National Stroke Association

The National Stroke Association instituted process to certify stroke rehabilitation specialists. clinical stroke rehabilitation specialist (CSRS) ensures that therapists are expert stroke clinicians through a rigorous set of courses and written examination and a nationally recognized credential, the CSRS certification.

Phases of Stroke Rehabilitation

In Stroke Rehabilitation the  patients, under go  hospital-based care (acute care, inpatient stroke rehabilitation, or subacute stroke rehabilitation), outpatient stroke rehabilitation, and home community-based care.

Acute Phase Stroke rehabilitation

Nowadays the acute care hospital stays (average stay is about 5 days). However, early discharge leads to an increase in the number of serious medical complications which is seen during sub-acute rehabilitation or at home.

During acute care, the therapist assists in ongoing monitoring of the patient’s recovery and is alert for changes in the patient’s status (e.g., changes in vital signs [HR, BP, RR], drop in O2 saturation levels, skin changes, alterations in mental status and consciousness).

The goals of the treatment in the acute stage are:

1. Prevent ignorance or unawareness of hemiplegic side.
2. Decrease tendency to develop synergy in chronic stage.
3. Prevention of any joint restriction or stiffness.
4. Prevention of complications due to immobilization like chest complication, deconditioning of bone and muscles, etc.
5. Early weight bearing.
6. Psychological counseling.
7. Education to the family.

 These goals can be achieved through following treatment

Sub acute Phase Stroke rehabilitation

Rehabilitation services are certified by the Commission on Accreditation of Rehabilitation Facilities and the Joint Commission. This consists of inpatient stroke  rehabilitation if the patient can tolerate an intensity of services consisting of two or more rehabilitation disciplines, 6 days a week for a minimum of 3 hr of active rehabilitation per day.

If the patient requires less intensive services, transfer to a transitional care unit within a skilled nursing facility. Here rehabilitation services are less intense, ranging from 60 to 90 minutes of therapy services 5 days per week. In this phase of rehabilitation, more dependent patients may respond well to electromechanical gait training.

Chronic Phase Stroke rehabilitation

Rehabilitation services in the chronic phase are more than 6 months of post-stroke. This consists of an Outpatient stroke rehabilitation facility, in a community setting, or at home. The interventions that are performed in the subacute stage are continued and progress in this phase.

Outpatient services are prescribed for the patient who is discharged from inpatient rehabilitation, is in need of continuing rehabilitation, and can enter and exit the home with ease. Telerehabilitation may be used as a mode of therapy delivery as it has been found comparable to in-person delivery.

The moderate- to high-intensity treadmill training, circuit class, and high dose of repetitive task practice. Those for UE use include constraint-induced movement therapy (CIMT), mental practice, mirror therapy, interventions for sensory impairment, and virtual reality.

Home-based care

Arrangement of the Patient’s Room

Due to the lesion, the patient suffers from sensory deprivation that leads to neglect of the hemiplegic side which can be greatly influenced by patient’s head position. Hence all the forms of stimulus like the entrance to the room, the relatives, television, etc. should be present on the hemiplegic side so that patient is forced to turn to that side which will stimulate awareness of the hemiplegic side

Mobilization and Stretching

Passive exercises should be given of all movements at all the joints for at least 10 repetitions three to four times in a day.

Gentle passive exercises and stretching of various bi-articular muscles should be given as they are very prone to develop tightness. Thus muscles like tendon Achilles, hamstring, quadriceps, adductors, tensor fascia leti, biceps, wrist flexors, etc. should be stretched.

Splints may be given to maintain the body parts.

Weight-bearing Activities

Weight-bearing exercises in stroke rehabilitation are necessary to promote the development of tone in the muscles and also to maintain the absorption of calcium into the bones.

The patient should be given activities like bridging, supine on elbows, sitting with weight bearing on affected arm, and standing should be given as soon as possible within limitation of the patient’s general medical status.

Chest Physiotherapy

Chest physiotherapy in the form of inspiratory breathing exercises should be given to maintain the lung compliance and to prevent any chances of secretion accumulation in lungs .

Oropharyngeal Retraining

Retraining your swallowing and breathing pattern by oropharyngeal exercises such as Tongue-to-palate resistance training (TPRT), Shaker exercise, Tongue-strengthening exercises (TSEs), Chin tuck against resistance (CTAR), Tongue push up and push down and Tongue slide, etc.  We also perform these similar exercises  in Dysphagia.  

How to facilitate the swallowing in Stroke patients?

• Swallowing difficulty can be counteracted by giving a proper positioning and by developing a proper head.
• Avoid Slouched positioning or feeding in the supine position
• Stroking over the neck area
• Ice massaging of the tongue
• Stimulating lip closure is one of the various techniques

Counseling

If the patient becomes depressed over the period, the therapist should try and motivate the patient. The therapist should have a very cheerful and confident attitude, which will help the patient in keeping a high morale.