Physical therapists work with large numbers of stroke victims in various settings (inpatient/outpatient rehabilitation, acute care hospitals, subacute care hospitals, skilled nursing facilities, home healthcare, hospital and private outpatient clinics) to improve their functional recovery and quality of life. Stroke is the most significant cause of serious, long-term disability in the United States. The time it takes to recover from a stroke depends on the extent of damage to the brain. More than half of stroke survivors regain their functional independence, while 15% to 30% are permanently disabled, and 20% still require in-patient care three months after the stroke.Roger, V., Go, A. S., Lloyd-Jones, D., Adams, R. J., Berry, J. D., Brown, T. M., . . . Wylie-Rosett, J. (2011). Heart disease and stroke statistics--2011 update: A report from the american heart association. Circulation, 123(4), e18-e209. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=mnh&AN=21160056&site=ehost-live Following a stroke, the patient's degree of disability is largely determined by their available mobility. Lack of efficient residual muscle function following a stroke limits endurance in most stroke survivors.Bogey, R., & Hornby, G. T. (2007). Gait training strategies utilized in poststroke rehabilitation: Are we really making a difference? Topics in Stroke Rehabilitation, 14(6), 1-8. doi:10.1310/tsr1406-1
History
Physical Therapy
Physical therapy is a health care profession that provides services to clients, helping them maintain, develop, and restore maximum movement and functional ability throughout the lifespan. These services are provided in situations where movement and function are endangered by ageing, injury, disease or environmental factors.World Confederation for Physical Therapy.Description of physical therapy. Retrieved October 24, 2011, from http://www.wcpt.org/node/28657
Physical Therapists (PTs) are trained to diagnose and treat physical conditions which impact quality of life and movement potential of individuals. Physical Therapy practice includes the spheres of health promotion, disease prevention, treatment/intervention, habilitation, and rehabilitation.
Physical therapy is designed to help recover functionality, reduce the chances of having another stroke, and improve daily living. One important focus in rehabilitation is aerobic training, as the cardiorespiratory fitness of most stroke survivors is extremely low at the beginning of rehabilitation.
Stroke
Stroke is a clinical event caused by an acute interruption of blood flow to a part of the brain or spinal cord. Stroke results from the lack of oxygen that occurs when an artery to the brain becomes blocked by a clot (cerebral infarction) or bursts (cerebral hemorrhage). Stroke is the third leading cause of death in the United States, trailing only heart disease and cancer.
Neuroplasticity
Neuroplasticity is the capability of parts of the central nervous system (CNS) to change their structure and function in response to conditions and events.Harvey, R. L. (2009). Improving poststroke recovery: Neuroplasticity and task-oriented training. Current Treatment Options in Cardiovascular Medicine, 11(3), 251-259. This adaptability of CNS to change allows the nervous system to reorganize and relearn in response to environmental stimulation thus contributing to recovery from various brain and spinal cord injuries.Johnston, M. V. (2009). Plasticity in the developing brain: Implications for rehabilitation. Developmental Disabilities Research Reviews, 15(2), 94-101. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=mnh&AN=19489084&site=ehost-live
Changes within the brain both structurally and functionally can be detected by transcranial magnetic stimulation(TMS), magnetic resonance imaging, and positron emission tomography. Clinical trials have shown neuroplasticity through constraint-induced movement therapy used with patients having hemiparesis after stroke.
Interventions
For many stroke victims, motor learning, which contributes to patients' acquisition of motor skills, is a vital part of the physical therapy treatments utilized in rehabilitation protocols. Physical therapy interventions used in patient care range from the conventional interventions such as the Bobath, Brunnstrom, and proprioceptive neuromuscular facilitation (PNF) to more recent therapies like promotion of specific/functional/repetitive tasks, constraint-induced movement therapy, electrical stimulation, and different types of gait training. All of the interventions listed below have been researched and described in the physical therapy literature. Additionally, stroke patients should incorporate a scheduled aerobic exercise at an appropriate intensity. Treadmill or cycling can be used jointly with task-focused walking, task-oriented practice balance exercise, aquatic therapy, and strength training to develop fitness and function simultaneously.
Conventional interventions
The rehabilitation techniques of Bobath and Brunnstrom, as well as proprioceptive neuromuscular facilitation (PNF) focus primarily on retraining motor control by facilitating the desired movement patterns or inhibiting less-desired ones. When comparing the more conventional neurofacilitation approaches with recent interventions for stroke, no significant improvement in walking or activities of daily living have been seen with the more conventional approaches.
Bobath
The Bobath technique is partially founded on the thought that a normal reflex mechanism is the basis for normal movement patterns. After stroke, patients with hemiplegia are limited in their movement patterns and tend to exhibit more flexor and/or extensor synergies. The Bobath approach is used as an intervention for patients with hemiparesis, but there is insufficient evidence for its impact on gait.
Brunnstrom
To regain global synergistic movements and muscle tone the Brunnstrom approach utilizes coupled reactions, primitive postural reactions, and resistance. There is insufficient evidence to support the use of the Brunnstrom approach with gait training after stroke.
Proprioceptive neuromuscular facilitation (PNF)
PNF is used to facilitate movement via the use of resistance. Resistance is limited to an amount that does not allow abnormal movement patterns.
Recent interventions
Task oriented learning
Task oriented training focuses on skill acquisition through the motor learning of functional tasks. Practice of these skilled motor learning tasks is the key to cortical reorganization. Principles of task oriented training include specificity of training, constrained use of the impaired limb, mass practice, shaping of skill, saliency of task, and knowledge of performance and results. Recent evidence suggests that exercise-based rehabilitation approaches, including aerobic training, resistance exercise, and task-oriented therapy, play a critical role in improving functional outcomes after stroke. A systematic review found that combined rehabilitation programs (e.g., integrating strength, aerobic, and functional training) are more effective than single-modality interventions for improving gait, upper extremity function, and activities of daily living. Additionally, early initiation of active rehabilitation is associated with better recovery outcomes compared to prolonged rest.
Specific/functional/repetitive tasks
Repetitive task training for improving functional ability after stroke was analyzed in a Cochrane Review. The authors/reviewers focused on task specificity more than repetition. They looked at 14 studies and found that even though improvements in walking distance, walking speed, and sit to stand ability were demonstrated with practiced functional activities, six months later improvements failed to be maintained. Small improvements were shown with acts of daily living and no impact was seen with arm/hand function with repetitive practice of tasks. The duration of time after stroke had no impact on training outcomes.French, B., Thomas, L. H., Leathley, M. J., Sutton, C. J., McAdam, J., Forster, A., . . . Watkins, C. L. (2007). Repetitive task training for improving functional ability after stroke. Cochrane Database of Systematic Reviews (Online), (4), CD006073. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=mnh&AN=17943883&site=ehost-live
Circuit class therapy (CCT) is another intervention using repetitive task training with functional tasks. A Cochrane review of studies of the effects of circuit class therapy on the improvement of mobility after stroke revealed that people with moderate stroke impairments may show improved mobility with this safe intervention. CCT may also decrease the number of days needed for inpatient care.English, C., & Hillier, S. L. (2010). Circuit class therapy for improving mobility after stroke. Cochrane Database of Systematic Reviews (Online), (7), CD007513. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=mnh&AN=20614460&site=ehost-live
Constraint induced movement therapy (CIMT)
Constraint induced movement therapy is utilized in patients with stroke as an intervention within rehabilitation settings. It is used to decrease learned non use of the affected limb and force the use of that limb while restraining the unaffected limb. Repetitive, functional tasks are performed to increase motor learning, motor skill, and function in the affected limb.
A study was conducted to look at feasibility and compare efficacy of a modified CIT protocol, traditional OT/PT, and no therapy at all for improving upper-limb outcomes for patients with subacute CVAs (cerebrovascular accident). Groups receiving no therapy and traditional therapy did not show improvements, but for patients instructed with modified CIT, improvements were seen in fine motor skills, outcome measures, and quality and amount of limb use. The evidence suggests effectiveness for using modified CIT with distributed practice and repeated use to increase functional use and decrease impairments. This study further supports various practice schedules as a tool to be used for motor learning development.Page, S. J., Sisto, S. A., Levine, P., Johnston, M. V., & Hughes, M. (2001). Modified constraint induced therapy: A randomized feasibility and efficacy study. Journal of Rehabilitation Research and Development, 38(5), 583-590. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=mnh&AN=11732835&site=ehost-live
Tarka and Kononen, 2009, have reported that "CIMT provides increasingly difficult motor challenge with a motor learning component, and thus provides activations in the brain that may enhance reorganization related to motor control." They conclude that CIMT when used on subjects with mild or moderate upper limb paresis is an effective technique to be used.Tarkka, I. M., & Könönen, M. (2009). Methods to improve constraint-induced movement therapy. Neurorehabilitation, 25(1), 59-68. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=mnh&AN=19713619&site=ehost-live
The EXCITE (Extremity Constraint Induced Therapy Evaluation) randomized clinical trial researched the effects of CIMT on upper extremity function in adults with stoke in the previous 6–9 months. The results of this study demonstrated that CIMT produced significant clinical improvement in arm movement lasting at least 1 year.
Activities of daily living (ADLs)
Activities of daily living include every day acts performed out of necessity to live and for self care. These include bathing, grooming, toileting, feeding, transfers (i.e. sit to stand, sit to lying), bed mobility, dressing, and locomotion/gait (walking).