9.1 Stroke (CVA) & Traumatic Brain Injury (TBI)

Stroke (CVA) & Traumatic Brain Injury (TBI) Rehabilitation

Cerebrovascular accidents (CVAs) and traumatic brain injuries (TBIs) represent two of the most prevalent and functionally catastrophic neurological diagnoses managed by Certified Occupational Therapy Assistants (COTAs) across acute care, inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), and outpatient neuro-rehabilitation clinics.

Restoring functional independence in Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs) requires the COTA to possess a deep understanding of neuroanatomy, hemispheric specialization, motor recovery stages, cognitive-perceptual hierarchies, and vital handling precautions to protect vulnerable hemiparetic structures.

1. Stroke (CVA) Etiology & Hemispheric Specialization

A cerebrovascular accident (CVA) occurs when cerebral blood flow is abruptly interrupted, resulting in neuronal ischemia, cellular necrosis, and localized sensorimotor and cognitive deficits. CVAs are classified into two primary pathophysiological mechanisms:

1. Ischemic Stroke (~87% of all CVAs): Caused by occlusion of a cerebral artery due to a local thrombus (thrombotic) or a travelling embolus (embolic, commonly secondary to atrial fibrillation or carotid stenosis). Transient Ischemic Attacks (TIAs) represent temporary, non-infarcing focal neurological episodes that fully resolve within 24 hours but serve as critical warning signs.
2. Hemorrhagic Stroke (~13% of all CVAs): Caused by the rupture of a weakened cerebral blood vessel, resulting in intracranial bleeding, hematoma expansion, and elevated intracranial pressure (ICP). Common etiologies include chronic hypertension, ruptured berry aneurysms (subarachnoid hemorrhage), and arteriovenous malformations (AVMs).

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|                   HEMISPHERIC CVA COMPARATIVE MATRIX                       |
|                                                                             |
|   LEFT HEMISPHERE CVA (Right Deficits)   | RIGHT HEMISPHERE CVA (Left Deficits)|
|   • Right hemiparesis / hemiplegia       | • Left hemiparesis / hemiplegia     |
|   • Aphasia (Expressive / Receptive)     | • Unilateral Left Spatial Neglect   |
|   • Motor / Ideomotor / Ideational       | • Left Homonymous Hemianopsia       |
|     Apraxia (motor planning deficits)    | • Anosognosia (unaware of deficits) |
|   • Cautious, slow, hesitant behavior    | • Impulsive, overconfident behavior |
|   • High frustration / depression        | • Poor safety awareness / judgment  |
|   • Intact spatial-perceptual skills     | • Spatial-perceptual & body scheme  |
|   • Difficulty with multi-step verbal    | • Fast-paced, careless motor errors |
|     directions; benefits from visual     | • Retains speech; poor pragmatic    |
|     demonstration & gestures             |   cues & prosody comprehension      |
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Detailed Breakdown: Left CVA vs. Right CVA Clinical Profiles

2. Traumatic Brain Injury (TBI) & The Glasgow Coma Scale (GCS)

Traumatic Brain Injury (TBI) results from an external mechanical force applied to the cranium, leading to temporary or permanent impairment of cognitive, physical, and psychosocial functions. Pathophysiological classifications include:

• Focal Injuries: Localized contusions, lacerations, or intracranial hematomas (epidural, subdural, subarachnoid, or intracerebral hematomas).
• Diffuse Axonal Injury (DAI): Widespread shearing and rotational tearing of microscopic axons within cerebral white matter tracts, corpus callosum, and brainstem, frequently caused by high-speed motor vehicle accidents or rotational trauma.
• Coup-Contrecoup Injury: Direct focal damage at the site of primary impact (coup) combined with rebound contusions on the diametrically opposite side of the skull (contrecoup).

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|                    GLASGOW COMA SCALE (GCS) SCORING                         |
|                                                                             |
|   EYE OPENING (1-4)       VERBAL RESPONSE (1-5)    MOTOR RESPONSE (1-6)     |
|   4 = Spontaneous         5 = Oriented             6 = Obeys commands       |
|   3 = To speech/sound     4 = Confused             5 = Localizes to pain    |
|   2 = To pressure/pain    3 = Inappropriate words  4 = Normal flexion (pull)|
|   1 = None                2 = Incomprehensible     3 = Abnormal flexion *   |
|                           1 = None                 2 = Extension **         |
|                                                    1 = None                 |
|                                                                             |
|   * Decorticate Posturing (Flexor): Arms flexed/adducted, wrists flexed,    |
|     legs extended and internally rotated. Damage: Cerebral hemispheres.     |
|   ** Decerebrate Posturing (Extensor): Arms rigidly extended/pronated,      |
|      wrists flexed, legs rigidly extended. Damage: Brainstem (Midbrain/Pons)|
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GCS Severity Stratification & Clinical Prognosis

• Severe TBI (GCS Score 3 to 8): State of coma; unconsciousness lasting $>6$ hours. High mortality rate; survivors require intensive multidisciplinary rehabilitation and extensive long-term assistance.
• Moderate TBI (GCS Score 9 to 12): Loss of consciousness lasting 30 minutes to 24 hours; post-traumatic amnesia (PTA) 1 to 7 days. Clients demonstrate focal neurological deficits, confusion, and variable rehabilitation potential.
• Mild TBI / Concussion (GCS Score 13 to 15): Loss of consciousness $<30$ minutes; post-traumatic amnesia $<24$ hours. Clients experience post-concussive syndrome, headaches, dizziness, photosensitivity, executive dysfunction, and emotional lability.

3. Rancho Los Amigos Levels of Cognitive Functioning (RLAS I to X)

The Rancho Los Amigos Levels of Cognitive Functioning (RLAS) is the gold-standard clinical rating scale utilized by occupational therapy practitioners to evaluate cognitive recovery, behavioral progression, and functional independence following TBI.

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|              RANCHO LOS AMIGOS LEVELS (RLAS) STAGES & OT FOCUS             |
|                                                                             |
|   [LOW LEVELS: I - III] (Total Assist)                                      |
|   • Level I: No Response                                                    |
|   • Level II: Generalized Response (gross, non-purposeful reaction)         |
|   • Level III: Localized Response (reacts directly to specific stimuli)     |
|   ==> OT Focus: Coma stimulation, positioning, contracture prevention splints|
|                                                                             |
|   [MID LEVELS: IV - VI] (Max to Mod Assist)                                 |
|   • Level IV: Confused-Agitated (bizarre, non-purposeful, combative)        |
|   • Level V: Confused-Inappropriate, Non-Agitated (distractible, confabulates)|
|   • Level VI: Confused-Appropriate (goal-directed with structure/cues)      |
|   ==> OT Focus: Low-stimulation environment, safety, routine ADL retraining |
|                                                                             |
|   [HIGH LEVELS: VII - X] (Min Assist to Mod Independent)                    |
|   • Level VII: Automatic-Appropriate (oriented, robot-like routine, low insight)|
|   • Level VIII: Purposeful-Appropriate (Standby Assist, memory aids used)   |
|   • Level IX: Purposeful-Appropriate (Standby Assist on Request)            |
|   • Level X: Purposeful-Appropriate (Modified Independent, multitasks)      |
|   ==> OT Focus: Executive function, community re-entry, vocational/IADLs    |
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Comprehensive Rancho Los Amigos Cognitive Recovery Matrix

4. Post-Stroke Shoulder Subluxation & Upper Extremity Management

Glenohumeral subluxation occurs in up to 80% of post-stroke clients with upper extremity hemiplegia. It is defined as the partial dislocation of the humeral head downward (inferior), forward (anterior), or backward (posterior) out of the shallow glenoid fossa.

Pathomechanics of Inferior Shoulder Subluxation:

1. Flaccidity Phase: Acute paralysis of the supraspinatus muscle (which locks the humeral head into the glenoid cavity) and the deltoid muscle creates severe joint laxity.
2. Gravitational Traction: The unsupported, dead weight of the flaccid arm pulls the humerus inferiorly, stretching the fibrous joint capsule, suprascapular nerve, and brachial plexus.
3. Scapular Malalignment: Downward rotation, protraction, and depression of the scapula alter the angle of the glenoid fossa, eliminating its natural shelf-like bony support.

+-----------------------------------------------------------------------------+
|                 SHOULDER SUBLUXATION BIOMECHANICAL MANAGEMENT               |
|                                                                             |
|   SEATED POSITIONING                 AMBULATION & TRANSFERS                 |
|   • Wheelchair Lap Tray / Arm Trough  • GivMohr Hemi-Sling / Dynamic Support |
|   • Forearm in neutral/slight        • Supports humerus in glenoid socket   |
|     pronation, hand supported        • Prevents gravitational stretch       |
|   • Symmetrical trunk alignment      • Frees elbow/wrist for movement       |
|                                                                             |
|   THERAPEUTIC INTERVENTIONS          CRITICAL CONTRAINDICATIONS             |
|   • Neuromuscular Electrical         • NEVER pull on hemiparetic arm during |
|     Stimulation (NMES) to post.        transfers, bed mobility, or sit-to-  |
|     deltoid & supraspinatus            stand!                               |
|   • Kinesiology Taping / strapping   • NEVER use overhead pulleys (pinches  |
|   • Scapular mobilization into         supraspinatus / causes impingement). |
|     upward rotation before PROM      • NEVER force PROM past pain threshold.|
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Standardized Subluxation Measurement (Fingerbreadth Palpation)

The COTA evaluates subluxation with the client seated upright, arm hanging unsupported at the side:

• The practitioner palpates the subacromial gap between the acromion process and the superior aspect of the humeral head.
• 0 Fingerbreadth: Normal alignment (no palpable gap).
• 1/2 to 1 Fingerbreadth: Mild subluxation (≈ 1 cm gap).
• 1.5 to 2 Fingerbreadths: Moderate subluxation (≈ 2 cm gap).
• $>2.5$ Fingerbreadths: Severe subluxation ($>3\text{ cm}$ gap).

[!CAUTION] Strict Handling Safety Precautions in Hemiplegia:

1. No Traction / Pulling: Never pull or grasp the hemiparetic upper extremity when rolling the client in bed, assisting from sit-to-stand, or guiding transfers. Always hold the client by the trunk, scapula, or pelvis.
2. Overhead Pulley Prohibition: Overhead traction pulleys cause violent, passive glenohumeral elevation without coordinated scapulothoracic upward rotation, pinching the supraspinatus tendon and subacromial bursa against the acromion, resulting in rotator cuff tears and debilitating Complex Regional Pain Syndrome (CRPS / Shoulder-Hand Syndrome).
3. Scapulohumeral Rhythm: Prior to moving the paretic arm into shoulder flexion or abduction above 90°, the practitioner must ensure the scapula is mobilized into upward rotation and protraction.

5. Clinical Scenario: COTA Neurological Rehabilitation in Practice

Clinical Case Vignette: An 54-year-old client who sustained a right middle cerebral artery (MCA) ischemic stroke 3 weeks ago is admitted to inpatient rehabilitation. The client presents with left hemiplegia, a 2-fingerbreadth inferior left shoulder subluxation, dense left unilateral spatial neglect, left homonymous hemianopsia, and profound anosognosia. When asked to stand, the client attempts to propel out of the wheelchair without locking the wheel locks or putting the left footplate up.

COTA Treatment Implementation:

1. Shoulder Subluxation & Positioning:
   • When seated in the wheelchair, the left upper extremity is supported in a custom wheelchair arm trough with a foam hand wedge, maintaining the humerus seated in the glenoid fossa and elevating the left hand slightly to minimize dependent edema.
   • During gait training and standing transfer tasks with physical therapy, a GivMohr sling is applied to provide dynamic proximal support without locking the elbow into flexion.
2. Neglect & Visual Scanning Training:
   • The COTA sets up a table-top morning hygiene grooming station with grooming items spread across the table. A bright red vertical visual anchor (strip of colored tape) is placed along the far-left border.
   • The COTA trains the client using the "Lighthouse Strategy" (rotating the head fully from left to right like a lighthouse searchlight) to scan across the field until locating the red anchor before picking up shaving cream or a toothbrush.
3. Impulsivity & Safety Checklists:
   • The COTA introduces a bold 3-step pictorial transfer checklist affixed to the wheelchair armrest: [1] LOCK BRAKES -> [2] FLIP FOOTRESTS UP -> [3] NOSE OVER TOES.
   • The COTA uses verbal and tactile redirection, requiring the client to point to and vocalize each step before initiating weight shifting.