Various literatures suggest different terminologies in occupational therapy depending on the school of thought. Hence, it is imperative to bring significance to underpinning words for the purpose of this assignment.
National Health Service (NHS) define occupational therapy as the evaluation and treatment of physical and psychiatric conditions using definite and purposeful activities to prevent disability and encourage independent functions in all aspects of daily life (www.nhscareers.nhsuk, 2008). Occupational therapy is a discipline that assists people of all ages to achieve health and life satisfaction through improving their ability to carry out the activities that they need or choose to do in their daily lives (College of Occupational Therapists [COT] 2006a).
Occupational therapists assess the impact of changes in motor function, sensation, coordination, visual perception, and cognition on an individual’s competence to engage in daily life tasks. Intervention enhances involvement in meaningful roles, tasks, and activities; minimizes secondary complications; and provides training and support to the patient and caregivers. (Rowland, 2008)
Occupational therapists’ concentrates on independence and function, person’s goal setting, and their expert skills in task adaptation and environmental adaptation emphasize the profession’s contribution to stroke rehabilitation. (Rowland 2008)
The fundamental intend of occupational therapy is predicated on occupational performance, it seeks to enhance health and well being of a person by limiting occupational dysfunction that is, when an individual is unable to articulate himself within his socio-cultural and physical environment because of illness, disability or lack of enabling skills indispensable for coping like the case of stroke in David.
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Background information on stroke
The diagnosis established that David had stroke, an occlusion in the middle cerebral artery. Stroke is the third most common cause of death in the UK; an estimation of 150,000 people has stroked each year and approximately 30% of people dying in the month after a stroke and 67,000 deaths each year. It is also the greatest cause of severe disability, 35% of all survivors are significantly disabled and will need help with daily occupation (Department of Health, 2001; Office of National Statistics, 2001;British Hearth Foundation, 2005).
The World Health Organisation (WHO) defines stroke as ‘a clinical syndrome, of presumed vascular origin, typified by rapidly developing signs of focal or global disturbance of cerebral function lasting more than 24 hours or leading to death’ (WHO, 1978). The two broad causes are ischemia and haemorrhage. Ischemic stroke results from a blockage of cerebral vessel and can be further classified into thrombosis or embolism. Hemorrhagic stroke results from the rupture of a blood vessel. Blood is release out of the vascular space, cutting off pathways and leading to pressure injuries to brain tissue. It could be either intracerebral (bleeding into the brain itself) or subarachnoid (bleeding into an area surrounding the brain) caused by hypertension, arteriovenous malformation, or aneurysm (Batel, 2004).
SYNOPSIS OF DAVID
David, a senior fireman officer was born 45 years ago and had worked for 27 years on a fulltime basis. He collapsed at work 8 weeks ago and was diagnosed with a left Cerebral Vascular Accident (CVA) or stroke. A scan following his admission revealed an occlusion in the middle cerebral artery. He was restless and irritable, responding to command physically but no verbal response, and was unable to move his right upper and lower limbs. His blood pressure is 180/75, Blood NAD. Urine testing revealed a high level of sugar. He is a proud family man, married for 22years, extremely sociable with strong passion for football.
APPLIED THEORTICAL MODEL
”A model is a simplified representation of a phenomenon that can account for certain data/relationships or a synthesised body of knowledge that links theory and practice”(Finlay, 2004 p73). Model gives us a way to frame a person’s problems and treatment (Finlay, 2004). Conversely, the theoretical direction on which these frames of reference are founded is not clear, this is why it is so complicated to follow their guiding principle to institute occupationally based practice (Ikiugu, 2004).
The Canadian Model of Occupational Performance (CMOP): Is employed to guide in David’s health needs because it will emphasis on occupational performance of David as a person, via occupation and environment, CMOP will critically analyse the components of David’s affective, cognitive, physical components and spirituality, the spirituality represent the inner strength that will allows David to keep functioning in the face of great challenges and adversity by engaging him in purposeful occupational activities, that influences his performance areas and bring about health and well-being within the context of adaptable environment fit for David.
Client centred practice originally evolved in psychology. It combines with systems approach, environmental theory and research into ‘flow’ by Csikszentmihalyi to provided CMOP with a broad interdisciplinary base of knowledge . He buttresses on exploration of flow, the subjective psychological state that occurs when we are totally adsorbed in an activity. He found that flow state involves feeling good, exceedingly motivated and being in the zone. During flow, concentration can be so intense that there is loss of self-consciousness a transitory reprieve from one’s worries; flow also promotes self -esteem, life satisfaction and the aptitude to cope with stress. This is contrary to the concept of occupational balance which is a more complex and holistic concept related to balance in life style and tasks. Balance is about the relationship between a person ,their occupations and their worlds.The model’s national development is a unique feature and so CMOP does not reflect the views of any one individual. However while some assume the model has no cultural bias and adaptation has been encouraged, little research has been conducted into the efficacy of its application in non western societies 
APPLYING CMOP TO DAVID
The initial process of occupational therapy assessment involves interviews with the David and his family to establish previously held life roles and the tasks and activities that were completed within these roles. Observational assessment is undertaken of personal self-care tasks, including showering, dressing, toileting, grooming, and eating, and domestic or instrumental tasks, including meal preparation, shopping, cleaning, laundry, and management of finances and medications. Establishing the level of assistance needed in each of these areas and David’s priorities will helps the occupational therapist target rehabilitation interventions appropriately and to measure progress towards David’s goals. Observation of activity limitations allows the occupational therapist to identify the impairments that underpin these limitations, including the motor, sensory and cognitive impact of stroke. (Rowland, 2008)
Davis was a fulltime fireman fighter before the stroke assessment regarding return to work commences in the acute setting. The occupational therapist gathers a history of the patient’s occupation, i.e., job duties (frequency and duration) and work conditions (hours, environment, etc.). Using the results of assessment of the sensorimotor, cognitive, visual-perceptual, and psychological abilities of the patient, the occupational therapist with the help of vocational rehabilitation therapist will considers David feasibility of returning to work, also conduct a workplace assessment and negotiate a graded return to work hours an duties (Trombly, 2002).
Leisure: David before the stroke engages in leisure activities he was a football fan and a football coach these are highly social activities that brings about his social inclusion. David derives joy, fulfilment relaxation, excitement, and stimulation. An occupational therapist will seek for ways to reengage him in these activities to enhance other areas of occupational performance.
CMOP is propagates client centeredness which promotes interdependent collaborative relationship between clients and therapist, outcome measure enabling client to rate importance, performance and satisfaction with self -care productivity and leisure activities they ‘need to’, ‘want to’, ‘or are expected to’. Consequently, an occupational therapist together with David will formulate the following achievable outcome as long-term goals:
David to gain increased somatosensory perception and will employ compensatory strategies order to perform ADL safely; David will gain strength, endurance, and control of movement in upper extremity in order to use this during performance of ADL due to the fact that he is presently unable to move his right upper and lower limbs. It also includes how David can improve motor planning ability in order to relearn old methods or relearn new methods of performing ADL.
Occupational therapist is more worried about how David will function effectively and independently in the home environment and to access the community. The occupational therapist will evaluate the need for a home assessment, taking into consideration the environmental barriers, specific impairments, risk of falls, and the needs of the patient/carer. The purpose of the assessment is to establish whether it is safe for David to return to their pre-stroke environment or see how the environment could be adapted to fit David.The assessment involves observing David’s ability to physically negotiate his environment and perform his usual activities. For instance, the occupational therapist may assess David’s ability to safely transfer from their bed or toilet, move on his wheel chair freely within the house, and cook within his kitchen
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OT APPLICATION TO STROKE
The implications of stroke are extremely varied and may include difficulties in motor ability, perceptual-cognitive skills, emotional reactions and social functioning. Occupational therapists look beyond these health conditions and analyse the impact of an individual’s specific pattern of component of problems on occupational performance (Molineux, 2004). For instance the left cerebral hemisphere, which is affected in the case of David, controls most functions on the right side of his body because of the decussating of motor fibres in the medulla. The stroke incidence in the case of David may produce symptoms discussed below:
Vision and Visual Perception
Stroke can also result in blind spot in the visual field usually on the right side to correct this, David will have to gain visual function or will employ compensatory strategies in order to resume previously performed ADL. Occupational therapists routinely screen for visual-perceptual impairments such as agnosia; visuospatial relations problems, eg, figure-ground, body scheme disorders, depth perception, and unilateral neglects, and impairments in constructional skills.  Other neurobehavioral changes, including praxis and acalculia, are commonly assessed in conjunction with visual-perceptual screening following a left hemisphere stroke.
Occupational therapists will work on Visual and perceptual impairments in David by retraining in specific skills, teaching compensation techniques, substitution of unimpaired skills, or adapting the task or environment.  Methods will include visual scanning training  to assist David with a hemianopia or neglect to locate items more accurately within his house. The depth perception problems in David may be encouraged to hold the handrail for additional proprioceptive cues to safely negotiate stairs, as well as to pace themselves and go more slowly down a flight of stairs. The praxis condition of David  or motor planning problems affecting one upper limb may initially practice a range of remediation techniques involving feedback, cueing, and functional repetitive practice to overcome the impairment. If David’s impairment of the stroke-affected hand is resistant to remediation methods, the occupational therapist may teach Daivd to compensate by using the other, unaffected, upper limb for tasks requiring greater precision such as gardening that he loves to do or washing his car, thus increasing the patient’s level of independence.
Memory and Cognition
The impact of the stroke on David’s memory, cognition, and executive skills can significantly affect his ability to participate in a rehabilitation program and to complete personal, domestic, leisure, and work-related tasks.  Difficulty in initiating regular tasks such as been a fire fighter,
coaching his foot ball team, washing his car, gardening activities as he use to do before even socialising with the member of his community or preparing breakfast, or impulsiveness that poses safety risks for the individual are practical examples of the effects of these impairments.
Sensory, Motor, and Upper Limb Function
Occupational therapy interventions will address David’s changes in motor power, muscle tone, sensory loss, motor planning/praxis, fine motor coordination, and hand function, with the aim of regaining upper limb control and function. Daily upper limb movement facilitation and positioning, massage, elevation, and compression were employed to address muscle weakness and edema of the left upper limb. Education was provided for safety in the care of his arm and practical training in one-handed methods of completing daily tasks, including dressing, grooming, and eating.
The occupational therapist will also assess David’s ability to plan, implement, and problem-solve tasks like making a simple meal, The OT may recommend the installation of grab rails in the shower and toilet, removal of a shower screen that limited safe access, purchase of a shower stool for seated showering as his balance remained impaired, and purchase of a lounge chair of a suitable height. Safely administering medications or prescribing a wheeled mobility tray for transporting meals and using the telephone to call for assistance. If David does not have the capacity to get out of bed, the occupational therapist trains family to safely operate an electric hoist or wheelchair. OT will continuously educate the patient and family members on the treatment program, this is essential for the smooth transition to his discharge.
An occupational therapist will need to consult with a social worker to help David and his family apply for Medicaid or other support, establish if it is financially possible to consult others professionals.
His cognitive impairment can be assessed during evaluation and treatment of occupational performance by focusing on the adaptive abilities of planning, judgment, problem solving and initiation. Depression is common with lesions in the left hemisphere as compared with the right hemisphere resulting in outbursts, anger or frustration when he cannot perform tasks that he was used to. These responses can further result in impaired personal interactions, inability to perform social and leisure activities or roles, and eventual experience social isolation.
Emotional Counselling: Prior to David’s stroke, he and Helen both had clearly defined traditional roles in the family. One potential issue for the family unit, now that David is likely to require a long period of rehabilitation at home, will there be tension between him and Helen due to extreme role reversal? Have a full time worker and David believing that a man must be the breadwinner for his family. If not managed correctly, this tension could have repercussions on the children’s adjustment and could trigger feelings of guilt, isolation and resentment within Helen and David’s relationship. In order to avoid this, and to ensure maximum family unity, communication on coping strategies for the whole family is crucial. Openness between all family members about the severity of the illness, coping strategies, a “we’re in this together” attitude, adjustments to daily life and incorporating care into it are just a few things which will help quell feelings of anxiety, fear, depression and resentfulness. Therapeutic use of leisure could be employed to organise activities that provide social interaction, pleasure, entertainment, or diversion like taking for a football match, knowing well that David is very sociable and has great passion for football. Leisure is a medium through which a person is able to learn and rehearse a wide range of skills that will enable him to respond appropriately and adaptively in different situations.
”To make available an activity to pass time or do a work out on a limb is not very complicated, but to facilitate an individual to engage in an activity that has purpose and meaningful for a client, and which help out in the improvement of performance skills, is the utmost art of the occupational therapist” (Creek, 1998,p.27). Hence, an attempt has been made to focus on applying occupational therapy concepts, which is engagement of occupation and meaningful activities to enhance occupational performance as it relates to David’s health condition. Research has demonstrated that stroke survivors with a positive self-efficacy report higher quality of life and fewer depressive symptoms (Robinson-smith, 2002b). CMOP model was applied as relevant evidence base.
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