Stroke Rehabilitation

Stroke RehabilitationNeuroplasticity
– Specificity matters
– Repetition matters
– Intensity matters
Jeffery Kleim and Theresa Jones. Principles of Experience-Dependent Neural Plasticity: Implications for Rehabilitation After Brain Damage. Journal of SLH Research. Vol 51: S225-S239. Feb 2008
– Time matters
– Salience matters
– Age matters
– Balance training
– Trunk control
– Pt satisfaction
– Increased independence
– Family training
– Family involvement
– Importance of patient and family input for goals of therapy
– Importance of patient and family participation towards goals
– Use of white board for daily goals or goal cards
– Interdisciplinary communication of goals, expectations, and involvement
(Nursing, physician, therapists, case management, social workers)
Rehab Techniques
– Neuromuscular re-education
– Constraint Induced Movement Therapy (CIMT)
Patients with L Hemiplegia
fall risk, poor quality of learning
– Prior coping style: Pts may have been impulsive prior to stroke
– Poor orientation of midline
emotionally labile, depression
– Prior coping styles
– Reduce distractions, one person cueing, noise to a minimum, TV off
– Hemianopia
– Receptive or global aphasia teach by demonstration and/or simple cues
(Contact the SLP for best way to communicate with pt)
Positioning with R Hemiplegia
– Homonymous hemianopia (visual field cut)
– Approach from hemi side and establish visual contact, if still having difficulties
then approach from non hemi side
– Consider bed positioning to allow maximal stimulation from hemi side
– Diplopia (double vision): allow maximal input to visual system
– No full eye patching, okay to patch on top of eye glasses, switch sides during day (2
glasses) ask OT department for glasses or use safety goggle
– Cortical blindness
– Midline orientation
– Education to family to address pt from neglected side
– Tactile input to neglected limbs
– Environmental stimulation for neglected side
– Perform transfers to strong side
Demonstrations: R Hemiplegia
– Range of motion
– Positioning in bed
– Positioning in chair
– Self care principles
– Transfers
– Ambulation
– Pt assisting with self range
– PROM Handout for UE (adaptive from Rancho)
– Lower Extremity:
(Pages 6-8 for the legs)
Best positioning: Flat on back, bed railing down, stand close to pt
Repetitions: 2-3 good slow stretches are better than 10 fast partial
Time to perform: 10 minutes to 45 minutes
Positioning in Bed
– Head positioning with towel roll
– Hemiplegic arm elevated above heart
– Hand with wash cloth roll
– Leg positioning with trochanter roll
– Foot positioning with Foothold boots vs Skil-Care heel float vs pillow for
positioning
– Hemiplegic arm supported on bedside table
– Legs in neutral position can use blanket roll to assist
– Feet flat on floor
Positioning with R Hemiplegia
Self Care Principles
– Encourage the use of the hemiplegic hand, if cannot do by self, then utilize hand over hand enablement
– Grooming, holding emesis basin, eating with hand on tray and cup in hand
– Dressing techniques
– Bathing and dressing
– Sensory stimulation
Bed Mobility
– Rolling: Towards weaker side
– Foot stool if feet are not touching ground
– If pt is pushing or leaning to one side, you can sit next to them
– Eyes open and focusing on vertical object in front of them
– Weight shifting for scooting forward
– Do not proceed to transfer if cannot easily sit at EOB
Rolling with(out) Assist
Rolling with Handrail
Bed Mobility with Assist
– Transfers and ambulation
smallest circumference
– Behind patient with one or both
hands
– Weight shifting, preventing falls
– How can I tell that it is tight enough:
– Enough space for your hands, but not enough space to move up or down
– How do I use this when the pt has drains:
– Depending on location of drains, can use higher or lower
– How do I use this when the pt is obese, breast tissue, rib fractures, surgical incisions
– Avoid painful areas, lift breast tissue when tightening belt, move gown material out of the way
Transfers
– Set up prior to transfer on pt’s strong side
– Set up chair with pillow, sheet, and chucks
– Line management:
– Place IV lines, catheters, and monitor cables in a position that allows a clear path for transfer
– Bed:
– Place gait belt while sitting at EOB,
may need second person for support
– Staff member set up:
– Hands on gait belt
– Trunk on hemiplegic side
– Legs together or staggered
forward during transfer
– Lift equipment: STEDY
Transfers: Stand Pivot (1) (Minimal/Moderate Assist)
Transfers: Stand Pivot (2) (Minimal/Moderate Assist)
Transfers: Using a Device (Minimal Assist)
Transfers: Things to Avoid
– Cannot lift against gravity = unable to support body weight
– Knee will either collapse or have a knee extension thrust
– Can my patient perform a transfer without buckling or an extension thrust:
– Yes: Proceed to walking (check with therapist for proper device)
– No: Perform transfer only, do not progress to ambulation
– If ambulation is necessary: use gait belt, tie gown base to observe knee, use hand on their knee to prevent collapse, use a second person for line management, follow with chair or WC
– Just because a pt can walk, does not mean that they should walk
– Does my pt have strong legs, but a weaker arm?
– Modify FWW by adding build up, may also need manual assist
Therapy in Settings (Typical progression)
– Intensive Care Unit:
– ROM by self, visual rehab, sensory stimulation, sitting balance, potentially transfers,
changing bed into chair position to work on upright tolerance
– Step Down Unit:
railing), transfer on toilet vs commode
– Acute Rehabilitation Unit:
– WC based tasks ADLs progression to ambulation, stair training, community
reintegration, car transfers, care giver training, specialized equipment, fall recovery
References
– Medicare.gov
– CMS.gov
– Rehabnurse.org
– Stroke.org
– Kleim, J and Jones, T: Principles of Experience-Dependent Neural Plasticity: Implications for Rehabilitation After Brain Damage. Journal of SLH Research. Vol 51: S225-S239. Feb 2008
– Figueroa, J, Basford, J, and Low, P. Preventing and Treating Orthostatic Hypotension: Easy as A, B, C. Cleve Clin J Med. 2010 May;77(5):298-306.
– Occupational ToolKit
– Can send email to: [email protected]