-
2
014
MA
Hea
lthca
re L
td
CARE PLANNING
Preventing muscular contractures through routine stroke patient
careDiana De and Emma Wynn
I t is a sad fact that stroke is one of the top three causes of
death in the UK, 2030% of people who have a stroke die within a
month (National Audit Office, 2005; Scottish Intercollegiate
Guidelines Network, 2010). For those who do survive, stroke is a
leading cause of adult disability, often having a devastating
impact on the quality of lives for survivors and their families
(McKevitt et al, 2010). Lasting psychological effects charted by
Murray et al (2009) include stroke-associated loss of cognitive and
communication skills, depression and other mental health problems.
These can reduce the persons motivation to mobilise, resulting in
an exacerbation of any postural complications developed
post-cerebrovascular event. The long-term physical effects of
stroke complications can lead to chronic discomfort, immobility and
pain. These can result in sleep deprivation, poor sanitation and
inadequate nutrition. These additional impediments can be
infuriating for stroke patients, who for the majority of their
lives would have been independently mobile and self-caring, and can
compromise an effective rehabilitation programme (Turtan and
Britton, 2005). They can also contribute to an increased demand on
health and social care resources, a reduction in the persons
quality of life experience, and, foremost, a lifetime dependency on
others. From a financial perspective, the resulting higher-level
care at home and longer periods of hospital stay increase the costs
to the NHS and social care services (Lewis and Byblow, 2004). This
article focuses on the prevention of worsening physical
disability.
StrokeA cerebrovascular accident (CVA) or stroke can be caused
by a blood clot or a haemorrhage within the brain, often resulting
in long-lasting neurological deficits, affecting mobility,
cognition, sight or communication (Nair and Peate, 2009). Damage to
the descending pathways in the brain during a stroke causes spinal
motor neurons to lose their connection to muscles and the tendons
around them (Miribagheri et al, 2008). These early
pathophysiological changes can result in sudden degenerative
changes within those muscle and tendon mechanics, owing to both
muscular groups being underused following an acute neurological
injury (Young, 1994). This can be characterised in stroke patients
who may then be left with a reduction of muscle tone to the upper
and/or
Diana De, Senior Lecturer, Adult Nursing, University o f South
Wales; Emma Wynn, Staff Nurse, Intensive Care Unit, Guys and St
Thomas NHS Foundation Trust, London
Accepted fo r publication: Ju n e 2 0 1 4
AbstractThe aim o f this article is to elevate the standard o f
ward-based routine care by informing readers about the prevention
and management o f muscular contractures post-cerebrovascular
accident (CVA). Musculoskeletal complications can develop at any
time during the acute or latter stages o f stroke care and
rehabilitation; therefore, it is imperative that all nurses
understand the importance o f correct limb placement and some o f
the detrimental complications that can occur. By placing more onus
on therapeutic positioning and earlier mobilisation, nurses,
working alongside allied health professionals, can significantly
improve morbidity-related outcomes.
Key words: Cerebrovascular accident Contracture Musculoskeletal
abnormalities Stroke Disease management Nursing rehabilitation
Patient positioning
lower body extremities. This subsequently results in limited
mobility and can cause long-term disability (Baek et al, 2009).
Morbidity after a stroke affects at least 450000 people across
England (Department of Health (DH),2006). In Wales, a third of
people who have suffered a stroke are left with a long-term
disability (Welsh Government, 2012). Stroke has a more devastating
impact than any other chronic disease on the health of the UK
population, something that the World Health Organisation (WHO)
indicated back in 2004, in their Atlas of Heart Disease and Stroke
(Mackay et al, 2004).
Musculoskeletal complications: overviewHemiparesis (paralysis
down one side of the body, opposite to the haemorrhage/infarction
side within the brain) has long been known to be a direct
consequence of stroke, affecting more than 80% of survivors
(Sommerfield et al, 2004). The severity of a stroke determines the
amount of hemiparesis experienced by individual stroke patients and
it is hemiparesis that directly affects the other confounding
musculoskeletal complications outlined in this section.
Shoulder/glenohumeral subluxation (GHS) is where the humeral
head partially separates from the glenoid cavity, leading to
additional muscle and soft tissue strain around the shoulder
(Herding and Kessler, 2006). GHS has been reported to occur in up
to 84% of all hemiparetic stroke patients by Seneviratne et al
(2005). Hemiplegic shoulder pain (HSP), reported from 2 weeks to 1
year post stroke, is also reported to occur in up to 84% of cases
(Rajaratnam et al, 2007). Spasticity, an additional musculoskeletal
complication, which results in uncontrolled and discomfited
movements,
British Journal of Nursing, 2014, Vol 23, No 14 781
-
Figure 1. Exercising finger digits in the affected limb:
squeezing a rubber ball
Figure 2. Supporting patients under the arm when mobilising is
common
is considered to occur as a result of increased or decreased
overall muscle tone. This affects around 1739% of stroke patients,
approximately 3 months post stroke, with 3860% affected 1 year on
according to Lundstrom et al (2008). Some reports of spasticity
have even been documented as early as 1 week post stroke (Malhotra
et al, 2008).This demonstrates that the development of
complications can begin immediately post stroke, emphasising the
need for timely instigation of specialist rehabilitative care and
positioning. Abnormal leg and arm postures induced by spasticity
and/or contractures (which represent abnormal shortening of muscle
resulting in distortion of joint and loss of movement) can also
create difficulties with sitting and mobilisation, and these
atypical postures can worsen as the severity of the disability
progresses. This makes activities of daily living, such as eating
and drinking, difficult to maintain. Sadly, examples of all of
these muscular-induced difficulties (Table 1), have been detailed
throughout a range of clinical settings, but occur less in the
specialised acute and rehabilitation stroke environments referred
to earlier. However, more recently,
individual recovery following an acute stroke has been shown to
be significantly enhanced if specialist therapy and wider social
care support packages can be instigated in a timely manner
(Griffiths, 2012).
Stroke care and managementAccording to the Stroke Association
(2010), someone suffers a stroke in England every 5 minutes, yet a
certain degree of reassurance can be found in the knowledge that
most UK hospitals nowadays contain a designated stroke unit. An
organised stroke unit is a hospital provision coordinated by a team
of doctors, nurses and therapists who specialise in looking after
stroke patients, often sharing infrastructure with hyperacute
services (a conglomeration of governmental, NHS and stroke
charities working to enhance best quality specialist services).
According to The Cochrane Collaboration(2013) , stroke patients who
receive organised inpatient care in a stroke unit are more likely
than outliers to survive their stroke, return home and become
independent in looking after themselves. This is good news for
those being admitted to such institutions of excellence. However,
what if you are a nurse caring for a stroke patient who was not
fortunate enough to have been admitted to a specialised stroke
unit? National clinical guidelines (Mant et al, 2004) uncovered
that, during a typical weekday, more than half of all stroke
patients were being cared for on a specialised stroke unit.
However, implications will remain for those patients being nursed
elsewhere, as these outliers may not always be subjected to stroke
intervention targets. This particular group of patients who are
admitted elsewhere in the hospital and away from a specialist unit
could appear to be at increased risk of developing poor
posture-related complications. Interestingly, Indredavik et al
(1999) identified a shorter time to mobilisation/physical training
as the most important factor affecting the discharge to home period
in a stroke unit; this was found to be longer in a general ward
setting.Thus, all ward-based nurses (and healthcare assistants),
need to understand the importance of early mobilisation and
rehabilitation, as well as the potentially detrimental effects that
can occur as a result of lack of appropriate positioning for any
patient who has experienced a stroke, and the potential to improve
care and patient outcomes by being more involved needs to be
realised.
Activity after stroke and contracture preventionSystematic
reviews by Field et al (2013) andVeerbeek et al(2014) recognise
physical activity to be beneficial following a CVA and uncovered
strong evidence for stroke patient interventions favouring
intensive, highly repetitive, task- orientated and task-specific
training in all phases post stroke. Meta-analysis (Evidence Based
Review of Stroke Rehabilitation (EBRSR), 2014) showed significant
positive effects for 13 interventions relating to gait, 11
interventions relating to arm-hand activities, 3 interventions for
physical fitness and another related to activities of daily living.
3 However, EBRSR (2014) also acknowledged that poorer J walking
ability, specific sensory motor functions, and low J mood were
found to be correlates for low levels of ;
o
physical activity affecting individual recovery. The
therapeutic
782 British Journal o f Nursing, 2014, Vol 23, No 14
-
2
014
MA
Hea
lthca
re L
td
CARE PLANNING
relationship between a nurse and patient could, therefore,
provide a much-needed motivational impetus to improve some of these
aspects that may hinder rehabilitation regimes.
Social stim ulationStudies have uncovered the unfortunately
small amount of time ward nurses actually spend interacting with
their stroke patients, despite their continuous presence (Moran et
al, 2009; Westbrook et al, 2011). This often results in long
periods of loneliness for the recovering patient
(Huijben-Schoenmakers et al, 2009). Bernhardt et al (2004) found
that stroke patients spend more than 60% of their therapeutic day
alone, often partaking in passive pursuits such as lying down or
watching television (Jones et al, 1998). Although time constraints
and stafF shortages can be an obstacle to all those responsible for
resource management, it is imperative that these constraints do not
affect the quality of any patients care during that crucial
rehabilitative period. Ward-based nurses need to collaborate and
find ways of increasing social stimulation. For example, a nurse
entering a bay or a telephone ringing could well provide enough of
a stimulus for a mobile stroke patient to reposition themselves or
exercise their affected limb independently (Figure 1). Thus,
multidisciplinary care plans, which incorporate these types of
mutually inclusive goals, could improve the overall quality of care
received and perceived by the service user and their families.
Earlier m obilisationThere is general consensus within the 16th
edition of the EBRSR (2014) that early mobilisation of a limb is
essential in the prevention of post-stroke complications in
agreement with the National Institute of Health and Care Excellence
(NICE) (2008) Stroke: diagnosis and initial management guidelines.
However, this must be balanced with the need to avoid overusage of
limb mobilisation. Lang et al (2007) observed that patients use
their ipsilateral arm (stronger) for a period of 8.4 hours per day
compared with the paretic arm (weaker) used for only 3.3 hours.
Mobilisation plans could be based on these given times and adjusted
to the expectation of the individual patient. For example, a
labourer may use their arms more, a pensioner may use them less. It
should be noted that over-using the ipsilateral arm for undertaking
most activities of daily living in turn can exacerbate further
weakness in the paretic arm over time. This is caused by dystonia,
which often relates to a painful range of movement disorders,
causing involuntary spasms and/or muscular contraction, and which
has been linked to impairments within central sensory integration
after CVA (Meskers et al, 2005).Therefore, earlier mobilisation and
emphasis on the importance of using both limbs needs to be
advocated in order to benefit the patients overall reduced mobility
(van Wijk et al, 2011; Askim et al, 2012). Knowledge of this may
reassure nurses and healthcare assistants about encouraging
patients to participate more in their day-to-day activities, such
as when reaching for objects, walking to the toilet, sitting out of
bed, standing and walking to the day room (Bernhardt et al, 2008).
However, nursing staff need to refrain from supporting a patient
under the arm (Figure 2) when mobilising them as this tends to
cause significant injury and pain to the hemiparetic/plegic arm
of
Table 1. M uscular-induced difficulties
G lenohum eral subluxation of th e shoulder (GHS)
Flaccid paralysis of th e affected side p reven ting m uscles
from stabilising th e shoulder correctly
H em iplegic shoulder pain (HSP)
The w eigh t of th e paretic arm and loss of m uscular su p p o
rt affects this type of shoulder pain frequently experienced w ith
stroke, causing hem iplegia
C ontractures Immobilisation of th e affected arm causes th e
fibro- ad ipose connective tissue to proliferate and occupy the
joint space, causing a contracture
Spasticity Resistance to stre tch a limb d u e to increase
hypertonicity
Nursing and midwifery grand round
All nurses/m idw ives by email
the stroke patient. Thus, earlier mobilisation of both limbs
could be seen to reap rewards for the patient, but it needs to be
based on sound patient assessment.
A s s e s s m e n tAccording to the stroke pathway guidance
(NICE, 2010), all patients admitted to a stroke unit should be
assessed and managed by stroke nursing staff and at least one
member of the specialist rehabilitation team within 24 hours of
admission to hospitalas well as by all relevant roles within the
specialist rehabilitation team within 72 hours, with documented
multidisciplinary goals agreed within 5 days of admission to
hospital. As per the Royal College of Physicians (2008) national
clinical guideline for stroke, outlying patients on general wards
are being seen by a physiotherapist within 24 hours and
occupational therapist within 72 hours post admission. However,
these assessments are often carried out without any nursing
input.
An early assessment facilitates initial hospital management and
prevention of musculoskeletal complications, thus improving overall
motor recovery, functional independence and quality of life for
patients (Zeferino and Aycock, 2010). Within the majority of
hospitals across the UK, the initial assessment of musculoskeletal
complications is predominantly undertaken by specially trained
physiotherapists and/or occupational therapists with assessment
beginning when the therapist is available. This may not be
immediate (Vuadens et al, 2005).The authors felt that ward nurses
could enhance this particular assessment process and reduce target
times further if they were included as part of a wider stroke care
team. In comparison with the ward-based nurse, evidence suggests
that those other allied health professionals only spend a
relatively small amount of time with stroke patients (Bernhardt et
al, 2007). Physiotherapists and occupational therapists have been
observed trying to create an assessment profile for a stroke
patient with a speech impediment during a time when relatives (who
were present on admission and who could have supplied supplemental
information to the admitting nurse) have left the premises. An
important role for a nurse in this situation is to provide
admission and observation information to the allied health
professional to assist in their assessment profile and to identify
which muscular contractures the patient may be at risk of
developing in a timelier manner and instil the correct
positioning.
British Journal o f Nursing, 2014,Vol 23, No 14 783
-
Positioning in bed
Lying on the backThis is the position most likely to encourage
spasticity, but some patients do like to lie on their back for a
while and it will be required for some treatments. Place two
pillows under the patients head and help him bend his head slightly
towards his unaffected shoulder and gently turn his head towards
his stroke side but do not use force.A small pillow is placed under
the buttock of the stroke side and should extend just to the knee;
this will relax the leg and prevent it turning out at the hip. A
pillow is placed under the stroke arm which is kept straight at the
elbow and, if possible, the palms of the hand facing upwards. The
bed must be the correct height to promote independence and safety
for the patient, family and healthcare workers.
This should always be encouraged w ith the stroke shoulder well
forward so that the body weight is supported on the flat of the
shoulder blade and not on the point o f the shoulder. Place the
stroke leg w ith the thigh so that it is in line with the trunk,
and bend the knee slightly. The unaffected leg should be brought
forward and placed w ith the knee bent on a pillow in front o f the
affected leg for comfort. This prevents the patient rolling onto
his back. Lastly, bend the head forward a little.
Lying on the unaffected sideAgain, the stroke arm should be well
forward, keeping the elbow straight and supported on a pillow. The
stroke leg should be brought far enough in front o f the body to
prevent the patient rolling onto the back, the knee bent and leg
supported on a pillow. A small pillow can then be placed under the
patients waist to maintain the line o f the spine. When lying on
the side position, the patient should have tw o pillows only under
the head.
Sitting position in a chairThe patient should sit upright well
back in the chairand should not slump to one side.A table should be
used to support the stroke arm which then rests on a pillow. The
arm should be positioned w ith palm facing downwards, fingers and
thumb straight and elbow straight. The stroke leg may need to be
supported by a pillow beneath the buttock on the stroke side to
prevent the knee rolling outwards and so keep the foot flat. The
occupational therapist w ill advise on the appropriate type of
chair for safety and independence.
Figure 3. Avoiding tile pitfalls o f poor positioning
Lying on the stroke side
CollaborationSimply cooperating more closely and transparently
with other allied health professionals can enhance nursing
knowledge of affected musculoskeletal complications and correct
positioning. Perhaps in an outreach type of role, experienced
stroke unit nurses, physiotherapists and occupational therapists
could share information and stress the importance and benefits of
early mobilisation and limb positioning to ward-based nursing and
ancillary staff. Simply reiterating, for example, during handover
that specific intervention during the acute phase after stroke
improves motor recovery emphasises the potential beneficial effect
of therapeutic interventions for the affected arm (Feys et al,
1998). This may prompt ward staff to reflect on their current
practice and consider a more
informed approach towards aiding pressure relief care in the
future. Results from a quasi-experimental study by Jones et al
(1998) showed that although it was possible to effect a degree of
change in nurses knowledge and awareness of the practice of
positioning following the attendance of a set of formal teaching
sessions, the quality of patient positioning still remained
variable. The study concluded that more effective ways of improving
positioning need to be developed.
More inclusion of pictorial or prescribed manoeuvres may serve
to guide ward nurses via an integrated care plan and direct them to
gain appropriate rehabilitation support resources. More direct
approaches in undergraduate and postgraduate nursing programmes
such as clinical simulation titled, for example, Stroke Care: how
to optimise positioning of the hemiplegic patient in order to
prevent muscular contractures, may benefit current and future
nursing practice. Involving service user and specialist allied
healthcare individual participation may also enhance the delivery
of these types of sessions. This and further research is vital for
inspiring ward nurses and nurse educators to influence, develop and
improve stroke patients quality of care. Close guidance and
supervision by therapists could instil ward nurses with the
confidence to implement better risk management of muscular
contractures, patient safety and overall clinical outcomes for
their stroke patients.
Practical advice: to move or not to moveCorrect limb positioning
requires particular attention to both upper and lower extremities
to prevent or manage further musculoskeletal complications (Mee and
Bee, 2007). Unfortunately, practical advice about repositioning
affected limbs does not tend to be promoted well in most
traditional nursing care plans or preregistration nursing
programmes. Supplementary guidance from specially trained
rehabilitation therapists and national guidelines such as NICE
(2013) are necessary to inform best practice. Ward-based nurses
need to be instilled with the latest evidence-based knowledge,
skills and confidence to implement effective limb positioning and
effective rehabilitative care for stroke patients, as they often
refrain as a result of the fear of doing something wrong or of
causing pain and distress to a relatively new stroke patient.
Optimal rehabilitative care delivery needs to be free from
conflicting advice, as this could be hampering current practice and
mobilisation efforts from being implemented with stroke patients
undergoing general ward-based care.
Continuing careCurrently, ward-based nursing appears to be
predominantly focused on completing nutritional, skin integrity,
falls and swallowing assessments (Chamanga, 2010), with little
regard given to preventing musculoskeletal complications. Assessing
musculoskeletal complications would require a shift in cultural
thinking, but could lead to timelier care planning for earlier
mobilisation and optimal patient positioning. Nurses could play a
greater role in the 24-hour regime and maintenance that contracture
prevention requires and which therapists are not able to provide.
Repetitive movements have long been a key aspect of motor learning,
strengthening the connections between neurons following a stroke
(Hebb,
784 British Journal of Nursing, 2014, Vol 23, No 14
2
014
MA
Hea
lthca
re L
td
-
20
14 M
A H
ealth
care
Ltd
CARE PLANNING
1949). The most effective rehabilitation plan would require the
nurse to collaborate with the multidisciplinary team during
continuous assessment and management of the stroke patients
musculoskeletal complications to ensure reduced discomfort and an
effective enforcement of both management and treatment. It has long
been seen that continuity is vital when observing improvements or
changes in the patient, both physically and psychologically (Wade
and Halligan, 2003). Nurses provide a 24-hour presence from
admission to discharge (Perry et al, 2004). This continuity means
that nurses know their patients and, therefore, are well-placed to
encourage the prevention o f muscular contractures. The development
of a therapeutic nurse-patient relationship starts during
admission. During this phase, the nurse is able to observe the
patient noting any stroke-affected musculoskeletal complications
that may interfere with a patients activities of daily
living.Therefore, developing a more integrated, multidisciplinary,
holistically inclusive assessment/management tool may contribute to
nurses providing a more accurate physical profile and could enhance
future follow-on rehabilitative care. This is not a novel idea:
Lincoln et al (1996) advocated that all staff should be trained to
place patients in positions to reduce the risks of complications
such as contractures, respiratory complications and pressure
sores.
Clinical governanceNurses duty of care requires work alongside
allied colleagues who normally provide impetus care in this area of
stroke rehabilitative care to maintain quality
assurance.Physiotherapists and occupational therapists can help
improve insufficient knowledge gaps regarding musculoskeletal
complications. Nevertheless, all o f those involved in the
implementation o f intentional rounding (Box 1) need to be made
aware that they can become key players towards prevention and
management o f debilitating muscular contractures, which impinge on
the quality o f life of so many patients following a stroke. This
should be the case regardless of the situation or environment in
which a stroke patient is being cared for, i.e. specialist unit or
within a general ward setting. Positioning of the stroke patient
requires more than simply turning the patient from side to side in
order to alleviate pressure. A decision about how long it is safe
to leave a stroke patient sitting in a chair should be based on
their general medical condition as well as the results of skin
inspection (Benbow, 2008). Effective positioning should involve
specific attention to both upper and lower extremities, to prevent
or manage newly attained musculoskeletal complications (Mee and
Bee, 2007). NICE (2014) referred to a 2-hour period of sitting
which, in many cases, will be the maximum that the bodies o f
older, ill patients will tolerate, both physiologically and
psychologically. However, this may not be achievable on all
stroke-care settings, such as within the community.
ConclusionMany nurses position patients as part of a daily
routine. However, they may not always be conscious o f the
therapeutic advantages or disadvantages positioning has on
musculoskeletal complications. This article aimed to supplement the
knowledge o f everyday ward-based routine care for stroke patients.
By informing practice in the prevention of muscular
Box 1. Five key po in ts o f in ten tio na l round ing
Concerns about essential nursing care have drawn attention to
ensuring
fundam ental care is delivered reliably
Intentional round ing involves health professionals carrying ou
t regular checks
w ith ind ividual patients at set intervals
The approach helps nurses focus on clear, measurable aims for
undertaking the
round It also helps fron tline teams to organise workloads on
the w ard
Rounding can reduce adverse incidents, o ffer patients greater
com fort and ease
the ir anxiety
Source: Fitzsimons e t al, 2011
contractures post cerebrovascular accident (CVA) through better
limb positioning and earlier mobilisation, it is hoped that there
will be closer multidisciplinary team working and reduced
complications. With ward staff perhaps gaining some reassurance
from the evidence presented here that early mobilisation of
affected limbs is not always perceived as being detrimental to
stroke care, the more conscious nurse and ancillarys awareness
could significantly enhance rehabilitative care and correct limb
positioning.
A distinct lack o f nursing research available on
musculoskeletal complications, positioning and early mobilising
stroke patients was unearthed. Also highlighted was the lack of
specific nursing guidance and protocols for musculoskeletal
complications for the stroke patient being nursed outside the
specialist stroke unit, which was surprising as stroke patients are
cared for across primary and secondary settings with these
complications often witnessed.The majority of stroke positioning
research is carried out by physiotherapists and occupational
therapists, so generalisation to nurses can be taken with caution
until more current research becomes available for determining the
most effective positions to enhance stroke patient recovery and
avoiding the pitfalls o f poor positioning (Figure 3).
In the meantime, future work on the development of educational
manual handling programmes, which could be delivered to nurses in
conjunction with allied physiotherapy colleagues, could benefit
many ward-based nursing teams across hospitals and even those based
in community settings.Expertise should be shared for the greater
good. Envisaging the development o f a stroke unit outreach-type
advice service could be a successful bid to reduce further the
complication of muscular contractures. Under the guidance of an
informed nursing team, staff could quite easily provide the social
stimulation to enable stroke patients to mobilise limbs much
earlier or more frequently and remain in more optimal positions for
much lengthier periods, rather than only during times when the
specialist therapist visits the ward. IH 3
Conflict of interest: none.
AskiniT, Bernhardt J, Loge AD, Indredavik B (2012) Stroke
patients do not need to be inactive in the first two-weeks after
stroke: results from a stroke unit focused on early rehabilitation.
Int J Stroke 7(1): 25-31. doi: 10.1111/j.1747- 4949.2011.00697.x.
Epub 2011
Baek JH , Kim JW, Kim SY, O h DW, Yoo EY. (2009) Acute effect o
f repeated passive motion exercise on shoulder position sense in
patients with hemiplegia: a pilot study. NeuroRehabilitation
25(2):101-6. doi: 10.3233/NRE-2009-0504
Benbow M (2008) Pressure ulcer prevention and pressure-relieving
surfaces. Br J Nurs 17(13): 830-5
Bernhardt J, Dewey H, Thrift A, Donnan G (2004) Inactive and
alone: physical activity within the first 14 days o f acute stroke
unit care. Stroke 35(4): 1005-9
British Journal of Nursing, 2014, Vol 23, No 14 785
-
KEY POINTS
Musculoskeletal com plications post stroke can include hem ip
leg ic shoulder pain, spasticity, glenohum eral subluxation and
contractures to the paretic/ p leg ic lim b
Musculoskeletal com plications can cause pain, discom fort,
depression, sleep deprivation, poor sanitation and inadequate
nutrition
Earlier m obilisation and correct position ing o f the hem ip
leg ic lim b w ill
a lleviate chronic d iscom fort, im m obility and pain to
achieve effective rehabilitation post stroke
A musculoskeletal com plication assessment by the nurse could be
easily
integrated w ith o ther admission assessments for provision o f
a m ore accurate physical pro file for position ing and
rehabilitation planning
Ensuring tim e ly liaison w ith the m utlid iscip linary team
can facilitate a
m ore organised and integrated rehabilitation plan specific to
the patients personality and needs
Nurses predom inantly p rov ide 24-hour care and have the ab
ility to ensure that stroke patients receive ongoing, holistic
rehabilitation
Bernhardt J, Chan J, Nicola I, Collier JM (2007) Litde therapy,
litde physical activity: rehabilitation within the first 14 days o
f organized stroke unit care. J Rehabil Med 39(1): 43-8
Bernhardt J, Dewey H, Thrift A, Collier J, Donnan G (2008) A
very early rehabilitation trial for stroke (AVERT): phase II safety
and feasibility. Stroke 39(2): 390-6. doi:
10.1161/STROKEAHA.107.492363
Chamanga ET (2010) A critical review o f the Waterlow tool.
Journal of Community Nursing 24(3): 26-32
Department o f Health (2006) Essence of Care: Benchmarks for the
Fundamental Aspects of Care. D H, London, http://tinyud.com/qx8rdgq
(accessed 10 July 2010)
Dowswell G, Dowswell T, Young J (2000) Adjusting stroke patients
poor position: an observational study J Adv Nurs 32(2): 286-91
Evidence-Based Review o f Stroke Rehabilitation (2014)
Evidence-Based Review of Stroke Rehabilitation, 16th edn. EBRSR,
London, http://www.ebrsr.com/ (accessed 4 July 2014)
Feys HM, DeWeerdtWJ, Selz BE et al (1998) Effect o f a
therapeutic intervention for the hemiplegic upper limb in the acute
phase after stroke: a single-blind, randomized, controlled
multicenter trial. Stroke 29(4):785-92
Field MJ, Gebruers N, Sundaram TS, Nicholson S, Mead G (2013)
Physical Activity after Stroke: A Systematic Review and
Meta-Analysis. IS R N Stroke 2013: Article 464176:13 pages.
doi:10.1155/2013/464176
Fitzsimons B, Bartley A, Cornwell J (2011) Intentional Rounding:
Its Role in Supporting Essential Care. Nurs Times 107(27): 18-21.
http://tinyurl.com/ n473v86 (accessed 4 July 2014)
Griffiths L (2012) Message by the Minister for Health and Social
Services. In: Welsh Government. Together Against Stroke. Crown
Copyright, Cardiff, h ttp :// tinyurl.com/kc33kox (accessed 4 July
2014)
Hebb D O (1949) The Organization of Behaviour: A
Neuropsychological Theory. Tohn Wiley, New York
Herding D, Kessler R M (2006) Management of Common
Musculoskeletal Disorders: Physical Therapy Principles and Methods,
4th edn. Lippincott Williams & Wilkins, Philadelphia
Huijben-Schoenmakers M, Gamel C, Hafiteinsdottir TB (2009)
Filling up the hours: how do stroke patients on a rehabilitation
nursing home spend the day? Clin Rehabil 23(12): 1145-50. doi:
10.1177/0269215509341526
Indredavik B, Bakke F, Slordahl SA, Rokseth R , Haheim LL (1999)
Stroke unit treatment. 10-year follow-up. Stroke 30(8): 1524-7
Jones A, Carr EK, Newham DJ,Wilson-Barnett J (1998) Positioning
o f stroke patients: evaluation o f a teaching intervention with
nurses. Stroke 29(8): 1612-7
Lang CE, Wagner JM , Edwards DF, Dromerick AW (2007) Upper
extremity use in people with hemiparesis in the first few weeks
after stroke./ Neurol Phys Ther 31(2): 56-63
Lewis GN, Byblow W D (2004) Neurophysiological and behavioural
adaptations to a bilateral training intervention in individuals
following stroke. Clin Rehabil 18(1): 48-59
Lincoln NB, Willis D, Philips SA, Juby LC, Berman P (1996)
Comparison of rehabilitation practice on hospital wards for stroke
patients. Stroke 27(1): 18-23
Lundstrom E, Terent A, Borg J (2008) Prevalence o f disabling
spasticity 1 year after first-ever stroke. Eur J Neurol 15(6):
533-9. doi: 10.111 l/j.1468 1331.2008.02114.x
Mackay J, Mensah GA, Mendis S, Greenlund K (2004) The Atlas of
Heart Disease and Stroke. World Health Organization, Geneva
Malhotra S, Cousins E, Ward A, Day C, Jones P, Roffe C, Pandyan
A (2008) An investigation into the agreement between clinical,
biomechanical and neurophysiological measures o f spasticity
22(12): 1105-15. doi:
10.1177/0269215508095089Mant J, Wade DT, W inner S (2004) Health
care needs assessment: Stroke.
In: Stevens A, Raftery J, Mant J et al, eds. Health care needs
assessment: the epidemiologically based needs assessment reviews,
2nd edn. Radcliffe Medical Press, Oxford: 141244
McKevitt C, Fudge N, Redfern J, Sheldenkar A, Crichton S, Wolfe
C (2010).UK Stroke Survivor Needs Survey: Final Report. The Stroke
Association, London
Mee LY, Bee W H (2007) A comparison study on nurses and
therapists perception on the positioning o f stroke patients in
Singapore General Hospital, lnt J Nurs Prod 13(4): 209-21
Meskers CG, Koppe PA, Konijnenbelt MH, Veeger DH, Janssen T W
(2005) Kinematic alterations in the ipsilateral shoulder o f
patients with hemiplegia due to stroke. Am J Phys Med Rehabil
84(2): 97-105
Mirbagheri MM, Alibiglou L, Thajchayapong M, Rymer W Z (2008)
Muscle and reflex changes with varying jo in t angle in hemiparetic
stroke.! Neuroeng Rehabil 5(6): 1-16
Moran A, Scott A, Darbyshire P (2009) Communicating with nurses:
patients views on effective support while on haemodialysis. Nurs
Times 105(25): 22-5. http://tinyurl.com/nfew2ug (accessed 4 July
2014)
Murray J, Young J, Forster A (2009) Measuring outcomes in the
longer term after a stroke. Clin Rehabil 23(10): 918-21. doi:
10.1177/0269215509341525
Nair M, Peate I (2009) Fundamentals o f Applied Pathophysiology.
An Essential Guide for Nursing Students. Wiley Blackwell, West
Sussex
National Audit Office (2005) Reducing Brain Damage: Faster
access to better stroke care. Department o f Health, London,
http://tinyurl.com/kr5mwzm (accessed 4 July 2014)
National Institute for Health and Care Excellence (2008) Stroke:
Diagnosis and initial management o f acute stroke and transient
ischaemic attack (TIA) NICE guidelines [CG68]. NICE, London,
http://tinyurl.com/mnxn7u9 (accessed 4 July 2014)
National Institute for Health and Care Excellence (2010) Stroke
quality standard. NICE quality standards [QS2], NICE, London,
http://tinyurl.com/ mmq67eh (accessed 4 July 2014)
National Institute for Health and Care Excellence (2013) Stroke
rehabilitation: Long-term rehabilitation after stroke. NICE
guidelines [CG162], h ttp :// tinyurl.com/o2e9jlp (accessed 4 July
2014)
National Institute for Health and Care Excellence (2014)
Pressure ulcers: prevention and management o f pressure ulcers.
NICE guidelines [CG179]. http://tinyurl.com/odotpwv (accessed 10
July 2014)
Perry L, Brooks W, Hamilton S (2004) Exploring nurses
perspectives o f stroke care. Nurs Stand 19(12): 33-8
Rajaratnam BS,Venketasubramanian N, Kumar PV, Goh JC, ChanY H
(2007) Predictability o f simple clinical tests to identify
shoulder pain after stroke. Arch Phys Med Rehabil 88(8):
1016-21
Royal College o f Physicians (2008) Stroke - National clinical
guideline for diagnosis and initial management o f acute stroke and
transient ischaemic attack (TIA). RCP, London,
http://tinyurl.com/pykfz9z (accessed 15 July 2014)
Schurr K, Ada L (2006) Observation o f arm behaviour in healthy
elderly people: implications for contracture prevention after
stroke. Aust J Physiother 52(2): 129-33
Scottish Intercollegiate Guidelines Network (2010) Management o
f patients with stroke: Rehabilitation, prevention and management o
f complications, and discharge planning. A national clinical
guideline. SIGN, Edinburgh. http://www.sign.ac.uk/pdf/signll8.pdf
(accessed 10 July 2014)
Seneviratne C ,Then KL, Reimer M (2005) Post-stroke shoulder
subluxation: a concern for neuroscience nurses. Axone 27(1):
26-31
Sommerfeld DK, Eek EU, Svensson AK, Holmqvist LW, von Arbin M H
(2004) Spasticity after stroke: its occurrence and association with
motor impairments and activity limitations. Stroke. 35(1): 134-9.
Epub 2003
The Cochrane Collaboration (2013) Organised inpatient (stroke
unit) care for stroke, http://tinyurl.com/p5gl7y7 (accessed 10 July
2014)
The Stroke Association (2010) Stroke Association Manifesto
2010-2015. h ttp :// tinyurl.com/jwv5j53 (accessed 4 July 2014)
Turton AJ, Britton E (2005) A pilot randomized controlled trial
o f a daily muscle stretch regime to prevent contractures in the
arm after stroke. Clin Rehabil 19(6): 600-12
van Wijk R , Cumming T, Churilov L, Donnan G, Bernhardt J (2011)
An early mobilization protocol successfully delivers more and
earlier therapy to acute stroke patients: further results from
phase II o f AVERT. Neurorehabil Neural Repair 26(1): 20-6. doi:
10.1177/1545968311407779. Epub 2011
VeerbeekJM, van Wegen E, van Peppen R et al (2014) W hat is the
evidence for physical therapy poststroke? A systematic review and
meta-analysis. PLoS One 9(2): e87987. doi:
10.1371/journal.pone.0087987
Vuadens P, Barnes MP, Peyton R , Laurent B (2005) Spasticity and
pain after stroke. In: Barnes M, Dobkin B, Bogousslavsky J, eds.
Recovery after Stroke. Cambridge University Press, Cambridge:
286-320
Wade DT, Halligan P (2003) New wine in old bottles: the W H O
ICF as an explanatory model o f human behaviour. Clin Rehabil
17(4): 349-54
Welsh Government (2012) Together Against Stroke. Crown
Copyright, Cardiff.http://tinyurl.com/kc33kox (accessed 4 July
2014)
Westbrook JI, Duffield C, Li L, Creswick NJ (2011) How much time
do nurses have for patients? a longitudinal study quantifying
hospital nurses patterns o f task time distribution and
interactions with health professionals. BM C Health Services
Research 11: 319. doi:10.1186/1472-6963-11-319
YoungJ (1994) Is stroke better managed in the community?
Community care allows patients to reach their full potential. BMJ
309(6965): 1356-7
Zeferino SI, Aycock D M (2010) Poststroke shoulder pain:
inevitable or preventable? Rehabil Nurs 35(4): 147-51
786 British Journal o f Nursing, 2014, Voi 23, No 14
-
Copyright of British Journal of Nursing is the property of Mark
Allen Publishing Ltd and itscontent may not be copied or emailed to
multiple sites or posted to a listserv without thecopyright
holder's express written permission. However, users may print,
download, or emailarticles for individual use.