stroke rehabilitation - pmr refresher course

1. ACUTE MANAGEMENT OF
STROKE
WHAT A REHAB PHYSICIAN
NEED TO KNOW
Dr. Trilochan Srivastava
MD, DM (Neurology)
Fellowship in Cerebrovascular Intervention
Professor
Department of Neurology
SMS Medical College, Jaipur

2. DISABLING

3. AC STROKE/BRAIN ATTACK
 Definition of Stroke
 Types of Strokes
 Risk factors for Stroke
 Signs and symptoms of Stroke
 Investigations & Treatment
 Rehab

4. WHAT IS A STROKE?
 Brain tissue is
damaged from a
sudden loss of blood
flow, resulting in acute
loss of neurological
function
 Causes:
 Blockage (blood clot)
occurring inside a blood
vessel
 Blood vessel leaks
blood due to rupture

5. TYPES OF STROKES
 Ischemic Stroke
(85%)
 Brain hemorrhage
(Hemorrhagic
Stroke) (15%)

6. TYPES OF ISCHEMIC STROKE
- Thrombotic Stroke
 Blood flow is blocked to the brain
 Embolic Stroke
 Blood clot travels to the brain

7. Strokes occur
in the brain
and affect the
opposite side
of the body

8. Strokes can affect different parts of the brain,
this results in patients experiencing different
symptoms

9. BRAIN HEMORRHAGE
 Bleeding occurs within the brain due
to rupture of a blood vessel -
 High blood pressure
 Rupture of an aneurysm
 Coagulation disorder

10. SIGNS & SYMPTOMS OF STROKE
 Sudden numbness or weakness
of the face, arm, or leg, especially
on one side of the body
 Sudden trouble in speaking,
understanding or confusion
 Sudden trouble seeing in one or
both eyes
 Sudden trouble in walking,
dizziness, loss of balance or
coordination
 Sudden, severe headache with
no known cause
 Convulsion

11. SIGNS OF STROKE: ACT FAST!

12. WARNINGS SIGNALS OF BRAIN
HEMORRHAGE
 Abrupt headaches
 Nausea and Vomiting
 Unconsciousness
 Weakness one half of body
 Convulsion
 Various Neurological abnormalities

13. SUB-ARACHNOID HEMORRHAGE
 When the aneurysm ruptures, the stroke
victim may experience -
 A terrible headache
 Neck Stiffness
 Vomiting
 Altered states of consciousness.
 Stupor, rigidity, and coma.

14. MINI-ISCHEMIC STROKES /TRANSIENT
ISCHEMIC ATTACKS (TIAS)
 TIAs are mini-ischemic strokes
 A stroke-like event lasting minutes, or hours, that
occurs when the brain is deprived of oxygen-rich blood
temporarily, but in which the effects wear off
completely after the blood-flow returns
 Usually caused by tiny Emboli (often formed of pieces
of calcium fatty plaque) that lodge in an artery to the
brain. They typically break up quickly and dissolve but
they do temporarily block the supply of blood to the brain.
 TIA’s do not result in permanent brain damage

15. MINI-ISCHEMIC STROKES /TRANSIENT
ISCHEMIC ATTACKS (TIAS)
 TIA is serious and too often ignored
 TIA’s should not be ignored
More that 1/3 of people will go on to have
an actual stroke
5% of strokes will occur within 1 month of the
TIA or first stroke
12% will occur within 1 year
20% will occur within 2 years
25% will occur within 3 years

16.  Diagnostic Testing
- Blood test
CT or MRI of the brain
ECG
Carotid Ultrasound
Echocardiogram

17. BLOOD WORK - LABS
 CBC, Blood Sugar, Lipid Profile, RFT,
Coagulation profile is done on all
patients.

18. BRAIN CT/MRI

19. ECG – may show irregular heart beats

20. Carotid Ultrasound – will show if there is stenosis
(narrowing of the blood vessel)

21. CEREBRAL ANGIOGRAPHY (DSA)

22. Echocardiogram – detects if any thrombus
(blood clot) within the heart chambers

23. ACT IN TIME
 Stroke is a medical emergency. Every
minute counts when someone is having a
stroke.
 The longer blood flow is cut off to the brain,
the greater the damage.
 Immediate treatment can save people's
lives and enhance their chances for
successful recovery

24. TIME IS BRAIN
 Time is very important in order to receive this
medication
 Window of opportunity to start treating stroke
patients is 4.5 hours, but to be evaluated and
receive treatment, patients need to get to the
hospital within 4 hours

25. TPA (TISSUE PLASMINOGEN
ACTIVATOR)
 is a clot-busting drug
 Ischemic strokes, the most common
type of strokes, can be treated with a
drug called t-PA, that dissolves blood
clots obstructing blood flow to the
brain

26. MEDICATIONS
 Aspirin (for ischemic
stroke)
 Clopidogrel
 Dipyridamole
 BP and Diabetes
medication if needed
 Cholesterol lowering
medicines

27. Neurovascular intervention in
Stroke

28. INTERVENTIONS IN STROKE
 Intra-arterial thrombolysis
 Mechenical Thrombectomy
 Carotid Angioplasty and Stenting
 Intracranial angioplasty & Stenting
 Aneurysm
 Cerebral Vasospasm
 AVM
 dAVF

29. MODERN ANGIOGRAPHY - DSA
Digital Subtraction Angiography

30. Angio without substraction DSA

31. OUR CEREBRAL DSA MACHINE

32. CEREBRAL INFARCTCEREBRAL INFARCT
6 Hours
Infarct
Ischaemic
penumbra

33. MECHANICAL THROMBECTOMY
(FOR REMOVING CLOT)
 Ischemic stroke due to large intracranial
vessel occlusion
 Retrieve clot in patients experiencing
acute ischemic stroke
 Within 6-8 hrs
 Immediately restore blood flow
 Conjunction with medical therapies (IV
and IA)*

34. DEVICE SELECTION AND
PREPARATION
34

35. POSITIONING AND DEPLOYMENT
OF STENT RETRIEVER
35

36. POSITIONING AND DEPLOYMENT
36

37. FAST FLOW RESTORATION
37

38. RECOVERY
38

40. MCA OCCLUSION

41. BA OCCLUSION

42. CAROTID ANGIOPLASTY &
STENTING
Balloon Dilatation Stent Placement

43. CAS
52 Y F Recurrent TIA, Rt hempareis

45. CAROTID ANGIOPLASTY &
STENTING
Pre Post
At 1 yr F/U No further TIA/stroke at and restenosis (Doppler)

47. INTRA-CRANIAL ANGIOPLASTY
 Not recommended routinely until recurrent
TIA/stroke inspite optimal medical
treatment

48. INTRA-CRANIAL ANGIOPLASTY
42 year male, HT, DM, recurrent TIA
left side inspite double anti-platelets &
statin
DSA: 80% stenosis, Rt
Cavernous ICA

49. INTRA-CRANIAL ANGIOPLASTY
Pre: 80% stenosis
Post stenting: 20%
stenosis
Clinical F/U after 3 years : No TIA/ stroke

50. INTERVENTION IN SAH

51. COILING OF ANEURYSM
Using a femoral arterial guide catheter, a series of GDCs (radio-opaque,
MRI-compatible, platinum coils) are deployed through a microcatheter
into an aneurysm until occlusion is achieved.

52. SAH GRADE 1; 50 F

53. PARACLENOID ANEURYSM

54. COILING LEFT PARACLENOID
ANEURYSM
CTA after 6 month: No residual filling of aneurysm; Asymptomatic
Pre Post

55. AVM EMBOLIZATION

56. AVM
Pre Post

57. AVM EMBOLIZATION – GLUE CAST

58. HOSPITAL TREATMENT FOR
STROKE
 Medical Management
Diet
Physical & Occupational Therapy
Speech Therapy if indicated
Nursing care

59. AC STROKE -REHABILITATION
SERVICES
 Physical Therapy
 Occupational Therapy
 Speech-Language Therapy

60. HOSPITAL TREATMENT FOR
STROKE
 Rehabilitation
 Physiotherapist Consultation
 Determine what type of therapy best
for patient
 Rehab Unit
 Home Care with PT/OT

61. DIFFERENT REHABILITATION
SETTINGS
Inpatient
Rehab Facility (IRF)
Outpatient
Rehabilitation
Skilled Nursing
Facility (SNF)
Home Health
Rehabilitation

62. STROKE REHAB: HOW MUCH, HOW
FAST?
 Higher intensity stroke rehab
(e.g., > 3hrs therapy daily)
produces greater functional
gains
 Very early (<24hrs) high-dose
mobilization protocol may be
harmful to favorable recovery
(AVERT trial Lancet.
2015;386(9988):46–55.)
 It is recommended that
early rehabilitation for
hospitalized stroke
patients be provided in
environments with
organized, inter-professional
stroke care. [I,A]
ACNR 2015;15(4):6-8. Online 21/09/2015
http://www.acnr.co.uk/2015/09/the-future-of-stroke-
rehabilitation-upper-limb-recovery/

63. EARLY MOBILISATION
 If patient's condition is stable, active mobilisation
should begin as soon as possible, within 24-48 ho
urs of admission
 Early mobilisation is beneficial to patient outcome by
reducing the complication
 It has strong positive psychological benefit for the
patient
 Specific tasks (turning from side to side in bed, sitting in bed)
and self-care activities (self-feeding, grooming and dressing) can
be given for early mobilisation.

64. ASSESSMENT OF DISABILITY AND
NEEDS
 All individuals with stroke be
provided a formal assessment of
their ADLs and communication
abilities, and functional
mobility before discharge from
acute care hospitalization
 Residual neurological deficits;
activity limitations, cognitive,
communicative, and
psychological status;
swallowing ability; level of
family/caregiver support;
capacity of family/caregiver
[I,C]
FIM

65. DYSPHAGIA SCREENING AND
MANAGEMENT
FACTS
Dysphagia affects about
half of stroke patients
within 3 days of stroke
onset.
About half of these
aspirate, and about one
third of the aspirators
develop pneumonia.
Early tube feeding,
within 7 days, reduces
mortality.
Better functional outcomes
were seen when PEG was
delayed 2 or 3 weeks.
 NG feeding should be used
for short-term (2-3 weeks)
nutritional support for
patients who cannot swallow
safely; PEG tubes should be
placed in patients with
chronic inability to
swallow. [I,B]
FOOD Trial Collaboration, Health
Technol Assess 2006, Jan;10(2), 1-120.

66. MOTOR, COMMUNICATION, COGNITIVE
ASSESSMENT
FACTS
Cognitive screening
tests include the
Neurobehavioral Cognitive
Status Examination and
the Montreal Cognitive
Assessment.
 Motor impairment assessments
(strength, tone, finger movements,
coordination) with standardized tools may
be useful. [IIb,C]
 Communication assessment should
consist of interview, conversation,
observation, standardized tests, or
nonstandardized items; assess speech,
language, cognitive-communication,
pragmatics, reading, and writing;
identify communicative strengths and
weaknesses; and identify helpful
compensatory strategies. [I,B]
 Screening for cognitive deficits is
recommended for all stroke patients
before discharge home. [I,B]

67. COGNITIVE ENHANCEMENT
STRATEGIES
“There is some
evidence of benefit of
rivastigmine in VCI
from trial data from
three studies
 Donepezil, Galantamine,
Memantine
 The usefulness of
[cholinesterase
inhibitors] in post-stroke
cognitive impairment is not
well established. [IIb,B]
 Depression has been
reported in up to 33% of
stroke survivors compared
with 13% of controls.
 The usefulness of
[antidepressants] in post-stroke
cognitive impairment is not well
established. [IIb,B]

68. TREATING APHASIA
Up to 40% of stroke
survivors experience
aphasia.
Daily aphasia
therapy very early
in stroke recovery
(starting at 3 days)
improved outcomes in
people with moderate
to severe aphasia.
 Speech and language
therapy is recommended
for aphasia. [I,A]
 Brain stimulation
techniques are considered
experimental, not for
routine use. [III,B]
 Some drug studies have
shown promise (donepezil,
galantamine, memantine).
TMS device for stroke motor recovery
at Houston Methodist Neurological
Institute (The Synapse, Summer 2016)

69. IMPROVING MOBILITY
Gait-related
activities include
standing, sitting
down, stair climbing,
turning,
transferring, using a
wheelchair, and
actual walking.
 Intensive, repetitive,
mobility-task training
is recommended. [I,A]

70. FALL PREVENTION
 Up to 70% of individuals
with a stroke fall during
the first 6 months
 It is recommended that
individuals with stroke
discharged to the community
participate in exercise
programs with balance
training to reduce falls. [I,B]
 It is reasonable that
individuals with stroke and
their caregivers receive
information targeted to home
and environmental
modifications designed to
reduce falls. [IIa,B]

71. DVT PROPHYLAXIS
 DVT is common after stroke
 LMWH is superior to UFH by meta-
analysis/Cochrane review
 Elastic compression stockings do
not prevent DVT, and increase skin
complications.
 In ischemic stroke, prophylactic dose
UFH or LMWH should be used for
the duration of the acute and rehab
hospital stay or until the stroke
survivor regains mobility. [I,A]
 In ischemic stroke, it is reasonable to
use LMWH over UFH for prevention of
DVT. [IIa,A]
 In ICH, it may be reasonable to use
prophylactic UFH/LMFH started
between 2 and 4 days after the
hemorrhage. [IIb,C]
 In both ischemic stroke and ICH,
elastic compression stockings are not
useful. [III,B/C]TEDS

72. SEIZURE PROPHYLAXIS
 About 1.5% of stroke
patients will have a seizure
during rehab.
 Lifetime risk of seizure after
stroke has various estimates,
ranging from 3% to 67%.
 Many of the seizure
medications dampen
mechanisms of neural
plasticity that aid recovery.
 Any patient who develops
a seizure should be treated
with standard
management approaches,
including a search for
reversible causes of seizure in
addition to potential use of
antiepileptic drugs. [I,C]
 Routine seizure
prophylaxis for patients
with ischemic or
hemorrhagic stroke is not
recommended. [III,C]

73. IMPROVING UPPER EXTREMITY
ADLS
 Only a small fraction of
people fully recover from
upper limb weakness after
stroke
 Conventional task-specific
training involves repeated
practice of functional, goal-
oriented activities.
 Functional tasks should be
practiced. [I,A]
 All individuals with stroke
should receive
individualized ADL
training. [I,A]
Stroke, 2005

74. TREATING SPASTICITY
 Spasticity: a velocity dependent
resistance to muscle stretch
 Prevalence after stroke ranges
from 25% to 43% over the first
year.
 Oral antispasticity agents
have a marginal effect on
reducing generalized spasticity,
but dose-limiting side effects are
common.
 Botulinum toxin is
recommended in upper limb
muscles to reduce spasticity to
improve ROM, dressing,
hygiene, and limb positioning.
[I,A]
 Botulinum toxin into lower limb
muscles is recommended to
reduce spasticity interfering
with gait. [I,A]
 The use of splints and taping
are not recommended for
prevention of wrist and finger
spasticity after stroke. [III,B]

75. HEMIPLEGIC SHOULDER PAIN
 Up to 22% of stroke patients
experience shoulder pain
during the first year.
 Motor impairment and
shoulder subluxation are
predictive factors
 Hemiplegic shoulder pain
is multifactorial.
 A trial of neuromodulating
pain medication is reasonable
for patients with hemiplegic
shoulder pain with sensory
changes including allodynia or
hyperpathia. [IIa,A]
 It is reasonable to consider
positioning and use of
supportive devices and slings
for shoulder subluxation. [IIa,C]
 Surgical tenotomy of pectoralis
major, lattisimus dorsi, teres
major, or subscapularis may be
considered with severe
hemiplegia and ↓ROM. [IIb,C]

76. CENTRAL PAIN AFTER STROKE
 Central pain is classically
associated with thalamic
stroke, but can result from
stroke anywhere in
spinothalamic and
thalamocortical tracts
 Usually burning or aching, and
associated with allodynia to
touch, cold, or movement
 Incidence is 8%, typically
beginning within a few days, and
the majority within the 1st
month.
 Amitriptyline and lamotrigine
are reasonable first-line
pharmacological treatments.
[IIa,B]
 Pregabalin, gabapentin,
carbamazepine, or phenytoin
may be considered second-line
treatments. [IIb,B]
 TENS has not been established
as an effective treatment.
[III,B]

77. PREVENTION OF JOINT
CONTRACTURES
 60% of patients with hemiplegic
stroke will develop joint
contracture
 Contractures cause pain and
inhibit self-care
 Positioning of hemiplegic shoulder in
maximum external rotation while
the patient is either sitting or in bed
for 30 minutes daily is probably
indicated. [IIa,B]
 Resting hand/wrist splints, along
with regular stretching and spasticity
management in patients lacking
active hand movement, may be
considered. [IIb,C]
 Resting ankle splints used at night
and during assisted standing may be
considered for prevention of ankle
contracture in the hemiplegic limb.
[IIb,C]

78. BLADDER INCONTINENCE
 Urinary incontinence
- 50% incontinence during acute phase
- ~ 20% at six months
- Risk: age, stroke severity, diabetes
- Indwelling catheter : management of fluids,
prevent urinary retention, skin breakdown
- Use of foley catheter > 48 hours
UTI

79. FECAL INCONTINENCE
 Improve within 2 weeks
 Continued fecal incontinence poor prognosis

80. REHABILITATION DURING ACUTE
PHASE
TASKS:
 Range of Motion Stretching Exercises
 Frequent Position Changes
 Sitting in Upright Position to Improve
Orthostatic Tolerance
 Psychological Counseling
 Patient and Family Education

81. REHABILITATION DURING ACUTE
PHASE
TASKS:
 Training Personal Care Skills, Mobility, and
Ambulation Training
 Bladder and Bowel Management
 Evaluation of Swallowing Function
 Initiate Nutrition and Hydration
 Identification and Treatment of Depression

82. PROGNOSIS
 10% of stroke survivors recover almost
completely
 25% recover with minor impairments
 40% experience moderate to severe
impairments requiring special care
 10% require care within either a skilled-care or
other long-term care facility
 15% die shortly after the stroke

83. STROKE REHABILITATION
OUTCOMES
 80% Independent Mobility
 70% Independent Personal Care
 40% Outside Home
 30% Work

84. REHABILITATION EFFECTIVENESS
AHCPR Recommendation:
“Whenever possible, patients with acute strokes
should receive coordinated diagnostic, acute
management, preventive, and rehabilitative
services.”
(Research evidence =A;
Expert opinion=consensus)

85. STROKES ARE AN EMERGENCY
 If you are having a Stroke come to the hospital
right away- Call 108
Conclusion 1

86. SIGNS OF STROKE: ACT FAST!
If you believe someone is having a stroke – if he or she suddenly
loses the ability to speak, move an arm or leg on one side, or
experiences facial paralysis on one side – call 108 immediately!

87. CONCLUSION (2)
 Rehabilitation therapy should start as early as
possible, once medical stability is reached
 Spontaneous recovery can be impressive, but
rehabilitation-induced recovery seems to be gr
eater on average.
 Even though the most marked improvement is
achieved during the first 3 months, rehabilitatio
n should be continued for a longer period to prev
ent subsequent deterioration.

88. CONCLUSION (3)
 No patient should be excluded from rehabilitation unless
he is too ill or too cognitively devastated to participate in
a treatment program.
 Proper positioning and early passive ROM exercises help
to avoid complications at a flaccid stage
 Family members should participate in therapy sessions.

89. REHABILITATION MANAGEMENT
 Mobility
 Activity of daily living
 Communication
 Swallowing
 Orthosis
 Shoulder pain
 Spasticity
 Cognitive and perception
 Mood
 Bowel and bladder incontinence

90. REDUCE YOUR CHANCES OF
HAVING A STROKE!
 Quit smoking
 Exercise 30 minutes a day
 Eat right
See your doctor, take your medications and
keep these risk factors under control:
 High blood pressure
 Heart disease
 Diabetes
 High cholesterol

91. THANK YOU!