Stroke Rehab
As many of you asked, you wanted to learn more about stroke rehab and what that looks like. So, let's start by getting a full understanding of what a stroke exactly is. The term "stroke" is interchangeable with the medical term, cerebrovascular accident, commonly abbreviated as a "CVA". A stroke is a neurological condition that can have lasting impairments. A CVA occurs when there is a reduced amount of blood supply to the brain which deprives the brain of oxygen and nutrients for a small or long duration of time. This can occur from a blockage or a rupture/bleeding in the brain. When the brain is deprived of oxygen, the brain is not adequately supplied with blood and is not being fed the nutrients it needs in order to function properly. A stroke tends to occur abruptly and will require immediate medical attention. The sooner medical attention is received, the higher the possibility of reversing symptoms and decreasing the severity of symptoms. The amount of oxygen deprivation dictates how severe the symptoms of a CVA is and depending on where the blockage/hemorrhage occurs, which dictate what symptoms occur based on the location of the brain functions. Time is of the essence when it comes to seeking initial medical attention for individuals who have just experienced a stroke. Here are several different types of strokes.
Types of CVAs
1. Ischemic stroke: An ischemic stroke occurs when there is a blockage in an artery supplying blood to the brain. This can be a blood clot or stenosis of the arteries. This is the most common type of stroke.
2. Hemorrhagic stroke: A hemorrhagic stroke occurs when an artery ruptures or leaks blood into the brain. This causes intracranial pressure and damages brain cells. High blood pressure and aneurysms are a common cause of hemorrhagic strokes. There are two types of hemorrhagic strokes.
a. Intracerebral hemorrhage: This is the most common type of hemorrhagic stroke. This occurs when an artery bursts in the brain and floods the surrounding tissue with blood.
b. Subarachnoid hemorrhage: This occurs when there is bleeding in between the space of the tissue and the subarachnoid layer. This type of stroke occurs less often.
3. Transient Ischemic Attack (TIA): Referenced as a mini-stroke. TIA is caused by a blockage, but a temporary blockage. The blockage usually lasts for less than 5 minutes. During a TIA, the blood supply to the brain is temporarily blocked. TIAs can be a warning sign for future strokes if medical attention is not sought out. Symptoms are generally less severe, and temporary.
Treatment Options for Prompt Medical Attention (within 24 hours of Symptom Onset)
tPA: Tissue Plasminogen Activator (tPA) is a clot bursting medication given to dismantle the clots of ischemic strokes. This MUST be given to the individual within 4.5 hours of the start of symptoms in order to be effective.
Endovascular Treatment: This is a surgical option to remove the clot. This must be done within 24 hours of first experiencing symptoms.
Signs of a Stroke
B E F A S T
This is a good acronym to remember the key signs of a stroke.
Balance- Is the individual having sudden difficulties balancing and walking?
Eyes- Is the individual experiencing impaired vision?
Face- Is there any single side facial dropping?
Arms- Is the individual having difficulty lifting one arm in full flexion?
Speech- Is the individual slurring their speech or having difficulty talking?
Time- It's time to call 9-1-1. The sooner the symptoms are recognized, the better the chances to decrease the severity of the symptoms.
Sometimes, individuals will also experience dizziness and a sudden severe headache.
Effects of Stroke:
Depending on where the lesion occurs in the brain, dictates what is affected. A stroke can occur on the left hemisphere, right hemisphere, cerebellum, or brain stem. These symptoms will depend on the individual and the severity of the CVA.
Right hemisphere effects:
Left-sided weakness/paralysis/sensory impairments
Left side neglect
Denial of impairments
Visual disturbances (left visual field of each eye)
Spatial problems
Depth perceptions
Directions
Poor body awareness
Memory deficits
Behavioral changes
Impulsivity
Inappropriateness
Depression
Left hemisphere effects:
Right-sided weakness/paralysis/sensory impairments
Aphasia (speech impairments/challenging understanding)
Visual disturbances ( right visual field of each eye)
Difficulty with logic
Math
Reasoning
Organizing
Impaired ability to read, write and learn new information
Memory deficits
Behavioral changes
Depression
Cautiousness
Cerebellum Effects:
Ataxia (inability to walk, challenges with coordination and balance)
Dizziness
Headaches
Nausea/Vomiting
Brainstem Effects:
Impairments with vital functions
Breathing
Heart functions
Body temperature control
Balance and coordination
Weakness/paralysis
Chewing, swallowing and speaking
Vision impairments
Coma
Death
CVA Related Assessments
Here are some common assessments that will be done when an individual experiences a CVA. These assessments do depend on the setting. Some assessments might look different from acute care vs inpatient rehab vs outpatient facility.
ROM- You will always test ROM. The individual may not be able to perform AROM, and that's okay. They may be very weak and not have the brain to muscle connection to fire the muscle on command to lift their affected limb. Encourage them to try to lift or bend as you assist them to see if you can feel the muscle firing as going through the range of motion for AAROM. But always test for PROM. Get a feel for what the end feels are and get an idea of what their functional range is. Is the end feel hard- does it feel stuck? Be gentle with PROM and ensure to ask them how it feels as you get closer to the end of the range.
-PROM, AAROM, AROM
-Vibratory tools are great for assisting with AAROM. Place the vibratory stimulation tool on the muscle belly to fire the muscle you are trying to contract. This may fatigue the muscle, but it is intended to help stimulate that contraction and help rewire that connection from the brain to limb.
-Shoulder arc (most rehab facilities will have this)
MMT- It is important to get an understanding of what the strength is in the non-affected side to see what the functional abilities are of the individual in terms of strength. Depending on the severity of the affected side, you may not test the affected side if it is flaccid. That being said, the affected could be flaccid or it could present with a lot of tone.
Cognition- A mini-mental exam is always conducted with patients who have had a stroke. Ask their name, date of birth, where they are and a simple question like what month is it?
Vision (checking for unilateral neglect -H test)- This is a test that can often get overlooked. There may be unilateral neglect present. And if so, sometimes the patient won't acknowledge a whole side of their body. So when you perform vision tests, ensure that you cross the midline and follow their eyes as it crosses over to both sides. For instance, if they only complete half of the H test and only see the part of the H on the R side, that is a concern for L sided neglect.
Sensation- We always test sensation. This is important to see if they can feel dull/sharp pain and get an understanding if there are impairments for temperature for ADLs such as bathing, washing face/hands, etc.
Barthel Index- More advanced assessment, but may be used in later stages of therapy to assess ADL abilities and limitations.
Fatigue scale- More advanced assessment, but good to get an idea of what their endurance looks like for ADLs/IADLs.
Balance- Assessing balance will be seen in rehab settings. This will be critical in assessing their safety for bed mobility, transfers, and gait training.
-Functional Reach Test can be done from the bedside as a basic assessment for balance.
-Berg Balance Scale is a more complex balance assessment.
How to Prevent a Stroke
1. Exercise. Exercise is a critical aspect of stroke prevention. It is so important to keep our bodies active to remain healthy by increasing circulation throughout the body and creating a strong heart. It is recommended to exercise for at least 30 minutes a day to remain active!
2. Eat well. What we put into our bodies, not only nourishes our bodies but constantly putting the wrong foods into our bodies can be detrimental. Our arteries rely on expanded pathways to pump blood to the heart effectively. Foods with high amounts of low-density lipoproteins (LDL) create plaque on our arterial walls which narrows the canal for blood to flow through. When the plaque becomes so thick, it increases blood pressure since the pathway is now very narrow and requires more force to push the blood through.
3. Lower blood pressure (BP). High blood pressure is a big risk factor for CVAs. There is an increased risk for blood clots to occur and cause blockages in narrowed arteries. More often than not, high blood pressure can be a result of high cholesterol.
4. Lower cholesterol. High amounts of LDL aka "bad cholesterol" increase BP. It is okay to have cholesterol in our diet. But we want to ensure that it is more of the high-density lipoproteins (HDL) aka "good cholesterol" rather than the LDL.
5. KNOW THE SIGNS
-B.E.F.A.S.T
Rehab/Interventions
There is so much to cover for stroke rehab. So we will start with the basics and go a little bit more in-depth as the week goes on with some of these concepts. One of the main aspects of rehab for stroke patients will be neuro re-education. Neuro re-education is the retraining of the muscles, brain, and nerves to work together to be able to produce coordinated movements, engage in strengthening and be able to function adequately. The umbrella of neuro re-ed is quite big. This can entail using modalities such as electrical stimulation to try to trigger and fire muscles to contract and produce movements, this can mean using an arm skateboard for AAROM to help improve strength, or this can be a component of mirror therapy, etc. The list goes on and on! Below are some additional stroke rehab interventions.
Neuro-Developmental treatment is based on the concept of neuroplasticity and aligns itself with the idea that the brain can change and reorganize itself based on practice and experience.
-This includes postural alignment and movement patterns
-Sensory feedback
-Encourage the affected side to engage in developmental and functional activities
PNF patterns
ADL training- functional/strength training to be able to do basic everyday task such as lift the arm to brush teeth, provide adaptation as needed. Simulating these activities is important to see what their limitations are. They may say they have no challenges, but make sure to see them perform them! Because sometimes they do have cognitive impairments.
Positioning
This is important to ensure that contractures are not developing. Ensure that the individual is switching positions every 2 hours whether they are in a bed or wheelchair. This can lead to pressure ulcers if they are not continually repositioning.
Orthotics can be used for contractures or increased tone to prevent deformity and help preserve the joint.
Adaptations/Home modifications
Built-up tools
Weighted utensils
Handle extensions
Stationery items to help hold items in place if they only have one functional hand
Tenodesis grasp attachments
Leg lifter
Grab bars
Shower chair/tub transfer bench
Reacher
Raised toilet seats
Color-coded lists
Stretching- necessary for stroke patients that have increased tone. We want to ensure we are preserving the integrity of the joints and keeping them mobile. This will mostly be PROM and working on extension movement patterns. Since tone is more commonly seen in flexor synergies.
Modalities
Electrical Stimulation ( E-Stim/ ES)
TENS
IFC
Heat
Used to relax the muscles and allow for more movement
Teach body awareness and to protect affected limbs
This cannot be emphasized enough! Body awareness is so important, especially for patients who have unilateral neglect! They no longer can acknowledge a side of their body. This can be seen with a flaccid upper extremity seen with hemiplegia. Often this upper extremity can dangle which can cause subluxation of the shoulder. Whether the individual is walking, they should have the UE in a sling to stabilize it correctly into the shoulder socket, or if they are in a wheelchair, the affected arm should be on an arm tray. Teach them to use their non-affected arm to lift and protect their affected arm. This can also be a concern for getting the arm or fingers of the affected arm pinched in the wheelchair if it is dangling!
Weight-bearing, weight-bearing weight-bearing!! Provide proprioception into that affected limb to help rewire the brain to recognize the limb and regain sensation back into the affected side.
Fine Motor control (FMC)
Pegboard
Visual tracking activities
Crossing midline
Matching/sorting for cognition
CIMT- This technique is constraint-induced movement therapy which immobilizes the non-affected arm to prompt the individual to use the affected arm to strengthen or to deter away from unilateral neglect
Patient education- it's really important to educate the patient and their family on home adaptations, importance of body awareness, using non-affected arm to actively assist affected arm to help reconnect those neural connections to brain.
Mirror therapy for visual feedback
Gait training (this is mostly done with physical therapy, but us OTs might also be apart of gait training as well)