Patients recovering from stroke and experiencing mobility difficulties are a common diagnosis seen by Steven Nicholson, PT.  Neurological patients present some unique challenges in the inpatient environment. We asked Steven how he works with an acute care approach to neuro, and he recommended these three focuses to help short-term patients reach a safe and improved level of stability before discharge.

Education

The initial goal must be education for both the patient and the family/primary caregiver. Because the patient may be experiencing cognitive impairment due to the stroke, it is important to provide comprehensive education for the family.

I start by fully explaining what a stroke is and what they can do to help minimize the effects of the stroke on functional activities and prevent further strokes or neurological insults. I also discuss the five pillars of a healthy life that lead patients to discover a foundation for continuous improvement.

1. Nutrition – Make sure the nutritionist is involved. Proper nutrition is incredibly important for optimal post-stroke care. Advise patients to watch calorie intake (especially unhealthy snacks and extra portions), and eat only what the nutritionist recommends.
2. Sleep/Activity – You’ll often have floods of friends and family coming in to the patient’s room, stimulating the patient when in fact they need time to shut down and rest. Using their finite amount of energy in a constructive way will lead them back to a path of independent living.
3. Exercise – Start their daily exercise regimen early. They will have a home exercise program, which needs to begin while they are in the hospital for better carry-over.
4. Compliance – Whether following medication instructions or adhering to medical advice, compliance is key. Not taking medication may trigger another neurological event in some patients with a propensity for stroke.
5. Spiritual – While a personal preference, prayer or meditation has been a tremendous help in many of my patients. I frequently call the chaplain to come in and pray once the patient/family report being receptive to the idea.

Activity

With acute neuro, your goal is to increase patient activity levels as soon as possible. Start small and work on sitting balance/tolerance/posture including dynamic and static activities. Rhythmic stabilization works well combined with proper positioning and support of the weaker side. Then work on standing and transfers out of the bed to a chair. Once you’ve developed a safe way for the patient to get in and out of bed, demonstrate it to the nursing staff until they feel comfortable transferring the patient. The sooner you develop this foundation, the better you can maintain skin integrity and move on to address other deficits.

Each individual is a unique case, so an eclectic and customized approach to therapy is often best. I usually combine knowledge from my Neuro-Developmental Treatment (NDT) certification with other neurological treatment approaches. Working with diverse patient populations over the years has allowed me, when necessary, to think outside the proverbial neuro box. We often fabricate treatment props to advance therapeutic activities and exercises as well as mock AFOs and wheelchair positioning devices. No two strokes are the same, and it’s best to get the patient a variety of opportunities and various stimuli. Don’t always do the same movement over and over again. Because normal movement is variable (we’re not robots!) and we tend to move in different ways, your approach should mirror this.

Using NDT techniques, I use key points of control by stimulating the patient’s muscles during specific movements to accomplish a task. Doing this, you can gradually let the patient’s muscles do more of the work. Your body becomes part of the patient’s body, and as they get better you do less and less and the patient does more and more. True NDT is time-consuming, but you can use some techniques in the limited time you have with these acute patients. Always balance what the patient’s body is capable of doing on its own and what you or an assistive device can stabilize enough to improve functional mobility. Additionally, I always incorporate closed chain activities, which are less taxing on the patient and integral to recovery.

Teamwork

With stroke patients a multidisciplinary approach is necessary for ongoing recovery. Ensure PT, OT and SLP are involved in the patient’s care as well as all levels of nursing care. Each member of the team brings different approaches and strengths. Working together often leads to the patient accomplishing more.

Steven Nicholson, PT has 15 years’ experience across orthopedic, pediatric and neurological physical therapy and has been a RehabVisions therapist since 2005. His passion is neurologic physical therapy and he has received specialized clinical training for the Neuro-Developmental Treatment (NDT) certification.