BMH Medical Journal

BMH Med. J. 2020; 7(Suppl): Early Online. Geriatrics & Gerontology Initiative: International Workshop on Care of the Elderly

Abstract: Comprehensive rehabilitation is essential to improve the functional outcome post stroke. This article reviews the deficits in different areas and rehabilitative interventions to improve the ability of the patient. Care of the elderly including the importance of safe ambulation and independent performance of ADL (Activities of Daily Living) is also dealt with.

Keywords: stroke, comprehensive rehabilitation, elderly, fall prevention, home modifications, assistive devices

Stroke rehabilitation

"You don't have to see the whole staircase, just take the first step" Martin Luther King Jr.

A stroke almost, if not all, devastates both the patient and the caregivers. There you have a patient having multiple difficulties and disabilities, all of a sudden. It takes time for them, even to accept this fact. Most stroke survivors experience functional improvement but the pattern, rate and ultimate outcome differ across patients [1]. That is why a good rehab team under a Physiatrist is required to critically assess and get the best out of the patient in minimum time [1].

Good rehabilitation is all about awareness of patients' capabilities and his/her deficiencies [2]. As a rule, it should always be comprehensive, but sadly, very few centers have it in that concept. And the exposure to good quality rehab is bare minimum at medical undergraduate level; therefore, even doctors are not fully aware of the potential of a rehab team. A physiatrist, who is an expert in the assessment of such people, should be formulating a detailed plan and then a team including various therapists and clinical psychologists must be working together to see that it is being accomplished. The team leader will obviously be the patient, and his/her functional preferences will also be important in formulating the team's goal. Overall goal should be completely realistic to both the patient and his physician.

The rehab of any neurological disease, in subacute and chronic phases, usually utilize the same therapeutic tenets, irrespective of etiology [2]. Particularly in stroke, only the motor part may be evident, but there will be multiple areas where there are deficits, including cognitive, sensory, autonomic, bowel and bladder issues [2]. Assessing it and helping the patient achieve the maximum possible potential is important. Neuronal plasticity contributes to functional recovery through dendritic sprouting over time, new synapse formation, and the processes of long-term potentiation and depression [3]. Evidence suggests that plasticity can be bettered by external conditions including medicines, electrical stimulation and forced use of the affected limb [3]. Though the mechanisms have not been definitively elucidated, repetitive use of the affected part appears to be the most important for interventions for neurological recovery after stroke [4].

Rehab should begin once the vitals are stable, except in certain cases like Subarachnoid hemorrhage and in presence of nuchal rigidity [2]. The AVERT trial [5] and other studies have pitched in for very early mobilization protocols. The goals always begin from preventing complications. As we eagerly wait for natural recovery to occur and try to augment whatever potential the patient has, it would be catastrophic if patients succumb to complications. State of the art nursing care should be provided, meanwhile.

Regarding functional improvement, minimal goals must be made initially and then gradually raised. Patient's medical status should be medically reviewed in between. The concept of learned nonuse [4] should be kept in mind, and the patient should be made to sit with support, provided there is no contraindication. Once the patient is trained to roll over, avoid airbed/waterbed, as it will significantly impair mobility. With knee support, they can be made to stand in a standing frame, after proper assessment. Thrombophlebitis of hemiplegic lower extremity may be overlooked. It can explain persistent edema even after they start ambulation exercises.

When making them stand from sitting position, ask the patient to lean forward and push up from the chair. The affected thigh might bend at knee, hip and ankle. Train to hesitate a few moments and relax the muscles so that it is fully extended [2]. Conscious hemiplegic patient without medical complications should be out of bed within 48 hours [5]. For transfer, the classical technique used in hemiplegics is known as pivot transfer [6].

The initial step in training to make them walk is improving their stance. Then we have to improve step length of gait. Partial Body Weight Supported Treadmill Training can help for the same. The swing phase patterns of hip, knee, and ankle motions on the hemiplegic side have been characterized by reduced hip, decreased knee flexion, and reduced dorsiflexion or continuous ankle plantarflexion [7]. Proper training can make the patient improve from this pattern. Slowly, training on curbs, ramps and stairs should be taught. When climbing stairs, ask them to keep the unaffected (good) limb first and while coming down, their affected (bad) limb first [2].

Figure 1(a): Parallel bar and steps

Figure 1(b): Partial body weight support treadmill training

Incipient occlusion of femoral artery can lead to ischemic neuropathy [2]. It particularly involves deep fibular nerve; it presents as pronounced foot drop, lost hyperactive tendon reflexes and first web space sensory loss. Surgical intervention is advisable, if that is the case.

The specific neuromuscular disability responsible for the deficit in function is corrected by appropriate treatment of abnormal factors, such as improvement of weak muscles or coordination exercises. The majority of recovery of muscle strength occurs within the first 3 months after stroke and reaches a plateau by 6 months [8]. However, severely impaired stroke survivors are expected to recover less fully and take longer to reach a plateau than moderately or minimally impaired patients. The intelligent use of Physical medicine's aids and modalities is also important. An increase in muscle strength is of little value, unless it is functionally significant. By intelligent exploitation of patients' residual capabilities and by the use of many of these devices, patient can be made functionally better. In all cases, complete self-care is a significant goal.

It is better to avoid making them mobile in a wheelchair, as it may affect their motivation to go around walking. But, in certain situations, if they require one, it should be a low wheelchair so that they can propel themselves by the unaffected leg. One-arm drive wheelchair is usually too complicated.

Improvement in Upper limb function takes more time, especially in Middle Cerebral Artery stroke [8]. Many basic self-care activities can be performed with a single, neurologically intact upper limb. Learned non-use prohibits volitional use of the neurologically impaired upper limb, and use of the impaired limb is a critical requisite for inducing the neuroplastic changes that lead to motor recovery. Modified CIMT (Constraint induced movement therapy) program [3] that requires formal therapy for 30 minutes, 3 days/week over 10 weeks, is practised in many places. Improvement in Activities of daily living is commonly measured by Functional Independence Measure (FIM score) and Barthels index [6].

Concomitantly, other issues, like swallowing, should be taken care of. As 40% of patients with acute stroke experience silent aspiration, a nasogastric tube is must for every patient post stroke, and oral feeding should begin only after proper assessment [2,6]. Use of semisolid diet and avoidance of clear water should be advised. Swallowing difficulty can lead to aspiration and pneumonia, malnutrition, and dehydration [3]. A swallow therapist begins with swallowing exercises including supraglottic swallow, super supraglottic swallow, Mendelsohn maneuver, Shakers exercises etc. [9]. In whom swallowing is taking time to improve, go for compensatory techniques like head turn to weaker side, head tilt to stronger side or simple chin tuck [9]. Silent aspiration can be ruled out using video fluoroscopy before removing the Ryles tube [3].

Cognitive impairments are very common. Particularly among older stroke survivors, there is a high prevalence of premorbid cognitive decline, often undiagnosed prior to the stroke [1]. Many patients have difficulty in integrating the information he receives from the environment. He/she may make judgements based on faulty information and this can lead to frustration. They can also have limited adaptive responses to changes in environment - they will display rigid, stereotyped behavior when these changes occur. Agnosia is also not uncommon, where there is an inability to associate an object with its use; be cautious not to keep dangerous objects inside their reach in that case [1]. Left hemi spatial neglect may be accompanied by a right gaze preference in severe cases, but subtler impairments may require formal testing to identify [3]. Commonly used bedside tests for visual neglect include letter cancellation tasks or line bisection. Apraxia is a disorder of motor planning. Ideomotor apraxia may be detected when a person is unable to carry out a task on command such as "comb your hair". This type of apraxia is most common in individuals with dominant hemisphere strokes [3]. Patients with lesions of the non dominant parietal lobe may have apraxia of dressing [3].

Sensory involvement significantly complicates patients rehab program. In case the patient has hemianopia, the therapist has to be clearly instructed that the patient's visual stimulus should be presented in the intact field of vision. Motor coordination performances do not yield results if position sense recognition is not preserved.

Bowel and bladder control are equally important. Often, it means the difference between social acceptance and rejection. Indwelling catheter should be removed early; give bedpan (female)/urinal (male), and later, after the patient is trained to transfer, give bedside commode [2]. High sitting seat in toilet should be advised. Strong grab bars, bench, shower stools can help in making them as independent as possible [10]. It is worth mentioning that standing and ambulation helps in resuming normal bowel and bladder function.

Communication and language impairments usually take longer to improve. Aphasia and dysarthria can be effectively managed with the help of a speech therapist [3]. In the early stages of rehabilitation, it is important for the speech therapist to help the patient establish a reliable means for basic yes/no communication. The therapist then progresses to specific techniques based on the patient's deficits. Aphasia can cause a patient to be depressed and can be misdiagnosed as psychotic. It will improve if aphasia is managed. Usually, patients with Broca's (nonfluent) aphasia with large hemisphere lesions tend to have little recovery [3]. If speech center is still involved in the chronic stage, alternative and augmentative communication methods will have to be considered.

Pain and spasticity in the extremities are grave concerns in rehab. Hemiplegic pain may be due to various reasons and the reported prevalence ranges from 34% to 84% [3]. Usually interventional procedures like Suprascapular nerve block, done by the Physiatrist, alleviates it [3]. Complex regional pain syndrome is fairly common and is managed with wax therapy and mobilization [3]. If there is swelling with pitting edema, it may be due to lack of therapy [2]. If not amenable, physiatrists go for stellate ganglion block. But shoulder movements usually do not respond well to this block. Pulley exercises for the shoulder should not be prescribed until there is 60 to 70 degrees of passive abduction; otherwise it will only increase the scapulothoracic substitution [2]. A large number of other musculoskeletal injuries can occur, ranging from acute ankle sprains, to subacute injuries such as knee inflammation from recurvatum during gait [3].

Botulinum toxin injections (preferably Ultrasound guided, where we can isolate each muscle separately) should be given after thorough functional assessment and we should have clear goals post injection. Dynamic bracing improves the results [6]. If the assessment is proper, the procedure increases the functional independence of the patient.

Bracing, in addition to spasticity management, also helps in improvement of motor function and prevention of complications [6]. Understanding of proper biomechanics of each joint is instrumental for that. The decision as to whether patient should be braced must be carefully considered in view of the additional weight of the splint and patients' proneness to fatigue. In fact, many a times, improper bracing leads to compounding of adverse events.

Newer advances in rehabilitation include Robotic therapy and Virtual Reality training. Robotic therapy's greatest advantage could be in its capacity to induce more repetitions of limb movement (massed practice) within a given period [6]. Virtual reality training has proved to be really useful, especially in upper limb impairments [6].

In short, the central manifestations including psychological disturbances, spatial perception deficits, emotional instability, speech and writing problems, visual defects, hearing loss, incontinence, thalamic pain syndrome and extremity manifestations like motor function, spasticity, rigidity, ataxia, clonus, sensory changes, contractures, pain in peripheral limbs should be managed as a whole, for proper rehab to take place. And, for the patient, each step is important, as it motivates them to try for the next. The significance of a proper rehab plan, which is modified through periodic team evaluations, can not be overstressed.

Care of Elderly at Home

Elderly people are more prone to multiple comorbidities and falls and hence, have to be taken care of. Safe ambulation and independently performing their activities of daily living should be considered in this regard. The goal is to mobilize themselves safely and help them do all their daily activities independently, thus making them self-sufficient.

Ambulation

There are four general levels of ambulation - community, household, ambulation for exercise and non ambulatory state [3]. Community ambulation is ambulating unassisted in and outside the home for reasonable distances (>150 ft) with or without braces and assistive devices [3].

For smooth and safe ambulation, assistive devices, home modifications and fall prevention strategies help, according to the functional level of the patient [2,3,6]. Patient education regarding safe movement, healthy posture and rationalising expectations are of paramount importance.

Assistive devices

Assistive aids include walker, canes, axillary, elbow and platform crutches. The type of aid required depends on the assistance required for the person. Opposite the affected side, the weight transmission for a unilateral cane is 20 to 25 % [6]. With a forearm cane, it is 40 to 50%. With bilateral crutches, it is estimated at up to 80% [3].

Figure 2: Assistive aids

Canes should be held at the stronger side, and while walking, the weaker leg and the cane should be moved together [3]. The total height of the cane or walker should ideally be the length from the heel to the greater trochanter [6]. Where stability is compromised, a wide-based cane may provide a greater base of support.

Crutches give more stability and the most common are axillary crutches. The ideal length required is the distance from the axilla to the heel [6]. Elbow crutches are also a routine part of rehab, before beginning training on a cane.

Walkers are frame devices that provide wider base of support. They are used for people who require maximal assistance [6].

Home modifications

Homes may present several physical barriers to independence and safe mobility. Universal design standards [10] maximize accessibility and function and minimize the requirement for future modifications. Salient features of universal design are one-story living, no-step entries, wide doorways and hallways, and extra floor space. They allow easier use of a wheelchair and assistive devices.

Common examples of barriers [11] include absent or unsteady entrance or stairway railings, poor lighting, slippery bathroom or kitchen floors, low toilet seats, unstable furniture, clutter etc.

For improving accessibility, commonsense moves as repositioning furniture, removing rugs, eliminating clutter, moving electrical cords can really help [2]. People who have suffered strokes with hemi-paresis, or amputees, may have only one arm with the functional capability to use a handrail. Therefore, handrails should be provided on both sides of passageways [2].

For ramps, the correct slope is a 1-inch rise for every 1 foot of run [6]. Ramps can be made, in addition to the stairs, for smooth transportation (Figure 3).

Figure 3: Steps and ramp

Steps should have uniform riser heights and uniform tread depth. Stair treads should be no less than 11 inches in depth. Lighting sources are provided best at both the top and bottom of stairways to minimize shadows [12].

Grab bars are essential items at the toilet and shower/bathtub locations and should be mounted at 33 to 36 inches above the floor [12]. The standard size for a grab bar is 1-1/4 to 1-1/2 inches in diameter and should be 1-1/2 inches away from the wall [12]. Grab bars come in metal or plastic and in many sizes and colors (Figure 4).

Figure 4: Bathroom modifications

Bath Chairs enable a person to use a bathtub without sitting on the tub floor. This type of chair can be used in a shower and also has a cutout seat for personal hygiene and a removable pan for commode use. Standard toilets can usually be modified by raising their height, by adding a raised seat or a spacer underneath the base [12].

In kitchen, pull out work boards, use of switch controlled power sinks and spring loaded switch for garbage disposal are worth considering [12].

Fall prevention strategies

Age-related physiologic declines in multiple organ systems lead to the increased incidence of falls in the elderly [3]. Falls may be due to decreased neuromuscular coordination, mental status issues such as confusion and dizziness or environmental factors such as poor lighting and loose rugs [3]. The loss of muscle mass, usually 3% to 5% per decade after age 30, itself can lead to falls and fracture in the elderly [3]. Whereas young adults tend to fall to the side or backward, the elderly tend to fall sideways or drop in place, especially those with unsteady gaits [3]. Fall on side can lead to fracture of neck of femur.

The process of fall can be divided into four phases - Instability phase, where balance is lost; descent phase; impact phase and post-impact phase [3]. At each stage, interventions are to be done to prevent falls.

To prevent instability, general conditioning exercises, appropriate provision of assistive devices, adequate footwear, avoiding high heels, osteogenic exercise programs and modification of medications should be done.

To reduce the velocity of descent and impact phases, there should be general strength training and proprioceptive stimulation of both lower limbs [3]. Research also shows that the least number of falls occurs with vinyl flooring, and wooden subfloors [3]. There are different types of hip protectors (inverted U shape) too [3], which can reduce the impact of fall. Artificial intelligence powered smart homes with multiple sensors are also expected to help frail people in reducing falls by sending them appropriate warnings [13].

Activities of daily living

For performing activities of daily living, there are various modified devices that can be used, in case a person has difficulty to perform it the normal way.

For feeding, simple measures like keeping a wet cloth under plate, plate guard, adapted cup holder, spoon etc. can be really helpful [2]. Adaptations in dressing include Velcro straps and use of reachers.

As such, care of elderly is an important aspect, which has to be taken care of. In many homes, they stay alone and even in others, their dependency is huge. It is the collective duty of the society to help them age gracefully.

Conclusion

Comprehensive rehabilitation is essential in helping stroke patients reach their maximum functional potential. It needs a team approach and have to tackle issues including cognition, motor, sensory, speech and more.

Care of elderly becomes a reality only when a multitude of things fall into place including home modifications, use of assistive aids and modifications of equipment of daily use.

References

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Stroke Rehabilitation and Care of Elderly at Home