- 10-40% of stroke survivors experience moderate to severe impairments requiring special care or long-term facilities, while 15% die shortly after the stroke. - Stroke rehabilitation aims to restore lost abilities, prevent complications, and improve quality of life through therapies targeting mobility, activities of daily living, communication, swallowing, orthotics, and cognitive/emotional issues. - Early rehabilitation beginning within 24-48 hours, a systematic assessment, careful therapy planning, gradual progression, and family involvement promote successful recovery from stroke.

1. Stroke Rehabilitation
DR TAREK NASRALA
28 / 12 / 2014

2. 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

3. 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

4. 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

5. 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 activi
ties

6. 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

7. 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

8. 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-feedin
g, grooming and dressing) can be given for early m
obilisation.

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

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

11. Aim
• Improve
– Movement
– Balance
– coordination
• Safety

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

13. Treadmill training with body
weight support

14. Robotics

15. 2. Activity of daily living
• Occupational therapy
– Self care Dressing
Grooming
Toilet use
Bathing
Eating
– Adapt or specially design device

27. 3. Communication
• Speech and language therapy
• Common communication disorder
– Aphasia *Receptive - auditory
- reading
*Expressive - speaking
- writing
*Global
*Anomic - forget interrelated
groups of words
– Dysarthria

28. Goal of treatment
• Facilitate recovery of communication
develop strategies to compensate
- Gesture
- Picture
- Communication board
- Computer

33. 4. Swallowing
• Dysphagia : abnormal in swallowing fluids
or food
– Increase risk of pneumonia and malnutrition

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

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

36. Shoulder slings

37. Shoulder slings

38. 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

39. Hand splints

40. Foot slings

41. - Plastic
- Metal
• stability of ankle
• balance
• speed walking
• Not enhance recovery
Ankle Foot Orthosis

42. Plastic AFO Metal AFO
Ankle Foot Orthosis

43. 6. Shoulder pain
• Sensorimotor dysfunction of upper
extremities
• 72% of stroke patient in first year
• Delay rehabilitation

44. Treatment
• Electrical stimulation
• Shoulder strapping
• Mobilization (esp. External rotator,
abduction) prevent frozen shoulder,
shoulder hand pain
• Medical
• Intraarticular injections
• Modalities : ice, heat, massage
• Strengthening

45. 7. Spasticity
• Velocity dependent hyperactivity of
tonic streth reflexes

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

47. 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)

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

49. Treatment
• Orientation - time
- place
- person
• Memory
• Repetitive
• Environment
• Problem solving

50. 9. Mood
• 1. Post stroke depression (PSD)
• 2. Anxiety
• 3. Emotionalism (emotional lability)
– Improve with time

51. 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

52. • Fecal incontinence
– Improve within 2 weeks
– Continued fecal incontinence poor prognosis

53. • 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

54. 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 g
reater on average.
• Even though the most marked improvement is
achieved during the first 3 months, rehabilita
tion should be continued for a longer period t
o prevent subsequent deterioration.

55. Conclusion
• No patient should be excluded from rehabilitation
unless he is too ill or too cognitively devastated to par
ticipate 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.