االنعام سورة163و162اآلية

Impairment Impairment

DisabilityDisability

Handicap Handicap

Stroke

Need

Continuous rehabilitation

Sensory Disturbance

Sensory Disturbance

Neurological DisordersNeurological Disorders

Neurological DisordersNeurological Disorders

Gait problems Gait problems

Perceptual Impairment

Perceptual Impairment

Neuromuscular impairment

Neuromuscular impairment

Impaired U.E Function

Impaired U.E Function

BalanceDisordersBalance

Disorders

stroke

Inability to carry out activities of daily living and social activitiesInability to carry out activities of daily living and social activities

Motor Impairment

Lack of cortical driveLack of cortical drive Lack of cortical driveLack of cortical drive

Disorganization of the motor outputDisorganization of the motor output

Disorganization of the motor outputDisorganization of the motor output

Lack of firing of agonist

Lack of firing of agonist

Over activities of the antagonist

Over activities of the antagonist

Neuromuscular impairmentcan be attributed to

Cocontraction of the agonist and antagonist

Cocontraction of the agonist and antagonist

Task specific control problemTask specific control problem

Inability to recruit muscle during automatic taskInability to recruit muscle during automatic task

Standing Balance TaskStanding Balance Task Locomotor Task (walking)Locomotor Task (walking)

Such asSuch as

Upper Extremity Tasks Upper Extremity Tasks (Grasping – Reaching – Manipulation (Grasping – Reaching – Manipulation

– – Feeding & Dressing)Feeding & Dressing)

Following stroke some of tasks are generally become more difficult

Normal Standing Balance

Development of skilled movements

Locomotion Manipulation

High priority should be given to the treatment of postural control problems

INTEGRAL PART OF ALL MOTOR ABILITIES

SO,SO,

ESSENTIAL FOR

attributed to

Loss of somatosensory sensation.Loss of somatosensory sensation.Muscle weakness.Muscle weakness.Spasticity leads to incoordination. Spasticity leads to incoordination. Impaired equilibrium reactions.Impaired equilibrium reactions.Loss of anticipatory reactions.Loss of anticipatory reactions.

Disturbed standing balance task in stroke patients

Disturbed walking task in stroke patient can be attributed to

Inability to maintain standing balance.Difficulty to shift weight bearing.Inability to take step by the affected limb.Improper joint alignment of L.L.Difficulty to control the position of the feet in standing.

Different therapeutic approaches are available for

management of stroke patient

Although

The functional outcome result is

limited.

There are controversial There are controversial issues about the best issues about the best

physiotherapeutic program physiotherapeutic program for rehabilitation of stroke for rehabilitation of stroke

patientspatients

TASK ORIENTED APPROACHTASK ORIENTED APPROACH

Aims to

Reduce disability by optimizing performance of every day task

Based on

Principles of Motor re-learning

System theory of motor control

Training functional movement skill

ProprioceptiveProprioceptive

stimulationstimulation

Modify functional behavior

Modulate motor behavior

Sensory awareness

Proper motor Proper motor engramengram

Training the posture reactions. Training the posture reactions. Training the rising reactionsTraining the rising reactionsControl spasticity and maintain length of the muscle. Control spasticity and maintain length of the muscle. Elimination of unnecessary muscle activity.Elimination of unnecessary muscle activity. Elicit muscle activity necessary for standing balance.Elicit muscle activity necessary for standing balance. Training the antigravity mechanism.Training the antigravity mechanism. Training weight bearing on both legs. Training weight bearing on both legs. Training weight bearing on affected leg.Training weight bearing on affected leg. Practice of the standing task.Practice of the standing task.

Strategies used to achieve Strategies used to achieve standing balance taskstanding balance task

Strategies used to achieve Strategies used to achieve standing balance taskstanding balance task

Sensory awareness

Postural response

Regain normal alignment

ms. strength control spasticity

Standing Balance Standing Balance TaskTask

Muscle strength

Task Oriented ApproachTask Oriented Approach

Parietal lobe

Motor cortex

Appropriate motor neurons

& appropriate number

Appropriate motor neurons

& appropriate numberInappropriate motor neuronsInappropriate motor neurons

Unnecessary activities & Inappropriate co-contraction

Unnecessary activities & Inappropriate co-contraction

Descending excitatory impulses to agonist muscles (more firing)

Abnormal activities of Spastic muscle (reciprocal innervation)

Postural control & balancePostural control & balance

Reducing neural hyper Reducing neural hyper excitability at CNSexcitability at CNS

Spatial orientation.Spatial orientation.

Repeated joint approximationRepeated joint approximation

Muscle toneMuscle tone

Unnecessary ms. activityUnnecessary ms. activity

+ Prime mover (agonist) &

- Antagonist & synergist.

Inappropriate co-cont.

Reducing ms. toneReducing ms. tone

BridgingBridging

HalfHalf bridgingbridging

Exercise to facilitate more Exercise to facilitate more normal movement pattern in normal movement pattern in trunk, pelvis and lower trunk, pelvis and lower extremitiesextremities

with with assistanceassistance

To facilitate selective dorsiflexionTo facilitate selective dorsiflexion,, Hip and knee flexionHip and knee flexion

Exercise to facilitate or Exercise to facilitate or improve selective hip improve selective hip abductors from side lying abductors from side lying

position.position.

Exercise to facilitate the Exercise to facilitate the antigravity mechanism: antigravity mechanism: (facilitation of back extensors (facilitation of back extensors

and hip extensors).and hip extensors).

11

22

Exercise to facilitate and Exercise to facilitate and train postural control from train postural control from quadriped positionquadriped position

11 22

33 44

Weight shift Weight shift exercise exercise from side to from side to side side to improve to improve symmetry of symmetry of weight weight bearingbearing

Training the Training the rising rising reactions reactions (Training on (Training on sitting to sitting to standing standing task):task):

Activities in standing with Activities in standing with weight on both legs:weight on both legs:

Exercise to Exercise to facilitate facilitate and train and train postural postural control from control from standing standing positionposition

Activities in standing with Activities in standing with concentration of weight concentration of weight bearing on the hemiplegic’s bearing on the hemiplegic’s leg.leg.

11 22

33

44

Standing with his weightStanding with his weight over the hemiplegic legover the hemiplegic leg

Task oriented approach depend on Task oriented approach depend on Active participation of the patientActive participation of the patient

Blood supply to brain 20 %Blood supply to brain 20 %

Remodeling of cortical mapRemodeling of cortical map

Brain cells to functionBrain cells to function

More improvement of the ms. responseMore improvement of the ms. response

Physiological efficiencyPhysiological efficiencyMechanical efficiencyMechanical efficiency

Psychological status of the pt.Psychological status of the pt.

Repetitive Stimulus and practiceRepetitive Stimulus and practice Repetitive Stimulus and practiceRepetitive Stimulus and practice

StimulateStimulate functionfunction

StimulateStimulate functionfunction

Skill acquisitionSkill acquisition

Cortical Cortical reorganizareorganiza

tiontionEnhance the rate of spontaneous Enhance the rate of spontaneous

& & optimize recoveryoptimize recovery

Task Oriented ApproachTask Oriented Approach

Task oriented approach via Task oriented approach via early program of proprioceptive early program of proprioceptive training is a beneficial modality training is a beneficial modality for improving the functional for improving the functional outcome and optimizing the outcome and optimizing the recovery in stroke patients.recovery in stroke patients.