Now we're going to talk about rehabilitation. Continuum of care. Rehabilitation begins in the acute care hospital, even at times in the intensive care unit. Then it can transition to acute inpatient stroke rehabilitation, subacute inpatient stroke rehabilitation, home stroke rehabilitation, and outpatient stroke rehabilitation. Key rehabilitation components include nursing, physical therapy, occupational therapy, speech-language pathology, psychology, social work, nutritionists, therapeutic recreation, and others. Often patients who are undergoing stroke rehabilitation require a wheelchair, at least in the acute phase. So when you prescribe a wheelchair for patients with stroke, things that may be unique to this prescription include a lower sitting base, a removable armrest, elevating leg rests, brake extensions, an acrylic versus other material lap board to support the affected upper extremity, arm trough, and seat cushion. Orthotics or braces often are essential in stroke rehabilitation. They could be static or dynamic, can involve the upper limb or the lower limb. Probably in stroke rehabilitation, the common type of braces are ankle-foot orthoses, and they could be created from all types of material, most traditionally metal and leather, but in recent years, more so thermoplastic design due to lighter weight and ease of modifiability. Types of ankle-foot orthoses include solid ankle, particularly for patients with very weak distal lower extremity strength. Posterior leaf spring orthoses for patients who have fairly strong plantar flexors at their ankle. Hinged ankle foot orthoses, and these can often be through a computerized design. In the acute care setting and sometimes beyond, a multi-potus boot or splint can be used to prevent the shortening of heel cords to prevent an equinovarious deformity. Learning objective number four, recognize the major theories of rehabilitation, including motor recovery post-stroke. A classic article from 1951 was by Twitchell in the journal called Brain, and the title of the article was The Restoration of Motor Function Following Hemiplegia in Man. He looked at about 120 patients, mostly with strokes involving the middle cerebral artery, and he basically observed his findings. He found that within 48 hours after stroke, many patients had an increase in reflexes on the impaired side and an increase in muscle tone often associated with spasticity in the upper extremity usually involving the flexor muscles and in the lower extremity usually involving the extensor muscles. Twitchell noticed that ankle clonus could appear in patients as early as day one and generally by day 38. He also documented the presence of flexor synergy patterns that can occur in the upper and lower extremity followed by extensor synergy patterns. Spasticity tended to decrease as voluntary muscle movement increased, and even if the motor recovery was complete, reflexes often were increased a sustained basis. In middle cerebral arterial strokes, the upper limb is more impaired generally than the lower limb. Motor recovery tends to occur earlier and more completely in the lower limb, and what Twitchell found was that in his group of patients, most motor recovery occurred within the first three months with only minor recovery after six months. In the 1990s, Jorgensen et al. published a series of papers in the Copenhagen Stroke Study looking at a much larger population of almost 1,200 acute stroke patients. Function was measured with the Barthel index, and some of the findings included that 95% of all patients reach their best neurological level within 11 weeks, just under three months, and that 95% of all patients reach their best activities of daily living function within 13 weeks or three months. Their best walking function was reached within about 11 weeks, and that the time course for neurological and functional recovery was related to the initial stroke severity and initial functional disability. The prognosis for mild to moderate stroke patients, they found, was generally good, and it was highly variable prognosis for more severe stroke patients. Negative predictors in terms of motor recovery include no measurable grasp strength by four weeks, severe proximal upper extremity spasticity, a prolonged period of flaccidity, and a late return of shoulder flexors and AD ductors beyond 13 days. They found that only about 10% of patients with initial complete upper limb plegia gained good hand function, but there was up to a 70% chance of a good or full recovery with some hand function motoring at four weeks. Brunstrom described the stages of recovery after stroke. Stage 1 was flaccidity initially without any voluntary movement or stretch reflex on the affected side. Stage 2, minimal voluntary movement with the development of spasticity. Stage 3, the increase in spasticity with the beginning of voluntary movement control and synergistic movement. Stage 4, a decrease in spasticity with some movement patterns developing independent of synergy. Stage 5, a further decrease in spasticity with more independence and relearning of complex movements with basic synergies losing their dominance. And in Stage 6, approaching normalcy with isolated joint movements and a gradual normalization of voluntary coordination with spasticity almost disappearing. Question. In a patient with left hemian attention with a right brain stroke, effective therapy options include A, prism lenses to shift the visual field to the right. B, left eye monocular patching. C, visual scanning training. D, increased right-sided verbal stimuli. E, ANC. The answer is E, ANC. In cases of left hemian attention, prism adaptation is a productive way of achieving long-lasting improvements. Eye patching procedures that provide right half-field patching of both eyes or right monocular patching have also been effective, providing increased nonverbal stimuli from the left side has been shown to decrease hemian attention, but increased verbal stimuli have not been effective. Physical therapy and stroke rehabilitation has a variety of schools of thought. Brunstrom talks about use of cutaneous and proprioceptive stimuli in central facilitation. Rood talks about modification of muscle tone and involuntary muscle activity via cutaneous sensory stimulation. Bobath, or neurodevelopmental treatment, talks about the use of task-specific postures while suppressing synergies with sensory input and motor feedback. Knott and Voss, or proprioceptive neuromuscular facilitation, involves the use of reflexes and patterning techniques. The take-home point with this is that at any type of a rehabilitation center, it would be a good idea to have at least more than one type of approach available to patients in stroke rehabilitation. So Knott and Voss, or proprioceptive neuromuscular facilitation, talks about spiral and diagnostic components of movement to facilitate movement patterns having more functional relevance than simply strengthening individual and group muscles. The theory is that body will use muscle groups synergistically related when performing a functional activity. You try to stimulate nerve, muscle, and sensory receptors to evoke response through manual stimulation to increase ease of movement and promote function. Resistance is used during spiral and diagonal movement patterns. The goal is to facilitate impulses to other body parts, increasing membrane potentials of surrounding alpha motor neurons. Neurodevelopment technique, NDT, the bow-bath technique, the goal is to normalize tone, inhibit primitive movement patterns, and facilitate automatic voluntary reactions and subsequent normal movement patterns. This is probably the most common approach used in neuro-remotative settings. The theory behind it is that pathological movement patterns, such as limb synergies and primitive reflexes, must not be used for training. Because continuous use of the pathologic pathways may make it too readily available, and it may suppress abnormal muscle patterns before normal patterns are introduced. So mass synergistic movements are avoided. So this is clearly opposite to the Brunstrom approach. This is the Brunstrom approach or movement therapy, where they actually use primitive synergistic patterns to improve motor control through central facilitation. The idea behind this is that the damaged central nervous system is exposed to older movement patterns that are considered normal recovery processes before normal movement patterns are achieved. Patients are taught to use and control patterns available to them at a point during recovery through use of cutaneous and proprioceptive stimuli. The sensory-motor approach, championed by Rude, is to modify muscle tone and voluntary motor activity by using cutaneous stimulation such as ice, soft brushing, slow stroking, tendon tapping, vibration, joint compression, and quick stretching to promote activation of proximal muscles.

stroke rehabilitation

continuum of care

motor recovery post-stroke

therapy options

right brain stroke