STROKE

1. Classify stroke. Explain in detail about the clinical features, physiotherapy assessment
and management for 45 years female with right hemiplegia duration 1/2 years
2. Write assessment for hemiplegic shoulder and its physiotherapy management.
3. Describe the Hemiplegic gait and its physiotherapy management.
4. Define Tone. And management for Spasticity in Hemiplegia

PHYSIOTHERAPY ASSESMENT
45 Years old female with Right Hemiplegia since 6 month
• Left hemisphere is affected
• VITALs: Fully Conscious
• Higher Mental functions: Sequencing deficits/Motor Apraxia
• Cranial nerves: UMN Facial Palsy
• Sensory: Right sided
• Reflex: hyperreflexia
• Muscle ROM:Reduced
• Muscle Tone: Spastic
• Muscle strength: Reduced
• Balance: Reduced equilibrium reactions, high risk of falling
• Gait: Hemiplegic gait, requires assistance
• ADLs: Initiation>Transition>Completion
• SCALES: Fugl-Meyer assesment, Functional Independence measure, Berg Balance Scale

PROBLEM LIST
Body Structure and Function
Activity Limitation
Participation Restriction

GOALS
Restore function
Prevent limitations
Reeducation of patterns of control

TREATMENT
Reeducating basic trunk movement components
Linking coordinated trunk and extremity patterns
a. Weight bearing
b. Movements in space
Preventing, minimizing, eliminating secondary impairments
Teaching appropriate compensations
Teaching independent practice routine

SPASTICITY
• Management of Spasticity-Related Effects:Interventions targeting spasticity aim to
address immobility, soft-tissue contractures, and deformity. Early mobilization and
daily stretching are crucial to maintain muscle and soft tissue length, ensuring optimal
positioning.
• Stretching and Rhythmic Techniques:Although research on the effectiveness of
stretching is varied and inconclusive, rhythmic rotation, a manual technique using slow,
gentle rotations, can help gain initial range of motion. Once full range is achieved, the
limb should be maintained in a lengthened position to encourage autogenic inhibition
and relaxation.
• Specific Positioning for Sustained Stretching:For example, the shoulder should be
extended, abducted, and externally rotated, while the elbow, wrist, and fingers are
extended. The hand is positioned in weight-bearing and held for several minutes. In
cases of quadriceps spasticity, weight-bearing in kneeling or quadruped positions can
be beneficial. Trunk stiffness may be reduced using rhythmic rotation or trunk patterns
that emphasize rotational movements.
• Active Exercise for Antagonist Muscles:Active exercises should focus on engaging
weak antagonist muscles using slow, controlled movements. Techniques such as
stretching, tapping, or light resistance can facilitate muscle activation, promoting
reciprocal inhibition. Excessive effort should be avoided, as it may exacerbate
spasticity.
• Use of Modalities for Spasticity Treatment:Modalities like cold therapy, massage, and
electrical stimulation can help manage spasticity. Cold therapy reduces nerve
conduction and muscle spindle activity, temporarily decreasing tone for about 20 to
30 minutes. Functional electrical stimulation (FES) can target weak antagonist muscles
and decrease tone through reciprocal inhibition.

• Orthotic Devices for Spasticity Management:Orthotic devices, such as inflatable

pressure splints, static resting splints, and serial casts, can help maintain spastic
muscles in a lengthened position, decreasing hypertonia and maintaining or improving
PROM. These devices also control unwanted synergistic movements and stabilize
limbs during early weight-bearing activities.

HEMIPLEGIC GAIT is loss of controlled movement into planterflexion at heelstrike, loss of

ankle movement from heel strike to midstance (resulting in loss of trunk balance and forward
momentum for pushoff) and loss of normal combination of movement patterns at end of
stance (hip extension, knee flexion and ankle extension) and at the end if swing (hip flexion
with Knee extension and ankle flexion)

Loss of
Loss of Loss of
Loss of Trunk
Ankle Normal
Controlled Balance and
Movement Movement
Movement Forward
from Heel Patterns at
at Heel Momentum
Strike to End of
Strike during
Midstance Stance/Swing
Pushoff

Task-specific overground locomotor training (LT):Appropriate stretching, particularly of the

calf mus cles, and strengthening exercises for LE muscles are important preparatory
[Link] bars and ambulation aids (e.g., walkers, hemiwalkers, can assist in early
gait stability and [Link] practice with an overhead harness and partial body weight
support provides the least interfer ence with early balance and walking activities.
• 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:
he 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: hrough 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

Locomotor Training using Body Weight Support and Motorized Treadmill Training
Robotic-Assisted Locomotor Training

HEMIPLEGIC SHOULDER
• Causes of Hemiplegic Shoulder Pain:
• Flaccid and spastic presentations can both lead to shoulder pain.
• In the flaccid stage, proprioceptive impairment, muscle paralysis, and lack of
tone reduce the support of the rotator cuff muscles, especially the
supraspinatus, leading to reliance on ligaments and the capsule for support.
• Glenohumeral subluxation occurs due to the absence of muscular support, with
mechanical stresses and gravitational forces causing persistent malalignment
and eventual pain.
• In the spastic stage, abnormal muscle tone leads to poor scapular positioning,
restricted movement, and joint subluxation.
• Consequences of Poor Scapulohumeral Rhythm:
• Poor scapulohumeral rhythm leads to glenohumeral friction-compression
stresses, particularly during flexion or abduction.
• This can result in shoulder impingement syndrome, further exacerbating
shoulder pain.
• Secondary Complications:
• Tightness in ligaments, tendons, and joint capsules can develop, leading to
adhesive capsulitis ("frozen shoulder").
• Improper handling and positioning of the affected upper extremity (UE) can
cause joint microtrauma and exacerbate pain.
• Activities Leading to Shoulder Trauma:
• Traumatizing activities include passive range of motion (PROM) without scapular
mobilization, traction on the UE during transfers, and the use of reciprocal
pulleys.
• Interventions for Shoulder Pain and Subluxation:
• Interventions include neuromuscular electrical stimulation (NMES) therapy,
electromyography (EMG) biofeedback, taping, and the use of slings to reduce
subluxation.
• Complex Regional Pain Syndrome Type 1 (CRPS-1):
• Also known as shoulder-hand syndrome (SHS) or reflex sympathetic dystrophy.
• Caused by proximal trauma to the shoulder or neck, stroke, or autonomic
nervous system changes.
• Initial symptoms include intermittent pain limited to the shoulder, progressing to
intense pain involving the entire extremity in later stages.
• Stages of CRPS-1:
• Stage 1 (Vasomotor Changes): Discoloration (pale pink or cool skin),
temperature changes, and hypersensitivity to touch or pressure.
• Stage 2 (Dystrophic Changes): Muscle and skin atrophy, vasospasm,
hyperhidrosis, and coarse hair and nails. Early osteoporosis may be evident.
• Stage 3 (Atrophic Phase): Progressive atrophy of skin, muscles, and bones, with
severe osteoporosis, pericapsular fibrosis, and joint deformities (clawed hand).
• Management of CRPS-1:
• Early diagnosis is crucial for effective treatment.
• Prevention protocols should be implemented, particularly proper positioning
and handling of the affected arm.
• PROM and mobilization techniques should be performed with caution, limiting
shoulder flexion and abduction to 90 degrees or stopping at the point of pain.
• Education and Handling:
• All caregivers, including family members, nurses, and aides, should be educated
on proper handling and mobilization of the affected UE to avoid trauma and
traction injuries.
• Pain and Edema Management:
• Pain may be managed with oral analgesics or local corticosteroid injections
(though repeat injections are not recommended due to weakening of the
rotator cuff).
• Intractable pain may require surgical nerve blocks.
• Active Movements and Additional Interventions:
• Active UE movements are encouraged to maintain shoulder range of motion
(e.g., pushing a tabletop therapy ball).
• Managing edema is essential, and no infusions should be administered into the
hemiplegic hand.