Eclectic approach to stroke

management-2
S.Rajan Chellappa,
Senior Physiotherapist,
PGIMER.
Eclectic approach
 An eclectic approach is a therapeutic approach that incorporates a
variety of therapeutic principles and philosophies to create the
ideal treatment program to meet the specific needs of the patient or
client.
 Since patients with hemiplegia present with variable symptoms,
rigid adherence to any one approach may yield unsatisfactory
results.
 Choice of therapeutic techniques may also dependent on other
factors, including ease of delivering care, cost-effectiveness and
length of treatment.
 The success of a particular technique also depends upon the
physiotherapist who is delivering the therapeutic technique and the
response of the patient towards the same.
Impairments of stroke.
 Sensory impairment
 Pain
 Musculoskeletal changes.
 Visual changes.  Neurological changes.



Motor impairment
Muscle weakness.
 Seizures.
 Alteration in tone.  Hydrocephalus.
 Abnormal synergy pattern.  Cardiovascular changes.
 Abnormal reflexes.
 Altered coordination.
 Thrombophlebitis/ DVT.
 Altered motor programming.  Pulmonary changes.
 Postural control and balance impairment.-
Pushers syndrome.
 Integumentary.
 Speech, language and swallowing.
 Perception and cognition.
 Emotional status.
 Bladder and Bowel function impairment.

Primary impairments Secondary impairments

Physiotherapy Management
 The following outline of Physiotherapy is not a
fixed regime or program for all patients, but
provides suggestions for activities which will be of
benefit to many. Frequent assessment must be made
as the problems arising from hemiplegia will be
different for each individual. Management must be
carefully selected and progressed.
 Therapists select interventions based on an accurate
examination of existing impairments, activity
limitations, and goals.
Physiotherapy Management
 A- Management program in acute stage of recovery.
 B- Management program in sub-acute and chronic

stage of recovery.
A- Management program in acute stage
of recovery.
- Rehabilitation during the acute stage can begin as soon as the
patient is medically stabilized, typically within 72 hours.

Goals of physiotherapy during the early rehabilitation will include,

i) To prevent respiratory complications.

ii) To maintain ROM and deformity.

iii) To promote awareness, active movement and use of the

hemiplegic side.
iv) To improve functional bed mobility.

v) To prevent secondary complications (DVT, pressure sores etc).

vi) To reassurance of patients and the immediate relatives.

A- Management program in acute stage
of recovery.
 Interventions include but are not limited to,
1. Pulmonary or chest physiotherapy,
2. Positioning,
3. Passive range of motion exercises (ROM),
4. and gradually progress in to functional mobility
training- mobilizations (e.g., bed mobility, sitting,
transfers, locomotion), ADL training.
Chest Physiotherapy in acute stage of
recovery.
 i) Segmental breathing  i) Deep breathing exercises.
exercises.  Ii) Huffing and Coughing.
 ii) Vibrations and  Iii) Incentive spirometry.
percussions.
 Iii) postural drainage
positions.
 Iv) Suction

For the unconscious/ For the conscious and

Disoriented patients. obeying verbal commands.
Positioning in acute stage of recovery.
 Positioning of the patient is one of the first considerations during early
rehabilitation.
 The room should be arranged to maximize patient’s awareness of the
hemiplegic side. Therefore, the bed positioned with the hemiplegic side
towards the main part of room, door and source of interaction will
stimulate the patient to turn toward and engage the affected side. The
resulting sensory stimulation to the stroke side promotes integration and
symmetry of the two sides of the body.
 Effective positioning prevents undesirable postures, which can lead to
contractures or decubitus ulcers.
 Since most stroke patients will become spastic, a positioning program also
aims to position the patient out of tone dependent and reflex dependent
postures.
Positioning in acute stage of recovery.
 Patients are generally placed on a positioning schedule, with turning every
2to 3 hours. Assumption of upright postures is promoted as soon as
possible.
 Attention should also be directed to the hemiplegic shoulder. Correct
positioning protects the shoulder from downward displacement by
controlling the scapula position in slight protraction and upward rotation.
Gentle approximation forces through the shoulder joint can also assist in
shoulder subluxation.
Positioning in acute stage of recovery
contd….
 Common positions that should be promoted includes:
 Lying in supine.
 Lying on the sound side.
 Lying on the affected side.
 Sitting.
Positioning in acute stage of recovery
Passive ROM exercises in acute stage of
recovery.
 To prevent soft tissue impingement in the subacromial
space, careful attention to external rotation of humerus
and scapular mobilizations on upward rotation and
protraction should be emphasized, especially ranges
approach 90° of elevation.
 The PROM are carried out gently without much

application of force. The speed of movement is kept

slow and rhythmic.
Passive ROM exercises in acute stage of
recovery.
 Uses of PROM:
- Creates an imprint on the brain,
- Aid in peripheral blood circulation,
- Prevent tightness, contractures and deformities, and
- Prevent bedsores and deep vein thrombosis.
B- Management program in sub-acute and chronic stage of recovery.

 Goals of Physiotherapy:
i) Manage sensory impairments.
ii) Promote selective movement control and normalize
postural tone.
iii) Improve postural control and balance.
iv) Develop independent functional mobility skills.
v) Prevent or minimize secondary complications.
vi) Compensate for perceptual loss.
B- Management program in sub-acute
and chronic stage of recovery.
 Interventions include the following, but not limited to;
1)Interventions to improve sensory function.
2) Interventions to improve motor function.
2-1 Interventions to improve flexibility and joint integrity.
2-2 interventions to decrease spasticity.
2-3 interventions to improve movement control.
2-4 interventions to improve muscle strength.
2-5 interventions to improve postural control and functional mobility.
2-6 interventions to improve upper extremity function.
2-7 interventions to improve balance.
2- 8 interventions to improve locomotion.
3) Interventions to improve feeding and swallowing function.
Interventions to improve sensory function
 Patients who have significant sensory impairments may demonstrate
impaired or absent spontaneous movement.

 The more the patient can be encouraged to use the affected side, the greater
the chance of increased awareness and function. Otherwise it may cause
learned nonuse phenomenon, which can contribute to further
deterioration.
Interventions to improve sensory
function
 Sensory retraining  Sensory stimulation
programs include use intervention includes
of  compression
 Mirror therapy techniques (weight-
bearing, manual
 Repetitive sensory compression, inflatable
discrimination pressure splints,
activities, intermittent pneumatic
 Bilateral simultaneous compression),
movements, and  mobilizations,
repetitive task  electrical stimulation,
practice.  thermal stimulation,
Mirror therapy (MT)
 MT is a form of motor imagery in which a mirror is used to convey
visual stimuli to the brain through observation of one's sound body part as
it carries out a set of movements.
 A mirror is placed in the patient’s mid sagittal plane, presenting the
patient with the mirror image of his or her less affected limb as if it were
the hemiparetic limb.
 It was first introduced by Ramachandran et al for individuals with arm
amputation.
 For patients with stroke, MT has been shown to improve LE recovery and
ankle dorsiflexion.
 MT has also been shown to improve UE recovery and distal motor
function and recovery from hemi-neglect.
 Use of mirrors is contraindicated in patients with marked visuospatial
perceptual impairments.
Mirror therapy
2-1 Interventions to improve flexibility and joint integrity :

 Soft tissue, joint mobilization & ROM exercise.

 PROM, AAROM & AROM with end range stretch. to

maintain jt range and contracture prevention
 Precaution is required more than 90 degrees of shoulder flexion –
scapular mobilisation esp- upward rotation and protraction to
prevent soft tissue impingement in the sub-acromial space.

 Full elbow ROM is important to prevent elbow flexor tightness

following flexor spasticity.
 Full wrist ROM is important to prevent wrist flexor tightness.
2-1 Interventions to improve flexibility and
joint integrity:
 Splinting - resting hand splint more appropriate for night time
use than daytime.
 Self assisted ROM exercises:

1) Arm cradling- horizontal Abd& add.

2) Table top polishing – horizontal Abd& add.
3) Self overhead activities in supine & sitting & reaching to
the floor.
2-2 Interventions to decrease spasticity-

 Positioning – to allow the stretch and sustained stretch,

and in anti synergistic pattern.
 Use rhythmic rotation and prolonged stretch. Example:
sitting with extended arm support.
 Use slow rocking movements. Example:
 i- in crook-lying position- log rolling & segmental rolling.
 ii- in crook lying position – holding the both knees
together with clasped hand, and practice the rocking
movements.
 iii- practice rocking movements in quadruped position.
2-2 Interventions to decrease spasticity-

 Use weight bearing positioning in kneeling and quadruped.

 Use rotational upper trunk movements in PNF diagonal patterns.
 Ask patient to perform side sitting on the affected side to stretch
spastic side flexor muscles.
 Use reciprocal inhibition to reduce tone in the agonist ( spastic )
muscles.
 Splinting example- functional resting hand splint, finger abduction
splint and knee immobilizer.
 Use ice wraps or ice packs to decrease neural firing rates. Slow icing /
prolonged icing.
 Use electrical stimulation to the antagonist muscles.
 Soothing verbal commands and relaxation techniques – to provide
overall calming influence and generally relax tone.
2-3 Interventions to improve movement control

 During initial training, focus is mainly on dissociation of

different body segments (ability to move the different
parts of the body or limb separately) and selective (out of
synergy) movement patterns.
 Select the postures that assist the desired movements
through optimal biomechanical stabilization. As control
develops, postures can be changed to more difficult ones
that challenge developing control.
 For example elbow extension can be attempted in side-
lying with the shoulder flexed to 90 degree. The posture
can then be changed to sitting and finally standing.
2-3 Interventions to improve movement control

 Movements started with assisted/ guided and shifted to

active control as soon as possible, progressed to
resistance exercises to facilitate correct movement
responses through proprioceptive loading.

 As control develops exercises can shift to include slow

active reciprocal contractions of agonist and antagonist
muscles first in limited ranges, then in full range.
2-4 Interventions to improve muscle strength:

 Strengthening of agonist & antagonistic muscles.

 For weak patients (<3/5), gravity eliminated exercise using powder
boards, sling suspension, or aquatic ex is indicated
 Gravity-resisted active movts are indicated (>3/5 strength) using free
weights, therabands, sand bags & isokinetic devices
 Use exercise precaution (valsalva maneuver) with HTN and patients
with cardiopulmonary dysfunction.
 Use eccentric exercises to decrease cardiovascular stress; use
exercises in sitting upright position for HTN.
 Decrease risk of injury for older adults with CVA immobilized for
long periods of time by starting with concentric low intensity
exercises, allowing enough rest periods and monitoring for fatigue
and DOMS.
2-5 Interventions to improve postural control and functional mobility :

Aim:
 To achieve trunk symmetry.
 To encourage the use of both sides of the body.

 Rolling:
 Practice rolling on both sides.
 Focus rolling towards the unaffected side to challenge the affected
side, use the hands prayer position to assist the movement.
 Supine to sit and back:
 Focus on rising from the unaffected side and into a sidelying on
elbow is important to promote early weight bearing and elongating
the lateral trunk flexors, which may be spastic.
2-5 Interventions to improve postural control
and functional mobility:
Sitting:
 Focus on achieving a symmetrical posture of spine and pelvis and feet flat.
 Provide verbal and tactile cues to help symmetry.
 Use UEs in front or at sides for support in early sitting.
 Use gentle bouncing on a therapy ball to promote pelvic and trunk alignment.
 Focus on lateral weight shifts to affected side to challenge the patient.
 Scooting ( Butt walking) in sitting helps with mobility for dressing; coming
to end of seat to place feet back under the body helps with transitional
movements.
Bridging:
 To develop trunk and hip extensor control for bedpan, pressure relief,
scooting, and sit to stand transfers. Initially stabilize foot to achieve affected
LE hook lying position, and progressed to affected LE only, (single leg
bridging), then placing unaffected foot on a ball while bridging.
2-5 Interventions to improve postural control
and functional mobility:
 Sit to stand and sit down transfers:
 Ask the patient to use momentum to shift body forward.
 Have the patients feet well back to allow ankle DF and assist with forward
rotation; have patients hands in clasped position; in the beginning elevate the
patients seat to decrease hip/knee extension, later lower the seat height.
 Practice small range partial squats with patient against a wall.
 Standing modified plantigrade postion:
 Early standing posture to develop postural and extremity control assisting
quadriceps in extension.
 Standing:
 First using high table or wall support for stabilization , then weight shifting in all
positions, and finally reaching in all directions and stepping.
 Transfers:
 Transfers to both sides focusing toward the affected side, use different surfaces
and heights.
Interventions to improve motor
function
For pushers syndrome:
 The patient uses the stronger UE or LE to push over to the weaker

side, often result in instability and falls.

 Management:
 Passive correction often fails.
 Use visual stimuli to correct. Ex- patient should be asked to look

at their posture in the mirror and ask them to correct the posture.
 Sit on the normal side & ask patient to lean on you (or) position

the patient with the stronger side next to a wall and instructed to
lean toward the wall.
 A short height cane is used, to encourage weight shift to the

stronger side.
2-6 Interventions to improve UE function:
 Extended arm weight bearing with hand placed on a support surface (promotes
stabilization and decreases flexor synergy); approximation (for stimulation of shoulder
and scapular stabilizers and elbow extensors).
 Reaching: to improve scapular protraction, upward rotation, and elbow wrist and finger
extension; beginning reaching starts in side lying; advanced reaching includes
independently lifting and reaching forward; and standing and reaching to pick an object
from a shelf.
 Grasp and manipulation: begins with voluntary gross grasp and release; voluntary
release is more difficult than grasp; patient needs positioning, stretching, and inhibitory
techniques to decrease flexion, to facilitate extension.
 Initial hand tasks include using the more affected hand to stabilize, ex- hand stabilizes
paper / food, while the stronger hand writes/ cuts. Or holding a book with both hands for
reading.
 Practice advanced wrist and finger extension activities such as using utensils to eat,
writing, drinking from a cup or picking up coins.
 Advance training – CIMT, biofeedback, NMES, FES.
For hemiplegic shoulder pain:
 Instruction to caregivers regarding proper handling &

positioning of shoulder joint.

 Interventions to reduce subluxation pain include

NMES, gentle mobilization (grade 1 & 2) cryotherapy.

 Use of overhead pulley is contraindicated.
 Use of supportive devices & slings: humeral cuff sling.
 Taping (strapping) to facilitate or inhibit muscles

around scapula.
2-7 Interventions to improve balance:

 Goal of balance training are to increase the consistency, range,

and speed of self initiated movements while encouraging
symmetry and maximum use of the more affected side.
 Once postural alignment and static stability is achieved in upright
postures, then proceed to center of mass control training.
 1) Weight shifts first in sitting, then in standing, encourage
symmetrical weight training in sitting and standing.
 2) Decrease BOS: in sitting- LE uncrossed to crossed; in standing
from wide to narrow and tandem; standing on single leg.
 3) Alter support surfaces: sitting on mat to therapy ball; standing
on floor to dense foam.
2.7- Interventions to improve
balance
 4)Alter sensory inputs: eyes open to eyes closed.
 5) Upper extremity movements: single UE raises to bilateral
UE raises; reaching; picking objects off table, stool, floor.
 6) lower extremity movements: single LE raises, stepping
(forward, backward, side- step-up); marching in place; foot on
ball, moving ball.
 7) trunk movements: head and trunk rotations; looking up at
ceiling or down to floor.
 8) dual task training: such as kicking ball in standing, throwing
activities, carrying an object while walking.
 9) enhanced training activities: force platform biofeedback
system can also be used to improve balance training.
2.8- Interventions to improve locomotion:

I - Preparation for the stance phase of gait: -

 Aim: To encourage weight bearing on the affected side.

1) To activate hip extensors, abductors, knee extensors and dorsiflexors- use PNF LE
D1extension pattern, holding against elastic band resistance around upper thighs in
supine or standing positions.
2) Standing: forward step up and down of normal leg, while the therapist standing on
the affected side.
3) Standing: lateral step up and down of normal leg, while the therapist standing on
the affected side.
4) Standing: ask the patient to draw large letters on the floor with his normal leg,
while the therapist standing on the affected side.
5) standing with affected leg on a low height (15cm) stool: putting the normal leg
further and further back.
6) standing with affected leg on a low height (15cm) stool: putting the normal leg step
up and over.
2.8- Interventions to improve locomotion:

II- preparation for the Swing phase of gait: -

 A- To facilitate pelvic control( forward pelvic rotation)-

1) by lower trunk rotation exercises in side lying, supine, crook lying, kneeling and standing.
2) pelvic shifts while sitting on a therapy ball.

 B- To activate hip adduction –

1) use supine PNF LE D1 flexion pattern.
2) sitting- crossing and uncrossing the affected LE over the unaffected LE.
3)standing- step-ups.

 C- To correct knee hyper extension

1) practice reciprocal action (smooth reversals of flexion and extension) should be practiced- use
foot slides in supine, hook lying and in sitting.
2) In standing position guide his pelvis forward and down, to release his knee on affected side.
Instruct him to straighten it again without pushing it back. Practice this while weight bearing on
the normal leg.
3) partial wall squats in standing.
2.8- Interventions to improve locomotion:
 D- To facilitate toe-off at the end of stance-
1) bridging.
2) supine hip extension with knee flexion over the side of
the mat pushing down through the heel.
2.8- Interventions to improve locomotion:
Facilitation of gait:
 Initial gait training between parallel bars – Patient pelvis held on

either side from behind to facilitate pelvic movements by

applying forward pressure during stance phase; and downward
pressure during the swing phase.
 Proceed outside bars with aids & then without aids.

 Walking forward, backward, sideways & in cross patterns.

Using technology:
 Progress to body weight supported tread mill training to maintain

the natural rhythm of walking and speed.

 Functional electrical stimulation.

 Robotic technology.
3- Interventions to 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 straw.
 Food presentation in proper position.
 Texture of food should be semisolid.
 Tasty food should be given to facilitate swallowing reflex.
 Stroking the neck during swallowing.
References
 O’ Sullivan SB, Schmitz TJ. Stroke. Physical
rehabilitation. 5th ed., NewDelhi: Jaypee
Brothers, 2007.
 Darcy A. Umphred. Neurological

Rehabilitation, 5th ed., Mosby Elsevier,

Missouri, 2007.
 Cash’s textbook of Neurology for

Physiotherapists, 4th ed., NewDelhi: Jaypee

Brothers,1993.