J Am Board Fam Pract: first published as 10.3122/jabfm.5.4.389 on 1 July 1992. Downloaded from The Complications Of Immobility In The Elderly Stroke Patient

Elise M. Coletta, M.D., andJohn B. Murphy, M.D.

Abstract: Background: Approximately 500,000 persons in the United States suffer a stroke each year; the majority of these individuals are 6S years of age or older. The neurological impairment occurring as the result of stroke can lead to both acute and chronic disability. Further medical complication and disability are often the result of immobility-related Uloess that occurs whne the patient is still in the hospital. Methods: A MEDLINE search for articles published from 1980 to 1990 was made using the key words immobilization and stroke rehabilitation. The bibliographies of these articles, key rehabilitation and geriatric textbooks, the bibliographies of these textbooks, and the authors' personal files were also sources of information. Results tmtl Conclusions: Immobility-related medical complication and disability can be substantially reduced by identifying risk factors and applying preventive measures. As long-term providers of medical care, family physicians are in a position to devise a preventive care pJan for immobility-related disability and to appreciate the beneficial effects of such a plan on patient outcome. 0 Am Board Fam Pract 1992; 5:389-97.)

Most family physicians care for stroke patients normal aging produces physiologic changes that and witness not only the acute neurologic event of put the elderly individual at increased risk from stroke, with its physical and functional effects, but bed rest.4 also the related chronic disability. The present US The potential consequences of immobility in population of long-term disabled stroke survivors the stroke patient and appropriate preventive is large, estimated at about 2 million persons. l ,2 strategies are listed in Table 1. Early mobilization Because family physicians care for many of these and an activity prescription are key points in each individuals, methods of reducing stroke-related preventive'intervention. In many cases clinicians http://www.jabfm.org/ disability are important to the family practitioner. are not attentive to activity orders. A recent study Acute and chronic disability from stroke has of hospitalized, elderly, medical-surgical patients several causes; the two most important are the in five New England hospitals revealed that of a functional effects of the neurologic impairment total of 3500 patient days covering the first 7 days itself and the added functional decline related to of admission, 13 percent of patient days had no immobility. Although in many cases modem sci­ activity order in effect and that a similar percent­ ence cannot substantially reduce the actual neuro­ age of patient days had a bed rest order.s On on 28 September 2021 by guest. Protected copyright. logic deficit, immobility-related decline is pre­ average, 8 percent of patients had a bed rest' order ventable} This review focuses on the approaches for the entire 7 days studied. S All too often the designed to prevent the adverse consequences of hospitalized elderly patient is kept in bed for ill­ immobility. It is important that this aspect of defined medical reasons, because the physician acute stroke management be considered early, as forgets to advance the activity order or because immobility-related functional decline can occur mobilization is thought to strain available man­ in an elderly stroke patient within a few days. As power. In. reality, there are very few medical an additional factor in the older stroke patient, illnesses that require strict bed rest, and the mo­ bile, conditioned, aged patient requires less phys­ Submitted, revised, 28 February 1992. ical assistance in the long run. From the Memorial Hospital of Rhode Island, and the Depart­ Although the stroke patient is discussed spe­ ment of Family Medicine, Brown University, Providence, RI. cifically in this review, the information presented Address reprint requestS to Elise M. Coletta, M.D., Department is generally relevant to any immobilized elderly of Medical Rehabilitation, Memorial Hospital of Rhode Island, 111 Brewster Street, Pawtucket, RI 02860. person.

Immobility of the Stroke Patient 389 ThbIe 1. Prewmtive S1rategies for Potential Complkatlonl of immobility In the Dderly Stroke Patient. J Am Board Fam Pract: first published as 10.3122/jabfm.5.4.389 on 1 July 1992. Downloaded from Complication Preventive Strategies Skin Decubitus ulcer Early mobilization Frequent body repositioning Daily skin inspection Pressure-relieving mattress surface Bowel and bladder management Adequate nutrition Bowel Constipation Early mobilization Fecal impaction Bowel clean-out, if necessary Fecal incontinence High-fiber diet Adequate fluid intake Stool softeners Bowel evacuation regimen Bladder Urinary tract infection Hydration

Urinary retention Early mobilization Urinary incontinence (overflow) Investigate for secondary causes of retention Prompted voiding Intermittent catheterization, as necessary Avoid Foley catheter drainage, if possible Cardiovascular Orthostatic hypotension Early mobilization Elastic stockings Slow devation from supine to sit to stand Daily "leg dangling" Adequate fluid intake

Deep venous thrombosis and pulmonary embolus Early mobilization Elastic stockings Subcutaneous heparin Range-of-motion joint exercises Pulmonary Atelectasis Early mobilization

Aspiration pneumonia Prompt assessment and management of dysphagia http://www.jabfm.org/ Bedside respiratory care Proper positioning Metabolic and endocrine Osteoporosis Early mobilization and weight bearing

Urinary tract stones Early mobilization Adequate fluid intake

Urinary acidification, if necessary on 28 September 2021 by guest. Protected copyright. Musculoskeletal Deconditioning Early mobilization Daily passive and, if tolerated, active assistive range-of-motion exercises Bed mobility training Daily weight bearing Encourage activities of daily living

Contractures Early mobilization Proper bed positioning Range-of-motion exercises Neuropsychiatric Sensory deprivation and depression Early mobilization Appropriate communication system Increase patient interaction with staff and fiunily Provide necessary adaptive aids Environmental orienting cues

390 JABFP July-August 1992 Vol. 5 No.4 ,. skin maceration occur if there is inattention to

Skin J Am Board Fam Pract: first published as 10.3122/jabfm.5.4.389 on 1 July 1992. Downloaded from Decubitus Ulcer incontinence and skin occlusion by bedding.lo There are four physical factors involved in the From both a time and cost perspective, decubi­ development of decubiti: pressure, shearing tus ulcers are much more easily prevented than force, friction, and moisture. The stroke patient cured.12 Important points in prevention include is at increased risk of skin breakdown because of prompt mobilization, bowel and bladder man­ all four factors. Additionally, stroke patients are agement, early assessment and attention to the often immobile, incontinent, and confused. provision of nutrition, daily skin inspection, a Edema, sensory impairment, malnutrition, poor pressure-relieving mattress surface, and frequent circulation, and anemia also predispose to skin repositioning.13 Although the "tum every 2 hours breakdown.6,7 The consequences of skin break­ rule" is quoted in general texts, the necessary down in the stroke patient include local infec­ frequency for turning is unclear and probably tion, pain, positioning problems, a delay in am­ varies with the patient's risk status.ll,14 Regard­ bulation because of the location of the decubitus, ing positioning, the right and left 30-degree and worsening spasticity, as the lesion is a noci­ oblique positions will relieve the five major ceptive stimulus.8 pressure points of the sacrum, greater trochan­ In general, elderly patients are more prone to ters, ischial tuberosities, lateral malleoli, and skin breakdown because of a higher rate of con­ heels.6,lO,14 These bony areas should be inspected tributing comorbid illnesses, as well as intrinsic for skin change with every repositioning; non­ age-related cutaneous changes. Age-related skin blanching erythema is a prelude to breakdown. changes that increase the risk of traumatic injury When positioning a patient, limbs that rest include delayed wound healing because of de­ against each other should be separated with a creased epithelial cell turnover, thinning of sub­ pillow. If erythema is present, heels can be el­ cutaneous tissue, loss of collagen elasticity, dermal evated from the bed by placing a pillow under the atrophy, and flattening of rete pegs.9 calf. A sheepskin placed over the sheets can re­ Compounding these age-related risks, the eld­ duce skin friction and maceration. erly immobile stroke patient can be exposed to the Regarding mattress surface, the appropriate four physical factors noted above. For example, pressure-relieving device is unclear. Regular pressure phenomena occur under bony promi­ 2-inch eggcrate foam pads do not substantially nences when an individual lies on a normal mat­ decrease local pressure but can increase comfort tress. lO As capillary pressure (32 mmHg) is ex­ and still help in decubitus prevention. IS Other http://www.jabfm.org/ ceeded, local tissue ischemia develops. As shown foam pads of different construction (Geo-matt"') in animal studies, pressure effects are an essential, have minimal cost and will decrease local pressure but not solitary, component of decubiti forma­ below capillary pressure. IS Air fluidized beds tion.u Substantial pressures (up to 290 mmHg) (Clinitron'IV) and alternating pressure air mat­ do not produce breakdown in pig skin.ll Much tresses (Clinicare'IV) work well but are expensive,

lower pressures ("" 45 mmHg), however, result in and the former impair bed mobility and trans­ on 28 September 2021 by guest. Protected copyright. decubiti when coupled with other adverse physi­ fers. l1 No pressure-relieving mattress surface re­ cal factors. ll These additional factors are almost places the need for regular turning and skin in­ always present in a bedridden patient. One factor, spection. Special beds are not needed for the shearing force, is particularly relevant for the sa­ typical stroke patient if a good program of pre­ cral area. The sitting patient (including the pa­ vention is instituted early. tient sitting on a reclining chair) or the supine, bedfast patient whose head of the bed is raised Bowel greater than 30 degrees can slide forward, creat­ ConstljMtlon, Fectlllmpactlon, tm4 Fectli ing a strong shearing force on the sacrum.10 This IfICOfItInence shearing force stretches dermal blood vessels and The increased sympathetic nervous system re­ decreases cutaneous blood flow, thereby com­ sponse to bed rest results in inhibition of gastro­ pounding the tissue ischemia from pressure phe­ intestinal peristalsis and consequent constipation nomena.ll Friction develops when patients are and fecal impaction.4,l6,17 Additionally, many pulled across bed linens. Finally, moisture and elders are chronically constipated and take medi-

Immobility of the Stroke Patient 391 cations with potential constipating effect. Drugs morning, 15 to 30 minutes after breakfast, to take J Am Board Fam Pract: first published as 10.3122/jabfm.5.4.389 on 1 July 1992. Downloaded from that cause constipation include nonsteroidal anti­ advantage of the gastrocolic reflex. 2o Also, a inflammatory agents, calcium channel blockers, commode or toilet is preferable to a bedpan so opioids, iron supplements, phosphate-containing intra-abdominal pressure can assist in com­ antacids, and medications with anticholinergic plete evacuation. Finally, on a predetermined activity. schedule based on the patient's premorbid bowel Fecal impaction can be of two types, colonic habits, a glycerin or bisacodyl suppository can and dyschezic. Colonic impaction occurs when be used if the patient does not pass a stool there is prolonged transit time in the entire large spontaneously. To work most effectively, the intestine, which results in water absorption from suppository must be placed next to the bowel the stool and the development of hard fecal wall, where its local irritant effect can stimulate masses in the colon and rectum. In dyschezic the sacral evacuation reflex. Scheduled cathar­ impaction, transport is normal until the sigmoid tics can also be used but can lead to incontinent colon and rectum, where a large mass of soft feces episodes. is formed. Soft stool, therefore, does not rule out impaction but can point to its cause. I8 Bladder Often fecal impaction presents clinically as Urinary Traet Infection, Urinary Retention, and fecal incontinence. I8 Leakage of stool occurs Urinary Incontinence when feces overload the rectum, causing a de­ The stroke patient is prone to developing a uri­ crease in sphincter tone and stool release. Other nary tract infection because of many potential nonneurogenic causes of fecal incontinence in­ factors including a preexistent atonic bladder, the clude overuse of stool softeners and cathartics and change in urogenital flora with hospitalization, the effects of functional limitations. Examples of possible comorbid conditions, such as malnutri­ the latter are impaired mobility and impaired tion and prostate enlargement, poor perineal hy­ communication that could limit access to the toi­ giene, and most importandy, the common use of let and impaired cognition that could limit aware­ a Foley catheter. Catheter drainage should be ness of the need to use the toilet. In the stroke used for a limited number of indicated conditions patient these nonneurogenic causes of fecal in­ that are discussed below, not as a matter of medi­ continence are much more common than is in­ calor nursing convenience. continence caused by a neurologically impaired Bed rest promotes urinary retention through bowel. In fact, because of the nature of bladder several mechanisms. Postvoid residual urine is http://www.jabfm.org/ and bowel innervation, if there is no urinary in­ often increased because of incomplete relaxation continence, any fecal incontinence is almost ex­ of perineal muscles during supine voiding. Also, clusively from a nonneurogenic cause. I9 The gravitational forces and intra-abdominal pressure presentation of the fecal incontinence can give a have a lessened effect on supine voiding. 16 Outlet clue as to its cause. Patients with fecal impaction obstruction, medications, and comorbid disease usually leak a small amount of loose stool also can be factors in increasing residual urine or on 28 September 2021 by guest. Protected copyright. throughout the day; patients with a neurologically causing retention. A patient with urinary reten­ impaired bowel will be incontinent of a small, tion should be examined for causes of oudet ob­ formed stool, once or twice daily, coincident with struction, such as fecal impaction, urethral stric­ their gastrocolic reflex. ture, or prostatic enlargement. Additionally, The prevention and treatment of constipation, elderly patients often are receiving medications fecal impaction, and fecal incontinence include that can compound the effects of bed rest on the same basic principles. Cathartics can be re­ residual urine. Medications with anticholinergic quired initially to clean out the bowel. A moder­ effect (e.g., tricyclic antidepressants, antihista­ ately high-fiber diet, stool softeners, and ade­ mines, and neuroleptics) will cause detrusor re­ quate fluid intake are needed to maintain a soft, laxation, calcium channel blockers directly impair formed stool. detrusor contractility, and adrenergic blockers The final factor is an established regimen for (e.g., reserpine, ephedrine, and phenylpropanola­ bowel evacuation. It is recommended that the mine) will increase sphincter tone and cause out­ patient use the toilet daily, preferably in the let obstruction.20 Comorbid disease, such as dia-

392 JABFP July-August 1992 Vol. S No.4 betes, can be associated with an atonic bladder. A Cardiovascular Effects chronic neurogenic bladder can be occult if be­ Ortbosllltie Hypotension J Am Board Fam Pract: first published as 10.3122/jabfm.5.4.389 on 1 July 1992. Downloaded from fore being bedridden the patient has been suc­ Orthostatic hypotension is a relatively common cessfully voiding despite having high postvoid re­ event in the aged, occurring in 20 to 25 percent of sidual urine volumes. Retention only develops unselected elderly patients.4,22 Postural hypoten­ with the added insult of immobility. Urinary re­ sion is due to physiologic changes of aging along tention can lead to overflow incontinence as urine with coincident factors of disease and drug use.4,22 output exceeds bladder capacity. The ill effects of orthostatic hypotension in the Except during the acute flaccid muscle phase, stroke patient can be serious and include stroke stroke does not cause urinary retention or over­ extension and falls resulting in fracture. flow incontinence. When either of these two Age-related changes affecting postural mecha­ conditions occurs, it is more likely caused by im­ nisms include a decrease in baroreceptor and ~­ mobility compounded by the factors or diseases adrenergic receptor sensitivity, a decrease in rest­ discussed above. In a true neurogenic bladder ing ventricular stroke volume, and a blunted caused by stroke, incontinence is due to loss of response of stroke volume and cardiac output to central inhibition over bladder contraction.21 stress.4,22 Disease states that can contribute or Bladder emptying and, therefore, postvoid re­ lead to orthostatic hypotension include diabetes sidual urine are normal (less than 50 to 70 mL), mellitus, vitamin B deficiencies, hypothyroidism, but uninhibited bladder contractions result in Parkinson disease, and any process leading to urge incontinence. Even with urge incontinence, hypovolemia.22 Medications that can result functional issues rather than true neurologic dam­ in orthostatic hypotension include diuretics, age could be the cause. Again, as in fecal inconti­ anti-hypertensives, antidepressants, and major nence, the physician should consider functional tranquilizers.22 causes, such as impaired mobility, communica­ Bed rest further increases the rate of orthostatic tion, and cognition. hypotension in the already predisposed aged The patient who has experienced several days patient. The normal postural compensatory or more of bladder distention may require tempo­ changes in heart rate, stroke volume, and cardiac rary bladder rest by catheter draining. Causes output are lost after only 1 or 2 weeks of bed contributing to retention should always be rest.4,16,17,23 Shorter periods of inactivity will sought. For acute retention, for example, as oc­ still have a negative effect on postural mecha­ curs during the acute flaccid muscle stage of nisms, especially in the predisposed elderly pa­ http://www.jabfm.org/ stroke, a short period of regular, intermittent tient.16 Additionally, the diuresis precipitated by (every 6 to 8 hours) bladder catheterizations bed rest increases the tendency toward or­ might be all that is necessary. The goal offrequent thostatic hypotension.24 Subsequent recondition­ catheterizations is to maintain bladder volume ing of postural reflexes takes time. In young per­ at no greater than 400 mL. Greater volumes sons placed at bed rest for 3 weeks, recovery

will cause overdistention and lesser ones might required 1.5 to 2.5 months.2S It is reasonable to on 28 September 2021 by guest. Protected copyright. not provide an adequate stimulus for voiding. assume postural recovery woulcJ..take at least as As detrusor tone recovers, voiding again occurs, long in older persons. postvoid residual urine decreases, and catheter­ Several simple measures will decrease the oc­ ization becomes unnecessary. In all cases, man­ currence of orthostatic hypotension. The use of ual bladder pressure (Crede method) techniques thigh-high elastic stockings minimizes postural can be taught to increase emptying. A program hypotension by decreasing venous pooling when of timed voiding (every 2 to 4 hours) on a the legs are in a dependent position.17,22 Slowly commode or toilet should also be initiated to elevating the patient to a sitting position and encourage a schedule of bladder emptying. pausing before standing are also recommended. Prompted voiding is also important in the pre­ Maintaining proper fluid intake, getting the pa­ vention of immobility-related urinary reten­ tient out of bed early in the hospital course, or at tion. Persistendy high postvoid residual urine or least having the patient sit upright daily with legs urinary retention should prompt referral to a dangling will also prevent the loss of postural urologist. reflexes.4,22,24

Immobility of the Stroke Patient 393 Deep Venous Tbrombosls lind Pulmonary propriate management of dysphagia, bedside res­ J Am Board Fam Pract: first published as 10.3122/jabfm.5.4.389 on 1 July 1992. Downloaded from Embolism piratory care (e.g., incentive spirometry), and at­ Stroke patients have a high occurrence of deep tention to proper positioning. Moving the patient venous thrombosis.26 Puhnonary embolism is re­ to an upright chair position will improve dia­ sponsible for 12 percent of deaths in the first week phragmatic movement, increase aeration of basal after stroke.27 There are several reasons for the high lung segments, and increase arterial oxygen ten­ rate of thromboembolic complications after stroke. sion (Pa02).4 The family physician must also be The diuresis associated with bed rest leads to in­ vigilant about looking for aspiration pneumonia, creased blood viscosity through a decrease in plasma as its symptoms can be insidious and nonspecific. volume. A reduction in venous blood flow and in­ The first indication of a problem could be a creased venous pooling occur in the paretic limbs of change in cognitive or physical function. Mild stroke patients and can account for the higher rate tachypnea, without fever, could be the only of deep venous thrombosis in the weak versus non­ change in vital signs. paralyzed extremity.4 Bed rest can also lead to stasis through mechanical compression of leg veins. Metabolic and Endocrine Effects Early mobilization, the use of elastic or intermit­ Osteoporosis tent compression stockings, institution of range of Although usually not recognized as clinically im­ motion exercises, and the appropriate use of subcu­ portant, there are major metabolic and endocrine taneous heparin are thought to help prevent deep changes with bed rest and immobility. These venous thrombosis.26 The successful deep venous changes occur slowly and insidiously and require thrombosis prevention trials with prophylactic ad­ a prolonged recovery period for reversal. 16 Only ministration of subcutaneous heparin and graded the major effects are discussed here. compression stockings have been conducted in In studies done on normal men confined to postoperative patients and in those with nonstroke bed, researchers found a 0.9 percent weekly loss medical conditions (congestive heart failure, myo­ of bone density from lumbar vertebrae.4 Im­ cardial infarction), but not specifically in stroke pa­ mobility leads to osteoporosis through several tients.28-30 Nonetheless, it is probable that a similar mechanisms. First, bony growth is encouraged positive effect of such treatment would result in along lines of bone stress from weight bearing and stroke patients.26 the normal movement of tendons and ligaments. This fact might account for a greater loss of cal­

Pulmonary Disorders cium in weight-bearing bones. Second, immo­ http://www.jabfm.org/ Meledllsls andAsplrlltfon Pneunumlll bility is associated with decreased osteoblast and Six percent of deaths in the first 2 to 4 weeks after increased osteoclast activity.4 Elderly patients are stroke are caused by aspiration pneumonia.27,31 particularly at risk for disuse osteoporosis because The stroke patient is at particular risk for this of an age-related decrease in osteoblast function complication because of the common occurrence and gastrointestinal' calcium absorption. In

of many factors: dysphagia, difficulty handling women, osteoporosis potential is further height­ on 28 September 2021 by guest. Protected copyright. secretions, altered level of consciousness, de­ ened by the effects of estrogen 10ss.33 For preven­ creased or absent cough reflex, decreased chest tion, weight-bearing exercise (e.g., walking) done movements on the hemiplegic side, and hospital­ several times a day could be sufficient to decrease acquired changes in oral flora. Bed rest worsens disuse osteoporosis.4 aspiration risk because the supine position results in a less effective cough, impaired clearance of UrInary T1'IICt Stones secretions, ventilation-perfusion mismatch, and Hypercalciuria and phosphaturia also occur after basilar atelectasis.4,16 These changes are particu­ 2 to 3 days of bed rest and lead to an increased risk larly important in the elderly patient because of of renal and bladder calculi.4,8,16 The supine posi­ an age-related increase in residual volume and tion will decrease urinary drainage from the renal decreases in lung recoil and respiratory muscle pelvis and ureters, and the combination of strength.32 . hypercalciuria, phosphaturia, and urinary stasis Prevention of atelectasis and aspiration pneu­ can promote stone formation, which then can monia is achieved by prompt assessment and ap- serve as a nidus for infection. 16 Prevention of

394 JABFP July-August 1992 Vol. S No.4 calculi is through maintenance of adequate fluid Data on the deconditioning effect of bed rest in J Am Board Fam Pract: first published as 10.3122/jabfm.5.4.389 on 1 July 1992. Downloaded from intake and, if necessary, urinary acidification. elders are limited. Studies have shown that as littl~ as 3 to 5 days of bed rest will lead to cardiovascular Musculoskeletal Effects de conditioning in the aged. 19 This rapid cardio­ Deeondltitmlng vascular deconditioning is in part due to known Deconditioning has two components: a decrease age-related decreases in stroke volume and car­ in muscle strength and endurance and a decrease diac output response to exercise.4 Deconditioning in cardiopulmonary endurance and exercise toler­ is obviously easier to prevent than treat. Patients ance. Bed rest adversely affects both components. should sit up in bed as soon as they are neuro­ The elderly stroke patient confined to bed must logically stable, usually within 24 to 48 hours.35,36 combat the effects of the neurologic deficit com­ The simple act of daily range-of-motion exer­ pounded by the deconditioning effect on im­ cises, both passive and, if tolerated, active assist­ paired and normal limbs and the cardiopulmo­ ive, done 5 to 10 minutes a day, can be helpful.l7 nary system. After a stroke, the additional Exercise while sitting or standing upright will disability conferred by deconditioning can pro­ decrease the loss of aerobic capacity.4 Bed mobil­ duce further loss of ambulation and independence ity training and daily weight bearing, through in activities of daily living skills (Table 2) and limit transfers to a chair or commode, can occur as soon the patient's ability to tolerate rehabilitation as sitting balance is sufficient for an upright pos­ exercises. ture.24 Basic activities of daily living should be The classic studies on the cardiovascular effects encouraged.24 of bed rest immobility involved conditioned young men.25 After 4 to 6 weeks of bed rest, these Conlrtlet"res men had an increase in basal heart rate, a decrease Many factors are responsible for the development in maximal oxygen consumption (V02 max) and of joint contractures in the early poststroke phase, exercise tolerance, and a blunted stroke volume including immobility, weakness, cognitive and and cardiac output response to exercise.4,16,17,19,25 perceptual deficits, and neglect of range-of­ Regarding muscle strength, MUller's studies, motion joint maintenance. In addition to cos­ which involved bed rest and cast immobilization metic alterations;- joint limitations are painful oflimbs, measured a 15 to 20 percent loss of initial and time consuming to reverse and interfere with muscle stt:ength after the first week of im­ positioning, thereby increasing the risk of skin

mobilization.l7,23,34,3S Bed rest with limited activ­ breakdown. Contractures also affect a patient's http://www.jabfm.org/ ity produced a less profound, but still important, independence by limiting activities of daily living loss of strength and endurance, especially in the and mobility skills. 23,37 large weight-bearing lower extremity muscles.23 An immobile joint will develop a contracture Even a 10 percent loss of strength after 1 week of within 3 to 4 weeks; if the joint is injured, impor­ bed rest can be enough to make a marginally tant loss of range can occur in as little as 2 weeks.38 independent elderly person dependent in activi­ From both a time and cost perspective, pre­ on 28 September 2021 by guest. Protected copyright. ties of daily living.24 vention of contractures is effective. The key to prevention is proper, varied bed positioning and prompt institution of range-of-motion 18ble Z. PuIlC1ioD81 StatuI Measures. exercises. Stroke rehabilitation texts and articles Measures of Physical Functioning Items Included contain clear pictures of the various bed posi­ Activities of daily living Bathing tions that should be used with the stroke Dressing patient during the flaccid muscle phase.8,37 Toileting Transfer Proper positioning in the spastic stroke phase is Continence more complex; Bobath's text or hospital physi­ Bladder cal therapists should be consulted for informa­ Bowel tion.39 Regarding range-of-motion exercises, Feeding Mobility Walks Mossman's stroke rehabilitation text has good in­ Propels wheelchair structional illustrations.23,40 Three repetitions of (as applicable) range-of-motion movement at each joint, done

Immobility of the Stroke Patient 395 tWice a day, should be sufficient to prevent become unable to take advantage of a hospital­ contractures.8,38 level rehabilitation program. For example, bed­ J Am Board Fam Pract: first published as 10.3122/jabfm.5.4.389 on 1 July 1992. Downloaded from rest-related deconditioning can limit exercise tol­ Neuropsychiatric Effects erance to such an extent that a stroke patient Sensory DepriVlltion lind Depression might not tolerate the level of exercise required in The effects of sensory deprivation are well de­ a hospital-level rehabilitation program. Also, im­ scribed in a variety of populations, including mobility-related medical problems, such as deep prisoners in solitary confinement, healthy venous thrombosis and decubiti, can prolong the young subjects in experimental settings, and acute hospitalization and delay rehabilitation unit hospitalized patients.4 Affective changes and admission. Because the majority of neurologic perceptual distortions have been recognized recovery and maximal functional improvement with social isolation alone; when immobiliza­ generally occur in the first few 1l\onths after tion is combined with social isolation, cognition stroke,8,19,41 a delay in intensive rehabilitation is also affected}9 Hospitalized elderly stroke could result in irretrievably lost function. Conse­ patients are at particularly high risk for sensory quently, although a formal rehabilitation program deprivation, as they are often immobile and begins after acute hospital discharge, rehabilita­ cognitively impaired and could have premorbid tion potential can be maximized through prompt visual impairment, auditory deprivation, and development of a preventive plan for the adverse other pre-existing immobilizing conditions. Be­ consequences of immobility. cause of the stroke, the patient's communication abilities might be impaired, and staff could in­ We thank Drs. William Reichel and Bruce Lazarus for their appropriately limit attempts at conversation. helpful review of this manuscript. Additionally, the sterile hospital environment provides little sensory stimulation. As a group, therefore, aged stroke patients are at great risk for the effects of sensory deprivation. Sensory. References 1. Hayes SH, Carroll SR. Early intervention care in the deprivation will precipitate or worsen depres­ acute stroke patient. Arch Phys Med Rehabil 1986; sion and cause anxiety, confusion, and non­ 67:319-21. compliant behavior.19 Each could lead to iatro­ 2. Feigenson JS. Stroke rehabilitation: effectiveness, genic complications as the physician attempts to benefits, and costs. Some practical considerations. Stroke 1979; 10:1-4. treat these behaviors. http://www.jabfm.org/ 3. Hunt TE. Rehabilitation of the elderly. In: Reichel Prevention of sensory deprivation is aimed at W, editor. The geriatric patient. New York: HP Pub­ increasing patient interaction with staff and lishing, 1978:172-80. family through attempts at communication and 4. Harper CM, Lyles YM. Physiology and compli­ participation in activities of daily living. It is im- cations of bed rest. J Am Geriatr Soc 1988; 36: . perative to maintain communication with the pa­ 1047-54. 5. Lazarus BA, Murphy ]B, Coletta EM, McQuade

tient, whether it be verbal, gestural, or through on 28 September 2021 by guest. Protected copyright. WH, Culpepper L. The delivery of physical activity pictures. Also, the placement of orienting infor­ to hospitalized elderly patients. Arch Intern Med mation, such as calendars, clocks, and family pic­ 1991; 151:2452-6. tures, and the provision of necessary glasses and 6. Sine RD. Pressure sores: development, pathogenesis, hearing aids are helpful.23 prevention and treatment. In: Sine Robert 0, Liss SE, Roush RE, Holcomb]D, editors. Basic rehabili­ tation techniques. Germantown, MD: Aspen Sys­ Rehabilitation Potential tem, 1977:191-202. A common therapeutic consideration in the aged 7. Kelly JF, Winograd CH. A functional approach to stroke patient is discharge to a hospital-level re­ stroke management in elderly patients.] Am Geriatr habilitation program. For the appropriate patient, Soc 1985; 33:48-60. the comprehensive, interdisciplinary team ap­ 8. DeLisa JA, Mikulic MA, Melnick RR, Miller RM. proach of the rehabilitation unit provides the best Stroke rehabilitation: part n. Recovery and compli­ cations. Am Fam Physician 1982; 26:143-51. chance of functional improvement. Immobility­ 9. Fenske NA, Lober CWO Skin changes of aging: related disability can be so important that pathological implications. Geriatrics 1990; 45: an otherwise appropriate stroke patient might 27-35.

396 JABFP July-August 1992 Vol. 5 No.4

IL .. 10. Goode PS, Allman RM. The prevention and man­ 26. Prevention of venous thrombosis and pulmonary agement of pressure ulcers. Med ain North Am embolism. NIH Consensus Conference. JAMA J Am Board Fam Pract: first published as 10.3122/jabfm.5.4.389 on 1 July 1992. Downloaded from 1989; 73:1511-24. 1986; 256:744-9. 11. Kosiak M, Kottke Fl. Prevention and rehabilita­ 27. Caplan LR. Stein RW. Stroke, a clinical approach. tion of ischemic ulcers. In: Kottke FJ, Lehmann JF, Stoneham, MA: Butterworth Publishers, 1986. editors. Krusen's handbook of physical medicine and 28. Fasting H, Andersen K, Kraemmer-Nielsen H, rehabilitation. 4th ed. Philadelphia: W.B. Saunders, Husted SE, Koopmann HD. Simonsen 0, et al. Pre­ 1990:976-87. vention of post operative deep venous thrombosis. 12. !toh M, Lee MH. The epidemiology of disability as Low-dose heparin versus graded pressure stockings. related to rehabilitation medicine. In: Kottke Fl, Acta Chir Scand 1985; 151:245-8. Lehmann JF, editors. Krusen's handbook of physical 29. Allan A, WtlliamsJT, BoltonJp, LeQuesne LP. The medicine and rehabilitation. 4th ed. Philadelphia: use of graduated compression stockings in the pre­ W.B. Saunders, 1990:215-33. vention of postoperative deep venous thrombosis. Br 13. Allman RM. Pressure ulcers. In: Hazzard WR, An­ J Surg 1983; 70:172-4. dres R, Bierman EL, Blass JP, editors. Principles of 30. Lawrence D, Kakkar vv. Graduated, static, external geriatric medicine and gerontology. 2nd ed. New compression of the lower limb: a physiological as­ York: McGraw Hill, 1990: 1204-11. sessment. BrJ Surg 1980; 67:119-21. 14. Smith DM, Wmsemius DK, Besdine RW. Pressure 31. ElliotJL. Swallowing disorders in the elderly: a guide sores in the elderly: can this outcome be improved? to diagnosis and treatment. Geriatrics 1988; 43:95- J Gen Intern Med 1991; 6:81-93. 100,104.113. 15. Treatment of pressure ulcers. Med Lett Drugs Ther 32. Tockman MS. Aging of the respiratory system. In: 1990; 32:17. Hazzard WR, Andres R, Bierman EL. Blass JP, edi­ 16. Halar EM, Bell KR. Rehabilitation's relationship to tors. Principles of geriatric medicine and gerontol­ inactivity. In: Kottke Fj, Lehmann ]F, editors. ogy. 2nd ed. New York: McGraw Hill, 1990: Krusen's handbook of physical medicine and reha­ 499-508. bilitation. 4th ed. Philadelphia: W.B. Saunders, 33. Kraenzlin ME. Calcium and bone hemostasis with 1990:1113-33. aging. In: Hazzard WR, Andres R, Bierman EL, 17. Vall bona C. Bodily responses to immobilization. In: BlassJP, editors. Principles of geriatric medicine and Kottke FJ, Stillwell GK, Lehmann JF, editors. gerontology. 2nd ed. New York: McGraw Hill. Krusen's handbook of physical medicine and reha­ 1990:799-812. bilitation. 3rd ed. Philadelphia: W.B. Saunders, 34. Miiller EA. Influence of training and of inactivity on 1982:963-76. muscle strength. Arch Phys Med Rehabil 1970; 18. Smith RG. Fecal incontinence. J Am Geriatr Soc 51:449-62. . 1983; 31:694-7. 35. Anderson TP. Rehabilitation of patients with com­ 19. Anderson TP. Rehabilitation of patients with com­ pleted stroke. In: Kottke Fl, Stillwell GK, Lehmann pleted stroke. In: Kottke FJ, Lehmann JF, editors. JF, editors. Krusen's handbook of physical medicine Krusen's handbook of physical medicine and reha­ and rehabilitation. 3rd ed. Philadelphia: W.B. http://www.jabfm.org/ bilitation. 4th ed. Philadelphia: W.B. Saunders, Saunders. 1982:583-603. 1990:656-78. 36. Rusk HA. Rehabilitation medicine. St. Louis: CV 20. Perkash I. Management of neurogenic dysfunction Mosby, 1977. of the bladder and bowel. In: Kottke Fj, Stillwell 37. Ellwood PM Jr. Bed positioning. In: Kottke Fl, Leh­ GK, Lehmann JF, editors. Krusen's handbook of mann JF, editors. Krusen's handbook of physical physical medicine and rehabilitation. 3rd ed. Phila­ medicine and rehabilitation. 4th ed. Philadelphia:

delphia: W.B. Saunders, 1982:724-45. W.B. Saunders, 1990:520-8. on 28 September 2021 by guest. Protected copyright. 21. Borrie MJ, Campbell AJ, Caradoc-Davies TH, 38. Kottke FJ. Therapeutic exercise to maintain mobil­ Spears GR Urinary incontinence after stroke: a pro­ ity. In: Kottke FJ. Stillwell GK, LehmannJF, editors. spective study. Age Ageing 1986; 15: 177-81. Krusen's handbook of physical medicine and reha­ 22. Rosenthal MJ, Maliboff B. Postural hypotension: its bilitation. 3rd ed. Philadelphia: W.B. Saunders, meaning and management in the elderly. Geriatrics 1982:389-402. 1988; 43:31-4,39-42. 39. Bobath B. Adult hemiplegia: evaluation and treat­ 23. Mossman PL. A problem oriented approach to ment. 2nd ed. London: William Heinemann Medi­ stroke rehabilitation. Springfield, IL: Charles C cal Books, 1978. Thomas, 1976. 40. Sharpless JW Mossman's problem oriented ap­ 24. Hoenig HM, Rubenstein LR Hospital associated de­ proach to stroke rehabilitation. 2nd 00. Springfield, conditioning and dysfunction. J Am Geriatr Soc IL: Charles C Thomas, 1982. 1991; 39:220-2. 41. Hewer RL. Rehabilitation of stroke. In: Illis LS. 25. Taylor HL, Henschel A, Brozek J. Keys A. Effects Sedgwick EM, Glanville HJ. editors. Rehabilitation of bed rest on cardiovascular function and work per­ of the neurological patient Oxford: Blackwell Scien­ formance.J Appl Physio11949; 2:223-39. tific, 1982: 153-79.

hnmobility of the Stroke Patient 397