Stroke RehabilitationStroke Rehabilitation

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2 / 4 / 2008

National Stroke AssociationNational Stroke Association

10% of stroke survivors recover almost 10% of stroke survivors recover almost completelycompletely25% recover with minimal impairment25% recover with minimal impairment40% experience moderate to severe 40% experience moderate to severe impairments that require special careimpairments that require special care10% require care in a nursing home or 10% require care in a nursing home or other long-term facilityother long-term facility15% die shortly after the stroke15% die shortly after the strokeApproximately 14% of stroke survivors Approximately 14% of stroke survivors experience a second stroke in the first experience a second stroke in the first year following a strokeyear following a stroke

Effect of a StrokeEffect of a Stroke

1. Weakness on the side of the body opposite the 1. Weakness on the side of the body opposite the site of the brain affected by the strokesite of the brain affected by the stroke2. Spasticity, stiffness in muscles, painful muscle 2. Spasticity, stiffness in muscles, painful muscle spasmsspasms3. Problems with balance and/or coordination3. Problems with balance and/or coordination4. Problems using language, including having 4. Problems using language, including having difficulty understanding speech or difficulty understanding speech or writing(aphasia); and knowing the right words but writing(aphasia); and knowing the right words but having trouble saying them clearly (dysarthria)having trouble saying them clearly (dysarthria)5. Being unaware of or ignoring sensations on one 5. Being unaware of or ignoring sensations on one side of the body (bodily neglect or inattention)side of the body (bodily neglect or inattention)6. Pain, numbness or odd sensations6. Pain, numbness or odd sensations

Effect of a StrokeEffect of a Stroke ( (con’t)con’t)

7. Problems with memory, thinking, 7. Problems with memory, thinking, attention or learningattention or learning8. Being8. Being unaware of the effects of a strokeunaware of the effects of a stroke9. Trouble swallowing (dysphagia)9. Trouble swallowing (dysphagia)10. Problems with bowel or bladder control10. Problems with bowel or bladder control11. Fatigue11. Fatigue12. Difficulty controlling emotions 12. Difficulty controlling emotions (emotional lability)(emotional lability)13. Depression13. Depression14. Difficulties with daily tasks14. Difficulties with daily tasks

Rehabilitation GoalRehabilitation Goal

To restore lost abilities as much as To restore lost abilities as much as possible possible

- To prevent stroke related complications - To prevent stroke related complications

To improve the patient's quality of life To improve the patient's quality of life

To educate the patient and family about h To educate the patient and family about h ow to prevent recurrent strokes ow to prevent recurrent strokes

- Promote re integration into family, home, - Promote re integration into family, home, work, leisure and community activities work, leisure and community activities

Successful Rehabilitation Successful Rehabilitation

Depend onDepend on

- how early rehabilitation begins- how early rehabilitation begins

- the extent of the brain injury- the extent of the brain injury

- the survivor’s attitude- the survivor’s attitude

- the rehabilitation team’s skill- the rehabilitation team’s skill

- the cooperation of family and - the cooperation of family and caregivercaregiver

Basic Principles of Rehabilitatio Basic Principles of Rehabilitationn

24 4To begin as possible early (first to 24 4To begin as possible early (first to 8 ) 8 )

- 27Toassessthepatientsyst emat i cal l y (fi r st day) - 27Toassessthepatientsyst emat i cal l y (fi r st day)

To pr epar e t he t her apy pl an car ef ul l y To pr epar e t he t her apy pl an car ef ul l y

TT TTTTT TT TT TTTTTT TT TTTTT TT TT TTTTTT To include the type of rehabilitation approa To include the type of rehabilitation approa ch specific to deficits ch specific to deficits

TTTTTTTT TTTTTTTTT TTTTTTTT TTTTTTTTT’ TTTTTTTT TTTTTTTTT TTTTTTTT TTTTTTTTT’

Multidisciplinary Team Multidisciplinary Team

TTTTTTTTTTTTTT TTTTTTTTTT TTTTTTTTTTTTTT TTTTTTTTTT TTTTTTTTTTTT TTT TTTTTT TTTTTTTTT , TTTTTTTTTTTT TTT TTTTTT TTTTTTTTT ,TTTTTT TTTTTT TTTTTT TTTTTT TTTTTTTTT TTTTTTTTT

Recreational therapist Recreational therapistPsychologistPsychologistTTTTTTTTTT TTTTTTTTTTTTTT TTTTTTTTTT TTTTTTTTTT TTTTTTTTTTTTTT TTTTTTTTTT TTTTTT TTTTTT TTTTTTTTTTTTTTTTTTPatient, caregiverPatient, caregiver

Early Mobilisation Early Mobilisation

If patient's condition is stable, however, activemo If patient's condition is stable, however, activemo bilisationshouldbeginas soonaspossible,within bilisationshouldbeginas soonaspossible,within

2 4 to4 8 hoursofadmission 2 4 to4 8 hoursofadmission Earl ymobi l i sati on i s benefi ci al topati ent o Earl ymobi l i sati on i s benefi ci al topati ent o

utcomeby reduci ngthecompl i cati on utcomeby reduci ngthecompl i cati on I t has strongposi ti vepsychol ogi cal benefi t I t has strongposi ti vepsychol ogi cal benefi t

for thepati ent for thepati ent - Specifictasks(turningfromsidetosidei nbed,si tti ngi nbed)andsel f careacti v - Specifictasks(turningfromsidetosidei nbed,si tti ngi nbed)andsel f careacti v - ities(selffeeding,groominganddressi ng)canbegi venfor earl ymobi l i - ities(selffeeding,groominganddressi ng)canbegi venfor earl ymobi l isation.sation.

Rehabilitation ManagementRehabilitation Management

MobilityMobilityActivity of daily livingActivity of daily livingCommunicationCommunicationSwallowingSwallowingOrthosisOrthosisShoulder painShoulder painSpasticitySpasticityCognitive and perceptionCognitive and perceptionMoodMoodBowel and bladder incontinenceBowel and bladder incontinence

1. Mobility1. Mobility

PhysiotherapyPhysiotherapy– Conventional therapiesConventional therapies– Neurophysiological therapiesNeurophysiological therapies

Conventional therapiesConventional therapiesTherapeutic ExercisesTherapeutic Exercises

Traditional Functional RetrainingTraditional Functional Retraining

Range Of Motion (ROM) ExercisesRange Of Motion (ROM) Exercises

Muscle Strengthening ExercisesMuscle Strengthening Exercises

Mobilization activitiesMobilization activities

Fitness trainingFitness training

Compensatory TechniquesCompensatory Techniques

Neurophysiological ApproachesNeurophysiological Approaches

1. Muscle Re-education Approach 1. Muscle Re-education Approach (1920S)(1920S)

2. Neurodevelopmental Approaches 2. Neurodevelopmental Approaches (1940-(1940-70S)70S)– Sensorimotor Approach Sensorimotor Approach (Rood, 1940S)(Rood, 1940S)

– Movement Therapy Approach Movement Therapy Approach (Brunnstrom, 1950S)(Brunnstrom, 1950S)

– NDT Approach (Bobath, 1960-70S)NDT Approach (Bobath, 1960-70S)– PNF Approach PNF Approach (Knot and Voss,1960-70S)(Knot and Voss,1960-70S)

3. Motor Relearning Program for Stroke 3. Motor Relearning Program for Stroke (1980S)(1980S)

4. Contemporary Task Oriented Approach 4. Contemporary Task Oriented Approach (1990S)(1990S)

AimAim

Improve Improve – MovementMovement– BalanceBalance– coordinationcoordination

SafetySafety

Basic Physical TherapyBasic Physical Therapy

Bed positioning, mobilityBed positioning, mobility

Range of motion exercises Range of motion exercises (ROME)(ROME)

Sitting/trunk controlSitting/trunk control

TransferTransfer

WalkingWalking

Stair climbingStair climbing

Treadmill training with body Treadmill training with body weight supportweight support

RoboticsRobotics

2. Activity of daily living2. Activity of daily living

Occupational therapyOccupational therapy– Self careSelf care DressingDressing

GroomingGroomingToilet useToilet use

BathingBathingEatingEating

– Adapt or specially design deviceAdapt or specially design device

3. Communication3. Communication

Speech and language therapySpeech and language therapy

Common communication disorderCommon communication disorder– Aphasia Aphasia *Receptive*Receptive - - auditoryauditory

- reading- reading

*Expressive*Expressive - - speakingspeaking- -

writingwriting *Global*Global*Anomic*Anomic

- - forget interrelatedforget interrelated groups of wordsgroups of words

– DysarthriaDysarthria

Goal of treatmentGoal of treatment

Facilitate recovery of communication Facilitate recovery of communication develop strategies to compensatedevelop strategies to compensate

- Gesture- Gesture

- Picture- Picture

- Communication board- Communication board

- Computer- Computer

4. Swallowing 4. Swallowing

Dysphagia : abnormal in swallowing Dysphagia : abnormal in swallowing fluids or foodfluids or food

– Increase risk of pneumonia and Increase risk of pneumonia and malnutritionmalnutrition

Treatment Treatment

Posture changePosture change

Heightening sensory inputHeightening sensory input

Swallow maneuversSwallow maneuvers

Active exerciseActive exercise

Diet modificationDiet modification

5. Orthosis5. Orthosis

Shoulder slingsShoulder slings

Hand splintHand splint

Foot slingsFoot slings

Ankle foot orthosisAnkle foot orthosis

Shoulder slings

Shoulder slings

Hand splintsHand splints

Flaccid = functional positionFlaccid = functional position– Wrist extend 20 – 30 degreeWrist extend 20 – 30 degree– Flex MCP joint 45 degreeFlex MCP joint 45 degree– Flex PIP joint 30 - 45 degreeFlex PIP joint 30 - 45 degree– Flex DIP joint 20 degreeFlex DIP joint 20 degree

Hand splints

Foot slings

- Plastic- Plastic- MetalMetal

stability of anklestability of ankle balancebalance speed walkingspeed walkingNot enhance recoveryNot enhance recovery

Ankle Foot OrthosisAnkle Foot Orthosis

Plastic AFO Metal AFO

Ankle Foot OrthosisAnkle Foot Orthosis

6. Shoulder pain6. Shoulder pain

Sensorimotor dysfunction of upper Sensorimotor dysfunction of upper extremitiesextremities

72% of stroke patient in first year72% of stroke patient in first year

Delay rehabilitationDelay rehabilitation

TreatmentTreatment

Electrical stimulationElectrical stimulation

Shoulder strappingShoulder strapping

Mobilization (esp. External rotator, Mobilization (esp. External rotator, abduction) prevent frozen shoulder, abduction) prevent frozen shoulder, shoulder hand painshoulder hand pain

MedicalMedical

Intraarticular injectionsIntraarticular injections

Modalities : ice, heat, massageModalities : ice, heat, massage

Strengthening Strengthening

7. Spasticity7. Spasticity

Velocity dependent hyperactivity Velocity dependent hyperactivity of tonic streth reflexesof tonic streth reflexes

Aim of treatmentAim of treatment

PainPain

ROMROM

CosmaticCosmatic

HygieneHygiene

MobilityMobility

Easy use orthosisEasy use orthosis

Delay surgeryDelay surgery

TreatmentTreatment

Avoid noxious stimuliAvoid noxious stimuliPositioning, passive stretching, ROMEPositioning, passive stretching, ROMESplinting, serial casting, surgical correctionSplinting, serial casting, surgical correctionMedical Medical - tizanidine- tizanidine

- baclofen- baclofen- dantrolen- dantrolen- avoid diazepam- avoid diazepam

Botulinum toxin A injection Botulinum toxin A injection Phenol / alcoholPhenol / alcoholNeurosurgical procedure (selective dorsal Neurosurgical procedure (selective dorsal rhizotomy)rhizotomy)

8. Coginitive and perception8. Coginitive and perception

Attention deficitsAttention deficits

Visual neglectVisual neglect

Unilateral neglectUnilateral neglect

Memory deficitsMemory deficits

Problem solving difficultiesProblem solving difficulties

TreatmentTreatment OrientationOrientation - time- time

- place- place- person- person

MemoryMemory

RepetitiveRepetitive

EnvironmentEnvironment

Problem solvingProblem solving

9. Mood 9. Mood

1. Post stroke depression (PSD)1. Post stroke depression (PSD)

2. Anxiety 2. Anxiety

3. Emotionalism (emotional lability) 3. Emotionalism (emotional lability) – Improve with timeImprove with time

10. Bowel and bladder 10. Bowel and bladder incontinenceincontinence

Urinary incontinenceUrinary incontinence- 50% incontinence during acute phase- 50% incontinence during acute phase- with time, ~ 20% at six months- with time, ~ 20% at six months- Risk: age, stroke severity, diabetes- Risk: age, stroke severity, diabetes- Indwelling catheter : management of - Indwelling catheter : management of fluids, prevent urinary retention, skin fluids, prevent urinary retention, skin breakdownbreakdown- Use of foley catheter > 48 hours UTI- Use of foley catheter > 48 hours UTI

Fecal incontinence Fecal incontinence – Improve within 2 weeksImprove within 2 weeks– Continued fecal incontinence poor prognosisContinued fecal incontinence poor prognosis

Constipation, fecal impactionConstipation, fecal impaction– More commonMore common– Immobility, inadequate fluid or food Immobility, inadequate fluid or food

intake, depression or anxiety, cognitive intake, depression or anxiety, cognitive deficitdeficit

Management Management – Adequate intake of fluidAdequate intake of fluid– Bulk and fiber foodBulk and fiber food– Bowel trainingBowel training

Conclusion (1) Conclusion (1)

Rehabilitation therapy should start as Rehabilitation therapy should start as early as possible, once medical stability is early as possible, once medical stability is reachedreached

Spontaneous recovery can be impressive, b Spontaneous recovery can be impressive, b - ut rehabilitation induced recovery seems to - ut rehabilitation induced recovery seems to be greater on average. be greater on average.

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uld be continued for a longer period to prev uld be continued for a longer period to prev TTTTTTTTTT TTTTTTTTTTTTTT. TTTTTTTTTT TTTTTTTTTTTTTT.

(( (2 (( (2

NN o patient should be excluded from rehabilitation o patient should be excluded from rehabilitation unless he is too ill or too cognitively devastated to unless he is too ill or too cognitively devastated to

participate in a treatment program. participate in a treatment program. Proper positioning and early passive ROM exercise Proper positioning and early passive ROM exercise

s help to avoid complications at a flaccid stage. s help to avoid complications at a flaccid stage. Family members should participate in therapy ses Family members should participate in therapy ses

sions. sions. The family should also be referred to community g The family should also be referred to community g

roups that offer psychosocial support such as strok roups that offer psychosocial support such as strok e clubs at the time of discharge. e clubs at the time of discharge.