Neurorehabilitation principles and

consequenses for the professional

Berna Rood, MSc, Nurse
PUM
University Medical Centre Nijmegen
The Netherlands
Berna.Rood@Radboudumc.nl
2006 Barrow Nursing Symposium Setting the Standard… Building the Future November 2-3, 2006
Rumah sakit saya
• Acute phase
• Neurorehabilitation phase
• Chronic phase
 STROKE CARE: ACUTE CARE
 Medical treatment
 Monitoring vital functions
 Prevention of complications
 Secundair prevention
 Assessment, sensomotor and cognitive functioning
 Multidisciplinary treatment
 Start neurorehabilitation from day 1 FROM THE FIRST DAY!!
 Neurorehabilitation starts on day 1
Early mobilization, within 24-hours after the stroke, the change of
complications, death and permanent ADL dependent will decrease (Level A)

Early start of neurorehabilitation (within 24 hours) leads to a better and faster

functional recovery (level B)
STROKE CARE ACUUT:TIME IS BRAIN
 ACUUT CARE: TREATMENT INFARCTION
• Intravenous trombolysis rtPA (within 4,5 hours)
• Intra-arterial trombolysis (within 6 hours)
 Stroke unit: acute care
Effectiveness
• 18% dying patients
• 20% independent living at home

Reasons for effects

• Expertise in acute care for stroke
• Multidisciplinairy team (including nurses)
• Multidisciplinairy treatment goals
 REASONS FOR EFFECTS STROKE UNIT
• Educates stroke team
• Immediate CT / MRI available
• Stroke Protocols/guidelines available
• mobilization within 24 hours possible
• Teammeetings
• Education staff
• Education patients/family
 STROKE TEAM
Positive effect on:
• Survival,
• Duration stay in hospital / rehabilitation,
• Independency of daily activities

when patient is treated by specialised interdisciplinar stroke-team,

compared to usual care
 Trombolysis
• Filmpje dhr mclean
 STROKE CARE 3 PHASES

Neurorehabilitation: Training and (re)Learning daily functioning

 STROKE CARE 3 PHASES

Chronic care: care in the community

 Neurorehabilitation
Neurorehabilitation is a holistic approach aiming to rehabilitate
patients with neurological disorders.
Neurorehabilitation is patient focused, inclusive for the family and
other relatives, and paying attention to activities and participation
in the community, as well as the underlying functions and
impairments.
 Neurorehabilitation
Combination of therapy with the aim of recovery of body
functions and learning of compensationstrategies (adaptatie).
Neurorehabilitation consists learning of skills and patient
education
Neurorehabilitation
 Neurorehabilitation
• Starts early: day 1 (most effective outcome)
• Starts in the hospital and continuation to community care
• Learning by doing
• Meaningful activities
• Multidisciplinary team
• Assessment of functions, activities and partipation level
• Contribution family / caregivers
 NEUROREHABILITATION

Learning process aiming at functioning in daily live

Outcomes:
• Relearn skills: ADL!
• Learn to maintain functions and skills
• Use functions and skills in new situations
• quality of life
• Prevent complications (e.g shoulderpain, choking)

2006 Barrow Nursing Symposium Setting the Standard… Building the Future November 2-3, 2006
 BAPAK THOMAS
• 56 years old.
• He´s got a paralysis of his arm and leg and a facial paralysis.
• He is now in the neurorehabilitation phase.

transfer
• Film Thomas
 ADL SKILLS

Moving the hand Touching Skills

 LEARNING BY DOING
Task-orientated practice (learning skills) will reorganize the nerve networks of
the brain (level of evidence: B)

More hours task-oriented practice has a positive effect on the speed of

functional recovery, mobility and recovery of skills (level A)
 PLASTICITY OF THE BRAIN
• Billions of neuron continuous making of new connections
• Neurons are not able to divide
• Continuous loss of connections
• Basis for all kind of learning
• In the past: what is damaged is damaged
• Now: plasticity (=ability to change)

2006 Barrow Nursing Symposium Setting the Standard… Building the Future November 2-3, 2006
 HOW DO WE LEARN: PLASTICITY

• Network

• Damage

• Healing

2006 Barrow Nursing Symposium Setting the Standard… Building the Future November 2-3, 2006
NEUROREHABILITATION

person
task

environment
Driving a car
 FUNCTIONAL CONTEXT

Training and exercise in the functional context has a positive effect

on learning a movement or skill.

When possible it is preferred to practise in the personal

environment of the patient
 Bapak THOMAS
• 56 years old.
• He´s got a paralysis of his arm and leg and a facial paralysis.
• He is now in the neurorehabilitation phase.

wassen
 BALANCE

Practising balance during ADL tasks:

Better sitting and standing balance

Better basic activities

 IBU JANS
Infarct cerebri media. After 48 hours on the stroke-unit, she is on the
neurological ward. She has an intensive rehabilitation program on the ward.
She will go home next week and the neurorehabilitation continous at home.
 IMPORTANT FACTS
• Intensity of treatment: hours, frequency
• Task-specific: learn activity in daily tasks ( otherwise no
generalisation to other skills)
• Context-specific: own house or environment
• Training of functions necessary to make training of activities
possible: training of muscle strength, balance, endurance, trunc
balance, bilateral armtraining
GUIDE FOR PRACTICE BY THE PATIENT
AND FAMILY

Individual

Groups

Homework

Digital
 NURSING
Neurorehabilitation = learning process
= education

education means consistency, uniformity

and balanced teamwork

2006 Barrow Nursing Symposium Setting the Standard… Building the Future November 2-3, 2006
 NURSING
Nurses can offer a patient a consistent and continuous therapeutic
environment because of:

• 24 hours care
• ADL
• Functional situations
• Rich environments for motor & cognitive learning

2006 Barrow Nursing Symposium Setting the Standard… Building the Future November 2-3, 2006
 INTENSIVE PRACTICE
Intensive practice (average of 1,5 hours per day), better outcome:
• Walking skills,
• ADL
• ADL independence (like walking, dressing, washing)
• Instrumental ADL skills (like walking outside, cooking, and
perform household activities). (Level A)
 NURSING
This means that what we see as ‘basic care’ in fact is an important
starting point for therapy in neurorehabilitation!

2006 Barrow Nursing Symposium Setting the Standard… Building the Future November 2-3, 2006
NURSING REASONING PROCESS
 WHAT IS NECESSARY TO START
Case history: intake

Personal facts:
• what kind of person, which education?

Environmental facts:
• caregivers, house (stairs, living alone)

Functioning before stroke:

• Active? Other diseases/problems? Work? Tasks? Activities leasure
time?
 GOALS OF THE PATIENT

• Patient makes a list of goals

• Patient chooses 5 most important goals
 OBSERVATION OF THE PATIENT:
WHAT / HOW

• Making transfers: on the bed, from the bed, sitting to standing

• Standing: with or without help
• Walking: needs help? How? Problems?
• Washing and dressing
Bapak THOMAS

wassen
 TREATMENT PLAN
• Shared decision making: together with patient,
• The goals of the treatment plan are clear for patient/care-giver and rehab-
team
• SMART goals: specific, measurable, acceptable/achievable, realistic, time-
related

Central:
• wishes
• needs
• expectations of patient and caregiver
 BALANCE
 Imbalance lying

 Medium balance Sitting

 Sufficient balance Standing

 Level 1 Level 2 Level 3 Level 4 Level 5 Level 6 Level 7

Nonbalance Mediocre balance Sufficient balance

Lying Lying Sitting Sitting Sitting Standing Standing

Is able to lie Is able to lie Is able to sit Is able to sit Is able to sit Is able to stand Is able to stand
and to do little and to do and to do little and to do and to be and to limited and to be active
activities activities, activities medium active activities
activities
 Imbalance
(Lying) Functional level 1

The patient is able to lie

but has unsufficient
head/trunk balance to  Training on bed
be used in movements  Ask patient to help with basic
in bed.
activities
 Avoid fear of patients
 Give physical instructions to
patients (talk with your hands)
 Offer easy tasks: don’t ask to
much
 Imbalance
(Lying) Functional level 2

The patient is able to lie  Training on bed

and move the trunk and
head, but has insufficient  Ask patient to help with basic
head/trunkbalance to sit activities
independently while being  Avoid fear of patients
active.
 Give physical instructions to
patients (talk with your hands)
 Use patients funtions and skills
 Stimulate and activate the
affected arm
 Guidance
Medium balance
(Sitting)
The patient is able to sit,
but gets out of balance
while carrying out
activities.
Functional level 3
Wash lower part of the body on
bed
Upper part of the body washed
at the wash basin
The patient is sitting well
supported
The patients keeps the balance
The nurse takes over the
activities of the patient.
 Medium balance
(Sitting)
The patient is able to sit
and to carry out activities
in distance of the middline.
He can´t keep his balance
when he reaches outside
the midline.
Functional level 4
Wash lower part of the body on
bed
Upper part of the body washed
at the wash basin
The patient is able to wash the
upperpart by himself
The transfer to the toilet is
possible
 Medium balance
(Sitting)
Functional level 5

The patient is able to sit Washing and dressing at the

and to carry out activities wash basis in a sitting position
and keeping full balance.
Use patients funtions and skills
Let the patient solve problems
Facilitate patients trunk
movements while crossing the
legs.
Let the patient organize his/her
own gear if possible
Sufficient balance
(Standing) Functional level 6

The patient is able to Washing and dressing at the

stand but is restricted in wash basin in sitting and
activities within the standing position
middline. Stimulate patients selfcare
Guiding if possible
Stimulate the patient to take
weight on both legs.
Use routine activities and
automatical skills.
Sufficient balance
(Standing) Functional level 7

The patient is able to be Guiding if possible.

active in a standing  Stimulate the patient to carry
position without lossing out activities in a standing
the balance position.
 Prediction arm functioning and walking
Day 2/3 post stroke:

Fingerextension + shoulder abductions within 72 hours after stroke:

98% change of recovery arm/hand of 6 months.

Sit balance, little activity hip, knee, ankle within 72 hours after stroke:

96% change of recovery of walking independently after 6 months.

.
 USE IT OR LOSE IT

Patients with cognitive disorder, inactivity, depression and-or

fatique have a bigger change to decrease in mobility and activities
of daily living on longterm. (≥ 6 months after stroke)
• Neurorehabilitation is ‘learning by doing’
• Outcomes are optimal functioning, relearning & maintaining &
generalizing of functions and skills and quality of life
• Based on plasticity and behavior as brain behavior
• Start at the very first day
• Nurses can offer a consistent and continuous therapeutic
environment
2006 Barrow Nursing Symposium Setting the Standard… Building the Future November 2-3, 2006
TERIMA KASIH!