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Stroke: PT Assessment and Management
1.
2. Stroke 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. It 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. It 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. Third leading cause of death
The incidence of stroke is about 1.25
times greater for males than females
Most common cause of disability among
adults
Dr. L. Surbala (MPT Neuro)
6. 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)
Atherothromboembolism
Dr. L. Surbala (MPT Neuro)
7. Infective endocarditis & HIV infection
Tumour
Perioperative stroke (due to hypotension and boundary
zone infarction, trauma to and dissection of neck
arteries, paradoxical embolism, fat embolism, infective endocarditis)
Migraine
Chronic meningitis
Inflammatory bowel disease (ulcerative and Crohn's
colitis)
Hypoglycemia
Snake bite, fat embolism
Dr. L. Surbala (MPT Neuro)
8. NON MODIFIABLE
MODIFIABLE
Ageing & gender
Positive family history
Circadian and seasonal
factors (peaks between 10
am till noon)
Heart disease
Diabetes mellitus
Hypertension
Peripheral arterial disease
Blood pathology (increased
haematocrit, clotting
abnormalities, sickle cell
anaemia etc)
Hyperlipidemia
TIA
Smoking
Obesity
Lack of physical exercise
or sedentary life style
Diet & excess alcohol
consumption
Oral contraceptives
Infection (meningeal
infection)
Psychological factors
Vasectomy
Dr. L. Surbala (MPT Neuro)
9. Sudden numbness or weakness of face, arm, or
leg, on one side of body
Sudden confusion, trouble speaking or
understanding
Sudden blurring of vision
Sudden onset of dizziness, loss of balance or
coordination
Sudden, severe headaches with no known cause
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. Ischemia 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
Ischemia produce cerebral edema, that
begins within minutes of insult &
reaches a maximum by 3 to 4 days.
Swelling gradually subsides & generally
disappears by 2 to 3 weeks
Dr. L. Surbala (MPT Neuro)
11. Oedema elevates ICP, leading to
intracranial HT & neurological
deterioration associated with
contralateral & caudal shifts of brain
structures
Cerebral 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. Depending on the cause
• Haemorrhagic stroke
Intracranial haemorrhage
Subarachnoid haemorrhage
Signs of raised ICP will be evident with a history of a
traumatic accident
Dr. L. Surbala (MPT Neuro)
13. • Ischemic stroke
Thrombotic: more common. Usually occurs in the
sleeping hours. Characterised by gradual onset of
symptoms
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. Depending 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. Depending 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. Depending on the symptoms
• MCA Syndrome
• ACA Syndrome
• PCA syndrome
• Vertebro basilar artery syndrome
Vertebral artery
Basilar artery
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. Contralateral hemiplegia (UL & face more
affected than LL)
Contralateral hemisensory loss (UL & face
more 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)
21. Coordination disorders such as tremor or
ataxia
Contralateral homonymous field deficit
Cortical blindness
Cognitive impairment including memory
impairment
Contralateral sensory impairment
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. Contralateral Hemiplegia or monoplegia
of 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, sucking
reflex
Dr. L. Surbala (MPT Neuro)
24. Locked-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. 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
Ataxic hemiparesis
Dysarthria
Clumsy hand syndrome
Sensory/motor stroke
Dystonia/involuntary movements
Dr. L. Surbala (MPT Neuro)
29. 1. 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. 2. 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. 3. 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. 4. 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. Muscles not involved in either synergy
• Latissimus dorsi
• Teres major
• Serratus anterior
• Finger extensors
• Ankle evertors
Dr. L. Surbala (MPT Neuro)
35. 6. 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
The most commonly seen is asymmetric tonic neck
reflex (ATNR)
• Associated reactions are also present in patients
who exhibit strong spasticity and synergies
unintentional movements of hemiparetic limb caused by
voluntary action of another limb
by stimulation of yawning, sneezing, or coughing.
Dr. L. Surbala (MPT Neuro)
36. 7. 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. 8. 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.
Ideational apraxia
Ideomotor apraxia
Dr. L. Surbala (MPT Neuro)
38. 9. 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. 10. 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. 11. 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. 12. 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.
emotional outbursts of uncontrolled or exaggerated
laughing or crying that are inconsistent with mood.
• Depression is extremely common
persistent feelings of sadness,feelings of
hopelessness, worthlessness or helplessness.
Dr. L. Surbala (MPT Neuro)
42. 13. 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. 1. Musculoskeletal changes
• Loss of voluntary movement and immobility can
result in loss of ROM & contractures.
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. 2. 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. 3. Thrombophlebitis & deep venous
thrombosis (DVT)
• complications for all immobilized patients.
Dr. L. Surbala (MPT Neuro)
47. 4. 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. 5. 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. 6. Integumentary
• The skin breaks down over bony prominences
from pressure, friction, shearing, and/or
maceration
Dr. L. Surbala (MPT Neuro)
51. CT 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. Magnetic 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. Cerebral 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. Fastest in first weeks after onset
Measurable neurological & functional
recovery occurring in first month after
stroke.
Continue to make measurable functional
gains for months or years after insult
Dr. L. Surbala (MPT Neuro)
55. Late 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. Recovery also depends on severity of
stroke
Depends on type of stroke –
hemorrhagic or ischemic
Varies from individual to individual
Depends on intensity of therapy
Depends on age of the patient
Dr. L. Surbala (MPT Neuro)
57. A male patient with a known case of
hypertension came to emergency
department with history of sudden
collapse & LOC
On examination there is decrease DTR
on right side of body with +ve Babinski’s
sign
There is gradual regain of consciousness
but seems to be confused
Dr. L. Surbala (MPT Neuro)
58. After a few days in hospital he regain
some of his LL movement but less
improvement in UL
On 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. What is the condition?
What may be the cause?
What emergency investigation is called
for ?
Which artery may be involved?
Which areas of the brain is involved?
Dr. L. Surbala (MPT Neuro)
60.
61. Abrupt onset with rapid coma is
suggestive of cerebral hemorrhage.
Severe headache typically precedes LOC
Embolus also occurs rapidly, with no
warning, & is frequently associated with
heart disease or heart complications.
Uneven onset is typical with thrombosis.
Dr. L. Surbala (MPT Neuro)
62. Past 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. 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 be
observed
Dr. L. Surbala (MPT Neuro)
64. May present with hypertension
Pain
Shoulder pain, secondary to subluxation, is a common
issue
Shoulder-hand syndrome involves swelling &
tenderness in hand and pain in entire limb
Complex Regional Pain Syndrome involves pain &
swelling of hand
Dr. L. Surbala (MPT Neuro)
65. Expressive and/or receptive aphasia
Attention disorders
Memory deficits, including declarative
and procedural memory
Executive function deficits
Dr. L. Surbala (MPT Neuro)
66. Visual field deficits
Weakness & sensory loss in facial
musculature
Deficits in laryngeal & pharyngeal function
Hypoactive gag reflex
Diminished, but perceived, superficial
sensations
Dr. L. Surbala (MPT Neuro)
67. Hemi sensory loss (dysesthesia, or
hyperesthesia, joint position & movement sense)
May be able to identify sensations but difficulty
in localizing
Cortical sensations s/a 2 point
discrimination, stereognosis & graphaesthesia are
affected secondary to loss of grip function
Agnosia
Perceptual problems
Unilateral spatial neglect
Pusher syndrome
Dr. L. Surbala (MPT Neuro)
69. Soft tissue shortening and contractures
Increased muscle stiffness
Joint immobility
Disuse-provoked soft tissue changes
Over extensibility of capsular
structures of Glenohumeral joint
Dr. L. Surbala (MPT Neuro)
70. Synergistic patterns of movement
Hypertonicity
Weakness
Associated movements or synkinesis
Apraxia including motor & verbal apraxia
Dr. L. Surbala (MPT Neuro)
71. Exaggerated deep tendon reflexes
Diminished superficial reflexes
Positive Babinski’s reflex
Impaired Righting, equilibrium, and
protective reactions
Abnormal primitive reflex (ATNR) may
be present
Dr. L. Surbala (MPT Neuro)
72. A sling for Glenohumeral support
AFO
Cane
Dr. L. Surbala (MPT Neuro)
73. BP, RR, & HR at rest & during exercise
may have a sudden rise
Review pulse oximetry, blood gas, tidal
volume, & vital capacity
Administer a 2 or 6-minute walk test
Administer Borg RPE after walk test or
other physical activity
Dr. L. Surbala (MPT Neuro)
74. Edema may occur in affected limbs
May 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. Decreased extension of hip &
hyperextension of knee
Decreased flexion of knee & hip during
swing phase
Decreased ankle DF at initial contact &
during stance resulting in hip
circumduction
Trendelenburg
Dr. L. Surbala (MPT Neuro)
77. Compromised 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. Spastic patterns can involve flexion &
abduction of arm, flexion of elbow, &
supination of elbow with finger flexion
Hip & knee extension with ankle
plantarflexion & inversion
Protracted & depressed
shoulder, scoliosis & hip hiking
Dr. L. Surbala (MPT Neuro)
79. Using FIM, Barthel index, FMA
There is compromised basic as well as
instrumental ADL
Ambulatory capacity is compromised
Dr. L. Surbala (MPT Neuro)
80. Flaccid bowel & bladder during the acute
stage
Bowel & bladder function gradually
regains
Uninhibited bladder if frontal lobe is
involved
Constipation is frequently seen
Dr. L. Surbala (MPT Neuro)
86. Improve respiratory & circulatory
function
• Breathing exercise
• Chest expansion exercise
• Postural drainage
• Huffing & Coughing techniques
• Passive & active ankle & toe exercise
(after careful & thorough examination of
cardiopulmonary system)
Dr. L. Surbala (MPT Neuro)
87. 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 mattress
Dr. L. Surbala (MPT Neuro)
88. Prevent 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. 5 days a week for a minimum of 3 hours
of active rehabilitation per day
Intensive rehabilitation if vitals are
stable
Dr. L. Surbala (MPT Neuro)
90.
91. Positioning hemiplegic side towards door or
main part of room
Presentation of repeated sensory stimuli
Stretching, stroking, superficial & deep
pressure, 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 UE
Dr. L. Surbala (MPT Neuro)
92. Soft tissue, joint mobilization & ROM
exercise
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 floor
Dr. L. Surbala (MPT Neuro)
93. Strengthening of agonist & antagonistic
muscle
Graded ex program using free
weights, therabands, sand bags &
isokinetic devices
For weak patients (<3/5), gravity-
eliminated ex using powder boards, sling
suspension, or aquatic ex is indicated
Gravity-resisted active movts are
indicated (>3/5 strength)
Dr. L. Surbala (MPT Neuro)
94. Sustained stretch & slow iceing of spastic
muscle
Rhythmic rotations
Weight bearing exercise
Prolonged & firm pressure application
Slow rocking movement
Positioning in anti synergistic pattern
Rhythmic initiation
Air splints
Neural warmth
Electrical stimulation
Dr. L. Surbala (MPT Neuro)
95. Dissociation & selection of desired movt
patterns
Select postures that assist desired
movements through optimal biomechanical
stabilization & use of optimal point in
range
Start with assisted movt, followed by
active & resisted movt
Task oriented exercise
Dr. L. Surbala (MPT Neuro)
96. Suggested 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. In 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. Proper handling & positioning of shoulder
joint
Reducing subluxation, NMES, gentle
mobilization (grade 1 & 2)
Use of supportive devices & slings
Use of overhead pulley is contraindicated
TENS & heat therapy
Dr. L. Surbala (MPT Neuro)
100. Strengthening muscles in appropriate
pattern
Suggested 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
Facilitation of DF
Cycling & treadmill training
Dr. L. Surbala (MPT Neuro)
101. Facilitate symmetrical wt bearing on both side
Postural perturbations can be induced in
different positions
Sit or stand on movable surface to increase
challenge
Reaching activities
Dual task training s/a kicking ball in
standing, throwing activities, carrying an object
while walking
Divert attention
Single limb stance
Exercise on trampoline
Dr. L. Surbala (MPT Neuro)
102. Initial gait training between parallel
bars
Proceed outside bars with aids & then
without aids
Walking forward, backward, sideways &
in cross patterns
PBWSTT with higher speed improve
overall locomotor activity & overground
speed
Proper 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. Proper head position in chin down position
Movements of lips, tongue, cheeks, & jaw
Firm pressure to anterior 3rd of tongue
with tongue depressor to stimulate
posterior elevation of tongue,
Puffing, blowing bubbles, & drinking thick
liquids through straw
Food presentation in proper position
Texture of food should be smooth
Tasty food should be given to facilitate
swallowing reflex
Stroking the neck during swallowing
Dr. L. Surbala (MPT Neuro)
105. 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 environment
Dr. L. Surbala (MPT Neuro)
106. Give factual information, counsel family
members about patient’s capabilities &
limitations
Give information as much as Pt or family
can assimilate
Provide open discussion & communication
Be supportive, sensitive & maintain a
positive supporting nature
Give psychological support
Refer to help groups
Dr. L. Surbala (MPT Neuro)
107. Family member should participate daily
in the therapy session & learn exercises
Home visits should be made prior to
discharge
Architectural modifications, assistive
devices or orthotics should be ready
before discharge
Identify 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.
Darcy A. Umphred. Neurological
Rehabilitation, 5th ed., Mosby
Elsevier, Missouri, 2007.
Dr. L. Surbala (MPT Neuro)