Chapter 5 - Stroke Rehabilitation Flashcards
10 Risk Factors for Poor Functional Outcome in Stroke 🔑🔑 MOCK
Patient (Medical History)
- Old age
- Prior stroke
- Medical comorbidity
- Delayed acute medical care
- Delayed rehabilitation
- Large lesion
- Coma at onset
Psychosocial History
- Unmarried
- Unemployed
- Depression
- Poor social support
Clinical Examination (MMSE - CN - Neuro - BB)
- Cognitive deficits
- Aphasia
- Visuospatial perceptual deficits
- Homonymous hemianopsia
- Dense hemiplegia
- Urinary incontinence
- Bowel incontinence
Functional History
- Low FIM on admission to rehab
- Inability to perform ADL
- Poor sitting balance
PM&R Secrets 3rd Edition p454
List 10 risk factors for acute stroke mortality 🔑🔑
- Old age
- Hemorrhagic stroke
- Brainstem involvement
- Decreased level of consciousness
- Stroke severity
- Cardiac disease
- Diabetes mellitus
- EKG abnormalities
- Delay in medical care
- Elevated blood sugar in nondiabetics
- Admission from nursing home
Cuccurollo 4th Edition Chapter 1 Stroke pg47
List 10 risk factors for disability after stroke 🔑🔑
💡 History (Present & Past) - Physical Exam (MMSE, Neuro) - Bowel & Bladder
HISTORY
- Old age
- Previous stroke
- Previous functional disability
- Diabetes mellitus
- Cardiac disease / MI
- Bilateral lesions
- Delay in rehabilitation
- Delay in medical care
- Incontinence persisting >2 weeks
EXAMINATION (VITALS - MMSE - NEURO)
- EKG abnormalities
- Decreased level of consciousness
- Impaired cognition
- Global aphasia
- Severe neglect
- Sensory and visual deficits
- Severe stroke: minimal motor recovery at 4 weeks
- Poor sitting balance
Cuccurollo 4th Edition Chapter 1 Stroke pg48
DeLisa 6th Edition Chapter 23 Stroke pg568
Factors influencing return to work include
- Educational level
- Type of pre-stroke employment
- Degree of physical and cognitive impairment
- Young age
- Mild neurological impairment
- Absent of (aphasia-apraxia- agnosia-depression)
- No or mild cognition & communication deficit.
- Independency in ambulation & ADL
What are the strongest predictors of recovery post stroke? Good and bad predictors? 🔑🔑
💡 Motor recovery of hand by 4 weeks, there is up to a 70% chance of making a full or good recovery
MOST POWERFUL PREDICTORS
- Age <55 years is better prognosis
- Initial stroke severity (most predictive factor)
GOOD PREDICTORS
- Active finger extension
- Shoulder abduction
POOR PREDICTORS → Patients with shoulder spasticity and flaccid fingers
- Severe proximal spasticity
- Complete arm paralysis at onset
- Prolonged “flaccidity” period
- No measurable grasp strength by 4 weeks
- Late return of proprioceptive facilitation (tapping) response >9 days
- Return of proximal traction response (shoulder flexors/adductors) >13 days
Evidence-Based Review of Stroke Rehabilitation 2020 Module 4 pg3&6
Cuccurollo 4th Edition Chapter 1 Stroke pg27-28
Name 2 types of recovery after stroke
What is the difference between remedial and compensatory rehabilitation?
Patient is unhappy about his rehab progression post-stroke, what do you replay? 🔑🔑
1- Neurological - Intrinsic - Spontaneous - Remedial
- Recovery of neurological impairments, result of brain recovery/reorganization
- Influence by rehabilitation
- Most at first 3 months
2- Functional - Adaptive - Compensatory
- Recovery by improving function, mobility and activities of daily living irrespective of neurological impairment which is influenced by rehabilitation.
- Influence by neurological recovery, rehabilitation and motivation
General
- 70% improvement within 6 months as natural process
- Depends on integrity of corticospinal tract, more damage = less recovery.
- Proportion is unaffected by rehabilitation therapies
- It’s more driven by adaptive or compensatory learning strategy
- High motivation related to better functional outcomes
Stroke Rehabilitation Clinician Handbook 2020 Model 2 pg2
List 3 factors influence the recovery after stroke 🔑🔑
- Neurological recovery
- Rehabilitation
- Motivation
Stroke Rehabilitation Clinician Handbook 2020 Model 2 pg2
List 3 local mechanisms for recovery post-stroke 🔑🔑
- Resolution of post-stroke edema
- Resolution of diaschesis.
- Reperfusion of the ischemic penumbra
Stroke Rehabilitation Clinician Handbook 2020 Model 2 pg3
Describe the three bands of stroke severity. 🔑
Importance of implying early FIM score on stroke patient.
Which of the three bands does not usually require in-patient rehabilitation?
Upper band = milder strokes (FIM > 80)
Rehab gains limited by “ceiling” or “plateauing” effect
Middle band = moderate strokes (FIM = 40-80)
Marked gains in rehab and 85% discharged to community
Lower band = severe strokes (FIM <40)
Unlikely to achieve functional independence (unless young) and smallest likelihood of community discharge.
Upper band or the milder stroke patient does not usually require in-patient rehabilitation
Stroke survivors discharged to the community will be provided with ambulatory services for one hour of each appropriate therapy, two to five times per week, as tolerated by the patient and as indicated by patient need. If only one discipline is required (e.g., speech-language pathology), then the stroke survivor will be provide with that one service. (Evidence Level 3)
Stroke Rehabilitation Clinician Handbook 2020 Model 2 pg6
Describe the usual motor recovery after stroke. 🔑 (Ward Call)
Time Frame
Day 1-2
Total loss of voluntary movement and loss or decrease of tendon reflexes.
Day 2
Increased deep tendon reflexes
From 1 Day to 1 Month
Spasticity increases, clonus of the ankle plantar flexors appears
From 1 Week to 2 Months
First “intentional” movements (shoulder flexion) appear.
Starting with flexor synergy pattern develops (with shoulder, elbow, wrist, and finger flexion)
Followed by extensor synergy pattern
Other Notes
- Motor recovery in the leg occurs earlier and is more complete than in the arm.
- Major recovery takes place in the first 3 months
- Minor additional recovery occurs after 6 months post stroke
Cuccurollo 4th Edition Chapter 1 Stroke pg27
Limb synergy patterns 🔑
Flexion Synergy Pattern in Arm
- Shoulder abduction & external rotation
- Elbow flexion
- Forearm supination
- Wrist and finger flexion
Extensor Synergy Pattern in Leg
- Hip adduction and extension
- Knee extension
- Ankle planter flexion and inversion
PMR Secrets Chapter 54 Stroke pg448
What is the difference between the bobath approach and brunnstrom approach to stroke rehabilitation? 🔑🔑 EXAM 2021
BOBATH APPROACH
Normalize tone by inhibition of primitive patterns of movement
Encourages voluntary reactions and normal movement patterns
BRUNNSTROM APPROACH
Encourages the use of abnormal movements (synergistic patterns) to improve motor control
Cuccurollo 4th Edition Chapter 1 Stroke pg29
Brunnstrom stages of motor recovery 🔑🔑 EXAM
1- Flaccidity (immediately after the onset)
No “voluntary” movements on the affected side can be initiated.
2- Spasticity appears
Basic synergy patterns appear
Minimal voluntary movements may be present.
3- Spasticity is prominent
Voluntary control with synergies.
4- Decrease in spasticity
Voluntary control outside the flexor and extensor synergies.
5- Further decrease in spasticity
Selective muscle activation independently from synergies.
6- Disappearance or minimal spasticity
Isolated movements are performed in a smooth, phasic, well-coordinated manner.
Cuccurollo 4th Edition Chapter 1 Stroke pg28
DeLisa 5th Edition Chapter 23 Stroke Rehabilitation pg565 Table 23.9
Give 3 reasons why a patient with a right MCA infarct may not be able to drive 🔑🔑
Another Q: List 4 things to check prior to driving for stroke patient. 🔑
List 3 advices for stroke patient returning to driving. 🔑 (OSCE Q)
MMSE (ORARL.C)
- Disorientation
- Cognitive deficits (problem solving - poor insight - poor judgment)
- Language difficulties (receptive aphasia).
- Left hemineglect
- Constructional apraxia
- Visual field cuts (Hemianopsia)
- Left Hemiparesis (neck rotation, hand-steering & leg-pedals motor power)
- Seizure disorder.
ADVICES
- Driving in an unfamiliar area.
- Driving at night.
- Driving when tired (includes long distances).
- Parallel parking.
- Driving in rush hour, particularly in a large city.
- Driving on busy multilane high speed expressways.
Ref: first principles.
Benefits of early mobilization after stroke 🔑🔑 EXAM
- Improve orthostatic intolerance.
- Prevent deconditioning
- Prevent skin breakdown
- Decrease DVT
- Decrease contracture formation
DeLisa 5th Edition Chapter 23 Stroke Rehabilitation pg559
List 4 treatment methods for Hemiplegic Side 🔑🔑 EXAM
What are upper limb strategies for rehabilitation in stroke 🔑🔑
💡 Patients should engage in training that is: meaningful, engaging, repetitive, progressively adapted, task-specific and goal-oriented.
- Range of motion exercises (Suspension, Cable pulley)
- Strength training (Leg press machine)
- Bilateral arm training (Cycling ergometer)
- Gait training (Manual, support, robotic)
- Retraining trunk control (Static & dynamic balance)
- Functional Electrical Stimulation (FES)
- Traditional or modified constraint-induced movement therapy (CIMT)
- Mirror therapy (Neglect and Postural Correction)
- Sensory stimulation (TENS, acupuncture, biofeedback)
- Compensatory techniques for ADLs (i.e. Transfer and Dressing)
- Repetitive transcranial magnetic stimulation (rTMS)
- Robotics gait and hand exoskeleton +/- Virtual reality
- Graded Repetitive Arm Supplementary Program (GRASP)
Cuccurollo 4th Edition Chapter 1 Stroke pg29-30
Stroke Rehabilitation Clinician Handbook 2020 Model 4 pg12
List 4 adaptive equipment’s for dressing can be used by stroke patient. 🔑🔑 EXAM
DRESSING
- Velcro closure
- Button hooks
- Long handled reachers
- Sock donning aid
- Long handled shoehorn
- Elastic shoe laces
FEEDING
- Mug with two handles
- Scooper bowel
- Universal Utensil
- Plate-guards
HYGIENE
- Safety rails / grab bars
- Comodo Chair
- Handheld shower
- Tub bench board
- Transfer board
- Electric toothbrush
Braddom ,3rd edition, P1199
Mention two types of hand orthosis and list 4 benefits. 🔑
Types
- Static/passive (volar splint) → anti-spasticity or universal cuff for utensils
- Dynamic/active (Saeboflex) → functional grip
Aims are:
- Reduction in spasticity
- Reduction in pain
- Improvement in functional outcome
- Prevention of contracture
- Prevention of edema
Traditional or modified constraint-induced movement therapy (CIMT) should be considered for a select group of stroke patients. List 2 requirements to be met & mention program considerations 🔑🔑
ANSWER 1
- At least 20 degrees active wrist extension
- At least 10 degrees of active finger extension
- Minimal sensory or cognitive deficits
Stroke Rehabilitation Clinician Handbook 2020 Model 4 pg16
ANSWER 2
EXCITE trial
- At least 10 degrees active wrist extension.
- At least 10 degrees active thumb abduction/extension.
- At least 10 degrees active extension of two other digits
Cuccurollo 4th Edition Chapter 1 pg29
PROGRAM CONSIDERATIONS
💡 Training regimen: 6+ hours/day 5 days/week 2+ weeks
Activities Include:
- Reaching and grasping objects
- Stacking blocks
- Moving blocks from container to another
- Turning papers
- Flipping playing cards
- Write and erasing chalkboard
- Feeding.
- Modified CIMT can use as little as 1 hr a day for 5 days for 10 weeks.
- Restrictive mitt worn over the sound hand during 90% of waking hours, preventing its use, thus encouraging the use of the hemiplegic hand
- Patient is encouraged to use the hemiplegic hand as much as possible during whole day.
PMR Secrets 3rd Edition Chapter 52 pg424
What are 4 strategies to help a patient with short term memory? 🔑
EXTERNAL STRATEGIES
- Assistive electronic devices
- Notebook
INTERNAL STRATEGIES
- Retrieval strategies (active recall)
- Imagery based training
- Repetition
Ref: EBRSR module 12 pg 39.
Optimal duration of rehab session per week or day in stroke patient? 🔑🔑
The Canadian Stroke Guidelines recommend minimum of
- Three hours of direct task-specific therapy
- Five days per week
Also for aphasia → Intensive Speech and Language Therapy (1hr/d, 5d/wk)
Stroke Rehabilitation Clinician Handbook 2020 Model 2 pg37
Would you allow for weekend pass or not? Patient is newly admitted. 🔑🔑
The evidence on weekend therapy providing better outcomes on 5 day per week therapy is mixed. Better to be tailored on patient’s condition.
i.e. Some patients prefer weekend therapy while others prefer social gathering and return to their usual activities.
Stroke Rehabilitation Clinician Handbook 2020 Model 2 pg37
When to shift patient to OPD based rehabilitation?
List 3 Importance of Outpatient Therapy 🔑
Discharge
Patients are typically admitted to an outpatient program with a mean FIM score of over 100 which mean on average they are capable of living at home with no or minimal help.
Benefits
- Allows for earlier discharge of stroke rehabilitation patients into the community
- Rehab gains are reinforced and maintained in outpatient therapy.
- Inexpensive compared to inpatient stroke rehabilitation
Location
No difference in efficacy between home or hospital-based therapy during outpatient rehabilitation
Duration
Therapy should be provided for a minimum of 45 minutes per day
Stroke Rehabilitation Clinician Handbook 2020 Model 2 pg49-52
List 4 advantages of Early Supported Discharge (ESD)
- Avoiding complication of prolonged hospital admission
- Improving patient confidence
- Encouraging more focus on self-directed recovery
- Focusing on more realistic rehabilitation goals
- Providing rehabilitation in a more relevant environment
- More realistic understanding of future recovery
Stroke Rehabilitation Clinician Handbook 2020 Model 2 pg54
Mention 4 benefits of AFO in stroke patient.🔑🔑 MOCK
- Prevent foot drop in swing phase
- Easy to negotiate stairs
- Reduce energy cost
- Increase walking speed
PMR Secrets, Second edition, P113
List 4 Aims in Applying Orthosis 🔑🔑
- Reduction in spasticity
- Prevention of contracture
- Improvement in functional outcome
- Reduction in pain
- Prevention of edema
Stroke Rehabilitation Clinician Handbook 2020 Model 4 pg37
List 3 causes of excess planterflexion in stroke patient. 🔑🔑
Mention 1 muscle to inject to improve planter flexion and inversion 🔑🔑
- Spastic calf muscles
- Decreased motor recruitment of dorsiflexion muscles (foot drop)
- Co-activation of several muscle groups both planterflexors and dorsiflexors.
Injection: Tibialis Posterior
PMR Secrets Chapter 54 Stroke pg449
Spastic Equinovarus. List 4 complications if left not treated. 🔑
- Pain on weight bearing
- Increased loading phase
- Shortened stance phase
- Ankle instability
- Genu varum & recurvatum
- Abnormal base of support
- Unstable gait , impaired balance → risk of fall
- Interference with transfers
Stroke Rehabilitation Clinician Handbook 2020 Model 3 pg52
Stroke patient with hyper extended knees, how do you manage him?🔑
- Weak Hamstring → Swedish Knee Brace or Brace with dial lock + strength exercises
- Spastic quadriceps → Botox
- Drop foot → AFO to increase ankle dorsiflexion leading to knee flexion moment arm.
- Tight Achillis Tendon → Body weighted stretch, cryotherapy
Compare normal gait to typical hemiplegic gait. 4 marks 🔑🔑
- Slower cadence
- Longer stance duration
- Longer double limb support
- Circumduction or hip hiking
- Reduced hip flexion at initial contact
- Reduced hip extension at toes off
- Reduced knee flexion in swing phase
- Excess ankle planterflexion in initial contact and mid swing (Reduced dorsiflexion)
- Reduced ankle planterflexion at toes off
PMR Secrets Chapter 54 Stroke pg448
Woman with stroke, cerebellar ataxia, no weakness, what is the best mobility aid 🔑🔑
Walker
What medication would like to prescribe in order to have better recovery 🔑
Serotonin-selective reuptake inhibitors (SSRIs)
FLAME trial: Early prescription of fluoxetine (Prozac) with physiotherapy enhanced motor recovery after 3 months
Cuccurollo 4th Edition Chapter 1 Stroke pg30
Interventions for Mobility Impairment Post Stroke
