Stroke: PT Assessment and Management


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Stroke: PT Assessment and Management

  1. 1. Stroke is an acute onset of neurologicaldysfunction due to an abnormality incerebral circulation with resultant signs& symptoms which corresponds toinvolvement of focal areas of the brainDr. L. Surbala (MPT Neuro)
  2. 2. It is defined as the sudden onset ofneurological deficits due to anabnormality in cerebral circulation withthe signs and symptoms lasting for morethan 24 hours or longerDr. L. Surbala (MPT Neuro)
  3. 3. It is defined as the sudden onset ofneurological deficits due to anabnormality in cerebral circulation withthe signs and symptoms lasting for lessthan 24 hoursDr. L. Surbala (MPT Neuro)
  4. 4. Third leading cause of deathThe incidence of stroke is about 1.25times greater for males than femalesMost common cause of disability amongadultsDr. L. Surbala (MPT Neuro)
  5. 5. 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)AtherothromboembolismDr. L. Surbala (MPT Neuro)
  6. 6.  Infective endocarditis & HIV infection Tumour Perioperative stroke (due to hypotension and boundaryzone infarction, trauma to and dissection of neckarteries, paradoxical embolism, fat embolism, infective endocarditis) Migraine Chronic meningitis Inflammatory bowel disease (ulcerative and Crohnscolitis) Hypoglycemia Snake bite, fat embolismDr. L. Surbala (MPT Neuro)
  7. 7. NON MODIFIABLEMODIFIABLE Ageing & gender Positive family history Circadian and seasonalfactors (peaks between 10am till noon) Heart disease Diabetes mellitus Hypertension Peripheral arterial disease Blood pathology (increasedhaematocrit, clottingabnormalities, sickle cellanaemia etc) Hyperlipidemia TIA Smoking Obesity Lack of physical exerciseor sedentary life style Diet & excess alcoholconsumption Oral contraceptives Infection (meningealinfection) Psychological factors VasectomyDr. L. Surbala (MPT Neuro)
  8. 8.  Sudden numbness or weakness of face, arm, orleg, on one side of body Sudden confusion, trouble speaking orunderstanding Sudden blurring of vision Sudden onset of dizziness, loss of balance orcoordination Sudden, severe headaches with no known cause Other important but less common stroke symptomsinclude:• Sudden nausea, fever, & vomiting distinguished from a viralillness by speed of onset (minutes or hours vs several days)• Brief loss of consciousness or a period of decreasedconsciousness (fainting, confusion, convulsions, or coma)Dr. L. Surbala (MPT Neuro)
  9. 9. Ischemia results in irreversible cellulardamage with a core area of focalinfarction within minutes• Transitional area surrounding core is termedischemic penumbra & consists of viable butmetabolically lethargic cellsIschemia produce cerebral edema, thatbegins within minutes of insult &reaches a maximum by 3 to 4 days.Swelling gradually subsides & generallydisappears by 2 to 3 weeksDr. L. Surbala (MPT Neuro)
  10. 10. Oedema elevates ICP, leading tointracranial HT & neurologicaldeterioration associated withcontralateral & caudal shifts of brainstructuresCerebral edema is the most frequentcause of death in acute stroke & ischaracteristic of large infarcts involvingMCA & ICADr. L. Surbala (MPT Neuro)
  11. 11. Depending on the cause• Haemorrhagic stroke Intracranial haemorrhage Subarachnoid haemorrhage Signs of raised ICP will be evident with a history of atraumatic accidentDr. L. Surbala (MPT Neuro)
  12. 12. • Ischemic stroke Thrombotic: more common. Usually occurs in thesleeping hours. Characterised by gradual onset ofsymptoms Embolic: Occurs in the waking hours of the day.Sudden onset of symptoms preceded by giddiness inmost conditionsDr. L. Surbala (MPT Neuro)
  13. 13. Depending on the severity• Mild stroke: symptoms subside with no deficitin a week period• Moderate stroke: symptoms recover in a periodof 3 - 6 months with minimal neurologicaldeficit• Severe stroke: there is no complete recoveryof the symptoms even after 1 years. Alwaysends up with severe neurological deficitDr. L. Surbala (MPT Neuro)
  14. 14. Depending on the duration• Acute stroke: to a period of one week or untilspasticity develops• Sub acute stroke: after the development ofspasticity & last for a period of 3-12 months• Chronic stroke: more than 12 monthsDr. L. Surbala (MPT Neuro)
  15. 15. Depending on the symptoms• MCA Syndrome• ACA Syndrome• PCA syndrome• Vertebro basilar artery syndrome Vertebral artery Basilar artery Internal carotid artery• Lacunar syndromeDr. L. Surbala (MPT Neuro)
  16. 16. • Stage 1: recovery occurs in a stereotypedsequence of events that begins with a period offlaccidity immediately following acute episode.No movement of limbs can be elicited• Stage 2: basic limb synergies or some of theircomponents may appear as associated reactions.Minimal voluntary movement may be present.Spasticity begins to developDr. L. Surbala (MPT Neuro)
  17. 17. • Stage 3: Gains voluntary control of movementsynergy although full range is not developed.Spasticity has further increased• Stage 4: some movement combination that do notfollow the synergy are mastered first withdifficulty & later with more ease. Spasticitybegins to declineDr. L. Surbala (MPT Neuro)
  18. 18. • Stage 5: more difficult movement are learnt asthe basic limb synergy lose their dominanceover motor roots. Spasticity further declines• Stage 6: disappearance of spasticity, individualjoint movement become possible & coordinationapproaches normal. Normal motor function isrestoredDr. L. Surbala (MPT Neuro)
  19. 19.  Contralateral hemiplegia (UL & face moreaffected than LL) Contralateral hemisensory loss (UL & facemore 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)Dr. L. Surbala (MPT Neuro)
  20. 20.  Coordination disorders such as tremor orataxia Contralateral homonymous field deficit Cortical blindness Cognitive impairment including memoryimpairment Contralateral sensory impairment Thalamic syndrome (abnormal sensation ofsevere pain from light touch ortemperature changes) Weber’s syndrome (contralateralhemiplegia & third nerve palsy)Dr. L. Surbala (MPT Neuro)
  21. 21. Contralateral Hemiplegia or monoplegiaof 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, suckingreflexDr. L. Surbala (MPT Neuro)
  22. 22.  Medial medullary syndrome (vertebralartery) Lateral medullary (Wallenbergs) 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 syndromeDr. L. Surbala (MPT Neuro)
  23. 23. Locked-in syndrome (LIS)• Acute hemiparesis rapidly progressing totetraplegia & lower bulbar paralysis (CN Vthrough XII are involved)• Initially patient is dysarthria & dysphonic &progresses to mutism (anarthria)• There is preserved consciousness & sensation• Horizontal eye movements are impaired butvertical eye movements & blinking remainintact.• Communication can be established via these eyemovements.Dr. L. Surbala (MPT Neuro)
  24. 24.  Caused by small vessel disease of deep whitemater• Pure motor lacunar stroke: posterior limb of internalcapsule, pons, & pyramids• Pure sensory lacunar stroke: ventrolateral thalamusor thalamocortical projections Ataxic hemiparesis Dysarthria Clumsy hand syndrome Sensory/motor stroke Dystonia/involuntary movementsDr. L. Surbala (MPT Neuro)
  25. 25. Dr. L. Surbala (MPT Neuro)
  26. 26. Dr. L. Surbala (MPT Neuro)
  27. 27. Dr. L. Surbala (MPT Neuro)
  28. 28. 1. Altered sensation• Pain (central pain or thalamic pain syndromecharacterized by constant, severe burning painwith intermittent sharp pains• Hyperalgesia• Loud sound, bright light etc. may trigger painDr. L. Surbala (MPT Neuro)
  29. 29. 2. Vision• Homonymous hemianopia, a visual fielddefect, occurs with lesions involving the opticradiation (MCA) or to primary visual cortex(PCA)• Visual neglect & problems with depthperception, and spatial relationshipsDr. L. Surbala (MPT Neuro)
  30. 30. 3. Weakness• Usually seen in the contralateral side of thelesion• MCA stroke are more common so weakness islargely seen in the UL in clinical practice• Distal muscle are more affected than proximalmuscles• Mild weakness of ipsilateral sideDr. L. Surbala (MPT Neuro)
  31. 31. 4. Alteration of tone• Flaccidity (hypotonicity) is present immediatelyafter stroke• Spasticity (hypertonicity) emerges in about 90percent of casesDr. L. Surbala (MPT Neuro)
  32. 32. 5. Abnormal synergyDr. L. Surbala (MPT Neuro)
  33. 33. Muscles not involved in either synergy• Latissimus dorsi• Teres major• Serratus anterior• Finger extensors• Ankle evertorsDr. L. Surbala (MPT Neuro)
  34. 34. 6. Abnormal reflexes• Initially, hyporeflexia with flaccidity & laterhyperreflexia• May demonstrate clonus, & +ve Babinski• Movement of head or position of body may elicit achange in tone or movement of extremities The most commonly seen is asymmetric tonic neckreflex (ATNR)• Associated reactions are also present in patientswho exhibit strong spasticity and synergies unintentional movements of hemiparetic limb caused byvoluntary action of another limb by stimulation of yawning, sneezing, or coughing.Dr. L. Surbala (MPT Neuro)
  35. 35. 7. Altered co ordination• Proprioceptive losses can result in sensoryataxia• Strokes affecting cerebellum typically producecerebellar ataxia (e.g.basilar arterysyndrome, pontine syndromes) & motorweakness.• Basal ganglia involvement (PCA syndrome) maylead to bradykinesia or involuntary movementsDr. L. Surbala (MPT Neuro)
  36. 36. 8. Altered motor programing• Motor praxis is ability to plan & executecoordinated movement• Lesions of premotor frontal cortex of eitherhemisphere, left inferior parietal lobe, & corpuscallosum can produce apraxia.• Apraxia is more evident with left hemispheredamage than right and is commonly seen withaphasia. Ideational apraxia Ideomotor apraxiaDr. L. Surbala (MPT Neuro)
  37. 37. 9. Postural Control & Balance• Impairments in steadiness, symmetry, & dynamicstability• Problems may exist when reacting to adestabilizing external force (reactive posturalcontrol) or during self-initiated movements(anticipatory postural control).• Pusher syndrome: characterized by active pushingwith stronger extremities toward affectedside, leading to lateral postural imbalanceDr. L. Surbala (MPT Neuro)
  38. 38. 10. Speech, Language, and Swallowing• Lesions involving cortex of dominant hemisphere• Aphasia: impairment of languagecomprehension, formulation, and use.• Dysarthria: motor speech disorders caused bylesions of CNS or PNS that mediate speechproduction.• Dysphagia, occurs with lesions affecting medullarybrainstem (CN IX and X), large vessel pontinelesions, as well as in acute MCA and PCA lesionDr. L. Surbala (MPT Neuro)
  39. 39. 11. Perception and Cognition• They are the result of lesions in right parietalcortex & seen more with left hemiplegia thanright.• These may include disorders of bodyscheme/body image, spatial relations, andagnosias.Dr. L. Surbala (MPT Neuro)
  40. 40. 12. Emotional Status• Lesions of brain affecting frontallobe, hypothalamus, & limbic system• May demonstrate pseudobulbar affect(PBA), also known as emotional lability oremotional dysregulation syndrome. emotional outbursts of uncontrolled or exaggeratedlaughing or crying that are inconsistent with mood.• Depression is extremely common persistent feelings of sadness,feelings ofhopelessness, worthlessness or helplessness.Dr. L. Surbala (MPT Neuro)
  41. 41. 13. Bladder and Bowel Function• Disturbances of bladder function are commonduring acute phase• Urinary incontinence can result from bladderhyperreflexia or hyporeflexia, disturbances ofsphincter control, or sensory loss.• Disturbances of bowel function can includeincontinence & diarrhea or constipationDr. L. Surbala (MPT Neuro)
  42. 42. Hemispheric Behavioral Differences.Dr. L. Surbala (MPT Neuro)
  43. 43. 1. Musculoskeletal changes• Loss of voluntary movement and immobility canresult in loss of ROM & contractures. Contractures are apparent in spastic muscles ofparetic limbs• Disuse atrophy & muscle weakness results frominactivity and immobility• Osteoporosis, results from decreased physicalactivity, changes in protein nutrition, hormonaldeficiency, & calcium deficiency.Dr. L. Surbala (MPT Neuro)
  44. 44. 2. Neurological signs• Seizures occur in a small % of patients - morecommon in occlusive carotid disease than inMCA disease• Hydrocephalus is rare but can occur withsubarachnoid or intracerebral hemorrhage.Dr. L. Surbala (MPT Neuro)
  45. 45. 3. Thrombophlebitis & deep venousthrombosis (DVT)• complications for all immobilized patients.Dr. L. Surbala (MPT Neuro)
  46. 46. 4. Cardiac Function• Stroke as a result of underlying coronaryartery disease (CAD) may demonstrateimpaired CO, cardiac decompensation, & rhythmdisorders.• If these problems persist, they can altercerebral perfusion & produce additional focalsigns (e.g., mental confusion).• Cardiac limitations in exercise toleranceDr. L. Surbala (MPT Neuro)
  47. 47. 5. Pulmonary Function• Decreased lung volume, decreased pulmonaryperfusion & vital capacity & altered chest wallexcursion• Aspiration, occurs in about one third ofpatients with dysphagia.Dr. L. Surbala (MPT Neuro)
  48. 48. 6. Integumentary• The skin breaks down over bony prominencesfrom pressure, friction, shearing, and/ormacerationDr. L. Surbala (MPT Neuro)
  49. 49. Urine analysisCBC countBlood sugar levelBlood cholesterol & lipid profileCardiac evaluationLumbar punctureDr. L. Surbala (MPT Neuro)
  50. 50. CT Scan• In acute phase, CT scans are used to rule outbrain lesions such as tumor or abscess & toidentify hemorrhagic stroke• In sub-acute phase, CT scans can identifydevelopment of cerebral edema (within 3 days)& cerebral infarction (within 3 to 5 days) byshowing areas of decreased density.Dr. L. Surbala (MPT Neuro)
  51. 51. Magnetic Resonance Imaging (MRI).• MRI is more sensitive in diagnosis of acutestrokes, allowing detection of cerebralinfarction within 2 to 6 hours after stroke.• It is also able to detail extent of infarction orhemorrhage & can detect smaller lesionsDr. L. Surbala (MPT Neuro)
  52. 52. Cerebral Angiography.• Involves injection of radiopaque dye into bloodvessels with subsequent radiography.• It provides visualization of vascular system andused when surgery is considered (carotidstenosis, AVM).Dr. L. Surbala (MPT Neuro)
  53. 53. Fastest in first weeks after onsetMeasurable neurological & functionalrecovery occurring in first month afterstroke.Continue to make measurable functionalgains for months or years after insultDr. L. Surbala (MPT Neuro)
  54. 54. Late recovery of function is also seen inpatients with chronic stroke whoundergo extensive functional training• These changes are due to function-inducedplasticityDr. L. Surbala (MPT Neuro)
  55. 55. Recovery also depends on severity ofstrokeDepends on type of stroke –hemorrhagic or ischemicVaries from individual to individualDepends on intensity of therapyDepends on age of the patientDr. L. Surbala (MPT Neuro)
  56. 56. A male patient with a known case ofhypertension came to emergencydepartment with history of suddencollapse & LOCOn examination there is decrease DTRon right side of body with +ve Babinski’ssignThere is gradual regain of consciousnessbut seems to be confusedDr. L. Surbala (MPT Neuro)
  57. 57. After a few days in hospital he regainsome of his LL movement but lessimprovement in ULOn careful examination he has rightHomonymous hemianopia & sensory lossincluding two-pointdiscrimination, texture, & sense ofweightHe also has unilateral neglect & Broca’s(expressive) aphasiaDr. L. Surbala (MPT Neuro)
  58. 58. What is the condition?What may be the cause?What emergency investigation is calledfor ?Which artery may be involved?Which areas of the brain is involved?Dr. L. Surbala (MPT Neuro)
  59. 59. Abrupt onset with rapid coma issuggestive of cerebral hemorrhage.Severe headache typically precedes LOCEmbolus also occurs rapidly, with nowarning, & is frequently associated withheart disease or heart complications.Uneven onset is typical with thrombosis.Dr. L. Surbala (MPT Neuro)
  60. 60. Past history include TIAs or headtrauma, presence of major or minor riskfactors, medications, positive familyhistory, & recent alterations in patientfunctionDr. L. Surbala (MPT Neuro)
  61. 61. 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 beobservedDr. L. Surbala (MPT Neuro)
  62. 62. May present with hypertensionPain Shoulder pain, secondary to subluxation, is a commonissue Shoulder-hand syndrome involves swelling &tenderness in hand and pain in entire limb Complex Regional Pain Syndrome involves pain &swelling of handDr. L. Surbala (MPT Neuro)
  63. 63. Expressive and/or receptive aphasiaAttention disordersMemory deficits, including declarativeand procedural memoryExecutive function deficitsDr. L. Surbala (MPT Neuro)
  64. 64. Visual field deficitsWeakness & sensory loss in facialmusculatureDeficits in laryngeal & pharyngeal functionHypoactive gag reflexDiminished, but perceived, superficialsensationsDr. L. Surbala (MPT Neuro)
  65. 65.  Hemi sensory loss (dysesthesia, orhyperesthesia, joint position & movement sense) May be able to identify sensations but difficultyin localizing Cortical sensations s/a 2 pointdiscrimination, stereognosis & graphaesthesia areaffected secondary to loss of grip function Agnosia Perceptual problems Unilateral spatial neglect Pusher syndromeDr. L. Surbala (MPT Neuro)
  66. 66. Glenohumeral subluxationShoulder impingement syndromeAdhesive capsulitisComplex Regional Pain Syndrome andShoulder-Hand SyndromeDr. L. Surbala (MPT Neuro)
  67. 67. Soft tissue shortening and contracturesIncreased muscle stiffnessJoint immobilityDisuse-provoked soft tissue changesOver extensibility of capsularstructures of Glenohumeral jointDr. L. Surbala (MPT Neuro)
  68. 68. Synergistic patterns of movementHypertonicityWeaknessAssociated movements or synkinesisApraxia including motor & verbal apraxiaDr. L. Surbala (MPT Neuro)
  69. 69. Exaggerated deep tendon reflexesDiminished superficial reflexesPositive Babinski’s reflexImpaired Righting, equilibrium, andprotective reactionsAbnormal primitive reflex (ATNR) maybe presentDr. L. Surbala (MPT Neuro)
  70. 70. A sling for Glenohumeral supportAFOCaneDr. L. Surbala (MPT Neuro)
  71. 71. BP, RR, & HR at rest & during exercisemay have a sudden riseReview pulse oximetry, blood gas, tidalvolume, & vital capacityAdminister a 2 or 6-minute walk testAdminister Borg RPE after walk test orother physical activityDr. L. Surbala (MPT Neuro)
  72. 72. Edema may occur in affected limbsMay be associated with shoulder handsyndromeDr. L. Surbala (MPT Neuro)
  73. 73. • Decrease Tidal volume & vital capacity• Decrease Respiratory muscle strength• Ability to cough & strength of cough isdecreases• Dyspnea during exerciseDr. L. Surbala (MPT Neuro)
  74. 74. Decreased extension of hip &hyperextension of kneeDecreased flexion of knee & hip duringswing phaseDecreased ankle DF at initial contact &during stance resulting in hipcircumductionTrendelenburgDr. L. Surbala (MPT Neuro)
  75. 75. Compromised static as well as dynamicbalancePusher’s syndrome may be presentresulting in fall on the affected sideDr. L. Surbala (MPT Neuro)
  76. 76. Spastic patterns can involve flexion &abduction of arm, flexion of elbow, &supination of elbow with finger flexionHip & knee extension with ankleplantarflexion & inversionProtracted & depressedshoulder, scoliosis & hip hikingDr. L. Surbala (MPT Neuro)
  77. 77. Using FIM, Barthel index, FMAThere is compromised basic as well asinstrumental ADLAmbulatory capacity is compromisedDr. L. Surbala (MPT Neuro)
  78. 78. Flaccid bowel & bladder during the acutestageBowel & bladder function graduallyregainsUninhibited bladder if frontal lobe isinvolvedConstipation is frequently seenDr. L. Surbala (MPT Neuro)
  79. 79. Tonal abnormalitiesMuscular weaknessSynergistic patternTightness & contractureImbalance & incoordinationGait abnormalitiesPostural abnormalitiesFunctional disabilityDr. L. Surbala (MPT Neuro)
  80. 80. Positioning strategiesImprove respiratory & circulatoryfunctionPrevent pressure soresPrevent from deconditioningDr. L. Surbala (MPT Neuro)
  81. 81. Positioning strategies• In supine• In side lying on normal side• In side lying on affected sideDr. L. Surbala (MPT Neuro)
  82. 82. Dr. L. Surbala (MPT Neuro)
  83. 83. Improve respiratory & circulatoryfunction• Breathing exercise• Chest expansion exercise• Postural drainage• Huffing & Coughing techniques• Passive & active ankle & toe exercise (after careful & thorough examination ofcardiopulmonary system)Dr. L. Surbala (MPT Neuro)
  84. 84. 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 mattressDr. L. Surbala (MPT Neuro)
  85. 85. Prevent from deconditioning• Early mobilization in the bed (activeturning, supine to sit, sit to supine, sitting, sitto stand)• Pelvic bridging exercise• Early propped up positioning, sitting & thenlater to standing• Moving around the bed• Facilitate movement of functioning limbsDr. L. Surbala (MPT Neuro)
  86. 86. 5 days a week for a minimum of 3 hoursof active rehabilitation per dayIntensive rehabilitation if vitals arestableDr. L. Surbala (MPT Neuro)
  87. 87.  Positioning hemiplegic side towards door ormain part of room Presentation of repeated sensory stimuli Stretching, stroking, superficial & deeppressure, 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 UEDr. L. Surbala (MPT Neuro)
  88. 88. Soft tissue, joint mobilization & ROMexercise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 floorDr. L. Surbala (MPT Neuro)
  89. 89. Strengthening of agonist & antagonisticmuscleGraded ex program using freeweights, therabands, sand bags &isokinetic devicesFor weak patients (<3/5), gravity-eliminated ex using powder boards, slingsuspension, or aquatic ex is indicatedGravity-resisted active movts areindicated (>3/5 strength)Dr. L. Surbala (MPT Neuro)
  90. 90.  Sustained stretch & slow iceing of spasticmuscle Rhythmic rotations Weight bearing exercise Prolonged & firm pressure application Slow rocking movement Positioning in anti synergistic pattern Rhythmic initiation Air splints Neural warmth Electrical stimulationDr. L. Surbala (MPT Neuro)
  91. 91. Dissociation & selection of desired movtpatternsSelect postures that assist desiredmovements through optimal biomechanicalstabilization & use of optimal point inrangeStart with assisted movt, followed byactive & resisted movtTask oriented exerciseDr. L. Surbala (MPT Neuro)
  92. 92. Suggested exercise• Rolling• Supine to sit & sit to supine• Sitting• Bridging• Sit to stand & Sit down• Modified plantigrade• Standing• TransferDr. L. Surbala (MPT Neuro)
  93. 93. In pusher syndrome• Passive correction often fails• Use visual stimuli to correct• Sit on the normal side & ask patient to lean onyou• Sitting on swiss ball• Environmental boundary can be used e.g. corneror doorwayDr. L. Surbala (MPT Neuro)
  94. 94. • Early mobilization, ROM, & positioning strategies• Relearning of movt pattern & retraining of missingcomponent• 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 toopposite shoulder• Advance training – CIMT, biofeedback, NMES, FESDr. L. Surbala (MPT Neuro)
  95. 95. Proper handling & positioning of shoulderjointReducing subluxation, NMES, gentlemobilization (grade 1 & 2)Use of supportive devices & slingsUse of overhead pulley is contraindicatedTENS & heat therapyDr. L. Surbala (MPT Neuro)
  96. 96. Strengthening muscles in appropriatepatternSuggested activities• PNF pattern of LL• Holding against elastic band resistance aroundupper thighs in supine or standing positions• Standing, lateral side-steps• Exercise to improve pelvic controlFacilitation of DFCycling & treadmill trainingDr. L. Surbala (MPT Neuro)
  97. 97.  Facilitate symmetrical wt bearing on both side Postural perturbations can be induced indifferent positions Sit or stand on movable surface to increasechallenge Reaching activities Dual task training s/a kicking ball instanding, throwing activities, carrying an objectwhile walking Divert attention Single limb stance Exercise on trampolineDr. L. Surbala (MPT Neuro)
  98. 98. Initial gait training between parallelbarsProceed outside bars with aids & thenwithout aidsWalking forward, backward, sideways &in cross patternsPBWSTT with higher speed improveoverall locomotor activity & overgroundspeedProper use of orthotics & wheelchairDr. L. Surbala (MPT Neuro)
  99. 99. • Early mobilization & functional activity• Treadmill training & cycle ergometer• Symptom limited graded ex. training• Ex at 40- 70 % of VO2max, 3 times a week for20-60 minutes• Proper rest should be given• Gradually progressed to 30 minutes continousprogram• Regular ex reduces risk of recurrent strokeDr. L. Surbala (MPT Neuro)
  100. 100.  Proper head position in chin down position Movements of lips, tongue, cheeks, & jaw Firm pressure to anterior 3rd of tonguewith tongue depressor to stimulateposterior elevation of tongue, Puffing, blowing bubbles, & drinking thickliquids through straw Food presentation in proper position Texture of food should be smooth Tasty food should be given to facilitateswallowing reflex Stroking the neck during swallowingDr. L. Surbala (MPT Neuro)
  101. 101. 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 environmentDr. L. Surbala (MPT Neuro)
  102. 102. Give factual information, counsel familymembers about patient’s capabilities &limitationsGive information as much as Pt or familycan assimilateProvide open discussion & communicationBe supportive, sensitive & maintain apositive supporting natureGive psychological supportRefer to help groupsDr. L. Surbala (MPT Neuro)
  103. 103. Family member should participate dailyin the therapy session & learn exercisesHome visits should be made prior todischargeArchitectural modifications, assistivedevices or orthotics should be readybefore dischargeIdentify community service & provideinformation to the patientDr. L. Surbala (MPT Neuro)
  104. 104. O’ Sullivan SB, Schmitz TJ. Stroke.Physical rehabilitation. 5th ed., NewDelhi: Jaypee Brothers, 2007.Darcy A. Umphred. NeurologicalRehabilitation, 5th ed., MosbyElsevier, Missouri, 2007.Dr. L. Surbala (MPT Neuro)