Hemmorhagic stroke

hello everybody!

I have a 69 year old female patient diagnosed L hemiplegia. She's disoriented as to time, place and distance. still in flaccid stage. Blood pressure is not stable but her diastolic mostly my concern...40mmhg or 50 mmhg. She has also a left shoulder subluxation about 1 finger and it is always the cause of pain upon sidelying on the affected side and upon sitting. My management includes...ES to supraspinatus and deltoid muscle for 30 mins, extensor muscles of the forearm for 15 mins, extensores of the lower extremities for 15 mins, AAROM on Right side and PROM on Left side. we do also sitting balance tolerance for 10 mins.

My question is ....what is mostly the highest functional level of this patient? She's also diabetic by the way...and is there a possibility for her to walk again?

Thanks and more power....

Can't give prognosis on so little data
Your EMS on supraspinatus should slowly be increased to up to six hours continuous and is for pain control not functon. If you have lost external rotation you can expect to have no elevation past 90 degrees and SHOULD NOT be trying to range past this. Before ranging make sure you approximate the shoulder to eliminate impingement and levering on ligaments. Do not do pulley work or have the patient do auto assisted flexion into elevation. This will only increase pain and cause further loss of range. Always have the arm supported when sitting . In lying never lie directly on the shoulder but rather pull the shoulder forward so weight bearing is on the scapula. A quarter turn off supine is recommended rather than fully over on the side. In supine supporting the arm in some abd, flex, and ext rot is ideal.
Its not unusual for fatique to be the limiting factor initially but this usually improves.
Rather than all the other EMS functional activity would probably be better.

highmode

I agree with high mode when he/she speaks about little data!
since how long this lady is in the described status?
What about her disoriantation? has she got proprioceptive impairment? does she fell her left side? are the exercise passive/active involving her attention? sorry for all this question but to speak about "function" it seems too early, anyway the cognitive approach could be ususfull to reduce the disorientation and increase body awareness....
robyxco

Hi,
I think EMS to Hip Extensors is totally contraindicated in this case.
Your patient with walk with a little bit more patience. She might need cueing.Employ PNF.
Love

I two would like to know how long she is post stroke and also where and what her lesion is? That said one might generally suggest that a left hemiplegia is often a little slower to progress and with more residual lower limb issues that a right hemi. I would say however that often left upper limbs show remarkable restoration of function whereas right can turn into a spastic paralysis, perhaps the result of walking to early?

Only time will tell but keep us informed of progress and perhaps we can suggest a few rehab approaches. For now really work on her sitting balance as this forms the base of support for everything else. :)

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. 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 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.

See Achievement of Human Potential


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).

See Proprioceptive Neuromuscular Facilitation

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

See Bobath

D-A motor relearning programme :

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 Australian region.

See Motor Relearning

See Motor Relearning for Upper Extremity

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

See Brunnstrom's Movement therapy Approach

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.

See More on Stroke