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Home > RNJ > 2009 > September/October > Editorial: Reversing Patient Inactivity and Isolation

Editorial: Reversing Patient Inactivity and Isolation
Elaine Tilka Miller, DNS RN CRRN FAHA FAAN Editor

The rehabilitation process is often exhausting for patients and sometimes pushes the boundaries of their capabilities. However, there is still a great deal of unused and unproductive time that could lead to more positive outcomes if patients are properly cued. Emerging data suggest that rehabilitation patients are often not focusing on supplementary exercises and activities beyond the confines of formal therapy. This is noteworthy because most rehabilitation patients may have a great deal of “down time” that could be redirected to enhance their recovery process.

The stroke literature reveals that stroke survivors spend a sizable portion of their day inactive and alone. Bernhardt, Dewey, Thrift, and Donnan (2004) discovered that in a sample of 58 stroke survivors, more than 50% of the day was spent bed resting, 28% sitting, and only 13% devoted to preventing complications or improving mobility. In addition, although the majority of these survivors had only mild-to-moderate neurological impairment, they were alone more than 60% of the time while hospitalized.

Findings from “A Very Early Rehabilitation Trial for Stroke (AVERT)” also indicate that mobilization within 24 hours for acute stroke survivors (most with mild-to-moderate impairment) appears safe and feasible (Bernhardt, Dewey, Thrift, Collier, & Donnan, 2008). A larger randomized control trial (RCT) is in progress to further assess the efficacy of the early mobilization intervention and its cost-effectiveness. If the results of this RCT support the earlier findings, then early mobilization may become a higher priority for stroke survivors while in acute care. This demand for earlier exercise may extend well beyond traditional therapy sessions and occupy more of the survivor’s “down time.”

Rehabilitation nurses are well acquainted with the patient’s need to have adequate rest prior to therapy, but the aforementioned research findings involving stroke survivors raise questions about the best balance between time in therapies, time for rest, and additional practice time for exercises learned in therapy (e.g., hand or leg exercises). Although evidence-based physical activity and exercise care standards exist (Gordon et al., 2004), it is still somewhat unclear how specific patient characteristics (i.e., gender, age, general health state, stamina, patient preferences, time since admission, comorbiities) currently and in the future may affect the balance between exercise and rest.

For many stroke survivors and their families, the ability to walk serves as a major indicator associated with progress and recovery (Derosier, Rochette, Noreau, Bravo, & Boutin, 2002; Mayo et al., 1999). Conversely, the inability to walk frequently leads to difficulties navigating within the survivor’s home and community as well as reduced opportunities for social interaction. Therefore, the achievement of mobility is extremely important to both patients and families.

In general, rehabilitation nurses are in a unique position to reduce patient inactivity and isolation. As a result of 24/7 contact with patients, nurses usually have the greatest opportunity to be well informed regarding their abilities, concerns, progress, family situations, living environments, and other resources. With this holistic and individualized perspective, nurses are more prepared to provide a tailored, supportive, and safe environment for added exercise practice. In addition, nurses are usually strong patient advocates who can ensure that educational and motivating posters, signs, demonstrations, or other educational programs can be provided to enhance the likelihood that patients will safely and regularly perform the recommended exercises and not exceed their capabilities. Nurses can also encourage families to become more involved in patient care and help with recommended bedside exercises, thereby building the patient’s and family’s confidence while reinforcing the necessity of continued exercise and social support to maintain the gains achieved in rehabilitation.

As the science that guides our practice continues to evolve, nurses will remain an essential member of the interdisciplinary team to help translate evidence into practice. Admittedly, patients need time for rest and personal time, but perhaps we can encourage them more consistently to practice the activities learned in therapy during their “off time” and also work with them to identify those actions that will reduce their sense of isolation. Then we need to share our experiences with one another to advance our practice.

References

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, 29, 390–396.

Bernhardt, J., Dewey, H., Thrift, A., & Donnan, G. (2004). Inactive and alone: Physical activity within the first 14 days of acute stroke unit care. Stroke, 35, 1005–1009.

Derosier, J., Rochette, A., Noreau, L., Bravo, G., & Boutin, C. (2002). Predictors of handicap following post stroke rehabilitation. Disability and Rehabilitation, 24, 774–785.

Gordon, N. F., Gulancik, M., Costa, F., Fletcher, G., Franklin, B. A., Roth, E. J., et al. (2004). Physical activity and exercise recommendations for stroke survivors; An American Heart Association Subcommittee Statement on Cariovascular Nursing; the Council on Cardiovascular Nursing; the Council on Nutrition, Physical Activity, and Metabolism; and the Stroke Council. Circulation, 109(16), 2031–2041.

Mayo, N. E., Wood-Dauphinee, S., Ahmed, S., Gordon, C., Higgins, J., McEwen, S., et al. (1999). Disablement following stroke. Disability and Rehabilitation, 21, 258–268.

VanHook, P. (2009). The domains of stroke recovery: A synopsis of the literature. Journal of Neuroscience Nursing, 41(1), 6–12.