The critical strategies about stroke and stroke

rehabilitation

Presented by

Dr. Magdy Ahmed Arafa

INTRODUCTION

Stroke is the third commonest cause of death (after heart diseases and cancers), is probably the commonest cause of disability, and accounts for a large proportion of health care resources.

The World Health Organization defines stroke as “rapidly developing clinical signs of focal or global disturbance of cerebral function, with symptoms lasting 24 hours or leading to death, with no apparent cause other than vascular origin.

Successful prevention of stroke may be possible with the identification of important risk factors such as

1. Preventive Strategies for Stroke

Atrial fibrillation

Carotid stenosis

Diabetes

Smoking

Hypertension

Hyperlipidemia and hyperuricemia

Clotting inhibitory factors

Antiphospholipid antibodies

Anticardiolipin antibodies

Myxomatous degeneration of the mitral valve

Carotid endarterectomy in symptomatic patients with severe carotid stenosis

Asymptomatic patients with carotid stenosis should be educated about the symptoms of transient ischaemic attacks and referred for surgery if and when become symptomatic

Aspirin and Ticlopidine provides a good antiplatelet agents for prvention of stroke

Screening for atrial fibrillation by palpation of the pulse and measurement of blood pressure for prevention of stroke

Major advances have been made in recent years in the prevention of stroke as:

Thrombolysis (with recombinant tissue plasminogen activator, streptokinase or urokinase).

Anticoagulation: (Coumarin and Heparin).

Antiplatelet agents: (Asprin and ticlopidine).

Neuroprotection (N-methyl-D-asparate (NMDA) receptor antagonists).

Specific Therapeutic Strategies of Acute Ischaemic Stroke

Various specific treatments designed to reduce intracranial pressure are often used for primary intracerebral haemorrhage, including osmotic agents such as mannitol, urea or glycerol, steroids or hyperventilation and sometimes evacuation of haematoma in an accessible location such as cerebellum, putmen, thalamus or termporal lobe may be life saving. However, when the patient’s condition is stable and the haemorrhage is not life-threating, it is not clear that emergency evacuation of the clot is beneficial more than conservative treatment.

Specific Therapeutic Strategies of Haemorrhagic Stroke

1. Respiratory Problems

General Strategies for Certain Critical Problems of Stroke Patients

3. Raised Intracranial Pressure

5. Glycaemic Control

4. Swallowing, Hydration, and Nutrition

2. Circulatory Problems

6. Ischaemic Heart Disease

8. Pressure Areas

10. Venous Thromboembolism Prophylaxis

9. Bladder Management

7. Pyrexia

12. Stroke in Evolution11. Epileptic Seizures

14. Pain of the Shoulder13. Depression

Basic Principals of Stroke Rehabilitation

Goals: Optimal functional recovery is the ultimate goal in stroke rehabilitation.

Stroke units:

1. Better skilled staff offering more specialized care

2. Better organization of services and family integration.

3. Earlier implementation of rehabilitation services.

4. High intensity of daily treatment

Rehabilitation team

physiotherapist

speech therapist

chiropodist

nurse Doctors

home help

occupational therapist

clinical psychologist

social workers

Weakness of specific muscles

The pre-requisites for successful stroke rehabilitation

Abnormal postural adjustments

Abnormal muscle tone

Abnormal movement synergies and primitive reactions.

Lack of mobility between structures of shoulder and pelvic girdles

Incorrect timing of component within a movement pattern

Loss of interjoint co-ordination.

The most common challenging sequelae after stroke are:

Sever disability on admission

The indicators of the functional outcome of stroke patients:

Previous stroke

Urinary and bowel incontinence

Advanced age

Visuo-spatial deficits

Determinants of poor functional outcome

Determinants of good functional outcome

Urinary continence

Rapid improvement

Young age

Good perceptual abilities and Cognition

Steps of Stroke Rehabilitation

1.Assessment

2. Planning (Goal setting)

3. Intervention

Assessment

Assessment of stroke should include assessment of impairments of consciousness, physical impairments (including sensory, motor, equilibrium and co-ordination tests), cognitive impairments (e.g. perception, language and memory), visual impairments (e.g. field defects), emotional problems and urinary impairments (e.g. urinary incontinence).

Motor System Evaluation

1. Movement possibilities

2. Postural Mechanisms

2.1. Postural muscle tone

2.2. Trunk control

2.3. Righting reactions

2.4. Equilibrium reactions

2.5. Protective reactions

3. Functional activities

Planning (Goal setting)

The motor re-learning model of stroke rehabilitation

Task-oriented-rehabilitation programmes of stroke rehabilitation

Developmental strategies for stroke rehabilitation

Functional therapy model for stroke rehabilitation

Intervention

Physical therapy

Occupational therapy

Speech therapy

Recreation therapy

Physical therapy

Developmental model

Stage 1: Normalization of tone and reflexive integration

Stage 2: Early mobility

Stage 3: Stability

Stage 4: Controlled mobility

Stage 5: Skills