Ischemic stroke in the frontal lobe

Etiology

A stroke, or cerebrovascular accident (CVA), is the sudden disruption of blood flow to the brain and surrounding tissues resulting in neurological deficits. (1) Strokes are generally categorized as hemorrhagic or non-hemorrhagic. (1) Non-hemorrhagic strokes, more commonly called ischemic strokes, account for 87% of all strokes. (2)

Ischemic stroke

Ischemic strokes occur when a specific area of the brain does not have blood supply, robbing that area of needed oxygen and nutrients. This lack of oxygen supply results in brain cell damage or death. (1) This interruption of blood supply is caused by either an embolism, which is a blood clot that formed in the body and travelled in blood vessels to the brain, or thrombosis, which is an obstruction due to a blood clot that formed in the brain. (1)

Prevalence and incidence of stroke

Currently, prevalence of stroke in Canada (the number of people living with a stroke in Canada), as well as incidence (the number of people diagnosed with stroke each year), are largely unknown as there is no central database to collect this information. (3) It has been estimated that over 300,000 Canadians are living with the effects of stroke. (4)

In the US, it is estimated that the prevalence of stroke is 6,400,000 Americans over the age of 20 years with approximately 795,000 people experiencing a new or recurrent stroke each year. (5)

Common signs and symptoms

Warning signs of a stroke

While signs and symptoms of a stroke are different depending on the size and location of damage in the brain, the American Heart Association and National Stroke Association (6) report the common signs of a stroke include:

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, loss of balance or coordination
Sudden severe headache with no known cause

Figure 1: Flow chart of ischemic stroke in the frontal lobe

Transient ischemic attacks

Some individuals may experience “mini-strokes” which are called transient ischemic attacks (TIA). TIAs produce one or more symptoms similar to the above, but the symptoms last for less than 24 hours. Symptoms include (7):

Fleeting blindness in one eye
Hemiparesis (weakness on one side of the body)
Hemiplegia (paralysis on one side of the body)
Aphasia (impairment of language ability)
Dizziness
Double vision
Staggering

These symptoms are caused by a temporary blockage (between 30 seconds and 10 minutes) of blood supply to the brain. (2) Transient ischemic attacks usually do not cause permanent neurological damage, but are an important warning sign that a more serious stroke may occur. People who have had a TIA are 9.5 times more likely to have a stroke (7)

Risk factors

There are two main categories of risk factors:

Preventable: smoking, alcohol use, physical inactivity, poor nutrition, obesity , high blood pressure , and diabetes
Non-preventable: older age, gender (females are more likely to have a stroke), ethnicity, and family history of stroke (8)

Importantly, most strokes can be prevented by reducing risk factors. (3)

Differential diagnosis

To distinguish a stroke from other conditions with similar symptom profiles (such as a brain tumour , epileptic seizure , metabolic encephalopathy or a cerebral abscess ) a variety of diagnostic techniques are used. (9) Physical examinations, cardiac testing (electrocardiography, echocardiography to check for irregular heartbeats), neuroimaging techniques, blood tests, and tests of the fluid in the spine may be done by medical staff. (8) Through the use of computed tomography (CT) and magnetic resonance imaging (MRI), the location, cause, and severity of a stroke can be determined. As CTs and MRIs may not be able to find small changes in the brain, other diagnostic tools, for example non-invasive studies of blood vessels and invasive studies of the arterial system, may be used. Following diagnosis of a stroke, the individual is evaluated to determine the effects of the stroke. (8) This evaluation is performed by different members of the health care team including doctors, occupational therapists , speech-language pathologists , and physical therapists.

Possible effects of a stroke in the frontal lobe

Body function by brain location

As different areas of the brain are responsible for specific functions of the body, different patterns of functional loss may result. (10) While a stroke can affect any part of the brain, this Wikipedia post focuses on the effect of an ischemic stroke in the frontal lobe the brain. Because each hemisphere of the brain controls the opposite side of the body, a stroke in the left hemisphere would cause difficulties on the right side of the body, while a stroke on the right side of the brain would cause difficulties on the left side of the body. Some of the major effects of a stroke in the frontal lobe are:

Brain Area	Difficulty
Damage to any area of the frontal lobe	Executive function deficits
Damage to posterior (back) of the frontal lobe	Moving limbs (paralysis)
Damage to the central (middle) area of the frontal lobe	Moving the eyes, planning movement (apraxia), speaking (Broca’s aphasia/expressive aphasia)
Damage the anterior (front) of the frontal lobe	Attention, understanding/expressing emotion (apathy)

Recovery rates

A variety of factors including age, how severe the stroke was, when treatment began, and how effective the treatment was, will affect the recovery rate following a stroke. The National Stroke Association estimates recovery guidelines as follows (7):

10% of stroke survivors recover almost completely
25% recover with minor impairment
40% experience moderate to severe impairments
10% require care in a nursing home or other long-term care facility
15% die shortly after having a stroke

Occupational therapy (OT) has been shown to play an important part in the recovery process for people who have had a stroke. (11)

Occupational therapy and stroke rehabilitation

Occupations and occupational therapy

"Occupational therapy is the art and science of enabling engagement in everyday living, through occupation." (12 p372) "Occupation is everything people do to occupy their time; caring for themselves (self-care), enjoying life (leisure) and contributing to the social and economic fabric of their communities (productivity)." (13 p30) Occupational therapists work with individuals who are experiencing challenges or difficulties while striving to perform everyday occupations that are purposeful and/or meaningful to them. (11,13,14) The occupational therapy process in stroke therapy includes (14,15):

Assessing the individual’s abilities, skills, and resources
Identifying the individual’s areas of difficulty and setting goals together
Helping the individual with deciding on routines and strategies to address difficulties and achieve goals

Assessments

Occupational therapists use assessments to find the areas where their clients are having difficulty performing any activities they need or want to do as a result of injury or illness. (15) Assessment can occur at any stage (observation of occupational performance , intervention to resolve difficulties, or evaluation of treatment outcomes) of the occupational therapy treatment process. (16) The assessments performed by occupational therapists are different from those used by other health care professionals because the goal in OT is to improve function. (14,15) Occupational therapists often use a combination of self-report measures (e.g. questionnaires) and functional assessments (e.g. observation of task performance) to evaluate their client’s potential areas of difficulty. Self-report measures enable the therapist to understand what the individual thinks or feels about their own level of functioning. (15) Functional assessments allow the therapist to observe what the client actually does when carrying out certain tasks or activities. (15,17)

Functional assessments

Functional assessments focus on the three major domains within occupational therapy (self-care, leisure, productivity). Self-care includes activities of daily living (ADLs) such as eating, bathing, and dressing, as well as instrumental activities of daily living (IADLs) which include more complex tasks such as grocery shopping, managing finances, and paying bills. (13,17) Leisure includes occupations such as socializing, and participating in sports and outdoor activities. (13) Productivity includes occupations such as homemaking, parenting, and employment. (13) Functional assessments (15):

Can be informal and formal
Are done in real life and simulated environments
Examine both strengths and weaknesses of the person
Involve observation and analysis of an individual’s ability to complete various every day activities such as:
Getting dressed (Activities of Daily Living assessment)
Making a meal (Rabideau Kitchen Evaluation - Revised)
Using the telephone (Test of Everyday Attention)
Determine specific impairments and their impact on daily occupational performance
Guide treatment intervention
Provide a way to check treatment outcome (e.g. did the therapy work?)

Specific assessments used in stroke rehabilitation

The following assessments are examples of the specific assessments an occupational therapist might use with their client who has had a stroke in their frontal lobe. These assessments measure the difficulties that are commonly found in frontal lobe damage. They will give the therapist more specific information regarding the amount of difficulty the individual is having in area's of occupation as a result of the stroke.

Multiple Errands Test (MET) (18-21)

Carried out in naturalistic/real world settings (e.g. local shopping area)
Individual performs multistep tasks requiring executive functioning (e.g. collect specific information, remember to be at particular place at particular time, shop for specific items, follow specific rules throughout assessment)
Site-specific and simplified versions of assessments have been developed and tested (e.g. hospital setting, different cities and shopping centres) as well as virtual environments using video

Behavioral Assessment of Dysexecutive Syndrome (BADS) (22)

Battery of six tests and two questionnaires
Tests require individual to plan, initiate, monitor and adjust behaviour in response to task demands
Questionnaires seek information on frequency of particular behaviours
One questionnaire answered by individual, other answered by family member or caregiver

Chedoke-McMaster Stroke Assessment

Consists of two parts:

Impairment Inventory assesses physical deficits in 6 dimensions (e.g. postural control, shoulder pain)
Activity Inventory assesses functional ability in gross motor and walking skills (e.g. transferring to a chair, climbing stairs); amount of assistance required is measured

The Stroke Impact Scale (23)

Comprehensive self-report measure that considers 8 domains (strength, hand function, ADL/IADL, mobility, communication, emotion, memory & thinking, and participation/social role function)
Provides measure of an individual’s perceived quality of life, which is of key importance to occupational therapy

While an exhaustive list is beyond the scope of this Wikipedia post, there are numerous non-stroke specific assessments that a therapist may use in the treatment of individuals who have had a stroke in the frontal lobe. These include:

Canadian Occupational Performance Measure (COPM)
Mini-Mental Status Examination (MMSE)
Barthel Index
Rivermead Perceptual Assessment Battery (RPAB)
Assessment of Motor and Process Skills (AMPS)
Cognistat
Chessington Occupational Therapy Neurological Assessment Battery (COTNAB)
Rivermead Behavioural Memory Test (RBMT)
Functional Independence Measure (FIM)
Trail Making Test Parts A and B[K32]
Cognitive Assessment of Minnesota (CAM)
Allen Cognitive Levels (ACL)
Frontal Assessment Battery (FAB)
Loewenstein Occupational Therapy Cognitive Assessment (LOTCA)
Test of Everyday Attention (TEA)
Clock Drawing Test (CDT)
Adelaide Driver Self-Assessment Scale (ADSES)

Occupational therapists decide on which assessment to use based on a number of factors including: cost, time, which assessments/tools are available and best for the client, how accessible supplies/resources needed to carry out the assessment are, qualification requirements to administer the test, the common assessments used at the facility in which the therapist works, and the preference and/or comfort level of the therapist.

Identifying areas of difficulty and implications on occupation for people living with the effects of stroke

Occupational performance issues

Occupational performance issues (OPIs) are related to an individual’s difficulty in their self-care, productivity and/or leisure occupations. Occupational therapists help their clients to identify OPIs (24), and set goals to achieve optimal functioning following a stroke. Following is a sample of potential OPIs that may result from a stroke in different locations of the frontal lobe:

Damage to any part of the frontal lobe

Executive function

Executive functions are the more complicated thinking skills, for example: planning, problem solving and beginning an activity. The entire frontal lobe plays an important role in using these skills. (25) Therefore, damage to any part of the frontal lobe can result in difficulties with executive functioning. Major difficulties in executive functions can be seen in even the simplest tasks, including the ability to complete one’s own morning routine. (26)

OPI: Self Care

Individuals may have difficulty showering or washing related to inability to begin actions (e.g. which part of the body to wash) and need for instruction from others.

OPI: Productivity

Individuals may have difficulty grocery shopping related to inability to problem solve. If an individual was unable to locate an item in the grocery store, she/he may not be able to think of a solution (e.g. asking a clerk or finding a similar product).

OPI: Leisure

Individuals may have difficulty preparing to go to the recreation centre for a swim related to planning and organizing leisure occupations. For instance, one must plan transportation, consider time constraints or pool scheduling, and plan and organize the necessary items (e.g. a clean dry swimsuit, towel, and change for a locker).

Damage to the posterior part of the frontal lobe

Motor damage

Motor damage following a frontal lobe stroke can include muscle weakness or paralysis of one side of the body (opposite to the side of the brain affected by the stroke). (25) Difficulty with movement can lead to decreased participation in everyday occupations. (25)

OPI: Leisure

Individuals may have difficulty performing the physical components of sex with a partner related to muscle paralysis, weakness and/or inability to use both sides of the body.

Damage to the central part of the frontal lobe

Loss of Ability to Move the Eyes

Inability to move the eyes may result in difficulty following moving objects with the eyes (object tracking), inability to accurately and quickly move eyes to look at a new object, and difficulty maintaining focus on an object for a long time. (25)

OPI: Leisure

Individuals may have difficulty with activities like reading related to the inability to maintain visual focus on objects for a long time or difficulties with shifting vision to a new point of focus. (25)

Apraxia

Apraxia is a movement disorder where individuals can no longer plan, order or perform skilled movements. (14,25) Individuals with apraxia may be unable to carry out activities because they have difficulty following the steps or using objects correctly. (14,25)

OPI: Self-care

Individuals may have difficulty putting on a shirt related to the inability to plan, order, and then perform multiple steps of the movement (e.g. may not position the shirt correctly before putting it on or may do up the buttons first).

Broca’s Aphasia/Expressive Aphasia

Broca’s area is a region of the frontal lobe that controls the production of speech. Damage to this area of the brain will result in difficulty or inability speaking. (25) Individuals with Broca’s aphasia may avoid situations where they will have to speak to others. (25)

OPI: Productivity

Individuals may have difficulty returning to work related to their inability to verbally communicate with others. (27) In fact, difficulties with speech can lead to unemployment. (25)

Damage to the anterior part of the frontal lobe

Difficulty with Attention

There are many different types of attention: selective, sustained, alternating, divided, and focused. (14) Individuals with a frontal stroke might have difficulties with any one of these attention types. It may seem like they are having trouble focusing on a specific task (sustained), like they are unable to block out distractions (selective), that they are having difficulty shifting their focus between two tasks at once (alternating) or that they are having difficulty managing multiple tasks at once (divided). (14)

OPI: Self-care

Individuals may have difficulty applying makeup in a busy hospital environment related to poor selective attention.

Apathy

Apathy is the emotional indifference towards all aspects of life. It may lead to decreased motivation and energy levels. (25)

OPI: Productivity

Individuals may have difficulty with completing tasks and performing at work related to lack of motivation and energy.

Occupational therapy interventions in stroke rehabilitation

Role of occupational therapists

The purpose of occupational therapy in stroke rehabilitation is to enable participation in activities of daily living, and improve the quality of life for individuals who have had a stroke. (14) In addition to addressing their client’s occupational difficulties, occupational therapists can provide many other valued services. An occupational therapist can evaluate and assist with their client’s adjustment to the stroke and how they are coping with the resulting rehabilitation process. (17) If their client gives consent, the occupational therapist will want to include the family in their client’s rehabilitation by educating them on the role of occupational therapy in their recovery and how they can be involved. (17)

Occupational therapists:

Work with other health care professionals (including doctors, nurses, social workers, speech-language pathologists, psychologists, dieticians and rehabilitation assistants) to ensure the best care for the individual (17)
Treat the individual recovering from a stroke in different settings throughout the rehabilitation process including: (17)

In the acute care hospital setting, within a few weeks of the stroke
In rehabilitation centers where individuals may stay for up to several months following their stroke
In out-patient clinics after the individual has returned home
In the individual’s home as a community therapist

Assist with discharge from the hospital. This involves:

Determining the right place for the client to continue their rehabilitation. This may be a rehabilitation centre, or it may be home. The OT, social worker and healthcare team collaborate with the individual and their family to determine what location is most suitable.
Finding out what assistive technologies the individual has at home, and providing information to the individual/family about how to acquire and set-up the equipment. See below for examples of assistive technologies used in the bathroom.

Educate the individual on pressure sores, experienced by 21% of individuals who have had a stroke, and which are completely avoidable with education and preventive measures
Fit the individual for appropriate mobility aids such as a wheelchair, scooter, walker or cane and teach the individual how to use them
Educate the individual on proper body positions in bed and sitting to protect the weak side of the body and avoid pressure sores
Teach the individual exercises to avoid contractures
Select and/or custom make splints to prevent and/or correct contractures
Educate the individual on fall prevention techniques
Provide information on community resources that may be of help to the individual and their family
Teach the individual new ways of doing things one-handed if necessary, and recommend adaptive equipment to make one-handed techniques easier
Help the individual re-train their body to try to regain lost abilities

Sample interventions

Occupational performance issues can be resolved by helping people to regain their abilities, or by changing the demands of the activity or physical environment. (28) Below are samples of the interventions an occupational therapist would use with someone who has had an ischemic frontal lobe stroke, based on some of the OPIs outlined above.

Intervention for a leisure OPI

OPI: If you are having difficulty participating in sexual activity with a partner related to expressive aphasia, weakness (14), paralysis, apathy, apraxia, executive functioning, or impaired concentration.

An OT could help by (1):

Recommending suitable sexual positions
Suggesting techniques to establish sexual activity based on your needs
Providing eduction on non-verbal communication such as touching and gesturing
Helping change the bedroom environment to minimize distractions
Helping you and/or your partner recognize that your lack of sexual motivation is stroke related, and encourage your partner to initiate sexual activity
Providing education on ways to conserve energy such as sexual positions that use less energy or engaging in sex during the time of day when your energy level is highest
Providing information on assistive technology (e.g. positioning wedges to make sex easier)

Intervention for a self-care OPI

OPI: If you are having difficulty showering related to weakness, paralysis, apathy, poor vision (29), apraxia, impaired executive functioning or impaired concentration.

An OT could help by (1,14,29,30):

Assessing your bathroom and suggesting assistive technology based on your needs to help with weakness and paralysis. Common showering aids include:

Bath transfer bench/bath board/shower chair
Non-slip mat
Tub/stall grab bar
Long handled sponge
Wash mitt
Soap on a rope or suction soap holder
Pump spray shampoo bottle
Hand-held shower head
Towels with loops to anchor for one-handed drying

Teaching you transfer techniques to get in and out of the bath and/or shower
Teaching you one-handed showering skills
Encouraging you to use the hand and arm affected by the stroke as much as possible
Creating a shower routine that includes tips for energy conservation and safety

Intervention for a productivity OPI

OPI: If you are having difficulty grocery shopping related to impaired executive functioning, weakness, paralysis, poor vision, expressive aphasia, impaired concentration, apraxia or apathy.

An OT can help by (1):

Providing you with a list of community resources for grocery delivery, meal programs, and transportation. Online resources are particularly useful for people with expressive aphasia
Educating you on ways to conserve energy (e.g. organizing grocery list according to location in store, using a lightweight cart, placing money in an easily accessible area)
Teaching problem solving skills to help you solve grocery shopping issues (e.g. difficulty finding items)
Helping plan your shopping routine and route around store
Grading the activity, or gradually increasing the difficulty of the task, to help you learn to shop with increasing independence

External links

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