Care of Patients Post-stroke: The What, How, Why and What Now

By Kelley Williams, OTR/L, BCG, CDP, LSVT

Occupational Therapist

Ask any therapist what a stroke is and they can, almost without hesitation, answer this basic question. From an intellectual standpoint, we can spout off the what, the how, and sometimes the why of a cerebrovascular accident (CVA). Those of us neuro-nerds can even tell you, down to the artery, how our textbooks tell us they should present.

Let’s fast forward. Past the textbooks, past memorizing the internal workings of the brain. You’ve now been sent an order to evaluate and treat a real patient who had a CVA. What exactly does this tell you? This diagnostic label starts your wheels turning and presents you with a frame of reference but only really provides you with 10 percent of the story. So how do you prepare for this scenario? How do you reveal the other 90 percent? My suggestion is to shelve any preconceived notions of what you think you will find. There’s a good chance that, though the information you learned and still have stored in your brain from all of those late nights studying and from the plethora of knowledge and skills gained in your clinical rotations will prove to be essential, you may also find unexpected things. Take your time and be prepared to discover the other 90 percent of your patient’s story. It’s only then that you’ll know the path to travel with them to help them reach their goals.

What is a CVA?

Without laying eyes on the patient, you know right away that they’ve had a stroke. Let’s review exactly what that means. A stroke is defined by the American Stroke Association as a disorder of the brain that occurs when blood vessels that carry oxygen to the brain are blocked or rupture. This causes a disruption of blood flow and vital nutrients to the brain and cell death to the localized area in which the stroke occurred. This cell death is the root cause of any motor or sensory deficit noted in someone who has had a CVA. In a nutshell, it is an event or accident that has occurred within the vascular system of the cerebrum, hence “cerebrovascular accident.” Of note, this title, though appropriate for the vast majority of strokes, doesn’t adequately label a stroke that occurs in the cerebellum or brain stem. In any case, no matter the location of injury, a CVA causes some degree of disruption of brain function.

The manifestations of a CVA will differ depending upon the site and extent of the injury. A few of the most common presentations after a stroke include:

• Weakness and/or numbness on the side of the body contralateral to the site of injury
• Sudden difficulty walking
• Incoordination in the hand on the affected side
• Difficulty swallowing or speaking
• New onset of confusion
• Emotional lability
• Visual perceptual deficits

A patient may also present differently depending upon the amount of time that has passed since the initial CVA. The acute phase is defined as the two-week period immediately following the initial event, and the sub-acute phase ranges from two weeks to six months after the event. In the chronic phase of a CVA, known as the period of time three to six months and beyond after the initial event, the patient may begin to display deficits that are more chronic in nature (ie pain and contractures). Response to exercise may also look very different in the chronic phase due to the body’s adaptation over time to a previously prescribed standard routine, so this should be considered when assigning a home exercise program.

Having an approximate date of diagnosis provides invaluable information. This knowledge will allow for the provision of care that is individualized per your patient’s needs at that precise time in their diagnosis.

How does a CVA occur?

As stated, a CVA can be caused by either a blockage or a rupture. In the first scenario, which is referred to as an ischemic stroke, the vessels within the brain become blocked or narrowed by fatty deposits that have accumulated in the vessels or by a clot that has traveled through the bloodstream and becomes lodged within the vessel. Ischemic strokes are the most common, making up 87 percent of stroke cases. A mini-stroke, or transient ischemic attack (TIA), occurs when a clot temporarily blocks a vessel but is subsequently dissolved or dislodged leaving little to no damage to the surrounding brain cells and tissue. The word transient, by definition, means something that is temporary, so simply put it is a temporary stroke.

In the second scenario, referred to as a hemorrhagic stroke, a weakened blood vessel within the brain or in the subarachnoid space surrounding the brain leaks or ruptures. When this occurs, the blood accumulates and compresses the surrounding brain tissue. The effects of a hemorrhagic stroke depend upon both the extent of the bleed and the nearby cerebral real estate affected by the spread of blood. Hemorrhagic strokes make up around 13 percent of stroke cases.

Why did this CVA happen?

Now we get down to the meat of it. Why did this event happen in the first place? What put this particular person at risk for a CVA? Could it have been prevented and can we reduce the risk of recurrence?

This information is crucial if we expect to help our patients to recognize and control their risk factors. As therapists, and particularly those of us based in the home, we are the eyes and ears of the medical team. It is our responsibility to educate our patients, monitor, and report vital signs, provide interventions and caregiver training to improve medical management, and continuously reassess for patient and family follow-through.

According to the Mayo Clinic, there are both lifestyle risk factors and medical risk factors that are “potentially treatable.” Examples of these factors include:

• Physical inactivity
• Increased body weight
• High blood pressure
• High cholesterol
• Diabetes
• Smoking
• Cardiovascular diseases such as atrial fibrillation

It would take a great deal of time to explain the body’s physiological response to each of these risk factors but suffice it to say if any of these factors are present, they warrant consideration. Think about your patients for a moment. How many of them have one of these risk factors? How many of them have all of these risk factors?

What do we do now?

So, we have a diagnosis and a written medical history. Somewhere within the order, there may be a note about “weakness” or “limited mobility.” The patient may require “ADL assistance” or a “cognitive evaluation.” This provides the healthcare team with the reason for the initial referral, but it lacks specifics. Where are they weak? How limited is their cognition, and what areas of their life are most affected? What ADLs do they require assistance to complete and who is currently helping to complete them? How do we obtain this knowledge to provide the best care for our patients in their specific stage of recovery? The answer is a thorough initial evaluation and daily ongoing assessments.

Evaluation and Intervention

With the diagnosis in hand, greet your patient with an open mind. Dive into their medical history. Ask questions related to their medication schedule and administration. Ask about their goals, their roles and responsibilities, their level of community participation, and their support system. If it has been more than six months since the initial stroke, ask about any past experiences with therapy services.

Notice I haven’t mentioned anything yet about assessing their motor or sensory systems. It’s not because this information isn’t important. As therapists who specialize in treating motor and sensory deficits, we will need to know these things to provide the best, most evidence-based treatments. These assessments should be a part of the initial evaluation process. Without understanding the patient as a person, knowing the resources they have available, and uncovering lingering risk factors, it will be much more difficult to provide quality treatment that establishes your patient’s long term success after discharge.

Once the subjective information is gathered, or even while the interview is unfolding, choose the appropriate objective measures that will best identify the patient’s motor and sensory deficits based upon this information. This will allow you to plan interventions in the direction necessary for appropriate gains. For example, if you discover during the evaluation process that your patient has been managing all of the medications in the household, perform a cognitive or medication administration assessment. This will help you determine whether or not your interventions should include education, the use of modified tools, or scheduling reminders to improve the long-term management of medications. If your patient enjoys doing jigsaw puzzles with their grandchildren, choose an outcome measure such as the nine-hole peg test (9HPT) or Moberg Pick-up test to determine the effects of the stroke. Choose specific dexterity skills to address during your daily treatment sessions based upon the results. A high-risk fall patient may require a TUG or Berg to assess for mobility and balance needs to allow them to walk on uneven ground and tend to their flower bed.

These are just a few examples, but the take-home point is to structure your assessments and your subsequent interventions based upon each specific patient’s needs, values, and goals. Don’t get stuck using the same outcomes measures for each patient because they are familiar and easy to administer. Research the available outcome measures, look at the indication for each measure to determine its relevance to this specific patient after a stroke and choose interventions that will support improvement in these measures and movement toward the patient’s end goal.

Acute vs. Chronic Management

A CVA can potentially be a lifelong event for a patient, their family, friends, and caregivers. Managing the effects in the acute phase can greatly influence the move into the chronic phase. If we have the opportunity to provide therapy in the acute phase or subacute phase, it is our privilege to provide our patients with the most appropriate, evidence-based, properly dosed treatment to affect change. Tasks should be salient, challenging, and functional. Education should be ongoing and realistic. The goal is to provide them with the tools they need to be successful in continuing their therapeutic journey. If a patient in the acute phase isn’t given the proper tools individualized for their specific needs, they may move into a chronic phase that is less manageable and will require ongoing services. As you can imagine, this can be a financial hardship after many years of chronic disease management.

If your patient happens to already be in the chronic phase of a stroke, assess their current needs. A mix of remediation and compensation may be needed to further progress their physical abilities as well as to provide an avenue for increased participation in daily tasks. For example, revamp their lower extremity strengthening program, but consider a brace that will provide stability and reduce the risk of falls during household and community mobility. Help them to increase their trunk flexion but also provide them with adaptive equipment to increase their ability to don their socks and shoes. Additional considerations in the chronic phase include:

• Contracture management
• Positioning and use of specialty seating to reduce risk of decubiti
• Pain management
• Environmental modifications to allow for long term accessibility of the home
• Use of communication devices and memory aids

Risk Factors and Ongoing Support

How can we help our patients manage risk factors? Educate, educate, educate! Review medications and check for adherence to prescribed dosage and frequency. Check vital signs with each visit and report abnormal findings, particularly if these findings remain consistent and the patient is symptomatic. I recommend starting a vital signs log. This hard copy will provide the patient with something to take with them to their next doctor’s appointment. During your daily sessions, listen for reports of ongoing headaches, dizziness, and pounding in the ears. Check for and report any new irregularities in heart rhythm. If a patient is diabetic, ask about their method of glucose testing. Do they have a glucometer and are they able to use it effectively? If not, set a goal and work toward their independence. Again, this is by no means an exhaustive list, but you will get to know your patients, and by developing a working relationship with them, you will know when something isn’t right. Evaluate, educate, and report your findings to reduce your patient’s risk of an additional stroke.

From day one, patients and their caregivers should be provided with the education and resources they need to succeed, both in the short and long term. This includes ongoing support through the use of caregiver respite services, local support groups, and national resources. Below are a few resources related to multiple areas of stroke recovery including those appropriate to guide clinicians through the rehabilitation process. Be sure to also research any local support groups, respite care companies, or active day centers that may provide community integration and caregiver support.

• American Stroke Association – This is a great resource for the most basic information related to stroke, as well as a wonderful resource for managing conditions in an emergency situation. You are not alone is a specific link on the site that provides resources for stroke survivors.
• The Internet Stroke Center – This website has a plethora of resources including links to national support groups, chat rooms, success stories, and links to informational websites such as the Mayo Clinic and the American Stroke Association.
• Stroke Mark – This is a research-based website providing the most up-to-date evidence-based information related to medical and rehabilitative management of stroke.
• Rehabilitation in the Subacute and Chronic Stage after Stroke – This is a website designed for rehabilitation professionals to guide the intervention process based upon the phase of the stroke.

The following books are reader-friendly resources that provide patients and their caregivers with tips and recommendations for maintaining the quality of life:

• Living with Stroke – A Guide for Patients and Their Families, Author – Richard Senelick
• After a Stroke – 500 Tips for Living Well, Author – Cleo Hutton