Stroke is a major cause of death and disability in India. Rehabilitation after a stroke aims to help patients regain independence and function through a team-based approach. Rehabilitation occurs in phases, beginning in the acute post-stroke period and continuing through outpatient care. It focuses on improving impairments, preventing complications, and enhancing quality of life through restoration and compensation strategies that capitalize on the brain's neuroplasticity. Common post-stroke impairments include motor deficits, cognitive issues, swallowing difficulties, and pain. An individualized rehabilitation plan incorporating exercise, therapy, and lifestyle changes can help patients achieve their goals.

1. PRESENTER :- Dr. Abhinav Kinagi
MODERATOR :- Dr. Kishore Kumar Ubrangala
27/05/2020

2.  Stroke burden in INDIA
 Stroke Rehabilitation – Definition, Team
 Phase of Rehabilitation, their focus & setting
 Concept of Neuroplasticity
 Approaches
 Common Post-stroke impairments & their
management
 Life style changes after stroke
 Employment & Return to work
 Driving after stroke
 Take Home Message

3.  4th leading cause of death (ICMR 2016)
 5th leading cause of Disability Adjusted Life Years
(DALY) in India in 2016
 Responsible for 3.5% of DALY in India
 Crude Prevalence Rate :- 116-163/1,00,000
persons (2016)
 More than half will have significant deficits in
mobility, cognition, and their ability to perform
activities of daily living (ADLs)

5.  After a stroke, you may have to change or re-
learn how you live day to day.
 Getting quality rehab from a strong team of
therapists leads to better recovery
 The goal of rehab is to become as independent
as possible.

6. Particular emphasis will be on:
 the recovery of function (performance)
 prevention of secondary complications
 reduction of caregiver burden, and
 improvement of overall quality of life.
 Physical medicine and rehabilitation or
Physiatry

7.  Rehabilitation is a team effort. This team
communicates about and coordinates the
care to help achieve your goals
 Physician and Neurologist
 Physiatrist
 Physical therapist (PT)

8.  Occupational therapist (OT)
 Rehabilitation nurse
 Speech-language pathologists (SLP)

9.  Recreation therapist (RT)
 Psychiatrist or psychologist
 Vocational rehabilitation counselor

10. Rehab programs focus on assessing and
improving:
 ADLs
 Mobility
 Communication skills
 Cognitive skills
 Social skills
 Psychological functioning

11.  Once thought that there was no regenerative
ability in the brain or spinal cord – limiting
potential for functional recovery.
 NEUROPLASTICITY
– resulting form active exercise

12. Complementary strategies of approaches to
stroke recovery:
 Compensatory
 Restorative (Remedial, Therapeutic)

13. Finding a new way to perform and complete a
task
 Using of a cane in the setting of hemiparesis
resulting in safer walking.
 Installing a ramp in lieu of stairs.
 Learning to use the left arm to complete
tasks in the setting of right hemiparesis.

14.  Attempt to develop new or repair damaged
neural networks through active exercise
 Ex: Constraint-induced movement therapy
 Both approaches used simultaneously:
 The rehabilitation team chooses the
appropriate therapies to enhance
performance and facilitate recovery.

15.  Acute
 Post-acute
 Chronic phase

16.  As soon as the patient is medically stable and
capable
 Multidisciplinary rehabilitation team

17.  Early mobilization is defined as ‘trained
rehabilitation therapists and nursing staff
assisting the patient with task-specific
activities’.
 Early and regular mobilization in short
sessions within 24 hours of diagnosis of
stroke predicted better outcomes at 3
months.

18.  Coma at onset of stroke
 Urinary incontinence
 Poor cognitive function
 Severe hemiplegia
 Perceptual and spatial disorders
 Depression

19.  An independent level of function before
stroke is a positive factor, and full
assessment of premorbid function is
recommended.

20.  Use to reduce neural inflammation, modify
synaptic function, and restore cortical
network balance.
 Dopamine and catecholamine agonists &
anti-cholinergic antagonist
 Selective serotonin reuptake inhibitor (SSRI).
(FLAME) trial

21.  To facilitate recovery, minimize
complications, and maximize function
following stroke.
 The most common settings are: an inpatient
rehabilitation facility, skilled nursing facility,
long-term acute care hospital, home-based
services, and outpatient services.
 Home health care agency (HHCAs)

23.  Neurogenic bladder and bowel dysfunction
are defined as any alteration in the
controlled, predictable, and socially
acceptable elimination of bodily waste after
neurologic injury.

26.  2nd leading cause of impaired cognition and
dementia
 30% of stroke survivors develop dementia
within 1 year of the onset of their stroke
 Even minor strokes may affect cognition and
executive functions,(TIA) transient ischemic
attacks also may be associated with impaired
cognition

27.  The areas most affected: memory, language &
communication, orientation, attention, and
executive function
 Impact the patient’s ability to perform ADLs
 Younger stroke survivors - will often affect
their chance of returning to work (RTW)

28.  Evaluation by physiatry and neuropsychology,
and is followed by treatment by speech
language pathologist (SLP) and occupational
therapy (OT)
 Major goal: Improving the impairments (such
as retraining memory function), and/or
establish new patterns of cognitive activity
 A secondary goal: provide compensation
strategies to cope with the disabling impact of
the impairment.

31.  Aphasia is a disorder of language resulting from
damage to the language-dominant hemisphere of
the brain (usually the left side)
 Non-fluent aphasia
 Fluent aphasia
 Treatment by the SLP

32.  Include Apraxia of speech and Dysarthria.
 Apraxia - (an impairment in “motor
planning”)
 Dysarthria - 20% to 30% - Articulation deficit
 Treatment by SLP

33.  Visuo-spatial neglect
 43% of patients - right hemispheric damage
 17% - left hemispheric damage
 Encouragingly, neglect following stroke
usually improves within a few weeks after
onset.

34. Persons with stroke who have
 poor balance,
 low balance confidence,
 fear of falls and/or are at risk for falls
should be provided with a balance-training
program

35.  Eye exercises for treatment of convergence
insufficiency are recommended

36.  Affects 25% to 65% of patients
 Results from abnormal functioning of the
muscles of the mouth, pharynx and upper
esophageal sphincter

37.  Food and/or drink exiting the patient’s
nose
 Oxygen desaturation
 Persistent cough
 Change in voice quality during meals

38.  Pocketing
 Earliest - Sensation of food being stuck in
the throat
 Silent Aspiration

39.  Aspiration pneumonia
 Malnutrition
 Dehydration
 Prolonged hospitalization
 Mortality

40.  History taking
 Video fluoroscopic swallow study, also known as the
modified barium swallow (MBS) study
 SLP
 Fiberoptic endoscopic evaluation of swallowing test
 Treatment strategies: strengthening exercises,
compensatory strategies during swallowing, and
changes in food type, amount, and consistency.
 Supervision during meals

41. Stroke survivors may experience pain resulting
from
 central &
 peripheral mechanisms
 as well as - psychological factors

42.  Poststroke pain syndromes
 Hemiplegic shoulder pain
 Shoulder subluxation
 Rotator cuff injury
 Arthralgia
 Osteoarthritis
 Impingement syndrome
 Bicipital tendonitis
 Complex regional pain syndrome
 Heterotopic ossification, spasticity, and
joint contractures

43.  Chronic neuropathic disorder typically experienced
within the first month after stroke but ranging from 1
week to 10 years
 Prevalence - 7% to 35%
 Pain - intermittent or constant, with sensory
abnormalities, and is described as burning, aching, icy,
pricking, and lacerating
 Pharmacologic agents : TCA, SSRIs, Membrane
stabilizing agents such as gabapentin and pregabalin,
AED, Corticosteroids, and Opioids.
 Nonpharmacologic approach : Prescription of exercise
therapy to improve strength, flexibility, and function.

44.  Shoulder pain on the weak limb in a person
with hemiplegic stroke.
 It is present in 25% of stroke survivors.

45.  Rotator cuff injury
 Subluxation
 Shoulder-hand syndrome
 Myofascial pain syndrome
 Adhesive capsulitis
 Spasticity
 Contracture

46.  Pain can develop as early as 2 weeks after
stroke but is more commonly seen at 2 to 3
months.
 Treatment: Effective pain control with similar
agents used to treat CPSP, subacromial
steroid injection, physical modalities, and a
program of rehabilitation.

47.  Resting hand/wrist splints along with regular
stretching and spasticity management
 Resting ankle splints used at night and during
assisted standing may be considered for
prevention of ankle contracture in a
hemiplegic limb.

48. Prophylactic-dose subcutaneous heparin
(unfractionated heparin or low-molecular-
weight heparin) should be used for the duration
of the
 acute and rehabilitation hospital stay or
 until the stroke survivor regains mobility.

50. Neuropsychiatric disorders:
 Depression(PSD) – Most common 30%
 Anxiety disorder
 Pseudobulbar affect
 Anosognosia

52.  Feelings of sadness
 Hopelessness or helplessness
 Irritability
 Changes in eating, sleeping and thinking

53. Pseudobulbar affect, also called “emotional
lability,”
“reflex crying” or “labile mood,”
can cause :-
 Rapid mood changes — a person may “spill
over into tears” for no obvious reason and
then quickly stop crying or start laughing.
 Crying or laughing that doesn’t match a
person’s mood.
 Crying or laughing at unusual times or that
lasts longer than seems appropriate.

55.  Feeling of exhaustion and a lack of energy and
effort
 Frequency :- 29% to 77%
 May inhibit participation and progress in
rehabilitation
 The symptom often develops after physical or
mental activity and usually improves with rest

56. Treatment approaches:
 Antidepressants (SSRIs)
 Modafinil
 Counseling - good sleep hygiene
 Regular exercise

57.  Frequency :- 30%
 Commonly found in the shoulder, flexor muscles
of the upper arm (elbow, wrist, and fingers), and
extensor muscles of the lower limb (knee and
ankle)
 Complications :- pain, contracture, worsened
mobility, poor quality of life, and increased
caregiver burden
 Early detection and management of spasticity
may help mitigate these complications.

58.  PT or OT
 Stretching modalities
 Oral antispasm agents (Baclofen, Tizanidine,
and Dantrolene)
 Physiatric management
 True joint contracture needs a surgical
consultation.

59.  Frequency :- 57% to 75%
 Common complaints - decline in libido,
decrease in coital frequency, reduction in
vaginal lubrication and orgasm in women, and
poor or failed erection and ejaculation in men.
 Pharmacologic management
 Counseling by the multidisciplinary team

61.  Don’t smoke and avoid second-hand smoke.
 Improve your eating habits
(Eat foods low in saturated fat, trans fat, sodium
and added sugars)
 Be physically active
 Take your medicine as directed
 Get your blood pressure checked regularly
 Reach and maintain a healthy weight
 Decrease your stress level
 Seek emotional support when it’s needed
 Have regular medical checkup

63.  Stroke in the young
 To help determine if the stroke survivor is
able to safely RTW, a referral may be made to
OT or PT for a functional capacity evaluation.

65.  Limitations :- motor, visual, and cognitive
impairments
 State regulations
 Specialized centers where PT or OT assist
with screening and driver evaluation
 Neuropsychology evaluation

84.  There is life – and hope – after Stroke.
 With time, new routines will become second
nature.
 Rehabilitation can build patient’s strength,
capability and confidence.
 It can help the patient to continue his/her
daily activities despite the effects of Stroke

85.  Team approach
 Evidence based practice
 Neuroplasticity and motor learning principle
 Early mobilisation
 Aerobic training
 Comprehensive attention to all post-stroke
impairments

86.  Leroy R Lindsay, Diane A T, Michel W O. Updated Approach to Stroke
Rehabilitation. Med Clin N Am 2020;
 https://www.stroke.org/ (American Stroke Association)
 Guidelines for Prevention & Management of Stroke, National Programme
for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases
& Stroke (NPCDCS) - Directorate General of Health Services Ministry of
Health and Family Welfare – GOI 2019
 https://www.heart.org/ (American Heart Association )
 Harrisons Principles of Internal Medicine - 20th edition