Lecture 10 - Rehabilitation And Recovery Following Stroke

Question 1

What are the physical impairments following a stroke?

Answer 1

Reduced muscle strength.
Altered sensation.
Coordination problems - often referred to as ataxia.
Balance impairment.
Hemiplegia - severe or complete loss of strength in one side of the body.
Altered gait pattern - how you walk.

Question 2

What areas of the brain affect these physical impairments?

Answer 2

Primary motor area (affects hemiplegia, motor weakness and poor voluntary control).
Basal ganglia (affects poor trunk control, balance, rigidity).
Anterior precentral gyrus in the frontal lobe (affects poor static and dynamic balance, motor planning and ataxia, and tremors).
Upper motor neuron system of CNS (spasticity = muscle stiffness/tightness).

Question 3

What is the National Institute of Health Stroke Scale (NIHSS) and what are the pros and cons?

Answer 3

It is a brief scale that looks at physical impairments following a stroke.
Pros:
- Good reliability.
- Sensitive for serial monitoring of patients - doesn’t have practice effects.
Cons:
- Can’t pick up all deficits because it is a brief scale.
- Doesn’t identify the cause of the deficit.
(Brewer et al., 2012)

Question 4

What is the Barthel Index (BI) and what are the pros and cons?

Answer 4

It is an assessment of daily activities.
Pros:
- Used widely, brief and easy to administer.
- High reliability.
Cons:
- Has low sensitivity.
- Not suitable for patients who are bed bound.
(Brewer et al., 2012).

Question 5

What is the Modified Rankin Scale (mRS) and what are the pros and cons?

Answer 5

It is a broad measure that directly assesses deficits in daily activities.
Pros:
- Easy to administer.
- Good reliability and validity.
Cons:
- As it is broad, it may not be specific enough which makes it difficult to identify the problem.
(Brewer et al., 2012).

Question 6

What is neurological physiotherapy?

Answer 6

It involves the treatment of people with movement and function disorders that have originated from problems within the nervous and neuromuscular system.
Could be for a stroke or another neurological issue.
Patients are examined for difficulties and what needs to be addressed then a focus plan is made through physiotherapy.

Question 7

Why is physiotherapy helpful for stroke survivors?

Answer 7

Motor impairments affect around 80% of stroke survivors, ranging from paralysis to difficulties with endurance.
Improving motor impairment can give them a better quality of life.

Question 8

What are the 3 types of physiotherapy used for stroke survivors?

Answer 8

Strength training - offered to those with muscle weakness in attempt to strengthen muscles. Could include progressive strength building e.g. increasing number of reps (may include bands or weights).
Walking therapies - used to improve walking/train people how to walk again. it is recommended for those with gait problems and may involve the use of a treadmill.
Fitness training - encouraging people to participate in physical activity, it is recommended for those with limited physical impairments.

Question 9

What is Functional Electrical Stimulation (FES)?

Answer 9

FES stimulates the nerves and activates weakened muscles. It is often used for foot drop (a muscular weakness which makes it difficult to life the front part of your foot) but can be used for any limbs.
Can also be used MS, Parkinsons etc.

Question 10

What evidence is there supporting FES?

Answer 10

There is evidence it can improve mobility of the hand.

Question 11

What is Transcranial Magnetic Stimulation (TMS)?

Answer 11

Stimulates the brain at a scalp level to activate neurons in the brain through an electrical current using a magnetic field.
As it is not invasive, not as affective if the lesion is deep in the brain.
May be used in addition to physiotherapy.

Question 12

What evidence supports TMS?

Answer 12

Ganguly et al. (2013):
- Can improve motor function.
- Short and long term benefit.
Brewer et al. (2012):
- Affective in improving upper limb paralysis.

Question 13

What is robotics as a treatment of physical impairment?

Answer 13

Used to help stroke victims improve the use of their arm by helping the brain and arm learn to work together again through the use of a robot attached to the arm supporting the right amount of movement help.
The robotic arm delivers a precise degree of force, velocity, duration and repetition of movement.

Question 14

What evidence supports robotics as a treatment of physical impairment?

Answer 14

Branin and Zorowitz (2012):
- Improves activities of daily living.
- Improves arm function but does not improve muscle strength so helpful to combine with physiotherapy.
Brewer et al. (2012):
- More likely to improve arm motor function and generic activities of daily life.
- Also been affected in terms of robot-assisted gait training.

Question 15

What is virtual reality as a treatment for physical impairment?

Answer 15

Created an interactive, motivating environment to enhance the effects of repetitive task training.
It is often combined with robotics to encourage individuals to keep motivated and complete the task.

Question 16

What evidence supports virtual reality as a treatment for physical impairment?

Answer 16

Brewer et al. (2013):
- Found positive outcomes when combined with robotic.
- But mixed results to further studies may be required.

Question 17

What is Mirror Therapy?

Answer 17

A mirror is used to create a reflective illusion of an affected limb in order to create positive visual feedback of a limb movement. In the somatosensory cortex we have a map which represents various areas of the body (the homunculus).

Question 18

What evidence supports Mirror Therapy (MT)?

Answer 18

Brewer et al. (2013):
- Combined with other rehabilitation it has shown some benefits.
- But further research is required to determine practice intensity and duration.
Brewer et al. (2012):
- Benefits seen in motor recovery and hand-related functioning and found to persist at 6 month follow-up.

Question 19

What is contracture management?

Answer 19

Performing stretching exercises daily in attempt to make muscles longer, decrease spasticity and prevent contracture.
A muscle contracture is a permanent shortening of a muscle or joint (in response to prolonged hypertonic spasticity) - can affect daily living e.g. putting out clothes.
Splinting, casting and bracing may also be used.

Question 20

What is fatigue management?

Answer 20

Includes the identification of triggers and re-energises, environmental modifications and lifestyle changes.
Important as fatigue is common after stroke and can decrease concentration, memory and reduce ability to cope with social interactions.

Question 21

What is neurological recovery?

Answer 21

Recovery at the level of the brain - what changes we see in the brain.
Split into early recovery (local processes) that happen in minutes, hours etc. such as the resolution of post-stroke swelling and recovery of partially damaged neurons.
And late recovery (neuroplasticity) that happens over months/years which require training and include the modification in structural and functional organisation e.g. new synapses.

Question 22

What is functional recovery?

Answer 22

Recovery in everyday life such as how people adapt to life and how much they engage in training.
This can occur in the presence of absence of neurological recovery and the quality and intensity of therapy plays a key role.

Question 23

Which factors can affect recovery?

Answer 23

Age, comorbidities, stroke severity, motivation, family support and level of dependency.
These factors may interact and a combination of these can affect recovery.
Also by involving the patient in goal setting has been shown to encourage patient motivation (Brewer et al., 2012).

Question 24

How does stroke impact the family?

Answer 24

It poses a significant challenge for pre-existing relationship patterns.
Might have to make changes within the home and the family.
Might be transitions involved e.g. if the main caregiver was the one who had the stroke.
Might need to work to earn more money.

Question 25

What impact does the family have on stroke recovery?

Answer 25

If the family system is supportive, flexible, adaptive and high functioning then this facilitates a successful outcome.
Family therapy can help the individual who has had a stroke and their family to work together for a better outcome and overall improve quality of life.

Question 26

What is the time course of recovery like?

Answer 26

Hours = medical e.g. surgery or medication.
Hours-days = early mobilisation (starting to sit up or move around).
Days-weeks = restoring impairments in order to regain activities.
Days-months = task-orientated practice and rehabilitation to improve activities of daily living and social interaction.
Weeks-months = environmental adaptions at home e.g. a stairlift or downstairs bathroom (takes planning and money).
Months-years = maintenance of physical condition and monitoring of quality of life e.g. engaging in physical therapy still.

Question 27

What neurological factors have been found to predict stroke recovery?

Answer 27

Blood biomarker levels and aortic stiffness have been associated with stroke outcome (Brewer et al., 2012).

Question 28

What evidence supports physiotherapy?

Answer 28

Brewer et al. (2012):
Strength training has shown beneficial outcomes on motor recovery - specifically on grip strength and upper limb function.
Increasing time spent on exercise in the first 6 months post-stroke result in significant improvements in walking ability.

Question 29

What is stem cell therapy?

Answer 29

The potential to repair the infarcts area of the brain through enhancing neuroprotective and repair mechanisms. It promotes revascularisation and reduces cerebral inflammation after stroke (Brewer et al., 2012).

Question 30

What neurotransmitter systems have been studied in stroke recovery?

Answer 30

Brewer et al. (2012):
- Noradrenergic enhancement resulted in increased motor performance.
- Amphetamine in rat models have shown improvements.
- Also studies of dopamine show improvement.
Ganguly et al. (2013):
- Fluoxetine (an SSRI) - significant change in impairment levels and reduces impairment and disability.