Functional Impairments Of Stroke

1. Functional Impairments Of Stroke Information was produced and/or compiled by the Alberta Provincial Stroke Strategy and written permission is required before reprinting any information contained in this document. 12/07:12/08[R]

2. Purpose The purpose of this presentation is to provide a general overview of common functional impairments of stroke, the basic anatomy and physiology related to these impairments and to provide the learner with tips on how to deal with each functional impairment.

3. Target Audience Health care providers who require basic knowledge of the functional impairments of stroke

4. Learning Objectives • Identify 10 common functional impairments of stroke • Identify the basic anatomy and physiology related to each functional impairment • Identify tips to assist stroke survivors to manage the functional impairments

5. Common Effects By Hemisphere Figure 1, HSFO, 2002

6. Common Functional Impairments • Mobility • Arm/hand function • Speech and language • Cognition • Vision • Visual perception • Motor planning • Urinary continence • Swallowing and aspiration • Nutrition Figure 2, adapted from WHO, 2001

7. Mobility • Hemiplegia and mobility • Mobility after stroke may be affected by a number of factors: • Loss of motor control • Sensation • Fatigue • Muscle tone • Balance • Posture • Perception

8. Tips For Assisting With Mobility • Stroke survivors should be mobilized as early as possible • Ensure safety and comfort while promoting independence • Avoid over-tiring the survivor • Each person is unique • Move slowly and gently • Talk with the survivor • Encourage participation • Use good body mechanics • Position the affected arm

9. Hand And Arm Function • Stroke may affect a survivor’s hand and arm function • Hand and arm recovery may be slower than the lower extremity • Most recovery occurs in the first 3 months but improvement can occur even months and years in the future

10. Painful Hemiplegic Shoulder • Painful shoulder occurs in 40% to 60% • Major impact on ADLs and rehab • Etiology is complex: • Glenohumeral subluxation • Spasticity of the shoulder muscles • Impingement • Soft tissue trauma • Rotator cuff tears • Reflex sympathetic dystrophy • Myofascial pain • Referred pain from the neck • Take home message: HANDLE WITH CARE

11. Painful Hemiplegic Shoulder Subluxation Figure 3 – Normal and subluxed shoulder Figure 4

12. Tips For Assisting With Hand And Arm Function • Never pull on the survivor’s affected arm • Positioning • Reposition the “forgotten arm” • Support the affected arm during transfers • Sling use

13. Speech And Language • Difficulty in using or understanding language, which results from damage to the brain • Aphasia or dysphasia • Dysarthria • Dyspraxia of speech

14. Tips For Communication Strategies to help you get your message across • Look at the person • Appropriate tone of voice • One idea at a time • Write down key words • Use gestures and facial expressions • Use objects • Use YES/NO questions • Draw simple pictures

15. Tips For Communication Strategies to help the person with communication problems get their message across • Encourage writing or drawing • Encourage pointing • Identify the general topic and then move to the details • Ask YES/NO questions • Use words that you have written down

16. Cognition • Two-thirds may experience cognitive impairment • Most recovery occurs in the first three months, but may continue for at least the first year • Cognitive changes may include: • Attention • Executive functioning • Processing speed • Memory • Orientation

17. Tips To Assist With Cognition Depends on the nature of cognitive impairment • Orientation • Attention • Memory • Impulsivity • Planning and starting a task • Decreased information processing speed

18. Vision • Vision problems are common following stroke • Double vision (diplopia) • Changes in clarity of vision (visual acuity) • Visual field impairment (hemianopia)

19. Tips To Assist With Vision • Visual acuity • Bring glasses to hospital or rehabilitation • Optometrist referral if glasses are in poor condition • Double vision • Patching • Consider the use of prisms • Hemianopia • Compensate through scanning • Consider the use of prisms

20. Visual Perception • Unilateral spatial neglect (USN) is inability to respond to sensory stimuli presented on the survivor’s affected side • USN is more common in individuals who have right-sided lesions than left.

21. Tips To Assist With Unilateral Spatial Neglect • Arrange the environment • Approach the survivor from the unaffected side • Use a positive approach • Use visual cues to assist the survivor

22. Motor Planning The inability to perform purposeful movements even though the survivor has the physical ability and understands the task Figure 5

23. Tips To Assist With Motor Planning • Use physical cues • Use short and simple instructions • Use verbal cues and instructions • Break the task down into small steps • Maintain a consistent routine • Provide support and encouragement • Provide hand-over-hand guidance • Refer to rehab

24. Urinary Continence • The loss of control of urine or inability to hold urine until the bathroom is reached • Stroke may impact normal bladder function • Indirect impact of stroke • Environmental considerations

25. Tips For Assisting With Urinary Continence • Urinary incontinence can be treated • Timed voiding • Prompted voiding • Bladder retraining with urge suppression • Pelvic muscle exercises • Compensatory rehabilitation • Remove catheter ASAP

26. Swallowing And Aspiration • Dysphagia is difficulty swallowing • 29 to 65% of stroke survivors • Common in brainstem or bilateral stroke • Frequent in unilateral stroke • Aspiration

27. Tips For Swallowing And Aspiration • NPO until screened by a trained individual • Referral to an expert in swallowing • Referral to a dietician • Individuals with dysphagia should feed themselves • Low risk feeding strategies

28. Nutrition • Malnutrition is common problem after stroke • Patients consume fewer calories and protein following stroke

29. Tips For Nutrition • Nasogastric tubes • Intragastric feeding tubes • Oral supplementation improves energy and protein intake

30. Discussion Discussion and questions

31. Prepared by: Margaret Grant, BScOT Rehabilitation Education Coordinator Alberta Provincial Stroke Strategy Reviewed by: Dr. Carmen Tuchak, BSc(Hons), MD, FRCP(C) Clinical Director Glenrose Hospital Stroke Program Edmonton , Alberta Luchie Swinton, BScOT Rehabilitation Facilitator Calgary Stroke Program Calgary, Alberta Functional Impairments of Stroke Gayle Thompson RN(NP), MN Education Project Manager Alberta Provincial Stroke Strategy