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Stroke: PT Assessment and Management
1.
2. ď‚žStroke 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
Dr. L. Surbala (MPT Neuro)
3. ď‚žIt 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
Dr. L. Surbala (MPT Neuro)
4. ď‚žIt 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
Dr. L. Surbala (MPT Neuro)
5. ď‚žThird leading cause of death
ď‚žThe incidence of stroke is about 1.25
times greater for males than females
ď‚žMost common cause of disability among
adults
Dr. L. Surbala (MPT Neuro)
6. ď‚žAtherosclerosis
ď‚žCerebral Thrombus
ď‚žCerebral embolus
ď‚žEmbolism from the heart (cardiac origin)
ď‚žIntracranial hemorrhage
ď‚žSubarachnoid hemorrhage
ď‚žIntracranial small vessel disease
ď‚žArterial aneurysms
ď‚žArterio-venous malformation
ď‚žHaematological disorders
(haemoglobinopathies, leukemia)
Atherothromboembolism
Dr. L. Surbala (MPT Neuro)
7. ď‚ž Infective endocarditis & HIV infection
ď‚ž Tumour
ď‚ž Perioperative stroke (due to hypotension and boundary
zone infarction, trauma to and dissection of neck
arteries, paradoxical embolism, fat embolism, infective endocarditis)
ď‚ž Migraine
ď‚ž Chronic meningitis
ď‚ž Inflammatory bowel disease (ulcerative and Crohn's
colitis)
ď‚ž Hypoglycemia
ď‚ž Snake bite, fat embolism
Dr. L. Surbala (MPT Neuro)
8. NON MODIFIABLE
MODIFIABLE
ď‚ž Ageing & gender
ď‚ž Positive family history
ď‚ž Circadian and seasonal
factors (peaks between 10
am till noon)
ď‚ž Heart disease
ď‚ž Diabetes mellitus
ď‚ž Hypertension
ď‚ž Peripheral arterial disease
ď‚ž Blood pathology (increased
haematocrit, clotting
abnormalities, sickle cell
anaemia etc)
ď‚ž Hyperlipidemia
ď‚ž TIA
ď‚ž Smoking
ď‚ž Obesity
ď‚ž Lack of physical exercise
or sedentary life style
ď‚ž Diet & excess alcohol
consumption
ď‚ž Oral contraceptives
ď‚ž Infection (meningeal
infection)
ď‚ž Psychological factors
ď‚ž Vasectomy
Dr. L. Surbala (MPT Neuro)
9. ď‚ž Sudden numbness or weakness of face, arm, or
leg, on one side of body
ď‚ž Sudden confusion, trouble speaking or
understanding
ď‚ž Sudden blurring of vision
ď‚ž Sudden onset of dizziness, loss of balance or
coordination
ď‚ž Sudden, severe headaches with no known cause
ď‚ž 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)
Dr. L. Surbala (MPT Neuro)
10. ď‚žIschemia 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
ď‚žIschemia produce cerebral edema, that
begins within minutes of insult &
reaches a maximum by 3 to 4 days.
ď‚žSwelling gradually subsides & generally
disappears by 2 to 3 weeks
Dr. L. Surbala (MPT Neuro)
11. ď‚žOedema elevates ICP, leading to
intracranial HT & neurological
deterioration associated with
contralateral & caudal shifts of brain
structures
ď‚žCerebral edema is the most frequent
cause of death in acute stroke & is
characteristic of large infarcts involving
MCA & ICA
Dr. L. Surbala (MPT Neuro)
12. ď‚žDepending on the cause
• Haemorrhagic stroke
ď‚– Intracranial haemorrhage
ď‚– Subarachnoid haemorrhage
ď‚– Signs of raised ICP will be evident with a history of a
traumatic accident
Dr. L. Surbala (MPT Neuro)
13. • Ischemic stroke
ď‚– Thrombotic: more common. Usually occurs in the
sleeping hours. Characterised by gradual onset of
symptoms
ď‚– Embolic: Occurs in the waking hours of the day.
Sudden onset of symptoms preceded by giddiness in
most conditions
Dr. L. Surbala (MPT Neuro)
14. ď‚žDepending 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
Dr. L. Surbala (MPT Neuro)
15. ď‚žDepending 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
Dr. L. Surbala (MPT Neuro)
16. ď‚žDepending on the symptoms
• MCA Syndrome
• ACA Syndrome
• PCA syndrome
• Vertebro basilar artery syndrome
ď‚– Vertebral artery
ď‚– Basilar artery
ď‚– Internal carotid artery
• Lacunar syndrome
Dr. L. Surbala (MPT Neuro)
17. • 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
Dr. L. Surbala (MPT Neuro)
18. • 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
Dr. L. Surbala (MPT Neuro)
19. • 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
Dr. L. Surbala (MPT Neuro)
20. ď‚ž Contralateral hemiplegia (UL & face more
affected than LL)
ď‚ž Contralateral hemisensory loss (UL & face
more affected than LL)
ď‚ž Ideomotor apraxia
ď‚ž Ataxia of contralateral limb
ď‚ž Contralateral Homonymous hemianopia
ď‚ž Left hemisphere infarction
• Contralateral neglect
• Possible contralateral visual field deficit
• Aphasia: Broca’s (expressive) or Wernicke’s
(receptive)
Dr. L. Surbala (MPT Neuro)
21. ď‚ž Coordination disorders such as tremor or
ataxia
ď‚ž Contralateral homonymous field deficit
ď‚ž Cortical blindness
ď‚ž Cognitive impairment including memory
impairment
ď‚ž Contralateral sensory impairment
ď‚ž Thalamic syndrome (abnormal sensation of
severe pain from light touch or
temperature changes)
 Weber’s syndrome (contralateral
hemiplegia & third nerve palsy)
Dr. L. Surbala (MPT Neuro)
22. ď‚žContralateral Hemiplegia or monoplegia
of LL (LL more affected than UL)
ď‚žContralateral sensory loss of LL
ď‚žUrinary incontinence
ď‚žProblems with imitation & bimanual task
ď‚žAbulia (akinetic mutism)
ď‚žApraxia
ď‚žAmnesia
ď‚žContralateral grasp reflex, sucking
reflex
Dr. L. Surbala (MPT Neuro)
24. ď‚žLocked-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.
Dr. L. Surbala (MPT Neuro)
25. ď‚ž 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
ď‚ž Ataxic hemiparesis
ď‚ž Dysarthria
ď‚ž Clumsy hand syndrome
ď‚ž Sensory/motor stroke
ď‚ž Dystonia/involuntary movements
Dr. L. Surbala (MPT Neuro)
29. ď‚ž1. 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
Dr. L. Surbala (MPT Neuro)
30. ď‚ž2. 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
Dr. L. Surbala (MPT Neuro)
31. ď‚ž3. 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
Dr. L. Surbala (MPT Neuro)
32. ď‚ž4. Alteration of tone
• Flaccidity (hypotonicity) is present immediately
after stroke
• Spasticity (hypertonicity) emerges in about 90
percent of cases
Dr. L. Surbala (MPT Neuro)
34. ď‚žMuscles not involved in either synergy
• Latissimus dorsi
• Teres major
• Serratus anterior
• Finger extensors
• Ankle evertors
Dr. L. Surbala (MPT Neuro)
35. ď‚ž6. 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
ď‚– The most commonly seen is asymmetric tonic neck
reflex (ATNR)
• Associated reactions are also present in patients
who exhibit strong spasticity and synergies
ď‚– unintentional movements of hemiparetic limb caused by
voluntary action of another limb
ď‚– by stimulation of yawning, sneezing, or coughing.
Dr. L. Surbala (MPT Neuro)
36. ď‚ž7. 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
Dr. L. Surbala (MPT Neuro)
37. ď‚ž8. 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.
ď‚– Ideational apraxia
ď‚– Ideomotor apraxia
Dr. L. Surbala (MPT Neuro)
38. ď‚ž9. 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
Dr. L. Surbala (MPT Neuro)
39. ď‚ž10. 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
Dr. L. Surbala (MPT Neuro)
40. ď‚ž11. 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.
Dr. L. Surbala (MPT Neuro)
41. ď‚ž12. 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.
ď‚– emotional outbursts of uncontrolled or exaggerated
laughing or crying that are inconsistent with mood.
• Depression is extremely common
ď‚– persistent feelings of sadness,feelings of
hopelessness, worthlessness or helplessness.
Dr. L. Surbala (MPT Neuro)
42. ď‚ž13. 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
Dr. L. Surbala (MPT Neuro)
44. ď‚ž1. Musculoskeletal changes
• Loss of voluntary movement and immobility can
result in loss of ROM & contractures.
ď‚– 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.
Dr. L. Surbala (MPT Neuro)
45. ď‚ž2. 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.
Dr. L. Surbala (MPT Neuro)
46. ď‚ž3. Thrombophlebitis & deep venous
thrombosis (DVT)
• complications for all immobilized patients.
Dr. L. Surbala (MPT Neuro)
47. ď‚ž4. 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
Dr. L. Surbala (MPT Neuro)
48. ď‚ž5. Pulmonary Function
• Decreased lung volume, decreased pulmonary
perfusion & vital capacity & altered chest wall
excursion
• Aspiration, occurs in about one third of
patients with dysphagia.
Dr. L. Surbala (MPT Neuro)
49. ď‚ž6. Integumentary
• The skin breaks down over bony prominences
from pressure, friction, shearing, and/or
maceration
Dr. L. Surbala (MPT Neuro)
51. ď‚žCT 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.
Dr. L. Surbala (MPT Neuro)
52. ď‚žMagnetic 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
Dr. L. Surbala (MPT Neuro)
53. ď‚žCerebral 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).
Dr. L. Surbala (MPT Neuro)
54. ď‚žFastest in first weeks after onset
ď‚žMeasurable neurological & functional
recovery occurring in first month after
stroke.
ď‚žContinue to make measurable functional
gains for months or years after insult
Dr. L. Surbala (MPT Neuro)
55. ď‚žLate recovery of function is also seen in
patients with chronic stroke who
undergo extensive functional training
• These changes are due to function-induced
plasticity
Dr. L. Surbala (MPT Neuro)
56. ď‚žRecovery also depends on severity of
stroke
Depends on type of stroke –
hemorrhagic or ischemic
ď‚žVaries from individual to individual
ď‚žDepends on intensity of therapy
ď‚žDepends on age of the patient
Dr. L. Surbala (MPT Neuro)
57. ď‚žA male patient with a known case of
hypertension came to emergency
department with history of sudden
collapse & LOC
ď‚žOn examination there is decrease DTR
on right side of body with +ve Babinski’s
sign
ď‚žThere is gradual regain of consciousness
but seems to be confused
Dr. L. Surbala (MPT Neuro)
58. ď‚žAfter a few days in hospital he regain
some of his LL movement but less
improvement in UL
ď‚žOn 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) aphasiaDr. L. Surbala (MPT Neuro)
59. ď‚žWhat is the condition?
ď‚žWhat may be the cause?
ď‚žWhat emergency investigation is called
for ?
ď‚žWhich artery may be involved?
ď‚žWhich areas of the brain is involved?
Dr. L. Surbala (MPT Neuro)
60.
61. ď‚žAbrupt onset with rapid coma is
suggestive of cerebral hemorrhage.
ď‚žSevere headache typically precedes LOC
ď‚žEmbolus also occurs rapidly, with no
warning, & is frequently associated with
heart disease or heart complications.
ď‚žUneven onset is typical with thrombosis.
Dr. L. Surbala (MPT Neuro)
62. ď‚žPast history include TIAs or head
trauma, presence of major or minor risk
factors, medications, positive family
history, & recent alterations in patient
function
Dr. L. Surbala (MPT Neuro)
63. ď‚žMay have abnormal posturing of limbs
ď‚žSynergistic patterns in the UL & LL
ď‚žFacial asymmetry
ď‚žMay use a walking aid E.g. cane
ď‚žAbnormal gait pattern may also be
observed
Dr. L. Surbala (MPT Neuro)
64. ď‚žMay present with hypertension
ď‚žPain
ď‚– Shoulder pain, secondary to subluxation, is a common
issue
ď‚– Shoulder-hand syndrome involves swelling &
tenderness in hand and pain in entire limb
ď‚– Complex Regional Pain Syndrome involves pain &
swelling of hand
Dr. L. Surbala (MPT Neuro)
65. ď‚žExpressive and/or receptive aphasia
ď‚žAttention disorders
ď‚žMemory deficits, including declarative
and procedural memory
ď‚žExecutive function deficits
Dr. L. Surbala (MPT Neuro)
66. ď‚žVisual field deficits
ď‚žWeakness & sensory loss in facial
musculature
ď‚žDeficits in laryngeal & pharyngeal function
ď‚žHypoactive gag reflex
ď‚žDiminished, but perceived, superficial
sensations
Dr. L. Surbala (MPT Neuro)
67. ď‚ž Hemi sensory loss (dysesthesia, or
hyperesthesia, joint position & movement sense)
ď‚ž May be able to identify sensations but difficulty
in localizing
ď‚ž Cortical sensations s/a 2 point
discrimination, stereognosis & graphaesthesia are
affected secondary to loss of grip function
ď‚ž Agnosia
ď‚ž Perceptual problems
ď‚ž Unilateral spatial neglect
ď‚ž Pusher syndrome
Dr. L. Surbala (MPT Neuro)
69. ď‚žSoft tissue shortening and contractures
ď‚žIncreased muscle stiffness
ď‚žJoint immobility
ď‚žDisuse-provoked soft tissue changes
ď‚žOver extensibility of capsular
structures of Glenohumeral joint
Dr. L. Surbala (MPT Neuro)
70. ď‚žSynergistic patterns of movement
ď‚žHypertonicity
ď‚žWeakness
ď‚žAssociated movements or synkinesis
ď‚žApraxia including motor & verbal apraxia
Dr. L. Surbala (MPT Neuro)
71. ď‚žExaggerated deep tendon reflexes
ď‚žDiminished superficial reflexes
Positive Babinski’s reflex
ď‚žImpaired Righting, equilibrium, and
protective reactions
ď‚žAbnormal primitive reflex (ATNR) may
be present
Dr. L. Surbala (MPT Neuro)
72. ď‚žA sling for Glenohumeral support
ď‚žAFO
ď‚žCane
Dr. L. Surbala (MPT Neuro)
73. ď‚žBP, RR, & HR at rest & during exercise
may have a sudden rise
ď‚žReview pulse oximetry, blood gas, tidal
volume, & vital capacity
ď‚žAdminister a 2 or 6-minute walk test
ď‚žAdminister Borg RPE after walk test or
other physical activity
Dr. L. Surbala (MPT Neuro)
74. ď‚žEdema may occur in affected limbs
ď‚žMay be associated with shoulder hand
syndrome
Dr. L. Surbala (MPT Neuro)
75. • Decrease Tidal volume & vital capacity
• Decrease Respiratory muscle strength
• Ability to cough & strength of cough is
decreases
• Dyspnea during exercise
Dr. L. Surbala (MPT Neuro)
76. ď‚žDecreased extension of hip &
hyperextension of knee
ď‚žDecreased flexion of knee & hip during
swing phase
ď‚žDecreased ankle DF at initial contact &
during stance resulting in hip
circumduction
ď‚žTrendelenburg
Dr. L. Surbala (MPT Neuro)
77. ď‚žCompromised static as well as dynamic
balance
Pusher’s syndrome may be present
resulting in fall on the affected side
Dr. L. Surbala (MPT Neuro)
78. ď‚žSpastic patterns can involve flexion &
abduction of arm, flexion of elbow, &
supination of elbow with finger flexion
ď‚žHip & knee extension with ankle
plantarflexion & inversion
ď‚žProtracted & depressed
shoulder, scoliosis & hip hiking
Dr. L. Surbala (MPT Neuro)
79. ď‚žUsing FIM, Barthel index, FMA
ď‚žThere is compromised basic as well as
instrumental ADL
ď‚žAmbulatory capacity is compromised
Dr. L. Surbala (MPT Neuro)
80. ď‚žFlaccid bowel & bladder during the acute
stage
ď‚žBowel & bladder function gradually
regains
ď‚žUninhibited bladder if frontal lobe is
involved
ď‚žConstipation is frequently seen
Dr. L. Surbala (MPT Neuro)
86. ď‚žImprove respiratory & circulatory
function
• Breathing exercise
• Chest expansion exercise
• Postural drainage
• Huffing & Coughing techniques
• Passive & active ankle & toe exercise
ď‚– (after careful & thorough examination of
cardiopulmonary system)
Dr. L. Surbala (MPT Neuro)
87. ď‚žPrevent 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
Dr. L. Surbala (MPT Neuro)
88. ď‚žPrevent 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
Dr. L. Surbala (MPT Neuro)
89. ď‚ž5 days a week for a minimum of 3 hours
of active rehabilitation per day
ď‚žIntensive rehabilitation if vitals are
stable
Dr. L. Surbala (MPT Neuro)
90.
91. ď‚ž Positioning hemiplegic side towards door or
main part of room
ď‚ž Presentation of repeated sensory stimuli
ď‚ž Stretching, stroking, superficial & deep
pressure, iceing, vibration etc.
ď‚ž Wt bearing ex & Joint approximation tech
ď‚ž Stoking with different texture fabrics
ď‚ž Pressure application
ď‚ž Improve other senses like use of visual &
auditory
ď‚ž PNF tech., use of bilateral UE
Dr. L. Surbala (MPT Neuro)
92. ď‚žSoft tissue, joint mobilization & ROM
exercise
ď‚žAROM & PROM with end range stretch
ď‚žEffective positioning & edema reduction
ď‚žStretching program & splinting
ď‚žSuggested activities
• Arm cradling
• Table top polishing
• Self overhead activities in supine & sitting &
reaching to the floor
Dr. L. Surbala (MPT Neuro)
93. ď‚žStrengthening of agonist & antagonistic
muscle
ď‚žGraded ex program using free
weights, therabands, sand bags &
isokinetic devices
ď‚žFor weak patients (<3/5), gravity-
eliminated ex using powder boards, sling
suspension, or aquatic ex is indicated
ď‚žGravity-resisted active movts are
indicated (>3/5 strength)
Dr. L. Surbala (MPT Neuro)
94. ď‚ž Sustained stretch & slow iceing of spastic
muscle
ď‚ž Rhythmic rotations
ď‚ž Weight bearing exercise
ď‚ž Prolonged & firm pressure application
ď‚ž Slow rocking movement
ď‚ž Positioning in anti synergistic pattern
ď‚ž Rhythmic initiation
ď‚ž Air splints
ď‚ž Neural warmth
ď‚ž Electrical stimulation
Dr. L. Surbala (MPT Neuro)
95. ď‚žDissociation & selection of desired movt
patterns
ď‚žSelect postures that assist desired
movements through optimal biomechanical
stabilization & use of optimal point in
range
ď‚žStart with assisted movt, followed by
active & resisted movt
ď‚žTask oriented exercise
Dr. L. Surbala (MPT Neuro)
96. ď‚žSuggested exercise
• Rolling
• Supine to sit & sit to supine
• Sitting
• Bridging
• Sit to stand & Sit down
• Modified plantigrade
• Standing
• Transfer
Dr. L. Surbala (MPT Neuro)
97. ď‚žIn 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
Dr. L. Surbala (MPT Neuro)
98. • 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
Dr. L. Surbala (MPT Neuro)
99. ď‚žProper handling & positioning of shoulder
joint
ď‚žReducing subluxation, NMES, gentle
mobilization (grade 1 & 2)
ď‚žUse of supportive devices & slings
ď‚žUse of overhead pulley is contraindicated
ď‚žTENS & heat therapy
Dr. L. Surbala (MPT Neuro)
100. ď‚žStrengthening muscles in appropriate
pattern
ď‚žSuggested 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
ď‚žFacilitation of DF
ď‚žCycling & treadmill training
Dr. L. Surbala (MPT Neuro)
101. ď‚ž Facilitate symmetrical wt bearing on both side
ď‚ž Postural perturbations can be induced in
different positions
ď‚ž Sit or stand on movable surface to increase
challenge
ď‚ž Reaching activities
ď‚ž Dual task training s/a kicking ball in
standing, throwing activities, carrying an object
while walking
ď‚ž Divert attention
ď‚ž Single limb stance
ď‚ž Exercise on trampoline
Dr. L. Surbala (MPT Neuro)
102. ď‚žInitial gait training between parallel
bars
ď‚žProceed outside bars with aids & then
without aids
ď‚žWalking forward, backward, sideways &
in cross patterns
ď‚žPBWSTT with higher speed improve
overall locomotor activity & overground
speed
ď‚žProper use of orthotics & wheelchair
Dr. L. Surbala (MPT Neuro)
103. • 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
Dr. L. Surbala (MPT Neuro)
104. ď‚ž Proper head position in chin down position
ď‚ž Movements of lips, tongue, cheeks, & jaw
ď‚ž Firm pressure to anterior 3rd of tongue
with tongue depressor to stimulate
posterior elevation of tongue,
ď‚ž Puffing, blowing bubbles, & drinking thick
liquids through straw
ď‚ž Food presentation in proper position
ď‚ž Texture of food should be smooth
ď‚ž Tasty food should be given to facilitate
swallowing reflex
ď‚ž Stroking the neck during swallowing
Dr. L. Surbala (MPT Neuro)
105. ď‚žStrategy development
• Patient as an active explorer of activity
• Modify strategy of activity in correct patterns
ď‚žFeedback
• Intrinsic or extrinsic feedback
• Positive & negative feedbacks
ď‚žPractice
• Repeated practice of functional activity
• Practice in different environment
Dr. L. Surbala (MPT Neuro)
106. ď‚žGive factual information, counsel family
members about patient’s capabilities &
limitations
ď‚žGive information as much as Pt or family
can assimilate
ď‚žProvide open discussion & communication
ď‚žBe supportive, sensitive & maintain a
positive supporting nature
ď‚žGive psychological support
ď‚žRefer to help groups
Dr. L. Surbala (MPT Neuro)
107. ď‚žFamily member should participate daily
in the therapy session & learn exercises
ď‚žHome visits should be made prior to
discharge
ď‚žArchitectural modifications, assistive
devices or orthotics should be ready
before discharge
ď‚žIdentify community service & provide
information to the patient
Dr. L. Surbala (MPT Neuro)
108. O’ Sullivan SB, Schmitz TJ. Stroke.
Physical rehabilitation. 5th ed., New
Delhi: Jaypee Brothers, 2007.
ď‚žDarcy A. Umphred. Neurological
Rehabilitation, 5th ed., Mosby
Elsevier, Missouri, 2007.
Dr. L. Surbala (MPT Neuro)