Of all neurological diagnoses, cerebral vascular accident (CVA) is the most common rehabilitation diagnosis. For most patients with CVA, the therapist is the most important social contact outside of the family.1
Of all the challenges associated with stroke and CVA, hemiplegia can easily be considered the most disabling. Therefore, exercises, strategies and techniques to assist the patient in recovery of function of the upper and lower extremities are vital to neurological rehabilitation. Furthermore, therapists must have multiple tools to use, as no two patients with hemiplegia are the same. Additionally, patients often may not respond in the same way from one treatment session to the next, secondary to the effect of internal and external stressors on tone and cognition of the patient.
The two main theories of stroke recovery and approaches for treatment are Bobath (NDT) and Brunnstrom–and the two theories differ markedly from each other. Bobath uses facilitation and inhibition techniques to allow patients to feel normal movement, while also preventing patients from using abnormal movement patterns. Brunnstrom encourages movement by any means possible, including spasticity and associated reactions, to allow the patient to obtain an upright position and ambulation as soon as possible, thereby avoiding being bedridden.2
The techniques for treatment provided below are not a comparison and contrast of these two approaches, but rather a combination of different techniques from both these and other approaches to aid in muscle re-education.
For patients with stroke, one of the first assessments that must be made relates to muscle re-education. This involves whether the limb cannot move due to inhibition of afferent neural activity to the agonist muscle, or if the antagonist muscle group has increased tone, preventing a weakened agonist muscle from overcoming the antagonist tone and moving the desired limb. For optimal results, therapists must treat both weakness and tone.3
Limb and muscle positioning must also be addressed, especially in early recovery stages. In a maximally shortened position, a high number of actin and myosin filaments are cross-linked, and thereby unable to produce sufficient force to move the limb. In a maximally lengthened position, a minimal degree of cross-linking is occurring and, again, the muscle is unable to produce enough force to perform active movement. The optimal position for muscle re-education is at a position of slight stretch. This length tension relationship allows the muscle to produce the greatest amount of tension.4 Therefore, initial muscle re-education should be done in a position of slight stretch.
Tools and Modalities
There are many different techniques that can be used for muscle re-education, but they can and should be divided into the different stages of muscle recovery. The first stage is no movement, then trace contractions of the muscle, followed by movement in a gravity-eliminated position, and finally, movement against gravity. When a patient cannot actively contract a muscle, modalities, tactile stimulation, reflexes and environmental settings can be used to facilitate early movement.
Modalities are commonly and effectively used to elicit movement in the flaccid stage. Noxious stimulation can include pressure to the toes, ice to the soles of the feet or shin, or using a pen cap. Ice can either be used to stimulate tone, applied with a quick stroke, or applied over a prolonged period to decrease tone of the antagonist muscles.
One of the most effective modality techniques is electrical stimulation. Throughout the literature, electrical stimulation has been found to increase both strength and voluntary movement.5 When used in combination with biofeedback, more than 100 percent increases in strength and ROM have been found.6 Electrical stimulation has also been found to improve posture with stimulation to the third and seventh thoracic spinal process.7Weight shifting increased 50 percent with stimulation to the hip and knee muscles.8 Shoulder subluxation has been shown to decrease with electrical stimulation,9 while upper limb disability has been improved by 17 percent.10, 11
Tactile stimulation, tapping and quick stretch approaches can help the patient initiate movement and encourage additional movement in the limb. Tapping the muscle belly elicits a stretch-like reflex that will cause a muscle to contract. A quick stretch to the muscle by moving the entire extremity in the opposite direction of desired movement uses the same reflex to cause movement.
Neurodevelopmental reflexes that are normally integrated into movement patterns very early in infancy may be released after a period of brain injury, and the resulting muscle contractions may interfere with normal movement patterns, but also can be used to stimulate tone and contractions.12 The neurodevelopmental reflexes that can be easily used in muscle re-education are the tonic neck reflexes, positive supporting reflex and withdrawal reflex.
Asymmetrical tonic neck reflex involves rotation of the neck. The rotation of the neck can increase extensor tone on the ipsilateral side of the rotation and increased flexion tone on the contralateral side of rotation. Symmetrical tonic neck reflex is caused from neck flexion and extension. Neck extensions cause increased extension tone (decreased flexion tone) in the upper extremities and decreased extension tone (increased flexion tone) in the lower extremities. Neck flexion causes increased flexion tone (decreased extension tone) in the upper extremities, and decreased flexion tone (increased extension tone) in the lower extremities. Whether increased tone of the agonist or decreasing tone of the antagonist muscle group, positioning of the neck is an easy yet potentially valuable technique to use to maximize the mechanical advantage of the muscle group being trained.
The positive supporting reflex is demonstrated by stimulation to the soles of the feet. With different stimuli, the lower extremity can be brought into ankle plantar flexion, inversion, knee extension, hip extension, adduction and internal rotation.
The withdrawal reflex occurs when a noxious stimulus is applied to the lower extremity. With stimulation, the ipsilateral extremity withdraws or flexes, while the contralateral extremity extends. The withdrawal reflex is a protective response, but can be very effective in early muscle re-education.
Another useful set of tools are those using associated reactions. Associated reactions occur when the movement of one limb causes movement of the opposite limb. In the upper extremity, resisted elbow flexion causes contralateral elbow flexion while extension causes extension. Shoulder abduction causes abduction, and adduction causes adduction. In the lower extremity, resisted hip abduction causes abduction, and adduction causes adduction. However, resisted hip flexion causes opposite hip extension and hip extension causes hip flexion. Many patients relearn to walk by initially using associated reactions in the lower extremities (e.g., during gait, as one extremity is flexing and the opposite extremity is extending).
Reflexes and associated reactions are often overlooked or not used at all, because persistent reflex activity can interfere with normal functional movements. However, in early recovery of stroke, patients can get frustrated by the lack of voluntary movement in the affected limbs. Until the brain heals, atrophy of muscle groups will occur. These tools can help minimize atrophy and demonstrate to patients that they have some control over the affected limb until voluntary movement is achieved. As voluntary movement returns, treatment strategies should be initiated to decrease the need to use reflexes and reactions.13 However, if voluntary movement does not return, patients can be trained to use these techniques for functional movement.
Once the patient is able to produce some movement of the affected muscles, the same techniques can be used to further strengthen this movement. In addition, different techniques can be used to further promote voluntary movement. Electrical stimulation continues to be effective during this stage, but can be more effective if the patient attempts active contractions at the surge of electrical input.
Placing the limb in a gravity-eliminated position is also an effective technique. At this stage, the muscle is very weak and will probably not be able to lift the weight of the limb against gravity. Placing the patient sidelying helps training for flexors and extensors, and the supine position helps abductors and adductors. Using a platform to support the limb in side-lying can maintain the limb in the desired plane of movement. Powder on a powder board, wheeled skate board devices and pulley systems can decrease friction, making movement even easier for a weakened muscle. If limb movement is still unable to be achieved, use reflexes, associated reactions and/or tactile stimulation. Modalities can be used to stimulate agonist tone and/or decreasing the tone of the antagonist.
Once movement is achieved in a sidelying position, external aids to movement must be decreased. Begin by eliminating modalities to antagonist muscles, tactile stimulation, associated reactions and powder, pulleys or skate devices. To further increase strengthening in this position, weights can be applied to the limb. The weights will add resistance by increasing friction against the supporting surface. The friction resistance can be gradually increased to segue into a gravity-dependent position.
To transition from gravity-eliminated to gravity-dependent positions, additional techniques can be used. “Placing” the limb in a gravity-dependent position and releasing the limb can first cause muscle activity secondary to the stretch reflex. In addition, different muscle contractions require less force while still increasing muscle strength. Eccentric contractions require the least amount of force. If a limb is placed and released, and the patient can slow the descent, muscle activity and strengthening will result.14 Objective progress can be documented by measuring the length of time of the descent—the longer the limb takes to descend, the greater the muscle activity.
The patient will then need to stop and hold the movement during the descent at different ranges of motion, using an isometric contraction. After isometric contractions are achieved, small arc concentric contractions can be executed.
While using muscle contractions and placing, remember length tension relationships and lever arms–use tactile stimulation and modalities to maximize the patient’s mechanical advantage.
Once the patient can actively move the limb against gravity, normal resistance training can be implemented. Exercise bands and manual resistance are useful, as well as weights and machines. Resistance training does not increase abnormal tone in stroke patients.3,15
One additional treatment that can be effectively used throughout the entire course of stroke rehabilitation and muscle re-education is weight bearing. Through the positive supporting reflex, muscle activity can be elicited in the lower extremity. Direct weight bearing to the upper and lower extremities also has been shown to increase motor neuron activity in both the upper and lower extremity.16 This phenomenon is unique to patients with stroke.
There are many simple exercises that have been shown to increase function in patients, due in part to increasing weight bearing. Sit-to-stand exercises done as early as days one or two post-incident have resulted in less disability as early as days five to seven.17
Bicycling used with biofeedback can improve weight shifting to the affected extremity.18 Additionally, pedaling can be used to facilitate and coordinate muscle activities even in patients with severe hemiparesis.19
Hocherman and Dickstein used a rocker board with upper extremity support, five minutes side to side and five minutes front to back at 0.5 cycles per second, to increase weight-bearing, increase all lower extremity strength and improve control of sway and postural reactions.20
Forward stepping with the uninvolved lower extremity causing weight bearing on the involved extremity increased walking outcomes in all the participants studied.21
Splinting the extremity to prevent buckling makes weight bearing exercises safer for the patient, easier to perform for the therapist, and consequently can be done early in recovery.
Using simple bathroom scales to measure how much weight can be put through the extremity is a useful feedback tool for the patient as well as an easy way to show objective progress.
Weight bearing, which can be improved through exercise, is vital not only for increasing muscle activity but for functional outcomes as well. There is a relationship between sway values at the first assessment and falls. Sway values (which can be associated with the increased ability to weight bear on the affected extremity) improve with stroke recovery.
Stance symmetry has an important relationship with stroke severity and inability to bear weight is correlated with length of stay in the hospital.22 In addition, weight bearing has been correlated with improved initiation of gait and forward momentum needed in gait;23 and decreased use of abnormal postural synergies, weakness and slower postural reactions.
Patients with stroke have many obstacles during rehabilitation and recovery. Therapists must have many techniques to deal with these challenges. The more tools therapists have, the more apt they will be to meet these challenges as they are encountered. Hemiparesis is difficult and often frustrating for both the patient and the therapist. Fortunately for therapists, there are tools and strategies to assist in treatment and recovery.