stroke physical therapy

In Stroke Physical Therapy plays an important role in the process of rehabilitation. As a part of the interdisciplinary team, physiotherapists work in concert with the managing doctor and other rehabilitation specialists to provide stroke patients with a comprehensive rehabilitation program. The stroke physical therapy rehabilitation program involves a dynamic process of assessment, goal-setting, treatment and evaluation; its coverage spans from the acute stage, through the rehabilitation stage, to the community stage.

The whole rehabilitation program is predicated on two general components. The first includes preventive measure targeted at maintaining physical integrity and minimizing complications that will prevent or prolong functional return. These measures should begin immediately post stroke and continue as long as necessary. The second component is restorative treatment aimed at promoting functional recovery. This phase should begin as soon as the patient is medically and neurologically stable and has the cognitive and physical ability to participate actively in a rehabilitation program. In brief, the aims of physical therapy interventions are to promote motor recovery, optimize sensory functions, enhance functional independence, and prevent secondary complications.

Goals of Physical therapy

Management of stroke patients begins as the acute care during acute hospitalization and continues as rehabilitative care as soon as patient’s medical & neurological status has stabilized. Moreover, community reintegration of patients continues during the community care stage.

1. Acute Care

Aims :

1) Prevent recurrent stroke
2) Monitor vital signs, dysphasia adequate nutrition, bladder & bowel function.
3) Prevent complications
4) Mobilize the patient
5) Encourage resumption of self-care activities
6) Provide emotional support & education for patient & family
7)Screen for rehabilitation and choice of settings 

2. Rehabilitation care

Aims :

1) Set rehabilitation goals; develop rehabilitation plan and monitor progress
2) Manage sensori-motor deficits
3) Improve functional mobility & independence
4) Prevent & treat complications
5) Monitor functional health conditions
6) Discharge planning (safe residence recommendation, patient & care givers education & continuity of care)
7) Community – reintegration 

3. Community care

Aims :

1) Assist patient to reintegrate into community
2) Enhance family and caregivers functioning
3) Co-ordinate continuity of patient care 
4) Promote health and safety and prevent further hospitalization
5) Give advice on community supports, valued activities and vocational reintegrate

Stroke Physical Therapy assessment includes

a) Patient characteristics

• Demographics (age, gender).
• History of illness.
• Prior activity level (low to very high).
• Prior socialization (isolated to outgoing).
• Expectations regarding stroke outcomes and need for assistance.

b) Family and caregiver characteristics

• Members of household and relationship to patient.
• Other potential caregivers.
• Capacity to provide physical, emotional, instrumental support.

c) Impairments

e.g. speech, seeing, tone, muscle strength, balance, and co-ordination.

d) Activities

e.g. communication, movement, use of assistive devices and technical aids.

e) Participation

e.g. mobility, personal maintenance, social relationships, work, leisure, hobby, economic life

f) Environment factors

e.g. personal support and assistance, social and economic institutions, physical environment such as access to building and key facilities within living quarters, safety considerations, access to resources and activities in community.

Special consideration

Shoulder assessment

Shoulder subluxation and pain is a major and frequent complication in patients with hemiplegia. (Joynt, 1992; Grossen-Sils, and Schenkman, 1985). As many as 80% of patients with cerebrovascular accident has been reported to show shoulder subluxation. Clinical examination of shoulder should include thorough evaluation of pain , range of movement, motor control, and shoulder subluxation.

Setting rehabilitation goals

In Stroke Physical Therapy both short-term and long- term goals need to be realistic in terms of current levels of disability and the potential for recovery. Goals should be mutually agreed to by the patient, family, and rehabilitation team and should be documented in the medical record in explicit, measurable terms.

Developing the rehabilitation management plan

In Stroke Physical Therapy the rehabilitation management plan should indicate the specific treatments planned and their sequence, intensity, frequency, and expected duration. Measures to prevent complications of stroke and recurrent strokes should be continued.

Stroke Physical Therapy Interventions

(1). Improving motor control

a.Neurofacilitatory Techniques

In Stroke Physical Therapy these therapeutic interventions use sensory stimuli (e.g. quick stretch, brushing, reflex stimulation and associated reactions) ,which are based on neurological theories, to facilitate movement in patients following stroke (Duncan,1997). The following are the different approaches: -

i.Bobath

Berta & Karel Bobath’s approach focuses to control responses from damaged postural reflex mechanism. Emphasis is placed on affected inputs facilitation and normal movement patterns (Bobath, 1990).

ii.Brunnstrom

Brunnstrom approach is one form of neurological exercise therapy in 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) from the perspective of the functional recovery of stroke patients. The result of this study showed no clear differences in the effectiveness between the two methods within the framework of functional recovery.

iii.Rood

Emphasise the use of activities in developmental sequences, sensation stimulation and muscle work classification. Cutaneous stimuli such as icing, tapping and brushing are employed to facilitate activities.

iv. Proprioceptive neuromuscular facilitation (PNF)

Developed by Knott and Voss, they advocated the use of peripheral inputs as stretch and resisted movement to reinforce existing motor response. Total patterns of movement are used in treatment and are followed in a developmental sequence.

It was shown that the commutative effect of PNF is beneficial to stroke patient (Wong, 1994). Comparing the effectiveness of PNF, Bobath approach and traditional exercise, Dickstein et al (1986)demonstrated that no one approach is superior to the rest of the others (AHCPR, 1995).

b. Learning theory approach

i. Conductive education

In Stroke Physical Therapy, Conductive education is one of the methods in treating neurological conditions including hemiplegic patients. Cotton and Kinsman (1984) demonstrated a neuropsychological approach using the concept of CE for adult hemiplegia. The patient is taught how to guide his movements towards each task-part of the task by using his own speech - rhythmical intention.

ii. Motor relearning theory

Carr & Shepherd, both are Australian physiotherapists, developed this approach in 1980. It emphasises the practice of functional tasks and importance of relearning real-life activities for patients. Principles of learning and biomechanical analysis of movements and tasks are important. (Carr and Shepherd, 1987)

There is no evidence adequately supporting the superiority of one type of exercise approaches over another. However, the aim of therapeutic approach is to increase physical independence and to facilitate the motor control of skill acquisition and there is strong evidence to support the effect of rehabilitation in terms of improved functional independence and reduced mortality.

c. Functional electrical stimulation (FES)

FES is a modality that applied a short burst of electrical current to the hemiplegic muscle or nerve. In Stroke Physical Therapy, FES has been demonstrated to be beneficial to restore motor control, spasticity, and reduction of hemiplegic shoulder pain and subluxation. It is concluded that FES can enhance 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 recent meta- analysis of randomized controlled trial study showed 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, range of motion and reduction of severity of subluxation and pain of hemiplegic shoulder.

d. Biofeedback

Biofeedback is a modality that facilitates the cognizant of electromyographic activity in selected muscle or awareness of joint position sense via visual or auditory cues. In Stroke Physical Therapy the result of studies in biofeedback is controversial. A meta-analysis of 8 randomized controlled trials of biofeedback therapy demonstrated that electromyographic biofeedback could improve motor function in stroke patient (Schleenbaker, 1993). Another meta-analysis study on EMG has showed that EMG biofeedbcak is superior to conventional therapy alone for improving ankle dorsiflexion muscle strength (Moreland et al., 1998. Erbil and co-workers (1996) showed that biofeedback could improve earlier postural control to improve impaired sitting balance. Conflicting meta-analysis study by Glanz et al (1995) showing that biofeedback was not efficacious in improving range of motion in ankle and shoulder in stroke patient. Moreland (1994) conducted another meta-analysis concluded that EMG biofeedback alone or with conventional therapy did not superior to conventional physical therapy in improving upper- extremity function in adult stroke patient.

(2) Hemiplegic shoulder management

Shoulder subluxation and pain of the affected arm is not uncommon in at least 30% of all patient after stroke (RCP, 1998) ,whereas subluxation is found in 80% of stroke patients (Najenson et al., 1971). It is associated with severity of disability and is common in patients in rehabilitation setting. Suggested interventions are as follows:

a) Exercise

Active weight bearing exercise can be used as a means of improving motor control of the affected arm; introducing and grading tactile, proprioceptive, and kinesthetic stimulation; and preventing edema and pain. In Stroke Physical Therapy, Upper extremity weight bearing can be used to lengthen or inhibit tight or spastic muscles while simultaneously facilitating muscles that are not active (Donatelli, 1991). According to Robert (1992), the amount of shoulder pain in hemipelgia was related most to loss of motion. He advocated that the provision of ROM exercise (caution to avoid imprigement) as treatment as early as possible. 

b) Functional electrical stimulation

Functional electrical stimulation (FES) is an increasingly popular treatment for the hemiplegic stroke patient. It has been applied in stroke physical therapy for the treatment of shoulder subluxation (Faghri et al.,1994), spasticity (Stefanovska et al., 1991) and functionally, for the restoration of function in the upper and lower limb (Kralji et al., 1993). In Stroke Physical Therapy, Electrical stimulation is effective in reducing pain and severity 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 Therapy, proper positioning and handling of hemiplegic shoulder, whenever in bed, sitting and standing or during lifting, can prevent shoulder injury is recommended in the AHCPR & SIGN guidelines for stroke rehabilitation. In Stroke Physical Therapy, 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 every one including family on handling technique.

d) Neuro-facilitation

e) Passive limb physiotherapy

Maintenance of full pain-free range of movement without traumatizing the joint and the structures can be carried out. In Stroke Physical Therapy, at no time should pain in or around the shoulder joint be produced during treatment. (Davies, 1991).

f) Pain relief physiotherapy

Passive mobilisation as described by Maitland, can be useful in gaining relief of pain and range of movement (Davies, 1991). In Stroke Physical Therapy other treatment modalities such as thermal, electrical, cryotherapy etc. can be applied for shoulder pains of musculoskeletal in nature.

g) Reciprocal pulley The use of reciprocal pulley appears to increase risk of developing shoulder pain in stroke patients. It is not related to the presence of subluxation or to muscle strength. (Kumar et al., 1990)

h) Sling

In Stroke Physical Therapy the use of sling is controversial. No shoulder support will correct glenohumeral joint subluxation. However, it may prevent the flaccid arm from hanging against the body during functional activities, thus decreasing shoulder joint pain. They also help to relieve downward traction on the shoulder capsule caused by the weight of the arm (Hurd, Farrell, and Waylonis, 1974 ; Donatelli ,1991).

(3) Limb physiotherapy

Limb physiotherapy/Stroke Physical Therapy includes passive, assisted-active and active range-of-motion exercise for the hemiplegic limbs. This can be an effective management for prevention of limb contractures and spasticity and is recommended within AHCPR (1995). Self-assisted limb exercise 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 reduction of complication for stroke patients

(4) Chest physiotherapy

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

(5) Positioning

 In Stroke Physical Therapy consistent “reflex-inhibitory” patterns of posture in resting is encouraged to discourage physical complication of stroke and to improve recovery (Bobath, 1990).

Meanwhile, therapeutic positioning is a widely advocated strategy to discourage the development of abnormal tone, contractures, pain and respiratory complications. It is an important element in maximizing the patient's functional gains and quality of life.

(6) Tone management

A goal of Stroke Physical Therapy interventions has been to “normalize tone to normalize movement.” Therapy modalities for reducing tone include stretching, prolonged stretching, passive manipulation by therapists, weight bearing, ice, contraction of muscles antagonistic to spastic muscles, splinting, and casting. Research on tone-reducing techniques has been hampered by the inadequacies of methods to measure spasticity (Knutsson and Martensson, 1980) and 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 do not 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 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).

(7) Sensory re-education

Bobath and other therapy approaches recommend the use of sensory stimulation to promote sensory recovery of stroke patients.

(8) Balance retraining

Re-establishment of balance function in patients following stroke has been advocated as an essential component in the practice of stroke physical therapy (Nichols, 1997). Some studies of patients with hemiparesis revealed that these patients have greater amount of postural sway, asymmetry with greater weight on the non-paretic leg, and a decreased ability to move within a weight-bearing posture (Dickstein, Nissan, Pillar, and Scheer, 1984; Horak, Esselman, Anderson, and Lynch, 1984). Meanwhile, research has demonstrated moderate relationships between balance function and parameters such as gait speed, independence, wheelchair mobility, reaching, as well as 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 on the effectiveness of treatment of disturbed balance can be found in studies comparing effects of balance retraining plus physiotherapy treatment and physiotherapy treatment alone.

(9) Fall prevention

In Stroke Physical Therapy, falls are one of the most frequent complications( Dromerick and Reading, 1994), and the consequences of which are likely to have a negative effect on the rehabilitation process and its outcome. According to the systematic review of the Cochrane Library (1999), which evaluatedthe effectiveness of several fall prevention interventions in the elderly, there was significant protection against falling from interventions which targeted multiple, identified, risk factors in individual patients. The same is true for interventions which focused on behavioural interventions targeting environmental hazards plus other risk factors

(10) Gait re-education

Recovery of independent mobility is an important goal for the immobile patient, and much 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 contrast Carr and Shepherd advocates task-related training with methods to increase strength, coordination and flexible MS system to develop skill in walking while Treadmill training combined with use of suspension tube. Some patient’s body weight can effective in regaining walking ability, when used as an adjunct to convention therapy 3 months after active training (Visintin et al., 1998; Wall and Tunbal 1987; Richards et al., 1993).

(11) Functional Mobility Training

To handle through the functional limitations of stroke patients, functional tasks are taught to them based on movement analysis principles. In Stroke Physical Therapy these tasks include bridging, rolling to sit to stand and vice versa, transfer skills, walking and stairing etc (Mak et al., 2000).

Published studies report that many patients improve during rehabilitation. The strongest evidence of benefit is 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 helps prevent compilations e.g. DVT, skin breakdown contracture and pneumonia. Evidence have shown better orthrostatic tolerance (Asberg, 1989) and earlier ambulation (Hayes and Carroll, 1986).

(12) Upper limb training

By 3 months poststroke, approximately 37% of the individuals continues to have decreased upper extremities (UE) function. Recovery of UE function lags behind that of the lower extremities because of the more complex motor skill required of the UE in daily life tasks. That means many individuals who have a stroke are at risk for lowered quality of life.

Many approaches to the physical rehabilitation of adults post-stroke exist that attempt to maximize motor skill recovery. However the literature does not support the efficacy of any single approach. The followings are the current approaches to motor rehabilitation of the UE.

a) Facilitation models

They 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 is some evidence that practice based on the facilitation models can result in improved motor control of UE ( Dickstein et al,1986, Grade A; Wagenaar et al, 1990 ). However, intervention based on the facilitation models has not been effective in 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 Therapy, Functional electric stimulation (FES) can be effective in increasing the electric activity of muscles or increased active range of motion in individuals with stroke ( Dimitrijevic et al., 1996; Fields, 1987; Faghri et al., 1994,; Kraft, Fitts and Hammond, 1992 ). Some evidence shown that FES may be more effective than facilitation approaches ( Bowman, Baker and Waters, 1979; Hummelsheim, Maier-Loth and Eickhof, 1997 ).

c) Electromyographic biofeedback

In Stroke Physical Therapy, biofeedback can contribute to improvements in motor control at 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 studies have shown 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, the ability to generalize these skills and incorporate them into daily life is not measured.

d) Constraint-induced therapy

Constraint-Induced (CI) therapy was designed to overcome the learned nonuse of the affected UE. In the most extreme form of CI therapy, individual post-stroke are prevented from using the less affected UE by keeping it in a splint and sling for at least 90% of their waking hours. Studies have 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 is retained for at least as long as 2 years ( Taub and Wolf, 1997 ). However, CI therapy, currently are effective only in those with distal voluntary movement ( Taub and Wolf, 1997 ).

(13) Mobility appliances and equipment

Small changes in an individual's local 'environment' can greatly increase independence, use of a wheelchair or walking stick. However, little research has been done for these 'treatments'. It is acknowledged that walking aids and mobility appliances may benefit selected patients.

Tyson and Ashburn (1994) showed that walking aids had effect in poor walkers - a benefical effect on gait (Level of evidence = III, Recommendation = Grade B). Lu and coworkers (1997) concluded that wrist crease stick is better than stick measured to greater trochanter. (Level of evidence = IIb, Recommendation = Grade A

(14) Acupuncture 

The World Health Organisation (WHO) has listed acupuncture as a possible treatment for pariesis after stroke. Studies had sown its beneficial effects in strike rehabilitation.

Chen et al. (1990) had performed a controlled clinical trial of acupuncture in 108 stroke patients. They stated that the total effective rate of increasing average muscle power by at least one grade was 83.3% in the acupuncture group compared with the controlled group which was 63.4% (p<0.05).

Hua et al. (1993) had reported a significant difference in changes of neurological score between the acupuncture group and the control group after 4 weeks of treatment in a RCT and no adverse effects were observed in patients treated with acupuncture.

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(15) Vasomotor training 

Early stimulation of the muscle pump can reduce the venous stasis and enhance the general circulation of the body. It then hastens the recovery process.

(16) Oedema management

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

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