Stroke

Rehabilitation can enhance functional performance after a stroke. The success of rehabilitation depends on the patient's general condition, range of motion, muscle strength, bowel and bladder function, premorbid functional and cognitive ability, social situation (eg, likelihood of returning to the community), learning ability, motivation, coping skills, and ability to participate in rehabilitation under the supervision of nurses and physical therapists. Impairment of comprehension often makes rehabilitation very difficult.

Starting rehabilitation early--ie, as soon as patients are medically stable--may prevent secondary disabilities (eg, contractures) and depression. Preventive measures for some complications (eg, pressure sores) must be started even before patients are medically stable.

Patients can safely sit up once they are fully conscious and their neurologic deficits are no longer progressing, usually within 48 hours of the stroke. Early in the rehabilitation period, when the affected extremities are flaccid, each joint is passively exercised through the normal range of motion three to four times daily. (see Table 28-1) For patients with hemiplegia, placing one or two pillows under the affected arm can prevent dislocation of the shoulder. If the arm is flaccid, a well-constructed sling can prevent the weight of the arm and hand from overstretching the deltoid muscle and subluxating the shoulder. A posterior foot splint applied with the ankle in a 90° position can prevent equinus deformity (talipes equinus) and footdrop.

Reeducation and coordination exercises of the affected extremities are added as soon as tolerated, often within 1 week. Active and active-assistive range-of-motion exercises are started shortly afterward to maintain range of motion and, if indicated, to increase muscle strength.

Resistive muscle-strengthening exercises for hemiplegic extremities are controversial because they may increase spasticity, which develops insidiously; if spasticity develops, resistive exercises are stopped. Active exercise of the unaffected extremities must be encouraged, as long as it does not cause fatigue. Various activities of daily living (eg, moving in bed, turning, changing position, sitting up) should be practiced. For hemiplegic patients, the most important muscle for ambulation is the unaffected quadriceps. If weak, this muscle must be strengthened to assist the hemiplegic side.

Regaining the ability to get out of bed and to transfer to a chair or wheelchair safely and independently is important for the patient's psychologic and physical well-being. Ambulation problems, spasticity, visual field defects (eg, hemianopia), incoordination, and aphasia require specific therapy.

Ambulation problems: Before ambulation exercises can be started, patients must be able to stand. Patients first learn to stand from the sitting position. The height of the seat may need to be adjusted. Patients must stand with the hips and knees fully extended, leaning slightly forward and toward the unaffected side. Using the parallel bars is the safest way to practice standing.

The goal of ambulation exercises is to establish and maintain a safe gait, not to restore a normal gait. Most hemiplegic patients have a gait abnormality. During ambulation exercises, patients place the feet > 6 inches apart and grasp the parallel bars with the unaffected hand. Patients take a shorter step with the hemiplegic leg and a longer step with the unaffected leg. Patients who begin walking without the parallel bars may need physical assistance from and, later, close supervision by the therapist. Generally, patients use a cane or walker when first walking without the parallel bars. The diameter of the cane handle should be large enough to accommodate an arthritic hand.

For stair climbing, ascent starts with the better leg, and descent with the affected leg (good leads up; bad leads down). If possible, patients ascend and descend with the railing on the unaffected side, so that they can grasp the railing. Looking up the staircase may cause vertigo and should be avoided. During descent, the patient should use a cane. The cane should be moved to the lower step shortly before descending with the bad leg.

Patients must learn to prevent falls, which are the most common accident among stroke patients and which often result in hip fracture. Usually, patients explain the fall by saying, "The knees gave way." For hemiplegic patients, who almost always fall on their hemiplegic side, leaning their affected side against a railing (when standing or climbing stairs) can help prevent falls. Performing strengthening exercises for weak muscles, particularly in the trunk and legs, can also help.

For patients with symptomatic orthostatic hypotension, treatment includes support stockings, drugs, and training on a tilt table. Because hemiplegic patients are prone to vertigo, they should change body position slowly and take a moment after standing to establish equilibrium before walking. Comfortable, supportive shoes should be worn, with rubber soles and with heels no higher than 2 cm (3/4 inch).

Spasticity: In some stroke patients, spasticity develops. Spasticity may be painful and debilitating, and it may or may not help ambulation. Slightly spastic knee extensors can lock the knee during standing or cause hyperextension (genu recurvatum), which may require a knee brace with an extension stop. Resistance applied to spastic plantar flexors causes ankle clonus; a short leg brace without a spring mechanism minimizes this problem.

Flexor spasticity develops in most hemiplegic hands and wrists. Unless patients perform range-of-motion exercises several times a day, flexion contracture may develop rapidly in those with flexor spasticity, resulting in pain and difficulty maintaining personal hygiene. Patients and family members are taught and strongly encouraged to perform these exercises. A hand or wrist splint may also be useful, particularly at night. One that is easy to apply and to clean is best.

Heat or cold therapy can temporarily decrease spasticity and allow the muscle to be stretched. Benzodiazepines may be used for hemiplegic patients to minimize apprehension and anxiety, particularly during the initial stage of rehabilitation, but not to reduce spasticity. The effectiveness of long-term benzodiazepine use for reducing spasticity is questionable. Methocarbamol has limited value in relieving spasticity and causes sedation.

Hemianopia: Patients with hemianopia (defective vision or blindness in half the visual field of one or both eyes) should be made aware of it and taught to move their heads toward the hemiplegic side when scanning. Family members can help by placing important objects and by approaching the patient on the patient's unaffected side. Repositioning the bed so that the patient can see a person entering the room through the doorway may be useful. While walking, patients with hemianopia tend to bump into the door frame or obstacles on the hemiplegic side; they may need special training to avoid this problem.

Lack of fine coordination: After a stroke, fine coordination may be absent, causing patients to become frustrated. They may need to modify activities and use assistive devices.