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Editors

MinnaRiekkinen

Rehabilitation of a Patient with Cerebrovascular Disorder

Essentials

  • The best results are achieved by starting rehabilitation early.
    • Rehabilitation takes place most rapidly during the subacute phase, at 3 to 6 months, depending on the case.
  • Individual assessment by a multidisciplinary team of specialists is needed to assess who will benefit from rehabilitation.
  • The mortality and the risk of becoming dependent on permanent institutional care are both lower in patients who at an early stage of the disease onset were treated within a rehabilitation unit that operates on multidisciplinary basis, when compared with patients who were treated at a regular hospital ward. The effectiveness of the treatment can also be seen in reduced duration of treatment, lower level of disability and increased quality of life.
  • Firstly, assign specific rehabilitation objectives (e.g. return to work or independent living at home). Then create a plan for achieving the objectives. The objectives should be reassessed and changed as necessary.
  • Multidisciplinary cooperation is essential. The rehabilitation team should consist of a physician, nurse, social worker, physiotherapist, occupational therapist, speech therapist and neuropsychologist.
  • Provision of sufficient information to patients and their relatives forms an important part of rehabilitation Information Provision for Stroke Patients and Their Caregivers.

Background

  • Stroke is the traditional clinical name for a disturbance in cerebral function due to cerebral infarction, cerebral haemorrhage or subarachnoid haemorrhage. The term preferred today is cerebrovascular disorder.
  • The prognosis has improved with further development of acute treatment, rehabilitation and secondary prevention.
  • Many stroke survivors have symptoms interfering with their daily life. The most significant symptoms are
    • paralysis of extremities and dysaesthesia
    • visual field defects
    • cognitive dysfunction
      • aphasia, or difficulty in producing and understanding speech Aphasia
      • apraxia, or loss of the ability to perform learned purposeful movements Neuropsychological Disorders
      • agnosia, or impaired ability to recognize the significance of sensory stimuli Neuropsychological Disorders
      • dysfunction of memory, concentration, attention or executive functions
      • visuospatial dysfunction
      • ignoring one side of the body (neglect syndrome).

Various forms of therapy and their efficacy

Physiotherapy Physical Rehabilitation Approaches for the Recovery of Function and Mobility Following Stroke, Physical Fitness Training for Stroke Patients, Supportive Devices for Subluxation of the Shoulder after Stroke, Electrostimulation for Promoting Recovery of Movement or Functional Ability after Stroke, Electrical Stimulation and Mental Practice for Function of the Upper Limb after Stroke, Electromyographic Biofeedback for the Recovery of Motor Function after Stroke, Interventions for Preventing Falls after Stroke, Physiotherapy for the Recovery of Postural Control and Lower Limb Function Following Stroke, Electromechanical-Assisted Training for Walking after Stroke, Repetitive Task Training for Improving Functional Ability after Stroke, Interventions for Motor Apraxia Following Stroke, Orthotic Devices after Stroke and other Non-Progressive Brain Lesions, Overground Physical Therapy Gait Training for Chronic Stroke Patients with Mobility Deficits, Simultaneous Bilateral Training for Improving Arm Function after Stroke, Circuit Class Therapy for Improving Mobility after Stroke, Water-Based Exercises for Improving Activities of Daily Living after Stroke, Transcranial Stimulation Therapies for Improving Function after Stroke

  • Motor recovery can be improved by intensifying physiotherapy.
  • The results of various methods do not differ significantly; early initiation of physiotherapy and training the target issue or skill are decisive.
  • Electromechanical assistive devices are used for gait training in patients who are unable to walk by themselves. Those walking independently benefit from training on a treadmill, particularly with respect to walking speed and distance. In addition to devices, the training should contain other types of physiotherapy, such as gait training with mobility assistive devices.
  • Bimanual training, which involves simultaneous movements by both hands, may improve the function of the upper limbs.
  • Gait training improves walking ability even at the late phase (more than 6 months after the cerebrovascular disorder).

Occupational therapy Occupational Therapy after Stroke

  • At the acute stage, assess the stroke patient's skills, coping at home and need for rehabilitation.
  • At the subacute stage, promote independent coping in daily activities and participation in meaningful daily life at home as well as in recreational and business settings.
  • Support the patient's active role and own responsibility for rehabilitation.
  • Occupational therapy is useful particularly in rehabilitation concentrating on primary and secondary daily activities, improves social participation and thus increases general activity.
  • Occupational therapists and physiotherapists use partly the same methods. Occupational therapists' methods include e.g. repetitive task-oriented training, constraint-induced movement therapy, guided (or mental) imagery, virtual reality training Virtual Reality for Stroke Rehabilitation, mirror therapy, action observation and strength training.

Speech therapy

  • Speech therapy is used to support recovery from swallowing problems, dysarthria and difficulties in speech production.
  • Speech therapy adapted individually to the patient's condition may be useful in early as well as late rehabilitation of patients with aphasia.
  • There is insufficient evidence for the effect of speech therapy on dysarthria.
  • Active swallowing therapy may improve swallowing function and reduce the risk for complications.
  • Intensive speech therapy will promote resumption of a normal diet.

Neuropsychological rehabilitation Non-Pharmacological Interventions for Perceptual Disorders Following Stroke and other Adult-Acquired, Non-Progressive Brain Injury, Interventions for Visual Field Defects in Patients with Stroke

  • Neuropsychological rehabilitation is used whenever it is considered appropriate based on neuropsychological examination.
  • Rehabilitation concentrates on the cognitive disturbance, behavioural changes and recognition of symptoms. The patient's emotional and psychosocial state should be considered at the same time.
  • When rehabilitating patients with visuospatial disturbances and neglect Cognitive Rehabilitation for Spatial Neglect Following Stroke, strategic training and direct symptom training are effective if associated with increased awareness of the symptoms.
  • Rehabilitation for attention deficit Cognitive Rehabilitation for Attention Deficits Following Stroke, memory and executive disturbances may be effective.
  • In addition to neuropsychological rehabilitation, neuropsychological counselling (1-5 sessions) may promote return to work of patients with mild symptoms.

New rehabilitation solutions

  • Telerehabilitation as well as technological solutions which make rehabilitation more easily available and increase efficiency
    • Neuropsychological digital care pathway
    • VR headset in the rehabilitation of neglect
    • Robotic-assisted solutions in physiotherapy and occupational therapy

Pharmacotherapy affecting rehabilitation Interventions for Treating Anxiety after Stroke, Interventions for Preventing Depression after Stroke

  • Antidepressants may be used to promote successful rehabilitation; especially SSRIs have been studied in this context.
    • Fluoxetine (20 mg daily) is the most extensively studied drug, but it has not been unambiguously shown to enhance the effect of rehabilitation.
  • Drugs with a negative effect on rehabilitation include, for example, benzodiazepines, phenytoin and haloperidol.
  • Depressed patients with cerebral infarction benefit from medication. Pharmaceutical Interventions for Emotionalism after Stroke
    • After the acute phase, half of the patients suffer from depression.
    • Organic depression occurring during the acute phase usually resolves within the first month without specific treatment.
    • The incidence of severe depression increases within the first year, and it is associated with an increased risk of long-term institutional care.
    • Selective serotonin reuptake inhibitors (SSRI) are the first-line treatment Selective Serotonin Reuptake Inhibitors (Ssris) for Stroke Recovery.
      • Botulin treatment can be used to reduce spasticity of both upper and lower limbs Spasticity. The significance of such treatment for the patient's performance should be assessed at the beginning of treatment. The duration of the treatment is usually 1 year or exceptionally at most 2 years because the benefit from the treatment is limited to the period of plastic reshaping.

Adaptation training

  • Based on follow-up studies, adaptation training may improve psychosocial coping and reduce depression.

Aids

  • The need for aids should be assessed individually.
  • Aids should be fitted and instruction provided for their use both at the beginning and repeatedly later as necessary to obtain the full benefit.
  • Aids for alleviating memory and executive disturbances may help in coping with daily activities.
  • Means of communication supporting and replacing speech, as well as audiphones are important. They reduce problems caused by speech and language defects.

Rehabilitation process Rehabilitation for Patients Living at Home More Than One Year after Stroke, Interventions for Nutritional Support in Subacute Stroke, Early Supported Discharge Services for People with Acute Stroke

  • Nursing with a rehabilitational character, including postural therapy, should be started immediately to activate bodily sensations to promote rehabilitation and to prevent functional trunk and limb problems.
  • Early mobilisation reduces the risk of pressure sores, pneumonia, deep venous thrombosis and pulmonary embolism, as well as of pressure sores.
  • A rehabilitation assessment should be performed within the first week or as soon as the patient's general condition allows. Assessment of the prognosis forms an essential part of the rehabilitation assessment. If, for example, a severe infection or surgical procedure worsens the situation or the patient's general health, reliable assessment may not be possible until significantly later.
  • Active rehabilitation should be started as soon as the patient's condition is sufficiently stable. Rehabilitation is clearly more effective if started within one week than if started after 2 weeks - 1 month.
  • A multidisciplinary rehabilitation plan should be made for patients needing rehabilitation. This should be drawn up jointly by the unit responsible for treatment, a multidisciplinary team, the patient and his/her relatives.
  • Rehabilitation should be provided for those needing it in a multidisciplinary rehabilitation unit; stroke patients benefit from multidisciplinary rehabilitation regardless of their age or sex or the severity of the disease.
    • Mortality and the risk of permanent institutional care are lower among patients treated in such units than among those treated in an ordinary in-patient ward and, in addition, periods of treatment are shorter, the degree of disability is lower and the quality of life is better. The additional benefit persists during follow-up.
  • Patients who will be discharged back to home may benefit from accelerated discharge and from rehabilitation provided at home. Goal-oriented and therapist-guided rehabilitation may maintain and improve the functional capacity of patients living at home within a year after the cerebrovascular disturbance.
  • When organizing rehabilitation for a patient, individual needs and regional circumstances need to be taken into account. The benefit of rehabilitation provided in an outpatient setting is increased when it is included in an organized care pathway of cerebrovascular disturbances.
  • Active rehabilitation should be continued for as long as significant recovery can be seen. The patient's functional ability can be improved by outpatient rehabilitation for at least one year after discharge.
  • For patients with permanent disability, monitoring and assessment of the need for rehabilitation no less than once a year is recommended for the rest of the patient's life, as well as rehabilitation depending on the assessment. Primary health care will be responsible for this and consult a multidisciplinary rehabilitation unit as necessary.

Implementation of rehabilitation

  • Rehabilitation is based on a rehabilitation plan made by the public health care unit responsible for treating the patient and planning his/her rehabilitation.
  • Vocational rehabilitation can be provided for working-age people who are estimated to have the prerequisites for returning to work. Vocational rehabilitation is arranged by the social insurance system, employment pensions institutions and employment authorities. Occupational health care has a central role for patients with employment contracts.

References

  • Pereira S, Graham JR, Shahabaz A et al. Rehabilitation of individuals with severe stroke: synthesis of best evidence and challenges in implementation. Top Stroke Rehabil 2012;19(2):122-31. [PubMed]

Evidence Summaries ⬆