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Stroke Neurorehab
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Early Diagnosis and Management Process
- Background: Basic Mechanisms of a Stroke
- Ischemic
- Hemmoragic
- Advantages of Rapid Response - Minimizing Damage
- Early Medical Management: Initial Assessment
and Documentation
- Stroke etiology and areas of brain involved
- Identification
of symptoms and basic functioning
- Imaging tools (type, location(s))
- Types/severity of neurological deficits
- Check for dysphasia (problem with swallowing)
- Types/severity of comorbid diseases
- Any complications and abnormal health patterns
- Changes in clinical status over time
- Estimate (e.g., through interviews) functional status prior
to stroke
- Medical Management for All Stages
- Nutrition/hydration/sleep/rest
- Stabilize medical condition
- Take steps to prevent recurrent stroke
- Minimize risk factors (these include hypertension, smoking,
diabetes, high serum cholesterol, heavy alcohol consumption)
- Medications include oral anticoagulants, aspirin
- Surgery
- Secondary complications include:
- Deep vein thrombosis (DVT)
- Dysphasia (problem with swallowing) and aspiration
- Skin breakdown
- Bladder/bowel function
- Prevention of urinary tract infections
- Seizures/falls Acute care
monitoring will include:
- Spasticity/contractures
- Shoulder injury (positioning
- Screening for Rehab (typically 1-3 days after trauma)
- Alternatives:
- Needs specific rehab services
- Needs comprehensive rehab
- Needs further recuperation before rehab decision
- Too incapacitated for rehab
- Assessment
- Baseline, during, after ...
- Scales (covered in Module 5)
- Neurological deficit (NIH Stroke Scale)
- ADL abilities: FIM, Barthel
- Motor function/skills (Fugl-Meyer,
MAS, AMPS, Jebson, ...)
- Mental status (many), depression (many)
- Balance (Berg), Mobility (Rivermead)
- Speech/language aphasia (many)
- Activity log (MAL for amount/quality of use)
- Quality of life/health status, satisfaction,
...
- Pragmatic
- Emotional status, motivation, communication level,
endurance, tolerance for rehab
- Social/environmental: presence of caregiver, living
situation, family, ...
- Resources and available rehab programs
- Inpatient
- comprehensive rehab hospital
- acute care hospital
- Nursing homes
- Outpatient rehab (typically several hours for
3-4 visits/week
- Home rehab (typically some therapy, nursing
visits)
- Prognosis (more next class period)
- With/without rehab (spontaneous recovery vs spontaneous
& rehab)
- Goal-Setting and Plan for Intervention
- Key forms of intervention
(more later, and in Module 6)
- Therapy (PT, OT, speech):
- considerations: type, timing, intensity,
duration
- controversy:
- aim: maximize "functional
outcomes"
- focus more on returning ADL functions
or (longer-term) skill development?
- Medication (ranging from oral to Botox injections)
- Education and support for self-care
Common Functional Impairments
- General
- Each is unique
- Over 75% are hemiplegic (i.e., affecting mostly
one side of body)
- Neurological domains
- motor (face, arm, leg)
- sensory (loss of sensations, change in sensation (altered
sensitivity, numbness/tingling), loss of perception
- vision (monocular visual loss, left-sided neglect,
etc.)
- language (dysphasia - disturbances include comprehension,
naming, repetition, fluency, reading, writing)
- Muscle weakness (force, power deficit)
- Sensory reflex deficit
- Spasticity/spasms
- Posture/movement asymmetry & balance/gait
- Poor gross/fine coordination
- Often stages (related to spontaneous recovery, neural plasticity):
- Flaccadic/weak then spastic/stiff
- Synergy patterns evolve
- Typically lower extremity recovers earlier and better
than upper
- Whole Body/Legs
- Weakness and/or spasticity big issues
- Standing - asymmetric body weight support, posture
- Gait - slow & asymmetric
- Arm
- Shoulder dysfunction
- Reaching and arm positioning
- Tendency for flexor synergy (flexed elbow &wrist, thus
hand in front of chest)
- Grasping/manipulation: Tendency for weak wrist/finger extensors
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Module
4Functional Impairments and
Intervention Strategies