REHABILITATION OF REHABILITATION OF PATIENTS WITH PATIENTS WITH

HEMIPLEGIAHEMIPLEGIA

RehabilitationRehabilitation– purpose - restore function following an illness or purpose - restore function following an illness or

injury, with the goal of maximizing a person’s injury, with the goal of maximizing a person’s ability to achieve fullest life possibleability to achieve fullest life possible

– The ultimate aim of stroke research and The ultimate aim of stroke research and rehabilitation after stroke is to reduce rehabilitation after stroke is to reduce impairment, disability and handicap and to impairment, disability and handicap and to enhance the quality of life.enhance the quality of life.

Interdisciplinary teamInterdisciplinary team– physicians, nurses, PT, OT, speech-language physicians, nurses, PT, OT, speech-language

therapists, psychologists, social workers, therapists, psychologists, social workers, recreational therapists.recreational therapists.

RehabilitationRehabilitation

Rehabilitation therapy should start as Rehabilitation therapy should start as early as possible, once medical stability is early as possible, once medical stability is reachedreached

Spontaneous recovery can be impressive, b Spontaneous recovery can be impressive, b - ut rehabilitation induced recovery seems to - ut rehabilitation induced recovery seems to be greater on average. be greater on average.

Even though the most marked improvemen Even though the most marked improvemen t is achieved during the first 3 months, reha t is achieved during the first 3 months, reha

bilitation should be continued for a longer p bilitation should be continued for a longer p eriod to prevent subsequent deterioration. eriod to prevent subsequent deterioration.

RehabilitationRehabilitation

NN o patient should be excluded from rehabilitation o patient should be excluded from rehabilitation unless he is too ill or too cognitively devastated to unless he is too ill or too cognitively devastated to

participate in a treatment program. participate in a treatment program. Proper positioning and early passive ROM exercise Proper positioning and early passive ROM exercise

s help to avoid complications at a flaccid stage. s help to avoid complications at a flaccid stage. Family members should participate in therapy ses Family members should participate in therapy ses

sions. sions. The family should also be referred to community g The family should also be referred to community g

roups that offer psychosocial support such as strok roups that offer psychosocial support such as strok e clubs at the time of discharge. e clubs at the time of discharge.

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Poor PrognosisPoor Prognosis

Decreased alertness,inattention,poor Decreased alertness,inattention,poor memory,inability to learn new tasks or memory,inability to learn new tasks or follow simple commandsfollow simple commandssevere neglect or anosognosiasevere neglect or anosognosiasignificant medical problems esp, significant medical problems esp, cardiovascular or DJDcardiovascular or DJDserious language disturbanceserious language disturbanceless well defined & economic problemless well defined & economic problem

Effect of a StrokeEffect of a Stroke

1. Weakness on the side of the body opposite the 1. Weakness on the side of the body opposite the site of the brain affected by the strokesite of the brain affected by the stroke2. Spasticity, stiffness in muscles, painful muscle 2. Spasticity, stiffness in muscles, painful muscle spasmsspasms3. Problems with balance and/or coordination3. Problems with balance and/or coordination4. Problems using language, including having 4. Problems using language, including having difficulty understanding speech or difficulty understanding speech or writing(aphasia); and knowing the right words but writing(aphasia); and knowing the right words but having trouble saying them clearly (dysarthria)having trouble saying them clearly (dysarthria)5. Being unaware of or ignoring sensations on one 5. Being unaware of or ignoring sensations on one side of the body (bodily neglect or inattention)side of the body (bodily neglect or inattention)6. Pain, numbness or odd sensations6. Pain, numbness or odd sensations

Effect of a StrokeEffect of a Stroke ( (con’t)con’t)

7. Problems with memory, thinking, 7. Problems with memory, thinking, attention or learningattention or learning8. Being8. Being unaware of the effects of a strokeunaware of the effects of a stroke9. Trouble swallowing (dysphagia)9. Trouble swallowing (dysphagia)10. Problems with bowel or bladder control10. Problems with bowel or bladder control11. Fatigue11. Fatigue12. Difficulty controlling emotions 12. Difficulty controlling emotions (emotional lability)(emotional lability)13. Depression13. Depression14. Difficulties with daily tasks14. Difficulties with daily tasks

Rehabilitation GoalRehabilitation Goal

To restore lost abilities as much as To restore lost abilities as much as possible possible

- To prevent stroke related complications - To prevent stroke related complications

To improve the patient's quality of life To improve the patient's quality of life

To educate the patient and family about To educate the patient and family about how to prevent recurrent strokes how to prevent recurrent strokes

- Promote re integration into family, home, - Promote re integration into family, home, work, leisure and community activities work, leisure and community activities

Successful Rehabilitation Successful Rehabilitation

Depend onDepend on

- how early rehabilitation begins- how early rehabilitation begins

- the extent of the brain injury- the extent of the brain injury

- the survivor’s attitude- the survivor’s attitude

- the rehabilitation team’s skill- the rehabilitation team’s skill

- the cooperation of family and - the cooperation of family and caregivercaregiver

Basic Principles of Rehabilitatio Basic Principles of Rehabilitationn

To begin as possible early (first hours) To begin as possible early (first hours)

To assess the patient systematically To assess the patient systematically

To prepare the therapy plan carefully To prepare the therapy plan carefully

To build up in stages To build up in stages

To include the type of rehabilitation approa To include the type of rehabilitation approa ch specific to deficits ch specific to deficits

To evaluate patient To evaluate patient’’ s progress regularly s progress regularly

Rehabilitation ManagementRehabilitation Management

MobilityMobilityActivity of daily livingActivity of daily livingCommunicationCommunicationSwallowingSwallowingOrthosisOrthosisShoulder painShoulder painSpasticitySpasticityCognitive and perceptionCognitive and perceptionMoodMoodBowel and bladder incontinenceBowel and bladder incontinence

MobilityMobility

PhysiotherapyPhysiotherapy– Conventional therapiesConventional therapies– Neurophysiological therapiesNeurophysiological therapies

Conventional therapiesConventional therapiesTherapeutic ExercisesTherapeutic Exercises

Traditional Functional RetrainingTraditional Functional Retraining

Range Of Motion (ROM) ExercisesRange Of Motion (ROM) Exercises

Muscle Strengthening ExercisesMuscle Strengthening Exercises

Mobilization activitiesMobilization activities

Fitness trainingFitness training

Compensatory TechniquesCompensatory Techniques

Neurophysiological ApproachesNeurophysiological Approaches

1. Muscle Re-education Approach 1. Muscle Re-education Approach (1920S)(1920S)

2. Neurodevelopmental Approaches 2. Neurodevelopmental Approaches (1940-(1940-70S)70S)– Sensorimotor Approach Sensorimotor Approach (Rood, 1940S)(Rood, 1940S)

– Movement Therapy Approach Movement Therapy Approach (Brunnstrom, 1950S)(Brunnstrom, 1950S)

– NDT Approach (Bobath, 1960-70S)NDT Approach (Bobath, 1960-70S)– PNF Approach PNF Approach (Knot and Voss,1960-70S)(Knot and Voss,1960-70S)

3. Motor Relearning Program for Stroke 3. Motor Relearning Program for Stroke (1980S)(1980S)

4. Contemporary Task Oriented Approach 4. Contemporary Task Oriented Approach (1990S)(1990S)

AimAim

Improve Improve – MovementMovement– BalanceBalance– coordinationcoordination

SafetySafety

Basic Physical TherapyBasic Physical Therapy

Bed positioning, mobilityBed positioning, mobility

Range of motion exercises Range of motion exercises (ROME)(ROME)

Sitting/trunk controlSitting/trunk control

TransferTransfer

WalkingWalking

Stair climbingStair climbing

Treadmill training with body Treadmill training with body weight supportweight support

RoboticsRobotics

Activity of daily livingActivity of daily living

Occupational therapyOccupational therapy– Self careSelf care DressingDressing

GroomingGroomingToilet useToilet use

BathingBathingEatingEating

– Adapt or specially design deviceAdapt or specially design device

Constraint-Induced Movement Constraint-Induced Movement Therapy (CIMT)Therapy (CIMT)

Principle of Principle of FORCED USE to FORCED USE to avoid the Learned avoid the Learned Nonuse of the Nonuse of the paretic side for paretic side for Stroke patientsStroke patients

Mainly for training Mainly for training of upper extremityof upper extremity

Exercise Therapy Exercise Therapy Neurodevelopmental techniques by BobathStresses exercises that tend to normalize muscle tone and prevent excessive spasticityThrough special reflex-inhibiting postures & movementsIn beginning spasticity,Slow, sustained stretching for spastic musclesVibration of antagonist muscles to reduce tone through reciprocal inhibition.

Exercise Therapy to Develop Exercise Therapy to Develop Motor ControlMotor Control

Facilitation techniques:1. Roodinvolves superficial cutaneous stimulation using stroking, brushing, tapping & icing or vibration to evoke voluntary muscle activation2. BrunnstromEmphasized synergistic patterns* of movement that develop during recovery from hemiplegiaEncouraged the development of flexor & extensor synergies during early recovery, hoping that synergistic activation of muscle would, with training, transition into voluntary activation.

Exercise Therapy to Develop Exercise Therapy to Develop Motor ControlMotor Control

Facilitation techniques:3. Kabat’s Proprioceptive Neuromuscular Facilitation (PNF)Relies on quick stretching and manual resistance of muscle activation of the limbs in functional direction, which are often spiral and diagonal.

Exercise Therapy to Develop Exercise Therapy to Develop Motor ControlMotor Control

Conventional methods:Conventional methods:•StretchingStretching & strengthening & strengthening

•Attempting to retrain weak muscles Attempting to retrain weak muscles through through

reeducationreeducation

HydrotherapyHydrotherapy

Management- Balance TrainingManagement- Balance Training

Management- coordination Training Management- coordination Training Bully Therapy Bully Therapy

OrthosisOrthosis

Shoulder slingsShoulder slings

Hand splintHand splint

Foot slingsFoot slings

Ankle foot orthosisAnkle foot orthosis

Shoulder slings

Shoulder slings

Hand splintsHand splints

Flaccid = functional positionFlaccid = functional position– Wrist extend 20 – 30 degreeWrist extend 20 – 30 degree– Flex MCP joint 45 degreeFlex MCP joint 45 degree– Flex PIP joint 30 - 45 degreeFlex PIP joint 30 - 45 degree– Flex DIP joint 20 degreeFlex DIP joint 20 degree

Hand splints

Foot slings

- Plastic- Plastic- MetalMetal

stability of anklestability of ankle balancebalance speed walkingspeed walkingNot enhance recoveryNot enhance recovery

Ankle Foot OrthosisAnkle Foot Orthosis

Plastic AFO Metal AFO

Ankle Foot OrthosisAnkle Foot Orthosis

Shoulder painShoulder pain

Sensorimotor dysfunction of upper Sensorimotor dysfunction of upper extremitiesextremities

72% of stroke patient in first year72% of stroke patient in first year

Delay rehabilitationDelay rehabilitation

Causes of Hemiplegic Shoulder Pain Causes of Hemiplegic Shoulder Pain

• aetiology of hemiplegic shoulder pain is probably multifactorial.aetiology of hemiplegic shoulder pain is probably multifactorial.• Spasticity Spasticity and hemiplegic shoulder pain are related. particularly and hemiplegic shoulder pain are related. particularly

of the subscapularis and pectoralis musclesof the subscapularis and pectoralis muscles• It is uncertain whether shoulder It is uncertain whether shoulder subluxationsubluxation causes hemiplegic causes hemiplegic

shoulder painshoulder pain• the sustained hemiplegic posture: shoulder contractures or the sustained hemiplegic posture: shoulder contractures or

restricted shoulder range of motionrestricted shoulder range of motion• reflex sympathetic dystrophyreflex sympathetic dystrophy• Poor handling and positioning of the affected upper limb in stroke Poor handling and positioning of the affected upper limb in stroke

patients contribute toward shoulder pain.patients contribute toward shoulder pain.• Many types of shoulder pathology have been suggested as Many types of shoulder pathology have been suggested as

causes of shoulder pain including shoulder subluxation, capsulitis, causes of shoulder pain including shoulder subluxation, capsulitis, tendonitis, rotator cuff injury, bursitis, impingement syndrome, tendonitis, rotator cuff injury, bursitis, impingement syndrome, spasticity, CRPS, brachial plexus injury, and proximal spasticity, CRPS, brachial plexus injury, and proximal mononeuropathiesmononeuropathies

Exercise Therapy to Develop Motor Exercise Therapy to Develop Motor ControlControl

Facilitation techniques:Facilitation techniques:

Kabat’s Proprioceptive Neuromuscular Facilitation Kabat’s Proprioceptive Neuromuscular Facilitation

(PNF)(PNF)

TreatmentTreatment

Electrical stimulationElectrical stimulation

Shoulder strappingShoulder strapping

Mobilization (esp. External rotator, Mobilization (esp. External rotator, abduction) prevent frozen shoulder, abduction) prevent frozen shoulder, shoulder hand painshoulder hand pain

MedicalMedical

Intraarticular injectionsIntraarticular injections

Modalities : ice, heat, massageModalities : ice, heat, massage

Strengthening Strengthening

SpasticitySpasticity

Velocity dependent hyperactivity Velocity dependent hyperactivity of tonic stretch reflexesof tonic stretch reflexes

Aim of treatmentAim of treatment

PainPain

ROMROM

CosmaticCosmatic

HygieneHygiene

MobilityMobility

Easy use orthosisEasy use orthosis

Delay surgeryDelay surgery

TreatmentTreatment

Avoid noxious stimuliAvoid noxious stimuliPositioning, passive stretching, ROMEPositioning, passive stretching, ROMESplinting, serial casting, surgical correctionSplinting, serial casting, surgical correctionMedical Medical - tizanidine- tizanidine

- baclofen- baclofen- dantrolen- dantrolen- avoid diazepam- avoid diazepam

Botulinum toxin A injection Botulinum toxin A injection Phenol / alcoholPhenol / alcoholNeurosurgical procedure (selective dorsal Neurosurgical procedure (selective dorsal rhizotomy)rhizotomy)

Bowel and bladder Bowel and bladder incontinenceincontinence

Urinary incontinenceUrinary incontinence- 50% incontinence during acute phase- 50% incontinence during acute phase- with time, ~ 20% at six months- with time, ~ 20% at six months- Risk: age, stroke severity, diabetes- Risk: age, stroke severity, diabetes- Indwelling catheter : management of - Indwelling catheter : management of fluids, prevent urinary retention, skin fluids, prevent urinary retention, skin breakdownbreakdown- Use of foley catheter > 48 hours UTI- Use of foley catheter > 48 hours UTI

Fecal incontinence Fecal incontinence – Improve within 2 weeksImprove within 2 weeks– Continued fecal incontinence poor prognosisContinued fecal incontinence poor prognosis

Constipation, fecal impactionConstipation, fecal impaction– More commonMore common– Immobility, inadequate fluid or food Immobility, inadequate fluid or food

intake, depression or anxiety, cognitive intake, depression or anxiety, cognitive deficitdeficit

Management Management – Adequate intake of fluidAdequate intake of fluid– Bulk and fiber foodBulk and fiber food– Bowel trainingBowel training