REHABILITATION MEDICINE

3.1 Post-Stroke Rehabilitation (Dr. Kelvin Chan)

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

SIGNS AND SYMPTOMS

DOMINANT hemisphere
NON-TRAUMATIC BRAIN INJURY o (usually left)
2 TYPES: o Right hemiparesis
o ISCHEMIC o Right hemisensory loss
characterized by the sudden loss of blood circulation to o Left gaze preference
an area of the brain, resulting in a corresponding loss of o Right visual field cut
neurologic function o Aphasia
o Neglect (atypical)
NONDOMINANT hemisphere
o Left hemiparesis
o Left hemisensory loss
o Right gaze preference
o Left visual field cut

GENERAL MEDICAL MANAGEMENT

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

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
RISK FACTORS: o Coordinated interdisciplinary team
o hypertension, diabetes mellitus o Staff: special interest in the management of
o smoking, illicit drug use stroke, access to ongoing professional
o arrhythmia and valvular disease education and training
o Clear communication regular team meeting
Most common: MCA infarct
o Active encouragement of patients and their
o contralateral weakness
cares to active involvement in rehabilitation
o sensory loss
o homonymous hemianopsia Cardiac Precautions
New onset of cardio-pulmonary symptoms
Heart rate decrease > 20% of baseline
HR increase > 50% of baseline

KIM VILLANUEVA, PTRP 1

 SBP increase to 240 mmHg SPASTICITY
SBP decrease >/= 30 mmHg from baseline to < 90 Painful and debilitating
mmHg Slightly spastic knee extensors can lock the knee during
DBP increase to 120 mmHg standing or cause hyperextension (genu recurvatum),
which may require a knee brace with an extension stop.
CRITERIA FOR ADMISSION TO A COMPREHENSIVE Flexor spasticity develops in most hemiplegic hands
REHABILITATION PROGRAM and wrists
Stable neurologic status
o flexion contracture may develop rapidly,
Significant existing neuro deficit
Identified disability affecting at least 2 of the ff: resulting in pain and difficulty maintaining
o Mobility personal hygiene
o Self-care activities o range-of-motion exercises several times a day
o Communication o hand or wrist splint may also be useful,
o Bowel, bladder control particularly at night.
o Swallowing o Patients and family members are taught to do
Sufficient cognitive function to learn
these exercises, which are strongly
Sufficient communicative ability to emerge with the
therapists encouraged
Physical ability to tolerate the active program Heat or cold therapy can temporarily decrease
Achievable therapeutic goal spasticity and allow the muscle to be stretched

MOBILIZATION Brunnstrom Stages Of Motor Recovery

Within 12-24 hrs, if possible Stage 1 no activation of the limb
Daily active/passive rom exercises Stage 2 (+) spasticity; (+) weak basic flexor and
Progressively increased activity extensor synergies
Changes of position in bed Stage 3 prominent spasticity; px voluntarily moves
the limb, but muscle activation is all within
MANAGEMENT CONSEQUENCE OF STROKE the synergy patterns
A. SENSORY MOTOR IMPAIRMENTS Stage 4 decline in spasticity and influence of
Strength synergy; less restrictions; difficult easy
o Progressive resistance exercise movement progression
o EMF biofeedback
o Electrical stimulation Stage5 continued decline in spasticity; px able to
o Task specific training demonstrate isolated joint movements;
Sensation more complex movement combinations
o Sensory-specific training
o Sensory-related training Stage 6 (-) spasticity; near normal to normal
o Cutaneous electrical stimulation movement and coordination
Spasticity (Brunnstrom stages of motor recovery)
o Botulinium toxin (not permanent)
o Intrathecal baclofen (anti-spastic medication) CONTRACTURES
o Dynamic splinting Hemiplegia is often associated with contractures.
o Vibration Placing 1 or 2 pillows under the affected arm prevent
o Stretch dislocation of the shoulder.
o EMG biofeedback Posterior foot splint applied with the ankle in a 90
Contractures
position prevent equinus deformity and foot drop
o Prolonged positions in a lengthened position
(splint) Reeducation and coordination exercises of the affected
o Electrical stimulation extremities are added as soon as tolerated, often within
o Casting 1 week.
Subluxation of shoulders Active and active-assistive range-of-motion exercise
o Electrical stimulation (supraspinatus and o Active exercise of the unaffected extremities
deltoid) must be encouraged
o Firm support device
Most important muscle for ambulation: unaffected
Swelling of extremity
o Electrical stimulation quadriceps
o CPM in elevation o If weak, this muscle must be strengthened to
o Pressure garments assist the hemiplegic side
Cardiovascular fitness Posterior foot splint applied with the ankle in a 90
Falling position prevent equinus deformity (talipes equinus)
and footdrop

B. PHYSICAL ACTIVITY
Sitting task specific activity
Stand-up from chair

KIM VILLANUEVA, PTRP 2

 Standing tilt table FUNCTIONAL ELECTRICAL STIMULATION (FES)
Walking generate muscle contraction to perform a task
o joint position feedback Bursts of high intensity electrical impulses via surface
o cueing of cadence of the body in stimulated nerves
o treadmill
ARMin-ROBOT ASSISTED
o multichannel electrical stimulation
Movement: prevent joint degeneration & preserve joint
Transfers
Gait re-training mobility
Upper limb activity ADL therapy
GAME therapy
C. ACTIVITIES OF DAILY LIVING: Occupational Therapy
VR-BASED INTERACTIVE COGNITIVE THERAPY
D. COGNITIVE CAPACITY Mirror neurohypothesis
Attention and concentration cognitive therapy Stimulate action observation system that could encourage
Memory external cues and prompting plasticity and repair
Executive function external cues
E. VISUOSPATIAL COMPLICATIONS
Visual function Neurologic(toxic or metabolism)
o prism glasses Medical
o computer-based visual restitution o Pulmonary aspiration/pneumonia, UTI,
Agnosia Depression, Musculoskeletal
Neglect Aspiration Pneumonia
o Cognitive rehabilitation o Oral stimulation; Patient should me sitting
Apraxia upright with forward; Modifying consistency of
o strategy training food from pureed liquid to thickened liquid;
Aphasia NGT if swallowing is not safe
o group therapy UTI (common because of neurogenic bladder)
o speech therapy Musculoskeletal Pain
o augmentative alternative communication o shoulder and arm pain develops early, several
device weeks to 6 months post onset
COMMUNICATION Shoulder subluxation
o Due to weak supraspinatus and deltoid muscle;
Aphasia
Managed by placing lap board; Stimulating
o Intervention
weak muscles; Relaxing the shoulder depressor
Use of gestures
and internal rotator
Constraint induced
Reflex Sympathetic Dystrophy
o Enhance treatment
Deep Vein Thrombosis
Supported conversation technique
Computer-based therapy
INDICATORS OF POOR PROGNOSIS
Dyspraxia
Proprioceptive facilitation > 9 days
DYSPHAGIA Traction response of shoulder flexors/adductors >13
Compensating strategy days
o Positioning Prolonged flaccid period
o Therapeutic maneuver Onset of motion >2-4 weeks
o Modify food and fluids Severe proximal spasticity
Adjunctive method Absence of voluntary hand movement >4-6 weeks
o shaker therapy
o Thermo-tactile stimulation FACTORS PREDICTIVE OF POOR ADL
severity of stroke
o Electrical stimulation
o severe weakness
o poor sitting balance
MULTIMODAL REACTIVATION OF SENSORIMOTOR o visuospatial deficits
MECHANISM o mental changes
Provide afferent proprioceptive feedback o incontinence
Motor planning and execution areas by embedding the o low initial ADL scores
movement in task oriented areas time interval: onset to rehabilitation
Stimulate motor planning areas by directing attention to advance age
a task and encouraging rehearsal of intended
movements

KIM VILLANUEVA, PTRP 3

 APHASIA

STUDY THIS DIAGRAM LUMALABAS SYA SA SAMPLEX

TYPES FLUENCY COMPREHENSION REPETITION

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

THANK YOU DOYENNE SADICON!

KIM VILLANUEVA, PTRP 4