quarta-feira, 23 de março de 2011

Stroke exercises

Here are some therapeutic activities for patients that suffered from stroke. The following exercises will teach the patient to:
1.      Do effective bridging in bed;
2.      Roll in bed and transfer from supine lying to sit on edge of bed;
3.      Hold sitting and standing;
4.      Reach in all directions and to the floor while in sitting and in standing;
5.      Transfer from bed to chair and back;
6.      Walk with or without assistive device and/or outside help.
7.      perform voluntary activities with the affected upper limb such as: in sitting with arms supported on a table: reaching forward, weight bearing on the affected hand, bring a glass to his mouth, pick and release object on a table, etc…
8.      Perform voluntary activities with the affected lower limb such as: using a bed or table for support in stancing, step up and down forward on a stool, step up and down sideways on a stool, sitto-stand from different height and walks as often as possible.


Supported, sitting in bed with arms placed on a table or pillow, the patient is asked to reach and use his sound upper limb in activities according to his interest.
Assisted sitting on edge of bed, with arms supported on table and feet on floor or stool, the patient is asked to do any activity with sound upper and lower limbs.
While he performs these tasks with his sound side, he is also applying body weight on the affected side, thus, stimulating it.
With the patient seated on edge of bed, practice reaching and weight bearing activities with the affected side. These sitting activities are aimed at stimulating motor control in an upright position. Patient will be placed in the sitting position with as much help as needed. Remember that bed mobility activities are more demanding in energy and for this reason will be done after a few days of starting treatment.

Bed mobility activities
The bridging in bed can be done through stabilization of the lower limbs on the ankle or around the knees.
To roll in bed to the sound side, the affected arm can be placed across the chest and the affected knee flexed. The patient is asked to bring his head and affected shoulder towards the opposite side while pushing himself with the affected foot.
Progressively transfer from supine lying to sitting on the edge of bed: start from a supported 80 to 90 degrees sitting position in bed and ask the patient to come and sit on his sound side edge of bed. Progressively bring the head of the bed down so that patient is trained to achieve lie to sit independently.
To progressively achieve independent sit-to-stand, you must progress from a high to a low surface. Before attempting to stand, the feet must be well positioned on the floor behind the knee and the head and shoulder well forward over the knees. The physical therapist, positioned in front of the patient or on his/her affected side, must use a walking belt around the patient’s waist and hold the patient by this belt, leaving the patient’s upper limbs free. Then gradually, the sitting surface will be progressively brought down until the normal height of a chair.
Walk with the patient around the bed or the treatment table. With the physical therapist standing behind or on the patient’s affected side, practice walking around the patient’s bed which he may use for support with his/her sound hand. He can practice walking forward, sideways and backward. Progressively, use less manual contact, so that patient gets used to walk more independently.
It is not recommended to use parallel bars to train walking as the bars give too much passive support and patient end up developing overuse of the sound hand on the bar.
When the patient is ready to walk away from the table or stable surface, give the patient a simple straight stick to help walking. It is not recommended at this stage to use a quadripode as it tends to produce a completely abnormal gait pattern.

Activities in standing
Reaching in standing: with the patient standing and positioned in front of a table, asked him to reach in all directions. While reaching with the sound hand, the affected hand is positioned in weight-bearing on the table.
With the sound hand supporting on the table or on the wall, the patient is asked to step on a low stool (8cm). Progression may be done by asking the patient to do the stepping without support. Later a higher stool may be used.

Prevention of stress, trauma and pain of the affected shoulder
Use proper positioning of the upper limb while the patient is in any given position. Avoid dangerous handling methods, especially while passive mobilization is performed and while helping patient to move in and out of position. Always support the arm when patient is sitting either in front or sideways on a high table. Use a belt to hold on patient, as it is preferable not to hold the affected upper limb. Never pull the affected arm. Exercise the upper limb actively to gain as much as possible motor control. Practice specially reaching in lying and in sitting arm supported on a table and weight-bearing on an open hand, in sitting. Encourage patient to use his/her affected hand to assist the sound hand during functional activities

Home program
Give oral and written information to patient and care givers on exercises, transfers and walking. If possible make a home visit or meet with the family to discuss home environment and patient’s needs for assistive devices and assistance during daily living activities

[1] Charlebois-Refae, N., Al-Mohanna, A., Zmani, A., Refae, N., Al-Ramezi, K., Mohammad, S., Al-Jwear, N. Physical Therapy Protocol For Acute Care Adult Hemiplegia. Ministry of Health - Kuwait

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