A Pragmatic approach to the development of a ...

[Research Report]

A Pragmatic approach to the development of a therapeutic protocol for enhancing motor control and coordination in chronic stroke patients – Review Study Shashank Ghai1*, Ishan Ghai2

Abstract: This review shall help to present an ideological therapeutic practice for management of patients suffering from stroke especially with chronic duration. This incorporates evaluating, execution and arrangements of different treatment and maneuvers applied in the treatment, in a significant order, so as to enhance and produce early rehabilitation. Various rehabilitative techniques for instance relaxation technique, inhibition technique, facilitation technique, mobilization maneuvers, proprioceptive facilitation techniques in a specific pattern, might produce an efficient and viable rehabilitative approach. Formulating a functional exercise regime, post initiation of these techniques, shall produce effective results, adding to the benefits in a better rehabilitation process. In addition to these techniques, a regular motivating approach with the patient, repetition of such techniques and exercise regimes on regular

[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]

Page 41

[Research Report] intervals and encouraging the patient to perform the given activities, while verbalizing them, are very important and has been found to be extremely effective. The application of manual techniques, under guidance of a highly skilled physical therapist shall have proven productive results, extremely beneficial in rehabilitating stroke patients. Keywords:

Therapeutic,

Maneuvers,

Relaxation,

Inhibition,

Facilitation,

Mobilization,

Proprioceptive

Introduction:

a sudden initiation of neurological signs worst

and symptoms as a result of interruption in

neurological ailment ever encountered, it

blood supply to definite regions in the

affects both the physical as well as the

brain. A stroke arises as a result of

mental aspect of the patient.. If this

cerebrovascular mishaps, which could be

condition is not attended immediately the

characterized as Ischemic or hemorrhagic.

patient is left with severe physical and

Roughly

mental disabilities, fully dependent on the

cerebrovascular mishaps are as a result of

family /society for its care. Further, as the

Ischemia, twenty percent occur as a result

time passes, the physical and mental

of hemorrhage and the remaining ten

condition of patient further deteriorates1. A

percent are of idiopathic origin3-5.

majority of patients fail to recover and lead



Stroke

is

one

of

the

many

a normal healthy life. The stroke affects

Ischemic CVA - It arises from hypoxia

of a stroke and occurs due to hindrance

neurological disability suffered by the

in one of the vital cerebral arteries

adult population throughout the world. It is

middle, posterior and anterior cerebral

the prime cause for about twenty five

arteries or their minor perforating

percent of all accounted deaths in the

branches to deeper parts of the brain.

developed nations; also it is one of the

They may happen as an outcome of

major causative factors for permanent

thrombosis and those that resulted

disabilities, most prevalent among the

from a stroke, every year. Stroke stands for

all

blood supply. It is most common cause

be one of the most common reasons of

above the age of forty five years suffer

of

brain tissues as an outcome of scarce

on the entire family. Stroke is depicted to

hundred people, out of every one lakh,

percent

or diminished oxygen supply to the

not only the patient, but also has a bearing

elderly population2. Approximately four

seventy

from an embolus. 

Hemorrhagic CVA – This condition is triggered

by

subarachnoid

hemorrhage,


intra-cerebral, arterial-

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[Research Report] venous deformity and lacunar infarcts

develops

characteristic

patterns

of

8

resulting from irregular bleeding from

hypertonicity or spasticity . Spasticity, a

rupture of a cerebral vessel. The

motor

incidence of the hemorrhage is less

exaggerated deep tendon reflexes and

among people those are younger than

increased muscle tone. It develops from

forty five years of age, furthermore the

hyper-excitability of monosynaptic stretch

chances of stroke grows after sixty five

reflex.

years. The combined cause of intra

spasticity

cerebral hemorrhage includes vessel

resistance to passive stretching of the

malformation and changes in the

involved muscle, hyper-reflexia of deep

integrity of cerebral vessels brought on

tendon

by the properties by hypertension and

extremities in flexion or extension, co-

2, 5

ageing

.

disorder

is

Clinically,

characterized

the

presents

reflexes,

patient

with

by

with

increased

posturing

of

the

contraction of muscles, and stereotypical

Necessity for mobility is the key reasons

movement patterns which are called

for admitting of a patient to an In-patient

synergies. Other impairments may include

restoration department post stroke. A lot of

Sensory

the exertion is engaged in the patients to

impairments,

retain the ability to walk at least in the

respiratory impairments, Bowel bladder

7

home, prior to their discharge . Despite of these efforts majority of the survivors with initial paralysis of the leg do not retain the normal gait pattern, and roughly all other survivors are unable to walk without full physical assistance. The primary clinical manifestation in patients following stroke, is the spectrum of motor problems resulting from damage to the motor cortex. Initially, a patient may present with a state of low muscle tone or flaccidity. Flaccid muscles lack the ability to generate muscle contractions and coordinate movements. This condition of relative low muscle tone is usually transient, and the patient soon

impairments,

Communication

orofacial

impairments,

dysfunction etc9. Objective of Study

The objective of the review study is to enhance the rehabilitation process of a patient suffering from chronic stroke, specifically aiming towards for their speedy motor control and co-ordination10. Our effort shall be conceptualize an ideal exercise regime accompanied by various maneuvering

techniques,

approach

contributing a bit towards easing the suffering of stroke patients, expedite recovery leading to early rehabilitation, thereby paying back for betterment of our society2.


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[Research Report] Relaxation Therapy Maneuvers:

techniques are found to be most effective

Relaxation techniques (Diagram 1.0) are

in case of patients presenting with

exceptionally beneficial for promoting

spasticity8.

relaxation in the patients affected by

implemented in order to attain a lower

6

Various

methods

can

be

chronic stroke . The relaxation technique

tone. The main emphasis is on reflex

helps in reducing the mental stress the

inhibiting

patient suffers whilst he/she is affected by

development of righting and equilibrium

stroke;

the

reactions and the use of key points of

confidence and determination of a patient

control. Also, inhibition of muscle groups

it

helps

in

alleviating

7

patterns

of

activity,

the

towards the treatment .

by influencing the bias placed on muscle



It helps in reducing the spasticity the

spindles through the tendons of Golgi

patient

organ10.







encounters

as

a

clinical

manifestation of chronic stroke.

The goal of the therapy is to oppose the

It helps in reducing the stiffness, which

irregular postural reflex, the actions and

also serves as a clinical manifestation

also to facilitate normal motor patterns and

and arises as a result of immobilization

balance

reactions11.

and sustained spasticity.

activities

mainly

It helps in relaxation and strengthening

segments is important if the desired

of the respiratory component which

outcome is to change the tone more

also

distally. Movement must be superimposed

is

affected

as

a

-clinical

Commencing in

proximal

the body

manifestation of chronic stroke.

on the improved tonal state if carryover is

The relaxation component of the

to occur. Prolonged application of ice

therapeutic protocol can include deep

might be beneficial. Weight bearing is

breathing

another

techniques,

positioning, passive

appropriate

inhibitory

technique.

relaxed

Positioning a limb in an inhibitory pattern

suspension

is extremely important; Air splints could

hydrotherapy, movements,

useful

also

techniques etc.

be

employed

to

assist

with

positioning, tone reduction and sensory Inhibitory Therapy Maneuvers:

The further hypothesis of the proposed study

includes

implementation

and

awareness12, 13. Mobilization of Joints:

execution of Inhibitory techniques and

For refining the range of motion of the

positions

patient’s joint can be accomplished by use

(Diagram

2.0).

Inhibitory

of mobilization maneuvers, it also terms to [Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]

Page 44

[Research Report] benefit as mobility exercises. In addition to

The

this, mobilizing the joints in the direction

implemented by stimulating:

of facilitation



of Proprioceptive, neural

facilitation

Cutaneous

methods

receptors:

can

Quick

be

light

and muscular parts patterns has proven to

brushing, application of ice, brisk

be useful14. The range of the particular

stroking by manual touch, tapping etc.

grades of mobilization should be taken

Muscle

very carefully. These manipulations should

unexpected stretch, slow full stretch,

only be executed by a skilled physical

vibrations

therapist.

weight bearing and an approximation

spindle

receptors:

(Mechanical

Quick

vibrators),

of joints etc also executing Primitive Facilitation Therapy Methods

(spinal) or tonic (brain stem) reflexes

It is extremely important to perform facilitation techniques to prepare the patient for the performance of functional activities15. The facilitation techniques are based on the known physiological facts that skeleton-motor units with different enzyme profiles play a distinct role in the control of movement and posture, and how afferent input can influence different controls on these in the Central nervous system16. The Selection of appropriate afferent stimuli is important to exploit the potentiality of tissues to change at the molecular level. This facilitates attainment of motor goals, and helps to prevent perpetuation

of

abnormal

influences

imposed by pathological changes. These are implemented in order to reduce the protective muscle spasm, increase soft tissue range, and elicit normal postural reactions and to strengthen and activate the 17

weaker muscle groups .

are extremely beneficial18. Proprioception, Neural and Muscular Facilitation and Development:

Proprioception is well-defined as the perception of oneself in harmony to the atmosphere

(Diagram

3.0).

The

proprioceptive facilitation methods depend largely

on

stimulation

of

the

proprioceptors (special position sensing receptors) for growing the request made on the neuromuscular mechanism to attain and facilitate its reaction19. Management by these methods aims to summate the effects of facilitation to increase the reaction of the neuromuscular mechanism. Proprioceptive stimulation (Diagram 4.0) is mainly instigated to increase the demands made by intentional efforts, the initiation of some reflex reactions and physiological principles concerned with the interaction of antagonistic muscles are used in a few methods20. Resistance and


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[Research Report] stretch are employed manually to muscles

An exercise regime (Diagram 4.0 – 8.0)

occupied to accomplish patterns of mass

involving simple practical activities of

movement and active instructions provide

day-to-day life is exceptionally vital for

encouragement to the patient’s intentional

teaching normal control and coordination

effort. Maximal resistance is measured to

to a patient27-29. The simple goal is to

be the most vital means for stimulating the

establish control of movement; such that

proprioceptors21. The methods concerned

the patient is able and self-assured in his

with its application are rudimentary.

skill to carry out those activities which are

Methods of emphasis are intended to

vital for freedom in day-to-day life. The

correct

the

intact sensory mechanism of sight, sound

neuromuscular feature of the body22. The

and touch can be utilized for prompt

numerous methods are cited as follows:

results29-31. The additional significant vital



incoordination

within

Movement on patterns (Diagram

issues are attentiveness, accuracy and

5.0, 6.0, 7.0, 8.0).

replications. The rapidity, replication and



Manual contact.

respite periods must be allotted rendering



Stretch stimulus and stretch reflex.

to the patient’s potential. The complication



Traction and approximation

in



Spoken instructions to the patient

progressively through the course of the



Consecutive

therapy.

timing

of

muscle

exercise

designs

should

intensify

contractions.

Other Employable Approaches:



Resistance.

Motivation is an extremely imperative



Reinforcement.

feature of the therapy. It should be

These procedures of the therapy, gain the

instigated

maximum amount of action which could

recovery. A patient suffering from stroke,

be accomplished at each voluntary effort

is not only affected physically, mentally

and the maximum possible number of

but emotionally also. The low down

replications of the activity to stimulate the

sentiment, subtle moral and breakdown is

response23-26. This procedure demonstrates

very common in such patients. It plays a

to be an effective means of gaining and

noteworthy

hastening the patient’s recovery.

rehabilitation of these problems. The

Employable Exercise Regimes:

during

role

the

in

progression

managing

of

the

therapists aim should be to not just employ physical exercise, but also to build an sensitive rapport with the patient, boosting


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[Research Report] their morale and confidence of patients,



First and foremost the implementation

enabling better recovery and preparing

of the Relaxation techniques shall be

them to engage towards future recovery

extremely useful for reducing the

tasks30.

developed

Application of patient friendly

and

stiffness

among the chronic stroke patients3.

methods where the Physical therapist who remains consulted by a sociologist, clinical

spasticity



Followed by this regime, introduction

psychologist, furthermore, he/she conducts

of inhibitory techniques shall prove

a method on various groups of patients,

exceptionally beneficial, as deploying

inspiring them to together speak their

post relaxation techniques to the

actions and execute the actions as they do

patient, the developed spasticity and

so,

stiffness could be effectively reduced.

originally

comparatively

beginning

simplified

with

patterns

of

Inhibitory

techniques

implemented

exercise and during the advanced stages of

against the synergy patterns would not

recovery, continuing to more compound

only help in reducing the developed

and practical activities31. Replications of

spasticity, but also would help in

regime of actions, over sufficient periods

developing

of time, is anticipated, to influence change in muscle unit type so that they are more

movements 

32

the 32-33

functional

.

Later, with the introduction of the

suitable to the demands made upon them .

Facilitation

For example, the execution of Frenkel

Mobilization techniques on patients,

movements accomplished at consistent

might prove to be very useful, as the

intermissions with aggregated complexity.

manual mobilization when applied to

techniques

and

the

the affected joints, helps improve the

Probable outcome of this approach:

certain

range of motion at the patient’s joint,

techniques have been conceptualized for

in addition to maintaining the muscle

speedy rehabilitation of chronic stroke

mobility (as the already relaxed spastic

patients.

and stiff muscles would allow the joint

For

the

proposed

Based

research,

upon

my

practical

to move) 34.

experience in treating stroke patients, In this

review,

we

have

formulated

a



The Facilitation techniques on the

Hypothesis, by deploying various physical,

other hand might prove to be effective

sociological & psychological techniques to

when applied with the mobilization

rectify symptomatic manifestations, in the

techniques

patient’s, on one-to-one basis.

spasticity would exert less stress on the

because


the

reduced

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[Research Report]



opposite muscle group and hence its

touch, and hearing, to develop the

implementation would help develop

coordination. The replications are very

and strengthen the weaker muscle

significant; the intricacy, the sessions

groups35.

of exercise must be preceded slowly as

Proprioceptive drills are valuable at

the condition of the patient recovers36-

advanced phase, as during this period

39

the spasticity is reduced; after the



Replication of these procedures on a

mobilization, the range of motion

consistent

increases

significant.

and

the

facilitation

techniques help stimulate the weaker muscle(s)

hence

performing



the

proprioception at this stage might prove

to

be

most

is

extremely

Encouraging the patient at regular

treatment is essential. 

Dynamic involvement of the patient in

in

the management is extremely valuable,

improving the coordination patterns

furthermore making the patient speak

within the affected parts.

effective

interval

intervals during the course of the

functional activities that improve the



.

36

the

movement

accordingly

whilst

Presenting plain, functional exercise

accomplishing

regimes at this stage is valuable; the

treatment will deliver supplementary

main

benefits40-43.

module

unharmed

is

sensory

to

employ

aspects

the

2.

3.

4.

5.

throughout

the

vision,

References 1.

it

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[Research Report] 36. Knott, M. Neuromuscular facilitation in the treatment of rheumatoid arthritis. Phys Ther, 1964; 44:737-739. 37. Sady, SP, Wortman, M, and Blanke, D. Flexibility training: Ballistic, static, or proprioceptive neuromuscular facilitation? Arch Phys Med Rehab, 1982; 63: 251. 38. Scholz, JP, Campbell, SK. Muscle spindles and the regulation of movement. Phys Ther, 1980; 60:1416-1423. 39. Voss, DE. Everything is there before you discover it. Phys Ther, 1982; 62(11): 1617-1624. 40. Wardlaw, C. Evaluation and treatment of the movement system with proprioceptive

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Diagram 1.0


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[Research Report]

Diagram 2.0

Diagram 3.0


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Diagram 4.0

Diagram 5.0

Diagram 6.0


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Diagram 7.0

Diagram 8.0

2.

Corresponding Author *Corresponding Author Dep’t. Of physiotherapy, Savig Healthcare Clinic New Delhi, India [email protected] Contact +9111- 47541414 [email protected] 1. Physiotherapist, Savih Healthcare Clinic, New Delhi, India. Research Scholar, Jacobs University gGmbh, Bremen, Germany. © 2014 PGIP. All rights reserved.

Available online at www.pgip.co.uk/jopsm

Postgraduate Institute of Physiotherapy


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