A Multidisciplinary Team Approach to Stroke Recovery: Case Study of John Doe

“A Multidisciplinary Team Approach to Stroke Recovery: Case Study of John Doe” by Alyssa Morgan-Paul

 

John Doe enjoyed playing golf and spending time with his children and grandchildren. After John retired in early 2010, he spent most of his days catching up on the news, reading the newspaper, and watching television. John showed no interest in adding physical activity into his daily routine, even though his loving wife, Mary, of 45 years was active and encouraged him to join her every morning. Mary started each day with a walk, and in the afternoons she joined the neighborhood ladies in some sort of physical activity: tennis, aerobics, swimming laps, or a Zumba class. Mary cooked dinner every night, but like a true southerner, she loved to use lard and butter on everything, which John loved!

At John’s doctor’s visit at the end of 2010, these were his vitals: height 5’10, weight 210 lbs, blood pressure 140/94, and pulse oximeter 94%.  John also told the doctor his hands and feet turn a bluish color when he does not use them for a while. John also has a medical history of high blood pressure, but he occasionally takes the medicine prescribed to him because he does not think it is a necessity. John feels healthy overall, but his doctor, Dr. Bird, disagrees. Dr. Bird continues to educate John on the importance of exercising to lower his weight, watching what he eats by cutting down on his lipid and carbohydrate intake, and taking his prescribed medicines daily. This visit was more of the same with Dr. Bird educating John on what he needs to do to prevent a serious illness from occurring. This time Dr. Bird emphasized the strain John is putting on his left ventricle by not taking his medicine and told John about his chances of having a stroke. Dr. Bird pulled up the American Stroke Association’s website, and they looked at it together. Dr. Bird highlighted that 800,000 people this year in the U.S. will have a stroke. Stroke is the number five cause of death in the United States. Every four minutes, someone has a stroke. Dr. Bird finished his lecture with telling John that stroke is the leading cause of long-term disability. As always, John left the doctor’s office and did not change anything about his life style.

As John continued to live his unhealthy, sedentary lifestyle, his risk of health complications increased. On January 2nd, 2011, John was one of the first 800,000 people in the US to have a stroke that year. Mary was the first one to notice a difference in John. She saw the warning signs identified by the American Stroke Association. Mary saw one side of John’s face drooping, and he was slurring most of his words. Mary had taken a CPR class a while back and remembered the instructor also giving them warning signs of stroke: F.A.S.T. F- facial droop, A- arm weakness, S-slurred speech, and T-time to call 911. Mary did just that and called 911. John was admitted to the stroke floor in the local hospital. The initial tests determined John had had an ischemic stroke.

Silverman et al. (2009) defines an ischemic stroke as “a disruption in the blood flow to part of the brain… because of an occlusion of a blood vessel” (p.1).  John was moved about the hospital to many professionals to assess the effects of his stroke. Some of those include physical and occupational therapists, a psychologist, and a neurologist. The Internet Stroke Center (2017) notifies the reader that a physical examination is next to determine the effects of the stroke. The doctor checked blood pressure, pulse, and examines the rest of John’s body. Neurologic testing included detailed tests of John’s muscles and nerves. The physical and occupational therapists also checked John’s strength, sensations, coordination, and reflexes. In addition to those tests, they also checked John’s memory, speech, and thinking. By completing all of these tests, the doctors were able to better identify effects of the ischemic stroke.

The results of John’s examination concluded left side weakness, paralysis, and spasticity. John was unable to recall common household objects (spoon, shirt, chair) and slurred many of the words he said. The exam also showed high blood pressure. A week after the stroke, Mary told the doctors that John was not himself. He did not want to get out of bed, watch television to catch up on the news, and preferred to be alone. With this report, John saw a psychologist and was diagnosed with post-stroke depression.

John experienced a traumatic event that impacted most areas of his brain. Due to the effects of the stroke on John’s brain and body, the best way the professionals serving him knew how to help him improve was through a multidisciplinary team approach. A multidisciplinary team is defined as “a group of health care workers who are members of different disciplines (professions e.g. Psychiatrists, Social Workers, etc.), each providing specific services to the patient. The team members independently treat various issues a patient may have, focusing on the issues in which they specialise.” (Health Service Executive, 2016). With this approach, John had his neurologist, psychiatrist, speech therapist, occupational therapist, physical therapist, speech and language pathologist and social worker working together within their disciplines to improve the disabilities affecting John after the stroke.

As Kalra and Harris (2010) reported, “Multidisciplinary team work is considered to be the gold standard for delivering specialist rehabilitation. The characteristics and dynamics of the multidisciplinary team are central to delivery of… quality care. “ (p.254). In further research, Stroke Unit Trialists’ Collaboration, as cited by, Kalra and Harris, agreed with the hospital’s approach to John’s care, “There is strong evidence that patients who receive care from multidisciplinary specialist teams in organised stroke units are more likely to be alive, independent and living at home one year after stroke” (2010, p.268). John was apprehensive at first to be involved with a number of specialists, but after he and Mary were shown this research they were ready to get him started.

The initial assessments completed during John’s first few days at the hospital set up the treatment plans for each professional working with John. John attended at least three hours of therapy a day, one hour with his physical therapist (PT), one hour with his occupational therapist (OT) and one hour with his speech language pathologist (SLP).

It was almost immediate that Mary noticed improved strength and coordination in John’s left arm and increased use of his left hand. After the stroke, John was unable to independently put a shirt on over his head or button it up due to the paralysis and weakness within his left arm and hand.  After four weeks of OT, John was able to get the shirt on, and with some assistive technology, he began to button some of the buttons. Due to increased spasticity, John had a hard time using utensils for eating with his left hand and strictly ate with his right. The OT addressed this, and with intentional activities and interventions, John could now hold utensils in his left hand and was about 75% accurate in getting the food to his mouth. Since John showed signs of inability to recall common household objects, John and his therapist worked on labeling objects, finding them throughout the gym during their sessions, and having conversations about common household items. These activities worked on John’s memory. In John’s case, the OT decided to focus their tasks and therapy sessions to activities of daily living, recalling, and memory. McPherson and Ellis-Hill (2007) summarized a study by Legg and colleagues on the importance of OT’s in the rehabilitation of stroke survivors. Legg and colleagues report, “occupational therapy targeted towards activities of daily living significantly increased performance on scores of personal activities of daily living and reduced the risk of poor outcome” (p.922). Legg and colleagues and McPherson and Ellis-Hill all agreed with the use of an OT to help John improve his independence and decrease the risk of having a poor outcome.

            John’s PT worked with him on weight bearing, walking, and transfers from his wheelchair because Nozoe et al. noted, “survivors of a disabling stroke also had decreased physical activity because of their dysfunction” (2016 p. 625). John’s PT was aware of this statistic and even though John presented left side weakness, paralysis, and spasticity, it was especially important for him to be physically active by walking, weight bearing, and participating in transfers from his wheelchair. Although John was not fond of standing and moving around due to his loss in balance and coordination, he saw an improvement in his ability to stand and walk. Mary also saw an improvement in John’s ability to be more mobile with his left arm and leg. She also saw an increase in his strength in holding himself up and walking.

According to American Speech-Language-Hearing Association, a Speech-Language Pathologists (SLP’s) (2017) will “work to prevent, assess, diagnose, and treat speech, language, social communication, cognitive-communication, and swallowing disorders in children and adults.” This is the model John’s SLP used to treat John’s slurred words. With intentional interventions, the SLP and John spent time engaged in one on one conversation, John reading aloud to him, and John conversing with others he did not know well. Mary told the SLP that John had initiated more conversations with her, would talk to the nurses when they came in to check on him, and was more easily understood.

            While therapy helped John improve his physical abilities, he still struggled with depression. According to Johnson (2008), “Cognitive behavioral therapy (CBT) techniques have the potential for reducing depressive symptoms.” (as cited in Kraus, Kunik and Stanley, 2007, p.157) John’s psychologist also shared information from Mitchel et al. (2008): “in stroke patients… [some] recently demonstrated significant statistical and clinical reductions in depressive symptom scores using CBT techniques in conjunction with antidepressant therapy” (p. 141). John and Mary, feeling confident from the research article presented to them that adding CBT therapy and antidepressant therapy to John’s treatment plan would be beneficial.

Langhorne, Bernhardt and Kwakkel (2011) noted “stroke rehabilitation typically entails a cyclical process involving: (1) assessment, to identify and quantify the patient’s needs; (2) goal setting, to define realistic and attainable goals for improvement; (3) intervention, to assist in the achievement of goals; and (4) reassessment, to assess progress against agreed goals” (p.1695). This was the process used in John’s treatment plan. John was initially assessed to determine the disabilities of the stroke. The professionals of the multidisciplinary team set goals for John to work on during his eight weeks at the hospital. Each professional designed intentional interventions to combat the effects of the stroke and they reassessed when needed. Once all of this work was done, and John had met all of the goals given to him, John was released from the hospital! At a follow up doctor’s appointment in November 2011, John reported that he had gained most of his independence; he still had some spasticity in his left arm and leg but had not lost his balance since he had been home. He also told Dr. Bird that his memory had improved and only had mild difficulty recalling memories from many years ago. John also shared that his speech had returned to what it was before the stoke. Although, John felt pretty happy most days, he continues to take his prescribed anti-depressant, as he should to keep away the depressive thoughts. Mary also informed Dr. Bird, that John took his blood pressure medicine daily, and now joined Mary for a walk in the evening, and she changed her ways of cooking to help them both get their weight to a healthy amount!

 

 

References

American Speech-Language-Hearing Association. (2017). Speech-language pathologists- about speech-language pathology. Retrieved from http://www.asha.org/Students/Speech-Language-Pathologists/

American Stroke Association. (2017). Impact of stroke (stroke statistics). Retrieved from http://www.strokeassociation.org/STROKEORG/AboutStroke/Impact-of-Stroke-Stroke-statistics_UCM_310728_Article.jsp#.WPYTnVLMzVo

Health Service Executive. (2016). Multi-disciplinary team. http://www.hse.ie/eng/services/list/4/Mental_Health_Services/dsc/communityservices/Multidisciplinaryteam.html

Kalra, L., Harris, R. (2010). Practical guide to comprehensive stroke care, meeting population needs: Stroke rehabilitation. Retrieved from http://web.a.ebscohost.com.proxy189.nclive.org/ehost/ebookviewer/ebook/ZTYwMHh3d19fMzc0OTAwX19BTg2?sid=0a6b4f03-4212-47c8-96a7-9bde018f87ec@sessionmgr4007&vid=9&format=EB&lpid=lp_253&rid=0

Kraus, C. A., Kunik, M. E., & Stanley, M. A. (2007). Use of cognitive behavioral therapy in late-life psychiatric disorders. Geriatrics, 62(6), 21-26. Retrieved from https://login.proxy189.nclive.org/login?url=http://search.proquest.com/docview/216363750?accountid=15152

Langhorne, P., Bernhardt, J., & Kwakkel, G. (2011). Stroke care 2: Stroke rehabilitation. The Lancet, 377(9778), 1693-702. Retrieved from https://login.proxy189.nclive.org/login?url=http://search.proquest.com/docview/867093824?accountid=15152

McPherson, K. M., & Ellis-Hill, C. (2007). Occupational therapy after stroke. BMJ: British Medical Journal, 335(7626), 894. doi:http://dx.doi.org/10.1136/bmj.39370.600729.BE March 30, 2017

Mitchell, P. H., Becker, K. J., Buzaitis, A., Cain, K. C., Fruin, M., Kohen, R., et al. (2008). Brief psychosocial/behavioral intervention with antidepressant reduces post-stroke depression significantly more than antidepressant alone [Abstract]. Stroke, 39(2), 543.

Nozoe, M., Kitamura, Y., Kanai, M., Kubo, H., Mase, K., Shimada, S., (2016). Physical activity in acute ischemis stroke patients during hospitalization. Retrieved from http://doi.org.proxy189.nclive.org/10.1016/j.ijcard.2015.09.077

Silverman, I. E., & Rymer, M. M. (2009). Ischemic stroke: An atlas of investigation and treatment. Oxford: Clinical Publishing. http://web.b.ebscohost.com.proxy189.nclive.org/ehost/ebookviewer/ebook/ZTYwMHh3d19fMjcyNTU3X19BTg2?sid=7a69da98-b343-47c2-b961-a2a6d69bae31@sessionmgr104&vid=10&format=EB&lpid=lp_103&rid=0

Stroke Unit Trialists’ Collaboration. Organised inpatient (stroke unit) care for stroke. Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD000197. DOI: 10.1002/14651858.CD000197.pub2. 


The Internet Stroke Center. (2017). How a stroke is diagnosed. Retrieved from http://www.strokecenter.org/patients/stroke-diagnosis/how-a-stroke-is-diagnosed/