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REHABILITATION OF

PATIENTS WITH
HEMIPLEGIA

Rehabilitation

purpose - restore function following an illness or


injury, with the goal of maximizing a persons
ability to achieve fullest life possible
The ultimate aim of stroke research and
rehabilitation after stroke is to reduce
impairment, disability and handicap and to
enhance the quality of life.

Interdisciplinary team

physicians, nurses, PT, OT, speech-language


therapists, psychologists, social workers,
recreational therapists.

Rehabilitation
Rehabilitation therapy should start as early as
possible, once medical stability is reached
Spontaneous recovery can be impressive, but
rehabilitation-induced recovery seems to be g
reater on average.
Even though the most marked improvement is
achieved during the first 3 months, rehabilita
tion should be continued for a longer period t
o prevent subsequent deterioration.

Rehabilitation
No patient should be excluded from rehabilitation
unless he is too ill or too cognitively devastated to pa
rticipate in a treatment program.
Proper positioning and early passive ROM exercises
help to avoid complications at a flaccid stage.
Family members should participate in therapy
sessions.
The family should also be referred to community
groups that offer psychosocial support such as stroke
clubs at the time of discharge.

Poor Prognosis
Decreased alertness,inattention,poor
memory,inability to learn new tasks or
follow simple commands
severe neglect or anosognosia
significant medical problems esp,
cardiovascular or DJD
serious language disturbance
less well defined & economic problem
5

Effect of a Stroke
1. Weakness on the side of the body opposite the site
of the brain affected by the stroke
2. Spasticity, stiffness in muscles, painful muscle
spasms
3. Problems with balance and/or coordination
4. Problems using language, including having difficulty
understanding speech or writing(aphasia); and knowing
the right words but having trouble saying them
clearly (dysarthria)
5. Being unaware of or ignoring sensations on one side
of the body (bodily neglect or inattention)
6. Pain, numbness or odd sensations

Effect of a Stroke (cont)


7. Problems with memory, thinking, attention
or learning
8. Being unaware of the effects of a stroke
9. Trouble swallowing (dysphagia)
10. Problems with bowel or bladder control
11. Fatigue
12. Difficulty controlling emotions (emotional
lability)
13. Depression
14. Difficulties with daily tasks

Rehabilitation Goal
To restore lost abilities as much as
possible
To prevent stroke-related complications
To improve the patient's quality of life
To educate the patient and family about
how to prevent recurrent strokes
Promote re-integration into family, home,
work, leisure and community activities

Successful Rehabilitation
Depend on
- how early rehabilitation begins
- the extent of the brain injury
- the survivors attitude
- the rehabilitation teams skill
- the cooperation of family and
caregiver

Basic Principles of Rehabilitation


To begin as possible early (first hours)
To assess the patient systematically
To prepare the therapy plan carefully
To build up in stages
To include the type of rehabilitation approach
specific to deficits
To evaluate patients progress regularly

Rehabilitation Management
Mobility
Activity of daily living
Communication
Swallowing
Orthosis
Shoulder pain
Spasticity
Cognitive and perception
Mood
Bowel and bladder incontinence

Mobility
Physiotherapy

Conventional therapies
Neurophysiological therapies

Conventional therapies
Therapeutic Exercises
Traditional Functional Retraining

Range Of Motion (ROM) Exercises


Muscle Strengthening Exercises
Mobilization activities
Fitness training
Compensatory Techniques

Neurophysiological Approaches
1. Muscle Re-education Approach (1920S)
2. Neurodevelopmental Approaches (1940-70S)

Sensorimotor Approach (Rood, 1940S)


Movement Therapy Approach (Brunnstrom, 1950S)
NDT Approach (Bobath, 1960-70S)
PNF Approach (Knot and Voss,1960-70S)

3. Motor Relearning Program for Stroke


(1980S)

4. Contemporary Task Oriented Approach


(1990S)

Aim
Improve

Movement
Balance
coordination

Safety

Basic Physical Therapy


Bed positioning, mobility
Range of motion exercises (ROME)
Sitting/trunk control
Transfer
Walking
Stair climbing

Treadmill training with body


weight support

Robotics

Activity of daily living


Occupational therapy
Self care

Dressing
Grooming
Toilet use
Bathing
Eating
Adapt or specially design device

Constraint-Induced Movement
Therapy (CIMT)
Principle of
FORCED USE to
avoid the Learned
Nonuse of the
paretic side for
Stroke patients
Mainly for training
of upper extremity

Exercise Therapy
Neurodevelopmental techniques by Bobath
Stresses exercises that tend to normalize
muscle tone and prevent excessive
spasticity
Through special reflex-inhibiting postures &
movements
In beginning spasticity,
Slow, sustained stretching for spastic
muscles
Vibration of antagonist muscles to reduce
tone
through reciprocal inhibition.

Exercise Therapy to Develop


Motor
Control
Facilitation techniques:
1. Rood
involves superficial cutaneous stimulation using
stroking, brushing, tapping & icing or vibration
to evoke voluntary muscle activation
2. Brunnstrom
Emphasized synergistic patterns* of movement
that develop during recovery from hemiplegia
Encouraged the development of flexor &
extensor synergies during early recovery,
hoping that synergistic activation of muscle
would, with training, transition into voluntary
activation.

Exercise Therapy to Develop


Motor Control
Facilitation techniques:
3. Kabats Proprioceptive
Neuromuscular Facilitation (PNF)
Relies on quick stretching and
manual resistance of muscle
activation of the limbs in functional
direction, which are often spiral and
diagonal.

Exercise Therapy to Develop


Motor Control
Conventional methods:
Stretching & strengthening
Attempting to retrain weak muscles
through
reeducation

Hydrotherapy

Management- Balance Training

Management- coordination Training


Bully Therapy

Orthosis
Shoulder slings
Hand splint
Foot slings
Ankle foot orthosis

Shoulder slings

Shoulder slings

Hand splints
Flaccid = functional position

Wrist extend 20 30 degree


Flex MCP joint 45 degree
Flex PIP joint 30 - 45 degree
Flex DIP joint 20 degree

Hand splints

Foot slings

Ankle Foot Orthosis


- Plastic
- Metal

stability of ankle
balance
speed walking
Not enhance recovery

Ankle Foot Orthosis

Plastic AFO

Metal AFO

Shoulder pain
Sensorimotor dysfunction of upper
extremities
72% of stroke patient in first year
Delay rehabilitation

Causes of Hemiplegic Shoulder Pain

aetiology of hemiplegic shoulder pain is probably multifactorial.


Spasticity and hemiplegic shoulder pain are related. particularly
of the subscapularis and pectoralis muscles
It is uncertain whether shoulder subluxation causes hemiplegic
shoulder pain
the sustained hemiplegic posture: shoulder contractures or
restricted shoulder range of motion
reflex sympathetic dystrophy
Poor handling and positioning of the affected upper limb in stroke
patients contribute toward shoulder pain.
Many types of shoulder pathology have been suggested as
causes of shoulder pain including shoulder subluxation, capsulitis,
tendonitis, rotator cuff injury, bursitis, impingement syndrome,
spasticity, CRPS, brachial plexus injury, and proximal
mononeuropathies

Exercise Therapy to Develop Motor


Control
Facilitation techniques:
Kabats Proprioceptive Neuromuscular Facilitation

(PNF)

Treatment
Electrical stimulation
Shoulder strapping
Mobilization (esp. External rotator,
abduction)
prevent frozen shoulder,
shoulder hand pain
Medical
Intraarticular injections
Modalities : ice, heat, massage
Strengthening

Spasticity
Velocity dependent hyperactivity of
tonic stretch reflexes

Aim of treatment
Pain
ROM
Cosmatic
Hygiene
Mobility
Easy use orthosis
Delay surgery

Treatment
Avoid noxious stimuli
Positioning, passive stretching, ROME
Splinting, serial casting, surgical correction
Medical - tizanidine
- baclofen
- dantrolen
- avoid diazepam
Botulinum toxin A injection
Phenol / alcohol
Neurosurgical procedure (selective dorsal
rhizotomy)

Bowel and bladder incontinence


Urinary incontinence
- 50% incontinence during acute phase
- with time, ~ 20% at six months
- Risk: age, stroke severity, diabetes
- Indwelling catheter : management of
fluids, prevent urinary retention, skin
breakdown
- Use of foley catheter > 48 hours
UTI

Fecal incontinence
Improve within 2 weeks
Continued fecal incontinence poor prognosis

Constipation, fecal impaction

More common
Immobility, inadequate fluid or food intake,
depression or anxiety, cognitive deficit

Management

Adequate intake of fluid


Bulk and fiber food
Bowel training

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