Practical Tips for Acute Stroke Rehabilitation

1. Practical Tips for Acute Stroke Rehabilitation • Presented by Kim Kennedy (PT), Lindsey Bright (OT) • & Katherine Churchward (SLP)

2. 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

3. FMC Stroke Unit • 17 Beds + 2 Overcapacity • Rounds – Twice weekly • Treatment areas in Rehabilitation Department

4. 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

5. 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

6. Other Factors Impacting Rehab • Protection of Hemiparetic Limbs • Global Aphasia • Depression • Falls • Skin Care

7. APSS Rehabilitation Outcome Measures(Pilot)

8. 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

9. Mrs. X’s PMH • HTN • Right MCA aneurysm-surgically clipped in 98’ • Right MCA infarct

10. 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

11. 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

12. 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

13. Medical Status in first 24-48 hours • NG in situ • On room air, SpO2 97% • IV running with Heparin infusing • BP 144/75

14. Initial Assessment ~ OT/PT • Initial interview with pt. & spouse • Bedside dangle on unit, standing transfer to bedside chair • Session was brief due to lability

15. Initial Assessment ~ OT • ADL Ax • Box & Blocks Ax • Visual Ax (biVABA) • Informal cognitive assessment • U/E functional tasks - bilateral & unilateral

16. 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

17. 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

18. 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

19. 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

20. Initial Assessment ~ SLP • Swallow • Communication - verbal expression, auditory comprehension & written expression • Strategies to improve verbal expression & auditory comprehension • Education of patient & family

21. 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

22. 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

23. Rehab Goals • Increase independence with transfers & ambulation • Minimize tone through positioning, handling, & pt. awareness • Incorporate right side of body into functional tasks

24. Rehab Goals • Automatic visual scanning & compensation • Improve information recall & carry over from session to session • Facilitate independence in ADLs

25. 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

26. 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

27. Treatment ~ PT • Transfer training • Sit → stand • High sitting balance activities loading Right U/E • Pre - gait activities loading Right L/E • Gait retraining

28. Use of Equipment ~ PT • Slider • Overbed table • Shopping cart • 4 wheeled walker • CaligaLoc brace

29. 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

30. 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)

31. 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

32. 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”

33. Week Two & Three • Transfer to neuro rehab program • OT, PT, SLP, & RecT

34. Week Two & Three PT • Gait retraining • Stair activities • Increase awareness of right side of body & environment through visual & tactile cues

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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