Post-Stroke Rehabilitation

1. Post-Stroke Rehabilitation By Barbara K. Bailes Ed.D.,RN.CS NP-C

2. Rehabilitation • purpose - restore function following an illness or injury, with the goal of maximizing a person’s ability to achieve fullest life possible • “planned withdrawal of support” • Interdisciplinary team • physicians, nurses, PT, OT, speech-language therapists, psychologists, social workers, recreational therapists.

3. Initial goals of therapy & rehab include: • prevent & treat medical problems • maximize functional independence • promote resumption of pts pre-existing lifestyle • reintegrate pt into home & community • enhance quality of life • facilitate psychologic & social adaptation

4. Additional principles: • basic learning process • tailored to patient’s ability • feedback essential • family involvement • patient/family education • get family involved early to achieve reality of condition • continuous monitoring of progress • you must document appropriately in order to receive payment for services

5. Rehabilitation begins as soon as possible after admission for acute care • ideally pt is provided care by a stroke team on a stroke unit. • After stroke - 70-80% of pts cannot walk independently • later only 15-20% are not able to walk independently

6. Interventions to prevent medical complications • deep breathing & coughing • skin inspections • swallowing evaluations • seating pt in chair • have pt perform ADLs without assistance (as much as possible • treat sleep disorders • start mobilization process as soon as possible • evaluate communications & begin needed training

7. comorbidities in stroke patients: • hypertension & hypertensive heart disease • coronary heart disease • obesity • diabetes mellitus • arthritis • left ventricular hypertrophy • congestive heart failure

8. Rehabilitation: • Screening exam for rehabilitation performed as soon as possible by expert in rehab. • reviews medical record & various instruments to assess status • rehab programs • inpatient rehab hospitals • rehab units in acute care facilities • outpatient & home rehab

9. Available levels of care • Acute inpatient rehab (acute days) • most aggressive treatment • all disciplines on team & weekly team meetings • criteria (1 or more pertinent disabilities) • mobility ADLs • bowel/bladder swallowing • pain management able to learn • adequate endurance (sit 1 hr & participates in programs)

10. Long term acute care (LTAC) • length of stay at least 18 days (acute care days) • length of stay is deciding factor for this facility • team meetings biweekly • all disciplines available

11. Skilled nursing facility (SNF): • skilled days • pt has variable capabilities • less intense rehab • hospital based - length of stay 3-4 weels • community based - length of stay longer • nursing experience varies

12. Home rehabilitation • home health (no supervision of providers) • nursing, PT, OT, ST • Pros • home setting • learning skills to be used at home • beneficial if transportation for outpt services not available • Cons • caregiver burden • less supervision and no peer support

13. Assessment of stroke pts: • document diagnosis of stroke, etiology, area of brain involved & clinical manifestations • identify treatment during acute phase • identify pts most likely to benefit from rehab. • Select appropriate rehab setting • provides basis for rehab treatment plan • monitor progress during rehab & readiness for discharge • monitor progress following discharge

14. pts medically unstable: • not suitable for rehab program • too disabled by paralysis • severely impaired cognition • serious comorbid condition • those with complex medical problems: • given rehab in facilities with 24 hr coverage.

15. Rehab evaluation completed: • within 3 working days of admission to intense rehab program • within 7 days of admission to lower intensity facility • within 3 visits in outpatient or home rehab • Initial H & PE • during first visit or within first 24 hrs

16. Time course of recovery from stroke: • most rapid recovery 1st 3 months • then, during first year • slow recovery of language & visuospatial functions • slow recovery of motor strength & performance

17. Disability following stroke: • mobility • common during acute stroke period • large majority able to walk with or without assistance 6 months - 1 year later • Activities of daily living (ADLs) • total or partial dependence - about 80% (3 weeks post-stroke) & about 30% 6 months-5years

18. Communication • most experience some degree of spontaneous improvement • one study reported frequency of aphasia decreased from 24% 7 days post-stroke to 12% 6 months later.

19. Neuropsychological functioning • cognitive dysfunction, visuospatial deficits & affective disorders (primarily depression) • depression present in approximately 30% of post-stroke pts (3 months) and to a slightly lesser %age 12 months post-stroke

20. Assessment: • level of consciousness • strong predictor of adverse outcomes post-stroke • more likely with: • extensive brain damage • brain stem involvement • cerebral edema or increased intracranial pressure • prolonged deep coma is rare; more likely to complicate intracranial hemorrhage than infarction • continued

21. Evaluation of consciousness requires: • observation of spontaneous behavior & responses • level of consciousness • 0= alert - fully alert & keenly responsive • 1= drowsy - drowsy; arouses with minor stimulation; obeys, answers and responds to commands • 2= stuporous; lethargic but requires repeated stimulation to attend; may need painful/strong stimuli to follow commands • 3= coma - comatose; responds with reflective mot or automatic responses; otherwise pt unresponsive

22. Level of consciousness - questions: • ask pt to respond to 2 questions • the month of the year & his/her age • answer must be correct - no partial credit for being close (being off age by one year; gives wrong answer and then corrects self)

23. Level of consciousness - commands • asked to follow two commands • open and close his/her eyes • make a grip (close & open hand) • initial response is scored • if hemiparesis - response in unaffected limb is assessed (left limb affected - uses right limb) or attempts to use affected limb - both scored as a normal response.

24. Cognitive disorders: • disorders of higher brain function common post-stroke • full dementia rare following first stroke • assess with: • interactions with others & responses to questions on orientation (name, place, day of week, etc) • mental status exam • differentiate cognitive deficits from communication problems

25. Motor deficits • nature & severity reflect type, location & extent of vascular lesions • can occur in isolation or accompanied by sensory, cognitive, or speech deficits • weakness & paralysis most common; incoordination, clumsiness, involuntary movement or abnormal postures can occur • face, upper extremity & lower extremity can be involved alone or in combination continued

26. During recovery, the arm remains affected for a longer time than the leg & has less complete return of function. • Common patterns • hemiparesis (one arm, one leg) • monoparesis (upper extremity most commonly) • apraxia - unable to sequence movement patterns but has muscle strength • continue

27. Assess: • limb position at rest; spontaneous limb movements & strength • grade 0 - no movement • grade 1 - palpable contraction or flicker • grade 2 - contraction with gravity eliminated • grade 3 - movement against gravity • grade 4 - movement against resistance but weaker than other side • grade 5 - normal strength • continued

28. Other assessment: • increased (spasticity) or decreased (faccidity) muscle tone • identified from degree of resistance felt to rapid limb movement • bradykinesia (slow movements) or abnormalities (chorea, athetosis, or hemibalismus) • record • ability to walk & perform skilled movements (handwriting; use of utensils) • most experience some spontaneous recovery; persistent deficits need rehab to improve ADLs

29. Assessment: • extend his/her arm outstretched in front of body at 90 degrees (sitting) or 45 degrees (if supine) - for 10 seconds • if limb paralyzed - test normal limb first • if arthritis or non-stroke related limitations - judge best motor response • if reflexive response - flexor or extensor posturing - response scored at a 4 • continued

30. Assessment continued: • 0=no drift - able to hold outstretched limb for 10 sec • 1=drift - able to hold outstretched limb for 10 sec but there is some fluttering or drift of limb; falls to intermediate position • 2=some effort against gravity - not able to hold outstretched limb for 10 sec but some effort against gravity • continued

31. 3=no effort against gravity - not able to bring limb off the bed but there is some effort against gravity. If limb raised to correct position by examiner, pt is unable to sustain the position • 4=no movement - unable to move limb. No effort against gravity • 9=untestable - may be used only if limb is missing or amputated or if shoulder joint is fused

32. Assessment: • motor function - leg • supine pt asked to hold outstretched leg 30 degrees above the bed • position is held for 5 seconds • same assessment from 0 - 4 • 9=intestable - may be used only if limb is missing or hip joint is fused

33. Limb ataxia • Balance & coordination disturbances caused by dysfunction of cerebellum o r vestibular system • bedside assessment - finger-to- nose, heel-to-shin, alternating movements • motor or sensory deficits • incoordination in the absence of motor or sensory loss known as ataxia • test ability to walk, tandem waling, Romberg

34. Assessment: • test normal side first • 0=absent - able to perform finger-to-nose & heel-to-shin tasks well; movements smooth & accurate • 1=present unilaterally -either arm or leg; able to perform one of two tasks well • 2=present unilaterally both arms & legs or bilaterally • 9=untestable -used only if all motor function scores =4, limb missing,amputated, fused.

35. Interventions: goal is prevention of 2ndary impairments by enabling the person to regain inhibitory control over abnormal patterns of movement & restored postural control: • back lying enhances extensor tone & prone enhances flexor tone • position pt in the “antispasticity pattern” • shoulders positioned in external rotation to oppose the internal rotation of the latissimus dorsi • hips in internal rotation - to oppose gluteus maximus which acts as an external rotator of the hip.

36. Forearms are extended with hands in supinatiion; hand splints are helpful. • lower extremities (knees, ankles, and hips) positioned in flexion. • Unopposed plantar flexion & inversion at the ankle can lead to problems later; the foot should be maintained in a neutral position • Elonginate the trunk on the affected side • Use supine position with care since it encourages “spasticity pattern”. • Side lying is most neutral position; lying on sound side is good position; lying on affected side is ok if all limbs properly placed.

37. Upper extremity injury, pain, impairment & contractures seen in hemiplegia: • a continuum of arm pain, shoulder-hand syndrome -reflex sympathetic dystrophy • arm pain - common impairment • shoulder-hand syndrome • painful shoulder, especially on movement with edema forearm and hand • reflex shoulder dystrophy - • erythema, sweating, pain, edema

38. Treatment: • ROM within painfree arc • positioning to prevent subluxation • lap board and elevated trough wedge for elevation • when sitting • bandage sling (early and when ambulating) to prevent tugging on arm during positioning. • NSAIDs, steroids, other analgesia • nerve blocks

39. Somatosensory deficits • range from loss of simply sensory modalities to complex sensory disorders • c/o - numbness, tingling, or abnormal sensations (dysesthesia) • exhibit - excessive reactions to sensory stimuli (hyperesthesia) • bedside exam • test sensory - pain, temperature, proprioception, kinesthesia & pallesthesia (sense of vibration)

40. Assessment: • assess with pin in proximal portions of all 4 limbs; ask how stimulus feels (sharp or dull) • eyes do not need to be closed • response to stimulus on right & left compared • if does not respond to noxious stimulus on one side, score is 2 • persons with severe depression of consciousness should be examined • continued

41. Score • 0=normal - no sensory loss to pin is detected • 1=partial loss - mild to moderate diminution in perception to pain stimulation is recognized; may involve more than one limb • 2=dense loss - severe sensory loss so that patient not aware of being touched; does not respond to noxious stimuli applied to that side of body

42. Visual disorders: • visual deficits commonly- homonymous hemianopia • assess visual field defect vs visual neglect • visual neglect(may improve spontaneously while visual field deficits do not • color vision may be disrupted • paralysis of conjugate gaze - poor prognostic sign • others motility disturbances (brain stem) • diplopia, vertigo, oscillopsia, visual distortions

43. Unilateral neglect • pts lack of awareness of specific body part or external environment • occurs primarily in nondominant (usually right) hemispheric strokes • sensory stimuli (vision, hearing somatosensory) in left half of environment ignored or evoke muted responses • severely afflicted - deny problems or illnesses or may not even recognize their own body parts cont’d

44. Bedside evaluation • pt turned to right & will often not turn toward an observer on left. • Ignores items in left visual field when asked to describe a complex picture • ignores sensory stimuli on left • assess: • visual fields both eyes & count fingers in all 4 quadrants • neglect usually improves spontaneously and relatively quickly but hampers rehab initially.

45. Speech & language deficits • aphasia: • common after stroke in language-dominant hemisphere • may cause disturbances in comprehension, speech, verbal expression, reading & writing. • Bedside evaluation • naming objects, observing patterns of fluency, adequacy of content, use of grammerical forms, ability to repeat & comprehension of spoken word • cont’d

46. Neuromotor disturbances (dysarthria & apraxia of speech) need to differentiated from aphasia • dysarthria: • may be due to dysfunction of larynx, palate, tongue, lips, or mouth • causes difficulty in making speech sounds clearly, abnormalities in prosody

47. Apraxia • unable to perform previously learned tasks. • Unable to protrude their tongue on command - but then spontaneously stick out tongue & lick lips. • Trunkal apraxia - difficulty performing whole body commands - standing, turning, sitting • limb apraxia - involves mostly hands and arms (wave, salute, etc)

48. Aphasia - difficulty/inability to speak • Two groups: fluent & nonfluent • nonfluent aphasia: • difficulty with speech production • amount of speech is reduced • speech is labored & dysarthric; lacks normal rhythm & accentuation • fluent aphasia • uses fairly normal amount of speech • words & phrases spoken without effort • words not slurred or dysarthric

49. Broca’s aphasia • nonfluent aphasia characterized by diminished speech output • words & syllables uttered with effort; mechanisms of tongue, mouth, lips & check function abnormal • sounds - stuttered and dysarthric - labored • comprehension of spoken word preserved • most are apraxic - do not correctly follow spoken commands even though they understand meaning of commands • writing is sparse & agrammatical

50. Wernicke’s aphasia • many paraphasic errors (using wrong words) • sound-alike & mean-alike words, jargon, nonword sounds & neologisms. • Usually not aware that they are speaking nonsense • comprehension of spoken language is defective • write with normal penmanship but use many wrong words • reading comprehension do better with written words • usually no hemiparesis - but do have right hemianopia or upper quadrantaniopia • some become paranoid & aggressive