HANDLING A STROKE PATIENT

The most common type of stroke is an ischaemic stroke, which happens when a clot blocks an artery that carries blood to the brain. The second type of stroke is a bleed, when a blood vessel bursts, causing bleeding into the brain. This is called a hemorrhagic stroke. Weakness or paralysis (hemiplegia) is one of the most recognisable and most common symptoms of a stroke. It usually happens on one side of the body. Weakness or paralysis of an arm or leg is often made worse by stiffness (spasticity) of the muscles and joints. Loss of balance can be caused by damage to the cerebellum. Or it may happen because of paralysis resulting in muscle weakness and loss of coordination. Many people also experience problems with speaking and understanding, and with reading and writing. This difficulty with language is called dysphasia. All of these things have an impact on how we handle patients. Decreased muscle tone is often associated with weakness and paralysis and if patients are not handled correctly damage can be caused to joints, particularly of the upper limb. Loss of strength and balance in one side will affect the patients mobility, consequently making handling more difficult and presenting more risks. Communication difficulties also present challenges when handling a patient and trying to help them with rehabilitation. POSITIONING OF STROKE PATIENTS

Lying on the affected side

Lying on the unaffected side

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Lying on back

Sitting up in bed

Sitting up in chair In each position the patient is well supported with pillows in a good posture to avoid straining joints prevent increased muscle tone. Furniture should be positioned on the affected side of the patient to encourage them to use this side. The side that the stroke affects is often neglected and part of the rehabilitation process is to make them use that side. SHOULDER CARE Shoulder problems affect 70% of all stroke sufferers. The affected arm initially needs to be well supported on a pillow, as gravity acting on the weight of the arm can dislocate the shoulder joint. Stroke patients should never be pulled, however gently, by the arm. A physiotherapist will then work to restore normal movement and postural control. Some people can feel a gap at the shoulder joint (known as subluxation). This does not mean that the shoulder is dislocated, but it is a warning sign that the joint is not
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supported properly by the muscles. There is a risk that the soft tissue around the joint can become impinged, causing inflammation, pain

Subluxation is when the head of the humerus slips out of the glenoid socket. Cause of shoulder problems due to incorrect handling: a) Lifting distally when dressing b) Drag lift c) Pulling back in chair incorrectly d) Pulling arm as a guide when walking and supporting e) Nursing supine (on back) increased reflex activity

GOLDEN RULES FOR STROKE

1. Lie patient on their back only for short periods of time. Laying them on their side is preferable. 2. Never touch balls of the feet of toe pads as it can increase extensor tone. 3. Meals to be taken out of bed and not in a semi-recumbent position. 4. Always support affected arm in extension in chair. 5. Keep patient aware of affected side i.e. locker and chair on affected side. 6. Approach patient on affected side after the first few days. 7. Dont label patients as lazy when they forget how to do something like dressing as it could be apraxia 8. Mobilise shoulder with humerus in external rotation and scapula protracted. 9. Move the arm by supporting the whole forearm and shoulder not just the hand. 10. Early appropriate handling and positioning facilitates recovery.

REFLEXES
When we are born our bodies tend to function reflexly e.g. pretend to drop a baby and it will elicit a startle reflex; put a finger in palm of babys hand and it will grip/grasp. We soon learn to do things voluntarily and the reflex is lost i.e. it is controlled by the higher centres in the brain (cortical control is developed). After a CVA the cortical control is often lost and the reflex comes to the fore again.

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Labarinthe reflex: Brought about by changes in head position in space. if nursed supine leads to increased extensor tone in leg in prone to increased flexor tone if extensor tone ++ then appears as reduction only (relative) if sitting for long time flexed, head extended to see then increased tone in lower leg and slipping forward off chair - bent head during sitting causes reduced extension and collapse into seat Symmetrical tonic neck reflexes: To maintain balance and equilibrium. semi recumbent supine in bed/ chair causes increased tone in leg extensors and arm flexors patient has difficulty getting from lying to sitting because he has to raise his head if walks with head down then increased extensor tone in leg and flexor in arm. transferring bed to wheelchair increases extensor tone in leg and flexors in arm if he looks up increases extension in arm and flexion in leg.

Asymmetrical tonic neck reflexes: - if you turn head to the right, arm and leg on that side increase extensor tone - babies use this to fixate and grasp things - if patient turns head away from affected side it increases the tone - if standing and walking delayed, flexor tone increases in affected leg even when lying. Positive supporting reflex - exteroceptive stimulus to skin on toe pads and ball of foot stimulated increased extensor tone eg babies precursor to walking. - Never touch ball of foot leads to increased extensor tone, leg rigid, knee hyperextended, cannot put heel to floor or release hip and knee to bring leg forward and cannot swing weight forward over foot. Crossed Extensor reflex: increased extensor tone in one leg when other is flexed precursor to walking and crawling. lying supine patient unable to bridge unaided bends sound leg then affected leg has increased tone. Patient allowed to stand from sitting with weight over sound leg, then unable to weight bear because affected leg has increased flexor tone.

University of Surrey Moving and Handling 2006

University of Surrey Moving and Handling 2006