BIODATA :

Nama : Bayu Santoso

Pendidikan : Dokter dari F.K. Unair ( 1972
Dokter Sesialis Rehabilitasi Medik dari Santo Tomas
University, Manila, Philippines
Pendidikan tambahan : Addis Ababa,
Ethiopia ( leprosy rehabilitation) University of London
( Community Based Rehabilitation) Stoke Mandeville Hospital ,
U.K. ( spinal cord injury rehabilitation) St Radboud Hospital,
Nijmegen, Netherland (Electrodiagnostic) New South Wales
University, Sydney ( Hospital Management)
Pekerjaan : Kabag Ilmu Kedokteran
Fisik&Rehabilitasi, FK Unair / RSU
Dr.Soetomo KPS IKFR, FK Unair
Status: Kawin ( 1 isteri, 3 anak, 1 cucu )
Assalamu'alaikum wr. wb.
School of Medicine
Airlangga University
GRAHA AMERTA
The International Wing
Dr. Soetomo General Hospital
Surabaya
Selamat Siang
STROKE REHABILITATION

Bayu Santoso
Department of Physical Medicine and Rehabilitation
School of Medicine, Airlangga University
Dr. Soetomo General Hospital
Surabaya
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
MANAGEMENT OF STROKE :

1. NON-SURGICAL ( Neurology )
SURGICAL ( Neurosurgery )
2. REHABILITATION
Never a simple task / always
complicated
should be a tailor-made program
The first step of Rehabilitation
Medicine Program :

TO ESTABLISH THE
DIAGNOSIS OF STROKE
Haemorrhagic / Non-Haemorrhagic ?
Which cerebral artery is involved ?
WHY THIS IS IMPORTANT ?
1. To anticipate the possible
problems which will be developing
2. To decide the appropriate
rehabilitation medicine strategy
Vertebro- basilar system
( posterior system )

Carotid system
( anterior system )
CAROTID
SYSTEM

VERTEBRO-
BASILAR
SYSTEM
ACA

MCA
ARTERY MAIN PROBLEMS REHABILITATION
STRATEGY

ACA Hemiparesis ( LE>UE) Gait training

Foot drop Orthoses
Hemianesthesia Sensory stimulation
UE Apraxia Language training
Transcortical motor aphasia DH Language training
Mental confusion Psychological counseling

MCA Hemiplegia, UE = LE ( main stem ) Gait and ADL

UE > LE (upper div.)
Hemianesthesia Sensory stimulation
Homonymous hemianopsia Positioning, Ambulation Ex.
Unhibited Neurogenic bladder (Type 2) Bladder training
Dysphagia Feeding exercise
DH : Global aphasia (main stem) Language training
Broca aphasia, Apraxia (upper div.) Language training
Wernicke aphasia Language training
NDH : Aprosody Language training
Visuo-spatial deficit Ambulation training
Neglect syndrome
ARTERY MAIN PROBLEMS REHABILITATION
STRATEGY

PCA Hemiparesis Movement & ambulation Ex.

Homonymous hemianopsia
Ataxia, Tremor, Choreo-athetoid
Sup. sensation deficits
Pain (Dejerine-Roussy Syndr)
Memory deficits
Positioning, Ambulation Ex.
Balance and coord. exercise
Sensory & motor exercise
Cognitive training

V-B Ataxia, Choreiform movements, Motor and sensory Exercises

Horners syndr, Deafness, Language training
SYSTEM Sensory deficits, Dysphagia, Feeding exercise, etc
Dysphonia, Nystagmus.
Hemialternans syndr.: Benedikt,
Parinaud,Weber, Foville, Millard-
Gubler, Raymond-Cestan,
Gasperini
FUNCTIONAL PROGNOSIS 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
GOALS OF REHABILITATION MEDICINE
PROGRAM
1. Preventing complications
2. Teaching new adaptive methods
3. Ensuring that appropriate aids are provided
and used properly
4. Retraining the damaged nervous system
and preventing or overcoming learned
disuse
5. Enhancing Quality of Life
EXTINCTION PHENOMENON

POSITION SENSE
EXERCISE PROGRAM :
1.TRADITIONAL / CONVENTIONAL
METHOD
2.NEURODEVELOPMENTAL /
NEUROPHYSIOLOGICAL METHODS
Brunnstrom
Rood
Bobath
Kabat, Knott, Voss ( PNF )
SENSORY MOTOR INTERACTION
PHYSICAL THERAPY
OCCUPATIONAL
THERAPY
 SHOULDER
SUBLUXATION

BE CAREFUL
for

SHOULDER-HAND
SYNDROME
 GAIT ANALYSIS

SAGITTAL
PLANE

FRONTAL
PLANE
 NORMAL HUMAN LOCOMOTION
a series of rhythmical, alternating movements of extremities & trunk
forward movement of CoG

GAIT CYCLE

STANCE PHASE SWING PHASE

HEEL STRIKE FOOT FLAT MID STANCE PUSH OFF ACCELERATION MID SWING DECCELERATION

0 10 20 30 40 50 60 70 80 90 100
R DS R SS L DS L SS

DS 2 extremities are in contact with ground simultaneously ~ to the cadence

GENERAL CHARACTERISTIC
OF NORMAL GAIT

1. Vertical Displacement of CoG ( 2 inches : MS, DS)

2. Lateral Displacement of CoG (2 inches)
3. Width of the Walking Base (2-4 inches)
4. Horizontal Dip of the Pelvis (5o)
5. Knee Flexion on stance Phase (20o, after HS)
6. Cadence (70-130x/min, av: 90x/min 2.5 miles/h)
 Hemiplegic Gait
Anterior rotation of the
pelvis
Circumduction
Equinovarus foot
Short strides

ENERGY EXPENDITURE
STEPS OF AMBULATION TRAINING
AMBULATION TRAINING
&
GAIT EXERCISES

START LOW, GO SLOW

WALKERS
AXILLARY CRUTCHES

ENERGY EXPENDITURE >>

RAMPS, CURBS,
STAIRS
LANGUAGE PROBLEMS
 R. HEMIPLEGIA vs L. HEMIPLEGIA

LEFT HEMISPHERE RIGHT HEMISPHERE

STROKE STROKE
Language problems Visio-motor perceptual deficits
( APHASIA ) Visual memory deficits
Left sided neglect
Reduced insight
Uncoordinated ADL
Superficial and Deep sensory
deficits
RIGHT HEMISPHERE COMMUNICATION
IMPAIRMENT (RHCI)
1. LINGUISTIC : confrontation naming word fluency
auditory comprehension
dysgraphia
2. NONLINGUISTIC : left neglect
visuospatial deficits impaired processing
in context
3. EXTRALINGUISTIC: Topic maintenance
impulsivity in response Literal
interpretation insensitivity to communication
situation interpreting and producing afective facial
expression interpreting
and producing prosodic features of verbal messages
GESCHWINDS MODEL OF CORTICAL
AREAS INVOLVED IN SPEECH
 Classification of Aphasia
Classification Fluency Comprehen Repetition Naming
sion
Global Poor Poor Poor Poor

Broca Poor Good Varies Poor

Wernicke Good Poor Poor Poor

Conduction Good Good Poor Poor

Anomic Good Good Good Poor

Transcortic- Poor Good Good Poor

al motor
Transcortic- Good Poor Good Poor
al sensory
 Post. Lesion Good Good Naming
Normal / Dysarthric?
Repetition

Good
Poor Naming Anomic (MCA, Angular
Comprehension Poor gyr.)
Repetition
Conduction (MCA,
Fluent Good Arcuate
Repetition
fasciculus)
Poor
Comprehension Poor Transcortical sensory
Repetition
(PCA, Parieto-occipital)
APHASIA Good
Wernickes
Good Repetition Transcortical motor
Comprehension (MCA,Temporal)
Poor ( ACA, Prefrontal )
Repetition
Brocas ( MCA, Frontal
Non-
Good
lobe)
Fluent
Poor Repetition
Comprehension
Poor Mixed transcortical
Repetition
(ACA, PCA, Watershed
Ant. lesion zone)
 Mother
tongue

SPEECH THERAPY
 GOOD
PROGNOSIS

GOOD,
COMPREHENSIVE,
MOTIVATION
WELL-PLANNED
PROGRAM
WC FDR JS
Thank you very much
FLUENCY, COMPREHENSION, REPETITION

1. FLUENCY : a. Fluent : lesion in posterior to the central

sulcus b. Non-fluent :
lesion anterior to the central sulcus
2. COMPREHENSION : a. Oral
comrehension : lesion in MCA distribution
b. Reading comprehension : PCA distribution
3. REPETITION: a. Poor repetition :
MCA lesions b. Good repetition : lesions
outside the language cortex
Dirgahayu
HUT XVIII
RS Pertamina
Balikpapan
Thank you very much
Hari 1-3 :
Posisi di tempat tidur yang benar (proper bed positioning)
Mencegah dekubitus pada tempat-tempat yang menonjol
Evaluasi awal tentang refleks-refleks, tonus dan kekuatan otot
Mulai latihan pasif luas gerak sendi ataupun latihan aktif asistif
luas gerak sendi
Latihan pernafasan
Latihan duduk bertahap

Hari 3-7 :
Latihan pindah tempat (transfer) : kursi roda ke tempat tidur,
kursi roda ke kasur latihan
Latihan ambulasi secara bertahap, selalu dimulai dalam
parallel bars (palang sejajar)
Latihan aktifitas hidup sehari-hari di bagian Terapi Okupasi
Evaluasi psikologik
Minggu 2-3 :
Latihan ambulasi di luar parallel bars dengan alat bantu :
walker atau cane
Latihan naik dan turun tangga
Latiihan aktifitas hidup sehari-hari diteruskan

Minggu 3-6 :
Persiapan program latihan di rumah dengan mengikut
sertakan keluarga
Latihan aktifitas hidup sehari-hari secara mandiri
Latihan ambulasi mandiri