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Stroke

Rehabilitation

Presented by Karen Carlson OTR/L


and Cathy Roys, PT, DPT
Neuroplasticity

– Use it or lose it – Time matters


– Use it and improve it – Salience matters
– Specificity matters – Age matters
– Repetition matters – Transference
– Intensity matters – Interference

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
Importance of Early Mobilization

– Maintain cardiovascular endurance – Balance training


– Neuroplasticity – Trunk control
– Orthostatic hypotension – Pt satisfaction
– Minimize hemi spatial neglect – Increased independence
– Minimize visual deficits – Family training
– Minimize changes in muscle tone – 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 – Bed mobility

– Positioning in bed – Proper use of gait belt

– Positioning in chair – Transfers

– Self care principles – Ambulation


Range of Motion

– Upper Extremity: – Lower Extremity:


Shoulder and hand position Ankle and hip position
– Pt assisting with self range – Passive Range of Motion
– PROM Handout for UE (adaptive (Pages 6-8 for the legs)
from Rancho)

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: – How can I tell that it is tight enough:


– Transfers and ambulation – Enough space for your hands, but not
enough space to move up or down
– Where do I put it:
– How do I use this when the pt has
– Between hips and axilla at drains:
smallest circumference
– Depending on location of drains, can
– Where do I hold it: use higher or lower
– Behind patient with one or both – How do I use this when the pt is
hands obese, breast tissue, rib fractures,
surgical incisions
– How can it help me:
– Avoid painful areas, lift breast tissue
– Weight shifting, preventing falls when tightening belt, move gown
material out of the way
Transfers

– Chair position: – Place gait belt while sitting at EOB,


– Set up prior to transfer on pt’s strong may need second person for support
side
– Staff member set up:
– Set up chair with pillow, sheet, and
chucks – Hands on gait belt

– Line management: – Block hemi-paretic knee, foot assist

– Place IV lines, catheters, and monitor – Trunk on hemiplegic side


cables in a position that allows a clear – Legs together or staggered
path for transfer
– Allow pt’s trunk and knees to move
– Bed: forward during transfer
– Use seat deflate option to bring feet
– Lift equipment: STEDY
towards floor
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: croys@uci.edu


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