EXMENES FINALES Licenciatura en Terapia Ocupacional

1) STROKE
Stroke, or cerebrovascular accident (CVA) is known to be caused by infarct of
brain tissue secondary to oxygen deprivation. As a result, the patient ay be paralysed
(heiplegic) or weak (heiparetic) on the side of the body opposite to the side of the
CVA. !eurological deficits of all types ay occur in addition to the otor signs, the
exact side and extent of the lesion in the brain deterining which neurological deficits
will be anifested poststroke.
"hat stroke cause is anoxic daage to nervous tissue that is anifested by
various syptos depending on where the blood supply was lost. #unctions subserved
by the affected brain tissue are either teporarily disrupted or peranently lost
depending on the etiology and extent of nervous tissue daage. Should the occlusion of
haeorrhage affect only a sall branch of one of these a$or arteries, then the
syptos would reflect only loss of the function controlled by the area reflected. %f
collateral circulation is established or resorption of oedea occurs, recovery reflects
this.
Studies are needed to correlate differences in effectiveness of treatent ethods
to site of lesion. Such inforation would allow greater precision in treatent planning
and prediction of treatent outcoes. &owever, even in patients with the sae
neurological deficit, the ipact of the disability is different, depending on the patient's
life situation. Stroke rehabilitation should consider the patient's entire life cycle, not
erely focus on the specific neurological deficits.
%n ()( persons who survived * onths poststroke, (+, were totally
independent- ), were dependent (scored (. or less on /arthel %ndex)- and ((, were
partially independent (scored .0 to )., on the /arthel. %t is estiated that of those
patients who survive 1 to . years postroke, (0 to *0, becoe functionally independent.
20 to 1., reain dependent, and the rest becoe partially independent.
Spontaneous recovery of function ay occur in a stroke patient because oedea
subsides or non3functional but viable neurons reactivate. 4ecovery ay also occur due
to physiological reorganisation of the neuronal connections and5or developent of new
behavioural strategies. "hat can be said fro these observations is that individual
differences in neural connections and learned behaviours play a a$or role in functional
recovery.
4ehabilitation potential is high for those who can reestablish inforational
inputs to the sensory association areas of the brain that direct or redirect otor
progras. /ecause anatoical connections reorganise during recovery, otor patterns
need to be relearned but they rarely return to the prestroke level, especially those
involving distal uscles, which are ore likely to be directly innervated by
corticospinal otorneurons. 6he occupational therapist's goal is to increase the stroke
patient's independence in occupational perforance tasks.
%t is a well3known fact that no two3stroke patients will display the sae
syptos to the sae degree. 7ven if the sae sites were infarcted, the syptos
could vary due to individual anatoical, genetic, and environental differences.
Careful evaluation ust be done to reveal both the deficits and their probable
interrelatedness. &owever, if the therapist were to adinister all the tests needed in
order to discover all possible deficits before starting treatent, the patient would be
discharged before treatent began8 6herefore, rather than use an inductive and
reasoning process, the therapist ust use a deductive one by starting with the self3care
evaluation. 7very stroke patient is evaluated for level of independent functioning in
self3care tasks.
7valuation ay include easureent of sensation, uscle tone, autoatic
postural ad$ustents, voluntary otor control, perception, and cognition. %f otor
control is intact, the therapist will evaluate uscle strength and dexterity. Additionally,
inforation concerning other factors that affect the ability of the person to progress or
learn ust be gathered. 6hese factors include the presence of speech and language
disorders or visual deficits. 6he presence of, or potential for developing, secondary
otor deficits that will liit function also ust be evaluated. 7otional status of the
patient and level of adaptation to the stroke not only by the patient but also by his
faily will affect outcoe and need to be evaluated, as does the patient's degree of
otivation to recover. 9otivation also plays a a$or role in functional recovery.
An evaluation for that allows recording of all evaluation results helps in
treatent planning. Such fors are usually developed by each occupational therapy
departent, and what they reflect is its philosophy regarding treatent of the stroke
patient.
A) Ubiue ! "arue en el te#to la in$or"aci%n nece&aria para 'eci'ir &i la&
&i(uiente& a$ir"acione& &on )er'a'era& *+) o $al&a& *F),
a) Los dficits neurolgicos pos ACV pueden determinarse de acuerdo al lugar donde se produjo la
lesin y su extensin.
b) La relacin diferencias en la efectividad de los tratamientos/ubicacin de la lesin es suficiente para
planificar el tratamiento.
c) Un valor del ndice de !art"el superior a #$% en personas &ue "an sobrevivido a un ACV indica
dependencia funcional total.
d) Los patrones motores nunca pueden ser reaprendidos.
e) Las evaluaciones pre'tratamiento est(n estandari)adas.
-) Re&pon'a la& &i(uiente& pre(unta&.
a) *+or &u es necesario reali)ar una cuidadosa evaluacin de cada paciente con ACV,
b) *-u se sugiere al respecto,
c) .numere% en forma sinttica% todos los aspectos a tener en cuenta en la evaluacin.
/) Tra'u0ca lo& p1rra$o& II2 III ! +,
3) /O4NITI+E AN5 6ER/E6TUAL E+ALUATION AN5 TREATMENT
E)aluation an' Treat"ent o$ perceptual 'e$icit&
Coprehensive perceptual evaluation re:uires selection of various subtests for
specific deficits that are put together by the therapist to for the test battery for a
specific patient. 6here is one test battery available, however, that evaluates visual
perception as a whole- that is the 9otor3#ree Visual ;erception 6est (9V;6). 6he
9V;6, which was originally designed for children, easures spacial relations, visual
discriination, figure3ground perception, visual closure, and visual eory. %t has been
adapted for use with brain3daaged adults and standardi<ed on a noral adult
population. 6he test was adapted by adding a tie factor and intepretational guidelines
designed to deterine lack of copensation for visual field deficits and5or unilateral
neglect. %f a patient underresponds to test ites directed to one side of the body, a field
defect is suspected and this side is not used to deterine the patient=' perceptual ability.
%nteprretation of severity of unilateral visual neglect ust be ade cautiously, as ild
functional unilateral visual neglect does not consistently correlate with underresponding
on this test. 6he score on this test gives an overall easure of visual perception and is
not eant to be differentiated into the various areas tested. ;lease refer to the adult test
anual for specific adinistration instructions.
BODY SCHEME
/ody schee is the awareness of body parts and position of the body and its
parts in relation to theselves and ob$ects in the environent. 4elated deficits include
right5left disorientation, ipaired body part identification, finger agnosia, anosognosia,
and unilateral neglect.
>isorders of body schee as easured by body part identification and right5left
discriination are ore fre:uently observed in ?/> patients. &owever, failure can be
the result of several probles@ 2) verbal 1) sensory A) conceptual, or () visuospatial.
6herefore, patients ay exhibit deficits in body schee under one test condition, but
not under a different condition. #or exaple, a 4/> patient ay have no difficulty
indicating right5left or body part on self, but be unable to indicate right5left on a
confronting person or to iitate right5left oveents due to a visuospatial proble.
9ac >onald describes a test of bosy schee that includes finger agnosia,
right5left discriination, body part identification, and body revisuali<ation. Scores on
this test by neurologically ipaired and nonneurologicallu ipaired adults were
significantly different at the 0.002 level of probability.
6he goal of treatent of body schee disorders is to increase the patient's
awareness of his body and decrease his disorientation. 6reatent starts in a low3
stiulation environent. As the patient becoes less disoriented, treatent can be
expanded to the clinic. 9aro suggests a sensory integrative approach to treatent of
body schee disorders that includes controlled sensory stiulation and developental
otor patterns adinistered under conditions of decreased stress to help the patient in
reorgani<ing his body schee. She recoends beginning with tactile rubdowns,
progressing to rolling over, followed by prone3on3elbows posture. 6here is no
docuentation of the effectiveness of this treatent approach.
Right/Left Discrimination
4ight5left (45?) discriination denotes an ability to understand the concepts of
right and left. 45? disorientation to one's own body is uncoon in nonaphasic
patients. &owever, 4/> patients exhibit difficulty in identifying body parts of a
confronting person. !onaphasic 4/> patients tend to perfor ade:uately on 45? tasks.
%t appears that poor 45? discriination in aphasic ?/> patients is due to a language
proble, whereas the deficit seen in 4/> patients is ost likely due to visuospatial
deficits. !onaphasic patients with general ental ipairent also exhibit deficits in this
area, ost probably due to a conceptual proble.
Evaluation
6ests of 45? discriination usually include orientation to one's own body (e.g.,
Btouch your left earC), orientation to a confronting person (e.g., Btouch y left handC),
or a cobination of both. 6he coplexity is increased by re:uiring double uncrossed
tasks (e.g., Btouch your right knees with your right handC) or double crossed tasks (e.g.,
Btouch your right knee with your left elbowC)
/enton et al. present a standardi<ed 103ite test that re:uires the patient to point
to laterali<ed body parts on coand and takes about . in to adinister (see 6able
+.A). A total score of less than 2+ is considered defective. ;erforance patterns can be
classified as noral (score of 2+310, no ore than one error on the first 21 Bown bodyC
ites- generali<ed defect (score of less than 2+, ore than one error on the first 21 Bown
bodyC ites- confronting person defect (score of less than 2+, no ore than one error on
Bown bodyC ites and no ore than two errors on the reaining ites)- specific Bown
bodyC deficit (ore than one error on the 21 Bown bodyC ites) and systeatic reversal
(score of 2+310 when perforance is scored in reverse fashion, no ore than one error
on Bown bodyC ites).
Realice la& acti)i'a'e& ue &e 'etallan a continuaci%n
2) 6radu<ca el tDtulo :ue se encuentra ba$o el subtDtulo Evaluation and
treatment of perceptual evaluation.
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