Rehabilitating Stroke Survivors through OT

Introduction

This essay explores how occupational therapy could be used to rehabilitate young adults post stroke. The main focus of the essay is on the evidence-based interventions. Amy is 30 years old and lives alone with her dog. She was divorced before she had her first stroke. She enjoys driving to work at her local call centre. Post stroke has affected her coordination and balance. She suffers from numbness in her limbs which has limited her day to day activities. Blurred vision has affected her performance at her computing job. Her job is very sedentary, therefore doesn’t require a lot of movement. This causes stiffness and pain in her affected limbs and the interventions stated in this essay, along with potential healthcare dissertation help, will promote exercise and movement through day to day activities and incorporating her daily lifestyle such as walking her dog and regaining confidence and self-esteem to continue her usual routine which includes driving her car. This will allow Amy to reach optimal levels of movement. Stroke comes about whenever the supply of blood to some parts of the human brain is reduced or interrupted completely which leads to deprivation of the brain tissues off nutrients and oxygen (Benjamin et al. 2017). After the supply of oxygen is interrupted, the death of brain cells begins. Strokes are medical emergencies which require prompt treatment. Potential complications and damage of the brain can be prevented by early actions.

Some signs and symptoms of stroke that need to be observed keenly include;

Troubles with understanding and speaking confusion may be experienced and words may be slurred and one could even have difficulties with speech comprehension. Numbness or paralysis of the leg, arm or face someone could develop paralysis, weakness or numbness all of a sudden in their faces, legs or even arms. Often, that just begins in one side of the human body. The easiest way to check for this is raising both arms over the head at the same time and observing whether any of the arms will begin to fall (Mozaffarian et al. 2016). If any of the arms begins to fall, then the person may be having a stroke. Additionally, whenever one tries to smile, one side of their mouth could begin to droop. Vision problems with either one or both eyes, blurred vision in one or in either eyes or they could even begin to see double. Severe sudden headaches which are accompanied by altered consciousness, laziness and vomiting could be indications of stroke. Someone could stumble or experience sudden dizziness, loss of coordination or loss of balance. In the United Kingdom, stroke is a primary cause of long term disability that affects millions of people and which is as a result of bursting of blood vessels or occlusions in the brain. Usually, the appearance of stroke is sudden and damages localised portions of the brain and brings about different impairments like motor, language, cognitive deficits, sensory and visual perceptual. Strokes have the potential of leading to severe cognition and mobility limitations leading to difficulties in performance of daily living activities. The National Stroke Association did a survey that found that up to 87% of the long term survivors of stroke had concurrent motor problems, walking difficulties were reported in 54% of the long term survivors of stroke, 58% of them had plasticity and hand movement problems were reported in 52% of the long term survivors of stroke (Benjamin et al. 2018).

Leisure activities limitations may also be brought about by mild stroke and other meaningful roles in life (Mozaffarian et al. 2016). There is a relation between excess depression and stroke and decreased functioning abilities among the survivors of stroke and their caregivers. Most of the individuals who survive stroke return home to environments that are full of challenges. Often, the survivors of stroke are normally recommended to occupational therapy and that is done with the hopes that they get better. The UK Government identifies stroke as one of the leading causes of disability in adults and estimates that up to 4 million people in the UK live with the effects of stroke (GOV.UK, 2018). As a result of this there are millions of UK residents that know the first-hand effects of stroke as a result of having family members or friends who live with stroke and who constantly require their help. Most of the individuals who experience strokes require some form of rehabilitation when on their paths to recovery and both they and their families require some form of rehabilitation (Cea-Soriano et al. 2017). Occupational therapy comes in handy in the rehabilitation process as they make it more effective and productive for their needs that are personal. It is worth noting that whenever occupational therapy becomes part of the process of rehabilitation, the recovery process is made even easier by the evidence-based methods of occupational therapy which also make the process of recovery more meaningful. That gives post stroke patients and their caregivers the opportunities of living their lives to the fullest.

Interventions

Occupational Therapy addresses the mental, cognitive and physical challenges that stroke brings about and are also capable of helping the survivors of stroke to regain their abilities of taking part in the day to day activities through different evidence-based methods (Gittler and Davis, 2018). Occupational therapy takes a holistic view of post stroke patients taking into consideration their different needs, environment, activities and limitations that are new to them. They are usually in good positions to recommend equipment for the home that have the potential of helping the people in building their endurance and strength, help in compensation for loss of memory and vision and further provision of activities that have the potential of rebuilding self-esteem. Occupational therapy goals being part of the process of rehabilitation is to facilitate the individuals to go back to the highest levels of performance in their valued occupations (Carey et al. 2017). For example, Amy could practice using her stairs by holding onto handrail with assistance and slowly increase her level of performance and self-esteem independently. According to Stark et al. (2018), those individuals who receive occupational therapy interventions have a higher likelihood of being independent and have a less likelihood of deteriorating in the performance of their day to day activities once their treatment comes to an end. Interventions that involve occupational therapy could also be associated with reduced caregiver time, increased life quality for the individuals who are recovering from stroke together with their families and reduced weight on caregivers. Whenever post stroke patients are capable of returning to their homes and functioning independently they require to learn about community and transitional reintegration services that could assist them with engagement with their environments (Kwakkel et al. 2015). Occupational therapists identify these resources, conduct teaching sessions that are comprehensive and incorporation of work-related tasks like treatment activities that help the individuals who survived stroke and their families to learn programs and techniques that assist in improving the abilities of clients to participate in different occupation areas.

Usually, the focus of occupational therapy is on helping those individuals who have cognitive, sensory and physical disabilities to be as independent as possible in the different areas of their lives. Occupational therapy is a health profession that is client centred and that is concerned with the promotion of wellbeing and health through occupation. Practitioners of occupational therapy also address the environmental. Social and physiological factors that have the potential of affecting functioning. It is worth noting that there are differences between Physical Therapy and Occupational Therapy in that, the focus of physical therapy is on strength, pain, joint motion range, gross motor functioning and endurance, while the focus of occupational therapy is on the refined motor skills, deficits in sensory processing, cognitive skills and the different visual-perceptual skills. The occupation in occupational therapy stands for the different daily activities that people are engaged in as families, individuals and communities in a bid to bring purpose and meaning to their lives and also for occupation of time.

Occupational therapists also have the capabilities of carrying out evaluations/assessments for the determination of whether clients are capable of returning to important and specific activities that they were able to perform before their condition like driving (Bushnell et al. 2018). Amy was provided aids and advised by an occupational therapist to attend programs of driver rehabilitation. However, if she was considered not to be safe to drive, occupational therapist usually recommend alternative community mobility alternatives. Occupational therapists have higher likelihoods of spending more time with post stroke patients than other professionals and are in key positions to help in the alleviation of some of the emotional and physical challenges of the clients (Gillen, 2015). Clients could also be encouraged by occupational therapist to work towards achievement of their goals and also in creation of a support balance whenever their clients are discouraged. Families and friends are also affected post stroke. It is worth noting that while brain damages following a stroke cannot be reversed by rehabilitation, rehabilitation is helpful in that it helps the brain in learning new ways of doing things such that people are able to achieve the best long-term outcomes. According to Richardson et al. (2016), Occupational therapy effectively improves the occupational performance of clients and as such, should be part of the process of rehabilitation because it improves the occupational performance of the client fully, giving them a chance to live their lives to the fullest.

Implementation interventions are defined as strategies that are aimed at increasing the application of research-based knowledge in practice of healthcare (Wolf et al. 2015). There are different interventions for implementation that can be used in rehabilitation of stroke victims and these include the creation of new multidisciplinary teams or changing equipment or facilities (arrangements for delivery), utilising pay for performance or external funding (arrangements for governance) utilisation of external funding or pay for performance (arrangements for finance) such as government providing funds for time of work while Amy gets better. The aim of implementation activities is usually to produce changes in the behaviours of people together with the environments in which they operate in, or even both. Implementation interventions tend to target change in different levels, for instance, organisations, teams, systems and individual health professionals and could be tailored to overcome the barriers that have been identified for implementation (Platz, 2019). For instance, feedback and audit, that involves provision of summaries for clinical performance to health professionals over time periods that are specified are hypothesised to work by changing the awareness of the health professionals together with their beliefs about their current practice and subsequent consequences changing self-efficacy, perceived subjective norms or though direction of attention to specific tasks. Another implementation intervention that is recognised is the use of opinion leaders whereby individuals who occupy positions that are influential socially within systems are capable of promoting and further affecting changes in behaviour through leadership that is informal (Gillespie et al. 2015). This strategy for implementation is proposed to work through interpersonal skills and communication that is persuasive where opinion leaders assist the other people in the identification of catalyse change and best-practice evidence.

As at now, the different stakeholders in rehabilitation of stroke victims do not have synthesised evidence base for guiding implementation. The European Implementation Score Collaboration carried out a study in 2015 that highlighted the growing international interest in the use of implementation strategies. Jones, (2015) conducted a systematic review of rehabilitation implementation which demonstrated an awareness of implementation within professions that are involved with rehabilitation, evidenced by the increase in different implementation studies that were published in the past recent years. Delivery arrangements are interventions that are usually aimed at production of change through consideration of when, how and wherever healthcare is delivered and organised, and who delivers healthcare; for instance, services for transportation, triage, systems for safety, telemedicine and care pathways (Gillespie et al. 2015). Financial arrangements are those interventions that are aimed at production of changes through insurance schemes putting into consideration the collection of funds, the procedure of purchasing services and the use of financial disincentives and incentives that are targeted; for instance, out-of-pocket payments and user fees, pay for performance and voucher schemes. Governance arrangements are those interventions that are aimed at production of change through putting into consideration those processes and rules that have an effect on the way through which power is exercised and that is with particular regard to accountability, authority, coherence, participation and openness. Some of the examples include accreditation of professionals in healthcare, involvement in policy decisions and those policies that regulate liability for professionals in healthcare (Wolf et al. 2015).

Implementation strategies are aimed at production of changes in healthcare organisations, healthcare professional’s behaviours, the use of health services by recipients of healthcare; for instance, feedback and audit, materials that are educational, educational meetings, local opinion leaders, educational outreach visits ad tailoring (Luker et al. 2015). A major recent development in healthcare delivery has been Evidence-based practice which involves the explicit thinking from clinical research to clinical decision making. Clinicians who make use of the EBP approach should always formulate key questions whenever they are faced with clinical problems and then search for the best evidence externally and do a critical and relevant appraisal of the evidence to their problem and then apply it in solving of clinical problems. The movement in Evidence-based practice makes an attempt to encourage and even force professionals and other individuals involved in the making of decisions to pay increased attention towards evidence that informs their making of decisions. Evidence based practice is usually aimed towards eliminating practices that are outdated and unsound in favour of the more effective practices through shifting the basis of the decision making towards scientific research that is firmly grounded away from experiences that are not systematic. It is worth noting that it is not all health practitioners who are trained in approaches that are evidence based and often, members of public are usually not aware of the existence of evidence-based practices. As a result of this, the treatment accorded to customers is not always the best available treatment. When done correct, there are many advantages that can be accrued from utilisation of the EBP approach. These include improving the quality of clinical decision making and encouragement of life long professional learning (Hanna & Rowe, 2017). It is possible to tailor improve the quality the quality of decision making that is clinical in addition to making and encouraging life-long learning that is professional. The clinical question determines the most reliable and appropriate evidence form. Whenever the clinical question is concerned with treatment`s effectiveness, the most reliable evidence is provided by randomised trials that are controlled.

An eight point guiding framework was developed by Lennon and Bassile (2009) for provision of a strong framework of evidence-based practice for development of plans for treatment. The different elements in the framework include;

The ICF

This is a framework that describes disability and functioning in relation to specific health conditions. The ICF framework is an approach of patient care that shifts the conceptual emphasis away from negative connotations like disability and further places focus on individual`s physical abilities instead of the systems level. The framework is a classification of disability and functioning whose main focus is on three perspectives; Societal, Individual and Body. The importance of interplay is underscored by these three perspectives and they also underscore the influence of both external and internal factors to the health condition of every individual (Lloyd et al. 2018). The dimension of activities in this framework covers the range of activities that are performed by individuals while the dimension of participation classifies those areas of life where there are barriers and individuals for every individual with the overall framework providing a mechanism that documents how individual functioning is affected by environmental impacts.

Team Work

Different healthcare professions are involved in care provision and information exchange with the patients and members of their families and as such, for coordination of the processes of rehabilitation, teamwork plays a critical role. Team working is one factor that is quite essential in the improvement of outcomes for patients after they suffer from stroke as was highlighted by the Stroke Unit Trialists Collaboration.

Patient-centred Care

Whenever care is centred on the patient, there are improvements in self-care, life quality, and satisfaction with care, reduced anxiety and increased engagement. It is always necessary to involve patients together with those who take care of them in the processes of creating treatment plans and provision of information on how to go about with decision making and selection of treatment solutions and as such, it is necessary to place emphasis on patients as the makers of decisions and solvers of problems. In this case, Amy would be well aware of the interventions being planned out for her rehabilitation as her goals will be considered. Setting of goals provides care that is centred on patients through facilitation of autonomy and appropriate responsibility and information pacing (Belagaje, 2017).

Neural Plasticity

Neurons refer to those nerve cells that are found in human brains. Axons make up individual neural cells and are linked to one another by synapses which are small spaces. Plastic connotes moulding, sculpting and modifying. As such, neuroplasticity refers to the brains potential in reorganisation through creation of new neural pathways to adapt whenever it requires. Neuroimaging advancements have proven that plasticity comes about as a result of the damage of nervous systems and also as results of therapy and experience facilitating spontaneous recovery following the damage of the brain that follows after a stroke. Stokes and Stack (2012) posit that neuroplasticity changes abilities imply that post stroke therapy is aimed at movement recovery and function more than the promotion of independence using the side that is not affected, for example, compensation.

A Systems Model of Motor Control

After injury of the neurological system, or after one gets a neurological disease, alteration of the neutral pathways of the body happens and that goes a long way in affecting those nerves that control sensation and movement. These kinds of changes bring about different symptoms that are associated with neurological disorders. Those responses and movements that used to be automatic become abnormal and difficult to produce in the normal ways. There have been different methods that have been used in description of human movement with different Motor Control models being used in the description. There are different theories for Motor Control which include production of automatic, reflexive, voluntary and adaptive movements that include multiple systems of the body (central processing, output and input) and other multiple levels within the nervous system. Within the neurology field, different researchers recommend the adoption of Motor Control systems model that incorporate neurophysiology, motor learning and biomechanics principles which put into consideration solutions for learning based on patient, environment and task interactions. It is important for therapists to have an awareness of all of this when they go about planning their interventions. Therapists are usually capable of altering the tasks and the environment in ways which would enable their patients to achieve their goals (Hildebrand, 2015).

Skills Acquisition

Acquisition of skills is the science that underpins learning of movement and execution and is more commonly referred to as motor control and learning. It is possible to divide acquisition of skills and motor learning into three phases which include; the Cognitive Stage, the Associative Stage and Autonomous Stage. Unique characteristics are embodied in every stage that are relative to the level of performance of every other athlete of certain activities and skills (Belagaje, 2017). All of these are affected by a range of environmental constraints that include different factors like the instruction levels, feedback frequency and quality, decision making opportunities, exposure to other sports and cultural and socio-economic limitations. Amy could improve her motor control when better by even taking her dog for a walk and walking to the shops every morning to get the newspaper and at home she can play board games.

Self-Efficacy (self-management)

This is related to the beliefs of an individual in their capacities to execute those behaviours that are deemed necessary for production of specific performance attainments (Maddux, 2016). Management of self-incorporating active involvement of in decisions regarding shared responsibility and treatment have become parts that are critical for the rehabilitation of those individuals who have neurological conditions that are long term. To ensure that the process of rehabilitation is focused on the patient and has patient involvement, it is necessary to have a proper understanding of what it is and why it has grown into a key element (Kristensen et al. 2016).

Conclusion

The treatment and recovery for post stroke patient is aided by Evidence-Based Practice. Post stroke patients want and demand the best available treatment (Baker et al. 2018). The intervention created for use with Amy’s condition allowed improvement of her occupational performance. One of the reasons as to why clinicians are not aware that majority of the clinicians pine for treatments that are more evidence-based and robust is confusion that is brought about by timing. Stroke survivors are observed to trust systems during their acute and the sub-acute phases which generally fall between 3 to 6 months (Bernhardt et al. 2017). It is notable that it is quite soon after they have been discharged from therapy that survivors begin to question the methods that were used. So one would ask how is it that clinicians for whom stroke is one of the different pathologies they deal with keep abreast and further implement emerging options for treatment of stroke. That is achieved by simply keeping it simple (Gittler & Davis, 2018). Things get simpler when a clinician narrows down to recovery. Some of the recommendations for treatment approaches include; recommending strongly, motor recovery programs early on in rehabilitation from stroke, there is not sufficient evidence to recommend for or against the use of neuron developmental training (NDT) when that is compared to other approaches of treatment for motor retraining following acute strokes, it is important for motor recovery programs to incorporate multiple interventions whose emphasis is on repetition, progressive difficulties and functional task practice; motor recovery interventions that include improvement of ambulation should include cardiovascular strengthening and exercise fitness; putting into consideration the use of strength training as the therapeutic approaches’ component in paretic patients (Baker et al. 2018).

Evidence-based perspectives are based on the assumptions that the scientific evidence of occupational therapy`s effectiveness could be judged as being more or less strong and valid in line with a hierarchy of research designs, an assessment of the researches` quality or even both. Standards of evidence are aed by AOTA that are modelled on the standards of evidence developed in evidence-based medicine. The model standardises and further ranks those values of scientific evidence for biomedical practice making use of the system for grading that is presented in the field of “Rating Scheme for the Strength of the Evidence.” The highest level of evidence in the system includes literature systematic reviews, randomised control trials (RCTs) and meta-analyses. Participants in RCTs are allocated to either interventions or control groups and then a comparison is done of both groups’ outcomes. The Level II studies are another level of evidence whereby there are no randomised assignments to control groups or treatments. Level III studies do not have control groups and Level IV studies make use of single case experimental designs that are at times reported over several participants. Level V studies are basically expert opinions and case studies that include literature reviews that are narrative and consensus statements (Lynch et al. 2017). Future OT interventions for stroke rehabilitation could include further research into how different age groups, or cultures could battle their condition. Culture and religion is important to a lot of patients, future therapy interventions could focus more on this when planning rehabilitation techniques.

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