What are the principles of rehabilitation after a basal ganglia (basal ganglia) stroke?

Rehabilitation Principles After Basal Ganglia Stroke

Multidisciplinary rehabilitation, including regular team meetings and discharge planning, should be performed to improve functional outcome and reduce morbidity and mortality in patients with basal ganglia stroke. 1

Core Principles of Rehabilitation

Timing of Rehabilitation

• Begin rehabilitation between 24-48 hours after stroke onset, but NOT within the first 24 hours 1
• Very early and intense mobilization within the first 24 hours is harmful and associated with lower likelihood of good recovery 1
• Early rehabilitation (24-48 hours post-onset) should include ADL training, stretching, and functional task training 1

Rehabilitation Team Structure

• Treatment should occur on a specialized, geographically defined stroke rehabilitation unit 1
• The interprofessional team should include:
  • Physicians (including physiatrists)
  • Nurses
  • Physical therapists
  • Occupational therapists
  • Speech-language pathologists
  • Social workers
  • Dieticians 1

Assessment and Planning

• Initial assessment by rehabilitation professionals should occur within 48 hours of admission 1
• Use standardized, valid assessment tools to evaluate impairments, functional limitations, and participation restrictions 1
• Conduct at least one formal interprofessional team meeting weekly to discuss progress, problems, goals, and discharge planning 1

Intensity and Duration

• Provide three hours per day of direct task-specific therapy, five days a week 1
• More therapy results in better outcomes 1
• Optimal dose appears to be 30-60 minutes per day, 5-7 days per week 2

Specific Rehabilitation Approaches

Motor Recovery

1. Task-specific practice:

   • Focus on repetitive, meaningful activities 1
   • Circuit class therapy with overground walking practice 1
   • For patients with difficulty standing, provide activities that challenge balance 1

2. Upper extremity rehabilitation:

   • For patients with some active wrist and finger extension, provide constraint-induced movement therapy 1
   • Consider mirror therapy for patients with severe paresis 1
   • Practice reaching beyond arm's length while sitting with supervision 1

3. Lower extremity rehabilitation:

   • Practice standing up for those with difficulty 1
   • Consider rhythmic auditory stimulation for improving gait parameters 1
   • Provide progressive resistance training that is meaningful, engaging, and goal-oriented 1

Dysphagia Management

• Regular monitoring and reassessment of swallowing function 1
• Early implementation of behavioral approaches:
  • Swallowing exercises (e.g., shaker exercises, chin tuck against resistance)
  • Environmental modifications
  • Safe swallowing advice
  • Appropriate dietary modifications 1
• Ensure good oral and dental hygiene 1

Communication Disorders

• Speech and language pathologist evaluation for communication and related cognitive disorders is strongly recommended 1
• For post-stroke basal ganglia aphasia, which can occur in up to 22% of cases, consider:
  • Speech rehabilitation
  • Possible transcranial magnetic stimulation as an adjunctive therapy 3

Prevention of Complications

Skin Care

• Regular skin assessments using objective scales (e.g., Braden scale) 1
• Minimize skin friction and pressure, provide appropriate support surfaces 1
• Regular turning, good skin hygiene, and use of specialized mattresses and cushions 1

Deep Vein Thrombosis Prevention

• Early mobilization (walking at least 50 feet daily when possible) 1
• Consider subcutaneous low-dose unfractionated heparin 1
• Use intermittent pneumatic compression devices and compression stockings 1

Mental Health Support

• Screen for and treat depression, which adversely affects recovery 4
• Consider SSRIs which may benefit motor recovery beyond their antidepressant effects 4
• Provide education and support for emotional adjustment 1

Patient and Family Involvement

• Include patients, family, and caregivers as essential members of the rehabilitation team 1
• Provide formal and informal education to patients and caregivers 1
• Implement person-centered, collaborative goal setting that is clearly communicated, documented, and regularly reviewed 1

Common Pitfalls to Avoid

1. Starting mobilization too early (within first 24 hours) can worsen outcomes 1
2. Failing to provide sufficient therapy intensity (aim for 3 hours/day, 5 days/week) 1
3. Not addressing dysphagia early, which can lead to aspiration pneumonia
4. Overlooking depression, which significantly impacts recovery 4
5. Using fluoxetine solely to enhance functional status in patients without depression (not effective) 1
6. Neglecting regular interprofessional team meetings and coordinated care planning 1

By following these evidence-based principles, rehabilitation after basal ganglia stroke can maximize functional recovery, reduce complications, and improve quality of life for patients.