A Patient’s Journey of Self Discovery Post R-CVA.
Sex and sexuality after a stroke are usually overlooked among health care professionals. The Occupational Therapy Practice Framework: Domain and Process, 2nd Edition lists sexual activity as an activity of daily living (ADL).1 Post stroke patients tend to develop several kinds of dysfunctions as a result of the incident, for example; lack of coordination, paralysis, visual perception, aphasia, sensory deficits among other issues including impotence. Korpelainen, Nieminen, & Myllala suggests that Cerebrovascular Accident (CVA) may commonly result in sexual dysfunction, leading to a marked decrease in sexual activity.2 While working in the sub-acute setting most clinicians tends to provide services to post stroke victims. Some patients like to reveal personal history and establish an immediate rapport with the therapist, others are afraid to express their own feeling due to increased shame among themselves. From 1999 to 2009, the relative rate of stroke death fell by 36% and the actual number of stroke deaths declined by 23%. Yet each year around 795000 people continue to experience a new or recurrent stroke (Ischemic or Hemorrhagic). Approximately 610000 of these are first attacks and 185000 are recurrent attacks. On average, every 40 seconds, someone in the United States has a stroke and dies of one approximately every four minutes stated Go AS, Mozaffarian, Roger, et, al.3
“A male patient was admitted to a sub-acute rehabilitation center. He was in his mid 60’s and prior his incident he was completely independent in all areas of self-care and mobility. He mentioned that he has lived with his partner for many years and had a successful sexual life. This gentleman experienced a R-CVA resulting in L-Hemiplegia with lack of mobility ranging from upper to lower extremities, sensory deficits, decrease communication skills and demonstrated decrease safety awareness. This patient worked hard during his rehabilitation sessions and made daily improvements. He was able to regain 60% of AROM of LUE; ADL’s such as dressing/bathing/toileting/grooming and hygiene were at Sup level upon discharge with a length of stay of 2 months during inpatient rehabilitation services. During his stay he seemed anxious as if he wanted to ask personal questions but couldn’t, he stopped himself every time and said “never mind”. When he was asked about what was happening he denied his feelings and concentrated on the assigned task. One day as part of OT assessments he was asked about his sexual expectations as part of his daily routine. He nervously started to laugh and then stated he was ashamed about sexual dysfunction and how he felt unworthy of his partner”.
The Baby-Boom generations feels strongly that sex is for every age, not just for the young. Most adults, regardless of their age, are interested in sex, find sex satisfying, and consider sex to be an important part of their lives mentioned by National Council of Aging.4 People with disabilities, especially stroke patients exhibit changes involving body chemistry and composition. Interpersonal factors and coping mechanism are affected as well as cognitive processing where denial sets in and the person experience subsequent anxiety and/or depression as the result of the current situation and deficits. Perception and body image are some of the most important aspects people have to overcome in order to regain confidence and improve quality of life. Burton stated that if a person feels inadequate as a sexual, sensual and lovable human being, the motivation to pursue other avenues of life can be affected.5 Therefore, education must be provided in order to achieve higher goal expectancy facilitating and promoting sense of awareness and increased self-esteem that will help to cope with disabilities and its related co-morbidities.
As occupational therapists we need prioritize patient’s basic values and beliefs. Sexual history should be taken during the evaluation or during the re-assessment period as permitted by the patient. Sexual consultation should not only be discussed with client but with present partner in order to synchronize their desires and address their needs prior to discharge. Also a review of medications is important due to the fact that most of the drugs administered to stroke patient could result in sexual dysfunction and the inability to copulate. Hawton found that medications being received by male stroke patients included anti-hypertensives (30%), anticonvulsants (18%), anticoagulant (18%), analgesics (18%), diuretics (14%), hypnotics (10%), muscle relaxants (10%), vasodilators (6%), antidepressants (8%), hypoglycaemic agents (6%), and minor tranquilizers (6%), as well as a number of other preparations.6 Sexuality comprises more than just sexual intercourse. It’s a complex phenomenon that includes psychological, biological, behavioral and interpersonal behavior according to Shah.7 People with chronic diseases and long-term disability such as Stroke/CVA tend to develop the fear of continuing their sexual life.
The Dash (Disabilities of the Arm, Shoulder and Hand)
Stroke Impact Scale
Changes in Sexual Functioning Questionnaire
Sexual Interaction System Scale
The PLISSIT intervention model (permission, limited, information, specific suggestions, intensive therapy)
As part of treatment implementation for this patient, discussions on how to regain his confidence and self-esteem was introduced during treatment sessions. Documentation such as pamphlets with detailed sexual positions including pictures was discussed with both parties as a couple for compensation of deficits including fatigue and lack of mobility due to hemiplegia. Recommendations on using pillows, lubrication and other mechanical devices were also discussed. ROM, muscle strength, modalities and self-care retraining were part of daily routine during the rehabilitation stay. During his journey at the rehabilitation center, he discovered that having a disability does not impede the person achieve his fullest potential for recovery. This patient recognized his fears, concerns and was able to manage it accordingly. He was able to manage his anxiety and overcome depression in order to fulfill his desire and improve his quality of life. Sexual rehabilitation is designed to be person-centered, time-based, functionally-oriented and aims to maximize activity and participation (social integration) using a biopsychosocial model described by Ng, Sanson, Zhang, Khan.8
Occupational therapists have an important role when it comes to sexuality and patient care. Some of their roles are to provide education in areas of ADL’s, mobility, implementation of adaptation, remediation and/or modification techniques during treatments in order to improve overall functional performance. Allowing patients to explain their concerns, feelings and emotions in regards to sexual performance are essential to achieving higher level of awareness. A range of formats may be used in sexual rehabilitation, including oral information, visual information, written materials, audiovisual and practical training. Sexual rehabilitation may be short-term (such as once-off counseling or a medication prescription) or longer-term, for example providing cognitive behavioral therapy targeting psychological and physical aspects of sex and intimacy described by Song.9 Quality of life is achievable when there is willingness to articulate, adapt or modify patient’s behavior within the environment. Part of our job as Occupational Therapist should be introducing more evidence based research during our treatment plan and overall course of care. Activity analysis needs to be implemented at a higher-level power in order to assist with problem solving when it comes to dealing with clients with chronic diseases and disabilities such as stroke.
- American Occupational Therapy Association. (2008). Occupational therapy practice framework: Domain and process (2nd ed.). American Journal of Occupational Therapy, 62, 625-683. Doi:10.5014/ajot.62.6.625.
- Koperlainen, J.T., Nieminen, P., & Myllyla, V. V. (1999). Sexual functioning among stroke patients and their spouses. Stroke, 30, 715-719.
- Go AS, Mozaffarian D, Roger VL, et al; the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2013 update: a report from the American Heart Association. Circulation. 2013;127:e6-245.
- National Council of Aging. (1998). Half of older Americans report they are sexually active. Available at www.ncoa.org/content.cfm?sectionID=105&detail=128.
- Pendleton, H.M, & Schultz-Krohn, W. (2006). Sexuality and Physical Dysfunction. In Burton, G.U, Pedretti’s Occupational Therapy Practice Skills for Physical Dysfunction Six Edition (p. 249). St. Louis, Missouri: Mosby Elsevier Inc.
- Hawton, K., 1984. Sexual adjusment of men who have had strokes. Journal of Psychosomatic Research, 28 (3), 243-249.
- Shah, M., 2009. Sexuality after stroke. In Stein, J., Harvey, L.R., Macko, F.R., Winstein, J. C., & Zorowitz, D.R. (Eds.), Stroke, Recovery & Rehabilitation (pp.721-734). New York: Demos Medical Publishing.
- Ng, L., Sanson. J., Zhang. N.Y., Khan. F. Interventions for sexual dysfunction following stroke (Protocol). Cochrane Database of Systematic Reviews 2014, Issue 7. Art. NO: CD011189.DOI: 1002/14651858. CD011189.
- Song, H., Oh, H., Kim, H., & Seo, W., 2011. Effects of a sexual rehabilitation intervention program on stroke patients and their spouses. Neurorehabilitation, 28 (2), 143-150.