Theoretical Basis-Occupational therapy and stroke

Theoretical Basis
Occupational Therapy and Stroke
1/31/2023 Anan Ghabbash 1

Conceptual models of practice
• The Model of Human Occupation (MOHO).
• The Canadian Model of Occupational
Performance and Engagement (CMOP-E).
• The Australian Occupational Performance
Model (OPM(A)).
• Activities Therapy
• The Kawa (River) Model

Frames of Reference.
• Client- Centered Frame of Reference
• Biomechanical Frame of Reference
• Rehabilitative Frame of Reference
• Motor Control Frame of Reference
• Behavioral Frame of Reference
• Cognitive Frame of Reference
• Psychodynamic Frame of Reference
• Cognitive Perceptual Frame of Reference

Intervention approaches
• Restorative approach
(Remedial Approach)
• Adaptive
(compensatory/functional)
Approach
• Cognitive Rehabilitation
Approach
• Normal Movement
(Bobath-based approach)
• Proprioceptive
Neuromuscular Facilitation
(PNF)
• Rood approach
• Movement science
• Constraint-induced
movement therapy
approach
• Bilateral arm
training/isokinematic
training approach
• Mental imagery approach
• Electromyography (bio)
feedback.
• Functional electrical
stimulation.
• Robotics.

Client-Centred Frame of Reference
is a humanistic approach which originated with
psychotherapist Carl Rogers and was further developed by
occupational therapists in Canada (Canadian Association of
Occupational Therapists, 2002; Townsend and Polatajko,
2007).
Key concepts of the approach include:
• Client autonomy and right to informed choice;
• Partnership between client and therapist to work together
to negotiate therapy
• Goals and processes;
• Responsibility of the client for his/her own health and
ethical responsibility of the therapist to ensure no harm
• Empowering and enabling clients to achieve their
occupational goals;

Client- Centred Frame of Reference
continued
• Understanding clients individual contexts through respect
and listening;
• Accessibility of services to meet clients needs; and respect
for diversity.
• It recognizes that ‘the client’ might also be the family,
carers or institution in addition to the person referred.
• Practical strategies for application throughout the OT
process have been outlined (Canadian Association of
Occupational Therapists, 2002; Parker in Duncan, 2006: p.
193; Townsend and Polatajko, 2007).
• Motivational interviewing is a behaviour change method
that falls under this frame of reference (Miller and Rollnick,
2002).

Biomechanical Frame of Reference
• is a bottom-up frame of reference, useful for understanding
occupational performance capacity in more detail.
• It considers the anatomy and physiology and mechanics of human
movement (kinesiology) focusing on musculoskeletal,
neuromuscular and cardiorespiratory systems.
• Occupational therapy approaches that fit within this frame of
reference include graded activities to improve movement strength,
endurance, range of motion and sensation, work hardening,
energy conservation, ergonomics, assistive devices, splinting and
joint protection.
• Thus approaches to prevent deterioration, restore function or
compensate for limitations are significant here.
• Nevertheless, the primary assessment and outcome for
occupational therapy should always be in the context of meaningful
occupation.

Rehabilitative Frame of Reference
• draws on medical, physical and social sciences.
• It considers rehabilitation as the process of
helping patients competently fulfil daily activities
and social roles and focuses on therapists
teaching, patients learning adaptive
• (compensatory/functional) methods, assistive
equipment and environmental modifications to
restore function when underlying impairments
cannot be remediated and successful
• rehabilitation is dependent on motivation and
cognitive skills.

Motor Control Frame of Reference
• considers the relationship between the central
nervous system in relation to motor function
and reacquisition of coordinated skilled
movement but recognizes the influence of
other systems (sensory input and cognitive
processing),
• environmental context and learning principles
(such as attention, feedback, active
participation and goal-directed movement).

Motor Control Frame of Reference
continued
• In comparison to a biomechanical frame of reference,
emphasis is on muscle tone, reflexes and movement patterns.
• Many restorative (remedial) intervention approaches fall
under this heading, including
• Bobath’s neurodevelopmental(normal movement)approach,
• Carr and Shepherd’s movement science/motor
• relearning,
• Rood, Brunnstrom’s Movement Therapy,
• Proprioceptive Neuromuscular Facilitation,
• Mental imagery and
• Constraint-Induced Movement Therapy

Behavioural Frame of Reference
• considers learning principles arising from stimulus response
models such as Pavlov’s classical condition and Skinner’s
operant conditioning where behavioural responses to
stimuli or triggers can be modified through exposure and
manipulation of the consequences.
• This frame of reference is useful for
• behaviour modification such as
• desensitisation or
• Reduction of anxiety-related symptoms as well as for
• New learning principles such as
• Repetition and
• Positive feedback.

Cognitive Frame of Reference
• originated in psychiatry and psychoanalytical
theory with the work of Aaron Beck.
• This frame of reference examines the links
between the patients’ automatic thinking, their
behaviour and emotional response.
• Dysfunctional beliefs, values and thinking may be
distorted, unrealistic and unhelpful.
• These are explored and challenged to change
patients’ perceptions and emotional response to
events.

continued
• Cognitive-behavioural therapy (CBT) links the cognitive and
behavioural frames of reference together.
• It utilises a problem-focused approach to explore patients’
underlying thoughts, beliefs and physiological responses
associated with specific triggers and the consequences of
dysfunctional behavioural responses that might maintain
these.
• Dysfunctional thinking and beliefs in response to triggers
are then challenged to change patient’s perspectives and
more adaptive (compensatory/functional) behaviour can be
tested out in safe environments such as role play, facilitated
groups and graded activity scheduling.

continued
• Adaptive (compensatory/functional) behaviour is
reinforced through patients’ feelings of self-efficacy,
consequences that disprove dysfunctional beliefs and
therapist feedback, which is recorded in activity diaries.
• Techniques can be deceptively simple and specialist
training is required. Considering its inherent overlap with
clinical psychology Duncan (2006)
• further cautions that a cognitive-behavioural frame of
reference should be used in conjunction with an
occupation-focussed conceptual model of practice to
maintain professional role and identity and to enhance the
therapeutic potential of the patient–therapist partnership.

continued
• CBT has been successfully used in mental health
for the intervention of anxiety, depression,
personality disorders and substance abuse. It has
also been used for chronic pain and chronic
fatigue syndrome (Duncan, 2006).
• Although CBT appears useful for stroke patients
and is probably employed to some degree during
rehabilitation, further research is required on the
effectiveness of CBT strategies with stroke
patients (Lincoln and Flannaghan, 2003).

Psychodynamic Frame of Reference
• originated with Sigmund Freud’s controversial theories
but has been developed to focus on understanding the
relationship between past experience and present
difficulties.
• It highlights links between unconscious motivations
and emotions which are operationalised through
interpersonal interaction, behaviour and occupation.
• For example, mechanisms such as repression, denial,
projection, reaction formation, intellectualisation,
rationalisation, regression, sublimation and
compensation protect the psyche against anxiety
arising from unconscious internal conflict.

Psychodynamic Frame of Reference
continued
• These internal conflicts and underlying
emotions and motivations can be
therapeutically explored and symbolically
resolved through creative (projective
activities, meaningful occupations, reflection,
group work processes and therapeutic
relationships to achieve a sense of wellness
(Blair and Daniel in Duncan, 2006: p. 233).

Cognitive Perceptual Frame of
Reference
• draws on neuroscience and neuropsychology and
focuses on the components and interaction of
cognitive and perceptual skills that impact on
occupational performance.
• Treatment approaches can be categorised into
remedial/bottom-up/skills training or
• adaptive/top-down/strategy training approaches
• recognising the brain’s capacity but limited potential to
repair following brain injury (Feaver and Edmans in
Duncan, 2006: p. 277; Kielhofner, 2008).
• A wide range of cognitive and perceptual tools and
treatment strategies fall under this umbrella.

Cognitive Perceptual Frame of
Reference continued
• In addition to the above theoretical constructs
which assist in guiding occupational therapy
practice, the emerging theories of neuroplasticity
are utilised in current neurological practice.
• A knowledge of neuroplasticity can assist the
occupational therapist in selecting an
intervention/approach for the individual patient
and will assist in clinical reasoning and
justification of the intervention administered.

Neuroplasticity
• Despite recognition that post-injury experience could result in adaptive or
maladaptive responses, historically it was believed that neurones in the
adult mammal’s central nervous system (CNS) were ‘hard wired’ like an
electrical circuit that could not regenerate or repair after injury (Gage,
2002).
• Thus, recovery in neurorehabilitation focussed on strategies that
discouraged maladaptive behaviour and focussed on adaptive functional
behaviour and goal achievement (Cohen, 1999).
• This was supported by evidence that neurorehabilitation improved patient
outcomes (Intercollegiate Stroke Working Party (ISWP), 2008).
• However, more recent advances in neuroscience and functional imaging
have demonstrated evidence of neuroplasticity – the brain’s considerable
capacity for neural reorganisation (Nudo and Friel, 1999).

Neuroplasticity continued
• Consequently, momentum has escalated for therapists
to understand the scientific basis of neurorehabilitation
to capitalise on this to enhance true recovery of
function following stroke (Aisen, 1999; Mateer and
Kerns, 2000; Pomeroy and Tallis, 2002b).
• From conception to death, neuroplastic changes occur.
These can be associated with normal responses to
experiences such as maturation, development and
learning (Hallet, 1995; Kotulak, 1998).
• Therefore, cells are constantly adapting to the
challenges of the internal and externa environment
(Stephenson, 1996).

Intervention approaches
• Despite evidence of neuroplasticity, predicting recovery
potentials remains challenging.
• Some combinations of symptoms will be more amenable to
true recovery while other combinations will have limited
capacity, requiring an adaptive (compensatory/functional)
approach to learn to adapt to activity limitations.
• Thus, occupational therapists will always need both
restorative and adaptive treatment approaches as
components of neurorehabilitation.
• Further, some patients may just want to achieve
independence as quickly as possible and ‘may not be overly
concerned about how they perform these activities’
(Lennon et al., 2001: p. 260).

Restorative approach (remedial approach)
• The restorative (remedial) approach relies upon theories of
neuroplasticity and the ability of the brain to reorganise itself
(Nirkko et al., 1997; Nudo, 1998; Marshall et al., 2000).
• Neurophysiological approaches such as normal movement and
motor relearning are included within the restorative (remedial)
approach.
• the therapist provides controlled visual, auditory, vestibular, tactile,
proprioceptive and kinaesthetic stimulation to promote normal CNS
processing of sensory information.
• Therefore, normal sensory processing should help the patient make
normal perceptual motor responses required for performance of
functional tasks.
• This approach therefore aims to reduce the impairment to
subsequently improve activity and participation.

Restorative approach (remedial approach) continued
• Neistadt (1990) also classes ‘transfer of training’ under
restorative (remedial) approaches.
• Activities, such as puzzles and pegboards, provide practice
in perceptual skills.
• It is implicit within this approach that these tasks are
appropriately graded to challenge the patient and
encourage the brain to adaptively reorganise itself for
successful behaviours.
• People with cognitive impairments tend not to be able to
transfer learned skills, and although some minor, short-
term effects may be seen, the long-term impact and lack of
transferrable skills tend to make this a time-intensive and
less-effective approach for people with cognitive problems.
• Restoration of impairments tends to be more successful for
people with motor impairments alone.

Adaptive (compensatory/functional)
approach continued
• The adaptive (compensatory/functional)
approach focuses on repetition of particular
skills which are normally associated with
activities of daily living (ADL).
• It is based on the belief that man is functional
animal and his ability to do so is essential for
his well-being (Turner et al., 1996).

approach continued
• Adaptive (compensatory/functional) approaches
are traditionally used when restoration is unlikely
and assumes that certain functions will not
recover (Zoltan, 2007).
• Compensation for loss of function is achieved by
changing the activity, environment or patient
behaviour by using external assistance, modifying
the task or changing the goal or by practice until
the task becomes easier in a variety of
environments.

approach continued
• The advantages of this approach are that it is patient-centred,
easy to explain, uses problem solving, meets short-term
needs and gives quick results.
• The disadvantages of this approach are that the therapist may
not consider a range of options open to the patient and may
succumb to organisational pressures for quick functional
results at the expense of maximizing true recovery potential
for the patient, leading the therapist to become prescriptive
in a ‘one size fits all’ method.
• It can lead to negativity by the patient who is asked to
recognise a permanent condition and its limitations without
any attempt to remediate the underlying skills.

Cognitive rehabilitation approach
• Cognitive rehabilitation therapy is a systematic
and functionally oriented approach to improve
cognitive functioning either by restoring cognitive
processing skills that are impaired and/or helping
the patient learn new ways to compensate for the
impairment(s) (Malia and Brannagan, 2005;
Halligan and Wade, 2007).
• Cognitive rehabilitation is very similar to physical
rehabilitation but usually involves all of the
following:

continued
• Assessment – to determine the specific impairments involved and
their functional impact on occupational performance.
• Education – to develop patients’ and others’ awareness of cognitive
strengths and weaknesses and how they influence occupational
performance. Without developing awareness and self-monitoring
skills, the patient will not engage in therapy and will not be able to
independently implement treatment strategies on their own – the
ultimate aim of rehabilitation!
• Process training – to restore the impaired cognitive skill through
targeted practice and retraining of the skill itself. This is usually
completed out of context in pen and paper tasks to enable patients
to consciously focus on the targeted skill and may be given as
homework activities.

continued
• Strategy training – to learn how to use external and internal
adaptive strategies to overcome the impaired skill. This
involves targeted rehearsal of the taught strategy in a variety
of contexts.
• Functional activities training – to consciously apply strategies
learnt in process and strategy training in everyday life.
• Evaluation – is required at impairment, activity and
participation levels to determine the effectiveness of
intervention.
• (Malia and Brannagan, 2005; Halligan and Wade, 2007)
• Although in physical rehabilitation simultaneous use of both
restorative and adaptive approaches is used cautiously, in
cognitive rehabilitation use of both process and strategy
training simultaneously is encouraged.

continued
• Cognitive interventions must be tailored to the
individual and are more effective if interventions
are collaboratively worked between patient, carer
and therapist.
• The goals should be mutually set and
functionally relevant to the individual. Therapists
should also use eclectic and multiple approaches
to address the effect and emotional components
of cognitive loss (Halligan and Wade, 2007).

continued
• Although research population heterogeneity, treatment variability and use
of broad outcome measures have limited conclusive recommendations for
cognitive rehabilitation to date, Rohling et al.’s (2009)
• meta-analysis suggests a few core evidence-based principles for cognitive
rehabilitation, including starting treatment early, older patients (≥55 years
old) can still benefit from cognitive rehabilitation and targeted
interventions (particularly for attention and visual spatial neglect) are
more effective than generalised interventions.
• The reader is referred to key documents regarding details of specific
evidence supporting the effectiveness of cognitive-perceptual
rehabilitation of attention, memory, visuospatial perception, neglect,
executive function and praxis skills (Cicerone et al., 2000; Lincol et al.,
2000; Cappa et al., 2005; Cicerone et al., 2005; Bowen and Lincoln, 2007;
das Nair and Lincoln, 2007; ISWP, 2008; West et al., 2008; Rohling et al.,
2009).

Normal movement (Bobath-based
approach)
• The normal movement approach is the most
commonly used restorative approach to physical
neurorehabilitation in the UK (Walker et al., 2000;
Lennon, 2003).
• It is also known as Bobath o neurodevelopmental
treatment (NDT) as it was originally founded by
the Bobaths in the 1970s and based on
neurodevelopmental reflex-hierarchical theory
that hypothesised spasticity as a product of
overactive reflexes.

approach) continued
• Originally, treatment utilized reflex inhibiting patterns and
progressed patients through a neurodevelopmental sequence
(Bobath, 1990).
• However, Bobath treatment techniques have changed since the last
Bobath publication in the 1990s.
• The current ‘Bobath Concept’ of normal movement has evolved to
incorporate present-day knowledge and a systems theory of motor
control, motor learning, neural and muscle plasticity and
biomechanics (Raine, 2006, 2007; .
• International Bobath Instructors Training Association (IBITA), 2008).
However, there has been much debate in the literature regarding
the validity and reliability of this evolution which has confounded
evidence-based practice (Langhammer, 2001; Brock et al., 2002;
Mayston, 2008).

approach) continued
• The Normal movement approach is a problem-solving or clinical
reasoning process rather than a series of treatments or techniques,
generally requiring a postgraduate level of training to enable more
efficient movement patterns (IBITA, 2008).
• It is based on the assumption that ‘too much effort by the patient
and overuse of the unaffected side reinforce abnormal tone and
movement of the affected side’ (Lennon, 2001: p. 925).
• Abnormal movement leads to inaccuracy, effort, fatigue,
compensatory movements, muscle tension, overuse, pain, injury
and ultimately task avoidance and dependency.
• Thus, the approach aims to improve disturbances in function,
movement and postural control following a lesion in the CNS by
relearning more efficient movement through experience, with
active participation of the patient, which is ultimately goal directed
(Lennon, 1996; Raine, 2007).

Bobath-based approach Key terms
• Base of support: This refers to the supporting
surface, the body part in contact with it and the
relationship between the two. In order to accept
the base of support, a person needs movement
to relate to it and use it as a reference point.
• Centre of gravity: A constant downward force
with which man must develop the ability to
interact, in order to move selectively. It is
constant and the effect is felt if displaced.
• Postural set: An alignment of key points in
relation to an accepted base of support.

continue
• Balance reactions:
• (a) Equilibrium reactions: Automatic adaptations of postural tone in
response to gravity and displacement.
• (b) Righting reactions: Sequences of selective movements in
patterns in response to displacement. Functionally they allowthe
loss regaining of midline through trunk righting, head of righting,
stepping reactions and protective extension of the upper limbs.
• Normal postural tone: A continuous partial state of muscle
contraction which is high enough to resist gravity and low enough
to allow selective movement to take place.
• Associated reactions: Pathological increases in tone, in response to
a stimulus, which are beyond the person’s level of inhibitory
control. They reflect a loss of reciprocal innervation.

continue
• Key points: Areas of the body, such as the
head, thorax, pelvis, shoulders, hips, hands
and feet, where postural tone can most easily
be changed. Each key point provides a large
source of proprioceptive input to the CNS.
Key points are used to:
• (a) Facilitate and control movements; and
• (b) Alter postural tone.

Bobath-based approach
Assessment/evaluation
• Assessment involves observation and analysis of movement of
deviation from normal movement patterns and identification of
compensatory strategies.
• In particular, the influence of gravity, relationship with base of
support, alignment and relationship of key points to each other,
the ability to move within a posture, transfer weight and to create
another posture, initiation and development of a pattern of
movement (selectivity).
• In addition, the potential for change is explored through use of
handling skills to influence tone, alignment, fixation, stiffness, etc.,
• as well as use of movement experience, repetition, speed, voice
and environment.
• As a problem-solving approach, assessment, hypothesis formation,
treatment and evaluation are a constant process.

Bobath-based approach
Techniques/methods
• The therapist uses afferent inputs, particularly
proprioceptive handling skills of key points of control, to
influence muscle tone and activity, correct alignment, block
abnormal movements and facilitate more normal selective
movement patterns for goal-directed tasks in which the
patient is an active participant (Lennon, 2001; IBITA, 2008).
• In addition, therapists use experience of movement,
repetition, speed, voice, environmental manipulation and
feedback (British Bobath Tutors Association, 2003).
• Bobath discourages unsupervised patient practice and/or
use of aids that risk adopting abnormal movement
patterns; thus, consistent 24-hour handling is encouraged
(Lennon, 1996; van Vliet et al., 2001).

Bobath : Use of normal movement in
improving functional ability
• Preparation
Good knowledge/awareness of normal
movement is necessary to analyse deviation
from the normal.
• Think about how you do daily activities –
What is the normal sequence of movements?
• Prior to session take time to plan and analyse
intervention strategy.

Bobath Activity analysis
• When carrying out in-depth activity analysis of normal
movement components of a functional task, consider
the following:
• Alignment and symmetry of key points.
• Ability to move in/out of postures.
• Acceptance of base of support.
• Balance and ability to transfer weight as opposed to
shifting centre of gravity over the base of support.
• Ability to adopt anticipatory posture requirements, for
example, to alter trunk and pelvic alignment to move a
leg or position the hand in relation to the object in
preparation for grasp.

• Identify limitations from sensorimotor,
neuromuscular and musculoskeletal systems, for
example, proximal stability, pain, oedema,
restricted range of motion, tone, sensation,
proprioception, strength, hand function.
• Consider the influence of gravity, objects and the
environment on movements.
• Consider the cognitive-perceptual demands of
the task, for example, understanding goal,
motivation, concentration, memory.
• Positioning.

• Is the movement normal in pattern – efficient,
selective, effortless and goal directed?
• Identify any abnormal/effortful movement
patterns.
– Where is movement initiated from – proximally
versus distally?
– Where does movement appear to be blocked?
– Where does the patient gain their stability from?
– Where is the effort/instability coming from?

Bobath ADL Treatment strategies
• During treatment, normalise tone before you start and
monitor as you progress. Some preparation may be
needed prior to the ADL.
Treatment strategies include the following:
• Negotiate occupational goals so treatment is
motivating, meaningful and goal directed.
• Altering postural alignment.
• Changing the base of support (increase BOS to reduce
hypertonicity, and decrease BOS to increase tone if
hypotonic). Consider standing, sitting, lying, position of
feet, using arms to prop, backrests.

• Modify the environment, for example, firmness of
supporting surface, chair height/design, object
orientation and placement.
• Encourage self-initiation of movement and self-
monitoring of abnormal tone/ movement.
• Facilitate key points but do not overhandle – patient
should be active in movement rather than passive.
• Grade activities and treatment time appropriately to
be therapeutically challenging while working within
patients’ physical and cognitive capacity.
•

• Learning principles of task-related training, repetition and
practice. Vary object characteristics, task context, speed
and directional demands of the activity.
• Give clear visual/verbal/proprioceptive/written
instructions and feedback.
• Use equipment to complement normal movement
patterns/compensation. ‘Normal activity’ does not utilise
aids to independence other than as a last resort. Aids may
be used to minimise effort and disability.
• Maximising carryover and skill acquisition through practice
and repetition. Train the patient, carer and ward staff to
monitor and adjust alignment, movement patterns and
environment (where appropriate).

Proprioceptive neuromuscular
facilitation PNF
• Proprioceptive neuromuscular facilitation (PNF) as a
neuophysiological treatment approach was first
advocated to American therapists by Knott and Voss in
the 1950s.
• It is based on Sherrington’s and Kabat’s theories about
the reflexive relationships between agonist and
antagonist muscles which can be manipulated to
control the contraction and relaxation of specific
muscles groups and thus facilitate normal movement.
• It also emphasises that ‘the brain registers total
movement and not individual muscle action’ (Schultz-
Krohn et al., 2006: p. 748)

PNF -Assessment
• Assessment considers the relationship between proximal and distal
functions, agonists and antagonists, in total patterns of movement
observed during functional activities. Particular observations are
made with regard to:
• Balance of tone – Is there an abnormal dominance of flexor or
extensor tone?
• Alignment – Are body segments aligned in midline or shifted to one
side?
• Stability and mobility – Is more or less required?
• Which sensory input (auditory, visual or tactile) the client is most
responsive to?
• Which facilitatory technique the client responds to best?
(Schultz-Krohn et al., 2006)

PNF Intervention
• Intervention is goal directed;
• involves the use of mass movement patterns that
are diagonal (crossing midline) and spiral
(rotational) in nature; and involves the use of
total patterns of movement and posture
(developmental postures).
• These diagonal movements and developmental
postures are observed in many functional ADL.
Thus, treatment activities demand tonal balance
and motor control in meaningful tasks that are
appropriately graded.

PNF Intervention :
Facilitatory strategies include use of:
• Verbal commands.
• Visual cues.
• Tactile cues.
• Diagonal placement and use of objects during functional activities.
• Stretch to facilitate innervation of the stretched muscle.
• Traction and approximation to stimulate joint receptors for carrying and weight-
bearing functions.
• Application of maximal resistance that still allows patients to have full range of
motion and smooth coordinated movement to enhance proprioceptive feedback
and strength.
• Use of repeated contractions and rhythmic initiation to facilitate agonist muscles.
• Use of isotonic and isometric contractions of the antagonist to induce subsequent
contraction of the agonist.
• Muscle relaxation techniques (such as contract-relax, hold-relax, slow reversal-
holdrelax and rhythmic rotation).

Treatment implementation
Diagonal patterns

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Rood approach
• This intervention is based on reflexive and hierarchical models of
the nervous system. Use of developmental postures and sensory
stimulation applied to muscles and joints are used to stimulate a
motor response that can either facilitate or inhibit muscle tone in
preparation for normal movement.
• Rood’s concept is therefore based upon the concept of correct
sensory stimulation being applied to the sensory receptors and
eliciting the correct motor reflex which can be utilised in normal
movement patterns (Rood, 1962).
• Some of these techniques such as icing, brushing hair follicles and
tapping the muscle belly have since been found to be short lived
and unpredictable, and thus no longer used
• (Schultz-Krohn et al., 2006).
• Nevertheless the following Rood techniques may still be useful:

Rood techniques
Facilitatory techniques
• Facilitatory techniques to increase muscle tone tend to be
proprioceptive and include the following:
• Heavy joint compression where a compression force greater than
body weight is applied by the therapist through the longitudinal axis
of the bone to facilitate joint co-contraction.
• Weighted cuffs, sandbags and weight-bearing can also be used.
• Quick stretch followed by applying resistance to contracting
muscle.
• Vestibular stimulation to influence tone, balance and facilitate
protective neck, trunk and limb extension.
• Vibration has been found to have systemic effects and use of
electrical stimulation has become more favoured.

Rood techniques
Inhibitory techniques
• Inhibitory techniques to reduce muscle tone include
the following:
• Neutral warmth provided by insulating body heat with
fabrics such as blankets or neoprene.
• Slow, rhythmic stroking with deep pressure.
• Light joint compression where a compression of body
weight or less can inhibit tone around joints.
• Vestibular stimulation through slow rocking to develop
ability to move in and out of postures.

Rood approach
• These techniques are preparatory.
• Purposeful activity then follows so that the
patient applies the effects of the triggered
motor responses during functional activities.
The occupational therapist can also use visual
or auditory prompts to encourage the
required responses within intervention.

Movement science
• This remedial approach to physical neurorehabilitation is also
known as motor relearning programming (MRP), functional and
task-oriented approaches, founded by Carr and Shepherd in the
1980s (Carr and Shepherd, 1987).
• It emphasises the practice of the functional task or action itself as
the remedial component promoted by principles of motor learning,
including use of instruction, explanation, manual assistance, visual
and verbal feedback on performance, reinforcement and contextual
practice. Thus,
• it aims to facilitate motor relearning through use of meaningful
activity, feedback and practice.
• This approach emphasises neuroplasticity and addresses concerns
regarding negative effects of compensatory use of the affected side,
learned non-use and use of adaptive aids on motor learning by
altering task requirements.

Movement science Assessment
• Assessment utilises functional task analysis
where the patient’s performance is compared
to norms and analysed to identify the specific
biomechanical components of movement that
are problematic.
• Hypotheses as to the biomechanical reason
for altered movement are tested to direct
intervention.

Movement science
Techniques/methods
The intervention programme involves the following:
• Training the missing or impaired components in
relation to a functional task goal using instruction,
verbal and visual feedback and manual guidance.
• Manual guidance may be passive or the therapist may
spatially or temporally ‘constrain’ or stabilise parts of
the limb to reduce the degrees of freedom that the
patient is required to control.
• As the patient improves, this ‘constraint’ is reduced
and replaced by verbal guidance or becomes object
mediated.

Movement science
Techniques/methods
• Feedback will depend on the stage of learning the patient is at, moving from more
extrinsic to more intrinsic sources as patients progress. Fitts and Posner (1967)
describe three stages of learning:
• – Cognitive – Patient requires external cues and prompts how to perform the skill
accurately. Mental imagery can also be used here.
• – Associative – Patient begins to refine the skill through practice, repetition and
intrinsic sensory feedback.
• – Autonomous – The skill becomes automatic for the patient and there is less need
for conscious cognitive processing. The patient starts to generalise the skill across
different environments and transfer the skill to different tasks. Task-specific, goal-
oriented exercises are emphasised with self-monitored practice of
• functional tasks outside of training sessions. Structured learning with involvement
of other staff and patient relatives is encouraged for a consistent approach.
• Transference of training with variation of context to aid motor learning.
• Positioning and muscle stretching to maintain soft tissue length and minimise
spasticity re also utilised.

• In physiotherapy practice, MRP is reported to
differ to Bobath concept approaches in the
principles of learning followed (degree and
type of feedback provided), the type of stimuli
used (degree of use of everyday objects
during treatment) and the emphasis on task-
specific practice (Marsden and Greenwood,
2005; van Vliet et al., 2005; ISWP, 2008).

Constraint-induced movement
therapy approach
• Constraint-induced movement therapy (CIMT) is
a behavioural approach that involves restraint of
the unaffected arm with intensive training of the
paretic arm conducted by a clinician using
shaping and repetition (Wolf et al., 2006).
• Shaping involves small steps of progressing
difficulty and activities are designed to enable
patients to carry out parts of a movement
sequence; verbal feedback is always positive for
any small gains made (Zoltan, 2007).

therapy approach
• Taub (1980) described learnt non-use of the
affected upper limb in monkeys whereby the
animal stops using the affected upper limb
due to frustration from lack of success.
• This learned non-use corresponded to
decreased cortical representation. Applying
theories of neuroplasticity, CIMT was found to
reverse this effect and improve recovery and
function of the affected upper limb.

therapy approach
• There is now a substantial body of evidence
supporting this technique and CIMT is
recommended in the National Clinical
Guidelines for Stroke (ISWP, 2008).
• Patients should be at least 2 weeks post stroke
onset, have at least 10 degrees of voluntary
finger extension, have good cognition and be
independently mobile before CIMT is
considered (ISWP, 2008).

therapy approach
• In trials such asWolf et al. (2006), Taub et al. (2006) and
Fritz et al. (2005), the patients received 6 hours of CIMT
and wore the restraint for 90% of the waking day for 2 or
more weeks.
• In addition to restraint and intensive task-oriented practice,
CIMT includes the use of a ‘transfer package’ of behavioural
methods to facilitate transfer of training outside the clinical
setting. The package includes a behaviour contract (for
both the patient and the caregiver providing support), daily
diary of activities to address psychosocial barriers, Motor
Activity log, personalised home skill assignment and daily
home practice (Blanton et al., 2008).

therapy approach
• The practicalities of incorporating CIMT into
daily practice, both in hospital and in the
community, are a challenge and only a limited
number of patients will benefit.
• However, the evidence is now clear and
therapists must keep this technique in mind
for appropriate
• patients.

Bilateral arm training/isokinematic
training approach
• Bilateral arm training is where the unaffected limb
facilitates the affected limb in synergistic coordinated
voluntary movements and is recommended for subacute
and chronic phases of recovery (Stewart et al., 2006; ISWP,
2008).
• It is based on theories that contralesional activation may
activate the lesioned hemisphere or adaptively strengthen
ipsilateral pathways to facilitate recovery of the affected
limb.
• In contrast to CIMT, patients at all severity levels may
benefit from bilateral arm training to some degree but may
require different training approaches (McCombe Waller
and Whitall, 2008).

Bilateral arm training/isokinematic
training approach
• Occupational therapists should incorporate this
approach into the intervention plans of patients
who may benefit. Many activities that
occupational therapists traditionally use could be
modified to involve this targeted practice.
• It is important to remember that in the research
the training was conducted intensively for 50–90
minutes 5 days/week for between 2 and 8 weeks,
which may be difficult to implement in everyday
clinical practice (Stewart et al., 2006).

Mental imagery approach
• Mental imagery or mental practice has been described as
the internal rehearsal of movements without any physical
movements (Jeannerod, 1994; Crammond, 1997).
• An essential part of mental imagery is the ability to create
clear and powerful images of the task required on demand.
• The practice must have functional relevance and meaning
to the individual to enable more successful visualisation.
Athletes and musicians are known to use mental imagery
training to improve their performance, that is, athletes
mentally practise the body movements required for
particular body actions when the field is not feasible
(Ryan and Simons, 1981).

• Little is known about the neurophysiological
mechanisms underlying recovery of motor
function following mental practice in patients
with stroke.
• With advances in neuroimaging techniques, these
mechanisms could be better understood and
assist in the selection of specific intervention
strategies either in combination with mental
practice or in isolation.
(Butler and Page, 2006).

• Caldara et al. (2004) evaluated studies on the role of
executive motor systems (primary motor area M1)
during imagery.
• They concluded that primary motor structures are
involved to the same extent in actual or imagined
execution and of motor acts and that differences only
take place at the late preparation period and consist of
a quantitative modulation of activity in the structures.
• Thus, using mental imagery to activate these areas may
maintain neuronal activity that would deteriorate
without stimulation and prime pathways in readiness
to promote motor function.

• Although there is some evidence that mental
imagery is useful following stroke, systematic
reviews suggest that further research is
required to clarify the content and
measurement of mental imagery
(Braun et al., 2006; Zimmermann-Schlatter et
al., 2008).

Electromyographic (bio) feedback
• Involves the use of external electrodes applied to muscles
and instrumentation to convert electrical potentials from
muscles into audio or visual information.
• This augmented feedback is based on behavioural and
motor learning theory where extrinsic feedback is used to
supplement potential impaired intrinsic sensory-perceptual
feedback to improve reacquisition of motor skills.
• There is some evidence to support its use to augment
standard treatment (Woodford and Price, 2007) but routine
use outside of clinical trials is not recommended (ISWP,
2008).

Functional electrical stimulation
• Electrostimulation is thought to be beneficial to
train and strengthen muscle contractions.
• However, results remain inconclusive and should
not be used routinely outside specialist clinical
trials (Pomeroy et al., 2006; ISWP, 2008).
• Nevertheless, there is some evidence for its use
to manage persistent subluxed shoulder pain and
foot drop where orthoses are ineffective and
improved gait is demonstrated with use
(ISWP, 2008).

Robotics
• An emerging strategy is the use of
electromechanical and robotic devices.
Although some training-specific benefits have
been found for improving motor strength, no
evidence has been found for improvements in
ADL (Mehrholz et al., 2008).
• Exploration into robotics to augment
repetitive practice and incorporate more distal
limb function is required.

Mirror box
To counteract this, Ramachandran reasoned, the brain needs to receive visual
feedback that the arm is moving in the correct manner. Ramachandran
and William Hirstein “constructed a ‘virtual reality box,’” (mirror box) to
allow “patients to perceive movement in a non-existent arm." The box has
a mirror and a place to put the existing and phantom arms. The patient
sees his real arm in the mirror, which creates the illusion of two arms.
When the patient sends motor commands to both arms, they receive
visual feedback that his phantom hand is moving properly. For many
patients, this technique has been effective in relieving phantom limb pain.
(http://www.ted.com/talks/vilayanur_ramachandran_on_your_mind.html0)

The Mirror box
• Uses the activity of motor command pathways from
the unaffected region to supplement the damaged
region.
• Increases the use of spared pathways
• Promotes functional integration of the motor and
somatosensory cortex in limb movement
• Creates neuroplastic changes within the brain
(Quoted in parts from: current principles and clinical applications of neuromuscular retraining for facial
paralysis; Jodi Maron Barth and Gincy L. Stezar, unpublished manual October 2009)
https://www.youtube.com/watch?v=1BnsQO7
a4Og

Intervention of perceptual
impairments
• Intervention of perceptual impairments involves a
mixture of restorative (remedial) and adaptive
(compensatory/functional) approaches.
• The restorative (remedial) approach can be
generalised, as practice on a particular perceptual task
will affect the patient’s performance on similar
perceptual tasks.
• The adaptive (compensatory/functional) approach can
be interpreted as repetitive practice of particular tasks,
usually activities of daily living, which will make the
patient more independent in these particular tasks.

Neglect
• is the most common perceptual impairment suffered
by stroke patients and occurs over several sensory
systems; vision, touch and auditory.
• Neglect presents in different spatial domains and these
include the following:
• Body (personal) space – the immediate area of space
of the person.
• Reaching (peripersonal) space – the area extending to
arm’s reach of the person.
• Far (extrapersonal) space – the area extending far
from the person.

General intervention tips
• Consider the grade of the task; the complexity of the task increases the
likelihood of errors.
• Consider the types of prompts, that is, visual, verbal, physical or
questioning prompts and pausing before providing a prompt.
• Consider using written or visual instructions.
• Learning can be achieved through repetition and practice.
• Reinforce positive behaviours rather than negative ones.
• Stage components of the task, that is, break down the task and encourage
the patient to complete one stage at a time.
• Use verbal rehearsal, that is, encourage the patient to talk through the
task before
• completing it, errors can then be corrected before they are performed.
• Establish patterns and routines.
• Provide consistency in approach.

Specific intervention strategies
• Body scheme
• Aim: For the patient to be aware of parts of
the body and their relationship to each other
and how they are used within function.

Body scheme
Restorative (remedial) strategies
• Ask the patient to verbally identify parts of the body
(Johnstone and Stonnington, 2001).
• Encourage the patient to verbalise positions of parts of the
body to improve awareness.
• Provide tactile stimulation, for example, rub a rough cloth
on the patient’s arm while
• naming it before placing their arm through a sleeve (Zoltan,
2007).
• Identify parts of the body before washing or dressing
them.
• Incorporate bilateral activities that facilitate normal
movement and improve body scheme (Zoltan, 2007).

Body scheme
Adaptive (compensatory/functional) strategies
• Provision of instructions that name parts of
the body, such as ‘wash your arm’ (Zoltan,
• 2007).
• If the patient has functional awareness,
provide cues such as ‘move the part of the
body
• that you use to hold things’ instead of ‘move
your hand’ (Zoltan, 2007).

Impaired midline awareness
• This presentation is often termed the ‘Pusher
syndrome’.
• Patients have a severe misconception of their own
upright orientation.
• Patients experience their own upright as 20◦ tilted to
the ipsilesional side.
• Patients present by pushing themselves over towards
their affected side and are often overactive on their
unaffected side.
• Aim: To regain the awareness of midline.

• For the patient to become aware of midline by using
visual feedback, place a mirror in front of them and
instruct the patient to self-correct themselves back to
midline.
• In all postural sets, ask the patient to identify the
position of their body and describe their relationship to
supporting surface (Karnath and Broetz, 2003).
• Get the patient to move between postural sets and for
them to maintain their balance.

• Place pillows on the overactive side to provide extra
supporting surfaces to enhance the patient’s feeling of
security.
• When seated in a wheelchair place the hospital bed in
a high position on the overactive side to enhance
feelings of security.
• Teach the patient to use vertical structures within the
room such as door or window
• frames to adjust balance with reference to these
markers (Karnath and Broetz, 2003).

Unilateral neglect
• Aim: The patient to become aware of both
sides of their environment.

Unilateral neglect
Restorative strategies
• Use activities that cross midline, for example, personal care activities.
• During activities of daily living sessions place stimuli on the patient’s affected side
and prompt and encourage them to look over to their affected side. Place
necessary items
• in midline and to their affected side using cues to locate all items and ask patients
verbalise the location of items to practise spatial scanning.
• Practise shifting attention from left to right. Cue patients to target stimuli in
neglected space to assist attentional shifts.
• Move necessary items from midline to their affected side, such as the knife in
midline and the butter further into the left side.
• Cancellation tasks such as maze or word searches to practise scanning left to right.
• 2D scanning tasks, that is, paper and pen tasks or more dynamic such as room
searches.
• Computer games that require scanning from side to side.
• Tactile stimulation onto the neglected part of the body, using vibration, mildly hot
or cold stimuli (Johnstone and Stonnington, 2001).

Unilateral neglect
• Adaptive (compensatory/functional) strategies.
• Place objects in midline and gradually move objects further into
the patients’ affected side.
• Approach patients from the midline.
• When reading, anchor the page and draw a red line down the
affected side so that the patient becomes aware of how far across
the page to start reading (Johnstone and Stonnington, 2001).
• Adapt the environment; remove clutter on the affected side
(Johnstone and Stonnington, 2001).
• Encourage the patient to turn their plate round to ensure all the
meal is eaten. The National Clinical Guidelines for Stroke (ISWP,
2008) recommend that meal times should be monitored to ensure
that food is not missed.
• Teach the patient to turn their heads to become more aware of the
affected side.

Other intervention approaches
for unilateral neglect.
• Constraint-induced movement therapy
• Constraint-induced movement therapy (CIMT) forces
the use of the affected side by either placing a sling or
mitt on the unaffected arm (Taub et al., 1998).
• CIMT attempts to reverse the learnt non-use of the
affected arm; however, to be able to use this technique
there needs to be enough return of movement that
would allow the patient to functionally use their
• affected hand. CIMT reports to be a useful intervention
method for unilateral neglect.

Eye patching
• Studies have shown that using glasses that
occlude the good (ipsilesional) side of vision
• in each eye, the patient is forced to direct
their gaze to their contralesional side (Beis
• et al., 1999). Compliance with this technique
can be difficult as it is the patient’s natural
• inclination to gaze towards the occluded side.

Prism glasses
• There is evidence of the positive effects of prism adaptation (Parton
et al., 2004). A 10◦
• rightward horizontal shift of the visual field can be achieved by
wearing prism glasses.
• Within studies such as Rossetti et al. (1998), patients were asked to
point to a target either side of midline while wearing the glasses.
• Following the use of this technique the patients demonstrated
immediate improvements in tests of neglect. McIntosh et al. (2002)
have also shown these improvements to be made post 9 months
following stroke.
• The National Clinical Guidelines for Stroke (ISWP, 2008) recommend
using prisms if the unawareness is severe and persistent.

Visual discrimination
• Aim:
To become aware of the relationship of objects
to objects or self, to identify foreground from
background, position in space and depth and
distance.

• Teach the patient to retrieve items following
verbal instructions with spatial concepts, for
example, ‘get the brush on top of the dresser
behind the bed’.
• Teach the patent to place different items in
different parts of the room.
• Use of tactile kinaesthetic strategies such as
guiding the patient to the object.
• Encourage the patient to verbalise the position
of parts of the body to improve awareness.

• Organise the objects so that they are in the same
place.
• Mark drawers where key items are kept.
• Encourage the patient to feel and describe
objects.
• Remove clutter in the environment (Johnstone
and Stonnington, 2001).
• Place objects on contrasting surfaces, for
example, white soap on a dark coloured cloth.

Visual agnosia
Agnosia is the inability to recognise objects even though the elementary
visual functions remain unimpaired (Farah, 1995). Lissauer in 1890
distinguished between two types of visual agnosia, the apperceptive and
associative agnosias.
• Apperceptive agnosia is where recognition fails because of impairment of
visual perception.
• Patients do not see objects normally and cannot therefore respond to
them. Associative agnosia is when perception is intact to allow
recognition; however, recognition cannot take place due to impaired
semantic knowledge not confined to vision but confined to the naming of
the object.
• Patients with apperceptive agnosia are unable to copy drawings or match
objects due to impaired visual perception. Patients with associative
agnosias are able to copy drawings but cannot describe the function of
objects (Farah, 1995).
• Aim: To be able to identify objects through vision.

Visual agnosia
• Present objects in a straight position rather than other
orientation.
• Encourage the patient to recognise differences and
similarities between items.
• Start with items that are very different and gradually
upgrade to items with subtle
• variations, for example, shape, size or colour.
• Encourage the patient to verbalise differences, that is,
naming objects and differences between objects.

Visual agnosia
• Teach the patient to consider and think critically. Utilise verbal strategies
where the patient describes the perceptual and functional characteristics of
the object to aid retrieval of the object name.
• Use other senses to identify the object, that is, touch, smell or sound.
• Show the object in a natural context.
• Adding texture or edge orientation to objects may assist into providing cues
to identification.
• Use premorbid orientation of objects, that is, did they keep a T-shirt kept in
the drawer or on a hanger.
• If categorisation is intact ask the patient to identify which category the object
would belong to.
• Provide labels for objects to maximise independence.

Summary of evidence for approaches
• It has been demonstrated that comprehensive
occupational therapy intervention for stroke is
effective for reducing activity limitations in
personal and extended ADL and improving social
participation (Trombly and Ma, 2002; Steultjens
et al., 2003; Walker et al., 2004; Legg et al.,
2007).
• However, evidence for specific approaches used
to achieve these outcomes or for restoration of
impairments is less clear (Ma and Trombly, 2002).

Tactile agnosia (stereognosis)
Aim: To be able to identify objects through
touch.
• Exploratory hand movements for object
identification. Explore the object by touching
the surfaces and edges of the object, holding
the object in the hand to obtain information
on its size, shape and weight.

Tactile agnosia (stereognosis)
• Education of problems and how these affect
function.
• Utilise other senses, that is, vision and touch
from the unaffected hand.
• Teach the patient to focus on specific properties
of the object.
• Use familiar objects within functional tasks.
• Use objects within context.

Management of Cognitive
Impairments
Definition of cognition
Cognition refers to those mental
functions which help us to acquire,
organise, manipulate
and use information and knowledge. It
includes all of our ‘thinking’ processes.

Cognitive functions
Cognitive functions which may be impaired following a stroke
include the following:
• Attention – the ability to focus on specific sensory stimuli and
suppress distractions.
• Attention is required for many other cognitive functions to
occur.
• Memory – the ability to retain and recall information.
• Perception – ‘making sense of the senses’ – a cognitive
process .
• Language – understanding and expression.
• Praxis – motor planning.
• Executive functions – skills which are needed to plan organise
and execute a task.

Cognitive rehabilitation
Approaches
• The main rehabilitative approaches used by
occupational therapists, within cognitive rehabilitation,
are:
• Remediation (restoration).
• Adaptive (compensatory/functional).
Occupational therapists tend to favour a functional
approach for the rehabilitation of people with cognitive
impairment, including task-specific training and the use
of activities which are meaningful and familiar.
A selection of interventions may be required to meet
individual needs.

Principles of intervention for the
rehabilitation of people with cognitive
impairment:
• Goal orientated – the person with cognitive problems is more
likely to engage in rehabilitation if they contribute to the selection
of the activities they participate in.
• Goals should be meaningful and relevant. Goals direct the content
and process of interventions and must be relevant to the
individual’s needs and wishes. Long and short-term goals are set
and they should be, as far as possible ‘SMART’, that is, Specific;
Measurable Achievable (with some challenge); Realistic (within the
environment and resources available) and Timescales should be set
and there should be a regular review of goals with the patient,
family/carer and team.
• ‘If the patient, their family, and the treating team are all working
towards the same agreed goals, a satisfactory outcome is more
likely’ (Turner-Stokes, 2003).

Principles of intervention for the
rehabilitation of people with
cognitive impairment:
• Individualised – a selection of strategies and intervention techniques
may be required as people will have individual interests and responses
to interventions.
• Educate and include relevant family/carers/friends and significant
others – so that they understand the difficulties a person may be
having and can assist with the application of strategies and provide
support.
• Focus on functional improvement – including a way of measuring this
improvement, such as goal attainment and performance measures.
• Include psychological and emotional support – people with cognitive
problems can develop anxiety, depression and a sense of loss of
control and self-esteem. These should be acknowledged and
interventions provided to support management of these problems,
such as anxiety management training, relaxation training and
medication.

Intervention strategies
• Task-specific training – or functional
retraining, stresses the value of the use of
specific and relevant functional tasks.
Emphasis is placed on task characteristics, in
order to support behavioural change (Wilson,
1998).
• Practise – repetition over time and use of
retained capacity assists learning.

Intervention strategies
• Errorless learning – people with brain injury, including stroke, may not learn from
their mistakes so an approach which supports the achievement of a successful
outcome by cueing the correct response is more likely to enhance learning. This
has been evidenced in studies of people with memory problems (Wilson et al.,
1994).
• Environmental adaptation – regulation of noise and distractions; clearing
environmental clutter; and adaptations such as message boards.
• Compensation and strategy training – external aids and adapted methods – for
example, use of memory aids such as pagers, diaries and calendars.
• Prompts and instruction – direct instruction and guided assistance may support
relearning of skills.
• Restoration/skills training – this has limited support for the restoration of
cognitive problems although some studies of attention have reported improved
skills when specific retraining of basic attention capacity is offered. Retraining
tends to be more effective when embedded in a meaningful and functional
context, targeting the specific level of attention impairment of the individual
(Cicerone et al., 2005).

Attention
• Attention is required for most other cognitive
functions to take place. It is dependent on an
adequate degree of arousal and alertness and
helps us to process a large amount of
information on a daily basis. Attention is
commonly affected after stroke, especially in
the early stages of recovery.

Attention
• To help with our understanding of attention it can be useful to think of it in
a hierarchy, as presented by Sohlberg and Mateer (1989) who described
different levels of attention:
• Focused – an initial response to fix attention on a specific stimuli, for
example, responding to your name being called.
• Sustained – this level relates to the brain’s ability to maintain attention on
a single task; also referred to as concentration, for example, reading a
book.
• Selective – this refers to the brain’s ability to filter out unwanted stimuli in
order to attend more closely to detail or something important, for
example, looking for someone in a busy room.
• Alternating – this is the brain’s ability to shift its attention from one thing
to another, for example, listening to a lecture and taking notes.
• Divided – this is about multitasking, doing more than one thing at one
time, for example, driving and talking to a passenger.

Attention problems Intervention
• A functional approach using meaningful tasks
can be used. Michel and Mateer (2006)
suggest that intervention should be focused
on training specific functional skills rather
than the underlying processes.

Attention problems Intervention
• The National Clinical Guidelines for Stroke (ISWP, 2008) recommend that
patients should be taught strategies to compensate for their reduced
attention.
• If attention continues to be a problem, strategies can be implemented.
• This can be done by providing structure to the patient’s day such as using
a diary system. Minimise distraction in the patient’s environment and
ensure the patient has a quiet place they can go to if they become
overstimulated as this may manifest in agitated behaviour. Use of
prompting to maintain the patient’s attention during tasks can be useful
(prompts can be verbal or visual).
• hese techniques should be taught to families and carers to alleviate the
potential emotional stress attention problems can bring to both patient
and their carers. If the patient is going home or is at home, safety
implications of poor attention should be noted as it will often present
similarly to problems with memory.

Memory
Memory allows us to retain and recall information for all aspects of
daily living. Attention is essential to allow us to attend to information
and select what is to be stored in our memory systems. The main
processes associated with memory function are as follows:
• Attention – to the information that has to be remembered.
• Encoding – sensory information is converted into meaningful data
for storage.
• Storage – in long-term memory systems.
• Consolidation – rehearsal and practice of information to enhance
the strength of the
• memory.
• Retrieval – accessing information through recall or recognition.

Memory systems
• Sensory memory (sensory registration) – allows us to attend
to relevant information and transfer it to our short and
long-term memory systems. If not used, the information is
discarded.
• Working memory (short-term memory) – a temporary
storehouse of information which is retained for long
enough for us to act up on it, for example, dialling a phone
number when looking it up in the phone book.
• New sensory memories act with stored long-term
memories to manipulate and use information in a
meaningful way. If new information is to be stored as long-
term memories, it needs to be consolidated and stored in
one of the long-term memory systems.

Memory systems
• Long-term memory – information is processed and stored in
different types of long-term memory systems:
• Semantic memory – knowledge and facts;
• Episodic memory – past events and activities;
• Prospective memory – remembering to do things in the future;
• Procedural memory – learned motor, cognitive and language
processes.
Semantic memory, episodic memory and prospective memory are
referred to collectively as ‘declarative’ or ‘explicit’ memory, and
procedural memory is also known as ‘non-declarative’ or ‘implicit’
memory.
Problems can occur in any one of the memory systems and can affect
the ability to form new memories ‘anterograde amnesia’ or access
stored memories ‘retrograde amnesia’.

• There is some evidence that adaptive approaches for
self-care may be more effective than restorative
approaches, but this conclusion may be confounded by
lack of distinction between stage of recovery and
heterogeneous research (Haslam and Beaulieu, 2007).
• The majority of evidence for specific treatment
approaches is predominantly generic or physiotherapy
based, despite similarities (Booth and Hewison, 2002)
and inherent differences between the disciplines
where occupational therapy by its very nature is
taskspecific and application of treatment approaches is
likely to differ (Ballinger et al., 1999; De Wit et al.,
2006; De Wit, 2007).

• Langhorne et al.’s (2009) systematic review of
motor recovery after stroke highlights difficulties,
making conclusions from research with
heterogeneous populations, varied intervention
protocols and questionable use of sensitive,
targeted outcome measures that consider change
at both impairment and functional levels.
• Nevertheless, approaches that involve high-
intensity, repetitive task-specific practice and
feedback on performance may be particularly
influential on recovery.

• Thus to be truly evidence based, occupational therapists
will need to continue to draw on appropriate evidence that
is specific to their individual patients’ contexts and the
setting in which they work, as evidence to date can only
provide broad guidance.
• Further, task-specific research is required to guide
therapists’ clinical reasoning to accurately predict patients’
recovery potential and educate patients about choice of
specific treatments.
• More information is required regarding the characteristics
and symptoms of who benefits, what is it about specific
treatments that work, when is the most appropriate time
to implement specific treatments and at what intensity.

Self-evaluation questions
• 1. What are the similarities and differences, advantages
and disadvantages between a normal movement
approach and a motor relearning approach?
• 2. (a) What conceptual models, frames of reference
and intervention approaches do you use in your
practice?
• (b) How do they relate? Draw a mind map or
conceptual model to describe the theoretical basis of
your practice and how your models, frames of
reference and intervention approaches link together.
• (c) Write a reflection on this for your CPD and compare
with others in your team.

• 3. What conceptual models, frames of reference would be
useful to consider in your practice that you do not already
use? Draw up a plan of how you could integrate a new
model or frame of reference into your practice.
• 4. What intervention approaches do you already use in
your practice? In a reflection, consider comparing the
strengths and limitations of each approach that you use?
• 5. What approaches would you like to know more about?
Pick one and plan an in-service training session on it for
your colleagues (including a reflection on how it worked
with one of your patients).
• 6. What are the four main mechanisms of neuronal
plasticity?

• 7. Within synaptic transmission, what is the
mechanism for short-term potentiation (STP)?
• 8. Within synaptic transmission, what is the
mechanism for long-term potentiation (LTP)?
• 9. How does the restorative (remedial)
approach relate to neuroplasticity?
• 10. Select a restorative (remedial) approach
and justify its use in utilising the theories of
neuroplasticity.

Theoretical Basis-Occupational therapy and stroke

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