Principles of stroke rehab

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Principles of stroke rehab

  1. 1. Stroke Rehabilitation Dr Deshan Kumar Registrar TTSH Rehabilitation Centre
  2. 2. Definition• From Latin “ habilitas “ – to make able• Literal translation – “ to be able again “• The process of helping a person achieve the highest level of function, independence and quality of life
  3. 3. Why impt• 4th leading cause of death• Prevalence of 3.65 % in adults > 50 years old• Leading cause of long term disability• 63% of stroke survivors in Singapore are moderately to severely disabled 3 months after stroke
  4. 4. Types of Stroke Intracerebral Ischemic (~74%) hemorrhage(~24%)30 day survival 73-81% 30 day survival 36%
  5. 5. Recovery• Neurological recovery • from early spontaneous recovery • usually within the initial few weeks when penumbral area recovers their function• Functional recovery • recovery in everyday function with adaptation and training in presence/ absence of natural neurologic recovery • lags neurological recovery by 2 weeks • the part most helped by rehabilitation
  6. 6. Neurological Recovery• Early recovery ( Local processes ) 2. Resolution of post stroke edema 3. Reperfusion of ischemic penumbra 4. Resorption of local toxins 5. Recovery of partially damaged ischemic neurons• Later recovery ( Neuroplasticity ) • Ability of nervous system to modify structural and functional organisation 1. Collateral sprouting of new synaptic connections 2. Unmasking of previously latent functional pathways 3. Reversibility from diaschisis 4. Denervation supersensitivity
  7. 7. Neurological Recovery• Majority of neurological recovery in first 3 months• 5% of patients continuing to show recovery for up to 1 year• Return of motor power not synonymous with recovery of function
  8. 8. Functional Recovery• Improvement in independence in areas of self care and mobility• Dependent on quality and intensity of therapy• Dependent on patient’s motivation• Modifiable by interventions
  9. 9. Copenhagen Stroke Study
  10. 10. Stroke Rehabilitation• ~ 10% of patients have complete spontaneous recovery• ~10% do not benefit from rehab due to severity of lesion• remaining ~80% will benefit from rehabilitation
  11. 11. Stroke Rehab Principles• Identify impairments• Careful attention to comorbidities and complications• Early goal directed treatment• Systematic assessment of progress• Experienced interdisciplinary team• Education• Comprehensive discharge planning
  12. 12. Early Mobilisation• If condition stable – To start active mobilisation within 24-48 hours• Early mobilisation reduces complications• Strong positive psychological benefit• Tolerance for therapy affected by stroke severity, medical stability, mental status, level of function
  13. 13. Early Mobilisation• Physiologically sound changes in bed position• Range of motion exercises• Specific tasks ( sitting up, turning from side to side )• Self care activities ( feeding, grooming, dressing )
  14. 14. Secondary Complications• Recurrent Stroke• DVT• Pressure sores• Bowel /bladder dysfunction• Dysphagia
  15. 15. Pressure Sores• Pressure ulcer risk assessment tools eg. Braden scale• High risk patients ( dependent in mobility, DM, peripheral vascular disease, urine incontinence, low BMI)• Thorough assessment of skin integrity• Proper positioning, turning, transferring• Avoid skin injury from friction/ excessive pressure
  16. 16. Bladder/Bowel• Urine incontinence• Constipation• To remove indwelling catheters ASAP• Establish proper bladder and bowel regime
  17. 17. Dysphagia• Leads to aspiration pneumonia and malnutrition• Swallowing screen to be done for all patients• If abnormal, speech therapist to perform complete bedside examination• Videofluoroscopy Swallowing Study• Functional Endoscopic Examination of Swallowing
  18. 18. Criteria for Admission to Rehab Programme• Stable neurological status• Significant persisting neurologic deficit• Identified disability affecting at least 2 of the following: • Mobility • Self- care • Communication • Bowel/bladder control • Swallowing• Sufficient cognition to learn• Sufficient communicative ability to engage with therapists• Physical ability to tolerate the active program• Achievable therapeutic goals
  19. 19. International Classification of Functioning• Impairment• Activity limitation• Participation barrier
  20. 20. Stroke Impairments• Cognitive• Communication• Motor• Sensory• Visual
  21. 21. Outcome Measures• Stroke Severity – NIHSS• Upper and lower extremity function – Fugyl Meyer• Visual perception – Line bisection• Balance – Berg Balance• Cognition – MMSE• ADLs and ambulation – FIM score, Barthel index
  22. 22. FIM Score• Functional Independence Measure• 18 items 1. Selfcare (dress, eat, groom, toilet, bathe) 2. Sphincter control (bowel and bladder) 3. Transfers (bed, toilet, tub) 4. Locomotion (walking or wheelchair) 5. Communication (comprehension and expression) 6. Social/ cognition (Problem solving and memory)• Scored into one of seven levels of function ranging from complete dependence (level 1) to complete independence (level 7).
  23. 23. Rehabilitation Goals• Specific• Measurable• Acheivable• Realistic• Timely
  24. 24. Interdisciplinary Team• Rehabilitation physician• Nurse• Physiotherapist• Occupational therapist• Speech therapist• Psychologist• Social Worker• Prosthetist and Orthotist• Dietician
  25. 25. Stroke rehab: Where?• Inpatient• Community Hospital• Nursing Home• Day Rehabilitation Centres• Home based therapy (eg. Community rehab programme)
  26. 26. Stroke- Awareness of Self
  27. 27. Stroke: Improving Mobility and Balance
  28. 28. Stroke: Improving Upper Limb Function Functional electrical stimulation (FES)
  29. 29. Stroke- Upper Limb Function
  30. 30. Stroke- Improving self care
  31. 31. Stroke- Higher ADLS
  32. 32. Stroke- Dysphagia Therapy
  33. 33. Stroke- Improving Communication
  34. 34. Late Rehabilitation Issues • Spasticity• Psychological maladjustment • Hemiplegic shoulder• Depression pain • Rotator cuff injury• Sexuality • Spasticity • Subluxation• Vocational • Complex regional pain syndrome• Driving • Contactures• Equipment needs • Central post stroke pain
  35. 35. Spasticity• Proper positioning of limb• Passive ranging and stretching• Functional electrical stimulation• Pharmacological ( baclofen, clonazepam, dantrolene)• Alcohol/phenol neurolysis• IM botox• Surgical options eg. Intrathecal baclofen pumps, tendon release
  36. 36. Stages of Motor Recovery (Brunstromm )I Flaccid limbII Some spasticity with weak flexor and extensor synergiesIII Prominent spasticity; voluntary motion occurs within synergy patternsIV Some selective activation of muscles outside of synergy patterns. Spasticity reducedV Most limb movement independent from limb synergy; spasticity further reduced but still present with rapid movementsVI Near normal coordination with isolated movementsVII Restoration to normal
  37. 37. Shoulder Pain - Spasticity
  38. 38. Shoulder pain- Spasticity NeurolysisSerial casting
  39. 39. Shoulder pain- SubluxationSUBLUXATION
  40. 40. lSlings, straps, Proper positioningsupports Arm trough/lapboard - Reduction of subluxation in sitting and standing - Dynamic joint compression of shoulder, elbow and wrist during standing - Avoiding pulling on affected arm during transfers
  41. 41. Functional Electrical Stimulation• Target strengthening muscles around shoulder• Can stimulate supraspinatus and posterior deltoid
  42. 42. Shoulder pain- Subacromial Impingement
  43. 43. Post-stroke Depression May present early or late Negative impact on function Difficult diagnosis: Æ Aphasia/Dysarthria Æ Cognitive impairment Æ Neglect Treatment: Restoration of function Drugs : SSRI, TCA Psychosocial support Cognitive behavioural therapy
  44. 44. Driving• Promotes independence and help avoid sense of isolation• Neuropsychological testing for persons with cognitive or behavioural disorders • impulsivity • poor attention span • slowed decision making• Simulated driving test• Adaptive driving instruction program• Driving Assessment and rehabilitation program (DARP)
  45. 45. Return to work• Important determinant of the quality of life• “Work hardening” therapy• Greatest opportunities to support vocational reintegration are in the areas of education and advocacy
  46. 46. Rehabilitation Toolbox• Pharmacological agents• Constraint Induced Movement Therapy (CIMT )• Mental imagery• Functional Electrical Stimulation• Transcranial Magnetic Stimulation• Transcranial Direct Cortical Stimulation• Virtual Reality• Robotic Technology
  47. 47. Pharmacology• SSRI eg. Fluoxetine• Dopaminergic agents eg. Levodopa, memantine• Acetylcholinesterase inhibitors eg. donepezil• Piracetam
  48. 48. CIMT• Evidence for arm improvement ( EXCITE trial )• Good upper limb is constrained ( 90% of patient’s waking time )• Affected upper limb trained in functional tasks• Must have some wrist and finger function before starting
  49. 49. Mental Imagery• Mirror box therapy• Small trials• Better evidence for use to improve upper limb function• Must be used in combination with therapy
  50. 50. Functional Electrical Stimulation• Bioness Arm Unit• Used as a neuroprosthesis• Functional aid to performing ADL• Can aid motor recovery
  51. 51. Functional Electrical Stimulation• Lower extremity FES unit• Facilitate more fluid gait• Has a gait sensor, miniature control unit and is wireless• Increased walking speed
  52. 52. Transcranial Magnetic Stimulation
  53. 53. Transcranial DirectCortical Stimulation
  54. 54. Virtual Rehab• Shown to have improvement in balance and gait• Immersive vs. non immersive• Wii games
  55. 55. Robotic Technology• New class of clinical tools• Highly reproducible motor learning experience• Relieves strenous repetitive effort of therapists
  56. 56. Robotic Technology
  57. 57. Functional outcome following stroke• ~1 in 10 functionally independent at time of stroke and nearly one-half are independent at 6 months• Most improvements in ADLs occurs during the 1st 6 months- up to 5% of pts may show continued measurable improvement at 12 months post- stroke
  58. 58. Predictors of Functional Outcome• Severity of stroke• Age• Sitting balance• Admission FIM score
  59. 59. Typical disabilities• Typical disabilities in some specific activities at 6 months post- stroke • Unable to walk (15%) • Needs assist transfer (20%) • Needs assist to bathe (50%) • Needs assist to dress (30%)
  60. 60. Poor Prognostic Indicators for Upper Limb Recovery• Severe proximal spasticity• Prolonged flaccid period• Absence of voluntary hand movement at 4-6 weeks• Onset of movement at >2-4 weeks• Full recovery is usually complete within 3 months of onset
  61. 61. Prognosis• Best neurological recovery is seen by 11 wks for 95% of patients• Prognosis in patients with mild or moderate stroke is usually excellent• Most ADL recovery (Barthel Index) is by 12.5 weeks with daily PT/OT• But recovery could take 2 years or more• Periodic rehabilitation interventions may be necessary to maintain function
  62. 62. THE END…… THANK YOU

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