POST STROKE REHABILITATION

The goals of rehabilitation
The goals of rehabilitation are to help survivors become as independent as possible and to attain the best possible quality of life. Even though rehabilitation does not "cure" stroke ie it does not reverse brain damage, it can substantially help people achieve the best possible long-term outcome.

POST STROKE REHABILITATION
Rehabilitation helps stroke survivors relearn skills that are lost when part of the brain is damaged. For example,

v These skills can include coordinating leg movements in order to walk or carrying out the steps involved in any complex activity.
v Rehabilitation also teaches survivors new ways of performing tasks to compensate for any residual disabilities. Patients may need to learn how to bathe and dress using only one hand, or how to communicate effectively when their ability to use language has been compromised..
v Rehabilitative therapy begins in the acute-care hospital after the patient's medical condition has been stabilized, often within 24 to 48 hours after the stroke.
v The first steps involve promoting independent movement because many patients are paralyzed or seriously weakened. Patients are encouraged to change positions frequently while lying in bed and to engage in passive or active range-of-motion exercises to strengthen their stroke-impaired limbs. ("Passive" range-of-motion exercises are those in which the therapist actively helps the patient move a limb repeatedly, whereas "active" exercises are performed by the patient with no physical assistance from the therapist.) Patients progress from sitting up and transferring between the bed and a chair to standing, bearing their own weight, and walking, with or without assistance. Rehabilitation nurses and therapists help patients perform progressively more complex and demanding tasks, such as bathing, dressing, and using a toilet, and they encourage patients to begin using their stroke-impaired limbs while engaging in those tasks. For some stroke survivors, rehabilitation will be an ongoing process to maintain and refine skills and could involve working with specialists for months or years after the stroke.

DISABILITIES CAUSED AS A RESULT OF STROKE
The types and degrees of disability that follow a stroke depend upon which area of the brain is damaged. Generally, stroke can cause five types of disabilities: paralysis or problems controlling movement; sensory disturbances including pain; problems using or understanding language; problems with thinking and memory; and emotional disturbances.

Paralysis or problems controlling movement (motor control)

v Paralysis is one of the most common disabilities resulting from stroke. The paralysis is usually on the side of the body opposite the side of the brain damaged by stroke, and may affect the face, an arm, a leg, or the entire side of the body.
v One-sided paralysis is called hemiplegia (one-sided weakness is called hemiparesis). Stroke patients with hemiparesis or hemiplegia may have difficulty with everyday activities such as walking or grasping objects.
v Some stroke patients have problems with swallowing, called dysphagia, due to damage to the part of the brain that controls the muscles for swallowing.
v Damage to a lower part of the brain, the cerebellum, can affect the body's ability to coordinate movement, a disability called ataxia, leading to problems with body posture, walking, and balance.

Sensory disturbances including pain

v Stroke patients may lose the ability to feel touch, pain, temperature, or position ETC.. Some stroke patients experience pain, numbness or odd sensations of tingling or prickling in paralyzed or weakened limbs, a condition known as paresthesia.
v Stroke survivors frequently have a variety of chronic pain syndromes resulting from stroke-induced damage to the nervous system (neuropathic pain). Patients who have a seriously weakened or paralyzed arm commonly experience moderate to severe pain that radiates outward from the shoulder. Most often, the pain results from a joint becoming immobilized due to lack of movement and the tendons and ligaments around the joint become fixed in one position. This is commonly called a "frozen" joint; "passive" movement at the joint in a paralyzed limb is essential to prevent painful "freezing" and to allow easy movement if and when voluntary motor strength returns.
v In some stroke patients, pathways for sensation in the brain are damaged, causing the transmission of false signals that result in the sensation of pain in a limb or side of the body that has the sensory deficit. The most common of these pain syndromes is called "thalamic pain syndrome," which can be difficult to treat even with medications.
v The loss of urinary continence is fairly common immediately after a stroke and often results from a combination of sensory and motor deficits. Stroke survivors may lose the ability to sense the need to urinate or the ability to control muscles of the bladder. Some may lack enough mobility to reach a toilet in time. Loss of bowel control or constipation may also occur. Permanent incontinence after a stroke is uncommon. But even a temporary loss of bowel or bladder control can be emotionally difficult for stroke survivors.

Problems using or understanding language (aphasia)

v At least one-fourth of all stroke survivors experience language impairments, involving the ability to speak, write, and understand spoken and written language. A stroke-induced injury to any of the brain's language-control centers can severely impair verbal communication. Damage to a language center located on the dominant side of the brain, known as Broca's area, causes expressive aphasia. People with this type of aphasia have difficulty conveying their thoughts through words or writing....
v The most severe form of aphasia, global aphasia, is caused by extensive damage to several areas involved in language function. People with global aphasia lose nearly all their linguistic abilities; they can neither understand language nor use it to convey thought.
v A less severe form of aphasia, called anomic or amnesic aphasia, occurs when there is only a minimal amount of brain damage;. People with anomic aphasia may simply selectively forget interrelated groups of words, such as the names of people or particular kinds of objects.

Problems with thinking and memory

v Stroke can cause damage to parts of the brain responsible for memory, learning, and awareness.
v Stroke survivors may have dramatically shortened attention spans or may experience deficits in short-term memory. Individuals also may lose their ability to make plans, comprehend meaning, learn new tasks, or engage in other complex mental activities.
v Two fairly common deficits resulting from stroke are anosognosia, an inability to acknowledge the reality of the physical impairments resulting from stroke, and neglect, the loss of the ability to respond to objects or sensory stimuli located on one side of the body, usually the stroke-impaired side.
v Stroke survivors who develop apraxia lose their ability to plan the steps involved in a complex task and to carry the steps out in the proper sequence. Stroke survivors with apraxia may also have problems following a set of instructions. Apraxia appears to be caused by a disruption of the subtle connections that exist between thought and action.

Emotional disturbances

v Many people who survive a stroke feel fear, anxiety, frustration, anger, sadness, and a sense of grief for their physical and mental losses. Some emotional disturbances and personality changes are caused by the physical effects of brain damage.
v Clinical depression, which is a sense of hopelessness that disrupts an individual's ability to function, appears to be the emotional disorder most commonly experienced by stroke survivors. Signs of clinical depression include sleep disturbances, a radical change in eating patterns that may lead to sudden weight loss or gain, lethargy, social withdrawal, irritability, fatigue, self-loathing, and suicidal thoughts. Post-stroke depression can be treated with antidepressant medications and psychological counseling.

MEDICAL PROFESSIONALS INVOLVED IN POST STROKE REHABILITATION

Post-stroke rehabilitation involves physicians; rehabilitation nurses; physical, occupational, recreational, speech-language, and vocational therapists; and mental health professionals.

Physicians

v Physicians have the primary responsibility for managing and coordinating the long-term care of stroke survivors, including recommending which rehabilitation programs will best address individual needs.
v Physicians are also responsible for caring for the stroke survivor's general health and providing guidance aimed at preventing a second stroke, such as controlling high blood pressure or diabetes and eliminating risk factors such as cigarette smoking, excessive weight, a high-cholesterol diet, and high alcohol consumption.

Rehabilitation nurses

v Nurses specializing in rehabilitation help survivors relearn how to carry out the basic activities of daily living.
v They also educate survivors about routine health care, such as how to follow a medication schedule, how to care for the skin, how to manage transfers between a bed and a wheelchair, and special needs for people with diabetes.
v Rehabilitation nurses also work with survivors to reduce risk factors that may lead to a second stroke, and provide training for caregivers.
v Nurses are closely involved in helping stroke survivors manage personal care issues, such as bathing and controlling incontinence. I f problems of incontinence continues catheterization is usually done.

Physical therapists

v Physical therapists specialize in treating disabilities related to motor and sensory impairments.
v . They assess the stroke survivor's strength, endurance, range of motion, gait abnormalities, and sensory deficits to design individualized rehabilitation programs aimed at regaining control over motor functions.
v Physical therapists help survivors regain the use of stroke-impaired reduce the effect of remaining deficits.
v Establishes ongoing exercise programs to help people retain their newly learned skills. Disabled people tend to avoid using impaired limbs, a behavior called learned non-use. However, the repetitive use of impaired limbs encourages brain plasticity** and helps reduce disabilities.
v Strategies used by physical therapists to encourage the use of impaired limbs include selective sensory stimulation such as tapping or stroking, active and passive range-of-motion exercises, and temporary restraint of healthy limbs while practicing motor tasks. Some physical therapists may use a new technology, transcutaneous electrical nerve stimulation (TENS), that encourages brain reorganization and recovery of function. TENS involves using a small probe that generates an electrical current to stimulate nerve activity in stroke-impaired limbs.
v A recent trend in physical therapy emphasizes the effectiveness of engaging in goal-directed activities, such as playing games, to promote coordination.

Occupational and recreational therapists

v Like physical therapists, occupational therapists are concerned with improving motor and sensory abilities.
v They help survivors relearn skills needed for performing self-directed activities-occupations-such as personal grooming, preparing meals, and housecleaning. Therapists can teach some survivors how to adapt to driving and provide on-road training.
v They often teach people to divide a complex activity into its component parts, practice each part, and then perform the whole sequence of actions. This strategy can improve coordination.

Speech-language therapists

v Speech-language pathologists help stroke survivors with aphasia relearn how to use language or develop alternative means of communication. They also help people improve their ability to swallow
v . Some forms of short-term therapy can improve comprehension rapidly. Intensive exercises such as repeating the therapist's words, practicing following directions, and doing reading or writing exercises form the cornerstone of language rehabilitation...
v Symbol boards or sign language can be used., speech-language pathologists work with the individual to devise strategies to overcome or minimize swallowing deficit. Sometimes, simply changing body position and improving posture during eating can bring about improvement. The texture of foods can be modified to make swallowing easier; for example, thin liquids, which often cause choking, can be thickened. Changing eating habits by taking small bites and chewing slowly can also help alleviate dysphagia.

Vocational therapists

v Approximately one-fourth of all strokes occur in people between the ages of 45 and 65. For most people in this age group, returning to work is a major concern. Vocational therapists perform many of the same functions that ordinary career counselors do
v Most important, vocational therapists educate disabled individuals about their rights and protections as defined by the Americans with Disabilities Act of 1990. This law requires employers to make "reasonable accommodations" for disabled employees. Vocational therapists frequently act as mediators between employers and employees to negotiate the provision of reasonable accommodations in the workplace.

PLACES FOR REHABILITATION FOR STROKE PATIENTS
Rehabilitation should begin as soon as a stroke patient is stable, often within 24 to 48 hours after a stroke. This first stage of rehabilitation usually occurs within an acute-care hospital. At the time of discharge from the hospital, the stroke patient and family coordinate with hospital social workers to locate a suitable living arrangement. Many stroke survivors return home, but some move into some type of medical facility.

• Inpatient rehabilitation units

Inpatient facilities may be freestanding or part of larger hospital complexes. Patients stay in the facility, usually for 2 to 3 weeks, and engage in a coordinated, intensive program of rehabilitation. Such programs often involve at least 3 hours of active therapy a day, 5 or 6 days a week

• Outpatient units

Outpatient facilities are often part of a larger hospital complex and provide access to physicians and the full range of therapists specializing in stroke rehabilitation. Patients typically spend several hours, often 3 days each week, at the facility taking part in coordinated therapy sessions and return home at night. Comprehensive outpatient facilities frequently offer treatment programs as intense as those of inpatient facilities, but they also can offer less demanding regimens, depending on the patient's physical capacity.

• Nursing facilities

Rehabilitative services available at nursing facilities are more variable than are those at inpatient and outpatient units. Skilled nursing facilities usually place a greater emphasis on rehabilitation, whereas traditional nursing homes emphasize residential care.

• Home-based rehabilitation programs

Stroke survivors may participate in an intensive level of therapy several hours per week or follow a less demanding regimen. The major disadvantage of home-based rehabilitation programs is the lack of specialized equipment.

RESEARCH

The National Institute of Neurological Disorders and Stroke (NINDS), a component of the Federal Government's National Institutes of Health (NIH), has primary responsibility for sponsoring research on disorders of the brain and nervous system, including the acute phase of stroke and the restoration of function after stroke.
The NINDS also supports research on ways to enhance repair and regeneration of the central nervous system.
Scientists funded by the NINDS are studying how the brain responds to experience or adapts to injury by reorganizing its functions (plasticity) by using noninvasive imaging technologies to map patterns of biological activity inside the brain.
Other NINDS-sponsored scientists are looking at brain reorganization after stroke and determining whether specific rehabilitative techniques, such as constraint-induced movement therapy and transcranial magnetic stimulation, can stimulate brain plasticity, thereby improving motor function and decreasing disability.

NURSING DIAGNOSIS:IMPAIRED VERBAL COMMUNICATION
NANDA DEFINITION

: Decreased, delayed, or absent ability to receive, process, transnsmit and use a system of symbols

Defining Characteristics:
Inability to find, recognize, or understand words
*Difficulty vocalizing words
* Inability to recall familiar words, phrases, or names of known persons, objects, and places
* Unable to speak dominant language
* Problems in receiving the type of sensory input being sent or sending the type of input necessary for understanding

* Related Factors:
v Brain injury that adversely affects the transmission, reception or interpretation of language or other forms of communication
* Structural problem (e.g., cleft palate, laryngectomy, tracheostomy, intubation, or wired jaws)
* Cultural difference (e.g., speaks different language)
* Dyspnea
* Fatigue
* Sensory challenge involving hearing or vision

Expected Outcomes Patient is able to use a form of communication to get needs met and to relate effectively with persons and his or her environment.

ASSESS THE FOLLOWING

v The patient’s primary and preferred means of communication (e.g., verbal, written, gestures).
v Ability to understand spoken word. It is important for health care workers to understand that the construct of gestured language has an entirely different structure from verbal and written English. Signed English is not the true language of the deaf community but an instructional mechanism developed to teach it the structure of English so that individuals with hearing impairments may read and write it. Some members of the deaf community learn to do so effectively. American Sign Language is the true language of the deaf community. U.S. federal law requires the use of an official interpreter to communicate with persons who choose to receive informed consent and other important medical information in their own language.

o The patient’s preferred language for verbal and written communication. Patients may speak a language quite well without being able to read it effectively. Discharge self-care and follow-up information must be communicated and reinforced with written information that the patient can use. The nurse can no longer assume that it is the patient’s responsibility to grasp the information that is being provided. In recognition of the vast array of cultures and physical challenges that patients face, it is the nurse’s responsibility to communicate effectively.

o Ability to understand written words, pictures, gestures. In some cases the only way to be certain that communication has been effective is to arrange for a certified interpreter to validate information from both sides of the dialogue.

* Assess conditions or situations that may hinder the patient’s ability to use or understand language, such as the following:

• Alternate airway (e.g., tracheostomy, oral or nasal intubation). When air does not pass over vocal cords, sounds are not produced.
  
• Orofacial/maxillary problems (e.g., wired jaws). Words are articulated by coordinated movement of mouth and tongue; when movement is impinged, communication may be ineffective.
• Assess for presence of expressive aphasia (inability to convey information verbally) and receptive aphasia (i.e., word meaning may be scrambled during the processing of information by the patient’s brain).
• Assess for presence and history of dyspnea. Patients who are experiencing breathing problems may reduce or cease verbal communication that may complicate their respiratory efforts.
• Assess energy level. Fatigue and/or shortness of breath can make communication difficult or impossible.
• Assess knowledge of patient’s, family’s, or caregiver’s understanding of sign language, as appropriate. Individuals who have no formal training in sign language usually develop mechanisms for communication; but since communication is such a critical aspect of everyone’s life, consider formal training for patient and caregivers to enhance communication.

THERAPEUTIC INTERVENTIONS
* Assist the patient in seeking an evaluation of his or her home and work settings. This will evaluate the need for things such as assistive devices, talking computers, telephone typing device, and interpreters.
* Anticipate patient needs and pay attention to nonverbal cues. The nurse should set aside enough time to attend to all of the details of patient care. Care measures may take longer to complete in the presence of a communication deficit.
* Place important objects within reach. This maximizes patient’s sense of independence.
* Provide alternate means of communication for times when interpreters are not available (e.g., a phone contact who can interpret the patient’s needs).
* Encourage patient’s attempts to communicate; praise attempts and achievements.
* Listen attentively when patient attempts to communicate. Clarify your understanding of the patient’s communication with the patient or an interpreter.
* Never talk in front of patient as though he or she comprehends nothing. This will prevent increasing the patient’s sense of frustration and feelings of helplessness.
* Keep distractions such as television and radio at a minimum when talking to patient. This will keep patient focused, decrease stimuli going to the brain for interpretation, and enhance the nurse’s ability to listen.
* Do not speak loudly unless patient is hearing-impaired. Loud talking does not improve the patient’s ability to understand if the barriers are primary language, aphasia, or a sensory deficit.
* Maintain eye contact with patient when speaking. Stand close, within patient’s line of vision (generally midline). Patients may have defect in field of vision or may need to see the nurse’s face or lips to enhance understanding of what is being communicated.
* Give the patient ample time to respond. It may be difficult for patients to respond under pressure; they may need extra time to organize responses, find the correct word, or make necessary language translations.
* Praise patient’s accomplishments. Acknowledge his or her frustrations. The inability to communicate enhances a patient’s sense of isolation and may promote a sense of helplessness.
* If the patient’s ability to speak is limited to yes and no answers, try to phrase questions so that the patient can use these responses.
* Use short sentences and ask only one question at a time. This allows the patient to stay focused on one thought.
* Speak slowly and distinctly, repeating key words to prevent confusion. Supplement verbal communication with meaningful gestures. This provides the patient with more channels through which information can be communicated.
* Give concrete directions that the patient is physically capable of doing (e.g., "point to the pain," "open your mouth," and "turn your head").
* Avoid finishing sentences for the patient. Allow the patient to complete his or her sentence and thought; but if the patient appears to be having difficulty, ask the patient for permission to help them. Say the word or phrase slowly and distinctly if help is requested. Be calm and accepting during attempts; do not say you understand if you do not. This may increase frustration and decrease the patient’s trust in you.
* When patient has difficulty with verbal expressions, support the work the patient is doing in speech therapy by providing practice sessions often throughout the day. Begin with simple words (e.g., "yes," "no," "this is a cup"), then progress.
* When patient cannot identify objects by name, give practice in receiving word images (e.g., point to an object and clearly enunciate its name: "cup" or "pen").
* Correct errors. Not correcting errors reinforces undesirable performance, and will make correction more difficult later.
* Provide a list of words patient can say; add new words to it. Share this list with family, significant others, and other care providers. This broadens the group of people with whom the patient can communicate.
* Provide patient with word-and-phrase cards, writing pad and pencil, or picture board. This is especially helpful for intubated and tracheal patients or those whose jaws are wired.
* Carry on a one-way conversation with a totally aphasic patient. It may not be possible to determine what information is understood by the patient, but it should not be assumed that the patient understands nothing about his or her environment.
* Consult a speech therapist for additional help. See that patient is well-rested before each session with the speech therapist. Fatigue may have an adverse effect on learning ability.
* Consider use of electronic speech generator in postlaryngectomy patients.
Education/Continuity of Care
* Inform patient, significant other, or caregiver of the type of aphasia the patient has and how it affects speech, language skills, and understanding. Many family members assume that a patient’s mentation has been affected by a brain injury; this may or may not be true, and if true, some of the effects may be amenable to remediation.
* Offer significant others the opportunity to ask questions about patient’s communication problem. It is important for the family to know that there are many ways to send information to someone and that time may be needed to understand the special needs of the patient.
* Provide answers and helpful suggestions for what is known while not providing false assurances.
* Encourage family member/caregiver to talk to patient even though patient may not respond. This decreases patient’s sense of isolation and may assist in recovery from aphasia.
* Encourage patient to socialize with family and friends. Communication should be encouraged despite impairment.
* Explain that brain injury decreases attention span.
* Suggest that the family engage the patient often throughout the day for short periods. Encourage the family to look for cues that the patient is overstimulated or fatigued.
* Provide patient with an appointment with a speech therapist, if not already done.
* Inform patient and significant others to seek information about aphasia from the American Speech-Language-Hearing Association, 10810 Rockwell Pike, Rockville, MD 20852.
* Deaf patients and their families should be referred to their local hearing society for community support, education, and sign language training.