Stroke Physiotherapy Management

Prognosis consists of

The environment the patient is exposed to during the recovery period

Severity of their deficits

Individual characteristics of the patient

Expected outcomes are related to

Will they be able to drive? Work? Play sport?

Will they have to use a walking aid?

Are they suitable for rehab?

How long will they be in the hospital?

Will they be able to walk again?

Will they be able return home?

Expected stroke outcomes

TACI 65% dead, 39% dependent, 4% independent

PACI 10% dead, 34% dependent, 55% independent

LACI 7% dead, 26% dependent, 66% independent

POCI 14% dead, 18% dependent, 68% independent

Predictors of Recovery - Poor functional outcomes linked to:

prior stroke

severe stroke - particularly motor loss

prolonged unconsciousness

urinary incontinence > 1 week

cognitive deficits

presence of unilateral spatial neglect (R hemisphere)

older age

presence of comorbidities

poor pre-level of function

depression

Found that slower return to independent walking was associated with:

older age

diabetes

severe stroke

hemorrhagic stroke

right hemisphere stroke

Biomarkers of stroke recovery: Blood biomarkers 

Neuronal function 

Immune response

Blood vessel circulation

Lipids/ Metabolism

Neuroplasticity

Anatomic and functional reorganisation of neural pathway

Spontaneous Recovery

Restitution of non-infarcted penumbral areas

Resolution of diaschisis

Behavioral Compensation 

Adaptations that enable compensation for impairments (ie. circumduing leg to compensate for loss of DF)

Stroke Recovery Background Concept 1

Local process of neurological recovery occur early on

Resolution of oedema, resolution of diaschisis, and reperfusion of the penumbral region

Stroke Recovery Background Concept 2

Heightened sensitivity for neuroplastic change (within hours of stroke) upregulation of genes responsible for neuronal growth; increase in long term potentiation enables synaptic strengthening; axonal sprouting around the infarct site; alterations in neurotransmitters

Stroke Recovery Background Concept 3

Cortical reorganization occurs later in the neurological recovery process. It is dependent on not only the lesion site but on the surrounding environment and remote locations that have structural connections with the injured area.

Stroke Recovery Background Concept 4

Neurological recovery peaks within the first three months post stroke and may continue at a slower pace in the following months

Functional recovery can continue for an extended period of time after the completion of neurological recovery. Overall, recovery is generally greater and quicker in milder strokes

Neurological Assessment- Impairments

Vision

Sensation

Proprioception

PROM and AROM UL and LL

Muscle strength UL and LL

Tone/spasticity

Co-ordination

Shoulder pain / subluxation

Neurological Assessment- Functional Assessment

Bed mobility - bridging, rolling, lie-sit

Sitting alignment and balance

Sit-to-stand

Standing alignment and balance

Transfers

Gait

Specific balance outcome measures

High level activities - stairs, outdoor mobility, jumping, running, hopping

Upper limb Assessment 

• Scapula stability / Wt bearing

• Reach

• Grasp

  • Manipulation 

Dyscontrol after stroke

motor impairment (70% -99%)

sensory impairment (66%)

visual inattention (58%)

neglect (43%)

apraxia (39%)

aphasia (33%)

dysphagia (38%) •

dysarthria (35%)

visual disturbances (35%)

cognitive dysfunction (21%)

Motor Assessment Scale for Stroke

Most commonly used outcome measure by physiotherapists in Australia for stroke

Early Management Aims - Physio

Maintain respiratory function

Monitor muscle length and ROM

Prevent complications and overcoming learned non-use through positive movement experiences

Early mobilisation and retraining

Ensure appropriate aids are issued and used correctly

Retraining bed mobility 

Rolling 

Bridging 

Sit over bed edge 

Increased risk of falls associated with

Stroke related impairments

Medication side effects (sedative or psychotropic meds)

Disability in self care

Cognitive and perceptual impairments

History of falls

For those at risk of falling - Recommendations

1. Management plan should be initiated

2. Comprehensive home assessment

3. Individually prescribed exercise program and advice on safety should be provided. Should involve functional training with a balance component

Summary - aims of physiotherapy post-stroke

Optimise cardiorespiratory function

Engage in targeted task-orientated training 

Optimise motor performance & strength via neuromuscular training

Prevent secondary complications & maintain flexibility (pain, loss of range etc)

Increase physical activity and fitness • Inspire interest and motivation