STROKE REHABILITATION

Dept.of Physical Medicine & Rehabilitation School of Medicine Brawijaya University

Introduction

• Definition of Stroke• Sudden focal (sometimes global) neurologic

deficit secondary to occlusion or rupture of blood vessels supplying the brain

• Symptoms > 24 hours = stroke• Symptoms < 24 hours = T I A• Reversible ischemic neurologic deficit

(RIND)

Epidemiology

• Stroke after heart disease and cancer• Nearly four million stroke survivors in United States• 46 % decline in cerebral infarcts and hemorrhages,

decline attibuted to better management of blood pressure, heart disease, decrease in cigarette smoking, etc

• Incidence increase 17 % from 1975-79 period to 1980-84

Risk factors

• Nonmodifiable: age,sex(male>female), race (African Americans 2X >whites>Asians), risk more than doubles each decade after age 55, family history of stroke

• Modifiable : Hypertension, history TIA, heart disease, diabetes, cigarette smoking, high dose estrogen, hyperlipidemia, obesity

PROBLEMS OF STROKE PATIENTS

• MUSCLE WEAKNESS

• AMBULATION• ADL

. COMMUNICATION• VOCATIONAL• DYSPHAGIA

• SPASTICITY• SHOULDER PAIN• BLADDER/BOWEL

DYSFUNCTIONS• DVT

Mobilization 6 – 12 months

Acute Phase : Stable Phase :

- BED EXERCISE - Mobilization- Positioning /Turning

- ROM Exercise- Strengthening

- THROMBOSIS : 3 DAYS

- BLEEDING : 2 – 3 WEEKS

REHABILITATION

• The primary goal of stroke is functional enhancement by maximizing the independent, life style and dignity of the patient.

• This approach implies rehabilitative efforts from a physical, behavioral, cognitive, social, vocational, adaptive and re-educational point of view.

Predictors of motor recovery

• Severity of arm weakness at onset• With complete arm paralysis at onset, there is a

poor prognosis of recovery of useful hand function (only 9 % gain good recovery of hand function)

• Timing of return of hand movement : - if the patien shows some motor recovery of the hand by 4 weeks, there is up to 70 % chance of making a full or good recovery.

- poor prognosis with no measurable graps strength by 4 weeks

• Poor prognosis associated also with :

- Severe proximal spasticity

- Prolonged flaccidity period

- Late return of proprioceptive faciltation

(tapping) response > 9 days

- Late return of proximal traction response

(shoulder flexor/adductors) >13 days

Carotid system

( anterior system )

Vertebro- basilar system

( posterior system )

CAROTID SYSTEM

VERTEBRO-BASILAR SYSTEM

Rehabilitation methods for motor deficits

Traditional Therapy :

Traditional therapeutic exercise program consists positioning, ROM exercise, strengthening,mobilization, compensatory techniques, endurance training.

Traditional approuches for improving motor control and coordination

N D A

• Propioceptive Neuromuscular Facilitation

• Bobath

• Brunstrom

• Car and Shepard approach

• Rood approach

• Behavioral approach

EXERCISE PROGRAM :1. TRADITIONAL / CONVENTIONAL

METHOD/UNILATERAL : regain motor control consist of stretching and strengthening, attempting to retrain muscle weakness thought reeducation.

2. NEURODEVELOPMENTAL /BILATERAL/ NEUROPHYSIOLOGICAL METHODS

Brunnstrom

Rood

Bobath (stresses exercise & prevent excessive spasticity)

Kabat, Knott, Voss ( PNF )

There is a strong belief that early mobilization is beneficial to patient outcome by reducing the risks of DVT, gastroesophageal regurgitation and aspiration pneumonia, contracture formation, skin breakdown, and orthostatic intolerance.

UPPER EXTREMITY MANAGEMENT

• Shoulder pain : 70-80 % of stroke patients with hemiplegia have shoulder pain with varriying degrees of severity of the patients with shoulder pain,

• The majority (85 %) will develop it during the spastic phase of recovery.

• It is generally accepted that the most common causes of hemiplegic shoulder pain are the shoulder hand syndrome / reflex sympathetic dystrophy (RSD) and soft tissue lesions (including plexus lesions)

Other Aspects of Stroke Rehabilitation

Spasticity Management :• Usually seen days to weeks after ischemic strokes• Usually follows classic UE flexor and LE extensor

patterns• Clinical features include velocity dependent

resistance to passive movement of affected muscle at rest, and posturing in the patterns previously mentioned during ambulation and with iritative/noxious stimuli

D V T

• Common medical complication after stroke, occurring in 20 % - & 75 % of untreated survivors (60% - 75 % in affected extremity, 25 % proximal DVT)

Bladder Dysfunction

• Incidence of urinary incontinent is 50% - 70%• Remove indwelling catheter --- perform postvoid

residual, intermittent catheterization – perform urodynamics evaluation

Bowel Dysfunction

• Incidence of bowel incontinent in stroke patients 31%

• Tx : treat underlying cause (eg; bowel infection, diarrhea), timed-toileting schedule, training in toilet transfer and communication skills

Dysphagia

• Incidence 30% - 45 %

• 67 % of brainstem strokes

• 28 % of all left hemispheric strokes

• 21 % of all right hemispheric strokes

Predictors on bedside swallowing exam of aspiration include :

- Abnormal cough, cough after swallow, dysphonia

- Dysarthria, abnormal gag reflex

Swallowing

• Three phase :

1. Oral

2. Pharyngeal

3. Esophageal

Aphasia

• Aphasia is an impairment of the ability to utilize language due to brain damage.

Characterized by paraphasias, word finding difficulties and impaired comprehension.

Also common, but obligatory, features are disturbances in reading and writing, non verbal constructional and problem solving difficulty and imparment of gesture

Hemiplegic GaitAnterior rotation of the pelvis

Circumduction

Equinovarus foot

Short strides

ENERGY EXPENDITURE

STEPS OF AMBULATION TRAINING

AMBULATION TRAINING & GAIT EXERCISES

START SLOW, GO SLOW

WALKERS

AXILLARY CRUTCHES

ENERGY EXPENDITURE >>

RAMPS, CURBS, STAIRS

SPEECH THERAPY

Mother tongue

GOOD PROGNOSIS

GOOD,

COMPREHENSIVE,

WELL-PLANNED PROGRAM

MOTIVATION

Acute phase

Acute phase

STABLE PHASE

STABLE PHASE

Disfagia Frequent and serious complication stroke – Tx oral stimulation

Intensive motor training of the more-affected upper extremity by a procedure termed “shaping” for 6 hours a day for 10 consecutive weekdays

Motor restriction of the less-affected hand for the full 14 days of the intervention

Constraint-induced movement therapy (CIMT)

Activity Score

Feeding 0 = unable 5 = needs help cutting, spreading butter, etc., or requires modified diet 10 = independent

0 5 10

Bathing 0 = dependent 5 = independent (or in shower) 0 5

Grooming 0 = needs to help with personal care 5 = independent face/hair/teeth/shaving (implements provided) 0 5

Dressing 0 = dependent 5 = needs help but can do about half unaided 10 = independent (including buttons, zips, laces, etc.)

0 5 10

Bowels 0 = incontinent (or needs to be given enemas) 5 = occasional accident 10 = continent

0 5 10

Bladder 0 = incontinent, or catheterized and unable to manage alone 5 = occasional accident 10 = continent

0 5 10

Toilet Use 0 = dependent 5 = needs some help, but can do something alone 10 = independent (on and off, dressing, wiping)

0 5 10

Transfers (bed to chair and back)0 = unable, no sitting balance5 = major help (one or two people, physical), can sit10 = minor help (verbal or physical)15 = independent

0 5 10 15

Mobility (on level surfaces)0 = immobile or < 50 yards5 = wheelchair independent, including corners, > 50 yards10 = walks with help of one person (verbal or physical) > 50 yards15 = independent (but may use any aid; for example, stick) > 50 yards

0 5 10 15

Stairs 0 = unable 5 = needs help (verbal, physical, carrying aid) 10 = independent

0 5 10

TOTAL (0 - 100) ________

Barthel Index Classification :

1-20 : Totally dependent 1

21-60 : Severely dependent 2

61-90 : Moderate dependent 3

91-99 : Mild dependent 4

100 : Independent 5

The Rehabilitation program doesn’t finish when the patient

leaves the hospital, and almost all patients benefit continued therapy.

Functional Recovery and Disability Factors

• As stroke mortality has decline in the last few decades, the number of stroke survivors with impairment and disabilities has increase

• 78 -85 % of stroke patients regain ability to walk• 48 %-58 % regain independence with self care

skills• 10 %-29 % are admitted to nursing homes