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Clinician's Handbook

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The Stroke Rehabilitation Clinician's Handbook is intended to be a learning resource for residents and a useful compliment to the Stroke Rehabilitation Evidence Based Review for clinicians.

The Stroke Rehabilitation Clinician Handbook is intended to be a learning resource for residents and a useful compliment to the Stroke Rehabilitation Evidence Based Review for clinicians. It is a new resource available with the 16th edition update of the Stroke Rehabilitation Evidence Based Review. The content is based on a series of lectures and case studies, and will continually be updated and refined.

The impairments associated with a stroke exhibit a wide diversity of clinical signs and symptoms. Disability, which is multifactorial in its determination, varies according to the degree of neurological recovery, the site of the lesion, the patient's premorbid status and the environmental support systems.
Clinical evidence is reviewed as it pertains to stroke lesion location (cerebral, right & left hemispheres; lacunar and brain stem), related disorders (emotional, visual spatial perceptual, communication, fatigue, etc.) and artery or arteries affected.

Essential to stroke rehabilitation is the accurate diagnosis and management of neurological deficits. Stroke affects the physical, psychological, and emotional health of the patient and often results in long-term disability. As well, stroke severity and location can impact the brain's mechanisms of reorganization and the patient's rehabilitation needs. Effective stroke rehabilitation programs are characterised by an interdisciplinary team working cohesively and closely to provide a comprehensive rehabilitation program for each patient. These programs vary in terms of the types of therapies offered as well as their intensity and duration. There is also a growing interest in outpatient stroke rehabilitation as a less expensive alternative to hospital-based programs. This chapter focuses on post-stroke outcomes and the impact of rehabilitation, as well as outpatient rehabilitation.

Recurrent strokes appear to contribute a disproportionate share to the overall national burden of stroke, principally due to costs associated with long-term disability (e.g. nursing home care and re-hospitalization). The secondary prevention of stroke includes strategies used to reduce the risk of stroke recurrence among patients who had previously presented with a stroke or TIA. This chapter provides information on risk factor management programs, management of hypertension, diabetes, hyperlipidemia, the role of infection, lifestyle modification (diet, smoking, use of alcohol, physical activity) as well as treatment for atherosclerosis and cardiac abnormalities (e.g. atrial fibrillation) and reperfusion techniques.

Rehabilitation techniques of sensorimotor complications post stroke fall loosely into one of two categories; the compensatory approach or the restorative approach. The goal of the compensatory approach towards treatment is not necessarily on improving motor recovery or reducing impairments but rather on teaching patients a new skill, even if it only involves pragmatically using the non-involved side (Gresham et al. 1995). The restorative approach focuses on traditional physical therapy exercises and neuromuscular facilitation, which involves sensorimotor stimulation, exercises and resistance training, designed to enhance motor recovery and maximize brain recovery of the neurological impairment (Gresham et al. 1995).
In this chapter, rehabilitation of mobility and lower extremity complications is assessed. An overview of literature pertaining to the compensatory approach and the restorative approach is provided. Treatment targets discussed include balance retraining, gait retraining, strength training, cardiovascular conditioning and treatment of contractures in the lower extremities. Technologies used to aid rehabilitation include assistive devices, electrical stimulation, and splints.

Upper extremity complications are common following stroke and may be seriously debilitating. Regaining mobility in the upper extremities is often more difficult than in lower extremities, which can seriously impact the progress of rehabilitation. This chapter provides current information regarding upper extremity interventions. Topics include robotic devices for movement therapy, virtual reality technology, spasticity treatment, EMG/biofeedback, transcutaneous electrical nerve stimulation, functional electric stimulation, and hand edema treatment. Neurodevelopmental upper extremity therapy techniques are reviewed along with repetitive/task-specific training, sensorimotor interventions, hand splinting and constraint induced movement therapy.

Risk for developing dementia may be up to 10 times greater among individuals with stroke than for those without. In this chapter, we examine issues around the definition, prevalence and natural history of post-stroke cognitive impairment as well as its clinical consequences. Risk factors for cognitive impairment are reviewed and the association between the treatment of hypertension and prevention of cognitive decline and dementia is explored. Identified treatment interventions include cognitive rehabilitation strategies (for the remediation of attention, memory, and executive functioning and problem-solving), electroacupuncture and TENS, music listening and pharmacotherapy. Reviews of the impact, risk factors, clinical consequences and treatment of both delirium and apraxia post-stroke are also provided. This chapter also reviews the treatment of perceptual disorders following stroke focussing primarily on unilateral spatial neglect (USN). Unilateral spatial neglect has been reported to have a negative impact on functional recovery, length of rehabilitation stay, and need for assistance after discharge.

Medical issues post stroke are those which are within the domain of the doctor and the nurses, but are unrelated to secondary stroke prevention. Not only do these complications occur relatively frequently, but they have also been shown to contribute to poor outcome. As such, an understanding of these disorders is critically important to stroke care and management.
Although the number of potential medical complications is extensive, this chapter will focus on five of the most common and clinically relevant: dysphagia, venous thromboembolism, seizures, and central pain states. Both short-term and long-term complications will be evaluated.

Depression is a common complication post-stroke affecting approximately one-third of patients. The presence of post-stroke depression has been associated with decreases in functional recovery, social activity and cognition. In addition, the presence of mental health disorders following stroke may be associated with increased mortality. This chapter discusses the prevalence, natural history and risk factors for post-stroke depression as well as issues around its assessment and impact on rehabilitation outcomes. Strategies for the prevention and management of post-stroke depression are reviewed.
While the majority of stroke survivors return to live in the community, re-integration may be an enormous challenge. The ability to return to an acceptable lifestyle, participating in both social and domestic activities is important for perceived quality of life. The chapter will also examine issues arising following discharge from hospital care or rehabilitation into the community. These include social support, impact of caregiving on informal carers, family functioning, provision of information and education, leisure activities, driving, sexuality and return to work.