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Stroke Assessment & Rehabilitation

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Stroke Assessment & Rehabilitation

Stroke is also known as Cerebrovascular Accident. This results in the sudden death of the brain cells due to the O2 deficiency when the blood flow to the brain is lost by obstruction/rupture of cerebral arteries which supplies to the brain. Stroke prevention requires the management of the many risk factors important to stroke development. It is important to diagnose stroke as early as possible to reduce the risk of more damage and functional loss. Stroke recovery is an inhomogeneous process, therefore, it is challenging to predict the actual post-stroke outcomes which assure a holistic approach. Rehabilitation can be provided in inpatient or outpatient departments to stroke survivors.

Stroke is also known as Cerebrovascular Accident. This results in the sudden death of the brain cells due to the O2 deficiency when the blood flow to the brain is lost by obstruction/rupture of cerebral arteries which supplies to the brain. Stroke prevention requires the management of the many risk factors important to stroke development. It is important to diagnose stroke as early as possible to reduce the risk of more damage and functional loss. Stroke recovery is an inhomogeneous process, therefore, it is challenging to predict the actual post-stroke outcomes which assure a holistic approach. Rehabilitation can be provided in inpatient or outpatient departments to stroke survivors.

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Stroke Assessment & Rehabilitation

  1. 1. STROKE HIMANI KAUSHIK
  2. 2. Stroke: • Also known as Cerebrovascular Accident (CVA) • Results in the sudden death of the brain cells due to the: O2 deficiency when the blood flow to the brain is lost by obstruction/rupture of cerebral arteries which supplies to the brain1. • Loss of neurological functions, lasting more than 24 hours or leading to death.
  3. 3. • CVA is distinguished from transient ischemic attack2: TIA defined as a temporary interruption of blood supply to the brain may last for few minutes to 24 hours with no evidence of infarction. • Residual neurological deficits are those that persist longer than 3 weeks3. • Reversible ischemic neurological deficits are resolve spontaneously as brain swelling subsides, generally within 3 weeks3.
  4. 4. • Worldwide, stroke is the 2nd leading cause of mortality rate and the 3rd leading cause of disability1. • Globally, 70% of CVA and 87% of both CVA related mortality rates and disability adjusted life year (DALY) occur in low and middle income territories1.
  5. 5. Types and Pathology of Stroke • The pathology and etiology of subtypes of stroke vary among populations of different age, race, ethnic origin and nationality.
  6. 6. Ischemic stroke2,4: • Most common type of stroke, affecting about 87% of all stroke cases. • Caused by thrombus, emboli, impaired cerebral blood flow and lack of essential oxygen and nutrients. • Etiologically, subtypes of ischemic stroke are classified: i. Acc. to the TOAST classification, ii. ASCOD phenotyping system: (A: atherosclerosis, S:small vessels disesase, C: cardiac conditions, O: any other causes, D: dissection (i.e. cryptogenic)), iii. and the causative classification system.
  7. 7. Hemorrhagic stroke2,4: • When abnormal bleeding occurs into the extravascular areas of the brain, results from the rupture of cerebral blood vessels or trauma. • Affecting about 13% of the all stroke cases. • The most common causes are: hypertension (30-60%), cerebral amyloid angiopathy (10-30%), anticoagulations (1-2%) and vascular structural lesions (3-8%) and undetermined causes (5-20%). • It is classified according to its anatomical site or expected etiology. The most common sites of intracerebral hemorrhage (IH) are: supraperitoneal (85-95%), including deep (50-75%) and lobar(25-40%).
  8. 8. Risk factors5 • Risk factors are: i. Modifiable (diet, PA, smoking, obesity, HTN, etc.) ii. Non-modifiable (age, gender, genetic etc.) • Stroke prevention requires management of the many risk factors important to the stroke development.
  9. 9.  Hypertension: • Most common modifiable risk factor for stroke • The specific target for BP less than 140/90mmHg in patients with an ischemic stroke and 130/80mmHg for lacunar strokes  Hyperlipidemia: • Narrowing and hardening of artery.
  10. 10.  Diabetes mellitus and metabolic disorders: • Are at higher risks for recurrent ischemic stroke and for the occurrence of new TIA cases • Metabolic disorders increases chances of 1.5 to 2.3 times in women  Obesity: • one of the risk factor of ischemic stroke • with every one unit increase in body mass index (BMI), increases chances about 5%  Another important risk factors for stroke is cardiovascular disease that represents multiple components
  11. 11.  Cigarette smoking, tobacco and alcohol consumption significantly increases the two times more chances of the stroke.  Prevalence of sedentary lifestyle is reported to be: • 31.5% in women, • 28.5% in men and • increased with age about 50%  Women with early menopause increases two times more chances of ischemic stroke as compare to women with late menopause.
  12. 12. Syndromes of Stroke • Syndromes of the stroke depends on the: i. site of the occlusion, ii. size, iii. nature and iv. availability of the collateral blood flow • And, symptoms may depend on the rapidity of the occlusion of cerebral blood flow .
  13. 13.  Anterior cerebral artery syndrome6: Areas Involved Clinical Presentation Anteromedial caudate nucleus, anterior limb of the internal capsule and anterior perforated substance Damage of B/L corticopontine fibers and lower limb strip Frontal lobe or posterolateral parietal lobe B/L ACA infarct Posteromedial superior frontal gyrus Contralateral face and lower limb weakness Homolateral ataxia and crural hemiparesis Alien hand syndrome Glabellar tap, utilization behavior, graping and anoyher primitive reflexes Urinary incontinence
  14. 14.  Middle cerebral artery syndrome7: Areas Involved Clinical Presentation Primary motor cortex, somatosensory cortical area and internal capsule Lateral inferior frontal lobe (Broca’s area) Superior temporal gyrus (wernicke’s area) Lateral inferior frontal lobe and superior temporal gyrus Contralateral face, trunk and upper limbs weakness and sensory loss Speech production and language comprehension Auditory comprehension and language development Global aphasia
  15. 15. Areas Involved Clinical Presentation Frontal cortex Brodmann area 8 Lacunar infarcts of MCA Right side hemisphere (non-dominant) Parietal lobe Premotor and primary cortex Ipsilateral eye deviation is observed, impairing planning of eye movement and contralateral homonymous hemianopia It is involves purely motor functions Hemi-neglect syndrome, apraxia, anosognosia, and hemi-spatial neglect Ataxia of contralateral lobe (sensory loss) Limb kinetic apraxia
  16. 16.  Posterior cerebral artery syndrome8: Areas Involved Clinical Presentation Unilateral infarct if occipital lobe and primary visual cortex Infarction of temporal lobe involving Meyer loop and inferior parietal lobe supracalcarine Posterior choroidal artery occlusion Inferior occipital areas, occipital areas, fusiform gyrus and anterior temporal cortex Contralateral homonymous hemianopia with macular sparing Quadrantanopia Visual deficits, neuropsychological impairments and hemisensory deficits Prosopagnosia
  17. 17. Areas Involved Clinical Presentation Parietal lobe Posterior part of corpus callosum and dominant calcarine Lesion of inferomedial B/L temporal lobes or dominant side Non-dominant or B/L primary visual areas Ventral posterolateral nucleus of thalamus 3rd nerve and cerebral peduncle of midbrain Visual agnosia Dyslexia, without agraphia, anomia and problem in color discrimination Memory defect Topographic disorientation Pain, dysesthesias, sensory loss Weber’s syndrome
  18. 18. Areas Involved Clinical Presentation Subthalamic nucleus and pallidal connections Cerebral peduncle of midbrain Supranuclear fibers of 3rd CN Involuntary movements, intentional tremors, hemiballismus, choreoathetosis Contralateral hemiplegia Paresis of vertical eye movement, slight miosis and ptosis and sluggish pupillary eye response
  19. 19.  Vertebrobasilar artery syndrome9: Areas Involved Clinical Presentation Mid basilar artery (Pontine ischemia) (locked-in syndrome) Intrcranial vertebral artery (lateral medullary ischemia) Quadriplegia, anarthria, preserved conciousness, ipsilateral CN 7 palsy, hemiparesis, hemiataxia, occulomotor defect, arm posturing Wallenburg syndrome: decrease in pain/temp. sensation on the ipsilateral face and contralateral body, horners syndrome, limb ataxia, hoarse voice, dysphagia. Dizziness Diplopia
  20. 20. Areas Involved Clinical Presentation Distal basilar artery (rostral midbrain / thalamic ischemia) Origin of extracranial vertebral artery (cerebellar ischemia) Comatose state, defective gaze, hemiparesis and hemiataxia, diplopia, speech difficulties, altered mental status, small poorly reactive pupils, weakness, ataxia. Dizziness, blurred vision, ataxia, vomitting
  21. 21. • Wake up stroke: it is defined as the ischemic stroke that is associated with neurological symptoms on awakening that were not present prior to falling asleep. {Jenny, et al; 2017}, {Mark N. Rubin et al; 2015} • Watershed stroke: it is also known as border zone infarcts involves the junction of the two distal fields of two non-anastomosing arteries, evolve in hemodynamic risk zones. Accounts for up to 10% of cerebral infarcts. {Ina Juergenson et al; 2011}
  22. 22. • Young stroke: is the stroke occurs in those patients who are younger than the 40 or 49 years. Young stroke results in devastating of productive years and impact on QOL of young person’s (Risk factors like dyslipidemia, smoking, HTN and genetics). {Smajlovic, 2015},{Dayna Griffiths et al; 2011} • Brainstem stroke: almost 10% of ischemic stroke leads to the brainstem strokes affect the pons more commonly than the midbrain or medulla. Brainstem hemorrhage are due to ischemic events and hypertension is the most common cause. {A. Ortiz de Mendivil et al; 2013}
  23. 23. • Silent brain infarction: it is often incidentally detected in patients during MRI evaluations. SBI can contribute to the cognitive dysfunction, dementia, and increased overall mortality. {Ajay Gupta et al; 2017} • Cryptogenic Stroke: it is defined as obscure or unknown origin of cerebral ischemia. The cause of cryptogenic stroke is undetermined because some causes truly remain unknown these are transitory or reversible. {Josef Finsterer, 2010}
  24. 24. • Lacunar infarction: are small subcortical lesions with a size less than 15mm in diameter, caused by penetration of large cerebral artery, most commonly which forms the circle of willis. Most commonly occurs in MCA and distal basilar arteries. {Prashanth et al; 2019}.
  25. 25. Cortical Homunculus
  26. 26.  Hemispheric differences following of stroke3: Right Hemisphere Left Hemisphere Left side hemiplegia/paresis and sensory loss Visual perceptual impairments Behavioral deficits (quick, impulsive, poor judgment, inability to self control) Intellectual deficits (difficulty in abstract reasoning, problem solving, ridity of thought, memory impairment) Right side hemiplegia/paresis and sensory loss Speech and language impairments Behavioral deficits (slow, cautious, disorganized, often very aware of deficit) Intellectual deficits (disorganized problem solving, difficulty in initiating task, highly distactible)
  27. 27. Emotional deficits (difficulty to perceive emotion and express negative emotion) Task performance (fluctuations) Emotional deficits (difficulty to express positive emotion) Task performance (apraxia)
  28. 28. Neurological Impairments and Associated Problems
  29. 29. • Altered level of consciousness • Speech and language impairments • Dysphagia • Cognitive dysfunction • Sensory and motor deficits • Emotional dysregulation • Hemispheric altered behavioral differences • Perceptual dysfunction • Seizures • Bowel and bladder dysfunction • Cardiorespiratory dysfunction • DVT and Pulmonary embolus • Osteoporosis and fracture risk • Orthostatic hypotension • Pressure sores
  30. 30. Medical Diagnosis of Stroke2,3 • It is important to diagnose stroke as early as possible to reduce the risk of more damage and functional loss.
  31. 31. • Accurate history obtained from the patient or if the patient is unconscious or uncommunicative then from the family about the onset of neurological symptoms is necessary. • Typical symptoms of stroke include sudden unilateral weakness, numbness, visual loss, diplopia, altered speech, ataxia and non-orthostatic vertigo. • Associated symptoms like severe headache (worst headache of my life) in the cases of subarachnoid hemorrhage. An embolus occur rapidly without any warning signs.
  32. 32. • Diagnostically, the FAST (face, arm, speech, time) test aids screening for stroke. It is sensitive and specific test for the recognition of stroke in the emergency units. • The physical examination of the patient includes an investigation of vital signs (HR, B.P., RR, body temp. and SPO2).
  33. 33. • Cerebral imaging is the important tool for diagnosis and to rule out the ischemic, hemorrhagic and other CNS pathologies10. • Non-contrast CT scans has near perfect sensitivity to detect the fresh intracranial hemorrhagic stroke but its sensitivity is poor in detecting the ischemic stroke if it is recent, small and in the posterior fossa10. • Diffusion weighted MRI detects acute ischemic stroke in about 90% of patients and about third of patient with transient symptoms less than 24 hours.
  34. 34. Figure: A: axial CT scan shows right side MCA infarct with hemorrhagic transformation transformation and midline shift to the left side.
  35. 35. • CT angiography are more readily available is a minimally invasive study requires a intravenous contrast. This provides the clear images of cerebral blood vessels. This allows for accurate diagnosis and decisions in the clinical arena10. If CT angiogram reveals an occlusion of a major blood vessels within the 3 hours time limit, then it allows to administer the tPA more confidently in the case of stroke.
  36. 36.  MR angiography in the setting of stroke to help in decision making. It can be detect high grade atherosclerotic lesions in neck and brain and also helpful for less common ischemic stroke such as vertebral and carotid artery dissection10.  Transcranial doppler sonography examination of the head and doppler imaging of carotid vessels are helpful in evaluation of stroke. This is used for unstable patients and patients who are not eligible for MRI and CT scans10.
  37. 37.  Digital subtraction angiography is the gold standard for the diagnosis of many cerebrovascular disease. It is a x-ray of carotid artery with a special dye injected into an artery thru the femoral artery. Useful tool to detect the blood flow thru the constricted vessels and delayed filling of capillaries. It is useful for treatment purposes10.  Acc. to cochrane study first assessment of the stroke must be completed in the first 48-72 hours.
  38. 38. Management of Stroke • Recent recommendations for the acute stroke management based on the diagnosis of ischemic and hemorrhagic stroke using computed tomography (CT) scans. • It requires multiple health care specialties and multiple approaches, depending on the mature of the patient’s deficits.
  39. 39. Patient Consultant specialist doctor Associated physicians Neurologicat physiotherapist / occupational thaerapist Family members or care givers Social support Speech and language therapist Nursing staff Psycholo gist Dietecians Neurosurge ons team
  40. 40.  GOALS: • To improve cerebral perfusion • Maintain adequate oxygenation • Maintain adequate blood pressure • Maintain sufficient cardiac output • Restore fluid and electrolyte balance • Maintain blood glucose level • Control ICP, edema, seizures, infections and herniation • Maintain cognitive skills • Maintain bowel bladder functions and reduce risk of DVT • Maintain skin integrity, joints and functional activities
  41. 41.  Drugs used: • Thrombolytics11: (Alteplase (rtPA)) • Anticoagulants11: (warfarin, heparin) • Antiplatelet therapy11: (aspirin, clopidogrel) • Antihypertensive drugs12: (Angiotensin II- inhibitors, calcium channel blockers, diuretics, ACE-inhibitors, beta- blockers) • Antispasmodics13: (baclofen, dantrolene, tizanidine, tolperisone, alcohol, phenol, botulinum toxin)
  42. 42. • Anticonvulsants14: (carbamazepine, chlonazepam, clobazam, ethosuximide, gabapentin, phenytoin, zonisamide, lamotrigine, vigabtrin and diazepam) • Antidepressants15: (paroxetine, fluoxetine (also used for motor recovery)) • Anticholesterol agents16,17: (statins)
  43. 43.  Intravenous thrombolysis18 (IV) with recombinant tissue plasminogen activator (rtPA) recommended within 3 hours to 4.5 hours of symptom onset increases the chances of functional independence at 3 months by one-third. In the first 90 minutes after stroke it is more beneficial. • IV rtPA patient requires a BP to be <185 mmHg systolic and <110 mmHg diastolic before the 24 hours of treatment and to the first 24 Hours of the treament. • Hemorrhage is the most common complication after the thrombolysis.
  44. 44. • Contraindications18: Severe head trauma within 3 months Severe ischemic stroke within 3 months Hemorrhage Previous history of hemorrhagic stroke Pediatric and younger than 18 years patiens Pregnancy AVM and aneurysm
  45. 45.  Mechanical Thrombectomy19,20: • It is effective treatment modality for anterior large vessels occlusions in acute ischemic stroke recognized as a standard care. Thrombectomy may be reasonable within the first 6 hours of symptom onset but also indicated carefully up to the 24 hours of symptoms onset. It is not recommended for the patients who are more than the 80 years of the age. • This approach significantly helps in improving the functional outcomes and quality of life of the patients.
  46. 46.  Decompressive Craniectomy21: • It is a old concept i.e. surgically opening the skull to relieve raised intracranial pressure (ICP). It is a good treatment approach for malignant stroke in all the age groups. It is recommended within the 72 hours of the onset of the symptoms. • Surgical complications of DC can occur at any phase which is classified as early and late phase complications. For e.g. hemorrhage, CSF infections and disturbance, seizures. General complications like DVT, UTI and pneumonia.
  47. 47. Physiotherapy Assessment and Management of Stroke • Stroke recovery is inhomogeneous process therefore it is challenging to predict the actual post stroke outcomes which assure a wholistic approach. Rehabilitation can be provided in in-patient or out-patient departments to the stroke survivors. • Framework of recovery post-stroke divided into: hyper acute phase (0-24 hours), acute phase (1-7 days), early sub-acute phase (7 days – 3 months), late sub-acute phase (3-6 months), chronic phase (lasting more than 6 months) and some exceptions are always present.
  48. 48. Figure shows: Framework of biological recovery of stroke patients. .
  49. 49. Environmental factors Personal factors Most relevant categories that are affected after stroke acc. to ICF model Contextual factors
  50. 50. Examination • History, observation and examination all plays an important role in deciding the rehab program of stroke patients. It gives us the clear picture or idea of the patients impairments and help us to plan the treatment according to the patients requirements.
  51. 51. Outcome Measures These are used for: • Assessment purpose • Designing a treatment • Re-evaluation (for recovery)
  52. 52.  Higher mental functions:(using GCS scale as a gold standard or MMSE or NHISS scale) • Consciousness • Orientation • Memory • Attention • Speech  Cranial nerve integrity  Sensation • Superficial sensation • Deep sensation • Combined cortical sensation
  53. 53.  Reflexes • Superficial reflexes • Deep tendon reflexes • Pathological reflexes  Motor functions • Muscle tone (flaccid or spastic (using modified ashworth scale) • Range of motions • Synergy patterns (using VMC scale) • Limb girth  Posture control and balance • Check perceptual (pusher) syndrome • BBS • FRT or mFRT • Time Up Go Test • Trunk impairment scale
  54. 54.  Coordination function: • Equilibrium or Non-equilibrium tests  Gait and locomotion: • Functional gait assessment • Dynamic gait index  Integumentary integrity • Grading of pressure sores  Cardio-respiratory function: • Type of breathing pattern • Chest expansion • Cough effectiveness
  55. 55.  Bowel and Bladder function (spastic or flaccid)  Functional capacity • Fugl-Meyer Assessment of Physical performance (FMA) • Stroke Rehabilitation Assessment of Movement (STREAM) • Stroke Impact Scale (SIS) • Motor assessment scale (MAS) • Barthel index (BI) • Functional independence measure (FIM)
  56. 56. PT Treatment Goals • Physiotherapy focused to maintain preserved functionality, strength, improve limb functions, activity of daily living, and quality of life of an individual and decreases the stay duration of the stroke survivors in the hospitals.
  57. 57. SHORT TERM GOALS • To improve cognitive functions • Reduce of risk of secondary impairment • To maintain pulmonary functions • To reduce pain • To maintain mobility • To improve transfers • Sensory and motor re-education • Patient and caregivers counseling • To reduce spasticity LONG TERM GOALS • To improve mobility • To improve muscle strength • Improve balance • To improve gait functions • Independence in self-care and ADL’s • To improve QOL
  58. 58. Hours: medical Hours to days: early mobilisation Days to weeks: restoring impairments in order to regain activities Days to months: task oriented training with adaptive learning and compensation strategies and specific rehabilitation techniques Weeks to months: environmental adaptations and home care Months to years: maintenance of physical condition and improving QOL Hypothetical: Pattern of recovery post-stroke with time
  59. 59. Different Techniques of PT Treatment
  60. 60.  EARLY MOBILIZATION22,23: • Early mobilization (in-bed or out-bed) has been an important part of acute stroke care unit. • Patients are mobilized out of bed during hospital stay shows an improvement in neurological functions, decrease muscles disuse, improved muscle strength, reduced complications and improves the functional independency. • The time spent of upright position or out of bed is gradually increased throughout the hospital stay of the stroke patients.
  61. 61.  CONSTRAINT INDUCED MOVEMENT THERAPY24: • CIMT was designed to overcome upper extremity (UE) impairments poststroke. This intervention is used for stroke patients to improve UE functions. Modified CIMT (mCIMT) has also been used for the patients of the stroke. • The original CIMT is a form of therapy that includes 3 components: 1) wearing a padded glove in non-paretic hand for the 90 % of waking hours, 2) functional training with high numbers of repetition for at least 6 hours per day, 3) behavioral methods designed to involve patient in his real-world environment activities. • mCIMT does not consists of 3 components but based on the repetitive, functional training of the paretic hand and non-paretic hand is constrained with the padded glove.
  62. 62.  MIRROR THERAPY (MT)25: • Poststroke paresis or paralysis of the one side of the body is commonly occurs which frequently cause problems in ADL’s. • MT is one of the modality used for the stoke patients to improve the motor functions of the paretic side of the body within the 6 months poststroke. In this mirror is placed in the patients mid- sagittal plane so that the image of a moving non-paretic side gives the illusion of normal movements in the paretic side of the body. Different areas of the brain for movement, pain and sensations are stimulated by this MT but still the working of MT is unclear.
  63. 63.  TASK TRAINING26: • Task training involves the active training of functional tasks and it is a component of recent therapy approaches in stroke rehabilitation. • Stroke can cause problems with upper limb and lower limb functional movements of either side of the body. • Repeated task training is a part of rehab protocol used to help in recovery of functional ability after the stroke, like when we learned any of the activities for the first time e.g. writing, eating, dressing, walking etc. • People who practiced functional tasks showed a small improvement in upper limb activities, lower limb activities and functional ambulation.
  64. 64.  FUNCTIONAL ELECTRICAL STIMULATION27,28: • FES is one of the interventions which are used in stroke rehabilitation with aims to improve sensory functions, muscle strength and endurance, gait, hand functions, prevent shoulder subluxation and reduce spasticity. • FES is an effective treatment therapy in order to improve functional activities of the stroke patients and significant results are obtained from FES when applied within the 2 months of stroke optimal results have been found when FES is used in stroke rehabilitation program.
  65. 65.  EMG BIOFEEDBACK29,30: • EMG biofeedback is one of the interventions which are used to improve the functional tasks and motor learning in the rehabilitation of stroke. EMG biofeedback is used in combination with the conventional therapy for improving ADL’s and functional activities of upper extremity and lower extremity.
  66. 66.  TREADMILL TRAINING31: • Treadmill training is used in rehabilitation after the stroke and might help to improve the gait functions of the stroke patients. • Treadmill training is used in two ways i.e. with or without the body weight support using a harness. After the stroke patients had some gait impairments and many could leave with these impairments and not able to walk independently or without any assistance.
  67. 67.  VIRTUAL REALITY32: • Virtual reality is a new intervention which includes video games in stroke rehabilitation with commercial gaming in clinical setups to increase spent time for the therapy. • Virtual reality may be helpful in improving functional activities and ADL’s when used as an adjunct care. After stroke many patients have difficulty in proprioceptive and cognitive functions. Virtual reality is an interactive treatment including video game therapy provided to patients after the stroke. • This protocol based on computer programs designed to stimulate real world. This type of therapy is more motivating, interesting and interactive sessions for stroke patients.
  68. 68.  ROBOTICS33: • Robots are used in rehabilitation of stroke as an innovative therapy. Robotic devices used as assisted devices to carry out the tasks simple and consistent. Robots are designed or capable to program the repetitive physical activities without fatiguing the muscles. • Robotics is technology based intervention or incorporates with the software to record the functional tasks and provide visual feedbacks. Robots as exercise devices are used in current scenario of the stroke rehabilitation. • Robots assist the movements to improve the muscle power and mobility of the stroke survivors.
  69. 69.  MUSCLE STRENGTHENING34: • Muscle weakness is commonly occurs after the stroke and can result in a reduced physical activity. This muscle weakness causes the imbalance in the muscular activities and results in postural asymmetry, balance and coordination problems and gait disturbance. • Strengthening protocols includes the resistance training, aerobic training, task specific training and functional electrical stimulation. Muscle strengthening exercises shows the slight improvement in muscle strength, mobility, functional activities, balance and gait after the stroke. • A low level of aerobic and endurance exercise training shows better results in muscle strength, mobility and quality of life as compare to the high intensity training.
  70. 70.  PHYSICAL FITNESS TRAINING35: • Physical fitness levels vary among everybody and it is important for all of us to carry out ADL’s such as walking, stair climbing. • Physical fitness levels are decreased after the stroke and it may reduce their ability to perform ADL’s and worsens stroke related disability. Because of this reason fitness training has been approached as a beneficial intervention for stroke patients. • Physical fitness training comprised of cardio-respiratory (endurance) training, resistance (strength) training and mixed training interventions which is a combination of cardio- respiratory and resistance training. Cardio-respiratory training and mixed training improved the walking speed, walking endurance and slightly improves the balance at the end of the intervention.
  71. 71.  FAMILY AND CAREGIVERS SUPPORT36: • Family/caregivers plays an important role for the poststroke treatment plan. Stroke increases the burden on the families/caregivers which leads to the depression and distress. • Families/caregivers and stroke survivors both sustain a significant impact on their psychosocial health. • Some education programs are organized for the family/caregivers and stroke patients to provide supportive knowledge and information for solving their problems which helps to improve the quality of life and decrease the burden.
  72. 72.  KNOWLEDGE AND ATTITUDE TOWARDS STROKE37: • The spread of knowledge about stroke risk factors and warning signs is important to prevent stroke morbidity and mortality rates. • Educational programs organized in the communities thru media, advertisements, etc. to enhance an awareness among the population. It has been shown that increasing stroke knowledge with means of public resulted in shorter time presentation to the emergency departments following stroke. • Public education promoting awareness changes the attitude towards the stroke and increase seriousness of stroke management, thereby reducing the burden of stroke among Indians and other developing countries.
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