Rehabilitation after stroke

Zsuzsanna Vekerdy MD, PhD

UMCSCDepartment ofRehabilitation andPhysical Medicine,Debrecen Hungary

What does health mean?

What does disability mean?

Definition

WHO (1946)„ … a state of complete

physical, mental, andsocial well-being and not merely the abscence ofdisease or infirmity”

Recent use refers to it as a multidimensionalconstruct involving PHYSICAL, EMOTIONAL, FUNCTIONAL, AND SOCIAL domains

Health is a "resource for everyday life, not the objective ofliving",

and

"health is a positive concept emphasizing social andpersonal resources, as well as physical capacities."

(1986 WHO "Ottawa Charter for Health Promotion”)

"Convention on the Rights of Persons withDisabilities and Optional Protocol”

Was adopted on 13 December 2006 at the United Nations Headquartersin New York, and was opened for signature on 30 March 2007 http://www.un.org/esa/socdev/enable/conventioninfo.htm

The Convention marks a "paradigm shift" in attitudes andapproaches to persons with disabilities. It takes to a newheight the movement from viewing persons withdisabilities as "objects" of charity, medical treatment andsocial protection towards viewing persons with disabilitiesas "subjects" with rights, who are capable of claimingthose rights and making decisions for their lives based ontheir free and informed consent as well as being activemembers of society.

Ultimate goal of patients

Social participation and quality of life

Physical health = enabler of well-being

Capacity to accomplish self-care = first steptowards participation

Rehabilitation after strokeEarly rehabilitation (as soon as medical condition has been stabilized)

• within 24-48 hoursCritical period – brain could swell, condition might deterorientate

AVERT (A Very Early Rehabilitation Trial) early rehabilitation is safeBernhardt J et al.: Stroke 2008;39:390-2.

• 1 week: condition stops changing, deficits seen at first tend to improve ontheir own

Early Acute Hospital Discharge (EAHD) –neutral effect on health outcomes AND financial savings

BeechR et al.: Stroke 1999;30:729-35

QUESTION: is the patient ready and fit for rehabilitation?Medical condition / cooperation / realistic goals

Stroke and Brain AttackNIH Stroke Scale Definitions

· 1.a. Level of Consciousness· 1.b. Level of Consciousness - Questions· 1.c. Level of Consciousness - Commands· 2. Gaze· 3. Visual Field· 4. FacialMovement (Facial Paresis)· 5. Motor Function - Arms(Left and Right Arm)· 6.Motor Function - Legs (Left and Right Leg)· 7. Limb Ataxia· 8. Sensory· 9.Best Language· 10. Dysarthria· 11. Neglect (Extinction and Inattention)

1.a. Level of Consciousness

This global measure of responsiveness is assessed by the patient'sinteractions with the physician at the bedside when the patient is firstexamined. The physician should stimulate the patient (by patting ortapping the patient) to determine the best level of consciousness. Onoccasion, more noxious stimuli, such as pinching, may be required tocheck the level of consciousness.

0 = Alert - Patient is fully alert and keenly responsive1 = Drowsy - Patient is drowsy but can be aroused with minor

stimulation. The patient obeys, answers, and responds tocommands

2 = Stuporous - Patient is lethargic but requires repeated stimulation toattend. The patient may need painful or strong stimuli torespond to or follow commands.

3 = Coma - Patient is comatose and responds only with reflexivemotor or automatic responses. Otherwise, the patient is unresponsive.

• 10. Dysarthria

• The primary method of examination is to ask the patient to read andpronounce a standard list of words from a sheet of paper. If thepatient is unable to read the words because of visual loss, thephysician may say the word and ask the patient to repeat it. If thepatient has severe aphasia, the clarity of articulation of spontaneousspeech should be rated. If the patient is mute or comatose (item 9, Best Language = 3 ) or has an endotracheal tube, this item can be rated as 9 - untestable.

• 0 = Normal articulation Patient is able to pronounce the wordsclearly and without any problem in articulation.

• 1 = Mild to moderate dysarthria Patient has problems inarticulation. Mild to moderate slurring of words is noted. The patientcan be understood but with some difficulty.

• 2 = Near unintelligible or worse Patient's speech is so slurred thatit is unintelligible

• 9 = Untestable May be used only if item 9, Best Language = 3, or ifthe patient has an endotracheal tube.

What disabilities can result from stroke?

1. Paralysis (paresis) or problemscontrolling movement (motor control)

2. Sensory disturbances including pain3. Problems using or understanding

language4. Problems of thinking and memory5. Emotional disturbances

Typically paralysis in one-sided: hemiplegia / hemiparesis– Reachinng and grasping objects– Dysphagia– Ataxia

What disabilities can result form stroke?

1. Paralysis (paresis) or problemscontrolling movement (motor control)

2. Sensory disturbances including pain3. Problems using or understanding

language4. Problems of thinking and memory5. Emotional disturbances

Patients may lose the ability to feel touch, pain, temperature, positionDisability to recognize objectsLoss of recognition of one’s own limb(„neglect”)Paresthesia (pain, numbness, odd sensation, tingling, prickling)Chronic pain syndromes (neuropathic pain) –shoulder, immobilized „frozen joint”Loss of urinary continence (sensory andmotor deficits) – „urge” incontnence

What disabilities can result form stroke?

1. Paralysis (paresis) or problemscontrolling movement (motor control)

2. Sensory disturbances including pain3. Problems using or understanding

language4. Problems of thinking and memory5. Emotional disturbances

• Appr.- 25% of stroke survivors havelanguage problems

Aphasia: motor – Broca areareceptive – Wernicke areaglobalanmestic / anomic

What disabilities can result form stroke?

1. Paralysis (paresis) or problemscontrolling movement (motor control)

2. Sensory disturbances including pain3. Problems using or understanding

language4. Problems of thinking and memory5. Emotional disturbances

Memory, learning, awarenessShort-term attention / memory deficitsLose ability to make plans, comprehend meaning,

learn new task, engaged in complex tasks:

anosognosia – inability to recognize thephysical disabilityneglect – loss of the ability to respond toobjects or sensory stimuli located on oneside (stroke –impaired side)

What disabilities can result form stroke?

1. Paralysis (paresis) or problemscontrolling movement (motor control)

2. Sensory disturbances including pain3. Problems using or understanding

language4. Problems of thinking and memory5. Emotional disturbances

• Fear, anxiety, frustration, anger, sadness, a sense of grief for their physical andmental losses

• Clinical depression with• Sleep disturbances• Radical changes in eating patterns (extreme

weight loss or gain)• Social withdrawal• Irritability• Fatigue

The process of rehabilitation

OtherPhysiciansneurologist

Orthotistsprosthetist

Vocationalcouncellor

Recreationalspecialist

Neuro-psychologist

Speechtherapist

Socialworker

OTOccupational

therapist

PhysicalTherapists

PT

rehabnurses

PRM specialist

PATIENTand

FAMILY

Team members invovolvedIn stroke rehabilitation

Role of PRM specialist /physiatrist

• Managing and coordinating long-term careof stroke survivors

• Recommending and conductingrehabilitation program

• Guiding general health and preventingsecond stroke: controlling high bloodpressure, DM, eliminating risk factors(smoking, obesity, high-cholesterol diet, high alcohol consumption)

Team members involved inrehabilitation after stroke

Mobility

Transfers

Positioning

Toilet and hygenie

Dressing

Feeding

Communication

PT

OT

Speech T

Rehabnurses

Why is the self-care and Aivity of DailyLiving (ADL) important in rehabilitation?

In developed nations about 30 % of waking hours of a typical person is spent performing self-maintenence activities

Discharge pattern of persons with stroke fromrehabilitation inpatient units determined in 70% bythe ability to function independently (bathing, toileting, social interaction, dressing and eating)

Mauthe RW, Haaf DC, Hajn P et al. Arch Phys Med Rehabil 1996:77:10-13.

Functional Independence Measure (FIM)items

Self care ADMIT DISCHG FOL-UPA. EatingB. GroomingC. BathingD. Dressing –upper bodyE. Dressing – lower bodyF. Toileting

Sphincter controlG. Bladder managementH. Bowel management

MobilityTransferI. Bed, chair, wheelchairJ. ToiletK. Tub, showerLocomotionL. Walk/wheel ChairM. Stairs

WC

Functional Independence Measure (FIM)

ADMIT DISCHG FOL-UPCommunication

N. ComprehensionO. Expression

Social cognitionP. Social interactionQ. Problem solvingR. Memory

Total FIM

minimum score: 18 maximum score: 126

AVVN

Functional Independence Measure (FIM)scoring

Levels: NO HELPER: 7 complete independence (timely, safely)6 Modified independence (device)

Modified dependenceHELPER: 5 Supervision

4 Minimal assist (Subject=75%+)3 Modifiedoderate assist (Subject=50%+)

Complete dependence2 Maximal assist (Subject=25%+)1 Total assist (Subject=0%+)

Physical therapyStrategy: to regain the use ofstroke-impaired limbsand to teachcompensatory strategies

Therapies: TENS, active and passive ROM excercises, CIMT

Goal:Improve coordination, balance, reduce spasticity, reduceweakness

Special approach:Goal-orinented activites e.g. games

UE

• Constraint-induced movement therapy (CIMT) / modified (mCIMT)

Wu CY et al.: A randomized controled trial of modified contstraint-inducedmovement therapy for elderly survisors.. Arch Phys Med Rehabil 2007;88:273-8.

• Bilateral training protocols (functional tasks / repetitive arm movements)

Stewart KC et al: Bilateral movement training and stroke rehabilitation: a sytematic review and meta-analysis. J Neurol Sci 2006;244:89-95

Botulinum A toxin infiltration (local spasticity treatment)Effects on ADL / treatment of shoulder pain

LE• Mobilty / walking /

strengthening

Orthoses (KO/KAFO) –stabilize the knee

Crutches, walkersPhysiotherapyFunctional Electric

Stimulation (FES)Electromechanically-

assisted training (EMAT)

KneeOrthesis (KO)

Knee-Ankle-Foot-Orthesis

(KAFO)

Standing-assistivedevice

Hip-Knee-Ankle-FootOrthesis HKAFO

Electro-mechanically assisted training

Mehrhollz J et al: Electromechanical-assisted training for walking after strokeCochrane Database for Systematic Reviews 2007, Issue 4. Art No CD006185

EMAT+PT

Occupational therapy

• Improving motor and sensory abilities• Relearn skills in self-directed activities

(personal grooming, household activities, etc.)

• Teach compensatory stretegies• Use special tools• Changes in home enviroment – safety,

barrier-free, facilitate functioning• Apraxia treatment

Further therapies

• Speech-language therapies• Treatment of swallowing• Neuropsychilogical training (apraxia,

memory, attention)• Vocational therapy• Rectreational therapy

Complications• Immobilisation

– infections, constipation,thrombo-embolisation, pressure sores

• Spasticity and paralysis– shoulder– Contracturs– Heterotropic ossification– Fall, fractures

• Brain damage– Seizures (epileptic)– Pain– Stress ulcer– hydrocephalus

• Other– Depression– Comfort– hygiene

Paralysis„dropped shoulder” Corrective „hanger”

Adducted andinternally rotated

shoulder

• Functional problems: grooming, dressing, pain.

• Complication: „frozenshoulder”

Bended(flexed) elbow

Functional problems: patienthits his/her own nose

Difficulties in care /hygiene

Flexed fingers – smells bad, hygiene, scars

Splint for theresting period

Equinus-varusleg

• Functional problems:

– No stable standing /walking (swing phase)

– Hich-hiking toe – shoe!– Pain– Pressure sores

Splints / special shoes / operation

Types of rehabilition sevices

• Inpatient rehabilitation units (early, activerehabilitation)

• Outpatient units (programmablerehabilitation)

• Home-based rehabilitation programs(CRB)

• Nursing facilities

QOL in RehabilitationMedicine

• Generic vs. disability-related• Individually weighted measures of QOL

Influencing factors of QOL are similar instroke, TBI, SCI and SM

Depression, cognitive deficits, physicallimitations, social integration, employmentactivities, functional abilities

Readings

• J.A.DeLisa (ed): Physical Medicine andRehabilitation /Principles and practice/ 4th ed. 2005. Lippincott Williams and Wilkins, Philadelphia, Baltimore, NY, London, BA, HK, Sydney, Tokyo

• White Book On Physical andRehabilitation Medicine in Europe. 2006 www.euro-prm.org

• M.P.Barnes, A.B.Ward (eds): Textbookof Rehabilitation Medicine. 2000. Oxford University Press

Product Review• Stroke Prevention and Recovery: The Ultimate Video

Guide Stroke Education Limited• The product comes out of Stroke Education Limited,

a group which is based in New Zealand and chairedby Professor Valery Feigin, M.D., Ph.D., FAAN. (3 DVD-s)

• The second DVD on "Home Care and Rehabilitation" three sections: "Early Care and Hygiene," "RehabilitationExercises," and "Moving Around."

www.stroke.education.com