The overall goal for professionals whotreat patients during the acute phasepoststroke is to achieve the best out-

come possible. For neurological care, the bestoutcome means interventions to maximizesurvival and to minimize the extent of neuro-logic impairment. During the acute phase ofcare, optimum survival also requires excellentmedical care for prevention and treatment ofcomorbidities and medical complications.The best late outcome requires optimum reha-bilitation, which includes therapy to facilitateneurologic recovery and measures to preventphysical complications that might otherwiselimit achievement of full functional potential.

From a rehabilitation perspective, inter-vention during the acute phase of carebegins on the day of onset and continuesuntil it is judged that the patient is stableenough to engage in a program of active,more intensive rehabilitation. The durationof the acute phase of care, before intensivetherapy begins, may be from 1 day to aweek. Concurrent medical comorbiditiesand complications may prolong this period.Patients are often initially obtunded, para-lyzed, and totally dependent. They are at

risk for development of early medical com-plications such as pneumonia, urinaryinfections, and deep venous thrombosis.These conditions will delay active partici-pation in rehabilitation and will interferewith recovery. It is the thesis of mostauthors that if stroke patients are activatedas early as possible post onset, complica-tions will be minimized, restoration willoccur more quickly, and ultimate functionaloutcome will be improved.

It is useful to consider rehabilitation ofstroke patients as a continuum that begins inthe early phase of care with preventivemeasures and more passive interventions.As patients become stable, they are able to

48

Murray E. Brandstater, MBBS, PhD, FRCP(C), is Professor and Chairman, Department of PhysicalMedicine & Rehabilitation, Loma Linda UniversityMedical Center, Loma Linda, California.

Lori A. Shutter, MD, is Associate Professor ofNeurology, and is Director, NeuroTrauma Unit,Loma Linda University and Medical Center andCasa Colina Centers for Rehabilitation, Loma Linda,California.

Top Stroke Rehabil 2002;9(2):48–56© 2002 Thomas Land Publishers, Inc.

The immediate care of a stroke patient admitted to hospital is best provided in a dedicated stroke unit,within which all of the key components of care can be coordinated. Neurologic diagnosis and interven-tion and general medical care are essential elements of acute stroke management. However, optimal out-come requires a comprehensive and multidisciplinary approach, which includes rehabilitation interven-tions. During the initial phases of care, rehabilitation interventions are mostly passive and emphasizeprevention of secondary co-impairments such as contractures, pressure ulcers, and deconditioning.Rehabilitation interventions should be incorporated into care protocols for all patients and should beginimmediately. As the patient becomes stable, more intensive therapy can be initiated in preparation for tran-sition into the postacute phase of active rehabilitation. Key words: cerebrovascular accident, passive rangeof motion, physical therapy techniques

Rehabilitation Interventions DuringAcute Care of Stroke Patients

Murray E. Brandstater and Lori A. Shutter

transition into a more active therapeutic pro-gram where the emphasis is on remediationof deficits and improvement in functionthrough compensation and learning. Thisphase of rehabilitation occurs in a dedicatedrehabilitation unit. Once the patient is dis-charged home from the hospital, the laterphase of rehabilitation emphasizes reinte-gration into family and community, social-ization, and psychological adjustment.

Goals of Early Rehabilitation

Rehabilitation interventions during theacute phase of care for stroke patients shouldbegin immediately and occur concurrentlywith the neurologic and medical aspects ofcare. The specific goals of rehabilitation dur-ing this early phase of care include:

• maintenance of adequate nutritionand hydration,

• prevention of tracheal aspiration andpneumonia,

• prevention of contractures,• prevention of pressure ulcers,• prevention of urinary complications,• limitation of deconditioning,• impairment remediation,• initiation of counseling for

psychological adjustment and family support, and

• development of goals for postacute care.

Some of these goals emphasize avoid-ance of potential complications that mayaffect any acutely ill patient who is con-fined to bed. The preventive measuresshould be part of all good medical andnursing care. Other goals more specificallyaddress stroke-related issues. For thepatient, most of the interventions per-formed during the acute phase of care are

passive and require little active participa-tion. It is only when the patient is medical-ly stable and has transitioned out of theacute unit into a postacute rehabilitationsetting that he or she is expected to active-ly engage in a physically more intensivetherapeutic program.

Maintenance of adequate nutrition andhydration

Maintenance of adequate nutrition andhydration is part of all good medical andnursing care and should be incorporatedinto the standard care of all patients.Stroke patients who are alert and able toswallow may take food and fluids orally.A bedside swallow evaluation should beperformed first, before oral feeding isstarted, to ensure that swallowing is safe.Patients are then started on an appropriatediet. However, if patients are deemed tobe at risk for aspiration, or are obtundedor unresponsive, a nasogastric feedingtube will be necessary. Patients should begiven adequate calories and sufficientprotein to maintain a positive nitrogenbalance. Their nutritional intake shouldbe monitored to ensure that these goalsare met. For an average adult, the targetfluid intake is 3 L a day. Any intake shortof this target from oral or tube feedingsshould be made up by intravenous infu-sion. Any patient who has an upper gas-trointestinal problem and cannot toleratealimentation should be a candidate fortotal parenteral nutrition.

Prevention of aspiration and pneumonia

Dysphagia is a frequent and serious com-plication observed in patients after a stroke.

Rehabilitation Interventions 49

50 TOPICS IN STROKE REHABILITATION/SUMMER 2002

It is common in patients with brainstem andbilateral lesions, but it is also often a prob-lem in patients with unilateral hemispherelesions. Overall, the incidence of dysphagiamay be up to 50% of all stroke patientsadmitted to hospital.1,2 When dysphagia ispresent, there is a high risk for trachealaspiration and pneumonia. The coughreflex, which would normally be expectedwith food or fluids in the larynx or tracheain normal participants, is suppressed andmay be absent in up to two thirds of patientswith acute stroke.3 Oral feedings should notbe attempted if patients are lethargic orunresponsive. A careful bedside swallowevaluation should be performed in allpatients before oral fluids or feedings arestarted. Wherever doubt exists about theadequacy of swallowing, a videofluo-roscopy of a barium swallow should be per-formed to observe the movements associat-ed with swallowing. It is often prudent tobegin oral feedings with 100% supervisionby a staff person. It should be noted thatfeeding through a nasogastric tube does notprevent aspiration, because gastroe-sophageal reflux may occur, especiallywhen bolus feedings are given with thepatient lying flat in bed.

Prevention of contractures

Hemiplegic patients are at high risk fordevelopment of contractures. These aremyogenic, induced by fixed shortening ofthe muscle bellies, and accompanied byspasticity. The muscle paralysis associatedwith corticospinal tract lesions limits orprevents voluntary limb movement.Patients are hence immobile. They are usu-ally placed supine in bed with their para-lyzed limbs extended. Initially, muscles are

flaccid, but over days or several weeks tonereturns in the paralyzed muscles. Whenspasticity develops in hemiplegia, the legstays extended but the arm assumes a pos-ture in which the shoulder is adducted andinternally rotated, the elbow is flexed, theforearm is pronated, and fingers are flexed.Immobility of a limb with a muscle in ashortened position unloads the muscle. Thephysiologic response to persistent muscleunloading is rapid loss of muscle fiberlength with loss of sarcomeres and someaccumulation of connective tissue.4–6

The immobilization of muscles in a short-ened position is the initial mechanismresponsible for the development of musclecontractures. The rate of protein synthesisin paralyzed muscle rapidly decreases,which results in loss of myofibrils as wellas fiber length. Muscle atrophy developsquite rapidly even though the paralysis isdue to a lesion of the upper motor neuron.These changes of muscle shortening andatrophy and connective tissue accumulationcan be detected within a few days of onsetof paralysis on histologic analysis.7 There isan increased ratio of collagen to musclefibers and increase in collagen cross-link-ages leading to reduced muscle compliance,muscle rigidity, and what becomes a myo-genic contracture. These effects can beobserved clinically as an increased resist-ance to passive stretch. This change in thepassive properties of paralyzed muscles inpatients with hemiplegia (i.e., myogeniccontracture) is often masked by the devel-opment of spasticity.8

In addition to the connective tissuechanges and muscle shortening that con-tribute to reduced muscle compliance inhemiplegia, spasticity and hypertoniadevelop in the paralyzed muscles due to

Rehabilitation Interventions 51

involuntary activation of motor units. Bothspasticity and changes within the musclesincrease the resistance of muscles to pas-sive stretch.8 This change in the mechanicalproperties of muscles progresses and leadseventually to fixed contractures, which areobserved clinically as decreased passivejoint range of motion. In an immobile limb,the habitual position maintained by a jointdetermines the length of the adjacent mus-cles and the nature and extent of any con-tracture.

Although it takes days and even weeks formuscle contractures to develop, the processbegins in the acute phase immediately afterparalysis occurs. The harmful effects ofimmobilization on muscles can be mini-mized by passive stretching.9,10 Passiverange-of-motion exercises are usually per-formed by a therapist who manually stretch-es shortened muscles with a brief high-loadforce. This technique has the potential,when performed correctly, to limit thosechanges that would otherwise lead to intrin-sic muscle contracture, that is, loss of mus-cle fiber length and development of fibrosisaround and within the muscle fascicles.

In addition to preservation of musclelength, stretching is also beneficial in reduc-ing motor neuron excitability and in reduc-ing spasticity.11,12 The duration of maintainedstretch appears to be important in determin-ing the extent of reduction in muscle tone,with more prolonged stretch being moreeffective in reducing spasticity than briefstretching. Controlled trials have shown thatchronic stretch by use of casts or splints isbetter than passive range-of-motion exercis-es for reduction of spasticity.13

In the context of acute stroke, when mus-cles are flaccid, the daily performance ofpassive range-of-motion exercises for all

limb joints is the minimum treatmentrequired for prevention of contractures. It ispreferable for passive stretching and jointrange of motion to be done twice daily. Thestretching exercise may be brief, but itshould achieve full muscle stretch, that is,complete range of joint motion. In thosepatients with prominent spasticity, consid-eration should be given to application ofprolonged stretch by use of splints to main-tain muscle length. The ankle plantar flex-ors are often spastic quite early post onsetand are at a high risk for development of acontracture. It may be difficult to preventtheir contracture with simple daily normalstretching. An ankle-foot orthosis with arigid ankle set in a few degrees of dorsi-flexion is often useful in preventing musclecontracture in these spastic patients.

Prevention of pressure ulcers

Acute stroke patients are at high risk forpressure ulcers. They are usually older, andwith paralysis they are immobile and unableto move themselves or roll over in bed. Theymay have impaired mental status withreduced sensory perception and be less awareof the need to change position. The nutrition-al status of many stroke patients is marginalor poor, and they may be incontinent.

The principal factor that causes pressureulcers in all patients confined to bed is pro-longed loading of tissue over bony promi-nences. Increased pressure in skin andsuperficial tissue reduces local capillaryperfusion and leads to ischemia and tissuenecrosis. The sites where pressure ulcersoften occur are over the heels, lateral malle-oli, and the sacrum. Ulcers occur at thesesites because of prolonged immobility inthe supine position. Shearing of the skin

52 TOPICS IN STROKE REHABILITATION/SUMMER 2002

may be an additional factor over the sacrumwhen patients adopt a poor sitting positionor sit with the head of the bed elevated.

The keys to prevention of pressure ulcersare relief of pressure and maintenance ofclean, dry skin. The simplest and most uni-versal method used to relieve pressure isfrequent manual lifting and turning of thepatient to reposition the body. A schedule ofturning the patient every 2 hours is accept-ed as a standard for nursing care of thesepatients. The nursing care protocol for treat-ment of acute stroke patients should includeobligatory turning and repositioning of thepatient every 2 hours. However, even ifsuch a protocol is followed, it is still neces-sary to regularly inspect the skin. Heel pro-tectors have been advocated to assist in pre-venting pressure ulcers over the heels.However, these are ineffective unless theylift the foot up to completely remove theheel from surface contact.14

Prevention of urinary complications

During the acute phase of care, the sacralreflexes that mediate micturition aredepressed and reflex bladder voiding is sup-pressed. The bladder will usually overdis-tend, and if it is not drained it will empty byoverflow incontinence. Urine output is usu-ally high in the first few days post onsetbecause of the need to maintain a high flu-id intake, often by intravenous infusion.Overdistention of the bladder is best avoid-ed in the acute phase by intermittentcatheterization every 4 to 6 hours, depend-ing on the rate of urine flow. The objectiveis to prevent the bladder from fillingbeyond about 500 mL and to stimulatephysiological filling and emptying.

Because an indwelling catheter enhances

the risk of urinary tract infection, its useshould be avoided. For practical reasons, anindwelling Foley catheter is often used forbladder drainage during the initial phase ofacute care so that urine output can be close-ly monitored. The indwelling cathetershould be removed as soon as possible,within a few days or less.

Limitation of deconditioning

The adverse effects of bed rest are wellknown. Some degree of deconditioning isinevitable even with short periods of bedrest and is more pronounced in the elderly.Multiple organ systems are affected as thebody adapts to decreased physical activityand recumbency.

Bed rest causes prominent and clinicallyapparent alterations in cardiovascularphysiology. Deconditioning occurs pro-gressively and is characterized by anincrease in the resting heart rate, a height-ened tachycardia in response to submaxi-mal exercise, a decrease in stroke volume,a decrease in cardiac output, and adecrease in maximum oxygen uptake.15,16

All of these changes contribute to somecharacteristic clinical features. Posturalhypotension accompanied by tachycardiais a common occurrence in deconditionedpatients, and it may be aggravated inpatients who are taking medications forhypertension. Deconditioned patients havereduced exercise tolerance and becomefatigued or short of breath at relatively lowlevels of exercise.

There are pulmonary alterations inpatients who are confined to bed. It ismore difficult for patients to clear secre-tions when they are lying down, whichpredisposes them to atelectasis and pneu-

Rehabilitation Interventions 53

monia. There is also an alteration in thebalance between perfusion and ventilationthat may contribute to reduced exercisetolerance.

Metabolic changes occur with bed rest.Diuresis occurs with a reduction in bloodvolume, which may contribute to posturalhypotension. The lack of muscle activitycontributes to carbohydrate intolerancewith reduced peripheral glucose uptake.The effect on carbohydrate metabolismcan be partly ameliorated by isotonic exer-cise in large muscle groups.17 For thehemiplegic patient, there is some benefitfrom active exercise of the unaffectedlimbs. Immobility results in increased cal-cium reabsorbtion from bone; in the elder-ly, this accelerates the development ofosteoporosis.

In the muscular system, weakness due todisuse progresses rapidly. With completebed rest and muscle inactivity, a patient’sstrength is lost at a rate of 10% to 15% aweek.18 For hemiplegic patients, this sec-ondary weakness involves affected andunaffected muscles and represents a consid-erable comorbidity that limits their abilityto physically compensate to overcome dis-ability caused by the hemiplegia. The gen-eralized weakness that accompanies decon-ditioning delays full, vigorous participationin an active therapeutic program when thepatient is medically stable and leaves theacute medical unit.

All of the changes that occur with immo-bility accompanying hemiplegia and bedrest are important secondary contributors todisability. They begin early, and some areclinically apparent within days. The limita-tion of the effects of deconditioning istherefore an important goal of rehabilitationintervention during the acute phase of care.

Prevention of deconditioning is obviouslyworthwhile, because it takes patients atleast as long to recover from disuse as fromthe duration of inactivity.

The beneficial effects of physical activity,being upright, and exercise are obvious.The approach to therapy for the acute strokepatient should incorporate a variety ofmeasures to facilitate early activation.Therapy should include getting the patientout of bed as soon as possible and facilitat-ing the patient’s active participation asmuch as possible in mobility activities,such as rolling over in bed, sitting up, andtransferring. Patients should be encouragedto actively use the unaffected limbs. Thetherapist should monitor the patient duringthese activities, especially for symptoms ofcardiovascular insufficiency such ashypotension or hypertension, angina, dysp-nea, or excessive tachycardia. These symp-toms should prompt careful evaluation ofthe patient to determine the reasons for car-diovascular instability and to set appropri-ate parameters for safe therapy.

Impairment remediation

The stay in the acute stroke unit is usuallyquite short, and patients are not usually ableto participate actively in a designated thera-py program. Therapy that is directed atremediation, especially of the hemiplegia, isa feature of the intensive postacute phase ofrehabilitation. There are some impairments,however, that can create a sense of isolationand confusion in the patient. For example,prominent sensory loss, hemineglect, visualfield defects, and aphasia can act as barriersbetween the patients and their environment.

The health care team members who pro-vide care to these patients should recog-

54 TOPICS IN STROKE REHABILITATION/SUMMER 2002

nize the nature of the neurological deficitsand respond with appropriate interactionand stimulation. There are many ways thatstaff can contribute to a milieu that facili-tates patients’ awareness and promotes apositive response rather than withdrawal.Some of these measures include initiatingfrequent social and physical contact withthe patients, providing frequent simpleand clear communication about what hashappened and reassurance about plans forfurther treatment, encouraging family andfriends to be present and supportive, andapproaching patients on their unaffectedside to ensure that they can attend to thosepresent and talking. If perceptual deficitspersist in the patient, it will be appropriatelater for staff to provide perceptualretraining to facilitate amelioration ofthose deficits. But in the acute phase ofcare, it is more important for the staff tointeract with the patient than to focus onthe deficits.

Measures to facilitate reorientation, self-awareness, contact with others, and com-munication will not remediate the impair-ments, but these measures will begin theprocess of engagement with self, staff, andthe environment that will be necessary forthe patient to progress during subsequentrehabilitation.

Initiation of counseling for psychologicaladjustment and family support

The abrupt change in the life situationof a patient with an acute stroke is a dev-astating event. There is initial concern bypatient and family about survival, andthen there is fear about the uncertain con-sequences of continuing disability. Boththe patient and family need good commu-

nication from health care professionalsabout the immediate issues. But with sur-vival of the patient, members of the reha-bilitation team should create a supportiveenvironment in which realistic projectionsare made about potential for recovery andinformation is given about the contribu-tion of postacute rehabilitation. Thephysician should provide appropriatemedical information, but other team mem-bers play an important role in communi-cating the broader context within whichthe complex issues of rehabilitation willbe addressed.

Development of goals for postacute care

Once the patient is medically and neuro-logically stable, which may be as early asthe first or second day post onset, thepatient should be evaluated for admission toa comprehensive rehabilitation program.The content of the evaluation is summa-rized in the box titled, “Screening forRehabilitation,” which is adapted from theAHCPR Guideline.19

The information from this screening willprovide guidance for the team in decidingthe optimal type and intensity level of con-tinuing rehabilitation.20 The optimal timingof the transition from acute care to activerehabilitation is generally recommended tobe as soon as the patient is medically stableenough to participate in an intensive pro-gram of therapy.21–26

Selection of the appropriate setting forcontinued rehabilitation for the patientdepends on the patient’s medical andfunctional status. The AHCPR Guideline19

contains a decision tree to assist care-givers in making choices for postacuterehabilitation.

Rehabilitation Interventions 55

Summary

Treatment protocols for management ofstroke patients should incorporate rehabili-tation interventions throughout all phasesof care, from the acute unit through to out-patient therapy after discharge and to rein-tegration into family and community.Within this rehabilitation continuum, spe-cific interventions change as the patientprogresses. In the acute unit, when thefocus of care is on neurologic and medicalissues, rehabilitation interventions arelargely preventive and supportive. Effortsare directed at limiting the debilitatingeffects of bed rest by activating patients asearly as possible and aim to prevent com-plications such as contractures that wouldotherwise interfere with functional recov-ery. It is believed that early activation andtransition of patients as quickly as possibleinto more intensive rehabilitation will min-imize complications, expedite recovery,and improve ultimate outcome.

Screening for Rehabilitation

1. Medical status• Neurologic diagnosis• Neurologic deficits including mental

status, vision, language, motor, per-ceptual deficits

• Comorbid diseases• Health status: nutrition, hydration,

ability to swallow, bowel and bladdercontinence, skin integrity, activity tol-erance, sleep patterns

2. Functional status• Status prior to stroke• Current functional status – mobility,

self-care• Mental status and ability to learn• Functional communication• Physical activity tolerance• Emotional status, motivation

3. Social and environmental factors• Present living situation• Presence of spouse or significant

other• Extent of support of family and

friends• Ethnicity and native language• Adjustment of patient and family

to stroke

56 TOPICS IN STROKE REHABILITATION/SUMMER 2002

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