OS 211 [A]: Integration, Control, and Behavior
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Lec 14: Stroke Rehabilitation
December 5, 2013
Dr. Sharon Ignacio
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TOPIC OUTLINE
I.
II.
Introduction
Rehabilitation Concerns in Stroke Patients
A. Motor Impairment
B. Communication and Language Impairment
C. Cognitive Impairment
D. Swallowing Problems (Dysphagia)
E. Pain Syndromes
F. Pressure Ulcers
G. Deep Vein Thrombosis
H. Spasticity
I. Urinary Incontinence
J. Psychological Problems
K. Rehabilitation of Stroke Patients
III. Assessment of a Stroke Patient
A. ICF classification of functioning, disability and health
B. Assessment of Impairment, Disability and Handicap
C. Assessment of Neurologic Status NIHSS
D. Assessment of Function
IV. Recovery and Rehabilitation
A. Recovery
B. Rehabilitation
V. The Case
A. MOTOR IMPAIRMENT
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Hemiparesis- 88% of stroke patients
o In hemiplegic patients, there is usually flexion synergy in upper
extremities (flexed elbow, wrist, fingers) and extension synergy in
lower extremities)
o Compensation for extension synergy in lower extremities include
abduction, circumduction, and flexion of foot so it won’t drag along
the floor
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Involved Vessels
o Middle Cerebral Artery
 More commonly involved than the ACA
 Arm more involved than the leg; the degree of functional
recovery in the arm is less than the leg
 Upper limb relies on fine motor control of hand for functional
tasks; gross movement does not result in substantial level of
function
o Anterior Cerebral Artery
 Lower limb more involved than the upper limb
 Distal upper limb more preserved
Whirlwind Trans! The parts with smaller font size were not discussed
thoroughly by the lecturer
I. INTRODUCTION
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Stroke is one of the most serious neurologic problems in the world
today
Third leading cause of deaths in the US
Worldwide, approximately 15 million with stroke each year
o Stroke Society of the Philippines (video) data: 20 million people with stroke
each year
 Stroke kills 5 million people annually
 Number 2 killer worldwide; number 1 killer in Asia
 Leading cause of disability
780,000 new or recurrent cases annually in the United States (one every 45
seconds)
600,000 – first strokes
280,000 – second or recurrent strokes (usually worse than the 1st)
Stroke Facts
From the National Heart, Lung and Blood Institute (NHLBI)
Framingham Stroke Study
 31% of stroke survivors require assistance in activities of daily living
(ADL)
 20% of stroke survivors require assistance in mobility
 71% of stroke survivors who worked could not work 7 years after
their strokes
 There are more younger patients today than there were before.
Visual and Spatial Deficiency
Psychological/Emotional Deficit
Sensory Deficits
Swallowing Problems
Skin Breakdown
Risk for DVT
Bowel and Bladder dysfunction
Malnutrition
Pain – Central pain , RSD, Contracture, Spasticity, Bursitis
Spasticity
Pulmonary aspiration and Pneumonia
Urinary Tract Infection
Motor Recovery in Stroke
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Copenhagen Stroke Study
o 95% stroke survivors – best neurologic level achieved in 11
weeks (3 months-expect neurologic recovery)
 Milder Strokes – earlier recovery
 Severe Strokes – 15 weeks on the average
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However, recovery varies (co-morbidities, location and size of the lesion).
Stroke survivors with chronic stable motor deficits can experience improved
motor function with an intensive rehab program.
Mechanisms of Recovery
o Recovery of function in portions of ischemic penumbra
o Resolution of edema and mass effect
o Cerebral plasticity and brain reorganization
 Alterations in cortical maps associated with plasticity
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Goals of Stroke Rehabilitation
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Recovery may continue over a longer period of time in some patients with
significant partial return of voluntary movement
Modifications in neuronal networks are use-dependent
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Techniques that promote non-use may inhibit recovery
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80-90% of patient’s waking time is used exercising affected limb to maximize
recovery
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Stroke rehabilitation involves retraining the patient to optimize
potential (based on their co-morbid conditions and health status)
and improve quality of life
Primary goals of rehabilitation: “prevent complications, minimize
impairment, and maximize function.”
Other goals:
o Prevent, recognize, manage and minimize the impact of
preexisting medical conditions and secondary medical
complications
o Facilitate psychosocial adaptation by both patient and family
o Promote reintegration in society in order to resume life roles
o Enhance quality of life
Classic Posturing of a Stroke Patient
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Synergy – helps patient to become more functional, patient can
move the distal portion of extremities with the aid of movement of
proximal portion (eg. moving wrist/fingers by moving shoulder)
Flexor
synergy
II. REHABILITATION CONCERNS IN STROKE PATIENTS
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Assessment of cognition and arousal is important for determining
the patient’s capabilities and limitations for coping with their stroke
and assuring success of the rehabilitation process. The results of the
assessment may impact the choice of treatment and disposition of
the patient
o Motor Impairment (most common problem) – paralysis
o Communication Impairment – dysarthria
o Cognitive Deficits
AICA, LEA, JEBBICK
Extensor
synergy
Upper Limb
Shoulder Retraction
Shoulder Abduction
Shoulder External Rotation
Elbow Flexion
Forearm Supination
Wrist Flexion
Finger Flexion
Shoulder Protraction
Shoulder Adduction
Elbow Extension
Forearm Pronation
Wrist Extension
Lower Limb
Hip Flexion
Hip Abduction
Hip External Rotation
Knee Flexion
Ankle Eversion
Dorsiflexion
Toe Extension
Hip Extension
Hip Adduction
Knee Extension
Ankle Inversion
Plantarflexion
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Lec 14: Stroke Rehabilitation
Finger Flexion
Toe Flexion
Table 1. Synergy Patterns in Motor Recovery
 Upper extremity in Flexion Synergy
o Shoulder internally rotated
o Elbow, wrist and fingers flexed
 Lower extremity in Extension Synergy
o Hip abducted
o Knee extended
o Foot plantarflexed
o If lower extremity is in Flexion Synergy – difficult for px to walk
Brain Reorganization
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Process of reorganization is dynamic
Reorganization dependent on the nature of injury, substrates
involved and the duration since the initial insult
Strict localization of function to one anatomic site vs multiple widely
distributed pathways
Other pathways in brain “wake up” to replace affected site
Plasticity is strongly influenced by use → more aggressive rehab
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Active repetitive movement training- MOST IMPORTANT in
facilitating motor relearning after stroke
Repetition , task-oriented
Direct influence on the process of functional reorganization in the
brain
Enhances neurologic recovery
Strategies for motor relearning:
o Impairment-oriented training
o Constraint-induced movement therapy (CIMT)
 Ideally for patients with motor strength of at least 2/5
 Patients assigned to CIMT wore immobilizing mitts over
unaffected hand
 Use affected hand 80-90% of their waking hours
 During a 2-week period
 6 hours per day: one-on-one training
o Extremity Constraint-Induced Therapy Evaluation (EXCITE)
 Upper extremity hemiparesis
 34% reduction in time to task completion
 26% improvement in the proportion of tasks completed with affected arm
Pharmacologic Therapies to Enhance Motor Recovery
 Selective Serotonin Reuptake Inhibitors (SSRI) – regulate memory,
mood and sleep; activate cortical motor areas (Citalopram –
improved hand dexterity; Fluoxetine – improved motor skill)
 Dopamine – single dose 100 mg levodopa and one dose 25 mg
carbidopa may promote neuroplasticity in the cerebral cortex for
memory and learning
 “OFF LABEL” USE (?)
 Once discovered – influence course of rehabilitation (?)
B. COMMUNICATION AND LANGUAGE IMPAIRMENT
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Treadmill location training with assistance of a robot-drive gait
orthosis.
Helps in building muscle mass in hemiparetic patients
Assists walking movements
Adjustable in force, body weight support and speed
Identify which muscles need to be trained
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Motor Imagery
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Representations of a given motor act internally rehearsed in working
memory WITHOUT motor output
o Ask px to practice movement and be specific in instructing patient
eg. grasping the pizza to putting it in mouth
Mental practice (MP) of a particular motor skill activate the same
musculature and neural areas as physical practice of the skill
o Setting described
o Subject imagined doing the activity
o Subject would go through the visual image from a first person
perspective: sensations included
o Lasts 20 minutes, wherein the last 10 minutes are focused on the
setting
(From 2015) Mirror imagery: placing a mirror opposite the patient’s
good hand (for example) and allowing the brain to perceive that the
affected hand is moving appropriately as well
Video Games and Virtual Reality
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Also utilized to assist the recovery of stroke patients
o With the help of a robot, patient’s hand moves to the target
In the first few days of confinement, we need to know what the
patient needs
40% of post-stroke patients suffer from communication impairment
Language Impairment
(Aphasias)
Lokomat
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Stimulate precise areas of the human cortex of the brain with
electrodes to produce movement
Simultaneously measures effect of stimuli on the CNS and PNS
responsible for movement
Stimuli are given by a small electromagnetic coil
* It is not a big deal whether you use high-tech or low-tech way of
treating the patient’s motor impairment, what is important is that the
rehabilitation should be: 1.) task-specific 2.) repetitive and 3.) gain
feedback
Motor Relearning
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Motor - non-fluent, expressive,
Broca’s
Sensory – fluent, receptive,
Wernicke’s
Anomia – milder form of
aphasia
Global: combined motor and
sensory
Word salad, neologisms
AICA, LEA, JEBBICK
Speech Impairment
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Refers
to
the
motor
mechanisms in the production
of words
Dysarthria:
difficulty
in
articulation
Dysphonia
Treatment methods for aphasia
o Language oriented treatment
o Direct stimulation response treatment
o Treatment of aphasic perseveration (??)
o Visual action therapy
o Oral reading for aphasia
o Conversational coaching
Constraint Induced Language Therapy – cannot use gestures; you
have to see the actual movement
Goals:
o Facilitate recovery of communication
o Develop strategies to compensate for communication disorders
o Counsel and educate people caring for the patient
 Minimizes patient isolation and encourages patient to be
actively involved in the program
 Use gestures, com board and word retrieval
C. COGNITIVE IMPAIRMENT
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Impact of stroke on cognitive function depends on:
o Size and location of lesion
o Presence of absence of co-morbid factors (prior stroke,
dementia, neurological conditions)
May affect the rate of progress of rehabilitation
Possible impairments:
Perceptual
Impairment
(esp. if right side of
the brain is
affected)
Apraxia
Attention Deficits
Brain Stimulation
OS 211
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Processing of information impaired
o Visual, tactile or auditory hemi spatial
neglect
o Astereognosis – inability to identify
objects in the hand
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Disorder in motor planning
Inability to execute a movement
 Due to frontal, parietal and temporal lesions
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Lec 14: Stroke Rehabilitation
D. DYSPHAGIA (SWALLOWING PROBLEMS)
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Characterized by drooling, coughing as they try to swallow
45% of all stroke patients admitted in a hospital
Silent aspiration (px doesn’t cough when aspirating) in 40-70% of
patients with dysphagia
Risk of Aspiration Pneumonia and other complications
(Malnutrition) → NGT
Evaluation by simply talking to the patient, positive if you notice
dysarthria (poor articulation caused by muscle weakness)
Screening Test: Simple Bedside Swallowing Evaluation (GUSS)
o To see if the patient can eat food of different consistencies
Definitive Test: Modified Barium Swallow and FEES (Fiberoptic
endoscopic evaluation of swallowing)
Management
o If the patient is not able to swallow at all, insert a tube
o If the patient can swallow, just modify the consistency of food
Predictors of Aspiration Risk after CVA
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Dysphonia
Dysarthria
Abnormal Gag Reflex
Abnormal volitional cough (weak cough on command)
Cough within 1 minute of water ingestion (5,10,20 cc)
Voice changes after swallowing (5,10,20 cc)
Gugging Swallowing Screening (GUSS)
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Quick and reliable method to identify stroke patients with dysphagia
and aspiration risk
Simple, stepwise bedside screen that allows a graded rating with
separate evaluations for nonfluid and fluid nutrition starting with
nonfluid textures
Validity established by fiberoptic endoscopic evaluation of
swallowing
Ask if patient can swallow (normal swallowing < 2 secs: Check if
they can cough voluntarily. Check drooling in upright position)
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2. Musculoskeletal Pain
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Glenohumeral subluxation - esp in px with very flaccid tone
Spasticity, Contracture
Treatment: Use of slings, antispasticity med
Bursitis, Tendinitis, Osteoarthritis
3. Upper Limb Complex Regional Pain Syndrome (CRPS)
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Reflex Sympathetic Dystrophy (RSD), Shoulder Hand Syndrome
(SHS) – just affects hand and shoulder
More of a neuropathic type of pain, not musculoskeletal
o Neuropathic pain syndrome: Autonomic dysfunction plus severe
pain
Swelling → severe pain → atrophy, osteoporotic changes
Limitation of motion, swelling, pain, and redness. When swelling
disappears: atrophy, color changes and sometimes, osteoporosis
Criteria:
o Sensory – allodynia or hyperesthesia
o Vasomotor – temperature/skin color changes; becomes
hyperemic
AICA, LEA, JEBBICK
Pain Assessment (use 0 to 10 scale)
Determine etiology (i.e. musculoskeletal and neuropathic)
Characterize pain (location, quality, quantity, duration, intensity,
aggravating and relieving factors)
o To determine if somatic or neuropathic type of pain
o OLDCART: Onset, Location, Duration, Character, Aggravating
factors, Relieving factors, Treatment
Control Pain – interferes with therapy
Use lower doses of centrally acting analgesics
o Confusion and deterioration of cognitive performance
o Interfere with the rehabilitation process
F. PRESSURE ULCERS
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1. Central Pain/ Thalamic Pain
Strokes involving spino-thalamo-cortical pathways
Burning in character
Begins a few weeks post-stroke
May be constant, moderate, or severe
Treatment
o Antidepressants (amitriptyline, nortriptyline, trazodone), opiod
analgesics, anti convulsants (carbamazepine, gabapentin,
phenytoin)
o Antispasticity drugs
o Transcutaneous electrical nerve stimulation (TENS)
o Multimodality treatment eg. including Physical Therapy
o Sudomotor/Edema – edema/sweating (early)
o Motor/Trophic changes – weakness, hair, nail, skin change (late)
Best cure: Prevention through early mobilization
o CRPS usually appear 2 weeks to several moths after the stroke
Treatment: ROM, proper positioning, desensitization
Meds: Tramadol, Gabapentin, Amitriptyline
Others: TENS, desensitization, regional blocks, stellate ganglion
blocks
Recommendations for Pain
E. PAIN SYNDROMES
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OS 211
Occurs in 9% of all hospitalized patients, complication of
immobilization, especially those with communication problems
Bed sores are costly to treat (up to 350,000 Php) and may need
surgical intervention
Concurrent neuropathy and parkinsonism may cause less sensation,
increasing risk for developing pressure ulcers
Recommendations:
o Thorough assessment of skin integrity on admission and
monitoring daily thereafter
o Proper positioning, turning and transferring techniques
o Judicious use of barrier sprays, lubricants, special mattresses,
protective dressing and padding
o Avoid skin injury due to friction or excessive pressure
Risk Factors:
o Mobility
o Diabetes
o Peripheral Vascular Disease
o Urinary Incontinence
o Lower BMI
o End-stage disease
o From 2015: Low Glasgow Coma Scale  higher chance of having
pressure ulcer
Braden Scale for Risk of Pressure Ulcers
 Sensory
 Perception
 Moisture
 Activity
 Mobility in bed
 Nutrition
 Friction and Shear
Maximum score of 23 (best prognosis)
Minimum score of 6 (worst prognosis)
At risk for pressure ulcer if score ≤ 16
G. DEEP VEIN THROMBOSIS
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Patients usually just lying down
Present with leg swelling and pain on lower extremity
Assess properly since there are possible differentials eg. cellulitis
Can be detected by Duplex scan (imaging modality)
Can be unilateral or bilateral
Could cause pulmonary embolism  death (PREVENT by
examining the extremities e.g. swelling)
DVT Prophylaxis:
o Use of pneumatic compression devices and compression (antiembolic) stockings combined with subcutaneous heparin reduces
risk of DVT and Pulmonary Embolism in stroke patients
o Early passive range of motion (exercises to maintain/improve
mobility soon after injury/surgery)
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Lec 14: Stroke Rehabilitation
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Difficult to treat if with hemorrhagic stroke – treatments like heparin
might cause bleeding
If a patient already has DVT:
o Anticoagulation with low molecular weight heparin
o Inferior vena cava filter
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H. SPASTICITY
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Defined as a velocity dependent increase in tonic stretch reflex due
to loss or lack of normal inhibition
Resistance of muscle to passive movement
Related to the golgi tendon reflex
Positive component: Increased tone, clonus
Negative component: Weakness, loss of dexterity
Increase in muscle tone  muscle shortening  contracture  pain,
affects activities of daily living
Spasticity can help stroke patient ambulate but if too rigid  difficulty
Spasticity can mask motor strength, patient cannot move extremity
o Treat spasticity since recovery requires movement
Treatment of Spasticity:
o Therapeutic modalities
o Oral medications: Baclofen, Diazepam, Dantrolene
 Usually result to tired and weaker muscles, so botulinum toxin
is better (and it is more muscle-specific)
o Clonidine Tizanidine
o Botulinum toxin – can be applied to specific muscles (e.g.
gastrocnemius), but temporary (3-4 months) and expensive (1 vial
of 500 unit botulinum toxin = P26, 000)
o Phenol
o Orthopedic intervention-lengthening of tendon with contracture
Modified Ashworth Score
 Grade 0 – no increase in muscle tone
 Grade 1 – slight increase in muscle tone; catch and release; minimal
resistance at the end range of motion
 Grade 1+ - slight increase in muscle tone; catch followed by minimal
resistance throughout the remainder (less than half of the range of
movement)
 Grade 2 – more marked increase in muscle tone through most of
range of motion, but affected part easily moved
 Grade 3 – considerable increase in tone; passive movement
difficulty
 Grade 4 – affected part rigid in flexion or extension
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Even if the patient has good motor strength with no spasticity, but
there is no motivation for him/her to move and be productive (bedbound at home), then there is minimal chance of recovery
Factors that lead to depression:
o Physical and personal losses
o State of helplessness
Treatment
o Medication
 Fluoxetine (antidepressant) – also improves motor
strength/can help in motor recovery
 Selective serotonin reuptake inhibitors
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AICA, LEA, JEBBICK
What needs to be assessed:
1. Risk factors for Stroke and Coronary Heart Disease
o Non-modifiable: Age, Sex
o Modifiable: Hypertension, Obesity, Cardiac/Arrhythmia,
Diabetes, Hypercholesterolemia
2. Medical co-morbodities/complications
3. Neurologic and cognitive status (NIHSS-National Institute of
Health Stroke Scale, GCS-Glasgow Coma Score etc.)
4. ICF-International Classification of Functioning, Disability and
Health
5. Psychological assessment and Family/caregiver support
6. Assessment of Impairment/Disability/Handicap
7. Rehabilitation needs/functional assessment
8. Rehab Progress
9. Discharge Environment (i.e. home assessment and safety,
functional needs, motivation and preferences)
A. INTERNATIONAL CLASSIFICATION OF FUNCTIONING,
DISABILITY AND HEALTH
Health Condition (Disorder/ Disease): Stroke
Body Function/Structure
Activities
(Impairment)
(Disability)
Limitation
Lower Extremity Weakness
Walking
Table 1. ICF in Stroke
Note: words in () are old terms
J. PSYCHOLOGICAL PROBLEMS
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Must be integrated in the management of all stroke patients
Begins as soon as the patient is medically stable
Assessment of medical status, rehabilitation needs and function,
psychosocial and family support
Goal setting with patient and family
III. ASSESSMENT OF A STROKE PATIENT
Insert Foley catheter immediately and change as often as possible
Remove catheter when sensation returns and check for retention
Acute use of indwelling catheter:
o To facilitate management of fluids
o To prevent urinary retention
o To reduce skin breakdown in patients with stroke
Foley catheter use for more than 48 hrs after stroke increases risk of UTI
Frequent urination may increase the risk of bed sores
Depression: 50% incidence
History of prestroke functioning (eg. demography, past physical
conditions and response to treatment, substance use, psychiatric,
emotional and mental status, education and employment, coping
strategies)
Resources (e.g. income and benefits, housing and social network)
Spiritual and cultural activities
Leisure time and preferred activities
Family/caregiver situation and relationships
Patient/family/caregiver understanding of the condition, treatment
and prognosis
Hopes and expectations for care
Medications: Tricyclic antidepressants, serotonin reuptake inhibitors,
monoamine oxidase inhibitors
Family members have become an integral part of the long-term
picture for care of stroke patients
K. REHABILITATION OF STROKE PATIENTS
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50% of stroke patients in the acute stage (usually due to flaccid type
of bladder  urine retention = overflow incontinence)
Higher incidence in:
o Increased age
o Increased stroke severity
o Presence of diabetes and other disabling diseases
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 Serotonin and norepinephrine reuptake inhibitors
 Tricyclic antidepressants
 Monoamine oxidase inhibitors
Cognitive behavioral therapy
Communication
Realistic goals
Stress and anxiety management
Psychosocial Assessment
I. URINARY INCONTINENCE
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OS 211
Participation
(Handicap)
Restriction
Employment
B. ASSESSMENT OF IMPAIRMENT, DISABILITY, AND HANDICAP
Ma’am just flashed parts B, C, and D.
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Rehabilitation must prevent disabilities and handicaps
Impairments caused by stroke:
o Hemiplegia
o Visual loss
o Incoordination
o Sensory deficit
o Cognitive deficit
o Language
o Pain
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Lec 14: Stroke Rehabilitation
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o Spasticity
C. ASSESSMENT OF NEUROLOGICAL STATUS (NIHSS)
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NIHSS-NIH Stroke Scale: quantifies neurologic status
Score
Greater than 15
4-15
Less than 4
0
Table 2. NIHSS Stroke Scale
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No symptom at all
No significant disability
Can 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
Require some help but able to walk without assistance
4
Moderately severe disability
5
Severe disability; bedridden
Table 5. Modified Rankin Scale
Score
Greater than 16
*Neurologic recovery is different from functional recovery
D. ASSESSMENT OF FUNCTION
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Setting realistic goals
Helps determine need for changes in program
Index for decisions on admission and discharge from a rehabilitation
or extended care facility
Guide for determining safety and risk of injury in performing a
particular task
Barthel Index Scores, Functional Independence Measurement (FIM)
Score and Modified Rankin Score
o Barthel and FIM most commonly used
o Higher score (80/100) – better functional recovery
o < 20 – poor recovery
Barthel Index Score
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Measures functional independence in personal care and mobility
Good construct validity and high reliability, used as primary endpoint
in many clinical trials
Self-care
Dressing (0, 5, 10)
Bladder (0, 5, 10)
Bowels (0, 5, 10)
Feeding (0, 5, 10)
Bathing (0, 5)
Grooming (0, 5)
Toilet Use (0, 5, 10)
Mobility
Transfers (0, 5, 10, 15)
Mobility/ Ambulation (0, 5, 10, 15)
Stairs (0, 5, 10)
Table 4. Barthel Activities of Daily Living Index
Scoring: 100 = Perfect Score
> 80 = 
; < 60 = 
Functional Independence Score (FIM)
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Items organized into 6 subscales and assesses 2 dimensions:
physical and cognitive
Advantage: can be administered by patient or family interview
Disadvantage: gradation between assistance scales not so clearly
defined, time consuming
Functional Dimension
Cognitive Dimensions
Eating
Grooming
Bathing
Dressing Upper Body
Dressing Lower Body
Toileting
Bladder Management
Bowel Management
Bed, Chair, Wheelchair Transfer
Toilet Transfer
Tub/Shower Transfer
Walking/Wheelchair
Stairs
Glasgow Outcome Score (not mentioned)
 GOLD STANDARD in determining whether other stroke scales have
good construct validity, high reliability for head injuries
 Tests whether good recovery is expected
 No clear demarcations between levels
Score
Description
1
Death
2
Persistent Vegetative State
3
Severe Disability
4
Moderate Disability
5
Good Recovery
Table 6. Glasgow Outcome Score
Factors Predicting Poor Functional Outcome
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Advanced age (older – poorer functional outcome)
Co-morbidities – MI, DM
Severity of stroke – severe weakness, poor sitting balance, visual
and spatial deficits, mental changes, incontinence, low initial ADL
scores
Large vessel infarctions – related to volume
Lacunar infarcts – usually excellent recovery
Time interval – onset to rehabilitation
Initial ADL assessment (FIM score) – poorer functional outcome
Guidelines to predict outcome useful but NOT PRECISE (several
variables to be considered)
Other Outcome Measures
 Hemianopsia
 Posture and balance
 Sensory function
 Bowel or bladder incontinence
 Severity of paralysis
 Depression and emotional state
 Motivation
 Family support
IV. REHABILITATION PROGRAM
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Comprehension
Expression
Social Interaction
Problem Solving
Memory
A disability scale, a clinician-reported measure of global disability
For evaluating stroke patient outcomes and as an endpoint in clinical
trials
Does not really describe the patient’s functional status
0
1
Description
Major Stroke
Moderate Stroke
Mild Stroke
Normal
Prognostication
High probability of death; severe
disability
Less than 6
Good recovery
Table 3. NIHSS Scores for Prognostication
OS 211
Must be integrated in the management of all stroke patients
Begins as soon as the patient is medically stable
Assessment of medical status, rehabilitation needs and function,
psychosocial and family support
Goal setting with patient and family
A. RECOVERY
Neurologic Recovery (from 2015)

Early Phase Post Stroke - Resolution of pathologic processes in the ischemic
penumbra
o Ischemia
o Metabolic injury
o Edema
o Hemorrhage
Late Recovery in Stroke (from 2015)
Modified Rankin Scale
AICA, LEA, JEBBICK

Neuroplasticity (re-organization of the brain)
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Lec 14: Stroke Rehabilitation
o Allows structural and functional organization
o Restitution of partially damaged pathways
o Expansion of representational brain maps (recruitment of neurons not
ordinarily used in an activity)
o Modification in neuronal network

Advances in Mechanisms of Recovery
o Process of reorganization is dynamic and dependent on the nature of
injury, substrates involved, and the duration since the initial insult
o Strict localization of function to one anatomic site versus multiple widely
distributed pathways
Paradigms in Stroke Rehabilitation


Traditional
o In 3 months, the patient would have attained maximum recovery/strength of
the affected side, so just maximize the use of the good side
o Rehabilitation entails training for new techniques to compensate for
impairments
o Intense therapy avoided on the weak upper limb









Reorganization in the brain occurs with both recovery and learning
Motor learning mechanisms operative during spontaneous stroke
recovery and interact with rehabilitative training
Rehabilitation techniques need to be geared toward patients’
specific motor deficits

Early Mobilization






Can prevent the following:
o DVT
o Skin Breakdown
o Contracture Formation
o Constipation
o Pneumonia
Range-of-motion exercises
Changes of bed position
Progressive increase in the level of activity
Self-care activities
Additional strategies may be incorporated based on assessment to
prevent further complications
Proper Positioning of Extremities



Functional position
Avoid position of comfort
Use splints (e.g. hand splints and posterior ankle splints) and
orthosis (an orthopedic appliance or apparatus used to support,
align, prevent or correct deformities) → prevent contractures
Exercises



Range of motion exercises
Stretching exercises
Strengthening exercises
Mobility and Transfers



Improve standing balance and endurance
Transfers
Ambulation eg. climbing stairs, ramps
Functional Training


Doing activities of daily living eg. dressing
To enable the patients to be independent
Partial Body Weight Support for Treadmill Training (from 2015)



Must be integrated in the management of all stroke patients
Should begin as soon as medically stable
Involves the assessment of medical status, rehabilitation needs and
function, psychosocial and family support
Goal setting with patient and family – should be centered on the
patient (px determines goals)
Do not only focus on the medical aspect, socialization of recovering
stroke patients is also important
 Go beyond the medical problems: the patient has a life to live,
therefore we should consider the patient’s recovery (through
rehabilitation)
V. THE CASE

Basis of Rehabilitation (from 2015)


Treadmill training with partial body weight support superior to non–
body weight–supported treadmill training
Adjunct to conventional therapy for mild to moderate dysfunction
resulting in impaired gait
RCP (The Royal College of Physicians) Guideline: Use in patients
not walking 3 months after an acute stroke
Important Points to Remember for the Rehab of Stroke Patients
Paradigm Shift – new advances in imaging and rehabilitation have shown
that the brain can compensate for function lost as a result of stroke
B. REHABILITATION
OS 211

RF is a 55 yo taxi driver who consulted you because of difficulty in
ambulation. He tells you that he had a stroke about 2 months ago
when he presented with a sudden onset of right sided hemiplegia.
His records showed that he was diagnosed to have a stroke due to a
hypertensive bleed of the basal ganglia of about 10 cc. He stayed in
the hospital for about 2 weeks, able to sit up with assist.
Pertinent PE Findings:
o He is oriented to three spheres
o Good recent and remote memory
o He has good comprehension although has slight dysarthria
o Presence of spasticity of right upper and lower extremity (Modified
Ashworth Score of 2)
o Pain on right shoulder and hand
o Limitation of motion of right shoulder
o Slight swelling of the right hand
o Swelling of the right foot
o Motor strength of the right upper extremity is 1/5
o MMT of right lower extremity is 1/5
o Patient still has difficulty in walking and still assisted in ADLs
Discussion:
o Based on age (55yo), good prognosis.
o Based on etiology of stroke (hypertensive bleed), good prognosis.
Bleed has better prognosis than ischemia.
o Based on amount of blood (10cc from basal ganglia), good
prognosis.
o Based on MMT (1/5), we can try to rehabilitate the patient but
there is no assurance that the patient can regain 5/5 motor
strength.  Guarded prognosis (hard to determine prognosis)
o Why is there difficulty in walking? Due to muscle spasticity and
muscle strength of 1/5. We can give botulinum toxin to treat the
spasticity so that we can initiate muscle strengthening. Reminder!
It is important to correctly identify the specific muscle involved
para you make tusok tusok the botox there. -Jeb
o Why is there pain? Shoulder hand syndrome! (see explanation
above! Upper Limb Complex Regional Pain Syndrome) It is
important for the doctor to identify this early, because it is hard to
treat if detected later on.
END OF TRANSCRIPTION
Aica: Hi PHIve Star! <3 Hi Harvey and Extra D’yiz. I’m getting so kilig it’s
almost Christmas!!! 
Lea: Jingle bell, jingle bell, jingle bell rock. Jingle bells swing and jingle
bells ring. Snowing and blowing up bushels of fun PAAAKKK. Now the
jingle hop has begun. (Mean Girls). Hi Kit! Good luck. Palibre.
Jebbick: Dahil naggreet ang 2 kong transmates sa kiligfriend nila..Hi
CPMA! =)
Unloading of lower extremities by supporting a portion of body
weight
Provides symmetrical removal weight from the lower extremities
Facilitate locomotor abilities after stroke
AICA, LEA, JEBBICK
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AICA, LEA, JEBBICK
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