REHABILITATION MEDICINE

3.1 Post-Stroke Rehabilitation (Dr. Kelvin Chan)

FEU-NRMF MEDICINE BATCH 2017
Date: March 2016
--------------------------------------------------------------------------------------------------------------------------------------------------------- Predictors of EARLY death:
STROKE / CEREBROVASCULAR ACCIDENT
o impaired, loss of consciousness in 1st 24 hours
Survival Rate
o 1st: infarct 10%, hemorrhage 50%
o After 1st month: 6% per year

NON-TRAUMATIC BRAIN INJURY

2 TYPES:
o ISCHEMIC
characterized by the sudden loss of blood circulation to
an area of the brain, resulting in a corresponding loss of
neurologic function

o HEMORRHAGIC
bleeding occurs directly into the brain parenchyma; usual
mechanism is thought to be leakage from small
intracerebral arteries damaged by chronic hypertension

GENERAL MEDICAL MANAGEMENT

Make correct diagnosis
Establish causes particularly if treatable
Attempt to reduce early mortality and later disability by
maintenance of vital functions, treatment of any
systemic complications, recognition of treatment of any
cause of neurologic deterioration
Initiate secondary prevention in patients who might
benefit
Treat any coincidental disorders

RISK FACTORS:
o hypertension, diabetes mellitus
o smoking, illicit drug use
o arrhythmia and valvular disease
Most common: MCA infarct
o contralateral weakness
o sensory loss
o homonymous hemianopsia

SIGNS AND SYMPTOMS

DOMINANT hemisphere
o (usually left)
o Right hemiparesis
o Right hemisensory loss
o Left gaze preference
o Right visual field cut
o Aphasia
o Neglect (atypical)
NONDOMINANT hemisphere
o Left hemiparesis
o Left hemisensory loss
o Right gaze preference
o Left visual field cut

POST STROKE REHABILITATION

Major underlying theme:
o maximize quality of life, hollistic approach and
maximize level of independence
Key issues in ACUTE phase of stroke:
o Specialized stroke units
o Comprehensive interdisciplinary assessment
(24-48 hours)
o Safe feeding
Effective stroke care
o Coordinated interdisciplinary team
o Staff: special interest in the management of
stroke, access to ongoing professional
education and training
o Clear communication regular team meeting
o Active encouragement of patients and their
cares to active involvement in rehabilitation

Cardiac Precautions
New onset of cardio-pulmonary symptoms
Heart rate decrease > 20% of baseline
HR increase > 50% of baseline

KIM VILLANUEVA, PTRP

SBP increase to 240 mmHg

SBP decrease >/= 30 mmHg from baseline to < 90
mmHg
DBP increase to 120 mmHg

CRITERIA FOR ADMISSION TO A COMPREHENSIVE

REHABILITATION PROGRAM
Stable neurologic status
Significant existing neuro deficit
Identified disability affecting at least 2 of the ff:
o Mobility
o Self-care activities
o Communication
o Bowel, bladder control
o Swallowing
Sufficient cognitive function to learn
Sufficient communicative ability to emerge with the
therapists
Physical ability to tolerate the active program
Achievable therapeutic goal
MOBILIZATION
Within 12-24 hrs, if possible
Daily active/passive rom exercises
Progressively increased activity
Changes of position in bed
MANAGEMENT CONSEQUENCE OF STROKE
A. SENSORY MOTOR IMPAIRMENTS
Strength
o Progressive resistance exercise
o EMF biofeedback
o Electrical stimulation
o Task specific training
Sensation
o Sensory-specific training
o Sensory-related training
o Cutaneous electrical stimulation
Spasticity (Brunnstrom stages of motor recovery)
o Botulinium toxin (not permanent)
o Intrathecal baclofen (anti-spastic medication)
o Dynamic splinting
o Vibration
o Stretch
o EMG biofeedback
Contractures
o Prolonged positions in a lengthened position
(splint)
o Electrical stimulation
o Casting
Subluxation of shoulders
o Electrical stimulation (supraspinatus and
deltoid)
o Firm support device
Swelling of extremity
o Electrical stimulation
o CPM in elevation
o Pressure garments
Cardiovascular fitness
Falling

SPASTICITY
Painful and debilitating
Slightly spastic knee extensors can lock the knee during
standing or cause hyperextension (genu recurvatum),
which may require a knee brace with an extension stop.
Flexor spasticity develops in most hemiplegic hands
and wrists
o flexion contracture may develop rapidly,
resulting in pain and difficulty maintaining
personal hygiene
o range-of-motion exercises several times a day
o hand or wrist splint may also be useful,
particularly at night.
o Patients and family members are taught to do
these
exercises,
which
are
strongly
encouraged
Heat or cold therapy can temporarily decrease
spasticity and allow the muscle to be stretched
Brunnstrom Stages Of Motor Recovery
no activation of the limb
(+) spasticity; (+) weak basic flexor and
extensor synergies
Stage 3
prominent spasticity; px voluntarily moves
the limb, but muscle activation is all within
the synergy patterns
Stage 1
Stage 2

Stage 4

decline in spasticity and influence of

synergy; less restrictions; difficult easy
movement progression

Stage5

continued decline in spasticity; px able to

demonstrate isolated joint movements;
more complex movement combinations

Stage 6

(-) spasticity; near normal to normal

movement and coordination

CONTRACTURES
Hemiplegia is often associated with contractures.
Placing 1 or 2 pillows under the affected arm prevent
dislocation of the shoulder.
Posterior foot splint applied with the ankle in a 90
position prevent equinus deformity and foot drop
Reeducation and coordination exercises of the affected
extremities are added as soon as tolerated, often within
1 week.
Active and active-assistive range-of-motion exercise
o Active exercise of the unaffected extremities
must be encouraged
Most important muscle for ambulation: unaffected
quadriceps
o
If weak, this muscle must be strengthened to
assist the hemiplegic side
Posterior foot splint applied with the ankle in a 90
position prevent equinus deformity (talipes equinus)
and footdrop
B. PHYSICAL ACTIVITY
Sitting task specific activity
Stand-up from chair

KIM VILLANUEVA, PTRP

Standing tilt table

Walking
o joint position feedback
o cueing of cadence
o treadmill
o multichannel electrical stimulation
Transfers
Gait re-training
Upper limb activity

FUNCTIONAL ELECTRICAL STIMULATION (FES)

generate muscle contraction to perform a task
Bursts of high intensity electrical impulses via surface
of the body in stimulated nerves
ARMin-ROBOT ASSISTED
Movement: prevent joint degeneration & preserve joint
mobility
ADL therapy
GAME therapy

C. ACTIVITIES OF DAILY LIVING: Occupational Therapy

D. COGNITIVE CAPACITY
Attention and concentration cognitive therapy
Memory external cues and prompting
Executive function external cues
E. VISUOSPATIAL
Visual function
o prism glasses
o computer-based visual restitution
Agnosia
Neglect
o Cognitive rehabilitation
Apraxia
o strategy training
Aphasia
o group therapy
o speech therapy
o augmentative
alternative
communication
device
COMMUNICATION
Aphasia
o Intervention

Use of gestures

Constraint induced
o Enhance treatment

Supported conversation technique

Computer-based therapy
Dyspraxia
DYSPHAGIA
Compensating strategy
o Positioning
o Therapeutic maneuver
o Modify food and fluids
Adjunctive method
o shaker therapy
o Thermo-tactile stimulation
o Electrical stimulation
MULTIMODAL
REACTIVATION
OF
SENSORIMOTOR
MECHANISM
Provide afferent proprioceptive feedback
Motor planning and execution areas by embedding the
movement in task oriented areas
Stimulate motor planning areas by directing attention to
a task and encouraging rehearsal of intended
movements

VR-BASED INTERACTIVE COGNITIVE THERAPY

Mirror neurohypothesis
Stimulate action observation system that could encourage
plasticity and repair

COMPLICATIONS
Neurologic(toxic or metabolism)
Medical
o Pulmonary
aspiration/pneumonia,
UTI,
Depression, Musculoskeletal
Aspiration Pneumonia
o Oral stimulation; Patient should me sitting
upright with forward; Modifying consistency of
food from pureed liquid to thickened liquid;
NGT if swallowing is not safe
UTI (common because of neurogenic bladder)
Musculoskeletal Pain
o shoulder and arm pain develops early, several
weeks to 6 months post onset
Shoulder subluxation
o Due to weak supraspinatus and deltoid muscle;
Managed by placing lap board; Stimulating
weak muscles; Relaxing the shoulder depressor
and internal rotator
Reflex Sympathetic Dystrophy
Deep Vein Thrombosis
INDICATORS OF POOR PROGNOSIS
Proprioceptive facilitation > 9 days
Traction response of shoulder flexors/adductors >13
days
Prolonged flaccid period
Onset of motion >2-4 weeks
Severe proximal spasticity
Absence of voluntary hand movement >4-6 weeks
FACTORS PREDICTIVE OF POOR ADL
severity of stroke
o severe weakness
o poor sitting balance
o visuospatial deficits
o mental changes
o incontinence
o low initial ADL scores
time interval: onset to rehabilitation
advance age

KIM VILLANUEVA, PTRP

APHASIA

STUDY THIS DIAGRAM LUMALABAS SYA SA SAMPLEX

TYPES

FLUENCY

COMPREHENSION

REPETITION

GLOBAL APHASIA
MIXED
TRANSCORTICAL
APHASIA
BROCAS APHASIA
TRANSCORTICAL
MOTOR APHASIA
WERNICKES APHASIA
TRANSCORTICAL
SENSORY APHASIA
CONDUCTION
APHASIA
ANOMIC APHASIA

IMPAIRED
IMPAIRED

IMPAIRED
IMPAIRED

IMPAIRED
GOOD

IMPAIRED
IMPAIRED

GOOD
GOOD

IMPAIRED
GOOD

GOOD
GOOD

IMPAIRED
IMPAIRED

IMPAIRED
GOOD

GOOD

GOOD

IMPAIRED

GOOD

GOOD

GOOD

THANK YOU DOYENNE SADICON!

KIM VILLANUEVA, PTRP