stroke rehab

[sps]

Dear fellow physios,

i think i need a helping hand with a stroke patient.

He has had a RIGHT CVA about 20 days ago. Unfortunately, they let him go from hospital 10 days after the stroke.

I started seeing him last week and has no movement at all on LEFT arm.I read that no shoulder shrug or finger movements are not good prognosis.I am using electrical stimulation, massage with a brush, passive movements and PNF patterns to re-learn the movements.Last Monday he had spontaneous adduction of LEFT SHOULDER that's gone again.Do you think his arm will recover?

As for his LEFT LEG, he has no control of knee extension.How can we manage locking of the knee?

Thank you all

Spyros

[umamadhu]

Hi Spyros,
For the locking of the knee,teach the patient to weight bear on his knee-left with proper support in the front.I think u have jus started with this patient.I think i cant say about the recovery at the moment,also what is his age?
If he is stable enough,do activities in the left side ,do he uses more of his hand and balances in his left side more. like passing a ball or some object.In this way, body awareness and patterns of movements can be easily taught to the patient. uma madhu.

[charlize29]

Hi Spyros,

I have had patients who were unable to even do elbow flexion and at the same time finger flexion for a month or two but with tapping and stimulation of the affected part done intensively during therapy sessions it will provide you with good results, sometimes you have to vary the position and not just stick to one.. others will also have no intiation at the beginning of the range but at the midrange or end-range of elbow flexion ( or any other ROM) you will get a contraction... and of course a STRONG command of instruction produces REALLY GOOD RESULTS. I guarantee you that. Been doing it for 3 years now hahaha!!! Usually I notice that patients do not respond to voices that are not loud enough. Mine works all the time... Goodluck to you!!!

Regards,
Charlize29

[charlize29]

Try adapting "Constraint-induced movement therapy" It works!!!

Cheers!!

[The therapist]

hiiiii dear
here i will give you some guid lines to add it to your rehab. programm

1-Regardin the shoulder apply electric stimulation for posterion fibers of deltoid + the supraspinatus to reduce the chance of sublaxation and pain

2-Encourage the TURNNING ACTIVITIES as early as possible

3-Focus On stretching of Latissmus dorsi mucsle as it tend to get tight affecting trunk stability and gait pattern

Regarding locking of knee joint i have a point of view here ,, the spastisty have positive feature in locking the knee joint and it will appear sooner ar later . ..But u can stimulate the locking action by:

1-try to apply approximation from knelling Position as it stimulat the locking by quadriceps muscle

2-Also try to teach the patient how to stand from sitting to stimulat the knee locking

3-Apply electric stimulation for the VMO (Vustus Medialis Oblicus) muscle on the medial aspect of thigh

finally you can use the knee orthosis for locking the knee during gait training


I HOPE U GET GOOD RESULT
my regards
THE THERAPIST ('',)

[clarett]

You can also get him doing self-assisted shoulder flexion if you teach him how to do it correctly.
Try active- assisted movements rather than passive movements. As he has no activity get him to imagine the muscles contracting as you're doing the movement. If he finds this difficult get him to move his right arm simultaneously so he can use the sensation of the movement in his right to imagine how it would feel in the left.
How is his sensation? If his sensation is good - assist him to handle different objects with his hand to provide stimulation.

Let us know how you're getting on.

[umamadhu]

Hi,
Motivation is the key factor in a stroke patient.Do a lot of talking.Ask him to first believe and visualize that ,he will be better.Also tell him that there is no magical potion that wud make him ok jus overnite,he has to struggle with u to attain the movement.
Activities like drawing with a crayon in his affected hand will give him a break from those strenuous exercises. Good luck!umamadhu.

[charlize29]

I agree that motivation plays an important part in the rehabilitation process. Concentration and what umamadhu said about visualization helps. Stroke patients need a a lot of psychological support. Praising them for a small movement made would enable them to do more and feel encouraged. And if you could encourage him or her "TO HELP YOU" instead of you telling him to do it, they would be more willing to do so. It is not just on how you elicit a movement or response from them that is important but on how you build a rapport to every individual that makes the whole rehabiltiaiton process successful.

Cheers!!

Regards,
Charlize29

[sps]

thank you all for your immediate response.

i'm sure it' d help a lot

sps

[consultant]

Thanks for good case study

[fire_ice]

hello everybody it was really nice going through all this but i just wanna knw one thing is that y we want that patient to lock his knee coz if we r doing so no muscle activity of quads is seen as the joint is locked but insted we want him to learn to control his knee joint , so we must forget about asking him to lock the knee joint and instead start with eccentric knee extension exercise so that he develops control over his knee , u can start this first in supine lying and then in standing , and is standing we should go for stance training with knee slightly bend rather than knee completely extended that will stress the quads muscle and strengthening will take place.

[umamadhu]

Hi fire ice,
We are trying to put the patient in an anti-spastic pattern first.
Next,STABILITY is important than strengthening.Another point is that, CREATING AWARENESS OF THE BODY PARTS.Each time the patient should know he has to use the affected side more to initiate a movement.when this is achieved strengthening can be started.

[syllee]

I am new to this forum, and am a 24/7 caregiver to my mother (67 years young) that had a hemhorgic stroke in February of this year. I've heard so many different time frames for recover. I've heard up to 6 months up to 2 years.

Am I on the correct forum to ask question about my concern in her therpy and such.

[Dee]

Hi
The speed and extent of recovery will depend on many factors including the extent of brain damage, which parts of the brain are affected, what your mum's general health is like, what support she has, what treatment she receives, how motivated she is, whether the CVA has affected her ability to attend and understand and whether her perception e.g. sensation, orientation in space etc have been affected. Secondary problems such as muscle contractures, incontinence and pain to name but a few can also have an impact. It is impossible to put an accurate time frame on recovery because every stroke is unique for the above reasons. In my experience, the largest changes are seen in the first 3-4 months. Recovery gradually slows over the next year and can eventually become infuriatingly slow. There is a finite ability of the brain to make all the plastic changes required to completely restore normal movement. So, in all but the most minor CVAs, does life return completely to normal. On an optimistic note, I regularly work with patients 2-3 years post CVA who are still changing and provided the patient is persuing normal movement it can be expected they will continue to improve albeit slowly. Hope this helps and sorry I can't say it will be OK in so many months.

[DR.urvashi]

can u tell me about the past stroke management of shoulder sub luxation?

[SagarNaik]

Originally Posted by DR.urvashi

can u tell me about the past stroke management of shoulder sub luxation?

Dear Dr. Urvashi,

You can follow the attached file for evidence based approach for painful shoulder after storke.

Following topics for treatment are covered in the attached file.
1) Positioning of the Hemiplegic Shoulder
2) Slings and other Aids
3) Strapping the Hemiplegic Shoulder
4) Active Therapies in the Hemiplegic Shoulder
5) Injections in the Hemiplegic Shoulder
6) Functional Electrical Stimulation in the Hemiplegic Shoulder
7) Surgery as treatment for muscle imbalance

Hope this would be helpful.