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

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
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.
• Initial goals of therapy & rehab include:
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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 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
• 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
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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:
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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)
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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):
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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 cont’d
• 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
• cont’d
– 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
• 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
• 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
• Conduction aphasia
– probably a variant of Wernicke’s 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:
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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:
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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
• cont’d
– 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
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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:
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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 Broca’s or
Wenicke’s 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