4 Strategies for OT Management of Stroke in Acute Care

Every year, more than 795,000 people experience a stroke in the United States (cdc.gov, 2017). Therefore the chances are high that you will encounter one of these individuals in your occupational therapy practice, no matter what practice setting you work in.

For occupational therapists working in acute care, working with someone who has experienced a stroke is almost a guarantee. As we all know, no two strokes are alike. However, there are common deficits we can be prepared to address in our acute care practice that will set the client up for continued success during their rehabilitation journey.

Here are 4 strategies acute care OTs and COTAs can use when working with a client who has experienced a stroke:

1. Ensure that there are plans for upper extremity management.

This may include taping, use of a sling or splint, or the use of a support on the wheelchair to manage the affected side to avoid pain and prevent subluxation. This video from Legacy Health demonstrates kinesiotaping as part of a stroke rehab program.

Create signage and wearing schedules to get as many caregivers on board as possible early on in stroke recovery. Pictures are a great way to ensure that slings and splints are put on and stored correctly. Hang them in plain sight for maximum adherence.

Consider a neurologic sling like the Giv Mohr to promote proper upper extremity positioning and arm swing. Initially, using a sling for safety during transfers is important and gets a patient and family into a routine of long term use. Using a specialized neuro sling promotes proper UE alignment and prevents the limitations that may occur when using a traditional orthopedic sling. Work with a patient on donning the sling independently or having them instruct family and caregivers.

2. Encourage mobilization of the UE early and often, teaching patient and caregivers strategies for UE involvement.

Assess a patient’s level of function using FUEL Levels to determine how a patient can functionally involve their affected side (Van Lew et al, 2015). Each session should involve opportunities to activate and involve the affected side. Once the patient’s FUEL level is determined, there are several ideas for how to incorporate the hand and arm functionally no matter the level of deficit.

Encouraging a patient to attend to the affected arm is important to elicit as much activation as possible in the early days post-stroke. Simple activities such as having the patient use their own active motion to reposition the affected arm, using the affected side to lock wheelchair brakes, open doors and weight bear on a sturdy surface (such as a countertop) are all ways to encourage activation and attention early on.

3. Set the patient up for (visual) success

Do a brief vision screen if you suspect visual challenges after stroke to start to discover a patient’s deficits. Assessing visual fields, convergence and oculomotor abilities can assist in identifying a visual issue that can be addressed right away from a functional standpoint.

If visual issues are present, particularly inattention behaviors, position the patient on the side of the room that forces them to attend to the side of inattention. Ask family, friends, and the interdisciplinary team to stand on the patient’s affected side to encourage them to attend. This approach may seem counterintuitive, and the team may need some education to help the patient learn to address their entire environment, which is necessary for safety.

If the patient has a visual field cut, set up the room to encourage scanning into the compromised field. Some ideas include stickers on the four corners of the door to encourage scanning for mobility, cues on the mirror or in workspace such as a bedside table to encourage the patient to find all boundaries of a surface.

Strategies like highlighting the left or right side of reading materials can start to teach patients to scan until they see the boundary. This can be helpful for reading materials such as food menus, newspapers, and discharge instructions.

4. Address deficits in functional cognition

Cognition can and should be addressed in everyday task performance. As occupational therapists, we are skilled in performance-based cognitive assessment. Cognitive considerations for OTs include managing medication, ensuring home safety, cooking, maintaining healthy lifestyle behaviors, and facilitating positive social interactions (AOTA, 2019) as well as the problem-solving and executive function skills that occur during basic ADL activity.

Implement strategies that can prevent harmful events (such as falls) from occurring for your neurologically-impaired client. Cognitive levels post-stroke can vary widely, and each client will require individual strategies based on their level of cognitive impairment.

Enable compensatory strategies that can improve function while the brain is healing. Your client may not need to use them long term, but try to focus on safety and success in the short-term acute care environment.

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Because every stroke is different, it can feel overwhelming where to start when you have a new stroke client on your OT caseload. But, if you keep these four areas in mind — UE management planning, early mobilization of the UE, functional vision and functional cognition — you can be confident that you are off to the right start using these strategies for your stroke clients, in acute care and beyond.

References:

AOTA 2019: https://www.aota.org/Advocacy-Policy/Federal-Reg-Affairs/Medicare/Guidance/role-OT-assessing-functional-cognition.aspx
CDC 2017: https://www.cdc.gov/stroke/facts.htm
Van Lew et al 2015: https://ajot.aota.org/article.aspx?articleid=2465090

We want to give a huge thanks to guest authors Lauren Sheehan, OTD, OTR/L and Melissa Kimmerling, EdD, MOT, OTR/L for writing this article. A bit about the authors:

Lauren Sheehan, OTD, OTR/L, has been an occupational therapist for 10 years in a neuro-rehabilitation clinical setting, working with individuals with neurologic injuries and illnesses. She also spent a handful of years in clinic administration and director of rehab roles for small community hospitals as well as facilities in large, urban areas. She has spent the last two years of her career working for rehabilitation technology companies to assist with product and process development for products that serve stroke patients. She’s currently the Field Clinical Manager for NeuroLutions, a device company committed to developing quality products for patients through innovation such as BCI (Brain Computer Interface) stroke rehabilitation technology. She has a passion for supporting individuals with neurologic injury and illness through greater accessibility to technologies that can be used at home to increase function and improve quality of life. Outside of work, Lauren enjoys singing, cycling, and traveling.

Melissa Kimmerling, EdD, MOT, OTR/L, is the Program Director for the Master in Occupational Therapy Program at Nebraska Methodist College in Omaha, Nebraska. She has worked at the College for four years, spending three years in full time teaching with another Masters program before that. Prior to her transition to academia, Melissa worked full time in acute care and post-acute rehabilitation for four years. She currently maintains an active clinical practice for a local traveling company providing services in home health and wheelchair seating and positioning. Melissa has a passion for advocacy and increasing access to therapy services for all populations. In her free time, Melissa enjoys crafting with her best friend while their little ones play.