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6 years post - stroke px
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6 years post - stroke px - March 2, 2006 1:35:00 AM
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Ahlecs76
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I had a patient come in today who suffered a stroke 6 years ago. He comes in wanting to see if there is anything else PT can do for him. On assessment I find a very tight right side. Upper extremity is tight and still is in the flexion synergy and lower extremities in the extension synergy. He walks with a quad cane independently but with difficulty. Would an aggressive program of stretching and NDT's to break the tightness all over on the right side work for this guy given that his stroke was 6 years ago? Would treatment be useful? Tnx!
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Re: 6 years post - stroke px - March 2, 2006 4:01:00 AM
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FLAOrthoPT
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ok let me be the cynic:
first if you plan on having this covered by any conventional insurance, good luck, and let me know how you did it. Second, At this stage of his recovery, I'd merely look at functional actvities. If he is safe and independent with activities, there really is not much else to do. I do not think with plasticity of neural processing you are going to ellicit any sort of tone or motor control change at this point regardless of techniques. Did you ever wonder if extension tone in the lower extremity is our body's way of compensating to provide a stable base to walk off of in the absence of normal neural synchronicity? I mean even if you had miracle pills and could reduce or elliminate his lower tone, would he then be able to walk?
All that being said, I'd stay away from tryng to make too many changes to impairments at this point, his body has probably done what it can to make him functional against gravity, that being flexion of th euppers extension of the lowers and trying to change those may just make him wheelchair bound.
Ben
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Re: 6 years post - stroke px - March 2, 2006 6:06:00 AM
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Jeffre
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I agree with Ben. At this point all you can really do is to check to see if he is functionaly safe. Any flexor activity has likely turned into a 6yr old contracture, good luck trying to show any progress stretching that out with 3x/week treatment. Maybe you could teach him how to use a hemi walker instead of a quad cane.
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Re: 6 years post - stroke px - March 2, 2006 10:00:00 AM
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nari
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It is never too late to achieve some changes - I have seen reversal of flexor synergy after 10 years in that pattern. Neural plasticity is not set in concrete patterning.
BUT aggressive stretching will simply make things worse. No stretches!
Contractures do not necessarily result every time; only if there has been secondary joint changes, and they are NOT inevitable.
Unless you are very familiar with neurodynamics, I agree with the above posts. See if you can improve his gait; I would avoid forcing him to use a walker as this simply reinforces the synergy.
Nari
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Re: 6 years post - stroke px - March 2, 2006 3:38:00 PM
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FLAOrthoPT
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nari but is the synnergy a bad thing? why can't we think for a minute that it is only logical to reinforce those patterns that would help eliminate disadvantage of gravity; that being extension in the lowers and flexion in the uppers. I am not saying we all should encourage patterns of this nature, but maybe the body is doing it purposely to achieve greater upright function, just a different way of looking at it perhaps.
Ben
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Re: 6 years post - stroke px - March 2, 2006 4:14:00 PM
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nari
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Ben
You're right - flexor/extensor synergy is very useful if we need to keep a patient upright and have ascertained we can do no more.
Without it they have much reduced mobility and higher risk of falls. But I was thinking along the lines of reducing the degree of hypertonicity in the hemilimbs first, if possible.
The moot point is that some can be rescued years after the stroke rehab, and it is worth trying, for a couple of weeks 1-2x week. Some can't be rescued, agreed++, but we don't know that until a trial is done.
An awful lot also depends on whether it is a(R) or(L)stroke, and if the patient's English is OK, and someone to assist at home with rehab...etc.
Nari
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Re: 6 years post - stroke px - March 2, 2006 4:59:00 PM
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FLAOrthoPT
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Ok, I will agree just for the sake of the next part of the argument. Here in the states, there is no way you can get any form of insurance to pay for this treatment, I agree it is too bad insurance dictates care, which means socioeconomic status dictates care, but such is reality in our health care delivery system. So all this being said, if it were going to cost an individual who is living on a fixed income of social security about 800 dollars a month to give this a trial, would you still recommend it? no right or wrong answer, just curious as to you perspective outside the us of a.
Ben
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Re: 6 years post - stroke px - March 2, 2006 5:56:00 PM
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nari
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Bloomin'good question, Ben. If an individual had the ready money and requested a trial of PT, then so be it. If they were TOLD to have a trial of PT, then the PT should explain the situation to the best of their ability and the patient then decides.
On a fixed income with only s/s....nope. Better spent on something else that may be ephemeral but sweet....
I forget at times that I speak from my terms of reference with respect to our health system.
Nari
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Re: 6 years post - stroke px - March 3, 2006 1:08:00 AM
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Ahlecs76
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Hello Everyone!
Thank you all for your posts. All were helpful in giving me ideas that I could incorporate in my treatment. Let me try to get to the gist of it all, you guys were mentioning about me concentrating more on restoring as much function as possible and not be so aggressive on stretching as this could actually be detrimental however you also want me to give tone reduction and stretching a trial.
I am not encumbered by insurance issues as I am writing this from the Philippines. My patient can afford treatment and is willing to pay for them all.
If there any other treatment ideas you have for me I would welcome them all
Much Thanks
Alex
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Re: 6 years post - stroke px - March 3, 2006 9:02:00 AM
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nari
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Alex
I don't know what NDT exactly means or what it entails, but neurodynamic techniques as indicated by David Butler and Michael Shacklock are not stretches. Anything but. Which is why I said that if you are not familiar with the method, it is best not to use it. When it works, it makes a huge difference, if it is applied as "stretches" it can be disastrous.
If your patient is willing to try, definitely give him a chance. PNF can be useful, particularly in the trunk; otherwise a trial of walking with the unaffected arm restrained out of sight, using a mirror, can help to educate. Until the extensor pattern in the affected leg is reduced during gait, however, the affected arm will not change. I have used SoftCast on the affected knee to prevent full extension, or a thick bandage; and then restrained the unaffected arm. The brain needs to be fooled into thinking the mirror image of the unaffected arm is the affected one, and release the chains on it.
Mirror therapy, as introduced by Ramachandran, can be very effective; look up some of his work with mirrors if you can...
There's no guarantee of success; the brain may have lost its plasticity in the area of the CVA,
or not.
It's difficult to explain what to try without any visible knowledge of the patient's status; as you can appreciate.
By the way, is he able to walk without a cane? If so, that is preferable if he is safe within the supervision of yourself. A cane tends to reinforce the brain's notion of disability.
Nari
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Re: 6 years post - stroke px - March 6, 2006 11:46:00 AM
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Ahlecs76
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Thank you Nari!
I was considering neurodevelopmental techniques as used by bobath for the patient. Stretching was to be a different management technique to just to prevent development of contractures. I will also certainly consider your suggestion of doing PNF.
Where can I find some of Ramachandran's work on mirror therapy. Sounds like biofeedback to me but I would like to find out if there is anything more that could be done.
He seems not to be able to walk without his quad cane and is very dependent on it for ambulation.
Thank you once more for your suggestions.
Alex
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Re: 6 years post - stroke px - March 6, 2006 1:18:00 PM
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nari
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Alex
I don't know much about NDT, then, as it seems to be unrelated to neurodynamics as I know it -ie mobilisation of the nervous system. I recall it is used in paediatrics - which I avoided.
If you have access to journals, search for Ramachandran / mirror therapy. Biofeedback is something I am not familiar with either, but you may be right; they may be similar. All that is used is a mirror, so that only one limb can be seen, and the input makes the brain think the affected limb is "normal".
Nari
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Re: 6 years post - stroke px - March 7, 2006 3:46:00 AM
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Sebastian Asselbergs
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Also, just recently read an article in a newspaper where it was mentioned that even years post-stroke, patients can recover brain function. The gist of the story was, that the functional upper limb was immobilised.....and the "permanently" disabled side made some to moderate recovery....I am sorry but i can't recall what journal it was quoted from..
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Re: 6 years post - stroke px - March 7, 2006 3:48:00 AM
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Sebastian Asselbergs
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Ok I found it: Thursday in the American Heart Association's online journal Stroke.
Was a small sample study...
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Re: 6 years post - stroke px - March 27, 2006 2:03:00 PM
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Ahlecs76
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Thanks you Junction 13. I'm a big fan of NDT's and PNF but I just recently practicing so I am sort of really just doing this stuff and trying to explore other effective ways of treating. What exactly do you mean when you say I should try a mechanical approach. Would you perhaps mean being eclectic in my treatment choices? Much thanks again..
Alex
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Re: 6 years post - stroke px - December 30, 2006 5:54:00 AM
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blast7
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My graduate research thesis looked at locomotive recovery after treadmill training and some of our patients were greater than 10 years post-stroke. They were found to have made significant gains in gait after 8 weeks of training measured by the GAITrite. Our on-campus clinic specialized in providing Physical Therapy to patients with neurological disorders (such as stroke) that no longer can receive reimbursable PT services through their HMO. Many of these patients still made significant gains years after their stroke. I would not give up on these patients.
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Re: 6 years post - stroke px - January 1, 2007 5:45:00 PM
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nari
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I would agree with blast7's post. Constraint therapy (immobilising the unaffected arm/leg) has been shown to be effective, but cannot recall the references. At least one was the Aust Journal of Physiotherapy.
The problem with constraint therapy is the compliance of patient and well-meaning family, who crack up seeing their relative struggle to function, understandably.
With the few I've seen and used constraint therapy with, one fellow had total function (but not full ROM) restored to an arm, nonfunctional for 10 years post-stroke.
I also can verify empirically treadmill work with hemi lower limbs; it is inexpensive (just an ordinary treadmill, nothing posh)and always worth trying.
I do realise that cost is a major factor in long term rehab in the USA...especially if the outcome is rather grey.
Nari
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Re: 6 years post - stroke px - April 10, 2007 1:01:00 PM
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Dr Simon Bacaltos
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After six years, looking at the soft and skeletal tissue adaptations not discounting the CNS habituation you'll have a tough time at restoring this patient to his/her "ideal" body image. Just be pragmatic, this patient is already walking with a quad cane, the best or optimal you could get is safe and efficiency of walking using his/her quad cane.
Remember you're fighting not just neuro-musculoskeletal adaptations you're up against various aging body systems (e.g. cardiac, pulmonary, integumentary).
I'd like to suggest body weight supported therapy on or off treadmill (BWST), there has been many publications of using these form of therapy.
Use the proven motor relearning techniques such as delayed feedback, variety of practice schedules (random or block practices) and mental practice (activates premotor cortex).
I don't think NDT could work, but maybe PNF pattern using stretch and agonist contraction would help activate muscles (intrafusal, extrafusal, Golgi tendon)
Soft tissue mobilization to hopefully alter soft tissue extensibility.
Joint mobilization to improve osteokinematics and arthokinematics of a joint.
Myofascial release to improve facial system and lymphatic flow.
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Re: 6 years post - stroke px - April 10, 2007 2:46:00 PM
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ajoe
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Ahlecs76,
...i would be very interested in knowing what the patient would like to achieve and what his personal rehab goals are upon visiting you.
1) Increase quality of movement ?
2) Decrease pain ?
3) Increase independence with ADLs ?
4) Re-gain "ideal" body image ?
I think this should form the basis of "his" treatment plan and help you as a therapist determine if you can indeed can help the patient with what they anticipate/hope to gain. If perhaps his goals are un-realistic based on what we all know from the evidence and history of stroke he may consider changing his foci onto some new purposefull activty in his life. The parts are only a sum of the whole and he may need to recenter on that.
I would agree with Dr. Bacaltos that if the real drive behind a re-visit to therapy is to re-gain "ideal" body image than that is a mighty big bite to chew at this stage.
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