Stroke Physiotherapy management

Stroke Physiotherapy 

• Improving motor control

a.Neurofacilitatory Techniques
In Stroke Physical rehabilitation these therapeutic interventions use sensory stimuli (e.g. quick stretch, brushing, reflex stimulation and associated reactions) ,that are based on neurological theories, to facilitate movement in patients following stroke (Duncan,1997). Listed here are the different approaches: -
i.Bobath
Berta & Karel Bobath’s approach focuses to manage responses from damaged postural reflex mechanism. Emphasis is positioned on affected inputs facilitation and normal movement patterns (Bobath, 1990).
ii.Brunnstrom
Brunnstrom approach is a form of neurological exercise therapy within the rehabilitation of stroke patients. The relative effectiveness of Neuro-developmental treatment (N.D.T.) versus the Brunnstrom method was studied by Wagenaar and colleagues (1990) in the perspective of the functional recovery of stroke patients. Caused by this study showed no clear variations in the effectiveness between your two methods inside the framework of functional recovery.
iii.Rood
Emphasise using activities in developmental sequences, sensation stimulation and muscle work classification. Cutaneous stimuli for example icing, tapping and brushing are widely-used to facilitate activities.
iv. Proprioceptive neuromuscular facilitation (PNF)
Produced by Knott and Voss, they advocated using peripheral inputs as stretch and resisted movement to strengthen existing motor response. Total patterns of motion are used in treatment and therefore are followed in a developmental sequence.
It had been shown that the commutative effect of PNF is helpful to stroke patient (Wong, 1994). Comparing the potency of PNF, Bobath approach and traditional exercise, Dickstein et al (1986)indicated that no one approach surpasses the rest of the others (AHCPR, 1995).
b. Learning theory approach
i. Conductive education
In Stroke Physical rehabilitation, Conductive education is one of the methods for neurological conditions including hemiplegic patients. Cotton and Kinsman (1984) demonstrated a neuropsychological approach while using concept of CE for adult hemiplegia. The individual is taught how you can guide his movements towards each task-part from the task by using their own speech - rhythmical intention.
ii. Motor relearning theory
Carr & Shepherd, both of them are Australian physiotherapists, developed this method in 1980. It emphasises the concept of functional tasks and need for relearning real-life activities for patients. Principles of learning and biomechanical analysis of movements and jobs are important. (Carr and Shepherd, 1987)
There isn't any evidence adequately supporting the superiority of 1 type of exercise approaches over another. However, the purpose of therapeutic approach would be to increase physical independence and also to facilitate the motor charge of skill acquisition and there's strong evidence to aid the effect of rehabilitation when it comes to improved functional independence and reduced mortality.
c. Functional electrical stimulation (FES)
FES is really a modality that applied a brief burst of electrical current towards the hemiplegic muscle or nerve.In Stroke Physical rehabilitation, FES has been demonstrated to be good for restore motor control, spasticity, and decrease in hemiplegic shoulder pain and subluxation. It's concluded that FES can boost the upper extremity motor recovery of acute stroke patient (Chae et al., 1998; Faghri et al., 1994; Francisco, 1998). Alfieri (1982) and Levin et al (1992) suggested that FES could reduce spasticity in stroke patient. A current meta- analysis of randomized controlled trial study demonstrated that FES improves motor strength (Glanz 1996). Study by Faghri et al (1994) have identified that FES can significantly improve arm function, electromygraphic activity of posterior deltoid, flexibility and reduction of harshness of subluxation and pain of hemiplegic shoulder.
d. Biofeedback
Biofeedback is really a modality that facilitates the cognizant of electromyographic activity in selected muscle or understanding of joint position sense via visual or auditory cues.In Stroke Physical rehabilitation the result of studies in biofeedback is controversial. A meta-analysis of 8 randomized controlled trials of biofeedback therapy indicated that electromyographic biofeedback could improve motor function in stroke patient (Schleenbaker, 1993). Another meta-analysis study on EMG has demonstrated that EMG biofeedbcak is superior to conventional therapy alone for improving ankle dorsiflexion muscle strength (Moreland et al., 1998. Erbil and co-workers (1996) demonstrated that biofeedback could improve earlier postural control to enhance impaired sitting balance. Conflicting meta-analysis study by Glanz et al (1995) showing that biofeedback wasn't efficacious in improving flexibility in ankle and shoulder in stroke patient. Moreland (1994) conducted another meta-analysis figured EMG biofeedback alone or with conventional therapy didn't superior to conventional physical rehabilitation in improving upper- extremity function in adult stroke patient.

• Chest physiotherapy

In Stroke Physical rehabilitation, evidence shows that both cough and forced expiratory technique (FET) can eliminate induced radio aerosol particles in lung field. Directed coughing and FET bring a technique for bronchial hygiene clearance in stroke patient.

• Positioning 

In Stroke Physical rehabilitation consistent “reflex-inhibitory” patterns of posture in resting is inspired to discourage physical complication of stroke and also to improve recovery (Bobath, 1990).
Meanwhile, therapeutic positioning is really a widely advocated technique to discourage the development of abnormal tone, contractures, pain and respiratory complications. It's an important element in maximizing the patient's functional gains and excellence of life.

• Tone management

An objective of Stroke Physical rehabilitation interventions has been to “normalize tone to normalize movement.” Therapy modalities for reducing tone include stretching, prolonged stretching, passive manipulation by therapists, standing and walking, ice, contraction of muscles antagonistic to spastic muscles, splinting, and casting. Research on tone-reducing techniques continues to be hampered by the inadequacies of techniques to measure spasticity (Knutsson and Martensson, 1980) and also the uncertainty about the relationship between spasticity and volitional motor control (Knutsson and Martensson, 1980; Sahrmann and Norton, 1977). Manual stretch of finger muscles, pressure splints, and dantrolene sodium don't produce apparent long-term improvement in motor control (Carey, 1990; Katrak, Cole, Poulus, and McCauley, 1992; Poole, Whitney, Hangeland, and Baker, 1990). Dorsal resting hand splints reduced spasticity a lot more than volar splints, but the effect on motor control is uncertain (Charait, 1968) while TENS stimulation showed improvement for chronic spasticity of lower extremities (Hui-Chan and Levin, 1992).

• Sensory re-education

Bobath along with other therapy approaches recommend using sensory stimulation to advertise sensory recovery of stroke patients.

• Hemiplegic shoulder management

Shoulder subluxation and pain from the affected arm isn't uncommon in a minimum of 30% of all patient after stroke (RCP, 1998) ,whereas subluxation can be found in 80% of stroke patients (Najenson et al., 1971). It's associated with severity of disability and it is common in patients in rehabilitation setting.Suggested interventions are listed below:
a) Exercise
Active standing and walking exercise can be used as an easy method of improving motor charge of the affected arm; introducing and grading tactile, proprioceptive, and kinesthetic stimulation; and preventing edema and pain.In Stroke Physical rehabilitation, Upper extremity weight bearing may be used to lengthen or inhibit tight or spastic muscles while simultaneously facilitating muscles that aren't active (Donatelli, 1991). According to Robert (1992), the quantity of shoulder pain in hemipelgia was related most to loss of movement. He advocated the provision of ROM exercise (caution to prevent imprigement) as treatment as early as possible. AHCPR (1995) recommended ROM exercise shouldn't carry the shoulder beyond 900 of flexor and abduction unless there's upward rotation of scapular and external rotation from the humeral head.
b) Functional electrical stimulation
Functional electrical stimulation (FES) is definitely an increasingly popular treatment for the hemiplegic stroke patient. It's been applied in stroke physical rehabilitation for the treatment of shoulder subluxation (Faghri et al.,1994), spasticity (Stefanovska et al., 1991) and functionally, for the restoration of function within the upper and lower limb (Kralji et al., 1993).In Stroke Physical rehabilitation, Electrical stimulation works well in reducing pain and harshness of subluxation, and possibly in facilitating recovery of arm function (Faghri, et al., 1994; Linn, et al., 1999).
c) Positioning & proper handling
In Stroke Physical rehabilitation, proper positioning and handling of hemiplegic shoulder, whenever during sex, sitting and standing or during lifting, can prevent shoulder injury is usually recommended in the AHCPR & SIGN guidelines for stroke rehabilitation. In Stroke Physical rehabilitation, positioning can be therapeutic for tone control and neuro-facilitation of stroke patients (Davies, 1991). Braus et al 94 found shoulder hand syndrome reduced from 27% to 8% by instruction to each one including family on handling technique.
d) Neuro-facilitation
e) Passive limb physiotherapy
Maintenance of full pain-free selection of movement without traumatizing the joint and also the structures can be carried out.In Stroke Physical rehabilitation, at no time should pain around or in the shoulder joint be manufactured during treatment. (Davies, 1991).
f) Pain alleviation physiotherapy
Passive mobilisation as explained Maitland, can be useful in gaining pain relief and range of movement (Davies, 1991). In Stroke Physical rehabilitation other treatment modalities for example thermal, electrical, cryotherapy etc. does apply for shoulder pains of musculoskeletal anyway.
g) Reciprocal pulley
Using reciprocal pulley seems to increase risk of developing shoulder pain in stroke patients. It's not related to the presence of subluxation in order to muscle strength. (Kumar et al., 1990)
h) Sling
In Stroke Physical rehabilitation the use of sling is controversial. No shoulder support will correct shoulder joint subluxation. However, it may avoid the flaccid arm from hanging from the body during functional activities, thus decreasing shoulder pain. They also help to relieve downward traction around the shoulder capsule brought on by the weight of the arm (Hurd, Farrell, and Waylonis, 1974 ; Donatelli ,1991).

• Limb physiotherapy

Limb physiotherapy/Stroke Physical rehabilitation includes passive, assisted-active and active range-of-motion exercise for the hemiplegic limbs. This is often an effective management for protection against limb contractures and spasticity and it is recommended within AHCPR (1995). Self-assisted limb being active is effective for reducing spasticity and shoulder protection (Davis, 1991). Adams and coworkers (1994) recommended passive full-range-of-motion exercise for parlysed limb for potential decrease in complication for stroke patients

• Balance retraining

Reestablishment of balance function in patients following stroke continues to be advocated as an essential component within the practice of stroke physical rehabilitation (Nichols, 1997). Some studies of patients with hemiparesis says these patients have greater quantity of postural sway, asymmetry with greater weight around the non-paretic leg, and a decreased capability to move within a weight-bearing posture (Dickstein, Nissan, Pillar, and Scheer, 1984; Horak, Esselman, Anderson, and Lynch, 1984). Meanwhile, studies have demonstrated moderate relationships between balance function and parameters for example gait speed, independence, wheelchair mobility, reaching, in addition to dressing (Dickstein et al., 1984; Horak et al., 1984; Bohannon, 1987; Fishman, Nichols, Colby, and Sachs, 1996; Liston and Brouwer, 1996; Nichols, Miller, Colby and Pease, 1996). Some tenable support around the effectiveness of treatment of disturbed balance are available in studies comparing results of balance retraining plus physiotherapy treatment and physiotherapy treatment alone.

• Fall prevention

In Stroke Physical rehabilitation, falls are one of the most typical complications( Dromerick and Reading, 1994), and also the consequences of which will probably have a negative impact on the rehabilitation process and it is outcome. According to the systematic overview of the Cochrane Library (1999), which evaluatedthe effectiveness of countless fall prevention interventions within the elderly, there was significant protection against falling from interventions which targeted multiple, identified, risks in individual patients. This is also true for interventions which centered on behavioural interventions targeting environmental hazards plus other risks

• Gait re-education

Recovery of independent mobility is a vital goal for the immobile patient, and far therapy is devoted to gait-reeducation. Bobath assume abnormal postural reflex activity is caused of dysfunction so gait training involved tone normalization and preparatory activity for gait activity. In comparison Carr and Shepherd advocates task-related training with techniques to increase strength, coordination and versatile MS system to build up skill in walking while Treadmill training coupled with use of suspension tube. Some patient’s body weight can good at regaining walking ability, when used being an adjunct to convention therapy 3 months after active training (Visintin et al., 1998; Wall and Tunbal 1987; Richards et al., 1993).

• Functional Mobility Training

To deal with through the functional limitations of stroke patients, functional jobs are taught to them according to movement analysis principles. In Stroke Physical rehabilitation these tasks include bridging, rolling to sit down to stand and the other way around, transfer skills, walking and stairing etc (Mak et al., 2000).
Published studies are convinced that many patients improve during rehabilitation. The best evidence of benefit comes from studies that have enrolled patients with chronic deficits or have included a no-treatment control group (Wade et al., 1992; Smith and Ashburn et al., 1981).
Meanwhile, early mobilization aids in preventing compilations e.g. DVT, skin breakdown contracture and pneumonia. Evidence show better orthrostatic tolerance (Asberg, 1989) and earlier ambulation (Hayes and Carroll, 1986).

• Upper limb training

By 3 months poststroke, approximately 37% of the people continues to have decreased upper extremities (UE) function. Recovery of UE function lags behind those of the lower extremities due to the more complex motor skill required from the UE in daily life tasks. Which means many individuals who have a stroke are in risk for lowered quality of life.
Many methods to the physical rehabilitation of adults post-stroke exist that make an effort to maximize motor skill recovery. Nevertheless the literature does not offer the efficacy of any single approach. The followings would be the current approaches to motor rehabilitation from the UE.
a) Facilitation models
Those are the most common methods of intervention for the deficits in UE motor skills including Bobath, proprioceptive neuromuscular facilitation, Brunnstrom’s movement therapy and Rood’s sensorimotor approach. There's some evidence that practice in line with the facilitation models can result in improved motor charge of UE ( Dickstein et al,1986, Grade A; Wagenaar et al, 1990 ). However, intervention in line with the facilitation models has not been good at restoring the fine hand coordination required for the performance of actions ( Kraft, Fitts & Hammond, 1992; Butefisch et al, 1995 ).
b) Functional electric stimulation
In Stroke Physical rehabilitation, Functional electric stimulation (FES) could be effective in increasing the electric activity of muscles or increased active flexibility in individuals with stroke ( Dimitrijevic et al., 1996; Fields, 1987; Faghri et al., 1994,; Kraft, Fitts and Hammond, 1992 ). Some evidence shown that FES might be more effective than facilitation approaches ( Bowman, Baker and Waters, 1979; Hummelsheim, Maier-Loth and Eickhof, 1997 ).
c) Electromyographic biofeedback
In Stroke Physical rehabilitation, biofeedback can bring about improvements in motor control in the neuromuscular and movement levels ( Kraft, Fitts and Hammond, 1992; Moreland and Thomson, 1994; Wissel et al., 1989; Wolf and Binder-MacLoed, 1983; Wolf, LeCraw and Barton,1989; Wolf et al., 1994 ). Some research indicates improvments in the ability to perform actions during post-testing after biofeedback training ( Wissel et al.,1989; Wolf and Binder-MacLoed, 1983; Moreland and Thomson, 1994). However, a chance to generalize these skills and incorporate them into daily life isn't measured.
d) Constraint-induced therapy
Constraint-Induced (CI) therapy was created to overcome the learned nonuse from the affected UE. In the most extreme type of CI therapy, individual post-stroke are prevented by using the less affected UE by continuing to keep it in a splint and sling for a minimum of 90% of their waking hours. Research has found that the most extreme of CI therapy can effect rapid improvement in UE motor skill ( Nudo et al., 1996; Taub and Wolf, 1997; Taub et al., 1993; Wolf et al., 1989 ) and that's retained for at least so long as 2 years ( Taub and Wolf, 1997 ). However, CI therapy, currently work only in individuals with distal voluntary movement ( Taub and Wolf, 1997 ).

• Mobility appliances and equipment

Small alterations in an individual's local 'environment' can greatly increase independence, utilization of a wheelchair or walking stick. However, little studies have been done for these 'treatments'. It's acknowledged that walking aids and mobility appliances will benefit selected patients.
Tyson and Ashburn (1994) demonstrated that walking aids had effect in poor walkers - a benefical impact on gait (Level of evidence = III, Recommendation = Grade B). Lu and coworkers (1997) figured wrist crease stick is preferable to stick measured to greater trochanter. (Degree of evidence = IIb, Recommendation = Grade A

• Vasomotor training 

Early stimulation from the muscle pump can help to eliminate the venous stasis and boost the general circulationof the body. After that it hastens the process of recovery.

• Oedema management

Utilization of intermittent pneumatic pump, elastic stocking or bandages and massage can facilitate the venous return from the oedematous limbs. Therefore, the elasticity and adaptability musculoskeletal system could be maintained and enhance process of recovery and prevent complications like pressure ulcer.