Stroke Presentation 2023

Created and presented by Hannah Catterall (Level 5 Occupational Therapy student)

Start

case study of stroke patient using cmop-e

14 & 15 - References

13 - Timeline

1- Patient Overview

2- Diagnosis

3- Initial Assessment

4-8 CMOP-E Overview

12- Interventions

11- The OT Process

10- MDT

9- Quote

index

• Patient pseudonym = Mr. A

• 53 year old male

• Presenting complaint: sudden onset left sided weakness and facial droop on 53rd birthday

• CT scan showed 35mm area of high attenuation centred on the right basal ganglia, consistent with acute intraparenchymal haemorrhage

• Past medical history: nil of note

• No family history of stroke

Mr. A

statistics from american association of neurological surgeons (2023)

• Intraparenchymal haemorrhage is bleeding into the brain when a hematoma is formed within the brain parenchyma

• There is a wide variety of reasons due to which haemorrhage can occur including, but not limited to, hypertension, coagulopathy, infection, vasculitis, and trauma (Tenny et al 2023)

• This type of stroke accounts for 10-15% of all strokes associated with mortality (Rajashekar and Liang, 2023)
• More common in men
• More common in African and Asian people
• More common after 55 years of age

intraparenchymal haemorrhage

• stimulation to encourage return of sensation in left limbs

• lower limb exercises to strengthen weak muscles

• Mr a's own goal = to be able to walk and draw again

Goal Setting

• 0/5 (oxford scale) muscle power in left side

• no sensation in left upper or lower limbs

• unable to assess co-ordination in left side

• proprioception and vision ok

• mild sublaxation in left shoulder

• transfers at initial assessment = SARA STEDY with AO2

Initial Assessment

• The Canadian Model of Occupational Performance (CMOP) is based on a set of values and beliefs concerning occupation, person, environment, and client-centred practice (Hagedorn, 2001)

• The CMOP is an interactive model showing relationships between person, environment, and occupation (Townsend & Polatajko, 2007)

• CMOP-E goes one step further than CMOP, to explore occupational engagement

• The model is broken down into 3 main areas; person, environment and occupation

CMOP-E in Practice

• Affective - willingness to engage with medical staff, intermittently tearful = ? post-stroke emotionalism

• Cognitive - no significant decline in cognitive function, cognitive screening completed on day 2 with no obvious areas of concern

• Physical - considerable left sided weakness upon admission, left sided facial droop, no difficulties swallowing or with speech

Mr. A as a 'person'

• Physical environment - Mr. A mentioned he was overwhelmed with the noise and smells in hospital
• Social environment - Mr. A's wife, siblings, parents and friends visited him during hospital stay
• Cultural environment - not practising in religion, traditional family values, changes to daily routine
• Institutional environment - following the rules and timings of hospital care (e.g. mealtimes, rules regarding leaving the ward)

Mr. A and 'environment'

• Self-care - showering, dental care, laughing and joking, love and relationship with wife and wider family
• Productivity - role as breadwinner at home, earning money, paying mortgage and other bills, career as Architect
• Leisure - carpentry, drawing and designing, architecture, spending time with wife and family, going to the pub, walking pet dog, keeping fit

Mr. A and 'occupations'

• Mr A's motivation as a husband, breadwinner, architect, hobbyist

• Engagement is what makes occupations meaningful to individuals...

• What motivates a person to fulfil their occuaptions?

So... what is engagement?

The most recent NICE guidelines for Stroke management suggest that "A core multidisciplinary stroke rehabilitation team should comprise the following professionals with expertise in stroke rehabilitation: consultant physicians specialising in stroke, nurses, physiotherapists, occupational therapists, speech and language therapists, dietitians, clinical psychologists or clinical neuropsychologists, orthoptists, rehabilitation assistants and social workers" (NICE Guidelines for Stroke rehabilitation in adults, 2023).

• Speech & Language Therapists
• Therapy Assistants
• Occupational Therapists

• Stroke Consultants and Doctors
• Stroke Nurse and Nurses
• Health Care Assistants
• Physiotherapists

Multi Disciplinary Team involved in Mr. A's care

Goal setting during OT intervention may be enhanced by exploring clients' meaningful life experiences including past and current roles, responsibilities, and activities which are particularly meaningful to individual clients (Eschenfelder, 2009)

• Use of outcome measures
• Achieving goals set at evaluation stage
• Re-evaluation

• Evidence based interventions and therapy

The O.T. Process

• Initial assessment
• Goal setting
• Identifying deficits

+ ifo

Evaluation

Intervention

Outcomes

• Electrical Stimulation

• Upper limb exercises

• Theraputty

• AFO

Theory guides actions and helps therapists carry out their job better (Tupin & Iwama, 2011), and provides occupational therapists with the basis of knowledge for what they practice (Duncan et al., 2009)

Interventions used

13/11/2023

4 weeks

08/12/2023

Discharged home, with referral to Early Stroke Rehabilitation Team

Ongoing rehabilitation in Stroke Ward at MKUH

Stroke and admission to hospital

Step by step - Mr. A's rehab journey at MKUH

-American Association of Neurological Surgeons (2023) Intracerebral Haemorrhage [Online] Available from: https://www.aans.org/en/Patients/Neurosurgical-Conditions-and-Treatments/Intracerebral-Hemorrhage Duncan et. al (2009) Foundations for Practice in Occupational Therapy. Edinburgh: Elsevier. Eschenfelder, V.G., 2005. Shaping the goal setting process in OT: The role of meaningful occupation. Physical & Occupational Therapy In Geriatrics, 23(4), pp.67-81. Gross BA, Jankowitz BT, Friedlander RM. Cerebral Intraparenchymal Haemorrhage: A Review. JAMA. 2019;321(13):1295–1303 [Online] Available from: doi:10.1001/jama.2019.2413 National Institute for Health and Care Excellence (2023) Stroke Rehabilitation in Adults - NICE Guideline NG236 [Online] Available from: https://www.nice.org.uk/guidance/ng236 National Institute for Health and Care Excellence (2022) Stroke and transient ischaemic attack in over 16s: diagnosis and initial management - NICE Guideline NG128 [Online] Available from: https://www.nice.org.uk/guidance/ng128

References

Rajashekar D, Liang JW (2003) Intracerebral Haemorrhage (2023) [Online] Available from: https://www.ncbi.nlm.nih.gov/books/NBK553103 Tenny S, Thorell W. Intracranial Haemorrhage. [Updated 2023 Feb 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470242/ Townsend, E. A., & Polatajko, H. J. (2007). Enabling occupation II: Advancing an occupational therapy vision for health, well-being, & justice through occupation. Ottawa: CAOT Publications ACE. Turpin, Merrill. & Iwama, M. K. (2011) Using occupational therapy models in practice: a field guide. Edinburgh: Churchill Livingstone.

References continued