Movement or monotony? The outcome of stroke.
Subject: Paralysis (Care and treatment)
Author: Draper, Margaret C.
Pub Date: 07/01/2011
Publication: Name: New Zealand Journal of Physiotherapy Publisher: New Zealand Society of Physiotherapists Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 New Zealand Society of Physiotherapists ISSN: 0303-7193
Issue: Date: July, 2011 Source Volume: 39 Source Issue: 2
Accession Number: 288537986
Full Text: Until a few years ago stroke was one of the motor handicaps for which there was the least rehabilitation. With increasing awareness of the size and significance of the stroke problem it is now certainly one of the better known syndromes, and is extensively described in clinical neurology. Improvement in hemiplegia rehabilitation methods has not been attained by perfecting techniques which had proved their worth in the treatment of other motor diseases, for example fracture sequalae, but rather by a re-examination of the problem in the light of scientific data in the field of neurophysiology. Today's concept of neuromuscular retraining requires an understanding of the specific nature of stroke disability.

An essential foundation for stroke rehabilitation is a full assessment of the patient's abilities as well as his problems. Dissemination of this information throughout the team on a need-to-know basis must be made so that hospital staff and relatives under stand the patient and his needs.

Hippocrates first described stroke as apoplexy, the Greek word for 'strike down'. The word 'stroke' defines a clinical event: a vascular lesion in neurological territory. It is a disease with an acute, though not particularly dramatic onset, and a chronic end, leaving in its wake a lasting neurological deficit. For the patient and his relatives it is a very frightening experience. There is little wonder that it is accompanied by feelings of despair and depression, maybe anger and aggression, with fear of eventual dependency on others in the future.

Frequently a stroke produces a complete and sudden change; there is no time for the patient to adjust gradually. He is probably quite confused and disorientated, a state which may be accentuated if hospital admission is required, for surroundings and people are all strange to him. The two sides of the body present him with different sensations. He is, so to speak, divided into two halves with no interplay between the sound side and the affected side.

Initially the patient is unwell and bedfast, being nursed in side lying with a pillow between his legs to prevent internal rotation and adduction of the affected leg when this is uppermost. The shoulder must be eased forward into protraction and the arm relatively extended and supported on a pillow. These positions will help to prevent the patterns of spasticity and incorrect pro proprioceptive input which can occur even at this early stage. A bed-cradle will prevent bedcovers pushing the foot into inversion and plantarflexion.

Whenever the patient is turned and moved there is always a great fear of falling towards the affected side. Remember the heaviness of this side. Furthermore, there is no balance or arm support on that side. This fear of falling increases spasticity. (Everyone becomes tense when afraid of falling.)

Rotation of the trunk in side-lying, that is, movements of one part of the body on another, such as the shoulder girdle and pelvis, are the start of automatic body righting reactions. These movements give the patient the idea of what is required for rolling over or for moving from supine to either side. This last movement is needed to get up from lying to sit over the bed side. They are at first stimulated and guided with the patient watching and concentrating on the feel of the movement and its purpose.

Every precaution must be taken at this stage to make the patient feel secure at all times, in all requested activities. Every reassurance should be given that the present state of helpless and undignified dependency will be a transient one.

Physiotherapy should commence early, confining activities to those done in bed when the medical condition necessitates. It must be active and positive, providing the patient with the opportunity to re-establish his relationship with the environment and to experience a feeling of normal movement. This can be achieved by providing the patient with information about the movement he is performing with the therapist's assistance. For example, 'Reach up towards your head', or if he is semiconscious or unconscious, 'I am taking your hand to touch your head; and again when able to co-operate, 'Look at your hand'. This expectation of a response from the patient will elicit better responses than a pure passive movement. Further, it gives both auditory and visual feedback to reinforce his attempts at motor performance, possibly a more important consideration than mere maintenance of joint range.

In the early stages following stroke onset when hypotonia is prevalent and movement appears impossible, the effect of appropriate stimuli will compound or summate to produce a flicker of response, possibly in a small part of the range only at first. It also reinforces the patient's sensation of where he is in space. Only when the patient has learned the feel of normal sensation of movement again can he recognise and control it.

The ultimate aim of treatment is to develop and to use the maximal potential of the affected side integrated with movements of the sound side. He must become aware of movements of the head and the trunk at all times, even when moving the limbs, that is he must become aware of the co-ordinated activity and actions which occur when one shifts weight from one hip to the other.

At all times it is important to treat the patient as a whole, not the sound side only, where some independence may be gained fairly rapidly, while the hemiplegic side, especially the arm, is written-off. (Fortunately that practice is nowadays far less common.) However, IF permitted he quickly learns to over compensate with the sound side, orientating to the sound side during all activities. Therefore, establishment of body symmetry is all important as faulty habits are difficult to eradicate.

Automatic (involuntary) movement provides a base on which all voluntary movement is superimposed. Also it requires little conscious effort on the part of the patient. Too much effort by the patient indicates likely over-activity of the sound side. Further, it could lead to too much increase of muscle tone and spasticity. Spasticity must be inhibited if it asserts itself and associated reactions guarded against at all times.

Once the patient can come to sitting over the side of the bed, usually within a couple of days, he must learn to cope with the effects of gravity acting on his body. Learning to adjust, and to restore normal body alignment, posture and balance is begun by slow, gentle rocking to shift weight sideways, forwards, diagonally, etc. The therapist must guide and correct the necessary head and trunk compensations which should occur. Progression is by bringing in greater displacements of the centre of gravity and regaining balance.

From this it will be appreciated that the initial emphasis is placed on the possibility of controlling muscle tone, preventing it from becoming too high and thereby inhibiting more normal movements and sensations. It is now realised that a treatment programme which is based largely on compensatory activities, as was emphasised years ago, leads to an increase in spasticity and a decrease in the activity of the affected side. It is certainly more difficult, indeed, often impossible, to gain subsequent restoration of function of the affected side at a later stage once spasticity has become well established.

MEANS OF INHIBITING SPASTICITY

Inevitably patients with spasticity will be encountered. Briefly listed are some indications of how physiotherapy may assist in reducing spasticity when it is present.

The first of these uses joint approximation or compression.

Stimulation of joint and pressure receptors in a limb by the therapist giving compression through the arm (or leg) in lying and later by the patient in sitting (or standing) helps improve stability in that limb. When movement is superimposed on the weightbearing limb, by gentle rocking or swaying movements of the body, the feeling of weightbearing is increased and control in this position is learned. Though the exact mechanisms are unclear, function is improved as spasticity lessens. Symmetry of body is also encouraged.

Secondly, there are a number of facilitatory methods which can be used on less dominantly spastic muscle groups with consequent reduction of spasticity in their antagonists. For example, the forearm extensors are less spastic than the wrist and finger flexors. The typical posture of the spastic hemiplegia is a tightly fisted hand with inability to open the hand or release grasp. Therefore this flexion 'deformity' inhibits any possible extensor response.

1. One of the facilitatory methods is exteroceptive stimulation in the form of light touch and temperature (cold) stimulation--the so-called brushing and icing techniques. The brushing is done with a battery-operated brush lightly touching the appropriate skin area, that is the dermatomes whose nerve root supply is the same as the muscle to be stimulated. Ice is applied for 3-5 seconds to the same areas as those brushed.

The effects of brushing and icing are to increase fusimotor activity so making the neuromuscle spindle more responsive to stretch stimuli when these are applied secondarily. Hence, these techniques must be used in conjunction with stimulating techniques to the forearm extensors.

The same methods can be used around the mouth and over the cheeks to stimulate oro-facial tone. Disabilities of dribbling and a drooping mouth are embarrassing to the patient. Improving his appearance helps morale and motivation as well as the functions of eating, drinking and probably also his speech.

Though these techniques appear relatively simple to apply there are some precautions which must be observed and an understanding of the goals to be achieved is a basic prerequisite.

2. Use of vibration applied over a skeletal muscle with a mechanical vibrator is another method. This induces a reflex contraction of the muscle vibrated-the tonic vibration reflex--and simultaneous relaxation of its antagonist.

This adjunct seems most effective in patients with apparent 'weakness' of movement and gives improved awareness of the movement required as well as a focus for attention.

Thirdly, there exist a variety of measures aimed specifically at producing inhibitory effects.

(i) Having the patient grip on a hard cone placed in his hand and reinforced by the therapist, gives inhibitory pressure of the long flexor tendons, the thenar and hypothenar eminence. The objective is to gain co-contraction of the forearm musculature but release of the grasping so that the patient will be able to open his hand and use it more functionally. Note this gripping by the patient must be on a hard surface. Never encourage that well-meaning person who advises him 'to squeeze a ball' for this soft grip facilitates grasp and release becomes even more impossible to achieve.

(ii) Prolonged ice application either by immersion in ice water or an ice pack may be used as an inhibitory adjunct. Cooling reduces the conductivity of nerves and so lessens the sensitivity of the neuromuscle spindle. Hence, the increased tone is decreased (that is, hyper-reactivity is reduced). Further, there is persistence of the tonal decrease even when the muscle is exercised. If then, during this period, function can be improved, there is every likelihood of a carry-over to the patient's benefit.

(iii) Use can be made of reflex inhibiting patterns. By altering the abnormal postures and movements seen as a result of spasticity, hypertonicity can be reduced. In effect the side-lying position described earlier is making use of reflex inhibiting patterns.

The fourth major consideration is electromyographic bio feedback, a more recent development. This gives the patient a means of monitoring the state of his muscular activity. It can be used either to help reduce tension where this is excessive or to increase muscle activity when this is required for a particular action.

While it is important to consider the symptoms of stroke, the neurological reasons for these symptoms, and to have a command of techniques, one must never lose sight of the all important fact that these are a means to an end. Success can be judged only by the degree to which the patient's symptoms have been inhibited and function and quality of life improved. The main objective of any treatment, whatever the technique used, must remain the same, to give the patient the incentive and ability to act for himself, to move and not to lead a life of monotony. The art lies in the enlightened withdrawal of support. These techniques often appear to doctors to lack the seal of scientific respectability. Drugs can be evaluated against a placebo by means of a double blind cross-over trial. No-one has devised, nor ever will, a convincing placebo physiotherapist let alone a patient so blind that he is unaware whether he is having exercises or not.

Commentary

It is always interesting to look back in time and reflect on where we were as a profession. This article, written in 1981 by Margaret Draper certainly captures a time when the Bobath concept was beginning to be embraced by physiotherapists working with stroke patients. At the time an emerging understanding of neurophysiology, particularly regarding spasticity was influencing our practice and the article reflects this with a section outlining techniques to inhibit spasticity in highly spastic muscle groups and facilitate activity in less spastic muscle groups. Of great importance in this article is Margaret Draper's underlying message; that physiotherapy for people with stroke should be based on current knowledge of movement control. Today's approaches to neurological rehabilitation are built on knowledge of motor control and motor learning that emphasise task related practice, the importance of repetition, the importance of intensity and frequency of practice, and the importance of the specificity of the task to real life functional movement. Our understanding of spasticity is greater than before and, in particular, the evidence that increasing spasticity during exercise based rehabilitation has no detrimental effect on functional movement has significantly changed practice. Physiotherapists operating within a contemporary framework would not hesitate to use effortful strength and power training, they would consider the structuring of practice to emphasise task specificity and try very hard to ensure that the amount of practice was high enough to result in neuroplastic changes within the brain.

Whilst the detail of what we would do in our practice has changed since the 1980's there are some statements within Draper's article that hold true today. That rehabilitation should start early and should be active, that the patient should be treated as a whole, and that success is only judged by the extent to which function and quality of life are improved are ideas that remain pertinent today. One thing I am sure of is that in thirty years time our practice will have changed again, in line with new knowledge of how the brain controls movement.

Assoc Prof Denise Taylor

Health and Rehabilitation Research Institute

AUT

BIBLIOGRAPHY

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Bobath B (1977). Treatment of Adult hemiplegia. Physiotherapy 60, 310.

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Draper M (1967). Sensibility and the Hand. NZ J Physio 3, 11.

Draper, M. (1968). Aids to Improving Vocalization. NZ J Physio 3, 11.

Draper, M. (1972). The Clinical Application of Muscle Vibration. NZ J Physio 4, 31.

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Margaret C Draper, mcsp, DipTPnzrp, Director of Physiotherapy Services, North Canterbury Hospital Board Paper delivered at the Third Annual Conference of Geriatric Medicine & Gerontology, Wellington, November 1980.
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