Stroke Rehabilitation

1. Stroke Rehabilitation พญ.พรพิมล มาศสกุลพรรณ สถาบันประสาทวิทยา 2 / 4 / 2008

2. National Stroke Association • 10% of stroke survivors recover almost completely • 25% recover with minimal impairment • 40% experience moderate to severe impairments that require special care • 10% require care in a nursing home or other long-term facility • 15% die shortly after the stroke • Approximately 14% of stroke survivors experience a second stroke in the first year following a stroke

3. Effect of a Stroke • 1. Weakness on the side of the body opposite the site of the brain affected by the stroke • 2. Spasticity, stiffness in muscles, painful muscle spasms • 3. Problems with balance and/or coordination • 4. Problems using language, including having difficulty understanding speech or writing(aphasia); and knowing the right words but having trouble saying them clearly (dysarthria) • 5. Being unaware of or ignoring sensations on one side of the body (bodily neglect or inattention) • 6. Pain, numbness or odd sensations

4. Effect of a Stroke (con’t) • 7. Problems with memory, thinking, attention or learning • 8. Beingunaware of the effects of a stroke • 9. Trouble swallowing (dysphagia) • 10. Problems with bowel or bladder control • 11. Fatigue • 12. Difficulty controlling emotions (emotional lability) • 13. Depression • 14. Difficulties with daily tasks

5. Rehabilitation Goal • To restore lost abilities as much as possible • To prevent stroke-related complications • To improve the patient's quality of life • To educate the patient and family about how to prevent recurrent strokes • Promote re-integration into family, home, work, leisure and community activities

6. Successful Rehabilitation Depend on - how early rehabilitation begins - the extent of the brain injury - the survivor’s attitude - the rehabilitation team’s skill - the cooperation of family and caregiver

7. Basic Principles of Rehabilitation • To begin as possible early (first 24 to 48 hours) • To assess the patient systematically (first 2-7 day) • To prepare the therapy plan carefully • To build up in stages • To include the type of rehabilitation approach specific to deficits • To evaluate patient’s progress regularly

8. Multidisciplinary Team • Rehabilitation specialist • Physical, occupational and speech therapist • Social worker • Dietician • Recreational therapist • Psychologist • Vocational rehabilitation counsellor • Nurses • Orthotist • Patient, caregiver

9. Early Mobilisation • If patient's condition is stable, however, active mobilisation should begin as soon as possible, within 24 to 48 hours of admission • Early mobilisation is beneficial to patient outcome by reducing the complication • It has strong positive psychological benefit for the patient • Specific tasks (turning from side to side in bed, sitting in bed) and self-care activities (self-feeding, grooming and dressing) can be given for early mobilisation.

10. Rehabilitation Management • Mobility • Activity of daily living • Communication • Swallowing • Orthosis • Shoulder pain • Spasticity • Cognitive and perception • Mood • Bowel and bladder incontinence

11. 1. Mobility • Physiotherapy • Conventional therapies • Neurophysiological therapies

12. Conventional therapiesTherapeutic ExercisesTraditional Functional Retraining • Range Of Motion (ROM) Exercises • Muscle Strengthening Exercises • Mobilization activities • Fitness training • Compensatory Techniques

13. Neurophysiological Approaches • 1. Muscle Re-education Approach (1920S) • 2. Neurodevelopmental Approaches (1940-70S) • Sensorimotor Approach (Rood, 1940S) • Movement Therapy Approach (Brunnstrom, 1950S) • NDT Approach (Bobath, 1960-70S) • PNF Approach (Knot and Voss,1960-70S) • 3. Motor Relearning Program for Stroke (1980S) • 4. Contemporary Task Oriented Approach (1990S)

14. Aim • Improve • Movement • Balance • coordination • Safety

15. Basic Physical Therapy • Bed positioning, mobility • Range of motion exercises (ROME) • Sitting/trunk control • Transfer • Walking • Stair climbing

16. Treadmill training with body weight support

17. Robotics

18. 2. Activity of daily living • Occupational therapy • Self care Dressing Grooming Toilet use Bathing Eating • Adapt or specially design device

30. 3. Communication • Speech and language therapy • Common communication disorder • Aphasia *Receptive - auditory - reading *Expressive - speaking - writing *Global *Anomic - forget interrelatedgroups of words • Dysarthria

31. Goal of treatment • Facilitate recovery of communication develop strategies to compensate - Gesture - Picture - Communication board - Computer

36. 4. Swallowing • Dysphagia : abnormal in swallowing fluids or food • Increase risk of pneumonia and malnutrition

37. Treatment • Posture change • Heightening sensory input • Swallow maneuvers • Active exercise • Diet modification

38. 5. Orthosis • Shoulder slings • Hand splint • Foot slings • Ankle foot orthosis

39. Shoulder slings

40. Shoulder slings

41. Hand splints • Flaccid = functional position • Wrist extend 20 – 30 degree • Flex MCP joint 45 degree • Flex PIP joint 30 - 45 degree • Flex DIP joint 20 degree

42. Hand splints

43. Foot slings

44. Ankle Foot Orthosis - Plastic • Metal • stability of ankle • balance • speed walking • Not enhance recovery

45. Ankle Foot Orthosis Metal AFO Plastic AFO

46. 6. Shoulder pain • Sensorimotor dysfunction of upper extremities • 72% of stroke patient in first year • Delay rehabilitation

47. Treatment • Electrical stimulation • Shoulder strapping • Mobilization (esp. External rotator, abduction) prevent frozen shoulder, shoulder hand pain • Medical • Intraarticular injections • Modalities : ice, heat, massage • Strengthening

48. 7. Spasticity • Velocity dependent hyperactivity of tonic streth reflexes

49. Aim of treatment • Pain • ROM • Cosmatic • Hygiene • Mobility • Easy use orthosis • Delay surgery

50. Treatment • Avoid noxious stimuli • Positioning, passive stretching, ROME • Splinting, serial casting, surgical correction • Medical - tizanidine - baclofen - dantrolen - avoid diazepam • Botulinum toxin A injection • Phenol / alcohol • Neurosurgical procedure (selective dorsal rhizotomy)