1. REHABILITATION OF PATIENTS WITH HEMIPLEGIA

2. Interdisciplinary team
Rehabilitation
purpose - restore function following an illness or injury, with the goal of maximizing a person’s ability to achieve fullest life possible
The ultimate aim of stroke research and rehabilitation after stroke is to reduce impairment, disability and handicap and to enhance the quality of life.
Interdisciplinary team
physicians, nurses, PT, OT, speech-language therapists, psychologists, social workers, recreational therapists.

3. Rehabilitation
Rehabilitation therapy should start as early as possible, once medical stability is reached
Spontaneous recovery can be impressive, but rehabilitation-induced recovery seems to be greater on average.
Even though the most marked improvement is achieved during the first 3 months, rehabilitation should be continued for a longer period to prevent subsequent deterioration.

4. Rehabilitation
No patient should be excluded from rehabilitation unless he is too ill or too cognitively devastated to participate in a treatment program.
Proper positioning and early passive ROM exercises help to avoid complications at a flaccid stage.
Family members should participate in therapy sessions.
The family should also be referred to community groups that offer psychosocial support such as stroke clubs at the time of discharge.

5. Poor Prognosis
Decreased alertness,inattention,poor memory,inability to learn new tasks or follow simple commands
severe neglect or anosognosia
significant medical problems esp, cardiovascular or DJD
serious language disturbance
less well defined & economic problem

6. Effect of a Stroke
1. Weakness on the side of the body opposite the site of the brain affected by the stroke
2. Spasticity, stiffness in muscles, painful muscle spasms
3. Problems with balance and/or coordination
4. Problems using language, including having difficulty understanding speech or writing(aphasia); and knowing the right words but having trouble saying them clearly (dysarthria)
5. Being unaware of or ignoring sensations on one side of the body (bodily neglect or inattention)
6. Pain, numbness or odd sensations

7. Effect of a Stroke (con’t)
7. Problems with memory, thinking, attention or learning
8. Being unaware of the effects of a stroke
9. Trouble swallowing (dysphagia)
10. Problems with bowel or bladder control
11. Fatigue
12. Difficulty controlling emotions (emotional lability)
13. Depression
14. Difficulties with daily tasks

8. Rehabilitation Goal To restore lost abilities as much as possible
To prevent stroke-related complications
To improve the patient's quality of life
To educate the patient and family about how to prevent recurrent strokes
Promote re-integration into family, home, work, leisure and community activities

9. Successful Rehabilitation
Depend on
- how early rehabilitation begins
- the extent of the brain injury
- the survivor’s attitude
- the rehabilitation team’s skill
- the cooperation of family and caregiver

10. Basic Principles of Rehabilitation
To begin as possible early (first hours)
To assess the patient systematically
To prepare the therapy plan carefully
To build up in stages
To include the type of rehabilitation approach specific to deficits
To evaluate patient’s progress regularly

11. Rehabilitation Management
Mobility
Activity of daily living
Communication
Swallowing
Orthosis
Shoulder pain
Spasticity
Cognitive and perception
Mood
Bowel and bladder incontinence

12. Mobility Physiotherapy Conventional therapies
Neurophysiological therapies

13. Conventional therapies Therapeutic Exercises Traditional Functional Retraining
Range Of Motion (ROM) Exercises
Muscle Strengthening Exercises
Mobilization activities
Fitness training
Compensatory Techniques

14. Neurophysiological Approaches
1. Muscle Re-education Approach (1920S)
2. Neurodevelopmental Approaches ( S)
Sensorimotor Approach (Rood, 1940S)
Movement Therapy Approach (Brunnstrom, 1950S)
NDT Approach (Bobath, S)
PNF Approach (Knot and Voss, S)
3. Motor Relearning Program for Stroke (1980S)
4. Contemporary Task Oriented Approach (1990S)

15. Aim
Improve
Movement
Balance
coordination
Safety

16. Basic Physical Therapy
Bed positioning, mobility
Range of motion exercises (ROME)
Sitting/trunk control
Transfer
Walking
Stair climbing

17. Treadmill training with body weight support

18. Robotics

19. Activity of daily living
Occupational therapy
Self care Dressing Grooming Toilet use Bathing Eating
Adapt or specially design device

20. Constraint-Induced Movement Therapy (CIMT)
Principle of FORCED USE to avoid the Learned Nonuse of the paretic side for Stroke patients
Mainly for training of upper extremity

22. Exercise Therapy Neurodevelopmental techniques by Bobath
Stresses exercises that tend to normalize
muscle tone and prevent excessive spasticity
Through special reflex-inhibiting postures &
movements
In beginning spasticity,
Slow, sustained stretching for spastic muscles
Vibration of antagonist muscles to reduce tone
through reciprocal inhibition.

23. Exercise Therapy to Develop Motor Control
Facilitation techniques:
1. Rood
involves superficial cutaneous stimulation using stroking, brushing, tapping & icing or vibration to evoke voluntary muscle activation
2. Brunnstrom
Emphasized synergistic patterns* of movement that develop during recovery from hemiplegia
Encouraged the development of flexor & extensor synergies during early recovery, hoping that synergistic activation of muscle would, with training, transition into voluntary activation.

24. Exercise Therapy to Develop Motor Control
Facilitation techniques:
3. Kabat’s Proprioceptive Neuromuscular Facilitation (PNF)
Relies on quick stretching and manual resistance of muscle activation of the limbs in functional direction, which are often spiral and diagonal.

25. Exercise Therapy to Develop Motor Control
Conventional methods:
Stretching & strengthening
Attempting to retrain weak muscles through
reeducation

27. Hydrotherapy

28. Management- Balance Training

29. Management- coordination Training Bully Therapy

30. Orthosis
Shoulder slings
Hand splint
Foot slings
Ankle foot orthosis

31. Shoulder slings

32. Shoulder slings

33. Hand splints Flaccid = functional position Wrist extend 20 – 30 degree
Flex MCP joint 45 degree
Flex PIP joint degree
Flex DIP joint 20 degree

34. Hand splints

35. Foot slings

36. Ankle Foot Orthosis - Plastic Metal stability of ankle balance
speed walking
Not enhance recovery

37. Ankle Foot Orthosis
Metal AFO
Plastic AFO

38. Shoulder pain Sensorimotor dysfunction of upper extremities
72% of stroke patient in first year
Delay rehabilitation

39. Causes of Hemiplegic Shoulder Pain
aetiology of hemiplegic shoulder pain is probably multifactorial.
Spasticity and hemiplegic shoulder pain are related. particularly of the subscapularis and pectoralis muscles
It is uncertain whether shoulder subluxation causes hemiplegic shoulder pain
the sustained hemiplegic posture: shoulder contractures or restricted shoulder range of motion
reflex sympathetic dystrophy
Poor handling and positioning of the affected upper limb in stroke patients contribute toward shoulder pain.
Many types of shoulder pathology have been suggested as causes of shoulder pain including shoulder subluxation, capsulitis, tendonitis, rotator cuff injury, bursitis, impingement syndrome, spasticity, CRPS, brachial plexus injury, and proximal mononeuropathies

40. Exercise Therapy to Develop Motor Control
Facilitation techniques:
Kabat’s Proprioceptive Neuromuscular Facilitation (PNF)

41. Treatment Electrical stimulation Shoulder strapping
Mobilization (esp. External rotator, abduction) prevent frozen shoulder, shoulder hand pain
Medical
Intraarticular injections
Modalities : ice, heat, massage
Strengthening

42. Spasticity
Velocity dependent hyperactivity of tonic streth reflexes

43. Aim of treatment Pain ROM Cosmatic Hygiene Mobility Easy use orthosis
Delay surgery

44. Treatment Avoid noxious stimuli Positioning, passive stretching, ROME
Splinting, serial casting, surgical correction
Medical - tizanidine baclofen dantrolen avoid diazepam
Botulinum toxin A injection
Phenol / alcohol
Neurosurgical procedure (selective dorsal rhizotomy)

45. Bowel and bladder incontinence
Urinary incontinence
- 50% incontinence during acute phase
- with time, ~ 20% at six months
- Risk: age, stroke severity, diabetes
- Indwelling catheter : management of fluids, prevent urinary retention, skin breakdown
- Use of foley catheter > 48 hours UTI

46. Fecal incontinence Improve within 2 weeks
Continued fecal incontinence poor prognosis

47. Constipation, fecal impaction
More common
Immobility, inadequate fluid or food intake, depression or anxiety, cognitive deficit
Management
Adequate intake of fluid
Bulk and fiber food
Bowel training