BEST STROKE PHYSIO REHABILITATION

Nurse in retirement home helping an elderly woman to recover her muscle strength. Physiotherapy and social worker
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Physiotherapy is vital in stroke recovery as it improves recovery of function and mobility. NICE recommends a minimum of 45 minutes of physiotherapy five days a week as part of a seven-day specialist stroke rehabilitation service. Stroke is also known as cerebrovascular accident.

Why physiotherapy after a stroke attack

  • According to Stokes and Stack (2012), physiotherapy enables individuals with stroke attacks to achieve their optimal physical potential and functional independence.
  • Physical therapists work with stroke survivors to keep flaccid muscles toned and stimulated, even before they regain voluntary movement.
  • Patients learn everyday skills and retrain their healthy brain cells to control the affected body parts.
  • Improve balance, coordination, and other basic skills are essential to the overall quality of life.
  • Current evidence suggests that Physical Rehabilitation, comprising a selection of components from different approaches. The approaches are beneficial in restoring function and mobility after CVA (cerebrovascular accident).
  • Physical therapy helps to stimulate affected muscles and nerves to maintain circulation and prevent stiffness.
Nurse helping a disabled old man to recovery after an injury. The man lies in hospital bed in a retirement home

STAGES OF STROKE RECOVERY AND PHYSIO TREATMENTS

Stage 1: Flaccidity

The first stage of the Brunnstrom approach is the period immediately after a stroke when the connection between the muscles and brain is so damaged that flaccid paralysis (flaccidity) sets in. no muscle movement would lead to atrophy if it lasts for a very long time.

Treatment plan

  • Passive range-of-motion exercises: this type of exercise is effective for activating neuroplasticity. 
  • Therapeutic positioning of flaccid limbs.

Stage 2: Spasticity Appears

In the second stage of stroke recovery, the brain and muscles start to reconnect, resulting in light stimulation of muscle fibers.

Treatment plan

  • Passive ROM exercises 
  • Mild Active ROM exercises

Stage 3: Spasticity Increases

At this stage, spasticity will reach its peak, and it can cause discomfort and even pain. Recovery gets better from here with hard work and the right physiotherapy treatments. 

Treatment 

  • Active and passive range of motion exercises
  • Splinting/bracing can also be helpful for spasticity, so speak with your therapists about this.

Stage 4: Spasticity Decreases

Treatment 

  • strengthening exercises
  • stretching exercises

Stage 5: Complex Movement Returns

Treatment 

  • Fine skill movement therapies

Stage 6: Spasticity Disappears

  • Constraint-induced movement therapy (CIMT)
  • aerobic exercises such as staircase climbing and cycling

Stage 7: Normal Function Returns

Interventions in stroke recovery

A healthcare worker and senior patient in hospital, physiotherapy concept.

Positioning Therapeutic positioning aims to reduce skin damage, limb swelling, shoulder pain or subluxation, and discomfort, and maximize function and maintain soft tissue length. Positioning may assist in the reduction of respiratory complications such as those caused by aspiration and avoid compromising hydration and nutrition. The aim of positioning the patient is to promote optimal recovery and comfort by modulating muscle tone, providing appropriate sensory information, increasing spatial awareness, improving the ability to interact with the environment, and preventing complications such as contracture and pressure sores.

Evidence 

There is no Randomized Control Trial evidence to support the recommendation of any one position over another. A survey of physiotherapy current positioning practices found the most commonly recommended positions are: sitting in an armchair as recommended by 98% of respondents; side-lying on the unaffected side, then side-lying on the affected side. Sitting in a wheelchair (78%, 95% CI 74 to 82%) with supine lying is less commonly recommended.

Early Mobilization

Early mobilization aims to reduce the time between CVA and the first time the patient leaves the bed, increasing the amount of physical activity the patient engages in outside of bed. Early mobilization (e.g., sitting out of bed, transfers, standing, and walking) aims to minimize the risk of complications of immobility and improve functional recovery. 

There remains some ongoing discussion about the exact meaning of very early mobilization. Verbeek et al., (2014). define early mobilization as ‘mobilizing a patient out of bed within 24 hours after the stroke attack, and encouraging them to practice outside the bed. 

Recent recommendations are due to the AVERT Trial RCT of over 2000 individuals with acute CVD. The research showed that very early, more frequent, higher dose mobilization focused on out-of-bed activities plus usual care was worse than the conventional care alone. The care and early mobilization led to enormous disability at three months with no effect on immobility-related complications or walking recovery.

Constraint-Induced Movement Therapy

Woman in her 70s being assisted by a physio in her 40s to regain full arm mobility

Constraint-induced movement therapy (CIMT) involves intensive targeted practice with the affected limb while restraining the non-affected limb, which means that during task-specific activities, individuals with hemiplegic CVD use their affected limb. 

The affected arm and leg are not sufficiently used often, even with some muscle power. And is known as Learned non-use. The Constraint-induced movement therapy (CIMT) approach addresses the learned non-use. The non-affected limb was constrained hence forcing the affected limb to work. This forced-use therapy combined with shaping and goal-directed training is known as CIMT.

Different categories of CIMT can be used in Stroke depending on the duration of the immobilization of the paretic arm and the intensity of task-specific practice:

Original CIMT Applied for 2 to 3 weeks consisting of immobilization of the non-paretic arm with a padded mitt for 90% of waking hours utilizing task-oriented training with a high number of repetitions for 6 hours a day with behavioral strategies to improve both compliance and transfer of the activities practiced from the clinical setting to the home environment of patients. 

High-intensity mCIMT Consists of immobilization of the non-paretic arm with a padded mitt for 90% of waking hours, of 3 to 6 hours of task-oriented training a day. Found to be more beneficial in the acute stage of rehabilitation with a minimal effect on chronic upper limb impairment. 

Low-intensity mCIMT Consists of immobilization of the non-paretic arm with a padded mitt for > 0% to < 90% of waking hours with between 0 to 3 hours of task-oriented training a day. 

Electrical Stimulation

Electrical stimulation moderately improves upper limb activity compared to no intervention and training alone. Current evidence suggests that electrical stimulation should be used in stroke rehabilitation to improve the ability to perform functional upper limb activities.

CONCLUSION

The functional disabilities and movement limitations are complications of Stroke managed with physiotherapy. Physiotherapy rehabilitation restores Stroke patients to optimal form and function. 

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