post stroke rehab summer

8/12/2019 Post Stroke Rehab Summer

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Post-Stroke Rehabilitation

By

Barbara K. Bailes Ed.D.,RN.CS NP-C


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Rehabilitation purpose - restore function following an illness

or injury, with the goal of maximizing a persons ability to achieve fullest life possible

planned withdrawal of support

Interdisciplinary team physicians, nurses, PT, OT, speech-language

therapists, psychologists, social workers,recreational therapists.


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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


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Additional principles: basic learning process

tailored to patients 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


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Rehabilitation begins as soon as possibleafter admission for acute care

ideally pt is provided care by a stroke team on astroke unit.

After stroke - 70-80% of pts cannot walkindependently

later only 15-20% are not able to walkindependently


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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


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comorbidities in stroke patients: hypertension & hypertensive heart disease

coronary heart disease obesity diabetes mellitus arthritis

left ventricular hypertrophy congestive heart failure


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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


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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)


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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


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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


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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


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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


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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.


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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


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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


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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


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Communication most experience some degree of spontaneous

improvement one study reported frequency of aphasia decreasedfrom 24% 7 days post-stroke to 12% 6 months later.


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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 %age12 months post-stroke


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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


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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 followcommands 3= coma - comatose; responds with reflective mot or

automatic responses; otherwise pt unresponsive


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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 wronganswer and then corrects self)


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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) orattempts to use affected limb - both scored as anormal response.


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Cognitive disorders: disorders of higher brain function common post-

stroke full dementia rare following first stroke assess with:

interactions with others & responses to questions onorientation (name, place, day of week, etc)

mental status exam

differentiate cognitive deficits from communication problems


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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 movementor abnormal postures can occur

face, upper extremity & lower extremity can beinvolved alone or in combination continued


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During recovery, the arm remains affected for alonger time than the leg & has less complete returnof function.

Common patterns hemiparesis (one arm, one leg) monoparesis (upper extremity most commonly)

apraxia - unable to sequence movement patterns buthas muscle strength

continue


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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 weakerthan other side grade 5 - normal strength

continued


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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


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Assessment: extend his/her arm outstretched in front of body at

90 degrees (sitting) or 45 degrees (if supine) - for 10seconds

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


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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 tointermediate position

2=some effort against gravity - not able to holdoutstretched limb for 10 sec but some effort againstgravity

continued


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3=no effort against gravity - not able to bring limboff the bed but there is some effort against gravity.If limb raised to correct position by examiner, pt isunable to sustain the position

4=no movement - unable to move limb. No effortagainst gravity

9=untestable - may be used only if limb is missingor amputated or if shoulder joint is fused


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Assessment: motor function - leg

supine pt asked to hold outstretched leg 30 degrees abovethe 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


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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


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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.


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Interventions: goal is prevention of 2ndaryimpairments by enabling the person to regain

inhibitory control over abnormal patterns ofmovement & 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.


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Forearms are extended with hands in supinatiion; handsplints 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 aneutral position

Elonginate the trunk on the affected side

Use supine position with care since it encouragesspasticity pattern.

Side lying is most neutral position; lying on sound side isgood position; lying on affected side is ok if all limbs

properly placed.


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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 edemaforearm and hand

reflex shoulder dystrophy - erythema, sweating, pain, edema


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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


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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)


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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


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Score 0=normal - no sensory loss to pin is detected

1=partial loss - mild to moderate diminution in perception to pain stimulation is recognized; mayinvolve more than one limb

2=dense loss - severe sensory loss so that patient notaware of being touched; does not respond to noxiousstimuli applied to that side of body


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Visual disorders: visual deficits commonly- homonymous hemianopia

assess visual field defect vs visual neglect visual neglect(may improve spontaneously while visualfield 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


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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 mutedresponses

severely afflicted - deny problems or illnesses ormay not even recognize their own body parts contd


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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 acomplex picture

ignores sensory stimuli on left

assess: visual fields both eyes & count fingers in all 4 quadrants

neglect usually improves spontaneously andrelatively quickly but hampers rehab initially.


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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

contd


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Neuromotor disturbances (dysarthria & apraxiaof 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


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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)


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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


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Brocas aphasia nonfluent aphasia characterized by diminished speech

output

words & syllables uttered with effort; mechanisms oftongue, 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 ofcommands

writing is sparse & agrammatical


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Wernickes 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


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Conduction aphasia probably a variant of Wernickes aphasia uses wrong words but are generally able to convey

thoughts and ideas well. Repetition of spoke language is poor some retention of speech comprehension most have accompanying slight motor & sensory

abnormalities in the right limbs


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Acquired disorders of written language alexia (or dyslexia)

defective ability to read & understand written language most common cause is aphasia may also be related to defective visual perception

alexia with agraphia cannot read, write or spell.

Alexia without agraphia can write and spell correctly but cannot read some can write a letter but not read back the same


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Pain severe headache, neck pain, face pain can result

from hemorrhage or ischemic stroke orcomplications of stroke

adhesive capsule, rotator cuff tear, reflex sympatheticdystrophy, entrapment of ulnar, median or peronealnerves, pressure ulcer or contractors

neurogenic pain - usually involves the thalamus, may notappear for weeks of months post-stroke; involvescontralateral half of body; may be intense and relentless;spontaneous recovery is rare.


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Dysphagia (swallowing disorders) may be due to dysfunction of lips, mouth, tongue,

palate, pharynx, larynx or proximal esophagus deficits can occur with any phase of swallowing assessment essential before any PO fluids given


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dysphagia in stroke: frequent complication of stroke

resolves fairly rapidly in most pts following stroke detected in 30-65% of persons with stroke small number of persons have clinically silent

aspiration of food/fluids

responsible for aspiration pneumonia, infection andairway obstruction.


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Anatomic landmarks - pharynx & larynx


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Phases of normal swallowing


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Swallowing - complex act involvingcoordination activity of mouth, pharynx, larynx& esophagus

four phases of swallowing: oral preparatory oral propulsive

pharyngeal esophageal


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Oral preparatory processing of the bolus to render it swallowable

oral propulsive propelling food from oral cavity into oropharynx

pharyngeal phase soft palate elevates; hyoid bone & larynx move upward &

forward

vocal folds move up to midline & epiglottis folds backward to protect airway

contd


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Tongue pushes backward and downward into pharynx to propel bolus down assisted by pharyngeal walls whichmove inward with a progressive wave of contraction fromtop to bottom

upper esophageal sphincter relaxes during pharyngeal phase of swallowing & is pulled open by forwardmovement of hyoid bone & larynx

sphincter closes after passage of food; pharyngealstructures return to reference position


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Esophageal phase bolus moved downward by peristaltic wave lower esophageal sphincter relaxes and allows propulsion

of bolus into stomach closes after bolus enters the stomach preventing

gastroesophageal reflex


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Assessment: careful pharyngeal & laryngeal nerve exam; testing

of facial muscles, tongue function & cough response observation during eating

dribbles from mouth; pockets food on one side of mouth coughs or chokes when swallowing drains food or liquid from nose

holds food in back of throat for long intervals c/o nasal burning or tickling of throat wet, hoarse voice; (dysphonia)


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Age-related changes that affect swallowing: reduced salivary gland secretion increased mastication required to prepare food increased time to prepare food bolus tendency to hold bolus on floor of mouth initially reduced laryngeal & hyoid bone elevation due to

drop in resting laryngeal position slowing of pharyngeal contractions triggering of pharyngeal phase more posteriorly delayed triggering of pharyngeal phase - swallowing


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Radiographic evaluation modified barium swallow

small bolus volumes of different consistencies of food

videofluorographic swallowing study (VFSS) gold standard for evaluating mechanism of swallowing pt given food mixed with barium to make radiopaque eats & drinks while radiographic images are observed by

physician and speech-language pathologist demonstrates anatomic structures, motion of structures &

passage of food


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Bowel and/or bladder disturbances: urinary incontinence

inattention, mental status change, immobility, bladderhyperreflexia, or hyporeflexia

disturbances of sphincter control or sensory loss all evaluated to identify treatable conditions (UTI) do not use/remove catheter as soon as possible


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Evaluation - best language pt identifies standard groups of objects & reading

series of sentences first response only is measured if corrects self later, response still considered

abnormal read three sentences from a page of sentences

continued


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Scoring: 0=no aphasia - able to read sentences well & able to

correctly identify objects on paper 1=mild aphasia -mild to moderate naming errors,

word finding errors, mild impairment incomprehension or expression

2=severe aphasia - difficulty in reading as well asnaming objects; pts with either Brocas orWenickes aphasia

3=mute


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Evaluation - dysasthria: ask pt to read and pronounce standard list of words. If unable to read words because of visual lost, say

the word and have pt repeat if severe aphasia, clarity of articulation of

spontaneous speech should be rated


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Score: 0=normal articulation - able to pronounce words

clearly and without problems with articulation 1=mild to moderate dysarthria - problem with

articulation; mild to moderate slurring of wordsnoted; can be understood with some difficulty

2=near unintelligible or worse - speech so slurred asto be unintelligable

9=untestable - endotracheal tube, mute


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post stroke rehab summer

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