"Effective Stroke Management:

Practical Skills and Techniques"

Yara Alassady
Stroke

• A stroke occurs when the blood supply to your brain is interrupted or

reduced. This deprives your brain of oxygen and nutrients, which can
cause your brain cells to die.

• A stroke may be caused by a blocked artery (ischemic stroke) or the

leaking or bursting of a blood vessel (hemorrhagic stroke)
Effect of a Stroke
•1. Weakness on the side of the body opposite the site of the brain
affected by the stroke

•2.Spasticity, stiffness in muscles, painful muscle , spasms

•3. Problems with balance and/or coordination

•4. Problems using language, including having difficulty understanding

speech or writing(aphasia); and knowing the right words but having
trouble saying them clearly (dysarthria)

•5. Being unaware of or ignoring sensations on one side of the body

(bodily neglect or inattention)
• After a stroke, some people have trouble with language in two main
ways:

1.Aphasia: This means they have a hard time understanding or using

words. For example, they might not understand what someone is saying,
or they might know what they want to say but can’t find the right words.
2.Dysarthria: This means they have trouble moving the muscles needed
for clear speech. They know the words they want to say, but their speech
may come out slurred or hard to understand.

• Both of these conditions make it harder to communicate, even if the

person’s thoughts are clear.
 Effect of a Stroke (can't)

• 7. Problems with memory, thinking, attention or learning

• 8. Being unaware of the effects of a stroke

• 9. Trouble swallowing (dysphagia)

• 10. Problems with bowel or bladder control

• 11. Fatigue

• 12. Difficulty controlling emotions (emotional lability)

• 13. Depression

• 14. Difficulties with daily tasks

 Successful Rehabilitation depend on:

• How early rehabilitation begins

• The extent of the brain injury

• The survivor's attitude

• The rehabilitation team's skill

• The cooperation of family and caregiver

• Starting as a physical therapist with a stroke patient requires a
thorough understanding of their condition, a structured assessment,
and a well-organized treatment plan.
• The goal in the initial stages is to create a safe and effective
environment to help the patient regain mobility, strength, and
functional independence. Here’s a step-by-step approach to starting
with a stroke patient:
Step 1: Initial Evaluation and
Assessment
• Patient History:

• Stroke Type: Determine whether the patient had an ischemic or hemorrhagic stroke.
This will help you understand the potential severity of the neurological impairment.
• Onset and Timing: Understand how much time has passed since the stroke. Acute
phase (0-72 hours), subacute phase (1-3 weeks), or chronic phase (>6 months) will
affect your approach.
• Comorbidities: Check for conditions like hypertension, diabetes, or heart disease that
could affect rehabilitation.
• Functional Status: What was the patient's baseline mobility before the stroke? This
helps gauge their level of independence and recovery potential.
Neurological and Physical
Examination:
• MRC Muscle Strength Scale: Assess muscle strength for each limb using
the MRC scale (Grade 0-5). Start with the affected side.
• Range of Motion (ROM): Assess the flexibility and mobility of joints
(especially the affected side).
• Postural Control and Balance
• Sensory Function: Assess light touch, proprioception, and pain
sensation to understand sensory loss.
• Functional Mobility: Assess the patient’s ability to perform activities of
daily living (ADLs) like sitting, standing, and walking, even if with
assistance
Step 1: Device Use and Support
(If Necessary)
• Neuromuscular Stimulation (Optional for Grade 0-1
Patients):
• If the patient has no voluntary muscle contraction
(Grade 0), neuromuscular electrical stimulation
(NMES) or functional electrical stimulation (FES)
may be used to stimulate muscle contractions and
prevent atrophy.
Infrared therapy can be used in stroke rehabilitation, primarily for pain
relief, muscle relaxation, and improving circulation. It helps reduce
swelling, alleviate muscle spasticity, and promote tissue healing.

Benefits:
• Pain relief and muscle relaxation.
• Improved circulation and reduced swelling.
• Helps with spasticity and improves range of motion.
• Facilitates tissue healing
Step 2: Passive Range of Motion (PROM)
and Stretching
• A. Passive Range of Motion (PROM):
• Goal: Keep joints moving to prevent stiffness and contractures.
• How to Perform:
• Gently move the patient’s limbs through their available range of motion, assisting with
passive movements (you do the movement for them).
• Focus on the shoulder, elbow, wrist, hip, knee, and ankle joints.
• Hold each position for a few seconds, moving in slow, controlled motions.
• PROM should be done regularly, typically 2-3 times per day, depending on the
patient’s condition.

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Stretching:

• Goal: Improve flexibility and reduce spasticity (if present).

• How to Perform:
• Gently stretch tight muscles and soft tissues. For example, stretch the calf
muscles, hamstrings, or wrist flexors if these are tight.
• Avoid overstretching or causing discomfort. Be mindful of muscle tone—
some stroke patients may have spasticity, which could make muscles tight
and resistant to stretching.
• Use gentle, sustained stretches rather than quick or forceful ones.
 Step 3: Strengthening and Exercise
Progression
• Once the patient starts showing some signs of muscle activity (Grade 1+
or Grade 2), you can begin working on strengthening exercises and
improving functional mobility.
. Early Strengthening (Grade 1
to 2):
• Goal: Activate the muscles, even if only through isometric contractions
(muscle tension without movement).
• How to Perform:
• Begin with isometric exercises where the patient tries to contract the muscle
without moving the joint.
• Use manual resistance for basic activation, such as gently pressing against the
patient’s hand or foot while they try to move against the resistance.
• If some muscle movement is visible (Grade 2), progress to active-assisted exercises
where the therapist helps the patient move the limb through the range of motion.
Examples of Isometric Exercises
for Stroke Patients
• 1. Upper Limb Isometrics (for Arm or
Shoulder)
• Bicep Isometric Contraction:
• How: The patient tries to bend their arm at
the elbow while the therapist provides
resistance (e.g., pressing against the patient’s
palm or arm).
• Goal: Strengthen the biceps without moving
the joint.
• Duration: Hold for 5-10 seconds, then relax.
• Repetitions: 5-10 repetitions, 2-3 sets.
• Shoulder Isometric:
• How: The patient presses their hand against a wall or table, trying to
move the shoulder in all directions (forward, sideways, or backward)
while the therapist provides resistance.
• Goal: Strengthen shoulder muscles without movement.
• Duration: Hold for 5-10 seconds, then relax.
• Repetitions: 5-10 repetitions, 2-3 sets
Lower Limb Isometrics (for Leg
or Hip)
• Quad Isometric Contraction:
• How: The patient attempts to
straighten their knee while the
therapist provides resistance (e.g.,
pressing gently on the top of the knee
or ankle).
• Goal: Strengthen the quadriceps
muscles without joint movement.
• Duration: Hold for 5-10 seconds, then
relax.
• Repetitions: 5-10 repetitions, 2-3 sets.
 Hip Isometric Contraction:

• How: The patient can perform isometric

exercises for the hip by pressing their leg
out (abduction) or trying to press the heel
into the floor while maintaining a neutral
position.
• Goal: Activate the hip muscles without
movement.
• Duration: Hold for 5-10 seconds, then relax.
• Repetitions: 5-10 repetitions, 2-3 sets.
• Grade 0-1: Start with gentle isometric exercises using minimal
resistance. The focus should be on activating the muscle without
overexerting the patient.
• Grade 2-3: As the patient gains strength and muscle control, increase
the resistance slightly, and progress to exercises that involve larger
ranges of motion (while still avoiding joint movement initially).
• Grade 4-5: Once the patient gains more strength and control, progress
to dynamic strengthening exercises that include full-range motion.
Dynamic strengthening exercises for stroke
patients:

1.Sit-to-Stand (Chair Rise)

2.Heel and Toe Raises (Standing)
3.Step-Ups
4.Wall Push-Ups
5.Bicep Curls with Resistance Bands or
Weights
6.Step and Reach (Lateral or Forward)
7.Leg Extensions (Seated or Standing)
8.Bridge Exercises
9.Arm Raises (Front and Lateral)
Standing and Balance Exercises
(Grade 2-3)
• Improve postural control and weight-bearing tolerance.
• How to Perform:
• Start with weight shifting exercises in sitting or standing positions
(as tolerated)
• .Focus on static balance exercises first (e.g., sitting with less support,
standing with minimal assistance).
• Once strength improves, try dynamic balance activities like reaching
for objects while seated or standing, or taking small steps with
assistance.
weight shifting exercises
• Preventing pressure sores (also known as pressure ulcers or
bedsores) is an essential aspect of stroke rehabilitation, especially for
patients with reduced mobility, sensation, or poor circulation.
Pressure sores develop when sustained pressure on the skin reduces
blood flow, leading to tissue damage.