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[edit] Background

[edit] Definition

A stroke is the sudden death of brain cells caused by a drastic decrease in blood flow. It can also occur when an artery in the brain ruptures. Strokes are also referred to as cerebrovascular accidents.

[edit] Risk Factors

Individuals with high blood pressure, high cholesterol, diabetes, or an irregular heartbeat are at a higher risk of having a stroke. Two other risk factors include smoking and increased age.[1]

[edit] Symptoms

The following are possible indications that an individual is having a stroke:

  • Paralysis
  • Difficulty with speech
  • Loss of vision
  • Paresthesias
  • Dysphagia[1]

[edit] Side Effects and Treatments

  • One side effect from a stroke is pathological crying. This is caused by the disturbance of serotoninergic neurotransmission. The patients who experienced citalopram treatment had a decrease in pathological crying by 50% or more. There was also a decrease in depression.[2]
  • Depression is a very common side effect from a stroke. Research was completed on the treatment trazodone hydrochloride. Patients that received treatment from trazodone showed consistent improvement with their depression.[3]

[edit] Physiotherapy

Physiotherapy is highly recommended for individuals post-stroke. All forms of physiotherapy are helpful. Although most patients stop physical rehabilitation several months after the stroke, it has been proven that continuing with physiotherapy will increase aerobic capacity and sensorimotor function.[4]

[edit] Occupational Therapy

Occupational therapy is suggested for stroke survivors because it helps improve personal activities of daily living.[5] This form of therapy focuses on recovering patients through purposeful activity. It is offered to stroke survivors that are not admitted to a hospital.[6]

[edit] History

[edit] Early 20th Century

[edit] Understanding Apoplexy

For ages, the exact mechanism of injury behind stroke was not understood. Hippocrates of ancient Greece noted a condition called apoplexy, in which a person would suddenly fall to the ground and suffer symptoms of head trauma normally associated with a strike, or hit to the head.[7] Apoplexy, which is now referred to as stroke, or cerebrovascular accident (CVA), remained a mysterious and misunderstood condition until the early 20th century. [7] Due to the lack of understanding of CVA, prior to the 19th and early 20th century there were not many documented studies on physical therapy applied specifically to victims of apoplexy or CVA.[8]

[edit] Physical Therapy

In 1894, a Canadian by the name of Dr. Edward Playter first coined the term "physiotherapy",[9] and by the 20th century physical and occupational therapy were well on their way to becoming fully recognized professions. However, they were mostly concerned with the rehabilitation of injured war veterans.[8] It wasn't until the 1940's that the first large strides were made in the treatment of CVA using physical and occupational therapies.[8]

[edit] 1940's

In the 1940's an occupational therapist and physical therapist named Margaret Rood began developing a treatment model for people with hemiplegia (one-sided paralysis) due to CVA.[10] Her model focused on motor development by strengthening the affected muscle groups. This was achieved by repeating simple movements such as muscular reflexes and gradually increasing the complexity of movements until the patient was able to exercise more motor control over the motions.[10] There were four major stages to this gradual increase in movement complexity:[10]

  • Mobility
    • This stage focused on basic movements of the affected muscle groups.
    • Exercises might have included abducting one's arm or flexing one's knee.
  • Stability
    • This stage focused on balance and muscular endurance.
    • Exercises might have included standing still while maintaining equilibrium, or holding an arm up for an extended time.
  • Controlled Mobility
    • This stage combined the first two stages and challenged the patient with more complex movements.
    • Exercises might have included walking while maintaining equilibrium or touching one's nose with the forefinger without losing one's balance.
  • Skill
    • This stage focused on dexterity and manipulation of objects.
    • Exercises might have included grasping a ball, or tying one's shoe lace.

[edit] 1950's

In the 1950's Dr. Norman Kabat, a neurophysiologist, along with two physical therapists, Maggy Knott and Dorothy Voss, developed their own treatment method for patients with hemiplegia due to CVA.[10] They called their model Proprioceptive Neuromuscular Facilitation (PNF). This method, much like Margaret Rood's, focused on strengthening affected muscle groups and developing what they called "mass movement patterns".[10] This was done by reenforcing normal movement patterns in the CNS with repetitive and progressive exercises.

[edit] 1960's

In the 1960's a Soviet researcher named Nikolai Bernstein, notable for having coined the term "biomechanics", advanced the understanding of the pathophysiology of the CNS in those with hemiplegia due to CVA.[10] Up until then, physical therapists had been focusing treatment on strengthening the affected muscles.[10] Bernstein's work lead to a change in focus from strengthening muscles to improving muscular coordination.[10]

[edit] 1970's

Several improvements in CVA rehabilitation using physical therapy came in the wake of Nikolai Berstein's publications.[10] Previous treatment models focused on strengthening weakened muscles or allowing unaffected muscles to compensate for the disabled ones.[10] In the 1970's there was a shift in focus from training isolated muscles to larger movement patterns.[11] Two of the most well-documented and widely practiced therapeutic models were the Brunnstrom model, developed by Signe Brunnstrom, and the Neuro-Developmental Treatment (NDT) model, developed by Berta and Karel Bobath.[11]

[edit] Brunnstrom Approach

Signe Brunnstrom, a Swedish physical therapist who emigrated to the United States, was one of the first physical therapists to put less emphasis on rebuilding muscle strength.[11] Rather, she focused on muscular coordination and movement patterns. She was aware, thanks to Nikolai Bernstein's work, that dead neurons will not grow back. However, undamaged neurons could alter their function in order to compensate. Her methods were based on the idea that while the higher CNS functions may be gone in CVA victims, the more primitive functions remain intact.[11] These "primitive movements" are mainly reflexive in nature. Therefore her treatment method involved invoking reflexive movements, then gradually teaching the patient to exert more and more control over the muscles or joints involved.[11]

Video of a physical therapist invoking a "primitive movement" or "reflexive movement."

Brunnstrom's treatments were administered in a gymnasium with an assortment of equipment such as:[11]

  • Dynamometers
    • Used for triggering reflexes.
  • Mats
    • Used for exercises such as flexing and extending the legs.
  • Balls
    • Used for grasping exercises.
  • Mirrors
    • Allowed the patient to monitor their own movements.

[edit] Neuro-Developmental Treatment

The NDT model was developed by husband and wife, Karel and Berta Bobath.[11] Berta was a physical therapist and Karel was a neurophysiologist. They emigrated from Germany and ended up living in London, England. There they began treatment of adult hemiplegia due to CVA. Like Brunnstrom, their treatment focused on muscle coordination rather than strength. However, where Brunnstrom began treatment with primitive, or reflexive, movements and allowed the patient to then apply these movements to a variety of everyday tasks, the Bobaths decided that rehabilitation should be focused around these everyday tasks.[11] They too, attempted to refocus the intact neurons to compensate for the dead ones, but they did so by using familiar movements and objects from the patient's daily life.[11] They found that patients were able to perform normal daily functions more easily by practicing these familiar motions.[11] In contrast to Brunnstrom's treatment, which were done in a gymnasium, the NDT model could be done anywhere the patient felt comfortable or familiar.[11] The equipment used during treatment was everyday objects such as: chairs, beds, socks, shoes, etc.[11]

Video of a physical therapist rehabilitating familiar movements and everyday tasks.

[edit] 1980's

In the 1980's Janet Carr and Roberta Shepherd developed a treatment for CVA rehabilitation which they called the Motor Relearning Programme (MRP).[10] What made their approach distinct was that they would analyze the patients performing specific tasks and compare their motions to that of normal biomechanical function.[10] They would then break these tasks down into smaller components and slowly evolve the patient's treatment to involve the full task.[10] They would provide manual feedback if necessary but mostly relied upon verbal and visual feedback to help the patient along.[10] They would strongly encourage patients to employ their own biofeedback mechanisms to set goals and limitations.[10] MRP therapy, much like the Bobath's NDT, was performed in a variety of environments, not specifically in a lab or gymnasium.[10]

[edit] 1990's

In the 1990's Catherine Trombly, an occupational therapist, developed her own theory for rehabilitation of CVA victims.[12] Her method was called the Occupational Functioning Model (OFM). This method is primarily concerned with providing the patient with a sense of competency and self-efficacy.[12] To accomplish this, patients must set a goal or task for themselves. For example, a patient may wish to relearn how to prepare a meal. This task would be broken down into a hierarchy of components as follows:[12]

  • First Level Capacity:
    • Reflex based responses that underlie voluntary movement.
    • i.e. reflexive grasping or releasing which contribute to graded grasp.
  • Developed Capacity:
    • Refinements gained through maturation or learning.
    • i.e. graded grasp to accommodate size and shape of the potato being peeled.
  • Ability:
    • Skills developed through experience.
    • i.e. hand-eye coordination is required to peel the potato.
  • Activity:
    • Smaller units of behaviour which contribute to performing a task.
    • i.e. peeling a potato is an activity involved in the task of meal preparation.
  • Task:
    • The goal or occupation a patient wishes to achieve.
    • i.e. preparing a meal.

Each of these above components would be exercised in succession until the patient can perform the task or goal that was set out in the beginning.[12]

[edit] Target Audience

The main demographic affected by stoke is seniors. Studies show the chances of having a stroke doubles between the ages of 55 and 85. Stroke is considered the disease of aging but it can still occur during childhood and adolescence. As we age the high risk factors of stroke begin to increase. These factors are:

  • High blood pressure
  • High blood cholesterol
  • Diabetes
  • Heart disease

High blood pressure is known to be the most important risk factor as symptoms or warning signals are difficult to detect. There are also some less important factors such as:

  • Smoking
  • Gender
  • Race
  • Family history

Studies show that males are at higher risk for stroke, but have a higher survival rate than females. African Americans are also at increased risk for stroke because sickle cell disease is more widespread, which increases the risk of stroke. If one's family history includes the high risk factors for stroke the result is an increased genetic heritability of stroke.

[13] Retreived by:How do you get a Stroke?

[14] Retreived by:Brain Basics:Preventing Stroke

[edit] Research

[edit] A Comparison of Physical Activity Patterns

Research done In Melbourne, Australia and Trondheim, Norway helped compare the best observed outcomes of stroke patients using very early mobilization techniques. The purpose of this research was to examine the differences in activity level according to the severity of the disabilities encountered in stroke patients. In these 2 studies early mobilization was defined as out of bed activity within 24 hours of admission to hospital.[15] This is noted to be a key feature of early stroke unit care. Even though early mobilization is one aspect in caring for a patient there is evidence that shows early mobilization can reduce the chance of death or long term disability.[15] In this study two groups were monitored from 8:00am to 5:00pm in 10 minute intervals over a day's period of time as this was considered to be the most active part of a patients' day.[15] During these observations 11 activities were recorded.[15] These activities were:

  1. No activity
  2. Read/talk/watch TV
  3. Eating
  4. Sitting up in bed
  5. Sitting out of bed
  6. Transfer with a hoist
  7. Roll/sit up
  8. Sit with no support
  9. Transfer with feet on the floor
  10. Standing activities
  11. Walking activities

After these activities were recorded they were then categorized in to 4 sections:[15]

  • Nontherapeutic
  • Minimal therapeutic activity
  • Moderate therapeutic activity
  • High therapeutic activity

This study found that Throndheim patients on average spent 21% less time resting in bed and about 10% more time doing activities that consisted of walking and standing in comparison to Melbourne patients.[15] This study indeed found that very early mobilization is an important factor to recovery from stroke. The group that seemed to benefit the most was the Trondheim group who used the advantages of early mobilization more frequently which resulted in a faster recovery process.[15]

A Comparison of Physical Activity Patterns in Melbourne, Australia and Trondheim, Norway

[edit] A Pilot Study of a Home-Based Exercise Program

The goal of this research is to create a home based approach of rehabilitation for a stroke patients. During this research the stroke patient was first evaluated for their ability to walk, climb stairs, get in and out of bed, and other day-to-day activities such as laundry, meal preparation and bathing. The patients would then perform exercises to improve such things as strength, balance, endurance and to improve the use of affected extremities.[16] This program consisted of 3 weekly visits for a period of 8 weeks.[16] Each session took approximately 1.5 hours that began with a warmup and then was divided into 4 categories.[16]

  • Warmup:
    • 10 minute warmup that consisted of balancing and flexibility activities.
  • Section 1:
    • Threaband exercises involved the use of elastic bands with various levels of resistance.
      • When a victim suffered stroke disabilities that were to weak for Theraband exercises they would then use PNF exercises.
    • Assistive and resistive exercises that used Proprioceptive Neuromuscular Facilitation Patterns (PNF).
    • Targeted both the upper and lower extremities.
    • Exercises consisted of flexion, abduction, rotation, extension and adduction of affected limbs and joints.
    • Once the patient could complete 2 sets of 10 repetitions through the available ranges of motion the resistance level would than be increased or in the case of a weaker patient the manual resistance in PNF exercises would be increased.
  • Section 2:
    • Focused on balance exercises for 15 minutes.
    • Most stroke patients progressed through these tasks with difficulty.
  • Section 3:
    • Patients were encouraged to use their affected upper extremities in different functional activities.
  • Section 4
    • Included the progression of walking or biking.
    • The patent was encouraged to walk or bike at a slow pace.
    • Eventually they were encouraged to increase their speed to a level that would allow them to continuously exercise for a minimal time of 20 minutes.
    • During this procedure their heart rate and blood pressure was monitored and recorded.

The stroke patient was then influenced to continue these physical activity standards for an additional 4 weeks on their own.[16]

This study has allowed researchers to modify their treatment program to improve outcomes for future trials. The study ultimately showed that home-based rehabilitation programs that focus on strength, balance, endurance and manual activities are effective treatments for stroke patients.[16]

A Randomized, Controlled Pilot Study of a Home-Based Program for Individuals With Mild and Moderate Stroke

[edit] Virtual Reality Based Rehabilitation Speeds Up Functional Recovery of the Upper Extremities

The purpose of this study is to consider more home base self managed rehabilitation for stroke patients to encourage recovery after stroke. A promising technology that was discovered in known as the Virtual Reality (VR).[17] This tool helps diagnose, monitor and induce functional recovery after one experiences a stroke[17]. The Rehabilitation Gaming System (RGS) is a virtual reality tool developed for the rehabilitation of motor deficits of the upper extremities.[17] This system is a multi-level adaptive tool that provides a training program with levels that have capable limitations for the victims extremities. This system retains quantitative and qualitative information of the performance while the patient is doing certain tasks which results in a detailed assessment of the deficits of the patient.[17] RGS combines concepts of action execution and observation with an automatic individualization of training.[17] This study influences many acute stroke patients to use the Rehabilitation Gaming System as they compared the obstacle tasks of the system to recovery time.

This RGS consists of virtual flying spheres that move towards the patient. The patient is asked to intercept these spheres by using the virtual arms.[17] The difficulty of the task is modulated by the speed of the spheres, interval of appearance between consecutive spheres and the range of dispersion in the field of view.[17]These results are considered in such a way that allows us to adapt the difficulty of the task in an individual's performance of a certain task or subject. Moreover, the proposed task has graded difficulty and specificity: a ‘Hitting’ task to train range of movement and speed; a ‘Grasping’ task to train finger flexure; and finally a ‘Placing’ task to train grasp, displacement and release.[17]

These tasks were presented to the patients at specific times during the study. Acute stroke patients used the RGS during a 12 week process while also using other conventional therapy.[17] Meanwhile a control group performed a time matched alternative treatment, which consisted of intense occupational therapy or non-specific interactive games.[17] After the treatment procedure came to an end the results of the experiment showed that the group that used the RGS significantly improved performance in paretic arm speed.[17] Also it provided evidence that the RGS group presented a significantly faster improvement over time for all the clinical scales during the treatment period.[17] This study concludes that rehabilitation with the RGS facilitates the functional recovery of the upper extremities and that this system is therefore a promising tool for stroke neurorehabilitation.[17] This study also proves that stroke patients who suffer with less severe disabilities can have a successful recovery with advancements such as the Rehabilitation Game System.

A Randomized Controlled Pilot Study in the Acute Phase of a Stroke Using the Rehabilitation Gaming System

[edit] Exercise Training in a Predominantly African-American Group of Stroke Survivors

In the present study, 35 African-American stroke survivors were studied to determine if intense excerise would their overall fitness.[18] The participants needed to meet the expectations of a certain criteria, and have a blood test results in normal limits to particpate in the study. The method and measurements of the study were broken up in to four activities:

  1. Peak oxygen uptake
  2. Strength
  3. Flexibility
  4. Body composition

The peak oxygen uptake is an exercise that tests the heart rate and blood pressure of the particpant that is cycling on a machine. The blood pressure was first taken in lying, sitting and standing position before the cycling started. A ramp cylce ergometer was used to allow the participant to start at 20 W and increase by 10 W every minute.[18] The heart rate and blood pressure were recorded every two minutes, and the following changes were focused on: respiratory eschange ratio, peak heart rate, abnormal blood pressure and being inbale to pedal over 50 rmp.[18] The strength of the particpants was tested by using the bench press and seated leg press machines. The participants were instructed to perform 10 repitions on each exercise. The handgrip strength of the particpant was also tested, these tests were done on seperate day of the peak oxygen uptake.[18] Flexibility was tested in the hamstrings and lower back. The measure used for this was a sit and reacg box. The particpants were instructed to sit on the floor with their feet in front of them, and to reach with their fingers to their feet. The distance measured from the fingers to the center of the box was used for these results.[18] The body composition was evaluated using simple tests and measures. The height, weight,skin-fold measures, and waist to hip ratio was measured. All the tests required using a tape measure except the skin-fold measures. For the men the chest, abdomen, and thigh regions were measured, for women triceps, suprailiac and thigh locations were measured using a Harpended skin-fold caliper.[18]

The 12 week training program was broken down in to week by week training. The first couple weeks, safety was taught to the particpants and how to use the equipment. In the third and fourth week particpants were told what their expectionations were on the selected machine that their training levels required.[18] Week five, particpants then began to exercise, the goal was to get the participants to have one hour of physical activity a day, 3 days a week. Modifications of the exercises were made for patients with abdnoral blood pressure in the orginal testing, a certain training program was assigned to each participant depending on thier results of the peak oxygen uptake. Participants trained on such equipment: bench press, seated leg press, seated leg curl,triceps push-down, seated shoulder press, seated row, lat pull-down, and biceps curl.[18] The intensity of the work out was increased as the particpants moved on, the blood pressure and heart rate of the particpant was also recorded at the end of each set.[18] All particpants were supervised by professionals during the activities.[18] Control groups were also used during this study.

At the end of the 12 weeks, the results were put together. In the strength section of the training, leg press and bench press showed a significant increase in strength, the hand grip test did not show such results.[18] Flexibility was significantly gained in the hamstring and lower back locations. When the participants body composition was remeasured at the end of the 12 weeks, it revealed that there was significant weight loss through out the participants. This study proved that 1 hour a day, 3 times a week improved the physical fitness of stroke survivors using endurance, strength and flexibility.[18] Stroke recurrence is extremely common in stroke survivors, as well as cardiac disease, being physcially active as a stroke survivor can reduce these chances. The surprising results of the program was that everyone loved it. All participants enjoyed benefitting their health and none of the participants dropped out of the program.[18] If the participants get a couple weeks to be trained with the safety of the machines, it is more likely that the results will come out better if the participants are educated with when it is an appropriate time to stop the exercise, therefore less injuries.[18] The program was successful and the participants should continue training in order to reduce the risks of further disease and functional decrease.[18]

[edit] Reduceing the Energy Expenditure and Cardiovascular Demands of Hemiparetic Gait in Chronic Stroke Patients

In the present study a low-intensity program for elderly stroke patients investigated reductions in the energy expenditure and cardiovascular demands of hemiparetic ambulation.[19] The participants were made up of nine elderly men above the age of 50. Since a treadmill was being used in this study and there was physical activity invovlved, history of the patient had to be accounted for, patients with neuropsychiatric conditions limited the participation in the study.[19]For each patient, an enrty treadmill ambulation screening tests were desgined to determine the target velocity of each patient.[19] Patients that were able to walk 0.5 mph underwent other effort exercises.

The program consisted of a 6-months low-intensity exercise, 40 minutes, three times per week.[19] A teadmill was used as a walking device for the patient (handrail available) different mph and incline were used on the treadmill to gather data. A task that involved no incline and 1 mph, was used to evaluate the VO2 of the partipcant. All participants performed submaximal and maximal tests to ensure the reliability of the treadmill.[19] Inspired and expired air volumes were measured, O2 and CO2 were evaluated every 30 seconds. The ventilation, CO2 production and the respiratory exchange rate of the participant was recored constantly.[19] Then time was allowed to find a steady state in VO2, VO2 did not achieve steady state within 6 minutes a submaximal exercised was perfromed a the day after.[19]

The results of this program proved that the 6 months of aerobic training can reduce VO2 steady state and in heart rate ratio. The program concluded that 21% of energy expenditure was reduced while walking.[19] Weight-loss was not a significant factor in the program, and not needed to reduce the energy expenditure.[19]The process was gradual and increased over the 6 month period, these aerobic exercises enhance mobility and cardiovasular fitness in stroke survivors. a decline in heart rate, suggest that the participant is involved in cardiovasular conditioning.[19]It is known that cadiac disease is at high risk for stroke survivors, with the study proving that cardiovascular conditioning is improved, it could prevent this disease if stroke patients stay active.[19]

[edit] Existing Physical Activity Programs

[edit] Burke Rehab

The Burke Rehabilitation Hospital’s stroke rehabilitation program provides services for both the patients and families in all phases of rehabilitative care. These stroke specialists and their teams assess each person's abilities and help each stroke survivor develop realistic short-term and long-term goals, applying the latest research and technology methods.

Occupational Therapy The goal of occupational therapy is to assist patients in becoming as independent as possible with your daily activities. These activities may include dressing, personal hygiene, feeding yourself, getting around your home and community, pursuit of household, work-related or leisure activities, and all the other activities that occupy your day [20]. Patients are put through numerous tests that pin point what activities they struggle to complete on their own. Occupational therapists work with their patients to set goals they wish to achieve throughout the rehabilitation process. There are various types of equipment that can be used depending on the specific needs of the patient. This equipment includes hand splints, bathroom equipment, wheelchair, and adapted utensils[20]. Occupational therapists also work alongside the patient’s family members and teach them how to help their loved one adapt to their new surroundings and alter familiar tasks in a way that fits the patients needs. The overall goal of an occupational therapy team is to make the transition back home for their patients are smooth and positive as possible.

Physical Therapy Physical therapy (PT) is used on patients who have suffered from traumatic injuries, repetitive motions, chronic conditions and congenital defects resulting in physical limitations. The goal of this therapy is to restore and improve the altered function in a patient and assist them in becoming as independent as possible. Each patient goes through an overall evaluation and his or her results allow the therapist to set up a specialized treatment plan specifically geared towards their needs. This program will include exercise to restore or improve range of motion, muscle strength, posture alignment, breathing patterns, circulation, balance, coordination and endurance. Within physical therapy a wide range of equipment and programs are used. Some of the equipment used is canes, walkers, braces, and artificial limbs[20]. Programs can include therapeutic, aquatic and general conditioning. Following the arrival of the patient back to their home, an outpatient therapy program is put into place to ensure a continued success in their rehab process.

Recreational Therapy Recreation therapists use a wide range of techniques to help patients make improvements in the physical, cognitive, emotional, social, and leisure areas of their lives. They assist patients in developing skills, knowledge and behaviors for daily living and community involvement. Recreation therapists work with the patient to incorporate specific interests into therapy to achieve ideal outcomes that transfer to real life situations. Common programs include computer games, altered sports, and crafts[20]. Recreational therapy values the patient’s opinion and aims to give their patient a positive outlook on their present circumstances.

Burke Rehab

[edit] Treadmill Therapy

Treadmill Therapy (TT) is a more recent advance in stroke rehabilitation. It involves the use of technology and a large system of sensors, braces, and a standing frame in which the patient is attached to. Patients are strapped into the standing frame that holds their body weight, allowing them to stand upright.The purpose of Treadmill Therapy is to gradually re-teach stroke patients the basic movements of walking. A focus is put onto the motions of moving, bending of the knee and foot placement on the ground as starting blocks to strengthen the patients confidence and teach the forgotten task. Depending on the limitations of the patient, help from a therapist may be needed to move the patient’s legs in a walk-like motion.[21]The progress is continually tracked and with time the amount of body weight the patient bares on their own is increased. Treadmill therapy is specifically geared towards stroke patients who have lost minimal to all control of their lower extremities.

Video of Lokomat at Madonna Rehabilitation Hospital.

Treadmill Therapy

[edit] GRASP (Graded Repetitive Arm Supplementary Program)

GRASP is a 5 month rehabilitation program for arm and hand exercises for post-stroke development. This program is assisted by Physiotherapists and Occupational therapists for post-stroke patients to improve the stroke-affected arm and hand function. GRASP encourages friends, family members and caregivers for motivation, and encouragement for positive outcomes for rehabilitation [22]. There are three levels of rehabilitation for GRASP:

  1. For individuals with minimal grasp ability. This level focuses mainly on gross motor exercises.
  2. For individuals with moderate hand and arm impairment. This level introduces some fine motor exercises.
  3. For individuals with mild to moderate hand and arm impairment and this level includes both gross and fine motor exercises.

Each level involves using exercise such as: The Total Arm Stretch, Shoulder Shrugs, Hand and Wrist Stretch, Squeezing, Rolling a Ball, and many more. It is recommended for patients to perform exercises at least one hour a day, for 7 days a week. These exercises aim to improve strength, range of motion, decrease pain, and improve life satisfaction. After 5 month stay, it is encouraged to continue exercises at home [22].


[edit] Rapid Step Therapy

Rapid Step Therapy is a rehabilitation-training program that recognizes that individuals who have suffered from stroke, show a delayed initiation and execution of stepping reactions as well as weight-bearing asymmetry. Rapid Step Therapy involves repeated postural perturbations to improve control of compensatory stepping in an individual with stroke.[23]

The Figure describes the process of Rapid Step Therapy:

A patient wears a cable attachment harness, which is connected to a cable attached to the wall (picture did not fully capture). The cable supports the patient as he/she leans, and supports the portions of his/her body weight. A load cell in the cable attachment records the amount of the patient’s body weight, which allows the cable prior to the perturbation to support it. A pin is then pulled, releasing the cable and causing the patient to fall forward. When the patient starts to fall forward, a compensatory step is required to maintain stability. However, if the patient is unable to do so, a safety harness attached above to prevent falling to the floor would support him/her. Force-plates beneath the patient’s feet record ground reaction forces following the perturbation and provided information on unloading, foot-off, and foot-contact times [23].

[edit] Critique

[edit] Occupational Therapy

The basis of occupational therapy (OC) relies on the attitude of the stroke survivor. Occupational therapy is a very personal therapy and is based on goal setting. To be successful the patients have to have the right attitude about their situation and accepting of the new alterations they are going to have to make in there everyday life. In many cases when a person has lost movement in key parts of the body the change alters their personality and interferes with OC. With occupational therapy a lot of focus is put on the support team of the stroke survivor, i.e.: family, doctor, friends, and it can become very time consuming and exhausting on all parts. Occupational therapy can be helpful if implemented at the right time in the recovery process of the survivor and determination for success is present in all people involved. The success of this program promises a rise in popularity and research in the field of stroke rehabilitation in the near future.

[edit] Physical Therapy

Physical therapy (PT) is a well-researched and proven form of rehabilitation in stroke victims. Due to the many tests preformed, very accurate programs are set up that specifically suit each individuals needs. Physical therapy gives patients options and chances to find what suits them best and what renders the greatest results. This therapy also allows for patients to continue on with their success after leaving the hospital due outpatient programs involving mild at home exercises. Physical therapy is a life-long rehabilitation program that improves all aspects of the body.

[edit] Recreational Therapy

Recreational therapy is a subtler form of rehabilitation that focus’s the restoring of “normal” to the affected patients life. This therapy improves the personal well-being of the patient and can occur simultaneously to other more physically vigorous programs. It gives the patient confidence and is important in keeping the patient positive throughout their recovery. Recreational therapists are important people in the lives of stroke victims and the program gives hope to everyone involved in the recovery process.

[edit] GRASP

GRASP is a beneficial rehabilitation program for those who have suffered from stroke that has affected arm and/or hand function. It is a good program because it is self-administered. Individuals are able to work at their own pace, and their own ability in order to return to functional recovery. Although it is a self-administered program, the coordinators supply exercise kits for proper performance, and a study therapist to check on a patient's progress. However, one negative about GRASP, is the fact that it is self-administered. People may have difficulty to perform exercises due to the lack of motivation and encouragement. GRASP strongly encourages friends, family and caregiver's support for their functional recovery for that reason.

[edit] Treadmill Therapy

Treadmill therapy (TT) is a positive and successful form of rehabilitation for stroke patients. In the cases recorded, TT reduced the amount of personal assistance a patient needed after a stroke and increased the amount of body weight they could bare. TT also improved overall physical performance in patients with minor stroke affects and better postural control was observed in all patients. Treadmill therapy is a safe program that links technology with professional care. The tracking methods of TT allow for the patient to see his/her own success, making goal setting/ achieving easier. The success of this program promises a rise in popularity and research in the field of stroke rehabilitation in the near future.

[edit] Rapid Step Therapy

Rapid Step Therapy would not be a recommended program for those who have suffered from stroke. Rapid Step Therapy can be considered as a dehumanizing approach to rehabilitation as it does not fulfill reality due to the fact a patient is controlled by technology. It can be considered an uncomfortable approach to rehabilitation due to the fact that a patient is strapped in a harness supported by cables. Rapid Step is not a beneficial program because patients are unable to perform tasks on a day-to-day basis to maintain functional recovery as it can only be performed in a hospital setting. Once a post-stroke patient leaves the hospital, they are unable to continue therapy as they do not have the equipment for performance.

[edit] Best Practice Activity Suggestions

[edit] Passive Range of Motion

This exercise usually takes place close to the beginning of rehab. It is when an external force is used to move or rotate the injury body part. The movement of the injured limb is done by the patient, a caregiver or therapist, and if appropriate a machine. It is important to keep movement of affected limbs, even if paralyzed, to prevent risks of joint contracture. Passive range of motion is needed to keep blood flowing, reduce pain and tissue from becoming irritated. Even daily tasks such as cutting your finger nails or washing self can be painful because of joint contracture.

Stroke Rehab

This video demostrates all the possible ranges of motion that can be used in assisting a stroke patient. The women be used as an example has never had a stroke. When dealing with a stroke patient, awareness of pain and the flexabilty of the injured limb is considered.

Video of Passive Range of Motion Exercises.

[edit] Active Assistive Range of Motion

Active assistive range of motion is when a patient has a weak limb that an only make movement to a certain point. The weak limb then needs assistance either moving the limb themselves or with the help of a therapist. This range of motion eventually helps improve the strength to of the limb so that it can complete movement on its own.

Stroke Rehab

The following video is an example of a patient being assisted with the movement of a weak limb. In this case the patient can only lift their arm so far without some assistance.

Video of Active Assistive Range of Motion.

[edit] Strengthen or Resistance Rehab

This type of rehab allows the patient to regain and improve muscle mass. They usually work with a therapist that will create an unique plan specifically targeting the affected and injured muscles. Many activities are inquired to successfully progress the strength gradually where needed. The therapist incorporates equipment such as rubber bands, dumb bells, putty and exercise machines.

Stroke Rehab

[edit] Balance Exercises

Many stroke victims experience the lost of balance when in the process of recovery. Therapists will first work with the patients to gradually regain the balance of sitting up. This procedure will need to focus on strengthening the core. After this procedure is accomplished a therapist with then gradually work on the balance used to stand and walk. Balancing is one of the best practice activity as it decreases the chances of falling and harming oneself.

Stroke Rehab

[edit] Weight Bearing Exercises

These types of rehab exercises are usually not familiar to stroke patients. These forms of exercises are considered to be one of the most important forms of rehab a stroke patient could participate in. Weight bearing exercises help improve and strengthen the muscle mass of muscle that were weaken due to stroke. These types of exercises also help to prevent bone loss. For example, if a stroke patient experience that one side of their body is weaker than the other one might compensate for their weaker side. This could result is the decrease of bone density. This bone loss or decrease in bone density could lead to brittle bones which then could result in many fractures or brakes. When doing these exercises it is important to focus on ones arms and legs as they are major limbs that are used daily.

Stroke Rehab

[edit] Future Directions

Stroke rehabilitation has come a long way through the years. What is surprising is the building block design stroke rehabilitation has taken on. Therapies and programs that were used 30 years ago can still be recognized in modern day exercises today. Each new advance in stroke rehab relies on past programs to be successful. Muscles strength and coordination will always play a key role in the recovery process, what lies in the future however is the role technology is going to play. Technology will create more chances for better analysis of data. Along with this, with time more and more knowledge involving the body and new advances in the medical world will help doctors and therapists create better recovery programs for their patients. Programs such as the Virtual Reality therapy and Treadmill therapy are two examples were technology has entered the world of rehabilitation. These programs are just the beginning of what is yet to be discovered in the technological world of rehabilitation.

[edit] External Links

Heart & Stroke Foundation

Treadmill Therapy Scholarly Article

Canadian March of Dimes

Children's Hemiplegia and Stroke Association Stroke & Hemiplegia

Graded Repetitive Arm Supplementary Program (GRASP)

Burke Rehabilitation Center

[edit] Notes and References

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  2. Anderson, G., Vestergaard, K. D., & Rills, J. O. (1993). Citalopram for post-stroke pathological crying. The Lancet, 342(8875), 837-839. Retrieved from
  3. Reding, M. J., Orto, L. A., Winter, S. W., Fortuna, I. M., Di Ponte, P., & McDowell, F. H. (1986). Antidepressant therapy after stroke. Archives of Neurology, 43(8), 763-765. Retrieved from
  4. Gordon, N. F., Gulanick, M., Costa, F., Fletcher, G., Franklin, B. A., Roth, E. J., & Shephard, T. (2004). Physical activity and exercise recommendations for stroke survivors. Retrieved from
  5. McPherson, K. M., & Ellis-Hill, C. (2007). Occupational therapy after stroke. BMJ, 335(7626), 894-895. Retrieved from
  6. Walker, M. F., Gladman, J. R. F., Lincoln, N. B., Slemonsma, P., & Whiteley, T. (1999). Occupational therapy for stroke patients not admitted to hospital: A randomised controlled trial. The Lancet, 354(9175), 278-280. Retrieved from
  7. 7.0 7.1 Fields, William S. & Lemak, Noreen A. (1989). A history of stroke: Its recognition and treatment. New York: Oxford University Press.
  8. 8.0 8.1 8.2 Moffat, M. (1996). Three quarters of a century of healing the generations. Physical Therapy. 76(11) 1242-1252
  9. Korobov, Stanislav A. (2005). Editorial - Towards the origin of the term physiotherapy: Dr. Edward Player's contribution of 1894. Physiotherapy Research International. 10(3) 123-124.
  10. 10.00 10.01 10.02 10.03 10.04 10.05 10.06 10.07 10.08 10.09 10.10 10.11 10.12 10.13 10.14 10.15 Bennett, Susan E. & Karnes, James L. (1998) Neurological disabilities: Assessment and treatment. Philadelphia: Lippincott Williams & Wilkins.
  11. 11.00 11.01 11.02 11.03 11.04 11.05 11.06 11.07 11.08 11.09 11.10 11.11 Lettinga, A. T., Helders, P. J. M., Mol, A., & Rispens, P. (1997). Differentiation as a qualitative research strategy: A comparative analysis of Bobath and Brunnstrom approaches to treatment of stroke patients. Physiotherapy. 83(10) 538-546.
  12. 12.0 12.1 12.2 12.3 Trombly, Catherine A. (1995). Occupation: Purposfulness and meaningfulness as therapeutic mechanisms. American Journal of Occupational Therapy. 49(10) 960-972
  13. Patient Health International (2011) How do you get a stroke?
  14. Nation Institution of Neurological Disorders and Stroke (2011)Brain Basics:Preventing Stroke
  15. 15.0 15.1 15.2 15.3 15.4 15.5 15.6 Bernhardt, J., Chitravas, N., Meslo, I. L., Thrift, A. G., Indrevalk. B. (2008). A comparison of physical activity patterns in Melbourne, Australia and Throndheim, Norway. American Stroke Association, 39, 2059-2065
  16. 16.0 16.1 16.2 16.3 16.4 Duncan,P., Richards, L., Wallace, D., Stroker-Yates, P., Pohl, P., Luchies, C., Ogle, A., Studenski, S., (1998). A randomized, controlled pilot study of a home-based exercise program for individuals. American Heart Association, 29, 2055-2060
  17. 17.00 17.01 17.02 17.03 17.04 17.05 17.06 17.07 17.08 17.09 17.10 17.11 17.12 Cameirao, M. D.,Badia, S. B., Daurte, E., Verschure, P. E. (2011) A randomized controlled pilot study in the acute phase of stroke using rehabilitation gaming system. Virtual reality based rehabilitation speeds up functional recovery of the upper extremities after stroke, 29, 5, 287-298
  18. 18.00 18.01 18.02 18.03 18.04 18.05 18.06 18.07 18.08 18.09 18.10 18.11 18.12 18.13 18.14 JAMES H. RIMMER, BARTH RILEY, TODD CREVISTON, and TERRY NICOLA. Exercise training in a predomnatly African-American group of stroke survivors (2000) 1990-1996
  19. 19.00 19.01 19.02 19.03 19.04 19.05 19.06 19.07 19.08 19.09 19.10 R.F. Macko, MD; C.A. DeSouza, PhD; L.D. Tretter, BS; Treadmill Aerobic Exercise Training Reduces the Energy Expenditure and Cardiovascular Demands of Hemiparetic Gait in Chronic Stroke Patients (1997), 28, 326-330
  20. 20.0 20.1 20.2 20.3 Burke Rehab: Stroke Recovery Program. Burke Rehab. N.p., n.d. Web. 10 Nov. 2011.
  21. Høyer, E., Normann, B., Sørsdal, R., & Strand, L. (2010). Rehabilitation including treadmill therapy for patients with incomplete locked-in syndrome after stroke; a case series study of motor recovery. Brain Injury, 24(1), 34-45. doi:10.3109/02699050903471805
  22. 22.0 22.1 Eng, J. (2009). GRASP.
  23. 23.0 23.1 Mansfield, A., Inness, E., & Komar , J., et al. (2011). Training rapid stepping responses in an individual with stroke. . Physical Therapy, 91(6), 958-969.
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