STROKEPart-2

(Rehabilitation)

Dr. Manik Jamatia3rd Year Resident, PM&R Deptt.

SMS Medical College, Jaipur

PG Teaching, August 2016

Introduction• Non-traumatic brain injury - occlusion or rupture cerebral blood

vessels, results sudden neurologic deficit characterized by loss of motor control, altered sensation, cognitive or language impairment, disequilibrium, or coma

• Two major categories: ₋ Ischemic - vascular occlusion ₋ Haemorrhagic - bleeding within parenchyma of brain

• Resultant neurological deficits generally referred to as impairments, which may or may not result in functional limitations often characterized as disability

Objectives and Goal• Objectives

₋ achieve maximum level of functional independence; ₋ facilitate neurological recovery, ₋ minimize disability; ₋ successfully reintegrate back into home, family, and

community; ₋ re-establish a meaningful and gratifying life.

• Goals are accomplished through ₋ exercise and other treatments to facilitate recovery and reduce

impairments; ₋ functional training to compensate for residual impairments;

and ₋ use of assistive devices, such as braces or wheelchair, to

substitute for lost function.

Acute Stroke Management • Goals of acute stroke management

i. limit or reverse neurologic damage through thrombolysis or neuro-protection

ii. monitor and prevent secondary stroke complications• Intravenous thrombolysis with recombinant tissue plasminogen

activator (rTPA), known to be effective when administered to appropriate individuals within 3 hours of symptom

• Development of effective neuroprotective agent remains one of major goals in acute stroke care but has thus far not been successful

Secondary Stroke Prevention • Involves a multipronged effort at risk factor reduction

₋ involve behavioural change (exercise, smoking cessation etc.)₋ dietary modifications to optimize treatment of associated

medical risk factors• Use of specific medications for stroke prevention• Antiplatelet medications are appropriate for majority of patients

for secondary prevention of ischemic stroke ₋ Aspirin in doses of 50 to 325 mg provides a reduction in stroke

of approx. 25%₋ Clopidogrel is another antiplatelet agent with a different

mechanism of action from aspirin₋ Dipyridamole, generally prescribed as part a fixed dose

combination with aspirin

• Warfarin use for stroke prevention is restricted to patients with atrial fibrillation or other known cardiac or other embolic source, for most indications, a target INR of 2 to 3 is used

• HMG-CoA reductase inhibitors or statins used for cholesterol-lowering effect might also have anti-inflammatory effects on vascular intima and lead to plaque reduction

• Carotid endarterectomy reduces the risk of stroke in those patients with single or multiple TIAs

• Carotid stenting has been studied as an alternative to carotid endarterectomy

Rehabilitation during the Acute Phase • Care of stroke survivors is organized in variety of different

systems around world• Many patients with acute stroke have dysphagia and are at risk

for aspiration and pneumonia• Protection against aspiration (and resulting pneumonia) includes

₋ avoiding oral feeding in patients who are not alert₋ even in alert patients, ability to swallow should be assessed

carefully before oral intake• During acute phase, nasogastric tube feeding or gastrostomy tube

placement may prove necessary • Patients who are lying flat in bed are at significant risk for

regurgitation and aspiration, and head of the bed should be kept elevated

• Impairment of bladder control is frequent following a stroke, which may initially cause a hypotonic bladder with overflow incontinence

• If an indwelling catheter is used, it should be removed as soon as possible, with careful monitoring to insure that appropriate voiding resumes

• For occasional patient with persistent urinary retention after stroke, regular intermittent catheterization is preferable to an indwelling catheter

• Patients with hemiplegia are at high risk for development of contractures due to immobility

• Spasticity, if present at this early stage, may contribute to the development of contractures through sustained posturing of the limbs

• Harmful effects of immobility can be ameliorated by regular passive stretching and moving the joints through a full range of motion, preferably at least twice daily

• Risk of deep venous thrombosis is high, especially in patients with hemiplegia

• Every patient should, therefore, have some form of deep vein thrombosis (DVT) prophylaxis, either subcutaneous heparin or external pneumatic compression boots or both

• Early mobilization is beneficial by reducing risks of ₋ DVT, ₋ deconditioning, ₋ gastroesophageal regurgitation and aspiration pneumonia, ₋ contracture formation, ₋ skin breakdown, and ₋ orthostatic intolerance

• Mobilization involves a set of physical activities that may be started passively but that quickly progress to active participation by the patient

• Specific tasks include ₋ turning from side to side in bed and changing position, ₋ sitting up in bed, ₋ transferring to a wheelchair, ₋ standing, and ₋ walking

• Mobilization also includes self-care activities such as self-feeding, grooming, and dressing

• Timing and progression in these activities depend on the patient’s condition

• Activities should begin as soon as possible unless the stroke survivor is unresponsive or medically/neurologically unstable

Recovery from Stroke Early recovery ( Local processes )

- Resolution of post stroke edema - Reperfusion of ischemic penumbra- Resorption of local toxins - Recovery of partially damaged ischemic neurons

Later recovery ( Neuroplasticity ) - Ability of nervous system to modify structural and functional organization

- Collateral sprouting of new synaptic connections - Unmasking of previously latent functional pathways- Reversibility from diaschisis- Denervation supersensitivity

Copenhagen Stroke Study

Specific Stroke Impairments and Their Rehabilitation • Initial examination of patient with an acute stroke includes

thorough neurologic examination• Neurologic findings are used by the rehabilitation team for

₋ prognostication, ₋ development of the rehabilitation plan, and ₋ selection of the appropriate setting for rehabilitation

• Reassessment of the patient during rehabilitation provides a means of monitoring progress and subsequently evaluating outcome

Therapeutic Approaches to the Upper Limb• Referred to as sensorimotor techniques, these treatments encompass

a range of therapies intended to promote motor recovery• Basic of these approaches include

₋ strengthening, range of motion exercises, ₋ Balance training, and postural control

• A therapeutic technique specifically developed for patients with stroke was proposed by Brunnstrom

• Bobath developed the therapeutic approach now known as neurodevelopmental technique

• Task-oriented approach to therapeutic exercise described by Carr and Shepherd encourages movement during functional tasks

Approach DescriptionBobath(1990)

Aims to reduce spasticity and synergies by using inhibitory postures and movements in order to facilitate normal autonomic responses that are involved in voluntary movement

Brunnstrom's Movement Therapy(1970)

Emphasis on synergistic patterns of movement that develop during recovery from hemiplegia. Encourages the development of flexor and extensor synergies during early recovery, assuming that synergistic activation of the muscle will result in voluntary movement

Proprioceptive Neuromuscular Facilitation (PNF) (Myers 1995)

Emphasis on using the patient's stronger movement patterns for strengthening the weaker motions. PNF techniques use manual stimulation and verbal instructions to induce desired movement patterns and enhance motor function

• Constraint-induced movement therapy (CIMT) is one of recently developed therapies based on current concepts of neuroplasticity

• Based on theory proposed by Edward Taub • Use of affected limb can be augmented by forced use of impaired

limb through a process of restraining the intact limb• CIMT in clinical trials has two general forms

₋ Original CIMT = 90% of waking hrs + 6 or more hrs/day therapy * 2weeks

₋ Modified CIMT = 5h/day * 5days/week + 3h therapy three times/week * 10 weeks

• Participants must have at least partial wrist and finger extension, have adequateproximal limb control, and have sufficient balance during limb restraint

• NMES refers to electrical stimulation of lower motor neuron or its terminal branches, causing depolarization of motor neuron and subsequent activation of corresponding muscle

• Muscle activation via NMES requires an intact motor unit, NMES applications are well suited for upper motor neuron injury such as occurs in stroke

• Therapeutic applications have been designed to promote motor recovery, whereas functional applications have been designed to provide functional movement during stimulation only

• The term neuroprosthesis refers to functional application of NMES where the paralyzed limb undergoes stimulation in a coordinated sequence resulting in functional movement

• Robotic therapies for upper limb have also been developed based on current concepts of neuroplasticity, that is, forced use, massed practice, shaping, and skillacquisition

• Robotic therapy’s greatest advantage could be in its capacity to induce more repetitions of upper limb movement (massed practice) within a given period compared with therapies based on volitional movement alone

• Robotic devices can induce passive or assisted limb movement that is typically directed toward a computer-generated visual target

• More advanced iterations of robot can provide tactile feedback that kinematically corrects user’s movement, promoting movement during skill acquisition

• Others includes Mental Imagery

Therapeutic Approaches to Walking• Important factors that influence walking ability after stroke

include weakness, balance, coordination, spatial orientation, and cognitive function

• The standard rehabilitation technique for gait training after stroke is to walk overground

• A very common gait training system is body weight–supported treadmill training (BWSTT)

• Superior for gait training to neurodevelopmental techniques that use practice of balance and weight bearing before stepping and walking

• Advanced iterations of the robot can provide tactile feedback that kinetically and kinematically corrects the user’s movement

• Robotic therapy theoretically promotes movement during skill acquisition

Non-invasive Brain Stimulation• TMS - delivered by passing a strong but brief electrical current

through an insulated coil placed on the skull• Current induces a transient magnetic field that flows parallel to

the coil, crosses the scalp, and generates an electric current in the cortex, depolarizing neurons

• TMS has been used in two different ways• diagnostic tool to assess excitability level of cortical networks• intervention to induce changes in excitability with ultimate

intention of modulating behavior• tDCS is applied through two surface electrodes placed on the

scalp• Depending on duration and polarity of stimulation, tDCS can

increase or depress excitability in stimulated region

Spasticity• Motor disorder characterized by a velocity-dependent increase in

tonic stretch reflexes and can contribute to motor impairment, pain, and disability after stroke

• Managed with exercise therapy, anti-spastic medication or by focal management with botulinum toxin or phenol injections

• Use of static resting splints for hand and ankle can help prevent contractures and reduce tone

• Intrathecal baclofen delivered by implanted infusion pump provides excellent lower limb spasticity control in patients with stroke

Cognition, Language, and CommunicationDisorders

• Approximately one third to half of stroke survivors experience speech and language disorders

• Recovery from aphasia usually occurs at slower rate and over more prolonged time course than does motor recovery

• Language comprehension usually returns earlier and to greater extent than oral expression

• Goal of speech therapy is to improve the patient’s ability to speak, understand, read, and write, and to assist patients to develop strategies that compensate for or circumvent speech and language problems that are not directly remediable

• Selected Treatment Methods for Aphasia₋ Language-oriented treatment₋ Direct stimulus–response treatment₋ Treatment of aphasic perseveration₋ Visual action therapy₋ Oral reading for aphasia₋ Conversational coaching₋ Promoting aphasic communicative effectiveness₋ Computerized visual communication (using alternative

communication systems)₋ Programmatic combinations of approaches₋ Augmentative communication device

• For dysarthria, exercise modalities include ₋ sensory stimulation procedures, ₋ exercises designed to strengthen oromotor speech muscles, ₋ respiratory training procedures, and ₋ retraining of articulatory patterns and sequences of gestures

• Attention problems after stroke are often treated using computerized activities or “paper and pencil” tasks

• Memory problems after stroke are often treated using cognitive rehabilitation programs that retrain memory function or teach patients compensatory strategies to cope despite memory impairment

Swallowing and Nutrition• Dysphagia, occurs in approximately one third to half of all stroke

survivors and places the stroke patient at risk for aspiration and pneumonia, malnutrition, and dehydration

• Malnutrition was related to length of stay and functional outcome, increased the risk for infections, pressure sores, and poor outcome

• Compensatory treatments for disordered swallowing function include changing posture and positioning for swallowing, learning new swallowing maneuvers, and changing food amounts and textures

• Percutaneous endoscopic gastrostomy feedings can improve outcome and nutrition in stroke patients

Shoulder Pain• Shoulder pain is common complication after stroke that can

inhibit recovery and reduce the quality of life• Prevalence of shoulder pain in post stroke hemiplegia ranges from

34% to 84%• Causes ₋ Brachial plexopathy

₋ Axillary neuropathy₋ Suprascapular

neuropathy₋ Myofascial pain₋ Spasticity₋ Soft tissue

contracture

₋ Capsulitis₋ Subluxation₋ Impingement syndrome₋ Rotator cuff injury₋ Bicipital tendonitis₋ Complex regional pain

syndrome type 1

• Capsulitis- includes range of motion, avoidance of exacerbating conditions such as the use of swath-type slings, proper limb positioning, management of underlying spasticity, and reduction of inflammation with modalities, medications, or intraarticular injection of steroids

• Impingement - managed by maintaining scapular mobility, using proper technique during stretch, treating spasticity, and, when possible, strengthening internal and external rotators of the shoulder, education of local inflammation through the use of oral agents or injected steroids

• CRPS1 - known previously as reflex sympathetic dystrophy or shoulder–hand syndrome, is a constellation of symptoms

• typically affects the shoulder, wrist, and hand but typically spares the elbow

• Phasesi. Primary inflammatory phase - by painful range of motion,

edema, warmth, and erythema of hand and wristii. Secondary - by atrophic skin changes, progressive loss of

range of motion, reduced skin temperature, and occasionally pain reduction

iii. A final phase - by irreversible skin and muscle atrophy, variable pain, severe loss of range of motion, and extensive osteoporosis

• Oral prednisone and exercise are the initial treatments• More invasive measures, such as cervical sympathetic ganglia

blocks, Bier blocks, and cervical sympathectomy, might be warranted in refractory cases

• Central poststroke pain (CPSP) - characterized as constant or intermittent pain occurring after stroke, which is located in areas of body that have sensory abnormalities

• Pain described as burning (50%), aching (35%), pricking (20%), or lacerating (15%)

• Changes in temperature, touch, movement, or emotion can worsen pain, whereas rest most commonly relieves pain

• Pharmacotherapy for CPSP includes amitriptyline (25 to 75 mg), which reduced pain - Carbamazepine, Lamotrigine, Gabapentin

• Nonpharmacological approaches such as transcutaneous electrical nerve stimulation have variable effectiveness

Bowel and Bladder Control• Incontinence of bowel and bladder occurs in one third to two

thirds of patients after stroke and, if it persists, can pose a challenge to preparing family caregivers for patient’s return to home

• Most common reason for incontinence after stroke is uninhibited evacuation of bladder or bowel

• Timed voiding is primary treatment strategy for patients with persistent uninhibited bladder

• Bladder ultrasound post void estimates with good accuracy the residual volume

• If residuals high (>200 mL), use of α-blocking agents such as tamsulosin in both male and female patients can promote complete voiding

• If voiding is complete, then use of anticholinergic agents such as oxybutynin can allow for larger bladder volumes before urgency occurs

• Some patients might need both α-blocking and anticholinergic agents to achieve a timely voiding pattern,

• The use of intermittent catheterization or indwelling catheter is also an option, depending on the goals of the patient and caregiver

• Bowel retraining can usually be achieved in patients with stroke using standard techniques of planned bowel evacuation after meals and the use of laxative agents such as senna and suppositories

• Providing a bedside commode is also useful for patients with mobility deficits or who have difficulty rapidly accessing the commode within their home

Depression and Psychosocial Considerations• New onset and persistence of disability can give rise to variety of

psychologic reactions in patients who have sustained a stroke, including sadness, grief, anxiety, depression, despair, anger, frustration, and confusion

• Addressing these issues is a critical component of rehabilitation program

• Treatment consists of psychotherapy, psychosocial support, milieu therapy, and medications

• Antidepressant medication Escitalopram to treat poststroke depression demonstrated improvement in cognitive functioning

• Serotonin-specific reuptake inhibitor medications are now widely accepted as effective treatment interventions for poststroke depression

• Sexual dysfunction has been reported in 40% to 70% of stroke survivors

• Its cause is largely psychologic • Issues related to self-esteem, affection, and relationships should

be emphasized, as should specific practical suggestions on positioning, timing, and techniques

• Dealing with family issues is essential• Families can experience a variety of emotions, including grief,

sadness, depression, anxiety, and guilt• Family interventions usually include individual counselling,

education, and support groups• Peer support is one component of patient care activities that

probably exerts a favourable effect on successful rehabilitation of stroke patient

• Presence of other patients with similar disabilities on stroke rehabilitation unit can assist in

₋ reduce fear and anxiety often associated with new onset of physically disabling or disfiguring conditions

₋ can counsel and support each other in ways that even well-meaning and experienced professionals cannot

₋ Finally, patients not only gain insight into their disability but also garner specific suggestions for functional skill performance or about adaptive equipment from other patients who have already been through the experience

Management of Medical Comorbidities and Prevention of Complications in Rehabilitation

• Stroke rarely occurs in isolation• Most patients with stroke have many other medical comorbidities

that can be categorized as follows:₋ Pre-existing medical illnesses that necessitate ongoing care

during the rehabilitation program ( hypertension and diabetes)₋ General health functions affected by the stroke ( nutrition and

hydration)₋ Secondary poststroke complications ( deep venous thrombosis

and pneumonia)₋ Acute poststroke exacerbations of pre-existing chronic diseases

(an angina attack during physical exercise in a patient with a history of ischemic heart disease)

• Preventing and treating comorbid medical conditions and medical complications are major components of rehabilitation treatment of stroke patients because they enable rehabilitation to take place and to exert maximum effectiveness

• The clinical tasks in managing these problems are to ₋ prevent medical complications, ₋ promptly and appropriately diagnose and treat complications

when they occur, ₋ manage both pre-existing medical illness and ongoing general

health functions during rehabilitation

Common Medical Comorbidities and Complications After Stroke

₋ Seizure₋ Spasticity₋ Contracture₋ Central poststroke

pain syndrome₋ Falls and injuries₋ Medication

overuse₋ Poor endurance₋ Fatigue₋ Insomnia

₋ Thromboembolic disease

₋ Pneumonia₋ Ventilatory

insufficiency₋ Hypertension₋ Orthostatic

hypotension₋ Angina₋ Congestive heart

failure₋ Cardiac arrhythmias₋ Diabetes mellitus₋ Prior stroke₋ Recurrent stroke

₋ Urinary tract infection

₋ Bladder dysfunction₋ Bowel dysfunction₋ Pressure sore₋ Dehydration₋ Malnutrition₋ Dysphagia₋ Shoulder

dysfunction₋ Complex regional

pain syndrome Depression

₋ Sexual dysfunction

• Physiologic Deconditioning - accompanies both acute medical illness and prolonged bed rest that might be enforced immediately after its onset

• Contribute to fatigue, endurance limitations, poor exercise tolerance, orthostatic hypotension, lack of motivation, and depression - can adversely affect the course of recovery and rehabilitation

• Preventive techniques include ₋ early mobilization, ₋ early and gradually increasing participation in rehabilitation,

and ₋ development and implementation of a schedule that balances

rest and activity• It should be noted that long-term stroke survivors, even those

with nearly fullneurologic recovery, frequently report easy fatigability and endurance limitations

• Venous Thromboembolism - incidence varies between 40% and 50% for deep vein thrombosis and 10% for pulmonary embolism

• In patients in whom haemorrhagic stroke has been ruled out, repeated doses of low-dose heparin or low-molecular-weight heparin compounds have been documented to be effective

• Obstructive Sleep Apnoea - OSA occurs when there are significant apnoea episodes persisting for more than 10 seconds each, ultimately leading to decreases in oxygen saturation in blood, and sometimes followed by sudden arousal

• Principal among the measures used to facilitate normal sleep are encouraging increased physical activity, provision of psychologic support, and implementation of steps to enhance sleep hygiene

• Falls - occur with striking frequency in stroke survivors, with most reports indicating that patients who sustain right hemisphere strokes are at substantially greater risk for falling than those with left

• Prevention approaches emphasize balance training, cognitive training, safety training (especially with caregivers), ensuring supervision during mobility activities, eliminating environmental hazards, and use of assistive devices

• Osteoporosis - at increased risk for long bone fractures from reduced bone mineral density as a consequence of immobilization

• at risk of frequency of falls, • use of bisphosphonates, is helpful in people with stroke

Specialized Equipments

• Adaptive and durable medical equipment can be used to assist stroke patients to become more independent and to facilitate functional skill performance

• It is important to consider patient’s functional level, level of adaptation to disability, architecture of living environment, and instruction in use of all devices and equipment

• Many types of devices are available to assist stroke patient in achieving an improved level of independence

• Includes adaptive devices to assist in the performance -

Adapted feeding utensils₋ Utensils with built-up

handles₋ Universal cuff₋ Rocker knife₋ Non-skid mats₋ Plate guards or

scoop dishes₋ Cup holder₋ Adapted cups

Bathing and grooming devices₋ Long-handled sponge₋ Washcloth mitt₋ Adapted shaving

equipment₋ Handheld shower nozzle₋ Soap on a rope₋ Stand-up mirror₋ Built-up toothbrush,

comb, hairbrushTub and shower transfer equipment₋ Non-skid mat₋ Grab bars₋ Transfer seats₋ Shower chair or bench₋ Hydraulic and motorized

tub lifts

Dressing devices₋ Velcro closures₋ Button hooks₋ Long-handled

reachers₋ Sock donning aid₋ Long-handled

shoehorn₋ Elastic shoelaces

Walking devices₋ Single-point cane₋ Quad cane₋ Hemi walker₋ Standard walker₋ Rolling walker

• Upper limb resting hand splints are usually used to prevent deformity and to maintain the hemiplegic wrist in a functional, slightly extended position

• For patients with wrist or finger flexion contractures, serial casting of the upper limb can assist in restoring functional range of motion

• The AFO is frequently provided to improve the positioning of the foot and ankle and to facilitate an optimal gait pattern

• Type of AFO prescribed depends on the patient’s strength and biomechanics during walking

Caregiver Training• One of most important interventions is training of families and

other caregivers in specific care techniques to ₋ prevent complications, ₋ perform physical functions, and ₋ encourage patients to perform any activities they are capable

of doing• Training in problem-solving techniques can help family members

provide effective support in the home environment• Family members serve as members of the rehabilitation team and

participate actively in the rehabilitation process• In addition to providing psychologic support, they also provide

practical assistance to the patient in the treatment program and preparation for return home

Transition to the Community,Follow-up, and Aftercare

• The effects of stroke can be enduring, and therefore rehabilitation is a lifelong activity involving restoration of patients to their fullest physical, mental, and social capabilities

• For this reason, medical rehabilitation for stroke survivors includes the many physical, social, and organizational aspects of aftercare of stroke patients

• Long-term quality of life is accomplished through an interdisciplinary approachthat includes helping the patient to achieve maximal independent functioning in daily activities, and training family members and other personal caregivers in performance of specific physical skills

• Major efforts toward preparation for discharge are directed toward securing community resources

• These include competent and reliable professional or other attendant care, home nursing visits, outpatient or home therapy, and community transportation and recreational programs

• Teaching patients about stroke, medications, fluid intake, diet, exercises, catheter care, feeding tube use, tracheostomy management, signs and symptoms of common complications such as infections, and specific functional task performance greatly facilitates a smooth transition to home and minimizes likelihood of medical problems after discharge

• Follow-up medical monitoring and care are also important

Rehabilitation Outcomes• Functional and Social Outcomes - One of most striking aspects of

caring for stroke patients is common observation that their physical performance,functional abilities, and quality of life are considerably better after rehabilitation and during long-term care than immediately after the stroke

• Predictors of Outcome - Potentially important factors includes:₋ Type, distribution, pattern, and severity of physical impairment ₋ Cognitive, language, communication, and learning ability ₋ Number, types, and severity of comorbid medical conditions

and ongoing health functions₋ Coping ability and coping style ₋ Nature and degree of family and other social supports Type

and quality of specific rehabilitation training program

• The strongest and most consistent predictor of discharge functional ability is admission functional ability

• Strongest predictors of adverse outcomes are • coma at onset, • persistent incontinence, • poor cognitive function, • severe hemiplegia, • lack of return of motor function after 1 month, • previous stroke, • visuospatial perceptual deficit, • unilateral hemineglect, • significant cardiovascular disease, • large cerebral lesion, and • presence of multiple neurologic deficits

Conclusion• Stroke rehabilitation continues to the prototype rehabilitation

effort involving nearly all common rehabilitation problems and requiring effort of all members of interdisciplinary rehabilitation team

• New scientific evidence on necessity of rehabilitation interventions for neural reorganization and functional recovery has set a foundation for stroke rehabilitation research in coming decades

• Application of physical exercise and newer modalities, as well as pharmacology, surgery, cortical brain stimulation, and robotics, is now under clinical investigation

Reference• Physical Medicine and Rehabilitation Braddom, 4th Edition

- RANDALL L. BRADDOM MD, MS

• DeLisa's Physical Medicine and Rehabilitation Principles and Practice, 5th Edition

- Walter R. Frontera, MD, PhD, FAAPM&R, FACSM