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    Rehabilitation of Patients After Stroke

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    Roger
    This document discusses rehabilitation for patients with hemiplegia following a stroke. An interdisciplinary team works to restore function and maximize independence through therapies like physical therapy, occupational therapy and speech language pathology. Rehabilitation should begin as early as possible and continue over an extended period to address issues like mobility, activities of daily living, communication, swallowing, orthotics, shoulder pain, spasticity and more. The goal is to improve impairments and quality of life while promoting community reintegration. Proper rehabilitation management and family support can lead to successful recovery.

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    © All Rights Reserved
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    Rehabilitation of Patients After Stroke

    Uploaded by

    Roger
    280 views47 pages
    This document discusses rehabilitation for patients with hemiplegia following a stroke. An interdisciplinary team works to restore function and maximize independence through therapies like physical therapy, occupational therapy and speech language pathology. Rehabilitation should begin as early as possible and continue over an extended period to address issues like mobility, activities of daily living, communication, swallowing, orthotics, shoulder pain, spasticity and more. The goal is to improve impairments and quality of life while promoting community reintegration. Proper rehabilitation management and family support can lead to successful recovery.

    Original Description:

    Neurological Rehabilitation

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    This document discusses rehabilitation for patients with hemiplegia following a stroke. An interdisciplinary team works to restore function and maximize independence through therapies like physical therapy, occupational therapy and speech language pathology. Rehabilitation should begin as early as possible and continue over an extended period to address issues like mobility, activities of daily living, communication, swallowing, orthotics, shoulder pain, spasticity and more. The goal is to improve impairments and quality of life while promoting community reintegration. Proper rehabilitation management and family support can lead to successful recovery.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    280 views47 pages

    Rehabilitation of Patients After Stroke

    Uploaded by

    Roger
    This document discusses rehabilitation for patients with hemiplegia following a stroke. An interdisciplinary team works to restore function and maximize independence through therapies like physical therapy, occupational therapy and speech language pathology. Rehabilitation should begin as early as possible and continue over an extended period to address issues like mobility, activities of daily living, communication, swallowing, orthotics, shoulder pain, spasticity and more. The goal is to improve impairments and quality of life while promoting community reintegration. Proper rehabilitation management and family support can lead to successful recovery.

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    © All Rights Reserved
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    At a glance
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    The key takeaways are that rehabilitation aims to restore function and maximize quality of life through an interdisciplinary team approach.

    Rehabilitation therapy should start as early as possible once medical stability is reached, and should continue for a longer period to prevent deterioration and maximize recovery.

    Techniques used in rehabilitation include Kabat's Proprioceptive Neuromuscular Facilitation, electrical stimulation, shoulder strapping, mobilization exercises, strengthening exercises and more.

    REHABILITATION OF

    PATIENTS WITH
    HEMIPLEGIA

    Rehabilitation

    purpose - restore function following an illness or


    injury, with the goal of maximizing a persons
    ability to achieve fullest life possible
    The ultimate aim of stroke research and
    rehabilitation after stroke is to reduce
    impairment, disability and handicap and to
    enhance the quality of life.

    Interdisciplinary team

    physicians, nurses, PT, OT, speech-language


    therapists, psychologists, social workers,
    recreational therapists.

    Rehabilitation
    Rehabilitation therapy should start as early as
    possible, once medical stability is reached
    Spontaneous recovery can be impressive, but
    rehabilitation-induced recovery seems to be g
    reater on average.
    Even though the most marked improvement is
    achieved during the first 3 months, rehabilita
    tion should be continued for a longer period t
    o prevent subsequent deterioration.

    Rehabilitation
    No patient should be excluded from rehabilitation
    unless he is too ill or too cognitively devastated to pa
    rticipate in a treatment program.
    Proper positioning and early passive ROM exercises
    help to avoid complications at a flaccid stage.
    Family members should participate in therapy
    sessions.
    The family should also be referred to community
    groups that offer psychosocial support such as stroke
    clubs at the time of discharge.

    Poor Prognosis
    Decreased alertness,inattention,poor
    memory,inability to learn new tasks or
    follow simple commands
    severe neglect or anosognosia
    significant medical problems esp,
    cardiovascular or DJD
    serious language disturbance
    less well defined & economic problem
    5

    Effect of a Stroke
    1. Weakness on the side of the body opposite the site
    of the brain affected by the stroke
    2. Spasticity, stiffness in muscles, painful muscle
    spasms
    3. Problems with balance and/or coordination
    4. Problems using language, including having difficulty
    understanding speech or writing(aphasia); and knowing
    the right words but having trouble saying them
    clearly (dysarthria)
    5. Being unaware of or ignoring sensations on one side
    of the body (bodily neglect or inattention)
    6. Pain, numbness or odd sensations

    Effect of a Stroke (cont)


    7. Problems with memory, thinking, attention
    or learning
    8. Being unaware of the effects of a stroke
    9. Trouble swallowing (dysphagia)
    10. Problems with bowel or bladder control
    11. Fatigue
    12. Difficulty controlling emotions (emotional
    lability)
    13. Depression
    14. Difficulties with daily tasks

    Rehabilitation Goal
    To restore lost abilities as much as
    possible
    To prevent stroke-related complications
    To improve the patient's quality of life
    To educate the patient and family about
    how to prevent recurrent strokes
    Promote re-integration into family, home,
    work, leisure and community activities

    Successful Rehabilitation
    Depend on
    - how early rehabilitation begins
    - the extent of the brain injury
    - the survivors attitude
    - the rehabilitation teams skill
    - the cooperation of family and
    caregiver

    Basic Principles of Rehabilitation


    To begin as possible early (first hours)
    To assess the patient systematically
    To prepare the therapy plan carefully
    To build up in stages
    To include the type of rehabilitation approach
    specific to deficits
    To evaluate patients progress regularly

    Rehabilitation Management
    Mobility
    Activity of daily living
    Communication
    Swallowing
    Orthosis
    Shoulder pain
    Spasticity
    Cognitive and perception
    Mood
    Bowel and bladder incontinence

    Mobility
    Physiotherapy

    Conventional therapies
    Neurophysiological therapies

    Conventional therapies
    Therapeutic Exercises
    Traditional Functional Retraining

    Range Of Motion (ROM) Exercises


    Muscle Strengthening Exercises
    Mobilization activities
    Fitness training
    Compensatory Techniques

    Neurophysiological Approaches
    1. Muscle Re-education Approach (1920S)
    2. Neurodevelopmental Approaches (1940-70S)

    Sensorimotor Approach (Rood, 1940S)


    Movement Therapy Approach (Brunnstrom, 1950S)
    NDT Approach (Bobath, 1960-70S)
    PNF Approach (Knot and Voss,1960-70S)

    3. Motor Relearning Program for Stroke


    (1980S)

    4. Contemporary Task Oriented Approach


    (1990S)

    Aim
    Improve

    Movement
    Balance
    coordination

    Safety

    Basic Physical Therapy


    Bed positioning, mobility
    Range of motion exercises (ROME)
    Sitting/trunk control
    Transfer
    Walking
    Stair climbing

    Treadmill training with body


    weight support

    Robotics

    Activity of daily living


    Occupational therapy
    Self care

    Dressing
    Grooming
    Toilet use
    Bathing
    Eating
    Adapt or specially design device

    Constraint-Induced Movement
    Therapy (CIMT)
    Principle of
    FORCED USE to
    avoid the Learned
    Nonuse of the
    paretic side for
    Stroke patients
    Mainly for training
    of upper extremity

    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
    through reciprocal inhibition.

    Exercise Therapy to Develop


    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.

    Exercise Therapy to Develop


    Motor Control
    Facilitation techniques:
    3. Kabats 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.

    Exercise Therapy to Develop


    Motor Control
    Conventional methods:
    Stretching & strengthening
    Attempting to retrain weak muscles
    through
    reeducation

    Hydrotherapy

    Management- Balance Training

    Management- coordination Training


    Bully Therapy

    Orthosis
    Shoulder slings
    Hand splint
    Foot slings
    Ankle foot orthosis

    Shoulder slings

    Shoulder slings

    Hand splints
    Flaccid = functional position

    Wrist extend 20 30 degree


    Flex MCP joint 45 degree
    Flex PIP joint 30 - 45 degree
    Flex DIP joint 20 degree

    Hand splints

    Foot slings

    Ankle Foot Orthosis


    - Plastic
    - Metal

    stability of ankle
    balance
    speed walking
    Not enhance recovery

    Ankle Foot Orthosis

    Plastic AFO

    Metal AFO

    Shoulder pain
    Sensorimotor dysfunction of upper
    extremities
    72% of stroke patient in first year
    Delay rehabilitation

    Causes of Hemiplegic Shoulder Pain

    aetiology of hemiplegic shoulder pain is probably multifactorial.


    Spasticity and hemiplegic shoulder pain are related. particularly
    of the subscapularis and pectoralis muscles
    It is uncertain whether shoulder subluxation causes hemiplegic
    shoulder pain
    the sustained hemiplegic posture: shoulder contractures or
    restricted shoulder range of motion
    reflex sympathetic dystrophy
    Poor handling and positioning of the affected upper limb in stroke
    patients contribute toward shoulder pain.
    Many types of shoulder pathology have been suggested as
    causes of shoulder pain including shoulder subluxation, capsulitis,
    tendonitis, rotator cuff injury, bursitis, impingement syndrome,
    spasticity, CRPS, brachial plexus injury, and proximal
    mononeuropathies

    Exercise Therapy to Develop Motor


    Control
    Facilitation techniques:
    Kabats Proprioceptive Neuromuscular Facilitation

    (PNF)

    Treatment
    Electrical stimulation
    Shoulder strapping
    Mobilization (esp. External rotator,
    abduction)
    prevent frozen shoulder,
    shoulder hand pain
    Medical
    Intraarticular injections
    Modalities : ice, heat, massage
    Strengthening

    Spasticity
    Velocity dependent hyperactivity of
    tonic stretch reflexes

    Aim of treatment
    Pain
    ROM
    Cosmatic
    Hygiene
    Mobility
    Easy use orthosis
    Delay surgery

    Treatment
    Avoid noxious stimuli
    Positioning, passive stretching, ROME
    Splinting, serial casting, surgical correction
    Medical - tizanidine
    - baclofen
    - dantrolen
    - avoid diazepam
    Botulinum toxin A injection
    Phenol / alcohol
    Neurosurgical procedure (selective dorsal
    rhizotomy)

    Bowel and bladder incontinence


    Urinary incontinence
    - 50% incontinence during acute phase
    - with time, ~ 20% at six months
    - Risk: age, stroke severity, diabetes
    - Indwelling catheter : management of
    fluids, prevent urinary retention, skin
    breakdown
    - Use of foley catheter > 48 hours
    UTI

    Fecal incontinence
    Improve within 2 weeks
    Continued fecal incontinence poor prognosis

    Constipation, fecal impaction

    More common
    Immobility, inadequate fluid or food intake,
    depression or anxiety, cognitive deficit

    Management

    Adequate intake of fluid


    Bulk and fiber food
    Bowel training

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