Stroke Rehabilitation:

Let's Get Physical: Rehabilitation for Body,

Mind, and Soul

DR. RANI H. LINDBERG, M.D., FAAPMR

Assistant Professor

Residency Program Director

BHRI Brain Injury Team, Medical Director

 Goals and Objectives

—  Describe the field of Physical Medicine and

Rehabilitation

—  Discuss qualifications for inpatient rehabilitation

—  Review the timing and goals of Stroke Rehabilitation

—  Review complications related to stroke and their

effects on rehabilitation of a stroke patient
Physical Medicine and Rehabilitation: What is it?

— ABMS 1947
¡ Physical Medicine (Thermal, E-stim, U/S)
¡ Rehabilitation (WWII)

— Physiatry / Physiatrist
¡  “fizzy AT” trist vs. fizz EYE” uh trist”

¡  Diagnosis, treatment, and rehabilitation of primarily

neuromusculoskeletal and cardiopulmonary disorders, that
may produce temporary or permanent impairment.

¡  PM&R
 PM&R: What do they do?

—  Focus: Maximize Function / Quality of life

¡  Physiatry: area of expertise is the functioning of the
whole patient, as compared with focusing on a specific
organ system or systems.

¡  Prescribe Medications and Therapy

¡  Team Approach

(e.g., Physical / Occupational Therapy)
 The Physiatric Approach
—  Chief complaint
—  Baseline level of function
—  Current level of function

— What are the current barriers

that are preventing the patient
from reaching their desired level
of function?
Who “qualifies” for inpatient rehabilitation?
 Qualifying Diagnoses for Inpatient Rehab

• Stroke
• Spinal cord injury
• Congenital deformity
• Amputation
• Major multiple trauma
• Hip fracture
• Brain injury
• Neurological disorders (e.g., Multiple Sclerosis, Parkinson’s)
• Burns
• 3 different arthritis conditions for which appropriate, aggressive, and
sustained outpatient therapy has failed, and
• Joint replacement
 Theory Behind Early Stroke Rehab

Neuroplasticity:
—  Modifications in neural networks are use
dependent

—  Need stimulation from:

-Active rehabilitation
-The environment

www.omkararetreats.com
Timing for Inpatient Rehabilitation after Stroke?

Studies show fewer days between onset of stroke and

initiation of stroke rehabilitation is associated with
improved functional outcome at discharge and
shorter rehabilitation length of stay.
 Stroke Rehabilitation: Goals

—  Functional enhancement by maximizing each

patient’s:

-Independence
-Lifestyle
-Dignity

—  Focus on physical, behavioral, cognitive, social,

vocational, adaptive, and re-educational points of
view.
 Programs for Patients After Stroke

—   Speech, Language and Cognitive Training

—   Mobility Training
—   Self-Care Training
—   Peer Support Outpatient
—   Family Stroke Education Group
—   Specialized Feeding and Swallowing Program
—   Driver Rehabilitation
—   Outpatient Therapy
 Rehabilitation Team Members

—  Physiatrists (physicians who specialize in physical and rehabilitation

medicine)
—  Consulting Physicians
—  Rehabilitation Nurses
—  Physical Therapists
—  Occupational Therapists
—  Chaplains
—   Care Coordinators/Social Workers
—  Respiratory Therapists
—  Speech-Language Pathologists
—  Registered Dietitians
—  Therapeutic Recreation Specialists
—  Driver Rehabilitation Instructors
—  Neuropsychologists

www.aaritcare.com
Stroke Rehabilitation: Team Approach

Patient and family

Physician
Physical Therapist
Occupational Therapist
Speech Language Pathologist
Rehab Neuropsychologist
Rehab Nursing and Aides
Rehab Case Coordinator
Recreational Therapist
Chaplain
Nutritionist
Orthotist
Vocational Therapist
 Functional Independent Measures

—  Global measure of functional independence.

—  The total FIM rating ranges from 18-126 (i.e., 18
items rated on a 1-7 ordinal scale)
—  FIM component subscores:
Self-care: bathing, eating, grooming, dressing upper/lower body, toileting
Mobility: Transfers (toilet; bed, chair, and wheelchair; tub and shower transfers)
and locomotion (stairs, walk and wheelchair locomotion)
Sphincter: Bladder and bowel control
Cognitive: Communication, psychosocial
 Special rehabilitation
interventions and modalities

NEUROREHABILITATION
Rehabilitation for the body

“LET’S GET PHYSICAL”

 Motor Impairment and Recovery due to Stroke

—  Up to 88% of stroke patients have hemiparesis

—  Most recovery in 1st three months with minor

recovery after six months

—  Typically, leg recovers before arm

-Lower extremity pattern:
flexor synergy à extensor synergy
-Upper extremity pattern:
flexor synergy à extensor synergy
 Predictors of Motor Recovery Post-Stroke

—  Severity of arm weakness

¡  9% with good recovery of hand function

—  Timing of motor return in hand

¡  If some return by 4 wks, 70% chance of full to good recovery

Poor Prognostic indicators:

1)  Severe proximal spasticity
2)  Prolonged “flaccidity” period
3)  Late return of proprioceptive response >9 days
4)  Late return of proximal traction response>13 days
 Rehabilitation Methods for Motor Deficits

—  Traditional therapies consist of:

1.  Positioning and ROM exercises
2.  Mobilization
3.  Compensatory techniques
4.  Strengthening and endurance training

For stroke rehabilitation, these exercises emphasize

repetition of movements, importance of sensation to
control movement, and developing basic movements and
postures to improve motor control and coordination
 Mobility Training

§  Motor assessment should include strength, active and passive range
of motion, tone, gross and fine motor coordination, balance, apraxia,
and mobility.

§  Motor function is addressed via rehabilitation efforts with

strengthening, balance and gait training, orthoses, transcutaneous
electrical nerve stimulation (TENS), robot-assisted movement
therapy, constraint-induced movement therapy, and body-weight-
supported treadmill training, and upper extremity interventions in
order to improve activities of daily living.

§  Functional electrical stimulation may help facilitate movement or

compensate for lack of voluntary movement.

Wells, George A., et al. "Ottawa Panel Evidence-Based Clinical Practice Guidelines for Post-Stroke
Rehabilitation." Topics in Stroke Rehabilitation 2006; 13(2), 1-269. DOI: 10.1310/3TKX-7XEC-2DTG-XQKH
 Technology in Rehabilitation

—  Functional electrical stimulation:

may help facilitate movement or compensate for lack of
voluntary movement.
—  Body-weight-supported (BWS) therapy:
A harness provides support of body weight over a treadmill or
other surface, while a therapist can observe and correct any
unwanted gait pattern.
—  Robotics:
Robotic assisted gait devices are used for mobility training.
Lightweight, motorized exoskeletons have become available very
recently, but they are very expensive and slow. Studies are needed
to show if they can be practically used as an augment to standard
therapy.
Functional
Electric
Stimulation
BWS therapy
and Robotics
in Rehab

www.biodex.com

http://www.umrehabortho.org/programs/outpatient/services/
lokomat

http://www.gizmag.com/armassist-stroke-rehabilitation-with-video-games/19282/
 Technology in Rehabilitation

—  Virtual reality (VR):

—  Virtual environments and objects provide the user
with visual feedback and repetitive skills practice.
—  A 2015 Cochrane review17 found VR to be beneficial
in improving upper limb function and ADL function
as an adjunctive therapy or when compared with the
same amount of standard therapy.
—  Other 2015 review studies have shown efficacy of VR
in improving neglect18, balance and mobility19.
Virtual Reality
in Rehab

www.intechopen.com

www.fitness-gaming.com
 •  This therapy involves placing a mirror in
Mirror the mid-sagittal plane, allowing the
Therapy patient to visualize the reflection of the
non-paretic limb as if it were the paretic
limb.

•  Studies have generally shown statistically

significant gains in motor function.

•  The visual illusion of functional mobility

in the hemiparetic limb results in
stimulation of adaptive brain plasticity to
counteract maladaptive neuro-plastic
changes.

www.recoverfromstroke.blogspot.com
 •  CIMT is performed by restricting the
unaffected limb for 90% of waking hours for
Constraint 14 days, while intensively training the use of
the affected arm.
-induced
•  A number of studies have shown that CIMT
Movement induces a use-dependent increase in cortical
Therapy reorganization of the areas of the brain
controlling the more affected limb.8,9

•  Studies have demonstrated significant

improvements in motor and functional
outcomes, although there have been mixed
results.

•  CIMT is shown to be effective in patients who

have active wrist extension, active finger
extension,10 good cognition, limited spasticity,
and preserved balance.
www.thestrokefoundation .com
Dynamic
splinting
Ambulation
Assistive Devices
Bracing

http://faculty.valpo.edu/bmorriso/
Rehabilitation for the mind

COGNITIVE LANGUAGE THERAPIES

www.reddit.com
Cognitive Language Impairments

Cognitive assessment should address

arousal, attention, visual neglect,
learning, memory, executive function,
and problem solving.
 Aphasia

www.braininjury-explanation.com
 —  Impairment of the ability to
utilize language due to brain
Aphasia injury

—  Can also include impairment in

reading, writing, and problem
solving.

—  Aphasiaà Longer rehabilitation

length of stay
—  Aphasiaà Decreased
rehabilitation efficiency
 Hemispatial Neglect

Deficit in attention to and awareness of one side of space

defined by the inability of a person to process stimuli on one
side of the body or environment

•  Three quarters of patients with acute stroke have signs of neglect

• Unawareness of deficit in 20% to 58% of patients

• Pts with neglect took longer to recover than other stroke patients with
similar stroke pathology and impairment.

• Pts with neglect required more therapy input and have longer rehab LOS
 Neglect Treatment

—  Scanning
—  Trunk rotation therapy
—  Eye Patching, Prism
glasses
—  Constraint-Induced
Therapy
—  Mirror Therapy
—  Neurostimulation
medications

http://blogs.discovermagazine.com/loom/2010/09/
Innovations in —  Noninvasive Brain
Cognitive Stimulation (NIBS) -
Rehab Transcranial magnetic and
direct current stimulation:
—  Mild magnetic/electric
stimulation applied to the scalp.
—  Theory: Neuromodulation of
plasticity and cortical excitability.
—  NIBS has been shown to improve
motor function, gait, language
(aphasia) and cognitive (neglect)
deficits, and mood.
Other Common Complications
after Stroke

PROBLEMS ENCOUNTERED BEFORE, DURING,

AND AFTER REHAB
 Dysphagia

—  Overall incidence ~30-45% of stroke survivors

—  Signs of abnormal swallow:

Abnormal and/or weak cough
Cough after swallow
Dysphonia
Dysarthria
Abnormal gag reflex
Voice change after swallow
Difficulty handling secretions
 Aspiration

—  Missed on bedside swallow study in 40-60% of pts!!

—  FEES and VFSS better at detected silent aspiration

—  Aspiration pneumonia risk factors:

DECREASED LEVEL OF CONCIOUSNESS
Tracheostomy
Emesis
Reflux
NGT feeding
Dysphagia
 Treating Dysphagia and Prevention Aspiration

—  Changing head position/posture

—  Elevation of head of bed

—  Feeding in the upright position

—  Using chin tuck technique

—  Turning head toward plegic/paretic side

—  Diet modification

—  Oral/motor exercises by Speech therapist

 Falls

—  Risk factors for in Hospital falls:

¡  R>L Hemispheric stroke; Neglect and visuospatial deficits;
Impulsivity; bilateral strokes; confusion; male; poor ADL;
urinary incontinence; use of sedatives and diuretics.

—  Preventive measures:

¡  Adequate staffing; education; patient strength training;
balance training; cognitive remediation; restraints with
monitoring; bed/chair alarms; timed voiding; minimize use of
sedatives and diuretics.

*Moroz A, et al. Arch Phys Med Rehabil 2004;85(3 Suppl):S11-14.

 Stroke: Shoulder Pain

Subluxation

Traction neuropathy

Bicipital tendinitis

RTC/Impingement

Frozen shoulder

Complex Regional Pain Syndrome

Treatment for
Shoulder Pain
• Proper positioning
and arm awareness
• Bracing/sling

• Estim

• Armboard/trough
for wheelchair
• ROM excercises

• Injections
 Dependent Edema

—  Treatment includes:

ROM exercises
Elevation of limb
Compression stockings or gloves
SCDs
Massage

http://www.foot-pain-explained.com/edema.html
 Spasticity after Stroke

—  Onset: days to weeks

—  Upper extremity- flexion, lower extremity- extension
—  Velocity dependent resistance to passive movement
of affected limb

www.informahealthcare.com
 Spasticity after Stroke: Treatment

—  Slow, sustained stretching program

—  Splinting
—  Serial casting
—  Cold modalities
—  Medications: Baclofen, Zanaflex, Benzos
—  Injections: Botox, Phenol
—  Intrathecal Baclofen Pumps
—  Surgery

www.rehabmart.com
 DVT after Stroke

—  Occurs in 20-75% of untreated Stroke survivors

—  60-75% of DVTs occur in hemiplegic limb
—  PE occurs in 1-2% of cases

—  Prophylaxis:
Subcutaneous heparin or LMWH
SCDs
TED hose
 Bladder Dysfunction

—  50-75% of stroke patient have urinary incontinence

during the 1st month post stroke, 15% after 6 mths
—  Etiology is multifactorial
—  Voiding disorders: areflexia, uninhibited spastic
bladder, outlet obstruction
—  Treatment: tx underlying cause, regulate fluid intake,
timed voiding, education, and medication

—  When removing foley caths: remember to

check PVRs!
 Bowel Dysfunction

—  Incidence of incontinence: 31% of stroke patients

—  Typically resolves after the 1st two weeks s/p stroke
—  Decreased continence usually related to decreased
mobility or communication impairments
—  Treatment includes transfer training and timed
toileting.
—  Constipation is common and treated by improved
fluid intake, diet modification, stool softeners and
stimulants.
Rehabilitation for the Soul

www.compassionfatigue.ca
 Depression

—  Prevalence: ~40% of stroke patients

—  May be related to neurotransmitter depletion from stroke

lesions and psychological response to physical/personal losses
associated with stroke

—  Risk factors: female, prior psych hx, severe impairment,

nonfluent aphasia, lack of social support

—  Persistent depressionà delayed recovery and poor functional

outcome

—  Treatment: Neuropsychology, medications

Outcomes and Return to Work
 Outcomes

—  The most reliable predictor of functional outcome

during Rehab is the patient’s functional ability on
admission. An admission FIM score >60 is a good
indicator.*

—  Persistant urinary or fecal incontinence and the

presence of a social support system is the key
determinate in the ultimate discharge
destination.**

* Ween JE, et al. Neurology. 1996;46:388-392.

* *Brandstater M. In DeLisa ed. Rehabiliatation Medicine 3rd ed.
1998;1165-1189.
 Predicting Outcomes
—  Age
—  Severity of stroke
—  Prior stroke
—  Persistant urinary
incontinence
—  Bowel incontinence
—  Visuospatial deficits
—  Unilateral hemineglect
—  Coma at onset
—  Poor cognitive function
—  Multiple neruologic deficits
—  Impaired sitting balance
—  Poor social supports
—  Limitations in ADLs
—  Depression
—  Severe aphasia
—  Severe comorbid medical
conditions
—  Cerebral metabolic rate
(PET scan)
 Ambulation Potential

—  Copenhagen Stroke study: 63% presented with

impaired walking. Those who survived - 22% did
not regain the ability to walk; 66% achieved
independent walking, and 95% reached their
maximum walking function at 11 months.*

—  Most common lower extremity is an ankle-foot

orthosis (AFO) – both speed of gait and energy
consumption can be improved using an AFO. **

*Jorgensen HS, et al. Stroke 1999;10(4):887-906.

**Fowler PT, et al. J Orthop Res 1993;11:416-421.
 Return to Work

—  Negative factors that effect return to work:

¡  Low score on the Barthel Index

¡  Prolonged rehabilitation length of stay

¡  Aphasia

¡  Prior EtOH abuse

Neuropsychological testing
Functional Capacity Evaluation
Return to work with restrictions

www.guyanachronicle.com
 How to prepare a patient for inpatient
rehabilitation

—  Initiate early rehab therapies: PT, OT, Speech, PM&R

—  Prevent complications:
-Early ROM, stretching, and splinting to prevent
contractures
-Shoulder slings and proper arm position in bed
-High suspicion for dysphagia and close monitoring for
aspiration
-DVT prophylaxis
-Monitor nutrition- PEG tube placement early if delayed
recovery expected
- Monitor for neglect and help patient compensate for it!
- Bladder/bowel: timed voids if possible. Check PVRs!
QUESTIONS?
 References

—  Braddom. Physical Medicine and Rehabilitation. 3rd edition.

—  Cuccurullo. Physical Medicine and Rehabilitation Board Review. 2004
—  Maulden S.A. et al. Timing of Initiation of Rehabilitation After Stroke. Arch Phys Med Rehabil. 2005. 86 (Suppl 2): S34-40.
—  Bryan J. et al. Stroke and Neurodegenerative Disorders. 1. Acute Stroke Evaluation, Management, Risks, Prevention, and
Prognosis. Arch Phys Med Rehabil. 2004. 85 (Suppl 1): S3-9.
—  Ross A. Bogey et al. Stroke and Neurodegenerative Disorders. 3. Stroke: Rehabilitation Management. Arch Phys Med Rehabil.
2004. 85 (Suppl 1): S15-20.
—  Page et al. Efficacy of Modified Constraint-Induced Movement Therapy in Chronic Stroke: A Single-Blinded Randomized
Controlled Trial. Arch Phys Med Rehabil . 2004. 85: 14-18.
—  Sütbeyaz et al. Mirror Therapy Enhances Lower-Extremity Motor Recovery and Motor Functioning After Stroke: A
Randomized Controlled Trial. Arch Phys Med Rehabil. 2007. 88: 555-559.
—  Gialanella et al. Rehabilitation Length of Stay in Patients Suffering from Aphasia After Stroke. Topics in Stroke
Rehabilitation. Nov/Dec 2009. 437-444.
—  Pierce and Buxbaum. Treatments of Unilateral Neglect: A Review. Arch Phys Med Rehabil. 2002. 83: 256-268.
—  Blanton S, Wilsey H, Wolf SL. Constraint-induced movement therapy in stroke rehabilitation: perspectives on future clinical
applications. Neurorehabilitation. 2008;23:15-28
—  Wang W, Wang A, Yu L, et al. Constraint-induced movement therapy promotes brain functional reorganization in stroke
patients with hemiplegia. Neural Regeneration Research. 2012;7(32):2548-2553. doi:10.3969/j.issn.1673-5374.2012.32.010
—  Miller EL, Murray L, Richards L, et al. Comprehensive overview of nursing and interdisciplinary rehabilitation care of the
stroke patient: a scientific statement from the American heart association. Stroke. 2010;41(10):2402–2448
—  Claflin ES, Krishnan C, Khot SP. Emerging Treatments for Motor Rehabilitation After Stroke. The Neurohospitalist. 2015;5(2):
77-88. doi:10.1177/1941874414561023.
—  Ifejika-Jones NL, Barrett AM. Rehabilitation—Emerging Technologies, Innovative Therapies, and Future Objectives.
Neurotherapeutics. 2011;8(3):452-462. doi:10.1007/s13311-011-0057-x.