Community OT

"For many stroke survivors and their families, the real work of recovery begins after formal rehabilitation. One of  the most important tasks of a rehabilitation program is to help those involved to prepare for this stage of recovery" (Gresham et al, 1995, p143).

Ive never recieved therapy of any kind in my own home. And I havent spent any time as a patient in a hospital since I was 4. But if I had to choose between the two I would pick therapy in my own home. Community OT, Ive found as a student is intense. From the outside looking in, it looks simple. Before placement I always read up on what roles to expect and what kind of workload etc. I always go into each placement gearing to just jump in. Entering community therapy was tricky for me. Working relationships are different between client and therapist, theyre closer. Interdisciplinary relationships between colleagues was the norm. I observed far more emotional investment in this context that I did at my hospital placement. I was gobsmacked how my supervisor could turn simple chitchat and a cup of tea into a simple and straightforward home assessment, to then later look at the notes and see details that were incrediably expansive and I remember thinking, "how did she get all that information from what I just saw?"
Observation and interpersonal skills need to be very much honed in this context, among other things. In a qualitative study on the perception of community occupational therapy, participants with hemiplegia rated these things to have a positive affect: convenience, therapeutic environment, social contact and control (Stephenson & Wiles, 2000).

Although most individuals who have had a stroke improve in basic functional abilities such as self cares, activities in the home and walking, a lot still have limitations in getting back their their original social role. Again, from my teeny tiny scope of student experience I found that men were more unhappy with recovery in the home. When I asked them what they wanted I got, "I want to go back to work." Going back to work was a huge motivating factor that can spur both men and women on. As an occupational therapist (soon to be), that doing is integral to human life. It is what makes us - us. Our doing gives us our role, our efficacy, it affects our body both positively and negatively, it affects future generations as well. To some people their job is tied in with their wellbeing. Helping them get there sounds almost cliched yet a wonderful kind of occupational therapy.


References


Gresham, G. E., Duncan, P. E., Stason, W. B., Adams, H. P., Adelman, A. M., Alexander, D. N., Bishop, D. S., Diller, L., Donaldson, N. E. Granger, C. V., Holland, A. L., Kelly-Hayes, M., McDowell, F. H., Myers, L., Phipps, M. A., Roth, E. J., Siebens, H. C., Tarvin, G. A., & Trombly, C. A. (1995). Post stroke rehabilitation. Clinical Practice Guideline 16. (AHCPR Publication 95-0662). Rockville, MD: United States Agency for Health Care Policy and Research. 


Stephenson, S., & Wiles, R. (2000). Advantages and disadvantages of the home setting for therapy: views of patients and therapists. British Journal of Occupational Therapy, 63(2), 59-64.

Compensatory techniques

While on my 4th placement (neuro rehab) I often had clients who had hemiplegia or hemiparesis. After a couple of seperate sessions I had with two male clients (one a stroke survivor and the other had MS)  I noted both of their opinions toward dressing. They both had a high regard for indepedence, and told me of their multiple frustrations of tying their shoes in a way that was presentable, easy to administer strong during wear and easy to undo. This piqued my curiosity and I asked my supervisor if there were any resources to do with techniques for tying shoelaces one handed. There were a few pictorial examples which I showed to my clients and as a joint session the three of us trialled this version. I was the only one to achieve the paper version. This would not do. And I felt I really need to know a method really well in order to confidently assist them.

I found a video similar to this and asked permission to access youtube during work hours for my clients. I practiced the technique at home multiple times. I remember it took both men about 4 sessions to master this skill and they were really pleased with the results. So was I.
In society, shoelace tying is a milestone often associated with child development. We may not often look at a person's shoes, but to these men, the ability to independently tie their shoelaces was very important and was a skill that also encouraged hand and finger dexterity and tactile perception. It increased their motivation and self efficacy and gave me (the student) a teaching AND learning opportunity.

Hemiplegia and the shoulder

Shoulder dysfunction is a common post CVA complication. In the acute phase the hemiplegic upper limb is often flaccid, and unless properly positioned and handled during this crucial period, subluxation and joint malalignment can occur (Roy, Sands, & Hill, 1994).
Neurological recovery is most often very rapid in the first three months but continues throughout the first year and beyond. Because of its rapid pace, acute assessment and intervention is very important in predicting future outcomes with recovery.

Relevance to Occupational Therapy
 A patient is referred to occupational therapy because of deficits in the performance areas of activities of daily living (ADL's), work and leisure. The assessment and evaluation process identifies the underlying components (sensorimotor, cognitive, phychosocial) and contextual factos that limit functional performance (Van Dyck, 1999). In the case of the hemiplegic shoulder, only neuromuscular skeletal aspects are looked at in the acute phase. Upperlimb (shoulders, arms & hands) mobility has an important focus to the occupational therapist as it is essential for the basic completion of ADL's. While physiotherapists typically focus on the same performance components but usually in relation to the lower limbs and improving the patient/client's general energy levels. This is why occupational therapists and physiotherapists share such a close working relationship. Walking and improving one's physical endurance after a CVA as well as regaining functional skills are placed in high regard by the patients/client's as well as the health professional. When people ask me for a basic comparison of skill definition between the two groups that is what I usually give. I know that it is generally a stereotypical casting of two professions but it is based on my student experiences. I personally view physiotherapy as like a sibling to OT in the world of allied health.

As stated before, hemiplegia is a common side effect of a CVA. So is unilateral neglect. I will mention this briefly and how it affects recovery in the upper limb after a stroke. Unilateral neglect is a neuropsychological condition which occurs when damage (eg by a stroke) is done to the right cerebral hemisphere side of the brain. This causes a visual perceptual deficit where the person becomes unaware of that side of their body (Menon-Nair, Korner-Bitensky, Wood-Dauphinee & Robertson, 2006). To a client the left side of their body will not exist to them. For example they will bump into things, shave one side of their face (even if their looking in a mirror), or when asked to draw a clock may draw a circle then put all the numbers on one side. Add this side affect to hemiplegia and you've got a recipe where the most robust joint in the body (shoulder) is weak, or heavy or worse ignored due to impaired perception. Add in gravity which naturally pulls us towards the ground. If the shoulder joint is not protected or used during the acute period then deconditioning, pain, immobilization, contractures and subluxation occurs. Contactures are when the muscles and skin around the ground shorten, making full range of motion painful and near impossible. Subluxation is where the muscles and tendons protecting the shoulder girdle weaken against gravity and the humerus bone slowly and painfully dislocates. I saw this once on a client where their clavicle was raised and their arm was just hanging there. There was also this reasonably sized dent in their shoulder that was big enough to stick my finger in (though of course I didnt).

Heres an exemplar picture of a subluxed shoulder: 









So what does an OT do?

• (Re)Education: This starts the minute the client/patient is medically stable and carries through all the way to community services. Eg Involving the impaired side in tasks, educating and reinforcing medical staff on preventative positioning, slow upper body rolling, positioning of shoulder/arm while sitting, indorsing symmetrical standing. 

For a definition on the service of occupational therapy please click here


References


Menon-Nair, A., Korner-Bitensky, N., Wood-Dauphinee, S., & Robertson, E. (2006). Assessment of unilateral spatial neglect post stroke in Canadian acute care hospitals: are we neglecting neglect? Clinical Rehabilitation, 20, 623-634.

Roy, C., Sands, M. R., & Hill, L. D. (1994). Shoulder pain in acutely admitted hemiplegic's. Clinical Rehabilitation, 8(4), 334-40.

Van Dyck, W. R. (1999). Integrating treatment of the hemiplegic shoulder with self care. OT Practice, 31(1), 32-37. 


Picture of cat. Retrieved from http://thenonist.com/index.php/annex/permalink/hemispatial_neglect/ on 04/09/10. Site last updated on 04/09/10.

Hemiplegia & Acute Services

So this is going to be the first of a few posts I would like to make in relation to stroke recovery. Because the implications of a stroke are so varying and many, I have chosen to stick with hemiplegia because of its relevance to occupational therapy and because it is probably the most common disability (due to stroke) I have worked with as a student.

Hemiplegia is originally a Greek word, "hemi" meaning half and "plegia" meaning paralysis. It is a common side affect after a CVA where if a lesion occurs on the right side of the brain, the paralysis will be on the left side. And if the lesion is on the left side of the brain then the same for the right side of the body (namely the head, arm and leg of that side). Hemiplegia is similar to another condition called hemiparesis, but it is far more serious. Hemiparesis is usually characterized by one side of the body that is affected not by paralysis, but by a less severe state of weakness.

In acute services, care is focus on diagnosing the the cause, the type of CVA, and the site in order to prevent further lesion progression, secondary medical complications and the treatment of acute neurological symptoms (Trombly Latham & Radomski, 2008). Intervention in an intensive care unit is usually of the pharmacological and surgical kind. During my 3rd placement, I heard about a few drugs that are used for ischemic strokes: aspirin, heparin and warfarin. Out of curiosity I perused a nurse's drug guide and discovered these drugs are commonly used as a blood thinner which restores flow of oxygen and prevents further damage. Once a client/patient is in a stable condition they are then transferred to the acute neurological ward. In a qualitative study done in Australia to define the role of occupational therapy in acute neurology, participants stated that after head injuries, strokes were the most common diagnosis on their caseload (Griffin, 2002).
In relation to hemiplegia these outcomes in acute services are described as:

• Thorough assessment in order to a. make a timely and appropriate referral to rehabilitative and/or community services if necessary and b. establish the patient's baseline performance in order to plan & prioritise intervention, and to help MDT in organising appropriate discharge planning.
• Assisting the patient to reach highest level of independence (re self care & functional activities)
• Prevent/reduce occurrence of deformities that will have an impact on the aforementioned.
• Establish, maintain & improve functional upper limb movements
• Provide education to patient and/or family members on compensatory techniques and aides.

References 

Griffin, S. (2002). Occupational Therapy Practice in Acute Care Neurology and Orthopaedics. Journal of Allied Health, 31(1), 35-42.


Woodson, A. M. (2008). Stroke. In M. V. Radomski, & C. A. Latham Trombly. Occupational Therapy for Physical Dysfunction (pp1001-1041). Baltimore, MD: Lippincott Williams & Wilkins.