- A New Perspective
By: Grainne McKeown B.Sc.. M.I.S.C.P.,M.C.S.P.
Rehabilitation of neurological conditions requires Specialist Physiotherapy. Historically these disabling conditions were treated with the aim of regaining function as quickly as possible at the expense of the affected limbs. One major problem associated with stroke is excessive muscle stiffness in the affected limbs (known as spasticity). Using this treatment approach spasticity in the affected limbs was often increased and movements made more difficult. With time functional loss and eventual immobility were often the result.
Management of stroke was originally based on the concept that damage to the brain was irreparable. Recovery of the affected side was therefore not a consideration. Treatment was often directed towards strengthening the good side to compensate for the loss of function on the affected side. No attempt was made to influence spasticity as a means of facilitating recovery.
The 1940's and 1950's saw the development of new treatment approaches in the management of neurological conditions. This initiated specialization in Neurological Physiotherapy. Among the numerous approaches in use today the "Bobath" concept has been shown to be very beneficial.
The principle of treatment is to restore 'normal movement'. This involves treating the affected and unaffected sides to improve normal daily functions.
Recent evidence suggests there is considerable potential for recovery of the brain following a stroke. This supports the concept that change can occur. Patients have the ability to learn to move more normally and unwanted spasticity can be influenced.
Historically it was thought that following a stroke recovery continued for up to two years post injury. This time scale is unfounded. Recovery may continue for many years after a stroke. However rehabilitation in the initial phase post stroke will have the most significant effect. Indeed many long term strokes (1 year+) develop problems as time progresses. This may include pain, stiffness, functional deterioration and often immobility all of which may benefit from treatment.
Physiotherapy aims to restore a person to their optimal functional potential within the limits of his/her abilities and needs.
Physical problems associated with a stroke are:
Modern Physiotherapy approaches to those problems include treatment techniques which relax muscles when tight and stimulate muscles when weak. The physiotherapist through her handling of specific bodily parts influences the muscles and guides the patient through a particular movement e.g. learning to sit, turning in bed or standing up. In time the patient may learn to carry out a movement with better control and less assistance. A thorough understanding of normal movements is necessary when analysing why abnormal movements present in a stroke patient may cause difficulty with a particular function.
Disability resulting from stroke is variable in each individual. Research indicates that following a stroke most individuals regain the ability to walk. However many are slow and may never walk outside. This means a comprehensive assessment is essential for planning an effective rehabilitation programme This includes detailed examination of:
From this a specific management programme is devised which may include:
Goals are set by the therapist and patient/carer which include functional tasks relevant to lifestyle. Rehabilitation begins on the day of the stroke. This initially consists of positioning and passive stretches to maintain muscle and joint range, together with a close liaison with medical staff. Early mobilisation of the patient is encouraged as soon as possible when the medical condition allows.
An essential role of the Physiotherapist is to impart appropriate handling skills to family and carers. This ensures that continuity carries over into the daily routine.
As the ultimate aim of rehabilitation is for the individual to experience as normal a life as possible then rehabilitation does not stop at discharge from hospital but continues after the patient has returned to the community.
A critical stage of personal development is the initial few weeks following hospital discharge when a person experiments with their environment e.g. shopping, meeting friends. Many barriers may limit the disabled person e.g. access to buildings, crowds of people, embarrassment with their disability. A lack of confidence to tackle such barriers and eventual avoidance can lead to isolation and depression. The individual may become less active both physically and socially, reducing the opportunity for further recovery. Lack of resources and limited out-patient and community stroke programmes may result in therapy being withdrawn too early. This leaves the patient feeling abandoned and thinking there is no further chance of recovery. Guidance and encouragement is therefore needed to resume community activities.
Stroke rehabilitation should therefore take into consideration social and psychological outcome, as well as physical function when planning a management programme enabling a person to return to an active lifestyle and not merely an existence.