BIODATA :

•Nama : Bayu Santoso

•Pendidikan : Dokter dari F.K. Unair ( 1972
Dokter Sesialis Rehabilitasi Medik dari Santo Tomas
University, Manila, Philippines
•Pendidikan tambahan :
Addis Ababa, Ethiopia ( leprosy rehabilitation)
University of London ( Community Based Rehabilitation)
Stoke Mandeville Hospital , U.K. ( spinal cord injury rehabilitation)
St Radboud Hospital, Nijmegen, Netherland (Electrodiagnostic)
New South Wales University, Sydney ( Hospital Management)
•Pekerjaan :
Kabag Ilmu Kedokteran Fisik&Rehabilitasi, FK Unair / RSU
Dr.Soetomo
KPS IKFR, FK Unair
•Status: Kawin ( 1 isteri, 3 anak, 1 cucu )
STROKE REHABILITATION

Bayu Santoso
Department of Physical Medicine and Rehabilitation
School of Medicine, Airlangga University
Dr. Soetomo General Hospital
Surabaya
AS A KILLER :

1.CARDIOVASCULAR
DISEASE
2.CANCER

3.STROKE
FACTS ABOUT STROKE :

1. A stroke does not have to be

fatal
2. Strokes can be prevented
3. Most strokes have good
prognosis functionally
MANAGEMENT OF STROKE :

1. NON-SURGICAL ( Neurology )
SURGICAL ( Neurosurgery )
1. REHABILITATION
• Never a simple task / always complicated
• should be a “tailor-made program”
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
ACA

MCA
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

MCA Hemiplegia, UE = LE ( main stem ) Gait and ADL

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 REHABILITATION
STRATEGY

PCA Hemiparesis Movement & ambulation Ex.

Homonymous hemianopsia
Ataxia, Tremor, Choreo-athetoid
Sup. sensation deficits
Pain (Dejerine-Roussy Syndr)
Memory deficits
Positioning, Ambulation Ex.
Balance and coord. exercise
Sensory & motor exercise
Cognitive training

V-B Ataxia, Choreiform movements, Motor and sensory Exercises

Horner’s syndr, Deafness, Language training
SYSTEM Sensory deficits, Dysphagia, Feeding exercise, etc
Dysphonia, Nystagmus.
Hemialternans syndr.: Benedikt,
Parinaud,Weber, Foville, Millard-
Gubler, Raymond-Cestan,
Gasperini
FUNCTIONAL PROGNOSIS OF STROKE :
1. 75% of patients will reach independent level
of self-care or with minimal help
2. 75% will reach independent level of
ambulation with canes / ambulation device
3. Almost all patients will be able to control
bladder and bowel
4. Only 10% of patients fall into severe
disabilities and will be bedriddened
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
EXTINCTION PHENOMENON

POSITION SENSE
EXERCISE PROGRAM :
1.TRADITIONAL / CONVENTIONAL
METHOD
2.NEURODEVELOPMENTAL /
NEUROPHYSIOLOGICAL METHODS
Brunnstrom
Rood
Bobath
Kabat, Knott, Voss ( PNF )
SENSORY MOTOR INTERACTION
PHYSICAL THERAPY
OCCUPATIONAL
THERAPY
 SHOULDER
SUBLUXATION

BE CAREFUL
for

SHOULDER-HAND
SYNDROME
 GAIT ANALYSIS

SAGITTAL
PLANE

FRONTAL
PLANE
 NORMAL HUMAN LOCOMOTION
a series of rhythmical, alternating movements of extremities & trunk
 forward movement of CoG

GAIT CYCLE

STANCE PHASE SWING PHASE

HEEL STRIKE FOOT FLAT MID STANCE PUSH OFF ACCELERATION MID SWING DECCELERATION

0 10 20 30 40 50 60 70 80 90 100
R DS R SS L DS L SS

DS  2 extremities are in contact with ground simultaneously ~ to the cadence

 GENERAL CHARACTERISTIC
OF NORMAL GAIT

1. Vertical Displacement of CoG ( 2 inches : MS, DS)

2. Lateral Displacement of CoG (2 inches)
3. Width of the Walking Base (2-4 inches)
4. Horizontal Dip of the Pelvis (5o)
5. Knee Flexion on stance Phase (20o, after HS)
6. Cadence (70-130x/min, av: 90x/min  2.5 miles/h)
 Hemiplegic Gait
Anterior rotation of the
pelvis
Circumduction
Equinovarus foot
Short strides

ENERGY EXPENDITURE
LANGUAGE PROBLEMS
 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
RIGHT HEMISPHERE COMMUNICATION
IMPAIRMENT (RHCI)
1. LINGUISTIC : confrontation naming
word fluency
auditory comprehension
dysgraphia
2. NONLINGUISTIC : left neglect
visuospatial deficits
impaired processing in context
3. EXTRALINGUISTIC: Topic maintenance
impulsivity in response
Literal interpretation
insensitivity to communication situation
interpreting and producing afective facial
expression
interpreting and producing prosodic features of
verbal messages
GESCHWIND’S MODEL OF CORTICAL
AREAS INVOLVED IN SPEECH
 Classification of Aphasia
Classification Fluency Comprehen Repetition Naming
sion
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
Transcortic- Poor Good Good Poor
al motor
Transcortic- Good Poor Good Poor
al sensory
 Post. Lesion Good Good Naming
Normal / Dysarthric?
Repetition
Good Poor Naming Anomic (MCA, Angular gyr.)
Comprehension Poor
Conduction (MCA, Arcuate
Repetition

Fluent
fasciculus)
Good
Repetition Transcortical sensory
Poor
(PCA, Parieto-occipital)
Comprehension Poor
Repetition Wernicke’s (MCA,Temporal)
APHASIA
Good
Transcortical motor
Good Repetition
Comprehension ( ACA, Prefrontal )
Poor
Broca’s ( MCA, Frontal lobe)
Repetition
Non-
Fluent Good
Poor
Repetition Mixed transcortical
Comprehension
(ACA, PCA, Watershed zone)
Poor
Repetition Global (MCA, Multilobes)
Ant. lesion
FLUENCY, COMPREHENSION, REPETITION

1. FLUENCY : a. Fluent : lesion in posterior to the central

sulcus
b. Non-fluent : lesion anterior to the central
sulcus
2. COMPREHENSION :
a. Oral comrehension : lesion in MCA distribution
b. Reading comprehension : PCA distribution
3. REPETITION:
a. Poor repetition : MCA lesions
b. Good repetition : lesions outside the language
cortex
 Dirgahayu
HUT XVIII
RS Pertamina
Balikpapan