STROKE REHABILITATION

Doctor, what is
definition of stroke ?
DEFINITION
The WHO defines stroke as

“ rapidly developing clinical signs of focal (at times

global) disturbance of cerebral function, lasting
more than 24 hours or leading to death with no
apparent cause other than that of vascular origin ”
Could you describe
the risk factor?
RISK FACTORS
 Nonmodifiable
- Age ( increase after age 55 yr)
- Sex (male > female)
- Race (African American 2 x > White > Asian)
- Family history of stroke
RISK FACTORS
Modifiable (treatable)
 Hypertension
 History of TIA/prior stroke
 Heart disease : CHF,
CAD,Valvular heart disease,
AF
 Diabetes
 Cigarette smoking
 Carotid stenosis
 Cocain use
 High dose estrogen
 Systemic disease associated
with hypercoagualable state
 Hyperlipidemia
 Migrain headaches
 Sleep apnea
 Patent foramen ovale
CLASSIFICATION OF STROKE

Types of stroke ?
CLASSIFICATION OF STROKE
 Pathophysiology

 Ischemic strokes are

caused by decreased
blood flow to a region of
the brain resulting in
death of brain tissue.

 Hemorrhagic strokes
are caused by a rupture of
vessels in the brain and
secondary bleeding into
brain tissue.
• Ischemic strokes can undergo hemorrhagic transformation and turn into
hemorrhagic strokes.
 Ischemic Hemorrhagic
Subarachnoid
Type Thrombotic Embolic Lacunar Intracerebral (ruptured
(hypertensive) aneurysm)
Incidence 60% 20% 5% 10% 5%
Factors Occurs when
associated Occurs during Occurs while the patient is Occurs during
with onset sleep awake calm and activity
unstressed
Perfusion Small lesion
Major failure distal to seen mainly: From ruptured
causes / site of severe putamen, Hypertension aneurysms and
etiology stenosis or Due mainly to pons, vascular
occlusion of cardiac source thalamus, malformation
major vessels caudate,
internal
capsule
Gradual onset
Presentation Slowly Sudden, Abrupt or or sudden
progressive immediate gradual onset onset of local Sudden onset
deficit deficit neurologic
deficit

Source : Sara Cuccurullo

CLASSIFICATION OF STROKE

Another
classification ?
 CLASSIFICATION OF STROKE
 Time of stroke
- TIA
- RIND
- Stroke in evolution
- Complete stroke
CLASSIFICATION OF STROKE

Please explain about

Bamford clinical classification ???

Stroke
The Oxford Community Stroke Project
classification (OCSP, also known as the
Bamford or Oxford classification) relies
primarily on the initial symptoms
To understand bamford’s clinical
classification, you should know about
Circle of Willis

Bamford Clinical Classification
Total Anterior Circulation Syndrome (TACS)
Partial Anterior Circulation Syndrome (PACS)
Posterior Circulation Syndrome (POCS)
Lacunar Syndromes (LACS)
Neuroanatomic location of ischemic stroke
ARTERY MAIN PROBLEMS

• Sensory & motor deficit face/arm > leg

Superior • Head & eyes deviated toward side of infarct
divison
(rolandic and • Left side lesion (DH) global aphasia initially, then
prerolandic area) turns into Broca’s aphasia
• Right side lesion (NDH) deficit spatial perception,
MIDDLE apraxia, hemineglect
CEREBRAL
ARTERY
(MCA) Inferior division
(lateral temporal
• Homonymous hemianopsia
and inferior • Left side lesion  Wernicke’s aphasia
parietal lobes) • Right side lesion  left visual neglect

Sources : Sara Cuccurullo

ACA

MCA
 Neuroanatomic location of ischemic
stroke
ARTERY MAIN PROBLEMS

ANTERIOR • Hemiparesis LE > UE

CEREBRAL • Personality disfunction
ARTERY • Head and eyes may be deviated
(ACA) toward side lesion acutely
• Urinary incontinence with
contralateral grasp reflex
• Disturbances in gait and stance
= gait apraxia
 Neuroanatomic location of ischemic stroke
ARTERY MAIN PROBLEMS

POSTERIOR • Hemisensory deficit

CEREBRAL • Visual impairment
ARTERY (PCA) • Visual agnosia
• Prosopagnosia (can’t read faces)
• Alexia (can’t read)
Neuroanatomic location of ischemic stroke
SYNDROMES LOCATION
ARTERY MAIN PROBLEMS

WEBER’S Medial basal • Ipsilateral third nerve palsy

midbrain • Contralateral hemiplegia
VERTEBRO
BASILAR
SYSTEM • Ipsilateral third nerve palsy
BENEDICT’S Tegmentum of • Contralateral loss of pain &
midbrain temperature sensation
• Contralateral loss of joint position
• Contralateral ataxia
• Contralateral chorea

LOCKED-IN Bilateral basal • Bilateral hemiplegia

pons • Bilateral cranial nerve palsy

Source : Braddom
 Neuroanatomic location of ischemic
stroke
SYNDROMES LOCATION
ARTERY MAIN PROBLEMS

MILLARD- Lateral pons • Ipsilateral sixth nerve palsy

GUBLER • Ipsilateral facial weakness
VERTEBRO • Contralateral hemiplegia
BASILAR
SYSTEM

• Ipsilateral hemiataxia
• Ipsilateral loss of facial pain &
WALLENBERG’S Lateral medulla temperature sensation
• Contralateral loss of body pain &
temperature sensation
• Nystagmus
• Ipsilateral Horner’s syndrome
• Dysphagia & dysphonia

Source : Braddom
Lacunar Strokes

constitute approximately 20% of all

strokes, resulting from occlusions in
the deep penetrating branches of
the large vessels that perfuse the
subcortical structures, including
internal capsule, basal ganglia,
thalamus, and brainstem.
Common risk factors for lacunar
strokes include hypertension,
diabetes, and hyperlipidemia.
Is it the same if stroke occurs in the Left or Right
Hemisphere ?
 Characteristics of Right and Left Hemiplegic Patients

Right Hemiplegic Left Hemiplegic

(Left-Brain Injured) (Right-Brain Injured)
Communication Visual/motor perceptual
impairment problems
Learns by demonstration Loss of visual memory
Will learn from mistakes Left side neglect
May require supervision Impulsive
due to communication Lack insight/judgement,
problems requires supervision
OK, I knew about stroke. But
I’ve got one. When should
rehabilitation begin after
all????
Timing of therapy
Specific therapy schedules should be individual for
each patient
The literature doesn’t provide specific guidelines on
the a amount of therapy needed for specific
problems
Endurance, medical stability, mood, motivation, and
other considerations affect the degree and duration
of physical patient can tolerate

Source : Braddom
much of the benefits in mortality appear to relate to
prevention and/or earlier recognition of medical
complications of stroke and earlier mobilization
The timing and progression depend on the patient’s
condition. These activities should begin as soon as
possible (generally within 24 to 48 hours of
admission) unless the stroke survivor is unresponsive
or medically/neurologically unstable
How to manage PMR
program to a stroke
patient ?
PMR Management in a stroke patient
Acute phase
Sub acute phase
Chronic phase

Source : Module
ACUTE PHASE

Stroke

Goals :
• Prevent complications of stroke
• Prevent complications of immobilization
ACUTE PHASE
What can I do ????
 Intervention PMR in acute phase ?
- Maintain skin integrity
- Prevent arise sinergic pattern and spastic ↑
- Prevent joint stiffness and shortening of the muscles
- Prevent cardiorespiratory complication
- Contend swallowing function disorder and prevent
aspiration
- Management of communication disorder
- Bowel and bladder management
- Multisensory stimulation

Source : module
Rehabilitation during the acute post stroke phase
 Evaluate & manage medical problem
 Monitor and adjust medication
 Maintain hydration & nutrition
 Facilitate rest and sleep
 Venous thromboembolism prophylaxis
 Proper bed and chair positioning
 Frequent turns & position changes
 Range of motion exercises
 Deep breathing and cough exc
 Frequent skin inspections
 Swallowing evaluation
 Safety measures
 Removal of indwelling catheter, if possible, with planned, timbed
Bowel evacuation regimen
Sitting in chair
Supervised bedside exc
Self-performance of ADL
Mobilization exc
Standing & gait training as able
Educational program on stroke, recovery, and personal care
Communication evaluation and training
Psychological support to the patient
Family education and support

Source : Braddom
SUBACUTE PHASE
Goals :
- Optimally neurologic recovery and
reorganization process
- Minimize and prevent complications
 Intervention PMR in subacute phase ?
- Continue the acute phase intervention
- Swallowing function therapy
- Therapeutic exercise :
1. Muscle reeducation approach
2. Neuro-facilitation approach
(Bobath, PNF, Rood, Brunnstrom)
3. Conductive educational approach
4. Motor learning approach
5. Strength training and physical conditioning
 Intervention PMR in subacute phase
6. Constraint-induced movement therapy
7. Body-weight support treadmil training
8. Cognitive perceptual therapy
9. Visual imagery approach
- Electrotherapy
1. Electrical stimulation
2. Biofeedback
- Cardiorespiration fitness therapy
- Orthotic
- Assisted walking aids / ADL aids
 Intervention PMR in subacute phase

- Emotion counselling
- Sexual counselling
- Educate to prevent complications
- Group therapy
CHRONIC PHASE
Goals :
- Optimally functional ability
- Maintain functional ability that had been
achieved
- Prevent complications
- Optimaly quality of life
 Intervention PMR in chronic phase ?
Adaptation training
Revocational training
Counselling and education for resocialization
Home program to maintain :
- prevent joint stiffness and shortening of the muscles
- fitness training
- activity daily living according to independence level
Education and training to family/care giver to prevent
complications
Complications ?
Bronchopneumonia
Ulcer pressure
Shoulder subluxation
Shouder hand syndrome
Osteoarthrosis
Osteoporosis
Neuropatic pain
Dementia
Prognosis ?
Depend on :
Large and location of the lession
Comorbiditas
Complications
Motivation of the patient
Familly support
Facility dan professional terapist
How we can predict patient
outcome?
National Institute of Health Stroke Scale (NIHSS)
 NIHSS is a systematic assessment tool that provides a
quantitative measure of stroke-related neurologic deficit.

 The scale is simple, valid, and should take no more than 5-

8 minutes to perform by a trained health care provider.

 Maximum score of NIHSS is 42. Patients with scores > 10

are consider to have moderate-to-severe strokes. Patients
with scores under 4 are considered to have mild strokes.

 Though the NIHSS is simple and standardized, training is

necessary to ensure all providers score patients in a
standardized way. Web-based training tools and
certifications are available.
NIHSS training:
Http://www.ninds.nih.G
ov/doctors/stroke_scale
_training.htm
 Modified Rankins Scale
• A simple, validated outcome measure that focuses on a person’s level of
function.

• Commonly used in patients with neurologic disorders, particularly

stroke.

• Discrete measures, ranges 0-6. No halves or thirds!

• Can be done in person or over the telephone

• Other more detailed outcome measures include the Barthel Index, the
Glascow Outcome Score, etc.
Modified Rankins Scale
 What is
Neuroplasticity?
Neuroplasticity refers to the ability of the central
nervous system to reorganize and remodel, articularly
after central nervous system injury.
Possible mechanisms of neural plasticity con
tributing to functional recovery might include:
 dendritic sprouting over time,
 new synapse formation, and
 the processes of long-term potentiation and depression
 Unmasking of secondary neural circuit

Source : Braddom
Clinical Application Neuroplasticity
in Rehabilitation

Task-specific, repetitive training

Constrained induced Movement
Therapy (CIMT)
Robotic trainers
Motor imagery
CIMT
warrant the most attention because it is safe,
does not require added technology, and has
been among the most extensively studied.
based on a theory proposed by Edward Taub that
patients with motor impair ment in an upper limb
after stroke learn to depend more on the
unaffected limb for performing functional tasks
because attempts to use the affected arm often
result in failure and frustration.
Taub also demonstrated that primates can be trained
to perform tasks with the affected limb through
successive approximations of the desired task,
which is the behavioral technique known as shaping.
 The original CIMT program consists of 2 weeks of
constrain -ing the intact upper limb for 90% of
waking hours com -bined with approximately 6
hr/day of institutionally based therapy designed to
force use of the impaired upper limb during task-
oriented activities.
Participants must have at least partial wrist and
finger extension, have adequate proximal limb
control, and have sufficient balance dur -ing limb
restraint
Robotic trainers
A very common gait training system that is now
available in many physical therapy clinics is body
weight–supported treadmill training (BWSTT).
BWSTT uses a standard tread -mill and an overhead
counterweighted cable system with a rock climbing–
style harness
Thank You
Beberapa contoh alat bantu untuk melakukan aktivitas
kehidupan sehari - hari