Stroke rehabilitation pmr refresher course

1. Stroke Rehabilitation
managing the Physical Impairments
– an overview
Dr George Zachariah
Dept of PMR
Govt Medical college , Thiruvanathapuram

2. Special acknowledgements
• Dr Mrinal Joshi ( Rehabilitation Foundation society )
• Dr Abdul Gafoor , Prof & HOD
• Our stroke patients and their family
• My teachers, colleagues & Family
• Almighty

3. Lesson plan
• Definition
• Importance of penumbra
• Why early rehab
• Phases of rehab
• Rehab plan & team
• Phases described
• Newer rehab interventions supporting neuroplasticity
• Conclusion ( if time permits – our experience)

4. Stroke / CVA
• Stroke is an acute
neurological deficit
lasting more than 24
hours due to a focal
disruption of cerebral
circulation.

5. Definition
• STROKE – previously known medically as
CVA , is the rapidly developing loss of
brain function due to disturbance in blood
supply to the brain. Wikipedia 2010
• the term “stroke” is not consistently defined in clinical practice, in
clinical research, or in assessments of the public health. The classic
definition is mainly clinical and does not account for advances in
science and technology.
• Stroke 2013 AHA/ASA expert consensus
ICD - 10 , Chapter VI , G 45 & 46

6. Stroke Rehabilitation
• Stroke Rehabilitation is a progressive,
dynamic, goal oriented process aimed at
enabling a person. with impairment to
reach their optimal physical, cognitive,
emotional, communicative, and social
functional level.
– Heart & Stroke foundation, Canada
• Rehabilitation helps stroke survivors relearn skills that
are lost when part of the brain is damaged
• NINDS.

7. Priorities in Stroke management
• Stabilise the medical condition
• Control life threatening complications
• Improve blood flow
• Limit secondary complications
• Early Rehab
• Prevent another stroke

8. Prevention
• Exercises
• Stop smoking
• Control hypertension
• Treat diabetes
• Anti platelet drugs
• Anticoagulation
• Carotid end arterectomy

9. Prevention
• S. cholestrol <200mg /d
National cholestrol Edu Prgm
RBS < 200mg% Davidson Txtbk

10. Penumbra

11. Current concept in stroke
management
• >20ml/100g/min of cerebral blood flow can
sustain neural activity
• <10ml/100g/min cellular death
• 20-10ml/100g/min Na+ K+ pump fails
• Basic cell intact but electrically silent
• This rim “ischemic penumbra”

12. • Stroke intervention before 6 hrs saves the
penumbra. National stroke association
• Insulin & glucose control is
Neuroprotective.
• Antipatelet drugs + BP control

13. Penumbra
• Longer ischemic time for reperfusion
destroys the cells--------Neurology
• Longer delay in activity also destroys the
functions of this penumbra ---- rehab

14. Early Rehab saves the
Penumbra

15. REHAB
“ Consideration of a patients rehabilitation
needs should commence at the same time
as Acute Medical management. ”
Pg 1207, Davidsons Principle & Practise of Medicine – 20e

16. Very Early Mobilisation (VEM)
• Introduction
– Very early rehab with emphasis on
mobilization may contribute to improved
functional outcome after stroke.
– Greatest contributors to better outcome was
better BP control and early mobilization.

17. A Very Early Rehabilitation Trial
(AVERT) for Stroke phase II safety
and feasibility
• Julie Benhardt,Helen Dewey et al
• National stroke Research Institute –
Australia
• 3 phases
• Stroke 2008, 39:390 AHA

18. VEM
• Study setting
– 2 stroke units in teaching hospitals in
Melbourne Australia
• Study design
– Prospective,open randomised controlled trial,
blinded, outcome assessment design

19. VEM
• Results
– Mobilization VEM 18 hrs SC 30 hrs
– Adverse events VEM 15 SC 14
– Falls VEM 19.7 SC 22.8/1000
– Disability at 3 months
• Better outcome VEM 39.5% SC 30.3 %
– Disability at 12 months
• No significant difference
– Case fatality at 3 months
• 15.5% as compared to 20 % in population of stroke Pts

20. VEM
• Summary
– AVERT protocol in which mobilization occurs within
24 hrs is a safe and feasible approach
• further
– PHASE III AVERT is on 2104 patients multicenter
study at 30 centers in 3 countries
– Unblinded early reports
• Death rates 5.8% n=170 C Cassel medscape 2008

21. Physical Impairments of Stroke
-focal areas of brain
Area Impairment remarks
Primary motor area in the
precentral gyrus( motor
Homunculus )- Int capsule-
pyramidal tract
Hemiplegia in various proportions, motor
weakness and poor voluntary control
Synergy patterns
Basal ganglia & extrapyramidal
systems
Poor trunk control, balance , rigidity Falls, poor transfers
Anterior to precentral gyrus, in
the frontal lobe with connections
to IC, Basal ganglia, cerebellum
Poor static & dynamic balance, motor
planning, ataxia, chorea, hemiballismus,
tremors
Falls poor sitting &
standing balance ,
ADLs affected
UMN system of CNS, esp internal
capsule
Spasticity- increase in tonic & phasic
spasticity
Contractures, joint
pains, loss of function
( ref- compiled from rehabilitation of stroke syndromes-Chap 51 PMR 3rd Ed Braddom)

22. Impairments in Stroke
prevalence
Framingham Study
Enass, Catherine et al-
Estimate of prevelance of A/c Stroke impairments
in multi ethnic population ( South London stroke
registry) n=1259 Stroke 2001
impairment percentage
Gaze paresis 18.4 %
Field defect 26.1
Visual neglect 19.8
Sensory inattention 19.4
LL motor deficit 27.2
UL motor deficit 77.4
Ataxia 7.2
UL sensory deficit 30.3
Dysphagia 44.7
Dysphasia 23
Urinary incontinence 48.2 %

23. Framingham Study
only 1 in 10 strokes were completely independent
Participation & Activity Percentage of
patients
No Vocation post stroke 63%
Reduced socialisation 59%
Reduced use of transport 44%
Dependant in ADLs 32%
Dependant with dressing 30%
Transfer assistance 20%
Unable to walk 15%

24. Strategies to manage -Stroke Impairments
impairment problem intervention
Upper limb
involvement
Spasticity
Weakness
Coordination
Pain shoulder
CRPS
Drugs,BTx, splints, positioning,
Halter, antagonistic muscle
strengthening.
CIMT, NMES, FES,
Contrast bath, mirror therapy,
Bobath, Task oriented Approach
Lower limb
involvement
Spasticity, weakness,
Poor control, stability
contracture
Prone lying, exercises, stretching &
position
AFO, Drugs, Injections, serial
casting, tendon lengthening, FES,
BWSTT, Robot Assisted training,
Bobath,
Trunk control &
stability
Rigidity, Balance, Transfers
affected
Bridging, trunkal exercises, BWSTT,
Transfer training, railing, Tripod
Apraxia & neglect Difficulty with ADLs esp
Dressing& hygiene, Gait, siting
balance,neglect is a disorder of
Visual & spatial attention
Sensory motor integration, sensory
input from affected site, Mirror
therapy,Transfer training, Standing
balance training.

25. managing impairments
• Restoration of Locomotion is one of the main
goals in Stroke Rehab
• Gait is affected due to
• Muscle weakness
• Spasticity
• Sensory motor control loss
• Impaired cognition
• Shorter steps, longer stance phase

26. Managing Trunkal imbalance
• Trunk biomechanics during hemiplegic gait after stroke – A
systematic review, Vancriekinge T et al – Gait & Posture 2017
• Decreased trunkal coordination & Ltd strength
• Pelvic step is influenced
• Increased mediolateral trunk sway
• Specific exercises, walking aid, orthosis help control these defects
• Weight bearing Asymmetry associated with Postural instability
– Systematic review- Kamphius J – Stroke Res Treatment 2013
• WBA – weight bearing asymmetry towards the non paretic side is common
• WBA- poorer COP trajectory synchrony
• Increase in WBA- increases postural sway
• Training of weight bearing symmetry is a major focus of stroke rehab

27. Role of Ankle foot orthosis in improving locomotion &
functional recovery in Patients with Stroke- a Prospective rehab
study
H Sankarnarayanan,Anupam Gupta et al- Journal of Neuroscience & rural
Prac-2016
• N=26
• Outcome measures – 6 minute walk test, speed of 10
Mt walk, FIM
• MCID in 6MWT ( 50 M)
• 34.6% of Pts using AFO & 11.5% of Pts not using AFO
• All Pts had subjective improvement while using AFO
• Conclusion
• Use of AFO in stroke = mixed response
• 2/3rd of patients had no effect
• AFO provided mediolateral stability & helped in swing Phase.

28. Stroke Rehabilitation
Phases
Phase purpose action remarks
Phase I Evaluation Medical, functional
& Life situation
Phase II Rx, Arrest
pathogenesis
Drugs &
interventions
Phase III Enhancement Exercises,
counselling &
orrthosis
Strengthening
&balance
Phase IV Task reacquisition ADL& gait training
Phase V Environmental
modification
Home & Workplace
modifications ,
Return to society

29. Phase I- Evaluation
Personal details emphasis
History Functional H/o & review of systems
General Examination Vitals & deformities
Systemic examination complications
CNS Visual, aphasia, Neglect, spasticity
Neuromusculoskeletal
Exam
Tone, voluntary control ,power ,synergy,
contractures
Functional evaluation ADLs, Balance, Transfers, Gait
Scales & scores

30. Evaluation
scale
NIHSS National institute of health stroke scale
FIM Functional Independence measure - ADLs
Modified Rankin
scale
Disability
Fugel Meyer Spastic hand function
MAL or Wolf scale Hand function ( Motor activity Log)
Hoffer & Bullock ambulation
One minute walk
test
walking
Get up & go test ambulation
Star cancellation Visual neglect
Gait Analysis

31. Enumeration of
Impairments, Activity & participation,
complications
Sl
no
Medical
issues
complications impairment Activity participation remarks
1 diabetes Shoulder
subluxation
hemiplegia Walking
affected
Duty as driver for
ambulance
affected
2 infarct Ataxia Rt side Poor
sitting
Poor
dynamic
balance
Regular
attendance to
community meet
affected
3 Able to
feed
Parenting &
decisions -fair
4 Good family
interactions

32. Rehab planning – eg.
Sl
No
Impairments Action Rehab team
1 spasticity Positioning, Baclofen, Injection, ortrhosis -
-WHO, Articulated AFO
Nursing,
Physiatrist,
Orthotist
2 Limb contracture
Equinus
Stretching, serial casting,, Physio,
Physiatrist/ Ortho
3 Aspiration
Pneumonia
Ryles , Good mouth hygiene, antibiotics
chest PT
Nursing, PT
4 Shoulder
subluxation
ES to deltoid , Shoulder halter PT, Orthotist
5 Falls Counselling, balance training, tripod Nursing, OT,
Orthotist
6 Aphasia Speech stimulation Speech therapist
Body image &
neglect
Mirror therapy and sensory stroking OT
Followed by an informed instruction to
each member after the team meet

33. Stroke Rehab team
• Physiatrist
• Neuro Physician
• Psychiatrist
• Occupational therapist
• Physiotherapist
• Rehab nurse
• Speech language pathologist
• Orthotist
• Social worker…….

34. Phase III-- Enhancement
• Common rehab interventions in a classical hemiplegic Stroke with
spasticity and equinus , for ambulation ..
• ROM exercises, gentle stretching , distal to proximal
stroking of the limb to improve sensory input, Bridging to
improve trunk control, biofeedback balance training
exercises, tilting table and standing frame for bedridden
patients, standing weight shifts and , orthotics like AFO &
cock up splints(WHO) and shoulder halter, walking Aids
like tripod walking stick. Electrical stimulation & FES.

35. Phase IV -- Task Reacquisition
• Once the person with Stroke has achieved adequate
sitting balance and standing balance
• he/she could be progressed to Task reacquisition
like
• Gait training, step climbing , ADL training-
one hand dressing, toileting & feeding .
• reach out to an over head shelf, open a door,
• manage a computer/ laptop
• later even driving a modified car.

36. Phase V--Environmental
Modifications
• railings on the better side
• Grab bars in bathrooms
• Water health faucet on the able side
• Toilet chairs with arm rest
• Railing on the bed for a confused patient
• Chairs with high seats

37. Family
• Take the patient & family into confidence
• Explain the disease process
• Its treatment options, impairments, prognosis for
recovery
• Focus on accepting the condition
• Motivate for regular exercises and life style
changes
• Move focus from impairments to Activity &
participation.

38. Neuroplasticity
Neuroplasticity refers to the ability of
the CNS to reorganise and remodel
particularly after CNS injury

39. Functional recovery following stroke
cellular level
• Dentritic sprouting
• New synapse formation
• Long term potentiation and depression of
cerebral cortex
• Undamaged areas taking up lost function of
infarcted areas
• Prevention of Diaschisis

40. Peri infarct reorganisation
• Alteration of cortical motor maps after
primary motor cortex lesions – “ vicarious
reorganisation”.
• FMRI studies
– Dorsal shift of cortical activation near areas of
infarct
– Eg : recovery of finger movements
following small cortical lesions
picked up in FMRI

41. Rehab interventions supporting
Neuroplasticity
• Distal to proximal stroking of the limbs
affected
• Active assisted & simulated ADLs
• Task oriented approach
– Carr & Shepperd
• Simulated activities
• Bobath approach

42. Rehab interventions supporting
Neuroplasticity
• Bodyweighted
supported treadmill
training –BWSTT
• “ massed practice with
progressive wt bearing”
• Pamela et al – n=408
• NEJM-2011
• compared Home exs to BSTT
• Fugel meyer, walking speed &
Berg scale
• After 6 months similar gains in
walking speed

43. Rehab interventions supporting
Neuroplasticity
• Robotic devices can
induce repetitive
passive or assisted limb
movement
• Cortical excitability in
FMRI was a good
predictor for functional
gains following Robot
assisted training
• Millot, Spencer & Chan

44. Rehab interventions supporting
Neuroplasticity
• Virtual reality
• Adding imagery to
movement , lit up
additional brain regions
in FMRI
– Stewart & Crammer
• studies

45. Rehab interventions supporting
Neuroplasticity
• Constrained induced
movement Therapy
• Proposed by Edward
Taub & supported by
Randolph
• Improving function of
impaired limb by
blocking the good limb
in a arm sling

46. Rehab interventions
• Rythmic auditory
stimulation- RAS
• Can enhance gait
function by improving
the pace for walking
• In gait velocity, stride
length, & cadence
• Rebecca Hayden , IJNs ,
2009

47. Rehab interventions
• Recent studies using
FMRI & r TMS show
that the adult brain is
also capable of adaptive
plasticity., with
undamaged areas
taking up lost function
• EMG initiated FES-
Menta move

48. Rehab intervention supporting
Cortical remapping
• Mirror therapy
• form of Motor imagery
where a mirror in the
sagittal plane is used to
convey visual stimuli of
the normal limb
movement when the
affected limb is hidden
• VS Ramachandran-
Phantoms in the brain

49. Summary
• Though there is a battery of rehab
interventions to improve physical function of
stroke impairments
• Stand alone none can guarantee a complete
recovery
• Only a judicious combination of the same can
bring better results

50. Role of the Physiatrist
• Brain programmer … neuroplasticity, retrain
• Engineer … biomechanics of gait
• Team guide … coordinate, be aware
• Friend
• Doctor … help the patient take
decisions.

51. Role of Physiatrist
• A Friendly Doctor

52. conclusion
• Save the penumbra
• Evaluate well – function & risk factors
• Enumerate- Impairment, activity,
participation & complications
• Rehab plan
• Support team work
• Help the person with stroke back into society.

53. Thank you

54. If Time Permits

55. Our experiences…
• RajaLakshmi (name changed)
• 60 yrs old Lady
• CVA Lt Hemiplegia
• Atrial Fibrillation (on Warf)
• Hypertension & Dyslipidemia
• Subclinical Hypothyroidism

57. • 60 yr old Rajalakshmi is a grand mother who
had retd as a administrative staff.
• Hypertensive last 4-5 yrs on drugs
• 2 am she fell down after vomiting in the
bathroom.
• She was able to speak but could not walk after
this
• Noticed weakness of Lt UL & LL

58. RajaLakshmi
• Referred to Our Dept at 2 wks.
• P.R – 76/mt irreg, BP 150/100, RR –
Temp 98 F
• Hemineglect
• Hemianopia and UMN Facial Palsy
• Grade 0 power with Hypertonia Lt UL & LL.

59. At admission
• FIM - 59/126
• NIHSS – 11/42
• m Rankin scale – 4/6
• She was unable to sit up and was dependent
in all ADLs with significant neglect on lt side

60. Rajalakshmi
• Put on early mobilisation program which
included
• Positioning of arm in Abd & ER
• Positioning of leg in Abd & Ankle in Neutral
• Distal to proximal stroking
• TA, hamstring, add & finger flexor stretching.

61. Rajalakshmi
• Bridging
• Knee rolls
• Sitting up on bed on Rt side
• Caregiver was adviced to interact with patient
only from the left side
• Low intensity , 3-5 repetition of each set every
2 hrs was given by caregiver.

62. Rajalakshmi
• Progressed from
• tilting table to standing table to parallel bars
over 2-3 weeks
• OT for ADL training & sensory integration for
Lt side
• PT for gross motor skills
• Wrist hand orthosis & Shoe insert AFO.

64. Rajalakshmi
• She is now standing independently in parallel
bars with an AFO
• Independent in Feeding,brushing,toileting
• Partially dependent in bathing,dressing
• Vitals PR - 76/mt BP–140/90 Temp – 98F
• Voluntary control better in the knee extensors
• FIM – 73/126

66. On the flip side…
• Shobana (name changed)
• 65 yrs old housewife
• Hypertension and dyslipidemia (on drugs)
• Was referred to PMR on day 5 of the Stroke.
• Rt Sided weakness and Global Aphasia.
• CT scan – Lt Fronto-parietal infarct

67. Shobana
• On day 2 in PMR
• Progressive Drowsiness & unresponsive to
stimuli ….. vitals were stable
• Medicine Consultation
• Rpt CT scan – Evolving Rt parietal infarct
• Shifted to the ICU ….

68. Stroke spectrum
Comatosed unstable patient
to
RIND

69. Prevention is always better than
rehabilitation