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Preventing muscular contractures through routine stroke patient careDiana De and Emma Wynn

I t is a sad fact that stroke is one of the top three causes of death in the UK, 2030% of people who have a stroke die within a month (National Audit Office, 2005; Scottish Intercollegiate Guidelines Network, 2010). For those who do survive, stroke is a leading cause of adult disability, often having a devastating impact on the quality of lives for survivors and their families (McKevitt et al, 2010). Lasting psychological effects charted by Murray et al (2009) include stroke-associated loss of cognitive and communication skills, depression and other mental health problems. These can reduce the persons motivation to mobilise, resulting in an exacerbation of any postural complications developed post-cerebrovascular event. The long-term physical effects of stroke complications can lead to chronic discomfort, immobility and pain. These can result in sleep deprivation, poor sanitation and inadequate nutrition. These additional impediments can be infuriating for stroke patients, who for the majority of their lives would have been independently mobile and self-caring, and can compromise an effective rehabilitation programme (Turtan and Britton, 2005). They can also contribute to an increased demand on health and social care resources, a reduction in the persons quality of life experience, and, foremost, a lifetime dependency on others. From a financial perspective, the resulting higher-level care at home and longer periods of hospital stay increase the costs to the NHS and social care services (Lewis and Byblow, 2004). This article focuses on the prevention of worsening physical disability.

StrokeA cerebrovascular accident (CVA) or stroke can be caused by a blood clot or a haemorrhage within the brain, often resulting in long-lasting neurological deficits, affecting mobility, cognition, sight or communication (Nair and Peate, 2009). Damage to the descending pathways in the brain during a stroke causes spinal motor neurons to lose their connection to muscles and the tendons around them (Miribagheri et al, 2008). These early pathophysiological changes can result in sudden degenerative changes within those muscle and tendon mechanics, owing to both muscular groups being underused following an acute neurological injury (Young, 1994). This can be characterised in stroke patients who may then be left with a reduction of muscle tone to the upper and/or

Diana De, Senior Lecturer, Adult Nursing, University o f South Wales; Emma Wynn, Staff Nurse, Intensive Care Unit, Guys and St Thomas NHS Foundation Trust, London

Accepted fo r publication: Ju n e 2 0 1 4

AbstractThe aim o f this article is to elevate the standard o f ward-based routine care by informing readers about the prevention and management o f muscular contractures post-cerebrovascular accident (CVA). Musculoskeletal complications can develop at any time during the acute or latter stages o f stroke care and rehabilitation; therefore, it is imperative that all nurses understand the importance o f correct limb placement and some o f the detrimental complications that can occur. By placing more onus on therapeutic positioning and earlier mobilisation, nurses, working alongside allied health professionals, can significantly improve morbidity-related outcomes.

Key words: Cerebrovascular accident Contracture Musculoskeletal abnormalities Stroke Disease management Nursing rehabilitation Patient positioning

lower body extremities. This subsequently results in limited mobility and can cause long-term disability (Baek et al, 2009).

Morbidity after a stroke affects at least 450000 people across England (Department of Health (DH),2006). In Wales, a third of people who have suffered a stroke are left with a long-term disability (Welsh Government, 2012). Stroke has a more devastating impact than any other chronic disease on the health of the UK population, something that the World Health Organisation (WHO) indicated back in 2004, in their Atlas of Heart Disease and Stroke (Mackay et al, 2004).

Musculoskeletal complications: overviewHemiparesis (paralysis down one side of the body, opposite to the haemorrhage/infarction side within the brain) has long been known to be a direct consequence of stroke, affecting more than 80% of survivors (Sommerfield et al, 2004). The severity of a stroke determines the amount of hemiparesis experienced by individual stroke patients and it is hemiparesis that directly affects the other confounding musculoskeletal complications outlined in this section.

Shoulder/glenohumeral subluxation (GHS) is where the humeral head partially separates from the glenoid cavity, leading to additional muscle and soft tissue strain around the shoulder (Herding and Kessler, 2006). GHS has been reported to occur in up to 84% of all hemiparetic stroke patients by Seneviratne et al (2005). Hemiplegic shoulder pain (HSP), reported from 2 weeks to 1 year post stroke, is also reported to occur in up to 84% of cases (Rajaratnam et al, 2007). Spasticity, an additional musculoskeletal complication, which results in uncontrolled and discomfited movements,

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Figure 1. Exercising finger digits in the affected limb: squeezing a rubber ball

Figure 2. Supporting patients under the arm when mobilising is common

is considered to occur as a result of increased or decreased overall muscle tone. This affects around 1739% of stroke patients, approximately 3 months post stroke, with 3860% affected 1 year on according to Lundstrom et al (2008). Some reports of spasticity have even been documented as early as 1 week post stroke (Malhotra et al, 2008).This demonstrates that the development of complications can begin immediately post stroke, emphasising the need for timely instigation of specialist rehabilitative care and positioning. Abnormal leg and arm postures induced by spasticity and/or contractures (which represent abnormal shortening of muscle resulting in distortion of joint and loss of movement) can also create difficulties with sitting and mobilisation, and these atypical postures can worsen as the severity of the disability progresses. This makes activities of daily living, such as eating and drinking, difficult to maintain. Sadly, examples of all of these muscular-induced difficulties (Table 1), have been detailed throughout a range of clinical settings, but occur less in the specialised acute and rehabilitation stroke environments referred to earlier. However, more recently,

individual recovery following an acute stroke has been shown to be significantly enhanced if specialist therapy and wider social care support packages can be instigated in a timely manner (Griffiths, 2012).

Stroke care and managementAccording to the Stroke Association (2010), someone suffers a stroke in England every 5 minutes, yet a certain degree of reassurance can be found in the knowledge that most UK hospitals nowadays contain a designated stroke unit. An organised stroke unit is a hospital provision coordinated by a team of doctors, nurses and therapists who specialise in looking after stroke patients, often sharing infrastructure with hyperacute services (a conglomeration of governmental, NHS and stroke charities working to enhance best quality specialist services). According to The Cochrane Collaboration(2013) , stroke patients who receive organised inpatient care in a stroke unit are more likely than outliers to survive their stroke, return home and become independent in looking after themselves. This is good news for those being admitted to such institutions of excellence. However, what if you are a nurse caring for a stroke patient who was not fortunate enough to have been admitted to a specialised stroke unit? National clinical guidelines (Mant et al, 2004) uncovered that, during a typical weekday, more than half of all stroke patients were being cared for on a specialised stroke unit. However, implications will remain for those patients being nursed elsewhere, as these outliers may not always be subjected to stroke intervention targets. This particular group of patients who are admitted elsewhere in the hospital and away from a specialist unit could appear to be at increased risk of developing poor posture-related complications. Interestingly, Indredavik et al (1999) identified a shorter time to mobilisation/physical training as the most important factor affecting the discharge to home period in a stroke unit; this was found to be longer in a general ward setting.Thus, all ward-based nurses (and healthcare assistants), need to understand the importance of early mobilisation and rehabilitation, as well as the potentially detrimental effects that can occur as a result of lack of appropriate positioning for any patient who has experienced a stroke, and the potential to improve care and patient outcomes by being more involved needs to be realised.

Activity after stroke and contracture preventionSystematic reviews by Field et al (2013) andVeerbeek et al(2014) recognise physical activity to be beneficial following a CVA and uncovered strong evidence for stroke patient interventions favouring intensive, highly repetitive, task- orientated and task-specific training in all phases post stroke. Meta-analysis (Evidence Based Review of Stroke Rehabilitation (EBRSR), 2014) showed significant positive effects for 13 interventions relating to gait, 11 interventions relating to arm-hand activities, 3 interventions for physical fitness and another related to activities of daily living. 3 However, EBRSR (2014) also acknowledged that poorer J walking ability, specific sensory motor functions, and low J mood were found to be correlates for low levels of ;

o

physical activity affecting individual recovery. The therapeutic

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relationship between a nurse and patient could, therefore, provide a much-needed motivational impetus to improve some of these aspects that may hinder rehabilitation regimes.

Social stim ulationStudies have uncovered the unfortunately small amount of time ward nurses actually spend interacting with their stroke patients, despite their continuous presence (Moran et al, 2009; Westbrook et al, 2011). This often results in long periods of loneliness for the recovering patient (Huijben-Schoenmakers et al, 2009). Bernhardt et al (2004) found that stroke patients spend more than 60% of their therapeutic day alone, often partaking in passive pursuits such as lying down or watching television (Jones et al, 1998). Although time constraints and stafF shortages can be an obstacle to all those responsible for resource management, it is imperative that these constraints do not affect the quality of any patients care during that crucial rehabilitative period. Ward-based nurses need to collaborate and find ways of increasing social stimulation. For example, a nurse entering a bay or a telephone ringing could well provide enough of a stimulus for a mobile stroke patient to reposition themselves or exercise their affected limb independently (Figure 1). Thus, multidisciplinary care plans, which incorporate these types of mutually inclusive goals, could improve the overall quality of care received and perceived by the service user and their families.

Earlier m obilisationThere is general consensus within the 16th edition of the EBRSR (2014) that early mobilisation of a limb is essential in the prevention of post-stroke complications in agreement with the National Institute of Health and Care Excellence (NICE) (2008) Stroke: diagnosis and initial management guidelines. However, this must be balanced with the need to avoid overusage of limb mobilisation. Lang et al (2007) observed that patients use their ipsilateral arm (stronger) for a period of 8.4 hours per day compared with the paretic arm (weaker) used for only 3.3 hours. Mobilisation plans could be based on these given times and adjusted to the expectation of the individual patient. For example, a labourer may use their arms more, a pensioner may use them less. It should be noted that over-using the ipsilateral arm for undertaking most activities of daily living in turn can exacerbate further weakness in the paretic arm over time. This is caused by dystonia, which often relates to a painful range of movement disorders, causing involuntary spasms and/or muscular contraction, and which has been linked to impairments within central sensory integration after CVA (Meskers et al, 2005).Therefore, earlier mobilisation and emphasis on the importance of using both limbs needs to be advocated in order to benefit the patients overall reduced mobility (van Wijk et al, 2011; Askim et al, 2012). Knowledge of this may reassure nurses and healthcare assistants about encouraging patients to participate more in their day-to-day activities, such as when reaching for objects, walking to the toilet, sitting out of bed, standing and walking to the day room (Bernhardt et al, 2008). However, nursing staff need to refrain from supporting a patient under the arm (Figure 2) when mobilising them as this tends to cause significant injury and pain to the hemiparetic/plegic arm of

Table 1. M uscular-induced difficulties

G lenohum eral subluxation of th e shoulder (GHS)

Flaccid paralysis of th e affected side p reven ting m uscles from stabilising th e shoulder correctly

H em iplegic shoulder pain (HSP)

The w eigh t of th e paretic arm and loss of m uscular su p p o rt affects this type of shoulder pain frequently experienced w ith stroke, causing hem iplegia

C ontractures Immobilisation of th e affected arm causes th e fibro- ad ipose connective tissue to proliferate and occupy the joint space, causing a contracture

Spasticity Resistance to stre tch a limb d u e to increase hypertonicity

Nursing and midwifery grand round

All nurses/m idw ives by email

the stroke patient. Thus, earlier mobilisation of both limbs could be seen to reap rewards for the patient, but it needs to be based on sound patient assessment.

A s s e s s m e n tAccording to the stroke pathway guidance (NICE, 2010), all patients admitted to a stroke unit should be assessed and managed by stroke nursing staff and at least one member of the specialist rehabilitation team within 24 hours of admission to hospitalas well as by all relevant roles within the specialist rehabilitation team within 72 hours, with documented multidisciplinary goals agreed within 5 days of admission to hospital. As per the Royal College of Physicians (2008) national clinical guideline for stroke, outlying patients on general wards are being seen by a physiotherapist within 24 hours and occupational therapist within 72 hours post admission. However, these assessments are often carried out without any nursing input.

An early assessment facilitates initial hospital management and prevention of musculoskeletal complications, thus improving overall motor recovery, functional independence and quality of life for patients (Zeferino and Aycock, 2010). Within the majority of hospitals across the UK, the initial assessment of musculoskeletal complications is predominantly undertaken by specially trained physiotherapists and/or occupational therapists with assessment beginning when the therapist is available. This may not be immediate (Vuadens et al, 2005).The authors felt that ward nurses could enhance this particular assessment process and reduce target times further if they were included as part of a wider stroke care team. In comparison with the ward-based nurse, evidence suggests that those other allied health professionals only spend a relatively small amount of time with stroke patients (Bernhardt et al, 2007). Physiotherapists and occupational therapists have been observed trying to create an assessment profile for a stroke patient with a speech impediment during a time when relatives (who were present on admission and who could have supplied supplemental information to the admitting nurse) have left the premises. An important role for a nurse in this situation is to provide admission and observation information to the allied health professional to assist in their assessment profile and to identify which muscular contractures the patient may be at risk of developing in a timelier manner and instil the correct positioning.

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Positioning in bed

Lying on the backThis is the position most likely to encourage spasticity, but some patients do like to lie on their back for a while and it will be required for some treatments. Place two pillows under the patients head and help him bend his head slightly towards his unaffected shoulder and gently turn his head towards his stroke side but do not use force.A small pillow is placed under the buttock of the stroke side and should extend just to the knee; this will relax the leg and prevent it turning out at the hip. A pillow is placed under the stroke arm which is kept straight at the elbow and, if possible, the palms of the hand facing upwards. The bed must be the correct height to promote independence and safety for the patient, family and healthcare workers.

This should always be encouraged w ith the stroke shoulder well forward so that the body weight is supported on the flat of the shoulder blade and not on the point o f the shoulder. Place the stroke leg w ith the thigh so that it is in line with the trunk, and bend the knee slightly. The unaffected leg should be brought forward and placed w ith the knee bent on a pillow in front o f the affected leg for comfort. This prevents the patient rolling onto his back. Lastly, bend the head forward a little.

Lying on the unaffected sideAgain, the stroke arm should be well forward, keeping the elbow straight and supported on a pillow. The stroke leg should be brought far enough in front o f the body to prevent the patient rolling onto the back, the knee bent and leg supported on a pillow. A small pillow can then be placed under the patients waist to maintain the line o f the spine. When lying on the side position, the patient should have tw o pillows only under the head.

Sitting position in a chairThe patient should sit upright well back in the chairand should not slump to one side.A table should be used to support the stroke arm which then rests on a pillow. The arm should be positioned w ith palm facing downwards, fingers and thumb straight and elbow straight. The stroke leg may need to be supported by a pillow beneath the buttock on the stroke side to prevent the knee rolling outwards and so keep the foot flat. The occupational therapist w ill advise on the appropriate type of chair for safety and independence.

Figure 3. Avoiding tile pitfalls o f poor positioning

Lying on the stroke side

CollaborationSimply cooperating more closely and transparently with other allied health professionals can enhance nursing knowledge of affected musculoskeletal complications and correct positioning. Perhaps in an outreach type of role, experienced stroke unit nurses, physiotherapists and occupational therapists could share information and stress the importance and benefits of early mobilisation and limb positioning to ward-based nursing and ancillary staff. Simply reiterating, for example, during handover that specific intervention during the acute phase after stroke improves motor recovery emphasises the potential beneficial effect of therapeutic interventions for the affected arm (Feys et al, 1998). This may prompt ward staff to reflect on their current practice and consider a more

informed approach towards aiding pressure relief care in the future. Results from a quasi-experimental study by Jones et al (1998) showed that although it was possible to effect a degree of change in nurses knowledge and awareness of the practice of positioning following the attendance of a set of formal teaching sessions, the quality of patient positioning still remained variable. The study concluded that more effective ways of improving positioning need to be developed.

More inclusion of pictorial or prescribed manoeuvres may serve to guide ward nurses via an integrated care plan and direct them to gain appropriate rehabilitation support resources. More direct approaches in undergraduate and postgraduate nursing programmes such as clinical simulation titled, for example, Stroke Care: how to optimise positioning of the hemiplegic patient in order to prevent muscular contractures, may benefit current and future nursing practice. Involving service user and specialist allied healthcare individual participation may also enhance the delivery of these types of sessions. This and further research is vital for inspiring ward nurses and nurse educators to influence, develop and improve stroke patients quality of care. Close guidance and supervision by therapists could instil ward nurses with the confidence to implement better risk management of muscular contractures, patient safety and overall clinical outcomes for their stroke patients.

Practical advice: to move or not to moveCorrect limb positioning requires particular attention to both upper and lower extremities to prevent or manage further musculoskeletal complications (Mee and Bee, 2007). Unfortunately, practical advice about repositioning affected limbs does not tend to be promoted well in most traditional nursing care plans or preregistration nursing programmes. Supplementary guidance from specially trained rehabilitation therapists and national guidelines such as NICE (2013) are necessary to inform best practice. Ward-based nurses need to be instilled with the latest evidence-based knowledge, skills and confidence to implement effective limb positioning and effective rehabilitative care for stroke patients, as they often refrain as a result of the fear of doing something wrong or of causing pain and distress to a relatively new stroke patient. Optimal rehabilitative care delivery needs to be free from conflicting advice, as this could be hampering current practice and mobilisation efforts from being implemented with stroke patients undergoing general ward-based care.

Continuing careCurrently, ward-based nursing appears to be predominantly focused on completing nutritional, skin integrity, falls and swallowing assessments (Chamanga, 2010), with little regard given to preventing musculoskeletal complications. Assessing musculoskeletal complications would require a shift in cultural thinking, but could lead to timelier care planning for earlier mobilisation and optimal patient positioning. Nurses could play a greater role in the 24-hour regime and maintenance that contracture prevention requires and which therapists are not able to provide. Repetitive movements have long been a key aspect of motor learning, strengthening the connections between neurons following a stroke (Hebb,

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1949). The most effective rehabilitation plan would require the nurse to collaborate with the multidisciplinary team during continuous assessment and management of the stroke patients musculoskeletal complications to ensure reduced discomfort and an effective enforcement of both management and treatment. It has long been seen that continuity is vital when observing improvements or changes in the patient, both physically and psychologically (Wade and Halligan, 2003). Nurses provide a 24-hour presence from admission to discharge (Perry et al, 2004). This continuity means that nurses know their patients and, therefore, are well-placed to encourage the prevention o f muscular contractures. The development of a therapeutic nurse-patient relationship starts during admission. During this phase, the nurse is able to observe the patient noting any stroke-affected musculoskeletal complications that may interfere with a patients activities of daily living.Therefore, developing a more integrated, multidisciplinary, holistically inclusive assessment/management tool may contribute to nurses providing a more accurate physical profile and could enhance future follow-on rehabilitative care. This is not a novel idea: Lincoln et al (1996) advocated that all staff should be trained to place patients in positions to reduce the risks of complications such as contractures, respiratory complications and pressure sores.

Clinical governanceNurses duty of care requires work alongside allied colleagues who normally provide impetus care in this area of stroke rehabilitative care to maintain quality assurance.Physiotherapists and occupational therapists can help improve insufficient knowledge gaps regarding musculoskeletal complications. Nevertheless, all o f those involved in the implementation o f intentional rounding (Box 1) need to be made aware that they can become key players towards prevention and management o f debilitating muscular contractures, which impinge on the quality o f life of so many patients following a stroke. This should be the case regardless of the situation or environment in which a stroke patient is being cared for, i.e. specialist unit or within a general ward setting. Positioning of the stroke patient requires more than simply turning the patient from side to side in order to alleviate pressure. A decision about how long it is safe to leave a stroke patient sitting in a chair should be based on their general medical condition as well as the results of skin inspection (Benbow, 2008). Effective positioning should involve specific attention to both upper and lower extremities, to prevent or manage newly attained musculoskeletal complications (Mee and Bee, 2007). NICE (2014) referred to a 2-hour period of sitting which, in many cases, will be the maximum that the bodies o f older, ill patients will tolerate, both physiologically and psychologically. However, this may not be achievable on all stroke-care settings, such as within the community.

ConclusionMany nurses position patients as part of a daily routine. However, they may not always be conscious o f the therapeutic advantages or disadvantages positioning has on musculoskeletal complications. This article aimed to supplement the knowledge o f everyday ward-based routine care for stroke patients. By informing practice in the prevention of muscular

Box 1. Five key po in ts o f in ten tio na l round ing

Concerns about essential nursing care have drawn attention to ensuring

fundam ental care is delivered reliably

Intentional round ing involves health professionals carrying ou t regular checks

w ith ind ividual patients at set intervals

The approach helps nurses focus on clear, measurable aims for undertaking the

round It also helps fron tline teams to organise workloads on the w ard

Rounding can reduce adverse incidents, o ffer patients greater com fort and ease

the ir anxiety

Source: Fitzsimons e t al, 2011

contractures post cerebrovascular accident (CVA) through better limb positioning and earlier mobilisation, it is hoped that there will be closer multidisciplinary team working and reduced complications. With ward staff perhaps gaining some reassurance from the evidence presented here that early mobilisation of affected limbs is not always perceived as being detrimental to stroke care, the more conscious nurse and ancillarys awareness could significantly enhance rehabilitative care and correct limb positioning.

A distinct lack o f nursing research available on musculoskeletal complications, positioning and early mobilising stroke patients was unearthed. Also highlighted was the lack of specific nursing guidance and protocols for musculoskeletal complications for the stroke patient being nursed outside the specialist stroke unit, which was surprising as stroke patients are cared for across primary and secondary settings with these complications often witnessed.The majority of stroke positioning research is carried out by physiotherapists and occupational therapists, so generalisation to nurses can be taken with caution until more current research becomes available for determining the most effective positions to enhance stroke patient recovery and avoiding the pitfalls o f poor positioning (Figure 3).

In the meantime, future work on the development of educational manual handling programmes, which could be delivered to nurses in conjunction with allied physiotherapy colleagues, could benefit many ward-based nursing teams across hospitals and even those based in community settings.Expertise should be shared for the greater good. Envisaging the development o f a stroke unit outreach-type advice service could be a successful bid to reduce further the complication of muscular contractures. Under the guidance of an informed nursing team, staff could quite easily provide the social stimulation to enable stroke patients to mobilise limbs much earlier or more frequently and remain in more optimal positions for much lengthier periods, rather than only during times when the specialist therapist visits the ward. IH 3

Conflict of interest: none.

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KEY POINTS

Musculoskeletal com plications post stroke can include hem ip leg ic shoulder pain, spasticity, glenohum eral subluxation and contractures to the paretic/ p leg ic lim b

Musculoskeletal com plications can cause pain, discom fort, depression, sleep deprivation, poor sanitation and inadequate nutrition

Earlier m obilisation and correct position ing o f the hem ip leg ic lim b w ill

a lleviate chronic d iscom fort, im m obility and pain to achieve effective rehabilitation post stroke

A musculoskeletal com plication assessment by the nurse could be easily

integrated w ith o ther admission assessments for provision o f a m ore accurate physical pro file for position ing and rehabilitation planning

Ensuring tim e ly liaison w ith the m utlid iscip linary team can facilitate a

m ore organised and integrated rehabilitation plan specific to the patients personality and needs

Nurses predom inantly p rov ide 24-hour care and have the ab ility to ensure that stroke patients receive ongoing, holistic rehabilitation

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