D R . R A N I H A L E Y L I N D B E R G , M . D .

U A M S D E P T . O F P H Y S I C A L M E D I C I N E A N D R E H A B I L I T A T I O N

Stroke Rehabilitation

Goals and Objectives

Describe the field of Physical Medicine and Rehabilitation

Discuss qualifications for inpatient rehabilitation Review goals of Stroke Rehabilitation Review complications related to stroke and their

effects on rehabilitation of a stroke patient

Physical Medicine and Rehabilitation: What is it?

ABMS 1947�Physical Medicine (Thermal, E-stim, U/S)�Rehabilitation (WWII)

Physiatry / Physiatrist � Diagnosis, treatment, and rehabilitation of primarily

neuromusculoskeletal and cardiopulmonary disorders, that may produce temporary or permanent impairment.

� PM&R

PM&R: What do they do?

Focus: Maximize Function / Quality of life� Physiatry: area of expertise is the functioning of the

whole patient, as compared with focusing on a specific organ system or systems.

� Prescribe Medications and Therapy

� Team Approach (e.g., Physical / Occupational Therapy)

The Physiatric Approach

Chief complaint Baseline level of function Current level of function

What are the current barriers that are preventing the patient from reaching their desired level of function?

Who “qualifies” for inpatient rehabilitation?

Qualifying Diagnoses for Inpatient Rehab

• Stroke• Spinal cord injury• Congenital deformity• Amputation• Major multiple trauma• Hip fracture• Brain injury• Neurological disorders (e.g., Multiple Sclerosis, Parkinson’s)• Burns• 3 different arthritis conditions for which appropriate, aggressive, and

sustained outpatient therapy has failed, and• Joint replacement

Theory Behind Early Stroke Rehab

Neuroplasticity:Modifications in neural networks are use

dependent

Need stimulation from:-Active rehabilitation-The environment

Timing for Inpatient Rehabilitation after Stroke?

Studies show fewer days between onset of stroke rehab and initiation of rehabilitation is associated with improved functional outcome at discharge and

shorter rehabilitation length of stay.

Stroke Rehabilitation: Goals

Functional enhancement by maximizing each patient’s:

-Independence-Lifestyle-Dignity

Focus on physical, behavioral, cognitive, social, vocational, adaptive, and re-educational points of view.

Programs for Patients After Stroke

Speech, Language and Cognitive Training Mobility Training Self-Care Training Peer Support Outpatient Family Stroke Education Group Specialized Feeding and Swallowing Program Driver Rehabilitation Outpatient Therapy

Rehabilitation Team Members

Physiatrists Consulting PhysiciansRehabilitation Nurses

Physical TherapistsOccupational Therapists

Care Coordinators/Social WorkersRespiratory Therapists

Speech-Language PathologistsRegistered Dietitians

Therapeutic Recreation SpecialistsDriver Rehabilitation Instructors

NeuropsychologistsChaplains

Stroke Rehabilitation: Team Approach

Patient and familyPhysician

Physical TherapistOccupational Therapist

Speech Language PathologistRehab NeuropsychologistRehab Nursing and AidesRehab Case CoordinatorRecreational Therapist

ChaplainNutritionist

OrthotistVocational Therapist

Functional Independent Measures

Global measure of functional independence. The total FIM rating ranges from 18-126 (i.e., 18

items rated on a 1-7 ordinal scale) FIM component subscores:

Self-care: bathing, eating, grooming, dressing upper/lower body, toileting

Mobility: Transfers (toilet; bed, chair, and wheelchair; tub and shower transfers) and locomotion (stairs, walk and wheelchair locomotion)

Sphincter: Bladder and bowel controlCognitive: Communication, psychosocial

Motor Impairment and Recovery due to Stroke

Up to 88% of stroke patients have hemiparesis

Most recovery in 1st three months with minor recovery after six months

Typically, leg recovers before arm-Lower extremity pattern:

flexor synergy �extensor synergy-Upper extremity pattern:

flexor synergy �extensor synergy

Predictors of Motor Recovery Post-Stroke

Severity of arm weakness� 9% with good recovery of hand function

Timing of motor return in hand� If some return by 4 wks, 70% chance of full to good recovery

Poor Prognostic indicators:1) Severe proximal spasticity2) Prolonged “flaccidity” period3) Late return of proprioceptive response >9 days4) Late return of proximal traction response>13 days

Brunnstrom Stages of Stroke Recovery

1. Flaccidity

2. Spasticity appears

3. Increased spasticity, basic synergy pattern appears, minimal voluntary movements

4. Decreased spasticity, some movements out of synergy patterns

5. Further decrease in spasticity, more complex movement combinations, synergy patterns no longer dominate

6. Disappearance of spasticity, able to move individual joints, coordination near normal

7. Normal function is returned

Rehabilitation Methods for Motor Deficits

Traditional therapies consist of:1. Positioning and ROM exercises2. Mobilization3. Compensatory techniques4. Strengthening and endurance training

For stroke rehabilitation, these exercises emphasize repetition of movements, importance of sensation to control movement, and developing basic movements and postures to improve motor control and coordination

Major Theories of Rehabilitation Training

Proprioceptive Neuromuscular Facilitation (Voss)Neurodevelopmental Technique (Bobath)

Brunnstrom/Movement ApproachRood/Sensorimotor approach

Motor Relearning programBehavioral approach

Special therapies and modalities

Functional Electrical Stimulation

• Mirror Therapy for Hemiplegia/Neglect• Dynamic Splinting• Constraint-induced Movement Therapy• Assistive devices and bracing for ambulation

P R O B L E M S E N C O U N T E R E D B E F O R E , D U R I N G , A N D A F T E R R E H A B

Complications after Stroke

Hemispatial Neglect

Deficit in attention to and awareness of one side of space defined by the inability of a person to process stimuli on one side of the body or environment

• Three quarters of patients with acute stroke have signs of neglect

•Unawareness of deficit in 20% to 58% of patients

•Pts with neglect took longer to recover than other stroke patients with similar stroke pathology and impairment.

•Pts with neglect required more therapy input and have longer rehab LOS

Neglect Treatment

Scanning Trunk rotation therapy Eye Patching, Prism

glasses Constraint-Induced

Therapy Mirror Therapy Neurostimulation

medications

http://blogs.discovermagazine.com/loom/2010/09/

Falls

Risk factors for in Hospital falls:� R>L Hemispheric stroke; Neglect and visuospatial deficits;

Impulsivity; bilateral strokes; confusion; male; poor ADL; urinary incontinence; use of sedatives and diuretics.

Preventive measures:� Adequate staffing; education; patient strength training;

balance training; cognitive remediation; restraints with monitoring; bed/chair alarms; timed voiding; minimize use of sedatives and diuretics.

*Moroz A, et al. Arch Phys Med Rehabil 2004;85(3 Suppl):S11-14.

Stroke: Shoulder Pain

Subluxation

Traction neuropathy

Bicipital tendinitis

RTC/Impingement

Frozen shoulder

Complex Regional Pain Syndrome

Treatment for Shoulder Pain

•Proper positioning and arm awareness

•Bracing/sling

•Estim

•Armboard/trough for wheelchair

•ROM excercises

•Injections

Dependent Edema

Treatment includes:ROM exercisesElevation of limbCompression stockings or glovesSCDsMassage

http://www.foot-pain-explained.com/edema.html

Spasticity after Stroke

Onset: days to weeks Upper extremity- flexion, lower extremity- extension Velocity dependent resistance to passive movement

of affected limb

www.informahealthcare.com

Spasticity after Stroke: Treatment

Slow, sustained stretching program Splinting Serial casting Cold modalities Medications: Baclofen, Zanaflex, Benzos Injections: Botox, Phenol Intrathecal Baclofen Pumps Surgery

www.rehabmart.com

DVT after Stroke

Occurs in 20-75% of untreated Stroke survivors 60-75% of DVTs occur in hemiplegic limb PE occurs in 1-2% of cases

Prophylaxis:Subcutaneous heparin or LMWHSCDsTED hose

Bladder Dysfunction

50-75% of stroke patient have urinary incontinence during the 1st month post stroke, 15% after 6 mths

Etiology is multifactorial Voiding disorders: areflexia, uninhibited spastic

bladder, outlet obstruction Treatment: tx underlying cause, regulate fluid intake,

timed voiding, education, and medication

When removing foley caths: remember to check PVRs!

Bowel Dysfunction

Incidence of incontinence: 31% of stroke patients Typically resolves after the 1st two weeks s/p stroke Decreased continence usually related to decreased

mobility or communication impairments Treatment includes transfer training and timed

toileting. Constipation is common and treated by improved

fluid intake, diet modification, stool softeners and stimulants.

Dysphagia

Overall incidence ~30-45% of stroke survivors

Signs of abnormal swallow:Abnormal and/or weak cough

Cough after swallowDysphoniaDysarthria

Abnormal gag reflexVoice change after swallow

Difficulty handling secretions

Aspiration

Missed on bedside swallow study in 40-60% of pts!! FEES and VFSS better at detected silent aspiration

Aspiration pneumonia risk factors:DECREASED LEVEL OF CONCIOUSNESS

TracheostomyEmesisReflux

NGT feedingDysphagia

Treating Dysphagia and Prevention Aspiration

Changing head position/posture

Elevation of head of bed

Feeding in the upright position

Using chin tuck technique

Turning head toward plegic/paretic side

Diet modification

Oral/motor exercises by Speech therapist

Aphasia

Impairment of the ability to utilize language due to brain injury

Can also include impairment in reading, writing, and problem solving.

Aphasia�Longer rehabilitation length of stay Aphasia�Decreased rehabilitation efficiency

Depression

Prevalence: ~40% of stroke patients

May be related to neurotransmitter depletion from stroke lesions and psychological response to physical/personal losses associated with stroke

Risk factors: female, prior psych hx, severe impairment, nonfluent aphasia, lack of social support

Persistent depression�delayed recovery and poor functional outcome

Treatment: Neuropsychology, medications

Seizures

Classification: at stroke onset, early after stroke, late after stroke

Early seizures usually due to metabolic derangement from acute ischemic/hemorrhagic injury and often do not recur

Stroke patients requiring inpatient rehab have higher probability of having seizure

If seizure occurs 2 wks after stroke, increased likelihood of recurrence

Treatment: Seizure precautions, anticonvulsants

Outcomes and Return to Work

Outcomes

The most reliable predictor of functional outcome during Rehab is the patient’s functional ability on admission. An admission FIM score >60 is a good indicator.*

Persistant urinary or fecal incontinence and the presence of a social support system is the key determinate in the ultimate discharge destination.**

* Ween JE, et al. Neurology. 1996;46:388-392.* *Brandstater M. In DeLisa ed. Rehabilitation Medicine 3rd ed. 1998;1165-

1189.

Predicting Outcomes

Age Severity of stroke Prior stroke Persistant urinary

incontinence Bowel incontinence Visuospatial deficits Unilateral hemineglect Coma at onset Poor cognitive function

Multiple neruologic deficits Impaired sitting balance Poor social supports Limitations in ADLs Depression Severe aphasia Severe comorbid medical

conditions Cerebral metabolic rate

(PET scan)

Ambulation Potential

Copenhagen Stroke study: 63% presented with impaired walking. Those who survived - 22% did not regain the ability to walk; 66% achieved independent walking, and 95% reached their maximum walking function at 11 months.*

Most common lower extremity is an ankle-foot orthosis (AFO) – both speed of gait and energy consumption can be improved using an AFO. **

*Jorgensen HS, et al. Stroke 1999;10(4):887-906.**Fowler PT, et al. J Orthop Res 1993;11:416-421.

Return to Work

Negative factors that effect return to work:� Low score on the Barthel Index� Prolonged rehabilitation length of stay� Aphasia� Prior EtOH abuse

Neuropsychological testingFunctional Capacity EvaluationReturn to work with restrictions

How to prepare a patient for inpatient rehabilitation

Initiate early rehab therapies: PT, OT, Speech, PM&R Prevent complications:

-Early ROM, stretching, and splinting to prevent contractures-Shoulder slings and proper arm position in bed-High suspicion for dysphagia and close monitoring for aspiration-DVT prophylaxis-Monitor nutrition- PEG tube placement early if delayed recovery expected- Monitor for neglect and help patient compensate for it!- Bladder/bowel: timed voids if possible. Check PVRs!

References

Braddom. Physical Medicine and Rehabilitation. 3rd edition. Cuccurullo. Physical Medicine and Rehabilitation Board Review. 2004 Maulden S.A. et al. Timing of Initiation of Rehabilitation After Stroke. Arch Phys

Med Rehabil. 2005. 86 (Suppl 2): S34-40. Bryan J. et al. Stroke and Neurodegenerative Disorders. 1. Acute Stroke Evaluation,

Management, Risks, Prevention, and Prognosis. Arch Phys Med Rehabil. 2004. 85 (Suppl 1): S3-9.

Ross A. Bogey et al. Stroke and Neurodegenerative Disorders. 3. Stroke: Rehabilitation Management. Arch Phys Med Rehabil. 2004. 85 (Suppl 1): S15-20.

Page et al. Efficacy of Modified Constraint-Induced Movement Therapy in Chronic Stroke: A Single-Blinded Randomized Controlled Trial. Arch Phys Med Rehabil . 2004. 85: 14-18.

Sütbeyaz et al. Mirror Therapy Enhances Lower-Extremity Motor Recovery and Motor Functioning After Stroke: A Randomized Controlled Trial. Arch Phys Med Rehabil. 2007. 88: 555-559.

Gialanella et al. Rehabilitation Length of Stay in Patients Suffering from Aphasia After Stroke. Topics in Stroke Rehabilitation. Nov/Dec 2009. 437-444.

Pierce and Buxbaum. Treatments of Unilateral Neglect: A Review. Arch Phys Med Rehabil. 2002. 83: 256-268.