Physiotherapy Management in Stroke Conditions

MODULE 1 PHYSIOTHERAPY MANAGEMENT IN STROKE CONDITIONS Stroke is a clinical manifestation of impaired brain function, both focal and global (comprehensive), which occurs quickly, lasts more than 24 hours or causes death, without any other cause than vascular disorders. 1. Physiotherapy Problems a. Weakness in one side of the body b. Posture disorders c. Sensory disturbances d. Dysarthria e. The face is not symmetrical f. Balance disorders g. Coordination disorders 2. Physiotherapy diagnosis Functional disorderssitting/ standing/ walking/ gait patterns/ office activities/ selling activities consequence muscle weakness, / posture disorders / balance disorders / coordination disorders / cognitive disorders/ in connection with ischemic/ hemorrhagic stroke. 3. Objectives of Physiotherapy a. Short term goals Goals that can be achieved in the near future. In general, the short-term goal of hemiparesis ec stroke is to facilitate muscle b. Long term goals The final result that the patient expects after receiving the intervention. In general, the long -term goal of long-term hemiparesis ec stroke is that the patient is able to perform ADLs and walk independently D. Equipment Required 1. Mattress 2. Bed Treatment 3. Load (Dumbbells) E. Practical Activities 1. Acute Phase Physiotherapy Intervention a. Positioning Position the patient to sleep on the left and right side alternately every 2 hours b. Functional mobilization of limbs Perform passive movements in all limb joints slowly and in a pattern c. Stretching Stretching the lower extremity muscles to prevent contractures and spasticity is done with slow movements without causing excessive muscle stretching. Repeat 3-5 times d. Head control exercises (Neck Control) The therapist facilitates that the patient's movements are directed towards flexion and rotation. Movement pattern: Flexion-Lateral flexion right-rotation right.Facilitate patients to perform flexion, extension, right rotation and left rotation movements independently without assistance. e. Proprioceptive stimulation with traction & approximation and activation techniques. 1) Proprioceptive stimulation of the fingers and toes (Bobat Method). Position the patient to sleep on the edge of the bed. The therapist performs flexion, approximation and stretching movements on the patient's fingers and toes to activate the intrinsic muscles. f. Traction and Approximation of the upper extremities Position the patient on the edge of the bed, the therapist is right next to him and makes approximating movements on the shoulder. g. Inhibition using the Bobath method Inhibition is an attempt to inhibit and reduce spastic muscle tone. Inhibition techniques. Which is given by positioning the limb opposite to the spastic pattern that will appear during the spastic phase and is given an approximation. h. Upper extremity functional stimulation In the flaccid phase, muscle tone in the limbs is still very low (hypotonic) so that active movement does not allow. Carrying out functional movements passively by a physiotherapist or by a patient assisted by healthy limbs with functional movement patterns will send information to the brain. The passive movements given are accompanied by commands/instructions according to the movements which act as stimulation for hearing (audio). Every movement made must be seen by the patient as a visual stimulus. This audio & visual stimulation will provide information to the brain about good and correct functional movements. Functional movements are carried out repeatedly so that coordinated movements occur consciously and become automatic reflexes based on skills in daily living activities (ADLs).The movement exercises given are the same for all patients, adjusted to the patient's condition.The movements in this exercise are based on the PNF pattern of the scapula, arms, pelvis and legs. 1) Scapula Movement patterns: Anterior-elevation and anterior-depression; Posterior-elevation; Posterio-depression. The patient sleeps on his side and the physiotherapist is behind the patient. The therapist's hands fixate on the front and back of the shoulder. Give the patient the signal to pull the shoulders forward and down while the therapist moves the scapula towards anterior depression and posterior elevation. Likewise, this is done in the direction of anterior elevation and posterior depression of the scapula. 2) Upper extremities The position of the patient is lying on his back at the edge of the bed, the therapist is next to the patient. Aba aba: "hold your fingers - turn and lift" Starting position: Extension-abduction-endorotation. Movement: Flexion-adduction-exorotation. Ask the patient to watch every movement of his hand. 3) Pelvic: Position the patient on his side at the edge of the bed, the therapist is behind the patient, the therapist's hands are right on the patient's pelvic (SIAS).Movement pattern: Anteriordepression; anterior-elevation; posterior-depression; posterior- elevation 4) Limbs Position the patient on the therapist's bed next to the patient. The therapist's grip is on the patient's knees and instep, directing the patient to open his legs outward. i. Exercises to strengthen the abdominal muscles while sleeping on your side The activity of sleeping on your side from sleeping on your back requires good abdominal muscle strength. In the condition of hemiparesis ec stroke, the patient has difficulty rolling over to the healthy side from a supine sleeping position. This is caused by decreased strength of the head, scapula and pelvis and spasticity in trunk extension. For this reason, the exercises that can be done are: 1) Sleeping position on the healthy side Position the patient on his side at the edge of the bed, the therapist's position is right behind the patient, the therapist's hands are on the pelvic and scapula, then the therapist pulls the scapula and pelvic towards the back and the patient is instructed to pull the scapula and pelvic towards the front against the pressure of the therapist. 2) Sleeping position half on your side to the healthy side Exercise movements in an inclined position are performed in a half-inclined position. 2. Recovery Phase Physiotherapy Intervention Spastic changes in tone (hypertonus) can appear gradually and vary in degree from mild to severe. In the spastic phase, movements begin to appear in some limbs, both upper limbs and lower limbs, with a typical synergistic pattern due to abnormal muscle tone (hypertonus) in one part of the group, resulting in an imbalance between agonist and antagonist muscles which inhibits selective movement. In this phase, the principle of physiotherapy is to reduce spastic muscle tone towards normal, activate muscles that function as stabilization and teach selective movements with continuous sensory stimulation as a facilitation effort: a. Scapula Control is active The patient sleeps on his side with his back to the physiotherapist and on the edge of the bed Movement pattern: Anterior depression (on the weak side) of the scapula anteriorly while being instructed to deflate the stomach. b. Pelvic control (pelvic control) 1) The patient's position is tilted on the bed, the therapist is behind the patient. Therapist's hands on the Spina Anterior Superior Iliaca (SIAS) area. Movement pattern: Anterior pelvic elevation (weak side) 2) Bridging The patient's position lies on his back and his knees and hips are bent 90 degrees. The therapist's hands fixate both pelvis. The patient is instructed to lift the pelvis until it is off the mattress. The therapist facilitates keeping the pelvis symmetrical. c. Upper and lower limb exercises. 1) Upper limbs The patient sleeps on his back, the therapist is on the patient's weak side. S tarting position : Extension-adduction-endorotation. Movement pattern: Flexion-abduction-exorotation. Instructions: Lift - turn out - open sideways. Flexion-abduction-exorotation movement pattern. 2) Lower limbs (PNF) The patient sleeps on his back, the therapist is on the patient's weak side. Starting position: Extension-adduction-endorotation. Movement pattern: Flexion-abduction-exorotation. Instructions: Lift-turn-open sideways. d. Practice sitting on the healthy side of the body Exercises are performed from the patient's position sleeping on the healthy side. Steps taken: 1) The patient is first instructed to raise the head. 2) The patient raises his body with the help of the healthy arm pressing on the bed until the body is lifted and the elbow of the healthy arm supports the body weight. 3) The patient is instructed to maintain the body position when the elbow of the healthy arm is supported, and the therapist gives a light push to the patient's shoulder backwards to train the patient's balance. 4) The patient is instructed to raise the body to a sitting position while straightening the elbow of the healthy arm as assistance and then asked to maintain the sitting position so as not to fall. e. Correct sitting posture Ask the patient to sit with both hands upright on the thighs, head straight forward without looking down and shoulders symmetrical and maintain this position for at least 30 seconds. 2) Dynamic balance (a) Position the patient sitting at the edge of the bed with feet flat on the floor. Ask the patient to raise his arms alternately, right and left, and the patient tries to maintain his posture in an upright position without swaying. (b) Ask the patient to tilt his body to the right and left and maintain posture so as not to fall