Post-Stroke Rehab Center

Post-Stroke Rehab Center Master Thesis Project

Grace Allen

Hochschule Anhalt - DIA 2016/17 1st. supervisor Joris Fach 2nd. supervisor Roger Bundschuh

CONTENT PAGE 05

RECOVERY by Joris Fach

07

REGAINING MOBILITY by Grace Allen

09 STROKE 23 CONSEQUENCES 35

STROKE RECOVERY

53 CONCEPT 61 LOCATION 85 PROGRAM 91 PROJECT 117

BIBLIOGRAPHY

3

4

RECOVERY

by Joris Fach In a health obsessed society, in which fitness clubs and organic food stores spring up at every street corner, the loss of agility and productivity is not an option. Hence, whenever bad luck does strike, it causes daily routines to collapse. Recovery always takes too long and lasting dysfunctions are ruinous.

As such, our health has become part of a social equation, differentiating often underfunded public care from exclusive private rehabilitation centers.

Additionally, the ownership of health-related data has become highly sensitive, as it is utterly valuable to both pharmaceutical companies, as well as future employers.

Overall, however, the health care industry is one of the most reliably growing ones of recent years. Hospitals have expanded into imposing conglomerates of impenetrable bigness that often fail to connect to their context on almost every level. Pharmaceutical enterprises treat themselves to lush campuses, marking their newly acquired power and influence.

Keeping all of the above in mind, we will commence the semester by looking at the human body itself, understanding its organic functions and amazing resilience, but also study sports injuries, chronic diseases, psychological instabilities, drug addictions and their respective treatments. As the radius of mobility become restrained, the design of immediate surroundings becomes crucial. We will thus speculate on productive environments for recovery, imagining paradisiacal states of urban arcadia in which physical rehabilitation overlaps with exciting cultural programs, making every step of a recovery an exciting one for both body and mind.

- Recovery -

5

6

REGAINING MOBILITY

by Grace Allen Everything we do is controlled by our brain, which is the most important organ of the human body. Almost every human behavior involves motor function, such as eating, talking or walking. The motor system can be affected as a consequence of a stroke, which is the second leading cause of death and a leading cause of disability worldwide.

Stroke survivors struggle with the impairments produced by this sudden event.

The most common impairment is the difficulty to move and walk. Fortunately, medical science has gone forward, offering nowadays rehabilitation programs for stroke survivors, which are crucial for the patients to become as independent as possible.

Regarding the fact that stroke incidence is increasing in developing countries, the Post-Stroke Rehab Center will take place in Lima, Peru. This location is perfect for this project because of its lackness of specialized stroke rehab facilities. The purpose of the rehab center will be to keep the patients active and make them enjoy the facilities, so that they get engaged with the therapies in order to make fast progress and return back to normal life as soon as possible.

This goal will be achieved through a social and architectural ambition. The social ambition is to make the building a dynamic neighborhood, meaning that the building will encourage an active interaction between the patients, visitors and professionals, as if it was a small neighborhood. About the architectural ambition, as movement is significant in therapy, the project will be designed to be experienced through movement. The architectural promenade is a great complement for the social aim and also a useful exercise for the patients.

- Regaining mobility -

7

8

STROKE A stroke is a medical emergency that happens suddenly. It can be a devastating event that permanently changes a person’s ability to function, making life frustrating and depressing.

9

DEFINITION A Stroke is the sudden death of some brain cells due to lack of oxygen when the blood flow to the brain is interrupted. A stroke is also known as brain attack or Cerebral Vascular Accident (CVA). [1]

LACK OF O2

BLOOD

10

- Stroke definition -

TYPES Ischemic Stroke (87%)

Hemorrhagic Stroke (13%)

Occurs when a blood vessel that supplies oxygenated blood to the brain becomes blocked or clogged and impairs blood flow to part of the brain. The brain cells and tissues begin to die within minutes from lack of oxygen and nutrients. [2]

Occurs when a blood vessel that supplies oxygenated blood to the brain ruptures and bleeds, then brain cells and tissues do not receive oxygen and nutrients and die.

Pressure builds up in surrounding tissues, irritation and swelling occur.[3]

Area deprived

Area of

of blood

bleeding

Obstruction blocks blood

Weakened vessel ruptures

flow to part of the brain

causing bleeding in the brain

87%

13%

- Stroke types -

11

HISTORY

Even though doctors nowadays know the causes and implications of a stroke, it has not always been well-understood. Hippocrates first recognized stroke more than 2,400 years ago and called it apoplexy. This condition was named after the sudden paralysis and change in the well-being that a person develops. While apoplexy described what we know today as effects of a stroke, Hippocrates did not clarify that the condition actually happens in the brain.

It was not until the mid-1600‘s that Jacob Wepfer discovered that something disrupted the blood supply in the brains of people who died from apoplexy. In some of these cases, there was massive bleeding in the brain, while in others, the arteries were blocked.

Medical science continued to make advances regarding the cause, symptoms, and treatment of apoplexy. Is in 1689 that William Cole introduces the word stroke in the field of medicine. Finally, in 1928, apoplexy was divided into categories based on the cause of the blood vessel problem. This led to the term Cerebral Vascular Accident (CVA). [4], [5], [6]

12

- Stroke history -

400 B.C.

Hippocrates is the first to recognize stroke and call it apoplexy, but even though it describes the effects of a stroke (mainly a sudden paralysis), at this moment it was not related to the brain.

William Harvey discovers that

1616-1628

blood was pumped around the body by the heart into the circulatory system.

1658

J. Wepfer relates apoplexy with an interruption of blood supply in the brains.

1689

William Cole introduces the word stroke in the field of medicine.

1928

Apoplexy is divided into categories based on the cause of the vessel problem. This leads to the term cerebral vascular accident (CVA).

Henry Barnett discovers that

1976

aspirins can prevent strokes.

Cigarettes are found to be a risk

1980‘s

factor for strokes.

1990

The American Stroke Association starts using the term brain attack.

Magnetic resonance imaging (MRI)

1994

is introduced for stroke diagnosis.

1998

F.A.S.T. method is developed to help detect stroke victims.

- Stroke history -

13

GENERAL STATISTICS Every year, 16.9 million people worldwide suffer a stroke. [7] Out of these, 6.7 million people die.[8] And another 5 million are left permanently disabled.[9] Stroke is a leading cause of disability over the world, which may include loss of vision and / or speech, paralysis and confusion. Globally, stroke is the second leading cause of death after ischemic heart disease. [8]

DISEASE

14

DEATHS

Ischemic heart disease

7.4 million

Stroke

6.7 million

COPD

3.1 million

Lower respiratory infections

3.1 million

Trachea bronchus, Lung cancer

1.6 million

HIV / AIDS

1.5 million

Diarrhoeal diseases

1.5 million

Diabetes mellitus

1.5 million

Road injury

1.3 million

Hipersensitive heart disease

1.1 million

- General statistics -

World population = 7 .4 B [10]

Stroke incidence = 16.9 M

Mortality

6,7

Permanent

5

disable

Rest of

5,2

survivors

M 1

2

3

- General statistics -

4

5

6

15

RISK FACTORS [11] Non modifiable risk factors:

16

Age

Family history

Previous stroke

Previous heart attack

- Non modifiable risk factors -

Strokes can be prevented by controlling the modifiable risk factors, which are:

High blood pressure

High cholesterol level

Diabetes

Poor diet

Smoke & drugs

Obesity

Lack of exercise

Heavy alcohol drinking

Stress

- Modifiable risk factors -

17

SYMPTOMS

Stroke symptoms typically start suddenly, over seconds to minutes. Often, there is more than one symptom at the same time. The symptoms depend on the area of the brain affected. Knowing the symptoms of a stroke is the first step to ensure that medical help is received immediately.

The most common symptoms of a stroke include:

18

[12]

•

Sudden numbness or weakness of face, arm and/or leg; particularly on one side of the body. This may range from total paralysis of one side of the body to mild clumsiness of one hand.

•

Sudden confusion including trouble with speaking and understanding.

Speech disturbance may often show up as an inability to put thoughts into words, the substitution of a similar word for another of different meaning, or slurring of speech.

•

Sudden trouble with seeing in one or both eyes, such as blindness, blurred vision, double vision or other visual disturbances.

•

Sudden trouble walking, including dizziness, unsteadiness, loss of balance, lack of coordination and difficulty controlling movements.

•

Sudden and severe headache with no known cause. Headache is more common in hemorrhagic stroke victims than in ischemic ones.

- Stroke symptoms -

Symptoms

Sided weakness

Speaking problems

Vision problems

Dizziness

Severe headache

- Stroke symptoms -

19

EASY RECOGNITION

A stroke is a medical emergency and need immediate medical attention. It happens fast and will often occur before an individual can be seen by a doctor for a proper diagnosis. The acronym F.A.S.T. is an easy way to remember the signs of stroke, and can help identify more quickly if a person is having a stroke: ( F ) A C E - Ask the person to smile. Does one side of the Face droop?

(A)RM - Ask the person to raise both arms. Does one Arm drift downward? ( S ) P E E C H - Ask the person to repeat a simple phrase. Is the Speech slurred or strange? ( T ) I M E - If you observe any of these signs, is Time to call an ambulance immediately.

The F.A.S.T. checklist does not cover every possible symptom of a stroke.

However, it is easy to remember and it is estimated that about 8 or 9 in 10 people with a stroke will have one or more F.A.S.T. signs.[13]

20

- Easy recognition -

- Easy recognition -

21

22

CONSEQUENCES The effects of stroke vary from person to person based on the type of stroke and on what portion and location of the brain has been affected. According to this, several impairments can be developed; which can be permanent, short term or long term conditions.

23

THE BRAIN

The brain is the most important organ of the human body that controls everything we do. It is a complex tissue that consists of three main parts: [14]

•

Cerebrum (or Cerebral Cortex)

•

Cerebellum

•

Brain stem

Cerebrum

24

Cerebellum

- The brain -

Brain stem

- The brain -

25

FUNCTIONS OF THE BRAIN

Cerebrum The cerebrum or cerebral cortex is the largest part of the brain and occupies the top and front portions of the skull. Overall, it controls movement, sensation, speech, thinking, reasoning, memory, vision, and emotions.

The cerebrum is divided into the right and left sides, or hemispheres. A stroke that occurs in one hemisphere of the cerebrum leads to physical difficulties on the opposite side of the body because the right hemisphere controls the left side of the body and the left hemisphere controls the right side of the body.[15] At the same time, the cerebrum is divided in lobes or sections, these are frontal, parietal, occipital and temporal lobes. Each section has specific roles.

Some skills and traits occur in more than one section.

The frontal lobe is responsible for movement, intelligence, reasoning, behavior, memory and personality. The parietal lobe is responsible for intelligence, reasoning, language, sensation, reading and telling right from left. The occipital lobe is responsible for vision and spatial orientation. And the temporal lobe is responsible for speech, behavior, memory, hearing, vision, taste, emotions, feelings and learning.

Depending on the location and side of the cerebrum affected by the stroke, any, or all of these functions may be impaired.

26

- Functions of the brain -

- Functions of the brain -

27

Cerebellum The Cerebellum is located beneath and behind the cerebrum towards the back of the skull. It receives information from the body through the spinal cord.

It is responsible for balance, coordination and fine muscles control. Although strokes are less likely in the cerebellum area, the effects can be severe.

Common effects of strokes in the cerebellum are the inability to walk, lack of coordination and balance, inability to make rapid movements, inability to grab objects, slurred speech, dizziness, headache, nausea and vomiting.

Brain stem The brain stem is located at the base of the brain, right above the spinal cord.

It is responsible for many of the body’s vital functions, such as heartbeat, blood pressure, swallowing and breathing. It also helps control the main nerves involved with eye movement, hearing, speech and chewing.

Even a small stroke in the brain stem can cause severe problems as many nerves pass through here, from the brain to the spinal cord. When a stroke occurs in the brain stem, it can affect both sides of the body and may leave someone in a ‘locked-in’ state. When a locked-in state occurs, the patient is unable to speak or achieve any movement below the neck. [16]

28

- Functions of the brain -

Parietal lobe

Temporal lobe

Language

Hearing

Intelligence

Feelings

Sensation

Speech

Reasoning

Behavior

Reading

Memory

Right/Left

Vision Taste

Occipital lobe

Frontal lobe

Sight

Thinking

Orientation

Memory Behavior Movement Reasoning

Cerebellum

Personality

Balance Coordination

Brain stem Heartbeat Blood pressure Swallowing Breathing Chewing Eye movement Speech Hearing

- Functions of the brain -

29

IMPAIRMENTS Several conditions may develop after a stroke due to loss or defficiency of some functions. Most are common and will improve with time and rehabilitation.

These impairments can be short term, long term or even permanent and are; hemiparesis or hemiplegia (weakness or paralysis of one side of the body), balance and coordination difficulties, pain and numbness, visual and perception problems, aphasia or dysarthria (language problems), cognitive problems (troubles with memory and reasoning), behavioral and emotional changes, fatigue, dysphagia (difficulties with swallowing), incontinence, spasticity and muscle atrophy, and seizures. [17] Hemiparesis / hemiplegia

Balance / coordination difficulties

Pain / numbness

Visual & perception problems

Cognitive problems

Aphasia / Dysarthria

Dysphagia

Behavioral / emotional changes

Fatigue

Spasticity / muscle atrophy

Incontinence

Seizures

Most patients experience hemiparesis or hemiplegia.

30

- Impairments -

- Impairments -

31

SEVERITY OF THE STROKE The severity of the stroke can be measured with several methods. Today, the most used one is the National Institute of Health Stroke Scale (NIHSS). It was originally developed in 1989 and is now a valid tool to assess stroke severity.

According to NIHSS, the measurement consists in giving a score depending on the ability of the patient to obey simple tasks, which are related to the impairments caused by the stroke, such as papillary response, sensory loss, visual neglect, dysarthria, aphasia and so on. There are 15 tasks overall, each task is graded on an ordinal scale ranging from 0 to 2, 0 to 3, or 0 to 4 points, where 0 means no impairment and the highest score means total impairment.

At the end of the evaluation, all the points are summed to a total score ranging from 0 to 42, where higher score indicates greater severity. The evaluation can be completed within 10 minutes and requires minimum equipment.

Stroke severity according to NIHSS is stratified as follows: [18]

•

Very Severe

=

>24

•

Moderate to Severe

=

15 – 24

•

Moderate

=

5 – 14

•

Mild or minor

=

1–4

•

No stroke

=

0

NIHSS results predict the hospital disposition. 80% of stroke survivors with a score less than 5 will be discharged to home, patients with a score between 6 and 13 typically require inpatient rehabilitation, and patients with a score higher than 14 frequently require long term skilled care (nursing facility). [19] The NIHSS is then repeated at regular intervals or after significant changes in the patient‘s condition. This history of scores can then be used to monitor the effectiveness of treatment and to quantify the progress of the patient.

80% of patients with score

Patients with score <14 frequently

<5 are discharged to home

require long term skilled care

Mild

Moderate

Severe

Very severe

1

5

15

25

Patients with a 6-13 score typically require inpatient rehabilitation

32

- Severity of the stroke -

42

Level Of Consciousness

Score

Motor leg - Left

Score

LOC questions

Score

Motor leg - Right

Score

LOC commands

Score

Limb ataxia

Score

Best gaze

Score

Sensory

Score

Visual fields

Score

Best language

Score

Facial palsy

Score

Dysarthria

Score

Motor arm - Left

Score

Extinction & Inattention

Score

Motor arm - Right

Score

NIHSS result

Total score

- Severity of the stroke -

33

34

STROKE RECOVERY The recovery from a stroke can take time. Immediate medical attention as soon as the signs of the stroke appear is crucial for a better and faster recovery. The road to recovery may be different for each patient, but rehabilitation plays a significant role in this path.

35

RECOVERY PROCESS

Stroke is a medical emergency, and immediate attention will more likely lead to a better recovery and reduce the chances of permanent damage or disability. The National Institute of Neurologiccal Disorders and Stroke (NINDS) recommends a door to needle (DTN) time of 1 hour or less. Stroke recovery happens as soon as the emergency is under control. The process of recovering from a stroke may consist of several steps, it normally includes treatment, spontaneous recovery, rehabilitation, and return to community living.

Treatment following a stroke usually begins with attention in the hospital, called acute care. This first step includes helping the patient survive, preventing a new stroke and taking care of any other medical problems. The stay in the hospital during acute care can last 1 or 2 weeks.

Spontaneous recovery happens naturally soon after the stroke. During this step, some abilities that have been lost usually start to come back. This process may begin during the stay of the patient at the hospital and is quickest during the first few weeks, but it sometimes continues for a long time.

Rehabilitation should start as soon as possible. It usually begins while the patient is still in acute care. According to their needs before being discharged from hospital, most patients are advised to continue rehabilitation afterwards.

The last stage in stroke recovery begins with the personâ&#x20AC;&#x2DC;s return to community living after acute care or rehabilitation. This stage can last for a lifetime as the stroke survivor and family learn to live with the effects of the stroke. This may include doing common tasks in new ways. [20]

36

- Recovery process -

Road to recovery

Stroke

Emergency

Treatment: Acute care

Spontaneous recovery

Rehabilitation

Return to community living

Recovery

- Recovery process -

37

SPONTANEOUS RECOVERY The spontaneous recovery is usually manifested within the first six months and it varies from patient to patient. It is what the patient would obtain even without a rehabilitation program and depends on how damaged is the brain and the ability of the brain to heal.

The spontaneous recovery may happen as follows: 1. The brain cells that were seriously damaged, die and never recover.

2. Other cells which were only partially damaged, recover and start working again. This process takes place during the first few weeks after the stroke happened.

3. Parts of the brain which are unaffected by the stroke begin to take over functions of the dead parts.

After this, the patient adapts to the loss of function and learns new ways of living with the damaged brain and the impairments that can persist. [21]

38

1° seriously damaged brain

2° partially damaged brain

3° unaffected brain cells take

cells die

cells recover

over dead cells

- Spontaneous recovery -

- Spontaneous recovery -

39

REHABILITATION OPTIONS

After acute care treatment in the hospital, rehabilitation aims to build strength, capability and confidence so that patients can continue daily activities. Most patients present one or several impairments, and rahabilitation is a must in their road to recovery.

There are different types of rehabilitation programs depending on the ability of the patient to take part in therapy and to the patients needs. According to these, doctors decide which type of rehabilitation program is suitable for each individual patient.

The main difference between the rehabilitation options is the type of setting where the treatment will take place. According to the setting, the options are divided in two categories, inpatient and outpatient. Inpatient treatment means that the patient will live in the same environment where the rehabilitation will occur, and is very demanding. Outpatient programs are less intensive and provide treatment without requiring an overnight or extended stay.

The different types of rehabilitation programs vary depending on the range of services provided, the frequency of the services, and the types of patients that best fit the program. According to these characteristics, the options are acute care or rehab hospitals, sub-acute care facilities, long-term care facilities, outpatient facilities and home health agencies.

Patients may move among various levels of care during their recovery. For instance, a patient can begin with a sub acute care facility program and continue with a home health agency afterwards. [22]

40

- Rehabilitation options -

Program

Services

Acute care

Full range

Setting

Frequency

Candidate

Patient

Inpatient

Hospital

Several

Patients

or rehab

or special

hours every

with many

hospitals

rehab unit

day

medical issues that may develop problems

Sub-acute

Wide range

facilities

Long-term

Several

care facilities

Rehab

Some hours

Patients

center,

almost every

with serious

rehab unit,

day

Inpatient

disabilities

SNF*, SNH*,

but unable

skilled

to handle the

nursing unit

demands of

in a hospital

acute care

Nursing

2 - 3 days

Patients

home, SNF*

per week

with medical

Outpatient

problems under control, but need nursing care

Outpatient

Several

facilities

Doctorâ&#x20AC;&#x2DC;s

2 - 3 days

Patients

office,

per week

with medical

outpatient

problems

centers,

under control

adult day

and can

centers

travel to get

Outpatient

treatment

Home health

Specific

Home

As needed

agencies

Patients who

Outpatient

live at home but unable to travel to get treatment

*SNF = Skilled Nursing Facility (short term nursing care)

*SNH = Skilled Nursing Home (long term nursing care)

- Rehabilitation options -

41

REHABILITATION DISCIPLINES A multidisciplinary team of healthcare professionals leads the rehabilitation, aiming to restore the independence of the patient. The rehab team includes a physiatrist, a neurologist, a rehabilitation nurse, physical therapist, a occupational therapist, a speech language pathologist, a dietitian, a social worker, a neuropsychologist, a case manager and a recreation therapist. [22] Physiatrist

Neurologist

Specializes in

Dietitian

Teaches survivors about

rehabilitation following

healthy eating and

injuries, accidents or

special diets (low salt,

illness

low, fat and so on)

Specializes in

Social worker

Helps stroke survivors

prevention, diagnosis

make decisions about

and treatment of stroke

rehab programs, living

and other diseases of

arrangements, insurance

the brain and spinal cord

and support services in the home

Rehabilitation nurse

Specializes in helping

Neuropsychologist

Diagnoses and treats

people with disabilities;

survivors who may

helps survivors manage

be facing changes in

health problems that are

thinking, memory and

risk factors of stroke and

behavior after stroke

adjust to life after stroke

Physical therapist (PT)

Helps stroke survivors

Case manager

Helps survivors facilitate

with problems in moving

follow-up to acute care,

and balance; suggests

coordinate care from

exercises to stregthen

multiple providers and

muscles for walking,

link to local services

standing and so on

Occupational therapist

Language pathologist

42

Helps stroke survivors

Recreation therapist

Helps stroke survivors

learn strategies to

learn strategies to

manage daily activities

improve the thinking and

such as eating, bathing,

movement skills needed

dressing, writing or

to join in recreational

cooking

activities

Helps stroke survivors

Optometrist

Prescribes, administers

re-learn language skills

and oversees progress

(talking, reading and

throughout vision

writing); and shares

restoration training or

strategies to help with

completion of vision

swallowing problems

compensation therapy

- Rehabilitation disciplines -

- Rehabilitation disciplines -

43

PHYSIOTHERAPY Physiotherapy or physical therapy (PT) is an essential component of stroke rehabilitation, about 85% of patients need it. A stroke can damage brain regions that affect movement and physical therapists are specialized in treating disabilities related to motor and sensory impairments. [23] Physiotherapy may include:

•

Massage

Generally suitable for all patients. The form and firmness of the massage will be tailored to the particular case. This treatment is use to decrease muscle pain and prevent its atrophy.

•

Hydrotherapy

Also known as aquatic physiotherapy, commonly takes place in a specialised pool but can be carried out in a normal swimming pool as long as it is shallow and reasonably warm. During a hydrotherapy session the therapist will encourage the patient to do exercises which, coupled with the pressure of the water, will improve circulation and allow the muscles and joints to move freely.

•

Electrotherapy

This treatment involves the use of controlled electric shocks in order to increase nerve activity. Electrotherapy is used to decrease muscle pain and aid muscle repair and regeneration.

•

Exercise and Movement

One of the fundamental concepts of physiotherapy is to improve the range of movement of joints and muscles. Physiotherapists often use a variety of exercises and stretches to improve flexibility and reduce stiffness.

85%

15%

85% of patients need physiotherapy

44

- Physiotherapy -

Massage

Hydrotherapy

Electrotherapy

Exercise & movement

- Physiotherapy -

45

NEUROLOGICAL PHYSIOTHERAPY Physiotherapists use their knowledge and skills to improve a range of conditions associated with different systems of the body. According to this, there are different types of physiotherapies, which are:

•

Neurological

•

Neuromusculoskeletal -

back pain, sports injuries, arthritis

•

Cardiovascular

-

heart attack

•

Respiratory

-

asthma, chronic obstructive pulmonary

-

stroke, multiple sclerosis, parkinson

Neurological physiotherapy or neurophysiotherapy is the specific branch of physiotherapy that treats patients with problems originated in the brain, such as stroke victims. [24]

Type of physiotherapy for stroke victims

Physiotherapy (PT)

46

Neurological

Neuromusculoskeletal

Cardiovascular

Respiratory

- Neurological physiotherapy -

The main focus of physiotherapy after a stroke is to help the patient learn to use both sides of the body again and regain as much strength and movement as possible. This is accomplished through guided movements and repetitive actions.

Neurological physiotherapists must address three main components of normal motor system, posture to recover balance and strength of both sides of the body, movement to recover the ability of walking, and function (working closely with neurological occupational therapists) to improve quality of life.

Neurological physiotherapy aim

Posture

Movement

Function

- Neurological physiotherapy -

47

EXERCISE TECHNIQUES Exercises in stroke rehabilitation can relay on several strategies. Depending on the part of the body and type of the ability affected, the phiysiotherapist may suggest some or all of the following types of exercises:

•

Strengthening or resistance

This type of exercise helps improving the muscle strength and coordination. It often consists of performing activities that involve moving a body part against resistance, what will gradually and progressively overload the muscles so that they will get stronger.

•

Mobility

Mobility training helps with walking and position. It may include learning to use walking aids, such as braces, walkers or canes, to support the body while relearning how to walk.

•

Constraint induced or forced use

This technique involves limiting the movement of the unaffected side of the body and forcing the weak side to attempt activities. This strategy can help improve the function of the affected limbs.

•

Range of motion

This training style helps promote joint flexibility, reduce muscle tension (spasticity) and increase muscular endurance. The exercise consists basically on repetitive stretching movements, such as flexion, extension, rotation, abduction, adduction, circumduction, supination, pronation, inversion and eversion. The movements can be done by the patient using the weak limb (active), by the patient using the strong limb to guide the weak limb (active assistive), or by the therapist guiding the patient‘s weakl limb (passive).

•

Mirror Therapy

Mirror therapy is a form of motor imagery in which a mirror is used to convey visual stimuli to the brain. It consists of using movements of the stronger body part to trick our brain into thinking that the weaker body part is moving. It involves placing the affected limb behind a mirror, which is sited in a way that the reflection of the opposing limb appears in place of the hidden limb.

These type of exercises are the most known and used ones in stroke rehabilitation. [25]

48

- Exercise techniques -

Exercise techniques

Strengthening (resistance)

Mobility

Constraint induced (forced use)

Range of motion

Mirror therapy

- Exercise techniques -

49

RECREATIONAL THERAPY In rehabilitation, patients can fall into a monotonous routine, but recreational therapy can add variety to it. This discipline uses leisure activities to help the patient regain independence and promote physical and mental wellness.

Recreational therapy may include:

•

Arts & crafts

Recreational area involves every type of creative activity, such as pottery, painting, drawing and others. These leisure activities help the patient to improve the fine motor skills and the emotional health. [30]

•

Board gaming

Traditional board games like chess, scrabble, monopoly and others, can actually help with brain functions, such as reasoning, memory, decision making, information processing and much more. [28]

•

Virtual reality gaming

Video games are more exciting to incorporate into a rehab process. They may include a simple playstation or nintendo wii to play in group or alone. But it may also be more sophisticated and require special devices that the patient should wear while performing simple movements like raising arms or waving hands, which correspond to actions within the on-screen game. With these movements, patients are not just performing repetitive motions, they are also transforming the normal therapy into a game, making it funnier. [27]

•

Pet therapy

Pet therapy relies on the pre-existing human-animal bond, consisting of a guided interaction between a person and a trained animal. Dogs and cats are most commonly used in pet therapy, which aims to promote improvement in physical, social, emotional and cognitive functions. It can help the patient with self-acceptance, relaxation, empathy and motor skills. In rehabilitation, people may be less bored and more motivated to practice therapies when working with a pet. [26]

•

Other leisure activities

Recreational therapy may also include other leisure activities such as sports, cooking, gardening, dancing, yoga, meditation, and so on. [29] All these activities may motivate the patient to enjoy therapy while healing the body (physical and mentally). Thus, recreational therapy is useful for patients‘ progress while having fun, interacting with others and getting engaged with therapy.

50

- Recreational therapy -

Recreational therapy

Arts & crafts

Board gaming

Virtual reality gaming

Pet therapy

Other leisure activities

- Recreational therapy -

51

52

CONCEPT Regarding the big amount of time that patients spend in rehab facilities, the project will aim to keep the patients active and make them enjoy therapies so that they feel motivated during the recovery process in order to make fast progress; hence, return to normal life as soon as possible. The design will focus on inviting the patients to move throughout the building. Therapies together with leisure activities will play an important role, creating a lively pathway throughout the rehab centre, in benefit of the patientsâ&#x20AC;&#x2DC; experience and progress.

53

Typical circulation in health facilities

54

Circulation aim: architectural promenade

- Circulation study -

Promenade of activities (Leisure & Therapies)

Leisure / optional activities

Mandatory therapies

Social interaction

- Concept -

Motivation

55

SOCIAL APPROACH The project will be based on a dynamic neighborhood as a social approach.

This means that the building will be designed to encourage an active interaction between its users (patients, visitors and professionals), as it was a small, complete and lively neighborhood, where people share and gather in different spaces and experience several activities. This ambition is thought for patients to enjoy the facilities and the therapies as well, so that they feel motivated and engaged with the rehabilitation program in order to complete it positively.

People and activities attract other people. As the patients pass a significant period of time in the rehab center and have a lot of free time, the goal is to encourage them to spend more time outside their rooms by having the opportunity to perfom additional recreational therapy (optional leisure activities), such as pottery art, pet therapy, board gaming, sports, gardening, among others. This not only will help them to avoid depression and boredom, but will also encourage them to have social interaction.

In other words, the social approach of the project is to create a community by promoting social interaction through a combination of activities, which will produce motivation.

Dynamic neighborhood

What?

Activities

How?

Motivation

Why?

56

- Social approach -

Social interaction

A neighborhood, as an urban environment, is meant to be a scenario of several human activities, the necessary, the optional and the social activities.

By blending together necessary activities (mandatory therapies) with optional activities (additional leisure activies), the social activities (interaction) will happen spontaneously as a result of the first two. This will keep the patients active and make them use and enjoy the facilities, so that they get engaged with the therapies in order to make fast and good progress; hence, return to normal life as soon as possible.

In a city for instance, when outdoor areas are of poor quality, only the completely necessary activities happen (going to work or school). When outdoor areas are of high quality, necessary activities take place with approximately the same frequency but tend to last longer because the physical conditions are better; and additionally, optional activities will also happen because place and situation now invite people to stop by. When necessary and optional activities present better conditions of space, social activities are better supported.

Compared with a city, the rehab center as a dynamic neighborhood will bring out the same reactions in people. [31]

Poor physical condition of space

Good physical condition of space

Necessary activities

Optional activities

Social activities

- Social approach -

57

ARCHITECTURAL AMBITION As movement is essential in rehabilitation, the project will be designed under an architectural ambition that will apply movement to experience the building.

This concept is known as architectural promenade, introduced by Le Corbusier and later applied by others, like Rogelio Salmona and Rem Koolhaas. Le Corbusier thought of experiencing a building through movement, creating a relation between human, space and time. It is not just about circulation, or going from one space to another one, it is about the experience of walking through a building and discovering unexpected spaces and visual frames; resulting in a mysterious and exciting pathway that holds a sequence of functions and views, where people is prompted to use their faculties of memory, imagination, analysis and reasoning.

This intention will invite the patients to get out of their rooms and experience the several activities that the facilities offer along an appealing sequence of spaces. That way, they will enjoy rehabilitation and get engaged with it, which will lead to a faster and better recovery. This ambition is not only an interesting way to develop the project, but also a great mate of the social approach.

Le Corbusier‘s architectural promenade follows a formula consisting of a sequence of elements usually used in narratives structures. The elements are:

•

Threshold (introduction)

The narrative path starts with a threshold or introduction. It exposes the building from the street to the entrance; being doors the main characters.

•

Sensitizing vestibule (disorientation)

The narrative path continues with the sensitising vestibule or disorientation where the building starts its development. This space is the hall or lobby, that often takes a form of a cube and is higher. It sometimes occupies a particular position within the exterior wall, causing blurring between interior and exterior.

•

Questioning (savoir habiter)

The climax of the narrative path is called questioning (savoir habiter). It shows unexpected spaces by anticipation or surprise (may include frame views).

•

Reorientation (resolution)

Ramps or stairs act as point of reorientation, which is the resolution of the sequence. These elements frequently change position and form in the building.

•

Culmination

The promenade usually culminates on the roof.

58

- Architectural ambition -

[32]

Elements of architectural promenade

Introduction

Exposition Doors

Sensitising vestibule

Lobbies Interior - exterior Scale

Questioning

Framing Doors Perspective Resistance Surprise

Reorientation

Ramps Stairs

Culmination

Roofs Gardens

- Architectural ambition -

59

60

LOCATION As stroke incidence is increasing in developing countries, the Post Stroke Rehab Center will take place in Lima, Peru.

61

LOCATION OVERLOOK The project will be located in Lima, the capital of Peru.

Peru presents an underprivileged health facilities situation and Lima in particular is an overpopulated city, where hospitals are collapsing. As stroke incidence is increasing in developing countries, this location is perfect for the Post Stroke Rehab Center. Moreover, Years Lived with Disability (YLD) are also increasing in Peru, growing in a faster rythm than the average worldwide, according to the numbers from the years 1990 to 2015.

Regarding specialized stroke rehabilitation, there is a lack of facilities of this kind. Rehabilitation basically takes place in private clinics during acute hospitalization. Some independent facilities for rehabilitation exist, but these are general and small physiotherapy centers, where the treatment is not necessary specialized for stroke victims. [33]

Peru

World

YLD growth

62

1990

1995

2000

- Location overlook -

2005

2010

2015

Peru

Lima (Region)

Lima (City)

- Location overlook -

63

SITE LOCATION

Lima has grown considerably marking how its territorry is divided. The Historical Center is the area of its creation in 1535, which now is mainly touristic and commercial. Callao Constitutional Province is a city in conurbation with Lima (main seaport). Around the year 1940, Lima started growing along the North and South axis, followed by the expansion to the East axis; conforming what we call the Cones (edges) of Lima. The heart of the city is the area known as the Modern Center, formed by the most appealing and hybrid districts.

The site chosen is located in the district of Santiago de Surco, a developed district established in the Modern Center of Lima. It is a convenient location, due to a permanent activity in this part of the city (most people move from the Cones to the Modern Center). [34]

Historical Center

Modern Center

North Cone

South Cone

East Cone

Callao

64

- Site location -

District of Santiago de Surco

Plot

- Site location -

65

SITE SELECTION

The site chosen is a convenient location, based the following parameters of consideration:

â&#x20AC;˘

Proximity to existing health facilities

Two important private clinics are in the same street where the site is located.

â&#x20AC;˘

Accessibility

The site is located between three main avenues, which eases accessibility.

Proximity to health facilities

66

Accessibility

- Site selection -

SITE ANALYSIS

- Site analysis -

67

Dimensions

5.75

m.

.72

118

111

.09

m.

m.

1.21 m.

Area 14,202 sqm

21

62.

23.4

1m

.

m.

35.9

m.

4m

24

.51

.

62.70 m

.

68

- Site dimensions -

35.09 m.

Topography

50 cm.

25 cm.

- Site topography -

69

Sun exposure

70

- Site sun exposure -

Wind direction

- Site wind direction -

71

Mass & void

72

- Site mass & void -

Green areas

Private recreational clubs

Public Parks

- Site green areas -

73

Uses

1

2

3

6

Office

74

4

7

Education

5

8

9

Commerce

- Site uses -

Religious

Residential

Health

Places of interest

1. Jockey Club

2. Lima Central Tower

3. Capital El Derby

4. Cronos

5. US Embassy

6. Tezza Clinic

7. San Pablo Clinic

8. El Polo street mall

9. Lima Polo Club

- Site places of interest -

75

Accessibility

Manuel Olguin Av.

El Derby Av.

El Polo Av.

Local streets

76

Pio XII St.

La Encalada Av.

Main streets

- Site accessibility -

El Cortijo St.

Public transportation

To Javier Prado Av.

To Javier Prado Av.

To Primavera Av.

- Site public transportation -

77

Traffic

Intense traffic

78

Moderate traffic

- Site traffic -

Light traffic

Users behavior

Go & stay doing optional activities

Go & stay for recreational events

- Site users behavior -

Stop by and go

79

Noise

80

- Site Noise -

Street sections

6.66 m.

7.11 m.

3.22 m.

8.37 m.

6.38 m.

31.74 m.

El Derby Av.

3.31 m.

10.67 m.

1.49 m.

7.41 m.

1.00 m. 3.82 m.

2.35 m.

30.05 m.

La Encalada Av.

3.21 m.

10.59 m.

2.59 m.

16.39 m.

El Polo Av.

- Site street sections -

81

Views

82

- Site views -

El Polo Av. - La Encalada Av.

El Derby Av. - Encalada Av.

El Derby Av. - El Polo Av.

- Site views -

83

84

PROGRAM The Rehab Center will be oriented to patients from Lima with a moderate level of impairments from stroke. The program will hold the multidisciplinary rehabilitation plan, aiming attention in physical therapy together with leisure activities.

85

SCOPE

Unfortunatley, very little has been published about stroke in Peru. But the available statistics show that the incidence of stroke in Peru is of 11,775 cases per year. Out of these, 7,242 die, remaining then 4,533 stroke survivors all over the country. [35] Being Lima the densest city in Peru, with one third of the total population, it can be asumed that one third out of the 4,533 stroke survivors are in Lima, meaning 1,511 cases.

The Rehab Center will be oriented to stroke survivors from Lima who present a moderate stroke severity level, according the scores that the patients obtain in the NIHSS evaluation. Patients with moderate severity represent more than half of the stroke survivors in Lima, with 55%. While patients with severe and very severe level respresent 27% and the ones with mild severity only 18%.

Thus, there are 831 cases in Lima of stroke survivors with moderate severity.[36] Considering that the average lenght of stay (LOS) of patients in stroke rehabilitation is of 46 days, the facility may need to attend 105 patients simultaneously. [37]

86

- Scope -

Lima

Scope : 105 patients

1,511 new stroke survivors per year

(by 46 days of LOS in rehab)

Moderate

831

Severe % very severe

Mild

10

20

30

40

50

60

- Scope -

70

80

90

100

%

87

LIST OF SPACES

88

Lobby

Reception

Chapel

Cafe

Gift shop

Pharmacy

Multipurpose room

Public WC

Outpatients dresser

Patients WC

Inpatients bedrooms

Walking salon

Therapy pool

OT room

Massage room

Speaking room

Electrotherapy room

Recreational room

Physical training room

Gym

Pottery space

Pet therapy area

Board gaming

Video gaming

TV room

Painting room

Sewing room

Gardening area

Living room

Dining room

Sports area

Adm. offices

Meeting room

Evaluation room

Storage

Services

- List of spaces -

- Functional diagram -

89

90

PROJECT The Post - Stroke Rehab Center is focused in patients who present a moderate level of stroke severity. This type of stroke victims experiences some impairments (mostly temporal) and need rehabilitation, but donâ&#x20AC;&#x2DC;t need much or constant assistance and typically have a good outcome.

The project is located in Lima, Peru, in a settled and developed area of the city center. This is beneficial for the patients to become as independent as possible, since they are not isolated from real life.

Trying to avoid the typical boring circulations of existing hospitals, the idea is that the rehab center is not percieved as a health facility, but a as place toy enjoy, from inside and from outside. Plus, the distribution should protect the intimate area (bedrooms) from the noisy exterior.

91

Maximum built area (1 floor)

Main entrance

Rounded corners

Courtyard

Setback (parking)

Integrating roof

Corner tilted up

92

- Shape development -

Back entrance

- Site plan -

93

94

- Closed (private) spaces -

- Circulation & open spaces -

95

Back: administration & service

Therapies & leisure activities

96

Front: complementary activities (public)

- General distribution -

Therapies & leisure activities

Corner: main recreational space

- Structure -

97

98

- Proposal in context -

- Interior distribution -

99

100

- Basement -

- Grounfloor -

101

102

- Elevation -

103

104

- Section -

105

106

- Section -

107

108

- Section -

- Glass facade detail -

109

110

- Collage from promenade -

111

112

- Collage from courtyard -

113

114

- Collage from private rooms -

115

116

BIBLIOGRAPHY 1 National Stroke Association. “What is a Stroke?” www.stroke.org http://www.stroke.org/understand-stroke/what-stroke (Accessed Jan 25, 2017) 2 American Stroke Association & American Heart Association. “Ischemic Strokes (Clots).” www.strokeassociation.org http://www.strokeassociation.org/ STROKEORG/AboutStroke/TypesofStroke/IschemicClots/Ischemic-StrokesClots_UCM_310939_Article.jsp#.WIj9SfnhDDc (Accessed Jan 25, 2017) 3 American Stroke Association & American Heart Association.

“Hemorrhagic Strokes (Bleeds).” www.strokeassociation.org http:// www.strokeassociation.org/STROKEORG/AboutStroke/TypesofStroke/ HemorrhagicBleeds/Hemorrhagic-Strokes-Bleeds_UCM_310940_Article. jsp#.WIj9ZfnhDDc (Accessed Jan 25, 2017) 4 Johns Hopkins Medicine. “History of Stroke.” www.hopkinsmedicine. org http://www.hopkinsmedicine.org/healthlibrary/conditions/nervous_ system_disorders/history_of_stroke_85,P00223/ (Accessed Jan 25, 2017) 5 Wikipedia. “Timeline of stroke.” en.wikipedia.org https://en.wikipedia. org/wiki/Timeline_of_stroke (Accessed Jan 25, 2017) 6 American Stroke Association & American Heart Association. “An Updated Definition of Stroke for the 21st Century.” AHA/ASA Expert Consensus Document. (2013) doi: 10.1161/STR.0b013e318296aeca

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7 American Heart Association. “Heart Disease and Stroke Statistics—2015 Update.” AHA Statistical Update. (2014) doi: 10.1161/ CIR.0000000000000152 8 World Health Organization. “The top 10 causes of death.“ www.who. int http://www.who.int/mediacentre/factsheets/fs310/en/index.html (Accessed Jan 25, 2017) 9 World Heart Federation. “Stroke.” www.world-heart-federation. org http://www.world-heart-federation.org/cardiovascular-health/stroke/ (Accessed Jan 25, 2017) 10 Wikipedia. “World population.” en.wikipedia.org https://en.wikipedia. org/wiki/World_population (Accessed Jan 25, 2017) 11 American Stroke Association & American Heart Association. “Stroke Risk Factors.” www.strokeassociation.org http://www.strokeassociation.org/ STROKEORG/AboutStroke/UnderstandingRisk/Understanding-Stroke-Risk_ UCM_308539_SubHomePage.jsp (Accessed Jan 25, 2017) 12 National Stroke Association. “Signs and Symptoms of Stroke.” www. stroke.org http://www.stroke.org/understand-stroke/recognizing-stroke/signsand-symptoms-stroke (Accessed Jan 25, 2017) 13 National Stroke Association. “Act FAST.” www.stroke.org http://www. stroke.org/understand-stroke/recognizing-stroke/act-fast (Accessed Jan 25, 2017) 14 Johns Hopkins Medicine. “Effects of Stroke.” www.hopkinsmedicine. org http://www.hopkinsmedicine.org/healthlibrary/conditions/nervous_ system_disorders/effects_of_stroke_brain_attack_85,P00777/ (Accessed Jan 25, 2017) 15 The Internet Stroke Center. “Anatomy of the Brain.” www.strokecenter. org http://www.strokecenter.org/professionals/brain-anatomy/anatomy-of-thebrain/ (Accessed Jan 25, 2017) 16 University of Wisconsin. “Brain Lobes and Effects of Stroke.” UW Health. (2016) http://www.uwhealth.org/healthfacts/stroke/5593.pdf 17 Moawad, Heidi. “Long Term Effects of Stroke.” www. verywell.com https://www.verywell.com/stroke-effects-4014476 (Accessed Jan 25, 2017) 18 Wikipedia. “National Institute of Health Stroke Scale.” en.wikipedia. org https://en.wikipedia.org/wiki/National_Institutes_of_Health_Stroke_Scale (Accessed Jan 25, 2017)

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19 Rehabilitation Measures Database. “Rehab Measures: National Institute of Health Stroke Scale.” www.rehabmeasures.org http://www. rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?ID=914 (Accessed Jan 25, 2017) 20 The Internet Stroke Center. “Recovering After a Stroke: A Patient and Family Guide.” US Agency for HealthCare Research and Quality, Consumer Guide Number 16, Publication No. 95-0664 (1995) http://www.strokecenter. org/wp-content/uploads/2011/08/Recovering-After-a-Stroke.pdf 21 Volunteer Stroke Scheme. “Stroke FAQs.” www.strokescheme.ie http://www.strokescheme.ie/go/information/stroke_faqs#630700B3-DA6C44EB-BC15C512779C6F76 (Accessed Jan 25, 2017) 22 National Stroke Association. “Hope: The Stroke Recovery Guide.”

Stroke Smart. (2010) https://www.stroke.org/sites/default/files/resources/ NSA-Hope-Guide.pdf 23 Sports Medicine Information “What does physiotherapy involve.” www. nsmi.org.uk http://www.nsmi.org.uk/articles/physiotherapy/physiotherapyinvolve.html (Accessed Jan 25, 2017) 24 Chartered Society of Physiotherapy “What is Physiotherapy” www. csp.org.uk http://www.csp.org.uk/your-health/what-physiotherapy (Accessed Jan 25, 2017) 25 Stroke Rehab. “Stroke Rehab Exercises.” www.stroke-rehab.com http://www.stroke-rehab.com/stroke-rehab-exercises.html (Accessed Jan 25, 2017) 26 Health Line. “Pet Therapy.” www. healthline.com http://www.healthline.com/health/pet-therapy#Overview1 (Accessed Jan 25, 2017) 27 New York Dynamic Neuromuscular Rehabilitation & Physical Therapy.

“Virtual Reality in Stroke Rehabilitation.” nydnrehab.com https://nydnrehab. com/treatment-methods/neurorehab/virtual-reality-in-stroke-rehabilitation/ (Accessed Jan 25, 2017) 28 Mills, Mike “Playing around with Recovery.” Everyday survival (2006) http://strokeassociation.org/idc/groups/stroke-public/@wcm/@hcm/@sta/ documents/downloadable/ucm_314582.pdf 29 Flint Rehabilitation Devices. “Recreational Therapy after Stroke” www.flintrehab.com https://www.flintrehab.com/2015/recreational-therapyafter-stroke/ (Accessed Jan 25, 2017)

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30 Saul, Kathy. “Art Therapy.” Stroke Net strokenetwork.org/newsletter/therapies/ArtTherapy.htm

(2008)

http://www.

31 Gehl, Jan. 2011. “Life between Buildings: Using Public Space.”

Washington, DC: Island Press.

32 Samuel, Flora. 2010. “Le Corbusier and The Architectural Promenade” Basel: BirkHauser.

33 Global Health data Exchange. http://ghdx.healthdata.org/gbdresults-tool 34 Wikipedia. “Lima Metropolitana.” es.wikipedia.org es.wikipedia.org/wiki/Lima_Metropolitana (Accessed Jan 25, 2017)

https://

35 Global Health data Exchange. http://ghdx.healthdata.org/gbdresults-tool 36 Pub Med Central Canada. “Predictors of Functional outcome among Stroke Patients in Lima, Peru.” (2013) http://pubmedcentralcanada.ca/pmcc/ articles/PMC3659203/ 37 Feigenson, Joel & Greenberg Susan. “Factors Influencing Outcome and Length of Stay in a Stroke Rehabilitation Unit.” Stroke Journal of The American Heart Association (1977) doi: 10.1161/01.STR.8.6.657 Images about site https://www.google.de/maps/@-12.0982539,-76.9716219,17.5z?hl=es-419

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c

I Dessau International Architecture School Anhalt University Department 3 Š 2016/17