stroke: pt assessment and management
TRANSCRIPT
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STROKE
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Dr. L. Surbala (MPT Neuro)
Introduction Stroke is an acute onset of
neurological dysfunction due to an abnormality in cerebral circulation with resultant signs & symptoms which corresponds to involvement of focal areas of the brain
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Dr. L. Surbala (MPT Neuro)
Acc. To who It is defined as the sudden onset of
neurological deficits due to an abnormality in cerebral circulation with the signs and symptoms lasting for more than 24 hours or longer
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Dr. L. Surbala (MPT Neuro)
Transient ischemic attack It is defined as the sudden onset of
neurological deficits due to an abnormality in cerebral circulation with the signs and symptoms lasting for less than 24 hours
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Dr. L. Surbala (MPT Neuro)
Epidemiology Third leading cause of death The incidence of stroke is about 1.25
times greater for males than females Most common cause of disability
among adults
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Dr. L. Surbala (MPT Neuro)
Etiology Atherosclerosis Cerebral Thrombus Cerebral embolus Embolism from the heart (cardiac origin) Intracranial hemorrhage Subarachnoid hemorrhage Intracranial small vessel disease Arterial aneurysms Arterio-venous malformation Haematological disorders
(haemoglobinopathies, leukemia)
Atherothromboembolism
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Dr. L. Surbala (MPT Neuro)
Miscellaneous rare causes of stroke Infective endocarditis & HIV infection Tumour Perioperative stroke (due to hypotension and boundary
zone infarction, trauma to and dissection of neck arteries, paradoxical embolism, fat embolism, infective endocarditis)
Migraine Chronic meningitis Inflammatory bowel disease (ulcerative and
Crohn's colitis) Hypoglycemia Snake bite, fat embolism
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Dr. L. Surbala (MPT Neuro)
Risk factors NON MODIFIABLE
MODIFIABLE
Ageing & gender Positive family history Circadian and seasonal
factors (peaks between 10 am till noon)
Heart disease Diabetes mellitus Hypertension Peripheral arterial
disease Blood pathology
(increased haematocrit, clotting abnormalities, sickle cell anaemia etc)
Hyperlipidemia TIA
Smoking Obesity Lack of physical exercise
or sedentary life style Diet & excess alcohol
consumption Oral contraceptives Infection (meningeal
infection) Psychological factors Vasectomy
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Dr. L. Surbala (MPT Neuro)
warning signs of stroke Sudden numbness or weakness of face, arm, or leg,
on one side of body Sudden confusion, trouble speaking or understanding Sudden blurring of vision Sudden onset of dizziness, loss of balance or
coordination Sudden, severe headaches with no known cause Other important but less common stroke symptoms
include:• Sudden nausea, fever, & vomiting distinguished from a viral
illness by speed of onset (minutes or hours vs several days)• Brief loss of consciousness or a period of decreased
consciousness (fainting, confusion, convulsions, or coma)
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Dr. L. Surbala (MPT Neuro)
Pathophysiology Ischemia results in irreversible cellular
damage with a core area of focal infarction within minutes• Transitional area surrounding core is termed
ischemic penumbra & consists of viable but metabolically lethargic cells
Ischemia produce cerebral edema, that begins within minutes of insult & reaches a maximum by 3 to 4 days.
Swelling gradually subsides & generally disappears by 2 to 3 weeks
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Dr. L. Surbala (MPT Neuro)
Oedema elevates ICP, leading to intracranial HT & neurological deterioration associated with contralateral & caudal shifts of brain structures
Cerebral edema is the most frequent cause of death in acute stroke & is characteristic of large infarcts involving MCA & ICA
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Dr. L. Surbala (MPT Neuro)
Classification Depending on the cause
• Haemorrhagic stroke Intracranial haemorrhage Subarachnoid haemorrhage
Signs of raised ICP will be evident with a history of a traumatic accident
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Dr. L. Surbala (MPT Neuro)
• Ischemic stroke Thrombotic: more common. Usually occurs in the
sleeping hours. Characterised by gradual onset of symptoms
Embolic: Occurs in the waking hours of the day. Sudden onset of symptoms preceded by giddiness in most conditions
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Dr. L. Surbala (MPT Neuro)
Depending on the severity • Mild stroke: symptoms subside with no
deficit in a week period • Moderate stroke: symptoms recover in a
period of 3 - 6 months with minimal neurological deficit
• Severe stroke: there is no complete recovery of the symptoms even after 1 years. Always ends up with severe neurological deficit
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Dr. L. Surbala (MPT Neuro)
Depending on the duration • Acute stroke: to a period of one week or
until spasticity develops • Sub acute stroke: after the development
of spasticity & last for a period of 3-12 months
• Chronic stroke: more than 12 months
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Dr. L. Surbala (MPT Neuro)
Depending on the symptoms • MCA Syndrome • ACA Syndrome • PCA syndrome • Vertebro basilar artery syndrome
Vertebral artery Basilar artery Internal carotid artery
• Lacunar syndrome
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Dr. L. Surbala (MPT Neuro)
stages of recovery• Stage 1: recovery occurs in a stereotyped
sequence of events that begins with a period of flaccidity immediately following acute episode. No movement of limbs can be elicited
• Stage 2: basic limb synergies or some of their components may appear as associated reactions. Minimal voluntary movement may be present. Spasticity begins to develop
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Dr. L. Surbala (MPT Neuro)
• Stage 3: Gains voluntary control of movement synergy although full range is not developed. Spasticity has further increased
• Stage 4: some movement combination that do not follow the synergy are mastered first with difficulty & later with more ease. Spasticity begins to decline
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Dr. L. Surbala (MPT Neuro)
• Stage 5: more difficult movement are learnt as the basic limb synergy lose their dominance over motor roots. Spasticity further declines
• Stage 6: disappearance of spasticity, individual joint movement become possible & coordination approaches normal. Normal motor function is restored
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Dr. L. Surbala (MPT Neuro)
mca Contralateral hemiplegia (UL & face more
affected than LL) Contralateral hemisensory loss (UL & face
more affected than LL) Ideomotor apraxia Ataxia of contralateral limb Contralateral Homonymous hemianopia Left hemisphere infarction
• Contralateral neglect• Possible contralateral visual field deficit• Aphasia: Broca’s (expressive) or Wernicke’s (receptive)
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Dr. L. Surbala (MPT Neuro)
pca Coordination disorders such as tremor or ataxia Contralateral homonymous field deficit Cortical blindness Cognitive impairment including memory
impairment Contralateral sensory impairment Thalamic syndrome (abnormal sensation of
severe pain from light touch or temperature changes)
Weber’s syndrome (contralateral hemiplegia & third nerve palsy)
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Dr. L. Surbala (MPT Neuro)
aca Contralateral Hemiplegia or monoplegia
of LL (LL more affected than UL) Contralateral sensory loss of LL Urinary incontinence Problems with imitation & bimanual task Abulia (akinetic mutism) Apraxia Amnesia Contralateral grasp reflex, sucking reflex
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Dr. L. Surbala (MPT Neuro)
Vertibro-Basilar artery syndromes Medial medullary syndrome (vertebral artery) Lateral medullary (Wallenberg's) syndrome
(PICA) Complete basilar artery syndrome (locked-in
syndrome) Medial inferior pontine syndrome Lateral inferior pontine syndrome (AICA) Medial midpontine syndrome Lateral midpontine syndrome Medial superior pontine syndrome Lateral superior pontine syndrome
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Dr. L. Surbala (MPT Neuro)
Locked-in syndrome (LIS) • Acute hemiparesis rapidly progressing to
tetraplegia & lower bulbar paralysis (CN V through XII are involved)
• Initially patient is dysarthria & dysphonic & progresses to mutism (anarthria)
• There is preserved consciousness & sensation• Horizontal eye movements are impaired but
vertical eye movements & blinking remain intact.
• Communication can be established via these eye movements.
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Dr. L. Surbala (MPT Neuro)
Lacunar syndrome Caused by small vessel disease of deep
white mater• Pure motor lacunar stroke: posterior limb of internal
capsule, pons, & pyramids• Pure sensory lacunar stroke: ventrolateral thalamus
or thalamocortical projections Ataxic hemiparesis Dysarthria Clumsy hand syndrome Sensory/motor stroke Dystonia/involuntary movements
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Dr. L. Surbala (MPT Neuro)
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Dr. L. Surbala (MPT Neuro)
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Dr. L. Surbala (MPT Neuro)
Red flag
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Dr. L. Surbala (MPT Neuro)
Primary impairment 1. Altered sensation
• Pain (central pain or thalamic pain syndrome characterized by constant, severe burning pain with intermittent sharp pains
• Hyperalgesia • Loud sound, bright light etc. may trigger
pain
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Dr. L. Surbala (MPT Neuro)
2. Vision • Homonymous hemianopia, a visual field
defect, occurs with lesions involving the optic radiation (MCA) or to primary visual cortex (PCA)
• Visual neglect & problems with depth perception, and spatial relationships
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Dr. L. Surbala (MPT Neuro)
3. Weakness• Usually seen in the contralateral side of the
lesion • MCA stroke are more common so weakness
is largely seen in the UL in clinical practice • Distal muscle are more affected than
proximal muscles • Mild weakness of ipsilateral side
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Dr. L. Surbala (MPT Neuro)
4. Alteration of tone • Flaccidity (hypotonicity) is present
immediately after stroke• Spasticity (hypertonicity) emerges in
about 90 percent of cases
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Dr. L. Surbala (MPT Neuro)
5. Abnormal synergy
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Dr. L. Surbala (MPT Neuro)
Muscles not involved in either synergy • Latissimus dorsi• Teres major• Serratus anterior• Finger extensors• Ankle evertors
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Dr. L. Surbala (MPT Neuro)
6. Abnormal reflexes • Initially, hyporeflexia with flaccidity & later
hyperreflexia • May demonstrate clonus, & +ve Babinski• Movement of head or position of body may elicit a
change in tone or movement of extremities The most commonly seen is asymmetric tonic neck reflex
(ATNR) • Associated reactions are also present in patients
who exhibit strong spasticity and synergies unintentional movements of hemiparetic limb caused by
voluntary action of another limb by stimulation of yawning, sneezing, or coughing.
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Dr. L. Surbala (MPT Neuro)
7. Altered co ordination • Proprioceptive losses can result in sensory
ataxia• Strokes affecting cerebellum typically
produce cerebellar ataxia (e.g.basilar artery syndrome, pontine syndromes) & motor weakness.
• Basal ganglia involvement (PCA syndrome) may lead to bradykinesia or involuntary movements
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Dr. L. Surbala (MPT Neuro)
8. Altered motor programing • Motor praxis is ability to plan & execute
coordinated movement• Lesions of premotor frontal cortex of either
hemisphere, left inferior parietal lobe, & corpus callosum can produce apraxia.
• Apraxia is more evident with left hemisphere damage than right and is commonly seen with aphasia. Ideational apraxia Ideomotor apraxia
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Dr. L. Surbala (MPT Neuro)
9. Postural Control & Balance• Impairments in steadiness, symmetry, &
dynamic stability• Problems may exist when reacting to a
destabilizing external force (reactive postural control) or during self-initiated movements (anticipatory postural control).
• Pusher syndrome: characterized by active pushing with stronger extremities toward affected side, leading to lateral postural imbalance
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Dr. L. Surbala (MPT Neuro)
10. Speech, Language, and Swallowing• Lesions involving cortex of dominant hemisphere• Aphasia: impairment of language
comprehension, formulation, and use. • Dysarthria: motor speech disorders caused by
lesions of CNS or PNS that mediate speech production.
• Dysphagia, occurs with lesions affecting medullary brainstem (CN IX and X), large vessel pontine lesions, as well as in acute MCA and PCA lesion
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Dr. L. Surbala (MPT Neuro)
11. Perception and Cognition• They are the result of lesions in right
parietal cortex & seen more with left hemiplegia than right.
• These may include disorders of body scheme/body image, spatial relations, and agnosias.
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Dr. L. Surbala (MPT Neuro)
12. Emotional Status• Lesions of brain affecting frontal lobe,
hypothalamus, & limbic system • May demonstrate pseudobulbar affect (PBA), also known as emotional lability or emotional dysregulation syndrome. emotional outbursts of uncontrolled or exaggerated
laughing or crying that are inconsistent with mood. • Depression is extremely common
persistent feelings of sadness,feelings of hopelessness, worthlessness or helplessness.
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Dr. L. Surbala (MPT Neuro)
13. Bladder and Bowel Function• Disturbances of bladder function are
common during acute phase• Urinary incontinence can result from
bladder hyperreflexia or hyporeflexia, disturbances of sphincter control, or sensory loss.
• Disturbances of bowel function can include incontinence & diarrhea or constipation
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Dr. L. Surbala (MPT Neuro)
Hemispheric Behavioral Differences.
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Dr. L. Surbala (MPT Neuro)
Indirect Impairments 1. Musculoskeletal changes
• Loss of voluntary movement and immobility can result in loss of ROM & contractures. Contractures are apparent in spastic muscles of
paretic limbs • Disuse atrophy & muscle weakness results
from inactivity and immobility• Osteoporosis, results from decreased physical
activity, changes in protein nutrition, hormonal deficiency, & calcium deficiency.
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Dr. L. Surbala (MPT Neuro)
2. Neurological signs• Seizures occur in a small % of patients -
more common in occlusive carotid disease than in MCA disease
• Hydrocephalus is rare but can occur with subarachnoid or intracerebral hemorrhage.
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Dr. L. Surbala (MPT Neuro)
3. Thrombophlebitis & deep venous thrombosis (DVT) • complications for all immobilized patients.
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Dr. L. Surbala (MPT Neuro)
4. Cardiac Function• Stroke as a result of underlying coronary
artery disease (CAD) may demonstrate impaired CO, cardiac decompensation, & rhythm disorders.
• If these problems persist, they can alter cerebral perfusion & produce additional focal signs (e.g., mental confusion).
• Cardiac limitations in exercise tolerance
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Dr. L. Surbala (MPT Neuro)
5. Pulmonary Function• Decreased lung volume, decreased
pulmonary perfusion & vital capacity & altered chest wall excursion
• Aspiration, occurs in about one third of patients with dysphagia.
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Dr. L. Surbala (MPT Neuro)
6. Integumentary• The skin breaks down over bony
prominences from pressure, friction, shearing, and/or maceration
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Dr. L. Surbala (MPT Neuro)
Tests and Measures Urine analysis CBC count Blood sugar level Blood cholesterol & lipid profile Cardiac evaluation Lumbar puncture
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Dr. L. Surbala (MPT Neuro)
Imaging CT Scan
• In acute phase, CT scans are used to rule out brain lesions such as tumor or abscess & to identify hemorrhagic stroke
• In sub-acute phase, CT scans can identify development of cerebral edema (within 3 days) & cerebral infarction (within 3 to 5 days) by showing areas of decreased density.
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Dr. L. Surbala (MPT Neuro)
Magnetic Resonance Imaging (MRI). • MRI is more sensitive in diagnosis of acute
strokes, allowing detection of cerebral infarction within 2 to 6 hours after stroke.
• It is also able to detail extent of infarction or hemorrhage & can detect smaller lesions
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Dr. L. Surbala (MPT Neuro)
Cerebral Angiography. • Involves injection of radiopaque dye into
blood vessels with subsequent radiography. • It provides visualization of vascular system
and used when surgery is considered (carotid stenosis, AVM).
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Dr. L. Surbala (MPT Neuro)
Recovery and Prognosis Fastest in first weeks after onset Measurable neurological & functional
recovery occurring in first month after stroke.
Continue to make measurable functional gains for months or years after insult
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Dr. L. Surbala (MPT Neuro)
Late recovery of function is also seen in patients with chronic stroke who undergo extensive functional training• These changes are due to function-induced
plasticity
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Dr. L. Surbala (MPT Neuro)
Variation of recovery Recovery also depends on severity of
stroke Depends on type of stroke –
hemorrhagic or ischemic Varies from individual to individual Depends on intensity of therapy Depends on age of the patient
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Dr. L. Surbala (MPT Neuro)
A case A male patient with a known case of
hypertension came to emergency department with history of sudden collapse & LOC
On examination there is decrease DTR on right side of body with +ve Babinski’s sign
There is gradual regain of consciousness but seems to be confused
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Dr. L. Surbala (MPT Neuro)
After a few days in hospital he regain some of his LL movement but less improvement in UL
On careful examination he has right Homonymous hemianopia & sensory loss including two-point discrimination, texture, & sense of weight
He also has unilateral neglect & Broca’s (expressive) aphasia
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Dr. L. Surbala (MPT Neuro)
What is the condition? What may be the cause? What emergency investigation is
called for ? Which artery may be involved? Which areas of the brain is involved?
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PT assessment
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Dr. L. Surbala (MPT Neuro)
History Abrupt onset with rapid coma is
suggestive of cerebral hemorrhage. Severe headache typically precedes
LOC Embolus also occurs rapidly, with no
warning, & is frequently associated with heart disease or heart complications.
Uneven onset is typical with thrombosis.
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Dr. L. Surbala (MPT Neuro)
Past history include TIAs or head trauma, presence of major or minor risk factors, medications, positive family history, & recent alterations in patient function
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Dr. L. Surbala (MPT Neuro)
Observation May have abnormal posturing of
limbs Synergistic patterns in the UL & LL Facial asymmetry May use a walking aid E.g. cane Abnormal gait pattern may also be
observed
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Dr. L. Surbala (MPT Neuro)
Vitals May present with hypertension Pain
Shoulder pain, secondary to subluxation, is a common issue
Shoulder-hand syndrome involves swelling & tenderness in hand and pain in entire limb
Complex Regional Pain Syndrome involves pain & swelling of hand
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Dr. L. Surbala (MPT Neuro)
Arousal, Attention & Cognition Expressive and/or receptive aphasia Attention disorders Memory deficits, including
declarative and procedural memory Executive function deficits
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Dr. L. Surbala (MPT Neuro)
Cranial Nerve Integrity Visual field deficits Weakness & sensory loss in facial
musculature Deficits in laryngeal & pharyngeal
function Hypoactive gag reflex Diminished, but perceived, superficial
sensations
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Dr. L. Surbala (MPT Neuro)
Sensory integrity Hemi sensory loss (dysesthesia, or
hyperesthesia, joint position & movement sense) May be able to identify sensations but difficulty
in localizing Cortical sensations s/a 2 point discrimination,
stereognosis & graphaesthesia are affected secondary to loss of grip function
Agnosia Perceptual problems Unilateral spatial neglect Pusher syndrome
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Dr. L. Surbala (MPT Neuro)
Joint Integrity and Mobility Glenohumeral subluxation Shoulder impingement syndrome Adhesive capsulitis Complex Regional Pain Syndrome and
Shoulder-Hand Syndrome
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Dr. L. Surbala (MPT Neuro)
Range of Motion Soft tissue shortening and
contractures Increased muscle stiffness Joint immobility Disuse-provoked soft tissue changes Over extensibility of capsular
structures of Glenohumeral joint
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Dr. L. Surbala (MPT Neuro)
Motor Function Synergistic patterns of movement Hypertonicity Weakness Associated movements or synkinesis Apraxia including motor & verbal
apraxia
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Dr. L. Surbala (MPT Neuro)
Reflex Integrity Exaggerated deep tendon reflexes Diminished superficial reflexes Positive Babinski’s reflex Impaired Righting, equilibrium, and
protective reactions Abnormal primitive reflex (ATNR) may
be present
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Dr. L. Surbala (MPT Neuro)
Assistive & Adaptive Devices A sling for Glenohumeral support AFO Cane
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Dr. L. Surbala (MPT Neuro)
Aerobic Capacity/Endurance BP, RR, & HR at rest & during
exercise may have a sudden rise Review pulse oximetry, blood gas,
tidal volume, & vital capacity Administer a 2 or 6-minute walk test Administer Borg RPE after walk test
or other physical activity
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Dr. L. Surbala (MPT Neuro)
Circulation (Arterial, Venous & Lymphatic)
Edema may occur in affected limbs May be associated with shoulder
hand syndrome
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Dr. L. Surbala (MPT Neuro)
Ventilation & Respiration• Decrease Tidal volume & vital capacity• Decrease Respiratory muscle strength• Ability to cough & strength of cough is
decreases • Dyspnea during exercise
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Dr. L. Surbala (MPT Neuro)
Gait & Locomotion Decreased extension of hip &
hyperextension of knee Decreased flexion of knee & hip
during swing phase Decreased ankle DF at initial contact
& during stance resulting in hip circumduction
Trendelenburg
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Dr. L. Surbala (MPT Neuro)
Balance Compromised static as well as
dynamic balance Pusher’s syndrome may be present
resulting in fall on the affected side
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Dr. L. Surbala (MPT Neuro)
Posture Spastic patterns can involve flexion &
abduction of arm, flexion of elbow, & supination of elbow with finger flexion
Hip & knee extension with ankle plantarflexion & inversion
Protracted & depressed shoulder, scoliosis & hip hiking
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Dr. L. Surbala (MPT Neuro)
Functional assessment Using FIM, Barthel index, FMA There is compromised basic as well
as instrumental ADL Ambulatory capacity is compromised
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Dr. L. Surbala (MPT Neuro)
Bowel & bladder Flaccid bowel & bladder during the
acute stage Bowel & bladder function gradually
regains Uninhibited bladder if frontal lobe is
involved Constipation is frequently seen
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Dr. L. Surbala (MPT Neuro)
Problem list Tonal abnormalities Muscular weakness Synergistic pattern Tightness & contracture Imbalance & incoordination Gait abnormalities Postural abnormalities Functional disability
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PT management
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Dr. L. Surbala (MPT Neuro)
Acute stage Positioning strategies Improve respiratory & circulatory
function Prevent pressure sores Prevent from deconditioning
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Dr. L. Surbala (MPT Neuro)
Positioning strategies • In supine • In side lying on normal side • In side lying on affected side
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Dr. L. Surbala (MPT Neuro)
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Dr. L. Surbala (MPT Neuro)
Improve respiratory & circulatory function • Breathing exercise• Chest expansion exercise • Postural drainage • Huffing & Coughing techniques• Passive & active ankle & toe exercise
(after careful & thorough examination of cardiopulmonary system)
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Dr. L. Surbala (MPT Neuro)
Prevent pressure sores• Proper positioning • Relieve pressure points by padding &
cushion • Frequent turning & changing position• Prevent from moisture • Use cotton clothing • Tight fitting cloth is prevented • Use of water bed, air bed & foam mattress
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Dr. L. Surbala (MPT Neuro)
Prevent from deconditioning • Early mobilization in the bed (active turning,
supine to sit, sit to supine, sitting, sit to stand)
• Pelvic bridging exercise • Early propped up positioning, sitting & then
later to standing • Moving around the bed • Facilitate movement of functioning limbs
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Dr. L. Surbala (MPT Neuro)
Post acute stage 5 days a week for a minimum of 3
hours of active rehabilitation per day Intensive rehabilitation if vitals are
stable
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PT interventions
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Dr. L. Surbala (MPT Neuro)
Improve sensory function Positioning hemiplegic side towards door or
main part of room Presentation of repeated sensory stimuli Stretching, stroking, superficial & deep
pressure, iceing, vibration etc. Wt bearing ex & Joint approximation tech Stoking with different texture fabrics Pressure application Improve other senses like use of visual &
auditory PNF tech., use of bilateral UE
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Dr. L. Surbala (MPT Neuro)
Flexibility & joint integrity Soft tissue, joint mobilization & ROM
exercise AROM & PROM with end range stretch Effective positioning & edema reduction Stretching program & splinting Suggested activities
• Arm cradling • Table top polishing • Self overhead activities in supine & sitting &
reaching to the floor
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Dr. L. Surbala (MPT Neuro)
Improve strength Strengthening of agonist & antagonistic
muscle Graded ex program using free weights,
therabands, sand bags & isokinetic devices
For weak patients (<3/5), gravity-eliminated ex using powder boards, sling suspension, or aquatic ex is indicated
Gravity-resisted active movts are indicated (>3/5 strength)
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Dr. L. Surbala (MPT Neuro)
Manage spasticity Sustained stretch & slow iceing of spastic
muscle Rhythmic rotations Weight bearing exercise Prolonged & firm pressure application Slow rocking movement Positioning in anti synergistic pattern Rhythmic initiation Air splints Neural warmth Electrical stimulation
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Dr. L. Surbala (MPT Neuro)
Improve movt control Dissociation & selection of desired
movt patterns Select postures that assist desired
movements through optimal biomechanical stabilization & use of optimal point in range
Start with assisted movt, followed by active & resisted movt
Task oriented exercise
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Dr. L. Surbala (MPT Neuro)
Postural control & functional mobility
Suggested exercise • Rolling • Supine to sit & sit to supine • Sitting • Bridging • Sit to stand & Sit down • Modified plantigrade • Standing • Transfer
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Dr. L. Surbala (MPT Neuro)
In pusher syndrome • Passive correction often fails • Use visual stimuli to correct • Sit on the normal side & ask patient to lean
on you • Sitting on swiss ball • Environmental boundary can be used e.g.
corner or doorway
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Dr. L. Surbala (MPT Neuro)
Improve ue function • Early mobilization, ROM, & positioning strategies• Relearning of movt pattern & retraining of missing
component • UL weight bearing exercise • Dynamic stabilization exercise • Picking up objects, Reaching activities • Lifting activities• Manipulation of common objects • Push up ex. in various position• Kitchen sink exercise • Functional movement like hand to mouth & hand to
opposite shoulder • Advance training – CIMT, biofeedback, NMES, FES
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Dr. L. Surbala (MPT Neuro)
Managing shoulder pain Proper handling & positioning of
shoulder joint Reducing subluxation, NMES, gentle
mobilization (grade 1 & 2) Use of supportive devices & slings Use of overhead pulley is
contraindicated TENS & heat therapy
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Dr. L. Surbala (MPT Neuro)
Improve LL function Strengthening muscles in appropriate
pattern Suggested activities
• PNF pattern of LL• Holding against elastic band resistance around
upper thighs in supine or standing positions• Standing, lateral side-steps• Exercise to improve pelvic control
Facilitation of DF Cycling & treadmill training
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Dr. L. Surbala (MPT Neuro)
Improve balance Facilitate symmetrical wt bearing on both side Postural perturbations can be induced in different
positions Sit or stand on movable surface to increase
challenge Reaching activities Dual task training s/a kicking ball in standing,
throwing activities, carrying an object while walking
Divert attention Single limb stance Exercise on trampoline
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Dr. L. Surbala (MPT Neuro)
Improve locomotion Initial gait training between parallel bars Proceed outside bars with aids & then
without aids Walking forward, backward, sideways &
in cross patterns PBWSTT with higher speed improve
overall locomotor activity & overground speed
Proper use of orthotics & wheelchair
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Dr. L. Surbala (MPT Neuro)
Improve aerobic function • Early mobilization & functional activity • Treadmill training & cycle ergometer • Symptom limited graded ex. training • Ex at 40- 70 % of VO2max, 3 times a week
for 20-60 minutes • Proper rest should be given • Gradually progressed to 30 minutes
continous program• Regular ex reduces risk of recurrent stroke
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Dr. L. Surbala (MPT Neuro)
Improve feeding & swallowing Proper head position in chin down position Movements of lips, tongue, cheeks, & jaw Firm pressure to anterior 3rd of tongue with tongue
depressor to stimulate posterior elevation of tongue,
Puffing, blowing bubbles, & drinking thick liquids through straw
Food presentation in proper position Texture of food should be smooth Tasty food should be given to facilitate swallowing
reflex Stroking the neck during swallowing
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Dr. L. Surbala (MPT Neuro)
Improve motor learning Strategy development
• Patient as an active explorer of activity • Modify strategy of activity in correct
patterns Feedback
• Intrinsic or extrinsic feedback • Positive & negative feedbacks
Practice• Repeated practice of functional activity • Practice in different environment
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Dr. L. Surbala (MPT Neuro)
Patient & family education Give factual information, counsel family
members about patient’s capabilities & limitations
Give information as much as Pt or family can assimilate
Provide open discussion & communication Be supportive, sensitive & maintain a
positive supporting nature Give psychological support Refer to help groups
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Dr. L. Surbala (MPT Neuro)
Discharge planning Family member should participate
daily in the therapy session & learn exercises
Home visits should be made prior to discharge
Architectural modifications, assistive devices or orthotics should be ready before discharge
Identify community service & provide information to the patient
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Dr. L. Surbala (MPT Neuro)
References O’ Sullivan SB, Schmitz TJ. Stroke.
Physical rehabilitation. 5th ed., New Delhi: Jaypee Brothers, 2007.
Darcy A. Umphred. Neurological Rehabilitation, 5th ed., Mosby Elsevier, Missouri, 2007.