CNS: Stroke Rehabilitation

• A stroke happens when blood flow to the brain is blocked or when there's sudden bleeding in the brain.
• Strokes are insults/injuries/events, which consequences can vary widely, ranging from death to full recovery.

Hemiplegia

• Hemiplegia is a non-progressive condition causing paralysis on one side of the body. It can result from a stroke or be caused by genetics, SCI, or other brain injuries.
• Paralysis occurs on the opposite side of the brain lesion. The effects can be temporary or permanent.
• Immediately post-stroke, muscles on the affected side are weak or flaccid, and flaccid paralysis can lead to spastic paralysis due to uninhibited alpha motor neuron firing.
• A common paralysis pattern include a flexor pattern in the upper limb combined with an extensor pattern in the lower limb.

Symptoms of Hemiplegia

• Altered posture due to spasticity.
• Altered gait, such as a circumducted gait.
• Hemiplegic shoulder with GH add, IR, and scapular retraction.
• Seizures, edema, pain, and compensatory changes.
• Sensory deficit.
• Shoulder-hand syndrome results in decreased ROM of GH & hand, followed with throbbing pain & edema..
• Neglect of the affected side.
• Behavioral & emotional changes.
• Visual impairment and speech difficulties.
• Cognitive impairment.

Observations for strokes

• Spasticity pattern on the affected side.
• Circumducted gait and impaired balance/weight shifting.
• Ambulatory aids like canes and walkers are used.
• Muscle bulk differences between affected and unaffected sides.
• Functional abilities vary depending on stroke severity.
• Postural asymmetries.
• Neglect of the affected side.
• Intensive rehab usually lasts 18 months.

Risk Factors for Strokes

• A stroke happens when blood supply to the brain is interrupted. The level of impairment depends on the location and degree of damage done. There are 3 main types of strokes:
• Ischemic stroke: blood clot
• Hemorrhagic stroke: vessel bursts.
• Transient ischemic attack (TIA): mini strokes lasting less than 24 hours.
• In rare cases, conditions such as a tumor, infection, or brain swelling can cause a stroke.

Controllable Stroke Risk Factors:

• Unhealthy weight, hypertension, high cholesterol, diabetes, heart disease.
• Physical inactivity.
• Excessive alcohol & drug abuse.
• Smoking.
• Stress.
• Birth control/hormones replacement therapy (HRT).

Uncontrollable Stroke Risk Factors:

• Sex
• Age
• Family history
• Ethnicity
• Personal circumstances
• History of stroke or TIA

Key modifiable stroke risk factors:

• Blood pressure: hypertension is linked to hemorrhagic strokes.
• Atherosclerosis: linked to ischemic strokes.

Warning Signs of Stroke:

• Sudden numbness or weakness in the face, arm, or leg, especially on one side of the body.
• Sudden confusion or trouble speaking or understanding speech.
• Sudden vision problems in one or both eyes.
• Sudden difficulty walking or dizziness, or problems with balance & coordination.
• Severe headache with no known cause.

FAST - Stroke First Aid

• Face: Facial numbness or weakness, especially on one side.
• Arm: Arm numbness or weakness, especially on one side.
• Speech: Slurred speech or difficulty speaking or understanding.
• Time: Call EMS/9-1-1 immediately.

Brunnstrom stages of stroke recovery

• Stage 1: Flaccidity, no voluntary movements
• Stage 2: Spasticity/basic synergy patterns appear, and minimal voluntary movements may be present.
• Stage 3: Patient gains voluntary control over synergies and increased increased spasticity
• Stage 4: Some movement patterns out of synergy are mastered. Spasticity decreases
• Stage 5: Basic synergies lose their dominance over motor acts. Further decrease in spasticity.
• Stage 6: Disappearance of spasticity: Individual joint movements become possible. Coordination approaches normal..
• Stage 7: Normal function is restored.

Massage Emphasis by Brunnstrom Stage

• Stage 1 - Flaccidity: PROM, passive stretch (gentle), positioning to support upper limb, especially shoulder.
• Stage 2 - Spasticity develops & abnormal synergies: PROM (slow, gentle) and massage for sensory stimulation.
• Stage 3 - Spasticity increases: Continue above techniques with increased emphasis on stress reduction.
• Stage 4 - Spasticity decreases: Massage to relax spastic/synergistic areas and continue above techniques.
• Stage 5 - Spasticity continues to decrease: PNF patterning and begin strengthening routine.
• Stage 6 - Spasticity disappears & coordination reappears: Focus on fine motor skills with PNF patterning.

Synergy

• A synergy is when a whole series of muscles are recruited when just a few are needed
• Example: Reaching forward causes shoulder abduction and elevation, with wrist flexion

Synergy Patterns / Upper Limb:

• Flexor Synergy (most common):
  • Shoulder internal rotation/adduction
  • Elbow flexion
  • Forearm supination
  • Wrist flexion
• Extensor Synergy Pattern

Assessment

• Palpation
• ROM
• Sensory testing
• Brunnstrom stages of stroke recovery

Goals and Treatment Planning

• Promote relaxation.
• Decrease pain.
• Address postural changes/muscle imbalances.
• Decrease edema via nodal pumping, shunting, MLD, hydro.
• Decrease spasticity.
• Maintain joint health through joint traction/play.
• Full body integration.

Rationale for Treatment and Planning

• Relaxation and stress management: Stress makes spasticity worse.
• PROM and stretching: Prevents neglect of the affected limb, maintains sensory mapping, and prevents contracture formation.
• Tone reduction: Lowers tone of spastic or overused muscles
• Decreasing edema is important for tissue health.
• Muscle Stimulation: Stimulates muscles outside of synergy or opposite to spasticity.
• PROM and joint play: Maintains joint health.
• ROODS, PNF, Stretching/strengthening: Full body integration for overall wellbeing.

Explore stroke underlying conditions, types, and risk factors. Understand immediate post-stroke effects, muscle tone, spasticity, and gait abnormalities. Review upper limb patterns and recovery expectations after a stroke.