Stroke Rehabilitation - UCI Health · PDF fileStroke Rehabilitation Presented by Karen Carlson OTR/L and Cathy Roys, PT, DPT . Neuroplasticity – Use it or lose it ... Patients with

Stroke

Rehabilitation

Presented by Karen Carlson OTR/L

and Cathy Roys, PT, DPT

Neuroplasticity

– Use it or lose it

– Use it and improve it

– 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

– Transference

– Interference

Importance of Early Mobilization

– Maintain cardiovascular endurance

– Neuroplasticity

– Orthostatic hypotension

– Minimize hemi spatial neglect

– Minimize visual deficits

– Minimize changes in muscle tone

– Balance training

– Trunk control

– Pt satisfaction

– Increased independence

– Family training

– Family involvement

Collaboration for Goals of Care

– 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

– Neuro Developmental Technique (NDT)

– Neuro-Integrative Functional Rehabilitation and Habilitation (IFRAH)

– Constraint Induced Movement Therapy (CIMT)

Patients with L Hemiplegia

– Performance style: Impulsive, denial of deficit, poor safety awareness, increased

fall risk, poor quality of learning

– Prior coping style: Pts may have been impulsive prior to stroke

– Poor orientation of midline

– Visual perceptual deficits

– Hemianopia

Positioning with L Hemiplegia

Patients with R Hemiplegia

– Performance style: Learning deficit influenced by communication loss,

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

Vision

– 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

Hemi Spatial Neglect

– Positioning for increased stimulation of neglected side

– 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

– Bed mobility

– Proper use of gait belt

– Transfers

– Ambulation

Range of Motion

– Upper Extremity: Shoulder and hand position

– Pt assisting with self range

– PROM Handout for UE (adaptive from Rancho)

– Lower Extremity:

Ankle and hip position

– Passive Range of Motion

(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

– Bed positioning in room to incorporate hemiplegic side

– 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

Positioning in Chair

– Chair positioning with family addressing from hemiplegic side

– Trunk positioning with blanket roll to maintain upright

– 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

– Paretic extremity in first and out last

– Bathing and dressing

– Encourage firm rubbing of hemi-paretic side

– Sensory stimulation

Bed Mobility

– Bed: Prior to movement max inflate bed

– Rolling: Towards weaker side

– Sitting balance: Address upright orientation

– 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

Getting OOB with Railing

Getting OOB no Railing

Getting into Bed without Railing

Bed Mobility with Assist

Gait Belt

– When do I use it:

– Transfers and ambulation

– Where do I put it:

– Between hips and axilla at

smallest circumference

– Where do I hold it:

– Behind patient with one or both

hands

– How can it help me:

– 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

– Chair position:

– 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:

– Use seat deflate option to bring feet towards floor

– Place gait belt while sitting at EOB,

may need second person for support

– Staff member set up:

– Hands on gait belt

– Block hemi-paretic knee, foot assist

– Trunk on hemiplegic side

– Legs together or staggered

– Allow pt’s trunk and knees to move

forward during transfer

– Lift equipment: STEDY

Transfers: Squat Pivot (Maximal/Total A)

Transfers: Stand Pivot (1) (Minimal/Moderate Assist)

Transfers: Stand Pivot (2) (Minimal/Moderate Assist)

Transfers: Using a Device (Minimal Assist)

Transfers: Things to Avoid

Ambulation

– Prior to ambulating:

– Assess movement of hemiplegic leg

– 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:

– Self care, transfers, increase sitting endurance, potentially ambulation (may use

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

Questions

– Can send email to: [email protected]

– Asks a therapist on your floor for hands on assist if needing clarification