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Stroke Part 1: Overview & Functional Impairment | OT Miri | OT Miri | YouTubeToText
YouTube Transcript: Stroke Part 1: Overview & Functional Impairment | OT Miri
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Video Transcript
did you know that someone in the united
states has a stroke every 40 seconds
and every four minutes someone dies of a stroke
stroke
it's no surprise then that stroke comes
in as one of the top leading causes of
long-term disability in the united
states and it's an important practice
area for occupational therapy and one
that i'm really excited to talk to you
guys about today
hi everyone it's been a long time
welcome back to the ot mary channel my
name is mary i'm a licensed occupational
therapist and in today's video i'll be
talking about stroke and some main
functional impairments you may see with
patients who have had a stroke
now because of the sheer volume of
content that'll be covered in just this
video alone
i'll be saving assessments and
intervention for another video next time
not today
now i've been wanting to make a video on
stroke for a really long time like three years
years
but also resist it because there's just
so much content from learning the
anatomy to the pathophysiology and intervention
intervention
so i was torn because on the one hand i
wanted to make this like really short
and simple sweet overview for you guys
but i also knew that there really isn't
a shortcut to understanding and really
learning the complexities of this
condition so
in the end at least for me um i decided
to get into the trenches and really
study the different and wide variety of
ways that stroke can affect our functioning
functioning
and unfortunately memorization just
won't be good enough for learning
neurological conditions so this video is
going to be a tad bit long but stay with
me let's get through this together and
and
be sure to check the video description
for links to all the resources that i
love and found to be very helpful some
of which are actually just for
motivation and inspiration i still go
back to a lot of these resources um
when i want to refresh my memory or i
just find myself feeling stuck and want
to be inspired so that'll all be listed
below okay
all right so let's get started there's a
lot to cover like i said i want you guys
to get comfortable and take your mind to
a happy place because you'll absorb a
lot more and retain better when you're
feeling relaxed we know that right
so um what is a stroke
well the medical term for stroke is
cerebral vascular accident and it's
characterized by
neurological deficits that occur when a
blood supply to the brain is interrupted
or impaired and oxygen cannot get to our
brain and this is bad news because our
brain needs constant and constant supply
of oxygen which is carried in the blood
through our blood vessels so when this
rich oxygenated blood is cut off or interrupted
interrupted
the brain won't get the oxygen it needs
and the brain tissues in that area will
begin to die and that's how we get stroke
stroke
so what causes this impairment of blood flow
flow
what is a mechanism by which our blood
supply to the brain gets cut off or interrupted
interrupted
well there are two main causes
mechanisms and these strokes are
actually classified by these mechanisms
so the first way that our blood flow can
be interrupted is through a blockage in
the blood vessel like a blood clot so
you can think of it like
a clog in the pipe of the drain where
everything gets blocked so when you get
a blockage in your blood vessel it'll
obstruct the flow of blood to the brain
and this type of stroke is called
ischemic stroke which accounts for
about 87 of all strokes
and um there are two types of ischemic
stroke i'll go over them very briefly
thrombotic and embolic stroke both of
which have to do with some sort of
blockage in our blood vessel uh with a
thrombotic stroke you have a thrombus
hence the name thrombotic stroke and
thrombus is just a medical term for
blood clot so it's a blood clot that
develops in the artery supplying blood
to the brain obstructing blood flow and
this type of stroke is often seen in
older patients especially those with um
high cholesterol and atherosclerosis
now a second type of ischemic stroke is
called an embolic stroke and this is due
to a blood clot that forms somewhere
else in the body and it travels um
ultimately getting lodged or stuck somewhere
somewhere
um on its path to
the brain obstructing blood flow so the
key thing to know here
is that an ambulance is basically any
floating or moving particle like fat
cholesterol plaque or any foreign body
that leaves its site of origin and it
travels in the bloodstream so
a thrombotic stroke occurs when a
thrombus or a blood clot develops and
blocks blood flow at the site where it
originated it stays there and it blocks it
it
when this thrombus breaks off and it
starts to move and eventually
gets lost somewhere while it's traveling
away from its side of origination you
have an embolic stroke embolic stroke so
i know i spent a bit of time on that
actually more than i wanted to but this
was actually always very confusing for
me when i was in school so i wanted to
help make that distinction clear between
the two types of ischemic stroke now
now
in both of these ischemic stroke types
there's an occlusion like that said
right or blockage somewhere in the blood vessel
vessel
and that's why for ischemic stroke you
guys uh thrombolytic agents like tpa
it's short for tissue plasminogen activator
activator
are used as first line of treatment in
the acute medical management so it's not
something that we do but it's still
important for us to know and you can
think of tpas like clot busters that
work to dissolve the clot that's
blocking the blood flow basically opens
up the occluded vessels and restores
blood to the
ischemic areas
and time is brain so we want to get this
in as soon as possible
so as for
the window of time that is most
effective there's actually ongoing
research and the exact treatment protocols
protocols
uh continue to get defined and redefined
as we learn more but the use of a
three-hour window from the onset of
symptoms have shown favorable outcomes so
so
helpful hint here if you're ever with a
patient or loved ones experiencing a
stroke note the time of symptom onset because
because
one of the first questions that will be
asked at the hospital is what time do
the symptoms appear
all right so
so
um now let's move on to the second major
type of stroke this major classification
which is um hemorrhagic stroke and this
accounts for around 13 of all strokes so
it's far less common than ischemic
strokes and that's a good thing because
hemorrhagic strokes have a much higher
rate of morbidity and mortality
so in this type of stroke a weakened
blood vessel ruptures and it bleeds into
the brain tissue or into the spaces
around the brain so here instead of a
blockage in the vessel like you have
with the ischemic stroke you have a
breakage in the vessel so if we were to
go back to using that pipe as an example
a hemorrhagic stroke is like having a
leaky or busted pipe that ultimately
breaks as opposed to a clot pipe in
ischemic stroke okay
now when that bleeding goes into the
brain tissue we call that intracerebral which
which
often results from hypertension so
chronic or severe hypertension um it can
also be caused by artery venous
malformation avm and if you don't know
what that is it's basically like
your blood vessels when they form
abnormally and they become all tangled
and over time these tangled blood
vessels get weak and can burst so
hypertension and avm are common causes
of intracerebral hemorrhage
but you can also have bleeding in the subarachnoid
subarachnoid
space and serachnoid hemorrhage is
usually caused by ruptured aneurysm
which as you know occurs when you have
abnormal ballooning or
bulge in the weakened wall of the blood
vessel right and it breaks
so these are some of the causes um and
there are other ones that i won't be
going over in this video but these are
some of the main causes of hemorrhagic stroke
stroke now
now
usually with a hemorrhagic stroke it'll
come on suddenly and the person will
complain about a very bad headache they
might say it's like the worst headache
of their life and i remember this one by
remembering president roosevelt who is
reported to have said
i have a terrific pain who caused their
pain terrific i have a terrific pain in
the back of my head
before collapsing and dying later that
day and he had suffered a massive
cerebral hemorrhagic stroke so
now for something like a hemorrhagic
stroke would the patient still be given
a thrombolytic agent like tpa
no right because as i mentioned earlier
thrombolytic agents uh work to dissolve
a blood clot and there's no blood clot
to desert dissolve here with the
bleeding hemorrhagic stroke and one of
the major risks of administering tpa's
bleeding so
probably wouldn't be a solid plan for
patients that's already bleeding in the
brain right
so that's why when a patient comes in
with a stroke they're like rushed to get
imaging done first to rapidly determine
whether or not there's a bleeding
because if it's hemorrhagic the
treatment and medical management will
look very different
so that was a review of two major types
of stroke
and before i move on to risk factors i
want to briefly mention um also
transient ischemic attacks pia they're
sometimes referred to as a mini stroke
and transient means temporary and we now
know what an ischemic stroke means
ischemic means there's some sort of
blockage so a transient ischemic attack
is a temporary blockage leading to
obstruction of blood flow so like
ischemic strokes tiaa's are often caused
by blood clots and
since it's transient um it'll usually
result within an hour to several hours
but unlike ischemic strokes which leaves
you with tissue damage there's actually
no infarction with tia so no lasting damage
damage however
however
tiaa is a serious warning sign that you
can have a stroke and if i remember
correctly more than a third of people
who have a tia actually go on to have a
stroke within one year if they don't get
treatment so
not something to take lightly because
the diagnosis of tia can lead to medical
interventions that can ultimately
prevent an eventual stroke right
right so
so
now let's go over some
risk factors beginning with
non-modifiable risk factor so things you
can't control or change to reduce your
risk of having a stroke
for one age
no one no one can stop aging
with an increase in age your risk for
stroke goes up and that's for both men
and women
secondly your gender unfortunate for me
women have a higher lifetime risk of
stroke than men and it kills more women
than men
your race is another non-modifiable risk
factor african americans are
disproportionately affected experiencing
higher risk of death
from a stroke and caucasians and also um
what is it your family history your
family history and genetics also matter
so if your parent grandparents sister
brother has had a stroke
especially before reaching age 65 you
may be at greater risk
finally someone who's had a stroke has a
much higher risk of having another one
than those who have not had one so a
prior history of having had a stroke is
also a non-modifiable risk factor since
you can't change your past but it's not
all gloom and doom but there are still
many things we can do to risk our
chances of having a stroke and we can do
that by working on modifiable risk
factors so these are things we can
control or change so let's go over them
these are the
hopeful ones the first one is hypertension
hypertension
hypertension you guys is one of the most
important modifiable risk factor
because it's the leading cause of stroke
um other non-modifiable risk factors
include diabetes hyperlipidemia
smoking obesity and physical inactivity
as well
oh my goodness i have so many of these
and heart disorders such as atrial
fibrillation as we discussed earlier
also increases the risk of having a
stroke so cardiovascular risk reduction
including treating hyperlipidemia
is an important part of reducing our
risk for stroke
now one of the best ways you can quickly
detect symptoms of a stroke
is by using the acronym fast
f is for facial drooping does one side
of the face droop or is it numb as a
person to smile is this person's smile
uneven is it even
and a is for arm weakness so is one arm
weak or numb
you can ask the person to raise both
arms does one of the arms drift downward
and you'll hear the term arm drift a lot
right um that's when one arm drifts downward
downward
and s is for speech speech difficulties
um is there trouble speaking or
understanding speech is the speech slurred
slurred
and finally t for time um because if you
see these signs it's time to call 9-1-1
there are certainly other symptoms and
signs and if you'd like to hear a
first-hand account from someone who's
experienced this oh my goodness you guys
there's a great ted talk it's not too
long i think it's about 10 minutes
and a book by a neuroanatomist so this
is someone who literally studies the
brain and how it works a brain scientist
named jill taylor and what are the odds
that she experienced strogan delivers a
remarkable witty funny powerful
first first-hand account of experiencing
a stroke
uh i cried in life laughed through it
it's it's great it's called a my stroke
of insight
so um take a listen when you want a break
break
all right so we're going to shift gears
now and talk about some functional
impairments so everything i talked about
up to this point it's important to know
it's good to know but this is really
where i think we need to have a great understanding
understanding
because it's where we can really make
impact as ot practitioners
because we play such a huge role in
stroke rehabilitation so to start let's
first go through motor impairment which
can present with hemiparesis or hemiplegia
hemiplegia
now parisis refers to weakness and
pleasure refers to paralysis so the
impairment can range from a mild
weakness to a complete paralysis and one
way um i like to remember paresis is by
associating the word paresis but
preserved paris is preserved because
it's not a complete paralysis you have
some preservation so think of preserved
with paresis and remember that with some
preservation paresis is less severe than
flesia and the word hemi in hemiparesis
or hemiplegia means it's affecting only
one half of the body and it's on the
side that's contralateral to the
hemisphere of the brain with the lesion
so that's the side of the body opposite
from where there was a lesion which
means if you have a lesion in the left
hemisphere you'll have right hemiplegia
and a lesion in the right hemisphere
will produce left hemiplegia
okay so given this weakness what do you
think might be some functional limitations
limitations
well from one you'll observe
male alignment and the
patient's posture immediately after
stroke and this can be due
not only to weakness but also muscle
imbalance as well as effects of gravity too
too
but this male alignment and the effects
of it will be especially evident in the
loss of trunk and postural control
you guys this may not seem like a big
deal right now if you've never dealt
with it dealt with it because we don't
ever think about the role our trunk
plays into our everyday movement
but our trunk control is what allows us
to change our body position
shift weight control movement against
gravity reach out to grab things within
or outside our arm reach without falling
over everywhere so from dressing
toileting bathing grooming to eating we
use our trunk control pretty much to
perform just about all of our adls and
research shows a clear association
between trunk control and um
functional independence but in patients
with stroke what you'll see is poor
trunk control that leads to poor city
balance that slump posture with
trunk flexion and posterior pelvic pills
malalignment and
difficulty adjusting the trunk to arm movements
movements
all of which makes falls and injuries
that much more likely so restoring trunk
control as well as sitting balance is
one of the main goals in stroke
rehabilitation and we'll be talking more
about this in part two of my stroke
series where i'll go over
treatment and intervention but trunk
control postural control very important
what else um
um
well in addition to poor sitting balance
patients with a weakness will also have
challenges with activities that require
lower extremities and that's because
when you're standing the weakness won't
support the weight of your body which
will affect the patient's ability to
bear way through the affected leg now
you throw in spasticity weakness uneven
weight distribution through the lower extremities
extremities
and um oh fear of falling which is very real
real
do you think this person would be able
to assume and maintain upright standing posture
posture
or shift weight
that'd be challenging right so what
you'll often see is an asymmetrical
posture and weight distribution as well
as poor upright stability which will not
only increase their risk for false but
also significantly impact their ability
to do all the functional tasks that
require both static and dynamic standing
like cooking doing the dishes reaching
over to get something from the cabinets
and i mean the list goes on it's endless
another set of challenges that comes
after stroke and these are really
important too
are impaired postural reactions and
postural strategies
which are really crucial for balance and
maintaining upright postural control
you guys if you don't know or remember
what these uh postural reactions and
strategies are i would highly recommend
that you familiarize yourself with them
uh because
they're pretty important
actually let me just go over them real
quick because we're gonna need to know
them anyway when we talk about
intervention in the next video so
basically in short patients with a
stroke typically have postural imbalance
and impair postural adjustment
strategies and these include the ankle
strategies the hip strategy and the
stepping strategy you might have read
them or learned them in the school
and you will most often notice these
deficits manifest
in our patients and their ability
inability to maintain or restore their
balance again when their equilibrium is
thrown off somehow it could be thrown
off in a small way or thrown off in a
big way and that's because maintaining
our balance requires spontaneous
automatic adjustments so this isn't
something we do consciously but
everything we do from sitting
staying seated standing up moving
forward backward all require
instantaneous adjustments in our sense
of balance and requires knowledge of
where we are in space so when we lose
that ability we lose our balance and
remember these reactions don't just help
us in dynamic movement situations they
also help us in static situations
because our bodies are
constantly making these automatic
spontaneous adjustments even when we are
just standing still um
um
let me give you some concrete examples
so you can get a better idea so i want
everyone to stand up stand up for a
minute with your feet about shoulder
are you standing
it's a good way to take a break too
movement is good for us okay so stand up
and now um just observe
are you standing absolutely still with
this isn't something we think about
consciously and you may not have noticed
it but we're actually moving and swaying
in tiny movements and this is happening
at the ankle joint where the muscles
around the ankles activate and moves
constantly in slow swing motion
this you guys is called the ankle
strategy and these are employed when
there's a very little or a small
amplitude of perturbation so this is
known as one of our first line of
defenses against falls because it's what
helps us stay standing in upright
posture by maintaining our center of
mass basically over its base of support
and all of this requires strength range
of motion and um what's that word uh
drawing a blink here
proprioception proprioception in the
ankles and the ability to bear weight
through the feet so think about how
challenging it would be for our patients
with hemiparesis or hemiplegia
without ankle strategy our ability to
perform standing activities
uh let alone just stand like waiting in
a line in a grocery store or at the
concert or standing over the stove to like
like
you know nurse your soup and stir
will be greatly impacted now
now
when we go beyond small perturbations
that our ankles cannot correct we move
on to hip strategy which gets triggered
when there's like big and fast
perturbations so in other words when you
get that sudden and forceful disturbance
to your base of support the muscles
around your hips uh hip joint will
activate and response and move to
wherever it needs to go so we don't fall
outside our cone of stability now hip
strategies also gets
activated when um
the support surface is too narrow or any
surface that's more narrow than your
feet so that can include things like
walking on a tightrope or a beam if
you're a gymnast or slacklining
now when neither ankle nor hip
strategies are enough to restore our balance
balance
stepping strategy kicks in to save the
day and this is that dynamic situation i
talked about earlier
and it's triggered when the perturbation
is so big so large so forceful that we
have to take a step to widen our base of
support because your center of gravity
has been displaced beyond the base of
support now an example that comes to
mind uh when i think about stepping
strategy takes me back decades back to
my college days in berkeley when i used
to take bart to san francisco no matter
what time of day i got into the train
there was never any seats and i always
found myself standing and whenever the
train came to a sudden halt
i'd stop myself from falling by taking a step
step
and i never did this with a thought okay
mary time to take a step wide on the
base of your support so you don't fall
it was just an instant reaction right so
with the stepping strategy we are
actually modifying our base of support
by broadening it and all of this is
happening without much thought because
it's an automatic postural reaction that
our bodies come equipped with
so i hadn't plan on talking about this
one but
if not now i would have come in the
second video so i'm actually glad i
talked about it because these are really
important and you can see
how important these are because with
patients who've had a stroke these
postural adjustment strategies are
impaired and you will notice these episodes
episodes
manifest in their inability to assume
and maintain a posture standing posture
a proper standing posture as well as
inability to find balance again when
their equilibrium is thrown off so
there's an increased risk for falls and
a significant impact to their everyday
adls okay
oh i'm talking really fast
all right well we're gonna shift gears
now and talk about upper extremity impairments
impairments
now whenever you're learning about
postural complication you'll almost
always hear about subluxation of a
glenohumeral joint because it's so
common and subluxation is basically a
partial dislocation of the shoulder
joint where the upper arm bone or the
humerus become partially dislocated from
the shoulder pocket or socket or the
glitter fossa
and just as our shoulders move in
several directions displacement can also
happen in several directions meaning it
can be inferior anterior or superior now
now
when it comes to the mechanism of how
subluxation happens after a neurological
event like stroke
the mechanism remains somewhat
controversial but let's think through
this together and see how subluxation
can occur with a patient with hemiplegia
so for one as we discussed earlier after
a patient has had a stroke what you'll
have is this
muscle weakness right
and this profoundly affects the
patient's ability to actively position
the spine and the trunk as well as the
arm in upright posture
now you throw in gravitational pull
that's happening on the entire upper
extremity pulling the weight of your
heavy flaccid arm and you don't have the
shoulder muscle strength or the ability
to recruit appropriate muscles to hold
the humerus in place now over time the
weight of the unsupported arm will cause
the humeral head to sublux downward into
the glenoid fossa
another factor to consider is spasticity
of the shoulder complex mainly the
subscapularis and pectoralis this pool
of the muscles
can also cause subluxation
now one thing i want to mention real
quick before i move on is that not all
sublex shoulders are painful
and the relationship between shoulder
supplexation and pain is really not clear
clear
but not all painful shoulders are sublex
and not all supply shoulders are painful
though pain can exist okay
um what other postural complications
might you see in the upper extremity
let's see
um well we already talked about this a
little bit with subluxation about how
our limbs become vulnerable to
gravitational pull with weakness well
well
combine that now with acute low tone
stage patients undergo after stroke
where there's little to no muscle activity
activity
this is especially bad
because this inability to recruit
appropriate muscles or maintain muscle
activity and strength will result in changes
changes
to the resting alignment of our limbs
and you end up with structural changes
in the skeletal muscles so you get this
abnormal skeletal muscle basically which
leads to all sorts of other secondary
complications like edema
soft tissue contracture
shortening of muscle
you have over stretching of the joint
capsule and the glenohumeral joint and
just overall damage and injury to the
joints and soft tissue and that makes
sense right i mean if you have weakness
and lack of control or sensation in one
side of your body
you can get injured doing pretty much
anything and if you work in the neural
setting you may be familiar with these
challenges and have plenty of examples
but if we were to use an arm as an
example when a patient has a weak arm
that arm may just be dangling around um
getting caught under over in between i
mean it's pretty much at risk of getting
pinned or caught on any surface during
better wheelchair mobility um i still
remember when i was doing stroke rounds
during my time at usc i observed the
patient sitting on his hand in like the
most awkward way and just
looking at his hand made me cringe
inside because it was positioned in such
a painful and uncomfortable way
so i think understanding how this
combination of weakness and immobility
gravitational pull the weight of the
unsupported arm and how all of that
contribute to abnormal skeletal muscle
is really important uh for us to
understand the patient's movement
patterns and this really helps us set
the foundation for how we treat our patients
patients
all right so that's it for upper
extremity experiment um impairment for
this video but if you plan on working in
the neural setting
know that the research and science for
evaluating treating upper extremity
impairment never ends
as this is a very complex issue
and there's so much more to be learned
than this brief overview i just
presented here in this video
all right what's next uh all right well
let's switch gears now and go over
communication impairments um now you
guys know that i have a separate video
on this it's title of facial my youtube
channel and website so i'm gonna just
breeze through this session um starting
with global aphasia
this is the most severe form of aphasia
and it's the loss of all language
abilities so it's a global law spanning
all aspects of language speaking
understanding reading writing
then there's broca's aphasia also known
as expressive aphasia because there's
impairment in the expression of language
so you might hear slowed speech
lots of pauses omission and words and that
that
cadence and rhythm that accompanies our
normal speech will be absent so to
remember this one think broken with
broke up it's broke us broken speech
now contrast that to warranty's aphasia
in word against aphasia they talk
fluently and speech is produced with no
effort but the person's speech is devoid
of meaning and will not make any sense
so where broca's was a deficit in
expressive language with trouble speaking
speaking
wernicke's area is primarily involved in
comprehension which is why it's also
known as receptive aphasia because of
the impairment and auditory reception
finally we have anomic aphasia which is
difficulty finding and naming words and
objects with speaking and writing and
patients with anomic aphasia will have
difficulty with word retrieval and
they'll also have trouble expressing the
words that they want to say
now these are all very different um than dysarthria
dysarthria
and dysarthria is a disorder of
articulation so this has more to do with
weak or inefficient motor movements that
prevent patients from speaking clearly
and it can be from weakness paralysis
and coordination or involuntary movement
of those muscles used for speech so
dysarthria is a is in a different
category of communication disorder than
aphasia and there are subcategories of
dysarthria like a toxic dysarthria
dysarthria but
we're not gonna go through them here
because i think that's just too much detail
detail
for this intro video all right
um what's next
perceptual deficits
we'll talk about perceptual deficits now
i'm gonna cover some of the main ones
only that you might see because there's
so many and i don't want to spend too
much time on this portion
but the first one we'll talk about is a
spatial relations and positioning
this one is referring to our ability to
know where objects are in space and how
they relate to each other so this one's
easy you just gotta think of the word spatial
spatial
with space so where things are in space
and relations with how they relate to
each other
and when there's impairment in this area
patients will have trouble perceiving distance
distance
as well as understanding how and where
to place objects so you might see a
patient who would accidentally knock
something over
because they either overestimated or
underestimated distance or you can
clinically manifest as patients having
trouble positioning their toothbrush
while trying to apply the toothpaste
onto the brush okay
okay
then there is spatial neglect this is
referring to the inability to orient and
respond to the contralateral stimuli in
other words there is a failure to
respond to things that is on the side
opposite a brain lesion so if you have
damage to the right side of the brain
you will neglect stimuli on the left and
neglect is most commonly seen in
patients with the right hemisphere brain
damage so the clinical presentation
you'll see
typically is neglect on the left side
um so you've probably heard this being
referred to as left neglect and this can
pretty much affect everything you do in
your daily activities um
um
for example when having a meal patients
with spatial neglect may only eat from
the right side of the plate leaving the
entire left side untouched
um what other clinical implications
might you see
well for patients that are still in the
hospital we might we have to consider
that they may not be able to find a call
button that's on the left side of the
wall right and this is why you may see
ots using compensatory strategies initially
initially
moving and placing important items like
call by 10 and phone on the left side
now i want to quickly mention that
spatial neglige is not the same as
having a visual field deficit although
they're often confused and can look
alike a patient with stroke may
certainly have a visual field deficit
but remember spatial neglect on one side
is more about deficits and visual
attention and scanning so
so
neglect is a disorder of inattention
which is why you might sometimes hear
neglect being referred to as hemi
inattention because patients with a
spatial neglect will not make an attempt
to direct search toward the neglected side
side
all right so we'll talk more about this
later when we talk about the visual
impairments but for now please remember
that neglect is not the same thing as
visual field deficit though they can
co-exist and being able to diagnose them
properly will be important because
treatment will look different depending
on whether you have challenges with inattention
inattention
versus an actual cut in your visual field
field okay
okay
now what happens when um neglect occurs
within our own personal space um
um
body neglect so this is when the patient
neglects his own body on the
contralateral side so what you might see
here is patient shaving only half of the
face and leaving the other side untouched
untouched
or not washing the affected side
but this deficit can affect so much more
beyond just grooming because neglecting
the effective side can also mean that
you're not using the affected limbs
appropriately so body neglect can affect
things like mobility too because
patients may not integrate the
entire left side of their body during
bed mobility and transfers so that's
body neglect then it can present a lot
of challenges
all right now um let's take a look at
this image here
can you recognize what kind of animal
this is
her body is somewhat contorted and in a
position that is not typical to what you
may see regularly but can you still tell
what it is
how about this one were you able to
recognize these images as an image of a
dog even though they were placed in
oddly different positions
well you probably did because you have
the ability to identify objects despite
variations from the norm meaning a
change in size or shape or color
location or position won't affect your
ability to recognize the object right
this is called form constancy and for
people who've suffered a stroke this
ability may be lost and they'll have
difficulty recognizing an object when it
changes or varies from its normal
position or size or shape so for example
a cup that's turned upside down or a
computer that's placed i don't know
toppled over and it's placed on its side
or a pen or pencil that's
three times larger than his size so to
remember this one just remember the
meaning of the word constant
consonant refers to a
situation or a state of affairs that
doesn't change right so form constancy
is knowing that the object has not
changed despite its change in size shape
or position
all right let's look at a different
image now um here i want you to
see if you can locate the scissors this
is my kitchen utensil drawer that i just organized
organized
it was a clutter mess embarrassing so
i cleaned it up for you guys
did you guys find
it this is called figure ground
discrimination it's the ability to
distinguish objects in the foreground
from objects in the background so in
other words it's differentiating or
locating an object from its natural
background and patients with thicker
ground difficulty may not be able to
find a night from a drawer full of
utensils like you just did
what other examples can you think of for
figure ground discrimination
how about a dresser full of different
clothes can you imagine how hard it'd be
to locate a pair of socks on a drawer
full of all different items in the
foreground in the background
um how about sorting and matching your
socks during laundry i mean you can see
how this can impact so many things in
our adls right another example in the
bathroom is trying to find your
toothbrush that's mixed in with all the
cluttered items on the sink well maybe
your sink is not cluttered mine is so
cluttered it's
i mean the list goes on
all right so next one let's look at this
image can you see my little dog stella
in this image
the rest of her body is covered by my
dress and you can only see her head
which is also positioned sideways but
can you still recognize that this is a dog
dog
how about this one
um do you see it even though it's
partially covered
this you guys is visual closure which is
the ability to accurately um identify
objects that are partially covered or
missing so even if there is like an
incomplete representation a missing
piece this ability helps you quickly
make sense of what you see
and identify the object even if the
entire object is not all visible to you
uh so this means that you do not have to
see every detail in order to recognize
something which is what allowed you to
quickly locate my dog and the apple and
the images i just showed you
but for patients who have difficulty
with visual closure they'll have trouble
completing the image that's partially
covered or missing uh like the dog on my
lap or the apple that was partially covered
covered
but other real life examples include
ability to identify objects while in the
community so think about how many
traffic light signs or sides you come
across when you're driving and many of
these are actually
often hidden behind a tree or covered
partially by buildings and other
structures now what would happen if you
can complete this image in your head
because it's partially covered these
traffic signs and lights i mean not good
right so to remember this one i like to
think of the word closure because one of
the definitions of that word is finding
a sense of resolution or conclusion at
the end of something so when you find
closure you will have closed out and
finished something and that way visual
closure is when you find resolution by
completing the missing piece in your
mind's eye to complete the incomplete representation
representation
does that make sense
all right so next
different types of agnosias starting
with visual agnosia now visual agnosia
is when a patient is
unable to identify objects by looking at it
it
although they have normal visual
foundation skills
so the patient's vision and visual
perception are intact but they'll have
difficulty recognizing or naming
familiar objects so patients with visual
agnosia may have to hold the object and
use tactile cues you know through touch
or they can use their sense of smell
to smell it if it has a distinguishable
smell like wine like flour to identify
the object
now to remember the term visual agnosia
remember the root words a is without and
gnosis means knowledge so without knowledge
knowledge
people with visual agnosia do not have
knowledge of the object because they
can't recognize it even while actually
looking and seeing the object
um now that you know the root word
meaning for agnosia it'll be easier to
know and remember other forms of agnosia
so for example
color agnosia
as the name implies is the inability to
recognize color despite intact color
perception so even though your eyes may
be capable of distinguishing the colors
the world might be seen in shade of gray
black or white
so think of how hard it would be to
drive especially with traffic lights
when you have color agnosia
and then there is tactile agnosia which
is the inability to recognize common
objects by touch or tactile manipulation
although basic tactile sensation is
intact and many of us done this
have done this while driving and i'm
definitely guilty of it but have you
ever reached into your bag or purse to
find something without like looking
you're like fishing around for it well
the seemingly simple ability to identify
something by touch alone without visual
input is compromised in patients with
tactile agnosia
all right
um and
then there is oh somato agnosia which is
a disorder of body scheme and uh this
comes from the root words of matter
which means body this is where the
patient fails to recognize their own
body parts and how they relate to each other
other
so uh this is a strange one so with somatognosia
somatognosia
patients may put their arms in through
the leg holes when they're dressing or
if you're working with them they might
even try to put your arm into their
shirt in the process of trying to get
dressed so there's a disconnect
somewhere here with the body scheme and
the inability to recognize their own
body part
which can present so many challenges and
everyday adls
then there is prosopagnosia
prosopagnosia
this one is the inability to recognize
faces which makes sense because the
origin of the word prozo means face
not surprisingly then this deficit is
sometimes referred to as facial
blindness and in some cases patients may
not even recognize their own face in the
mirror or in the photo and
and
you know the way i remember this one is to
to
just think of the word prozo person
since prozo looks and sounds somewhat
like a person so inability to recognize
a person's face okay
uh finally i want to talk about a nose
of nausea this one is referring to a
lack of understanding the insight or
awareness of your conditions so
um to remember this term just think of
the root words again a means without
nozo means disease and nausea is
knowledge so in this case without
knowledge of the disease
now at first glance this may not seem
like a big deal you might think oh
they're just in denial they're going
through a hard time but
think about the clinical manifestation
and how this lack of awareness can
affect someone who has hemiplegia post stroke
stroke
this patient not realizing that they
have an impairment may overestimate
their abilities making them more likely
to engage in potentially risky
situations increasing their risk of
falls um this lack of awareness can also
show as a lack of concern about the
deficit which would definitely affect
their level of motivation to participate
in therapy or get better so
it's really important for us to be aware
of this condition and to work through
these challenges with our patients
oh my goodness that was a lot
a lot to digest a lot to say
and i really had
trouble uh studying all this when i was
preparing for the exam but you know what
i didn't have was a study buddy so
hopefully um as you're going through
these but to me you won't feel too
overwhelmed that's the hope at least but
we're almost done now so you're uh
you know need to take a break feel free
to pause here okay okay
okay
next i want to quickly go over some
cognitive impairments might see because
these deficits are also very common with
stroke and i'm just going to breeze
through this section too because most of
these are pretty uh straightforward so
to start let's talk about initiation
patients who've had a stroke may have
difficulty with initiation of an
activity or task or movement so
basically starting something starting an activity
activity
then there is attention the ability to
maintain and sustain focus and i think
this is something we all struggle with
to a degree especially when we're trying
to do something and get something done
but here i'm actually talking about the
kind of attention deficit that gets in
the way of completing what would be a
relatively simple task that may not even
require like 30 seconds to complete like
brushing your hair washing your face
this can present as inability to attend
to something but it can also show as
inability to drown out or screen out
distractions or irrelevant stimuli from
our environment
then there's organization super simple
we know this work this is simply the
ability to arrange things into order but
more specifically in our context of how
we work this is the ability to organize
in order to perform the task efficiently
and engage in meaningful tasks so
remember we are occupational therapy
practitioners so we're always looking at
skills and abilities that affect our
ability to
perform meaningful and purposeful tasks
right so in the kitchen this skill might
look like taking out all the ingredients
you need at the same time from the
refrigerator or in the workspace it
might look like gathering all the
materials you need like paper pencil notebook
notebook
everything you need to take notes okay
similarly sequencing sequencing is
another executive function deficit you
may see related to completing a task
sequencing is the ability to complete
the steps of a task in the right order
and finally we see challenges in the
area of problem solving so this is the
ability to find solutions and solve problems
problems
so let's put all these deficits together
and see how they might affect the simple
task of
putting on our shoes
as an example first you have to
uh initiate the tasks and start the
process of putting on your shoes right
so the initiation then you have to stay
focused and keep your attention
on the task at hand without getting
distracted or getting drowned out by
other things in the environment other
distractions and then you have to
organize by getting everything you need
like shoes and socks then after that you
have to sequence this task and all the
steps involved by first putting on the
socks then shoes then tying your
shoelaces and when you mess up or come
across a challenge like realizing that
you forgot to put on your socks before
putting on your shoes then you have to
figure it out and problem solve
these are things that you and i do
without a thought but there's actually
really a lot that goes into an activity
as simple as putting on a pair of shoes
and lucky for our patients we are
trained in activity analysis and can
break this down and help them
so these are some cognitive impairments
and they're definitely important for us
to know okay
okay
um moving on next we're going to talk
about apraxia and um this is another
video that i have already on youtube and
on my website so check that out i won't
go into too much uh detail here i'm just
gonna touch on the subject
but in short apraxia is a dysfunction where
where
there's a difficulty in performing
purposeful skilled movement
and this
deficit is not attributed to or
explained by sensory motor deficits or
comprehension deficits and one type of a
proxy you may see is ideational apraxia
which occurs when there's a breakdown of
the ideation or conceptualization
process so patients with ideational
apraxia will have no idea
or they won't have the right idea on how
to perform a task or how to
conceptualize a multi-step movement so
they'll have trouble using objects
appropriately because they've lost the
perception of the object's purpose so in
the clinical setting you may see a
patient trying to write with a spoon or
using a comb to brush the teeth now
compare that to ideomotor apraxia this
is also referred to as motor apraxia commonly
commonly
unlike ideational apraxia where the
patient has no idea what to do a patient
with idiomotor apraxia will know what to
do and we'll be able to explain what the
purpose of the task is but
the patient cannot produce the movement
despite having the sensory and motor
skills to perform the task upon command
so you may observe a patient performing
a certain movement or action
automatically in context but you ask
them to do it again later
and they'll have a hard time mimicking
or completing the planned movement
really interesting stuff uh finally
there's um construction a constructional
apraxia and this one's easy to remember
if you think of a construction worker
building on a house because
constructional apraxia is referring to
the inability to assemble uh pieces or
parts into a two or three dimensional
hole like assembling uh furniture or
organizing food in the pantry or
anything else that requires putting or
assembling pieces together to form a
hole okay so that was a quick review of apraxia
apraxia
now we're going to go on to
visual impairments now earlier
when we were talking about spatial
neglect i briefly noted how spatial
neglect is not the same as visual field
deficit right well
well
uh let's first begin by talking about
one of the most common visual field
deficits homonymous hemianopia you might
hear it as homonymous hemianopia tube
and this one is important to know
because homonymous hemianopia is the
most common
type of visual field loss and stroke is
the most common cause of homonymous
hemianopia so what is it
this is a complete loss of visual field
on the same side in both eyes so you can
either have two right or the two left
halves of the visual fields meaning uh
the patient sees only one side right or
left of the visual world of each eye
it's such a bizarre condition and the
position the patient who has a left
homonymous hemianopia for example may
think that they're just or that they've
just lost vision in their left eye when
in fact they've lost vision in the left
half of each eye
so this presents a real challenge
because now
uh the patient thinks that their whole
world that they see is the remaining
half that they're seeing
and as you can imagine
this can significantly affect a
patient's ability to carry out his adls
and iadls because they cannot recognize
that there are moving objects or
obstacles in their missing visual field
this makes it very difficult to move
from one place to another especially
when they're navigating an unfamiliar environment
environment
so imagine how hard driving would be i
mean i don't think you could drive with
this uh condition unless you really
received a lot of therapy and treatment
for because half of your visual field
was cut and you couldn't see pedestrians
or cars coming into intersection i mean
even simple things like taking a walk
around the neighborhood could be
challenging because you couldn't
navigate all the obstacles so there's
definitely an increased risk for falls
as you bump into things or knock things over
over
okay and now there are other visual
impairments that can occur with stroke and
and
these include like eye movement
disorders like the cods you may hear it
as a kids
pursuits versions accommodation and fixation
fixation
i'll go over them very quickly
um so cods are like
rapid eye movement that occurs when the
eyes move from one point to another in
the visual field it's basically like
rapid ballistic
shifts or jumping gaze from one part of
the visual field to another in order to
change the point of fixation so
basically going from looking at one
thing to another rapidly
and you know what i always think of or
imagine when i think about psychotic eye movements
movements cats
cats
these cute little cats their eyes are
always jumping from one fixation to
another i mean they're like masters at
it right in contrast
smooth pursuit movement so in smooth
pursuit the eyes move smoothly and it's
used to follow
or track a moving target so it's a much
slower tracking movement of the eyes
that helps us keep our focus on a moving target
target
then there's divergence which is the
ability to aim the eyes at a target and
track it as it moves closer
towards you or away from you
and when the eyes are moving uh to track
the object as it's coming closer it's
called convergence
and it's when our eyes move inward to
focus on a nearby object like reading
working on a computer or looking at your phone
phone
and so when you have convergence
insufficiency your eyes have trouble
working together and they don't turn in
or converge while focusing on an object
that is close by and midline near your
face now divergence is the opposite of
convergence is the ability to turn both
of your eyes
outward to look at a distant object and
we can test for divergence and
sufficiency by moving the target further
away and seeing if both eyes remain
fixed on the same target
and affected patients will often
experience double vision when viewing
distant objects
then there is accommodation um which is
the ability
uh for the eyes to maintain um
as well as change focus when looking at
different distances so uh in the way
that a camera changes focus
for various distances our eyes need to
change focus when we change focus too so
right now you're looking at me you're
watching me on the screen which if
you're sitting on a desk might be like
16 to 20 inches from your face well look
up real quick from your screen and like
look at something um in the distance
like a wall on the um the the clock
on the wall and come back to the screen
real quick
uh when you quickly shifted your gaze
and changed focus from near to far and
then from far to near
were you able to bring these images into
clear focus quickly
well that's accommodative facility and
uh there are other type of accommodative
dysfunction but we won't go into all of
them here but it's basically your
ability to bring to clear focus things
at different distances
and the last one we'll talk about is
fixation you can tell i'm talking really
my voice is going
it's just as the word implies fixation
it's the ability to fixate on something
visually like looking at a painting at a
museum or observing that painting or
anything in detail with focus and a
steady gaze so it's basically the
ability to hold your eyes steady and
maintain focus
on whatever it is that you're looking at okay
okay
so that's all we'll talk about for
visual deficits
finally um
very quickly let's talk about
psychosocial component of stroke
recovery as we just learned
stroke can leave a patient with
debilitating impairment and people often
lose the ability to do things that they
were able to do so effortlessly and as
people whose
our identities are so often and so
indelibly linked with the work that we
do and the role that we play
a stroke can really have devastating
consequences on the patient's sense of
self and identity as they try to relearn
how to do the most simple tasks again
so the incidence of depression anxiety mania
mania
even personality disorders are quite common
common
and while physical therapy of the body
the physical body is important we also
know that the mental health component
which i think is so often neglected is
equally important because if we lose
ourselves up here then
everything becomes that much harder right
right so
so
um that concludes our video for today
but on that note i want to really
encourage you guys uh while you're
studying and going through this very
important next step of becoming a therapist
therapist
please take grace and take care of your
own mental health
um i know that this test is looming
before you like the biggest greatest
mountain you must overcome and conquer
before you can do anything else but
time stops for no one and tomorrow is
never guaranteed
you know um
um
i recently lost a friend uh
uh
someone i shared a very deep connection
with to hemorrhagic stroke it's actually
what uh really made me want to make this video
video
i met this man during my travel through
southeast asia and like we instantly
connected we were kindred spirits he was
also from l.a and what happened happened
to be traveling at the time for his
incredible humanitarian work which he's
widely known for and we kept in touch
even through long distance because you
know we just really connected and one
time he was visiting in the states and
um he was staying only 15 minutes away
from me and i wanted to see him but i
was just so busy like i kept justifying
saying i'll see him once this very
hectic season of my life passes i just
giving birth the first year was really
hard as a new mom
um but the next time i heard from him or
about him it was through our mutual
friend who let me know that he was in a
coma and
i went to see him immediately and again
but he never woke up and he passed a
year later
a year and a half later and i still
wonder like to this day
if he heard my voice when i was talking
to him and the words i spoke to him did
he hear me say i'm sorry
say i'm sorry thank you i love you and all the things
thank you i love you and all the things that i wish i could have said to him
that i wish i could have said to him you know before he passed so
i don't know i share this story because as important as it is to do everything
as important as it is to do everything that we prioritize for ourselves today
that we prioritize for ourselves today um i think we really have to ask
um i think we really have to ask ourselves
ourselves why are we trying to pass the exam what
why are we trying to pass the exam what is the goal isn't it to make a
is the goal isn't it to make a difference to help people heal and to
difference to help people heal and to help them regain their independence in a
help them regain their independence in a meaningful and fulfilling way
meaningful and fulfilling way well i think that process of living
well i think that process of living fully each and every day it has to begin
fully each and every day it has to begin with us and we should never put that
with us and we should never put that process on a pause and
process on a pause and every day we have to we must make time
every day we have to we must make time to do something that's meaningful and
to do something that's meaningful and important and fulfilling for ourselves
important and fulfilling for ourselves whether that's calling somebody that we
whether that's calling somebody that we love to let them know that we love them
love to let them know that we love them or finding time to meet up with a friend
or finding time to meet up with a friend who you haven't seen in ages because
who you haven't seen in ages because life has gotten so busy
anyway so that's our video for today i really hope this video was helpful to
really hope this video was helpful to you
i love you guys take good care and please do something
take good care and please do something meaningful today that fills your cup
meaningful today that fills your cup whatever that may be
whatever that may be [Music]
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