CLINICAL Stroke Rehabilitation: Cognitive Deficits – Occupational

REVIEW Therapy

Indexing Metadata/Description
› Title/condition: Stroke Rehabilitation: Cognitive Deficits – Occupational Therapy
› Synonyms: Occupational therapy – cognitive deficits: stroke rehabilitation; cognitive
deficits – occupational therapy: stroke rehabilitation; cerebrovascular accident
rehabilitation: cognitive deficits – occupational therapy; CVA rehabilitation: cognitive
deficits – occupational therapy
› Anatomical location/body part affected: The brain (cerebral cortex, cerebellum, and/or
brainstem)
› Area(s) of specialty: Neurological Rehabilitation
› Description: A stroke is an acquired injury to the brain caused by reduced blood supply
leading to infarction (necrosis of brain tissue) or by a hemorrhage within the parenchyma
of the brain(1,2,30)
• An estimated 6.8 million Americans ≥ 20 years of age have had a stroke. Overall stroke
prevalence is estimated at 2.8%(29)
• More than half of patients with stroke experience cognitive deficits(32)
› ICD-10 codes
• I61 intracerebral hemorrhage
–I61.0 intracerebral hemorrhage in hemisphere, subcortical
–I61.1 intracerebral hemorrhage in hemisphere, cortical
–I61.2 intracerebral hemorrhage in hemisphere, unspecified
–I61.3 intracerebral hemorrhage in brain stem
–I61.4 intracerebral hemorrhage in cerebellum
–I61.5 intracerebral hemorrhage in traventricular
–I61.6 intracerebral hemorrhage, multiple localized
–I61.8 other intracerebral hemorrhage
–I61.9 intracerebral hemorrhage, unspecified
Authors • I62 other nontraumatic intracranial hemorrhage
Heather Wiemer, MA, CCC-SLP
Cinahl Information Systems, Glendale, CA
–I62.0 subdural hemorrhage(acute) (nontraumatic)
Ellenore Palmer, BScPT, MSc –I62.1 nontraumatic extradural hemorrhage
Cinahl Information Systems, Glendale, CA –I62.9 intracranial hemorrhage (nontraumatic), unspecified
• I63 cerebral infarction
Reviewers –I63.0 cerebral infarction due to thrombosis of precerebral arteries
Diane Matlick, PT
Cinahl Information Systems, Glendale, CA
–I63.1 cerebral infarction due to embolism of precerebral arteries
Rehabilitation Operations Council –I63.2 cerebral infarction due to unspecified occlusion or stenosis of precerebral arteries
Glendale Adventist Medical Center, –I63.3 cerebral infarction due to thrombosis of cerebral arteries
Glendale, CA
–I63.4 cerebral infarction due to embolism of cerebral arteries
–I63.5 cerebral infarction due to unspecified occlusion or stenosis of cerebral arteries
Editor
Sharon Richman, DHSc, MSPT, PT –I63.6 cerebral infarction due to cerebral venous thrombosis, nonpyogenic
Cinahl Information Systems, Glendale, CA –I63.8 other cerebral infarction
–I63.9 cerebral infarction, unspecified
• I64 stroke, not specified as hemorrhage or infarction
October 22, 2021 • I65 occlusion and stenosis of precerebral arteries, not resulting in cerebral infarction

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or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare
professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206
 –I65.0 occlusion and stenosis of vertebral artery
–I65.1 occlusion and stenosis of basilar artery
–I65.2 occlusion and stenosis of carotid artery
–I65.3 occlusion and stenosis of multiple and bilateral precerebral arteries
–I65.8 occlusion and stenosis of other precerebral artery
–I65.9 occlusion and stenosis of unspecified precerebral artery
• I66 occlusion and stenosis of cerebral arteries, not resulting in cerebral infarction
–I66.0 occlusion and stenosis of middle cerebral artery
–I66.1 occlusion and stenosis of anterior cerebral artery
–I66.2 occlusion and stenosis of posterior cerebral artery
–I66.3 occlusion and stenosis of cerebellar arteries
–I66.4 occlusion and stenosis of multiple and bilateral cerebral arteries
–I66.8 occlusion and stenosis of other cerebral artery
–I66.9 occlusion and stenosis of unspecified cerebral artery
• I69 sequelae of cerebrovascular disease
–I69.0 sequelae of subarachnoid hemorrhage
–I69.1 sequelae of intracerebral hemorrhage
–I69.2 sequelae of other nontraumatic intracranial hemorrhage
–I69.3 sequelae of cerebral infarction
–I69.4 sequelae of stroke, not specified as hemorrhage or infarction
–I69.8 sequelae of other and unspecified cerebrovascular diseases
• H53.8 other visual disturbances
• R41.8 other and unspecified symptoms and signs involving cognitive functions and awareness
• R44.8 other and unspecified symptoms and signs involving general sensations and perceptions
(ICD codes are provided for the reader’s reference, not for billing purposes)
› Reimbursement: Reimbursement for therapy will depend on insurance contract coverage; no specific special agencies are
applicable for this condition. No specific issues or information regarding reimbursement has been identified
› Presentation/signs and symptoms: Each survivor of stroke presents differently as a result of the specific location and
severity of the stroke.(2) Cognitive impairments that might be observed in survivors of stroke include:
• disorientation and confusion(3,4)
• impaired executive functioning skills(5)
• impaired reasoning and sequential thought(3,4)
• impaired memory(5)
• lack of organization and problem-solving skills(3,4)
• reduced attention and concentration(3,5)
• reduced judgment and safety awareness(3)
• impulsiveness(3)
• reduced processing speed/reaction time(4)
• For a full list of signs and symptoms of stroke, see Clinical Review…Stroke Rehabilitation: Occupational Therapy–an
Overview; CINAHL Topic ID Number: T708955

Causes, Pathogenesis, & Risk Factors

› Causes: Stroke is caused by decreased blood supply to an area of the brain (ischemic) or a hemorrhage in the brain
(hemorrhagic)(1,30)
• Ischemic(1,6)
–Thrombotic: caused by occlusion of large or small vessels due to atherosclerotic vascular disease(1)
–Embolic: caused by a cardiac or arterial embolism blocking blood flow in a large or small vessel of the brain(1,6)
 –Lacunar infarcts(7,8)
- Small lesions that occur in the deeper parts of the brain (basal ganglia, thalamus, white matter) and in the brainstem(7,8)
- Caused by occlusion of the arterioles (deep penetrating branches of major cerebral arteries);(9) associated with poorly
controlled hypertension, diabetes, severe atherosclerosis of small vessels, and small vessel disease(7)
–Ischemic etiologies account for about 80% of all strokes(1,6)
• Hemorrhagic(6,30)
–Includes subarachnoid and intracerebral hemorrhage(6)
–Hemorrhagic strokes may be caused by the following:(30)
- Arteriovenous malformation (AVM)(6)
- Blood disorders (e.g., leukemia, hemophilia)(7)
- Cerebral amyloidosis(7)
- Hypertension(6,7)
- Intracranial neoplasm(7,8)
- Ruptured intracranial aneurysm(6,7)
- Traumatic rupture of vessels(9)
› Pathogenesis
• Ischemic strokes: prolonged lack of blood flow to brain cells (neurons, glial and endothelial cells) results in infarction of
these cells(8)
–Circulatory arrest results in irreversible cellular damage within minutes; the core area of this damage is referred to as the
ischemic penumbra(5)
- In addition to the death of cells in the penumbra, there is also potentially reversible damage to surrounding brain cells;
immediate medical intervention is the best hope for reversing this damage(5)
- Ischemic strokes also cause cerebral edema, which elevates intracranial pressure and may lead to worsening
neurological deficits, loss of consciousness, coma, and/or death(5)
–For thrombotic ischemic strokes, a critical degree of atherosclerosis causes the complete or almost complete blockage of
blood flow to a local area of the brain(9)
–For embolic ischemic strokes, the blockage of blood flow is a result of a clot forming elsewhere in the body, breaking off,
and traveling to and lodging in a vessel of the brain(9)
• Hemorrhagic strokes: hemorrhage in the brain leads to edema, mass effect, and midline shift; for patients with extensive
hemorrhage with significant cerebral edema, herniation and death may result(30,41)
• Stroke results in upper motor neuron lesions that lead to motor deficits such as hemiplegia, as well as lower motor neuron
lesions of cranial nerves leading to deficits such as facial weakness(6)
• Disruption of connections between areas of cortex that associate complex types of information leads to impaired cognition
and function
› Risk factors
• All patients with symptomatic stroke or transient ischemic attack (TIA) should be considered to be at increased risk for
vascular cognitive impairment(42)
• Risk factors for vascular disease and poststroke vascular cognitive impairment include(42)
–neuroimaging findings of covert stroke or white matter disease on neuroimaging
–hypertension
–diabetes
–atrial fibrillation
–other cardiac disease
–sleep apnea
Overall Contraindications/Precautions
› An occupational therapy assessment should include the patient and family/friends as appropriate; including the patient’s
familial and social network in the rehabilitation process may assist in the patient’s psychosocial recovery
› Be sensitive to pain in survivors of stroke; some patients will have hypersensitivity to pain and others will have
hyposensitivity; ensure that the patient has a reliable means of communicating pain throughout evaluation and
treatment(5,11,12)
› Patients are at risk for shoulder pain or dysfunction. Do not support through hemiplegic arm for mobility and transfers.
Ensure that hemiplegic arm is adequately supported
› Monitor patient’s signs and symptoms; refer to physician if there are signs of a new stroke
› Seizures can develop as a late complication of stroke(2,5)
› Hydrocephalus (i.e., accumulation of excess cerebrospinal fluid [CSF] within the cerebral cavity) can occur following
hemorrhagic stroke; symptoms include headache, nausea, vomiting, visual disturbance, and increasing lethargy and/or ataxia;
refer to physician immediately if these symptoms are noted or reported(5)
› Risk of deep vein thrombosis (DVT) is significantly increased in patients with hemiplegia; assess for signs of DVT (e.g.,
redness, warmth, pain, tenderness, swelling) and refer to physician urgently if these symptoms are present(2,5)
› Aspiration pneumonia can occur in survivors of stroke who have dysphagia; refer to physician if patient complains of
difficulty swallowing, persistent wet cough, or fever(2)
• Dysphagia screening is recommended given the consequences of not adequately identifying dysphagia(31)
• 42–67% of patients present with dysphagia within 3 days of stroke. Fifty percent of these patients aspirate, and one third of
patients who aspirate develop pneumonia that requires treatment(31)
• Screening typically is administered by a nurse, speech-language pathologist (SLP), or physician
• Follow aspiration prevention protocols during assessment and treatment, including limiting oral intake and maintaining
upright position as indicated
› Patients who have had a stroke may be at risk for falls. Follow fall-preventionprotocols
› See specific Contraindications/precautions to examination and Contraindications/precautions under Assessment/Plan
of Care

Examination
› Contraindications/precautions to examination
• Patients who have had a stroke will have different patterns of deficits as a result of the specific size and location of lesion;
occupational therapy evaluations for survivors of stroke should utilize a client-centered approach to most effectively
evaluate deficits and needs(6,13)
–A client-centered approach is based on the following principles: (6)
- The patient is uniquely qualified to make decisions about his or her occupational functioning
- The patient should have an active role in determining goals and desired outcomes
- The patient-therapist relationship should be interdependent
- Evaluation and treatment should focus on the patient’s culture, roles, interests, etc.
- When the patient can define the problems that he or she would like to work on, the patient also becomes a problem
solver
- The patient should evaluate his or her own performance and set personal goals
› History
• History of present illness/injury
–Mechanism of injury or etiology of illness: Review medical chart and physician reports to ascertain information about
the size, location, type, and extent of the stroke
- Was the stroke ischemic or hemorrhagic? How soon did the patient receive medical intervention after onset of stroke?
- Is the patient in the acute, subacute, or chronic stage of stroke?
- What were the initial presenting signs and symptoms of the stroke? How have the signs and symptoms changed since
presentation?
- Impairments may resolve spontaneously as brain swelling resolves and neurotransmission resumes. Persistent
impairments may lead to lasting disability(5)
 - Most patients gain some degree of intrinsic (neurological) and adaptive recovery(3)
- What complications has the patient experienced (e.g., DVT, pneumonia, shoulder pain)?
–Course of treatment
- Medical management: Medical management of acute stroke involves determining the cause and location of a stroke
with imaging tests such as MRI and CT scan, preventing further brain damage/progression of the stroke and secondary
medical complications, and treating acute neurological symptoms(3)
- Treatment for acute ischemic stroke focuses on restoration of blood flow to blockage to reduce neuronal damage.(3)
Thrombolytic drugs (such as tissue plasminogen activator [t-PA]) are used to break up a clot and immediately restore
blood flow (limiting permanent damage); however, these must be administered within 3 hours of stroke onset(2,3)
- t-PA has been shown to prevent permanent disability in patients appropriate for its use(2)
- Blood thinners may be prescribed to improve blood flow through blocked vessels(3)
- Hemorrhagic strokes are managed acutely by controlling intracranial pressure, preventing re-bleeding and vasospasm,
and maintaining cerebral perfusion(3)
- Surgical intervention for stroke may involve craniotomy in the acute phase to stop bleeding and for evacuation of large
intracerebral hematoma or due to swelling from increased intracranial pressure.(2) Carotid endarterectomy (CEA) is
recommended for patients with carotid territory stroke and 70–90% ipsilateral carotid stenosis(1,2)
- Initial medical management may include mechanical ventilation with intubation, monitoring of intracranial pressure,
and controlling modifiable risk factors such as hypertension and arrhythmias. Feeding tubes (nasogastric [NG] or
gastrostomy [G]) might be necessary for short- or long-term nutrition in patients with dysphagia
- Nonpharmacologic medical interventions for stroke include above-the-knee elastic stockings and pneumatic boots to
prevent pulmonary emboli(1)
- Medications for current illness/injury: Determine what medications the physician has prescribed; are they being taken
as prescribed?
- Blood thinners or antiplatelet therapy may be utilized for patients with ischemic stroke.(1,3) Warfarin (an anticoagulant)
may be prescribed for patients with embolic stroke and/or atrial fibrillation(1,2)
- Medications to control blood pressure (BP)/hypertension(1)
- Patients with history of stroke may be placed on a combination of an angiotensin-converting enzyme (ACE) inhibitor
and thiazide-type diuretic to control hypertension and prevent recurrent stroke(1)
- Antispasticity medications such as baclofen or dantrolene may be prescribed for patients with muscle spasticity(2)
- Physician may manage spasticity by injecting phenol or botulinum toxin into spastic muscle(2)
- Stool softeners or laxatives for patients with bowel dysfunction(6)
- Anticholinergic medications for urinary incontinence(2)
- SSRIs for post stroke depression(2)
- Antiseizure medications and pain medications are commonly prescribed
- Diagnostic tests completed: Usual tests for this condition are the following:
- Diagnostic imaging (e.g., MRI, CT scan, chest X-ray)(1,2)
- Blood work (CBC, platelets, PT[INR], PTT, BUN, creatinine, glucose, urinalysis)(1)
- Cerebral angiography for suspected aneurysm(1,2)
- Cardiac tests for suspected embolic etiology:
- Electrocardiogram (ECG/EKG)(1)
- Serial cardiac enzymes(1)
- Transthoracic and/or transesophageal echocardiogram (TTE/TEE)(1,2)
- Holter monitor(1,2)
- Carotid Doppler(1)
- BP monitoring
- Speech and language evaluation(6)
 - Swallow evaluation(2)
- Transcranial or carotid Doppler study(5)
- Urodynamic studies(2)
- Home remedies/alternative therapies: Document any use of home remedies (e.g., ice or heating pack) or alternative
therapies (e.g., acupuncture) and whether they help
- Previous therapy: Document whether patient has had speech, occupational, or physical therapy for this or other
conditions and what specific treatments were helpful or not helpful
–Aggravating/easing factors:Regarding cognitive problems specifically, what factors appear to worsen or improve
symptoms?
- Patients often have increased difficulty with memory and attention in noisy, distracting environments
- Survivors of stroke may notice increased pain, specifically headaches, when performing cognitive tasks
–Nature of symptoms: Document nature of symptoms, including difficulty paying attention/concentrating, poor judgment
and/or safety awareness, memory deficits (short-term, long-term, working memory), impaired executive functioning, etc.
–Rating of symptoms: Use a visual analog scale (VAS) (or other nonverbal scale for patients with aphasia) or 0–10 scale
to assess symptoms at their best, at their worst, and at the moment (specifically address if pain is present now and how
much)
–Pattern of symptoms: Document changes in symptoms throughout the day and night, if any (A.M., mid-day, P.M.,
night); also document changes in symptoms due to weather or other external variables
–Sleep disturbance: Document number of wakings/night
- Does patient have sleep apnea? Does patient use a continuous positive airway pressure (CPAP) device?
- Sleep apnea is reported to occur in two thirds to three quarters of patients after stroke(29)
- Sleep apnea is also a risk factor for stroke(29)
–Other symptoms: Document other symptoms patient may be experiencing that could exacerbate the condition and/or
symptoms that could be indicative of a need to refer to physician (e.g., dizziness, headache, nausea, bowel/bladder/sexual
dysfunction)
- Seizures may develop as a late complication of stroke(2,5)
- Hydrocephalus (i.e., accumulation of excess CSF within the cerebral cavity) can occur following hemorrhagic stroke;
symptoms include headache, nausea, vomiting, visual disturbance, and increasing lethargy and/or ataxia; refer to
physician immediately if these symptoms are noted or reported(5)
- Risk of DVT is significantly increased in patients with hemiplegia; assess for signs of DVT (e.g., redness, warmth, pain,
tenderness, swelling) and refer to physician urgently if these symptoms are present; document positive Homans’ sign
(discomfort behind the knee on forced dorsiflexion of the foot that results from DVT in the calf veins)(2,5)
- Aspiration pneumonia can occur in survivors of stroke who have dysphagia; refer to physician if patient complains of
difficulty swallowing, persistent wet cough, and/or fever(2)
–Respiratory status: Note respiratory status
- Pulmonary function often is impaired in stroke survivors(5)
- Does the patient require supplemental oxygen? Tracheostomy tube, nasal cannula, or breathing mask?
- Does the patient become short of breath? If so, when? Standing? Walking? With exercise?
- Does the patient report light-headedness or dizziness?
- Does the patient have any comorbid respiratory conditions (e.g., COPD, asthma)? How are they controlled? Any
smoking history?
–Psychosocial status
- All patients with stroke are at high risk of poststroke depression at any stage of recovery(42)
- Other psychosocial issues that occur in survivors of stroke include pseudobulbar affect (emotional lability), apathy,
euphoria, isolation, and social withdrawal(5)
- Document psychosocial status; inquire about symptoms of depression and other emotional distress; refer to psychiatrist,
psychologist, or social work when appropriate
- The Beck Depression Inventory (BDI) is a useful tool for screening patients for depression(5)
–Hearing: Note patient’s hearing abilities
- Does the patient speak loudly even in close, quiet conversational environments?
 - If the patient appears to have impaired hearing, refer to audiology for further workup
–Barriers to learning
- Are there any barriers to learning? Yes__ No__
- If Yes, describe _________________________
- Common barriers to learning in post stroke patients include aphasia, perceptual impairments (e.g., neglect), and
cognitive impairments
• Medical history
–Past medical history
- Previous history of same/similar diagnosis
- Is there a prior history of stroke, TIA, or cognitive impairment?
- If so, what deficits were preexisting?
- Is there history of other cardiovascular disease, including hypertension, arterial stenosis, etc.?
- Comorbid diagnoses: Ask patient or caregiver about other problems, including diabetes, cancer, heart disease,
complications of pregnancy, psychiatric disorders, and orthopedic disorders
- Medications previously prescribed: Obtain a comprehensive list of medications prescribed and/or being taken
(including OTC drugs)
- Some medications prescribed for management of cardiovascular disease and/or late effects of stroke can cause or
exacerbate cognitive impairment; discuss side effects of all medications with the patient’s physician
- Other symptoms: Ask patient or caregiver about other symptoms patient may be experiencing
• Social/occupational history
–Patient’s goals: Document what the patient and family/caregiver hope to accomplish with therapy and in general
–Vocation/avocation and associated repetitive behaviors, if any
- What is the patient’s occupation and role(s) within his or her family?(5)
- Is he or she currently employed?
- Is the patient hoping to return to work?
- The 2015 Canadian Stroke Best Practice Recommendations (CSBPR)include asking patient about vocational interests
and assessing potential return to work early in the rehabilitation phase; providing vocational rehabilitation services,
where appropriate; and educating and encouraging employers to provide modifications and flexibility to allow
patients to return to vocation(43)
- What activities, hobbies, etc., did the patient enjoy prior to the stroke?
- A patient/caregiver interview may be helpful to gain insight into the patient’s hobbies, family/community role, interests,
prior work status, and home responsibilities
- The 2015 CSBPR state to give patients the opportunity to discuss pre-stroke leisure pursuits, assess for rehabilitation
needs to resume these activities, and encourage participation(43)
–Functional limitations/assistance with ADLs/adaptive equipment: What current assistive or adaptive equipment
is available to the patient at home? Can it still be utilized based on patient’s current level of physical and cognitive
functioning?
- Document both high- and low-tech adaptations and equipment
–Living environment
- Who is the patient’s primary caregiver?(13)
- The patient’s primary caregiver plays an important role in utilization of rehabilitation services and overall outcomes of
therapy(13,14)
- Patients with live-in caregivers who receive outside assistance are most likely to utilize both inpatient and outpatient
therapy(14)
- If the patient has no caregiver or the patient’s caregiver is not receiving guidance or assistance with the patient’s care,
refer to social worker or case management(13)
- With whom does the patient live (e.g., spouse/partner, parents, children, siblings, grandparents, caregivers)?
- Are there pets in the home?
- Identify if there are barriers to independence in the home; are any modifications necessary?(5)
- Inquire about the levels of the home, including stairs, numbers of floors, etc.
- Recommendation to remove any objects from the floor such as rugs and cords to minimize the risk for falls
 - A home visit may be beneficial to provide functional and realistic environmental modifications around the house
› Relevant tests and measures: (While tests and measures are listed in alphabetical order, sequencing should be
appropriate to patient medical condition, functional status, and setting.) Measures described below are specific to
assessment of cognitive deficits following stroke; for an overview of all areas of occupational therapy assessment post
stroke, see Clinical Review…Stroke Rehabilitation: Occupational Therapy—an Overview, referenced above; also see the
series of Clinical Reviews on specific areas of stroke rehabilitation
• Arousal, attention, cognition (including memory, problem solving)
–Note patient’s ability to communicate and level of arousal as well as memory, attention, problem solving, and orientation
to person, place, time, and situation; obtain and review any cognitive or neuropsychological testing results completed by
other medical professionals
- Initially, survivors of stroke may have difficulty maintaining arousal; assessment of cognitive skills is an ongoing
process and cognition should be reassessed regularly(5)
–A full cognitive evaluation should assess the following areas:
- Attention and concentration(3,5)
- Assess sustained, selective, alternating, and divided attention(5)
- Executive functioning skills(5)
- Judgment and safety awareness(3)
- Memory(5)
- Survivors of stroke may present with perseveration and/or confabulation related to impaired memory(5)
- Orientation(3,4)
- Organization and problem solving(3,4)
- Including planning, organizing, initiating, and thinking through simple and complex problems(4)
- Money and medication management
- Processing speed/reaction time(4)
- May be measured with a reactometer (i.e., a device that can measure a person’s reaction time to light or sound
stimulation; also measures the speed of the psychomotor reaction of the patient’s CNS)(4)
- Reasoning and sequential thought(3,4)
–Initial screening for cognitive deficits may include brief screening tools such as the Mini-Mental State Examination
(MMSE) and the Neurobehavioral Cognitive Status Examination (NCSE), which are evidence-based screening tools for
cognitive functioning(3,4,6,15,16)
- MMSE:(15)screens for overall cognitive impairment; sections include orientation to time, orientation to place,
registration, attention and calculation, recall, naming, repetition, comprehension, reading, writing, and drawing
- An accurate tool for measuring dementia, the MMSE is not necessarily effective in assessing cognitive impairment in
patients with stroke(39)
- NCSE:(16) assesses orientation, attention, auditory and visual memory, spatial perceptual skills, calculation skills, and
reasoning; skills are scored separately so that specific deficits can be identified
- Once the specific areas of cognitive impairment are identified, complete further in-depth testing of each specific area
- Authors of a study in Canada indicated that when the MMSE was used as the only tool to monitor cognitive changes in
patients post stroke, impairments of executive functioning often were missed(17)
–Assess self-awareness; self-awareness is the ability to recognize physical or cognitive deficits(18)
- Self-awareness can be assessed through comparing a patient’s self-rating of his or her own performance to the rating of a
family member or rehabilitation staff(18)
- Increasing self-awareness in individuals who have had a stroke through counseling and education can improve overall
functional outcomes(18)
- Anosognosia is the inability to recognize these deficits, or a lack of self-awareness, that can occur as a result of damage
to the brain(18)
- For additional information on anosognosia, see Clinical Review…Anosognosia; CINAHL Topic ID Number: T708764
–Visual-spatial neglect can occur as a result of stroke(19)
 - Visual-spatial neglect is associated with lower functional outcomes in survivors of stroke(19)
- Visual-spatial neglect is more common and severe in patients with right-hemisphere strokes who present with left-sided
inattention/left neglect(19)
- Left visual-spatial neglect can result in injury to the left side, as the patient is unaware of his or her own left limbs(20)
- For information on assessment and treatment of unilateral neglect, see Clinical Review…Stroke Rehabilitation:
Unilateral Neglect; CINAHL Topic ID Number: T708897
–For patients with significant cognitive impairment, referral to neuropsychology is appropriate for extensive assessment
and input regarding cognitive intervention.(2) Refer to speech-language pathology reports regarding speech, language, or
cognitive-linguistic impairments(5)
–Occupational therapists (OTs)play an important role in assessing the impact of cognitive impairment on patients’ ability to
perform ADLs andresume their life roles andoccupations.OTs along with a multidisciplinary team should use a range of
assessment tools during the cognitive rehabilitation process(33)
- Authors of a study surveyed occupational therapists’ reasons for selection of and challenges with using various cognitive
assessments in patients following stroke and traumatic brain injury(33)
- OTs ranked occupational-performance-based assessments as the most important method (69% of OTs reported using
these assessments for more than 75% of their patients with cognitive impairment)
- Occupational-performance-based assessments (e.g., Perceive, Recall, Plan, and Perform system of task analysis)rely
on therapist observationin patients’ ability to perform ADLs and other activities. This can lead to a lack of quantitative
data and was the biggest challenge OTs identified. However, these assessment methods are still highly recommended
• Assistive and adaptive devices: Assess the patient’s need for and/or use of assistive and adaptive devices. Patients with
cognitive impairments may have difficulty incorporating assistive and adaptive devices into ADL tasks; incorrect use of
devices, including brakes and locking mechanisms, can increase the risk of falls
–Mobility aids
- Cane
- Walker
- Wheelchair
- Crutches
- Hemi-walker
- Ankle-foot orthoses (AFOs)
–Toileting and shower equipment
- Grab bars
- Bedside commode
- Bedside urinal
- Raised toilet seat
- Elevated footrest at the toilet
- Tub bench or shower chair
–ADL/IADL aids
- Reachers
- Personal digital assistant (PDA)
- Large-print reading material
- Adaptive/ergonomic computer/mouse/keyboard
- Text-to-speech software
- Adaptive cooking equipment
–For more information on assistive technology for patients with stroke who have cognitive deficits, please see Clinical
Review…Assistive Technology for Patients with Cognitive Impairments (Occupational Therapy); CINAHL Topic ID
Number: T901902
• Functional mobility (including transfers, etc.): Bed mobility and transfers should be assessed to determine the amount of
assistance needed for the patient to perform each activity
–Survivors of stroke with cognitive impairments may have additional difficulty with functional mobility as a result of
reduced planning, thinking, problem solving, and/or initiating abilities(4)
 –Difficulty with functional mobility may also result from apraxia, an acquired disorder of motor planning that can result
from stroke
- Patients with apraxia present with inability to execute learned purposeful movements despite having the physical
capacity, the cognitive understanding of the task, and the desire to perform the movements
–Test static and dynamic activities
–Timed Up & Go (TUG) test: a measurement of mobility; includes tasks such as standing from a sitting position, walking,
turning, stopping, and sitting down, which are all important for independent mobility(21)
- Dual task TUG—the addition of a cognitive task to the TUG test (e.g., counting backwards by 3s) may improve the
test’s ability to predict falls
–FIM—an 18-item, 7-level ordinal scale assessing functional mobility, ADLs, language skills, and cognition(22)
• Perception (e.g., visual field, spatial relations)
–Perception of spatial relationships, textures, and shapes frequently is impaired in stroke survivors(20)
- Poor spatial perception may interfere with balance and subsequently limit the patient’s ability to sit, stand, and walk
safely(20)
–Ocular motor screening includes tracking through all planes, visual accommodation, and clarity of vision(5)
- Document complaints of double vision, optic pain, or visual field cuts(5)
- Document use of eye patching
–Recommend referral to ophthalmology or neuro-ophthalmology as appropriate if symptoms of visual disturbances are
noted during evaluation
- For additional information on assessment and treatment of patients with visual impairments, see Clinical Review…Visual
Dysfunction: Occupational Therapy; CINAHL Topic ID Number: T708963
• Self-care/ADLs (objective testing): Assess safety and ability to perform ADLs: brushing teeth, combing hair, dressing
upper and lower extremities, managing clothing, using the toilet, applying makeup or shaving the face, bathing, eating
–Sequencing the steps involved in ADL tasks can be significantly more difficult for survivors of stroke with cognitive
impairment(6)
–Bowel and bladder function may be impaired as a result of stroke, especially in the acute phase(5)
–Survivors of stroke with cognitive impairments are likely to achieve independence in upper-body dressing tasks if they
can use two hands; for those individuals with hemiparesis and cognitive impairment, improvement in dressing skills is
likely with practice even if complete independence is not achievable(23)
–When assessing the feeding skills of stroke survivors, refer to speech-languagepathology report regarding swallowing
ability and food/liquid restrictions, if applicable(5)
–For community-dwelling and other high-functioning patients, assess IADLs such as driving (car transfers), meal
preparation, shopping, and housework
- Lawton and Brody Instrumental Activities of Daily Living Scale
- Includes items related to using the telephone, taking public transportation, shopping, meal preparation, housework, and
medication and money management
–The FIM, the Physical Self-Maintenance Scale (PSMS), the Assessment of Motor and Process Skills (AMPS), the
Kohlman Evaluation of Living Skills (KELS), the Frenchay Activities Index, and the Barthel Activities of Daily Living
Index (BI) are appropriate standardized measures for ADLs(6)
–For additional information on assessment and treatment of ADLs, see Clinical Review…Stroke: Activities of Daily Living;
CINAHL Topic ID Number: T708720
• Sensory testing: Stroke may impair sensation(1,5,20)
–Loss of sensation and proprioception in survivors of stroke can increase risk of self-injury to the affected limb(5)
- Proprioceptive loss may result in sensory ataxia(5)
–Examine for sensory impairment in affected limb(s); pinprick, temperature, pressure, proprioception, vibration(1,5)
• Special tests specific to diagnosis
–The NIH Stroke Scale is a stroke deficit scale that scores 15 items (includes consciousness, vision, extraocular movement,
facial control, limb strength, ataxia, sensation, speech and language)(6)
 –Árnadóttir OT-ADL Neurobehavioral Evaluation (A-ONE) objectively assesses the way in which the patient’s deficits
affect both self-care and mobility tasks(6)
–QOL
- The Short Form Health Survey (SF-36) evaluates overall independence, emotional and mental health, limitations to
previous roles, and social status(6)
–The Canadian Occupational Performance Measure (COPM) evaluates function through evaluation at baseline and status
throughout treatment utilizing the patient’s direct input in the scale(6)
- The COPM allows patients to identify goals in therapy that are personally meaningful; useful for client-centered
approach to therapy(24)
–The Loewenstein Occupational Therapy Cognition Assessment (LOTCA) is an occupational therapy assessment scale that
includes 26 items in areas that include orientation, visual perception, spatial perception, praxis, visuomotor organization,
thinking operations, memory, and attention and absorption(34)
- In a study conducted in China, the LOTCA was found to be useful for detecting cognitive impairment in patients with
stroke
- There is good agreement between the LOTCA and the MMSE
- Compared with the MMSE, the LOTCA can detect vascular cognitive impairment that is not dementia earlier and more
comprehensively
–The Cognitive Behavioral Rating Scale (CBRS) is a newly developed scale designed to assess cognitive function through
observation(35)
- In a study conducted in Japan, the CBRS was found to have high reliability and validity for the assessment of cognitive
function in patients with stroke(35)
- The study included 180 patients with stroke and 58 patients with orthopedic conditions
–The Montreal Cognitive Assessment (MoCA) is a 30-item test that is designed to assess a patient’s memory, visuospatial
abilities, and executive function(38,39)
- Authors of a systematic review of 51 studies compared the MMSE and MoCA and concluded that the MoCA is
currently the best assessment tool for cognitive screening in stroke patients(38)
–The Brief Memory and Executive Test (BMET) is a rapid screening tool that measures executive function and processing
speed
- A quick and sensitive tool for detecting cognitive impairment in patients with cerebral small vessel disease(40)

Assessment/Plan of Care
› Contraindications/precautions
• Only those contraindications/precautions applicable to this diagnosis are mentioned below, including with regard to
modalities. Rehabilitation professionals should always use their professional judgment
• Patients with this diagnosis are at risk for falls; follow facility protocols for fall prevention and post fall-prevention
instructions at bedside, if inpatient. Ensure that patient and family/caregivers are aware of the potential for falls
and educated about fall-prevention strategies. Discharge criteria should include independence with fall-prevention
strategies
• Clinicians should follow the guidelines of their clinic/hospital and what is ordered by the patient’s physician. The summary
presented below is meant to serve as a guide, not to replace orders from a physician or a clinic’s specific protocols
• Low-intensity rehabilitation should begin once the patient is medically stable; early mobilization can prevent or lessen
harmful effects of deconditioning and secondary impairments(5,12)
• Early assessment of the patient’s environment (e.g., the hospital room) as well as identification and modification of barriers
(e.g., modifying the call bell for improved access to nursing care) may help motivate the patient for rehabilitation(13)
› Diagnosis/need for treatment: The OT must consider each patient’s risk factors and deficits to determine if the patient is
an appropriate candidate for therapy; a multifaceted, multidisciplinary approach is indicated for stroke survivors who have
cognitive deficits and may benefit from occupational therapy
› Rule out: The patient’s medical team will rule out TIA as well as migraine, seizure, brain tumor, and other neurologic
disorders (such as multiple sclerosis) prior to diagnosing stroke(1,2)
› Prognosis:
• Initial prognosis for survival is better for patients with ischemic strokes versus hemorrhagic strokes.(7) Loss of
consciousness with stroke is associated with poorer prognosis overall(7)
• The degree to which patients will recover from stroke varies significantly according to severity of initial deficits, etiology
of the stroke, and concurrent medical and/or surgical complications(1)
• Initially, (within the first few weeks) improvements occur rapidly due to spontaneous recovery(3,5)
• Later recovery is thought to result from structural and functional reorganization within the brain(3)
• Prognosis for cognitive improvement will depend on several factors, including prior cognitive abilities, severity of stroke,
response to and motivation for therapy, psychosocial status, and comorbid disease or injury
• Stroke is the most common cause of adult disability in the United States.(8,29)In a study conducted by the National Heart,
Lung, and Blood Institute, among ischemic stroke survivors who were ≥65 years of age the following disabilities were
observed at 6 months after stroke(29)
–50% had some hemiparesis
–30% were unable to walk without assistance
–46% had cognitive deficits
–35% had depressive symptoms
–19% had aphasia
–26% were dependent in ADLs
–26% were institutionalized in a nursing home
› Referral to other disciplines
• Referral to physical therapy if the patient has difficulty with gait, ambulation, transfers, or weight-bearing(2,5)
• Referral to speech therapy if the patient has speech, language, cognitive-linguistic, or swallowing problems(2,5)
• Referral to neuropsychology for significant cognitive impairment and/or additional in-depth cognitive assessment(2,5)
• Referral to ophthalmology or neuro-ophthalmology for assessment and treatment of post stroke visual disturbances(5)
• Referral to dietitian if the patient has any feeding or swallowing difficulties and may be at risk for malnutrition; patient may
require supplements or supplemental feedings(5)
• Referral to recreational or vocational therapist for returning to activities of leisure and employment(5)
• Referral to audiology if the patient appears to have a hearing impairment
• Referral to psychiatry, psychology, or social work if patient appears depressed or anxious, is having difficulty coping with
stroke/disability, and/or may benefit from assistance with issues such as facility placement(2,5)
› Other considerations: Involvement of the patient’s caregiver, family members, and friends is very important for
maximizing treatment outcomes(5)
› Treatment summary: The goals of occupational therapy for survivors of stroke are to improve overall functioning and
maintain or return to highest level of independence possible(13)
• Authors of a 2015 systematic review evaluated the available evidence for the effectiveness of cognitive rehabilitation for
patients with stroke. They found there is insufficient high-quality research to support recommendations for clinical practice.
They made the following conclusions(37)
–Although attention deficits, spatial neglect, and motor apraxia improved immediately following some treatments, these
improvements were not lasting
–Treatments did not result in improvement in memory deficits, perceptual disorders, and executive function impairment
–The authors do not believe the lack of evidence indicates thattreatments addressing cognitive impairments in patients
following stroke are not effective, but that more studies are needed
• Since the publication of this systematic review there have been additional studies evaluating cognitive rehabilitation
treatments in patients following stroke
–Authors of an RCT (N = 36) compared two personalized and adaptive cognitive rehabilitation approaches in patients
following stroke. They compared paper-and-pencil tasks to virtual-reality-based intervention tools and their impact on the
different domains measured by the MoCA. Both tools personalized and adapted treatments(45)
- Pencil-and-paper intervention group:Interventions generated were delivered to the patient on paper. The patient was
instructed to use the arm he or she felt most comfortable with
 - Virtual-reality-based intervention group: Interventions were similar to the paper-and-pencil tasks but weresituated in
various virtual locations similar to those in the real world (e.g., streets, sidewalks, buildings, shops, parks)
- The intervention time was 1 month (12 sessions), with data collected pre-treatment, post-treatment, and at a 2-month
follow-up
- The virtual-reality-based intervention compared to the pencil-and-paperintervention was superior in general cognitive
functioning, visuospatial ability, and executive functions on the MoCA
–Authors of an RCT (N = 48) evaluated the effect of Baduanjin exercise on cognitive function in patients with post-stroke
cognitive impairment(47)
- Baduanjin intervention group: Baduanjin is a mind-body exercise that uses 8 different movements requiring
coordination of the body, breathing, and mind. It requires sustained attention, focus, and multitasking
- Patients were assigned to the Baduanjin group or to a control group treated with medication and traditional
rehabilitation. Baduanjin group recevieved training 3x/week for 40 minutes a day for 24 weeks
- MoCA score improvements for the Baduanjin group were significantly greater than the control group at 16 weeks of
intervention, 24 weeks, and 28 weeks
- Baduanjin training in patients following stroke with cognitive impairments can improve global cognitive function,
memory, motor execution, attention, and ADLs
–Authors of an RCT (N = 30) evaluated the effects of cognitive-motor dual-tasktraining combined with auditory motor
synchronization training on cognitive functioning in patients following stroke. Patients received either cognitive-motor
dual-task training only (control group) or cognitive-motordual-task training with auditory motor synchronization training
(experimental group)(50)
- Control group:Received cognitive-motor dual-task training 3x/week for 30-minute sessions for 6 weeks. This training
consisted of motor tasks associated with balance and posture while simultaneously performing a cognitive task
associated with attention, memory, and executive function (e.g., while performing trunk rotations the patient must name
the days of the week in reverse order)
- Experimental group: Received the same cognitive-motor dual-task training 3x/week for 15minutes of eachsession for 6
weeks as the control group. The remaining 15 minutes of each session involvedauditory motor synchronization training.
This training consisted of 13 differentmotor tasksperformed while pressing the hand or foot trigger of a metronome
at appropriate times (e.g., the two-hand task involved tapping both hands rhythmically while making a semicircular
movement to match the reference sound)
- Results indicated that cognitive-motor dual-task training combined with auditory motor synchronization was more
effective than the cognitive-motordual-task training alone in improving cognition
• In general, occupational therapy for stroke focuses on two guiding principles: intrinsic recovery and adaptive recovery.(13)
Intrinsic recovery involves restoration of function of damaged neural pathways through local changes of blood flow,
metabolism, and/or neurotransmitter concentrations.(13) As the degree of intrinsic recovery will be different for each patient
and generally is dictated by severity of stroke, adaptive recovery complements intrinsic recovery.(13) Adaptive recovery
involves educating patients in compensatory techniques to increase overall independence and reduce the level of disability
created by physical impairments(13)
–Examples of intrinsic recovery for patients with cognitive impairment include increased sustained attention to tasks,
improved problem-solving skills with ADLs, and faster speed of processing with functional tasks(3)
–Examples of adaptive techniques for patients with cognitive impairment include use of a journal to recall the events of the
day, modifying the environment, utilizing pictures as a reminder for following safety precautions, and having alarms to
remind the patient to take his or her medications properly(3)
• In addition to identifying the patient’s cognitive impairments, it is also the role of the OT to educate both the patient
and family members on the nature of the patient’s specific impairments and help them understand how the patient best
processes information(6)
• It is the responsibility of the OT to develop person-centered goals for patients following stroke. This can be more difficult
in patients with cognitive impairments, but it is still extremely important for the OT to involve the patient in the process.
Authors of a qualitative study interviewed rehabilitation specialists to gain more perspective on effective strategies(46)
–Five themes emerged in the goal-setting process: flexibility, building trusting relationships, enabling empowerment,
techniques for one-to-one interaction, and involving relatives
• Researchers have found that incorporating the principles of motor, sensory, cognitive, and affective rehabilitation into
task-specific activities (e.g., toileting) is significantly more effective than rote practice (e.g., leg squats)(12,13)
• Stroke patients with cognitive deficitsprior to strokeface barriers in their recovery
–Authors of a study found that patients in inpatient rehabilitation units in the United Kingdom who had cognitive
impairments prior to their stroke received 16 fewer therapy sessions (physical and occupational therapy sessions
combined) over the first 8 weeks post-stroke than those patients with no prior cognitive impairment. The authors could
not determine whether this affected these patients’ outcomes, but noted that patients with a prior diagnosis of cognitive
impairments face barriers in access to stroke rehabilitation(44)
–MoCA scores can predict functional gain in patients following stroke treated in inpatient rehabilitation. Authors of a
study defined 3 subgroups of scores: normal (score of 25–30), mildly impaired (score of 20–24), and moderately impaired
(score less than 19).The FIM score assessed functional gain. Mean relative functional gain (mRFG) quantified the amount
of functional gain achieved as a percentage of the total functional gain possible and mean relative functional efficiency
(mRFE)which adjusts for length of stay on the FIM total(51)
- Patients in the normal range had greater mRFG and MRFE than the mildy impaired group. The moderately impaired
group had significantly worse mRFG and MRFE than the mildly impaired group
- The moderately impaired group had the least functional gain and the least efficient gains, and a smaller proportion of
individuals in this group had a clinically meaningful FIM gain
- The authors recommended that patients with a MoCA score below 20 receive additional cognitive remediation
interventions, intensive practice, and/or modification and tailoring of treatment strategies to mitigate the risk of poorer
functional gains
• Study on functional improvements in patients following stroke with and without cognitive deficits
–Authors of a study (N = 143) compared the effects of a 12-month task-specificbalance training program on the balance
outcome measures of patients following stroke with and without cognitive impairments(49)
- Patients received task-specific balance training 3x/week for 60 minutes/session for 12 months
- Berg balance scores were measured at baseline and at 4th, 8th, and 12th months
- There was a significant improvement in scores at all time points in patients with cognitive impairments and in those
without cognitive impairments. There was no significant difference in the amount of improvement after the 8th and 12th
months between the two groups
- Cognitive impairments did not impede balance improvements
• Types of treatments for patients following stroke with cognitive deficits
–Results of an evidence-based review suggest that a variety of interventions are effective in improving occupational
performance of adults with cognitive impairment after stroke(36)
- Forty-six articles were evaluated. Interventions for the following impairments were included: general cognitive deficits,
executive dysfunction, apraxia, memory loss, attention deficits, visual field deficits, and unilateral neglect
- Evidence supports the use of general cognitive rehabilitation to improve global cognitive function, as well as
visuospatial training, post stroke
- Evidence to support an individualized home rehabilitation program to improve global cognitive function is insufficient
- Limited evidence supports the use of time pressure management for improvement of daily task performance
- Evidence to support use of virtual technology to remediate multitasking deficits or exercise and recreation
programming to improve executive functioning and memory is limited
- Evidence exists for the effectiveness of cognitive rehabilitation in improving ADLs in persons with apraxia after stroke
- Evidence related to improving ADLs for persons with memory loss after stroke is limited
- There is insufficient evidence to support attention process training as an effective treatment for attention deficits after
stroke
- There is evidence that a variety of interventions are effective in improving occupational performance in patients with
unilateral neglect after stroke
- Interventions include prisms, visual scanning training, mirror therapy, right half-field eye-patching, spatial cueing,
and family participation
–In a study conducted in Kuwait involving 18 survivors of stroke, subject-performed tasks (SPTs) and
experimenter-performed tasks (EPTs) were compared to verbal-only directions to determine which method was better for
physical and occupational therapy treatment(25)
- SPT: method of teaching patient a technique or strategy by having the patient perform the task himself or herself
 - EPT: method of teaching patient a technique or strategy by demonstrating the task for the patient while the patient
observes
- Results indicated that survivors of stroke with memory difficulties learn better when SPT or EPT is utilized rather than
having the therapist simply instruct the patient verbally; i.e., patients will learn and recall information better when
therapists use a “show me” technique rather than a “tell me” technique
–In a case study conducted in the United States that utilized task-orientedtraining for ADL impairment with an 83-year-old
female patient who had a left-sided stroke and cognitive impairments related to a history of moderate dementia,
researchers reported increased level of independence on all self-careitems at discharge(26)
• For an overview of all areas of occupational therapy treatment post stroke, see Clinical Review…Stroke Rehabilitation:
Occupational Therapy—an Overview, referenced above; see also the series of Clinical Reviews on specific areas of stroke
rehabilitation

.
Problem Goal Intervention Expected Progression Home Program
ADL/IADL impairment Increase functional Functional training With functional training Provide patient and
independence with _ and use of assistive family/caregivers with
ADLs and IADLs Task-oriented training devices, the patient’s written instructions
_ ability to complete regarding functional
_ ADL and IADL tasks activities that can be
ADL training independently should performed at home
_ improve and correct use and/
IADL training or application of
_ equipment
_
For patients with
cognitive impairments,
it is essential that the
OT utilize task analysis
to break down even
very simple ADL tasks
into their smallest
components(6)
_
_
Prescription,
application of devices
and equipment
_
Recommendation of
appropriate assistive
devices to promote
further independence
_
_
Training of the patient
to utilize device during
ADLs/IADLs
_
_
See Treatment
summary, above
Cognitive impairments Improve the patient’s Functional training As the patient’s Provide the patient with
cognitive capabilities in _ cognitive abilities cognitive exercises;
functional tasks Therapy will focus on improve, the OT will daily completion
improving the specific increase cognitive of exercises as
cognitive skills (such demands and task recommended by the
as increasing attention complexity treating OT
to tasks or improving
problem-solving skills),
as well as incorporating
compensatory strategies
into functional
activities
_
_
Compensatory
strategies include
memory logs, visual
aids, checklists,
diagrams, maps,
limiting distractions,
etc.(3)
_
_
See Treatment
summary, above
Perceptual impairments Improve the patient’s Functional training As the patient’s sensory Provide the patient
perceptual capabilities _ and perceptual abilities with perceptual
in functional tasks To increase tactile improve, the OT will exercises; daily
awareness, OT may increase cognitive completion of exercises
provide repetitive demands and task as recommended by the
stimulation of the complexity treating OT
affected hand with
various textures such as
foam, terry cloth, and
Velcro(3)
_
_
Therapy will focus
on improving
perceptual skills, as
well as incorporating
compensatory strategies
into functional
activities
_
_
See Treatment
summary, above

.
Desired Outcomes/Outcome Measures
› Desired outcomes/Outcome measures
• Improved cognitive functioning
–MMSE
–NCSE
–A-ONE
–Montreal Cognitive Assessment
–NIH Stroke Scale
• Increased independence with ADLs and/or IADLs
–TUG test
–Lawton and Brody Instrumental Activities of Daily Living Scale
–FIM
–PSMS
–AMPS
–KELS
–BI
–COPM
–SF-36

Maintenance or Prevention
› Prevention of stroke focuses on addressing modifiable risk factors,(9) including:
• Cessation of cigarette smoking(2,10)
• Controlling hypertension, diabetes, heart disease, and/or hyperlipidemia with appropriate medications and lifestyle
modifications(2)
• Maintaining a healthy weight(1,2,10)
–Bariatric surgery has been associated with a decrease in cardiovascular disease and death(MI and stroke)(29)
• Increasing physical activity(2,10)
• Seeking treatment for alcohol and/or drug abuse(1,2,10)
• Eating a healthy diet low in fat(2,10)
–A Dietary Approaches to Stop Hypertension (DASH)–type diet that increased consumption of either protein or
unsaturated fat had similar or greater beneficial effects on cardiovascular disease risk factors compared with the low-fat
standard DASH diet(29)
› The role of OTs in helping to prevent recurrent strokes in their patients includes health promotion and disease prevention
through education about the modification of the above risk factors(27)
› Prevention of long-term disability or limiting the effects of a stroke involves seeking medical care immediately upon noting
warning signs of stroke(9)
• The American Heart Association and American Stroke Association recommend seeking medical attention if you experience
(or see someone experience) the following warning signs:(28)
–Sudden numbness or weakness of the face, arm, or leg, especially on one side of the body
–Sudden confusion, trouble speaking or understanding
–Sudden trouble seeing in one or both eyes
–Sudden trouble walking, dizziness, or loss of balance or coordination
–Sudden, severe headache with no known cause
› Based on a 2020 study,cognitive reserve (derived in this study byeducation level, occupation, and life experiences) provides
a buffer against cognitive impairment caused by stroke and enhances cognitive recovery after stroke(48)

Patient Education
› American Stroke Association, https://www.stroke.org/
 Coding Matrix
References are rated using the following codes, listed in order of strength:

M Published meta-analysis RV Published review of the literature PP Policies, procedures, protocols

SR Published systematic or integrative literature review
RCT Published research (randomized controlled trial)
R Published research (not randomized controlled trial)
C Case histories, case studies
G Published guidelines
RU Published research utilization report
QI Published quality improvement report
L Legislation
PGR Published government report
PFR Published funded report
X Practice exemplars, stories, opinions
GI General or background information/texts/reports
U Unpublished research, reviews, poster presentations or
other such materials
CP Conference proceedings, abstracts, presentation

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