Passive range of motion post-stroke/ neurological condition.

[ICU PT]

Hi everyone,

I have heard conflicting views/evidence regarding the use of PROM in the stroke/neuro population. I have not been able to find much in the way of conclusive evidence to support effectiveness of PROM although evidence does indicate that prolonged stretching, particularly long finger flexors and ankle DFs is beneficial post-stroke. In the hospital that I currently work at, PROM is NOT used in this population. I would like to hear from others to get a sense of standard practice in your hospital/clinic and the rational behind using or not using PROM in this population.

Thanks in advance.

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[MrPhysio+]

Hi ICU PT,
Good question. The field of Neuro has always been controversial, especially stroke. I have to admit being a little out of practise in this area, but used to work with closed head injury patients in the past.
Neuroplasticity is the key to recovery for any brain damage, therefore checking into this knowledge base could provide the answers. It is my belief that the damaged brain requires constant reminders of the stored movement patterns,
without which recovery is slowed. Initial phases of stroke causes some anoxic damage due to compromised blood supply flow (bleed or clot), then brain swelling causes further compression. If a clot, thrombus dissolving medication should be given within three hours, although recent evidence states that it is worthwhile within six hours post stroke. Recovery can be very much hastened with these drugs. Obviously thrombus thinners are contraindicated in bleeds.

As swelling reduces it will be more possible to differentiate areas left undamaged, those that have shut down due to compression but no permanent damage, those areas that are damaged but partially operative and those areas of brain that have died. The remodelling around the dead or damaged areas requires stimulation for the brain to have a reason to institute neural repair. The old days of believing that the brain cannot form new interconnections are over.

The unconcious brain will still accept some inputs if the person is eventually going to recover ie brain death is unlikely. If the patient is unconcious, taking the limb through passive movements will likely maintain inputs. This is way before any discussion of muscle tone increases, contractures, hemiplegic limbs etc are considered. The glenohumeral joint should be supported on the affected side to avoid dislocation if the arm is flaccid / no tone, otherwise axillary nerve damage could occur exacerbating problems.

If the patient is conscious, explain the situation and use the unaffected side to assist movement pattern reminders. Teach the patient to use the unaffected side to move the affected side. Ensure that the patient is thinking about what they are trying to achieve. Increase all input cues, visual, kinaesthetic, sound (verbal encouragement), use mirrors and feedback from relatives. The richer the recovery environment the better. As strange as it may sound, allowing the conscious patient to see videos of their pre stroke movement can be utilised as another input. Mirror boxes are becoming more popular to fool the brain into working.

If the movement patterns are kept up front in the patients mind then less retraining may be required later. The movement also helps the joint retain synovial fluid movement in joints improving lubrication and feeding joint cartilage. If the joints are permitted to become stiff and tight then it is far harder for the patient to overcome this resistance as muscle control returns. Prolonged delay in active muscle control means muscle atrophy from disuse and difficulty to use the limb against gravity let alone stiff joints.

I have probably gone on a bit too long here, so will finish.
If you have any further questions please feel free to ask.
Cheers,
MrPhysio+

[ICU PT]

Thanks Mr Physio+,

You make several very good points. Neuro literature strongly indicates the importance of "using" the affected side to promote recovery post-stroke through neuroplasticity and to prevent learned non-use. In school we are educated on PROM for many conditions, especially those where the patient lacks active movement and is at risk of developing contractures from prolonged bedrest, positioning,etc. My questions would be 1) as the muscle spindle is likely stretched during PROM, initiating the stretch reflex, is it likely that PROM in the neuro population could increase tone in the hemiparetic side? If anyone has clinical experience or evidence to speak for or against the use of PROM, I would love to hear it.

[MrPhysio+]

Hello ICU PT,
Thanks for the discussion question. I believe the answer may lay in the way the stretch is applied. A stretch reflex will occur if the muscle spindle detects a quick movement into elongation or if the spindle is approaching
an excessive stretch for its length. Should stretching be carried out slowly and not to excessive lengthening of the spindle then a strong reflex would not occur, reducing tone side effects.
Also, if the antagonist muscle is stretched first to elicit a stretch reflex in it then the accompanying inhibitory effect supplied to the muscle spindle that you really want to stretch will be reduced.
There are other physio techniques that can also reduce tone in muscles. A careful application of tone reduction techniques along with ongoing assessment of the patients tone during treatment can achieve
the desired result.

Unfortunately a lot of treatments are not black and white in the balance between wanted and unwanted effects. If the overall improvement in a patients outcome (increased function, active voluntary movements, decreased
retraining of neuro-muscular patterning etc) is possible, short term and controlled increases in tone should not be problematic.

Tonal balance is important between the flaccid muscle and the normally toned muscle, with upper limb flexion postures and lower limb extension postures.
To summarise; the difference between central and spinal tonal changes as they affect function need to be kept clear. Sometimes treating one area will impact negatively upon the other area in neurological rehab, but compromise
will be necessary. As a patient progresses the balance / emphasis of treatment will change. Acute, semi acute and longer term rehabilitation present different challenges often dependent upon the severity of the original damage, patient age and other factors (psychological, general health). My thoughts are that in the acute phase it is important to preserve the movement patterns then deal with the rest as assessment indicates.

I look forward to hearing from others working in this field.
MrPhysio+