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  • Try to make you session meaningful and purposeful 

  • Try to incorporate your client's priorities and concerns

  • To to achieve the best possible outcomes for your client, try to work closely with members of an interdisciplinary team of physicians, physical therapists, speech therapists


It is a disease of cerebral vasculature causing a failure to supply oxygen to the brain.


Impairments following stroke can affect:

  • Perception

  • Sensory

  • Cognition

  • Motor Control

  • Upper Limb Function

  • Shoulder Subluxation

  • Pain

  • Voluntary control

  • Occupational Performance Areas

















































































Internal capsule

Basal Ganglia

There are two types of stroke Ischemic and Hemorrhagic strokes.


Stroke classifications described in table1:


Table 1

[1] The space that exists between the arachnoid and the pia mater.


Table 2 describes the function of the external structures of the brain:


Table 2

Cranial nerves: (table 4)


Table 4

2- The artery that is involved:

  • Internal carotid artery

  • Middle cerebral artery

  • Anterior cerebral artery

  • Posterior cerebral artery

  • Cerebellar artery

  • Vertebra-Basilar artery 

Table 3 describes the impairments associated with each artery:


Table 3

[4] Defective vision or blindness right or left halves of visual fields of both eyes.

[5} Broca’s aphasia: speech production / Wernicke’s aphasia: language comprehension

[6] Ideational apraxia: inability to carry out tasks in the proper order/ ideomotor apraxia: individual is able to perform task automatically but unable to carry the movement on command

[7] Fail to report, respond or orient to meaningful stimuli presented on the affected side

[8] Fail to distinguish an object from background

[9] Defects confined mostly to about one fourth of an eye's visual space

[10] The inability to orient in the surrounding, inability to find the way in a large environment

[11] The ability to identify or sort objects, shapes, symbols, letters, and/or words, despite differences in size or position.

[12] Inability to recognize and identify objects, persons, or sounds correctly

The Symptoms depend on:

1- The part of the brain that loses blood supply:

  • Thalamus:

    • Anterolateral: Visual neglect

    • Lateral: sensory symptoms

    • Bilateral: memory deficits

    • Posterior: alert/ conscious


  • Internal capsule: Pure motor dysfunction

  • Basal ganglia: dysarthria*and lack of initiative

  • Cerebellum: Ataxia**

*A motor speech disorder in which the muscles that are used to produce speech are damaged, paralyzed, or weakened.

**Lack of voluntary coordination causing gait abnormality.



TBI is an insult to the brain caused by an external physical force with resultant loss of consciousness.

It can be either closed or open brain injury:

  • Closed brain injury:

    • No penetration to the skull

    • Resulting from falls, motor vehicle crashes

    • Focal damage* and diffuse damage to axons

    • Effects tend to be broad (diffuse)


  • Open brain injury:

    • Penetration to the skull

    • Focal damage and some diffuse damage

Changes after TBI:

  • Loss of consciousness/ coma

  • Post-Traumatic Amnesia (PTA): s a state of confusion that occurs immediately following a traumatic brain injury (TBI) in which the injured person is disoriented and unable to remember events that occur after the injury.

  • Ataxia: Impairment of the cerebellum or tracts from it along with impaired proprioception.

    • Incoordination

    • Impaired standing

    • It occurs in the entire body

    • Ranges from mild to severe

  • Tone Abnormality: Hypotonicity to Hypertonicity during recovery at higher cognitive level/ Rigidity during the comatose stage.

  • Limitations of Joint ROM: Before initiating intervention, OT need to determine with the physician cause of decreased ROM.

  • Cognitive deficits which include:

    • Attention and concentration

    • Processing of information

    • Memory

    • Executive functions: plan, organize, set goals

    • Abstract thinking: ability to hold and manipulate a concept in one’s mind

    • Impaired initiation and termination of activities

    • Speech and communication

  • Psychosocial Skills: Loneliness/ decreased in relationships: so the Family is a primary source of social and leisure activity for many persons with TBI.

*Widespread cerebral injury

**Localized injury in the brain occurring immediately after the injury and easily visualized by CT or MRI

Vertebral column consists of 33 vertebrae:

  • 7 cervical

  • 12 thoracic

  • 5 lumbar

  • 5 fused sacral

  • 4 fused coccygeal


Spinal cord:

It is a long, thin, tubular structure made up of nervous tissue which extends from medulla oblongata and end in  L1/L2


Spinal nerves:

The spinal nerves are relatively large nerves that are formed by the merging of a sensory nerve root and a motor nerve root. These nerve roots emerge directly from the spinal cord sensory nerve roots from the back of the spinal cord and the motor nerve roots from the front of the spinal cord. As they join, they form the spinal nerves on the sides of the spinal cord.

There are 31 pairs of spinal nerves including:

  • Eight cervical spinal nerves on each side of the spine called C1 through C8

  • Twelve thoracic spinal nerves in each side of the body called T1 through T12

  • Five lumbar spinal nerves on each side called L1 through L5

  • Five sacral spinal nerves in each side called S1 through S5

  • One coccygeal nerve on each side, Co1

Dermatomes: (check picture 2 and 3)

  • Area of skin innervated by sensory axons within a particular segmental nerve root.

  • Important to determine the level of injury.

  • Useful in assessing Improvement and deterioration.


Myotomes: (check picture 2 and 3) + Table5

  • Segmental nerve root innervation a muscle.

  • Important in determining level of injury.






Picture 2

Picture 3

Picture 1


Table 5

Spinal cord injury (SCI): insult to spinal cord resulting in a change in the normal function either temporary or permanent:

  • Motor

  • Sensory

  • Autonomic


Complications following spinal cord injury:

  • Pressure sores

  • Spasticity

  • Orthostatic Hypotension

  • Autonomic Dysreflexia

  • Heterotopic ossification

  • Osteoporosis


Classifications of SCI:

  • Skeletal and neurologic level: the regions of SC which they occur (cervical, thoracic, and lumbar) and the numerical order of the neurological segments.

    • Ex: C6 refers to the 6th neurological segment of the cervical region of the SC as the last fully intact neurological segment.


  • Completeness (degree of injury):

    • Complete injury: Absence of sensory and motor function in the lowest sacral segments (S4-S5) > no sacral sparing

    • Incomplete injury: preservation of any sensory and/ or motor function below the neurological level > presence of sacral sparing. (check table 6)


Classifications of incomplete SCI and associated impairments: (Table 6)




















Table 6

Level of injury in spinal cord injury and extent of paralysis described in table 7:


Table 7

Amylotrophic lateral sclerosis (ALS): It’s a group of progressive, degenerative neuromuscular diseases, also known as motor neuron disease.

  • The neurologic process involves destruction of motor neurons within the spinal cord, brainstem, and motor cortex.

  • Affected individual exhibits combination of both Upper motor neuron and Lower motor neuron deficits, including:

    • Abnormal fatigue

    • Decreased strength

    • Speech deficits (slurred speech)

    • Spasticity, muscle cramps

    • However, cognition, bowel and bladder, sensory, eye function are not affected early.








Functional stages of ALS:

The early stage:

  • Patient experiences generalized fatigue and specific localized weakness to one side of the body, one limb or upper or lower trunk.

  • The ADLs are specifically impaired.


The disability stage:

  • ADLs and function are very limited, all extremities and trunk show significant signs of limitation.

  • Caregiver roles are significant.


The end stage:

  • Patient becomes nearly fully dependent on caregiver for most if not all ADLs.

  • Very minimal to no function in all extremities.

  • The patient positioning is limited to the bed or to the wheelchair (preferably powered wheelchair).


Huntington's disease is a rare, inherited disease that causes the progressive  degeneration of nerve cells in the brain.









Symptoms associated with HD:

  • Progressive disorder (voluntary and involuntary) in the hands:

    • Twitching of the hands

    • Difficulty manipulating small objects

  • Chorea:

    • It is  a jerky, rapid, uncontrolled and irregular movement.

    • Disappear during sleep

  • Oral function difficulties:

    • Abnormal facial expression

    • Aspiration*, dysarthria**      

  • Difficulty performing voluntary movements:

    • Akinesia***

    • Bradykinesia****

  • Behavior (irritability, anxiety, depression)

  • Cognitive (concertation, memory, plan, abstract thinking)

  • Difficulty maintaining adequate work performance

  • Verbal communication is spread until middle or late stage of HD

  • As HD progress, other symptoms can develop, including:

    • Depression

    • Chorea becomes more severe and may involve entire body

    • Hypertonia (rigid)

    • Disturbance in gait and balance

    • Sever difficulty in eye movements


When something you swallow "goes down the wrong way" and enters your airway or lungs.

** A motor speech disorder in which the muscles that are used to produce speech are damaged, paralyzed, or weakened.

*** The loss of ability to move your muscles voluntarily.
**** Slowness of movement

Multiple sclerosis: is a progressive disease of the brain and spinal cord (CNS) that caused by an autoimmune system reaction to the myelin sheath characterized by relapses and remissions eventually it can affects the axons by scaring and cause permanent damage.








Symptoms: According to lesions, location characterized by unpredictable repeated relapsed followed by remission.

  • Paresthesia                    ,sensory loss in extremities

  • Diplopia: Double vision, causes a person to see two images of a single object, and visual loss in one eye.

  • Fatigue

  • Emotional lability

  • Cognitive deficits

In Later stages, other symptoms develop, including:

  • Paralysis of LE

  • Dysarthria:

  • Dysphagia

  • Severe visual impairment nystagmus

  • Ataxia:

  • Spasticity

  • Impaired cognition

Is an abnormal sensation of the skin (tingling, pricking, chilling, burning, numbness) with no apparent physical cause


Parkinson’s disease: Is a progressive neurodegenerative motor system disorder causing dysfunction in both voluntary and involuntary movements.

For more information, check this link:






Impairments of Parkinson:

  • Tremor                 (Resting, asymmetric, peripheral, UL>LL)

  • Mask face

  • Flex posture

  • Poor balance (frequent fall)

  • Shuffling gait

  • Freezing: Decreased arm movement, no trunk rotation

  • Difficulty in fine movement

  • Autonomic System (constipation, ­ increased salivation)

  • Oral & speech impairment (quiet,  ̄ decreased swallowing)

  • Cognitive Impairment

    • Fairly normal in early stages

    • Impairment (attention, learning, comprehension)

    • Dementia over 70 years

  • Behavior Change (depression, motivation, sleepless)

  • Movement:

  • Difficulty in initiating (akinesia)

  • Slowness of movement (bradykinesia)


  • Rigidity (hypertonicity) impairs smooth movement

    • 1st the neck + shoulder

    • 2nd the extremities + face

Is an involuntary rhythmic shaking movement in one or more parts of the body.


Dementia: is an (umbrella term) or general word used for progressive disorders of the brain:

Associated problems:

  • Memory loss

  • problems in Language, perception, thinking and judgment

Interfere with:

  • learning, communicating, relating and even caring for self





Most common types of dementia:

1. Alzheimer's Disease (AD)

  • AD makes up 50-70% of all dementias


2. Vascular Dementia

  • 2nd most common type of dementia

  • It is caused by a lack of blood flow to the brain. It can be related to atherosclerotic disease or stroke



3. Lewy Body Dementia

  • It is caused by protein deposits in nerve cells. This interrupts chemical messages in the brain and causes memory loss and disorientation

  • Dementia with Lewy bodies shares many symptoms with PD and AD


4. Fronto-Temporal Dementia

  • It affects the front and side parts of the brain, which are the areas that control language and behavior. It is also known as Pick’s disease


Alzheimer’s disease:

  • A type of dementia

  • It is an irreversible, progressive brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks.





Associated symptoms:

  • Predominately-early episodic memory difficulties

  • Difficulties with STM and recall / orientation

  • Problems in finding correct names

  • Word finding and ability to generate words

  • Significantly impaired social life

  • Significantly impaired occupational function

  • Gradual onset

  • Continuing decline: Not due to CNS or other

  • Conditions: (e.g., PD, delirium, schizophrenia)

To know more about the OT role with Alzheimer’s disease, check this file .





For more information about Alzheimer’s disease: watch this video: (


 Polyneuropathy: It refers to the conditions that result when multiple peripheral nerves that carry messages to and from the brain and spinal cord to the rest of the body become damaged, which is also commonly called peripheral neuropathy.







Characterized by symmetrical, distal motor and sensory deficits that have a graded increase in severity distally.




1. Motor symptoms:

  • Positive : Muscle cramps, fasciculations

  • Negative : early distal toe and ankle extensor weakness resulting in trips and falls

2. Sensory symptoms:

  • Prickling, searing, burning, and tight sensations

  • Paresthesia: Unpleasant sensations arising spontaneously without apparent stimulus

  • Hyperalgesia: Painful hypersensitivity to noxious stimuli

  • Neuropathic pain: cardinal feature of many neuropathies

  • Allodynia: perception of non-painful stimuli as painful


3. Autonomic dysfunction

  1. Fainting spells (lose consciousness for a short amount of time )

  2. Sweating reduced or excessive

  3. Heat intolerance

  4. Bladder- Bowel dysfunction

  5. Orthostatic lightheadedness: is a form of low blood pressure that happens when you stand up from sitting or lying down which can make you feel dizzy or lightheaded.


Guillain Barre Syndrome (GBS): is a rare neurological disorder in which the body's immune system mistakenly attacks part of its peripheral nervous system—the network of nerves located outside of the brain and spinal cord.










GBS usually affects the feet or hands first, before spreading to other parts of the body.

Early symptoms:

Symptoms of Guillain-Barré syndrome usually develop over hours or days and tend to start in the feet and hands before spreading to the arms and legs.


  • Numbness

  • Pins and needles

  • Muscle weakness

  • Pain during activities that shouldn't cause pain

  • Problems with balance and co-ordination: due to Nerve damage to the legs (peripheral neuropathy).

  • Supervision while standing, walking, and transferring.

  • These symptoms usually affect both sides of the body at the same time

Later symptoms:

The symptoms may continue to get worse over the next few days or weeks. Some people are only mildly affected, but others may have:

  • Difficulty walking without assistance

  • Inability to move the legs, arms and/or face (paralysis)

  • Difficulty breathing

  • Blurred or double vision

  • Difficulty speaking

  • Problems swallowing or chewing

  • Difficulty peeing, and constipation

  • Persistent and/or severe pain

GBS usually reaches its most severe point within 4 weeks. It may then remain stable for a few weeks or months before gradually improving.

Muscular dystrophy is a group of inherited diseases that damage and weaken your muscles over time. This damage and weakness is due to the lack of a protein called dystrophin, which is necessary for normal muscle function.

  • muscular dystrophy has different types according to the muscles that are affected. (check table 8)


Primary: Affect muscle structure

Secondary: Affect musculoskeletal system

The symptoms Include:

  • Muscle weakness

  • Progressive muscle atrophy

  • Joints contracture

  • Poor balance (frequent falls)

  • Abnormal gait pattern (waddling)

  • Scoliosis: which is an abnormal curvature of your spine

  • Cardiomyopathy

  • Respiratory difficulty




















Table 8

 Myasthenia gravis is a chronic autoimmune, neuromuscular disease that causes weakness in the skeletal muscles that worsens after periods of activity and improves after periods of rest.









  • Weakness of the eye muscles (called ocular myasthenia)

  • Drooping of one or both eyelids (ptosis)

  • Blurred or double vision (diplopia)

  • A change in facial expression

  • Difficulty swallowing

  • Shortness of breath

  • Impaired speech (dysarthria)

  • Weakness in the arms, hands, fingers, legs, and neck.

Sometimes the severe weakness of myasthenia gravis may cause respiratory failure, which requires immediate emergency medical care.


In occupational therapy, one of our focuses is the patient’s ability to participate effectively in their activities of daily living, comprising of their basic activities of daily living (ADLs), which include bathing, dressing, feeding, mobility, and grooming and instrumental activities of daily living (IADLs) which include caring for others, driving, financial management, home management/maintenance, meal preparation, and shopping. 


Following a neurological disease, often individuals will notice difficulties in their ability to participate in their ADLs and IADLs. This may be due to cognitive, perceptual, sensory, or motor dysfunctions. Therefore, it’s necessary to assess the patient’s ability to perform ADLs and IADLs

Description: It is an 18-item, clinician-reported scale that assesses function of activities of daily living (ADL)in six areas including self-care, continence, mobility, transfers, communication, and cognition.

Scale: Each of the 18 items is graded on a scale of 1–7 based on level of independence in that item.

Scoring: FIM scores can be measured at admission to and discharge from inpatient rehabilitation


7= Complete independence (timely, safely)

6= Modified independence (extra time, devices)


Modified dependence:

5= Supervision (subject= 100%+)

4= Minimal assist (subject= 75%+)

3= Moderate assist (subject= 50%+)


Complete dependence

2= Maximal assist (subject= 25%+)

1= Total assist (subject= less than 25%)


For more information, check this link:

For a copy, check this file 

Description: It is an ordinal scale used to measure performance in activities of daily living (ADLs).

Items: it includes 10 personal activities: feeding, personal toileting, bathing, dressing and undressing, getting on and off a toilet, controlling bladder, controlling bowel, moving from wheelchair to bed and returning, walking on level surface (or propelling a wheelchair if unable to walk) and ascending and descending stairs.

Scoring: Sum the patient's scores for each item. Total possible scores range from 0 – 20, with lower scores indicating increased disability.


If used to measure improvement after rehabilitation, changes of more than two points in the total score reflect a probable genuine change, and change on one item from fully dependent to independent is also likely to be reliable.


For a copy, check this file: 

Description: is the most appropriate instrument to assess functional status as a measurement of the client’s ability to perform activities of daily living ADLs) independently. 

Items:  six items ( bathing, dressing, toileting, transferring, continence, and feeding).

Scoring: Clients are scored yes/no for independence in each of the six functions.

  • 6 indicates full function.

  • 4 indicates moderate impairment.

  • 2 or less indicates severe functional impairment.

For a copy check this file:

Description: An observational assessment that allows for the simultaneous evaluation of motor and process skills and their effect on the ability of an individual to perform complex or instrumental and personal activities of daily living (IADL).

Number of items:  36 items (16 motor skills items, 20 process skills items)

Time to administer:  30-40 minutes

Scoring: uses a 4-point Likert scale to rate the client’s performance on 16 motor and 20 process skills.

How to obtain the tool?         

The AMPS manual and software can be purchased online at

Description: A standardized self-report assessment tool that is used to determine an individual's level of independence with instrumental activities of daily living (IADL).

Time: The Lawton IADL Scale takes approximately 10 minutes to complete.

For a copy, check this file: 

Description: it is a standardized assessment tool that seeks to provide information relating to an individual's ability to achieve successful and independent community living. Furthermore, this assessment tool has been proven to be effective for estimating the competence of individuals with a mental health diagnosis to live independently.

Subscales: it has five subscales, including:

  • Memory orientation (e.g., recall a shopping list)

  • Managing money (e.g., completing monetary calculations)

  • Managing home and transportation (e.g., using a telephone)

  • Health and safety (e.g., how to respond to an emergency situation)

  • Social adjustment (e.g., attitudes about interpersonal relationships)


Time to administer: it takes approximately 20 minutes to administer.

Scoring interpretation: The final score from the ILS determines if the individual falls within the category of low, moderate or high functioning for each subsection.

For a copy, check this file:

The American Spinal Injury Association Impairment Scale (ASIA)

Description:  is a standardized neurological examination used to assess the sensory and motor levels which were affected by the spinal cord injury. 

The scale has five classification levels, ranging from complete loss of neural function in the affected area to completely normal.

It is available but you should take permission to reprint using this link:

Description: It’s used to measure muscle tone through measuring resistance during passive soft-tissue stretching and is used as a simple measure of spasticity.

Precaution: if the patient has subluxation, avoid testing the tone.


  • 0 = no increase in muscle tone

  • 1 = slight increase in muscle tone; manifested by a catch and release or by minimal resistance at the end of ROM.

  • 1+= slight increase in muscle tone; manifested by a catch, followed by minimal resistance throughout the reminder (less than half) of the ROM.

  • 2 = more marked increase in muscle tone through most of the ROM, but affected part/s easily moved.

  • 3 = considerable increase in muscle tone, passive movement is difficult.

  • 4 = affected part/s are rigid in flexion or extension.


For a copy, check this file: 


Description: It is the amount of movement that is possible at a joint, and its measured using the goniometer.

As the ROM should be adequate to engage in meaningful and purposeful occupations, it should be measured to determine the limitation and how it interferes with the performance in areas of occupation.

Range of motion is either Passive or Active:

  • Passive range of motion (PROM): the joint is moved by the muscles that act on the joint.

  • Active range of motion (AROM): the joint is moved by an outside force.

Procedure of ROM:

  • Expose the area:

    • Explain to the patient and give instruction, placing the client as required.

  • Stabilization: stabilizing proximal joint to limit movement to joint being assessed.

  • Goniometer measurement:

    • Placement of axis, stationary, and movable arms.

    • Recording from starting degree position.


  1. Joint inflammation

  2. Taking medication for pain/ muscle relaxants

  3. Osteoporosis/ hypermobility/ subluxation of joint

  4. Hemophilia/ hematoma/ injury to soft tissue

  5. Newly fracture

  6. Prolong immobilization

  7. Fragile bone condition


  1. Joint dislocation

  2. Unhealed fracture

  3. Immediately after surgery of soft tissue surrounding joint.

For more information about performing ROM for Upper extremity: check these videos:

Description: It is a procedure for the evaluation of muscle strength, based upon the effective performance of a movement in relation to the forces of gravity or manual resistance through the available Range of motion (ROM).


  • 0 = no muscle contraction can be seen or felt

  • 1 = contraction can be observed or felt, but there is no motion

  • -2= part moves through incomplete ROM with gravity minimized

  • 2 = parts move through complete ROM with gravity minimized

  • +2= parts move through less than 50% of available ROM against gravity or through complete ROM with gravity minimized against slight resistance

  • -3= parts move through more than 50% of available ROM against gravity

  • 3 = parts move through complete ROM against gravity

  • +3= parts move through complete ROM against gravity and slight resistance

  • 4 = parts move through complete ROM against gravity and moderate resistance

  • 5 = parts move through complete ROM against gravity and maximal resistance


For more detailed information about MMT: check this book: 

Daniels and Worthingham's Muscle Testing: Techniques of Manual Examination and Performance Testing (Daniels & Worthington's Muscle Testing (Hislop)) 9th Edition

The book is Available in amazon: visit this link if you want to purchase it:

  • Berg balance scale:

Description: 14-item scale designed to measure balance of the older adult in a clinical setting.

Time: 15-20 minutes

Scoring: A five-point ordinal scale, ranging from 0-4. “0” indicates the lowest level of function and “4” the highest level of function. Total Score = 56

Scoring interpretation:

41-56 = low fall risk

 21-40 = medium fall risk

 0 –20 = high fall risk

For more information, check this Video:

For a copy: Upload file name:  

  • Functional Reach Test:

Description: It is a single item test developed as a quick screen for balance problems in older adults. It Measures the distance between the length of an outstretched arm in a maximal forward reach, while maintaining a fixed base of support, in standing. Modified Functional Reach Test (Adapted for individuals who are unable to stand)

Time: 1-2 minutes


  • A score of 6 inches or less indicates a significant increased risk for falls.

  • A score between 6-10 inches indicates a moderate risk for falls.

For a copy, check this file: Upload file: 

  • Minnesota Manual Dexterity Test:

Description: Standardized performance-based evaluation that measures simple, rapid hand-eye coordination and arm-hand dexterity (gross motor skills).

Time: Approximately 56 minutes

Availability: It should be purchased: it costs $200.00 Kit; $12.50 Additional score sheets using this link: 


For more information about the test, check this file: 

For a descriptive manual, check this file: 

  • Purdue beg board test:

Description; It measures gross movement of the arm, hand and fingers, and fingertip dexterity. 

For more information, check this link:

To know how it done, check this video:

For the kit,  it should be purchased using this link:



  • Grip strength: Using handheld dynamometery

 For more information, visit hand therapy 

  • Pinch strength: using pinch meter.

There are three types: 

  • Tip- to tip: the pinch meter is placed between the tip of the thumb and the tip of the index finger.

  • Tripod (chuck): The pinch meter is placed between the pad of the thumb and pad of the index and middle fingers.

  • Lateral: The pinch meter is placed between the pad of the thumb and the lateral surface of the index finger.

 For more information, visit hand therapy (assessment section)

Cognitive screening: 

Standardized assessment:

  • Test of Everyday Attention(TEA):

Description: It measures 3 aspects of attention—selective attention, sustained attention, and attention switching—using everyday materials.