Exercises In Stroke

Subagyo

Stroke is one of the most disabling condition. It is the second leading cause of death after
heart disease. One modality for stroke survivor was exercise. The benefit of exercises was to
maintain the ability to move, doing activity of the daily living, and return to the previous jobs.

The problems of stroke survivor

If the stroke patients freed from death, they were against the handicapped that made
difficulties performing some activities. Ambulation, caused by limitation weak of synergy
patterns only, poor upright trunk control, inability to achieve single-limb support during stance
phase, and inability to advance the leg during swing phase. Impaired balance may be caused by
deficits in motor and sensory function, cerebellar lesions, and vestibular dysfunctions.
Assessment of motor impairment includes an evaluation of tone, strength, coordination, and
balance. The Medical Research Council (MRC) six-point scale, 0 for total paralysis, to 5, for
normal strength is used to assess strength. The MRC scale is designed to assess the strength of
individual muscles, and it is therefore most useful in grading strength in patients with lower
motor neuron lesions. There is difficulty to the use of this scale in patients with upper motor
neuron lesions, such as stroke, because the patients not be able to selectively activate a particular
muscle in isolation and will be given a 0 grade on the MRC scale. The patient may be able to
forcefully exerted a flexor or extensor synergy pattern. The capacity of the patient to move a
joint may be restricted by spasticity, as tone increased during recovery. Cocontraction of
agonists and antagonists can diminish the force of muscle contraction

Table 1. Brunnstrom Stages of Motor Recovery (1966,1970)

STAGE CHARACTERISTIC
Stage 1 No voluntary movement of the limb (flaccidity)
Stage 2 Spasticity appears, and weak basic flexor and extensor synergic patterns are present
Stage 3 Spasticity is prominent; the patient voluntarily moves the limb, but muscle activation is all within the
synergy patterns
Stage 4 The patient begins to activate muscles selectively outside the flexor and extensor synergies
Stage 5 Spasticity decreases; most muscle activation is selective and independent from the limb synergies
Stage 6 Isolated movements are performed in a smooth, phasic, well-coordinated manner, spasticity disappear
Stage 7 Normal function is restored

Shoulder subluxation and pericapsulitis adhesive, usually developed if hemiplegic

survivor tried to initiate ambulation in upright position. Complex Regional Pain Syndrome or
Reflex Symphathetic Dystrophy often present as one comorbidity after shoulder subluxation. The
signs and symptoms are frozen shoulder and wrist pain beside edema wrist and hand
simultaneously. The later will give result stiffness at wrist, MCP and interphalanx joint.
 Spasticity arise due to loss of inhibition from supranuclear and usually appear after 1
until 40 days post hemiplegia developed. Deep vein thrombosis was developed due to prolonged
immobilization. Bladder and bowel dysfunction if stroke involving area frontal lobe or disturbed
pons micturition axis. Dysphagia, usually interfere oral or pharyngeal phase if there are
involvement of cranial nerves due to topical lesion in midbrain and brainstem.
Communication disorders have several kind pathologies process. Dysarthria was the mild
disorders, aphasia /dysphasia or apraxia were more disabling disorders.

The aim of exercises

The objective performing exercise in the stroke survivor is to relearn the function of
cerebral hemisphere to do some tasks for maximal functional independence, prevent the next
stroke attack, to facilitate psychologies and social adaption for stroke survivor and caregiver,
support vocational and environmental reintegration, and enhance the quality of life.

The kind of exercises in stroke

The first that be recognized is traditional or compensatory rehabilitation therapeutic
exercises, consist of exercise that enhan ced the non affected side compensated the affected
side, for examples i.e., ROM exercises, technique strengthening, mobilization activity and
endurance training. This is will give assymetrical condition, although independence state can be
get more early.
The later procedure exercise was Neuromuscular Development approach, or bilateral
approach, that concerned to enhance the affected side beside also as good as the non affected
side, consist of PNF, Bobath approach, Brunnstrom approach, and sensorimotor approach.
Sensory Re-education, involves retraining the sensory system in the attempt to improve
sensation and hand function.
Balance Exercise, work to get balancing, sitting balance exercises focus on strengthening
the core or trunk musculature. Standing balance exercises will help improve a patients ability to
stand in place as well as walk or perform activities without loss of balance. Balance exercises are
important in helping prevent falls.
Cognitive Exercises may involve exercises to improve memory, problem solving,
reasoning, following directions, initiation of activity, and comprehension. The occupational
therapist may also work on cognitive activities with a patient to help with daily tasks such as
paying bills, cooking, dressing, toileting and another work activities.
Constraint-induced movement therapy (CIMT), developed by Dr.Edward Taub , forces
the use of the affected side by restraining the unaffected side. With CIMT, the therapist
constrains the survivors unaffected arm in a sling. The survivor then uses his or her affected arm
repetitively and intensively for two weeks or more; today, CIMT is increasingly common
because it has proven effective at improving survivors lives.
Gait training, at first started with parallel bar, and when stable within upright position,
can train ambulation with walker or tripod / quadripod.
Partially weight bearing support with treadmill one effort to ambulate especially for
stroke survivor with bad balance, and low level muscle strength and moderate to severe level of
spasticity. The use of Robotic is another modalities for the stroke survivors to regain ability to
walk.
Exercise for dysphagia: this may include thickened liquids, pureed food, or even nutrition
through a feeding tube if a patients swallowing ability is severely impaired (Nasogastric tube).
One may not even be aware that they are aspirating food or drink so it is important to have a
swallow study after a stroke using fiber optic endoscopic study (FEES) and participate in any
exercises or recommendations made by the speech therapist. Strengthening oral muscles,
combined with NMES will give good results.
Facilitation Exercises, especially correlated with postural performance, will increase
stability of the erector trunks. For recent years, facilitation exercise was used to enhance upper
extermity function using mirror exercise, that will increase the performance of activity daily
living.
Exercise for stroke survivor is done to get recovery of cerebro-spinal links with the end
results was return of vital function. There are many kind of exercise for stroke that each of it
have specific objective. It means the Physiatrist should know the specific problem for each
stroke survivor that handicapped, and then give the proper exercise.

Refferences
Stein J, Brandstater ME, 2010. Stroke Rehabilitation. In: Physical Medicine and Rehabilitation
Principles and Practice, 5th Ed De Lisa JA. Philadelphia : Lippincot William &Wilkins.
Zorowitz,Baerga E,Cuccurullo S, 2004. Stroke. In: Cuccurullo S, Editor, Physical Medicine and
Rehabilitation Board Review. New York : Demos Medical Publishing.