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

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

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

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

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

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

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

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

9. Available levels of care –Acute inpatient rehab (acute days) most aggressive treatment all disciplines on team & weekly team meetings criteria (1 or more pertinent disabilities) –mobilityADLs –bowel/bladderswallowing –pain managementable to learn –adequate endurance (sit 1 hr & participates in programs)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

51. 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

52. –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

53. –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.

54. –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

55. –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.

56. Anatomic landmarks - pharynx & larynx

57. Phases of normal swallowing

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

59. 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

60. –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

61. 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

62. –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)

63. –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

64. –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

65. –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

66. –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

67. –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

68. –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

69. –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