This document provides an overview of physiotherapy management for stroke. It begins with definitions of stroke and transient ischemic attack. It then discusses risk factors, types, signs and symptoms, diagnosis, and medical management of stroke. The remainder of the document focuses on the physiotherapy assessment and treatment approaches in both the acute and post-acute stages. The assessment covers various body functions and structures, while the treatment approaches aim to improve motor function, mobility, balance, sensation, flexibility, strength, and reduce spasticity to achieve functional independence.
Retraining of motor control basing on understanding of normal movement & analysis of motor dysfunction.
Emphasis of MRP is on practice of specific activities, the training of cognitive control over muscles & movt. Components of activities & conscious elimination of unnecessary muscle activity.
In rehabilitation programme involve – real life activities included.
NDT, BOBATH TECHNIQUE, BASIC IDEA OF BOBATH, CONCEPT OF BOBATH, NEUROPHYSIOLOGY OF NDT, ICF MODEL, PRINCIPLES OF TREATMENT OF NDT IN STROKE AND CP, AUTOMATIC AND EQUILIBRIUM REACTIONS, KEY POINTS OF CONTROL, FACILITATION, INHIBITION AND HANDLING IN NDT
Retraining of motor control basing on understanding of normal movement & analysis of motor dysfunction.
Emphasis of MRP is on practice of specific activities, the training of cognitive control over muscles & movt. Components of activities & conscious elimination of unnecessary muscle activity.
In rehabilitation programme involve – real life activities included.
NDT, BOBATH TECHNIQUE, BASIC IDEA OF BOBATH, CONCEPT OF BOBATH, NEUROPHYSIOLOGY OF NDT, ICF MODEL, PRINCIPLES OF TREATMENT OF NDT IN STROKE AND CP, AUTOMATIC AND EQUILIBRIUM REACTIONS, KEY POINTS OF CONTROL, FACILITATION, INHIBITION AND HANDLING IN NDT
-Detailed Introduction, Patho-physiology, Evaluation & Physiotherapy Management of Parkinsonism.
-Clinical classification is discussed.
-Various measures of evaluation and physical therapy is discussed in this.
Hierachical theory- says that higher centers control on lower center; but when higher center damage then this inhibitory control from the higher center is loss which leads to exageration of the movt.
In normal individual, these occur a smooth, rhythmic movt. Because there is a presence of control from higher center on lower center.
Controlled use of sensory stimulus.
Specific Motor response
Normalization of muscle tone
Use of Developmental sequences.
Sensorimotor development = from lower to higher level.
Use of activity to demand a purposeful response.
Practice of sensory motor response is necessary for motor learning.
This presentation give an upto date insightful information on balance/postural assessment and key domains of Occupational Therapy during assessment of balance using different scales.
A brief presentation regarding etiology , clinical features , and management of chronic limb ischemia. It was presented by our unit at Department of surgery , Patna medical college
-Detailed Introduction, Patho-physiology, Evaluation & Physiotherapy Management of Parkinsonism.
-Clinical classification is discussed.
-Various measures of evaluation and physical therapy is discussed in this.
Hierachical theory- says that higher centers control on lower center; but when higher center damage then this inhibitory control from the higher center is loss which leads to exageration of the movt.
In normal individual, these occur a smooth, rhythmic movt. Because there is a presence of control from higher center on lower center.
Controlled use of sensory stimulus.
Specific Motor response
Normalization of muscle tone
Use of Developmental sequences.
Sensorimotor development = from lower to higher level.
Use of activity to demand a purposeful response.
Practice of sensory motor response is necessary for motor learning.
This presentation give an upto date insightful information on balance/postural assessment and key domains of Occupational Therapy during assessment of balance using different scales.
A brief presentation regarding etiology , clinical features , and management of chronic limb ischemia. It was presented by our unit at Department of surgery , Patna medical college
"Demystifying Common Neurological Disorders: A Primer for Future Healthcare Professionals with Dr. Ganesh"
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The dimensions of healthcare quality refer to various attributes or aspects that define the standard of healthcare services. These dimensions are used to evaluate, measure, and improve the quality of care provided to patients. A comprehensive understanding of these dimensions ensures that healthcare systems can address various aspects of patient care effectively and holistically. Dimensions of Healthcare Quality and Performance of care include the following; Appropriateness, Availability, Competence, Continuity, Effectiveness, Efficiency, Efficacy, Prevention, Respect and Care, Safety as well as Timeliness.
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Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
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2. INTRODUCTION
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
Stroke is defined by WHO 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.
3. TRANSIENT ISCHAEMIC ATTACK
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.
EPIDEMIOLOGY:
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.
5. MISCELLANEOUS RARE CAUSES
OF STROKE
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, )
Migraine
Chronic meningitis
Inflammatory bowel disease (ulcerative and Crohn's
colitis)
Hypoglycemia
Snake bite,
fat embolism etc.
6. RISK FACTORS OF STROKE
NON-MODIFIABLE MODIFIABLE
Ageing
gender
Positive family history
Genetic factors(African American).
Circadian and seasonal factors (peaks
between 10 am till noon) .
POTENTIALLY MODIFIABLE
Well accepted:
Arterial fibrillation
Vavular disease
Left artrial thrombosis
MI.
Heart disease
Diabetes mellitus
Hypertension
TIA
Peripheral artery disease
Hyperlipidemia
Blood pathology;
-increased haematocrit
-Clothing abnormalities
-sickle cell anaemia
Smoking
Obesity
Lack of physical exercise or sedentary
life style
Diet & excess alcohol consumption
Oral contraceptives
Infection (meningeal infection)
Psychological factors
Vasectomy
7. TYPES OF STROKE
ISCHAEMIC STROKE
Thrombotic: more common.
Usually occurs in the sleeping hours.
• Ischemia results in irreversible
cellular damage with a core area of
focal infarction within minutes
• 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
HAEMORRHAGIC STROKE
• Haemorrhagic stroke may may be
associated with:
Intracranial haemorrhage
Subarachnoid haemorrhage
• Signs of raised ICP will be evident
with a history of a traumatic
accident
• May have history of hypertension.
8. 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
deficits
• Severe stroke: there is no complete
recovery of the symptoms even after
1 years. Always ends up with severe
neurological deficits
DEPENDING ON DURATION OF
THE SYMPTOMS
• Acute stroke:Up 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
9. SIGNS AND SYMPTOMS OF STROKE
• Sudden numbness or
weakness of face, arm
• Hemiparessis/quadrep
aresis
• Hemi neglect
• Limb/truncal ataxia
• Sudden confusion
• Aphasia,dysarthria
• impaired
understanding
• Sudden blurring of
vision,diplopia
• Incoordination
• Loss of balance
• Sudden severe
headache
• Sudden feeling
dizziness
Less commonly:
• Sudden nausea, fever,
& vomiting.
• Brief loss /decreased
consciousness (fainting,
confusion,
convulsions,coma).
10. DIAGNOSIS OF STROKE
CT SCAN
Standard for eveluation of acute stroke and to rule out
other conditions such as tumor ,abscess,haemorrhages
and other brain lesion.
MRI SCAN
Allows for a better evaluation of the course of the acute
treatment.
Identifies infarction and rules out other conditions and
identifies late haemorrhage.
CEREBRAL ANGIOGRAPHY
Involves injection of radiopaque dye into blood vessels
with subsequent radiography.
• It provides visualization of vascular system and (carotid
stenosis, AVM).
11. MEDICAL MANAGEMENT OF
STROKE
THROBOLYTIC DRUGS(Alteplase
[Activase or tPA]): Desolves clots and
reestablish blood flow.
ANTICOAGULANTS:( warfarin
[Coumadin], heparin, dabigatran etexilate
[Pradaxa) helps in in thinning the blood
and prevent blood clothing.
ANTIPLATELET THERAPY
acetylsalicylic acid [aspirin].
ANTISPASMODICS/SPASMOLYTI
CS (e.g., carisoprodol [Soma],
chlorzoaxazone [Parafon Forte],
cyclobenzaprin[Flexeril],
diazepam
ANTI SPASTICS (e.g., baclofen
[Lioresal], dantrolene sodium
[Dantrium], diazepam [Valium],
tizanidine [Zanaflex]).
ANTI CONVULSANTS (e.g.,
carbamazepine [Tegretol],
clonazepam [Klonopin],
diazepam , phenobarbital .
ANTIHYPERTENSIVE: (e.g., ACE inhibitors,
alpha-blockers, beta-blockers, calcium
channel blockers, diuretics.
ANTICHOLESTEROL
AGENTS:(atorvastatin calcium [Lipitor],
rosuvastatin calcium.
ANTI DEPRESSANTSs (e.g.,
fluoxetine [Prozac], monoamine
oxidase inhibitors, sertraline.
12. PT ASSESSMENT
HISTORY:
Detailed history of the patient should be taken.
Abrupt onset with rapid coma is suggestive of cerebral
hemorrhage.
Severe headache typically precedes loss of consciousness.
Embolus also occurs rapidly, with no warning, & is frequently
associated with heart disease or heart complications.
Uneven onset is typical with thrombosis
Past history include TIAs or head trauma, presence of major
or minor risk factors, medications, positive family history, &
recent alterations in patient function.
13. •Level of consciousness: Arousal, attention, and cognition:
Mental status, insight, motivation.
Impaired alertness and attention, perseveration, confabulation,
confusion, disorientation, distractibility, memory deficits, impaired
judgment etc.
•Emotional status: Depression, pseudobulbar affect; apathy,
euphoria. Attention disorders
Memory deficits, including declarative and procedural memory.
•Behavioral style :Impulsive or cautious behavioral styles.
Frustration, irritability
•Communication and language: coordinate efforts with the
speech-language pathologist
14. OBSERVATION
May have abnormal posturing of limbs Synergistic
patterns in the UL & LL .
Facial asymmetry
May use a walking aid such cane
Abnormal gait pattern may also be observed
Circumductory gait pattern may be observed.
15. VITALS
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.
16. CRANIAL NERVE INTEGRITY
Visual field deficits
Weakness & sensory loss in facial musculature
Deficits in laryngeal & pharyngeal function
Hypoactive gag reflex
Diminished, but perceived, superficial sensation etc.
17. SENSORY INTEGRITY
Hemi sensory loss (dysesthesia, or hyperesthesia, joint
position & movement sense)
May be able to identify sensations but difficulty in localizing it.
Cortical sensations :
such as 2 point discrimination, stereognosis &
graphaesthesia are affected secondary to loss of grip
function.
Agnosia
Perceptual problems
Unilateral spatial neglect
Pusher syndrome.
19. RANGE OF MOTION
May be decreased due to:
Soft tissue shortening and contractures
Increased muscle stiffness
Joint immobility and muscle weakness.
Disuse-provoked soft tissue changes
Over extensibility of capsular structures of
Glenohumeral.
20. MOTOR FUNCTION
Synergistic patterns of movement
Hypertonicity
Weakness
Associated movements or synkinesis
Apraxia including motor & verbal apraxia.
21. REFLEX INTEGRITY
Exaggerated deep tendon reflexes
Diminished superficial reflexes
Positive Babinski’s reflex
Impaired Righting, equilibrium, and protective reactions
Abnormal primitive reflex (ATNR) may be present .
23. AEROBIC CAPACITY AND
ENDURANCE
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.
25. VENTILATION AND RESPIRATION
Decrease Tidal volume & vital capacity
• Decrease Respiratory muscle strength
• Ability to cough & strength of cough is decreases
• Dyspnea during exercise.
26. GAIT AND LOCOMOTION
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
27. BALANCE
Compromised static as well as dynamic balance
Pusher’s syndrome may be present resulting in fall on
the affected side.
28. POSTURE
Spastic patterns can involve flexion & abduction of arm
flexion of elbow, supination of forearm with finger
flexion.
Hip & knee extension ,ankle plantar flexion & inversion.
Protracted & depressed shoulder
scoliosis
hip hiking
29. FUNCTIONAL ASSESSMENT
Using FIM
Barthel index
FMA
There is compromised basic as well as instrumental
ADL
Ambulatory capacity is compromised.
30. BOWEL AND BLADDER
Flaccid bowel & bladder during the acute stage
Bowel & bladder function gradually improve.
Uninhibited bladder if frontal lobe is involved
Constipation is frequently seen.
32. GOALS OF TREATMENT
Long term goals
Improve muscle performance
Improve muscle strenght
Improve balance andcoordination
Improve muscle endurance
Improve postural control
Functional indepence in ADL.
Short term goals
Decrease pain
Improve sensation
Prevent secondary complications
Patient and family education
Improve joint mobility and integrity.
Improve muscle tone
33. NEUROFACILITATORY
APPROACHES IN USE
NDT
PNF
GMI
BRUNNSTROM
CIMT
BIOFEED BACK
ROOD’S APPROACH
FES
NMES
ROBOTIC THERAPY
MRP ETC.
34. PHYSIOTHERAPY
MANAGEMENT OF STROKE
ACUTE STAGE:
Positioning strategies include placing patient :
In supine
In side lying on normal side
In side lying on affected side
Improve respiratory & circulatory function
Prevent pressure sores
Prevent from deconditioning
37. IMPROVE RESPIRATION AND
CIRCULATION
To 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)
38. PREVENT BED 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
39. PREVENT DECONDITIONING
Early mobilization in the bed (active turning, supine to
sit, sit to supine, sitting, sit to stand)
Pelvic bridging exercise
Early propped up positionin
sitting & then later to standing
Moving around the bed
Facilitate movement of functioning limbs .
40. POST ACUTE STAGE
5 days a week of active rehabilitation per day
Intensive rehabilitation if vitals are stable
41. IMPROVE SENSORY FUNCTION
Positioning hemiplegic side towards door or main part of
room
Presentation of repeated sensory stimuli auch as
Stretching, stroking, superficial & deep pressure, iceing,
vibration etc.
Wt bearing ex & Joint approximation tech
Stroking with different texture fabrics Pressure
application
Improve other senses like use of visual & auditory
PNF tech., use of bilateral UE
42. IMPROVE FLEXIBILITY AND JOINT
INTEGRITY
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 over head activities in supine , sitting & reaching to
the floor .
43. IMPROVE STRENGHT
Strengthening of agonist & antagonistic muscle
Graded ex program using free weights, therabands,
sand bags & isokinetic devices .
For weak patients (<3/5), gravity eliminated exercises
using powder boards, sling suspension, or aquatic ex is
indicated
Gravity-resisted active movements are indicated (>3/5
strength)
44. REDUCE SPASTICITY
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
45. IMPROVE MOTOR ONTROL
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 movement, followed by active &
resisted movement
Task oriented exercise .
46. IMPROVE UPPER LIMB
FUNCTION
• 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.
47. REDUCE SHOULDER PAIN
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
48. IMPROVE POSTURAL CONTROL &
FUNCTIONAL MOBILITY
Suggested exercise
• Rolling
• Supine to sit & sit to supine
• Sitting
• Bridging
• Sit to stand & Sit down
• Modified plantigrade
• Standing
• Transfer
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
49. IMPROVE LOWER LIMB
FUCTION
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
50. IMPROVE BALANCE
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
51. IMPROVE LOCOMOTION
Initial gait training between parallel bars
Proceed outside bars with aids & then without aids
Walking forward, backward, sideways & in cross patterns
Proper use of orthotics & wheelchair
52. IMPROVE AEROBIC FUNCTION
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
53. IMPROVE FEEDING AND
SWALLOWING
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
straws.
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
54. IMPROVE MOTOR LEARNING
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
55. PATIENT AND FAMILY
EDUCATION
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
56. DISCHARGE PLANNING
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
57. REFERENCES
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.