STROKE REHABILITATION

Maysita Dhamayanti, SpKFR, MKedKlin

Rehabilitation Medicine, Siloam Hospitals Bekasi Timur
Webinar December 17th, 2020
 STROKE

Suatu gangguan neurologis (defisit neurologis), baik lokal

maupun global yang berkembang cepat (akut) akibat
gangguan fungsi otak dengan gejala gejala yang
berlangsung selama 24 jam atau lebih dan dapat
menyebabkan kematian tanpa adanya penyebab lain yang
jelas selain vaskuler.
STROKE :

THIS IS NOT JUST A

DISEASE,

THIS IS A DISASTER !
1.CARDIOVASCULAR
DISEASE
2.CANCER

3.STROKE
AS A DISABLING DISEASE :

STROKE IS THE
CHAMPION
…it is the single most expensive disease, costing
some $ 1.2 billion a year, even before the costs of
physicians services and nursing home and other
nonhospitalized care are figure in..
( Stroke Foundation, Inc. N.Y. )
DATA ABOUT STROKE IN INDONESIA
 STROKE CAN BE PREVENTED

STROKE CAN BE PREVENTED

 Recovery stroke
Kecepatan dipengaruhi oleh: umur, penyakit otak
lain, komorbiditas fisik dan psikologis lain

Recovery tercepat: 3-4 bulan setelah stroke (sangat

dipengaruhi oleh intervensi terapi)
Rata-rata recovery terjadi pada 6 bulan pertama
Bisa berlanjut sampai 2 tahun
Setelah 2 tahun --> sangat lambat

Prognosis fungsional SH lebih baik daripada SNH

 Outcome pasca stroke

35% (1 dari 3) survivor dengan paralisis AGB

tidak mencapai fungsional, dan 25% dari
semua survivor tidak dapat berjalan
independen

6 bulan pasca stroke , 65% (2/3) mereka

dengan kelemahan AGA tidak dapat
menggunakan tangan yang terkena untuk
tugas fungsional normal.
 Prognosis
Prognostik baik:
- Tidak ada koma
- Recovery motorik awal, terutama ibu jari tangan dan kaki
- Continence
Prognostik buruk:
- Koma
- Usia tua
- Incontinence
- Defisit / gangguan komunikasi bermakna
- Gangguan kognitif
- Spatial neglect
- Tidak ada gerakan AGB pada 2 minggu pertama
- Flaccid AGA tanpa gerakan jari tangan selektif pada 4 minggu
Komplikasi pasca stroke

Sistem Saraf Kurang nutrisi

edema cerebri, kejang

Infeksi Immobilisasi
Pneumonia, ISK DVT, ulkus decubitus

Muskuloskeletal Psikososial
stifness, kontraktur Depresi
The first step of Rehabilitation
Medicine Program :

TO ESTABLISH THE
DIAGNOSIS OF STROKE
Haemorrhagic / Non-Haemorrhagic ?
Which cerebral artery is involved ?
WHY THIS IS IMPORTANT ?
1. To anticipate the possible
problems which will be developing
2. To decide the appropriate
rehabilitation medicine strategy
Vertebro- basilar system
( posterior system )

Carotid system
( anterior system )
CAROTID
SYSTEM

VERTEBRO-
BASILAR
SYSTEM
ARTERY MAIN PROBLEMS REHABILITATION
STRATEGY
ACA Hemiparesis ( LE>UE) Gait training
Foot drop Orthoses
Hemianesthesia Sensory stimulation
UE Apraxia Language training
Transcortical motor aphasia DH Language training
Mental confusion Psychological counseling
Hemiplegia, UE = LE ( main stem ) Gait and ADL
MCA
UE > LE (upper div.)
Hemianesthesia Sensory stimulation
Homonymous hemianopsia Positioning, Ambulation Ex.
Unhibited Neurogenic bladder (Type 2) Bladder training
Dysphagia Feeding exercise
DH : Global aphasia (main stem) Language training
Broca aphasia, Apraxia (upper div.) Language training
Wernicke aphasia Language training
NDH : Aprosody Language training
Visuo-spatial deficit Ambulation training
Neglect syndrome
ARTERY MAIN PROBLEMS
PCA Hemiparesis
Homonymous hemianopsia
Ataxia, Tremor, Choreo-athetoid
Sup. sensation deficits
Pain (Dejerine-Roussy Syndr)
Memory deficits
V-B Ataxia, Choreiform movements, Horner’s
syndr, Deafness, Sensory deficits,
SYSTEM Dysphagia, Dysphonia, Nystagmus.
Hemialternans syndr.: Benedikt,
Parinaud,Weber, Foville, Millard-Gubler,
Raymond-Cestan, Gasperini
REHABILITATION STRATEGY
Movement & ambulation Ex.
Positioning, Ambulation Ex.
Balance and coord. exercise
Sensory & motor exercise
Cognitive training
Motor and sensory Exercises
Language training
Feeding exercise, etc
 GOALS OF REHABILITATION MEDICINE
PROGRAM
1. Preventing complications
2. Teaching new adaptive methods
3. Ensuring that appropriate aids are provided and used
properly
4. Retraining the damaged nervous system and preventing
or overcoming “learned disuse”
5. Enhancing Quality of Life
 SHOULDER
SUBLUXATION

BE CAREFUL
for

SHOULDER-HAND
SYNDROME
 GAIT ANALYSIS

SAGITTAL
PLANE

FRONTAL
PLANE
 Hemiplegic Gait
Anterior rotation of the
pelvis
Circumduction
Equinovarus foot
Short strides

ENERGY EXPENDITURE
Acute phase
Acute phase
Acute phase
Stable phase
STABLE PHASE
STABLE PHASE
STEPS OF AMBULATION TRAINING
AMBULATION TRAINING
&
GAIT EXERCISES

START LOW, GO SLOW

WALKERS
AXILLARY CRUTCHES

ENERGY EXPENDITURE >>

RAMPS, CURBS,
STAIRS
 R. HEMIPLEGIA vs L. HEMIPLEGIA

LEFT HEMISPHERE RIGHT HEMISPHERE

STROKE STROKE
Language problems Visio-motor perceptual deficits
( APHASIA ) Visual memory deficits
Left sided neglect
Reduced insight
Uncoordinated ADL
Superficial and Deep sensory
deficits
 Classification of Aphasia
Classification Fluency Comprehensio Repetition Naming
n
Global Poor Poor Poor Poor
Broca Poor Good Varies Poor
Wernicke Good Poor Poor Poor
Conduction Good Good Poor Poor
Anomic Good Good Good Poor
Transcortical Poor Good Good Poor
motor
Transcortical Good Poor Good Poor
sensory
 Mother
tongue

SPEECH THERAPY
Disfagia –Tx oral
stimulation
Constraint-induced movement
therapy (CIMT)
 Activity Score

Feeding 0 = unable
5 = needs help cutting, spreading butter, etc., or requires modified diet 0 5 10
10 = independent

Bathing 0 = dependent
0 5
5 = independent (or in shower)

Grooming 0 = needs to help with personal care

0 5
5 = independent face/hair/teeth/shaving (implements provided)

Dressing 0 = dependent
5 = needs help but can do about half unaided 0 5 10
10 = independent (including buttons, zips, laces, etc.)

Bowels 0 = incontinent (or needs to be given enemas)

5 = occasional accident 0 5 10
10 = continent
Barthel Index Classification :
Bladder 0 = incontinent, or catheterized and unable to manage alone
5 = occasional accident 0 5 10 1-20 : Totally dependent 1
10 = continent

Toilet Use 0 = dependent

5 = needs some help, but can do something alone 0 5 10
21-60 : Severely dependent 2
10 = independent (on and off, dressing, wiping)

Transfers (bed to chair and back)

61-90 : Moderate dependent 3
0 = unable, no sitting balance
5 = major help (one or two people, physical), can sit 0 5 10 15
10 = minor help (verbal or physical) 91-99 : Mild dependent 4
15 = independent

Mobility (on level surfaces) 100 : Independent 5

0 = immobile or < 50 yards
5 = wheelchair independent, including corners, > 50 yards 0 5 10 15
10 = walks with help of one person (verbal or physical) > 50 yards
15 = independent (but may use any aid; for example, stick) > 50 yards

Stairs 0 = unable
5 = needs help (verbal, physical, carrying aid) 0 5 10
10 = independent

TOTAL (0 - 100) ________

 KESIMPULAN

1 Stroke merupakan penyebab disabilitas

terbesar
2. Manajemen stroke secara komprehensif
diperlukan sejak fase akut sampai kronik
3. Rehabilitasi dilakukan untuk mencapai
fungsi seoptimal mungkin dan meningkatkan
kualitas hidup