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stroke-rehabilitation.pdf
- 1. Stroke Rehabilitation Presented by KarenCarlson OTR/L and Cathy Roys, PT, DPT
- 2. Neuroplasticity – Use itor 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
- 3. Importance of EarlyMobilization – 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
- 4. Collaboration for Goalsof 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)
- 5. Rehab Techniques – Neuromuscularre-education – Neuro Developmental Technique (NDT) – Neuro-Integrative Functional Rehabilitation and Habilitation (IFRAH) – Constraint Induced Movement Therapy (CIMT)
- 6. Patients with LHemiplegia – 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
- 7. Positioning with LHemiplegia
- 8. Patients with RHemiplegia – 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)
- 9. Positioning with RHemiplegia
- 10. 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
- 11. 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
- 12. Demonstrations: R Hemiplegia –Range of motion – Positioning in bed – Positioning in chair – Self care principles – Bed mobility – Proper use of gait belt – Transfers – Ambulation
- 13. 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
- 14. 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
- 15. 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
- 16. Positioning with RHemiplegia
- 17. 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
- 18. 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
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- 21. Getting OOB withRailing
- 22. Getting OOB noRailing
- 23. Getting into Bedwithout Railing
- 24. Bed Mobility withAssist
- 25. Gait Belt – Whendo 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
- 26. 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
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- 28. Transfers: Stand Pivot(1) (Minimal/Moderate Assist)
- 29. Transfers: Stand Pivot(2) (Minimal/Moderate Assist)
- 30. Transfers: Using aDevice (Minimal Assist)
- 31. Transfers: Things toAvoid
- 32. Ambulation – Prior toambulating: – 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
- 33. Therapy in Settings (Typicalprogression) – 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
- 34. 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
- 35. Questions – Can sendemail to: croys@uci.edu – Asks a therapist on your floor for hands on assist if needing clarification