Stroke: Rehabilitation Outpatient Clinic

Samantha MacFarlane, Thusa Maheswaran, Leeatte Frisch-Israel, Amanda Pipino & Stephanie Stankov Assessment and Therapeutic Interventions II Professor Karen Hirshfled December 07, 2012

What is a Stroke?
Blood clots cause blockage in the brain Blood vessel tear causes bleeding in brain Two types: Ischemic Stroke Hemorrhagic Stroke Both cut off oxygen to the brain and cells begin to die within minutes Can affect different parts of the brain and lead to the following: Movement Issues, Balance, Endurance, Sensory Awareness, Vision, Communication, Judgment, Learning, Memory, Emotions Recovery is possible, but 2/3 of stroke victims suffer some disability depending on location and severity of stroke

 Rehabilitation
Crucial part of recovery for stroke victims Effects may deteriorate ones current capabilities May need to modify, relearn or redefine how individuals live

Rehabilitation does not reverse the effect of stroke

Stroke rehabilitation helps clients return to independent living Its goals are to build your strength, capability and confidence so you can continue your daily activities despite the effects of your stroke

Continuing Rehabilitation Care

What will I do in rehabilitation? Dependent on individual basis which may include:
Self-care skills such as feeding, grooming, bathing and dressing Mobility skills such as transferring, walking or self-propelling a wheelchair Communication skills in speech and language Cognitive skills such as memory or problem solving Social skills for interacting with other people

Application of TR Approaches

Clinical Approaches

Personal Growth Approaches

Outcome-orientedMeaningful, relevant and realistic

Benefits-based programmingParticipation in program, emphasizing benefits of activity, rather than activity itself

Continuity of lifestyleContinuing activities and behaviours participant had prior to stroke to maintain quality of life

TR Core Values
After suffering from a stroke, individuals still have the right to participate in leisure without barriers TRs can adapt programs so all individuals can be included Individuals differ on what they believe to be optimal health TR can influence individuals on achieving their view of what optimal health is TR looks at the whole person when assessing individual needs

Right to Leisure

Optimal Health

Individuals can determine their quality of life based on their own perceptions of well-being, happiness, physical and mental status, relationships, level of independence, work, financial status, living situation, etc. TR contributes by introducing and facilitating all areas of leisure to enhance individuals quality of life

Quality of Life

Autonomy
Individuals are free to choose their own leisure pursuits TR programs are based on the individuals interests, not what the TR determines they should do

Application of TR Model
Therapeutic Recreation Service Model
Purpose: Help client obtain optimal health and well-being with 4 components
1. 2. 3. 4. Diagnosis/Needs Assessment Treatment/Rehabilitation Education Prevention/Health Promotion

This model utilizes recreation for both treatment and leisure

Why This Model Was Chosen

It is a continuum focus on client needs and then progresses to health promotion The relationship between TR/Client that changes It begins with focus on client needs, a goal is established

Diagnostic Protocols for Population

Programs Artistic or Craft Programs (also includes music, dance, woodworking Strengthens creativity, personal growth, and problem resolution Engage in a process that is physical, emotional and intellectual Increases range of motion and coordination Encourage communication both verbally and visually Sporting Programs (walking, sports, games, etc.) Work on increasing functional motor performance Incorporated aerobic exercise training To improve strength and timing of muscle activations To improve cardio-respiratory fitness Aqua Therapy Water has natural buoyancy -lowers muscle and joint stress level Water has natural resistance that can help strengthen muscles Improve aerobic conditioning increases cardiovascular health and stamina Brain Fitness Stimulate cognitive development Enhance and maintain attention skills; memory and recall; visual and spatial processing Stress management training and practice

Brush Strokes

NAME OF THE PROGRAM

Brush Strokes

RATIONALE
Our program is designed to help stroke survivors who are no longer in hospital to reach their rehabilitation goals

IDENTIFICATION OF CLIENTS
Stroke victims of any age Any cognitive and physical functioning level Referred by Health Care Professionals

RISKS FOR PARTICIPATION

Emotional risk of frustration and anger Frustration due to client inability lack of capabilities Suggestions: TR assistance when necessary

3 SETS OF PROGRAM CRITERIA

30 minutes, 1 day/week, for 12 weeks Open program Weekly focus changes Different form of art/craft Clients/TR coloration on weekly theme Improving gross and fine motor skills that were lost due to stroke Improved physical and cognitive abilities

STAFF CREDENTIALS
Staff have to be aware of any potential barriers that will affect involvement Staff have to plan accordingly as to how they intend clients to participate during the brush stroke program

REFERENCES USED TO DEVELOP PROGRAM PROTOCOL

Therapeutic Recreation in Leadership and Programming, R. Kuntsler

For clients develop skills through arts and crafts that can transfer into everyday life Stimulate them emotionally and physically

Session Outline for Intervention

Duration of Session
30 minutes

Description
Clients will paint and decorate holiday ornaments Clients will be using and trying to build back fine and gross motor skills that may have been lost during the stroke

Tools and Equipment

Plain ornaments Paint Paintbrushes Table Tablecloth

Space and Environmental Requirements

Large table for decorating and drying ornaments Table needs to be large enough for multiple wheelchairs to sit around

Length of Program
12 weeks

Special considerations
Most clients will have lost fine and gross motor skills will require assistance

Teaching Techniques
Hand over hand Mirroring

Motivational Strategy
For older clients with grandchildren you can make an ornament for their grandkids

Goals of Brush Strokes

Our program is designed to help stroke survivors who are not longer in hospital to reach their rehabilitation goals To increase gross & fine motor skills, physical and cognitive function, develop new skills using arts and crafts

Arts & Crafts Program

Art program increases the following:
Physical and cognitive abilities Regaining lost functions such as left or right side paralysis

Fine motor skills Adapted equipment and activity modifications Help develop new skills Help cope with stress and frustration due to stroke Creative outlet Fun

TR program will increase leisure skills for outpatient population Keeps them in contact with the TR and continuing to work on their rehabilitation

Case Study
Lou-Ann is a 64 year old woman who, 6 months ago suffered a left sided stroke while tending to her flower shop. Her symptoms include right side motor impairment, and has difficult moving her arm, but still has limited function in her hand. She has not suffered any language impairment, but sometimes has trouble identifying objects around her. Lou-Ann enjoys crafts, being creative especially with her hands, and socializing. Lou-Ann needs a low stress program, that will help her improve mobility in her arms and hand and help her regain fine motor skills.

Client Specific Goal

Lou-Ann will demonstrate the ability to paint 5 brush strokes with her right hand for a duration of 5 minutes without using aid, as observed by TR.

Standardized Assessment
CERT PHYS DIS or CERT REHAB
Outpatients Loss of function Provides starting point of capabilities Measures
Gross Motor, Fine Motor, Locomotion, Motor Skills, Sensory, Cognition, Communication, and Behaviour

Reassessment for improvements +

Evaluation
Determines clients functional ability Formulate treatment objectives Assess clients strengths Evaluate progress

Case Study Example: Evaluate Lou-Anns progress with the following:

Self-Evaluation
Was the activity meaningful? Does she feel the activity helped her mobility?

TR Observation
Start simple and increase challenge (FLOW) to track progress

Duration
Observe Lou-Anns ability to continuously maintain right hand fine motor skills

Recommendations
Program variations
Client participation/choice

Equipment used an assessment tool

Different mediums utilized
Paint types, clay, play-doh, scrapbooking, stickers, crafting

Client participation weekly is beneficial for progress Weekly promotion of program

Facilitation of Intervention
FACILITATION TECHNIQUES
Introduction Name game Theme Info for TRs
TR/support staff for client Techniques
Hand-over hand

References
AATQ. (2012). About art therapy. Retrieved December 02, 2012, from http://aatq.org/en/arttherapy.php ACE Fitness. (n.d). Starting a stroke recovery fitness program. Retrieved December 03, 2012, from https://www.acefitness.org/fitfacts/fitfacts_display.aspx?itemid=2604 American Heart Association. (2011, April). Post-stroke rehabilitation. Retrieved December 03, 2012, from http://www.strokeassociation.org/STROKEORG/LifeAfterStroke/RegainingIndependence/PhysicalC hallenges/Post-Stroke-Rehabilitation_UCM_310447_Article.jsp Duncan P, Richards L, Wallace D, et al. (1998). A randomized, controlled pilot study of a home-based exercise program for individuals with mild and moderate stroke. Stroke. 1998;29: 20552060 Hirshfeld, K. (2012). Assessments and common concerns in tr [PowerPoint slides]. Retrieved from my Seneca Website: https://my.senecacollege.ca/webapps/portal/frameset.jsp Hirshfeld, K. (2012). TRC 502 Class 3 [PowerPoint slides]. Retrieved from my Seneca Website: https://my.senecacollege.ca/webapps/portal/frameset.jsp Nevins, P. (2011). The effects of left sided stroke. Retrieved December 03, 2012, from http://www.livestrong.com/article/91868-effects-left-sided-stroke/#ixzz2E2EoxZEW Postit Science. (2012). Stroke. Retrieved December 03, 2012, from http://www.positscience.com/whybrainhq/world-class-science/peer-reviewed-research/ongoing-research-in-specific-healthconditions/stroke Saint Lukes Health System. (2012). Brain fitness. Retrieved December 03, 2012, from https://www.saintlukeshealthsystem.org/service/brain-stroke/brain-fitness Welch, C. (2010, May). What are the benefits of aqua therapy. Retrieved December 03, 2012, from http://www.livestrong.com/article/124996-benefits-aqua-therapy/