Impairments and Functional Limitations
ADL, IADL, productivity and leisure impairment
Impaired functional mobility
Hemiparesis or hemiplegia of the upper and lower extremities
Spasticity
Impaired postural control and balance
Impaired coordination
Limited activity tolerance and endurance
Impaired sensation
Central post-stroke pain
Language disorders (aphasia, dysarthria, dyspraxia)
Dysphasia
Visual and perceptual impairment
Cognitive impairment
Behavioral disorders (depression, lability, low frustration tolerance, impulsivity)
Bladder and bowel dysfunction
Potential secondary complications may include biomechanical shoulder pain (biceps tendonitis, rotator cuff pathology, adhesive capsulitis, complex regional pain syndrome), edema (upper and lower extremity), pressure ulcers, joint contractures, depression, DVT’s, aspiration pneumonia, seizures, fall risk

Assessments
Assessment of Motor and Process Skills
Chedoke-McMaster Stroke Assessment Scale
Modified Ashworth Scale of Spasticity
Stroke Impact Scale

Occupational Therapy Intervention
ADL, IADL, productivity and leisure training

• Safely incorporate affected extremity with all activities.
• Use compensatory techniques (task modification, one-handed techniques, hand-over-hand guiding, task segmentation, backward chaining).
• Recommend and/or provide adaptive equipment. Rocker knife, inner lip plates, holders for books or playing cards, stabilizing devices for activities that traditionally require two-handed performance (cutting vegetables, cleaning dentures), and keyboards adapted for one-handed computer use.
• Instruct in pacing and energy conservation strategies.

Train in safe and efficient functional mobility (sit-to-stand, bed mobility skills, transfers, standing, ambulation, and wheelchair mobility) during ADL and IADL tasks.

Provide functional posture and balance activities.

• Focus on stability, weight shifting, body awareness, trunk rotation & elongation.
• Have patient turn toward affected side when reaching.
• Set up room so the patient must physically move to their affected side.
• Provide reach-grasp-hold-release activities, in standing and sitting, with and without support.

Provide activities and exercises to uninvolved side to prevent loss of ROM and strength.

Restore function of the upper extremity. Use a variety of remedial approaches according to the needs of the patient.

• Provide early mobilization and positioning.
• Incorporate task-oriented/task specific training.
• Provide opportunities to use and move the arm throughout the day (use of mobile arm support, overhead suspension sling, functional splinting such as wrist cock-up, and dynamic finger extension splints).
• Provide modified constraint-induced movement therapy or constraint-induced movement therapy.
• Instruct an arm and hand strengthening exercise program.
• Cyclic NMES during functional movements and activity.
• Instruct in a functional dynamic orthoses (SaeboFlex, SaeboReach).
• Use cognitive strategies (mirror therapy, mental imagery/practice, action observation).
• Provide sensory re-education intervention.
  
  • Avoid increasing spasticity.
  • Encourage use of extremity in functional tasks.
  • Provide weight-bearing activities.
  • Provide sensory stimulation activities.
  • Teach compensatory techniques and safety measures for sensory deficits. Use vision to compensate for sensory loss. Test bath/dish water temperature using the intact extremity or a thermometer. Use a thermal regulation valve to lower water temperature. Avoid using heating pads on impaired extremities. Wear gloves to prevent frostbite. Avoid going barefoot. Wear sunscreen to prevent sunburn. Avoid cuts and burns in kitchen. Use intact hand to handle sharp kitchen utensils. Perform skin checks.
• Prevent or manage hand edema.
  
  • Teach active self-range of motion exercises in elevation.
  • Position hand in elevation
  • Use retrograde massage.
  • Use gentle grade 1-2 mobilizations for the hand and fingers.
  • Provide a compression garment.
• Manage spasticity.
  
  • Prevent contractures.
  • Provide PROM, SROM and stretching exercises.
  • Instruct in positioning in bed, chair and during mobility.
  • Select use of splinting to protect hand/wrist. Resting hand splint for flaccid to mild tone, spasticity splint for moderate to high tone. Reassess frequently and discontinue of there is no benefit.
  • Post-Botox injections, provide strengthening/FES to antagonists, stretching and splinting
• Prevent or manage shoulder pain.
  
  • Avoid overaggressive therapy and overhead pulleys.
  • Mobilize and strengthen the scapula.
  • Position arm with cubital fossa facing up, 45º shoulder abduction and comfortable shoulder external rotation.
  • Provide firm support devices such as lap trays and arm troughs.
  • Range of motion exercises should not move the shoulder beyond 90°of flexion and abduction unless there is upward rotation of the scapula and external rotation of the humeral head.li>
  • o Manage acquired orthopedic conditions (biceps tendonitis, impingement syndrome, adhesive capsulitis, rotator cuff pathologies, CRPS).
  • Use functional electrical stimulation (FES) for shoulder subluxation.

Instruct patient and caregivers in care of the affected extremity.

• Prevent and control of edema.
• Teach passive ROM exercises.
• Teach self-ROM exercises.
• Protect and support the affected arm during bed mobility, transfers and ambulation using slings, a pocket, or hand hold and during wheelchair use by using a hemi tray or arm trough.
• Teach proper positioning in bed, chair and wheelchair.
• Instruct in care and use of positioning splints.

Teach compensatory strategies for perceptual deficits.

Provide cognitive retraining and train in the use of compensatory strategies.

Provide education about fall risk and prevention strategies.

Community reintegration

• Complete a comprehensive, performance-based home assessment. Recommend and/or provide modifications, adaptive equipment and/or assistive technology.
• Encourage leisure and social participation.
• Address ability to drive safely. Provide referral to driving rehab specialist and/or explore alternative transportation options.
• Recommend vocational rehabilitation strategies to assist with return to work if appropriate.

Teach strategies to incorporate wellness and health management routines into daily activities.

Educate patient and caregivers about stroke, the availability of community resources. and support groups. Provide educational materials about stress management, coping strategies, and occupational balance.

Patient and Caregiver Education Handouts
Edema (Swelling) Control of the Arm(s)
Edema (Swelling) Control of the Leg(s)
In and Out of Bed - Toward Your Weaker Left Side
In and Out of Bed - Toward Your Weaker Right Side
Position in Bed - Left Side Weakness
Position in Bed - Right Side Weakness
Position Your Arm - Left Side Weakness
Position Your Arm - Right Side Weakness
Protect the Arm - Left Side Weakness
Protect the Arm - Right Side Weakness
Splint/Brace Instructions
Stress Management
Tips to Conserve Energy
Using a Front Wheel Walker (2 wheels)
Wheelchair Safety

Patient and Caregiver Exercise Handouts
Balance Exercises - Sitting and Standing
Fine Motor Strengthening and Coordination Activities
Gross Motor Tasks
Level 1 Activities - Help Your Weaker Arm Move
Level 2 Activities - Use Your Weaker Arm to Passively Hold
Level 3 Activities - Use Your Weaker Arm to Actively Move and Hold
Level 4 Activities - Use Your Weaker Arm with Gross Motor
Level 5 Activities - Use Your Weaker Arm with Fine Motor
Passive Range of Motion - One Side Weakness
Posture Exercises
Putty Exercises
Scapular Mobility and Strength Exercises
Self Range of Motion
Upper Body Active Range of Motion
Upper Body Exercises - Dumbbells
Upper Body Exercises - Holding a Ball
Upper Body Strength Activities
Use Your Arm to Actively Move and Hold
Use Your Arm to Hold Passively
Use Your Arm with Assisted Guiding
Use Your Arm with Gross Motor Activities
Use Your Arm with Self-Guiding
Weight Bearing Exercises

Additional Treatment Guides
Activities of Daily Living
Apraxia
Balance
Cognition
Depression
Fall Risk Assessment and Prevention
Functional Mobility
Handwriting
Health Management
Home Safety and Modification
Therapeutic Exercise
Visual Skills
Wheelchair Seating, Positioning, and Mobility