Quadriceps muscle setting and gluteal setting exercises are started early to improve the
muscle strength needed for walking; these are performed at least five times daily for 10
minutes at a time.
Preparing for Ambulation
As soon as possible, the patient is assisted out of bed. Usually an active rehabilitation
program is started as soon as the patient regains consciousness. The patient is first
taught to maintain balance while sitting and then to learn to balance while standing. If
the patient has difficulty in achieving standing balance, a tilt table, which slowly brings
the patient to an upright position, can be used. Tilt tables are especially helpful for
patients who have been on bed rest for prolonged periods and have orthostatic blood
pressure changes.
If the patient needs a wheelchair, the folding type with hand brakes is the most practical
because it allows the patient to manipulate the chair. The chair should be low enough to
allow the patient to propel it with the uninvolved foot and narrow enough to permit it to
be used in the home. When the patient is transferred from the wheelchair, the brakes
must be applied and locked on both sides of the chair.
The patient is usually ready to walk as soon as standing balance is achieved. Parallel
bars are useful in these first efforts. A chair or wheelchair should be readily available in
case the patient suddenly becomes fatigued or feels dizzy.
The training periods for ambulation should be short and frequent. As the patient gains
strength and confidence, an adjustable cane can be used for support. Generally, a three-
or four-pronged cane provides a stable support in the early phases of rehabilitation.
Preventing Shoulder Pain
As many as 70% of stroke patients suffer severe pain in the shoulder that prevents them
from learning new skills. Shoulder function is essential in achieving balance and
performing transfers and self-care activities. Three problems can occur: painful
shoulder, subluxation of the shoulder, and shoulder–hand syndrome.
A flaccid shoulder joint may be overstretched by the use of excessive force in turning
the patient or from overstrenuous arm and shoulder movement. To prevent shoulder
pain, the nurse should never lift the patient by the flaccid shoulder or pull on the