How is Physiotherapy Performed to a Paralyzed Patient?

After a stroke, there may be complete or partial loss of strength in one half of the body. Almost 90% of patients who have had a stroke experience some degree of weakness in the first days. In a stroke and damage to the left side of the brain, there is weakness on the right side of the body. Language and memory functions are affected more in left brain injuries. In a stroke or damage to the right side of the brain, weakness occurs on the left side of the body. Facial recognition and non-verbal communication skills are more affected in right brain injuries. In the paralyzed patient, physical therapy consists of the acute period in the intensive care or neurology service, then inpatient treatment in the physical therapy and rehabilitation service, and then outpatient follow-up and treatment stages.

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In patients with paralysis, symptoms such as muscle weakness, muscle stiffness (spasticity), muscle wasting, seizures, pain, loss of balance, gait difficulties, weakness in hand dexterity, deterioration in spatial perception, coordination disorder, and fatigue may occur. One-sided loss of strength in the body is called hemiplegia. The term hemiparesis is used for partial weakness.

Although hemiplegia or hemiparesis developing after stroke-stroke are severe problems, they have a high chance of improvement with physical therapy and rehabilitation methods. Physical therapy and rehabilitation is a dynamic process that includes patient evaluation, goal setting, treatment and re-evaluation. Rehabilitation has two main purposes: The first is to prevent the occurrence of complications related to stroke, that is, unwanted additional problems, and the second is to provide functional recovery. Complication prevention approaches start from the first day after stroke and last as long as necessary. Functional recovery approaches begin when the patient is medically and neurologically stable and is able to actively participate in the rehabilitation program cognitively and physically. In addition, compensatory methods can be applied to increase the existing skills and quality of life in patients who have reached a certain stage in rehabilitation. Some examples of physical therapy applications in paralyzed patients:

joint range of motion exercises

In joint range of motion (ROM) exercises, muscle stiffness and joint stiffness (contracture) are prevented by moving the paralyzed arm and leg. If the arm or leg cannot be moved at all by the patient, these movements must be done by someone else. This is called passive ROM exercise. If the patient can move his arm or leg a little, but cannot complete the desired movement and someone else needs help to complete it, then assisted (assistive) ROM exercises are performed. If the patient can perform joint movements himself, then active ROM exercises are applied.

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Positioning

In the acute period, that is, in the first days after the stroke, a position change should be made at least every 2 hours for patients who cannot turn over on their own. Otherwise, bedsores may open. Correct positioning of the paralyzed shoulder by supporting it reduces the risk of shoulder pain and shoulder drop. Correct positioning of the paralyzed hand and foot reduces muscle stiffness called spasticity and joint stiffness.

Swallowing rehabilitation

Swallowing disorders may develop in paralyzed patients. Food eaten as a result of swallowing disorder may escape into the lungs and cause infection. The person may not be able to take the nutrients that his body needs by mouth. In this case, swallowing evaluation is done first. It is checked that the patient can safely swallow the foods in which consistency and swallowing rehabilitation is started. If there is a swallowing disorder, nutrition is provided by methods such as nasogastric tube or PEG.

speech therapy

Speech and communication difficulties may develop, especially in left brain injuries. These problems may cause additional problems such as depression and anxiety in the patient. For this reason, it is very important to start speech therapy early in patients with speech disorders (aphasia).

flexibility exercises

Flexibility exercises are another physical therapy application in a stroke patient. Involuntary excessive contraction and shortening of some muscles may occur after a stroke. Stretching or flexibility exercises are applied to prevent muscle shortening and joint stiffness that may develop as a result. Flexibility exercises are also helpful in correcting the patient’s posture. It also has a positive effect on blood circulation, balance and coordination.

strengthening exercises

Another method for physical therapy in the paralyzed patient is strengthening exercises. It can be performed in patients with partial paralysis who have some voluntary movement. Various elastic bands, small weights, sandbags can be used in strengthening exercises. In addition to increasing muscle strength, it has benefits such as improving balance and coordination and preventing osteoporosis.

neurointerventional techniques

Neurointerventional techniques, which use sensory stimuli to facilitate voluntary movements, are frequently used in stroke rehabilitation. There are different physiotherapy approaches such as Bobath, Brunnstrom, Rood, proprioceptive neuromuscular facilitation. There are other techniques that are based on theories about how to learn movement. The aim of these is to get better results by integrating scientific knowledge about the development process of the brain in infancy, the learning mechanism and the reflection of sensory stimuli on movement responses into physiotherapy approaches.

walking exercises

Regaining the paralyzed patient is an important treatment goal. For this purpose, standing balance is provided, weight transfer, stepping, walking exercises on the parallel bar, step-climbing exercises are applied. Transfers, that is, transitioning from bed to chair, activities such as sitting and getting up are taught. Robotic rehabilitation can be applied with a body weight supported treadmill, anti-gravity treadmill or walking robot in order to start walking training earlier in patients who cannot bear their body weight. Such cutting-edge methods ensure that walking exercises are started intensively in the early period when the plasticity of the brain is highest.

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cardiovascular exercises

One of the biggest challenges for paralyzed patients is the feeling of fatigue. For patients who regain walking ability, the next goal is to increase walking distance. Most patients have difficulty walking 500 meters at a steady pace. Cardiovascular exercises are aimed at increasing the heart’s blood pumping capacity and endurance (endurance). It can be applied in different ways such as walking on a treadmill and in-water exercises.

balance exercises

Restoring balance while standing and walking is one of the most important goals of physical therapy in patients with paralysis. Factors such as posture, changes in muscle tone, and weakness disrupt the patient’s balance. In some strokes, the parts of the brain and cerebellum that regulate balance are damaged, and therefore balance is lost. Balance rehabilitation can be done with simple tools or special computerized balance devices. Improving the balance reflects positively on many areas such as the patient’s walking speed, independence, lying and dressing skills. Fall prevention measures are another part of balance rehabilitation.

electrical stimulation

In patients with hemiplegia or hemiparesis, electrical stimulation can be applied to paralyzed muscles to prevent muscle wasting and to strengthen muscles. Electrodes are placed on the skin on the weak muscles in the arm or leg, and electrical currents are given and the muscles are contracted. If these contractions are coordinated with purposeful voluntary efforts, it is called functional electrical stimulation.

Biofeedback

In the biofeedback method, electromyographic information about the contraction of a particular muscle or the position of the joint is converted into visual or auditory cues. Thus, the patient receives feedback about his work. Increasing the awareness of the patient about the movement and getting feedback every time provides an improvement in performance.

paralyzed hand treatment

In addition to applications such as range of motion, stretching, strengthening exercises, neurointerventional techniques, electrical stimulation, biofeedback, which we have mentioned above, occupational therapy specific to various tasks is performed in paralyzed hand rehabilitation. Hand and arm robots help hand and arm exercises to be done intensely, repetitively, controlled and safely. Methods such as forced use therapy and mirror therapy can also be useful.

Mandatory use treatment

In the compulsory use treatment, the use of the patient’s healthy arm is restricted with a glove or sling. He is forced to use his paralyzed hand to do his daily work. In this form of treatment, compulsory use is applied up to six hours a day. It is recommended to have some voluntary wrist and finger movement in the patient to apply forced use therapy. The original compulsive use therapy has been modified in various ways. Thus, protocols have been defined with a frequency and duration varying from 30 minutes to 6 hours a day, from 2 days to 7 days a week, from 2 weeks to 12 weeks, at home or in the hospital.

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mental exercises

In mental exercises, the patient visualizes doing exercises with his paralyzed arm or leg. This method is also used by athletes and musicians for performance improvement. Even if there is no real movement during mental exercise, activation occurs in nerve cells related to movement in the brain. If mental exercises are combined with physical therapy exercises, they increase the benefit obtained from them.

Muscle stiffness (tonus) and spasticity treatment

In stroke patients, certain muscles on the paralyzed side may contract excessively involuntarily. This is called spasticity. Due to spasticity, the patient may not be able to press the tip of his finger and heel while walking, may not be able to move his knee easily, his hand may remain in the form of a fist, and his wrist and elbow may remain bent. In the treatment of spasticity, proper positioning of the joints, range of motion and stretching exercises, improvement of functional skills with purposeful exercises, various physical therapy applications, muscle relaxant drugs and botox injections are performed.

Sensory rehabilitation

The problem of neglecting one side of the body or the environment, called neglect syndrome, may occur in paralyzed patients, especially in strokes in which the right brain is damaged. Paralysis can lead to various impairments and losses in the senses of sight, hearing, touch, taste, and smell. There may be changes in the perception of pain. Sensory rehabilitation techniques are used in the treatment of these problems.

Assistive device and tools

Various body-worn devices for the hands and feet of paralyzed patients can be used to prevent joint stiffness and facilitate walking. These devices, which are attached to the hand or foot, are called orthoses. According to the patient’s balance and walking skills, the use of walking aids such as walker, tripod, cane is taught.

home and landscaping

Home and landscaping is also necessary to facilitate living with stroke. Ramp instead of threshold, high toilet seat, grab bars increase one’s independence in home life.

Conclusion

As can be seen, physical therapy methods in the paralyzed patient are very diverse. There is no rule that it will be applied to every patient. Treatment is planned according to the patient’s current skills and goals. This comprehensive treatment is a team effort. The physical therapy and rehabilitation specialist evaluates the paralyzed patient in all aspects, plans the treatment and follows up. Along with the specialist physician, health workers such as rehabilitation nurse, physiotherapist, occupational therapist, speech therapist, orthotic technician, dietitian, social worker form the rehabilitation team.

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