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Introduction

Ninety percent of stroke patients have a residual deficit, and nearly 50 % have a motor deficit. Conventional rehabilitation methods have shown modest results. There is substantial research in pharmacological and technological approaches to enhance recovery. You should familiarize yourself with the rehabilitative approaches and scales for measuring level of function and disability. Please take note of the evolving criteria involved in admitting stroke patients to various facilities for post-stroke care.

Goals of Rehab

  • To reach maximal physical, functional, and psycho-social recovery within limits of the patient’s level of impairment, to optimized activities of daily living

    • Includes speech and cognitive aspects

  • Relearning skills that were present prior to event

  • Adaptation

  • Priority is on self-care and mobility

  • Rehab should begin within 24 h of stroke

Natural History of Motor Recovery

  • Most recovery occurs within first 3–12 months

  • Patients with some residual function are most likely to improve

    • Degree of damage to the corticospinal tract can predict outcome

  • Patients with a plegic limb are less likely to respond

  • Can predict severity of outcome based on recovery at 1 month

    • Upper extremity: poor outcome likely if no voluntary movement at 15 days, or no grip at 1 month

    • Lower extremity: voluntary movement of hip at 1 week can indicate eventual mobility, albeit with the aid of an assistive device or ankle orthosis

  • Pattern of recovery

    • Recovery almost always occurs in the proximal muscles of upper and lower extremities first

    • Treatment with SSRI has been shown to improve motor recovery in selected patients (See FLAME trial below); however, scales such as NIHSS , mRS, and Montgomery Depression Scale showed no improvement

Scales

  • Measure disability or functional status

    • Functional Independence Measure (FIM): a thorough measure of function (as well as social interactions, cognitive function, balance); indicates how much assistance is required to carry out activities of daily living (ADL): dressing, feeding, bathing, toileting

      • Most commonly used scale measuring functionality after stroke, recommended by American Stroke Association

    • Barthel Index (BI): measure of a patient’s ability for self-care and mobility (ADLs such as feeding, dressing, grooming, and bathing)

    • NIHSS : quantitative scale measuring symptom severity, not level of disability; concordant with stroke volume. Biased toward anterior circulation strokes, particularly left hemisphere, with poor evaluation of cranial nerves and gait

    • Modified Rankin Scale (mRS): measure of disability and dependence after stroke, differentiating the presence of symptoms, ability to carry out usual activities, ability to look after oneself, and ability to walk independently

    • Glasgow Outcome Scale (GOS): measure of outcome after brain injury, studied to assess level of consciousness; not used in stroke assessment

    • Stroke Impact Scale (SIS): assesses overall status of functioning, communication, cognition, emotion, following stroke

Rehab Techniques and Approaches

  • Vary from patient to patient

    • Constraint-induced movement therapy (CIMT)

      • Constraint of the unaffected hand (usually with a mitt), forcing the subject to use the stroke-affected hand

      • Requires daily, intensive training to be superior to conventional therapy

      • Requires at least 20° of wrist extension and 10° of motion in each finger (i.e., ineffective in a hemiplegic limb)

    • Robotic devices

      • Unclear if superior to conventional physical therapy

    • Functional electrical stimulation

      • Effective in some patients, not widespread

      • No evidence that it improves function

      • Bilateral arm training, electrical or magnetic brain stimulation, sensory stimulation

    • Focus initially is on balance, transfers, supported ambulation (parallel bars), gradually advancing to cane with progressively smaller base of support (rolling walker, quad cane, J handle or straight cane), less assistance from others

    • Ambulation

      • Usually starts with sitting balance, advances to ambulation with support, then less support

      • Partial body weight support: patient partially supported with harness to allow for a relatively normal gait pattern

        • Can be done with or without a treadmill

      • Patient encouraged to place weight on paretic leg with pursuance of optimal biomechanical and neuromotor gait patterns

      • Graduate to walking on uneven ground, stairs, etc

    • Ankle Foot Orthotic (AFO):

      • Prevents plantar flexion, inversion, and knee hyperextension (recurvatum)

      • Improves dorsiflexion, promotes better heel strike, provides ankle stability

      • Improves biomechanics of gait

      • Prevents pressure sores

      • Most patients do not require this for long term

    • Wheelchairs

      • Important features include seat depth and width, and height of back

      • Even weight distribution avoids pressure ulcers

      • For a person with severe hemiplegia, the seat should be 1.5–2 in. lower than standard wheelchair to allow them to propel the chair using strong arm

Specific Deficits

  • Aphasia and dysarthria

    • Recovery twice as good if therapy begun within first 4 weeks of stroke

    • Aphasia : acquired impairment of verbal language behavior

      • Occurs in about 25 % of stroke patients

      • Recovery depends on initial severity

      • Intensive treatment (2 hours a day, 4 days a week) is more effective than a similar number of sessions more spread out

      • Mixed results for pharmacological approaches such as amphetamines, dopaminergic agonists, acetylcholinesterase, and piracetam

    • Dysarthria

      • If severe, consideration is given to augmentative or alternative communication devices

  • Neglect

    • Defined as inattention to a hemispace contralateral to the lesion, commonly due to right hemispheric strokes

    • Spatial Neglect: difficulty attending to one side, often accompanied with visual or sensory neglect as well

    • High risk of falls

    • Treatment complicated by lack of insight into limitation

    • Visual, verbal cues can help

    • Prism therapy has been used for hemispatial neglect, which shifts objects from the left, more over to the right

    • Other attempts include eye patches, virtual reality, vestibular stimulation

    • Dysphagia

      • Disruption of normal swallowing mechanism

      • Aspiration is the main concern

      • Bedside swallow evaluation by nurse or speech-language pathologist

      • Silent aspirators: no clinical symptoms

      • Usually improves with time

      • Beneficial effects of percutaneous endoscopic gastrostomy (PEG) are uncertain

      • High mortality post-PEG placement

    • Shoulder Pain

      • Occurs in up to 80 % of poststroke patients

      • Onset is delayed and occurs in rehab usually

      • Risk of injury to shoulder is higher during flaccid period when shoulder is unstable

        • Possible causes: Subdeltoid bursitis, supraspinatus tendinitis, brachial plexopathy, rotator cuff tears, subluxation of humeral head out of glenoid fossa

      • Care should be taken to protect shoulder during rehab and transfers to avoid traction or torsion

    • Spasticity

      • Upper motor neuron syndrome involving increased tone, muscle co-contraction, synergistic motor movements, spasms, clonus

      • Very common after stroke, more common in younger patients, and those with more severe weakness

      • Can result in functional impairment, muscle atrophy, pain, neuropathy, skin breakdown, ulcers

      • Upper limb spasticity: shoulder adduction, elbow/wrist/finger flexion

      • Lower limb spasticity: hip adduction, flexed or extended knee, striatal toe, equinovarus foot

      • Treatment: positioning, stretching, splinting

        • Phenol and alcohol injections reduce spasticity effectively in poststroke patients, but effects are irreversible, and with many side effects

          • Indicated for debilitating or painful spasticity

        • Baclofen and benzodiazepine (act on GABA receptors), muscle relaxants (monoamines) should be used with caution as they are sedating and could compromise motor recovery and lead to generalized weakness

          • Consider intrathecal baclofen if oral treatment is inadequate in controlling lower limb spasticity or is not tolerated

          • Valium contraindicated in acute setting

        • Botulinum toxin – most widely used treatment for focal spasticity

          • Inhibits the release of acetylcholine at the neuromuscular junction

          • FDA approved for treatment of upper and lower limb spasticity

          • Essential that botulinum toxin injections are given in conjunction with physiotherapy in order to obtain the maximum benefit

          • Reversible, needs to be repeated every three months

          • Increased tone in lower extremity usually provides stability, therefore many patients only get treatment in upper extremity during ambulation

Poststroke Depression

  • Prevalence 20–80 %, peak is 3–6 months after stroke

  • Associated with increased mortality and greater cognitive impairments compared to those not depressed

  • Associated with worse functional outcome

  • Early diagnosis and treatment is crucial

  • May be associated with left-sided lesions, but this remains controversial

  • Pharmacological therapies first line and used without any controlled studies done

  • Nonpharmacological management strategies are expensive, not studied well, and underutilized

Driving

  • Only 30–60 % of poststroke patients are able to resume driving

  • Requires attention, concentration, intact vision, rapid response times

  • On-road testing with experienced facility usually recommended for poststroke patients wishing to drive

  • Adapted vehicles with steering wheel pegs, accelerator extensions can be used for patients with hemiparesis

Rehabilitation Facilities

  • Long-term acute care hospital (LTACH) medical comorbidities requiring intensive care

    • Medicare requires 3 day ICU stay in acute care hospitals prior to admission

  • Acute care rehabilitation

    • Rehabilitation facility with full range of rehab services

    • 24/7 medical care

    • Must be attentive to therapies for at least 3 hours a day for admission

  • Subacute Facility

    • Less demanding than acute care rehab

    • Daily nursing and wide range of rehab services

    • May stay at the facility for longer periods of time

  • Long-term care facility

    • Survivors who require 24/7 nursing care (nursing home)

    • May have one or more rehab services

  • Home health agency

    • Specific rehab in home settings

Notable Trials

FLAME (2011): Randomized French trial testing the efficacy of fluoxetine in improving the recovery of stroke patients with hemiplegia or hemiparesis. Patients were randomized to fluoxetine 20 mg daily versus placebo for 3 months, starting 5–10 days after stroke onset, in conjunction with PT. The study found that in patients with moderate-to-severe motor deficit, early treatment with fluoxetine with PT improved motor recovery after 3 months (Chollet et al. 2011).