Slide 1 Pain and Stroke

Slide 2 Credits This presentation was adapted from the Canadian Central South Regional Stroke Program Presentation, “Pain in Stroke”, September 2007, Funded by the Ministry of Health and Long-Term Care. This presentation was adapted from the Canadian Central South Regional Stroke Program Presentation, “Pain in Stroke”, September 2007, Funded by the Ministry of Health and Long-Term Care.

Slide 3 Session Overview The types of stroke. The types of stroke. The common changes that result from stroke. The common changes that result from stroke. The connection between stroke and pain. The connection between stroke and pain. Review how residents may expresses their pain (verbal and non-verbal). Review how residents may expresses their pain (verbal and non-verbal). Identify strategies to assist in minimizing pain from occurring. Identify strategies to assist in minimizing pain from occurring. Identify what needs to happen when a resident is identified as being in pain. Identify what needs to happen when a resident is identified as being in pain.

Slide 4 What is a Stroke An interruption of the supply of blood and oxygen to an area of the brain. An interruption of the supply of blood and oxygen to an area of the brain. This causes the brain cells in an area to die, and reduces the brain function in that area. This causes the brain cells in an area to die, and reduces the brain function in that area. The area of the body controlled by the damaged area in unable to function properly. The area of the body controlled by the damaged area in unable to function properly. There are two types of stroke. There are two types of stroke.

Slide 5 What is a Stroke? A Guide to Understanding Stroke, Heart and Stroke Foundation of Canada, 1996 A stroke can happen when a blood clot blocks a blood vessel in the brain. 80% of strokes are this type.

Slide 6 What is a Stroke? A Guide to Understanding Stroke, Heart and Stroke Foundation of Canada, 1996 A stroke can also happen when a blood vessel breaks and results in bleeding in the brain. 20% of strokes are this type.

Slide 7 Risk factors you can do something about… High blood pressure High blood pressure High blood cholesterol High blood cholesterol Heart disease Heart disease Diabetes Diabetes Being overweight Being overweight Excessive alcohol use Excessive alcohol use Physical inactivity Physical inactivity Smoking Smoking Stress Stress Pearson et.al., (2002) AHA Guidelines for Primary Prevention of Cardiovascular Disease and Stroke: 2002 Update: Consensus Panel Guide to Comprehensive Risk Reduction for Adult Patients Without Coronary or Other Atherosclerotic Vascular Diseases Circulation, 106,

Slide 8 Stroke Statistics There are between 40,000 and 50,000 strokes survivors in Canada each year. There are between 40,000 and 50,000 strokes survivors in Canada each year. 10% (4-5,000) of strokes survivors each year require long-term care. 10% (4-5,000) of strokes survivors each year require long-term care. 40% (16-20,000) of strokes survivors each year are left with a moderate to severe impairment. 40% (16-20,000) of strokes survivors each year are left with a moderate to severe impairment. ews&From=SubCategory

Slide 9 What does a resident who has had a stroke look like in LTC?

Slide 10 What are some of the effects of a stroke? Paralysis or weakness on one side of the body; Paralysis or weakness on one side of the body; Vision problems; Vision problems; Trouble speaking or understanding language; Trouble speaking or understanding language;

Slide 11 What are some other effects of a stroke? Inability to recognize or use familiar objects Inability to recognize or use familiar objects Tiredness; Tiredness; Depression; Depression;

Slide 12 What are some other effects of a stroke? Exaggerated or inappropriate emotional responses; Exaggerated or inappropriate emotional responses; Difficulty learning and remembering new information; and Difficulty learning and remembering new information; and Changes in personality. Changes in personality.

Slide 13

Slide 14 Up to 70% of seniors in long-term care have untreated pain Up to 70% of seniors in long-term care have untreated pain. Won et.al., (2004) Persistent Nonmalignant Pain and Analgesic Prescribing Patterns in Elderly Nursing Home Residents Journal of the American Geriatric Society 52(6), Ferrell, B.A., Ferrell, B.R., Rivera, L. (1995) Pain in cognitively impaired nursing home patients. Journal of Pain and Symptom Management 10 (8), 591–598.

Slide 15 Pain is such an uncomfortable feeling that even a tiny amount of it is enough to ruin every enjoyment Will Rogers

Slide 16 Pain after stroke is a symptom often forgotten and unnoticed, although it is reported to be a great problem in care. Widar M, Alström G. Disability after stroke and the influence of long-term pain on everyday life. Scand J Caring Sci 2002;16:

Slide 17 Types of Stroke Pain 1. Shoulder Pain 2. Stiffness and Tightness of Muscles 3. Nerve Pain Adapted from:

Slide 18 Shoulder Pain Up to 72% of stroke survivors have shoulder pain This occurs due to little or no voluntary movement of the upper limb Carefully position and handle the limb to prevent pain Risk of dislocating (subluxed) shoulder The Postgraduate Medical Journal (2001); 77:

Slide 19 Stiffness and Tightness of Muscles Support affected arm at all timesSupport affected arm at all times Don’t do passive range of motion exercises on the limb unless you’re trainedDon’t do passive range of motion exercises on the limb unless you’re trained Never pull on a limb during a transfer, positioning or walkingNever pull on a limb during a transfer, positioning or walking Pay attention to supported positioning and good alignmentPay attention to supported positioning and good alignment BE CAREFUL! Harvey, R.L. (1998) Tailoring therapy to a stroke patient’s potential Postgraduate Medicine Online. Vol 104 (2)

Slide 20 Nerve Pain Descriptors: Burning Burning aching aching pricking pricking cutting, piercing, or stabbing cutting, piercing, or stabbing numbness numbness cold ↑ pain cold ↑ pain Leijon et. al., (1989) Hansen, 2004, Morley-Forster, 2006

Slide 21 How would the pain show?

Slide 22 Potential Pain Behaviors Pain words (“ouch”, “ow”, “Stop!”) Pain words (“ouch”, “ow”, “Stop!”) Rubbing a painful area Rubbing a painful area Pain noises (groaning, moaning) Pain noises (groaning, moaning) Bracing Bracing Pain faces (grimacing, furrowed brow) Pain faces (grimacing, furrowed brow) Restlessness Restlessness Changes from typical behaviour Changes from typical behaviour Resistance to care Resistance to care Jones et.al., (2005) Measuring Pain Intensity in Nursing Home Residents. Journal of Pain and Symptom Management, Volume 30, Issue 6, Pages

Slide 23 Do These… If a resident’s usual behavior changes, consider pain as a possible cause (poor appetite, depressive symptoms, sleep problems, changes in function, agitated behavior, refusal of care, restlessness) If a resident’s usual behavior changes, consider pain as a possible cause (poor appetite, depressive symptoms, sleep problems, changes in function, agitated behavior, refusal of care, restlessness) Follow up on the resident’s report of pain – ask more about it Follow up on the resident’s report of pain – ask more about it AND, TELL SOMEONE! AND, TELL SOMEONE! Adapted from: K.S. (2000). Improving assessment and treatment of pain in cognitively impaired nursing home residents. Annals of Long-Term Care, 8,

Slide 24 And These… Ask yes/no questions Use the word “pain,” and also try other simple words (aching, sore, hurts) Point areas thought to be painful while asking questions Ask about pain during or following movement Adapted from: K.S. (2000). Improving assessment and treatment of pain in cognitively impaired nursing home residents. Annals of Long-Term Care, 8,

Slide 25 And These… Be patient with residents and allow them to explain their pain Be aware that just because a pain medication is prescribed and administered, the pain is not necessarily relieved Adapted from: K.S. (2000). Improving assessment and treatment of pain in cognitively impaired nursing home residents. Annals of Long-Term Care, 8,

Slide 26 Challenges with Pain Residents don’t report pain because they don’t want to be a burden (Loeb, 1999) Residents may have stroke-related sensory or cognitive impairments (Martin et. al., 2005 Can J Nurs Res, 37: ) Residents are not asked if they are experiencing pain. D.T. Cowan et al. (2003) International Journal of Nursing Studies 40:291–298

Slide 27 Residents in Pain  or no enjoyment of recreational activities  or no enjoyment of recreational activities decreased mobility decreased mobility decreased socialization decreased socialization anxiety anxiety sleep disturbances sleep disturbances impaired posture impaired posture D.T. Cowan et al. / International Journal of Nursing Studies 40 (2003) 291–298

Slide 28 Residents in Pain  appetite  appetite  memory  memory depression depression changes in bowel and bladder function changes in bowel and bladder function  participation in dressing and grooming  participation in dressing and grooming  irritability  irritability resistance to care resistance to care D.T. Cowan et al. / International Journal of Nursing Studies 40 (2003) 291–298

Slide 29 Nurses in all practice settings should assess clients for pain using a validated tool (such as the Numeric Rating Scale or the Verbal Analog Scale). Heart and Stroke Foundation of Ontario and Registered Nurses’ Association of Ontario (2005). Stroke Assessment Across the Continuum of Care. Toronto: Heart and Stroke Foundation of Ontario and Registered Nurses’ Association of Ontario, 39.

Slide 30 Numeric Pain Rating Scale From McCaffery, M. Pasero C; Pain: Clinical manual, p. 63., Copyrighted by Mosby, Inc. Heart and Stroke Foundation of Ontario and Registered Nurses’ Association of Ontario (2005). Stroke Assessment Across the Continuum of Care. Toronto: Heart and Stroke Foundation of Ontario and Registered Nurses’ Association of Ontario, 100.

Slide 31 You can use a rating scale to describe: How the pain feels at its worst How the pain feels most of the time How the pain feels at its least How the pain changes with treatment

Slide 32 Please, be aware that persistent pain makes it difficult for residents to participate in their own care. Check to see if the resident has had their pain medication before you begin their care.

Slide 33 General Strategies to Reduce Stroke-related Pain Don’t pull on the arm Don’t pull on the arm Don’t let it dangle Don’t let it dangle Don’t raise the arm above the shoulder Don’t raise the arm above the shoulder Always be gentle Always be gentle Harvey, R.L. (1998) Tailoring therapy to a stroke patient’s potential Postgraduate Medicine Online. Vol 104 (2)

Slide 34 Bathing Always keep affected arm supported while washing Always keep affected arm supported while washing Do not let the affected arm dangle at side of body Do not let the affected arm dangle at side of body Always support the person’s whole arm at the wrist and elbow while moving during any activity Always support the person’s whole arm at the wrist and elbow while moving during any activity Adapted from Harvey, R.L. (1998) Tailoring therapy to a stroke patient’s potential Postgraduate Medicine Online. Vol 104 (2)

Slide 35 Dressing Dress weaker arm first Dress weaker arm first choose easy to fit clothing choose easy to fit clothing

Slide 36 Toileting Use recommended toileting equipment for the resident (commode, urinal) Use recommended toileting equipment for the resident (commode, urinal) Remind the resident to use the recommended equipment (grab bars) Remind the resident to use the recommended equipment (grab bars)

Slide 37 Eating Ensure person is positioned best for safety and comfort when eating Ensure person is positioned best for safety and comfort when eating Remember to use the adaptive equipment for the resident (lipped plate, built-up grips, adjustments to table height) Remember to use the adaptive equipment for the resident (lipped plate, built-up grips, adjustments to table height)

Slide 38 Walking/Transfers Assist resident to wear proper footwear Assist resident to wear proper footwear Ensure that they are positioned to transfer safely Ensure that they are positioned to transfer safely Ask registered staff to request an OT/PT assessment for transfer and walking strategies

Slide 39 Case Study: Clara Clara is a resident at Cozy Acres Nursing Home and has recently arrived there from hospital after having a stroke. Clara is right-handed. Clara is a resident at Cozy Acres Nursing Home and has recently arrived there from hospital after having a stroke. Clara is right-handed. Clara is unable to speak and her responses, even Y/N are unreliable. Clara is unable to speak and her responses, even Y/N are unreliable. Clara has severe weakness in her right arm. Clara has severe weakness in her right arm. She needs help dressing her weak arm and with buttons, and with grooming, and removing her pants for her toileting. She needs help dressing her weak arm and with buttons, and with grooming, and removing her pants for her toileting. Clara requires assistance with walking (walker) and transfers with supervision from bed to chair/commode. Clara requires assistance with walking (walker) and transfers with supervision from bed to chair/commode.

Slide 40 Clara What are some of the strategies that you would use to assist Clara to decrease her chance of experiencing pain during her morning care?

Slide 41 Clara When you go into Clara’s room to begin her morning care Clara pushes you away, is unwilling to allow you to care for her. Clara withdraws when you touch her on the right side and is tense. What do you think is going on? Could Clara be in pain? Could something else be going on with Clara?

Slide 42 Pain is inevitable. Suffering is optional. M. Kathleen Casey

Slide 43 Next Steps… You are the eyes and ears of your facility You are the eyes and ears of your facility Be aware of the diagnosis of your residents Be aware of the diagnosis of your residents Take this information and use it with the residents that you work with. Take this information and use it with the residents that you work with. Share this information with other staff. Share this information with other staff.

Slide 44 Acknowledgements Best Practices long term care advisory group Best Practices long term care advisory group Best Practices long term care evaluation group Best Practices long term care evaluation group Best Practice Pain Working Group, Brant Best Practice Pain Working Group, Brant Darrell Yip and Erica Moyer, Physiotherapists, Integrated Stroke Unit, Hamilton General Hospital. Darrell Yip and Erica Moyer, Physiotherapists, Integrated Stroke Unit, Hamilton General Hospital. Mary-Lou van der Horst, Regional Best Practice Coordinator Long-Term Care Central South Region Mary-Lou van der Horst, Regional Best Practice Coordinator Long-Term Care Central South Region Wendy MacDougal, Regional Best Practice Coordinator Long-Term Care Central West. Wendy MacDougal, Regional Best Practice Coordinator Long-Term Care Central West. Rhonda Whiteman, Hamilton Health Sciences, Best Practice Coordinator Rhonda Whiteman, Hamilton Health Sciences, Best Practice Coordinator Tammy Tebbutt, District Stroke Coordinator, Waterloo/Wellington Region Tammy Tebbutt, District Stroke Coordinator, Waterloo/Wellington Region Central South Regional Stroke Program Central South Regional Stroke Program Maryann Watts, Hamilton Health Sciences, Clinical Manager Neuro- ambulatory Centre Maryann Watts, Hamilton Health Sciences, Clinical Manager Neuro- ambulatory Centre Melanie Fall Stratton, Regional Stroke Program, Program Manager, Melanie Fall Stratton, Regional Stroke Program, Program Manager, Kim Young, Regional Stroke Program, Community and Long-term Care Specialist Kim Young, Regional Stroke Program, Community and Long-term Care Specialist Lisa Colizza, Regional Stroke Program, Regional Stroke Development Specialist Lisa Colizza, Regional Stroke Program, Regional Stroke Development Specialist Nancy van Essen, Regional Stroke Program, Stroke Rehabilitation Coordinator Nancy van Essen, Regional Stroke Program, Stroke Rehabilitation Coordinator Carol Pereira, Regional Stroke Program, LTC Project Coordinator Carol Pereira, Regional Stroke Program, LTC Project Coordinator