WEEK 2Lecture 2.1 PTY 223 Physiotherapy management of stroke.pptx

PHYSIOTHERAPY MANAGEMENT OF STROKE LECTURE 2.1 (1.5 HOURS) PTY233 LECTURE DELIVERED BY: DR. BALKHIS BANU AIMS OF THE LECTURE To revise typical symptoms of movement dysfunction following stroke To describe the role of the physiotherapist in the acute & rehabilitation stroke setting To...

PHYSIOTHERAPY MANAGEMENT OF STROKE LECTURE 2.1 (1.5 HOURS) PTY233 LECTURE DELIVERED BY: DR. BALKHIS BANU AIMS OF THE LECTURE To revise typical symptoms of movement dysfunction following stroke To describe the role of the physiotherapist in the acute & rehabilitation stroke setting To compare the physiotherapy management of different types of stroke To describe the pathophysiology & treatment of hemiplegic shoulder pain To describe the attributes of a Stroke Unit 2 REVIEW Two main stroke presentations: infarct and hemorrhage (ICH or SAH) Symptoms of stroke is related to the location and the extent of damage Mortality of hemorrhage is greater Patients with SAH/sub arachnoid Hemorrhage are likely to undergo surgical intervention (less likely with ICH) 3 TREATING THE STROKE PATIENT Have knowledge of anatomy & pathophysiology of different stroke types. Be aware of contraindications relevant for each stroke type. Be aware of any relevant protocols within the stroke ward (and clinical practice guidelines). 4 WORKING PLAN FOR STROKE TREATMENT Get relevant information Look before touching, prepare envt Prioritize assessment components if fatigue/tolerance an issue Develop ward management plan Communicate assessment findings Develop discharge plan (with all AHP- Allied health 5 professionals) AIMS OF ACUTE PHYSIOTHERAPY INTERVENTION To improve/maintain chest status To commence neurorehabilitation as soon as possible To maintain/normalize musculoskeletal status of any immobile limbs To formulate an appropriate discharge plan in 6 consultation with other AHP RISK FACTORS FOR CHEST INFECTION POST ACUTE NEUROLOGICAL INJURY Prolonged immobility impaired respiratory drive decreased cough reflex decreased bulbar (swallowing) function decreased intercostal muscle function premorbid lung disease 7 poor head/sitting posture Day 10 post SAH – Sub arachnoid haemorrhage Drowsy, immobile Poor head and trunk posture L hemiplegia Depressed cough reflex Aspiration risk (trache) Premorbid COPD- Chronic obstructive pulmonary disease 8  THE EFFECT OF A CHEST INFECTION Possible respiratory focus of raised ICP- Intra cranial pressure Pulmonary secretions Atelectasis  PCO 2  ICP Segmental collapse Atelectasis - complete or partial collapse of the entire lung or area (lobe) of the lung. The partial pressure of carbon dioxide (PCO2) is the measure of carbon dioxide within arterial 9 or venous blood.  RESPIRATORY MANAGEMENT Due to communication/arousal problems with many stroke patients, limited active participation may be possible. Consider strategies such as manual techniques to facilitate sputum clearance/improve AE, reflex cough activation, early mobilising as a ‘chest’ Rx 10  ACUTE NEUROREHABILITATION Bed positioning regime to manage abnormal tone, paralyzed limbs, joint/muscle range, at-risk joints e.g. shoulder Early mobilising of the acute patient (within 24/24) Early commencement of functional tasks such as rolling, reaching 11  BED POSITIONING REGIME Protect at risk joints Maintain functional ROM Encourage spatial awareness of L & R sides of body 12 13  BENEFITS OF EARLY MOBILISING FOR THE ACUTE STROKE PATIENT Reduced sick role Improved respiratory function (SaO2- Oxygen saturation (SaO2) is a measurement of the percentage of how much hemoglobin is saturated with oxygen. ) Reduced risk of pressure sores and DVT Improved continence training outcome Reduced risk of aspiration when eating Improved arousal (LOC/ level of consciousness is not a contraindication) Increased sensory input e.g. vestibular 14 Stimulation of postural muscles e.g. neck EARLY MOBILISING 15  CONTRAINDICATIONS FOR EARLY MOBILISING Related to stability of medical condition Related to stability of neurological condition (refer to GCS- Glasgow coma scale) Related to specific neurosurgical procedure Difference in mobilising infarct v ICH v SAH 16  CONTRAINDICATIONS FOR EARLY MOBILISING Blood pressure below or above appropriate limits set by Doctor (especially SAH, ICH- intracerebral haemorrhage) Unstable ICP (e.g. patient with large hemorrhage, cared for in ICU) Specific surgeons’ post-op protocols (determine from protocol manual, nurse in charge, RMO) Non neurological reason e.g. #NOF/ fracture of neck of femur + stroke 17  EARLY ACTIVITIES FOR THE ACUTE NEUROLOGICAL PATIENT Sitting balance (head and trunk control) Sit to stand (transfers) Shoulder care (implementation of preventative techniques for at-risk joint) Rolling/bed mobility (esp if RIB- rest in bed) Upper limb training (in lying or sitting) Management of musculoskeletal system 18  HEMIPLEGIC SHOULDER During the initial period following a stroke, the hemiplegic arm is flaccid or hypotonic. The shoulder muscles are unable to anchor the humeral head within the glenoid cavity, resulting in a high risk of shoulder subluxation. 19 SHOULDER ANATOMY/FUNCTION 20  ROTATOR CUFF Supraspinatus, infraspinatus, teres minor & subscapularis Tendons blend and reinforce capsule (and prevent slackening of capsule) Provide dynamic stabilisation to shoulder joint via joint compression Inferior pull offsets superior pull of deltoid (force couple) 21  HEMIPLEGIC SHOULDER Pain may develop due to Weakness Joint immobility Disuse-provoked soft tissue and joint changes Over extensibility of capsular structures of the GH joint Pinching of stretched soft tissues between joint surfaces Abnormal biomechanical function of joint during shoulder elevation & at rest 22 DVD clip – hemiplegic shoulder  HEMIPLEGIC SHOULDER Persistent maintenance of GHJ/gleno humeral joint internal rotation and adduction Weakness of GHJ external rotation and abduction 23 PATHOGENESIS OF HEMIPLEGIC SHOULDER PAIN ? Subluxation (rotator cuff paresis) ? Trauma (eg from adverse handling or positioning) ? Spasticity/impingement ? Adaptive shortening of joint structures 24  SHOULDER PATHOLOGY Adhesive capsulitis/stiffness and pain in shoulder joint due to tight and thickened connective tissues. (50%) Shoulder subluxation (44%) Rotator cuff tears (22%) Shoulder-hand syndrome- e.g. reflex sympathetic dystrophy affecting the upper extremities and characterized by pain in and stiffening of the shoulder followed by swelling and stiffening of the hand and fingers.(16%) 25  HEMIPLEGIC SHOULDER PAIN Has a negative effect on functional recovery Previously thought to be directly related to subluxation hence prevention of subluxed joint the key Subluxation may be a causative factor in development of RSD- reflex sympathetic dystrophy (RSD), this type occurs after an illness or injury that didn't directly damage the nerves in your affected limb. 26  HEMIPLEGIC SHOULDER MANAGEMENT Prevention of subluxation/trauma (handling, use of slings/supports, ‘alert’ bands) Maintenance of normal PROM (positioning programs) Scapula mobilising Retraining of active movement control (active exercise, EPA- electro physical agents) Functional electrical stimulation Intra articular injections 27 No universal agreement as to the ‘gold standard’ for upper limb support – Collar and cuff, Hook hemi harness, triangular sling, chair trays, pillows all used 28 Shoulder care is a TEAM effort 29 30 HEMIPLEGIC SHOULDER MANAGEMENT 31  STROKE UNIT Geographically centralised ward Dedicated, skilled, multidisciplinary staff Includes additional components such as regular team meetings, family meetings, discharge meetings Includes educational components to staff & families 32  STROKE UNIT EFFICACY Cochrane review with 28 trial involving 5855 participants in 2013, showed that patients who receive organised stroke unit care are more likely to survive their stroke, return home and become independent in looking after themselves. A variety of different types of stroke unit have been developed. The best results appear to come from those which are based in a dedicated ward. 33  WHAT’S SO SPECIAL ABOUT STROKE UNITS? Organisation Multidisciplinary, earlier therapy start, family involvement, enriched environment Specialisation Staff expertise, closer monitoring Education More education provided to staff and families/patients re stroke care 34