A biopsychosocial approach to stroke physiotherapy. This is a move to integrate the personal and environmental factors to the standing biomedical understanding of the disease for a tailor-made treatment.

1. Presented by
Stroke rehabilitation in a
biopsychosocial context
13 February 2017
Gerald F.P. Ramos, PhD, MPhil, BSPT
Stroke & Physiotherapy
Neurology

2. Goal(s)
Slide # 2
Students will be able to
identify
describe
analyze
understand
explain
impairments
limitations
restrictions
of stroke (CVD) patients.

3. Perception (Part vs Whole)
Slide # 3
Mercedes de Barcelona
Pyke Koch (1930)

4. Framework
http://www.rehab-scales.org/images/blocks/1176903286/image-1.png?1176975371
Slide # 4
The International Classification of Functioning, Disability and Health

5. Framework
https://media.lanecc.edu/users/howardc/PTA204L/204LNeuromuscReEd/204L%20Hemiplegia.gif
Slide # 5
Pathophysiology
Impairments
Limitations
Restrictions

6. Definition of Stroke
http://worldneurologyonline.com/article/stroke-definition-in-the-icd-11-at-the-who/
Slide # 6
• Clinical history and examination
• Neuroimaging
• (Neuropathological) autopsy
• Infarction at single or multiple sites of the brain
or retina
• Haemorrhage within the brain parenchyma, the
ventricular system, or the subarachnoid space
• AcuteONSET
PRESENTATION
DURATION
DIAGNOSIS
• Focal neurological dysfunction
• ≤ 24 hours (Transient)
• > 24 hours (Major)
CAUSE
• Clinical history and examination
• Neuroimaging
• (Neuropathological) autopsy
• Infarction at single or multiple sites of the brain
or retina
• Haemorrhage within the brain parenchyma, the
ventricular system, or the subarachnoid space
• AcuteONSET
PRESENTATION
DURATION
DIAGNOSIS
• Focal neurological dysfunction
• ≤ 24 hours (Transient)
• > 24 hours (Major)
CAUSE

7. Review: Circle of Willis
Visible Anatomy
Slide # 7

8. Taxonomy of Stroke: Anatomy
http://www.patienthelp.org/wp-content/uploads/2015/04/Falx-Cerebri.jpg
Slide # 8

9. Taxonomy of Stroke: Aetiology
Felten DL & Shetty AN. Netter’s atlas of neuroscience. 2nd ed. Philadelphia: Saunders Elsevier; 2010.
Slide # 9

10. Taxonomy of Stroke: Management
http://www.askdoctork.com/content/uploads/2014/06/iStock_Stroke_000019644735XSmall.jpg
http://3.bp.blogspot.com/-OrccQ6dRj_4/VR1ex1mTtRI/AAAAAAAAGrQ/3QvLKC4NWMw/s1600/stroke%2Bpic.jpg Slide # 10

11. Epidemiology
http://www.worldstrokecampaign.org/learn/facts-and-figures.html
http://www.world-heart-federation.org/cardiovascular-health/stroke/ Slide # 11
Worldwide incidence and mortality rates for all strokes
6
deaths
30
incidents
60seconds
every
~15M incidents/year
~6M deaths/year

12. Epidemiology
Feigin VL et al. Atlas of the global burden of stroke (1990-2013): The GBD 2013 Study. Neuroepidemiology 2015; 45:230-236.
Slide # 12
Worldwide prevalence of Ischaemic Stroke in 2013 (per 100,000)

13. Epidemiology
Feigin VL et al. Atlas of the global burden of stroke (1990-2013): The GBD 2013 Study. Neuroepidemiology 2015; 45:230-236.
Slide # 13
Worldwide prevalence of Haemorrhagic Stroke in 2013 (per 100,000)

14. Epidemiology
Truelsen T et al., Stroke incidence and prevalence in Europe: a review of available data. Eur J Neurol. 2006; 13:581-98.
Slide # 14
European stroke events projection (males+females)

15. Epidemiology
1 Wolma J,et al. Ethnicity a risk factor? The relation between ethnicity and large- and small-vessel disease in White people, Black
people, and Asians within a hospital-based population. European Journal of Neurology; 2009; 16: 522–527.
2 O’Sullivan SB, Schmitz TJ, Fulk GD (eds). Physical Rehabilitation. 6th ed. Philadelphia, Pennsylvania: FA Davis; 2014.
Slide # 15
Non-Modifiable Risk factors for stroke
Increasing age
Ethnicity/Race (varies with type of stroke)1
Sex: Men > Women except for:2
 Women with menopause before 42 y/o
 Pregnancy, birth, 6-months postpartum
 Preeclampsia
 Contraceptive use
Genetic predisposition/Family history of stroke
Increasing age
Ethnicity/Race (varies with type of stroke)1
Sex: Men > Women except for:2
 Women with menopause before 42 y/o
 Pregnancy, birth, 6-months postpartum
 Preeclampsia
 Contraceptive use
Genetic predisposition/Family history of stroke

16. Epidemiology
1 Soler EP, Ruiz VC. Epidemiology and Risk Factors of Cerebral Ischemia and Ischemic Heart Diseases: Similarities and Differences.
Current Cardiology Reviews. 2010;6(3):138-149.
2 https://www.eurekalert.org/pub_releases/2016-07/tl-tls071416.php
Slide # 16
Modifiable Risk factors for stroke1
HYPERTENSION  Most important modifiable risk factor2
HEART DISEASE
ARRHYTHMIAS  Atrial fibrillation
DIABETES MELLITUS
HYPERCHOLESTEROLEMIA  High “Bad” Cholesterol
HEMATOCRIT  Increased
SLEEP APNEA
SMOKING
SEDENTARY LIFESTYLE
OBESITY
DIET
ALCOHOL ABUSE
HYPERTENSION  Most important modifiable risk factor2
HEART DISEASE
ARRHYTHMIAS  Atrial fibrillation
DIABETES MELLITUS
HYPERCHOLESTEROLEMIA  High “Bad” Cholesterol
HEMATOCRIT  Increased
SLEEP APNEA
SMOKING
SEDENTARY LIFESTYLE
OBESITY
DIET
ALCOHOL ABUSE

17. Complications + Comorbidities
Christian A & Batmangelich S (eds). Physical Medicine and Rehabilitation Patient-Centered Care: Mastering the competencies.
New York: Demos Medical; 2015 Slide # 17

18. Complications + Comorbidities
Christian A & Batmangelich S (eds). Physical Medicine and Rehabilitation Patient-Centered Care: Mastering the competencies.
New York: Demos Medical; 2015 Slide # 18

19. Complications + Comorbidities
Christian A & Batmangelich S (eds). Physical Medicine and Rehabilitation Patient-Centered Care: Mastering the competencies.
New York: Demos Medical; 2015 Slide # 19

20. Complications + Comorbidities
Christian A & Batmangelich S (eds). Physical Medicine and Rehabilitation Patient-Centered Care: Mastering the competencies.
New York: Demos Medical; 2015 Slide # 20

21. Complications + Comorbidities
Christian A & Batmangelich S (eds). Physical Medicine and Rehabilitation Patient-Centered Care: Mastering the competencies.
New York: Demos Medical; 2015 Slide # 21

22. Review: Brain/CNS Functions
Adapted from Umphred DA et al. Umphred’s Neurological Rehabilitation. 6th ed. St. Louis, Missouri: Elsevier Mosby; 2013; p 101.
Slide # 22

23. CNS Functions & ICF Levels
Slide # 23

24. CNS Functions & ICF Levels
Slide # 24

25. CNS Functions & ICF Levels
Slide # 25
FUNCTIONS
LEVELS Sensorimotor Cognitive-
perceptual
Limbic-emotional
Pathology Primary motor
cortex
Broca’s area Insular cortex
Impairment Hemiplegia Expressive aphasia Anorexia
Limitation Drawing Talking/Speaking Malnutrition
Restriction Not able to draw
blueprints
Meeting at work Less eating out

26. Phases of Stroke Rehabilitation
Verbeek JM et al. KNGF Stroke Practice Guidelines. 2014.
Slide # 26
Hyperacute
Acute
Subacute
Chronic
Hyperacute
Acute
Subacute
Chronic

27. Hypothetical Recovery Pattern
Dispa D et al. Rehabilitation of motor function after stroke: a multiple systematic review focused on techniques to stimulate upper
extremity recovery. Front Hum Neurosci. 2016; 10:442. Slide # 27

28. Possible directions of Adapatation
Umphred DA et al. Umphred’s Neurological Rehabilitation. 6th ed. St. Louis, Missouri: Elsevier Mosby; 2013.
Slide # 28

29. Overview of Treatments
O’Sullivan SB, Schmitz TJ, Fulk GD (eds). Physical Rehabilitation. 6th ed. Philadelphia, Pennsylvania: FA Davis; 2014.
Slide # 29
• NMES
• Orthoses
• Sitting-Standing balance exercises
• Body-weight supported treadmill training (BWSTT)
• Robot-assisted training
• Circuit class training
• Muscle strengthening
• Hydrotherapy
• Mirroring; Mental imagery
• Simultaneous bilateral therapy
• Constraint-induced movement therapy
• NMES
• Orthoses
• Sitting-Standing balance exercises
• Body-weight supported treadmill training (BWSTT)
• Robot-assisted training
• Circuit class training
• Muscle strengthening
• Hydrotherapy
• Mirroring; Mental imagery
• Simultaneous bilateral therapy
• Constraint-induced movement therapy

30. Acute Rehab Activities/Goals
• Monitoring patient status
• Early mobilisation
• Positioning
• Functional mobility training
• Bed mobility, sitting/standing endurance, transfers, gait
• ADL training
• ROME
• Splinting
• Patient-Carer education
• Risk factors, pathophysiology, current condition
• Recovery process, POC, care-setting transitions
O’Sullivan SB, Schmitz TJ, Fulk GD (eds). Physical Rehabilitation. 6th ed. Philadelphia, Pennsylvania: FA Davis; 2014.
Slide # 30
• Monitoring patient status
• Early mobilisation
• Positioning
• Functional mobility training
• Bed mobility, sitting/standing endurance, transfers, gait
• ADL training
• ROME
• Splinting
• Patient-Carer education
• Risk factors, pathophysiology, current condition
• Recovery process, POC, care-setting transitions

31. Post-acute Rehab Activities/Goals
• Continued mobilisation
• Aerobic endurance
• Gait training
• Functional training
• ADL training/Work-hardening
• Use of adaptive devices
O’Sullivan SB, Schmitz TJ, Fulk GD (eds). Physical Rehabilitation. 6th ed. Philadelphia, Pennsylvania: FA Davis; 2014.
Slide # 31
• Continued mobilisation
• Aerobic endurance
• Gait training
• Functional training
• ADL training/Work-hardening
• Use of adaptive devices

32. Bed positioning
http://cdn.quotesgram.com/img/87/16/142879932-113798491.png
Slide # 32

33. Bed mobility exercises
O’Sullivan SB, Schmitz TJ, Fulk GD (eds). Physical Rehabilitation. 6th ed. Philadelphia, Pennsylvania: FA Davis; 2014.
Slide # 33

34. Transfers
http://www.allegromedical.com/images/products/pivotdisc-ill2.gif
Slide # 34

35. ADL training
O’Sullivan SB, Schmitz TJ, Fulk GD (eds). Physical Rehabilitation. 6th ed. Philadelphia, Pennsylvania: FA Davis; 2014.
https://s-media-cache-ak0.pinimg.com/736x/8c/de/60/8cde6074710a993e31109a0b62984591.jpg Slide # 35

36. Gait training
O’Sullivan SB, Schmitz TJ, Fulk GD (eds). Physical Rehabilitation. 6th ed. Philadelphia, Pennsylvania: FA Davis; 2014.
http://www.buykorea.org/images/files_new/mp/gd/2013/08/12/20130812095843026_020_RE.jpg Slide # 36

37. Adaptive devices/Home changes
Slide # 37

38. Orthoses
Slide # 38

39. Overview of Neurologic Exercises
Belda Louis J-M et al. Rehabilitation of gait after sroke: a review towards a top-down approach. J of Neuroengineering and
Rehabilitation; 2011, 8:66. Slide # 39
• Neurodevelopmental Treatment (NDT) a.k.a.
Bobath concept
• Proprioceptive neuromuscular facilitation (PNF)
• Brunnström’s concept
• Rood’s concept
• Johnstone therapy
• Ayres’ method
• Perfetti’s method
• Carr-Shephard’s Motor relearning progrmme (MRP)
• Perfetti’s method
• Affolter’s method
NeurophysiologicalapproachesMotorlearningapproaches

40. Economic Impact of Stroke
https://thumbnails-visually.netdna-ssl.com/stroke--how-much-impact-does-it-have-on-the-uk_5029155532671.jpg
http://www.pfizer.com/files/health/VOMPapers_AFIB-Stroke_Infographics0101.jpg Slide # 40
in the U.S.

41. Stroke Prevention
Slide # 41

42. Conclusion/Summary
Slide # 42
• Psychological and social factors contribute to a
more holistic understanding of the disease than
with biomedical factors alone.
• A holistic understanding enables the development
of tailor-made rehabilitation programmes.
• Early rehabilitation maximizes potential for
functional recovery.
• Task- and context-specific exercises improve
functional recovery.
• Stroke remains a challenge given an ageing
population.
• Psychological and social factors contribute to a
more holistic understanding of the disease than
with biomedical factors alone.
• A holistic understanding enables the development
of tailor-made rehabilitation programmes.
• Early rehabilitation maximizes potential for
functional recovery.
• Task- and context-specific exercises improve
functional recovery.
• Stroke remains a challenge given an ageing
population.