[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]
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[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,
[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]
intra-cerebral, arterial-
Page 42
[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
[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]
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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
[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]
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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
[Journal of Physiotherapy & Sports Medicine][Volume 3][Issue 1][June 2014]
the
reduced
Page 47
[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,
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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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Diagram 2.0
Diagram 3.0
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[Research Report]
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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