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Rehabilitation after stroke


Learning objectives

  • Understand the role of rehabilitation
  • Delivery of rehabilitation
  • Use of equipment
  • Roles of members of the Multidisciplinary team

Introduction

  • Rehabilitation is the process through which patients are assisted in regaining functions to allow them to gain independence.
  • To enable this to happen patients usually need to have a rehabable pathology where there will be structural repair associated with improved function
  • This can be optimised by therapists can channel towards functional gains.
  • Therapy and "use" can promote the formation of new synaptic connections
  • In the early days and weeks and months following stroke there are healing pathological processes detailed below
  • Active rehabilitation can further improve outcome beyond that which would have been seen with a more passive approach.
  • Other concepts such as neuroplasticity also help to explain improvements seen post stroke.

Pathophysiology

Early Pathological improvements
  • Resolution of post stroke oedema
  • Resolution of haematoma or haemorrhagic transformation
  • Resolution of raised ICP
  • Regaining blood-brain barrier
  • Resolved secondary infections and complications
  • Reperfusion of ischaemic penumbra
  • Resorption of toxic metabolites
  • Removal of blood and its waste products
  • Removal of free radical
  • Recovery of partially damaged neurones and glial cells
Late Pathological improvements
  • Restructuring of function and order
  • Development of new synaptic connections
  • Denervation supersensitivity

Basic Principles of Stroke Rehabilitation

  • Restitution: depends upon improvements based on local repair such as reduction of oedema, absorption of blood or restoration of axonal transport as listed above
  • Substitution: focuses on functional adaptation to the deficit, through partially restoring neural networks and compensation for the lost or broken connections after injury. Substitution can be a process of partial reorganization of cortical representation for movement and changes in activity in components of the motor network.
  • Compensation: aims to improve the mismatch between the patient's disability and expectations, as well as demands of the patient's environment. Compensation acts upon the locomotor system, and in particular it has an impact on increasing the time, effort and amount of training of the damaged skill?"

Fitness for therapies

  • There are some basic requirements and that is a patient who is well enough to engage with therapies.
  • Ongoing sickness, vomiting, diarrhoea and headache and such need addressed so that the patient can commit to rehab.
  • Need to manage urinary tract infections and heart failure and ensure adequate nutrition.
  • There needs to be sufficient cognitive function for the patient to understand what they are asked to do and why.
  • It is difficult to engage patients with severe delirium or dementia with active therapies.
  • It is important for the teams to identify causes and actions plans to speed up the time to mobility.

Most of the neurological recovery occurs within the first 3 months. The initial therapy can be delivered as an inpatient on the HASU with plans for either inpatient as early supported discharge for ongoing needs. Some patients approximately 5% may show ongoing recovery for up to a year. An improvement in some motor power may not translated into a change in function. There are many factors such as patient motivation and mood and cognition involved in carry over between sessions. A small group do not benefit from rehabilitation as they have coexistent diseases such as active malignancy or severe cardiorespiratory disease or severe frailty or dementia or mental health issues and a lack of physiological reserve to engage meaningfully with what is often exhausting work for them.

Stages of recovery

Comments
0%stroke survivors recover almost completely
25% recover with minor impairments
40% experience moderate to severe impairments requiring special care
10% require care in a nursing home or other long-term care facility
15% die shortly after the stroke

First steps

  • In most patients the first encounter is looking at simply getting a patient safely out of bed.
  • Early mobilisation usually starts at 24-48 hrs post stroke.
  • Early improvements has strong psychological benefits
  • The therapists usually begin with sitting balance to see if a patient has enough position sense and truncal strength to sit themselves up with their centre of gravity in the midline.
  • Good Positioning helps comfort, tolerance, skin protection and developing postural stability
  • If this is intact then therapists can consider seating and get the patient out of bed.
  • Therapists work on specific tasks - sitting up, turning in bed and then more function tasks such as feeding, grooming and dressing
  • If the patient needs a great deal of support then a bucket chair is used.
  • Comfortable chairs are such as they remove much of the active part of sitting which is an active process.
  • The bucket chair provides a great deal of support. In the early days after stroke patients can tire quickly doing even very basic tasks such as sitting out, but this usually improves.
  • In many organisations, the role of OT and PT often merges and many work together as a team and this is often optimal in delivering the most therapy in a window of time without the patient losing their concentration or becoming functionally fatigued.
Complications to prevent or detect and manage
  • Recurrent stroke
  • DVT
  • Dysphagia
  • Malnutrition
  • Pressure sores and skin integrity
  • Depression
  • Constipation
  • Faecal incontinence
  • Urinary incontinence

How long

  • If one is setting weekly goals then it soon becomes clear when no further progress is being made and it's at this stage that rehabilitation can be withdrawn.
  • As I explain we try to change the patient but when that stops we change the world around the patient and so therapists may be involved in getting a hospital bed at home or other various aids and appliances which are helpful for the patient. Some patients need the visit of carers to help with personal all daycare
Basic Principles
  • Identify impairments - cognitive, communication, motor, sensory, visual
  • Early mobilisation and sitting out
  • Ensure safe swallow before feeding to avoid aspiration pneumonia. Bedside exam which may be supplemented with videoflouroscopy
  • Assess Nutrition
  • Avoid indwelling catheters
  • Establish bowel/bladder regimen
  • Screen for and manage Depression
  • Manage Constipation
  • Goal setting with patient

The Team

  • All staff should be involved in rehabilitation and much work can be done when therapists are not there.
  • Patients should always be encouraged to do as much for themselves as their abilities and fatigue allow.
  • Therapy staff will leave exercises and activities for the patient to do when they are not present. It is useful if staff and families can continue this work.
  • The rehab staff includes the nurses and health care assistants, the physiotherapist and occupational therapists.
  • Speech and language therapists looking at swallowing and speech, dieticians optimising intake and psychologists looking at those with severe mood impairment.
  • It is important that therapy staff and clinicians discuss patients.
  • I often find a detailed therapy assessment incredibly good at picking up neurology which I may well have missed.
  • It is important to always respect the advice and help of therapy staff who are often very experienced.
Interdisciplinary team
  • Medical staff - consultant and junior doctors
  • Stroke ward Nurse
  • Physiotherapists and assistants
  • Occupational therapists and assistants
  • Speech and language therapists
  • Social worker
  • Neuropsychologist
  • Dieticians
  • Orthopists

Stages of recovery

Comments
0 Bed bound and unable to sit in chair
1Bed to chair existence. Sits out for short periods < 2 hours
2 Bed to chair existence. Sits out for longer periods > 2 hours
3 Bed to chair existence. Sits out for longer periods > 4 hours and is standing with support
4 Bed to chair existence. Sits out for longer periods > 4 hours and is standing with support of one
5 Bed to chair existence. Sits out for longer periods > 4 hours and is stepping with support of one
6 Sits out normally. Can stand with frame. Steps < 5 m
7 Sits out normally. Can stand with frame. Steps > 5 m
8 Walks with stick short distance< 10 m
9 Walks with stick short distance > 10 m
Outcome measures
  • Stroke severity - NIHSS
  • Upper/Lower limb function - Fugyl meyer
  • Visual perception - line bisection
  • Balance - Berg Balance score
  • Cognition - MMSE, MOCA, Aphasia friendly tools
  • ADLS ; FIM, Barthel
  • Mood screening

Goal setting

  • Therapy is not open ended and can only be justified if it delivers and this can only be determined by setting goals.
  • These must be specific, and patient centred and personalised where possible. They should be measurable and achievable. They need to be realistic within the time determined. Goals can be broken down into long term and short term.
  • Key to good therapy is to constantly move the process on by defining realistic and achievable goals and setting a time for these.
  • It is important to be constantly accessing progress through quantifiable assessments.
  • The patient should be involved in setting goals, especially as things advance. For one patient doing stairs may be a goal.
  • For others that might not be so relevant, and they simply want to be able to walk into the garden safely.
SMART Goals
  • Specific
  • Measurable
  • Achievable
  • Realistic
  • Timed
Outcome measures
  • Stroke severity - NIHSS
  • Upper/Lower limb function - Fugyl meyer
  • Visual perception - line bisection
  • Balance - Berg Balance score
  • Cognition - MMSE, MOCA, Aphasia friendly tools
  • ADLS ; FIM, Barthel
  • Mood screening -
Later rehabilitation Issues
  • Psychological maladjustment
  • Depression
  • Sexuality
  • Vocational
  • Driving
  • Equipment needs
  • Spasticity
  • Shoulder issues : Damage to rotator cuff, Spasticity, subluxation, regional pain syndromes, contractures
  • Central pain syndromes

Location

For most patients, rehabilitation starts in hospital and then can continue with early supported discharge. Some may need transfer to an inpatient rehabilitation ward which may be off site such as in a community hospital bed. For some who go to placement some rehabilitation may continue if there are SMART goals still to be achieved.

Stroke localisation and deficits

Visuospatial neglect: abnormal processing of externally derived visual spatial informaiton usually due to damage within the righ parietal lobe. Possibility of rehabilitation. Vestibular and optokinetic stimulation, transcutaneous mechanical vibrations, electric vibrations, prism adaptation, etc.

Equipment

NameFunction
The ReTurn is a multi-functional, pivoting and transportation platform. For users who still retain some strength, ReTurn stimulates the natural pattern of moving when progressing from sit-to-stand and it also strengthens a range of muscles. Able to move in any direction, the ReTurn is easy-to-use and allows perfect positioning on the chair every time. Having a range of hand-holds allows the user to position their hands in the optimum position for the transfer. For transfers out of a low chair, the user can raise their hand position during the transfer, like climbing a ladder. The ReTurn belt supports the pelvic area and is used as a handling belt during the raise. Once the user is stood, it attaches to the ReTurn to secure and hold the user during turning.
Supportive chair for those patients in early days to enable them to get out of bed. The chair provides good lateral and back support and allows tilting.
A wheeled commode can be useful to allow toileting out of bed when the patient cannot mobilise as far as the toilet. These may be used at home for the same reason when the toilet is too far away or on another level. It needs an able-bodied person to clean them afterwards. The patient needs to be able to transfer out of bed with minimal assistance and to be able to sit securely on the commode.
Bed lever can help patients with weakness to sit up and to get out of bed. The horizontal part slides under the mattress.

Constraint Induced Movement Therapy

  • This is a form of rehabilitation which restrains the unaffected side to focus entirely on the affected side. The constraint may be with a sling or mitt for 90% of waking hours, while intensively inducing the use of the more-affected arm. Repetitive training of the weak limb is usually performed for six hours a day for a two to three-week period.
  • Compliance of the patient for this is needed. Benefits may be seen in those individuals with some active wrist and hand movement. Studies have explored the efficacy of this intervention for improving functional outcomes post-stroke.

Rehabilitation robotics

This is an active area of rehabilitation study.

Role of Staff

  • Rehabilitation is performed by the patient in concert with therapy staff. Physiotherapists look particularly at physical aspects. Abnormal tone, weakness, ataxia and other neurological functions. Their job is to work to accentuate improvements in tone, weakness, balance and translate these into functional return such as the ability to walk safely. The occupational therapists look more at the next step which is suing the improvements in weakness, tone and dexterity to do things that can aid independence - to wash oneself, to change clothes etc.
  • They can also look at higher functions such as mood and cognition. How decisions are made. They are focused on looking at tasks such as a kitchen assessment which of themselves are valuable tests of vision, strength and cognitive function as well as organisational skills and executive functioning. It's quite fascinating the level of complexity and the information that can be learned by watching a patient perform a simple kitchen task.

Assessing Disability with Modified Rankin Score

Comments
0 No symptoms at all
1 No significant disability despite symptoms; able to carry out all usual duties and activities
2 Slight disability; unable to carry out all previous activities, but able to look after own affairs without assistance
3 Moderate disability; requiring some help, but able to walk without assistance
4 Moderately severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistance
5 Severe disability; bedridden, incontinent and requiring constant nursing care and attention
6 Dead

References


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