2. Neuroplasticity
– Use it or lose it
– Use it and improve it
– Specificity matters
– Repetition matters
– Intensity matters
Jeffery Kleim and Theresa Jones. Principles of Experience-Dependent Neural Plasticity: Implications for
Rehabilitation After Brain Damage. Journal of SLH Research. Vol 51: S225-S239. Feb 2008
– Time matters
– Salience matters
– Age matters
– Transference
– Interference
3. Importance of Early Mobilization
– Maintain cardiovascular endurance
– Neuroplasticity
– Orthostatic hypotension
– Minimize hemi spatial neglect
– Minimize visual deficits
– Minimize changes in muscle tone
– Balance training
– Trunk control
– Pt satisfaction
– Increased independence
– Family training
– Family involvement
4. Collaboration for Goals of Care
– Importance of patient and family input for goals of therapy
– Importance of patient and family participation towards goals
– Use of white board for daily goals or goal cards
– Interdisciplinary communication of goals, expectations, and involvement
(Nursing, physician, therapists, case management, social workers)
6. Patients with L Hemiplegia
– Performance style: Impulsive, denial of deficit, poor safety awareness, increased
fall risk, poor quality of learning
– Prior coping style: Pts may have been impulsive prior to stroke
– Poor orientation of midline
– Visual perceptual deficits
– Hemianopia
8. Patients with R Hemiplegia
– Performance style: Learning deficit influenced by communication loss,
emotionally labile, depression
– Prior coping styles
– Reduce distractions, one person cueing, noise to a minimum, TV off
– Hemianopia
– Receptive or global aphasia teach by demonstration and/or simple cues
(Contact the SLP for best way to communicate with pt)
10. Vision
– Homonymous hemianopia (visual field cut)
– Approach from hemi side and establish visual contact, if still having difficulties
then approach from non hemi side
– Consider bed positioning to allow maximal stimulation from hemi side
– Diplopia (double vision): allow maximal input to visual system
– No full eye patching, okay to patch on top of eye glasses, switch sides during day (2
glasses) ask OT department for glasses or use safety goggle
– Cortical blindness
– Midline orientation
11. Hemi Spatial Neglect
– Positioning for increased stimulation
of neglected side
– Education to family to address pt from
neglected side
– Tactile input to neglected limbs
– Environmental stimulation for
neglected side
– Perform transfers to strong side
12. Demonstrations: R Hemiplegia
– Range of motion
– Positioning in bed
– Positioning in chair
– Self care principles
– Bed mobility
– Proper use of gait belt
– Transfers
– Ambulation
13. Range of Motion
– Upper Extremity:
Shoulder and hand position
– Pt assisting with self range
– PROM Handout for UE (adaptive
from Rancho)
– Lower Extremity:
Ankle and hip position
– Passive Range of Motion
(Pages 6-8 for the legs)
Best positioning: Flat on back, bed railing down, stand close to pt
Repetitions: 2-3 good slow stretches are better than 10 fast partial
Time to perform: 10 minutes to 45 minutes
14. Positioning in Bed
– Bed positioning in room to incorporate hemiplegic side
– Head positioning with towel roll
– Hemiplegic arm elevated above heart
– Hand with wash cloth roll
– Leg positioning with trochanter roll
– Foot positioning with Foothold boots vs Skil-Care heel float vs pillow for
positioning
15. Positioning in Chair
– Chair positioning with family addressing from hemiplegic side
– Trunk positioning with blanket roll to maintain upright
– Hemiplegic arm supported on bedside table
– Legs in neutral position can use blanket roll to assist
– Feet flat on floor
17. Self Care Principles
– Encourage the use of the hemiplegic hand, if cannot do by self, then
utilize hand over hand enablement
– Grooming, holding emesis basin, eating with hand on tray and cup in hand
– Dressing techniques
– Paretic extremity in first and out last
– Bathing and dressing
– Encourage firm rubbing of hemi-paretic side
– Sensory stimulation
18. Bed Mobility
– Bed: Prior to movement max inflate bed
– Rolling: Towards weaker side
– Sitting balance: Address upright orientation
– Foot stool if feet are not touching ground
– If pt is pushing or leaning to one side, you can sit next to them
– Eyes open and focusing on vertical object in front of them
– Weight shifting for scooting forward
– Do not proceed to transfer if cannot easily sit at EOB
25. Gait Belt
– When do I use it:
– Transfers and ambulation
– Where do I put it:
– Between hips and axilla at
smallest circumference
– Where do I hold it:
– Behind patient with one or both
hands
– How can it help me:
– Weight shifting, preventing falls
– How can I tell that it is tight enough:
– Enough space for your hands, but not
enough space to move up or down
– How do I use this when the pt has
drains:
– Depending on location of drains, can
use higher or lower
– How do I use this when the pt is
obese, breast tissue, rib fractures,
surgical incisions
– Avoid painful areas, lift breast tissue
when tightening belt, move gown
material out of the way
26. Transfers
– Chair position:
– Set up prior to transfer on pt’s strong
side
– Set up chair with pillow, sheet, and
chucks
– Line management:
– Place IV lines, catheters, and monitor
cables in a position that allows a clear
path for transfer
– Bed:
– Use seat deflate option to bring feet
towards floor
– Place gait belt while sitting at EOB,
may need second person for support
– Staff member set up:
– Hands on gait belt
– Block hemi-paretic knee, foot assist
– Trunk on hemiplegic side
– Legs together or staggered
– Allow pt’s trunk and knees to move
forward during transfer
– Lift equipment: STEDY
32. Ambulation
– Prior to ambulating:
– Assess movement of hemiplegic leg
– Cannot lift against gravity = unable to support body weight
– Knee will either collapse or have a knee extension thrust
– Can my patient perform a transfer without buckling or an extension thrust:
– Yes: Proceed to walking (check with therapist for proper device)
– No: Perform transfer only, do not progress to ambulation
– If ambulation is necessary: use gait belt, tie gown base to observe knee, use hand on their knee to
prevent collapse, use a second person for line management, follow with chair or WC
– Just because a pt can walk, does not mean that they should walk
– Does my pt have strong legs, but a weaker arm?
– Modify FWW by adding build up, may also need manual assist
33. Therapy in Settings
(Typical progression)
– Intensive Care Unit:
– ROM by self, visual rehab, sensory stimulation, sitting balance, potentially transfers,
changing bed into chair position to work on upright tolerance
– Step Down Unit:
– Self care, transfers, increase sitting endurance, potentially ambulation (may use
railing), transfer on toilet vs commode
– Acute Rehabilitation Unit:
– WC based tasks ADLs progression to ambulation, stair training, community
reintegration, car transfers, care giver training, specialized equipment, fall recovery
34. References
– Medicare.gov
– CMS.gov
– Rehabnurse.org
– Stroke.org
– Kleim, J and Jones, T: Principles of Experience-Dependent Neural Plasticity:
Implications for Rehabilitation After Brain Damage. Journal of SLH Research. Vol 51:
S225-S239. Feb 2008
– Figueroa, J, Basford, J, and Low, P. Preventing and Treating Orthostatic Hypotension:
Easy as A, B, C. Cleve Clin J Med. 2010 May;77(5):298-306.
– Occupational ToolKit
35. Questions
– Can send email to: croys@uci.edu
– Asks a therapist on your floor for hands on assist if needing clarification
