Practical

Guidelines in

Stroke Rehab

Dr. Varsha Soni(PT)

Neurorehab Incharge

Pacific Centre of

Neurosciences

Key Points

• NeuroRehab Team

• Role of Rehab

• Recovery

• Acute / ICU Management

• Subacute /Ward Management

• Chronic /OPD Management

• Support Group

NeuroRehab Team

Specialized stroke team has a favorable effect on survival rates, length of stay, & ADL independence, compared to regular care at a non-specialized ward. (Level 1)

Patient

Role of Rehab

NeuroRehab Definition“A process whereby patientswho suffer from impairmentfollowing neurologic diseasesregain their former abilities or, iffull recovery is not possible,achieve their optimum physical,mental, social and vocationalcapacity.”

Recovery• Neurological recovery

– Early recovery (Local Processes)

– Late recovery (Neuroplasticity)

modification in structural and functional organization

• Functional recovery

– Recovery in everyday function with adaptationand training in presence/ absence of naturalneurologic recovery

– Dependent on quality ,intensity of therapy &patient’s motivation

Neuroplasticity Principle

1. Use It or Lose It2. Use It and Improve3. Specificity4. Repetition Matters5. Intensity Matters6. Time Matters7. Salience Matters 8. Age Matters9. Interference

Motor Learning

• Reacquisition of previously learned movement skill that are lost due to pathology or sensory, motor or cognitive impairment. This process is often referred to as recovery of function.

• Feedback– Intrinsic or extrinsic feedback

– KP or KR

• Practice– Massed vs. Distributed practice

– Constant vs. Variable practice

ICU Management

• Positioning

• Respiratory Care

• Prevention of 2ndry ComplicatnDVT

Pressure Sore

Msk Complication

Deconditioning

• Early Mobilisation

Positioning

Early Mobilisation

• If condition stable – To start active mobilisation within 24-48 hours

• Physiologically sound changes in bed position & ROM exercise.

• Specific tasks ( sitting up, turning from side to side ) & Self care activities ( feeding, grooming, dressing )

• Tolerance for therapy affected by stroke severity, medical stability, mental status, cardiac instability & level of Consciousness.

Conti..

• Early mobilisation reduces complications and enhances functional recovery (Level 1)

• Strong positive psychological benefit

• It remains unclear whether early mobilization from the bed, i.e. within 24 hours after the stroke, is more effective than later mobilization as regards complications, neurological deterioration, fatigue, basic ADL activities and discharge home. (Level 1)

Ward Management

• Bedside Mobilization

(out of the bed)

• Transfer Training

• Different approaches

-Follow the evidence

• Current treatment methods

• Shoulder Management

Transfer Training

Bedside Mobilisation

Different Approaches

• Neurodevelopment Approach/ Bobath Therapy

• Rood’s Approach

• Brunnstorm Approach

• Proprioceptive Neuromuscular Facilitation

• Motor Relearning Program

• No single therapy was superior than other. Mixed therapy was better than no treatment or placebo for improving physical function. (Cochrane Review, Pollock et al).

Current Treatment Methods

• CIMT [Level 1]

• Bimanual Training[ Level 2]

• Mirror Therapy [LEVEL 2]

• Mental Imagery [Level 3]

• NMES/ FES [Level 2]

• EMG- Biofeedback [Level 3]

• Virtual Reality [Level 2]

• BWSTT [Level 2]

Shoulder Management

• Prevent shoulder pain & impingement by proper handling & caregiver education.

• Use of NMES/ Sling

• Mx for severe or chronic case

1. Eliminate pain

2. Desensitization

3. Eliminate Hand edema

4. Introduce pain free ROM by reestablishing scapular mobility

5. Beginning with guided arm movt below 60 deg, gradually increase variability and complexity

OPD/ Follow Up Care

• Goal Setting

Restorative/compensatory

• Trunk Control Training

• Upper Extremity Training

• Lower Extremity Training

• Gait Training

• Endurance/ fitness training

• Balance Training

Predictive Prognosis

• Most improvements in ADLs occurs during the 1st

6 months- up to 5% of pts may show improvement even at 12 months post- stroke

• But recovery could take 2 years or more

• Prognosis in patients with mild or moderate stroke is usually excellent

Improving Trunk Control

• Trunk forms a foundation for any posture & movement.

• Post hemi - loss of selective muscle activity in trunk & tone - Compensatory movement is seen

• Rx focus on

-Trunk rotation, side flexion [all cardinal plane]

-Combination of movement

-Balance reaction[Anticipatory & Reactive]

-Functional Activity

Poor Prognostic Indicators for Upper Limb Recovery

• Severe proximal spasticity

• Prolonged flaccid period

• Absence of voluntary hand

movement at 4-6 weeks

• Full recovery is usually complete within 3 months of

onset

Improve UE Function

• Relearning of movt pattern & retraining of missing component

• Upper body initiated wt shift pattern[reaching & picking object]

• UL weight bearing & Dynamic stabilization exercise

• Functional movement & Combination movt

• Power production - Throwing

• Fine motor function- Object Manipulation

• Spastic Hand Rehab- Botox

• Adjuncts – Orthoses, CIMT, BF, NMES, VR, Robotics

Improve LE function

• Strengthening muscles in appropriate pattern & Functional pattern.

• Training for posterior weight shift, Anterior weight shift & Lateral weight shift (sitting).

• Co-ordinated combination movement

• Power production [Kicking]

• Cycling & treadmill training

Gait Training

• Initial gait training between parallel bars then outside bars with aids & then without aids

• In all direction & turning

• Foot clearance

– Orthoses, Taping & FES

• PBWSTT with higher speed improve overall locomotor activity & over ground speed

Improve Aerobic Function

• Prevent recurrent stroke & cardiovascular events. Remedial gait retraining; supervised or home-based walking or treadmill training programs

• Improve Aerobic fitness.Large-muscle activities (e.g. walking, treadmill, stationary cycle, combined arm-leg ergometry, arm ergometry, seated stepper)

Symptom limited graded exs training

40-70% of VO2max, 3-7 d/week for 20-60min/session

Balance Training

• Facilitate symmetrical wt bearing on both side

• Anticipatory and Reactive postural strategy training in different plane

• Dual task training s/a kicking ball in standing, throwing activities, carrying an object while walking, cognitive task

• Single limb stance and walking on unstable surface

• Ball Exercise

Support Group

• www.ssgu.org

• www.strokeindia.org

• www.strokeassociation.org

• www.stroke.org

References

• KNGF Guidelines for Stroke 2014.

• Physical Activity and Exercise Recommendations for Stroke Survivors. American Heart Association/American Stroke Association, 2014.

• Cochrane Database

• O’ Sullivan SB, Schmitz TJ. Stroke. Physical rehabilitation. 5th ed., 2007.

• Darcy A. Umphred. Neurological Rehabilitation, 6th

ed., 2012.

• Right in the Middle: Patricia Davis

Take home message

• Team Approach

• Evidence Based Practice

• Early Mobilisation

• SMART Goal

• Different approach’s & Treatment adjuncts

• Aerobic Training

• Neuroplasticity & Motor learning principle