Post-Stroke Rehabilitation

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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 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

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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 decreased
  from 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 age 12 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 follow commands
• 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
  wrong answer 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)
  or attempts to use affected limb - both scored as
  a normal 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
  on orientation (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 movement or abnormal
  postures can occur
• face, upper extremity lower extremity can be
  involved alone or in combination continued

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• 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

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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 weaker
  than 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 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

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

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• 3no 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
• 4no movement - unable to move limb. No effort
  against gravity
• 9untestable - may be used only if limb is
  missing or amputated or if shoulder joint is fused

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

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• 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.

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• 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.

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

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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
  muted responses
• severely afflicted - deny problems or illnesses
  or may 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 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.

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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 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

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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
  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

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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 or
  complications of stroke
• adhesive capsule, rotator cuff tear, reflex
  sympathetic dystrophy, entrapment of ulnar,
  median or peroneal nerves, pressure ulcer or
  contractors
• neurogenic pain - usually involves the thalamus,
  may not appear for weeks of months post-stroke
  involves contralateral 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
  and airway obstruction.

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• Anatomic landmarks - pharynx larynx

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• Phases of normal swallowing

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• Swallowing - complex act involving coordination
  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
  which move inward with a progressive wave of
  contraction from top to bottom
• upper esophageal sphincter relaxes during
  pharyngeal phase of swallowing is pulled open
  by forward movement of hyoid bone larynx
• sphincter closes after passage of food
  pharyngeal structures 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,
  bladder hyperreflexia, 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
• 0no aphasia - able to read sentences well able
  to correctly identify objects on paper
• 1mild aphasia -mild to moderate naming errors,
  word finding errors, mild impairment in
  comprehension or expression
• 2severe aphasia - difficulty in reading as well
  as naming objects pts with either Brocas or
  Wenickes aphasia
• 3mute

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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
• 0normal articulation - able to pronounce words
  clearly and without problems with articulation
• 1mild to moderate dysarthria - problem with
  articulation mild to moderate slurring of words
  noted can be understood with some difficulty
• 2near unintelligible or worse - speech so
  slurred as to be unintelligable
• 9untestable - endotracheal tube, mute

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