STROKE REHABILITATION

Dept.of Physical Medicine & Rehabilitation

School of Medicine Brawijaya University

Introduction
Definition of Stroke
Sudden focal (sometimes global) neurologic
deficit secondary to occlusion or rupture of
blood vessels supplying the brain
Symptoms > 24 hours = stroke
Symptoms < 24 hours = T I A
Reversible ischemic neurologic deficit
(RIND)

Epidemiology
Stroke after heart disease and cancer
Nearly four million stroke survivors in United States
46 % decline in cerebral infarcts and hemorrhages,
decline attibuted to better management of blood
pressure, heart disease, decrease in cigarette smoking,
etc
Incidence increase 17 % from 1975-79 period to
1980-84

Risk factors
Nonmodifiable: age,sex(male>female), race
(African Americans 2X >whites>Asians), risk
more than doubles each decade after age 55,
family history of stroke
Modifiable : Hypertension, history TIA,
heart disease, diabetes, cigarette smoking,
high dose estrogen, hyperlipidemia, obesity

PROBLEMS OF STROKE PATIENTS

MUSCLE
WEAKNESS
AMBULATION
ADL
. COMMUNICATION
VOCATIONAL
DYSPHAGIA

SPASTICITY
SHOULDER PAIN
BLADDER/BOWEL
DYSFUNCTIONS
DVT

Mobilization
6 12 months
Acute Phase : Stable Phase :
- BED EXERCISE- Mobilization
- Positioning /Turning
- ROM Exercise
- Strengthening

- THROMBOSIS : 3 DAYS
- BLEEDING : 2 3 WEEKS

REHABILITATION
The primary goal of stroke is functional
enhancement by maximizing the
independent, life style and dignity of the
patient.
This approach implies rehabilitative efforts
from a physical, behavioral, cognitive,
social, vocational, adaptive and reeducational point of view.

Predictors of motor recovery

Severity of arm weakness at onset
With complete arm paralysis at onset, there is a
poor prognosis of recovery of useful hand function
(only 9 % gain good recovery of hand function)
Timing of return of hand movement : - if the
patien shows some motor recovery of the hand by
4 weeks, there is up to 70 % chance of making a
full or good recovery.
- poor prognosis with no measurable graps
strength by 4 weeks

 Poor prognosis associated also with :

- Severe proximal spasticity
- Prolonged flaccidity period
- Late return of proprioceptive faciltation
(tapping) response > 9 days
- Late return of proximal traction response
(shoulder flexor/adductors) >13 days

Vertebro- basilar system

( posterior system )

Carotid system
( anterior system )

CAROTID
SYSTEM

VERTEBROBASILAR
SYSTEM

Rehabilitation methods for motor deficits

Traditional Therapy :
Traditional therapeutic exercise program consists
positioning, ROM exercise,
strengthening,mobilization, compensatory
techniques, endurance training.
Traditional approuches for improving motor
control and coordination

NDA

Propioceptive Neuromuscular Facilitation

Bobath
Brunstrom
Car and Shepard approach
Rood approach
Behavioral approach

EXERCISE PROGRAM :
1. TRADITIONAL / CONVENTIONAL
METHOD/UNILATERAL : regain motor control consist of
stretching and strengthening, attempting to retrain muscle
weakness thought reeducation.
2. NEURODEVELOPMENTAL /BILATERAL/
NEUROPHYSIOLOGICAL METHODS
Brunnstrom
Rood
Bobath (stresses exercise & prevent excessive spasticity)
Kabat, Knott, Voss ( PNF )

There is a strong belief that early

mobilization is beneficial to patient outcome
by reducing the risks of DVT,
gastroesophageal regurgitation and
aspiration pneumonia, contracture
formation, skin breakdown, and orthostatic
intolerance.

UPPER EXTREMITY
MANAGEMENT
Shoulder pain : 70-80 % of stroke patients with
hemiplegia have shoulder pain with varriying
degrees of severity of the patients with shoulder
pain,
The majority (85 %) will develop it during the
spastic phase of recovery.
It is generally accepted that the most common
causes of hemiplegic shoulder pain are the
shoulder hand syndrome / reflex sympathetic
dystrophy (RSD) and soft tissue lesions (including
plexus lesions)

Other Aspects of Stroke Rehabilitation

Spasticity Management :
Usually seen days to weeks after ischemic strokes
Usually follows classic UE flexor and LE extensor
patterns
Clinical features include velocity dependent
resistance to passive movement of affected muscle
at rest, and posturing in the patterns previously
mentioned during ambulation and with
iritative/noxious stimuli

DVT
Common medical complication after stroke,
occurring in 20 % - & 75 % of untreated
survivors (60% - 75 % in affected
extremity, 25 % proximal DVT)

Bladder Dysfunction
Incidence of urinary incontinent is 50% - 70%
Remove indwelling catheter --- perform postvoid
residual, intermittent catheterization perform
urodynamics evaluation

Bowel Dysfunction
Incidence of bowel incontinent in stroke
patients 31%
Tx : treat underlying cause (eg; bowel
infection, diarrhea), timed-toileting
schedule, training in toilet transfer and
communication skills

Dysphagia

Incidence 30% - 45 %
67 % of brainstem strokes
28 % of all left hemispheric strokes
21 % of all right hemispheric strokes
Predictors on bedside swallowing exam of
aspiration include :
- Abnormal cough, cough after swallow,
dysphonia
- Dysarthria, abnormal gag reflex

Swallowing
Three phase :
1. Oral
2. Pharyngeal
3. Esophageal

Aphasia
Aphasia is an impairment of the ability to
utilize language due to brain damage.
Characterized by paraphasias, word finding
difficulties and impaired comprehension.
Also common, but obligatory, features are
disturbances in reading and writing, non
verbal constructional and problem solving
difficulty and imparment of gesture

Hemiplegic Gait
Anterior rotation of the
pelvis
Circumduction
Equinovarus foot
Short strides

ENERGY EXPENDITURE

STEPS OF AMBULATION TRAINING

AMBULATION TRAINING
& GAIT EXERCISES

START SLOW, GO SLOW

WALKERS

AXILLARY CRUTCHES

ENERGY EXPENDITURE >>

RAMPS, CURBS,
STAIRS

Mother
tongue

SPEECH THERAPY

GOOD
PROGNOSIS

GOOD,
MOTIVATION

COMPREHENSIVE,
WELL-PLANNED
PROGRAM

Acute phase

Acute phase

STABLE PHASE

STABLE PHASE

Disfagia Frequent and serious complication

stroke Tx oral stimulation

Constraint-induced movement therapy

(CIMT)

Intensive motor training of the

more-affected upper extremity by a
procedure termed shaping for 6
hours a day for 10 consecutive
weekdays
Motor restriction of the lessaffected hand for the full 14 days of
the intervention

Activity

Score

Feeding 0 = unable
5 = needs help cutting, spreading butter, etc., or requires modified diet
10 = independent

Bathing 0 = dependent
5 = independent (or in shower)

5 10

Grooming 0 = needs to help with personal care

5 = independent face/hair/teeth/shaving (implements provided)

Dressing 0 = dependent
5 = needs help but can do about half unaided
10 = independent (including buttons, zips, laces, etc.)

Bowels 0 = incontinent (or needs to be given enemas)

5 = occasional accident
10 = continent

5 10

Bladder 0 = incontinent, or catheterized and unable to manage alone

5 = occasional accident
10 = continent

5 10

Toilet Use 0 = dependent

5 = needs some help, but can do something alone
10 = independent (on and off, dressing, wiping)

5 10

10

Transfers (bed to chair and back)

0 = unable, no sitting balance
5 = major help (one or two people, physical), can sit
10 = minor help (verbal or physical)
15 = independent

5 10 15

Mobility (on level surfaces)

0 = immobile or < 50 yards
5 = wheelchair independent, including corners, > 50 yards
10 = walks with help of one person (verbal or physical) > 50 yards
15 = independent (but may use any aid; for example, stick) > 50 yards

5 10 15

Stairs 0 = unable
5 = needs help (verbal, physical, carrying aid)
10 = independent

TOTAL (0 - 100)

________

10

Barthel Index Classification :

1-20

: Totally dependent

21-60

: Severely dependent

61-90

: Moderate dependent

91-99

: Mild dependent

100

: Independent

The Rehabilitation program

doesnt finish when the patient
leaves the hospital, and almost all
patients benefit continued therapy.

Functional Recovery
and Disability Factors

As stroke mortality has decline in the last few

decades, the number of stroke survivors with
impairment and disabilities has increase
78 -85 % of stroke patients regain ability to walk
48 %-58 % regain independence with self care
skills
10 %-29 % are admitted to nursing homes