Stroke: PT Assessment and Management

neurological physiotherapy, stroke rehabilitation

1. STROKE

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 Dr. L. Surbala (MPT Neuro)

3. Acc. To who 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. Transient ischemic 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 Dr. L. Surbala (MPT Neuro)

5. Epidemiology T hird 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. Etiology 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. 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, infective endocarditis ) Migraine Chronic meningitis Inflammatory bowel disease (ulcerative and Crohn's colitis) Hypoglycemia Snake bite, fat embolism Dr. L. Surbala (MPT Neuro)

8. Risk factors 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. warning signs of stroke 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. Pathophysiology 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. Classification 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. stages of recovery 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. mca 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. pca 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. aca 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)

23. Vertibro - Basilar artery syndromes Medial medullary syndrome (vertebral artery) Lateral medullary (Wallenberg's) 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 syndrome 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. Lacunar syndrome 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 C lumsy hand syndrome Sensory/motor stroke D ystonia/involuntary movements Dr. L. Surbala (MPT Neuro)

26. Dr. L. Surbala (MPT Neuro)

27. Dr. L. Surbala (MPT Neuro)

28. Red flag Dr. L. Surbala (MPT Neuro)

29. Primary impairment 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)

33. 5. Abnormal synergy Dr. L. Surbala (MPT Neuro)

34. Muscles not involved in either synergy L atissimus dorsi T eres major Serratus anterior F inger extensors A nkle evertors Dr. L. Surbala (MPT Neuro)

35. 6. Abnormal reflexes Initially , hyporeflexia with flaccidity & later hyperreflexia M ay 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 I mpairments 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 L esions involving cortex of dominant hemisphere Aphasia: impairment of language comprehension, formulation, and use. D ysarthria: motor speech disorders caused by lesions of CNS or PNS that mediate speech production . D ysphagia , 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)

43. Hemispheric Behavioral Differences . Dr. L. Surbala (MPT Neuro)

44. Indirect Impairments 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 S troke 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)

50. Tests and Measures Urine analysis CBC count Blood sugar level Blood cholesterol & lipid profile Cardiac evaluation Lumbar puncture Dr. L. Surbala (MPT Neuro)

51. Imaging 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. Recovery and Prognosis F astest in first weeks after onset M easurable neurological & functional recovery occurring in first month after stroke. C ontinue 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. Variation of recovery 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 case 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) aphasia Dr. 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. PT assessment

61. History Abrupt onset with rapid coma is suggestive of cerebral hemorrhage. Severe headache typically precedes LOC E mbolus 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. Observation 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. 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 Dr. L. Surbala (MPT Neuro)

65. Arousal, Attention & Cognition Expressive and/or receptive aphasia Attention disorders Memory deficits, including declarative and procedural memory Executive function deficits Dr. L. Surbala (MPT Neuro)

66. Cranial Nerve Integrity 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. Sensory integrity 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)

68. Joint Integrity and Mobility Glenohumeral subluxation Shoulder impingement syndrome Adhesive capsulitis Complex Regional Pain Syndrome and Shoulder-Hand Syndrome Dr. L. Surbala (MPT Neuro)

69. Range of Motion 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. Motor Function Synergistic patterns of movement Hypertonicity Weakness Associated movements or synkinesis Apraxia including motor & verbal apraxia Dr. L. Surbala (MPT Neuro)

71. Reflex Integrity Exaggerated deep tendon reflexes Diminished superficial reflexes Positive B abinski’s reflex Impaired Righting, equilibrium, and protective reactions Abnormal primitive reflex (ATNR) may be present Dr. L. Surbala (MPT Neuro)

72. Assistive & Adaptive Devices A sling for Glenohumeral support AFO Cane Dr. L. Surbala (MPT Neuro)

73. Aerobic Capacity/Endurance BP, RR, & HR at rest & during exercise may have a sudden rise R eview 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. Circulation (Arterial, Venous & Lymphatic ) Edema may occur in affected limbs May be associated with shoulder hand syndrome Dr. L. Surbala (MPT Neuro)

75. Ventilation & Respiration 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. Gait & 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 Trendelenburg Dr. L. Surbala (MPT Neuro)

77. Balance 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. Posture 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. Functional assessment Using FIM, Barthel index, FMA There is compromised basic as well as instrumental ADL Ambulatory capacity is compromised Dr. L. Surbala (MPT Neuro)

80. Bowel & bladder 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)

81. Problem list Tonal abnormalities Muscular weakness Synergistic pattern Tightness & contracture Imbalance & incoordination Gait abnormalities Postural abnormalities Functional disability Dr. L. Surbala (MPT Neuro)

82. PT management

83. Acute stage Positioning strategies Improve respiratory & circulatory function Prevent pressure sores Prevent from deconditioning Dr. L. Surbala (MPT Neuro)

84. Positioning strategies In supine In side lying on normal side In side lying on affected side Dr. L. Surbala (MPT Neuro)

85. 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. Post acute stage 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. PT interventions

91. Improve sensory function 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. Flexibility & 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 overhead activities in supine & sitting & reaching to the floor Dr. L. Surbala (MPT Neuro)

93. Improve strength 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. Manage 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 Dr. L. Surbala (MPT Neuro)

95. Improve movt control Dissociation & selection of desired movt patterns S elect postures that assist desired movements through optimal b iomechanical 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. Postural control & functional mobility 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. Improve ue function E arly 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. Managing 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 Dr. L. Surbala (MPT Neuro)

100. Improve LL function 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. 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 Dr. L. Surbala (MPT Neuro)

102. Improve locomotion 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. Improve aerobic function Early mobilization & functional activity Treadmill training & cycle ergometer Symptom limited graded ex. t raining 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. Improve feeding & swallowing Proper head position in chin down position M ovements of lips, tongue, cheeks , & jaw Firm pressure to anterior 3 rd 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. 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 Dr. L. Surbala (MPT Neuro)

106. Patient & 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 Dr. L. Surbala (MPT Neuro)

107. Discharge planning Family member should participate daily in the therapy session & learn exercises Home visits should be made p rior 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. References O’ Sullivan SB, Schmitz TJ. Stroke. Physical rehabilitation. 5 th ed., New Delhi: Jaypee Brothers, 2007 . Darcy A. Umphred . Neurological Rehabilitation, 5 th ed., Mosby Elsevier, Missouri, 2007. Dr. L. Surbala (MPT Neuro)