Physiotherapy and Stroke Rehabilitation
By Gisele Penzhorn (DPhty, BSpExSc)
What is a stroke?
Stroke AKA Cerebrovascular Accident (CVA) the result of which causes the sudden death of brain cells in a localised area, due to lack of oxygen
Stroke Types:
Ischaemic stroke: A clot blocks blood flow to an area of the brain (85% of all strokes)
Haemorrhagic stroke: Bleeding occurs inside or around brain tissue (15% of strokes)
Neuroplasticity
Neuroplasticity is the ability of the central nervous system to remodel itself. It is how we adapt to changing conditions, learn new facts and develop new skills. This is the guiding principle in stroke rehabilitation
Neuroplasticity can be influenced by enriched or impoverished environments, patterns of use or disuse, sensory input and motor skill practice
How does Neuroplasticity effect rehabilitation post stroke?
The most important principles are:
- Specificity – we learn what we practice
- Repetition – high repetitions required to cement learning and create long term recovery
- Intensity – enough repetitions within a period of time. Intensive programs have a high rate of success
- Timing – need to promote learning of normal timing of muscle activity. Movements must be preformed with this ultimate goal
- Difficulty – need to get the difficulty level right. Not too hard; not too easy
- Salience – needs to be relevant to the individual.
Motor Learning occurs along a continuum:
Evidence-based Physiotherapy interventions:
- Therapeutic positioning aims to reduce skin damage, limb swelling, shoulder pain or subluxation and discomfort, and maximise function and maintain soft tissue length (muscle, tendons, and ligaments)
- Assists in reducing respiratory complications such as those caused by aspiration and avoid compromising hydration nutrition
- Balance difficulties are common for many people post-stroke usually due to a combination of reduced limb and trunk motor control, altered sensation and sometimes centrally determined (the central nervous system) changes to body representation such that the person does not recognise their posture in relation to the upright.
- Impaired balance often leads to reduced confidence, fear of falling and increased risks of falls
- Evidence suggests that trunk exercise training improves trunk performance and dynamic sitting balance, while task specific training improves dynamic and sitting and standing balance
- Interventions must be frequent with a strong focus on task specific challenges (such as leg strengthening exercises, circuit training, walking over-ground, and treadmill training with and without body weight support
- Treadmill training is effective for gait re-education as well as aerobic function
- Treadmill training can be completed with the patient’s body weight, or partially supported in a harness for individuals with significant functional limitations
- Bilateral arm training (both arms) to assist in coordination of bi-manual skills
- Constraint Induced Movement Therapy (CIMT) where the functional arm is prevented from performing a task, allowing the less functional arm to do the work. This therapy is most effective when combined with goal-directed training
- Mild electrical stimulation is applied to the affected body part, causing a muscle contraction
- FES should be used together with motor training to improve limb function
- Tasks should be specific to the individual and their functional goals
- Motor imagery (MI) is a mental process of rehearsal for a given action in order to improve motor function while Mental Practice (MP) is a training method where the person practises the movements and activities ‘in the mind’.
- Evidence shows that mental practice in conjunction with physical therapies increases restoration of limb function
- The benefits of aerobic exercise are well known in all populations.
- Rehabilitation must be tailored to the individual’s fitness levels and level of disability
- Circuit training has been shown to be effective in terms of walking speed, stair walking and walking distance.
- Training should be task specific and may be done one-on-one, or in groups of 6-8
- Routine stretching is not recommended
- Adjunct therapies to Botox such as electrical stimulation, taping, and stretching may be used together to reduce spasticity
- Fatigue is a common long-term concern for patients post stroke and can lead to depression and anxiety
- Strategies include identifying triggers, environmental modifications, and lifestyle changes, scheduling and pacing, as well as cognitive strategies and finding energising triggers