Rehab 3.1 - Stroke Rehabilitation (Dr. Chan) - KV.pdf

REHABILITATION MEDICINE 3.1 Post-Stroke Rehabilitation (Dr. Kelvin Chan) FEU-NRMF MEDICINE BATCH 2017 Date: March 2016 ---------------------------------------------------------------------------------------------------------------------------------------------------------• Predictors of EARLY death: STROKE / CEREBROVASCULAR ACCIDENT o impaired, loss of consciousness in 1st 24 hours • Survival Rate o 1st: infarct – 10%, hemorrhage – 50% o After 1st month: 6% per year

• NON-TRAUMATIC BRAIN INJURY • 2 TYPES: o ISCHEMIC § characterized by the sudden loss of blood circulation to an area of the brain, resulting in a corresponding loss of neurologic function

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

GENERAL MEDICAL MANAGEMENT à Make correct diagnosis à Establish causes particularly if treatable à 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 à Initiate secondary prevention in patients who might benefit à Treat any coincidental disorders

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• RISK FACTORS: o hypertension, diabetes mellitus o smoking, illicit drug use o arrhythmia and valvular disease • Most common: MCA infarct o contralateral weakness o sensory loss o homonymous hemianopsia

SIGNS AND SYMPTOMS DOMINANT hemisphere o (usually left) o Right hemiparesis o Right hemisensory loss o Left gaze preference o Right visual field cut o Aphasia o Neglect (atypical) NONDOMINANT hemisphere o Left hemiparesis o Left hemisensory loss o Right gaze preference o Left visual field cut

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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 o Coordinated interdisciplinary team o Staff: special interest in the management of stroke, access to ongoing professional education and training o Clear communication – regular team meeting o Active encouragement of patients and their cares to active involvement in rehabilitation

Cardiac Precautions à New onset of cardio-pulmonary symptoms à Heart rate decrease > 20% of baseline à HR increase > 50% of baseline

KIM VILLANUEVA, PTRP

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SBP increase to 240 mmHg SBP decrease >/= 30 mmHg from baseline to < 90 mmHg DBP increase to 120 mmHg

CRITERIA FOR ADMISSION TO A COMPREHENSIVE REHABILITATION PROGRAM à Stable neurologic status à Significant existing neuro deficit à Identified disability affecting at least 2 of the ff: o Mobility o Self-care activities o Communication o Bowel, bladder control o Swallowing à Sufficient cognitive function to learn à Sufficient communicative ability to emerge with the therapists à Physical ability to tolerate the active program à Achievable therapeutic goal MOBILIZATION à Within 12-24 hrs, if possible à Daily active/passive rom exercises à Progressively increased activity à Changes of position in bed MANAGEMENT CONSEQUENCE OF STROKE A. SENSORY MOTOR IMPAIRMENTS à Strength o Progressive resistance exercise o EMF biofeedback o Electrical stimulation o Task specific training à Sensation o Sensory-specific training o Sensory-related training o Cutaneous electrical stimulation à Spasticity (Brunnstrom stages of motor recovery) o Botulinium toxin (not permanent) o Intrathecal baclofen (anti-spastic medication) o Dynamic splinting o Vibration o Stretch o EMG biofeedback à Contractures o Prolonged positions in a lengthened position (splint) o Electrical stimulation o Casting à Subluxation of shoulders o Electrical stimulation (supraspinatus and deltoid) o Firm support device à Swelling of extremity o Electrical stimulation o CPM in elevation o Pressure garments à Cardiovascular fitness à Falling

SPASTICITY à Painful and debilitating à Slightly spastic knee extensors can lock the knee during standing or cause hyperextension (genu recurvatum), which may require a knee brace with an extension stop. à Flexor spasticity develops in most hemiplegic hands and wrists o flexion contracture may develop rapidly, resulting in pain and difficulty maintaining personal hygiene o range-of-motion exercises several times a day o hand or wrist splint may also be useful, particularly at night. o Patients and family members are taught to do these exercises, which are strongly encouraged à Heat or cold therapy can temporarily decrease spasticity and allow the muscle to be stretched Brunnstrom Stages Of Motor Recovery no activation of the limb (+) spasticity; (+) weak basic flexor and extensor synergies Stage 3 prominent spasticity; px voluntarily moves the limb, but muscle activation is all within the synergy patterns Stage 1 Stage 2

Stage 4

decline in spasticity and influence of synergy; less restrictions; difficult à easy movement progression

Stage5

continued decline in spasticity; px able to demonstrate isolated joint movements; more complex movement combinations

Stage 6

(-) spasticity; near normal to normal movement and coordination

CONTRACTURES à Hemiplegia is often associated with contractures. à Placing 1 or 2 pillows under the affected arm à prevent dislocation of the shoulder. à Posterior foot splint applied with the ankle in a 90° position à prevent equinus deformity and foot drop à Reeducation and coordination exercises of the affected extremities are added as soon as tolerated, often within 1 week. à Active and active-assistive range-of-motion exercise o Active exercise of the unaffected extremities must be encouraged à Most important muscle for ambulation: unaffected quadriceps o If weak, this muscle must be strengthened to assist the hemiplegic side à Posterior foot splint applied with the ankle in a 90° position à prevent equinus deformity (talipes equinus) and footdrop B. PHYSICAL ACTIVITY à Sitting – task specific activity à Stand-up from chair

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Standing – tilt table Walking o joint position feedback o cueing of cadence o treadmill o multichannel electrical stimulation Transfers Gait re-training Upper limb activity

FUNCTIONAL ELECTRICAL STIMULATION (FES) à generate muscle contraction to perform a task à Bursts of high intensity electrical impulses via surface of the body in stimulated nerves ARMin-ROBOT ASSISTED à Movement: prevent joint degeneration & preserve joint mobility à ADL therapy à GAME therapy

C. ACTIVITIES OF DAILY LIVING: Occupational Therapy D. COGNITIVE CAPACITY à Attention and concentration – cognitive therapy à Memory – external cues and prompting à Executive function – external cues E. VISUOSPATIAL à Visual function o prism glasses o computer-based visual restitution à Agnosia à Neglect o Cognitive rehabilitation à Apraxia o strategy training à Aphasia o group therapy o speech therapy o augmentative alternative communication device COMMUNICATION à Aphasia o Intervention § Use of gestures § Constraint induced o Enhance treatment § Supported conversation technique § Computer-based therapy à Dyspraxia DYSPHAGIA à Compensating strategy o Positioning o Therapeutic maneuver o Modify food and fluids à Adjunctive method o ‘shaker’ therapy o Thermo-tactile stimulation o Electrical stimulation MULTIMODAL REACTIVATION OF SENSORIMOTOR MECHANISM à Provide afferent proprioceptive feedback à Motor planning and execution areas by embedding the movement in task oriented areas à Stimulate motor planning areas by directing attention to a task and encouraging rehearsal of intended movements

VR-BASED INTERACTIVE COGNITIVE THERAPY • Mirror neurohypothesis • Stimulate action observation system that could encourage plasticity and repair à à

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COMPLICATIONS Neurologic(toxic or metabolism) Medical o Pulmonary aspiration/pneumonia, UTI, Depression, Musculoskeletal Aspiration Pneumonia o Oral stimulation; Patient should me sitting upright with forward; Modifying consistency of food from pureed liquid to thickened liquid; NGT if swallowing is not safe UTI (common because of neurogenic bladder) Musculoskeletal Pain o shoulder and arm pain develops early, several weeks to 6 months post onset Shoulder subluxation o Due to weak supraspinatus and deltoid muscle; Managed by placing lap board; Stimulating weak muscles; Relaxing the shoulder depressor and internal rotator Reflex Sympathetic Dystrophy Deep Vein Thrombosis INDICATORS OF POOR PROGNOSIS Proprioceptive facilitation > 9 days Traction response of shoulder flexors/adductors >13 days Prolonged flaccid period Onset of motion >2-4 weeks Severe proximal spasticity Absence of voluntary hand movement >4-6 weeks FACTORS PREDICTIVE OF POOR ADL severity of stroke o severe weakness o poor sitting balance o visuospatial deficits o mental changes o incontinence o low initial ADL scores time interval: onset to rehabilitation advance age

KIM VILLANUEVA, PTRP

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APHASIA

STUDY THIS DIAGRAM LUMALABAS SYA SA SAMPLEX

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GLOBAL APHASIA MIXED TRANSCORTICAL APHASIA BROCA’S APHASIA TRANSCORTICAL MOTOR APHASIA WERNICKE’S APHASIA TRANSCORTICAL SENSORY APHASIA CONDUCTION APHASIA ANOMIC APHASIA

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GOOD GOOD

IMPAIRED GOOD

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IMPAIRED

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THANK YOU DOYENNE SADICON!

KIM VILLANUEVA, PTRP

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