PMR PG Teaching

1. STROKE
Part-2
(Rehabilitation)
Dr. Manik Jamatia
3rd Year Resident, PM&R Deptt.
SMS Medical College, Jaipur
PG Teaching, August 2016

2. Introduction
• Non-traumatic brain injury - occlusion or rupture cerebral blood vessels,
results sudden neurologic deficit characterized by loss of motor control,
altered sensation, cognitive or language impairment, disequilibrium, or
coma
• Two major categories:
₋ Ischemic - vascular occlusion
₋ Haemorrhagic - bleeding within parenchyma of brain
• Resultant neurological deficits generally referred to as impairments, which
may or may not result in functional limitations often characterized as
disability

3. Objectives and Goal
• Objectives
₋ achieve maximum level of functional independence;
₋ facilitate neurological recovery,
₋ minimize disability;
₋ successfully reintegrate back into home, family, and community;
₋ re-establish a meaningful and gratifying life.
• Goals are accomplished through
₋ exercise and other treatments to facilitate recovery and reduce
impairments;
₋ functional training to compensate for residual impairments; and
₋ use of assistive devices, such as braces or wheelchair, to substitute for
lost function.

4. Acute Stroke Management
• Goals of acute stroke management
i. limit or reverse neurologic damage through thrombolysis or neuro-
protection
ii. monitor and prevent secondary stroke complications
• Intravenous thrombolysis with recombinant tissue plasminogen activator
(rTPA), known to be effective when administered to appropriate individuals
within 3 hours of symptom
• Development of effective neuroprotective agent remains one of major goals
in acute stroke care but has thus far not been successful

5. Secondary Stroke Prevention
• Involves a multipronged effort at risk factor reduction
₋ involve behavioural change (exercise, smoking cessation etc.)
₋ dietary modifications to optimize treatment of associated medical risk
factors
• Use of specific medications for stroke prevention
• Antiplatelet medications are appropriate for majority of patients for
secondary prevention of ischemic stroke
₋ Aspirin in doses of 50 to 325 mg provides a reduction in stroke of
approx. 25%
₋ Clopidogrel is another antiplatelet agent with a different mechanism of
action from aspirin
₋ Dipyridamole, generally prescribed as part a fixed dose combination
with aspirin

6. • Warfarin use for stroke prevention is restricted to patients with atrial
fibrillation or other known cardiac or other embolic source, for most
indications, a target INR of 2 to 3 is used
• HMG-CoA reductase inhibitors or statins used for cholesterol-lowering
effect might also have anti-inflammatory effects on vascular intima and lead
to plaque reduction
• Carotid endarterectomy reduces the risk of stroke in those patients with
single or multiple TIAs
• Carotid stenting has been studied as an alternative to carotid
endarterectomy

7. Rehabilitation during the Acute Phase
• Care of stroke survivors is organized in variety of different systems around
world
• Many patients with acute stroke have dysphagia and are at risk for
aspiration and pneumonia
• Protection against aspiration (and resulting pneumonia) includes
₋ avoiding oral feeding in patients who are not alert
₋ even in alert patients, ability to swallow should be assessed carefully
before oral intake
• During acute phase, nasogastric tube feeding or gastrostomy tube
placement may prove necessary
• Patients who are lying flat in bed are at significant risk for regurgitation and
aspiration, and head of the bed should be kept elevated

8. • Impairment of bladder control is frequent following a stroke, which may
initially cause a hypotonic bladder with overflow incontinence
• If an indwelling catheter is used, it should be removed as soon as possible,
with careful monitoring to insure that appropriate voiding resumes
• For occasional patient with persistent urinary retention after stroke, regular
intermittent catheterization is preferable to an indwelling catheter
• Patients with hemiplegia are at high risk for development of contractures
due to immobility
• Spasticity, if present at this early stage, may contribute to the development
of contractures through sustained posturing of the limbs
• Harmful effects of immobility can be ameliorated by regular passive
stretching and moving the joints through a full range of motion, preferably
at least twice daily

9. • Risk of deep venous thrombosis is high, especially in patients with
hemiplegia
• Every patient should, therefore, have some form of deep vein thrombosis
(DVT) prophylaxis, either subcutaneous heparin or external pneumatic
compression boots or both
• Early mobilization is beneficial by reducing risks of
₋ DVT,
₋ deconditioning,
₋ gastroesophageal regurgitation and aspiration pneumonia,
₋ contracture formation,
₋ skin breakdown, and
₋ orthostatic intolerance

10. • Mobilization involves a set of physical activities that may be started
passively but that quickly progress to active participation by the patient
• Specific tasks include
₋ turning from side to side in bed and changing position,
₋ sitting up in bed,
₋ transferring to a wheelchair,
₋ standing, and
₋ walking
• Mobilization also includes self-care activities such as self-feeding,
grooming, and dressing
• Timing and progression in these activities depend on the patient’s condition
• Activities should begin as soon as possible unless the stroke survivor is
unresponsive or medically/neurologically unstable

11. Recovery from Stroke
Early recovery ( Local processes )
- Resolution of post stroke edema
- Reperfusion of ischemic penumbra
- Resorption of local toxins
- Recovery of partially damaged ischemic neurons
Later recovery ( Neuroplasticity ) - Ability of nervous system to modify
structural and functional organization
- Collateral sprouting of new synaptic connections
- Unmasking of previously latent functional pathways
- Reversibility from diaschisis
- Denervation supersensitivity

12. Copenhagen Stroke Study

13. Specific Stroke Impairments and Their
Rehabilitation
• Initial examination of patient with an acute stroke includes thorough
neurologic examination
• Neurologic findings are used by the rehabilitation team for
₋ prognostication,
₋ development of the rehabilitation plan, and
₋ selection of the appropriate setting for rehabilitation
• Reassessment of the patient during rehabilitation provides a means of
monitoring progress and subsequently evaluating outcome

14. Therapeutic Approaches to the Upper Limb
• Referred to as sensorimotor techniques, these treatments encompass a range
of therapies intended to promote motor recovery
• Basic of these approaches include
₋ strengthening, range of motion exercises,
₋ Balance training, and postural control
• A therapeutic technique specifically developed for patients with stroke was
proposed by Brunnstrom
• Bobath developed the therapeutic approach now known as
neurodevelopmental technique
• Task-oriented approach to therapeutic exercise described by Carr and
Shepherd encourages movement during functional tasks

15. Approach Description
Bobath
(1990)
Aims to reduce spasticity and synergies by using inhibitory
postures and movements in order to facilitate normal
autonomic responses that are involved in voluntary
movement
Brunnstrom's
Movement
Therapy
(1970)
Emphasis on synergistic patterns of movement that
develop during recovery from hemiplegia. Encourages the
development of flexor and extensor synergies during early
recovery, assuming that synergistic activation of the
muscle will result in voluntary movement
Proprioceptive
Neuromuscular
Facilitation (PNF)
(Myers 1995)
Emphasis on using the patient's stronger movement
patterns for strengthening the weaker motions. PNF
techniques use manual stimulation and verbal instructions
to induce desired movement patterns and enhance motor
function

16. • Constraint-induced movement therapy (CIMT) is one of recently developed
therapies based on current concepts of neuroplasticity
• Based on theory proposed by Edward Taub
• Use of affected limb can be augmented by forced use of impaired limb
through a process of restraining the intact limb
• CIMT in clinical trials has two general forms
₋ Original CIMT = 90% of waking hrs + 6 or more hrs/day therapy *
2weeks
₋ Modified CIMT = 5h/day * 5days/week + 3h therapy three times/week *
10 weeks
• Participants must have at least partial wrist and finger extension, have
adequate
proximal limb control, and have sufficient balance during limb restraint

17. • NMES refers to electrical stimulation of lower motor neuron or its terminal
branches, causing depolarization of motor neuron and subsequent
activation of corresponding muscle
• Muscle activation via NMES requires an intact motor unit, NMES
applications are well suited for upper motor neuron injury such as occurs in
stroke
• Therapeutic applications have been designed to promote motor recovery,
whereas functional applications have been designed to provide functional
movement during stimulation only
• The term neuroprosthesis refers to functional application of NMES where
the paralyzed limb undergoes stimulation in a coordinated sequence
resulting in functional movement

18. • Robotic therapies for upper limb have also been developed based on
current concepts of neuroplasticity, that is, forced use, massed practice,
shaping, and skill
acquisition
• Robotic therapy’s greatest advantage could be in its capacity to induce
more repetitions of upper limb movement (massed practice) within a given
period compared with therapies based on volitional movement alone
• Robotic devices can induce passive or assisted limb movement that is
typically directed toward a computer-generated visual target
• More advanced iterations of robot can provide tactile feedback that
kinematically corrects user’s movement, promoting movement during skill
acquisition
• Others includes Mental Imagery

19. Therapeutic Approaches to Walking
• Important factors that influence walking ability after stroke include
weakness, balance, coordination, spatial orientation, and cognitive function
• The standard rehabilitation technique for gait training after stroke is to walk
overground
• A very common gait training system is body weight–supported treadmill
training (BWSTT)
• Superior for gait training to neurodevelopmental techniques that use
practice of balance and weight bearing before stepping and walking
• Advanced iterations of the robot can provide tactile feedback that kinetically
and kinematically corrects the user’s movement
• Robotic therapy theoretically promotes movement during skill acquisition

20. Non-invasive Brain Stimulation
• TMS - delivered by passing a strong but brief electrical current through an
insulated coil placed on the skull
• Current induces a transient magnetic field that flows parallel to the coil,
crosses the scalp, and generates an electric current in the cortex,
depolarizing neurons
• TMS has been used in two different ways
• diagnostic tool to assess excitability level of cortical networks
• intervention to induce changes in excitability with ultimate intention of
modulating behavior
• tDCS is applied through two surface electrodes placed on the scalp
• Depending on duration and polarity of stimulation, tDCS can increase or
depress excitability in stimulated region

21. Spasticity
• Motor disorder characterized by a velocity-dependent increase in tonic
stretch reflexes and can contribute to motor impairment, pain, and disability
after stroke
• Managed with exercise therapy, anti-spastic medication or by focal
management with botulinum toxin or phenol injections
• Use of static resting splints for hand and ankle can help prevent
contractures and reduce tone
• Intrathecal baclofen delivered by implanted infusion pump provides
excellent lower limb spasticity control in patients with stroke

22. Cognition, Language, and Communication
Disorders
• Approximately one third to half of stroke survivors experience speech and
language disorders
• Recovery from aphasia usually occurs at slower rate and over more
prolonged time course than does motor recovery
• Language comprehension usually returns earlier and to greater extent than
oral expression
• Goal of speech therapy is to improve the patient’s ability to speak,
understand, read, and write, and to assist patients to develop strategies
that compensate for or circumvent speech and language problems that are
not directly remediable

23. • Selected Treatment Methods for Aphasia
₋ Language-oriented treatment
₋ Direct stimulus–response treatment
₋ Treatment of aphasic perseveration
₋ Visual action therapy
₋ Oral reading for aphasia
₋ Conversational coaching
₋ Promoting aphasic communicative effectiveness
₋ Computerized visual communication (using alternative communication
systems)
₋ Programmatic combinations of approaches
₋ Augmentative communication device

24. • For dysarthria, exercise modalities include
₋ sensory stimulation procedures,
₋ exercises designed to strengthen oromotor speech muscles,
₋ respiratory training procedures, and
₋ retraining of articulatory patterns and sequences of gestures
• Attention problems after stroke are often treated using computerized
activities or “paper and pencil” tasks
• Memory problems after stroke are often treated using cognitive
rehabilitation programs that retrain memory function or teach patients
compensatory strategies to cope despite memory impairment

25. Swallowing and Nutrition
• Dysphagia, occurs in approximately one third to half of all stroke survivors
and places the stroke patient at risk for aspiration and pneumonia,
malnutrition, and dehydration
• Malnutrition was related to length of stay and functional outcome, increased
the risk for infections, pressure sores, and poor outcome
• Compensatory treatments for disordered swallowing function include
changing posture and positioning for swallowing, learning new swallowing
maneuvers, and changing food amounts and textures
• Percutaneous endoscopic gastrostomy feedings can improve outcome and
nutrition in stroke patients

26. Shoulder Pain
• Shoulder pain is common complication after stroke that can inhibit recovery
and reduce the quality of life
• Prevalence of shoulder pain in post stroke hemiplegia ranges from 34% to
84%
• Causes ₋ Brachial plexopathy
₋ Axillary neuropathy
₋ Suprascapular
neuropathy
₋ Myofascial pain
₋ Spasticity
₋ Soft tissue contracture
₋ Capsulitis
₋ Subluxation
₋ Impingement syndrome
₋ Rotator cuff injury
₋ Bicipital tendonitis
₋ Complex regional pain syndrome
type 1

27. • Capsulitis- includes range of motion, avoidance of exacerbating conditions
such as the use of swath-type slings, proper limb positioning, management
of underlying spasticity, and reduction of inflammation with modalities,
medications, or intraarticular injection of steroids
• Impingement - managed by maintaining scapular mobility, using proper
technique during stretch, treating spasticity, and, when possible,
strengthening internal and external rotators of the shoulder, education of
local inflammation through the use of oral agents or injected steroids

28. • CRPS1 - known previously as reflex sympathetic dystrophy or shoulder–
hand syndrome, is a constellation of symptoms
• typically affects the shoulder, wrist, and hand but typically spares the elbow
• Phases
i. Primary inflammatory phase - by painful range of motion, edema,
warmth, and erythema of hand and wrist
ii. Secondary - by atrophic skin changes, progressive loss of range of
motion, reduced skin temperature, and occasionally pain reduction
iii. A final phase - by irreversible skin and muscle atrophy, variable pain,
severe loss of range of motion, and extensive osteoporosis
• Oral prednisone and exercise are the initial treatments
• More invasive measures, such as cervical sympathetic ganglia blocks, Bier
blocks, and cervical sympathectomy, might be warranted in refractory
cases

29. • Central poststroke pain (CPSP) - characterized as constant or intermittent
pain occurring after stroke, which is located in areas of body that have
sensory abnormalities
• Pain described as burning (50%), aching (35%), pricking (20%), or
lacerating (15%)
• Changes in temperature, touch, movement, or emotion can worsen pain,
whereas rest most commonly relieves pain
• Pharmacotherapy for CPSP includes amitriptyline (25 to 75 mg), which
reduced pain - Carbamazepine, Lamotrigine, Gabapentin
• Nonpharmacological approaches such as transcutaneous electrical nerve
stimulation have variable effectiveness

30. Bowel and Bladder Control
• Incontinence of bowel and bladder occurs in one third to two thirds of
patients after stroke and, if it persists, can pose a challenge to preparing
family caregivers for patient’s return to home
• Most common reason for incontinence after stroke is uninhibited
evacuation of bladder or bowel
• Timed voiding is primary treatment strategy for patients with persistent
uninhibited bladder
• Bladder ultrasound post void estimates with good accuracy the residual
volume
• If residuals high (>200 mL), use of α-blocking agents such as tamsulosin in
both male and female patients can promote complete voiding

31. • If voiding is complete, then use of anticholinergic agents such as
oxybutynin can allow for larger bladder volumes before urgency occurs
• Some patients might need both α-blocking and anticholinergic agents to
achieve a timely voiding pattern,
• The use of intermittent catheterization or indwelling catheter is also an
option, depending on the goals of the patient and caregiver
• Bowel retraining can usually be achieved in patients with stroke using
standard techniques of planned bowel evacuation after meals and the use
of laxative agents such as senna and suppositories
• Providing a bedside commode is also useful for patients with mobility
deficits or who have difficulty rapidly accessing the commode within their
home

32. Depression and Psychosocial Considerations
• New onset and persistence of disability can give rise to variety of
psychologic reactions in patients who have sustained a stroke, including
sadness, grief, anxiety, depression, despair, anger, frustration, and
confusion
• Addressing these issues is a critical component of rehabilitation program
• Treatment consists of psychotherapy, psychosocial support, milieu therapy,
and medications
• Antidepressant medication Escitalopram to treat poststroke depression
demonstrated improvement in cognitive functioning
• Serotonin-specific reuptake inhibitor medications are now widely accepted
as effective treatment interventions for poststroke depression

33. • Sexual dysfunction has been reported in 40% to 70% of stroke survivors
• Its cause is largely psychologic
• Issues related to self-esteem, affection, and relationships should be
emphasized, as should specific practical suggestions on positioning, timing,
and techniques
• Dealing with family issues is essential
• Families can experience a variety of emotions, including grief, sadness,
depression, anxiety, and guilt
• Family interventions usually include individual counselling, education, and
support groups
• Peer support is one component of patient care activities that probably
exerts a favourable effect on successful rehabilitation of stroke patient

34. • Presence of other patients with similar disabilities on stroke rehabilitation
unit can assist in
₋ reduce fear and anxiety often associated with new onset of physically
disabling or disfiguring conditions
₋ can counsel and support each other in ways that even well-meaning
and experienced professionals cannot
₋ Finally, patients not only gain insight into their disability but also garner
specific suggestions for functional skill performance or about adaptive
equipment from other patients who have already been through the
experience

35. Management of Medical Comorbidities and Prevention of
Complications in Rehabilitation
• Stroke rarely occurs in isolation
• Most patients with stroke have many other medical comorbidities that can
be categorized as follows:
₋ Pre-existing medical illnesses that necessitate ongoing care during the
rehabilitation program ( hypertension and diabetes)
₋ General health functions affected by the stroke ( nutrition and hydration)
₋ Secondary poststroke complications ( deep venous thrombosis and
pneumonia)
₋ Acute poststroke exacerbations of pre-existing chronic diseases (an
angina attack during physical exercise in a patient with a history of
ischemic heart disease)

36. • Preventing and treating comorbid medical conditions and medical
complications are major components of rehabilitation treatment of stroke
patients because they enable rehabilitation to take place and to exert
maximum effectiveness
• The clinical tasks in managing these problems are to
₋ prevent medical complications,
₋ promptly and appropriately diagnose and treat complications when they
occur,
₋ manage both pre-existing medical illness and ongoing general health
functions during rehabilitation

37. Common Medical Comorbidities and
Complications After Stroke
₋ Seizure
₋ Spasticity
₋ Contracture
₋ Central poststroke
pain syndrome
₋ Falls and injuries
₋ Medication overuse
₋ Poor endurance
₋ Fatigue
₋ Insomnia
₋ Thromboembolic
disease
₋ Pneumonia
₋ Ventilatory insufficiency
₋ Hypertension
₋ Orthostatic hypotension
₋ Angina
₋ Congestive heart failure
₋ Cardiac arrhythmias
₋ Diabetes mellitus
₋ Prior stroke
₋ Recurrent stroke
₋ Urinary tract infection
₋ Bladder dysfunction
₋ Bowel dysfunction
₋ Pressure sore
₋ Dehydration
₋ Malnutrition
₋ Dysphagia
₋ Shoulder dysfunction
₋ Complex regional pain
syndrome Depression
₋ Sexual dysfunction

38. • Physiologic Deconditioning - accompanies both acute medical illness and
prolonged bed rest that might be enforced immediately after its onset
• Contribute to fatigue, endurance limitations, poor exercise tolerance,
orthostatic hypotension, lack of motivation, and depression - can adversely
affect the course of recovery and rehabilitation
• Preventive techniques include
₋ early mobilization,
₋ early and gradually increasing participation in rehabilitation, and
₋ development and implementation of a schedule that balances rest and
activity
• It should be noted that long-term stroke survivors, even those with nearly
full
neurologic recovery, frequently report easy fatigability and endurance
limitations

39. • Venous Thromboembolism - incidence varies between 40% and 50% for
deep vein thrombosis and 10% for pulmonary embolism
• In patients in whom haemorrhagic stroke has been ruled out, repeated
doses of low-dose heparin or low-molecular-weight heparin compounds
have been documented to be effective
• Obstructive Sleep Apnoea - OSA occurs when there are significant apnoea
episodes persisting for more than 10 seconds each, ultimately leading to
decreases in oxygen saturation in blood, and sometimes followed by
sudden arousal
• Principal among the measures used to facilitate normal sleep are
encouraging increased physical activity, provision of psychologic support,
and implementation of steps to enhance sleep hygiene

40. • Falls - occur with striking frequency in stroke survivors, with most reports
indicating that patients who sustain right hemisphere strokes are at
substantially greater risk for falling than those with left
• Prevention approaches emphasize balance training, cognitive training,
safety training (especially with caregivers), ensuring supervision during
mobility activities, eliminating environmental hazards, and use of assistive
devices
• Osteoporosis - at increased risk for long bone fractures from reduced bone
mineral density as a consequence of immobilization
• at risk of frequency of falls,
• use of bisphosphonates, is helpful in people with stroke

41. Specialized Equipments
• Adaptive and durable medical equipment can be used to assist stroke
patients to become more independent and to facilitate functional skill
performance
• It is important to consider patient’s functional level, level of adaptation to
disability, architecture of living environment, and instruction in use of all
devices and equipment
• Many types of devices are available to assist stroke patient in achieving an
improved level of independence
• Includes adaptive devices to assist in the performance -

42. Adapted feeding utensils
₋ Utensils with built-up
handles
₋ Universal cuff
₋ Rocker knife
₋ Non-skid mats
₋ Plate guards or scoop
dishes
₋ Cup holder
₋ Adapted cups
Bathing and grooming devices
₋ Long-handled sponge
₋ Washcloth mitt
₋ Adapted shaving equipment
₋ Handheld shower nozzle
₋ Soap on a rope
₋ Stand-up mirror
₋ Built-up toothbrush, comb,
hairbrush
Tub and shower transfer
equipment
₋ Non-skid mat
₋ Grab bars
₋ Transfer seats
₋ Shower chair or bench
₋ Hydraulic and motorized tub
lifts
Dressing devices
₋ Velcro closures
₋ Button hooks
₋ Long-handled
reachers
₋ Sock donning aid
₋ Long-handled
shoehorn
₋ Elastic shoelaces
Walking devices
₋ Single-point cane
₋ Quad cane
₋ Hemi walker
₋ Standard walker
₋ Rolling walker

43. • Upper limb resting hand splints are usually used to prevent deformity and
to maintain the hemiplegic wrist in a functional, slightly extended position
• For patients with wrist or finger flexion contractures, serial casting of the
upper limb can assist in restoring functional range of motion
• The AFO is frequently provided to improve the positioning of the foot and
ankle and to facilitate an optimal gait pattern
• Type of AFO prescribed depends on the patient’s strength and
biomechanics during walking

44. Caregiver Training
• One of most important interventions is training of families and other
caregivers in specific care techniques to
₋ prevent complications,
₋ perform physical functions, and
₋ encourage patients to perform any activities they are capable of doing
• Training in problem-solving techniques can help family members provide
effective support in the home environment
• Family members serve as members of the rehabilitation team and
participate actively in the rehabilitation process
• In addition to providing psychologic support, they also provide practical
assistance to the patient in the treatment program and preparation for
return home

45. Transition to the Community,
Follow-up, and Aftercare
• The effects of stroke can be enduring, and therefore rehabilitation is a
lifelong activity involving restoration of patients to their fullest physical,
mental, and social capabilities
• For this reason, medical rehabilitation for stroke survivors includes the
many physical, social, and organizational aspects of aftercare of stroke
patients
• Long-term quality of life is accomplished through an interdisciplinary
approach
that includes helping the patient to achieve maximal independent
functioning in daily activities, and training family members and other
personal caregivers in performance of specific physical skills

46. • Major efforts toward preparation for discharge are directed toward securing
community resources
• These include competent and reliable professional or other attendant care,
home nursing visits, outpatient or home therapy, and community
transportation and recreational programs
• Teaching patients about stroke, medications, fluid intake, diet, exercises,
catheter care, feeding tube use, tracheostomy management, signs and
symptoms of common complications such as infections, and specific
functional task performance greatly facilitates a smooth transition to home
and minimizes likelihood of medical problems after discharge
• Follow-up medical monitoring and care are also important

47. Rehabilitation Outcomes
• Functional and Social Outcomes - One of most striking aspects of caring
for stroke patients is common observation that their physical performance,
functional abilities, and quality of life are considerably better after
rehabilitation and during long-term care than immediately after the stroke
• Predictors of Outcome - Potentially important factors includes:
₋ Type, distribution, pattern, and severity of physical impairment
₋ Cognitive, language, communication, and learning ability
₋ Number, types, and severity of comorbid medical conditions and
ongoing health functions
₋ Coping ability and coping style
₋ Nature and degree of family and other social supports Type and quality
of specific rehabilitation training program

48. • The strongest and most consistent predictor of discharge functional ability
is admission functional ability
• Strongest predictors of adverse outcomes are
• coma at onset,
• persistent incontinence,
• poor cognitive function,
• severe hemiplegia,
• lack of return of motor function after 1 month,
• previous stroke,
• visuospatial perceptual deficit,
• unilateral hemineglect,
• significant cardiovascular disease,
• large cerebral lesion, and
• presence of multiple neurologic deficits

49. Conclusion
• Stroke rehabilitation continues to the prototype rehabilitation effort involving
nearly all common rehabilitation problems and requiring effort of all
members of interdisciplinary rehabilitation team
• New scientific evidence on necessity of rehabilitation interventions for
neural reorganization and functional recovery has set a foundation for
stroke rehabilitation research in coming decades
• Application of physical exercise and newer modalities, as well as
pharmacology, surgery, cortical brain stimulation, and robotics, is now
under clinical investigation

50. Reference
• Physical Medicine and Rehabilitation Braddom, 4th Edition
- RANDALL L. BRADDOM MD, MS
• DeLisa's Physical Medicine and Rehabilitation Principles and Practice, 5th
Edition
- Walter R. Frontera, MD, PhD, FAAPM&R, FACSM