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Stroke Rehabilitation. พญ.พรพิมล มาศสกุลพรรณ สถาบันประสาทวิทยา. 2 / 4 / 2008. 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

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stroke rehabilitation

Stroke Rehabilitation

พญ.พรพิมล มาศสกุลพรรณ

สถาบันประสาทวิทยา

2 / 4 / 2008

national stroke association
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
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
Effect of a Stroke (con’t)
  • 7. Problems with memory, thinking, attention or learning
  • 8. Beingunaware 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
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
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
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
multidisciplinary team
Multidisciplinary Team
  • Rehabilitation specialist
  • Physical, occupational and speech therapist
  • Social worker
  • Dietician
  • Recreational therapist
  • Psychologist
  • Vocational rehabilitation counsellor
  • Nurses
  • Orthotist
  • Patient, caregiver
early mobilisation
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
Rehabilitation Management
  • Mobility
  • Activity of daily living
  • Communication
  • Swallowing
  • Orthosis
  • Shoulder pain
  • Spasticity
  • Cognitive and perception
  • Mood
  • Bowel and bladder incontinence
1 mobility
1. Mobility
  • Physiotherapy
    • Conventional therapies
    • Neurophysiological therapies
conventional therapies therapeutic exercises traditional functional retraining
Conventional therapiesTherapeutic ExercisesTraditional Functional Retraining
  • Range Of Motion (ROM) Exercises
  • Muscle Strengthening Exercises
  • Mobilization activities
  • Fitness training
  • Compensatory Techniques
neurophysiological approaches
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)
slide14
Aim
  • Improve
    • Movement
    • Balance
    • coordination
  • Safety
basic physical therapy
Basic Physical Therapy
  • Bed positioning, mobility
  • Range of motion exercises (ROME)
  • Sitting/trunk control
  • Transfer
  • Walking
  • Stair climbing
2 activity of daily living
2. Activity of daily living
  • Occupational therapy
    • Self care Dressing Grooming Toilet use Bathing Eating
    • Adapt or specially design device
3 communication
3. Communication
  • Speech and language therapy
  • Common communication disorder
    • Aphasia *Receptive - auditory - reading *Expressive - speaking - writing *Global *Anomic - forget interrelatedgroups of words
    • Dysarthria
goal of treatment
Goal of treatment
  • Facilitate recovery of communication develop strategies to compensate

- Gesture

- Picture

- Communication board

- Computer

4 swallowing
4. Swallowing
  • Dysphagia : abnormal in swallowing fluids or food
    • Increase risk of pneumonia and malnutrition
treatment
Treatment
  • Posture change
  • Heightening sensory input
  • Swallow maneuvers
  • Active exercise
  • Diet modification
5 orthosis
5. Orthosis
  • Shoulder slings
  • Hand splint
  • Foot slings
  • Ankle foot orthosis
hand splints
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
ankle foot orthosis
Ankle Foot Orthosis

- Plastic

  • Metal
  • stability of ankle
  • balance
  • speed walking
  • Not enhance recovery
ankle foot orthosis1
Ankle Foot Orthosis

Metal AFO

Plastic AFO

6 shoulder pain
6. Shoulder pain
  • Sensorimotor dysfunction of upper extremities
  • 72% of stroke patient in first year
  • Delay rehabilitation
treatment1
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
7. Spasticity
  • Velocity dependent hyperactivity of tonic streth reflexes
aim of treatment
Aim of treatment
  • Pain
  • ROM
  • Cosmatic
  • Hygiene
  • Mobility
  • Easy use orthosis
  • Delay surgery
treatment2
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
8. Coginitive and perception
  • Attention deficits
  • Visual neglect
  • Unilateral neglect
  • Memory deficits
  • Problem solving difficulties
treatment3
Treatment
  • Orientation - time - place - person
  • Memory
  • Repetitive
  • Environment
  • Problem solving
9 mood
9. Mood
  • 1. Post stroke depression (PSD)
  • 2. Anxiety
  • 3. Emotionalism (emotional lability)
    • Improve with time
10 bowel and bladder incontinence
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

slide55
Fecal incontinence
    • Improve within 2 weeks
    • Continued fecal incontinence poor prognosis
slide56
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 1
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.
conclusion 2
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.