This document discusses the management of stroke. It defines stroke and describes the two main types: ischemic and hemorrhagic. It then outlines the modifiable and non-modifiable risk factors for stroke. The management of stroke involves both medical management to treat the underlying causes and prevent complications, as well as rehabilitation through physiotherapy to regain functions like mobility, balance and independence through techniques like Bobath and gait retraining. The overall goal of management is to reduce the impact of stroke on daily living.

2. Management Of Stroke
Prepared By:
A.K.M.Minarul Tawhid
3rd year B sc in Physiotherapy Student
BHPI,CRP,Savar,Dhaka-1343

3. Content:
What is Stroke?
Risk factors of Stroke.
Complication of Stroke.
Management of Stroke.

4. Stroke:
According to WHO-`A rapidly developed clinical
sign of focal disturbance of cerebral function of
presumed vascular origin of more than 24 hours
duration.”
Types:
 Ischemic- 80% of total stroke.
 Haemorrhagic- 20% of total stroke.

5. Risk factors:
Potentially Modifiable Factors:
 Transient ischemic attack (TIA)- Early sign of stroke.
 Hypertension.
 Diabetes mellitus.
 Cardiac disease.
 Atrial fibrillation.
 Left ventricular hypertrophy.
 High cholesterol.
 Smoking,Alchohol.
 Congestive heart failure.
 Contraceptive pills.

6. Non-modifiable factor:
 Age.
 Sex- Male are more affected than female.
 Heredity.

7. Complication:
Early complication:
 Respiratory complication- Bronchopneumonia.
 Pulmonary embolism- DVT form & then embolism.
 Pressure sore- Due to sensory deficit in bony
prominent area. It can also occur by Bacterial infection
due to improper catheterization.

8. Late complication:
 Decreased Flexibility-
 Immobility.
 Decreased AROM.
 Decreased soft tissue length.
 Contracture.
 Deformity.
 Shoulder Sublaxation and pain-
 Low tone.
 Malalignment.
 Adhesive capsulitis.
 Repetitive micro trauma.

9. Urinary incontinence.
Decreased functional activities.
Abnormal gait(Hemiplegic gait).
Communication problem-
Dysarthria (Problems of articulation).
Dysphasia (Difficulty in speech, Receptive/Expressive).
Aphasia (Total inability to speech).
Loss of facial expression & gesture.

10. Recovery:
Whatever the cause of stroke, a proportion of patients will
recover some degree which depends on the following factors-
 The site & extent of the initial lesion.
 The age of the patient.
 The capacity to achieved a motor goal related to functional
movement.
 The capacity of nervous system to reorganize
(Neuroplasticity).
 The motivation & attitude of patient towards recovery.
 The premorbid status of patient.
N:B>Maximum recovery occurs within first 8-12 weeks.

11. Management:
Medical Management:
 Aspirin in ischemic stroke to prevent recurrence or extension.
 Patients with hemiplegias should have antiembolic stockings
& anticoagulants, such as Warfarin as prophylaxis against DVT.
 Aspiration Pneumonia occurs about 15-25% patients. Adverse
outcome reduced by appropriate nursing, chest physiotherapy
& medication.
 In TIA,if heart is considered a likely source of emboli then long
term treatment with anticoagulents indicated.Atherosclerosis
leading to tight stenosis of internal carotid artery, can be
confirmed angiographically & treated surgically by carotid
endarterectomy.
 Patients with haematomas are also treated surgically.
 Neurological deficit is maximal in outset & if not severe, the
patient can be managed at home satisfactorily.

12. Nutritional management:
Swallowing
assessment.
Dietary
modification.
Palatal stimulation.

13. Definition of Rehabilitation:
“The active participation of a disabled person
and others to reduce the impact of disease
and disability on daily life”

14. Principles of rehabilitation
 Assess impact of disease on patient’s life-
 At levels of function, skill and independence.
 Set goals-
 Restoration of independence.
 Relevant to patient’s priorities.
 Realistic.
 Tackle barriers to goals-
 At levels of impairment, disability and handicap.
 Multi-disciplinary approach.

15. Physiotherapy Management:
Aims of Physiotherapy:
Early stage-
 To maintain airway.
 To maintain normal soft tissue length.
 To normalize muscle tone.
 To maintain healthy skin & prevent pressure sore.
Sub-acute stage-
 To maintain ROM.
 To maintain good respiratory status.
 To start active rehabilitation.

16. Active rehabilitation stage:
 To normalize muscle tone.
 To maintain normal postural alignment.
 To aid function and independence.
 To provide appropriate sensory stimulation.
 To help in regaining balance.
 To decrease the neglect of one side.
 To re-educate the gait.

17. Discharge:
 To withdraw the direct treatment.
 To emphasis on patients independence.
Follow-up:
 To review the in outdoor to monitor progress.
 To deterioration in function and treat accordingly.

18. Physiotherapy Management:
Physiotherapy for unconscious patients:
 Respiratory function:
Regular & frequent turning.
Percussion ,vibration to the chest & springing. Postural
drainage if indicated or if patient unconscious for prolong
period & if necessary some form of intubation or suction.
 Musculoskeletal integrity:
Range of motion exercise.
Positioning to maintain muscle length and prevent muscle
shortening & increased stiffness.
Active exercise and task related training should be
instituted as soon as the patient is conscious.

19. Bobath approach:
It is the most common & effective treatment procedure for
Stroke patients. Some key points are given below-
Patient should be in comfortable position.
Motor key point must be stable.
Movement will be proximal to distal.
No passive movement but active assisted.
In all trunk is main.
No static balance, all are dynamic balance.

20. Physiotherapy for medically stable patients:
Upper limb:
Use Bobath sling if patient have sublaxation in shoulder.
Rolling for relaxation.
Slow stretching for normalize muscle tone.
Active assisted movement in shoulder,elbow,wrist.Not
more than 90 degree if shoulder is sublaxed.
Shoulder mobilization for pain& stiffness (Frozen
shoulder).
Movement with mobilization for muscle pain & stiffness.
Hand & finger mobilization.
Strengthening exercise if patient able to perform.

21. Spasticity management:

22. Weight bearing exercise through limb for sensory stimulus
& normalize muscle tone.
Afferent cutaneous stimuli.
Trunk & Pelvis:
Trunk control exercise by manually or by using Gym ball.
Pelvic tilting exercise.
Bridging exercise by both leg & one leg.
Different Kneeling exercise.
Dynamic sitting balance practice.

23. Transfer training:

24. Lower Limb:
Rolling for relaxation.
Stretching for normalize muscle tone.
Active movement for hip, knee & ankle joint.
Movement with mobilization for muscle pain & stiffness.
Active & passive TA stretching.
Foot mobilization.
Strengthening exercise by Gym ball & sand bag.
Weight bearing exercise through limb for sensory stimulus
& normalize muscle tone.
Afferent cutaneous stimuli.

25. Gait re-education:
Dynamic standing balance practice.
Stepping practice.
Selective knee flexion practice beside the wall.
Weight shifting practice.

26. Gait training:

27. Self care modification:

28. Promote independence:
 Family role.
 Employment rehabilitation-
 Re-learn previous work skills.
 Modify circumstances of current job.
 Alternative job.
 Recreation.
 Promote relearning for future development-
 adrenergic medication

29. Reference:
 Neurological Rehabilitation: Optimizing
Performance- Janet H. Carr & Roberta B. Shepherd
 Neurological Physiotherapy-Professor Maria Stokes
 Physical Management in Neurological
Rehabilitation- Maria Stokes
 Right in The Middle- Patricia M. Davies

30. Question-

31. THANK YOU
EVERYBODY