Report A5 Examination, Evaluation, and Intervention with an Individual Poststroke with Cognitive Impairments

Case Report A5 Examination, Evaluation, and Interv ention with an Individual Poststroke with Cognitive Impairments

Katy Kerris

A5.1 Introduction

The rate of cognitive impairment is high in patients poststroke. A study of 645 patients poststroke found 38% had cognitive dysfunction at 3 months poststroke.1 Another study identified cognitive dysfunction poststroke at 3 months to be 39%, at 1 year 35%, at 2 years 30%, and at 3 years 32% (n = 163).² Researchers using 17 scored items measuring cognitive skills identified cognitive impairment in 35% of patients poststroke (n = 227) compared with only 3% of controls (n = 240).³ Most recently, a study of life satisfaction poststroke found memory deficits in 32% of stroke survivors (n = 94).⁴

Coping with cognitive impairments presents challenges for survivors of stroke as well as their caregivers, adding to caregiver burden. Caregivers of persons showing memory impairment poststroke reported lower life satisfaction than caregivers of persons without cognitive problems poststroke.⁴ Individuals who are cognitively intact are able to live independently and/or require less supervision at home than do those with cognitive impairment.⁵

The effectiveness of cognitive rehabilitation strategies following stroke has not been well studied. A recent review of medical databases found only 10 studies on this topic.⁶ Still, identification of cognitive dysfunction at the time of evaluation can guide intervention planning and daily provision for intervention with patients cognitively involved poststroke. Intervention strategies blend the judicious use of handling, working within activities that are relevant and meaningful to the client, and careful selection of the environment and task setup to optimize outcomes. In individuals who have cognitive impairments poststroke or post–traumatic brain injury for instance, intervention strategies, including the therapist’s handling strategies, need not be discussed and described in detail with the patient. This information requires high levels of attention, concentration, and understanding of language, which are all common cognitive system impairments in individuals after stroke.

Handling is still used but, if used correctly, requires only nonverbal interaction between the client and the therapist. The Neuro-Developmental Treatment (NDT)-educated therapist’s use of familiar and relevant activities and specifically selected environmental setups to subcortically guide an individual into more efficient postures, alignments, and the automatic use of the more affected side need not involve a high degree of language and cognitive processing demands. The lack of awareness and error recognition often seen in these individuals can be addressed by enabling them to have more normal movement experiences and drawing attention to these when they occur.

Incorporation of family and caregivers during intervention is key for carryover to home and other functional environments. Constraint-induced movement therapy (CIMT) research has also demonstrated the importance of intensive practice in a person’s recovery poststroke.^7,8,9.10 With this intensive practice in mind, educating and incorporating the family and caregivers in functional training practice and a home exercise program to remediate impairments is key to an individual’s recovery poststroke.

The following case report describes the examination findings and intervention strategies chosen for a woman poststroke who demonstrated significant cognitive dysfunction, particularly in attention and judgment. Her care plan focused on movement practice in her clinic sessions and via a home activity program (HAP) within functional tasks that were immediately important and relevant to her, limiting the amount of verbal and cognitive information given to her. This case report also describes the strategies used in attempts to engage her husband and family in her rehabilitation program and the challenges encountered when these social factors proved complex.

A5.2 Case Description

PW is a 65-year-old woman with a past medical history that includes Bell’s palsy, diabetes mellitus, hypertension, dyslipidemia, chronic anxiety, and circulation problems. She suffered a right anterior communicating artery (ACA) stroke on October 2, 2010. This case report outlines the details of PW’s course in outpatient (OP) therapy over a 4-month period.

A5.2.1 Course of Care

• Inpatient rehabilitation for 5 weeks.

• Home health care services for ~2 months.

• OP therapy for ~4 months.

A5.2.2 Social History

PW is married and lives in a two-level duplex with her husband. Her prior functional level was complete independence, including working full time as a fifth grade teacher. She managed her household, doing most of the cooking and cleaning for her husband, and was relatively healthy. PW is right handed.

A5.2.3 Personal Goal

Her goal was to return to her profession as a fifth grade teacher by mid-March 2011.

A5.2.4 Examination and Evaluation

PW was admitted to OP rehabilitation on January 6, 2011, and received therapy for 4 months. Notes from home health care listed the following functional and mobility status at the time of admission to OP therapy:

• Sit to stand minimal assist.

• Stand pivot transfers with moderate assist (husband provides maximal assist, with PW grabbing around his neck).

• Walking with front-wheeled walker, 60 feet with moderate assist, including physical cues for knee control, foot position, and postural alignment.

During the course of her OP therapy, she had a fall at home on February 21, 2011, and spent 1 night in the hospital, undergoing a barrage of tests, including a left shoulder X-ray (showing mild degenerative changes at the acromioclavicular joint and a magnetic resonance imaging (MRI) scan showing the “old” right ACA infarct with encephalomalacia and volume loss as well as a trace subarachnoid hemorrhage in the left frontal lobe sulci and left sylvian fissure. She was discharged from OP rehabilitation during the recovery phase from this fall and stayed with family out of town. She returned to the OP clinic for reevaluation and continuation of intervention beginning March 21, 2011. At that time, it was felt her functional status and impairments were essentially the same as on initial evaluation. Thus the following details of her examination findings are from January 2011.

A5.2.5 Social, Environmental, and Contextual Factors

PW’s husband expressed frustration with her lack of independence and progress and felt she was not trying to improve. He appeared to have limited insight into her deficits, especially her cognitive deficits. PW’s sister, who lives nearby, was supportive, attended therapy with her, and attempted to integrate ideas learned in therapy in PW’s home. The sister expressed concern about her sister’s living situation. Other living situations were being considered, but none had worked out yet due to the desires of PW, her family, and financial constraints.

A5.2.6 Participation/Participation Restrictions

As already noted, PW had been a fifth grade teacher and was popular with her students. She was active in her church, and she and her husband had also assisted their daughter in daily child care while their daughter was at work. After her stroke, she was unable to return to work, babysit her granddaughter, or participate in her church activities without assistance.

She did not demonstrate any significant visual or communication issues. Her speech was clear. She was able to talk on the phone, write clearly and in a timely manner with her right hand, read documents the length of magazine articles only, and did not require glasses for vision. She was no longer able to drive and could access the community only with assistance. She required supervision at home at all times; she could not be left alone for even short periods.

A5.2.7 Activity/Activity Limitations

Observational posture and movement analysis was used in addition to standardized tests to determine PW’s baseline performance measures. Her baseline functional status in January 2010 follows.

Observation of Activity with Posture and Movement Analysis

Dressing

• PW required minimal assist for setup to retrieve her clothing and to don her posterior leaf splint and left shoe.

• She attended adequately to the left side while dressing.

• She completed the task(s) using only her right hand unless cued. She could grasp, release, and pick up small objects (such as her underwear) with her left hand as long as these were positioned immediately in front of her such that she did not need to flex/abduct her glenohumeral (GH) joint past 45°.

• She complained of extreme pain in her left shoulder with lateral or posterior reach and any forward reach past 45° flexion. Pain levels in the arm were reported to be 8/10, with pain at rest and with movement.

Bathing

• PW required minimal assist to complete the entire task safely, especially to wash her lower limbs and bottom.

Indoor and Outdoor Mobility

• PW used a wheelchair as her primary means of mobility.

• The house was thickly carpeted throughout, except the bathroom and kitchen; she reported difficulty in propelling her wheelchair independently.

• PW was short in stature, making positioning for self-propelling less than ideal.

Her feet barely reached the floor in her hemi-height wheelchair.

She often sat forward, propelling with her right leg hooked under the left; she did not automatically use her left leg to assist with foot propelling.

She was unable to use her left arm in the task.

• Prior to admission to OP therapy, she had some training in the use of a front-wheeled walker but was not doing this because her husband felt it was more time consuming for him to assist her in walking than to allow her to propel her chair.

Ambulation

• PW walked with a front-wheeled walker and assistance of one person primarily in therapy, short indoor distances only.

• She was able to hold the walker with her left hand (i.e., her hand did not fall off).

• During stance phase, her left hip remained in hip flexion, and she either overflexed or hyperextended her right knee in the last 20° of knee extension. Throughout stance and swing phase, her upper trunk leaned to the right with observed left scapular elevation.

• There was increased supination of the left foot, especially when wearing the posterior leaf splint and shoe. Standing and walking with socks or barefoot showed similar patterns but to a lesser degree.

Stairs

• Most of the living space in PW’s two-level duplex was on the second floor.

• She required minimal assist to ascend and descend 14 steps using a railing on the right side and a step-to pattern with the right leg leading.

Getting In and Out of Bed

• PW required standby assist (SBA) to get in and out of bed.

• PW frequently required assistance to get positioned in bed. Her mattress was soft, and they used flannel sheets as well as an incontinence pad. These conditions created too much friction for her to shift herself well. It was recommended that she avoid wearing pajamas and/or use different sheets along with a duvet style comforter to move more easily in bed.

• In the OP clinic, she was able to scoot on a mat with minimal assistance. She did not use her left limbs unless cued.

• Sit to side-lying to the left side required moderate assist due to shoulder pain.

• PW often complained of dizziness when moving from supine to sit.