Rehabilitation and recovery following stroke

Question 1

Rehabilitation

Answer 1

rehab is a collective approach, involving:

• speech and language therapy (aphasia)
• clinical psychologists (families)
• doctors/nurses (initial assessments/ diagnosis and pharmacological treatment)
• physiotherapists (exercise)
• occupational therapists (Adaptation/ training)
• family/ friends (local support)
• -> multidisciplinary stroke team = to get best outcome

rehab is a dynamic process with the overall aim of reducing disability and improving quality of life

cognitive therapy
psychotherapy
pharamacological treatment

Question 2

Key physical impairments

Answer 2

reduced muscle strength
altered sensation
coordination problems
balance impairments
hemiparesis (paralysis on one side of the body)
altered gait pattern

Question 3

Assessment: stroke scales (3)

Answer 3

1) NIHSS ( national institute of health stroke scale)
- brief scale with reliability
- sensitive for serial monitoring of patients after stroke
- doesn’t identify cause of deficit (Too brief, not sensitive enough)
- no practice effects (=good to look at as a measure over time)
2) Barthel index
- brief and easy to administer
- used widely
- high reliability
- low sensitivity and not suitable for those who are bed bound/ paralysed as it assesses activities of daily life
3) MRS
- global disability scale
- easy to readminister
- good reliability and validity
- broad measure to assess deficits directly
- may not be specific enough which makes it difficult to identify the problem
- - in some circumstances we may use a combination of scales
- - really key measure when it comes to tailoring treatment

Question 4

Physiotherapy

Answer 4

treatment plan made for patient
–> physical problems usually affect about 80% of stroke survivors
- stroke is also the leading cause of disability
- we want to help the individual maximise their independence (improve quality of life by reducing disability)
-usually offered to patients who have:
weakness in limbs
sensory disturbances
balance problems
paralysis

1) strength training
- rebuild muscles/ help muscle weakness
- progressive strength building through increasing repetitions of body weight activities, weights of resistance exercises
2) fitness training
- for those who don’t have physical impairments really but they may have small changes to mobility
- encourage them to engage in physical activity
3) walking therapies
- often use treadmills
- often used in severe cases (can often need to be suspended to help them get going)
- recommended for those with gait problems

tasks that we do automatically can often be very difficult for stroke patients and require a lot of concentration and effort

physiotherapy isn’t the only option!
(can use TMS)

Question 5

Transcranial magnetic stimulation (TMS)

• promotes?
• neuroplasticity def?
• how it works?
• evidence?

Answer 5

promote neuroplasticity and recovery following stroke
-an electric current is induced in the underlying cortex by a magnetic field, this causes an increase in cortical excitability in the lesion areas (area affected by stroke)
(neuroplasticity = reorganisation of the brain or forming new neural connections)
- studies found it to be effective in improving upper limb paralysis
- all of these therapies are working at the level of the brain, not just limb
- safe/ painless/ non-invasive

evidence:
Ganguly et al(2013)
-rTMS paired with task can improve motor function
-short and long term trial found an overall benefit
-dependent on lesion location (subcortical = easy to target, deep in brain = difficult/ not suitable)
-further research required (relatively new)

Question 6

Robotics

combined with physiotherapy

Answer 6

-programme robot to understand function of limb
- if patient can’t carry out full movement the robot assists = teaches brain movement
- using electromechanical and robot-assisted arm training for improving generic activities of daily living, arm function and arm muscle strength
-stroke patients actively or passively interact with a robotic arm that delivers a precise degree of force, velocity, duration and repetition of movement in a stereotyped movement
evidence:
(Branin and Zorowitz, 2012)
- improves daily living activities
- improves arm function
-no improvement in muscle strength (why we need to combine with physiotherapy)

Question 7

Virtual reality

Answer 7

combination of robotics and VR often

• by creating an interactive, motivating environment, virtual reality can enhance the effect of repetitive task training
• movement in the unaffected arm can trigger a response in the affected arm, this is because the 2 hemispheres can communicate
• cross-hemisphere communication can stimulate the affected region of the brain
• by combining with robotics it can encourage individuals to keep motivated and to complete the task
  evidence: Brewer et al, 2013
• combined with robotics
• mixed results
• further studies are required

Question 8

Mirror therapy

Answer 8

• not commonly used
  -little financial cost
• FMRI whilst doing therapy shows neurons fire when observing unaffected limbs in mirror
  = tricks brain into thinking affected limb is working = can improve sensation in affected limb
• Brewer et al 2013 - some studies have found 1 hr of mirror training a day can be effective (alongside other therapies)
  -further research required to determine practice intensity and duration
  HOW IT WORKS:
  2 key areas involved:
• primary somatosensory cortex
• motor cortex
  = info sent to somatosensory cortex about sensation
  -somatosensory cortex communicates with motor cortex so it can respond accordingly (integrates info)
• in mirror therapy the visual feedback they’re receiving from viewing the reflection can make it possible for them to perceive sensation in affected limb
  = reactivating pathways that have been damaged by stroke

Question 9

Occupational therapy

Answer 9

• important for recovery
• relearning everyday activities
• can build patients confidence

Question 10

Factors which may affect recovery

Answer 10

• age
• comorbidities
• stroke severity
• motivation
• family support
• level of dependency (v. dependent after stroke = can hinder recovery, so need to regain independence)

Question 11

2 levels of recovery

Answer 11

1) Neurological recovery
a) early recovery (local processes)
- resolution of post stroke swelling
- reperfusion of ischaemic tissue
- recovery of partially damaged neurons
b) late recovery (neuroplasticity)
- training
- modification in structural and functional organisation
2) functional recovery
- adaptation
- training
- presence/ absence of neurological recovery
- quality of therapy
- intensity of therapy
- motivation
- how early therapy is started

Question 12

Road to recovery
-hours
-days
-weeks
months
years

Answer 12

recovery for every patient has a different time course

• hours = medical
• hours-days = early mobilisation
• days- weeks = restoring impairments in order to regain activities
• days - months = task-oriented practice, rehabilitation to improve activities of daily living and social interaction
• weeks-months = environmental adaptations and services at home
• months - years = maintenance of physical condition and monitoring quality of life

Question 13

Family functions

Answer 13

stroke can change family dynamics

• can pose significant challenge for pre-existing relationship patterns
• psychosocial transition will usually take place to accommodate for the temporary or permanent changes following stroke
• involves: transition of roles, responsibilities and patterns of emotional support to accommodate the stroke survivors cognitive and social impairments
• family members may need to make adjustments to their lives to accommodate, and take on more responsibility
• also may need to adapt homes eg. chair access
• physical, financial and practical demands as well as emotionally distressing
• SUCCESSFUL OUTCOME IF: family is supportive, flexible, adaptive and high functioning
• family therapy can improve quality of life for both