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Abstract
The 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 w ords: Cerebrovascular accident Contracture Musculoskeletal
abnormalities Stroke Disease management Nursing rehabilitation
Patient positioning
Stroke
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Figure 1. Exercising finger digits in the affected limb: squeezing a rubber ball
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CARE PLANNING
sh o u ld e r (GHS)
H em iplegic sh o u ld e r
pain (HSP)
Earlier m obilisation
There 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 over
usage 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
C ontractures
Spasticity
g ra n d round
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Positioning in bed
Lying on the back
This 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 tw o 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
o f the hand facing upwards. The bed must be the
correct height to promote independence and safety
for the patient, family and healthcare workers.
Collaboration
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Continuing care
Currently, 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,
CARE PLANNING
Clinical governance
Nurses duty o f care requires work alongside allied colleagues
w ho normally provide impetus care in this area o f 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 o f so many patients following
a stroke. This should be the case regardless o f the situation or
environment in which a stroke patient is being cared for, i.e.
specialist unit or w ithin a general ward setting. Positioning
o f 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 o f 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). N IC E (2014) referred to a 2-hour period o f 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.
2 0 1 4 MA Healthcare Ltd
Conclusion
Many nurses position patients as part o f 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 o f muscular
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KEY POINTS
M usculoskeletal co m p lica tion s p ost stroke can include h e m ip le g ic shoulder
pain, spasticity, glenohum eral subluxation and contractures to the p a re tic/
p le g ic lim b
M usculoskeletal co m plications can cause pain, discom fort, depression, sleep
d e p riva tio n , p o o r sanitation and inadequate n utrition
Earlier m ob ilisation and correct p o s itio n in g o f the h e m ip le g ic lim b w ill
alleviate chronic d isco m fort, im m o b ility and pain to achieve effective
reh abilitation p ost stroke
A m usculoskeletal co m p lica tion assessment by the nurse could be easily
integrated w ith o th e r adm ission assessments fo r p ro vision o f a m ore accurate
physical p ro file for p o sitio n in g and rehabilitation planning
Ensuring tim e ly liaison w ith the m utlid iscip lin a ry team can facilitate a
m o re organised and integrated rehabilitation plan specific to the p a tie n ts
personality and needs
Nurses p re d o m in a n tly p ro v id e 2 4 -h o u r care and have the a b ility to ensure
th a t stroke patients receive o n g o in g , 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 E T (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)
786
10.1177/0269215508095089
M ant J, Wade DT, W inner S (2004) Health care needs assessment: Stroke.
In: Stevens A, Raftery J, M ant 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).
U K Stroke Survivor Needs Survey: Final Report. The Stroke Association, London
M ee 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 M H , 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 M M , Alibiglou L, Thajchayapong M, Rym er 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 /kr5m w zm (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 /m nxn7u9 (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. N IC E 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. N IC E guidelines [CG179].
http://tinyurl.com /odotpw v (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 , C h an Y 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. AustJ 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://w w w .sign.ac.uk/pdf/signll8.pdf (accessed 10 July 2014)
Seneviratne C ,T hen KL, Reim er 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 m otor 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)
T he 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) N ew 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) H ow much time do
nurses have for patients? a longitudinal study quantifying hospital nurses
patterns o f task time distribution and interactions w ith health professionals.
B M C Health Services Research 11: 319. doi:10.1186/1472-6963-11-319
Y oungJ (1994) Is stroke better managed in the community? C om m unity 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
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