maximize quality of life

affects both the choices of specific

interventions and the manner in which
clinical activities are performed

Non traumatic brain injury

occlusion or rupture of cerebral blood vessels
results in sudden neurologic deficit
characterized by loss of motor control, altered
sensation, cognitive or language impairment,
disequilibrium, or coma
excludes non-vascular conditions that can
present with stroke

seizure, syncope, traumatic brain injury, or brain

tumor.

Hemorrhagic (15%)
Ischemic (85%)

Intracranial
Hemorrhage
Intracerebral
10%
Rupture of weakened
vessels within the
brain parenchyma:
hypertension,
atriovenous
malformation, or tumor

Subarachnoid
5%
Aneurysmal rupture
of cerebral artery
with blood loss into
the space
surrounding the
brain

large vessel thrombosis (40%) *

small vessel thrombosis (20%) *
* Caused by atherosclerotic cerebrovascular
disease

cerebral embolism (20%)

valvular disease or atrial fibrillation

cerebral vasculitis or cerebral

hypoperfusion (5%)

Motor control and strength

Motor coordination and balance
Spasticity
Sensation
Language and communication
Apraxia
Neglect syndrome
Dysphagia
Uninhibited bladder and bowel

affects the primary motor area.

Recovery:

Initially (+) hemiplegia, weakness and poor control

of voluntary movements assoc with muscle tone.
As voluntary movement returns:
1st: non-functional mass flexion and extension of the
limbs.
Synergy patterns or mass contraction of multiple muscle
groups are seen.
Later: movement patterns can be independent or synergy.

trunk control and stability, coordination

of movement patterns, and balance all
involve complex extrapyramidal systems
that are frequently disrupted by stroke.
Extrapyramidal disorders can be a
major impediment to functional recovery
but are often amenable to therapeutic
exercise.
Anatomy: Premotor area (ant to central
gyrus) motor planning

is a velocity-dependent increase in
resistance to muscle stretch that
develops after an upper motor
neuron injury within the central
nervous system
Inc in both tonic and phasic reflex.

loss of sensation after stroke can have a

significant effect on joint and skin
protection, balance, coordination, and motor
control.
Injury to the sensory pathways typically
causes hypoesthesia or reduced sensation
however, patients with lesions in the
thalamus or spinothalamic tract
occasionally experience severe pain that
can interfere with functional recovery and
rehabilitation care.

aphasia
impairment of language
but typical lesions that cause aphasia
affect comprehension and the use of
symbolic material for the purpose of
communication and meaning.
Testing of language

examination

of oral expression, verbal

comprehension, naming reading, writing and
repeating

Broca-type aphasia

Wernickes aphasia

sensory aphasia
lesion is l at the auditory association area (Wernickes area)

Conduction aphasia

primary language deficit

mildly compromised comprehension
impaired facial expression
lesion is at the motor association area (Brocas area).
associated with transcortical aphasia

with severely impaired repetition of language

lesion of arcuate fasciculus.

Disorders of reading (alexia) and writing (agraphia)

disconnection of the primary language area from the

primary visual cortices, which correlates to lesion in the
angular gyrus.

disorders of skilled movements in the

absence of motor, sensory, or
cognitive impairment.
difficulty performing simple functional
activities.
Most commonly seen in left
hemisphere strokes and affects the
left non-hemiplegic limb.

Hemispatial neglect
failure to report, respond, or orient to novel or
meaningful stimuli presented to the side opposite
a brain lesion. (Heilman et. Al)
significantly contributes to disability after stroke
has negative impact on sitting balance, visual
perception, wheelchair mobility, safety awareness,
skin and joint protection and fall risk.
Neglect - disorder of visual and spatial attention
and is associated with temporoparietal strokes
and lesions of the frontal eye fields, cingulate
gyrus, thalamus and reticular formation.

30-65% of patients with unilateral or

bilateral hemispheric and brainstem
infarction.
Risk for aspiration pneumonia

strongly associated with a delayed initiation of

pharyngeal reflex and reduced pharyngeal transit
time.
reduced labial and lingual mobility and sensation,
unilateral neglect, pooling of pharyngeal residue
within the vallecula and pyriform sinuses, and
cricopharyngeal dysmotility.
Laryngeal elevation during swallow normally
declines with age and can have negative influence
on aspiration after stroke.

Bladder and bowel incontinence

Incontinence - lack of voluntary
inhibition to void from upper motor
neuron injury, and results in urgency of
urination.
Bowel incontinence - uninhibited
reflex emptying by the same
mechanism as the uninhibited bladder.

Main Stem:

Contralateral hemiplegia (complete, affecting

the upper and lower limbs and lower portions of
the face equally)
Contralateral hemianesthesia
Contralateral hemianopia
Head and eye turning toward lesion
Dysphagia
Uninhibited neurogenic bladder
Dominant hemisphere

Global aphasia
Apraxia

Non-dominant hemisphere

Aprosody and affective agnosia

Visuospatial deficit
Neglect syndrome

Upper Division:
Contralateral hemiplegia (leg relatively spared than
hand and face)
Contralateral hemianesthesia
Contralateral hemianopia
Head and eye turning toward lesion
Dysphagia
Uninhibited neurogenic bladder

Dominant hemisphere

Broca aphasia
Apraxia

Non-dominant hemisphere

Aprosody
Visuospatial deficit
Neglect syndrome

*hemiplegia and language comprehenssion not as severe

*sparing of M1 segement of MCA

Lower Division:
Contralateral homonymous
hemianopia
Dominant hemisphere

Non-dominant hemisphere

Wernicke aphasia
Affective agnosia

Contralateral hemiplegia (hand

relatively spared than arm and leg)
Contralateral hemianesthesia
Head or eye turning toward lesion
Grasp reflex groping
Paratonia (or Gegenhalten)
Disconnection apraxia
Akinetic mutism (abulia)

Thalamus

Blood supply : perforating arteries of

the PCA
Infarcts in this region cause
hemisensory deficits ,including
hypoesthesia , dysesthesia, occasional
hyperesthesia or pain

Visual disturbances injury to the lateral

geniculate, temporal, occipital and occipital
visual radiations

Damage to visual association area

Dyschromatopsia (altered color
discrimination)

Impaired memory infarction of the

temporal lobe and hippocampal Gyri

Brainstem

Complex structure cranial nerves,

bulbar nuclei, and the tracts

Bulbar nuclei form afferent and efferent

cranial nerves innervates the
ipsilateral side of the body

Ascending and descending bulbar and

spinal tracts innervate contralaterally

Unilateral brain stem strokes loss of

cranila nerve function ipsilatererally and
sensimotor dysfunction contrallaterally

Cerebellar strokes ipsilateral ataxia

Brain stem strokes Ipsilateral,

contralateral , or bilateral limb ataxia

Syndrome

Location

Structural Injury

Characteristics

Weber

Medial basal
midbrain

Third cranial nerve

Corticospinal tract

Benedikt

Tegmentum of
midbrain

Third cranial nerve

Spinothalamic tract
Medial lemniscus
Superior cerebellar
peduncle
Red nucleus

Ipsilateral third
nerve palsy
Contralateral
hemiplegia
Ipsilateral third
nerve palsy
Contralateral loss of
pain and
temperature
sensation
Contralateral loss of
joint position
Contralateral ataxia
Contralateral chorea

Locked in

Bilateral basal pons

Corticospinal tract
Corticobulbar tract

Bilateral hemiplegia
Bilateral cranial
nerve palsy
(upward gaze
spared)

Syndrome

Location

Structural Injury

Characteristics

Millard-Gubler

Lateral pons

Sixth cranial nerve

Seventh cranial
nerve
Corticospinal tract

Wallenberg

Lateral medulla

Spinocerebellar tract
Fifth cranial nerve
Spinothalamic tract
Vestibular nuclei
Sympathetic tract
Nucleus ambiguus

Ipsilateral sixth
nerve palsy
Ipsilateral facial
weakness
Contralateral
hemiplegia
Ipsilateral
hemiataxia
Ipsilateral loss of
facial pain and
temperature
sensation
Contralateral loss of
pain and
temperature
sensation
Nystagmus
Ipsilateral Horner
syndrome
Dysphagia and
dysphonia

Located within the

deep white matter,
basal ganglia,
thalamus and pons

Result from occlusion

of single, small
perforating arteries

USA stroke yearly incidence is

700,000

500,000 new strokes

200,000 recurrent strokes

28% stroke in persons younger than

65 years
Children annual incidence is 2.7
strokes/ 100,00

Incidence is 19% higher among adult

men than women in ALL races.

Black men <65 years old incidence is

2X-3X higher than among whites

Relative incidence among black women

compared to white women is even higher.

Asian countries rate of stroke is higher

than in the USA

MODIFIABLE :
1. Hypertension

Systolic BP >165 mmHg, or a diastolic

blood pressure > 95 mmHg
Increases the relative risk of stroke by a
factor of 6
10-12 mmHg reduction of systolic and a
5-6 reduction of diastolic pressure
35% reduction in stroke risk in both
hypertensive and normotensive patients.

B. SMOKING

Framingham study confirmed that

smoking is independently associated
with an increased risk of
atherothrombotic stroke in both men and
women

Relative risk heavy smokers ( > 40

cigarettes per day) is twice than of light
smokers (< 10 cigarettes per day)

Cessation reverses risk to that nonsmokers within 5 years after quitting

3. Hypercholesterolemia

Indirect risk factor for stroke role has

not been epidemiologically linked to
increased stroke incidence per se

Association between carotid artery

atherosclerosis and increased serum
cholesterol levels

HMG CoA reductase inhibitors or

statins reduce the risk of stroke

Targets for patients with Coronary

heart
disease:

LDL <100 mg/dl

Total Cholesterol < 200 mg/dl
HDL > 60 mg/dl

4. Diabetes Mellitus

Increases the relative risk of Ischemic

stroke 3-6 times than the general
population.

20% prevalence among stroke survivors

5. Other risk factors

Obesity , heart disease ,
hyperhomocysteinemia

age , sec , race and previous stroke

Previous stroke risk for recurrent

stroke is significant

NEUROPLASTICITY- refers to the ability

of the central nervous system to
reorganize and remodel, particularly
following central nervous system injury.

Motor recovery after central nervous

system injury occurs through poorly
understood process of cortical
remodeling, but only as a response to
task- oriented motor training.

Basic strengthening, ROM exercises,

balance training, and postural control
A therapeutic technique which
encourages early movement based on
well-organized patterns of motor
recovery Brunnstrom
Neurodevelopmental technique Bobath
and Bobath

Inhibits abnormal postures and movement

and facilitates isolated muscle control

A technique that incorporates cutaneous

stimuli to facilitate movement Rood
Task-oriented approach to therapeutic
execrises encourages movement during
functional tasks Carr and Shepherd
Side by side comparison of these
techniques have not shown superiority of
one over another.

Differs from that of the lower limb

1.
2.

3.
4.

spontaneous motor recovery is slower and less

complete
Basic self- care activities can be performed with
one intact upper limb whereas both lower limbs
are required for bipedal locomotion
Benchmarks for inpatient rehabilitation require
rapid gains in functional independence.
The ability to influence motor recovery through
rehab interventions had little scientific basis
until the past decades

Upper limb rehab often focused on

strategies where the intact upper limb
compensated for the impaired upper limb
Must seek balance between use of
compensatory strategies and
interventions to promote neurologic
recovery of the impaired upper limb such
as CONSTRAINT- INDUCED MOVEMENT
THERAPY (CIMT)

Based on theory by Edward Taub patients

with motor impairment in an upper limb
after stroke learn to depend more on the
unaffected limb for performing functional
tasks, because attempts to use the affected
arm often result in failure and frustration.
OPERANT CONDITIONING- failed attempts to
use the upper limb produce a kind of
negative feedback which reduces future
attempts even further

Use of affected limb can be augmented by

forced use of the impaired limb through the
process of constraining the intact upper limb
with a body jacket
Cortical reorganization in response to
behavioral interventions Randolph Nudo
Repetitive movement alone is not sufficient,
new skill acquisition and reacquisition of lost
skills is required to induce cortical
reorganization

Neuromuscular Electrical Stimulation

Electrical stimulation of the lower motor

neuron or its terminal branches, causing
depolarization nd subsequent muscle
contraction
Well suited for upper motor neuron
paralysis such as occurs in stroke
Delivered via electrodes placed on the skin
on or near peripheral nerve or near the
muscle motor point.

Body weight- supported treadmill

training (BWSTT)

Can induce spontaneous step over step

hind limb movement in spinalized animals
and can improve bipedal locomotion in
humans with incomplete spinal cord injury
The need for two or more skilled therapists
to ensure appropriate kinematics of the
trunk, pelvis and lower limb during initial
treatment has been practical limitation for
clinical use.

Robotic- assisted motor retraining

has been studied for both upper and
lower limb rehabilitation after stroke

Can induce passive or assisted limb

movement
Promotes movement during skill acquisition
Infatigable, has potential to induce
movement repetitions to modulte motor
recovery

Has distinct advantage of

inducing repetitions without the
need for continuous involvement
of a therapist
Can only target shoulder, elbow
and wrist movements and do not
directly address finger movement

Pharmacologic agents facilitate

motor retraining after experimentally
induced stroke in animals
agents that reduce or inhibit the action
of noradrenaline and GABA generally
inhibit recovery
Agents that increase noradrenaline can
enhance recovery

Other intervention in various stages of

investigations

Transcranial magnetic stimulation

Cortical brain stimulation
Neuronal transplantation
Use of autologous marrow stromal cells

Defined as a motor disorder

characterized by a velocity- dependent
increase in tonic stretch reflex and can
contribute to motor impairment, pain,
and disability following stroke
Can be managed with exercise therapy
or by focal management with botulinum
toxin or phenol injections.
If severe, can be very disabling and
difficult to treat

Critical to managing spasticity in

patients with stroke is educating on the
benefits and necessity of daily
stretching, especially of the shoulder,
wrist, fingers, hip and ankles
Needed to reduce resting and dynamic
tone and prevention soft tissue
contracture.

Botulinum toxin- quite popular for the

management of localized limb
spasticity , because it is easy to use,
has a repeatable dose- dependent
effect and has low side effect profile
Requires only EMG
Favored over oral antispasticity agents

Intrathecal baclofen

Delivered by implanted infusion pump

provides excellent lower limb spasticity
control in patients with stroke and improve
functional gait in some cases

1/3 to of stroke survivors experience

speech and language disorders
Language and perceptual functions
tend to demonstrate some degree of
natural improvement after stroke, but
their recovery patterns can be more
variable than those seen in motor
functionn

Prevalence of aphasia declines from

about during acute phase to about 1/5
or less during later stages after stroke
Recovery occurs at a slower rate and
over a more prolonged time course than
does motor recovery
Most aphasia recover during the first 3-6
months

Greatest improvement during the latter

half of the first year after stroke
Non-fluent aphasia have less favorable
prognosis than those with fluent aphasia
Most of the recovery of perceptual deficits
such as unilateral spatial neglect, denial of
illness, loss of facial recognition and motor
impersistence occurred within the first 20
weeks after stroke, some improvement
could be seen up to 1 year later

Goals of therapy

improve the patients ability to speak,

understand, read and write
Assist patient to develop strategies that
compensate for or circumvent speesh and
language problems
Improve quality of life

Strategies and techniques:

MELODIC INTONATION THERAPY approach

designed to use the non- injured functioning
neural pathways in the non- dominant
hemisphere that carry the musical function
ENCOURAGING VERBALIZATION
CONVERSATIONAL COACHING
ORAL READING

For dysarthria:

STIMULATION PROCEDURES
EXERCISES TO STRENGTHEN OROMOTOR
SPEECH MUSCLES
RESPIRATORY TRAINING PROCEDURES
RETRAINING OF ARTICULATORY PATTERNS
NAD SEQUENCES OF GESTURES

For visual- spatial perceptual deficits:

PRISM GLASSES
PROVIDING VISUOSPATIAL CUEING TO
COMPENSATE FOR VISUOSPATIAL LOSSES
INCREASING AWARENESS OF DEFICITS WITH
CUES
USING COMPUTER-ASSISTED TRAINING
EYE PATCHING

for language problems resulting from

right hemisphere stroke:
IMPROVING ORGANIZATION OF
LANGUAGE
LEARNING TO USE LANGUAGE WITHIN
SOCIAL CONTEXTS
LEARNING TO INTERPRET FIGURATIVE
LANGUAGE

Dysphagia or impaired swallowing 1/3

to of all stroke survivors
High risk for aspiration and pneumonia,
malnutrition and dehydration
Compensatory treatments:

Changing posture and positioning for

swallowing
Learning new swallowing maneuvers
Changing food amount and textures

Common complication after stroke that

can inhibit recovery and reduce the
quality of life
No single type of shoulder pathology can
account for all shoulder pain after stroke
Pathogenesis remains controversial
* Reported prevalence of post stroke
shoulder pain 34% - 84%

Causes of Shoulder Pain:

1. Shoulder subluxation
2. Increased translation of the humeral
head relative to the glenoid fossa.
2. Capsulitis
frozen shoulder
Due to decrease shoulder ROM especially
external rotation and abduction

Due to shortening of capsule and

ligaments
Treatment:
ROM exercise
Proper limb positioning
Steroids

3. Impingement syndrome
Due to:
Limited scapular rotation during humeral
abduction
Imbalance bet. Stronger deltoid and
weaker rotator muscles in hemiplegia
Treatment:
ROM exercise
Proper technique during stretching
Steroids

4. Complex Regional Pain Syndrome Type

1
AKA shoulder-hand syndrome
Pain in shoulder and hand
Elbow is not affected
Treatment:
Oral prednisone
Exercise

The most common reason for

incontinence after stroke is uninhibited
evacuation of bladder or bowel
Treatment for persistent uninhibited
bladder:
Timed voiding
Alpha blocking agents
Treatment for bowel problems:
Laxative

Depression, anxiety and fear. Addressing this

issues is a critical component of rehabilitation
program.
One of the major factors influencing both the
degree of participation in a therapy program
and the outcome achieved is patient
motivation.
Patients who cooperate with therapeutic efforts
and who have the determination to improve are
more likely to participate in a therapy program.

Positive reinforcement
Behavioral modification
Family support
Counseling
Recreational activities
Peer support

The Framingham Heart study reported

that, compared with age and sex matched
control subjects, stroke survivors had
significantly greater frequencies of
hypertension, hypertensive heart disease,
coronary heart disease, obesity, diabetes
mellitus, arthritis, left ventricular
hypertrophy and congestive heart failure.
Medical problems in stroke patients
undergoing rehabilitation can be
categorized as follows

Preexisting medical illnesses that

necessitate ongoing care during the
rehabilitation program
General health function affected by the
stroke
Secondary poststroke complications
Acute poststroke exacerbations of preexisting chronic diseases.

The rehabilitation interventions also

have the potential to adversely affect
the medical condition, causing
exacerbation of the disease. Medical
complications can occur during the
rehabilitation program, requiring
diagnostic evaluation, prompt
recognition and appropriate
management..

Preventing and treating co-morbid

medical conditions and medical
complications are major components of
rehabilitation treatment of stroke
patients, as they enable rehabilitation
to take place and exert maximum
effectiveness

Physiologic deconditioning accompanies both

acute medical illness and prolonged bed rest that
might be enforced immediately after its onset.
Deconditioning contribute to fatigue, endurance
limitation, poor exercise tolerance, orthostatic
hypotension, lack of motivation and depression.
Preventive techniques are early ambulation,
early and gradually participation in rehabilitation
Venous Thromboembolism 40 50% are deep
venous thrombosis. Stroke patients should be
given prophylaxis in whom hemorrhage have
been ruled out. They should be given heparin or
low molecular weight heparin.

Pneumonia occurs about 1/3 of stroke

patients. Dysphagia, present about
one-third to half of all stroke patients
causes aspiration pneumonia. Other
causes are abnormal central breathing
patterns, general debility, hemiparetic
weakness of ventilatory muscles.

Cardiac disease can be causal,

consequential or coincidental in stroke,
with rates of association with 75% of
hypertension, 32-62% of coronary heart
disease, 40-70% for various
arrhythmias and 12-18% for congestive
heart failure. Screen patients before
engaging in exercise.

Falls occur with striking frequency in

stroke survivors, with most report
indicating that patients who sustain
right hemispheric strokes are in greater
risk in falling. Prevention approaches
emphasize in balance training,
cognitive training, safety training,
ensuring supervision.

The importance of early activation of

patients with stroke, to reduce the problems
associated with deconditioning and
prolonged bed rest, underscores the value
of early initiation of stroke rehabilitation
activities in the comprehensive care of the
post stroke patient. Bed side or active
exercises, early gait training, training in the
performance of activities of daily living such
as dressing, patient and family teaching
and swallowing training can be initiated
during acute poststroke phase.

Comprehensive acute inpatient stroke

rehabilitation refers to the traditional
interdisciplinary hospital-based
coordinated program of medical,
nursing and therapy services.

Long-term acute care conventionally

provides medical treatment for patients
who suffer prolonged illness with
medical complexity, such as requiring
ventilator management.

Skilled nursing facilities now commonly

provide rehabilitation services, ofted
designated as subacute rehabilitation.
These programs are appropriate for stroke
patients who need comprehensive and
coordinated therapy services for functional
training in an institutional setting, but in a
less intensive program than is used at the
acute level of rehabilitation.

All the same therapy services that are

provided in comprehensive inpatient
rehabilitation are offered, but without
the overnight stay.

Many stroke patients need traditional

outpatient therapy services. These
services are also provided in an
outpatient setting, but do not entail the
coordination, comprehensiveness,
group therapy and team conferences
that characterize day rehabilitation.

The home is the most familiar

environment for the patient and family,
and therapy in the home allows patient
and family to learn specific functional
task in the setting in which skills will be
used most often.

Adaptive and durable medical equipment

can be used to assist stroke patients to
become more independent to facilitate
functional skill performance.
Adapted feeding utensils
* Utensil with built-up handles
* Universal cuff
* Rocker knife
* Non skid mats
* Plate guards or scoop dishes
* Cup holder
* Adapted cups

Bathing and grooming services

* Long-handed sponge
* Washcloth mitt
* Adaptive shaving equipment
* Handheld shower nozzle
* Soap on a rope
* Stand up mirror
* Built-up toothbrush, comb, hairbrush

Tub and shower transfer equipment

* Non skid mat
* Grab bars
* Transfer seats
* Shower chair or bench
* Hydraulic and motorized tub lifts

Dressing services
* Velcro closures
* Button hooks
* Long-handed reachers
* Sock donning aid
* Long-handed shoehorn
* Elastic shoelaces

Walking devices
* Single-point cape
* Quad cane
* Hemiwalker
* Standard walker
* Riding walker

incidence of stroke in the USA = 700,000

500,000 new strokes
200,000 recurrent strokes
disease of older individuals
28% < 65 years In adults

atherosclerosis - primary cause of ischemic stroke

cerebrovascular anomalies, congenital heart

disease, carotid dissection, sickle cell disease,
inherited disorders of coagulation, and previous
infection with varicella zoster
Hemorrhagic stroke - moya moya disease and
hemophilia

Incidence of stroke
19% M>F
Stroke is 3rd leading
cause of death in USA
Stroke survivors
-rehabilitation
services
Stroke rehabilitation
will have an important
role in reducing the
burden of long-term
stroke care on society.

Age
Sex
Race
previous stroke

first 6 hours implementation of acute stroke

management

intravenous recombinant tissue plasminogen activator

(rt-PA)
> most commonly used treatment
> is a thrombolytic agent that can only be given
safely within 3 hours of stroke onset
Heparin > frequently administered intravenously in
the acute setting to arrest stroke progression or to
prevent its recurrence.
However, there may be a role for anticoagulation in
patients who present with cardioembolic stroke, stroke
in evolution, stroke in large artery atherosclerosis, or
in the case of arterial dissections

Initial medical care

Neurologic monitoring to prevent and manage
medical complications that compromise cerebral
tissue perfusion.
For obtunded patients, concern for airway
protection is critical to maintain oxygenation, and an
endotracheal tube should be placed with ventilatory
support if nessesary.
Cerebral edema and acute hydrocephalus - requires
placement of an external ventriculostomoy device to
relieve intracranial pressure.
Brainstem compression and hydrocephalus - surgical
decompression of the posterior fossa can be lifesaving

Cranial magnetic resonance imaging (MRI)

> extent of brain injury and identify
potential structural abnormalities
>more sensitive than ct scan (lacunar24hrs; acute stroke-48hrs; test of choice for
imaging of posterior fossa)
Cranial CT is the test of choice for
examination of hemorrhage (acute setting;
less expensive)

With subacute or chronic

hemorrhagic stroke MRI
can differentiate
methemoglobin from the
soft tissue and is better
than CT for detection of
late hemorrhages.
Magnetic resonance
angiography - noninvasive option for
examining extra and
intracranial cerebral
vessels. (carotid artery
dissection)

ultrasonography
-standard diagnostic
tool in the
evaluation of acute
stroke (noninvasiveness)
Arterial duplex
scanning screening tool for
carotid atherosclesis
Transthoracic
echocardiography suspected cerebral
embolism

reduce the incidence of first-time and

recurrent stroke

Antiplatelet therapy -reduce the risk of non-fatal stroke

by 25% in men and women
Aspirin - most frequently prescribed antiplatelet agent
for secondary stroke and cardiovascular disease
prevention
- irreversible inhibition of cyclooxygenasedependent platelet aggregation
Clopidogrel - non-aspirin antiplatelet agent
- prevents platelet aggregation for the life
of the cell by inhibiting ADP-induced platelet aggregation,
without affecting prostaglandin metabolism
Surgical Management

Consider:
Patients functional level
Level of adaptation to the disability
Architecture of the living environment
Instruction in the use of all devices and
equipment

Hemiplegic patient
>wheelchair with
lowered base
(propulsion)
Foot drop
> posterior leaf spring
orthosis
Ankle Foot Orthosis
ankle and foot
weakness and
dystonia

1.

2.

3.

To consider in
prescribing AFOs:
Stability of the knee
during the stance of
gait
Medial and lateral
stability of the ankle
during stance and swing
Degree of plantar
flexion or foot drop
during swwing phase

One of the most important

interventions is the training of families
and other caregivers in specific care
techniques to prevent complications,
perform physical functions, and
encourage patients to perform any
activities they are capable of doing.
Family involvement smooth transition
to community and safe functioning of
the patient in the home environment

Good functional mobility and self-care by

adulthood
majority of people with childhood stroke who
have motor impairments at stroke onset will
have some residual hemiplegia or other
motor deficit
rehabilitation approaches are usually
reflective of techniques that are applied to
patients with spastic hemiplegia
Onset of stroke < 3 y/o, cognitive
impairment at onset and a history of seizure
- poorer functional outcome in adulthood

Functional therapy interventions includes:

Complex instrumental activities of daily living like

shopping, homemaking, community level
mobility, childcare and care of elderly parents
Communication and cognitive training should
focus on money management skills and
vocational activities
Psychologic counseling of the patient and family
should be instituted
Recreational and social programs aerobic training
or fitness exercise groups and community reentry
training all enhance the quality of their life

Advancing age - marker

for the presence of
medical comorbidities,
prior strokes and
limited social supports.
Older adults often
require more medical
monitoring, longer
recovery times,
reduced exercise
intensities, or more
psychosocial support
during their
rehabilitation program
than young adults.

Rehabilitation is a lifelong activity involving

the restoration of patients to their fullest
physical, mental and social capabilities.
Long term quality of life is accomplished
through an interdisciplinary approach :
- helping the patient to achieve maximal
independent and functioning in daily
activities
-training family members and other
personal caregivers in the performance of
specific physical skills
-continuing mobilization exercises

Outcomes after stroke

can be assessed by the
following
Medical morbidity
Mortality
Level of impairment
Length of hospital stay
Cost of care
Functional limitations
Placement at the time
of discharge

Physical performance, functional abilities and

quality of life are better after rehabilitation and
during long term care than immediately after
stroke.
Uniform Data System for Medical Rehabilitation
reported that stroke patients had greatest
improvements in the ff areas:
- locomotion
- mobility
- self-care
- sphincter control
Less improvement - communication and social
cognition measures.

Many factors play a role in

predicting the outcome of an
individual patient involved in a
stroke rehabilitation program. This
include:

Type, distribution, pattern, and

severity of physical impairment.
Cognitive, language,
communication, and learning
ability.
Numbers, types, and severity of
co morbid conditions and
ongoing health functions.
Coping ability and style.
Nature and degree of family and
other social supports.
Type and quality of specific
rehabilitation training
program.

Age
Educational level
Severity of stroke
Type of stroke
Localization of stroke
Size of stroke
Prior stroke
Multiple neurological deficits
Initial functional status
Congestive heart failure
Other medical comorbidities
Premorbid dementia
Days from stroke onset to
rehabilitation
Coma at onset
Cognitive function
Language function
Perceptual function
Hemianopsia

Coma at onset
Cognitive function
Language function
Perceptual function
Hemianopsia
Posture and balance
Sensory function
Bowel incontinence
Bladder incontinence
Severity of paralysis
Depression and emotional state
Motivation
Family involvement and support
Posture and balance
Sensory function
Bowel incontinence
Bladder incontinence

Coma at onset
Persistent incontinence
Poor cognitive function
Severe hemiplegia
Lack of return of motor function after 1 mo.
Prior stroke
Visual spatial perceptual deficit
Unilateral hemineglect
Significant cardiovascular disease
Large cerebral lesion
Presence of multiple neurologic deficits

Improvement in performance:

Early initiation of treatment >

duration of
intervention