Wendell Nakamura

LEARNING OBJECTIVES: Identify common modifiable and non-modifiable risk factors for CVA. Summarize the signs and symptoms of common types of CVA and their underlying neuroanatomy and pathophysiology. Summarize common medical interventions for CVA. Analyze common physical, cognitive, behavioral, and social challenges associated with CVA and their impact on occupational performance.

CASE STUDY: Beatrice Zouch is a 72-year-old female who recently experienced a left hemispheric stroke that resulted in severe expressive aphasia and right-sided hemiparesis. She lives alone in a senior apartment complex where, prior to her stroke, she was very active. Since returning home from a long-term rehab facility, she has struggled with her activities of daily living and is embarrassed about her aphasia. Home health care services, including nursing and physical therapy, occupational therapy, and speech therapy have been ordered. Read more about Mrs. Zouch by following this link to her EHR.

A cerebrovascular accident (CVA), more commonly known as stroke, is an umbrella term used to describe one of several acute medical conditions where either blood flow to the brain is blocked or a blood vessel in the brain ruptures. It is a life-threatening condition and requires immediate medical attention. The effects of a CVA can significantly impact a person’s ability to move, see, think, and communicate. While strokes can occur at any age throughout the life course, it most frequently affects people over the age of 65 years (National Institute of Neurological Diseases and Stroke [NINDS], n.d.b). Notably, people who live in rural communities have higher rates of mortality from stroke than their urban counterparts (Georgakakos et al., 2022). The sooner that medical treatment is administered, the lower the likelihood of death or disability.

To gain a better understanding of cerebrovascular accidents and how they impact the occupational functioning of individuals, this section explores 1) the global, national, and local contexts for stroke; 2) common modifiable and non-modifiable risk factors for stroke; 3) the signs and symptoms of common kinds of stroke and their underlying neuroanatomy and pathophysiology; 4) common medical interventions for stroke; and 5) common sequelae associated with stroke and their impact on occupational performance.

The reader is very strongly encouraged to review fundamental movement patterns (Chapter 12), the cardiovascular system (Section 10.1), the arterial supply of the central nervous system (Section 8.1), glenohumeral joint subluxation (Section 12.3), and muscle spasticity (Section 8.1.1) of this Course Manual.

Epidemiology

Cardiovascular diseases (CVDs) are a group of health conditions that involve the heart and blood vessels. They include cerebrovascular accidents and many of the cardiac conditions covered in Section 10.1 of this Course Manual (hypertension, arrhythmias, atherosclerosis, myocardial infarction, and congestive heart failure). The World Health Organization (WHO; 2021; 2024) and Centers for Disease Control and Prevention (CDC; n.d.b) provide some startling statistics on the global and national impact of CVDs.

• CVDs were the second leading cause of death and disability across the globe in 2020 and 2021, after COVID-19.
• On a global scale, CVD accounted for approximately 32% of all deaths in 2019, three quarters of which occurred in low- and middle-income countries and 85% of which were caused by myocardial infarction (heart attack) and cerebrovascular disease (stroke).
• In the U.S., 17.5% of all deaths accounted for were due to stroke in 2022.
• Every year, approximately 795,000 people in the U.S. experience a stroke, about 76.7% of whom have a new stroke and about 23.3% of whom have previously experienced a stroke.

Global Burden of Disease

In a systematic review of the literature on the worldwide economic burden of stroke, Strilciuc et al. (2021) estimated that the U.S. spent an average of $59,900 per patient per year in 2020, the highest of all high-income countries studied. This figure included costs associated with insurance and individual payers, societal costs, and provider costs.

Rochman et al. (2021) conducted a separate literature review of direct and indirect costs associated with stroke and estimated that average lengths of stay in an inpatient setting was between 11 and 27 days, depending on severity, complications, and patient demographic profile. Direct medical and nonmedical costs, including inpatient and outpatient care, rehabilitation, transportation, household expenses, and informal caregiving, accounted for nearly 65% of total costs. Indirect costs, including absenteeism and lost productivity, made up the remainder.

Health Disparities

As with many other serious health conditions, there are wide disparities in health outcomes across the world for people following stroke. According to Feigin et al. (2024), the highest rates of incidence and prevalence of stroke occurred in low- and middle-income countries. Even within high-income countries, however, disparities in stroke incidence exist along racial, ethnic, socioeconomic, and geographical lines (Prust et al., 2024).

In urban communities, significant disparities exist in healthcare access and treatment for people who experienced a stroke. In a systematic review of the literature from 2010 through 2021, Ikeme et al. (2022) found that White patients were more likely to access emergency services and receive clot-busting (thrombolytic) medication and other clot removing procedures (thrombectomy) than their Black, Asian, and Hispanic counterparts. The authors note that factors such as insurance status, poorer literacy at recognizing early stroke symptoms, and patient overall mistrust in the healthcare system are likely factors that negatively influence outcomes for marginalized populations. Furthermore, the authors suggested that biases in systemic and organizational practices, such as longer emergency room wait times and poorer utilization of care pathways, may also play a significant role in stroke management and outcomes in Black and Hispanic communities.

In rural communities, similar factors account for disparities in life-saving access and in-hospital care. In a systematic review of the literature from 2012 to 2017, Hammond et al. (2020) found that compared to their urban counterparts, people from rural communities who were hospitalized for stroke were more often White, older than 75 years, and in the lowest quartile of income. The use of thrombolytics and thrombectomies were significantly lower for rural communities. As a result, in-hospital mortality from stroke was higher in rural communities than in urban centers.

Significant disparities also exist when considering mortality from stroke. Deaths due to stroke are increasingly occurring among the younger population (ages 35-64 years), especially among White, non-Hispanic, under-insured, rural populations where substance abuse is prevalent (de Havenon et al., 2023). By contrast, older individuals who died of stroke were more likely to be from urban, predominantly Black and Hispanic communities where income and opportunities for employment were low (de Havenon et al., 2023). Unsurprisingly, death rates from stroke increase with age (Atchison & Powers-Dirette, 2017; Bhatt et al., 2008) and incidence rates of stroke double every decade after 55 years of age (Boehme et al., 2017). Men ages 45-74 years also have higher rates of death from stroke than women (Washington State Department of Health, 2016). Communities with lower socioeconomic status are associated with shorter survival rates following stroke (Washington Department of Health, 2016) and are the highest among Black and Native American communities (Aldayel et al., 2017; Washington State Department of Health, 2016).

Clinical Presentation of Cerebrovascular Accident

Cerebrovascular accidents can occur anywhere along the central nervous system, including the cerebral hemispheres, subcortical regions, brainstem, or cerebellum and can be separated into two main types: hemorrhagic and ischemic.

• Hemorrhagic strokes are CVAs where an artery in the brain ruptures and leaks blood into brain tissue. The leaked blood can pool and because of the limited intracranial space, may exert pressure on brain tissue and damage them. Hemorrhagic strokes include intracranial hemorrhage (ICH; in the brain tissue space withing the cranial vault) and subarachnoid hemorrhage (SAH; in the space between the membrane that surrounds the brain tissue and the cranial vault) and account for approximately 13% of all stroke cases (Benjamin et al., 2019). The most common cause of hemorrhagic stroke is uncontrolled hypertension (Unnithan et al., 2023). Common sites for hemorrhagic CVA include basal ganglia (50%), cerebral cortices (10% to 20%), thalamus (15%), pons and brainstem (10% to 20%), and cerebellum (10%; Unnithan 2023). To view an interactive digital model of a hemorrhagic stroke, follow this link.
• Ischemic strokes (ischemia = reduced blood flow resulting in tissue death) are CVAs where blood flow through an artery that supplies oxygen-rich blood to brain tissue is blocked. It is the most common type of CVA and accounts for approximately 87% of all strokes (Benjamin et al., 2019). Irreversible neuronal cell death occurs in as little as 5 – 10 minutes of blood flow being blocked, depriving neural tissue of oxygen and nutrients (Schriner & Delahunt, 2024). To view an interactive digital model of ischemic strokes, follow this link.

A transient ischemic attack, or TIA, is a temporary or mini ischemic stroke whose symptoms can resolve within an hour, usually within a few minutes (Panuganti et al., 2023). People with a history of TIAs are at significantly higher risk for CVA (Panuganti et al., 2023). To view an interactive digital model of TIA, follow this link.

Ischemic strokes can be subclassified according to where the blood clot is formed.

• Thrombotic (thrombus = blood clot formed in vasculature) – A blood clot formed in the large blood vessels of the brain, usually due to atherosclerosis (Hui et al., 2024). You will recall from Section 10.1 of this Course Manual that atherosclerosis is a build-up of plaque within the walls of arteries, narrowing the lumen (stenosis) and reducing the blood-flow to tissues.
• Lacunar – A specific kind of thrombotic stroke accounting for approximately 20% to 25% of ischemic strokes, lacunar strokes occur because of a blood clot formed deep in a cerebral artery in subcortical spaces, including the branches of the Circle of Willis, anterior cerebral artery (ACA), middle cerebral artery (MCA), posterior cerebral artery (PCA), or basilar artery (Gore et al., 2024)
• Embolic (embolism = blockage by a foreign substance such as blood clot, air bubble, or fat deposit) – A blood clot formed in the body (frequently the heart, lungs, or lower extremities) that travels to the brain and occludes blood flow.

Modifiable and Non-modifiable Risk Factors

There are many factors that contribute to an increased risk of stroke. Among modifiable risk factors, high body mass index (BMI), diet high in sugary beverages, low rates of physical activity, tobacco use, and excessive alcohol consumption were the highest contributors of stroke (Feigin et al., 2024). Extremes of environmental ambient temperature were among the leading causes for non-modifiable risk factors for stroke (Feigin et al., 2024). Other non-modifiable risk factors include age (older), family history, race (Black and Hispanic), gender (women), and prior stroke, TIA, or heart attack (American Stroke Association, n.d.).

Neuropathophysiology

We’ll focus our discussion of neuropathophysiology and associated clinical presentations on ischemic CVAs since they are the most common and are likely to be encountered in occupational therapy practice.

• Left Hemispheric Middle Cerebral Artery (MCA) CVA. The middle cerebral artery is the most common site of blockage for ischemic strokes (Nogles & Goluska, 2023). It branches from the internal carotid artery and supplies oxygen-rich blood to parts of the frontal, parietal, and temporal lobes of the cerebral cortex and to parts of the basal ganglia. Because the MCA covers a large number of structures, presentation can vary widely, depending on which branches of the MCA are occluded. The left cerebral hemisphere controls most of the functions on the right side of the body due to the decussation of nerves at the medulla oblongata. A left hemispheric MCA CVA may produce the following symptoms (Schriner & Delahunt, 2024):
  • loss of voluntary movement and coordination on the contralateral side of the face, trunk, and extremities.
  • impaired sensation of the contralateral side of the face, trunk, and extremities, including pain, temperature, vibration, tactile, proprioception, and kinesthesia.
  • expressive and/or receptive aphasia, including speech, writing, and reading.
  • dysarthria (difficulty with articulation due to loss of motor control of muscles of the face, lips, and tongue).
  • dysphagia (difficulty with managing food textures and liquids due to loss of motor control of muscles of the face, lips, and tongue).
  • visual impairments, especially in the right visual field.
  • impairments in executive functioning, emotional regulation, attention, motivation, and memory.
• Right Hemispheric Middle Cerebral Artery (MCA) CVA. The right cerebral hemisphere controls most of the functions on the left side of the body. A right hemispheric MCA CVA may produce the following symptoms (Schriner & Delahunt, 2024):
  • loss of voluntary movement and coordination on the contralateral side of the face, trunk, and extremities.
  • impaired sensation on the contralateral side of the face, trunk, and extremities, including pain, temperature, vibration, tactile, proprioception, and kinesthesia.
  • visual impairments, especially in the left visual field.
  • hemi-inattention (a cognitive impairment where the client does not attend to the left visual field). This is different than a visual field cut.
  • apraxia (impairments in motor planning where a client is unable to perform a movement pattern) in the absence of a motor control impairment.
  • impulsive behavior and poor awareness of deficits.
• Anterior Cerebral Artery (ACA) CVA. The areas of the brain that are supplied by the ACA include parts of the frontal lobe, parietal lobe, and temporal lobe of the cerebral cortex and parts of the basal ganglia. Occlusions to the ACA occur with much less frequency than with the MCA due to the anterior communicating artery in the Circle of Willis (Schriner & Delahunt, 2024). An ACA CVA may produce the following symptoms (Casano et al., 2023; Schriner & Delahunt, 2024):
  • loss of voluntary movement and coordination on the contralateral side of the face, trunk, and extremities (lower extremity is much more affected than the upper extremity).
  • impaired sensation on the contralateral side of the face, trunk, and extremities, including pain, temperature, vibration, tactile, proprioception, and kinesthesia (lower extremity is much more affected than the upper extremity).
  • loss of conscious control of bowel and bladder.
  • loss of postural control and balance in sitting, standing, and walking.
  • loss of emotional expression (flat affect).
  • apraxia (loss of motor planning).
  • impairments in executive functioning, emotional regulation, attention, motivation, and memory.
• Posterior Cerebral Artery (PCA), vertebrobasilar, pontine, and cerebellar CVA. The areas supplied by the vertebrobasilar arteries are included here together because they are all connected and presentations are very similar (Alwood & Dossani, 2023; Ikram & Zafar, 2023; Ioannides et al., 2024; Kuybu et al., 2023; Malla & Jillella, 2023). The areas of the brain that are covered by these arteries are the second most common occurrence of ischemic strokes (Schriner & Delahunt, 2024) and include parts of the occipital lobe, basal ganglia, and all of the structures of the mesencephalon and rhombencephalon. Symptoms of these kinds of strokes may include:
  • visual disturbances, including oculomotor coordination.
  • impairments in temperature sensation,
  • impaired ability to read or name objects.
  • dysequilibrium (vertigo).
  • dystonia (abnormal muscle tone).
  • impaired motor coordination, including ataxia and dysmetria (over- or under-shooting or judging distance while reaching for a target).
  • dysphagia (difficulty with managing food textures and liquids due to loss of motor control of muscles of the face, lips, and tongue).

FOCUS ON CLINICAL APPLICATION: The NIH Stroke Scale (NINDS, n.d.a) is a widely used assessment of the severity of stroke across eleven domains: Level of consciousness: The client is measured on level of alertness, orientation to month and age, and ability to follow simple one-step commands (open and close eyes, grip and release examiner’s hand). Eye gaze: The client is asked to track examiner’s finger as it moves in horizontal line across the visual field. Visual fields: Either the finger counting method or the confrontation test may be used. Facial palsy: The client is asked to smile or raise eyebrows. The client is scored based on facial symmetry. Arm motor control: The client is asked to hold out their arm at approximately 90 degrees of shoulder flexion if seated or 45 degrees of shoulder flexion if supine. Each arm is tested individually, beginning with the non-paretic limb. The client is scored on their ability to hold their arm without drifting for 10 seconds. Leg motor control: The client is asked to hold out their leg at approximately 30 degrees of hip flexion and knee fully extended while in supine. Each leg is tested individually, beginning with the non-paretic limb. The client is scored on their ability to hold their leg without drifting for 5 seconds. Limb ataxia: The client is asked to touch the examiner’s finger, then touch the client’s nose. The client is also instructed to touch one heel to the opposite ankle and slide their heel along their shin. The test is performed on both sides. Sensation: The client is scored on their ability to sense a sharp pain from a pin prick or neurotip. Language: The client is asked to describe what is happening in a provided picture, name items on a sheet of paper, and read from a list of sentences. Dysarthria: The client is scored on their level of dysarthria present in the previous item. Extinction and inattention: The client is scored on their level of attention to visual and tactile stimuli presented in the visual field (such as line cancellation test). Each domain is scored numerically. A total score can range between 0 and 42; a higher number represents greater severity. To download a copy of the NIH Stroke Scale with instructions, follow this link. To watch a video on the NIH Stroke Scale and its administration, follow this link. To view a video of the NIH Stroke Scale being administered, follow this link. A client’s NIHSS score will be continually assessed throughout their hospital stay, as it can change on an hourly basis. General guidelines for total scores are as follows: 0 = no stroke 1-4 = minor stroke 5-15 = moderate stroke 16-20 = moderate/severe stroke 21-42 = severe stroke The score can help clinicians determine an appropriate level of discharge from the hospital (SNF, home health, outpatient).

Medical Interventions

Usually, the first line of defense for ischemic strokes are to restore blood flow to brain tissue through the administration of clot busters. The most effective medication for this is tissue plasminogen activator (tPA). It is only effective, however, if administered up to 4.5 hours after the first signs of occlusion (NINDS, n.d.c). tPA is an enzyme that travels through the bloodstream and to the site of the clot to break it down and restore blood flow. With the restoration of oxygenated blood, brain tissue that’s already damaged cannot be repaired, but tPA can prevent further damage caused by the event. Note that tPA should never be administered in the event of a hemorrhagic stroke because it thins the blood, which would make the hemorrhage worse.

Once the CVA has been stabilized, medical management depends on the type of CVA sustained, the extent of damage, and the presence of any comorbidities. Clients are typically put on a regimen of anticoagulants (blood thinners), cholesterol-lowering medications, and/or antihypertensives (NINDS, n.d.a). Some clients may also require supplemental oxygen through a nasal cannula to improve oxygen perfusion (NINDS, n.d.a).

FOCUS ON CLINICAL APPLICATION: Following a CVA, it is important for the occupational therapist to provide interventions that also protect against secondary complications that may be experienced by clients as a result of stroke: subluxation of the glenohumeral joint, pain, joint contractures, and depression. Glenohumeral joint subluxation: The reader will recall from Section 12.3 of this Course Manual that shoulder subluxation occurs as a result of the loss of motor control of the rotator cuff muscles, which have the primary function of approximating the head of the humerus into the glenoid fossa of the scapula. Due to the pull of gravity on the upper limb and loss of motor control of the rotator cuff, the subluxation typically happens in the inferior direction and can easily be visualized or palpated on the client. It is estimated that between 17% and 81% of client with hemiplegia develop a subluxation (Vitoonpong & Chang, 2023). Occupational therapy interventions for shoulder subluxation include electrical stimulation, taping, therapeutic exercise and activities, patterned movement, and sling use. Specific intervention strategies and their applications are beyond the scope of this course and will be explored in another course in the curriculum. Pain: Following a stroke, many clients experience pain as a secondary complication. There are four primary categories of pain related to stroke that we’ll cover: joint pain, muscle pain, pain from altered sensitivity, and shoulder-hand syndrome. Joint pain: One of the sequalae of stroke previously discussed is dystonia (abnormal muscle tone). Following a stroke, muscle tone undergoes several changes. Flaccidity occurs in the early stages of recovery and can result in shoulder subluxation. A glenohumeral joint where the humeral head is not in contact with the glenoid fossa has altered biomechanical movement, often resulting in impingement syndrome or blunt force injury. Due to decreased sensation or awareness of the hemiparetic limb, injuries at the glenohumeral joint are especially common. Limbs may get caught on objects in the environment, such as wheelchairs, clothing, or furniture. Muscle pain: As muscle tone gradually increases throughout recovery, the limb flexors (especially the elbow flexors) begin to contract with either increased force or with poor joint alignment. Pain as a result of increased muscle tone is often experienced by people following stroke. Pain related to altered sensitivity: Due to changes in tactile sensitivity (at the peripheral neurons), as well as how sensations are processed and perceived (by the somatosensory cortex), many people experience sensory pain as a result of stroke. Pain perception may often be perceived in excess of actual stimuli (hyperalgesia) or in responses to stimuli that are not normally noxious (allyodynia). Complex Regional Pain Syndrome: A set of symptoms experienced by some people following a stroke event, characterized by chronic hyperalgesic or allodynic pain, edema, and changes in skin temperature. The reader should review the discussion of CRPS from the “Focus on Clinical Application #1” (yellow) box of Section 8.2 of the Course Manual. Joint contractures: Over prolonged periods of immobility and due to high muscle tone, many survivors of stroke develop joint contractures (a shortening of the joint space, usually in flexion), especially of the upper limb and hand. Muscle activation of the antagonists muscles (usually the extensors) and education and training in skin protection strategies are usually the first to be addressed in occupational therapy intrventions.

Impact on Occupational Performance

Depending on the extent of the stroke and the area of the CNS affected, stroke can have devastating effects on a person’s occupational performance and well-being. In this section, we will consider different aspects of a person’s life that may be affected by stroke.

• Activities of Daily Living (ADL): Stroke can significantly decrease one’s ability to participate in daily activities (Amarshi et al., 2006; de Graaf et al., 2018; Rhoda et al., 2011; Urimubenshi, 2015) due to changes in the sensory, motor, and cognitive body systems, particularly those activities that require bimanual coordination and dexterity. The effects of stroke can impact one’s safety and independence in performance and participation of ADLs such as grooming, bathing, and toileting, often resulting in requiring caregiver support. Changes in sense of touch, temperature, pain, and proprioception will have significant impacts on the use of both the upper and lower affected limbs.
  
  Sensory loss rarely occurs in isolation and typically accompanies loss of motor function. The fundamental movement patterns discussed in Chapter 12 of this Course Manual can all be impacted. Most typically, flaccid hemiparesis (loss of muscle tone) occurs for the first few weeks to months following stroke. This is usually followed by a period of hypertonicity or spasticity, as described in Section 8.1.1 of this Course Manual.
• Instrumental Activities of Daily Living (IADL): Following a CVA, most individuals require some assistance with IADL, including housekeeping, meal preparation, yard care, pet care, child/pet care, shopping, transportation, communication management, personal safety, time management, and financial management. For example, people who have homonymous hemianopsia will likely have difficulty with securing groceries and preparing a simple meal or cleaning the house. Someone with expressive or receptive aphasia may struggle with communication management activities, such as making doctor appointments or filling prescription medications. People with apraxia will likely struggle with complex meal preparation or yard care.
• Health management and personal safety: After a stroke, individuals may have difficulty managing medications (taking the right amount at the right times) due to impairments in attention, memory, or the visual system. They may also not be able to take appropriate actions in the event of a fire or to prevent burns from water or the stove due to impairments in executive functioning or sensory perception.
• Rest and sleep: Rest and sleep are crucial for healing, cognitive functioning, neuroplasticity, and restoration of motor functioning. As a result of stroke, changes in sleep patterns or other sleep disturbances are likely. Preparation for sleep may be difficult due to sensory or motor impairments. Sleep continuity may be difficulty due to changes in arousal states. Additionally, managing sleep-related breathing disorders (such as sleep apnea) require the continuation of sleep routines and habits, which may also be affected by stroke.
• Work, play, and leisure: Roles, habits, and routines associated with work, play, and leisure participation are typically negatively impacted by stroke. Loss of sensory, motor, cognitive, and perceptual changes often occur and these changes can lead to changes in a person’s mental health. Symptoms of depression and anxiety are often associated with changes in roles and routines following stroke (American Stroke Association, 2019; Chun et al., 2018; Robinson & Jorge, 2015).
• Social engagement and caregiver dependence: Sedentary lifestyle behavior may result following stroke (English et al., 2016). Decreased social engagement and alterations of one’s perception of life (Amarshi et al., 2006) are also shown to be a common result of stroke. Increased caregiver dependence (Skolarus et al., 2016) and increased interpersonal relationship strain between stroke survivors and family caregivers (McCarthy et al., 2020) also typically occur.

Summary

Cerebrovascular accident is the most pervasive health conditions in the U.S. and around the word, a major contributor to preventable disability and death. Cardiovascular conditions such as hypertension, atherosclerosis, and hypercholesterolemia are modifiable risk factors that can be addressed through health promotion programs run by occupational therapists. The most common type of stroke is the embolic type of the middle cerebral artery. These types can result in major impacts to occupational performance skills and body functions and have profound impacts on occupational participation, social engagement, and caregiver dependence. Occupational therapists possess the medical knowledge, skills, and insights to improve the lives of people following stroke in every practice setting, from primary and acute care to outpatient clinics.

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