The physical therapist can provide splints and braces to support joints and limbs, to treat and prevent complications (eg, shoulder-hand syndrome, spasticity), and to assist the patient in walking.

Early after stroke, patients often have flaccid paralysis that can potentiate further complications such as contractures, joint subluxation, and nerve pressure palsies. For instance, common upper extremity examples are shoulder subluxation, ulnar neuropathy, and elbow flexion contractures. Physical therapy should focus on appropriate positioning and avoidance of traction, which can harm joints previously stabilized by muscular tone. Range of motion (ROM) should be preserved during this phase. Later efforts can be pursed to reeducate weak musculature through modalities that provide sensory feedback.


Neuromuscular electrical stimulation

Since no sling design definitively prevents or treats shoulder subluxation, an effective alternative available is NMES. It was reported that the aim of NMES is to reduce subluxation of the hemiplegic shoulder without the use of restrictive splints. NMES may even elicit strong sedative effects on pain by acting on sensory nerves. It is believed that it also could be used prophylactically as a temporary means of splinting the shoulder until recovery of motor function is sufficient enough to support the glenohumeral joint. Numerous other studies have suggested that it also improves spasticity and enhances muscle strength of the hemiparetic limb.
A study found that patients with hemiplegia and subluxation who received 5 weeks of NMES had significantly more improvement in pain relief, reduced subluxation, quicker motor recovery, and possibly facilitated recovery of shoulder function. These results were maintained for up to 2 years. However, it was recommended that patients continue exercising to maintain control of their pain. In chronic hemiplegic stroke and TBI patients, there was used percutaneous NMES (perc-NMES) in the posterior deltoid and supraspinatus muscles 6 hours per day for 6 weeks. This resulted in reduced subluxation and improvements in pain and disability. These results were maintained during 3 months of follow-up. It was subsequently followed this up with a study comparing transcutaneous-NMES with perc-NMES. It was found that perc-NMES is less painful, has a much easier application, and has potential for long-term use.
This study also found a reduction of shoulder subluxation, with possible enhancement of recovery and improvement in shoulder pain. At this point, the optimal muscles and number to stimulate has not been established. Using muscles with strong superior and medially directed forces, as well as those stabilizing the scapula, may significantly enhance the efficacy of this intervention.

Even after 6 months poststroke, forced active repetitive movements of the paretic limb through the use of NMES appears to enhance motor and functional recovery. This has been clinically proven to occur as a result of neuroplasticity, in which active repetitive training of the hemiparetic limb causes functional reorganization in the adjacent intact cortex, subsequently allowing for maximum motor recovery. There was treatment of the extensor digitorum communis (EDC) and extensor carpi radialis (ECR) by combining neuromuscular stimulation with active repetitive wrist and finger extension exercises for one hour per day for a total of 15 sessions, subsequently producing significantly enhanced motor recovery that was maintained for up to 12 weeks. However, no significant functional effect was proven.

See Biofeedback and electrical Stimulation for Stroke Recovery

See Functional Electrical Stimulation and Upper Extremity Motor Relearning

Active Repetition

The use of active repetition has been shown to maximize motor relearning when used in the appropriate candidate. It is found that stroke patients who were less severely impaired (ie, possessed some early volitional arm movement) prior to treatment benefited from the use of early additional therapies that involved repetitive movements and functional tasks. However, patients with severe arm impairment showed very little improvement in function irrespective of receiving additional therapies. This data supports previous clinical trials that suggest there is no current physical therapy approach that results in sustained improvements of upper limb function in patients who are severely impaired. In patients who are severely impaired, the use of adaptive techniques and equipment may be an appropriate rehabilitation strategy.
Following basic concepts be used during muscle reeducation:

Patient should visualize (ie, mirror) specific movements.
Verbally reinforce intended movements and encourage the feel of specific motions.
Copy similar motions performed simultaneously by the contralateral arm.
Position the UE to decrease scapular depression and retraction.
Apply sensory stimulation simultaneously to movements.
Use prone exercises to stimulate righting reflexes that tend to imitate primitive motor function.
Start seated and standing stimulation exercises to help decrease subluxation and modify synergy patterns.
Attempt to increase passive range of motion (PROM) with gentle slow motion, rhythmic stabilization, or voluntary contraction followed by relaxation or gentle stretching.
Avoid vigorous traction on the arm when stretching connective tissue around the spastic joint.
Use of electric stimulation can enhance muscle relaxation.
Use the functional arm to simultaneously train the paretic arm to improve ROM and proprioceptive stimulation.
Use modalities (eg, ice, transcutaneous electrical nerve stimulation [TENS], vibration) to diminish spasticity.
Surgical Intervention: In the past, surgical release of tendons and muscle was commonly performed on patients experiencing prolonged spasticity and synergy. For patients experiencing a painful spastic shoulder, surgical transection of the subscapularis and pectoralis tendons was performed to eliminate internal rotation and adduction forces. Hecht et al reported that following treatment, up to 88% of these patients had improved pain and increased ROM, with some developing active abduction. Today, this form of treatment rarely is used.

Stroke syndromes present with various alterations in motor, sensory, and cognitive function, each unique in clinical presentation and prognosis. Although there are general principles of stroke recovery, no two patients share the same experience. Understanding the correlated physiologic and anatomic changes in the brain helps identify which syndrome is present and how best to institute comprehensive rehabilitation to meet the individual needs of the patient.

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