Stroke Rehabilitation

DR TAREK NASRALA

28 / 12 / 2014

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

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

Effect of a Stroke (con’t)• 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

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

Successful Rehabilitation Depend on

- how early rehabilitation begins- the extent of the brain injury- the survivor’s attitude- the rehabilitation team’s skill- the cooperation of family and caregiver

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 patient’s progress regularly

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.

Rehabilitation Management• Mobility• Activity of daily living• Communication• Swallowing• Orthosis• Shoulder pain• Spasticity• Cognitive and perception• Mood• Bowel and bladder incontinence

Mobility

Therapeutic Exercises• Range Of Motion (ROM) Exercises• Muscle Strengthening Exercises• Mobilization activities• Fitness training• Compensatory Techniques

Aim• Improve

– Movement– Balance– coordination

• Safety

Basic Physical Therapy

• Bed positioning, mobility• Range of motion exercises (ROME)• Sitting/trunk control• Transfer• Walking• Stair climbing

Treadmill training with body weight support

Robotics

2. Activity of daily living• Occupational therapy

– Self care DressingGroomingToilet useBathingEating

– Adapt or specially design device

3. Communication• Speech and language therapy• Common communication disorder

– Aphasia *Receptive - auditory- reading

*Expressive - speaking- writing

*Global*Anomic - forget interrelated

groups of words– Dysarthria

Goal of treatment• Facilitate recovery of communication

develop strategies to compensate- Gesture- Picture- Communication board- Computer

4. Swallowing • Dysphagia : abnormal in swallowing fluids

or food

– Increase risk of pneumonia and malnutrition

Treatment • Posture change• Heightening sensory input• Swallow maneuvers• Active exercise• Diet modification

5. Orthosis• Shoulder slings• Hand splint• Foot slings• Ankle foot orthosis

Shoulder slings

Shoulder slings

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

Hand splints

Foot slings

- Plastic- Metal

• stability of ankle• balance• speed walking• Not enhance recovery

Ankle Foot Orthosis

Plastic AFO Metal AFO

Ankle Foot Orthosis

6. Shoulder pain• Sensorimotor dysfunction of upper

extremities• 72% of stroke patient in first year• Delay rehabilitation

Treatment• Electrical stimulation• Shoulder strapping• Mobilization (esp. External rotator,

abduction) prevent frozen shoulder, shoulder hand pain

• Medical• Intraarticular injections• Modalities : ice, heat, massage• Strengthening

7. Spasticity

• Velocity dependent hyperactivity of tonic streth reflexes

Aim of treatment• Pain• ROM• Cosmatic• Hygiene• Mobility• Easy use orthosis• Delay surgery

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)

8. Coginitive and perception• Attention deficits• Visual neglect• Unilateral neglect• Memory deficits• Problem solving difficulties

Treatment • Orientation - time

- place- person

• Memory• Repetitive• Environment• Problem solving

9. Mood • 1. Post stroke depression (PSD)• 2. Anxiety • 3. Emotionalism (emotional lability)

– Improve with time

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

• Fecal incontinence – Improve within 2 weeks

– Continued fecal incontinence poor prognosis

• 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

Conclusion • 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.

Conclusion • 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.