Post-Stroke Rehabilitation

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

 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.

 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

 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

 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

 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

 comorbidities in stroke patients:

hypertension & hypertensive heart disease coronary heart disease obesity diabetes mellitus arthritis left ventricular hypertrophy congestive heart failure

 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

 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)

 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

 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

 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

 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

 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.

 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

 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

 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

 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.

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

 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

 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

 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)

 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.

 Cognitive disorders:
disorders of higher brain function common poststroke 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

 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

 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

 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

 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

 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

 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

 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

 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

 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

 Assessment:
test normal side first 0=absent - able to perform finger-to-nose & heel-toshin 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.

 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.

 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.

 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

 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

 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)

 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

 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

 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

 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

 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.

 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

 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

 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)

 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

 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

 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

 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

 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

 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.

 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

 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.

 Anatomic landmarks - pharynx & larynx

 Phases of normal swallowing

 Swallowing - complex act involving coordination activity of mouth, pharynx, larynx & esophagus four phases of swallowing:
oral preparatory oral propulsive pharyngeal esophageal

 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

 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

 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

 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)

 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

 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

 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

 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

 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 in comprehension or expression 2=severe aphasia - difficulty in reading as well as naming objects; pts with either Brocas or Wenickes aphasia 3=mute

 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

 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 words noted; can be understood with some difficulty 2=near unintelligible or worse - speech so slurred as to be unintelligable 9=untestable - endotracheal tube, mute