COURSE PRICE: $10.00
CONTACT HOURS: 1
Approval of physical therapy CE varies by state. You are responsible for obtaining approval from your licensing agency before taking the course if you want the course to count towards meeting your CE requirements. Read our PT Course Approvals FAQ for more information.
The planners and authors of this CE activity have disclosed no relevant financial relationships with any commercial companies pertaining to this activity.
Michael Jay Katz has taught anatomy, physical diagnosis, and scientific writing in the medical school of Case Western Reserve University for more than twenty-five years. He has written sixteen books and eighty papers and essays. He is currently the anatomy and physiology consultant for Taber's Cyclopedic Medical Dictionary.
Copyright © 2010 Wild Iris Medical Education, Inc. All Rights Reserved.
COURSE OBJECTIVE: The purpose of this course is to present the primary elements of post-hospital care recovering stroke patients.
Upon completion of this course, you will be able to:
Acute care for a stroke takes place over the course of days, but recovery and rehabilitation takes place over the course of months and years.
In the United States, the average hospital stay for an acute stroke patient was 4.9 days in 2006 (CDC, 2010b). From the hospital, 30% of stroke patients were discharged home with no planned home health care, 17% were discharged home with planned home health care, 20% were discharged to a rehabilitation center, and 33% were sent to a skilled nursing facility (Kind et al., 2010).
As the hospital stroke team turns a stroke patient over to the rehabilitation team, the patient, family, and caregivers need to be informed, educated, and “kept in the loop.” After the hospitalization, these people will be making the day-to-day healthcare decisions, and these decisions need to be based on accurate, realistic information. For example, post-stroke patients need to understand their medications; they need to know:
Patient education will already have begun during a patient's hospitalization, with stroke nurses explaining the causes for the patient's symptoms and the reasoning behind the treatments (Summers et al., 2009). Yet the sudden influx of medical information at discharge can be overwhelming. Therefore, patients and families should be given instructions and guidelines in the form of printed materials that can be reviewed at home. Nurses should also include a list of medically accurate stroke websites; the “Resources” section at the end of this course offers some suggestions.
THE ROLE OF NURSES IN THE DISCHARGE PROCESS
Nurses are the key players in organizing a patient's discharge from the hospital. Nurses are with the patient throughout the day, and they have seen the full range of the patient's limitations and dependencies. While a patient is still in the hospital, nurses on the stroke team initiate the patient's transition into the appropriate supervised rehabilitation programs. As the time of discharge approaches, nurses arrange to have a patient's limitations assessed formally by specialists—physiotherapists, occupational therapists, speech therapists, psychologists, and nutritionists. These professionals then make recommendations that can be taken into account before physicians have begun discharging the patient.
Nurses are also the family educators. Nurses explain the pathology of the patient's particular stroke, they describe practical problems that the patient will face, and they outline the methods for preventing a recurrence of the stroke. A nurse will demonstrate how to manage continuing healthcare problems, such as changing dressings and applying topical medicines. A nurse will give advice to caregivers and family about communicating with a patient who is aphasic or who has significant motor or sensory deficits. A nurse should also check to see that follow-up visits with a physician are scheduled and that the family and patient are aware of these appointments.
In their discussions with the patient and family, a nurse should explain that almost 3/4 of stroke survivors will eventually need their family's assistance at home and that the practicalities and costs of that home help should be thought through in advance. Finally, a nurse should make sure that a social worker or community liaison provides referrals to government and nonprofit help agencies, support groups, and other helpful community resources (Summers et al., 2009).
Discharge from the hospital is the beginning of what is often an arduous process. After a stroke, patients can be limited in their ability to interact with the world or in their ability to independently carry out their wishes. For example, they may be unable to speak clearly, or they may be unable to move one of their limbs. Recovering lost skills through physical rehabilitation is one major goal of post-hospital recovery.
There is a great deal of variability in how fast and to what extent people recover after a stroke. There are, however, some general time lines of recovery. After a stroke, patients reach their maximum ability to perform activities of daily living more slowly when their stroke has left them severely disabled. Mildly disabled stroke patients tend to reach their best level of functioning 2-1/2 months after the stroke. Moderately disabled stroke patients reach their peak in about 3 months. However, severely disabled stroke patients may still be improving 5 months after the stroke (Stein, 2008).
Patients take longer to recover from more disabling strokes, and their progress is slow. Because some skills return very slowly while other abilities are never regained, post-stroke physical rehabilitation tries to help patients get on with their lives by learning substitute skills as well as by working on regaining lost skills.
As they restrengthen their minds and bodies and learn new adaptations, stroke patients are medically vulnerable. One-fifth of the men and 1/4 of the women who have had their first stroke will die within the year, and 1/4 of stroke survivors will have another stroke within 5 years (University Hospital, n.d.). Therefore, after discharge from the hospital, patients need to embrace lifestyle and medical regimens that reduce the risk of further strokes. Prevention of additional strokes through medical rehabilitation is a second major goal of post-hospital recovery.
COMPREHENSIVE DISEASE MANAGEMENT PROGRAMS
Coordinating the various medical and lifestyle regimens that are needed to reduce the risk of another stroke can be a complex task. As an aid, medical rehabilitation can be more efficiently organized using a comprehensive disease management program that will ensure thorough medical care after a patient's discharge (Furie et al., 2009).
One good example is the PROTECT program, which is designed for ischemic stroke patients and was developed at the UCLA Medical Center. This program begins its post-hospital care planning while the patient is still in the hospital. PROTECT uses only existing resources and personnel to create an individualized regimen of medications (antithrombotics, ACE-inhibitors, thiazide diuretics, and statins), exercise, diet, education, and regular check-ups that continue for a year.
The PROTECT program is designed to be easy to implement. Its website offers information and printable forms, including a preprinted admission order sheet, a medication algorithm, a patient tracking form, interdisciplinary sheets, patient information sheets (in English and Spanish), the draft of a letter to the primary care physician and a discharge summary template (PROTECT, 2002).
After a stroke, the patient's health is unstable, and they are at risk for cardiovascular problems and for additional strokes. Medically, the post-hospital goals for a stroke patient are to avoid or to quickly deal with medical complications and to prevent the recurrence of strokes. Plans to safeguard a patient's health can be called medical rehabilitation. A number of medical conditions need to be addressed in a medical rehabilitation program.
Patients with ischemic strokes are assumed to have underlying prothrombotic conditions. For ischemic strokes not due to emboli originating in the heart, daily aspirin, aspirin plus dipyridamole, or aspirin plus clopidogrel are usually prescribed (Furie et al., 2009). For cardioembolic ischemic strokes (e.g., from atrial fibrillation), warfarin (Coumadin) is the more effective antithrombotic medication (Manning & Hart, 2009). (Without a specific medical reason, aspirin must not be added to warfarin therapy.) New evidence suggests that, in the future, strokes from atrial fibrillation may be more safely prevented by different antithrombotic drugs, such as vitamin K-antagonists or dabigatron, or by new techniques for suppressing the arrhythmia (McArthur & Lees, 2010).
High blood pressure puts a stroke victim at risk for additional strokes; therefore, reducing hypertension is a generally accepted post-stroke goal. One common guideline suggests gradually reducing the blood pressure of a post-stroke patient over several months, with an end goal of <130/80 mm Hg. A diuretic or a diuretic plus an ACE inhibitor are usually the recommended medications. This blood pressure goal comes with caveats:
Diabetes doubles a person's risk for having an ischemic stroke. Maintaining good glycemic control, with HbA1c levels <7%, will reduce the microvascular (e.g., retinal and kidney) complications of diabetes. By itself, good glycemic control has not been shown to have a large effect on reducing a diabetic patient's risk for stroke; nonetheless, good glycemic control is recommended for all diabetic stroke patients.
Overweight patients also have an increased risk of stroke. “As with glycemic control, there are no data to confirm that weight reduction will reduce the risk of recurrent stroke. However, weight reduction is potentially beneficial for improved control of other important parameters, including blood pressure, blood glucose, and serum lipid levels” (Furie et al., 2009). The recommendation is that patients maintain a body mass index (BMI) between 18.5 and 24.9 kg/m2 and a waist circumference of <102 cm (40 in) for men and <88 cm (35 in) for women.
For both diabetes and excess body weight, lifestyle changes (e.g., improved diet and increased exercise) are key parts of the medical rehabilitation program.
Dyslipidemia is abnormal amounts of lipids and lipoproteins in the blood. High levels of low-density lipoprotein cholesterol (LDL cholesterol), low levels of high-density lipoprotein cholesterol (HDL cholesterol), and a high ratio of total cholesterol to HDL cholesterol each put a person at risk for developing atherosclerosis of the carotid artery. Evidence is unclear, however, as to whether there is a direct relationship between specific dyslipidemias and stroke risk.
Nonetheless, drug therapy with statins does reduce a person's risk of having an ischemic stroke. This effect is thought to be mainly a function of a statin's antiatherothrombotic actions rather than its cholesterol-lowering actions. Current recommendations include:
Clinical depression is common after stroke; in fact, it has been estimated that as many as 40% of patients suffer treatable depression (Stein, 2008). Patients at high risk for clinical depression or anxiety can be identified within the first 2 weeks after a stroke with the brief and easy-to-use Hospital Anxiety and Depression Scale (Sagen et al., 2010, 2009). Other brief depression assessment tools have also proven useful (Pfeil et al., 2009; Roger & Johnson-Greene, 2009; Lee et al., 2008). Post-stroke depression is usually treated with selective serotonin reuptake inhibitors, such as fluoxetine, paroxetine, or sertraline.
After a stroke, it is not unusual for patients to develop other medical problems. The following table shows some of these problems and the medications used to treat them.
| Problem | Medication |
|---|---|
| Source: Stein, 2008. | |
| Bladder instability | Anticholinergics (e.g., oxybutynin or tolterodine) |
| Erectile dysfunction | Phosphodiesterase type 5 inhibitors (sildenafil, vardenafil) |
| Impaired mental arousal | Stimulants (dextroamphetamine, methylphenidate) |
| Muscle spasticity | Antispasmodics (e.g., baclofen, dantrolene, diazepam, tizanidine) |
| Pain syndromes | Anticonvulsants (carbamazepine, gabapentine) |
| Seizure disorders | Anticonvulsants (carbamazepine, gabapentine) |
Certain stroke patients may benefit from additional medical procedures. Carotid endarterectomy is often recommended for ischemic stroke patients with ipsilateral carotid artery stenosis >70%. Endarterectomy is also appropriate in some patients with ipsilateral stenosis between 50% and 70%. Carotid stenting is used as an alternative to endarterectomy in some medical centers (Stein, 2008; Summers et al., 2009).
Patients who had a subarachnoid hemorrhage (SAH) and subsequent aneurysm clipping or coil placement have a risk of recurrent bleeding. The most vulnerable patients are those who are elderly, who smoke, who are hypertensive, or who had large or multiple aneurysms. For SAH patients who were treated surgically or endovascularly, it is suggested that the status of their obliterated aneurysm be checked with imaging at 3 and 6 months after the procedure (Singer et al., 2009).
Residual movement problems, such as joint contractures, can sometimes be improved surgically, although rigorous physical therapy is usually the most successful way to regain strength and control of muscles. Typically, spontaneous recovery of motor abilities occurs in the first 6–8 weeks, and physical rehabilitation can continue the progress. By 6–9 months, most patients have reached the peak of their recovery. Any surgical intervention is usually held until >6 months after the stroke, at which time a realistic picture of the patient's permanent limitations becomes clearer (Sawyer, 2007).
Medical rehabilitation is most effective when patients make therapeutic changes in their daily lives. Smokers should quit, heavy people should lose weight, sedentary people should exercise, and high-fat, high-calorie diets should be replaced with low-fat high-fiber diets. Each of these lifestyle modifications can slow the progression of atherosclerosis and help to maintain lower blood pressures
These principles—stop smoking, eat a healthy diet, exercise, and stay thin—will be familiar to most patients. It is the job of the medical rehabilitation team to work with the patient to give specificity to these familiar general statements. The medical team needs to offer practical advice that the patient can follow and that the patient believes is worth following.
Therapeutic lifestyle changes begin with smoking cessation. Carbon monoxide and other poisons in cigarette smoke damage cells throughout the body, and cigarette smoking increases the risk of all forms of stroke: the more a person smokes, the higher the risk. Therefore, stroke patients who smoke are strongly urged to stop smoking (Furie et al., 2009).
Many people find it difficult to stop smoking. A nurse or other member of the stroke team can begin by telling a patient that continued smoking increases their risk of recurrent stroke, serious heart problems, and death, while stopping smoking reduces these risks.
THE 5 A's FOR SMOKERS
Health counselors are encouraged to use the five A's with their patients who smoke:
The American Dietetic Association has collected evidence demonstrating that a low-fat diet with 12 g to 33 g per day of fiber from whole foods or up to 42.5 g per day from supplements can help to reduce blood pressure, correct dyslipidemia, reduce indicators of chronic inflammation, and reduce weight (Am. Diet. Assoc., 2008). A low-fat/high-fiber diet has also been shown to reduce the risk of developing coronary artery disease.
In one large study of elderly people (Mozaffarian et al., 2003), eating whole-grain fiber in the equivalent of an extra two slices of whole-grain bread per day reduced the number of:
Dietary counseling programs can help to maintain long-term improvements in a patient's eating habits. A dietary counseling program begins with a dietary history and measures the patient's height, weight, and waist circumference. Patients (or their families) are then given diaries in which to record their complete food and drink intake for five days. At follow-up visits, the patient's height, weight, and waist circumference are measured, the patient's progress is charted, and specific dietary recommendations are suggested. The diet rehabilitation program should continue until the patient has found a stable, healthy eating routine.
Overweight ischemic stroke patients should be encouraged to lose weight. The recommended goal is to maintain a body mass index (BMI) between 18.5 and 24.9 kg/m2 and a waist circumference for men <102 cm (40 in) and for women <88 cm (35 in).
| 21 | 22 | 23 | 24 | 25 | 26 | 27 | 28 | 29 | 30 | 31 | |
|---|---|---|---|---|---|---|---|---|---|---|---|
| *Weight is measured with underwear but not shoes. | |||||||||||
| BMI values for selected heights between 4'10" and 6'3" and for selected weights between 100 lbs and 248 lbs. BMI values are kilograms of body weight per square meter of body surface area (kg/m2). BMI is an indirect measure of body fat. The BMI of a normal person is 18.5 to 24.9 kg/m2. An overweight person has a BMI of 25 to 29.9 kg/m2. An obese person has a BMI of >30 kg/m2. (Source: NHLBI, 2008.) | |||||||||||
| 4'10" | 100 | 105 | 110 | 115 | 119 | 124 | 129 | 134 | 138 | 143 | 148 |
| 5'0" | 107 | 112 | 118 | 123 | 128 | 133 | 138 | 143 | 148 | 153 | 158 |
| 5'1" | 111 | 116 | 122 | 127 | 132 | 137 | 143 | 148 | 153 | 158 | 164 |
| 5'3" | 118 | 124 | 130 | 135 | 141 | 146 | 152 | 158 | 163 | 169 | 175 |
| 5'5" | 126 | 132 | 138 | 144 | 150 | 156 | 162 | 168 | 174 | 180 | 186 |
| 5'7" | 134 | 140 | 146 | 153 | 159 | 166 | 172 | 178 | 185 | 191 | 198 |
| 5'9" | 142 | 149 | 155 | 162 | 169 | 176 | 182 | 189 | 196 | 203 | 209 |
| 5"11" | 150 | 157 | 165 | 172 | 179 | 186 | 193 | 200 | 208 | 215 | 222 |
| 6'1" | 159 | 166 | 174 | 182 | 189 | 197 | 204 | 212 | 219 | 227 | 248 |
| 6'3" | 168 | 176 | 184 | 192 | 200 | 208 | 216 | 224 | 232 | 240 | 248 |
The most effective way to lose weight and to maintain the lower weight is by participating in a comprehensive weight-loss program that combines low-calorie diets, behavior modification, and regular exercise. Physicians and nurses can encourage their patients in the difficult task of losing weight by checking a patient's BMI and waist circumference at each follow-up visit (Antman et al., 2007; Fraker et al., 2007).
Regular exercise helps to correct dyslipidemia. It also reduces insulin resistance, decreases platelet aggregation, aids weight loss, improves sleep, and gives people a sense of well-being. Regular physical exercise is recommended for ischemic stroke patients who are capable of it. A common recommendation is 30 minutes of moderate-intensity activity on at least three different days each week (Furie et al., 2009). (Brisk walking is an example of a moderate-intensity physical activity.) For patients who have neurological deficits after an ischemic stroke, a supervised therapeutic exercise program is usually recommended (Summers et al., 2009).
After a stroke, a patient may no longer fit into the environment and lifestyle that they were living before they became ill. Previously, they may have been entirely independent, able to go to the bathroom, and able to dress, eat, and travel without assistance. They could talk on the phone, write letters, and figure out their finances by themselves. Some or all of these tasks may now be beyond them. Post-stroke rehabilitation programs ease a patient into a lifestyle that gives them optimal independence and protection.
Physical rehabilitation is needed because strokes commonly lead to functional limitations. Patients can be left with motor deficits, such as difficulty walking, speaking, or swallowing, and they can find themselves unable to perform the basic activities of daily living without assistance. Patients can also be left with sensory deficits, such as disturbances of vision or balance or a lack of perception of pain from injuries. Patients can lose cognitive abilities and become forgetful, inattentive, or unable to learn. Stroke patients can have reduced mobility and reduced ability to communicate, they can be incontinent and unable to function sexually, and their post-stroke lives can become narrow, constricted, and asocial.
For a stroke patient older than 65 years, 6 months after a stroke:
Physical rehabilitation programs aim to reactivate and broaden a stroke patient's life. The rehabilitation goals are to restrengthen the patient's weakened muscular, sensory, and cognitive facilities and to teach the patient ways around those neurological deficits that cannot be reversed.
Strokes frequently reduce a patient's independence by leaving them unable to perform certain movements. For example, they may no longer be able to grasp things with a hand, balance when standing, or walk without assistance.
Overall, 65% to 75% of stroke patients will recover sufficiently to be able to walk, although some will be dependent on braces, support, or other assistance. However, to become ambulatory, patients who have motor deficits need regular range-of-motion exercises throughout the 3- to 4-month period during which their nervous systems are actively recovering. Standing and walking should be practiced as soon as possible. In some cases, electrical stimulation of muscles can help to retain muscle strength and to keep joints fully moveable (Sawyer, 2007).
Compared to recovery for walking, fewer patients recover satisfactory function in an upper extremity that has been disabled by a stroke. As many as 1/3 of stroke patients who have significant dysfunction in their upper limb will not improve significantly and will always have a functionless limb (Sawyer, 2007).
The key to improving any of the lost motor functions is physical rehabilitation. There is a wide range of specific physical rehabilitation programs, but they are all based on movement and exercise. The most common therapeutic exercise programs focus on practical achievements, aiming to make stroke patients more mobile and more independent when performing their actual normal activities of daily living (Stein, 2008).
Many training techniques have been developed for motor function improvement, but no one path to functional improvement has emerged as the standard for stroke rehabilitation (Kalra, 2010). There are, however, commonly agreed-upon principles. A recent comprehensive review found that all effective exercise techniques for reducing motor impairments and improving motor functioning share these four features:
Regardless of the particular muscles or skills to be improved, exercises designed to meet these four criteria appear to be the most effective (Langhorne et al., 2009).
Therapeutic exercise improves the muscles and the lower motor neuron circuits used in the task that is exercised. In addition, the best exercises work more centrally: effective physical therapy appears to act as a guide for the cortical reorganization that is part of the brain's innate recovery from a stroke.
Frontier research continues to discover details about the interactions between exercise and neural reorganization, and the new insights are being used to design novel physical therapy techniques, such as using virtual reality in exercise training (Stein, 2008).
Contracting a single muscle will lead to a ballistic, uncontrolled movement; to make a controlled movement, it is necessary to simultaneously activate opposing muscles. After a stroke, the weakness or paralysis of muscles can impair the use of the opposing muscles, and movements produced by the opposing muscles will be poorly controlled.
This problem is especially apparent at joints, where opposing muscles are used as stabilizers to limit movement in unwanted directions. At joints, the lost muscular opposition can sometimes be replaced by braces or splints. (Braces and splints can be bulky, awkward, or heavy; to be used effectively, these assistive devices need to be lightweight, comfortable, and cosmetically acceptable.)
For example, selective bracing can improve walking after a stroke that has affected the motor functioning of a lower limb. Both hip and knee joint movements can be impaired in hemiplegia, but it is imbalance and instability at the ankle joint that most limits walking. For instance, after a stroke, the equinus deformity of the ankle is common; here, muscle weaknesses leave the foot excessively plantar-flexed. To counteract the weakened ankle dorsiflexors (or, sometimes, the hypertonic ankle plantar-flexors), the patient can wear ankle braces (i.e., lightweight ankle-foot orthoses) to hold the ankle joint in a normal position and significantly improve walking. When bracing is not successful, surgical release of the gastrocnemius fascia can ease the plantar-flexion of an equinus deformity (Takahashi and Shrestha, 2002).
Besides braces, a wide array of technical aids is available to assist stroke patients in overcoming neurological deficits. For mobility, for example, walking can be assisted with canes and walkers. Hemi-wheelchairs, which are low to the ground, allow patients to use their own legs for propulsion. Power wheelchairs and motorized scooters require no lower limb muscles and can be driven using hand controls.
The engineering of assistive technologies is a creative and promising field. Research has shown that patients' brains can directly interface with robotic devices to control upper and lower limbs for tasks such as walking and handling objects. The hope is that these devices will eventually become commercially available (Stein, 2008; Kalra, 2010).
Besides causing motor deficits, strokes can leave a patient with impaired vision or with reductions in somatic or visceral sensation; it is estimated that 60% of stroke patients have sensory impairments. Glasses, hearing aids, and other assistive devices have long been used to compensate for such sensory deficits.
Recent work has taken stroke therapists in a new direction. There is now evidence that more complex sensory and cognitive problems caused by a stroke can be repaired.
For example, hemianopia (the loss of vision in 1/2 of the visual field in one or both eyes) is now being treated directly with a range of new techniques. One technology uses prismatic lenses to project some of the lost visual world onto the functional part of the retina; this reduces the amount of visual space that is hidden by the hemianopia. Another technique widens the accessible visual space by training patients to increase their natural saccades (spontaneous small visual jumps made by the eye); wider saccades take in more of the visual space and increase the patient's field of vision. In small studies, both of these new techniques appear to be effective (Kalra, 2010).
Cognitive abilities can also be impaired by strokes. Patients can have decreases in memory, attention, insight, or comprehension. Neuropsychological assessments done before a stroke patient is discharged can identify many of these problems and alert stroke rehabilitators to specific problems that need work. For example, classifying aphasia early allows patients to be enrolled in appropriate rehabilitation programs, many of which utilize specialized computer software for visual word manipulation or speech synthesis.
Cognitive evaluations are especially useful when counseling patients' families and caregivers. Stroke victims may not be the same bright and independent people that they once were; now they may appear forgetful, depressed, irrational, or aphasic. The family can be overwhelmed by the changes and unable to sort out the true deficits from the secondary effects of those deficits.
Rehabilitators can help by being both realistic and constructive. To make improvements in a patient's cognitive abilities, rehabilitation programs must work at the level at which the patient is currently functioning. Therefore, rehabilitators, who can see the patient more objectively than close family or friends, must give families and caregivers a realistic evaluation of the patient. Additionally, rehabilitators should offer a list of specific and practical actions that family and caregivers can do to help the patient to progress (Stein, 2008).
Recovery from a stroke usually requires long-term coordinated and continuing medical and physical rehabilitation. Nonetheless, rehabilitation workers should remain hopeful—even patients who have been left with severe disabilities from their stroke will still be gradually improving >5 months afterward.
Patients recover from strokes because of the ability of the brain to learn new ways to accomplish old tasks. This learning takes time, and medical rehabilitation tries to maintain a patient's health during that time by, among other things, preventing additional strokes.
Meanwhile, physical rehabilitation tries to maximize the speed at which the brain retrains itself and to substitute tasks that are more manageable for those functions that cannot be relearned. In other words, physical rehabilitation programs aim to reactivate and broaden a stroke patient's life.
American Stroke Association (A Division of American Heart Association)
http://www.strokeassociation.org
Brain Aneurysm Foundation
http://www.bafound.org
Brain Attack Coalition
http://www.stroke-site.org
Internet Stroke Center
http://www.strokecenter.org
National Aphasia Association
http://www.aphasia.org
National Institute of Neurologic Disorders and Stroke
http://www.ninds.nih.gov/disorders/stroke/stroke.htm
National Stroke Association
http://www.stroke.org
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