Therapists select interventions based on an accurate examination of existing impairments, activity limitations, and goals. Functional, task-specific training is the mainstay of therapy and is designed to assist patients in regaining control of functional movement patterns. Improved motor control and strength of the trunk and limbs, with an emphasis on the more involved side, is achieved through specific reeducation strategies. Intense practice both during therapy sessions and outside of therapy is needed to effect meaningful change. The therapist needs to incorporate motor learning principles and behavioral shaping techniques to effectively support learning. It is also important to create an environment that supports learning and provides the typical challenges of everyday life. In cases of severe deficits, limited recovery, and/or multiple co-morbidities, compensatory training strategies may be necessary to promote resumption of function using the less involved extremities and alternate movement patterns. Strategies to improve motor function are discussed fully in Chapter 10.
Evidence-based practice (EBP) promotes the use of current best research evidence along with individual clinical expertise in order to reach informed decisions about patient care. EBP allows therapists to identify the best (most effective) techniques and to take responsibility for evaluating their practice on an ongoing basis. Studies designed to delineate differences between exercise approaches for the patient with stroke (e.g., neuromuscular reeducation and facilitation approaches [neurodevelopmental treatment (NDT), proprioceptive neuromuscular facilitation (PNF)], motor relearning program, functional training) have often failed to demonstrate clear superiority of one approach over another.44,46,114,115,116,117 Conclusions from Cochrane reviewers state, "There is insufficient evidence to conclude that any one physiotherapy approach is more effective in promoting recovery of lower limb function or postural control following stroke than any other approach. We recommend that future research should concentrate on investigating the effectiveness of clearly described individual techniques and task-specific treatments, regardless of their historical or philosophical origin."44, p. 4 Many studies are subject to methodological flaws. For example, studies used small sample sizes, failed to include a control group or to control for experimenter bias and co-interventions, and/or utilized poorly defined treatments and/or inappropriate outcome measures. There are a limited number of large, multicenter, randomized controlled trials (RCTs) that offer clinicians a higher level of confidence. Some will be discussed later in this section (e.g., STEPS trial, LEAPS trial, EXCITE trial). Evidence concerning the effectiveness of task-oriented training is presented in Chapter 10, Box 10.1, and Box 15.9 (later in this chapter). Important conclusions to be drawn from these studies are that (1) collectively they provide consistent evidence for the beneficial effects of physical therapy when compared to no treatment or placebo control; and (2) studies on task-oriented training have yielded positive results in terms of improving locomotor function (post-stroke locomotor training studies) and UE function (CIMT training studies). Specificity of training and increased intensity of training are important factors in these positive results.
It is important to point out that there is no one intervention optimal for all patients with stroke. Because patients with stroke are a diverse group with variable levels of function, interventions must be carefully selected based on individual abilities and needs. Therapists need to select interventions that have the greatest chance of successfully remediating existing impairments and promoting functional recovery. The choice of interventions must also take into consideration a number of other factors, including phase of post-stroke recovery (acute, postacute, chronic), age of the patient, number of co-morbidities, social and financial resources, and potential discharge placement. Early emphasis on improving functional independence provides an important source of motivation for both the patient and family.
Strategies to Improve Motor Learning
Motor skill learning is based on the brain's capacity for recovery through mechanisms of reorganization and adaptation. An effective rehabilitation plan capitalizes on this potential and encourages active participation—the patient must be fully engaged. Activities are selected that are meaningful and important to the patient. Optimal motor learning can be promoted through attention to a number of factors, most importantly, strategy development, feedback, and practice. Carr and Shepherd118 describe many of these strategies in their book A Motor Relearning Programme for Stroke.
The therapist first assists the patient in learning the desired task (cognitive stage). Explicit verbal instructions are used to direct the patient's attention to the task. More specifically, critical task elements and successful outcomes are identified. The desired task is demonstrated at the ideal performance speeds. The patient then begins to practice. If the task has a number of interrelated steps, practice of component parts may precede practice of the whole task. It is important, however, not to delay practice of the integrated task because this may interfere with effective transfer of learning. The therapist should give clear, simple verbal instructions and not overload the patient with excessive or wordy instructions. There is some evidence to suggest that providing excessive information about the task can be disruptive to learning, especially for patients with MCA stroke involving the sensorimotor cortex. This interference may block formation of the implicit motor plan.119,120 Correct performance should be reinforced and intervention provided when movement errors become consistent. Active participation is essential for learning; there is no learning with passive movements. Practicing the movements on the less affected side first can yield important transfer effects.
Mental practice or mental rehearsal is the systematic application of imagery techniques for improving performance and learning. The patient is instructed to visualize the movement and imagine himself or herself functionally using the affected limb. Mental practice can be facilitated through the use of audiotapes and has been successfully combined with physical practice to enhance UE recovery121 and LE recovery and walking ability (gait speed) in patients with stroke.122 When used in an RCT of early post-stroke patients, recovery of hand movements was not superior using motor imagery than with an equally intense conventional therapy.123
As practice progresses, the patient is asked to self-examine performance and identify problems, specifically, what difficulties exist, what can be done to correct the difficulties, and what movements can be eliminated or refined. If a complex task is practiced, the patient is asked to identify if the correct components were performed, how the individual components fit together, and if they were appropriately sequenced. If the patient is unable to provide an accurate assessment of problems, the therapist can prompt the patient in decision making using guiding questions and utilize demonstration to help identify problems. For example, if the patient consistently falls to the right while standing, questions can be directed toward this problem (e.g., "In what direction did you fall?" "What do you need to do to prevent yourself from falling?"). The patient is thus actively involved in developing task analysis and problem-solving skills leading to improved ability to self-correct movements. These skills are essential in ensuring independence in the home and community.
Feedback can be intrinsic (naturally occurring as part of the movement response) or extrinsic (provided by the therapist). During early motor learning the therapist provides extrinsic feedback (e.g., verbal cueing, manual cueing), and manual guidance to shape performance. It is important to monitor performance carefully and provide accurate feedback. The patient's attention should be directed to naturally occurring intrinsic feedback. During early intervention visual inputs are critical for motor learning. This can be facilitated by having the patient look at the movement (a central concept of PNF).124,125 During later learning (associative phase), proprioception becomes important for movement refinement. This can be encouraged by early and carefully reinforced weight-bearing (approximation) on the more affected side during upright activities. Additional proprioceptive inputs (manual contacts, tapping, stretch, light tracking resistance, antigravity postures) can be used to improve feedback and stimulate learning. The patient should be encouraged to "feel the movement" while learning to distinguish correct movement responses from incorrect ones. Surface EMG biofeedback can be used to provide augmented feedback. Exteroceptive inputs (light rubbing, stroking) may be used to provide additional sources of sensory inputs, particularly where distortions of proprioception exist. As treatment progresses, the emphasis again shifts from extrinsic to intrinsic feedback and to self-monitoring and self-correcting movement responses. Great care must be taken to avoid dependence on the therapist (i.e., the patient is only able to move with the therapist's manual or verbal assistance) by providing decreasing amounts of physical guidance and augmented feedback. This requires careful consideration during each treatment session. Therapists should allow the patient adequate time for introspection about the movements and available feedback.
The use of a mirror can be an effective adjunct for some patients to improve motor function using visual feedback. Mirror therapy (MT) is a therapeutic intervention that focuses on moving the less impaired limb while watching its mirror reflection. A mirror is placed in the patient's midsagittal plane, presenting the patient with the mirror image of his or her less affected limb as if it were the hemiparetic limb. It was first introduced by Ramachandran et al126 for individuals with arm amputation. For patients with stroke, MT has been shown to improve LE recovery and ankle dorsiflexion.127 MT has also been shown to improve UE recovery and distal motor function and recovery from hemineglect.128,129 In these studies, both the mirror groups and the control groups also participated in a conventional stroke rehabilitation program. It is important to note that use of mirrors is contraindicated in patients with marked visuospatial perceptual impairments.
Practice, practice, and more practice is essential for motor skill learning and recovery. The therapist needs to organize the patient's therapy session to ensure optimal practice. Blocked practice (constant repetition of a single task) is used to improve initial performance and motivation, especially for patients with disorganized movements. Most hospitalized patients also initially require a distributed practice schedule with adequate rest periods owing to limited endurance as both physical and cognitive fatigue can result in decreased performance. The patient should be encouraged to self-monitor practice sessions and recognize when fatigue may be setting in and rest is required. The therapist needs to progress the patient to variable practice (practice of more than one task within a session) using a serial or random order as soon as possible. Variable practice improves performance and results in better retention of learned skills and improved ability to adapt to changing task demands. Patient, staff, and family efforts should be coordinated to ensure continued and consistent practice during off-therapy times.
Careful attention to the learning environment will also yield important therapeutic gains. Distractions should be reduced and a consistent and comfortable environment provided in which the patient can learn. For many patients with stroke and cognitive/perceptual deficits, this will initially be a closed environment with limited distractions. Later the environment can be varied, providing an appropriate level of contextual interference. Thus the patient is progressed toward performing the same skill in a more open environment, with variable and real-life challenges. The addition of Easy Street Environments to many rehabilitation centers provides an important tool to simulate community environments.
Motivation is key to successful learning. The patient should be fully involved in collaborative goal-setting from the beginning and continually reminded of the goal, the task, what progress has been made, and the expected outcomes. Treatment sessions should include positive experiences, ensuring the patient experiences success in therapy and instilling self-confidence. Beginning and ending the therapy session on a positive note (a successful activity) is a helpful strategy. Self-efficacy ratings and summary comments can be used to monitor progress (e.g., "What successes did you achieve in therapy today?"). Supportive strategies should be discussed with family and caregivers. Finally, the therapist needs to continually communicate support and encouragement. Recovery from stroke is an extremely stressful experience that will challenge the coping abilities of both patient and family.
Interventions to Improve Sensory Function
Patients who have significant sensory impairments may demonstrate impaired or absent spontaneous movement. The more the patient can be encouraged to use the affected side, the greater the chance of increased awareness and function. Conversely, the patient who refuses to use the hemiplegic side contributes to the problems imposed by lack of sensorimotor experience. Without attention during treatment, this learned nonuse phenomenon can contribute to further deterioration.130
Multiple interventions for UE sensory impairment after stroke have been described. These can be categorized into sensory retraining or sensory stimulation approaches. Sensory retraining programs include use of mirror therapy (previously discussed), repetitive sensory discrimination activities, bilateral simultaneous movements, and repetitive task practice (e.g., sensorimotor integrative treatment with its focus on normalizing tone, practice of functional activity, and use of augmented sensory cues). Sensory stimulation intervention includes compression techniques (weight-bearing, manual compression, inflatable pressure splints, intermittent pneumatic compression), mobilizations, electrical stimulation, thermal stimulation, or magnetic stimulation. In a review of 13 studies, Cochrane reviewers48 found significant clinical and methodological diversity, limited RCT trials, generally small sample sizes with inadequate data, variability in outcome measures, and limited used of functional performance and participation outcome measures. They concluded there was insufficient evidence to support or refute the effectiveness of many of these interventions in improving sensory function. Limited evidence was found in support of the following:
Mirror therapy for improving detection of light touch, pressure, and temperature pain
Thermal stimulation intervention for improving rate of recovery of sensation
Intermittent pneumatic compression for improving tactile and kinesthetic sensation
The results of a systematic review of sensory retraining by Schabrun and Hillier131 were similar with additional support found for electrical stimulation interventions.
During functional training, the therapist needs to maximize weight-bearing and compression of the sensory deficient limbs. Approximation can be applied with the sensory-deficient UE weight-bearing in sitting or standing/modified plantigrade position and to the pelvis during standing activities. While sitting on a ball, the patient can practice bouncing. The compression and approximation that occur through the spine enhances activity in the postural extensors. During the application of sensory stimulation to the more involved limbs, the therapist directs the patient's attention and assists in shaping the patient's responses.132,133
A safety education program should be instituted early for patients, family, and caregivers to improve awareness of sensory impairments and ensure protection of anesthetic limbs. This is particularly important for preventing UE trauma during transfer and wheelchair activities.
Interventions to Improve Hemianopsia and Unilateral Neglect
Patients with hemianopsia or unilateral neglect demonstrate a lack of awareness of the contralesional side. The impairments are more pervasive in patients with neglect and in its most severe form (anosognosia) may extend to a total unawareness of the disability or the extent of the problems. These patients benefit from training strategies that encourage awareness and use of the environment on the hemiparetic side and use of the hemiparetic extremities. It is important to teach active visual scanning movements through turning of the head and axial trunk rotation to the more involved side. Cueing (e.g., visual, verbal, or motor cues) is used to direct the patient's attention. For example, a red anchor line can be taped on the floor and the patient directed to visually follow the line from one side to the other. Or a red ribbon can be attached to the patient's hemiparetic wrist and the patient directed to keep the red ribbon in sight. Scanning movements can also be stimulated using visual tracking tasks using a computer. Patients are given feedback about the success of their efforts and reinforcement for each successful performance (shaping). Imagery has also been shown to help (e.g., "Imagine you are a lighthouse beam; use your beam to sweep and scan the floor from one side to the other"). During therapy, the therapist stimulates and encourages active voluntary movements of the neglected limbs while encouraging the patient to look at his or her limbs while moving. UE exercises that involve crossing the midline toward the hemiparetic side (e.g., reaching activities or PNF chop or lift patterns) are important. Functional activities that encourage bilateral interaction are also valuable (e.g., pouring a drink and drinking from a cup; picking up an object with the more involved hand and placing it in the other; "dusting a tabletop" with a cloth held by both hands). The therapist needs to maximize the patient's attention by optimizing visual, tactile, or proprioceptive stimuli on the more affected side. These can include stroking, brushing, tapping, or vibrating the hemiparetic limbs. The therapist also needs to consistently reorient the patient as inattention develops. Patients with very low levels of arousal are likely to be less responsive to therapy efforts.134,135,136
Interventions to Improve Flexibility and Joint Integrity
Soft tissue/joint mobilization and ROM exercises are initiated early to maintain joint integrity and mobility and prevent contractures. Passive ROM (PROM), and AROM when possible, with terminal stretch should be performed daily in all motions. If a contracture is developing, more frequent ROM (twice daily or more) is necessary.
Positioning strategies are also important in maintaining soft tissue length (Box 15.8). Effective positioning of the hemiparetic extremities encourages proper joint alignment while positioning the limbs out of the abnormal postures typically assumed. The use of protective devices such as resting splints may be necessary. Coordination with staff, family, and caregivers is essential for long-term management.
Box 15.8 Positioning Strategies to Reduce Common Malalignments
Head/neck: Neutral and symmetrical; supported on pillow.
Trunk: Aligned in midline.
More affected UE: Scapular protracted, shoulder forward and slightly abducted; arm supported on a pillow; elbow extended with hand resting on a pillow; wrist neutral, fingers extended, and thumb abducted.
More affected LE: Hip forward (pelvis protracted); knee on a small pillow or towel roll to prevent hyperextension; nothing against the soles of feet. For persistent plantarflexion, a splint can be used to position the foot and ankle in neutral position.
Side-lying on Less Affected Side
Head/neck: Neutral and symmetrical.
Trunk: Aligned in midline; small pillow or towel can be placed under the rib cage to elongate the hemiplegic side.
More affected UE: Scapular protracted, shoulder forward; arm on a supporting pillow with elbow extended, wrist neutral, fingers extended, and thumb abducted.
More affected LE: Hip forward and flexed, knee flexed and supported on a pillow.
Side-lying on More Affected Side
Head/neck: Neutral and symmetrical.
Trunk: Aligned in midline.
More affected UE: Scapular protracted; shoulder forward; arm placed in slight abduction and external rotation; elbow extended, forearm supinated, wrist neutral, fingers extended, and thumb abducted.
More affected LE: Hip extended and knee flexed and supported by pillows. An alternative position is slight hip and knee flexion with pelvic protraction.
Sitting in an Armchair or Wheelchair
Head/neck: Neutral and symmetrical; head directly above pelvis.
Trunk: Spine extension.
Pelvis: Aligned in neutral with weight-bearing on both buttocks.
More affected UE: Shoulder protracted and forward; elbow supported on an arm trough or lapboard; forearm, wrist neutral, fingers extended, and thumb abducted (resting splint as needed).
Both LEs: Hips flexed to 90°, positioned in neutral with respect to rotation.
In the UE, correct PROM techniques require careful attention to external rotation and distraction of the humerus, especially as ranges approach 90° of flexion or more. The scapula should be mobilized on the thoracic wall with an emphasis on upward rotation and protraction to prevent soft tissue impingement in the subacromial space during overhead movements of the arm (Fig. 15.7) and to prepare for forward reach patterns. The use of overhead pulleys for self-ROM is contraindicated because of failure to achieve the above requirements for scapulohumeral movement. Full extension of the elbow is important because the majority of patients with stroke develop tightness in elbow flexors as a result of excess flexor spasticity. Normal length of wrist and finger extensors should also be maintained as tightness is typical in flexion. This can be achieved functionally through sitting, weight-bearing on the extended paretic UE with the wrist extended and fingers open and extended (Fig. 15.8). Edema and tonal changes may produce impingement with wrist extension. In this situation, the carpal bones should be mobilized before stretching at the wrist.
Range-of-motion exercises for the hemiparetic UE. The therapist carefully mobilizes the scapula during arm elevation.
Sitting, with extended arm support. The therapist assists in stabilizing the elbow and fingers in extension.
Strategies to teach patients safe self-ROM activities should be instituted early. Suggested activities include the following:
Arm cradling: The stronger UE cradles and lifts the more affected UE to 90° humeral flexion; the arm is moved into positions of horizontal abduction and adduction. Active trunk rotation is combined with the arm movements.
Table-top polishing: The more affected UE is positioned in humeral flexion with scapular protraction and elbow extension; both hands are positioned on a towel. The less affected hand moves the paretic hand by pulling on the towel (forward, and side-to-side). Trunk movements and ROM are optimized by placing the chair slightly back from the table.
Sitting, the patient leans forward and reaches both hands down to the floor. This position encourages forward flexion of the humerus with scapular protraction, and extension of the elbow, wrist, and fingers.
Supine, hands are clasped together and placed behind the head, the elbows fall flat to the mat. This activity should be considered only if scapula upward mobility is present. Hands clasped, self-overhead movements are contraindicated if scapulohumeral rhythm is lacking.
When sitting in a wheelchair, the patient's paretic UE can be positioned on an arm trough (shallow elbow/forearm support) attached to the armrest. The shoulder is positioned in 5° of abduction and flexion and neutral rotation; elbow in 90° flexion and slightly forward; forearm pronated; and hand in a functional resting position. Splinting the hand is also common. A volar resting (pan) splint positions the forearm, wrist, and fingers in a functional position (20° to 30° of wrist extension, metacarpophalangeal [MP] flexion 40° to 45°, interphalangeal [IP] flexion 10° to 20°, and thumb opposition). A resting splint is appropriate for nighttime use, allowing patients daytime use of their hand. In the presence of spasticity, tone-reducing devices can be considered (e.g., finger abduction splint, firm cone, spasticity reduction splint, or inflatable pressure splint).
As most patients regain some use of their LEs early in recovery, ROM techniques focus on individual patient needs with attention to several common areas of impairment. For many patients, voluntary movement in the foot and ankle is limited owing to plantarflexor spasticity and/or dorsiflexor weakness. Weight-shifting activities in modified plantigrade (forward shift stretches the plantarflexors) or prolonged static positioning using adaptive equipment (i.e., tilt table with toe wedges) can be used to gain range. Facilitation of active contraction of dorsiflexors can also be combined with stretching to provide reciprocal inhibition to plantarflexors. If synergistic influence is strong, the patient can be effectively positioned while supine on a mat with the paretic LE abducted off the side with knee flexed and foot flat on the floor or a stool. This position of hip abduction and extension with knee flexion serves to breakup synergistic dominance and position the limb out of the typical spastic scissoring posture. If the patient spends considerable time sitting in a wheelchair, care should be taken to stretch the hip flexors. If hip flexor contractures are allowed to develop, they can lead to increased difficulty with standing, transfers, and ambulation.
Interventions to Improve Strength
Muscle weakness is a major impairment after stroke and contributes to significant activity limitations (e.g., walking, sit-to-stand transfers, stair climbing, UE activities). Progressive resistive strength training has been shown to improve muscle strength in individuals with stroke,137,138,139,140,141,142,143,144,145,146,147,148,149 with no evidence of a detrimental increase in spasticity or reduction in ROM.137,138 Most studies have indicated improvements in function,138,142,143,145,149 although some have failed to demonstrate carryover to improved function.137 Specificity of training as well as variable intensities of training may explain this inconsistency.
Exercise modalities for strengthening include free weights, elastic bands or tubing, and machines (PRE, isokinetics). For patients who are very weak (less than 3/5), gravity-minimized exercises using powder boards, sling suspension, or aquatic exercise is indicated. Gravity-resisted active movements are indicated for patients who demonstrate 3/5 strength (e.g., arm lifts, leg lifts). Patients who demonstrate adequate strength in independent gravity-resisted movement (e.g., 8 to 12 repetitions) can be progressed to exercise using added resistance (e.g., free weights, bands, or machines). Ideally resistance training should occur 2 to 3 times a week; three sets of 8 to 12 repetitions per exercise should be used.24
Combining resistance training with task-oriented functional activities enhances carryover in terms of improving function (e.g., sit-to-stand transfers, partial wall squats [Fig. 15.9], step-ups, stair climbing while the patient is wearing weighted cuffs). Circuit training workstations can be used to maximize muscle training.145 Lifting free weights or using elastic bands places added demands for postural stability in sitting and standing and is an important element of training to improve postural control.
Partial wall squats using a small ball; the therapist assists in control of knee.
Many patients with stroke demonstrate poor hand function with no effective grasp. Specially designed gloves may be necessary to ensure maintained contact with exercise equipment (e.g., leather mitts with Velcro®, wrist cuffs). Patients with impaired sensation are at increased risk for injury and should be monitored closely. Patients with postural deficits should be safely positioned to prevent falls (e.g., stable seat, corner standing while lifting free weights).
In determining a safe exercise prescription, it is important to remember the high incidence of hypertension and cardiac disease in patients with stroke. High-intensity strengthening exercises (sustained maximal effort) is generally contraindicated in patients with recent stroke and unstable BP. Isometric exercise that is accompanied by the Valsalva maneuver and dangerous elevations in BP is also contraindicated. Dynamic exercises performed in an upright position (sitting) produce less elevations in BP than recumbent/supine exercises. For patients at risk, submaximal protocols using low-intensity exercises (e.g., 30% to 50% of maximal voluntary contraction) are appropriate for initial exercise. Varying the exercises is also an effective strategy to reduce cardiovascular risk. The therapist needs to ensure that warm-ups and cool-downs are adequate and the overall exercise progression is gradual.
Interventions to Manage Spasticity
Patients who demonstrate spasticity can benefit from interventions designed to manage the effects of spasticity (immobility, soft-tissue contracture, and deformity). These include early mobilization and daily stretching to maintain the length of spastic muscles and soft tissues and promote optimal positioning.150 It is important to note that the methodological quality of research studies in this area is diverse and not well controlled, and available evidence about the effectiveness of stretching is inconclusive.151,152 The technique of rhythmic rotation, a manual technique that incorporates slow gentle rotations of the limb while progressively moving the limb into its lengthening range, can be effective in gaining initial range.153 Once full range is achieved, the limb is positioned in the lengthened position. For example, the shoulder is extended, abducted, and externally rotated with the elbow, wrist, and fingers extended. The hand is positioned in weight-bearing to the patient's side (see Fig. 15.8) and maintained for several minutes. The benefits of sustained stretching include relaxation through mechanisms of autogenic inhibition. In sitting, slow rocking movements can be added to increase relaxation effects from influences of slow vestibular stimulation. Spasticity in the quadriceps can be similarly inhibited through prolonged positioning and weight-bearing in kneeling or quadruped positions. A reduction in truncal stiffness can be promoted using techniques of rhythmic rotation or rhythmic initiation combined with axial trunk rotation (e.g., in side-lying, sitting or hook-lying, segmental trunk rotation).153 PNF upper trunk patterns (chopping or lifting) that emphasize rotational movements of the trunk can also be effective in maintaining range and reducing trunk stiffness.125 Side sitting on the hemiparetic side provides sustained stretch to the spastic side flexors. The patient, family members, and caregivers should be taught safe ROM and stretching techniques.
Active exercise should focus on the activation of the weak antagonist muscles using slow, controlled movements. Local facilitation techniques (e.g., stretch, tapping, light resistance) can be added to enhance the action of very weak antagonist muscles. Contraction helps reduce agonist tone through the effects of reciprocal inhibition. Thus, in the UE, efforts are directed toward active contractions of the elbow extensors in the presence of flexor spasticity, whereas in the LE efforts are directed toward active contractions of the knee flexors with extensor spasticity. It is important to remember that reciprocal relationships may not be within normal ranges, particularly in the presence of strong spastic co-contraction. Excessive effort should be avoided because it can have a negative effect on spasticity. Soothing verbal commands and cognitive relaxation techniques (mental imagery) can be used to provide an overall calming influence and generally relax tone while pain has the opposite effect.
Modalities can be used to treat spasticity. These include the application of cold, massage, and electrical stimulation. Cold slows nerve conduction and decreases muscle spindle activity. These factors can lead to a temporary reduction of tone. Cold can be applied with ice packs or ice massage (duration 10 to 20 minutes) or using vapocoolants. The effects of cold are short-lived, generally lasting for about 20 to 30 minutes. Functional electrical stimulation (FES) can be used to target the weak antagonist muscles (e.g., peroneal nerve stimulators) and works to decrease tone through the effects of reciprocal inhibition. FES has been used with some success to decrease tone during the treatment time.152
Orthotic devices can be used to maintain the spastic muscle in its lengthened position and help decrease hypertonia and increase or maintain PROM. These include inflatable pressure splints,154 static or resting splints, and serial casts.155,156 Air splints can also help control unwanted synergistic movements and stabilize limbs during early weight-bearing activities (e.g., sitting, modified plantigrade). Patients with a flaccid, hypotonic limb may also benefit from the use of pressure splints to provide sensory input and initial stabilization. Long or full limb pressure splints also assist in controlling edema, a common problem of paralyzed limbs. Positioning the splinted limb in elevation can assist in reducing edema.
Interventions to Improve Movement Control
Activities that promote voluntary movement control, postural control, and functional use of the extremities are the primary focus of initial movement training. Patients with stroke typically present with loss of dissociated or fractionated movements with obligatory synergy patterns. For example, coordinated grasp and manipulation are lost as the fingers respond with strong flexion when lifting the arm results in elbow flexion with flexion, abduction, and external rotation of the shoulder. Interlimb and intralimb control is also abnormal with movements of one limb linked to movements of the other through associated reactions. During initial training, the therapist needs to focus on dissociation of different body segments (the ability to isolate and move the different parts of the body or limb separately) and selective (out-of-synergy) movement patterns. For example, the more affected UE is stabilized in an extended weight-bearing position while the patient practices stepping movements in modified plantigrade position.
The linking together of the proper components of movement and the refinement of isolated control requires a great deal of concentration and volitional control. Movements that are performed too quickly or with too much force will be ineffective in producing the control needed. Thus, the therapist needs to instruct the patient to avoid excessive effort during movement. The therapist should aim for as much normalcy in movement as possible and select postures that assist the desired movements through optimal biomechanical stabilization and/or use of the optimal point in the range. As control develops, postures can be changed to more difficult ones that challenge developing control. For example, initial elbow extension can be first attempted in side-lying with the shoulder flexed to 90° (e.g., the patient pushes the arm forward, extending the elbow). The posture can then be changed to sitting, and finally standing.
The therapist may need to assist (guide) initial movement attempts or use facilitation techniques (e.g., stretch, resistance, electrical stimulation). Movements should shift to active control as soon as possible. Often the resistance of gravity acting on the body or slight manual resistance is enough to initiate or facilitate correct movement responses through proprioceptive loading.
Repetitive task-specific training is the main focus of the rehabilitation program. The tasks selected should be relevant and important to the patient (e.g., reaching and manipulation, walking, stair climbing). Normal function implies variability of movements. Muscles need to be activated in varied activities using varied types of contractions. All three types—eccentric, isometric, and concentric—are important to include in an exercise program. For the patient with stroke who demonstrates very weak movements, isometric and eccentric contractions should be practiced before concentric contractions because they utilize elastic elements and muscle spindle support more efficiently. For the same amount of tension, fewer motor units are required. Practice of functional tasks that utilize variations of contractions should also be implemented. For example, the patient who practices modified wall squats in standing is utilizing a sequence of eccentric (lowering), isometric (holding), and concentric (extending) contractions of the hip and knee extensors (Fig. 15.9). Weak muscles (typically antagonistic to strong spastic muscles) should be activated first in unidirectional movements. As control develops, exercises can shift to include slow active reciprocal contractions of agonist and antagonist muscles first in limited ranges, then in full range. This emphasis on balanced interaction of both agonists and antagonists is crucial for normal coordination and function. Proprioceptive neuromuscular facilitation patterns can be effective for the patient with limited voluntary control with its emphasis on normal synergistic patterns (e.g., D1 patterns), reversals of antagonists, and proprioceptive loading through light resistance.124,125 Excellent resources for exercise and training for patients with stroke can be found in the works of Carr and Shepherd,157 Davies,158,159 and Howle.160
Strategies to Improve Upper Extremity Function
Patients with MCA syndrome may exhibit severe sensory, motor, and functional impairments of the UE with limited recovery. These patients benefit from early mobilization, ROM, and positioning strategies, previously discussed in this chapter. Compensatory training strategies and environmental adaptations should be considered to maximize function. For patients who achieve some recovery of voluntary movement, training strategies should focus on repetitive, task-specific practice. UE training activities should be closely coordinated with the occupational therapist.
UE Weight-Bearing as a Postural Support
Postural shift toward the more affected side with weight-bearing on the extended arm and stabilized hand on a support surface is an important early activity to promote proximal stabilization and counteract the effects of excess flexor hypertonus and a dominant flexion synergy. Approximation can be used to increase activity of shoulder/scapular stabilizers and tapping can facilitate the elbow extensors. Weight-bearing activities are performed in sitting (see Fig. 15.8), modified plantigrade (Fig. 15.10), and standing positions. Control should progress from holding to dynamic stabilization activities. For example, the patient stabilizes with the more affected UE while performing weight shifts and functional tasks with the stronger UE (e.g., reaching). As previously mentioned, the more affected UE should also be recruited for postural assistance during functional training activities (e.g., pushing up from side-lying into sitting).161
Standing in modified plantigrade, both UEs extended and weight-bearing; the therapist assists elbow extension of the hemiparetic UE while providing approximation through the shoulder.
Task-Oriented Reaching and Manipulation
Patients with stroke have difficulty regaining control of scapular upward rotation and protraction, elbow extension, and wrist and finger extension necessary for forward reach and manipulation. Reaching and manipulation also requires accurate processing and use of visual–perceptual information. Patients with limited voluntary control can practice initial reaching in a supported position (e.g., side-lying with arm supported by therapist or on a powder board, sitting with the UE resting on a tabletop). The patient is encouraged to slide the hand forward over tabletop, recruiting shoulder flexors, scapular protractors, and elbow extensors. A cloth can be used to decrease friction effects as the patient practices wiping or polishing a table. The patient can also practice reaching forward and downward touching the floor. More advanced reaching activities include independent lifting and reaching forward (e.g., UE placed into a shirt sleeve), overhead, or sideward. A PNF D1 thrust pattern can be practiced (reverse thrust is contraindicated as the limb is moving into a flexion synergy pattern). Combining reaching with increased balance challenges in modified plantigrade or standing should also be incorporated. For example, the patient can practice pushing a ball side-to-side or forward-backward while standing in modified plantigrade (Fig. 15.11). Or in standing the patient can practice reaching to pick an object up off a shelf, a low stool, or the floor. Varying the height and distance reached, increasing the weight of objects held in the hand, or increasing the speed and accuracy requirements can increase difficulty. Substitution movements (e.g., trunk or head lateral movements) should not be allowed. Excessive shoulder elevation should also be discouraged.161
Standing in modified plantigrade with hemiparetic hand positioned on small ball; the patient practices rolling the ball from side-to-side; the therapist stabilizes the elbow and shoulder.
Meaningful task-oriented practice involving grasp and manipulation is important for stimulating recovery. Initial hand movements typically include gross grasp and release while advanced hand patterns (fine motor control) may not be present unless there is more advanced recovery. Voluntary release is generally much more difficult to achieve than voluntary grasp, and stretching/positioning and inhibitory techniques may be necessary to facilitate extension movements. Initial hand tasks can include using the more affected hand to stabilize (e.g., hand stabilizes paper while the stronger hand writes, hand stabilizes food while the stronger hand cuts) or holding a book with both hands for reading. The patient should be encouraged to use the weaker hand to assist in ADL (e.g., washing the upper body with a washcloth, bringing food to mouth). Forks, toothbrushes, and pens may need to have built-up handles for grasp. Task training should combine reach patterns with hand activity (e.g., picking sock off floor, reaching for an object off a shelf). Advanced hand activities include practice of wrist and finger extension, opposition, and mani pulation of objects (e.g., using utensils to eat, drinking from a cup, writing, picking up and reorienting coins, paperclips, or other objects). Pronation often predominates while active supination without elbow and shoulder flexion is difficult to achieve. The therapist must observe movements carefully and assist in eliminating those aspects of movement patterns that interfere with effective and efficient control. Graded physical assist and use of mental practice/imagery techniques can be helpful to improve learning and performance.157,161,162
Constraint-Induced Movement Therapy
Constraint-induced movement therapy (CIMT) is a multifaceted intervention designed to promote increased use of the more affected UE. The patient is engaged in intense task-oriented practice of the more affected UE for up to 6 hours a day, performed on consecutive weekdays for 10 to 15 days (Fig. 15.12). The less affected UE is restrained from use by having the patient wear a safety mitt up to 90% of waking hours.163 The therapist uses shaping techniques to modify and progress performance (e.g., an object is lifted and placed at increasing distances away from the patient). Feedback, coaching, modeling, and encouragement are provided during practice. Behavioral methods designed to ensure adherence to exercise and developing task-oriented behaviors include engaging the patient in:
Constraint-induced movement therapy (CIMT). The patient practices a pegboard task using the hemiparetic hand while the less affected hand wears a mitt. The therapist times the activity while encouraging the patient.
Self-monitoring of target behaviors (e.g., mode of activity, duration, frequency, perceived exertion, and overall response to activity)
Problem-solving to identify obstacles and generate potential solutions
Behavioral contracting to engage the patient in carrying out behaviors throughout the day
Social support strategies to educate and enlist caregivers in provident optimal support
The reader is referred to the work of Morris and Taub164,165 for a more complete description of these techniques. Modified CIMT (mCIMT) has also been used for patients with stroke. For example, Page et al166,167 used 30 minutes of functional task practice and shaping techniques 3 days per week, and restraint of the less affected UE for up to 5 hours per day. Training occurred over an extended 10-week period. This outpatient protocol increased the use and function of the more affected arm.166,167
Significant gains in motor function and a moderate reduction in disability following CIMT have been demonstrated in patients with stroke.45,168,169 The EXCITE trial was a large prospective, single-blind, randomized, multisite study that included 222 patients after stroke. CIMT was compared to customary care and found to significantly improve outcomes as measured by the Wolf Motor Function test and the Motor Activity Log.170 Associated changes in brain organization with CIMT have also been demonstrated on functional magnetic resonance imaging (fMRI), including an apparent shift in motor cortical activation toward other ipsilateral areas and the contralesional hemisphere.171 Significant gains have also been reported in the patients receiving mCIMT.165,166,172 It is important to note that patients were included in the studies if they had potential for recovery and some residual upper arm and hand movement (active wrist and finger extension) but tended not to use the arm. Limited pain or spasticity and absence of cognitive impairment were also inclusion criteria. Many early studies involved patients with chronic stroke (greater than 1 year). Evidence also exists for positive results with subacute stroke patients (less than 1 year)170 and acute patients (less than 2 weeks after stroke).173 The Cochrane researchers in their review of the literature concluded that evidence supporting maintained improvement from CIMT over 6 months is lacking.45 The reader is referred to additional discussion in Chapter 10 and a summary of research findings presented in Box 10.1 Evidence Summary CIMT.
Simultaneous Bilateral Training
Simultaneous bilateral training involves using both arms simultaneously alone or in combination with augmented sensory feedback. Bilateral arm training with rhythmic auditory cueing (BATRAC) is an example of this intervention.174 It is theorized that similar movement in the less affected extremity facilitates movement in the more affected extremity. Positive results have been reported in improving motor recovery after stroke.174,175,176 When compared to usual or conventional care, simultaneous bilateral training was not shown to be significantly better than other UE interventions in terms of improvements in ADL, arm or hand movements, or scores on motor impairment measures. The Cochrane reviewers cited lack of high-quality evidence in these findings.47
Electromyographic biofeedback (EMG-BFB) has been used to improve motor function in patients following stroke. The technique allows patients to alter motor unit activity based on augmented audio and visual feedback information. Training can focus on voluntary inhibition of spastic muscles (e.g., reducing firing frequency of spastic finger flexors), or on increasing kinesthetic awareness and recruitment of motor units in weak, hypoactive muscles (e.g., wrist/forearm extensor muscles). Patients in late recovery for whom spontaneous recovery is more or less complete (greater than 6 months post-stroke) have demonstrated positive results that have been attributed to biofeedback therapy.177,178 Reported benefits include improvements in ROM, voluntary control, and function. Researchers indicate that effectiveness of biofeedback neuromuscular reeducation is greatest when used as an adjunct to task-specific training.
Neuromuscular electrical stimulation (NMES) has been used with patients recovering from stroke to reduce spasticity, improve sensory awareness, prevent or reduce shoulder subluxation, and stimulate volitional movements.179,180,181,182 NMES has been shown to increase the ability of muscle to exert force by preferentially activating the fast-contracting motor units. Effective treatment results have been reported for improving function in wrist extensors and the deltoid and supraspinatus muscles. In the latter example, glenohumeral alignment was improved and subluxation reduced. As with the biofeedback research, optimal results have been obtained when combined with task-specific training.182
Robotic devices have been developed to assist the patient with moderate to severe motor impairments in improving UE function and recovery. They are used in conjunction with task-oriented training and motor learning principles. Robots work to restore lost motor function and can include pneumatic actuators (acting as muscles) to power the device or passive robotic systems using elastic bands or springs. Reach and grasp/release movements are typically targeted. These devices are used to augment therapist-patient interventions and enable high levels of intensive practice.183 Limited evidence exists of treatment efficacy that can be generalized to arm and hand use during ADL. High cost of equipment limits widespread use in the clinical setting.184
Management of Shoulder Pain
Several causes of hemiplegic shoulder pain have been identified that can be broadly divided into flaccid and spastic presentations. In the flaccid stage, proprioceptive impairment, lack of tone, and muscle paralysis reduce the support and normal seating action of the rotator cuff muscles, particularly the supraspinatus. The ligaments and capsule thus become the shoulder's sole support. The normal orientation of the glenoid fossa is upward, outward, and forward, so that it keeps the superior capsule taut and stabilizes the humerus mechanically. In the absence of supporting musculature, any abduction or forward flexion of the humerus, or scapular depression and downward rotation, reduces this stabilization and causes the humerus to sublux. Initially the subluxation is not painful, but mechanical stresses resulting from traction and gravitational forces produce persistent malalignment and pain. Glenohumeral friction–compression stresses also occur between the humeral head and superior soft tissues during flexion or abduction movements in the absence of normal scapulohumeral rhythm (shoulder impingement syndrome). During the spastic stage, abnormal muscle tone may contribute to poor scapular position (depression, retraction, and downward rotation) and to subluxation and restricted movement. Secondary tightness in ligaments, tendons, and joint capsule can develop quickly. Adhesive capsulitis (intracapsular inflammation and "frozen shoulder") can occur. Poor handling and positioning of the more affected UE have been implicated in producing joint microtrauma and pain. Activities that traumatize the shoulder include PROM without adequate mobilization of the scapula (promoting normal scapulohumeral rhythm), traction or pulling on the UE during a transfer, or using reciprocal pulleys.185,186,187 An incorrectly aligned joint can significantly impair the patient's ability to move. Additional interventions aimed at reducing subluxation can include NMES therapy, EMG biofeedback, taping, and slings.
Complex regional pain syndrome type 1 (CRPS-1), also known as shoulder-hand syndrome (SHS) or reflex sympathetic dystrophy, is caused by proximal trauma to the shoulder or neck or can occur with stroke and may be the result of autonomic nervous system (ANS) changes. Clinical factors associated with its development include motor deficits, spasticity, sensory deficits, and initial coma.188 Early on, pain is intermittent and limited to the shoulder. During later stages pain is intense and involves the whole extremity. CRPS-1 is associated with a range of other symptoms. Stiffness and limitations in ROM occur. The wrist tends to assume a flexed position with intense pain likely during wrist extension movements. The elbow is not typically involved. Early stage 1 vasomotor changes include discoloration (pale pink or cool) and alterations in temperature. The skin may be hypersensitive to touch, pressure, or temperature variations. The patient typically guards against movement attempts. Stage 2 is characterized by subsiding pain and early dystrophic changes: muscle and skin atrophy, vasospasm, hyperhidrosis (increased sweating), and coarse hair and nails. There is radiographic evidence of early osteoporosis. In stage 3, the atrophic phase, pain and vasomotor changes are rare. There is progressive atrophy of the skin, muscles, and bones (severe osteoporosis is evident). Pericapsular fibrosis and articular changes become pronounced. The hand typically becomes contracted in a clawed position with MP extension and IP flexion (similar to the intrinsic minus hand). There is marked atrophy of thenar and hypothenar muscles with flattening of the hand. Chances of reversal of signs and symptoms are high for stage 1 and variable for stage 2, whereas stage 3 changes are largely irreversible.188
Early diagnosis and identification of factors that cause CRPS is essential. Interventions are selected based on examination findings. Because of close daily contact with the patient, the physical therapist is frequently one of the first to recognize and report early signs and symptoms. A prevention protocol should be implemented.189 In the flaccid stage, the arm should be supported at all times. Proper positioning and handling are essential. In bed, patients should be positioned so they cannot roll onto the more affected UE, compressing it. In supine and wheelchair sitting the scapula/shoulder should be supported with the arm forward in slight abduction and neutral rotation. During transfers and standing supportive devices should be considered to prevent traction injury (see section below). Interventions aimed at reducing pain and stiffness include appropriate PROM and mobilization techniques (gentle grade 1 to 2 mobilizations). PROM to the UE without scapular mobilization is not permitted. PROM of the shoulder should be limited to 90 degrees during flexion and abduction or to the point of pain, not beyond the pain position. The therapist needs to ensure that everyone involved in assisting the patient (e.g., family member, caregiver, nurses, and aides) has been instructed in proper handling/mobilization of the UE and recognizes the importance of avoiding trauma and traction injuries during PROM, transfers, and wheelchair activities. Active movements of the UE are encouraged to promote shoulder ROM (e.g., pushing away a tabletop therapy ball while standing). Interventions to manage edema are also a consideration. Additional considerations include no infusions into the veins of the hemiplegic hand. Persistent pain may be managed with oral analgesics or local injection techniques (corticosteroids). Repeat steroid injections are not recommended due to likely weakening of the rotator cuff. With intractable pain, surgical nerve blocks may be considered.187
A patient with hypotonia is at increased risk of shoulder traction injury. Slings can be used to prevent soft-tissue stretching (e.g., supraspinatus, capsular stretching) and relieve pressure on the neurovascular bundle (e.g., brachial plexus/brachial artery). They support the weight of the arm and protect the patient. They also free up the therapist to attend to postural/trunk control during functional activities. However, slings have a number of negative features. They do little to reduce subluxation or improve shoulder function, especially if scapular and trunk malalignment are not adequately addressed. Most slings have the additional negative feature of positioning the arm close to the body in adduction, internal rotation, and elbow flexion. With prolonged use, contractures and increased flexor tone may develop. Slings also contribute to body scheme disorders and body neglect. Prolonged use of slings blocks spontaneous use of the UE and contributes to learned nonuse. Slings may also block balance reactions involving the UE.
There are considerable differences in the effectiveness of the various types of slings. A pouch sling or single strap hemisling with two cuffs that support the elbow and wrist provides minimal mechanical support of the humerus. An alternate approach to the traditional sling is a humeral cuff sling. This device has an arm cuff on the distal humerus supported by a figure-eight harness. It provides humeral support with slight external rotation while allowing elbow extension, and may also provide some reduction of subluxation. This style of sling can be worn for longer periods because it does not restrict the elbow in a flexed position or limit distal function.190,191,192
Close collaboration with the occupational therapist is important in the appropriate selection and use of slings. Gillen161 suggests the following guidelines:
Therapists should minimize sling use during rehabilitation.
Slings may be useful for initial transfer and gait training.
Slings that position the UE in flexion are less desirable and should be used only for select upright activities and only for short time periods.
No one sling is appropriate for all patients; selection and use should be carefully evaluated and sling effectiveness carefully reevaluated.
Effective alternatives to use of a sling should be considered: humeral taping (strapping) to facilitate or inhibit musculature surrounding the scapula; NMES. The hand can also be positioned in a garment pocket.
The patient, family members, and caregivers should be instructed in and allowed to practice proper use of the support. As recovery progresses and spasticity and voluntary movement emerge, spontaneous reduction of shoulder subluxation may occur. Slings have no value at this point in recovery.
For patients using a wheelchair, an arm board or lap tray can provide support for the flaccid arm. A lateral elbow guard and/or straps may be necessary if the patient's arm slips off the side. Patients with decreased sensation are at risk for hand injury if the hand becomes stuck in the spokes of the wheelchair; elbow trauma can occur if the elbow slips off the side (e.g., the elbow hits as the patient is going through a doorway).
Strategies to Improve Lower Extremity Function
LE training activities essentially prepare the patient for the gait. This requires breaking up the obligatory synergy patterns. For example, during midstance hip and knee extensors need to be activated with hip abductors and dorsiflexors. Suggested activities include PNF LE D1 extension pattern; holding against elastic band resistance around the upper thighs in supine or standing positions; and standing, lateral side-steps. Hip adduction should be stressed during flexion movements of the hip and knee. Suggested activities include supine, PNF LE D1 flexion pattern; sitting, crossing, and uncrossing the more affected LE over the less affected; and standing step-ups. Hip extension with knee flexion is needed to allow for toe-off at the end of stance. Activities that can be used to promote knee flexion with hip extension include bridging (Fig. 15.13), supine hip extension with knee flexion over the side of the mat pushing down through the heel, or standing, unilateral heel rises. Pelvic control is important and can be promoted through lower trunk rotation (LTR) activities that emphasize forward pelvic rotation (protraction); post-stroke, the patient typically demonstrates a retracted and elevated pelvis. Lower trunk rotation can be practiced in side-lying; supine, modified hook-lying; kneeling; or standing. Sitting on a therapy ball, pelvic shifting is another useful activity to promote pelvic control. Control of knee motions is often problematic; post-stroke, the patient with knee weakness typically exhibits hyperextension when standing. Reciprocal action (smooth reversals of flexion and extension movements) should be stressed early, beginning first in supine (e.g., foot slides in hook-lying), sitting (e.g., foot slides under the chair), partial sitting, or partial wall squats in standing.
The patient practices bridging, combining hip extension with knee flexion; the therapist assists using tactile and proprioceptive cues to stimulate the hip extensors on the hemiparetic LE.
An effective progression increases the challenge to the patient gradually by modifying postures while reducing synergy influence (e.g., hip abduction can be performed first in hook-lying, then supine, side-lying, modified plantigrade, and finally standing). Dorsiflexors can be activated in sitting by first having the patient hold and slowly let the forefoot move down, then pull the forefoot up. This simulates the functional expectations of the normal gait cycle as the foot goes from swing phase through stance. The sequence can then be repeated in standing, a much more difficult position in which to control dorsiflexors. Voluntary control of eversion is often the most difficult motion to achieve because these muscles do not function in either synergy. The application of stretch and resistance to these muscles during an activity that recruits dorsiflexors and evertors may be effective in initiating a response (e.g., in bridging, knee rocks side-to-side).
Interventions to Improve Functional Status
The loss of sensory and motor function on one side will present a tremendous challenge for the patient struggling to relearn postural control and functional mobility. Initial treatment strategies should focus on trunk symmetry and use of both sides of the body. Progression is from guided movements to active movements as soon as the patient is able to assume independent control. Suggested functional training activities include the following.
Rolling to both sides should be practiced; rolling onto the less affected side will prove more difficult. Extremity movement patterns (e.g., PNF D1 flexion of the LE) can be used to enhance the movement. Care must be taken to ensure the patient does not leave the more affected UE behind but rather brings it forward. This can be accomplished by having the patient clasp the hands together first. The more affected LE can be used to assist in rolling by pushing off from a flexed and adducted, hook-lying position (Fig. 15.14). Rolling onto the more affected side and into a side-lying–on–elbow position is important to promote early weight-bearing. This position also has the added benefit of elongating the lateral trunk flexors, which may be spastic.
Early mobility activities: rolling onto the unaffected side. The therapist assists the movement through contacts on the knees and clasped hands.
The patient should practice moving from supine-to-sit leading from both sides, with an emphasis on rising with the more involved side leading (closest to the edge of bed or mat). The therapist can provide assistance from side-lying on the more affected side by shifting the LEs over the edge of the bed or mat while the patient pushes up into sitting using both UEs for support. Controlled lowering should also be practiced.
Bridging activities help develop trunk and hip extensor control important for use of a bedpan, pressure relief on the buttocks, initial bed mobility (scooting), and sit-to-stand transfers. It also develops advanced LE out-of-synergy control (hip extension with knee flexion) and stimulates early weight-bearing through the foot (see Fig. 15.13). Bridging activities include independent assumption of the posture, holding in the posture, and moving in the posture (lateral weight shifts, bridge-and-placing hips to one side). If the more affected LE is unable to hold in a hook-lying position, the therapist will need to assist by stabilizing the foot. Lifting the less affected foot off the surface (placing it on a small ball) while maintaining the pelvis level significantly increases the difficulty and can be used to increase demands on the more affected side. Difficulty can also be increased by varying the position of the UEs, from extended and abducted at the sides, to arms folded across the chest or hands clasped together overhead in a prayer position.
Early training in sitting should focus on achieving a symmetrical posture with proper spine and pelvic alignment. The pelvis should be neutral, spine straight. Feet should be flat on the support surface. Typically, patients with stroke will sit asymmetrically with weight borne more on the less affected side, pelvis in a posterior tilt, and upper trunk flexed (kyphotic). Lateral flexion to the affected side is also common. The therapist can manually guide the patient into the correct sitting position and provide verbal and tactile cues. Early sitting can be assisted by having the patient use the UEs for bilateral support at sides or in front on tabletop, a large ball, or the therapist's shoulders with the therapist sitting directly in front of the patient. Sitting on a therapy ball can also be used to promote pelvic alignment and mobility (pelvic rotations) and trunk upright alignment (gentle bouncing). Sitting control should be progressed from first holding steady in the posture (stability) to moving in the posture (dynamic stability), and finally to dynamic challenges (reaching). A common problem with hemiplegia is the inability of the upper trunk to move independently of the lower trunk (dissociate). Upper trunk mobility with reciprocal flexion/extension, lateral flexion, and rotation movements should therefore be practiced. PNF lift/reverse patterns with the less involved arm leading can be used to promote upper trunk rotation and bilateral UE activity with the more involved arm moving out of synergy, and crossing the midline (important for unilateral neglect) (Fig. 15.15). Lateral weight shifts to the more affected side typically are the most difficult. Manual contacts in the direction of the movement combined with gentle resistance can provide important early learning cues. The patient should also practice scooting in sitting ("butt walking") to ensure mobility for dressing (putting pants on) and practice initial positioning for sit-to-stand transitions (coming to the edge of the seat to place the feet back and under the body).
Sitting, patient practices PNF lift pattern (less affected UE leading). The pattern promotes upper trunk rotation, bilateral UE activity with the hemiparetic UE moving out of synergy, and crossing the midline.
Sit-to-Stand and Sit-Down Transfers
Sit-to-stand transfers should be practiced with a focus on symmetrical weight-bearing, coordinated muscular responses, and adequate timing. Initially the patient must actively flex the trunk and use momentum to shift the body mass forward (flexion-momentum phase). The feet should be placed well back to allow ankle dorsiflexors to assist with forward rotation. The patient with stroke typically demonstrates decreased forward movement and momentum. The therapist should focus the patient's eyes on a visual target directly in front at eye level and use verbal cues to facilitate the desired movements ("move your shoulders forward and stand up"). The patient can be assisted in this phase by keeping both UEs forward with hands clasped together. Pushing off with both hands on the support surface is not effective in producing the forward weight shift and should be discouraged. The patient's movements must then be directed into the extension phase, which requires hip and knee extensors to produce vertical movement into the upright position. The therapist can provide tactile and proprioceptive cues to assist knee extension (Fig. 15.16). The height of the seat can be elevated at first to decrease the extensor force required. Progression is then to lower seat heights. Increased weight-bearing on the stronger LE can be achieved by varying the initial foot position, placing the stronger foot slightly behind the weaker foot. As the patient improves, the position of the feet can be reversed to focus attention on increased use of the weaker side. The patient with stroke typically accomplishes standing up very slowly. With repetitive practice, the patient should be encouraged to focus on increasing the speed of the movement and to not pause between the two phases. Using a prayer position (hands clasped together and held straight ahead with elbows extended) reduces UE push-off. The patient with stroke also demonstrates decreased control in sitting down owing to lack of eccentric control and will sit down abruptly after moving partially through the range.
Sit-to-stand transitions. The therapist assists the patient in straightening the hemiparetic knee while bringing the center of mass forward. Hands are clasped together.
Eccentric movements (small range movements) can be practiced with the patient positioned back against a wall doing partial wall squats. Lower trunk rotation can be promoted by having the patient practice sit-to-stand using a platform mat. From standing, the patient shifts the pelvis laterally to the more affected side, and then sits down. By using this activity, the patient can move all the way around the mat alternating standing and controlled sitting, focusing on moving toward the weaker side.
Modified plantigrade is an ideal early standing posture to develop postural and extremity control. The more affected UE is extended and weight-bearing (an out-of-synergy posture), while the more affected LE is holding in extension (also an out-of-synergy pattern of hip flexion with knee extension). The forward trunk position creates an extension moment at the knee, thus assisting weak knee extensors. In addition, the posture has a wide (four-limb) BOS and is very stable (see Fig. 15.10). Progression should again be from holding in the posture to moving in the posture (weight shifts) to reaching tasks.
Initial upright standing can be enhanced using fingertip light touch-down support on a high table or wall. As soon as possible, the patient should be encouraged to practice standing with unilateral UE support (more affected side) and then free standing (no UE support). As in other postures, an appropriate progression includes first holding in the posture, to moving in the posture (weight shifts), and finally withstanding challenges to dynamic balance (e.g., reaching in all directions, stepping). The patient is instructed in proper symmetry and alignment. Gentle resistance can be applied to assist in holding, using the PNF technique of rhythmic stabilization. Weight shifts should incorporate moving forward-backward, side-to-side, and diagonally (incorporating upper trunk rotation). Lateral weight shifts to the more affected side are the most difficult. Manual contacts in the direction of the movement combined with gentle resistance can provide important early learning cues.
During early transfers, the patient may require maximal assistance. Adjusting the hospital bed to the height of the chair or wheelchair will help to decrease the difficulty of the transfer. Staff often emphasize the sound side by placing the chair to that side and having the patient stand and pivot a quarter turn on the stronger LE before sitting down. Although this compensatory strategy promotes early transfers, it neglects the weaker side and may make subsequent training more difficult. The patient should be taught to transfer to both sides, with emphasis on moving toward the more affected side. Practice to both sides has functional significance, because most bathrooms are not large enough to allow positioning of the wheelchair on both sides of a tub or toilet. Also, the patient is not likely to be able to reposition the wheelchair once he or she transfers into bed so that a transfer toward the same side can be achieved when getting out of bed. When transferring, the patient's affected arm can be stabilized in extension and external rotation against the therapist's body. Alternatively, the patient's UEs (hands in prayer position) can be placed in front or to one side on the therapist's shoulders. The therapist can then assist by using manual contacts, either at the upper trunk or pelvis. The more affected LE may be stabilized by the therapist's knee exerting a counter-force on the patient's knee as needed. Transfer training should include practice in transferring to various different surfaces and heights (e.g., wheelchair, toilet, tub seat, car).
Functional training is begun early and continued throughout the course of rehabilitation. Training activities and postures are varied according to individual needs. Additional postures such as modified prone-on-elbows (tabletop weight-bearing), quadruped, side-sitting, kneeling, and half-kneeling may be appropriate and can be used to increase the level of difficulty and focus on specific body segments and deficiencies in control. Some postures may not be appropriate (e.g., prone-on-elbows for the patient with cardiorespiratory compromise or a flaccid, subluxed UE, or kneeling for the patient with osteoarthritis). Advanced functional training should include practice in getting down to and up from the floor in the event of a fall. See Improving Functional Outcomes in Physical Rehabilitation150 for more complete descriptions and additional training activities.
Interventions to Improve Postural Control and Balance
Stroke results in significant changes in postural control and balance. Patients typically exhibit delayed, varied, or absent balance responses with impairments in latency, amplitude, and timing of muscle activity. Falls and fracture can occur and lead to a loss of confidence in balance and locomotor skills.193 It is therefore important to proceed slowly in training and to select challenges appropriate for the patient's level of control. The goals of training are to progressively increase the level of difficulty (e.g., range and speed of self-initiated movements) while encouraging consistency, symmetry, and maximum use of the more affected side. Supportive devices such as a posterior leg splint, gait belt, or body-weight-support harness can be used to assist in early standing to instill confidence and prevent falls.
Once postural alignment and static stability is achieved in upright postures, the patient is ready for center-of-mass (COM) control training. In sitting and standing, the patient is instructed to explore his or her LOS through low-frequency weight shifting.
The patient learns how far in any one direction he or she can safely move and how to align the COM within the BOS to maintain upright stability. The therapist needs to stress symmetrical weight-bearing, as well as activities that promote shifting toward the more affected side. Weight-bearing on the more affected hip (sitting) and foot (standing) is encouraged while unnecessary activity of the less affected limbs (grabbing for support) is discouraged. The therapist increases the difficulty of the activity by manipulating the following:
Base of support: Sitting, LEs uncrossed to crossed; standing, wide to narrow to tandem position; standing on one LE (beginning with less affected, progression to more affected LE)
Support surface: Sitting on a mat to sitting on a therapy ball; standing on the floor to standing on dense foam
Sensory inputs: Eyes open (EO) to eyes closed (EC); feet on firm surface or foam
UE position/support: Light touch-down support; UEs extended out to the side to UEs folded across the chest
UE movements: Single UE raises to bilateral UE raises (symmetrical, asymmetrical); reaching movements with emphasis to the more affected side; picking objects off table, stool, floor
LE movements: Single LE support, stepping (forward-backward, side; step-ups); marching in place; foot on ball, moving ball
Trunk movements: Head and trunk rotations; looking up at ceiling or down to floor
Destabilizing functional activities: Sit-to-stand, sit-down, turning, floor-to-standing, lunges
Walking activities: Forward, backward, sideward, crossed step
Dual-task training: Standing while catching or kicking a ball; standing while talking; standing while holding a tray with a glass of water
Modifying environmental conditions: Closed to open environments
Postural strategy training is an important component of intervention. Ankle strategies can be promoted through small range anterior-posterior shifts or by applying a small perturbation at the hips (forward-backward). Standing on a half-foam roller or wobble board also promotes ankle strategies, but may be too advanced for some patients during early rehabilitation. Hip strategies can be promoted through larger anterior-posterior shifts or stronger perturbations. Medial-lateral hip strategies are promoted by tandem stance (on floor or foam roller). Stepping strategies are promoted by increased displacements of the COM (e.g., forward, backward, or sideward leans that move the COM outside of the BOS). The therapist can apply an elastic band around the hips, offering resistance to the forward lean. Resistance that is quickly released once the patient achieves the desired lean will necessitate a step to control balance. Step-ups (small step to large; foam surface) should also be practiced.
The patient's full attention and concentration is required and should be directed toward completion of the task at hand. The therapist provides well-timed feedback to help the patient correct alignment and adjust postural control while minimizing hands-on support (only as needed). During balance training, the patient should be encouraged to actively problem solve. The patient is presented with challenges, identifies potential problems, and recruits safe strategies to maintain balance. Adaptability of skills needed for successful community reentry is promoted. Safety education about fall prevention is a critical factor in ensuring maintenance of the patient's hard-won functional independence.194
Research supports the effectiveness of balance training programs in improving balance ability for patients with stroke. Programs that demanded high frequency and duration had a high dropout rate for patients with acute stroke, largely due to medical reasons or fatigue. A reasonable exercise prescription for this group might include a frequency of 5 sessions per week for 45 to 60 minutes per session. For patients with subacute and chronic stroke, more intense individualized programs are possible. A combination of interventions that focused on static and dynamic balance was most often used. Both one-on-one training and group programs have produced positive results. Finally, there is limited evidence that balance performance may deteriorate once the intervention is stopped.195,196
Force Platform Biofeedback
Force platform biofeedback (center-of-pressure biofeedback) provided to the patient while standing on a computerized forceplate system can be used to improve balance. The patient practices voluntary movement shifts in response to computer generated visual feedback. Patients can also practice responding to unexpected platform tilts (perturbations) in order to improve reactive balance control. A safety harness may be required during early training; holding on with one or both hands is discouraged.
Improvements with biofeedback/forceplate training have been found in steadiness (reduced sway),197,198 postural symmetry,197,198 and dynamic stability.198,199,200 Evidence is stronger and more consistent for the latter two parameters than for changes in steadiness.201 There is limited evidence of carryover of improved balance during functional skills, specifically transfer skills and endurance,200 functional reach,202 and measures of ADL and mobility.198 Carryover to improved locomotor performance has not been demonstrated.197,200 Failure to find significant correlations to gait is most likely related to specificity of training, specifically a dissimilarity between training mode and outcome measure. Studies comparing conventional balance training with biofeedback/forceplate training based on improvements on functional balance measures (Berg Balance Scale, Timed Up and Go) have failed to show any significant differences between the training modes; both interventions were effective in improving balance.203,204
The Patient with Ipsilateral Pushing (Pusher Syndrome)
The patient with ipsilateral pushing presents with an entirely different set of postural control and balance problems. The patient sits or stands asymmetrically, but with most of the weight shifted toward the weaker side. The patient uses the stronger UE or LE to push over to the weaker side, often resulting in instability and falls. Efforts by the therapist to passively correct the patient's tilted posture often result in the patient pushing stronger. Training needs to emphasize upright positions with active movement shifts toward the stronger side. Use of visual stimuli is effective as patients retain the ability to correct posture with such stimuli but may not be able to do so spontaneously. Patients should be asked to look at their posture and see if they are upright. Environmental prompts can be used to assist orientation. These can include use of a mirror if visuospatial deficits are not present or vertical structures in the environment. For example, the therapist can sit on the patient's less involved side and instruct the patient to "lean over to me." Or the patient can be positioned with the stronger side next to a wall and instructed to "lean toward the wall."95 Therapists can provide verbal and tactile cues for postural orientation. To improve sitting posture, training activities can include sitting on a therapy ball to promote symmetry and sitting. In early standing the weaker LE is often flexed and has difficulty supporting the body on that side. Extension can be assisted by the use of an air splint or a posterior leg splint or by direct tapping over the quadriceps muscle. The modified plantigrade position is effective for early supported standing; however, the therapist should focus on unilateral support using the weaker UE. Again, an air splint can be used to assist extension of the weaker arm. If a cane is used, it can be shortened to encourage weight shift to the stronger side. An environmental boundary can be used to achieve symmetrical standing (e.g., standing in a doorway or corner standing). It is important to limit pushing with the sound extremities. For example, in sitting or standing, the therapist should block the stronger limb from drifting laterally into abduction and extension and pushing.205,206 During wheelchair sitting, the patient should be assisted to maintain upright posture and midline orientation. Motor learning strategies are very effective in reducing the effects of this disorder and enhancing recovery. In particular, the therapist should demonstrate correct orientation to vertical, provide consistent feedback about body orientation, and practice correct orientation and weight shifts. The patient should be fully involved in problem solving. For example, the therapist should ask questions such as "what direction are you tilted?" and "what direction do you have to move in order to achieve vertical?" Karnath et al93 indicate that the prognosis for recovery is good with effective training.
Interventions to Improve Gait and Locomotion
Task-Specific Overground Locomotor Training
An accurate analysis of a patient's walking pattern is critical to planning effective interventions (see Box 15.5). These abnormalities arise as a result of impairments in flexibility, strength, movement control, coordination, and balance. Critical areas of stance phase control that will need to be addressed include initial weight acceptance, midstance control, and forward weight advancement during stance on the more involved limb. During swing, control of knee and foot for toe clearance and foot placement are key requirements (Fig. 15.17). Finally, persistent posturing of the UE in flexion and adduction during gait should be addressed. This latter problem can be effectively controlled through positioning the hemiplegic UE in extension and abduction with the hand open.
Assisted overground gait training. The therapist provides assistance in stabilizing the hemiparetic knee and weight transfer onto the more affected side.
Task-specific overground locomotor training (LT) focuses on practicing a variety of activities and on improving the quality of walking and walking endurance. Appropriate stretching, particularly of the calf muscles, and strengthening exercises for LE muscles are important preparatory interventions. Parallel bars and ambulation aids (e.g., walkers, hemiwalkers, quad canes) can assist in early gait stability and safety. However, prolonged use of these devices can be problematic for a patient who has the potential to walk without the device. There is increased loading on UEs and the stronger LE. With prolonged use, the patient also fails to develop appropriate balance mechanisms while asymmetry is promoted. There is an excessive weight shift toward the less affected side with the use of a hemiwalker or quad cane. Prolonged use of a walker encourages a forward trunk position with maximum loading on the UEs. Gait is typically slower with assistive devices and overall locomotor rhythm is impaired. It is important to progress patients as quickly as possible to the least restrictive device and to no device whenever possible. Gait practice with an overhead harness and partial body weight support provides the least interference with early balance and walking activities.
The patient should practice functional, task-specific skills, including the following:
Walking forward: Focus is on moving out of synergy by combining hip and knee extension with hip abduction (scissoring is common).
Walking backward: Focus is on moving out of synergy by combining hip extensors with knee flexors.
Side stepping: Focus is on moving out of synergy by combining hip abductors with hip and knee extensors.
Crossed stepping: The PNF activity of braiding combines side-stepping and cross-stepping.
Step-up/step-down activities; lateral step-ups.
Stair climbing, step-over-step.
Walking in a simulated home environment: Through doorways, over and around obstacles, stairs in/out of the home.
Walking in a community environment: Walking on ramps, curbs, uneven terrain, over and around obstacles.
Activities that involve coincident timing: Crossing at a streetlight; stepping on and off elevators or escalators; walking through automatic doors.
Dual-task activities: Walking while holding a ball, bouncing a ball, carrying a tray, carrying on a conversation.
Balance activities: Tandem walking on a line, walking on/off foam.
Initially walking will be slow and deliberate. As control develops, the patient is encouraged to improve rhythm and speed of walking. Even steps can be facilitated by the use of real-time, rhythmic auditory cues (e.g., verbal cues, clapping, metronome) and foot markers placed on the floor. Progression is to longer steps and to increased overall distances with faster speeds. The patient should also practice walking in varying complex environments. This encourages the development of the patient's skills to adapt walking as needed (e.g., vary speeds, direction, navigate changing support surface). Timing and reciprocity of LE movements can be improved with the use of a motorized treadmill, cycle ergometer, and Kinetron® isokinetic training. Functional practice in real-life environments will assist the patient in developing the confidence needed for meeting the demands of community reentry.
A Cochrane Systematic Review of research on overground LT for individuals with chronic stroke included nine studies involving 499 participants. Results were mixed. Improvements in walking speed and functional performance (Timed Up and Go Test, 6-Minute Walk Test) were found in some studies. Overall, the researchers felt there was insufficient evidence to determine the benefits on broad measures of walking function. Again, lack of high-quality research (RCTs) was cited.207 Limited data exist with subacute stroke patients.
Locomotor Training using Body Weight Support and Motorized Treadmill Training
While locomotor control is distributed across discrete regions of the CNS, walking is primarily a brainstem and spinal cord function. For example, locomotor central pattern generators (CPGs) have been identified as existing in the ventral spinal cord while integrating command centers have been identified in the medial medullary reticular formation. Thus, patients with cortical stroke may be able to regain the ability to walk. The CNS is responsive to training-induced plastic changes in locomotor function and recovery. Thus, patients with limited recovery who lack voluntary isolated control can still be trained to walk. Although sensation is normally used for walking, patients can also learn to walk with limited sensation.
Body weight support (BWS) and motorized treadmill training (TT) allows the clinician to improve recovery of walking ability after stroke using intensive task-oriented training. Normal kinematics and phase relationships of the full gait cycle are promoted, including limb loading in midstance and unweighting and stepping during swing. Initially, manual assistance can be provided by trainers to normalize gait in the presence of muscle weakness and impaired balance. For example, one therapist provides manual assistance to foot placement during stepping movements of the weaker LE while a second therapist stands behind the patient and provides manual assistance to pelvic rotation movements (Fig. 15.18). An overhead harness is used to support a portion of the patient's weight (e.g., 30% progressing down to 20%, and 10%). The harness controls the upright position of the patient in the absence of good postural stability and reduces fear of falling. The use of a harness also eliminates the need for adaptive UE support to compensate for LE weakness (e.g., as seen with the use of a walker).
Locomotor training using body weight support and a motorized treadmill. One therapist manually assists pelvic motions while a second therapist assists stepping of the hemiparetic left LE.
As improvements in walking occur, the harness is removed and full weight-bearing is allowed. At this point, the patient is practicing supervised walking on a treadmill. Initially the treadmill speeds are slow (e.g., 0.52 mph [0.23 m/sec]) and are gradually increased as the patient's walking ability is improved (e.g., 0.95 mph [0.42 m/sec]).101 Progression is to task-specific practice and overground walking. See Chapter 11, Locomotor Training, for additional discussion.
Treadmill training and BWS is a relatively safe task-oriented LT activity that has been extensively studied in patients recovering from stroke.208,209,210,211,212,213,214,215,216,217,218,219,220,221,222,223 In a Cochrane Systematic Review,49 the researchers identified 15 high-quality trials with 622 post-stroke participants. They concluded that there were no significant statistical differences between TT, with or without BWS, and other physiotherapy interventions on outcomes of walking dependency, speed, and endurance. For people who were independent walkers at the start of treatment, higher walking speeds were evident, though not significantly so. Patients with stroke who were dependent in walking at the start of treatment may benefit from TT with BWS, though data were limited to support this conclusion. Serious adverse events were uncommon. Individual studies have reported improvements in walking speed,211,212,213,214,215,222 distance,211,215,216 endurance,211,218,219 and walking function.211 Treadmill training is a safe intervention for patients with acute and subacute stroke,208,209,216,217,218,221 as well as for chronic stroke210,211,212, 219 (see Box 15.9 Evidence Summary).
Box 15.9 Evidence Summary Post-Stroke Locomotor Training Using Body Weight Support and Motorized Treadmill Training
|Reference ||Subjects ||Design/Intervention ||Duration ||Results ||Comments |
|Richards et al209 (1993) ||27 subjects ||RCT; compared early task-based PT (standing, weight-shifting, and Kinetron exercises; TT), 1.74 hr/day with conventional PT intervention groups (1.79 hr/day and 0.73 hr/day) Outcome measures: FMA, BI, BBS, gait velocity at 6-month follow-up ||Daily ||Significant improvement in gait velocity for task-based PT group ||Small sample size One of the pioneering early studies |
|Visintin et al211 (1998) ||100 subjects postacute phase ||RCT; TT: compared BWS (BWSTT) with no-BWS (no-BWSTT) Outcome measures: balance (BBS); motor recovery (STREAM); OG walking speed and endurance ||4/wk for 6 wk ||BWSTT group demonstrated significant improvement over no-BWSTT in balance, motor recovery, and OG walking speed and endurance ||79% BWSTT group progressed to full weight-bearing OG walking; improvements were sustained; good sample size; one of the pioneering early studies |
|Nilsson et al213 (2001) ||60 subjects postacute stage ||RCT; compared walking using BWSTT with OG walking training (motor relearning approach) Outcome measures: FIM, FMA, FAC, 10-m walk test, and BBS ||30 min/day, 5/wk for 2 months ||Both groups improved on function (FIM, FAC), balance (BBS), and walking speed ||10-month follow-up Good sample size |
|Sullivan et al215 (2002) ||24 subjects with chronic stroke ||Nonrandomized cohort design Intervention program: BWSTT, 3 groups of varying speeds (slow speeds 0.22 m/sec; variable speeds 0.22 m/sec to 0.89 m/sec; fast speeds greater than 0.89 m/sec) Outcome measures: FMA, 10-m walk; self-selected walking speed OG ||12 sessions, 20-min duration, over 4-5 wk ||Training at fast speeds was more effective at improving speeds of OG walking than training at slow or variable speeds ||No control group Gains maintained at 3 months Small sample size |
|Dean et al218 (2010) (the MOBILIZE trial) ||12 subjects, within 4 weeks of stroke, undergoing inpatient rehab, unable to walk ||RCT 2 groups: (1) BWSTT, (2) OG walking ||30 min/day ||At 6 months, no difference between indep walkers from both groups in terms of speed or stride; indep walkers in BWSTT group walked 57 m further (6-Minute Walk Test) and rated their walking 1 point (out of 10) higher than OG group ||BWSTT is safe and feasible for patient with subacute stroke; supports better walking capacity and perception of walking compared to OG walking |
|Sullivan et al222 (2007) (the STEPS trial) ||80 subjects, ambulatory; 4 mo-5 yr post-stroke ||RCT; 4 groups of combined interventions: (1) BWSTT with UE ergometry (BWSTT/UE-EX), (2) leg cycle ergometry with UE-EX (CYCLE/UE-EX), (3) BWSTT with leg cycling (BWSTT/CYCLE), and (4) BWSTT with LE progressive resistive exercise (BWSTT/LE-EX) ||Exercise sessions were 4/wk for 6 wk (24 total sessions) Outcome measures: self-selected and fast walking speeds, 6-Minute Walk Test ||The BWSTT/UE-EX group had significantly greater increases in walking speed compared to CYCLE/UE-EX group; both groups improved walking distance; all BWSTT groups increased walking speed and distance ||Task-specific BWSTT was more effective in improving walking speed and maintaining gains at 6 mo than leg cycling (CYCLE/UE-EX) LE strength training alternated daily with BWSTT (BWSTT/LE-EX) did not provide an added benefit |
|Moseley et al49 (2009) (Cochrane Database Systematic Review) ||15 high-quality studies, 622 subjects ||Meta-analysis of LT studies Outcomes: walking dependency, speed, and endurance ||Variable by study ||No significant statis tical differences between TT, with or without BWS, and other physiotherapy interventions on outcomes; indep walkers at start of treatment tended to develop higher walking speeds; dep walkers at start of treatment may benefit from BWS; few adverse events reported ||Physiotherapy, both BWSTT and conventional LT, were effective in improving walking function in patients post-stroke |
|Franceschini et al221(2009) ||97 subjects, within 6 weeks of stroke onset ||RCT; 2 intervention groups: (1) conventional rehab plus BWSTT, (2) conventional rehab plus OG gait training Outcome measures = Motricity Index, Trunk Control Test, Barthel Index, Functional Ambulation Categories, 10-Meter and 6-Minute Walk Tests, Walking Handicap Scale ||60-min sessions every weekday for 4 weeks ||After treatment, all patients were able to walk Both groups showed significant improvement on all outcome measures ||In subacute patients, BWSTT is as feasible and effective as conventional gait training |
|Lewek et al227 (2009) ||19 subjects with chronic stroke (> 6 mo) ||RCT; comparing therapist-assisted versus robotic-assisted LT Outcome measures: gait analysis (kinematic coordination), self-selected speed during OG walking ||4 wk of LT, 3 sessions of LT per week for 4 weeks ||LT with therapist assistance resulted in significant improvements in consistency of intralimb movements of the impaired limb ||Providing consistent (fixed) kinematic assistance during robotic-assisted LT did not result in improvements in intralimb consistency Small sample size |
|Duncan et al224 (2011) (the LEAPS trial) ||408 subjects with stroke (2 months; stratified into 2 groups: (1) moderate impairment (able to walk 0.4 to (0.8 m/sec); and (2) severe impairment (able to walk (0.4 m/sec) ||RCT; 3 intervention groups: (1) BWSTT 2 mo after stroke (early LT), (2) BWSTT 6 mo after stroke (late LT), and (3) home-based exercise program Outcome measure: proportion of participants with improvement in walking ability at 1 yr (walking speed, motor recovery, balance, functional status, and quality of life) ||36 sessions of 90 min each for 12-16 wk ||52% of all participants improved in walking ability; no significant differences between groups in terms of walking function; multiple falls were more common in severe impairment group receiving early LT ||LT using BWSTT was not found superior to progressive exercise at home managed by a physical therapist |
The Locomotor Experience Applied Post-Stroke (LEAPS) trial was a large, multicenter randomized controlled trial.223,224 Four hundred eight participants were recruited from six inpatient rehabilitation centers and stratified according to walking impairment. Those with moderate impairment were able to walk 0.4 to less than 0.8 m per second while those in the severe group were able to walk less than 0.4 m per second. Participants were randomly assigned to one of three treatment groups: (1) early locomotor training using BWS TT 2 months after stroke, (2) late locomotor training using BWS TT 6 months after stroke, and (3) home exercise using therapist-directed exercise training 2 months after stroke. The latter group received exercises designed to improve flexibility, strength, coordination, and balance along with encouragement for daily walking. Each intervention had similar intensity and duration (36 sessions of 90 minutes each for 12 to 16 weeks). The researchers found that all participants increased in their functional walking ability. No significant differences were found between the groups in terms of improvements in walking speed, motor recovery, balance, functional status, and quality of life. Outcomes of participants in the early and late locomotor training (LT) groups also revealed no significant differences at 1 year. The researchers concluded that early intervention may accelerate gains in walking ability after stroke. The research reviewed supports the benefits of physical therapy in improving walking outcomes. There is no clear evidence of the superiority of one type of intervention over another.
Robotic-Assisted Locomotor Training
Electromechanical, robotic-assisted LT is used in rehabilitation to improve walking after stroke. In a Cochrane Systematic Database review, Mehrholz et al 54 reviewed 17 trials involving 837 participants. When combined with conventional physiotherapy, these devices were found to increase the odds of patients becoming independent walkers. Increases in gait speed or walking capacity were not found. Study differences were noted in variations of (1) initial level of patient independence in walking, (2) duration and frequency of treatment, and (3) use of electrical stimulation used in some devices. In a systematic review of 16 studies that included a total of 558 patients, Tefertiller et al found that no studies demonstrated a significantly improved functional ambulatory capacity with conventional LT or TT with BWS and manual assistance versus TT with BWS and robotic assistance.225 Lewek et al226 found that therapist-assisted LT when compared to robotic-assisted LT resulted in significant improvements in coordination of intralimb kinematics, lending support to the value of variable practice versus constant practice. In a systematic review of studies recruiting nonambulatory patients early after stroke (6 studies involving 549 participants), Ada et al227 found that mechanically assisted LT with BWS resulted in more people walking independently at 4 weeks and at 6 months.
Functional Electrical Stimulation
Functional Electrical Stimulation (FES) can be used to stimulate dorsiflexor function and improve the gait pattern of patients with drop foot. Sufficient strength in the quadriceps muscle is needed to prevent the knee from buckling. This requirement limits the number of patients who can successfully use the device. The patient wears a small, lightweight cuff that fits just below the knee. Electrodes are positioned to stimulate the anterior tibialis and the peroneus longus muscles. A gait sensor attaches to the patients shoe and transmits a wireless signal to the stimulator. The level of stimulation can be adjusted by a handheld remote control, which also allows the patient to turn the device off and on. The device can be used as a bridge to the recovery of normal motor function or, in the absence of recovery, can be used indefinitely. FES training should be paired with a comprehensive physical therapy POC. In a systematic review of the literature (30 studies), Roche et al228 reported that FES had a significant positive effect on gait with improvements noted in gait speed and physiological cost index (PCI) in patients with chronic stroke. FES is theorized to have a positive effect on brain plasticity with its provision of high-level sensory-motor input into the CNS.229 This may explain research findings of improved gait function with FES when compared to orthotic intervention.230
Orthotics and Assistive Devices
An orthosis may be required when persistent problems prevent safe ambulation (e.g., inadequate ankle dorsiflexion during swing, mediolateral ankle instability, and insufficient push-off during late stance). Prescription will depend on the unique problems each patient presents. The pattern of instability and weakness at the ankle and knee and the extent and severity of spasticity and sensory deficits of the limb are major considerations when prescribing an orthosis. Temporary devices (e.g., dorsiflexor assists) may be used during the early stages while recovery is proceeding to allow the patient to practice standing and walking. Use of a temporary orthosis also provides insight into the type of components that will most effectively address the patient's needs. Permanent devices are prescribed once the patient's status stabilizes. Consultation with a certified orthotist and clinic team is initiated if a permanent orthosis is needed.
Foot-Ankle Controls. An ankle-foot orthosis (AFO) is commonly prescribed to control impaired ankle/foot function. These may include a custom-molded polypropylene AFO (posterior leaf spring, modified AFO, or solid ankle AFO), or conventional double upright/dual channel AFO. The least restrictive AFO is the posterior leaf spring (PLS) used to control drop foot. An AFO of higher-density plastic that covers more surface area can provide additional control of calcaneal and forefoot inversion and eversion. A solid ankle molded AFO provides maximum stabilization through its lateral trim lines that project more anteriorly. Movement in all planes (dorsiflexion, plantarflexion, inversion, and eversion) is limited. The conventional double upright metal AFO may be indicated for patients who cannot tolerate plastic AFOs owing to sensory impairments, girth fluctuations, or diabetic neuropathy, or who require additional controls. A posterior stop can be added to limit plantarflexion while a spring assist can be added to assist dorsiflexion (Klenzak joint). Advantages of a conventional AFO include better stabilization of the ankle, allowing improved heel-strike and push-off.231 Disadvantages include heavier weight, less cosmetic appearance, and increased difficulty donning and doffing.
Knee Controls. Knee instability following stroke can be controlled with an AFO by adjusting the position of the ankle. An ankle set in 5° dorsiflexion limits knee hyperextension, while an ankle set in 5° plantarflexion decreases the flexor moment and stabilizes the knee during midstance. A patient with knee hyperextension without foot and/or ankle instability may benefit from the application of a Swedish Knee Cage or strapping to protect the knee. Extensive bracing using a knee-ankle-foot orthosis (KAFO) is rarely indicated or successful. The added weight and restrictions in normal knee joint motion significantly increase energy costs and limit independent function.
The need for an orthosis or a particular type of orthosis may change with continuing recovery. The therapist may need to recommend a change in prescription or discontinuing the use of a device. With limited reimbursements, ordering a new orthosis may prove problematic and speaks to the need to anticipate changes when ordering the initial device. For example, a good option for the patient who needs a custom-molded solid AFO is to order a hinged AFO with a plantarflexion stop. As the patient regains sufficient knee and dorsiflexor control, the device can be adjusted to remove the stop and allow the hinges to work. Orthotic training includes donning and doffing, skin inspections, and education in safe use of the device during gait. See Chapter 30, Orthotics, for a more complete description of orthotic devices, examination, and training.
Most patients require the use of a wheelchair for mobility at some point during their recovery. Patients with stroke exhibit typical postural asymmetries, which need to be carefully evaluated. These include the following:
Trunk laterally flexed to the weaker side; head may also be flexed to the weaker side.
Pelvic posterior tilt with some obliquity (lower on the unaffected side).
LE rolled out into abduction and external rotation; if spasticity is present, increased hip extension, adduction, and internal rotation with knee extension may occur; foot is typically plantarflexed and inverted.
UE held flexed and adducted to the trunk with increased elbow, wrist, and finger flexion. With flaccidity, the shoulder is subluxed with the hand dangling in a dependent position.
Positioning in a wheelchair needs to correct for these postural asymmetries and ensure correct sitting posture. The reader is referred to Chapter 32, The Prescriptive Wheelchair, for a more complete discussion of general principles of prescription and wheelchair adaptations.
A patient with stroke can learn to propel a wheelchair using the stronger UE and LE. The seat-to-floor height is critical in ensuring successful use of the foot for steering and propulsion. A hemi-height wheelchair with a lower seat-to-floor height (17.5 in [44.45 cm]) may be required. A standard wheelchair has a seat-to-floor height of 19.5 in (49.53 cm). One-arm drive chairs in which both handrims are placed on one wheel were designed for individuals with only one functional UE. The patient with stroke is rarely successful in using this type of chair because it takes a great deal of strength and coordination to propel the wheelchair in a forward direction. It is contraindicated in patients with significant perceptual and cognitive impairments. A power wheelchair may be required for some individuals who cannot successfully use a manual wheelchair and will depend on a wheelchair as their primary means of locomotion. The therapist needs to consider individual needs and reimbursement policies when ordering a wheelchair. It is important to balance both present and future needs as providers restrict frequent reordering of a new wheelchair. It is also important to remember that prolonged used of a wheelchair contributes to learned nonuse and may limit recovery, especially if walking is a primary goal of therapy. Wheelchair training activities include patient and caregiver instruction in the use, maintenance, and safety of all parts of the wheelchair (e.g., brakes, leg rests, removable armrests). The patient needs to be instructed in methods of propulsion and given the opportunity to practice on level and varied surfaces (e.g., ramps, outdoor terrain). Transfers (to and from bed, toilet, tub, car) should also be practiced once the patient receives the prescriptive wheelchair.
Interventions to Improve Aerobic Capacity and Endurance
Patients with stroke demonstrate decreased levels of physical conditioning following periods of prolonged immobility and reduced activity. The energy costs to complete many functional tasks are higher than normal owing to the abnormal ways in which the activities are performed. Many patients also demonstrate concomitant cardiovascular disease and may experience hypertension, serious dysrhythmias, and volitional fatigue. Patients with stroke require careful determination of cardiopulmonary responses during exercise and appropriate monitoring.
Individuals recovering from stroke can benefit from endurance (aerobic) training to improve cardiovascular function. During the early acute stages, functional activity training is appropriate (e.g., overground walking). During the postacute stage, patients/clients may be able to engage in more traditional exercise training modes such as treadmill walking, cycle ergometry (upper and lower body ergometer), or seated stepper. Patients with balance impairments will benefit from treadmill training or overground walking with a safety harness, or a recumbent cycle ergometer. To ensure safety, patients should receive a thorough examination and supervised exercise test before starting a training program (e.g., symptom-limited graded exercise test). Prescriptive elements include mode (type of exercise), frequency, intensity, and duration (see Chapter 13, Heart Disease). Choice of training mode depends on the individual's abilities and interests. Intensities are typically in the range of 40% to 70% of maximal oxygen uptake. Suggested frequency is three to five days per week for 20 to 60 minutes per session. Frequency may be increased to daily if lower intensities are used. Because of the level of deconditioning, patients with stroke should begin with intermittent training protocols but can be progressed to 30 minutes of continuous exercise. The use of a training log or exercise diary is an excellent way to help the patient keep track of prescriptive elements, objective measurements (heart rate, BP), and subjective reactions (RPE, perceived enjoyment). Adequate supervision, monitoring, and safety education about warning signs for impending stroke and heart attack are critical components.24,232
Careful monitoring of exercise is essential. For patients at risk, BP, heart rate (HR), and RPE should be taken initially, during, and after each exercise. As exercise progresses, less frequent monitoring can be implemented. The therapist also needs to monitor breathing rate and pattern, ensuring breath holding and Valsalva do not occur. Patients should be instructed in how to measure their own HR and RPE. They should also be taught the warning signs for when to stop exercising. These include the following:
Lightheadedness or dizziness
Chest heaviness, pain, or tightness; angina
Palpitations or irregular heart beat
Sudden shortness of breath not due to increased activity
Volitional fatigue and exhaustion
Patients who are on medications that limit cardiac output (e.g., beta-blockers) will demonstrate reduced HR responses and lower peak HRs. Patients taking diuretics to reduce fluid volume may demonstrate altered electrolyte balance with resulting dysrhythmias. Patients taking vasodilators may require a longer cool-down period after exercise to prevent post-exercise hypotension.24
Patients undergoing an aerobic conditioning program demonstrate improvements in physical fitness, functional status, psychological outlook, and self-esteem. Regular exercise may also have the additional benefit of reducing risk of recurrent stroke or heart attack. Patients who participate in a regular conditioning program may be more successful in adopting continuing, life-long exercise habits and in moving beyond the disability associated with stroke. In a Cochrane Database Systematic Review, Brazzelli et al51 reviewed 32 trials with 1,414 participants and found that cardiorespiratory fitness training after stroke can improve walking performance including maximal walking speed, preferred gait speed, and walking capacity while reducing dependence during walking. Training effects were retained at follow-up. Adverse effects including death were infrequent.
Circuit class training (CCT) for improving mobility after stroke was the subject of a Cochrane Systematic Database Review.52 English and Hillier52 reviewed 6 trials with 292 participants (inpatients or community-dwelling) and found that CCT was safe and effective for improving mobility for people after moderate stroke. It may also reduce inpatient length of stay. Rose et al233 reported on the effectiveness of a circuit training physical therapy (CTPT) program in the acute rehabilitation setting. Patients received a 60-minute training session, 5 days/wk, using four task-specific stations. Activities were stratified and tailored to patients' specific mobility levels (nonambulatory, severe, moderate, and mild groups). In addition, a 30-minute daily session was dedicated to critical inpatient rehabilitation issues (family and home program education, wheelchair and orthotic prescription). When compared to standard physical therapy (SPT) of the same intensity, the CTPT groups showed significantly greater improvements in gait speed, primarily in ambulatory patients.