Stroke Rehabilitation

STROKE REHABILITATION

Dept.of Physical Medicine & Rehabilitation

Medical School of Brawijaya University

Dwi Indriani Lestari, dr, SpRM

Introduction
• Definition of Stroke
• Sudden fokal (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 anfarcts and
hemorrhages, decline attibuted to better
management of blood pressure, heart disease,
decrease in cigarette smoking, etc
• Incidence increase 17 % from 1975-79 perod 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

REHABILITATION OF STROKE
• 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 reeducational 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

Vertebro- basilar system
( posterior system )

Carotid system
( anterior system )

CAROTID
SYSTEM

VERTEBROBASILAR
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

NDA
•
•
•
•
•
•

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 )

UPPER EXTREMITY
MANAGEMENT
• Shoulder pain : 70-80 % of stroke patients
with hemiplegia have shoulderpain with variying
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
ccauses 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 irritative/noxious stimuli

DVT
• 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 Gait
Anterior 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

Mother
tongue

SPEECH THERAPY

GOOD
PROGNOSIS

GOOD,
MOTIVATION

COMPREHENSIVE,
WELL-PLANNED
PROGRAM

Acute phase

Acute phase

STABLE PHASE

STABLE PHASE

Disfagia Frequent and serious complication
stroke – Tx oral stimulation

Constraint-induced movement therapy
(CIMT)
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

Activity

Score

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

0

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

5 10

0

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

5

0

5

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

0

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

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

0

5

10

Barthel Index Classification :

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

0

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

0

1-20

: Totally dependent

1

5 10

21-60

: Severely dependent

2

5 10

61-90

: Moderate dependent

3

91-99

: Mild dependent

4

100

: Independent

5

5 10 15

5 10 15

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

0

TOTAL (0 - 100)

________

5

10

The Rehabilitation program
doesn’t finish when the patient
leaves the hospital, and almost all
patients benefit continued
theraphy.

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