Physiotherapy for stroke rehab

1. Physical therapy Interventions in stroke
Dr. Misbah Ghous
DPT, MSNMPT,PGD

2. Interventions…
• Strategies to Improve Motor Learning
• Interventions to Improve Sensory Function
• Interventions to Improve Hemianopia and Unilateral Neglect
• Interventions to Improve Flexibility and Joint Integrity
• Interventions to Improve Strength
• Interventions to Manage Spasticity
• Interventions to Improve Movement Control
• Strategies to Improve Upper Extremity Function
• Strategies to Improve Lower Extremity Function
• Interventions to Improve Functional Status
• Interventions to Improve Postural Control and Balance
• Interventions to Improve Gait and Locomotion
• Interventions to Improve Aerobic Capacity and Endurance

5. Cont..
• Ipsilateral pushing (also known as pusher syndrome or
• contraversive pushing)
• 10% Acute phase
• Posterolateral thalamus.
• Clinical Assessment Scale for Contraversive Pushing (SCP),
• 1) spontaneous body posture with tilting toward the more paretic side,
• (2) an increase of pushing force by the less involved extremities
• evidenced by increased abduction and extension,
• (3) resistance to passive correction of the posture.
• The scores for each criteria range from 0 to 1.

6. Strategies to Improve Motor Learning
• Acute phase
• Subacute phase
• Chronic Phase
1- Bed mobility, PROM,AAROMs
2-6 days—3hrs, 5 days---60-90 mins
3- 2-3 days—60-90 mins

7. Strategies to Improve Motor Learning
• Patient engagement and motivation
• Motor relearning program for stroke
• Strategy development
• Feedback
• Practice
• Mirror therapy
• Mental practice
• Contextual interference
• Closed environment
• open environment

8. InterventionstoImprove SensoryFunction
• Sensory re-training program
• Mirror therapy
• Sensory stimulation intervention
• Compression, weightbearing, mobilization, pneumatic
compression, electrical, thermal and magnetic stimulation,
stroking, brushing, vibrating, tapping
• Sensory –motor integrative treatment; functional activities
with augmented sensory cues

9. Interventions to Improve Hemianopsia and
Unilateral Neglect
• Using paretic side
• Conducive environment
• Encourage awareness about the environment and about
paralyzed side
• Imagery

10. InterventionstoImproveFlexibility&JointIntegrity
• AROM
• PROM
• Positioning strategies
• Protective devises e.g Resting splints
• Edema prevention
• Overhead pulleys for self ROM is contraindicated??

11. Earlymobilityactivities:rollingontotheunaffectedside.Thetherapist
assiststhemovementthroughcontactsonthekneesandclasped
hands.

14. Interventions to Improve Strength
• Progressive strengthening exercise
• Combining resisted exercises with task oriented functional
activities e.g sit-to-stand transfers, partial wall squats step-
ups, stair climbing while the patient is wearing weighted cuffs
• Circuit training workstations
• Lifting weights
• Using elastic bands places added demands for postural stability
in sitting and standing and is an important element of training
to improve postural control.
• Exercise precautions; safety and protection
• Submaximal exercise.
• High intensity resisted exercise not recommended

15. Cont..
• Exercise modalities for strengthening include free weights, elastic
bands or tubing, and machines .
• For patients who are very weak (less than 3/5), gravity-minimized
exercises using powder boards, sling suspension, or aquatic exercise
is indicated.
• Gravity-resisted active movements are indicated for patients who
demonstrate 3/5 strength (e.g., arm lifts, leg lifts).
• Patients who demonstrate adequate strength in independent gravity-
resisted movement (e.g., 8 to 12 repetitions) can be progressed to
exercise using added resistance (e.g., free weights, bands, or
machines).
• Ideally resistance training should occur 2 to 3 times a week; three
sets of 8 to 12 repetitions per exercise should be used.

16. Interventions to Manage Spasticity
• Position and posture
• Sustained stretching
• Rhythmic rotations
• Autogenic relaxation
• Reciprocal inhibition
• Weight bearing exercise
• Bridging activities
• Ice
• Massage
• FES
• Orthotic devices

17. SPLINTS
A volar resting (pan) splint positions the forearm, wrist, and
fingers in a
• functional position (20° to 30° of wrist extension,
• metacarpophalangeal [MP] flexion 40° to 45°,
• interphalangeal [IP] flexion 10° to 20°, and thumb opposition
• WHEELCHAIR positioning:
• When sitting in a wheelchair, the patient’s paretic UE
• can be positioned on an arm trough (shallow elbow/ forearm
support) attached to the armrest.
• The shoulder is positioned in 5° of abduction and flexion and
neutral,rotation; elbow in 90° flexion and slightly forward;
• forearm pronated; and hand in a functional resting position.

18. InterventionstoImprove MovementControl
• Disassociation
• Out of synergy selective movements
• PNF
• Weightbearing activities
• Repetitive task-specific training
• Blocked practice
• Variable practice

20. StrategiestoImprove UpperExtremityFunction
• UE Weight-Bearing as a Postural Support
• Task-Oriented Reaching and Manipulation
• Constraint-Induced Movement therapy
• Simultaneous Bilateral Training
• Electromyographic Biofeedback
• Neuromuscular electrical stimulation (NMES)
• Robot-Assisted therapy
• Management of Shoulder Pain
• shoulder impingement syndrome
• Adhesive capsulitis
• Complex regional pain syndrome (CRPS)
• Supportive Devices

21. Modified CIMT (mCIMT)
• Modified CIMT (mCIMT) has also been used for patients with
stroke.
• For example, 30 minutes of functional task practice and
• shaping techniques 3 days per week, and restraint of
• the less affected UE for up to 5 hours per day. Training
• occurred over an extended 10-week period

22. Interventions For UE…
• Arm cradling
• Table-top polishing
• Sitting, the patient leans forward and reaches both
• hands down to the floor.
• Supine, hands are clasped together and placed behind
• the head, the elbows fall flat to the mat
• BATRAC
• WOLF Motor Function Test.

23. WMFT..
• The original version consisted of 21 item; the widely used version of the
WMFT consists of 17 items Composed of 3 parts:
• Time
• Functional ability
• Strength
• Includes 15 function-based tasks and 2 strength based tasks Performance
time is referred to as WMFT-TIME
• Functional ability is referred to as WMFT-FAS
• Items 1-6 involve timed functional tasks, items 7-14 are measures of
strength, and the remaining 9 items consist of analyzing movement quality
when completing various tasks Examiner should test the less affected
upper extremity followed by the most affected side.
• Uses a 6-point ordinal scale "0" = “does not attempt with the involved arm”
to "5" = “arm does participate; movement appears to be normal.”
• Maximum score is 75 Lower scores are indicative of lower functioning
levels WMFT-TIME allows 120 seconds per task

27. Strategies to Improve Lower Extremity
Function
• Preparation for standing and walking
• Activation of hip, knee and musculature
• PNF
• Weight bearing

30. InterventionstoImprove PosturalControl &Balance
• Postural alignment
• Static stability
• Dynamic stability
• Postural strategy training
• Ankle strategy
• Hip strategy
• Stepping strategy
• Force platform biofeedback (center-of-pressure biofeedback)

31. InterventionstoImprove GaitandLocomotion
• Task-Specific Overground Locomotor Training
• Locomotor Training using Body Weight
• Support and Motorized Treadmill Training
• Robotic-Assisted Locomotor Training
• Functional Electrical Stimulation
• Orthotics and Assistive Devices (AFO)
• Wheel chair

32. Interventions to Improve Gait and
Locomotion
The patient should practice functional, task-specific skills,
including the following
Walking forward
 Walking backward
Side stepping
Crossed stepping
Step-up/step-down activities
lateral step-ups.
Stair climbing,
Walking in a simulated home environment:
Walking in a community environment:

35. InterventionstoImproveAerobicCapacityEndurance
• Decreased levels of physical conditioning
• The energy costs to complete many functional tasks are higher
than normal
• Concomitant cardiovascular disease
• Exercise precaution
• Lightheadedness or dizziness
• Chest heaviness, pain, or tightness; angina
• Palpitations or irregular heart beat
• Sudden shortness of breath not due to increased activity
• Volitional fatigue and exhaustion
• Circuit class training (CCT) or circuit training physical therapy
(CTPT)

36. PATIENT/CLIENT-RELATEDINSTRUCTION
• Give accurate, factual information; counsel family members about the
patient’s capabilities and limitations;
• Structure interventions carefully, giving only as much information as the
patient or family need or can assimilate; provide reinforcement and repetition.
• Adapt interventions to ensure they are appropriate to the educational and
cultural background of the patient and family.
• Offer a variety of educational interventions: didactic sessions, books,
brochures, and videotapes, and family participation in therapy.
• Provide a forum for open discussion and communication.
• Be supportive, sensitive, and maintain a positive, hopeful manner.
• Assist patients and families in confronting alternatives and developing
problem-solving abilities.
• Motivate and provide positive reinforcement in therapy; enhance patient
satisfaction and self-esteem.
• Refer patients and families to support and self-help groups
• Psychotherapy and counseling (e.g., sexual, leisure, vocational) can assist in
improving overall quality of life and should be recommended as needed.

37. DISCHARGE PLANNING
• Planning for discharge begins early in rehabilitation and involves the
patient and family.
• Potential placement (safe place of residence), level of family and
community support, and need for continued medical and
rehabilitation services should all be explored.
• Family members should regularly participate in therapy sessions to
learn exercises and activities designed to support the patient’s
independence.
• Discharge should be considered when reasonable treatment
goals/outcomes are attained.
• Indication of the attainment of a functional ceiling can be considered
when there is lack of evidence of progress at two successive
evaluations over a period of 2 weeks.
• Home visits should be made prior to discharge to determine the
home’s physical structure and accessibility.

38. RECOVERY AND OUTCOMES
• Most patients with stroke regain their independent living status following
discharge.

39. OUTCOME MEASURES
• The Trunk Impairment Scale was developed to evaluate
• motor impairment of the trunk after stroke. It includes
• 3 items of static control, 10 items of dynamic balance
• control, and 4 items of coordination. The items are
• tested in the sitting position (edge of bed or treatment
• table) without back or arm support. Each item is
• performed three times with the highest score accepted.
• Scores range from a minimum of 0 (unable) to a
• maximum of 23
• The Function in Sitting Test (FIST) was developed by
• expert consensus as a test for sitting balance, consist of 14
items

40. Stroke with Poor outcome
1. advanced age
2. Severe motor impairments (prolonged paralysis, apraxia)
3. Persistent medical problems (incontinence)
4. Impaired cognitive function (decreased alertness, poor
attention span, judgment, memory), severe language
disturbances, and an inability to learn new tasks or follow
simple commands
5. Severe visuospatial hemineglect
6. Other less well-defined social and economic problems

42. References
• Physical Rehabilitation Schmitz, Thomas O’ sullivan
• Carr, J. H., & Shepherd, R. B. (1987). A motor relearning programme
for stroke (2nd ed.). Oxford: Butterworth-Heinemann