REHABILITASI MEDIK PADA

PENDERITA STROKE

Dr. NOVITA SARI DEWI, Sp. KFR

STROKE :
THIS IS NOT JUST A DISEASE,

THIS IS A DISASTER !
AS A KILLER :

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. )
FACTS ABOUT STROKE :

1.A stroke does not have to be fatal

2. Strokes can be prevented
3. Most strokes have good prognosis
functionally
 DEFINITION
The WHO defines stroke as

“ rapidly developing clinical signs of focal (at times

global) disturbance of cerebral function, lasting more
than 24 hours or leading to death with no apparent
cause other than that of vascular origin ”
RISK FACTORS

 Nonmodifiable
- Age ( increase after age 55 yr)
- Sex (male > female)
- Race (African American 2 x > White > Asian)
- Family history of stroke
RISK FACTORS

 Modifiable (treatable)
- Hypertension
- History of TIA/prior stroke
- Heart disease : CHF, CAD,Valvular heart disease, AF
- Diabetes
- Cigarette smoking
- Carotid stenosis
- Cocain use
- High dose estrogen
- Systemic disease associated with hypercoagualable state
- Hyperlipidemia
- Migrain headaches
- Sleep apnea
- Patent foramen ovale
Types of stroke ?
 Ischemic Hemorrhagic

Subarachnoid
Type Thrombotic Embolic Lacunar Intracerebral (ruptured
(hypertensive) aneurysm)

Factors Occurs when the

associated with Occurs during Occurs while patient is calm Occurs during
onset sleep awake and unstressed activity

Perfusion failure Small lesion

Major causes / distal to site of seen From ruptured
etiology severe stenosis mainly:putamen, Hypertension aneurysms and
or occlusion of Due mainly to pons, thalamus, vascular
major vessels cardiac source caudate, malformation
internal capsule

Gradual onset
Presentation Slowly Sudden, Abrupt or or sudden onset
progressive immediate gradual onset of local Sudden onset
deficit deficit neurologic
deficit
Source : Sara Cuccurullo
 Time of stoke
- TIA
- RIND
- Stroke in evolution
- Complete stroke
Temporal Classification of Stroke
 TIA : transient ischemic attack
 Neurological symptoms develop and disappear over
several minutes and completely resolve within 24 hours
 RIND : reversible ischemic neurological deficit
 Longer than 24 hours
 Stroke in evolution
 Unstable ischemic
 Completed stroke
 Stable neurological status
 Neuroanatomic location of ischemic
stroke
ARTERY MAIN PROBLEMS

• Sensory & motor deficit face/arm > leg

Superior divison • Head & eyes deviated toward side of infarct
(rolandic and • Left side lesion (DH) global aphasia initially, then
prerolandic area)
turns into Broca’s aphasia
• Right side lesion (NDH) deficit spatial perception,
MIDDLE apraxia, hemineglect
CEREBRAL
ARTERY
(MCA)
Inferior division • Homonymous hemianopsia
(lateral temporal
• Left side lesion  Wernicke’s aphasia
and inferior
parietal lobes) • Right side lesion  left visual neglect

Sources : Sara Cuccurullo

ACA

MCA
 Neuroanatomic location of ischemic
stroke
ARTERY MAIN PROBLEMS

ANTERIOR • Hemiparesis LE > UE

CEREBRAL • Personality disfunction
ARTERY (ACA) • Head and eyes may be deviated toward side lesion acutely
• Urinary incontinence with contralateral grasp reflex
• Disturbances in gait and stance = gait apraxia

POSTERIOR • Hemisensory deficit

CEREBRAL • Visual impairment
ARTERY (PCA) • Visual agnosia
• Prosopagnosia (can’t read faces)
• Alexia (can’t read)
 SYNDROMES LOCATION
ARTERY MAIN PROBLEMS

WEBER’S Medial basal • Ipsilateral third nerve palsy

midbrain • Contralateral hemiplegia
VERTEBROBA
SILAR SYSTEM
• Ipsilateral third nerve palsy
BENEDICT’S Tegmentum of • Contralateral loss of pain &
midbrain temperature sensation
• Contralateral loss of joint position
• Contralateral ataxia
• Contralateral chorea

LOCKED-IN Bilateral basal • Bilateral hemiplegia

pons • Bilateral cranial nerve palsy

Source : Braddom
 SYNDROMES LOCATION
ARTERY MAIN PROBLEMS

MILLARD-GUBLER Lateral pons • Ipsilateral sixth nerve palsy

• Ipsilateral facial weakness
VERTEBROBA
SILAR SYSTEM
• Contralateral hemiplegia

• Ipsilateral hemiataxia
• Ipsilateral loss of facial pain &
WALLENBERG’S Lateral medulla temperature sensation
• Contralateral loss of body pain &
temperature sensation
• Nystagmus
• Ipsilateral Horner’s syndrome
• Dysphagia & dysphonia

Source : Braddom
 Characteristics of Right and Left Hemiplegic Patients

Left Hemiplegic (Right-Brain

Right Hemiplegic (Left-Brain Injured) Injured)

 Communication  Visual/motor perceptual

impairment
 Learns by demonstration
 Will learn from mistakes
 May require supervision
due to communication
problems
problems
 Loss of visual memory
 Left side neglect
 Impulsive
 Lack insight/judgement,
requires supervision
Timing of therapy
 Specific therapy schedules should be individual for
each patient
 The literature doesn’t provide specific guidelines on
the a amount of therapy needed for specific
problems
 Endurance, medical stability, mood, motivation, and
other considerations affect the degree and duration
of physical patient can tolerate

Source : Braddom
 much of the benefits in mortality appear to relate
to prevention and/or earlier recognition of medical
complications of stroke and earlier mobilization
 The timing and progression depend on the patient’s
condition. These activities should begin as soon as
possible (generally within 24 to 48 hours of
admission) unless the stroke survivor is unresponsive
or medically/neurologically unstable
PROBLEM REHAB
 GANGGUAN GERAK
 GANGGUAN KESEIMBANGAN
 GANGGUAN SENSIBILITAS
 GANGGUAN MENELAN
 GANGGUAN KOGNITIF
 GANGGUAN KOMUNIKASI
 GANGGUAN FUNGSI SEKSUAL
 GANGGUAN BERKEMIH
 GANGGUAN DEFEKASI
 GANGGUAN PSIKIS
 GANGGUAN FUNGSIONAL
FLEXION SINERGY PATTERN
 ADDUCTION AND INTERNA ROTATION SHOULDER
 FLEXION ELBOW
 PRONATION FOREARM
 FLEXION WRIST AND FINGER
PMR Management in a stroke patient

 Acute phase
 Sub acute phase
 Chronic phase

Source : Module
 ACUTE PHASE

Stroke

Goals :
• Prevent complications of stroke
• Prevent complications of immobilization
 Intervention PMR in acute phase ?

- Maintain skin integrity

- Prevent arise sinergic pattern and spastic ↑
- Prevent joint stiffness and shortening of the muscles
- Prevent cardiorespiratory complication
- Contend swallowing function disorder and prevent
aspiration
- Management of communication disorder
- Bowel and bladder management
- Multisensory stimulation

Source : module
 Rehabilitation during the acute
poststroke phase
 Evaluate & manage medical problem
 Monitor and adjust medication
 Maintain hydration & nutrition
 Facilitate rest and sleep
 Venous thromboembolism prophylaxis
 Proper bed and chair positioning
 Frequent turns & position changes
 Range of motion exercises
 Deep breathing and cough exc
 Frequent skin inspections
 Swallowing evaluation
 Safety measures
 Removal of indwelling catheter, if possible, with planned, timbed toileting
program
 Bowel evacuation regimen
 Sitting in chair
 Supervised bedside exc
 Self-performance of ADL
 Mobilization exc
 Standing & gait training as able
 Educational program on stroke, recovery, and personal
care
 Communication evaluation and training
 Psychological support to the patient
 Family education and support
Source : Braddom
SUBACUTE PHASE
 Goals :
- Optimally neurologic recovery and
reorganization process
- Minimize and prevent complications
- Continue the acute phase intervention
- Swallowing function therapy
- Therapeutic exercise :
1. Muscle reeducation approach
2. Neuro-facilitation approach
(Bobath, PNF, Rood, Brunnstrom)
3. Conductive educational approach
4. Motor learning approach
5. Strength training and physical
conditioning
 6. Constraint-induced movement therapy
7. Body-weight support treadmil training
8. Cognitive perceptual therapy
9. Visual imagery approach
- Electrotherapy
1. Electrical stimulation
2. Biofeedback
- Cardiorespiration fitness therapy
- Orthotic
- Assisted walking aids / ADL aids
- Emotion counselling
- Sexual counselling
- Educate to prevent complications
- Group therapy
CHRONIC PHASE
 Goals :
- Optimally functional ability
- Maintain functional ability that had been
achieved
- Prevent complications
- Optimaly quality of life
 Intervention PMR in chronic phase ?
 Adaptation training
 Revocational training
 Counselling and education for resocialization
 Home program to maintain :
- prevent joint stiffness and shortening of the muscles
- fitness training
- activity daily living according to independence level
 Education and training to family/care giver to prevent
complications
Complications ?
 Bronchopneumonia
 Ulcer pressure
 Shoulder subluxation
 Shouder hand syndrome
 Osteoarthrosis
 Osteoporosis
 Neuropatic pain
 Dementia
Prognosis ?
Depend on :
 Large and location of the lession

 Comorbiditas

 Complications

 Motivation of the patient

 Familly support

 Facility dan professional terapist

FUNCTIONAL PROFUNCTIONAL PROGNOSIS
OF STROKEGNOSIS 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
PHYSICAL THERAPY
OCCUPATIONAL
THERAPY
Beberapa contoh alat bantu untuk melakukan aktivitas
kehidupan sehari - hari
 POSITIONING IN STROKE

LYING IN HEMIPLEGI SIDE

LYING IN UNAFFECTED SIDE
LYING ON YOUR BACK
Rehabilitation program
 Sasaran program :
 Mencegah , mengenal dan menangani kondisi-kondisi medik
penyerta stroke termasuk mencegah serangan stroke ulang,
memperbaiki hidrasi dan nutrisi
 Memaksimalkan kemandirian fungsional melalui berbagai
program latihan
 Memfasilitasi terjadinya adaptasi kehidupan psikologis dan
sosial penderita dan keluarga
 Mendorong reintegrasi dalam kehidupan di masyarakat
dan tempat kerja
 Memperbaiki kualitas hidup
 Kapan program rehabilitasi dimulai?
 Program rehabilitasi dimulai sejak masuk rumah
sakit dan ditujukan untuk mencegah terjadinya
komplikasi tirah baring lama
 Program mobilisasi dimulai setelah keadaan
penderita stabil, tidak ada komplikasi dan tidak
ada kondisi medis yang membahayakan jiwa
penderita
Panduan program rehabilitasi
pasca stroke
 Hari 1 – 3 :
 Posisidi tempat tidur yang benar
 Mencegah dekubitus

 Evaluasi awal tentang reflex, tonus dan kekuatan otot

 Mulai latihan pasif luas gerak sendi

 Latihan pernafasan

 Latihan duduk bertahap

Proper positioning
Rehabilitation program
 Sasaran program :
 Mencegah , mengenal dan menangani kondisi-kondisi medik
penyerta stroke termasuk mencegah serangan stroke ulang,
memperbaiki hidrasi dan nutrisi
 Memaksimalkan kemandirian fungsional melalui berbagai
program latihan
 Memfasilitasi terjadinya adaptasi kehidupan psikologis dan
sosial penderita dan keluarga
 Mendorong reintegrasi dalam kehidupan di masyarakat
dan tempat kerja
 Memperbaiki kualitas hidup
Panduan program rehabilitasi
pasca stroke
 Hari 3-7 :
 Latihan duduk
 Mulai latihan berdiri disamping tempat tidur

 Hari 7-14
 Latihan transfer
 Latihan ambulasi bertahap, selalu dimulai dg paralel bar
 Latihan aktifitas hidup sehari-hari
 Latihan komunikasi bila ada gangguan
Panduan program rehabilitasi
pasca stroke
 Minggu 2-3 :
 Latihan ambulasi diluar paralel bar
 Latihan naik turun tangga

 Latihan aktifitas hidup sehari-hari diteruskan

 Latihan bahasa diteruskan

Panduan program rehabilitasi
pasca stroke
 Minggu 3-6 :
 Persiapan program latihan di rumah
 Latihan aktifitas hidup sehari-hari mandiri

 Latihan ambulasi mandiri