REHABILITATION AFTER REHABILITATION AFTER VASCULAR NEUROLOGICAL VASCULAR NEUROLOGICAL

SURGERYSURGERY

CASE STUDY: STROKE

HERMAN NDJAMEN

DEFINITION OF STROKE BY THE WHO

“Stroke is a cerebrovascular event with rapidly developing clinical signs of focal or global disturbances of cerebral function, with signs lasting 14 hours or longer or leading to death, with no apparent cause other than of vascular origin.”

Stroke StatisticsStroke Statistics

Third leading cause of death in U.S. Leading cause of severe disability in U.S. Estimated one-third to one-half have

disability Most common reason for rehabilitation

So What Are The Signs of Stroke?

Sudden numbness or weakness in the face, arm, or leg, especially on one side of the body.

Sudden confusion, trouble speaking, or difficulty understanding speech.

Sudden trouble seeing in one or both eyes. Sudden trouble walking, dizziness, loss of

balance, or lack of coordination.

TYPES OF STROKE

ISCHEMIC Intracerebral Hemorrhage

POST-STROKE REHAB INCLUDES:

PHYSIOTHERAPEUTIC REHABILITATION PHARMACOLOGICAL REHABILITATION PSYCHOLOGICAL REHABILITATION

Elements of Stroke Rehabilitation

1. Prevention of secondary complications.

2. Remediation or treatment to reduce the effects of neurologic impairment.

3. Compensatory techniques to offset or adapt to residual disabilities handicaps.

4. Maintenance of long-term function.

5. Reintegration into community and/or work.

The Goals of Stroke Rehabilitation

Prevent, Recognize, and Manage Comorbid Medical Conditions

Maximize Functional Independence Optimize Psychosocial Adaptation of

Patients and Families Facilitate Resumption of Prior Life Roles

and Community Reintegration Enhance Quality of Life

Stroke Rehab Principles

Identify impairments Careful attention to comorbidities and

complications Early goal directed treatment Systematic assessment of progress Experienced interdisciplinary team Education Comprehensive discharge planning

Criteria for Admission to Rehab Programme

*Stable neurological status*Significant persisting neurologic deficit*Identified disability affecting at least 2 of the following:

MobilitySelf- careCommunicationBowel/bladder controlSwallowing

*Sufficient cognition to learn*Sufficient communicative ability to engage with therapists*Physical ability to tolerate the active program*Achievable therapeutic goals

Stroke rehab: Where?

• Inpatient

• Community Hospital

• Nursing Home

• Day Rehabilitation Centres

• Home based therapy (eg. Community rehab programme)

Rehabilitation during the Acute Phase

GOALS:Prevention of Medical

ComplicationsPrevention of Deconditioning

and ContracturesTraining of New Skills

Rehabilitation during the Acute Phase

TASKS: Range of Motion Stretching Exercises Frequent Position Changes Sitting in Upright Position to Improve

Orthostatic Tolerance Psychological Counseling Patient and Family Education

Rehabilitation during the Acute Phase

TASKS: Training Personal Care Skills, Mobility,

and Ambulation Training Bladder and Bowel Management Evaluation of Swallowing Function Initiate Nutrition and Hydration Identification and Treatment of

Depression

Stroke Rehabilitation Interventions

Functional Skills Training– Personal Care Skills– Mobility Activities– Instrumental Activities of Daily Living

Stroke Rehabilitation Interventions

Therapeutic Exercises– Flexibility– Strength– Coordination– Fitness

Stroke Rehabilitation Interventions

Spasticity Management:– Positioning and Orthotics– Stretching and Other Exercises– Medications– Injections

Stroke Rehabilitation Interventions

Aphasia Treatment: – Individual Supervised Practice and Training – Group Speech Therapy– Encourage Verbalizations– Conversational Coaching– Melodic Intonation Therapy– Oral Reading– Computerized Training– Medications

Stroke Rehabilitation Interventions

Treatment of Depression: Endogenous vs. Reactive Natural Recovery Interventions:

– Professional Counseling and Psychotherapy– Peer Relationships and Family Involvement– Medications

New Rehabilitation Interventions

Partial Body Weight-Supported Treadmill Training

Pedaling Biofeedback Electrical Stimulation Constraint-Induced Muscle Training Robotic-Assisted Therapeutic Exercise

Functional Electrical Stimulation

Constraint Induced Movement Therapy (CIMT )

Evidence for arm improvement ( EXCITE trial )

Good upper limb is constrained ( 90% of patient’s waking time )

Affected upper limb trained in functional tasks

Must have some wrist and finger function before starting

Virtual Rehab

Shown to have improvement in balance and gait

Immersive vs. non immersive

Wii games

Robotic Technology

New class of clinical tools

Highly reproducible motor learning experience

Relieves strenous repetitive effort of therapists

Stroke Rehabilitation Outcomes

80% Independent Mobility 70% Independent Personal Care 40% Outside Home 30% Work

Factors Affecting Outcomes

Neurological Deficits Motivation Level Learning Ability Level of Emotional and Social Support Coping and Adaptability Medical Comorbidities Rehabilitation and Training