13. Poor prognosis associated also with: No measurable grasp
strength by 4 weeks Severe proximal spasticity Prolonged flaccidity
period Late return of proprioceptive facilitation (tapping)
response > 9 days Late return of proximal traction response
(shoulder flexors/adductors) > 13 days
14. Brunnstrom (1966, 1970) and Sawner (1992) also described
the process of recovery following stroke-induced hemiplegia. The
process was divided into a number of stages: 1. Flaccidity
(immediately after the onset) No voluntary movements on the
affected side can be initiated. 2. Spasticity appears. Basic
synergy patterns appear. Minimal voluntary movements may be
present. 3. Patient gains voluntary control over synergies.
Increase in spasticity.
15. 4. Some movement patterns out of synergy are mastered
(synergy patterns still predominate). Decrease in spasticity. 5. If
progress continues, more complex movement combinations are learned
as the basic synergies lose their dominance over motor acts.
Further decrease in spasticity. 6. Disappearance of spasticity.
Individual joint movements become possible and coordination
approaches normal. 7. Normal function is restored.
16. Upper Lower Hand I flaccid II spasticity developing
Associated movement/reaction Little or no active finger flexion III
Synergy pattern Muscle tone Triple extension(lock knee tip toe
ankle inversion) Mass grasp Use hook grasp but no release No
voluntary extension
17. Upper Lower Hand IV Block synergy pattern Placing the hand
behind the body Elevated the arm to supination Ankle dorsiflexed
Knee isolated extened Lateral prehension( ) release by thumb
movement Semivoluntary finger extension V Block synergy pattern
Arm-raised forward and overhead supination- pronation Ankle
dorsiflexion Knee isolated flexed Ankle Inversion/eversion Palmar
prehension VI RAM o r
18. 2 spasticity passivedorsiflexion 50% range of motion, ROM
modified Ashworth scale (103- 1-55) 1. 1 2. 1+ 3. 2 4. 4
19. Theories for stroke rehabilitation Brunnstrom theory PNF
theory Motor relearning theory Bobath theory: NDT:
Neural-Developmental Theory
20. 06/13/15 Jenny 29 Brunnstrom Theory Aim To encourage the
return of voluntary movement in hemiplegia patient through the use
of reflex activity and a range of sensory stimulation. The choice
of stimulation varies depending on which stage the patient has
reached in the recovery process.
21. Brunnstrom Theory Treatment The process is employed until
the primitive synergies are established, then facilitation is used
to develop some voluntary control. The preparation for walking
should be emphasized early but that extensive walking should be
postponed in order to avoid the development of a poor gait
pattern
22. 06/13/15 Jenny 31 PNF Theory Proprioceptive Neuromuscular
Facilitation Primary for the patient with neuromuscular dysfunction
Aim to promote movement and functional synergies of movement by
maximizing peripheral inputby maximizing peripheral input
23. 06/13/15 Jenny 32 PNF Theory Basis of practice People who
move normally have passed through a developmental
sequencedevelopmental sequence Diagonal and spiral patternsDiagonal
and spiral patterns of active and passive movements are encouraged
Treatment Providing appropriate sensory stimulus Following
activities in a developmental sequence Patterns and techniques
24. 06/13/15 Jenny 33 Motor relearning Theory By Carr and
Shepherd Aim To enable the disabled person to learn how toto learn
how to perform or improve performanceperform or improve performance
of actions critical to everyday life. Utilizing theories of
learningtheories of learning, in particular the use of practice and
knowledge of results to encourage people to learn and self monitor
Knowledge of biomechanics for analyzing movements and performance
of tasks
25. 06/13/15 Jenny 34 Motor relearning Theory Basis of practice
The motor control of posture and movement are interrelated and that
appropriate sensory input will help modulate the motor response to
a task The program is based on Elimination of unnecessary muscle
activity Feedback Practice The link between postural adjustment and
movement Task analysis and measurement are viewed as essential
elements of the framework.
26. 06/13/15 Jenny 35 Motor relearning Theory Treatment
Movement analysis and training follow the four steps Analysis of
the task Practice of the missing components Practice of the task
Transference of training A series of task has been chosen because
learning by normal subjects has been shown to be task-specific with
minimal carry-over from one activity to another
27. 06/13/15 Jenny 36 Bobath theory: NDT Aim To improve the
quality of movement on the affected sidethe quality of movement on
the affected side Key point controlKey point control is to allow
patients the experience of normal afferent input Basis of practice
The movement will be abnormal if it stems from a background of
abnormal toneabnormal tone Performing abnormal movements will
reinforce more abnormal movements Tone could be influenced by
altering the position or movement of proximal joints of the
body
28. 06/13/15 Jenny 37 Bobath Theory: NDT Treatment Treatment
centre around the facilitation of corrected movement by a therapist
who handles the body at key points of controlkey points of control
In recent years treatment has become more activeactive , dynamic
and functionally directed, dynamic and functionally directed..
Movement are not isolated to individual joints but take place in
patterns
29. 06/13/15 Jenny 38 Bobath theory: NDT To help the patient to
gain control over the released patterns of spasticity by their own
inhibition Auto-inhibition Give patient normal kinematics sensation
input to facilitated normal posture and movement Muscle
strengthening is notnot viewed as part of treatment There are no
set Bobath exercise
30.
31. bisection test (100-1-55)
32. (hypesthetic) (left neglect) (left hemianopia)
confrontation test (copy test) spontaneous drawing test behavioral
inattention test (line bisection test) (cancel- lation test)
36. (96-1-58) left hemianopsia left hemineglect left side
apraxia left eye blindness
37. (100-2-59) 70-80% spastic phase flaccid phase
38. POSTSTROKE SHOULDER PAIN 7084% of stroke patients with
hemiplegia have shoulder pain with varying degrees of severity. The
majority (85%) will develop it during the spastic phase of
recovery. The most common causes of hemiplegic shoulder pain are
complex regional pain syndrome type I (see below) and soft tissue
lesions (including plexus lesions).
39. Reflex sympathetic dystrophy (100-2-57)
40. Complex Regional Pain Syndrome Type I (CRPS Type I) Also
known as reflex sympathetic dystrophy [RSD], shoulder-hand
syndrome, or Sudeck atrophy. Disorder characterized by
sympathetic-maintained pain related sensory abnormalities abnormal
blood flow abnormalities in the motor system and changes in both
superficial and deep structures with trophic changes.
41. Stages Stage 1 (acute): Lasts 3 to 6 months. burning pain
diffuse swelling/edema exquisite tenderness hyperpathia and/or
allodynia vasomotor changes in hand/fingers (increased nail and
hair growth, hyperthermia or hypothermia, sweating).
42. Stages Stage 2 (dystrophic): Lasts 3 to 6 months pain
becomes more intense and spreads proximally skin/muscle atrophy
brawny edema cold insensitivity brittle nails/nail atrophy,
decreased ROM, mottled skin early atrophy, and osteopenia
(late)
43. Stages Stage 3 (atrophic): pain decreases trophic changes
occur: hand/skin appear pale and cyanotic with a smooth, shiny
appearance, feeling cool and dry bone demineralization progresses
with muscula weakness/atrophy, contractures/flexion deformities of
shoulder/ hand, tapering digits no vasomotor changes.
45. Shoulder Subluxation Treatment Shoulder sling use is
controversial. Pros: may be used when patient ambulates to support
extremity (may prevent upper extremity trauma, which in turn may
cause increase pain or predispose to development of RSD). Cons: may
encourage contractures in shoulder adduction/internal rotation,
elbow flexion(flexor synergy pattern). Other widely used treatments
for shoulder subluxation: Functional electrical stimulation (FES)
Arm board, arm trough, lapboardused in poor upper-extremity
recovery, primary wheelchair users. Arm board may overcorrect
subluxation. Overhead slingsprevents hand edema (may use foam wedge
on arm board).
