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Stroke rehabilitation: Traditional and modern approaches

Article in Neurology India · January 2003

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Neurology India
Medknow Publications on behalf of the Neurological Society of India
ISSN: 0028-3886
Vol. 50, Num. s1, 2002, pp. S85-S93

Neurology India, Vol. 50, (Suppl. 1), Dec, 2002, pp. S85-S93

Stroke Rehabilitation : Traditional and Modern Approaches

K.P.S. Nair,* A.B. Taly

Departments of Neurology and Psychiatric and Neurological Rehabilitation*, National Institute of

Mental Health and Neurosciences, Bangalore - 560 029, India.
Correspondence to : Dr. K.P.S. Nair, Departments of Psychiatric and Neurological Rehabilitation,*
National Institute of Mental Health and Neurosciences, Bangalore - 560 029, India.

Code Number: ni02168

Summary

The recovery from stroke is often slow and incomplete, leading to partial or complete loss of
locomotion, activities of daily living (ADL), cognition and communication skills. Aim of stroke
rehabilitation is to reduce the disabilities and enable the patient to return to community, which is
achieved by joint efforts of physicians, physiotherapists, occupational therapists, speech therapists,
nurses, social workers and psychologists. Rehabilitation of a stroke patient begins as soon as any
impairment is perceived and comprises traditional exercise programmes and neuropsychological
approaches with the primary aim of restoring mobility of patient. It also deals with issues related to
dysphagia, bowel and bladder care, shoulder dislocation, pressure sores, and prevention of deep
venous thrombosis. A good rehabilitation programme helps in promoting natural recovery, preventing
complications due to disabilities and adapting to disabilities.

Key words : Stroke, Rehabilitation.

Introduction

Stroke is a leading cause of long term disability in community as about 30 to 50% of the patients who
sustain a stroke are left with considerable residual deficits.1-3 A hospital based study done at National
Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India, showed that 57% of
subjects with stroke had moderate to severe disability at the time of discharge.4 The post stroke
disabilities are due to loss of locomotion and activity of daily living (ADL), cognition and
communication skills. These subjects often suffer from multiple disabilities and hence, require a
multidisciplinary team approach through physicians, physiotherapists, occupational therapists, speech
therapists, nurses, social workers and psychologists. Aim of stroke rehabilitation is to reduce the
disabilities and enable the patient to return to community.5

Natural history and biological basis of recovery

During the first week after the stroke 78-90% patients are dependent in some aspect for ADL. At six
months 40-62% and at one year 33-59% continue to remain dependent. In general, motor recovery is
fastest during early weeks and tends to plateau after eight to twelve weeks. Significant recovery can
occur up to six months and exceptionally upto two years or more after stroke.6 The exact mechanisms
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underlying recovery from stroke are not completely understood. The initial improvement occurs due to
resolution of edema and restoration of circulation to 'ischaemic penumbra'. Restoration of functions
occurring after initial four to six weeks is attributed to various factors like dendritic sprouting,
synaptogenesis, restoration of axonal transport, remyelination, unmasking of alternate pathways,
redevelopment of cortical inhibition, resolution of diaschisis, alteration in neuro transmitters and
bilaterality of brain functions.6-10 Many studies in animals have shown that recovery after cortical
injury occurs due to shift of functions to neighbouring areas. Similar functional reorganisation has
been demonstrated in human brain after stroke. However this neuronal reorganisation can be
maladaptive and can result in spasticity and seizures. Animal and human studies have shown that
quality of recovery can be improved by forcing the subject to use the affected limb more. About 10-
30% of fibres of pyramidal tract are uncrossed. Even some of the crossed pathways connect to
ipsilateral neurons through spinal interneurons. Vestibulospinal and reticulospinal tracts also connect
to motor neurons ipsilaterally. Chollet et al demonstrated that these ipsilateral motor pathways play a
role in recovery after stroke.11 Premotor area, supplementary motor area, sensory areas, basal ganglia
and cerebellum influence primary motor area through many neuronal networks. Some of these parallel
networks may be relatively spared and may play a role in recovery.

Several drugs adversely affect natural recovery after stroke. Drugs that antagonize the norepinephrine
system like haloperidol and phenoxybenzamine have been shown to delay the recovery after ischaemic
injury. It is not clear whether these effects are due to their action on norepinephrine or dopamine
system. Various other drugs like phenytoin, clonidine, alpha methyl dopa and scopolamine also delay
the recovery. Gamma amino butyric acid (GABA) and serotonin are major inhibitory transmitters in
central nervous system. Levels of both GABA and serotonin increase following cerebral ischaemia.
Drugs like benzodiazepines which facilitate GABA system interfere with recovery following stroke.6
Use of these drugs should be minimised in patients with stroke.

Natural recovery is often incomplete and depends on various factors like severity of stroke, presence
of comorbid conditions, and type of deficits.6 Prolonged flaccidity and absence of response to
proprioceptive stimuli after 10 days indicate poor natural recovery. Hemianaesthesia, hemianopia,
incontinence, prior stroke and older age are associated with poor locomotor recovery. Recovery of arm
functions is less than that of leg. Absence of measurable grip after four weeks is associated with poor
recovery. These patients survive for many years with disabilities and need long-term rehabilitation and
care.

Rehabilitation

First step of stroke rehabilitation is assessment, which involves identification, measurement and
recording of the impairment, disability, handicap, patients' needs and medical problems. Routine use
of outcome measures help in assessing effectiveness of the program, discharge planning,
communication between team members and staffing.12 An ideal assessment scale must measure all
different aspects of stroke, and should be valid, reliable, sensitive to changes, simple, short and
applicable by all members of rehabilitation team.13 Outcome of stroke rehabilitation depends to an
extent on nature and severity of impairment. Changes in impairment also provide an indication of
efficacy of therapeutic interventions in acute stroke. Various impairment scales measure different
aspects like motor power, tone, sensations, language, cognition, range of motion, visual fields, ataxia
and function of unaffected side. Commonly used stroke impairment scales include Brunnstrom-Fugl-
Meyer assessment, Chedoke-McMaster stroke assessment, Stroke impairment assessment set, Motor
assessment scale, Toronto stroke scale, Mathew stroke scale, National Institute of Health stroke scale,
Canadian neurological scale, Orgogozo score and hemispheric stroke scale. Various areas requiring
assessment in a stroke patient are activities of daily living (ADL), social functioning, intellectual
functioning, perception, speech, mobility, gait and arm functions.1 Scales used in assessment of
disabilities in stroke include motricity index, trunk control test, Rivermead mobility index, Frenchay
arm test, Nine hole peg test, Frenchay aphasia screening test, Mini-mental status examination, Barthel
index and Functional independence measure.3

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The process of stroke rehabilitation consists of "active" rehabilitation and 'preventive' rehabilitation.
Active rehabilitation promotes intrinsic and adaptive recovery to achieve best possible functional
outcome. Preventive rehabilitation includes early intervention, prevention and treatment of
complications and modification of risk factors.14

Active rehabilitation

Rehabilitation of a stroke patient begins as soon as any impairment is perceived. Passive range of
motion exercises to the paretic limb should be started at the earliest. Full range of motion of each joint
at least once a day is enough to prevent contractures. Occupational therapist can begin teaching single
handed techniques for feeding, grooming and dressing during the first week itself, depending on
patient's level of alertness and physical health. Once the stroke patient is medically stable and able to
tolerate being out of the bed, various therapeutic interventions can be started. Based on the knowledge
of natural recovery a number of techniques have been tried to augment the process of recovery of
motor control.

Physical therapy

Physical therapy is an important intervention helping the motor recovery of stroke patients. This can
be divided broadly into Traditional exercise programmes and Neurophysiological approaches.

Traditional exercise programmes

These exercises prevent complications of immobilization and improveADL skills at the earliest.
Functional independence can be obtained through maximal utilization of the sound side of the body.
These exercises can be divided into passive range of motion exercises and active joint by joint
exercises. In passive range of motion exercises the therapist or the caregiver moves various joints
passively through their entire range of motion. This helps in preventing contracture and development
of abnormal postures. In active exercises the patient actively moves the joints. These may be either
isotonic or isometric exercises. Initially patients attempt simple movements, and subsequently
complex movements and actions are tried. Multiple repetitions of the same movement help in motor
relearning.

Neuro-physiological approaches

These techniques are based on neurophysiological principles of motor control and recovery. The basic
principals of neurophysiological approaches are: a) application of sensory stimuli to facilitate or
inhibit an activity, (b) patient evaluation and treatment plans based on milestones of developments, (c)
utilization of reflexes to facilitate or inhibit any motor activity, (d) utilization of concepts of motor
relearning such as repetition, (e) focus on patient as a whole and (f) close interaction between the
therapist and the patient.15 These approaches stress on enhancement of the natural recovery process.
Various neurophysiological approaches include proprioceptive neuromuscular facilitation technique
(PNF), Bobath's neuro developmental approach, Brunmstorm's technique and Rood's approach.16 Each
of these therapies have advantages and limitations. Studies comparing traditional exercise programmes
and neurophysiological techniques have failed to show distinct differences in outcome.17,18 None of
these therapies have any proven superiority over others.19,20 Each of these techniques try to facilitate
recovery of motor control through different strategies. They can be integrated and used based on the
requirements of the patient, experience of the therapist and stage of motor recovery.15

Functional electrical stimulation (FES)

Electrical stimulation of the nerves result in contraction of muscles supplied by them. This technique
can be used to improve the muscle strength, control the movements, bowel, bladder and sexual
functions, maintenance of posture, standing and walking. FES is becoming popular in the treatment of
shoulder subluxation, spasticity and weakness of upper and lower limbs in hemiplegic patients. The
most useful technique is peroneal nerve stimulation to correct foot drop during swing phase of gait.
The common peroneal nerve is stimulated at the head of the fibula so as to cause eversion and

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dorsiflexion of the foot. The switch is under the heel of the affected leg. From heel off to heel strike
phase of gait the stimulator is switched on.21 Constant stimulations of quadriceps can be used to make
the patient stand. Reciprocal sequential stimulation of various leg muscles involved in walking is
possible now for making the patient ambulant. In FES, patient uses his own muscles, joints and bone
support for activities. This prevents muscle atrophy, bone demineralization and joints contractures.
FES helps in reducing the time spent by the therapists with individual patient. It is cosmetically
attractive than usual orthotic and assistive devices. Patients should be motivated and cooperative. FES
is contra-indicated in patients with obesity, marked spasticity, joint contracture, dysautonomia and
serious medical problem. The device is very expensive. The procedure is often painful and patient may
develop fatigue of muscles after repeated stimulation.

Electromyographic biofeedback

This is a technique by which subject is made aware of activity of muscles for better self regulation of
the motor functions.22 The activity of muscles are picked up using surface or needle electrodes. They
are converted into audio or visual signals for the patient. By this technique, patient can be taught to
relax or contract the muscles. Later, the same can be used to teach joint motion and co-ordinated
movement patterns. This technique uses intact auditory and visual pathways and helps to establish new
mechanism of motor control. The movements are normally stored as anagrams in cortical association
areas. EMG biofeedback helps to recall these anagrams using the auditory and visual cues.
Psychologically subject improves the performance by knowing the results of previous activity. Each
session lasts for 40 to 60 minutes. About 20 to 30 such sessions are needed for one patient.23 The
technique is useful for strengthening tibialis anterior, quadriceps, hamstrings and upper extremity
muscles. Kraft et al evaluated the use of EMG initiated electrical stimulation to improve arm and hand
functions in chronic hemiplegia. The authors suggested that combination of electrical stimulation with
voluntary effort improve the functional outcome.24

Ambulation and Gait training

The most frequently stated functional goal of stroke patients is restoration of ability to walk. During
the initial phases stroke patient can be kept on a firm mat and trained on range of motion exercises,
turning, side lying, limb movements and sitting balance. Once a patient is able to turn on the mat and
sit unsupported, it is possible to begin ambulation training. Ambulation is initiated at a hip-level fixed
hemibar about 15-20 feet in length. The patient should stand with hemiplegic side away from the bar
and practice moving from sit to stand, standing endurance and weight shifting. The patient is initially
supported between the hemibar and the therapist. After this stage, therapist can stand slightly behind
the patient and with his knee, advance the affected leg forwards. Once the patient is able to negotiate
25-50 feet at hemibar without any assistance from the therapist, he can be put on a quadruped cane.
This cane is held in the intact upper extremity. Patient is taught to advance the cane first and then the
affected leg. The quadruped cane provides more stability than the standard cane but less support than
the rigid hemibar. When the patient is walking with the quadruped cane and shows adequate gait, cane
sequence, balance and endurance, a standard cane can be substituted. Patient should be trained on stair
climbing during this period. Patient is taught to step up with the normal foot and down with the
affected one. Techniques for turning and negotiating uneven and out-door surfaces should be imparted
at this time. The family members should be encouraged to assist in ambulation. Both patient and
family members should get familiar with the process of ambulation and should be confident in
managing transfers, stairs, bathrooms and toilets. If possible, before discharge the patient should spend
several days at home to familiarize with the hemiplegic ambulation in real life surroundings. As the
patient is improving in his gait, bracing requirements will come up. Braces have to be prescribed
according to the patient's needs. Foot ankle brace for foot drop, long leg brace for knee buckling and
knee ankle combination braces may be used according to the requirement. As the patient improves, the
braces have to be modified in consultation with physiatrist, orthotist and the patient. As they start
walking, minor arthritic symptoms are likely to appear. These can be managed with nonsteroidal anti-
inflammatory drugs.25

Several new therapeutic strategies like 'kinetron' for reciprocal stepping motions, bicycle ergometer
and treadmill are being tried to improve the gait. The potential of treadmill to improve the locomotor
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abilities is only recently identified. Energy consumption, electromyographic changes and kinematic
data of the legs are similar during ground walking and treadmill testing. Waagfjord et al studied the
effects of treadmill training programme on the gait of a single hemiplegic patient three years after
stroke and found that base of support and step length improved after the programme.26 Dobkin et al
noted beneficial effects on gait symmetry and walking speed after treadmill training.27 Treadmill
training and posturography have opened up new avenues in evaluation and management of locomotor
problems of stroke patients.

Patients who fail to achieve functional ambulation must be taught to use wheel chair. The wheel chair
requirements of a hemiplegic patient are different from that of a paraplegic individual. The hemiplegic
wheel chair has a lower sitting base compared to normal standard wheel chairs so that patient can use
his unaffected leg to assist with wheel chair propulsion and guidance. A wheel chair with a reclining
backrest should be used for patients with poor truncal balance. Patients with orthostatic hypotension
and cardiopulmonary problems may not be able to use ordinary wheel chairs. Some of them may
benefit from a lightweight wheel chair. Motorized wheel chair is not ideal for stroke patient as visual
neglect; hemianopia, cognitive deficits and reduced reaction time may interfere with wheel chair
control. These patients must be taught how to transfer from bed to wheel chair and back. They must
also be able to transfer from wheel chair to toilet. Stand pivot transfer technique allow an otherwise
feeble elderly spouse to transfer the patient safely without strain. This technique makes maximal use
of body mechanics for safe and easy transfer of patients with hemiplegia.

Activities of daily living

One of the major objectives of stroke rehabilitation is to regain functional independence for ADL. If
the affected arm and hand is not used in ADL training, the motor recovery is delayed and incomplete.
From the onset of illness itself patient's arm should be kept mobile. Flexor arm positions should be
avoided as flexor contracture can interfere with the use of the limb even after motor recovery. When
falling towards the hemiplegic side, patients may be unable to use the upper limb to protect
themselves. Stimulation of extensor activity helps such patients during falls. The actual objects and
real life events will help in retrieval of movement patterns from memory. When some active
movements return to the affected limb, the patient should repeatedly perform these. In the absence of
active movements the limb can be guided through the movements of ADL as a therapy. The sensations
associated with such movements help in motor recovery. Use of arm and hand in simple tasks such as
dressing is the best way to facilitate motor recovery.28 Patients can be taught hemiparetic dressing
technique, which begins on hemiplegic side first. Patient must have adequate truncal balance and
ability to lean forward without falling. Velcro closures, pullovers and front buttoning clothing are
some of the adaptive measures, which assist the patient to dress independently. Similarly self-feeding
can be helped with the use of friction plates, rocker knives and other modified utensils. For grooming
also, different techniques and assistive devices are available. An occupational therapist can train the
patient in ADL and use of various assistive devices.29

Dysphagia

Dysphagia can impair hydration and nutrition and predispose to aspiration and respiratory
complications. Oral feeding ability of all stroke patients should be formally evaluated.30 The first step
is to examine the power and co-ordination of labial, lingual, buccal, pharyngeal and vocal cord
movements. While swallowing, palpate the pharyngeal and laryngeal muscles and feel for
contractions. Coughing or hoarseness of voice within a minute after drinking 90ml of water is a good
predictor for aspiration.14 A quantitative and qualitative assessment of dysphagia can be made by
video-fluoroscopy while patient swallows barium of different consistency. Pharyngeal transit times
provide a quantitative analysis of dysphagia.31 Effect of head and body posture should also be
documented. Vocal cord movements and functions can be evaluated by laryngoscopy. Patients can be
taught various sucking and tongue manipulation exercises, supraglottic cough and dry cough
sequences and compensating head and neck postures to assist swallowing. Patients suffering from
pseudobulbar dysphagia can be put on diet of pudding consistency while those with bulbar dysphagia
require tube feeding. Patients with facial weakness cannot suck and have drooling. Such patients can
be put on a soft solid diet that does not require much of suction and mastication. All stroke patients
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should take feeds only while sitting upright with head in slight flexion. Patients on nasogastric tube
should be fed with head end elevated by 30o during and for two hours after each feed. Complications
of nasogastric tube are epistaxis, gastric reflux, decreased pharyngeal sensation, displacement into
trachea, perforation of oesophagus, oesophageal strictures and oesophago-tracheal fistulae.32 The tube
placing should be checked before and after feeds. Most patient with unilateral hemispheric lesions can
swallow effectively within first three weeks after stroke. If nasogastric tube feeding has to be
continued beyond four weeks after stroke feeding, a percutaneous endoscopic gastrostomy (PEG) may
be required.32 Feeding gastrostomy is most commonly needed for patients with bihemispheric stroke,
unilateral lesions of the sylvian fissure and ponto-medullary infarcts.14 Complications of PEG are
abscess, necrotising fascitis, aspiration pneumonia, peritonitis, perforation, gastro-colic fistula,
haemorrhage and tube displacement.32

Bladder dysfunction

Bladder dysfunction is common among stroke patients but the location and size of the lesion do not
accurately predict the presence or type of bladder problem. The incidence of incontinence depends on
the interval between the stroke and evaluation. The reported figures are: 1st week - 60%, 6th week -
42%, and 12th week - 29%.33 The bladder dysfunction in a stroke patient may be due to inability to
communicate, immobility, dementia or neurogenic bladder dysfunction.34

Incontinence with normal urodynamic studies can be due to aphasia, dementia or immobility and can
be helped by a scheduled voiding programme. The patient is encouraged to pass urine once every four
hours by placing him on a bedside commode or taking him to urinal. If not beneficial, an external
collecting device like a condom catheter for men may be used.

If urodynamic study shows a hypotonic bladder, the detrusor contractions can be augmented with
Crede's technique and valsalva manoeuvre. If these noninvasive measures do not help, clean
intermittent catheterization should be done once in every six to eight hours. The bladder volume
should not be allowed to exceed 500 cc. Continuous drainage with indwelling Foley's catheter should
be avoided. These patients may also be benefited from cholinergic medications like urecholine and
bethanachol. The newer treatment methods of these patients include functional electrical stimulation
of bladder and pelvic nerves. In patients with detrusor irritability, scheduled voiding and
anticholinergic drugs like propantheline, oxybutinin and imipramine may be tried. However, they
should be avoided in patients with outlet obstruction or dementia.

The obstruction of bladder outlet may be mechanical due to hypertrophy of prostate and can be helped
with minor surgical procedure. Obstruction can be due to increased tone of the internal urethral
sphincter and can be helped with alpha-blockers like phenoxybenzamine or prazosin. If obstruction is
due to increased tone of the external sphincter, antispasticity drugs like baclofen, local injection of
botulinum toxin or sphincterotomy may help.34 Problem of incomplete voiding can be confirmed by
catheterization, immediately after voiding. If the volume of residual urine is more than 100 ml,
intermittent catheterization once every 6 hours may be done. Continuous indwelling catheter should be
avoided except in patients with prostatic hypertrophy waiting for surgery or those who cannot be kept
dry inspite of intermittent catheterization.

Bowel care

Constipation is common after stroke and can be prevented by including about 40-70 gm of fibre in the
diet daily. These agents include bran, methylcellulose, Ispaghula husk and sterculia. They should be
introduced gradually and only after cleaning impaction. Side effects include bloating, flatulence and
increased thirst. A bowel-training program may also help to regulate bowel movements. Regime
followed in our centre is as follows : Give the subject 200 to 250 ml of hot liquid to drink in the
morning. Position them on left lateral position and massage left lower quadrant of abdomen to
facilitate gastro-colic reflex. After 30 minutes make the patient sit on a bedside commode or toilet.
Patients feel more comfortable in toilet or bedside commode rather than with a bedpan. Subject should
be well supported. They should lean forward with feet slightly raised to put pressure on abdomen.
Foot blocks will help to position the legs in this position. Maintain this position for 20 minutes or
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patient gets a complete bowel movement. It may take one or two weeks to initiate a successful bowel
movement by this program. Gentle digital stimulation of rectal wall with glove finger for a minute also
helps in stimulating emptying. Rotate a gloved finger in anus until rectal wall is felt to relax or flatus
is passed and stool comes down. Stop after one minute and repeat until stool stops coming during two
successive stimulations. Rectal suppositories help to time the stool evacuation. Manual placement of
suppository stimulates the bowel wall physically. The suppository must be in direct contact with the
bowel wall to be effective. With the passage of stools, the suppository is also evacuated, thus the
problem of diarrhoea as with oral laxatives can be avoided. Patients with faecal impaction may require
enema, laxatives and occasionally manual evacuation. About 30% of patients with stroke suffer from
bowel incontinence at the time of admission and 10% at six months after stroke.35 Risk factors for
persistent faecal incontinence after stroke include older age, women, severe motor deficits and
diabetes. The incontinence is ascribed to limited mobility, failure to control defecation, inability to
request assistance and lack of concern. Management options include bowel scheduling, rewarding
maintenance of continence and provision of simple devices like bells to seek assistance for defecation.
Subjects with intractable incontinence will require pads and pants or a stoma. Containment products
like pants are often unsatisfactory. Toileting is difficult for people with severe physical disabilities
following stroke. This also restricts their personal, vocational and social activities. A colostomy or
ileostomy may provide containment, control over bowel management, reduce the time spend on bowel
care and improve quality of life.

Preventive rehabilitation

Various studies report that 56-95% of patients undergoing inpatient stroke rehabilitation develop
medical complications.36,37 These complications adversely affect outcome and prolong hospital stay.
These complications include pressure sores, deep venous system thrombosis, shoulder pain and
contractures. Most of these complications are preventable. Protocols for prevention, early detection
and treatment of common medical complications should be integral part of any stroke rehabilitation
programme.

Pressure sores

Pressure sores are common in elderly, undernourished and immobile stroke patients. Shearing forces
induced by pulling the patient across the uneven bed, local friction and moisture predispose to
pressure sores. Conventionally pressure sores are described in various stages. Stage I-non blanchable
erythema of intact skin. Stage II-Partial thickness skin loss, Stage III-full thickness skin loss, stage
IVextension into muscles and bones.38 Pressure sores often develop over lateral malleolus of an
externally rotated hemiplegic leg, sacrum, coccyx and greater trochanter in bed patients. In a patient
who can sit, the skin covering the ischial tuberosities is particularly vulnerable. The pressure sores can
be prevented by avoiding continuous pressure over bony prominences, changing the position once
every two hours, avoiding friction and moisture over the skin and proper positioning of the limbs
using sand bags. If there is a persistent localized skin erythema patient must be kept on pressure
relieving surfaces like waterbed or alternating pressure mattress. Wheel chairs should have egg crate
cushions to sit. The stroke patient with pressure sores must be put on a high protein diet supplemented
with zinc and vitamins. Some patients with severe sores require wound debridement, antibiotics and
plastic surgery.

Deep venous thrombosis (DVT)

This is one of the major preventable complications. I125 labelled fibrinogen leg scans of patients with
hemiplegia have shown evidence of DVT in 30-75% during the first week after stroke.14 About 5% of
the deaths in stroke patients are due to pulmonary embolism. The DVT can be prevented with
intermittent compression of calf muscles of the paretic leg, passive range of motion exercises and low
dose heparin or low molecular weight heparinoids. Consensus conference on prevention of venous
thrombosis and pulmonary embolism recommended low dose heparin prophylaxis for all patients with
non-haemorrhagic strokes and external pneumatic calf compression for the rest. The clinical signs and
symptoms of DVT are pain, tenderness, edema, discolouration and venous dilation of the affected
extremity. The other signs are pain over calf on dorsiflexion of the foot and presence of palpable cord
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like thickened veins. However, these clinical signs and symptoms are neither sensitive nor specific.
The objective tests used for confirming DVT include venography, impedance plethysmography,
doppler ultra sound scanning, magnetic resonance imaging and fibrinogen uptake test. Among
laboratory tests proposed as screening technique for detection of DVT, assay of D-dimer, a fibrin
degradation product is most promising.39 Treatment of DVT includes general and specific measures.
The general measures are: bed rest, elevation of the foot of the bed by 18", and nonsteroidal anti-
inflammatory drugs. Once specific measures are started the patient can be mobilized. Prior to
ambulation patient is given graduated compression stockings. The specific therapies available for
DVT are heparin, low molecular weight heparinoids, oral anticoagulants, thrombolytic agents and
ancrod. Once the acute phase is over, secondary prophylaxis with oral anti-coagulants or subcutaneous
heparin is employed. In selected cases, surgical interventions like thromebectomy, interruption of
inferior vena cava or insertion of a caval filter may be needed.

Shoulder pain

Around 75% of subjects with hemiplegia suffer from shoulder pain. This limits arm function and
interferes with therapy and sleep.25 Shoulder pain is due to excessive traction, subluxation, biceps
tendonitis, capsulitis, rotator cuff tear, myofascial pain, brachial plexopathy, suprascapular neuropathy,
heterotopic ossification, osteoporosis, fractures, contractures, over use, degenerative changes, reflex
sympathetic dystrophy, spasticity or flaccidity. Investigations include X-rays, MRI and bone scan.
Various modalities of treatment tried are non-steroidal antiinflammatory drugs, range of motion
exercises, therapeutic ultrasound, local injection of steroids and anaesthetics, transcutaneous electrical
nerve stimulation and stimulation of deltoid and supraspinatus muscle.

Positioning

Aim of positioning is to prevent development of abnormal posture, spasticity and contractures. Normal
anatomical alignment of head, trunk and limbs should be maintained.25 Limbs must be positioned
away from the direction of pull of spasticity. Hip and knee should be slightly bent with leg rolled
towards midline and arm rolled outwards with elbow, wrist and fingers straight and palm facing
outward with thumb pointing away from the body. Positioning is extremely important while patient is
lying on back as this is the position which facilitates development of spasticity. While lying on the
back, head tends to fall back resulting in extension of spine and internal rotation of shoulders. The hip
and knee will be extended with plantar flexion at ankle and leg will be externally rotated. When lying
on back, the head and affected shoulder should be well supported with pillows so that the arm is
slightly raised and rolled outwards with elbow and wrist extended and thumb pointing away from the
body. The hip must be supported with a pillow with hip and knee slightly bent with leg rolled towards
midline.40 While lying on normal side, the affected arm should be supported with pillows with 90
degrees flexion at shoulder. The hip and knee should be supported in slight flexion. Lying on the
affected side is very uncomfortable for the patient and will damage the affected shoulder joint. The
shoulder and arm should be placed well forward so that patient's body will not rest on affected
shoulder or arm. The affected leg should be flexed at knee and hip and normal limb should roll over
the affected limb. This will help to keep the hip internally rotated and straight. During sitting, head
and trunk should be in a straight line and body weight should be distributed equally between two
buttocks. The hips should be placed as back in the chair as possible. Keep the affected arm slightly
forwards on a wedge pillow The wrist and fingers should be supported by the pillow and should not be
allowed to hang unsupported. Place both feet flat on footrest.40

Outcome

Factors favouring a good outcome are good family support and financial status, higher social and
educational levels, early initiation of rehabilitation programme and expertise of the centre with stroke
rehabilitation. Patients with low motivation, confusion and disoriented thinking, withdrawn and
apathetic behaviour, previous strokes, nystagmus and prolonged unconsciousness do not improve with
rehabilitation programme. Extensive lesions, congestive cardiac failure, generalized athero sclerosis,
gross perceptual deficits, low level of education and old age also result in poor outcome scores.

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However, currently it is not possible to predict about outcome of an individual patient and therefore all
stroke patients should be given a trial of rehabilitation.

Effect of stroke on family

Survivors from stroke depend on their family members for emotional and physical support. Family
members have to support a patient with disabilities in spheres of locomotion, self-care,
communication, cognition, depression and personality changes. About 34-52% of care givers of
patients with stroke suffer from depression.41 Depression in caregivers is associated with post stroke
depression, poor rehabilitation outcome and increased need for institutionalised care in stroke patients.
Factors associated with high degree of depression in caregivers are spouse with stroke, lack of social
support, presence of physical problems in caregiver, and presence of depression, cognitive impairment
and abnormal behaviour in stroke patient.

Conclusion

Stroke is a common neurological disorder with complex process of recovery. Survivors of stroke are
often left with disabilities. It also results in depression and stress among caregivers and family
members. Rehabilitation helps in promoting natural recovery, preventing complications due to
disabilities and adapting to disabilities. Currently there is a need for precise definition, accurate
measurements of disability and outcome for evaluating different methods of stroke rehabilitation. A
well-planned coordinated strategy towards stroke rehabilitation is bound to yield good results.

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