Stroke affects 150,000 people each year in France and is the leading cause of acquired disability in adults. The occupational therapist plays a central role in care, intervening from the acute phase to the return home to optimize functional recovery. The consequences of the Stroke can be motor, cognitive, language, or behavioral, requiring a personalized multidisciplinary approach. Occupational rehabilitation aims to restore autonomy in daily activities and promote social reintegration. New technologies, such as the cognitive stimulation applications COCO THINKS and COCO MOVES, now effectively complement traditional rehabilitation methods.
150 000
Strokes per year in France
1st
Cause of acquired disability
75%
Have lasting effects
60%
Regain their autonomy

1. Understanding Stroke and its Neurological Consequences

Stroke occurs when blood flow to a part of the brain is abruptly interrupted, either by blockage (ischemic stroke - 80% of cases) or by rupture of a blood vessel (hemorrhagic stroke - 20% of cases). The consequences depend directly on the anatomical location and extent of the brain lesion, but also on the speed of initial medical intervention.

The neurological consequences of Stroke manifest in several dimensions that interact with each other. Hemiplegia or hemiparesis affects the side opposite the brain lesion, creating more or less severe motor deficits. Cognitive disorders can affect attention, memory, executive functions, or spatial perception. These multiple impairments require thorough assessment to adapt the rehabilitation strategy.

Post-stroke recovery relies on the mechanisms of brain plasticity, this remarkable ability of the brain to reorganize and create new neural connections. This plasticity is maximal in the first months following the Stroke but persists throughout life, justifying early and intensive rehabilitation to optimize chances of functional recovery.

💡 Factors Influencing Recovery

Brain plasticity can be stimulated by intensive, early, and repetitive rehabilitation. The patient's age, the size of the lesion, motivation, and social environment are determining factors in the recovery process. The occupational therapist must consider all these elements to personalize care.

💪

Motor Deficits

Hemiplegia, hemiparesis, spasticity, balance disorders, coordination difficulties, and fine motor skills issues

🧠

Cognitive disorders

Attention deficits, memory, executive functions, spatial hemineglect, language disorders

👁️

Perceptual disorders

Hemianopsia, visual neglect, body and spatial perception disorders

😔

Psycho-affective disorders

Post-Stroke depression, anxiety, chronic fatigue, mood and behavioral disorders

2. The chronological phases of occupational therapy management

Post-Stroke occupational therapy management is organized into several distinct phases, each with its specific objectives and intervention modalities. This sequential approach allows for the adaptation of rehabilitation to the clinical evolution of the patient and their changing needs. The occupational therapist intervenes from the acute hospital phase and supports the patient until their social and professional reintegration.

Coordination among the various healthcare professionals is essential at each phase to ensure continuity of care and optimize outcomes. The occupational therapist works closely with the medical team, physiotherapists, speech therapists, neuropsychologists, and social workers in a truly multidisciplinary approach.

The transitions between phases require particular preparation, especially for the transition from the hospital to follow-up and rehabilitation care, and then to home. These pivotal moments largely determine the success of reintegration and the patient's future quality of life.

1

Acute phase (0-2 weeks)

Location: Neurovascular unit, neurology department

Objectives: Prevention of secondary complications, postural maintenance, early assessment of deficits

Actions: Positioning in bed and chair, gentle passive mobilization, sensory stimulation, initial secure transfers

2

Subacute phase (2 weeks - 6 months)

Location: Neurological rehabilitation, MPR

Objectives: Maximum functional recovery, compensatory learning, preparation for return home

Actions: Intensive rehabilitation of the upper limb, cognitive work, retraining for daily activities

3

Chronic phase (after 6 months)

Location: Home, private practice, day hospital

Objectives: Maintenance of acquired skills, ongoing rehabilitation, social and professional participation

Actions: Maintenance rehabilitation, environmental adaptation, support for caregivers

CLINICAL EXPERTISE
Continuum of care in occupational therapy

The success of post-Stroke rehabilitation relies on the continuity and coherence of care between the different phases. Each transition must be anticipated and prepared to avoid breaks in care that can compromise the progress made.

Professional recommendations

Best practice guidelines recommend intensive rehabilitation (minimum 3 hours per day) as soon as the clinical condition allows, with a multimodal approach combining motor, cognitive, and functional rehabilitation to optimize neurological recovery.

3. Specialized occupational therapy assessment post-Stroke

The post-Stroke occupational therapy assessment forms the foundation of any effective rehabilitative intervention. It must be comprehensive, standardized, and regularly reassessed to monitor the patient's progress and adapt therapeutic goals. This assessment is based on the International Classification of Functioning (ICF) from the WHO, analyzing impairments, activity limitations, and participation restrictions.

The use of standardized and scientifically validated assessment tools allows for the objective quantification of the patient's abilities and measurement of the progress made. These measurements guide therapeutic decisions and facilitate communication among professionals. The assessment must also integrate environmental and personal factors that influence daily functioning.

The initial assessment, ideally conducted within 72 hours following the Stroke, establishes a baseline and defines rehabilitation priorities. It will be supplemented by regular reassessments to adjust the therapeutic plan according to clinical evolution and the patient's goals.

MIF (Measure of Functional Independence)

Assesses autonomy in 18 daily activities on a scale of 1 to 7

Barthel Index

Measures independence in 10 basic activities of daily living

ABILHAND

Assesses perceived manual ability for bimanual activities

Box and Block Test

Measures gross dexterity of the upper limb

Nine Hole Peg Test

Assesses fine dexterity and hand-eye coordination

MoCA (Montreal Cognitive Assessment)

Screening for mild to moderate cognitive disorders

Bell Test

Detection and quantification of spatial neglect

COPM (Canadian Occupational Performance Measure)

Assesses the patient's perception of their occupational performance

🎯 Priority assessment areas

  • Upper limb motor function: strength, tone, range, coordination, sensitivity
  • Cognitive functions: attention, memory, executive functions, hemispatial neglect
  • Autonomy in daily living activities: personal hygiene, dressing, meals, transfers
  • Communication and swallowing in connection with the speech therapist
  • Social participation and quality of life
  • Physical and social environment of the home
💡 Good evaluation practices

The assessment should be conducted under standardized conditions, away from meals and sedative treatments. It is important to consider the patient's fatigue and to break down the assessment if necessary. The active participation of the patient and their family in identifying rehabilitation priorities improves adherence to treatment.

4. Specialized rehabilitation of the upper limb post-Stroke

Rehabilitation of the upper limb represents a major challenge after a Stroke, as about 80% of patients initially present a deficit in this limb, and only 30 to 40% regain useful function. The rehabilitative approach must be early, intensive, and focused on meaningful functional activities for the patient. Modern techniques rely on the principles of neuroplasticity and motor learning.

Recovery of the upper limb generally follows a proximal-distal pattern, with recovery first of the shoulder and elbow, then the wrist and hand. This progression guides the planning of rehabilitative exercises. The occupational therapist must adapt their techniques according to the stage of recovery and the patient's residual abilities, always aiming for the highest possible function.

Modern therapeutic approaches prioritize task-oriented training and intensive repeated practice. The use of technological tools such as virtual reality or robotic devices effectively complements traditional techniques by increasing motivation and allowing precise quantification of progress.

🔒 Constraint-induced therapy

Restriction of the healthy limb for 6-8 hours a day to force the use of the affected limb. Effective in patients with residual function.

🪞 Mirror therapy

Visual illusion created by a mirror to stimulate contralateral motor areas. Particularly useful for neuropathic pain.

🎯 Task-oriented training

Functional exercises in real situations (cooking, office) to promote the transfer of learning.

⚡ Functional electrical stimulation

Assistance with movement through electrical stimulation synchronized with the patient's motor intention.

🥽 Virtual reality

Motivating immersive environments allowing for intensive rehabilitation with real-time feedback.

🤖 Rehabilitation robotics

Robotic devices for assistance and graded resistance during motor exercises.

📊 Objectives according to recovery level

🚫 Non-functional limb (Brunnstrom stages 1-2)

Prevention of complications (stiffness, pain), correct positioning, gentle passive mobilization, maintenance of joint range, sensory stimulation

🤝 Assistive limb (Brunnstrom stages 3-4)

Use as a stabilizer, assistance to the dominant hand, gross grasp training, bilateral exercises

✅ Functional limb (Brunnstrom stages 5-6)

Recovery of fine dexterity, automation of daily gestures, improvement of speed and accuracy, complex activities

Prevention of shoulder-hand syndrome

This painful complication affects 30% of hemiparetic patients. Prevention relies on correct positioning of the limb (avoiding glenohumeral subluxation), early and gentle mobilization, avoiding traction on the shoulder during transfers, and regular monitoring for the appearance of painful or inflammatory signs.

🔧 COCO THINKS and COCO MOVES Applications for Rehabilitation

DYNSEO applications offer eye-hand coordination exercises specifically designed for upper limb rehabilitation. COCO MOVES combines cognitive and motor stimulation to optimize functional recovery, while COCO THINKS specifically works on cognitive functions impacting the use of the upper limb.

5. Specialized Cognitive Rehabilitation after Stroke

Post-stroke cognitive disorders represent a major challenge in rehabilitation, affecting about 30% of patients and significantly impacting overall functional recovery. These disorders can be immediate or appear later, requiring prolonged monitoring and care. The occupational therapist works in conjunction with the neuropsychologist to offer ecological cognitive rehabilitation, focused on daily living activities.

The modern cognitive rehabilitation approach is based on scientific evidence of neuroplasticity and favors intensive and repetitive methods. Cognitive stimulation must be early, progressive, and tailored to the specific neuropsychological profile of each patient. The use of digital tools allows for intensified rehabilitation and ensures regular practice between sessions.

Cognitive rehabilitation must be transferred to real-life situations to be effective. The occupational therapist uses ecological situational training (therapeutic cooking, driving simulator, computer workshops) to promote the generalization of learning and improvement of functional autonomy.

🎯

Spatial Neglect

Neglect of one side of space, very disabling in daily life. Rehabilitation through visual scanning, external cues, environmental adaptation.

⚡

Attention Disorders

Difficulties in concentration, distractibility, cognitive fatigue. Progressive training of sustained and divided attention.

🧩

Memory Disorders

Impairments of working memory and learning. Compensatory strategies and external memory aids.

🎨

Dysexecutive Syndrome

Difficulties in planning, organization, mental flexibility. Training through solving complex problems.

🔄 Cognitive rehabilitation approaches

  • Restoration: Intensive exercises to recover cognitive functions altered by neuroplasticity
  • Compensation: Development of alternative strategies to bypass persistent deficits
  • Adaptation: Modification of the environment to reduce cognitive demands
  • Substitution: Use of technical aids to replace the failing function
TECHNOLOGICAL INNOVATION
Digital cognitive stimulation

Cognitive stimulation programs on tablets like COCO THINKS of DYNSEO offer varied and progressive exercises to specifically train cognitive functions altered after a Stroke. These tools allow for intensive rehabilitation, objective tracking of progress, and increased motivation through gamification.

Advantages of digital rehabilitation

The use of specialized applications allows for advanced individualization of exercises, automatic adjustment of difficulty, and precise quantification of performance. The patient can train daily at home, effectively complementing sessions with the therapist.

🏠 Ecological rehabilitation

Cognitive rehabilitation must be transferred to everyday life situations to be effective. Working on cognitive functions in real situations (meal preparation, budget management, using transportation) is more beneficial than decontextualized exercises. The occupational therapist uses therapeutic cooking, outings in the city, and domestic activities as rehabilitation supports.

6. Functional rehabilitation and daily autonomy

Functional rehabilitation is at the heart of post-Stroke occupational therapy intervention, aiming to enable the patient to carry out daily activities despite persistent neurological sequelae. This pragmatic approach focuses on adapting movements, learning compensatory techniques, and using appropriate technical aids to maximize functional independence.

A detailed analysis of each daily living activity allows for the identification of problematic steps and the proposal of personalized solutions. The occupational therapist breaks down complex activities into simpler subtasks, teaches new movement sequences adapted to residual capacities, and suggests environmental modifications to facilitate the autonomous completion of tasks.

Rehabilitation must take into account the patient's priorities and values, focusing on the activities that are most meaningful to them. The person-centered approach ensures better adherence to the rehabilitation process and increased satisfaction in achieving therapeutic goals. Family members and caregivers are involved in this process to ensure continuity and safety of learning.

🚿 Personal Care Activities

Adaptation of gestures to one hand, secure installation, technical aids (back brush, soap dispenser), sequential organization of tasks.

👕 Adaptive Dressing

Strategies for dressing with hemiparesis, choice of suitable clothing, one-handed buttoning techniques, easier shoe putting on.

🍽️ Eating Activities

Optimal positioning, adapted cutlery, one-handed cutting techniques, prevention of choking, nutritional independence.

🚶 Mobility and Transfers

Secure transfer techniques, use of walking aids, fall prevention, wheelchair mobility.

🏠 Domestic Activities

Kitchen layout, adapted cleaning techniques, shopping and supply, simplified administrative management.

🚗 Driving

Assessment of abilities, vehicle adaptations, retraining on simulator, connection with specialized driving schools.

🔧 Common Technical Aids Post-Stroke

  • Bathroom: Shower seat, grab bars, non-slip mat, toilet riser, adapted tap opener
  • Meals: Weighted and angled cutlery, rimmed plate, non-slip mat, adapted jar opener, nasal cut glass
  • Dressing: Button hook, long shoehorn, elastic laces, Velcro fastenings, front-opening clothing
  • Communication: Large-button phone, adapted touchscreen tablet, alert system, voice command
PERSONALIZED APPROACH
Canadian Occupational Performance Measure (COPM)

This client-centered assessment tool helps identify priority activities according to the patient and evaluates their perception of their performance and satisfaction. The COPM guides the definition of personalized goals and measures the functional impact of rehabilitation.

Areas of application

The MCRO explores three areas: personal care (hygiene, dressing, mobility), productivity (work, school, household tasks), and leisure (entertainment, socialization, sports). This holistic approach ensures comprehensive care for the patient's needs.

7. Preparation and support for returning home

The preparation for returning home is a critical step in post-Stroke care, largely determining the success of social reintegration and future quality of life. This phase requires a thorough assessment of the home environment, anticipation of potential difficulties, and close coordination among all stakeholders. The occupational therapist plays a central role in this complex transition.

The home visit allows for an in situ assessment of architectural obstacles, fall risks, and necessary adaptations to ensure the patient's safety and autonomy. This environmental assessment must be conducted early enough to allow for the necessary adjustments before hospital discharge. Collaboration with social services and funding organizations is often essential.

Supporting family caregivers is essential for the success of returning home. The occupational therapist trains relatives in transfer techniques, monitoring warning signs, and using assistive devices. This therapeutic education for caregivers helps prevent complications, reduce family stress, and maintain the gains from rehabilitation.

🏠 Architectural assessment

Analysis of obstacles: steps, thresholds, door widths, stairs, slippery floors, insufficient lighting

🛡️ Safety assessment

Identification of fall risks, dangerous areas, faulty equipment, accessibility of emergency services

🔧 Recommendations for adjustments

Grab bars, access ramps, enhanced lighting, non-slip floors, accessible shower

👥 Coordination of assistance

Organization of home help services, nursing care, physiotherapy, deliveries

📋 Steps for Preparing for Home Return

1. Preliminary Assessment

Functional assessment of the patient, evaluation of the home environment, analysis of needs for human and technical assistance

2. Recommendations and Adjustments

Adjustment quotes, funding requests, coordination with companies, ordering technical aids

3. Therapeutic Permission

Trial outing at home, validation of adjustments, necessary adjustments, training of caregivers

4. Definitive Exit

Transmission to city professionals, planning for follow-up, emergency numbers, control appointments

Fall Prevention at Home

Falls affect 30% of patients in the year following a Stroke. Prevention relies on adjusting lighting (motion detectors, night lighting), removing obstacles (slippery rugs, electrical cords), installing grab bars at strategic points, and educating the patient on safe mobility techniques. An emergency plan must be established with accessible emergency numbers.

👨‍👩‍👧‍👦 Training for family caregivers

The training for caregivers focuses on safe transfer techniques, monitoring signs of fatigue or distress, correct use of technical aids, and preventing caregiver burnout. Illustrated educational materials and practical demonstrations facilitate learning. Regular follow-up allows for adjustments to support according to evolving needs.

8. Innovative technologies and digital tools in rehabilitation

The integration of digital technologies is revolutionizing post-Stroke occupational therapy by offering new possibilities for intensive, motivating, and quantified rehabilitation. These tools effectively complement traditional approaches by enabling daily home training, objective tracking of progress, and advanced personalization of exercises according to the specific needs of each patient.

Applications of