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