Positioning in Bed and Passive Range-of-Motion Exercises After Stroke

Positioning after stroke is carried out with goals of preventing joint contractures, edema of the paretic extremity, pressure ulcers over bony prominences, and aspiration. The patient can be positioned fully supine or at 30 degrees head elevation (depending on aspiration risk) on a firm pressure relief mattress with hips slightly abducted, toes pointing up with use of towel rolls along the outer thigh or resting lower extremity splints and heels kept off the bed using pressure relief boots or pillows under the calves. Ankle plantar flexion contractures can be prevented by using a footboard or resting splints and upper extremity edema minimized by elevating the paretic arm on a pillow. Patients need to be turned a minimum of every 2 hours if they are not able to do so independently with the most efficacious side-lying position set at 30 degrees, using pillows to support the paretic arm and leg.

Passive range-of-motion exercises help prevent contractures that can develop in muscles and tendons of paretic limbs. During these exercises, the limb should be fully supported and brought through as full a range of motion as possible without causing pain.

Transfer training begins early in rehabilitation of the patient with hemiplegia. Ability to maintain a sitting position with assistance and following directions are the minimal requirements. An assisted transfer can be performed using a slide board, lateral scoot technique, or a stand-pivot technique, where the clinician may need to block the knee and provide significant physical assistance to move the patient from one sitting surface to another. This is best illustrated on moving from bed to wheelchair; as the patient recovers, the degree or assistance provided decreases with the ultimate goal of full independence.

Depression is another expected complication of any major stroke. It is very important to keep this possibility under consideration at all phases of rehabilitation therapy. Initial family support and encouragement is essential if at all possible. The clinician must be alert to loss of interest in pursuing rehabilitation efforts as well as the potentially depressing setting once a recent stroke patient is transferred to a rehabilitative setting where he or she is exposed to individuals with similar or worse outcomes not seeming to respond to therapy. Judicious use of antidepressant agents, including tricyclics and selected serotonin and epinephrine reuptake blockers, may prove beneficial. Cognitive therapy with a supervising psychiatrist and psychiatric social worker may also prove to be beneficial.

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