The document outlines practical guidelines for stroke rehabilitation, emphasizing the importance of a specialized neurorehab team and evidence-based approaches to recovery. It covers various aspects of management including acute care, ward management, and outpatient follow-up, along with strategies for enhancing functional recovery through techniques like early mobilization and tailored therapies. Key principles such as neuroplasticity and motor learning are highlighted as crucial for regaining skills and improving overall patient outcomes.

1. Practical
Guidelines in
Stroke Rehab
Dr. Varsha Soni(PT)
Neurorehab Incharge
Pacific Centre of
Neurosciences

2. Key Points
• NeuroRehab Team
• Role of Rehab
• Recovery
• Acute / ICU Management
• Subacute /Ward Management
• Chronic /OPD Management
• Support Group

3. NeuroRehab Team
Specialized stroke
team has a
favorable effect on
survival rates,
length of stay, &
ADL independence,
compared to
regular care at a
non-specialized
ward. (Level 1)
Patient

4. Role of Rehab
NeuroRehab Definition
“A process whereby patients
who suffer from impairment
following neurologic diseases
regain their former abilities or, if
full recovery is not possible,
achieve their optimum physical,
mental, social and vocational
capacity.”

5. Recovery
• Neurological recovery
– Early recovery (Local Processes)
– Late recovery (Neuroplasticity)
modification in structural and functional
organization
• Functional recovery
– Recovery in everyday function with adaptation
and training in presence/ absence of natural
neurologic recovery
– Dependent on quality ,intensity of therapy &
patient’s motivation

6. Neuroplasticity Principle
1. Use It or Lose It
2. Use It and Improve
3. Specificity
4. Repetition Matters
5. Intensity Matters
6. Time Matters
7. Salience Matters
8. Age Matters
9. Interference

7. Motor Learning
• Reacquisition of previously learned movement
skill that are lost due to pathology or sensory,
motor or cognitive impairment. This process is
often referred to as recovery of function.
• Feedback
– Intrinsic or extrinsic feedback
– KP or KR
• Practice
– Massed vs. Distributed practice
– Constant vs. Variable practice

8. ICU Management
• Positioning
• Respiratory Care
• Prevention of 2ndry Complicatn
DVT
Pressure Sore
Msk Complication
Deconditioning
• Early Mobilisation

9. Positioning

10. Early Mobilisation
• If condition stable – To start active mobilisation
within 24-48 hours
• Physiologically sound changes in bed position & ROM
exercise.
• Specific tasks ( sitting up, turning from side to side )
& Self care activities ( feeding, grooming, dressing )
• Tolerance for therapy affected by stroke severity,
medical stability, mental status, cardiac instability &
level of Consciousness.

11. Conti..
• Early mobilisation reduces complications and
enhances functional recovery (Level 1)
• Strong positive psychological benefit
• It remains unclear whether early mobilization
from the bed, i.e. within 24 hours after the
stroke, is more effective than later mobilization as
regards complications, neurological deterioration,
fatigue, basic ADL activities and discharge home.
(Level 1)

12. Ward Management
• Bedside Mobilization
(out of the bed)
• Transfer Training
• Different approaches
-Follow the evidence
• Current treatment methods
• Shoulder Management
Transfer Training

13. Bedside Mobilisation

14. Different Approaches
• Neurodevelopment Approach/ Bobath Therapy
• Rood’s Approach
• Brunnstorm Approach
• Proprioceptive Neuromuscular Facilitation
• Motor Relearning Program
• No single therapy was superior than other. Mixed
therapy was better than no treatment or
placebo for improving physical function.
(Cochrane Review, Pollock et al).

15. Current Treatment Methods
• CIMT [Level 1]
• Bimanual Training[ Level 2]
• Mirror Therapy [LEVEL 2]
• Mental Imagery [Level 3]
• NMES/ FES [Level 2]
• EMG- Biofeedback [Level 3]
• Virtual Reality [Level 2]
• BWSTT [Level 2]

16. Shoulder Management
• Prevent shoulder pain & impingement by proper
handling & caregiver education.
• Use of NMES/ Sling
• Mx for severe or chronic case
1. Eliminate pain
2. Desensitization
3. Eliminate Hand edema
4. Introduce pain free ROM by reestablishing
scapular mobility
5. Beginning with guided arm movt below 60 deg,
gradually increase variability and complexity

17. OPD/ Follow Up Care
• Goal Setting
Restorative/compensatory
• Trunk Control Training
• Upper Extremity Training
• Lower Extremity Training
• Gait Training
• Endurance/ fitness training
• Balance Training

18. Predictive Prognosis
• Most improvements in ADLs occurs during the 1st
6 months- up to 5% of pts may show
improvement even at 12 months post- stroke
• But recovery could take 2 years or more
• Prognosis in patients with mild or moderate
stroke is usually excellent

19. Improving Trunk Control
• Trunk forms a foundation for any posture &
movement.
• Post hemi - loss of selective muscle activity in
trunk & tone - Compensatory movement is seen
• Rx focus on
-Trunk rotation, side flexion [all cardinal plane]
-Combination of movement
-Balance reaction[Anticipatory & Reactive]
-Functional Activity

20. Poor Prognostic Indicators for Upper
Limb Recovery
• Severe proximal spasticity
• Prolonged flaccid period
• Absence of voluntary hand
movement at 4-6 weeks
• Full recovery is usually complete within 3 months of
onset

21. Improve UE Function
• Relearning of movt pattern & retraining of missing
component
• Upper body initiated wt shift pattern[reaching &
picking object]
• UL weight bearing & Dynamic stabilization exercise
• Functional movement & Combination movt
• Power production - Throwing
• Fine motor function- Object Manipulation
• Spastic Hand Rehab- Botox
• Adjuncts – Orthoses, CIMT, BF, NMES, VR, Robotics

22. Improve LE function
• Strengthening muscles in appropriate pattern
& Functional pattern.
• Training for posterior weight shift, Anterior
weight shift & Lateral weight shift (sitting).
• Co-ordinated combination movement
• Power production [Kicking]
• Cycling & treadmill training

23. Gait Training
• Initial gait training between parallel bars then
outside bars with aids & then without aids
• In all direction & turning
• Foot clearance
– Orthoses, Taping & FES
• PBWSTT with higher speed
improve overall locomotor
activity & over ground speed

24. Improve Aerobic Function
• Prevent recurrent stroke &
cardiovascular events.
Remedial gait retraining;
supervised or home-based walking
or treadmill training programs
• Improve Aerobic fitness.
Large-muscle activities (e.g. walking, treadmill,
stationary cycle, combined arm-leg ergometry, arm
ergometry, seated stepper)
Symptom limited graded exs training
40-70% of VO2max, 3-7 d/week for 20-60min/session

25. Balance Training
• Facilitate symmetrical wt bearing on both side
• Anticipatory and Reactive postural strategy
training in different plane
• Dual task training s/a kicking ball in standing,
throwing activities, carrying an object while
walking, cognitive task
• Single limb stance and walking on unstable
surface
• Ball Exercise

26. Support Group
• www.ssgu.org
• www.strokeindia.org
• www.strokeassociation.org
• www.stroke.org

27. References
• KNGF Guidelines for Stroke 2014.
• Physical Activity and Exercise Recommendations for
Stroke Survivors. American Heart
Association/American Stroke Association, 2014.
• Cochrane Database
• O’ Sullivan SB, Schmitz TJ. Stroke. Physical
rehabilitation. 5th ed., 2007.
• Darcy A. Umphred. Neurological Rehabilitation, 6th
ed., 2012.
• Right in the Middle: Patricia Davis

28. Take home message
• Team Approach
• Evidence Based Practice
• Early Mobilisation
• SMART Goal
• Different approach’s & Treatment adjuncts
• Aerobic Training
• Neuroplasticity & Motor learning principle