CARE PLANNING

Preventing muscular contractures

through routine stroke patient care
Diana De and Emma Wynn
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.

Abstract
The 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 w ords: 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).

Stroke

2014 MA Healthcare Ltd

A 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 under
used 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: J u n e 2 0 1 4

British Journal o f Nursing, 2014, Vol 23, No 14

Musculoskeletal complications: overview

Hemiparesis (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,

781

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 management

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,

782

According 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 prevention

Systematic 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, taskorientated 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.
However, EBRSR (2014) also acknowledged that poorer
walking ability, specific sensory motor functions, and low
mood were found to be correlates for low levels of
physical activity affecting individual recovery. The therapeutic

British Journal o f Nursing, 2014, Vol 23, N o 14

3
J
J
;
o

CARE PLANNING

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.

Table 1. M u scu lar-in d u ced difficulties

G lenohum eral
subluxation of th e

Flaccid paralysis of th e affected sid e p re v e n tin g m uscles

from stabilising th e sh o u ld er correctly

sh o u ld e r (GHS)

Social stim ulation

H em iplegic sh o u ld e r

Studies 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.

pain (HSP)

2014 M A Healthcare Ltd

Earlier m obilisation
There 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 over
usage 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

British Journal o f Nursing, 2014,Vol 23, N o 14

The w e ig h t of th e paretic arm a n d loss of m uscular

su p p o rt affects this ty p e o f sh o u ld e r pain frequently
e x p erien c e d w ith stro k e, c ausing hem ip leg ia

C ontractures

Im m obilisation of th e affected arm c au ses th e fibroa d ip o se c o n n ec tiv e tissue to proliferate a n d occu p y th e

joint sp a c e, c ausing a co n tractu re

Spasticity

Resistance to stre tc h a lim b d u e to in crease hypertonicity

N ursing and m idw ifery

All n u rse s/m id w iv e s by em ail

g ra n d round

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.
Assessm ent

According 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.

783

Positioning in bed
Lying on the back
This 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 tw o 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
o f the hand facing upwards. The bed must be the
correct height to promote independence and safety
for the patient, family and healthcare workers.

Lying on the stroke side

This should always be encouraged w ith the stroke shoulder well forward so that
the body w eight is supported on the flat o f 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 w ith
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 side

Again, the stroke arm should be w ell 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 chair

The patient should sit upright well back in
the chair and 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 thum b 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

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 move

Correct 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.

Collaboration

784

Continuing care
Currently, 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,

British Journal of Nursing, 2014, Vol 23, N o 14

2014 MA Healthcare Ltd

Simply 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

CARE PLANNING

1949). The most effective rehabilitation plan would require

the nurse to collaborate with the multidisciplinary team
during continuous assessment and management o f 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 o f a
therapeutic nurse-patient relationship starts during admission.
D uring this phase, the nurse is able to observe the patient
noting any stroke-affected musculoskeletal complications that
may interfere with a patients activities o f 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 governance
Nurses duty o f care requires work alongside allied colleagues
w ho normally provide impetus care in this area o f 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 o f so many patients following
a stroke. This should be the case regardless o f the situation or
environment in which a stroke patient is being cared for, i.e.
specialist unit or w ithin a general ward setting. Positioning
o f 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 o f 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). N IC E (2014) referred to a 2-hour period o f 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.

2 0 1 4 MA Healthcare Ltd

Conclusion
Many nurses position patients as part o f 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 o f muscular

British Journal of Nursing, 2014, Vol 23, N o 14

Box 1. Five k e y p o in ts o f in te n tio n a l ro u n d in g

Concerns a b o u t essential nursing care have draw n a tte n tio n to ensuring

fundam ental care is d e live re d reliably
In tentional ro u n d in g in vo lve s health professionals carrying o u t re g u la r checks
w ith in d ivid u a l patients a t set intervals
The approach helps nurses focus o n clear, m easurable aim s fo r un d e rta kin g th e
round
It also helps fro n tlin e team s to organise w o rklo a d s on th e w a rd
R ounding can reduce adverse incidents, o ffe r patients g re a te r c o m fo rt and ease
th e ir an xie ty
Source: Fitzsim ons 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. W ith ward staff perhaps gaining
some reassurance from the evidence presented here that early
mobilisation o f 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 o f 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 o f 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 o f
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
o f muscular contractures. U nder the guidance o f 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 m uch lengthier periods, rather than only during
times when the specialist therapist visits the ward.
IH 3
Conflict of interest: none.
AskiniT, Bernhardt J, Loge AD, Indredavik B (2012) Stroke patients do not need
to be inactive in the first two-weeks after stroke: results from a stroke unit
focused on early rehabilitation. Int J Stroke 7(1): 25-31. doi: 10.1111 /j.17474949.2011.00697.x. Epub 2011
Baek JH , Kim JW, Kim SY, O h DW, Yoo EY. (2009) Acute effect o f repeated
passive motion exercise on shoulder position sense in patients with hemiplegia:
a pilot study. NeuroRehabilitation 25(2):101-6. doi: 10.3233/NRE-2009-0504
Benbow M (2008) Pressure ulcer prevention and pressure-relieving surfaces. Br
J Nurs 17(13): 830-5
Bernhardt J, Dewey H, Thrift A, Donnan G (2004) Inactive and alone: physical
activity within the first 14 days o f acute stroke unit care. Stroke 35(4): 1005-9

785

KEY POINTS
M usculoskeletal co m p lica tion s p ost stroke can include h e m ip le g ic shoulder
pain, spasticity, glenohum eral subluxation and contractures to the p a re tic/
p le g ic lim b
M usculoskeletal co m plications can cause pain, discom fort, depression, sleep
d e p riva tio n , p o o r sanitation and inadequate n utrition
Earlier m ob ilisation and correct p o s itio n in g o f the h e m ip le g ic lim b w ill
alleviate chronic d isco m fort, im m o b ility and pain to achieve effective
reh abilitation p ost stroke
A m usculoskeletal co m p lica tion assessment by the nurse could be easily
integrated w ith o th e r adm ission assessments fo r p ro vision o f a m ore accurate
physical p ro file for p o sitio n in g and rehabilitation planning
Ensuring tim e ly liaison w ith the m utlid iscip lin a ry team can facilitate a
m o re organised and integrated rehabilitation plan specific to the p a tie n ts
personality and needs
Nurses p re d o m in a n tly p ro v id e 2 4 -h o u r care and have the a b ility to ensure
th a t stroke patients receive o n g o in g , holistic rehabilitation
Bernhardt J, Chan J, Nicola I, Collier JM (2007) Litde therapy, litde physical
activity: rehabilitation within the first 14 days o f organized stroke unit care. J
Rehabil Med 39(1): 43-8
Bernhardt J, Dewey H, Thrift A, Collier J, Donnan G (2008) A very early
rehabilitation trial for stroke (AVERT): phase II safety and feasibility. Stroke
39(2): 390-6. doi: 10.1161/STROKEAHA.107.492363
Chamanga E T (2010) A critical review o f the Waterlow tool. Journal of
Community Nursing 24(3): 26-32
Department o f Health (2006) Essence of Care: Benchmarks for the Fundamental
Aspects of Care. D H , London, http://tinyud.com /qx8rdgq (accessed 10 July

2010)

Dowswell G, Dowswell T,Young J (2000) Adjusting stroke patients poor position:

an observational study J Adv Nurs 32(2): 286-91
Evidence-Based Review o f Stroke Rehabilitation (2014) Evidence-Based Review
of Stroke Rehabilitation, 16th edn. E BRSR , London, http://w ww.ebrsr.com /
(accessed 4 July 2014)
Feys HM , DeWeerdtWJ, Selz BE et al (1998) Effect o f a therapeutic intervention
for the hemiplegic upper limb in the acute phase after stroke: a single-blind,
randomized, controlled multicenter trial. Stroke 29(4):785-92
Field MJ, Gebruers N, Sundaram TS, Nicholson S, Mead G (2013) Physical
Activity after Stroke: A Systematic Review and Meta-Analysis. IS R N Stroke
2013: Article 464176:13 pages. doi:10.1155/2013/464176
Fitzsimons B, Bartley A, Cornwell J (2011) Intentional Rounding: Its R ole in
Supporting Essential Care. Nurs Times 107(27): 18-21. http://tinyurl.com /
n473v86 (accessed 4 July 2014)
Griffiths L (2012) Message by the Minister for Health and Social Services. In:
Welsh Government. TogetherAgainst Stroke. Crown Copyright, Cardiff, h ttp ://
tinyurl.com/kc33kox (accessed 4 July 2014)
Hebb D O (1949) The Organization of Behaviour: A Neuropsychological Theory. Tohn
Wiley, New York
Herding D, Kessler R M (2006) Management of Common Musculoskeletal Disorders:
Physical Therapy Principles and Methods, 4th edn. Lippincott Williams & Wilkins,
Philadelphia
Huijben-Schoenmakers M, Gamel C, Hafiteinsdottir TB (2009) Filling up the
hours: how do stroke patients on a rehabilitation nursing hom e spend the day?
Clin Rehabil 23(12): 1145-50. doi: 10.1177/0269215509341526
Indredavik B, Bakke F, Slordahl SA, Rokseth R , Haheim LL (1999) Stroke unit
treatment. 10-year follow-up. Stroke 30(8): 1524-7
Jones A, Carr EK, Newham DJ,Wilson-Barnett J (1998) Positioning o f stroke
patients: evaluation o f a teaching intervention with nurses. Stroke 29(8):
1612-7
Lang CE, Wagner JM , Edwards DF, Dromerick AW (2007) Upper extremity use
in people with hemiparesis in the first few weeks after stroke./ Neurol Phys
Ther 31(2): 56-63
Lewis GN, Byblow W D (2004) Neurophysiological and behavioural adaptations
to a bilateral training intervention in individuals following stroke. Clin Rehabil
18(1): 48-59
Lincoln NB, Willis D, Philips SA, Juby LC, Berman P (1996) Comparison o f
rehabilitation practice on hospital wards for stroke patients. Stroke 27(1): 18-23
Lundstrom E, Terent A, Borg J (2008) Prevalence o f disabling spasticity 1
year after first-ever stroke. Eur J Neurol 15(6): 533-9. doi: 10.111 l/j.1468
1331.2008.02114.x
Mackay J, Mensah GA, Mendis S, Greenlund K (2004) The Atlas of Heart Disease
and Stroke. World Health Organization, Geneva
Malhotra S, Cousins E, Ward A, Day C, Jones P, Roffe C, Pandyan A
(2008) An investigation into the agreement between clinical, biomechanical
and neurophysiological measures o f spasticity 22(12): 1105-15. doi:

786

10.1177/0269215508095089
M ant J, Wade DT, W inner S (2004) Health care needs assessment: Stroke.
In: Stevens A, Raftery J, M ant J et al, eds. Health care needs assessment: the
epidemiologically based needs assessment reviews, 2nd edn. Radcliffe Medical Press,
Oxford: 141244
McKevitt C, Fudge N, Redfern J, Sheldenkar A, Crichton S, Wolfe C (2010).
U K Stroke Survivor Needs Survey: Final Report. The Stroke Association, London
M ee LY, Bee W H (2007) A comparison study on nurses and therapists
perception on the positioning o f stroke patients in Singapore General
Hospital, lnt J Nurs Prod 13(4): 209-21
Meskers CG, Koppe PA, Konijnenbelt M H , Veeger DH, Janssen T W (2005)
Kinematic alterations in the ipsilateral shoulder o f patients with hemiplegia
due to stroke. Am J Phys Med Rehabil 84(2): 97-105
Mirbagheri M M , Alibiglou L, Thajchayapong M, Rym er W Z (2008) Muscle
and reflex changes with varying jo in t angle in hemiparetic stroke.! Neuroeng
Rehabil 5(6): 1-16
Moran A, Scott A, Darbyshire P (2009) Communicating with nurses: patients
views on effective support while on haemodialysis. Nurs Times 105(25): 22-5.
http://tinyurl.com /nfew2ug (accessed 4 July 2014)
Murray J, Young J, Forster A (2009) Measuring outcomes in the longer term
after a stroke. Clin Rehabil 23(10): 918-21. doi: 10.1177/0269215509341525
Nair M, Peate I (2009) Fundamentals o f Applied Pathophysiology. An Essential
Guide for Nursing Students. Wiley Blackwell, West Sussex
National Audit Office (2005) Reducing Brain Damage: Faster access to better stroke
care. Department o f Health, London, http://tinyurl.com /kr5m w zm (accessed
4 July 2014)
National Institute for Health and Care Excellence (2008) Stroke: Diagnosis and
initial management o f acute stroke and transient ischaemic attack (TIA) NICE
guidelines [CG68]. NICE, London, http://tinyurl.com /m nxn7u9 (accessed
4 July 2014)
National Institute for Health and Care Excellence (2010) Stroke quality
standard. NICE quality standards [QS2], NICE, London, http://tinyurl.com /
mmq67eh (accessed 4 July 2014)
National Institute for Health and Care Excellence (2013) Stroke rehabilitation:
Long-term rehabilitation after stroke. N IC E guidelines [CG162], h ttp ://
tinyurl.com/o2e9jlp (accessed 4 July 2014)
National Institute for Health and Care Excellence (2014) Pressure ulcers:
prevention and management o f pressure ulcers. N IC E guidelines [CG179].
http://tinyurl.com /odotpw v (accessed 10 July 2014)
Perry L, Brooks W, Hamilton S (2004) Exploring nurses perspectives o f stroke
care. Nurs Stand 19(12): 33-8
Rajaratnam BS,Venketasubramanian N, Kumar PV, Goh JC , C h an Y H (2007)
Predictability o f simple clinical tests to identify shoulder pain after stroke. Arch
Phys Med Rehabil 88(8): 1016-21
Royal College o f Physicians (2008) Stroke - National clinical guideline for
diagnosis and initial management o f acute stroke and transient ischaemic
attack (TIA). RCP, London, http://tinyurl.com /pykfz9z (accessed 15 July
2014)
Schurr K, Ada L (2006) Observation o f arm behaviour in healthy elderly people:
implications for contracture prevention after stroke. AustJ Physiother 52(2): 129-33
Scottish Intercollegiate Guidelines Network (2010) Management o f patients
with stroke: Rehabilitation, prevention and management o f complications,
and discharge planning. A national clinical guideline. SIGN, Edinburgh.
http://w w w .sign.ac.uk/pdf/signll8.pdf (accessed 10 July 2014)
Seneviratne C ,T hen KL, Reim er M (2005) Post-stroke shoulder subluxation: a
concern for neuroscience nurses. Axone 27(1): 26-31
Sommerfeld DK, Eek EU, Svensson AK, Holmqvist LW, von Arbin M H (2004)
Spasticity after stroke: its occurrence and association with m otor impairments
and activity limitations. Stroke. 35(1): 134-9. Epub 2003
The Cochrane Collaboration (2013) Organised inpatient (stroke unit) care for
stroke, http://tinyurl.com /p5gl7y7 (accessed 10 July 2014)
T he Stroke Association (2010) Stroke Association Manifesto 2010-2015. h ttp ://
tinyurl.com/jwv5j53 (accessed 4 July 2014)
Turton AJ, Britton E (2005) A pilot randomized controlled trial o f a daily muscle
stretch regime to prevent contractures in the arm after stroke. Clin Rehabil
19(6): 600-12
van Wijk R , Cumming T, Churilov L, Donnan G, Bernhardt J (2011) An early
mobilization protocol successfully delivers more and earlier therapy to acute
stroke patients: further results from phase II o f AVERT. Neurorehabil Neural
Repair 26(1): 20-6. doi: 10.1177/1545968311407779. Epub 2011
VeerbeekJM, van Wegen E, van Peppen R et al (2014) W hat is the evidence for
physical therapy poststroke? A systematic review and meta-analysis. PLoS One
9(2): e87987. doi: 10.1371/journal.pone.0087987
Vuadens P, Barnes MP, Peyton R , Laurent B (2005) Spasticity and pain after
stroke. In: Barnes M, Dobkin B, Bogousslavsky J, eds. Recovery after Stroke.
Cambridge University Press, Cambridge: 286-320
Wade DT, Halligan P (2003) N ew wine in old bottles: the W H O ICF as an
explanatory model o f human behaviour. Clin Rehabil 17(4): 349-54
Welsh Government (2012) Together Against Stroke. Crown Copyright, Cardiff.
http://tinyurl.com /kc33kox (accessed 4 July 2014)
Westbrook JI, Duffield C, Li L, Creswick NJ (2011) H ow much time do
nurses have for patients? a longitudinal study quantifying hospital nurses
patterns o f task time distribution and interactions w ith health professionals.
B M C Health Services Research 11: 319. doi:10.1186/1472-6963-11-319
Y oungJ (1994) Is stroke better managed in the community? C om m unity care
allows patients to reach their full potential. BMJ 309(6965): 1356-7
Zeferino SI, Aycock D M (2010) Poststroke shoulder pain: inevitable or
preventable? Rehabil Nurs 35(4): 147-51

British Journal o f Nursing, 2014, Voi 23, N o 14

Copyright of British Journal of Nursing is the property of Mark Allen Publishing Ltd and its
content may not be copied or emailed to multiple sites or posted to a listserv without the
copyright holder's express written permission. However, users may print, download, or email
articles for individual use.