Stroke Rehabilitation

Dr Deshan KumarRegistrar

TTSH Rehabilitation Centre

Definition• From Latin “ habilitas “ – to make able• Literal translation – “ to be able again “• The process of helping a person

achieve the highest level of function, independence and quality of life

Why impt• 4th leading cause of death• Prevalence of 3.65 % in adults > 50

years old• Leading cause of long term disability• 63% of stroke survivors in Singapore

are moderately to severely disabled 3 months after stroke

Types of Stroke

Ischemic (~74%) Intracerebral

hemorrhage(~24%)

30 day survival 73-81% 30 day survival 36%

Recovery• Neurological recovery

• from early spontaneous recovery• usually within the initial few weeks when

penumbral area recovers their function

• Functional recovery• recovery in everyday function with adaptation

and training in presence/ absence of natural neurologic recovery

• lags neurological recovery by 2 weeks • the part most helped by rehabilitation

Neurological Recovery

• Early recovery ( Local processes )

1. Resolution of post stroke edema 2. Reperfusion of ischemic penumbra3. Resorption of local toxins 4. Recovery of partially damaged ischemic neurons

• Later recovery ( Neuroplasticity )• Ability of nervous system to modify structural and

functional organisation1. Collateral sprouting of new synaptic connections 2. Unmasking of previously latent functional pathways3. Reversibility from diaschisis4. Denervation supersensitivity

Neurological Recovery

• Majority of neurological recovery in first 3 months

• 5% of patients continuing to show recovery for up to 1 year

• Return of motor power not synonymous with recovery of function

Functional Recovery• Improvement in independence in areas

of self care and mobility• Dependent on quality and intensity of

therapy• Dependent on patient’s motivation• Modifiable by interventions

Copenhagen Stroke Study

Stroke Rehabilitation

• ~ 10% of patients have complete spontaneous recovery

• ~10% do not benefit from rehab due to severity of lesion

• remaining ~80% will benefit from rehabilitation

Stroke Rehab Principles

• Identify impairments

• Careful attention to comorbidities and complications

• Early goal directed treatment

• Systematic assessment of progress

• Experienced interdisciplinary team

• Education

• Comprehensive discharge planning

Early Mobilisation• If condition stable – To start active

mobilisation within 24-48 hours• Early mobilisation reduces complications • Strong positive psychological benefit• Tolerance for therapy affected by stroke

severity, medical stability, mental status, level of function

Early Mobilisation• Physiologically sound changes in bed

position• Range of motion exercises• Specific tasks ( sitting up, turning from

side to side ) • Self care activities ( feeding, grooming,

dressing )

Secondary Complications

• Recurrent Stroke• DVT• Pressure sores• Bowel /bladder dysfunction• Dysphagia

Pressure Sores• Pressure ulcer risk assessment tools eg.

Braden scale• High risk patients ( dependent in mobility, DM,

peripheral vascular disease, urine incontinence, low BMI)

• Thorough assessment of skin integrity• Proper positioning, turning, transferring• Avoid skin injury from friction/ excessive

pressure

Bladder/Bowel• Urine incontinence• Constipation• To remove indwelling catheters ASAP• Establish proper bladder and bowel

regime

Dysphagia• Leads to aspiration pneumonia and

malnutrition• Swallowing screen to be done for all patients• If abnormal, speech therapist to perform

complete bedside examination• Videofluoroscopy Swallowing Study• Functional Endoscopic Examination of

Swallowing

Criteria for Admission to Rehab Programme

• Stable neurological status• Significant persisting neurologic deficit• Identified disability affecting at least 2 of the

following:• Mobility• Self- care• Communication• Bowel/bladder control• Swallowing

• Sufficient cognition to learn• Sufficient communicative ability to engage with

therapists• Physical ability to tolerate the active program• Achievable therapeutic goals

International Classification of Functioning

• Impairment• Activity limitation• Participation barrier

Stroke Impairments• Cognitive• Communication • Motor• Sensory• Visual

Outcome Measures• Stroke Severity – NIHSS• Upper and lower extremity function – Fugyl

Meyer• Visual perception – Line bisection• Balance – Berg Balance• Cognition – MMSE• ADLs and ambulation – FIM score, Barthel

index

FIM Score• Functional Independence Measure• 18 items 1. Selfcare (dress, eat, groom, toilet, bathe) 2. Sphincter control (bowel and bladder) 3. Transfers (bed, toilet, tub) 4. Locomotion (walking or wheelchair) 5. Communication (comprehension and expression) 6. Social/ cognition (Problem solving and memory)

• Scored into one of seven levels of function ranging from complete dependence (level 1) to complete independence (level 7).

Rehabilitation Goals

• Specific• Measurable• Acheivable• Realistic• Timely

Interdisciplinary Team

• Rehabilitation physician

• Nurse

• Physiotherapist

• Occupational therapist

• Speech therapist

• Psychologist

• Social Worker

• Prosthetist and Orthotist

• Dietician

Stroke rehab: Where?

• Inpatient

• Community Hospital

• Nursing Home

• Day Rehabilitation Centres

• Home based therapy (eg. Community rehab programme)

Stroke- Awareness of Self

Stroke: Improving Mobility and Balance

Stroke: Improving Upper Limb Function

Functional electrical Functional electrical stimulation (FES)stimulation (FES)

Stroke- Upper Limb Function

Stroke- Improving self care

Stroke- Higher ADLS

Stroke- Dysphagia Therapy

Stroke- Improving Communication

Late Rehabilitation Issues

• Psychological maladjustment

• Depression

• Sexuality

• Vocational

• Driving

• Equipment needs

• Spasticity

• Hemiplegic shoulder pain• Rotator cuff injury• Spasticity• Subluxation• Complex regional

pain syndrome• Contactures

• Central post stroke pain

Spasticity• Proper positioning of limb

• Passive ranging and stretching

• Functional electrical stimulation

• Pharmacological ( baclofen, clonazepam, dantrolene)

• Alcohol/phenol neurolysis

• IM botox

• Surgical options eg. Intrathecal baclofen pumps, tendon release

Stages of Motor Recovery (Brunstromm )I Flaccid limb

II Some spasticity with weak flexor and extensor synergies

III Prominent spasticity; voluntary motion occurs within synergy patterns

IV Some selective activation of muscles outside of synergy patterns.

Spasticity reduced

V Most limb movement independent from limb synergy;

spasticity further reduced but still present with rapid movements

VI Near normal coordination with isolated movements

VII Restoration to normal

Shoulder Pain - Spasticity

Shoulder pain- Spasticity

Neurolysis

Serial casting

Shoulder pain- Subluxation

SUBLUXATION

Proper positioning Arm trough/lapboard

Slings, straps, supports

- Reduction of subluxation in sitting and standing- Dynamic joint compression of shoulder, elbow and wrist during standing- Avoiding pulling on affected arm during transfers

Functional Electrical

Stimulation• Target strengthening

muscles around shoulder• Can stimulate

supraspinatus and posterior deltoid

Shoulder pain- Subacromial Impingement

Post-stroke DepressionMay present early or lateNegative impact on functionDifficult diagnosis:

Aphasia/Dysarthria Cognitive impairment Neglect

Treatment: Restoration of functionDrugs : SSRI, TCAPsychosocial support Cognitive behavioural

therapy

Driving• Promotes independence and help avoid sense of isolation

• Neuropsychological testing for persons with cognitive or behavioural disorders • impulsivity• poor attention span• slowed decision making

• Simulated driving test

• Adaptive driving instruction program

• Driving Assessment and rehabilitation program (DARP)

Return to work• Important

determinant of the quality of life

• “Work hardening” therapy

• Greatest opportunities to support vocational reintegration are in the areas of education and advocacy

Rehabilitation Toolbox

• Pharmacological agents

• Constraint Induced Movement Therapy (CIMT )

• Mental imagery

• Functional Electrical Stimulation

• Transcranial Magnetic Stimulation

• Transcranial Direct Cortical Stimulation

• Virtual Reality

• Robotic Technology

Pharmacology• SSRI eg. Fluoxetine• Dopaminergic agents eg. Levodopa,

memantine• Acetylcholinesterase inhibitors eg.

donepezil• Piracetam

CIMT• Evidence for arm

improvement ( EXCITE trial )

• Good upper limb is constrained ( 90% of patient’s waking time )

• Affected upper limb trained in functional tasks

• Must have some wrist and finger function before starting

Mental Imagery• Mirror box therapy

• Small trials

• Better evidence for use to improve upper limb function

• Must be used in combination with therapy

Functional Electrical Stimulation

• Bioness Arm Unit

• Used as a neuroprosthesis

• Functional aid to performing ADL

• Can aid motor recovery

Functional Electrical Stimulation

• Lower extremity FES unit

• Facilitate more fluid gait

• Has a gait sensor, miniature control unit and is wireless

• Increased walking speed

Transcranial Magnetic Stimulation

Transcranial Direct Cortical Stimulation

Virtual Rehab• Shown to have

improvement in balance and gait

• Immersive vs. non immersive

• Wii games

Robotic Technology• New class of

clinical tools

• Highly reproducible motor learning experience

• Relieves strenous repetitive effort of therapists

Robotic Technology

Functional outcome following stroke

• ~1 in 10 functionally independent at time of stroke and nearly one-half are independent at 6 months

• Most improvements in ADLs occurs during the 1st 6 months- up to 5% of pts may show continued measurable improvement at 12 months post- stroke

Predictors of Functional Outcome

• Severity of stroke• Age • Sitting balance• Admission FIM score

Typical disabilities• Typical disabilities in some specific

activities at 6 months post- stroke• Unable to walk (15%)• Needs assist transfer (20%)• Needs assist to bathe (50%)• Needs assist to dress (30%)

Poor Prognostic Indicators for Upper Limb Recovery

• Severe proximal spasticity• Prolonged flaccid period• Absence of voluntary hand movement

at 4-6 weeks• Onset of movement at >2-4 weeks• Full recovery is usually complete within

3 months of onset

Prognosis• Best neurological recovery is seen by

11 wks for 95% of patients• Prognosis in patients with mild or

moderate stroke is usually excellent• Most ADL recovery (Barthel Index) is by

12.5 weeks with daily PT/OT• But recovery could take 2 years or more• Periodic rehabilitation interventions

may be necessary to maintain function

THE END……

THANK YOU