What are the best rehabilitation treatment specifications for stroke patients?

Stroke

Overview

Stroke is one of the leading causes of death and disability in India. A lack of blood supply to the brain due to a rupture, bleed or blockage in the blood vessels could lead to a stroke.

The loss of blood prevents blood and oxygen from reaching the brain’s tissues, without which, brain cells and tissue become damaged and begin to die within minutes. Loss of function from specific regions of the brain lead to subsequent impairments and loss of function. Symptoms of a stroke show up in the body parts controlled by the damaged areas of the brain.

Based on the interruption to the flow of blood to the brain there are different types of stroke, they are:

Ischemic Stroke – the most common type of stroke, this happens when a blood vessel supplying blood to your brain gets blocked by a blood clot.

Hemorrhagic Stroke – a bleed in the brain that damages the tissues

Transient Ischemic Attack (Mini-Stroke) – A temporary blockage in blood flow in the brain. Symptoms usually for few minutes to hours.

Brain Stem Stroke - This type happens in your brain stem which can affect both sides of the body leaving the person in a “locked in” state where you’re unable to speak or move below the neck

Cryptogenic Stroke - stroke of unknown cause

Risk Factors

There are few risk factors such as age, gender, family history that are non-modifiable but many can be controlled and are associated with life style, such as:

● hypertension/ high blood pressure

● smoking and alcoholism

● diabetes/ high blood sugar

● high cholesterol levels

● a diet high in fat (particularly saturated) and salt, but low in fiber, fruit and vegetables

● lack of regular exercise and physical activity

● obesity.

The presence of multiple risk factors increases the likelihood of stroke. Someone who has already experienced a stroke is more vulnerable to another episode.

Signs and Symptoms

It is helpful to know the signs of a stroke because the sooner a person having a stroke gets care, the better their outcome is likely to be.

Stroke symptoms can include:

● paralysis and spasticity (increased tone in the muscles)

● numbness or weakness in the arm, face, and leg, especially on one side of the body (Hemiplegia/Hemiparesis)

● trouble speaking or understanding speech

● severe, sudden headache with an unknown cause

● slurring speech

● vision problems, such as trouble seeing in one or both eyes with vision blackened or blurred, or double vision

● walking difficulties

● loss of balance or coordination

● dizziness

● cognitive impairment and confusion

● difficulty in bowel and urine clearance

A stroke requires immediate medical attention. If you suspect a stroke

BE FAST

B- Balance

E- Eyes (loss of vision)

F- Face drooping

A-Arm weakness

S- Speech difficulty

T- Time to call for help

Rehabilitation of a person with stroke should begin in the ICU itself and must continue until appropriate functions and quality of life are restored.

Hemiplegia

It is the most common symptoms of stroke where there is complete paralysis on one side of the body. Hemiparesis is weakness that affects one side of the body. Hemiplegia can affect the muscles of your face, arm, and leg on one side of your body, leading to significant limitations in activities of daily living walking to shaving.

If your stroke has affected the right side of your brain, your movement and sensation on the left side of your body may be affected. If it has damaged the left side of your brain, your movement and sensation on the right side may be affected.

The goals of the rehabilitation plan are specific to the patient’s abilities. For example, if you have leg weakness, your rehabilitation plan is more likely to focus on walking. If you have facial weakness, your rehabilitation plan may focus on swallowing, because choking while you eat can cause serious health problems, such as aspiration pneumonia.

Treatments

Tests

On visiting the emergency department CT and/or MRI would be performed to understand the cause for stroke that may be ischemic, hemorrhagic or due to the presence of lesions or tumors. A complete physical examination is crucial to understand the initial symptoms and the possible extent of the impact of the stroke.

Treatment Approaches for Stroke

The nature of treatment would depend on whether the stroke is ischemic or hemorrhagic.

For an ischemic stroke the drugs that can be used to break or dissolve clots must be given within 4.5 hours of presentation of symptoms. The gold standard treatment for this is tPA (tissue plasminogen activator).

If a hemorrhage is seen then the objective is to control the bleed and to limit the effects of excess fluid in the brain and subsequent intracranial pressure. For this a surgical clipping, endovascular embolization, surgical removal of arteriovenous malformation or stereotactic surgery etc, may be performed depending on the exact cause for the bleed.

Following the emergency treatment, the stroke care is focused on retrieving as much function as possible and return to independent living.

The most rigorous therapy program is recommended based on the overall health, age and degree of disability from stroke. Consideration must be given to the patient’s priorities, lifestyle and the support and presence of family members or care givers.

Rehabilitation may begin before you leave the hospital. After discharge, you might continue your rehabilitation at the same hospital, another rehabilitation center, as an outpatient, or at home.

Rehabilitation at PhysioTattva

There are different approaches and techniques that may be utilized as a part of neurological rehabilitation in the recovery from stroke.

The goal of rehabilitation is to ensure the recovery of lost functions, to limit the worsening of symptoms and limit disability and to enable the patients return to activities of daily living.

● Positioning

● Mobilization

● Balance training

● Mobility training

● Limb control

● Aerobic or cardio respiratory training

● Counselling

Positioning

Therapeutic positioning aims to decrease skin damage, swelling in the limbs, avoid shoulder issues such as pain and subluxation, and discomfort. It also helps in maximizing function and in order to avoid contracture in the limbs. The positioning is aimed to try to promote modulation of muscle tone which aids in recovery, providing appropriate sensory feedback, increasing spatial awareness, increase the ability to engage with the environment and prevention of complications such as pressure sores, and contracture.

Mobilization

The aim here is to decrease the time gap between stroke and the first instance the patient leaves the bed and to increase the amount of activity that the patient performs away from the bed. Activities such as sitting on bed, shifting to a chair, standing helps to reduce the risk of complications from immobility such as deep vein thrombosis, bed sores, contractures etc, thereby aiding in recovery.

Balance training

Difficulty in maintaining balance is a common complaint that is noted in individuals post stroke. There is a combination of decreased trunk and limb control, sensory disturbances and perceptual disturbances that contribute to balance impairments. Training focuses on addressing these issues either individually or collectively. Training focuses on improving trunk performance and improving dynamic sitting balance. In order to improve the standing and dynamic sitting balance, task specific training is recommended. Activities such as reach out while sitting, sitting or standing on unstable surfaces, obstacle clearance while walking etc are some strategies that can be used in order to improve balance.

Mobility

The ability to walk is a major priority for people following stroke. When affected it hinders the level of participation of an individual within the house and even in the community. Progressions from dynamic balance activities to more of gait training is crucial in order to relearn independent walking. Task specific exercises, tandem walking, obstacle clearance, lower limb strengthening, treadmill walking with and without body weight support are few methods with which a therapist may aid in recovery of mobility.

Limb control

One of the primary goals of a physical therapist is the functional motor recovery of limb functions in hemiplegia. Upper limb function is severely affected in most hemiplegics which significantly influences the activities of daily living and quality of life. Stretching and position maneuvers to reduce tone in the arms, dual task training and functional electrical stimulation are useful in improving hand and arm function.

Aerobic or cardio respiratory

Impaired trunk control and period of immobilization can significantly affect the endurance of a post stroke patient that may lead to easy fatigability and limitation of participation in activities or training. All aspects of training should have a cardiorespiratory focus such that there is a constant improvement in the stamina and activity performance of the patient.

Training through breathing exercises and progressions in treadmill training are helpful in improving aerobic activity and avoid respiratory complications such as pneumonia.

Counselling

Educating the family or care giver with regard to challenges post stroke, environmental changes, orthotic care, scope of recovery depending on the extent of injury is crucial in providing the psychological support that a patient needs in making a good recovery following stroke.

Conclusion

In summary, a multidisciplinary approach to stroke rehabilitation has been shown to be more effective. It is therefore recommended that patients who have experienced a stroke be treated by a team of physiotherapists, occupational therapists, speech and language therapists, and other healthcare professionals as appropriate, as soon as possible after the stroke.