# Occupational Therapy for Stroke > Occupational Therapy for stroke: ADL retraining, the dressing rule, hemiplegic shoulder care, Brunnstrom staging, CIMT candidacy and community reintegration. - Canonical URL: https://prepelephant.com/topics/allied/occupational-therapy/ot-for-stroke - Exam / course: Allied Health · Subject: Occupational Therapy - Publisher: PrepElephant (https://prepelephant.com) — Prepared and reviewed by the PrepElephant Academic Review Team - First published: 2026-10-02 - Last updated: 2026-10-02 - How to cite: "Occupational Therapy for Stroke", PrepElephant, https://prepelephant.com/topics/allied/occupational-therapy/ot-for-stroke ## Direct answer Recovery after stroke is time-limited by biology, not will: the first three to six months carry the greatest neuroplasticity, so occupational therapy front-loads its intensity there, pairing task-specific practice of real activities — dressing, bathing, eating, writing, kitchen work — with the right frame at the right moment (restorative early, compensatory later). Assessment tracks tone and synergy patterns through Brunnstrom's six stages, screens for unilateral neglect and hemianopia, and measures outcome with the FIM, the Modified Rankin Scale and the Canadian Occupational Performance Measure. The craft lies in details examiners love: the affected-side-first dressing rule, the protected handling of the flaccid hemiplegic shoulder, constraint-induced movement therapy only when active wrist and finger extension exist, and a family trained as co-therapist rather than bystander. ## What you must remember - **Brunnstrom applied to activity:** stage planning, not textbook recital — flaccidity calls for positioning and protection, synergy-dominant stages for bilateral tasks that carry the arm, and post-synergy stages for isolated, fine retraining. - **The dressing rule:** dress the affected side first, undress it last — the sound limb threads the weak one in, and the reverse when disrobing; taught in exactly this order. - **Hemiplegic shoulder discipline:** never pull the arm, never lift by the axilla, support it on a lap tray or arm trough in flaccidity; a subluxed, painful shoulder destroys willingness to use the limb. - **CIMT candidacy:** roughly 20 degrees of active wrist extension and 10 degrees of finger extension — prescribing it for a flail arm wastes the method and the patient. - **Adaptive kit that earns its place:** button hook, elastic laces, non-slip mat, plate guard, rocker knife, one-handed shoe horn — chosen after retraining, not instead of it. - **Outcome trio:** FIM for burden of care, Modified Rankin Scale (0-6) for global disability, Canadian Occupational Performance Measure for goals the patient actually owns. - **Whole-day management:** positioning, feeding posture and safe transfer habits are prescribed around the clock, because neuroplasticity does not clock out at session end. - **Indian reality:** early discharge makes home the rehabilitation unit; family training and task practice woven into household roles — kneading, sweeping, folding — supply the repetition and salience a ward cannot. ## A left MCA stroke that changed language, not just movement A 61-year-old college teacher, two weeks after a left middle cerebral artery infarct, has right hemiparesis and Broca-type aphasia — comprehension largely intact, speech laboured to a few words. The assessment is rebuilt for him: the COPM is taken with pointing and yes-no cards, goals chosen by picture. Treatment then runs on demonstration instead of instruction — he copies the dressing sequence modelled slowly, the therapist resisting every urge to explain verbally. Dressing follows the rule: the right, affected arm goes into the shirt sleeve first, always, with a written-and-pictured chart for the family. The right shoulder is protected with a lap tray from day one. Communication boards carry the ADL routines — a strip of pictures for bathing steps, for medication, for pain — and the wife is coached to allow the struggle rather than answer for him, because fluency returns through use, not silence. Writing retraining begins with the left hand in large strokes, since the right may take months. Emotional lability is explained in advance so tears at session four are read as physiology, not despair. At ten weeks he conducts a halting conversation, dresses standing with supervision, and has renegotiated two tuitions he can teach by demonstration — an outcome no aphasia scale would capture. ## Where students slip The BOT long case asks "train dressing in hemiplegia" and the marks sit in sequence detail: garment positioned on the lap, affected arm threaded first, sound arm second, head emerges last — candidates who say "encourage independence" without the order have given a philosophy, not a method. The second recurring error is the shoulder: hauling the flaccid arm during transfers is still the commonest ward-induced injury. The third is the plateau myth — restoration fades but compensation keeps improving function for years, so discharge is a plan, not an ending. ## Frequently asked questions ### What is the dressing rule in hemiplegia? Dress the affected side first and undress it last, because the sound limb can thread and free the weak one; reverse the sequence for disrobing. ### What extension is required before constraint-induced movement therapy? About 20 degrees of active wrist extension and 10 degrees of finger extension in the affected hand — below that, the method cannot work. ### How is the flaccid hemiplegic shoulder protected? Never pull the arm or lift by the axilla; support it on a lap tray or arm trough, position it in scaption, and handle it during all transfers with the same discipline. ### What does the Modified Rankin Scale measure and what is its range? Global disability after stroke from 0 (no symptoms) to 6 (death), the broadest single stroke outcome measure. ### Why train the family in stroke rehabilitation? After early discharge the home is the therapy setting in India, and family carry-over multiplies the dose far beyond clinic hours.