physiotherapy during the first 48 hours post stroke. (Full Version)

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victor cajun -> physiotherapy during the first 48 hours post stroke. (May 22, 2002 7:22:00 AM)

Does anyone have any up-to-date evidence or information with regard to the provision of physiotherapy treatment during the first 48 hours. Should patients be routinely positioned in alternate sidelying and sitting etc, and has this been shown to be effective in reducing the occurence of spasticity? Or should the patient be left during this initial phase, to stabilise and lessen the potential of overbombardment to the CNS.



amelia -> Re: physiotherapy during the first 48 hours post stroke. (May 22, 2002 9:05:00 AM)

Does anyone have any up-to-date evidence or information with regard to the provision of physiotherapy treatment during the first 48 hours. Should patients be routinely positioned in alternate sidelying and sitting etc, and has this been shown to be effective in reducing the occurence of spasticity? Or should the patient be left during this initial phase, to stabilise and lessen the potential of overbombardment to the CNS.


hey Victor,
i hope I am not being too cliched now, but it depends on the case and how stable your patient is.Lots of them are in stupor and some may be quite agressive. Besides if the basic paraments are not steady , its not that positioning or passive movements are contraindicated, its just that you shld consult with the doctor.About reducation in spasticity, splinting has shown to be quite effective in some studies, but it shld be started in the early stages. Postioning is usually for prevention in bed sores. Thats my two cents worth......
Amelia



victor cajun -> Re: physiotherapy during the first 48 hours post stroke. (May 23, 2002 7:18:00 AM)

Hi Amelia, thanks for the reply. Yeah I appreciate that a lot depends on patient's symptoms, extent and location of lesion etc. I was really wondering about the neurophysiological basis/justification for the use of positioning, or as you say is its use in the first 48 hours only to reduce the risk of pressure sores. I'm a bit vague about the theory of reflex inhibiting patterns, but thought that they were now felt to be too static to have any influence on the development of spasticity. Thanks for the ideas about splinting, any further info?

Victor



amelia -> Re: physiotherapy during the first 48 hours post stroke. (May 23, 2002 8:58:00 AM)

Victor
you know what, according to what I have been taught, nowadays the view is that, positioning, isnt a manouver to combat spasticity,RIP'S used to be thought to be useful, but then I think the emphasis is now on activating postural muscles, and abdominals , besides I feel that working toward reducing spasticity is a gravity eliminated plane like supine or prone lying, dosent really give results, like when you make the PT. really work in siting standing and intermediate postions.
What do you think abt this?



CNahrwold -> Re: physiotherapy during the first 48 hours post stroke. (December 4, 2002 5:41:00 PM)

Postioning in the hemipelgic patient is very important. Sidelying on the affected and unaffected side is great to challenge midline disturbances and to enhance body awareness with neglect. Positioning a patient on their affected side or weightbearing helps to send proprioceptive and tactile input back to the brain to stimulate movement, as well as to normalize tone. Keeping a patient on their affected side with their arm at a 90 degree angle in shoulder elevation and complete elbow extension helps the patient to promote shoulder protraction and helps to ellicite the extensor synergy. Keeping a patient in a supine position with the head of the bed at a 30 degree angle for long periods of time will create associated reactions with flexor spacticity secondary to the patients hips being in a flexed posture. All movement in the arms originates from the stability of the trunk and hips. If the hips have poor stability, movement in the arms will be difficult to facilitate. This flexed posture in the hips will eventually create poor stability. This is tough with patients needing feeding tubes, because the head of the bed needs to be at 30 degrees. Any suggestions?



valmarie -> Re: physiotherapy during the first 48 hours post stroke. (July 6, 2003 2:37:00 PM)

Yes, the HOB needs to be 30 degrees while feeding but it is important to work on stretching during therapy (don't take the whole time...5 minutes worth) for the hip flexors. You can stop the tube during this time. Family members can also learn the techniques you use to stretch.

I agree with what was mentioned earlier about activating the trunk muscles as well. I have found that even with patients who are stable but more somnolent are able to ellicit balance reactions in the sitting position. I have found it helpful, even when the patient is a max of 2, to sit EOB for 5 minutes or so to try to stimulate, to get weight bearing through the affected arm if possible, and to ellicit reactions and work on head and trunk control. All are excellent.

It is also very important as mentioned to use positioning as a way to combat neglect to the affected side. It is possible to place the patient in a side lieing position, with the HOB elevated if need be, and the bottom leg stretched out with the top one bent on a pillow. A different position is great for the patient. Think about it. We rarely sleep all night without moving. Our poor patients often remain all day AND night with only small changes in position.



jma -> Re: physiotherapy during the first 48 hours post stroke. (July 7, 2003 5:03:00 PM)

Hello,
You might want to look into a new book out called, "Stroke Rehabilitation: guidelines for exercsie and training to optimize motor skills", 2003 by Janet Carr and Roberta Shepherd, ISBN #0-75064-712-4 and look at chapter 8. It gives some interesting ideas for PT's to use in the acute phase as well as overall guidelines for training balance, reaching and manipulation, walking, sit to stand and strength training. Whats different about this book compared to my old textbooks from school is that it is based on research done. Hope this helps out. Still reading it

JMA



Eeyore_PT -> Re: physiotherapy during the first 48 hours post stroke. (May 16, 2004 7:52:00 AM)

I realize this thread is old, but I have a question. I have started a new job at a ECF.
I have a patient that is 4 months out from basal ganglia stroke; his trunk stability is still very poor with little firing on affected side. Yet he has some return in all muscles of affected leg. Would e-stim be appropriate to try to re-educate the trunk muscles?
What about ataxic swallowing... visually, the associated jaw and neck muscles are not coordinating. Would point e-stim to these muscles assist in development of swallowing coordination?
When I came to the ECF, he had been transferred from another place. His neck and shoulder muscles on the affected side were VERY short and tightened... mostly from his favorite positioning and the fact that they let him stay in it. He could not hold up his head because it caused the tissues to stretch and pull and was very uncomfortable. I have spent a lot of time stretching out mm and tissues and mobilizing vertebrae. He is developing his ability to hold head up better and for longer periods.

Just trying to figure out what I can do to help the patient with sitting balance and assist speech with her work with the pt.



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