stroke rehabilitation พญ. พรพิมล มาศสกุลพรรณ...

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  • Slide 1
  • Stroke Rehabilitation . 2 / 4 / 2008
  • Slide 2
  • National Stroke Association 10% of stroke survivors recover almost completely 25% recover with minimal impairment 40% experience moderate to severe impairments that require special care 10% require care in a nursing home or other long-term facility 15% die shortly after the stroke Approximately 14% of stroke survivors experience a second stroke in the first year following a stroke
  • Slide 3
  • Effect of a Stroke 1. Weakness on the side of the body opposite the site of the brain affected by the stroke 2. Spasticity, stiffness in muscles, painful muscle spasms 3. Problems with balance and/or coordination 4. Problems using language, including having difficulty understanding speech or writing(aphasia); and knowing the right words but having trouble saying them clearly (dysarthria) 5. Being unaware of or ignoring sensations on one side of the body (bodily neglect or inattention) 6. Pain, numbness or odd sensations
  • Slide 4
  • Effect of a Stroke (cont) 7. Problems with memory, thinking, attention or learning 8. Being unaware of the effects of a stroke 9. Trouble swallowing (dysphagia) 10. Problems with bowel or bladder control 11. Fatigue 12. Difficulty controlling emotions (emotional lability) 13. Depression 14. Difficulties with daily tasks
  • Slide 5
  • Rehabilitation Goal To restore lost abilities as much as possible To prevent stroke-related complications To improve the patient's quality of life To educate the patient and family about how to prevent recurrent strokes Promote re-integration into family, home, work, leisure and community activities
  • Slide 6
  • Successful Rehabilitation Depend on - how early rehabilitation begins - the extent of the brain injury - the survivors attitude - the rehabilitation teams skill - the cooperation of family and caregiver
  • Slide 7
  • Basic Principles of Rehabilitation To begin as possible early (first 24 to 48 hours) To assess the patient systematically (first 2- 7 day) To prepare the therapy plan carefully To build up in stages To include the type of rehabilitation approach specific to deficits To evaluate patients progress regularly
  • Slide 8
  • Multidisciplinary Team Rehabilitation specialist Physical, occupational and speech therapist Social worker Dietician Recreational therapist Psychologist Vocational rehabilitation counsellor NursesOrthotist Patient, caregiver
  • Slide 9
  • Early Mobilisation If patient's condition is stable, however, active mobilisation should begin as soon as possible, within 24 to 48 hours of admission Early mobilisation is beneficial to patient outcome by reducing the complication It has strong positive psychological benefit for the patient Specific tasks (turning from side to side in bed, sitting in bed) and self-care activities (self- feeding, grooming and dressing) can be given for early mobilisation.
  • Slide 10
  • Rehabilitation Management Mobility Activity of daily living CommunicationSwallowingOrthosis Shoulder pain Spasticity Cognitive and perception Mood Bowel and bladder incontinence
  • Slide 11
  • 1. Mobility Physiotherapy Conventional therapies Neurophysiological therapies
  • Slide 12
  • Conventional therapies Therapeutic Exercises Traditional Functional Retraining Range Of Motion (ROM) Exercises Muscle Strengthening Exercises Mobilization activities Fitness training Compensatory Techniques
  • Slide 13
  • Neurophysiological Approaches 1. Muscle Re-education Approach (1920S) 2. Neurodevelopmental Approaches (1940-70S) Sensorimotor Approach (Rood, 1940S) Movement Therapy Approach (Brunnstrom, 1950S) NDT Approach (Bobath, 1960-70S) PNF Approach (Knot and Voss,1960-70S) 3. Motor Relearning Program for Stroke (1980S) 4. Contemporary Task Oriented Approach (1990S)
  • Slide 14
  • Aim Improve Movement Balance coordination Safety
  • Slide 15
  • Basic Physical Therapy Bed positioning, mobility Range of motion exercises (ROME) Sitting/trunk control TransferWalking Stair climbing
  • Slide 16
  • Treadmill training with body weight support
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  • Robotics
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  • 2. Activity of daily living Occupational therapy Self careDressing Grooming Toilet use Bathing Eating Adapt or specially design device
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  • 3. Communication Speech and language therapy Common communication disorder Aphasia *Receptive- auditory - reading *Expressive- speaking - writing *Global *Anomic- forget interrelated groups of words Dysarthria
  • Slide 31
  • Goal of treatment Facilitate recovery of communication develop strategies to compensate - Gesture - Picture - Communication board - Computer
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  • 4. Swallowing Dysphagia : abnormal in swallowing fluids or food Increase risk of pneumonia and malnutrition
  • Slide 37
  • Treatment Posture change Heightening sensory input Swallow maneuvers Active exercise Diet modification
  • Slide 38
  • 5. Orthosis Shoulder slings Hand splint Foot slings Ankle foot orthosis
  • Slide 39
  • Shoulder slings
  • Slide 40
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  • Hand splints Flaccid = functional position Wrist extend 20 30 degree Flex MCP joint 45 degree Flex PIP joint 30 - 45 degree Flex DIP joint 20 degree
  • Slide 42
  • Hand splints
  • Slide 43
  • Foot slings
  • Slide 44
  • - Plastic - Metal stability of ankle stability of ankle balance balance speed walking speed walking Not enhance recovery Ankle Foot Orthosis
  • Slide 45
  • Plastic AFO Metal AFO Ankle Foot Orthosis
  • Slide 46
  • 6. Shoulder pain Sensorimotor dysfunction of upper extremities 72% of stroke patient in first year Delay rehabilitation
  • Slide 47
  • Treatment Electrical stimulation Shoulder strapping Mobilization (esp. External rotator, abduction) prevent frozen shoulder, shoulder hand pain Medical Intraarticular injections Modalities : ice, heat, massage Strengthening
  • Slide 48
  • 7. Spasticity Velocity dependent hyperactivity of tonic streth reflexes
  • Slide 49
  • Aim of treatment Pain Pain ROM ROMCosmaticHygiene Mobility Mobility Easy use orthosis Delay surgery
  • Slide 50
  • Treatment Avoid noxious stimuli Positioning, passive stretching, ROME Splinting, serial casting, surgical correction Medical - tizanidine - baclofen - dantrolen - avoid diazepam Botulinum toxin A injection Phenol / alcohol Neurosurgical procedure (selective dorsal rhizotomy)
  • Slide 51
  • 8. Coginitive and perception Attention deficits Visual neglect Unilateral neglect Memory deficits Problem solving difficulties
  • Slide 52
  • Treatment Orientation- time - place - person MemoryRepetitiveEnvironment Problem solving
  • Slide 53
  • 9. Mood 1. Post stroke depression (PSD) 2. Anxiety 3. Emotionalism (emotional lability) Improve with time
  • Slide 54
  • 10. Bowel and bladder incontinence Urinary incontinence - 50% incontinence during acute phase - with time, ~ 20% at six months - Risk: age, stroke severity, diabetes - Indwelling catheter : management of fluids, prevent urinary retention, skin breakdown - Use of foley catheter > 48 hours UTI
  • Slide 55
  • Fecal incontinence Improve within 2 weeks Continued fecal incontinence poor prognosis
  • Slide 56
  • Constipation, fecal impaction More common Immobility, inadequate fluid or food intake, depression or anxiety, cognitive deficit Management Adequate intake of fluid Bulk and fiber food Bowel training
  • Slide 57
  • Conclusion (1) Rehabilitation therapy should start as early as possible, once medical stability is reached Spontaneous recovery can be impressive, but rehabilitation-induced recovery seems to be greater on average. Even though the most marked improvement is achieved during the first 3 months, rehabilitation should be continued for a longer period to prevent subsequent deterioration.
  • Slide 58
  • Conclusion (2) No patient should be excluded from rehabilitation unless he is too ill or too cognitively devastated to participate in a treatment program. Proper positioning and early passive ROM exercises help to avoid complications at a flaccid stage. Family members should participate in therapy sessions. The family should also be referred to community groups that offer psychosocial support such as stroke clubs at the time of discharge.

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