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BRIGHAM & WOMENS HOSPITAL Department of Rehabilitation Services Occupational Therapy

Standard of Care: Stroke


Occupational Therapy management of the patient with cerebral vascular accident (CVA)/ stroke. Case Type / Diagnosis: This standard of care includes any patient with hemorrhagic, embolic stroke or infarct admitted to BWH with resulting neurological impairment. Indications for Treatment: Impaired sensorimotor dysfunction associated with area of lesion affecting face, head/neck, upper extremity or trunk. Patient who demonstrates significant decline or below baseline functional status / activity of daily living (ADL) dysfunction associated with lesion. Patient who demonstrates cognitive, visual integration or perceptual processing dysfunction associated with lesion.

Contraindications / Precautions for Treatment: Activity orders should always be clarified with MD if not documented in OT order or activity section of MD orders Refer to the Neuroscience Precautions and Considerations for Rehabilitation Services handout. (See Appendix I) Examination: Medical History: previous medical/surgical history especially previous neurological events and treatment, baseline physical and cognitive status History of Present Illness: series of events leading to hospitalization, date of onset, date of admission (to OSH, BWH), neurologic diagnostic procedures, patient complaints/symptoms, neurology/neurosurgery exam and assessment, and current or planned treatment Medications: various pharmacological agents may include anticonvulsants, diuretics, antihypertensives, thrombolytics, anticoagulants, and pain controlling agents. Side effects are associated with above medications and may resemble neurological symptoms including confusion, sedation, movement disorders, weakness, dizziness, headache, and neuropathy. It is important to determine medical status and relationship to functional presentation to determine if behavior or altered status is medicated related.

Standard of Care: Stroke


Social History: includes prior functional level including DME, adaptive equipment or services; home environment and skills necessary to remain living in current environment; family/caregiver/community support; education/work/leisure history and status; personal, professional, social roles; patient/family goals; self and family/community/social/cultural expectations. Examination
This section is intended to capture the minimum data set and identify specific circumstance(s) that might require additional tests and measures.

Motor skills (physical): Posture Mobility Coordination Strength and effort Energy Process skills (cognitive): Energy Knowledge Temporal organization Organizing space and objects Adaptation Interaction skills (communication): Physicality Information exchange Relations Evaluation / Assessment: Establish Diagnosis and Need for Skilled Services A patient with neurological symptoms associated with a brain lesion resulting in impairments or dysfunction altering his or her baseline functional status will benefit from a skilled occupational therapy assessment and intervention.

Standard of Care: Stroke


Problem List: Potential impairments may include but are not limited to the following: Affective, Cognitive, Perceptual Dysfunction Associated impairments: level of consciousness, orientation, sleep, temperament/personality, energy/drive, attention, memory, visuospatial integration, thought, mental language, sequencing, calculation, self/time experience Sensory Dysfunction and Pain Associated impairments: seeing, hearing, vestibular integration, proprioception, touch, temperature, pain Neuromusculoskeletal and Movement Related Dysfunction Associated impairments: joint mobility/stability, bone mobility, muscle power, muscle tone, muscle endurance, motor reflex, and involuntary movement Cardiovascular System Dysfunction Associated impairments: including altered BP, RR, HR, SaO2, and activity tolerance/fatigue level

Prognosis Predicted level of improvement post OT intervention is for the patient to return to maximal level of performance in areas of occupation and to resume performance patterns in appropriate environmental context within 1-12 months. Prognosis is highly dependent on the anatomical location and size of the lesion, neuro-recovery, co-morbidities, complications, secondary impairments, occupational context and activity demands. Goals Individual, specific, measurable, patient-directed goals with parameters and time frames are established to guide and reflect the effectiveness of intervention planning, as well as document patient progress. Goals reflect 1-6 week time frame and are designed to/may include: Maximize performance, participation in areas of occupation Maximize performance skills and patient factors to remedy/modify/prevent impairment Re-establish or modify performance patterns as result of disability Modify or promote context to maximize occupational performance

Standard of Care: Stroke


Age Specific Considerations Generally, the age range of all patients at BWH is 18-99+, although occasionally exceptions may apply. All normal physiological changes associated with aging are considered when devising treatment plans for the patient. See Geriatric Physical Therapy: A Clinical Approach, by Lewis and Bottomley for further details. All treatment plans are individualized based on the impairments and functional limitations found during the evaluation of the patient. The occupational therapist will consider all of the patients impairments, whether they are disease or age-based, and will provide a comprehensive assessment, prognosis and rehabilitation plan for each patient.

Treatment Planning / Interventions Established Pathway Established Protocol _X_ Yes, see attached. ___ Yes, see attached ___ No _X_ No

Interventions most commonly used for this case type/diagnosis.


This section is intended to capture the most commonly used interventions for this case type/diagnosis. It is not intended to be either inclusive or exclusive of appropriate interventions.

Remediation/restoration of performance skills, performance patterns and patient factors (body functions, body structures) when impairment results in declined functional performance. Modify/compensate/adapt context, activity demands and performance patterns for maximal occupational performance when the lesion results in patient factors that are not likely to change or performance skills that are not likely to improve. Prevent decline in performance skills, performance patterns, patient factors in a case of a small or uncomplicated lesion with good predicted outcome.

Frequency & Duration Frequency of treatment is dependent on the assessment and intensity required to achieve reasonable goals and activity level, minimize impairments and occupational dysfunction, and prevent further impairment and/or dysfunction. Duration of treatment is dependent on patient factors, participation level, and demands to produce the desired outcome for intervention.

Standard of Care: Stroke


Patient / family education Includes: Realistic expectations to restore impairment or dysfunction, as well as expected outcomes post rehab. Patient and family support/empathy for current condition Continuous instruction improving/enhancing occupational performance, patient satisfaction, adaptation, health and wellness, prevention of further impairment/dysfunction, and maximizing quality of life. Recommendations and referrals to other providers. Any member of the team may be consulted as patient needs arise. This team includes: Physical Therapy - LE weakness, immobility, gait training, LE orthosis needs Speech and Swallowing - language, swallowing dysfunction, aphasia Social Work - complex home situation, social issues Psychiatry/Neuropsychiatry - difficulty coping, h/o prior psychological dysfunction with new onset physical/cognitive impairments including executive dysfunction Care Coordination - discharge planning for maximal safety, continuity of care upon d/c to community/rehabilitation Re-evaluation / assessment Standard Time Frame: 10 days from completion of initial evaluation Other Possible Triggers: significant change in mental or medical status; significant motor or processing skill decline; s/p surgical procedure, interventional radiology or other invasive procedures; all OT goals met from last assessment or initial evaluation; no response to current OT intervention; or discharge to community/ rehabilitation. Discharge Planning Discharge planning occurs on an individual basis for each patient and is dependent on the patients medical, social, and functional needs at time of discharge. A coordinated effort is made among the entire team to plan the optimal setting for the safest possible discharge environment and continuation of treatment as needed. If the patient requires continued treatment in a structured setting, the likely disposition occurs to an extended care facility. This may include acute or sub-acute rehabilitation, skilled nursing facility, or assisted-living community. If the patient has met all inpatient goals set by the team, a home discharge is usually appropriate. If 24-hour assistance of a caretaker is required for a safe discharge, it is documented and clearly communicated to the family or caretaker providing the service. Depending on further skilled needs, a patient may discharge home without further services, with home OT services, with outpatient OT services, or recommended to a day program for adults with sensorimotor or cognitive impairments. 5

Standard of Care: Stroke


Bibliography / Reference List Lewis CB, Bottomley JM. Geriatric Physical Therapy: A Clinical Approach. E. Norwalk, CT: Prentice Hall, 1994. Malone, T. Physical and Occupational Therapy: Drug Implications for Practice. Philadelphia: Lippincott, William & Wilkins Publishers, 1989. Occupational Therapy Practice Framework: Domain and Process. American Journal of Occupational Therapy 56, 609-639. 2003. Stroke. National Institute of Neurological Disorders and Stroke. National Institutes of Health. Publication no. 99-2222. 1999. Umphred, DA. Neurological Rehabilitation. Boston: Mosby, 1995. Wall, N. Stroke Rehabilitation. In MK Logigian (ed), Adult Rehabilitation: A Team Approach for Therapists. Boston: Little, Brown and Company, 230-231.

N. Barrett, OTR/L Completed 8/03

2005, Department of Rehabilitation Services, Brigham & Womens Hospital, Boston, MA

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