Cerebrovascular

Accidents
strokes
 Definition

sudden onsetof neurologic

signs and symptoms resulting
from a disturbance of blood
supply to the brain.
 ETIOLOGY
Ischemic Cerebrovascular Accidents

Hemorrhagic Cerebrovascular Accident

Transient Ischemic Attacks

 Ischemic Cerebrovascular
Accidents
Ischemia is a condition of hypoxia or

decreased oxygenation to the brain tissue

.and results from poor blood supply

Ischemic strokes can be subdivided
:into two major categories
1-Thrombotic:due to atherosclerosis.

2-Embolic:due to cardiovascular disease,

specifically atrial fibrillation, myocardial

infarction, or valvular disease.

 ischemic penumbra
The area surrounding the infarcted
cerebral tissue.
 Glutamate
The cells that control glutamate levels are
compromised, which leads to
overstimulation of postsynaptic receptors.
This excessive level of glutamate in the
extracellular space facilitates the entry of
calcium ions into the cell. Calcium ions
enter the brain cells and further propagate
cellular destruction and death.
 calcium ions
Various destructive enzymes and free
radicals (neurotoxic by-products) are
activated by these calcium ions, and this
process leads to additional damage of
vital cellular structures.
 Hemorrhagic Cerebrovascular
Accidents
Types:
intracerebral hemorrhage: due to vessel-1
.malformation, hypertension and aging

Subarachnoid hemorrhages: due to-2

.aneurysm(berry) and vessel malformation

Arteriovenous malformations: arteries and-3

veins communicate directly without a conjoining
.capillary bed
Transient Ischemic Attacks
A TIA resembles a stroke in many ways.
1-The blood supply to the brain is
temporarily interrupted.
2-Neurologic dysfunction, including loss of
motor, sensory, or speech function.
3-These deficits, however, completely
resolve within 24 hours.
 MEDICAL INTERVENTION
Diagnosis.

Acute Medical Management.

 Diagnosis

hospitalization to determine the etiology

physical examination to
evaluate motor, sensory,
.speech, and reflex function

Subjective information received

from the patient or a family

computed tomographic scan or a

magnetic resonance image is performed to determine
whether the CVA is the result of ischemic or hemorrhagic
.injury
Acute Medical Management

monitoring the preventing the

patient's development of
neurologic function secondary
complications
Acute Medical Management
Regulation of the patient's blood
pressure, cerebral perfusion, and intracranial
pressure

improve blood flow and to minimize tissue

damage

Heparin diuretics calcium

channel
blockers

thrombolytic neuroprotective
agents
Acute Medical Management
Thrombolytic medications

tissue
plasminogen
activator (tPA)

helps to dissolve blood

clots and
increase blood flow
Acute Medical Management

Neuroprotective agents minimize tissue

damage

Medications that modifY or interfere with glutamate release

or enhance recovery from calcium overload
 Surgical intervention

placement of a metal
clip at the base of an aneurysm

removal of an abnormal
vessel

evacuation of a hematoma
 PREVENTION OF C.V.A
Risk factors:
1-hypertension. 2-heart disease.

3-diabetes mellitus. 4- hyperlipidemia.

5 cigarette smoking. 6- history of prior CVAs or TIAs.

7- sex: males more. 8- Race: African Americans.

9- family history. 10- alcohol consumption.

11- physical inactivity. 12- obesity, and age

,
,,
 STROKE SYNDROMES
1-Anterior Cerebral Artery Occlusion.
2-Middle Cerebral Artery Occlusion.
3-Vertebrobasilar Artery Occlusion.
4-Posterior Artery Occlusion.
5-Lacunar Infarcts.
6-Other Stroke Syndromes.
7-Thalamic Pain Syndrome.
8-Pusher Syndrome.
Circle of Willis
Anterior cerebral artery
 Anterior Cerebral Artery
Occlusion
Un common.
caused by an embolus.
Contralateral weakness and sensory loss
primarily in the lower extremity,
incontinence, aphasia, memory and
behavioral deficits.
Middle cerebral artery
Middle Cerebral Artery Occlusion
The most common.
Contralateral sensory loss and weakness
in the face and upper extremity.
less involvement in the lower extremity.
homonymous hemianopia.
global aphasia of dominant side.
loss of conjugate eye gaze.
vertebrobasilar artery
Vertebrobasilar Artery Occlusion
Often fatal.
Cranial nerve involvement (diplopia,
dysphagia, dysarthria, deafness, vertigo)
Ataxia, equilibrium disturbances,
headaches, and dizziness.
locked-in syndrome.
Posterior cerebral artery
 Posterior Artery Occlusion
Contralateral sensory loss, thalamic pain
syndrome, memory deficits.
homonymous hemianopia, visual agnosia,
and
cortical blindness
Lacunar Infarcts
 Lacunar Infarcts
encountered in the deep regions of the
brain including the internal capsule,
thalamus,basal ganglia, and pons.
common in individuals with diabetes and
hypertension.
Contralateral weakness and sensory loss,
ataxia, and dysarthria.
Parietal lobe
 Parietal lobe
The neurologic impairments:
-inattention or neglect.
-impaired perception of vertical, visual,
spatial, and topographic relationships.
-motor perseveration.
Hemisphere
of the brain
 Hemisphere
of the brain affected
left hemisphere of the brain.
-verbal and analytic side:
-process information sequentially and
observe detail.
-Speech and reading comprehension.
 Hemisphere
of the brain affected
The right hemisphere of the brain.
-More artistic hemisphere.
-look at information holistically.
-process nonverbal information.
-perceive emotions.
-aware of body image.
Thalamus
 Thalamic Pain Syndrome
Infarction or hemorrhage in the lateral
thalamus, the posterior limb of the internal
capsule, or the parietal lobe.
The patient experiences intolerable
burning pain and sensory perseveration.
Pusher Syndrome
 Pusher Syndrome
Right CVAs of the posterolateral thalamus.
Demonstrated in patients who actively push and lean toward
their hemiplegic side.
Efforts to passively correct the patient posture are met with
resistance.
clinical presentation:
1-cervical rotation and lateral flexion to
the right.
2-absent or significantly impaired tactile and
kinesthetic awareness.
3-visual deficits. 4-truncal asymmetries.
5-increased weight bearing on the left during
sitting activities.
6-difficulties with transfers as the patient pushes backward and
away with the right (uninvolved) extremities.
 What are the clinical findings:
PATIENT IMPAIRMENTS
Motor Impairments.
Motor Planning Deficits.
Sensory Impairments.
Communication Impairments.
Orofacial Deficits.
Respiratory Impairments.
Reflex Activity.
Spinal Reflexes.
 What are the clinical findings:
PATIENT IMPAIRMENTS
Deep Tendon Reflexes.
Brain Stem Reflexes.
Associated Reactions.
Bowel and Bladder Dysfunction.
Functional Limitations
 Motor Impairments
Damage to motor cortex

Spasticity
Flaccidity

lack the ability to generate a motor disorder characterized by

muscle contractions and to exaggerated deep tendon reflexes
initiate movement. and increased muscle tone.
 Spasticity
The classic theory of spasticity development:
-Upper motor neuron injury.
-Hierarchic view of the nervous system & the
development of motor control and movement.
-hyperexcitability of the monosynaptic stretch reflex.
- Theory is based on muscle spindle physiology.
-Increased output from sensory receptors controls
alpha motor neuron activity in the gray matter of the
spinal cord.
-Uninterrupted activity of the gamma efferent account
for continuous activation of the afferent system by
maintaining the muscle spindle's sensitivity to stretch.
 Spasticity
:today's view of spasticity

Abnormal processing of the defect in inhibitory modulation from higher

afferent (sensory) input cortical centers and spinal
after the stimulus reaches the spinal cord. interneuron pathways.
 Assessment of Tone
Modified Ashworth scale(0 - 4)
 Brunnstrom Stages of Motor
Recovery
1-Flaccidity: No voluntary or reflex activity.

II. Spasticity begins: Synergy patterns begin to develop.

III. Spasticity increases and reaches its peak: Movement

synergies of the involved upper or lower extremity.

IV. Spasticity begins to decrease: Deviation from the

movement synergies.

V. Spasticity continues to decrease:Movement synergies

are less.
 Brunnstrom Stages of Motor
Recovery
VI. Spasticity is essentially absent: Isolated
movements and combinations of movements.

VII. Return to normal function: Return of fine

motor skills.
 Development of Spasticity in
Proximal Muscle Groups

pelvis girdle
Shoulder girdle

Anterior tilting, pelvic

adduction and downward
retractors, hip adductors,
rotation of the scapula.
and hip internal rotators,
Increases tone in the shoulder
knee extensors, the ankle
adductors and internal rotators
plantar flexors and
muscles increases tone in the
supinators, and the toe
biceps, forearm pronators, and
.flexors
.wrist and finger flexors
 Other Motor Impairments
1-a stroke weakness are often unable to generate normal
levels of muscular force, tension, or torque to initiate
and control functional movements or to maintain a
posture.

2-Atrophy of remaining muscle fibers on the involved

side and motor units that are more easily fatigued.

3-The muscles controlling grip strength and the wrist and

finger flexors are the most severely affected muscle
groups.

4-The muscles on the uninvolved side can also exhibit

weakness.
Motor Planning Deficits
involvement of the left hemisphere

its primary role in the

sequencing of movements.

Apraxia

unable to remember the steps necessary to

achieve this movement goal such as a sit-
to-stand transfer
 Sensory Impairments
Strokes of the parietal lobe

Touch
Proprioception

With eyes closed

affect the patient's ability

control and coordinate movement perceive an upright

posture during sitting and standing
sequencing motor responses eye-hand coordination
Communication Impairments
Infarcts in the frontal and temporal lobes of the brain

Aphasia

,impairment of language comprehension

oral expression, and the use of symbols to
communicate ideas

Wernicke's aphasia global aphasia

Broca's aphasia Both
Expressive receptive
Other Communication Deficits

Emotional lability
Dysarthria

inability to control the muscles of right hemispheric infarcts

speech production
 Orofacial Deficits
CVAs of the brain
stem or midbrain

poor coordination between

facial eating and breathing
asymmetries

ptosis of the
eyelid
Inadequate lip closure
Dysphagia
 Respiratory Impairments
Hemiparesis
of the diaphragm
or external intercostal muscles

reduces cardiopulmonary
conditioning

Poor lung expansion

Lung volumes decrease

Decrease vital capacity

muscle and
cardiopulmonary fatigue
Oxygen consumption
increased
 Reflex Activity
Primitive spinal and brain stem reflexes

present at birth or extreme

during infancy fatigue or stress

continue to exist as underlying

components
damage of CNS
of volitional movement patterns
 Spinal Reflexes

Grasp

Flexor withdrawal

Cross extension
Startle
 Brain Stem Reflexes

Symmetric tonic
neck reflex
Tonic thumb reflex

Asymmetric tonic neck reflex Tonic labyrinthine reflex

 Deep Tendon Reflexes

biceps gastrocnemius-soleus
Achilles

quadriceps/patellar
brachioradialis

triceps

assessed on a 0 to 4+scale
 Associated Reactions
automatic movements that occur as a
result of active or resisted movement in another part of the
.body

Souques' phenomenon
Homolateral limb
synkinesis

Raimiste's phenomenon
Bowel and Bladder Dysfunction
Incontinence or the inability to control
urination

secondary to muscle paralysis

or inadequate sensory stimulation to the bladder

Early weight bearing through either bridging or standing

activities can assist the patient with regaining bladder
control
 Functional Limitations
lose the ability to perform activities of daily
living

feeding or bathing or may be unable to roll

over in bed, sit up, or walk

Great emphasis is placed on function in current physical

therapy practice
 COMPLICATIONS SEEN
FOLLOWING STROKE
Abnormal Posturing and Positioning

spasticity

shoulder dysfunction and pain

Flexion contractures
of the elbow, wrist, and fingers

gastrocnemius-soleus complex
Oral Medications of Spasticity

dantrolene sodium
Intrathecal
baclofen

diazepam
Botulinum toxin type A
 Advantage of Spasticity

around the shoulder joint may limit

in the lower extremity
the patient's predisposition
may assist a patient in ambulation
.for shoulder subluxation
Abnormal Posturing and
Positioning

Decrease tone

shoulder subluxation

Shoulder pain
 Complex Regional Pain
Syndrome
reflex
shoulder/hand syndrome sympathetic dystrophy

pain
atrophy
weakness

autonomic nervous system signs

and symptoms

edema movement disorders

 Three distinct stages of CRPS

Stage I Stage II
Stage III

burning and
aching pain; edema; warm, red
continuous, aching, and burning pain; edema irreversible, atrophic skin
skin; and accelerated hair
leading changes, as well as contractures
.and nail growth
to joint stiffness; thin, brittle nails; and thin, cool
.skin
Osteoporosis may also be evident on X-ray
 Additional Complications

increased risk of trauma and falls because of) 1(

impaired upper extremity and lower extremity protective
;reactions

increased risk of thrombophlebitis secondary) 2(

;to decreased efficiency of the calf skeletal muscle pump

;pain in specific muscles and joints) 3(

.depression) 4(
TREATMENT PLANNING

long-term goals short-term goals plan of care

do so in consultation with the patient and family

Information gathered
regarding the patient's previous level of function and the
patient's goals for resuming those activities

The PT should select interventions that are meaningful to

the patient, to assist the patient in returning to her or his
.prior level of function
 Functional Assessments

Functional Independence Fugl-Meyer

Measure (FIM) Assessment

,measures physical, psychologic used to quantify motor functioning

.and social function following a stroke

,self-care ,passive joint range of motion

. Transfers , pain

, locomotion , light touch

,communication ,proprioception

and cognition ,motor function

and balance
 Goals and Expectations
PT develop functional goals and expectations

:Interventions that address

,bed mobility

, transfers
on
nd ti
, ambulation a c a
t
n du
e
ti ly e
,stair negotiation a
P mi
wheelchair propulsion
fa

and safety
 Acute Care setting

Depending on the severity of the

Once the patient is medically stable
individual's stroke

Patients
who have sustained
patients may not be
uncomplicated CVAs
admitted to an acute
may be evaluated
care facility unless
by their physician
a strong medical
and instructed to
need exists
begin outpatient or
home-based therapies

Average lengths of hospitalization 2 to 4 days

 Patient's discharge plans

.Should begin at the time of the initial examination

The supervising pT`s responsibility is to begin the discharge

planning process
EARLY PHYSICAL THERAPY
INTERVENTION
Cardiopulmonary Retraining- 1

,myocardial infarctions, hypertension

and chronic obstructive pulmonary disease

,diaphragmatic weakness, generalized deconditioning

decreased endurance, and fatigue

affect the patient's

ability to participate in rehabilitation
Cardiopulmonary Retraining
Diaphragmatic Strengthening ?
. Expansion of the lateral lobes of the lungs

Deep breathing exercises by the use of blow bottles or incentive

.spirometers. And stretching activity of the lateral trunk

The patient's speech-language pathologist can assist the patient in

coordinating breathing during speaking and eating activities.

All patients should be instructed to avoid holding their breath during

activity performance because this phenomenon is known to

.increase blood pressure
 Positioning

One of the most important components of

our physical therapy interventions? Why
 Positioning
Positioning should be started immediately.
*Proper positioning out of synergy patterns
assists in:
improves respiratory and
increases oromotor function
motor function stimulating sensory awareness

assists in maintaining musculoskeletal deformities

normal range of motion in and the potential for pressure
the neck, trunk, and extremities ulcers can be minimized
?
 Model of Patient Example

Functional Disability
Pathology Impairment limitation

Fracture Decrease ROM

Cannot Unable to work
Immobilization Decrease muscle dress self
strength
 Model of Patient Example

Functional Disability
Pathology Impairment Limitation

Less of tone Cannot

Thrombosis sit,stand.walk.dress. Unable to work
Increase tone
Hemorrage eat wash.
Loss of sensation Transfer,Weight
bearing
Contracture
?
 Minimizing the Development of Abnormal
Tone and Patient Neglect ? Why +How
 Positions need to be altered as the patient's
mobility Improves and as tightness develops in various muscle
.groups

special attention must be placed on the achievement

of symmetry, midline orientation, and protraction of
.the scapula and pelvis

Care must also be taken to avoid the neglect of the involved

extremities
 Enhancing visual awareness of Hemipegic
side of the body ?
 Positioning the patient in side lying on the
involved side decreases the effects of this
neglect by increasing sensory input into the
affected joints and muscles.

Leaving Items within Reach

 Placing a washcloth or soft, squeezable
ball in the patient's palm ?

Footboard placed at the end of the

patient's bed ?
 A resting hand splint.

pair of low-top tennis shoes

 Early Functional Mobility Tasks

Bridging and Bridging with Approximation

.Hip extension over the edge of the bed or mat

Straight leg raising with the uninvolved lower extremity

Lower Trunk Rotation

 Importance of Movement
Assessment
timing of the move( 1)

.sequencing of muscle responses( 2)

.Amount of force generated by the muscle( 3)

.reciprocal release of muscle activity( 4)

 Direction of scapular mobilization
D1 PNF D2PNF
Elevation, Elevation
abduction, adduction
upward rotation upward rotation
Scapular Mobilization
Scapular mobility is essential in maintaining the
normal scapulohumeral rhythm necessary for upper extremity
.range of motion and functional reaching

If the scapula is
unable to move on the rib cage

the upper extremity will

become tightly flxed to the side of the body and thereby
limit the patient's ability to use the arm

develop tightness
or increased tone in the scapular elevators and retractors
)rhomboids, upper trapezius, and teres minor(
abnormal scapular positioning and upper
.extremity posturing
 Facilitation and Inhibition
Techniques
Depending on

quality of volitional
patient's motor presence or
movement
control absence of
abnormal tone

preparation for the patient's

.attempts at functional activities
 Facilitation Techniques

primitive (spinal) or quick stretching

tonic (brain stem) reflexes

tapping, vibration approximation, and

weight bearing
Inhibition Techniques
Slow, rhythmic
Weight bearing
rotation

static stretch with

Prolonged ice tendon pressure

.Once tone low attempt a movement or functional task

 Treatment Adjunct
Air (pressure) splints Johnstone (1995)

Assist
positioning sensory awareness

tone reduction

piece of equipment
 Inflatable air splints

.Long Arm Splint Elbow and

.Hand Splint

Foot Splint
Long Leg Splint
Neurodevelopmental Treatment
Approach by Karl and Berta
Bobath in the 1940s
Initially cerebral palsy Hemiplegia

gross and fine abnormal tone

motor delays .primitive reflexes
and movements

P.T Goal: inhibit abnormal postural reflex activity and movements

and to facilitate normal motor patterns
Neurodevelopmental Treatment
Approach
.static positioning of children in reflex inhibiting posture

focus on the patient's performance

.of the developmental sequence

emphasis shifted to the patient's postural reflex mechanism

Injury to the CNS would impair

an individual's postural reflex mechanism

Consequently, righting and equilibrium reactions impaired as

well as an individual's ability to hold a limb against gravity
would be impaired
 Neurodevelopmental Treatment
Approach
:The goal of physical therapy treatment shifted
.To facilitation of normal postural control mechanisms-1
To providing the patient with the sensation of normal movement-2
by inhibiting abnormal postural reflex activity and muscle
.tone

The focus of treatment was to reestablish the basic

components of movement

head and distal control

shift weight over static and dynamic
Trunk control midline orientation of the extremities
the base of suppor balance
Neurodevelopmental Treatment
Approach In a clinical context
control and guide the patient's motor performance through the use of
.sensory facilitation applied at key points of control

Thus, therapists could influence a patient's tone and abnormal movement

patterns by using key points of control

distal
head shoulders hips extremities
 Neurodevelopmental Treatment
Approach
,Once the patient's tone is at a more normal or manageable state

the therapist superimposes normal movements and postures

grade the manual assistance provided through these manual

contacts and gradually withdraw assistance as the patient learns to
control the movement independently

Patients must become active problem solvers of their own movement

deficits
Functional ActivitIes
Movement Transitions
Motor Control

Stability

Controlled mobility

Skilled activities
 Motor Control

Stability is defined as the ability to fix or maintain a position

or posture in relation to gravity

Controlled mobility
refers to the ability to maintain postural stability while moving

Skilled activities are described as coordinated, purposeful

.movements that are superimposed on a stable posture
.Sitting Posture: Positioning the Pelvis
Additional Sitting Balance Activities
 .Shoulder Subluxations

hypertonicity
flaccidity

Loss of muscle tone, stretch on scapular and shoulder

the capsule, and abnormal bony musculature and truncal rotational
alignment asymmetries

inferior anterior
subluxation subluxation
 Remediation of shoulder
subluxation

Active control
of the middle deltoid biofeedback
and rotator cuff muscles

functional electric slings

,stimulation

Weight bearing offers only temporary

,remediation of the condition
 Slings
clinicians disagree regarding the use of

promote neglect
hemiparesis and disregard

do little to support facilitate asymmetry

the shoulder
Weight-Shifting Activities
Weight-Shifting Activities
 Sitting Balance Activities to
Improve Trunk Control
Manual resistance
)rhythmic stabilization(
)alternating isometrics(

anteroposterior or
mediolateral direction rotational component
Assessing Protective Reactions

laterally anteriorly posteriorly

characterized by extension and abduction

Functional reaching
to facilitate weight shifting
in sitting
 Trunk Rotation

maintaining the necessary flexibility in the trunk

musculature

maintaining separation of the upper and lower

trunk

assists the patient's ability to rotate and dissociate

movements of the shoulder and pelvic girdles
 Standing

?When Why?
?How
Position of the Physical Therapist in Relation
to the Patient
 Position of the Physical Therapist in
Relation to the Patient
Why?

Sitting squat position Standing

in front of the patient in front of on the patient's
the patient Side

Avoided

safety belt must always be used

 Sit-to-Stand Transition
able to maintain the lower
extremities in flexion at the
hips, knees, and ankles
maintain a neutral or
slightly anterior tilt of the
pelvis during a forward
weight shift over the fixed
.feet
equal weight bearing on
both lower extremities
Symmetric foot placement,
with feet shoulder-width
apart, and the patient's feet
flat on the floor
The involved arm should
not be allowed to hang
down at the patient's side
 Sit-to-Stand Transition
Problems

plantar flexion excessive

contractures reliance on the uninvolved
of the ankles lower extremity

truncal asymmetry
lack of strength in
.their hip extensors

push up with the

upper extremity
 Establishing Knee Control
Quadriceps weakness or Decreased proprioceptive
inefficient gastrocnemius-soleus input from the joint
function

spastic
quadriceps
knee hyperextension
or genu
recurvatum
lack of balance between
the hamstrings
and quadriceps

Inadequate knee
control
for standing
Positioning the Standing Patient
Positioning the Standing Patient

Equal weight bearing on

both lower extremities erect trunk midline orientation
of the head

extremely low
function

Second Bedside
tilt table table
person
 Early Standing Activities
Weight Shifting

During bed mat table parallel bars

In anterior and
right and left
posterior directions

At the same
,monitor the position of the patient's hip
time
.knee, and ankle during all standing activities
Assessing Balance Responses
Assessing Balance Responses
strategie
s
ankle(

hip

stepping
Standing Progression (Walking)
Position of the Physical Therapist in
Relation to the Patient

sit or stand in front

of the patient

stand on the patient`hemiplegic side

Standing on
the patient's involved side avoided
Advancing the Uninvolved Lower
Extremity
promoting
single-limb support (weight bearing) on the involved lower
.extremity

take a small slide the foot

step forward

developmenl of increased lower

postural deviation extremity tone
 Advancing the Involved Lower
Extremity
extension synergy pattern

hip Circumduction
).hip abduction with internal rotation (

Pelvic Knee extension and

retraction ,ankle planterflexion

relearn an abnormal and abnormal stresses are increasingly

inefficient movement placed on the difficulty to
pattern involved joints change or replace
the abnormal
pattern+spasticity
Achieving a Normal Gait Pattern

Positioning the Advancing the

Pelvis Involved Lower
Extremity Forward

downward
and slightly
forward Backward
tactile cue on Stepping
the patient's
pelvis

flex (bend) the

involved knee Putting It
All Together
 Normal Components of Gait

ankle dorsiflexion

.advance the hip forward

flex the involved knee

trunk elongation

diagonal weight shift

to the uninvolved side by
.advancing the involved side
 Turning Around

step With
the uninvolved lower extremity

ready for the directional

.change

the toes are automatically

moved outward

ask the patient

to move the involved
.heel toward the midline
 Upper Extremity Positioning
during Ambulation
Flaccid arm Spastic arm

assistant"s
relax
upper extremity

Bedside table
Inhibiting handholds
and arm holds

patient's pocket
return of
reci procaI
arm swing
sling with good upper
extremity
motor return
 Following the Developmental Sequence
postures and movement transitions

need to perform if she falls activities of daily

.living

half-kneeling to standing

Tall-kneeling to half-kneeling
quadruped to
tall-kneeling
prone on elbows position
to a four-point (quadruped) position
 Following the Developmental Sequence
postures and movement transitions

Depend on

Cardiopulmonary
motor control function

Must be monitored
during challenging
positions
balance
 Prone Activities
difficult position for many older
patients

activities can be practiced

knee hip extension with

flexion the knees bent
 Prone Activities
on elbows

PNF techniques of
alternating isometrics hand or short arm air splint
and rhythmic
stabilization
Transition from Prone on Elbows
to Four-Point
Need

upper extremity long arm

in extension air splint

intact trunk
accept weight
control
on it without medical
complications
Four-Point Activities
 Transition from Four-Point to
Tall-Kneeling
Need

assistance at Small table in

the upper trunk front of the patient

Balance and muscular

control of the trunk

observe the patient's position in tall-kneeling

 Transition from Tall-Kneeling to
Half-Kneeling
controlled weight shift to one side

The trunk on the side

must shorten

Rotation of the trunk

opposite of the weight shift

The hip on the

.moving side must hike and slightly abduct

The moving knee

must remain flexed

the foot in a neutral to slightly dorsif1exed

position
Modified Plantigrade Position
Upper and lower extremity weight bearing

Proprioceptive
input

Tone
reduction

sensoy
awareness

Motor
recruitment
Modified Plantigrade Position
,rocking forward
backward Activities

to the sides

Alternating
isometrics

forward and
backward
stepping
,knee flexion
extension,and
squats
 Ambulation
Quality of Movement versus Function

whether they should allow the patient to walk

even though the patient's gait pattern does not
possess the desired quality of movement

Clinicians will continue to assist patients in

the achievement of more normal movement patterns during
performance of functional tasks
Selection of an Assistive Device

walkers straight
canes

wide-base narrow-base
Hemiwalkers
quad canes quad canes
Selection of an Assistive Device

more less support

stable cane initially

adequate
height
 Ambulation Training with
Assistive Devices
The patient needs to be
able to maintain a stable postural base at the pelvis and
trunk to initiate more distal movement

difficulty with standing or gait

activities

additional assistive
parallel
devices-bed Grocery cane
bars or at
side table carts the hemirail
Ambulation Progression with a
Cane

finally the uninvolved lower

extremity moves forward

followed by advancement of the cane with

the uninvolved hand
the patient advances the involved lower
extremity first
Ambulation Progression with a
Cane
Manual needs distance of
assistance the cane

assistance with maintain proper placement of the

the diagonal postural alignment involved upper
weight shift during ambulation extremity
Walking on Different Surfaces
standard
physical therapy gym
flooring

carpeting

Different sidewalks, grass, and gravel

terrain

Crowded negotiating
mall barriers
 Pusher Syndrome
weight bearing on the involved lower extremity

provision of appropriate tactile and

proprioceptive input

midline retraining in both sitting and standing positions

with the use of visual cues

incorporation of the hands during activity

performance

use of fixed resistance

on the patient's uninvolved side

lower the height of the assistive device

During gait training
to bear weight on the uninvolved side
activities
 Orthoses
Prefabricated Ankle-Foot Orthoses

found in the clinic or

.physical therapy gym

inexpensive

maintain the patient's ankle

and foot in a neutral or slightly
dorsiflexed position

dons the orthosis, and then the

shoe

movement of the tibia over the

fixed foot is difficult
 Orthoses
Posterior Leaf Splints

plastic
orthosis that controls ankle movement by limiting dorsiflexion
.and plantar flexion

During the stance phase of the

gait cycle, the posterior portion of the orthosis becomes
slightly bent

,As the patient advances the lower limb forward

the orthosis recoils and helps lift the foot to prevent
footdrop

Checking for
Skin Irritation
 Orthoses
Customized Ankle-Foot Orthoses

made by an cast of the patient's foot and then fabricates

orthotist the orthosis from the model

neutral or slightly dorsiflexed position

expensive
problems

patient today may not be what the

patient will need next week
 Orthoses
Articulated Ankle-Foot Orthoses AFO

locked in
dorsiflexion

heelstrike

hyperextend the anterior

knee stop
posterior
stop
advantages disadvantage

adjusted and changed expensive

at various times
 Orthoses
Metal upright orthoses

attached to the patient's shoe

choice for many years

lightweight nature and cosmoses

offers advantages in progression

of ankle motion

limited to use of one pair of shoes

 Orthoses
Knee-Ankle-Foot Orthoses AFOs

locks the patient's

knee in extension

difficult to don and are heavy

used
with patients with paraplegia
 MIDRECOVERY TO LATE
RECOVERY
Depending

injury recovery insurance

stage age
status

different practice Rehabilitation Outpatient

Subacute home
settings center clinic
unit

exercises performed in sitting and

standing positions
focus
on the achievement of functional skills
Negotiation of Environmental
Barriers

stairs curbs ramps

 .Stair Climbing with a Cane

going up going down

the stairs the stairs

leads with the

uninvolved foot lower the cane and the involved
lower extremity at
the same time if possible

followed by the involved leg

then lower the uninvolved leg

then the cane
Family Participation

practice the skills needed to assist

the patient at home and should be responsible for return
demonstrations in the clinic
Working on Fine Motor Skills
gain full control of the distal joint components

wrist, fingers, and ankle are unable to perform

.coordinated movements

fine motor activities

Dressing bathing grooming

hobbies or computer
interest Cooking gardening writing crafts
programming

If the involved arm lacks the

necessary motor control to complete
fine motor tasks positioned in weight bearing
 Advanced Exercises for the
Lower Extremity
work on hip and knee
extension from standing position

hip abduction

hip extension with the knee straight

hip flexion

knee flexion with the hip in a neutral or

slightly extended position

mini squats, resisted gait, and pushing an object

 Advanced Exercises for the
Ankle
rolling pin
active ankle dorsiflexion
under the foot

If good active dorsiflexion

and plantar flexion tapping
her foot

Drawing
alphabet kicking a small a circle
on the ball forward
floor
 Coordination ExerCises
upper Lower
extremities extremities

finger to
nose
alternating
heel to knee
finger to the
therapist's
finger
heel to toe
bilateral pronation
supination
toe to examiner's
finger
Finger
opposition
 Balance Exercises
static balance

standing with both Tandem standing on

feet together standing one foot

ankle, hip, and stepping

balance strategies
strategies

by displacing the patient's

center of gravity
 Dynamic Balance Activities

walking on Abrupt stopping change speed

uneven surfaces and starting or direction

tandem walking crossing one

foot over the other

walking on
walking
a balance walking in
side stepping backwards
beam a circle
Advanced Balance Exercises

remove the patient's visual feedback

patient stand on a level surface with eyes closed

Dynamic Balance Exercises
Dynamic Balance Exercises
Using
Movable Surfaces
Management of Abnormal Tone

Spasticity

active
movement

dominance of the
synergy patterns

Patients who sustain neurologic

injuries often lose the ability to perceive the sensory feedback
associated with normal movement
 Management of Abnormal Tone

Weight Tendon functional electrical

positioning pressure stimulation
bearing

Rhythmic chopping and

rotation lifting patterns air splints biofeedback

Rotational exercises
followed by activities
tapping and Prolonged
that incorporate vibration ,ice
weight bearing
 Recent Advances

Constraint-induced Body weight support (BWS)

movement treadmill training
therapy

intervention designed to intervention in the

reduce the effects of treatment of gait
learned nonuse disturbances

,improvements in gait velocity

endurance, and balance
Preparation for Discharge
Assessing the Patient's Home Environment

type of dwelling

apartment house trailer

rent own

occupational Family
,PT members
therapist
 Preparation for Discharge
Assessing the Patient's Home Environment
exterior
accessibility

Steps should not be higher than 7 inches (17.5 cm) or. 1

.deeper than 11 inches (27. 9 cm)

.Handrails should measure 32 inches (81.3 cm) in height. 2

One handrail should extend 18 inches (45.7 cm) beyond. 3

.the foot and top of the stairs

If a ramp is needed, the recommended grade for wheelchairs. 4

is 12 inches of ramp for every inch of threshold
.height
Ramps should be a minimum of 48 inches wide and. 5
.should be covered with a nonslip surface
A door width of 32 to 34 inches (81.3 to 86.3 cm) is. 6
acceptable and accommodates most wheelchairs
Preparation for Discharge
Assessing the Patient's Home Environment

interior accessibility

bedroom bathroom

kitchen
carpeting

transportation