Practical Tips for Acute Stroke Rehabilitation

Presented by Kim Kennedy (PT), Lindsey Bright (OT)

& Katherine Churchward (SLP)

Presentation Objectives

• Provide an overview of rehab on an acute stroke unit• Identify outcomes measures for acute stroke• Provide examples of applicable treatment activities• Provide an open forum for discussion of acute care

concerns

FMC Stroke Unit

• 17 Beds + 2 Overcapacity

• Rounds – Twice weekly

• Treatment areas in Rehabilitation Department

FMC Stroke Unit Team

• 2 FTE PT• 1.7 FTE OT• 0.7 FTE SLP- Communication• 0.3 FTE SLP- Dysphagia• 1.0 FTE Multidisciplinary TA• 0.6 FTE Social Worker• Nursing staff• 2 nurse practitioners• Transition Services• Neurologists rotate weekly

Medical Precautions Impacting Rehabilitation

• Hypertension

• Hyperglycemia

• Elevated Temperature

• Infection – i.e., Pneumonia, UTI

• GI Bleed

• DVT/PE

APSS Inservice By Mary Elizabeth Cooper: Preventing Complications of Stroke

http://www.strokestrategy.ab.ca/telehealth_presentations.html

Other Factors Impacting Rehab

• Protection of Hemiparetic Limbs

• Global Aphasia

• Depression

• Falls

• Skin Care

APSS Rehabilitation Outcome Measures(Pilot)

OT PT SLP

Alpha FIM Alpha FIM Alpha FIM

Box & Block Berg Balance Scale

ASHA - NOMS

AHS Orpington Orpington

Case Study – Mrs. X

• 64 y.o. female, Right hand dominant• Lived with husband in bungalow,

previously independent & active, retired• 2 wk hx vertigo, spells of leg numbness• Admitted with acute confusion, vertigo,

right hemiparesis, gait imbalance• CT Results:

• Subacute Right cerebellar & acute Left PCA, acute Left thalamic infarcts

Mrs. X’s PMH

• HTN

• Right MCA aneurysm-surgically clipped in 98’

• Right MCA infarct

First 24-48 Hours

• Referrals are received

• Initial assessment completed

• Outcome measures completed

• Swallowing screened by unit nursing & referral to SLP deemed appropriate

• Treatment goals established

• Education provided to pt & family

Clinical Presentation

• Abnormal tone right U/E > L/E limiting volitional movement

• Right sided ataxia

• Supervision for trunk control in sitting

• Mod. Assist x1 for sit → stand due to ataxia

• Decreased proprioception in right side body

• Right homonymous hemianopsia

Clinical Presentation

• Unable to follow 1 step commands consistently

• Required ++ cueing & redirection

• Slow processing

• Labile

• Fluent, vague language

• Marked difficulty with naming

• Unable to convey simple messages

• Semantic & phonemic paraphasic errors

Medical Status in first 24-48 hours

• NG in situ

• On room air, SpO2 97%

• IV running with Heparin infusing

• BP 144/75

Initial Assessment ~ OT/PT

• Initial interview with pt. & spouse

• Bedside dangle on unit, standing transfer to bedside chair

• Session was brief due to lability

Initial Assessment ~ OT

• ADL Ax• Box & Blocks Ax• Visual Ax (biVABA) • Informal cognitive

assessment• U/E functional

tasks - bilateral & unilateral

Initial Assessment Results ~ OT

• Mod. Assist x1 with verbal cueing for ADLs • assist with motor planning, visual compensation, physical assistance

• Difficulties with Right/Left discrimination

• Required verbal sequencing in U/E tasks & ADLs due to sensory ataxia

• Right U/E tone: distal > proximal

Initial Assessment Results ~ OT

• Smooth tracking, Right homonymous hemianopsia, mildly blurred

• ↓ working memory & procedural memory, delayed processing speed, ↓ sustained attention

• ↓ carry over of therapeutic strategies• ↓ awareness of unintentional right arm/hand

movements compounded by ↓ right field vision

Initial Assessment ~ PT

• Gross motor coordination

• Unable to complete BERG Balance Scale

• Range of motion

• Functional strength

• Functional mobility (i.e. Bed mobility, sit to stand, etc)

• Gait

Initial Assessment Results~ PT

• Sensory ataxia right U/E

• Full ROM of single joint movements

• General decreased strength right side • U/E grade 3-4/5

• L/E grade 4/5

• 1 person mod-assist for standing

• 2 person mod-assist for ambulation

• Over-recruitment of right U/E flexors & L/E extensors with dynamic standing activities

Initial Assessment ~ SLP

• Swallow

• Communication - verbal expression, auditory comprehension & written expression

• Strategies to improve verbal expression & auditory comprehension

• Education of patient & family

Initial Assessment Results~ SLP

• Placed on modified texture diet

• Fluent aphasia

• Required repetition & rephrasing of simple instructions most of the time

• Unable to write or print

• Unable to assess reading comprehension

Initial Assessment Results ~ SLP

• Conversational Sample:

E: “Can you tell me about your family?”

C: “They let me know that they have kids. They let me know that they me.”

• Naming: named 50% of common items, benefited from phonemic cueing

Rehab Goals

• Increase independence with transfers & ambulation

• Minimize tone through positioning, handling, & pt. awareness

• Incorporate right side of body into functional tasks

Rehab Goals

• Automatic visual scanning & compensation

• Improve information recall & carry over from session to session

• Facilitate independence in ADLs

Rehab Goals

• Improve awareness & insight

• Improve ability to convey simple ideas

• Improve ability to follow instructions in context of therapy

• Provide ongoing education to pt & family

Week One….

• D/C destination determined – tertiary neuro rehab program

• Pt. & spouse attended therapy in rehab dept. (three 30 min sessions daily)

• Seating arranged for pt. while in hospital

Treatment ~ PT

• Transfer training

• Sit → stand

• High sitting balance activities loading Right U/E

• Pre - gait activities loading Right L/E

• Gait retraining

Use of Equipment ~ PT

• Slider

• Overbed table

• Shopping cart

• 4 wheeled walker

• CaligaLoc brace

Treatment ~ OT

• Visual retraining & compensatory activities

(e.g., rectilinear scanning, visual pursuits with head turn)

• U/E coordination program (e.g., gross grasp, release, joint discrimination,

3 point pinch)

• ADL program with TA

• On-going cognitive assessment

as language improved

Use of Equipment ~ OT

• Peg boards – various sizes

• Cones – various widths

• Modified games – Checkers, Hi-Q, card games

• Functional sequencing cards

• Pen & paper tasks• Visual scan boards – peripersonal, extrapersonal

• Functional modalities (ie., buttons, shoelaces, folding towels etc)

Treatment ~ SLP

• Information provided re: condition & prognosis

• Diagnostic therapy – focus on verbal expression• Word retrieval activities: naming to description, naming

associated items (with appropriate cueing)• Determine most effective type of cueing & facilitative activities

• Use of strategies • Describing a target word that she cannot retrieve• Pause & think of the word

Conversation ~ One week

E: “Tell me a little bit about yourself”

C: “I used to enjoy gardening. Something I can see & feel for the season. You know?”

C: “And my cats. Two.”

E: “What kind of cats do you have?”

C: “One is a flat nose skinny thing. The other is a blue eyed four bigger Persion looking”

Week Two & Three

• Transfer to neuro rehab program

• OT, PT, SLP, & RecT

Week Two & Three PT

• Gait retraining

• Stair activities

• Increase awareness of right side of body & environment through visual & tactile cues

Week Two & Three OT

• Box & Block reAx, CMSA, CAHAI

• Bathroom equipment Ax for w/e pass

• ADL supervision by nursing

• Bilateral hand activities

• Handwriting exercises

Week Two & Three OT

• Right side scanning exercises using compensatory strategies

• Route finding & schedule tracking

• Incorporation of memory book in lieu of spouse’s assistance

Week Two & Three SLP

• FIM & CIHI completed

• Dysphagia monitoring

• Formal language assessment using the Western Aphasia Battery

• Ongoing treatment

• Home programming

• Participation in communication group

Role of SLP in Acute Stroke Care

• Dysphagia assessment

• Communication assessment/treatment• Initial working diagnosis, determine problem area with

most significant impact on communication• Provide education to Pt & family• Trial strategies to facilitate improved communication• Diagnostic treatment• Formal language assessment when Pt performance

somewhat stable

Role of Rehab Team in Acute Care

• Discipline specific assessments• Determination of discharge destination &

community needs• Inpatient rehab as indicated• Provision of ongoing education & support

to patient & family regarding outcomes, prognosis, & progress

• Collaboration with team regarding individual care needs

Special Thanks

Lucie Myles – PT stroke unit

Teresa Siebold – PT stroke unit

Patti Thomas – PT rehab unit

Nicole MacDonald “model” – OT stroke unit

Marian Tsaprailis – OT rehab unit

Rosalyn Korol – SLP rehab unit