Iwona Physio: stroke

Service organisation and the delivery of rehabilitation are typically focused in the first months of stroke and often fail to meet the long-term and evolving needs of people with stroke. Over time the nature of rehabilitation will shift from restorative to compensatory and adaptive approaches but rehabilitation should not end solely because natural recovery appears to have reached a plateau.

Here you can find common physiotherapy interventions required during further stroke recovery recommended by the National Clinical Guideline for Stroke (https://www.strokeaudit.org/SupportFiles/Documents/Guidelines/2016-National-Clinical-Guideline-for-Stroke-5t-(1).aspx)

Physiotherapy intervention	Description
Activities of daily living (ADLs)	difficulties that can occur after stroke affecting personal, domestic and extended activities of daily living (e.g. work and driving) help the person with stroke to engage in independent living and social participation.
Personal activities of daily living (PADL)	basic activities such as washing, dressing, bathing, going to the toilet, eating and drinking;
Extended activities of daily living (EADL)	encompass both domestic and community activities such as shopping, cooking and housework that allow complete or virtually complete independence. These activities also enable community and social participation.
Driving	it influences self-esteem and mood. healthcare professionals need to discuss and give advice on fitness to drive. The current UK regulations regarding driving are available online ( https://www.gov.uk/government/publications/assessing-fitness-to-drive-a-guide-for-medical-professionals).
Work and leisure	this refers to two related but different types of activity: productive work (paid or voluntary) and leisure activities. people with stroke may require specialist advice and support to enable them to resume these activities.
Arm function	approximately 70% of people experience altered arm function after a stroke, and this persists for about 40% of survivors. interventions used in routine practice to improve arm function and those that might help deliver repetitive and functionally relevant practice.
Apraxia	· difficulty performing purposeful actions due to disturbance of the conceptual ability to organise actions to achieve a goal. · people with apraxia often have problems carrying out everyday activities such as dressing or making a hot drink despite adequate strength and sensation. · they may also have difficulties in selecting the right object at the right time or in using everyday objects correctly. Apraxia can be detected using standardised tools (e.g. Test of Upper Limb Apraxia [TULIA]) and is usually associated with damage to the left cerebral hemisphere.
Attention and concentration	disturbed alertness is common after stroke especially in the first few days and weeks, and more so in non-dominant hemisphere stroke. attention impairments may persist in the longer term and may be specific (e.g. focusing, dividing or sustaining attention) or more generalised, affecting alertness and speed of processing and be evident in poor engagement or general slowness. attention problems may lead to fatigue, low mood and difficulty with independent living.
Executive function	refers to the ability to plan and execute a series of tasks, inhibit inappropriate automatic impulses, regulate emotional responses, foresee the consequences of actions and make judgments about risk. ‘dysexecutive syndrome’ encompasses various impairments, including difficulties with problem solving, planning, organising, initiating, inhibiting and monitoring behaviour. these can be detected using standardised tools (e.g. the Behavioural Assessment of the Dysexecutive Syndrome [BADS]). executive functions rely heavily upon attention and are associated with deficits in everyday function and independence.
Spatial awareness	problems with spatial awareness (also referred to as visual spatial neglect, sensory inattention etc.) refer to a reduced awareness of some part of the person’s body or their environment. it is more common in people with non-dominant hemisphere stroke (typically causing left -sided neglect) and those with hemianopia. behavioural symptoms include bumping into objects on the affected side or only reading one side of pages in newspapers or books. neglect can be detected using standardised assessments ( e.g. the Behavioural Inattention Test).
Weakness and ataxia	stroke frequently results in weakness, lack of co-ordination of movement (ataxia) and loss of selective movement. weakness on one side of the body (hemiparesis or hemiplegia) is a hallmark of stroke, affecting around 80% of people with stroke. It causes substantial disability, mainly through limiting mobility but also in affecting arm function. ataxia occurs in around 3% of ischaemic strokes, principally in cases involving the cerebellum but also as a consequence of severe sensory dysfunction (known as sensory ataxia). Examples of standardised measures of motor impairment include the Motricity Index and the Scale for the Assessment and Rating of Ataxia (SARA).
Balance	many people experience difficulty with balance after stroke. this is usually due to a combination of reduced limb and trunk motor control, altered sensation and sometimes centrally determined alteration in body representation such that the person misperceives their posture in relation to the upright. impaired balance reduces confidence and increases the risk of falls on walking.
Falls and fear of falling	people with stroke are at high risk of falls at all stages in their recovery. stroke-related balance deficits include reduced postural stability during standing and delayed and in co-ordinated responses to both self-induced and external perturbations. gait deficits include reduced propulsion at push-off, decreased hip and knee flexion at swing-phase and reduced stability at stance-phase. the high incidence of falls may be attributable to impairments of cognitive function, motor weakness, dual tasking and the planning and execution of tasks. non-stroke factors that increase the risk of falling in older people (e.g. multiple medications) are also common in people with stroke. falls may have serious physical and psychological consequences, including an increased risk of hip fracture (usually on the weaker side) and greater mortality and morbidity compared to people without stroke. fear of falling may lead to decreased physical activity, social isolation and loss of independence. interventions to prevent falls include education and adaptations e.g. low bed, chair alarms and are often multi-factorial, addressing physical and psychological aspects.
Walking	the highest priority for many people with limited mobility after stroke is to walk independently. the treatments and equipment aimed at improving walking and includes exercise. orthoses are external devices that support or enhance an impaired limb; commonly used after stroke are ankle-foot orthoses (AFOs) to support a hemiplegic foot and ankle.
Spasticity and contracture	spasticity can cause discomfort or pain for the person with stroke, difficulties for carers and is associated with activity limitation. spasticity is common, especially in a non-functional arm- estimates of prevalence vary from 19% to 43% depending on the timing of assessment. any joint that does not move frequently is at risk of developing shortening of surrounding tissues leading to restricted movement and this is referred to as a contracture, and is not uncommon in limbs affected by spasticity. contractures can impede activities such as washing or putting on clothes, and may also be uncomfortable or painful and limit the ability to sit in a wheelchair or mobilise.
Splinting	the process of applying a prolonged stretch through an external device, most commonly splints or serial casts, to prevent or treat contractures. Splinting is used to help manage tone, reduce pain and improve range of movement and function (passive and active). Standardised measures for ease of care and resistance to passive stretches include the Arm Activity measure and modified Ashworth Scale respectively.

According to a new national guidelines for stroke, rehabilitation plays an important role in recovery. It highlights that the frequency of therapy must enable stroke patients to meet their rehabilitation goals and therapy should continue as long as patients are willing and capable of participating and showing measurable benefit from treatment.

The National Clinical Guideline for Stroke pays attention into an early mobilisation. Those who are medically stable but with difficulties to move soon after a stroke should be offered frequent, short, daily mobilisations (45 min) and it should start between 24 and 48 hours after a stroke.

A stroke unit must be capable of providing rehabilitation to all its patients, providing a specialist early supported discharge service, so stroke patients can continue their rehabilitation at home.

Commissioners are recommended to look for specialist rehabilitation services which meet the specific health, social and vocational needs of people with stroke of all ages. And they should commission services capable of delivering specialist rehabilitation in out-patient and community settings, in liaison with inpatient services.

Why earlier, more frequent, and higher dose of out-of-bed sitting, standing, and walking activities are consider to be more effective than previously thought?

The research ‘Efficacy and safety of very early mobilisation within 24 h of stroke onset (AVERT): a randomised controlled trial’ answers to above question very well. It says that the very early mobilisation intervention significantly reduced the odds of a favourable outcome 3 months after stroke compared with lower dose usual care starting, on average, 5 h later.

The biological rationale underlying the potential for early out-of-bed training centres around three arguments: (1) that bed rest negatively affects the musculoskeletal, cardiovascular, respiratory, and immune systems,and might slow recovery; (2) that immobility-related complications are common early after stroke at a time when patients are very inactive; and (3) that there might be a narrow window of opportunity for brain plasticity and repair, and the optimum period for change could be early after stroke. Prompt start and more episodes of out-of-bed activity might therefore improve outcome.

Early Physiotherapy in intensive care	Positioning	· to reduce skin damage, limb swelling, shoulder pain or subluxation, and discomfort, · to maximise function · to maintain soft tissue length. · to reduce respiratory complications · avoid compromising hydration and nutrition. Recommendations Patients with acute stroke should have an initial specialist assessment for positioning as soon as possible and within 4 hours of arrival at hospital. Healthcare professionals responsible for the initial assessment of patients with acute stroke should be trained in how to position patients appropriately, taking into account the degree of their physical impairment after stroke When lying or sitting, patients with acute stroke should be positioned to minimise the risk of aspiration and other respiratory complications, shoulder pain and subluxation, contractures and skin pressure ulceration.
Early Physiotherapy in intensive care	Early mobilisation	· significantly reduced the odds of a favourable outcome 3 months after stroke compared with lower dose usual care starting, on average, 5 h later. Recommendations Patients with difficulty moving after stroke should be assessed as soon as possible within the first 24 hours of onset by an appropriately trained healthcare professional to determine the most appropriate and safe methods of transfer and mobilisation. Patients with difficulty moving early after stroke who are medically stable should be offered frequent, short daily mobilisations (sitting out of bed, standing or walking) by appropriately trained staff with access to appropriate equipment, typically beginning between 24 and 48 hours of stroke onset. Mobilisation within 24 hours of onset should only be for patients who require little or no assistance to mobilise.