Neuro patient query

[physioo]

Hi guys
I am treating this patient at the moment

Had R stroke 1 year ago. LL is exhibiting an increase in tone, but muscle strength is grade 4/5, however LL endurance is very poor.

I was considering emabrking on an exercise programe for this patient, emphasising on HAmstrings and quads, together with glud med and min exs (SLR, SHort arc quads, abd in lying, using light 1kg weights). I am a bit skeptical however, as IM afraid this might further increase tonal levels.

Can you help? thanks ppls:\

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[sdkashif]

Stroke rehabilitation is a combined and coordinated use of medical, social, educational, and vocational measures for retraining a person to his/her maximal physical, psychological, social, and vocational potential, consistent with physiologic and environmental limitations.

Many studies show that stroke rehabilitation is effective and can improve functional ability, even in patients who are elderly or medically ill and who have severe neurologic and functional deficits. Experts in stroke rehabilitation abound, but none have proven anything about rehabilitation to the satisfaction of anyone else.

Evidence from clinical trials supports the premise that early initiation of therapy influences the outcome favorably. When the initiation of therapy is delayed, patients may develop secondary avoidable complications, such as contractures and deconditioning, in the interim.

The course of motor recovery reaches a plateau after an early phase of progressive improvement. Most recovery takes place in the first 3 months, and only minor additional measurable improvement occurs after 6 months following onset; however, recovery may continue over a longer period of time in some patients who have significant partial return of voluntary movement.


A number of treatment approaches are available and you may chose according to your needs and assessement of the patient. These are

A-Conventional Physiotherapy programme - Traditional therapy - Range of motion, strengthening, mobilization, and compensatory techniques. After initial assessment, a physical therapy program should begin with passive exercises, where the major joints of the paretic limb are moved through a full range of movement (ROM). As soon as patients are stable and can tolerate more active therapy, encourage them to sit up (initially in bed and later in a chair), to stand, and to transfer safely; then, they can commence ambulating with assistance and aids as required. 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.

Independent ambulation is an important ultimate goal, often requiring several stages of recovery. Initially, patients exhibit poor trunk control, are unable to bear weight on the affected extremity, and are unable to advance the leg during the swing phase. Initial therapy should focus upon posture, trunk control, and weight transfer to the hemiparetic leg. Many patients have weakness of ankle dorsiflexion and require an ankle-foot orthosis (AFO) to prevent foot drop and maintain knee extension during weight bearing.

When the patient is stable, assess his or her ability to perform activities of daily living (ADL), such as dressing and undressing, bathing, personal grooming, toileting, preparing meals, and eating. The occupational therapist can advise on equipment that may allow the patient to be more independent. If the patient is returning home, an assessment of the residence identifies potential problems and necessary modifications (eg, handrails, moving a bed to a ground level room), thereby providing confidence to the patient and family.

Recreational therapy improves the functioning, independence, and self-confidence of patients following stroke through participation in individual and group recreational activities that they enjoyed before their strokes and through participation in new ones. The recreational therapist must assess the patient's medical condition and physical capabilities, as well as the patient's interests and hobbies. Then, the therapist must help the patient set realistic goals and make any necessary modifications to achieve these goals. Recreational therapy not only allows the stroke patient to practice motor skills but also allows the patient to remain socially active. Recreational therapy includes leisure activities, such as going for a walk, fishing, and gardening, as well as involvement in family and community activities, such as playing cards and going to a restaurant.

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B-PNF ( KABAT TECHNIQUES) Techniques- Proprioceptive Neuromuscular Facilitation Techniques - Knott, Voss - Proprioceptive neuromuscular facilitation

Stimulation of nerve/muscle/sensory receptors to evoke response through manual stimuli to increase ease of movement and promote function

Normal neuromuscular mechanism capable of wide range of motor activities within limits of anatomical structure, developmental level, and previously learned neuromuscular responses; integrated and efficient without awareness of individual muscle action, reflex activity, other reactions

Deficient neuromuscular mechanism inadequate to meet demands of life because of weakness, incoordination, adaptive joint shortening/immobility, muscle spasm, or spasticity

Specific demands placed by physical and occupational therapists have facilitating effects of neuromuscular mechanism and reverse limitations of patient

Mass-movement patterns keep with Beevor axiom (ie, the brain knows nothing of individual muscle action but only movement).

Proprioceptive neuromuscular facilitation (PNF) involves repeated muscle activation of the limbs by quick stretching, traction, approximation, and maximal manual resistance in functional directions (ie, spiral and diagonal patterns) to assist with motor relearning and increasing sensory input. Brennan asserts that it is based on the principles of normal human development (ie, mass movements precede individual movements, reflexive movements precede volitional movements, developments occur cephalically to caudally, control is gained proximally prior to distally, the timing of normal movements is distal to proximal). Lorish et al considers it to be an optimal method of stretching in patients with hemiplegia.

In an attempt to relax spastic antagonist muscle groups, rhythmic stabilization can be used, which involves alternating voluntary contractions of agonist and antagonist muscles. However, Brandstater reveals PNF to be more effective when muscle weakness is not due to upper motor neuron lesions.

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C-Bobath - Neurodevelopmental training Muscle patterns, not isolated movements, used for movement

Inability to direct nervous impulses to muscle in different combinations used by persons with intact CNS

Suppress abnormal muscle patterns before normal patterns are introduced

Associated reactions - Mass synergies avoided, may strengthen weak unresponsive muscles (reinforces abnormally increased tone reflexes and spasticity)

Uses reflex-inhibiting patterns to inhibit abnormal postural reactions, but facilitates automatic voluntary movements

Abnormal patterns modified at proximal key points of control (eg, neck, spine, shoulder, pelvis

the neurodevelopmental technique (NDT) is probably the most widely accepted method used in the development of motor control in patients with hemiplegia. Exercises that promote normal muscle tone and diminish excessive spasticity through the use of reflex-inhibiting postures are performed and allow the patient to feel normal movements while preventing the use of compensatory motions. This facilitates higher-level reactions and patterns in order to attain normal automatic motor responses that eventually allow the performance of skilled voluntary movement. Brandstater suggests that reciprocal inhibition also be used to temporarily reduce tone in spastic antagonist muscles through the use of a vibratory stimulus.

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D-A motor relearning programme :

Developed by Carr and Shephard, this practical method emphasizes motor relearning by practicing task-specific motor activities while sitting, standing, or walking. Therapists analyze each task, determine which components the patient cannot perform or has difficulty performing, trains the patient in those components of the task, and ensures carryover of this training during daily activities. Brenan maintains that ultimately, treatment focuses on eliminating unnecessary muscle activity, subsequently expediting skilled motor activities. Lorish et al contends that the use of task-specific training programs tends to be more consistent with modern theories of motor relearning.

It is mainly practised in Australia and have been originated there. Success with accelerated recovery has been claimed by the practitioner doing practising this method. Although many comparative studies have been done but its long term success over other physiotherapy methods has yet to be established through out the world after its use by the other practising physiotherapists all over the world particularly in other countries other than Australia region.

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E- Brunnstrom - Enhances specific synergies through use of cutaneous/proprioceptive stimuli; central facilitation using Twitchell's recovery

Assuming normal stages of recovery following stroke, Brunnstrom encouraged reflex tensing in order to develop flexor and extensor synergies during early recovery. According to Reding, induced synergistic reflexes transition into voluntary activation through central facilitation when applied to physiotherapy. Functional utilization uses techniques such as tonic stretches and voice commands to elicit muscle contractions.

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F-Sensorimotor integration

Advocated by Rood, the sensory integration system, as described by Brandstater, involves superficial sensory stimulation and feedback to the affected extremity by means of brushing, stroking, tapping, icing, vibration, sudden or gentle stretching of the muscle, and even electrical stimulation to facilitate muscle activation. The use of robot-aided sensorimotor stimulation also has been implemented. It was researched the effects of using a robotic device that interacts with the patient in real-time to enhance motor outcome. The robot was able to guide the powerless limb and provided a sensorimotor experience that responds quickly, just like hand-over-hand therapy. In their randomized blinded study, robot-trained subjects demonstrated improved motor outcome of the shoulder and elbow, as well as improved function.

So theoretically, if motor recovery does in fact depend on motor relearning, then optimal therapies can be tailored for individual patient needs through treatments performed by robotic devices. Overall, Volpe believes that "focused sensorimotor exercise appears to produce better motor outcome."

G-Biofeedback

Biofeedback is based on muscular relaxation and/or reeducation by verbal, visual, sensory, or auditory responses. Biofeedback is used in an attempt to relax the antagonist muscles, subsequently allowing the opposed agonists to function more effectively. In order to reeducate the UE, the spastic scapular and glenohumeral antagonist muscles need to be released in order for the agonists to work more proficiently. A common type of biofeedback, which was first introduced in 1960, involves the use of EMG for neuromuscular reeducation. Overall, trials involving EMG biofeedback have shown mixed results, and its cost-effectiveness is uncertain. However, a meta-analysis by Schleenbaker et al showed it to be an effective tool for neuromuscular reeducation and improving functional outcomes in stroke patients with hemiplegia.

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H-Active repetition

The use of active repetition has been shown to maximize motor relearning when used in the appropriate candidate. Perry et al 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.

I-Constraint-induced movement therapy

Constraint-induced movement therapy (CIT) is a family of therapies that induce patients who have had a stroke to greatly increase the amount and quality of movement of their paretic limb, in turn improving function. CIT is based on the theory of "learned nonuse". Following substantial neurological injury, a shocklike phenomenon, called diaschisis, results in a dramatically depressed condition of motor neuron function. During this shock period, the patient is unable to move the affected limb and subsequently learns to compensate with the functional limb. As the shock resolves and function starts to improve, attempts to use the affected limb result in clumsy and ineffective movements that positively reinforce continued compensation.

Treatment begins by restraining the functional limb during all waking hours, except for specified activities, and then forcing the patient to perform tasks almost exclusively with their paretic limb for up to 2 weeks. This usually produces measurable improvement of function in the paretic limb, as well as increases in speed and strength of contraction, provided some selective hand movement (slight wrist and finger extension), good balance, and good cognitive and communication skills are present.

A behavioral training technique called shaping often is used in conjunction with CIT. Shaping has resulted in substantial improvement of motor function. Shaping approaches a desired motor outcome in small successive steps through explicit positively reinforced feedback by the therapist. This allows subjects to experience successful gains in performance with relatively small amounts of motor improvement. A battery of approximately 60 tasks has been developed with a preliminary shaping plan for each task. Each task can be broken down into subtasks. Performance regressions are never punished and usually are ignored. If performance continues to exhibit no improvement after approximately 3 trials, the subject is encouraged to improve further at a later time, a simpler subtask is attempted, or an entirely different task is substituted. Eventually, an individualized task-oriented home program that emphasizes the use of the most impaired movements and joints is established.

Researchers report that patients tend to reach a plateau in motor recovery within 6-12 months following stroke. refuted this by studying the effectiveness of CIT in overcoming learned nonuse in chronic hemiplegic stroke patients. Compared to an attention-comparison group, the restrained subjects improved on each measure of motor function (ie, performance time, quality of movement, range of activities); in most cases, patients improved markedly. Two-year follow-up revealed that ADL functions had been maintained or increased. Researchers subsequently concluded that the use of CIT proved to be an effective means of restoring substantial motor function in chronic stroke patients.

See more on Constraint Induced Movement Therapy


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.

Kindly share your own clinical research and methods & techniques upon the physiotherapy management in stroke or hemiplegia.

[sdkashif]

The valuable references for Further reading are as follows:

Physical Therapy of the Shoulder. Second Edition By Robert A. Donatelli

Cash's Textbook of neurology for Physiotherapists. 4th Edition by Patricia A. Downie

Tidy's Physiotherapy. 13th Edition by Stuart Porter

Physical Rehabilitation. Assessment and Treatment. Third Edition. By Susan B. O'Sullivan & Thomas J. Schmitz

Clayton"s Electrotherapy. 10th Edition By Sheila Kitchen & Sarah Bazin

Clinical Electrotherapy. Second Edition by Nelson & Currier

Therapeutic Expercises. Foundation and techniques. Third Edition by Carolyn Kisner & Lynn Allen Colby

Carr JH, Shephard RB: A Motor Relearning Programme for Stroke. 2nd ed. Oxford: Butterworth-Heinemann; 1992

Morris DM: Constraint-Induced Movement Therapy for Motor Recovery After Stroke. NeuroRehabil 1997

Proprioceptive Neuromuscular Facilitation Techniques - Knott, Voss - PNF. Third Edition

Brunnstrom,S: Movement therapy in hemiplegia. Harper & Row, New York.

Bobath, B: Adult Hemiplegia: Evaluation and treatment. 2nd Edition

Calliet, R: The Shoulde in Hemiplegia. FA Davis, Philadelphia.

Davis P: Steps to follow- A guide to the treatment of adult hemiplegia, Springer-Verlag, New York. 1985

Duncon, P and Badke, M: Stroke rehabilitation: The recovery of motor Control. Year Book Medical publication, Chicago, 1987.

Charness, A: Stroke/Head Injury- A Guide to Functional out come in Physical Therapy Management.