Rehabilitation
Welcome to the Rehabilitation module.
This module will provide you with an interactive case study in which you will consider the components of successful rehabilitation.
This module continues the care of Mr Tanner, who we met in the ‘Stroke’ module.
Once you have completed the Pre-Module Test below you will be able to commence the Rehabilitation Case Study. The case study follows Mr Tanner’s rehabilitation. You are able to be a ‘virtual’ participant in the weekly multidisciplinary team meetings to discuss his assessment and progress.
Click on each discipline to hear the report and get a complete picture of the issues faced by Mr Tanner in his recovery process.
Module
- Interactive Case Study
- Rehabilitation
- Functional Assessment
- Goal Setting
- Week One Team Meeting
- Week Two Team Meeting
- Week Three Team Meeting
- Neurological Rehabilitation Clinic
- Case Summary
Mr George Tanner is a 72 year old man who recently suffered a TIA and subsequent major acute ischaemic stroke. He was effectively treated with thromobolysis. He has been transferred to the rehabilitation team because of residual dysphasia and right arm weakness.
Review Mr Tanner’s history through the links below before continuing the case.
- History of Presenting Complaint
- Medical History
- Medication History
- Social History
Mr Tanner has been referred for rehabilitation after a recent TIA and left-sided total anterior circulation infarct (TACI). He was treated with thrombolysis and within 15 minutes he was no longer aphasic, although his speech was still slow with some evidence of expressive dysphasia. His right arm weakness remains, but his right leg is much improved.
Mr Tanner has a history of high cholesterol, hypertension, ischaemic heart disease, diet controlled type 2 diabetes mellitus, and centripedal obesity.
He had a tonsillectomy at age 15, a right inguinal hernia repair at age 58 and an angioplasty at 64. He has also had several basal cell carcinomas removed from his face and ears and has been hospitalised numerous times for kidney stones.
Mr Tanner is currently taking the following medications:
- Aspirin 100 mg od and dipyridamole (“asasantin”)
- Perindopril 5 mg daily
- Simvastatin 20mg od
Mr Tanner is a retired farmer who lives with his wife and two sheep in Swan Hills. He was still driving and played bowls twice a week and darts at the local pub on Friday evenings. He is an ex-smoker with a 20 pack per year history and drinks 4 cans of beer per night and extra on bowls days.
Mr Tanner has one son and one daughter and 7 grandchildren. His son now manages the farm and Mr Tanner visits at busy times to help with shearing, seeding and harvest. His wife is well and manages the majority of household duties.
Mr Tanner has a family history of heart disease, hypertension and type 2 diabetes. He has had no prior incidence of depressive mood disorder that may increase risk of diminshed capacity to cope following stroke.
So what's stroke rehab all about?
Let's find out from one of the team experts...
click here for text option instead of audio...
Please think carefully about the perspective of clients embarking on a rehabilitation program. Stroke survivors tell us that maintaining hope is vital. Listen to these two descriptions of a stroke survivor
- overhearing discussion between therapists about her rehabilitation potential
- discussing her rehabilitation goals with a therapist
Client perspective - rehabilitation potential
Client perspective - hope
One of the most important first steps in planning a rehabilitation program is conducting a functional assessment.
Mr Tanner was independent in all ADL’s prior to his stroke. This is important information as premorbid functional status has an impact on the expected outcome of the rehabilitation program.
One day after Mr Tanner’s stroke and prior to the family and team meeting where rehabilitation goals will be discussed, registered nurse Wendy Carmichael visits Mr Tanner on the ward, to determine his level of functional independence.
Part of this assessment is to determine what level of rehabilitative care in suitable for Mr Tanner, inpatient or outpatient. It also informs planning and goal setting for rehabilitation and provides a baseline by which to compare Mr Tanner’s improvements in the weeks ahead.
Wendy is using the Barthel Index, but another scale that is commonly used in Australia is called the Functional Independence Measure.
Click here to see Mr Tanner’s initial Barthel Index Score
Barthel Index Results
Mr Tanner scored 55/100 on the Barthel Index. Due to his hemiparesis, he is having some trouble holding cutlery and therefore needs assistance with some aspects of eating. The same applies to grooming and dressing, where he has trouble with shaving, dental care and doing up buttons and zips. He is continent using his bowels and has had only one incident of urinary incontinence. His right leg weakness has improved significantly, but Mr Tanner still has some problems with transferring, walking unaided and would not be safe to climb or descend stairs.
Now that Mr Tanner’s functional abilities have been carefully assessed, goals for his rehabilitation can now be defined.
Goal setting is a crucial process in rehabilitative care, and like the rehabilitative process, should be indivisualised.
For rehabilitation to be effective, the goals must be:
- Meaningful – appropriate to the problems and circumstances of Mr Tanner
- Agreed upon through consultation with Mr Tanner, his family and the rehab team.
- Clearly communicated, recorded and able to be measured.
- Realistic in that they are challenging but attainable.
- In accordance with a realistic time frame that will shape the teams plan of action.
Goals should never be vague or general. As a guide, you might think about the following components of goal setting:
- who
- will do what
- under what circumstances
- to what degree of success
Goals should initially be short term and task oriented in order to maximise opportunities for auccess. This will help build motivation to reach longer term goals.
Mr Tanner should also be assessed for depression, since this may affect his chances of successful rehabilitation. For more information on this, click here.
Mr Tanner's Rehab Goals
Based on the results of Mr Tanner’s Barthel Index, and taking in to account his physical, physiological and psychological impairments, which of the following do you think would be appropriate immediate goals for his rehabilitation?
Welcome to the multi-disciplinary team meeting for week 1 of Mr Tanner’s rehabilitation
Prior to Mr Tanner’s discharge from hospital, each team member reviewed his status.
Before proceeding review Mr Tanner's physical measures.
Please click on each team member to hear about their assessment of Mr Tanner. After reviewing each assessment, you will be returned to this page in order to progress through the reports of the multidisciplinary team.
- Physiotherapist
- Occupational Therapist
- Speech Pathologist
- General Practitioner
- Nurse
- Clinical Psychologist
- Dietitian
Ever wondered what role the physio plays in the multidisciplinary rehab team...
Now you don't have to! Click below and I'll explain it for you...
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I visited Mr Tanner this morning. He has dense right arm weakness, but has reasonable balance and good strength and control in his right leg. He is a little unsteady moving about. He seems to have lost a bit of confidence in his abilities.
Over the coming weeks we will work on restoring normal movement and functionality to the arm and on increasing his strength and confidence in mobilising.
I would also like to speak with Mr Tanner in regards to increasing his level of physical activity and will work with him on this during rehab, so that an exercise plan can be prescribed once formal rehabilitation is completed.
I think his progress will be accelerated if we refer him on to RITH (Rehab in the Home) as he is more likely to be active in his home environment. We will just need to work closely with Mrs Tanner and the carers. I do not want Mr Tanner reinforcing abnormal movement patterns, so we will need to keep a close eye on him.
Mrs Tanner seems to understand and accept this, so I think home based rehab may be a good option.
Stroke rehabilitation guidelines
Which of the following are relevant guidelines for early rehab post-stroke? Please choose your responses and submit your answer to obtain feedback.
An OT is also an important part of the multidisciplinary team.
Click below and I'll explain what we do to facilitate post-stroke rehabilitation...
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I assessed Mr Tanner yesterday. As previously mentioned, he has severe right arm and hand weakness. He is right-handed so this could pose significant difficulties for him. I asked him to perform a number of simple tasks, such as brushing his teeth, doing up a button, holding a cup of tea and buttering a slice of toast, none of which Mr Tanner was able to perform with his right hand. A major focus of his occupational therapy over the next few weeks will be on assessing the functionality of this hand and aiming to restore normal use as much as possible. He will go on a home visit with me before discharge so that I can assess his functionality in the home in more detail, but in principle I tend to agree that home based rehab may be a good option for the Tanner’s.
Arm and Hand Function
How would you assess arm and hand function in Mr Tanner’s case? Please select your response/s and submit your answer for feedback.
Cognitive Screening Tools
I also did some basic cognitive screening with Mr Tanner and apart from the dysphasia, the results were not indicating major cognitive problems. However, since even subtle cognitive deficits post-stroke are highly predictive of decreased quality of life and of dementia, he may benefit from a more thorough neuropsychological assessment by a clinical neuropsychologist (where available). This would also give more insight into his cognitive strengths and weaknesses.
Neuropsychology
Cognitive deficits occur in more than half of stroke survivors (Hochstenbach et al., 1993) and are more important determinants of broader outcomes than physical disabilities (e.g. Patel et al., 2002; Cicerone et al., 2005). Impaired attention is the most prominent stroke-related neuropsychological change, with rates of 46% to 92% reported in acute stroke survivors (Hyndman et al., 2009). Impaired attention can result in impaired functional recovery, decreased quality of life and increased risk of falls.
Stroke patients belong to the main patient groups seen by neuropsychologists working in rehabilitation (Wilson, 2008). Neuropsychological rehabilitation is concerned with the amelioration of cognitive, emotional, psychosocial, and behavioural deficits caused by an insult to the brain. There is a widespread recognition that cognition, emotion, and psychosocial functioning are interlinked, and all should be targeted in rehabilitation (Gainotti 1993; Prigatano 1999; Wilson, 2008). Stroke rehabilitation is most successful when a team approach is adopted and when there is effective communication between medical personnel and the allied health staff. Numerous studies have been published on the efficacy of cognitive rehabilitation, ranging from single-case experimental designs to randomized controlled trials (e.g. Chestnut et al., 1999, Barker-Collo et al., 2009). Technology is increasingly used to help people compensate for cognitive difficulties. Guideline for good practice based on evidence for effective treatment of cognitive, emotional, and psychosocial difficulties are published (e.g. Wilson, 2008; Prigatano 1999; 2002, 2010).
Speech Pathologist's have a varied an important role in stroke rehabilitation.
If you would like to find out more about what we do and how we work with other members of the team, I'll be happy to explain it to you...
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Mr Tanner presented with moderate non-fluent
expressive dysphasia
as a result of his recent stroke and this will be the primary focus of his rehabilitation. Mild receptive difficulties were also noted for complex, lengthy information. Mr Tanner’s orofacial musculature was within normal limits and his swallowing function was intact.
When I assessed him this afternoon, Mr Tanner presented with limited meaningful verbal output. His speech was very slow and effortful and he had difficulty talking spontaneously about familiar topics. He was able to answer simple biographical questions with time and support (e.g. Where do you live? What work do you do?).
Mr Tanner’s speech and language skills were screened using the BEST-2 aphasia screen. He had difficulty naming and describing pictures making frequent semantic or word errors (e.g. “pin” for nail). He was able to comprehend single words, one and two stage commands and basic “yes” and “no” questions.
Mr Tanner was noted to become frustrated when word finding difficulties were experienced and he is avoiding conversations. This appears to be placing some strain on his wife. Over the coming weeks speech pathology intervention will target Mr Tanner’s language and functional communication skills, while providing education and support services to his family and staff on the ward.
Introduction of Speech Pathology
What is the recommended optimal time for the introduction of speech pathology after onset of stroke? Please select your answer and submit for feedback.
Appropriate therapy approaches
Which of the following therapy approaches would be appropriate for Mr Tanner? Please select your response/s and submit your answer for feedback.
I have been reviewing Mr Tanner regularly. His blood pressure has dropped and is currently under borderline control, at 140/105. I will continue to monitor this. I have recommended that he restart warfarin 2mg daily . Mr Tanners stroke was thought to be cardioembolic, secondary to his AF. This will not be a barrier for him entering RITH – I can refer Mr Tanner for domiciliary phlebotomy (blood tests).
Mr Tanner had AF and it was thought that a clot from his heart had travelled to his brain, causing the stroke.)
I have had a long talk with Mr and Mrs Tanner to try and help them understand the longer terms risks and benefits of warfarin therapy.
Secondary Prevention Measures
What secondary prevention measures would you recommend for Mr Tanner in order to reduce future stroke risk? Please select your response/s and submit your answer for feedback.
Since admission, Mr Tanner has had only one episode of incontinence. At this time, he was still quite disoriented post-stroke and due to his expressive dysphasia, he was unable to communicate his need to urinate in time for a nurse to help him to the bathroom. He now seems to be coping fine with toileting, although occasionally needs help there and back and/or getting up off the toilet.
He is ambulating quite well but his gait pattern needs further improvement so we are encouraging him not to walk without a nurse present so that we can ensure he follows the physio’s instructions. Falls risk due to physical, physiological and neurological factors will need to be regularly monitored in the weeks ahead.
After speaking to Mr and Mrs Tanner I felt that they are keen to work with us to make home based rehab successful. They really are eager to get out of hospital.
In the early stages, Mr Tanners will require help with his ADL’s, such as showering, dressing and eating, as he is experiencing some problems due to his hemiparetic right hand. This will be provided through a personal carer to assist his wife.
Preventing bladder problems
What are the most important factors to consider when trying to prevent bladder problems in someone who has recently had a stroke?
Preventing bladder problems - feedback
Mr Tanner is euthymic at present. However, I am concerned that a possible drop in mood may occur over the coming weeks. I have asked the ward staff to continue to monitor his mood closely until he goes home. If home based rehab goes ahead we’ll need to make sure team members visiting Mr Tanner remain vigilent for dysthymia.
As his expressive dysphasia begins to improve and he becomes more aware of his communicative restrictions, he may become frustrated. The same could apply to how quickly he recovers use of his right hand and is able to do simple tasks for himself.
Depression can prevent a stroke patient from fully participating in rehab activities, leading to sub-optimal outcomes and premature discharge from rehab programs. Early detection of a depressed mood/anhedonia is therefore very important.
Preventing Depression
Depression is a common psychological problem and can negatively impact upon a patient's recovery.
A dietitian's role in stroke rehabilitation extends beyond secondary prevention.
Click below to find out more about our role in the multidisciplinary team...
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I noted Mr Tanner’s assessments by other team members including: dental hygiene being managed by the OT and RNs, severe right arm and hand weakness necessitating assistance with some aspects of eating (cutting food, spreading butter, etc), no bowel or bladder problems (constipation, diarrhoea or incontinence) and an intact swallow. Due to the lack of dysphagia (difficulty swallowing), a texture modified diet and thickened fluids are not required. However a soft diet would still be of benefit to allow self feeding (no need to cut up food), but assistance to spread margarine on bread etc would still be required.
What is a texture modified diet?
Dysphagia (difficulty chewing and swallow solid foods) can result in aspiration of fluid/foods resulting in chest infection and increased mortality. To manage this fluids may need to be thickened and diet texture may need to be modified. In severe dysphagia cases saliva can be aspirated and in this case saliva may need to be suctioned from the patient’s mouth (and feeding would commonly start via nasogastric tube).
To see a how modified food and fluid diets are classified by the Dietitians Association of Australia and the Speech Pathology Association of Australia (2007), please click the tab below.
Mr Tanner should be routinely screened for malnutrition upon entering the rehabilitation ward as 30-50% of rehabilitation patients are malnourished. Valid malnutrition screening tools for use in the rehabilitation setting include the MNA-SF and Rapid Screen. Using the MNA-SF, Mr Tanner was found to have possible malnutrition, so a more thorough assessment using the MNA was undertaken.
What is MNA-SF?
The Mini Nutritional Assessment Short Form (MNA-SF) is used to screen for malnutrition, while the complete MNA can be used to diagnose malnutrition.
Based on the results of the MNA, Mr Tanner was found to be at risk of malnutrition, but not malnourished at this stage. The adequacy of his dietary intake needs to be assessed during admission (may become inadequate due to physical or psychological reasons).
Mr Tanner has essentially maintained his weight throughout his acute hospital admission (pre-rehabilitation admission). His energy requirements have decreased due to his restricted mobility and he has had assistance with eating which has enabled him to maintain an adequate intake. However a soft diet should enable him to eat with minimal assistance.
I spoke with Mr and Mrs Tanner together, with Mrs Tanner supplying most of the information, but Mr Tanner being given the opportunity to speak and provide advice about preferred food choices in hospital, etc. Mrs Tanner reports that Mr Tanner eats well in hospital (all meals) when assisted by staff members/herself. Mr Tanner would benefit from food/fluid charts being kept for the first 3-7 days of his rehabilitation and thereafter as needed to allow assessment of the adequacy of his intake.
Mrs Tanner’s recall of Mr Tanner’s dietary intake at home shows he consumed a nutritionally adequate diet pre-admission except for an inadequate intake of vegetables on some days. However his intake of total and saturated fat was too high for effective lipid management and he was not meeting lipid targets despite the statin therapy. Mr Tanner also consumed a high sodium diet and a reduction in salt intake to <4g/day (65mmol sodium) will assist with long term blood pressure management, reduction in recurrence of stroke/TIAs, reduced risk of other cardiovascular events and maintenance of normal renal function.
As previously mentioned, Mr Tanner’s intake of vegetables at home was often inadequate, although he does consume 2 serves of fruit daily. An increase in vegetable intake to > 5 serves daily and maintenance of his fruit intake will increase intake of vitamins, minerals, fibre and potassium. An increase in potassium will also help with long term blood pressure management and reduction in recurrence of stroke/TIAs and other cardiovascular events.
At home Mr Tanner's intake of carbohydrate (CHO) was sometimes excessive and a reduction in CHO intake at some meals (e.g. dinner) and consumption of regular low GI CHO portions over the day will assist with blood glucose level (BGL) management (Mx). Currently Mr Tanner's BGL are satisfactory (but not ideal). Improvements in dietary intake and weight will assist with long term BGL Mx however he will need ongoing monitoring of these by his doctor.
At home Mr Tanner’s alcohol intake was above recommendations and would have caused raised BGL, contributed to hypertension and excess body weight. Mr Tanner would benefit from reducing his intake as per his doctors instructions (already provided) or national recommendations (≤2 standard drinks per day and to include 2 alcohol free days per week).
Mr Tanner is obese with central adiposity and in the future weight loss will assist with lipid/BP/BGL management. He will also need to reduce his energy intake if his mobility continues to be reduced to prevent further weight gain. Reduced mobility may also result in raised BGL unless CHO/energy intake is restricted.
Mr Tanner’s biochemistry results show adequate nutritional status, fluid status, renal and liver function, however his lipids remain above target. His BGL collected 4x daily on the ward show satisfactory BGL control (e.g. 6-7mol/L fasting/premeal and ≤10mmol/L 2 hours post prandial), however these could be improved to good or ideal control (e.g. 4-6mol/L fasting/premeal and ≤8mmol/L 2 hours post prandial), with lifestyle change.
The aim of nutrition intervention is to provide a nutritionally adequate intake of appropriate texture (soft) foods/fluids, which prevent recurrence of stroke/TIAs and manages his co-morbidities while in hospital. Education will also be provided so this diet may be continued at home. As he is obese, weight and waist circumference loss would also be of benefit providing this occurs via a nutritionally adequate intake.
Requirements:
Energy for weight maintenance = (Harris Benedict, Activity Factor=1.2, Injury Factor=1.0) = 8473.2kJ
Energy for weight loss = 6000kJ (2500kJ below estimated requirements to allow >0.5kg loss/week).
Protein= 0.8-1.0g ptn/kg = 73.3g
Fluid 35-45ml/kg = 3200-4120ml/day
Sodium = <65mmol/day
Recommended diet for Mr Tanner: A soft, nutritionally adequate diet, low in energy/kilojoules, total and saturated fat, salt and sugar and high in fibre with low GI foods provided where possible. CHO portions must be controlled and spaced regularly over the day.
The above diet was ordered from the hospital kitchen and the menu ordering system was explained to Mrs and Mr Tanner. It was decided that Mrs Tanner would assist her husband in completing the daily menu.
The reasons for implementing the recommended diet were explained to Mr and Mrs Tanner who were willing to keep to the prescribed diet. This discussion was kept brief as they have received a lot of information from other health professionals since being admitted to the ward.
Stroke risk
Which of the following statements about relating to reducing stroke risk are correct? Please select your response/s and submit your answer for feedback.
Welcome to the Multi-disciplinary team meeting for week 2 of Mr Tanner’s rehabilitation.
Mr Tanner was successfully discharged three days after the last meeting and has now been at home for four days.
To see his current physical measures, please click here.
Please click on each team member to hear about Mr Tanner’s progress.
After reviewing each assessment, you will be returned to this page in order to progress through the reports of the multidisciplinary team.
- Physiotherapist
- Occupational Therapist
- Social Worker
- Speech Pathologist
- General Practitioner
- Nurse
- Clincial Psychologist
- Dietitian
Unfortunately, Mr Tanner has been experiencing worsening pain in his stroke affected shoulder. He has been instructed in ways to support his right arm correctly in sitting and lying and I have provided a GivMohr sling to use while he is mobilising.
I have been using functional, electrical stimulation (FES) movement re-education and soft tissue mobilisation techniques but the pain is persisting.
I have referred him to a doctor for further assessment. Otherwise, he is transferring and mobilising well and we have commenced him on a gentle walking exercise program.
Mr Tanner still fatigues easily with physical activity, but he does seem to be showing improvement in the distance that he is able to ambulate. As his leg strength and general endurance improves, his gait pattern and balance are becoming more normal. He continues to need supervision with mobility tasks.
If shoulder pain persists, Mr Tanner may benefit from a Multidisciplinary Pain Management Program.
I have been focussing on treating Mr Tanner’s hemiparetic hand, which is showing moderate improvement, although his pinch grip is still weak. He is having trouble with some tasks, such as holding a cup of water, holding utensils, doing up buttons and holding a pen.
Mr Tanner has enquired as to whether he will still be able to drive, as he values his independence and needs to be able to get to bowls. I advised him that at this point driving will not be possible, but that he may well be able to return to driving after further rehabilitation. I will arrange for a driving test to be scheduled for Mr Tanner in 2 months time. He didn’t like this advice but seemed more accepting after some discussion.
How might a social worker assist Mr Tanner in his rehabilitation?
I'd be happy to explain...
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Whilst Mr Tanner is under-going rehabilitation, transport has been arranged to help them get around, as Mrs Tanner no longer holds a current driving license and Mr Tanner in unable to drive. I have also arranged support for Mrs Tanner through HACC (Home and Community Care), as she is having trouble coping with some of the more arduous jobs around the house and yard that were previously attended to by Mr Tanner.
Mrs Tanner recently wanted to discuss the changes to their intimate relationship that might be necessary since he had his stroke. She has heard that sexual contact can increase the risk of stroke and is concerned about how this may affect her husband.
Mr Tanner’s expressive dysphasia is improving, although he is still having some trouble with word finding and longer utterances. His initiation of speech is much improved although does become affected when he is tired or feeling anxious or under pressure.
Mr Tanner’s blood pressure is still well controlled and is now down to 135 systolic.
X-ray and Ultrasound of the right shoulder showed no abnormality to account for Mr Tanner’s pain. The cause is most-likely therefore hemiplegic shoulder pain post-stroke. There is little scientific evidence regarding the best way to treat this, but pain relief will be necessary. As a first line treatment, an injection of cortisone has proved helpful. Intra-articular injections of steroidal or non-steroidal anti-inflammatories may be considered as on-going treatment in the short term.
Treating Shoulder Pain
Regarding Mr Tanner's shoulder pian, which of the following statements are most applicable?
Click to see feedback for each
- NSAIDS are a good option for Mr Tanners pain
- Putting up with some pain is better than getting addicted to pain killers
- Little can be done about shoulder pain. It is important that Mr Tanner understands this, as false hope can be crushing
- The xray and ultrasound were a waste of resources
Possibly – but particular cautions are relevant (eg given risk of gastritis) in the context of his warfarin therapy. Also, think about the other risks of NSAIDS (impaired renal function, fluid retention etc).
Some patient express this opinion. However generally it is beneficial to maintain pain relief during Mr Tanner’s rehabilitation as shoulder pain can hamper functional recovery. Good shoulder function is a prerequisite for effective hand function, as well as for performing multiple tasks involving mobility, ambulation, and activities of daily living (ADL).
Yes shoulder pain can be a very challenging problem in rehab and the team need to be honest with Mr and Mrs Tanner. However a multidisciplinary approach is essential in managing Mr Tanner’s shoulder pain.
In addition to pharmacological pain relief, the nurses and OT will be able to advise on appropriate positioning of the shoulder to help alleviate pain.
The physiotherapist can work with a number of specific physical, electrical and ultrasound techniques.
Cognitive behavioural therapy and specialist relaxation techniques, as advised by a psychologist, may also be instrumental in helping Mr Tanner sleep better and cope with his pain.
Yes, injudicious use of investigations can be a problem. But, in this case the team felt investigation was justified given he severity of Mr Tanner’s pain.
Mr Tanner is having some troubles performing his ADL’s due to his hemiparetic hand, particularly dressing and holding cups/cutlery. He gets quite frustrated at this.
Mr Tanner is also having difficulty sleeping due to his shoulder pain, which adds to his frustration. He has asked for a sleeping tablet. We are reluctant to offer benzodiazepines, but we are trying to find a more effective pain management for him. I have done a sleep hygiene prescription. Click here to view
Our clinical psychologist sometimes helps us with relaxation techniques if this isn’t effective.
Mr and Mrs Tanner and I have met with the personal care assistants to make sure that the care they are providing is not getting Mr Tanner into bad habits by consistently relying on the help of others. Mr Tanner should be encouraged to do what he can for himself, with help offered when required. All assistance should be consistent with the OT’s instructions. In particular we want Mr Tanner to use his shower chair. I have also made sure that the care assistants understand the showering and dressing care plan and which bits Mr Tanner can do.
I will go through it with the Tanners and care workers again next week after the OT and physio have updated the plan. I think it is a lot for the Tanners to understand so it will be helpful if I can reinforce what the OT and physio say.
I’ve spent a lot of time helping Mrs Tanner think about how Mr Tanner is still himself in many ways. I think she is beginning to think more positively about how Mr Tanner can live successfully with any residual impairments.
Avoiding Benzodiazepines
The reasons that RN Carmichael and her team want to avoid benzodiazepines include which of the following? Click on those you feel are relevant and submit your answer for feedback.
Mr Tanner’s mood has deteriorated since his initial assessment. This is largely due to his frustration at the limitations imposed by his hemiparetic right hand and his inability to sleep due to right-sided shoulder pain. His mood was irritable and he seemed pessimistic about the future, but I have assured him that the function of his hand is likely to improve significantly throughout rehab and that relaxation techniques can help overcome insomnia.
We practiced a number of relaxation techniques, including a progressive body scan to relax the entire body, sound meditation and guided meditation, which are often easier for people new to meditation.
Mr Tanner was sceptical at first as he thought meditation was ‘mumbo jumbo’. However, after practising each technique a number of times, his did admit that both his mind and body felt more relaxed.
Hopefully, regular use of meditation will help overcome pain and induce peaceful sleep by enhancing Mr Tanner's sense of self-control over his pain and combat feelings of helplessness and demoralisation.
I also used some CBT to introduce pain coping, anxiety management and self-efficacy strategies. We discussed the role negative thinking plays in potentiating and maintaining pain levels and feelings of anxiety and depression. I worked with Mr Tanner in challenging his negative thoughts and replacing them with more adaptive coping thoughts. I have also encouraged Mr Tanner to work towards gradually increasing his activity levels with a particular focus on scheduling pleasant events. An increase in the level and range of his activities should lead to an improvement in mood and motivation.
Cognitive Behavioural Therapy
Which of the following statements are true of Cognitive Behavioural Therapy (CBT)? Please select your response/s and submit your answer for feedback.
I noted the OT/RN assessments stating that Mr Tanner was still having difficulty eating and holding cups/cutlery with his right hand when tested on an unmodified texture, regular diet, thus he would benefit from staying on the soft diet.
Food and fluid charts show he is consuming a nutritionally adequate diet and fluids. He is having no problems with his bowels. The biochemistry and blood sugar results are unchanged.
When I spoke with the Tanners, Mr Tanner appeared to be communicating slightly better although he did get frustrated at times. I ensured that time was taken to allow him to speak when he wished to. Mr Tanner appeared accepting of the hospital diet and liked the independence that a soft diet provided, as he did not have to constantly rely on assistance. He appeared motivated to continue with the eating plan and was pleased that he had lost weight. Although a lower mood and increasing frustration have been reported by other members of the team, it is fortunate that this has not extended to Mr Tanners eating.
I began education regarding dietary changes with Mr and Mrs Tanner. Mrs Tanner reported that she had always cooked for Mr Tanner (who cannot boil an egg) and that the required dietary changes would not be too much of a burden for her to undertake. As many dietary changes were required, I kept the information as simple and concise as possible and provided written information/diet sheets. I also mentioned that Meals on Wheels were able to deliver meals for diabetic patients that can be texture modified and provided information about this service.
The social worker mentioned that she was organising HACC transport, so I requested that this include food shopping. I informed the social worker that I had provided meals on wheels information, but that Mrs Tanner had decided not to take-up that option yet.
Mr Tanner would benefit from continuing with the current diet plan.
Welcome to the Multi-disciplinary team meeting for week 3 of Mr Tanner’s rehabilitation
Mr Tanner has been re-assessed using the Barthel Index. Please click here to see the result.
To review Mr Tanner's physical measures, click here.
Then click on each team member to hear about Mr Tanner’s progress.
After reviewing each assessment, you will be returned to this page in order to progress through the reports of the multidisciplinary team.
- Physiotherapist
- Occupational Therapist
- Speech Pathologist
- General Practitioner
- Nurse
- Clinical Psychologist
- Dietitian
- Pharmacist
Mr Tanner’s shoulder pain is much improved following intra-articular pain relief. I will continue to see him three times per week for intensive physio aimed at maximising his right arm and hand function for two more weeks now that he is able to tolerate more treatment. I anticipate that Mr T will recover assistive function of his right arm but will be unlikely at this stage to make a full recovery. He is becoming increasingly competent using his left hand for many activities of daily living.
I will then transition him to neurology outpatients to supervise his progress over the next few months. In addition I have referred him to the Community Physiotherapy Service where he will attend a weekly exercise class supervised by a physiotherapist with the aim of increasing his exercise tolerance and confidence mobilising in the community. This group session also has the advantage of providing some social support for Mr T and his wife as the other participants are all stroke survivors and live his area.
Do you know what the likelihood is of recovering full function in the stroke affected arm, if deficits are still present at 3 weeks?
In those with complete paralysis initially after stroke, as few as 5% regain full arm function (Gowland C 1993);(Richards and Pohl 1999).
Interventions to improve arm function
Which of the following interventions have been shown to be most effective in improving arm function in people with some residual movement?
Due to intensive rehabilitation therapy, Mr Tanner has made good progress. However, he is still having some troubling pain in the right shoulder and difficulties in using his right hand. Consequently, there are a number of tasks that he still finds difficult to complete without help. These include doing up buttons, holding heavy items and cutting up meals. There are a number of other tasks that he is learning to do left-handed, such as brushing his teeth and using the kettle. The dentist will keep a close eye on dental hygiene to ensure that Mr Tanner takes well to left-handed brushing!
I am confident that with Mrs Tanner’s help, Mr Tanner will be able to safely remain at home at the end of rehabilitation. He is largely independent and only requires assistance with small tasks.
Functional Independence Aids
Are there any other options, apart from asking for assistance, that may help Mr Tanner to become more independent in bilateral tasks, such as fastening buttons and cutting his food?
Mr Tanner’s dysphasia continues to improve and he now experiences only occasional word finding difficulties and hesitations, especially when under time pressure. His communication is now very functional and he is able to access the community and use the telephone with minimal support. I have made a plan to transition Mr Tanner to weekly outpatient reviews from next week. I am confident that he can continue to improve his functional communication and level of participation and independence in the community, with the support of his wife and continued completion of his home exercise program.
Speech Pathology Goals
What Speech Pathology related goals would be appropriate for Mr Tanner to target at this stage of his rehabilitation? Review the goals below and select those that you feel are appropriate goals for Mr Tanner.
Mr Tanner’s blood pressure continues to improve and is now down to 130/86. Pain relief by way of an intra-articular injection of local anaesthetic appears to have been helpful in alleviating his right shoulder pain. We will re-assess in 3 months time to review need for an additional injection. His warfarin dose is now stable, and at present we are checking his INR every 2 weeks.
I am confident that Mr Tanner’s health has stabilised and he appears to have adopted the advice regarding dietary and lifestyle changes to reduce risk of future stroke.
I am going to speak with his GP to hand over long term control of Mr Tanner’s risk factors and to fill her in on the advice we have given Mr Tanner regarding his shoulder.
Regarding Mr Tanners ongoing medical care, which of the following statements are most applicable?
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- Mr Tanner is likely to adhere to his medical therapy because it was started in hospital
- Warfarin therapy should now be life long. It’s important to emphasise to Mr and Mrs Tanner that it should never be stopped
- As he’d “basically be a vegetable” Mr Tanner should not be referred back to hospital if another stroke occurs
- Mr Tanner is now stable, so he shouldn’t require monitoring of his antihypertensive or statin therapy
- Stroke is so common that the GP will not need any further help from the rehab team
Possibly, but given that in the majority of patients, non-concordance with prescribed therapies is very high, his use of medicines needs to be reviewed regularly.
Generally anticoagulant therapy would be long term. However therapy should be reviewed if Mr Tanner’s risk of bleeding complications changes.
Recovery from a major illness presents an opportunity to review patients’ wishes for future medical care. In Western Australia, a new legal framework is now in place.
People on long term medical therapy often warrant some monitoring. For example renal function would be checked periodically in someone on long term ACE inhibitor therapy. Similar cautions apply to statins in relation to LFTs.
Stroke is common, but GPs often appreciate ongoing contact with hospital teams to support the patient’s ambulatory care. Patients may be frustrated if they perceive the connection between the hospital and their GP as inefficient.
Mr Tanner is sleeping better after learning the meditation techniques. His wife bought him a small CD player and he enjoys listening to relaxation music and/or guided meditation CD’s when he is feeling uncomfortable.
His hand troubles persist, but he is able to mobilise well and can now hold a knife adequately but has trouble cutting with it. He still gets quite frustrated at the simple things he can’t do, but overall does appear to be coping better with his limitations.
He does, however, seem anxious about how he will cope at completion of rehabilitation, how his friend’s will react to his ‘disability’ and whether he will ever get normal use of his hand back.
HACC services will continue but I think when rehab is over Mrs Tanner will be able to set Mr Tanner up in the mornings – he will be able to do most things for himself. I don’t think ongoing personal care assistance will be needed, although I do feel it is worth the carers continuing for another couple of weeks, to make sure that good habits are reinforced. As discussed with the OT and physio, the carers are mainly providing supervision now. Actual hands on assistance is very light.
Given his anxieties, what advice might the nurse give Mr Tanner at this stage?
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- Following stroke there is sometimes slow but prolonged recovery
- Anxiety is best managed by ‘getting on with it’ and ‘throwing yourself in the deep end’, there’s no use worrying about it!
- Although not recommended for long term use for insomnia, a hypnotic-sedative could be used short term
- Don’t think about your hand – you will get depressed if you do
- Sometimes it can be helpful to talk to other people who have had a stroke. Would you like me to link you up with a support group?
Yes, many survivors of brain injury describe slow and gradual improvements. These may occur because of neuroplasticity.
Some people like a “straight forward” approach. However, many people with impairments and anxiety about new situations will appreciate planning how they will cope. This might include physical practice, mental rehearsals or role play in a safe environment.
Yes, benzodiazepines are sometimes a useful short term adjunct for people with very severe anxieties. However for most people the disadvantages of benzo therapy outweigh any benefits.
Depression is a real risk in the recovery from brain injury. However most rehab teams would try to prompt the client to develop more adaptive strategies than simply ignoring the injury.
There are a variety of support networks in most metropolitan areas. However, it is a very good idea to check with Mr Tanner prior to referral as individual patients respond differently to that sort of environment. The Stroke Foundation offers support people locally, and also provides online information for people who have had a stroke.
Mr Tanner is anxious about on-going functional limitations and about how his friends will react to seeing him. He is embarrassed that he can’t do all the things he used to and is worried people might treat him differently if they see him as an ‘invalid’. He is also concerned about the risk of having another stroke and facing further disability or even death.
I have been using CBT techniques to target Mr Tanner’s anxieties. He has been encouraged to use a 'thoughts diary' to self-monitor his thinking patterns with the intent of reinforcing and prompting the process of identifying and challenging negative thinking.
Mr Tanner may also benefit from attending a support group to provide him with an opportunity to share his experience, find some mutual support and decrease any social isolation. I have recommended local support groups and will ask the social worker to follow-up with Mr and Mrs Tanner should they wish to pursue this.
He will continue to see me once a fortnight over the next few months to continue his treatment, during which time I will closely monitor his mood and also any increases in anxiety. No medication is warranted at this stage.
Effects of meditation
Which of the following are evidence-based health effects of meditation?
Physical Measures
Wt=90.4kg
Biochemistry
Urea, Creatinine & Electrolytes – normal
Full Blood Count - normal
BGL measured on ward daily
0600hrs fasting: 5.1-6.5
1230hrs before lunch: 6.0-7.0
1800hrs before dinner: 5.3-6.7
2000hrs: 8.3-9.7mmol/L
Mr Tanner’s biochemistry results and BGL were virtually unchanged. He is achieving a good rate of weight loss (recommended rate of loss =0.5-1.0kg/week). Waist circumference is measured monthly (recommended rate of loss =1-4cm/month). It is likely that Mr Tanner’s BGL/lipids will not improve until he loses further weight e.g. at least a 5-10% loss.
The dietary plan/information for Mr Tanner was reviewed with Mr and Mrs Tanner. Mrs Tanner is still keen to cook the prescribed diet at home, but has kept the meals on wheels information in case she needs this in the future. Mr Tanner is looking forward to a beer when he gets home, but has agreed to restrict this to <2 standard drinks/day and to include at least 2 alcohol free days per week. He was disappointed at what he perceived as a slow rate of weight loss, so I reassured him that a loss of losing 0.5-1.0kg/week is a good rate of loss and that it is best to focus on eating and activity goals rather than weight-related goals. I have provided handover to the local dietitian in his area so he can continue to receive dietetic input after discharge.
Dieraty issues discussed/sheets provided include:
- Soft diet options
- Reducing salt intake (processed foods, label reading, etc)
- Increasing vegetable intake at lunch, dinner and snack times
- Reducing saturated fat intake (meat fats, dairy fats, processed foods)
- Reducing total fat (restrict amounts of olive/canola oil in cooking, sterol based margarine, avocado, nuts, etc)
- Eating fish 2-3 times per week and taking 4x regular fish oil capsules daily to lower triglyceride levels and reduce cardiovascular risk
- Reducing sugar intake (no sugar containing beverages, desserts, etc)
- Low glycaemic index CHO choices (sweet potato, porridge, etc)
- Limit alcohol intake to ≤2 standard drinks per day for men and include at least 2 alcohol free days per week
- Initial weight target is 5-10% loss (to 81-85kg) at 0.5-1.0kg/week and a waist circumference loss of 1-4cm/month
Note Mr Tanner dislikes snacks and eats his main meal at lunchtime.
Click here to see Mr Tanner's sample Meal Plan 6000kJ (1500kcal)
I have seen Mr Tanner and explained each of his medications and what they have been prescribed for. We also discussed the importance of adherence to medication in decreasing risk of future strokes. I’ve handed over to his community pharmacy to make sure that the asasantin supply ceases and that his warfarin supply is correct.
Mr Tanner's current medications are Simvastatin 20mg od and Warfarin 2mg daily.
Concerns regarding statin therapy
In regards to statin therapy, which of the following statements are true?
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- Mr Tanner needs to be very cautious because of the long term risk of memory problems
- Statin myopathy usually is apparent in the first few weeks of treatment
- Usually muscle symptoms will prove to be unrelated to statin therapy
- The need for dietary therapy is obviated
Mrs Tanner has indeed read lay media reports regarding several high profile case reports of memory loss which were highly publicised (https://www.telegraph.co.uk/health/4974840/Wonder-drug-that-stole-my-memory.html). However statins have been used very widely and the risk of many adverse effects is lower than that associated with placebo treatments.
In fact, myopathy can occur even after long term treatment and should be considered in any statin treated patient presenting with muscle problems.
This is true – diagnosis of possible statin muscle damage can be difficult in the absence of a specific diagnostic test available.
No – diet and exercise remain the first line treatments.
Mr Tanner attends the Neurological rehabilitation clinic/post Stroke clinic 3 months later.
Please click here to see Mr Tanner’s final Barthel index assessment.
Three months post discharge, Mr Tanner’s health has continued to improve. Happily, he passed his driving test, although his car required modifications to enable him to safely continue driving.
He still has some weakness in his right hand, which makes some tasks difficult. However, Mr Tanner has accommodated for this well and Mrs Tanner helps him with the simple tasks that his hand prevents him from completing. Mr Tanner is overjoyed that while he has difficulty holding a cup, he can still manage a bowling ball!
Mr Tanner adhered to dietary advice and has lost 5kg. He is also walking regularly and has significantly reduced his alcohol intake. He now only has one or two light beers on bowls days and otherwise doesn’t drink any alcohol at all.
Mr Tanner’s blood pressure is well controlled at 125/85 and his mood has improved and stabilised without medication.
Post-Module Test
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The physiotherapy consult finds her Berg balance scale is 27/56. She has difficulty transferring, turning, reaching and balancing on one foot. The physio recommends some lower limb strengthening and gait exercises and some mild exercises to help rebuild her wasted quadriceps. It is important that Mrs Scott maintains participation in physical activity, in order to maintain muscle strength and joint range of movement and to improve her balance.
The physiotherapist prescribed specific mobility exercises (including stretches in prone lying) and specific strengthening exercises for hands and her leg extensors (which can be performed as a home program).
The physiotherapist uses models of anatomy to explain the physiology of voiding and bladder control problems. To help reduce stress incontinence, Mrs Scott’s pelvic floor muscles are assessed and found to be lax. Mrs Scott has been performing the exercises prescribed by the NCA, so the physiotherapist checks her technique to ensure she is doing them correctly. Further advice was needed to refine technique. Mrs Scott is aware that she needs to do these exercises at least 5 times per day, every day in order to recondition her pelvic floor.
To further address urge incontinence Mrs Scott will perform timed voiding, as advised by the NCA.
Fortunately, Mrs Wood has a normal CT scan.
CT is a relatively inexpensive, quick and non-invasive scan that produces images of brain structures such as the grey matter, white matter, cerebrospinal fluid cavities and blood vessels. These images may also reveal abnormalities such as tumours, strokes, and head injuries. The role of CT imaging in the diagnosis of dementia is primarily one of exclusion. Evidence based guidelines suggest that structural neuro-imaging with either CT or MRI scan is appropriate in the routine initial evaluation of patients with dementia.
MRI is a structural neuro-imaging method that provides images of the brain and other anatomical structures. Some studies using MRI have demonstrated that medial temporal lobe (MTL) atrophy can be predictive of Dementia Alzheimer’s Type (DAT) and that has been associated with neuropsychological and post-mortem data. MRI may assist in the diagnosis of DAT.
An MRI may be obtained if it is suspected that the patient has dementia, however MRI is not required to make a diagnosis of dementia
Dr Zheng’s brain MRI is provided below:
Brain imaging indicates volume loss, consistent with dementia. No evidence of masses or vascular disease.
General Appearance:
Mr Thomas is sweating and looks short of breath. His legs are constantly moving and he appears confused and agitated. His skin is moist and tribal scarring is noted on left and right upper arms, midline of chest and left and right thighs. His eyes are wandering and he appears to have trouble maintaining attention, although this does fluctuate. Admission staff report that his speech was slow and at times, incoherent. Mr Thomas also exhibited impaired orientation. His wife reports that he had trouble sleeping last night.
Height: 168cms
Weight: 75kgs
Temperature: 36.7
Respirations: 28 shallow
Please move your cursor over Mr Thomas as if you were examining him. You must complete the examination before you go on.
General Observations:
Patient answered greeting when approached. He is sitting in a chair with no evidence of agitation or distress. Mr Thomas is now eating a full diet, opens bowels daily and urine output is in keeping with fluid intake. His mouth is moist and mucosa intact. The IV access is removed.
Height: 168cms
Weight: 75kgs
Temperature: 36.7
Respirations: 18 even
Cognitive Testing
MMSE – 25/30 – may indicate resolution of delirium
KICA – 35/39 –Improvement in KICA score supports diagnosis of delirium.
Mrs Thomas does not think Mr Thomas is quite back to baseline, but is improving day by day.
General Appearance:
Mr Scott looks well. His affect is reactive but be appears to be slightly anxious.
Height: 184cms
Weight: 98kg (which has remained constant)
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General Appearance:
Mrs Scott looks well. She is reactive but has restricted mobility.
Height: 164cms
Weight: 76kg (which has remained constant)
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Please move your cursor over Dr Zheng as if you were examining him. You must complete the examination before you go on.
General Appearance:
No tremor is observed. He is well groomed and does not appear anxious. He has normal attention and affect.
Height: 160cms
Weight: 70kgs
Temperature: 37.1
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General Appearance:
General Appearance: Mrs Browning looks well. Her affect is reactive and she doesn’t appear to be distressed or anxious.
Height: 178cms
Weight: 65kg (has remained constant)
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General Appearance:
Mrs Browning looks happy and healthy.
Height: 178cms
Weight: 65kg (has remained constant)
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General Appearance:
Mrs Browning appears well. She is well presented, and is in high spirits.
Height: 178cms
Weight: 66kg (an increase of 1 kg)
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General Appearance:
Your general observation is that Mrs Browning appears to be a very alert, independent and capable elderly woman. She is cheery, well presented and easily mobile.
Height: 178cms
Weight: 67.5kg (an increase of 1.5 kg)
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