spoken
SPEECH AND LANGUAGE COMMUNICATION language.45 However, from the previous description,
SYMPTOMS* ENHANCEMENT†
aphasia obviously has both receptive and expressive com-
ponents. Furthermore, comprehension of spoken lan-
May be mute at onset Prompting required for
Difficulty initiating speech speech engagement and guage is uneven and at times unexpected.43,45,99 For ex-
Flat affect initiation: ample, the authors have found the simple instruction
Sentence repetition is Prompt the patient to use “pick up the spoon and put it in the bowl” is usually more
fluent and effortless a notebook for daily difficult than the whole body command “stand up and
Sentence length is reduced activities turn around.” If the person catches the right word or in-
Comprehension of spoken Use written cues to terprets the context sufficiently, responses may be surpris-
and written language is prompt communication ingly appropriate and may obscure the severity of the
generally spared (i.e., when asking language comprehension problem.43,45,74
Impaired executive func- patients if they did their Comprehension can be facilitated by discussing topics of
tion (i.e., organization of exercises, write down the
personal relevance, giving the patient time to process the
speech output, narrative anticipated response)
information, signaling changes in topic, stating the same
skills, all varieties of
discourse, engagement idea in different words, and providing visual cues.74 The
evident both in spoken staff also needs to remember the patient’s difficulty in de-
and written output) tecting a communication breakdown, so it is up to the com-
municative partner to fill in and assist in any way possible
with the needed repair.45 Comprehension of written lan-
*Adapted from Goodglass and associates43 and Hedge.51
†Adapted from Hedge51 and Simmons Mackie.103 guage is impaired so that use of written cues, written home-
work, and schedules may not be helpful for these patients,
particularly in the early stages.74 Most of these patients will
 Chapter 20 • Managing Speech and Language Deficits after Stroke 545

have no right upper extremity weakness and that writing These word finding problems and anomia can range from
may be fluently executed. However, the content of writing mild to severe.13,102,103 Persons with conduction aphasia
samples usually mirrors speech production and contains also have difficulty reading aloud and make frequent
neologisms, meaningless content, and inappropriately sound errors.13 This function improves over time but
spelled words.43,74 limits the use of written scripts as a treatment procedure.
Depending on their social behavior and their commu- Writing varies in effectiveness, but graphic production
nication partners, these individuals can live a rich life after typically contains some errors in grammar, spelling, and
stroke.74 In time, many patients with Wernicke’s aphasia word retrieval.13 Patients with conduction aphasia are
successfully use a “communication book” that contains aware of their errors and may be highly frustrated by their
nouns of personal relevance.106 Some of these patients are inability to properly string together the sequence of
remarkably independent despite the global severity of sounds required to say polysyllabic words such as “statisti-
their aphasia.74 See Table 20-4. cal analysis.”43 This syndrome is fairly rare and has a rela-
tively good prognosis, evolving in time to a mild anomic
Conduction Aphasia aphasia.13,102,103
The neuroanatomical correlate for conduction aphasia is It is the authors’ experience that when working with
somewhat controversial, but most agree that it is usually this group, professionals need to support the patient’s at-
due to a small lesion in the supramarginal gyrus.26 tempts to communicate by being an active communica-
The outstanding feature of conduction aphasia is rela- tion partner and accepting imprecise productions. The
tively fluent spontaneous speech with disproportionately production of complex scientific terms, medical terminol-
poor sentence repetition.13,43 Spontaneous speech is char- ogy, and the names of pharmaceuticals will always be dif-
acterized by “abundant literal paraphasias”13 (sound sub- ficult for the patient with conduction aphasia. Inaccurate
stitutions), especially in the early stages. The progressive production of words, if the words resemble the target suf-
approximation or targeting of sound sequences is com- ficiently, may not limit the transfer of ideas. The therapist
mon. For example, to say the word “bench,” the individual should avoid requesting verbatim repetition of instruc-
may make the following attempts to arrive at the required tions including repetition of numbers (telephone num-
word “chench . . . nech . . . pench . . . spench . . . bench.” bers, dates, etc.) and recall of specific complicated words.

Table 20-4
Suggestions for Improving Communication: Wernicke’s Aphasia
WERNICKE’S APHASIA: SPEECH AND LANGUAGE GUIDELINES FOR COMMUNICATION
SYMPTOMS* ENHANCEMENT†

Speech initiation is easy (hyperfluent) Stop strategy: Use gestures to cue a patient to stop the flow
Fluent uninterrupted strings of words of speech
Well-articulated Refocus patient to change topics
Neologisms and verbal paraphasia Provide written nouns (key words or pictures to convey
Jargon information)
Grammatically coherent: small words fall into place Allow circumlocution
automatically Simplify written and spoken material
Inability to repeat words Provide meaningful contexts for tasks—personal relevance is
Intact prosody and intonation helpful
Little awareness of errors Speak slowly clearly and at normal loudness levels
Poor speech comprehension Face the person when you talk to them
Unaware of comprehension limitation Give the person time to understand
Dyslexia and dysgraphia Write down key words to change topics and support
comprehension
Use common words and simple direct sentence structures
Say the same thing differently
Rely on the speech-language pathology evaluation to guide
choice of reading material level
Anticipate writing difficulty

*Adapted from Goodglass and associates43 and Hedge.51

†Adapted from Marshall.74
546 Stroke Rehabilitation

Communication can also be improved by realizing that contrast, on confrontation naming tasks, their speech is
the person probably understands even complex language, “empty” and they use frequent circumlocutions. Their
reads sophisticated material silently, and responds well to naming difficulty poses a significant functional limita-
cues. In addition, the person can learn new material and tion in situations where clear, concise verbal function is
develop new skills.102,103 See Table 20-5. required.13
In anomic aphasia, comprehension of spoken and writ-
Anomic Aphasia ten material is marred by subtle deficits.13 For example,
Since all syndromes of fluent aphasia are characterized by the patient may have no difficulty following conversation
a reduction in the retrieval of nouns, the use of the term when talking about pictures in a photograph album or
“anomic aphasia” becomes arbitrary, as it is both a symp- listening to a paragraph about current events where con-
tom and diagnostic category.13,41 It is also well-accepted text supports comprehension.43 On the other hand, the
that anomic aphasia is regularly the end point of other authors have found that they may do rather poorly on
aphasias, and because of this feature, there is no one neu- specific nonredundant content (e.g., the Revised Token
roanatomical site associated with the classification of Test instructions, “Point to the green square and the
anomic aphasia.13 white circle.”)78
According to Goodglass, Kaplan, and Barresi,43 the The occupational therapist needs to be aware that it is
“major feature of anomic aphasia is the prominence of easy to miss the language deficits in individuals with
word-finding difficulty in the context of fluent, gram- anomic aphasia and needs to look for difficulty with con-
matically well-formed speech.”43 There are few parapha- frontation naming. For example, these patients have dif-
sias, and comprehension is “relatively intact.”43 Patients ficulty both saying and understanding unfamiliar names
with anomic aphasia may be underidentified because (staff members, pharmaceuticals, locations, and names
their speech is fluent and their content is substantive. In of medical conditions), putting them at risk for making
errors.42 The listener might be tempted to overestimate
the communicative skills of the person with anomic apha-
sia and to expect the individual to return to work. There-
Table 20-5 fore, recognizing the disorder and developing strategies
that enhance the person’s ability to perform on the job are
Suggestions for Improving Communication: essential.42 The authors find that collaboration with the
Conduction Aphasia vocational rehabilitation counselor facilitates reintegra-
CONDUCTION APHASIA: GUIDELINES FOR tion into the individual’s work life (Table 20-6).
SPEECH AND LANGUAGE COMMUNICATION
SYMPTOMS* ENHANCEMENT Global Aphasia
Global aphasia is common, especially in the acute phase
Fluent conversational Refrain from expecting
after a large left middle cerebral artery stroke.26,40 Some-
speech, but unusually verbatim repetition of
poor speech repetition numbers, words, times this aphasia is also found when a patient has two or
Abundant literal parapha- sentences more smaller left hemisphere strokes.26 The main feature
sia (sound substitutions) Allow circumlocution is that all language modalities are severely impaired.18 It is
Some word substitutions Encourage alternate important to remember that “global” when describing
Polysyllabic words are methods of supplying aphasia does not mean “total.”18,19 Speech may be limited
more difficult than target words to automaticisms (“yes,” social greetings, and curse words)
shorter words Give plenty of time to and recurrent utterances (e.g., “ah-dig-ah-dig-ah-dig” or
Naming is variable (from express self “television . . . television . . . television”). Speech repeti-
poor to good) Encourage patient to use tion can be limited to serial speech (counting, days of the
Preserved speech shorter simpler words or
week, and overlearned material such as prayers and lyrics
comprehension to use pantomime
of familiar songs).43 In the early stages, patients with global
Oral reading is poor; Encourage patient to use
characterized by words own cueing strategies aphasia have only rudimentary comprehension of spoken
containing phonemic Refrain from activities language. The patient appears to rely almost entirely on
paraphasia (literal) requiring reading aloud, facial expression, vocal intonation, and contextual cues to
Silent reading e.g., scripts understand others. Speech comprehension almost always
comprehension is good Rely on the speech- improves to some extent; some patients can be reclassified
Writing can be language pathology as a milder aphasia, such as Broca’s or conduction apha-
comparable to speech evaluation to guide sia.18 However, speech comprehension remains impaired
writing activities in many cases, and small gains in language comprehension
*Adapted from Goodglass and associates43 and Hedge.51 do not always change the aphasia diagnosis.18 In the begin-
ning, reading may be restricted to familiar nouns and
 Chapter 20 • Managing Speech and Language Deficits after Stroke 547

Table 20-6 Topic shifting is enhanced if the communicative partner

Suggestions for Improving Communication: uses visual prompting such as providing key word choices
Anomic Aphasia from which a patient can choose the word(s). The writ-
ing of key words to support communication is essential
ANOMIC APHASIA: GUIDELINES FOR in enabling the patient to participate actively in conver-
SPEECH AND LANGUAGE COMMUNICATION sation.18,58 In a therapeutic session, it is helpful to limit
SYMPTOMS* ENHANCEMENT
the goals and procedures to one or two, provide breaks,
Object naming is Allow patient to refer to extra time, and a set routine to facilitate successful com-
disproportionally word lists to locate target munication in individuals who have global aphasia.18 See
impaired relative to word Table 20-7.
preserved speech fluency Encourage patient to
Word substitutions and describe target noun
COGNITIVE COMMUNICATION IMPAIRMENT
circumlocution are Allow circumlocution
common Refrain from confronta- Common etiologies of cognitive communicative impair-
Repetition is sometimes tion naming tasks ment are right hemisphere stroke and vascular dementia
quite preserved Ask patient if he or she
(formerly known as “multi-infarct dementia”).84 The uni-
Comprehension of spoken wants the listener to
fying factors for this disorder are reductions in attention,
and written material supply the word
relatively preserved but Consider use of word concentration, memory, and problem-solving. The im-
variable prediction software for pact of these factors ranges widely, and the resulting com-
Writing parallels speaking writing tasks munication disorder is complex.84
Refrain from
overestimating adequacy Right Brain
of comprehension Although most patients with a right brain stroke “do well
in straightforward conversation,”84 their communication
*Adapted from Goodglass and associates43 and Hedge.51 abilities are not “normal.” Some individuals with right
brain damage have speech and/or language problems and
an upper motor neuron dysarthria.84 This dysarthria is
characterized by slight imprecision of articulation, harsh
voice quality, and monotonal delivery.33 Rarely is overall
verbs, and writing is usually limited to random lines on a speech intelligibility affected.33 These patients often lack
page or single letters. Writing of one’s own name and appropriate and meaningful vocal inflection, and emo-
some numbers may improve in time. In the chronic phase, tional display is blunted.84 In addition, speech rate,
gestures and nonoral means of communication are often rhythm, and melody are sometimes abnormal.33 Some
effective compensations for the severe reduction in lan- right brain damaged (RBD) patients also have mild lan-
guage abilities.18 guage deficits and display difficulty on clinical tasks such
Patients with global aphasia may be withdrawn and as confrontational naming, divergent naming (category
unaware or they may be alert, oriented, and extremely naming), and word recall.84 These language problems
aware.18 The alert patient is usually described as having seem more related to cognitive deficits of attention and
better comprehension than is actually the case.101 Frus- memory than language dysfunction.84 Frequently, there is
tration tolerance is variable and may be related to the a reduction in comprehension of word meanings and dif-
patient’s self-awareness.18 ficulty processing metaphors that result in unusual and
To facilitate rehabilitation, the occupational therapist concrete decoding of language.83 On rare instances, RBD
should speak to the patient in direct, short instructions patients present aphasia; however, the aphasia is atypical
that pair simple and explicit language structures with (also known as “crossed aphasia”).26,83
modeling and manual cues18 (i.e., “right arm first” fol- Another component of right brain injury cognitive
lowed by a gentle touch on the right arm, rather than communicative impairment is an alteration in pragmatic
“don’t use your left arm for this”) The mere use of too communication and discourse.84 When describing an
many words may overwhelm the individual with global event, the patient with right brain communicative deficits
aphasia.18 Communication partners need to be aware will become tangential and overly detailed and show a
that gestures and facial expressions are cues that the pa- tendency toward hyperverbosity.87,88 Although relatively
tient with global aphasia uses to understand his or her infrequent, some patients use confabulation to make up
world.18 Therefore, clinicians need to pay attention to stories to help them explain events that they do not under-
facial expression and use a natural and appropriate vocal stand.83 The patient’s discourse is sometimes redundant
tone.18 The simple social language used to begin conver- and irrelevant.84 These issues can be seen in this descrip-
sations is necessary in establishing rapport and trust.18 tion of the “Cookie Theft” picture43 (see Fig. 20-1): “The
548 Stroke Rehabilitation

Table 20-7
Suggestions for Improving Communication: Global Aphasia
GLOBAL APHASIA: SPEECH AND LANGUAGE GUIDELINES FOR COMMUNICATION
CHARACTERISTICS* ENHANCEMENT†

All aspects of language are severely impaired For both expression and comprehension:
Speech limited to automaticisms (e.g., “yes” “OK” numbers Rely on visual (nonlanguage) cues
in series) Pictures
Unable to repeat Gestures
Unable to produce speech sounds voluntarily Facial expression, body language
Jargon may be present Signs and signal
Auditory comprehension limited to simple material of high Emphasize important words in a sentence
personal relevance Provide simple verbal or written word choices when
Appears to understand when patient does not appropriate
Silent reading limited to recognition of own name Keep all stimuli personally relevant
Unable to read aloud Accept any and all modes of communication
Unable to write words Encourage inclusion in social conversation and singing
Awareness of/reliance on social cues may be good activities
Encourage speech activities (e.g., counting, prayers)
Focus on doing things together rather than talking about
things

*Adapted from Goodglass and associates43 and Hedge.51

†Adapted from Simmons-Mackie.103

woman just got home from work and she is thinking about productively in treatment to a lack of motivation or de-
dinner. She might go to the restaurant so doesn’t have to creased initiation. However, the failure seems, to the au-
cook and clean up. The kitchen is pretty clean for someone thors, most likely a consequence of the alterations in
who works. The curtains are clean.” This description cognition, particularly the reduction of insight.84 This
highlights the communication issues frequently observed failure to derive implied meaning from what is said af-
in RBD patients: the absence of the relationship of the fects decisions at every stage of the rehabilitation pro-
individuals in the picture (woman rather than mother), ir- cess.84 The patient may not understand that his or her
relevant and tangential content that misses the activity of impairments affect the ability to live independently or
the picture (washing the dishes and ignoring her children), return to work because of his or her inability to connect
misses the emotion (the woman’s distraction while the the impairment with the failure to negotiate the tasks of
water overflows the sink), neglect of the left side of the daily life.
page (the description misses the children on the left side of The cognitive communication deficits described pre-
the picture), and the focus on inconsequential details (“the viously are exacerbated by nonlinguistic communicative
curtains are clean”). impairments that include left neglect, reduced and dis-
Furthermore, a lack of insight and concreteness may turbed attention, anosognosia (failure to recognize defi-
reduce the patient’s ability to participate in the setting of cits) prosopagnosia; and visual and spatial perception
rehabilitation goals. Goals, such as reducing impulsivity deficits.73,83 The factors that most affect communication
or increasing safety awareness, have little meaning to are neglect, inattention, reduced awareness, and impul-
the RBD patient. For example, when the authors ask the sivity. The failure to respond to speakers in the left visual
patients if they have noticed that they tend to neglect the field affects the pragmatic interaction with communica-
left side of space, they probably will deny the problem.84 tion partners.5,73,84 In addition, left neglect can be paired
However, they may readily acknowledge that people re- with cognitive issues that affect reading and writing.73,84
peatedly tell them “look to the left.” In the authors’ ex- Difficulty reading prescriptions and inadequacies in fill-
perience, the patient will not appreciate the goal or ing out medical forms affect the patient’s compliance in
meaningfulness of the activity unless the therapist makes medical care. While these skills are not central to com-
the consequence of the neglect evident to the patient munication, they seriously influence the rehabilitation
(i.e., not seeing dangers on the left). In the authors’ expe- team’s decisions about prognosis, discharge, and burden
rience, clinicians sometimes ascribe the failure to work of care.84
 Chapter 20 • Managing Speech and Language Deficits after Stroke 549

Little is known about the recovery of communication The stroke-related communication difficulties encom-
deficits in the RBD patient.73,84 Speech-language pathol- pass a broad range of disorders, each with its own unique
ogy intervention is frequently focused on specific tasks characteristics. Having an understanding of the relative
that show concrete changes.84 Direct unambiguous cues strengths and difficulties of the various communicative
can sometimes be successful in inhibiting the hyperver- disorders allows the occupational therapist to detect and
bosity.84 When working on a task that requires listening understand the communicative issues their stroke patients
to directions, following written instructions, writing present. Better understanding of speech, language, and
checks, or filling out forms, the attention and concentra- cognitive disorders can only increase communicative
tion impairments are being addressed in concrete every- competence and minimize the impact of the patient’s
day communicative tasks. There is literature on improve- communication disorder on rehabilitation.
ment of left neglect5 in reading and writing, an area of
possible collaboration between speech-language pathol- REVIEW QUESTIONS
ogy and occupational therapy. See Chapter 19.
1. What is the difference between Broca’s aphasia and
Vascular Dementia apraxia of speech?
This underappreciated dementia32,81 was formerly 2. Name three strategies that would be helpful when
known as “multi-infarct dementia” or “hardening of the working with a client presenting with Wernicke’s
arteries,” and it may resemble Alzheimer disease in the aphasia.
severity of the functional cognitive impairments. But 3. Name three strategies that would be helpful when
vascular dementia differs from Alzheimer in important working with a client presenting with Broca’s aphasia.
characteristics.54 While the disease is progressive, it is 4. Name three strategies that would be helpful when
stepwise rather than sloping in progression.46 There are working with a client presenting with global aphasia.
periods of slight but sometimes meaningful improve- 5. What is the clinical presentation of conduction
ments in communication.90 In general, the disease is aphasia?
most often described as “microvascular” or “small vessel
disease.”81 The symptoms are heterogeneous and based REFERENCES
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 b i rg i tta ber n s pån g
j o s ef i n e l am pi n en

chapter 21

Enhancing Performance
of Activities of Daily Living

key terms
occupational therapy intervention assessment of motor and process
process model skills

chapter objectives
After completing this chapter, the reader will be able to accomplish the following:
1. Understand the occupational therapy process using a client-centered top-down approach.
2. Recognize the effect of a stroke on a person’s engagement in activities of daily living.
3. Discuss the occupational therapy reasoning process for enhancing engagement in activi-
ties of daily living.
4. Understand the basics for documentation and goal writing during the whole intervention
process.
5. Understand the different models of interventions used for instrumental activities of daily
living.

In this chapter, two cases will be presented where the client-centered intervention process and on showing
occupational therapist has used an intervention pro- how the Assessment of Motor and Process Skills (AMPS)
cess to enhance the performance of activities of daily can be used as a guide in planning OT interventions.
living (ADL) after stroke. The process model used is Within stroke rehabilitation, there is a growing body
occupation-based, top-down, and client-centered. The of knowledge that patients will benefit from a team ap-
Occupational Therapy Intervention Process Model proach to rehabilitation, from the acute to the later stages
(OTIPM)3 has been used at the hospital where the two of the rehabilitation.9 At the rehabilitation department
cases are being treated for over ten years and is the where the cases in this chapter participated, the team
base for a general program used for all patients at the works with an interdisciplinary view where the client is
occupational therapy (OT) department. The complete included in the team as a member. Together with the
process model is shown in Fig. 21-1, and all steps will client, all team members participate and formulate the
be described in the two cases, Astrid and August. This goals at the initial planning meeting. The occupational
chapter focuses on leading the reader through the therapist’s contribution to this team approach has a clear

553
554 Stroke Rehabilitation

Identify resources
Establish
and limitations within
client-centered
client-centered
performance context
performance context
Develop
therapeutic
rapport and
collaborative
relationships
Plan and implement
Identify and prioritize Select adaptive occupation to
reported strengths compensatory model compensate for decreased
and problems of occupational skill
occupational performance

Plan and implement

Observe client’s Select a model occupation-based
task performance for education educational program
and implement and teaching focused on performance
performance analysis of daily life tasks

Define and describe Reevaluate for enhanced

actions the client does Define/clarify or
and satisfying occupational
and does not perform interpret cause
performance
effectively

Plan and implement

Select a model for
acquisitional occupation
occupational skills training
to reacquire/develop
(acquisitional model)
occupational skill

Select a model for Plan and implement

enhancement of person restorative occupation to
factors and body functions restore/develop person
(restorative model) factors and body functions

Figure 21-1 Occupational Therapy Intervention Process Model. (From Fisher AG: Occupa-
tional therapy intervention process model, Fort Collins, Colo, 2009, Three Star Press.)

focus on the client’s ability to perform those daily tasks services that OT may provide to a specific client group in
that he or she wants the ability to do and that hold mean- a particular setting. In Västerbotten County, a group of
ing given the circumstances in which the client lives.15 It occupational therapists developed a general program
is, therefore, important that the occupational therapist from which more specific programs can be developed.
start the intervention process by finding out the areas of These programs are based on Fisher’s OTIPM;3 the gen-
interest and meaning for each individual client. To do so eral OT program developed in Sweden is also included in
means that the occupational therapist uses so called top- Fisher’s text.3 The OTIPM describes the process from
down reasoning, which immediately gives the occupational the first meeting with the client and the different OT
therapist knowledge about the areas in the client’s every- interventions and through the whole rehabilitation pro-
day life that he or she views as most important, given the cess until the final meeting with the client. The descrip-
current situation. Top-down reasoning is separated from tion of the two cases will use this model to clarify the
bottom-up reasoning, where the occupational therapist process and to suggest interventions for the specific
initially focuses on evaluating the client’s body functions cases. The OTIPM will be used to demonstrate how OT
and/or environmental factors. The identified decreased services can be provided in a manner that is top-down,
functions are then viewed as the cause of the client’s prob- client-centered, and occupation-based.
lems in the everyday doings. The cases will be described according to the OTIPM
In Sweden, where these cases take place, it is common model and, according to the OT program used at this
practice to develop an OT program that describes the particular rehabilitation unit (see Fig. 21-1).
 Chapter 21 • Enhancing Performance of Activities of Daily Living 555

As the intervention process progresses, evaluations will There is also another ADL assessment available to use
be used to help each step of the process. One of the main as a structure during a first meeting with a client.”14,16 This
sources of information gathering on the actual ability to ADL-taxonomy is conceptualized as a divided large circle
perform daily tasks is the AMPS.2 Other standardized as- where each area of daily tasks has its own slice (Fig. 21-2,
sessments can also be used to document the status of A and B). All slices are then divided into the actions
performance of ADL after stroke and are summarized in included in each task domain according to a hierarchy of
Table 21-1. difficulty. The areas include eating and drinking, mobility,
The AMPS is a standardized evaluation of personal and going to the toilet, dressing, personal hygiene, grooming,
instrumental ADL, which can be performed with persons communication, transportation, cooking, shopping, clean-
with any diagnosis and at any age from 2-years-old to over ing, and washing. Located at the top of the circle is a blank
100-years-old, as long as the person is interested in and slice where the occupational therapist can add areas of
has experience doing daily tasks. To become a trained and importance to the client that are not included in the listed
calibrated AMPS rater, the occupational therapist must areas (i.e., leisure tasks).
attend a five-day training course and test 10 people after In rehabilitation departments in Sweden and else-
the course. When the potential rater demonstrates the where, it is common to work with interdisciplinary teams.5
ability to score AMPS in a valid and reliable manner, he This means that several professions are involved in the
or she becomes a calibrated AMPS rater and has full ac- whole rehabilitation process, and members contribute
cess to reports generated by the AMPS computer scoring their specific expertise to the team through their profes-
program. The use of these reports in practice will be dem- sion specific assessments, which allows them to get the
onstrated in this chapter. full picture of the patient needs. The team members col-
The AMPS is an observational method of evaluating a laborate closely and assist each other in solving problems
person’s skills in daily tasks. In all, 36 skills are evaluated: that arise during the rehabilitation process. The patient is
16 ADL motor skills and 20 ADL process skills (Box 21-1). a member of the team. The patient’s rehabilitation goals
There are 86 different standardized tasks that are stan- are the basis for the goals of the team, and they guide the
dardized in the AMPS. Both personal and instrumental decision about which team members to involve in the re-
ADL tasks are included. The tasks represent several differ- habilitation process, a decision that can also change over
ent cultures and levels of difficulties. Each person is ob- time as the goals change.5,11 The following two cases show
served doing two or more tasks and is scored on each of when and how this interdisciplinary teamwork is imple-
the 36 items for each task. Examples of standardized tasks mented in the rehabilitation process.
are listed in Box 21-2. To implement an AMPS observa-
tion, the process includes finding out relevant and chal- GERIATRIC DAY REHABILITATION: CLIENT
lenging tasks for the client to perform in order to get LIVING IN COMFORT (ASSISTED) LIVING
the most complete and comprehensive evaluation of the
client’s performance. Several steps are required in order to Astrid is a 72-year-old woman who had a stroke eight
conduct an AMPS evaluation according to the standard- months ago. The computerized tomography (CT) scan
ized procedures.2 After the observation, the scores are then showed a cerebral hemorrhage in the basal ganglia through
entered into the AMPS software, and several reports can to the ventricles on the left side of the brain. She had a
be generated that will assist the occupational therapist in right-sided hemiparesis, aphasia, and she was substantially
the intervention planning process. depressed. Initially, she had low arousal due to the cere-
When the AMPS is used in its full potential as a stan- bral edema and received rehabilitation for two weeks on
dardized tool, it will generate two ability measures that the stroke unit in the hospital.
will inform the therapist and the client about ADL ability During this period:
in relation to effort, efficiency, safety, and independence. ■ She required substantial assistance to transfer into
Occasionally, the occupational therapist calibrated as an her recliner wheelchair. The staff used a sling at-
AMPS user meets a client where none of the 85 tasks are tached to the ceiling to move her from bed to chair.
relevant to the client. In those occasions, the occupa- ■ She required a two person assist for her hygiene and
tional therapist can perform a nonstandardized AMPS dressing, which was done bedside, although she did
evaluation by observing the client doing a task of rele- try to participate when she was able.
vance that is an appropriate challenge and chosen by the ■ She had aphasia, but she could answer yes and no
client. During this instance, the therapist cannot use the to questions, and she did understand simple en-
AMPS software, but can get detailed information on couragements.
which of the skill items the client has problems perform- ■ She fatigued easily.
ing and can use that information in the documentation Two weeks after her stroke, she was moved to the geriatric
and the continuing process of planning and implement- rehabilitation unit and met an occupational therapist the
ing interventions. first day. Since Astrid had difficulty speaking and was easily
 556
Stroke Rehabilitation
Table 21-1
Standardized Assessments
ADELAIDE NOTTINGHAM
RIVERMEAD ADL ACTIVITIES FRENCHAY EXTENDED ADL INSTRUMENTAL LAWTON INSTRUMENTAL
ASSESSMENT PROFILE ACTIVITIES INDEX SCALE ACTIVITY MEASURE ADL SCALE

Authors
Whiting and Lincoln, Bond and Clark, Holbrook and Nouri and Grimby and Lawton and Brody, 19698
198017 19981 Skilbeck, 19836 Lincoln, 198712 colleagues, 19964
Meal preparation
Prepare a meal Prepare main meal Prepare main meals Make a hot drink Cook a main meal Prepare a meal
Prepare a hot drink Wash dishes Wash dishes Make a hot snack Prepare simple meal
Prepare a snack Wash dishes
Take hot drinks
between rooms
Domestic activities
Heavy cleaning Heavy housework Heavy housework Housework Cleaning house Laundry
Light cleaning Light housework Light housework Wash small Washing clothes Housekeeping
Handwash clothes Wash clothes Wash clothes clothing items Manage medications
Iron clothes Household or car Household or car Full clothes wash Manage finances
Hang out washing maintenance maintenance
Bed making
Gardening
Light gardening Gardening Manage own
Heavy gardening garden
Productive activities
Voluntary or paid Gainful work
employment
Care for other
family members
Shopping/community activities
Carry shopping Household Local shopping Shopping Large scale shopping Shopping
Cope with money shopping Manage own Small scale shopping
Personal shopping money
Transportation
Use public Drive a car or or- Drive car or go on Use public Use public Use public transportation
transportation: bus ganize transport bus transportation transportation Car/taxi
Transport self to shop Travel outings or Drive a car
car rides
Leisure/social activities
Community social Social occasions Go out socially Use telephone
activities Hobby Use the
Outdoor social Reading books telephone
activities Read newspapers
Invite people or books
to home Write letters

Chapter 21 • Enhancing Performance of Activities of Daily Living

Hobby
Telephone calls to
family/friends
Attend religious
events
Outdoor recre-
ation or sporting
activity

Mobility: outdoors
Outdoor mobility Walk outdoors Walk outside Walk outside Locomotion
Crossing roads Cross roads outdoors
Get in and out of car In/out of car
Walk on uneven
ground

Continued

557
 558
Stroke Rehabilitation
Table 21-1
Standardized Assessments—cont’d
ADELAIDE NOTTINGHAM
RIVERMEAD ADL ACTIVITIES FRENCHAY EXTENDED ADL INSTRUMENTAL LAWTON INSTRUMENTAL
ASSESSMENT PROFILE ACTIVITIES INDEX SCALE ACTIVITY MEASURE ADL SCALE

Mobility: indoors
Indoor mobility Climb stairs
Mobility to lavatory
Move bed to chair
Move floor to chair
Basic self-care
Drinking Feed yourself
Clean teeth
Comb hair
Wash face and hands
Apply makeup or
shave
Eating
Undress
Dressing
Wash in bath
In and out of bath
Overall wash

Modified from Park S: Enhancing engagement in instrumental activities of daily living: an occupational therapy perspective. In Gillen G, Burkhardt A, editors: Stroke rehabilitation: a
function based approach, ed 2, St. Louis, 2004, Elsevier.
 Chapter 21 • Enhancing Performance of Activities of Daily Living 559

Box 21-1 fatigued, the main information was gathered via medical
The Items Observed and Evaluated in the records and through telephone contact with one of Astrid’s
Assessment of Motor and Process Skills daughters.
(AMPS) The rehabilitation goals at this subacute stage
included:
List of the motor and process skills observed during task 1. To be able to propel independently in the wheel-
performance: chair on a flat surface
MOTOR SKILLS PROCESS SKILLS 2. To transfer from wheelchair to bed or toilet with
Body position Sustaining performance verbal instructions and support handles
3. To know the day of the week, time of day, and the
Stabilizes Paces*
Aligns Attends
date
Positions Heeds 4. To adjust the temperature of the water from the
faucet
Obtaining and holding Applying knowledge 5. To manage upper body grooming and dressing in-
objects dependently
Chooses
Reaches Uses 6. To make own breakfast (i.e., make cooked oatmeal
Bends Handles independently)
Grips Inquires At the time for discharge from the geriatric rehabilita-
Manipulates tion unit three months later, the first four goals were
Coordinates Temporal organization
met. Tasks included in goal numbers five and six still
Initiates
Moving self and objects required physical assistance. A referral was sent to the
Continues
Moves Sequences
geriatric day rehabilitation unit for continuing rehabili-
Lifts Terminates tation. Astrid moved to a “comfort living” complex for
Walks elderly and had access to home care 24 hours a day.
Transports Organizing space and Comfort living is the client’s own apartment in a com-
Calibrates objects plex for older persons with access to jointly owned areas
Flows Searches/locates and dining room.
Gathers
Sustaining performance Establish Client-Centered Performance Context
Organizes
Endures Restores About two months later and now five months after the
Paces* Navigates stroke, Astrid was admitted to the geriatric day rehabilita-
Adapting performance tion unit. She arrived with her ex-husband Emil at the
Notices/responds
first visit with the occupational therapist. The occupa-
Adjusts tional therapist, Maria, carried out an initial interview to
Accommodates establish the client-centered performance context, and
Benefits she asked Astrid to describe for her how a usual day was
laid out. For guidance in the first step, Maria used the
*Paces is considered both a motor and a process skill
OTIPM and ADL-taxonomy, which helped her visualize
From Fisher AG: Assessment of motor and process skills, ed 6,
Fort Collins, Colo, 2006, Three Star Press.

Eating and
Box 21-2 drinking Washing

Examples of Standardized AMPS Tasks

Mobility Cleaning
PADL IADL
Putting on shoes and socks Making breakfast Going to
Shopping
Brushing teeth Repotting a small the toilet
Upper body grooming/ houseplant Dressing Cooking
bathing Fresh fruit salad
Sweeping the floor Personal
Transportation
Raking grass cuttings or hygiene
leaves
A Grooming Communication
Shopping
Figure 21-2 A, The ADL Taxonomy.
Continued
560 Stroke Rehabilitation

ACTIVITIES ACTIONS

Eating and drinking 1. Eating, that is, getting food from a plate or
Defined as getting food from the table, to eat and equivalent into one’s mouth and eating
drink. The activity comprises the following actions: 2. Drinking, that is, getting the liquid from a
glass or cup or equivalent into one’s mouth
and drinking
3. Getting food and liquid and cutting up/
preparing food
Mobility 1. Transfer in bed, that is, changing positions,
Defined as goal directed mobility of the body from turning over and sitting up
one place to another. The activity comprises the 2. Transferring the body from bed to chair or
following actions: between two chairs
3. Walking or moving from one room to another
(the same floor)
4. Walking or moving from one floor to another
5. Walking or moving in and out of the house
6. Walking or moving in the neighborhood
Going to the toilet 1. Bowel and urine elimination, volitional
Defined as getting to the toilet room in time and 2. Getting on and off the toilet and cleaning
performing the necessary elimination. The activity oneself after elimination
comprises the following actions: 3. Arranging clothes and equipment such as
pads and sanitary towels, washing hands
4. Getting to and from the toilet room in time
Dressing 1. Undressing
Defined as getting the necessary clothes and shoes, 2. Dressing upper trunk
dressing and undressing. The activity comprises the 3. Dressing lower trunk
following actions: 4. Pulling on stockings/pantyhose/shoes
5. Getting necessary clothes from closets
and drawers
Personal hygiene 1. Washing hands and face
Defined as getting to and from the hygiene room, 2. Washing body/bathing/showering
washing hair and body, and getting dry. The activity 3. Washing one’s hair
comprises the following actions: 4. Getting to and from the hygiene room
Grooming 1. Combing one’s hair
Defined as other hygiene activities concerning one 2. Brushing teeth
specific part of the body. The activity comprises the 3. Shaving/make-up
following actions: 4. Manicuring
5. Pedicuring
Communication 1. Calling for attention/communicate
Defined as transferring information between a 2. Taking part in a conversation
transmitter and a receiver and managing actual 3. Using the telephone
equipment. The activity comprises the following 4. Reading
actions: 5. Writing by hand and/or using a word-
processor
Transportation 1. Going by car
Defined as getting to, in and out of public or 2. Going by bus, tram, tube
private transportation. The activity comprises 3. Going by train, boat, airplane
the following actions: 4. Riding bicycle/moped
5. Driving car/motorcycle
Cooking 1. Preparing a cool meal
Defined as planning, and taking out equipment, 2. Heating up liquid or prepared food
preparation, cooking, laying the table, and washing 3. Cooking a hot meal
the dishes. The activity comprises the following
actions:
Shopping 1. Making plans for shopping (shopping list/
Defined as making plans for shopping, getting to order)
the store, taking out groceries, paying for them, and 2. Daily or small quantity shopping in neighbor-
bringing them home. The activity comprises the hood shop
following actions: 3. Weekly or large quantity shopping
Cleaning 1. Daily light cleaning
Defined as light cleaning: making the bed, “clearing 2. Weekly heavy cleaning
away/tidying up,” wiping off, dusting. Heavy cleaning;
vacuum cleaning/washing floors, washing toilet and
bathroom. The activity comprises the following actions:
Washing 1. Light washing by hand
Defined as transportation of laundry to and from the 2. Light washing in washing machine
washing place, sorting, washing/ironing/mangling the 3. Heavy washing in washing machine
B laundry. The activity comprises the following actions: (e.g., sheets)
Figure 21-2, cont’d
For legend see opposite page
 Chapter 21 • Enhancing Performance of Activities of Daily Living 561

Figure 21-2, cont’d B, Operational Definitions of Activities and Actions included in the
ADL Taxonomy. (A is from Törnqvist K, Sonn U: Towards an ADL taxonomy for occupa-
tional therapists, Scand J Occup Ther 1[2], 69-76, 1994. B is from Sonn U, Törnqvist K,
Svensson E: The ADL taxonomy - from individual categorical data to ordinal categorical
data. Scand J Occup Ther 6[1]:11-20, 1999.)

the daily tasks for the client. Maria summarized Astrid’s Cultural Dimension
occupational performance context according to the ten Astrid is a typical Swedish woman, and her cultural be-
dimensions in the process model, OTIPM. liefs, values, customs and where and how she performs her
daily life tasks are similar to other persons in Sweden of
Environmental Dimension the same age.
Astrid had recently moved to a comfort living complex
for elderly persons (55⫹). Her apartment has two rooms Motivational Dimension
and a kitchen, and it is adapted for functional limita- Astrid enjoyed keeping her home nice and tidy. She has also
tions. The bedroom has a bed with rails, a book shelf, read several journals about gardening and home decorating
and a bedside table close by with a telephone, a digital and fictional books. She is motivated to invite her friends to
day and night calendar. The living room has a sofa, her apartment and wants to be able to do that independently.
armchairs, a TV, and a dining room table with two When she currently has visitors, the guests have to make
chairs close to the kitchen area. In the kitchen, there is their own coffee. She also wishes to be able to eat a meal us-
a refrigerator and microwave oven located high up. As- ing the usual utensils, since it bothers her that others see her
trid can reach the lowest shelf in the refrigerator from using only her fork while eating (in Sweden it is customary
her wheelchair. The apartment has a large bathroom to use both knife and fork during a meal, with knife in right
with a shower, including a shower stool and toilet with hand and fork in left hand during the whole eating process).
a raised seat and armrests. The bathroom also has a Because of this, she does not want to eat in the dining room
washing machine and tumbler. In her current living ar- but instead chooses to have the staff prepare her food for her
rangement, Astrid has access to home care staff 24 hours in her apartment. Due to the same reason, she would like to
and can also use the jointly owned areas of the living be able to walk without assistive devices.
complex, i.e., dining room, library, TV room, and spa Astrid would like to be able to manage her daily tasks
unit. Astrid does not use these areas because of her cur- herself again, such as inviting her friends for coffee, make
rent problems with mobility, and she cannot propel the her own breakfast, make her own sandwich, and manage
distance required for this. going to the toilet by herself and safely.

Social Dimension Institutional Dimension

Astrid has a lot of support from her ex-husband Emil, who Astrid has several resources available to her of which she
is now responsible for her finances. She has some close now needs to make use:
friends as well. Prior to her stroke, she lived alone in her ■ The home help staff to help with her personal hy-
own apartment and managed all her daily tasks on her giene, dressing, and toileting. The staff also helps
own. Astrid is divorced and has two grown daughters, one her to prepare her meals, and they supervise trans-
in the south of the country and one abroad. Earlier she fers among wheelchair, bed, and toilet. She also re-
often traveled to her daughters and their families and ceives help with cleaning and shopping.
spent a lot of time with her grandchildren. Now they will ■ Her ex-husband and daughters are responsible for
have to travel to her instead. her finances, and her ex-husband supports her in
other situations.
Role Dimension ■ Currently she also has support from the team at ge-
Astrid is a mother and caretaker. Previously Astrid spent a riatric day rehabilitation.
lot of time in the forest, picking wild berries and mush-
rooms, and enjoying walks. She also has a great interest in Body Function Dimension
gardening. Being together with friends and participating Astrid presents with right-sided hemiparesis and aphasia.
in the city’s culture such as theatre, concerts, and movies She initially presented with low arousal secondary to ce-
have also been important interests of hers. rebral edema. Right after the stroke, she sat in a recliner
562 Stroke Rehabilitation

wheelchair and was lifted with a mechanical lift. She also Adaptation Dimension
presented with fatigue and depression (which was treated Astrid has difficulty fully participating in an effective
medically). Currently, Astrid’s memory problems and de- manner due to her lack of initiative. Her fatigue also lim-
creased ability to use her right arm and hand are her big- its her today. Therefore, she needs support from the staff
gest problems. She has pain in her right shoulder, causing at her living complex and from relatives, so that the reha-
her to have problems moving her arm effectively, al- bilitation can continue during the whole day. The helping
though she has good ability to grip with her right hand. staff need to be familiar with Astrid’s problems, so they
Some of her problems can also be related to her apraxia. can best supervise and support Astrid in her daily tasks.
Astrid wants to be able to walk independently and safely
with her rolling walker. Astrid usually sits in her wheel- Develop Therapeutic Rapport and Collaborative
chair and has problems propelling herself, as the chair is Relationships
too high for her to strike her heel. When Maria, the occupational therapist, met Astrid, and
Emil, they started to develop rapport and identified per-
Task Dimension sons to include in the collaborative relationship during
Astrid expressed that her greatest problem today is to the intervention process.
move herself. She would like to be able to safely walk with During this first meeting, Astrid had Emil as a support.
her rolling walker. She also thinks it is important to man- His role was to confirm what she tried to say and to pro-
age by herself as much as possible during her daily tasks. vide moral support for her, and as such, he is involved in
She would like to manage to perform simple everyday the collaborative relationship. Astrid managed the inter-
tasks on her own, and her highest priority is to again be view to a great extent by herself and only occasionally
able to make coffee with cookies for her friends, make her looked at her ex-husband for support when she was un-
breakfast (oatmeal), make an open-faced sandwich, and sure. Maria tried to identify the problems that Astrid de-
eat with knife and fork. She also wishes to be able to write scribed as they discussed her everyday habits. Maria also
with her right hand again. was keen to listen and to show empathy for the situation
that Astrid described.
Temporal Dimension
One ordinary day in Astrid’s life starts when the staff at Identify Resources and Limitations within
her living complex comes in and wakes her up at 7:30 am. Client-Centered Performance Context
They help her to her wheelchair, into the bathroom, and Due to their first meeting, Maria has gathered the infor-
onto the toilet. Astrid can do these actions herself with mation from Astrid that she herself can identify and con-
supervision and verbal assistance. She transfers herself to sider as current resources and limitations. This informa-
the shower stool and receives help with showering and tion will be important for the occupational therapist as
dressing. She tries to participate as much as possible. After background information that she can use throughout the
the morning hygiene routine, the staff makes her break- intervention process. The occupational therapist tries to
fast. She eats and reads the daily newspaper. She then lies have a focus on occupations as she documents the infor-
down to rest until lunchtime. The staff then returns, helps mation that she has gathered from Astrid.
her to the bathroom, and makes her lunch. Presently, the Documentation of initial OT evaluation:
staff needs to cut the food into small pieces, so that she
can eat with her fork in the left hand. After lunch, Astrid
usually has a session of practicing walking with the staff.
She will use her rolling walker, and the staff uses a gait Background Information and Reason
belt. In the afternoons, she will often have visitors, who for Referral
will prepare the afternoon snack for themselves and her. Background: Astrid is a 72-year-old retired woman that
Astrid will rest again before dinner, when the staff comes lives in a small apartment in a comfort living complex for
to her room and helps her to the bathroom and to prepare elderly and has around the clock service. A rehabilitation
dinner. In the evening, she watches TV and reads the plan is made together with the team and Astrid. She uses a
newspaper. She goes to bed around 9:00 pm. Astrid still wheelchair and would like to be able to walk independently
fatigues during the day and needs to rest several times. with a rolling walker and to manage simple daily chores
herself (i.e., to make her own breakfast, invite friends for a
But in between her rests, she would like to manage more
coffee snack, eat with cutlery). She also wishes to be able to
daily tasks herself.
use the toilet independently. She survived a left-sided
Astrid lives at home in the comfort living complex and stroke about 5 months ago. She is weaker in the right hand
uses the option to take a taxi (mobility service) to the ge- and leg, still has some aphasia (she can make herself under-
riatric day rehabilitation two afternoons every week (be- stood and understands most conversations), and has im-
tween 1:00 and 3:00 pm). She will continue to do so until paired memory, impaired initiative, and fatigue.
she meets her rehabilitation goals.
 Chapter 21 • Enhancing Performance of Activities of Daily Living 563

Astrid chose to make cooked oatmeal for one person,

Reason for referral: Referred to the geriatric day reha-
since she usually ate that for breakfast. Although the
bilitation for rehabilitation by the interdisciplinary team.
Will be evaluated and receive interventions in daily tasks AMPS was not used as a standardized tool, the occupa-
by the occupational therapist. tional therapist could still use the skills of the AMPS to
describe the performance. The AMPS skills observed
during the performance are inserted in the next section in
parentheses.
Identify and prioritize reported strengths and problems of
occupational performance. Observation in Prioritized Task
Another outcome from the first meeting between the To Make Breakfast. Astrid was observed in the clinic
client and the occupational therapist is the client’s self- kitchen as she cooked oatmeal and served jam, milk, and
reported strengths and problems of performance. At this oats. As they set up the environment before the perfor-
meeting, the occupational therapist can use the Canadian mance of the task, they decided to move the objects that
Occupational Performance Measure (COPM),7 ADL tax- were located high in the cupboards down to the lower
onomy14,16 or other available instruments that guide the shelf so Astrid could reach them. Before the observation,
interview and give a structure that can support the client Maria and Astrid located all the tools and materials needed
in identifying and prioritizing important limitations with in the task. Astrid started to perform the task and collected
daily occupations. Since Astrid has both aphasia and some all the materials and tools that she needed to make the
memory loss, it was difficult to use the COPM. The ADL oatmeal, but she does not gather the salt (initiates, search/
taxonomy was easier to use with Astrid during this first locates, gathers). She had an ineffective ability to move
time, and one of Astrid’s daughters was contacted for fur- herself in the wheelchair in the kitchen, since the wheel-
ther information. chair was too high for her (moves, reaches, bends). She
Documentation from initial OT evaluation, part II: also took a lot of time and effort to gather the objects and
reported level of performance and prioritized task to place them for easy access (paces, endures, organizes).
performance. She was ineffective as she scooped the oats from the bag
Maria documented the identified strengths and prob- with a measuring cup as she held the measuring cup with
lems according to Astrid’s information as follows: her right hand and could not reach the oats in the bag that
she held with her left hand (grips, coordinates, navigates,
handles). She stopped, hesitated, and then moved the bag
Self-Reported Level of Performance of oats to her right hand and the measuring cup to her left
hand (continues, notice/responds, accommodates). She
Astrid describes that she feels dependent on other persons
around her all the time. As she currently requires substan- was now able to gather the amount of oats that she needed
tial assistance for her everyday doings, she would like to be from the bag. Astrid then asked for salt, and the therapist
able to perform some everyday tasks herself. She prioritizes gave her a general cue/clue where to find it (inquires,
highest to be able to make coffee and snacks for her friends, search/locates). Astrid did not organize the materials in an
to make her own breakfast, eat with cutlery, make an open- effective manner on her workspace, and there was a risk
faced sandwich, and write with the right hand again. that she would knock over the milk carton with her left
Priorities: elbow when she reached over to pick up the jam jar (orga-
■ Make coffee snack (brew coffee, serve coffee and nizes, navigates). She tried to open the jar, but did not have
cookies at the table) enough strength to open the lid and asked for needed help
■ Make a portion of hot oatmeal independently
(coordinates, calibrates, accommodates). She also needed
■ To cut/separate the food on the plate and eat with
verbal assistance to keep the pan on counter while she
cutlery
■ Make an open-faced sandwich independently
scooped the oats into the bowl; she tried with her right
■ To write with right hand again hand and then with her left hand, but needed assistance to
scoop the oats in a safe manner (coordinates, handles). She
served the oats in the bowl at the kitchen table, and re-
stored all items to their original storage place. This task
Observe Client’s Task Performance and Implement took 45 minutes to complete.
Performance Analysis
Presently in the rehabilitation process, it was time for Initial Evaluation: Observed Current Level
Maria to observe Astrid’s actual performance before they of Performance
decide about which intervention to initiate. At the next Global Baseline: Cooking Oatmeal. Astrid was mod-
visit, Maria thus had planned for an observation of Astrid’s erately inefficient and showed moderate increase in effort,
performance. Astrid chose to make her breakfast. There from being able to firmly touch the floor with her feet to
was no formal AMPS evaluation made at this time, and move a wheelchair properly. She also had a minimal need
564 Stroke Rehabilitation

for verbal assistance for finding the salt, and a moderate were recorded as ineffective or markedly deficit according
degree of physical assistance to open the jam jar and scoop to AMPS criteria.
the cooked oats into bowl. Astrid chose to start with the task of making a sand-
wich and decided to make a cheese sandwich with sliced
Specific Baseline. Astrid moved herself in her wheel- cucumber on top. Astrid demonstrated an inefficient
chair with moderate effort, which affected her ability to ability to reach into the refrigerator for needed objects,
position herself in relation to the task in order to en- as she placed herself far from the refrigerator with her
hance task performance (e.g., she sat with her left side wheelchair and sat leaning back in the wheelchair (stabi-
toward the workplace where her right side was too far lize, reach, bend). She was ineffective in transporting
away to reach effectively with her right hand). Her awk- herself in the wheelchair as the chair is too high for her.
ward sitting affected her ability to organize the tools and She placed herself diagonally in relation to the work
material on the workplace. All task objects were placed area, which led to an ineffective way to use her right
very close together, and she then bumped into the milk hand. She tried to spread the butter on the sandwich
carton with the elbow when she reached for jam. She with the knife in the right hand. She lost her grip on the
also had limited ability to safely scoop the oatmeal from knife, and, after sometime, she switched to the other
the pan. Astrid mobilized herself and task objects in an hand (grips, manipulates, coordinates, calibrates, flows).
ineffective manner. The objects in the task were organized close together,
When Astrid was made familiar with the environment leading to problems for her to navigate the workspace.
in the kitchen, Maria completed a standardized AMPS She also had a decreased ability to accommodate and
evaluation to evaluate her OT in an effective manner. The adjust to the situations during the task (organize, navi-
standardized ADL assessment will help the occupational gate, accommodate, adjust). She showed a decreased
therapist get more detailed information on actions prob- ability to use objects, as she chose a knife to pick up a
lematic for Astrid. The AMPS is well-suited for the evalu- slice of cheese and then continued to use the knife to
ation phase since it will define and describe the actions of pick up slices of cucumber as well. The task took about
performance that Astrid performs effectively or not. 20 minutes for her to accomplish, primarily due to her
limited ability to transport herself with the wheelchair in
AMPS Evaluation the kitchen.
The stroke affects Astrid in many aspects of her everyday Since Astrid still had energy, she also wanted to do the
life and to a great extent. The occupational therapist uses second task, sweeping the floor of the kitchen. The verbal
the information she has about Astrid to decide that Astrid contract was that she should sweep the whole floor in the
must choose tasks that are calibrated as average or easier kitchen and move lightweight furniture that were in her
than average in the AMPS process task hierarchy. Draw- way. During this task, she had the same inefficient way of
ing on the list of prioritized tasks that Astrid made earlier, transporting herself (moves), and she tried but was not
the occupational therapist presented a list of five possible able to move chairs, which meant that she did not reach
task choices: sweeping the floor, folding laundry, setting a (reach) visible crumbs, although she tried to bend forward
table for four persons, making an open-faced sandwich (markedly decreased ability to adjust). She gripped the
with meat and a vegetable, and handwashing dishes. As- brush with her right hand but changed to the left hand
trid prioritized some of these tasks and wanted to be able and swept with the left hand instead (manipulates, coordi-
to do them independently again. nates, accommodates). She navigated inefficiently, and her
Astrid chose to make a sandwich with cheese and sliced wheelchair became stuck on a chair that she was not able
vegetable (average task difficulty) and to sweep the floor to move in order to sweep the floor (organize). She did
(easier than average task). She decided to start her perfor- not sweep the whole floor and did not restore until a ver-
mance making the sandwich, since she now felt familiar in bal cue (restore, heed) was given. She asked if she should
the kitchen and had knowledge of the location of things she restore the brush to original place and was scored down
would need. Before the observation, the occupational ther- for the item terminates.
apist and Astrid set up the environment to make sure that The occupational therapist, Maria, then filled in the
Astrid had tried to open all cupboards and drawers, includ- AMPS score form and entered the results into the AMPS
ing the refrigerator door, and knew the location of all the computer software. See a summary of Astrid’s Motor and
things she needed. The setting up of the environment is Process Skills from the Summary report in Figs. 21-3
also done prior to each task, so the client has an environ- and 21-4.
ment that is as similar to her own home as possible to The AMPS software also generates a graphic report
perform the task. The objects needed in this task were (Fig. 21-5) of the motor and process skills indicated on
moved from the upper cupboards down into drawers within linear measures. Each scale also has a cutoff, where a score
reach for Astrid sitting in her wheelchair. The actions below the cutoff indicates problems of performance in
marked in parentheses in the following text are actions that terms of effort, efficiency, safety, or need for assistance.
 Chapter 21 • Enhancing Performance of Activities of Daily Living 565

ASSESSMENT OF MOTOR AND PROCESS SKILLS (AMPS)

PERFORMANCE SKILL SUMMARY
Caution: Item and total raw scores are not valid representations of client performance, and they cannot be used for
documentation or statistical analyses. Raw scores must be analyzed using the AMPS computer-scoring software to
create ADL ability measures. Only ADL ability measures are valid for measuring change.

Client: Evaluation date:

Id: 37 Occupational therapist:

Task 1: F-7: Open-face meat or cheese sandwich with sliced vegetable (Average)
Task 2: J-1: Sweeping the floor (Average)
Overall performance in each skill area is summarized below using the following scale:
A ⫽ Adequate skill, no apparent disruption was observed
I ⫽ Ineffective skill, moderate disruption was observed
MD⫽ Markedly deficient skill, observed problems were severe enough to be unsafe or to require
therapist intervention

MOTOR SKILLS: Skills observed when client moved self and objects during A I MD
task performance
Body Position
STABILIZES: Does not lose balance when interacting with task objects X
ALIGNS: Does not persistently support oneself during task performance X
POSITIONS the arm or body effectively in relation to task objects X
Obtaining and Holding Objects
REACHES effectively for task objects X
BENDS or twists the body appropriate to the task X
GRIPS: Securely grasps task objects X
MANIPULATES talk objects as needed for task performance X
COORDINATES two body parts to securely stabilize task objects X
Moving Self and Objects
MOVES: Effectively pushes/pulls task objects and opens/closes doors or X
drawers
LIFTS task objects effectively X
WALKS effectively within the task environment X
TRANSPORTS task objects effectively from one place to another X
CALIBRATES the force and speed of task-related actions X
FLOWS: Uses smooth arm and hand movements when interacting with task X
objects
Sustaining Performance
ENDURES for the duration of the task performance X
PACES: Maintains an effective rate of task performance X

Figure 21-3 Astrid’s AMPS summary report at baseline: Motor Skills.

The graphic report shows that Astrid’s motor ability is ADL process ability measure below 1.0 logits indicates
below the cutoff on the motor scale. Astrid’s motor ability that the person needs assistance. Approximately 93% of
indicates that she has increased effort when performing persons below the ADL process cutoff need assistance to
ADL tasks. Approximately 95% of well, elderly persons of live in the community. Both Astrid’s cognitive and motor
her age have ADL motor ability between 1.07 and 3.27 impairments after her stroke affects her ADL perfor-
logits, and her ability at 0.01 logits is thus lower than age mance. More information about the AMPS scales and
expectations. Astrid’s process ability is also below the cut- cutoff can be found in the AMPS manual.2
off on the process scale. This indicates that she experiences After the observation using the standardized AMPS, the
decreased safety, independence, and/or efficiency when occupational therapist can also look at the hierarchy of the
she performs familiar ADL tasks. About 95% of healthy standardized tasks in the AMPS manual and make assump-
persons of Astrid’s age have an ADL process ability mea- tions about other tasks in the hierarchy that will be easier or
sure between 0.59 and 2.55 logits, thus her ADL process harder for Astrid to perform. For example, since she showed
ability at 0.45 logits is lower than age expectations. An increased effort and decreased efficiency making a sandwich
566 Stroke Rehabilitation

ASSESSMENT OF MOTOR AND PROCESS SKILLS (AMPS)

PERFORMANCE SKILL SUMMARY
Caution: Item and total raw scores are not valid representations of client performance, and they cannot be used for
documentation or statistical analyses. Raw scores must be analyzed using the AMPS computer-scoring software to
create ADL ability measures. Only ADL ability measures are valid for measuring change.

Client: Evaluation date:

Id: 37 Occupational therapist:

Task 1: F-7: Open-face meat or cheese sandwich with sliced vegetable (Average)
Task 2: J-1: Sweeping the floor (Average)
Overall performance in each skill area is summarized below using the following scale:
A ⫽ Adequate skill, no apparent disruption was observed
I ⫽ Ineffective skill, moderate disruption was observed
MD⫽ Markedly deficient skill, observed problems were severe enough to be unsafe or to require
therapist intervention

PROCESS SKILLS: Skills observed when client (a) selected, interacted with, A I MD
and used task tools and materials; and (b) modified task
actions, when needed, to complete the task performance

Sustaining Performance
PACES: Maintains an effective rate of task performance X
ATTENDS: Does not look away from task performance X
HEEDS the goal of the specified task X
Applying Knowledge
CHOOSES appropriate tools and materials needed for task performance X
USES task objects according to their intended purposes X
HANDLES task objects with care X
INQUIRES: Asks for needed task-related information X
Temporal Organization
INITIATES actions or steps of task without hesitation X
CONTINUES task actions through to completion X
SEQUENCES the steps of the task in a logical manner X
TERMINATES task actions or steps appropriately X
Organizing Space and Objects
SEARCHES for and effectively LOCATES task tools and materials X
GATHERS tools and materials effectively into the task workspace X
ORGANIZES tools and materials in an orderly and spatially appropriate X
fashion
RESTORES: Puts away tools and materials and cleans the workspace X
NAVIGATES: Maneuvers the hand and body around obstacles in the task X
environment
Adapting Performance
NOTICES and RESPONDS to task-relevant cues from the environment X
ADJUSTS: Changes workplaces or adjusts switches and dials to overcome X
problems
ACCOMMODATES: Modifies one’s actions to overcome problems X
BENEFITS: Prevents task-related problems from persisting X

Figure 21-4 Astrid’s AMPS summary report at baseline: Process Skills.

and sweeping the floor, she would have fewer problems print a narrative report of the observed performance.
with tasks such as folding laundry or making the bed. This report gives information about the AMPS, the ob-
served tasks, and some information about the strengths
Define and Describe the Actions of Performance of the performance. It also includes information on how
the Client Does and Does Not Perform Effectively. Also well the performance compares to persons in the same
available from the AMPS software is the possibility to age group.
 Chapter 21 • Enhancing Performance of Activities of Daily Living 567

ASSESSMENT OF MOTOR AND PROCESS SKILLS (AMPS)

GRAPHIC REPORT

Client: DATE MOTOR PROCESS

Occupational therapist: Evaluation 1 0.01 0.45

ADL MOTOR ADL PROCESS

4 3

Less
More likely to be safe
physical effort ADL performance
and independent living
performing 3 2 more efficient
in the community
ADL

ADL ADL
2 ⬍ Motor 1 ⬍ Process
Cutoff Cutoff
Some
Some inefficiencies;
increased Some concerns for safe 1
93% of persons
physical effort and/or independent living
1 0 below cutoff need
performing in the community
assistance
ADL

1 0 ⫺1

More ⫺1 ⫺2
Less likely to be safe
physical effort ADL performance
and/or independent living
performing less efficient
in the community
ADL
⫺2 ⫺3

⫺3 ⫺4
Figure 21-5 AMPS graphic report of Astrid’s performance at baseline. The numbers on the
Activities of Daily Living (ADL) motor and ADL process scales are units of ADL ability
(logits). The results are reported as ADL motor and ADL process measures plotted in relation
to the AMPS scale cutoffs. Measures below the cutoffs indicate that there was diminished quality
or effectiveness of performance of instrumental and/or personal ADL. See the AMPS Narrative
Report for further information regarding the interpretation of a single AMPS evaluation.

Grouping Skills of Most Concern into Meaningful Cluster 3: Grips and Coordinates. Astrid tried to sweep
Clusters. The next step was to group the skills found to be the floor with the broom in her right hand, but could not
of most concern into meaningful clusters. These clusters hold her grip effectively, and had problems getting the
can help document the problems observed in Astrid’s per- dirt onto the dust-pan.
formance. Astrid’s limitations could thus be summarized
into the following clusters: Cluster 4: Paces. Due to problems in moving herself
effectively, she had problems maintaining an acceptable
Cluster 1: Moves and Positions. Astrid had problems tempo throughout the task. Every task took a long time to
related to moving around in the task environment in an finish.
effective manner, which resulted in problems related to
positioning herself in an effective way to use the task Cluster 5: Organizes. Astrid placed the objects too
objects. close to each other, which resulted in problems (i.e., in
spreading the butter on the bread as the container was too
Cluster 2: Reaches and Bends. She had problems close to the bread).
reaching for and reaching into the refrigerator, despite The strengths of Astrid’s performance are also sum-
the fact that she tried to bend forward (also due to marized, since her strengths could be used as interven-
cluster 1). tions were planned with Astrid during her rehabilitation
568 Stroke Rehabilitation

period. Astrid’s strengths could be summarized into the joint meeting and to plan the continuous care and reha-
following cluster. bilitation for Astrid. This happened as Astrid arrived for
her fifth meeting at the geriatric day rehabilitation. The
Cluster 6: Endures, Attends, Continues, Sequences, goals that Astrid and the occupational therapist had
Searches/Locates, Gathers. Astrid was motivated and agreed upon, and were prioritized by Astrid, are written
endured through both tasks. She stayed focused and con- below. These tasks will be the focus during the following
tinued the performance to the end of the tasks. She com- OT visits at the geriatric day rehabilitation two times a
pleted all of the actions in the correct order and had no week for some time. The following goals were also in-
problems finding and gathering the tools and materials she cluded in the common team goals.
needed for the tasks.
Goal 1. Astrid will, with supervision, safely manage to
Define/Clarify or Interpret Cause serve coffee and cookies to her friends. This includes
When the occupational therapist has evaluated the quality brewing coffee, taking out cookies and placing on a plate,
of the performance of the client, the occupational thera- setting the table with coffee cups and saucers, and serving
pist is ready to clarify or interpret the cause of the prob- at a table (Fig. 21-6).
lems of occupational performance. When the occupa-
tional therapist looked through her notes that summarized Goal 2. Astrid will, with verbal support from the staff
the ten dimensions, what she had documented in the pa- at her living complex, initiate and, in an effective and safe
tient files, and the information gathered from the other way, make herself a portion of warm oatmeal using an
members of the team, it became clear that Astrid’s prob- adapted work chair (the chair will allow her to reach her
lems were due to both her limited motor skills and the cupboards and at the same time allow her to propel her
cognitive impairments that she had acquired from her chair in an effective manner).
stroke eight months earlier (body function dimension).
Astrid also demonstrated problems related to organiz- Goal 3. Astrid will independently and efficiently make
ing the tools and materials in the environment, such as her own sandwich with one spread (i.e. easy spread
moving the furniture, organization in kitchen, and wheel- butter), sliced cheese, and pre-sliced vegetable, using a
chair use (environmental dimension). Currently she also nonslip device and a rolling work chair.
did not receive the support to be as independent as possi-
ble that she needed from the staff at her living complex. Goal 4. Astrid will independently and effectively man-
age to eat a meal with both cutlery (i.e. knife and fork,
Documentation from Initial Occupational Therapy simultaneously).
Evaluation: Interpretation of Cause
This is what Maria documented in Astrid’s files: Goal 5. Astrid will manage to write a sentence from a
newspaper or book by herself with the right hand.

Interpretation Select Intervention Model and Plan and Implement

Occupation-Based Interventions
Limited motor skills and cognitive impairments limit the
As this step in the OT process is reached, it is now time
quality of ADL task performance. Lack of sufficient sup-
port from others and limited possibility to try and per- to select the interventions, as described in the OTIPM.
form daily tasks after stroke further hinder ADL task The four models suggested include: the restorative
performance.

Document Client’s Baseline and Goals. From the

AMPS results, it might be important to verify and maybe
change some of the rehabilitation goals set together with
Astrid. Thus, Maria reasoned together with Astrid that a
more realistic goal was to manage some of the tasks with
supervision instead of a goal of being independent. She
wanted, for example, to make coffee for her friends, and
after having observed Astrid, the occupational therapist
was aware that it might be more realistic for her to aim to
perform this task with some supervision. With the sup-
port from her daughter, Astrid was very clear in what she
wished to accomplish during her rehabilitation. After the
initial evaluation phase, it was time for the team to have a Figure 21-6 Client-centered goal 1.
 Chapter 21 • Enhancing Performance of Activities of Daily Living 569

occupation model, the acquisitional occupation model person factors or body functions; and (4) Occupation-Based
(Fig. 21-7), the adaptive occupation model (Fig. 21-8), and Educational Programs focused on performance of daily life
the occupation-based educational programs (Fig. 21-9). tasks. Astrid’s occupational therapist used three of the
Together with Astrid, the team discussed how to pri- models, and the plan in each area is described below:
oritize the goals and with which goal to start the inter-
vention. Before each intervention session, the occupa-
tional therapist observed the client doing each of the Intervention Plan
prioritized tasks to evaluate the resources and limitations Adaptive occupation:
of the performance, according to the process model in ■ Trying out technical aides: work chair with wheels,
OTIPM. antislip device, new wheelchair cushion
■ Adaptation of tasks: presliced cucumber and cheese

Implementing Occupation-Based Interventions ■ Adaptation of environment: relocating tools and mate-

In the OTIPM, four different models of interventions are rials in kitchen

Education program:
described, which all have a focus on occupation. The four
■ Supervision of caring staff: during ADL tasks priori-
models of praxis are: (1) Adaptive Occupation to compensate
tized by Astrid
for decreased occupational skill; (2) Acquisitional Occupation Acquisitional occupation:
to reacquire, develop, or maintain occupational skill; ■ Training of tasks: eating with cutlery, handwriting
(3) Restorative Occupation to restore, develop, or maintain

Plan and implement acquisitional

occupation and/or plan and implement
Plan and implement restorative occupation
acquisitional occupation
to reacquire, develop, or
maintain occupational skill Direct or indirect
intervention

Plan and implement

restorative occupation
to restore, develop, or
maintain person factors Grade via modifying Consultation
or body functions or adapting task and education

Figure 21-7 Acquisitional and restorative occupation. (From Fisher AG: Occupational therapy
intervention process model, Fort Collins, CO, 2009, Three Star Press.)

Plan and implement adaptive occupation to

compensate for decreased occupational skill

Adaptation

Education Consultation
Plan and implement
adaptive occupation to
compensate for decreased
occupational skill Adaptation stategies

Provide adapted Teach Modify task

equipment or alternative or or physical
assistive compensatory or social
technology stategies environments

Figure 21-8 Adaptive occupation. (From Fisher AG: Occupational therapy intervention process
model, Fort Collins, CO, 2009, Three Star Press.)
570 Stroke Rehabilitation

Plan and implement occupation-based educational

programs focused on performance of daily life tasks
Plan and implement
occupation-based
educational programs Education Consultation
focused on performance
of daily life tasks

Lectures and
workshops for
client groups

Figure 21-9 Occupation-based educational programs. (From Fisher AG: Occupational therapy
intervention process model, Fort Collins, CO, 2009, Three Star Press.)

After reading through the notes that she had taken so this initial practice, she also needed supervision in how to
far, the occupational therapist, together with Astrid, use it in the tasks that she had prioritized (i.e., making
reached the conclusion that they would start by making warm oats, making coffee for her friends, or making a
adjustments to the wheelchair that was far too high for sandwich). Simultaneously the staff at her living complex
Astrid to propel herself effectively. This had consistently received supervision from the occupational therapist on
been the biggest struggle for her in all observed tasks and how to support Astrid when she used the chair, how to
was a prerequisite to reach her goals. Therefore, the oc- tend to the chair, and how to use it in a safe manner.
cupational therapist chose the model of adaptive compen-
sation at this stage. Goal: To Make a Sandwich
Assistive Devices/Domestic Technical Aides. During the
Adaptive Occupation observation of Astrid when she prepared a sandwich, it
Wheelchair. The occupational therapist arranged for became clear that she had problems gripping the sand-
Astrid to change her seat cushion to one that was not so wich in an effective way; the sandwich was close to falling
thick, which meant that Astrid was immediately able to off the table into her lap, and it slid over the table while
propel herself forward both effectively and quickly by us- she was spreading the butter. Astrid tried a nonslip mat
ing her feet. After trying this cushion for a few days, As- used to hold the bread in the same place as she spread the
trid still wanted to change back to the higher cushion. butter. She was very satisfied after she had tried it. With
The occupational therapist then tried to find a wheelchair this mat under her sandwich, she could safely spread but-
that had a lower seat, but was not successful. At the same ter. After this purchase, Astrid practiced with the occupa-
time, Astrid made progress with the physiotherapist and tional therapist a few times, and within two weeks, Astrid
started to be able to walk with a rolling walker and an as- could make her own sandwich with presliced cheese and
sistant. Since the occupational therapist wanted to take cucumber for her afternoon snack at the day rehab.
this into account, she thought through Astrid’s situation After this goal was met, the occupational therapist and
once again (through all the steps in OTIPM) and reached Astrid continued working on the next goal (to make coffee
the conclusion that Astrid might be able to use a rolling and cookies for her friends and make cooked oats). To
work chair, with a brake and adjustable height seat, for her reach these goals, the occupational therapist reasoned that
to use at home instead of a wheelchair (see Fig. 21-6). she would need to use two different models. She decided
This chair would make reaching easier for Astrid, since to use the compensatory model and the model for educa-
she also had difficulty reaching up to the fridge and upper tion and teaching.
cupboards. It was still hard to imagine how safely Astrid
would learn to walk in the future, so for the time being, Goals: Make Coffee and Cookies for Her Friends
Astrid could have this chair on loan. Astrid thought that and Make Cooked Oats for Breakfast
this was a good idea, and the occupational therapist or- Environmental Adaptation. Since it is not possible to
dered the chair from the technical aides department. carry out all of the rehabilitation initiated at the geriatric
When she received the chair, it needed to be adjusted to day rehabilitation in the clients home, the occupational
fit Astrid, and she needed training in how to maneuver therapist, together with the client, will adapt the kitchen in
and use it in a safe manner (i.e., locking the brakes before the clinic to be as similar to the client’s home as possible
sitting down onto the chair, before standing up, or raising (i.e., the objects needed in the different tasks were placed
it to the highest level [maximum seat height 75 cm]). After in a way to imitate the situation in Astrid’s home). This was
 Chapter 21 • Enhancing Performance of Activities of Daily Living 571

possible to accomplish after the home visit that the occu- the clinic. Initially during the practice, Astrid had a hard
pational therapist had done earlier and became aware of time holding the pen, and the occupational therapist had
how Astrid had her home organized. While the rehabilita- to place it in her hand for her to be able to use it. Maria
tion sessions mostly took place at the clinic, the occupa- gave her simple crosswords to solve at home. As soon as
tional therapist had a few opportunities during the reha- she could hold the pen herself, it was also easier for her to
bilitation period to evaluate the progress in Astrid’s home. write. First she used block letters, and after about three
In Astrid’s home, it became obvious that Astrid needed to weeks of training, she was able to write script again with
reorganize some of the kitchen cupboards to enhance her some effort. While she was able to manage to copy text or
ability to reach the objects she wanted to use more fre- solve a simple crossword, it was not possible for Astrid to
quently (either as she was using the wheelchair or the work write spontaneously, due to her aphasia.
chair). In both the clinic and Astrid’s home, there was lim-
ited ability to adapt all; for example, the coffee maker was Reevaluate for Enhanced and Satisfying Occupational
not possible to move at both locations, since it must be Performance
close to an electric outlet and to the sink. The next section will describe the change in occupational
performance for some of the goals that Astrid had set to-
Occupation-Based Education Program gether with the occupational therapist.
The occupational therapist continued to reason in rela-
tion to the results from the AMPS observation. Since Baseline: Make a Portion of Hot Oatmeal
Astrid had process skill ability at 0.45 logits, which indi- Independently. Astrid needed both verbal support in
cates a need for assistance, the occupational therapist finding the salt and holding the pan to serve the oats and
considered her need for help to safely make coffee (de- physical assistance to open the jam jar when she made
creased ability to reach, place, use, handle, organize, ac- cooked oats. Her performance was moderately ineffective,
commodate, adjust) by educating the staff in how to best and she performed the task with moderate effort and
support Astrid without doing the task for her. The occu- needed supervision.
pational therapist informed the staff that it is important
that Astrid performs as many actions as possible by herself Goal. Astrid will, with verbal support from the staff at
in each task. At the same time, the staff would need watch her living complex, initiate and, in an effective and safe
over and intervene in case of safety risks. The occupa- way, make herself a portion of warm oatmeal using an
tional therapist thus used educational principles. adapted work chair.

Acquisitional Occupation Current Status. When the occupational therapist ob-

After some time in the day rehabilitation program, Astrid served Astrid to evaluate this goal during a home visit, As-
had reached her first goals, and they now started to work trid managed to make her cooked oats with only verbal as-
on goals 4 and 5. To reach these goals, the occupational sistance and support for safety. When Astrid used the rolling
therapist chose the acquisitional model, which is used for chair, she performed the task without effort and effectively.
occupational skills training.
Result. Goal was met.
Goal: To Eat With Knife and Fork Again. Initially
the occupational therapist simulated the task of eating with Baseline: Make an Open-Faced Sandwich
knife and fork using a slice of bread to imitate a thin slice Independently. Astrid managed to make a sandwich with
of beef, and Astrid tried to cut it up using the cutlery and presliced cheese and cucumber if the objects were located
then eat it. They practiced this situation once every time within reach for her in the chair. It was with great effort
they met for two weeks. When Astrid mastered this simu- that she could transport herself and place herself appro-
lated task, the occupational therapist went to Astrid’s home priately in relation to the actions required for the task.
to observe her during a meal. The staff at her living com- The task took a long time for her to accomplish, and she
plex let Astrid cut her own food herself in order for her to was moderately ineffective.
practice in a natural (ecologically relevant) condition.
Goal. Astrid will independently and efficiently make
Goal: To Write with Her Right Hand. Astrid had her own sandwich with one spread (i.e., easy spread but-
some remaining aphasia and apraxia and had a hard time ter), sliced cheese, and presliced vegetable, using a nonslip
writing spontaneously, which was revealed already as the device and a rolling work chair.
occupational therapist observed her. The occupational
therapist started with simple writing exercises, like writ- Current Status. Astrid managed to make a sandwich
ing a word to describe a picture. Astrid also wanted to readily and effectively when using a nonslip pad and can
have homework that she could do in between the times at reach all needed tools and materials.
572 Stroke Rehabilitation

Result. Goal was met. initially, it is appropriate to use the AMPS at the end of
During the continuing time at the rehabilitation unit, the the treatment period to find out if ability has increased
occupational therapist and Astrid continued to work toward during the rehabilitation period.
the set goals in the same manner as described previously. Five days before Astrid was discharged, Maria com-
pleted a new AMPS evaluation. Astrid chose the same
Reevaluation Using the AMPS tasks that she performed at the first evaluation: sweeping
As the goals that Astrid set together with Maria, the oc- the floor and making a sandwich with cheese and a vege-
cupational therapist, have been reached, it is important to table. The AMPS summary report showed the scoring of
notice the changes that have occurred and to document the motor and process skills for the two observed tasks
these changes. To do so, both formal standardized evalu- and documents if the performance was adequate, ineffec-
ations of performance and of the client’s satisfaction with tive, or markedly deficient (Figs. 21-10 and 21-11). The
the results can be used. Since Maria used the AMPS AMPS graphic report showed a significant change in her
initially to observe and evaluate the performance skills motor skills, from 0.01 logits to 0.84 logits. No significant

ASSESSMENT OF MOTOR AND PROCESS SKILLS (AMPS)

PERFORMANCE SKILL SUMMARY
Caution: Item and total raw scores are not valid representations of client performance, and they cannot be used for
documentation or statistical analyses. Raw scores must be analyzed using the AMPS computer-scoring software to
create ADL ability measures. Only ADL ability measures are valid for measuring change.

Client: Evaluation date:

Id: 37 Occupational therapist:

Task 1: J-1: Sweeping the floor (Average)

Task 2: F-7: Open-face meat or cheese sandwich with sliced vegetable (Average)
Overall performance in each skill area is summarized below using the following scale:
A ⫽ Adequate skill, no apparent disruption was observed
I ⫽ Ineffective skill, moderate disruption was observed
MD⫽ Markedly deficient skill, observed problems were severe enough to be unsafe or to require
therapist intervention

MOTOR SKILLS: Skills observed when client moved self and objects during A I MD
task performance
Body Position
STABILIZES: Does not lose balance when interacting with task objects X
ALIGNS: Does not persistently support oneself during task performance X
POSITIONS the arm or body effectively in relation to task objects X
Obtaining and Holding Objects
REACHES effectively for task objects X
BENDS or twists the body appropriate to the task X
GRIPS: Securely grasps task objects X
MANIPULATES task objects as needed for task performance X
COORDINATES two body parts to securely stabilize task objects X
Moving Self and Objects
MOVES: Effectively pushes/pulls task objects and opens/closes doors or X
drawers
LIFTS task objects effectively X
WALKS effectively within the task environment X
TRANSPORTS task objects effectively from one place to another X
CALIBRATES the force and speed of task-related actions X
FLOWS: Uses smooth arm and hand movements when interacting with task X
objects
Sustaining Performance
ENDURES for the duration of the task performance X
PACES: Maintains an effective rate of task performance X

Figure 21-10 AMPS summary report for Astrid at discharge: Motor Skills.
 Chapter 21 • Enhancing Performance of Activities of Daily Living 573

ASSESSMENT OF MOTOR AND PROCESS SKILLS (AMPS)

PERFORMANCE SKILL SUMMARY
Caution: Item and total raw scores are not valid representations of client performance, and they cannot be used for
documentation or statistical analyses. Raw scores must be analyzed using the AMPS computer-scoring software to
create ADL ability measures. Only ADL ability measures are valid for measuring change.

Client: Evaluation date:

Id: 37 Occupational therapist:

Task 1: J-1: Sweeping the floor (Average)

Task 2: F-7: Open-face meat or cheese sandwich with sliced vegetable (Average)
Overall performance in each skill area is summarized below using the following scale:
A ⫽ Adequate skill, no apparent disruption was observed
I ⫽ Ineffective skill, moderate disruption was observed
MD⫽ Markedly deficient skill, observed problems were severe enough to be unsafe or to require
therapist intervention

PROCESS SKILLS: Skills observed when client (a) selected, interacted with, A I MD
and used task tools and materials; and (b) modified task
actions, when needed, to complete the task performance

Sustaining Performance
PACES: Maintains an effective rate of task performance X
ATTENDS: Does not look away from task performance X
HEEDS the goal of the specified task X
Applying Knowledge
CHOOSES appropriate tools and materials needed for task performance X
USES task objects according to their intended purposes X
HANDLES task objects with care X
INQUIRES: Asks for needed task-related information X
Temporal Organization
INITIATES actions or steps of task without hesitation X
CONTINUES task actions through to completion X
SEQUENCES the steps of the task in a logical manner X
TERMINATES task actions or steps appropriately X
Organizing Space and Objects
SEARCHES for and effectively LOCATES task tools and materials X
GATHERS tools and materials effectively into the task workspace X
ORGANIZES tools and materials in an orderly and spatially appropriate X
fashion
RESTORES: Puts away tools and materials and cleans the workspace X
NAVIGATES: Maneuvers the hand and body around obstacles in the task X
environment
Adapting Performance
NOTICES and RESPONDS to task-relevant cues from the environment X
ADJUSTS: Changes workplaces or adjusts switches and dials to overcome X
problems
ACCOMMODATES: Modifies one’s actions to overcome problems X
BENEFITS: Prevents task-related problems from persisting X

Figure 21-11 AMPS summary report for Astrid at discharge: Process Skills.

change was noted on process skills. See the graphic report GERIATRIC DAY REHABILITATION: CLIENT
in Fig. 21-12. LIVING AT HOME
Astrid reached all her goals according to the plan and
was discharged knowing she would be able to manage the In the second case, the focus will be on the day rehabilita-
tasks she wanted with the support from the staff at her tion services for the client, August. Initially some back-
living complex. ground will be given.
574 Stroke Rehabilitation

ASSESSMENT OF MOTOR AND PROCESS SKILLS (AMPS)

GRAPHIC REPORT

Client: DATE MOTOR PROCESS

Occupational therapist: Evaluation 1 0.84 0.48

ADL MOTOR ADL PROCESS

4 3

Less
More likely to be safe
physical effort ADL performance
and independent living
performing 3 2 more efficient
in the community
ADL

ADL ADL
2 ⬍ Motor 1 ⬍ Process
Cutoff Cutoff
Some
Some inefficiencies;
increased Some concerns for safe 1
93% of persons
physical effort and/or independent living
1 0 below cutoff need
performing in the community
1 assistance
ADL

0 ⫺1

More ⫺1 ⫺2
Less likely to be safe
physical effort ADL performance
and/or independent living
performing less efficient
in the community
ADL
⫺2 ⫺3

⫺3 ⫺4
Figure 21-12 AMPS graphic report for Astrid at discharge. The numbers on the activities of
daily living (ADL) motor and ADL process scales are units of ADL ability (logits). The results
are reported as ADL motor and ADL process measures plotted in relation to the AMPS scale
cutoffs. Measures below the cutoffs indicate that there was diminished quality or effectiveness
of performance of instrumental and/or personal ADL. See the AMPS Narrative Report for
further information regarding the interpretation of a single AMPS evaluation.

Acute goals for the rehabilitation, and those goals were:

August, 66-years-old, woke up in the morning four 1. Managing daily hygiene.
months ago with a left-sided hemiparesis. CT showed 2. Manage dressing independently.
“demarked ischemic areas on the right side temporal and 3. Manage visits to the toilet independently.
frontal in the basal ganglia.” He was admitted as an inpa- Six weeks later August was discharged, having met his
tient to the hospital’s stroke unit. During the stay at the goals. August was also able to walk independently with a
hospital, August suffered from fatigue and memory im- rolling walker. August was discharged to his home, and
pairments. After inpatient rehabilitation, he was able to was placed on a waiting list for continuous training at the
walk with the support of two persons and needed help geriatric day rehabilitation unit.
with personal ADL. In the beginning of the following year, about four
months after his stroke, August started at the geriatric
Subacute day rehabilitation unit. At his first visit, he met the oc-
After the acute phase of the stroke, he was moved to a cupational therapist, Maria, who conducted an interview
geriatric stroke rehabilitation ward two weeks after his with him. She had prepared herself by reading the refer-
stroke and met an occupational therapist the same day. ral and earlier patient files from when he was an inpa-
Together the occupational therapist and August set the tient. Maria worked with the OTIPM as her frame of
 Chapter 21 • Enhancing Performance of Activities of Daily Living 575

reference, which guided her work as an occupational step is 45 cm) at the main entrance, where August usually
therapist. At this first meeting, August informed her enters the house. He has received supportive railings on
about his illness and described a typical day for him at both sides of the entrance to manage the different levels.
this stage. The occupational therapist listened for the There is a home office with a computer, office chair
daily life tasks that he described as problematic, and she (no brakes), and a telephone. He manages most of his
asked him several questions to clarify his strengths and company’s bookkeeping in this office. He can manage the
problems in ADL. After their meeting, to get a clear office chair safely. It is hard for him to manage the tele-
picture of August and his circumstances and concerns, phone with his left hand, but he can manage the computer
she documented the key information she collected from with his right hand. His house is located nearby the forest,
the patient files, according to the ten dimensions de- and there are a bicycle and a car parked in front of the
scribed in the OTIPM. As August became a day patient house.
at the geriatric day rehabilitation unit, he met with all
the professionals in the team to establish the focus of the Social Dimension
rehabilitation at the time. The team worked interdisci- August’s wife is supportive, and she and August seem
plinary, as suggested in the literature, in order to deliver to have a good relationship. The three children are
quality geriatric care.10 To work interdisciplinary means also available in times of need. August also has many
that the patient is a natural member of the team, and friends and relatives that he frequently visits during his
the patient’s goals are formulated as common team goals leisure time.
for the rehabilitation of the patient. The needs of
the patient dictate which members of the team will be Role Dimension
involved and participate in the rehabilitation of the pa- August and his wife have a traditional, Swedish role distri-
tient. The members of the team can shift during the bution in the home (i.e., August takes care of the mainte-
rehabilitation process. The occupational therapist on the nance of the house and the outdoors, and his wife is re-
team will use the patient’s prioritized tasks as her focus sponsible for the domestic care). August’s role is to
during rehabilitation. maintain the outside of their house. During winter, that
means snow shoveling, but now he gets help with snow-
BEGINNING OF THE OCCUPATIONAL clearance from a neighbor. August would like to manage
THERAPY INTERVENTION PROCESS MODEL this independently. In the summer, maintaining the house
means mowing the lawn, which August would like to
Establish Client-Centered Performance Context manage by himself. August will prepare simple ready-
When his occupational therapist, Maria, began the inter- made food and also makes “fika” (coffee and cookies),
vention process with August, she first met him for an in- while his wife cooks food from scratch.
terview to find out August’s current situation/status and Before his stroke, August worked in his own company
his goals for the future. During this interview, the client together with his wife. His main tasks were bookkeeping.
and the therapist also developed a therapeutic rapport and He is worried about what will happen to the company in
a collaborative relationship. The information that the the future, and if he will be able to manage as before.
therapist gathered during this first meeting were used to August identifies himself as a traditional man in the
identify and prioritize strengths and problems with occu- village where he lives (i.e., as a hunter and fisherman, and
pational performance, and hindrances and resources in “knowledgeable in most things”). He also worries about
the client-centered performance context that supported being able to hunt again or taking the dogs for walks in
and limited his occupational performance. Some informa- the forest. Currently he cannot perform these tasks.
tion was also “stored” for use later in the process, espe-
cially information about resources and limitations within Cultural Dimension
the client-centered performance context. She learned the August lives in a farmer village where “everybody knows
following information as she established a global picture everybody else.” He shares the customs, habits, values,
of the client-centered performance context. and beliefs with the other people in the area, a traditional
village in the north of Sweden. August had a hard time
Environmental Dimension initially as he was not able to manage his “typical male”
August lives with his wife and dog in a house with three tasks in the home: snow clearance, walking the dog, driv-
bedrooms, kitchen, and living room, in a farming village ing the car/motorbike, and mowing the lawn.
outside the main city in northern Sweden. They have
three adult children and two grandchildren. Their house Motivational Dimension
is on one level; the toilet has a raised seat with armrests, In his leisure time, August spends a lot of time in nature,
and the shower has a shower stool. There are no thresh- mainly hunting and fishing. He hunts mainly for moose
olds in the house, but there is a small level change (one and small game. This is something that he enjoys, and he
576 Stroke Rehabilitation

would like to regain this ability. He was also responsible, August has progressed well during his rehabilitation
together with a friend, for managing the local shooting mainly because he is motivated and is in otherwise very
range. He hopes to be able to continue this during the good physical condition.
upcoming hunting season. August used to make daily
walks together with his hunting dog, walking in the forest Adaptation Dimension
or biking, and he wants to pursue this again. He is also August has the ability to adjust to his current circum-
interested in motors and has his own motorbike and has stances and takes in instructions for exercise/training and
enjoyed ballroom dancing. continues the training at home by himself in between the
rehabilitation visits.
Institutional Dimension He uses his wife and friends to increase his activity
August’s wife supports him, and he has no demands from repertoire in his everyday life and makes sure that he can
society to go back to work since he had planned to retire try to regain activities/tasks that he has done earlier him-
during this year. He has the whole team at the day reha- self (i.e., walking the dog and mending inventories at the
bilitation unit supporting him for the time during his re- shooting range).
habilitation. There are no medical restrictions related to
August’s impairments that limit him from doing the tasks Develop Therapeutic Rapport and Collaborative
that he has done before. Relationships
August was motivated for the continuous rehabilitation
Body Function Dimension and positive that he would be able to practice more at the
August survived a right-sided stroke about four months rehabilitation unit. He told the occupational therapist,
ago. He has a weakness in both left hand/arm and leg, but Maria, how he managed during the days at home and re-
can walk safely and independently with a rolling walker. viewed areas of difficulty. Maria listened carefully and
August feels depressed and has a hard time sleeping at asked follow-up questions as needed, so that she would
night. He is easily fatigued. get a complete picture of August’s performance context.
They both felt they had a nice therapeutic relation after
Task Dimension this conversation.
August describes his biggest problems, which are his
highest priorities. He wants to manage to hold a tele- Identify and Prioritize Reported Strengths
phone receiver with left hand at the same time as he and Problems of Occupational Performance
makes notes with his right hand. He also wants to hold After the collection of information on the ten dimen-
his hunting weapon in a correct way, and hopefully later sions needed to establish the client-centered perfor-
he would like to continue to hunt. He also mentions mance context, the occupational therapist needs to
wanting to hold a potato on the fork with one hand and summarize the information. As the OTIPM is followed,
peel it with the knife in the other hand. Another task that two parts are documented: (1) resources and limitations
he wishes to do is walking the dog. For him to do this, he within the client-centered performance context, and
needs to be able to walk safely with a walking stick and (2) self-reported strengths and problems of occupa-
manage to lead the dog on a leash without the dog pull- tional performance.
ing him. Due to his decreased balance and gait, this is The documentation at this stage is described below.
currently not possible.

Temporal Dimension
A usual day in August’s life right now is that he rises up Background information: August is 66-years-old and lives
early in the morning, completes his bathroom routine, in a village outside a major city with his wife. They run a
gets dressed, eats breakfast, and reads the daily newspa- company together. August is responsible for the book-
per. He then exercises for one hour, eats another small keeping. The rehabilitation starts by the team developing
snack in midmorning, and then takes a rest and watches a rehabilitation plan together. August’s main interests are
TV. He has a coffee midday and exercises for another hunting, caring for his dog, and being outside in the for-
half hour. Afterwards he cooks/warms dinner and est. August expresses problems using his left hand the way
he wants to (i.e., holding his hunting rifle), and his weak
watches TV in the evening. He goes to bed around
left leg interferes with performing his other interests.
10:00 pm.
Reason for initial referral: August was referred to day
August lives at home during the outpatient rehabili- rehabilitation unit in the geriatric department for inter-
tation and goes by taxi the 30 km into town two morn- disciplinary team rehabilitation. August will meet with
ings a week between 9:00 and 11:30 am. This will con- Maria, the occupational therapist, for evaluation and
tinue until he meets the rehabilitation goals documented intervention.
together with the team, in about two to four months.
 Chapter 21 • Enhancing Performance of Activities of Daily Living 577

The first part is to identify the resources and limita- them. The Canadian Occupational Performance Mea-
tions within this client’s performance context, and how sure (COPM)7 is a tool that can be used, since it will
the limitations hinder the client’s engagement in his life clarify and describe the strengths and limitations of the
roles. From the list of tasks discussed, the client priori- client. Maria administered the COPM at the beginning
tizes which he finds to be most important. The perfor- of the rehabilitation period. The COPM helped Maria
mance of tasks that support the clients engagement in life and August priorities for intervention. See August’s
roles are the strengths, while those tasks that the client COPM results in Fig. 21-13.
experience as problems to perform and that hinder the August also put priority on driving again, but in
engagement in life roles are limitations. At this stage, it Sweden there is a common rule that each person who has
might be appropriate to use another instrument to ver- a stroke is not allowed to drive during the first six months
balize the strengths and limitations and to prioritize after the stroke.

STEP 1A: Self-Care Importance

Personal Care Eat with cutlery 9
(e.g., dressing, bathing,
feeding, hygiene)

Functional Mobility
Walk in the forest 10
(e.g., transfers, Bike 8
indoor, outdoor)

Community Management
(e.g., transportation,
Drive a car 10
shopping, finances)

STEP 1B: Productivity

Paid/Unpaid Work Speak in telephone and 9

(e.g., finding/keeping
a job, volunteering)
simultaneously take notes
Bookkeeping 7
Household Management
Shovel snow 7
(e.g., cleaning, doing Cut grass 7
laundry, cooking)

Play/School
(e.g., play skills,
homework)

STEP 1C: Leisure

Quiet Recreation
(e.g., hobbies,
crafts, reading)

Active Recreation
Walk the dog 9
(e.g., sports, Hunting 10
outings, travel)
Manage local shooting range 8
Barn dance 5
Socialization
(e.g., visiting, phone calls,
parties, correspondence)

Figure 21-13 Results from August’s interview using step 1 of the Canadian Occupational
Performance Measure. (Modified from Law M, Baptiste S, Carswell A, et al: Canadian occupa-
tional performance measure, Toronto, Ontorio 1994, CAOT Publications ACE.)
578 Stroke Rehabilitation

analysis will give Maria the opportunity to evaluate the

Identified Level of Performance:
quality of the client’s performance when executing a
August manages his morning routines and simple domestic chosen task. Maria planned to use a standardized instru-
chores independently, although he cannot manage peeling ment to evaluate August’s performance, and she decided
his potatoes at mealtime since he cannot grasp the fork in to use the AMPS, for her performance analysis. Since
his left hand.* He has problems talking on the phone and the tasks that August had problems performing were
simultaneously taking notes, which he needs to do to run not available as task choices in the AMPS, she did the
his company. August is unable to walk his dog in the forest,
observation with her “AMPS eyes” and could thus de-
which was his duty earlier. He also reports that he is not
scribe his performance using the AMPS vocabulary, but
able to attend to his house and garden chores in a safe man-
ner, due to his limited balance and limited grip with his left she was not able to enter the information into the
hand. He also wants to be able to hold his rifle in a correct AMPS software. The information was still very valuable
way and, if possible, also hunt during the fall again. and helped her in her documentation of August’s
Reported priorities: performance.
■ Being able to eat with both cutlery again (knife and
fork) Make a Phone Call and Take Notes. In August’s
■ Talk in the telephone and simultaneously take notes case, the occupational therapist wanted to observe the
■ Hold a rifle in a safe and “right way” (shooting position) client perform some daily tasks that he experienced dif-
■ Walk the dog in the forest independently
ficulties performing and that he had prioritized. August
chose to start by showing how he used the telephone.
*In Swedish culture, it is common for each person to peel boiled The observation was carried out at the OT department,
potatoes by holding the potato in the air, supported on a fork held in using the telephone of the occupational therapist. It be-
one hand, while the person simultaneously removes the peel using a
came obvious that August was not able to hold the re-
knife held in the other hand (Fig. 21-14).
ceiver in an effective manner, as it slid out of his hand. He
was not able to hold it long enough, so that he would be
able to make notes at the same time with the pen in his
right hand.
After the observation, Maria and August discussed how
he had experienced the task, and the occupational thera-
pist told him what she had observed as his strengths and
limitations during his performance. Maria also suggested
that he could do the task by leaning the elbow on the ta-
ble, but August expressed a need to do the task without
elbow support.

Peel Boiled Potatoes with Knife and Fork. At

the third observation, August performed the task of
peeling a boiled potato on a plate in front of him at
the kitchen table. He sat on a chair by the table and
had the plate with potatoes in front of him, with cut-
lery on the side of the plate (fork to the right and knife
to the left of the plate). It was hard for August to
turn his left hand in an effective manner to put the
fork into the potatoes. As he pierced the potato on the
fork, he had difficulty holding it to peel the skin
off with the knife in his right hand. His arm was un-
steady, and he was not able to hold the position for the
Figure 21-14 Relearning to use cutlery. amount of time needed to peel the whole potato. He
managed slightly better when he leaned his left lower
arm on the table, but still did not have an effective
performance.
Observe Client’s Task Performance and Implement
Performance Analysis Define and Describe Actions the Client Does and Does
As the OTIPM is followed, it is time for Maria to ob- Not Perform Effectively
serve August doing some of the tasks that he identified The occupational therapist made a note in the patient file
as being problematic for him. This first performance about the observed and measured baseline.
 Chapter 21 • Enhancing Performance of Activities of Daily Living 579

him have to reach far to pick one up in order to make

Baseline: August managed to perform the task “making a
notes. This provided some limitation since he had trouble
phone call” with a mild degree of effort (the grip on the
receiver), a modest degree of disorganization, and an un- holding the receiver with his left hand at the same time.
desirable use of time (he lost his grip and needed to use He had limited ability to grip and coordinate. He was also
his right hand instead), which resulted in the inability to limited in attending to the task of talking in the phone,
make notes at the same time as he spoke on the phone. since he needed to concentrate on holding the receiver in
his left hand and simultaneously making notes with his
right hand. August was ineffective in accommodating his
actions and his work area.
Grouping Skills of Most Concern into Meaningful
Clusters. August’s limitations can be summarized into Global Baseline: Peeling Potato. August performed
the following clusters: the task of peeling the potatoes using cutlery with moder-
ate effort and a mild degree of disorganization.
Cluster 1: Positions and Coordinates. August needs to
place the arm in a position that facilitates continuation of Specific Baseline: Peeling Potato. August had prob-
the task and coordinate both limbs. August has limited lems manipulating the fork in a necessary way with his left
ability to hold the arm in the needed position long enough hand, which resulted in limitations in the ability to pierce
to make notes with his right hand. the fork into the potato and position it for ease of peeling
with the knife in the right hand. His elbow was angled out
Cluster 2: Grips, Manipulates with His Left Hand, and from the body as he performed the task. He hesitated
Lifts. August has a limitation in holding the fork in his before he accommodated by putting the arm onto the ta-
left hand in a position to facilitate peeling with the knife ble for support.
in the right hand. In the same manner, Maria evaluated the other highly
prioritized tasks: to shoot with a hunting rifle and to walk
Cluster 3: Attends and Organizes. August showed limi- the dog. These observations were made at a shooting
tations in listening to the conversation on the telephone range and at home as he walked his dog.
at the same time as he took notes. The limitation was in-
creased as the pen and paper were placed too far away at Define/Clarify or Interpret the Cause. When
the desk Maria had evaluated the quality of her client’s perfor-
mance, she continued to clarify or interpret the cause of
Cluster 4: Paces, Heeds, Chooses, Continues, and the limitations observed. This can be done by taking into
Sequences. August also had strengths. August shows a nice account all information collected during the establish-
pace as he performs the tasks, and he also works toward ment of the client-centered performance context, by
completion of the task. He chooses the tools and materi- thinking about that the observations made on the client’s
als, and works continuously without interruption and performance, and by administering other evaluations
completes both tasks in an orderly sequence. through interviews and nonstandardized or standardized
evaluations. To underscore the unique focus in OT on
Initial Evaluation activity and participation, activity and participation must
Baseline: Observed. When Maria, the occupational be documented.
therapist, has summarized the strengths and limitations, When Maria looked through her notes from the
she continues to document August’s baseline, both the ten dimensions, she saw that August’s problem was
global baseline and the specific baseline. Both these base- mainly related to his hemiparetic left arm and leg.
lines will be documented in the patient files and will be Maria also noted that August had a swollen left hand,
used as the base as the team plans the rehabilitation, in- increased spasticity, and decreased coordination in the
cluding setting the goals with August. elbow and hand. This influenced his occupational
performance and primarily the fine motor aspects of the
Global Baseline: Making Phone Call. The occupa- performance. Due to his left-sided weakness, he also
tional therapist documented in the files the observed and had problems with balance; however, Maria did not
measurable global baseline: August managed the task of need to investigate that further, since she had informa-
making a phone call with mild degree of effort and was tion from the interdisciplinary team members to con-
moderately effective, which limited him to make the notes firm these observations. During the team conference
at the same time. held once a week, the whole team received a very thor-
ough picture of the client, as all members of the team
Specific Baseline: Making Phone Call. August had presented their results of evaluations and tests to the
the pens far away from his sitting position, which made other team members.
580 Stroke Rehabilitation

Initial Occupational Therapy Evaluation made a home visit earlier, she was able to give precise and
and Interpretation of Cause concrete advice on what to do and how to go about per-
Decreased motor function in the left side, increased tone, forming tasks at home. For example, she encouraged him
and decreased balance influenced how August performed to answer the phone at home using his left hand, turning
his prioritized daily tasks. Decreased fine motor control, a on the switch of the lights also using his left hand, practic-
swollen hand, and decreased strength in his left hand had ing peeling potatoes at meals at home, and, with his wife,
disrupted his ability to grip and manipulate objects. At- taking walks with their dog using walking poles.
tending to two things simultaneously was also limited. The
decreased balance and muscle weakness in his leg affected Acquisitional Occupation to Reacquire, Develop,
his ability to walk in the forest and walk the dog. or Maintain Occupational Skill
At the day rehabilitation clinic, Maria and August decided
Document Client’s Baseline and Goals to start training the task of making a phone call and taking
The interdisciplinary team met with August to plan and notes, and the task of peeling boiled potatoes using a knife
set goals to reach during the rehabilitation period. Maria and fork, since both these goals were possible to reach in
brought her notes of the global and specific baselines, and a short time. August practices these two tasks at every oc-
together they set the following goals: casion during OT (two times, 45 minutes each week). To
■ To eat a meal using both knife and fork without ef- use the cutlery, the training was done in the training
fort and in an efficient manner kitchen at the clinic, and the telephone practice was done
■ To talk on the phone and make simultaneous notes in the OT office. The aim of the practice was for August
effectively and with minimal effort to practice to use efficient grips as much as possible, and
■ To hold a rifle in a safe and effective way to practice multiple repetitions of the task. For example,
■ To walk the dog independently and safely in the in the early sessions August peeled one to two potatoes,
forest. and it took him up to 10 minutes, and at the end of
Maria needed to select an intervention model, and plan therapy, he managed five to six potatoes in the same time
and implement occupation-based interventions. Each frame. The occupational therapist also encouraged him to
member of the team worked according to his or her spe- practice in between sessions at home. After about one
cific focus and towards those goals. For example, the month, the goals were met.
physiotherapist worked with training of underlying body
functions (i.e., increase balance, muscle strength, endur- Adaptive Occupation to Compensate for Ineffective Actions
ance, fine motor) to strengthen August’s body, so that he When those first goals were met, they proceeded with the
could meet his goals. The occupational therapist contin- goal focused on shooting with a hunting rifle. Since the goal
ued her process in line with OTIPM and now the time was to shoot with his own rifle, it was safer for both August
had come to choose a model for intervention that would and Maria to start with an air gun inside a shooting range.
cover the goals and focus on occupations. The occupational therapist thus used a shooting range avail-
able at another OT department in the hospital. August
Occupation-Based Interventions in Instrumental started to practice sitting in an office chair with wheels that
Activities of Daily Life needed to be locked before starting. The chair was placed in
front of a table with a large piece of foam-rubber to be used
as a support for the elbow under his left arm (Fig. 21-15).
Intervention Plan He practiced shooting about 30 to 35 minutes each session.
Acquisitional occupation: making phone calls, eating
with cutlery
Adaptive occupation: using the air gun (available in
OT department), sitting at a table with support under
arm, taking the dog for a walk, and doing “Nordic walk-
ing” with poles with supervision from wife
Restorative occupation: introduced to a program to
practice training with affected hand using therapeutic
putty at home. Received a glove for compression of hand
to prevent edema of the hand

August visited the day rehabilitation unit and met the oc-
cupational therapist twice a week. In between, he prac-
ticed everyday at home with a self-training program and
other home tasks. Since the occupational therapist had Figure 21-15 Adaptations to support hunting occupation.
 Chapter 21 • Enhancing Performance of Activities of Daily Living 581

Initially he needed frequent breaks, but as he continued to manner, Maria also assessed August by asking him how
practice, he became stronger and needed fewer breaks. Au- he managed in the different occupations. In this way, she
gust was skilled and managed to perform the task in an ef- did not have to observe him in all tasks to appraise his
fective and safe manner after some practice. But as time progress.
came to discharge August, there was concern that his own After one month of training, August managed to
heavier hunting rifle would be too difficult for him to use. safely hold the receiver of the telephone and simultane-
Since Maria and the rest of the team had the opinion that ously make notes (Fig. 21-16). He could also peel pota-
August did not have any serious cognitive impairments after toes using a knife and fork and eat with all cutlery
his stroke, they encouraged August to practice with his own again. The more August used his left hand actively
rifle in their shooting range when he felt he was ready. Au- in daily tasks, the more the edema diminished. When
gust also thought of acquiring an elbow support, a portable he was discharged after five and a half months (i.e., 34
telescope pole with a “u” for the elbow, for use when he treatment sessions), the goal to be able to walk in
hunted in the forest. the forest and to safely walk the dog using a pole for
support also were achieved. He was also able to shoot
Restorative Occupation to Restore Personal Factors with an air gun with support under his elbow. He had
and Body Function not been able to try hunting yet, since the hunting sea-
Initially in the rehabilitation period, the occupational ther- son had not yet started. See evaluation of results in
apist prepared a program for hand training with therapeu- Table 21-2.
tic putty that August could use himself to practice, intensify
the home training, and hopefully minimize the edema in
his left hand. Maria also tried out a compression glove for
treatment of the edema. She informed August to use the
glove during day time when the hand was not engaged.

Intervention Summary
■ Occupational training to peel boiled potatoes and make
phone calls
■ Home exercise program with training therapeutic putty
and eating with cutlery at home
■ Air-rifle shooting at a shooting range
■ Reevaluate for enhanced and satisfying occupational
performance

Documentation of Client’s Current Ability and Result

When August made progress, it was important for the
occupational therapist to document this in his files. Since Figure 21-16 Improved occupational performance related to
August could evaluate his own ability in an adequate work tasks.

Table 21-2
Evaluation of Results
GOAL BASELINE STATUS CURRENT STATUS

To eat a meal using both knife August performed the task of peeling the August can manage to eat a meal without
and fork without effort and potatoes using cutlery with moderate ef- effort and effectively with both cutlery.
in an efficient manner fort and a mild degree of disorganization.
To talk on the phone and take August managed the task of making a August can talk in the telephone and take
simultaneous notes effec- phone call with mild degree of effort and notes simultaneously in an effective
tively and with minimal was moderately effective, which limited manner and without effort.
effort his taking notes at the same time.
To hold a rifle in a safe and August could hold an air gun in shooting August can shoot with an air gun, sitting
effective way position, with support under left elbow, with support under left elbow, in a safe
safely and with mild ineffectiveness. and effective manner
To walk the dog indepen- August needed support from one person August can walk the dog in the forest in-
dently and safely in the and walking sticks to safely walk in the dependently and safely if using a walk-
forest forest. ing pole.
582 Stroke Rehabilitation

Results. August had reached all his goals according to 5. Hall P, Weaver L: Interdisciplinary education and teamwork: a long
the initial plan from when he started his rehabilitation. and winding road. Med Educ 35(9):867–875, 2001.
6. Holbrook M, Skilbeck CE: An activities index for use with stroke
After another three months, a follow-up phone call was patients. Age Ageing 12(2):166, 1983.
made, and he then informed the team that he was able to 7. Law M, Baptiste S, Carswell A, McColl MA, et al: Canadian occupa-
use his hunting rifle at the shooting range when he had the tional performance measure (Rev. 4th ed.), Ottawa, Ontario, 2005,
elbow support attached to his left elbow. Less than one year CAOT Publications ACE.
after his stroke, August also was able to return to hunting. 8. Lawton, MP, Brody, EM: Assessment of older people: Self-
maintaining and instrumental activities of daily living. Gerontologist
9(3):179–186, 1969.
REVIEW QUESTIONS 9. Legg LA: Therapy-based rehabilitation services for stroke patients
at home. Cochrane Database Syst Rev (1):CD002925, 2003.
1. What are the key components of the OTIPM? 10. Leipzig RM, Hyer K, Ek K, et al: Attitudes toward working on in-
2. What are four examples of motor and process skills terdisciplinary healthcare teams: A comparison by discipline. J Am
Geriatr Soc 50(6): 1114–1148, 2002.
included on the AMPS? 11. National Board of Health and Welfare: A grant to stimulate early and
3. What are examples of interventions that would be con- coordinated rehabilitation— about the rehabilitation process, content and
sidered adaptive occupation? application. (in Swedish: “Stimulansbidrag för tidig och samordnad
4. What are examples of interventions that would be con- rehabilitering— om rehabiliteringsprocessen, innebörd och
sidered acquisitional occupation? tillämpning”.) 2000. 04 ISSN 1403–338, 2000.
12. Nouri FM, Lincoln NB: An extended activities of daily living scale
5. What are examples of interventions that would be con- for stroke patients. Clin Rehabil 1(4):123, 1987.
sidered restorative occupation? 13. Park S: Enhancing Engagement in Instrumental Activities of Daily
6. What are examples of interventions that would be con- Living: An Occupational Therapy Perspective. In Gillen G. &
sidered occupation-based educational programs? Burkhardt A, editors: Stroke Rehabilitation: A Function Based Approach,
2nd edition, St. Louis, 2004, Elsevier.
14. Sonn U, Törnqvist K, Svensson E: The ADL taxonomy— from
REFERENCES individual categorical data to ordinal categorical data. Scand J Occup
1. Bond MJ, Clark MS: Clinical applications of the Adelaide Activities Ther 6(1):11–20, 1999.
Profile. Clin Rehabil 12(3):228, 1998. 15. Steultjens EMJ, Dekker J, Bouter LM, et al: Evidence of the efficacy
2. Fisher AG: AMPS Assessment of motor and process skills. Volume 2: User of occupational therapy in different conditions: an overview of sys-
manual (6th ed.), Fort Collins, CO, 2006, Three Star Press. tematic reviews. Clin Rehabil 19(3):247–254, 2004.
3. Fisher AG: Occupational therapy intervention process model, Fort Collins, 16. Törnqvist K, Sonn U: Towards an ADL taxonomy for occupational
CO, 2009, Three Star Press. therapists. Scand J Occup Ther 1(2):69–76, 1994.
4. Grimby G Andren, E Holmgren E, et al: Structure of a combination 17. Whiting S, Lincoln NB: An ADL assessment for stroke patients.
of functional independence measure and instrumental activity mea- Bri J Occup Ther 43:44, 1980.
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1996.
 j u di th ro g ers
m e g an ki rs h bau m

chapter 22

Parenting after Stroke

key terms
adaptive baby care equipment one-handed baby care visual history
adaptive baby care techniques transition tasks

chapter objectives
After completing this chapter, the reader will be able to accomplish the following:
1. Describe visual history.
2. Describe transitional tasks.
3. Have a basic understanding of one-handed baby care task performance.
4. Identify examples of adapted baby care equipment.
5. Apply parent child collaboration to a baby care task.
6. Identify an emotional or cognitive problem that can affect baby care.
7. Appreciate the importance of teamwork between occupational therapists and mental
health practitioners in services to parents who have had strokes.

This chapter will discuss caring for an infant or child by children. Grandparents who have had strokes may want to
those who have had a stroke. The chapter will raise issues participate fully in the lives of their grandchildren or may
that caregivers and prospective caregivers may encounter need to act as primary caregivers.
and will provide options available to them. The focus is Some people may feel that the task is insurmountable,
mainly on physical caring of infants, but also includes but experience has indicated that bringing up a child is an
emotional and cognitive issues relevant to parenting chil- achievable goal for many stroke survivors. In fact, work-
dren of varied ages. The goal of this chapter is to provide ing toward this goal can increase confidence, help reinte-
practical advice to occupational therapists, so they can grate the family, enhance general functioning, and reduce
help caregivers find adaptive methods to carry out the feelings of depression.
tasks of childcare. Material in the chapter is based primarily on interven-
Although strokes are most common after the age of tion and research with parents with physical or cognitive
65-years-old, they can occur at any age. For example, disabilities and their children at Through the Looking Glass
women may have a stroke during pregnancy or during the (TLG) in Berkeley, California, since its founding in 1982.
postpartum period. Men or women may have strokes be- TLG is a disability culture and independent living-based
fore considering parenthood or when they already have organization that has pioneered research, training,

583
584 Stroke Rehabilitation

resource development, and services for families in which overstressing the body during care and to help reduce de-
a family member has a disability or medical issue, and is pression associated with postnatal onset or worsening of
The National Center for Parents with Disabilities and disability. By increasing the caregiving role of the parent
their Families, funded by National Institute on Disability with a disability, stress was lessened in the couple; there was
and Rehabilitation Research (NIDRR), U.S. Department more balance of functioning in the family system.
of Education. Illustrative examples in this chapter are
based on services provided to TLG clients who had VISUAL HISTORY
strokes and raised babies and children. This research and
intervention framework is summarized, as follows, focus- TLG has emphasized the use of videotaping in both re-
ing on points that are particularly salient for serving par- search and intervention because of the lack of images of
ents who have experienced strokes. parenting by individuals with physical disabilities, which
affects diverse professionals, including occupational ther-
RESEARCH ON PARENT/CHILD apists, and parents and their family members. The occu-
COLLABORATION pational therapy (OT) team coined the term visual history
to refer to the mental image most people have of the way
The groundbreaking study of the interaction of mothers a task is accomplished.12 For example, when people imag-
with physical disabilities and their babies (funded by the ine holding a baby, they think of a baby in someone’s
National Easter Seal Research Foundation, 1985 to 1988) arms. Such limited visual histories may interfere with the
documented the reciprocal and natural process of adapta- goal of learning to accomplish a task in a new way. Thus,
tion to disability obstacles as it developed between 10 occupational therapists and clients need to be aware of
mothers and their babies.6 Basic care (feeding, bathing, their limited visual history and the need to expand and
lifting, carrying, dressing/diapering) was videotaped from change it. For instance, holding a baby can be accom-
birth through toddlerhood. These families were not re- plished by attaching an infant car seat to a wheelchair
ceiving intervention or baby care adaptations. Analysis of (Fig. 22-1). In order to expand visual history regarding
videotapes mapped the gradual mutual adaptation process parenting, TLG has developed DVDs showing different
during interaction between parent and infant. Results techniques of accomplishing baby care tasks, including
documented the mothers’ ingenuity in developing their one-handed techniques often needed in parents who have
own adaptations, the infants’ early adaptation, and the experienced strokes.
mothers’ facilitation of the infants’ adaptation.
Based on the natural adaptation process recorded in OCCUPATIONAL THERAPY ASSESSMENT
this study, subsequent intervention was developed that TO GUIDE BABY CARE ADAPTATIONS
facilitated collaboration between parent and infant during
baby care tasks, such as that described in the Adaptive TLG developed an assessment tool to guide occupational
Techniques and Strategies section of this chapter. practice with parents with disabilities and their babies
and toddlers. The assessment provides a framework for
RESEARCH ON BABY CARE ADAPTIVE understanding the complexity of OT support of caring
EQUIPMENT for a baby when a parent has a physical disability. This

In the 1990s, TLG conducted three research projects

(funded by NIDRR, U.S. Department of Education), spe-
cifically focused on developing and evaluating the impact of
baby care adaptations for parents with physical disabili-
ties.6,12,14 The equipment development was informed by
adaptations invented by mothers in the previous Easter Seal
study. For example, in that study, several mothers lifted their
babies with one hand by grasping their babies’ clothing. In
the subsequent baby care equipment development projects,
TLG designed and used lifting harnesses as a more secure
version of this natural adaptation. All three equipment stud-
ies used analyzed videotapes of care and interaction prior to
and subsequent to providing baby care adaptive equipment.
Such equipment was found to have a positive effect on
parent/baby interaction, in addition to reducing difficulty,
pain, and fatigue relating to baby care. The equipment also Figure 22-1 Wheelchair and infant car seat adaptations to
seemed to prevent secondary disability complications from support parenting occupations.
 Chapter 22 • Parenting after Stroke 585

assessment tool, The Baby Care Assessment for Parents with the child. Ongoing training and reflective supervision are
Physical Limitations or Disabilities,15 guides the OT practi- integral to these services.
tioner in intervention work and analyzing potential ob-
stacles. It brings together the parent’s perspective and the Working with Pregnant Women Poststroke
occupational therapist’s skill in task analysis. This tool Working with a woman who is trying to decide whether
provides an extensive review of all baby care functioning to become pregnant or who is in the first trimester of
within the home and community relative to the parent’s pregnancy is a challenge for the OT practitioner who has
needs and/or wishes. The tool identifies the parent’s to imagine both how pregnancy may impact the client’s
strengths and highlights the obstacles that are interfering mobility and how her limitations may affect her ability to
with his or her ability to complete the task in the least care for the baby. It is helpful for women to understand
demanding, most efficient, safe, and ergonomic manner that physical difficulties from a stroke need not close off
and with a method that supports and enhances the parent- the option to have a child. During pregnancy, mobility
child relationship. This assessment tool also has a parent generally is affected from the latter part of the second
interview section, which helps the occupational therapist trimester, when the center of gravity has changed, to de-
find the activities important to the parent. It incorporates livery.10 This change in the center of gravity will most
the disability philosophy of independent living, i.e., hav- likely affect walking, standing up, and/or transferring in
ing opportunities to make decisions that affect one’s life and out of bed, cars, etc. See Chapters 14 and 15. The
and to choose which activities one wants to pursue. It woman may benefit from a mobility device (walker or
should be noted that the assessment emphasizes visiting wheelchair/scooter). It might be beneficial to consult a
in the home and community. physical therapist. If the leg is mildly involved, a rollator
(four-wheeled walker) would be a good choice. It could
INTERVENTION MODEL not only make her stable but also could be used for carry-
ing her baby around the house. If the affected leg is very
TLG’s research has informed its intervention with thou- involved, walking can be difficult, and a motorized wheel-
sands of parents with disabilities and their children. The chair/scooter could be the most appropriate choice. See
intervention model has been described and rigorously Chapter 26.
evaluated since the 1980s, demonstrating positive out- Willingness to accept a motorized vehicle (wheelchair
comes with particularly stressed families in which parent or scooter) can be problematic for the prospective mother.
and/or child has a disability.5,6 The intervention model It is important for the future mother to understand that
includes multidisciplinary teamwork emphasizing: the wheelchair/scooter would make her more comfort-
1. Infant/parent and family relationships, integrating able, less likely to fall, and more able to conserve energy
infant mental health and family systems expertise and care for the baby after birth. If she tries a motorized
2. Parenting and intervention adaptations to address piece of equipment for an activity such as shopping, she
diverse disability issues may realize how easy some activities can be. She may also
3. Developmental expertise regarding infants and be concerned about how she will be able to care for the
children baby. A discussion of the adaptive techniques described in
4. Integrating and respecting personal/family disabil- this chapter may ease her mind about solutions to physical
ity and cultural experience limitations. However, a crucial issue in decision-making
5. Functioning in the natural environment, through about parenthood is how the stroke has affected emo-
home and community-based assessment, interven- tional and cognitive functioning.
tion, monitoring, and referrals
A family in which a parent has experienced a stroke is usu- Facilitating Relationships between Babies
ally served in the home and community by an occupational and Parents Poststroke
therapist who assesses and provides baby care adaptations, Without appropriate supports, a stroke occurring late in
introduces cognitive adaptations, consults on environmen- pregnancy or postpartum can be devastating to a mother,
tal access, and monitors infant/child development issues family, and infant/parent relationship. Since hospitaliza-
and continued safety and appropriateness of the adapta- tion creates a separation between mother and child, it is
tions over time. The occupational therapist works closely critical to consider the need to promote attachment dur-
with the home visiting mental health practitioner who at- ing the subacute phase of rehabilitation. The occupational
tends to the emotional issues in parent, child, and family, therapist should have attachment activities as part of the
such as grieving, loss, depression, volatility or impulse treatment plan. Attachment activities will change depend-
control, management of children’s behavior, couple con- ing on the age of the baby or child. All baby care activities
flict, and changes in family roles and functioning. Both can support the relationship between parent and child.
providers facilitate interaction between parents and their However, if the baby is under 9-months-old, holding,
infants or children and monitor safety and well-being of feeding, and soothing are particularly essential activities.
586 Stroke Rehabilitation

If the caregiver has sustained a stroke when his or her

discharged at 3-days-old and went home with John, his
child is a toddler, or if the caregiver who had sustained an
dad. Darla’s parents moved in to help with David. Darla
earlier stroke comes in seeking help, the emphasis is more
was in a coma in intensive care unit for several days. As
on supporting and scaffolding interaction between parent
soon as she was transferred to the subacute unit, her
and child, for instance during play, snack, snuggle time,
family was able to bring David to her. The hospital staff
and outings, in order to promote the parent and child
put David in a sling baby carrier. Although David was
relationship.
secured in the sling, Darla feared that he would fall.
Facilitating Physical Care by the Parent The hospital staff was unaware that her concern was
because of her need for some support when sitting. She
Being able to provide physical care to the baby is one of
had not yet gained sufficient trunk control and in-
the essential elements in parenting. For a caregiver who
creased sitting balance, so holding her baby increased
has had a stroke to pursue the dream of caring for a baby,
her anxiety. In this situation, the occupational therapist
he or she may need baby care equipment, appropriate du-
could have checked with Darla and discovered why she
rable medical equipment (DME), and adaptive techniques.
felt insecure holding her baby, and then a more appro-
Transitional tasks refer to tasks that are necessary before
priate position could have been found. One such posi-
accomplishing or between basic baby care tasks. There-
tion would have been to have her lie on her more af-
fore, it is important to begin intervention with these tasks:
fected side with David side lying on her arm, so that
(1) holding, (2) carrying and moving, (3) transfers, and
they could look at each other and so that Darla could
(4) positional change.12
kiss and touch him.
■ Holding: The task of holding is a prerequisite for
carrying, transferring, feeding, changing, burping,
or comforting your child.
■ Carrying and moving: The task of carrying is a pre-
requisite for moving around the house and commu- Carrying and Moving
nity. If a caregiver cannot carry or move the baby, TLG has recommended a four-wheeled walker, also
then he or she will be confined to functioning in one known as a rollator, for safely moving the baby around
room. the house. This walker has been used successfully with
■ Transfers: The task of transfer is a prerequisite to caregivers with hemiplegia (where half of the body is
being able to do several activities such as diapering paralyzed) and with those with ataxia (problems with
and putting the baby into a crib or high chair coordination), because it keeps both baby and parent
■ Positional change: The task of positional change is a physically stable. This piece of equipment consists of a
prerequisite for being able to burp a baby or diaper baby carrier securely attached to a walker seat. The
change a baby. A positional change is defined as baby carrier can be a bouncy seat or a booster seat, al-
changing a position of the baby while the baby re- though the former is more difficult to attach. TLG
mains on the same surface. prefers a feeding seat that can be positioned in several
ways, such as reclining for an infant or more upright for
Holding the older baby. Moreover, having a baby seat on the
Holding involves contact with the baby, whether it is di- walker positions the baby at an optimal height for trans-
rectly in the mother’s arms or with the aid of a holding fers (Fig. 22-2).
device. It is essential that the parent feel confident that the When the walker is introduced depends on the stability
baby is secure and for the baby to experience this security. of the parent. It has been successfully used during inpa-
Useful positions and holding devices for a parent with tient physical therapy to help prepare the caregiver for
limited sitting balance include: going home. However, it is designed to be used only
■ Side lying for both baby and parent within a household. Extreme caution needs to be used if
■ Parent’s bed at 45 degree angle, sitting the adapted walker is moved over any uneven or raised
■ Sling, nursing pillows, wedge pillow surface since it is top heavy with a baby on it. In consulta-
tion with a rehabilitation engineer, adding weights to the
lower part of the walker can be considered to compensate
CASE STUDY 1 for the added weight of the baby. Otherwise, strategies are
used by parents with physical disabilities that may be less
Darla had a cerebellar stroke at 81⁄2 months of preg-
feasible with parents that also have cognitive difficulties,
nancy. Immediately following the stroke, her son David
i.e., putting the back wheels over the raised surface sepa-
was delivered by caesarean section. He was healthy and
rately, lifting one of the sides of the walker over the raised
weighed 6 pounds 10 ounces. His lungs were fully de-
surface with an arm, or using a leg to nudge one side of
veloped, and he did not need hospitalization, so he was
the walker at a time. The occupational therapist should
 Chapter 22 • Parenting after Stroke 587

A B
Figure 22-2 A and B, Walker and baby seat adaptations to support parenting occupations.

carefully assess the safe use of the adapted walker during the double neck pillow, which consists of two neck
home visits. pillows.
If the parent prefers or needs to use a manual or mo-
torized wheelchair, there are several types of devices for Positional Changes
holding the baby.11 The following adaptations are espe- Positional change examples are described in the discus-
cially easy to use. Using a wedged piece of form as wide sion of burping and diapering in the Adaptive Techniques
as the parent’s lap, 8 inches thick at the parent’s knees, and Strategies section of the chapter.
and slanted down to 3 inches thick at the parent’s waist
can provide a surface for moving, feeding, and playing Transfers
with the baby. The wedge should be covered in wash- Lifting an infant who does not yet have head control can
able fabric and have a strap attached to go around pose a challenge for people with limited upper extremity
the parent’s waist, and a strap attached to hold the baby use. The easiest solution is to use a baby carrier sling
securely on the pillow (Fig. 22-3). Another design that (see equipment chart). If the baby does not accept the
can be used for an older baby with good head control is sling, the following technique can be used while a parent
is in a sitting position in order to transfer from lap
to surface. (1) Choose or arrange surfaces that are high
enough to avoid back strain. (2) Place the functional hand
under the baby’s head. (3) Bend over and simultaneously
pull the baby to caregiver’s chest. The chest acts like an-
other arm to support and hold the baby. (4) Straighten up
and move the baby. A caregiver can wear a fanny pack
stuffed full of soft material that can provide additional
support for the baby’s bottom (Fig. 22-4). It is crucial to
assess whether a parent can move in a balanced and se-
cure way from a sit to a standing position holding the
baby in this manner.
Caregivers have been successful using a lifting harness
to transfer the baby from one surface to another. Note
that the lifting harness cannot be used until the baby has
Figure 22-3 Adapted wedge to support parenting occupations. head control, so prior to this period parents should use
588 Stroke Rehabilitation

CASE STUDY 2
Michael, an older father and the primary caregiver of
his son, had a stroke affecting his left hemisphere
shortly after his son Sam’s birth. His wife Karen
worked full time. His right arm was more involved
than his leg. When Sam was 1-year-old, he was in the
70% percentile in height and weight. Michael was still
successful using the lifting harness to transfer Sam.
Michael wanted to continue using it even though he
was experiencing considerable pain in his left shoulder.
An occupational therapist from TLG showed him the
adaptive technique of giving Sam a boost up to a higher
surface by reaching between his legs from behind Sam’s
back. This approach provided enough advantage for
Sam to climb up and importantly reduced the use of
Michael’s shoulder muscles and lessened his pain. The
occupational therapist’s developmental background
helped her know when to introduce Sam to climbing
that would help with care. She brought steps, so Sam
could climb into the high chair.

Figure 22-4 Adapted fanny pack to support parenting

occupations.
Providing Adaptive Baby Care Equipment
Appropriate equipment can make caring for a child pos-
sible for a person who has had a stroke. Some equipment
is essential for use in conjunction with certain techniques,
while other items simply make the tasks easier or may be
crucial to care.

Bedtime
TLG gets more calls about issues with bedtime than any
other topic. For most clients, the greatest difficulty occurs
in the course of the transfer activity of putting the baby in
bed. The parent can often enjoy the ritual of dressing his
or her child in night clothes, reading a book, cuddling,
and perhaps singing a song, but since most cribs are inac-
cessible, the soothing bedtime activities feel incomplete,
resulting in frustration for parent and child alike.
Some commercially available infant beds allow the
Figure 22-5 Lifting harness to support parenting occupations. child to sleep with the parent, but these have flaws. The
Co-Sleeper, which attaches to the adult bed, poses prob-
lems for parents with disabilities, since it can make it
difficult to get out of bed. The parent must slide to the
an infant carrier sling. A good template for making a foot of the bed to get out. Another make, the Snuggle
harness is using a baby vest on the market (www. Nest, lasts only a few months because only the youngest
babybair.com) with added straps using one inch webbing infants fit into them.
(Fig. 22-5). Lifting a toddler with a harness can produce Commercially available cribs can be adapted to meet
repetitive stress injury, because of the added weight. the needs of parents with physical disabilities, but the oc-
Therefore, toddlers should be taught to climb onto the cupational therapist must be careful to consider safety in
desired surface using parent-child collaboration tech- choosing an adaptation. TLG does not recommend cribs
niques. If the surface is too high, TLG has found steps with gate openings because the baby can roll out when the
with short risers, making them easier for toddlers to parent backs away in order to open the side. TLG recom-
climb. mends use of a sliding door design, so that the parent can
 Chapter 22 • Parenting after Stroke 589

block the entrance with her body as the door slides to the to prevent the baby from rolling off a desk or table. If the pad
side. When using a sliding door, one needs to install a lock is put on a table, it may slip around. If the pad is attached to
that is workable for the parent but not for the child. TLG plywood, the pad will be prevented from slipping around,
has used a two-step lock, but this could be difficult for a and a toy mobile can be used.
parent who has apraxia or sequencing issues. TLG does To make this piece of equipment, use a piece of ply-
not recommend using a top bar to stabilize the sliding wood 11⁄2⬙ wider than the concave diapering pad, and
door because babies can hit their heads coming out, espe- cover the bottom of the wood with nonslip shelving mate-
cially if the baby is already crying and upset. Adaptations rial. A threaded phalange is added to the plywood, so PVC
of commercially available cribs cause problems to struc- piping for the mobile can be attached to the plywood.
tural integrity; therefore, adapted cribs need to be fre- Drilling holes into the polyvinyl chloride (PVC) piping
quently checked to assure safety (Fig. 22-6). and fastening an electrical cord affixes interactive toys,
such as squeaky animals or plastic books (Fig. 22-7).
Childproofing
Home visiting is essential to address childproofing. Some Examples of Equipment on the Market
childproofing can be adult proofing, since devices may be Prior to customizing or developing new baby care adapta-
too complicated for a parent because of cognitive and tions, the occupational therapist should explore the chang-
physical difficulty. It is necessary to try several types of ing options of commercially available equipment that can
devices to see which one is successful. The process will be support baby care by a parent who has experienced a
an opportunity to assess visual and visual neglect issues, stroke (Table 22-1).
apraxia, sequencing, and motor planning. See Chapters 16
to 18. It should be noted that access without raised Durable Medical Equipment
thresholds for walkers and wheelchair access needs to be In addition to baby care equipment, the caregiver may
considered when using safety gates. need assistive mobility technology, such as a power wheel-
chair, scooter, or four-wheeled walker. Transporting the
Diapering Equipment baby safely can increase the need for this equipment.
Following a stroke, some parents find it more comfortable to DME can be an issue to a caregiver within the household
sit when diapering, while others still prefer to stand. For or if he or she cannot keep up with the family out in the
those who prefer to sit, there are several options using com- community. Unfortunately, the caregiver may face diffi-
puter tables. Computer tables come in different sizes, shapes, culties acquiring appropriate mobility equipment, as there
and costs. For families who may not have space for another may be no coverage if he or she can walk within the
table and need to conserve space in their house, a dining household or inadequate coverage of costs (such as for a
room table works well. If a table is used for another activity, motorized wheelchair).
it is important to have a diapering surface that can be re-
moved from the table. Whether the parent sits or stands, it Adaptive Techniques and Strategies
is very helpful to use a toy mobile that uses interactive toys These techniques were devised for the caregiver who has
to keep the baby occupied during the diapering process. the use, or partial use, of one arm.16 Many of these tech-
Using a concave diapering pad and a safety strap is essential niques also emphasize baby collaboration with the parent.

Figure 22-6 Adaptations to crib to support parenting Figure 22-7 Adapted diapering surface to support parenting
occupations. occupations.
590 Stroke Rehabilitation

Table 22-1
Commercially Available Baby Care Equipment
ACTIVITY OR TASK COMMERCIALLY AVAILABLE EQUIPMENT

Bed time Arms Reach cosleeper (can make it difficult for the caregiver to get out of
Cosleeper (attached to the parent’s bed) bed)
Cosleep in parent’s bed Snuggle Nest
Diapering 1. A computer table can be used to change the baby while sitting.
2. A concave diapering pad should be used.
3. A toy mobile with interactive toys to entertain the baby during long
diapering.
Dressing 1. Long one-piece suits with zippers by Gerber and others with key rings
attached to zippers
2. Onesies (T-shirt closure at the crotch) with Velcro closure
3. Fleece bunting with no legs for winter
Holding equipment 1. Infant carrier sling can be used lying down, seated, and standing.
2. Nursing pillows (Hugster, Boppy, Kid Kozy, My Baby Nest) can be used
lying down and seated.
Breastfeeding 1. Easy Expression bra supports the breast and can hold a pump in place.
2. Breast shield or breast shell
Bottle feeding Bottle holders
Burping Lifting harness adapted from (Babybair) vest
Carrying and moving for a parent who Four-wheeled walker (Rollator) with seat attached
has hemiplegia/paresis and/or ataxia
Wheelchair user (motorized) with use Sling (see previously)
of one hand
Transfers Lifting harness adapted from (Babybair) vest
Going out into the community 1. Car seats (try fastening the straps at the store)
2. Walking harness: toddler backpack, child safety harness backpack
3. Stroller (look for attributes: lightweight, easy to collapse, easy to open,
easy to transfer baby)

During inpatient rehabilitation services, the OT clinician regarding possible harm to the baby from medications
can introduce baby care techniques. It is important to being used. An additional source of this information is
include baby care tasks in the treatment plan. For exam- the Organization of Teratology Information Specialists at
ple, some of the patient’s own activities can serve two (866) 626-6847.
purposes. As the caregiver learns how to dress herself, he If the mother breastfed prior to hospitalization and she
or she can also learn how to dress the baby. This can mo- would like to continue breastfeeding during hospitaliza-
tivate the parent and help reduce depression. tion, it will require the availability of the family or other
support people, so the baby can breastfeed regularly. If
Feeding: Combining Adaptive Baby Care Equipment she wants to breastfeed but is unable to see the baby often
and Techniques enough, a breast pump can be used to express milk until
Feeding is one of the most important aspects of care she reunites with her baby. The breast milk can help her
in the formation and maintenance of a parent/child feel connected with her baby and feel that she is the
relationship. source of the best possible nourishment. A useful bra for
pumping is one that contains the pump, so it is hands-free
Breastfeeding. Being able to breastfeed can be im- (Easy Expression). In addition, the bra exposes the
portant for the relationship between mother and baby areola, making it easier for the baby to latch on since the
and can give the mother self-confidence and hope that breast tissue is held back and hand use is not needed. A
she can continue her role as mom. If the mother’s stroke “breast shield” or “breast shell,” also used for flat or in-
was due to high blood pressure, she may need blood pres- verted nipples, can also be used to hold the areola back.
sure medication and/or blood thinners, which could af- Finding a good position to feed the baby is critical. To
fect breast milk and therefore breastfeeding. Prior to hold and feed the baby on the nonaffected side can be emo-
breastfeeding, it is important to consult with physicians tionally disconcerting, because the mother cannot use her
 Chapter 22 • Parenting after Stroke 591

functional arm. Therefore, it is usually best to position the Fastening the Diaper. After the caregiver places the
baby on a pillow rather than the nonaffected arm. It is im- diaper under the baby and brings the diaper through
portant to try various breastfeeding pillows on the market the legs, the front of the caregiver’s wrist should rest on
to see what works best, and it is best to use a pillow with a the baby’s pelvis in order to secure the diaper. The thumb
waist strap, so it will be secured on the mother’s lap. and one to two fingers grab the tab or corner, and then
the remaining fingers of the same hand walk the tab over
Bottle Feeding. Sometimes the new mother may de- to fasten it down. On the other side of the diaper, some of
cide to bottle feed, which can be a good choice and should the fingers hold the diaper tab or corner, while the re-
be respected. Bottle feeding is another task that promotes maining fingers and palm hold the diaper steady to fasten
the parent/child relationship, but holding a bottle can be the tab
difficult. A bottle holder can eliminate the frustration a
parent may experience when trying to hold both the baby Nighttime. Many parents find it more difficult to be
and bottle steady. Bottle holders can be found on the coordinated in the middle of the night. One mother de-
Internet. Important problems relating to formula prepa- vised a method to help her overcome this problem. She
ration are dealt with in the Cognitive Issues section. put two diapers on her baby at bedtime. The only thing
she had to do in the middle of the night was to pull the
Burping interior diaper out and then refasten the remaining one.
Whether breastfeeding or bottle feeding, most people
with the use of one functional arm need a technique to Position. Parents have varied preferences for their
help the infant burp. Typically, visual history involves a positions during diapering. Some caregivers prefer to
picture of burping a baby over the shoulder. For many have their functional arm closer to the baby’s feet, while
parents with a disability, burping over the shoulder can be others prefer to have their functional arm closer to the
difficult or impossible, as it requires both coordination baby’s head, and still others prefer to face the baby’s feet.
and the use of two arms. However, there are other equally Therefore, it is important for the caregiver to try each of
effective techniques, and learning them can increase the those positions to find the most comfortable one.
caregiver’s sense of confidence and independence. One of
the successful techniques developed by TLG is called the Undressing and Dressing
sit and lean. This is an example of a positional change, a Birth to 3-Years-Old. Dressing is one of the most
transitional task discussed earlier. Using this method, the difficult baby care activities to do one-handed. Many
caregiver holds the baby on his or her lap facing away times parents with disability think that they should
from the body. Supporting the baby by placing one arm dress the baby as most people do, on the diapering sur-
across the baby’s chest, the caregiver then leans forward. face. However, having a baby on the diapering table is
This puts gentle pressure on the baby’s stomach and fa- generally harder for a parent who has the use of just
cilitates a burp.16 one hand because they don’t have enough advantage
Another technique is to lay the baby prone (face down) and control at such a distance from their body. The fol-
on the caregiver’s lap and pat the baby’s back.10 Alterna- lowing techniques can help the caregiver make this task
tively, the caregiver can lay the baby on the right side, less difficult. In all cases, it is helpful if the clothing is
rolled slightly towards the stomach and rub on the back. a little too large, since it will come on and off more
A third technique begins with lifting the baby’s legs up easily.
before putting the baby into a sit, with the parent then
putting his or her hand under the baby’s bottom and Dressing a Younger Baby. It is important to position
bouncing upwards. the infant as close to one’s body as possible, since it gives
the best advantage. Using a nursing pillow such as the
Diapering Hugster or Boppy will place the infant in a good position
In diapering a child, application of the parent-child col- on the caregiver’s lap and make maneuvering clothes over
laborative technique is essential. Most babies can be the baby’s head easier. Easy open fasteners will facilitate
“trained” to do the “bottoms up” technique. Parents can dressing and undressing the baby. Snaps can be difficult to
teach their baby to lift his or her bottom by lifting the undo with one hand. Velcro closures and zippers are good
baby’s bottom with the working arm and saying, “Up, up” substitutes for snaps.
simultaneously. With time, many babies will then lift their
bottoms when cued with the words “up, up or butt up.” Undressing a Younger Baby. After the clothing is
With infants who are premature or still mostly in the unfastened, the parent begins with the sleeves, even if the
flexed position, the caregiver can rest the baby’s bottom baby is dressed in a one-piece garment. First, the hem of
on the caregiver’s functional palm and lift the child onto the sleeve needs to be pulled away from the baby with a
the diaper. slight shaking of the clothing, which will encourage the
592 Stroke Rehabilitation

baby to flex a limb to withdraw it from the sleeve. The grabs one side of the sock of the open end and catches the
parent may need to ensure that the garment is not stuck baby’s big toe with the other side. After the sock is on
on the elbow by pulling it around the joint. Once the el- the big toe, the caregiver pulls the rest of the sock onto
bow is out, the rest of the arm and hand should follow the rest of the toes and continues to pull the sock onto the
easily. This process should be repeated with the other foot. The caregiver then grabs the sock from the under-
arm. To remove a shirt, the front of the garment should side and pulls the sock over the heel.
be grasped and scrunched together from the neckline to
the lower hem. Then it can be pulled away from the baby’s Dressing and Undressing a Toddler. This age is one
face and lifted over the head from the front. of the most demanding, because the children try to assert
For dressing an infant in a “onesie” (a shirt that is pre- their independence and therefore are less cooperative.
vented from riding up due to a closure between the legs) Once the baby crawls and walks, the bed may not be a
or shirt, the garment can be put on the top of the head as workable surface. Because the bed affords the child with
the baby lies on the nursing pillow. The front of the gar- plenty of room to attempt an escape, the couch is a better
ment can be scrunched together from top to bottom and choice as it is more contained.
pulled over the back of the infant’s head. The baby’s head Putting on the shirt or one-piece garment is easier if
is held between the parent’s forearm and chest. The front the toddler is on the parent’s lap. Having a strong col-
of the garment is scrunched up in the parent’s hand, laboration between toddler and parent will help greatly in
pulled away from the baby’s face, and pulled down. Then this process. As with the infant and baby, it is helpful to
the back of the baby’s garment can be pulled down and the use a larger size shirt with a large opening at the neck.
infant’s arms pulled into the sleeves.
If the garment has a zipper, it does not matter if the Car Seats
arms or legs are put in first, though many parents prefer Latching safety straps of car seats is essential, but fasten-
to put the arms in first and then the legs before fastening ing them can be difficult even for people with two hands.
the zipper. It is important for the caregiver to experiment with a
variety of brands in order to find the easiest to use. The
Dressing an Older Baby. When the baby is too large chest strap must be narrow enough to be grasped and
to fit on the caregiver’s lap, it is helpful to place the baby closed with one hand. Engaging the straps is easier if the
near the parent such as on a bed and to use a nursing pil- crotch strap is short and stable, so that it does not wob-
low for support. As with infants, it is important to find ble. Caregivers will find it easier to sit with the affected
garments that have easy fasteners. To put a baby into a arm next to the car seat and to use the functional arm
one-piece garment, first the fasteners should be undone across his or her own midline to provide more strength
and the item laid on the dressing surface near the parent. and advantage.
Next the baby is placed on top of the one-piece, the legs
are put in first, and then the arm is directed into the Placing Children in Car Seats
sleeve. By pushing slightly on the elbow, the baby will be Infants
encouraged to extend his or her arm fully into the sleeve. 1. Place the infant car seat in the middle of the back
These steps need to be repeated with the other sleeve and seat.
with the pant leg, encouraging the knees to extend. 2. Sit with the functional arm next to the car seat.
3. Cradle the baby in the elbow of the functional arm.
Undressing an Older Baby. Removing a one-piece 4. Lean across the car to position the baby correctly in
garment can be accomplished by using the following the car seat. While leaning, the upper arm will support
technique: After unzipping, pull the opening of the one- the baby’s head.
piece garment toward a shoulder. Pull the garment off the 5. Slide the baby in place and gently remove the hand.
baby’s shoulder. Then pull down from the hem of the Once the infant can be lifted with a harness, the caregiver
sleeve to encourage the baby to withdraw the arm, and should sit in the back seat with the affected side next to
shake the clothing to encourage the baby to remove the the car seat to make it easier to latch the safety straps.
arm entirely from the clothing. To remove the legs from
the one-piece suit, the parent will pull the foot part of the Crawling Babies. The caregiver sits in the back seat,
clothing or pant legs away from the baby. If the baby has with the affected side next to the car seat and the baby on
been encouraged with “butt up,” the baby can help with the lap. With practice, babies can learn to crawl into the
lifting his or her butt and legs up while the pant legs are car seat. The therapist or another adult can help during
pulled off. the learning process.

Socks. Putting on a baby sock is easier for the care- Toddlers. It is too hard to lift a toddler into the car and
giver than putting on his or her own socks. The caregiver car seat. Instead, the caregiver should have the toddler
 Chapter 22 • Parenting after Stroke 593

climb into the car seat. If the seat is too high for the tod-
minutes. If Jerry did not want a bottle, Bob did not know
dler to climb up into, a step-stool can be placed on the
what to do. Bob became overwhelmed and perseverated
floor. To protect the caregiver’s back, he or she should sit
on only giving the bottle. TLG offered a mental health
on the back seat while attaching the straps.
clinician, but the offer was declined. The occupational
Cognitive Issues therapist tried varied strategies, such as relaxation tech-
niques, which were not successful. She tried having Bob
Cognitive impairment is present in the majority of patients
take Jerry outside more frequently in order to create a
with stroke, so it is crucial to identify any impairment and
new pattern. Since Bob could read, she introduced a
assess the impact on parenting.3 The caregiver may lose
picture of a crying baby with captions of “try diaper
many aspects of cognitive functioning: the ability to speak,
changing, try putting baby to sleep, try going outside.”
read, or follow directions (completely or partially), and
Because Bob’s impairment was significant and the oc-
other impairments may occur. See Chapters 16 to 20. Cog-
cupational therapist’s interventions were only partially
nitive assessment can pinpoint the cognitive difficulties and
successful, an outside caregiver was recommended and
strengths, so that interventions can be developed to com-
brought in to help for part of the day. Additional strate-
pensate for parenting difficulties. The occupational thera-
gies would have been possible with support from cogni-
pist must determine which specific parenting tasks may be
tive therapy and mental health specialists. In retrospect,
problematic and which impairments lead to these difficul-
it might have been helpful to use a tape of the baby
ties. TLG currently has a project developing parenting
crying with repeated practice of calming the baby and
adaptive strategies in relation to cognitive impairments,
putting the baby in the crib; if these were unsuccessful,
such as those identified in the cognitive assessment. For
then the practice of options that calmed the father
example, if the parent has hemianopsia or visual neglect, it
(e.g., music) might have helped. A list of calming strate-
can affect keeping track of a moving baby. Attaching bells
gies for the father might have been tried. However,
in the baby’s clothing and/or shoes securely, or buying
when progress is slow or uncertain to succeed, the prior-
shoes with built-in squeakers (search the Internet for
ity is the welfare of the baby, and community supports
squeaky shoes for children) could help. If the parent has
may be crucial to support the family.
figure-ground problems that affect distinguishing between
the diaper and diaper pad, a dark cover for the diapering
surface, visually contrasting with a diaper, could help.
The parent may have trouble making formula because of Emotional Issues
difficulty with following directions, sequencing, or motor When parents have significant difficulties with communi-
planning/apraxia. Infants can develop failure to thrive or cation, both cognitively and emotionally, there can be a
seizures from improperly diluted formula, so it is crucial to profound effect on parenting, and teamwork between oc-
monitor this area of the parent’s functioning and the infant’s cupational therapists and mental health practitioners is
weight gain. An occupational therapist can work closely crucial. However, it is important to keep in mind that all
with the other home visitors, public health nurse, pediatri- parents need support; all parenting is interdependent.
cian, and family to accomplish this. When the parent has Many people now live away from their immediate family,
problems making formula and qualifies for the Women, which can be stressful for both parent and partner. If a
Infant, Children (WIC) program, federal regulations of partner who has been providing assistance goes back to
WIC support the provision of premixed formula. work, it is important that the parent who has had a stroke
Some cognitive difficulties are much more challenging has enough support or is safe and confident to care for the
during parenting, of course, such as difficulties with atten- baby by himself or herself. A social worker/therapist can
tion, multitasking, and judgment. When parents have help assess the situation, support the family in adjusting to
these problems, the use of adaptive equipment and tech- new roles, provide referrals of community resources, and
niques can be more complex. The process needs to be help integrate outside support into the family system.
more closely monitored during home visiting by occupa- Otherwise the role of a spouse can be so focused on care
tional therapists working as a team with mental health, that the couple relationship suffers, or an older child can
other home visitors, and family members. be inappropriately used as a caregiver.

CASE STUDY 3 CASE STUDY 4

Bob had a stroke during his wife’s pregnancy. Bob be- Janice, a mother with school-age children, had a new
came the primary caregiver, while his wife Carol became baby. A month after the birth, she had a stroke and had
the bread winner. Bob had a great deal of difficulty left hemiplegia as a result. Janice was discharged from
caring for Jerry when Jerry cried for longer than two the hospital following basic rehabilitation without any
Continued
594 Stroke Rehabilitation

CASE STUDY 4 and the crucial role of early mental health intervention
have been well-established.7,9
information on how to care for her baby Lois. Her TLG has found that limit-setting or behavior manage-
husband had to work full-time at this point. Janice felt ment is often challenging for parents with cognitive dis-
her only alternative was to keep her older daughter abilities, partially due to difficulties with consistency.
Sandy home from school to do baby care. When the When parents who have had strokes have emotional con-
home visits began, both an occupational therapist and trol or anger management in addition to communication
a mental health clinician went in as a team due to the and physical difficulties, it is important that occupational
level of the mother’s anxiety about her ability to pro- therapists and mental health providers work collabora-
vide care with a disability. As an experienced mother, tively in this difficult yet essential area of parenting.
she had a strong “visual history” of care as a nondis-
abled mother. The occupational therapist gave Janice Discipline from Crawling through Toddling
baby care equipment (rollator with baby seat) and In order for caregivers who have had a stroke to disci-
taught one-handed baby care techniques so she could pline successfully, it is important to teach parent and
care for her baby without support. Since her cognitive child to collaborate. Parent/child collaboration helps fa-
problems were minimal, she absorbed information cilitate development of the baby and creates a special
readily. Almost immediately, Janice was able to inde- bond. To restore and maintain the parent/child relation-
pendently care for her child, and her daughter Sandy ship it is crucial to support enjoyable interaction between
went back to school. The mental health clinician was them, e.g., identifying roles and play where the parent
able to ease Janice’s anxiety and facilitate the relation- can be effective, offering adaptations to support positive
ships between mother, infant, and older child. mutual experiences. Children tend to be more collabora-
tive and act out less when they have fun with the parent
and see them in effective roles.
To understand how to discipline with a physical dis-
Care by Others ability, it is important to change the “visual history” peo-
Other stroke survivors may receive help from their in- ple have about discipline. For instance, with a cruising
laws or their own parents. Grandparents may be con- baby, the best practice is for the occupational therapist to
cerned about both their own child and the new baby, and help the parent learn to entice the baby to come to him or
want to decrease the stress on everyone. When grandpar- her. A crawling baby is hard to pick up in the middle of a
ents live nearby, they may step in with good intentions but room when the parent is standing up. This can put the
may not give the new parent sufficient opportunity to parent at risk for secondary injury (back injury and/or
learn how to take care of the baby. The insufficient con- shoulder pain) and falling. Developmentally, toddlers en-
tact between parent and baby can impede the attachment joy and learn from the game of chase. Typically, they love
and adaptation process, and intensify depression and to run away from their parents. For a parent with physical
grieving in the parent. When this happens, the occupa- disabilities, it is essential to teach the toddler to chase the
tional therapist may need to bring in a mental health parent.
consultant to help with family dynamics.4 In addition,
grandparents should be included in OT sessions, so the
grandparents can observe how well the parent is doing. CASE STUDY 5
When the parent uses a personal assistant or attendant,
Alicia had a stroke and returned home when her child,
it is also important that the parent interact with the baby
Ramon, was one and just learning to walk. The occu-
sufficiently to develop and maintain the parent/child rela-
pational therapist taught Alicia to entice Ramon to
tionship. Even during an assistant’s care, the parent can
come to her. Having an arsenal of enticing items, such
participate and hold the baby’s attention (e.g., by talking
as a bottle, toy cell phone, car, etc., is essential to en-
or touching), and can appear more psychologically central
gage the baby and make the baby want to crawl over to
to the baby by verbally directing the care.2
the parent. Since Ramon liked to crumple paper and
Mental health professionals’ involvement can help
chew on it, he was shown a piece of paper, which was
identify and address the common psychological difficul-
shaken to make noise; he was told, “Look, look at the
ties associated with stroke, including anxiety, depression,
paper!” Once Ramon came over to get his paper, Alicia
and grief. Problems of frustration, reduced emotional
was able to lift him onto the couch where she was sit-
control, and anger especially call for mental health assess-
ting by using a one-handed technique, bringing her
ment and intervention regarding their impact on parent-
hand down Ramon’s back and lifting him up from un-
ing. Experiencing cognitive impairment or aphasia can be
der his crotch. Alicia said, “The technique helped reduce
associated with or can deepen the depression. The long-
my anxiety by knowing that my baby will come to me.
term negative impact of maternal depression on infants
 Chapter 22 • Parenting after Stroke 595

during recreation: “Public recreational sites such as play-

The worry that he might get into trouble was making
grounds and parks are either inaccessible altogether or
me tense, and this technique gave me the feeling that
only accessible for young children with disabilities—
I was in control.” The mental health clinician also ad-
rarely for a parent/adult with a disability.”8 Parents also
dressed Alicia’s anxiety, anger, and depression, which
reported needing assistance in recreation with their chil-
could have created more obstacles in the parent/child
dren. Parents with attention problems or difficulties with
relationship.
the authority required to manage behavior in public
places may need mental health services to facilitate inter-
action and possibly an ongoing adult companion during
Temper Tantrums outings. When a parent with a physical and/or cognitive
When a toddler throws a temper tantrum, it is usually disability goes out in the community with a toddler, it is
impossible to have the child go to the parent, but there important to have a walking harness. One good type of
are other techniques. Most parents with a stroke cannot harness is a backpack with a tether. The harness can pre-
pick up kicking and screaming children and take them to vent the toddler from running away, but will not stop the
their room. However, the belief that taking a misbehaving screaming of a toddler having a tantrum. One good tech-
child to his or her room is the only appropriate response nique for the parent to try during the tantrum is making
is due to visual history preventing caregivers from seeing a call on a cell phone as a diversion technique, taking ad-
alternative approaches. It is important to remember that vantage of the desire of toddlers and preschoolers to en-
the point of the separation is separation. Having the par- gage with or talk with parents whenever they get on the
ent leave the room is equally effective. It is, of course, phone.
important to have rooms child-proofed and ensure that
the child will be safe when left alone. Parenting Older Children
Since a stroke can occur at any time, it can happen when
TRANSITION NAVIGATING SOCIAL a parent has school-age children. If a parent has had a
OBSTACLES INTEGRAL TO PARENTING stroke prior to birth, the parent’s disability is integral to
the child’s experience of the parent. For an older child
Getting Out in the Community whose parent has a stroke, the changes in the parent are
Going out in the community is a typical family activity, typically experienced as loss of the parent as the child has
but can pose problems for a caregiver with a disability. known him or her, and grieving about this loss can take
the form of depression or acting out. Providing continuity
Transportation in contacts between parent and child, including during
In a national survey and in national and regional task force hospitalization, can be helpful, so that loss is less compli-
reports, parents with disabilities have reported that the cated by separation. Older children are often acutely
availability of transportation had more of an impact on aware of social stigma directed toward the parent, and
being able to parent with a disability than any other is- teasing and embarrassment about differences may be is-
sue.8,13 Since many people who have experienced a stroke sues. Parent and child can strategize together about re-
can no longer drive, they are often left relying on para- sponses to teasing. One parent taught her child to answer
transit services for individuals with disabilities. Unfortu- “So what?!” and this was successful in ending the hostile
nately, there are many problems involved in using this comments. Some parents have found that ongoing par-
service, especially for parents with disabilities transport- ticipation in the classroom helped. Communication with
ing their children. One such difficulty is that paratransit older children about the social prejudice and barriers can
does not provide car seats for children. This becomes es- raise their consciousness about social justice issues (e.g.,
pecially problematic when the child requires a car seat for transportation obstacles can make it difficult for the older
children from 20 to 60 pounds, given the bulk of such child to participate in organized sports and other events
carriers. Parents using paratransit are therefore forced to when there is not another available adult or adequate
lug bulky car seats around with them during the day, paratransit services). The role of mental health practitio-
which is impossible for many parents with physical dis- ners is heightened for the child and for the parent, since
abilities. See Chapter 23. depression is so problematical during parenting.
Occupational therapists have a crucial role in facilitat-
Recreation ing functioning, so the child and parent can navigate new
Being able to take child to a playground is a common out- obstacles and enjoy interaction and play. If the caregiver
ing for parents; however, recreation is an area fraught has lost the ability to read, being able to use computer
with problems for parents with physical and/or cognitive software or other devices that can read books is an alter-
disabilities. The task force reports and national survey of native. There are options of software on all subjects that
parents with disabilities have identified access problems can help the caregiver be present while the child learns a
596 Stroke Rehabilitation

skill and does homework. When there is no parent or My father suffered a major stroke in 2004, and many of the
family member who can assist with homework, TLG also effects of that stroke are still with him today . . . Witnessing his
recommends tutoring for school-age children, ideally in- strength and tenacity has taught me to be strong just like he is.
cluding or coordinated with respectful services to the He has also taught me the value of family, and that it is the best
parent providing assistance (e.g., in structuring time and thing you can have in life. Lastly, but probably the greatest thing
he ever taught me is to always work hard toward your dreams
place to complete homework). Some family recreation
and never give up hope . . . Not a day goes by where my father
choices may have become too difficult (e.g., hiking, doesn’t work hard to get back to normal. He is unable to work
beachcombing). However, there are outdoor activities as a cabinetmaker and can’t use his right hand or speak clearly.
that have been adapted for people who are disabled (e.g., He may not know it now, but he has helped me so much to be-
skiing, bicycling, sailing, horseback riding) that the family come stronger, just by watching how hard he worked. Living
can join. with a disabled parent has made me stronger when I am faced
with harsh conditions and has taught me to always work hard to
CASE STUDY 6 get where I need to be . . . . . Since I could walk, the only thing
I have wanted to do in life is play baseball, and I hope to play
Jim and Mary had two older children in junior high professionally one day . . . I figured out that I had to work hard
to achieve my dreams. I remembered my dad and how he
and high school when a surprise pregnancy occurred.
struggled with physical therapy every day until he was sweating
Soon after Sharon was born, Jim had a left hemi- and crying, and I started lifting weights at school, stayed after
sphere stroke resulting in aphasia and right hemiple- practice an hour longer than the other players, [and] got extra
gia. Jim was not the only one in the family who had help from my coach and other instructors, so I could be a better
depression; his wife and older children also did. They player. I feel so blessed that my dad taught me this lesson of
felt they had lost their father/husband who had had a working hard to “get better” because I have now been recruited
great sense of humor and enjoyed the outdoors. by several colleges to play on their baseball teams . . .
A TLG family mental health clinician and the occu- Seeing my dad have the stroke has done nothing but add fuel
pational therapist helped the family change how they to my fire to get to where I want to be. My dad has not missed
looked at their recreational activities. The mental a game since he got out of the hospital, and he still does his best
health clinician and occupational therapist worked to teach me how to play the game . . . I only hope that when I
am older that I can be half the man my father is. You see, I con-
together to help the family adjust to new activities
sider myself lucky to be living with the man who can’t get the
that were fun for them, such as playing card games or words out all the time, whose right hand doesn’t work quite
board games. TLG was able to help them join an- right, and who walks with a limp, because the alternative is
other disability community program that provided something that I don’t want to think about. I live with the man
outdoor activities. The family started doing adapted who suffered a severe stroke in 2004, but since then has taught
bike trips every month. me enough lessons to last me multiple lifetimes.
Allen Etzler III, Walkersville, MD

TLG has assisted many parents who have had strokes to

Although there can be pitfalls for parents who have had find ways to navigate and enjoy the caregiving experience.
strokes, there are also many beautiful success stories. Teamwork between occupational therapists and mental
TLG has funded scholarships for high school seniors health practitioners can increase the parent’s role and ef-
or college students whose parents have disabilities. fectiveness, address obstacles, support the relationship
Allen Etzler III, one of the 2009 national winners has a between parent and child, and assist the functioning of the
father who experienced a stroke. He wrote:1 entire family system.

The Impact of Growing Up with a Parent with a REVIEW QUESTIONS

Disability
Some people will look at him and see weakness, but I look at 1. Describe techniques that would be useful in helping a
him and see nothing but strength and fortitude. Some people parent with hemiplegia burp a child independently.
may look at him and see a man who cannot get his words out as 2. Name the four transitional tasks to master as the start-
well as he wants too, but I look at him and see a man who speaks ing point of intervention.
volumes to me. Some people may look at him and see a man
3. What is an appropriate diapering technique to teach a
whose hand doesn’t work quite right, but I look at him and see
a man who gives hugs and handshakes as strong and comforting
parent with hemiplegia?
as they ever were. Some people may look at him and see a man 4. What are the steps to teaching dressing and undressing
who walks with a limp on his right side, but I see a man who a younger baby? An older baby?
hopped to first base at our father-son baseball game, unashamed 5. What is the correct sequence of placing an infant in a
of his deficits and the obstacles that lay before him, because he car seat for a parent who has unilateral upper extremity
just wants to be there for me, his son. impairment?
 Chapter 22 • Parenting after Stroke 597

REFERENCES 10. Rogers J: Disabled woman’s guide to pregnancy and birth, New York,
2006, Demos Medical Publishing.
1. Etzler, Allen, III 2009. Through the Looking Glass Scholarship
11. Through the Looking Glass: Adaptive parenting equipment: Idea book 1
Recipient. Unpublished essay.
(NIDRR Grant No. H133G10146), Berkeley, 1995, Through the
2. Groah SL, editor: Managing spinal cord injury: A guide to living well
Looking Glass.
with spinal cord injury, Washington, DC, 2005, NRH Press.
12. Through the Looking Glass: Developing adaptive equipment and tech-
3. Hoffman M, Schmitt F, Bromley E: Comprehensive cognitive neuro-
niques for physically disabled parents and their babies within the context of
logical assessment in stroke. Acta Neurol Scand 119(3):162–171, 2009.
psycho-social services, Final Report (NIDRR Grant No. H133G10146),
4. Kirshbaum M: Disabilities in the family: Babycare assistive technology for
Berkeley, 1995, Through the Looking Glass.
parents with physical disabilities: Relational, systems, & cultural perspec-
13. Toms Barker LT, Maralani V: Challenges and strategies of disabled
tives, AFTA Newsletter 20–26, Spring 1997.
parents: Findings from a national survey of parents with disabilities, Final
5. Kirshbaum M: A disability culture perspective on early intervention
Report (NIDRR, Rehabilitation Research and Training Grant No.
with parents with physical or cognitive disabilities and their babies.
H133B30076), Berkeley, 1997, Through the Looking Glass.
Infants Young Child 13(3):9–20, 2005.
14. Tuleja C, Rogers J, Vensand K, et al: Continuation of adaptive parenting
6. Kirshbaum M, Olkin R: Parents with physical, systemic, or visual
equipment development, Berkeley, 1998, Through the Looking Glass.
disabilities. Sex Disabil 20(1):65–80, 2002.
15. Tuleja C, Rogers J, Kirshbaum M, et al: Baby care assessment for
7. Lyons-Ruth K, Zoll D, Connell D, Grunebaum HU: The depressed
parents with physical limitations or disabilities: An occupational therapy
mother and her one-year-old infant: Environment, interaction,
evaluation, Berkeley, 2005, Through the Looking Glass.
attachment, and infant development. New Dir Child Dev (34):61–82,
16. Vensand K, Rogers J, Tuleja C, et al: Adaptive baby care equipment:
1986.
Guidelines, prototypes & resources, Berkeley, 2000, Through the Look-
8. Preston P: Visible, diverse and united: A report of the Bay Area parents
ing Glass.
with disabilities and deaf parents task force meeting, Berkeley, 2006,
Through the Looking Glass.
9. Radke-Yarrow M: Attachment patterns in children of depressed
mothers. In Parkes CM, Stevenson-Hinde J, editors: Attachment
across the life cycle, New York, 1991, Tavistock/Routledge.
 su s an l . pi erce

chapter 23

Driving and Community

Mobility as an Instrumental
Activity of Daily Living

key terms
driving and community mobility mobility prescription on-road evaluation
driver rehabilitation therapist occupational therapy generalist in predriving clinical evaluation
ecological validity driving transportation choices
independent transportation occupational therapy specialist in
driving

chapter objectives
After completing this chapter, the reader will be able to accomplish the following:
1. Define driving and community mobility as instrumental activities of daily living.
2. Identify the role of occupational therapy in addressing driving and community mobility
issues at different stages of rehabilitation and recovery for the stroke survivor.
3. Understand the legal issues associated with involvement of driving issues and how to
manage liability risks.
4. Identify performance skill deficits related to a stroke and client factors that can interfere
with the occupation of driving.
5. Understand the current accepted practice for a comprehensive driving evaluation for the
stroke survivor.
6. Identify resources for information, education, and referral in addressing driving and
community mobility as an instrumental activity of daily living.

Following a stroke, the occupational therapist considers used in ADL.” Driving and community mobility are in-
the many types of occupations in which the client engages. cluded within the domain of occupational therapy (OT)
The Occupational Therapy Practice Framework1 defines and in the profession’s scope of practice.1 Community
instrumental activities of daily living (IADL) as activities mobility is defined in the framework1 as “moving around in
“to support daily life within the home and community that the community and using public or private transportation,
often require more complex interactions than self-care such as driving, walking, bicycling, or accessing and riding

598
 Chapter 23 • Driving and Community Mobility as an Instrumental Activity of Daily Living 599

in buses, taxi cabs or other transportation systems.” The distances traversable on foot. Reduced mobility in the
OT practitioner during evaluation and intervention con- community by an individual can result in a lower self-
siders the client’s own perspective of how driving and com- esteem, depression, and feelings of uselessness, loneli-
munity mobility meets his or her needs and interests. ness, and unhappiness.
Evaluation and intervention for functional and com- The performance skills necessary for safe driving begin
munity mobility should center on safe mobility for the to deteriorate around the age of 55-years-old and dra-
patient in the home and in the community for meeting his matically decline after age 75-years-old.27 Approximately
or her life needs and interests. For some following a 72% of strokes occur in persons older than 65-years-old.
stroke, driving may play a major role in getting to and In addition to normal aging conditions, the brain damage
from a job or it may be the means of obtaining nourish- from a cerebral infarct and its clinical manifestations can
ment and medications. Driving a motor vehicle is a com- affect the person’s driving skills. The specific motor, sen-
mon form of transportation used by clients recovering sory, and cognitive deficits depend on the location and
from a stroke, and therefore, addressing driving and/or severity of the cerebrovascular damage (see Chapters 1 and
community mobility is a crucial IADL that must be ad- 18). This damage can cause one or more temporary or
dressed by OT. permanent impairments. Of the approximately 80% of
In 2005 American Occupational Therapy Association’s persons who survive the initial period, 75% are left with
(AOTA) Representative Assembly adopted an official residual perceptual-cognitive dysfunction.21 These or
statement on Driving and Community Mobility.36 The other impairments or additional client factors not related
document stated that “All occupational therapists and oc- to the stroke may affect safe driving for this person. The
cupational therapy assistants possess the education and occupational therapist must evaluate each patient recover-
training necessary to address driving and community mo- ing from a stroke individually, because the location and
bility as an IADL. Throughout the evaluation and inter- nature of the stroke can produce different problems and
vention process, all practitioners recognize the impact of deficits, and everyone will have a different occupational
clients’ aging, disability, or risk factors on driving and profile.
community mobility. Through the use of clinical reason- Achieving or not achieving independent transportation
ing skills, practitioners use information about client for a stroke survivor can impede or affect greatly all other
strengths and weaknesses in performance skills, perfor- IADL. Carp,5 a California psychologist who has studied
mance patterns, contexts, and client factors to deduce older drivers, used the conceptual model in Fig. 23-1 to
potential difficulties with occupational performance in detail the determinants of emotional and social well-
driving and community mobility.” In the continuum of being. Life maintenance needs to include nourishment,
activities of daily living (ADL), the occupational therapist clothing, medical care, banking, and pharmaceuticals.
must consider mobility in the rehabilitation process of the Community resources for meeting these needs include
patient recovering from a stroke. grocery and drug stores, department stores, physician’s
As with all other ADL and IADL, the occupational offices, and banks. If a person has no access to these re-
therapist considers the occupation of driving for a client sources, independent living becomes nearly impossible.
with the holistic approach of examining the client factors, Other needs, labeled higher order, include needs for so-
the performance skills, the performance patterns and hab- cial interaction, usefulness, recreation, and religious expe-
its, the contextual and environmental factors, and the ac- rience. Carp’s research of investigative studies supported
tivity demands. A determination is made as to any difficul- the idea that “if life is to have an acceptable quality,
ties or issues in these areas that affect occupational higher-order needs such as those expressed in trips for
performance for driving. Intervention is then structured relaxation and enjoyment and religious activities are also
to improve or enhance the problem areas prior to dis- essential.”
charge from OT. If independent driving cannot be a The Occupational Therapy Practice Framework1 sup-
short- or long-term goal for the client who is recovering ported Carp’s ideas by articulating that OT has a contri-
from a stroke, then the occupational therapist must ad- bution “to promote the health and participation of people,
dress the community mobility issues by examining the organizations, and populations through engagement in
client’s resources in the community and assisting the cli- occupation.” The Framework1 continued that “all people
ent and family with good and safe transportation choices. need to be able or enabled to engage in the occupations of
A century ago, individuals could walk to work, shops, their need and choice, to grow through what they do, and
friends’ homes, churches, and most other destinations. to experience independence or interdependence, equality,
Today, with the primary mode of transportation being participation, security, health and well-being.”
the personal vehicle and with the distance separating The threat of losing a driver’s license may have devas-
homes and businesses in the suburbs, few destinations are tating effects on a stroke survivor’s motivation to main-
now within walking distance. Impairments and activity tain independence in other areas of daily living. The
limitations caused by a stroke or age can further shorten primary fear of elderly persons is not death but losing
600 Stroke Rehabilitation

Qualities of Mobility Need/Resource Outcomes

Life-maintenance needs
Food
Clothing
Doctor
Medicine
Banking

Congruence Independent
living

Life-maintenance resources
Grocery store
Clothing store
Doctor’s office
Pharmacy
Bank
Feasibility

Safety

Personal control Higher-order needs

Well-being
Socializing
Self-esteem
Usefulness
Usefulness
Recreation
Happiness
Worship
Loneliness
Anxiety
Congruence Depression

Higher-order resources
Friends, family
Volunteer services
Recreational places
Church/synagogue

Figure 23-1 The determinants and dynamics of emotional and social well-being. (Modified
from Transportation Research Board—National Research Council, Special Report 218, Trans-
portation in an aging society, Washington, DC, 1988.)

their independence and becoming burdens to their loved

more complex ADL and therefore must be taken with
ones.3 Carp5 stated the following:
careful thought and serious consideration by using the
Loss of license is a serious fear among drivers, a threat to their best critical thinking methods by the rehabilitation team.
autonomy, usefulness, and self-esteem . . . A century ago people Law enforcement officers or driver licensing personnel
could walk to work, shops, others’ homes, religious services, and cannot address this issue effectively, which has potentially
most destinations. Few destinations [today] lie within walking dangerous consequences to the stroke survivor or to pe-
distance for any person . . . Mobility is a key influence on destrians or other road users. Elderly drivers who do not
the congruence term in the model . . . Satisfaction of life- self-regulate effectively are not detected easily with stan-
maintenance and higher order needs require going out into dard licensing procedures.21 Furthermore, doubt exists as
the community . . . The loss of a license would mean inability
to whether most licensing staffs have the skills necessary
to go where they needed to go and therefore meet their needs
to detect these problem drivers.8
independently . . . Just as receipt of the first driver’s license is an
important rite of passage to adulthood and independence, license
loss formally identifies one as “over the hill.” DRIVING AND COMMUNITY MOBILITY IS A
CRUCIAL ACTIVITY OF DAILY LIVING SKILL
Driving or being independent in community mobility
by another means is inseparable with being one’s own Community mobility is paramount to the patient recov-
person and taking care of oneself. The issue is more than ering from stroke and attempting to maintain a produc-
just one of losing mobility. Rendering an opinion as to tive lifestyle in the work, home, or social arenas. The
whether the patient recovering from a stroke is capable of occupation of driving and community mobility is such an
driving has lasting implications. Driving is one of the important activity that it requires inclusion with other
 Chapter 23 • Driving and Community Mobility as an Instrumental Activity of Daily Living 601

ADL issues in OT. If the rehabilitation team addresses Mobility

safety in functional mobility or safety in the kitchen for
the stroke survivor, then safety in driving demands ad-
Play Work
dressing. If driving and community mobility is within the
domain of OT, then it is the occupational therapist’s re-
Cooking Housecleaning Communication
sponsibility to address it as with any other ADL such as
dressing, cooking, bathing, and functional ambulation.
“Each area of mobility requires a certain skill level in oc- Bathing Eating Grooming Dressing
cupational performance. A hierarchy of skills dictates the Figure 23-2 Pyramid model for rehabilitation of activities of
order in which each area is addressed. Mobility in basic daily living.
activities of daily living (BADL) is first, followed by mo-
bility in instrumental activities of daily living (IADL).
Some occupational therapy (OT) goals for motor, sen- activities. Functional mobility tasks allow an individual to
sory, perceptual, and cognitive functioning must be function independently by moving from one place to an-
achieved prior to ADL training and specifically mobility other. Successful community mobility allows a person to
training.”29 move about his or her community and environment and
The occupational therapist should begin to discuss driv- the person’s ability to drive or use other transportation
ing and community mobility early on in the stroke survivor’s choices may make the difference in the stroke survivor
rehabilitation and recovery intervention. Such discussion returning to his or her living situation prior to the stroke.
will lead to patient and family education and acceptance Because persons of all ages can suffer a stroke, driving or
early to reinforce their responsibility and requirements in transportation choices as a community mobility issue
the process of the patient’s regaining independent driving or must be on the ADL repertoire for the occupational
his or her need to investigate alternative transportation therapist to explore, evaluate, and provide intervention as
choices. The early discussion also will lessen the family’s necessary. The occupational therapist must understand
stress and anxiety over the issue of driving for their family the significance of community mobility for the total well-
member, for they will not have to shoulder the burden of being of the client. A holistic view presents driving as a
telling the person that he or she cannot drive and then deal- vital link between the client and the outside world.
ing with an angry family member.
“As an activity that contributes to independence and REHABILITATION TEAM’S RESPONSIBILITY
quality of life, driving falls squarely within the province of
occupational therapy practice,” Johansson stated.18 The The entire rehabilitation team must address the issue of
discipline of OT has been given the role of evaluating driving or transportation for the stroke survivor, with
clients regarding their ability to drive a motor vehicle members addressing the issue within their own profes-
primarily because of the wide spectrum of physical, cogni- sional expertise (Fig. 23-3). The rehabilitation team must
tive, and perceptual skills that fall under the realm of get involved with this issue because they are concerned
OT.19 In addition, occupational therapists have a back- with the overall functioning of the client and his or her
ground in psychosocial dysfunction that can be key in resulting quality of life after a stroke. They are in the best
giving the therapist the necessary therapeutic attitude and position to identify any existing or potential contributors
approach to this sensitive issue to understand how it can to driving risk. In addition, families need assistance and
affect the psychosocial and emotional well-being of the guidance with this highly sensitive issue before they take
patient. The AOTA has identified older driver evaluation the family member home. The rehabilitation team must
and retraining as an important specialty area for practitio- define a fair and reasonable course of action. They must
ners to consider because of the broad approach of the weigh client-physician or client-therapist confidentiality
profession to evaluation and treatment. Eberhard, a for- versus public safety. The social and ethical dilemma faced
mer senior research psychologist at the National Highway by medical professionals and the department of driver
and Traffic Safety Administration, said that he “envisions licensing is to strike a balance between protecting the
a key role for the OT profession in maintaining elders’ person’s privilege to drive and the safety of other road
automotive proficiency. OT practitioners have clear in- users, including pedestrians, other drivers, and vehicle
sights into the need for mobility. They have the skills to passengers.
assess functional mobility and the skills to enhance it.”26 Each team member has a role and responsibility and
In all settings, the occupational therapist is concerned should be ready to address related issues as they arise.
with the performance level of ADL, with mobility being For example, the physician, as the head of the rehabilita-
at the top of the pyramid (Fig. 23-2). The daily living task tion team and medical authority, must take a leading role
of functional mobility involves bed and wheelchair mobil- with this issue. The physician should be the first to in-
ity, transfers, and functional ambulation while performing form the client and family that because of its complexity
602 Stroke Rehabilitation

driving evaluation if deemed necessary after discharge and

can assist the OT Generalist in Driving and the family
members in identifying alternative transportation choices
in their specific community environment.
The OT practitioner will play the largest role and the
greatest responsibility in addressing the occupation of
driving for the stroke survivor. The roles of the OT prac-
titioner have been defined in an AOTA online course
entitled Driving and Community Mobility for Older
Adults: Occupational Therapy Roles:16 “Occupational
therapists are already educated and trained to address
many of the important issues associated with driving and
community mobility, and they must be ready to take on
the role of the occupational therapy Driving and Com-
munity Generalist whatever the practice setting. In addi-
tion, an increasing number of occupational therapists
• Physician must prepare and be available to assume the role of the
• Social worker Occupational Therapy Driver Rehabilitation Specialist.”
• Occupational therapist
• Physical therapist
The Occupational Therapy Driving and Community
• Rehabilitation nurse Mobility Generalist (Generalist in Driving) is defined as
• Speech therapist “all occupational therapists and occupational therapy as-
• Neuropsychologist sistants with all the education, training and credentials
Figure 23-3 Driving should be addressed as appropriate by necessary to practice occupational therapy but who do not
each member of the rehabilitation team following the same possess specialized training and experience in driver eval-
policies and procedures. The process depends on good commu- uation or driver rehabilitation.” The Occupational Therapy
nication among the team members. Driver Rehabilitation Specialist (Specialist in Driving) is
defined as occupational therapists and OT assistants with
all the education, training, and credentials of an OT prac-
and demand of high functional levels of skills, driving titioner in addition to the advanced knowledge and skills
will be one the last activities addressed in the person’s in the specialty field of driver evaluation and driver reha-
rehabilitation and recovery. bilitation (including intervention, vehicle modifications,
Other team members also play a role in addressing the and adapted driving equipment).
occupation of driving in relation to their specific area of While the OT Generalist in Driving begins addressing
knowledge and skill. For example, the nurse can provide a issues and skills as they relate to the activity of driving
list of medications with which the client will be discharged early on for the stroke survivor, it may be necessary to
home and note any side effects that could affect safe driv- seek the expertise of an OT Specialist in Driving at some
ing. The speech-language pathologist may address the point for an on-road evaluation. The physician should
need for a client with aphasia to begin carrying a personal inform the stroke survivor and the family that the client
identification card, so that if he or she is involved in an should not drive until the team and the OT Generalist in
accident or is stopped by a police officer, the card would Driving or Specialist in Driving has considered all aspects
explain the speech difficulties. The speech-language pa- necessary to evaluate the occupation of driving.
thologist also may inform the occupational therapist of
any language deficits that might be contraindicated for OCCUPATIONAL THERAPISTS’ CHANGING
safe driving. For example, if the stroke survivor has global ROLE WITH THE STROKE SURVIVOR
aphasia and needs to be evaluated for driving using driv-
ing aids, he or she may have difficulty with verbal instruc- “Occupational therapists are responsible for all aspects of
tions on a new task, with directions, or with reading road OT service delivery and are accountable for the safety and
signs. The physical therapist can reinforce the reality that effectiveness of that service delivery process.”1 The
the person with dense right hemiplegia will not be able to occupational therapist’s unique background and training
use the right foot for driving because of lack of necessary in evaluation and intervention in the performance skill
motor and sensory function. The physical therapist can areas of motor and praxis skills, sensory-perception skills,
also work on the goal of the client entering and exiting a emotional regulation skills, cognitive skills, and commu-
vehicle with or without an orthotic device. The social nication and social skills coupled with the understanding
worker can counsel the family to reinforce the team’s dis- of client factors and environment and contextual factors
charge recommendations related to referral for a formal assist the therapist to understand all issues related to the
 Chapter 23 • Driving and Community Mobility as an Instrumental Activity of Daily Living 603

occupation of driving. In addition, the occupational ther- the therapist in the next phase. The point is that driving
apist’s background and understanding of psychological should be addressed early and as commonly as dressing,
and emotional issues assists the therapist greatly in han- grooming, and other mobility issues. Whether the ap-
dling the delicate issue of driving when just speaking of propriate time is in the acute care phase or the rehabilita-
driving can cause anxiety, defensiveness, and other psy- tion phase, the therapist should be equipped to address
chological stress for not only the stroke survivor but also driving in an appropriate way.
family members. The occupational therapist’s role many
times is to educate, listen, and counsel not only the client Rehabilitation Phase
but also family members. The occupational therapist’s As the stroke survivor moves into the rehabilitation phase,
keen ability to look at the “whole person” is important to the foregoing information would be passed on to the re-
the process in considering all aspects of engagement in habilitation unit therapist. The primary rehabilitation
community mobility, including driving, and how all the occupational therapist would pick up the issue by address-
different aspects are interrelated and have transactional ing driving as an IADL in the initial evaluation for an
relationships. intervention plan with the stroke survivor as for other
The occupational therapist’s role changes during dif- ADL such as dressing, bathing, and cooking. To address
ferent phases as the stroke survivor moves through acute driving as an IADL and assess factors that may affect safe
care hospitalization, inpatient and outpatient rehabilita- driving, the occupational therapist requires an under-
tion, discharge, and community follow-up. As the person standing of all factors and skills involved in driving and
moves through these phases, the occupational therapist activity demands of driving. With an understanding of the
addresses issues of driving relevant to each phase. The level of skill performance demanded in the driving task,
level of involvement varies during each phase. Driving or the occupational therapist can include intervention, with
community mobility should be an established IADL goal driving in mind, much as the therapist would for other
early on with all other ADL goals and have a well-defined ADL tasks.
intervention plan toward the stroke survivor’s stated out- Driving an automobile is a complex task involving a hi-
come with this activity. The outcome regarding this erarchy of skills. Adequate motor response and physical
IADL is the end-result of the OT process throughout control of the vehicle are essential skills but are secondary
each recovery stage with the stroke survivor. Each occu- to accurate perception and understanding of ever-changing
pational therapist that the stroke survivor sees along the traffic environments and unpredictable situations. A driver
continuum of care must understand his or her role and processes information and makes conscious or unconscious
responsibility at the level that he or she treats the client. decisions using (1) environmental information such as traf-
fic lights, road markings, road signs, and other road users;
Acute Care Phase (2) attention and perceptual mechanisms using visual
During the initial hospital phase following a stroke, the search, spatial relations, and time and space management;
role for the occupational therapist is primarily one of (3) reasoning, problem-solving, and planning to analyze
inquiry and fact finding. One of the most common ques- each situation and understand cause and effect; and (4) re-
tions initially asked by a person in this phase is “Can I sponse by physical control, adjustment, and compromise.
drive again?” or “When will I be able to drive again?” Table 23-1 gives an overview of occupational performance
The therapist must be able to answer the question when in driving.
asked and to speak with confidence about how this activ-
ity will be addressed along the continuum of care. The Preexisting or Progressive Age-Related Conditions
therapist can inquire whether the stroke survivor had In addition to conditions or problems associated with the
been a licensed driver before and what was the frequency primary diagnosis of a stroke, the therapist should explore
and circumstances of driving. For example, did the per- other preexisting medical or aging conditions that require
son drive to work or drive his or her children to school? attention. Stressel39 writes the following:
Does the person live in a rural or suburban area? Was the
person the primary driver in the family? Did the person In general, aging results in the normal deterioration of the
drive intrastate, interstate, or just locally? Is the person at physical, cognitive, and visual functioning. People age at differ-
a stage at which he or she already had begun to limit driv- ent rates, and age-related problems that are known to affect
driver performance do not occur in all people at the same rate
ing to daylight only or within short distances of home?
or to the same degree. The rate of decline is very individualized,
Is independent driving a goal for the person now? If and chronological age is not a good predictor of an individual’s
the client has memory, cognitive, or speech deficits, the capabilities. As the prevalence of disease increases with age, it
family may need to be consulted to obtain or verify the becomes more difficult to differentiate between functional losses
information given by the client. If the stroke survivor due to the effects of disease versus functional loss associated with
passes through the hospital phase quickly, then these the aging process. The process of aging is inescapable. Age-
questions may need to be explored more completely by related changes are characteristically detrimental in nature,
604 Stroke Rehabilitation

Table 23-1
Occupational Performance in Driving for a Stroke Survivor

BASIC SKILL AREAS PERFORMANCE FACTORS

Physical demands
One functional upper extremity and lower extremity Operation of primary/secondary vehicle controls with or
without adaptive equipment
Visual demands
Visual acuity: 20/40 in at least one eye Reading/understanding road signs
Reading odometer and dash gauges
Can influence depth perception
Identification of stimuli seen in side vision
Peripheral vision: ⬎130 degrees of total field of Awareness of stimuli in side vision
vision with both eyes Visual scanning
More useful than visual acuity
Good eye function/quality of vision: disease or Cataracts: poor glare recovery, poor night vision
age-related problems Diabetic retinopathy: blind spots, see incomplete driving scene
Glaucoma: blurriness, blindness
Visual-perceptual demands
Spatial relations Reading/responding to road signs/markings; perception of space
around car
Figure-ground Maneuvering through parking lot; finding road signs in a
visually busy environment
Visual closure Discrimination of high- and low-priority issues; seeing the
whole picture with incomplete cues
Visual memory Time and space management; delay response time
Form constancy Visual analysis in busy and/or low-light environments
Visual discrimination Analysis of road signs by shape and color
Cognitive demands
Strategic skills Choice of route
Time of day to take trip
Planning a sequence of trips or stops
Evaluating general risks in traffic (under varying traffic, road,
and weather conditions)
Tactical skills Anticipatory driving behavior
Adjusting speed to varying traffic conditions
Quick decisions related to expected or unexpected situations
Judgment/reasoning to estimate risks
Operational skills (combines physical, visual, and cognitive)
Attention:
Focused Responding to specific stimuli
Sustained Maintaining focus during continuous driving
Selective Maintaining focus in face of distractions
Alternating Mental flexibility to focus between several tasks requiring
attention
Divided Responding simultaneously to multiple tasks or multiple task
demands
Complex reaction time (appropriateness and
timeliness of response)
Memory skills
Recent Remembering destination, path to take, and event
Procedural Subconscious operation of vehicle controls as old, learned
behavior
 Chapter 23 • Driving and Community Mobility as an Instrumental Activity of Daily Living 605

process driving and community mobility will be ad-

cumulative and irreversible over time, but often lack sharply dressed. The therapist should be able to speak with au-
defined points of transition. Changes begin at different chrono- thority and confidence of the process of addressing driv-
logical ages, progress at varying rates, and do not affect each
ing, the timing, the referral procedure if referral to an OT
body system in the same way. Although some diseases and dete-
rioration may present themselves suddenly, generally there is a
driver rehabilitation specialist is necessary, and the avail-
slow accumulation of deficits. able resources. The therapist must speak with first-hand
knowledge of the value of the on-road evaluation, if nec-
Several examples to illustrate this point are the stroke essary, so that the client and family will equally value the
survivor who has had insulin-dependent type 2 diabetes comprehensive driver evaluation services of the OT Spe-
for 25 years. He was diagnosed with diabetic retinopathy cialist in Driving. The stroke survivor and family should
and had two laser surgeries for treatment. Another stroke know at that point that the client cannot drive until a
survivor has been on kidney dialysis for two years after conclusion has been reached by the collaboration of the
having an allergic reaction to a medication that damaged OT practitioner and the rehabilitation team. By the OT
the kidneys. Each of these preexisting conditions, separate practitioner giving the client the information at an early
from any deficits related to the stroke, could increase risk stage, the client will be prepared and more cooperative in
factors associated with safe driving and should be ad- moving through the process and knowing what to expect
dressed separately in terms of the affect on the driving along the way. Speaking specifically about the activity of
task. Box 23-1 lists other examples of nonstroke factors to driving will help the client understand that the interven-
consider. Communication with the family, rehabilitation tion plan includes treatment along the continuum of care
physician, neurologist, and perhaps the primary care phy- that will improve and enhance his or her performance
sician is important to synthesize the patient’s entire medi- skills related to driving an automobile.
cal history and consider all potential client factors that Driving is one area that scares many family members of
may affect the stroke survivor returning to independent stroke survivors. They need to be informed as well, so
driving. they can provide the necessary assistance and support for
After driving and community mobility are addressed in the client throughout the process in regards to the issue
the initial gathering of the occupational profile, the sec- of driving. The family can begin dealing with the reality
ond stage of involvement for the occupational therapist and can plan for alternative transportation choices for the
during the rehabilitation period is the crucial area of edu- stroke survivor until it has been finally determined that
cation of the stroke survivor and the family regarding in- they have the driver competency to begin driving again.
dividual responsibility in the whole process. In this phase, This should lessen the family’s fears and anxiety and bring
the client must be informed how, when, and by what them into an active role in the process while allowing
them to remain in the background regarding the ultimate
decisions about driving. In other words, the family cannot
Box 23-1 be blamed for the stroke survivor’s temporary or perma-
Nonstroke Medical Factors That Potentially nent loss of driving privileges. By addressing the driving
Can Affect Driving Safety issue in the medical setting, the family is relieved of hav-
ing to address the issue themselves with the stroke survi-
■ Previous history of stroke or transient ischemic attack vor, which many times can cause frustration and emo-
■ Diabetes
tional stress from the stroke survivor’s anger, lack of
■ Visual problems such as cataracts, glaucoma, macular
insight, or poor judgment.
degeneration, or diabetic retinopathy
■ Arthritis and osteoarthritis Medical Reporting with Driver Licensing
■ Surgeries that caused limitations such as hip/knee
Authorities
replacements or cervical laminectomy
■ Respiratory conditions such as emphysema or chronic Each state has licensing requirements and reporting laws.
obstructive pulmonary disease Many states do not require a driver to report a new
■ Amputations medical episode resulting in disability between license
■ Other neuromuscular conditions such as polio, renewals. Some states allow only a doctor to report a
multiple sclerosis, or muscular dystrophy medical condition that may preclude safe driving. Other
■ Dementia or Alzheimer states may allow professionals such as a law enforcement
■ Polypharmacy: multiple medications with interacting
officer or allied health professional or even nonprofes-
effects; prescription and over-the-counter looked at
sionals such as a neighbor or family member to report a
separately and in synergistic combination
■ Psychological diagnoses such as bipolar disease, driver’s medical condition or to raise a concern. Occupa-
depression, or schizophrenia tional therapists should investigate the requirements for
■ Parkinson’s disease the state in which they work to develop a consistent pro-
cedure to use with every client that includes a set policy
606 Stroke Rehabilitation

approved by the administration and legal departments of Evaluation of IADL of driving by OT Generalist
the facility and understood by each team member. Many in Driving to develop intervention plan and to
improve or enhance driving performance skills
states have medical advisory boards to their departments during initial therapy and rehabilitation.
of driver licensing that are good resources for licensing
requirements and the medical reporting process.
The American Association of Motor Vehicle Adminis- If determination is made that an on-road
evaluation is needed, then referral to OT
trators (AAMVA) at www.aamva.org is a nonprofit organi- Specialist in Driving for a comprehensive
zation that develops model programs in motor vehicle driver evaluation
administration, police traffic services, and highway safety.
The AAMVA works with the National Highway Traffic
Safety Administration to review Medical Advisory Boards Vehicle/equipment evaluation
and driver licensing renewal procedures throughout the
United States. This information can be accessed from
On-road evaluation
their website. The AAMVA also serves as an information
and awareness resource regarding older driver issues.
That testing procedures in driver examination offices Additional driver training if needed
do not evaluate fully all skills related to driving is common
knowledge, particularly when the driver may have a
medical condition or deficit that is not physically obvious. Mobility prescription for equipment needs
Examiners may not have knowledge of an applicant’s di-
agnosis unless the person informs them or a physician
Vehicle inspection/fitting
provides written notification. These examiners do not
have an understanding of possible implications of disabil- Figure 23-4 The driving evaluation process for a stroke
ity on driving skills. For example, a person with a com- survivor.
plete right homonymous hemianopsia, which is a com-
mon vision deficit after a stroke, usually does not pass the
visual requirements of most states for a minimum of 125
to 140 degrees of continuous field of vision. The typical
methods of vision testing by driver licensing offices mea- Timely referral
sure only visual acuity and not visual fields. A person can
have 20/40 visual acuity, which is acceptable in most ⫹
states; however, the driver examiner may never know the Qualified driver rehabilitation
person has homonymous hemianopsia. therapist

Predriving Clinic Screening ⫹

A comprehensive driving evaluation for a person who has Proper evaluation tools
had a stroke may include the steps illustrated in Fig. 23-4. ⫹
The process for addressing driving and community mo-
bility as an IADL starts during the initial OT in the acute Appropriate vehicle and equipment
care setting and continues through inpatient rehabilita- ⫹
tion therapy, outpatient rehabilitation therapy, and be-
Adequate on-road assessment
yond. Along this continuum of care, the occupational
therapist should continue including the IADL of driving ⫹
and/or community mobility until the conclusion is drawn Funding
and the outcome decided. A successful completion of this
process depends on many factors that can influence the ⫹
outcome, as noted in Fig. 23-5. A predriving screening by Qualified equipment installer
the occupational therapist should be completed prior to
the client being discharged from inpatient rehabilitation ⫹
and outpatient therapy. The purpose of the predriving Client coordination
screen near discharge is multifaceted. The OT Generalist
⫹
in Driving should:
1. Evaluate for any residual deficits in the performance Family support
skill areas of motor and praxis skills, sensory- Figure 23-5 Factors that influence the driving evaluation
perceptual skills, emotional regulation skills, cognitive process.
 Chapter 23 • Driving and Community Mobility as an Instrumental Activity of Daily Living 607

skills, and communication and social skills, and deter- already discussed. If a stroke survivor has a complete
mine whether any of these deficits could or would homonymous hemianopsia, then the therapist should tell
interfere with driving performance skills. the client and family that a return to driving is not possi-
2. Determine with the full team’s input if the client can ble because of the requirements of the state unless the
begin driving or should not drive upon inpatient condition resolves itself enough to meet the field of vision
discharge, and document in the medical records requirements. Table 23-2 has examples of problem areas
that the client was informed of the conclusion. to note.
3. Determine if a more in-depth driver evaluation by When structuring the predrive clinical screening, the
an OT Specialist in Driving is necessary, and begin therapist should be guided by common sense and
the referral process. evidence-based practice where applicable to use appropri-
4. Determine if the client can benefit from further ate clinical tools and tests as they relate to driving. Al-
therapy to improve and enhance his or her skills in though typical clinical tools and equipment in an OT de-
outpatient therapy, and pass on the intervention partment can be used for this screening, the therapist may
goal of driving to the outpatient occupational need additional specialized equipment for more relevance
therapist. to driving. Clients may be more cooperative with the
The inpatient and outpatient occupational therapist clinical evaluation for the IADL of driving if they appreci-
should have knowledge of the appropriate state licensing ate its relevancy to the driving task. For example, the client
laws and understand the necessary level required in each may feel frustrated and angry working on a puzzle or paper
performance skill area needed for safe driving so that the maze during the therapist’s predrive clinical screening but
appropriate information can be passed on to the OT Spe- may understand the importance of a test that provides
cialist in Driving. For example, if the patient has left ne- specific data related to driving such as reaction time, driv-
glect or serious visual-perceptual deficits, these conditions ing risk behavior assessed using a clinical tool to measure
are contraindicative for safe driving unless they resolve divided and selective attention, and a measuring of cogni-
early. Another example is the field of vision requirement tive abilities for safe driving with a clinical tool that

Table 23-2
Examples of Stroke-Related Deficits to Identify during Initial Assessment That May Impact Driving
Performance

DEFICIT POTENTIAL ISSUES FOR FUTURE RETURN TO DRIVING

Left or right neglect May not see or respond to road signs or markings; may ride to extreme right or left of
lane; may miss turning lanes; will not look to affected side at intersections
Loss of field of vision Will be surprised by unexpected stimuli or events that move into field of vision suddenly
from blind area, may collide with something the driver did not even see such as a person
stepping off a sidewalk or a car lane changing from the field loss side
Dense hemiplegia May require adaptive devices to compensate for motor dysfunction in one or both affected
extremities
Seizure Most states have a required period of being seizure-free, with or without medication.
Complex regional pain Pain or strong medications may affect mood and be a distracting factor; associated motor
syndrome type I (reflex deficits may require adaptive equipment for driving; posturing of the affected limb while
sympathetic dystrophy) driving is important.
Sensory-perceptual Body positioning behind the steering wheel is difficult due to visual neglect or body
imaging issues, inadequate spatial relations or time/space management, and poor depth
perception, leading to short following distance and stopping distance, inadequate
determination of speed and distance of approaching vehicle for making a safe
unprotected left turn.
Communicate difficulties such Misreads signs or other road user cues; becomes distracted when attempting to talk
as aphasia
Impulsivity, poor inhibition Responds or reacts without thinking or seeing the consequences; does not see the entire
driving picture to make sound judgments and decisions
Denial, poor insight Does not see or understand overall performance skill deficits or how the deficits interfere
with safe driving; improvement difficult because he or she does not feel there is any need
for improvement
Memory May not remember where destination is or how to get there; becomes confused and
anxious when cannot find street, misses a street, or is faced with a detour
608 Stroke Rehabilitation

assesses memory, judgment, decision-making, attention, Box 23-3

and motor speed abilities. The therapist should describe Clinical Evaluation Tools with Face Validity
the relevance of any test given, so the client will be moti- and/or Correlation to On-Road Driving
vated to perform well on the test. The assessment of Performance
motor/praxis skills and sensory-perceptual skills is gener-
ally easy for the therapist to set up because the assessment Cognitive Behavioral Driver’s Inventory
and techniques used in these areas are similar to those used Psychological Software Services
in other settings and with other disabilities. The difference www.neuroscience.cnter.com/pss/
is that the therapist must keep a mind set on the activity
Elemental Driving System
demands of driving as they do similarly with cooking,
Life Science Associates
dressing, and other ADL they consider. 1 Fenimore Road
The therapist should attempt to use clinical tools and Bayport, NY 11705
tests during this phase that have the most significance to (631) 472–2111
the driving task. Box 23-2 lists some of the more common [email protected]
clinical tests. Additional tools and devices are available on
the market that can be used in the clinic with driver- Braking Test Computer
related tasks and have a degree of face validity and statisti- Vericom Computers
cal correlation (Box 23-3). 14320 James Road, Suite 200
Engum and colleagues9 noted the following: “Knowing Rogers, MN 55374
the patient’s diagnosis or pathology typically does not yield 1–800–533–5547
www.vericomcomputers.com
predictions about the patient’s ability to drive. . . . Even
loss of brain mass is not deemed to be an exact predictor
of driving skills . . . neuropsychological tests, which can
detect gross organic impairment or provide useful catalogs functioning such as attention, concentration, rapid deci-
of patients’ impairments and abilities, do not seem to as- sion-making, visual-motor speed and coordination, visual
sess driver potential.” The OT Generalist in Driving must scanning and acuity, and shifting attention from one task
collaborate with the OT Specialist in Driving to coordi- to another. Their results demonstrated that more than
nate the tests and tools used, so duplication is not done. 95% of the patients receiving passing scores on the CBDI
Their four-year research project with more than were judged independently by an on-road driving test as
230 brain-damaged patients led to the development of safe to operate a motor vehicle. Conversely, all patients
the Cognitive Behavioral Drivers Inventory (CBDI). This who failed the CBDI were judged as unsafe drivers in the
inventory is designed to assess aspects of cognitive independently administered road test.9 A subsequent
study by some of the same authors in 1988 completed a
double-blind test of the validity of the CBDI. Again, the
Box 23-2
authors found a high correlation between the results of
Examples of the Common Clinical Tests Used the CBDI and the independent road test.8 Although the
as Needed CBDI is psychometrically strong, it has no face validity.
The CBDI is useful, but the Elemental Driver Simulator
■ Trailsmaking Part A and B
■ Gardner Test of Visual Perceptual Skills
has face validity and may be better understood by patients
■ Motor-Free Visual Perceptual Test—3 as being relative to driving because it involves operating
■ Cognitive Linquistic Quick Test simulated primary car controls (Fig. 23-6).
■ Rey-Osterreith Complex Figure Test Gianutsos,11 the originator of the Elemental Driving
■ Digit Symbol Simulator, stated, “road tests lack the basic psychometric
■ Gardner Reversal requisites of tests—standardization, reliability and empiri-
■ Neglect (HVN) Screen cal validity.” She described the Elemental Driving Simula-
■ Short Blessed Test or Mini-Mental Status Exam tor as a “computer-based quasi-simulator that is based on
■ Draw-a-Clock or Draw-a-Person test objective, norm-referenced measures of the cognitive abil-
■ DriveABLE Assessment ities regarded as critical for driving.” These cognitive
■ DriveSafe Simulator
abilities include mental processing efficiency, simultaneous
■ Simple reaction time
■ Road smart judgment test
information processing, perceptual-motor skills, and im-
■ Gross Impairments Screening Battery of General pulse control. The Elemental Driving Simulator also at-
Physical and Mental Abilities (GRIMPS) tempts to measure insight and judgment by comparing
■ Porteus Maze Test self-appraisal with performance. Research by Gianutsos11
■ Raven Progressive Matrices and Engum and colleagues9 indicated a significant correla-
tion in the Elemental Driving Simulator and CBDI. These
 Chapter 23 • Driving and Community Mobility as an Instrumental Activity of Daily Living 609

The 2008 OT Practice Framework1 describes perfor-

mance skills as observable, concrete, goal directed actions
that a client uses to engage in daily life occupations. Mul-
tiple factors, such as the context in which the occupation is
performed, the specific demands of the activity being at-
tempted, and the client’s body functions and structures,
affect the client’s ability to demonstrate performance skills.
With this in mind, the OT Generalist in Driving should
evaluate the stroke survivor’s performance skills for driving
with consideration of all of the client factors, contextual/
environmental factors, and the activity demands of the oc-
cupation of driving for this particular individual.
Discussion of the components of a predriving clinical
evaluation at this stage follows.

Motor and Praxis Skill Assessment

The motor and praxis skill assessment should involve a brief
functional look at the patient’s active range of motion,
muscle strength, sensory modalities, bilateral and unilateral
gross and fine motor coordination, and any abnormalities
such as muscle tone, spasticity, stereotypical patterns, and
associated reactions. A slowing of physical functioning can
affect reaction time in responding to stimuli in the environ-
ment. Slower reaction time among older drivers may be
caused by motor change or delayed visual processing. The
loss of strength and range of motion can prevent the person
from safely operating the primary or secondary controls of
the vehicle. If the person has the necessary isolated control
in the affected arm with appropriate sensation and smooth
coordination, he or she may be able to continue using this
arm for two-handed steering. For liability reasons, the OT
Figure 23-6 The Elemental Driving Simulator. (Courtesy Life
Generalist in Driving will not evaluate or recommend adap-
Science Associates, Bayport, NY.)
tive equipment for driving but should be familiar with op-
tions available for the stroke survivor, so that the interven-
tion plan may include education of the client and family on
researchers believe that their results confirm the reliability the importance of seeing the OT Specialist in Driving. The
and validity of their clinical driving assessment programs. OT Generalist in Driving should also consider the person’s
By using the Elemental Driving Simulator or CBDI, the functional mobility in regards to ambulating to and from a
therapist obtains not only objective data but also recorded vehicle and loading any assistive devices. Preintervention in
information relevant to the driving task. More impor- this area can save time for the OT Specialist in Driving.
tantly, data from these tests have demonstrated reliability In driving, an affected limb cannot be used at all if the
and validity with published norms and standardized rules. necessary functional skills are not available since it could
The drawbacks to these tools are that they are expensive, be unsafe and cause the driver to lose control of the vehi-
time consuming to give, and require the use of a proper cle. An example would be an upper extremity that has a
computer, which can be intimidating for an older person. stereotypical flexor pattern with little isolated control. If
The predriving clinical evaluation can be organized the patient cannot use the affected arm safely, then various
similar to or along with a typical discharge evaluation of kinds of adaptive equipment and driving aids are available
performance skill areas and an ADL and IADL evalua- that can be used to aid one-handed steering or for reach of
tion. The screening would be an obvious emphasis on secondary control functions that the impaired extremity
driving skill requirements in an attempt to determine if should operate. For example, the left hand generally oper-
the person is ready for referral for the on-road assessment ates the turn signals and the right hand generally operates
or if the referral should be delayed to a better time. One the gear selector. Fig. 23-7 gives examples of adaptive
should remember that if the person is referred too early, equipment for driving that is recommended by the OT
the results may produce negative consequences for the Specialist in Driving to assist with various vehicle controls.
person’s driving privileges. Some states require a spinner knob even if the person can
610 Stroke Rehabilitation

equipment, if any, is viable and necessary. After the moving

assessment, the therapist may determine that the person
requires equipment when initially it was thought he or she
could use the affected upper or lower limb.
For secondary controls that are operated in a stationary
position, the stroke survivor may be able to use compen-
Spinner knob
satory methods for these controls; for example, using the
left hand for inserting and turning the ignition key or
operating the gearshift lever. If this is difficult, adaptive
aids such as a gear selector crossover and key extension
may be appropriate. Special panoramic mirrors can be
beneficial when neck range of motion is limited or to in-
crease visual awareness to the rear, sides, and blind spots
(Figs. 23-8 and 23-9). These mirrors do not compensate
for loss of peripheral vision, so they are not useful for cor-
rection of homonymous hemianopsia.
Left foot accelerator
Sensory-Perceptual Assessment
A visual assessment is crucial because driving depends so
much on visual input. A visual assessment in regards
to the task of driving is more than mere checking of a
patient’s visual acuity and depth perception. Scheiman,32
a rehabilitation optometrist who works with patients
with various diagnoses, stated that good vision is more
than clear vision: “the individual must have the ability to
Turn signal crossover
use his eyes for extended periods of time without dis-
Figure 23-7 Typical driving aids for a person recovering from comfort, be able to analyze and interpret the incoming
stroke. (Courtesy Mobility Products and Design, Winamac, Ind.)

palm the wheel and control it well with the remaining

good arm. Compensatory techniques with special equip-
ment can assist only with physically controlling a vehicle
and do not resolve the person’s other potential problem
area with cognitive and sensory-perceptual skills.
Regarding lower extremity function, if the patient does
not have isolated control in the right lower extremity, then
the person will require a left foot gas pedal (see Fig. 23-7).
If the person has recovery in muscle strength, sensation,
and coordination in the right leg, then the patient may be
able to continue using this leg normally on the pedals. If
the person wears a lightweight short leg brace and has
some minimal movement in the ankle, and all other fac-
tors—such as strength, sensation, and coordination—are
good, then this person still may be able to use the right leg Figure 23-8 SmartView Mirror by Interactive Driving Sys-
for gas and brake operation or just gas operation. If move- tems. This mirror eliminates the confusion noted in the typical
ment to the brake pedal is slow with or without a brace, or spot convex mirror and increases rear vision by dividing the mir-
the hip or knee fatigues quickly, then teaching a two- ror into two areas. The outside half of the SmartView mirror
footed driving method may be possible if this is allowed in (white arrow) shows objects in the blind spot of the vehicle, or
the state of residence and the person has plantarflexion and Danger Zone. If a car is detected in the Danger Zone, the driver
dorsiflexion in the affected ankle. Proprioception is neces- must not move in front of it. In this photograph, the car shown
sary and should be evaluated carefully. The OT Specialist is detected by the mirror to be in the driver’s Danger Zone. The
in Driving will determine if the stroke survivor has good upper inside quadrant of the mirror (black arrow) is boxed and
foot placement, good pedal regulation, and acceptable re- shows the Safe Zone. If a car is seen in the box—and stays in the
action time using the affected leg. The in-vehicle and on- box—the driver may move in front of it. (Courtesy Interactive
road evaluation will determine which method and what Driving Systems, Cheshire, Conn.)
 Chapter 23 • Driving and Community Mobility as an Instrumental Activity of Daily Living 611

View with
rearview
mirror

View with
the
Lanechanger

B
Figure 23-9 A, The Lanechanger mirror combines a standard rearview mirror with a convex
mirror. B, This convex mirror provides a wider angle of vision and increased safety. (Courtesy
The Lanechanger, Quebec, Canada.)

information, and respond to what is being seen.” His 140 degrees. Eye test charts can be used to ascertain
experience indicates that nearly half of the patients ad- visual acuity. A commercially available stereoscopic vi-
mitted to a rehabilitation center with stroke or traumatic sion tester that is self-contained and often used by driver
brain injury have visual system deficits, primarily in the licensing agencies may be applicable to a clinical setting.
area of binocular vision and accommodation. Other In addition to visual acuity, these machines also screen
commonly reported vision problems include reduced for depth perception or stereopsis, contrast sensitivity,
visual acuity, decreased contrast sensitivity, visual field road sign recognition, phoria, fusion, and horizontal
deficits, visual neglect, strabismus, oculomotor dysfunc- perimeter vision. These machines have limitations
tion, and accommodative and stereopsis dysfunction. See that the therapist must take into consideration when
Chapter 16. using them and interpreting the results. For example,
The stroke survivor should be evaluated visually ac- stereoscopic vision testers rely on binocular vision. If a
cording to the vision requirements for licensing of the patient does not possess binocular vision for whatever
state. This usually includes visual acuity of 20/40 in at reason, this machine can be used only on a limited basis.
least one eye and a total field of vision of at least 130 to Box 23-4 lists vision testing resources. If any suspicions
612 Stroke Rehabilitation

Box 23-4
Resources for Vision Testing Equipment
Bernell Corporation
4016 North Home St.
Mishawaka, IN 46545
(800) 348–2225 Normal visual field Right homonymous
hemianopsia

Keystone View
www.keystoneview.com

Porto-Clinic
Driver Testing Equipment
1309 South Main Ave.
Scranton, PA 18504
Right superior quadranopsia Right inferior quadranopsia
Stereo Optical Company
www.stereooptical.com Figure 23-10 Representation of normal visual field in the eyes
and typical visual field defects.

of problem areas arise, the stroke survivor should be Aside from visual deficits that may occur because of
referred to an eye care specialist. If the patient does not the stroke, the occupational therapist also must consider
meet basic state requirements, an eye care specialist the normal change in visual skills occurring due to the
should see the patient before an on-road assessment. For person’s age. Testing eye range of motion, tracking, pur-
example, if the stroke survivor does not meet the state’s suits, and saccades can be done quickly with a few hand-
visual requirement for peripheral vision, then he or she held sticks or a tracking ball. As does any organ in
and the family should be educated on this fact and never the body, the eye loses some of its capability with age.
referred to the OT Specialist in Driving. This informa- The pupil of the eye becomes less elastic and restricts the
tion should be reported to the state’s medical review amount of light let into the retina. Many elderly patients
board with the Department of Driver Licensing, so the complain of difficulty driving at night or during weather
state can make a decision to suspend the person’s driving conditions when the illumination is poor, such as in rain,
privileges (see Box 23-4). fog, or snow. Cataracts, glaucoma, and macular degen-
Some states allow a loss of vision in the upper quadrant eration are common among elderly persons. Cataracts, a
as long as the lateral median in the superior quadrant is clouding of the lenses, also can affect night driving and
normal (Fig. 23-10). The exact degree of visual field avail- can produce hazy vision during the day. Cataract surgery
able in each eye should be assessed quantitatively. Gianutsos has a 90% success rate in a healthy older person who does
and Suchoff13 have suggested that perimetric and func- not have comorbidities. Glaucoma, an increase in ocular
tional visual fields also are important to assess. A patient pressure that damages the optic nerve and retinal nerve
with complete homonymous hemianopsia may have only fibers, begins by affecting side vision first and eventually
110 degrees of total visual field. Whenever an occupa- compromises central vision. It is a treatable condition,
tional therapist suspects that a patient has any degree of and a referral to the appropriate eye care specialist is
peripheral vision loss, an objective test using machines important before performing the on-road assessment.
such as the Goldman or Humphrey perimeter test should The therapist should consider diabetic retinopathy for a
be used. An OT clinic generally cannot afford expensive, person with a history of diabetes. When the degree of
large objective perimeter machines that can quantitatively macular degeneration is so great that it affects the central
measure exact degrees of visual fields in all quadrants. The vision to a point that the person cannot see anything in
therapist can perform a finger confrontation test or use a this visual area, then the patient needs to stop driving.
horizontal perimeter tool, and while this will confirm a Therapists can assess visual scanning, awareness, and at-
complete hemianopsia, the test is not inclusive or objec- tention in the clinic by using some of the subtests in the
tive. Before concluding that the patient cannot drive with visual-perceptual and cognitive tests discussed later in
this impairment, the therapist must make a referral to a this chapter.
local eye care specialist that uses one of the machines Because speed and movement can influence visual and
noted previously to get an accurate report of the exact visual-perceptual skills, the therapist must make the final
field of vision. determination of the proficiency and effectiveness of
 Chapter 23 • Driving and Community Mobility as an Instrumental Activity of Daily Living 613

these areas for driving in the vehicle and in the dynamic orientation, concentration, learning (short-term mem-
moving traffic environment. For example, the speed of a ory), and problem-solving. Diffuse cognitive deficits
vehicle decreases visual acuity and side vision. If a person occur more frequently in patients with large frontal
has 200 degrees of visual field, at 20 miles per hour, the strokes, visuospatial deficits in right hemisphere strokes,
field is reduced to 104 degrees; at 40 miles per hour, to and apraxia in left hemisphere strokes.46 Unilateral ne-
70 degrees; and at 60 miles per hour, to 40 degrees. glect has been reported in half of the patients with right
Speed also decreases visual acuity; the faster the speed, brain damage and in 20% to 25% with left brain dam-
the less time available to react to visual stimuli in the age.38 Diller and Weinberg7 reported that “patients with
environment.34 The Visual Attention Analyzer Model left hemiparesis often experience accidents that are
2000 (Visual Resources, Chicago, Ill.) assesses the size of related to difficulties in dealing with space, while acci-
the useful field of view and comprises three subtests to dents in patients with right hemiparesis are often related
evaluate processing speed, divided attention, and selec- to slowness in processing information.”
tive attention (see Chapter 19). This machine can be Patients are generally more aware of motor problems
helpful to the OT Generalist in Driving as the machine than they are of cognitive problems.13 Gresham and col-
evaluates and provides training modules that can be used leagues14 noted that “unawareness of the stroke (or its
in intervention to improve the person’s visual attention manifestations) is often found in patients with lesions in
and processing speed. the nondominant hemisphere. It can lead to impulsive,
unsafe behavior in a patient who may otherwise appear
Visual-Perception and Cognitive Assessment relatively normal with respect to physical functioning.”
According to Toglia,40 the limitation to the deficit-specific Patients’ poor insight into their own problem areas can be
approach to perception is that “it equates difficulty in dangerous because patients may not be aware of serious
performance of a specific task with a deficit . . . [and] does driver errors and the potentially fatal consequences of
not consider the underlying reasons for failure or the their actions.
conditions that influence performance.” For example, a The occupational therapist can use common verbal and
patient may score low on a typical OT clinical test of written tasks to assess the areas of visual perceptual func-
visual-perceptual skills; nevertheless, the results may be a tioning such as spatial relations, visual discrimination,
consequence of reduced visual acuity or accommodation form constancy, depth perception and visual memory, se-
and not necessarily a specific visual-perceptual deficit. quential memory, and visual closure. Two commonly used
A stroke survivor who has serious visual-perceptual tests are the Gardner Test of Visual Perceptual Skills and
deficits will have difficulty throughout rehabilitation.43 the Motor-Free Visual Perception Test—3, which is stan-
The occupational therapist will complete documentation dardized for adults age 70-years-old or older. The Motor-
and observations of deficits in these areas during routine Free Visual Perception Test—Vertical is for those who
evaluation and intervention. The stroke survivor should have difficulty with horizontally presented stimuli such as
not be referred to the OT Specialist in Driving until the stroke survivors.
deficit areas no longer interfere with basic ADL. If the Therapists can use a variety of cognitive tests to assess
therapist understands the definition of each visual- memory, language, orientation, attention, concentration,
perceptual category and the way deficits in each area af- reasoning, and problem-solving. The Helm-Estabrooks
fect a person’s basic self-care skills, a further analysis of Cognitive Linguistic Quick Test can be administered in
the activity demands of driving can show the way persis- 20 to 30 minutes; is standardized for adults with acquired
tent problems in these areas can interfere with driving neurological dysfunction, ages 18- to 89-years-old; and
performance skills (see Chapter 18 and Chapter 19). can be used to identify a person’s cognitive strengths and
Driving requires a combination of perceptual skills in weaknesses. This test gives a “snapshot” assessment of the
which cognitive performance plays a major role. Strong status of these five cognitive domains: attention, memory,
cognitive abilities are fundamental to attentiveness in language, executive functions, and visuospatial skills (see
the driving task, recognition of stimuli, and choice of Chapters 18 and 19).
the appropriate way to respond. A decline in cognitive During the administration of these clinical tests,
abilities can significantly influence a person’s ability to one must remember that these tests are static and two-
plan, judge, and act adequately. A cognitively impaired dimensional and do not begin to simulate the dynamics of
person may have difficulty maneuvering a vehicle the driving task. French and Hanson10 stated “controversy
through rapidly changing traffic with many unexpected continues about which cognitive-perceptual assessments
actions and reactions from other drivers, passengers, are the best predictors of behind-the-wheel performance.”
pedestrians, and bicyclists. Cognitive impairment has The authors summarized studies performed by Galski,
been linked to higher motor vehicle crash rates in el- Bruno, and Elhe in 1992 that found a significant correla-
derly individuals.6 Problem areas may involve attention, tion between seven tests: “Part A of the Trailsmaking Test,
614 Stroke Rehabilitation

the Rey-Osterreith Complex Figure Test, the Porteus search for hazardous situations or conditions, identify
Maze Test, the Visual Form Discrimination, the Double potential and immediate hazards, predict the effect of the
Letter Cancellation, the Wechsler Adult Intelligence hazard, decide the way to evade the hazard, and execute
Scale—Revised Block Design Test, and Raven’s Progressive evasive driving actions.44 The drawback to this test is that
Matrices and the behind-the-wheel evaluation . . . . the it takes about 45 minutes to administer. Additional time is
[continued] research suggests that a combination of neuro- then necessary to review the answer video with the pa-
psychological testing, visual screening, physical function- tient, an essential step for any learning or understanding
ing, and actual driving (simulators and on-the-road evalua- to take place for the patient or the therapist.
tions) is necessary to predict driving performance.” Because the Driver Performance Test has no statistical
Engum and colleagues9 defined basic operational and validity, the therapist should decide whether to use valu-
behavioral skills as “attention, concentration, rapid able time administering it during this phase or letting the
decision-making, stimulus discrimination/response driver rehabilitation therapist use it in the next phase of
differentiation, sequencing, visual-motor speed and co- the process. An important consideration is that this rap-
ordination, visual scanning, and acuity and attention idly timed test may produce stress in the stroke survivor
shifting.” Table 23-3 describes several performance ar- because it requires quick problem-solving and decision-
eas and the way deficits in these areas can affect driving making, marking on an answer sheet while having atten-
performance. tion divided, and retaining information. The test taker
An appropriate end to the predrive clinical evaluation has only a few seconds to choose an answer and then
may involve several tests to assess procedural memory for must go on to the next traffic scene because the test has
driving, knowledge of road rules, and road sign and/or no built-in delay or pause. If the test taker gets behind,
situational problem-solving, reasoning, and judgment. he or she may become disorganized or distracted and not
Several formal tests can be used. The Driver Performance be able to respond to the next scene. Although quick
Test, distributed by the Advanced Driving Skills Institute thinking and reaction are important for driving, the
(Orlando, Fla.), is a video of simulated real-world driving Driver Performance Test may be a better tool to use after
scenes and provides insight into the patient’s perceptual the patient has passed all clinical tests and road tests, and
capabilities, psychomotor responses, and decision-making may be a more effective tool to use when the therapist
strategies. Using a driver education defensive driving determines that the patient needs more practice, training,
technique of identifying, predicting, deciding, and execut- or review in the areas tested by the Driver Performance
ing, the Driver Performance Test requires the patient to Test (Box 23-5).

Table 23-3
Effects of Various Deficits in a Stroke Survivor on Driving Performance
TYPE OF DEFICIT EFFECT ON DRIVING PERFORMANCE

Higher cognitive functions, Cannot remember route to take to location or loses way if makes wrong turn; may not
memory, ability to learn remember road names but can remember the route; severe deficits in higher functions may
impede safe driving; unless the patient recovering from stroke is a new driver, the inability
to learn new tasks may not impede safe driving; may require directions to be repeated
Motor Usually does not impede safe driving because compensatory driving techniques or adaptive
driving aids can be used
Disturbances in balance May impede car transfers or loading of mobility device (e.g., wheelchair or walker); steering
and coordination device, left-foot accelerator, or turn signal adaptation may compensate for inability to use
the upper or lower extremity
Somatosensory Generally does not interfere with driving because a person does not use an extremity with
lack of sensation or with limiting pain while driving
Vision disorders Severe visual loss or ocular motility disturbances may impede safe driving; the deficit may
lead to the patient not meeting driver licensing requirements; persons with homonymous
hemianopsia are not allowed to drive in most states; other age-related deficits such as
glaucoma, cataracts, and diabetic retinopathy may impede safe driving.
Unilateral neglect A contraindication for safe driving
Speech and language Expressive aphasia, dysarthria, or apraxias of speech are usually not problems in driving,
although attempting to carry on a conversation while driving may cause distraction;
receptive aphasia may impede the driver from understanding directions or conversation.
Pain The unaffected extremities may be used to drive; does not impede driving unless it is so
severe it causes a distraction.
 Chapter 23 • Driving and Community Mobility as an Instrumental Activity of Daily Living 615

Box 23-5 ment of the car. Again, the decision lies in the occupa-
Resources for Assessment of Driving tional therapist’s skill to combine clinical observations and
Knowledge and Judgment analysis with clinical reasoning and judgment of in-car
performance.
Driver Performance Test and Safe Performance
On-Road Test:
DETERMINATION OF READINESS
Advanced Driving Skills Institute
www.advdrivskills.com
FOR THE ROAD TEST
Driving is one of the most complex activities a person may
Drivers Edge Rehabilitation Course:
perform, requires integration of many performance areas,
InterActive Enterprises
852 Martin Drive
and should always be at the top of the ADL pyramid.
Palatine, IL 60067 Because of its complexity, driving should be one of the last
1–847–358–9508 (fax) ADL attempted following a stroke.28 The stroke survivor
[email protected] must have reached all other ADL goals before being ready
for the difficult ADL of driving. With abbreviated inpa-
tient rehabilitation stays for stroke survivors becoming
the norm, the driving evaluation should not take place
IMPORTANCE OF THE COMBINATION until the patient has been discharged from the outpatient
OF A CLINICAL EVALUATION AND treatment program or has recovered to a maximal level of
AN ON-ROAD EVALUATION independence in the performance of other ADL. If the
person is referred too early, he or she may not do well and
A comprehensive driver evaluation should involve the may lose driving privileges. If the person is referred too
two phases of a clinical evaluation and an on-road evalu- late, then he or she may begin driving without an evalua-
ation. A therapist’s decision regarding the patient’s tion or the necessary medical approval and put other
motor, sensory-perceptual, and cognitive abilities for persons at risk.
driving should not be based solely on a clinical test(s) or Timeliness of the referral for the formal road test is
solely on an on-road test. In a 1994 review of driver as- important. Typically, the appropriate time for a referral to
sessment methods at the Jewish Rehabilitation Center in the driver rehabilitation therapist is not until two to four
Montreal, Canada, the chief of research and her associ- months after discharge from the inpatient facility. An ex-
ates found that 95% of their patients were given on-road ception to this timeline is if the person suffered a mild
tests because no clear cutoff score based on typical clini- stroke or transient ischemic attack and recovered quickly
cal tests was reliable in predicting whether a person was with minimal residual deficits. This person may be evalu-
unsafe to drive.21 Earlier studies suggested that persons ated as early as two to four weeks after discharge from the
who pass tests for cognitive deficits do not require road inpatient facility. The clinical occupational therapist is the
tests.25,33 Experienced certified driver rehabilitation spe- best person to determine whether the stroke survivor is
cialists (CDRS) typically do not agree with this opinion, ready for the formal road test before discharge as an inpa-
and other more recent studies have found that clinical tient or to determine an estimation of time for readiness
testing alone is insufficient and recommend a mandatory after discharge to include in the team’s discharge planning
driving test.4,20,42 and final recommendations to the patient and family. In-
A therapist should not deny a stroke survivor the op- put from all team members should be sought. The physi-
portunity to have the road test based on the clinical find- cian should provide only medical clearance when all par-
ings only unless the patient has obvious serious perfor- ties agree that the stroke survivor is ready for the on-road
mance skill issues or does not meet the basic requirements evaluation.
given by the department of driver licensing. The therapist A timely referral by the physician or other team mem-
at this point can make only an assumption regarding sig- bers may reduce the likelihood that the patient may be-
nificant deficits and the potential for them to interfere gin driving with no supervision from a family member or
with driving performance. There is little correlation be- friend. The physician should communicate effectively to
tween typical clinical tests and real driving performance, the stroke survivor that he or she should abstain from all
so the therapist performing the formal driving test on the driving until an evaluation has been completed. This
road should make the conclusion regarding the stroke recommendation should be documented and verbally
survivor’s driving abilities. Occupational therapists who communicated to the person’s caregivers. For liability
are experienced driver rehabilitation therapists say that protection of the rehabilitation facility and team
some patients who do well on clinical tests perform poorly members, the patient should be required to sign a form
in the car. However, they agree that some patients who do demonstrating understanding of the recommendations
poorly in the clinic perform well in the familiar environ- given and indicating willingness to comply. Each team
616 Stroke Rehabilitation

member that has verbally given the same recommenda- development process that is available for application
tions to the patient should document in the progress year round. Adaptive Mobility Services, based in
notes or discharge summary when and what instructions Orlando, Florida, has offered since 1984 educational
were given to the patient. If it appears that the person workshops for the allied health professional who need
will not comply with the recommendations, the reha- advanced knowledge and skill in the field of driver
bilitation team (doctor or therapists) should advise the evaluation as a OT Generalist in Driving or an OT
department of driver licensing. Specialist is Driving. It now offers in-person and online
The therapist should caution the patient and the CE opportunities. Box 23-6 has contact information on
family against practicing a week or so before the ap- these organizations.
pointment with the driver rehabilitation therapist. This After receiving a referral on a stroke survivor for a
strategy is unsafe and needless and puts the patient at comprehensive driver evaluation, the first step for the OT
risk to be sued by parties for driving while impaired, Specialist in Driving or the driver rehabilitation therapist
which can cause personal and property damage. In addi- is to talk with the primary clinical occupational therapist
tion, insurance companies may be able to claim fraud in the inpatient or outpatient unit to obtain any pertinent
and violation of their regulations, so that they are not information about the stroke survivor. If any questions
monetarily responsible for any damages ordered by a arise about performance skill areas that the occupational
court. The potential consequences are not worth the therapist cannot answer, the driver rehabilitation therapist
risk and associated liability, and family members should would talk with the person in the appropriate discipline,
be informed. such as physical therapy, speech therapy, neuropsychol-
ogy, or rehabilitation optometry.
OCCUPATIONAL THERAPIST Second, the driver rehabilitation therapist interviews
AS A SPECIALIST IN DRIVING the patient and the family and obtains a full medical
OR DRIVER REHABILITATION THERAPIST
The impact of persisting sensory, perceptual, motor, and Box 23-6
cognitive deficits on driving risk levels must be addressed
through an objective, formal evaluation on the road and Resources for Professional Education, Driver
in a specially adapted evaluation vehicle. The profes- Education Materials, and Networking
sional performing this part of the driving evaluation must AAA
have a medical background, knowledge of driver educa- Traffic Safety
tion principles, and special training and skill in in-vehicle 1000 AAA Drive, Box 78
techniques and methods. The allied health professional Heathrow, FL 32746–5080
in this role is called the driver rehabilitation therapist to
distinguish the therapist from a commercial driving Adaptive Mobility Services (AMS)
school instructor. Department of Continuing Education
According to the 2009 membership directory of the 1000 Delaney Ave.
Orlando, FL 32806
Association of Driver Rehabilitation Specialists, most
(407) 426–8020
therapists certified by this organization have an OT www.adaptivemobility.com
background. Since 2005 the AOTA created an Older
Driver Initiative to coordinate multiple projects related American Occupational Therapy Association (AOTA)
to increasing the occupational therapist’s awareness and 4720 Montgomery Lane
professional training in addressing the occupation of Bethesda, MD 20814–1220
driving and community mobility. The projects com- (800) 877–1383
pleted as of 2009 include an evidence-based literature www.aota.org
review, publication of OT Practice Guidelines for Driv-
ing and Community Mobility for Older Adults (2006), Association of Driver Rehabilitation Specialists (ADED;
Older Driver Microsite (www.aota.org/olderdriver), and formerly called Association of Driver Educators for
the Disabled)
a specialty certification in driver rehabilitation and
www.aded.net or www.driver-ed.org
community mobility. AOTA also has a variety of educa-
tional opportunities available at their annual conference Safety Industries
or at their website for continuing education. The AOTA P.O. Box 1137
offers a professional certification designation (specialty McGill, NV 89318
certification in driving and community mobility 1–775–235–7766
[SCDCM] or driving and community mobility assis- www.safety-industries.com
tants [SCADCM]) through a portfolio and professional
 Chapter 23 • Driving and Community Mobility as an Instrumental Activity of Daily Living 617

history including any other medical or health issues in The occupational therapist’s unique skill in analysis of
addition to the stroke that must be considered. The activity and occupational performance is of great benefit
therapist should review the patient’s progress in rehabili- in this role. The therapist’s keen observation skills and
tation, discuss the unaccomplished goals in each disci- knowledge of what to look for are also invaluable during
pline, and confirm all facts regarding the patient’s occu- the in-car work. Because the therapist understands the
pation of driving including driving history, the role of diagnosis and all implications, the therapist can plan a
driving for this person, and contextual and environmen- route specific to each client. The therapist should strive
tal factors. Driving abilities may be impaired because of for ecological validity, which simply means that the (eval-
adverse drug effects or age-related factors such as physi- uation and) training takes into consideration the actual
ological changes and age-associated diseases and condi- environment from which the client comes and will return.
tions including arthritis, cataracts, memory loss, and The environment includes home, neighborhood, and
hearing loss. The therapist should explore the stroke community where the person works, plays, and/or goes to
survivor and family’s knowledge and perspective of prob- school.29
lems with other coexisting medical conditions in areas The driver rehabilitation therapist must have a work-
that may not necessarily be related to the stroke diagnosis ing knowledge of deficits associated with a stroke, age-
to understand the whole person. For example, if the related issues, medication implications, and the relation-
stroke survivor has a history of diabetes and has had the ship of all to the driving task. The driver rehabilitation
right leg amputated, the driver rehabilitation therapist therapist must appreciate the importance of driving to
would be prudent to explore the potential problems that the stroke survivor and work in the client’s best interest
may occur in the patient’s left leg. This may affect equip- while also considering the safety and well-being of the
ment recommendations in terms of a left foot gas pedal public. An allied health professional is most qualified by
versus a set of hand controls. education and skill standards to perform the clinical
The therapist should check the status of the person’s evaluation based on professional licensure, ethical stan-
driver’s license, ensure that it is still valid, and note any dards, and guidelines. Some hospitals and rehabilitation
restrictions already placed on the license. A driver’s li- centers consider using a commercial driving school in-
cense is considered public property, so the therapist can structor or a retired driver educator from a school to
contact the appropriate office with the department of complete the on-road assessment so they do not have
driver licensing to check on the license status. Most de- to invest in an evaluation car. They may consider the
partments of driver licensing do not allow a person to liability cost reduced by using a driving school, but this
drive if the license has been suspended or has expired. is not always the case.
Most states have a Medical Advisory Board that with the
appropriate medical approval may issue a temporary driv- USE OF DRIVING SCHOOL INSTRUCTORS
ing permit for evaluation purposes only. The stroke survi- AND DRIVER EDUCATORS
vor and family must be told that this permit is not to be
used to practice before the actual road test appointment The use of an individual without an allied health back-
with the driver rehabilitation therapist. ground in this role should be studied carefully and con-
The on-road phase of the driver evaluation is crucial to sidered by the rehabilitation team, the employer, and
the final decision about a person’s driving abilities. The legal counsel. This decision could result in an inadequate
value of the in-vehicle and the in-traffic assessment can- outcome if the person performing the road test does not
not be underestimated. The professional performing this understand diagnoses, disabilities, and the way to ob-
step must have knowledge of driver education principles, serve and assess each performance skill level in the car.
road rules, and state laws and must know how to assess all The person’s educational background, personal refer-
driving abilities in the car. This person must know the ences, work history, and working knowledge of diagno-
breakdown of performance components involved in spe- ses should be considered carefully. State requirements
cific driving tasks and must understand the purpose of for licensing as a commercial driving school instructor
planning a specific route for each person, what to look for, varies greatly, with no special training required to work
and what can be done to elicit underlying suspected be- with persons with disabilities. In many states, a person
haviors. This professional is not a passive passenger sit- can obtain a commercial driving instructor (CDI) license
ting on the right side of the car simply giving directions. by having a high school diploma, a good driving record
The person must have verbal, visual, and physical skills with no criminal record, and proof of good health. Some
required to control the driver and the vehicle throughout states do require taking an in-depth driver education
the test.31 The therapist must know how to approach the course to be licensed as a CDI; however, other states
driver with constructive criticism and how to react and require less. Many driving schools exist to teach new
handle the emotional and psychological factors that come drivers to pass a road test so that they can obtain driver’s
into play with this portion of the evaluation. licenses; the focus is not on analyzing driving behavior.
618 Stroke Rehabilitation

In summary, a typical commercial driving school in- passed completely onto the person just performing the
structor is usually not a professional, has no understand- road test. The therapist and/or rehabilitation team that
ing of disabilities, and tends to concentrate on teaching referred the stroke survivor to a particular person for the
a person to pass a road test. The instructor’s motivation road test may share liability if wrong decisions are made
is often to provide a revenue-generating service. A reha- or poor conclusions are drawn and incompetence is
bilitation driving program would need to find a knowl- proved.
edgeable and experienced driving school instructor who
has also obtained specialized training with disabilities. VEHICLE AND EQUIPMENT ASSESSMENT
An instructor listed as a CDRS with the Association of
Driver Rehabilitation Specialists will have met their cri- Before conducting the road test, the driver rehabilitation
teria for this credential. therapist must determine if any problem areas exist in the
A person with a degree in education and a certification performance skills areas, client factors, contextual and
in driver education may have a more professional ap- environment factors that may have an impact on making
proach. This individual has a professional college degree the recommendations for adaptive equipment, setting the
in education with special study in driver education and is driving route, and drawing a conclusion regarding the
well-equipped to educate a person regarding the whole entire picture of the occupation of driving and commu-
responsibility of driving. This person, although having nity mobility for this person. Final determination of adap-
the professional background, would not have the medical tive driving equipment needs should be confirmed in a
background for understanding all medical implications of moving assessment in the evaluation vehicle; however, the
a stroke survivor. The biggest limiting factor today to patient’s own vehicle must be considered at some point.
finding a driver educator is that many high school driver The majority of adults, particularly elderly adults, typi-
education programs are being closed because of funding cally own a vehicle with automatic transmission, which is
and liability issues; therefore, fewer individuals opt for required for the installation of most driving aids.
special study in this field, and consequently, fewer study Usually the driving equipment needed by a person with
programs exist for them. left or right hemiplegia is minimal and not costly (be-
Whether a CDI or a driver educator is used, the oc- tween $100 and $1000); but additional costs exist for
cupational therapist must work with and advise this per- special instruction and training on the devices in a dual-
son about the patient’s strengths and weaknesses and controlled vehicle. For example, if a left foot gas pedal
probable behaviors that may be observed or expected device is required, the stroke survivor must be instructed
based on the clinical evaluation and intervention. The in its safe use and be given time for a cerebral transfer
therapist also can assist this person in handling particular from using the right foot to the left foot to take place.
problem areas and can provide recommendations for ap- This in-car training and practice with the driver rehabili-
propriate remedial training to see whether the driver can tation therapist should help prevent any accidents and
compensate for problems seen in the car. allow the stroke survivor to be safe in the vehicle opera-
If the driving instructor or driver educator has little or tion with the new device and the new way of driving.
no experience working with stroke survivors, the therapist Proper use of the equipment also should be ascertained in
must remain closely involved with the road test to ensure a dynamic situation; however, the driver should be given
proper and continued understanding of the driver’s defi- sufficient learning time before being taken into complex
cits and that the progress or lack of progress is observed traffic situations. A driving range or neighborhood with
correctly. The therapist may need to be in the evaluation light traffic and speeds of 15 to 25 miles per hour is a safe,
vehicle only for the first and last session, but the thera- undemanding, and nonthreatening environment in which
pist’s collaboration with in-car person for the outcome is to start. Even if the patient has no equipment needs, this
very important and should be documented. The OT Gen- environment provides time for the patient to become fa-
eralist in Driving or Specialist in Driving should remain miliar with the evaluation vehicle and the verbal direc-
as the supervisor of the person performing the road test tions of the therapist or instructor.
and can be held responsible for any decisions or actions
made by this person. The members of the “driving team,” ON-ROAD DRIVING EVALUATION
comprised of the driver rehabilitation therapist and the
driving school instructor or driver educator, always should A driver must make multiple decisions constantly and in-
keep in mind that they must follow a standard of care, terpret information correctly and quickly for safe driving
show reasonable judgment, and avoid negligent action in (Fig. 23-11). Smith35 stated the following: “Driving a
their work and decisions. Any accidents or collisions in an modern passenger vehicle on a clear day in light traffic
evaluation car or wrongly clearing a person for driving does not overtax any dimension of performance (percep-
can produce potential litigation against all parties associ- tual, cognitive, or physical). However, in heavy traffic at
ated with the driver evaluation process. The liability is not high speed, at night on poorly marked roads, at a complex
 Chapter 23 • Driving and Community Mobility as an Instrumental Activity of Daily Living 619

Your Mind Make Changes

Set priorities. Guide your eyes. Speed Path

Identify problem. Make decisions. Timing Position

Driving conditions: Roadway features:

Roadway surface Hills
visibility Curves
Field of view Intersections
Width of path Dividers
Lane blockers Medians
One way
Multilanes

Traffic controls:
Traffic signs
Traffic lights Own vehicle:
Pavement lines Space needs
Road markings Position
Path
Timing
Space
Other users:
Their needs
Their problems
Their actions

Figure 23-11 Visual and cognitive processing for driving.

intersection, or in a potential accident situation, the de- that are readily visible but also may have more subtle vi-
mands placed on drivers can exceed their abilities.” sual, visuoperceptual, or cognitive problems not easily
Smith35 described a step procedure necessary for safe apparent by observation.
driving: More than half of all stroke survivors who drove cars
1. The driver must see or hear a situation developing before their strokes stop driving afterward.23 Factors that
(stimulus registered and sampled at the visual, audi- are associated most commonly with driving cessation are
tory, or perceptual level). older age at the time of stroke and the presence of cogni-
2. The driver must recognize it (stimulus recognition tive deficits.14 Wilson and Smith46 investigated the driving
at the cognitive level). performance of patients after stroke using two control
3. The driver must decide the way to respond (cogni- groups on a planned driving course. The results indicated
tive level). that the patients recovering from stroke performed more
4. The driver must execute the physical maneuver poorly than did the control subjects. Specific problems
(motor level). identified included difficulties entering and leaving an
According to Gianutsos,12 the New York State Vocational interstate, lack of awareness of other potential interacting
and Educational Services for Individuals with Disabilities vehicles, and difficulty in reacting to emergencies. Analy-
committee that addressed this issue concluded in its report ses of the more likely performance components causing
on August 13, 1993 that no candidate should be advanced the driving errors were concluded to be difficulty in visual
to driving without a behind-the-wheel test. Numerous scanning, lane positioning, appropriate speed, coordina-
studies have investigated driving after a stroke or head in- tion of separate visual scans, interaction with same direc-
jury. These patients can be most difficult to assess for driv- tional traffic, and maintaining a safe distance from other
ing because they may not only have physical disabilities vehicles.
620 Stroke Rehabilitation

A simple five- to 10-minute road test given by a state This perspective aids the therapist in spending sufficient
driver’s license examiner is not adequate to assess fully all and quality time during the work in the car.
areas that must be considered in driving after a stroke. The therapist must understand and plan the goals, ob-
The examiner primarily is evaluating physical control of jectives, and structuring for the in-traffic evaluation. Ev-
the vehicle during basic skills tests such as perpendicular ery mile of road the patient is requested to drive should
or parallel parking, backing up, three-point turns, and have a purpose. Ramsey,31 a driver educator from West
right and left turns. Many times drivers are not even Virginia who has more than 30 years of experience work-
tested in traffic, or if they are, traffic exposure is light and ing with persons with diverse disabilities, stated that if
short. The panel of the U.S. Department of Health and driver evaluators or educators go straight for more than a
Human Resources that determined poststroke rehabilita- mile, they are “taking a joy ride” and are not assessing ef-
tion guidelines reflected in their report that “stroke survi- fectively a person’s ability to drive. Driving straight is
vors may be able to pass a driving test despite having vi- easier than making vehicle and speed adjustments for left
sual spatial deficits or problems with easy distractibility, and right turns and for merging. The visual and mental
impulsive behaviors, or slowed decision making that may demands on the driver are greatly increased in executing
impair their ability to drive safely under unpredictable multiple-step procedures with divided attention demands.
road conditions.”14 In addition, the driver license exam- The therapist can use a planned route by which to evalu-
iner rarely has knowledge of all the adaptive equipment ate every patient. The route for a stroke survivor should
available for physical deficits to determine recommenda- focus on problem areas seen with the patient’s particular
tions. The stroke survivor requires a medical-oriented deficit areas. Routes familiar and unfamiliar to the driver
evaluation and training in a dual-controlled vehicle, nei- may have to be used to expose the person to many com-
ther of which is available from driver license examiners. If plex driving situations. If possible, the driver rehabilita-
adaptive equipment is required for continued safe driving, tion therapist should start or end the test in the driver’s
the stroke survivor generally requires a longer period of home environment, because the patient likely will per-
training because compensation or adaptation involves form better and be more relaxed on familiar roads. In this
breaking old habits (e.g., using the left foot on a left side familiar context, the driver rehabilitation therapist can get
mounted gas pedal rather than the right foot). an understanding of the traffic and roads that the stroke
Driving is an overlearned skill for the experienced el- survivor normally encounters during driving and can get
derly driver, so the on-road driving assessment phase a picture of how well the driver plans his or her routes. If
generally does not require teaching the patient to drive. routes are dangerous, such as one that includes an unpro-
Many operational components come back naturally to the tected left turn against heavy traffic, the driver rehabilita-
patient unless a problem associated with dementia, agno- tion therapist can counsel the driver about the danger of
sia, or apraxia is evident. Patients’ strategic skills may be this maneuver and the high risk and accident potential of
impaired by any sensory-perceptual, or cognitive deficits this situation and can assist in finding a safer route.
that remain. Not to be overlooked is the increased anxiety The therapist must be flexible during the road test,
and stress that this phase of the driver evaluation can in- guiding the patient on and off the planned route as
voke for the person being evaluated. The driver rehabili- needed. For example, if a stroke survivor with poor in-
tation therapist can be a valuable asset in a supportive, sight and visual awareness starts to miss a stop sign or run
therapeutic way during the first 15 minutes of the road through a yield sign without looking both ways or does
test. The therapist should make every effort to relax the not show any reaction to a lane ending sign, then this
patient and to let the patient know what to expect and person should be taken off the planned route for instruc-
how the verbal directions will be given. The evaluation tion and practice to see whether improvement is possible.
car may be different from the stroke survivor’s, and this This driver should not be taken into more complex driv-
can affect his or her disposition. The evaluation vehicle ing situations in which a hazard may be posed to other
may have many different types of adaptive equipment, and road users until the problem is corrected. A stroke survi-
the therapist needs to know how to remove equipment vor with expressive and receptive aphasia may be dis-
that may get in the way of a driver. For example, if the tracted from the driving scene while attempting to process
brake or gas rod of a hand control interferes with a driver the therapist’s verbal directions during driving. In this
who uses his or her right foot moving on and off the fac- case, the patient may benefit from being taken around the
tory gas pedal and brake, the therapist should know how familiar home environment and allowed to self-direct in
to remove the rods for this patient.30 By allowing time to driving from one destination to another such as the bank,
let the person become familiar with the evaluation vehicle, drugstore, or doctor’s office.
the driver may be more relaxed for the rest of the test. Common driving errors committed by elderly drivers
The driver rehabilitation therapist always should keep in may be related to sensory-perceptual or cognitive dys-
mind how important driving is to each person and how function, or an overall decline (Box 23-7). The driver not
crucial the final decision is on the rest of the person’s life. only must see objects in the path of travel but also must
 Chapter 23 • Driving and Community Mobility as an Instrumental Activity of Daily Living 621

Box 23-7 Box 23-8

Common Driving Errors in Older Drivers Examples of Driving Behaviors to be
Observed during the In-Traffic Assessment
■ Difficulty backing up and making turns
■ Not seeing traffic signs or other cars quickly enough ■ Visually searching traffic environment (20 to
■ Difficulty in locating and retrieving information from 30 seconds ahead)
dashboard displays and traffic signs ■ Demonstrating safe physical control of the vehicle at
■ Delayed glare recovery when driving at night all times
■ Not checking rearview mirrors and blind spots ■ Maintaining safe speeds
■ Bumping into curbs and objects ■ Smooth braking
■ Not yielding to oncoming traffic or right-of-way ■ Demonstrating good lane selection
vehicles ■ Maintaining a safe following distance
■ Irregular or slow vehicle speeds ■ Backing the vehicle
■ Making turns
■ Navigating curves
■ Changing lanes and merging
understand their implications for safety to adjust driving ■ Judging gaps at intersections
accordingly. The most frequent citations for older drivers, ■ Making passing maneuvers
noted by McKnight24 in his report “Driver and Pedestrian ■ Performing parallel and angle parking
■ Interacting with traffic in a low-risk manner
Training,” involved failure to heed stop signs, traffic
■ Entering and exiting expressways
lights, no left turn signs, and other signs and signals.
■ Using turn signals appropriately
Underwood41 noted that “safe driving requires complex
■ Demonstrating proper use of all mirrors
cognitive skills, including vigilance, rapid visual scanning ■ Checking blind spots
with attention to environmental detail, rapid processing ■ Finding and using turn lanes properly
of multiple stimuli in several sensory modalities, adequate ■ Observing and responding to road signs
judgment, and rapid decision-making.” Emotional and
behavioral factors and characteristics also come into play
many times.
There is synergistic performance of many skills and makes a decision regarding the stroke survivor’s ability to
abilities for safe driving. Activity analysis is a valuable tool continue driving safely with or without restrictions. The
in which the occupational therapist is well-trained. Break- occupational therapist’s clinical reasoning and judgment
ing the driving task down to its simple performance com- skills are invaluable at this point to consider all observa-
ponents can assist greatly with relevant analysis of the tions, findings, and results from both the clinical and the
clinical test results and in starting a patient in the car in a on-road evaluation. Results from both phases and conver-
nonthreatening and stress-reducing fashion (Box 23-8). sations with family members and other team members
A well-planned road and traffic route for the on-road must be considered in drawing a conclusion.
evaluation has the following purposes: If the therapist determines that the stroke survivor can
■ To assess the driver’s ability to enter and exit the continue to drive, then the driver rehabilitation therapist
vehicle safely and store any mobility aids efficiently should write an evaluation summary supporting licensure
■ To assess the driver’s understanding and operation of and specifying vehicle and equipment recommendations
all vehicle primary and secondary controls as needed. The 2000 edition of the American Heritage
■ To assess the driver’s need for adaptive devices or Dictionary of the English Language, Fourth Edition, defined
techniques for driving safely prescription as “a formula directing the preparation of
■ To assess the driver’s operational and strategic abili- something.” In the context of driving, the term mobility
ties in various traffic, speed, and road conditions prescription is used to direct the patient, the equipment
■ To assess the driver’s memory for the roads and installer, and possibly a funding source to the specific
paths to various common locations equipment needs of the patient.30
■ To assess driving performance skills in the real dy- The document should be written specifically for the
namic driving environment stroke survivor and his or her vehicle. The mobility pre-
scription should be inclusive, considering every aspect of
ADAPTIVE EQUIPMENT MOBILITY the vehicle, the driving task, and all related mobility fac-
PRESCRIPTION tors such as the way the driver operates the steering col-
umn controls, loads or carries a manual wheelchair or
After the stroke survivor has been through the clinical quad cane, or opens the door or trunk of the vehicle.
evaluation, the vehicle and equipment evaluation and the The mobility prescription should not be guesswork or
on-road evaluation, the driver rehabilitation therapist estimation but should be based on a thorough and objective
622 Stroke Rehabilitation

assessment after the stroke survivor has been observed us- a patient who wears a large shoe size, and the dealer
ing each piece of equipment or device safely. Many stroke does not account for this fact when determining the
survivors often need several driving sessions until they are location of the left foot gas pedal in relation to the
deemed safe drivers with new adaptive equipment. The brake. The therapist must check the position of
mobility prescription should indicate to all appropriate par- both pedals to make sure that the patient does not
ties that the patient has completed a comprehensive driving inadvertently hit both pedals simultaneously.
evaluation successfully, that the driver rehabilitation thera- 3. Driver licensing or relicensing: The driver rehabilita-
pist has made an objective determination that the patient tion therapist should inform the client of the re-
can drive safely, and that the equipment prescribed is nec- quirements of the department of driver licensing
essary for the person to return to safe driving.30 and provide assistance if necessary in obtaining a
Guiding the stroke survivor to a competent and quali- valid driver’s license with the appropriate restric-
fied mobility equipment dealer or installer is important. tions. The client may need to be taken for a road
The driver rehabilitation therapist should identify all of test in the evaluation vehicle or may require the
the appropriate dealers in the patient’s community and driver rehabilitation therapist’s guidance and assis-
communicate with the business by sending the mobility tance to communicate with the medical review
prescription to them. The dealer should be factory board for having the driver’s license reinstated after
trained or certified by the equipment manufacturer to a suspension for medical reasons.
install the specific devices prescribed. The dealer should 4. Communication with the rehabilitation team: Written
respect the therapist’s expertise and role so as not to over- and/or verbal communication, particularly with the
step boundaries and install equipment without a prescrip- physician and the family regarding the outcome of
tion or substitute, delete, change, or add items on the the driving evaluation, is important so that all par-
document. ties understand and support the results and any
follow-up services that have been recommended. If
FOLLOW-UP RECOMMENDATIONS the client has a progressive condition such as the
beginning of cataracts, macular degeneration, re-
The final task for the driver rehabilitation therapist is to flex sympathetic dystrophy or complex regional
provide any necessary follow-up recommendations from pain syndrome, Parkinson’s disease, dementia, or
the on-road assessment. These may include the following: Alzheimer’s disease, the physician and medical re-
1. Additional driver training: for further practice with view board should be notified of the need for peri-
the adaptive equipment in a dual-controlled evalua- odic driver reevaluation.
tion vehicle 5. Client and family counseling: Counseling is important
2. A final equipment inspection and fitting: Inspection if the stroke survivor can no longer drive safely.
and fitting of equipment by the driver rehabilita- This outcome requires the therapist to gently in-
tion therapist should be done after the installation form the patient directly with compassion, support,
of the equipment and before the client is released and understanding and give the person time to ex-
to drive. The purposes for the inspection and fit- press his or her emotions and feelings about retiring
ting are: (1) to verify that all mobility prescription from driving. As hard as it is to complete this part of
items have been installed, (2) to verify that the the job, this is an important aspect for the driver
equipment is installed and working properly, and rehabilitation therapist to handle with respect of the
(3) to observe the client driving with the equipment person’s dignity.
to determine if any adjustments are needed. The The loss of a driver’s license changes a person’s life dra-
dealer does not have the knowledge about the pa- matically. The person may no longer be able to live alone
tient and may not know or understand the way to or remain in the house that has been home for decades.
adjust equipment for a particular person’s needs. The person may become dependent on others for trans-
Equipment may be installed properly and still portation and may have to cut out many social activities.
not work optimally for the driver if it has not been The person may be forced to use a taxi or public bus to
adjusted for safe use. For example, the therapist get to destinations important for purchasing services and
may prescribe a spinner knob at the 5 o’clock posi- goods for daily living. The person should be informed
tion on the steering wheel, but the dealer may place that taxis are expensive means of transportation but are
the knob at 1 o’clock position. The stroke survivor still cheaper than owning a car and paying for mainte-
has a weak right shoulder and fatigues quickly if nance, gas, and insurance.
the arm is held suspended against gravity for a The occupational therapist can use his or her psycho-
long period. The lower position on the wheel al- logical background and holistic thinking to counsel the
lows the patient to maintain the arm in a resting stroke survivor and the family on community mobility
position while steering straight. Another example is choices after driver cessation. The therapist needs to give
 Chapter 23 • Driving and Community Mobility as an Instrumental Activity of Daily Living 623

the client and family additional information and resources professionals of stroke survivors should be diligent in al-
at this time and should discuss transportation choices ways recommending a thorough driving evaluation and
available to the person. The following are suggestions to supporting all aspects of the evaluation. Health care pro-
ease the psychological effects of learning about negative fessionals working with stroke survivors must remember
outcomes of a driving evaluation: that protective privilege ends where public peril begins.30
1. The therapist should give the person a frank and Every physician and rehabilitation staff member, if for no
honest description of observable driving behaviors other reason than because of the liability, should consider
or problems areas that do not allow for safe driving. the issue of driving after a stroke. If the facility does not
Discussion of the clinical results and the road test is have a driving program, a referral to a qualified program
helpful because time is needed for the information in the community should be made, and the referral should
and consequences to be processed. The therapist be documented in the chart. A discussion of the concept
should give the person an opportunity to discuss the of shared liability in each party follows.
results and ask questions.
2. A significant other should be present with the stroke Patient’s Liability
survivor at this point for psychological support, for The driver has an ethical responsibility to avoid harming
help in deciding the best way of securing other self or others. Each state department of motor vehicles
transportation choices, and perhaps for a discussion grants a person the privilege of a driver’s license based on
of selling a vehicle and turning in a driver’s license criteria and regulations that vary from state to state. The
for a state identification card. driver must realize that the driving privilege can lead to
3. Available counseling through the doctor, psycholo- potential disaster through injury to persons and destruc-
gist, or other senior health counselor should be tion of property if residual functional deficits interfere
sought to assist the person psychologically. The cli- with driving skills. Persons recovering from a stroke who
ent likely will go through an expression of a variety cannot master the operational, tactical, and strategic skills
of feelings and emotions such as denial, anger, re- necessary to operate a motor vehicle safely present a clear
sentment, and depression. Family members and risk of injury to themselves, their passengers, pedestrians,
friends should be available to check on the person in and other operators of motor vehicles.2
case depression becomes deep enough to require The OT should address the liability issues for the fam-
frequent counseling. ily before discharge as an inpatient. The family should
4. Community mobility must be resolved for the per- understand that following the rehabilitation team’s rec-
son who can no longer drive. The therapist should ommendations for driving cessation until a driving as-
recruit family members or friends for personal er- sessment can be made will lessen their liability risk.
rands and appointments. Information about op- Families are entrusted with ensuring compliance with the
tional transportation for senior citizens and persons recommendations after discharge from the inpatient re-
with disabilities should be given in detail and in habilitation stay. They should be encouraged, if neces-
writing. If necessary, the person should be taken on sary, to take the stroke survivor driver’s license and/or
a city bus route to an appointment and instructed in vehicle keys and even relocate any vehicle to which the
the way to use the route and bus map guide. The person may have access before the person is discharged
therapist may discuss the option of keeping the per- from the rehabilitation facility. The entire rehabilitation
sonal car and hiring a neighbor or friend to drive it team must reinforce this information so the family is in-
several days of the week for any necessary trips. To formed properly, prepared, and willing to take their role
continue community mobility goals to the end, it and responsibility seriously and to follow through with
may be necessary for the occupational therapist to the recommendations.
evaluate the stroke survivor’s ability to use other The rehabilitation team or family member should
transportation options by actually observing the never hesitate to report the stroke survivor to the depart-
person using the various options and determine ment of driver licensing if the person does not comply
which is best suited for the client. with the team’s recommendations and is deemed unsafe
to self or the public while driving. If the physician hesi-
LIABILITY CONSIDERATIONS tates to address driving to a patient or thinks liability may
be avoided by not addressing the issue, another team
Because of the inherent nature of driving, all parties must member should contact the department of driver licens-
address the degree of liability concerning the stroke sur- ing if allowable in that state. Each state differs in the re-
vivor who drives, including the physician, the rehabilita- quirements for reporting a person, so the occupational
tion team, the clinical occupational therapist addressing therapist should investigate the procedure for the pa-
driving as an IADL, the driver rehabilitation therapist, the tient’s resident state. Obtaining a copy of the state’s stat-
client, and the family. The physician and other treating ute is important, as is talking to the department of driver
624 Stroke Rehabilitation

licensing or medical review board. By performing a an The physician’s decision to report a patient should be based
internet search using the letters “DMV,” each state Divi- on the amount of risk involved in allowing the person to
sion of Motor Vehicles website can be found. continue driving. The physician should protect patients
The March 1993 AOTA physical disabilities special from further harm or injury to themselves or others. States
interest section newsletter discussed the legal consider- that have a mandatory reporting law also protect individuals
ations for driver rehabilitation programs in terms of the by a state statute who report medical conditions from being
responsibility of the patient, physician, and occupational sued for slander or character defamation by divulging per-
therapist.30 To avoid any legal difficulties with the driver’s sonal information to the department of driver licensing. For
insurance, the stroke survivor should notify his or her car further protection, the name of the reporting person is not
insurance company about the stroke, the results of the revealed to the licensee.
driving evaluation, and the validation of the person’s driv- A review of past court opinions and judgments reveals
ing ability by the department of motor vehicles. Failure to rulings for and against physicians. Jacobs,17 in a 1978 ar-
notify the insurance company may result in a claim of ticle titled “Reporting the Handicapped Driver,” cited
fraud if the patient has an accident. As a result, the stroke several lawsuits against physicians. In a 1920 invasion of
survivor who is driving may be held completely or par- privacy lawsuit, Simonsen v. Swenson, the physician was
tially liable for costs rewarded in court judgments for vindicated of any wrongdoing by proving that the public
property damage, bodily damage, pain, suffering, and loss welfare was being protected. In Freese v. Lemmon, 210
of any parties involved in the accident because of con- NW2d 576 (Iowa, 1973), a physician was found guilty of
tributory negligence. malpractice because he failed to warn and counsel a pa-
tient about the possible effects a medical condition might
Physician’s Liability have on driving ability. In this case, the patient had been
In the past 20 years, court precedent has established that diagnosed with epilepsy. The physician did not advise the
physicians have responsibility for protecting the public person to stop driving. The person had a seizure while
health even if it conflicts with the patient’s right to privacy driving and struck a pedestrian. In a 1986 lawsuit Tarasoff
and confidentiality. This duty to warn society for the v. Regents of the University of California (551 p. 2d 334, at
greater good has been upheld by the courts. Conse- 344 [1986]), a psychologist working in the student health
quently, the physician’s liability to inform third parties has department on campus was held liable because of his fail-
increased. Few, if any, exceptions to this rule exist, so any ure to alert and advise campus authorities properly when
person who has had a brain trauma or damage should be a student reported to him an intention to murder his girl-
assessed objectively for safe driving skills. Failure to ad- friend. The court ruled the psychologist had a duty to
dress these issues with the stroke survivor and concerned break confidentiality and warn the potential victim. The
others may expose a health care provider to a charge of court’s opinion concluded that the “protective privilege
negligence. ends where the public peril begins.” The court also stated
Some states have mandatory reporting laws. A physi- the following:3 “The physician treating a mentally ill pa-
cian must report a new disability or diagnosis to the de- tient, just as a doctor treating a physical illness, bears a
partment of driver licensing. In states that lack this law, duty to use reasonable care to give threatened persons
some physicians may overlook, ignore, or hesitate to re- such warnings as are essential to avert foreseeable danger
port a patient for fear of losing a patient. The physician arising from his patient’s condition or treatment.”
may feel a loyalty toward patients he or she has treated for Antrim and Engum,2 in an article titled “The Driving
many years. A patient may attempt to influence the phy- Dilemma and the Law: Patients Striving for Indepen-
sician’s decision by indicating that he or she is the only dence Versus Public Safety,” described other legal cases
driver in the family and driving is crucial to continued illustrating practitioner liability. In Naidu v. Laird, 539
independent living. Although this may be true, the physi- A2d 1064 (Del. 1988), the court heard that Laird was
cian’s first thought should be the safety and protection of killed in a car accident by a known psychotic person who
the patient and the public. If the physician or others on had been involved in several similar accidents in which he
the rehabilitation team are unsure the patient will comply drove his car deliberately into someone else’s car. When
with the recommendations as given regarding driving, the taking his medication, the psychotic person was generally
person should be reported to the department of driver manageable, appropriate, and capable of living semi-
licensing without hesitation. independently. When not taking his medication, he had
The American Medical Association (AMA) now encour- violent tendencies that presented a risk of harm to himself
ages physicians to make driver safety a routine part of geri- and others. Laird’s widow sued the psychotic person
atric medical services. The AMA in 2003 published the and the treating physician, Dr. Naidu, for wrongful
Physician’s Guide to Assessing and Counseling Older Drivers. death. The court ruled in favor of the plaintiff. The court
Information about this book and other resources is available stated “a psychiatrist owes an affirmative duty to persons
through their website at www.ama-assn.org/go/olderdriver. other than the patient to exercise reasonable care in the
 Chapter 23 • Driving and Community Mobility as an Instrumental Activity of Daily Living 625

treatment and discharge of their patients.” Antrim defined driver rehabilitation program was found not to be liable
reasonable care as the degree of care, skill, and diligence for the driving mistake of a former patient that resulted in
that a reasonably prudent psychiatrist engaged in a similar a motor vehicle accident that caused the death of a pas-
practice and in similar conditions ordinarily would have senger in another vehicle.
exercised in like circumstances. For risk management the driver rehabilitation thera-
Antrim and Engum2 further discussed the California pist should follow safe, accepted practices (Box 23-9). The
case Myers v. Quesenberry, 144 Cal App 3d 888 evaluation car must be viewed as an evaluation tool that
(1983), which involved a car accident of a patient of must be adjusted to each client’s use and maintained in
Dr. Quesenberry who was being treated for diabetes proper working order just as any machine in the OT
and receiving prenatal care. The doctor knew that his clinic. Proper training by qualified professionals in the
patient had been seriously affected during two previous field and practice with in-car skills prepares the therapist
pregnancies that resulted in one stillbirth. During the for the work in the car. An Adaptive Mobility Services
third pregnancy, the patient’s diabetes could not be sta- workshop titled Take the Wheel: A Driver Education Work-
bilized. During an office examination, the physician shop for the Therapist provides this type of knowledge, in-
discovered the fetus had died. Dr. Quesenberry advised struction, and practice in a real evaluation vehicle with
the patient to have a dilation and curettage procedure. mock patients.
He instructed her to drive immediately to a hospital. An occupational therapist must be credentialed ade-
Emotionally distraught, the patient suffered a diabetic quately to enhance the value of his or her professional
attack in route and lost control of her car, striking a opinion. The therapist must have a strong working knowl-
pedestrian, Myers. The court noted that a fundamental edge of each step of a comprehensive driving evaluation
principle of tort law held physicians liable for injuries and must use the accepted practices in the industry consci-
caused by their failure to exercise reasonable care. A entiously. The therapist must follow any industry guide-
physician must warn a patient if the patient’s condition lines, standards of practice, and code of ethics that exist for
or medications renders certain conduct such as operat- the OT profession. Wendy Kaplan19 in a 1999 AOTA
ing a motor vehicle dangerous to others. physical disabilities special interest section quarterly news-
A physician must appreciate the complexity and dan- letter article titled “The Occupation of Driving: Legal and
gers of driving and understand that certain conditions or Ethical Issues” stated that “Therapists should be aware of
deficits may impair driving performance. A physician medical reporting requirements for impaired driving laws
should recognize limitations in having the tools and abili- that exist in their state of practice. The AOTA Code of
ties to evaluate a person’s driving skills fully in the office Ethics creates an obligation for administrative occupational
or hospital. A physician should be informed about the
expertise and role of the occupational therapist and the
driver rehabilitation therapist to refer patients for a Box 23-9
medical-oriented and comprehensive driving evaluation. Strategies for Risk Management
Occupational Therapist’s Liability The driver rehabilitation therapist can reduce liability risk
The occupational therapist’s responsibility can be as great by the following:
■ Have a medical background with knowledge in driver
and serious as the physician’s is. The level of liability in-
education principles.
creases as the therapist’s role and responsibility increase.
■ Have advanced and specialized education and skill in
The therapist seeing the patient in the acute care setting
the field of driver evaluation.
who addresses only driving from a factual standpoint has ■ Have a working knowledge of each step of the com-
little liability, if any. However, if the inpatient or outpa- prehensive driving evaluation.
tient occupational therapist chooses not to inform the ■ Know and practice accepted standard of care in driver
patient or the family of their responsibility with this issue, evaluations.
then the therapist may be liable for an act of omission. ■ Ensure that the evaluation vehicle is equipped with in-
The OT Specialist in Driving or the driver rehabilita- structor’s safety equipment.
tion therapist has the greatest degree of vulnerability to ■ Set the vehicle for each client per the individual

liability lawsuits compared with an occupational therapist needs.

■ Know how to control the vehicle from the right side,
in the clinic or hospital. The nature of the job, in which
physically and verbally.
the therapist takes a person in traffic, has inherent risks. A
■ Use sound judgment and good clinical reasoning.
definitive legal case that eases the liability position of the ■ Use good observation and visual skills.
driver rehabilitation therapist was White v. Moss Rehab, ■ Use good documentation and communication
et al. (Philadelphia, 1995) when the court declined “to procedures.
recognize a common-law third party cause of action for ■ Carry professional liability insurance.
educational malpractice against a driving school.” The
626 Stroke Rehabilitation

therapists to be aware of the laws related the health care procedure defined, the therapist may be held liable for
practitioners and driving as well as to disseminate that omitting that portion of the test. Legal counsel should
knowledge. It is the role of the manager to create depart- review the wording of the driving program policies and
mental policies consistent with those laws and provide the procedures.
administrative support necessary for observance of those The therapist is responsible for ensuring that all evalu-
policies.” For legal protection, all therapists, and especially ative or testing equipment works when needed. For ex-
those in this specialty area, should have their own profes- ample, therapists can use several commercially available
sional liability insurance in addition to coverage from the devices to test visual acuity and night vision. If the ma-
employer. If the therapist is ever drawn into a lawsuit, he or chine that measures night vision is not working when the
she must have representation by a personal attorney and therapist evaluates a patient with a diagnosis in which
not a third-party interest. night vision could be a suspected problem (such as glau-
The driver rehabilitation therapist should possess all coma), the therapist may be found negligent for not hav-
necessary clinical and vehicle tools, tests, and skills used to ing the machine fully functioning when the patient was
pass judgment fairly and accurately on a person’s driving evaluated. The therapist may make a statement in the
future. The therapist should evaluate a client’s driving summary indicating that rendering an opinion on the is-
ability fully, considering the safety of the client and the sue was impossible; however, in making a conclusion re-
public at large. The therapist should avoid zealousness as garding the person’s driving ability, night vision should be
an advocate for the client whose skills are in question. tested appropriately.
The occupational therapist’s perspective of looking at the
whole person is key to making the best decision. The Communication and Documentation
contextual and environmental factors are very important Communication and documentation are important keys
to consider. The person may only need to drive within a to lessening everyone’s liability throughout the entire
5 mile radius of his or her home and has lived at the same process of addressing driving issues for the stroke survi-
address for many years. If the patient will require a man- vor. The stroke survivor and the family need to be in-
ual wheelchair permanently, then this may affect the ve- formed of the requirements of the state department of
hicle and equipment recommendations. If the person will driver licensing. These requirements vary from state to
be moving to a different location to be close to family and state. In the rehabilitation phase, the stroke survivor and
is unfamiliar with the area, then memory, learning skills, family should sign a document that becomes a perma-
and directionality may be greater factors than when a nent part of the medical record that describes the infor-
person will be returning to a familiar environment in mation, recommendations, and follow-up plans given by
which he or she has resided for many years. the rehabilitation team regarding driving and commu-
Antrim2 is a practicing attorney and a member of the nity mobility.
board of reviewers of the journal Cognitive Rehabilitation. Documentation of addressing the IADL of driving and
He strongly suggests that current legal authority appears community mobility is crucial and necessary for several
ready to impose liability on health care professionals for purposes. This documentation can be used to justify an
negligence in failing to address their patients’ abilities to adaptive equipment purchase for a third-party payer, in-
drive. Antrim recommends that health care professionals form the department of motor vehicles and a physician of
use a standard of care in making these recommendations the patient’s driving performance, and help defend the
and that their evaluation process should include guide- therapist in a court of law or during a deposition in which
lines for making those decisions reasonably and responsi- professional judgment or expertise is deposed. The thera-
bly. The AOTA Practice Guidelines for Driving and Commu- pist should keep in mind that if something is not docu-
nity Mobility for Older Adults offers recommended practices mented on paper, in the eyes of the court it was not done.
for the occupational therapist. This documentation is more vulnerable than usual be-
In a 1986 article, Steich37 explained that the law holds cause it is scrutinized far more than is the documentation
professionals to a higher standard than it does the public of in-house therapy for ADL training. Because driving is
because professionals consider themselves more highly an ADL that can kill,28 the parties involved must maintain
skilled in their particular fields of expertise. For example, the highest degree of competence, thoroughness, and se-
the driver rehabilitation therapist owes a greater duty of riousness at all times. The documentation of a driving
care to a client and the public than does a parent teaching program is at greater risk to be subpoenaed by an attorney
a child to drive. Steich goes on to explain that the occupa- searching for liability for a lawsuit.
tional therapist must do something wrong or fail to do The OT notes should document all aspects of how
something that should have been done to be held liable. If the IADL of driving was addressed just as they would
the policies and procedures of a program define the steps for any other ADL or IADL. For example, reports
that should be performed to complete a comprehensive throughout the continuum of OT at the various levels
driver evaluation but the therapist fails to use the tool or of rehabilitation and recovery should include such things
 Chapter 23 • Driving and Community Mobility as an Instrumental Activity of Daily Living 627

as interactions with the stroke survivor, the way the on the client and family’s finances, assets, and security if
patient performed in each step, and the clinical reason- an accident occurs.
ing inherent in the decision-making and final outcome Since driving and community mobility are in the do-
regarding the person’s ability to drive. Therapists should main of OT as an IADL, the occupational therapist must
avoid statements such as “the patient has potential to be address and be involved in the evaluation, intervention,
a safe driver.” The therapist must have enough confi- and outcome for determining safety to return to driving
dence with the patient’s abilities and in his or her own or to use other transportation choices. AOTA is the pri-
professional judgment to document “the patient is a safe mary provider of information and education for the oc-
driver.” cupational therapist in addressing the IADL of driving
Another method of documentation is to say “today the and community mobility as an OT Generalist in Driving
patient drove safely in the following situations.” The or as an OT Specialist in Driving. A stroke survivor pre-
documentation should account for the time and days sents unique problems that must be looked at individually.
spent with a patient. The therapist should note positive The outcome regarding the client’s driving abilities must
and negative observations or scores. Incomplete, illegible, be made on reliable, objective information and with good
and poorly written documentation is hard to defend in clinical reasoning and judgment.
court if an expert witness is used to judge the driver reha-
bilitation therapist’s work and decisions. As with the phy- REVIEW QUESTIONS
sician cases noted previously, an expert witness with simi-
lar practice to the therapist’s may be called to testify 1. Describe why the occupational therapist should in-
regarding standard procedure in similar conditions. This clude driving and community mobility as an IADL.
witness may not be able to testify that the driver rehabili- 2. Describe at least five activities that illustrate the im-
tation therapist acted with a reasonable care of duty if the portance of community mobility to a patient who has
documentation cannot support conclusions with evidence. had a stroke.
Evidence of professional continuing education is impor- 3. Describe the requirements for an occupational thera-
tant to show that the therapist knowledge is updated with pist to be an OT Specialist in Driving or a driver re-
current standard of practice. habilitation therapist.
After a complete driving evaluation, the therapist 4. What specific areas should be evaluated during the
should explain final recommendations thoroughly to the clinical evaluation portion of a comprehensive driver
stroke survivor and family members. The referring physi- evaluation for a client with left hemiplegia from a
cian should receive written notification of the outcome of stroke?
the evaluation. The therapist should document the re- 5. Describe the liability issues involved for the client,
sults, recommendations, and follow-up services to be physician, therapist, and facility.
done in the client’s chart. The client should sign the writ- 6. Identify four driving behaviors or errors that may be
ten recommendations to demonstrate legal proof of expla- seen in a driver with left side neglect.
nation of the findings. If the results of the evaluation are 7. Identify specific performance skills (e.g., motor,
negative, a team member may inform the proper driver sensory-perceptual, cognitive, and communication)
licensing authority in the client’s state of residency. used in the following steps of each driving task:
■ Lane change to the right
■ Rearview mirror check
SUMMARY
■ Right outside mirror check
Driving and community mobility must be included and ■ Right turn signal
addressed as an IADL in the OT evaluation and interven- ■ Right head check
tion for the stroke survivor. Driving after a stroke is pos- ■ Gradual and small turn of wheel to right
sible for some persons, but addressing driving along the ■ Cancel turn signal
continuum of OT is necessary so that a driver evaluation ■ Accelerate as appropriate
with a qualified driver rehabilitation therapist is com- 8. List at least six factors influencing a successful driving
pleted before the person returns to driving. The physician evaluation process.
and other team members must educate stroke survivors 9. What is the purpose of the mobility prescription?
and their families early in rehabilitation concerning the List all its uses.
necessity and importance of the evaluation. The issues of 10. What adaptive driving equipment may be used for the
liability and insurance arising from a stroke survivor driv- following deficits?
ing without a valid license, without the doctor’s approval, ■ Use of one hand only for steering
without necessary equipment, and/or without a docu- ■ Nonuse of right lower extremity
mented formal driving evaluation should be explained ■ Nonuse of left upper extremity
carefully. Emphasis should be on the detrimental effects ■ Lack of neck motion (particularly rotation)
628 Stroke Rehabilitation

11. List four purposes for the road test. 20. Katz RT, Golden RS, Butter J, et al: Driving safety after brain
12. How can a therapist plan a driving route with eco- damage: follow-up of 22 patients with matched controls. Arch Phys
Med Rehabil 71(2):133, 1990.
logical validity for the stroke survivor? 21. Korner-Bitensky N, Sofer S, Kaizer F, et al: Assessing ability to
13. Describe why the occupational therapist is suited to drive following an acute neurological event: are we on the right
perform the on-road assessment. road? Can J Occup Ther 61(3):141–148, 1994.
22. Deleted.
23. Legh-Smith J, Wade DT, Hewer RL: Driving after a stroke. J R Soc
REFERENCES Med 79(4):200–203, 1986.
1. American Occupational Therapy Association: Occupational Ther- 24. McKnight JA: Driver and pedestrian training, vol II, Washington,
apy practice framework: domain and process. Am J Occup Ther D.C., 1988, Transportation Research Board.
62(6):625–683, 2008. 25. Nouri FM, Tinson DJ, Lincoln NB: Cognitive ability and driving
2. Antrim MJ, Engum ES: The driving dilemma and the law: patients after stroke. Int Disabil Stud 9(3):110–115, 1987.
striving for independence versus public safety. Cognit Rehabil 7(2): 26. Eberhard J: On the road again. AOTA OT Week 5:16, 1998.
16–19, 1989. 27. Persson D: The elderly driver: deciding when to stop. Gerontologist
3. Blum J: Keeping seniors on the move. Columbus Monthly 8:72, 1993. 33(1):88–91, 1993.
4. Brooke MM, Questad KA, Patterson DR, et al: Driving evaluation 28. Pierce S: A roadmap for driver rehabilitation. AOTA OT Pract
after traumatic brain injury. Am J Phys Med Rehabil 71(3):177–182, 10(1):30–38, 1996.
1992. 29. Pierce S: Restoring competence in mobility. In Trombly C,
5. Carp FM: Significance of mobility for the well being of the elderly. Radomski M, editors: Occupational therapy for physical dysfunction,
Transport Aging Soc 2:1–20, 1988. ed 5, Philadelphia, 2002, Lippincott Williams & Wilkins.
6. Committee for the Study on Improving Mobility and Safety for Older 30. Pierce S, Blackburn C: Building blocks for becoming a driver rehabilita-
Persons. In Transportation in an aging society, vol 1, Washington, D.C., tion therapist, Orlando, FL, 2008, Adaptive Mobility Services.
1988, Transportation Research Board. 31. Ramsey B: Take the wheel: a driver education course for the therapist,
7. Diller L, Weinberg J: Evidence for accident-prone behavior in course notes, Orlando, FL, 1996, Adaptive Mobility Services.
hemiplegic patients. Arch Phys Med Rehabil 51(6):358–363, 32. Scheiman M: Understanding and managing visual deficits: theory screen-
1970. ing procedures, intervention techniques, course notes, Atlanta, 1996,
8. Engum ES: Criterion-related validity of the cognitive behavioral Vision Education Seminars.
driver’s inventory: brain-injured patients versus normal control. 33. Sivak M, Olson PL, Kewman DG, et al: Driving and perceptual/
Cognit Rehabil 8(2):20, 1990. cognitive skills and behavioral consequences of brain damage. Arch
9. Engum ES, Pendergras T, Cron L, et al: Cognitive behavioral Phys Med Rehabil 62(10):476–483, 1981.
driver’s inventory. Cognit Rehabil 6(5):34–50, 1988. 34. Slavin S: Association of Driver Educators for the Disabled confer-
10. French D, Hanson C: Survey of driver rehabilitation programs. Am ence presentation, Keynote Speaker Address, Orlando, FL, 1987.
J Occup Ther 53(4):344–7, 1999. 35. Smith EE: Choice research time: an analysis of the major theoretical
11. Gianutsos R: Driving advisement with the elemental driving simula- positions. Psychol Bull 69:77, 1968.
tor (EDS): when less suffices, behavior research methods. Instrum 36. Stav WB, Pierce S, Wheatley CJ, Davis ES: Driving and community
Comput 26:183, 1997. mobility. Am J Occup Ther 59(6):666–670, 2005.
12. Gianutsos R: Personal communications, Sept 1996 and July 2010. 37. Steich T: Malpractice insurance important for occupational therapy
Refer to www.driverrehab.com and www.sites.google.com/site/ personnel. OT News 40:7, 1986.
elementaldrivingsimulator for more information. 38. Stone SP, Wilson B, Wroot A, et al: The assessment of visuo-spatial
13. Gianutsos R, Suchoff IB: Visual fields after brain injury: manage- neglect after acute stroke. J Neurol Neurosurg Psychiatry 54(4):
ment issues for the occupational therapist. In Scheiman M, editor: 345–350, 1991.
Vision: screening and intervention techniques for occupational therapists, 39. Stressel DL: American Occupational Therapy Association continu-
Thorofare, NJ, 1996, Slack. ing education article: Driving issues of the older adult. OT Practice
14. Gresham GE, Duncan P, Stason W, et al: Post-stroke rehabilita- 5:CE1–CE8, 2000.
tion: clinical practice guideline, Rockville, MD, 1995, US Depart- 40. Toglia JP: Visual perception of objects: an approach to assessment
ment of Health and Human Services, Public Health Service, and intervention. Am J Occup Ther 43(9):587, 1993.
Agency for Health Care Policy and Research, No 16, AHCPR 41. Underwood M: The older driver: clinical assessment and injury
Pub No 95–0662. prevention. Arch Intern Med 152(4):737, 1992.
15. Hibbard MR, Gordon WA, Stein DN, et al: Awareness of disability 42. Van Zomeran AH, Brouwer WH, Minderhoud JM: Acquired brain
in patients following stroke. Rehabil Psychol 37:103, 1992. damage and driving: a review. Arch Phys Med Rehabil 68(10):
16. Hunt L, Pierce S: Driving and Community Mobility for Older 697–705, 1987.
Adults: Occupational Therapy Roles. AOTA online course, 2009, 43. Warren M: A hierarchical model for evaluation and treatment of
pg 35, lesson 1. visual perceptual dysfunction in adult acquired brain injury, part 2.
17. Jacobs S: Reporting the handicapped driver. Arch Phys Med Rehabil Am J Occup Ther 47(1):55–66, 1993.
59(8):387–390, 1978. 44. Weaver J: In Driver performance test, Orlando, FL, 2009, Advanced
18. Johansson C: Top 10 emerging practice areas to watch in the new millen- Driving Skills Institute.
nium (website). www.aota.org/members/area7/index.asp. Accessed 45. Wilson B, Cockburn J, Halligan P: Development of a behavioral test
March 12, 2002. of visuospatial neglect. Arch Phys Med Rehabil 68(2):98–102, 1987.
19. Kaplan W: The occupation of driving: legal and ethical issues. 46. Wilson T, Smith T: Driving after stroke. Int Rehabil Med 5(4):
AOTA Phys Disabil Spec Interest Section Newsletter 22:3, 1999. 170–177, 1983.
 wen dy avery

chapter 24

Dysphagia Management

key terms
alternative nutrition dysphagia laryngeal penetration
aspiration feeding trials modified barium swallow
bedside evaluation fiberoptic endoscopic evaluation silent aspiration
bolus of swallowing
cervical auscultation

chapter objectives
After completing this chapter, the reader will be able to accomplish the following:
1. Describe the normal anatomy and physiology of the swallowing mechanism.
2. Discuss the effects of stroke on the swallowing mechanism.
3. Describe clinical and instrumental assessment of dysphagia following stroke.
4. Describe various rehabilitative and compensatory techniques used to treat dysphagia
after a stroke.
5. Discuss the efficacy of dysphagia intervention following stroke.

Dysphagia comes from the Greek prefix dys, meaning dif- represents a midsagittal view of the anatomical land-
ficult, and the Greek term phagein, meaning to eat. The marks of the head and neck important in swallowing.
occurrence of dysphagia, or difficulty swallowing, imme- Fig. 24-2 represents anatomical landmarks of the oral
diately after stroke is common, with a reported incidence cavity. The act of swallowing may be divided into five
as high as 51%.82 In patients with brainstem stroke, the separate stages: preoral, oral-preparatory, oral, pha-
incidence may be as high as 81%.60 Intervention for dys- ryngeal, and esophageal. Fig. 24-3 illustrates the ana-
phagia is a part of occupational therapy care for patients tomical division of the oral preparatory through
with stroke in a variety of settings. While initial evalua- esophageal stages.
tion and treatment for dysphagia is critical in the acute
care setting, patients often require reassessment in post- Preoral Stage
acute settings as well.35 See Chapter 1. During the preoral stage, the patient engages in tray or
plate setup and preparation; visual, visual-perceptual,
NORMAL ANATOMY AND PHYSIOLOGY and olfactory awareness of the food; and transportation
OF THE SWALLOWING MECHANISM of the food to the mouth (feeding) using a utensil, cup,
or fingers. Patients with stroke often have challenges
A prerequisite for successful intervention with pa- with preoral stage activities that benefit from occupa-
tients with dysphagia is knowledge of the anatomy and tional therapy interventions, even in the absence of
physiology of the swallowing mechanism. Fig. 24-1 dysphagia.

629
630 Stroke Rehabilitation

Hard palate

Soft palate

Valleculae

Epiglottis

Aryepiglottic
fold
Tongue
Piriform sinus

Mandible False
vocal cords
Hyoid bone True
vocal cords
Thyroid cartilage
Cricopharyngeal
Cricoid cartilage sphincter

Esophagus
Trachea

Figure 24-1 Midsagittal view of swallowing landmarks.

Frenulum of
upper lip

Soft palate
Palatopharyngeal
arch Pharyngeal
Palatine phase
Oral-
tonsil preparatory
and
Palatoglossal Uvula oral phase
arch Esophageal
phase

Posterior wall
of pharynx

Figure 24-2 Landmarks of the oral cavity. Figure 24-3 Stages of a normal swallow sagittal view.

bolus. The muscles of mastication prepare the food, if

Oral-Preparatory Stage solid, into a bolus of suitable texture for swallowing by
During the oral-preparatory stage (Fig. 24-4, A), the pa- manipulating the bolus using the muscles of mastication,
tient demonstrates adequate mouth opening, bolus recep- the jaw, and the cheeks. During this stage, the soft palate
tion, containment in the oral cavity, oral sensation for the rests on the back of the tongue to prevent food or fluid
bolus, and appreciation of the flavor and texture of the from trickling into the pharynx.
 Chapter 24 • Dysphagia Management 631

penetration. The epiglottis folds over the opening to the

Oral Stage larynx (the laryngeal vestibule) (see Fig. 24-4, C ), also pre-
During the oral stage of the swallow, the prepared bolus is venting airway penetration into the larynx and directing
propelled through the oral cavity toward the pharynx the bolus toward the piriform sinuses. The larynx rises and
(see Fig. 24-4, B ). The lips and buccal muscles contract and tilts anteriorly, and pharyngeal peristalsis squeezes the bo-
transport the bolus posteriorly as the tongue sequentially lus downward through the pharynx toward the cricopha-
pushes the bolus posteriorly against the hard palate, propel- ryngeal sphincter (see Fig. 24-4, D ). The cricopharyngeal
ling it through the oral cavity, to the base of the tongue. sphincter, which is at the superior aspect of the esophagus,
relaxes and allows the bolus to pass into the esophagus.
Pharyngeal Stage
During this stage of the swallow, the following events occur Esophageal Stage
in rapid sequence, producing a swallow response. The soft The esophageal stage begins as the bolus passes through
palate elevates, closing off the nasopharynx. Swallowing the cricopharyngeal sphincter (see Fig. 24-4, E ). The bolus
apnea, or cessation of breathing, occurs as the vocal folds is propelled through the esophagus by a sequential peri-
close, protecting the airway from aspiration and laryngeal staltic “stripping wave.” The lower esophageal sphincter

Soft palate

Epiglottis

Mandible
Base of
Vocal tongue
folds

A B

Epiglottis
Esophagus

Trachea

C D

Esophagus

E
Figure 24-4 A, The oral-preparatory stage. B, The oral stage. C and D, The pharyngeal
stage. E, The esophageal stage.
632 Stroke Rehabilitation

located at the base of the esophagus then relaxes, allowing to have greater incidence of laryngeal penetration and
the bolus to pass into the stomach. aspiration than those with left hemispheric middle cere-
bral artery stroke. Patients with right hemispheric stroke
Neural Control of Swallowing take longer to initiate a swallow response than those with
Cortical and subcortical centers control the voluntary as- a left hemispheric stroke. Oral and pharyngeal bolus mo-
pects of the swallow, particularly during the preoral, oral- bilization is slower in persons with right hemispheric
preparatory, and oral stages. The swallow response, which stroke than in healthy individuals. Patients with left hemi-
can be initiated voluntarily or involuntarily, is controlled spheric stroke experience slower bolus mobilization
by cranial nerves and their nuclei in the medulla, with through the pharynx compared with healthy individuals.
input from cortical and subcortical centers. Six cranial Oral time transit time may also be delayed in those with
nerves are involved in the swallow process50 (Box 24-1). left hemispheric stroke. Apraxia is present in those with
left hemispheric stroke.85 A study by Irie and Lu42 sug-
SIGNS OF DYSPHAGIA ASSOCIATED WITH gested that, in general, patients with left hemispheric
STROKE stroke tended to have primarily oral phase impairments
and those with right strokes tended to have impairment of
A variety of signs are observed directly or by videofluoros- oral and pharyngeal phases. Patients with left hemispheric
copy during swallowing following stroke. Veis and stroke tended to require fewer dysphagia interventions
Logemann91 found that 75% of patients assessed by vid- and to require alternative nutrition less than those with a
eofluoroscopy demonstrated more than one specific sign right sided stroke did. Pharyngeal and laryngeal sensory
with their swallowing. Signs and symptoms vary with lo- loss may play a role in reduced ability to respond to the
cation and size of the lesion or lesions caused by stroke. presence of a bolus in some stroke patients.5
Table 24-1 delineates specific impairments that one may
observe. Fig. 24-5 illustrates some of these impairments. Brainstem Stroke
Patients with dysphagia and stroke may have a tracheos- Patients with brainstem stroke have greater occurrence of
tomy and may require mechanical ventilation. Although persistent dysphagia than those with hemispheric stroke.6,59
this chapter does not cover these topics, the suggested With lateral medullary infarction (Wallenberg syndrome),
reading will provide the reader with more information. oral control may be near intact, but the ability to trigger
Studies have observed the differences between dysphagia and achieve an effective swallow is weak bilaterally, de-
in stroke patients by lesion location. spite a unilateral lesion.6 Reduced laryngeal elevation,
unilateral pharyngeal weakness, and reduced adduction of
Hemispheric Stroke the vocal cords may be seen, resulting in aspiration.91 A
In general, patients with hemispheric stroke have diffi- delayed or absent swallow response may be seen.55,60 Re-
culty with voluntary triggering of the swallow.6 Patients covery does occur in 88% of patients; however, it takes
with right hemispheric middle cerebral artery stroke tend longer than in those with hemispheric stroke.60

Pseudobulbar or Suprabulbar Palsy

Box 24-1
Pseudobulbar or suprabulbar palsy referes to hemispheric
Cranial Nerve Functions stroke that causes dysphagia affecting the upper motor neu-
STAGE ron. Symptoms include altered muscle tone on the contralat-
eral side to the affected hemisphere, and difficulty coordinat-
Oral Cranial nerve V (trigeminal): tactile and
proprioceptive sensation and motor ing oral and pharyngeal motions. Lacunar infarcts with
Cranial nerve VII (facial): taste and suprabulbar palsy demonstrate delayed trigger, absent trigger,
motor and/or slow swallow.30 Laryngeal penetration and aspiration
Pharyngeal Cranial nerve IX (glossopharyngeal): can occur with pseudobulbar palsy, especially acutely.
taste, pharyngeal peristalsis, saliva-
tion, and taste Lacunar Infarcts
Cranial nerve X (vagus): taste and Lacunar infarcts, often occurring in the periventricular areas,
motor, intrinsic laryngeal muscles, are not always associated with specific dysphagic signs.
pharyngeal peristalsis, and swallow
initiation Multiple Strokes
Cranial nerve XI (accessory): pharyngeal
peristalsis and head and neck stability
Patients with multiple strokes may demonstrate slow oral
Oral and Cranial nerve XII (hypoglossal): lingual movements and a delayed swallow response.55 Often mul-
pharyngeal movement and laryngeal and hyoid tiple deficits exist, resulting in a greater risk of aspiration.
movement Patients with bilateral stroke are more likely to have sen-
sory deficits in the pharynx and larynx.5
 Chapter 24 • Dysphagia Management 633

Table 24-1
Dysphagia Signs and Symptoms in Stroke Associated with the Stages of Swallowing*
STAGE OF THE BEDSIDE EVALUATION MODIFIED BARIUM PHYSIOLOGICAL
SWALLOW SYMPTOMS SWALLOW SIGNS SYMPTOMS

Preoral Poor sitting posture Unable to view Reduced trunk control

Reduced orientation to food Reduced cognition
Inability to identify edibles from Visual-perceptual or sensory
nonedibles or to recognize food deficits
Inability to open packages or to Reduced upper extremity func-
prepare and cut food on plate tion, control, or coordination
Inability to get bolus to mouth Apraxia
using utensils or hand Ataxia
Oral- Reduced mouth closure Loss of bolus onto lips, drooling Reduced oral-motor strength,
preparatory tone, range
Reduced lip, tongue, and cheek Decreased ability to form bolus, Abnormal reflexes
control incohesive bolus
Perioral food residue (on lips Barium observed on lips or cheeks Reduced perioral sensation
and/or face), drooling
Tongue thrust Anterior tongue movements Reflexive tongue movements
Disorganized tongue Random tongue motions Tongue tremors, weakness,
movements reduced coordination
Reduced mastication Ineffective mastication, with Weakness, tone alterations
unchewed bolus
Slow oral preparation time Slow oral time observed Weakness, poor sensory
awareness
Oral fatigue Slow oral movements Weakness, low muscle tone
Lengthy mealtime Unable to visualize length of meal Slow or poorly coordinated
overall movements
Oral Use of fingers to manipulate the Fingers observed at mouth Reduced awareness of or ability
bolus posteriorly to propel the bolus posteriorly
Holding of food in the mouth Slow oral transit time
Pocketing of food in oral sulci Oral residue on tongue and sulci, Reduced/absent muscle control
(pooling) lips, or palate to direct bolus
Drooling Barium observed outside of mouth Reduced or absent intraoral
sensation
Oral residue after attempts at Barium residue in mouth Difficulty collecting or
swallowing propelling the entire bolus
Reduced tongue elevation to Tongue pumping Apraxia, ataxia, muscle tone
propel the bolus posteriorly alteration, discoordination
Reduced anterior to posterior Random tongue motions
tongue movement/bolus
propulsion, disorganized
tongue movements
Slow oral transit time Slow oral transit time observed Fatigue, poor coordination
Pharyngeal Coughing/choking Premature loss of bolus into Cranial nerves X and IX:
hypopharynx reduced/absent swallow,
weakness of swallow response
Wet/gurgly breath and vocal Delayed or absent swallow
quality response
Absent swallow response
Difficulty initiating a swallow
Weak cough Repeated attempts at Reduced respiratory support/
coughing/clearing capacity
Ineffective cough, cannot clear Bilateral or unilateral vocal fold
aspirated or penetrated material paralysis

*This table is not an exhaustive list of signs and symptoms but is meant to suggest some causative factors for swallowing dysfunction.

Continued
634 Stroke Rehabilitation

Table 24-1
Dysphagia Signs and Symptoms in Stroke Associated with the Stages of Swallowing—cont’d

STAGE OF THE BEDSIDE EVALUATION MODIFIED BARIUM PHYSIOLOGICAL

SWALLOW SYMPTOMS SWALLOW SIGNS SYMPTOMS

Cranial nerves IX and X:

reduced or absent sensation
Complains of food sticking in Pharyngeal wall residue Cranial nerves IX and X:
throat Reduced pharyngeal
peristalsis
Increased throat clearing Valleculae and piriform sinus pooling
Multiple swallows (more than Ineffective multiple swallows to
two) clear residue
Nasal regurgitation Penetration of bolus into Incompetence of palatal seal of
nasopharynx nasopharynx
Penetration of bolus into Reduced epiglottal movement,
trachea above level of vocal folds reduced laryngeal elevation
Aspiration of bolus into trachea Reduced ability to prevent
below level of vocal folds entry of food material into
airway
Lengthy mealtime Delayed swallow
Esophageal Regurgitation, sour taste, Reflux: reduced upper esophageal Esophageal or gastric reflux
heartburn, awaking with a sphincter opening caused by
wet pillow reduced pharyngeal/laryngeal
Altered esophageal motility ob- movement, reflux
served on instrumental testing

entrance of food or liquid into the larynx, above the level

Resolution of Dysphagia Following Stroke of the vocal folds.55 Silent aspiration is defined as the en-
Dysphagia clinicians and researchers have noted that dif- trance of saliva, food, or liquid below the level of the true
ficulty with swallowing lessens in the seven days following vocal folds without a cough or any clinical signs of diffi-
acute stroke, although in one study 27% of patients still culty.38 Aspiration and laryngeal penetration occur when
were considered to be at risk by the physician. After six the ability of the swallowing mechanism to prevent mate-
months, only 8% retained dysphagia; however, 3% had rial from entering the airway is impaired.
developed new difficulty with swallowing.82 Logemann Aspiration is common in the acute phase following
noted that 95% of patients with a single, uncomplicated stroke, with a greater incidence in severe strokes and in
stroke returned to full oral intake after nine weeks, re- patients with pharyngeal sensory loss.33 Approximately
gardless of the location of the stroke.55 However, among 40% of stroke patients with dysphagia who aspirate do
that 95%, pharyngeal function was not completely normal not exhibit symptoms of aspiration during the bedside
and possibly contributed to even more severe dysphagia evaluation (silent aspiration).38 Of stroke patients selected
with a subsequent stroke.55 for a videofluoroscopic study, 48% to 55% were shown
actually to aspirate.28 Veis and Logemann91 found that
MEDICAL COMPLICATIONS ASSOCIATED 32% of the subjects assessed by videofluoroscopy aspi-
WITH DYSPHAGIA IN STROKE rated from pharyngeal stage problems, which the bedside
evaluation cannot detect. Mann and Hankey58 found that
Medical complications associated with dysphagia follow- aspiration was correlated with delayed oral transit and
ing stroke include aspiration pneumonia, dehydration, incomplete oral clearance of the bolus. Sensory deficits in
compromised nutrition, and death.81 the larynx and pharynx may be associated with aspiration.5
Patients with brainstem, subcortical, or bilateral stroke
Aspiration are at greater risk for aspiration.26
Aspiration refers to the penetration of food or liquid into Tolerance for aspiration appears to be individual and
the airway, below the level of the vocal folds, before, dur- may depend on the frequency, volume, and content of
ing, or after the swallow. Laryngeal penetration refers to the what is aspirated. Tolerance may also depend on the
 Chapter 24 • Dysphagia Management 635

Soft palate
Premature loss
of bolus into
hypopharynx
Vallecular
Pocketing pooling
Drooling in sulci
Piriform
Mandible sinus
pooling
Tongue Tracheal
penetration

A B
Oral residue

Vallecular
Oral pooling
residue
Piriform
sinus Entry of bolus
pooling into the esophagus
Bolus penetration
above the level
of the vocal folds Aspiration
of bolus into
the trachea
C D
Oral residue

Vallecular
pooling

Pocketing
in sulci
Bolus in
esophagus
Aspirated
material

E
Figure 24-5 Pathophysiology of dysphagia after stroke.

overall health of the individual patient. Information re- may occur in 11% of those with brainstem stroke.89 It oc-
garding who may tolerate aspiration and in what param- curs primarily the first few days after stroke.27 Saliva con-
eters is scarce. tains pathogens that may be causative factors for pneumo-
nia when saliva is aspirated.44,45
Aspiration Pneumonia
Aspiration can lead to aspiration pneumonia in patients Dehydration and Compromised Nutrition
with stroke,56,59,63,76,81 which may lead to hospitalization Dehydration is another possible consequence of dysphagia.
or death.63 Pneumonia is particularly common in stroke Schmidt and colleagues76 were unable to identify an in-
patients with multiple-location strokes, a history of airway creased risk of dehydration for patients with aspiration
disease, hypertension, diabetes, and aspiration during compared with those who did not aspirate. Dehydration
modified barium swallow (MBS).26,59 As aspiration may may be caused by the use of dysphagia diets that provide
occur with greater frequency in brainstem stroke, and it only thickened liquids to avoid aspiration.31,95 Dehydration
636 Stroke Rehabilitation

also may be caused by the patient’s inability to recognize Dysphagia screening tools identify patients in need of
thirst or to request a drink when thirsty. Nutritional status a complete clinical evaluation. Screening has been shown
also may be compromised by stroke81 for a variety of rea- to reduce the incidence of pneumonia, regardless of sever-
sons, including dysphagia, loss of appetite, decreased men- ity of the stroke.36 Several screenings are available in the
tal status, depression and other psychosocial factors, and literature, including the 3 ounce water test,24 the Burke
medication interactions. Dysphagia Screening Test,25 and the Gugging Swallow
Screen,90 which was developed for those with acute stroke.
Aspiration and Site of Lesion Facilities may also develop their own screening tests.
Teasell, Bach, and McRae88 reported that aspiration oc- Screening is least likely to identify the presence of dys-
curred in at least 9.9% of all patients who had unilateral phagia following stroke, clinical assessment is more sensi-
right hemispheric strokes, 12.1% of those who had unilat- tive, and MBS is most sensitive.59
eral left hemispheric strokes, 24% of those who had bilat- Identifying those at risk for aspiration and reducing
eral hemispheric strokes, and 39.5% of those who had possibility of severe medical consequences is a critical
brainstem strokes. Horner, Massey, and Brazer39 reported purpose of evaluation. However, a complete evaluation of
that aspiration occurred twice as often in those with bilat- swallowing addresses many other important issues for
eral stroke compared with those with unilateral stroke. those with stroke. The swallow may be simply mildly im-
Aspiration after bilateral stroke may be caused primarily paired; however, that may lead to a more seriously decom-
by incomplete laryngeal elevation and closure, which en- pensated swallow in the future as illness proceeds. Mild
courages aspiration during the swallow and reduces pha- challenges with swallowing may lead to inadequate nutri-
ryngeal peristalsis after the swallow, causing aspiration of tion. Pleasure, enjoyment, and socialization at meals may
residue. Alberts and colleagues2 reported that patients be severely impacted by mild impairments and may
with only small vessel infarcts had a decreased incidence gravely affect quality of life.
of aspiration versus those with large and small vessel in-
farcts. Aspiration may be correlated with pharyngeal Clinical Evaluation and Assessment
transit time, swallow response time, and duration of la- When the physician suspects dysphagia, the physician or-
ryngeal closure.69 ders a dysphagia evaluation. The physician, patient, nurs-
ing staff, and family also may identify the need for dyspha-
ROLE OF THE SWALLOWING TEAM gia evaluation. For patients who are NPO (not eating food
by mouth), the physician must stipulate whether evaluation
In inpatient settings, optimal management of dysphagia is will include attempting trials of food by mouth with the
performed by a multidisciplinary team. The team is re- patient. The evaluation examines factors that interfere with
sponsible for identification, evaluation, diagnosis, treat- feeding and swallowing function, the patient’s risk for aspi-
ment, and overall management of patients with dysphagia. ration, and factors that may contribute to a decrease in oral
The multidisciplinary team includes a designated pri- intake. The evaluation includes observational and direct
mary dysphagia therapist, usually the occupational therapist examination components: chart review, patient and care-
or speech-language pathologist, and the nurse, physician, giver interview, functional status, oral motor examination,
respiratory therapist, dietitian, and the patient, who plays an abnormal reflexes, pharyngeal examination, feeding trial,
active role in decision-making. For management of the dys- and a statement of impression and recommendations.
phagic patient to be successful, all persons involved in the Specific assessment tools may be developed by facilities
patient’s care should understand the swallowing impairment or a standardized assessment may be used. Appropriate
and the management techniques used. Ongoing education dysphagia standardized assessments for patients with
and follow-up are often necessary. stroke include the Dysphagia Evaluation Protocol,4 the
Mann Assessment of Swallowing Ability,57 and the Func-
EVALUATION OF SWALLOWING tional Oral Intake Scale.21 The latter two were standard-
ized on stroke populations. All of these assessments dem-
Evaluation is the process of gathering and interpreting onstrate a high degree of reliability.
information needed for intervention.37 Assessment refers
to use of specific standardized tools or tests used as part Chart Review
of overall evaluation.37 Dysphagia can be evaluated clini- The therapist first must review the patient’s chart carefully
cally and instrumentally. Clinical evaluation, which can- to ascertain pertinent facts from the medical and feeding
not rule out aspiration in those with stroke,83 usually history. Pertinent information includes the following:
precedes instrumental evaluation. Instrumental evalua- ■ Age52
tion is better at determining aspiration risk, and clinical ■ Previous evaluations and tests indicating current
evaluation helps to determine whether instrumental eval- status (positive infiltrate on chest x-ray examination;
uation is needed. ear, nose, and throat evaluation)
 Chapter 24 • Dysphagia Management 637

■ Primary diagnosis and date of onset If a patient is unable to self-position to achieve an upright
■ History of present illness, secondary diagnoses, and sitting position, this may interfere with feeding and swallow-
medical history, including history of dysphagia due ing. The occupational therapist should determine the amount
to conditions other than stroke of assistance required to position the patient in the bed or
■ History of aspiration pneumonia chair and whether the patient is able to maintain the position
■ History of weight loss, appetite, and nutrition, espe- independently. Ideally the patient should sit upright in a
cially with current inpatient admission chair with the pelvis in a slight anterior tilt, forearms weight-
■ Reduced oral intake and its possible relation to de- bearing on the tabletop, and the head and neck at midline
pression, pain, feeding dependence, and food prefer- and upright. The therapist also evaluates upper extremity
ences or dislikes and hand function as they relate to feeding.
■ Aspiration precautions Adaptive equipment or environmental adaptations may
■ Dietitian, chest physical therapy, and/or respiratory enable patients to feed themselves if possible. Adaptations
therapy evaluations for positioning include supporting feet that do not reach
■ Current method of nutritional intake the floor with a telephone book or foot rest, using wheel-
■ Current type of diet ordered chair cushions and other devices to improve upright pos-
■ Whether calorie counts are in place ture, and adjusting the table height as needed. Wheel-
■ Length of time on current diet chairs with removable or swing-away armrests allow the
■ Dietary restrictions (diabetic: no concentrated sug- patient to eat at the table. Alternatively, a full lap tray can
ars; cardiac: low sodium or low fat) be used with a wheelchair.
■ Food allergies The therapist should assess the patient’s ability to initi-
■ Current respiratory status ate and complete oral hygiene. A clean mouth is necessary
When reviewing the chart, the therapist must consider the for sensory appreciation of food, and good oral hygiene
patient’s ability to participate in the evaluation, which con- has been shown to reduce rates of pneumonia in an elderly
tributes to the ability to feed and swallow safely. Factors to populations.97 One-handed techniques and equipment
consider for mental status include primary language spo- create independence with oral care. See Chapter 28.
ken, level of alertness, ability to follow directions, insight For feeding, helpful items include Dycem to prevent the
into swallowing difficulty, cognitive and perceptual status, plate from slipping, a rocker knife and plate guard for one-
and ability to communicate needs. Because eating requires handed eating, a covered cup or straw for bringing bever-
a coordination of breathing and swallowing, respiratory ages to the mouth without spilling, and built-up utensils for
problems may affect a person’s ability to eat safely. The weak or poorly controlled grasp to encourage use of a
therapist should consider the following factors when evalu- hemiplegic dominant arm. Bent spoons for using a non-
ating the patient’s ability to eat orally: excessive oral secre- dominant upper extremity to feed also may be helpful.
tions, presence of tracheostomy, ventilator dependence and Adapted cups with lids reduce spilling and provide handles
ability to wean, and frequency and route of suctioning. for easy manipulation with a gross grasp; lids may have
holes for straws, if appropriate. Specially angled dysphagia
Patient/Caregiver Interview cups allow sipping without tilting the neck into extension.
Initial contact begins with medical nursing staff and in the Adaptations for reduced visual acuity, perception, and
patient’s room, where the occupational therapist may ask cognition may be useful at the table. The patient should
questions of the patient, family, and caregivers regarding the wear eyeglasses if they usually are used at mealtime. A
patient’s past and present eating function. This information colorful piece of paper or “anchor” may be needed to draw
may expand on that obtained during the chart review. the patient’s attention or vision to the neglected side of the
Observation begins as soon as the practitioner enters food array. A simplified presentation of one food item at a
the patient’s room. The therapist should observe the time can help to focus visual and general attention to the
room for any types of food that may indicate the patient’s eating task. For stroke patients who are distractible, eating
recent diet. Details to observe include the presence of an in a quiet, reduced-distraction setting promotes attention.
untouched meal tray; residual food on the patient’s face, Safety and pacing cues and supervision may be needed,
clothing, bed, or tray; and wet or hoarse breath sounds especially for those with left hemiplegia. For right hemi-
and abnormal vocal quality. The patient’s positioning in plegic patients with aphasia and apraxia, minimal use of
the bed or chair is also relevant. verbal directions and setup of the eating environment that
makes the activity obvious are helpful.
Functional Status
Functional status refers to the patient’s ability to move in Oral Examination
space and interact in the environment. Some functional The therapist must administer an oral motor examination
interventions may be needed during evaluation to elicit of the lips, cheeks, tongue, jaw, and palate before present-
optimal feeding and swallowing. ing food to the patient. The occupational therapist
638 Stroke Rehabilitation

determines whether range of motion, muscle tone, and

sensation (intraorally and extraorally) are decreased, in- Feeding Trial
creased, or within normal limits. Strength of oral struc- Feeding trials are appropriate for patients who are alert, able
tures is observed but may not be appropriate to assess to follow commands, and medically stable. Factors that may
because of the presence of abnormal muscle tone, which contraindicate feeding trials include absence of or signifi-
may invalidate strength testing. cantly reduced laryngeal elevation during dry swallows,
moderate to severe dysarthria, lethargy or severely impaired
Abnormal Reflexes mental status, and severe pulmonary compromise.4,68
If present, abnormal “primitive” reflexes can interfere Therapists may observe patients in a formal evaluation
with feeding. Primitive reflexes include the bite reflex, setting or informally at mealtime. Informal mealtime ob-
rooting reflex, and the jaw jerk. The gag reflex may be servation provides an efficient indication of the patient’s
hypersensitive, and hypersensitivity of internal and exter- eating ability and allows the evaluator to assess the patient’s
nal oral structures also may be present. ability to concentrate despite distractions and interrup-
tions. An informal evaluation allows for observation of the
Pharyngeal Examination rate of intake and the patient’s reaction to the presentation
Although unseen, the therapist may assess aspects of pha- of the meal.68 If the evaluation takes place in a formal set-
ryngeal function. Clinical features associated with dyspha- ting, or if this is the patient’s first attempt at eating follow-
gia severity include dysphonia, dysarthria, abnormal voli- ing a stroke, trials should begin with foods that are less
tional cough, abnormal gag reflex, coughing after likely to be aspirated, such as thick purees, which do not
swallowing, and voice change after swallowing.22 require much oral manipulation, since thin liquids are
■ Dry swallow. The ability to “dry” swallow (without more difficult to control in the oral cavity and pharynx.
food) provides information on the patient’s ability to The evaluation then progresses to include foods of more
initiate a swallow response. difficult consistencies, depending on the patient’s toler-
■ Vocal quality. A wet, gurgly vocal quality can indi- ance and medical status. Box 24-2 shows the usual progres-
cate pooling of secretions above the vocal cords, sion of consistencies (from easiest to most difficult) as
which normally are cleared by coughing or throat standardized in the National Dysphagia Diet (NDD). The
clearing. The patient may not perceive the pres- NDD is the American Dietetic Association’s recommended
ence of pooled secretions or may be unable to diet level hierarchy, developed in an attempt to standardize
cough them up and clear the throat. Voice hoarse- dysphagia diets offered in hospitals in the United States.3
ness or weakness may be due to unilateral or bilat- The therapist may evaluate all the food and fluid con-
eral weakness of the vocal cords. Wet voice or a sistencies shown in Box 24-2 or begin at the consistencies
weak-hoarse voice suggests that weakness of the
laryngeal structures may compromise the protec- Box 24-2
tion of the airway during swallow.74 Bolus Consistency Progression: The National
■ Volitional or reflexive cough. A volitional cough pro-
Dysphagia Diet
vides information about the strength of the vocal
cords and breath support for coughing. Presence of SOLID FOODS
reflexive cough indicates a lower risk of aspiration Level 1: Dysphagia-Pureed: homogenous, cohesive, and
and pneumonia.1 puddinglike; little chewing required; examples:
■ The gag reflex. In normal individuals, the presence or applesauce, pudding
absence of a gag reflex can vary. Horner and Massey38 Level 2: Dysphagia Mechanical-Altered: cohesive, moist,
noted that a poor gag reflex proved to be a poor in- semisolid foods requiring some chewing; examples: soft
dicator of prognosis for safer swallowing. Triggering macaroni and cheese, soft cooked vegetables
of the gag reflex with a tongue depressor is different Level 3: Dysphagia-Advanced: Soft foods requiring more
chewing
from triggering the gag reflex by a misdirected bo-
Regular: all foods allowed, including foods requiring chewing
lus. Food does not (normally) trigger a gag, because (meat) and mixed textures (cereal and milk; pills and water)
it is not a foreign substance or a noxious stimulus.
The presence or absence of a gag reflex in patients FLUIDS
with neurological impairments is not an accurate Spoon-thick
indicator of the patient’s ability to swallow safely.55 Honeylike
However, presence of a gag reflex does indicate Nectarlike
some level of sensory and motor function of the Thin
tenth cranial nerve, which is responsible for inner-
vating many structures that contribute to sensory (ADA, 2002)
and motor aspects of the swallow.
 Chapter 24 • Dysphagia Management 639

the patient currently tolerates. During the feeding trial, the patient’s neck for palpation of the larynx to assess la-
the occupational therapist should pay close attention ryngeal elevation.
to the nature and quality of oral manipulation of food and The therapist may assess breath and voice quality by
to the following indicators of laryngeal function. the ear and by cervical auscultation with a stethoscope.
An automatic cough occurs under many conditions, Cervical auscultation is accomplished by placing the dia-
including a dry throat, or when secretions have accumu- phragm of the stethoscope lateral to the trachea and infe-
lated around the vocal cords even before eating begins. To rior to the cricoid cartilage.87 The therapist may adjust
some extent, coughing occurs with normal breathing and placement until hearing cervical breath sounds. The nor-
at times when swallowing. Although an automatic cough mal pharyngeal stage includes swallow initiation promptly
may not be heard during a meal or feeding trial, its pres- after oral transit, an apneic period during the swallow, and
ence may signal that the patient is making efforts to clear exhalation immediately after the swallow, with clear breath
the airway of food or secretions and that there is difficulty sounds and vocal quality.98 Breath and vocal quality differ
with airway protection or aspiration of a particular texture in patients with dysphagia and often are characterized by
or textures. In normal swallowing, laryngeal penetration gurgling sounds, increased throat clearing, and a “wet”
occurs occasionally; material that is penetrated is cleared vocal quality, which may indicate pooling. The therapist
from the larynx with throat clearing and reswallowing and also may assess voice quality with the naked ear. Although
often does not result in a cough. However, laryngeal reac- cervical auscultation is an imprecise clinical method for
tion to aspirated material below the true vocal folds is the evaluation of aspiration, it has some correlation with
normally a cough, which ideally expels the aspirated ma- aspiration found on an MBS,98 and may be helpful in
terial.80 A strong cough is necessary to protect the airway quickly identifying those at high risk for aspiration.14
well. Horner, Massey, and Brazer39 reported that a weak Research of usefulness of pulse oximetry to detect aspi-
cough is more likely to occur in aspirating patients than in ration has shown mixed results and may not be particu-
nonaspirating patients. As with the gag reflex, the pres- larly useful.93
ence of a reflexive cough indicates that the structures of Common dysphagia signs and symptoms in stroke are
the larynx and pharynx innervated by cranial nerve X have compiled in Table 24-1. The therapist should make obser-
sensory and motor function to some extent and protect vations relating to these signs and symptoms for the oral-
the airway during meals.1 preparatory, oral, and pharyngeal stages for each food and
Full laryngeal elevation and depression indicates that a fluid consistency presented. Recommendations and inter-
swallow has occurred. Perlman and colleagues68 con- vention goals are based on these observations, medical
cluded that reduced hyoid elevation impairs the pharyn- history, prognosis, and instrumental assessment results.
geal stage of the swallow, thereby increasing the risk of
vallecular residue and pharyngeal stasis. These factors Instrumental Assessment of Dysphagia
may result in aspiration. Fig. 24-6 demonstrates the Instrumental evaluation refers to diagnostic testing using
proper positioning of the examiner’s hand and digits on instrumentation, the most important of which are MBS
(sometimes referred to as videofluoroscopy) and fiberoptic
endoscopic evaluation of swallowing (FEES) examina-
tions.11,21,48 These evaluations use diagnostic imaging
techniques and provide information about the anatomy
and physiology of the swallow, including aspiration, which
cannot be determined during a clinical assessment.70
They also may be rehabilitative procedures to assess effi-
cacy and progress of compensatory techniques. The MBS
and FEES provide information regarding the oral stage
and the unseen pharyngeal stage of the swallow and can
provide information about the patient’s ability to protect
the airway during swallow, which clinical evaluation can-
not. Other instrumental evaluations commonly used to
assess dysphagic patients with stroke include ultrasound
and electromyography.

Modified Barium Swallow

The MBS or videofluoroscopic evaluation of swallowing
allows the clinician to directly view the oral, pharyngeal,
and esophageal aspects of the swallow. The MBS also al-
Figure 24-6 Palpation during the swallowing evaluation. lows the clinician to observe aspiration before, during, and
640 Stroke Rehabilitation

after the swallow.51 MBS allows for greater accuracy in inhibits a completely normal swallow. The FEES is mini-
identifying dysphagia in stroke patients compared with mally invasive, and the patient must be able to tolerate the
clinical evaluation or screening.59 The MBS ideally is per- procedure. This procedure is contraindicated for patients
formed jointly by the radiologist and the occupational with cardiac dysrhythmias, respiratory distress, bleeding
therapist. Food and liquid boluses are mixed with barium, disorders, anatomical deviations (narrow nasal passage),
which is radiopaque. Alternatively, plain barium may be agitated or hostile patients, or patients with movement
used, which is available in different thicknesses. The pa- disorders.84 The FEES is particularly useful for patients
tient must be positioned in an upright position and prefer- who cannot undergo a MBS for the foregoing reasons or
ably feeds himself or herself. The swallows are noted by a who require frequent reassessment. Clinical benefits of
fluoroscopy unit and are recorded onto videotape or FEES include assessment of airway protection when vocal
DVD. Thus, each stage of the swallow may be viewed dur- cord involvement or impaired adduction is suspected, as-
ing the assessment and reviewed later. The MBS not only sessment of laryngeal/pharyngeal sensation, and direct
allows the clinician to view swallow function and rule out visualization of anatomy when it is believed to be a con-
aspiration but also provides useful information regarding tributing factor in dysphagia.
compensatory swallowing strategies, discussed later in this
chapter, and provides a determination of the amount, fre- Ultrasound
quency, and quality of aspiration. The MBS also can assess Ultrasound is the method of choice if only oral function
how well the patient is able to deal with aspirated or pen- is to be assessed. Ultrasound is a noninvasive, dynamical
etrated material (e.g., his or her ability to clear aspirated evaluation of swallowing that shows the anatomy. This
material back into the pharynx). One study indicated that procedure uses normal foods and liquids and is safe to use
three specific observable aspects are related to aspiration in with patients who are unable to follow directions.84 The
those with stroke: pharyngeal transit time, swallow re- disadvantage of ultrasound is that it can visualize only the
sponse time, and duration of closure of the larynx.69 oral preparatory and oral stages of the swallow.
The MBS does expose the patient to some levels of ra-
diation, and the ability of the patient to cooperate and Electromyography
follow directions is important for the success of informa- Surface electromyography measures myoelectrical im-
tion gathering and for minimizing radiation exposure. The pulses resulting from the firing of motor units. Surface
MBS is difficult to achieve with patients who are in the electrodes are applied to the skin over specific muscles or
intensive care unit, are difficult to position, and/or are dif- muscle groups, producing a line tracing representing am-
ficult to transport to a radiology suite, although newer plitude or strength of a contraction. Targeting of one
technology available at some medical centers permits MBS muscle or the pharyngeal constrictor muscles is not pos-
at the bedside. Naturally, MBS presents function at a spe- sible. Placement of electrodes under the chin is used to
cific moment in time, and reliability with real world swal- detect motion of the suprahyoid muscles to assess whether
lowing function is not guaranteed, which therapists who a swallow has occurred.40
use MBS results must consider. Additionally, interrater
reliability of MBS performance assessment may vary.86 OUTCOME SCALES
Fiberoptic Endoscopic Evaluation of Swallowing Outcome scales are useful in categorizing dysphagia once
FEES involves passing an endoscope with a light and evaluation is completed. The Dysphagia Outcome and
camera through one of the patient’s nares, down to the Severity Scale is a seven category scale;66 the Functional
level of the valleculae. Before the assessment, lidocaine Outcome Swallowing Scale is a five point scale.75 The
spray is used to numb the nares. Liquid and solid boluses Functional Oral Intake Scale, a seven point scale, was
are dyed with green food coloring for easy visualization. developed for patients with stroke.21
Images of the pharynx and larynx then are visualized and
can be videotaped. This assessment is performed by an EVALUATION IMPRESSIONS
otolaryngologist, a trained occupational therapist, or a AND RECOMMENDATIONS
speech-language pathologist. The FEES allows the exam-
iner to evaluate pharyngeal and laryngeal function and to After gathering information from all aspects of the clinical
assess the amount of residue present on the vocal cords or assessment and instrumental evaluations, the therapist
pooled in the valleculae or pyriform sinuses after a swal- must determine whether further instrumental evaluation
low. Thus, one can assess aspiration and competence in of swallowing, discussed subsequently, is warranted. Of-
protecting the airway. One study suggested that FEES ten concerns about unseen pharyngeal function determine
may be more sensitive in detecting aspiration than MBS.46 whether a referral for instrumental assessment is appro-
However, FEES cannot always explain the reason that priate, important since pharyngeal stage deficits are com-
aspiration occurs, and the presence of the endoscopy tube mon in acute stroke. Whether feeding should be oral or
 Chapter 24 • Dysphagia Management 641

nonoral is a decision to be made by the team.32 If, follow- made a purposeful choice not be given artificial feedings.
ing a compete assessment, a patient clearly is aspirating or The medical team must determine the length of time the
is at high risk for aspiration, NPO is recommended. patient will be NPO and the optimal nutritional route. One
In acute care settings, NPO is often a short-term situ- study has suggested that stroke patients who are not toler-
ation for stroke patients until swallowing improves, which ating spoon-fed thick fluids or purees by 14 days following
it often does. For patients with complex medical condi- their stroke will need an alternative nutritional route such
tions including stroke and resulting long-term dysphagia, as a percutaneous endoscopic gastrostomy, defined later.96
for whom NPO may be a longer situation, the team Two primary feeding routes generally are used: enteral,
should consider the impact of such a decision on the pa- which uses a gastrointestinal route, and parenteral, which
tient and family.47 The caregivers and patient provide in- uses an intravenous route. Table 24-2 summarizes the risks
formation about the patient’s quality of life and prefer- and benefits of alternative feeding routes.
ences regarding medical intervention. If oral feeding is
initiated against medical advice, mealtime management Enteral Feedings
guidelines should be provided to optimize safety and em- Noninvasive Tube Feedings
phasize food consistencies least likely to be aspirated. Noninvasive tube feedings are most appropriate for short
periods. A nasogastric tube is placed through the nose.
ALTERNATIVE MEANS OF NUTRITION Food in the form of an enteric feeding formula and water
pass through the tube into the stomach (Fig. 24-7). Feed-
Following evaluation, some patients may not be deemed ings may be given intermittently via boluses with a large
candidates for oral feeding. They require alternative means syringe or constantly using a pump. Nasogastric tubes do
of nutrition19 unless they or their designated surrogate have not prevent pneumonia, however.27

Table 24-2
Risks and Benefits Associated with Oral, Enteral, and Parenteral Nutritional Support
TYPE OF NUTRITIONAL
SUPPORT POSSIBLE RISKS AND DRAWBACKS BENEFITS

Oral Possible tracheal aspiration Psychologically pleasurable

Possible inability to ingest sufficient Allows occupational performance of eating and
calories feeding
Poor patient satisfaction (with limited Provides socialization experience
dysphagia diet) Promotes normal digestion
Nasogastric Ulceration Routine procedure
Bleeding Affordable
Fistula Begins immediately
Gastroesophageal reflux, aspiration Easily reversible
Oropharyngeal discomfort
Poor patient satisfaction and compliance
Surgical gastrostomy Requires general anesthesia Common procedure
Bleeding Good for long-term care if gastrointestinal tract
Gastroesophageal reflux, aspiration is inaccessible
Diarrhea Easily replaceable
Stomal irritation Removes tube from head/neck region
Nonsurgical placement available (PEG)
Jejunostomy Peritonitis Minimizes gastroesophageal reflux
Diarrhea Can be used when stomach cannot tolerate diet
Difficult to replace Nonsurgical placement available (PEJ)
TPN Sepsis Fewer complications in patients with dysphagia
Infection at site and malnutrition
Short-term alimentation For use in nonfunctioning gastrointestinal tract
Pneumothorax Minimizes risk of aspirating stomach contents
Expensive

Adapted from Groher ME: Formulating feeding decisions for acute dysphagic patients, Occup Ther Pract 3:27, 1992.
PEG, Percutaneous endoscopic gastrostomy; PEJ, percutaneous endoscopic jejunostomy; TPN, total parenteral nutrition.
642 Stroke Rehabilitation

DYSPHAGIA INTERVENTION IN STROKE

Following evaluation, the patient and occupational thera-
pist jointly determine specific swallowing goals. Family
Nasopharynx members and other caregivers may be involved in this
process. For some patients, an initial goal is developing
Epiglottis insight into their dysphagia, lack of which is commonly
seen in patients with stroke.67 Development of insight is
Valleculae
associated with better swallowing outcomes as patients
understand and follow intervention strategies.67
Trachea
Esophagus Interventions for dysphagia caused by stroke may be
remedial (rehabilitative), compensatory, or a combination
of both. Whether remedial or compensatory, the goals of
intervention include reduction of aspiration risk, improv-
ing the quality of the swallow, and developing indepen-
dence in feedings skills and behaviors at mealtime. In the
acute phase after a stroke, patients may require daily re-
evaluation and adjustment in the intervention plan be-
cause their status may change daily.
Body of
the stomach Intervention Techniques
Treatments for dysphagia include positioning, feeding
Figure 24-7 Placement of a nasogastric tube. techniques, improvement of oral responses, facilitation of
pharyngeal and laryngeal movements, facilitation of swal-
lowing, therapeutic swallowing techniques, and diet mod-
Invasive Feeding Methods ification. Assuring good nutrition and hydration, mainte-
Invasive feeding methods are used when a patient is ac- nance of eating by mouth, oral hygiene programs, and use
tivity aspirating, for whom prolonged and severe dyspha- of oral, pharyngeal and laryngeal structures in conversa-
gia is expected. Tube feeding may be considered a reha- tion are critical.
bilitative technique when recovery is anticipated.43
Percutaneous gastrostomy tubes are most often used and Positioning
are placed with the patient under local anesthesia. The An upright seated position allows optimal function of the
surgeon inserts an endoscope through the mouth into the muscles of swallowing, maximizes alertness for the fa-
stomach, makes a small incision in the stomach, and then tigued or somewhat lethargic patient, and minimizes re-
threads a tube through the endoscope out through the flux. It aids in optimizing expiration during cough,28
abdominal wall. Special enteric formulas and water are which is an important safety reflex. An upright seated
administered for tube feeding. A percutaneous endo- position can be achieved in a chair or wheelchair, at the
scopic gastrostomy may be “advanced” into the jejunum, edge of the bed if balance allows, or in bed if necessary.
creating a percutaneous endoscopic jejunostomy to help
avoid reflux. Feeding
Occasionally, a patient will require a surgical gastros- Feeding oneself allows the optimal coordination of upper
tomy. Often this is the case if there is a history of gastric extremity and oral motor responses and the best awareness
disease and/or scarring. With the patient under general of bolus approach. Awareness of the bolus, via visual and
anesthesia, a surgeon makes an incision in the abdomen olfactory appreciation, provides oral readiness for the
and then places a gastrostomy tube directly into the stom- bolus.54 Manual guiding for stroke survivors with partial
ach. Occasionally, a tube is placed into the jejunum to dominant upper extremity movement, particularly those
reduce the reflux of stomach material into the esophagus, with left cerebrovascular accident and apraxia, is a useful way
which gastrostomy tubes may cause. Food passes through to facilitate feeding in concert with upper extremity func-
the tube into the stomach. tional goals. Constraint induced therapy may encourage use
of the affected dominant arm for eating. See Chapter 10.
Parenteral Feedings
Total parenteral nutrition administers a complete meta- Improving Oral Responses
bolic diet through a central vein, whereas peripheral Interventions begin with symmetrical body position and
parenteral nutrition administers the diet through a pe- then are directed toward the affected side of the face to try
ripheral vein. to create symmetrical movement. When increased skeletal
 Chapter 24 • Dysphagia Management 643

muscle activity (hypertonicity) is present, passive stretch- Facilitation of Swallowing

ing of tight musculature such as a tight cheek with the Different methods are available to facilitate a swallow
back of a spoon or gloved finger is useful. When patients when its initiation is weak or delayed:
present with hypotonicity or low-toned motion in the oral ■ Thermal-tactile stimulation consists of stroking the
structures, the therapist encourages movement using faucial arches with a chilled laryngeal mirror before
functional speech and eating tasks; for example, using oral eating and has been shown to speed the onset of the
exercises such as blowing or sucking tasks to elicit move- swallow response and the total swallow time in
ment. Overflow motions or increased activity of undesired stroke patients.73 A study indicated that the use of
motions should be discouraged. The therapist can provide citrus flavored cold stimulus was optimal; however,
sensory stimulation for reduced sensation using a gloved the effect lasted for only one swallow.77
hand inside and outside the mouth. Having the patient ■ Surface electromyography has been used to retrain
accomplish regular oral hygiene helps to establish sensory brainstem stroke patients with chronic dysphagia to
awareness and motor responses. For abnormally height- eat safely by mouth20 and also has been demon-
ened sensation, graded sensory stimulation programs help strated to be useful in providing biofeedback for re-
the patient tolerate stimulation of the face and oral cavity laxing high tone in laryngeal musculature, which
to accept food and utensils. The therapist addresses ab- allows an improved swallow response.40
normal reflexes with positioning and avoiding the stimuli ■ Electrical stimulation. Neuromuscular electrical stim-
that trigger the response.23 ulation therapy is used to target specific muscle
Weakness (as opposed to hypotonicity) of oral struc- groups to strengthen the swallow response. The
tures may be an issue with the debilitated stroke patient VitalStim unit was developed by the Chattanooga
with reduced endurance. Some dysphagia therapists find group specifically for swallowing therapy. Practitio-
that direct oral range of motion exercises are useful and ners must be certified to perform this therapy. One
often progress patients to gentle oral progressive resistive metaanalysis has demonstrated that this modality is
exercises. Tongue exercises have been shown to improve effective for strengthening the swallow.18
swallow pressure and airway safety in patients with both ■ Improving quality of the swallow. Different techniques
acute and chronic stroke.72 Lip exercises have been found to improve the bolus direction during the swallow
to improve lip force for eating in stroke patients.34 A new have been attempted with dysphagia patients. Pa-
study suggests that strength training does not exacerbate tients with stroke often have residue in the affected
spasticity, as previously thought.7 cheek; using the tongue to clear the bolus or massag-
While the patient eats, alteration in bolus qualities ing the cheek with the hand are helpful to route the
may help to trigger oral responses to food and thus im- bolus back to the center of the tongue. Holding the
prove the ensuing pharyngeal responses. Pushing down affected lip closed with a finger to allow oral con-
slightly with the spoon on the tongue as the bolus is in- tainment of the bolus may be necessary. Having the
troduced into the mouth can help with sensory aware- patient chew with the hemiparetic side of the jaw
ness. Presentation of a cold bolus13 or a sour bolus53 can stimulates movement and function and helps the
facilitate oral and also pharyngeal responses. Alternating patient to practice transfer of the bolus between the
food textures with each mouthful—for example, alternat- two molar surfaces.
ing fluids with solids—is a way of altering sensory input Using a chin tuck position during the swallow may be
with each bite.55 beneficial in decreasing aspiration in persons who experi-
ence a delayed pharyngeal swallow and reduced airway
Facilitation of Pharyngeal and Laryngeal Movements closure if the source of aspiration is material pooled in the
Exercises involving pulling the tongue back, yawning, and valleculae.80 The study by Shanahan and colleagues80 did
gargling with saliva serve to strengthen retraction of the not find a decrease in the risk of aspiration with pooling
base of the tongue,92 which is necessary to execute a swal- in the piriform sinus with chin tuck. Chin tuck causes the
low. Shaker exercises strengthen laryngeal elevation.79 To structures of the pharynx to move posteriorly, reducing
accomplish Shaker exercises, the therapist has the patient the size of the opening to the larynx.94
perform repetitive tucking of the chin to the chest while Full rotation of the head causes the bolus to move away
supine. Shaker exercises have been shown to help patients from the direction of rotation and can be used to direct
with chronic dysphagia who are fed by tube to return to the bolus down the intact side of the pharynx.65
eating food by mouth.78 Encouraging the patient to talk, The “effortful swallow” is done by contracting the
cough, and clear the throat intermittently provides func- muscles of the throat hard during the swallow; this moves
tional exercise for motions of the pharynx and larynx. the base of the tongue posteriorly and helps to clear bolus
As with facilitation of oral motions, pharyngeal and from the valleculae.
laryngeal, strength training may assist in improving the The Mendelson maneuver, accomplished by pushing
force with which motions can be accomplished.16 the tongue into the hard palate while swallowing, has been
644 Stroke Rehabilitation

demonstrated to open the cricopharyngeal sphincter bet- whom recovery of lost function cannot be achieved, com-
ter and for a longer period, allowing the bolus to pass.10 pensatory strategies may be permanent.
Throat clearing and reswallowing may be useful in Regardless of whether it is rehabilitative or compensa-
clearing pooled residue and can be done with other swal- tory in nature, dysphagia intervention has been shown to
lowing techniques. improve aspects of oral and pharyngeal function61 and nu-
tritional status in patients with stroke.29 Dysphagia inter-
Diet Modification vention is associated with the ultimate ability to eat by
Research demonstrates that stroke patients aspirate less mouth in those with neurological diagnoses.17,62 Interven-
on pureed textures compared with liquids and soft tion has been shown in one small study to enable those with
solids.28 The American Dietetic Association has stan- chronic dysphagia requiring alternative nutrition sources to
dardized levels of a dysphagia diet, called the National return to eating by mouth with the use of surface electro-
Dysphagia Diet, which is appropriate for many diagno- myography biofeedback.41 Dysphagia intervention for pa-
ses, including stroke.3 Box 24-2 presents levels of diet tients with stroke has been shown to reduce the risk of as-
based on the NDD. Naturally, patients will require an piration pneumonia62 and thus is cost-effective.64
individual approach to determining safe and manage-
able textures to swallow. For example, carbonated liq-
uids, not noted on the NDD, have been found to reduce CASE STUDY 1
incidence of aspiration compared with noncarbonated Swallowing After Right Hemispheric Stroke
thin fluids.15
Mrs. Jones was admitted to the hospital with a right
Follow-Up Care middle cerebral artery stroke, resulting in a left hemi-
plegia with dysphagia. She had a nasogastric tube and
Follow-up dysphagia care is advised for determining
was not referred for dysphagia evaluation until she was
whether caregivers and patients understand and are com-
medically stable, a week after her admission. On evalu-
plying with recommendations; outpatient visits after acute
ation, she demonstrated a left facial droop involving
and rehabilitative inpatient care may be needed. Diets
reduced muscle tone in the lip, cheek, and tongue.
may need to be upgraded as improvements occur, and the
Drooling from the left side of her mouth was a prob-
patient and caregiver should be reminded about safe swal-
lem because of reduced sensation. The gag reflex was
lowing strategies and food textures.
reduced on the left side of the pharynx, although she
Patient and Caregiver Education could elicit a dry swallow with difficulty. Once her
dentures were inserted and the nasogastric tube was
The education process begins with initial contact with the
removed, a feeding trial was done. During the feeding
patient and caregivers and continues with follow-up visits,
trial, Mrs. Jones demonstrated pocketing of food in her
informational pamphlets, and referrals to other health
left cheek and in the sulcus between her lower jaw and
care professionals. Patients and caregivers must under-
cheek. She was able to swallow soft purees and honey-
stand the concept of dysphagia, including the causes and
thick fluids, although thin fluids extracted a cough. An
consequences of aspiration, because they cannot follow
MBS further revealed pooling in the pyriform sinuses
recommended treatment without knowledge of the prob-
and occasional laryngeal penetration with honey-thick
lem and its possible consequences. Anatomical pictures,
fluids, which was alleviated with a chin tuck and by
handouts, and verbal explanations are useful educational
intermittent throat clearing. At this time, she still had
tools. Precautionary signs placed by the bed also may be
an intravenous line, so hydration was not a concern.
helpful in reinforcing the need to follow mealtime man-
She was able to feed herself with her dominant right
agement guidelines.
hand once her tray was set up, with frequent cues to
Types and Efficacy of Dysphagia Intervention regard the left side of her plate because of left neglect.
She also needed cues to swallow each mouthful and eat
Recovery of swallowing function is likely due to a combi-
slowly because of reduced judgment and impulsivity.
nation of natural recovery and therapeutic effects. These
Mrs. Jones massaged her left cheek with tactile cues to
effects include facilitation of available motions where
move pocketed food back onto her tongue. Within a
structures and functions have been lost due to reduced
week, Mrs. Jones progressed to soft solids and nectar-
sensation and altered muscle tone, and volitional strength-
thick fluids, and her intravenous line was discontinued.
ening of weak structures. Neuroplasticity is facilitated by
The following week, she proceeded to thin fluids and
these interventions9 in ways that rehabilitation science has
ground solids and was able to prepare her tray inde-
yet to fully understand.71
pendently. She still needed occasional safety cues to eat
While swallowing compensations are used initially to
slowly, to take single sips, and to look at the left side of
encourage function in early stroke recovery, the goal for
her plate.
many is recovery of premorbid function. In those for
 Chapter 24 • Dysphagia Management 645

5. Aviv JE, Martin JH, Sacco RL, et al: Supraglottic and pharyngeal
CASE STUDY 2
sensory abnormalities in stroke patients with dysphagia. Ann Otol
Swallowing after Left Hemispheric Stroke Rhinol Laryngol 105(2):92–97, 1996.
6. Aydogdu I, Ertekin C, Sultan T, et al: Dysphagia in lateral medul-
Mr. Smith was admitted to the hospital with a left lary Infarctions (Wallenberg’s Syndrome). Stroke 32(9):2081–87,
middle cerebral artery stroke and was referred for 2001.
dysphagia evaluation the day after admission. His oral 7. Badics E, Wittmann A, Rupp M, et al: Systematic muscle building
exercises in the rehabilitation of stroke patients. Neurorehabilitation
movements and ability to follow commands were dif-
17(3):211–4, 2002.
ficult to assess formally because of aphasia. Active and 8. Badr C, Ekins MR, Ellis ER: The effect of body position on maximal
symmetrical motion of his lips, cheeks, and tongue expiratory pressure and flow. Aust J Physiother 48(2):95–102, 2002.
were observed on attempts to speak. Mr. Smith’s den- 9. Barrett AW, Smithard DG: Role of cerebral cortex plasticity in the
tition was intact. His gag reflex was intact, although recovery of swallowing function following dysphagia stroke. Dysphagia
24(1):83–90, 2009.
palatal movement was not observed because of inabil-
10. Bartolome G, Neumann S: Swallowing therapy in clients with neu-
ity to phonate on command; he was unable to produce rological disorders causing cricopharyngeal dysfunction. Dysphagia
an automatic cough. On the feeding trial, he initially 8(2):146, 1993.
demonstrated slow initiation of oral and hand-to- 11. Bastian RW: The videoendoscopic swallowing study: an alternative
mouth movement characteristic of apraxia, but once and partner to the videofluoroscopic swallowing study. Dysphagia
8(4):359–367, 1993.
he had eaten several bites, he was able to manipulate
12. Besson G, Bogousslavsky J, Regli F, Maeder P: Acute pseudobulbar
foods more efficiently during the preoral and oral- or suprabulbar palsy. Arch Neurol 8(5):501–507, 1991.
preparatory stages of the swallow. Mr. Smith was able 13. Bisch EM, Logemann JA, Rademaker AW, et al: Pharyngeal effects
to manage soufflé textures and soft chewable solids of bolus volume, viscosity, and temperature in clients with dysphagia
and to drink thin fluids using a dysphagia cup to pre- resulting from neurologic impairment and in normal subjects.
J Speech Hear Res 37(5):1041, 1994.
vent tipping his head back to swallow. He required
14. Borr C, Hielscher-Fastabend M, Lucking A: Reliability and validity
some tactile guiding to self-feed with his dominant of cervical auscultation. Dysphagia 2(3):225–34, 2007.
right upper extremity, which had exhibited isolated 15. Bulow M, Olsson R, Ekberg O: Videoradiographic analysis of how
but weak movements. Within the week, he was able to carbonated thin liquids and thickened liquids affect the physiology
chew and swallow food with regular textures. Upper of swallowing in subjects with aspiration on thin liquids. Acta Radio-
logica 44(4):366–372, 2003.
extremity function improved as well, and he could
16. Burkhead LM, Sapienza CM, Rosenbek JC: Strength training in
prepare his tray independently and cut solid foods us- dysphagia rehabilitation: principles, procedures, and directions for
ing his right hand in dominant fashion. future research. Dysphagia 22(3):251–65, 2007.
17. Carnaby G, Hankey GJ, Pizzi J: Behavioural intervention for dys-
phagia in acute stroke: a randomized controlled trial. Lancet Neurol
5(1):31–7, 2007.
REVIEW QUESTIONS 18. Carnaby-Mann GD, Crary MA: Examining the evidence on neuro-
1. Define aspiration. muscular electrical stimulation for swallowing: a meta-analysis.
Arch Otol Head Neck Surg 133(6):564–571, 2007.
2. Define laryngeal penetration. 19. Ciocon JO: Indications for tube feedings in elderly patients. Dyspha-
3. Describe the five stages of swallowing. Indicate three gia 5(1):1–5, 1990.
signs or symptoms of dysphagia at each stage. 20. Crary MA: A direct intervention program for chronic neurogenic
4. Name the cranial nerves and identify their functions in dysphagia secondary to brainstem stroke. Dysphagia 10(1):6–18, 1995.
swallowing. 21. Crary MA, Carnaby Mann GD, Groher ME: Initial psychometric
assessment of a functional oral intake scale for dysphagia in stroke
5. Name 10 items important for chart review. patients. Arch Phys Med Rehabil 86(8):1516–20, 2005.
6. Describe the elements of a dysphagia intervention pro- 22. Daniels SK, McAdam CP, Braily K, Foundas AL: Clinical assess-
gram for a stroke patient. ment of swallowing and prediction of dysphagia severity. Am J
7. Describe two advantages of FEES. Speech Lang Path 6:17–24, 1997.
8. Describe two advantages of an MBS. 23. Davies PM: Starting again, Berlin, 1994, Springer-Verlag.
24. DePippo KL, Hosas MA, Reding MJ: Validation of the 3–oz water
swallow test for aspiration following stroke. Arch Neurol 49(12):1259–
1261, 1992.
25. DePippo KL, Hosas MA, Reding MJ: The Burke dysphagia screen-
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 jes s i ca f arm an
j u d i t h di cker f ri edm an

chapter 25

Sexual Function and Intimacy

key terms
aging sexual function sexuality counseling
disability sexual rehabilitation
sexual dysfunction sexuality

chapter objectives
After completing this chapter, the reader will be able to accomplish the following:
1. Identify and describe the normal human sexual response cycle and the changes that occur
during the aging process.
2. Understand the effects of stroke on sexual function.
3. Identify the occupational therapist’s role in sexuality intervention.
4. Understand and apply the levels of the PLISSIT model that are appropriate for
occupational therapists.
5. Identify sexual impairments and how they affect function.
6. Plan treatment interventions for impairments affecting sexual function.

A discussion of sexuality includes not only specific sexual reciprocal concerns, tolerance, the forms of communica-
practices but also the attitudes, behaviors, thoughts, and tion that both include and go beyond words . . . sexuality
feelings associated with sex and sexuality. These include includes a range of behavior from smiling through
an individual’s perception of self as a sexual being, body orgasm; it is not just what happens between two people
image, self-esteem, participation and roles in relation- in bed.”
ships (sexual and other), sexual orientation, and beliefs Everyone can enjoy sex. Health care professionals must
and attitudes toward a wide range of sexual behaviors, be aware of their own attitudes toward sexuality. Our pa-
including masturbation, coitus, oral-genital sex, cud- tients may be different from ourselves: they may be older,
dling, and sensuality. Romano66 defined sexuality ex- may be of a different sexual orientation, or may have per-
pertly: “Sexuality is more than the art of sexual inter- manent or temporary disabilities. Just as differences
course. It involves for most . . . the whole business of among human beings are inherent, therapists must con-
relating to another person; the tenderness, the desire to sider and respect the variances in sexual behaviors, prefer-
give as well as take, the compliments, casual caresses, ences, and beliefs among individuals.

648
 Chapter 25 • Sexual Function and Intimacy 649

NORMAL HUMAN SEXUAL RESPONSE occurs over a period of several months to a few years.43
The major effects of menopause are as follows:
One must have an understanding of the normal human ■ Vasomotor syndrome (hot flashes)43
sexual response cycle before one can explore the rela- ■ Atrophic vaginitis (thinning of the vaginal walls)43
tionship between sexuality and disability. Masters and ■ Osteoporosis43
Johnson48 divided the human sexual response cycle into ■ A decrease in the rate, amount, and type of vaginal
four segments: (1) excitement, (2) plateau, (3) orgasm, fluid, which can cause pain during intercourse and
and (4) resolution. In each phase, definite physical may lead to infection74
changes occur in both sexes. During the excitement ■ Loss of contractility of vaginal muscles, which can
phase, physiological reactions occur because of somato- cause shorter orgasms74
sensory or psychogenic stimulation. In females, the ■ Decreased size of the uterus and clitoris and atrophy
nipples become erect, the vagina swells and becomes of the clitoral hood43
lubricated, the clitoris and the labia minora and majora ■ Loss of elasticity in breast tissue, causing sagging
swell, and the uterus and cervix retract. In males, the According to Laflin,43 regular muscle contractions help
penis grows erect and the testes rise. In both sexes, blood maintain the integrity of vaginal muscle tone, and “con-
pressure and heart rate increase. tact with the penis helps preserve the shape and size of the
During the plateau phase, respiration increases and vaginal space.” Therefore, an active sex life can have a
blood pressure and heart rate escalate further. In females, positive effect on genital function.
the areola surrounding the nipple swells, the orgasmic
platform forms (vasocongestion of the outer two thirds of Men
the vagina), and the color of the labia minora deepens As men grow older, the following changes occur:
from pink to red. In males, a full erection is achieved as ■ Erections are often less full, take longer to achieve,
the testes elevate further and the Cowper gland secretes and may require direct stimulation.74
preejaculatory fluid. ■ Ejaculatory control increases, ejaculation may only
Orgasms differ between the sexes; some women can occur every third sexual episode and is less forceful,
achieve multiple orgasms. In both sexes, peak pulse rate, and loss of erection after orgasm may occur
blood pressure, and respiration increase, as does muscle faster.43,74
tone. Rhythmic contractions of the orgasmic platform ■ The man may not be able to achieve another erec-
and the uterus occur in women, and rhythmic contrac- tion for 12 to 24 hours after orgasm.39
tions of the penis project semen forward in males. ■ Sperm volume decreases and the ejaculation may
Masters and Johnson48 recorded cardiac response and be less intense, which may affect the intensity of
found peak heart rates of 110 to 180 beats per minute dur- orgasm.43,74
ing orgasm. However, the mean maximum heart rate dur- ■ The size and firmness of the testes diminish.
ing sexual activity was 117.4 beats per minute in a study of ■ The testosterone level decreases.
middle-aged men with postcoronary disease.34 During Many elderly persons continue to enjoy sexual activity;
sexual activity, systolic and diastolic pressure increase however, a decline in sexual activity among elderly per-
(from 30 to 80 and 20 to 40 mm Hg, respectively). Respi- sons is common. Older persons do not necessarily lose
ration rates of up to 40 breaths per minute have been re- their desire for sex, but circumstances can make it difficult
corded, depending on the level of intensity and duration for them to engage in active sexual relationships. Leading
of sexual activity.48 causes of altered sexual activity in the older adult include
The resolution phase is characterized by the return to difficulty finding partners, illness, medication effects, wid-
preexcitement status, including reductions in blood pres- owhood, divorce, biases about masturbation, societal at-
sure, heart rate, and respiration. The genitals and breasts titudes about sex and the elderly, and even their own bi-
return to preexcitement size. ases and prejudices toward sexuality.65 Elderly persons
may view sex as something that only young, attractive
Aging and the Human Sexual Response Cycle persons do.
In normal human development, changes occur during the
aging process. Such changes affect sexuality61 in males and SEXUALITY AND NEUROLOGICAL FUNCTION
females and already may affect patients who have sus-
tained cerebrovascular accidents. Sexual function is controlled by the brain, spinal cord, and
peripheral nerves, whereas control of libido and sexual
Women pleasure are mediated by several areas in the cortex, mid-
Generally women experience menopause between the brain, and brainstem.56 Men experience reflexogenic and
ages of 40- and 50-years old; the cessation of menstrua- psychogenic erections. Reflexogenic erections are caused
tion is caused by a lack of production of estrogen that by direct stimulation to the penis and may occur without
650 Stroke Rehabilitation

conscious awareness, even in the absence of penile sensa- abilities to achieve erection and vaginal lubrication
tion. Psychogenic erections originate from mental activity were impaired, and the frequency of intercourse was
such as sexual fantasies and stimulating visual input and diminished.11,38,40,41,53,73 In contrast, at least one study
do not require direct penile stimulation. Reflexogenic documented that a small group of stroke survivors (19 of
erections are controlled by the nervous system through 192 patients studied) indicated an increase in libido fol-
the sacral roots, and psychogenic erections involve the lowing stroke.41 Isolated cases of hypersexuality and
sympathetic nerves between T11 and L2. Female sexual abnormal sexual behavior have been found to occur in
function is similar to that of males regarding nerve inner- individuals with temporal lobe lesions and concurrent
vation.77 The parasympathetic nerves S2 to S4 influence histories of poststroke seizure activity.28,54 In a study of
the clitoris and vaginal lubrication. “Contraction of the 13 female stroke survivors, the most common complaint
vaginal sphincter and pelvic floor occur with stimulation was found to be a decreased desire for sexual activity after
of the somatic aspect of the pudendal nerves (S2-S4),” ac- the stroke; only 5% of the women reported actual impair-
cording to Zasler.77 Neurological disability can cause or- ment in the production of vaginal secretions after the
ganic impotence by altering the blood flow needed for stroke.2 Most of the women reported no changes in their
penile erection and can cause problems with emission and abilities to achieve orgasm or in their menstrual periods.
ejaculation in males and with lubrication, clitoral en- In addition, although the stroke impaired sexual desire,
gorgement, and orgasm in females. Some of the subcorti- physiological function remained unimpaired. The authors
cal structures theorized to be involved in the neurology of concluded that nondominant hemispheric stroke is re-
sexuality are the reticular activating system and the hip- lated to decreased desire; five of seven patients with de-
pocampus, amygdala, and hypothalamus. According to creased desire had right brain involvement.
Zasler,77 the thalamus and basal ganglia are hypothesized The authors of several studies have attempted to deter-
to be involved with the mediation of sexual function. mine cerebral hemisphere dominance related to sexual
Some of the cortical areas involved are the frontal lobes function. Although some investigators found a greater de-
and the nondominant temporal lobe. “Lesions in the cline in sexual function with left-sided cerebrovascular
dominant hemisphere may produce aphasia or apraxia, accident, others found little or no difference between right
both of which could impede sexual activity. Nondominant and left cerebral hemisphere strokes.* One study of
hemisphere injury may result in . . . visuoperceptual defi- 109 men poststroke revealed that lesions in the right hemi-
cits, denial, and impulsiveness, all of which could impede sphere resulted in a significant decline in sexuality func-
expression of sexuality,” according to Zasler.77 Sexual tioning poststroke, including desire and frequency.36
stimulation is caused by stimulation of the brain or pe- Garden25 concluded, “There seems to be an overall con-
ripheral nerves, the former of which results from thoughts sensus that stroke patients maintain prestroke sexual desire
and psychological processes and the latter of which results but commonly experience sexual dysfunction including
from direct physical stimulation.54,72 erectile and libido problems. Changes in coital frequency
and libido are also common. As a result there can be great
EFFECTS OF STROKE ON SEXUAL potential for depression and loss of self esteem.”
FUNCTION The individual’s prestroke sexual activity is usually a
better indicator of poststroke activity.7,26,29,33,42,73 If the
The literature shows that common effects of stroke on individual was leading an active sex life before a stroke,
sexual function are decreased libido, impaired erectile and the likelihood of returning to sexual activities is good.
ejaculatory function, decreased vaginal lubrication, im- Younger age is also a predictor of resumption of sexual
paired ego and self-esteem, and depression. The motor, activity, although less so.33 Individuals who were without
sensory, cognitive, and physiological effects of stroke have a partner before a stroke have less opportunity to develop
been shown to affect the desire and ability to engage in new partnerships and resume sexual activity after a stroke.
sexual activities in many ways. Some research has been This decreased opportunity has to do with the effects of
focused on relating sexual dysfunction to the location of stroke itself and an individual’s impaired social contact,
the lesion. Some of the scientific literature recommends possible placement in a nursing home or other long-term
counseling for patients following stroke but does not pro- setting, depression, altered self-image, and the multitude
vide specific interventions.* As a result, therapists are left of psychological effects caused by stroke. In a study of 192
with insufficient information to treat sexual dysfunction stroke survivors and 94 spouses, the decline in sexual ac-
adequately. tivity after stroke was associated largely with individuals’
Numerous studies have found that among men and attitude toward sexuality, fears including erectile dysfunc-
women who had sustained strokes, libido was decreased, tion, and the inability to discuss sexuality issues.41

*References 6, 11, 13, 14, 24, 26 28, 29, 36, 41, 68-70, 73 *References 6, 11, 14, 26, 28, 38, 42, 57, 73
 Chapter 25 • Sexual Function and Intimacy 651

Erectile dysfunction may occur as a direct result of Decreased initiation, impulsivity, poor memory, decreased
stroke* and also may occur in men whose sexual part- speed of processing, and impaired executive functions are
ners have sustained strokes because of fear of causing possible effects of neurological dysfunction and clearly can
another stroke or hurting the partner or averse feelings affect sexual relations.71
toward the disabled partner.26,28,29,30 In women, vaginal McCormick, Riffer, and Thompson51 noted that sexual
lubrication may be insufficient, causing painful inter- activity is itself a form of human communication. When
course.2,11,25,26,40,73 verbal or nonverbal communication is impaired, sexual
The presence of nocturnal erections indicates psycho- activity may be affected.77 One study found that sexual ad-
logical versus organic reasons for erectile dysfunction. In justment was easiest for physically intact individuals with
a study by Korpelainen, Nieminen, and Myllyla,41 all of aphasia with spared comprehension and nonverbal commu-
the male subjects did experience nocturnal erections after nication.76 However, in one study involving 110 subjects, no
stroke, although 55% had impaired nocturnal erections. correlation between aphasia and poststroke sexual activity
Individuals with a history of taking cardiovascular medi- was found.70 Lemieux, Cohen-Schneider, and Holzapfel44
cations and those who had diabetes mellitus exhibited a reported that individuals with moderate and severe aphasia
greater frequency of erectile dysfunction after stroke than are not included in most studies because they are difficult to
those without. Bener and colleagues5 found similar results interview, so little is known about their sexuality after
in a study of 605 men following stroke; the likelihood of stroke. In their small study of aphasia and sexuality in six
erectile dysfunction increased with cardiovascular medi- couples, the researchers developed pictograms to facilitate
cations and comorbities including hypertension, hyper- communication with aphasic respondents. Although the ef-
cholestermia, and diabetes. Similarly, impaired vaginal fects of stroke on sexuality in this study were similar to those
lubrication was more common in women who had taken of previous studies, almost all the aphasic persons and their
cardiovascular medications prestroke.41 partners reported that aphasia had a negative effect on their
Initiation of sexual activity after discharge from the sex lives.
hospital may be difficult. A couple may delay sexual activ- The effect of stroke on psychological function is
ity because each partner waits for the other to initiate enormous11,28,36,42 (see Chapter 2). Studies by Giaquinto
sex.29,30 In a study by Goddess, Wagner, and Silverman,29 and colleagues28 and Korpelainen and colleagues40 found
one couple put off sexual activity for 15 months after the that the psychological impact of stroke was a greater fac-
husband’s stroke. The man was unsure whether his wife tor in sexual function after stroke than associated neuro-
would find him attractive or a suitable partner, and the logical deficits. The loss of function, including hemipa-
wife was concerned that sexual play for her husband may resis, sensory and balance disorders, pain, and cognitive,
be unsafe. perceptual, and impaired communication skills may have
Sensory impairment is common after stroke. Consider- an enormous negative effect on an individual’s self-
ing the significant role of touch in sexual expression, its image. As Strauss71 noted, the formulation of relation-
dysfunction also may contribute to sexual dysfunction.24,40 ships, sexual or other, requires some level of self-esteem.
In subjective reports of 50 stroke survivors, 19% of the An impaired image of one’s body and appearance can af-
subjects reported sensory deficits as the reason for dimin- fect the ability to make new relationships or maintain
ished sexual activity.40 However, the research is inconclu- existing ones. Loss of confidence and decreased self-
sive; a study by Aloni and colleagues1 of 15 male stroke esteem may result from the following:
patients showed that disturbed superficial and deep sensa- ■ Changes in appearance, including facial asymmetries
tion were not correlated with decreased desire. and diminished facial expression
Motor impairment can affect sexual function. De- ■ Changes in clothing style (inability to don pantyhose
creased range of motion, strength, endurance, balance, or walk in high heels due to required ankle-foot or-
abnormal skeletal muscle activity, impaired coordination, thosis)
and oral motor dysfunction may interfere with intercourse ■ Need for adaptive equipment or assistive devices
or other sexual activities. However, some research sug- such as a splint, wheelchair, or cane
gests that the degree of hemiplegic impairment is not a ■ Dependence in activities of daily living (ADL), such
major factor in sexual dysfunction.24,26 as the need to have food cut and to have assistance
Cognitive deficits also may affect the stroke survivor’s with toileting
social and sexual function. Fundamental cognitive abilities In addition to changes in self-perception, the stroke survivor
such as attention and concentration are prerequisites for so- suddenly may find a new role in relationships. For instance,
cial and sexual activities; distractibility and overstimulation a wife may discover that she is no longer able to carry out the
may cause anxiety and agitation, which prevent interaction. functions related to her role as wife because of the effects of
a stroke. The stroke survivor may depend more on other
family members. Role changes could affect the quality of an
*References 5, 11, 28, 33, 36, 40, 42, 69, 73 existing relationship.9,65 Such changes may be confusing and
652 Stroke Rehabilitation

stressful for the patient and the partner, particularly if the activity is two in one million for a person with heart dis-
stroke survivor requires assistance with self-care activities ease and that individuals who experience periods of anger
such as toileting or bathing. Dependence in ADL is a major or heavy exertion have a greater increase in actual risk
predictor of decreased sexual activity level after a stroke. In a because these behaviors occur with more frequency than
study by Kimura and colleagues,38 subjects who demon- sexual activity. However, the overall risk of myocardial
strated ADL impairments also exhibited a decline in sexual infarction is lower for patients who engage in regular ex-
activity. Sjogren and Fugl-Meyer reported similar findings as ercise, which has been shown to decrease the amount of
early as 1982.70 cardiac work required during sexual activity.
Impaired bladder function also may affect sexual activ- “At its peak, sexual activity is about as physically stren-
ity. Stroke often occurs in the elderly who may have un- uous as walking two to four miles per hour. The greatest
derlying genitourinary dysfunction (prostatic hypertro- levels of ‘exertion’ actually occur during orgasm, which
phy, stress incontinence). Proper evaluation by a urologist lasts only a brief amount of time.”67 Studies to determine
is indicated.47,62 Marinkovic and Badlani47 recommended cardiac expenditure are often performed on treadmills.
treatment of incontinence before addressing sexual dys- Palmeri and colleagues60 compared cardiac response dur-
function. Medications used to treat incontinence have ing sexual activity to treadmill testing; results indicated
side effects such as dry mouth, which can make kissing or that the amount of “work” during sexual activity was half
other oral activities unpleasant. If the individual takes ad- the maximal found on treadmill testing and that there are
ditional medication for other reasons (for example, di- different physiological responses to upright (i.e., treadmill
uretic agents), urine output may be increased. For the testing) versus supine activity (i.e., sexual activity). Aver-
individual with mobility impairments, quick and frequent age heart rates ranged from 108 to 128 beats per minute.
access to the bathroom may be difficult, resulting in epi- From a cardiac rehabilitation perspective, a patient is
sodes of incontinence. Incontinence may affect self- “safe” to resume sexual activity when the person can climb
esteem and may be a source of embarrassment.37 Bowel two flights of stairs or walk the length of a city block or its
incontinence is less common after cerebrovascular acci- equivalent at a brisk pace with no discomfort.34,45 This
dent because stroke patients typically are constipated be- parameter may be difficult to assess in some stroke pa-
cause of immobility, inactivity, and poor food and fluid tients because of mobility deficits, and alternative activi-
intake, which can cause bloating and discomfort.75 ties may have to be explored (for example, propelling a
Hypertension is a major risk factor for stroke, and re- wheelchair at a brisk pace with the use of unaffected arms
search indicates that hypertension is associated with sexual and legs). The effect of stroke on sexual function is diffi-
dysfunction in men and women. Burchardt and col- cult to assess without examining the types of medications
leagues8 reported a higher incidence and greater severity patients are taking. Antihypertensive agents have been
of erectile dysfunction in men with hypertension com- found to cause erectile dysfunction, impede ejaculation,
pared with an age-matched population without hyperten- and decrease libido.10,13,23,24,26 Some ␤-blockers are known
sion. The study also suggested that the erectile dysfunc- to affect erectile function and cause depression. One anti-
tion was linked to the hypertension and not to side effects hypertensive diuretic medication, spironolactone, is
of antihypertensive medications. Grimm and colleagues31 known to cause breast tenderness, galactorrhea (excessive
also found that “sexual dysfunction in hypertensive indi- secretion of the mammary glands), and gynecomastia
viduals may be related more to hypertension level than to (overdevelopment of the mammary glands), which is not
drug treatment.” Hypertensive women also report de- always reversible in men.13 In a study by Aloni, Schwartz,
creased lubrication, less frequent orgasm, and more fre- and Ring,2 six of the seven women who reported de-
quent pain with sexual activity than women without hy- creased sexual desire were taking anticoagulant drugs,
pertension; again, the effects were not related to the type suggesting that the medications may affect sexual func-
of treatment.19 tion. Medications other than those prescribed for stroke
Individuals who have had strokes often have a history management or hypertension may have additional side
of other medical problems, including heart disease, which effects such as rashes and feelings of fatigue that may af-
alone can cause functional impairments related to sexual fect a patient’s desire to participate in sexual activities.
activities. Often individuals with a history of myocardial Considering the potential side effects of various medica-
infarction or bypass surgery fear the resumption of sexual tions on sexual function and informing patients as neces-
activities.31,45,55 Muller and colleagues55 studied 858 pa- sary is the rehabilitation team’s responsibility.
tients who were sexually active in the year preceding
myocardial infarction and found that although the risk of SOCIETAL ATTITUDES
myocardial infarction increases in the two hours following
sexual activity, the risk is almost equivalent in patients Attitudes on the part of the public or the patient’s family
with and without heart disease. The research indicated members also may affect the patient emotionally or psy-
that the risk of myocardial infarction caused by sexual chologically. Although the Americans with Disabilities Act
 Chapter 25 • Sexual Function and Intimacy 653

has resulted in some improvement in public attitude, the Most occupational therapists receive some training in
fact remains that many persons still harshly judge indi- sexuality intervention. Even before the American Oc-
viduals who appear “different” from the rest of society and cupational Therapy Association listed sexual activity as
regard disabled individuals with fear and shame. Stroke an ADL, the authors of a 1988 study reported that 88%
survivors and persons with other disabilities perceive these of 50 occupational therapy programs included formal
attitudes and, as a result, avoid social or public situations. classroom training about sexual function, with an aver-
The media seldom depict persons with disabilities as full age of three and a half hours of class time devoted to
partners in sexual relationships. The stroke patient and this subject.63
partner, family members, and others may share the view
that persons with disabilities are sexless, “different,” and TEAM APPROACH
undeserving of social and sexual fulfillment. These atti-
tudes can affect patients’ existing relationships and their Although occupational therapists must be involved in
willingness to pursue new relationships. sexual health care, effective sexual rehabilitation, like
all rehabilitation, requires a team approach. The reha-
ROLE OF OCCUPATIONAL THERAPY bilitation team must address all the individual’s prob-
lems in a holistic way, and all team members should be
When persons experience changes in sexual function, knowledgeable about sexual issues and treatment op-
they may require professional intervention to cope with tions.46,77 If each member of the treatment team is edu-
these changes in sexual function and sexuality. What is cated and skilled in this area, the patient can choose the
the role of occupational therapy in sexuality interven- team member with whom he or she is most comfortable
tion for these patients, and what is required to fulfill to address sexual issues. In addition, each team member
this role? has different expertise from which the patient may ben-
Sexuality long has been considered an appropriate area efit. The physician may best address problems related
for occupational therapy intervention. Andamo3 stated to erectile dysfunction, relationship changes may re-
that “sexual function should be included in the occupa- quire social work intervention, and the speech and
tional therapy evaluation as it relates to the identification language pathologist may best address communication
of the patient’s abilities and limitations in his daily living difficulties.
necessary for the resumption of his various roles.” Neis- In reality, the health care team often ignores sexuality
tadt56 noted that as “holistic caregivers, dedicated to fa- issues, especially for the stroke population. A support
cilitating quality lives, occupational therapists should be group of 37 wives of stroke patients at a Veterans Admin-
prepared to address sexuality issues with their adolescent istration center reported that no one had spoken to them
and adult patients.” Couldrick15 argued that “with aware- about poststroke sexuality.51 In a 1988 study of sexuality
ness and skill development, occupational therapists can counseling in an inpatient rehabilitation program, only
affirm sexual identity, they can listen, and, with sometimes 20% of non–spinal cord injured patients (55% of whom
simple measures, they an address issues that fall within had a diagnosis of stroke) had received written materials
their professional roles.” The American Occupational on sex. Sexuality information was given voluntarily to
Therapy Association has continued to confirm the role of 32%.16 Rehabilitation professionals cite various reasons
occupational therapy by including sexual activity as an for not addressing sexuality with their patients, with the
ADL within the areas of occupation in the Occupational most common responses being that another team member
Therapy Practice Framework.59 is responsible for this intervention and that their knowl-
Occupational therapists are well-prepared to address edge is inadequate.51,57 In a pilot study of health care
sexuality problems in stroke patients; the sensory, motor, professionals who treat stroke patients, including occupa-
cognitive, and psychosocial impairments that interfere tional and physical therapists, lack of training and experi-
with sexual function are the same ones that affect other ence were cited as reasons to not address sexuality. Over
performance areas addressed by occupational therapy, in- half felt that they would be inhibited by either potentially
cluding other ADL and work and leisure activities. Oc- offending or embarrassing the patient. Perceptions of
cupational therapists’ skills of activity analysis and adapta- which team member is responsible for addressing sexual
tion, holistic orientation, and knowledge of biological and function varied.51 The physician, social worker, and psy-
behavioral sciences help them deal effectively with pa- chologist most often are cited as responsible for sexuality
tients’ sexual difficulties.21 Research indicates that depen- intervention.
dence in ADL is a major factor in decreased sexual activity In yet another study on sexuality counseling following
after stroke,38,70 further supporting the role of occupa- spinal cord injury, patients indicated a preference to speak
tional therapists in sexual rehabilitation by restoring with their occupational or physical therapist or nurse
patients to the highest possible level of independence and about their sexual concerns. Participants reported a posi-
role function. tive response to therapists who used an open and direct
654 Stroke Rehabilitation

style of communicating and otherwise were frustrated,

embarrassed, or intimidated by therapists who did not.
Although many of the subjects were not ready to discuss
sexuality early in their rehabilitation, they concurred that Intensive
therapy
knowing resources were available when they needed them
was vital.49 Specific
Besides being neglected in the clinic, sexual rehabilita- suggestions
tion has received little attention in research. However, a
general positive correlation has been found between suc- Limited
cessful sexual rehabilitation and positive adjustment to information
disability. The literature shows that patients with dis-
abilities are interested in the inclusion of sexuality in re-
habilitation and give sexuality a high priority.27 Studies
confirm that stroke survivors and their partners are inter-
ested in information and/or counseling about sexuality
Permission
after stroke.20,41
In clinical rehabilitation, “a job title does not always
define competencies,” and “no job title . . . excludes dis-
cussion of sexuality,” according to Chipouras and col-
leagues.12 The qualities necessary in a competent sexual- Requires special training
ity counselor for persons with disabilities have been
Can be performed by occupational therapists
described variously. Chipouras and colleagues12 empha- who have appropriate knowledge and skills
size comfort with sexuality, including one’s own, comfort
with disability, empathy, nonprojection of one’s own Can be performed by all occupational therapists
morals onto the patient, awareness of available resources, Figure 25-1 The PLISSIT model. PLISSIT, Permission, Lim-
basic knowledge of human sexuality, and awareness of ited Information, Specific Suggestions, and Intensive Therapy.
one’s own competency and willingness to refer to others
as necessary. The foundation of sexuality counseling con-
sists of awareness and knowledge, which one can gain Permission
through reading, in-service education, coursework, and Permission is the most basic and most frequently required
workshops. Therapists must develop skill in sexuality intervention. Permission consists of reassuring patients
counseling through practice, as for all clinical skills. Dis- that their actions and feelings are normal and acceptable.
comfort in dealing with sexuality need be no different All occupational therapists should strive to perform
from discomfort with other difficult disability issues. Oc- permission-level sexuality interventions. Recognizing that
cupational therapists address many personal and some- sexual behavior varies widely and not projecting one’s own
times painful issues with their patients. Increased compe- values or morals onto the patient is most important.
tency, skill, and comfort comes with practice. Practice of The practitioner must be proactive to provide patients
sexuality interventions through role play with other staff with permission. Waiting for the patient to bring up
members may be helpful in achieving greater comfort in sexual issues is not enough; the therapist must let the
conducting sexuality interventions. patient know that expressing sexual concerns is accept-
able. The simplest way to do this is to ask, “People who
PERMISSION, LIMITED INFORMATION, have had strokes sometimes have concerns or questions
SPECIFIC SUGGESTIONS, AND INTENSIVE about how they will be affected sexually. Do you have any
THERAPY concerns or questions in this area?” This line of ques-
tioning serves to normalize the concerns and gives pa-
The therapist may use various frameworks and models to tients the opportunity to say “no” if they are not com-
address sexuality issues in health care. Among the earliest fortable discussing sexuality with that person at that time.
and most prevalent is the PLISSIT model, developed by Asking also lets patients know that sexual concerns are
psychologist Annon.4 PLISSIT is an acronym for four considered legitimate and gives them permission to bring
levels of intervention: Permission, Limited Information, up sexual issues again if their needs change. The therapist
Specific Suggestions, and Intensive Therapy (Fig. 25-1). should ask questions in a language appropriate for the
Using this model, the practitioner can determine the type patient’s understanding, including the use of slang terms
and extent of sexuality intervention needed, whether he or if necessary.
she has the skills to perform the intervention, and whether The best time to bring up sexuality is usually at
to refer to a more qualified counselor. the initial evaluation, when other ADL issues also are
 Chapter 25 • Sexual Function and Intimacy 655

being addressed. If this is not feasible because of time more knowledge, time, and skill from the therapist but is
constraints or because the evaluating therapist will not be appropriate for some occupational therapists (Box 25-1).
treating the patient, sexuality should be brought up as The therapist should meet with the patient (and partner,
soon as is comfortable. Sexual concerns should be ex- if appropriate) in a comfortable, private setting and ob-
plored before home visits and in the formulation of dis- tain a sexual problem history. This history should in-
charge plans because the patient’s needs and concerns clude the following:
change throughout rehabilitation. ■ The patient’s assessment of the problem and its
Opportunities to give patients permission to express cause, onset, and course
themselves as sexual beings often occur spontaneously. ■ The patient’s attempts to solve the problem
On one rehabilitation unit, a 38-year-old Hispanic man ■ The patient’s goals
with a diagnosis of right cerebrovascular accident was
playing a getting-to-know-you game with the other pa- Box 25-1
tients, all of whom were older women. As part of the ac-
tivity, each member of the group was asked to name Competencies for Sexuality Interventions
something he or she liked. The women named things at Each PLISSIT Level
such as chocolate, flowers, and pets. The man said, “I like PERMISSION
women.” After a few seconds of silence, the occupational
To perform this level of sexuality intervention, the
therapist running the group said, “Of course you do; what therapist should do the following:
could be more natural?” The group members all nodded, ■ Acknowledge the sexuality of all persons.
and the activity continued. ■ Be comfortable with his or her own sexuality.
■ Believe that interest in sexuality is appropriate for
Limited Information everyone.
Sometimes simply reassuring patients about sexuality is ■ Be comfortable speaking directly about sexual issues
not enough. If patients do have concerns or questions, (or be willing to overcome discomfort).
they may require specific information related to their ■ Refrain from projecting personal sexual morals and

stated concerns. Most occupational therapists are quali- values onto others.
fied to provide patients with limited information. This LIMITED INFORMATION
level of intervention often is concerned with dispelling
To provide this level of intervention, the therapist
myths or misconceptions about sexuality. Limited infor- should fulfill the criteria listed for Permission and do
mation may be related to facts about the effect of disabil- the following:
ity on sexuality and sexual function. Handouts, pamphlets, ■ Have a basic understanding of human sexuality and its
and group education programs are good ways to provide many variations.
limited information. The patients may read and absorb ■ Understand the physiology of human sexual response.
information on their own and ask the practitioner for ■ Be able to analyze the effects of physical disability on
clarification as needed. The important issue is to limit the various sexual activities.
information to the patient’s specific concerns. The accu- ■ Be willing to seek and provide accurate sexual

racy of the information is also paramount. If the therapist information.

■ Be aware of the limitations of his or her own
does not have the information, he or she should help
knowledge base.
the patient get it before making a referral to another prac-
titioner. For example, a patient with a recent stroke SPECIFIC SUGGESTIONS
and complex cardiac history asks whether it is safe to have To perform this level of intervention, the therapist should
sex. Although the patient’s physician can provide the an- fulfill the criteria for Permission and Limited Information
swer, it is not enough for the therapist to say, “Ask your and do the following:
physician.” By bringing up the concern to the therapist, ■ Be familiar with various sexual activities.
the patient has chosen that person as an advocate. The ■ Be comfortable discussing specific sexual activities.
therapist might respond, “Your physician is best equipped ■ Be able to conduct a sexual problem history.

to answer that question. Would you feel comfortable ask- ■ Be able to adapt various sexual activities to accommo-

ing him or her yourself, or would you like me to contact date functional limitations.
him or her for you?” INTENSIVE THERAPY

Specific Suggestions To perform this level of sexuality intervention, the therapist

should fulfill the criteria for Permission, Limited Informa-
If a patient is experiencing a sexual problem, limited in- tion, and Specific Suggestions and do the following:
formation may not be enough to solve it. The next level ■ Have formal training in sex therapy, sexuality counsel-
of intervention is specific suggestions aimed at solving ing, or psychotherapy.
the specific problem. This type of intervention requires
656 Stroke Rehabilitation

Just as the occupational therapist would not initiate treat- their sexual problems or to include strangers in their inti-
ment of other problems without a full evaluation, the mate relationships. They want and benefit from the least
therapist must understand the sexual problem fully before intervention possible to help them solve their sexual prob-
making specific suggestions. After obtaining the sexual lems and deal with their concerns. Other therapists fear
problem history, the therapist should develop treatment that providing permission to discuss sexual concerns will
goals in collaboration with the patient. These goals may facilitate inappropriate patient sexual behavior. Recent
address learning the effects of stroke on sexual function; literature indicates that many health care workers are ex-
adapting to changes in sensory, motor, or cognitive func- posed to inappropriate sexual behavior on the part of pa-
tion; adapting to psychosocial and role changes; and im- tients during their careers, and they often lack training in
proving sexual communication. dealing with these behaviors. Less experienced therapists
One male stroke patient reported sexual problems after and students tend to ignore the behaviors even when they
a weekend visit home. A sexual problem history revealed are severe, which may result in high stress and difficult
that he had always preferred the male-superior position working conditions.35,50 Of course, any therapist who is
for intercourse. Since his cerebrovascular accident, in- exposed to sexual or other inappropriate behavior by any-
creased leg extensor skeletal muscle activity and weakness one should address the problem immediately. Patient be-
had prevented adequate pelvic thrusting in this position. haviors should be documented in the medical records;
With his occupational therapist, the patient discussed other staff members also may be affected. All new thera-
various new positions to increase mobility: lying on the pists and students should be encouraged to report harass-
affected side with knees bent or sitting in a chair with his ment and seek help with difficult situations.
partner seated facing him. Providing permission to patients to address sexual is-
sues directly actually decreases inappropriate behaviors.
Intensive Therapy Flirting, sexual jokes, and innuendos are often a patient’s
If the patient’s problems are beyond the scope of goal- way of indirectly expressing doubts and concerns about
oriented specific suggestions, he or she may require inten- sexuality after disability. One stroke patient, M.G., over-
sive therapy. This level of intervention is based on special- heard his occupational therapist inviting some coworkers
ized treatment skills and is beyond the scope of most to her home and asked, “When are you going to invite me
occupational therapists. Finding an appropriate referral over?” The therapist replied, “You know, M.G., that I am
for such patients, such as a psychologist, social worker, or your therapist, and although you’re a really nice person, it
sex therapist, is advisable. If the sexual problems predate would be unethical for us to have a social relationship. But
or are not related to the onset of disability, the patient tell me, are you interested in developing new social rela-
may require referral. tionships?” This question led to a lively discussion about
The PLISSIT model enables the health care professional M.G.’s returning interest in women and sex. The therapist
to adapt a sexuality program to the needs of the setting and was understanding and supportive. The patient made no
the population served. Although permission to express sex- further advances to her. By refocusing attention on the
ual concern is universal, the need for limited information patient, the therapist deflected the unwanted attention
and specific suggestions varies. The best way to assess the and responded to the patient’s real need for permission to
need for sexuality intervention is to ask patients about acknowledge his returning sexual feelings.
their concerns. Occupational therapist Andamo’s treatment
model3 uses a written problem checklist in which the patient DEVELOPING COMPETENCY
is asked to identify problems in whatever role he or she fills,
including that of sexual partner. By addressing sexuality in a Competency in sexuality intervention comprises three
multiproblem context, this model helps normalize sexual elements (see Box 25-1): comfort, knowledge, and skill.
concerns. The checklist includes two items related to sexual These elements are interrelated; individuals are more
problems and concerns about sexual activity. Patients who comfortable with things they know well (knowledge) and
check either item receive further intervention as needed, do well (skill). Suggestions for improving these compe-
including problem clarification, sexual history taking, and tencies follow.
the development of treatment goals and planning. Thera- ■ Comfort
pists can adapt any evaluation to include verbal questions ■ Reading (See resources and references at end of
about sexual concerns and can repeat questions before home chapter.)
visits or as discharge approaches because patients’ concerns ■ Films (Be aware that many are related to spinal cord
change over time. injuries.)
Underlying some health care workers’ reluctance to ■ Disability literature
address sexuality may be a fear of opening a Pandora’s box ■ Knowledge
of issues too difficult or intimate for them to handle. This ■ Readings (See resources and references at end of
is seldom the case. Most persons do not wish to disclose chapter.)
 Chapter 25 • Sexual Function and Intimacy 657

■ Lectures ■ Partners should discuss sensory loss beforehand; in

■ In-service education hemiplegia, there may be absent or diminished light
■ Skill touch, impaired proprioception, kinesthesia, or loss
■ Role playing with other staff members of stereognosis. Stimulation on areas of intact sensa-
■ Acquiring skill through practice tion and incorporation of stimuli to intact senses
■ Seeking a mentor for private supervision who spe- (e.g., using scents, keeping lights on for visual stimu-
cializes in sexuality lation, music, and stimulating language) may help
improve sensory abilities.
SPECIFIC SUGGESTIONS FOR TREATMENT ■ Individuals with severe sensory deficits must con-
sider skin protection during sexual activity to pre-
Many impairments that occur after cerebrovascular acci- vent skin breakdown.
dent may affect sexual function and sexuality. These defi- ■ In the case of impaired hand function, a vibrator
cits include sensorimotor, cognitive, communication, and can be attached with the use of Velcro to enable
psychosocial changes. With sexuality, as with other ADL, stimulation.
determining the underlying causes of the performance ■ Treatment of weakened muscles of facial expres-
problem can be challenging. The following section com- sion to improve body image and facial expression
prises a list of suggestions one may use during treatment. and strengthening of oral-motor muscles may en-
hance oral sexual activities such as kissing and oral-
Hemiparesis/Sensory Loss genital sex.
Patients with hemiparesis or sensory loss and their part-
ners may try the following suggestions: Cognitive/Perceptual/Neurobehavorial Impairments
■ Having the hemiplegic partner lie on the affected side Patients with cognitive/perceptual/neurobehavioral im-
frees the uninvolved side for touching; this position pairments and their partners may try the following
also provides support, permits active movement, and suggestions:
focuses attention on the intact side. Early treatment ■ Simple positions are recommended (see Figs. 25-4
by the rehabilitation team (occupational and physical and 25-5). Achieving a routine of sexual activity may
therapy) should include instructing the patient to lie be helpful if the person has difficulty moving spon-
comfortably on the affected side (Fig. 25-2). taneously. When the brain becomes used to a rou-
■ Impaired motor control (limb and trunk) may re- tine, it does not have to work as hard to plan move-
quire a change in coital positioning because the ments and the patient does not have to concentrate
hemiplegic partner may find it difficult to assume on how he or she is moving.57
certain positions. Alternatively, the unaffected part- ■ Hemianopsia or unilateral neglect may cause a per-
ner may assume the superior position in bed or on a son to ignore parts of the partner’s body or not re-
chair or lying on his or her side (Figs. 25-3 to 25-5). spond when approached from the affected side.
■ Positioning for comfort with the use of pillows can The unaffected partner must be sensitive to these
be incorporated into foreplay. deficits.

Figure 25-2 This position allows for genital fondling during rear entry vaginal or anal
penetration and is appropriate for opposite or same-sex couples. Either partner can participate
fully if lying on the hemiplegic side.
658 Stroke Rehabilitation

Decreased Endurance
Patients with decreased endurance and their partners may
try the following suggestions:
■ Sexual activities should be planned. The patient
should wait three hours after meals before engaging
in activities and avoid sex when fatigued. Instead,
this may be a good time for intimate cuddling, hug-
ging, or participating in massage.
■ Partners can deemphasize intercourse through ex-
ploration of other sexual activities such as mutual
masturbation and oral-genital sex.
■ Partners should consider sexual positions that use
less energy (see Figs. 25-4 and 25-5).
■ Sexual activities may be easier to do in the morning,
when energy may be greater, instead of the evening.

Inadequate Vaginal Lubrication

Patients with inadequate vaginal lubrication and their
Figure 25-3 This position is appropriate as an alternative to partners may try the following suggestions:
lying on a bed or other surface; it is a nice alternative for wheel- ■ A water-based lubricant should be used.
chair use and may break the barrier of the wheelchair being used ■ Foreplay should be extended to ensure adequate lu-
only for transport. brication of the vagina before intercourse.
■ Lubricated condoms may be helpful.
■ Nonverbal communication such as touching and ■ Both partners should keep in mind that impaired
gesturing are encouraged with partners who may vaginal lubrication also might be a normal age-
have speech or language disorders.57 related change.
■ Distractions such as loud music should be kept to a ■ A consultation with a gynecologist may be war-
minimum.57 ranted.
■ Individuals with memory impairment should keep a
log of daily activities, including sexual activities, in Erectile Dysfunction
an effort to remain oriented.57 Patients with erectile dysfunction and their partners may
■ Sexual role changes such as increased sexual initia- try the following suggestions:
tion by the nondisabled partner can help minimize ■ Medications for erectile dysfunction may be indi-
the effects of cognitive changes on sexual function. cated, which include Sildenafil citrate (Viagra), Var-
■ Partners may share fantasies or intimate thoughts in denafil (Levitra), and Tadalafil (Cialis).67 They are
writing or by using augmentative communication considered safe in combination with most cardiac
devices before and after sexual activity.57 medications and can be “safely recommended in all
■ A team approach may be helpful. Speech and lan- patients with stable cardiac conditions.”67 However,
guage pathologists can help the patient improve or they all come with warnings about use in patients
compensate for verbal and nonverbal communica- with history of stroke.64 Although inconclusive, silde-
tion deficits. nafil citrate has been reported to have potentially

Figure 25-4 This position is recommended if the female partner sustained motor or cognitive
impairment and requires less endurance for the partner on the bottom.
 Chapter 25 • Sexual Function and Intimacy 659

■ Pelvic muscle reeducation (with or without biofeed-

back) to improve strength and control of pelvic floor
muscles may be indicated.58
Contraception and Safer Sex
Most stroke patients are past the childbearing years; how-
ever, contraception remains an issue for those who are still
fertile. Menses may be affected after a stroke, although
Figure 25-5 This position is recommended if the male partner studies are inconclusive.48 However, the exploration of
sustained motor or cognitive impairment and requires less en- contraceptive methods may be necessary, depending on the
durance for the partner on the bottom. patient’s impairments. The functional abilities needed to
use condoms, a diaphragm, or a cervical cap include fine
motor abilities, motor praxis, and intact cognitive and per-
ceptual function.57 However, in some cases, the nondis-
positive effects in the treatment of neurological dis- abled partner can assist with contraception and work it into
ease, including stroke.22 For any person with stroke the sexual repertoire. For example, if a woman had a stroke
and/or cardiovascular disease, a physician should as- and her contraception of choice is the diaphragm but she
sess the safety of sexual activity and use of these cannot insert the device because of hemiplegia, her partner
medications. might do this for her. If the couple prefers, they can explore
■ Certain medications may have an effect on erection alternative methods of contraception. A review of other
in addition to the stroke itself. The patient and phy- methods may be warranted, particularly if the patient pre-
sician should discuss this possibility. viously used the pill or other contraceptive hormones,
■ The patient and partner should consider alternatives which have side effects, some of which affect circulation.72
to intercourse. Latex condoms are preferred for safer sexual practices
■ If erectile dysfunction is related to depression or against sexually transmitted diseases; however, an erect
another psychological issue, the therapist should penis is required. If the male has difficulty maintaining or
suggest that the patient discuss it with the appropri- achieving an erection, it may not be possible for him to
ate team member, such as the psychologist or use condoms effectively. Female condoms or alternative
psychiatrist. sexual practices minimizing contact with body fluids may
■ A ring placed on the base of the penis may help be explored, and individuals and couples should be edu-
maintain blood flow into the penis and help the pa- cated on options such as mutual masturbation and oral sex
tient maintain an erection. with the use of a dental dam, which is a latex sheet placed
■ Other treatment options for erectile dysfunction over the vulva during cunnilingus. The therapist is re-
require consultation with a urologist. These include sponsible for staying updated on current guidelines re-
vacuum constrictor devices, injection of vasoactive lated to safer sex practices if education on safer sex will be
agents, and penile prosthesis implantation.32 Use of included in treatment.
these therapies has not been studied in stroke survi-
vors52 and has decreased greatly since the advent of
sildenafil.18 CASE STUDY 1
“When Will My Husband’s Sex Drive Return?”
Incontinence
P.R. is a 52-year-old married man who previously suffered
Patients with incontinence and their partners may try the
a hemorrhagic left basal ganglia stroke. He was admitted
following suggestions:
to a subacute rehabilitation center with right hemiplegia
■ The patient should avoid fluids before engaging in
and language and short-term memory deficits. His right
sexual activity.40
upper and lower extremity sensation was absent for tactile
■ Men may wear a condom to prevent leakage onto
stimulation. He demonstrated increased flexor activity
the partner.
and had no active arm movement. P.R. required maximal
■ Patients on a voiding schedule should be encouraged
assistance with all transfers and ADL, and his activity
to adhere to the schedule to prevent accidents.
tolerance was poor. Before admission he had lived with
■ Towels should be available in case of accidents, and
his wife of 11⁄2 years and ran a business requiring frequent
the patient should discuss his or her situation be-
travel. P.R.’s wife also worked full-time and taught wom-
fore engaging in sexual activity to prevent embar-
en’s exercise classes in her free time.
rassment.
By his 18-day team conference, P.R. had made sub-
■ The patient should empty his or her bladder before
stantial gains. He was independent in stand-pivot
engaging in sexual activity.
Continued
660 Stroke Rehabilitation

CASE STUDY 1
Permission
“When Will My Husband’s Sex Drive Return?”—
cont’d The therapist assured P.R. that concern about sexuality
was common among stroke survivors and their sex
transfers and required minimal assistance in dressing. partners and that, after a life-threatening event, sexual
He demonstrated emerging sensation and motor con- concerns are a sign of returning health. They discussed
trol in his right arm and lower extremities. He was able the myth that middle-aged persons are not attractive
to walk during physical therapy with a cane and assis- and society’s insistence in portraying only young, thin,
tance from a therapist. His language function had im- beautiful persons as “sexy.” The therapist explained
proved, with only some word-finding deficits remain- that although health care workers are sometimes reluc-
ing. He and his wife attended the team meeting. Her tant to bring up sexuality, P.R. had the right to be as-
last question to the team was, “When will his sex drive sertive in getting any assistance he needed in this area.
return?” P.R. said, “Don’t worry, Honey, it will come
back like everything else.” The staff recommended dis- Limited Information
cussing this issue with the new neurologist, with whom P.R. was provided a verbal summary of the research on
the couple had an appointment the following day. stroke and sex. He was informed that some persons
On return from his neurologist, P.R. reported to his experience sexual dysfunction after stroke and that
speech therapist that he and his wife had “forgotten” to desire, libido, erection, ejaculation, and orgasm might
bring up sexuality. He reported achieving only partial be affected. The therapist emphasized the lack of cor-
erections. The therapist offered him a consultation with relation of sexual dysfunction to motor or sensory
an occupational therapist on staff who was knowledge- deficits and the high correlation between prestroke and
able about sexuality and disability, and he agreed. The poststroke sexual function. The therapist and P.R. dis-
speech therapist had received no training or information cussed the effect of antihypertensive medications on
about sexuality and had no experience in this area. P.R.’s sexual function. P.R. reported telling his physician that
treating occupational therapist, who was not present at he would not take any medication that had side effects
the team meeting, was willing to use part of P.R.’s sched- on sexual function. The physician prescribed a medica-
uled treatment time for the sexuality intervention. tion without sexual side effects.
The occupational therapist who specialized in sexu-
ality issues introduced herself to P.R. and made an ap- Specific Suggestions
pointment to meet with him the next week in his pri- Although P.R. reported no need for ideas to improve
vate room. She asked whether he had any specific his sexual function, a level of denial was evident in his
questions or concerns so she could prepare informa- assurances that “everything would come back.” The
tion for their meeting. He said the concerns were occupational therapist said, “Just as you’re participat-
mostly his wife’s and that he was confident his sex drive ing in therapy to improve your arm, leg, and speech,
would “return just like use of my arm and leg are going your sexual function will improve faster if you don’t
to return.” The occupational therapist suggested in- just sit around waiting for its return.” P.R. agreed that
cluding P.R.’s wife in the meeting, but P.R. said she was he felt as if he had a new, different body and that he
unavailable during the daytime so the occupational would find it helpful to explore and learn the responses
therapist might as well speak to him alone. of the new body. They discussed including his wife in
A brief sexual history revealed that P.R. had been single the sexual explorations, but she was uncomfortable
for 11 years before this second marriage and that he had with the lack of privacy in the facility.
been sexually active with a variety of women during that Because P.R. would be unlikely to have sexual rela-
time. He and his wife considered sex an extremely impor- tions with his wife before discharge, strategies were
tant part of their relationship. “People can be very sexy discussed for initiating sexual activity in a positive,
even though they don’t look it,” he explained. P.R. volun- nonthreatening way because early problems with erec-
teered that he and his wife would not need help with tile function are not necessarily predictive of continu-
sexual positioning for intercourse because they preferred ing problems. Alternative sexual activities also are
the female-superior position. P.R. admitted to decreased considered “real sex.”
sexual desire, which he attributed to fatigue, separation, Because of their prestroke sexual function, motiva-
and the nonconducive environment. He reported having tion, interest, maturity, and willingness to communi-
erections that he estimated at “three quarters of normal cate, P.R. and his wife were likely to make a good sexual
hardness,” which was an improvement. He reiterated that adjustment to the effects of stroke. However, the
he was sure everything would come back. therapist did offer information on treatment of erectile
The intervention included three levels of the or other sexual dysfunction, for in the future, if prob-
PLISSIT model. lems arose, she would not be available to P.R. after
 Chapter 25 • Sexual Function and Intimacy 661

discharge. She also reported the latest medical inter- socialize, not so much as to act on her sexual desires. In
ventions for erectile dysfunction, which would be fa- subsequent conversations, W.A.’s occupational thera-
miliar to any urologist. Although he felt he would not pist reassessed this situation, particularly as W.A. made
need it, P.R. seemed glad to know that treatment was progress with ADL and functional mobility. After six
readily available. months of treatment, W.A. was getting back out into
At this facility, sexual concerns were not addressed the community, attending an adult day care center, and
by any rehabilitation discipline. While treating P.R., participating in bingo games in her building. She was
the therapist had provided written information on the taught how to transfer on and off the furniture in the
sexual effects of cerebrovascular accident and the role social room to allow greater independence and a sense
of speech and language therapists in sexuality counsel- of normalcy. All areas of function, including sexuality,
ing to the speech therapist who referred him and sum- were reevaluated periodically during W.A.’s treatment
marized the results of the counseling session. Staff program, and her goals remained unchanged from her
members became aware that other patients might have initial evaluation.
sexual concerns but lacked the comfort level or asser- In this example, the issue of sexuality was related
tiveness to initiate the communication. The therapist less directly to actual sexual activities than to socializa-
was asked to provide an in-service on sexuality, which tion and flirting. Had the therapist neglected to pursue
was well-attended by members of the occupational W.A.’s early statement about wanting to “chase a man,”
therapy department and other interested staff. the patient’s needs might never have been met.

CASE STUDY 2
“I Want to Get Out of the Wheelchair CASE STUDY 3
So I Can Chase a Man” “Will I Ever Have Sex Again?”
W.A. is a 62-year-old woman who previously suffered L.E. was a 57-year-old woman with an unknown social
a right middle cerebral artery stroke with resulting left history who was admitted to a rehabilitation hospital
hemiparesis. After her initial and rehabilitation hospi- and who previously suffered a right cerebrovascular
talizations, she was discharged home for continued accident with left hemiplegia and perceptual deficits.
occupational and physical therapy. She lived in a senior At the initial evaluation, the occupational therapist
housing development, which had a social room on the asked whether L.E. had any sexual concerns. “Yes, I
premises. W.A. had been widowed for more than 15 want to know whether I’ll ever have sex again,” she said
years and reported that her husband had been an alco- tearfully. The occupational therapist realized that such
holic and a “terrible man.” During W.A.’s initial evalu- a question could not be answered and that the patient’s
ation at home, the occupational therapist asked what concerns needed clarification. Was L.E. concerned
her goals for rehabilitation were. W.A. was quick to about being able to find a partner? About “performing”
reply, “I want to be able to get out of the wheelchair so sexually? The therapist helped L.E. clarify her ques-
I can chase a man.” Sexuality had not been addressed tion with some probing, “What are you concerned
until this point in the evaluation. The therapist took about specifically? What do you think might get in the
the opportunity to ask W.A. whether she had a signifi- way of your having sex again?” L.E. reported having a
cant man in her life, to which W.A. replied “no.” The male friend with whom she had an active sex life. Her
therapist asked W.A. whether she had any concerns major concerns were whether she would regain enough
about resuming sexual activities after the stroke; again function to return home and whether sexual activity
W.A. replied “no.” She explained that she was not would provoke further strokes. The occupational ther-
looking to marry again and simply wanted to be ex- apist reassured L.E. that most persons can resume
posed to others so she could flirt. During this conser- sexual activity safely after a stroke and offered to help
vation, the therapist realized that further exploration of her consult her physician for medical clearance. The
sexual function was geared toward getting W.A. out therapist provided the limited information L.E. was
into the community again. W.A. had been limited in looking for through reassurance and by obtaining
this endeavor because of poor mobility and wheelchair medical clearance through another team member (that
dependency. is, the physician). The therapist was able to tie in all the
In this example, the therapist used the permission rehabilitation goals with the patient’s desire to return
level of the PLISSIT model. The patient brought up to her home and previous lifestyle, which strengthened
the topic herself, and it was discovered through further the collaboration between L.E. and the rehabilitation
questioning that W.A. was really referring to a need to staff.
662 Stroke Rehabilitation

PROGRAM DEVELOPMENT REVIEW QUESTIONS

The therapist should have support, resources, and refer- 1. What are the stages of the sexual response cycle and
rals available when addressing sexual issues. The therapist the associated physiological changes in males and
should inform supervisors and others on the rehabilita- females?
tion staff of activities. Resources and referral services 2. What are some of the normal changes in sexual func-
should be identified in other departments and outside the tion in aging men and women?
facility, if appropriate. The therapist should check the 3. Why does sexual activity decline among older persons?
existing policies on sexuality (if any) at the facility and 4. What are the four levels of sexuality intervention in the
strive to be in compliance. The therapist should report PLISSIT model? Which may be performed by occu-
experiences and provide education to others. If possible, pational therapists?
an interdisciplinary committee should be formed to ad- 5. What skills are needed to provide sexuality counseling
dress sexual issues and develop appropriate programs. to patients who have had strokes?
6. What common effects of stroke interfere with sexual
DOCUMENTATION AND BILLING function and sexuality? What are the best predictors of
poststroke sexual function?
Sexuality interventions may be billed and documented in
various ways, depending on the billing system and the is-
sues discussed. Appropriate categories include ADL train- REFERENCES
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patients. Sex Disabil 12(3):3, 1994.
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be maintained. Examples of goals include the following: dysfunction. Sex Disabil 3(1):26, 1980.
1. Patient will independently identify proper bed posi- 4. Annon JS: The PLISSIT model: a proposed conceptual scheme for
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41. Korpelainen JT, Nieminen P, Myllyla VV: Sexual functioning among hemiplegia. I. Aspects of sexual function. Scand J Rehabil Med
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42. Kwon SC, Kim JS: Poststroke emotional incontinence and de- 70. Sjogren K, Fugl-Meyer AR: Adjustment to life after stroke with
creased sexual activity. Cerebrosvasc Dis 13(1):31–37, 2002. special reference to sexual intercourse and leisure. J Psychosom Res
43. Laflin M: Sexuality and the elderly. In Lewis CB, editor: Aging: the 26(4):409–417, 1982.
health care challenge—an interdisciplinary approach to assessment and 71. Strauss D: Biopsychosocial issues in sexuality with the neurologi-
rehabilitative management, ed 2, Philadelphia, 1990, FA Davis. cally impaired patient. Sex Disabil 9(1):1, 1991.
44. Lemieux L, Cohen-Schneider R, Holzapfel S: Aphasia and sexuality. 72. Szasz G, Miller S, Anderson L: Guide to birth control counseling of
Sex Disabil 19(4):253, 2001. the physically handicapped. Can Med Assoc J 120(11):1353, 1979.
45. Mackey FG: Sexuality in coronary artery disease. Postgrad Med 73. Tamam Y, Tamam L, Akil E, et al: Post-stroke sexual functioning in first
80(1):58–60, 1986. stroke patients. European Journal of Neurology, 15(7):660–666, 2008.
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74. Thienhaus OJ: Practical overview of sexual function and advancing National Stroke Association
age. Geriatrics 43(8):63–67, 1988. 9707 East Easter Lane
75. US Department of Health and Human Services: Post-stroke rehabili- Englewood, CO 80112–5112
tation, Rockville, Md, 1995, Public Health Service Agency for 1–800–STROKES
Health Care Policy and Research, Clinical practice guideline 16, www.stroke.org
AHCPR Pub No 95–0662.
76. Wigg EH: Counseling the adult aphasic for sexual readjustment. Planned Parenthood Federation of America
Rehab Couns Bull Dec:10–119, 1973. www.plannedparenthood.org
77. Zasler ND: Sexuality in neurologic disability: an overview. Sex SIECUS (Sex Information and Education Council of the United States)
Disabil 9(1):1, 1991. 90 John St., Suite 704
New York, NY 10038
(212) 819–9770
SUGGESTED READINGS www.siecus.org
Finger WW: Prevention, assessment and treatment of sexual dysfunc-
tion following stroke. Sex Disabil 11(1):1, 1993. Sexuality and Disability Training Center
Kroll K, Levy Klein E: Enabling romance, Bethesda, MD, 1995, Wood- Boston University Medical Center
bine House. 88 East Newton St.
Novak PP, Mitchell MM: Professional involvement in sexuality counsel- Boston, MA 02118
ing for patients with spinal cord injuries. Am J Occup Ther 42(2): (617) 638–7358
105–112, 1988. www.stanleyducharme.com

The Stroke Association

SEXUALITY RESOURCES www.stroke.org.uk
American Association of Sex Education Counselors and Therapists
435 North Michigan Ave., Suite 1717 Stroke Clubs International
Chicago, IL 60611 805 Twelfth St.
(312) 644–0828 Galveston, TX 77550
www.aasect.org (409) 762–1022
[email protected]
American Congress of Rehabilitation Medicine
6801 Lake Plaza Drive, Suite B-205 Specific Websites:
Indianapolis, IN 46220
Disability resources: www.menstuff.org
(317) 915–2250
National Institute of Aging: www.nia.nih.gov
www.acrm.org
Sexual Health Network: www.sexualhealth.com
Institute on Independent Living: www.independentliving.org
American Stroke Association
Stroke Survivors without Partners: www.dateable.org
National Center
7272 Greenville Ave.
Dallas, TX 52231
1–888–4–STROKE
www.strokeassociation.org

Hazel K. Goddess Fund for Stroke Research

785 Park Ave.
New York, NY 10021–3552
(212) 734–8067
www.thegoddessfund.org
 m ary s h ea
c h ri s ti n e m . j o h an n

chapter 26

Seating and Wheeled Mobility

Prescription

key terms
client education mat evaluation seating system
deformity pressure distribution symmetrical postural alignment
functional mobility product trial team approach
functional positioning seated posture wheelchair

chapter objectives
After completing this chapter, the reader will be able to accomplish the following:
1. Understand the seating system and mobility system evaluation process.
2. Appreciate the difference between seating for rest and seating for activity performance.
3. Implement a treatment plan and identify the goals of the mobility device and seating and
positioning system.
4. Appreciate the pros and cons of different mobility bases and seating system components.
5. Understand the influence of the seating system on carryover of treatment goals.
6. Appreciate the importance of the team process throughout the evaluation and fitting/
delivery process.
7. Understand the importance of fitting and training with the recommended seating system
and mobility device.

The statistics from the National Stroke Association indi- potential to achieve the upmost independence and safety
cate that stroke is the leading cause of serious adult dis- with ADL. Consequently, it is important for a therapist
ability in the United States.12 Despite advances in reha- to develop a working knowledge of assistive technology.
bilitation and treatment approaches, many individuals Assistive technology is an umbrella term that includes seat-
have difficulty with mobility and performance of activi- ing and wheeled mobility, including manual and power
ties of daily living (ADL). An appropriate seating system wheelchairs, electronic aids to daily living (formerly
and mobility base is essential to maximize each client’s known as environmental control units), computer access

665
666 Stroke Rehabilitation

including workstation setup, and augmentative and alter- of seating system and mobility device evaluation and
native communication devices. provision.
This chapter provides a general introduction and
then focuses on the basic principles of seating and po- SOCIETAL ATTITUDES AND EXPECTATIONS
sitioning, the evaluation process, the fitting/delivery OF PERSONS WITH DISABILITIES
and training process, and the features of various seating
system products and mobility devices. Although the For the past 35 years, individuals with disabilities have
emphasis is on the seating and wheeled mobility pro- been lobbying for their needs and rights and have been
cess specific to persons with a stroke, many of these relatively successful with the passage of several laws. The
principles are appropriate for use with all individuals Americans with Disabilities Act has played a major role at
with disabilities who have impaired functioning and the International Classification of Functioning, Disability
disability. and Health (ICF)6 activities and participation level to in-
The terms client and individual with disability are used crease access to transportation and public places. This
interchangeably throughout the chapter for appropriate increase in environmental accessibility has enabled many
semantics. These terms consistently refer to the same individuals with disabilities to pursue their education,
person. employment, and leisure interests to become more active,
The wheelchair and seating system provision process productive members of society. These changes have fu-
is a collaborative process that begins with a client inter- eled the wheelchair manufacturing industry to develop
view and ends with fitting, training, and follow-up with and provide appropriate equipment to meet these more
the recommended wheelchair and seating system. A active lifestyles.
team approach throughout this process is essential to
ensure achievement of safety and the client’s goals. The REHABILITATION SERVICES
ideal wheelchair and seating system team consists of the
client; health care practitioners such as a medical doc- The provision of rehabilitation services has changed dras-
tor, an occupational and/or physical therapist, and a tically regarding length of stay on rehabilitation units and
speech pathologist (as needed); the caregiver and/or knowledge required to appreciate the variety of wheel-
significant other; and an assistive technology supplier. chair and seating system options. Initially, clients had
The client is the central person in the wheelchair and sufficient time in rehabilitation programs to adjust to the
seating system process, and the client’s goals are given changes in their bodies and reach their full potential be-
the highest priority. fore they received a wheelchair and integrated into their
If a client can communicate his or her needs and has discharge environment, preferably home. Today, because
the cognitive functioning to participate in decision- of the influence of traditional insurance funding limita-
making, then the therapist’s role is to empower him or tions, clients are discharged from rehabilitation units once
her, through education, to be more active in the decision- they are medically stable, have demonstrated restoration
making process. If a client has cognitive changes that limit gains, and have a support system in place to enable them
his or her ability to function and be involved in the to be relatively safe with their basic ADL. As a result,
decision-making process, then he or she is still central; therapists are forced to look at a permanent seating sys-
however, increased attention may be given to the caregiv- tem early to ensure that it will facilitate functional resto-
er’s needs and goals. ration and minimize the risk for increased deformity and
In the past 35 years, numerous changes have oc- secondary complications.
curred in the health care industry. These changes were Years ago an overall one-size-fits-all philosophy pre-
primarily at the environment level and include societal vailed and a limited number of wheelchair and seating
attitudes and expectations of persons with disabilities, system options were available for individuals with dis-
rehabilitation service provision, manufacturer produc- abilities. Because of changes in the manufacturing in-
tion of durable medical equipment, reimbursement pol- dustry, a multitude of product options now are available
icies, and system changes that include the development to facilitate optimal positioning for individuals with a
of authorities and organizations to organize, control, wide variety of needs. The knowledge base of therapists
and monitor assistive technology services. Due to these and the increased number of seating systems and acces-
changes in the wheelchair industry, increased emphasis sories now available can help decrease the progression
is on the client taking a more active role in medical care, of deformities, pain, and other secondary problems. An
increased expectations of returning to a previous level individual who is seated appropriately can access avail-
of activity and function, minimization of deformities able motor function, perform ADL with increased sense
and secondary complications, actual evaluation of trial of security, and can lead a healthier, more enriching life.
equipment, and the certification of a group of therapists Specific product options are addressed later in this
and suppliers with a basic wide-range knowledge base chapter.
 Chapter 26 • Seating and Wheeled Mobility Prescription 667

MANUFACTURER PRODUCTION Technology Suppliers (NRRTS), the American Academy

OF DURABLE MEDICAL EQUIPMENT of Physical Medicine and Rehabilitation, and the Founda-
tion for Physical Medicine and Rehabilitation have been
The durable medical equipment industry has grown tre- created to develop or have been active in developing stan-
mendously in the past 35 years to meet the increasing dards to ensure a higher standard of practice with wheel-
population of persons with disabilities and the increasing chair service provision. A monumental accomplishment
demand for more versatile, lighter-weight products. The was the American National Standards Institute/RESNA
increase in product options and advancement to lighter- Wheelchair Standards. These standards provided the in-
weight materials such as aluminum and titanium has re- dustry with increased consistency for wheelchair perfor-
sulted in a vast selection of off-the-shelf products that mance characteristics and measurements that are widely
have the potential to meet a wide array of needs. Manu- used by manufacturers to categorize and test wheelchairs.
facturers understand the need for persons with disabilities Consequently, these standards provide the wheelchair team
to try specific products to ensure they will meet their with the ability to compare similar products from different
needs. Accordingly, they often provide evaluation equip- manufacturers.
ment for clients to try. Another major accomplishment has been the develop-
ment of credentialing programs. The RESNA awards
REIMBURSEMENT POLICIES therapists and suppliers credentials for an assistive tech-
nology professional and a seating and mobility specialist.
Insurance companies are the funding source for the ma- The NRRTS awards a certified rehabilitation technology
jority of durable medical equipment provided for indi- supplier credential. These credentials increase the likeli-
viduals with disabilities. Unfortunately, as a result, the hood that the professional members of the treatment
funding source often influences the decision-making pro- team have a certain knowledge base of client’s needs and
cess. This discussion will focus primarily on Medicare assistive technology products.
guidelines because many private insurance companies fol- Numerous outcome studies have been performed and
low these guidelines, and Medicare is the primary funding are being performed at a multitude of levels to determine
source for individuals who are older than 65-years-old the efficacy of wheelchairs, seating system products, and
and have had a stroke. Medicare has specific codes and wheelchair service provisions. Specific topics studied in-
reimbursement guidelines for durable medical equip- clude long-term wheelchair use, wheelchair design, re-
ment. It is concerned primarily about mobility within the petitive stress injuries, propulsion methods, pressure re-
home and will consider payment for a device only after an lief techniques, and community integration. Many of
individual has received it. As a result, durable medical these studies have focused on the individuals with spinal
equipment suppliers have to take the risk and supply cord injury; however, the results are meaningful for all
equipment without receiving any guarantee of payment individuals who use wheelchairs as their primary means
from Medicare. Consequently, differences exist between of mobility. The results from these studies have influ-
individual supplier policies and what wheelchair and seat- enced manufacturing focuses and current practice with
ing system products suppliers are willing to provide. As wheelchair prescription trends. This has translated into
one can imagine, some suppliers hesitate to provide more higher-quality products that minimize an individual’s risk
complex, expensive equipment for individuals with more of injury and increase their efficiency with mobility for
involved needs. It is essential for the team to work to- increased integration into society. Continued involve-
gether to ensure that each individual has access to the best ment of health care practitioners in education, research,
product to meet his or her needs. If this is not possible and product development is essential to ensure that all
under Medicare guidelines, the client should notify the individuals with disabilities receive the best possible
local congressional representative, and the team should equipment to minimize their risk for secondary compli-
consider other funding sources. cations and maximize their ability to function indoors
and outdoors.
SYSTEM AND POLICY CHANGES:
DEVELOPMENT OF STANDARDS BIOMECHANICS OF SITTING
AND ORGANIZATIONS TO MONITOR
ASSISTIVE TECHNOLOGY SERVICES To appreciate and evaluate postural alignment, it is im-
portant to have an understanding of biomechanics. A
System changes have evolved over the past three decades therapist should understand basic anatomy of skeletal
and include the development of authorities and organiza- structures and their relationship to one another. The pel-
tions to organize, control, and monitor assistive technology vis is the foundation for sitting; consequently, knowledge
services. The Rehabilitation Engineers Society of North of the anatomy and biomechanical features of the pelvis
America (RESNA), the National Registry of Rehabilitation and its relationship with the musculature and fascia of the
668 Stroke Rehabilitation

spine and lower extremities is essential to understand how

changes in lower-extremity positioning influence the pel-
vis and subsequently the spine.
The pelvis moves anteriorly and posteriorly in the sag-
ittal plane around a coronal axis, laterally tilting in a fron-
tal plane around an anteroposterior axis and rotationally
in a transverse plane around a vertical axis. A stable neu-
tral position of the pelvis must be attained to provide the
optimal postural alignment of the spine (Fig. 26-1). In a
neutral pelvic position, the anterior superior iliac spine
(ASIS) is level in a frontal plane and level with or slightly
lower than the posterior superior iliac spine (PSIS) in the
sagittal plane. A pelvis is also positioned in neutral when
both ischial tuberosities bear weight equally (Fig. 26-2).
Palpating the ASIS and PSIS and then both right and left
anterior superior iliac spine can help the therapist to
determine the position of the pelvis. Fig. 26-3 shows
optimal sitting posture with a stable neutral pelvic posi-
tion and symmetrical positioning of the lower extremities
and trunk.

C spine

T spine

Figure 26-2 Appropriate spinal and pelvic alignment viewed

posteriorly.

L spine

ASIS
PSIS

Ischial
tuberosity

Figure 26-1 Lateral view of the spine and pelvis with appro-
priate alignment and spinal curvatures. C, Cervical; T, thoracic;
L, lumbar; ASIS, anterior superior iliac spine; PSIS, posterior Figure 26-3 Optimal alignment in seated posture. Note the
superior iliac spine. symmetrical pelvis and spinal alignment.
 Chapter 26 • Seating and Wheeled Mobility Prescription 669

ASSYMMETRICAL PELVIC POSITIONS, typically seen in individuals with decreased muscle re-
CONCERNS, AND COMMON CAUSES cruitment and overall muscle weakness.
A pelvic rotation is present when one ASIS is farther
Fig. 26-4, A, B, and C, shows changes in pelvic alignment. forward than the other (see Fig. 26-4, C). The posture can
Part A demonstrates lateral tilting of the pelvis, in which present as unequal leg length posturing when an individ-
one ASIS is higher than the other is. This pelvic obliquity ual is seated. This abnormal pelvic rotation influences the
results in unequal weight distribution through the ischial spine to move into a rotated position and predisposes an
tuberosities and a C- or an S-shaped spinal curve. This individual to a scoliotic curvature of the spine. Pelvic rota-
posture places an individual at a high risk for developing tion can create unequal weight distribution between the
a pressure sore under the lower, weight-bearing ischial ischial tuberosities, which can lead to pressure sores. This
tuberosity and secondary shoulder and neck discomfort. posture is commonly seen in individuals with asymmetri-
This problem is seen commonly in individuals with asym- cal muscle strength, asymmetrical muscle tone, limited
metrical muscular strength, asymmetrical muscle tone, hip joint mobility, lower extremity abduction, or adduc-
limited hip joint mobility, lower extremity hip flexion or tion limitations.
internal/external rotation range of motion limitations,
asymmetrical lower extremity muscle strength, and mid- WHEELCHAIR AND SEATING SYSTEM
line orientation deficits. ASSESSMENT
Fig. 26-4, B demonstrates a posterior pelvic tilt. A pos-
terior pelvic tilt occurs when the ASIS is higher than the Basic Principles
PSIS. This abnormal pelvic position results in a kyphotic Although accessibility and wheelchair technology have
spinal posture. A posterior pelvis with lumbar and tho- changed drastically over the past 30 years, Judai’s study7
racic spinal kyphosis results in changed weight distribu- is a reminder that the process still is evolving. Judai used
tion, with increased pressures on the sacrum and coccyx, the Psychosocial Impact of Assist Device Scale to assess
and a compensatory cervical hyperextension. This posture the psychosocial impact of assistive devices on individu-
can lead to pressure sores on the sacrum and coccyx, neck als one and three months following the stroke. His find-
and back pain, limited neck range of motion, and a de- ings for individuals who used wheelchairs indicated that
creased visual field. Posterior pelvic tilt is commonly seen some individuals reported a negative effect on their self-
in individuals with trunk weakness, muscle imbalance, esteem, competence, and adaptability. This is a re-
limited pelvic mobility, limited hip joint mobility, limited minder to be attentive to the social and attitudinal envi-
lower extremity hip flexion, and/or limited hamstring ronment that includes the stigma associated with using
muscle length. a wheelchair. Approaching each treatment session with
With anterior pelvic tilt, the ASIS is lower than the a positive tone and educating individuals about the ben-
PSIS. This pelvic position usually results in a more pro- efits of increased comfort and the potential ability to
nounced lordotic curve in the spine. This posture is function independently indoors and outdoors are im-
portant.7 It is also helpful if the team has a working
knowledge of community resources (i.e., support groups,
transportation, and general accessibility) by which to
educate the client about strategies for increased integra-
tion in the community.
Unfortunately, no specific formula exists to choosing
the “right” seating system and mobility base. However,
the set of guidelines discussed next can help the team
achieve the best combination of mobility base and seating
system with each client. The wheelchair and seating sys-
tem decision is the result of an intricate interplay among
an individual’s postural seated needs, personal preferences
C Rotation and goals, home and community environment, financial
situation, and method of transportation. It is important to
remember that the one-size-fits-all philosophy has no
place in seating system and mobility device prescription.
The wheelchair and seating system assessment is spe-
A Scoliosis B Kyphosis cific to each individual’s needs. After obtaining demo-
Figure 26-4 Common posturing following a stroke. A, Lateral graphic data, the assessment process generally begins at
tilting of the pelvis in a client with right-sided weakness. the ICF activities and participation level and progresses to
B, Posterior pelvic tilt with kyphosis. C, Trunk and pelvic rota- the body functions and structures level. Initially, an in-
tion (superior view). depth comprehensive interview with the wheelchair team
670 Stroke Rehabilitation

takes place to develop an understanding of an individual’s to ensure that everyone “understands what you are look-
functional goals, environments he needs to function in, ing for, how you will be going about it, and why this in-
ability to participate in ADL, and knowledge base of formation is important to reach a good end result.”2
wheelchair and seating system needs. The assessment Before beginning a mat assessment, it is important for
then continues to screen numerous body functions such as the therapist to understand some basic biomechanical and
muscle strength, balance, and cognition. This includes a seating principles. One of the main concepts is the dis-
mat evaluation, client education regarding postural needs tinction between flexible, difficult to correct, and fixed
and pros/cons of various seating and mobility base op- postural deformities. These concepts clarify skeletal posi-
tions, seating product and mobility product trial, and tions in the supine and seated mat assessment.
specifications of the wheelchair and seating system prod- The initial focus with a mat evaluation is to determine
ucts. It is extremely important to take the time to perform whether neutral pelvic and trunk alignment can be
a thorough assessment to avoid compromising the result achieved. If the pelvis is in an oblique position and lower
and to minimize time spent fixing mistakes.2 extremity influence has been accommodated for or ruled
out, the therapist should attempt to correct the pelvis
Step 1: Conduct a Comprehensive Interview manually.
The therapist should lead the team and conduct a com- If the pelvis stays in the corrected position, without
prehensive interview that includes the client’s diagnosis; handling, the deformity is considered flexible.19 If the
medical and surgical history; skin history; future medical pelvis goes back into the oblique position but is reposi-
and surgical considerations; allergies; precautions; pain; tioned easily to neutral and requires gentle therapeutic
funding sources; social support network; use of splints or handling to stay in neutral, the deformity is considered
orthotics; previous and current level of functioning; likes difficult to correct.19 If the pelvis cannot be repositioned
and dislikes with current equipment; equipment fit in manually into a neutral position, the deformity is consid-
home environment, work environment, and community; ered fixed.19 A pelvic obliquity is measured by the height
transportation method(s) (car, van, taxi, or bus); and the difference between each ASIS and is named for the side
client’s goals for the new or modified equipment. The that is lower.19 A subsequent section discusses seating
interview should include psychosocial issues with respect considerations for flexible, difficult to correct, and fixed
to roles and lifestyle preferences; basic and instrumental body structures.
ADL performance, including indoor and outdoor mobil- A thorough mat assessment can require two to four
ity; and transfer status. A physical status screening should persons and consists of four major components:
take place to ascertain passive and active range of motion, 1. Observation of the client in the clinic with the cur-
available movement patterns, muscle strength, sensation, rent or loaned equipment; the therapist assesses
endurance, balance, visual-perception, and cognition. If postural positioning in the wheelchair and screens
the client has moderate to severe oral-motor control is- muscle tone and strength. The specific focus should
sues, a speech pathologist should be a member of the include the influence of tone on movement, influ-
treatment team to ensure that the client’s communication ence of movement on tone, and influence of tone on
and/or augmentative communication needs are addressed postural control.
thoroughly. See Chapter 20. 2. For a supine mat assessment, the client is positioned
If this is a client’s first wheelchair, a home evaluation on a mat. This is essential to determine the bony
form is generally provided and additional education is structure, muscle flexibility (including muscle tone),
necessary to ensure that the client and significant others and range of motion of the client to achieve optimal
understand the environments that wheelchair maneuver- spinal-pelvic alignment. The assessment provides
ability will have impact on. the therapist with a “true” picture of each individual’s
potential to be seated with optimal spinal-pelvic
Step 2: Perform a Supine and Seated Mat alignment. The results from the supine assessment
Assessment are essential to guide how an individual is posi-
A mat assessment is an intimate evaluation that can be tioned or supported for the seated mat evaluation
intimidating and confusing to the client and significant 3. A seated mat assessment is essential to determine
others. The assessment involves therapeutic handling, the influence of gravity on the individual’s ability to
palpation, and range of motion. The results of the mat sit upright. The therapist can usually perform the
assessment are essential to determine the amount of sup- seated assessment with the client seated on the edge
port an individual requires for upright sitting, the goals of the mat with therapeutic handling by the thera-
and overall setup of the seating system, and the mobility pist and other members of the treatment team. At
base options needed to accommodate the recommended this time, muscle tone may be increased as the indi-
seating system. The therapist must take the time to ar- vidual attempts to hold his or her body up against
ticulate the purpose and importance of the mat evaluation gravity. If a client has moderate to significant
 Chapter 26 • Seating and Wheeled Mobility Prescription 671

postural needs, a positioning simulator can be help-

ful to support the client in the upright position. A Step 3: Provide Client and Team Education
more detailed description follows. Educating the client about the mat evaluation findings
4. Once an individual is positioned with maximum and their effect on postural alignment in a seated position
aligned posture on the mat or in the simulator, the is important. At that time, the therapist can review a cli-
time and location are ideal to take accurate mea- ent’s goals, and each team member should articulate their
surements of the client’s body. The five basic mea- goals to ensure that all are headed in the same direction.
surements for an active individual are seat width, Education is essential to enable an individual to partici-
seat depth, knee to heel (with shoe), elbow height, pate actively in the wheelchair and seating system trial
and distance from the seating surface to inferior and decide what compromises he or she is willing to make
angle of the scapula. All measurements can be docu- to maximize the ability to function in a wheelchair. Al-
mented in half-inch or one inch increments (e.g., though the client is the primary decision-maker, the
17.5-inch seat width). Chest width, axilla, top of therapist and assistive technology supplier should freely
shoulder, and occiput measurements are important discuss their professional opinions. Part of the educational
to obtain if an individual requires more aggressive process is to help a client prioritize what is most impor-
support (Fig. 26-5). tant, especially when future health, skin integrity, and
A simulator is a tool that permits the team to evaluate a secondary complications are a concern. There is no one
sitting client more easily with various angles and amounts wheelchair and seating system that is perfect for individu-
of support. This simulator is composed of planar surfaces als with stroke; the solution is perfect only when a client
that can be adjusted to different depths, and recline, and makes informed decisions about what various components
tilt to provide appropriate support. In addition, it consists will work best for his or her lifestyle.
of easily adjusted components (headrest, lateral support, It is helpful to discuss wheelchair and seating system
hip support, armrest, and footrest) that can be placed in needs in a general way and then to select products so that
numerous positions and are adjustable through knobs. a client can choose from two or three options. Using the
The simulator permits therapists to evaluate the seated mat evaluation results and understanding product features
position with an individual, evaluate the level of function and benefits is essential and described in detail later in this
with different positions, educate the client on the poten- chapter. The therapist and assistive technology supplier
tial to achieve the best possible resting posture, take more have the responsibility to clearly articulate the features,
accurate measurements, visually document potential for benefits, and pros and cons of various options to empower
increased alignment via pictures to funding sources, and the clients to select products to best meet their needs.
save an enormous amount of time with evaluating differ- Providing this information empowers the client and sig-
ent products. The simulator can help narrow the product nificant others to be educated, reinforces their confidence
options necessary for evaluation to provide optimal sup- in the decision of the team, and increases their satisfaction
port (Fig. 26-6). with the final product.

6
3
2
1
7

Figure 26-5 Measurements during the mat assessment. 1, Elbow height; 2, seat to inferior
angle of scapula; 3, axilla; 4, seat depth; 5, knee to heel; 6, chest width; 7, hip width.
672 Stroke Rehabilitation

maximize activity and participation, and medical and

functional justification for the wheelchair, wheelchair fea-
tures, and seating system recommendations. This is the
letter that the medical doctor reviews and signs once the
final additions are completed.
As the medical professionals are generating the let-
ter of medical necessity and organizing the medical
chart notes and prescriptions, the assistive technology
supplier contacts each of the manufacturers for price
quotes and generates a product description form. The
doctor reviews and signs this form. It is sent with the
letter of medical necessity and other insurance docu-
mentation to the assistive technology supplier for fund-
ing approval.

Step 6: Fitting, Training, and Delivery

After the team has recommended and documented the
person’s equipment needs, the job is only half over. It is
common for funding sources to question the team’s rec-
ommendation. It is important to respond as promptly as
possible to these inquiries and clearly communicate the
team’s goals.
Once the assistive technology supplier feels secure
Figure 26-6 Planar Simulator. (Courtesy of Prairie Seating that the equipment will be funded and in some cases
Corporation.) “approved” by the funding source, the equipment is or-
dered. All team members who were involved in steps 1 to
5 should be available for steps 6 and 7. During fitting,
Step 4: Equipment Trial training, and delivery, the wheelchair and seating system
Actual trial of seating system and wheelchair options is is set up and adjusted to specifically meet each client’s
the best case scenario; however, this is not always possible. needs. At this time, the therapist and assistive technology
If a manufacturer is unable to provide the team members supplier educate the client and significant others regard-
with the equipment they are considering, simulating the ing wheelchair and seating system parts management,
type of seating design and components is important for care, and general maintenance, including whom to con-
the team to ensure that the product is accomplishing what tact if problems arise. For example, if a client needs re-
they had hoped to achieve. placement parts, he or she is advised to contact the assis-
Actual trial of more complex, expensive equipment is tive technology supplier; if a client experiences physical
highly recommended to minimize unseen compatibility changes and is no longer comfortable, he or she is advised
and fit problems and ensure that the full system can meet to contact the medical doctor and the therapist.
the client’s needs and goals. Mobility skills training is essential to provide clients
Once the ideal wheelchair and seating system is de- with strategies and techniques for maximum safety and
cided upon, the team gathers around the client in the independence with mobility. This includes training for
“evaluation” wheelchair and seating system. At this point, manual wheelchair operation using the traditional ipsi-
the team decides the measurements of the product, speci- lateral arm-foot propulsion technique,3 a one-arm drive
fies wheelchair and seating system features with order wheelchair, or a power mobility product. Rudman and
forms, and provides additional education about the pros colleagues16 concluded that training was needed
and cons of specific features (such as pneumatic versus beyond the prescription of the wheelchair. This train-
solid tires). In an ideal situation, this is truly a collabora- ing is essential to provide clients with the ability to
tive team process. reach their full functional potential with activities and
participation.
Step 5: Documentation This fitting and delivery step is essential to ensure
At this point, the therapist has gathered all the informa- that the end product accomplishes the team’s goals
tion needed to write a letter of medical necessity. This and minimizes an individual’s risk for deformity and
letter is a concise summary of the client’s activities and secondary problems. Another benefit to this step is that
participation status, mat evaluation findings, problems it significantly reduces the potential for product
with existing equipment, wheelchair and seating needs to abandonment.
 Chapter 26 • Seating and Wheeled Mobility Prescription 673

an individual has a flexible or difficult to correct defor-

Step 7: Functional Outcome Measurement mity, the seating system should be set up to imitate the
and Follow-Up therapeutic handling to “correct” the deformity. At this
The ideal situation would be for an individual to attend a time, client education regarding repositioning strategies
follow-up treatment session three months after the fit- is helpful to ensure the client is aligned properly and to
ting and delivery or at least to participate in a phone in- facilitate neuromuscular reeducation. It is important to
terview with the therapist to determine the success of carefully monitor each client’s tolerance for correction
the wheelchair and seating system intervention. This step and adjust the seating system accordingly to maximize
is a true test to ensure achievement of the team’s goals. success. The process may require incremental steps to
Follow-up should focus on issues such as whether the achieve increased alignment or may involve backing down
equipment is holding up to the individual’s specific needs from an aggressive start. If a deformity is fixed, as much
and has made a difference on pain, quality of life, and aggressive support as possible is important to assist the
independent functioning. client around his deformity to decrease progression and to
Barker and colleagues1 reported that wheelchairs were minimize his or her risk for increased deformity.
an enabler of community participation. Pettersson and With more aggressive seating systems, a mobile person
colleagues13 used the Psychosocial Impact of Assistive can be “locked” up by the aggressive supports used to
Devices Scale and found that wheelchairs increased qual- achieve optimal spinal-pelvic alignment. Unfortunately,
ity of life for individuals after stroke. this often limits an individual’s ability to function. With
positioning for function, a compromise occurs to provide
MATCHING EQUIPMENT TO CLIENT as much support as possible for the resting body position
FUNCTION: SEATING SYSTEM PRINCIPLES without affecting or limiting an individual’s ability to func-
tion. Consequently, wheelchair seating is a continuum
Translating the Mat Evaluation into the Seating with safety and maximum postural support on one end and
System mobility for activity and participation on the other end. An
Once the mat assessment is completed, the therapist must ideal seating system should have some flexibility to provide
translate the measurements and ranges into the set-up of optimal spinal-pelvic alignment and facilitate function. It
the seating system and wheelchair. For example, if Mr. S. is important to maximize the potential movement options
has only 80 degrees of hip flexion range, the seat-to-back of individuals who use wheelchairs as their primary means
angle must be set up to accommodate this 10-degree of mobility. Individuals with good motor control may
limitation. Most back canes have an 8-degree bend rear- choose to sit on a chair or stool for more active function-
ward, and therefore a back support with some adjustabil- ing. For individuals who do not have as many mobility
ity is provided with an additional 2 to 7 degrees of open options available, the wheelchair must have the ability to
seat-to-back angle. The extra 5 degrees is necessary to accommodate both active and resting seated postures.
allow for some adjustment for comfort. It is important not Although online resources for wheelchair and seating
to position an individual at the maximum range available. system products are an excellent source of information and
Likewise, if Mr. S. has hamstring tightness (70 degrees education, online purchase of these products is not recom-
of knee extension with his hip at 80 degrees of flexion), mended because a client does not receive any of the ben-
the therapist must be cautious about using an elevating leg efits that an assistive technology supplier provides (i.e.,
rest, because it generally positions the lower extremity in assistance with set-up and assembly, on-site adjustments,
65 degrees of knee extension and would overstretch his and personalized modifications).9 In addition, an individual
tight hamstring musculature. Because Mr. S.’s hamstring purchasing equipment online misses the opportunity for
muscle cannot sufficiently elongate to tolerate this open the team evaluation and product trial and may not be in-
knee angle, his body will automatically compensate for tune to mild physical changes that have occurred since last
this, which would result in Mr. S sitting with a posterior receiving a wheelchair and seating system.
pelvic tilt. In this situation the team can order a 70-degree
standard footrest and use a longer heel loop for foot posi- GENERAL SEATING SYSTEM PRINCIPLES
tion rearward for a 70- to 75-degree knee angle, being FOR INDIVIDUALS WITH STROKE
mindful of caster (front wheel) clearance. This is essential
to adequately accommodate his hamstring muscle tight- Therapeutic intervention for individuals with brain dam-
ness and allow for optimal pelvic and spine positioning. age caused by a stroke depends on the severity of the in-
farct and the amount of functional change that has oc-
Flexible, Difficult to Correct, and Fixed Deformities curred, including physical, visual-perceptual, and cognitive
Once a therapist establishes what type of deformity is changes. Accordingly, wheelchair and seating system in-
present, he or she must figure out how to support the cli- tervention also depends on the level of functional changes
ent to minimize his or her risk for increased deformity. If and confounding variables, including the environment in
674 Stroke Rehabilitation

which the individual is functioning and the presence of Postural Stability and Control. Abnormal skeletal mus-
other diagnoses such as diabetes, hypertension, and coro- cle activity and pathological reflexes often influence the
nary artery disease. Seating systems for individuals with postural alignment of an individual with neurological in-
more involved needs may be more supportive because of sult. A seating system should provide a stable foundation
decreased plasticity in the central nervous system and for maximum postural alignment to reestablish the length
permanent brain damage.5 tension relationship of the muscles, balance muscle activ-
Individuals with hemiplegia resulting from stroke often ity, normalize muscle tone, and decrease compensatory
have difficulty controlling posture, balance reactions, and posturing. Improved postural stability provides individu-
smooth movement patterns that enable the performance als with the freedom to interact, move their extremities,
of functional tasks. Davies5 described the typical patterns and hold their heads in the midline position.2 Secondary
of adult hemiplegia (Table 26-1). benefits of improved stability and control are increased
For individuals who use a wheelchair as their primary ability to attend to what is happening in the environment,
means of mobility, seating and mobility recommendations increased interaction with the environment, improved
should address these typical patterns of adult hemiplegia. ability to assist in or perform ADL, and increased inde-
The following are typical seating system goals and seating pendence with mobility.
principles specific to individuals with stroke.
Proximal Muscle Stability to Enhance Distal Muscular
Goals of the Seating System Control. A stable base of support for the pelvis provides
The primary goals of seating and positioning at the ICF individuals with the opportunity to develop control and
body functions and structures level are as follows: balance of their trunk musculature. When the pelvis is
Provide adequate postural support stable, an individual’s center of gravity passes through the
■ To prevent deformity or minimize the risk of in- base of support, which helps promote stability. This cen-
creased deformity tral stability allows for distal extremity control. The client
■ To balance skeletal muscle activity is better able to access muscles for arm or leg movement,
■ To minimize compensatory postures head control, or oral motor control to perform functional
■ To maximize pressure distribution and minimize the tasks (i.e., hand function for dressing, leg movement for
risk of pressure ulcers wheelchair propulsion, midline head orientation for im-
■ To enhance distal extremity control proved visual tracking of objects, and oral motor control
■ For adequate comfort to maximize sitting tolerance for speech articulation or swallowing).
■ For autonomic nervous system functioning
The primary goals of seating and positioning at the ICF6 Decrease Development of Muscle Contracture and
activities and participation level are as follows: Skeletal Deformity. Decreased pelvic control, muscle
Provide adequate postural support weakness, and muscle imbalance contribute to asymmetri-
■ To maximize ability to perform functional activities cal posturing. Asymmetrical postures can result in short-
■ Aesthetically to enhance dignity and self-esteem and ening or tightening of muscle groups, which can lead to a
quality of life decreased range of motion in joints, increased tone,
■ To increase comfort for increased social interaction muscle contractures, and skeletal deformity. Asymmetri-
and participation in community activities cal posture must be corrected in a resting seated position

Table 26-1
Typical Patterns of Adult Hemiplegia
BODY PART COMMON POSTURE

Head Flexion toward hemiplegic side, neck rotation toward unaffected side
Upper extremity (flexion pattern) Scapula retraction, shoulder girdle depression, humeral adduction and internal rotation
Elbow flexion, forearm primarily in pronation; occasionally supination dominates
Wrist flexion and ulnar deviation
Thumb and finger flexion and adduction
Trunk Trunk rotation backward on hemiplegic side with lateral trunk flexion
Pelvis Posterior tilt with obliquity (lower on unaffected side)
Lower extremity Hip extension, adduction, and internal rotation
Knee extension
Foot plantar flexion and inversion
Toe flexion and adduction
 Chapter 26 • Seating and Wheeled Mobility Prescription 675

to minimize an individual’s risk for development of a fixed and reflexes to support the body upright against gravity.
deformity. If soft tissue and skeletal flexibility is preserved, The increased energy level associated with a more sym-
an individual can be encouraged successfully to sit with metrical posture increases sitting tolerance and an individ-
improved spinal-pelvic alignment through seating and ual’s ability to participate in functional activities within the
seating system accessories. This positioning serves as a home and the community.
guide that eventually can promote the development of
more balanced muscle control in that desired position. If Functional Positioning: An Active Seating System.
muscle control cannot be improved, good positioning Although the primary focus for seating intervention thus
provides adequate support. far has been on symmetry and alignment, a therapist must
remember that functional movement is asymmetrical and
Enhance Comfort and Appearance. With optimal pos- dynamic. As a result, it is essential to consider seating
tural support in the seated position, individuals feel and systems that allow for function and activity performance
look better. However, the process is not always a one-time and yet provide individuals with as much postural support
event; seating system modifications can be introduced as necessary to minimize their risk for increased defor-
gradually to facilitate neuromuscular reeducation. Once mity. It is important to remember that “body control is
an individual can tolerate increased postural alignment, interpreted and performed when the body understands its
the benefits are tenfold. Individuals who feel comfortable relationship to gravity, primarily through activation of the
and feel good about themselves are much more produc- vestibular system.”8
tive and functional. This can lead to increased social The pelvis is the foundation for seated posture. With
interaction, communication, and an improved quality this in mind, it is important to consider Kangas’ perspec-
of life. tive on pelvic stability. Kangas8 stated, “pelvic stability is
not simply a musculoskeletal posture but rather is a move-
Minimize Development of Pressure Ulcers. When im- ment of the body that includes an ongoing interaction of
paired sensation, motor control, or judgment affect an numerous systems, including the musculoskeletal, neuro-
individual’s ability to shift body weight, the client is usu- muscular, circulatory, respiratory, gastrointestinal, and en-
ally at risk for developing pressure ulcers. Essential as- docrinological systems.” Pelvic stability is “not simply a
pects of seating are to focus on pressure-redistributing musculoskeletal posture.” It involves a position of actively
cushions to maximize seating surface pressure dissemina- holding still rather than being passively restricted. For in-
tion and to consider a method of pressure relief (power dividuals with a stroke, an active seating system generally
tilt or recline) that the client can operate independently or provides as much seating surface as possible, a slightly
a tilt-in space or recliner wheelchair in which a caregiver anterior tilted seat, mild contour for upper leg positioning,
can perform the pressure-relief technique. Performance and weight-bearing of the feet on the floor to enable the
of regular (i.e., every half hour) pressure relief technique individual to position them as he or she chooses. This base
is essential to minimize risk of pressure ulcers. of support can provide the body with sufficient pelvic sta-
bility, and this position of active weight-bearing allows an
Improve Function of the Autonomic Nervous System. Ab- individual to assume an active task performance position
normal posturing, muscle shortening, and the inability to for eating, writing a check, or working at a computer.8
shift weight can increase pressure on internal organs and An active seating system can be attained easily with
other structures. When an individual is leaning forward or minor adjustments to the wheelchair and seating system
to the side because of poor pelvic or spinal muscle control, that is set-up slightly higher on the continuum for in-
a strain on circulation, digestion, and cardiopulmonary creased safety and adequate support. This is beneficial for
function can result. Postural supports can facilitate opti- times when an individual is more active (i.e., meal prepa-
mal pelvic, spinal, and trunk alignment, which in turn can ration in the kitchen). A seat wedge can be placed under
provide improved physiological functioning of the auto- the cushion and the footrests and positioning straps re-
nomic nervous system. Sufficient head and neck support moved to allow an individual to achieve a more active
can decrease the potential for aspiration when swallowing position. As with all intervention recommendations, the
problems exist.2 therapist and client should evaluate this intervention to-
gether to ensure that it provides adequate stability for
Increase Sitting Tolerance and Energy Level. If an indi- maximum safety with functioning. The art with mobility
vidual is well-supported and can function from the wheel- and seating system prescription is to achieve a balance
chair, sitting tolerance increases along with the ability to between positioning for functional activity performance
participate in therapy programs and functional activities. and symmetrical postural alignment for more sedentary
Individuals who receive adequate postural support experi- activities (i.e., watching television) and to minimize an
ence less fatigue and pain than those who fix and stabilize individual’s risk for increased deformity and secondary
continually with a higher level of abnormal muscle activity complications.
676 Stroke Rehabilitation

MATCHING EQUIPMENT TO CLIENT Contoured seating options provide a range of contours

FUNCTION: SEATING SYSTEMS from mild to aggressive. This type of seating system pro-
vides an excellent surface area for support that can en-
Seating and positioning is a continuum that encompasses hance postural alignment and pressure relief. Individuals
all of the foregoing goals and principles. It is important with minimal neuromuscular or central nervous system
for clients to understand that the wheelchair is not uncom- insults can benefit from the gentle cues that the slight
fortable; usually the seating system is. The seating system is contours of this seating system provide. Individuals can
the primary unit that influences body posture because it is also achieve independent transfers with the mild contour
the direct interface between the client and the wheelchair options.
and provides the client with the foundation for adequate Individuals with moderate impairments benefit more
postural support to rest and function. The mobility base from moderately contoured seating systems. These indi-
is a frame that has some seating components such as foot- viduals are less likely to perform independent transfers,
rests and armrests; however, its primary focus is mobility and the increased contours can meet their more involved
indoors and outdoors. It is essential to have a seating sys- postural support and pressure distribution needs. An ad-
tem that provides sufficient postural support interfaced vantage to an off-the-shelf contoured seating system is
with a wheelchair frame set at the appropriate angles to that it can be modified as an individual’s needs change. It
facilitate optimal spinal-pelvic alignment. Without appro- is important to remember that more aggressive contoured
priate postural support, an individual may be able to move supports really hold and support an individual, which is
about the environment; however, the risk for further de- ideal for postural alignment but can make transfers more
formity and pain is a major concern. A good rule of thumb difficult.
for optimal positioning is to start with the pelvis and then
proceed to the trunk and extremities. This approach fol- Custom Seating Options
lows the “support proximal to distal philosophy” inherent Custom seat cushions and backs provide adapted support
in numerous treatment approaches for individuals with to meet an individual’s specific needs. Customized seating
neurological dysfunction. systems are essential to provide maximum support, ac-
The importance of seating, goals, and assessment of commodation, and comfort for individuals with moderate
biomechanics and posture were reviewed previously. This to severe deformities. The concerns with custom-molded
section describes the types of seating systems available and seating systems is the lack of flexibility for changing pos-
their various features. Three basic styles of seating exist: tural support needs, the high cost, and the amount of la-
linear, contoured, and custom contoured. Each of these bor to create a customized seating system. An experienced
provides different levels of support to promote postural therapist and assistive technology supplier is essential to
alignment and pressure distribution. The definition of achieve a successful end product with this level of seating
each with their respective benefits and concerns follows. system.
In addition to the primary support surface contours,
Linear Seating Systems the angles and degree of postural support from gravity are
Linear seating systems (Table 26-2) are flat, noncontoured major considerations. Two dynamic seating system op-
planes of support. Linear seat cushions or backs can be tions available are recline and tilt-in-space seating sys-
custom-made or ordered from the factory in various sizes, tems. Both of these systems can position a person poste-
densities, and with different fabric covers. rior from the upright, 90-degree sitting for postural
Linear seating provides a firm, rigid seating base that support from gravity. A recline seating system is one in
can be beneficial for active individuals. Individuals with which the back support can be shifted backward or for-
minimal musculoskeletal involvement typically benefit ward for varying levels of support and upright posture
the most from linear seating. This seating is generally a (Fig. 26-7). A tilt-in-space seating system is one in which
lower cost option, and because of the flat surface, inde- the whole seating system (cushion and back support) tilts
pendent transfers are easy to achieve. Linear seating sys- backward for increased postural support from gravity.
tems provide the least amount of postural support; how- Both of these systems can provide individuals with in-
ever, because the human body is contoured, lack of creased postural support and a method of pressure distri-
support can result in higher peak pressures and pressure bution through movement of the seating system. A re-
ulcers for individuals with prominent bony structures. cliner or a tilt-in-space wheelchair is often beneficial for
individuals who need moderate to maximal support for
Contoured Seating Options upright sitting. These seating system options are available
Contoured seating system options (see Table 26-2) are in both manual and power wheelchairs. With a manual
designed to support the body ergonomically. They are seating system, a caregiver is essential to perform the
generally available in predetermined shapes of varying movement. A power-operated seating system can provide
contours in a wide range of sizes. an individual in the wheelchair with the ability to shift
Text continued on p.683
Table 26-2
Seating Systems
SEATING COMPONENT INDICATIONS FOR USE POSTURAL AND FUNCTIONAL CONSIDERATIONS

Solid insert Insert can provide a level base of support on the sling wheelchair A sling wheelchair seat encourages a posterior pelvic tilt with
seat. Slide insert inside the cover, under the cushion, and secure hip adduction and internal rotation. This sets an individual
to cushion base with Velcro. The cushion cover usually has up for a “slumped” posture. A solid insert is necessary to pro-
Velcro to attach the cushion securely to sling upholstery of the vide a firm and level base of support on the sling wheelchair
wheelchair. seat. This facilitates more neutral pelvic positioning for up-
right posture and upper body movement for functional
activities.
1.5–inch seat wedge Wedge slides inside the cushion cover, under the cushion. Wedge Wedge is a lightweight, easy to remove component to use for
can provide an anterior or posterior seat tilt. an anterior-sloped seat or a posterior-sloped seat. An anterior
tilt would facilitate upright positioning for an individual who
is working at a workstation or propelling with one arm and
one foot. A posterior tilt can assist with decreasing extensor
spasticity or creating a set, slight tilt for increased postural

Chapter 26 • Seating and Wheeled Mobility Prescription

support in a standard wheelchair.
Solid seat Remove wheelchair upholstery to install. To mount, solid seat Seat also encourages neutral pelvic alignment and lower ex-
hooks lock down on seat rails of wheelchair. The adjustable tremity alignment. One concern is that it adds a significant
hooks on the solid seat can be positioned to provide an anterior amount of weight to the wheelchair. Unless necessary to
or posterior tilt of solid seat and subsequently the cushion on achieve a low seat-to-floor height that cannot be achieved
the wheelchair frame. with a super low wheelchair, the weight disadvantage
outweighs the positioning advantages.
Foam cushion Foam linear cushions provide a stable base of support for individ- Cushions can enhance sitting posture, pressure distribution,
uals with mild postural support needs. The foam comes in vary- and increase comfort.
ing densities and can be layered in different densities to provide
support, comfort, and some pressure relief.

Contoured foam cushion Contoured foam cushion provides an increased surface area of The combination of stability and pressure relief is a major
support and pressure relief for individuals with mild to moderate advantage to this cushion. The weight is a consideration;
support and pressure distribution needs. A variety of foam densi- however, the advantage of a stable and pressure-distributing
ties are available. base of support minimizes the need for external supports.

Continued

677
 678
Stroke Rehabilitation
Table 26-2
Seating Systems—cont’d
SEATING COMPONENT INDICATIONS FOR USE POSTURAL AND FUNCTIONAL CONSIDERATIONS

“Pressure-relieving” cushion A firm, contoured cushion base with pressure-distributing gel These off-the-shelf cushions provide a superior level of pres-
(fluid medium) fluid pad on top provides stability and a high level of pressure sure distribution and good pelvic stability. This stability is
relief appropriate for all individuals who need moderate to sig- important for improved balance and for adequate support. It
nificant postural support and pressure distribution. The gel can improve function at a wheelchair level and minimize
bladder allows the pelvis to sink into it for full contact support compensatory posturing.
for adequate pressure distribution to minimize the risk of pres-
sure sores.

“Pressure-relieving” cushion The air medium allows the seated individual to sink into this The pressure distribution and lightweight qualities of this
(air medium) cushion for contoured support and a high degree of pressure cushion are unsurpassed. However, this cushion does not
distribution to minimize the risk of pressure ulcers. provide any stability, and additional postural supports such as
hip guides and adductors are essential for optimal alignment.
These supports increase weight of the whole wheelchair
system. Another concern is the continual air maintenance
required with this cushion.

Lumbar-sacral back support This component can provide support to the lumbar-sacral region This support is a low-cost method to provide minimal postural
to support the pelvis in neutral pelvic alignment. A more secure support for increased spinal-pelvic alignment. The support is
attachment method is recommended to keep it in position. easy to remove, which is an advantage for car transport but a
disadvantage because the support is not stable and can shift
out of place easily.

Solid back support The solid back insert provides firm support to facilitate improved This support is a low-cost method to provide minimal postural
postural alignment for individuals with good pelvic and trunk support for increased spinal-pelvic alignment. The support is
control. The support is easy to remove for transportability of the easy to remove, which is an advantage for car transport but a
wheelchair and usually is attached to the wheelchair back canes disadvantage because the support is not stable and can shift
with Velcro straps. out of place easily.
Pita back This solid back insert provides a firm support to facilitate im- This simple, low-cost back support can provide minimal pos-
proved postural alignment for individuals with good pelvic and tural support for increased spinal-pelvic alignment. The lack
trunk control. The support is easy to remove for transportability of foam makes the support easy to use; however, lack of suffi-
of the wheelchair and slides into and out of a pocket in the back cient padding is a concern for individuals using the wheel-
support upholstery. chair as a primary means of mobility.

Linear back support This solid back insert provides a more durable back support for This is a planar back support to enhance upright sitting. The
increased spinal-pelvic alignment. It is beneficial for individuals adjustable mounting brackets makes it possible to open up
with good postural control, is attached to the wheelchair frame seat-to-back angle to accommodate a hip range of motion
with quick-release hardware, and usually is linear with a solid limitation or for increased postural support and balance via
posterior base with foam in front. The support may be covered gravity. This hardware is durable. One concern is the weight
in vinyl or other materials. added to the wheelchair.

Adjustable-angle This back support can be attached to the wheelchair with quick- This back support provides mild contour to facilitate neutral
off-the-shelf back support release hardware. The support has generic, gentle contours that trunk posturing and increased spinal-pelvic alignment. The
provide a guide for increased postural alignment for individuals angle can be adjusted to open up seat-to-back angle to ac-
with mild to moderate positioning needs and can be used in its commodate a hip range of motion limitation or for increased
original configuration or can accommodate a contoured foam postural support and balance via gravity. This support is a

Chapter 26 • Seating and Wheeled Mobility Prescription

in-place back support. lightweight option that provides good support. One concern
is that more durable hardware may be necessary for individu-
als with significant spasticity.

Adjustable-angle custom This rigid back support can be attached to the wheelchair with This back support can provide moderate to significant support
back support quick-release or stationary hardware. The support often is posi- for individuals with flexible and fixed deformities. The hard-
tioned at an angle with a custom-contoured amount of support. ware can open up the seat-to-back angle for the foregoing
The shell can be reused if the foam insert needs to be modified. reasons. The contoured support provides maximum surface
This support benefits individuals with moderate to significant area contact to maximize alignment, accommodate deformi-
trunk weaknesses and/or flexible or fixed postural deformities. ties, and maximize pressure distribution to minimize the risk
for increased deformities and pressure sores.
Pelvic positioning belt Pelvic belts are designed to maintain optimal pelvic alignment and This support can be positioned at various angles depending on
minimize an individual’s risk for sliding out of the wheelchair. the individual’s needs and functional level. A pelvic belt at the
They are mounted to the seat frame via screws or straps and are traditional 45 degrees can limit pelvic mobility for an ante-
available with various angles of pull and various buckles such as rior weight shift for forward reach and functioning at a table.
auto and airline style. Padded belts are available to minimize pressure concerns,
and various buckles are available for maximum independence
with opening/closing.

Continued

679
 680
Table 26-2

Stroke Rehabilitation
Seating Systems—cont’d
SEATING COMPONENT INDICATIONS FOR USE POSTURAL AND FUNCTIONAL CONSIDERATIONS

Leg adductors A leg adductor can be attached to the wheelchair cushion base, Adductors can facilitate increased lower extremity alignment to
under the seat, or on the footrest hanger and is designed to max- minimize an individual’s risk of increased deformity and pain.
imize lower extremity alignment and prevent the legs from roll- The height of the adductor can limit side-to-side transfers; a
ing into abduction or external hip rotation. This is an example removable one can provide adequate support and increased
of an adductor added to the front of the cushion. safety with side transfers.

Hip guides Hip guides provide support to maximize pelvic alignment, can be In addition to the lateral supports, hip guides can provide a
contoured or linear, and usually are made of different density third point of control for individuals with fixed or flexible
foams with a solid back. Hip guides can be mounted onto the spinal curves or individuals who have a pelvic obliquity.
wheelchair armrests, seat pan, or back canes. The hardware can Removable hardware is often necessary for individuals who
be fixed or removable. This is an example of hip guides that are perform side-to-side transfers.
attached to the rear of the cushion.

Medial knee block (pommel) Medial knee blocks or pommels can maximize lower extremity Medial knee blocks are often necessary for individuals with se-
with flip-down hardware alignment. They are designed to minimize leg adduction and in- vere adductor spasticity. They are most successful when used
ternal hip rotation. For optimal support the medial knee blocks with the other postural supports to maximize overall postural
are custom-made in a variety of shapes and sizes. This contour is alignment. They can promote increased lower extremity
essential for adequate contour and fit for increased pelvic and alignment. Small medial knee blocks are helpful as a guide
lower extremity alignment. The knee blocks and pommels typi- for more neutral lower extremity posturing.
cally are constructed of a variety of foams with a solid inner
component and are attached to the wheelchair with various types
of hardware.
Pelvic obliquity build-up This component is usually mounted under the gel pad or created Foam or gel inserts are helpful for individuals with asymmetri-
with foam; it can be a gel or foam medium and can provide in- cal muscle strength. They can compensate for the decreased
creased support under the lower ischium to “correct” a defor- muscle bulk to facilitate a more level pelvic position. When
mity, under the weaker side to accommodate for muscle atrophy, used with hip guides, inserts can support optimal pelvic
or under the higher ischium to accommodate a deformity. alignment in individuals who have a flexible pelvis. One con-
This component may be used with hip guides to minimize lateral cern is the amount of pressure the inserts place on the ipsi-
tilting of the pelvis for increased spinal-pelvic alignment. lateral ischial tuberosity.17 Monitoring of pressure with this
treatment approach is important.
If a pelvic obliquity is fixed, positioning an insert under the
higher side is necessary. This will accommodate and support
the fixed pelvic obliquity, increase pressure distribution, and
minimize the risk of increased deformity.
Lateral trunk supports, These supports usually are mounted off the back support or back Individuals who have decreased trunk support often hold
straight and curved canes and are available in various sizes in planar or contoured themselves upright with their upper extremities. Lateral
levels of support. They are beneficial for individuals with trunk supports can provide increased trunk support to these indi-
weakness or a tendency to lean to one side. Another point of viduals so that they can use their extremities for bilateral
control, usually via hip guides, is necessary for adequate trunk upper extremity tasks. Lateral supports also can provide the
support to correct a flexible deformity or accommodate a fixed upper two points of control to correct or accommodate a
deformity. lateral spinal curve for increased midline positioning of the
The hardware to mount to the wheelchair can be stationary or torso in the wheelchair. The swing-away hardware is helpful
quick release. to position the lateral support out of the way for transfers,
dressing, and initial positioning in the wheelchair. Lateral
support hardware that aggressively contours to the back
support contour is necessary to keep the hardware profile
minimal to allow for adequate upper extremity mobility.
Curved lateral support pads provide improved contour and
support over planar lateral support pads.

Harness/anterior chest Anterior chest supports are mounted to the wheelchair via four This component can provide anterior trunk support to allow
support points of attachment, usually to each side of the back support an individual with poor trunk control to be more upright
and the seat rails. They are available in a variety of styles and are against gravity. This is helpful for more dynamic, engaging
beneficial for individuals with severe trunk weakness. These sup- activities (i.e., working at a desk). Therapists should consider

Chapter 26 • Seating and Wheeled Mobility Prescription

ports often are used with a tilt or recline seating system to maxi- this component after evaluating a recline or tilt-in-space seat-
mize postural support when an individual is more upright ing system for increased postural support in a more seden-
against gravity. tary, posterior position. The component can be helpful for
maximum trunk support for increased safety and stability
when negotiating varying terrain (i.e., ramps and door
saddles).

Head/neck support Head/neck supports can be mounted to the back support via This component is necessary for individuals with fair head
quick-release or flip down hardware. A headrest and/or neck control and for head and neck support when an individual
support is essential to provide adequate head support for indi- tilts back for pressure relief or improved postural support.
viduals with poor head or neck control. Additional pads and head bands are available for individuals
The quick release and flip down hardware is necessary to maneu- with significant head positioning needs. The head and neck
ver the headrest out of the way for positioning the client in the supports should be adjusted to support the head in as neutral
wheelchair, hair washing, etc. alignment as possible for optimal functioning (i.e., respira-
tion and feeding) and speech.

Continued

681
 682
Stroke Rehabilitation
Table 26-2
Seating Systems—cont’d
SEATING COMPONENT INDICATIONS FOR USE POSTURAL AND FUNCTIONAL CONSIDERATIONS

Wheel lock extension Wheel lock extensions can be mounted over the existing wheel Extensions are important for maximum independence and to
lock handle. They are available in various sizes. Wheel lock stabilize the wheelchair for functioning and safety with trans-
extensions provide a longer lever arm to make it possible to fers to and from the wheelchair.
access and lock/unlock the wheel locks if an individual cannot For individuals with stroke, a wheel lock extension on the
negotiate the standard wheel lock. wheel on the client’s weaker side is often very helpful for
independent use with either the weaker or the stronger upper
extremity.

Upper extremity support, Lap trays can be mounted over the armpad with “slide” hardware Adequate upper extremity support is essential to minimize an
full and half lap trays with an additional strap for stability, if necessary. They come in individual’s risk for increased shoulder pain and deformity.
full or half tray models in various sizes. They can provide A lap tray can provide a work surface for functional activities
individuals with a support surface for their paretic upper such as writing and feeding. The clear version can also pro-
extremity. vide an individual with a clear view of the feet for maximum
safety with wheelchair propulsion. Upper extremity edema is
often present in individuals who are unable to move their up-
per extremity functionally. A lap tray can facilitate increased
awareness of this extremity for edema management, weight-
bearing, and positioning to minimize upper extremity edema.
Arm trough An arm trough can be mounted on the standard armrest in place An arm trough provides optimal support for individuals with
of the armpad. The trough can provide more aggressive support absent to poor upper extremity control. Support is important
for adequate upper extremity joint protection. to minimize the risk for pain, subluxation, and edema. An
Full length armrests are often necessary to provide sufficient arm trough can provide an individual with a surface for upper
stability for an arm trough. extremity weight-bearing for functional reaching activities or
for repositioning his/her body in the wheelchair.
 Chapter 26 • Seating and Wheeled Mobility Prescription 683

to provide a firm and level base of support for the

pelvis on the sling wheelchair seat. This is essential
for all individuals at various stages of the rehabilita-
tion process. Initially, the support can facilitate car-
ryover of rehabilitation restoration goals and later
can provide a seating surface for upright functioning
at a wheelchair level.
■ Lower extremity positioning: The affected side is
typically postured in a position of hip adduction and
Recline Tilt in space internal rotation.2 This posture can be decreased
Figure 26-7 Recline versus tilt options. significantly with a mild contoured cushion and a
solid insert. For individuals with more significant
spasticity and lower extremity adduction, postural
position independently for pressure distribution, increase support via gravity through tilt, a padded pelvic belt,
postural support due to fatigue, decrease postural support hip guides, and a medial knee support should be
for more upright seated functioning (i.e., feeding), or considered. For individuals with severe adduction
meet varying environmental demands (i.e., increased re- and internal rotation, medial knee blocks are neces-
cline for improved support when descending a ramp). sary to minimize the risk for hip dislocation.
The concept of reclining the back of the seating ■ Trunk: The affected hemiplegic side typically pos-
system or slightly tilting the seating system can be per- tures with lateral trunk flexion.5 The lateral trunk
formed in 5- to 15-degree ranges in a standard wheel- flexion is often a consequence of decreased pelvic
chair through add-on back supports and/or seat wedges. alignment. Optimal pelvic positioning with a good
This is often necessary to accommodate hip range cushion and sacral support with a mild contoured
limitations or provide an individual with improved pos- back support can significantly decrease or fully
tural support and balance to function upright against correct the lateral trunk flexion. For individuals
gravity. One consideration is that this is a fixed, station- with severe weakness, hip guides and a build-up in
ary position in a standard wheelchair. The stability of a the cushion can compensate for asymmetrical mus-
recliner or tilt-in-space wheelchair that is specifically cle loss and provide optimal pelvic alignment. In
designed for tilt or recline is essential for this position addition, lateral trunk supports can be added as
to be a dynamic seating function. needed to support the body in alignment. Three
Table 26-2 describes a variety of seating system prod- points of control are essential for optimal trunk
ucts and secondary support products for seating systems support. Fig. 26-8 shows placement of these sup-
and depicts the seating component, its indications for use, ports. It is important to remember that a fixed
considerations for use, and the functional benefit.

FITTING THE PERSON BASED

ON FUNCTIONAL STATUS
The following list addresses body structures and the seat-
ing components that can be used for individuals with
hemiplegia and flexible deformities. This list encompasses
individuals who have a wide range of functional abilities.
One concept that is present throughout neurological re-
habilitation and seating and positioning is to always pro-
vide proximal support first and then support distally. An
example of this concept with an upper extremity support
is to provide sufficient trunk support first, before support-
ing the upper extremity on a half-lap tray. This is essential
to minimize the risk of injury to the shoulder girdle.
■ Pelvic positioning: Wheelchair upholstery stretches
over time; consequently, the sling facilitates poor
postural alignment with a posterior pelvic tilt, a pel-
vic obliquity, and lower extremity adduction and in- Three points of pressure
ternal rotation. A cushion with a solid base of sup- Figure 26-8 Three points of support for a lateral spinal
port (such as a wood insert) is highly recommended curve.
684 Stroke Rehabilitation

deformity is supported to minimize the risk of in- MOBILITY BASE CONSIDERATIONS

creased deformity. A flexible deformity can be
“corrected”; however; the therapist should moni- The primary goals are to increase safety and indepen-
tor an individual’s tolerance of this correction. dence with mobility and to provide an efficient method of
■ Upper extremity: If a client has mild limitations, ac- mobility. The primary goal of the mobility base at the
tive use is encouraged. If an individual has significant ICF6 activities and participation level is to maximize an
weakness, the affected upper extremity requires ad- individual’s ability to function and interact with the envi-
equate scapula and glenohumeral support and thus ronment. An example of this would be the ability to access
stability from a lap tray or arm trough to minimize a closet for clothing to dress.
the risk for increased pain and subluxation. Appro-
priate positioning is essential to facilitate optimal Unilateral Neglect
upper extremity alignment and motor return, and to Depending on the stroke, some clients present with uni-
maximize function. For a paretic upper extremity, lateral neglect at the body structures and function level.
optimal upper extremity alignment is with the shoul- This leads to significant challenges with activities and
der in 5 degrees of abduction and flexion with neu- participation. Several studies investigated unilateral ne-
tral rotation, the elbow in 90 degrees of flexion and glect and mobility including wheelchair mobility. Qiang
positioned slightly forward of the shoulder joint, the and colleagues15 used a wheelchair collision test to assess
forearm in a neutral or pronated position, and the behavioral unilateral neglect. Their investigation found
hand in a functional resting position. Functional high test-retest reliability with this as a simple screening
hand splints are often integrated into the seating test for unilateral neglect.
system for optimal wrist and hand support with the In addition to the test, several studies investigated
forearm supported on a lap tray. More aggressive the effect of unilateral neglect on mobility. Turton and
supports and straps may be used for individuals with colleagues18 found that differences in environmental
more severe spasticity. navigation were dependant on their mobility product
■ Head/neck: Typically, if an individual is seated with a use. They found that subjects with left side neglect
stable base of support at the pelvis and lower extrem- tended to drift to the left with wheelchair use. However,
ities and has adequate trunk control or support, the two of the same clients consistently drifted to the op-
asymmetrical neck posture decreases or disappears. posite side, the right side, when they ambulated. Punt
For individuals with moderate to severe involvement and colleagues14 found that differences in subject’s mo-
who require hip guides and lateral supports, a head- bility tendencies with drifting to the ipsilesional versus
rest can be placed on the chair to ensure proper sup- contralesional side were dependant on the environment.
port of the cervical spine and head. After stroke, head In open spaces, the clients with neglect tended to drift
support is generally recommended for clients with toward the ipsilesional side, and in tighter spaces. cli-
head/neck weakness, reflex activity, and/or to opti- ents with neglect tended to drift toward the contrale-
mize head positioning to address visual field neglect sional side. Both of these studies14,18 have implications
or other visual-perceptual challenges. in training individuals with neglect for safe mobility us-
■ Feet: Foot support typically is determined by the ing both manual and power wheelchairs. See Chapters
person’s functional level. Most individuals with 18 and 19.
hemiplegia who propel wheelchairs have the best
success with propulsion using the unaffected arm Manual Wheelchair Frame Styles
and leg. Consequently, the top of the cushion to Two basic types of manual wheelchair frame styles are
floor (seat-to-floor height) is a crucial measurement. available: rigid and folding. Rigid wheelchairs tend to be
The seat-to-floor height must allow the person’s lighter weight and more maneuverable than their folding
heel to access the ground for a successful heel strike counterparts. This is because of fewer moving parts and a
to propel the wheelchair effectively. It is also impor- shorter base length resulting from the integrated footrest
tant to consider the depth of the seat cushion. This design. Folding wheelchairs are designed with a cross
should be slightly shorter than a client’s seat depth brace that allows the chair to fold in half for transport and
or have an undercut/beveled base of the cushion for storage. The wheelchair style commonly recommended
adequate freedom of movement. A leg rest or foot- for individuals with stroke is the folding style, which is
rest should support the affected lower extremity. In because the style is traditional and most familiar to medi-
general, individuals with stroke do not benefit from cal professionals, can be folded up to store in the corner,
elevating leg rests. Elevating leg rests tend to cause fits into certain reimbursement codes, and is recognized
overstretching of the hamstring muscles and facili- easily by the general public.
tate posturing with a posterior pelvic tilt when An individual’s medical condition, functional status,
muscle imbalance or spasticity is present. seating system support needs, home environment,
 Chapter 26 • Seating and Wheeled Mobility Prescription 685

method of community mobility, and funding source are

Push handle
important variables that influence the style of wheel- Full-length
chair frame recommended. Wheelchair frames are arm rest
made of different materials to meet various chair weight
requirements. The weight of the wheelchair is impor-
tant if the person’s strength, endurance, and propulsion Sling-type Desk length
seat armrest
abilities are in question. A basic wheelchair is con-
structed of aluminum, is relatively heavy, and is appro-
priate for persons who are not active and do not use a
wheelchair as their primary means of mobility. These Caster
wheelchairs are durable enough for light everyday use
and are reasonably priced. Ultra-lightweight wheel-
chair frames typically are constructed with aircraft Standard
swing-away
aluminum or titanium and are durable but more costly footrest Heel
than standard wheelchairs. In general, these wheel- loop Wheel axle
chairs are not typically recommended for individuals plate
with stroke, even for individuals who will use a wheel- Figure 26-9 Basic style of wheelchair frame.
chair for their primary means of mobility. There are
many thoughts on why this better quality wheelchair is
not recommended, which include the wheelchair code
that the principal funding source Medicare has for this
level wheelchair and the documentation necessary for Standard
this level of wheelchair. height
Because of the increased incidence of repetitive stress Hemiheight
injuries in individuals who use wheelchairs as their pri- Superlow
mary method of mobility, a strong case can be made for
justification of an ultra-lightweight wheelchair for indi- 191⁄2
viduals who have sustained a stroke. For individuals with 171⁄2
141⁄2
hemiplegia, trunk weakness and use of one upper extrem-
ity for all mobility, transfers, and ADL performance is of
great concern. A study by Cowan and colleagues4 focused
on novice older adults and found that a more anterior Figure 26-10 Wheelchair seat-to-floor height differences.
axle position decreased the forces necessary to propel the
wheelchair, especially on everyday surfaces such as car-
pets and ramps. This author feels these results support Wheelchair Frame Seat-to-Floor Height
the use of an ultra-lightweight wheelchair for mobility. Three common seat-to-floor heights are these (Fig. 26-10):
Ultra-lightweight wheelchairs typically have an adjust- ■ Standard: 19.5 inches from seat to floor
able axle that can be adjusted lower for increased trunk ■ Hemi height: 17.5 inches from seat to floor
balance and slightly forward for a different center of ■ Super low: 14.5 inches from seat to floor
gravity and an optimal hand-to-wheel relationship. This The seat-to-floor height is the height from the floor to
adjustment can decrease the mechanical forces required the sling seat of the wheelchair. It is important to remem-
for wheelchair propulsion and is essential for energy ber that the height of the cushion chosen also influences
conservation and adequate joint protection of the upper the seat-to-floor height. The wheelchair frame height
extremity. For the same reasons, power mobility can be decision is based on the individual’s lower extremity knee-
considered as a viable option to preserve upper extremity to-heel measurement and what type of wheelchair propul-
function and maximize overall functioning and commu- sion the client uses.
nity mobility for individuals who have sustained a If an individual pushes the wheelchair with both arms
stroke. or is not independently propelling the wheelchair, the
Fig. 26-9 shows the basic wheelchair frame style. Con- footrest clearance is a major concern. After the client is
sideration of frame style, wheelchair accessories, and the positioned with good femoral support on the wheelchair
seating system is crucial to ensure adequate postural sup- cushion, approximately 3 inches of clearance should be
port and maximum function at a wheelchair level. between the footplate and the ground. This is essential
The following are wheelchair and wheelchair frame so that the client can negotiate ramps and uneven
features that are important to consider when recommend- surfaces without scraping the footplates on the ground.
ing a folding manual wheelchair. This seat-to-floor height is often compromised to
686 Stroke Rehabilitation

2 inches of clearance to allow for improved table and is the traction of the tire that results in increased
desk access. stability of the wheelchair for safe transfers. Unfor-
If an individual is negotiating the wheelchair with one tunately, the flat-free inserts decrease the shock ab-
arm and one foot, then the seat-to-floor height is crucial sorption potential and add weight to the tire.
for comfort of the hemiparetic lower extremity on the ■ Polyurethane tires are the least expensive and are
foot rest and adequate heel access for propulsion of the durable; however, they are heavier than pneumatic
wheelchair with one or both lower extremities.3 The indi- tires, provide no shock absorption, and handle vary-
vidual’s knee-to-heel measurement (taken with shoe on) is ing terrain poorly. In addition, the smoothness of
generally the exact measurement from the top of the the tire does not provide any traction of the wheel-
wheelchair cushion to the floor. The wheelchair should chair wheel on smooth flooring. Often these tires are
not be too high because the client will slide into a poste- the reason wheelchairs slide when persons transfer
rior pelvic tilt to obtain improved heel contact for effi- to and from them.
cient mobility.3
Wheel Handrims and One-Arm Drive Wheelchairs.
Wheel Style. Several styles of inner wheel support struc- Handrims are the circumferential rim on the outside of
ture are available. For the purpose of this chapter, discus- the tire to allow stroking and propulsion of the wheel.
sion is limited to mag wheels and spoke wheels. Wheel Hand rims are available in aluminum, plastic-coated, or
style is chosen based on an individual’s ability to care for projection styles. One-arm drive wheelchairs have two
and maintain the wheelchair. hand rims on one wheel only (Fig. 26-11).
The team should consider the following: The team should consider the following options:
■ The advantage of mag wheels is that they do not ■ Aluminum or composite hand rims are standard on
require maintenance. However, they do not have as most wheelchairs. Aluminum hand rims can become
much shock absorption as spoke wheels and can be slippery or cold in different weather conditions. As a
slightly heavier. result, most active wheelchair users wear specific
■ Spoke wheels are lighter than mag wheels; how- gloves to compensate for this.
ever, they require periodic tightening of the indi- ■ Plastic-coated hand rims are beneficial for individu-
vidual spokes. A local bicycle shop can perform this als with decreased grasp. The plastic coating pro-
adjustment. vides traction against an individual’s hand or a Dy-
cem glove. The one disadvantage is that individuals
Rear Wheel Size. Wheelchair wheels are measured from cannot let the rim run through their hands as they
the ground to the top of the wheel. They are available in descend hills and ramps because the friction will
12-, 20-, 22-, 24-, 25-, and 26-inch diameters. For indi- burn the skin on their hands.
viduals with stroke, the seat-to-floor height needs of the ■ Projection handrims are occasionally used for indi-
individual primarily determines the size of the rear wheel. viduals with decreased grasp. The disadvantages are
The team should consider the following: that they can increase the overall width of the wheel-
■ The standard wheel size is 24 inches. chair if they are not vertical and the propulsion
■ If an individual requires a super low wheelchair method is more labor intensive because one has to
height to fit a petite frame and/or for foot propul- look continually at the handrim to hit the projection.
sion, the size of the rear wheel can be 20 inches.

Tire Style. Numerous tire options are available; however,

for simplicity this section focuses on the types of tires
available for standard, folding wheelchairs: pneumatic,
pneumatic with flat-free inserts, and polyurethane.
The team should consider the following options: Left wheel rim
■ Pneumatic tires provide a smoother ride because of Right wheel rim
good shock absorption ability. The traction of the tires
provides good wheelchair stabilization for safety with
transfers, and the tires handle varying terrain better
than the other two options. The disadvantages are
maintenance of air pressure and the risk of a flat tire.
■ Pneumatic tires with flat-free inserts are pneumatic
tires with an insert to replace the air. This elimi-
nates the need for air pressure maintenance and the Figure 26-11 One-arm drive wheelchairs have two hand rims
possibility of flats. The benefit of this combination on one wheel only.
 Chapter 26 • Seating and Wheeled Mobility Prescription 687

One-arm drive wheelchairs have right- and left-hand rims (3, 4, 5, 6, and 8 inches) and two thicknesses (1 and
on the same side. This wheelchair was designed for indi- 1.5 inches).
viduals with only one functional upper extremity (see Fig. The team should consider the following:
26-11). The double hand rim allows one upper extremity ■ Large casters handle uneven terrain and door saddles
to control the wheelchair in all directions. Use of these well; however, they increase the turning radius of the
wheelchairs takes much strength and a high degree of wheelchair and provide higher rolling resistance to
coordination to move straight. In addition, this propul- the user.
sion method has a longer learning curve because the con- ■ Small casters are typical in super low and ultra-
cept is difficult to master. Mandy and colleagues11 docu- lightweight, rigid wheelchairs. They provide the
mented the inefficiency of mobility using a one-arm drive client with a lower front seat-to-floor height and
wheelchair and investigated an ankle controlled prototype improved maneuverability in small areas. The disad-
product to increased efficiency with manual wheelchair vantage of small casters is that they become stuck in
use. This product demonstrated promising potential for cracks and bumps on sidewalks and streets.
increased efficiency with mobility in a manual wheelchair. ■ Narrow-width casters handle smooth surfaces well
However, it is still in the prototype phase and not readily but can become stuck easily in uneven terrain.
available for purchase at this time. Unfortunately, unilat- ■ The 1.5-inch width is available on the 5- and 6-inch
eral hand-foot propulsion or a one-arm drive propulsion diameter casters. This option balances maneuver-
style are the only options available for individuals with ability and performance over uneven surfaces; the
hemiplegia at this time. Asking an individual to use his or smaller diameter provides improved maneuverability
her one functional upper extremity for wheelchair propul- in tight areas and the increased width facilitates tran-
sion is an excessive request if one considers that the client sitioning over different surfaces such as door saddles
also uses this one extremity for all other ADL. The study and prevents the casters from getting stuck in side-
by Barker colleagues1 study supports this and found the walk cracks.
effort to mobilize a manual wheelchair was a contextual
barrier for activities and participation. This study sup- Elevating Leg Rests and Footrests. Elevating leg rests
ports the concept that a power wheelchair should be can raise or lower the lower extremities if an individual
strongly considered for independent mobility along with requires this because of a medical condition (Fig. 26-12).
adequate upper extremity joint protection and energy Footrests have a fixed knee angle and support the lower
conservation. The increased community participation extremity in sitting.
with power mobility is supported in studies performed by The team should consider the following:
Barker and colleagues1 and Pettersson and colleagues.13 ■ Elevating leg rests typically are recommended for
individuals with limited knee angles (because of ar-
Wheel Axle Positioning. Standard wheelchairs allow min- thritis or other orthopedic diagnosis), poor circula-
imal or no axle adjustment. If a standard wheelchair allows tion in the lower extremities, or edema. These leg
for axle positioning, it only allows the wheel to go up and rests typically are overprescribed and should be con-
down in proportion to the front caster to create a hemi- or sidered carefully. An elevating leg rest usually pro-
standard-height wheelchair. On ultra-lightweight wheel- trudes out farther than a footrest. This increases the
chairs, an adjustable wheel axle plate allows for wheel po- overall length of the wheelchair and compromises
sitioning up and down and back and forth.
An adjustable axle position allows the chair to be fine-
tuned by adjustment of the wheel to the best position for
propulsion. This is essential for optimal wheel set-up for
an energy-efficient propulsion stroke4 and for minimizing
an individual’s risk for upper extremity repetitive strain
injuries. As the wheel is shifted slightly into a forward
position, wheel access is improved and propulsion is easier
for an individual. This adjustment should be performed Calf rest
with caution as it affects the balance of the wheelchair.
One concern is for individuals who have had a lower ex-
tremity amputation (because of a compounding diagnosis
such as diabetes); the axle is better placed in a rear posi- Elevating
tion to stabilize the wheelchair adequately. leg rest

Casters. Casters are the front wheels of the wheelchair Figure 26-12 Elevating leg rests raise or lower the lower
(see Fig. 26-9). They are available in several diameters extremities.
688 Stroke Rehabilitation

maneuverability. If an individual does not have ade- Armrests. Depending on the level of wheelchair, arm-
quate hamstring muscle elongation to tolerate this rests (see Fig. 26-9) are available in different styles:
large knee angle change, he or she will sit with a (1) fixed or removable with different height options: fixed
posterior pelvic tilt to compensate for the lack of and adjustable height, and (2) with two different length
muscle flexibility (Fig. 26-13).9 options: full and desk length.
■ The circulation benefits of these leg rests are ques- The team should consider the following:
tionable, since they do not raise the lower extremity ■ Fixed armrests are welded to the frame and set at a
above the heart in a standard wheelchair. standard height; they cannot be adjusted. This is
■ A major disadvantage to elevating leg rests is the sig- good for an individual who stands from the wheel-
nificant amount of weight they add to the wheelchair. chair; however, this design does not work for an in-
■ Footrests are available in different knee angles, typi- dividual who needs to transfer sideways to and from
cally 60, 70, and 75 degrees. The angle recommended the wheelchair.
should be based on the individual’s knee range and ■ Removable armrests can be positioned out of the
hamstring range from the mat evaluation. Proper way to allow an individual to transfer sideways into
adjustment of the footrest length is important to en- and out of the wheelchair. The armrests also can be
sure lower extremity stability and support in sitting. removed from the wheelchair frame for more com-
Swing-away removable footrests enable the footrests pact storage locations such as the trunk of a car.
to be shifted out of the way for increased safety with ■ Adjustable-height armrests allow for height adjust-
transfers and improved table accessibility. ment to provide sufficient glenohumeral support.
■ A 70-degree angle is usually a standard option and This is important for individuals with hemiparesis
provides a shorter turning radius than a wheelchair and shoulder subluxation.
with the 60-degree angle footrest. ■ Full-length arms provide full arm support at rest and
upper extremity support during sit to stand and
Footplates. Footplates are available in different materials stand-pivot transfers.
such as composite and aluminum and are available in dif- ■ Desk-length armrests are shorter. This can provide
ferent sizes with different angle options: angle adjustable an individual with the ability to maneuver close to
or standard. desks and tables for functional activities such as feed-
The team should consider the following: ing or writing.
■ The aluminum option is heavier and more durable
than a composite footplate. Power Mobility Products
■ An angle-adjustable footplate is essential to accom- Barker and colleagues1 studied stroke survivors and
modate ankle range of motion limitations and can wheelchair use. They found that a manual wheelchair was
be helpful in accommodating hamstring muscle actually a contextual barrier for individuals with stroke
limitations. and power wheelchair use enabled community participa-
tion. Studies by Makino and colleagues10 and Mandy and
colleagues11 also documented the inefficiency of mobility
using current techniques and products (a one-arm drive
wheelchair and ipsilateral hand/foot propulsion tech-
nique) and investigated different prototype products to
increased efficiency with manual wheelchair use. There
have been several products developed that show promis-
ing potential for increased efficiency with mobility in
Shortened a manual wheelchair.10,11 However, these products are
hamstring muscles
in the prototype phase, are not necessarily practical for
daily use, and are not readily available for purchase at
this time. As a result, power mobility appears to be an
Posterior enabling option for individuals with denser hemiplegia.
pelvic tilt Power mobility products frequently are recommended
for individuals who do not have the strength, endurance,
or coordination to negotiate a wheelchair manually. Power
mobility can provide individuals with increased indepen-
dent and safe mobility within the home and the commu-
nity. This mobility is essential to provide individuals with
Figure 26-13 Effect of shortened hamstrings on pelvic posi- increased ability to perform ADL and to perform their life
tioning. roles. At this time, it is important to note that clients need
 Chapter 26 • Seating and Wheeled Mobility Prescription 689

to present with a basic level of visual-perceptual and cog- Power Wheelchairs

nitive functioning and be available for power wheelchair Power wheelchairs are available with a folding frame or a
mobility skills training for a power wheelchair to be a safe power-base frame with the drive wheel in the front, mid-
method of mobility. The wheelchair industry has pro- dle, or rear position. For ease of discussion, power wheel-
gressed significantly in the past 20 years; consequently, a chairs are divided into the front-, center-, and rear-wheel
wide array of products now exist to meet the most chal- drive bases with the understanding that each of these
lenging physical needs. This section gives an overview of models can be classified further into a basic-level wheel-
power mobility products with a general list of consider- chair and a power-base wheelchair.
ations for each option. After the therapist determines that an individual has
the range of motion to sit in most wheelchair styles and
Power Scooters the sufficient visual-perceptual and cognitive level abili-
Scooters provide individuals who have good balance ties to move safely, the next important consideration is fit
and upper extremity control with a means of power mo- of the wheelchair into and within an individual’s home
bility. They are available in three- or four-wheel bases environment. This fit is critical and often influences the
(Fig. 26-14). Scooters have a long and narrow base, and as type of drive-wheel base selected.
a result, they are great for open areas and general outdoor
community mobility. They can be disassembled for car Front-Wheel Drive Wheelchairs. A front-wheel drive
transport; however, this is an awkward task to perform wheelchair is a base with the large drive wheel in the front.
and may present an injury risk for the caregiver. This style of wheelchair is a very stable base and is benefi-
The team should consider the following: cial for individuals with significant hamstring muscle limi-
■ Scooters generally have mildly contoured seating tations. Accommodation of hamstring tightness in a rear-
systems. They are similar to car seats, with a limited wheel drive base either places excessive weight on the
number of options. As a result, they cannot provide casters and compromises driving or an individual often
sufficient postural support for individuals who need has to be positioned high up to keep his feet above the
a moderate level of trunk support. caster wheels. A front wheel drive base is the only base that
■ In general, scooters are long and narrow. As a result, can accommodate positioning the feet as far back as pos-
they have a large turning radius and often do not fit sible without compromising the seat height and interfer-
and maneuver in well in most apartments and ing with casters or motors. The team should consider the
homes. following:
■ Four-wheeled scooters handle outdoor terrain bet- ■ A front-wheel drive wheelchair is an excellent option
ter but are less maneuverable in smaller areas. In for individuals who have certain environmental limi-
addition, they are heavier and therefore are more tations. This style of wheelchair is excellent for tight
difficult for a caregiver to break down for car turns into doorways at the end of a hall and maneu-
transport. vering at a desk, counter, or table.
■ A portable ramp is necessary for individuals to nego-
tiate curbs or one-step entrances more than 3 inches
high.
■ Because of the design of this base, turning occurs in
the rear, outside of the driver’s visual field. Conse-
quently, an individual requires excellent proprio-
ception to know where the wheelchair is for safe
mobility. This wheelchair base generally is not rec-
ommended if an individual has visual or cognitive
limitations.

Mid-Wheel Drive Wheelchairs. For the purpose of this

chapter, the term mid-wheel drive wheelchair includes
center-wheel drive wheelchairs. A mid-wheel drive wheel-
chair is a wheelchair base that has the drive wheel in the
center of the wheelchair with smaller wheels in the front
and the rear. This base requires wheels in the front and
Figure 26-14 Clients are appropriate for power scooters if the back for maximum stability of the wheelchair base.
they have good functional control of their upper extremities, Because the drive wheel is in the middle, this wheelchair
trunk control, and appropriate visual, perceptual, and cognitive usually has the smallest turning radius and is the most
skills. maneuverable in tight areas.
690 Stroke Rehabilitation

The team should consider the following:

■ Because of the design of this base, turning occurs at
Basic Power Wheelchair
the center, which is the same axis on which the body A basic power wheelchair is durable and can handle rela-
turns. As a result, some individuals feel that this is an tively level terrain. Most basic power wheelchairs operate
easier drive method to learn; however, one concern by joystick. The joystick controls the speed and direction
is that some of the turning occurs in the rear, outside of the wheelchair. Some basic power wheelchairs can even
of the driver’s visual field. Consequently, an indi- be folded for car transport.
vidual requires good proprioception to know where The team should consider the following:
the wheelchair is for safe mobility. This wheelchair ■ Basic power wheelchairs have basic electronics with
base generally is not recommended if an individual little programmability. Consequently, if an individ-
has more involved visual or cognitive limitations. ual requires a higher degree of electronics adjust-
■ A portable ramp is necessary for individuals to nego- ments because of tremors, spasticity, or ataxia, a
tiate curbs or one-step entrances more than 3 inches power base with more flexible electronics may be
high. indicated.
■ If an individual requires a moderate or aggressive
Rear-Wheel Drive Wheelchairs. A rear-wheel drive level of postural support, including a tilt or recline
wheelchair is the original style of power wheelchair in seating system, this wheelchair base would not meet
the United States. Because the drive wheel is in the rear that person’s needs.
position, most of the weight of the wheelchair is in the ■ Because of its folding crossbar and flexible frame,
rear. As a result, this style of wheelchair has small “anti- a power folding frame does not handle terrain as
tipper” wheels in the back for maximum safety ascending well as a power base. However, for basic power
inclines. mobility, the model is an efficient and reasonably
The team should consider the following: priced alternative.
■ This wheelchair base maneuvers similar to a car, and ■ Power folding frames are practical in theory but not in
consequently, many individuals find the drive famil- reality. Although the frame can be folded by pulling
iar and, as a result, the wheelchair easy to operate. out the batteries and battery tray, the wheelchair com-
■ This wheelchair base is easier to control at higher ponents are still heavy and awkward. Two strong
speeds than the comparable front-wheel drive and adults can lift the folded power frame in and out of a
mid-wheel drive models. van or car; however, daily use with one person assisting
■ Because of the design of this wheelchair base, the the individual with a stroke is difficult and unrealistic.
turning wheels are in front of the driver. As a result,
all turns happen within the driver’s visual field. This Power Wheelchair Bases. Power wheelchair bases are
is the optimal situation for individuals with sensory much more durable than basic power wheelchair frames.
(auditory), visual, or cognitive limitations because The frame style is more rigid, which translates into in-
this base provides the driver with the maximum creased durability, increased ability to handle uneven ter-
amount of visual input about the environment they rain, and a smoother ride. In addition, the base style
are negotiating. wheelchairs are often available with the option for more
■ Because of the design of this wheelchair base, the advanced, higher-level electronics and the option for a
footrests have to be positioned in front to allow the more supportive seating system such as a tilt or recline
casters to turn. This increases the overall length of seating system.
the wheelchair and results in a larger turning ra- The team must consider that power bases cannot be
dius. Consequently, a rear-wheel drive base is not disassembled for car transport. As a result, these individu-
as maneuverable in tight areas as a mid-wheel drive als would need access to transportation by a bus, ambu-
base. lette, or accessible van.
■ This wheelchair base can be assisted up an 8-inch
step and curbs, if necessary. If a rear-wheel drive Power Wheelchair Options. For most power wheelchairs,
wheelchair is tipped back onto the tippers, the a wide array of joystick handle and joystick mounting op-
amount of caster clearance determines the actual tions are available to position the joystick in the best loca-
height one can negotiate with assistance of another tion for an individual with a stroke. These include larger
person. This is important for one-step entrances and ball joystick handles, built-up cylindrical-type joystick
curbs that are 6 to 8 inches in height. This feature is handles, swing-away joystick mounts, and midline joystick
not a luxury but a necessity for individuals to access mounting brackets.
their favorite restaurants and stores without a ramp. On power wheelchairs with more advanced electron-
This is an advanced skill and should only be per- ics, alternative drive methods such as a single-switch
formed with a skilled therapist or supplier. scanner, a head array, or a pneumatic controller can be
 Chapter 26 • Seating and Wheeled Mobility Prescription 691

easily set up. These options can enable individuals who 14. Punt TD, Kitadono K, Hulleman J, et al: From both sides now:
do not have the upper extremity control to operate a crossover effects influence navigation in patients with unilateral
neglect. J et al: 79(4):464–466, 2008.
joystick or modified joystick to maneuver the wheelchair 15. Qiang W, Sonoda S, Suzuki M, et al: Reliability and validity of a
safely and independently. wheelchair collision test for screening behavior assessment of
unilateral neglect after stroke. Am J Phys Med Rehabil 84(3):161–166,
2005.
REVIEW QUESTIONS 16. Rudman DL, Heber D, Reid D: Living in a restricted occupational
world: The occupational experiences of stroke survivors who are
1. What are the most important considerations when wheelchair users and their caregivers. CJOT 73(3):
recommending a wheelchair and seating system? 141–152, 2006.
2. Why is a mat evaluation an important first step before 17. Shea M: A wheelchair cushion insert and its effect on pelvic pressure
considering a wheelchair and seating system? distribution. Proceedings of the twenty-third International RESNA
3. What is the treatment approach difference for a fixed Conference: Technology for the New Millennium, Orlando, FL, June
2000.
versus a flexible deformity? 18. Turton AJ, Dewar SJ, Lievesley A, et al: Walking and wheelchair
4. What is a wheelchair contributing factor to sitting with navigation in patients with left visual neglect. Neuropsych Rehabil
a posterior pelvic tilt? 19(2), 274–290, 2009.
5. What are the basic differences between a rigid and a 19. Zollars JA: Special seating: an illustrated guide, Minneapolis, MN,
folding wheelchair? 1996, Otto Back Orthopedic Industry.
6. In addition to the mat evaluation, what are important
areas to screen when considering power mobility? SUGGESTED READINGS
7. What are the differences between a front-wheel drive, Angelo J: Assistive technology for rehabilitation therapists, 1997, Philadelphia,
mid-wheel drive, and rear-wheel drive power wheel- FA Davis.
chair? Axleton P, Chesney D, Minkel, J, et al: The manual wheelchair training
guide, Santa Cruz, CA, 1998, Pax Press.
Axleton P, Minkel J, Chesney D: A guide to wheelchair selection: how to use
the ANSI/RESNA wheelchair standards to buy a wheelchair, Washington,
REFERENCES DC., 1994, Paralyzed Veterans of America.
Bergen AF: Positioning for function, Valhalla, NY, 1990, Valhalla
1. Barker DJ, Reid D, Cott C: The experience of senior stroke survi- Rehabilitation.
vors: factors in community participation among wheelchair users. Carr EK: Positioning of the stroke person: a review of the literature. Int
Can J Occup Ther 73(1):18–25, 2006. J Nurs Stud 29(4):355, 1992.
2. Bergen A: Assessment for seating and wheeled mobility systems. Ferido T: Spasticity in head trauma and CVA persons: etiology and
Team Rehab Rep. April 1998, 16. management. J Neurosci Nurs 20(1):17, 1988.
3. Buck S: Wheelchair propulsion by foot: assessment considerations. Lange ML: Positioning the upper extremities. OT Practice May 1999.
Top Stroke Rehabil 11(4):68–71, 2004. Lange ML: Power wheelchair access methods. OT Practice July/Aug
4. Cowan RE, Nash MS, Collinger JL, et al: Impact of surface type, 1999.
wheelchair weight, and axle position on wheelchair propulsion Lange ML: Tilt in space versus recline: new trends in an old debate. Tech
by novice older adults. Arch Phys Med Rehabil 90(7):1076–1083, Spec Interest Section Q 10(2): 1–3, 2000.
2009. Minkel JL: Sitting solutions: principles of wheelchair positioning and mobility
5. Davies PM: Steps to follow: a guide to the treatment of adult hemiplegia, devices, New Windsor, NY, 1996, Minkel Consulting.
Heidelberg, Germany, 1985, Springer-Verlag. Ramsey C: Power mobility access methods. Tech Spec Interest Section Q
6. International classification of functioning, disability and health: ICF short 9(3):1–3, 1999.
version, Geneva, 2001, World Health Organization. Sparacio J: The effects of seating on upper-extremity function. Tech Spec
7. Judai JW: Psychosocial impact of assistive devices in stroke. Proceedings Interest Section Q 9(2):1–2, 1999.
of the twenty-sixth International RESNA Conference on Technology and Sweet-Michaels B: Alternative methods for power wheelchair control:
Disability: Research, Design, Practice, and Policy, Atlanta, June 2003. then and now. Tech Spec Interest Section Q 9(3):1–4, 1999.
8. Kangas KM: The task performance position: providing seating for Taylor SJ: The head control dilemma. Tech Spec Interest Section Q 9(2):
accurate access to assistive technology. Physical Disabilities Special 1–3, 1999.
Interest Section Quarterly 23(3), 2000. Trefler E: Then and now: simulators have evolved from simple position-
9. Lipka DD: BuyerBeware.com. Physical Disabilities Special Interest Sec- ing chairs into devices with multiple uses and benefits. Is it time your
tion Quarterly 23(3):3, 2000. facility purchased one? Team Rehab Rep Feb:32, 1999.
10. Makino K, Wada F, Hachisuka K, et al: Speed and physiological US Department of Health and Human Services: In Pressure ulcers in
cost index of hemiplegic patients pedaling a wheelchair with both adults: prediction and prevention, Rockville MD, 1992, US Department
legs. J Rehabil Med 37(2):83–86, 2005. of Health and Human Services, AHCPR Pub No 92–0050.
11. Mandy A, Lesley S: Measures of energy expenditure and comfort in Vogel B: Maintaining your chair. New Mobility June:25, 2003.
an ESP wheelchair: a controlled trial using hemiplegic users. Disabil
Rehabil Assist Technol 4(3):137–142, 2009.
RESOURCES
12. National Stroke Association: What is stroke? (website). www.stroke.
org/site/DocServer/STROKE_101_Fact_Sheet.pdf?docID4541. Clinician websites
Accessed April 11, 2009. www.gatech.edu
13. Pettersson I, Ahlstrom G, Tornquiat K: The value of an outdoor www.iss.pitt.edu
powered wheelchair with regard to the quality of life of persons with www.resna.org
stroke: a follow up study. Asst Technol 19(3):143–153, 2007. www.pva.org
692 Stroke Rehabilitation

Manufacturer websites Consumer websites

www.aelseating.com www.rolli-moden.com
www.artgrouprehab.com www.spinlife.com
www.bodypoint.com www.sportaid.com
www.invacare.com www.stroke.org
www.pdgmobility.com Accessibility websites
www.permobilus.com www.access-board.gov – US Access Board
www.pridemobility.com
www.sunrisemedical.com
www.supracor.com
www.therohogroup.com
www.varilite.com
 c ath eri n e a. du ff y

chapter 27

Home Evaluation
and Modifications

key terms
accessibility durable medical equipment mobility
adaptations home environment safety
architectural barriers

chapter objectives
After completing this chapter, the reader will be able to accomplish the following:
1. Apply methods of assessing the home environment for barriers.
2. Understand architectural guidelines as established by the American National Standards
Institute.
3. Implement methods for modifying the home environment and increase safety and mobil-
ity independence for patients recovering from stroke.

A barrier-free environment in the home and community is Understanding the patient’s home environment is an
essential to successful independent living for individuals who integral part of treatment and discharge planning. A home
are elderly or physically disabled and particularly for indi- visit with the patient should occur well before the discharge
viduals who have suffered stroke.2 Throughout the rehabili- date to provide recommendations to facilitate safety and
tation process, therapists work with patients toward the goal independence. The therapist uses information gained from
of achieving independence in mobility and self-care. How- this home visit to modify the existing treatment plan and
ever, this process usually occurs in an institutionalized setting establish appropriate therapy goals. This chapter focuses
that is relatively free of architectural barriers.1 Architectural on architectural barriers commonly found in the home,
barriers are defined as architectural features (e.g., stairs and ways to eliminate them, basic wheelchair information, and
doors) in the home and community that make negotiating at a general overview of methods for assessment appropriate
will difficult or impossible for an individual. for patients who have had a stroke. This chapter—with its
Most individuals with disabilities wish to return to bulleted, quick-reference format—is intended to be used as
their own homes. For many, some type of durable medical a resource for practical suggestions that will assist the oc-
equipment and home modifications are necessary to cupational therapist’s clinical reasoning process when eval-
achieve easy access.3 uating the homes of stroke survivors.

693
694 Stroke Rehabilitation

BASIC GUIDELINES AND WHEELCHAIR ■ Note protection from the weather: Examine the
INFORMATION condition of surfaces over which the wheelchair
must travel (e.g., grass that becomes mud, concrete
The wheelchairs shown in Figs. 27-1 to 27-6 are based on with cracks, shaded bricks covered with moss, and
a standard adult-size chair. Dimensions vary with the size asphalt that softens in the hot summer sun).
of the patient using the chair. See Chapter 26 for informa- ■ Examine driveway: Note size and ability to accom-
tion regarding specific wheelchair adaptations. The thera- modate a wheelchair van; assess composition (solid
pist must know the specific size and type of wheelchair or boulevard style with a strip of dirt in the
being prescribed for the patient before making recom- middle); and determine whether surface is paved
mendations for home modifications. or gravel.
■ Survey surrounding area: Look for trees that drop
EVALUATING THE HOME nuts, branches, leaves, and pine cones; note location
of mailbox.
Evaluation for architectural barriers usually is organized
by room. In this approach, the therapist considers the fol- Entrances
lowing information during a home evaluation: Suggestions include the following:
■ Consider all entrances to evaluate accessibility; note
Exterior any entrances inaccessible to the patient.
Suggestions include the following: ■ Measure steps and landings and note the presence
■ Assess type of residence: Note whether dwelling is a and height of railings.
house or apartment building; determine whether ■ Measure all doorway widths and heights, including
dwelling has elevator or staircase access; examine interior doors to closets and between rooms.
steps (their number, height, width, and depth); note ■ Note the direction of each door swing, the presence
walkway railings and width; and assess distance and and height of any sills, and the height of any in-
grade between the dwelling entrance and the curb or stalled locks; determine whether screen doors open
driveway. outward and solid doors open inward, and assess the

Eye level

Desk arm Handle

Armrest
1090-1295

Lap
43-51

Seat
915
36
760
30
685
27

485
19

Toe
205
8

A
455

660
26
18

6
150 42
B 1065
Figure 27-1 Dimensions of standard adult manual wheelchair (metric measurements are in
millimeters). Width: 24 to 26 inches from rim to rim. Length: 42 to 43 inches. Height to push
handles from floor: 36 inches. Height to seat from floor: 19 to 19½ inches (excluding cushion).
Height to armrest from floor: 29 to 30 inches. note: Footrests may extend farther for very large
persons. (From American National Standards Institute: Accessible and usable buildings and facilities,
New York, 1992, The Institute.)
 Chapter 27 • Home Evaluation and Modifications 695

Interior
Suggestions include the following:
■ Assess the number of levels and whether the bedrooms
are located upstairs or downstairs; consider relocating
a bedroom downstairs for improved mobility.
■ Count and measure all steps (their height, width,
and landing), and note whether handrails exist on
both sides.

60 min
1525
■ Measure the dimensions of the staircase; note the
stair height, width, and depth.

Living Room and Hallways

Suggestions include the following:
■ Consider phone accessibility; height of light switches,
thermostats, and electrical sockets; furniture ar-
rangement; floor covering; and doorway width and
60 min
1525
thresholds. Note the width of the hallway and num-
ber of turns.
Figure 27-2 Wheelchair turning space of 360 degrees (metric
■ Determine whether the patient will be able to open
measurements are in millimeters). A 360-degree turn requires a
and close windows; note whether the windows slide
clear space of 60 by 60 inches. This space enables the individual
up and down or swing outward; and measure the
to turn without scraping the feet or maneuvering multiple times
height of the latches.
to accomplish a full turn. min, Minimum. (From American
National Standards Institute: Accessible and usable buildings and Bedroom
facilities, New York, 1992, The Institute.)
Suggestions include the following:
■ Measure doorway width, threshold height, and mat-
weight of the doors and whether they can be moved tress height.
from a wheelchair. ■ Consider space for hospital bed and bedside com-
■ If the patient lives in a building with an elevator, mode; note floor space and covering (i.e., carpet,
note whether the chair can be maneuvered into the wood, tile, or linoleum) because these may have an
elevator; assess whether the elevator stops flush with effect on walking and wheelchair mobility.
the landing; and consider whether the patient can ■ Note whether the bed is stable for transfer.
reach the buttons. ■ Assess the accessibility of dressers and closets.
36 min
915

36 min 48 min 36 min

915 1220 915
Figure 27-3 Wheelchair turning space of 90 degrees (metric measurements are in millime-
ters). A 90-degree turn requires a minimum of 36 inches for the wheelchair user to have clear
space for the feet and prevent scraping the hands on the wall. min, Minimum. (From American
National Standards Institute: Accessible and usable buildings and facilities, New York, 1992, The
Institute.)
696 Stroke Rehabilitation

32 min
815

Passage
24 max

1220
point

48
610

15 min
380
48
A 1220

36 min
915
Figure 27-4 Minimum clear width for doorways and halls
(metric measurements are in millimeters). A minimum of
32 inches of doorway width is required; the ideal is 36 inches.

760
30
Hallways should be a minimum of 36 inches wide to provide
sufficient clearance for wheelchair passage and allow the user to
propel the chair without scraping the hands. max, Maximum;
min, minimum. (From American National Standards Institute:
Accessible and usable buildings and facilities, New York, 1992, The
Institute.)
48
B 1220
Figure 27-5 Forward reach (metric measurements are in
millimeters). The maximal height an individual can reach
■ If a mechanical lift is being prescribed, ensure from a seated position is 48 inches. Height should be at least
enough room is available to maneuver it around 15 inches to prevent the wheelchair from tipping forward.
the bed. min, Minimum. (From American National Standards Insti-
tute: Accessible and usable buildings and facilities, New York,
Bathroom 1992, The Institute.)
Suggestions include the following:
■ Measure the door width and threshold height, and
note the direction of the door swing (inward or
outward).
■ Measure the entry width and note the type of entry
Kitchen
of the shower or bathtub; determine the inside and Suggestions include the following:
outside sill height and sill width; measure the length, ■ Measure the height and depth of the basin of the
width (inside top and bottom), and height of the sink, the distance to the faucet knobs, cabinet and
faucet; and note the type of shower head. counter heights, and refrigerator door heights.
■ Note whether the wall is plasterboard, tile, or ■ Consider table height in relation to wheelchair fit.
fiberglass; the type of wall affects the installation of ■ Note outlet height and location, type of controls and
grab bars. location on the stove and microwave, and height and
■ Measure the height of the toilet, the available space accessibility of light switches.
on the left and right, and the space in front of it;
check whether the toilet paper roll is within easy Laundry
reach; and consider the sink height and counter dis- Suggestions include the following:
tances to the left and right. ■ Note the location and measurements of the washer
■ Determine the presence of any nonslip treatment in and dryer if relevant.
the tub; note whether the patient has a shower cur- ■ Determine whether the washer and dryer are front
tain or a glass door. loading or top loading.
 Chapter 27 • Home Evaluation and Modifications 697

10 max budget and the extent of the structural changes necessary

255
to attain the patient’s goals. The therapist should consult
30
760 building contractors and obtain bids for extensive recon-
struction needs and to assist with determining the feasibil-
54 max ity of structural modifications. Generally, modifications
1370
should be made in accordance with the guidelines estab-
lished by the American National Standards Institute.1
15 min

The American National Standards Institute publishes

380

the document American National Standards for Buildings

and Facilities,1 which provides specifications to make build-
ings and other facilities accessible and usable for individu-
A als with physical disabilities. The examples provided are
reprinted to increase occupational therapists’ understand-
24 max 30
ing of specifications needed for patients who are recover-
610 760 ing from a stroke and who rely on wheelchairs for inde-
pendent mobility.
46 max
1170

Exterior
A parking space with a 4-foot aisle adjacent to it allows
34 max

an individual to maneuver a wheelchair alongside the

865

car. Pathways and walkways should be a minimum of

48 inches wide and have smooth surfaces to prevent tip-
ping and difficult wheelchair mobility. Motion-sensitive
B or automatically timed lighting along walkways provides
Figure 27-6 Side reach (metric measurements are in millime- safety. At least one entrance to the home should have
ters). The maximal height for reaching from the side position easy access. If all entrances are reached by stairs, the
without an obstruction is 54 inches. If an obstruction such as a number of steps influences the solution to creating a no-
countertop or shelf is present, the maximal height for side reach step entrance. Options include ramps, stair gliders, or
is 46 inches. max, Maximum; min, minimum. (From American porch lifts.
National Standards Institute: Accessible and usable buildings and
facilities, New York, 1992, The Institute.) General Comments on Ramps
The therapist should consider the following:
■ Assess whether the washer and dryer are installed ■ Ramps should be a minimum of 36 inches wide and
permanently or must be moved into place and set up have nonskid surfaces.
each time for use. ■ The ideal ratio of slope to rise is 1:12—every
inch of vertical rise requires 12 inches of ramp
Basement (Fig. 27-11).
The therapist should examine the staircase, railings, win- ■ Ramps should have level landings at the top and bot-
dows, furnace controls, fuse box, and lighting. tom of each run; the landing should be at least as
Sketches of each room with notations of problematic wide as the ramp; and to allow unobstructed ability
areas are useful for the therapist attempting home simula- to open the door, a 24-inch area is needed.
tion during treatment sessions. The therapist should ■ Handrails should be waist high for individuals who
provide a brief summary of findings with recommenda- can walk (a minimum of 34 to 38 inches) and should
tions for modifications and safety to the family. extend a minimum of 12 inches beyond the top and
bottom runs.
■ Ramps require railings or curbs at least 4 inches high
HOME EVALUATION FORMS
to prevent individuals from slipping off the ramp
Evaluation formats range from simple to complex, de-
pending on the therapist’s and patient’s needs. Figs. 27-7 General Comments on Stairs
to 27-10 show samples of home assessments. The therapist should consider the following:
■ According to American National Standards Insti-

MODIFICATIONS tute, all steps on a flight of stairs should have uni-

form riser heights (a maximum of 7 inches) and tread
The therapist’s recommendations should meet the pa- depth (a minimum of 11 inches)
tient’s need to function with the greatest level of indepen- ■ All stairs should have handrails; the handrail grasp-
dence and safety. The therapist must consider the patient’s ing surface should be 1⁄2 inch to 2 inches in diameter
Text continued on p.708
698 Stroke Rehabilitation

OCCUPATIONAL THERAPY
HOME ASSESSMENT WORKSHEET

Address visited
Date of assessment
Exterior:
Type of residence: Type of terrain:
 House  Own  Rent  Incline  Concrete/asphalt
 Apartment  Care home  Smooth  Rough
Distance from parked car to home: Walkway width: inches wide
Distance from home to curb:
Ramping space: 1 foot of ramp to 1 inch of elevation
Maximum length: 30 ft
Level platform: 5 square ft
Platform at door: 5 square ft
Railings

AREA IDEAL ACTUAL COMMENTS/DIAGRAM

Entrance:
Most accessible entry:
Front Rear Side Front Rear Side

Steps (ground to porch) 7 inches high with Number

nonskid stripes Height
Width
Depth

Carpet
Nonskid strip
Artificial turf

Landing Number
Width
Depth

Railings (ascending steps) 32 inches high– Left Right

extends 11/2 ft beyond
top and bottom step Height

Porch size 4 or 5 square ft Width

Depth
Height of step from porch 7 inches high
to house level
Doorway width 36 inches wide
Swing of door In Out
Screen door swing In Out
Threshold Level with floor

Staff Date Time

Figure 27-7 Occupational therapy home assessment worksheet. (Courtesy K. Hatae, V. Tully,
N. Wade; Honolulu, Hawaii.)
 Chapter 27 • Home Evaluation and Modifications 699

AREA IDEAL ACTUAL COMMENTS/DIAGRAM

Interior:
Number of levels within
the house
Number of steps
Steps 7 inches high with Number
nonskid stripes Height
Width
Depth

Railings (ascending steps) Left Right

Landing Height
Number
Width
Depth
Living Room:
Threshold Level with floor
Doorway width 36 inches wide
Floor covering Wood/tile
Furniture arrangement 5 square feet turning
space
Favorite chair Wheelchair height
Density Firm Height
Armrest Both sides
Phone accessibility No long wire
Cordless
Television accessibility Remote control
Outlets 18 inches from floor
Light switches 36 inches from floor
Hallways:
Width 36-48 inches wide Turns
Straight
Turns Straight
Floor covering Wood/tile
Bedroom:
Doorway width 36 inches wide
Door swing In Out
Threshold height Level with floor
Floor covering Wood/tile
Telephone accessibility Next to bed
Bed size Single, double,
queen, king
Mattress height Wheelchair height
Mattress density Firm
Space for hospital bed 36 inches x 88 inches
Space for bedside commode 24 inches x 24 inches
Night light Next to bed

Staff Date Time

Figure 27-7, cont’d

Continued
700 Stroke Rehabilitation

AREA IDEAL ACTUAL COMMENTS/DIAGRAM

Bell Next to bed
Outlets 18 inches from floor
Light switches 36 inches from floor
Wheelchair turning space 5 square ft ⫻
5 square ft
Dresser accessibility Toe space below
Closets:
Accessibility Bifold, curtain
Rod height No higher than 48
inches
Bathroom:
Threshold Level with floor
Door width
Door width (with door) 36 inches wide
Door swing In Out
Shower/tub:
Entry width Entry width
Type of entry Curtain Curtain, glass door
Sill height (outside)
Sill height (inside)
Sill width
Sill width–wall
Width (inside top)
Width (inside bottom)
Length (inside top)
Length (inside bottom)
Faucet height
Shower head (type) Removable for hose

Wall type (e.g., tile, Tile, fiberglass

fiberglass)

Toilet
Height
Distance on left
(sitting on toilet) 3-9 inches minimum
Distance on right 3-9 inches minimum
Distance in front 30 inches

Lavatory
Height 26-30 inches
Distance on left
Distance on right
Distance in front
Accessibility below

Staff Date Time

Figure 27-7, cont’d

 Chapter 27 • Home Evaluation and Modifications 701

AREA IDEAL ACTUAL COMMENTS/DIAGRAM

Electric outlets Open for knee space Yes No

Wall surface Wood

Floor covering No scatter rugs

Tile/linoleum

Wheelchair turning space 5 square ft

Kitchen:
Door width
Sink
Height
Knee space
Basin depth 61/2 inches deep
Type Double/single
Faucet control Double/single
Distance to faucet
Cabinets
Stove Gas/electric
Height
Controls Front Front/back/top
Oven-handle height
Type Wall/integral
Refrigerator
Door height
Door hinge Left/right
Freezer
Door height
Door hinge Left/right/side
Outlets
Light switches 36 inches from floor
Table height
Chair height
Counter height 30 inches high
Telephone accessibility
Appliances:

Staff Date Time

Figure 27-7, cont’d

Continued
702 Stroke Rehabilitation

AREA IDEAL ACTUAL COMMENTS/DIAGRAM

Laundry:
Location
Doorway width 36 inches
Number of steps Number
Height
Width
Depth
Railings (ascending steps) Left Right
Height
Washer door Front opening
Controls Front panel Front/back
Dryer door Front opening
Controls Front panel Front/back
Clothes line location Height

Patio:
Doorway width 36 inches
Type of door Sliding/hinged
Threshold Level with floor
Steps Number
Height
Width
Depth

Railings (ascending steps) Left Right

Height

Staff Date Time

Figure 27-7, cont’d

 Chapter 27 • Home Evaluation and Modifications 703

HOME VISIT EVALUATION

Name of patient: M/F Age:

Address: Phone number:

Diagnosis and disability:

Status of patient on discharge:

Ambulatory Status
Is patient ambulating independently? Yes No
Does patient use assistive device? If yes, what type?
Wheelchair? If yes: Standard Motorized
Cognitive Status
Is patient alert and oriented? Yes No
Does patient have memory deficits? Yes No
Judgement and safety awareness: Intact Impaired

Vision:
Hearing:

Who will be home to assist patient?

Family member Home attendant hours per day
In what capacity?
Self-care Domestic Total
For whom will patient be responsible?
Self Spouse Children (number)
For which activities of home management was patient formerly responsible?
Cooking Laundry Cleaning
Shopping Child care
For which activities of home management will patient now be responsible?
Cooking Laundry Cleaning
Shopping Child care

Actual home visit

Type of residence patient lives in:
House Apartment
What floor?
Is there an elevator? Yes No
Width of elevator (for w/c)
Are there stairs to enter house/apartment? Yes No
How many?
Are structural alterations allowed in residence? Yes No
How many rooms in house/apartment?
Can patient get to all rooms?
Bedroom Kitchen Bathroom Living room
(If patient is in a wheelchair, width of doorway must be at least 30-32 inches.)
If private house:
Can patient sleep on ground floor? Yes No
Are there bathrooms on every floor? Yes No

Figure 27-8 Home visit evaluation. (Courtesy K. Hatae, V. Tully, N. Wade; Honolulu,
Hawaii.) Continued
704 Stroke Rehabilitation

Bedroom
Width of doorway:
Height of bed:
Is there room for bedside commode? Yes No

Kitchen
Width of doorway:
Height of: Sink Stove Cabinets Table Chair
Where are meals eaten? Kitchen Dining room
How far is table from cooking area? From refrigerator?

Living Room
Width of doorway:
Height of: Sofa Chair
Do chairs have armrests? Yes No

Bathroom
Width of doorway:

Toilet
Height:
Width of space to nearest surface (e.g., wall, sink): Right Left
Are walls sturdy enough for grab bars? Yes No
Is there a shower stall? Bathtub? Bathtub with shower?
Does patient shower? Bathe? Shower in tub?

Shower stall
Glass doors Shower curtain
Is there a step up or down? Height
Are there grab bars? Yes No
Height of faucets:
Width of shower stall:
Length of shower stall:

Bathtub
Glass doors Shower curtain
Facing tub—where are faucets? Right Left Straight ahead
Height of faucets:
Height of bathtub:
Width of bathtub:
Length of bathtub:

Miscellaneous
Carpeting? Area rugs?
How many telephones does patient have? Wall phones Desk phones
Does patient currently own any adaptive equipment? What type?

Figure 27-8, cont’d

 Chapter 27 • Home Evaluation and Modifications 705

Equipment recommendations

Home adaptation recommendations

Follow-up

Equipment ordered from ,

(Vendor) (Phone number)

on .
(Date)

Equipment to be delivered to on .
(Date)

Date of home visit:

Did patient go on home visit?

(Name of occupational therapist) (Phone number)

Figure 27-8, cont’d

706 Stroke Rehabilitation

To:
Address:
From:
Date:

Purpose: RECOMMENDATIONS FOR PREVENTING FALLS

AND/OR INCREASING ACCESSIBILITY WITHIN THE HOME

Exterior
 Entrance: Use  Front  Back  Side  Other
 Stairs:  Use nonskid stripes on step edges.
 Reinforce stairs.  Remove:
 Handrails:  Install: Right/left  Secure handrails.
 Walkway:  Cover with nonslip material.  Remove:
 Repair broken walkway.
 Door:  Assist with door.
 Install door-closing mechanism.
 Add hook to door and
Notes:

Living Room
 Entrance:  Locate lamp close to entry of room.
 Floor:  Remove throw rugs.  Tape or tack down carpet.
 Clear walking path of electrical/phone cords.
 Space:  Clear room of furniture and other obstacles.
 Furniture:  Ensure that tables and chairs can provide support if leaned on.
 Remove furniture with wheels or unsteady bases.
 Remove low-lying objects (e.g., coffee tables).
Notes:

Hallway/Stairwell
 Lighting:  Install light.  Change light bulb.
 Handrails:  Install: Right/left  Secure for sturdiness.
 Other:  Remove obstacles:
Notes:

Bedroom
 Lighting:  Install nightlight and/or bedside lamp.
 Path from bed
to bathroom:  Remove obstacles:
 Bed:  Rearrange:
 Lower/elevate bed:
 Clothes:  Arrange closet:
 Other:  Install bell/intercom.
Notes:

Figure 27-9 Recommendations for preventing falls and/or increasing accessibility within the
home. (Courtesy K. Hatae, V. Tully, N. Wade; Honolulu, Hawaii.)
 Chapter 27 • Home Evaluation and Modifications 707

OCCUPATIONAL THERAPY
RECOMMENDATIONS FOR HOME MODIFICATIONS
FOR SAFETY AND ACCESSIBILITY

Patient name:

AREA OF RESPONSIBLE
CONCERN PROBLEM RECOMMENDATIONS PERSON

Bathroom
entrance  Doorway is too narrow.  Remove/widen door.
 Tub/shower entrance  Remove tub/shower
is too narrow: door and replace with
inches wide. curtain.
 Towel rack is unsteady  Remove and replace with
as support. grab bars.
 Throw rugs pose a trip  Remove rugs.
hazard.

Bathing  Balance is unsteady.  Sit to bathe.

 Rinsing is difficult.  Use a bath bench.
 Tub/shower floor is  Use grab bars.
slippery when wet.  Use a flexible shower hose.
 Use a nonskid bath mat.

Dressing  Balance is unsteady.  Dress on .

Using toilet  Getting on/off toilet  Keep toilet seat raised.

is difficult.  Use right/left toilet
 Toilet is too low. guard rails.
 Use grab bars on .

Kitchen

Laundry

Comments

Occupational Therapist Date

Figure 27-10 Occupational therapy recommendations for home modifications for safety and
accessibility. (Courtesy K. Hatae, V. Tully, N. Wade; Honolulu, Hawaii.)
708 Stroke Rehabilitation

Rise and have a nonslip surface; and handrails should be

Surface of ra
mp mounted approximately 11⁄2 inches away from the
wall to allow for adequate grasping space.

General Comments about Doors and Landings

Standard door width should be a minimum of 32 inches.
Horizontal projection Several solutions to narrow door problems do not require
or run replacing the entire frame and door with a wider doorway.
Existing hinges may be replaced with swing-clear hinges.
Thus the clear opening of the door may be enlarged by
Maximum horizontal 11⁄2 to 2 inches. Doorstops may be removed, adding an
Maximum rise projection
additional 3⁄4 inch to the clear opening width of the door-
Slope in mm ft m
1:12 to 1:15 30 760 30 9
way. Removal of existing doors can provide an additional
1:16 to 1:19 30 760 40 12
11⁄2 to 2 inches. Removing doors and doorstops can in-
1:20 30 760 50 15 crease door width 21⁄4 to 23⁄4 inches.
Small landings on either side of the door present prob-
Figure 27-11 Slope and rise of ramps. This diagram provides lems for a wheelchair or walker user because pulling a
the components of a single ramp run and a sample of ramp di- swinging door open is difficult if the assistive device al-
mensions. The slope ratio is an important consideration when ready is occupying the landing area over which the door
designing a ramp; slope creates hazardous wheelchair propul- must swing. A minimum of 18 inches for walkers and 26
sion conditions if it is too steep. (From American National inches for wheelchairs is needed outside the door swing
Standards Institute: Accessible and usable buildings and facilities, area (Fig. 27-12). Rather than enlarging a landing by re-
New York, 1992, The Institute.) moving walls and partitions, three options are available.
The door can be removed, an automatic door opener can
be installed, or a door pull loop with Velcro-type attach-
ments can be devised. The latter can assist individuals

18-26 inches

Figure 27-12 Door swing area. A minimum of 18 inches for walkers and 26 inches for wheel-
chairs is needed outside the swing area.
 Chapter 27 • Home Evaluation and Modifications 709

with closing a swing-in door. The loop can be constructed are lighter in weight (Fig. 27-15). Door thresholds higher
from 2-inch wide webbing material and should be at least than 1⁄4 inch should be removed or beveled to prevent
30 inches in length. A loop sewn at one end assists pa- tripping hazards and to remove barriers for wheelchair
tients with weak grasps. The other end can be fastened to users.
the door lever or knob using 1-inch wide Velcro-type
loops and hooks. Hardware
If doors are to be replaced, several options are avail- Lever door handles or doorknob adapters are preferable
able. If space is a limiting factor, sliding doors are useful to round twist doorknobs. Slide bolts, which can be
(Fig. 27-13). However, their weight and lateral movement reached from a seated position, may replace dead bolt
can make maneuvering difficult. Moreover, some sliding locks. Kick plates can be installed on doors to prevent
doors require floor tracks, which are obstacles for wheel- gouging and scratches from wheelchairs and walking aids.
chairs and persons who have difficulty walking. Pocket They should be as thin as possible to allow clear door
doors are effective if only occasional privacy is necessary width opening. They should extend from the bottom of
(Fig. 27-14). Folding doors require lateral movement but the door to a height of 10 to 16 inches.

Interior
Hallways, Living Room, and Dining Area
Hallways should be a minimum of 36 to 48 inches wide.
They should be free of protruding objects such as low
tables, coat racks, and planters. Thresholds should be
eliminated. Nonslip and low-friction surfaces are recom-
mended. Scatter rugs should be removed. Carpeting
should be removed or tacked or taped down to eliminate
trip hazards. Furniture should be rearranged to accom-
modate a wheelchair turning area of 5 square feet. Coffee
tables, ottomans, and other trip hazards should be elimi-
nated for patients who walk with assistive devices. A fa-
vorite chair can be increased in seat height by adding
medium-density foam cushions. Telephone and appliance
wires should be taped or tacked down. Easy access to light
fixtures and outlets is recommended. Appropriate height
Figure 27-13 Sliding door.

Figure 27-14 Pocket door. Figure 27-15 Folding door.

710 Stroke Rehabilitation

for wall switches is 36 to 48 inches. Outlets should be a

minimum of 18 inches above the floorboard. Rocker
switches and dimmer switches can reduce the fine ma-
nipulation required for operating light switches, or auto-
matic timer lights can be installed. Inexpensive environ-
mental control units can aid in independent operation of
television sets, radios, and other appliances.

Bedroom
The bedroom should be free of clutter and scatter rugs. A
minimum of 3 feet should be available on the side of the
bed to allow for wheelchair transfers. The height of the
bed should be equal to the height of the wheelchair for
safe transfers. If the bed is too low, it may be elevated on
blocks or a platform. Raising the bed also increases ease
for sit-to-stand transitions if the patient is ambulatory. A
firm mattress is recommended to improve bed mobility. A
trapeze can assist with mobility in bed if necessary. Side
rails provide safety from falls and also can be used as as-
sistive devices for rolling in bed. Dressers should have toe
space underneath and easy-glide drawers. Stackable bas- Figure 27-16 Toilevator.
kets may be a substitute for clothing storage. Closet doors
should be removed or replaced with folding doors or a
curtain. The height of the clothing rod should be a maxi- increases accessibility for transfers and improves safety
mum of 48 inches. conditions. The recommended height for tub rims is
17 to 19 inches. Shower stall thresholds should be
1
Bathroom ⁄2 inch high. A roll-in shower may be recommended
Doorway width may preclude bathroom access for the for nonambulatory individuals and should be a minimum
wheelchair user. Removing the door, installing a pocket or of 30 by 60 inches. Some tubs have rounded bottoms.
sliding door, or using a narrow rolling commode chair are This can present stability problems if a stationary leg of
options for entry to the bathroom for nonambulatory in- a tub bench is supposed to be positioned inside. A
dividuals. The optimal toilet seat height should be 17 to clamp-on tub bench is more suitable for such tubs. Re-
19 inches, which allows for level transfers from a wheel- gardless of the type of tub, the therapist should evaluate
chair and decreases the amount of bending required to get the individual’s balance and transfer method and archi-
up and down for those who can stand. Options for raising tectural constraints carefully to determine the most ap-
the height of the toilet include a raised toilet seat, an over- propriate and safest type of seat. A flexible shower spray
toilet commode, a drop-arm commode, or a Toilevator unit assists with rinsing; the hose should be a minimum
(Fig. 27-16). For individuals who have greater weakness of 60 inches long. The handle can be adapted for indi-
in their lower extremities than in their upper extremities, viduals with limited hand dexterity. Nonskid tub strips
a toilet safety frame may assist with sit-to-stand transi- or a rubber bath mat should be applied to the floor of the
tions. Grab bars should be installed throughout the bath- tub or shower stall and outside the tub to prevent falls.
room because surfaces become slippery and falls are more Fig. 27-17 gives samples of shower stall and shower seat
likely. The height of horizontal bars should range from 33 dimensions.
to 36 inches above the floor. The width of the bar should
be 11⁄4 to 11⁄2 inches to accommodate grasp efficiently. Sink and Lavatories
When bars are mounted adjacent to the wall, the distance The height of the sink should be a maximum of 34 inches
between the wall and the bar should be 11⁄2 inches so that above the floor. Wheelchair users need a minimum of
the patient’s fingers can reach around the bar but the arm 29 inches of height underneath the sink to enable them to
cannot slip through. Walls around the tub or shower stall have close access to the faucets and basin. Access prob-
should be reinforced. Bars should be mounted securely lems may be eliminated by removing cabinets or doors.
into the wall studs. Towel racks should be removed if they The mirror above the sink should be angled 1⁄4 to 1⁄2 inch
are likely to be used for support. for individuals who are seated. Water pipes should be in-
Glass doors on tub and shower stalls should be re- sulated to prevent contact burns. Hot and cold water
moved and replaced with a curtain. Glass doors can de- should mix and empty through a single faucet to mix water
tach from tracks and fall on the person. This renovation of variable temperatures. Water temperature controls
 Chapter 27 • Home Evaluation and Modifications 711

36
915
Back

Control wall
Seat wall

Side

30 min
Side
915
36

760
36 min

915
915

36
Lav

48 60
A 1220 B 1525
22-23 max
560-585

14 min-15 max
355-380
11⁄2 max
38

Full depth of stall

21⁄2 max
64

15 min-16 max
C 380-405
Figure 27-17 Transfer-type shower stall, roll-in shower stall, and shower seat design (metric
measurements are in millimeters). Lav, Lavatory; max, maximum, min, minimum. (From
American National Standards Institute: Accessible and usable buildings and facilities, New York,
1992, The Institute.)

should be set no higher than 115 degrees F. Ordinances in Countertops are generally 36 inches high, making ac-
some cities mandate a fixed maximum temperature for hot cessibility difficult for wheelchair users. Alternate counter
water for safety. Single-lever faucet controls are recom- or work surfaces can be adapted by adding pullout cutting
mended because they provide visual indication of water boards or placing a cutting board on top of a drawer that
temperature and do not require fine motor dexterity to has been opened partially. Height-adjustable countertops
operate. and cabinets provide easy access for individuals with lim-
ited reach; however, this option is expensive. The coun-
Kitchens tertop should have a maximum depth of 24 inches. The
The three most common kitchen layouts are L-shaped, corners and edges should be rounded. Base cabinets
aisle, and U-shaped. The L- or U-shaped configuration should have enough toe space at the bottom to accom-
can improve efficiency (Fig. 27-18). Work surfaces should modate wheelchair footplates. Retractable doors and lazy
be free of clutter, and small appliances that are used fre- Susans increase accessibility to stored items. Adapted
quently should be placed within reach. knobs or D-loop handles assist individuals with decreased
712 Stroke Rehabilitation

Figure 27-18 Common kitchen layouts.

coordination and grasp strength. Easy-glide drawers and to recommend a safe mechanical transfer system for the
pullout shelves may decrease energy expenditure. primary caregiver to use within the home.
The therapist also must take appliances into account. A From a historical perspective, standard lift systems
side-by-side refrigerator is recommended for increased were difficult to use because they generally required
access to the refrigerator and freezer. Shelves should be more than one person to operate and were difficult to
adjustable; lazy Susans may provide easier access to stored maneuver in limited spaces. Modern advances in technol-
food items. A wall-mounted oven and range top with stag- ogy have resulted in effective, safe, and more affordable
gered burners are recommended for wheelchair users. A equipment available to mobilize the more physically in-
mirror placed above the stove allows seated individuals to volved individual.
see the cooking process. Transparent pots are another al- An example of one system is the Barrier Free Lift.
ternative. Range controls should be located at the front or With this system, tracks usually are custom installed on
side to eliminate the need to reach over hot elements. the ceilings in patients’ homes. They allow the care-
Controls can be adapted for individuals with limited hand giver or home attendant to stay close to the patient
dexterity. Tactile or audible cues can assist individuals during the transfer process but do not require physical
with limited vision. For wall-mounted ovens, the controls exertion from the caregiver. Several benefits to using
should be no higher than 40 inches above the floor for a Barrier Free track system include prevention of
wheelchair user access. Microwave and toaster ovens may caregiver injuries and ensuring that furniture, carpets,
be convenient and safe alternatives for cooking. and other equipment do not get in the way of the lift
Sink basins should be a maximum of 61⁄2 inches deep. A (Fig. 27-19).
plastic or wooden rack can be used to raise the working
level. A retractable hose can increase the ease of rinsing FALL PREVENTION
dishes. Single-lever faucet controls are recommended and
should be positioned no farther than 21 inches from the The checklist in Fig. 27-20 is an adaptation from the fall
edge of the counter. prevention checklist used at the Rehabilitation Hospital
of the Pacific located in Honolulu, Hawaii. This checklist
Moving Around the Obstacles originally was used as a tool to provide education to fam-
General mobility and transfers will be difficult for the ily members and caregivers after the home evaluation
individual who has severe motor deficits. After a discus- process. The adjustments incorporate options for durable
sion of prognosis for motor return, it may be appropriate medical equipment. See Chapter 14.
 Chapter 27 • Home Evaluation and Modifications 713

Figure 27-19 Using a Barrier Free Lift, caregivers can now come in all sizes. (Courtesy Ted
Hensley, Barrier Free Lifts.)

Exterior Bathroom
__ Walkways have a smooth surface and are __ Door width is wide enough to permit
clear of objects. wheelchair access.
__ Outdoor lighting is sufficient for safe ambulation __ No thresholds are trip hazards.
and wheelchair maneuvering at night. __ Scatter rugs are removed.
__ Step surfaces are nonslip and edges are __ Grab bars are installed near toilet, tub,
clearly marked to prevent tripping. and entryway.
__ Steps are sturdy and handrails are secure. __ Toilet is proper height.
__ Nonskid bath mat or strips are installed
Living Room on floor of tub or shower.
__ Entryway and room are free of clutter to __ Tub or shower seat is available for bathing.
allow safe walking or wheelchair mobility.
__ Stepstools, ottomans, coffee tables, and Bedroom
other low-lying objects are out of the way __ Doorway entry is proper width.
to prevent trip hazards. __ Bed is proper height and firmness.
__ Chairs have armrests and are sturdy. __ Night lights are present.
__ Telephone and lighting are accessible; __ Hospital bed is available.
cords are tucked down. __ Side rails are installed.
__ Environmental controls are accessible. __ Bedside commode is available.

Hallway Kitchen
__ Doors that open into halls are removed. __ Table is sturdy.
__ Floor is clear of objects. __ Frequently used items are located at
__ Carpet borders and runners are secured. waist level.
__ Use of range top is avoided.
__ Microwave or toaster oven is available.
__ Throw rugs are removed.
__ Electrical cords are tied up or taped down.

Figure 27-20 Fall prevention checklist.

714 Stroke Rehabilitation

CASE STUDY The refrigerator door opened to the right, and the
Returning Home Safely and Independently stove had controls at the back of the range top. The
after Stroke cabinets were high and not accessible from a seated
position. The following recommendations were made:
J.J. is a 72-year-old woman who was admitted to the
hospital with a diagnosis of right hemispheric stroke. Living room
Her hospital course was uncomplicated, and she was 1. Remove one couch and coffee table.
2. Remove the area carpet and scatter rugs.
transferred to the rehabilitation unit four days later.
3. Relocate the lamps for easier access.
An occupational therapy evaluation was performed
and clinical findings were reported. Passive range of Bedroom
motion was within functional limits throughout all 1. Elevate the bed 4 inches on cinder blocks to equal the
joints in the upper extremities bilaterally. Strength was height of the wheelchair.
good in the right upper extremity. Minimal active 2. Place a plywood board beneath the mattress to increase
movement was present in the left shoulder, and one- firmness.
3. Remove the closet door and one dresser.
finger subluxation was noted. Sensation was intact for
4. Lower the height of the closet rod to 40 inches above
light touch, pain, and temperature. Functional abilities
the floor.
were impaired moderately because of decreased ability 5. Place a drop-arm commode chair next to the bed.
to bear weight on the left upper and lower extremities. 6. Place a night-light in the wall socket.
Sitting balance was fair. Standing balance was poor.
J.J. required moderate assistance for bed mobility. Bathroom
Sit-to-stand required maximal assistance of one person, 1. Remove the sliding glass doors and replace with a
and transfers required moderate to maximal assistance shower curtain.
2. Use a tub transfer bench and flexible shower hose for
depending on the surface. She was unable to walk at the
bathing.
time of evaluation, and wheelchair mobility skills re-
3. Place a 24-inch grab bar on the wall of the tub 33 inches
quired moderate assist. In self-care, a left neglect was from the floor.
noted during all activities. J.J. required set-up assis- 4. Park the wheelchair in front of the bathroom door and
tance for eating and grooming. Dressing and bathing walk with assistance.
required moderate to maximal assistance. 5. Place a chair in the bathroom in front of the sink to per-
J.J. was treated in occupational and physical therapy form grooming and dressing tasks.
for six weeks. During her fourth week of treatment, a 6. Tilt the mirror 1⁄2 inch.
home evaluation was scheduled. The therapy team felt
Kitchen
that having the patient present during the visit would 1. Reverse the door swing on the refrigerator.
be useful because she lived alone and still required the 2. Relocate frequently used items to the counter.
use of a wheelchair. She lived in a two-bedroom rental 3. Relocate the toaster oven to the kitchen table.
apartment in a building with a no-step entry and eleva-
tor. The apartment had large rooms, but wheelchair Communication
1. Purchase a portable cordless phone.
accessibility was limited because of excessive furniture
2. Consider registration with an emergency call service.
and thick carpeting. The hallway was narrow. Her bed-
room and bathroom were located off to the right of
J.J. agreed with the foregoing recommendations and
the hallway, and the second bedroom was located at the
requested permission from the landlord to install the
end of the hallway. She was unable to negotiate the
grab bar. During the rest of her inpatient rehabilitation
turn into her bedroom with the wheelchair because of
stay, the focus of treatment was placed on achieving
the hall and door width. The therapist suggested that
independence in bed-to-commode transfers, short-
she switch bedrooms and use the second bedroom as
distance walking, light meal preparation, and kitchen
her own. The bed was low with a soft mattress and the
tasks from wheelchair level in a home-simulating envi-
closet was not accessible because of narrow paths and
ronment. At the time of discharge, J.J. was indepen-
excessive furnishings. The bathroom was spacious and
dent in all self-care, transfers, and meal preparation.
easily could accommodate a wheelchair; however, the
She required contact guard for short distance ambula-
door was only 19 inches wide, preventing wheelchair
tion with a hemiwalker and was independent with
access. The bathroom had a combination tub and
wheelchair mobility. She was recommended for home
shower with sliding glass doors. The toilet was located
care services for follow-up therapy and assistance from
behind the door. The sink had round fixtures that were
a home health aide.
difficult to turn. The kitchen was wheelchair accessible.
 Chapter 27 • Home Evaluation and Modifications 715

REVIEW QUESTIONS REFERENCES

1. American National Standards Institute: Accessible and usable buildings
1. What options can an occupational therapist consider if and facilities, New York, 2003, The Institute.
existing doorways are too narrow for a wheelchair? 2. AOTA: AOTA’s societal statement on livable communities, Bethesda, MD,
2. What issues does an occupational therapist need to ad- 2008, AOTA.
3. Sabata DB, Shamber S, Williams M: Optimizing access to home, com-
dress for a wheelchair-dependent patient recovering
munity, and in workplace. In Radomski MV, Latham CAT, editors:
from stroke who is returning home? Occupational therapy for physical dysfunction, ed 6, Baltimore, 2008,
3. What modifications should be considered to make Williams & Wilkins.
bathrooms safe and accessible?
4. What are architectural barriers?
 p atri ci a a. ryan
j e n n i e w. s u l l i van

chapter 28

Activities of Daily Living

Adaptations: Managing
the Environment with
One-Handed Techniques

key terms
adaptive devices energy conservation instrumental activities of daily
adaptive techniques environmental modifications living
basic activities of daily living work simplification

chapter objectives
After completing this chapter, the reader will be able to accomplish the following:
1. Explore a variety of adaptive techniques and assistive devices to allow for completion of
activities of daily living.
2. Enhance performance of activities of daily living using principles of energy conservation
and work simplification.
3. Explore environmental modifications to enhance safety and ease of mobility in the
performance of activities of daily living.

Occupational therapy intervention for stroke survivors is challenging. According to the study described in “Com-
geared toward ameliorating deficits resulting from stroke pensation in Recovery of Upper Extremity Function Af-
and varies tremendously from one patient to another. For ter Stroke,”1a the emphasis of intervention during reha-
certain individuals, limited return of functional use of the bilitation for patients with extensive upper extremity
involved extremity makes performance of self-care and paralysis should be on teaching one-handed compensa-
instrumental activities of daily living (IADL) uniquely tory techniques. The occupational therapist is called to

716
 Chapter 28 • Activities of Daily Living Adaptations 717

use creative problem-solving abilities to enhance inde-

pendence in a wide range of activities, helping the patient Safety
achieve meaningful, realistic goals. Indeed recent evi- Helping patients negotiate the bedroom environment
dence strongly suggests that focused occupational ther- safely is a priority because this is an area in which many
apy makes a substantial impact in this area of activities self-care activities are performed. The height of the bed
limitations (Box 28-1). (See Chapter 21 for a comprehen- should allow the patient to sit comfortably with both feet
sive overview of IADL.) flat on the floor to provide a good base of support. If the
bed is too high or too low, the therapist can consider the
BASIC ENVIRONMENTAL CONSIDERATIONS following adaptations. Several inches can be sawed off or
added to the bedposts of a wooden bed to adjust the bed
Before initiating basic activity of daily living (BADL) height. Leg extensions are commercially available from a
training, the therapist should address the variety of envi- variety of rehabilitation catalogs. Another alternative is to
ronments in which the patient is required to perform. remove the bed frame entirely and use only the box spring
While surveying the patient’s environment, the therapist and mattress. Ideally, a double mattress should be used to
should consider the following criteria: improve ease of mobility and provide an increased sense
1. Safety factors of security. The mattress should be firm to allow for in-
2. Ease of mobility and performance of activities of creased postural stability and improved balance. The bed
daily living (ADL) should be placed within the room to allow access from
both sides. Use of a transfer handle positioned on the
patient’s noninvolved side improves safety and ease of
mobility in and out of the bed (Fig. 28-1).
Box 28-1 Bedroom furniture should be rearranged to eliminate
Evidence Briefs: ADL Retraining after Stroke obstacles hindering the patient from negotiating a path
to the bathroom or room exit. If possible, changes in the
■ A recent systematic review and metaanalysis aimed to floor surface should be avoided. Bare floor surface chang-
determine whether occupational therapy focused spe- ing to raised carpeting, for example, may increase the risk
cifically on personal ADL improves recovery for of falls.
patients after stroke. Nine randomized controlled
The sensory environment is another component to
trials including 1258 participants met the inclusion
criteria. The authors concluded, “Occupational ther-
consider. Factors such as sufficient lighting and a comfort-
apy focused on improving personal activities of daily able room temperature must be ensured. If inadequate,
living after stroke can improve performance and
reduce the risk of deterioration in these abilities.
Focused occupational therapy should be available to
everyone who has had a stroke.” (Legg, et al, 2007)
■ Steultjens and colleagues conducted a systematic
review to determine from the available literature
whether occupational therapy interventions improve
outcomes for stroke patients. The authors identified
and included 32 studies (18 were randomized con-
trolled trials). They documented significant effect
sizes for the efficacy of comprehensive occupational
therapy on primary ADL, extended ADL, and social
participation.
■ Trombly and Ma examined 15 studies involving 895
participants (mean age  70.3-years-old). Of these
studies, 11 (7 randomized controlled trials) “found
that role participation and instrumental and basic
activities of daily living performance improved signifi-
cantly more with training than with the control condi-
tions.” The authors concluded that “occupational
therapy effectively improves participation and activity
after stroke and recommend that therapists use struc-
tured instruction in specific, client-identified activities,
appropriate adaptations to enable performance,
practice within a familiar context, and feedback to
improve client performance.” Figure 28-1 Transfer handle. (Courtesy North Coast Medical,
San Jose, Calif.)
718 Stroke Rehabilitation

both conditions present safety obstacles. For example, if using functional assessment instruments in stroke reha-
the room temperature is too cold, the patient may experi- bilitation. Many instruments have been used in research
ence an increase in muscle activity, possibly decreasing and clinical practice to assess functional outcomes in
postural stability and the ability to perform self-care tasks patients who have survived a stroke (Table 28-1). See
successfully. (See Chapter 27 for a detailed review of home Chapter 21 for a review of standardized tools to assess
modifications.) IADL.

Ease of Mobility and Performance of Activities

of Daily Living BASIC ACTIVITIES OF DAILY LIVING
In addition to the safety of the environment, the therapist Grooming and Hygiene
also must consider arrangement of the bedroom to in- When performing hygiene and grooming, assistive devices
crease ease of mobility and performance of ADL. The and alternative methods often provide increased indepen-
therapist may use energy conservation and work simplifi- dence and safety and decreased energy expenditure.
cation techniques to teach the patient ways to prioritize,
organize, and limit work to save time and energy and to Toileting. A toilet tissue dispenser should be mounted
enhance the successful outcome of task performance. The within easy reach of the unaffected side and allow for easy,
following techniques should be considered: one-handed retrieval of tissue sheets. Two possibilities
1. Eliminate excess space. Enough space must be avail- include a tissue box dispenser mounted on the bathroom
able for ease of mobility without excess. Excess wall or an easy-load toilet paper holder, which eliminates
space forces a patient to travel greater distances, excessive paper roll waste. This alternative gives a more
draining personal energy resources. For example, aesthetic appearance, possibly improving acceptance by
the bathroom ideally should be directly off the bed- the patient (Fig. 28-2). Moist towelettes can be used in
room rather than down the hall. If this arrangement place of toilet paper and are a viable alternative for pa-
is not possible, a bedside commode and sitting table tients with urgency or impaired sphincter control.
with a mirror that can be set up to allow for perfor- Two devices that are available and recommended to
mance of toileting and grooming are useful modifi- increase independence in bladder care for women who
cations. A living room can be used to replace an have survived a stroke include the Asta-Cath and the
out-of-the-way bedroom. Feminal. Both products are available from A Products.
2. Arrange the room so that sequential tasks can be The Asta-Cath female catheter guide is a simple device
performed with minimal travel time in between. that assists women in locating their urinary meatus. As
3. Place appliances and controls where they can be ac- the Asta-Cath is inserted into the vagina, it spreads the
cessed easily. Lamps, alarm clocks, and telephones labia, and one hole aligns with the urinary meatus. The
should be placed where they are needed most often patient then can pass a No. 14 French or smaller catheter
and are most convenient for the patient. The use of into the bladder for emptying. The three alignment holes
environmental control units should be considered. allow for most anatomical differences (Fig. 28-3). The
4. Eliminate clutter. Thorough cleaning and organiza- Feminal is designed so that a woman can urinate in a re-
tion is essential to allow for easy retrieval of com- clined, seated, or standing position. When gently pressed
monly needed items. against the body, the unique shape creates a leak-proof
5. Arrange for easy access of clothing and toileting seal (Fig. 28-4).
supplies by eliminating excess reaching and bend-
ing. Shelves are easier to access than drawers are. If Showering and Bathing. Transferring from a slippery
drawers are used, they are easier to open with a tub, controlling water temperature, and washing ade-
central knob rather than handles. Also, closet rods quately in a slippery tub are safety factors to consider
can be lowered to eliminate excess reaching. An al- during bathing. Nonslip mats should be placed inside and
ternative solution includes use of a reacher. outside the tub. All toiletries should be placed where they
Therapists must be aware of the neurobehavioral defi- can be reached easily. Articles should be moved close to-
cits that affect BADL and IADL. These deficits influ- gether if the individual is sitting on a tub bench to ensure
ence equipment choices and training techniques (see safe reaching. To ensure safety of water temperature and
Chapters 17 and 18). ease of bathing, a handheld shower hose with control of
water flow may be used to prevent scalding. This device
FUNCTIONAL ASSESSMENT can be purchased through a variety of catalogs.
Long-handled scrub sponges and bath brushes are
The World Health Organization’s 2001 International excellent assistive devices for washing. A flex sponge is
Classification of Functioning, Disability and Health4 pro- able to bend in any direction to wash all of the body,
vides a useful conceptual framework while considering including the nonaffected arm, axilla, and shoulder,
 Chapter 28 • Activities of Daily Living Adaptations 719

Table 28-1
Examples of Functional Assessments for Stroke Survivors
INSTRUMENT BRIEF DESCRIPTION

American Heart Association Stroke The purpose of this instrument is to serve as a standardized and comprehensive
Outcome Classification classification system to document the impairments and disability resulting from
(Kelly-Hayes and colleagues, a stroke. The scale considers the number of neurological domains involved,
1998) severity of impairment, and level of function.
A-ONE (Arnadottir, this volume) Documents level of functional independence in basic ADL and mobility and
underlying neurobehavioral impairments. See Chapter 18.
Barthel ADL Index (Mahoney, Scores for activities are weighted so that the final item scores range from 0 for
1965) dependent performance to 15 for independent performance. Total score ranges
from 0 to 100. Activities include feeding, bathing, grooming, transfers, dressing,
bowel, bladder, toileting, walking, wheelchair use, and stair climbing.
Canadian Occupational Measures clients’ perceptions about performance and satisfaction with self-care,
Performance Measure (Law and productivity, and leisure. After identifying occupational performance issues, the
colleagues, 2005) clients rate their perception of performance and satisfaction with performance on
a 1 to 10 scale. The same scale is used for reassessment.
Functional Independence Measure Administered by members of the rehabilitation team by direct observation.
(FIM) (Keith and colleagues, A detailed scoring system is used, and therapists are trained to administer the
1987) FIM in a standardized manner. Items scored on a 1 to 7 scale include self-care,
sphincter control, mobility, locomotion, communication, social skill, and
cognition.
Modified Rankin Scale (van A 5 point scale used to rate disability and need for assistance.
Swieten and colleagues, 1988)

soap. If grasp is limited, the patient can use a terry cloth

wash mitt with a pocket to hold the bar of soap. The
aforementioned devices may be purchased through a
variety of rehabilitation catalogs. For those who must
rely on another to bathe them, a mechanical lift posi-
tions the person in a body sling. This lifting device has a
swing arm to allow a person to be suspended in a shower
or over a tub.

Shampooing. Shampoo in a pump spray bottle helps

avoid waste and reaches a broader area of the scalp. A full-
spray handheld shower is convenient for rinsing.

Drying. To decrease energy expenditure while drying, an

extra large towel or terry wraparound robe can be worn to
absorb most of the water. The back and nonaffected arm
are the most difficult areas to dry. The following proce-
Figure28-2 Easy-Load toilet paper holder. (Courtesy dure can be incorporated:
Sammons Preston, a BISSELL Company.) 1. Place the towel over one shoulder.
2. Reach behind and grasp the other end, pulling the
towel down across the back.
which may be difficult to reach (Fig. 28-5). Soap on a 3. Repeat the same procedure over the opposite
rope or a suction soap holder may be used to prevent shoulder.
soap from slipping about or getting lost in the water. An alternative method is to toss the towel over the top
The soap on the rope is hung around the neck or hung of a doorway and shut the door as much as possible to
within easy reach. Another alternative is to use liquid hold the towel in place. The patient then can pull the
soap in a pump container. A soaper sponge also may be towel across the back and shoulder with the nonaffected
used to wash without having to hold a slippery bar of extremity.
720 Stroke Rehabilitation

C
Figure 28-3 The Asta-Cath. (Available from A Products, www.aplusproducts.biz, [888]
843–3334.)

Washing at the Sink. Some individuals may have diffi- for personal hygiene needs. This system combines a spray
culty showering or bathing for a variety of reasons. An wand for bidet cleansing and a sitz bath (Fig. 28-6).
alternative method is to have body washes at the sink. The For individuals with low endurance who are unable to
easiest position in which to wash the affected arm is to shower or bathe at the sink, a total-body, pH-balanced
place the arm and axilla in the sink basin. To wash the cleanser may be used for shampooing, bathing, and incon-
unaffected arm, the individual steadies the soapy wash- tinence care. This product is available through a variety of
cloth over the edge of the sink and rubs the arm and hand rehabilitation catalogs. Drying techniques are the same as
over it. The patient then washes the rest of the body with previously described.
one hand. Again, a flex sponge is useful to wash all of the
body, including the nonaffected extremity. A supplement Performing Oral Hygiene. Oral hygiene care can be
to washing at the sink is the use of a bidet. The Hygen- done easily with one hand. A toothpaste dispenser can
ique Plus Bidet/Sitz Bath System is designed specifically dispense the correct amount of toothpaste on the brush
 Chapter 28 • Activities of Daily Living Adaptations 721

Figure 28-4 The Feminal. (Available from A Products, www.aplusproducts.biz, [888] 843–
3334.)

Figure 28-5Flex sponge. (Courtesy Sammons Preston, a

BISSELL Company.)

for individuals with limited hand function (Fig. 28-7).

The method of brushing (electrical or manual) is a per-
sonal choice. The use of an electrical toothbrush may
decrease energy expenditure because the brush vibrates
up and down, and the patient holds the arm in one posi-
tion. A Waterpik attachment is excellent for massaging
the gums and rinsing between the teeth. Suction tooth- Figure 28-6 Hygenique Plus Bidet/Sitz Bath System. (Cour-
brushes may be attached to a suction unit to prevent dys- tesy North Coast Medical, San Jose, Calif.)
phagia-related aspiration in individuals who cannot toler-
ate thin liquids.
The simplest method for denture care is to soak the
dentures overnight in a commercial denture cleanser. If
additional cleansing of dentures is needed, the patient can
use a suction denture brush.
Flossing teeth with one hand can be performed easily
and effectively with a commercially available dental floss
holder.

Applying Deodorant. Aerosol sprays are easier to apply

to the unaffected arm unless the individual has sufficient
function to reach the axilla with a roll-on or stick applica-
tor. The affected axilla must be placed passively away
from the body to apply deodorant. This can be accom-
plished by bending forward at the hips and allowing grav- Figure 28-7 Toothpaste dispenser. (Courtesy Sammons
ity to assist the arm away from the body. Preston, a BISSELL Company.)
722 Stroke Rehabilitation

Caring for Fingernails. Nail care of the affected hand

can be done easily with the noninvolved hand. Cleaning,
cutting, and filing the nails of the unaffected hand are
more difficult.
The following strategies may be used to ease nail
management:
1. To clean the unaffected hand, a nailbrush with suc-
tion cups for cleaning fingernails can be used.
2. To cut the nails of the unaffected hand, the patient
may use a one-hand fingernail clipper. When the
patient presses down on the board, the jaws of the
clipper close (Fig. 28-8).
3. Filing the nails of the unaffected hand can be done
in a variety of ways. A suction emery board is useful.
Other individuals may choose to use a homemade
device such as an emery board or sandpaper glued
to a piece of wood, a nail file secured to a table with
Figure 28-9 Footmate System. (Courtesy North Coast Medi-
masking tape, or a file wedged in a drawer.
cal, San Jose, Calif.)
4. Applying nail polish to the unaffected hand can be
done by mounting a clothespin on a piece of wood
with a C-clamp to hold the polish brush. The polish
is applied when the person moves the nail in rela-
tion to the brush.

Caring for Toenails. Cleansing toes can be accom-

plished with the use of a footbrush or Footmate System
(Fig. 28-9). Clipping toenails is easier if the feet are
soaked in warm water first. A pistol-grip remote toenail
clipper is one of several devices designed for one-handed
use to clip toenails; it allows one to reach the foot with
less bending (Fig. 28-10).

Hairstyling. Simple, short hairstyles are the easiest to

manage with one hand. Combing or styling long hair may
be easier using adjustable, long-handled grooming acces-
sories, available through various rehabilitation catalogs.

Figure 28-10 Pistol-grip remote toenail clipper. (Courtesy

Maddack, Pequannock, NJ.)

Lightweight splinting material also may be used to extend

the handles of an individual’s favorite grooming tools.
Blow-drying hair can be made easier by using a com-
mercial product called the Hands-Free Hair Dryer Holder,
which allows the unaffected hand free operation to style
hair (Fig. 28-11). An alternative method is a home-
devised product such as a position-adjustable hair dryer. A
Figure 28-8 One-hand fingernail clipper. (Courtesy Maddak, lightweight blow-dryer, a desk lamp with spring-balanced
Pequannock, NJ.) arms, a tension control knob at each joint, and a mounting
 Chapter 28 • Activities of Daily Living Adaptations 723

be able to achieve success without undue effort. Loose-

fitting clothes should be selected. Roomy clothes with
limited fasteners allow for increased ease of movement
and easier donning and doffing.
Dressing and undressing invariably involve awkward
movement patterns and a certain amount of sitting down
and standing up. Care must be taken to ensure that the
danger of falling is minimized. Management of clothes is
always difficult at first; the occupational therapist should
reinforce to the individual that independence and effi-
ciency are achieved through practice.

Fasteners
Many individuals with hemiplegia can learn to manage
fasteners if the following requirements are met:
■ Garments fit loosely.
Figure 28-11 Hands-free hair dryer holder. (Courtesy Sammons ■ Buttons and hooks are of a larger size.
Preston, a BISSELL Company.) ■ Fasteners are positioned in front of or on the nonaf-
fected side of the garment and are within sight.

bracket are the only materials needed to fabricate the de- Buttons. If the patient is unable to manage fasteners,
vice. The position-adjustable hair dryer requires limited the therapist can use the following adaptation:
body movement because the dryer can be positioned in 1. Remove the buttons from the garment and then sew
any plane desired.1 them back on over the buttonholes.
Brush attachments to the hair dryer also can be used 2. Using Velcro squares, sew the loop side of the Velcro
for blow-drying styles. A hot brush curling system can be over the original button side of the garment.
used for setting hair in simple hairstyles. 3. Sew the hook side of the Velcro under the button-
holes.
Shaving. Shaving can be done one-handed with any type The patient then simply uses hand pressure to close the
of razor. If a patient is unsteady with the motor skills, a garment. A standard collar extender also can be used.
Silk Effects razor reduces the risks of nicking the skin. An With this item, collars and cuffs are increased by 1⁄2 inch,
electric razor is easy to manage with one hand and is rec- increasing ease of management.
ommended for safety to prevent nicks.
Zippers. Zippers may be easier to manage if a ring or
Applying Makeup. The patient may apply makeup one- loop is added to the zipper tab. Patients should avoid
handed with practice. Grip and bottle makeup holders are open-ended zips. Patients can leave the zip fastened at the
useful to stabilize supplies; suction cups and rubber mats bottom and don the garment by pulling it on over the
also help stabilize grooming items. head. A large safety pin left fastened can prevent the zip-
per from sliding all the way down and detaching during
Dressing overhead donning.
Retraining an individual with hemiplegia who is limited
to the use of one hand to dress presents challenges to the Adaptive Dressing Techniques. Before initiating dress-
patient and the therapist. Specific deficits that the thera- ing training, the therapist should ensure the patient is
pist must address include the following: seated on a stable, supportive surface, preferably a
1. Impaired postural stability and balance sturdy armchair. Both of the patient’s feet should be
2. Decreased dexterity and work speed securely positioned on the floor to establish a solid base
3. Impaired ability to stabilize clothing articles and of support and increase postural stability. Clothing
body parts should be placed within easy reach and in the order in
4. Decreased endurance accompanied by increased which each item is required. This helps maximize en-
energy demands on the body ergy preservation.
5. Impaired sensory capabilities A wide variety of dressing techniques are described in
6. Possible cognitive and perceptual limitations the literature, depending on the particular treatment
When retraining the patient in dressing techniques, the theory incorporated by the therapist. Some general prin-
therapist should incorporate adequate time and allow- ciples that facilitate ease of one-handed dressing are de-
ances for rest breaks into the session. The patient should scribed in the following sections.
724 Stroke Rehabilitation

Shirtsleeves may need to be expanded or loose fitting to

Upper Extremity Dressing be pulled over the noninvolved hand. This can be achieved
Donning Garments with Front Fasteners. The patient by sewing a piece of elastic into the sleeve cuff to allow for
should follow these instructions for donning garments easy passage over the hand2 and to eliminate the difficulty
with front fasteners (Fig. 28-12): of managing a cuff button.
1. Pull the shirtsleeve onto the affected arm. The top button of a shirt collar is often difficult to
2. Pull the shirtsleeve over the affected shoulder. fasten. The button is usually small, and the collar fits
3. Swing the garment around until the other sleeve snugly around the neck. The problem can be eliminated
hangs down the back or pull the sleeve over the by replacing the button with a Velcro fastener.2
head and around the neck. The patient may even
anchor it by biting the sleeve. Donning Ties. Ties are difficult to manipulate single-
4. Reach to the back with the nonaffected arm handedly. The simplest solution is to use a conventional,
and place it into the opening of the remaining already-tied tie. A piece of elastic may be inserted into the
sleeve. back of the tie to replace a small part of the fabric. This
5. Use a shrugging motion with the nonaffected arm, allows for easy passage of the tie over the head. Clip-on
and straighten the sleeve into place. ties also are convenient to use.

Figure 28-12 Sequence for upper extremity dressing for a patient with left hemiplegia.
 Chapter 28 • Activities of Daily Living Adaptations 725

Donning Pullover Shirts Donning Pants and Underwear While Sitting Up

The patient should follow these instructions for donning The patient should follow this procedure for donning
pullover shirts: underwear and pants while sitting up (Fig. 28-13):
1. Use shirt tags or labels to identify the front and back 1. While sitting (preferably on a firm surface), cross
sides of the garment. the affected leg over the unaffected leg. Use clasped
2. Pull the correct sleeve onto the affected arm, and hands to lift the leg.
pull the garment onto the affected shoulder. 2. Put the correct pant leg over the affected foot and
3. Bend the head forward through the neck opening. pull it onto the leg.
4. Put the unaffected arm into the other sleeve. 3. Dress the unaffected leg.
5. Straighten the sleeve by rubbing the arm against the 4. Pull the pants up as far as possible while sitting; shift
leg. weight over each buttock.
6. Pull the garment over the torso. 5. Stand up to pull the pants up around the waist. If
balance is impaired, lean against a wall or sturdy
Donning Brassieres. Front-fastening bras are easier to piece of furniture to provide support and minimize
manage than bras that fasten in back. The bra should be the risk of falling. The patient also can use a pant
donned by putting the affected arm in first. Another clip. The pant clip attaches to the pants and an up-
method is to fasten the bra first and then put the bra on per body garment, and the clip holds the pants up
by donning it over the head. Larger hooks can be substi- while the patient transitions to standing, thereby
tuted for smaller hooks, or a Velcro strap and D ring may improving safety and function.
be sewn in as substitutions for the fastener. A bra extender
can be purchased and interchanged between bras; increas- Donning Skirts
ing the girth accommodation can ease donning. The patient should follow this procedure for donning skirts:
Patients may manage back-closure bras in the follow- 1. Put the skirt over the head and then pull it down.
ing way:2 2. Make sure to maneuver the fasteners to the front or
1. Align the bra around the waist so that the cups face the unaffected side for increased ease of fastening.
backward. The strap can be held in place by hug- 3. Twist the skirt around to the correct position.
ging it with the affected arm, by tucking it into the A skirt with an elasticized waist that expands to pass over
elasticized panty waist, or by using a clothespin to the head may be simpler.
hold it onto the pants.
2. Fasten the hooks in front. Donning Socks
3. Swivel the bra around so that the cups are in front. The patient should follow this procedure for donning
4. Pull the strap over the affected shoulder. socks (Fig. 28-14):
5. Using the thumb of the unaffected hand, pull the 1. Cross the affected leg over the other leg, using
strap over the unaffected shoulder. clasped hands to lift the leg.
The easiest solution, although not necessarily the most 2. With the leg in place, open the sock using the
aesthetic, is a fully elasticized bra such as a sports bra, thumb and index finger of the unaffected hand. Roll
which can be slipped on over the head. A hook-and-eye the sock down to the heel before slipping it on for
bra can be adapted by sewing the back fasteners together. greater ease in donning.
3. Bend forward at the hips to assist in reaching the
Lower Extremity Dressing foot. Pull the sock over the foot.
Donning Pants and Underwear While Lying in Bed 4. Don the sock on the unaffected foot in the same
The patient should follow this procedure for donning fashion.
underwear and pants in bed:
1. Bend the affected leg until the foot is within reach. Donning Shoes
The patient may use the unaffected leg to assist with The patient should follow this procedure for donning
this. shoes (Fig. 28-15):
2. Place the pants over the affected foot and allow the 1. Choose shoes that provide good support. A broad
leg to straighten into the pant leg. heel can provide better stability if balance is poor.
3. Put the unaffected leg into the pants and pull the Men’s standard dress shoes have a toe spring built
pants up as far as possible. into the front. For a patient recovering from stroke,
4. Using the unaffected leg, or if possible both legs, lift the toe spring may assist with toe clearance during
the pelvis off the bed. Wriggle the pants up to the the swing phase of gait.
waist. 2. Bring the affected foot closer to the body by cross-
5. Fasten the pants. (Velcro may be used in place of ing it over the unaffected leg or by using a small
buttons.) footstool.
726 Stroke Rehabilitation

B
Figure 28-13 Sequence for donning pants and underwear for a patient with left hemiplegia.
 Chapter 28 • Activities of Daily Living Adaptations 727

Figure 28-14 Sequence for donning socks for a patient with left hemiplegia.

3. With the leg in place, open the shoe as much as pos- top of the seam and the hook side to the front of the seam.
sible before attempting to put it on. The pant leg then can be opened up, allowing for easier
4. Bend forward at the hips to reach the foot. Place the manipulation of the orthotic over the calf.
shoe over the ball of the foot and pull it on. A help-
ful technique to aid with getting the shoe over the Adaptive Devices
foot is to mold a small piece of splinting material The therapist should introduce adaptive dressing devices
onto the shoe heel and allow it to harden. This only if the patient cannot otherwise perform dressing
helps to keep the heel rigid, preventing it from safely or efficiently. Dressing devices to consider might
buckling under as the foot slides in. include the following:
5. Shoes with Velcro closures are easy to manage with ■ A reacher, particularly if a patient has poor trunk
one hand. Shoelaces can be substituted with elastic control
laces or coilers that do not require tying. ■ A dressing stick, which can be useful to extend reach
if trunk balance is impaired and to push garments off
Donning Lower Extremity Orthotics. Lower extremity the affected side
orthotics can be difficult for patients to manage one-handed, ■ A long-handled shoehorn, which may assist the pa-
and patients may require assistance. In general, the donning tient in slipping on shoes
of orthotics is easier if placed into the shoe first. An adapta- All of the aforementioned devices are available from a
tion to the pant leg that may be helpful in donning the or- variety of rehabilitation catalogs.
thotic is to open the inseam of the pant cuff to the desired Walker, Drummond, and Lincoln3 completed a ran-
length. Stitch the loop side of a Velcro strip underneath the domized crossover study. One group (n  15) received
728 Stroke Rehabilitation

A B

C
Figure 28-15 A and B, Sequence for donning shoes for a patient with left hemiplegia. C, Heel
support fabricated from low-temperature plastic.

three months of no intervention followed by three months ■ Plate guards and scoop dishes are recommended to
of treatment; the other group (n  15) received three eliminate food getting pushed off the plate while
months of treatment followed by three months of no scooping or when buttering bread.
treatment. Treatment was provided by an occupational ■ A rocker knife or knife with serrated and curved
therapist and focused on dressing training for the sub- edges is easy to use with one hand if safety awareness
jects and their families. The subjects were assessed by an is intact.
independent evaluator using the Nottingham Stroke ■ Combined implements such as knife and fork or
Dressing Assessment; the Rivermead ADL Assessment, knife, fork, and spoon are available for purchase.
self-care section; and the Nottingham Health Profile. Safety in using these combined instruments is a con-
Both groups showed statistically improved performance cern if loss of sensation or weakness in oral-motor
during the treatment phase, neither group showed a structures is present. Utensils with built-up handles
change during the nontreatment phase, and subjects who also may be used to assist a weak grasp.
received treatment in the first three months maintained
their improvement. INSTRUMENTAL ACTIVITIES OF DAILY LIVING
Feeding Techniques Kitchen Activities
Positioning at the Table. The affected extremity should An individual with hemiplegia can accomplish kitchen
be supported in a good weight-bearing position on the tasks safely with adequate activity pacing; properly placed,
table. This position promotes appropriate upper extrem- secured equipment; and provision of adaptive devices.
ity alignment, visual awareness of the extremity, and trunk
symmetry. Energy Conservation and Work Simplification. A conse-
quence of weakness and impaired upper extremity func-
Use of Adaptive Devices. To avoid embarrassment while tion is that the individual with hemiplegia tires more
dining with others and to reach full independence with feed- quickly and thus needs to work at a slower pace. The fol-
ing, the patient often uses compensatory strategies and adap- lowing energy conservation guidelines should be included
tive equipment. The following equipment is recommended: in treatment plans focusing on increasing IADL:
■ Nonskid mats should be used to prevent slippage of ■ Allow increased time for task completion.
plates and bowls and to hold them steady during ■ Take frequent, short rest breaks.
meals. ■ Sit when working, when possible.
 Chapter 28 • Activities of Daily Living Adaptations 729

■ Avoid complicated procedures. The Zim jar opener is mounted easily to the wall or
■ Use ready-prepared foods when possible. underside of a cabinet and allows for one-handed screw
■ Use labor-saving equipment. (Electrical equipment cap removal of lids measuring from 1⁄2 to 31⁄2 inches in
such as microwaves and food processors with easy- diameter (Fig. 28-16).
to-control on-off switches and self-cleaning ovens A jar opener combined with a Belliclamp allows for
and self-defrosting freezers reduce manual labor re- easy opening of jar lids for individuals with weak grasps or
quirements.) A variety of cookbooks are available for use of only one hand. The Belliclamp holds jars and bot-
use with microwave ovens. Recipes tend to be sim- tles securely during use of the jar opener. The Spill Not
pler and require less preparation and shorter cook- Jar and Bottle Opener has a plastic nonskid base with
ing times. three rubber-lined openings to accommodate jars from 1
■ Arrange work surfaces at a height that allows for to 3 inches in diameter. A rubber lid opener provides a
maximal efficiency. firm grip for easy opening of jar tops. Lightweight electri-
■ Avoid excessive reaching and bending. cal or cordless can openers are easy to use with one hand
■ Reduce clutter. and are available from a variety of product catalogs and
To allow for easy access to supplies, items needed most appliance stores. An example is the E-Z Squeeze One
often should be kept on convenient shelves at the front of Handed Can Opener (Sammons-Preston).
the most accessible cupboards and drawers or at the back Patients can open cardboard boxes containing cereals,
of the work surface. rice, and instant potatoes one-handed by stabilizing them
firmly in a kitchen drawer and then carefully using scis-
Storage sors or the point of a knife to slit the boxtop open. Box
A variety of storage devices can be purchased that enhance toppers are inexpensive devices that easily slide open box
easy equipment access: tops and are ideal for one-handed use (Fig. 28-17).
■ Plastic-covered racks slide under or clip to the un- Pan holders keep pots and pans stabilized on a range
derside of shelves, increasing visible storage space. top while the individual stirs or sautés one-handed and are
They can be purchased at hardware stores. important to prevent spillage of hot food (Fig. 28-18).
■ Peg-Boards can be hung on the wall and used to A common device for stabilizing equipment and food
hang small pots, strainers, kitchen tongs, and spatu- items during food preparation is Dycem. The product is
las. made from gelatinous material, is nonslip on both sides,
■ Magnetic knife racks can be placed over a counter and is an easy, inexpensive alternative to help secure items
top and can be used to store knives, peelers, and such as pans and mixing bowls in place during cooking.
kitchen scissors. The Stay Put Suction Disc provides another means of
■ Lazy Susans, which can be placed in easy-to-reach securing bowls and plates to any smooth surface using
cupboards or at the back of a counter, are useful for vacuum pressure (Fig. 28-19). Mixing bowls with suction
persons who have trouble bending or reaching be-
yond the front of the cabinet; they allow for conve-
nient storage of jars, cans, and bottles.

Transport. Moving supplies safely about the kitchen is

another significant challenge for the person with hemiple-
gia. To avoid lifting and carrying, the patient can use a
rolling cart for transporting items from one side of the
kitchen to the other. Ideally, the cart should have a handle
at one end to provide support while walking. Dycem can
be used to help secure items on the cart shelves. A clip
secured to the side of the cart with glue can be used to
hold a cane or walking device while the person pushes the
cart with the noninvolved hand.

Stabilization. Patients can accomplish cooking activities

successfully single-handedly with adequate stabilization of
items. Tasks such as opening packages and containers,
peeling, slicing, making sandwiches, stirring, and mixing
create problems that usually can be solved by a variety of
self-help devices. The following paragraphs describe com- Figure 28-16 Zim jar opener. (Courtesy North Coast Medical,
monly used and readily accessible items for self-help. San Jose, Calif.)
730 Stroke Rehabilitation

Figure 28-17 Boxtopper. (Courtesy North Coast Medical, San

Jose, Calif.)

Figure 28-19 Stay Put Suction Disc. (Courtesy Sammons

Preston, a BISSELL Company.)

Stainless steel nails hold food in place for cutting and

chopping. Food guards keep food from sliding while the
individual spreads butter or sandwich spreads. Cutting
boards can be fabricated easily using 2-inch thick wood
and nails.

Food Storage. Rigid plastic containers with overlapping

lids usually are easy to open and seal with one hand.2 Plas-
tic containers with screw-top lids are ideal for storing rice,
sugar, flour, and other items that pour. Aluminum foil
molds easily with one hand and is useful for covering con-
Figure 28-18Pan holder. (Courtesy Sammons Preston, a
tainers and wrapping food that requires refrigeration.
BISSELL Company.)
Dish Washing. Nonstick cooking utensils are easy to
clean and make the cleanup process go quicker. Oven-to-
bases are available from a variety of product catalogs and table cookware cuts down on the number of supplies used.
allow for more vigorous one-handed stirring without slid- Pots and pans can be stabilized for scrubbing by position-
ing or tipping. Similarly, the Little Octopus Suction ing them on a wet dishcloth positioned in the corner of
Holders are inexpensive and provide double acting grip to the sink. For washing cups and glasses, the patient can use
anchor glasses, dishes, bowls, and other common objects a brush suctioned to the inside of the sink, such as a suc-
during meal preparation. Other items such as suction bot- tion bottle brush (Fig. 28-20).
tom nail brushes can useful during meal preparation to
clean fruits and vegetables. Home Maintenance
Cutting boards designed for one-handed use and de- Work simplification methods should be applied in the per-
signed from wood, Formica, or plastic come equipped formance of household tasks. Housework requires a great
with rubber suction feet to secure the board in place. deal of mobility and necessitates getting into awkward
 Chapter 28 • Activities of Daily Living Adaptations 731

Changing Sheets. Patients can manage sheets easily if

they are folded or unfolded in position on the bed. Pillows
should be kept on the bed during changing of the pillow-
cases so that the bed takes the weight of the pillow.

Laundry
Machine Washing Clothes. The patient should select fab-
ric and garment designs that are completely machine
washable and dryable and should use automatic machines.

Hand Washing Clothes. Soaking articles overnight in

soap or detergent can minimize the effort to remove dirt
with one hand. A washboard can be useful for scrubbing
out dirt and stubborn stains.

Wringing Clothes. Small articles can be rolled in a towel

and squeezed to remove excess water. Clothes can be wrung
Figure 28-20 Suction bottle brush. (Courtesy North Coast
out with one hand. Drip-dry clothes should be placed on a
Medical, San Jose, Calif.)
hanger before they are removed from the sink.

positions. Housework can be made easier by removing Ironing

clutter from the house. Time spent dusting is cut in half The patient should use a lightweight iron. Steam irons are
without added clutter. To conserve personal energy and efficient at removing creases from many materials.
ensure ease of performance, adaptive devices such as light- Most ironing boards are height adjustable so that the
weight, long-handled, and electronic tools may serve as individual can sit or stand when using them. Ironing
useful supplements. boards can be difficult and heavy to manage with one
hand. The board may be left permanently standing if
Caring for the Floor. Long-handled, freestanding dust- space permits. Ironing also can be done on the kitchen
pans; self-wringing sponge mops; electrical floor scrub- table or a counter covered with a folded towel or sheet.
bers; light upright vacuum cleaners with helping hand
attachments; and no-wax floors can ease the maintenance Sewing
of floor care. While mopping the floor, the individual Threading Needles. A patient can thread a needle easily
should use a rectangular bucket. This allows the sponge with one hand if the needle is held in a pincushion, pad-
mop to be soaked fully with water in a half-filled bucket ded armchair, or bar of soap. Self-threading needles and
as opposed to partial soaking in a round bucket. The automatic needle threaders also are available at most ma-
bucket should be filled and emptied on the floor with a jor department stores.
plastic jug to avoid heavy lifting.
Cutting. A patient can cut material if it is stabilized by
Cleaning the Bathroom. The patient should use a long- weight to prevent slipping. Although most scissors are for
handled reach sponge mop to clean the bathroom. This right-handed use, scissors and shears for left-handed use
product is available through a variety of rehabilitation are available.
catalogs. The risk of falling is great, and kneeling or sit-
ting should be considered in the performance of this Hand Sewing. The patient can perform hemming and
household task. sewing seams easily by placing material over a curved
Extra cleaning materials should be kept upstairs and object such as an armchair and holding it down with
downstairs to avoid unnecessary journeys. Items can be weights.
transported in an apron with large pockets, a shoulder
bag, or a wheeled cart. Machine Sewing. A patient can use a sewing machine
with one hand with practice according to safety
Bed Making. Bed making can be difficult with only one guidelines.
hand. Beds should be positioned so that access to both
sides is easy. To conserve energy, the patient can make the Communication
bed by completing each corner of one side from the un- Writing. Individuals whose strokes have affected their
dersheet to bedspread before moving to the other side to dominant sides need to consider dominance retraining to
repeat the operation. learn to write with the noninvolved hand. An important
732 Stroke Rehabilitation

goal for such individuals is to be able to sign their names CASE STUDY
legibly.
One-Handed Training after Stroke
Writing practice begins with exercises consisting of
continuous circles and connected up and down strokes. E.B. is a 74-year-old male recovering from a left stroke
Patients practice large strokes first and progress to smaller with right hemiplegia and a medical history of signifi-
ones. With increasing proficiency, patients practice al- cant hypertension. E.B. worked as an engineer for
phabet letters. At the initiation of training, patients 50 years but has been retired for the past two years. He
should use a larger-size pencil, crayon, or rubber pencil currently is married, and his wife works full-time. E.B.
grip attached to a standard pencil. The paper may be resides in a ground-floor apartment with three steps up
stabilized with Dycem or a clamp or by weighting the to enter the building.
paper down. E.B. was referred for home care services on discharge
Except for meeting the requirement of a functional from the hospital. Initial occupational therapy evaluation
signature, individuals may prefer to use another method revealed the following: He was alert and oriented to per-
of written communication. Individuals with hemiplegia son, place, situation, and time. His cognitive perceptual
can access equipment such as personal computers, tape status was intact. Before his stroke, E.B. was right-hand
recorders, and word processors easily. dominant. On evaluation, his right upper extremity was
flaccid. His left upper extremity had functional range of
Using the Telephone. Providing for easy access to motion and strength. Sensation was intact throughout.
the telephone is not a significant problem. Use of a Static and dynamic sitting balance was good. When
speakerphone can facilitate telephone use. Another standing, however, he was unsteady while performing
product, the commercially available phone holder, frees challenging tasks. His endurance for light activity was
the noninvolved hand for dialing or taking messages. poor. E.B. required assistance with the following ADL
This device consists of a flexible arm clamped to a tasks: bathing, grooming, feeding, dressing, simple meal
table, which holds the telephone receiver in a station- preparation, writing, and community-based activities.
ary position; the device is available through product The therapist established a number of treatment
catalogs. goals with the patient:

Long-Term Goals
COMMUNITY-BASED ACTIVITIES
1. E.B. will be independent in managing BADL using
Marketing and Grocery Shopping adaptive techniques and assistive devices as required.
Energy conservation should be applied in marketing 2. E.B. will be independent with simple meal prepa-
and grocery shopping. The individual should make a ration.
list of necessary items and anticipate weekly expenses 3. E.B. will be independent in shopping and banking.
to minimize trips to the cash machine. The patient
should categorize items according to aisles, thus limit- Short-Term Goals
ing excess walking around the store. The patient 1. E.B. will independently bathe himself using assistive
can use a lightweight pushcart to carry items around devices.
the store and home if a car is not available. Individuals 2. E.B. will independently clean and floss his teeth
using wheelchairs require assistance with shopping with use of assistive devices.
trips. The patient should place money in an easily ac- 3. E.B. will be able to cut and butter food indepen-
cessible pocket or purse to ensure easy retrieval at the dently with a rocker knife.
checkout line. An alternative is mail, phone, or online 4. E.B. will independently dress himself using adaptive
shopping. techniques and devices.
5. E.B. will independently prepare himself lunch.
Banking 6. E.B. will independently perform home-based finan-
Banking has become easier during the past decade. Indi- cial responsibilities.
viduals can go the bank, access money through automatic
Adaptations
teller machines, and bank by phone or online. If the pa-
tient’s signature has been altered because of loss of func- Before initiating basic ADL training, the therapist sur-
tion in the dominant hand, the bank must be notified. veyed the environment to ensure safety and ease of
Banks have varying policies regarding this situation. For mobility. The following changes were recommended
the most part, the new signature can be placed on file and implemented:
easily. Some banks, however, require a written and nota- 1. Excess clutter was removed from the bedroom,
rized letter from a physician before a new signature can bathroom, kitchen shelves, and drawers to ensure
be authorized.
 Chapter 28 • Activities of Daily Living Adaptations 733

easier access of needed supplies. Closet rods were E.B. also was required to make lunch for himself
lowered to allow for easier access of clothing. while his wife was at work. His favorite lunch was a
2. The bathroom floor rug was replaced with nonslip ham and cheese sandwich with lettuce and tomato and
mats inside and outside the tub. A tub transfer bench a glass of apple juice.
with handheld shower attachment was provided. The following kitchen adaptations were made:
3. A board was placed under the mattress to increase 1. E.B. used a rolling cart to gather necessary supplies
firmness, and a bedrail was placed on E.B.’s unin- at one time and maneuver them to the kitchen table,
volved side to increase safe transfers in and out where he could sit to complete the task.
of bed. 2. A cutting board was fabricated using 2-inch thick
4. A lamp was placed on a bedside table next to E.B. to wood, nails, and a plastic food guard glued to the
ensure sufficient lighting. side of the board. Using the board, E.B. was able to
ADL training was initiated with implementation of cut tomato slices successfully, stabilize lettuce, and
several adaptations: spread mayonnaise on a slice of bread while stabiliz-
ing it against the food guard.
Bathing 3. Presliced ham and cheese were stored in a plastic
1. Soap on a rope was used to stabilize the soap. zipper bag that E.B. could access easily and seal us-
2. A flex sponge enabled E.B. to reach all body parts ing the zipper bag sealer.
successfully. 4. Using a Zim jar opener, E.B. was able to open the
3. A pump spray shampoo bottle was used to avoid apple juice bottle top.
excess waste and keep shampoo from getting into
eyes. Dominance Retraining and Financial Management
4. E.B. reviewed one-handed drying techniques. E.B. was initially right-hand dominant. An important
goal for him was to be able to sign his name legibly on
Oral Hygiene legal documents. He was put on a program of writing
1. A toothpaste dispenser allowed for easy one-handed practice exercises. After obtaining a legible signature,
access. E.B. contacted the bank and was required to submit a
2. The Floss Aid dental floss holder allowed E.B. to copy of his new signature to be placed on file.
floss his teeth.
Marketing and Grocery Shopping
Nail Management As E.B.’s endurance improved, shopping outings with
1. A one-handed home device was fabricated from a his wife were encouraged. The following energy con-
nail clipper secured to a piece of plywood with suc- servation guidelines were incorporated:
tion feet attached. 1. E.B. made a list of necessary items and grouped
2. A pistol-grip toenail clipper enabled E.B. to cut his them according to aisles to limit excess walking.
toenails with less bending. 2. A lightweight pushcart was purchased to carry items
around the store and into the home.
Dressing 3. Before leaving home, E.B. would place his money in
1. Energy conservation techniques were reviewed be- an easily accessible pocket from which he could re-
cause of E.B.’s poor endurance. trieve it quickly at the checkout line.
2. E.B. was able to don and doff shirts but unable to
manipulate fasteners. Velcro was substituted for
buttons.
3. E.B. was able to don his pants successfully with the SUMMARY
support of a sturdy dresser placed next to the bed,
This chapter describes equipment recommendations and
which he leaned against to pull up his pants safely
practical and creative solutions that the occupational
while standing.
therapist can incorporate to assist patients in becoming
4. E.B. was able to don his shoes after a piece of splint-
more independent in performing BADL and IADL. For
ing material was molded into the shoe heel. Elastic
individuals with limited functional return of the involved
laces allowed for easy fastening.
upper extremity, compensatory techniques are crucial
Feeding and Simple Meal Preparation during the rehabilitation process and maximize the poten-
tial for reaching meaningful goals. As always, the therapist
A rocker knife, nonskid mat, and plate guard allowed
should concentrate on activities the patient finds most
E.B. to cut and butter his food successfully and without
meaningful and curtail activities the individual does not
spillage.
want to perform. For individuals with extensive paralysis
734 Stroke Rehabilitation

resulting from stroke, family members or hired outside 2. U. S. Department of Health and Human Services: Clinical practice
help may be required to assist with ADL. guidelines #16: post stroke rehabilitation, Rockville, MD, Agency for
Healthcare Policy and Research 1995.
3. Walker MF, Drummond AER, Lincoln NB: Evaluation of dressing
REVIEW QUESTIONS practice for stroke patients after discharge from hospital: a crossover
design study. Clin Rehabil 10(1):23, 1996.
1. When is use of compensatory strategies most advanta- 4. World Health Organization: International classification of function,
geous as part of the rehabilitation process? Geneva, 2001, The Organization.
2. What environmental considerations need to be taken
into account before the initiation of ADL training? SUGGESTED READINGS
3. Where can specific information regarding the reliabil-
Berger PE, Mensh S, Whitaker J: How to conquer the world with one
ity and validity of BADL evaluation instruments be hand . . . and an attitude, ed 2, Merrifield, VA, 2002, Positive Power
obtained? Publishing.
4. What are some compensatory techniques and adaptive Keith RA, Granger CV, Hamilton BB, et al: The functional indepen-
devices an individual may use during grooming and dence measure: a new tool for rehabilitation. In Eisenberg MG,
hygiene to compensate for loss of one upper extremity? Grzesiak RC, editors: Advances in clinical rehabilitation, vol 1,
New York, 1987, Springer-Verlag.
5. Which specific deficits need to be considered before Kelly-Hayes M, Robertson JT, Broderick JP, et al: The American Heart
the initiation of dressing training? Association Stroke Outcome Classification: executive summary. Circu-
6. What energy conservation and work simplification tech- lation 97(24):2474–8, 1998.
niques should be considered during IADL training? Law M: The Canadian occupational performance measure, ed 4, Ottawa,
7. Which compensatory techniques and adaptive devices 2005, CAOT Publications ACE.
Legg L, Drummond A, Leonardi-Bee J, et al: Occupational therapy for
should be considered to compensate during kitchen- patients with problems in personal activities of daily living after stroke:
based activities for loss of one upper extremity? systematic review of randomised trials. BMJ 335(7626):922, 2007.
8. What types of adaptive devices should be considered for Mahoney FI, Barthel D. Functional evaluation: the Barthel Index.
easier performance of home-maintenance activities? Md State Med J 14:56–61, 1965.
9. If a signature has been altered because of loss of Mayer TK: One-handed in a two-handed world, ed 2, Boston, 2000,
Prince-Gallison Press.
function in the dominant hand, what issues need to Nakayama H, Jorgensen HS, Raaschou HO, et al: Compensation in
be addressed before the patient resumes financial recovery of upper extremity function after stroke: the Copenhagen
responsibilities? stroke study. Arch Phys Med Rehabil 75(8):852–857, 1994.
Steultjens EMJ, Dekker J, Bouter LM, et al: Occupational therapy for
stroke patients: a systematic review. Stroke 34(3):676–687, 2003.
REFERENCES Trombly CA, Ma HI: A synthesis of the effects of occupational therapy
1. Feldmeier DM, Poole JL: The position-adjustable hair dryer. Am J for persons with stroke, Part I: Restoration of roles, tasks, and activi-
Occup Ther 41(4):246–247, 1987. ties. Am J Occup Ther 56(3):250–9, 2002.
1a. Nakayama H, Jorgensen HS, Raaschou HO, et al: Compensation in van Swieten J, Koudstaal P, Visser M, et al: Interobserver agreement for
recovery of upper extremity function after stroke: the Copenhagen the assessment of handicap in stroke patients. Stroke 19(5):604–607,
stroke study. Arch Phys Med Rehabil 75(8):852–857, 1994. 1988.
 g l en g i l l en

chapter 29

Leisure Participation
after Stroke

key terms
adaptive equipment leisure leisure satisfaction
extrinsic barriers leisure attitudes types of leisure
intrinsic barriers leisure roles

chapter objectives
After completing this chapter, the reader will be able to accomplish the following:
1. Define leisure, types of leisure, and functions of leisure activities.
2. Discuss the changes in an individual’s ability to engage in leisure tasks after a stroke.
3. Describe problems that may interfere with a patient’s participation in leisure tasks.
4. Present possible solutions to these problems.
5. Discuss research addressing leisure participation and occupational therapy interventions
after stroke.
6. Outline ways occupational therapists can adapt leisure tasks to allow partial or full partici-
pation by someone with a disability caused by a stroke.

Comprehensive stroke rehabilitation must include the to improving leisure skills and participation usually re-
consideration of leisure. This is particularly true as there is quires a team approach to meet the complex needs of
a renewed focus on decreasing activity limitations and stroke survivors.
participation restrictions and on improving quality of life This chapter provides a conceptual framework to help
as a critical outcome to measure after stroke. Rehabilita- therapists evaluate the leisure skills and improve the leisure
tion professionals are obligated professionally to address participation of patients who have survived a stroke. It fo-
changes in patients’ leisure roles and to use patients’ lei- cuses on increasing the ability of occupational therapists to
sure interests to plan treatment sessions. This area of improve the leisure skills and the quality of life of this
functioning is critical in the assessment of patients’ moti- population. Readers are encouraged to review Chapter 3
vation, quality of life, and self-esteem. Effective approaches with this chapter.

735
736 Stroke Rehabilitation

DEFINITION OF LEISURE occupant of a position perceives that he or she is unable

to meet role expectations.”20
The Practice Framework1 of the American Occupational Use of time is an important factor in leisure participa-
Therapy Association includes leisure under the heading tion. It is well-documented that individuals have impov-
Performance in Areas of Occupation. Leisure is described erished time use after stroke including leisure and social
as being “nonobligatory behavior, intrinsically motivated, participation. The therapist should analyze the person’s
and engaged in during discretionary time, that is, time not schedule to determine whether intervention is necessary.
committed to obligatory occupations such as work, self- In an inpatient rehabilitation unit, those with stroke
care, or sleep.”32 The Practice Framework includes the spend more time inactive and alone as compared to
following two subcategories: those without stroke.6 Additionally, at one month post-
1. Leisure exploration: identifying interests, skills, op- discharge, survivors struggle with establishing routines
portunities, and appropriate leisure activities in their day and coping with an increased amount of idle
2. Leisure participation: planning and participating in time. Subjects’ strategies for managing increased idle
appropriate leisure activities, maintaining a balance time include “passing time,” “waiting on time,” and
of leisure activities with other areas of occupation, “killing time.” 37
and obtaining, using, and maintaining equipment
and supplies as appropriate LEISURE, STROKE, AND OCCUPATIONAL
The Practice Framework also includes the following re- THERAPY
lated definitions:
■ Play: “any spontaneous or organized activity that In their review of the literature regarding the role of
provides enjoyment, entertainment, amusement, occupational therapy and leisure after stroke, Parker,
or diversion.”32 Play is further broken down into Gladman, and Drummond33 summarized the following:
play exploration (identifying appropriate play ac- ■ Stroke survivors often fail to resume full lives, re-
tivities), and play participation defined as “partici- gardless of whether they make a good physical re-
pating in play; maintaining a balance of play with covery.
other areas of occupation; and obtaining, using, ■ Participation restrictions such as a decline in social
and maintaining toys, equipment and supplies and leisure pursuits are prevalent.
appropriately.” ■ Customary goals of rehabilitation are focused on
■ Social participation: “organized patterns of behavior mobility and independence in self-care, but recovery
that are characteristic and expected of an individual in a broader sense may not be maximized if health
or a given position within a social system.”30 Social professionals concentrate exclusively on these goals.
participation can include community (engaging in ■ Leisure has been shown to be associated closely
activities that result in successful interaction at the with life satisfaction and is a worthwhile goal of
community level), family (engaging in required or rehabilitation.
desired family roles), and peer/friend (engaging in ■ Elderly persons show a decline in leisure activity,
activities at different levels of intimacy including which has been well-studied. This information may
engaging in sexual activity). See Chapter 25. provide a useful model for the more rapid decline
Leisure attitude is defined as the expressed amount of affect seen in stroke patients.
toward a given leisure-related object. According to Feibel ■ Further research is needed to confirm the finding
and Springer,14 “this attitude is a multiplicative function that specialized occupational therapy can be ef-
of a person’s beliefs that an object has certain characteris- fective in raising leisure activity and to show
tics and a personal evaluation of these characteristics.” whether this translates into improved psychologi-
Many factors affect an individual’s leisure attitudes. These cal well-being.
factors include social influences, personality, past experi- Widen-Holmqvist and colleagues42 studied a community-
ences, and motivation. Leisure attitudes play an important based sample of 20 patients living at home one to three
role in the choice and pursuit of leisure activities. A posi- years after hospitalization for stroke and who perceived
tive experience during an activity usually results in the that they were in need of rehabilitation services. Their
person continuing to engage in this pursuit. results included the following:
A leisure role is defined as a perceived identity associ- ■ Most of the subjects reported a change in activity
ated with a leisure task. Changes in a person’s roles and interest patterns after stroke.
throughout life are accompanied by shifts in leisure par- ■ Subjects had high motivation for current activities.
ticipation. Role changes resulting from disability may ■ Cognitive functions were within normal limits for all
cause role strain and role conflict: “Role strain refers to tested subjects.
the difficulty an individual experiences when attempting ■ Motor abilities and verbal performances frequently
to meet role obligations. Role conflict occurs when the were affected and varied considerably.
 Chapter 29 • Leisure Participation after Stroke 737

■ Social and leisure activities outside the home were pursuits are important for establishing and maintaining
identified as the most promising goals for community- social networks. A balance between work and play is im-
based rehabilitation programs and that by focusing on portant. Factors that influence participation in active lei-
such activities, improvement in quality of life for this sure activities include financial constraints, decreases in
population could possibly be achieved by individually functional skills, and decreases in social supports. Many
planned rehabilitation programs. older individuals replace active leisure tasks with more
Amarshi, Artero, and Reid2 published a qualitative study passive ones after experiencing decreases in physical and
of 12 stroke survivors and aimed to investigate the types cognitive abilities.
of social/leisure activities engaged in pre/poststroke, the
meaning attributed to leisure pursuits, and the process LEISURE ACTIVITIES DURING
involved in social/leisure participation following stroke. OCCUPATIONAL THERAPY
The authors identified four themes from their data:
■ Life has changed when characterized by reduced Occupational therapists working with patients who have
social/leisure activity, giving up favored leisure oc- had a stroke are concerned with the way these individu-
cupations, and having to rely on others. als spend their time. Often leisure and play interventions
■ Limitations to participation include physical impair- are considered secondary during the rehabilitation pro-
ments, cognitive impairments, transportation issues, cess as therapists focus on self-care and instrumental
and cost. activities of daily living (ADL). However, leisure activi-
■ Requirements for participation include social sup- ties can be equally meaningful to patients as they rede-
ports and interactions with others, fitting in with fine their life roles.2,39 Occupational therapists can inte-
others, accommodations related to transportation, grate leisure activities into the rehabilitation process in
and organization support such as structured groups two ways: occupation-as-end and occupation-as-means.40
and programs. Occupation-as-end40 refers to activities and/or tasks
■ Moving on with life and reengaging in leisure and that comprise a role. The patient chooses the occupation
social participation including initiate new activities, as a meaningful activity he or she wants to perform, needs
adapting activities, and maintaining a meaning life. to perform, or has to perform. Therapists may become
aware of these activities (e.g., bowling, crossword puzzles,
FACTORS AFFECTING LEISURE and making jewelry) via an interview process or a semi-
PERFORMANCE structured interview such as the Canadian Occupational
Performance Measure (COPM).25 When a (leisure) activ-
Many factors affect leisure participation, including the ity is defined by the patient, the therapist collaborates with
following: the patient to accomplish the goal through a variety of
■ Patterns of underlying impairments (i.e, cognitive, interventions including adaptation (e.g., enlarged print on
motor, psychological, or combinations) books), education (e.g., providing information regarding
■ Types of leisure tasks available transportation methods to and from a local pool), using
■ Stage of life remaining abilities, and/or remediation. Trombly40 pointed
■ Social and cultural environments out that when a therapist uses occupation-as-ends, the
■ Leisure attitudes, roles, and satisfaction therapist is not focused on using leisure activities to make
■ Use of time as discussed previously a change at the impairment level (e.g., improve scanning
■ Barriers to leisure participation ability), although this may occur as a secondary gain.
A strong, well-coordinated person may prefer physical Trombly suggested that the therapist use the following
leisure activities such as baseball, soccer, and basketball. principles to implement occupation-as-end:
Persons with less developed physical skills may be inter- ■ Organize the subtasks to be learned so the patient
ested in more intellectual leisure tasks such as reading, will succeed.
playing chess, and working puzzles. They also may be ■ Give clear instructions.
interested in creative leisure pursuits such as painting, ■ Use feedback to promote success (see Chapter 5).
photography, and quilting. ■ Structure the practice to ensure learning (see
Geographic location also may affect participation in Chapter 5).
leisure activities. If a person lives in a rural environment, ■ Make adaptations when needed (see Chapter 28).
leisure activities may include hiking, horseback riding, Occupation-as-means40 may be described as using (lei-
swimming, and fishing. Someone in an urban environment sure) occupations as a treatment to improve body system
may go shopping or to theaters, lectures, and museums. and body structure impairments. The (leisure) activity is
Leisure assumes various forms throughout life. The the change agent. The therapist may use leisure activities
amount and type of leisure activities depend on the per- like the Nintendo Wii to remediate impairments such as
son’s developmental stage.18 During adulthood, leisure weakness, postural dyscontrol, and neglect. Valued leisure
738 Stroke Rehabilitation

activities may be incorporated into the treatment plan to therapists in determining the type of leisure tasks patients
improve other functional areas. For example, the patient enjoyed before their stroke.17,28
may achieve postural and motor goals in a standing posi- Other usual and customary assessments can assist thera-
tion while engaging in a game of air hockey. See Chapter pists in making decisions regarding leisure interventions.
10 for examples of using occupation-as-means to remedi- For example, information regarding range of motion, skel-
ate upper extremity motor control dysfunction and Chap- etal muscle activity, strength, endurance, postural control
ter 19 for examples to improve cognitive-perceptual dys- and alignment, motor control, praxis, fine motor coordi-
function (Box 29-1). Therapists should be cautious about nation, and visual-motor integration is critical. The com-
relying too much on using occupation-as-means during plete cognitive and perceptual assessment provides neces-
treatment sessions; patients should be given a clear expla- sary information regarding the level of arousal, orientation,
nation related to why the activity was chosen. For exam- recognition, attention span, initiation and termination of
ple, when a patient has mild neglect, the therapist might activities, memory, sequencing, categorization, concept
say, “As we’ve both discovered, you are forgetting to look formation, spatial operations, problem-solving, learning,
for items on your left, such as not finding your tooth and generalization.
brush on the left side of the sink or the juice in the left Therapists should review the type of leisure activities
side of the refrigerator. We are going to try to get you to the patient performed before the stroke. For instance,
look left more often. We are going to play dominoes, and someone who mostly participated in individual leisure
I will put all of your dominoes on the left side. Try to look tasks may have been content with little social contact. If
left as often as possible, and I will remind you as needed.” the person enjoyed relational leisure tasks, social interac-
After the activity, processing should occur related to tions may be important.
whether the patient met the goals of the session (see The therapist must consider the patient’s stage in the
Chapter 19). If patients are not given this information, life cycle because participation in leisure changes during
they will not be able to make the connection between the the aging process. During adulthood, an individual’s par-
therapeutic activity and their functional goals. ticipation in leisure activities decreases because of de-
mands such as work, household maintenance, and child-
Evaluation of Leisure Skills care. The importance and meaning of leisure also change
When evaluating the leisure roles of patients, thera- as a person matures.
pists must consider seven factors that can affect leisure The physical, social, and cultural environments are
performance: critical in the development of leisure practices and the
1. Evaluation findings related to impairments and per- pursuit of leisure activities during adulthood. Information
formance in areas of occupation on the patient’s social and cultural networks helps the
2. Types of leisure activities that interest the patient therapist focus the treatment plan.
3. Patient’s stage in the life cycle The patient’s leisure attitudes, roles, and satisfaction
4. Physical, social, and cultural environments before the stroke are important factors to consider after
5. Patient’s previous leisure attitudes, roles, and satis- the stroke. The therapist should identify the impor-
faction tance of the selected leisure tasks and the patient’s
6. Patient’s past and present use of time level of satisfaction with them. Identifying the specific
7. Premorbid barriers aspects of the activity the patient finds enjoyable is
These factors can guide therapists in identifying leisure helpful. The therapist also should document the pa-
activities that must be modified and in assisting patients tient’s leisure roles by discussing topics such as family
with leisure exploration. A checklist (Fig. 29-1) can assist expectations.
The therapist can address past and present use of time
by asking patients to describe the way they spent their
Box 29-1 time before the stroke, whether they achieved a balance
Role of the Occupational Therapist between work and play, and whether they now require
additional time for nonleisure activities.
■ Evaluate patient’s physical, cognitive, and perceptual The therapist must address premorbid barriers to lei-
skills and environmental factors (social and cultural) sure participation, which are obstacles that kept patients
that affect leisure participation. from participating in the full scope of leisure activities
■ Provide treatment to improve patient’s limitations.
before their stroke and include intrinsic, environmental,
■ Provide adaptive equipment and adapt techniques to
improve leisure participation.
and communication barriers (Box 29-2).
■ Provide education about various community resources Many ways are available to assess an individual’s lei-
and alternative transportation methods to increase sure interests, such as a leisure interest checklist (see
participation. Fig. 29-1), a structured interview form, and a time log
(Fig. 29-2) that requires the patient to record previous
 Chapter 29 • Leisure Participation after Stroke 739

and current use of time. Therapists should strive to use were associated with higher subscores on the
standardized assessments. Nottingham Extended Activities of Daily Living
Examples of assessments the therapist can use to assess Scale, and lower Nottingham Leisure Questionnaire
leisure skills and participation in stroke survivors include scores were associated with living alone and worse
the following: emotional health.
■ Nottingham Leisure Questionnaire:11,12,35 This as- ■ Activity Card Sort:4 The card sort is used to measure
sessment was developed to measure the leisure activ- an individual’s participation or lack of participation
ity of stroke patients. The results of the interrater in instrumental, leisure, and social activities. See
reliability study were “excellent,” and the results for Chapter 3 for a full description.
the test-retest reliability study were “excellent” or ■ Canadian Occupational Performance Measure:25
“good.” Recently, the Nottingham Leisure Question- This semistructured interview covers three areas:
naire has been shortened (from 37 to 30 items) and leisure, self-care, and productivity. The patient iden-
the response categories have been collapsed (from five tifies and ranks areas of meaningful occupational
to three categories) to make it suitable for mail use.11 performance and rates the level of performance and
Higher Nottingham Leisure Questionnaire scores satisfaction.

Date Occupation
Name Marital status
Age Onset of stroke
Cultural background Children’s ages
Favorite leisure task Male Female

Please answer the following questions to enable your therapist to assist you in resuming/persuing your
leisure interests:

1. When do you perform leisure activities?

Morning Afternoon Evening Weekdays
Weekends Holidays Vacations

2. What type of leisure activities do you enjoy?

Physical Intellectual Arts Social
Solitary Structured Unstructured

3. Place a check mark next to the people who are involved in your leisure activities.
Significant other Spouse Children Parent
Sibling Friend Co-worker Pets
Relatives Grandparents Grandchildren

4. Do you want to resume your past leisure activities?

Yes No Do not know

5. If you do not want to resume past leisure activities, please place a check mark next to the reasons.
Loss of skills No time Depressed Resources not available
Afraid No transportation Decreased leisure performance
Decreased communciation skills No interest
Other—Please state the reason.

6. Are you satisfied with your present leisure activites?

Yes No—why? Do not know

Figure 29-1 Leisure interest checklist. Continued

740 Stroke Rehabilitation

Please check the types of leisure activities you enjoy:

Music Sports
Attending concerts Skiing
Singing Softball
Playing instruments Baseball
Conducting Football
Watching concerts on television Running
Listening to the radio Jogging
Biking
Dance Hockey
Tap Basketball
Ballet Skating
Folk Sailing
Jazz Other
Ballroom
Modern Table Games
Other Table tennis
Cards
Arts and Crafts Scrabble
Carpentry Dominoes
Sewing Puzzles
Knitting Chinese checkers
Needlepoint Checkers
Painting Othello
Quilting Chess
Ceramics Monopoly
Model making Backgammon
Drawing Trivial Pursuit
Sculpture Other
Photography
Other Relaxation
Meditation
Community Yoga
Volunteering T’ai chi
Travel Horticulture
Church Pet care
Temple
Other

Figure 29-1, cont’d

■ Leisure Competence Measure:22,23 This measure includes 25 items. Items are rated on 3-point scale.
provides information about leisure functioning and Assessment areas include playfulness, competence,
measures change in leisure function over time. The barriers, and knowledge.
tool includes nine areas: social contact, community ■ Frenchay Activities Index:41 This tool is used for as-
participation, leisure awareness, leisure attitude, so- sessing general (i.e, other than personal care) activi-
cial behaviors, cultural behaviors, leisure skills, in- ties of stroke survivors. The tool comprises 15 indi-
terpersonal skills, and community integration skills. vidual activities summed to give an overall score
Items are rated on the 7-point Likert scale. from 0 (low) to 45 (high).
■ Leisure Satisfaction Scale:5,36 This scale measures
the degree to which people’s personal needs are met Interventions to Improve Leisure Skills
through their leisure activities (24 items scored from The intervention process begins with obtaining the pa-
1 to 5; higher scores indicate greater satisfaction). tient’s leisure history. The therapist then reviews the results
■ Leisure Diagnostic Battery:7 The original version of the evaluation and determines the patient’s strengths and
includes 95 items, whereas the newer, shorter version limitations in relation to the performance components.
 Chapter 29 • Leisure Participation after Stroke 741

Box 29-2 3. Integrated

Factors Affecting Leisure Performance 4. Accessible
after Stroke At the first level noninvolvement, the person who has
the disability does not participate in any leisure tasks.
Type of leisure tasks Unconditional At the second level segregated, the patient participates
Compensatory or recuperative in structured activities developed for group members
Relational with the same disability group. Examples include com-
Role-determined
munity activities through local stroke organizations,
Stage in the life cycle Childhood
Young adult
stroke support groups, and specialized sports programs
Middle age (aquatics).
Later life The third level integrated “provides persons with
Social and cultural Support system (i.e, family disabilities the opportunity to be mainstreamed into
environments and friends) regular community recreation programs and to partici-
Nationality pate alongside nondisabled participants. This approach
Religion appears to go a long way toward helping to change the
Leisure attitudes, roles, Attitudes negative attitudes, stereotypes, stigmas, and myths as-
and satisfaction Roles sociated with persons with disabilities and the systems
Satisfaction that serve them.”38 The occupational therapist can in-
Use of time Present
struct patients in the use of adaptive equipment and
Past
Barriers to leisure Internal barriers
methods to pursue leisure activities successfully in the
participation Lack of knowledge community.
Decreased skills The fourth level accessible occurs when the individual
Decreased opportunities with a disability “is able to select and access preferred
Environmental barriers recreation programs with no more effort than his or her
Attitudes counterpart who is not disabled. . . . The participant is
Architectural able to realize his or her ultimate goal of achieving a sat-
Transportation isfying leisure lifestyle, free of any significant individual
Rules and regulations and external constraints.”38
Barriers of omission The therapist can use these levels to improve an indi-
Economic
vidual’s involvement gradually. For instance, if a patient
Communication barriers
Social skills
enjoys bowling and wants to return to this activity, the
Ability to speak therapist may locate or form a specialized bowling pro-
Ability to listen gram. When the patient develops skills, he or she may
join an integrated bowling program and eventually an ac-
cessible bowling program. This model can serve as a
guide for occupational therapists when introducing re-
Leisure tasks may be used to achieve the goals of occupa- sources for leisure services. Occupational therapists can
tional therapy treatment. Leisure activities may be used assist patients in exploring alternative types of leisure
during treatment sessions to remediate impairments, en- tasks that fulfill their needs. This may include expanding
hance the skill itself, or adapt the leisure activity itself. their leisure activity repertoires to improve the quality of
Therapists must identify the skills necessary to perform the their lives. Occupational therapists educate patients on
tasks and modify them according to each patient’s ability. available services.
The occupational therapist may provide treatment for neu- Treatment also can focus on helping patients and
romuscular, psychological, and cognitive deficits that will family members overcome barriers to leisure participa-
enable the patient to engage in the leisure activity. tion. Common barriers are intrinsic, environmental, and
The National Therapeutic Recreation Society pro- communication-related.
poses a continuum model of leisure service delivery. Ac- Intrinsic barriers are the results of the disability. These
cording to one description, “the ‘Leisure Ability Model’ barriers may include lack of knowledge about leisure ac-
serves as a guide for community recreation professionals tivities and programs, decreased educational activities,
to facilitate the movement of individuals with disabilities health problems related to the disability, psychological
from more intrusive, specialized recreation services into and physical dependence, and decreased skills.21
integrated leisure environments.”38 This model consists Occupational therapists can address intrinsic barriers in
of a continuum with four levels: a variety of ways. Remaining informed about current com-
1. Noninvolvement munity resources, support groups in the area, and profes-
2. Segregated sional leisure organizations designed to serve individuals
742 Stroke Rehabilitation

Physical Cognitive skills

Time Activity Environment assistance required Feelings

6:30 AM
7:00
7:30
8:00
8:30
9:00
9:30
10:00
10:30
11:00
11:30
12:00 PM
12:30
1:00
1:30
2:00
2:30
3:00
3:30
4:00
4:30
5:00
5:30
6:00
6:30
7:00
7:30
8:00
8:30
9:00
9:30
10:00
10:30
11:00
Figure 29-2 Patients can use a time log to record their previous and current use of time.

who have a physical disability is essential.8 These organiza- Occupational therapists can consult with architects,
tions include stroke support groups, wheelchair sport builders, and contractors to determine necessary modi-
leagues, and the American Heart Association. fications, such as installing a lift for a swimming pool.
Environmental barriers include attitudes, architectural See Chapter 27.
and ecological obstacles, transportation, rules and regula- Transportation barriers are another issue. Many per-
tions, and barriers of omission.21 The attitudes of others sons with disabilities cannot drive or take public transpor-
are a serious problem for persons who have disabilities. tation independently. Public transportation is not always
Attitudinal barriers result in negative behaviors, stigmas, wheelchair-accessible and when it is accessible, it does not
and decreased acceptance and participation in leisure always foster independence because a driver may be re-
tasks. Occupational therapists can suggest strategies that quired to operate the lift for the person to enter. The
patients can use to address social prejudices. Americans with Disabilities Act is correcting this problem
Architectural barriers prevent individuals who have gradually by requiring wheelchair-accessible transporta-
physical disabilities from participating in leisure activi- tion. Occupational therapists can educate patients about
ties. The main problem is accessibility as many build- the Americans with Disabilities Act and alternate methods
ings and sport facilities are not wheelchair accessible. of transportation. See Chapter 23.
 Chapter 29 • Leisure Participation after Stroke 743

Economic barriers also play a role in preventing indi- Occupational therapists need to document what types of
viduals with disabilities from performing leisure activities. intervention are most successful in improving engage-
For example, gym memberships are too costly even for ment in leisure activities after a stroke. At this point,
many able-bodied persons. Disabled individuals often live clinical trials focused on this issue had conflicting results.
on a fixed income and have many medical and living ex- Desrosiers and colleagues9 evaluated the effect of a lei-
penses. Occupational therapists can educate their patients sure education program on participation in and satisfac-
about available resources and community groups and en- tion with leisure activities (leisure-related outcomes), and
courage participation. well-being, depressive symptoms, and quality of life (pri-
The final barrier involves communication. Disabilities mary outcomes) after stroke via a randomized controlled
that affect the ability to speak, listen, or respond lead to trial. Experimental participants received the leisure educa-
poor social interaction during the leisure task. By training tion program at home once a week for eight to 12 weeks.
patients in the use of assistive technology to improve Control participants were visited at home at a similar fre-
communication skills, occupational therapists can play an quency. Participants were evaluated before and after the
active role in correcting this environmental barrier (see program by a blinded assessor. The leisure education pro-
Chapter 20). gram was carried out by an occupational and recreational
therapist for a maximum of 12 sessions. The program was
LEISURE INTERVENTIONS FOR STROKE divided into three components, as defined by Desrosiers
SURVIVORS: EVIDENCE-BASED PRACTICE and colleagues:
■ Leisure awareness (i.e, the perception and knowl-
A number of research studies address the issue of leisure edge people have of their leisure activities and how
activities after stroke. This literature can provide occupa- important they consider them)
tional therapists with valuable information about assessment ■ Self-awareness (i.e, people’s perception of them-
and adaptation of leisure skills for stroke patients.10,24,26,31 selves, and their values, attitudes, and capacities in
Research has demonstrated that many individuals who sus- regard to leisure activities)
tained a stroke do not resume many of their favorite social ■ Competency development that encompassed the
and leisure activities.19,29 Factors that affect leisure partici- perceived and real constraints identified by the per-
pation after stroke include the following: son and knowledge of alternatives to achieve auton-
■ Time omy in leisure activities (Fig. 29-3)
■ Meaningfulness of activities The authors found that the leisure education program was
■ Personal standards effective for improving participation in leisure activities,
■ Internal/external control improving satisfaction with leisure, and reducing depres-
■ Range of interests sion in people with stroke. There were no differences
■ Performance between the groups on the General Well-Being Schedule
■ Transportation or the Stroke-Adapted Sickness Impact Profile.
■ Social relations Drummond and Walker13 carried out a randomized,
Other studies have found the following: controlled trial to evaluate the effectiveness of a leisure
■ Individuals who sustained strokes do not resume rehabilitation program on functional performance and
leisure tasks because they do not have time. Their mood. Subjects were allocated randomly to three groups:
days usually are filled with exercises and self-care a leisure rehabilitation group, a conventional occupational
tasks. In addition, subjects reported that time passed therapy group, and a control group. The subjects assigned
slowly and they were bored.19,29 to the leisure and conventional occupational therapy
■ Disabilities resulting from stroke can lead to changes group received individual treatment at home after dis-
in family roles and social relationships, which may charge from hospital. Baseline assessments were carried
result in role strain or role conflict.20 out on admission to the study and at three and six months
■ Depression after stroke is related strongly to a de- after discharge from hospital by an evaluator blind to the
crease in social activities.14 trial. The results showed an increase only in the leisure
■ Stroke survivors do not resume normal social activi- scores for the leisure rehabilitation group, despite an age
ties after stroke. Factors include social and environ- imbalance in the study. The authors also concluded that
mental issues, emotional difficulties, and organic subjects receiving leisure rehabilitation performed signifi-
brain dysfunction. Activities outside the home ap- cantly better in mobility and psychological well-being
pear more difficult to resume than activities in the than the subjects in the other two groups.
home. Parker and colleagues34 evaluated the effects of leisure
■ Factors that affect life satisfaction after stroke in- therapy and conventional occupational therapy via a ran-
clude depression, poor ADL performance, and de- domized controlled trial (multicenter) using the out-
creased social activity outside the home.3 comes of mood, leisure participation, and independence
744 Stroke Rehabilitation

Step 1: Leisure awareness No Step 1A: Leisure awareness

Is leisure important to you? How can leisure be a benefit?

Yes

Step 2A: Self-awareness No Step 2B: Self-awareness

Is your current leisure practice What place could leisure activities
satisfactory? have in your life?

Step 3: Self awareness

Which leisure activities would you
like to do?

Step 4: Self-awareness Step 8: Leisure awareness

What do you get out of those What can you do instead?
activities?

Step 5: Self-awareness
How do you do it? No

Step 6: Self-awareness No Step 7: Competency development

Can you still do it this way? Can you do it another way?

Yes Yes

How to do it? Competency development

Steps 9A and B: Step 10: Step 11:

(Self-awareness) What abilities are required? What resources are
What are the barriers available?
limiting your participation?

Learning

Step 12:
Competency development
Autonomous practice and leisure
satisfaction

Figure 29-3 Summary of the leisure education program. (From Desrosiers J, Noreau L,
Rochette A, et al: Effect of a home leisure education program after stroke: a randomized
controlled trial. Arch Phys Med Rehabil 88(9):1095–1100, 2007.)

in ADL. Subjects included stroke survivors six and Leisure Questionnaire, assessed by mail and with tele-
12 months after hospital discharge. In total, the study phone follow-up for clarification. Eighty-five percent
included 466 patients from five centers in the United of survivors and 78% of survivors responded at six- and
Kingdom. The standardized assessments used in the trial 12-month follow-up, respectively. At six months and
included the General Health Questionnaire (12 items), the compared with the control group, those allocated to lei-
Nottingham Extended ADL Scale, and the Nottingham sure therapy did not have significantly better General
 Chapter 29 • Leisure Participation after Stroke 745

Health Questionnaire scores, leisure scores, and extended Jongbloed and Morgan19 designed a study to deter-
ADL scores. The group assigned to ADL did not have mine the efficacy of occupational therapy intervention
significantly better General Health Questionnaire scores related to the leisure activities of stroke survivors. The
and extended ADL scores and did not have significantly study included 40 discharged stroke patients who were
worse leisure scores. The results at 12 months were assigned randomly to an experimental group, which re-
similar. The authors concluded that in contrast to the ceived occupational therapy intervention related to lei-
findings of previous smaller trials, neither of the addi- sure activities, or to a control group. An independent
tional occupational therapy treatments showed a clear evaluator assessed the patients’ involvement in activities
beneficial effect on mood, leisure activity, or indepen- and satisfaction with that involvement on three separate
dence in ADL measured at six or 12 months. occasions. The authors found no statistically significant
A post hoc analysis by Logan and colleagues27 of the differences between the experimental and control groups
previously mentioned study by Parker and colleagues34 in activity involvement or satisfaction with that involve-
further examined the ADL and leisure groups. The ADL ment. The authors point out that the lack of significant
group received significantly more mobility training, trans- differences may be due to the intervention being limited
fer training, cleaning, dressing, cooking, and bathing in scope (five therapist visits) and the observation that
training, while sport, creative activities, games, hobbies, many environmental factors strongly influence activity
gardening, entertainment, and shopping were used sig- participation and satisfaction.
nificantly more in the leisure group. Fifteen items from
the outcome measures were identified as specific to these ADAPTING THE LEISURE TASK
interventions. The authors found no evidence that spe-
cific ADL or leisure interventions led to improvements in Reintroducing leisure activities to patients who have
specific relevant outcomes. sustained a stroke is important. If the patient does not
Gilbertson and Langhorne15 evaluated a short post- regain the skills needed to perform these leisure tasks,
discharge home-based occupational therapy service for many adaptive devices are on the market to enable full
stroke patients, including an assessment of the patients’ participation in these tasks. To select the most effective
satisfaction with occupational performance and service adaptive aid, the occupational therapist analyzes the
provision using a single-site, blind, randomized, con- skill components necessary to perform the chosen activ-
trolled trial. One hundred thirty-eight patients were ity. After identifying the components that limit perfor-
assigned randomly to a conventional outpatient follow- mance, the therapist selects and introduces an appropri-
up or conventional services plus six weeks of home- ate adaptive device. Occupational therapists provide
based occupational therapy. The data were collected patients with information about various organizations,
before discharge and at seven weeks and six months adaptive methods, and adaptive equipment that enhance
after discharge using the COPM, the Dartmouth Coop- and promote participation in leisure activities. Use of
erative (COOP) Charts, the London Handicap Scale, these resources enables patients to lead meaningful and
and a patient satisfaction questionnaire. At seven weeks, productive lives.
the intervention group reported significantly greater Many types of adaptive equipment enable patients who
changes in performance and satisfaction (COPM), bet- have use of one hand to participate in leisure tasks (e.g,
ter emotional scores (Dartmouth COOP Charts), and card holders, knitting-needle holders, fishing-pole hold-
improved work and leisure activity scores (London ers, and needlepoint holders). These products are avail-
Handicap Scale). The authors concluded that a six-week able from the Internet, catalogs, occupational therapists,
postdischarge home-based occupational therapy service and specialized organizations and stores.
could improve patients’ perceptions of their occupa-
tional performance and satisfaction with services but SUMMARY
may not have a long-term effect on subjective health
outcomes. Leisure is a complex phenomenon. A review of the litera-
Gladman and Lincoln16 reported findings of the ture reveals that leisure may be defined in various ways.
Domiciliary Stroke Rehabilitation (DOMINO) study Many factors influence an individual’s participation in
that compared home-based and hospital-based rehabili- leisure activities, such as roles, attitudes, satisfaction, stage
tation services for stroke patients via a randomized, in the life cycle, and intrinsic and extrinsic barriers. The
controlled trial, with 327 subjects enrolled after dis- role of the occupational therapist is multifaceted, includ-
charge from the hospital. No difference between the ing assessment, intervention through techniques and
services had been found at six months, but home therapy adaptive equipment, and patient and family education,
was better than outpatient therapy related to improving with an emphasis on community resources. Leisure ac-
household ability and leisure activity in the subjects who tivities may be used to improve a patient’s motivation,
originally were discharged from a stroke unit. quality of life, and self-esteem.
746 Stroke Rehabilitation

CASE STUDY 6. How would the occupational therapist assist a patient

and family members in resuming leisure activities in
Leisure Skills after Stroke
their community?
R.S. is a 74-year-old woman who sustained a right-
sided stroke four months ago. After completion of the REFERENCES
central nervous system assessment, interest checklist,
1. Amarshi F, Artero L, Reid D: Exploring social and leisure participa-
time log, and activity analysis form, the occupational tion among stroke survivors: Part two. Int J Ther Rehabil 13(5):
therapist established goals with R.S. 199–208, 2006.
Briefly, the results of the central nervous system as- 2. American Occupational Therapy Association (AOTA): Occupa-
sessment were as follows. Right upper extremity func- tional therapy practice framework: Domain and process, 2nd ed.
Am J Occup Ther 62(6):625–683, 2008.
tion was within normal limits. Left upper extremity
3. Astrom M, Asplund K, Astrom T: Psychosocial function and life
function revealed poor motor control with stereotypi- satisfaction after stroke. Stroke 23(4):527–531, 1992.
cal patterns present and impaired sensation through- 4. Baum CM, Edwards DF: Activity Card Sort, 2nd ed. Bethesda, MD,
out. Ability to shift weight anteriorly and laterally 2008, AOTA Press.
while in a seated position was fair. Sustained attention 5. Beard JG, Ragheb MG: The leisure satisfaction measure. J Leis Res
12(1):20–33, 1980.
skills were limited. She had a minimal left-sided inat-
6. Bear-Lehman J, Bassile CC, Gillen G: A comparison of time use on
tention to self and environment and minimal impair- an acute rehabilitation unit: Subjects with and without a stroke. Phys
ments with spatial relations. Occup Ther Geriatr 20(1):17–27, 2001.
R.S. has been widowed for five years and reported 7. Chang Y, Card JA: The reliability of the leisure diagnostic battery
feeling lonely, depressed, and fearful of falling. Her short form version B in assessing healthy, older individuals: a pre-
liminary study. Ther Recreation J 28(3):163, 1994.
three adult children live out of state, and her social
8. Dattilo J: Inclusive leisure services: responding to the rights of people with
network consists of supportive neighbors, church disabilities, State College, PA, 1994, Venture Publishing.
members, and her dog. 9. Desrosiers J, Noreau L, Rochette A, et al: Effect of a home leisure
Currently a home health aide assists R.S. with self- education program after stroke: a randomized controlled trial. Arch
care and home management tasks. R.S. requires activ- Phys Med Rehabil 88(9):1095–1100, 2007.
10. Drummond AE: Leisure activity after stroke. Int Disabil Stud
ity set-up for grooming and upper body hygiene,
12(4):157–160, 1990.
minimal assistance with upper body dressing and bath- 11. Drummond AE, Parker CJ, Gladman JR, et al: Development and
ing, moderate assistance with lower body dressing and validation of the Nottingham leisure questionnaire (NLQ). Clin
bathing, moderate assistance for stand-pivot transfers, Rehabil 15(6):647–656, 2001.
minimal assistance for bed mobility, and moderate as- 12. Drummond AE, Walker M: The Nottingham leisure questionnaire
for stroke patients. Br J Occup Ther 57:414–418, 1994.
sistance with meal preparation from a seated level. She
13. Drummond AE, Walker MF: A randomized controlled trial of lei-
is not performing her favorite leisure task of knitting. sure rehabilitation after stroke. Clin Rehabil 9(4):283, 1995.
How can an occupational therapist assist R.S.? 14. Feibel JH, Springer CJ: Depression and failure to resume social
activities after stroke. Arch Phys Med Rehabil 63(6):276–277, 1982.
15. Gilbertson L, Langhorne P: Home-based occupational therapy:
stroke patients’ satisfaction with occupational performance and
ACKNOWLEDGMENTS service provision. Br J Occup Ther 63(10):464, 2000.
16. Gladman JR, Lincoln NB: Follow-up of a controlled trial of domi-
The author would like to thank early contributors Denise A. ciliary stroke rehabilitation (DOMINO Study). Age Ageing 23(1):
Supon and Nancy C. Whyte. 9–13, 1994.
17. Holbrook M, Skilbeck CE: An activities index for use with stroke
patients. Age Ageing 12(2):166–170, 1983.
REVIEW QUESTIONS 18. Iso-Ahola S, Jackson E, Dunn E: Starting, ceasing and replacing
leisure activities over the life span. J Leisure Res 26(3):227–249, 1994.
1. List and define the types and purposes of leisure 19. Jongbloed L, Morgan D: An investigation of involvement in leisure
tasks. activities after a stroke. Am J Occup Ther 45(5):420–427, 1991.
2. What are the factors the therapist must address when 20. Jongbloed L, Stanton S, Fousek B: Family adaptation to altered
roles following a stroke. Can J Occup Ther 60(2):70, 1993.
evaluating an individual’s leisure participation and
21. Kennedy D, Austin D, Smith R: Special recreation opportunities for
performance after sustaining a stroke? Describe how persons with disabilities, Dubuque, IA, 1987, WC Brown.
these factors affect leisure participation and per- 22. Kloseck M, Crilly RG: Leisure competence measure: adult version I,
formance. London, Ontario, 1997, Data System.
3. What are leisure attitudes, roles, and satisfaction? 23. Kloseck M, Crilly RG, Hutchinson-Troyer, L: Measuring therapeu-
tic recreation outcomes in rehabilitation: Further testing of the
4. List and describe the environmental barriers that affect
Leisure Competence Measure. Ther Recreation J 35(1):31–42, 2001.
leisure participation. 24. Krefting L, Krefting D: Leisure activities after a stroke: an ethno-
5. What is the role of the occupational therapist in assess- graphic approach. Am J Occup Ther 45(5):429–436, 1991.
ing and improving a patient’s leisure participation after 25. Law M, Baptiste S, Carswell A, et al: Canadian occupational performance
a stroke? measure manual, ed 3, Ottawa, 1998, CAOT Publications ACE.
 Chapter 29 • Leisure Participation after Stroke 747

26. Lawrence L, Christie D: Quality of life after stroke: a three year 36. Raghed, M, Griffith, C: The contribution of leisure participation
follow-up. Age Ageing 8(3):167–172, 1979. and leisure satisfaction to life satisfaction of older persons. J Leis Res
27. Logan PA, Gladman JR, Drummond AE, Radford KA: A study of 14(4):295–306, 1982.
interventions and related outcomes in a randomized controlled trial 37. Rittman M, Faircloth C, Boylstein C, et al: The experience of time
of occupational therapy and leisure therapy for community stroke in the transition from hospital to home following stroke. J Rehabil
patients. Clin Rehabil 17(3):249–255, 2003. Res Devel 41(3A):259–68, 2004.
28. Matsutsuyu J: The interest checklist. Am J Occup Ther 23(4):323–328, 38. Schlelen S, Ray M: Community recreation and persons with disabilities:
1969. strategies for integration, Baltimore, 1988, Paul B Brookes.
29. Morgan D, Jongbloed L: Factors influencing leisure activities follow- 39. Soderback I, Ekholm J, Caneman G: Impairment/function and
ing a stroke: an exploratory study. Can J Occup Ther 57(4):223, 1990. disability/activity 3 years after cerebrovascular incident or brain
30. Mosey AC: Applied scientific inquiry in the health professions: An episte- trauma: a rehabilitation and occupational therapy view. Int Disabil
mological orientation, 2nd ed, Bethesda, MD, 1996, American Occu- Stud 13(3):67–73, 1991.
pational Therapy Association. 40. Trombly CA: Occupation. In Trombly CA, Radomski MV, editors:
31. Niemi M, Laaksonen R, Kotila M, et al: Quality of life 4 years after Occupational therapy for physical dysfunction, ed 5, New York, 2002,
stroke. Stroke 19(9): 1101–1107, 1988. Lippincott Williams & Wilkins.
32. Parham D, Fazio L, editors: Play in occupational therapy for children, St. 41. Wade DT, Legh-Smith J, Langton Hewer R: Social activities after
Louis, MO, 1997, Mosby. stroke: measurement and natural history using Frenchay activities
33. Parker CJ, Gladman JR, Drummond AE: The role of leisure in index. Int Rehabil Med 7(4):176–181, 1985.
stroke rehabilitation. Disabil Rehabil 19(1):1–5, 1997. 42. Widen-Holmqvist L, de Pedro-Cuesta J, Holm M, et al: Stroke
34. Parker CJ, Gladman JR, Drummond AE, et al: A multicentre ran- rehabilitation in Stockholm: basis for late intervention in patients
domized controlled trial of leisure therapy and conventional occu- living at home. Scand J Rehabil Med 25(4):173–181, 1993.
pational therapy after stroke, TOTAL Study Group, trial of occupa-
tional therapy and leisure. Clin Rehabil 15(1):42–52, 2001.
35. Parker CJ, Logan PA, Gladman JRF, Drummond AER: A shortened
version of the Nottingham Leisure Questionnaire. Clin Rehab
11(3):267–68, 1997.
 s a l vato re di m au ro *

chapter 30

A Survivor’s Perspective

THE EVENT The fact that I was musing about words minutes after
my stroke illustrates the most important “lucky” feature
It happened during breakfast, on a bright December of this unfortunate event: it had spared mentation and
morning, unannounced, almost gently, and absolutely speech. Although at times I suspect that my friends and
painlessly. I was wearing a thick terry cloth robe, which relatives may have welcomed a little aphasia on my part,
buffered my slumping to the floor and gave it (at least in talking, reading, and, soon enough, working have been
my visual memory) a slow-motion appearance. vital parts of my recovery, and I am certainly grateful for
I ended up on my left side on the parquet floor, reject- whatever forces, natural or supernatural, pushed the blood
ing my father-in-law’s offers of help, thrashing my right clot into the right rather than into the left carotid artery.
leg, holding onto the seat of my chair with my right Finding myself totally incapacitated in a hospital bed
hand, a little embarrassed and miffed that I did not seem was not as traumatic an experience as it would be now,
able to stand up. I also remember distinctly my irritation maybe because it occurred so shortly after a similar post-
at my mother-in-law’s plaintive demands that her hus- operative intensive care experience. Or else, unbeknown
band remove a piece of bread I was chewing on when the to me, I was in a slightly stuporous state that blessedly
stroke hit. She, a keen observer with an artist’s eye for quenched the emotional reactions to what was happening.
detail, had noticed that chewing motions had ceased on Although I seemed to remember every detail of those first
the left side of my mouth and food was stuck under the days after the stroke, later I discovered some curious gaps.
cheek. For example, I have no memory of having received a
Because I was recuperating from open heart surgery— Doppler scan. Months later, when a repeat scan was per-
a mitral valve repair that had been performed two weeks formed and I was shown the results of the first examina-
earlier—little diagnostic acumen, especially for a neu- tion, I had to admit to myself that I must have been in that
rologist, was required to conclude that I had suffered a same laboratory, which I did not remember, subjected to
stroke. Lying on my dining room floor waiting for the the same procedure, which seemed new to me, by the
ambulance, I ruminated about the inappropriateness of same technician, who greeted me cordially but whom I
the word stroke to describe what had happened to me, did not recognize.
which had been more like the gentle snuffing of a candle The question most often asked, especially by other
than a violent hit. Nevertheless, the term stroke (from the neurologists, is “What does it feel like to be hemiplegic?”
Latin ictus, which is still widely used in medical jargon) is I had asked myself the same question when seeing pa-
universally accepted and has equivalent words in most tients who had lost various degrees of motor control. The
Western languages. I concluded one of two things: either answer, again, at least in my case, is disappointingly
stroke referred to the suddenness of the event rather than simple: it really felt like nothing, like I had never been
to its outward manifestations or I had had an unusual able to use my left limbs; no exasperating feeling of for-
stroke. Now I know both things are probably true. mulating a mental command and getting no action oc-
curred. Nor do I think that this was because of loss or
diminution of left-body awareness (asomatoagnosia) or
*This chapter is dedicated to Maria Laura, Beppe, Giorgio, and sensation, because I had neither to any detectable extent.
Alessandra. My recovery would have been a lot slower without their Peculiarly, the frustration and anger with the sluggish
loving assistance and support. and clumsy left limbs, especially in the hand, came later

748
 Chapter 30 • A Survivor’s Perspective 749

as I was gradually regaining function and continue to this however, he kept his own council about his positive prog-
day. I do not remember how many times I have cursed nosis until much later, when my arm had in fact regained
and actually punched my left hand for not performing a good deal of function.
adequately, knocking things over, being in the way, or Another weird aspect of my stroke (and as it turned out
simply being ridiculously (and embarrassingly) tremulous a positive one) has been the complete lack of spasticity,
in reaching for objects. which has greatly facilitated the rehabilitation process.
However, at the time of admission to neurology, my The only hint of spasticity appeared during automatic
only frustration was related to being totally dependent on reactions such as stretching and yawning, when both left
others for everything, from turning in bed to performing limbs would spontaneously and uncontrollably go into
bodily functions. As an intensely (maybe a bit neuroti- extreme flexion.
cally) private person, as I had been all of my life, the loss
of privacy that comes with major illness was initially a big THERAPY
problem for me. The “silver lining” has been, in fact, the
acceptance of my physical frailty as a matter of fact. When the editor of this book, who had been my occupa-
How does a neurologist live with a neurological dis- tional therapist, asked me to write about my experiences
ease? I cannot answer this question appropriately because as a patient recovering from stroke and suggested the title
I lived my stroke as a patient, not as a neuroscientist. I “Notes of a Survivor,” I asked him whether he meant
asked few neurological questions and never wanted to see survivor of the stroke or survivor of physical and occupa-
my magnetic resonance imaging films. As I had done at the tional therapy. Lest my later comments sound too enthu-
time of my heart operation, I had full trust in the skill of siastic or be considered self-serving on the part of the
my physicians and colleagues first and my physical and oc- editor, let me start with a few negatives.
cupational therapists later and took a passive though coop- Both physical and occupational therapy are boring,
erative attitude throughout the healing process. I think consisting as they must of highly repetitive exercises and
this consciously ignorant and trusting position may have activities: the patient soon learns to count “reps,” longing
done me more good than a critical, controlling approach. to reach the magic number (usually 10—do therapists
Of course, seeing my own left toe go up in a classical have a functional rationale for this quota?) requested by
Babinski sign, witnessing my own excessive knee jerk, and the therapist. And no cheating is tolerated; therapists
feeling odd paresthesias in the left side of my body and have mastered a secret way of keeping track of reps auto-
“pins and needles” in my left hand were strangely inter- matically and privately even as they keep up a conversa-
esting experiences. Some peculiar phenomena may have tion with you, and they will not be defrauded of even a
escaped an untrained observer; for example, I noticed at few reps.
some point (perhaps two months after the stroke) that a Another thing—therapists have a bit of a sadistic trait
spontaneous Babinski sign occurred whenever I initiated that may be innate and predisposing to the job or else part
urination. This happened without exception and consisted of their professional training. As soon as you feel comfort-
of two or three jerky dorsiflexions of the left toe that able doing the required number of reps for any given ex-
promptly subsided as the stream of urine became steady. ercise, the number of reps usually goes up by five. The
This “urinary Babinski” persisted throughout the first idea, I think, is to keep you challenged, and you are. Fur-
year after the stroke and continues to occur sporadically thermore, consider pain; did you know that therapists
to this day. My colleagues in the stroke unit swear they distinguish between “good” pain and “bad” pain? Good
have never heard of a similar phenomenon, but physicians pain is the muscle soreness that comes from those five
and therapists may find inquiring about this systematically cycles of ten reps, a guarantee for the therapist that you
with patients recovering from stroke a worthwhile task. are doing your exercises and using the proper muscles.
Who knows, perhaps the “urinary Babinski” (DiMauro Bad pain is classified in imaginative ways; my occupational
sign?) will be added to the spontaneous Babinski sign ob- therapist, a man, used a scale of severity that ranged from
served by H. Houston Merritt on removing a patient’s “paper cut pain” to “labor pain,” at which point the secre-
slippers. tary on the occupational therapy floor, a woman, invari-
As every patient does, I worried about the extent of ably reminded us that we men did not know what we were
recovery I could expect. I was encouraged by the fact that talking about.
I could bend my leg from the very beginning. I would One other piece of good news and bad news—exercise
show this proudly to visitors and colleagues with the ex- works, but only as long as you keep exercising. The mo-
pectation of rosy prognostic pronouncements. I was con- ment you stop, you start losing ground, so that you are in
cerned by the total lack of movement in my left arm, but fact condemned to exercising for life, which to a Medi-
I learned later from a good friend, a pediatric neurologist, terranean soul such as I is a pretty harsh sentence. My
that he had felt optimistic about my future recovery be- way of surviving this torture is to make exercise part of a
cause from the first day I could flex my fingers. Wisely, highly routinized wake-up ritual, something I do almost
750 Stroke Rehabilitation

automatically, like brushing my teeth. This way I feel GOING HOME

slightly guilty when I skip the routine and, conversely,
when I do exercise, I enjoy that little heady virtuous feel- Falling is, of course, the big fear. I had fallen once in my
ing I remember from my jogging days. hospital room, and I fell once again a few days after my
So much for the negatives. The positive side of the return home. Finding myself on both occasions next to a
ledger is much larger. As a neurologist and a student of wall, I went through the steps my therapists had so care-
neuromuscular diseases, I am ashamed to confess that I fully rehearsed with me in the hospital gym, and on both
had virtually ignored physical therapy and occupational occasions I got up on my own. However, after my rela-
therapy—a never-never land where patients usually ended tives left, I had nightmares about falling in the middle of
up after the physicians concluded their brilliant diagnostic a room and not being able to get up and reach the phone
workups—and I had a vague notion of physical and oc- or the intercom. The problem was solved by the acquisi-
cupational therapists as robotlike technicians. A few ses- tion of a portable phone, which I slipped into my pocket
sions of occupational therapy and physical therapy suf- every night as soon as I entered my house. I never had to
ficed to change my views drastically. The first thing that use it, but it served its purpose as a “security blanket.”
impressed me was their knowledge of muscle anatomy Showering and getting dressed in the morning also
and physiology; I thought I knew muscles! Throughout took some adjusting, but I soon learned that what had ap-
the rehabilitation process, I was amazed at their under- peared in the hospital as slightly ridiculous procedures
standing of movement and lack thereof, muscle coordina- (left sleeve and pants leg first; hook the sock on your big
tion, and compensatory mechanisms. Thus, I had at all toe first, then slip in the other toes) were in fact precious
times the comforting notion that all exercises and activi- clues to a highly routinized and reasonably rapid process.
ties were rationally planned on the basis of my specific I took several months to remaster the tie knot, but I re-
deficits and needs and were not part of a “canned” pro- member with joy the pride of my occupational therapist
gram. Another encouraging sign was the therapists’ obvi- when I appeared at a clinic appointment wearing shirt and
ous satisfaction at every sign of improvement; far from tie instead of the usual turtleneck.
being automata, these people clearly loved their profes- Lest all this appear an exceedingly smooth return to
sion and took pleasure in a job well done. In fact, I came normal life, let me dwell for a moment on the frustrations
to admire both the dedication and the professionalism of to which I alluded in my opening paragraphs. Even a mild
my therapists so much that I developed the conviction— residual hemiparesis is an endless source of frustration in
which I expressed to the chairman of our Department of just about every aspect of daily life. I find dropping objects
Neurology—that all neurology residents ought to spend especially irritating and often remember with new empa-
at least a few weeks observing occupational and physical thy my son’s frequent outbursts as a clumsy adolescent—
therapists at work. All too often we neurologists are con- “I hate gravity!” Buttoning shirts, especially cuffs, can be
tent with our diagnostic workup of stroke patients and our a trying experience, and I have more than a few shirts with
intervention in the acute phase, only to lose sight of pa- ripped-off buttons to prove it. Frustration at times turns
tients’ progress. to rage, and I have occasionally punched my sluggish left
I developed a pain syndrome in my left shoulder that hand with my agile right one; even worse, I have punched
not only gave me sleepless nights (partly because of pain, a table, with the only result of having still a sluggish left
partly because of an exaggerated fear of dislocating my hand and a painful right one. One less disruptive way to
arm by sleeping on the left side) but also resulted in a deal with frustrating experiences is to curse; I have in-
“frozen shoulder,” a very painful condition that interfered vented a peculiar English/Italian hybrid curse (unprint-
with my occupational therapy. Again, I was impressed by able in either language) that I use as a mantra many times
the variety of approaches used by my therapists not just to a day. Naturally, the level of frustration and the threshold
alleviate the pain but also to resolve the problem, includ- for the “tantrums” vary considerably from day to day and
ing slinging, supporting my arm on an over-the-shoulder are influenced by mood; on some “bad days,” I notice that
bag, and taping my shoulder in conjunction with passive I am almost looking for a frustrating experience so I have
mobilization and massage. On that occasion, I found my- an excuse to explode, thus using the stroke as a scapegoat
self in another situation I usually experience from the for my bad mood.
other side; I volunteered to be the subject of a teaching Although I have never been a sportsman (library mouse
conference for occupational therapy trainees. Although I would be a more fitting definition), as my rehabilitation
derived some satisfaction from being materially useful to progressed, I have repeatedly had vivid dreams in which I
the medical profession (something akin to but fortunately ran; I just ran for the sake of running, and it felt both ex-
short of donating your body to the Department of Anat- hilarating and as easy as it had been before the stroke. I
omy) at our clinical conferences, I am now much more actually tried the motions of running while holding onto
aware of the discomfort caused to the patient by being an a shopping cart in the hallway of my apartment building,
object of study. but somehow the exhilaration of the dream wasn’t there.
 Chapter 30 • A Survivor’s Perspective 751

CONCLUDING REMARKS P.S. Just as Alexandre Dumas père felt obliged to write
“Twenty Years Later,” a follow-up to The Three Musketeers,
Although I cannot run, I can walk without a cane, I am so 10 years after my stroke I also feel obliged to offer a
independent in my daily activities, I have been able to follow-up. The good news is that I still walk indepen-
resume my (fortunately sedentary) job, and I travel around dently, work full-time, and travel extensively. The bad
the world. To be sure, this is not the typical outcome of news is that I never ran again—although running remains
stroke. Every patient is different, and I have been unusu- a recurrent subject of my dreams—and I still have pares-
ally lucky in that I was spared speech impediments and thesia in the left side of my body, mostly in the hand. Ad-
spasticity. This in turn has made my rehabilitation easier ditional problems are due to two situations, one of which
and more effective. is totally outside my will, while for the other I have to take
However, my left side was totally paralyzed only two full responsibility. The first has to do with aging and re-
and a half years ago (at age 54), and I am now enjoying lated troubles (still preferable to the alternative, to quote
a nearly normal life. Much of my progress has been Woody Allen). Thus, generalized arthritis has necessitated
because of the patient, steady, intelligent, and compas- a total left hip replacement, adding insult to the injury of
sionate work of my physical and occupational thera- the stroke and accentuating my limp. The second has to do
pists. The punchline of these “Notes of a Survivor” has with my physical laziness and my weakness for the Medi-
to be that not only can one survive a stroke, but brain terranean diet (which is the opposite of the Atkins diet):
plasticity does exist, and good physical and occupa- lack of exercise and excessive weight are not what my
tional therapy does improve the condition of every physical therapist recommended. And I hear about it about
patient recovering from stroke to a remarkable degree. every day because my physical therapist and I have devel-
Some improvement continues to occur (if you exercise, oped a wonderful personal relationship. You can call this
that is!) for a long time, although at a reduced pace. So, development a positive side effect of the stroke for me, and
who knows, maybe I will be able to run again before an occupational hazard for her. But it is a happy ending for
I turn 60. both, and who does not like a happy ending?
 b a rbara e. n eu h au s

chapter 31

A Survivor’s Perspective II:

Stroke

Somehow, I thought it would never happen; cancer, yes, It took getting used to the new experience as a patient.
but not this. My right arm lay lifeless at my side, and my It differed from other patient stories in many ways. I
right leg was too weak to lift from the sheet. For the sec- never lost consciousness, nor did I suddenly collapse. I
ond time in a week, I was in a hospital bed. My left arm watched for three days and went about my business while
was hooked up to a plastic bottle suspended from an intra- my right side got weaker. It was a busy time for me, since
venous (IV) pole, and a slender tube was relaying medica- I was anticipating a vacation trip to Europe with my
tion via my veins to the rest of my system. At least my brother and sister-in-law, and we exchanged frequent
body was someone else’s problem now, and I did not have phone calls to discuss plans. I felt I had no time to pay
to pretend any longer that everything was all right. But attention to the annoying weakness that hardly interfered
rather than feeling relaxed, my mind was racing, replaying with my ability. On Sunday night a friend came to dinner.
the events of the past six days. The symptoms were still not fully in my consciousness,
“I’ve had a TIA [transient ischemic attack].” On and I was able to prepare the meal by compensating with
Monday morning, I finally had to admit this to myself. It my left side. On the return from walking my friend to the
was the third day of gradually increasing weakness of my bus, I felt a strange urgency to get home to do the dishes
entire right side, and I knew I had a transient ischemic before I got weaker. When I finally got to bed, I fell into
attack, which temporarily interrupts the flow of blood a fitful, uneasy sleep. The next morning I couldn’t ignore
to the brain but then generally resolves itself within that I had had what the textbook refers to as a transient
24 hours. It is often the first warning of a stroke. ischemic attack.
I was strangely calm—nonfeeling—but then, the topic I had to repeat the hated phrase, “I think I’ve had a
of stroke was no stranger to me; for over 40 years I had TIA,” two more times; first, to the doctor’s receptionist to
been an occupational therapist and was familiar with neu- get an appointment, then to my brother in New Jersey,
rological problems. It was ironic—too ironic even for my asking him to take me to the doctor, since I knew I
ability to find humor in the darker side of life. I had worked couldn’t maneuver the car.
with men and women who themselves were the survivors of I tried to keep myself busy until my brother’s arrival.
strokes and other serious illnesses, and I had found great Although I was still trying to deny the reality, I packed an
satisfaction as I showed them how to manage daily life dur- overnight bag just in case I had to stay in the hospital. An
ing their recovery. I had listened to the stories men and added unpleasantness was the slurring of my speech that I
women told me of their strokes, recalling exactly where couldn’t control.
they were and what they were doing when they were Much to my satisfaction, once we had arrived in his
struck. Most stories included a dramatic part of losing con- office, the doctor confirmed my diagnosis and made an
sciousness and falling. These stories and many like them appointment for me right away to see a neurologist who
formed the content of the teaching that was the natural specializes in stroke. This was truly weird; just two
progression of my career from practice to education. Until months before, in my role as a retired adjunct professor, I
retiring, I had been a professor at Columbia University, and had been coordinating a course for student occupational
patient vignettes that helped to illustrate a particular point and physical therapists covering neurological problems,
punctuated many of my classes. and this doctor had been our guest lecturer on the topic

752
 Chapter 31 • A Survivor’s Perspective II: Stroke 753

of stroke. I had liked his calm, confident manner and the grabbed one end of the sheet on which I was lying, and
clarity with which he sketched out to the students the similar to the motion used to move sacks of meal to a
various areas of the brain that might be affected. I had waiting truck, transferred me onto the cold, hard surface
even remarked to a colleague that he was definitely some- of a narrow table. With two swift movements, the techni-
one I would consult if I ever needed a neurologist. All of cian wrapped the sheet around me in mummy fashion.
this played back to me now as I sat in his waiting room, “Let me have your glasses.” His outstretched hand was
anxiously anticipating my turn. close to my face, and I surrendered my last link with a
Luckily, I was in familiar territory. The neurologist’s world I could see. “First, you’ll hear the motor start, and
office was only three stories below where my own office then the scan will start to turn. Don’t move until I tell
had been. I felt a slight twinge of embarrassment as he you.” With that, he and his companion left the room.
came out to greet me. I tried to dredge up all the things I had read about CT
“I’m wearing a different hat today,” I slurred and scans, but all I could focus on was the cold and my tem-
forced a weak smile. His smile was warm and reassuring. porary blindness. The machine had started to whir at a
His neurological examination further established that I considerable volume. A lighted circle above my head be-
had had a stroke, and he confirmed the need to be hospi- gan to rotate and then gathered speed as the entire halo
talized for further tests. moved slowly back and forth. I shivered with cold and felt
While the doctor made the necessary phone calls to terribly vulnerable and alone. If I called for help, no one
admit me, my brother and sister-in-law took me to the would hear me above the din of the machine.
fifth floor of the adjoining hospital building where a After what seemed like an interminable time, the mo-
single room overlooking the Hudson was waiting for me. tor slowed down and stopped. The door was flung open,
When my family was satisfied that I was in capable and the technician returned. It was only after the noise
hands, I urged them to leave. I needed some time to had stopped that I became aware of its unnerving effect.
myself and yet, when the door closed behind them, I felt An unparalleled fatigue took over my body.
like a little girl on the first day at camp after the parents “Here are your glasses. I’ve called for a pickup,” were
have gone home. the last words the technician spoke before he vanished
It was difficult for me to grasp the seriousness of my again, this time for good. The silence in the room now
condition, although a slow dread began to hover in the became as frightening as the noise had been before. I
back of my mind. I had no pain and did not feel really sick, closed my eyes and must have dozed off. When the or-
so the idea of getting into an ill-fitting hospital gown in derly arrived, he seized the stretcher silently and retraced
the middle of the afternoon seemed ridiculous. What was the circuitous route until I was back in my room.
this going to do to my plans for the trip? Before I had Although my body felt exhausted, I could not get com-
much time for reflection, a very young resident stood at fortable in the bed. Each time I awoke from what seemed
my bedside, poised to take blood from my arm; her deft hours of sleep, the large clock on the wall indicated that
handling of the needle belied her youthful appearance. only a single hour had passed since I last checked. Now I
She was the first of a long line of men and women who had ample time to study the view from the large window
entered my room at all hours of the day and night to per- by my bed. I looked out on the majestic Hudson, a coal-
form some service that was much more useful to them black ribbon bordered by the blinking lights of the Jersey
than it was to me. The idea of using the hours around edge. Finally, the first hues of the morning began to
midnight for sleeping was not part of their thinking. lighten the sky, and the hospital came to life. Someone
Sometime during the next several hours, I was roused entered my room and switched on the bright overhead
from a restless sleep by something metallic banging into lights.
my bed. It was a stretcher on wheels. “I’ve come to take your blood pressure.” The speaker
“Your doctor ordered a CT [computed tomography] in white slacks and a pink T-shirt could have been anyone.
scan,” the orderly said with false cheeriness. Through my years as a therapist I was familiar with the
“Now?” It was hard to believe that my neurologist subtle signs of hospital dress and behavior code; a stetho-
would suddenly awaken with one thought in his mind—to scope loosely slung around the neck meant that you were
order a CT scan to be carried out during the next hour. a nurse.
Obediently I slid from my mattress to the stretcher that “Can you wash yourself?”
was parked alongside the bed. The orderly covered me “I think so.”
with a blanket and without another word, whisked me “Someone will bring you the basin in a few minutes.”
rapidly down numerous corridors and elevators to an- “Can I go to the bathroom first?”
other section of the hospital. We were now clearly in the “When the aide comes to wash you, she’ll give you a
basement approaching the double doors of the CT scan bed pan. We don’t have time to take you to the bathroom
suite where two technicians were waiting for me. Without now. All the patients have to be washed before the shift
interrupting the flow of their conversation, each of them ends at seven.” With that, she left the room. It was the
754 Stroke Rehabilitation

first example of hospital rules, made for the convenience I hoped that my discomfort at seeing Yaffa was not
of the staff, without consideration of patients’ needs. A too obvious; I remembered her well from my class. I was
feeling of utter powerlessness swept over me, and I knew certain that she felt an equal degree of unease. Romana
that, like thousands of others before me, I had now en- checked me over carefully, noting on her clipboard all
tered the world of the patient, aptly named for the quality the areas of function that I could or could not do. Oc-
that is the keystone for survival in the hospital setting. casionally, she asked a question of the student. She left
The day was punctuated by more tests and the visit of me some therapy putty and a piece of theraband, both
a hierarchy of doctors who represented all the develop- familiar parts of the beginning exercise program for the
mental steps in a physician’s career. Each of them ques- hand and arm.
tioned and probed. All of them wanted to feel my ex- “You know what to do with these,” she laughed some-
tremities, to see the amount of movement I could what apologetically; I returned the laugh.
demonstrate, and to ask about my medical history. For all “You want me to squeeze the putty?” She nodded and
of them, I was the cheerful, cooperative patient, an ap- then watched my efforts to close my fingers around the
proach that came to haunt me in the days that followed. apple-green mass. Although I squeezed as hard as I could,
Evaluations by the physical therapist, occupational I had not even dented the putty and felt utterly defeated.
therapist, and speech and hearing therapists were part of Our eyes met briefly, and Romana said the thing that I
the day’s schedule. The physical therapist that I recog- had offered lamely a hundred times when I had overesti-
nized from sight as a sweet, gentle young woman went mated a patient’s ability, “Try using the putty every day;
over most of the leg motions I had performed for the you’ll see that it will get easier each time you try.”
various doctors, but then she asked me to move back and After Romana and Yaffa had left, I had little time to
forth in the bed and to sit on the edge. It was clear that take stock of my situation before a new round of people
my right side hardly took part in carrying out all the re- stood in my doorway. This time it was Dr. Mitchell, the
quested movements, but the years of keeping fit were neurologist, with seven residents in tow. I recognized
paying off; I could support myself on my left side and even some of them from the interviews and blood tests of the
hobbled around the room, firmly hanging on to Kathy, day before. Dr. Mitchell greeted me with a question,
the physical therapist. “May we come in and talk to you for a few minutes?” I
I had never met the speech pathologist before. Her appreciated his consideration and was eager to cooperate.
manner was cheerful and matter-of-fact. Her role was not Between asking me to move my right side, he addressed
only to listen to the formation of sounds and words but the young doctors, asking them questions and sharing
also to test my comprehension and memory. I was ap- information about my condition. Then he turned to me.
palled when I listened to myself; no matter how much I “The CT scan shows a very small lesion deep in the brain.
tried to enunciate clearly, certain words came out slurred. The weakness should resolve itself in a few days, and you
I fared better with the comprehension and memory tests. can go for outpatient therapy. You may call your brother
Thank goodness, that part of me seemed to be intact. now to take you home. I’ll sign the necessary discharge
When I returned from more tests in another part of the papers.” With a cheery wave, he and his entourage walked
hospital, the occupational therapist entered the room. I out. I was left with a million unanswered questions.
was very familiar with most of the occupational therapists Although I should have been ecstatic about the verdict,
in the rehabilitation department; 12 of them had been the news left me stunned. Nothing had changed in my
research subjects in a study I had conducted and pub- condition since I had arrived yesterday. The fingers on my
lished, and I was currently gathering information from right hand could hardly move, my leg could barely sup-
their patients for a study that I was conducting with one port me, and I had to hold on to furniture to move around
of them. Fortunately, I was not acquainted with the two the room. I had expected more improvement than this
who worked with the patients on the stroke service but before being allowed to go home. But hadn’t the doctor
knew that a former student was doing her internship said that I would get my strength back? The most impor-
there. My patient role was still too new for me, and I was tant thing now was to share the good news with my
not ready for the exchange that would inevitably result brother and sister-in-law before the staff members changed
from seeing a colleague-in-becoming. their minds.
As soon as I saw the occupational therapist, I knew I My family’s delight made me feel a tinge of guilt at my
was in good hands. She was in her mid-20s, short, with own lack of enthusiasm. They offered to take me to their
Asian features. She spoke with a slight accent, but I could spacious house for a few days, a prospect I always enjoyed.
not identify her country of origin. She moved and talked Why wasn’t I glad to be going home? Aside from a loss of
with an air of competence. Directly behind her was the appetite, I did not feel ill, but I could not shake a vague
student. uneasiness that dampened my spirits. But as I waited, once
“I’m Romana, the occupational therapist, and I’ve again, for their arrival, I passed the time getting into my
brought a friend of yours to do the evaluation with me.” clothes as best I could. I recalled the hours of sitting with
 Chapter 31 • A Survivor’s Perspective II: Stroke 755

a patient, giving him or her advice on how to put a para- the stairs would create a real obstacle, especially since the
lyzed arm into a sleeve, putting on slacks while supported banister was only on the right side and my right hand was
by the bed. Fastenings like shoelaces I left for my sister- too weak to hold on to pull my body from stair to stair.
in-law to do; we were on such good terms that I did not The only sensible, but thoroughly undignified, way was to
hesitate to broach this subject with her. go up on all fours, getting little help from the right side. I
The genuine pleasure at seeing my family pushed aside saw myself as a lame wolf I had recently seen in a nature
the uncomfortable feeling that was gnawing at the back of film; my heart had gone out to the wolf that kept collaps-
my mind. I was grateful for the wheelchair that was re- ing onto his weak side and was no longer able to keep up
quired by the hospital to take me to the front door. Was with the pack.
it really only 24 hours since I had entered? Aside from the By the time I got into a bed where I had slept many
numerous black-and-blue marks left from the blood tests times before, I was totally exhausted. I had not realized
on both forearms I was certainly no worse, but was I that every move involved a carefully strategized plan that
better? Again, I reminded myself that I needed more time required the mental layout of the room and each piece of
to get stronger. furniture in relation to and its distance from its nearest
Once we were in the car, Jeff and Helen told me that neighbor. As long as I did not have to traverse any wide-
they had made numerous phone calls in the morning to open spaces, I would be all right. With that thought in
cancel our European trip. mind, I fell asleep.
“But why shouldn’t you go? I’ll surely be able to take For the next two days, we spent the hours with all the
care of myself by next Sunday,” I protested. “You were so routines that kept us close to the house. Knowing that I
much looking forward to seeing our cousins and your was safe, Helen and Jeff went for their usual swim in their
friend. Why should you give it all up on my account?” large backyard pool while I stayed at the kitchen table or
“We wouldn’t go without you.” Their reply was almost in a comfortable chair, reading. The canceled trip was still
in unison. “Anyway, we can go next year.” For the first preying heavily on my mind, and it was hard to keep my
time in 24 hours, I was near to tears, perhaps because it attention focused on a printed page. My usual nonflag-
was the first moment when I had dared to think about my ging energy had not returned, and I was most content to
feelings. All I could mutter was a bland, “Thank you; I stay in one place. In the afternoon, Helen suggested that
know I’ve spoiled the trip for all of us, and I’m truly the two of us might drive to the two stores from which
sorry.” Helen reached over from the driver’s seat and we had purchased gifts for the cousins in Germany and
squeezed my hand. Switzerland. Now we were taking the gifts back to the
As we headed toward their home in New Jersey, I knew stores where we had spent such a pleasant afternoon
I would be well cared for, and I began to feel better. Our choosing items that were suited to the temperaments of
conversation turned to everyday matters and to the things our friends and relatives.
we might do together now that the pressure of the trip I was grateful to Helen for suggesting this outing,
was off. Having an unexpected guest presented no prob- since she and I always enjoyed doing things together. I
lems to Helen and Jeff. As the parents of five children and knew that she would understand when I declined the
grandparents to four, life was a never-ending chain of chance to go into the stores with her; I just did not have
filled and empty beds and the feeding that was a part of the energy to walk from the car. While I waited for Helen
this. I knew I was welcome in every family activity, but in to return to the car, I tried to move my fingers and my leg
spite of our intimate relationship, each of us had main- and had to admit that I could not voluntarily move them
tained separate lives with a different set of friends and any better than the day before. Why was it taking so long
daily responsibilities. to get my strength back? Actually, in my 11 years of prac-
“Do you know, this is the first time I will be staying tice, I had never worked with anyone who had only a
overnight at a time other than Christmas,” I volunteered temporary stroke; by the time patients were referred to
as we approached their house. I had always loved the therapy, they were recovering from much more serious
canopy of old trees that joined branches over the street; conditions, but I could not shake the knowledge that I
they were an important part of keeping the summer heat was not getting better.
from their large old house. It sat at the top of a hill with a That evening, we decided that since it would be easier
steep driveway that had been the bane of my existence on for me to manage in my apartment, Jeff and Helen would
many winter nights after a family gathering. take me home and stay with me there for a few days. After
“Oh, yes!” Helen was genuinely excited by the pros- all, the cancellation of the trip had left us with lots of free
pect of being together for several days. time. An overnight visit by Jeff and Helen was a real nov-
The walk from the car was supported by Jeff; it seemed elty; the thought of it buoyed up my spirits immediately.
doable. When I got into the house, I found refuge in the They could sleep in my room, while I would be comfort-
first available chair and stayed there for most of the eve- able on the couch in my study. What I failed to remember
ning. Not until it was time to go to bed did I realize that at the time of making these plans was that a major repair
756 Stroke Rehabilitation

of the outside of my apartment building was underway, have to sit down on the edge and then lift my legs out one
and all tenants had been asked to move all terrace furni- by one. Somehow I lost my footing and came crashing
ture and plants inside. Since I thought that I would be down. When I finally came to rest on the floor of the
away for several weeks anyway, I had piled most of the empty tub I noticed with relief that my head was about
planters on the floor in the study, with just enough room three inches from the wall while I was lying on my back.
to move to the desk and the bed. Once again I was unhurt, but, like a beetle that had been
We retired at a reasonable hour, and I was glad not to turned on its back, I felt utterly helpless for fight or flight.
have to climb stairs tonight. Sometime in the night I got If I called loudly enough, Helen or Jeff would no doubt
up to go the bathroom. Apparently, my right leg had hear me. Considering that option for a moment, I decided
become even weaker and when I tried to stand next to I was not ready to capitulate to that extent; the thought of
the couch I lost my balance and fell backwards into one being pulled out of the bathtub stark naked by my brother
of the planters. I was conscious of a cracking sound, for- did not appeal to me, even in my helpless state. “Calm
tunately not of a bone but the branch of a flowering ge- down!” I firmly told myself. “You’re supposed to be a
ranium plant that had cushioned my fall and now held problem-solver.” I was able to call on the dormant forces
me captive. The ridiculousness of the situation made me that are part of our emergency system, and they did not
laugh in spite of myself, and for a moment I simply en- desert me. I turned over and with my left arm and leg, got
joyed the humor without having to figure out a way to myself first to a kneeling position with the left side hold-
return to my bed. Then I saw that I could not rely on my ing all my weight and then to sitting on the edge of the
body only to get me out of this predicament. I reached tub. Holding onto the sink, I pulled myself to standing
for a solid piece of furniture, pulled myself up with my next to the tub. I found that I was shaking, totally ex-
left arm, and stood firmly on my left leg. Thank good- hausted by the ordeal. Somehow I got myself dressed and
ness, it supported me well. returned to the study where I had spent the night.
Once back on the couch, I could not get to sleep. My By now Helen was up and came to look for me.
mind was racing almost as fast as my heart. I knew that I “I’ve got to go back to the hospital,” were my words
wasn’t getting better, and somehow I was not prepared for of greeting. I then relayed the details of the three falls
this. Would I just keep getting weaker and weaker? So far, to her.
my sensation was intact; I could feel everything that “I’m so glad you’ve decided to go back; we were think-
touched my right side, but was it only a matter of time ing the same thing as we watched you last night.” She
before that too disappeared? seemed as relieved as I was that the decision had been
My bodily needs became all too clear for me. I again made.
had to leave the couch to go to the bathroom. In almost a When I called Dr. Mitchell, his secretary told me he
Xerox copy of my previous escapade into the flowerpot, I was on rounds but would call me as soon as he got back to
fell again into one of the plants. This time I did not laugh, his office. If he was at all surprised by my call, his voice
but again, unhurt, I was able to extricate myself quickly. certainly did not reflect this when he called back. Instead,
At this rate, I would not have any flowers left. I was be- he said calmly we should come right over.
coming a hazard to myself and to the environment. Our departure from the house this time did not go un-
When I had returned from the bathroom a second time noticed by my fellow tenants who were just leaving for
by holding onto all the pieces of furniture along the way, work. It was not so easy to flash a cheery “Hi!” to neigh-
I tried in vain to find some rest. I stared at the ceiling, bors from the compromised position of being held up by
contemplating what lay ahead. I dared not face up to the Jeff and Helen while we made our way through the lobby
reality of what my body had imposed on me. Like a worn- out to the car. This time we drove right up to the busy
down music box that is ready to stop, the same tune front door of the hospital.
played over and over again, “You know you’re getting “There are always wheelchairs there,” I told Jeff, grate-
worse and worse. Why did you leave the hospital?” ful that I could give in to my inability to walk the long
Finally the first pink stripes along the visible sky told me corridors to Dr. Mitchell’s office. As an automatic gesture
that another hot day had started. I couldn’t bear lying on approaching the hospital doors, I slipped the chain with
there any longer, and I got up to take a shower; the my ID over my head; “This will give us much faster entree
warmth of the water had often cleared my head after to the different buildings,” I told Jeff and Helen. What I
sleepless nights and always made me feel better. did not tell them was that the simple act of wearing the ID
Although there was nothing to hold on to around the firmly established my role as faculty member rather than
tub, at least it wasn’t dark. Probably that was why I had having to yield completely to the patient role.
fallen during the night. The water felt soothing to my For the second time in four days, Dr. Mitchell con-
skin, and for a moment I felt cleansed of the demons that firmed my diagnosis following the neurological examina-
had become a part of my thinking. I turned off the water tion. “I thought I was supposed to be getting stronger, not
and approached the edge of the tub to get out. I would weaker.” My voice did not hide the indignation I felt.
 Chapter 31 • A Survivor’s Perspective II: Stroke 757

“You’re experiencing a progressive stroke, which can After a few moments of this, when I had begun to col-
go on over several days,” he said. In my long experience I lect myself, the door burst open and the first of the ever-
had not heard of this, and I questioned him further about present residents came in, sporting the now familiar
the length of time it would continue. “Usually it is fin- blood-taking kit.
ished by the fifth day,” he replied. Silently I counted back “We’ll be checking your blood every few hours.” Her
to the day I had felt the first signs of weakness; that was manner was friendly but businesslike. Hardly had she left
six days ago. By the time I figured it out, Dr. Mitchell had when a nurse entered, carrying the floppy plastic bag
left the room to ask his assistant to make the necessary filled with clear fluid; this meant that I was to have an
calls to get me readmitted to the hospital. infusion. Without a word she hung the sack of liquid on
When Dr. Mitchell returned, he stayed just long enough an arm of the pole that she wheeled from the corner of the
to tell me to go to the admitting office where they would tell room to my bedside. With a minimum of wasted motion,
us when the room was ready. “I’ll stop in to see you later she inserted the needle in my left forearm and held it in
on,” was all he said as a sign that the session was over. place by a strip of adhesive tape. She fitted the slender
I was very grateful for the wheelchair that Jeff now tube that extended from the bag of liquid into the needle
pushed through the many corridors that took us back to and turned the valve, and the liquid began to drip slowly
the hospital. At the admitting office, they already had into my veins. In response to my inquiry, she told me that
papers for me that I now had to sign. I had not expected I was to receive an infusion of heparin, which I recognized
that I would be totally unable to sign my name. After as a so-called blood thinner. I let out a long sigh of relief;
several futile attempts at guiding the pen, I had to admit at last someone was doing something that seemed vaguely
that this was impossible for me. helpful, and for a moment I relaxed. Then I realized that
“Just do the best you can; you can even put an X if you I was not only tethered to the IV pole, but that this virtu-
want.” ally made my left arm as useless as my right. Before I al-
The humiliation was almost more than I could stand; I lowed myself to go into a full-blown panic, I tested the
choked back the tears as best I could. We were told to wait slack in the tube and how far I could reach with my arm
until the bed was ready, and we sat in the waiting room before a tweak reminded me that I had reached the limit
along with other patients. At first it was rather interesting of my arm motion. I had to admit that this wasn’t too bad;
to watch and listen to the different snatches of life stories after all, I could reach as far as the top of my head, and if
unfolding around us. I was comfortable in the wheelchair I sat up, I could reach my knees. These were the limits of
with two good friends at my side; I had made all needed my world for now; I let out a sigh of resignation and fell
decisions for the moment and was ready to relinquish my into an exhausted sleep.
body to the wonders of the healing sciences. After what seemed to be only moments later, I woke up
It was hard to sustain my interest in the fate of other to the cheery sound of a man’s deep bass voice humming
people when my own had a much higher priority. Re- a tune as he entered my room.
peated inquiries of the clerk at the desk about the readi- “Hi, I’m Malcolm, your night nurse,” he smiled broadly,
ness of my bed resulted in the same answer: “They should and his rich Caribbean accent was undeniable. “I’ve come
be calling from the floor any minute now.” It was the first to check your pulse and blood pressure.”
of a chain of broken promises that I came to recognize as “Could you also call someone to help me to the bath-
one of the hallmarks of patient treatment. No one wants room? I need help with walking. Besides, I don’t know
to give a straight answer when they know how unpleasant how I can manage with the IV pole.”
the truth may be to the patient; it is far easier to promise “Sure. I can take you.”
a fulfillment of the patient’s request than to be in the role This was not exactly what I had bargained for. The idea
of the bad guy. And so the minutes turned into hours. of a man taking me into the bathroom was not very ap-
Finally, three hours after we had entered the waiting area, pealing, but since I could not think of a graceful way of
we were told that the bed was indeed ready, and I could getting around this, I moved myself to the edge of the bed
report to the fifth floor of the hospital. My room—with in anticipation of getting up.
only one bed—was again on the river side. After another Malcolm turned out to be a great help. He held me up
wait to get the necessary hospital paraphernalia, I was able effortlessly with his right arm while wheeling the pole
to convince Jeff and Helen that I was in good hands, and with the other hand. In spite of my sorry condition, I
they left for home. It was then that I became aware of the smiled inwardly. We were indeed an odd couple as we
enormous fatigue in my body, but even more so, the seri- headed toward the bathroom door. Once inside the bath-
ousness of my condition now faced me squarely. I had to room, I had to face another hurdle. Could I balance my
admit to myself I had lost the exhausting battle with de- body by standing solely on my left leg and use my left
nial, and I gave full expression to the overriding despair hand to pull down my pants? I decided to risk it, rather
that gripped me. My body shook with sobs that I did not than ask Malcolm to perform this task for me. There was
try to control. a limit to how much I was willing to ask for assistance,
758 Stroke Rehabilitation

and I needed to prove to myself that I was not totally were enough people in the hospital that knew me, and the
helpless. news soon leaked out. From then on, during the weeks of
“I’ll be all right now, Malcolm. Thanks a lot for your my stay in the hospital, the wide windowsill of my room
help,” I managed a smile. was always filled with fresh flowers or potted plants,
“Just pull this cord when you’re finished.” Malcolm thanks to the dozens of people whose good wishes were
handed me a slender cord that was attached to the switch expressed in this touching way. I felt ashamed of the feel-
for the bell. A fleeting thought crossed my mind; what- ings of self-pity that I had allowed to take over.
ever needs my body or soul now had had to be carried out Soon after the flowers, the first of a steady flow of visi-
with the help of other people or exclusively by my less tors from the University arrived. They managed to
skilled left hand. This, like everything else that was hap- squeeze in friendly calls before, during, and after their
pening to my independent lifestyle, would take some ad- work hours in the University. Now I had to face my defi-
justment on my part. cits head-on, and I experienced a sense of shame, espe-
The three days that followed were filled with the dull cially at my slurred speech. It was also exhausting to an-
hospital routine; frequent visits by doctors in all stages of swer “How did it happen?” again and again. Still, the
their development, always physically probing and asking visitors were bright spots in the monotony of the hospital
for more information; and the change in nursing shifts days. The ones I anticipated with the greatest pleasure
and the actions performed by each, depending on where were Helen and Jeff, my sister-in-law and brother. They
they found themselves on the hierarchy of professionals always brought fresh news of their family and also deliv-
and helpers. Some were extremely cheerful and encourag- ered my mail. I could count on them for all the support
ing; some showed the strain of severe staff shortages. and understanding I needed. Jeff had taken over the man-
There were also the small annoyances like a stuck win- agement of my finances; Helen took the bag of dirty
dow that took five days to get fixed. Of greater consequence clothes from the floor of my closet, and when I started to
to me were the details of my care that suddenly loomed object, she silenced me. I surrendered a further aspect of
larger than reality and reminded me at every moment just my independence, this part more willingly.
how helpless I really was. Perhaps in an effort to be kind or Another break in the routine was the daily visits of the
perhaps in a moment of absentmindedness, someone had therapists. I was concerned that nothing was being done
shut my door at night, thereby leaving me at the mercy of for my arm. I had seen too many tight, painful shoulders
my left hand to call the nurse. The first time the beeper and permanently weak wrists to risk similar complica-
announced that the heparin bag was empty, I rang the bell, tions, frequently the result of lengthy disuse. When I
and the remote voice at the end of the intercom told me voiced this to Romana, she brought me two wrist splints
that a nurse would come right away. The beeper screeched to try. I also began to exercise my arm with my other
unceasingly, without the appearance of the promised nurse. hand. It was the first action toward resuming charge of my
I began to feel my heart pounding fiercely, certain that I life, and it felt good.
would have another stroke because my blood was not get- Now the next hurdle to overcome was the decision by
ting the required dose of heparin. I tried feebly to call for the doctors and therapists of if and when I could be
help, but I had to admit that my voice barely reached to the moved to the rehabilitation floor. Of course, I was still
door. At last the nurse arrived with the new bag, totally receiving the heparin infusion; the needle would have to
unmoved by my near-panic state. be removed before I could begin a strenuous rehabilita-
“A short interruption like this doesn’t make any differ- tion program. Finally, six days after my second admission,
ence.” Her matter-of-fact response to my concern made the order came from the doctors; my blood had been
me realize that I was losing my cool and had become just thinned to the required level, and I was to be moved to the
like all the frightened patients whom I had tried to reas- eighth floor.
sure during my professional life. As promised, the two needles were removed from my
I had struggled to view the whole experience with an arm, and I was liberated from my tether. In spite of my
objective clinical gaze, but I found myself forced into the relief at the prospect of starting the rehabilitation pro-
role of docile sufferer, lacking the necessary willpower to gram, I felt the slightest twinge of sadness, much as I felt
do otherwise. Nothing seemed to be happening that was in grade school when I advanced to the next grade. I had
changing my condition; I began to feel very sorry for begun to think of the familiar routine of the fifth floor as
myself. more or less safe, and I had become used to the staff. I
I was aroused from this “blue funk” by the arrival of an knew that on the rehabilitation floor, patients were in
exquisitely blooming exotic plant sent by my colleagues at double rooms; there were also much higher expectations
the University. How had they learned of my whereabouts? for helping oneself placed on the patients; would I be able
According to the calendar, I was supposed to be on my to measure up? As always, there was a long wait ahead
way to Europe! I thought that since no one was expecting until finally, an attendant with a stretcher announced that
me back for three weeks, my secret was safe. But there he was moving me. But why the stretcher?
 Chapter 31 • A Survivor’s Perspective II: Stroke 759

“Oh that,” he explained, “That’s not for you. That’s for “The sink,” I responded, eager to have the chance to
all your plants and stuff. I’ll come back for you in a little fend for myself.
while with a wheelchair.” Then he left me sitting in bed, “Do you have slacks and a shirt to wear? Here we ex-
once again feeling abandoned. There was nothing to do pect people to wear their own clothes.” To be able to shed
but wait; to amuse myself, I looked out at the river, which the hospital gown after a week! Suddenly I realized how
was changing to its evening glow in preparation for the much I wanted to be restored to my former self and to
sunset. Most of my life I had lived within sight of a river; leave the patient role behind.
first, during my early childhood, it was the Danube with The nurse brought a wheelchair into our large room
its rushing brown current in spring, and during many of and parked it next to my bed.
my adult years, it was the Hudson. Now the steady flow “Can you transfer into this?” Her voice sounded
had become a source of comfort and assurance of the friendlier than before, and although I hadn’t attempted to
continuity of life. The lights on the side of the river were move from the bed to the wheelchair by myself, I had
already starting to blink when the door was flung open by worked with dozens of patients to teach them this skill. I
the returning orderly, this time pushing a wheelchair. He sat on the edge of my bed, slid down to stand on my left
lifted me nimbly into the chair and whisked me toward leg, pivoted around and grasped the left armrest before
the elevator to the eighth floor. Halfway down the hall he letting myself down in the chair. I had to gather each gar-
pushed me into a large double room with a similar picture ment I wanted to wear from the drawers of the nightstand
window facing the Hudson. My new roommate ap- and the closet and wheel myself to the bathroom door.
proached me, pushing a walker. Moving the wheelchair with only my left foot and arm
“Hi, I’m Virginia,” she extended her hand in a confident took a lot more skill than I remembered, but after several
way, and I shook it with my left. Virginia was a tall, black attempts to stop myself from merely going in a circle, I
woman with a matter-of-fact manner and a smile that hov- got the knack. The nurse moved an armchair into the
ered just behind her eyes. I liked her immediately. bathroom to the small space between the wall and the
“Why are you here? Did you have a stroke?” I knew sink. “Once you’re in the bathroom, I’ll help you transfer
that I bore all the signs of patients with whom I shared to the chair and then take the wheelchair out. Otherwise,
this diagnosis, but Virginia’s direct query caught me off you won’t be able to close the door.” I welcomed the pri-
guard. For the first time in days, I burst into tears. vacy that this would give me; how I would get back the
“No sense feeling sorry for yourself.” Virginia was wheelchair when I had finished was too far in the future
right, and her words became my special mantra during the to consider.
weeks that followed. But for now I was content to let Now began the long, arduous process of washing and
Virginia talk; it was obvious that she knew the routine of dressing myself, but the idea of doing all of this by myself
the floor. When we said good night, I felt relieved that behind a closed door seemed like the best thing that had
there was a person on the other side of the curtain that happened to me in a week! For the next 50 minutes, I was
was drawn during sleeping hours. fully occupied in breaking down each task into tiny steps
I woke frequently during the night; each time I and then, mostly by trial and error, carrying out each step
awoke, the big clock on the wall showed that only an with my left arm and leg and with my teeth and any work-
hour and a half had passed. Now that I was free to move ing part of my body that I could involve in completing a
in the bed, I realized that I couldn’t change my position given task. I had never thought of myself as even remotely
much more than I had when my left arm was held in ambidextrous, and my left hand had only complemented
place by the tubes. Besides, my right side kept getting in my right for any task that naturally called for bilateral
my way and I needed to move both the arm and the leg skill. Now I not only had to resort to being one-handed
with the other side. I was once again grateful that at least but also confining all hand use to the left.
I knew the technique, but that didn’t make the situation One of the first challenges was putting toothpaste on
more palatable nor me more comfortable. I watched the the toothbrush before I brushed my teeth. Like all of the
sky for the first signs of summer dawn that arrived at the activities of daily living, I had worked with patients on this,
same time as the noise in the corridor that announced so there was no mystery connected to it, but the frustration
that the rehabilitation floor was coming to life. Shortly I experienced before I even had toothpaste on the brush
thereafter, a hand reached for the light switch that was enormous. Flipping up the top of the tube presented
changed night into day. no problem, although it meant grasping the tube without
“Time to get up,” the raspy voice of the nurse called my thumb, since I needed the thumb free to push open the
loudly; I noticed that the clock confirmed that it was top. Obviously, I was out of practice; otherwise, I would
only 5:30. have remembered that the toothbrush has to be laid flat
“Do you want to bathe yourself in bed or sit by the sink and braced against an object to keep it from moving while
in the bathroom?” the nurse asked. I had noticed with the toothpaste was squeezed onto the bristles. Now I had
satisfaction that each of us had a private bath. to put the toothpaste down; why wasn’t there at least a
760 Stroke Rehabilitation

ledge on the edge of the sink on which to place the tooth- fastening my bra and putting on the sneakers that were
brush? When I put down the toothpaste to pick up the still in the closet. It was then I felt my exhaustion; I had
brush, the heavy tube fell into the sink where I left it mo- used up every ounce of energy of my body before the
mentarily; at least it couldn’t fall on the floor. Once I had day had even officially started.
wedged the toothbrush against the left faucet in hopes that Virginia was already seated in her chair fully dressed,
it would stay there, I was ready to retrieve the toothpaste her walker at her side.
and squeeze it onto the waiting toothbrush. Then, finding “I’m supposed to graduate to a cane today,” she an-
a place for the toothpaste, I picked up the toothbrush with nounced, “I’ll be going home when I can walk by myself.”
my left hand. However, before it reached my teeth, the How I envied her! She seemed so competent with every-
toothpaste had fallen off the brush and was clinging in a thing. A funny thought crossed my mind; I had often told
soggy mess to the edge of the sink. The second time I re- my students how patients compared their own progress to
peated the whole routine, I was successful and began to that of other patients even when they had quite different
brush my teeth rather clumsily with my left hand. When I diagnoses, “You should have seen me two weeks ago; I
had at last advanced to my socks, I was already so tired that couldn’t do anything.” Invariably, the second patient
the thought of the struggle was almost more than I could would gather hope from seeing that progress. Now I had
face. Then the “achiever half” of me chided the “flagging reached that stage of using Virginia as a role model, even
half”; I picked up the first of two socks that were the only though she had undergone thigh surgery only and her
remaining garments on the arm of the chair in which I was arms and hands were totally intact. In spite of everything,
sitting. Surely I could do this last step. Happily, I had not this type of black humor never ceased to amuse me!
lost the agility that has always allowed me to squeeze Three hours after our untimely reveille, breakfast ar-
through narrow spaces and bring my knees close to my rived. I realized that I was also weak from hunger and fell
chest! At least I could bring my left foot up to rest it on my on the food for the first time since leaving home. Just as
right knee. I decided to tackle the left sock first and found we finished, one of the physical therapists came to intro-
that my left foot cooperated nicely in the task by extending duce herself as the person who would be working with
the big toe so I could hook the sock over it. Then it was me. I recognized her immediately as a graduate of the
just a question of pulling the sock first over the rest of the physical therapy program whose students shared many
toes and the heel. science classes with our occupational therapy students.
It was a different story with the right sock. I lifted the She had been working several years and had fortunately
right foot up to the left knee but without the muscle lost some of the tentativeness of novice therapists. After
power to hold it, it slid down to the floor. I remembered we had talked for a few minutes and she had given me a
that I could expect no help from my right side. I leaned quick once-over, she promised to return later with my
over and brought my body closer to the foot, but I was total therapy schedule; the rest of the day I could relax! I
afraid that if I leaned over too far I would tip over. I sat was terribly disappointed and had to keep myself from
back as far as I could in the chair and leaned forward crying again. For this I had gotten out of bed at 5:30!
again, but when I was ready to hook the sock over the toe, Thank goodness the day’s visitors and several phone
the foot stayed flat on the floor. No sooner was the sock calls took my mind off the letdown. Virginia returned from
on the toe than I would pull it off accidentally in attempt- therapy sporting her new cane and was mighty proud of
ing to move the sock over the foot. After several more herself. Would I ever get to use a cane? It was hard to think
tries, I succeeded in getting the sock over the toe and beyond today, and I was not ready to create a new image
gradually working it over the static foot. In my delight at of myself as anything other than my former self. In the
seeing socks on both feet, I was glad to overlook that the effort to get used to so many new things, time had ceased
right sock was completely stretched out and hung limply to exist for me. I lived from moment to moment, and the
at the ankle. outlandishness of my current existence enveloped me to-
“Oh, well,” I sighed to myself with resignation. I real- tally. Once again, I was grateful that all responsibilities had
ized that I would have to lower my standards for achieving been taken from me, and no one was expecting anything
anything. I would have to settle for just doing a task with- more from me than being a good patient for my caretak-
out looking for quality. And I had to muster all the pa- ers, a role that I had described at great length to my stu-
tience I had slowly learned in the socialization process of dents. Although never expressed, the message was, “Be
becoming a therapist; only now it was not a question of compliant, don’t complain, don’t ask too many questions,
sitting on my hands in order not to give in to my desire to get well, and go home!” Here I was, very quickly behaving
help a struggling patient. I had to serve as my own cheer- just like every good patient in the hospital.
leader, goading myself on and applauding when I was Now that I was on the rehabilitation floor, life had a
done. peculiar déjà vu feel; just a week before I became ill, I
When the nurse came back to check on my progress, was interviewing patients in many of the rooms on this
I reported triumphantly that I needed help only with floor for a research project I was conducting with the
 Chapter 31 • A Survivor’s Perspective II: Stroke 761

occupational therapy department. Before I had time to Ilsa had told me, the therapists would come for me at the
dwell on this, Dr. Mitchell appeared, cheerful and ener- appointed hour. I was to start with physical therapy at
getic as always and seemingly very interested in my 9:30, then on to occupational therapy at 10:10, and fol-
condition. lowed by speech therapy until 11:30. Luckily for me,
“I’d like to get an MRI [magnetic resonance imaging] Romana was to remain as my occupational therapist, al-
on you. You’re not claustrophobic, are you?” he asked. though she usually worked with the acute patients only. I
The question was almost rhetorical, but it hit me hard. felt that it was better to have someone who was new to
For years I had heard reports of this procedure and had me, rather than any of the 12 occupational therapists who
seen videotapes of patients’ heads encased by the confin- had served as subjects for a study I had conducted and
ing cagelike structure; I had often remarked that I would which meanwhile had been published in a professional
die of fright—how easily we speak of death when it is not journal. As a patient, I had been stripped of all the profes-
imminent—if I ever had to have an MRI. sional trappings that one is bound to accumulate, but after
“Yes, I’m terribly claustrophobic,” I said and remem- 15 years of serving as director of a university program, I
bered the time I thought I was suffocating when I woke in was afraid that my history would serve to intimidate the
the upper bunk at camp with the ceiling ostensibly only young therapists. It was quite different with the physical
inches from my face. “Do I have to have an MRI?” I felt therapists, most of whom I did not know and from whom
ashamed of my childish, almost petulant question. I could expect ordinary patient treatment. When it came
“I think you’d better, so we can tell the exact place of time to meet the speech therapist, we recognized each
the lesion. I’m conducting a research project on brain other immediately as colleagues who had shared the same
function during hand movement at various points of re- monthly administrative department meetings for many
covery after stroke, and I’ll be there with you.” The dual years. Anne-Marie was nearer my own age than some of
possibility of contributing to research in an area that had the others, and I felt we understood each other right away.
always fascinated me and having Dr. Mitchell close by And yet I felt the stigma of being a disabled patient more
quickly convinced me, and I gave my consent. Besides, it acutely in speech than I did in either of the other two
was to be scheduled for next week and that seemed far in therapies.
the future. As expected, the first morning in therapy was taken up
Meanwhile, I had to face the weekend without having by a detailed assessment by each of the therapists. I was
started any therapy. My disappointment was mixed with glad to show off the movement in my arm and leg and was
the fear that I would begin to see in myself many of the pleased that these were not the only things that were rec-
complications that were the result of disuse. At night, dur- ognized as strengths. Rather than experiencing the de-
ing several sleepless hours, I suddenly discovered that I pression that was common when patients realized how
could slide my arm and leg across the sheet. That meant much they couldn’t do, I felt a surge of the need to excel
that a small amount of strength was returning to my that had driven me from my earliest years. As a child I had
limbs! I was so excited that I had to fight my urge to wake responded to the desire to please a very critical father
Virginia, who was sleeping soundly. After that, each time whom I adored; now I wanted to be the “best” rehabilita-
I awoke after a period of sleep, I had to move first my leg tion patient.
and then my arm to make sure that it had not been a From frequent visits to the rehabilitation floor, I knew
dream. As I knew, the slight movement did not have any that both occupational therapy and physical therapy were
functional value, but the feeling that resulted from it gave extremely lively places. The large, airy physical therapy
me a boost that got me through the rest of the weekend. gym had mats in several places where patients with diverse
I had hoped that perhaps we would be allowed to sleep problems were working with their therapists on strength-
longer on Saturday and Sunday, but the routine was un- ening exercises or resting between the different parts of
changed, since the only purpose of the early rising was the their program. While I sat in my wheelchair waiting for
schedule of the night nurses; their duty ended at 7 am, by Ilsa to finish with her first patient of the morning, I had a
which time all the patients had to be washed and dressed. chance to survey the other patients with whom I would be
“Patient-centered care,” one of the buzzwords of the sharing rehabilitation. I knew that in coming to this floor,
1990s, this was not. Like much of hospital practice, it I had become part of a distinct society who were bound
served the staff and the administration long before the together only by the fact that each of them had incurred
wishes of the patients were taken into consideration. a temporary and not-so-temporary loss of function, of
Finally, it was Monday, and today therapy was to begin self-image, and of role. I knew nothing of my new associ-
for me. As promised, Ilsa, the physical therapist, stopped ates except that they were patients; they, in turn, knew
in our room before she started working and had attached nothing of me. Once again, I was reminded of one of the
my therapy schedule to the back of my wheelchair in or- topics I had chosen for lectures: “People in the Patient
der to let the staff know where I was to be at any time Role.” Was it part of a self-fulfilling prophecy? I decided
during the day. Until I became familiar with the routine, that here I had an opportunity to fashion a totally new
762 Stroke Rehabilitation

personality, but the thought seemed entirely too fatigu- other for many years and knew that we could work well
ing. True to my old self, curiosity took over; I made up my together. He was also a favorite clinical instructor of our
mind to experience the new role as a fully participating students. Glen and one of his colleagues were editing a
member rather than an inquisitive spectator. Besides, I book on stroke rehabilitation, and several months before,
thought ruefully, I actually had little choice. The realiza- much to my surprise, had asked me to write the foreword.
tion of this made me feel teary. I turned my attention to I had told Glen that I was no longer as well-versed with
the bustling environment; I did not want to start my first the topic as I had been when I was teaching clinical
physical therapy session as an emotional disaster. courses, but when he asked a second time, I agreed. The
Approximately eight other patients were engaged in book was to appear on the market in several weeks. I
some type of exercise or walking practice with their own thought of this when Romana and I entered the occupa-
therapist. Laughter and jokes resounded everywhere; it tional therapy clinic and I spotted Glen working with a
was obvious that therapists and patients enjoyed working young man.
together. One woman with a newly fitted artificial leg was This was the place where I felt at home. In one of the
practicing walking in the parallel bars; she was perspiring momentary flashbacks that catch one unaware, I recalled
with the effort of lifting the heavy prosthesis in prepara- the reason for my becoming an occupational therapist
tion for each step, but she wanted us all to know that she over 40 years ago. I was still in high school searching for
was there. A man, who seemed younger than the rest of a career in medicine without blood when I heard about
us, was learning to step up and down simulated curbs us- occupational therapy. It allowed for direct work with
ing a cane. A very old and frail-looking lady was objecting people using my hands and a great deal of creativity of a
strenuously that she couldn’t stand on her operated side; special sort; assisting patients with the kinds of day-to-day
the therapist firmly but gently insisted that she try in spite physical, cognitive, and emotional problems that were
of the pain, and in a few minutes the patient was on her preventing them from living ordinary lives. All of the pa-
feet, tightly clenching the walker in front of her. Then it tients here, like myself, were learning to live with what
was my turn to begin. they had left after injury or disease had robbed them of a
Ilsa approached me with a broad smile and told me part of their function. In occupational therapy, they found
to wheel myself to one of the mats that was raised about a place and people who allowed them to mourn their
18 inches from the floor. I was told to transfer from the losses and then to move ahead to learning new ways of
wheelchair to the mat pivoting on my left leg. It was an accomplishing tasks. The aspect of my clinical work that
activity I had performed countless times with patients of I found most satisfying was literally to get into patients’
all sizes and in need of varying degrees of help; I remem- heads, to discover which tasks had the most meaning for
bered how I was filled with dread at the sight of patients them, and then to elicit each patient’s readiness to work
who were taller and heavier than myself and needing a on those tasks together until a satisfactory solution had
great deal of assistance. Thank goodness I was well- been found. This had allowed me to glimpse deeply into
schooled in this task and needed no help to get to the mat. other people’s lives and to discover what kinds of activities
Ilsa then checked every muscle for active and passive mo- were most important to people at different points in their
tion and pain. I was glad to be able to show the slight lives. It had also given me a chance to be a partner in the
motion I had in both arm and leg; Ilsa told me that was a roller coaster experience of recovery with men and women
very good sign. Before the session ended, she let me try from all walks of life. Now I was acutely aware that a long
one of the walkers in the gym, but since I couldn’t hold on process of moving through all the emotions from despair
with my right hand, this was still too difficult for me to to exhilaration that probably lay ahead for me as well.
attempt. It became a goal for a future session, something The occupational therapy clinic was a room with two
that seemed a distinct possibility. I had concluded my first distinct parts. There were also two large raised mats
session in physical therapy; Romana now pushed my where people were practicing all sorts of movements in
wheelchair to occupational therapy. preparation for carrying out some functional activity.
This place was extremely familiar to me; first, from my The other part was the “Easy Street” unit that had ar-
years as a clinician in similar departments, and more re- rived only several months before. “Easy Street” had re-
cently, as the place where I had been coming to gather ceived much publicity in professional journals, and one of
information on the patients who were the subjects in my its features was that, depending on the needs of the par-
current study. Conducting research in occupational ther- ticular rehabilitation center, it could include one or more
apy was one of the retirement projects I had promised daily life units such as a model apartment, a supermarket,
myself, and since this department had accepted my offer a street with curbs and a traffic light, a factory setup, a
with enthusiasm, I had been a weekly visitor on this floor, golf driving range, or a stationary car. I remembered the
interviewing patients about their perceptions of occupa- discussions we had as a faculty, wondering whether this
tional therapy. I had chosen the supervisor of occupational highly touted and equally highly priced equipment would
therapy as a research partner; Glen and I had known each really be worth the price and the large amount of space
 Chapter 31 • A Survivor’s Perspective II: Stroke 763

that was needed to house the various components. But were simplified to make it possible for all of us to partici-
even before I arrived as a patient, I had my answer. The pate in games like beanbag toss with a laundry basket as
majority of subjects in my recent study had all remem- the target or modified soccer with the goal of kicking a big
bered some aspect of their occupational therapy that they but light ball to each other. A very important aspect of the
practiced with their therapist in “Easy Street.” I had group was clearly socialization, and most of us got into
never dreamed that I would be a candidate for validation that component effortlessly. It was amazing to see the in-
of the equipment. ventiveness and enthusiasm of our leaders; I was quickly
But clearly there was much I had to do before I got to caught up in the laughter and the chance to be utterly ri-
that point. Romana first asked me to demonstrate all the diculous. During moments of waiting for my turn, I was
motion I had and also checked strength and coordination reminded once again of my own incapacity; the newly re-
in both arms. Then she asked me to describe a typical day, gained motion in my arm and leg was of little help to me,
making sure that I mentioned not only major tasks and and I had to confront the reality that I was one of thou-
responsibilities, but also what I did for pleasure, where, sands of people who were hemiplegic—“hemis,” as we af-
and with whom. At the end I felt she had quite a complete fectionately used to call them as therapists. I recalled the
picture of who I was and the types of skills, manual, cogni- group traits that characterized the “hemis,” depending on
tive, and social, I needed to approach my previous life- the side of the brain where the lesion was located; thank
style. We ended the session with setting long-range and goodness, I thought once again, I’m a right hemi whose
more immediate short-term goals. If the whole procedure dominant side was affected but who was not expected to
would not have been so familiar and right to me, I sup- have problems in thinking or behavior. My experience as a
pose I would have been more bewildered and over- therapist had borne out much of the textbook information,
whelmed than I was; I knew what I had to do to get where and I had always enjoyed working with right hemis, many
I was going, but would I find the strength to do the work of whom had aphasia, a language problem, or, like myself,
that would get me there? dysarthria, which is a problem involving the clarity but not
Across the hall from occupational therapy was Anne- the content of speech. I had liked the challenge of develop-
Marie’s office, where I was to go for speech therapy. We ing a partnership with a patient with aphasia and together
talked about old times, especially the monthly meeting discovering a new mode of communication, something
both of us had attended; Anne-Marie filled me in on de- like a secret language between us at first. But I was awak-
tails of the current politics in the department, and I re- ened from this reverie by a large balloon being tossed my
sponded to her news. This gave her the opportunity to way and the struggle to catch it with my left hand before it
listen to my thick, slurred speech and also to assess the hit me squarely in the face. “Go, Barbara, go!” the thera-
extent of the breathlessness that had plagued me since the pist encouraged; no one seemed to mind that I dropped
stroke. The deficient speech was of far greater concern to the ball. So ended my first morning in therapy. I was too
me than the paralyzed arm and leg, perhaps because drained by the morning’s activity to acknowledge the fact
speech and intellect are so closely linked on the social that in an hour and a half, the therapy routine would begin
measurement scale. It was good that Anne-Marie and I again.
could laugh together when I bungled sounds; otherwise, In the middle of the week, my roommate Virginia went
the situation would have been even harder to face. home, feeling satisfied that the recovery from the surgery
At 11:30, when I was totally exhausted, I was told that had progressed to the extent that she could carry on alone
during the hour before lunch, each patient was assigned to at home. For one night, I had the room all to myself,
a group for further physical activity, depending on one’s and I welcomed the solitude between the steady pace of
needs. I was sent to the strengthening group, which on visitors—professional and friends and family—that con-
that day consisted of about 10 other people. Seated in a tinued. I longed for a chance to be left alone, at least long
circle in our wheelchairs, we were an odd cross-section of enough to appraise where I was, not fully two weeks since
New York City demographics: black, white, and Hispanic the onset of the stroke. I also wished for an opportunity to
men and women, dressed in sweat suits or shorts, shirts, take off the cheerful mask that I was wearing, but the an-
and sneakers, we vaguely resembled a crowd at Yankee ticipated depression still had not come. I was just glad to
Stadium on a Saturday afternoon, although the average be alive, and aside from the obvious paralysis of my right
age was certainly above 50-years-old. Most of us were re- limbs and the breathless exhaustion, I felt perfectly well.
covering from strokes, with varying degrees of disability This came as a total surprise to me. In all the conversa-
on either the right or the left side. Some people were obvi- tions I had with patients who were recovering from a
ously seasoned members and knew the routine, which was stroke, it always seemed they had pain or other discom-
not difficult to understand. Far more difficult for all of us fort. The movement in my arm and leg was definitely re-
was to carry out the commands issued by one of the thera- turning; I could not yet move even against gravity. I still
pists in charge. The purpose of the group was to encour- wore the splint on my right wrist to keep that joint from
age use of our limbs in sport or recreational activities that tightening up in a contracted position.
764 Stroke Rehabilitation

Before I got too used to the luxury of having the large in my class decided to wrap me in the dark red velvet
sunny room all to myself, my new roommate arrived. My curtains that hung open at the edge of the stage. Before I
first impression of her was quite favorable; in a few sen- could object, I felt myself being spun around as the heavy
tences, Mrs. Gold told me not only her medical history, material enveloped me. I can still smell the thick dust that
but also enough details about her life that I knew she lived saturated the curtain; I felt trapped and unable to breathe.
near me, “in a very good section” of the neighborhood as I let out a piercing shriek, and the boy released the cur-
she emphasized, that she liked good quality and always tain. While I sobbed hysterically, the curtain fell away
bought the best, and that she had a daughter in California, from me and I stood free, feeling utterly humiliated in
whose marriage to a penniless college professor—at least front of my laughing classmates. That image stayed with
20 years ago—of which she still did not approve. Her me all these years and became particularly vivid while
daughter had come East to transfer her mother from an- Dr. Mitchell spoke further about the procedure.
other hospital, “a regular hellhole” she noted, where she “I’ll be with you in the room; you’ll be able to see me
had been taken after being hit by a van while crossing the through a mirror, and I’ll tell you exactly what to do, first
street. Now her only remaining injury was a small tear in with your left hand and then with your right.” Since I had
her bladder. She also needed to practice walking, since she already told him about my anxiety, I decided that my tell-
was off her feet a number of weeks. She was greatly re- ing him again would change nothing. If the procedure
lieved when, in response to one of her first questions, I were really life-threatening, I decided, I would have read
told her that yes, I was Jewish, too. She then asked for my about the consequences by now. “I’ll meet you down there
marital status and many other details about my personal tomorrow,” with a breezy wave of his hand, Dr. Mitchell
life that I had not expected to divulge within the first half- was gone, and I was left alone with my irrational fear.
hour of our meeting. At least I would have a respite for an hour tomorrow
When Mrs. Gold had been put to bed for the night, from the twice-daily therapy that consumed six hours of
she began to rummage in her pocketbook for her check- every day. With that small bit of comfort, I fell asleep. The
book, declaring it stolen after a few moments. I urged her next morning, an orderly arrived with the now-familiar
to look again and then suggested that it might be in her stretcher that took patients to special services in other parts
night table. Sure enough, there it was! She began to flip of the huge hospital. We arrived in one of the basement
through the check register and announced that her daugh- corridors clearly marked with a large sign that announced
ter, who now had power of attorney over Mrs. Gold’s fi- that we were approaching the MRI suite. “Caution—
nances, was squandering her money on God knows what. Electromagnetic Equipment—No Unauthorized Person-
“Why, here is a check for one hundred dollars to nel beyond this point!” a second sign heralded ominously.
Channel Thirteen! I never told her to do that.” In response to a special bell pressed by the orderly, the
For the rest of the evening she repeated the action of double doors swung open and closed behind us as soon as
getting the checkbook from the drawer and narrative of we were inside.
the check. I tried to reassure her by saying that she could Contrary to the CT scan room where I had been alone
ask her daughter about the money the next day. This re- with the machine, this room was a lively place, mostly oc-
sulted in a new cascade of accusations against her daugh- cupied by outpatients and a variety of technicians. After a
ter. Finally, after both of us were exhausted, Mrs. Gold fell long wait where no one seemed aware of my presence, a
asleep. For the next three and a half weeks, Mrs. Gold and man in shirtsleeves greeted me.
I shared the room, and she became both the much-needed “You’re Doctor Mitchell’s patient, aren’t you? I’m
scapegoat on whom to vent my anger and the equally Doctor Timoshenko, his assistant, and will prepare you
needed comic relief. How much of her confusion was her for the actual procedure. Please remove everything metal-
normal state and how much could be attributed to the ac- lic you are wearing, like your watch and your rings.”
cident I never found out, but although she had moments A nurse holding a little plastic box was standing next to
of complete clarity, she also was beset by feelings of per- me, her hand outstretched in anticipation.
secutions and paranoia that made ordinary conversation “I can only remove the ring on my left hand,” I volun-
almost impossible. Luckily, we spent many hours attend- teered, “my other hand is paralyzed.” Didn’t she realize
ing our respective therapies, and thus I did not encounter that herself? Without a word she slipped the ring from my
Mrs. Gold for most of every day. right finger, removed my watch, and proceeded to tackle
When Dr. Mitchell next came to see me, he told me my earrings. I wanted to scream! I was systematically be-
that the MRI had been scheduled for the following day. ing stripped of my identity, and felt the last vestige of
While he spoke very reassuring words, I could feel the myself disappearing into the little white box.
familiar cold dread spreading over me that was part of a “I need to take your glasses, too.” Reluctantly, I re-
childhood fear of suffocating. To my knowledge, the clos- linquished my remaining hold on reality. Anything
est I had ever come to that state was in third grade when could happen to me now, and I couldn’t even see my
we were rehearsing for a play. As a prank, one of the boys aggressors!
 Chapter 31 • A Survivor’s Perspective II: Stroke 765

Dr. Timoshenko wheeled me into another room where overwhelming, but I remembered my discussion of this
I could dimly see several people in lab coats seated before with Dr. Mitchell before the test.
computers. Beyond this outer room was the actual cham- “I’m only looking for brain activity while you attempt
ber with the large white machine into which I would be the movement.” His response had been reassuring, at least
placed during the test. Now Dr. Timoshenko and another for the moment. This got me through the second half of
man seized the sheet on which I was lying on both sides the test, touching each of my fingers to the thumb with
and at the familiar count of three hoisted my body onto equal lack of success on the right side.
the platform of the machine. I felt the hard, cold surface At the end of this trial, Dr. Mitchell patted my hand
against my spine and hoped that I would not have to re- approvingly. “You did very well.” He gave me a broad
main in this position very long. With deft hands, the two smile. “In about 10 minutes you’ll be finished.” He left
men strapped me down to the table, first making sure that the test chamber, and I was once again by myself. The
I was covered by a flannel sheet. Then a strip of adhesive clanging abated slightly. At least, I could expect an end to
tape across my forehead tethered my head to the platform the ordeal.
and gave the finishing touch to my immobilized, mummy- I wondered why, after Dr. Mitchell had completed his
like state. experiment, I had to remain in the machine, but all signs
“Here are earplugs to block out the noise made by the of human staffing of the machine had vanished on the
machine,” Dr. Timoshenko said. What else was part of the other side of the window, and I was once again all alone.
preparation? I was beginning to feel utterly dehumanized, Time seemed at a standstill; I recalled a story from the
and this was only the preparation! With their work appar- New Yorker that my father had told me when I was a little
ently completed, the two men left me alone. A dull, whir- girl. An elderly lady lived alone with her servants in a
ring sound came from somewhere in the machine; I could brownstone house with an elevator. On a Friday night,
vaguely hear voices on the other side of the window that after the butler and cook had gone off for the weekend,
looked into the next room. Just then the door was flung the woman got stuck in the elevator. She knew she could
open, and Dr. Mitchell entered with a technician. His not expect anyone to find her until the servants returned
usual cordial greeting sounded oddly remote through the on Sunday night, and to maintain both her mental and
rubber earplugs that a moment later, when the machine physical health until that time, she fashioned a totally ra-
was turned on, did little to drown out the penetrating tional plan for spending the next 48 hours in the elevator.
noise like a jackhammer all around my head. Before I was When her servants found her on Sunday night, she was
fully aware what was happening, the entire platform on not only quite composed, but aside from feeling parched
which I was lying slid soundlessly into the machine that and empty, was in good condition. Although I had long
now encased my head. I could only make out that the top since forgotten the details of the woman’s ordeal, her re-
of the enclosure was just inches from my face. This was the sourcefulness and self-control remained as a metaphor for
moment I had been dreading, and I sensed raw panic survival under adverse conditions. I now invented a plan
flooding over me. I could feel my breath coming in short for an eventual escape if no one came back to liberate me
gasps, and in spite of the chilly air that had bothered me within a reasonable time. But what was reasonable? I
moments before, I felt that I was burning up and had to get asked myself. And how would I know how much time had
out of this place. But before I could act on this impulse, I elapsed? Before I could ponder these questions, one of the
told myself that I was not the third grader wrapped in a technicians entered, removed the adhesive tape and
curtain and that there was plenty of air inside the box en- the other fetters, and placed me back on the mattress of
closing my head so that I would not suffocate. I closed my the stretcher that was a welcome relief from the granite-
eyes, took several deep breaths and slowly felt my equilib- like surface of the machine platform.
rium returning. I then surrendered myself to the state of The nurse with the little white box was no longer in
imprisonment and waited for whatever was ahead. the outside room. Who would return my belongings to
After what seemed to be hours, I saw Dr. Mitchell’s me? An attendant with a Herculean build approached my
striped shirt through the small overhead mirror. “How are stretcher.
you doing?” he asked. I could hardly distinguish his voice “Do you know where my glasses and other belongings
over the clanging knock of the jackhammer. “Are you are?” I asked.
ready to begin? First, with your left hand and then with “Yes, I have them.” He handed me my glasses and one
your right, open and close your fist as quickly as you can by one brought out my rings, earrings, and watch.
for thirty seconds. Wait until I say ‘go.’” He glanced at his “I need help with putting on everything except my
watch and then signaled with his hand and voice that I was glasses and one ring. I don’t suppose you’ve ever put a pair
to begin. The left hand was easy, but when the procedure of earrings on a woman?” I teased him, secretly hoping
was repeated with the right hand, I could not make the that he would become flustered at my question.
fingers move, no matter how hard I tried. The sheer effort “Oh, sure, I have a wife and two daughters.” Un-
of racing against the clock with nothing to show for it was daunted, with deft fingers, he replaced my earrings. Once
766 Stroke Rehabilitation

again, as he leaned over me with his big hulk, I felt my of hating myself for being a quitter, I was glad that
private space invaded, but he sensed nothing of this and, Romana recognized my readiness to work on something
after completing his task, wheeled me outside the MRI else until my strength had returned.
suite to a “holding station,” where other patients on Romana had provided me with elastic shoelaces that
stretchers and in wheelchairs were also waiting to be re- stayed laced up and knotted in place and did not require
turned to their floors. We were not a happy group; on the tying. Now there were just two dressing items with which
stretcher next to me, a tiny, shriveled old woman was I needed help: my bra and the strap of my watch. I re-
weeping quietly to herself, while a heavyset middle-aged membered trying to teach a one-handed bra technique to
man on the other side moaned loudly in pain. In the far patients and usually decided with the patient that it was
corner of the room, a seemingly disoriented figure in a not worth the enormous strain nor the equally great frus-
hospital gown swore loudly and effusively at no one in tration that this entailed. I had not been part of the bra-
particular. Yet no one at the desk paid the slightest atten- burning generation, and therefore never understood the
tion to any of us. The laughter and teasing of the orderlies symbolism of going without a bra. Getting into the bra
and nurses at the desk continued. I recalled an illustration was high on my priority list, and I was willing to spend the
of the powerlessness of the individual patient I had fre- time it took to learn this elusive skill. The idea was to
quently used in my teaching: a ladderlike hierarchy of the fasten the bra first, then slip the involved arm and the
hospital staff with a small, nondescript patient on the bot- head into the opening as if putting on a tee shirt, and fi-
tom rung. I was struck again by the feeling of powerless- nally pushing the healthy arm into the other armhole.
ness not only in terms of myself, but more importantly, in Theoretically, this works, but the reality was, at least with
any of the other patients to whom the hospital was a me, that I was left with the bra hanging on my right
strange, bewildering place where no one was willing to shoulder and around the neck. It was the closest I had
listen, much less understand their fear, pain, or loneliness. come to screaming, but before I uttered a sound, I began
And I, a supposed helper, was just as vulnerable as they to see the ridiculousness of the situation, and I laughed
were. I was relieved when a female attendant, without a instead. I decided to put on the bra without fastening it
word, took hold of my stretcher and wheeled me back to and dressing the rest of my body; sooner or later some
the eighth floor. female would appear in the room, and I could ask her to
By the end of the first week in therapy, I was standing fasten my bra.
upright with a walker and with one of the therapists at my I enjoyed speech therapy simply because Anne-Marie
side, taking the first halting steps. From the sheer social and I were definitely on a compatible wavelength, but I
acceptance of devices, the wheelchair had always seemed saw little progress in the clarity of my speaking. We spent
preferable to a walker, but I was glad to be able to move much time working on silly word exercises, and I even
forward from a standing position. At first, my grip was practiced these in my room, but certain consonants like
still so weak that I needed an auxiliary upright grab bar for “d” and “p” were slurred and ugly sounding. When any of
my right hand, but at least I was putting my right side to my colleagues or former students came to see me, I felt
some good use. Ilsa had built up the handle with ace ban- very self-conscious about my speech, but no one ever
dages to make the grasping surface thicker, but unless I mentioned it, although my family often commented on
concentrated on my hand, it would slip off inadvertently the low volume of my voice during our conversations.
and would need to be replaced in the required position. Although I was very grateful for the good wishes and
Within days I was walking all over the rehabilitation floor cheerful conversation they brought, the many visitors
and felt elated when I was able to see my visitors to the from the University were becoming a real burden, mainly
elevator. for their unpredictability. I had always found that the ID
With Romana, occupational therapy was also taking on card that allowed university employees carte blanche ac-
a more functional note, albeit with simulated tasks. My cess to the hospital to be a great help when we needed
least favorite activity—I groaned at the mere sight of the some clinical information or even for using one of the
plastic milk crate that held plastic bottles and containers corridors as a short cut. Now the privilege of going into
of various sizes and weights—was picking up these items the hospital at any time came back to haunt me; at any
one by one and placing them on the raised mat on which hour of the day, I could expect visitors in my room, and I
I was sitting. As I remembered from my clinical practice felt I had to be “on stage.” When I told Anne-Marie that
days, grasping an object was far easier than letting it go, these visits were even more fatiguing than five to six hours
unless the item was so heavy that I would drop it before I of therapy, she suggested that I tell my drop-in guests that
had a decent grip on it. This activity was clearly the most I had to rest my voice during mealtimes, a measure I ac-
tiring I attempted, and there was a noticeable point of no cepted and applied gratefully.
return, when all of Romana’s encouraging remarks could Far better were the announced or mutually arranged
not restore the required strength to pick up another ob- visits that I anticipated with pleasure. Such a visit was
ject, no matter how small or light. After the first few times from Marie, a colleague and friend who telephoned one
 Chapter 31 • A Survivor’s Perspective II: Stroke 767

Saturday and announced that she was bringing dinner. Mealtimes were also useful for seeing the similarities
Marie, of Italian descent and a marvelous cook, was cer- and differences among patients in response to their dis-
tain that I wasn’t eating enough and needed some home ability. I marveled at the way that premorbid personality
cooking. She came bearing not only a delicately prepared surfaced and either aided or impeded progress in differ-
dinner but also a bright tablecloth, real silver, cloth nap- ent patients. A tiny, very old lady whose strong accent I
kins, and pottery plates! At one of the round tables, Marie recognized as Viennese complained and demanded things
spread out her wealth, and we proceeded to have a gour- in a penetrating voice throughout each meal. She was
met meal while the other patients ate the usual hospital quite deaf and could not hear when one of the nurses told
fare nearby, casting envious glances in my direction. For a her she would come right away and so continued calling
moment I almost forgot that I still couldn’t cut meat and for help. I soon found out that the only way to calm her
had to eat everything except finger food with an awkward down was to sit next to her and engage her in conversa-
left hand. tion close to her ear. She then cheered up instantly and
After my first days on the rehabilitation floor, I decided listened to my shouted explanations that help was on its
that eating a meal alone or with a roommate in the same way. Mrs. Siegel told me repeatedly about many aspects
room that served as a bedroom was not conducive to of her life, particularly her age—she was 93-years-old—
stimulating my still lagging appetite, and so I chose to take and the fact that she was now cut off from her sister in
my meals in the day room, a large open space that served California because she could not hear her on the tele-
as a recreation or meeting room for both patients and staff. phone. At home she had a special phone; in fact, since she
A folding wall could be closed off to divide the space in had no family here, she had to rely on a friend who was
half, thereby allowing it to be used for several purposes not really a friend. Her repertoire of conversation topics
simultaneously. The last activity of the morning—the remained constant from meal to meal, and I soon became
“upright” group—was held on one side of the wall at the familiar with her litany of complaints. She frequently
same time as members of the staff met on the other to whimpered that the physical therapists made her work
discuss the progress and eventual discharge of patients. At too hard by forcing her to stand with her walker and take
mealtimes, the large round tables were pulled into the steps. Looking at the tiny, frail, and unhappy woman, I
center of the room and patients who wished could take almost agreed with her, but I was pleasantly surprised
their meals there. Some of us chose this setting, while oth- when several days after our first encounter, I saw her
ers preferred the privacy of their own rooms. Since most slowly taking steps pushing the walker, still complaining
of the staff were in the day room with the majority of the about working too hard.
patients, it was easier there to get assistance with any as- Seating arrangements for meals in the day room were
pect of a meal. Perhaps if I had not been used to watching up to us—one of the few choices we had. I usually sat with
people with chewing and swallowing difficulty eat, I too the same crowd who was by nature, and as a circumstance
would have preferred to stay in my room during meal- of their diagnoses, most communicative. Mrs. Gold, who
times, but after working with both children and adults who at first could not find her way anywhere on the rehabilita-
experienced these problems, I knew the atmosphere would tion floor, was my steady companion as we dragged our
not be as unpleasant for me as it appeared to be for pa- walkers along the hall to the dayroom for meals. Once
tients who did not return to the day room after their first there, we would sit together because that seemed to be the
meal there. Besides, I knew that my own eating was not up simplest way to deal with her. According to Mrs. Gold,
to the aesthetic standards I had been taught as a child. For she never got the dishes she had ordered, but when I
a strongly right-handed person like me, it was awkward to looked at the menu on her tray that she herself had com-
eat with the left hand, and I often ended with much of the pleted the day before, she usually had not circled the miss-
meal in my lap. ing items on her order, and I had to listen to her com-
Although the quality and the quantity of most meals plaints during the whole meal. When I could not seem to
were quite adequate, and those of us who had no dietary satisfy her demands, she called whatever staff person
restrictions could ask for as many dishes as we wished, whom she could see in the day room, addressing them
the plastic wrapping of the utensils and much of the food with a loud, “Mi-iss!” no matter who they were. The
was a daily source of frustration to those of us who did residents often visited their patients at meals, when the
not have use of two hands. Certain wrappings could be doctors knew that the patients were not in one of the
removed only by helping with the teeth or developing therapies. They were frequently the only staff in sight, but
other questionable methods for tearing the plastic. When Mrs. Gold did not discriminate in the persons selected to
one of us had devised a technique that seemed particu- carry out her demands; generally, the young doctors
larly effective, we quickly shared it with the others. To chuckled at these requests for help and good-naturedly
me, this teaching aspect was particularly important; it said they would call one of the aides. Mrs. Gold and I then
was the first small sign that I was reclaiming a part of my agreed that it would be more reasonable if I helped her fill
former self. out the menu for the following day to assure that she
768 Stroke Rehabilitation

would get the dishes she had selected. Filling out the bathtub, and I actually went to the grocery store of Easy
menu then became part of our daily ritual; I would read Street to do some “shopping.” There was a small shop-
aloud the choices to Mrs. Gold who said that she could ping cart in the store, the kind found in New York City
not see enough to read the menu. When she had made her neighborhood grocery stores. My task was to pick up
selection, I held the pencil and circled the items with my various items from the shelf, place them in the shopping
very awkward left hand much as I did when I completed cart, and walk to the cash register. Each of the plastic
my own menu. I marveled that the helpers in the kitchen fruits and vegetables and the empty boxes of cereal or
could decipher which dishes I had actually circled since containers of detergent were filled with a substance that
my scribbles on the page hardly resembled circles. But I calibrated its approximate real weight. I was expected to
knew that handwriting difficulties were a rather common- use my right hand for all one-handed tasks and could use
place deficit among most of the patients on the rehabilita- my left hand only to assist with normally bilateral activi-
tion floor. ties. After picking up a simulated tomato, a cucumber, and
Almost every one of us was eager to take advantage of a banana out of the vegetable bin, my arm was totally
the therapies. Although we each had at least two 30-minute worn out. Letting go of the objects was almost harder
sessions of individual treatment of each type of therapy than picking them up; my right hand hovered over the
daily, there were always other people around who were basket until I was able to release whatever I held in my
simultaneously working with their therapists. Only speech hand. Although I had done similar tasks with patients for
therapy was private, a fact that made it much easier for many years, I had never imagined that fatigue was the
me. As a result of spending so much time with the reha- constant companion of even the simplest tasks.
bilitation patients, I became very familiar with the rate or Although I still tired quickly with any type of physical
degree of progress of other people and they with mine. activity, I experienced the massive fatigue more totally
Pretty much everything we did in therapy was public when using my right hand. When I reached the end of my
knowledge, and for me, this served as a strong motivation muscle power, I felt literally like a windup toy that had
to try to succeed at everything I was asked to do. Both Ilsa run down and needed a new boost, one that was not im-
and Romana expected more of us each day, and in spite of mediately available to me. I was surprised how long it
being naturally fearful and in a constant state of fatigue, took before I felt ready to use the hand or arm again for a
I tried to rise to the challenges of their demands. When task requiring lifting of any but the lightest items. This
I was successful, my flickering battery of self-esteem felt was one of the few areas where I felt that the therapists did
recharged. But at the end of each day of therapy, in spite not fully understand that when a patient states unequivo-
of steady progress, I was so drained of energy that cally, as I did on several occasions, “I can’t do it again; I’m
I dragged myself back to my room just to sit and relax a exhausted!” that a two-minute rest period won’t restore
few moments before it was time to walk back to the day- the expended energy. I began to wonder whether, as a
room for dinner. Usually there were already visitors wait- practicing therapist, I had been as sensitive to each pa-
ing for me, and I was forced to muster a new round of tient’s fatigue as I should have been; I sent a silent apology
power for conversation and answers to the well-meaning to the many patients I had treated years ago.
inquiries about my progress. I had never experienced the kind of massive exhaustion
After three weeks in rehabilitation, my life had settled that now held my body in its grip. It was probably appar-
into a routine that served as a stable background for the ent to others in the breathlessness I experienced many
changes in my body and, I suppose, my soul. I became times during the day, especially when I was walking and
aware that I was living only in the present; I did not dwell talking at the same time. This brought to mind the old
much on the past because that could be painful, but I also dare we tried on one another as children: “Try rubbing
did not think ahead about my future. As long as I was in your stomach and patting the top of the head at the same
rehab, I must still be moving ahead, and so I really did not time!” I did not succeed even as a child, and the memory
think of myself as a fixed being, but rather as a work in of that made me smile somewhat ruefully each time I had
progress. Since I was still sleeping fitfully, I often found another breathless episode. When I mentioned these to
myself at night in a state of semiconsciousness, when Anne-Marie, she suggested I try to slow down my speech
I envisioned the same image of myself. I was a paper doll in normal conversation and continue to practice in my
folded at the waist because the upper half of my body room the breathing exercise I did with her twice every
was not strong enough to allow me to stand upright. By day—blowing as hard as I could into a thick tube that was
morning this had faded back into my subconscious, but connected to a plastic bottle with a calibrated gauge that
every night it returned. During the day, there were many registered the volume of my lung capacity. The gauge was
opportunities to prove to myself that I could indeed do useful in measuring my progress, but I never advanced
more than stand upright. My activities with both Ilsa and beyond a certain point, in spite of Anne-Marie’s motivat-
Romana had taken on a more practical tone; in occupa- ing cheers. For the rest of my body, there did not seem to
tional therapy, we practiced getting in and out of the be an immediate remedy. I always knew I had reached the
 Chapter 31 • A Survivor’s Perspective II: Stroke 769

end of my energy supply when I began to experience ac- to diminish the reality of our condition that confronted
tual nausea and a strong desire to lie down and shut off us every waking moment of each day. With Ben I could
the world. I never acted on the impulse, however; instead, count on being amused, and our shared laughter had a
I simply sat down on whatever surface was available and beneficial effect on both of us. Every afternoon just be-
waited for my equilibrium to be restored. Generally, that fore dinner, Ben’s wife Charlotte appeared and stayed
did not take longer than five minutes, and no one ever with him until visiting hours had ended. From what I
questioned my “time out.” learned, they had married less than 10 years ago, and she
My days took on another dimension when a patient appeared to be a housewife, free to spend many hours of
called Ben became more visible on the rehabilitation floor each day at the hospital. The couple readily accepted me
and took his meals with the rest of us. He was younger in their hospital dinners, and I was grateful to have one
than I was by about 10 years, but like me, he had survived meal daily away from the complainers.
a stroke that affected his right arm and leg; he also had I knew that I was progressing well, but I was still walk-
considerable slurring in his speech and, because the pa- ing with a walker and using my right hand only to assist
ralysis affected his chewing and swallowing muscles, he my left. The walker was light to move about, but it was
was on a special pureed diet. As a result, his tray always wider than I was and required enough space to get into
included many small dishes of unappetizing-looking pu- the places that were part of my present environment. As a
reed food of varying colors and several soft desserts. At result, I missed most of my phone calls, because the phone
first, he preferred to eat alone in his room or at a table by was on the nightstand on the right side of my bed and
himself in a corner of the large day room, but one day I meant walking around the bed to answer it. Maneuvering
asked him to move to our table, mainly because I sensed the walker and myself into the narrow space between the
he would be a better communicator than were some of the window and the bed took me much longer than most call-
other people. ers were willing to wait. No matter how quickly I tried to
I recognized him from the various therapies, especially move—and my quickest pace still resembled that of a
the movement group where his attempts at kickball or sloth—I never reached the phone before the caller had
ring toss were as unsuccessful as mine most of the time. hung up. Much as I tried to tell my callers that they
He caught my immediate attention by his unfailing sense should let the phone ring at least a dozen times, anyone
of humor that resounded readily with me. I had decided who called for the first time did not reach me. At first, this
that among other sequelae of the stroke, the slow, awk- was a source of frustration and disappointment, but after
ward way of carrying out most everyday activities would a while I realized that I was not in control of this, and I
appear utterly ridiculous if compared to my past life; I accepted the missed calls as a matter of course.
could tolerate my present lack of speed only if I looked I had now reached the third week in rehab. One of the
upon my performance as being a caricature of myself. most dramatic physical challenges was climbing the set of
Many of the quips that Ben tossed out to the group in four or five practice steps in the gym. Even with the aid of
general indicated to me that he operated on an equal the banister on the left, going up was bad enough, but
wavelength with me. When we were not sitting at the when I arrived at the platform on the top and faced for-
table with the others, we sat in other parts of the day- ward, the sight of the steps below me was a daunting
room, from where he and I could joke or make sarcastic prospect that made my heart beat madly. How would I get
comments about the food, the routine, and the other down? I was suddenly transported back to my childhood
patients without our being heard. Our favorite topic was, to the Sunday hikes in the German evergreen forest that
of course, Mrs. Gold, who gave us ample material for a frequently ended with a climb of the deserted observation
new script each day. She felt that most therapy was a tower for hunters and forest rangers. My father deemed
waste of time and was quite vocal about this, especially in that this activity would be a healthy challenge to my
the “upright group,” individually adapted to meet the brother and me. Although Jeff was quite unathletic and
needs of every member of the group. A staff person care- much preferred reading to sports, he did have the advan-
fully monitored each of us, since most were unsteady at tage of being older by a year and a half and thereby having
best in an upright position. During one of our particu- longer legs. Outwardly, at least, he showed no fear. Scal-
larly lively games that must have looked grotesque to the ing the ladder meant going up the rickety rungs that were
uninitiated, Mrs. Gold announced in a loud voice, “I much too far apart for my short legs, but I was expected
think this is a big waste of time!” Thereafter, from our to follow my brother. Under loud protestations I actually
corner Ben and I invented situations where we would tell reached the top. My immediate expression of victory was
Mrs. Gold that the doctors and therapists had selected clouded by the dreaded moment when I would have to
her as captain of all team sports or other similar crazy descend. As a simultaneously ambitious and compliant
ideas. Ben grew so enamored with his ideas that at times child, I never thought of refusing the climb up, especially
I felt I had to restrain him from carrying out the pranks. when my older brother accomplished this without diffi-
Although this was surely not my proudest hour, it helped culty, but when I saw how far I had come and realized that
770 Stroke Rehabilitation

the tiny man below with the smiling upturned face was exhausting day, I found myself wishing for a miracle. A
really my father, I froze and sobbed that I couldn’t come soundless voice from a part of myself that I rarely used
down. Eventually, my father’s encouraging words and ex- would say to me, “For just five minutes, I would like to
plicit directions on placement of each foot guided me feel normal again so I could move with ease!” I never
down, but it spoiled the hike for me for that day and many considered what would happen when those five minutes
days to come when I realized the performance had to be were up; that was part of the magical thinking, of course.
repeated. Now I could feel the same terror, but Ilsa was Once I had uttered that wish and cried for a moment with
less than six feet below; the sight of her brought me back the certainty of knowing I was asking for the impossible,
to the present and to the entirely achievable task of de- I somehow felt empowered again to carry on.
scending the steps, again holding on to the banister on the I was really so much better than I had been; I no longer
left side. wore the splint during the day and began to use my right
When I saw how difficult it was to accommodate to the hand more spontaneously. At night, as a precaution, I put
early bedtime routine of the hospital—if I went to sleep at the splint on for several additional days, and then devel-
9 pm, as many of the patients did, I woke at 2 am and lay oped the habit of putting my hand under the pillow so
awake waiting for dawn and the 5:30 reveille without ever that the weight of my head would keep the fingers from
falling asleep again—after a week of this, I decided to go curling up and the wrist supported. In occupational ther-
into the deserted day room and read. No one objected to apy, Romana and I were working on my handwriting; at
my being there, since by now all the nurses knew that this point, we were still unsure whether I should switch to
I did not need help getting myself ready for bed. I soon using the left hand. As children we had all practiced writ-
discovered that this was the hour and place for the aides’ ing with the left hand, as many of my classmates did, but
dinner, but they tolerated my presence on the other side I never perfected this skill and now found it awkward and
of the room with cheerful indifference. Instead of fatiguing. With the right hand, at first, the pen or pencil
reading—I still found it difficult to concentrate for an often fell from my grasp. Romana had a large selection of
extended period of time—I watched whatever “drama” adapted pens, all of which I tried with limited success.
the aides had selected as their dinner accompaniment Whenever I practiced writing, I was reminded of a visit
on the large-screen television and listened to their high- by one of the rehabilitation physicians who, after reading
spirited banter in the Caribbean patois I had come to love my chart, quipped in an almost jovial way, “You should do
after many visits to the islands. The performances on the very well, but you’ll never get your handwriting back.”
screen fascinated me by their sheer novelty; in my white, With that, he left the room. I was furious and hurt. How
middle-class culture I had never tuned in to an all black could he predict my recovery merely from reading my
channel. Now I watched the screenplays and commercials medical chart? Since I never saw him again, I did not even
in which all black stars were featured, accompanied by the have the satisfaction of asking him to explain the basis of
comments of the aides. A favorite topic of conversation his prognosis. Nevertheless, Romana and I continued in
was the Caribbean food that some of them brought from our efforts to find a writing utensil that was really useful
their homes. Although I was extremely interested to see for me. I was given sheets of writing exercises (large script
what they were eating, I did not want to spoil my coveted on wide lines not unlike the ones that I remembered from
role of silent participant-observer in their mealtimes. At elementary school when learning to write for the first
the end of an hour, with a collective sigh as someone time). I traced over the sample letters and then completed
glanced at her watch, the dinner break ended, and they the sheet on my own with varying results. Like with ev-
quickly cleaned up the remains of their meal before re- erything else, I tired rapidly; I also found this activity to
turning to their posts. One of them always passed close to be terribly boring, and I had to force myself to do it in the
my chair to hand me the remote control. Now I was truly rare moments without prescribed activity or visitors.
on my own, sitting in the semidark with only the huge At the end of the fourth week, the entire rehab team
screen of the television coming between me and the discussed my case as reported to me by Dr. Stuart, who
drowsiness that overcame me shortly after I was left alone. had been my attending physician and in charge of all the
I don’t think I ever saw the end of a program that I had patients on our floor. She and I related easily to one an-
selected. With my last bit of energy, I pushed my walker other, first, because we had attended the same department
through the silent corridor to my room, where I soon meetings for several years, and second, because as women,
joined Mrs. Gold in sleep. we had a similar perspective on many aspects of life. Now
Whether it was part of the denial that carried me she reported that the team had agreed that I should be
through the first few days following the onset of the ready for discharge in seven days, exactly five weeks from
stroke or another part of my psyche, I found myself on the date of my second admission. This would give me
several occasions using the “magical thinking” that many time to work on additional tasks that were important for
of my patients employed to escape a painful reality. More my particular lifestyle—living alone in an apartment on
than once, when I arrived in my room after a particularly the northern fringes of New York City. My initial reaction
 Chapter 31 • A Survivor’s Perspective II: Stroke 771

was neither surprise nor alarm. I was familiar with the would be able to judge if I could exchange the walker for
regulations that medical insurance dictated the maximum a cane.
length of stay by diagnosis, not status. I knew that by the Wisely, Ilsa had decided that I needed to save my en-
date that Dr. Stuart mentioned, I would have received the ergy for the actual walk in the street; I could therefore use
maximum number of days of inpatient treatment covered the wheelchair until we were outside. Our first stop on this
for a stroke. venture was the elevator that would take us down to the
Until that moment I had not allowed myself to think a lobby. I realized that there were many hurdles along
great deal about discharge; now I had to face the outside the way that six weeks before would have been just routine
world with the residual changes wrought by the stroke. parts of dealing mindlessly with the interaction of human
The first thing that came to mind was that I really was beings and technology. Suppose I could not wheel myself
ashamed to be seen in my community with a walker that through the open doors of the elevators before they closed
to me signified a far greater degree of dependency than I again automatically? Was I strong enough to manage the
was willing to accept. It also would place me in a large various doors that led to the busy hospital lobby? Thank
group of elderly people who, for one reason or another, goodness Ilsa was there to ward off any real danger. I could
used walkers to get around our community, usually ac- feel the fierce beating of my heart as the elevator stopped
companied by another person. I hated the thought of on our floor. I rolled over the threshold into the narrow
joining that group at this point in my life, and again I real- space left by the other passengers before the doors closed
ized the importance for me to get on the cane as quickly behind us and then rolled out again at the lobby level. One
as possible. The cane had become a metaphor for an older hurdle had been conquered. I exhaled gratefully and ap-
but independent person. proached the entrance to the lobby feeling somewhat less
My three therapists, Romana, Ilsa, and Anne-Marie, all anxious.
talked to me about the discharge date and the goals I As we left the hospital building, I realized that this
wanted to attain before leaving the hospital. Clearly, I had was the first fresh air I had breathed in five weeks. I had
to be able to prepare meals for myself and to increase my missed most of July and within the air-conditioned
endurance, not only for speaking without getting out of rooms of the hospital had forgotten how oppressive the
breath but also for tackling the five-block walk to the August heat could be in New York. Now it hit me as I
grocery store. Before we could put into practice any of stood up and took hold of the walker. Before I took the
these plans, I was faced by another weekend without first steps on the sidewalk, Ilsa bent toward me and said,
therapy, and this time I really resented the forced idleness “There’s a good chance that you’ll meet up with some of
imposed by the five-day treatment schedule. On Satur- the people you know around here; do you think that will
days the two recreation therapists were in charge of keep- that bother you?”
ing our minds and bodies stimulated, and since I had seen I was touched by her sensitivity. In the same way that I
for three weeks that attendance at the morning current had felt when the first colleague had approached my bed
events group and the afternoon cooking group was sparse, when the news of my stroke reached the university, I de-
I decided to join the groups once more in a show of col- cided that only the first encounter would be difficult. Be-
legial solidarity. I felt much closer to the other patients fore I had a chance to ponder this, I saw a colleague cross-
during therapy and meals where our disabilities formed a ing the street and approaching me.
common bond. It was much harder to feel the same con- “Hi, how are you? It’s good to see you again!” He
nection when we had a somewhat artificial conversation treated me quite normally, and I knew I would have little
about sports or the latest scandal from the daily news. difficulty relating to other colleagues in the same way.
Still, I gave the two young therapists a great deal of credit Not until I left the hospital environment would I have to
for their enthusiasm and inventiveness week after week. deal with the questions I expected from my neighbors. At
On Monday, my rehabilitation took on a new note of this moment, I was much more concerned with managing
immediacy; there were only four days of therapy before the uneven pavement and the hazards of crossing the
leaving the hospital! Both Ilsa and Romana had prepared street that Ilsa had included in the itinerary.
a list of very practical activities they wanted me to per- For the last 25 years of my professional life, this had
form before Friday, which included preparing my habitual been one of the most familiar corners; it was the intersec-
lunch from a shopping list prepared by myself and walk- tion where the university and the hospital met. How many
ing outside and taking a ride on a city bus with Ilsa along times in all seasons had I crossed here, running to and
in the event that I needed assistance. Ilsa and Romana had from classes, going to my office and the administration
also planned a home visit with me to see if any changes building? It was a bustling, unruly place, teeming with
were needed in the set-up of my apartment. It seemed to students, medical personnel, and ambulatory patients,
be an awful lot for me to accomplish in the short time, but some patiently waiting for the light and others, perenni-
the therapists assured me that we could get everything ally rushed and darting between the traffic to make it
done. After this afternoon’s walk outside on the street, Ilsa quickly to the other side. Gypsy cabs, unmindful of either
772 Stroke Rehabilitation

traffic lights or the people, were everywhere, adding to taken me almost half an hour to print out the names of six
the noise and confusion by blasting their horns at the vegetables! And they were barely legible. At least I had
slightest provocation. Did Ilsa really expect me to get into found a built-up pencil that I could grasp, and Romana
the midst of this? had given it to me to take home. However, for today I was
“I don’t think I can make it across before the light to remove and replace the sheets on the bed in the Easy
changes.” I hoped that she would agree with me, and we Street apartment. This was a task I remembered well from
could call the whole thing off. my days of being a clinician: one-handed bed-making is a
“Of course you can! Just don’t stop walking. Besides, slow, arduous procedure; the help that my right hand
I’ll be right next to you.” could offer at this point reduced neither the effort nor the
I knew that I could trust Ilsa not to set a challenge length of time that elapsed until the bedspread was safely
beyond my ability to meet it, and so, when the light back on the bed. Changing the pillowcase was especially
turned the next time, I stepped off the curb and met the hard; all the two-handed steps that turn this into an effi-
onrushing pedestrian traffic. Again I could hardly breathe cient, easily done task now became mostly unilateral.
for the wild beating of my heart. Was this going to be my Since I was still too unsteady with the cane, I had to use
partner in every new situation facing me? This time I felt the walker. I circled the bed a dozen times to tuck in
almost overwhelmed; Ilsa’s presence served both as a sheets and the blanket, but I proved to Romana and my-
protective and as an empowering mantle whenever a self that I was capable of performing this task by myself;
menacing task was ahead, and now, too, I made it safely once I got home, only I would need to know how much
to the other side. But I was not yet free to gloat over my time and energy it cost!
victory. I had progressed sufficiently to eating most of each
“Now let’s go back. Cars will stop when they see the meal with my right hand in an awkward manner. At first,
walker,” Ilsa said, as confident as ever, and I could not my hand often overshot its mark, and the food dropped
disappoint her. I held my breath and dragged myself back back on the plate or in my lap. I was plagued more by the
across the street. The waiting wheelchair was a welcome lack of coordination now than by the weakness. Also, I
haven, and I sank back into it, too exhausted to speak. had discovered another annoying aspect of hand function
Would every outing require that much courage and en- over which I had no control; whenever I coughed or was
ergy? Where would I find an endless supply of both? surprised by an unexpected noise, my hand shot up and I
Once again I was reminded how much the stroke had dropped whatever I was holding. Worst of all, if I was
taken from me. Could I really reclaim the missing parts of startled while I held a cup of juice or coffee, I would spill
my former self? the liquid all over the table. The first time this happened
Ilsa’s cheerful voice roused me. “You made it, you see! was during lunch at our large round table. I was holding a
You also showed me that tomorrow we can start with the roll in my right hand and was ready to take a bite when an
cane.” I immediately cheered up and could hardly wait to uncontrollable cough shook my body. My hand shot up
tell my family about my accomplishments. and flung the roll across the room in what must have
Helen then told me of her decision to stay with me at looked like very crazy behavior. I looked around quickly
my apartment for at least a week, thereby eliminating the to see if anyone had noticed, but luckily, everyone was too
need for home care from a stranger. This piece of news absorbed with his or her own meals. Though I was ini-
cheered me enormously, since the thought of having a tially amused at my action, it was a painful reminder of the
stranger stay with me was thoroughly unappealing and extent of neurological damage I had incurred. How many
had caused me a great deal of concern. After my outing years I had explained to my students that “a brain injury
with the walker, there were only four days of hospitaliza- can actually ‘undo’ the learning that has occurred in the
tion left. As promised, Ilsa had a cane waiting for me in neurological system in the course of normal development
physical therapy the next morning. I took my first steps of an infant. All of us are born with a ‘startle’ reflex that
rather unsteadily, with Ilsa holding the back of my slacks makes an infant raise its arms in response to a loud noise
for support. It was difficult to think of all the parts of or sudden striking of the surface on which the baby lies.
walking simultaneously and sequentially. Compared to This reflex is suppressed as part of normal development.
the walker, the cane had a much narrower base of support. A stroke will undo the suppression, and the reflex operates
I was grateful that I was not totally on my own as I walked as in early infancy.” Now as I lay awake in the early hours
along the long corridor. To give me additional practice, a of the following day, I recognized that this had actually
young male therapy aide was given the job of walking with happened to me as part of the larger picture of irreversible
me twice each day around the extended quadrangle that neurological loss. All of my recovery thus far was probably
covered the entire eighth floor. due to the fact that the brain is such a versatile organ with
I had done my homework for Romana for the next day: spare neurological pathways that can take over lost func-
making a list of all the items I would need for the salad I tions. This was powerful stuff, and while I accepted it as
was to prepare in the occupational therapy kitchen. It had theoretical information, I was not ready to accept it as
 Chapter 31 • A Survivor’s Perspective II: Stroke 773

inevitable fact. When I next saw Dr. Mitchell, I asked him routine home visit, and I pointed out to Romana all the
whether I would ever lose the startle reflex. His answer features of accessibility and safety they would be looking
was terse but friendly, “Probably not.” for: no scatter rugs to trip on, the placement of kitchen
As planned, Ilsa and Romana met me at 10 am the next utensils and dishes that I had to use every day, the loca-
morning to do the home visit at my apartment. At the tion of the telephone, and the layout of the bathroom.
front door of the hospital, one of them hailed a cab. Since “You’ll need a bench for the shower, and we’ll order
neither of them knew the way to my house, I felt totally in that in the hospital today. Otherwise, the apartment looks
charge of this outing. I gave the driver instructions of the good and you should be able to manage everything.”
route that had brought me home every day—not seated in “Did you really think that an occupational therapist’s
the back of a taxi, to be sure—but relishing the short, apartment would be full of hazards?” I couldn’t resist the
pleasant drive along the Hudson in back of the wheel of chance to tease the therapists.
my own car. Now as I watched the trees and the sky flash Leaving the apartment after such a brief visit was less
by, I wondered whether I would ever be capable of enjoy- difficult than I had thought it would be. There were sev-
ing the degree of independence that both night and day eral things I needed to practice while I was still in reha-
driving of my car had allowed. Thank goodness that was bilitation, such as the cooking experience and the ride on
not one of my immediate concerns. the city bus. Besides, Mrs. Gold was going home today,
I was surprised at the amount of anticipation that I now and I actually looked forward to the next two days alone.
felt as the taxi turned the last corner and swung into the That evening for the first time I allowed myself to
driveway of the apartment building. Except for one brief think about what it would be like at home. I realized how
visit by Helen to fetch me more shirts and slacks, no one much I had employed denial as a useful method of deal-
had entered the apartment since I had left it almost five ing with an unpleasant or unacceptable reality. I could
weeks ago. A quick composite of Sleeping Beauty and Rip make the problem disappear temporarily by just not
van Winkle flashed across my mind; would the rooms be thinking about it; when it next confronted me, as it in-
covered by cobwebs? evitably did, I was more ready to face it and work on a
The doorman rushed from the building when the cab solution. Although I would not recommend this style of
pulled up; his face lit up with a huge smile as he opened problem-solving to anyone else, it had certainly worked
the door. for me until now. Therefore, I was finally ready to con-
“Welcome back! How are you?” He extended his arm centrate on life at home, fully aware that there were
and helped me out of the car, flanked by the two thera- hazards and hurdles that would have to be surmounted,
pists. Before we could enter the building, however, I had and I would somehow manage them as I had all the previ-
to mount the single step that led up to the front door. In ous ones during my rehabilitation. Thank goodness I had
more than 10 years of living in this place, I had never learned long ago to hide my fears quite well and thereby
noticed that there was no railing and was genuinely sur- keep face. I recognized once again how unacceptable it
prised to see that oversight now. was to me to lose face. With these thoughts I finally
“Yipes!” was the only word I could utter. In her usual drifted off to sleep.
calm manner, Ilsa called out, “Just use the technique you Practicing the various curbs while using the cane was
used on the practice curbs in the gym.” I was very glad my assignment in physical therapy the next morning. At
that she was standing next to me as I mounted the step. one point, Ilsa made a seemingly innocent comment
Everything looked pleasantly familiar as I crossed the about doing this alone once I was home. Suddenly, all the
lobby and went up the three steps to the elevator, this emotions that I had kept to myself for five weeks broke
time firmly holding on to the banister. Even taking stairs the thin shell that held them in check; I was caught com-
with the cane presented few problems now that I could pletely off guard and burst into uncontrollable tears. Ilsa,
carry the cane in my right hand while the left grasped the seeing my state, quickly ushered me into an empty back
railing. room, where I spent the next 20 minutes sobbing noisily
I felt as if I were welcoming new friends to my home as in a way that was completely foreign to me. Try as I
I unlocked the door. My absence from the familiar rooms might, I could not stop crying. Ilsa tactfully left me alone
suddenly seemed much longer than the actual five weeks. and even brought me moist paper towels for my red eyes
I could recall coming home from college after a semester when the torrent seemed to be abating. The enormity of
away from home; there was always a comfortable recogni- what had happened had finally dawned on me. I was to-
tion of the furnishings, but I was no longer the same tally overcome by the thought of leaving the safe haven
person who had left. This time I was returning from a of the rehabilitation floor where we all had problems and
journey to unexplored terrain, and my physical relation- had been completely sheltered from the outside world.
ship to the objects was changed as well. No explanation about one’s condition was necessary, and
Romana’s voice brought me back to reality. “Is it OK if anyone needed medical or psychological help, it was
if we just look around?” I knew the considerations of a always available. Now I would have to cut through all the
774 Stroke Rehabilitation

red tape that stood between the health care system and or counter to the table meant holding the cane in my left
me. And then the dreaded “S” word flashed through my hand. This left the weak right hand to carry objects. After
mind; suppose I would have a second stroke! I knew that the first attempt I found that this was still too difficult for
the threat of a second stroke was much greater than that me. Romana had pointed out the teacart on which I
for the first time; the only preventable factor in my own placed all the objects that ordinarily I would have carried
case was keeping the blood pressure under control. The in both hands. This, too, was familiar, but nevertheless it
twice-daily reading of blood pressure had made me pain- struck me as totally wrong that now I was the patient
fully aware that it fluctuated considerably from day to rather than the teacher who showed patients how to carry
day. Before this episode, I had never been concerned objects on the cart that also served as a support while
about my blood pressure, which, as I was repeatedly told walking. My reward for completing the activity was the
by my doctor at my annual checkup, was within normal finished salad that Romana carried to the dining room for
limits for my age. In the hospital I was on the verge of me. Although I knew, theoretically, that walking and car-
panic when it seemed particularly high one day. I asked rying objects would be a problem at home, the cooking
to see Dr. Mitchell since I was sure I was having a second experience reminded me that I still had a lot of work to do
stroke. He reassured me that this was not the case and to at home.
be prepared for the frequent ups and downs. After his I found it difficult to believe that this had been my last
visit I felt ashamed about my hysterical reaction, but it full session in occupational therapy, since the afternoon’s
was a fear that did not leave me. Who would respond to therapy would be cut short as a result of the planned bus
my cries for help from home? As always, I calmed myself trip to Fort Tryon Park, and, after getting off the bus and
by calling on my reasoning system. At last I felt that my crossing the street, taking the bus back to the hospital.
equilibrium was at least partially restored. Although I was This was an outing I did not anticipate with pleasure.
drained by the experience, it was a necessary part of the Even with Ilsa’s guidance, I could not see myself being
healing process. able to hold the rail with my left hand while mounting the
I realized how long I had been in the back room when bus step in the time New York bus drivers usually allow
I saw Romana searching for me; she was ready to take me before starting up the bus again.
through the salad-making experience that would give her The ride on the elevator and walk to the front of the
a chance to observe my performance in the kitchen. I hospital were almost routine for me. I was glad that I did
hoped that my red eyes were not too obvious as I followed not need many repetitions of a procedure to overcome my
her into the occupational therapy kitchen where a bag greatest fears. However, when the bus approached our
with the salad ingredients on my shopping list was waiting corner, I would gladly have told Ilsa that I was not ready
for me. for this challenge. This was my last chance to practice this
“I know I don’t have to show you any of the equipment skill with supervision, and once more, reason took charge.
or the techniques,” she laughed, “You probably know I noticed that there were several other men and women of
them better than I do. I’ll just observe you from here. I’d my vintage with canes waiting for the bus. I would let
like to try out a new test on you; it includes such aspects some of them precede me and try to watch the technique
of your performance as safety, sequencing, and time. they employed. But then it was my turn. With Ilsa follow-
Please use your right or both hands whenever you can, ing close behind, I moved the cane to my right hand,
especially for removing dishes from the cabinets.” grasped the handrail with my left hand, and pulled myself
Romana was right; I had been through countless cook- up. Ilsa managed the tokens for us while I walked to one
ing experiences with patients. In fact, cooking and baking of the seats in front that had been vacated by a younger
had been among the most successful therapy sessions I rider when he saw me coming. Gratefully, I fell into one
had with many types of patients who needed not only to of the places designated “For elderly and disabled,” a seat
reacquire the physical skill but also to restore their self- that only five weeks before I would gladly have left for the
concept and self-confidence. While I was washing lettuce people who fit one of these groups. Now, involuntarily, I
and peeling the cucumber, I felt vaguely like the school- had joined their ranks. I was so totally preoccupied with
master Mr. Chips, who in his dreams recalled dozens of these thoughts that I paid no attention to the passing
his former pupils marching in front of him. scene or my fellow passengers, which would have been
Romana watched me wordlessly from a corner of the unthinkable for me before the stroke. Ilsa stood in front
large table at which I worked, sometimes standing, some- of me and reminded me that the next corner was the last
times sitting, while the salad slowly took shape. The se- stop, and once the bus had come to a stop, we would be
quential steps were in and of themselves not difficult for getting out. Again, I feared that I would not be able to get
me to do, mostly one-handed. I was appalled to realize out in time and slid to the edge of my seat to be ready as
how long the simple process of washing, peeling, and cut- soon as the bus came to a halt. Ilsa preceded me on the
ting six vegetables took—45 minutes—and all my remain- way out so she could supervise my getting down the bus
ing energy went into the process. Walking from the sink steps. In my eagerness to descend the steps, I stumbled
 Chapter 31 • A Survivor’s Perspective II: Stroke 775

and would have landed on the sidewalk had Ilsa not I had been told that I would not have therapy this
caught me. By now I was trembling all over. morning, but my three therapists were available for final
“The bus drivers will always wait until you are well questions and instructions. It was hard to say good-bye to
outside.” Ilsa’s voice was reassuring, but I could tell she all three: Anne-Marie and I had laughed together over the
was not pleased by my performance. “Let’s cross the street small successes and rough going as the slurring slowly left
since the bus is coming.” I was still completely rattled my speech; Romana, kindness personified, yet neverthe-
when I remounted the bus steps, but both the ascent and less very businesslike when it came to all of the activities
descent were accomplished without further incident. Still, of living; and Ilsa, to whom I had formed a deep relation-
I did not think I could ever find the courage again to ride ship based on her understanding and unfailing confidence
a city bus. in my ability; all three had guided my progress in a way
I was too excited to sleep more than a few hours that that far exceeded my expectations. I knew I would be back
night, anticipating all the good things connected to life in for occasional visits, since I still had the unfinished re-
my own apartment. One of the most annoying things of search project that I was hoping to complete, and this
sleeping in the hospital bed had been the rubber covering made it easier to leave them behind. I felt I owed the
of the mattress that was stiff, hot, and noisy each time I therapists so much; I could never adequately express my
changed my position. The thing I hated most, though, feelings to them without breaking down.
were the light blue hospital gowns, most of them too big When I returned to my room, Helen was already wait-
for me, so that they resulted in a rakish, off-the shoulder ing, and I was eager to go. The obligatory wheelchair was
look that gave me at the same time a waiflike appearance brought by an orderly who took me down to the front
not helpful to my sagging self-confidence. Worst of all, in door, where I happily exchanged the wheelchair for my
spite of daily washings in the hospital laundry, was the cane and the front seat of Helen’s car. At last I was free
acrid smell of having been worn by too many bodies, each and could put life in the hospital behind me!
with its personal odor. Tomorrow I could return to my I felt the same kind of euphoria that always signaled the
own bed and wear my own nightgown! end of an examination in college. Suddenly I could under-
When dawn finally came, I relished the sight of the stand patients with whom I had worked who relied on
Hudson whose steady, relentless flow had had such a calm- magical thinking that “everything will be all right once I
ing influence on me during the past five weeks. It had been get home.” It was a way of avoiding unpleasant challenges
a source of silent, steady support that spoke of the continu- in the hospital or confronting realities that seemed too
ity of life even in the face of changing seasons and circum- awful to face. In my case, it was somewhat different; I was
stances. It was comforting to know that it would always be tired of practicing in simulated situations and wanted to
there, whether I regarded it or not. The view of the river try what is was really like to have to solve a particular
had served me well, and I wished that the sight of it would problem.
be equally calming to future inhabitants of this bed. On the drive home, Helen and I talked about the way
Even the early reveille and the sponge bath at the sink we would spend the days together; her goal was to make
were easier to bear today, knowing that a few hours hence sure I could manage taking care of myself and preparing
I would be able to put hospital life behind me. But every meals with minimal help from a home care worker, whose
small part of the morning routine was tinged with a bit of salary for a few hours each day was covered by my insur-
sadness, nevertheless. Would I ever have that much guid- ance. We would practice walking as much as I could to
ance and support again from the people around me? build up my endurance. It seemed like a practical plan,
The head nurse breezed into my room. “I’ve come and I was eager to get started.
to give you the prescriptions for all the medications My arrival at home was similar to my visit, except for
Dr. Mitchell wants you to take. Get these filled as soon as one important difference; since it was later in the day, many
you get home.” She handed me several prescriptions in of my neighbors were passing through the lobby on their
an envelope. Her visit started a procession of various staff way in or out, and I was warmly greeted by several people.
members, each with his or her written orders for my new “We heard about your illness from Carlos.” Leave it to the
life. Dr. Stuart, who had checked on me almost daily, left doorman to inform the entire building population! I was
me a prescription for another rehabilitation center where touched by so much concern and offers of all kinds of help
I was to take a driving evaluation when I felt ready. At by tenants I hardly knew.
this point, that seemed like a distant goal, but I was When we reached my apartment, I was overcome by
pleased that she considered me a future candidate for exhaustion and sank into an easy chair where I stayed for
resuming driving. Even the social worker that I had several hours, grateful that no one was expecting me to be
hardly ever seen told me that a visiting nurse would anywhere or do anything. Helen plied me with food and
evaluate my need for a home health aide. For the mo- drink, after which I felt a new surge of energy. I was sur-
ment, Helen would be my helper, and I was relieved that prised that the visiting nurse that was scheduled to look in
I would not need other assistance. on me called to announce her house call in an hour. When
776 Stroke Rehabilitation

the doorbell rang, I picked up my cane and walked to the physical therapist, and experience had seasoned her to be
door to let in the visitor. more thorough. We enjoyed talking shoptalk for a few
“Hello, I’m Donna Vasquez. Are you the patient?” minutes before she rose to leave.
When I nodded my head, she continued, “I expected you “You’re really doing very well, and I don’t believe you
to be in bed! I’ve never had a patient greet me at the door need any home therapy. Just do the exercises on the stair-
before; you made my day!” With that she began her inter- case that I’ll show you.” With that she took me to the
view and evaluation, reviewed my medications, and said apartment house staircase where she demonstrated a num-
she would call me the next day, but since I was already so ber of exercises for strengthening my ankle. Then she, too,
independent and had Helen for the present, she felt that took the elevator down, leaving me in the questionable
her services were not required. Besides, the home thera- position of having lost all eligibility for further therapy
pists were to evaluate me the next day to determine what because I was too well! Instead of feeling elated that all
type of physical therapy and occupational therapy were to three health professionals independently of each other had
be ordered. pronounced me in such good condition, I felt rather aban-
Her assessment increased my confidence to the extent doned and let down. Helen considered the therapists’
that, almost giddily, I suggested to Helen that we cele- verdict as good news, and so I agreed with her.
brate by going out to dinner, since we had no food in the Now we were really on our own, rejoicing in the fact
house. that we could schedule the time together in any way that
“Are you sure you’re up to it?” Her query was prompted suited our fancy. It was delightful to be free of the rigid
by genuine concern, but when I answered in the affirma- hospital schedule!
tive, she was ready to take me up on the suggestion. I We filled the next days with short walks and frequent
thought it would be a good idea to face the public while I rests to build up my endurance. During a trip to the su-
was feeling so high. permarket by car, I found that I could use the grocery
People did not even look up from their dinners when cart almost like a walker, and so could look forward to
we entered. I became aware of the number of diners using shopping by myself. I was aware that the store made de-
canes, crutches, and wheelchairs who passed our table; I liveries, and I decided to investigate the possibility at a
felt I was in good company. It was the last time I ever wor- future time.
ried about the cane in public. Far more worrisome was my With every day we added another block to my destina-
tortoiselike gait; everyone on the sidewalk easily passed tion, and although I was completely exhausted each time
me. In the hospital this was the normal speed with which I reached my house, I saw that an increased distance was
patients progressed. Now obviously I had to compete well within the realm of possibility. Helen allowed me to
primarily with able-bodied individuals, and the match was try everything in the kitchen; she knew that I would not
not a good one. Nevertheless, Helen and I enjoyed our risk doing the impossible. Finally, seven days after I came
first outing; I was beginning to shed my patient skin. home, I was able to walk to the supermarket and back—
It was heavenly to sleep in my own bed again, and I the goal I had set for myself. Helen and I agreed that I
slept soundly. Next morning I stepped into the tub gin- could carry on by myself.
gerly, holding on to the sink for support, and was glad to As she packed her bag, we talked about the fact that my
sit on the shower bench that Romana had ordered for me. illness had brought us even closer together. Difficult
The fall in the shower five weeks before was still fresh in though it was to say good-bye, I was eager to try to fend
my memory, and I did not want to repeat it. On the other for myself as the new person I had become during the last
hand, a nurse had given me a shower only twice during six weeks. Seven weeks ago, the chance of my having a
more than a month in the hospital, and I was ready for the stroke at this time was not even in my realm of possibili-
experience of feeling really clean and refreshed. ties. I was anticipating many years of the good health that
As expected, the physical therapist came to assess my I enjoyed and that I considered my responsibility. Six
strength and gait. She was very young but appeared com- weeks ago, when I first took my place among the seriously
petent in checking my status. When she was finished, she ill men and women in the hospital, I did not remotely
gave me some exercises to do on my own but said I was envision that exactly 42 days later I would be well enough
too advanced for the home therapy to which I was enti- to resume my former life with only a few adjustments. But
tled. Shortly after she had left, the occupational therapist would I ever get back my prior self? Perhaps not, but as I
arrived, and like Romana on the home visit, she wanted to had learned, I had been blessed with a rich dose of the
inspect the apartment for safety hazards, after she had resilience that allows both body and spirit to seize the
determined my functional status. She was older than the second chance.
 Index

Page numbers followed by f indicate figures; t, tables; b, boxes.

A Acute care Alignment (Continued)

Abdominal wall muscles functional assessments in, 74 of scapulothoracic and glenohumeral joints, 254f
obliques, 159-160 goal setting in, 42b spinal, 668f
rectus abdominis, 159 issues of driving addressed during, 603 trunk, observations of, 169-170
transversus abdominis, 160 team approach in, 754 Alternate Cover Test, 428
Abducens nerve, 213-215f Acute stroke rehabilitation Alternating attention impairment, 527
ABILHAND questionnaire, 221 assessments used in, 31 Ambulation
Absorption, venous and lymphatic, 308-309 CIMT during, 236 intervention advancements, 397
manual stimulation methods, 313-317 communication, 37 speed, 391, 392-393
Accommodation, 418t, 420, 423 discharge planning, 42 Ambulatory patients, treatment activities and goals for,
Acquisitional occupation, 569f, 571, 580 dysphagia screening, 37 202b
Acquisition stage of learning, 106 early cognitive management, 36 American Association of Motor Vehicle Administrators
Action early intervention, 26 (AAMVA), 606
ecological approach to, 81 edema management, 35 American Heart Association Stroke Outcome
ineffective, compensation for, 580-581 family training, 39-42 Classification, 719t
Action Research Arm Test, 222 goal setting in acute care, 42 Amnesia
Active robot systems, 282 increasing spatial awareness, 36 anterograde, 524-525t
Active seating system, 675 interventions for, 31-35 retrograde, 524-525t
Activities of daily living (ADL). See also specific activities monitoring, 27-31 AMPS, 88, 221, 381, 430-431, 505-506t, 555
AMPS for, 88 basic ICU monitor, 28 evaluation of ADL performance in assisted living
apraxia and, 512-514, 513b feeding tubes, 30 setting, 564-568
and clinical reasoning with A-ONE, 489-490 ventilator, 30-31 graphic report, 561-562, 567f
definitions of, 457 positioning, 31-35 items observed and evaluated in, 559b
driving and community mobility as crucial ADL, functional activity during acute phase, 33-34 performance skill summary, 561, 565f, 566f
600-601 weight-bearing for function, 34-35 Ampullar nerves, 211f
dysfunction of area of occupation, 469-486 self-care training, 37-39 Anarthria, 538-539
effect of spatial impairments, 432-434f shoulder management, 35-36 Anatomy
enhancement skin protection, 36-37 of shoulder, 269f
in assisted living setting, 555-573 team approach, 26-27 of swallowing, 629-632
for elderly client living at home, 573-575 Adaptation(s) of trunk
grading, during acute stroke rehabilitation, 41b baby care, 584-585 muscular system, 159-161
instrumental. See Instrumental activities of daily dimension of OTIPM, 562, 576 skeletal system, 157-159
living (IADL) to doors in home, 709 Aneurysm, saccular, 9-10
neurobehavioral deficit effects, 462-467 of environment, 92-93, 186-187, 503, 518 Anger, and stroke risk, 50
assessment methods, 490-494 motor, 163 Angular motion, system of naming, 390f
one-handed techniques one-handed techniques Ankle-foot orthoses (AFOs), 403, 404f, 405f
adaptive devices, 727-728 basic ADL, 718-728 Ankle strategy, 191, 195, 205
dressing, 723, 724-727 basic environmental considerations, 717-718 Anomic aphasia, 546, 547t
feeding techniques, 728 community-based activities, 732-734 Anosognosia, 471, 482-484
grooming and hygiene, 718-728 IADL, 728-732 Anterior lobe of cerebellum, 399
performance of, 458 of performance, 566f Anterograde amnesia, 524-525t
processing during, 467-469 as treatment approach, 502t Antibiotics, for aspiration, 23
for regaining trunk control, 186 Adaptive equipment Anticlaw splint, 341f
retraining after stroke, 717b, 750 for baby care Anticoagulation agents, 16, 19
and systems model of motor behavior, 83-84 bedtime, 588-589 Antiplatelet agents, 16, 18-19
taxonomy, 559-561f childproofing, 589 Antiseizure medication, signs of excess of, 21b
trunk control during, 176-180 diapering, 589 Antithrombotic therapy, 16
weight-bearing during, 232f dressing devices, 727-728 Anxiety
Activities-Specific Balance Confidence Scale, 199, 382t eating/dining devices, 728 after stroke event, 21
Activity-based intervention mobility prescription, 621-622 coupled with depression, 53
amount of practice, 106 Adaptive occupation, 569f, 570, 580-581 in MRI machine, 765
background concepts, 101-102 Adelaide Activities Profile, 556-558t PTSD in stroke survivors, 53-54
constraint-induced movement therapy, 103 Adhesive changes, in hemiplegic shoulder, 261 Anxiety disorders, 55t
expectation for goal achievement, 111 Adjustable inflatable hand splint, 33b A-ONE, 430-431, 457, 458-461t, 476, 489-494,
foundational strategies for task performance, 104-105 Adjustment, to role and task performance limitations, 491-493t, 495-497f, 505-506t, 719t
freedom from mechanical constraints to movement, 90-91 Apathy, 52, 55t, 471
110 Age effects Aphasia, 536, 539
goals of training and learning, 104 on driving, 603-605 Broca, 540-542, 543t
neuroscience studies of brain plasticity, 102-103 on functional mobility, 351 fluent types of, 544
occupational therapy practice on sexual response cycle, 649 transcortical motor, 542-544, 544t
framework, 101-102 Agnosia, 460 Apraxia
guidelines for adults, 102 treatment for, 521 assessing, 505-506t
prerequisites to engaging in activity-based practice, Air splint, 331 functional deficits secondary to, 515b
109-110 for hand edema, 317-318 ideational, 464f, 472, 479-481f
promoting generalization of learning, 106-109 Alcohol, heavy consumption of, 26 interventions
self-monitoring skills, 110-111 Alexia, 522 direct training of whole activity, 514
structuring activity demands, 112-114 Alignment errorless completion, 512-514
task analysis and problem-solving skills, 111 biomechanical strategy training, 511-512
types of learning, 105-106 loss of, 264-268 task-specific training, 514-516
Activity Card Sort, 70f, 72t, 739 and splinting distal extremity, 339-340 motor, 473, 476-478, 484
Activity processing, in cognitive rehabilitation, 508 normal, and malalignments after stroke, 170t of speech, 542, 543t
Activity synthesis, 114 ocular, 427 treatment for, 510-516

777
778 Index

Arches Attention deficits Beds

palatoglossal, 630f alternating attention impairment, 527 infant, 588
palmar selective attention impairment, 526 mobility of, 33-34
loss of, 340-341 sustained attention impairment, 527 positioning of, 255b, 256f
splint fabrication guidelines for palmar support, Attitude Bedside evaluation, of swallowing, 633-634t
344, 347f leisure, 736, 741b Behavior
Armeo robotic device, 281, 298-299 social, regarding disability, 652-653, 666 associated with pusher syndrome, 401
ARMin exoskeletal robot, 282 Augmentative communication, 538-539 driving, during in-traffic assessment, 621b
ARMinIII, 298f Australian therapy, outcomes measures, 234b motor, systems model of, 83-84
Arm Motor Ability Test (AMAT), 222 AutoCITE, 283-295t, 302, 303f transitions in, 82
Arm-Respond Range of Motion Elbow Orthosis, Automatic cough, 639 Behavioral Inattention Test, 505-506t
348f Automatic postural reactions, 191f Behavior modification, in cognitive rehabilitation, 508
Armrests, 688 Autonomic nervous system, improved function of, 675 Behavioural Assessment of Dysexecutive Syndrome
Arm trough, 677-682t Awareness (BADS), 505-506t
Árnadóttir OT-ADL Neurobehavioral Evaluation. decreased, 508-509 Belly gutter splint, 335
See A-ONE suggestions for improving, 511b Belts
Arterial dissection, 11-12t Awareness training, for unilateral neglect, 516 gait or guarding, 410
Arterial line, in radial artery, 30f pelvic positioning, 677-682t
Arterial supply
B Benign paroxysmal positional vertigo (BPPV), 216
to cerebellum, 399-400 Babinski sign, 749 Bereavement, after stroke event, 21
to vestibular labyrinth, 212, 214 Baby care Berg Balance Scale, 198
Arterial system disease, 10, 11-12t adaptations, occupational therapy assessment, Biceps tendon, lesions in, 261
Arteriovenous malformation (AVM), 10 584-585 Bilateral arm training, 300-301
Ashworth scales, 251b adaptive equipment, 584 with rhythmic auditory cuing (BATRAC), 283-295t,
Aspiration bedtime, 588-589 300
associated with dysphagia, 634-635 childproofing, 589 Bilateral midbrain lesions, 538-539
and site of lesion, 636 diapering, 589 Bilateral upper extremity training, 225-229t, 244, 247b
treatment of, 23 adaptive techniques and strategies, 589-593 Bilateral upper motor neuron dysarthria, 538
Aspiration pneumonia, 635 burping, 591 Bi-Manu-Track, 283-295t, 300
Aspirin, 16 car seats, 592-593 Binocular diplopia, 427
Assessment methods diapering, 591 Biochemical perspective, on splinting, 327
for cognitive and perceptual deficits, 504-507 feeding, 590-591 Biofeedback, EMG, 299
for neurobehavioral deficits, 490-494 undressing and dressing, 591-592 in managing poststroke upper extremity, 225-229t
Assessment of Awareness of Disability, 509t discipline from crawling through toddling, 594-595 for upper extremity function, 243
Assessment of Motor and Process Skills. See AMPS durable medical equipment, 589 Biomechanical alignment
Assessments navigating social obstacles integral to parenting, loss of, 264-268
in acute care setting, 74 595-596 and splinting distal extremity, 339-340
of balance, 197-199 by others, 594 Blanket/towel roll, 33b
in relation to function, 199-200 physical care by parent Blocked practice, 383-384
home assessment worksheet, 698f carrying and moving, 586-587 Blood clot, swelling from, 312
of participation, 70-71 holding, 586 Blood lipids, 25-26
of quality of life, 71 positional changes, 587 Blood pressure, 29t
related to occupational performance, 90 transfers, 587-588 Blood supply
of seating system, 669-673 Back support, in seating systems, 677-682t to cerebellum, 399-400
standardized Baking Tray Task, 505-506t of vestibular labyrinth, 212
for ADL, 556-558t Balance Blood work, 15
in trunk evaluation process, 164-167 activity requirements for, 112-113 Bobath approach
used in acute stroke rehabilitation, 31, 32t CNS structures and, 191-192 outcome studies
Assistance, as intervention for apraxia, 515b postural control and, 191 implications for practice, 124
Assisted gaits, 409f, 410f sensory organization for, 190-191 outcomes measures, 119
Assisted living. See also Living independently in standing, 376-377 results of review, 124
client-centered performance context theories concerning, 189-190 study designs, 124
establishing, 559-562 training exercises, graduated, 216 timing of therapy, 119
OTIPM dimensions, 561 Balance impairments principles of, 119
resources and limitations in, 562-563 comprehensive evaluation, 192-200 Bobath finger spreader, 329f
developing therapeutic rapport, 562 balance assessments, 197-200 Bobath roll, 270
occupation-based education program, 571-573 component assessment, 194-197 Body functions
performance analysis, 563-571 subjective interview, 193 dimension of OTIPM, 561-562, 576
adaptive occupation, 570 documentation of, 206-207 Framework-II groups of, 457
AMPS evaluation, 564-568 goals and treatment plans, 200-201 neurological processing of, 463-467
documentation and interpretation of cause, and independence in community, 72 restorative occupation for, 581
568-569 retraining balance strategies, 205 terminology for, 459
occupation-based interventions, 569-571 role of endurance in treatment plan, 205 Body neglect
rehabilitation in, 555-573 treatment of asymmetrical weight distribution, during functional activities, 518t
Assisted Rehabilitation and Measurement (ARM) 201-205 unilateral, 475, 481
Guide, 283-295t, 297 Balloon angioplasty, 18 Body weight support (BWS)
Assistive devices Bandages, low stretch, 315-316 to improve gait, 143-152
canes, 407 Banking, adaptive techniques for, 732-733 treadmill training with, 397
crutches, 407-408 Barrier Free Lift, 712, 713f evidence table for, 149-151t
walkers, 408 Barriers Bolus consistency progression, 638b
Assistive technology, 92-93 to leisure participation, 741b Bone mineral density (BMD), 396
for memory impairments, 525 to participation and quality of life, 71-74 Bottle feeding, 591
for memory loss, 526b Barthel Index, 32t, 719t Bottom-up reasoning, 553-554
monitoring standards, 667 Basal ganglia, in balance control, 192t Botulinum toxin A, 252
Asta-Cath, 718, 720f Basement, evaluation of, 697 Box and Block Test, 222
Astereognosis, 522 Bases for power wheelchair, 690 Boxtopper, 730f
Asymmetrical pelvic positions, 669 Bathing Braces. See Orthoses
Asymmetrical weight distribution, treating, one-handed techniques, 718-719, 733 Brachial plexus injury, 261-262
201-205 recommendations for safety, 707f Brain
Ataxic dysarthria, 539 trunk control and, 177, 180 areas of cortical function, 7f, 8f
Atherosclerotic disease, 4-6 washing at sink, 720 CT scan, 14f
Attachments Bathroom long-term functional change with CIMT, 236-237
of external obliques, 159 cleaning, 731 MRI, 2
of internal obliques, 160 evaluation of, 696 plasticity of, 102-103
of latissimus dorsi, 161 and fall prevention, 713f Brain Injury Visual Assessment Battery for Adults, 420
of quadratus lumborum, 160 modifications to, 710, 714 Brainstem
of transverse abdominis, 160 to entrance, 707f in balance control, 192t
Attention Bed-level activities, 34f lesions in, 538-539
and arousal dysfunctions, 460 Bedroom MRI, 13f
driving and, 604t bed making, 731 Brainstem stroke
impairment of, 471 evaluation of, 695-696 dysphagia with, 632
stage of memory, 523t and fall prevention, 706f, 713f lateral, 214
Attention deficit hyperactivity disorder, 55t, 59 modifications to, 710, 714 Brassieres, donning, 725, 766
 Index 779

Breastfeeding, 590-591 Circumferential measurement, in evaluation of edema, Cognitive deficits

Bridging, 33-34 311 affecting sexual function, 651
analysis of movement, 354 Client-centered care, 68-69 parenting and, 593
problems with, 354 Client-centered performance context, 559-562 poststroke, 54
treatment strategies, 354-355 adaptive occupation, 570 and quality of life, 72
trunk control and, 177, 180 AMPS evaluation, 564-568 Cognitive dysfunction, leading to ideational apraxia, 464f
Broca aphasia, 540-542, 543t in assisted living setting, 559-562 Cognitive Failures Questionnaire, 505-506t
Brunel Balance Assessment Scale, 199 current level of performance, 563-564 Cognitive management, early, 36
Bubble study, 3 documentation and interpretation of cause, 568-569 Cognitive processing, for driving, 619f
Burping baby, 591 observation in prioritized task, 563 Cognitive strategies, 105, 108
Button-down shirts, 176-178 occupation-based interventions, 569-571 Collaboration
Buttons, 723 OTIPM dimensions, 561 and care of child by others, 594
resources and limitations in, 562-563 engaging patients in, 446
C Client education, on seating system assessment, 671 parent-child, 584
Cadence, 391 Client factors, 457, 459 Color perception, 418t
Calcium channel blockers, 17 neurological, dysfunction of, 477f, 479-481f, 482-483f, Combinations of dysarthria, 539
Canadian Occupational Performance Measure 485f Combined edema theory, 310
(COPM), 70-71, 72t, 87-88, 89f, 577, 719t, 739 processing of, 470f Commercial driving instructor, 617-618
Canes, 407 Client function, matching seating system equipment Communication
Capillaries, lymph, 309f to, 673-675, 676-683 adaptive techniques for, 731-732
Carbamazepine, 22t Client liability, regarding driving, 623-624 as ADL, 559-561f
Cardiac emboli, 3 Clinical evaluation alternative methods of, 37
Cardiac problems, swelling from, 312 plus on-road evaluation, 615 impairment following stroke, 535-536
Caregivers of swallowing, 636 key points regarding, 39b
adaptive techniques and strategies for parenting, Clinical implications and liability regarding driving, 626-627
589-593 for CIMT, 142 recommendations for independent living, 714
emotional well-being of, 58-59 for functional task-oriented training, 125 scope of, 535
interview, for swallowing, 637 for robot-aided motor training for upper limb Communication disorders
strategies for attention deficits, 527b function, 143 anarthria and locked-in syndrome, 538-539
Carotid artery, 215f for treadmill training with body weight support, 152 ataxic dysarthria, 539
stroke syndromes, 4-6t Clinical reasoning incidence and prevalence of, 536
Carotid Doppler study, 14 for cognitive and perceptual problems, 440-441 major dysarthrias associated with stroke, 537
Carotid endarterectomy, 19 conditional reasoning, 446-448 mixed conditions, 539
Carrying a baby, 586-587 discharge session, 447 spastic dysarthria, 538
Car seats, 592-593 intervention session, 447-448 unilateral upper motor neuron dysarthria, 537-538
Case control design, 118 definition of, 439 Community environment, in task-oriented approach, 95
Casters, wheelchair, 687 development in occupational therapy, 439 Community Integration Questionnaire, 71, 72t
Cataracts, 612 embodied knowledge, 449 Community mobility, driving and
Catastrophic reactions, 54 expertise and adaptive equipment mobility prescription, 621-622
Catherine Bergego Scale, 505-506t, 519f novice vs. expert therapists, 451 as crucial ADL skill, 600-601
Catheters stages in development of, 452t liability considerations, 623-627
Asta-Cath, 718, 720f student’s skills enhancement, 451-453 Community participation, strategies for, 105
condom catheters, 23 generalization reasoning, 449 Community reintegration, 75-78
Foley, 28 intervention session, 449 Compensation
intracranial pressure monitoring, 28-29 interactive reasoning, 444-446 in functional approach to treatment, 503
Cavalier shoulder support, 270 evaluation session, 445-446 oculomotor, 425
Central nervous system (CNS) structures, in equilibrium, intervention session, 445-446 in treating balance impairments, 201
191-192 language to describe types of, 441-450 Compensatory movements, from proximal weakness, 240f
Central vestibular projections, 213-214 narrative reasoning and chart talk, 442-443 Compensatory strategies
Cerebellar arteries, 399f evaluation session, 442-443 one-handed techniques
anterior and posterior, 214 intervention session, 443 basic ADL, 718-728
Cerebellar ICH, 9t pragmatic reasoning, 448 basic environmental considerations, 717-718
Cerebellar infarcts, 216, 399 evaluation session, 448 community-based activities, 732-734
Cerebellar lesions, 539 procedural reasoning, 443-444 IADL, 728-732
Cerebellum, in balance control, 192t intervention session, 444 in side lying-to-sit, 358-359
Cerebral artery process of, 102f Competency, in sexuality intervention, 655b, 656-657
dysfunction, resulting impairment patterns, 486, summary of different reasoning modes, 449-450 Complete blood count, 15f
487t intervention session, 450 Complex regional pain syndrome (CRPS). See also
stroke syndromes, 4-6t and theory, 440 Shoulder-hand syndrome (SHS)
Cerebral cortex transcripts and, 441 edema, 310-311
functional organization of, 465f in using A-ONE, 489-490 Complex regional pain syndrome (CRPS) type I, 258-271
functions of, 463, 466-467t worldview, 448-449 Complex rotation, as manipulation task, 230b
lesions of vestibular areas in, 216 discharge session, 449 Component assessment, in evaluation of balance
Cerebral edema, agents for, 17 evaluation session, 449 impairments, 194-197
Cerebral neoplasm, 10 Clinical Test of Sensory Organization and Balance, 198 Components of seating system, 677-682t
Cerebral perfusion, treatments for altering, 17 Clonazepam, 22t Component testing, correlation with functional
Cerebrovascular imaging, 12 Closed tasks, 109 activities, 204t
Cervical curvature, 158f changing environments and, 384 Comprehension, enhancement of, 540
Cervical roll, 38f weight-bearing/closed chain activity, 220-221 Computed tomography (CT), 12
Chaining, forward and backward, 525 Clustering, skills of most concern, 567-568, 579 of brain, 14f, 753
Chart review, of swallowing, 636-637 Cochlea, 211f Conceptual practice models
Chart talk Cognitive and perceptual deficits guiding interventions, 441
evaluation session, 442-443 assessment decisions, 504-507 and theory of clinical reasoning, 440f
intervention session, 443 goals, 528-530 Concrete thinking, 527
Checklist for fall prevention, 713f intervention strategies, 508 Conditional reasoning, 446-448, 450f
Checklist for leisure interests, 739f and sexual function, 657-658 discharge session, 447
Chedoke Arm and Hand Activity Inventory, 222 treatment approaches, 502-504 intervention session, 447-448
Chedoke–McMaster Stroke Assessment, 165 treatment considerations Condom catheters, 23
Childproofing, 589 environment, 507 Conduction aphasia, 545-546, 546t
Children generalization, 507 Cone splint, 33b
older, parenting of, 595-596 Cognitive and perceptual dysfunction Confabulations, 471
participation in caregiving activities, 58 clinical reasoning and, 440-441 Confrontation test, visual field, 423
placing in car seat, 592-593 leading to neurobehavioral deficits, 464f Confusion, 471
psychiatric conditions prevalence rate in, 55t Cognitive and perceptual status, evaluation of, 342 Congenital atrial septal defects, 3
with stroke, 59 Cognitive assessment Consistent motion tasks, 109
Chin tuck position, for swallowing, 643 in decision to splint, 342 Constraint-induced movement therapy (CIMT)
Chip bags, for swelling, 315, 316f for driving, 613-614 activity-based intervention and, 103
Cholesterol levels, 25-26 in evaluation of edema, 311 cortical reorganization with, 238b
Cigarette smoking, and risk of CHD, 25 Cognitive Behavioral Drivers Inventory, 608 evidence table, 132-141t
Circle of Willis, 7f Cognitive-communication disorders, 536 in managing poststroke upper extremity, 225-229t
Circuit training, 397 Cognitive-communication impairment modified, 93-94
Circulation, cerebral, 7f right brain, 547-549 outcome studies, 125-142
Circulatory system, blood and lymph, 309f vascular dementia, 549 clinical implications, 142
780 Index

Constraint-induced movement therapy (Continued) Dependency edema theory, 309-310 Driving: role of occupational therapist (Continued)
rationale and principles, 125 Depression, 471 predriving clinic screening, 606-609
traditional and modified protocols, 237t after stroke event, 22 preexisting or progressive age-related conditions,
for upper extremity function, 234-237 as barrier to participation, 73 603-605
Contextual factors impacting rehabilitation, 60 in rehabilitation phase, 603
effect on lesion location and depression onset, 53 sensory-perceptual assessment, 610-613
functional mobility, 351-352 poststroke, 53, 55t specialist in driving, 616-617
movement, 81 relationship to cerebrovascular disease, 52-53 visual-perception and cognitive assessment, 613-614
terminology for, 459 Depth perception, 431t Driving school instructors, 617-618
Contextual interference, 108 Diabetes, management of, 26 Drop-out splint, 334-335
Continuous passive motion (CPM), 317 Diapering Drying, one-handed techniques, 719
Continuum model of leisure service delivery, 741 adaptive strategies for, 591 Dry swallow, 638
Continuum of care equipment, 589 Dual obliquity, 339, 340f
fostering participation throughout, 74 Diaphragmatic breathing, MEM and, 315-316 Ductus reuniens, 211f
role of speech-language pathologist, 536-537 Diaries, 523 Durable medical equipment, 589, 667
in stroke rehabilitation, 76f Diet modification, for dysphagia, 644-645 Dynamical systems theory, 82
Contoured seating options, 676 Digit support, splint fabrication guidelines for, 346, 347f Dysarthria, 536
Contraceptives Diplopia, management of, 427-430 ataxic, 539
oral, 26 Direct training of whole activity, for apraxia, 514 spastic, 538
and safer sex, 659-661 Discharge planning, 42 unilateral upper motor neuron, 537-538
Contractures Discharge session, 447, 449 Dysphagia, 23
development of, 238 Discipline of children, 594-595 alternative means of nutrition, 641-642
joint, treatment with LLPS, 338-339 Disorientation, topographic, 475, 521-522 associated with stroke, 632-634
passive ROM for, 253-254 Dissociation, during functional tasks, 162 diet modification, 644-645
positioning for, 254-255 Distal attachment instrumental assessment, 639-640
prevention of, 19 of external obliques, 159 intervention in stroke, 642-644
proximal interphalangeal joint flexion, 335 of internal obliques, 160 medical complications
Contraversive pushing, 183-185, 184b, 400-402 of latissimus dorsi, 161 aspiration, 634-635
Control parameters of quadratus lumborum, 160 aspiration pneumonia, 635
critical, 92 of transverse abdominis, 160 dehydration and compromised nutrition, 635-636
in dynamical systems, 82 Distal extremity potential, symptoms of, 41b
identification of, 88 alignment, 267t resolution following stroke, 634
Convergence, near point of, 422, 429 deviations in, 340 screening for, 37
Cookie Theft Picture, 540, 541f loss of, 268 Dysrhythmias
Cooking, 559-561f prescribing and designing splints for, 336-341 prevention of, 25
Cooling therapy, 17 Distal interphalangeal (DIP) joint, 334, 337-338 treatment of, 19
Coping strategies Distractibility, 472
of carers, 59 Documentation
E
positive and negative characteristics, 61t of client’s current ability, 581 Early intervention, 26
and recovery, 50-51, 55-57 importance of, 206-207 Easy-Load toilet paper holder, 719f
Coronary heart disease (CHD), 25 and interpretation of cause, 568-569 Eating, 559-561f
Correction strap, metal AFO with, 406 and liability regarding driving, 626-627 neurobehavioral deficit effects, 484-486
Cough of seating system assessment, 672 one-handed, 767, 772-773
automatic, 639 of sexuality interventions, 662 trunk control and, 178, 179-180, 180f
volitional or reflexive, 638 Domain-specific training, 503 trunk control patterns and, 176b
Counseling Domestic activities, assessment of, 556-558t Echocardiography, 15
regarding driving, 622 Doors, in home, 708-709 Ecological approach to perception and action, 81
on sexuality, 653-654 Dorsal splinting, vs. volar splinting, 328-329 Edema
Cover-Uncover Test, 428 Dorsiflexion assist, Veterans Administration Prosthetic cerebral, agents for, 17
Cranial nerves Center orthosis for, 406f and decision to splint, 342
in cerebellar stroke, 400 Drains hand. See Hand edema
in diplopia, 428 external ventricular, 28, 30f management, in ICU, 35
in swallowing, 632b spinal, 29-30 Edema reduction massage, 312
Credentialing, by NRRTS, 667 Dressing, 559-561f Education
Crutches, 407-408 lower extremity dressing (seated), trunk control client and team, on seating system assessment, 671
Cues during, 178-179 driving, 617-618
acquisition and interpretation of, 444 neurobehavioral deficit effects, 479-482 leisure education program, 743, 744f
in cognitive and perceptual rehabilitation, 509 one-handed techniques, 733, 759 occupation-based program, 571-573
Cuffs, orthokinetic, 330 adaptive dressing devices, 727-728 on risk modification, 26
Culture adaptive techniques, 723 Effortful swallow, 643
dimension of OTIPM, 561, 575 fasteners, 723 Ejaculatory control, age effects, 649
effects on coping, 52 lower extremity dressing, 725-727 Elastic glove, for hand edema, 313
and impact of communication impairment, 535-536 upper extremity dressing, 724-725 Elastic laces, 403-404
psychological issues and, 56-57 recommendations for safety, 707f Electrical stimulation
and sick role, 56 trunk control during, 176-179, 179f effectiveness in decreasing arm impairment, 245t
Cushions, seating system, 677-682t and undressing baby, 591-592 EMG-triggered, 243-244, 283-295t
Custom seating options, 676-683 upper extremity dressing during gait training, 397
sequence for, 724f in managing poststroke upper extremity, 225-229t
D trunk control during, 176-178 for swallowing, 643
Daily planner, to promote upper extremity function, 241f and visuospatial impairment, 435t in treating hand edema, 319-320
Decision-making, concerning splinting, 342-343 Drinking activity, 559-561f for upper extremity function, 243
Declarative learning, 105-106 Driver rehabilitation therapist, 616-617 Electrocardiography, 15
Declarative memory, 524-525t Driver’s license Electromyography (EMG)
Deconditioning, 21, 23t loss of, 599-600 biofeedback, 299
Decubitus ulcers, prevention of, 23 requirements for, 622 in managing poststroke upper extremity, 225-229t
Deep venous thrombosis (DVT), 3 Driving for upper extremity function, 243
prevention of, 24-25 adaptive equipment mobility prescription, 621-622 electrical stimulation triggered by, 243-244, 283-295t
Defense mechanisms, 55-56 and community mobility in evaluation of swallowing, 640
Deficit-specific tests, 494 as crucial ADL skill, 600-601 Myomo e100 with, 301
Deformities, and seating systems, 673 liability considerations, 623-627 surface, 643
Degrees of freedom, 82 determination of readiness for road test, 615-616 Elemental Driving Simulator, 608-609
constraint of, 93 evaluation process, 606f Elevation, and retrograde massage, for hand edema, 313
stiffness and, 162-163 follow-up recommendations, 622-623 Embodied knowledge, 449
upper extremity, 238-239 on-road driving evaluation, 618-621 Embolic stroke, 3
Dehydration, associated with dysphagia, 635-636 clinical evaluation plus, 615 Emotional disturbances, 461
Deltoid, relationship with rotator cuff, 105f rehabilitation team’s responsibility, 601-602 Emotional issues, and parenting, 593-594
Dementia, 55t use of driving school instructors, 617-618 Emotional lability, 55t
poststroke, 54 vehicle and equipment assessment, 618 after stroke event, 21
vascular, 549 Driving: role of occupational therapist Emotional reactions to stroke, 51-52
Denial in acute care phase, 603 involuntary expression of emotion, 54
impacting driving, 607t medical reporting with driver licensing authorities, Emotional well-being, 600f
of unacceptable reality, 773 605-606 Empathy, 60
Deodorant, applying one-handed, 721 motor and praxis skill assessment, 609-610 Encoding stage of memory, 523t
 Index 781

Endarterectomy, 17-18 Evidence-based practice Feeding tubes, 30

carotid, 19 components of, 118 invasive, 642
Endolymph, 211 defined, 117 noninvasive, 641
Endurance leisure interventions, 743-745 Feminal, 718, 721f
decreased, sexual function and, 658 Evidence tables Fiberoptic endoscopic evaluation of swallowing, 640
and treatment for balance impairments, 205 for CIMT, 132-141t Field dependency, 472, 478, 484-486
Energy conservation, in kitchen, 728-729 for neurodevelopmental treatment/Bobath approach, Figure-ground discrimination, 431t
Energy level, increased, 675 120-123t driving and, 604t
Enteral feedings, noninvasive tube feedings, 641 for robot-assisted therapy, 144-148t Figure-ground impairment, 521
Entrances in home, evaluation of, 694-695 for task-oriented training, 126-131t Finger abduction splint, 329
Environment. See also Home environment for treadmill training with body weight support, Fingernail care, one-handed techniques, 722
adaptation of, 92-93, 186-187, 503, 518 149-151t Finger spreader, 329
arranging for increased spatial awareness, 36 Excess disability, 377-379 Firm cone, 329-330, 330f
changing, and functional mobility, 381-385 Executive Function Performance Test (EFPT), Fitting
for conducting assessment, 506-507 505-506t of equipment for driving, 622
creation of, 91 Executive functions for seating system, 672
dimension of OTIPM, 561, 575 impairments in, 527-528 Five-point gait pattern, using one device, 410
effects on functional mobility, 352 related to everyday living, 528t Fixation, 420
in systems model of motor behavior, 85b, 90 Exercise Flaring, of splint material, 344
in which treatment takes place, 507 eye, 429-430 Flexion (Buddy) strap, 338f
Epidemiology of stroke, 2 for hand edema, 318-319 Flexor control, trunk, 170-173, 173f
Episodic memory, 524-525t muscles in area just massaged, 314 Flexor lengthening, with serial splinting, 344-346
Equipment for oral structures, 643 Flexor pattern, stereotypical, 239f
for driving, inspection and fitting of, 622 sling suspension, 283-295t Flex sponge, 721f
durable medical, 589, 667 therapeutic, 186 Floating the patient heels, 38f
seating system value of, poststroke, 749-750 Flocculonodular lobe of cerebellum, 399
matching to client function, 673-675, 676-683 Exhaustion, 768 Floor care, one-handed techniques, 731
trial, 672 Exner’s classification of manipulation tasks, 230b Fluff test, 505-506t
in treating balance impairments, 201 Exoskeletal robot Foam chips, 316f
Erectile dysfunction, 651, 658-659 ARMin, 282, 298 Folding doors, 709f
Erector spinae group, 160-161 Myomo e100, 301 Foley catheter, 28
Errorless completion, 512-514 T-WREX, 282, 298-299 Follow-up recommendations, for driving rehabilitation,
Errorless learning, 525 Expertise 622-623
Errors clinical reasoning and, 451-453 Foot flat, 394
in driving, by older drivers, 621b stages in development of, 452t Footmate System, 722f
occupational, 457-462 Explicit learning process, 106 Foot placement
Esophageal stage of swallowing, 631-632, 633-634t Explicit memory, 524-525t in pivot transfers, 365f
Esophagus, 631f Exploration training, for apraxia, 514 in sit-to-stand, 375f
Espoused theories, 440 Expression, enhancement of, 540 Footplates, 688
Ethosuximide, 22t Extensor control, trunk, 173-174, 174f Footrests, 687-688
Etiology of hand edema Extensor tendons, contracture of, 337 Foot support, in seating systems, 684
combined edema theory, 310 Exterior of home Force control strategy, 358, 359f
CRPS edema, 310-311 evaluation of, 694 Forearm support, splint fabrication guidelines for,
dependency edema theory, 309-310 and fall prevention, 706f 344-346
minor trauma edema theory, 310 modifications Forefoot first, 394
overview of lymphatic and venous systems, 308-309 doors and landings, 708-709 Forward reach, in wheelchair, 696f
Evaluation hardware, 709 Four-point contralateral gait pattern, using two devices,
of conditions potentially affecting splinting, 342-343 ramps, 697 409
of functional mobility, 381, 382t stairs, 697-708 Frame styles, manual wheelchair, 684-688
of leisure skills, 738-740 External obliques, 159-160 Framework-II
ongoing, of capabilities and client goals, 75 External ventricular drain, 28, 30f body function groups, 457
on-road driving, 618-621 Extracranial-intracranial bypass, 18 terms used in, 458-461t
clinical evaluation plus, 615 Extraocular muscles, 420f Frenchay Activities Index, 382t, 556-558t, 740
of psychological condition, 60-61 Extrinsic feedback, 106-107 Frenchay Arm Test, 223
of upper extremity function, 221-223 Extrinsic shortening, 337f Frontal lobes, 466, 469
impairments to consider during, 244-258 Eye exercises, 429-430 Front-wheel drive wheelchairs, 689
using occupational therapy task-oriented approach, Eye patch, for diplopia management, 428 Frozen shoulder, 750
84-90 Frustration, 472, 748-749, 750
Evaluation of balance impairments, 192-200
F Fugl–Meyer Assessment, 167, 282-296
balance assessments, 197-200 Fabrication of upper extremity motor function, 223
component assessment, 194-197 orthotic devices, 403-404 Functional approach to treatment, 502-504
subjective interview, 193 splints Functional electrical stimulation (FES), 283-295t, 301
Evaluation of hand edema clinical reasoning, 347f Functional Independence Measure (FIM), 382t, 719t
circumferential measurement, 311 general, 343 Functional Independence Scale, 495-497f
cognitive and perceptual assessments, 311 specific, 344-346 Functional localization, for neurological processing of
sensibility testing, 312 Facial nerve, 211f body functions, 463-467
upper limb assessments, 311-312 Falls Functionally based robotic therapy, 296
visual and tactile evaluation, 312 at home, 756 Functional mobility
volumetric measurement, 311 prevention of, 20, 377-379 contextual factor effects, 351-352
Evaluation of swallowing in home, 706f, 713f enhancement of skill acquisition with
abnormal reflexes, 638 risk for, 371-372, 396 feedback, 379-380
chart review, 636-637 Falls Efficacy Scale, 382t manual guidance, 381
clinical evaluation and assessment, 636 Family training, 39-42 mental practice, 380-381
feeding trial, 638-639 for neurobehavioral deficits, 530 evaluation tools, 381
functional status, 637 regarding SHS, 259 literature overview, 350-351
instrumental assessment of dysphagia, 639-640 Far transfer of learning, 507 management of impairments affecting, 353t
oral examination, 637-638 Fasteners neurobehavioral deficit effects, 482-484
patient/caregiver interview, 637 for dressing, 723 as outcome of multiple processes, 352
pharyngeal examination, 638 front, donning garments with, 724 relationship to activities and participation, 351
Evaluation of trunk Fear of falling, 377, 379, 750 Functional mobility tasks
observations of trunk alignment/malalignment, Feedback and changing environments
169-170 in enhancing functional mobility, 379-380 closed tasks, 384
specific trunk movement patterns, 170-176 intervention strategy for apraxia, 515b consistent motion tasks, 385
standardized assessments, 164-167 minimal, 92 open tasks, 385
subjective interview, 163 from rehabilitation technologies, 304 practice conditions, 383-384
trunk control during ADL, 176-180 role in learning, 83 strategy development, 383
Evaluation sessions types of, 106-107 variable motionless tasks, 384-385
in chart talk, 442-443 Feeding baby locomotion requirements, 353
in interactive reasoning, 445-446 bottle feeding, 591 in sitting, 361-375
in narrative reasoning, 442-443 breastfeeding, 590-591 in standing, 375-379
in pragmatic reasoning, 448 Feeding oneself, 642 in supine position, 353-361
in worldview, 449 one-handed techniques, 728 Functional orthoses, 403
Everyday Memory Questionnaire, 505-506t Feeding trials, for swallowing, 638-639 Functional reach test, 198
782 Index

Functional scanning, 418t Graded sitting activities, 35 Home environment

Functional status Grasp, static, with limited shoulder movement, 233 evaluation
fitting person based on, 683-684 Gravity effects, reduction of, 92-93 basement, 697
and seating system principles, 673-674 Grocery shopping, adaptive techniques for, 732-733 bathroom, 696
swallowing and, 637 Grooming, 559-561f bedroom, 695-696
Functional task-oriented training neurobehavioral impairments and, 476-479 entrances, 694-695
evidence table, 126-131t one-handed techniques, 718-723 exterior, 694
outcome studies, 125 trunk control and, 177, 179 forms for, 697
principles of, 124 Group treatment, in cognitive rehabilitation, 508 interior, 695
Functional tasks Guarding techniques, 410-413 kitchen, 696
dissociation during, 162 Gugging Swallowing Screen (GUSS), 40f laundry, 696-697
practicing, 91 Guided-force training program, 297 living room and hallways, 695
in sitting, 362-363 Guidelines for splinting fall prevention, 712-714
spatial aspects of neglect during, 518t fabrication materials, 343-346 modification
visual processing during, 417-419 general, 343 exterior, 697-709
visuospatial skills challenged by, 435b interior, 709
Functional tests, for hemiplegic/paretic upper extremity,
H for managing visual acuity impairments, 424
222 Habituation exercises, in vestibular rehabilitation, 216 recommendations for, 707f
Hair care one-handed maintenance, 730-731
G one-handed techniques, 719, 722-723 and performance of ADL, 718
Gag reflex, 638 trunk control and, 177, 179 safety factors, 717-718, 756
Gait Hair cells, in otoliths, 211 in task-oriented approach, 95
assistive devices, 407-409 Hallways Home Falls and Accidents Screening Tool
BWS and treadmill training for, 143-152 evaluation of, 695 (HOME-FAST), 382t
guarding techniques, 410-413 and fall prevention, 706f, 713f Home health, 75
hemiplegic, 393-395 modifications to, 709-710 Home visit evaluation, 703f, 776
reliable parameters of, 391-395 Hamstrings, shortened, 688f Homonymous hemianopsia, 403, 424-425, 472
terminology, 392t Hand activity, reach patterns with, 233 Hook Hemi Harness, 270
training, 411 Hand-based thumb abduction splint, 333, 334f Humerus, 266
Gait analysis Hand edema alignment, 267t
causes of gait deviations, 395-396 etiology Humor, in interactive reasoning approach,
instrumented systems for, 389-390 overview of lymphatic and venous systems, 308-309 445-446
treatment interventions for abnormal gait, 396-397 theories of, 309-311 Hydrocephalus, prevention of, 21
Gait cycle, 390 evaluation methods, 311-312 Hygenique Plus Bidet/Sitz Bath System, 721f
distance dimensions of, 394f treatment methods Hygiene
phases of, 390, 391f, 392t electrical stimulation, 319-320 neurobehavioral impairments and, 476-479
ROM summary, 392f exercise and positioning, 318-319 one-handed techniques
Gait patterns manual lymphatic and venous absorption applying deodorant, 721
abnormal, 397-407 stimulation, 313-317 applying makeup, 723
cerebellar strokes, 399-400 pneumatic pump and air splints, 317-318 hair care, 719, 722-723
contraversive pushing, 400-402 splinting, 318 nail care, 722
orthotic interventions, 403-407 Handedness, retraining, 733 oral care, 720-721
perceptual deficits, 403 Handling, 186 shaving, 723
proprioceptive deficits, 402 Handmaster™, 301-302 showering and bathing, 718-719
visual deficits, 403 Hand muscles, normal excursion, 336f toileting, 718
five-point, using one device, 410 Hand placement areas, for MEM, 315b washing at sink, 720
four-point contralateral, using two devices, 409 Handrims, wheel, 686-687 personal, 559-561f
three-point, using two devices, 410 Hand robots Hyoid bone, 630f
two-point contralateral Hand Mentor™, 299 Hypercoagulable state, 11-12t
using one device, 409 HOWARD, 299-300 Hyperextension
using two devices, 409-410 Hand splinting, effectiveness of, 327 of MCP joint, 341f
Gardening, 556-558t Hand strength, assessment of, 95t in midstance, 394f
Gastrostomy, percutaneous endoscopic, 30 Hand Wrist Assistive Rehabilitation Device Hypertension
Generalization of learning (HOWARD), 281, 299-300, 300f effect on sexual activity, 652
in cognitive and perceptual deficits, 507 Haptic master, 283-295t, 297 management of, 25
contextual interference, 108 Hardware, for doors at home, 709 and prevention of stroke recurrence, 18
different task categories, 109 Harness, in seating systems, 677-682t Hypertensive bleed, 8-9
knowledge of performance, 107 Head movements, endolymph responsive to, 211 Hypertonus, reduction with splinting, 328
knowledge of results, 107 Head/neck support, in seating systems, 677-682t, 684 Hypotheses, generation and evaluation of, 444
practice conditions and schedules, 108-109 Health, defined, 67
practice in natural settings, 109 Heart rate, 29t I
strategy development, 107-108 Hemianopsia, 612 ICU monitor, basic
type of feedback, 106-107 homonymous, 403, 472 external ventricular drain, 28
whole vs. part practice, 108-109 management of, 424-434 Foley catheter, 28
Generalization reasoning, intervention session, 449 Hemiparesis/sensory loss, and sexuality, 657 intracranial pressure monitoring catheter, 28-29
Generalized motor programs (GMPs), 104-105 Hemiplegic gait, 393-395 IV line, 30
Genu recurvatum. See Hyperextension Hemiplegic shoulder pain prevention, 264b spinal drain, 29-30
Geriatric day rehabilitation Hemispheric dysfunction, 487t telemetry, 28
assisted living, 555-573 Hemispheric stroke ICU psychosis, 36, 37b
for client living at home, 573-575 dysphagia with, 632 Ideational apraxia, 464f, 472, 479-481f, 484-486
Getting up from floor, 369-370f left, swallowing after, 645 Imagery
Gift exchange, 446 right, swallowing after, 644 with errorless learning, 525
Glasgow Coma Scale, 32t Hemiwalker, 408f for upper extremity function, 241-243
Glaucoma, 612 Hemorrhage, subarachnoid and intraparenchymal, 486 Immediate feedback, 380
Glenohumeral joint Hemorrhagic conversion, 7-8 Immobilization, prolonged positioning after, 336
external rotation of, 258f Hemorrhagic stroke Impingement
loss of alignment, 265-268 arteriovenous malformation, 10 prevention of, 262-263
subluxation, 267, 270 control of vasospasm, 18 of subacromial space soft tissue, 261f
Global aphasia, 546-547, 548t hypertensive bleed, 8-9 Implicit learning process, 106
Glutamate antagonists, 17 lobar intracerebral bleed, 9 Implicit memory, 524-525t
Goal achievement management of, 44b Inattention
expectation for, 111 posttraumatic, 10 unilateral, 353t
through functional tasks, 240 prevention of rebleeding, 18 unilateral spatial, 478
Goals prevention of recurrence, 19 Incontinence
for one-handed training, 732 saccular aneurysm and subarachnoid bleed, 9-10 effect on sexual activity, 652, 659
to promote upper extremity function, 232-240 Heparin, in antithrombotic therapy, 16 urinary, 23, 73
of seating system, 674-675 Heterotopic ossification, 20 Independent living. See Living independently
therapeutic, and rehabilitation technology choices, 304 Hierarchical model of balance, 189 Inertial mechanism, 211-212
for treating cognitive and perceptual deficits, 528-530 Hip flexion, variations on degree of, 183 Infants, placing in car seat, 592
Goal setting Hip guides, in seating systems, 677-682t Infarcts
in activity-based intervention, 104 Hip strategy, 191, 195-196, 205 cerebellar, 216, 399
in acute care, 42b Historical perspective, of splinting, 327 lacunar, 632
for balance disorders, 200-201 Holding a baby, 586 Infection, swelling from, 312
 Index 783

Inflammatory conditions, causing arterial system Interventions using task-oriented approach (Continued) Learning (Continued)
disease, 11-12t mental practice/imagery, 241-244 strategy development, 107-108
Inflammatory subacute edema theory, 310 mirror therapy, 244 type of feedback, 106-107
Inflatable hand splint, 335 Interview whole vs. part practice, 108-109
Inflatable pressure splint, 332f for awareness, 509t goals of, 104
Inflexibility, cognitive, 527b comprehensive, for seating system assessment, 670 implicit and explicit learning processes, 106
Initiative, lack of, 479 patient/caregiver, for swallowing, 637 motor, 82-83
Injuries subjective procedural and declarative, 105-106
to extremity, and splinting distal extremity, 339 in evaluation of balance impairments, 193 task analysis and problem-solving skills, 111
orthopedic, superimposition of, 260-262 in trunk evaluation process, 163 transfer of, 106, 507
InMotion2 planar robot, 281f Intracerebral hemorrhage (ICH), hypertensive, 8, 9t Left foot accelerator, 610f
Innervation, of vestibular labyrinth, 212 Intracranial pressure monitoring catheter, 28-29 Leg adductors, 677-682t
Inpatient rehabilitation, 43b, 74-75 Intravenous (IV) line, 30 Leg rests, elevated, 687-688
Insight, decreased, 472 Intrinsic feedback, 106-107 Leisure, 67
Institutional dimension of OTIPM, 561, 576 Intrinsic muscles, normal excursion, 337f adaptation of leisure task, 745
Instrumental activities of daily living (IADL) Intrinsic shortening, testing for, 338f on COPM, 577f
occupation-based interventions, 580-581 Ironing, one-handed techniques, 731 definition of, 736
one-handed techniques Irritability, 473 interventions, 743-745
communication, 731-732 Ischemic stroke performance after stroke, 741b
home maintenance, 730-731 management of, 43-44b poststroke skills, 746b
ironing and sewing, 731 pathogenesis of, 2-4 skills evaluation, 738-740
kitchen activities, 728-732 pharmacological therapies, 16-17 Leisure activities, 96, 556-558t
Instrumental Activity Measure, 556-558t prevention of recurrence, 18-19 Leisure Competence Measure, 740
Instrumental evaluation, of dysphagia, 639-640 surgical therapies, 17-18 Leisure Diagnostic Battery, 740
Intensive care unit (ICU)/acute team Leisure participation, factors affecting, 737
members, 27t
J Leisure Satisfaction Scale, 740
prevention of skin breakdown by, 37 Jebsen-Taylor Test of Hand Function, 344-346 Lesion location
Intensive therapy, in PLISSIT model, 655b, 656 Jebsen Test of Hand Function, 222 aspiration and, 636
Interactive reasoning, 444-446, 450f, 463 JKF Coma Recovery Scale, 32t and depression onset, 53
evaluation session, 445-446 Joint contractures, treatment with LLPS, 338-339 and instances of anxiety, 53
intervention session, 445-446 Joystick options, 690 in visual pathway, 421f
Interior of home Judgment Liability considerations, for driving, 623-627
evaluation of, 695 impaired, 473 Life satisfaction, 69
modifications lack of, 478 Lifting harness, 713f
bathroom, 710 K for baby, 588f
bedroom, 710 Kettle Test, 505-506t Lighthouse Strategy, 507, 517-518
hallways and living room, 709-710 Kinematic analysis, 390 Light massage strokes, for hand edema, 314
kitchens, 711-712 Kinesiological linkage, 104-105 Limb activation, for unilateral neglect, 518
and moving around obstacles, 712 Kitchen Limb alignment, and trunk alignment, interdependence
sink and lavatories, 710-711 evaluation of, 696 of, 268
Intermediate transfer of learning, 507 and fall prevention, 713f Limbic lobes, 467
Internal obliques, 160 IADL adapted for one hand, 728-730 Limited information, in PLISSIT model, 655, 660
International Classification of Functioning, Disability and modifications to, 711-712, 714 Limits of stability, 195
Health (ICF), 66, 457, 458-461t practicing food preparation, 774 Linear seating systems, 676
and activity-based intervention, 101 Knee, splinting, pusher syndrome and, 402 Living independently. See also Assisted living
definition of health, 67 Knee-ankle-foot orthosis (KAFO), 403, 404f, 406-407 client-centered performance context
Interpretation of cause, 568-569, 579-580 Kneeling, 183 OTIPM dimensions, 575-576
Intervention model for parenting Knowledge of performance, 107 performance analysis, 578
adaptive techniques and strategies, 589-593 Knowledge of results, 107 prioritize reported strengths, 576-578
care by others, 594 Kyphosis, 162, 194f, 669f cognitive ability and, 54
cognitive issues, 593 and geriatric day rehabilitation, 573-575
discipline from crawling through toddling, 594-595 L initial evaluation, 579
durable medical equipment, 589 Lability, 473 interpretation of cause, 580
emotional issues, 593-594 Lacunar infarcts, dysphagia with, 632 intervention summary, 581-582
facilitating baby-parent relationships, 585-586 Lacunar syndrome, 6-7 occupation-based interventions in IADL,
facilitating physical care by parent, 586-588 Landings, in home, 708-709 580-581
providing adaptive baby care equipment, 588-589 Landmarks, of swallowing, 630f and recommendations for home safety, 714b
working with pregnant women poststroke, 585 Lanechanger mirror, 611f therapeutic rapport, 576-582
Interventions Language, to describe types of clinical reasoning, Living room
activity-based. See Activity-based intervention 441-450 evaluation of, 695
for acute stroke rehabilitation, 31-35 Language disorders, associated with stroke, 539-547 and fall prevention, 706f, 713f
for dysphagia, 642-644 Lap trays, 677-682t modifications to, 709-710, 714
gait Laryngeal movements, facilitation of, 643 Loading response, in gait cycle, 394
evidence-based, 398t Laryngeal penetration, 634 Lobar intracerebral bleed, 9
orthotic, 403-407 Lateral flexor control, 174, 175f Lobes
to improve leisure skills, 740-743 Lateral medullary syndrome, 214-216, 400 of cerebellum, 399
in managing poststroke upper extremity, 225-229t Latissimus dorsi, 161 of cerebral cortex, 466-467t
occupational therapy, for psychological issues, 62 Laundry activity, 559-561f Locked-in syndrome, 538-539
occupation-based, 569-571 one-handed techniques, 731 Lofstrand crutch, 408f
to promote upper extremity function, 232-240 Laundry room, evaluation of, 696-697 Longitudinal arch of hand, 340f
CIMT, 234-237 Lawton Instrumental ADL Scale, 556-558t Long-term memory, 524-525t
managing inefficient and ineffective movement Leaf spring AFO, 404-405 Loss
patterns, 237-240 Learned nonuse, 125 of driver’s license, 599-600, 622
sexual, competencies for, 655b promotion with resting splint, 332 of palmar arches, 340-341
traditional classifications of, 502t and splinting distal extremity, 341 of personal identity, 52
of upper extremity function, impairments to con- Learned suppression, 235 sense of, 51
sider during, 244-258 Learning Lower extremities
using involved upper extremity activity-based practice, 109-110 functioning of, driving and, 610
task-oriented reaching and manipulation, 223-231 errorless, 525 positioning, and fitting for seating, 683
weight-bearing to support function, 231-232 expectation for goal achievement and, 111 Lower extremity dressing
Intervention sessions foundational strategies one-handed techniques
in chart talk, 443 self-monitoring skills, 110-111 for orthotics, 727
in conditional reasoning, 447-448 for task performance, 104-105 pants and underwear, 725-727
in generalization reasoning, 449 freedom from mechanical constraints to movement skirts, socks, and shoes, 725-727
in interactive reasoning, 445-446 and, 110 seated, trunk control during, 178-179, 179f
in narrative reasoning, 443 generalization of Low-load prolonged stress (LLPS), treatment of joint
in procedural reasoning, 444 in cognitive and perceptual deficits, 507 contractures with, 338-339
summary of different reasoning modes, 450 contextual interference, 108 Low stretch bandages, 315-316
Interventions using task-oriented approach different task categories, 109 Lumbar curvature, 158f
bilateral training, 244 knowledge of performance, 107 Lumbricales, normal excursion, 337f
electrical stimulation, 243 knowledge of results, 107 Lymphatic absorption stimulation methods,
EMG biofeedback, 243 practice conditions and schedules, 108-109 313-317
EMG-triggered electrical stimulation, 243-244 practice in natural settings, 109 Lymphatic system, and hand edema, 308-309
784 Index

M Mirror therapy Muscle contraction, 250

MacKinnon splint, 333-334 in managing poststroke upper extremity, 225-229t Muscle imbalance, 264
Macular degeneration, 612 for upper extremity function, 244, 247f Muscle stability, as goal of seating system, 674
Magnetic resonance angiography (MRA), 14-15 MIT-MANUS robot, 282-296 Muscle strength
Magnetic resonance imaging (MRI), 12-14, 761, 764 Mobility base considerations abdominal, 168
Makeup, applying one-handed, 723 manual wheelchair frame styles, 684-688 trunk rotation, 168
Malalignment power mobility products, 688-689 Muscular system
common, after stroke, 170t power wheelchairs, 689-691 abdominal wall, 159-160
postural, 161-162 unilateral neglect, 684 posterior trunk muscles, 160-161
subluxation from, 266f Mobility prescription, adaptive equipment, 621-622 Musculoskeletal complications, 19-20
trunk, observations of, 169-170 Mobility tasks, 559-561f Myocardial infarction
Mania, poststroke, 55t assessment of, 556-558t prevention of, 25
Manipulation, task-oriented reaching and, 223-231 community mobility and driving, 600-601, 623-627 risk with sexual activity, 652
Manual Ability Measure (MAM-36), 221 ease of, and performance of ADL, 718 Myomo e100 NeuroRobotic system, 301
Manual edema mobilization (MEM), 313-315, 321-322, for regaining trunk control, 186
varying practice conditions for, 384
N
323
Modifications to home Nail care, one-handed techniques, 733
Manual guidance, in enhancing functional mobility,
exterior fingernails, 722
381
doors and landings, 708-709 toenails, 722
Manual muscle testing, 95t
hardware, 709 Naloxone, 17
Manual wheelchair frame styles, 684-688
ramps, 697 Narrative reasoning, 450f
armrests, 688
stairs, 697-708 evaluation session, 442-443
casters, 687
interior intervention session, 443
dimensions of, 694f
bathroom, 710 Narrow-based quad cane, 408f
elevating leg rests and footrests, 687-688
bedroom, 710 Nasogastric tube, 30
footplates, 688
hallways and living room, 709-712 National Registry of Rehabilitation Technology
rear wheel size, 686
kitchens, 711-712 Suppliers (NRRTS), 667
seat-to-floor height, 685-686
and moving around obstacles, 712 Natural settings, practice in, 109
tire style, 686
sink and lavatories, 710-711 Near transfer of learning, 507
wheel axle positioning, 687
for managing visual acuity impairments, 424 Negative symptoms after CNS lesion, 219
wheel handrims and one-arm drive wheelchairs,
Modified AFO, 405 Neglect
686-687
Modified Ashworth scale, 251b impacting driving, 607t, 614t
wheel style, 686
Modified barium swallow, 633-634t, 639-640 neurobehavioral impairments related to, 478
Massage, retrograde, elevation and, 313
Momentum strategy, 357-358, 358f and sensory loss, 403
Mastectomy, swelling from, 312
development of, 383 spatial aspects of, during functional activities, 518t
Mat assessment, supine and seated, 670-671
for sit-to-stand, 372 unilateral, 475, 481
Meal preparation, 578-579
Monitoring stroke survivor, 27-31 assessing, 505-506t
in assisted living setting, 556-558t, 563, 570
basic ICU monitor, 28 hand edema and, 318-319
one-handed techniques, 733
feeding tubes, 30 as mobility base consideration, 684
and visuospatial impairment, 435t
ventilator, 30-31 spatial, 475, 482-483f, 484
Measurements
Monofilament test, for sensibility, 312 treatment for, 516-518
circumferential, in evaluation of hand edema, 311
Morse Fall Scale, 382t vs. visual field loss, 517t
during mat assessment, 671f
Motivation Neoplasms, cerebral, 10
volumetric, in evaluation of hand edema, 311
dimension of OTIPM, 561, 575-576 Nerve blocks
Mechanical constraints, freedom from, 110
impaired, 473 for spasticity, 252
Medical management
Motor activity log, 221, 236 to subscapularis nerves, 263
of seizures, 22t
Motor adaptation, 163 NESS H200 Hand Rehabilitation System, 301
of stroke
Motor and praxis skill assessment, 609-610 Neural control of swallowing, 632
acute stroke management, 16
Motor apraxia, 473, 476-478, 484 Neurobehavior
future trends in, 25-26
Motor Assessment Scale, 165, 199, 222 elements of, 462f
hemorrhagic stroke, 18
Motor Assessment Scale for Stroke Patients, 381 occupation linking to neuronal activity, 457-462
ischemic stroke, 16-18
Motor behavior, systems model of, 83-84 Neurobehavioral deficits
principal goals of, 15
Motor control after stroke, 529
Medical Outcomes Study Short-Form Health Survey,
managing stiffness and degrees of freedom problem, effect on activity performance, 462-467
71, 72t
162-163 Neurobehavioral dysfunction, 459
Medical reporting, with driver licensing authorities,
motor adaptation, 163 Neurobehavioral impairments
605-606
musculoskeletal components, 161 and sexual function, 657-658
Medical studies, to clarify diagnoses, 15t
postural malalignment, 161-162 in stroke population, 507-508
Medications
systems model of, 81 during task performance, 476-486
to halt stroke progression, 51
in treatment of abnormal gait, 396-397 treatment with tooth-brushing task, 504b
for psychological conditions, 54-55
trunk muscle contractions, 161 Neurobehavioral Specific Impairment Subscale, 495-497f
Melville-Nelson Self-Care Assessment (SCA), 382t
Motor control dysfunction Neurodevelopmental treatment (NDT)/Bobath
Memory
functional task-oriented training, 124-152 approach, evidence table for, 120-123t
driving and, 604t, 607t
neurotherapeutic approaches, 119-124 Neurological complications, 20-21
notebooks and diaries, 523
Motor development, systems view of, 82 and splinting extremity, 344
stages of, 523t
Motor dysfunction, 459 Neurological function, sexuality and, 649-650
Memory impairments
Motor Free Visual Perception Test, 430 Neuromuscular electrical stimulation (NMES), 301, 319
terminology related to, 524-525t
Motor function impairment, 473 Neurophysiological perspective on splinting, 327
treatment for, 521-525
Motor impersistence, 371 Neuroprosthetic functional electrical stimulation,
Memory loss
Motor learning principles, 91-92 319-320
assistive technology for, 526b
Motor skills, AMPS summary, 561, 565f Neuroprotective agents, 17
short-term, 474, 478
Motor strategies Neuroscience studies of brain plasticity, 102-103
Mendelson maneuver, 643-644
developing, 108 Neurotherapeutic approaches
Menopause, 649
maladaptive, 110 outcome studies
Mental functions, global, 460, 478
Motricity Index, 223 implications for practice, 124
Mental practice
Movable surfaces, to challenge trunk control, 185-186 outcomes measures, 119
in enhancing functional mobility, 380-381
Movement results of review, 124
in managing poststroke upper extremity, 225-229t
compensatory, 240f study designs, 124
for upper extremity function, 241-243
context effect on, 81 timing of therapy, 119
Mental status examination, 61
freedom from mechanical constraints to, 110 principles of, 119
Metacarpophalangeal (MCP) joint, 328, 334, 337
head, endolymph responsive to, 211 NIH Stroke Scale, 32t
hyperextension of, 341f
individual strategies for, 352 Nine-Hole Peg Test, 222
Metal ankle joint, 406f
trunk, evaluation of specific patterns, 170-176 Nondeclarative memory, 524-525t
Metal orthoses, 405-406
Movement patterns Notebooks, 523
Metamemory, 524-525t
ineffective, 92-94 Nottingham Extended ADL Scale, 556-558t
Microcirculation level, of tissue fluid absorption, 308
inefficient and ineffective, managing, 237-240 Nottingham Leisure Questionnaire, 739
Microtrauma, to edematous hand tissue, 318
pathologic, 249 Nutrition
Midstance, 394
rolling, 356f alternative means of, 641-642
Midswing phase of gait cycle, 395
scooting, 364f compromised, associated with dysphagia, 635-636
Mid-wheel drive wheelchairs, 689-690
Mini FIM, 32t Multi-infarct dementia. See Vascular dementia O
Minor trauma edema theory, 310 Multiple Errands Test, 505-506t Object positioning, effect on trunk movements during
Mirror Image Motion Enabler (MIME), 282, Multiple strokes, dysphagia with, 632 reaching activities, 171-172t
283-295t, 296 Multi Podus Phase II System, 348f Oblique arch of hand, 343
 Index 785

Oblique retinacular ligament, 338f Open tasks, 109 Parietal lobes, 466, 469
Obliques changing environments and, 385 Partial visual occlusion, 428, 429f, 518
external, 159-160 reaching task/open chain activity, 220 Participation
internal, 160 Operational definitions activities and, 458
Observation cortical impairments, 471-475t assessment of, 70-71
of client-centered performance in prioritized task, neurobehavioral impairments during task perfor- barriers to, 71-74
563 mance, 476-486 community, strategies for, 105
of trunk alignment/malalignment, 169-170 Optic radiation, 418-419 enabling, 66-67
Observational gait analysis, 390 Oral care fostering throughout continuum of care, 74
Occipital lobes, 466, 469 one-handed techniques, 720-721, 733 leisure, barriers to, 741b
Occlusion, partial visual, 428, 429f trunk control and, 177, 179 relationship to functional mobility, 351
Occupation Oral contraceptives, 26 social
acquisitional, 569f, 580 Oral examination, for swallowing, 637-638 of carers, 59
areas of, 458 Oral-preparatory stage of swallowing, 630, 633-634t definition of, 736
dysfunction, 469-486 Oral responses, improving, 642-643 role in stroke recovery, 57
classifications of, 67 Oral stage of swallowing, 631, 633-634t Passive range of motion, 95t
importance of, 68b Organization for contractures, 253-254
improving participation through, 75-78b impaired, 474, 482-483f, 484, 519 for SHS, 260
restorative, 569f, 581 spatial, 561, 566f Passive robot systems, 282
Occupational error, 457-462 Orientation, topographic, 431t Patent foramen ovale, 3
Occupational performance tasks, 83-84, 85b, 87-88 Orpington Prognostic Scale, 32t Pathogenesis
driving, 604t Orthokinetic orthotics, 330 description of stroke syndromes, 2
reported strengths and problems with, 576-578 Orthopedic injuries, superimposition of, 260-262 ischemic stroke, 2-4
Occupational therapist Orthoptics, 429 strokelike syndromes, 10
approaches to driving Orthoses thrombotic stroke, 4-8
in acute care phase, 603 Armeo body-powered, 298f Pathophysiology
changing role with stroke survivor, 602-614 for gait, 403-407 of dysphagia after stroke, 635f
medical reporting with driver licensing authorities, inflatable hand splint, 335f of thrombotic stroke, 4
605-606 prefabricated, 348f Patterns of movement
motor and praxis skill assessment, 609-610 SaeboFlex, 302 ineffective, 92-94
predriving clinic screening, 606-609 Orthotics, lower extremity, donning one-handed, 727 inefficient and ineffective, managing, 237-240
preexisting or progressive age-related conditions, Osteoporosis pathologic, 249
603-605 and BMD, 396 rolling, 356f
in rehabilitation phase, 603 prevention of, 19-20 scooting, 364f
sensory-perceptual assessment, 610-613 Otoconia, 211-212 Pelvic/trunk alignment, loss of, 264
visual-perception and cognitive assessment, 613- Otoliths, 190, 210-212 Pelvis, 158
614 Outcome measures asymmetrical positions, 669
liability regarding driving, 625-626 Australian therapy, for occupational therapy upper in biomechanics of sitting, 667-668
role in occupation-as-means, 738b limb use scale, 234b obliquity, 162
as specialist in driving, 616-617 in neurotherapeutic approaches, 119 positioning, and fitting for seating, 683
Occupational therapy for seating system, 673 selective movement in bridging, 354f, 355f
assessment to guide baby care adaptations, 584-585 Outcome scales, for dysphagia, 640 stability of, 675
development of clinical reasoning in, 439 Outcome studies on neurotherapeutic techniques Perception
framework for activity-based intervention, 101-102 implications for practice, 124 assessment of, in evaluation of edema, 311
guidelines for adults with stroke, 102 outcomes measures, 119 color, 418t
leisure, stroke and, 736-737 results of review, 124 defective, dressing and, 479-480
leisure activities during, 737-743 study designs, 124 ecological approach to, 81
perspective on upper extremity function, 219 timing of therapy, 119 of trunk verticality, 168
role in sexuality intervention, 653 Outpatient therapy, 75 Perceptual deficits, and gait function, 403
treating inefficient and ineffective upper extremity CIMT protocol and, 236 Perceptual dysfunctions, visual skills and, 418t
patterns, 239-240 Overhead ROM, 256f Percutaneous endoscopic gastrostomy, 30
Occupational Therapy Intervention Process Model Oxygen saturation, 29t Performance-based assessment, for cognitive and
(OTIPM), 554f perceptual impairments, 504-506, 505-506t
dimensions of, 561, 575
P Performance skills, 458
Occupational therapy practice Padding, splint, 344 Performance tasks, occupational, 83-84, 85b, 87-88
activity-based intervention Pain syndromes Peripheral vestibular labyrinth, 210-212
framework, 101-102 effect on upper extremity function, 262-264 Permission, in PLISSIT model, 654-655, 660
guidelines for adults, 102 resulting in frozen shoulder, 750 Perseveration, 474, 478-479
evaluation of psychological conditions in stroke Palatoglossal arch, 630f treatment of, 516
patient, 60-61 Palmar arches Personal hygiene, 559-561f
intervention for psychological issues, 62 loss of, 340-341 neurobehavioral impairments and, 476-479
patient-centered focus, 60 splint fabrication guidelines for palmar support, one-handed techniques, 718-723
therapeutic relationship, 60 344, 347f Personality factors
Occupational Therapy Practice Framework: Domain and Palpation of larynx, 639f change in personality after stroke, 52, 55t
Process, 2nd Edition. See Framework-II Palpation points, 263f and coping with stress, 56
Occupational therapy task-oriented approach Pan holder, 730f recovery and, 50-51
evaluation framework using, 84-90 Pants, donning one-handed, 725 Pervasive impairments, 486
theoretical assumptions of, 81-82 Paradigm shifts in stroke rehabilitation, 118-152 Pet therapy, 362f
treatment principles using, 90-94 functional task-oriented training, 124-152 Pharyngeal examination, for swallowing, 638
Occupation-as-end, 737 neurotherapeutic approaches, 119-124 Pharyngeal movements, facilitation of, 643
Occupation-as-means, 737-738 Paradoxical embolus sources, 3 Pharyngeal stage of swallowing, 631, 633-634t
Occupation-based education program Paraphasia, 474 Phase shifts, 82
acquisitional occupation, 571 Parenteral feedings, 642 Phases of gait cycle, 390, 391f, 392f
AMPS evaluation, 572-573 Parenting Phases of sit-to-stand, 366-368, 371f
reevaluate for enhanced performance, 571-572 assessment tool to guide occupational practice, Phenobarbital, 22t
Occupation-based interventions, 569-571 584-585 Phenytoin, 22t
IADL, 580-581 baby care adaptive equipment, 584 Physical activity
Ocular mobility, 422, 427 care by others, 594 effect of spasticity, 251
Oculomotor compensation, 425 discipline, crawling through toddling, 594-595 and stroke incidence, 26
Oculomotor nerve, 213-215f and getting out in community, 595 Physical care of baby
Oculomotor ROM, 418t impact of growing up with disabled parent, 596 adaptive baby care equipment
Older adults older children, 595-596 bedtime, 588-589
aging and sexual response cycle, 649 parent-child collaboration, 584 childproofing, 589
errors in driving, 621b visual history, 584 diapering, 589
One-arm drive wheelchairs, 686-687 Parenting intervention model adaptive techniques and strategies, 589-593
One-handed techniques adaptive techniques and strategies, 589-593 burping, 591
basic ADL, 718-728 cognitive issues, 593 car seats, 592-593
basic environmental considerations, 717-718 durable medical equipment, 589 diapering, 591
community-based activities, 732-734 emotional issues, 593-594 feeding, 590-591
IADL, 728-732 facilitating baby-parent relationship, 585-586 undressing and dressing, 591-592
One-hand fingernail clipper, 722f facilitating physical care by parent, 586-588 carrying and moving, 586-587
On-road driving evaluation, 618-621 providing adaptive baby care equipment, 588-589 discipline from crawling through toddling, 594-595
clinical evaluation plus, 615 working with pregnant women poststroke, 585 durable medical equipment, 589
786 Index

Physical care of baby (Continued) Practice and learning (Continued) Psychological factors (Continued)
holding, 586 prerequisites to engaging in activity-based practice, poststroke dementia, 54
navigating social obstacles integral to parenting, 109-110 as predictors of stroke, 50
595-596 promoting generalization of learning, 106-109 prestroke, as predictors of recovery, 50-51
by others, 594 self-monitoring skills, 110-111 psychotic conditions, 54
positional changes, 587 task analysis and problem-solving skills, 111 sexual functioning poststroke, 651
transfers, 587-588 types of learning, 105-106 Psychotic conditions, poststroke, 54
Physical therapist Practice conditions Pullover shirts, 176, 725
distinguishing between good and bad pain, 749 contextual interference, 108 Pulmonary embolism, after stroke, 24
in team approach to driving, 602 for different task categories, 109 Pump points, MEM, 314, 315f, 321-322, 323
Physical therapy, 761-762 practice in natural settings, 109 Pure word deafness, 522
intensive, vs. robotic-driven protocol, 283-295t practice schedules, 108 Purkinje cells, 213-215f
Physician liability, regarding driving, 624-625 varying for changing environments, 383-384 Pursuits, 420
Physiological changes, contributing to weakness, 248b whole vs. part practice, 108-109 Pusher syndrome, 400-402
Physiology of swallowing, 629-632 Practicing treatment of, 183-185
Physiotherapy Evidence Database (PEDro) score, 118 ambulation, 397 Pushing, contraversive, 183-185, 184b, 400-402
Pistol-grip remote toenail clipper, 722f rolling, 385 Putamenal ICH, 9t
Planar Simulator, 672f sit-to-stand, 373-374
Plaque, atherosclerotic, 4 Pragmatic reasoning, 450f
Q
Plasticity, brain, 102-103 evaluation session, 448 Quadrantanopsia, 424-425, 612f
Play, 67 Praxis Quadratus lumborum, 160
definition of, 736 processing of, 467, 468f Quality of life
PLISSIT model, 654-656, 660 skill assessment for driving, 609-610 assessment of, 71
Pneumatic pump, for hand edema, 317-318 Predriving clinic screening, 606-609 barriers to, 71-74
Pocket doors, 709f Preexisting conditions, driving and, 603-605 in context of occupation, 69-70
Pommel, in seating systems, 677-682t Prefabricated splints, 346 Questionnaires
Pontine ICH, 9t Pregnant women poststroke, 585 ABILHAND questionnaire, 221
Pooling, in dysphagia, 635f Preoral stage of swallowing, 629, 633-634t Cognitive Failures Questionnaire, 505-506t
Positioning Pressure splint, 331 Community Integration Questionnaire, 71, 72t
for hand edema, 318-319 inflatable, 332f Everyday Memory Questionnaire, 505-506t
interdisciplinary team and, 31 Pressure ulcers Nottingham Leisure Questionnaire, 739
intervention for dysphagia, 642 seating systems and, 675 Prospective and Retrospective Memory Question-
in maintaining soft-tissue length, 254-255 stages of, 38t naire, 505-506t
in managing poststroke upper extremity, 225-229t Preswing phase of gait cycle, 395 R
object, effect on trunk movements during reaching Pretransfer phase, sit to stand, 35 Radiation, optic, 418-419
activities, 171-172t Prevalence Ramps
prolonged, after immobilization, 336 of communication disorders, 536 in home exterior, 697
for sexual activity, 657f, 658f, 659f of psychiatric conditions in children, 55t slope and rise of, 708f
and SHS, 259 of stroke, 1-2 Randomized clinical trials, 118
upper extremity, family educated on, 42 Prevention protocol, for SHS, 259, 260b Random practice, 92, 383-384
Positive symptoms after CNS lesion, 219 Primidone, 22t Range of motion (ROM)
Positron emission tomography (PET), 14 Prisms active, for heterotopical ossification, 20
Posterior lobe of cerebellum, 399 for diplopia, 429 gait cycle, 393f
Posterior pelvic tilt, 669f for visual field loss, 427 oculomotor, 418t
Posterior trunk muscles Problem identification, with COPM, 89f passive, 95t
erector spinae group, 160-161 Problem solving, 92 for contractures, 253-254
latissimus dorsi, 161 four-stage model of, 444 for SHS, 260
quadratus lumborum, 160 joint, 446 and patient management of extremity, 255-258
Poststroke depression, 53, 55t skills, and task analysis, 111 shoulder, family educated on, 42
Posttraumatic hemorrhagic stroke, 10 Procedural learning, 105-106 spine, sitting and, 362
Posttraumatic stress disorder (PTSD), 53-54, 55t Procedural memory, 524-525t trunk, maintaining or increasing, 182
Postural Assessment Scale for Stroke Patients, 165, Procedural reasoning, 443-444, 450f, 463 of vertebral column, 158t
198-199 Processing Reaching, 257f
Postural control of praxis, 467 to challenge available motor control, 242f
balance and, 191 during task performance, 467-469 to floor, 256-257
impaired, 246-248 Process skills, AMPS summary, 561, 566f retraining reach patterns, 231b
system of, 195-196 Productivity, 67 in standing, 378f
Postural malalignment, 161-162 on COPM, 577f task analysis, 220
Postural set, activity requirements for, 112 Program development, on poststroke sexuality, 662 task-oriented, and manipulation, 223-231
Postural stability Progressive resistive training, 283-295t trunk movements during, 171-172t, 185-186
effect on postural activity, 247-248 Progressive stroke, 757 unsupported, 297
as goal of seating system, 674 Projections, central vestibular, 213-214 while sitting, 362f
Postural support, upper extremity, 221f, 233 Prompts, in cognitive and perceptual rehabilitation, 510t Readiness
Posture Prone-on-elbows position, 183 for function, seated position of, 181b
as adjunct treatment Proprioceptive deficits, and gait function, 402 for road test, 615-616
degrees of hip flexion while seated, 183 Prosopagnosia, 522 Reading
kneeling, 183 Prospective and Retrospective Memory Questionnaire, affected in Broca aphasia, 541
prone on elbows, 183 505-506t hemianopsia and, 425-426
seated with legs crossed, 182 Prospective memory, 524-525t Rear-wheel drive wheelchairs, 690
sitting in front of table with forearm weight Proximal attachment Rebleeding, prevention of, 18
bearing, 182-183 of external obliques, 159 Rebound test, in evaluation of edema, 312
patterns in adult hemiplegia, 674t of internal obliques, 160 Recovery
starting posture, appropriateness of, 181-182 of latissimus dorsi, 161 caregiver’s emotional well-being and, 58-59
trunk, asymmetrical, 265f of quadratus lumborum, 160 children with stroke, 59
Posturing of transverse abdominis, 160 extent of, 749
following stroke, 669f Proximal interphalangeal (PIP) joint motivation and, 57
in persistent flexion, 343 contracture, 338f prestroke psychological factors as predictors of, 50-51
Pouch sling, 272f dynamic PIP extension splint, 337 social participation and, 57
Power mobility products, 688-689 flexion contractures, 335 Recreation, parenting and, 595
Power wheelchairs Pseudobulbar palsy, dysphagia with, 632 Rectus abdominis, 159
bases for, 690 Psychological complications of stroke, 21-22 Reduction massage, edema, 312
basic, 690 Psychological factors Reflexes
front-wheel drive, 689 anxiety disorders, 53-54 abnormal, for swallowing, 638
mid-wheel drive, 689-690 biological intervention, 54-55 startle, 772-773
options for, 690-691 cognitive deficits, 54 stretch, splinting effects, 328
rear-wheel drive, 690 coping strategies and recovery, 55-57 vestibuloocular, 213
Practice and learning depression, 52-53 Reflexive cough, 638
amount of practice, 106 discreet expression of emotion, 54 Reflex model of balance, 189
expectation for goal achievement, 111 emotional reactions to stroke, 51-52 Reflex sympathetic dystrophy (RSD), 310
foundational strategies for task performance, 104-105 lowered self-esteem, 54 Rehabilitation service provision, 666
freedom from mechanical constraints to movement, motivation and recovery, 57-59 leisure program, 743, 745
110 occupational therapy practice and, 60-62 Rehabilitation technologies
goals of training and learning, 104 personality change after stroke, 52 bilateral arm training, 300-301
 Index 787

Rehabilitation technologies (Continued) Role transitions, 51-52 Self-management program

clinical use of, 302-304 Rolling MEM, 314-315
comparison with other forms of therapy, 283-295t analysis of movement, 355-357 safe ROM activities, 255-258
devices for repetitive task practice, 302 in bed, 33 Self-monitoring skills, 110-111
FES, 301 to hemiplegic side, 356-357 Self-Regulation Skills Interview, 509t
Handmaster™, 301-302 practicing, 385 Self-report
hand robots, 299-300 to unaffected side, 357 assessment for cognitive and perceptual impairments,
Myomo e100 system, 301 Rolling walkers, 408 505-506t
rationale for development, 280-281 Rolyan humeral cuff sling, 270 on level of performance, 563b
robot-assisted therapy, 281-299 Rotation for upper extremity function, 221
theories guiding development, 281 downward, of scapula, 265 Semantic memory, 524-525t
Reimbursement policies, for durable medical equipment, simple and complex, 230b Semicircular canals, 190f, 210-211
667 Rotation control, trunk, 175-176 Sensibility testing, in evaluation of edema, 312
Reintegration to Normal Living, 71, 72t Rotator cuff Sensory function, 460
Relationships lesions, 261 loss, and sexuality, 657
between babies and parents poststroke, 585-586 relationship with deltoid muscle, 105f Sensory impairment, and decision to splint, 342
poststroke role in, 651-652 Rubber-based splint materials, 343-344 Sensory information, and motor output, 470f
therapeutic, 60 Sensory organization, 190-191
developing rapport, 562, 576-582
S testing, 196-197
Reliability and validity studies, A-ONE, 491-493t Saccades, 420, 423, 426-427 treatment planning and, 203-205
Remediation Saccular aneurysm, 9-10 Sensory-perceptual assessment, for driving, 610-613
in treating balance impairments, 201 Saccular nerve, 211f Sensory strategy, 190-191
in treating cognitive and perceptual deficits, 503 Saccule, 210-211 Sequencing impairment, 482-483f, 484, 519
Reorganization of brain activity, 441 Sacral curvature, 158f Serpentine splint, 334, 335f
Reo™ Therapy System, 298 SaeboFlex, 302 Sewing, one-handed techniques, 731
Repetitive motion devices Safety considerations Sexual function
AutoCITE, 302 for ADL, 707f and neurological function, 649-650
Hand Mentor™, 299 of home environment, 717-718 PLISSIT model and, 654-656
SaeboFlex, 302 for living independently, 714b resumption of, 661b
Repositioning maneuvers, 216 Westmead Home Safety Assessment, 382t role of occupational therapy, 653
Research articles Scale for Contraversive Pushing, 184b stroke effects, 650-652
criteria for evaluating, 118 Scalenus anticus syndrome, 319 Sexual function treatment suggestions
evidence tables Scanning, functional, 418t cognitive/perceptual/neurobehavioral impairments,
for CIMT, 132-141t Scanning training, for unilateral neglect, 517 657-658
for NDT/Bobath approach, 120-123t Scapula contraception and safer sex, 659-661
for robot-assisted therapy, 144-148t alignment, loss of, 264-265 decreased endurance, 658
for task-oriented training, 126-131t downward rotation, 265 erectile dysfunction, 658-659
for treadmill training with body weight support, mobilization of, 257, 259-260 hemiparesis/sensory loss, 657
149-151t Scapulohumeral rhythm, 104f inadequate vaginal lubrication, 658
Resistive training, progressive, 283-295t Schedules of practice, 108 incontinence, 659
Resting hand splint, 33b Scientific reasoning. See Procedural reasoning Sexual response
Resting splint, 332 Scoliosis, 194f, 266f, 669f normal, 649
Restlessness, 474 Scooters, power, 689 poststroke, 659-661b
Restorative approach to treatment, 503 Scooting prestroke, 650
Restorative occupation, 569f, 581 analysis of movement, 363 Shaving, one-handed techniques, 723
Retention phase of learning, 106 treatment strategies, 363 Shift, as manipulation task, 230b
Retraining trunk control and, 177, 180 Shirts
in ADL, 717b Screening button-down, 176-178
balance, 205, 207 predriving clinic, 606-609 pullover, 176, 725
gait visual, 419-420, 422-423b Shoes, donning one-handed, 725-727, 728f
after cerebellar stroke, 400 Seated position Shopping and community activities, 556-558t, 559-561f
pusher syndrome and, 401 with legs crossed, 182 Shortening, soft-tissue, and splints for distal extremity,
of reach patterns, 231b for mat assessment, 670-671 336-338
skills in, 91-92 optimal alignment in, 668f Short-term memory, 524-525t
Retrieval stage of memory, 523t of readiness for function, 181b Short-term memory loss, 474, 478
Retrograde amnesia, 524-525t Seating system assessment Shoulder
Retrograde massage, elevation and, 313 basic principles, 669-670 anatomy of, 269f
Rib cage, 158-159 conducting comprehensive interview, 670 hemiplegic, adhesive changes in, 261
rotation, 162 documentation, 672 management, in ICU, 35-36
Right brain stroke, 547-549 equipment trial, 672 supports, 268-271
Right/left discrimination, 431t fitting, training, and delivery, 672 Shoulder-hand syndrome (SHS), 258-271. See also
Risk factor modification, 25-26 functional outcome measurement and follow-up, 673 Complex regional pain syndrome (CRPS)
Risk management strategies, regarding driving, 625b performing supine and seated mat assessment, 670-671 Showering, one-handed techniques, 718-719
Risks providing client and team education, 671 Sick role, 56
for falls, 371-372, 396 Seating system principles Side effects of seizure drugs, 22t
for methods of nutritional support, 641t goals of seating system, 674-675 Side lying position, maintaining, 33
modifiable and nonmodifiable, 2t and level of functional changes, 673-674 Side lying-to-sit, 34
Rivermead ADL Assessment, 556-558t translating mat evaluation into seating system, 673 practicing, 386
Rivermead Behavioral Memory Test, 505-506t type of deformity present, 673 problems with, 358-359
Rivermead Motor Assessment (arm section), 223 Seating systems toward affected side, 359-360
Road test, readiness for, 615-616 contoured, 676 toward unaffected side, 360-361
Robot-aided motor training for upper limb function custom options, 676-683 treatment strategies, 359
evidence table, 144-148t fitting person based on functional status, 683-684 Side reach, in wheelchair, 697f
outcome studies, 143 linear, 676 Significant others, living with memory-impaired loved
rationale and principles, 142-143 and mobility base considerations, 684-691 ones, 526b
Robot-assisted therapy Seat-to-floor height of wheelchair frame, 685-686 Sign responses, 29t
active and passive robotic systems, 282 Seizures Silent aspiration, 634
ARM Guide, 297 drug therapy for, 22t Simple rotation, as manipulation task, 230b
ARMin, 298 impacting driving, 607t Simplification of kitchen work, 728-729
classes of robots, 281-282 treatment and management of, 20-21 Simulator, for evaluating sitting client, 671, 672f
Haptic Master, 297 Selective attention impairment, 526 Single-photon emission CT (SPECT), 14
MIME, 296 Self-Awareness of Deficits Interview, 509t Single-strap hemisling, 270
MIT-MANUS and InMotion2 robots, 282-296 Self-care Sink and lavatories, modifications to, 710-711
Reo™ Therapy System, 298 assessment of, 556-558t Sitting
T-WREX and Armeo, 298-299 in context of occupation, 67-68 analysis of movement, 361
Rock the baby activity, 256, 257f on COPM, 577f in bed, 34-35
Role changes, 736 training in, 37-39 biomechanics of, 667-668
Role Checklist, 86f Self-concept, meaning of loss in relation to, 51 in chair, 35
Role dimension of OTIPM, 561, 575 Self-determination theory, 68 correct alignment during, 194f
Role performance Self-efficacy, 68 at edge of bed, 35
assessment tools for, 86-87 Self-esteem in front of table with forearm weight-bearing, 182-183
limitations of, 90-91 lowered, 54 functional activities in, 362-363
in systems model of motor behavior, 83f, 84, 85b recovery and, 50-51 problems with, 361-362
788 Index

Sitting (Continued) Spinner knob, for driving, 610f Strategies (Continued)

pusher syndrome and, 401 Spinocerebellum, 399 coping. See Coping strategies
scooting, 363 Spiral ganglion, 211f development, for different environments, 383
therapeutic exercise while, 186 Splinting for ease of mobility and performance of ADL,
transfers, 363-366 decision-making process concerning, 342-343 718
varying surface for, 385f dorsal vs. volar, 328-329 to engage patients in collaborative effort, 446
Sit-to-stand, 365, 366-375 early phase of, 31 formulation during task performance, 107-108
altering features in clinical environment, 386 fabrication guidelines foundational
analysis of movement, 366-370 clinical reasoning, 347f for practice and learning, 110-111
pretransfer phase, 35 general, 343 for task performance, 104-105
problems with, 370-372 specific, 344-346 to manage functional deficits, 529b
treatment strategies, 372-375 general guidelines, 343 for performance, 91
Six minute walk test, 391 for hand edema, 318 sensory, 190-191
Skeletal system historical perspective, 327 treatment. See Treatment strategies
pelvis, 158 knee, pusher syndrome and, 402 visual search, 426
rib cage, 158-159 Splints visuospatial impairment-related, 435t
vertebral column, 157-158 air splint, 331 Strategy training, for apraxia, 511-512
Skills acquisition for hand edema, 317-318 Strength
clinical reasoning, 451 belly gutter splint, 335 hand, assessment of, 95t
enhancing techniques, 379-381 commonly used after stroke, 329-335 increased, manipulable task parameters for, 250b
Skin breakdown, prevention of, 23, 36-37 for distal extremity, designing/prescribing consider- Strengthening interventions, 249-250
Skirts, donning one-handed, 725 ations, 336-341 Stress
Sliding doors, 709f drop-out splint, 334-335 low-load prolonged (LLPS), treatment of joint
Slings finger spreader, 329 contractures with, 338-339
considerations when prescribing, 271b firm cone, 329-330 and risk for stroke, 50
effectiveness of, 269-270 hand-based thumb abduction splint, 333 Stretch reflex, splinting effects, 328
using during flaccid stage, 270-271 inflatable hand splint, 335 Stride, 391
Sling suspension exercises, 283-295t MacKinnon splint, 333-334 Stroke
SmartView Mirror, 610f orthokinetic orthotics, 330 acute, management of, 16
Social attitudes, regarding disability, 652-653, 666 orthokinetic wrist splint, 330 cerebellar, 399-400
Social dimension of OTIPM, 561, 575 padding, 344 deconditioning effects, 23t
Social participation pressure splint, 331 definition of, 2
of carers, 59 resting splint, 332 diagnosis, 10-14
definition of, 736 serpentine splint, 334 effects on sexual function, 650-652
role in stroke recovery, 57 spasticity reduction splint, 331 medical management of, 15-18, 25-26
Social support submaximal range splint, 334 patterns of impairments resulting from, 486
for caregivers, 58 thumb loop and thumb abduction splint, 333 prevention of complications and long-term sequelae,
and participation, 73 tone and positioning splint, 332-333 19-25
Social well-being, 600f wrist extension splint, 331-332 progressive, 757
Social worker, in team approach to driving, 602 Stability recurrence prevention, 18-19
Socks, donning one-handed, 725, 727f, 760 limits of, 195f workup for cause of, 14-15
Soft palate, 631f pelvic, 675 Stroke Adapted Sickness Impact Profile, 71, 72t
Soft-tissue postural Stroke Impact Scale, 71, 72t, 382t
elasticity, loss of, 253-258 effect on postural activity, 247-248 Strokelike syndromes, 10
shortening as goal of seating system, 674 Stroke survivor
with spasticity, 252-253 Stabilization, for one-handed kitchen work, 729-730 anxiety in MRI machine, 765
and splints for distal extremity, 336-338 Stabilizer, forearm weight-bearing as, 233 Babinski sign, 749
tightness, and decision to splint, 342 Stabilizing orthoses, 403 CT of brain, 753
Solid ankle AFO, 405 Stable origin of rectus abdominis, 159 denial of unacceptable reality, 773
Somatoagnosia, 475, 478 Stages of learning, 106 dressing
Somatosensory information, 190 Stages of memory, 523t brassieres, 766
Somesthetic sensory loss, 475 Stages of SHS, 259b one-handed techniques, 759
Spastic dysarthria, 538 Stages of swallowing, 629, 631f, 633-634t socks, 760
Spasticity Stair climbing, guarding of patient while, 411 driving issues, changing role of occupational
during automatic reactions, 749 Stairs, in home, 697-708 therapist in, 602-614
as cause of weakness, 90 and fall prevention, 706f eating one-handed, 767, 772-773
clinical presentation of, 250 Stance phase of gait cycle, 390, 391f, 392t exhaustion, 768
effect on physical activity, 251 Standing extent of recovery, 749
management of, 21 analysis of movement, 375 falls at home, 756
problems due to, 253t correct alignment during, 194f feelings of frustration, 748-749, 750
and splints for distal extremity, 336 fall prevention, 377-379 going home, 750
treatment modalities, 252 problems with, 375-376 home safety factors, 756
Spasticity reduction splint, 331 pusher syndrome and, 401 home visit evaluation, 776
Spastic paresis, 250 supported, 35 mentation, 748
Spatial awareness treatment activities and goals while, 202b monitoring, 27-31
increasing, 36 treatment strategies, 376-377 basic ICU monitor, 28
during transfer training, 370 from various surface levels, 372f feeding tubes, 30
Spatial neglect, unilateral, 475, 482-483f, 484 Stand-pivot transfers, 364-365 ventilator, 30-31
Spatial positioning impairment, 520-521 Starting posture, appropriate, 181-182 MRI evaluation, 761, 764
Spatial relations impairments, 430-434, 461, 464f, Startle reflex, 772-773 physical therapy, 761-762
475, 478, 479-481f Static grasp, with limited shoulder movement, 233 practicing food preparation in kitchen, 774
Spatial relations syndrome Stay Put Suction Disc, 730f progressive stroke, 757
figure-ground impairment, 521 Step, length or time, 391 PTSD in, 53-54
spatial positioning impairment, 520-521 Stepping strategy, 191, 196, 205 slurred speech, 754, 763, 766
spatial relation dysfunction, 519-520 Stereopsis, 418t, 422, 431t spasticity, 749
topographical disorientation, 521 Stereotypical flexor pattern, 239f startle reflex, 772-773
Specific suggestions in PLISSIT model, 655-656, 660-661 Stiffness, and degrees of freedom, 162-163 team approach in acute care, 754
Speech and language deficits, 73 Stockinette tube, cotton/elastic, 316-317 therapy, 749-750
cognitive communication impairment, 547-549 Storage devices, for kitchen, 729-730 TIA, 752
communication disorders Storage stage of memory, 523t toileting, in-hospital, 757-758
incidence and prevalence, 536 Stories, personal, exchanging, 446 tooth brushing, 759-760
management of, 537-539 Strabismus, 418t, 427 transfer to chair from wheelchair, 759
communication impairment after stroke, 535-536 Straight cane, 407f transition to being survivor, 51-52
language disorders associated with stroke, 539-547 Strapping using walker, 769
slurred speech, 754, 763, 766 flexion (Buddy) strap, 338f weakness, with progressive stroke, 757
types of communication problems, 536 of shoulder, 271, 272f writing practice, 770
Speech-language pathologist, in team approach to Velcro materials for, 344 Stroke syndromes, 4-6t
driving, 602 Strategic and tactical skills, driving and, 604t cerebellar infarcts, 216
Speech-language pathology, 536-537 Strategies lacunar, 8t
Spinal cord, 213-215f adaptive, for parenting, 589-593 lateral medullary syndrome, 214-216
Spinal curvatures, 158f, 668f ankle and hip, 191 lesions of vestibular areas in cerebral cortex, 216
points of support for, 683f balance, retraining, 205 Structured Observational Test of Function (SOTOF),
Spinal drain, 29-30 compensatory, in side lying-to-sit, 358-359 430-431
 Index 789

Structuring activity demands Task-oriented approach (Continued) Top-down reasoning, 553-554

activity selection and synthesis, 114 reaching, and manipulation, 223-231 Topographic disorientation, 475, 521-522
task analysis, 112-113 systems review of motor development, 82 Topographic orientation, 431t
Students, clinical reasoning skills enhancement, 451-453 using robot-assisted therapies, 281 Towel on table activity, 255-256
Subacromial space, 262f Task performance Trachea, 631f
Subacute rehabilitation, 43b cerebral cortical role, 463 Training of details, 512-514
Subarachnoid hemorrhage, 9-10 current level of performance, 563-564 Transcortical motor aphasia, 542-544, 544t
Subclavian artery, 215f limitations, 90-91 Transcranial Doppler study, 14
Subjective interview neurobehavioral impairments during, 476-486 Transfer handle, 717f
in evaluation of balance impairments, 193 observation in prioritized task, 563, 578 Transfer of learning, 106, 507
in trunk evaluation process, 163 processing during, 467-469 Transfers
Subluxation supported using involved upper extremity, 223-232 analysis of movement, 363
of glenohumeral joint, 267, 270 videotaping of, 518 of baby, 587-588
from malalignment, 266f Task selection and analysis, 85b, 88 car, 367f
patterns, in upper extremity after stroke, 267t Task-specific training, for apraxia, 514-516 near, intermediate, and far, 108
shoulder pain and, 263 Team approach, 26-27 training with different seating surfaces, 373f
Submaximal range splint, 332f, 334 in acute care, 754 treatment strategies, 363-366
Subscapularis, nerve blocks, 263 in assisted living setting, 555-573 wheel chair to tub bench, 368f
Summary feedback, 380 for elderly client living at home, 573-575 Transient ischemic attack (TIA), 752
Supination, of foot during swing phase, 395f to rehabilitation and issue of driving, 601-602 description of, 2
Supine activities to sexual health care, 653-654 Transition(s)
bridging, 354-355 to swallowing, 636 in behavior, 82
performance of, 353-354 to treating balance impairments, 200-201 to stroke survivor, 51-52
rolling, 355-357 Telemetry, 28 using upper extremity for assistance during, 233
therapeutic exercises, 186 Telephone, adaptive techniques for using, 732 Translation, as manipulation task, 230b
Supine mat assessment, 670-671 Temper tantrums, dealing with, 595 Transportation activities, 556-558t, 559-561f. See also
Supine shoulder management, 36 Temporal dimension of OTIPM, 562, 576 Driving
Supine-to-sit. See also Side lying-to-sit Temporal lobes, 467, 469-476 and parenting, 595
analysis of movement, 357-361 Terminal stance phase, 394 Transportation barriers, to leisure participation, 742
Supported sitting in chair, 35 Terminal swing phase, 395 Transport devices, for kitchen, 729
Suprabulbar palsy, dysphagia with, 632 Test batteries, 494 Transverse abdominis, 160
Supraspinatus, 265-266, 267 Test conditions, for assessing sensory organization, Transverse arch of hand, 340f
Suspension arm sling, 240f 196, 198t Traumatic brain injury, 10
Sustained attention impairment, 527 Test d’Evaluation des Membres Supérieurs de Treadmill training
Swallowing Personnes Agées (TEMPA), 222-223 with BWS, 397
anatomy and physiology of, 629-632 Test of Everyday Attention, 505-506t evidence table for, 149-151t
facilitation of, 643-644 Thalamic ICH, 9t to improve gait, 143-152
GUSS for, 40f Theories-in-use, 440 Treatment initiation, in ICU, 28b
role of multidisciplinary team, 636 Theory of learned helplessness, 103 Treatment plans
stages of, dysphagia signs associated with, 633-634t Therapeutic relationship, 60 for balance disorders, 200-201
Swallowing evaluation developing rapport, 562, 576-582 for gait function, interventional studies, 396-397
abnormal reflexes, 638 Therapists, clinical reasoning skills, 451 for neurobehavioral impairments, 508-528
chart review, 636-637 Therapy Wilmington Robotic Exoskeleton for perceptual or cognitive impairments, 502-504
clinical, 636 (T-WREX), 282, 283-295t, 298-299 Treatment principles, for upper extremity function,
feeding trial, 638-639 Thermal-tactile stimulation, 643 272-274
functional status, 637 Thermoplastic materials Treatment strategies
impressions of, 640-641 for orthotic devices, 404 for bridging, 354-355
instrumental assessment of dysphagia, 639-640 for splints, 343 for rolling to hemiplegic side, 356-357
oral examination, 637-638 Thoracic curvature, 158f for rolling to unaffected side, 357
patient/caregiver interview, 637 Thoracic outlet syndrome (TOS), 319 for scooting, 363
pharyngeal examination, 638 Thought processes, inflexible, 527 for side lying-to-sit, 359
Sweep, MEM, 314f Three-point gait pattern, using two devices, 410 for sit-to-stand, 372-375
Swelling, and edematous tissue, 312 Thrombi of unknown source, 3-4 for standing, 376-377
Swing phase of gait cycle, 390, 391f, 392t, 395 Thrombolytic therapy, 16-17 for transfers, 363-366
Systems model Thrombotic stroke Treatment techniques for trunk control
of balance, 189-190 atherothrombotic disease, 4-6 adapting environment, 186-187
of motor behavior, 83-84 hemorrhagic conversion, 7-8 assuming appropriate starting posture, 181-182
of motor control, 81 lacunar syndrome, 6-7 engaging in reaching activities, 185-186
Systems view of motor development, 82 pathophysiology of, 4 increasing trunk ROM, 182
Through the Looking Glass (TLG), 583-584 therapeutic exercise, 186
T Thumb loop and thumb abduction splint, 333 treating pusher syndrome, 183-185
Tactile agnosia, 521-522 Thumb support, splint fabrication guidelines for, using ADL and mobility tasks, 186
Tailor position, 35 346, 347f using various postures, 182-183
Taping, for shoulder instability, 272f Thyroid cartilage, 630f Trunk
Task analysis Ties, donning, 724 alignment, 267t
development of activity analysis skills by client, 113 Tilt, pelvic, 158 anatomy
for dissociation between body segments, 113 Timed Get Up and Go, 382t muscular system, 159-161
for postural set, 112 Timed Up and GO (TUG) test, 198 skeletal system, 157-159
and problem-solving skills, 111 Time log, 742f asymmetrical posture, 265f
upper extremity tasks, 220-221 Timing considerations for evaluation and treatment of, 163
using activity to assess client’s skills, 113 of intervention evaluation process
for weight shift and balance, 112-113 for CIMT, 142 observations of alignment/malalignment, 169-170
Task categories, 109 functional task-oriented training, 125 specific trunk movement patterns, 170-176
upper extremity, 235t of therapy, in NDT, 119 standardized assessments, 164-167
Task choices, to promote upper extremity function, Tinnetti Balance Test of the Performance-Oriented subjective interview, 163
232-240 Assessment of Mobility Problems, 382t trunk control during ADL, 176-180
Task dimension of OTIPM, 562, 576 Tire options, for manual wheelchair, 686 and fitting for seating, 683-684
Task-oriented approach Toddlers, placing in car seat, 592-593 impairments interfering with daily function, 157
of adjunct interventions Toenail care, one-handed techniques, 722 lateral supports in seating systems, 677-682t
bilateral training, 244 Toileting, 559-561f and limb, interdependence of alignment, 268
electrical stimulation, 243 in-hospital, 757-758 MEM beginning at, 313-314
EMG biofeedback, 243 one-handed techniques, 718 muscle contractions, 161
EMG-triggered electrical stimulation, 243-244 recommendations for safety, 707f Trunk control during ADL
mental practice/imagery, 241-243 trunk control and, 177, 180 bathing, 180
mirror therapy, 244 Toilevator, 710f bridging, 180
contemporary view of motor learning, 82-83 Tolerance eating, 179-180
dynamical systems theory, 82 for aspiration, 634-635 grooming, 179
with Haptic master, 297 sitting, increased, 675 lower extremity dressing (seated), 178-179
motor behavior systems model, 83-84 Tone and positioning splint, 332-333 scooting, 180
occupational therapy Tone-inhibiting AFOs, 405 sitting, 361
evaluation framework using, 84-90 Tongue, 630f toileting, 180
treatment principles using, 90-94 Tooth-brushing task, 504b, 759-760 upper extremity dressing, 176-178
underlying model of, 81-82 Toothpaste dispenser, 721f Trunk Control Test, 164t, 165, 169t, 382t
790 Index

Trunk control treatment techniques Upper limb function: robot-aided motor training Vocal chords, 630f
adapting environment, 186-187 evidence table, 144-148t Vocal quality
assuming appropriate starting posture, 181-187 outcome studies, 143 assessment of, 39b
engaging in reaching tasks, 185-186 rationale and principles, 142-143 in pharyngeal examination, 638
increasing trunk ROM, 182 Upper limb recovery: rehabilitation technologies Volar splinting
therapeutic exercise, 186 bilateral arm training, 300-301 vs. dorsal splinting, 328-329
treating pusher syndrome, 183-185 clinical use of, 302-304 volar-based resting splint, 332
using ADLs and mobility tasks, 186 comparison with other forms of therapy, 283-295t Volitional cough, 638
using various postures, 182-183 devices for repetitive task practice, 302 Volumetric measurement, in evaluation of edema, 311
Trunk impairment scales, 164t, 165, 166-167t, 168b, 169t FES, 301
Tube feedings Handmaster™, 301-302
W
invasive, 642 hand robots, 299-300 Walk cane, 408f
noninvasive, 641 Myomo e100 system, 301 Walkers, 408, 769
Turning space of wheelchair, 695f rationale for development, 280-281 for moving baby, 586-587
Turn signal crossover, 610f robot-assisted therapy, 281-299 Walking patterns, 408-409
Two-point contralateral gait pattern theories guiding development, 281 Wall, in maintaining standing position, 376f
using one device, 409 Upper limb use scale, Australian therapy outcomes Wallenberg syndrome, 214, 400
using two devices, 409-410 measures for, 234b Weakness
Urinary incontinence, 23, 73 effect on functional status, 248-250
U Urinary tract dysfunction, 23 of oral structures, 643
Ulcers, pressure U-shaped massage strokes, 314 with progressive stroke, 757
seating systems and, 675 Utricle, 210-211, 211f, 213-215f strengthening interventions for, 225-229t
stages of, 38t Uvula, 630f Websites
Ulnar deviation, extreme, 340 for driving judgment, 615b
Ultrasound, in evaluation of swallowing, 640 V for driving performance, 608b
Underwear, donning one-handed, 725 Vaginal lubrication, inadequate, 658 for fall prevention, 379b
Unilateral neglect, 475, 481 Valproic acid, 22t Weight-bearing activities
assessing, 505-506t Variable motionless tasks, 109 for function, 34-35
and hand edema, 318-319 changing environments and, 384-385 with superimposed motion, 233
as mobility base consideration, 684 Variable practice, 92 to support upper extremity function, 231-232
spatial, 475, 482-483f, 484 Vascular dementia, 54, 549 task analysis, 220-221
Unilateral neglect treatment Vascular emboli, 3 Weight distribution, asymmetrical, 201-205
awareness training, 516 Vasculitic conditions, causing arterial system disease, Weight shift
environmental adaptation, 518 11-12t activities requiring, 112-113, 400
Lighthouse Strategy, 517-518 Vasospasm, control of, 18 during reaching activities, 171-172t
limb activation, 518 Vehicle and equipment assessment, 618 in standing, 376, 377f, 378f
partial visual occlusion, 518 Velocity, walking, 391 during transfers and sit-to-stand, 365, 366f
scanning training, 517 Venous absorption stimulation methods, 313-317 in treating asymmetrical weight-bearing, 201-202, 203
videotaped feedback of task performance, 518 Venous system, and hand edema, 308-309 Well-being, 69
Unilateral treatment activities, 247b Venous thromboembolism (VTE), 24 emotional and social, 600f
Unilateral upper motor neuron dysarthria, 537-538 Venous thrombosis, 11-12t Wernicke aphasia, 544-545, 545t
Unsupported sitting, 35 Ventilator, 30-31 Westmead Home Safety Assessment, 382t
Upper extremities Vergence, 418t, 420 Wheel axle positioning, 687
dysfunction, causes of, 244f Vertebral column, 157-158 Wheelchair
impaired, supporting participation, 224f Vertebrobasilar syndromes, 4-6t adaptive occupation, 570
positioning Vertigo, benign paroxysmal positional (BPPV), 216 clear widths, 696f
family educated on, 42 Very far transfer of learning, 507 manual
and fitting for seating, 684 Vestibular rehabilitation, 216 dimensions of, 694f
poststroke, managing, 225-229t Vestibular system, 190 frame styles, 684-688
shoulder management in ICU, 35-36 central arterial supply, 214 power, 689-691
trunk control during dressing, 176-178, 179f central projections, 213-214 reclining vs. tilted back, 683f
Upper extremity dressing peripheral vestibular labyrinth, 210-212 and seating system assessment, 669-673
one-handed techniques in testing sensory organization, 196 side reach, 697f
brassieres, 725 Vestibulocerebellum, 399 transfer to chair from, 759
garments with front fasteners, 724 Vestibuloocular reflex (VOR), 213 turning space, 695f
pullover shirts, 725 Videotaping used for sexual activity, 658f
ties, 724 as feedback, 380 Wheelchair collision test, 505-506t
trunk control during, 176-178 of task performance, 518 Wheel handrims, 686-687
Upper extremity function Visual acuity, 418t, 422 Wheel lock extension, 677-682t
activity analysis of select tasks, 220-221 driving and, 604t, 610-613 Whole vs. part practice, 108-109
definitions and classifications, 219 impairments, managing, 424 Wide-based quad cane, 407f
evaluation tools, 221-223 Visual agnosia, 521-522 Wolf Motor Function Test, 222, 236
general treatment principles, 272-274 Visual field loss, vs. neglect, 517t Work, 67
impairments to consider during evaluation and Visual fields, 418t Working memory, 524-525t
intervention, 244-258 compensatory training, 426 World Health Organization Quality of Life Scale, 71, 72t
loss of soft-tissue elasticity, 253-258 confrontation test, 423 Worldview, 448-449
postural control, 246-248 deficits in, 421f discharge session, 449
spasticity, 250-253 management of, 424-434 evaluation session, 449
weakness, 248-250 Visual history, of parenting, 584 Wrist
interventions Visual pathways, 419f flexion, following decreased skeletal muscle activity, 340
to promote function, 232-240 Visual-perception assessment, for driving, 613-614 limited motion of, 268
task-oriented reaching and manipulation, Visual processing normal excursion, 336f
223-231 for driving, 619f Wrist extension splint, 331-332
used with task-oriented approach, 241-244 during functional tasks, 417-419 Wrist splint
weight-bearing to support function, 231-232 Visual search strategies, 426 fabrication guidelines for, 344-346, 347f
occupational therapy perspective, 219 Visual system, 190 orthokinetic, 330
shoulder-hand syndrome, 258-271 and balance control, 204 Writing, 770
loss of biomechanical alignment, 264-268 deficits, and gait function, 403 adaptive techniques for, 731-732
pain syndromes, 262-264 screening, 419-420, 422-423b affected in Broca aphasia, 541
shoulder supports, 268-271 Visuospatial agnosia, 521
superimposed orthopedic injuries, 260-262 Visuospatial impairments, 430-434
Z
Upper limb assessments, in evaluation of edema, functional improvement strategies for, 435t Zim jar opener, 729f
311-312 Vital signs, 29t Zippers, 723
Medications Commonly Used to Treat Stroke and its Comorbidities—cont’d
OTHER
MEDICAL
DRUG USE DOSAGE ROUTE SIDE EFFECTS ISSUES

Steroids
Androgenic steroids Testicular insufficiency, 25 to 50 mg IM Muscle wasting, weakness
antineoplastic
Betamethasone Inflammation, pain 1 to 9 mg IM, intra- Altered mental status (AMS),
(Celestone) injection articular osteoporosis, peptic ulcer,
glaucoma, diabetes mellitus
(DM), HTN
Cortisone Addison disease and 35 to 70 mg PO PO AMS, osteoporosis, peptic ulcer,
conditions such as qd glaucoma, DM, HTN
inflammation,
swelling, rashes,
asthma, and arthritis
Dexamethasone Acute spinal cord 0.75 to 10 mg up PO, IV AMS, osteoporosis, peptic ulcer, 1 mg  20 mg
(Decadron) injury, inflammation, to 1 g glaucoma, DM, HTN cortisone
swelling
Hydrocortisone Inflammation, swelling, Depends on IV, PO, AMS, osteoporosis, peptic ulcer, 1 mg  1 mg
rashes, asthma, route IM, glaucoma, DM, HTN cortisone
arthritis, etc. topical
Prednisone Inflammation, swelling, 5 to 60 mg qd PO AMS, osteoporosis, peptic ulcer, 1 mg  5 mg
(Deltasone) asthma, arthritis, etc. glaucoma, DM, HTN cortisone

Neurologicals
Baclofen (Lioresal) Skeletal muscle 5 to 20 mg PO Drowsiness, confusion, HA, Effect only seen in
relaxant, detrusor tid-qid N/V, constipation very high doses
dyssynergia
Bethanechol Cholinomimetic, 10 to 50 mg PO N/V, dry mouth, lethargy,
(Urecholine) enhances detrusor tid-qid constipation, retention
contractions
Dantrolene sodium Skeletal muscle 25 mg qd to PO, IV Drowsiness, dizziness, HA,
(Dantrium) relaxant, better 100 mg qid diarrhea, hepatitis, seizure
emptying in detrusor-
external sphincter
dyssynergia (DESD)
Dicyclomine (Bentyl) Anticholinergic, DESD 20 to 40 mg qid PO, IV N/V, dry mouth, lethargy,
constipation, dyspnea
Ephedrine, Stress incontinence in PO N/V, dry mouth, lethargy,
propanolamine females constipation
Hyoscyamine (Levsin) Detrusor 0.125 to 0.25 mg PO N/V, dry mouth, lethargy,
antispasmodic, DESD qid or 0.375- constipation
0.75 mg qd
sustained
release
Imipramine (Tofranil) Increases outlet 75 to 150 mg qd PO Orthostasis, heart block, N/V,
resistance, decreases anxiety, confusion, ataxia, dry
detrusor strength mouth
Oxybutynin Detrusor 5 mg bid-tid PO N/V, dry mouth, lethargy,
(Ditropan) antispasmodic, DESD constipation
Phenoxybenzamine Alpha-blocker, 10 mg bid PO Orthostasis, tachycardia,
(Dibenzyline) decreases outlet drowsiness, fatigue
resistance
Prazosin (Minipress) Alpha-blocker, lowers 1 mg bid-tid PO Syncope, sedation, HA, urinary
outlet resistance and retention
DESD
 OTHER
MEDICAL
DRUG USE DOSAGE ROUTE SIDE EFFECTS ISSUES

Anticoagulants
Acetylsalicylic acid Permanently acetylates 50 to 325 mg qd PO Gastric ulcers, bleeding
(aspirin) platelets to stop
thrombosis
Heparin DVT prophylaxis, 5000 u SQ 12° or SQ, IV Increased bleeding, hematomas,
stroke prevention, up to 1.5 2.0 GI bleeding
PVD  control
Ticlopidine (Ticlid) Stroke prevention 250 mg bid PO Diarrhea, N/V, neutropenia,
thrombocytopenia, bleeding
Warfarin (Coumadin) DVT prophylaxis, Titrate to PT PO Increased bleeding, hematomas,
stroke prevention, GI bleeding
PVD

Gastrointestinal medications
Anticholinergics Antidiarrheal As per PO, IM N/V, dry mouth, lethargy,
(Lomotil) preparation constipation, retention
Bisacodyl (Dulcolax) Constipation, bowel 1 to 3 tabs qd PO, PR Diarrhea, nausea
cleaning prn
Chlordiazepoxide Benzodiazepine/ 1 to 2 capsules PO N/V, dry mouth, lethargy,
(Librax) anticholinergic PO tid-qid constipation, retention
combination, irritable
bowel syndrome (IBS)
Dicyclomine (Bentyl) Anticholinergic, IBS 20 to 40 mg qid PO, IM N/V, dry mouth, lethargy,
constipation, dyspnea
Docusates (Colace, Stool softener 100 mg tid PO Diarrhea, nausea
etc.)
Glycopyrrolate Anticholinergic, peptic 1 mg tid PO, IM N/V, dry mouth, lethargy,
(Robinul) ulcer (adjunctive constipation, retention
therapy)
Hyoscyamine (Levsin) Anticholinergic, 0.125 to 0.25 mg PO, IV, N/V, dry mouth, lethargy,
detrusor qid SL, IM constipation, retention
antispasmodic, IBS
Lactulose (Cephulac) Constipation, hepatic 30 mL tid-qid PO, PR Diarrhea, nausea
encephalopathy
Loperamide Antidiarrheal 2 mg q stool PO, IM Lethargy, constipation Maximum dose
(Imodium) 16 mg/ 24°
Metoclopramide Gastroparesis, 10 to 15 mg qid PO, IM Restlessness, drowsiness, dystonia,
(Reglan) stimulates GI tract, hypotension, diarrhea,
antiemetic incontinence
Paregoric (opioids/ Antidiarrheal 1 to 2 capsules q PO Constipation, N/V
diphenylate) 4-6 h
Propantheline Peptic ulcer (adjunctive 30 mg qhs PO N/V, dry mouth, lethargy,
(Probanthine) therapy) constipation, retention
Senna concentrate Constipation 1 to 2 tabs qhs PO Diarrhea, nausea
(Senokot)
Anti–Bone-Forming agents
Etidronate disodium Heterotopic ossification 20 mg/kg/day  PO Diarrhea, N/V
(Didronel) 2 wk, then
10 mg/kg/day
 10 wk