REHABILITATION OF PATIENTS WITH HEMIPLEGIA

Interdisciplinary team Rehabilitation purpose - restore function following an illness or injury, with the goal of maximizing a person’s ability to achieve fullest life possible The ultimate aim of stroke research and rehabilitation after stroke is to reduce impairment, disability and handicap and to enhance the quality of life. Interdisciplinary team physicians, nurses, PT, OT, speech-language therapists, psychologists, social workers, recreational therapists.

Rehabilitation Rehabilitation therapy should start as early as possible, once medical stability is reached Spontaneous recovery can be impressive, but rehabilitation-induced recovery seems to be greater on average. Even though the most marked improvement is achieved during the first 3 months, rehabilitation should be continued for a longer period to prevent subsequent deterioration.

Rehabilitation No patient should be excluded from rehabilitation unless he is too ill or too cognitively devastated to participate in a treatment program. Proper positioning and early passive ROM exercises help to avoid complications at a flaccid stage. Family members should participate in therapy sessions. The family should also be referred to community groups that offer psychosocial support such as stroke clubs at the time of discharge.

Poor Prognosis Decreased alertness,inattention,poor memory,inability to learn new tasks or follow simple commands severe neglect or anosognosia significant medical problems esp, cardiovascular or DJD serious language disturbance less well defined & economic problem

Effect of a Stroke 1. Weakness on the side of the body opposite the site of the brain affected by the stroke 2. Spasticity, stiffness in muscles, painful muscle spasms 3. Problems with balance and/or coordination 4. Problems using language, including having difficulty understanding speech or writing(aphasia); and knowing the right words but having trouble saying them clearly (dysarthria) 5. Being unaware of or ignoring sensations on one side of the body (bodily neglect or inattention) 6. Pain, numbness or odd sensations

Effect of a Stroke (con’t) 7. Problems with memory, thinking, attention or learning 8. Being unaware of the effects of a stroke 9. Trouble swallowing (dysphagia) 10. Problems with bowel or bladder control 11. Fatigue 12. Difficulty controlling emotions (emotional lability) 13. Depression 14. Difficulties with daily tasks

Rehabilitation Goal To restore lost abilities as much as possible To prevent stroke-related complications To improve the patient's quality of life To educate the patient and family about how to prevent recurrent strokes Promote re-integration into family, home, work, leisure and community activities

Successful Rehabilitation Depend on - how early rehabilitation begins - the extent of the brain injury - the survivor’s attitude - the rehabilitation team’s skill - the cooperation of family and caregiver

Basic Principles of Rehabilitation To begin as possible early (first hours) To assess the patient systematically To prepare the therapy plan carefully To build up in stages To include the type of rehabilitation approach specific to deficits To evaluate patient’s progress regularly

Rehabilitation Management Mobility Activity of daily living Communication Swallowing Orthosis Shoulder pain Spasticity Cognitive and perception Mood Bowel and bladder incontinence

Mobility Physiotherapy Conventional therapies Neurophysiological therapies

Conventional therapies Therapeutic Exercises Traditional Functional Retraining Range Of Motion (ROM) Exercises Muscle Strengthening Exercises Mobilization activities Fitness training Compensatory Techniques

Neurophysiological Approaches 1. Muscle Re-education Approach (1920S) 2. Neurodevelopmental Approaches (1940-70S) Sensorimotor Approach (Rood, 1940S) Movement Therapy Approach (Brunnstrom, 1950S) NDT Approach (Bobath, 1960-70S) PNF Approach (Knot and Voss,1960-70S) 3. Motor Relearning Program for Stroke (1980S) 4. Contemporary Task Oriented Approach (1990S)

Aim Improve Movement Balance coordination Safety

Basic Physical Therapy Bed positioning, mobility Range of motion exercises (ROME) Sitting/trunk control Transfer Walking Stair climbing

Treadmill training with body weight support

Robotics

Activity of daily living Occupational therapy Self care Dressing Grooming Toilet use Bathing Eating Adapt or specially design device

Constraint-Induced Movement Therapy (CIMT) Principle of FORCED USE to avoid the Learned Nonuse of the paretic side for Stroke patients Mainly for training of upper extremity

Exercise Therapy Neurodevelopmental techniques by Bobath Stresses exercises that tend to normalize muscle tone and prevent excessive spasticity Through special reflex-inhibiting postures & movements In beginning spasticity, Slow, sustained stretching for spastic muscles Vibration of antagonist muscles to reduce tone through reciprocal inhibition.

Exercise Therapy to Develop Motor Control Facilitation techniques: 1. Rood involves superficial cutaneous stimulation using stroking, brushing, tapping & icing or vibration to evoke voluntary muscle activation 2. Brunnstrom Emphasized synergistic patterns* of movement that develop during recovery from hemiplegia Encouraged 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 Motor 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 Motor Control Conventional methods: Stretching & strengthening Attempting to retrain weak muscles through reeducation

Hydrotherapy

Management- Balance Training

Management- coordination Training Bully Therapy

Orthosis Shoulder slings Hand splint Foot slings Ankle foot orthosis

Shoulder slings

Shoulder slings

Hand splints Flaccid = functional position Wrist extend 20 – 30 degree Flex MCP joint 45 degree Flex PIP joint 30 - 45 degree Flex DIP joint 20 degree

Hand splints

Foot slings

Ankle Foot Orthosis - Plastic Metal stability of ankle balance speed walking Not enhance recovery

Ankle Foot Orthosis Metal AFO Plastic AFO

Shoulder pain Sensorimotor dysfunction of upper extremities 72% of stroke patient in first year Delay rehabilitation

Causes of Hemiplegic Shoulder Pain aetiology of hemiplegic shoulder pain is probably multifactorial. Spasticity and hemiplegic shoulder pain are related. particularly of the subscapularis and pectoralis muscles It is uncertain whether shoulder subluxation causes hemiplegic shoulder pain the sustained hemiplegic posture: shoulder contractures or restricted shoulder range of motion reflex sympathetic dystrophy Poor handling and positioning of the affected upper limb in stroke patients contribute toward shoulder pain. Many types of shoulder pathology have been suggested as causes of shoulder pain including shoulder subluxation, capsulitis, tendonitis, rotator cuff injury, bursitis, impingement syndrome, spasticity, CRPS, brachial plexus injury, and proximal mononeuropathies

Exercise Therapy to Develop Motor Control Facilitation techniques: Kabat’s Proprioceptive Neuromuscular Facilitation (PNF)

Treatment Electrical stimulation Shoulder strapping Mobilization (esp. External rotator, abduction) prevent frozen shoulder, shoulder hand pain Medical Intraarticular injections Modalities : ice, heat, massage Strengthening

Spasticity Velocity dependent hyperactivity of tonic streth reflexes

Aim of treatment Pain ROM Cosmatic Hygiene Mobility Easy use orthosis Delay surgery

Treatment Avoid noxious stimuli Positioning, passive stretching, ROME Splinting, serial casting, surgical correction Medical - tizanidine - baclofen - dantrolen - avoid diazepam Botulinum toxin A injection Phenol / alcohol Neurosurgical procedure (selective dorsal rhizotomy)

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

Fecal incontinence Improve within 2 weeks Continued fecal incontinence poor prognosis

Constipation, fecal impaction More common Immobility, inadequate fluid or food intake, depression or anxiety, cognitive deficit Management Adequate intake of fluid Bulk and fiber food Bowel training