Patient example, continued: best
family needs, introducing them to community- based programs prior to discharge and communica- tion with J’s primary care provider.
Short-term interdisciplinary goals for J include:
1 improve swallowing;
2 decreased frequency of urinary incontinence;
3 controlled hypertension;
4 improved cognition and communication;
5 decreased depressive symptoms;
6 decrease caregiver stress;
7 implementation of prevention plans to:
• prevent skin breakdown;
• prevent deep vein thrombosis;
• implement secondary prevention of recurrent stroke;
• prevent shoulder pain and limitations in range of motion;
• prevent falls;
8 independence in basic ADLs;
9 supervised gait, increased walking velocity, and improved endurance for walking;
Table 8.2 Standardized assessments
Standardized assessment Measures
National Institutes of Health Stroke Scale [23] 1 Assesses stroke severity and predicts likelihood of recovery
2 Should be administered at the time of hospital admission or within 24 hours of start of stroke
3 Scale should be repeated at the time of acute care discharge and results available or repeated at admission to rehabilitation facility
Montreal Cognitive Assessment (MoCA) [26] The MoCA is a cognitive screening test designed to assist health professionals for the detection of mild cognitive impairment.
It is more sensitive in detecting mild cognitive impairment than the Mini Mental State Examination.
Fugl-Meyer [45] Measures upper and lower extremity motor and sensory impairment. It “assesses the ability to move the arm and its segments selectively as well as sensation and passive joint mobility with an array of qualitatively rated items.”
Grip strength [46] Hand strength
Berg Balance Scale [32] Assesses static and dynamic posture as well as helps determine risk for falling Wolf Motor Function Test [9] Assesses upper-extremity function and improvement in stroke patients Ten-Meter Walk Test [33] Assesses and measures change in the patient’s speed of walking Six-Minute Walk Test [40] Assesses and measures endurance
Standardized swallowing assessment [24] Toronto Bedside Swallow Geriatric Depression Scale [29] Screens patient for depression
Pain Visual Analog Scale: 0–10
Line Bisection Test [47] A screening tool for the presence of unilateral neglect
Motor Free-Visual Perception Test [27] Perceptual tasks include spatial relationships, visual discrimination, fi gure–ground, visual closure, and visual memory. Performance in these areas provides a single score that represents the individual’s general visual perceptual ability.
Functional Independence Measure Assesses and measures changes in patient’s functional status
Table 8.3 Best practice recommendations for interventions
Problem Recommended best practice guideline
Left upper-extremity motor weakness • Initiate range of motion, strengthening program, position arm in view of patients
• Assess patient as candidate for constraint-induced movement therapy Left lower-extremity motor weakness • Functional strengthening training
• Assess patient as candidate for body weight-supported treadmill training (include assessment of cardiovascular function prior to participating)
Shoulder pain • Task-specifi c gait training
䊊 ROM – lateral rotation and assisted ROM in pain-free range. Do not move the shoulder above 90 degrees of fl exion and abduction unless the scapula is upwardly rotated.
䊊 Positioning and protection of the limb during functional tasks
䊊 Avoid the use of overhead pulleys
䊊 Educate staff and family to protect the shoulder
䊊 Modalities: ice, heat, massage
䊊 Strengthening of shoulder muscle groups
䊊 Physician may need to prescribe analgesics Sensory loss (left UE and LE) • Use sensory stimulation to regain sensation
Visual/spatial neglect • Need to differentiate between visual fi eld defi cits and attention defi cits
• Evaluate for neglect using standardized assessments
• If neglect is present, suggest treatment to teach patient to manage with the neglect. This includes visual scanning, adapting the environment, and educating the patient and family.
• Cognitive retraining is indicated (visual–spatial rehabilitation)
Dysphagia • Recommend swallow assessment using the Toronto Swallow Assessment (TOrr-BEST)
• If abnormal, refer to SLP for evaluation for prevention of aspiration (which could lead to aspiration pneumonia)
• Video fl uoroscopy swallowing study or a modifi ed barium swallow study may be performed.
• Consult dietetics if patient will require a special food consistency Cognitive impairment (attention,
neglect, fl at affect)
• Assess learning, memory, attention, visual neglect, apraxia, problem solving
• Recommend cognitive retraining/compensation
Dependence in ADLs/IADLs • Functional mobility training, rolling, transfers, wheelchair mobility, dressing, hygiene, etc.
• Recommend adaptive technology for safety and function
• Assess safety awareness, medicine management, and meal preparation Decreased walking speed/severe gait
impairment
• Task-specifi c mobility training, which incorporates functional strengthening, balance and aerobic exercises, and practice on a variety of walking tasks on different walking surfaces and in different environments
• A combination of task-specifi c training with a and treadmill training may be optimal.
• Assess for use of assistive devices/orthoses
Falls risk • Assess with Berg Balance Test
• History and conditions of falls
• Balance training, including walking under conditions of divided attention Communication impairment • Refer to SLP for assessment and treatment
• Assess listening, speaking, reading, writing, pragmatics
• Follow up for long-term communication diffi culties Caregiver stress • Patient and caregiver education/train caregiver to assist patient
• Evaluate needs
• Refer to social worker
• Provide support and community resources assessment
• Share assessment fi ndings and expected outcomes with family/caregivers
• Family conference
Problem Recommended best practice guideline
Risk for skin breakdown • The patient is at risk for skin breakdown because of decreased mobility.
• Skin integrity should be monitored daily.
• Proper attention must be paid to turning and positioning if patient has poor bed mobility.
Risk for DVT • Patient should be mobilized as soon as much as possible (out of bed, sitting, standing, and walking).
• Compression stockings
• Recommend use of subcutaneous low-dose unfractionated heparin Risk for malnutrition • Patient is at risk for malnutrition due to swallowing problems.
• Consult dietetics to develop a healthy diet based on necessary food consistencies as recommended by SLP and assist with feeding if necessary.
Urinary incontinence • Frequent, prompted voiding schedule
Recurrent stroke risk • Patient and family counseling to identify signs and symptoms of stroke
• Recommend programs to maintain and increase physical activity and healthy diet Risk for depression • Routine screening for depression
• Refer out for a comprehensive psychosocial assessment
• Include families and caregivers in the process Hypertension • Check blood pressure (desired BP 130/90)
• Re-evaluate medications used to control hypertension
• Recommend exercise/physical activity
Patient/family education • StrokEngine at www.strokengine.org is a very valuable educational tool for the patient and family.
The family could be provided the link so they can research all of the information for family and caregivers on their own.
• The patient and family should be educated and be made aware of all safety precautions that need to be taken for J.
• Hold a family conference with the rehabilitation team
• Provide patient with educational materials and identify someone who can be a point of contact for questions and concerns. Education is more effective when it can be an interactive process.
• Family should be included in therapy sessions and learn how to safely assist the patient with activities.
• Re-educate the family about the warning signs of stroke, and advise to seek immediate medical care in the presence of new stroke symptoms
• Document the education that takes place.
Referral and care coordination with primary care physician within 30 days
• Address stroke risk factors, diet and exercise, hypertension control, risk for depression;
recommend community rehabilitation programs as well as community-based activity programs, and stroke support groups, access to support services/community transportation or senior citizen activities.
• Provide the history of rehabilitation management, expected outcomes, and recommendations for continued care to the primary care physician. Provide the primary care physician the name of J’s rehabilitation case manager as a point of contact.
ADLs, activities of daily living; DVT, deep vein thrombosis; IADLs, instrumental activities of daily living; LE, lower extremity; ROM, range of motion; SLP, speech language pathology; UE, upper extremity.
Table 8.3 Continued
10 improve safety awareness and decrease falls risk;
11 motor recovery of the upper and lower extremity.
The long-term expectation for J is that he will return home with the support of his family. He is not expected to have a full recovery. He will adapt to the consequences of stroke and be independent in ADLs and home ambulation. He will become engaged in community-based physical and social activity programs and return to some leisure activities. J is not likely to be able to drive again or be fully independent in instrumental ADLs (e.g., manage fi nances, cook, clean, yard work) (Table 8.3).
To optimize recovery, J will require intensive and progressive exercise and training programs. The intensity with which stroke rehabilitation therapies are provided is correlated with the rate of recovery post-stroke. Highly repetitive practice and careful monitoring of direct therapy time are required to ensure that J is continuously engaged in interactive therapy. The use of therapy aides, robotic devices, and assistive technologies could be used to increase exposure to practice. Families and caregivers should be involved in therapy sessions and instructed in methods to encourage practice and utilization of new skills. Endurance for therapies should be increased and determined by heart rate, blood pres- sure, or Borg exertion scales.
J will require continued outpatient therapies after discharge and engagement in community-based activity programs. In addition to individualized therapy programs with physical therapy, occupa- tional therapy, and speech and language, well- resourced, community-based adaptive exercise programs should be recommended. These programs integrate social support, with physical activity, and training in instrumental ADLs to support continued recovery and to improve quality of life. Collaborat- ing with Area Agency on Aging Programs and Senior
Citizen Programs could be a low-cost method to provide ongoing physical activity.
The success of the rehabilitation and recovery programs for J should be periodically assessed using the Stroke Impact Scale. This self-report or proxy report instrument will capture J’s recovery of upper extremity and lower extremity function, communi- cation, emotional well-being, mobility, ADLs, and instrument ADLs, as well as participation. The Stroke Impact Scale can be administered within 1 month post-stroke and at follow-up 3, 6, or 1 year post-stroke. Due to the high incidence of falls in stroke survivors living in the community, history of falls and falls risk should be evaluated at each primary care visit and subsequent recommenda- tions made to manage and reduce the risk of falls.
Ongoing community-based care must include con- tinued monitoring and management of J’s hyperten- sion and screening and management of depressive symptoms.
There are substantial improvements in outcomes from well-organized, intensive acute rehabilitation programs. Stroke is, however, a chronic disease, and there is ever-growing evidence that individuals can continue to experience recovery beyond the initial 3 months. Community-based programs integrated with rehabilitation programs are needed to decrease the probability of functional decline post-recovery and to ensure better fi tness and improved quality of life for J. Adherence to post-stroke rehabilitation guidelines will maximize his independence and quality of life.