Stroke with dense hemiplegia

Dear fellow physios,

i think i need a helping hand with a stroke patient.

He has had a RIGHT CVA about 20 days ago. Unfortunately, they let him go from hospital 10 days after the stroke.

I started seeing him last week and has no movement at all on LEFT arm.I read that no shoulder shrug or finger movements are not good prognosis.I am using electrical stimulation, massage with a brush, passive movements and PNF patterns to re-learn the movements.Last Monday he had spontaneous adduction of LEFT SHOULDER that's gone again.Do you think his arm will recover?

As for his LEFT LEG, he has no control of knee extension.How can we manage locking of the knee?

Thank you all

Spyros

Hi Spyros,
For the locking of the knee,teach the patient to weight bear on his knee-left with proper support in the front.I think u have jus started with this patient.I think i cant say about the recovery at the moment,also what is his age?
If he is stable enough,do activities in the left side ,do he uses more of his hand and balances in his left side more. like passing a ball or some object.In this way, body awareness and patterns of movements can be easily taught to the patient. uma madhu.

Hi Spyros,

I have had patients who were unable to even do elbow flexion and at the same time finger flexion for a month or two but with tapping and stimulation of the affected part done intensively during therapy sessions it will provide you with good results, sometimes you have to vary the position and not just stick to one.. others will also have no intiation at the beginning of the range but at the midrange or end-range of elbow flexion ( or any other ROM) you will get a contraction... and of course a STRONG command of instruction produces REALLY GOOD RESULTS. I guarantee you that. Been doing it for 3 years now hahaha!!! Usually I notice that patients do not respond to voices that are not loud enough. Mine works all the time...:) Goodluck to you!!!

Regards,
Charlize29:D

Try adapting "Constraint-induced movement therapy" It works!!!

Cheers!!:D

hiiiii dear
here i will give you some guid lines to add it to your rehab. programm

1-Regardin the shoulder apply electric stimulation for posterion fibers of deltoid + the supraspinatus to reduce the chance of sublaxation and pain

2-Encourage the TURNNING ACTIVITIES as early as possible

3-Focus On stretching of Latissmus dorsi mucsle as it tend to get tight affecting trunk stability and gait pattern

Regarding locking of knee joint i have a point of view here ,, the spastisty have positive feature in locking the knee joint and it will appear sooner ar later . ..But u can stimulate the locking action by:

1-try to apply approximation from knelling Position as it stimulat the locking by quadriceps muscle

2-Also try to teach the patient how to stand from sitting to stimulat the knee locking

3-Apply electric stimulation for the VMO (Vustus Medialis Oblicus) muscle on the medial aspect of thigh

finally you can use the knee orthosis for locking the knee during gait training


I HOPE U GET GOOD RESULT
my regards
THE THERAPIST ('',)

You can also get him doing self-assisted shoulder flexion if you teach him how to do it correctly.
Try active- assisted movements rather than passive movements. As he has no activity get him to imagine the muscles contracting as you're doing the movement. If he finds this difficult get him to move his right arm simultaneously so he can use the sensation of the movement in his right to imagine how it would feel in the left.
How is his sensation? If his sensation is good - assist him to handle different objects with his hand to provide stimulation.

Let us know how you're getting on.

Hi,
Motivation is the key factor in a stroke patient.Do a lot of talking.Ask him to first believe and visualize that ,he will be better.Also tell him that there is no magical potion that wud make him ok jus overnite,he has to struggle with u to attain the movement.
Activities like drawing with a crayon in his affected hand will give him a break from those strenuous exercises. Good luck!umamadhu.

I agree that motivation plays an important part in the rehabilitation process. Concentration and what umamadhu said about visualization helps. Stroke patients need a a lot of psychological support. Praising them for a small movement made would enable them to do more and feel encouraged. And if you could encourage him or her "TO HELP YOU" instead of you telling him to do it, they would be more willing to do so. It is not just on how you elicit a movement or response from them that is important but on how you build a rapport to every individual that makes the whole rehabiltiaiton process successful. :)

Cheers!!

Regards,
Charlize29

thank you all for your immediate response.

i'm sure it' d help a lot

sps

hello everybody it was really nice going through all this but i just wanna knw one thing is that y we want that patient to lock his knee coz if we r doing so no muscle activity of quads is seen as the joint is locked but insted we want him to learn to control his knee joint , so we must forget about asking him to lock the knee joint and instead start with eccentric knee extension exercise so that he develops control over his knee , u can start this first in supine lying and then in standing , and is standing we should go for stance training with knee slightly bend rather than knee completely extended that will stress the quads muscle and strengthening will take place.

Hi fire ice,
We are trying to put the patient in an anti-spastic pattern first.
Next,STABILITY is important than strengthening.Another point is that, CREATING AWARENESS OF THE BODY PARTS.Each time the patient should know he has to use the affected side more to initiate a movement.when this is achieved strengthening can be started.

What about rehabilitation principles for a stroke patient who doesn't have any function at all in his arm? I've tried stuff like PNF, but there's no motor response at all (still trying though). Can't use NMES or anything like that because of his pacemaker. Haven't really found any good literature or studies for this ...

although it may depend on how long since the stroke that isn't sounding too good is it. If you really aren't getting any muscle contraction at all the probability of useful recovery is poor. a number of prognosis studies of the upper limb after stroke, using absent muscle function as a prognostic indicator, have shown this impairment to be highly predictive of failure to obtain functional recovery.

By the way use of NMES may not be an absolute contraindication in relation to pacemakers:

Safety of a combined strength and endurance traini... [Wien Klin Wochenschr. 2003] - PubMed result

Elsevier

...although these studies are small for harm studies and a bad outcome is so serious. I wonder if NMES was applied quite distally (not shoulder stimulation) under cardiology supervision if it might be ok?

If the patient wants you to persist even knowing the likelihood of a poor result how about other alternatives:
EMG biofeedback
Other stimulation techniques like using a muscle vibrator, tapping or ice stroking, combined with Instructions to voluntarily contract.
what about mental practice: this has some evidence for it although personally I find you usually have to have something to start with. NB there is quite a skill to using mental practice - you really have to get the patient to focus hard on the muscle contraction and up the motivation -0 sort of personal trainer approach.

Thanks for the reply. Aye, I've considered mental practice, or rather I'm trying to make the patient apply it while I'm doing the passive PNF-movements. As for NMES I've considered that also, despite the pacemaker, but unfortunately they're not planning on getting any nmes devices here. The budget here is pretty low... I've also considered mirror therapy, although we don't have anything like that either. Can't say I've tried ice stroking.

Communication with the patient is on a very basic level, since he has severe expressive aphasia and also alzheimers and some other stuff. I've explained the possibility of not being able to regain function, but our conversations tend to be a little one-sided... all he did then was give me a frowning look.

Hi,
thanks gcoe, your comments are phantastic - as usual ...

In regards to ice stroking: that's a very old technique with origins in Bobath, if I'm not mistaken. If your patient has got absolutely no muscle contractions, you really are dependent on techniques, which cause extreme reactions. So, I would also recommend the use of ice.

Mirror technique: we build our own. Wasn't even too difficult. Just a tray, a bathroom mirror from an op-shop and a self-made wooden device to hold the mirror up.

The expressive aphasia shouldn't really cause too much trouble. You can overcome this with charts, pictures, spelling devices etc. If you've got access, get your Speech Therapist to guide you along. However, if it is a problem, then I presume, your client has got mixed dysphasia - combining expressive and receptive deficits.

The Alzheimers is a major draw back, however. A Physio treatment on it's own is not going to make a great change. As we rely on patients to continue their 'therapy' on their own, you will need to have some help there, especially, if your patient is unable to remember the actual session or any education you have provided.

Maybe this (the receptive dysphasia + non practice time) is why there has been such a poor progress in the first place. You need muscle contractions to keep to your muscle alive. First you loose muscle fibres, but after a prolongued time of inactivity you can actually loose whole motor units. And that doesn't leave much hope. Haven't got the reference handy, which gives more detail, but the longer there is absolutely no activity, the worse the prognosis.


Regards,
Fyzzio

Good suggestions.

As for the aphasia, I believe it's not the impressive type, because he seems to understand everything I say to him. Unfortunately there's no speech therapist available. He's at a geriatric nursing home (not sure if that's the right term?), and I'm the sole physiotherapist there as well as a bunch of other places, which severely limits my rehabilitation time with individual patients.

I've tried to emphasize to him the importance of mental practice and trying to activate the arm himself in addition to the rehabilitation, but I can't be sure how much of that he actually does. He was in a pretty bad shape even before the stroke, and right now he can't really move at all himself. He needs total assistance for getting out of bed into a wheelchair, etc. Also, he gets exhausted really fast, even when the assistant nurses do passive movements to prevent contractures...

One peculiar thing is that I once saw him move his hand from his side to his belly when he was lying down in bed. That was perhaps 3 weeks ago. The assistant nurses have said that he has done that a few times, although not in the past weeks. There was never any discernable muscle activity before and after those moments though.

This case study is really useful, keep up.