Rehabilitation of Patients After Stroke

Full text

(1)

REHABILITATION OF

REHABILITATION OF

PATIENTS WITH

PATIENTS WITH

HEMIPLEGIA

HEMIPLEGIA

(2)

Rehabilitation

Rehabilitation

– purpose - restore function following an illness or purpose - restore function following an illness or injury, with the goal of maximizing a person’s

injury, with the goal of maximizing a person’s ability to achieve fullest life possible

ability to achieve fullest life possible

– The ultimate aim of stroke research and The ultimate aim of stroke research and rehabilitation after stroke is to reduce

rehabilitation after stroke is to reduce

impairment, disability and handicap and to impairment, disability and handicap and to enhance the quality of life.

enhance the quality of life.

Interdisciplinary team

Interdisciplinary team

– physicians, nurses, PT, OT, speech-language physicians, nurses, PT, OT, speech-language therapists, psychologists, social workers,

therapists, psychologists, social workers, recreational therapists.

(3)

Rehabilitation

Rehabilitation

Rehabilitation therapy should start as early as Rehabilitation therapy should start as early as

possible, once medical stability is reached possible, once medical stability is reached

Spontaneous recovery can be impressive, but Spontaneous recovery can be impressive, but

rehabilitation-induced recovery seems to be g rehabilitation-induced recovery seems to be g

reater on average. reater on average.

Even though the most marked improvement is Even though the most marked improvement is

achieved during the first 3 months, rehabilita achieved during the first 3 months, rehabilita

tion should be continued for a longer period t tion should be continued for a longer period t

o prevent subsequent deterioration. o prevent subsequent deterioration.

(4)

Rehabilitation

Rehabilitation

N

No patient should be excluded from rehabilitation o patient should be excluded from rehabilitation unless he is too ill or too cognitively devastated to pa unless he is too ill or too cognitively devastated to pa

rticipate in a treatment program. rticipate in a treatment program.

Proper positioning and early passive ROM exercises Proper positioning and early passive ROM exercises

help to avoid complications at a flaccid stage. help to avoid complications at a flaccid stage. Family members should participate in therapy Family members should participate in therapy

sessions. sessions.

The family should also be referred to community The family should also be referred to community

groups that offer psychosocial support such as stroke groups that offer psychosocial support such as stroke

clubs at the time of discharge. clubs at the time of discharge.

(5)

5 5

Poor Prognosis

Poor Prognosis

Decreased alertness,inattention,poor

Decreased alertness,inattention,poor

memory,inability to learn new tasks or

memory,inability to learn new tasks or

follow simple commands

follow simple commands

severe neglect or anosognosia

severe neglect or anosognosia

significant medical problems esp,

significant medical problems esp,

cardiovascular or DJD

cardiovascular or DJD

serious language disturbance

serious language disturbance

less well defined & economic problem

(6)

Effect of a Stroke

Effect of a Stroke

1. Weakness on the side of the body opposite the site 1. Weakness on the side of the body opposite the site

of the brain affected by the stroke of the brain affected by the stroke

2. Spasticity, stiffness in muscles, painful muscle 2. Spasticity, stiffness in muscles, painful muscle

spasms spasms

3. Problems with balance and/or coordination 3. Problems with balance and/or coordination

4. Problems using language, including having difficulty 4. Problems using language, including having difficulty

understanding speech or writing(aphasia); and knowing understanding speech or writing(aphasia); and knowing

the right words but having trouble saying them the right words but having trouble saying them

clearly (dysarthria) clearly (dysarthria)

5. Being unaware of or ignoring sensations on one side 5. Being unaware of or ignoring sensations on one side

of the body (bodily neglect or inattention) of the body (bodily neglect or inattention)

6. Pain, numbness or odd sensations 6. Pain, numbness or odd sensations

(7)

Effect of a Stroke

Effect of a Stroke

(

(

con’t)

con’t)

7. Problems with memory, thinking, attention 7. Problems with memory, thinking, attention

or learning or learning

8. Being

8. Being unaware of the effects of a strokeunaware of the effects of a stroke 9. Trouble swallowing (dysphagia)

9. Trouble swallowing (dysphagia)

10. Problems with bowel or bladder control 10. Problems with bowel or bladder control

11. Fatigue 11. Fatigue

12. Difficulty controlling emotions (emotional 12. Difficulty controlling emotions (emotional

lability) lability)

13. Depression 13. Depression

14. Difficulties with daily tasks 14. Difficulties with daily tasks

(8)

Rehabilitation Goal

Rehabilitation Goal

To restore lost abilities as much as

To restore lost abilities as much as

possible

possible

To prevent stroke-related complications

To prevent stroke-related complications

To improve the patient's quality of life

To improve the patient's quality of life

To educate the patient and family about

To educate the patient and family about

how to prevent recurrent strokes

how to prevent recurrent strokes

Promote re-integration into family, home,

Promote re-integration into family, home,

work, leisure and community activities

work, leisure and community activities

(9)

Successful Rehabilitation

Successful Rehabilitation

Depend on

Depend on

- how early rehabilitation begins

- how early rehabilitation begins

- the extent of the brain injury

- the extent of the brain injury

- the survivor’s attitude

- the survivor’s attitude

- the rehabilitation team’s skill

- the rehabilitation team’s skill

- the cooperation of family and

- the cooperation of family and

caregiver

(10)

Basic Principles of Rehabilitation

Basic Principles of Rehabilitation

To begin as possible early (first hours) To begin as possible early (first hours)

To assess the patient systematically To assess the patient systematically

To prepare the therapy plan carefully To prepare the therapy plan carefully

To build up in stages To build up in stages

To include the type of rehabilitation approach To include the type of rehabilitation approach

specific to deficits specific to deficits

To evaluate patient’

(11)

Rehabilitation Management

Rehabilitation Management

Mobility Mobility

Activity of daily living Activity of daily living

Communication Communication Swallowing Swallowing Orthosis Orthosis Shoulder pain Shoulder pain Spasticity Spasticity

Cognitive and perception Cognitive and perception

Mood Mood

Bowel and bladder incontinence Bowel and bladder incontinence

(12)

Mobility

Mobility

Physiotherapy

Physiotherapy

– Conventional therapiesConventional therapies

(13)

Conventional therapies

Conventional therapies

Therapeutic Exercises Therapeutic Exercises

Traditional Functional Retraining Traditional Functional Retraining

Range Of Motion (ROM) Exercises

Range Of Motion (ROM) Exercises

Muscle Strengthening Exercises

Muscle Strengthening Exercises

Mobilization activities

Mobilization activities

Fitness training

Fitness training

Compensatory Techniques

Compensatory Techniques

(14)

Neurophysiological Approaches

Neurophysiological Approaches

1. Muscle Re-education Approach

1. Muscle Re-education Approach (1920S)(1920S)

2. Neurodevelopmental Approaches

2. Neurodevelopmental Approaches (1940-70S)(1940-70S) – Sensorimotor Approach Sensorimotor Approach (Rood, 1940S)(Rood, 1940S)

– Movement Therapy Approach Movement Therapy Approach (Brunnstrom, 1950S)(Brunnstrom, 1950S)

– NDT Approach (Bobath, 1960-70S)NDT Approach (Bobath, 1960-70S) – PNF Approach PNF Approach (Knot and Voss,1960-70S)(Knot and Voss,1960-70S)

3. Motor Relearning Program for Stroke 3. Motor Relearning Program for Stroke

(1980S) (1980S)

4. Contemporary Task Oriented Approach 4. Contemporary Task Oriented Approach

(1990S) (1990S)

(15)

Aim

Aim

Improve

Improve

– MovementMovement – BalanceBalance – coordinationcoordination

Safety

Safety

(16)

Basic Physical Therapy

Basic Physical Therapy

Bed positioning, mobility

Bed positioning, mobility

Range of motion exercises (ROME)

Range of motion exercises (ROME)

Sitting/trunk control

Sitting/trunk control

Transfer

Transfer

Walking

Walking

Stair climbing

Stair climbing

(17)

Treadmill training with body

Treadmill training with body

weight support

weight support

(18)

Robotics

Robotics

(19)

Activity of daily living

Activity of daily living

Occupational therapy

Occupational therapy

– Self careSelf care DressingDressing Grooming Grooming Toilet use Toilet use Bathing Bathing Eating Eating

(20)

Constraint-Induced Movement

Constraint-Induced Movement

Therapy (CIMT)

Therapy (CIMT)

Principle of Principle of FORCED USE to FORCED USE to

avoid the Learned avoid the Learned

Nonuse of the Nonuse of the

paretic side for paretic side for Stroke patients Stroke patients

Mainly for training Mainly for training of upper extremity of upper extremity

(21)
(22)

Exercise Therapy

Exercise Therapy

Neurodevelopmental techniques by Bobath Stresses exercises that tend to normalize muscle tone and prevent excessive

spasticity

Through special reflex-inhibiting postures & movements

In beginning spasticity,

Slow, sustained stretching for spastic muscles

Vibration of antagonist muscles to reduce tone

(23)

Exercise Therapy to Develop

Exercise Therapy to Develop

Motor Control

Motor Control

Facilitation techniques: 1. Rood

involves superficial cutaneous stimulation using stroking, brushing, tapping & icing or vibration to evoke voluntary muscle activation

2. Brunnstrom

Emphasized synergistic patterns* of movement that develop during recovery from hemiplegia Encouraged the development of flexor &

extensor synergies during early recovery, hoping that synergistic activation of muscle would, with training, transition into voluntary activation.

(24)

Exercise Therapy to Develop

Exercise Therapy to Develop

Motor Control

Motor Control

Facilitation techniques:

3. Kabat’s Proprioceptive

Neuromuscular Facilitation (PNF) Relies on quick stretching and

manual resistance of muscle

activation of the limbs in functional direction, which are often spiral and diagonal.

(25)

Exercise Therapy to Develop

Exercise Therapy to Develop

Motor Control

Motor Control

Conventional methods:

Conventional methods:

Stretching

Stretching

& strengthening

& strengthening

Attempting to retrain weak muscles

Attempting to retrain weak muscles

through

through

(26)
(27)

Hydrotherapy

Hydrotherapy

(28)

Management- Balance Training

Management- Balance Training

(29)

Management- coordination Training

Management- coordination Training

Bully Therapy

Bully Therapy

(30)

Orthosis

Orthosis

Shoulder slings

Shoulder slings

Hand splint

Hand splint

Foot slings

Foot slings

Ankle foot orthosis

(31)
(32)
(33)

Hand splints

Hand splints

Flaccid = functional position Flaccid = functional position

– Wrist extend 20 – 30 degreeWrist extend 20 – 30 degree – Flex MCP joint 45 degreeFlex MCP joint 45 degree

– Flex PIP joint 30 - 45 degreeFlex PIP joint 30 - 45 degree – Flex DIP joint 20 degreeFlex DIP joint 20 degree

(34)
(35)
(36)

- Plastic

- Plastic

-

Metal

Metal

stability of ankle

stability of ankle

balance

balance

speed walking

speed walking

Not enhance recovery

Not enhance recovery

Ankle Foot Orthosis

Ankle Foot Orthosis

(37)

Plastic AFO Metal AFO

Ankle Foot Orthosis

Ankle Foot Orthosis

(38)

Shoulder pain

Shoulder pain

Sensorimotor dysfunction of upper

Sensorimotor dysfunction of upper

extremities

extremities

72% of stroke patient in first year

72% of stroke patient in first year

Delay rehabilitation

(39)

Causes of Hemiplegic Shoulder Pain

Causes of Hemiplegic Shoulder Pain

aetiology of hemiplegic shoulder pain is probably multifactorial.aetiology of hemiplegic shoulder pain is probably multifactorial.Spasticity Spasticity and hemiplegic shoulder pain are related. particularly and hemiplegic shoulder pain are related. particularly

of the subscapularis and pectoralis muscles

of the subscapularis and pectoralis muscles

It is uncertain whether shoulder It is uncertain whether shoulder subluxationsubluxation causes hemiplegic causes hemiplegic

shoulder pain

shoulder pain

the sustained hemiplegic posture: shoulder contractures or the sustained hemiplegic posture: shoulder contractures or

restricted shoulder range of motion

restricted shoulder range of motion

reflex sympathetic dystrophyreflex sympathetic dystrophy

Poor handling and positioning of the affected upper limb in stroke Poor handling and positioning of the affected upper limb in stroke

patients contribute toward shoulder pain.

patients contribute toward shoulder pain.

Many types of shoulder pathology have been suggested as Many types of shoulder pathology have been suggested as

causes of shoulder pain including shoulder subluxation, capsulitis,

causes of shoulder pain including shoulder subluxation, capsulitis,

tendonitis, rotator cuff injury, bursitis, impingement syndrome,

tendonitis, rotator cuff injury, bursitis, impingement syndrome,

spasticity, CRPS, brachial plexus injury, and proximal

spasticity, CRPS, brachial plexus injury, and proximal

mononeuropathies

(40)

Exercise Therapy to Develop Motor

Exercise Therapy to Develop Motor

Control

Control

Facilitation techniques: Facilitation techniques:

Kabat’s Proprioceptive Neuromuscular Facilitation Kabat’s Proprioceptive Neuromuscular Facilitation

(PNF)

(PNF)

(41)

Treatment

Treatment

Electrical stimulation Electrical stimulation Shoulder strapping Shoulder strapping

Mobilization (esp. External rotator, Mobilization (esp. External rotator,

abduction) prevent frozen shoulder, abduction) prevent frozen shoulder,

shoulder hand pain shoulder hand pain

Medical Medical

Intraarticular injections Intraarticular injections

Modalities : ice, heat, massage Modalities : ice, heat, massage

Strengthening Strengthening

(42)

Spasticity

Spasticity

Velocity dependent hyperactivity of

Velocity dependent hyperactivity of

tonic stretch reflexes

tonic stretch reflexes

(43)

Aim of treatment

Aim of treatment

Pain

Pain

ROM

ROM

Cosmatic

Cosmatic

Hygiene

Hygiene

Mobility

Mobility

Easy use orthosis

Easy use orthosis

Delay surgery

(44)

Treatment

Treatment

Avoid noxious stimuli Avoid noxious stimuli

Positioning, passive stretching, ROME Positioning, passive stretching, ROME

Splinting, serial casting, surgical correction Splinting, serial casting, surgical correction

Medical

Medical - tizanidine- tizanidine - baclofen - baclofen - dantrolen - dantrolen - avoid diazepam - avoid diazepam Botulinum toxin A injection Botulinum toxin A injection

Phenol / alcohol Phenol / alcohol

Neurosurgical procedure (selective dorsal Neurosurgical procedure (selective dorsal

rhizotomy) rhizotomy)

(45)

Bowel and bladder incontinence

Bowel and bladder incontinence

Urinary incontinence

Urinary incontinence

- 50% incontinence during acute phase

- 50% incontinence during acute phase

- with time, ~ 20% at six months

- with time, ~ 20% at six months

- Risk: age, stroke severity, diabetes

- Risk: age, stroke severity, diabetes

- Indwelling catheter : management of

- Indwelling catheter : management of

fluids, prevent urinary retention, skin

fluids, prevent urinary retention, skin

breakdown

breakdown

- Use of foley catheter > 48 hours

- Use of foley catheter > 48 hours

UTI

(46)

Fecal incontinence

Fecal incontinence

– Improve within 2 weeksImprove within 2 weeks

(47)

Constipation, fecal impaction

Constipation, fecal impaction

– More commonMore common

– Immobility, inadequate fluid or food intake, Immobility, inadequate fluid or food intake, depression or anxiety, cognitive deficit

depression or anxiety, cognitive deficit

Management

Management

– Adequate intake of fluidAdequate intake of fluid – Bulk and fiber foodBulk and fiber food

Figure

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References

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